key: cord- - cd sqab authors: housseine, natasha; punt, marieke c.; mohamed, ali gharib; said, said mzee; maaløe, nanna; zuithoff, nicolaas p. a.; meguid, tarek; franx, arie; grobbee, diederick e.; browne, joyce l.; rijken, marcus j. title: quality of intrapartum care: direct observations in a low-resource tertiary hospital date: - - journal: reprod health doi: . /s - - - sha: doc_id: cord_uid: cd sqab background: the majority of the world’s perinatal deaths occur in low- and middle-income countries. a substantial proportion occurs intrapartum and is avoidable with better care. at a low-resource tertiary hospital, this study assessed the quality of intrapartum care and adherence to locally-tailored clinical guidelines. methods: a non-participatory, structured, direct observation study was held at mnazi mmoja hospital, zanzibar, tanzania, between october and november . women in active labour were followed and structure, processes of labour care and outcomes of care systematically recorded. descriptive analyses were performed on the labour observations and compared to local guidelines and supplemented by qualitative findings. a poisson regression analysis assessed factors affecting foetal heart rate monitoring (fhrm) guidelines adherence. results: labouring women were observed. the nurse/midwife-to-labouring-women ratio of : , resulted in doctors providing a significant part of intrapartum monitoring. care during labour and two-thirds of deliveries was provided in a one-room labour ward with shared beds. screening for privacy and communication of examination findings were done in and %, respectively. for the majority, there was delayed recognition of labour progress and insufficient support in second stage of labour. while fhrm was generally performed suboptimally with a median interval of (interquartile range – ) minutes, occurrence of an intrapartum risk event (non-reassuring fhr, oxytocin use or poor progress) increased assessment frequency significantly (rate ratio . (ci . – . )). conclusions: neither international nor locally-adapted standards of intrapartum routine care were optimally achieved. this was most likely due to a grossly inadequate capacity of birth attendants; without whom innovative interventions at birth are unlikely to succeed. this calls for international and local stakeholders to address the root causes of unsafe intrafacility care in low-resource settings, including the number of skilled birth attendants required for safe and respectful births. every year around the world, . million babies die in the womb (stillbirths) and another . million die within days of birth (neonatal deaths). about half of these deaths are associated with problems that occur during birth in resource-poor settings. in this study, we assessed the quality of labour care at zanzibar's tertiary hospital, tanzania. we directly observed and carefully recorded the care given to women throughout birth and compared our findings to the local clinical guidelines of care at birth. in this busy hospital, care during birth was provided by young nurses, midwives and doctors with little direct supervision from seniors. conditions were difficult for both staff and pregnant women. labour and delivery took place in an open and crowded labour ward. each midwife took care of four women in labour simultaneously which resulted in insufficient support during birth. monitoring was not optimally performed according to the locally-tailored guidelines. for example, the baby's heart was monitored every min on average instead of the recommended min. staff, however, increased monitoring when certain problems were detected, such as when the baby's heart was not beating normally, when progress of labour was slow and when oxytocin was used to increase contraction. putting up a screen for privacy was done in about half of all vaginal examinations. in most cases, women were not informed of the findings after an examination. main reasons for birth attendants being unable to follow their clinical guidelines were that they are too few. thus an investment in sufficient and competent workforce in such labour wards is crucial. an estimated , maternal deaths and five million perinatal deaths occur yearly worldwide, with > % in low-and middle-income countries (lmics) [ ] . although childhood mortality has been reduced significantly, millennium development goal was not met in sub-saharan africa, as neonatal deaths went mostly ignored and now make up % of under- mortalities [ , ] . almost half the number of stillbirths and % of neonatal deaths in lmics are intrapartum-related, in contrast to high-income settings [ , ] . hence, ending intrapartum deaths by improved quality of intra-facility care is pivotal [ ] . yet, in sub-saharan africa, the increasing numbers of facility-based deliveries, have not resulted in better intrapartum care and progress to improve perinatal health outcomes is slowest [ ] [ ] [ ] . instead, in many facilities, international standards of intrapartum care have become more difficult to implement in the day-to-day reality. as found in our hospital, after unrealistic international guidelines were adapted to better suit the local resource-limited reality, significant improvements were observed in quality of care, stillbirths were reduced by one-third and the number of neonates with birth asphyxia nearly halved (box ) [ ] . quality of intrapartum care has mostly been assessed by retrospective analysis of existing medical records [ ] . however, written records (e.g. partographs) in lowresource settings are often incomplete, missing or inaccurate [ ] , and therefore might not reflect the actual care. the gold standard for clinical quality assessment is direct observation that captures the real-life experiences and behaviour of birth attendants; yet, they are rarely used [ , ] . similarly, few studies have assessed the adequacy of intrapartum foetal monitoring in low-resource settings [ ] [ ] [ ] [ ] [ ] . this study used continuous direct observation to assess the quality of intrapartum care, with a specific focus on foetal monitoring and the structural requirements to delivering intrapartum quality care. this was a prospective study consisting of labour observations at the maternity ward of mnazi mmoja hospital (mmh) in zanzibar, the united republic of tanzania, from october to november . the study adhered to a pre-determined protocol (additional file ) and strobe standards of reporting [ ] . this manuscript is part of the larger partoma project initiated in to improve quality of care (box ) [ ] . about , annual deliveries are assisted at mmh, and it is the only tertiary hospital on the zanzibar archipelago [ ] . at the time of the study, the labour unit consisted of an admission room, a one-room labour ward with beds, a three-bed delivery room, two postnatal rooms, and one theatre (fig. ) . for privacy reasons, women were not allowed to have a companion during childbirth in the busy the partoma project was initiated at zanzibar's tertiary hospital, tanzania in january . its objective was to improve quality of care and perinatal outcomes. skilled birth attendants were involved in focus groups discussions, adapting international labour management guidelines to better suit their local situation and participation in trainings. prior to the partoma intervention, the stillbirth rate was per total births ( % had positive foetal heart rate on admission) and the rate of apgar score of ≤ was per live births. at the th intervention month, stillbirth rate had decreased to per total births (relative risk . , % ci . - . ; intra-hospital singleton stillbirths reduced from to per total births) and apgar score ≤ fell to per live births (relative risk . , % ci . - . ). this was associated with improved quality of care, including improved foetal heart rate surveillance (a reduction in median time interval from last fhr to delivery from (iqr - ) to (iqr - ) minutes), more judicial use of oxytocin and improved management of women with severe hypertensive disorders. labour ward. skilled birth attendants (sbas) comprised nurse-midwives (diploma-level in nursing, except three seniors with university-level degree), resident doctors (general doctors) and six intern doctors (total n = ) who together provided routine labour care and comprehensive emergency obstetric and newborn care. on average, six to eight nurse-midwives and five doctors were allocated to the maternity unit in the morning shifts and a total of six sbas were in the remaining shifts (including weekends). these were the main roles of nurse-midwives: assessment on admission; intrapartum and postpartum care including supportive care, routine monitoring, administration of medication, vaginal deliveries, and perineal repair; maintenance of ward hygiene, and delivery sets. the roles of the doctors involved providing labour and postpartum care to high risk women and complicated deliveries and performing obstetric and gynaecological operations. direct supervision was provided by two senior midwives and two senior (visiting) doctors, only during morning shifts. in addition, there were three obstetricians who could be consulted and called for emergencies (additional file , cadre definitions). standards for labour management was according to the peer-reviewed partoma pocket guide version . [ ] . where, in collaboration with the sbas, international guidelines had been tailored to the situation at the hospital, including reductions in information load, ambiguity, and frequency of clinical assessments (additional file , comparison of fhrm recommendations) [ ] . the stillbirth rate was per total births, of which % occurred during intra-hospital care [ ] . the first women to reach active phase of labour (≥ cm cervical dilatation), either at admission or already in the ward, were selected for inclusion. exclusion criteria were absent foetal heart rate (fhr) on admission, elective or emergency caesarean section (cs) decided immediately after admission, and known congenital foetal anomaly incompatible with life. shifts of inclusion were planned beforehand to ensure representation of morning, evening, and night shifts throughout the week. labours were observed until delivery or diagnosis of intrauterine foetal death. approval from mnazi mmoja hospital and zanzibar medical and research ethical committee the local ethics committee (zamrec) was obtained (zamrec/ / may/ ). written informed consent in swahili was sought from all participating women. the aim of the study and the role of observers were introduced to all staff before commencing the study (not to cause blame or undermine the staff's devotion to labouring women). in case observers had concerns about the safety of a woman, they could express these concerns to the staff on duty and a senior staff could be called for assistance if needed. the study qualitatively described and quantified structural indicators and processes of intrapartum care, as described in the donabedian model [ ] . it focused on the aspects of intrapartum monitoring and supportive care (fig. ). in addition, the study determined adherence to the local fhrm guidelines (in terms of frequency and technique) [ ] , and the effect of five pre-identified predictors on fhrm frequency: pregnancy risk status (box ); occurrence of intrapartum risk events (box ) [ ] ; parity (nulliparity and multiparity); sba's years of experience with maternity care; and shift of inclusion. predictors were adopted from the nice [ ] and local partoma guidelines, and from the hypothesis that they would alter the frequency of observations and/or the quality of care. adherence to fhrm guidelines meant that the number of fhrms was at least equal to the expected frequency. expected frequencies of fhrm for low-risk labours, highrisk labours, and non-reassuring/abnormal fhr were set at , , and min, respectively [ ] . these were based on first stage of labour guidelines, because the start of second stage was often unknown. other variables recorded consisted of socio-demographic characteristics, risk assessment variables (box ), cervical dilatation, and fhr on admission (additional file ). the five observers were not qualified to act as birth attendants. one of the observers was a foreign final year medical student. the other four observers were newly graduated local medical students who had recently completed their studies and awaiting approval to start clinical internships. therefore, none of the observers were permitted to provide medical care in this setting. two observers per shift, both located in the labour room, conducted non-participatory direct observations. they recorded all care provided to each woman and performed hourly counts of the structural indicators (fig. ) . when a woman was taken to the delivery room or theatre, one observer followed her until birth. sociodemographic characteristics, risk assessment variables, assessments on admission and birth outcomes were collected using the women's records (antenatal card and hospital file). two data collection forms were created (additional file ), pilot tested, and used for the systematic recording [ ] ; one for processes of care provided per woman as well as cadre of staff who provided the care and birth outcomes, and one for hourly counts of number of birth attendants, labouring women, and functioning fhrm devices. both forms provided space for free-text description of e.g. supportive care (staff's and women's behaviour, presence of sba during delivery), decision-making, medical treatment, and physical space/environment. observer bias was a major concern. observers could have underreported assessments made by sbas or could have been involved in providing labour care. to minimise these biases, they were trained to recruit women into the study, make objective structured assessments with minimal intervention in care provision, and record their observations on the forms. they worked in pairs and observed a maximum of eight labouring women at a time. also, the presence of observers could have altered the behaviour and improved performance of the sbas (the hawthorne effect) [ ] . however, this effect was likely to be minimal because the labour ward was extremely busy. also, observations were made from an adequate distance, rather than by following the sba. the a priori sample size was estimated to be labours plus % to account for potential hindsight exclusion based on a maximum of five predictors, with the aim to detect a single predictor with an assumed effect size of a risk ratio of . , power of % and alpha of %. first, descriptive analyses were conducted on women's characteristics and number of staff, women, care provision, and fhrm devices. means were reported with standard deviations (sds), medians with interquartile ranges (iqrs), and frequencies with percentages. then, the proportion of observations adhering to local fhrm guidelines, privacy standards and communication practices were calculated using the following formula: number of observations divided by number of expected observations, given the duration of labour. four intervals were calculated: between two adjacent fhrms, vaginal examinations, contractions and the last fhr-to-delivery interval. differences between work shifts (day/evening/nights) were tested using one-way-anova for the number of staff, equipment and labouring women and chi-square test for composite adverse perinatal outcomes (i.e. stillbirths and apgar score < at min). furthermore, univariate and multivariate generalized linear models for poisson distributions were performed with the number of fhrms for each woman as an outcome to estimate the effect of the above-mentioned pre-selected predictors on local guidelines adherence. in the multivariate analysis, the predictor intrapartum risk event was dichotomised. results from the analysis were reported as rate ratios (rrs) with % confidence intervals and corresponding p-values. for this study, a rr may be interpreted as the increase in the number of fhrms either compared to a reference category or when a continuous predictor increases by one unit. the set frequency of fhrm was hourly and women with a total pre-delivery observation of less than one hour were excluded from this analysis. the statistical software used was spss version , and sas . . free-text comments were used to supplement quantitative findings on human resources, physical space, equipment, monitoring, and supportive care. the majority of the women observed ( . %, n = ) came directly from home, at term ( (± . ) weeks), and with a median cervical dilatation of five (iqr: - ) cm. inclusions were spread evenly between morning, evening, and night shifts ( . %, n = ; . %, n = ; and . %, n = , respectively). fifty-one women ( . %) were classified as high-risk on admission; the most common risk factors being hypertensive disorders ( . %, n = ), prematurity ( . %, n = ), breech presentation ( . %, n = , including two singletons and one twin pregnancy diagnosed close to delivery), previous uterine scar ( . %, n = ) and grand multiparity ( . %, n = ). in addition, . % (n = / ) of the remaining labouring women experienced one or more intrapartum risk events. of the ( %) labours augmented with oxytocin, two thirds (n = ) had crossed the action line of the partograph (i.e. poor progress). there were no maternal or neonatal deaths before hospital discharge, but there were four stillbirths ( . %) and ( . ) babies with apgar score less than seven at one minute (table ) . there was no statistical significance in composite perinatal outcomes between shifts of delivery (p = . ). structure: context in which care was provided human resources the majority of nurse-midwives and doctors ( %, n = / ) had a maximum of five years' experience in labour care (< year: %, n = / ; - years: %, n = / ; > years: %, n = / ). observation at hourly intervals showed an average of nine labouring women and two to three nurse-midwives in the labour and delivery rooms throughout the day (nurse/midwife-to-labouring-women ratio of : ). nurse-midwives performed all admission assessments, conducted . % ( / ) of intrapartum monitoring and the majority of vaginal deliveries ( . %, n = / ) ( table ). the resident doctor on duty also monitored women in labour ( . % of examinations, n = / ) and handled gynaecological and obstetric emergencies such as cs, obstetric haemorrhage and eclampsia. sharing of information within cadres occurred during handover rounds, and two clinical meetings in the morning shift in which mainly doctors attended. several sbas regularly worked at a continuous pace and attended to women; while others showed signs of exhaustion, such as decreased work speed, resting for long periods, sleeping during night shifts, and uncourteous behaviour towards women and colleagues, only offering help when women became too loud or in the presence of a senior. students and cleaners also shared tasks; they assisted during deliveries, offered psychological support, helped women with food and facilitated communication between women, sbas and their families who were restricted access to the maternity unit. partograph copies were available throughout the study period and were used in at least % (n = ) of labours; the remaining were either lost after delivery ( . %, n = ) or not used at all ( . %, n = ). difficulties encountered with fhrm devices were their scarcity or misplacement ( table ) , unavailability of gel for handheld dopplers and ultrasound, and non-functioning hand-held dopplers (n = ). other intermittent shortages included lack of essential medication (e.g. antihypertensive), and supplies for vacuum extraction, cs and normal delivery sets. the single-room labour ward was noisy and crowded, and consisted of women in all stages of labour and postdelivery. the number of women typically exceeded the number of beds, thus women often shared and changed beds. although specific areas of the room were reserved for high risk women and specific stages of labour, this localisation was not consistently used. two thirds of vaginal deliveries took place in the shared labour ward ( . %, n = / ), while . % (n = / ) reached the three-bed delivery room that had more privacy ( table ) . processes of routine care delivery provider-woman contact points were observed during labour and delivery, which included examinations consisting of fhrm (n = ), vaginal examinations (n = ), and other forms of care (n = ) ( table ) . maternal blood pressure and/or temperature were measured at of these time points. the median decision-delivery time interval for the emergency operative deliveries was (iqr: - ) minutes. labouring women were provided intermittent care collectively by the sbas on duty. they often called for attention, especially during contractions and when they felt the need to push. this prompted examination and diagnosis of second stage of labour in the majority of women who delivered vaginally ( . %, n = / ). in more than a quarter of women ( . %, n = / ), support during second stage was not provided until ≤ min before delivery; six of whom delivered unattended. six of the women were admitted with < cm cervical dilatation and also went through the entire first stage of labour unobserved. other actions associated with caring support, including use of a screen for privacy and communication during and after examinations (fhrm and/or vaginal examination) were conducted in . % (n = / ) and . % (n = / ) respectively. (table ). neonatal deaths before discharge ( . ) * unless otherwise specified values are given as number (percentage), ** of the live births, *** one stillbirth was delivered macerated. the median duration of labour observation was (iqr: - ) minutes in which the median frequency of fhrm was one (iqr: - ) and of vaginal examination two (iqr: - ). the median interval between two vaginal examinations in the first stage of labour was (iqr - ) minutes. in none of the cases, the strength and frequency of contractions were assessed by -min palpation per abdomen. two-thirds of fhrm were conducted with a delee or pinard stethoscope ( . %, n = / ; delee: n = , pinard: n = , both: n = ). ultrasound was primarily used in . %, (n = / ) of cases, while hand-held doppler was rarely used ( . %, n = / ). in the remaining cases, ultrasound, following use of stethoscope, was used to confirm fhr ( . %, n = / ). in . % (n = ) of labours, fhrm was only recorded on admission. for labours with more than one fhrm (n = ), the median interval between two fhrms was (iqr - ) minutes, with % (n = / ) of intervals within min, and . % (n = / ) beyond two hours. the median interval between the last fhrm and delivery was (iqr: - ) minutes (table ). of all fhrms observed, they were counted with a clock in . % (n = / ), maternal pulse simultaneously palpated in . % (n = / ), and contraction palpated in . % (n = / ) of cases. the locally recommended one-hour frequency of fhrm was adhered to in . % (n = ) women throughout labour (table ). there was no difference in last fhrm to delivery intervals between morning, evening, and night shifts. the presence of intrapartum risk events led to an increase in the number of fhrms observed, with a rate ratio (rr) of . this direct observation study reports on intrapartum care provided to women in a congested tertiary hospital in sub-saharan africa. it shows suboptimal birth attendance and adherence to local and international guidelines on timely care, including surveillance of the woman's vital signs, fhr, and labour progress. substantial findings of this study were the discontinuous care. lack of support and respectful care were reflected by a significant absence of communication, privacy, and support at the time of delivery. structural challenges observed were high workload compared to staff numbers, an unconducive environment and scarcity of monitoring devices. however, despite this congested and unconducive environment, sbas showed ability to provide evidence-based triage; they prioritised the monitoring of women who were recognised to have an intrapartum risk event (non-reassuring/abnormal fhr, oxytocin use, and crossing the action line) leading to a significant increase in frequency of fhr assessments. lack of attendance and delay in diagnosing second stage of labour in the majority of women was the rationale behind our conservative approach to determine fhrm guidelines adherence. we only compared fhrm to first stage expected frequencies, which were lower than second stage frequency. although this approach underreports the problem, the findings highlight the challenge of adhering to guidelines in these settings. in other resource-limited settings of sub-saharan africa, randomised control trials on innovative fhrm devices failed to show improvement in perinatal outcomes due values are given as mean (standard deviation) *significant level at . : there were less senior doctors in the evening and night, and less intern doctors at night compared to morning shifts to non-adherence to fhrm international guidelines and obstetric response [ ] [ ] [ ] [ ] . in this hospital, international guidelines were adapted to locally-acceptable minimum standards [ ] . compared to the situation before local guidelines were implemented, months prior, there was sustained multiple improvements in monitoring: including higher fhrm frequency, notably in women with intrapartum risk events, more timely oxytocin use for augmentation, improved care for women with severe hypertensive disorders, and lower intrapartum stillbirth rates [ , ] . an earlier study showed that these guidelines were positively viewed and were used by local staff [ ] . however, they are still far from being adhered to optimally which present an ethical dilemma of whether such guidelines can further reduce frequency of assessments. inadequate number of health workers, as reflected in the hourly mid-wife-to-labouring women ratio, remained the major bottleneck to following internationally agreed evidence-based standards of care optimally. for example, with one nurse-midwife attending four women simultaneously, there is insufficient time to palpate contractions in accordance to international recommendations (every min for -min duration), not to mention time for any other care or rest. providing support throughout birth was thus an overarching challenge, notably of women in early labour who were not considered as yet eligible for routine intrapartum care. however, women in general, including in sub-saharan africa, favour continuous birth companionship [ ] . evidence suggests that it is the most significant intervention during birth associated with positive effects on perinatal outcomes and women's experience of birth [ ] . as such the lack of support in this study, including in the second stage of labour, meant that women were likely to have had significant distress and negative birth experience. in addition to suboptimal care, this inevitably leads to a workforce with moral distress, burnout, and compassion fatigue hence, even less capable of giving compassionate care [ ] . in order to cope with the high workload, resident doctors performed a significant part of routine intrapartum care that is usually conducted by midwives. however, this may have impaired the ability to provide obstetric care to the large number of high-risk women and further disrupted midwifery-led supportive care. the lack of adequately trained sbas, in particular nurse-midwives, may have been exacerbated by lack of inter-professional collaboration and supervision of junior staff, as well as by inefficient organisation of space, workforce and tools [ ] . consequently, care remained severely suboptimal and the stillbirth rate persistently high, emphasising the need to first improve the basic structure of care. achieving minimal standards of care would require efficient allocation of available resources, organisation, supervision and teamwork as well as an adequate increase in human resources. moreover, birth companionship is a challenge in open and overcrowded labour wards. efforts should also be placed on how e.g. relatives and traditional birth attendants may assist the overstrained skilled birth attendants in providing continuous support during labour and delivery. we here report the labour observation aspect of a broader work that included an ethnographic study and a locally co-created intervention to improve quality of labour care. measurement of the quality of labour care is essential for identifying gaps, developing context-tailored interventions and monitoring of quality improvement processes. this unique systematic observation of intrapartum routine care overcomes the shortcomings of records-based studies in assessing quality of care. it allowed evaluation of the interactions between labouring women and their birth attendants, and the structural context care was provided in. the findings are supported by record-based quantitative partoma findings and also by mainly qualitative findings that showed similar suboptimal structural challenges to processes of care in numerous areas across sub-saharan africa and other low resource-settings [ , [ ] [ ] [ ] . however, observations are more resource-consuming than record-based assessments, hold a higher risk of the hawthorne effect, and may pose ethical dilemmas about the non-participatory nature of the observer and their moral responsibility to participant safety in understaffed settings. thus, a tradeoff of biased results for participant safety may be necessary. as the observers were not qualified birth attendants, they expressed any concerns on patient safety, including imminent delivery, to the staff on duty and in emergency situations, they assisted the staff when requested. observations show it was common practice for birth attendants to wait until signs of imminent delivery before attending to women in the second stage of labour. thus a few women delivered unattended, as a result of preventable delays to respond to women's call for help and not the mere absence of skilled birth attendants from the labour ward. limitations included the observer bias and hawthorne effect described above. also, the study aimed to measure and identify challenges, rather than detect differences in outcomes for varying quality of care. hence, it was still unable to determine the effect foetal monitoring has, if any, on birth outcomes [ ] . the results should then lead to adequately-powered studies including clinical auditing in other lmics to estimate the quality of the intrapartum (foetal) monitoring and linking it to birth outcomes. moreover, we were not able to determine the effect of staff experience and time of day on the quality of care as women were cared for by several birth attendants across multiple shifts. the admission assessment was retrieved from the patient file and not observed. numerous findings on admission which included smaller-than expected fundal height, undiagnosed twins, breech presentation, and intrauterine foetal death until close to delivery indicate inadequate risk assessment and suggests admission time as an important point for improvement to explore. in this reality check of intrapartum care, the quality of basic routine care in a tanzanian referral hospital remained unacceptable. it was not possible to provide respectful and safe care, and even to optimally follow locally adapted clinical guidelines, which took the local resources into account. this was particularly due to the disproportionate birth-attendant-to-labouring women ratio. ensuring a safe and positive birth experience requires local stakeholders and international community to urgently address the structural barriers in sub-saharan africa and invest in sufficient numbers of adequately trained and motivated staff for continuous support during labour. global , regional , national , and selected subnational levels of stillbirths , neonatal , infant , and under- mortality , - : a systematic analysis for the global burden of disease study every newborn: progress, priorities, and potential beyond survival stillbirths: rates, risk factors, and acceleration towards reducing intrapartum stillbirths and intrapartum-related neonatal deaths making pregnancy safer : the critical role of the skilled attendant: a joint statement by who , icm and figo. world health organization maternal health the scale , scope , coverage , 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emergency obstetric and newborn care: can performance indicators capture health system weaknesses? effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of zanzibar: a quasi-experimental pre-post study (the partoma study) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations our gratitude to rashid saleh khamis and mbweni makame ali for their valuable contribution to data collection. the authors declare that they have no competing interests. supplementary information accompanies this paper at https://doi.org/ . /s - - - . at the time of the study, nh was a clinician at the obstetrics and gynaecology department mnazi mmoja hospital and is a phd candidate at umc utrecht. her research is based on improving quality of intrapartum care, with a particular focus on foetal monitoring, in low resource setting. global health scholarship and dr. lieve page-christiaens at umc utrecht; and mnazi mmoja hospital in zanzibar. the funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report or the decision to submit for publication. the corresponding author had full access to all the data in the study and all authors had final responsibility for the decision to submit for publication. the datasets used and analysed during the current study are available from the corresponding author on reasonable request. approval from the local ethics committee (zamrec) was obtained (zamrec/ /may/ ). written informed consent in swahili was sought from all participating women. not applicable. key: cord- - a ga v authors: ribeiro, ana freitas; pellini, alessandra cristina guedes; kitagawa, beatriz yuko; marques, daniel; madalosso, geraldine; fred, joao; albernaz, ricardo kerti mangabeira; carvalhanas, telma regina marques pinto; zanetta, dirce maria trevisan title: severe influenza a(h n )pdm in pregnant women and neonatal outcomes, state of sao paulo, brazil, date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: a ga v to investigate the factors associated with death and describe the gestational outcomes in pregnant women with influenza a(h n )pdm , we conducted a case-control study (deaths and recovered) in hospitalized pregnant women with laboratory-confirmed influenza a(h n )pdm with severe acute respiratory illness (sari) in the state of são paulo from june to december , . all cases were evaluated, and four controls that were matched by the epidemiological week of hospitalization of the case were randomly selected for each case. cases and controls were selected from the national disease notification system-sinan influenza-web. the hospital records from hospitals were evaluated, and home interviews were conducted using standardized forms. a total of cases and controls were investigated. having had a previous health visit to a healthcare provider for an influenza episode before hospital admission was a risk factor for death (adjusted or (or(adj)) of . , % ci . – . ). although not significant in the multiple analysis (or(adj) of . , % ci . – . ), the (rd) trimester deserves attention, with an or = . , % ci . – . in the univariate analysis. antiviral treatment was a protective factor when administered within hours of symptom onset (or(adj) = . , % ci . – . ) and from to hours (or(adj) = . , % ci . – . ). there was a higher proportion of fetal deaths and preterm births among cases (p = . ) and live births with low weight (p = . ), compared to control subjects who gave birth during hospitalization. after discharge, control subjects had a favorable neonatal outcome. early antiviral treatment during the presence of a flu-like illness is an important factor in reducing mortality from influenza in pregnant women and unfavorable neonatal outcomes. it is important to monitor pregnant women, particularly in the (rd) trimester of gestation, with influenza illness for diagnosis and early treatment. introduction pregnancy constitutes an important risk for the development of influenza-related complications and hospitalization. the and influenza pandemics showed increased mortality in pregnant women [ , ] . the reasons for the increased risk during pregnancy probably derive from a combination of immunological and physiological factors. an increased susceptibility to certain intracellular pathogens has been described [ ] . the identification of a new viral subtype, influenza a(h n )pdm , in mexico and the united states in april and its worldwide dissemination led the who to announce the beginning of a pandemic in june [ ] . a study developed during the first month of the outbreak in united states estimated that the rate of admission for pandemic h n influenza in pregnant women was higher than in the general population ( . per , pregnant women, % ci . - . vs . per , population at risk, % ci . - . ) [ ] . since , the world health organization (who) has defined this group as the highest priority for vaccination [ ] . a study conducted in california among hospitalized pregnant women and women of reproductive age with influenza a(h n )pdm showed that pregnant women in the nd and rd trimesters who delayed treatment(! hours) were more likely to undergo admission to the icu or death [ ] . most studies evaluate risk factors for increased severity in pregnant women [ , , , ] and few studies have analyzed the risk factors for death in pregnant women from influenza a(h n )pdm . a systematic review study showed a higher risk of hospitalization in pregnant women with influenza a(h n )pdm , with relative risks ranging from . to . . however, only one study showed a higher risk of death in pregnant women with influenza a (h n )pdm (rr . ) and seven studies presented no significant risks ( . to . ) [ ] . meta-analysis also showed no higher risk of death in pregnant women with pandemic influenza, or . ( % ci . to . ) [ ] . a higher risk of fetal abnormalities in pregnant women with both seasonal influenza virus infection and a(h n )pdm infection was reported. in addition, women with a diagnosis of a(h n )pdm infection had a higher risk of placental problems, antepartum haemorrhage, and antepartum complications [ ] . during the pandemic, there were a significant number of deaths in pregnant women from influenza a(h n )pdm in são paulo, which justifies this study. the objective of this study was to analyze factors associated with death in pregnant women with influenza a(h n ) pdm and severe acute respiratory illness (sari) and describe the gestational and neonatal outcomes. the state of são paulo has a population of more than million inhabitants, with , live births in , according to data from the information department of the unified public health system (datasus) of the ministry of health. a case-control study was conducted that evaluated pregnant women living in são paulo with confirmed infection of influenza a(h n )pdm and hospitalized with sari, defined as: fever and cough and dyspnea or pneumonia or respiratory failure or tachypnea or radiological alterations consistent with pneumonia or oxygen therapy or mechanical ventilation. the definition of sari has been adapted from the one stated by the who to increase sensitivity in the detection of cases and controls [ ] . in , the ministry of health of brazil established the compulsory notification of any hospitalized case of influenza associated with sari and the inclusion of an epidemiological investigation into the influenza-web database of the national disease notification system (sinan). all hospitalized pregnant women who were notified with influenza associated with sari and eventually died during the epidemic period from july th to december st in são paulo were included in the analysis. for each death (case), four controls were randomly selected from those who recovered. the cases and controls were identified from the sinan, using the following variables for selection: rt-pcr (positive for influenza a/h n pdm ), final classification (confirmed), evolution (recovered or death), hospitalization (yes), date of hospitalization, hospital and residence in the são paulo state. the controls were matched by epidemiological week of admission date of the case to adjust for possible variations in access to treatment and clinical protocols. all pregnant women had a laboratory confirmation of influenza a(h n )pdm from a sample of respiratory secretions using the rt-pcr method, performed at the adolfo lutz institute, the public health laboratory [ ] . for data collection, trained health professionals used two standardized forms: one to collect hospital record information and the second was used for home interviews. for the cases, the interviews were conducted with close family members, and for the controls, the interviews were conducted with the patients themselves. the hospital form included the following variables: pathological history, health care, symptoms on admission, admission to the intensive care unit, antiviral treatment (the ministry of health released the antiviral oseltamivir), use of antibiotics, complications, laboratory tests, radiological examinations, evolution, gestational and neonatal outcomes. the home form included the following variables: sociodemographics, history of a previous health visit to a healthcare provider for the influenza episode that resulted in hospitalization (after the onset of symptoms and before hospital admission date), vaccination history and gestational and neonatal outcome. education level was classified as low (no schooling or incomplete primary), medium (complete primary or incomplete high school) or high (complete high school or university). occupations were grouped using the occupational risk pyramid for the pandemic in the occupational safety and health act of the national institute for occupational safety and health-cdc, which classified the occupation risk for influenza infection as low (professional managers and other university and technical professionals without close contact with the population), medium (professionals in the areas of education, trade, service and administration with close contact with the population), or high and very high risk (doctors, nurses, other health professionals and support staff in the health services) [ ] . a pre-test with patients with influenza a(h n )pdm was performed to identify and correct any errors. the questionnaires are presented in s data collection form and the complete data used in this study are shown in s database. the study was started during the epidemic to support the actions of epidemiological surveillance, and the use of the data was approved by the ethics committee of the school of public health of usp (protocol , of.coep/ / ). data collection complied with the recommendations of the national health council for research in human beings, including the signing of a consent form. clinical and demographic variables are presented as medians and interquartile ranges or percentages, mann-whitney u or chi-square tests were used for comparisons, as appropriate. odds ratios and % confidence intervals ( % ci) were calculated to evaluate factors associated with death. for the multiple logistic regression, variables were selected with a p of < . in the univariate analysis and those considered important for the adjustment. the initial model included: health plan; previous visit to a healthcare provider; the presence of at least one of the high-risk medical conditions for developing influenza-related complications (adapted from the centers for disease control and prevention): asthma, neurological and developmental disorders, heart disease, kidney disease, liver disease, hemoglobinopathies, endocrine disorders, immunosuppressive diseases and obesity, with the absence of these conditions as reference; the use of an antiviral [no use (as reference), hours from the first symptoms, > and hours, > hours], pregnancy trimester [ st and nd trimesters (as reference) and rd trimester]. the data were controlled for education level and age. the wald and hosmer-lemeshow tests were used to evaluate the significance of the variables and test the fit of the model, respectively. analyses were performed using spss (ibm, armonk, ny, usa), version . . p values of < . were considered significant. in são paulo, in , pregnant women with confirmed influenza a(h n )pdm infection notified in sinan eventually died. a total of controls were randomly selected among the pregnant women hospitalized with confirmed influenza a(h n )pdm infection notified in sinan who recovered. the investigation was conducted in hospitals where all cases and controls were hospitalized. with regard to the cases and controls initially identified in sinan for the study, files were missing or did not meet the case or control requirements, resulting in cases and controls reviewed. two pregnant women who died were identified in another study [ ] , and included in the present. the home interviews were performed for cases ( . %) and controls ( . %), as shown in fig . table presents the socio-demographic characteristics of the pregnant women. there were no significant differences in socio-demographic distribution between cases and controls, and median age, family income, education level, smoking history, occupational risk for influenza infection, previous pregnancy and existence of private health insurance were not associated with death. table shows the distribution of cases and controls according to clinical variables and visits to a healthcare provider. a total of . % of cases sought medical care for the influenza episode prior to hospitalization. this proportion was higher than that of the controls. when evaluating the preconditions for admission, the presence of other risk conditions for developing complications related to influenza did not differ in cases and controls. asthma and obesity were the most common conditions, among cases ( . % each) and controls ( . % vs. . %, respectively). the use of an antiviral during hospitalization was an important protective factor against death, with proportions of treatment at . % and . % in cases and controls, respectively. the proportions of women who received antiviral within the first hours of symptoms were % and . % in cases and controls, respectively. the protective effect was also observed for treatment starting within to hours ( . % and % in cases and controls, respectively). the initiation of treatment with an antiviral more than hours after the onset of symptoms did not present significant protection. the median number of days between the date of the first symptoms and hospitalization was four for the cases and two for the controls (p = . ). treatment with antibiotics was used in % of cases and . % of controls. the average number of antibiotics used was . for cases and . for controls. among the cases, there was a higher proportion of patients admitted to the intensive care unit ( . % vs. . %), and a higher proportion of cases underwent mechanical ventilation compared to controls ( % vs. %). the cases exhibited higher rates of complications than the controls ( % vs. . %), predominantly: respiratory distress syndrome ( . % vs. . %), shock ( . % vs. . %), sepsis ( . % vs. . %), infections ( . % vs. . %) and renal alterations ( . % vs. . %). there were three episodes of pre-eclampsia, which evolved to death (cases) and one in the control group. none of them fulfilled the definition of hellp syndrome, named for three features of the disease (hemolysis, elevated liver enzyme levels, and low platelet levels). all cases that evolve to death had influenza a(h n )pdm as the main cause in the death certificate. co-infection with other infectious agents occurred in . % of cases and . % of controls, with the following pathogens found: acinetobacter baumannii (n = ), klebsiella pneumoniae (n = ), staphylococcus aureus (n = ), pseudomonas aeruginosa (n = ), enterococcus spp. (n = ), candida spp (n = ), candida albicans (n = ), klebsiella spp. (n = ) and streptococcus pneumoniae (n = ). the results of chest radiology were assessed in . % of cases and in % of controls. among the cases, . % presented with alterations, with a consolidation pattern evident in % of cases. among the controls, . % presented alterations, with a consolidation pattern evident in . % of cases. table shows the findings from the laboratory examinations at the time of hospital admission. the cases presented lower median platelet, hemoglobin and hematocrit counts and severe influenza a(h n ) in pregnant women higher median levels of creatine phosphokinase-cpk, lactate dehydrogenase-ldh, glutamic oxaloacetic transaminase-got, urea and creatinine, with statistical significance. table presents the variables in the final multiple logistic regression model. having had a previous health visit to a healthcare provider for the influenza episode before hospitalization was a risk factor for death, or . ( % ci . - . ). antiviral treatment was a protective severe influenza a(h n ) in pregnant women factor for death when administered within the first hours after the onset of symptoms, or . ( % ci . - . ), and when administered to hours after the onset of symptoms, or . ( % ci . - . ). the third trimester of gestation, which was a significant risk factor in univariate analysis, lost significance in the multiple analysis, or . ( % ci . - . ), when antiviral treatment was included in the model. the proportion of women who did not receive any antiviral treatment was similar in the three trimesters of gestation ( . , . and % respectively) and the proportion of those who received the treatment after hours was higher in the rd trimester ( . %, . % and %, respectively for the st , nd and rd trimester of gestation. as shown in table , among the cases, . % of pregnant women had live births, with one twin birth, and . % of the women experienced fetal deaths, of which fetal deaths later (! weeks) represented . % of the total number of deaths. among the controls, . % delivered during hospitalization, with one twin birth. regarding the neonatal outcome in this group, there were . % fetal deaths and . % live births. considering the live births that occurred during hospitalization, in % of cases and in . % of controls a cesarean delivery was performed. the distribution of gestational outcomes shows a concentration of miscarriages and premature births among cases compared to controls who delivered during hospitalization: . % and . %, respectively (p = . ). among the controls who were discharged before delivery and who completed a home interview, % had live births, . % by cesarean delivery and . % at term. regarding the live births, among the cases, there was predominance of gestational age at birth between the nd and th weeks of pregnancy ( . %), and among the controls who delivered during hospitalization, . % occurred at weeks and over (p = . ). among the controls that gave birth after hospital discharge, . % of births were full term (! th week). analyzing the weight of live births, there was a higher proportion of low birthweight (< , g) among cases ( . %) than among controls who gave birth during hospitalization ( . %), p = . . considering control women who delivered after discharge, low birthweight occurred in only . % of the births. during hospitalization, . % ( in ; and days after birth) of the live births of cases and . % ( in ; days after birth) of live births of controls evolved to death after giving birth. none of the live births of control women who delivered after discharge evolved to death. the median gestational age, birth weight and apgar score in the st minute were significantly lower among cases than among controls who delivered during hospitalization. among the cases, . % of the newborns were admitted to the intensive care unit (icu), contrasting to only . % of newborns from controls who delivered during the hospitalization. when the weight of the newborns was compared with the gestational age, . % of newborns from cases were classified as small for the gestational age, and . % and . % of those from controls who gave birth during and after hospitalization, respectively, as shown in table . severe influenza a(h n ) in pregnant women the case control design, including all reported deaths of hospitalized patients who presented with laboratory confirmed influenza a(h n )pdm with sari in the state of são paulo, and the random selection of four controls for each case, with the collection of hospital data and home interviews, allowed for the expansion of the analysis of risk factors for death. it was possible to evaluate the gestational and neonatal outcomes, including those of pregnant women who delivered after hospital discharge. the main results suggest that an early search for care, the training of physicians for the proper treatment of pregnant women, and early antiviral administration can be protective factors against death. another noteworthy result was the presence of unfavorable neonatal outcomes, with a significant proportion of stillbirths and miscarriages, low birth weights and lower apgar scores among pregnant women who died. after hospital discharge, the patients had a favorable neonatal outcome. pre-eclampsia was present in six percent of women who evolved to death and in less than one percent of those who survived. despite the fact that all women who died had the influenza a (h n )pdm infection as the main cause of death in their death certificate, we cannot rule out the possibility that pre-eclampsia may have contributed to their unfavourable outcome. age distribution and race were not associated with a risk of death in pregnant women, similar to results in other studies [ , , ] . the third trimester of gestation lost its significance as risk factor for death in the multiple analyses, when antivirus treatment was included in the model. a higher proportion of women in the final period of gestation received the treatment after hours of symptoms than those who were at earlier stages of gestation. a meta-analysis study showed that the third trimester of gestation was a risk factor for death (or . , % ci . - . ) for pandemic influenza, when compared with those in the first or second trimester [ ] . although the present study did not confirm the association with the third trimester of gestation, its result indicates that it is important to monitor pregnant women with influenza illness, with special attention during this trimester, for diagnosis and early treatment. the pregnant women who had a previous health visit to a healthcare provider for the influenza episode before hospitalization had a higher risk of death. this increased risk could be an indication of difficulties in accessing hospitalization or lack of perception of the severity of the case by doctors or lack of recognition that, even in cases that are not serious, considering that pregnant women are in a high risk group for severity of the disease, early antiviral therapy should have been introduced. the median time between the first symptoms and hospitalization was twice as high among pregnant women who died. similar results were found when patients in general with influenza during the pandemic were evaluated in são paulo [ ] and in mexico [ ] . these findings also reinforce the need for pregnant women to have access to health services, particularly hospitalization in serious cases. the training of physicians concerning the proper care for pregnant women and the need to start early treatment are as important as the early search for care. the use of an antiviral medication was a protective factor death when administered within hours of symptom onset. several studies have shown an increased risk of death or worsening disease in pregnant women who started treatment late [ , , , , , , ] and in patients in general [ , , , , , , , ] . regarding the history of previous diseases, no differences in the presence of risk conditions for developing influenza-related complications were found between pregnant women who eventually died and those who recovered. however, surveillance showed a higher proportion of risk conditions among pregnant women who eventually died compared to those who survived [ ] . a study in china showed that obesity (bmi ! ) was a factor associated with mortality in patients with severe disease [ ] . this result is in line with the current study. although it was not possible to calculate bmi, a higher rate of obesity among the cases than among the controls was reported. there were a higher proportion of cases with co-infections than controls, consistent with other reported results [ ] . the patients who eventually died presented significant alterations in laboratory values when compared to controls. the alterations observed in cpk, ldh, platelets and creatinine were similar to those reported for patients in general [ , , , , ] . in pregnant women, there was also a decrease in the number of red blood cells. in relation to neonatal outcomes, there were a greater proportion of fetal deaths in patients who died than in controls that delivered either during hospitalization or after discharge. among the live births in the cases, there was a greater proportion of low birth weight, gestational age less than weeks, admitted to icu, lower scores on the apgar scale, when compared to the live births of controls that delivered during or after hospitalization. similar results were reported in studies that evaluated pregnant women infected with influenza a(h n ) pdm compared to women of childbearing age without infection [ ] , pregnant women with influenza a(h n )pdm with severe disease [ , ] or women who gave birth to live newborns during hospitalization [ , ] . control women who delivered after discharge from the hospital had favorable outcomes in their offspring, with a median apgar of both in the st and th minutes of life. considering all births in the state of são paulo during , according to the national system of live births-sinasc, % were delivered by cesarean, % were preterm birth (< weeks) and % had low birthweight ( g). in the control women of the study who gave birth after hospitalization, these proportions were also high ( . %, . % and . %, respectively). this study has limitations. underreporting of sari by health professionals as well as gaps in the sinan may have occurred. the notification of influenza through a new viral subtype associated with sari was initiated during the pandemic; consequently, the sensitivity may have varied with time. the quality of information from medical records can differ between hospitals. the use of standardized hospital and home questionnaires minimized these difficulties during data collection. although all hospital reports were reviewed, we were not able to establish the roles of other factors, such as secondary infections or obstetric factors, which could have contributed to death in the cases. the results presented in this study indicate that early treatment can prevent unfavorable outcomes in pregnant women and in their offspring and reinforce the need for the proper training of doctors for the clinical management of pregnant women and early administration of antiviral treatment. these findings also support interventions in situations of future pandemics and seasonal influenza with the goals of preventive 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australasian maternity outcomes surveillance system. critical illness due to a/h n influenza in pregnant and postpartum women population based cohort study we would like to thank the sao paulo state secretary of health, the santa casa de são paulo medical school for the collaboration in the preparation of the project. this study would not possible without the collaborations of the researchers and field coordinators, the epidemiological surveillance center, the disease control coordination, the adolfo lutz institute, municipal departments of health for data collection. we would also like to thank all those who contributed to this study, especially luiz roberto barradas barata (in memoriam). key: cord- -tpqsjjet authors: nan title: section ii: poster sessions date: - - journal: j urban health doi: . /jurban/jti sha: doc_id: cord_uid: tpqsjjet nan food and nutrition programs in large urban areas have not traditionally followed a systems approach towards mitigating food related health issues, and instead have relied upon specific issue interventions char deal with downstream indicators of illness and disease. in june of , the san francisco food alliance, a group of city agencies, community based organizations and residents, initiated a collahorarive indicator project called rhe san francisco food and agriculture assessment. in order to attend to root causes of food related illnesses and diseases, the purpose of the assessment is to provide a holistic, systemic view of san francisco\'s food system with a focus on three main areas that have a profound affect on urban public health: food assistance, urban agriculture, and food retailing. using participatory, consensus methods, the san francisco food alliance jointly developed a sec of indicators to assess the state of the local food system and co set benchmarks for future analysis. members collected data from various city and stare departments as well as community based organizations. through the use of geographic information systems software, a series of maps were created to illustrate the assets and limitations within the food system in different neighborhoods and throughout the city as a whole. this participatory assessment process illustrates how to more effectively attend to structural food systems issues in large urban areas by ( t) focusing on prevention rather than crisis management, ( ) emphasizing collaboration to ensure institutional and structural changes, and ( ) aptly translating data into meaningful community driven prevention activities. to ~xplore the strategies to overcome barriers to population sample, we examined the data from three rapid surveys conducted at los angeles county (lac). the surveys were community-based partic· patory surveys utilizing a modified two-stage cluster survey method. the field modifications of the method resulted in better design effect than conventional cluster sample survey (design effect dose to that if the survey was done as simple random sample survey of the same size). the surveys were con· ducte~ among parents of hispanic and african american children in lac. geographic area was selected and d .v ded int.o small c~usters. in the first stage, clusters were selected with probability proportionate to estimated size of children from the census data. these clusters were enumerated to identify and develop a list of households with eligible children from where a random sample was withdrawn. data collectmn for consented respondents involved - minutes in-home interview and abstraction of infor· ma~ion from vaccine record card. the survey staff had implemented community outreach activities designed to fost~r an~ maintain community trust and cooperation. the successful strategies included: developing re.lat on .w. th local community organizations; recruitment of community personnel and pro· vide them with training to conduct the enumeration and interview; teaming the trained community introduction: though much research has been done on the health and social benefits of pet ownership for many groups, there have been no explorations of what pet ownership can mean to adults who are marginalized, living on fixed incomes or on the street in canada. we are a community group of researchers from downtown toronto. made up of front line staff and community members, we believe that community research is important so that our concerns, visions, views and values are presented by us. we also believe that research can and should lead to social change. method: using qualitative and exploratory methods, we have investigated how pet ownership enriched and challenged the lives of homeless and transitionally housed people. our research team photographed and conducted one-on-one interviews with pet owners who have experienced home· lessncss and live on fixed incomes. we had community participation in the research through a partnership with the fred vicror centre camera club. many of the fred victor centre camera club members have experienced homelessness and being marginalized because of poverty. the members of the dub took the photos and assisted in developing the photos. they also participated in the presenta· tion of our project. results: we found that pet ownership brings important health and social benefits to our partici· pants. in one of the most poignant statements, one participant said that pet ownership " ... stops you from being invisible." another commented that "well, he taught me to slow down, cut down the heavy drugs .. " we also found that pet ownership brings challenges that can at times be difficult when one is liv· ing on a fixed income. we found that the most difficult thing for most of the pet owners was finding affordable vet care for their animals. conclusion: as a group, we decided that research should only be done if we try to make some cha.nges about what we have learned. we continue the project through exploring means of affecting social change--for example, ~eti.tions and informing others about the result of our project. we would like to present our ~mdmgs and experience with community-based participatory action resea.rch m an oral. presentarton at yo~r conference in october. our presentation will include com· mumty representation ~f. both front-hne staff and people with lived experience of marginalization and homdessness. if this is not accepted as an oral presentation, we are willing to present the project m poster format. introduction the concept of a healthy city was adopted by the world health organization some time ago and it includes strong support for local involvement in problem solving and implementation of solutions. while aimed at improving social, economic or environmental conditions in a given community, more significantly the process is considered to be a building block for poliq reform and larger scale 'hange, i.e. "acting locally while thinking globally." neighbourhood planning can he the entry point for citizens to hegin engaging with neighbours on issues of the greater common good. methods: this presentation will outline how two community driven projects have unfolded to address air pollution. the first was an uphill push to create bike lanes where car lanes previously existed and the second is an ongoing, multi-sectoral round table focused on pollution and planning. both dt•monstrate the importance of having support with the process and a health focus. borrowing from traditions of "technical aid"• and community development the health promoter /planner has incorporated a range of "determinants of health" into neighbourhood planning discussions. as in most urban conditions the physical environment is linked to a range of health stressors such as social isolation, crowding, noise, lack of open space /recreation, mobility and safety. however typical planning processes do not hring in a health perspective. health as a focus for neighbourhood planning is a powerful starti_ng point when discussing transportation planning or changing land-uses. by raising awareness on determmants of health, citizens can begin to better understand how to engage in a process and affect change. often local level politics are involved and citizens witness policy change in action. the environmental liaison committee and the dundas east hike lanes project resulted from local level initiatives aimed at finding solutions to air pollution -a priority identified hy the community. srchc supported the process with facilitation and technical aid. _the processs had tangible results that ultimately improve living conditions and health. •tn the united kmgdom plannm in the 's established "technical aid" offices much like our present day legal aid system to provide professional support and advocacy for communities undergoing change. p - (c) integrating community based research: the experience of street health, a community service agency i.aura cowan and jacqueline wood street health began offering services to homeless men and women in east downtown ~oronto in . nursing stations at drop-in centres and shelters were fo~lowed by hiv/aids prevent ~, harm reduction and mental health outreach, hepatitis c support, sleeping bag exchange, and personal tdennfication replacement and storage programs. as street health's progi;ams expanded, so to~ did the agency:s recognition that more nee~ed t~ be done to. address the underl~ing causes of, th~ soct~l and economic exclusion experienced by its clients. knowing t.h~t. a~voca~y ts. helped by . evtd~nce , street he.alt~ embarked on a community-based research (cbr) initiative to dent fy commumty-dnven research priorities within the homeless and underhoused population. methods: five focus groups were conducted with homeless people, asking participants to identify positive and negative forces in their lives, and which topics were important to take action on and learn more about. findings were validated through a validation meeting with participants. results: participants identified several important positive and negative forces in their lives. key positive forces included caring and respectful service delivery, hopefulness and peer networks. key negative forces included lack of access to adequate housing and income security, poor service delivery and negative perceptions of homeless people. five topics for future research emerged from the process, focusing on funding to address homelessness and housing; use of community services for homeless people; the daily survival needs of homeless people and barriers to transitioning out of homelessness; new approaches to service delivery that foster empowerment; and policy makers' understanding of poverty and homelessness. conclusions: although participants expressed numerous issues and provided much valuable insight, definitive research ideas and action areas were not clearly identified by participants. however, engagement in a cbr process led to some important lessons and benefits for street health. we learned that the community involvement of homeless people and front-line staff is critical to ensuring relevance and validity for a research project; that existing strong relationships with community parmers are essential to the successful implementation of a project involving marginalized groups; and that an action approach focusing on positive change can make research relevant to directly affected people and community agency staff. street health benefited from using a cbr approach, as the research process facilitated capacity building among staff and within the organization as a whole. p - (c) a collaborative process to achieve access to primary health care for black women and women of colour: a model of community based participartory research notisha massaquoi, charmaine williams, amoaba gooden, and tulika agerwal in the current healthcare environment, a significant number of black women and women of color face barriers to accessing effective, high quality services. research has identified several issues that contribute to decreased access to primary health care for this population however racism has emerged as an overarching determinant of health and healthcare access. this is further amplified by simultaneous membership in multiple groups that experience discrimination and barriers to healthcare for example those affected by sexism, homelessness, poverty, homophobia and heterosexism, disability and hiv infection. the collaborative process to achieve access to primary health care for black women and women of colour project was developed with the university of toronto faculty of social work and five community partners using a collaborative methodology to address a pressing need within the community ro increase access to primary health care for black women and women of colour. women's health in women's hands community health centre, sistering, parkdale community health centre, rexdale community health centre and planed parenthood of toronto developed this community-based participatory-action research project to collaboratively barriers affecting these women, and to develop a model of care that will increase their access to health services. this framework was developed using a process which ensured that community members from the target population and service providers working in multiculrural clinical settings, were a part of the research process. they were given the opportunity to shape the course of action, from the design of the project to the evaluation and dissemination phase. empowerment is a goal of the participatory action process, therefore, the research process has deliberately prioritized _ro enabling women to increase control over their health and well-being. in this session, the presenters will explore community-based participatory research and how such a model can be useful for understanding and contextualizing the experiences of black women and women of colour. they will address. the development and use of community parmerships, design and implementation of the research prorect, challenges encountered, lessons learnt and action outcomes. they will examine how the results from a collaborative community-based research project can be used as an action strategy to poster sessions v address che social determinants of women health. finally the session will provide tools for service providers and researchers to explore ways to increase partnerships and to integrate strategies to meet the needs of che target population who face multiple barriers to accessing services. lynn scruby and rachel rapaport beck the purpose of this project was ro bring traditionally disenfranchised winnipeg and surrounding area women into decision-making roles. the researchers have built upon the relationships and information gachered from a pilot project and enhanced the role of input from participants on their policy prioriries. the project is guided by an advisory committee consisting of program providers and community representatives, as well as the researchers. participants included program users at four family resource cencres, two in winnipeg and two located rurally, where they participated in focus groups. the participants answered a series of questions relating to their contact with government services and then provided inpuc as to their perceptions for needed changes within government policy. following data analysis, the researchers will return to the four centres to share the information and continue che discussion on methods for advocating for change. recommendations for program planning and policy development and implementation will be discussed and have relevance to all participants in the research program. women's health vera lefranc, louise hara, denise darrell, sonya boyce, and colleen reid women's experiences with paid and unpaid work, and with the formal and informal economies, have shifted over the last years. in british columbia, women's employability is affected by government legislation, federal and provincial policy changes, and local practices. two years ago we formed the coalition ior women's economic advancement to explore ways of dealing with women's worsening economic situations. since the formation of the coalition we have discussed the need for research into women's employabilicy and how women were coping and surviving. we also identified how the need to document the nature of women's employability and reliance on the informal economy bore significanc mechodological and ethical challenges. inherent in our approach is a social model of women's health that recognizes health as containing social, economic, and environmental determinants. we aim to examine the social contexc of women's healch by exploring and legitimizing women's own experiences, challenging medical dominance in understandings of health, and explaining women's health in terms of their subordination and marginalizacion. through using a feminist action research (far) methodology we will explore the relationship between women's employability and health in communities that represent bricish columbia's social, economic, cultural/ethnic, and geographic diversities: skidegate, fort st . .john, lumhy, and surrey. over the course of our year project, in each community we will establish and work with advisory committees, hire and train local researchers, conduct far (including a range of qualitative methods), and support action and advocacy. since the selected communities are diverse, the ways that the research unfolds will ·ary between communities. expected outcomes, such as the provision of a written report and resources, the establishment of a website for networking among the communities, and a video do.:umentary, are aimed at supporting the research participants, coalition members, and advisory conuniuces in their action efforts. p t (c) health & housing: assessing the impact of transitional housing for people living with hiv i aids currently, there is a dearth of available literature which examines supporrive housing for phas in the canadian context. using qualitative, one-on-one interviews we investigace the impact of transitional housing for phaswho have lived in the up to nine month long hastings program. our post<'r pr<·senta-t on will highlight research findings, as well as an examination of transitional housing and th<· imp;kt it has on the everyday lives of phas in canada. this research is one of two ground breaking undertakings within the province of ontario in which fife house is involved. p - (c) eating our way to justice: widening grassroots approaches to food security, the stop community food centre as a working model charles l.evkoe food hanks in north america have come co play a central role as the widespread response to growing rates of hunger. originally thought to be a short term-solution, over the last years, they have v poster sessions be · · · · d wi'thi'n society by filling the gaps in the social safety net while relieving govemcome mst tut ona ze . . . t f the ir responsibilities. dependent on corporate donations and sngmauzmg to users, food banks men so th' . · i i . are incapable of addressing the structural cause~ of ~u~ger. s pres~ntation w e~~ ore a ternanve approaches to addressing urban food security while bmldmg more sustamabl.e c~mmumt es. i:nrough the f t h st p community food centre, a toronto-based grassroots orgamzanon, a model is presented case e h'l k' b 'id · b that both responds to the emergency food needs of communities w e wor mg to. u ~ sustama le and just food system. termed, the community food centre model. (cfc), ~he s~op is worki?g to widen its approach to issues of food insecurity by combining respectful ~ rect service wit~ com~~mty ~evelop ment, social justice and environmental sustainability. through this approach, various critical discourses around hunger converge with different strategic and varied implications for a~ion. as a plac~-based organization, the stop is rooted within a geographical space and connected directly to a neighbourhood. through working to increase access to healthy food, it is active in maintaining people's dignity, building a strong and democratic community and educating for social change. connected to coalitions and alliances, the stop is also active in organizing across scales in connection with the global food justice movement. inner city shelter vicky stergiopoulos, carolyn dewa, katherine rouleau, shawn yoder, and lorne tugg introduction: in the city of toronto there are more than , hostel users each year, many with mental health and addiction issues. although shelters have responded in various ways to the health needs of their clients, evidence on the effectiveness of programs delivering mental health services to the home· less in canada has been scant. the objective of this community based research was to provide a forma· tive evaluation of a multi-agency collaborative care team providing comprehensive care for high needs clients at toronto's largest shelter for homeless men. methods: a logic model provided the framework for analysis. a chart review of clients referred over a nine month period was completed. demographic data were collected, and process and outcome indicators were identified for which data was obtained and analyzed. the two main outcome measures were mental status and housing status months after referral to the program. improvement or lack of improvement in mental status was established by chart review and team consensus. housing outcomes were determined by chart review and the hostel databases. results: of the clients referred % were single and % were unemployed. forty four percent had a psychiatric hospitalization within the previous two years. the prevalence of severe and persistent men· tal illness, alcohol and substance use disorders were %, % and % respectively. six months after referral to the program % of clients had improved mental status and % were housed. logistic regression controlling for the number of general practitioner and psychiatrist visits, presence of person· ality or substance use disorder and treatment non adherence identified two variables significantly associ· ated mental status improvement: the number of psychiatric visits (or, . ; % ci, . - . ) and treatment non adherence (or, . ; % ci, . - . ). the same two variables were associated with housing outcomes. history of forensic involvement, the presence of a personality or substance use disorder and the number of visits with a family physician were not significantly associated with either outcome. conclusions: despite the limitations in sample sire and study design, this study can yield useful informa· tion to program planners. our results suggest that strategies to improve treatment adherence and access to mental health specialists can improve outcomes for this population. although within primary care teams the appropriate collaborative care model for this population remains to be established, access to psychiatric follow up, in addition to psychiatric assessment services, may be an important component of a successful program. mount sinai hospital (msh) has become one of the pre-eminent hospitals in the world by contributing to the development of innovative approaches to effective health care and disease prevention. recently, the hospital has dedicated resources towards the development of a strategy aimed at enhancing the hospital's integration with its community partners. this approach will better serve the hospital in the current health care environment where local health integration networks have been struck to enhance and support local capacity to plan, coordinate and integrate service delivery. msh has had early success with developing partnerships. these alliances have been linked to programs serving key target populations with _estabhshe~. points of access to msh. recognizing the need to build upon these achievements to remain compe~mve, the hospital has developed a community integration strategy. at the forefront of this strategy is c.a.r.e (community advisory reference engine): the hospital's compendium of poster sessions v community partners. as a single point of access to community partner information, c.a.r.e. is more than a database. c.a.r.e. serves as the foundation for community-focused forecasting and a vehicle for inter and intra-organizational knowledge transfer. information gleaned from the catalog of community parmers can be used to prepare strategic, long-term partnership plans aimed at ensuring that a comprehensive array of services can be provided to the hospital community. c.a.r.e. also houses a permanent record of the hospital's alliances. this prevents administrative duplication and facilitates the formation of new alliances that best serve both the patient and the hospital. c.a.r.e. is not a stand-alone tool and is most powerful when combined with other aspects of the hospital's community integration strategy. it iscxpected that data from the hospital's community advisory committees and performance measurement department will also be stored alongside stakeholder details. this information can then be used to drive discussions at senior management and the board, ensuring congruence between stakeholder, patient and hospital objectives. the patient stands to benefit from this strategy. the unique, distinct point of reference to a wide array of community services provides case managers and discharge planners with the information they need to connect patients with appropriate community services. creating these linkages enhances the patient's capacity to convalesce in their homes or places of residence and fosters long-term connections to neighborhood supports. these connections can be used to assist with identifying patients' ongoing health care needs and potentially prevent readmission to hospital. introduction: recruiting high-risk drug users and sex workers for hiv-prevention research has often been hampered by limited access to hard to reach, socially stigmatized individuals. our recruitment effom have deployed ethnographic methodology to identify and target risk pockets. in particular, ethnographers have modeled their research on a street-outreach model, walking around with hiv-prevention materials and engaging in informal and structured conversations with local residents, and service providers, as well as self-identified drug users and sex workers. while such a methodology identifies people who feel comfortable engaging with outreach workers, it risks missing key connections with those who occupy the margins of even this marginal culture. methods: ethnographers formed a women's laundry group at a laundromat that had a central role as community switchboard and had previously functioned as a party location for the target population. the new manager helped the ethnographers invite women at high risk for hiv back into the space, this time as customers. during weekly laundry sessions, women initiated discussions about hiv-prevention, sexual health, and eventually, the vaccine research for which the center would be recruiting women. ra.its: the benefits of the group included reintroducing women to a familiar locale, this time as customers rather than unwelcome intruders; creating a span of time (wash and dry) to discuss issues important to me women and to gather data for future recruitment efforts; creating a location to meet women encountered during more traditional outreach research; establishing the site as a place for potential retention efforts; and supporting a local business. women who participated in the group completed a necessary household task while learning information that they could then bring back to the community, empowering them to be experts on hiv-prevention and vaccine research. some of these women now assist recruitment efforts. the challenges included keeping the group women-only, especially after lunch was provided, keeping the membership of the group focused on women at risk for hiv, and keeping the women in the group while they did their laundry. conclusion: public health educators and researchers can benefit from identifying alternate congregation sites within risk pockets to provide a comfortable space to discuss hiv prevention issues with high-risk community members. in our presentation, we will describe the context necessary for similar research, document the method's pitfalls and successes, and argue that the laundry group constitutes an ethical, respectful, community-based method for recruitment in an hiv-prevention vaccine trial. p - t (c) upgrading inner city infrastructure and services for improved environmental hygiene and health: a case of mirzapur in u.p. india madhusree mazumdar in urgency for agricultural and industrial progress to promote economic d.evelopment follo_wing independence, the government of india had neglected health promotion and given less emphasis on infrastructure to promote public health for enhanced human pro uct v_ity. ong wit r~p m astrucrure development, which has become essential if citie~ are to. act ~s harbmger.s of econ~nuc ~owth, especially after the adoption of the economic liberalization policy, importance _is a_lso ~emg g ve.n to foster environmental hygiene for preventive healthcare. the world health orga~ sat ~ is also trj:' ! g to help the government to build a lobby at the local level for the purpose by off~rmg to mrroduce_ its heal.thy city concept to improve public health conditions, so as to reduce th_e disease burden. this pape~ s a report of the efforts being made towards such a goal: the paper descr~bes ~ c~se study ?f ~ small city of india called mirzapur, located on the banks of the nver ganga, a ma or lifeline of india, m the eastern part of the state of uttar pradesh, where action for improvement began by building better sanitation and environmental infrastructure as per the ganga action plan, but continued with an effort to promote pre· ventive healthcare for overall social development through community participation in and around the city. asthma physician visits in toronto, canada tara burra, rahim moineddin, mohammad agha, and richard glazier introduction: air pollution and socio-economic status are both known to be associated with asthma in concentrated urban settings but little is known about the relationship between these factors. this study investigates socio-economic variation in ambulatory physician consultations for asthma and assesses possible effect modification of socio-economic status on the association between physician visits and ambient air pollution levels for children aged to and adults aged to in toronto, canada between and . methods: generalized additive models were used to estimate the adjusted relative risk of asthma physician visits associated with an interquartile range increase in sulphur dioxide, nitrogen dioxide, pm . , and ozone, respectively. results: a consistent socio-economic gradient in the number of physician visits was observed among children and adults and both sexes. positive associations between ambient concentrations of sul· phur dioxide, nitrogen dioxide and pm . and physician visits were observed across age and sex strata, whereas the associations with ozone were negative. the relative risk estimates for the low socio-«onomic group were not significantly greater than those for the high socio-economic group. conclusions: these findings suggest that increased ambulatory physician visits represent another component of the public health impact of exposure to urban air pollution. further, these results did not identify an age, sex, or socio-economic subgroup in which the association between physician visits and air pollution was significantly stronger than in any other population subgroup. eco-life-center (ela) in albania supports a holistic approach to justice, recognizing the environ· mental justice, social justice and economic justice depend upon and support each other. low income cit· izens and minorities suffer disproportionately from environmental hazards in the workplace, at home, and in their communities. inadequate laws, lax enforcement of existing environmental regulations, and ~ea.k penalties for infractions undermine environmental protection. in the last decade, the environmental ust ce m~ve~ent in tirana metropolis has provided a framework for identifying and exposing the links ~tween irrational development practices, disproportionate siting of toxic facilities, economic depres· s on, and a diminished quality of life in low-income communities and communities of color. the envi· ~onmental justice agenda has always been rooted in economic, racial, and social justice. tirana and the issues su.rroun~ing brow~fields redevelopment are crucial points of advocacy and activism for creating ~ubstantia~ social chan~~ m low-income communities and communities of color. we engaging intensively m prevcnnng co'.' mumnes, especially low income or minority communities, from being coerced by gov· ernmenta~ age_nc es or companies into siting hazardous materials, or accepting environmentally hazard· ous_ practices m order to create jobs. although environmental regulations do now exist to address the environmental, health, and social impacts of undesirable land uses, these regulations are difficult to poster sessions v enforce because many of these sites have been toxic-ridden for many years and investigation and cleanup of these sites can be expensive. removing health risks must be the main priority of all brown fields action plans. environmental health hazards are disproportionately concentrated in low-income communities of color. policy requirements and enforcement mechanisms to safeguard environmental health should be strengthened for all brownfields projects located in these communities. if sites are potentially endangering the health of the community, all efforts should be made for site remediation to be carried out to the highest cleanup standards possible towards the removal of this risk. the assurance of the health of the community should take precedence over any other benefits, economic or otherwise, expected to result from brownfields redevelopment. it's important to require from companies to observe a "good neighbor" policy that includes on-site visitations by a community watchdog committee, and the appointment of a neighborhood environmentalist to their board of directors in accordance with the environmental principles. vancouver - michael buzzelli, jason su, and nhu le this is the second paper of research programme concerned with the geographical patterning of environmental and population health at the urban neighbourhood scale. based on the vancouver metropolitan region, the aim is to better understand the role of neighbourhoods as epidemiological spaces where environmental and social characteristics combine as health processes and outcomes at the community and individual levels. this paper builds a cohort of commensurate neighbourhoods across all six censuses periods from to , assembles neighbourhood air pollution data (several criterion/health effects pollutants), and providing an analysis to demonstrate how air pollution systematically and consistently maps onto neighbourhood socioeconomic markers, in this case low education and lone-parent families. we conclude with a discussion of how the neighbourhood cohort can be further developed to address emergent priorities in the population and environmental health literatures, namely the need for temporally matched data, a lifecourse approach, and analyses that control for spatial scale effects. solid waste management and environment in mumbai (india) by uttam jakoji sonkamble and bairam paswan abstract: mumbi is the individual financial capital of india. the population of greater mumbai is , , and sq. km. area. the density of population , per sq. km. the dayto-day administration and rendering of public services within gr. mumbai is provided by the brihan mumbai mahanagar palika (mumbai corporation of gr. mumbai) that is a body of elected councilors on a -year team. mumcial corporation provides varies conservancy services such as street sweeping, collection of solid waste, removal and transportation, disposal of solid waste, disposal of dead bodies of animals, construction, maintance and cleaning of urinals and public sanitary conveniences. the solid waste becoming complicated due to increase in unplanned urbanization and industrialization, the environment has deteriorated significantly due to inter, intra and international migration stream to mumbai. the volume of inter state migration to mumbai is considerably high i.e. . lakh and international migrant . lakh have migrated to mumbai. present paper gives the view on solid waste management and its implications to environment and health. pollution from a wide varity of emission, such as from automobiles and industrial activities, has reached critical level in mumbai, causing respiratory, ocular, water born diseases and other health problems. sources of generation of waste are -household waste, commercial waste, institutional waste, street sweeping, silt removed from drain/nallah/cleanings. disposal of solid waste in gr. mumbai done under incineration . processing to produce organic manure. . vermi-composting . landfill the study shows that the quantity of waste disposal of through processing and conversion to organic ~anure is about - m.t. per day. the processing is done by a private agency m/s excel industries ltd. who had set up a plant at the chincholi dumping ground in western mumbai for this purpose. the corporation is also disposal a plant of its waste mainly market waste through the environment friendly, natural pro-ces~ known as vermi-composing about m.t. of market waste is disposed of in this manner at the various sites. there are four land fill sites are available and percent of the waste matter generated m mumbai is disposed of through landfill. continuous flow of migrant and increa~e in slum population is a complex barrier in the solid waste management whenever community pamc pat on work strongly than only we can achieved eco-friendly environment in mumbai. persons exposed to residential craffic have elevated races of respiratory morbidity an~ ~ortality. since poverty is an important determinant of ill-health, some h~ve argued that t~es~ assoc at ons may relate to che lower socioeconomic status of those living along ma or roads. our ob ect ve was to evaluate the association between traffic intensity at home and hospital admissions for respiratory diagnoses among montreal residents older than years. morning peak traffic estimates from the emmej montreal traffic model (motrem ) were used as an indicator of exposure to road traffic outside the homes of those hospitalised. the influence of socioeconomic status on the relationship between traffic intensity and hospital admissions for respiratory diagnoses was explored through assessment of confounding by lodging value, expressed as the dollar average over road segments. this indicator of socioeconomic status, as calculated from the montreal property assessment database, is available at a finer geographic scale than socioeconomic information accessible from the canadian census. there was an inverse relationship between traffic intensity estimates and lodging values for those hospitalised (rho - . , p vehicles during che hour morning peak), even after adjustment for lodging value (crude or . , cl % . - . ; adjusted or . , cl % . - . ). in montreal, elderly persons living along major roads are at higher risk of being hospitalised for respiratory illnesses, which appears not simply to reflect the fact that those living along major roads are at relative economic disadvantage. the paper argues that human beings ought to be at the centre of the concern for sustainable development. while acknowledging the importance of protecting natural resources and the ecosystem in order to secure long term global sustainability, the paper maintain that the proper starting point in the quest for urban sustainability in africa is the 'brown agenda' to improve che living and working environment of che people, especially che urban poor who face a more immediate environmental threat to their health and well-being. as the un-habitat has rightly observed, it is absolutely essential "to ensure that all people have a sufficient stake in the present to motivate them to take part in the struggle to secure the future for humanity.~ the human development approach calls for rethinking and broadening the narrow technical focus of conventional town planning and urban management in order to incorporate the emerging new ideas and principles of urban health and sustainability. i will examine how cities in sub-saharan africa have developed over the last fifty years; the extent to which government policies and programmes have facilitated or constrained urban growth, and the strategies needed to achieve better functioning, safer and more inclusive cities. in this regard i will explore insights from the united nations conferences of the s, especially local agenda of the rio summit, and the istanbul declaration/habitat agenda, paying particular attention to the principles of enablement, decentralization and partnership canvassed by these movements. also, i will consider the contributions of the various global initiatives especially the cities alliance for cities without slums sponsored by the world bank and other partners; che sustainable cities programme, the global campaigns for good governance and for secure tenure canvassed by unhabit at, the healthy cities programme promoted by who, and so on. the concluding section will reflect on the future of the african city; what form it will take, and how to bring about the changes needed to make the cities healthier, more productive and equitable, and better able to meet people's needs. heather jones-otazo, john clarke, donald cole, and miriam diamond urban areas, as centers of population and resource consumption, have elevated emissions and concentrations of a wide range of chemical contaminants. we have developed a modeling framework in which we first ~stimate the emissions and transport of contaminants in a city and second, use these estimates along with measured contaminant concentrations in food, to estimate the potential health risk posed by these che.micals. the latter is accomplished using risk assessment. we applied our modeling framework to consider two groups of chemical contaminants, polycyclic aromatic hydrocarbons (pah) a.nd the flame re~ardants polybrominated diphenyl ethers (pbde). pah originate from vehicles and stationary combustion sources. ~veral pah are potent carcinogens and some compounds also cause noncancer effects. pbdes are additive flame retardants used in polyurethane foams (e.g., car seats, furniture) fer sessions v and cl~ equipm~nt (e.g., compute~~· televisio~s). two out of three pbdes formulations are being voluntarily phased by mdustry due to rmng levels m human tissues and their world-wide distribution. pbdes have been .related to adv.erse neurological, developmental and reproductive effects in laboratory ijlimals. we apphed our modelmg framework to the city of toronto where we considered the southcattral area of by km that has a population of . million. for pah, local vehicle traffic and area sources contribute at least half of total pah in toronto. local contributions to pbdes range from - %, depending on the assumptions made. air concentrations of both compounds are about times higher downtown than km north of toronto. although measured pah concentrations in food date to the s, we estimate that the greatest exposure and contribution to lifetime cancer risk comes from ingestion of infant formula, which is consistent with toxicological evidence. the next greatest exposure and cancer risk are attributable to eating animal products (e.g. milk, eggs, fish). breathing downtown air contributes an additional percent to one's lifetime cancer risk. eating vegetables from a home garden localed downtown contributes negligibly to exposure and risk. for pbdes, the greatest lifetime exposure comes through breast milk (we did not have data for infant formula), followed by ingestion of dust by the toddler and infant. these results suggest strategies to mitigate exposure and health risk. p - (a) immigration and socioeconomic inequalities in cervical cancer screening in toronto, canada aisha lofters, rahim moineddin, maria creatore, mohammad agha, and richard glazier llltroduction: pap smears are recommended for cervical cancer screening from the onset of sexual activity to age . socioeconomic and ethnoracial gradients in self-reported cervical cancer screening have been documented in north america but there have been few direct measures of pap smear use among immigrants or other socially disadvantaged groups. our purpose was to investigate whether immigration and socioeconomic factors are related to cervical cancer screening in toronto, canada. methods: pap smears were identified using fee codes and laboratory codes in ontario physician service claims (ohip) for three years starting in for women age - and - . all women with any health system contact during the three years were used as the denominator. social and economic factors were derived from the canadian census for census tracts and divided into quintiles of roughly equal population. recent registrants, over % of whom are expected to be recent immigrants to canada, were identified as women who first registered for health coverage in ontario after january , . results: among , women age - and , women age - , . % and . %, rtspcctively, had pap smears within three years. low income, low education, recent immigration, visible minority and non-english language were all associated with lower rates (least advantaged quintile:most advantaged quintile rate ratios were . , . , . , . , . , respectively, p < . for all). similar gradients were found in both age groups. recent registrants comprised . % of women and had mm;h lower pap smear rates than non-recent registrants ( . % versus . % for women age - and . % versus . % for women age - ). conclnsions: pap smear rates in toronto fall well below those dictated by evidence-based practice. at the area level, immigration, visible minority, language and socioeconomic characteristics are associated with pap smear rates. recent registrants, representing a largely immigrant group, have particularly low rates. efforts to improve coverage of cervical cancer screening need to be directed to all ~omen, their providers and the health system but with special emphasis on women who recently arrived m ontario and those with social and economic disadvantage. challeges faced: a) most of the resources are now being ~pent in ~reventing the sprea.d of hiv/ aids and maintaining the lives of those already affected. b) skilled medical ~rs~nal are dymg under· mining the capacity to provide the required health care services. ~) th.e comphcat o~s of hiv/aids has complicated the treatment of other diseases e.g. tbs d) the ep dem c has led. to mcrease number of h n requiring care and support. this has further stretched the resources available for health care. orp a s d db . . i methods used on our research: . a simple community survey con ucte y our orgamzat on vo · unteers in three urban centres members of the community, workers and health care prov~ders were interviewed ... . meeting/discussions were organized in hospitals, commun.ity centre a~d with government officials ... . written questionnaires to health workers, doctors and pohcy makers m th.e health sectors. lessors learning: • the biggest-health bigger-go towards hiv/aids prevention • aids are spreading faster in those families which are poor and without education. •women are the most affected. •all health facilities are usually overcrowded with hiv/aids patients. actions needed:• community education oh how to prevent the spread of hiv/aids • hiv/aids testing need to be encouraged to detect early infections for proper medical cover. • people to eat healthy • people should avoid drugs. implications of our research: community members and civic society-introduction of home based care programs to take care of the sick who cannot get a space in the overcrowded public hospitals. prl-v a te sector private sector has established programs to support and care for the staff already affected. government provision of support to care-givers, in terms of resources and finances. training more health workers. introduction: australian prisons contain in excess of , prisoners. as in most other western countries, reliance on 'deprivation of liberty' is increasing. prisoner numbers are increasing at % per annum; incarceration of women has doubled in the last ten years. the impacts on the community are great - % of children have a parent in custody before their th birthday. for aboriginal communities, the harm is greater -aboriginal and/or torres strait islanders are incarcerated at a rate ten times higher than other australians. % of their children have a parent in custody before their th birthday. australian prisons operate under state and territory jurisdictions, there being no federal prison system. eight independent health systems, supporting the eight custodial systems, have evolved. this variability provides an unique opportunity to assess the capacity of these health providers in addressing the very high service needs of prisoners. results: five models of health service provision are identified -four of which operate in one form or another in australia: • provided by the custodial authority (queensland and western australia)• pro· vided by the health ministry through a secondary agent (south australia, the australian capital territory and tasmania) • provided through tendered contract by a private organization (victoria and northern territory) • provided by an independent health authority (new south wales) • (provided by medics as an integral component of the custodial enterprise) since the model of the independent health authority has developed in new south wales. the health needs of the prisoner population have been quantified, and attempts are being made to quantify specific health risks /benefits of incarceration. specific enquiry has been conducted into prisoner attitudes to their health care, including issues such as client information confidentiality and access to health services. specific reference will be made to: • two inmate health surveys • two inmate access surveys, and • two service demand studies. conclusions: the model of care provision, with legislative, ethical, funding and operational independence would seem provide the best opportunity to define and then respond to the health needs of prisoners. this model is being adopted in the united kingdom. better health outcomes in this high-risk group, could translate into healthier families and their communities. p - (a) lnregrated ethnic-specific health care systems: their development and role in increasing access to and quality of care for marginalized ethnic minorities joshua yang introduction: changing demographics in urban areas globally have resulted in urban health systems that are racially and ethnically homogenous relative to the patient populations they aim to serve. the resultant disparities in access to and quality of health care experienced by ethnic minority groups have been addressed by short-term, instirutional level strategies. noticeably absent, however, have been structural approaches to reducing culturally-rooted disparities in health care. the development of ethnic-specific h~alth car~ systems i~ a structural, long-term approach to reducing barriers to quality health care for eth· me mmonty populations. methods: this work is based on a qualitative study on the health care experiences of san francisco chinatown in the united states, an ethnic community with a model ethnic-specific health care infrastrucrure. using snowball sampling, interviews were conducted with key stakeholders and archival research was conducted to trace and model the developmental process that led to the current ethnic-specific health care system available to the chinese in san francisco. grounded theory was the methodology ijltd to analysis of qualitative data. the result of the study is four-stage developmental model of ethnic-specific health infrastrueture development that emerged from the data. the first stage of development is the creation of the human capital resources needed for an ethnic-specific health infrastructure, with emphasis on a bilingual and bicultural health care workforce. the second stage is the effective organization of health care resources for maximal access by constituents. the third is the strengthening and stability of those institutional forms through increased organizational capacity. integration of the ethnic-specific health care system into the mainstream health care infrastructure is the final stage of development for an ethnic-specific infrastructure. conclusion: integrated ethnic-specific health care systems are an effective, long-term strategy to address the linguistic and cultural barriers that are being faced by the spectrum of ethnic populations in urban areas, acting as culturally appropriate points of access to the mainstream health care system. the model presented is a roadmap to empower ethnic communities to act on the constraints of their health and political environments to improve their health care experiences. at a policy level, ethnic-specific health care organizations are an effective long-term strategy to increase access to care and improve qualiiy of care for marginalized ethnic groups. each stage of the model serves as a target area for policy interventions to address the access and care issues faced by culturally and linguistically diverse populations. users in baltimore md: - noya galai, gregory lucas, peter o'driscoll, david celentano, david vlahov, gregory kirk, and shruti mehta introduction: frequent use of emergency rooms (er) and hospitalizations among injection drug users (idus) has been reported and has often been attributed to lack of access to primary health care. however, there is little longitudinal data which examine health care utilization over individual drug use careers. we examined factors associated with hospitalizations, er and outpatient (op) visits among idus over years of follow-up. methods: idus were recruited through community outreach into the aids link to lntravenous experience (alive) study and followed semi-annually. , who had at least follow-up visits were included in this analysis. outcomes were self-reported episodes of hospitalizations and er/op visits in the prior six months. poisson regression was used accounting for intra-person correlation with generalized estimation equations. hits: at enrollment, % were male, % were african-american, % were hiv positive, median age was years, and median duration of drug use was years. over a total of , visits, mean individual rates of utilization were per person years (py) for hospitalizations and per py for er/op visits. adjusting for age and duration of drug use, factors significantly associated with higher rates of hospitalization included hiv infection (relative incidence [ri(, . ), female gender (ri, . ), homelessness (ri, . ), as well as not being employed, injecting at least daily, snorting heroin, havmg a regular source of health care, having health insurance and being in methadone mainte.nance treatment (mmt). similar associations were observed for er/op visits except for mmt which was not associated with er/op visits. additional factors associated with lower er/op visits were use of alcohol, crack, injecting at least daily and trading sex for drugs. % of the cohort accounted for % of total er/op visits, while % of the cohort never reported an op visit during follow-up. . . . lgbt) populations. we hypothesized that prov dmg .appomtments .for p~t ~nts w thm hours would ensure timely care, increase patient satisfaction, and improve practice eff c ency. further, we anticipated that the greatest change would occur amongst our homeless patients.. . methods: we tested an experimental introduction of advanced access scheduling (usmg a hour rule) in the primary care medical clinic. we tracked variables inclu~ing waiting ti~e fo~ next available appointment; number of patients seen; and no-show rates, for an eight week penod pnor to and post introduction of the new scheduling system. both patient and provider satisfaction were assessed using a brief survey ( questions rated on a -pt scale). results and conclusion: preliminary analyses demonstrated shorter waiting times for appointments across the clinic, decreased no-show rates, and increased clinic capacity. introduction of the advanced access scheduling also increased both patient and provider satisfaction. the new scheduling was initiated in july . quantitative analyses to measure initial and sustained changes, and to look at differential responses across populations within our clinic, are currently underway. introduction: there are three recognized approaches to linking socio-economic factors and health: use of census data, gis-based measures of accessibility/availability, and resident self-reported opinion on neighborhood conditions. this research project is primarily concerned with residents' views about their neighborhoods, identifying problems, and proposing policy changes to address them. the other two techniques will be used in future research to build a more comprehensive image of neighborhood depri· vation and health. methods: a telephone survey of london, ontario residents is currently being conducted to assess: a) community resource availability, quality, access and use, b) participation in neighborhood activities, c) perceived quality of neighborhood, d) neighborhood problems, and e) neighborhood cohesion. the survey instrument is composed of indices and scales previously validated and adapted to reflect london specifically. thirty city planning districts are used to define neighborhoods. the sample size for each neighborhood reflects the size of the planning district. responses will be compared within and across neighborhoods. data will be linked with census information to study variation across socio-eco· nomic and demographic groups. linear and gis-based methods will be used for analysis. preliminary results: the survey follows a qualitative study providing a first look at how experts involved in community resource planning and administration and city residents perceive the availability, accessibility, and quality of community resources linked to neighborhood health and wellbeing, and what are the most immediate needs that should be addressed. key-informant interviews and focus groups were used. the survey was pre-tested to ensure that the language and content reflects real experiences of city residents. the qualitative research confirmed our hypothesis that planning districts are an acceptable surrogate for neighborhood, and that the language and content of the survey is appropriate for imple· mentation in london. scales and indices showed good to excellent reliability and validity during the pre· test (cronbach's alpha from . - . ). preliminary results of the survey will be detailed at the conference. conclusions: this study will help assess where community resources are lacking or need improve· ment, thus contributing to a more effective allocation of public funds. it is also hypothesized that engaged neighborhoods with a well-developed sense of community are more likely to respond to health programs and interventions. it is hoped that this study will allow london residents to better understand the needs and problems of their neighborhoods and provide a research foundation to support local understandmg of community improvement with the goal of promoting healthy neighborhoods. p - (a) hiv positive in new york city and no outpatient care: who and why? hannah wolfe and victoria sharp introduction: there are approximately million hiv positive individuals living in the united sta!es. about. % of these know their hiy status and are enrolled in outpatient care. of the remaining yo, approx~mately half do not know their status; the other group frequently know their status but are not enrolled m any .sys~em of outpatient care. this group primarily accesses care through emergency departments. when md cated, they are admitted to hospitals, receive acute care services and then, upon poster sessions v di 'harge, disappear from the health care system until a new crisis occurs, when they return to the emergency department. as a large urban hiv center, caring for over individuals with hiv we have an active inpatient service ".'ith appr~xi~.ately discharges annually. we decided to survey our inpatients to better charactenze those md v duals who were not enrolled in any system of outpatient care. results: % of inpatients were not enrolled in regular outpatient care: % at roosevelt hospital and % at st.luke\'s hospital. substance abuse and homelessness were highly prevalent in the cohort of patients not enrolled in regular outpatient care. % of patients not in care (vs. % of those in care) were deemed in need of substance use treatment by the inpatient social worker. % of those not in care were homeless (vs. % of those in care.) patients not in care did not differ significantly from those in me in terms of age, race, or gender. patients not in care were asked "why not:" the two most frequent responses were: "i haven't really been sick before" and "i'd rather not think about my health. conclusions: this study suggests that there is an opportunity to engage these patients during their stay on the inpatient units and attempt to enroll them in outpatient care. simple referral to an hiv clinic is insufficient, particularly given the burden of homelessness and substance use in this population. efforts are currently underway to design an intervention to focus efforts on this group of patients. p .q (a) healthcare availability and accessibility in an urban area: the case of ibadan city, nigeria in oder to cater for the healthcare need of the populace, for many years after nigeria's politicl independence, empphasis was laid on the construction of teaching, general, and specialist hospital all of which were located in the urban centres. the realisation of the inadequacies of this approach in adequately meeting the healthcare needs of the people made the country to change and adopt the primary health care (phc) system in . the primary health care system which is in line with the alma ata declaration of of , wsa aimed at making health care available to as many people as possible on the basis of of equity and social justice. thus, close to two decades, nigeria has operated primary health care system as a strategy for providing health care for rural and urban dwellers. this study focusing on urban area, examimes the availabilty and accessibility of health care in one of nigeria's urban centre, ibadan city to be specific. this is done within the contest of the country's national heath policy of which pimary health care is the main thrust. the study also offers necessary suggestion for policy consideration. in spite of the accessibility to services provided by educated and trained midwifes in many parts of fars province (iran) there are still some deliveries conducted by untrained traditional birth attendants in rural parts of the province. as a result, a considerable proportion of deliveries are conducted under a higher risk due to unauthorised and uneducated attendants. this study has conducted to reveal the pro· portion of deliveries with un-authorized attendants and some spatial and social factors affecting the selection of delivery attendants. method: this study using a case control design compared some potentially effective parameters indud· ing: spatial, social and educational factors of mothers with deliveries attended by traditional midwifes (n= ) with those assisted by educated and trained midwifes (n= ). the mothers interviewed in our study were selected from rural areas using a cluster sampling method considering each village as a cluster. results: more than % of deliveries in the rural area were assisted by traditional midwifes. there are significant direct relationship between asking a traditional birth attendant for delivery and mother age, the number of previous deliveries and distance to a health facility provided for delivery. significant inverse relationships were found between mother's education and ability to use a vehicle to get to the facilities. conclusion: despite the accessibility of mothers to educated birth attendants and health facilities (according to the government health standards), some mothers still tend to ask traditional birth attendants for help. this is partly because of unrealistic definition of accessibility. the other considerable point is the preference of the traditional attendants for older and less educated mothers showing the necessity of changing theirs knowledge and attitude to understand the risks of deliveries attended by traditional and un-educated midwifes. p - (a) identification and optimization of service patterns provided by assertive community treatment teams in a major urban setting: preliminary findings &om toronto, canada jonathan weyman, peter gozdyra, margaret gehrs, daniela sota, and richard glazier objective: assertive community treatment (act) teams are financed by the ontario ministry of health and long-term care (mohltc) and are mandated to provide treatment, rehabilitation and support services in the community to people with severe and persistent mental illness. there are such teams located in various regions across the city of toronto conducting home visits - times per week to each of their approximately respective clients. each team consists of multidisciplinary health professionals who assist clients to identify their needs, establish goals and work toward them. due to complex referral patterns, the need for service continuity and the locations of supportive housing, clients of any one team are often found scattered across the city which increases home visit travel times and decreases efficiency of service provision. this project examines the locations of clients in relation to the home bases of all act teams and identifies options for overcoming the geographical challenges which arise in a large urban setting. methods: using geographic information systems (gis) we geocoded all client and act agency addresses and depicted them on location maps. at a later stage using spatial methods of network analysis we plan to calculate average travel rimes for each act team, propose optimization of catchment areas and assess potential travel time savings. resnlts: initial results show a substantial scattering of clients from several act teams and substan· rial overlap of visit travel routes for most teams. conclusions: reallocation of catchment areas and optimization of act teams' travel patterns should lead to substantial savings in travel times, increased service efficiency and better utilization of resourc_~· ~e l'<!tenri~i modifications to catchment areas must be conducted with appropriate attention to specific clients servtce needs, service continuity and applicable regulations by the mohl tc. venice lido is a popular island within and outside italy because it hosts the international cinema festival yearly. only few people remember the island for its hospital, which, in the fifties, was one of the most important hospitals in italy and in europe, being a modern center for wind-, sun-and thermal-therapy. since the sixties, its fame became to drop away, since its structure was no longer adequate for the evolving medicine science. at the end of the seventies all the wards were moved into a new big building in the same area. at present the hospital is made up by about forty 'pavilions' (mostly partially used or empty) and a big building, disseminated in a hectares area, on the sea front, on the m long beach. the aim of my research is to suggest a realistic solution, sustainable on the functional use of the area according to basic local needs and economically realizable. i used a philological and multi-disciplinary method, more in detail: -from historical documents, i found what was the very first call of the property and how it adapted to the needs of the demographic development and the sanitary supply over time; -by contacting some operators from different fields, i realized which functions were suitable to the buildings in existence, to the population's needs and to the present sanitary supply. moreover the planning idea considers: -the debate going on between local people who strongly want to preserve the property, and die ones who want to renew it by different new opportunities; and -the regional sanitary politics, aiming at rationalizing the regional hospitals dislocation, and the budget needs. this plan analyzes and proposes some new alternative solutions to satisfy different needs. the different activities will be dealt out and the environmental fall will be limited as much as possible. after having analyzed its basic call, considered its environmental peculiarities and its position, verified the emerging needs of the local population, the plan proposes different activities: the hospital; the social-rehabilitation center; the elderly house; the thermal center; the residential center; and other activities. such a plan wants to share in the solution of a basic problem by giving architectonic and functional dignity to an historical completely degraded area and by starting again a social-economical broken off process, by bringing in venice lido some fresh necessary elements for its so wished new throw. p - (c) dilemma of free health care in spokane, wa david bunting introduction: the paper reports on the activities of project access spokane [pas], a physician sponsored initiative to provide uncompensated health care to low income, uninsured residents of spokane county wa. program providers included all county hospitals, over physicians, other medical professionals, and specialized clinics. each prescription requires only a $ co-payment. sponsored and administered by the county medical society, pas is funded by local and national foundations, private corporations, municipalities, civic organizations and individuals. method: the paper is based on a first year assessment report funded by pas, using hcfa [health care financing administration] insurance claim data documenting utilization rates, disease categories and donated charge information and patient cares [centralized applications, referrals and enrollment status) data. results: while essentially free for enrollees, the program involved real costs. an administrative organization to refer over patients to any of over providers had to be developed and staffed, using both paid and unpaid personnel. methods to identify potential patients and veri.fy eligibility. had to ~devised. patient appointments and transportation had to be scheduled and monitored. pu~hc relanons, provider solicitations and fundraising activities were continuous. information requirements regarding program operation were also significant. data reporting the volume. ~nd value of dona~ed medical services were necessary to demonstrate accomplishments and attr~ct addmon~l support. providers required assurances their contributions were both significant and eqmtable. funding sources sought evidence that their support had important consequences. however, generating this ~~ta proved difficult. many providers failed to submit appropriate insurance claims forms because .of a~dmonal donated effort and administrative cost, thereby not only reducing their own apparent conmbut ons but also the overall significance of the program. conclusions: during its initial year, the estimated cost to deliver free health care was ~bout per enrollee. the lesson is that without an elaborate administrative structure and record keeping s.yst~~· efforts to provide free health care probably will fail. eligible enrollees c~n not be ~parated from in~hgi ble ones, care will not be accessed or delivered in an efficient manner, neither fundmg nor ~upport "". be offered without evidence of tangible benefits, and providers will withdraw if they perceive mequ table tteannent. v p - s (c) mobility in prostitution and the impact of health therese van der helm and henk sulman poster sessions introduction: many of the estimated . commer~ial ~ex wor~ers (c~w)in a'.' ~terdam ~~me from developing countries and eastern europe. to gain ins~ght mto their workmg and_ hvmg condinons the intermediary project (ip) at the municipal health serv ~e _contacts these women via ?utreach work on regular basis. since the new brothel law in october s ~troduc~d, ~sw ~rom outside the eu and who have no dutch residence permit are not allowed to work m prost tut n. smee then, many of these csw therefore have gone "underground." the consequences of the new law in the netherlands will be discussed with regard to the accessibility of csw and their risk for stl/hiv acquisition and unplanned pregnancies. methods: topics during outreach work are the interventions to increase the knowledge of safe sex and birth control for csw. written information is handed out in relevant languages and with addresses of health and social services. in conversations with the women, it appeared that many are not aware of these services. to provide easier access to health care for women, staff of the ip carries out free sti control csw working places, in windows brothels and sex houses. also, women are offered vaccination against hepatitis b (hbv). results: from january till july we approached csw for first contact. one third was dutch; others were from developing countries, other eu countries and eastern europe. sti consul· rations were done among non-iv drug using sex workers, of whom % was dutch. of these, % was diagnosed with syphilis, % with gonorrhea, and % with chlamydia. of women tested for hiv, none were infected. due to the high turnover of csw in .brothels, most wnmen were tested only once. among csw tested for hbv -of whom one third is dutch - % had antibodies for hbv, were carrier of hbv, most of whom came from hbv endemic areas. conclusions: sti control and hbv vaccination in brothels is an important support in health care. our findings suggest that csw do not play an important role in the transmission of sti. many csw are highly mobile and often not aware of the existing health and social services. continuous outreach is important to remain in contact with this mobile population. regulations in the new brothel law should not hamper contacts with (illegal) csw. heart disease (cho) is projected to become the leading cause of death. studies conducted in europe and the united states have proven a higher rate of cho in south asians who have migrated from south asia, most notably india, pakistan and bangladesh. approximately % of all heart attacks among south asian men occur under the age of ; % of them occur under the age of -unheard of in any other population. associated risk factors such as diabetes, high blood pressure and cholesterol are also com· mon in this group. the population of south asians residing in nyc has more than doubled over the past decade to over , , the majority being young, working-class and with limited health care access. many south asian men are employed as taxi drivers ( out of nyc taxi drivers are from south asial, working daily hour plus shifts. methods: acknowledging that this vulnerable, at-risk group was unavailable for outreach through conventional venues, three of the hospitals of the new york city health and hospital corporation, (elmhurst, queens and bellevue) conducted a one day outreach effort at nyc's jfk international air· ~rt's taxi holdin~ ar~a, ~here over one thousand taxis regularly assemble. bringing an outreach event directly to the taxi dnvers workplace, a tent was set up where cardiovascular-related health screenings, in~luding bl~ pressure, sugar, cholesterol, body mass index (bmi), were provided. results were shared with and explamed to the drivers and each participant received a south asian health education brochure. a total of taxi drivers who identified as south asian were involved. rau/ts: participants were all male, ranging from to years; mean age, . . screenings revealed % hypertensive; % had cholesterols over ; % blood glucose over ; % had a bmi greater than . conc~on: a unique outreach activity, adapting to logistical, occupational limitations, is pre· se~ted. on-site f~back and explanation of results, reiterating and reinforcing the concern that south asia~. men are at mcreased danger for early coronary heart disease, and the dissemination of a culturally sensmve and r~levant brochure, may heighten awareness of prevailing cardiac risk factors in this immi· grant community. p - (c) the community-hospital integration program framework: community-hospital panoenhips to improve the population's health john stevenson, richard blickstead, ann-marie marcolin, and sandi kendal v introduction: st. josephs health centre is a catholic community teaching hospital located in the heart of southwest toronto. st. joseph\'s was founded from a community-expressed need for hospital services, and since then has stayed committed to fostering a healthy community through collaboration and parmership. st. joseph's has developed an innovative model, the community-hospital integration program (chip), to strengthen st. joseph's partnerships with community stakeholders, and facilitates the building of links between community needs, service provision, and public policy outcomes to improve the health and wellness of the diverse neighbourhoods they together serve. methods: development of the chip framework st. joseph's health centre developed the chip framework through a multidisciplinary approach that included extensive international literature reviews, consultations, and key informant interviews with community service agencies and academics. to ensure active community voice, st. joseph's has hosted a number of community consultations including a community outreach forum attended by over ninety representatives from community partners. results: the chip framework the chip framework aims to improve the health and wellness of the urban communities served by st. josephs health centre through four intersecting pillars: • raising community voices provides an infrastructure and process that supports community stakeholder input into health care service planning, decision-making, and delivery by the hospital and across the continuum of care; • sharing reciprocal capacity promotes healthy communities through the sharing of our intellectual and physical capacity with our community partners; • cultivating integration initiatives facilitates vertical, horizontal, and intersectoral integration initiatives in support of community-identified needs and gaps; and • facilitating healthy exchange develops best practices in community integration through community-based research, and facilitates community voice in informing public policy. the chip framework drives the complex inter-relationships between community-hospital engagement, reciprocal capacity-building, integration initiatives, and community-based research and evaluation, to create an interconnected network of health care services. the fluidity and simplicity of this framework, and its dedication to balancing community needs and hospital mandate, posits the st. josephs health centre's chip model as an integral component in building healthy and thriving communities. p - (c) home based care promotion: improving acess to quality services and livelihood in the face of aids home based care is a service provided to persons affected/living with hiv/aids, a menu of care/support services at home/community. it is a prominent alternative approach. in uganda, hospital bed ocupacny is high, patient health care worker ratio deteriorating. empowering communities offers solutions to the problems; adressing cost, effectiveness of care. hiv/aids demands changes in attitudes, behaviour, approaches which is enhanced in home/community settings. for example art requires high levels of adherecnce, which medical workers have vety little opportunity to enforce. it also demands other support mechanisims in terms of nutrition, personal displine, etc which work best in stigma free environments. hence the relevance of home based care. this paper highlights the gaps that call for increased action in terms of home based care, examples of whre it has worked key challenges and recommendations for the future. p - (c) health care for one ... health care for alli katharina kovacs burns introduction: at the surface, it appears that every person in canada _has. ~ccess to a publicly funded health care system. those living in urban centers should have the best ava l~b hty, chmce, and access to a variety of health care services because of the distribution of health care services, fac lmes, and health professionals in concentrated in urban centers. this is not true for everyone -people with low income or who are homeless experience the challenges of social exclusion and being marginalized: there are many factors at play making it difficult for the latter group of people to access health care. service they need,.when they need them. health care is not as accessible or inclusive as intended. the quesuon to be explore.cl ~: if health care is available and accessible to one person, what makes it not available to all people? the ~ gmfic~nce of having marginalized people accessing health care and other services includes e~hanced quality of hfe and decreased risks associated with being homeless, and cost savings in ion~ ter~ w rh acute health care. methodology: community-based participatory research is applied m a case study on health care access and challenges experienced by low income and homeless people in one urban centre, edmonton, edmonton, and their challenges. the data is being gathered and ana_lyzed usmg basic m x~d methods. results: the results will focus on how services can be more mtegrated and accessible to all people with low income and who are homeless. there will also be discussion about specific perceptions of not only the service providers but also of people with low income an~ who are homeless~ and vario~s decision makers. the results will be compared to the literature regardmg health care services access mother urban centers in canada and elsewhere. conclusions: recommendations will need to address social exclusion and other factors which can make health care and other services more available to all people in the community. the implications for health care will also be discussed. additional information will be gathered in the next phases of the study to develop a community services access model. p - (c) availability and access exemplified: a case study beth hayhoe and ruth ewert introduction: access to health care in canada requires either the correct documentation or money. street youth have neither. in addition, health services in canada are designed by adults for adults. youth in general are often wary of having trust in adults with respect to their health concerns and frequently feel misunderstood. street youth are even more mistrustful of adults and public organizations, making their contact with health care professionals minimal. this combined with their risky behaviours and dangerous environment creates a population at risk for numerous health issues but with no place to have them investi· gated. at our non-government, not for profit health service designed specifically to provide a broad range of health care to street youth, professional services are provided almost entirely by volunteers. methods: using a retrospective analysis of the years of data gathered from this organization and reviewing the initial reasons gathered from youth about their needs, the success of the health centre was examined. results: all the things youth had listed as being important in a health centre have been implemented, and even more things have been added to improve the breadth and quality of services offered. the use of the health centre has increased by more than six times since its opening in . in addition, tens of thousands of visits have been paid to the health centre, costing the government and taxpayers nothing. as far as we know there is nothing else in canada that offers so many diverse and innovative services to youth in need. conclusion: it is clear from this case, that health care targeted at the needs of specific disadvan· taged populations can successfully provide them with appropriate health care. a model of accessible health care for marginalized populations can easily be developed for high impact and low cost from this successful case. toronto is one of the most ethno-racially diverse cities in the world of the estimated , , toronto residents, % ( , ) live in scarborough population growth in scarborough is faster than toronto. scarborough's population increased by % from to while toronto increased only by %. toronto's population is projected to increase by % ( ) in while scarbor· ough's will increase by %. (census canada ) low income, pove;ty, seniors, hidden homeless, new~omers to canada, the uninsured, are just a few of the issues concerning health care in our community. health care needs in scarborough are greatly impacted by diversity of ethnic and racial groups, poverty and settlement issues. this paper will share how the scarborough hospital (tsh) an urb~n communir_y hospital cares f~~ it~ community. tsh recognizes: •the changing community• b_arriers t~ accessing care • lnequalmes m health care the hospital in caring for its community pro· v ~es services that '!'e~e cu~turally, racially, and linguistically sensitive to our community. the paper will share the hospitals unique program on access and equity. the paper will share the needs in scar· borough and tsh's response to these needs: working in partnership with the local health committee, i:ne scarborough homeless co.mminee, the scarborough network of immigrant services organiza· nons a~d others. :' e paper will also share the many initiatives this urban community hospital has taken viz. community and home programs in service areas such as mental health, haemodialysis day care, t~~ home oxyg~n program, the palliative at-home program, and above all support for the volunteer clinic for the uninsured. j"'" tllu:lion: in canada's universal health care system it is generally assumed that everyone has equal access to health care. however, some immigrant groups in canada have historically been uninswed. these groups include failed refugee claimants, those overstaying their visas, and new immigrants in transition who are waiting to become eligible for health insurance. some estimates have suggested that at the present time there may be as many as one hundred thousand undocumented and thus uninsured immigrants in toronto alone. understandably, information on the characteristics of this marginalized population is very limited, since undocumented immigrants tend to have little contact with formal institutions. knowledge of the demographic characteristics of this population may aid in the development of health and social programs to better identify and meet the needs of undocumented immigrants in toronto. we conducted a review of all undocumented, uninsured patients, years of age or older at access alliance multicultural community health centre (aamchc) between and . demographic information such as age, gender, preferred language, length of time living in canada, selfreported education level and household income were recorded. rmdts: % of all adult patients at access alliance were undocumented and uninsured. % were under years of age (with a median age of years), % were women and only % spoke english. this group lived in canada for an average period of . years before they were first seen at aamchc. % of undocumented clients reported having completed at least a secondary or post-secondary education. % had self-reported household incomes of less than , $/year, while % of households reported earning less than $ , /year. the mean income per person in an average household was $/month. conchuions: uninsured individuals at aamchc were predominantly young females with limited knowledge of the english language. despite having attained a high level of education most were living well below the poverty line. recognition of these characteristics may assist in the development of health and social programs that are better adapted to meet the needs of undocumented immigrants. p - (c) sharing expertise: a role for the hospital lactation consultant in the community. badrgrmuul: st. michael's hospital is a tertiary care hospital that serves a large inner city population in downtown toronto. in order to provide care to this population, the hospital has developed a number of unique outreach roles. one such role was developed to work with pregnant and breastfeeding women living in regent park, a social housing complex located near the hospital. the population of regent park includes new immigrants, refugees and the socially disadvantaged. approach: the outreach lactation consultant provides care, as part of the canada prenatal nutrition program, in the community prenatally, in the hospital during their inpatient stay and postnatally when they return to the community. the continuity of care enhances the probability of long term successful breastfeeding. aside from the health benefits of breastmilk, breastfeeding is especially important for women who are financially needy and must depend on food banks for formula. . . lason learned: aher two years of partnership, the relationship between the an-hospital ~stpar tum experience for breastfeeding mothers and the community postpartum support, the breastfeeding rate ~thin this community is high. the professional support and visibility of the : ctation consultant, both m the hospital and in the community, contributes to the support of breastfee~m~.. . in light of ongoing funding constraints, this ha son between hospital and community could be at risk and discontinued. in light of the benefits to the mother/baby dyad, the lactation consultant as a community partner in the canada prenatal nutrition program should be safeguarded. . lldpodiu:tion: although the importance of adequate health care in pregna~cy is well recognised, ethnic disparities in utilization of prenatal care still exist in many western coun~~es. a fun~amental factor in these disparities may be language proficiency, as it influences women's ab hty. to ob~m and understand health information, to find the way in the health care system and to communicate with health care v poster sessions providers. we investigated the role of language proficiency in use and knowledge of folic acid as aspect of prenatal care in an urban multi-ethnic pregnancy c?hort. . . design: prospective cohort study. setting and parnc pants: amsterdam ~regnant women attending obstetric care providers for their first antenatal visit (n= ). country of birth defined ethnicity: the netherlands, surinam, antilles, turkey, morocco, ghana, other non-~est~m (nw) and other western (w) country. main outcome measures: knowledge about and use of.fohc a~d (fa) supplements in pregnancy, and determinants of these in diffe~~t ethnic ~~ups. deterrrunants mcl~ded age, ed~ tion, parity, pregnancy intention and dutch prof c ency. stansncs: ~ to co~p~re e~c groups, stranfied logistic regression (forward stepwise method) to explore determmants "'.'thm ethmc groups .. use of fa supplements was significantly lower among ghanaian, moroccan, turkish and other nw women ( %to %) than among dutch ( %) or other w women ( %). use amongsurinames and antillean women was intermediate ( %and %). ethnic differences in fa knowledge were similar. knowledge was the strongest determinant of use in all ethnic groups, with odds ratios (ors) ranging from . to . . language proficiency was the strongest determi~a~t of kno~ledge in ethnic groups with a mother tongue different from dutch (ors good vs. low proficiency ranging from . ro . ). educational level had a modifying role, as shown by an interaction effect between education and language proficiency in the nw group. here, the odds of having fa knowledge given a high education and good dutch proficiency was times the odds given a good proficiency but low education. conclusions: appropriate periconceptional use of folic acid supplements in non-western ethnic groups is low, reflecting an absence of knowledge that is largely determined by the inability to speak and understand the language of the habitual country. tailored interventions using communication channels most likely to address (pregnant) women from ethnic minority groups are necessary. apan from specific interventions, our results are in support of strong incentives on language education despite current political debate. introduction: recent research suggests living in an economically disadvantaged neighborhood is asso· ciated with decreased likelihood of undergoing mammography and increased risk of late-stage breast can· cer diagnosis. long distances and travel times to facilities offering low-or no-cost mammography may be imponant barriers to adherence to mammography screening recommendations for residents of economically disadvantaged neighborhoods. the purpose of this study was to examine whether facilities providing low-and no-cost screening mammography were less spatially accessible in low-income neighborhoods in chicago, and the extent to which the relationship between neighborhood income and the spatial accessibility of facilities varied by the proponion of african-american residents in the neighborhood. methods: the sample consisted of chicago neighborhoods. for each neighborhood, we con· structed three measures of the spatial accessibility of facilities: street network distance to the nearest facility, public transportation travel time to the nearest facility, and shortest automobile travel time to a facility. using decennial census data, we characterized the neighborhoods according to proportion of residents with incomes below the poverty line, proportion of residents in each of four raciavethnic groups (african-american, latino, white, and other), and population density. we used ordinary least squares (ols) and spatial exogenous lag regression to examine relationships. model estimated the relationship between neighborhood poverty and the spatial accessibility of facilities, adjusting for raciaveth· nic composition and population density. model added a multiplicative interaction term between neighborhood poverty and african-american. restllts: we identified deven facilities that provided low-or no-cost screening mammography to chicago residents in . we found that the distance and travel times via automobile and public trans· portation to facilities generally decreased as neighborhood poveny increased. however, we also found that the ~egative associations between neighborhood poverty and two of the spatial accessibility mea· sures -distance and public transportation travel time -were less strong in neighborhoods with the highest proponions of african-american residents. among neighborhoods in the highest tertile for poveny, th~ mean distance and mean public transportation travel time to facilities were over twice as long in neighborhoods in the highest tertile than in those in the lowest tenile of african-american residents. . ~ persistent socioeconomic and racial/ethnic disparities in breast cancer stage at diagno-s ~nd su~ val suggest that ensuring an equitable distribution of affordable mammography is a worth-w~e policy .goal. the ~~dy sugges~ that ~ture investigations should consider both neighborhood soc oecono d c charactensbes and rac avethmc composition when examining the spatial distribution of health resources. , ) . epidemiological data suggest tha~ hiv prevalence among msm is over % in some metropolitan cities, such .as beijing (ibid.). due to widespread homophobia in chinese society, however, this population remains invisible within current health/social services. lack of research on sexuality, specifically homosexuality, has impaired our understanding of health and health practices of chinese msm. focusing on the illness experiences of chinese msm with hiv/aids, this paper explores the socio-cultural impacts of hiv/ aids on this group. the data used for this paper were collected through semi-constructed in-depth face-toiace interviews with adult plwhas (including msm) in beijing, china. with the permission of the participants, the interviews were audio-taped or recorded in notes. the transcribed interviews and interview notes were analyzed by using n-vivo, a software program for qualitative data analysis. this phenomenological study aimed to understand the experiences chinese plwhas (including msm) from their own perspectives. results: it is found that the illness experiences of chinese msm with hiv/aids are profoundly shaped by the socio-cultural meanings of homosexuality, which are further complicated by the dominant discourses on hiv/aids in china. at a macro level, homophobia in the larger society has decreased the capability of this group to respond to this epidemic in a more efficient way. at a meso level, aids-phobia within the chinese msm circuits has prevented this group from openly confronting this disease and offering support to those who are already affected by it. at a micro level, however, these hiv-infected/ affected msm have tried their best to locate spaces to live and to construct hope for their future lives despite various barriers within family, community, and the larger society. this study suggests that facilitating chinese msm's response to the aids crisis urgently requires bridging awareness, commitment, knowledge and resources both within and without this group. it also illustrates the importance of understanding homosexuality in the local context of hiv i aids, which will be helpful for developing culturally sensitive hiv/aids programs for this population on the community, national and international levels. introduction: having a regular family doctor (rfd) is known to be positively correlated with a good medical follow up, including access to preventive and/or chronic care. inversely, a lack of primary care may lead to high rates of avoidable hospitalizations, especially among poor people and/or in underserved neighbourhoods. in such a matter, a recent comparative study showed that paris was better ranged than other cities, such as nyc, tokyo or london. nevertheless, despite a quasi universal health insurance and a high density of general practitioners, a noticeable fraction of the paris population does not have any regular physician and we aimed to understand who they are and for what reasons rhey don't have any rfd. mdbods: cross sectional population survey among a random sample of households in ~nderpriv ileged neighbourhoods in paris inner city, performed in , using a face-to-face quest nna re collecr- ng more than social and health characteristics. ruults: a quarter ( . %) of rhe study popularion did not have any rfd. this proporrion was iignificantly higher among male (or= . , %ci = [ . - . ), younger (e.g. or - /> .s l _= ._oo, " .ci = ( . - . )), and/or unemployed (or = . , %ci = ij . - . _ people. in multtvanate analysis, after a full adjustment on gender, age, health status, health insura~ce, income, occupat n and tducation level, we observed significant associations between having no rfd and: ~arrtal and_ pare~t hood status (e.g. or single no kids/in couple+kids = . , %ci = ( . - . ()~ quality of relattonsh ps with neighbours (or bad/good= . , %ci = [ . - . )), and length of residence m the neighbourhood (with a dose/effect statistical relationship). . co clusion: gender, age, employment status, mariral and parenthood stat~s as well as ~e gh bourhood anchorage seem to be major predictors of having a rfd, even when um.versa! health i~sur ance has reduced most of financial barriers. in urban contexts, where residential migrattons and single lift (or family ruptures) are frequent, specific information may be conducted to encourage people to ket rfd. :tu~y tries to assess the health effects and costs and also analyse the availability and accessibility to health care for poor. . methods: data for this study was collected by a survey on households of the local community living near the factories and households where radiation hazard w~s n?~ present. ~~art from mor· bidity status and health expenditure, data was collected ~n access, a~ail~b .hty and eff c ency of healrh care. a discriminant analysis was done to identify the vanables that d scnmmate between the study and control group households in terms of health care pattern. a contingent valuation survey was also undertaken among the study group to find out the factors affecting their willingness to pay for health insurance and was analysed using logit model. results: the health costs and indebtedness in families of the study group was high as compared to control group households and this was mainly due to high health expenditure. the discriminant analysis showed that expenditure incurred by private hospital inpatient and outpatient expenditure were significant variables, which discriminated between the two types of households. the logit analysis showed !hat variables like indebtedness of households, better health care and presence of radiation induced illnesses were significant factors influencing willingness to pay for health insurance. the study showed that study group households were dependent on private sector to get better health care and there were problems with access and availability at the public sector. conclusion: the study found out that the quality of life of the local community is poor due to health effects of radiation and the burden of radiation induced illnesses are so high for them. there is an urgent need for government intervention in this matter. there is also a need for the public sector to be efficient to cater to the needs of the poor. a health insurance or other forms of support to these households will improve the quality for health care services, better and fast access to health care facilities and reduces the financial burden of the local fishing community. the prevalence of substance abuse is an increasing problem among low-income urban women in puerto rico. latina access to treatment may play an important role in remission from substance abuse. little is known, however, about latinas' access to drug treatment. further, the role of social capital in substance abuse treatment utilization is unknown. this study examines the relative roles of social capital and other factors in obtaining substance abuse treatment, in a three-wave longitudinal study of women ages - living in high-risk urban areas of puerto rico, the inner city latina drug using study (icldus). social capital is measured at the individual level and includes variables from social support and networks, familism, physical environment, and religion instruments of the icdus. the study also elucidates the role of treatment received during the study in bringing about changes in social capital. the theoretical framework used in exploring the utilization of substance abuse treatment is the social support approach to social capital. the research addresses three main questions: ( t) does social capital predict parti~ipating in treatment programs? ( ) does participation in drug treatment programs increase social capital?, and ( ) is there a significant difference among treatment modalities in affecting change in ~ial capital? the findings revealed no significant association between levels of social capital and gettmg treatment. also, women who received drug treatment did not increase their levels of social capital. the findings, however, revealed a number of significant predictors of social capital and receiving drug ~buse treatment. predictors of social capital at wave iii include employment status, total monthly mcoi:rie, and baseline social capital. predictors of receiving drug abuse treatment include perception of physical health and total amount of money spent on drugs. other different variables were associated to treatment receipt prior to the icldus study. no significant difference in changes of social capital was found among users of different treatment modalities. this research represents an initial attempt to elucidate the two-way relationship between social capital and substance abuse treatment. more work is necessary to unden~nd. ~e role of political forces that promote social inequalities in creating drug abuse problems and ava lab hty of treatment; the relationship between the benefits provided by current treatment poster sessions v sctrings and treatment-seeking behaviors; the paths of recovery; and the efficacy and effectiveness of the trtaanent. and alejandro jadad health professionals in urban centres must meet the challenge of providing equitable care to a population with diverse needs and abilities to access and use available services. within the canadian health care system, providers are time-pressured and ill-equipped to deal with patients who face barriers of poverty, literacy, language, culture and social isolation. directing patients to needed supportive care services is even more difficult than providing them with appropriate technical care. a large proportion of the population do not have equitable access to services and face major problems navigating complex systems. new approaches are needed to bridge across diverse populations and reach out to underserved patients most in need. the objective of this project was to develop an innovative program to help underserved cancer patients access, understand and use needed health and social services. it implemented and evaluated, a pilot intervention employing trained 'personal health coaches' to assist underserved patients from a variety of ethno-linguistic, socio economic and educational backgrounds to meet their supportive cancer care needs. the intervention was tested with a group of underserved cancer patients at the princess margaret hospital, toronto. personal coaches helped patients identify needs, access information, and use supportive care services. triangulation was used to compare and contrast multiple sources of quantitative and qualitative evaluation data provided by patients, personal health coaches, and health care providers to assess needs, barriers and the effectiveness of the coach program. many patients faced multiple barriers and had complex unmet needs. barriers of poverty and language were the easiest to detect. a formal, systematic method to identify and meet supportive care needs was not in place at the hospital. however, when patients were referred to the program, an overwhelming majority of participants were highly satisfied with the intervention. the service also appeared to have important implications for improved technical health care by ensuring attendance at appointments, arranging transportation and translation services, encouraging adherence to therapy and mitigating financial hardship -using existing community services. this intervention identified a new approach that was effective in helping very needy patients navigate health and social services systems. such programs hold potential to improve both emotional and physical health out· comes. since assistance from a coach at the right time can prevent crises, it can create efficiencies in the health system. the successful use of individuals who were not licensed health professionals for this purpose has implications for health manpower planning. needle exchange programs (neps) have been distributing harm reduction materials in toronto since . counterfit harm reduction program is a small project operated out of a community health centre in south-east toronto. the project is operated by a single full-time coordinator, one pan-rime mobile outreach worker and two peers who work a few hours each week. all of counterfit's staff, peers, and volunteers identify themselves as active illicit drug users. yet the program dis~rib utes more needles and safer crack using kits and serves more illicit drug u~rs t~an the comb ~e~ number of all neps in toronto. this presentation will discuss the reasons behind this success, .s~ f cally the extended hours of operation, delivery models, and the inclusion of an. extremely marg ~ahzed community in all aspects of program design, implementation and eva.luat ?n. ~ounterfit was recently evaluated by drs. peggy milson and carol strike, two leading ep dem olog st and researchers in the hiv and nep fields in toronto and below are some of their findings: "the program has experienced considerable success in delivering a high quality, accessible and well-used program .... the pro· gram has allowed (service users) to become active participants in providing. services to others and has resulted in true community development in the best sense. " ... counterf t has ~~n verr succe~sful attracting and retaining clients, developing an effective peer-based model an.d assisting chen~s ~ th a vast range of issues .... the program has become a model for harm red~ctmn progr~ms withm the province of ontario and beyond." in june , the association of ?ntano co~mumty heal~~ <:en· ires recognized counterfit's acheivements with the excellence m community health initiatives award. in kenya, health outcomes and the performance of government health service~ have det~riorated since the late s, trends which coincide with a period of severe resource constramts necessitated by macro-economic stabilization measures after the extreme neo-liberalism of the s. when the govern· ment withdrew from direct service provision as reform trends and donor advocacy suggested, how does it perform its new indirect role of managing relations with new direct health services providers in terms of regulating, enabling, and managing relations with these health services providers? in this paper therefore, we seek to investigate how healthcare access and availability in the slums of nairobi has been impacted upon by the government's withdrawal from direct health care provision. the methodology involved col· leering primary data by conducting field visits to health institutions located in the slum areas of kibera and korogocho in nairobi. purposive random sampling was utilized in this study because this sampling technique allowed the researcher(s) to select those health care seekers and providers who had the required information with respect to the objectives of the study. in-depth interviews using a semi-structured ques· tionnaire were administered ro key informants in health care institutions. this sought to explore ways in which the government and the private sector had responded and addressed in practical terms to new demands of health care provision following the structural adjustment programmes of the s. this was complemented by secondary literature review of publications and records of key governmental, bilateral and multilateral development partners in nairobi. the study notes a number of weaknesses especially of kenya's ministry of health to perform its expected roles such as managing user fee revenue and financial sustainability of health insurance systems. this changing face of health services provision in kenya there· fore creates a complex situation, which demands greater understanding of the roles of competition and choice, regulatory structures and models of financing in shaving the evolution of health services. we rec· ommend that the introduction of user fees, decentralization of service provision and contracting-out of non-clinical to private and voluntary agencies require a new management culture, and new and clear insri· tutional relationships. experience with private sector involvement in health projects underlines the need not only for innovative financial structures to deal with a multitude of contractual, political, market and risks, but also building credible structures to ensure that health services projects are environmentally responsive, socially sensitive, economically viable, and politically feasible. purpose: the purpose of this study is to examine the status of mammography screening utilization and its predictors among muslim women living in southern california. methods: we conducted a cross-sectional study that included women aged ::!: years. we col· leered data using a questionnaire in the primary language of the subjects. the questionnaire included questions on demography; practices of breast self-examination (bse) and clinical breast examination (cbe); utilization of mammography; and family history of breast cancer. bivariate and multiple logistic regression analyses were performed to estimate the odds ratios of mammography use as a function of demographic and other predictor variables. . results: among the women, % were married, % were - years old, and % had family h story of breast cancer. thirty-two percent of the participating women never practiced bse and % had not undergone cbe during the past two years. the data indicated that % of the women did not have mammography in the last two years. logistic regression analysis showed that age ( r= . , % confi· dcnc~ interval (cl)=l. - . ), having clinical breast examination ( r= . , % cl= . - . ), and practtce of self-breast examination ( r= . , % cl= . - . ), were strong predictors of mammography use . . conclusions: the data point to the need for intervention targeting muslim women to inform and motivate th.cm a~ut practices for early detection of breast cancer and screening. further studies are needed to investigate the factors associated with low utilization of mammography among muslim women population in california. we conducted a review of the scientific literature and° government documents to describe ditnational health care program "barrio adentro" (inside the neighborhood). we also conducted qualiurivt interviews with members of the local health committees in urban settings to descrihe the comm unity participation component of the program. rtsmlts: until recently, the venezuelan public health system was characterized by a lack or limited access w health care ( % of the population) and long waiting lists that amounted to denial of service. moit than half of the mds worked in the five wealthiest metropolitan areas of the country. jn the spring oi , a pilot program hired cuban mds to live in the slums of caracas to provide health care to piople who had previously been marginalized from social programs. the program underwent a massive expansion and in only two years , cuban and , venezuelan health care providers were working acmss the country. they provide a daily average of - medical consultations and home visits, c lly out neighborhood rounds, and deliver health prevention initiatives, including immunization programs. they also provide generic medicines at no cost to patients, which treat % of presenting ill-ij!m, barrio adentro aims to build , clinics (primary care), , diagnostic and rehabilitation ctnrres (secondary care), and upgrade the current hospital infrastructure (tertiary care). local health committees survey the community to identify needs and organize a variety of lobby groups to improve dit material conditions of the community. last year, barrio adentro conducted . times the medical visits conducted by the ministry of health. the philosophy of care follows an integrated approach where btalrh is related to housing, education, employment, sports, environment, and food security. conclusions: barrio adentro is a unique collaboration between low-middle income countries to provide health care to people who have been traditionally excluded from social programs. this program shows that it is possible to develop an effective international collaboration based on participatory democracy. low-income americans are at the greatest risk of being uninsured and often face multiple health concerns. this evaluation of the neighborhood health initiative (nh!), an organization which uses multiple programmatic approaches to meet the multiple health needs of clients, reflected the program's many activities and the clients' many service needs. nh! serves low-income, underserved, and hard-to-reach residents in the des moines enterprise community. multiple approaches (fourth-generation evaluation, grounded theory, strengths-and needs-based) and methods (staff and client interviews, concept mapping, observations, qualitative and quantitative analysis) were used to achieve that reflection. results indicate good targeting of residents in the zip code and positive findings in the way of health insurance coverage and reported unmet health needs of clients. program activities were found to match client nttds, validating the organization\'s assessment of clients. important components of nhi were the staff composition and that the organization had become part of both the formal and informal networks. nhi positioned as a link between the target population and local health and social sc:rvice agencies, working to connect residents with services and information as well as aid local agencies in reaching this underserved population. p - (c) welfare: definition by new york city maribeth gregory for an individual who resides in new york city, to obtain health insurance under the medicaid policy one must fall under certain criteria .. (new york city's welfare programs ) if the individual _is on ssi or earns equal to or less than $ per month, he is entitled to receive no more than $ , m resources. a family the size of two would need to earn less than $ per month to qualify for no greater than ss, worth of medicaid benefits. a family of three would qualify for $ , is they earned less than $ per month and so on. introduction: the vancouver gay communiry has a significant number of asian descendan!l. because of their double minority status of being gay and asian, many asian men who have sex with men (msm) are struggling with unique issues. dealing with racism in both mainstream society and the gay communiry, cultural differences, traditional family relations, and language challenges can be some of their everyday srruggles. however, culturally, sexually, and linguistically specific services for asian msm are very limited. a lack of availability and accessibiliry of culturally appropriate sexual health services isolates asian msm from mainstream society, the gay community, and their own cultural communities, deprives them of self-esteem, and endangers their sexual well-being. this research focuses on the qualita· tive narrative voices of asian msm who express their issues related to their sexualiry and the challenges of asking for help. by listening to their voices, practitioners can get ideas of what we are missing and how we need to intervene in order to reach asian msm and ensure their sexual health. methods: since many asian msm are very discreet, it is crucial to build up trust relationships between the researcher and asian msm in order to collect qualitative data. for this reason, a community based participatory research model was adopted by forming a six week discussion group for asian msm. in each group session, the researcher tape recorded the discussion, observed interactions among the participants, and analyzed the data by focusing on participants' personal thoughts, experiences, and emotions for given discussion topics. ra lts: many asian msm share challenges such as coping with a language barrier, cultural differ· ences for interpreting issues and problems, and westerncentrism when they approach existing sexual health services. moreover, because of their fear of being disclosed in their small ethnic communities, a lot of asian msm feel insecure about seeking sexual health services when their issues are related to their sexual orientation. conclflsion: sexual health services should contain multilingual and multicultural capacities to meet minority clients' needs. for asian msm, outreach may be a more effective way to provide them with accessible sexual health services since many asian msm are closeted and are therefore reluctant to approach the services. building a communiry for asian msm is also a significant step toward including them in healthcare services. a communiry-based panicipatory approach can help to build a community for asian msm since it creates a rrust relationship between a worker and clients. p - (c) identifying key techniques to sustain interpretation services for assisting newcomers isolated by linguistic and cultural barriers from accessing health services s. gopi krishna lntrodaetion: the greater toronto area (gta) is home to many newcomer immigrants and other vulnerable groups who can't access health resources due to linguistic, cultural and systemic barriers. linguistic and cultural issues are of special concern to suburbs like scarborough, which is home to thousands of newcomer immigrants and refugees lacking fluency in english. multilingual community ~nterpreter. service~ (mcis) is a non-profit social service organization mandated to provide high quality mterpretanon services. to help newcomers access health services, mcis partnered with the scarborough network of immigrant serving organizations (sniso) to recruit and train volunteer interpreters to accompany clienrs lacking fluency in english and interpret for them to access health services at various locati?ns, incl~~ing communiry ~c:-lth centres/social service agencies and hospitals. the model envisioned agencies recruin~ and mcis ~.mm.g and creating an online database of pooled interpreter resources. this da.tabase, acces& bl~ to all pama~~g ?rganization is to be maintained through administrative/member · ship fees to. be ~ d by each parnapanng organization. this paper analyzes the results of the project, defines and identifies suc:cases before providing a detailed analysis for the reasons for the success . . methods:. this ~per~ q~ntitative (i.e. client numben) and qualitative analysis (i.e. results of key •~ormant m~rv ews with semce ~sers and interpreters) to analyze the project development, training and mplementanon phases of the project. it then identifies the successes and failures through the afore· mentioned analysis. poster sessions vss resljts: the results of the analysis can be summarized as: • the program saw modest success both ia l?lllls of numbers of clients served as well as sustainability at various locations, except in the hospital iririog. o the success of the program rests strongly on the commitment of not just the volunteer interprmr, but on service users acknowledgments through providing transponation allowance, small honororia, letter of reference etc. • the hospital sustained the program better at the hospital due to the iolume and nature of the need, as well as innate capacity for managing and acknowledging volunceers. collc/llsion: it is possible to facilitate and sustain vulnerable newcomer immigrants access to health !ul'ices through the training and commitment of an interpreter volunteer core. acknowledging volunteer commitment is key to the sustenance of the project. this finding is important to immigration and health policy given the significant numbers of newcomer immigrants arriving in canada's urban communities. nity program was established in to provide support to people dying at home, especially those who were waiting for admission to the resi<lential hospice. with the advent of haart and corresponding challenges for people living with hiv/aids in the community, the community program has developed a unique case management approach. this model features an interdisciplinary team providing a clientdrivcn service. the case manager provides continuity of care to clients in a variety of settings both within and outside of the health care system. a case study is used to demonstrate how formal and informal networks of support facilitate efficient and appropriate resource utilization to promote client health. this case study demonstrates the value of consistent coordination with a client who has complex physical, spiritual, substance use and mental health needs. the authors will show how they liaised with the housing authority, police, social services as well as the family physician, clinic staff and a hospital emergtncy room to ensure this client did not fall between the cracks. tarek hussain recognition of the importance of community involvement and sectoral cooperation in health and !ocial services, formalized in alma-ata declaration in , was reinforced at riga meeting held at the mid·point between alma-ata and the year . then at the th anniversary of alma-ata declaration, ir was declared that 'primary health care is everybody's business'. health does not exist in isolation. health cannot be defined only as an outcome of 'medical care' but also as one of 'social action'; the responsibility of disease prevention and health promotion rests not only on governments, but also with don·govemmentorgan izations, the community, and individuals. the major accomplishment to date may be that rhere is growing realization in the health sector that community involvement is more than a political right-it is absolute necessary. lessons have learned during the implementation of disease-specific l'cltical programmes, such as cdd, ari, and epi; first, integrated and holistic approaches to childcare art needed, and second, the need for community involvement has become evident. imc! is a broad inte-gra ed strategy with an overall objective contributing to reducing child morbidity and mortality in developing countries. and one of the imci components, 'community !mci', which is now broadening ~s an entry point for child-focused community development initiatives. community jmcl/c~ ld health is ~n mtcgrated approach to the promotion of key family and community practices that have impact on: child growth and development, disease prevention, home care for sick, malnourished child~en, a.nd care-seekmg behavior and compliance with advice and treatment. the presentation addres~es, m brief, the ~evel opinent of community !mci, operational aspect of community/im cl, key strategies and tools ava la~le for implementation of c/imci. the paper draws some successful programme examples on working logether for imc! with the community in various countries which had substantial benefns on programme outcomes. p - t (c) healthy child screening: an innovative service initiative ann-marie marcolin and joyce allen . introduction: with mounting attention for creative and integrated models of c~re .that are populallon and community focused, the healthy child screening initiative achiev.es t~ese pnncipl~s and more! . • parkdale high park rotary (sponsorship) the heal~h ~h ld scree? ?g is a ~opl~-centred model of care. agency and professional sector-specific silos are ehmmated, ~rov dmg f~~ hes wit~ one-sto~ access to primary prevention services in a local school gym! children at nsk are rece vmg early mtervent n and appropriate referrals to the right care provider, at the right time a~d in t~e right place. further, with a complimentary focus on prevention, the program serves to keep at nsk children healthy. healthy child screening results: the service model is developed around four distinct phases: ) planned outreach; ) coordinated intake and registration; ) interdisciplinary screening; and ) targeted referral. since the fall and through six collaborative healthy child screenings children ranging in age from to have benefited from this unique service model of care. conclusion: the presentation will provide practical information on the development and implementation of the model. there will also be a focus on lessons learned in building community service provider-hospital relationships. according to statistics canada ( ) % of the toronto population was born outside of canada and % were new immigrants. immigrants often arrive in canada in superior health compared to the canadian born population, but they lose this health advantage over time. changes in immigrant health status over time may be attributed to a variety of factors including barriers to accessing and receiving care as well as limitations in the mainstream health service organizations and their approaches to health care delivery (hyman, ) . for example, immigrant women are less likely to receive pap tests, which places them at a greater risk for developing cervical cancer. similarly, immigrant women receive less mammography screening than their canadian counterparts. the immigrant women's health centre mobile health unit (mhu) was created as an alternative care delivery model to address the need for increased accessibility as well as culturally and linguistically appropriate reproductive health care. toronto western hospital and the immigrant women's health centre have formed a collaborative partnership which incorporates a primary care nurse practitioner and lay ethnocultural counselors providing care on the mhu. currently, a qualitative ethnonursing study is underway to understand the unique experiences of women using the mhu for their reproductive health care as well as the perspectives of the mhu health care providers. based on a literature review and preliminary findings from provider and participant interviews, the proposed presentation will address the themes of health status for immigrant and refugee women, accessibility issues as well strategies to improve their reproductive health care. we will discuss benefits as well as limitations to health care provision using this alternative service delivery model. michael carden, brian edlin, andrew talal, elizabeth getter, and marla shu lntrod.ction: to date most active drug users have not had access to treatment for hepatitis c virus (hcv) infection and substantial barriers continue to exist that interfere with treatment availability for this population. methods: active illicit drug users interested in pursuing hcv care and treatment were recruited in partnership w~th co~munity-based organizations (cbo's) in new york city. baseline data were collected on quahty of hfe, substance use patterns, depression, health care utilization, hcv health beliefs and other relev.ant variables. medical evaluations were conducted, including liver biopsy when indicated, an~ treatment ts ~ffered when no contraindications are present. participants also receive psychiatric evaluahons to determme the appropriateness of interferon treatment. renlts: fifteen individuals have been recruited to date and received an initial medical evaluation. the mean age was years and _the average age of initial heroin or cocaine use was . . eight ( %) ha~ been homeless at least once m the last months and s ( %) were homeless for most or all of this penod. fourteen ( %) had a history of injection drug use with the mean age at first injection being s frsewons v ,an. elrven persc.!ns ( %) reported inje~~ng .heroin or cocaine within the last days while the .wing four ( l'o) reported regular non-m ect on use of cocaine and street-obtained benzodiazepines. sijiy seven percent of the sample (n= ) reported ever being referred to hcv treatment while ( t % ) ftponeddiattreann~nt had been offered by~ ~e.dical provider. none had ever received a liver biopsy or araanent. most believed that hcv was a s gmf cant threat to their health ( %) and that there was a pm)dchance they would eventually die if their hepatitis c was not treated ( %). though individuals % believed that there was no cure for hcv, ( %) reported that they would initiate treatment if i was recommended by their doctor. thirteen ( %) had a current psychiatric diagnosis including «pmsion, anxiety disorder, schizophrenia, schizoaffective disorder, and borderline and antisocial persooaliry disorders. among eight individuals who had the beck depression inventory administered, the mean score was . . attendance rates were % ( / ) at scheduled medical and psychiatric ppointments and % ( / ) at liver biopsy. <andtuions: active drug users, despite experiencing multiple psycho-social problems, can be mgaged in hcv care using a multidisciplinary approach, but require intensive follow-up support. hcv aunnent of active drug users should not be dismissed. n- (c) antiretroviral therapy in mv infected infants: when to initiate therapy an african experience kingsley okonkwo, ademola adeyemo, israel sokeye, and nwaife umeike /""°""ction: as technology for early diagnosis of human immunodeficiency virus [hiv] improves, m to commence highly active antiretroviral therapy [haarn is yet to be fully evaluated. this prospective study describes our initial experience with early haart in hiv infected nigerian infants and rqions the outcome. we also analyzed the socioeconomic implications of early haart therapy in infants in the african setting. method: hiv infected infants were started on haart before months and followed up at mkly intervals.we monitored baseline and monthly cd . conclusion: initial results suggest early haart before months resulted. in improv~d out~ome in african children. treatment appears to be as effective as in developed counmes. in. a~nca as. m most developing countries with limited resources it is possible and effective to use haart m ~~ants if p~oper llloniroring facilities are available. however the occurrence of long-term drug related tox c ty and mk of emergence of resistant viral strains create need for further evaluation of haart in infants. background: most risk factors for cardiovascular disease (cvd) can be mitigated through ~th clinical interventions and lifestyle change. we used data from a telephone survey of new york city (nyc) adults to characterize health care access and healthy behavior among those with three or more cvd risk factors. methods: the study population included respondents to the nyc community health survey (n= , ) self-reporting~ of the following: smoking, diabetes, high cholesterol level, high blood pres· sure, body mass index > , and age > (males) or > (females) (n= , ). results: based on self-report, an estimated . , ( %) of nyc adults have~ or more cvd risk factors. this population is % male, % white, % black, and % with s years of education. most report good access to health care, indicated by having health insurance ( %), regular doctor ( %), their blood pressure checked within last months ( %), and their choles· terol checked within the past year ( % ). only % reported getting at least minutes of exercise ~ times per week and only % eating ~ servings of fruits and vegetables the previous day. among current smokers, % attempted to quit in past months, but only % used medication or counseling. implications: these data suggest that most nyc adults known to be at high risk for cvd have access to regular health care, but most do not engage in healthy lifestyle or, if they smoke, attempt effective quit strategies. more clinic-based and population-level interventions are needed to support lifestyle change among those at high risk of cvd. introduction: recently, much interest has been directed at "obesogenic" (obesity-promoting) (swinburn, egger & raza, ) built environments, and at geographic information systems (gis) as a tool for their exploration. a major geographical concept is accessibility, or the ease of moving from an origin to a destination point, which has been recently explored in several health promotion-related stud· ies. there are several methods of calculating accessibility to an urban feature, each with its own strengths, drawbacks and level of precision that can be applied to various health promotion research issues. the purpose of this paper is to describe, compare and contrast four common methods of calculating accessibility to urban amenities in terms of their utility to obesity-related health promotion research. practical and conceptual issues surrounding these methods are introduced and discussed with the intent of providing health promotion researchers with information useful for selecting the most appropria e accessibility method for their research goal~ ~ethod: this paper describes methodological insights from two studies, both of which assessed the neighbourhood-level accessibility of fast-food establishments in edmonton, canada -one which used a relatively simple coverage method and one which used a more complex minimum cos method. res.its: both methods of calculating accessibility revealed similar patterns of high and low access to fast-food outlets. however, a major drawback of both methods is that they assume the characteristics of the a~e~ities and of the populations using them are all the same, and are static. the gravity potential method is introduced as an alternative, since it is ·capable of factoring in measures of quality and choice. a n~mber of conceptual and pr~ctical iss~es, illustrated by the example of situational influences on food choice, make the use of the gravity potential model unwieldy for health promotion research into sociallydetermined conditions such as obesity. co.nclusions: i~ ~ommended that geographical approaches be used in partnership with, or as a foun~ation for, ~admonal exploratory methodologies such as group interviews or other forms of commumty consultation that are more inclusive and representative of the populations of interest. qilhl in los angeles county ,,..ia shaheen, richard casey, fernando cardenas, holman arthurs, and richard baker ~the retinomax autorefractor has been used for vision screening of preschool age childien. ir bas been suggested to be used and test school age children but not been validated in this age poup. ob;taiw: to compare the results of retinomax autorefractor with findings from a comprehensive i!' examination using wet retinoscopy for refractive error. mllhods: children - years old recruited from elementary schools at los angeles county were iaml with snellen's chart and the retinomax autorefractor and bad comprehensive eye examination with dilation. the proportion of children with abnormal eye examination as well as diesensitiviry and specificity of the screening tools using retinomax autorefractor alone and in combinalion wirh snellen's chart. results of the children enrolled in the study (average age= . ± . years; age range, - years), ?% had abnormal eye examination using retinoscopy with dilation. for the lerinomax, the sensitivity was % ( % confidence interval [ci] %- %), and the specificity was % ( % ci, %- o/o). simultaneous testing using snellen's chart and retinomax resulted in gain in sitiviry ( %, % cl= , ), and loss in specificity ( %, % cl= %- %). the study showed that screening school age children with retinomax autorefractor could identify most cases with abnormal vision but would be associated with many false-positive results. simuhaneous resting using snellen's chart and retinomax maximize the case finding but with very low specificiry. mdhotjs: a language-stratified, random sample of members of the college of family physicians of canada received a confidential survey. the questionnaire collected data on socio-demographic characteristics, medical training, practice type, setting and hcv-related care practices. the self-adminisratd questionnaire was also made available to participants for completion on the internet. batdti: response proportion was %. median age was years ( % female) and the proporlionoffrench questionnaires was %. approximately % had completed family medicine residency lllining in canada; median year of training completion was . sixty-seven percent, % and % work in private offices/clinics, community hospitals and emergency departments, respectively. regarding ~practices, % had ever requested a hcv test and % of physicians had screened for hcv iafrction in rhe past months· median number of tests was . while % reported having no hcv-uaed patients in their practic~, % had - hcv-infected patients. regarding the level of hcv care provided, . % provide ongoing advanced hcv care including treatment and dose monitoring for ctmduions: in this sample of canadian family physicians, most had pro~ided hcv screening. to •least one patient in the past year. less than half had - hcv-infected patients and % provide ~:relared care the role of socio-demographic factors, medical training as wel_i as hcv ca~e percep-lldas rhe provision of appropriate hcv screening will be examined and described at the time of the canference. ' - (c) healthcare services: the context of nepal meen poudyal chhetri """ tl.ction healthcare service is related with the human rights and fundamental righ~ of the ci~ ciaaiuntry. however, the growing demand foi health care services, quality heal~care service, accessib b~ id die mass population and paucity of funds are the different but interrelated issues to .be ~ddressed. m nepat. n view of this context, public health sector in nepal is among other sectors, which is struggling -.i for scarce resources. . . . nepal, the problems in the field of healthcare servic~s do not bnut ~o the. paucity of faads and resources only, but there are other problems like: rural -urban imbalance, regional unbalance, poster sessio~ f the ll ·m ·ted resources poor healthcare services, inequity and inaccessibility of the poor management o , . poor people of the rural, remote and hilly areas for the healthcare services and so on.. . . . · . i f ct the best resource allocation is the one that max m zes t e sum o m ivi ua s u · ea t services. n a , · h d' ·b · · · h . ·t effi.ciency and efficient management are correlated. it might be t e re istn utmn of mes. ence, equi y, . . . . . income or redistribution of services. moreover, maximizanon of available resources, qua tty healthcare services and efficient management of them are the very important and necessary tools and techmques to meet the growing demand and quality healthcare services in nepal. p - (a) an jn-depth analysis of medical detox clients to assist in evidence based decision making xin li, huiying sun, ajay puri, david marsh, and aslam anis introduction: problematic substance use represents an ever-increasing public health challenge. in the vancouver coastal health (vch) region, there are more than , individuals having some probability of drug or alcohol dependence. to accommodate this potential demand for addiction related services, vch provides various services and treatment, including four levels of withdrawal management services (wms). clients seeking wms are screened and referred to appropriate services through a central telephone intake service (access i). the present study seeks to rigorously evaluate one of the services, vancouver detox, a medically monitored -bed residential detox facility, and its clients. doing so will allow decision makers to utilize evidence based decision-making in order to improve the accessibility and efficiency of wms, and therefore, the health of these clients. methods: we extract one-year data (october , -september , from an efficient and comprehensive database. the occupancy rate of the detox centre along with the clients' wait time for service and length of stay (los) are calculated. in addition, the effect of seasonality on these variables and the impact of the once per month welfare check issuance on the occupancy rate are also evaluated. results: among the clients (median age , % male) who were referred by access! to vancouver detox over the one-year period, were admitted. the majority ( %) of those who are not admitted are either lost to follow up (i.e., clients not having a fixed address or telephone) or declined service at time of callback. the median wait time was day [q -ql: - ], the median los was days iq -qt: - ], and the average bed occupancy rate was %. however, during the threeday welfare check issue period the occupancy rate was lower compared to the other days of the year % vs. %, p conclusion: our analysis indicates that there was a relatively short wait time at vancouver detox, however % of the potential clients were not served. in addition, the occupancy rate declined during the welfare check issuance period and during the summer. this suggests that accessibility and efficiency at vancouver detox could be improved by specifically addressing these factors. background: intimate partner violence (ipv) is associated with acute and chronic physical and men· tal health outcomes for women resulting in greater use of health services. yet, a vast literature attests to cultural variations in perceptions of health and help-seeking behaviour. fewer studies have examined differences in perceptions of ipv among women from ethnocultural communities. the recognition, definition, and understanding of ipv, as well as the language used to describe these experiences, may be different in these communities. as such, a woman's response, including whether or not to disclose or seek help, may vary according to her understanding of the problem. methods: this pilot study explores the influence of cultural factors on perceptions of and responses to ipv among canadian born and immigrant young women. in-depth focus group interviews were con· ducted with women, aged to years, living in toronto. open-ended and semi-structured interview questions were designed to elicit information regarding how young women socially construct jpv and where they would go to receive help. interviews were transcribed, then read and independently coded by the research team. codes were compared and disagreements resolved. qualitative software qsr n was used to assist with data management. . ruu~ts_: res~nses_abo~t what constitutes ipv were similar across the study groups. when considering specific ab.us ve ~ tuanons and types of relationships, participants held fairly relativistic views about ipv, especially with regard to help-seeking behaviour. cultural differences in beliefs about normaive m;ile/femal~ relations. familial.roles, and customs governing acceptable behaviours influenced partictpants perceptions about what n ght be helpful to abused women. interview data highlight the social l ter srnfons v suucrural _impact these factors ha:e on you?g women and provide details regarding the dynamics of cibnocultur~ m~uences on help-~eekmg behav ur: t~e ro~e of such factors such as gender inequality within rtlaoo?sh ps and t_he ~erce ved degree of ~oc al solat on and support nerworks are highlighted. collc~ the~ findmgs unde~score the _ mporta_nc_e of understanding cultural variations in percrprions of ipv ~ relanon to ~elp-seekmg beha~ ':'ur. th s_mformation is critical for health professionals iodiey may connnue developmg culturally sensmve practices, including screening guidelines and protorol s. ln addition, _this study demonstr~tes that focus group interviews are valuable for engaging young romen in discussions about ipv, helpmg them to 'name' their experiences, and consider sources of help when warranted. p -s (a) health problems and health care use of young drug users in amsterdam .wieke krol, evelien van geffen, angela buchholz, esther welp, erik van ameijden, and maria prins / trod ction: recent advances in health care and drug treatment have improved the health of populations with special social and health care needs, such as drug users. however, still a substantial number dots not have access to the type of services required to improve their health status. in the netherlands, tspccially young adult drug users (yad) whose primary drug is cocaine might have limited access to drugrreatment services. in this study we examined the history and current use of (drug associated) treatmmt services, the determinants for loss of contact, and the current health care needs in the young drug mm amsterdam study (yodam). methods: yodam started in and is embedded in the amsterdam cohort study among drug mm. data were derived from y ad aged < years who had used cocaine, heroin, ampheramines and i or methadone at least days a week during the months prior to enrolment. res lts:of yao, median age was years (range: - years), % was male and % had dutch nationality at enrolment. nearly all participants ( %) reported a history of contact with drug llt.lnnent services (methadone maintenance, rehabilitation clinics and judicial treatment), mental health car? (ambulant mental care and psychiatric hospital) or general treatment services (day-care, night-care, hdp for living arrangements, work and finance). however, only % reported contact in the past six l!xlllths. this figure was similar in the first and second follow-up visit. among y ad who reported no current contact with the health care system, % would like to have contact with general treatment serl' icts. among participants who have never had contact with drug treatment services, % used primarily cocaine compared with % and % among those who reported past or current contact, respectively. saied on the addiction severity index, % reported at least one mental health problem in the past days, but only % had current contact with mental health services. concl sion: results from this study among young adult drug users show that despite a high contact rm with health care providers, the health care system seems to lose contact with yao. since % indicatt the need of general treatment services, especially for arranging house and living conditions, health m services that effectively integrate general health care with drug treatment services and mental health care might be more successful to keep contact with young cocaine users. mtthods: respondents included adults aged and over who met dsm-iv diagn?snc criteria for an anxiety or depressive disorder in the past months. we performed two sets of logisnc regressmns. thtdichotomous dependent variables for each of the regressions indicated whether rhe respondenr_vis-ud a psychiatrist, psychologist, family physician or social worker in the _past_ months. no relationship for income. there was no significant interaction between educatmn an mco~:· r: ::or respondents with at least a high school education to seek help ~rom any of the four servic p were almost twice that for respondents who had not completed high school. th . d ec of analyses found che associacion becween educacion and use of md-provided care e secon s · · be d · · ·f· ly ·n che low income group for non-md care, the assoc anon cween e ucatlon and was s gm icant on -· . . . . use of social workers was significant in both income groups, but significant only for use of psychologists in che high-income group. . . . conclusion: we found differences in healch service use by education level. ind v duals who have nor compleced high school appeared co use less mental he~lt~ servi~es provided ~y psyc~iatrists, psycholo· gists, family physicians and social workers. we found limited e.v dence _suggesting the influence of educa· tion on service use varies according to income and type of service provider. results suggesc there may be a need to develop and evaluate progr~ms.designe~ to deliver targeted services to consumers who have noc completed high school. further quahtanve studies about the expen· ence of individuals with low education are needed to clarify whether education's relationship with ser· vice use is provider or consumer driven, and to disentangle the interrelated influences of income and education. system for homeless, hiv-infected patients in nyc? nancy sahler, chinazo cunningham, and kathryn anastos introduction: racial/ethnic disparities in access to health care have been consistently documented. one potential reason for disparities is that the cultural distance between minority patients and their providers discourage chese patients from seeking and continuing care. many institucions have incorporated cultural compecency craining and culturally sensicive models of health care delivery, hoping co encourage better relacionships becween patients and providers, more posicive views about the health care system, and, ulcimacely, improved health outcomes for minority patients. the current scudy tests whether cultural distance between physicians and patients, measured by racial discordance, predicts poorer patient attitudes about their providers and the health care system in a severely disadvantaged hiv-infected population in new york city that typically reports inconsistent patterns of health care. methods: we collected data from unscably housed black and latino/a people with hiv who reported having a regular health care provider. we asked them to report on their attitudes about their provider and the health care system using validated instruments. subjects were categorized as being racially "concordant" or "discordant" with their providers, and attitudes of these two groups were compared. results: the sample consisted of ( %) black and ( %) latino/a people, who reported having ( %) black physicians, ( %) latino/a physicians, ( %) white physicians, and ( %) physicians of another/unknown race/ethnicity. overall, ( %) subjects had physicians of a different race/ethnicity than their own. racial discordance did not predict negative attitudes about rela· tionship with providers: the mean rating of a i-item trust in provider scale (lo=high and o=low) was . for both concordant and discordant groups, and the mean score in -icem relationship with provider scale ( =high and !=low) was . for both groups. however discordance was significantly associated with distrust in che health care syscem: che mean score on a -icem scale ( =high discrust and l=low distrust) was . for discordant group and . for che concordant group (t= . , p= . ). we further explored these patterns separacely in black and lacino/a subgroups, and using different strategies ro conceptualize racial/ethic discordance. conclusions: in this sample of unscably housed black and latino/a people who receive hiv care in new york city, having a physician from the same racial/ethnic background may be less important for developing a positive doctor-patient relationship than for helping the patients to dispel fear and distrust about the health care system as a whole. we discuss the policy implications of these findings. ilene hyman and samuel noh . .abstract objectiw: this study examines patterns of mental healthcare utilization among ethiopian mm grants living in toronto. methods: a probability sample of ethiopian adults ( years and older) completed structured face-to-face interviews. variables ... define, especially who are non-health care providers. plan of analysis. results: approximately % of respondents received memal health services from mainstream healthcare providers and % consulted non-healthcare professionals. of those who sought mental health services from mainstream healthcare providers, . % saw family physicians, . % visited a psychiatrist. and . % consulted other healthcare providers. compared with males, a significantly higher proportion gsfer sessions v ri ftlnales consulted non-healthcare_ professionals for emotional or mental health problems (p< . ). tlbile ethiopian's overall use of mamstream healthcare services for emotional problems ( %) did not prlydiffer from the rate ( %) of the general population of ontario, only a small proportion ( . %) rjerhiopians with mental health needs used services from mainstream healthcare providers. of these, !oj% received family physicians' services, . % visited a psychiatrist, and . % consulted other healthll/c providers. our data also suggested that ethiopian immigrants were more likely to consult tradioooal healers than health professionals for emotional or mental health problems ( . % vs. . % ). our bivariate analyses found the number of somatic symptoms and stressful life events to be associated with an increased use of medical services and the presence of a mental disorder to be associated with a dfcreased use of medical services for emotional problems. however, using multivariate methods, only die number of somatic symptoms remained significantly associated with use of medical services for emooonal problems. diu#ssion: study findings suggest that there is a need for ethnic-specific and culturally-appropriate mrcrvention programs to help ethiopian immigrants and refugees with mental health needs. since there ~a strong association between somatic symptoms and the use family physicians' services, there appears robe a critical role for community-based family physicians to detect potential mental health problems among their ethiopian patients, and to provide appropriate treatment and/or referral. the authors acknowledge the centre of excellence for research in immigration and settlement (ceris) in toronto and canadian heritage who provided funding for the study. we also acknowledge linn clark whose editorial work has improved significantly the quality of this manuscript. we want to thank all the participants of the study, and the ethiopian community leaders without whose honest contributions the present study would have not been possible. this paper addresses the impact of the rationalization of health-care services on the clinical decision-making of emergency physicians in two urban hospital emergency departments in atlantic canada. using the combined strategies of observational analysis and in-depth interviewing, this study provides a qualitative understanding of how physicians and, by extension, patients are impacred by the increasing ancmpts to make health-care both more efficient and cost-effective. such attempts have resulted in significantly compromised access to primary care within the community. as a consequence, patients are, out of necessity, inappropriately relying upon emergency departments for primary care services as well as access to specialty services. within the hospital, rationalization has resulted in bed closures and severely rmricted access to in-patient services. emergency physicians and their patients are in a tenuous position having many needs but few resources. furthermore, in response to demands for greater accountability, physicians have also adopted rationality in the form of evidence-based medicine. ultimately, ho~ever, rationality whether imposed upon, or adopted by, the profession significantly undermines physu.: ans' ability to make decisions in the best interests of their patients. johnjasek, gretchen van wye, and bonnie kerker introduction: hispanics comprise an increasing proportion of th.e new york city (nyc) populanon !currently about %). like males in the general population, h spamc males (hm) have a lower prrval,nce of healthcare utilization than females. however, they face additional access barriers such as bnguage differences and high rates of uninsurance. they also bear a heavy burden of health problems lllehasobesity and hiv/aids. this paper examines patterns of healthcare access and ut hzat on by hm compared to other nyc adults and identifies key areas for intervention. . . . and older are significantly lower than the nhm popu anon . v. . , p<. ), though hi\' screening and immunizations are comparable between the two groups. conclusion: findings suggest that hm have less access t? healthcare than hf or nhm. hown r, hm ble to obtain certain discrete medical services as easily as other groups, perhapsdueto!rtor are a hm. i i . subsidized programs. for other services, utilization among s ower. mprovmg acc~tocareinthis group will help ensure routine, quality care, which can lead to a greater use of prevennve services iii! thus bener health outcomes. introduction: cancer registry is considered as one of the most important issues in cancer epidemiology and prevention. bias or under-reporting of cancer cases can affect the accuracy of the results of epidemiological studies and control programs. the aim of this study was to assess the reliability of the regional cancer report in a relatively small province (yasuj) with almost all facilities needed for c llcll diagnosis and treatment. methods: finding the total number of cancer cases we reviewed records of all patients diagnoicd with cancer (icd - ) and registered in any hospital or pathology centre from until i n yasuj and all ( ) surrounding provinces. results: of patients who were originally residents of yasui province, . % wereaccoulll!d for yasuj province. the proportion varies according to the type of cancer, for exarnplecancetsofdiglstive system, skin and breast were more frequently reported by yasuj's health facilities whereas cancmoi blood, brain and bone were mostly reported by neighbouring provinces. the remaining cases ( . % were diagnosed, treated and recorded by neighbouring provinces as their incident cases. this is partly because of the fact that patients seek medical services from other provinces as they believed that the facil. ities are offered by more experienced and higher quality stuffs and their relative's or temporary acooiii' modation addresses were reported as their place of residence. conclusion: measuring the spatial incidence of cancer according to the location of report ortht current address affected the spatial statistics of cancer. to correct this problem recording the permanm! address of diagnosed cases is important. p - (c). providing primary healthcare to a disadvantaged population at a university-run commumty healthcare facility tracey rickards the. c:ommuni~y .h~alth ~linic (chc) is a university sponsored nurse-managed primary bealthwt (p~c:l clime. the clm c is an innovative model of healthcare delivery in canada that has integrated tht principles of phc ser · · h' . vices wit ma community development framework. it serves to provide access to phc services for members of th · · illi · dru is ii be . . e community, particularly the poor and those who use or gs, we mg a service-learning facil'ty f d · · · · · · d rionll h . . .,m.:. · t · . meet c ient nee s. chmc nursing and social work staff and srudents r·--· ipa em various phc activities and h .l.hont" less i . f . outreac services in the local shelters and on the streels to'"" popu auon o fredericton as well th chc · model iii fosterin an on oi : . • e promotes and supports a harm reduction . · local d!or an~ h ng ~art:ersh p with aids new brunswick and their needle exchange program, w tha ing condoms and :xu:t h:~~~e e~aint~nance therapy clients, and with the clie~ts themselves ~_r; benefits of receiving health f ucation, a place to shower, and a small clothing and food oai~· care rom a nurse p · · d d · --""~'i"· are evidenced in th r research that involved needsaans mvo ves clients, staff, and students. to date the chc has unacn- · sessment/enviro i . d ; •• '"""" ll eva uanon. the clinic has also e . d nmenta scan, cost-benefit analysis, an on-go...,, "".'i'~ facility and compassionate lea x~mme the model of care delivery' focusing on nursing roles wi~ cj rmng among students. finally, the clinic strives to share the resu•p v . -arch with the community in which it provides service by distributing a bi-monthly newsletter, and plllicipating in in-services and educational sessions in a variety of situations. the plan for the future is coolinued research and the use of evidence-based practice in order to guide the staff in choosing how much n~ primary healthcare services to marginalized populations will be provided. n- (c) tuming up the volume: marginalized women's health concerns tckla hendrickson and betty jane richmond bdrotbu:tion: the marginalization of urban women due to socio-economic status and other determinants negatively affects their health and that of their families. this undermines the overall vitaliry of urban communities. for example, regarding access to primary health care, women of lower economic surus and education levels are less likely to be screened for breast and cervical cancer. what is not as widely reported is how marginalized urban women in ontario understand and articulate their lack of access to health care, how they attribute this, and the solutions that they offer. this paper reports on the rnults of the ontario women's health network (owhn) focus group project highlighting urban women's concerns and suggestions regarding access to health care. it also raises larger issues about urban health, dual-purpose focus group design, community-based research and health planning processes. mdhods: focus group methodology was used to facilitate a total of discussions with urban and rural women across ontario from to . the women were invited to participate by local women's and health agencies and represented a range of ages, incomes, and access issues. discussions focussed on women's current health concerns, access to health care, and information needs. results were analyzed using grounded theory. the focus groups departed from traditional focus group research goals and had two purposes: ) data collection and dissemination (representation of women's voices), and ) fostering closer social ties between women, local agencies, and owhn. the paper provides a discussion and rationale for a dual approach. rax/ts: the results confirm current research on women's health access in women's own voices: urban women report difficulty finding responsive doctors, accessing helpful information such as visual aids in doctors' offices, and prohibitive prescription costs, in contrast with rural women's key concern of finding a family doctor. the research suggests that women's health focus groups can address access issues by helping women to network and initiate collective solutions. the study shows that marginalized urban women are articulate about their health conctrns and those of their families, often understanding them in larger socio-economic frameworks; howtver, women need greater access to primary care and women-friendly information in more languages and in places that they go for other purposes. it is crucial that urban health planning processes consult directly with women as key health care managers, and turn up the volume on marginalized women's voices. women: an evaluation of awareness, attitudes and beliefs introduction: nigeria has one of the highest rates of human immunodeficiency virus ihivi seroprrvalence in the world. as in most developing countries vertical transmission from mother to child account for most hiv infection in nigerian children. the purpose of this study was ro. determine the awareness, attitudes and beliefs of pregnant nigerian women towards voluntary counseling and testing ivct! for hiv. mnbod: a pre-tested questionnaire was used to survey a cross section '.>f. pregnant women ~t (lrlleral antenatal clinics in awka, nigeria. data was reviewed based on willingness to ~c~ept or re ect vct and the reasons for disapproval. knowledge of hiv infection, routes of hiv transm ssmn and ant rnroviral therapy iart) was evaluated. hsults: % of the women had good knowledge of hiv, i % had fair knowledge while . % had poor knowledge of hiv infection. % of the women were not aware of the association of hreast milk feeding and transmission of hiv to their babies. majority of the women % approved v~t while % disapproved vct, % of those who approved said it was because vct could ~educe risk of rransmission of hiv to their babies. all respondents, % who accepted vc.i ~ere willing to be tnted if results are kept confidential only % accepted to be tested if vc.t results w. be s~ared w .th pinner and relatives % attributed their refusal to the effect it may have on their marriage whale '-gave the social 'and cultural stigmatization associated with hiv infection for their r~fusal.s % wall accept vct if they will be tested at the same time with their partners. ~ of ~omen wall pref~r to breast feed even if they tested positive to hiv. women with a higher education diploma were times v more likely to accept vct. knowledge of art for hiv infected pregnant women as a means of pre. vention of maternal to child transmission [pmtct) was generally poor, % of respondents wm aware of art in pregnancy. conclusion: the acceptance of vct by pregnant women seems to depend on their understanding that vct has proven benefits for their unborn child. socio-cultur al factors such as stigmatizationof hiv positive individuals appears to be the maj_or impedi~ent towards widespread acceptanee of ycr in nigeria. involvemen t of male partners may mpro~e attitudes t~wa~ds vct:the developmentofm novative health education strategies is essential to provide women with mformanon as regards the benefits of vct and other means of pmtct. p - (c) ethnic health care advisors in information centers on health care and welfare in four districts of amsterdam arlette hesselink, karien stronks, and arnoud verhoeff introduction : in amsterdam, migrants report a "worse actual health and a lower use of health care services than the native dutch population. this difference might be partly caused by problems migrants have with the dutch language and health care and welfare system. to support migrants finding their way through this system, in four districts in amsterdam information centers on health care and welfare were developed in which ethnic health care advisors were employed. their main task is to provide infor· mation to individuals or groups in order to bridge the gap between migrants and health care providers. methods: the implementat ion of the centers is evaluated using a process evaluation in order to give inside in the factors hampering and promoting the implementat ion. information is gathered using reports, attending meetings of local steering groups, and by semi-structu red interviews with persons (in)directly involved in the implementat ion of the centers. in addition, all individual and groupcontaets of the health care advisors are registered extensively. results: since four information centers, employing ethnic health care advisors, are implemented. the ethnicity of the health care advisors corresponds to the main migrant groups in the different districts (e.g. moroccan, turkeys, surinamese and african). depending on the local steering groups, the focus of the activities of the health care advisors in the centers varies. in total, around individual and group educational sessions have been registered since the start. most participants were positive about the individual and group sessions. the number of clients and type of questions asked depend highly on the location of the centers (e.g. as part of a welfare centre or as part of a housing corporation). in all districts implementa tion was hampered by lack of ongoing commitment of parties involved (e.g. health care providers, migrant organization s) and lack of integration with existing health care and welfare facilities. discussion: the migrant health advisors seem to have an important role in providing information on health and welfare to migrant clients, and therefore contribute in bridging the gap between migrants and professionals in health care and welfare. however, the lack of integration of the centers with the existing health care and welfare facilities in the different districts hampers further implementation . therefore, in most districts the information centres will be closed down as independent facilicities in the near future, and efforts are made to better connect the position of migrant health advisor in existing facilities. the who report ranks the philippines as ninth among countries with a high tb prevalence. about a fourth of the country's population is infected, with majority of cases coming from the lower socioeconomic segments of the community. metro manila is not only the economic and political capital of the philippines but also the site of major universities and educational institutions. initial interviews with the school's clinicians have established the need to come up with treatment guidelines and protocols for students and personnel when tb is diagnosed. these cases are often identified during annual physical examinations as part of the school's requirements. in many instances, students and personnel diagnosed with tb are referred to private physicians where they are often lost to follow-up and may have failure of treatment due to un monitored self-administered therapy. this practice ignores the school clinic's great potential as a tb treatment partner. through its single practice network (spn) initiative, the philippine tuberculosis initiatives for the private sector (philippine tips), has established a model wherein school clinics serve as satellite treatment partners of larger clinics in the delivery of the directly observed treatment, short course (dots) protocol. this "treatment at the source" allows school-based patients to get their free government-suppl ied tb medicines from the clinic each day. it also cancels out the difficulty in accessing medicines through the old model where the patient has to go to the larger clinic outside his/her school to get treatment. the model also enables the clinic to monitor the treatment progress of the student and assumes more responsibility over their health. this experience illustrates how social justice in health could be achieved from means other than fund generation. the harnessing of existing health service providers in urban communities through standardized models of treatment delivery increases the probability of treatment success, not only for tb but for other conditions as well. p - (c) voices for vulnerable populations: communalities across cbpr using qualitative methods martha ann carey, aja lesh, jo-ellen asbury, and mickey smith introduction: providing an opportunity to include, in all stages of health studies, the perspectives and experiences of vulnerable and marginalized populations is increasingly being recognized as a necessary component in uncovering new solutions to issues in health care. qualitative methods, especially focus groups, have been used to understand the perspectives and needs of community members and clinical staff in the development of program theory, process evaluation and refinement of interventions, and for understanding and interpreting results. however, little guidance is available for the optimal use of such information. methods: this presentation will draw on diverse experiences with children and their families in an asthma program in california, a preschool latino population in southern california, a small city afterschool prevention program for children in ohio, hiv/aids military personnel across all branches of the service in the united states, and methadone clinic clients in the south bronx in new york city. focus groups were used to elicit information from community members who would not usually have input into problem definitions and solutions. using a fairly common approach, thematic analysis as adapted from grounded theory, was used to identify concerns in each study. next we looked across these studies, in a meta-synthesis approach, to examine communalities in what was learned and in how information was used in program development and refinement. results: while the purposes and populations were diverse, and the type of concerns and the reporting of results varied, the conceptual framework that guided the planning and implementation of each study was similar, which led to a similar data analysis approach. we will briefly present the results of each study, and in more depth we will describe the communalities and how they were generated. conclusions: while some useful guidance for planning future studies of community based research was gained by looking across these diverse studies, it would be useful to pursue a broader examination of the range of populations and purposes to more fully develop guidance. background: the majority of studies examining the relationship between residential environments and cardiovascular disease have used census derived measures of neighborhood ses. there is a need to identify specific features of neighborhoods relevant to cardiovascular disease risk. we aim to ) develop methods· data on neighborhood conditions were collected from a telephone survey of s, fesi· dents in balth:.ore, md; forsyth county, nc; and new york, ny. a sample of of the i.ni~~l l'elpondents was re-interviewed - weeks after the initial interview t~ measure the tes~-~etest rebab ~ ty of ~e neighborhood scales. information was collected across seven ~e ghborho~ cond ~ons (aesth~~ ~uah~, walking environment, availability of healthy foods, safety, violence, social cohesion, and acnvmes with neighbors). neighborhoods were defined as census tracts or homogen~us census tra~ clusters. ~sycho metric properties.of the neighborhood scales were accessed by ca~cu~~.ng chronba~h s alpha~ (mtemal consistency) and intraclass correlation coefficients (test-r~test reliabilmes) .. pear~n s .corre~anons were calculated to test for associations between indicators of neighborhood ses (tncludmg d mens ons of race/ ethnic composition, family structure, housing, area crowding, residential stability, education, employment, occupation, and income/wealth) and our seven neighborhood scales. . chronbach's alphas ranged from . (walking environment) to . (violence). intraclass correlations ranged from . (waling environment) to . (safety) and wer~ high~~~ . ~ for ~urout of the seven neighborhood dimensions. our neighborhood scales (excluding achv hes with neighbors) were consistently correlated with commonly used census derived indicators of neighborhood ses. the results suggest that neighborhood attributes can be reliably measured. further development of such scales will improve our understanding of neighborhood conditions and their importance to health. childhood to young adulthood in a national u.s. sample jen jen chang lntrodfldion: prior studies indicate higher risk of substance use in children of depressed mothers, but no prior studies have followed up the offspring from childhood into adulthood to obtain more precise estimates of risk. this study aimed to examine the association between early exposure to maternal depl'elsive symptoms (mds) and offspring substance use across time in childhood, adolescence, and young adulthood. methods: data were obtained from the national longitudinal survey of youth. the study sample includes , mother-child/young adult dyads interviewed biennially between and with children aged to years old at baseline. data were gathered using a computer-assisted personal interview method. mds were measured in using the center for epidemiologic studies depression scale. offspring substance use was assessed biennially between and . logistic and passion regression models with generalized estimation equation approach was used for parameter estimates to account for possible correlations among repeated measures in a longitudinal study. rnlllta: most mothers in the study sample were whites ( %), urban residents ( %), had a mean age of years with at least a high school degree ( %). the mean child age at baseline was years old. offspring cigarette and alcohol use increased monotonically across childhood, adolescence, and young adulthood. differential risk of substance use by gender was observed. early exposure to mds was associated with increased risk of cigarette (adjusted odds ratio (aor) = . , % confidence interval ( ): . , . ) and marijuana use (aor = . , % ci: . , . ), but not with alcohol use across childhood, adolescence, and young adulthood, controlling for a child's characteristics, socioeconomic status, ~ligiosity, maternal drug use, and father's involvement. among the covariates, higher levels of father's mvolvement condluion: results from this study confirm previous suggestions that maternal depressive symptoms are associated with adverse child development. findings from the present study on early life experi-e~ce have the potential to inform valuable prevention programs for problem substance use before disturbances become severe and therefore, typically, much more difficult to ameliorate effectively. the ~act (~r-city men~ health study predicting filv/aids, club and other drug transi-b~) study a multi-level study aimed at determining the association between features of the urban enyjronment mental health, drug use, and risky sexual behaviors. the study is randomly sampling foster sessions v neighborhood residents and assessing the relations between characteristics of ethnographically defined urban neighborhoods and the health outcomes of interest. a limitation of existing systematic methods for evaluating the physical and social environments of urban neighborhoods is that they are expensive and time-consuming, therefore limiting the number of times such assessments can be conducted. this is particularly problematic for multi-year studies, where neighborhoods may change as a result of seasonality, gentrification, municipal projects, immigration and the like. therefore, we developed a simpler neighborhood assessment scale that systematically assessed the physical and social environment of urban neighborhoods. the impact neighborhood evaluation scale was developed based on existing and validated instruments, including the new york city housing and vacancy survey which is performed by the u.s. census bureau, and the nyc mayor's office of operations scorecard cleanliness program, and modified through pilot testing and cognitive testing with neighborhood residents. aspects of the physical environment assessed in the scale included physical decay, vacancy and construction, municipal investment and green space. aspects of the social environment measured include social disorder, social trust, affluence and formal and informal street economy. the scale assesses features of the neighborhood environment that are determined by personal (e.g., presence of dog feces), community (e.g., presence of a community garden), and municipal (e.g., street cleanliness) factors. the scale is administered systematically block-by-block in a neighborhood. trained research staff start at the northeast corner of an intersection and walk around the blocks in a clockwise direction. staff complete the scale for each street of the block, only evaluating the right side of the street. thus for each block, three or more assessments are completed. we are in the process of assessing psychometric properties of the instrument, including inter-rater reliability and internal consistency, and determining the minimum number of blocks or street segments that need to be assessed in order to provide an accurate estimate of the neighborhood environment. these data will be presented at the conference. obj«tive: to describe and analyze the perceptions of longterm injection drug users (idus) about their initiation into injecting. toronto. purposive sampling was used to seek out an ethnoculturally diverse sample of idus of both genders and from all areas of the city, through recruitment from harm reduction services and from referral by other study participants. interviews asked about drug use history including first use and first injecting, as well as questions about health issues, service utilization and needs. thematic analysis was used to examine initiation of drug use and of injection. results: two conditions appeared necessary for initiation of injection. one was a developed conception of drugs and their (desirable) effects, as suggested by the work of becker for marijuana. thus virtually all panicipants had used drugs by other routes prior to injecting, and had developed expectations about effects they considered pleasureable or beneficial. the second condition was a group and social context in which such use arose. no participants perceived their initiation to injecting as involving peer pressure. rather they suggested that they sought out peers with a similar social situation and interest in using drugs. observing injection by others often served as a means to initiate injection. injection served symbolic purposes for some participants, enhancing their status in their group and marking a transition to a different social world. concl ion: better understanding of social and contextual factors motivating drug users who initiate injection can assist in prevention efforts. ma!onty of them had higher educational level ( %-highschool or higher).about . yo adffiltted to have history of alcohol & another . % had history of smoking. only . % people were on hrt & . % were receiving steroid. majority of them ( . ) did not have history of osteoporosis. . % have difficulty in ambulating. only . % had family history of osteoporosis. bmd measurements as me~sured by dual xray absorptiometry (dexa) were used for the analysis. bmd results were compare~ w ~ rbc folate & serum vitamin b levels. no statistical significance found between bmd & serum v taffiln b level but high levels of folate level is associated with normal bmd in bivariate and multivariate analysis. conclusion: in the studied elderly population, there was no relationship between bmd and vitamin b ; but there was a significant association between folate levels & bmd. introduction: adolescence is a critical period for identity formation. western studies have investigated the relationship of identity to adolescent well-being. special emphasis has been placed on the influence of ethnic identity on health, especially among forced migrants in different foreign countries. methodology: this study asses by the means of an open ended question identity categorization among youth in three economically disadvantaged urban communities in beirut, the capital of lebanon. these three communities have different histories of displacement and different socio-demographic makeup. however, they share a history of displacement due to war. results and conclusion: the results indicated that nationality was the major category of identification in all three communities followed by origin and religion. however, the percentages that self-identify by particular identity categories were significantly different among youth in the three communities, perhaps reflecting different context in which they have grown up. mechanical heart valve replacement amanda hu, chi-ming chow, diem dao, lee errett, and mary keith introduction: patients with mechanical heart valves must follow lifelong warfarin therapy. war· farin, however, is a difficult drug to take because it has a narrow therapeutic window with potential seri· ous side effects. successful anticoagulation therapy is dependent upon the patient's knowledge of this drug; however, little is known regarding the determinants of such knowledge. the purpose of this study was to determine the influence of socioeconomic status on patients' knowledge of warfarin therapy. methods: a telephone survey was conducted among patients to months following mechan· ical heart valve replacement. a previously validated -item questionnaire was used to measure the patient's knowledge of warfarin, its side effects, and vitamin k food sources. demographic information, socioeconomic status data, and medical education information were also collected. results: sixty-one percent of participants had scores indicative of insufficient knowledge of warfarin therapy (score :s; %). age was negatively related to warfarin knowledge scores (r= . , p = . ). in univariate analysis, patients with family incomes greater than $ , , who had greater. than a grade education and who were employed or self employed had significantly higher warfarm knowledge scores (p= . , p= . and p= . respectively). gender, ethnicity, and warfar~n therapy prior to surgery were not related to warfarin knowledge scores. furthermore, none of t~e. m-hospital tea~hing practices significantly influenced warfarin knowledge scores. however, panic ~ants who _rece v~d post discharge co~unity counseling had significantly higher knowledge scores tn comp~r son with those who did not (p= . ). multivariate regression analysis revealed that und~r~tandmg the ~oncept of ?ternational normalized ratio (inr), knowing the acronym, age and receiving ~ommum !' counseling after discharge were the strongest predictors of warfarin kn~wledge. s~ oeconom c status was not an important predictor of knowledge scores on the multivanate analysis. poster sessions v ~the majority of patients at our institution have insufficient knowledge of warfarin therapy.post-discharge counseling, not socioeconomic status, was found to be an important predictor of warfarin knowledge. since improved knowledge has been associated with improved compliance and control, our findings support the need to develop a comprehensive post-discharge education program or, at least, to ensure that patients have access to a community counselor to compliment the in-hospital educatiop program. brenda stade, tony barozzino, lorna bartholomew, and michael sgro lnttotl#ction: due to the paucity of prospective studies conducted and the inconsistency of results, the effects of prenatal cocaine exposure on functional abilities during childhood remain unclear. unlike the diagnosis of fetal alcohol spectrum disorder, a presentation of prenatal cocaine exposure and developmental and cognitive disabilities does not meet the criteria for specialized services. implications for public policy and services are substantial. objective: to describe the characteristics of children exposed to cocaine during gestation who present to an inner city specialty clinic. mnbods: prospective cohort research design. sample and setting: children ages to years old, referred to an inner city prenatal substance exposure clinic since november, . data collection: data on consecutive children seen in the clinic were collected over an month period. instrument: a thirteen ( ) page intake and diagnostic form, and a detailed physical examination were used to collect data on prenatal substance history, school history, behavioral problems, neuro-psychological profile, growth and physical health of each of the participants. data analysis: content analysis of the data obtained was conducted. results: twenty children aged to years (mean= . years) participated in the study. all participants had a significant history of cocaine exposure and none had maternal history or laboratory (urine, meconium or hair) exposure to alcohol or other substances. none met the criteria of fetal alcohol spectrum disorder. all were greater than the tenth percentile on height, weight, and head circumference, and were physically healthy. twelve of the children had iqs at the th percentile or less. for all of the children, keeping up with age appropriate peers was an ongoing challenge because of problems in attention, motivation, motor control, sensory integration and expressive language. seventy-four percent of participants had significant behavioral and/or psychological problems including aggressiveness, hyperactivity, lying, poor peer relationships, extreme anxiety, phobias, and poor self-esteem. conclusion: pilot study results demonstrated that children prenatally exposed to cocaine have significant learning, behavioural, and social problems. further research focusing on the characteristics of children prenatally exposed to cocaine has the potential for changing policy and improving services for this population. methods: trained interviewers conducted anonymous quantitative surveys with a random sample (n= ) of female detainees upon providing informed consent. the survey focused on: sociodemographic background; health status; housing and neighborhood stability and social resource availability upon release. results: participants were % african-american, % white, % mixed race and % native american. participants' median age was , the reported median income was <s , year, and % reported receiving a high school diploma or equivalent. women reported a number of health conditions rypical of underserved populations, including asthma ( %), sexually transmitted infections ( %), high blood pressure ( %), hcv ( %), diabetes ( %) and hiv ( %). nearly half ( %) did not anticipate having a place to stay for at least days upon release. factors significantly associated housing stability upon release were: high family support score (adjusted odds ratio [aor) . ; % confidence interval ( % cl) . , . ), high neighborhood stability score (aor . ; % cl . , . ), wanting a commercial sex worker (csw) support group (aor . ; % cl . , . ); and identifying as bisexual (aor . ; % cl . , . ). women desired employment ( %), housing ( %), education ( %), drug treattnent ( %), help with custody of children ( %), childcare ( %), and domestic violence suppon ( %) services. conclusions: female detainees represent one of urban centers' most marginalized pcjpwatioos. short periods of detention represent a unique opportunity for _interven?~ns bri~ co~s and public health institutions. service providers should collaborate ~ th local ~ails to .p~de a con uwnof care for female detainees upon release that includes transportation , housing, residential drug treallllcnt, employment, education, family reunification, childcare and domestic viol~nce su~rt. ~pecial attenlion is warranted to lesbian and bisexual women and csws, who may be especially margmalized &om family and service-based support networks. introduction: "health care and ethnic minority immigrants" examines how health care policy dil· ferences between canada and the united states impact the health-related hardships, access and use of preventative care, and health outcomes of urban ethnic minority immigrants in both countries. methods: the findings of this paper build on the results of my qualitative comparative study of hotel workers in vancouver, bc and seattle, wa that revealed greater health related hardships for similarly matched employees in seattle compared to vancouver. in this paper, i examine the generalizability of these findings at the cross-national level for similar ethnic minority immigrant groups. i compare the impact of health care policy differences on specific groups that have emigrated to cities in both canada and the united states. these include immigrants from china, viemam, philippines, west indies, africa, sri lanka, pakistan, and latin america. comparative statistical analysis -utilizing rel· evant data from statistics canada and the u.s. census -reveal the extent to which health policy differ· ences help explain how current health policy in the united states disadvantages urban ethnic minority immigrants. results: many ethnic minority immigrants are a part of the working poor, a group which disproportionately lacks health insurance coverage in the united states. their position in the labour market makes them most vulnerable to exclusion from health care services. the data reveals how current u.s. health policy creates barriers for recently arrived ethnic minority immigrants to access health insurance and care. it remains difficult to ascribe health outcome differences directly to policy differences because of the challenge in disentangling the complex interacting interventing variables, including income inequality, that determine health outcomes. yer suggestive evidence suggests that health policy in the united states is harming the health of urban ethnic minority immigrants. the current health policy regime in the united states harms the health access, care, and outcomes of urban ethnic minority immigrants. comparing the fortunes of similar immigrants in cana· dian and u.s. cities reveals these patterns of disadvantage and some of their consequences. these barriers are an understudied factor in the sociological literature on "segmented assimilation" and social exclu· sion. the paper ends with policy recommendatio ns to improve access to health care among ethnic minor· ity immigrants in both countries, with the goal of reducing health related hardships, and improving health outcomes. mass index deyu pan, richard baker, and keith norris badtgrou~ over the past decades, there has been dramatic increase in prevalence of obesity in the us population. however, the relationship between obesity and the prevalence of cardiovascular dis· ease (cv~) risk factors in different race/ethnic groups over time is not well known. . ik~rgn: _we use cross-sectional , nationally representative surveys: national health and nutri· t nal examination survey (nhanes iii - (n= ) and nhanes nhanes - , including white, black, and hispa~ic races who were no~preg~ant, aged to years. res lt : the preval~nce of high cholesterol level (~ mg/dl), untreated high blood pressure ( : l / mm hg) an~ diabetes were calculated according to bmi group (lean, < ; overweight, - ; and obese, : ) for different race/ethnicity groups. over the approximately years period (from l ~ ~o [ ] [ ] [ ] [ ] , reducrion in cvd risk factors in non-hispanic white has been observed. for mmonty race/~hnicity groups, black and hispanic, there had been increases in prevalence in high blood fa pressure and diabetes. the lean group experienced larger increase in prevalence of those cvd risk ctors. . fo~~ the prevalence in cvd risk factors over time had reduced in most of the bmi ca egoes r t e w ~~e population. however, for black and hispanic, prevalence of of cvd risk factors ave generauy uncreased, especially in overweight and obese groups. methods: strategies identified to achieve these goals include: developing meaningful neighbourhood and district boundaries for comparing health information, providing free access to neighbourhood health profiles (including relevant data at the smallest level for which valid rates could be calculated); mapping relationships of inequality at a variety of nested levels; providing a range of formats (maps, tables) to meet the needs of users; providing technical support; seeking user input to advance and improve the site; and conducting workshops to foster access and use of data for decision-making , advocacy and collaboration. an evaluation strategy is being developed to assess the efforts and impact of these strategies. a preliminary assessment of the results of the first six months of activity will be completed in october . results: significant differences in health are shown at all the geographic levels indicating success in developing the boundaries. results tabulated for the first six months use of the site include: site visits; media use; reference/acknow ledgement of the site in other documents; number of contacts through presentations and workshops; feedback from users identifying strengths and limitations; and, response from health decision makers. members of the partnership are identifying additional tools and services to further support actions that reduce health inequalities. the assessment will be used to develop more specific goals, targets and monitoring mechanisms. conclusions: our experience with paper-based health profiles indicates that they have been used extensively for program planning and advocacy. the greater availability of information in a publiclyavailable web-based format is expected to translate into even greater usefulness and wider application. the web site has had considerable usage to date, extensive media coverage. site users and workshop participants have provided positive feedback and suggestions for next steps. the six month review will be available in october . in india, more than and a half people are hiv-positive and half a million have aids. india currently has the largest number of positive people in the world, oumumbering south africa and accounting for nearly one tenth of the global hiv/aids prevalence. the world bank predicts that by , there will be million hiv/aids cases in india. the central challenge facing hiv prevention efforts in south asia today is learning how to respond to the societal determinants of vulnerability to hiv. hiv/aids is an issue largely engulfed by social stigma. stigma and discrimination are often considered the foremost barriers to effective poster sess ns v prevention and care initiatives. stigma can make a person afraid of disclosing their status~ ~yone el se, and may make them feel depressed or alone. stigma can .also le~d to poor adherence to medicanon, ~ likelihood to access health and social services, and less desire to hve. hiv+ men and women may beafraidtotd! their co-workers that they have hiv for fear of their reactions or for fear of losing their jobs. in a study conducted of people living with hiv/aids in delhi, india ov~r. -~, many respo~ts shared their experiences of discrimination in their families, in their communmes, an~ m health ~e settmgs. these findings will be shared in the workshop, and will be compa~ed to m~ ex~nences workmg as an ~ co~l~ at the center for aids prevention studies in san francisco, cahforma and congreso de lannos unidos m philadelphia, pennsylvania. the workshop will include an overview of hiv/aids in urban contexts in tht united states (los angeles, san francisco, new york, philadelphia) and south asia (delhi, hyderabad, chennai). differences in methods for outreach, prevention and treatment efforts between devdoped world and developing world contexts will be discussed. a large portion of the workshop will be centered on discussion. participants will engage in an exercise to categorize their ideas of stigma. the workshop will also include a powerpoint presentation on the quantitative data gathered from the survey. the number of homeless and runaway youth is increasing in toronto, which is currently home to out of youth in the gt a who live alone, and it is the preferred locale for the street-involved and homeless youth. the city's youth population is expected to grow by nearly % by , the school dropout rate is rising, and there are is a paucity of empirical data on what works with these at-risk youth. over a two-year period, ( ) ( ) ( ) , youthlink-inner city, conducted an evaluation of the impact of a harm reduction program aimed at reducing street youth's risk of contracting/infecting others with the hep c virus, which has both short-term and long-term deleterious effects. demographic data from street-youth, along with resources/services used, employment methods, type and frequency of drug use, health status, police contacts, and their views of program impact were analyzed using a standardized sur· vey. additionally, focus groups with youth, agency staff and community key informants were conducted, as well as in-depth interviews with three youth, over a sixth-month period. this paper details study results, which both inform both practice and future study about what works, why it works, and how best to work with these vulnerable youth. sho~ed .that the wasteland in this area was contaminated by as cd zn pb cu simultaneously. the con-ta~matton of as ~d was quit significant. the contamination problems and environmental issues in this region are very. serious. the awareness on environmental and health issues was investigated by spot survey and analysis. overall awareness among the residents in the region is very poor. the measures must be taken to assu~e t~e .sustainable economy development by local and central gorvernments. keywords nandan guangx ; mmmg area; environmental awareness. concern like, epileptic fits, vision problems, earache, cough of more than weeks and urinary problems. ninety-five subjects did not take bath regularly and were exposed to sex. the health problems identified are only of a particular point of time and it may be difficult to interpret the depth of "iceberg" of the street children's world also draw the health-illness continuum. periodic interaction and follow-up is very difficult as they generally disappear from the research setting due to their frequent mobility for survival measures. as per the prediction of the iceberg theory, only some problems may have been identified, larger problems in respect to their health may not have been identified. in spite of various limitations, this attempt had proven that, it is possible to enter the street children world, explore the iceberg of illnesses, and establish data of health-illness continuum through an effective nursing agency. it is recommended to deworm these children, provide nutritional education, establish "condom corners" and "street children help line" in the city and urban slum areas and undertake action research on their health. malnutrition is a serious problem in developing countries like bangladesh. malnutrition causes a great deal of child suffering. malnutrition is one of the major causes of morbidity and mortality among the child. the aim of present study was to investigate the nutritional status and its relation to socioeconomic conditions of urban disadvantaged child of under five years age. nutritional status was determined by anthropoemetric measurement(heig ht, weight, mid-arm circumference etc.). determination of total protein and serum albumin were done for biochemical examination. haematological examination was done by blood haemoglobin profile estimation by cynmethhaemoglob in method and determination of haematocrit value or packed cell volume (pcv). stool examination for ova of hook worm, round worm, trichuris species and other species were also done. relevant information on socioeconomic characteristics was recorded by interviewing the house hold head using pretested questionnaire. our study demonstrated that nutritional status of the children are positively correlated with family income, parents level of formal education and negatively related to the family size. the effect of family income on the nutritional status, haematological and biochemical indices of urban disadvantaged child under five will be discussed in detail which will help us to determine proper way of utilization of health care facilities exists in developing countries. introduction: with the increase in morbidity and reduction in mortality and with the introduction of highly active antiretroviral therapy (haart), there is increasing focus on the determinants of healthrelated quality of life (hrqol) in hiv-infection. the focus on the present study is to examine the relationship between social support, depression, and hiv disease severity, and the extent to which these variables impact on hrqol in adult men with hiv-infection. methods: as part of a larger ongoing natural history study focusing on the neurobehavioural complications of hiv and aids, we administered questionnaires to assess depression (beck depression inventory), social support, and hrqol (mos-hiv) to adult men with hiv-infection. a structured interview was used to collect health information and data on hiv disease severity. physical and mental health summary scores (phs and mhs) were derived through principal components analysis. participants were grouped according to level of social support: "well supported" (n= ), "moderately supported" (n= ), "little or ineffective support" (n= ). analysis of variance was conducted to assess the effects of three levels of perceived social support, depression status (present vs absent), and hiv disease severity (aids vs non-aids) on mental and physical health dimensions of hrqol. potential interaction effects were also evaluated. results: social support was found to have a significant effect on both mhs and phs. presence of depression was found to have a significant effect on mhs but not phs. hiv disease severity (presence of aids diagnosis) was found to have a significant effect on phs but not mhs. manov a analyses revealed no significant interactions effects. conclusions and implications: level of social support, presence of depression and hiv disease severity were shown to have independent effects on hrqol. feeling "well supported" appears to have significant benefits for mental and physical health. biological indicators of hiv disease appear to have a selective impact on physical health while presence of depression is related to significant reductions in mental health. the development and evaluation of behavioural interventions to improve perceived social support network and depression will likely result in significant improvements in health outcomes of adults with hiv and aids. introduction: ongoing medical advances have greatly enhanced the longevity of penons living with aids (plwa). however, for certain subgroups living with hiv/aids, including, members of minority groups, women and the economically underprivilege d, aids outcomes have not changed so favorably. one obvious factor to consider when explaining disparities in aids outcomes is the environ· ment within which an individual resides. few studies of aids outcomes have focused on how commu· nity setting influences the effectiveness of care delivery. the principle research questions were: ) what is the relationship between the locations of areas with concentrations of pl wa and the distribution of both primary and ancillary service providers? ) how has the widespread availability of haart (after ) impacted aids outcomes at the community level? ) how do aids mortality and fatality rates vary when related community characteristics, such as household income, ethnic mix, and geographic access to primary and ancillary hiv/aids services are considered? we examine this issue across residential communities in the los angeles area. methods: los angeles county's comprehensive aids service providers database (compiled and maintained by aids project los angeles) was geo-referenced and distances between weighted mean population centers and the nearest hiv/aids service providers were calculated to provide a measure of access which was then merged with aids diagnosis and mortality data along with relevant socioeconomic and population indicators and for analysis using bivariate and multivariate statistics at the zip code level. results: there is a growing disparity in hiv/aids outcomes between low-income minority areas and affluent non-minority areas in the post-haart era (p = . ). ancillary aids services such as case management and counseling and testing are located near the places where low income hiv/aids service consumers are likely to live (p =. ). in spite of having more access to ancillary services low income areas continue to be associated with smaller decreases post-haart aids mortality rates (p= . ). conclusions: given the increasing disparities in aids outcomes between lower and upper income communities in the post -haart era, more specific research into the capacities of aids services providers and the efficiency of their interventions is required. although it is clear that ancillary services are operating in the areas of greatest need, their effectiveness remains limited. understanding the reasons for t~is, be they lack of adequate resources for inner city service providers, failure to reach target popula· tmns or other causes, requires additional research. in ? , y.out~ who were able to speak either french or english and had been absent from their parent's/ c~regivers ~es. dence for at least three consecutive nights took part in the survey which consisted of inter· viewer-adm ms tered question~aires. p.arti~i~an~s were recruited from drop in centres in cities across <?-nada.y~uth self-report as either using in ect on or non-injection drugs. statistical analyses were car· r ed out using sas version . the 'home' is a contested site for many women living in urban areas. women living in poverty and using illicit drugs are largely excluded from participation in dominant 'home-base' gender roles of wife and mother because of economic disadvantage. they thus 'make home' in ways that are specific to their everyday experiences. while research has established links between housing, health and drug use, this literature does not tend to consider the meanings that home may have within the lives of women who lack access to adequate tenured living spaces. this presentation reports the findings of my master's thesis work. using grounded theory methodology within a poststructuralist feminist conceptual framework, i conducted in-depth, open-ended interviews with women living in the toronto area. the women were recruited from within the community through posters at different social service agencies (e.g., drop-in centres, community health centres). they were asked to describe their housing experiences and what home meant to them over the course of their lives. through the data analysis process, a substantive theory of 'making home' for women living in poverty and using illicit drugs emerged. the central concept of making home is a continual process of learning about and interacting with the environment. the process of making home entails different subprocesses: finding home (knowing what is available and accessible, and accessing home), adaptation, and leaving home. the different meanings of home that women developed from their experiences and knowledge emerged as critical components for the process of making home. the women i interviewed were very mobile and experienced constant change with regards to home. home was not considered only in relation to physical living space. home could be made within a relationship or with regards to a possession. while dominant meanings of home relation to tenured living spaces are generally positive, my research indicated that home could also be a negative context. the presentation will describe my research process and findings as well as the theoretical and policy implications of my results. in the western democracies, social citizenship bundles the right to social provision (defined as a share of the social good, not necessarily proportionate to the market value of a citizen's contribution) with participation in the paid labour force. for this reason, social citizenship rights, which usually involve some kind of redistributive measures, are a key mechanism by which states ensure economic equality, or at least, economic equality of opportunity, but are also a mechanism of social exclusion. social rights are inscribed around a single kind of relationship, that which exists between a male family breadwinner and the paid labor market; those who make economic contributions that fall outside this relationship -such as unpaid care-work, or, work that occurs in shadow or underground economiesare to a greater or lesser degree barred from accessing citizen-based social provisions. furthermore, social provision that occurs outside of the breadwinner/market-eco nomy dyad is very often meanstested and is accompanied by regulatory state apparatuses (this includes a range of social services, from welfare payments, to child-care subsidies, to disability pensions). social citizenship is thus stratified; the legal relationship that is at the heart of social citizenship acts as a form of social closure against claims for a share of the social good made by those who are 'lesser' citizens than others. of particular interest in this paper is how citizenship inequalities translate into inequalities in the social provisions that emerge from economic participation: the right to safety on the job, protection from employer harassment, protection from the vagaries of the market as well the right to adequate, comprehensive, and appropriate health services. drawing on mixed methods, longitudinal data from adult sex workers (n= ) located in two research sites with different social welfare regimes -one in canada and one in the u.s. -we examine the consequences of working in a "shadow" or "underground" economy on various facets of health and access to health services, taking into consideration the mediating role that citizenship constructs and social welfare regimes play in accessing other key social and economic determinants of health. methods: the study population included methadone patients (re)admitted at the mhs in the period from / / to / / , born in the netherlands, morocco, surinam, dutch antilles or turkye, and officially registered in the population register of amsterdam. the population register was used to ascer· rain the vital status. causes of death were provided by the central bureau of statistics. mortality was categorised as hiv related, directly drug related (overdose) and other.mortality. results: the methadone patients had the following characteristics: years of age at entry; % male; % ethnic minority; % ever injected. in total, personyear (py) of observation time and deaths ( % hiv related, % overdose; % other) were observed. hence, the crude mortality rate was / py ( % ci - / py). the percentage of (ever) injectors was higher among the native dutch than among the ethnic minorities, % and % respectively. higher rates were observed among native dutch drug users compared to those belonging to an ethnic minority (age adjusted hazard ratio (hr) . ( % ci . - . ). the age adjusted hr of (ever) injecting drug users versus non injecting users was . ( % cl . - . ). after additional adjustment for route of administration a non significant difference between the dutch and ethnic minorities remained (hr . , % cl . - . , p-value . . conclusion: the mortality rate among the heroin users in amsterdam is strongly affected by the high prevalence of non-injecting drug use. moreover, this study confirms that differences in mortality between the native dutch and the ethnic minorities is related to differences in route of administration. the ongoing reduction of injecting drug use (due tot selctieve mortality, and switching route ofadministration and popularity of crack cocaine) may lead to a further reduction of mortality rates among heroin users in amsterdam. interventions preventing the initiation of injecting should be encouraged. . introduction: food insecurity is an inequality that is central in the lives of many low-income cana· d ans. people lack food security when regular access to nutritious food is limited or variable due to high prices'. low income, lack of transportation or inadequate food distribution, or they become disadvan· taged m other w~ys through the acquisition of food. a group comprising academics, health profession· als, and commumty workers who have experience in food insecurity, developed a pilot study in ottawa that sought to und~rstand the lived experience of food insecurity. the study also used the united states department of agriculture (usda) community food security module. methods: a series of group meetings determined the best research approaches; questionnaires and consent forms were developed by a working group. twenty-three self-identified food insecure respon· dents were interviewed. the data were analysed using frequency distributions· the food security module was coded according to the usda coding guide, and open-ended responses w~re coded using a grounded approach. renlts: preliminary results from our pilot study have given the research team cause for considerable concern. out of households without children, experienced food insecurity with hunger; ~ere at the severe l~vel. out of households with children, experienced food insecurity with hunger. ~•rst person reflecnons commonly featured feelings of depression low self-esteem and despair. participants' account tha d . an cu ty gettmg to the store, severely limited putting knowledge and skills mto practice. l'oster sessions v conclusion: based on these early findings, our research team is looking to challenge what appear to be assumptions about poverty and food insecurity and for best ways to use this information. some policy approaches and interventions that encourage people to eat better and exercise more, may be missing the mark for low-income individuals, and may serve to maintain food insecurity. future research will build on this pilot. with methods augmentation, and a comprehensive knowledge dissemination plan, we hope co contribute to research and policy frameworks at all levels. ps- (a) mental health and the corrections system: population-based analyses in urban, semi-urban, and rural settings julian somers, robert watts, and michelle patterson introduction: according to recent epidemiological research, rates of mental disorders vary considerably across countries and across regions within countries. nevertheless, rates of mental disorders (including substance use disorders) are consistently higher in populations involved in the corrections sys- em. courts have long recognized the heavy burden of mental illness within their purview, and have developed innovative programs to better manage the needs of such individuals. the majority of these innovations (e.g., specialized courts) exist in urban settings. however, few studies have examined the degree of variability in rates of different mental disorders between courts in urban and other settings (e.g., semi-urban, rural). variability between courts in different settings, if present, holds implications for needs-based resource planning. the present study was conducted as part of a long-term inter-ministerial collaboration in british columbia (bc). analyses were conducted on linked administrative data regarding population health and correctional services. a database was constructed including all individuals sentenced in bc in a single year (n= , ). corrections records were matched to records of health services utilization (hospital and outpatient services) for mental disorders and substance use disorders in the years preceding sentencing. services for mental health and substance-related problems were aggregated into three groups: severe mental illness (smi); less-severe mental illness (lsmi); alcohol/other drug (ad). courts were grouped, based on their annual volumes, inro three categories: "urban"; "semi-urban" and "rural." rates of service use for mental disorders were compared between groups for -year and -years preceding sentencing. results: there were significant differences in the rates of mental disorders in courts of different size (urban, semi-urban, rural) . however, differences between the rates of disorders within each of these groups exceeded the discrepancies between groups. comparatively high and low rates of disorders were observed in courts of each size. moreover, the courts with the highest rates of certain disorders (e.g., ad) did not have the highest rates of other types of mental disorders (e.g., smi). conclusions: rates of mental disorders differed significantly among the annual populations sentenced across courts in bc. urban courts (which process comparatively large numbers of people) have implemented services to address the needs of the mentally ill. the present analyses strongly suggest that program development should be closely linked to the demonstration of need. the results caution that a uniform approach to court programs for the mentally ill is likely to be inefficient, over-supplying services in some settings and underestimating need in others. results: public settings used for injection are characterized by highly unhygienic conditions, the presence of unsafely disposed syringes, limited availability of sterile syringes and a lack of sterile water for injecting. a number of unsafe injection practices observed were common among public injectors. the presence of police officers nearby and the potential of assault by street predators fostered rushed injecting among those consuming drugs in public spaces. the ecological features of these environments encourage unhygienic and unsafe injecting practices, heighten risk for overdose and the transmission of blood borne viruses. introduction: approximately % of women experience depression in the first weeks or months after giving birth. although it has been argued that postpartum depression (ppd) is a culture-bound p~ nomenon, experienced only in western, industrialized countries, recent international research studies have confirmed that the prevalence of ppd is similar around the world. however, little is known about variables that may influence the experience of ppd in women from diverse cultures and immigrant women. research is needed to identify the role culture may play in the presentation of ppd (i.e., types of symptoms most commonly reported), how women from various racial, ethnic and cultural backgrounds perceive and attribute their symptoms of ppd, and finally, how culture can be appropriately addressed in ppd treatment programs. method: to examine the role of culture in ppd, semi-structured interviews and self-report question· naires were administered to clients of the women's health centre of st. joseph's health centre, tor· onto. participants were identified as either first generation canadians (relative newcomen) (n= ) or second generation canadian (parents were immigrants to canada) (n= ). data were collected qd these two groups of women based on: severity of depression, symptom presentation, perceived role of social supports and culturally-specific traditions, and barriers and responses to treatment. the interview data were analyzed using qualitative methods (thematic content analysis), and the following themes were identified: ) stress about passing on their culture to their children, ) lack of social support and feelings of isolation, ) perceived importance or lack of importance of cultural based tra· ditions, ) conflicts with family members. about cultural traditions and beliefs, ) mental health stigma within ethnic communities and beyond, ) race-and sex-based discrimination, and ) language barriers. conclrllion: identifying the role culture plays in the presentation of ppd, and how women from diverse backgrounds perceive and attribute their symptoms of ppd, is critical in order to establishcultur· ally appropriate guidelines for treatment options. furthermore, information gathered from this study can be used to develop policies and resources for delivering culturally competent care for newcomer wo~ who are dealing with ppd as well as the issues around acculturation (i.e., language barriers, racism). llus is of particular importance for urban health centers which provide postpartum care to diverse groups of women, and particularly recent immigrants or newcomers. ps-~ (al. contaminated 'therapeutic landscape': perceptions of the aamjiwnaang fint nation keyln smith and isaac luginaah . in~: this. paper pres;ents the findings of an ongoing study among the aamjiwnaang f!rst nanon. aam wnaang is located m the heart of samia's 'chemical valley', surrounded by cherrucal ~(ants such as esso, imperial oil, shell, suncor energy, and canada's largest hazardous waste disposal sate. safety kleen. this fint nation community is located within the st. clair river •area of concem'. as destgna~ by health canada for the population of samia and the surrounding region. although this comm_umty, by way of. its proximity to the numerous chemical plants is already exposed to high levels pollu~on, recent che?ucal dumping in ~mjiwnaang, as well as a failed proposal for another ethanol plant m the community, only helped to mtensify community concerns about potential health impacts of exposure. research on the cultural beliefs and traditions of first nation communities has established that th~ ~isting rel~tionship between first nations people and 'mother earth' is not only physical, but also_ spmtual. in this study we explore how the complex relationship between the aamjiwnaang first naaon and 'mother earth' be ha · · · i .. may c ngmg a contammated 'therapeutic' landscape. the study a so ~lores h?w aam wnaang residents are coping with these changes and with the probable conramina· boa of their community. ra!jts: aamjiwnaang residents acknowledge that they are living in a contaminated environment and are being impacted by emissions from the surrounding 'chemical valley' especially for future generations, and have expressed concerns that members of the community and mother earth are 'sick' as a result of this exposure. while moving from that 'place' has been discussed, residents have strong personal and generational connections to the land and insist however, that aamjiwnaang is their 'home' and will remain that way despite growing community concerns about the impact from industry. the contribution of this study lies in the direct involvement of community leadership in designing and conducting this research and distributing the results to further local policy development regarding community concerns on the reserve. background: truck driver are at very high risk for drug abuse because the factor contributing to drug abuse among driver are multiple. it is important to gain an understanding of the key factors that contributing to drug abuse among truck drivers. methods: seventy-truck driver aged - years were conveniently selected from the population. all the participants were male. an interview schedule was developed in the light of literature data and data were collected by personal interview with informed consent in selected urban area of eastern part of nepal. results: a considerable percentage of truck driver have less knowledge about drug abuse, its effect on body and their complication. majority of the participants ( %) explained that lack of education, financial crisis were leading factors of drug abuse. the average numbers of respondents were believed that lack of meaning in life, marital disharmony. friendship with drug abuser, stress, tiredness, modernization of life pattern and freedom from the home pressure were the influencing risk factors to drug abuse. conchuion: this study reveals those truck drivers are at risk in urban area for developing drugs abuse, mostly influenced by social and environmental factors. hence, these groups should undergo certain educational programme to prevent not only drug abuse, but also prevent transmission of infectious disease among these groups. introduction: food insecurity is an inequality that is central in the lives of many low-income canadians. our group of university researchers, health professionals, and community developers conducted a study in ottawa with community workers who work with people identified as food insecure. the purpose of the study was to understand the nature of their work, and their perspectives, perceptions and experiences of the causes and consequences of food insecurity. (a parallel study was conducted with food insecure participants). methods: sampling was through local knowledge of organizations involved in the provision of food to community members. written permission for the researchers to contact workers in confidence was obtained from each organization. thirteen in-depth interviews were conducted. the interviews consisted of a number of open-ended questions. the data were collated, and analysed using a grounded approach. results: workers interviewed represented organizations that offered diverse programming and methods of food distribution intended to address the needs of the community. the provision of food was seen as a necessary response to address hunger that arose for the majority from poverty caused by low income, or levels of government income support and safety nets that were insufficient to support food requirements. workers reported that food requirements varied according to different. ethnic backgrounds, ages of recipients and family configurations, and with food preferences, and d'.etary (health) requirements. workers' observations of the effects of insufficient food on adults and children such as depression, low energy and non-participation or social disengagement matched those of food insecure respondents. food insecurity was cited as "another srressor among the mountain of problems." overall, workers presented a picture of a silent, stigmatized, poor population including children, and a lack of advocacy to address the issues. be tha th · ·ty the results suggest that workers and organizations, like the commuruty mem rs t ey msecun • · · · · f ilab'l' f food · t d ·n thei·r ab 'l 'ty to address food insecurity. l m tanons m terms o ava ty o , serve, are restnc e . . funding, and donations appeared to set the para? eters of pr~g:am r.espon~ to commuruty food msecurity. workers were concerned with program des g": and a~m mstranon that m general addr~d hunger on an emergency short-term basis, although food msecunty was long-ter_m for ~any. sustainable solutions that include knowledge translation strategies, and health and social pohcy responses were suggested and will be explored in future research that hopes to build on this pilot. background: socioeconomic deprivation as well as low levels of soc!al s.uppoi:r have .been associated with poor outcomes following cardiac surgery. pre-operative depression m ~anents with coron~ry artery disease awaiting cabg ranges from - % and is an independent predictor of post-operanve mortality. since st. michael's hospital has a large inner city population, this study was designed to determine the both the prevalence of depressive symptomatology (ds) in patients awaiting cabg as well as its relationship with socioeconomic status (ses) and social support. methods: consecutive patients referred for isolated cabg were invited to complete the centre for epidemiological studies depression scale (ces-d) as well as a social support scale and a life stressors inventory. a ces-d score of : represents mild ds and a score of : represents moderate to severe ds. participants also recorded information on functional status, perceived progression of heart failure, demographic and ses variables. all participants with ces-d scores : were considered to have ds. results: of the patients ( %) who returned the survey, ( . %) of participants had a ces-d score : with ( . %) of those having scores suggestive of severe depression. females and those with ongoing medical concerns tended to have more ds (p= . and p= . respectively). age was not related to ds. perceived worsening of symptoms and increased ccs angina class were significantly related to the presence of ds (p= . and p= . respectively) but not the number of diseased heart vessels. satisfaction with personal relationships including having someone to confide in (p= . ), feeling lonely (p= . ) and not having a partner (p= . ) were significantly related to ds. being very upset by a recent breakup in the immediate family was also significantly related to ds (p= . ). having greater than a grade education was the only ses variable related to ds (p= . ). multivariate logistic regression suggested that not being partnered and having low education were the most significant predictors of ds. conclnsion: pre-operative depression is present in at least one quarter of patients referred for cabg. since ds is related to poor outcomes following cabg, single patients with few social supports and low education should be considered at high risk for ds. these findings support the need for the development of supportive interventions in patients at risk in order to decrease post-operative morbidity. this study examines the relationship between childhood sexual abuse, sexual assault during adolescence, and hiv-risk-related behaviours in a sample of homeless youths. over the past decade, there has been increasing research devoted to the impact of childhood sexual abuse. some studies have suggested that the experience of childhood sexual abuse is associated with substance use and abuse, at· risk sexual behaviour and subsequent higher rates of hiv infection (ompad et al., ; cinq-mars et al., ; brown et al., ) . other studies have found that childhood abuse, especially sexual abuse, is c_o~n among stree~ youth (noell et al. ). this study compares sexually abused males and females livtng on the street ~th non-sexually abused street youth, with regards to unsafe sexual behaviours and e~ures to potmnal t:dv sources (e.g., tattooing, body piercing and injection drug use). the hypothe-sis oft~ ~nt study is that the prevalence of hn-risk-related behaviours will be higher among street youth vtctuns of sexual abuse than those who have not been sexually abused. the sample includes youths aged to who met specific criteria's for itinerancy ( male and female, with a mean ~of . y· and a standard deviation of . ). they were recruited through five organisations working ~th~ you~ and were~ of an ongoing cohort study. all youth completed a to minute ques· ~onnaue on their sexual behaviours, use of drugs and alcohol and other hiv risk behaviours. oral spec· unens for hiv testing were. also collected. a total of ( . %) youth reported at least one incident of ~i •~use/assault ( ~ girls ( . % of all the girls) and boys ( . % of all the boys]). preliminary descnpnve analyses pomt to sexually abused/assaulted youth showing the highest prevalence of sexual poster sessions v at-risk behaviours. for example, . % of sexual abuse/assault victims have engaged in prostitution in their lives compared with . % in the non-sexually abused/assaulted group. in addition, . % of sexual abuse/assault victims reported having injected drugs, compared with . % in the non-sexually abused/assaulted group. more statistical analyses will bring other significant factors to light, especially when we analyze separately those victim of childhood sexual abuse as compare to those victim of sexual assault after childhood. elucidating the risk factors for getting involved in hiv-risk-related behaviours is important for the development of comprehensive and appropriate prevention and treatment intervention strategies. introduction: new immigrants and refugees to canada frequently emigrate from regions of the world where intestinal parasitic infections with worms are endemic. of note, some of these parasites area capable of surviving for years to decades within a given host and can have life threatening consequences many years after initial infection. thus, early diagnosis and treatment of intestinal parasitic worms is considered important in high risk immigrant populations, however there remains a lack of consensus regarding the best method of accomplishing this. diagnosing worm infections through stool examinations is costly and has limited sensitivity, while presumptive treatment of all immigrants, although advocated by some, is expensive and results in healthy individuals being unnecessarily treated. herein, we examine the utility of a hematologic marker (i.e. peripheral blood eosinophilia) as a screening instrument to identify parasitic worm infections in new immigrants to toronto. we identified adults, years of age or older, who were screened for intestinal parasitic infections by stool examination as part of a recently developed screening protocol at a downtown toronto community health centre. we examined the prevalence of infections with worms and subsequently evaluated the impact of several demographic factors on the presence of worm infections. we also determined the sensitivity and specificity of peripheral blood eosinophilia (defined as greater than eosinophils per ml) as a marker for intestinal parasitic worm infections. results: overall, % of the immigrants tested had evidence of at least one worm infection on a single stool examination, while % of such individuals bad infections with multiple worms concurrently. age did not appear to be associated with the presence of worms, however % of males had evidence of worm infections compared with % of females (p= . ). immigrants from asia, sub-saharan africa, and central america had the highest burden of overall infection. the sensitivity and specificity of peripheral blood eosinophilia for worm infections was % and % respectively. conclusions: one in five recent immigrants presenting to a community health centre in downtown toronto had evidence of at least one intestinal parasitic worm infection. the highest burden of illness was in men and in those emigrating from less developed regions of the world. peripheral blood eosinophilia is a poor screening test for worm infections however its presence is highly suggestive of the existence of worms in new immigrants. more than a decade ago, the journal of american college health recommended that a national study be conducted to measure the health status of african american college students, 'both health disparities and [their] positive healthful behaviors' (fennell, ) . it was later decided that when exploring the level of health risk behaviors for african american students, gender is an important variable and should be included in the research (fennell, ) . at historically black college and universities (hbcus) college health researchers must tackle gender disparities through highly-effective health promotion and disease prevention programs. the purpose of this review is to examine the literature that addresses the overarching health behaviors (i.e. risky sexual behavior, poor diet, smoking, physical inactivity, etc.) of african american men who attend hbcus. despite the various social, cultural, and academic benefits of african american students who attend hbcus, the number of research studies that adequately address their health and health behaviors is limited. studies indicate that african american men who attend hbcus are actively engaged in poor health behaviors. compared to females at hbcus, african american men are more likely to behave in ways that could result in injuries and the use tobacco, alcohol, and ~ther dru~. the city of toronto has recently proposed to conduct a street count of the homeless. like proposals that have come before, this most recent proposal is controversial among many homeless advocates and service providers because it is perceived as intrusive, likely to undercount the target population, and unnecessary for addressing the problem. advocates of the count view it as necessary to gauge the scope of the problem and advise city leaders about how to most effectively direct resources ro.the various homeless services. this paper first reviews the history of efforts to count homeless populat ns m toronto, describing the motivations and arguments of people on both sides of the issue. second, the paper reviews the methodological complexities of counting homeless populations, describing approaches that use shelter-counts, administrative data and street observations. those interested in counts for toronto and elsewhere can benefit from this review of approaches that have been proposed and carried out in other municipalities. third, the paper proposes a new community-base d strategy that joins the skills of methodologists, local experts, and service providers to ensure a fair and accurate count. the method of systematic social observation avoids some of the problems of early counts by utilizing a repeated identification approach to minimize undercount bias. the method also has the advantage of involving and compensating homeless individuals for assisting with the street count estimates. the estimation approach can be implemented on a rolling basis throughout the year. drug transitions) is a multi-level study aimed at examining the associations between features of the urban environment and mental health, drug use, and risky sexual behaviors. research participants are being recruited in new york city (nyc) neighborhoods. an essential first step in the implementation of this study was to delineate boundaries for each target neighborhood that could then be used to establish sampling frames and as key units of analytic interest. although many neighborhood studies rely on pre-established definitions (e.g. those used for the census or administrative purposes), such definitions do not always reflect contemporary settlement patterns. we felt that street level observations were a neces· sary component of the definition process. methods: the procedures used to delineate neighborhoods were: ( ) development of census block maps of targeted areas; ( ) review of land use maps and census tract data to ensure, prior to going into the field, tha.t particular blocks are residential and likely to have sufficient population for recruitment purposes; and ( ) field vislts and observation in each of the targeted areas. field observations focused on: housing characteristics, including housing type and condition; characteristics of commercial areas, such as likely customer base (e.g. local or no~, socio-economic status and ethnicity of customers); pedestrian volume (including con· gregauons of people m parks and outside stores or residences); obstructions to pedestrian traffic (e.g. ma or thoroughfares, multi-block industry or institutions); and maintenance and use of open spaces. results: in making the final decisions regarding neighborhood boundaries and the inclusion or exclusion of particular. blocks, we considered a broad range of factors including evidence of homogeneity an~ heterogeneity (socmeconomic, ethnic, housing type, environmental) across blocks within and blocks ad acent to a nei.ghborhood, and across the sample neighborhoods; the potential for efficient recruit· ment of appropriate particip.ants (i.e. sufficient local pedestrian traffic); and boundaries used in reporting census data (s? that population data can be used in our analysis). . altho~gh utilization of field observations for neighborhood definitions is relatively time consuming (ap~~ox mately hours for a block area, with more diverse neighborhoods taking even longer), we annc p~t~ that it will substantially improve the quality and consistency of our data gath· ~rmg ~nd analyse~. spec f c e?'amples from neighborhoods defined through this process will be given dur· m~ this presentatmn. we will also discuss the merits and limitations of characterizing neighborhoods usmg street level observations. has been no consideration for how social networks are associated with sse. the objective of this study was to identify personal and social network characteristics associated with being a recipient of sse. in this cross-sectional study, idus who injected in the past months were recruited from syringe exchange programs in montreal, canada, between april and january . information on each participant and on the persons with whom contact had occurred in the past month were elicited using a structured, interviewer-administe red questionnaire. participants provided detailed demographic and drug use information on up to idu members with whom drugs or injecting materials were shared. using logistic regression, personal and network characteristics were examined in relation to receipt of sterile syringes. res.its: of idus, % reported receiving sterile syringes in the past month from another idu. the sample mean age was years (range - ), % male, % caucasian, and % cocaine injectors. in multivariate analyses adjusted for age and gender, recipients of sterile syringes were more likely than non-recipients to share drugs after preparation ( r= . ( . - . )), to require help or to have helped inject another idu (or= . ( . - . )), to have asked someone to get sterile syringes from a syringe exchange program (or= . [ . - . )), to lend syringes (or= . [ . - . ) ) and to use drug preparation water that was previously used by another iou ( r= . ( . - . ) ) during the past months. recipients also had a higher rate of change (p= . ) of idus in their drug injecting network during the past month. with respect to social networks, % ( / ) of idu network members were providers of sterile syringes and were more likely than non-providers to inject everyday (or= . ( . - . )). when stratified by their role as a sexual partner or as someone who provides support (e.g. friend, family member), further risk behaviours were observed in relation to sharing injecting materials with the participant. conclusion: recipients of sterile syringes and their idu network members had several high-risk behaviours for infection with bloodborne diseases. sse may afford an opportunity for the dissemination of other salutary behaviours such as information sharing on safe injecting practices between recipients and distributors. furthermore, drug injecting networks may be an avenue to reach idus who may not otherwise be exposed to preventive measures. there are numerous sources of stigma and labelling of mental and physical illness. first, the sociocultural dimension to stigma and labelling clearly influences patients, families, health care professionals and society's perception and treatment of illness. this creates multiple challenges related to illness identification and recovery, particularly in culturally diverse societies. second, the media is a major source of stigma and stereotyping with regard to a variety of mental and physical illnesses. despite increased public knowledge of many illnesses, studies have shown that stigma has intensified over the years in certain cases. a third element of stigma and labels appears with the use of diagnosis as a solution to human problems with the result that difficult to treat patients are repudiated and social issues are unaddressed. this presentation will serve to outline the development of stigma, various expressions of stigma, and consequences of stigma. it will provide some practical recommendations for the reduction of stigma related to mental and physical illness. purpose: to assess the knowledge, attitude, and practice about immunization for parent of - years old hispanic and african american children in los angeles county (lac). methods: we conducted two cluster surveys in lac. the sample was selected with probability proportionate to estimated size at the first stage and simple random sample of children at the second stage. data were collected through interview. we absuacted vaccine coverage data from immunization record card (irc) at home or from clinic records. the participation was % in hispanics and % in african americans populations. irc was not available at home for % of african american and % of hispanic children. results: all parents perceived their children got all necessary vaccine~. fa~orable attitudes to.w~rd immunization were reported by % of african american and % of h s?amc parents. '.he m~ ority of the parents ( % african american and % hispanic) agreed that vaccines prevent senous d se~ses among children. regarding vaccine safety, significantly more hispanic parents ( %) than african american parents ( %) mentioned that vaccines are safe. introduction: cervical cancer has been shown to be preventable by papanicolau tests in heterosexual women; however, the utility of papanicolau test in lesbians is controversial. cervical cancer is caused by the human papillomavirus (hpv) which is transmitted by sexual _intercourse; howev_er, its' transmission by homosexual intercourse is also controversial. the goal of this study was to review the evidence for papanicolau tests in lesbians. methods: a pub med, ovid ( ovid ( to , and cochrane library search was performed using the mesh headings "homosexuality , female," "vaginal smears," and "papillomavirus, human." in pub med, the clinical queries feature was used with "diagnosis" and "broad, sensitive" filters. a google advanced search of the internet was conducted with the terms "lesbian," "cervical cancer," and "pap rest." the url was limited to ".ca," ".edu," or ".gov." results: the search yielded original articles and reviews, but no cochrane reviews. none of the publications were canadian. website hits were found and selected websites were reviewed. studies showed that lesbians have fewer papanicolau tests than heterosexual women; however, many reported risk factors for cervical cancer, including multiple past or current sexual partners (male and female), early age of first coitus, history of sexually transmitted diseases, and cigarette smoking. hpv has been detected in - % of lesbians and - % of lesbians who have never had sex with men. case studies of abnormal papanicolau tests in lesbians who have never had sex with men have also been reponed. sexual transmission of hpv among lesbians can be explained by several factors: ) - % of lesbians have had sex with men and - % of lesbians continue to have sex with men. ) hpv may be transmitted by sexual behaviours among women, like digital-vaginal sex, digital-anal sex, oral sex, and the use of insertive sex toys. ) hpv transmission requires only skin-to-skin contact. genital hpv has been identified on human fingers. some professional organizations, like the society of obstetricians and gynecologists of canada and the american cancer society, recognize the need for papanicolau tests in lesbians. other organizations, like the canadian cancer society, do not have official policy statements. the current ontario cervical screening program does not specifically address lesbians. conclusion: although the data was limited, most studies recommended that lesbians should receive papanicolau tests. the frequency of these tests was controversial. policy makers and professional organizations should address the needs of this special population and make specific recommendations . monique chaaya, ahia sibai, hiam chemaitelly, and zana el roueiheb . literature concerning the mental and physical effect of work at an old age is contradictory. in addinon, urban environments are physically and socially harsh with reduced potential for income generation and employment and increased potential for depression. the present paper is an attempt to study how do work, or lack of work, link to the experience of depression among older adults in underprivileged lebanese urban communities. the data comes from a cross-sectional survey, where elderly residing in underprivileged communities in beirut, including a palestinian refugee camp, were successfully inter-v ewed through face-to-face interviews. logistic regression was performed to assess the effect of work on depression ad_justing for many other covariates. data showed that . % of people aged years and more were still workmg. there was a highly protective effect of work on depression in elderly males (or= . , % cl= . - . ). the current study is the first of its kind in the arab region and more work shou_ld be _don_e in this area. it is important for the lebanese government to consider elderly rights for social mclus n m terms of employment opportunities. amam nuru-jeter, nancy adler, and burton singer . l~u~on:_ the socioeconomic gradient is perhaps the most persistent and significant finding in social epidem ological research. the insistent nature of the ses effect is evidenced by its significance after acc?untmg for ~umerous confounds. the significance and magnitude of the effect, however, varies by ::•al group. evidence_ o_f the relative effect of race and ses is inconclusive. further, less attention has f ~ ptid to the specific interactions of race and ses than to examinations of which is a better predictor d ~ th. ~sues are further complicated by the explanatory complexity of the various measures of ses anl . owht ey relate to the health of various social groups. understanding the specific nature of these re a ons ips s necessary for guiding he ith d · i · · h a an soc a po mes and programs aimed at improving t e poster sessions v health of our most disadvantaged groups, and therefore population health, overall. this study examines the synergistic effects of ses with both race and gender in predicting group differences in mortality. methods: analyses use data from the national longitudinal mortality survey (n= , ) for the years , , and - ; and were linked to the national death index for deaths occurring through . results were confirmed using data from the national mortality followback survey for people who died in (n= , ) and the national health interview survey (denominator). we used correlation analysis and the standardized mortality ratio to examine ses (education and income), race, and gender as predictors of group differences in changes in mortality. results: for the total population, analyses support the income gradient showing significant declines in mortality ratios from low to high income along the income strata. education shows a significant drop in mortality with completion of high school and completion of college, exhibiting a threshold rather than a gradient effect. compared to whites, blacks receive diminishing health returns for each subsequent level of income and education; with whites closely mirroring the total population in ses thresholds. similarly, compared to men, women do not experience the same health gains at comparable ses levels. for education, black men and women only show significant mortality declines upon completion of high school. the ses gradient operates differently among race and gender subgroups. threshold effects suggest resource gains in life opportunities at particular milestones along the ses gradient. further, ses matters less for blacks and women compared to whites and men suggesting differing implications for health and social policy aimed at reducing disparities. objective: we assessed the impact of diabetes in a large puerto rican community of chicago by measuring the prevalence of diagnosed diabetes and calculating the diabetes mortality rate. methods: we analyzed data from a comprehensive health survey conducted in randomly selected households in community areas. questions on diagnosed diabetes and selected risk factors were asked. in addition, mortality data were analyzed in order to calculate the age-adjusted diabetes mortality rate. when possible, rates were compared to those found in other studies. results: the diabetes prevalence located in this community ( . %: % cl= . %- . %) is one of the highest ever reported for puerto ricans. for instance, it is more than three times higher than the prevalence for the us ( . %) and twice the prevalence for puerto ricans in new york ( . %) and puerto rico ( . %- . %). diagnosed diabetes was found to be significantly associated with obesity (p= . ). the prevalence was particularly high among older people, females, those horn in the us, and those with a family history. the diabetes mortality rate ( . per , population) was more than twice the rate for all of chicago ( . ) and the us ( . ). conclusions: understanding why the diabetes and mortality rates for puerto ricans in this commu· nity are so much higher than those of other communities is imperative. collaboration between researchers, service providers and community members can help address the issues of diabetes education, early screening and diagnosis and effective treatment needed in this community. introduction: sars is a respiratory illness that is spread from person to person through dose contact. this infectious disease outbreak was unusual due to the high rate of infection among health care workers. the aim of the study is to explore the demographic and attitudinal determinants of psychological distress due to sars among health care workers of a toronto hospital. methods: a total of adult participants completed questionnaires co assess psychological distress (impact of event scale -jes) and attitudes to sars. of these, participants completed the questionnaire during the sars i outbreak, and participants completed the questionnaire during the sars ii outbreak. participants also provided information on demographic variables, including occupation and exposure to sars. principal components analysis was used to derive eight attitudinal scales: fear: system, protection, prevention, job stress, stigma, instrumental coping, and psychological copm~. l ear regression analyses were applied to evaluate the associations of the demographic and amtudmal variables, as well as time, with psychological distress. . . regression analyses showed that time and higher scores on fear, ob stress, stigma'. and instrumental coping were associated with a higher total ies score: (r =. ). contrary to expectations, none of the demographic variables was associated with total ies score. conclusion: the presence of psychological distress in health care workers is indicative of intrusive or avoidant responses to thoughts, feelings, and memories associated with the sars outbreak. this study shows that ( ) fear for one's health and the he~lth of.others, ( ) ex~erien~in~ job stress, ( )_tbe per· ception of stigma, ( ) usage of instrumental copmg skills, ~n~ ( ) t m_e s grufi~an~ly c~nmb~te to increased psychological distress in health care workers. potential mterventmns during mfecttous diseaie outbreaks in health care settings should be targeted to minimize the impact of these factors. purpose: the purpose of this study was to expand knowledge regarding feeding practices, know!· edge and nutritional beliefs of mothers currently residing in the dominican republic (dr). the rising incidence of obesity in children is a major national health concern and obesity in first and second-generation immigrant children also continues to rise. we know that parents (particularly mothers) shape children's early diet patterns and that immigrant mothers experience additional challenges related to acculturation and assimilation into a new culture, however there is a paucity of literature concerning the effect of immigrant adaptation to american culture on the nutrition of children. in addition, new immigrant knowledge about the causes of obesity and the resulting health implications for childhood obesity has not been assessed and reported. this qualitative study used focus group methodology to discuss views and practices related to the introduction of food for infants and feeding practices for young children, along with a discussion on knowledge and beliefs related to the causes and health implications of child· hood obesity. ten dominican mothers' of young children (birth to years old) who reside in a small town in the western frontier area of the dr were participants in the focus group. results from this srudy will be compared to results from an identical study that will be conducted in fall with new immi· grant mothers from the dr to the boston area. we will compare feeding practices, beliefs and knowledge about nutrition for young children between these two groups. methods: using participatory principles, a focus group design was used to interview a group of mothers in the dr. the investigator along with a bilingual translator conducted the focus group. the session was tape recorded and is currently in the process of being transcribed and translated. transcribed data will be systematically analyzed themes will be identified. a qualitative data analysis software will be used to organize and code the data according to the specific aims of the study. supporting quotations will be selected to substrate each theme. lmpli~tions for urban health practice: an ultimate goal of this study is to lay a foundation for understanding the process of acculturation on feeding practices of mothers when they immigrate to the us. understanding beliefs, knowledge and feeding practices that mothers use with young children will help m ~he ~evelopment of culturally and linguistically appropriate educational strategies and materials for use m primary prevention of pediatric obesity. in canada more than seventy-five percent of immigrants choose to stay in three major urban centers of toronto, montreal and vancouver. approximately fifty percent of the immigrants eventually set· tie m ~~e greater tor<_>nto area. there is mounting evidence that the increasing immigrant population has a_ sigmfic~nt health disadvantage over canadian-born residents. this health disadvantage manifests particularly m the ma "ority of "mm "gr t h h d be · · h . . . . an s w o a en m canada for longer than ten years. this group as ~n associ~te~ with higher risk of chronic disease such as cardiovascular diseases. this disparity twccb n ma onty of the immigrant population and the canadian-born population is of great importance to ur an health providers d" · i i · b as isproporttonate y arge immigrant population has settled in the ma or ur an centers. generally the health stat f · · · · · · h h been . us most mm grants s dynamic. recent mm grants w o av_e ant •;ffca~ada _for less ~han ~en years are known to have a health advantage known as 'healthy imm • ~ants r::r · ~:s eff~ ~ defined by the observed superior health of both male and female recent immi- immigrant participation in canadian society particularly the labour market. a new explanation of the loss of 'healthy immigrant effect' is given with the help of additional factors. lt appears that the effects of social exclusion from the labour market leading to social inequalities first experienced by recent immigrant has been responsible for the loss of healthy immigrant effect. this loss results in the subsequent health disadvantage observed in the older immigrant population. a study on patients perspectives regarding tuberculosis treatment by s.j.chander, community health cell, bangalore, india. introduction: the national tuberculosis control programme was in place over three decades; still tuberculosis control remains a challenge unmet. every day about people die of tuberculosis in india. tuberculosis affects the poor more and the poor seek help from more than one place due to various reasons. this adversely affects the treatment outcome and the patient's pocket. many tuberculosis patients become non-adherence to treatment due to many reasons. the goal of the study was to understand the patient's perspective regarding tuberculois treatment provided by the bangalore city corporation. (bmc) under the rntcp (revised national tuberculosis control programme) using dots (directly observed treatment, short course) approach. bmc were identified. the information was collected using an in-depth interview technique. they were both male and female aged between - years suffering from pulmonary and extra pulmonary tuberculosis. all patients were from the poor socio economic background. results: most patients who first sought help from private practitioners were not diagnosed and treated correctly. they sought help form them as they were easily accessible and available but they. most patients sought help later than four weeks as they lacked awareness. a few of patients sought help from traditional healers and magicians, as it did not help they turned to allopathic practitioners. the patients interviewed were inadequately informed about various aspect of the disease due to fear of stigma. the patient's family members were generally supportive during the treatment period there was no report of negative attitude of neighbours who were aware of tuberculosis patients instead sympathetic attitude was reported. there exists many myth and misconception associated with marriage and sexual relationship while one suffers from tuberculosis. patients who visited referral hospitals reported that money was demanded for providing services. most patients had to borrow money for treatment. patients want health centres to be clean and be opened on time. they don't like the staff shouting at them to cover their mouth while coughing. conclusion: community education would lead to seek help early and to take preventive measures. adequate patient education would remove all myth and conception and help the patients adhere to treatment. since tb thrives among the poor, poverty eradiation measures need to be given more emphasis. mere treatment approach would not help control tuberculosis. lntrod#ction: the main causative factor in cervical cancer is the presence of oncogenic human papillomavitus (hpv). several factors have been identified in the acquisition of hpv infection and cervical cancer and include early coitarche, large number of lifetime sexual partners, tobacco smoking, poor diet, and concomitant sexually transmitted diseases. it is known that street youth are at much higher risk for these factors and are therefore at higher risk of acquiring hpv infection and cervical cancer. thus, we endeavoured to determine the prevalence of oncogenic hpv infection, and pap test abnormalities, in street youth. ~tbods: this quantitative study uses data collected from a non governmental, not for profit dropin centre for street youth in canada. over one hundred females between the ages of sixteen and twentyfour were enrolled in the study. of these females, all underwent pap testing about those with a previous history of an abnormal pap test, or an abnormal-appearing cervix on clinical examination, underwent hpv-deoxyribonucleic (dna) testing with the digene hybrid capture ii. results: data analysis is underway. the following results will be presented: ) number of positive hpv-dna results, ) pap test results in this group, ) recommended follow-up. . the results of this study will provide information about the prevalence of oncogemc hpv-dna infection and pap test abnormalities in a population of street youth. the practice implic~ tions related to our research include the potential for improved gynecologic care of street youth. in addition, our recommendations on the usefulness of hpv testing in this population will be addressed. methods: a health promotion and disease prevention tool was developed over a period of several years to meet the health needs of recent immigrants and refugees seen at access alliance multicultural community health centre (aamchc), an inner city community health centre in downtown toronto. this instrument was derived from the anecdotal experience of health care providers, a review of medical literature, and con· sultations with experts in migration health. herein we present the individual components of this instrument, aimed at promoting health and preventing disease in new immigrants and refugees to toronto. results: the health promotion and disease prevention tool for immigrants focuses on three primary health related areas: ) globally important infectious diseases including tuberculosis (tb), hiv/aids, syphilis, viral hepatitis, intestinal parasites, and vaccine preventable diseases (vpd), ) cancers caused by infectious diseases or those endemic to developing regions of the world, and ) mental illnesses includiog those developing among survivors of torture. the health needs of new immigrants and refugees are complex, heterogeneous, and ohen reflect conditions found in the immigrant's country of origin. ideally, the management of all new immigrants should be adapted to their experiences prior to migration, however the scale and complexity of this strategy prohibits its general use by healthcare providers in industrialized countries. an immigrant specific disease prevention instrument could help quickly identify and potentially prevent the spread of dangerous infectious diseases, detect cancers at earlier stages of development, and inform health care providers and decision makers about the most effective and efficient strategies to prevent serious illness in new immigrants and refugees. lntrodmction: as poverty continues to grip pakistan, the number of urban street children grows and has now reached alarming proportions, demanding far greater action than presently offered. urbanization, natural catastrophe, drought, disease, war and internal conflict, economic breakdown causing unemployment, and homelessness have forced families and children in search of a "better life," often putting children at risk of abuse and exploitation. objectives: to reduce drug use on the streets in particular injectable drug use and to prevent the transmission of stds/hiv/aids among vulnerable youth. methodology: baseline study and situation assessment of health problems particularly hiv and stds among street children of quetta, pakistan. the program launched a peer education program, including: awareness o_f self and body protection focusing on child sexual abuse, stds/hiv/aids , life skills, gender and sexual rights awareness, preventive health measures, and care at work. it also opened care and counseling center for these working and street children ar.d handed these centers over to local communities. relationships among aids-related knowledge and bt:liefs and sexual behavior of young adults were determined. rea.sons for unsafe sex included: misconception about disease etiology, conflicting cultural values, risk demal, partner pressur~, trust and partner significance, accusation of promiscuity, lack of community endorsement of protecnve measures, and barriers to condom access. in addition socio-economic pressure, physiological issues, poor community participation and anitudes and low ~ducation level limited the effectiveness of existing aids prevention education. according to 'the baseline study the male children are ex~ to ~owledge of safe sex through peers, hakims, and blue films. working children found sexual mfor~anon through older children and their teachers (ustad). recommendation s: it was found that working children are highly vulnerable to stds/hiv/aids, as they lack protective meas":res in sexual abuse and are unaware of safe sexual practices. conclusion: non-fatal overdose was a common occurrence for idu in vancouver, and was associated with several factors considered including crystal methamphetamine use. these findings indicate a need for structural interventions that seek to modify the social and contextual risks for overdose, increased access to treatment programs, and trials of novel interventions such as take-home naloxone programs. background: injection drug users (idus) are at elevated risk for involvement in the criminal justice system due to possession of illicit drugs and participation in drug sales or markets. the criminalization of drug use may produce significant social, economic and health consequences for urban poor drug users. injection-related risks have also been associated with criminal justice involvement or risk of such involvement. previous research has identified racial differences in drug-related arrests and incarceration in the general population. we assess whether criminal justice system involvement differs by race/ethnicity among a community sample of idus. we analyzed data collected from idus (n = , ) who were recruited in san francisco, and interviewed and tested for hiv. criminal justice system involvement was measured by arrest, incarceration, drug felony, and loss/denial of social services associated with the possession of a drug felony. multivariate analyses compared measures of criminal justice involvement and race/ethnicity after adjusting for socio-demographic and drug-use behaviors including drug preference, years of injection drug use, injection frequency, age, housing status, and gender. the six-month prevalence of arrest was highest for whites ( %), compared to african americans ( %) and latinos ( % ), in addition to the mean number of weeks spent in jail in the past months ( . vs. . and . weeks). these differences did not remain statistically significant in multivariate analyses. latinos reported the highest prevalence of a lifetime drug felony conviction ( %) and mean years of lifetime incarceration in prison ( . years), compared to african americans ( %, . years) and whites ( %, . years). being african american was independently associated with having a felony conviction and years of incarceration in prison as compared to whites. the history of involvement in the criminal justice system is widespread in this sample. when looking at racial/ethnic differences over a lifetime including total years of incarceration and drug felony conviction, the involvement of african americans in the criminal justice system is higher as compared to whites. more rigorous examination of these data and others on how criminal justice involvement varies by race, as well as the implications for the health and well-being of idus, is warranted. homelessness is a major social concern that has great im~act on th~se living.in urban commu?ities. metro manila, the capital of the philippines is a highly urbanized ar~ w. t~ the h gh~st concentration of urban poor population-an estimated , families or , , md v duals. this exploratory study v is the first definitive study done in manila that explores the needs and concerns of street dwdlent\omc. less. it aims to establish the demographic profile, lifestyle patterns and needs of the streetdwdlersindit six districts city of manila to establish a database for planning health and other related interventions. based on protocol-guid ed field interviews of street dwellers, the data is useful as a template for ref!!. ence in analyzing urban homelessness in asian developing country contexts. results of the study show that generally, the state of homelessness reflects a feeling of discontent, disenfranchisem ent and pow!!· lessness that contribute to their difficulty in getting out of the streets. the perceived problems andlar dangers in living on the streets are generally associated with their exposure to extreme weather condirioll! and their status of being vagrants making them prone to harassment by the police. the health needs of the street dweller respondents established in this study indicate that the existing health related servias for the homeless poor is ineffective. the street dweller respondents have little or no access to social and health services, if any. some respondents claimed that although they were able to get service from heallh centers or government hospitals, the medicines required for treatment are not usually free and are beyond their means. this group of homeless people needs well-planned interventions to hdp them improve their current situations and support their daily living. the expressed social needs of the sucet dweller respondents were significantly concentrated on the economic aspect, which is, having a perma· nent source of income to afford food, shelter, clothing and education. these reflect the street dweller' s need for personal upliftment and safety. in short, most of their expressed need is a combination of socioeconomic resources that would provide long-term options that are better than the choice of living on the streets. the suggested interventions based on the findings will be discussed. . methods: idu~ aged i and older who injected drugs within the prior month were recruited in usmg rds which relies on referral networks to generate unbiased prevalence estimates. a diverse and mon· vated g~o~p of idu "seeds." were given three uniquely coded coupons and encouraged to refer up to three other ehgibl~ idu~, for which they received $ usd per recruit. all subjects provided informed consent, an anonymous ~t erv ew and a venous blood sample for serologic testing of hiv, hcv and syphilis anti~!· results. a total of idus were recruited in tijuana and in juarez, of whom the maion!)' were .male < .l. % and . %) and median age was . melhotls: using the data from a multi-site survey on health and well being of a random sample of older chinese in seven canadian cities, this paper examined the effects of size of the chinese community and the health status of the aging chinese. the sample (n= , ) consisted of aging chinese aged years and older. physical and mental status of the participants was measured by a chinese version medical outcome study short form sf- . one-way analysis of variance and post-hoc scheffe test were used to test the differences in health status between the participants residing in cities representing three different sizes of the chinese community. regression analysis was also used to examine the contribution of size of the chinese community to physical and mental health status. rmdts: in general, aging chinese who resided in cities with a smaller chinese population were healthier than those who resided in cities with a larger chinese population. the size of the chinese community was significant in predicting both physical and mental health status of the participants. the findings also indicated the potential underlying effects of the variations in country of origin, access barriers, and socio-economic status of the aging chinese in communities with different chinese population size. the study concluded that size of an ethnic community affected the health status of the aging population from the same ethnic community. the intra-group diversity within the aging chinese identified in this study helped to demonstrate the different socio-cultural and structural challenges facing the aging population in different urban settings. urban health and demographic surveillance system, which is implemented by the african population & health research center (aphrc) in two slum settlements of nairobi city. this study focuses on common child illnesses including diarrhea, fever, cough, common cold and malaria, as well as on curative health care service utilization. measures of ses were created using information collected at the household level. other variables of interest included are maternal demographic and cultural factors, and child characteristics. statistical methods appropriate for clustered data were used to identify correlates of child morbidity. preliminary ratdts: morbidity was reported for , ( . %) out of , children accounting for a total of , illness episodes. cough, diarrhoea, runny nose/common cold, abdominal pains, malaria and fever made up the top six forms of morbidity. the only factors that had a significant associ· ation with morbidity were the child's age, ethnicity and type of toilet facility. however, all measures of socioeconomic status (mother's education, socioeconomic status, and mother's work status) had a significant effect on seeking outside care. age of child, severity of illness, type of illness and survival of father and mother were also significantly associated with seeking health care outside home. the results of this study have highlighted the need to address environmental conditions, basic amenities, and livelihood circumstances to improve child health in poor communities. the fact that socioeconomic indicators did not have a significant effect on prevalence of morbidity but were significant for health seeking behavior, indicate that while economic resources may have limited effect in preventing child illnesses when children are living in poor environmental conditions, being enlightened and having greater economic resources would mitigate the impact of the poor environmental conditions and reduce child mortality through better treatment of sick children. inequality in human life chances is about the most visible character of the third world urban space. f.conomic variability and social efficiency have often been fingered to justify such inequalities. within this separation households exist that share similar characteristics and are found to inhabit a given spatial unit of the 'city. the residential geography of cities in the third world is thus characterized by native areas whose core is made up of deteriorated slum property, poor living conditions and a decayed environment; features which personify deprivation in its unimaginable ma~t~de. there are .eviden~es that these conditions are manifested through disturbingly high levels of morbidity and mortality. ban · h h d-and a host of other factors (corrupt n, msens t ve leaders p, poor ur ty on t e one an , . · f · · · th t ) that suggest cracks in the levels and adherence to the prmc p es o socta usnce. ese governance, e c . . . . . ps £factors combine to reinforce the impacts of depnvat n and perpetuate these unpacts. by den· grou o . · "id . . bothh tifying health problems that are caused or driven by either matena _or soc a e~nvanon or , t e paper concludes that deprivation need not be accepted as a way. of hfe a~d a deliberate effon must be made to stem the tide of the on going levels of abject poverty m the third world. to the extent that income related poverty is about the most important of all ramifications of po~erty, efforts n_iu_st include fiscal empowerment of the poor in deprived areas like the inner c~ty. this will ~p~ove ~he willingness of such people to use facilities of care because they are able to effectively demand t, smce m real sense there is no such thing as free medical services. ). there were men with hiv-infection included in the present study (mean age and education of . (sd= . ) and . (sd= . ), respectively). a series of multiple regressions were used to examine the unique contributions of symptom burden (depression, cognitive, pain, fatigue), neuropsychologic al impairment (psychomotor efficiency), demographics (age and education) and hiv disease (cdc- staging) on iirs total score and jirs subscores: ( ) activities of daily living (work, recreation, diet, health, finances); ( ) psychosocial functioning (e.g., self-expression, community involvement); and ( ) intimacy (sex life and relationship with partner). resnlts: total iirs score (r " . ) was associated with aids diagnosis (ii= . , p < . ) and symptoms of pain (ii= - . , p < . ), fatigue (ji = - . , p < . ) and cognitive difficulties (p = . , p < . ). for the three dimensions of the iirs, multiple regression results revealed: ( ) activities of daily living (r = . ) were associated with aids diagnosis (ii = . , p < . ) and symptoms of pain <p =- j , p < . ), fatigue (ji = - . , p < . ) and cognitive difficulties (ji = . , p < . ); ( ) psychosocial functioning (r = . ) was associated with was associated with symptoms of fatigue (ii= - . , p < . ) and cognitive difficulties <ii = . , p < . ); and ( ) intimacy (r = . ) was related to was associated with symptoms of fatigue (ij = - . , p < . ) and cognitive difficulties (ii= . , p < . ). methods: the sif evaluation methodology involves a comprehensive database located at the sif, a randomly selected p~o.spective coh~rt of sif users, and two pre-existing external control cohorts. . . ~ts: in addmon to reporting process data and descriptions of the sif users, we report on data indicating that the establishment of the sif has been independently associated with reductions in public ~':°g ~ (p <?. ), and syringe sharing (aor = . [ %ci: . _ . ); p = . ) and other unsafe m ecnon pract _ces_ (p ~ . ), and increased uptake of detox services (log-rank p = . ). as well, we report on da~ md cat ng that the sif has not prompted adverse changes in community drug use patterns. the vancouver sif has been well accepted by the target population, and while adve~ events s~c~ as overdoses have occurred, these events have been successfully managed. externally compiled data indicate that the sif has been associated with substantial declines in public disorder !'oster sessions v associated with injection drug use, syringe sharing, and increased uptake of detox services. as well, the establishment of the sif has not exacerbated community drug use patterns. ongoing evaluation activities wiu involve assessing the impact of the sif on a variety of outcomes, including infectious disease transmission, fatal overdose, and utilization of health and social services. city, brazil, - maria cristina almeida, waleska caiaffa, renato assum;iio, and fernando proietti dengue cases were described according to time, space, intensity, age, gender, onset of symptoms, residence address and census tract. spatial distribution of two groups (children and women over years old and men aged - ) were compared, under assumption that they have distinct behaviors regarding their displacement around the city. analysis included local moran index, ripley\\'s k function and recurrence of census areas over time. about , cases were identified in seven epidemic waves. concentration of cases in small areas, followed by a spread either in space or time suggested endemic patterns. regarding age-gender groups, distinct patterns suggested that residence might not be a good proxy in determining the local of infection for men aged - . dengue is shifting to endemic pattern in this city and transmission may not be sole related to home environment, suggesting that additional spatial information must be couected aiming efficient control measures. murukan kandamuthan and subodh kandamuthan lnl uduction: illness or disablement of a child may affect the economic functioning of a family as it alters the employment pattern and earnings of parents this paper tries to assess the health status and the quality of life of disabled children, and how generally, severe disablement in a child affected their fami-lies\' finances, and to quantify any such effects the problems faced by children in their home and to provide information relevant to the formation of criteria for new or increased cash support. methods: a case-control study was done in the thiruvananthapuram district, capital city of kerala by selecting a random sample of families with severely disabled children below years and a random sample of normal children matched for age and occupation of the parents. comparative and subjective data were collected. money spent on children\'s medical care, loss of earnings of the parents, and other economic burden to the family due to the disability of the child in the family. a discriminant analysis along with univariate analysis was done to assess the factors that mostly differentiate the disabled and normal children. the mean expenditure of the families with a disabled child was rs. /-per month, which is significantly higher than the corresponding expenditure of rs. /-per month of families with normal child, (t= . , p <. ). of the disabled children, % were not getting any social security payments and % had no special concessions for medical and other educational purposes. the analysis of income and expenditure pattern indicated that financial impact of disablement in a child on the family is significant. the discriminant model results revealed that medical expenditure was a significant variable that differentiated the disabled and normal child. the study found that the health status and quality of life of the disabled children were far from satisfactory. this in fact affected the economic status of the disabled children. in addition to reduced earnings, there are extra costs for disabled children for travel, domestic help, medical care, and health care expenditures (hospital care, physician services, dentistry, drugs and others) for disabled individuals. a strong case can be made for their long-term care by improving the financial support to such families possibly through the introduction of an allowance specially to compensate for the earnings lost by parents due to the disability of their children. widows in india are considered disadvantage group of population. because they are characterized by pangs of separation from spouse, and consequently they go through mental agony, social ~s?lation, and economic dislocation. in addition to these, poverty, landlessness, homelessness, malnutr non etc. endure serious deterioration of their health. according to census , there are million women are widowed and one fourth live in urban areas. there is a noticeable increase of urban widows from the previous census (almost half). the paper examines the type of disability and chronic ailment borne among elderly widows ( years and above). fifty second round of national sample survey aske~ the individuals three sets of questions regarding their health: their status of health, whether they are physically poster sessions v immobile, and whether or not they have had any specific chronic illnesses. although health infrastruc- · ble ·n urban setting in india as compared to rural counterpart, prevalence of tures are arge y ava a . . . . . h · · · h h"gher "n urban areas analysis shows omt problems m old age qmte common c romc ness is muc • . . and nearly percent elderly widows are suffering from this ail'. ent in urban areas. one-fifth of widows are suffering from high/low bp. heart disease, diabetes and urinary problems are much ~ore pre~alent in urban areas though disabilities is comparatively lower in urban areas. however, the d~fference is not statistically significant. disability with respect to vision is more pronounced and one third_ of the total respondents have problems regarding eyesight. one fifths ofdderly widows are _ha.rd of hearing. though disability increases with age, similar trend is not observed with respect to chr~mc illness. the percepnon of self-health among elderly becomes poorer as their age increases. the perceived health status need not be always corrected to objective indicators of health. it is noted that around per~en~ of those perceived their health as "excellenr" or "very good" are found to be suffering from chrome disease of omts and percent have visual disability. to conclude an elderly widow living in urban areas have similar health problems as she jives in rural areas. this can be easily explained, as they were not made aware to seek treatment from health facility. in addition, the study shows that the economic conditions are deterrent factors for their illness. it is essential that intervention should be taken up improving their economic conditions so that wellbeing of this most vulnerable group of the society can be taken care of. heart failure is a disease that affects nearly million people world wide. the united states alone accounts for one third of this population. blacks are stricken with heart failure twice as often as whites. men are more likely to develop chf than women, however since the majority of the chf population are seniors, there are actually more women than men. congestive heart failure (chf) has become a pandemic. as the baby boomer generation ages, the number of chf cases will rise dramatically. (young, j. & mills, r., ). after the age of , each proceeding decade doubles the incidence level of chf. the average person has a in chance of developing heart failure within their lifespan according to the framingham study (nih.gov). individuals aging or older compose over half of the entire documented heart failure population. in this age group, chf is the leading cause of hospitalization. many patients are continuously readmitted. it is estimated that the chf population will increase by one million within the next years. mortality was at % for a two year period and % for five years (young, j. & mills, r., ). data from: aha as technology evolves, the understanding of the nature of heart failure has become clearer. in the beginning of the th century heart failure was diagnosed as a condition that presented with edema (swelling) in the extremities caused by water retention. treatment in the beginning of the past cenrury was limited to abdominal drainage and diuretics. the discovery of the heart's insufficient pumping ability in heart failure patients lead to new surgeries and devices such as heart transplants and ventricular assist devices (bridge until transplant is available). ventricular hypertrophy often occurs before the development of heart failure. hypertrophy is the term given for cardiac remodeling. cardiac remodeling also includes chamber dilation (young, j. & mills, r., ) . chf financial burden the us healthcare financing administration has ranked chf as the highest cost illness in the diagnose-related area. direct costs related to chf in the us for were nearly $ billion. these costs included hospital admissions, physician fees, home health aids and medications. indirect costs were over $ billion in . loss of jobs or death due to chf was the criteria for this category (young, j. & mills, r., ). . introduction: the injection drug user quality of life scale (iduqol) is a relatively new scale ~es gned to capture the unique and individual circumstances that determine quality of life among injection drug users (idus). the life areas comprising the instrument were based on the research literature an~ ~ocus group discussions with idus. the purpose of the present study was to evaluate the content validity of t.h~ iduqol using judgmental methods based on subject matter experts' (smes) ratings. content vah~ ty refers to the de~ee to which elements of an assessment tool are representative of the construct of interest and appropnate for a given population. methods: data were obtained from six smes, from the field of idu research and practice, who ~ere. asked t.o evaluate various aspects of the iduqol, including the title of the instrument, administraon instruchons, clarity of the names and descriptions of each life area, response format, scoring instruc-no~s and examples, record form and whether each life area should be included in the instrument. sme ratings were made using either or point scales. sm es were also given the opportunity to comment on poster sessions v each section and to suggest whether important life areas had been overlooked, were redundant, not relevant, or in need of revision. (cvi) and the ~v.erage ~eviation index (ad) were used to evaluate smes' agreement on ratings of the content vahd ty vanables. both measures provided support for the content validity of various aspects of the iduqol, although results from the stricter ad index noted some areas of disagreement, including the description of particular life areas (e.g., being useful, drugs, sex), the inclusion of some life areas (e.g., drug treatment, education, independence and free choice), and the ease of the scoring instructions. the findings from this study provide (a) content validity evidence to support the use of the iduqol as well as (b) recommendations to suengthen both the instrument (e.g., improved descriptions for some items) and the accompanying administration and scoring manual (e.g., an easier scoring template). changes made to the instrument and its manual make the iduqol even easier for researchers, practitioners, and program evaluators to use as a way of assessing, and tracking changes over time or as a result of interventions in, quality of life in injection drug users. introduction: strict adherence to prescribed regimens is required to derive maximal benefit from highly active antireuoviral therapy (haart) in persons living with hiv/aids (phas). adherence is a key determinant of the degree and durability of viral suppression. adherence is also essential in reducing the spread of hiv and ensuring that today's treatments remain effective for as long as possible. the objective of this study is to conduct a systematic review of the research literature on the effectiveness of education and patient support strategies for improving adherence to haart. methods: a systematic search of the core databases was performed from january until may . randomized controlled trials examining the effectiveness of education and patient support interventions to improve the adherence to haart were considered for inclusion. only those studies that measured adherence at a minimum of six weeks were included. study selection, quality assessments, and data abstraction were performed independently by two reviewers. results: study heterogeneity with respect to differing populations, interventions, outcomes, and length of follow-up did not allow for meta-analysis. we included studies involving , ph as. sample sizes ranged from to . study duration ranged from a single session to a variable number of sessions delivered over one year. many of the interventions involved the provision of an educational component to improve adherence and often addressed strategies to overcome barriers to adherence and the development of problem-solving skills. they ranged from simple interventions (e.g., the provision of reminder devices) to complex interventions (e.g., cognitive-behavioural therapy delivered by licensed psychologists). eleven of the studies demonstrated a statistically significant advantage associated with the described adherence intervention. the advantage associated with adherence outcomes does not seem to translate into the more clinically relevant outcome of viral suppression. only out of studies that reported virological or immunological results found a significant effect associated with the intervention. the studies had several methodological shortcomings. conclusions: there is a need for standardization and methodological rigour in the conduct of adherence trials. some interventions may have a significant impact on improving adherence. further research is required before any specific adherence improving strategy can confidently be incorporated into standard clinical practice. focus groups were used to collect data from a purposive sample of treatmentexperienced participants. focus group data were analyzed using a grou~ded t~eory appr~ach. i:ne themes identified from the interviews were used to identify the effects of ant rerrov rals on quality of hfe. the content of the mos-hiv was appraised against the themes identified from our analysis. participants also completed the mos-hiv survey and were asked whether the survey covered all important aspects of quality of life on antiretroviral medications. results: five key informant interviews and five focus groups with participants were used to identify effects on quality of life that are not directly ~aptu~ed by_ the mos-hiv health survey. our~~ showed that our participants described quality of hfe as mvol~mg_ a set of ~rsonal trad~ffs ~stay alive. in most cases, worsened quality of life was traded-off for gams ~ longevlty from ~~canon use. these eff~'ts or tradeoffs included: ( ) downstream consequences of side effects and toxlanes; ( ) loss of lrufe. pende~t decision-making privileges, ( ) having to choose drugs over ~areer; (~)burden of medication-taking responsibilities; and ( ) living life under a pretense and havmg to hide-the net effect of the tradeoffs, or "prices" to pay led to what was described as "longevity with hn without hope and future~. conclusion: our study highlights five major themes summarizing the impact of haart on quality on life, and suggests that currently used scales for measuring quality of life do not a~atd~ cap~e these findings and the associated consequences. the conceptual framework for measuring quality of bfe in hiv should be reconsidered in order to better capture the important effects of the medications on quality of life. this may involve widening the boundaries of the definition of health-related quality oflife to include aspects such as finances, employment, and housing. we should further consider the development of a haart adverse effect specific instrument, using a broad definition of adverse effect in order to capture all types of adverse impacts of hiv treatments on quality of life. introduction: measles (rubeola) is the most contagious vaccine preventable disease of humans. while cases of measles are uncommon in canada today, the disease continues to be a leading cause of morbidity and death in the developing world. as a result of human migration, measles cases still occur in canada, primari~ among immigrants, returning travelers, and other susceptible groups. canada's national advisory council on immunizations (naci) recommends that immigrants without records of measles immunization be considered for vac:cination since these individuals may not have been appropriately vaccinated in their native country. on rhe other hand, natural immunity to measles in immigrants is likely to be high given the high incidence of disease in developing parts of rhe world. thus it remains unclear if the most efficient strategy to achieve high levels of measles immunity in immigrants should entail initial serologic screening followed by vaccination of susceptible individuals or preemptive vaccination of all persons lacking immunization records. understanding the epidemiology of measles immunity in immigrant populations could help guide such decisions. . methods: we identified adults, years of age or older, who were screened for serologtc immunity to measles as part of a recently developed screening protocol at a downtown toronto community health centre. we subsequently determined if these individuals had any immunization records from their native country or from within canada. we then examined the relationship between several demographic factors and immunity to measles. results: % of immigrants had no prior immunization records. overall, % of the immigrants rested for immunity to measles were found to be immune; % of those under the age of , % of those between and years of age, % of those between and years of age, and % of those years of age or older. gender, education status, household income, and immigration status were nor ~ssoc ated wirh immunity to measles. immunity to measles was lowest among immigrants from eastern europe ( ~%), whil~ immigrants from other regions of the globe had greater than % immunity. c~lusrons: immigrants and refugees appear to have reasonably high levels of immunity to mea· sics, possibly related to natural infection wirh the measles virus. immigrants from eastern europe appear to have slightly. lower l~vel~ of immunity to the measles virus. universal screening for immunity to meales or preemptive vac:cmauon may both be inefficient public health strategies, however further research is needed to corroborate these findings. nancy r~ss, stephane tremblay, saeeda khan, daniel crouse, mark tremblay, and jean-marie berrhelor o~ve: the speed of the rise in obesity in places like canada suggests that rather than a shift in the gcncnc_ com~sirion of the population, the root of the obesity pandemic is an environment that suprrs ~besity. this paper examines the influence of neighbourhood and metropolitan characteristics. bour~lts:. while accounting. for individual socio-demographics and behaviours, residents of neighs with a large proportmn of poorly educated individuals had higher bmis than those living in poster sessions v neighbourhoods with more highly educated individuals (p <. ). residing in a neighbourhood with a high proportion of recent immigrants was associated with lower bmi for men (p<. ), but not women. neighbourhood dwelling density, a proxy for walkability, was not associated with bm! for either sex. metropolitan sprawl was associated with higher male bmi (p=. ) but the effect was negligible for women (p=. ). bmi was significantly lower for women (p<. ) living in a city in the province of quebec, even after accounting for the influence of individual and neighbourhood covariates. conclusions: bm! was strongly patterned by individual-level social position in urban canada. the incremental influence on bmi of neighbourhood related to the neighbourhood's social conditions and not to their physical form. metropolitan sprawl was associated with higher bm! for men, a group with longer car-dependent commutes than women. the findings suggest that both individuals and their environments (both social and physical) influence the distribution of bmi in urban populations. introduction: urban environments have been linked to a range of human health issues. in singapore, prevalence of end stage renal disease (esrd) is predicted to rise ( in to in , kidney international, vol. , . the clinical and economic burden of esrd has promoted development of strategies aimed at preventing the development and progression of chronic kidney disease. these include population based screening programs such as the national kidney foundation, sin-gapore\'s (nkfs) "partnership for prevention."the program, aims to reduce incidence of esrd through comprehensive intervention and screening for early detection of urinary abnormalities, blood pressure (bp), and random blood glucose (rbg). objective of this study is to examine gender, race and age wise prevalence of elevated bp, rbg and proteinuria. methodology: this current analysis includes , subjects, age to years, who underwent screening during september and december . participants were asked to give demographic information and the history of diseases. tests were given to get clinical information such as proteinuria, blood glucose, sbp, and dbp. blood pressure abnormalities were defined according to ]nc vi criteria. proteinuria was defined as the presence of plus or greater protein (equivalent to> mg/di) on dipstick analysis. results: there were , ( . %) males. racial distribution was chinese ( . % ), malay ( . % ), indians ( . %) and others ( . % ).among participants, who were apparently "healthy" (asymptomatic and without history of dm, ht, or kd), gender and race wise % prevalence of elevated (bp> / ), rbg (> mg/di) and positive urine dipstick for protein was as follows male: ( . ; . ; . ) female:( . ; . ; . ) chinese:( . ; . ; ) malay: ( . ; . ; . ) indian:( . ; . ; . ) others: ( . ; . ; . ) total:(l . , . , . ). percentage of participants with more than one abnormality were as follows. those with bp> / mmhg, % also had rbg> mg/dl and . % had proteinuria> i. those with rbg> mgldl, % also had proteinuria> and % had bp> / mmhg. those with proteinuria> , % also had rbg> mg/dl, and % had bp> / mmhg. conclusion: we conclude that sub clinical abnormalities in urinalysis, bp and rbg readings are prevalent across all genders and racial groups in the adult population. the overlap of abnormalities, point towards the high risk for esrd as well as cardiovascular disease. this indicates the urgent need for population based programs aimed at creating awareness, and initiatives to control and retard progression of disease. introduction: various theories have been proposed that link differential psychological vulnerability to health outcomes, including developmental theories about attachment, separation, and the formation of psychopathology. research in the area of psychosomatic medicine suggests an association between attachment style and physical illness, with stress as a mediator. there are two main hypotheses explored in the present study: ( t) that individuals living with hiv who were upsychologically vulne~able" at study entry would be more likely to experience symptoms of depression, anxiety and phys ca! illness over. the course of the -month study period; and ( ) life stressors and social support would mediate the relat nship between psychological vulnerability and the psychological ~nd physical outcomes. . (rsles), state-trait anxiety inventory (stai), beck depr~ssi~n lnvento~ (bdi), and~ _ -item pbys~i symptoms inventory. we characterized participants as havmg psychological vulnerability and low resilience" as scoring above on the raas (insecure attachment) or above on the das (negative expectations about oneself). . . . . . " . . ,, . results: at baseline, % of parnc pants were classified as havmg low resilience. focusmg on anxiety, the average cumulative stai score of the low-resilience group was significandy hi~e~ than that of the high-resilience group ( . sd= . versus . sd= . ; f(l, )= . , p <. ). similar results were obtained for bdi and physical symptoms (f( , )= . , p<. and f( , )= . , p<. , respec· tively). after controlling for resilience, the effects of variance in life stres".°rs averaged over time wa~ a_sig· nificant predictor of depressive and physical symptoms, but not of anxiety. ho~e_ver, these assooan~s became non-significant when four participants with high values were removed. s id larly, after controlling for resilience, the effects of variance in social support averaged over time became insignificant. conclusion: not only did "low resilience" predict poor psychological and physical outcomes, it was also predictive of life events and social support; that is, individuals who were low in resilience were more likely to experience more life events and poorer social support than individuals who were resilient. for individuals with vulnerability to physical, psychological, and social outcomes, there is need to develop and test interventions to improve health outcomes in this group. rajat kapoor, ruby gupta, and jugal kishore introduction: young people in india represent almost one-fourth of the total population. they face significant risks related to sexual and reproductive health. many lack the information and skills neces· sary to make informed sexual and reproductive health choices. objective: to study the level of awareness about contraceptives among youth residing in urban and rural areas of delhi. method: a sample of youths was selected from barwala (rural; n= ) and balmiki basti (urban slums; n= ) the field practice areas of the department of community medicine, maulana azad medical college, in delhi. a pre-tested questionnaire was used to collect the information. when/(calen· dar time), by , fisher exact and t were appliedxwhom (authors?). statistical tests such as as appropriate. result: nearly out of ( . %) youth had heard of at least one type of contraceptive and majority ( . %) had heard about condoms. however, awareness regarding usage of contraceptives was as low as . % for terminal methods to . % for condom. condom was the best technique before and after marriage and also after childbirth. the difference in rural and urban groups was statistically signif· icant (p=. , give confidence interval too, if you provide the exact p value). youth knew that contra· ceptives were easily available ( %), mainly at dispensary ( . %) and chemist shops ( . %). only . % knew about emergency contraception. only advantage of contraceptives cited was population con· trol ( . %); however, . % believed that they could also control hiv transmission. awareness of side effects was poor among both the groups but the differences were statistically significant for pills (p= . ). media was the main source of information ( %). majority of youth was willing to discuss a~ut contraceptive with their spouse ( . %), but not with others. . % youth believed that people in their age group use contraceptives. % of youth accepted that they had used contraceptives at least once. % felt children in family is appropriate, but only . % believed in year spacing. . conclusion: awareness about contraceptives is vital for youth to protect their sexual and reproduc· tive health .. knowledge about terminal methods, emergency contraception, and side effects of various contraceptives need to be strengthened in mass media and contraceptive awareness campaigns. mdbot:ls: elderly aged + were interviewed in poor communities in beirut the capital of f:ebanon, ~e of which is a palestinia~. refugee camp. depression was assessed using the i -item geriat· nc depressi~n score (~l?s- ). specific q~estions relating to the aspects of religiosity were asked as well as questions perta rung to demographic, psychosocial and health-related variables. results: depression was prevalent in % of the interviewed elderly with the highest proportion being in the palestinian refugee camp ( %). mosque attendance significantly reduced the odds of being depressed only for the palestinian respondents. depression was further associated, in particular communities, with low satisfaction with income, functional disability, and illness during last year. condiuion: religious practice, which was only related to depression among the refugee population, is discussed as more of an indicator of social cohesion, solidarity than an aspect of religiosity. furthermore, it has been suggested that minority groups rely on religious stratagems to cope with their pain more than other groups. implications of findings are discussed with particular relevance to the populations studied. nearly thirty percent of india's population lives in urban areas. the outcome of urbanization has resulted in rapid growth of urban slums. in a mega-city chennai, the slum populations ( . percent) face greater health hazards due to overcrowding, poor sanitation, lack of access to safe drinking water and environmental pollution. amongst the slum population the health of women and children are most neglected, resulting in burden of both communicable and non-communicable diseases. the focus of the paper is to present the epidemiology profile of children (below years) in slums of chennai, their health status, hygiene and nutritional factors, the social response to health, the trends in child health and urbanization over a decade, the health accessibility factors, the role of gender in health care and assessment impact of health education to children. the available data prove that child health in slums is worse than rural areas. though the slum population is decreasing there is a need to explore the program intervention and carry out surveys for collecting data on some specific health implications of the slum children. objective: during the summer of there was a heat wave in central europe, producing an excess number of deaths in many countries including spain. the city of barcelona was one of the places in spain where temperatures often surpassed the excess heat threshold related with an increase in mortality. the objective of the study was to determine whether the excess of mortality which occurred in barcelona was dependent on age, gender or educational level, important but often neglected dimensions of heat wave-related studies. methods: barcelona, the second largest city in spain ( , , inhabitants in ) , is located on the north eastern coast. we included all deaths of residents of barcelona older than years that occurred in the city during the months of june, july and august of and also during the same months during the preceding years. all the analyses were performed for each sex separately. the daily number of deaths in the year was compared with the mean daily number of deaths for the period - for each educational level. poisson regression models were fitted to obtain the rr of death in with respect to the period - for each educational level and age group. results: the excess of mortality during that summer was more important for women than for men and among older ages. although the increase was observed in all educational groups, in some age-groups the increase was larger for people with less than primary education. for example, for women in the group aged - , the rr of dying for compared to - for women with no education was . ( %ci: . - - ) and for women with primary education or higher was . ( %ci: . - . ). when we consider the number of excess deaths, for total mortality (>= years) the excess numbers were higher for those with no education ( . for women and . for men) and those with less than primary education ( . for women and - for men) than those with more than primary edm:ation ( . for women and - . for men). conclusion: age, gender and educational level were important in the barcelona heat wave. it is necessary to implement response plans to reduce heat morbidity and mortality. policies should he addressed to all population but also focusing particularly to the oldest population of low educational level. introduction: recently there has been much public discourse on homelessness and its imp~ct on health. measures have intensified to get people off the street into permanent housing. for maximum v poster sessions success it is important to first determine the needs of those to be housed. their views on housing and support requirements have to be considered, as th~y ar~ the ones affected. as few res.earch studies mclude the perspectives of homeless people themselves, httle is known on ho~ they e~penence the mpacrs on their health and what kinds of supports they believe they need to obtain housing and stay housed. the purpose of this study was to add the perspectives of homeless people to the discourse, based in the assumption that they are the experts on their own situations and needs. housing is seen as a major deter· minant of health. the research questions were: what are the effects of homelessness on health? what kind of supports are needed for homeless people to get off the street? both questions sought the views of homeless individuals on these issues. methods: this study is qualitative, descriptive, exploratory. semi-structured interviews were conducted with homeless persons on street corners, in parks and drop-ins. subsequently a thematic analysis was carried out on the data. results: the findings show that individuals' experiences of homelessness deeply affect their health. apart from physical impacts all talked about how their emotional health and self-esteem are affected. the system itself, rather than being useful, was often perceived as disabling and dehumanizing, resulting in hopelessness and resignation to life on the street. neither welfare nor minimum wage jobs are sufficient to live and pay rent. educational upgrading and job training, rather than enforced idleness, are desired by most initially. in general, the longer persons were homeless, the more they fell into patterned cycles of shelter /street life, temporary employment /unemployment, sometimes addictions and often unsuccessful housing episodes. conclusions: participants believe that resources should be put into training and education for acquisition of job skills and confidence to avoid homelessness or minimize its duration. to afford housing low-income people and welfare recipients need subsidies. early interventions, 'housing first', more humane and efficient processes for negotiating the welfare system, respectful treatment by service providers and some extra financial support in crisis initially, were suggested as helpful for avoiding homelessness altogether or helping most homeless people to leave the street. this study is a national homelessness initiative funded analysis examining the experiences and perceptions of street youth vis-a-vis their health/wellness status. through in-depth interviews with street youth in halifax, montreal, toronto, calgary, ottawa and vancouver, this paper explores healthy and not-so healthy practices of young people living on the street. qualitative interviews with health/ social service providers complement the analysis. more specifically, the investigation uncovers how street youth understand health and wellness; how they define good and bad health; and their experiences in accessing diverse health services. findings suggest that living on the street impacts physical, emotional and spiritual well·being, leading to cycles of despair, anger and helplessness. the majority of street youth services act as "brokers" for young people who desire health care services yet refuse to approach formal heal~h care organizational structures. as such, this study also provides case examples of promising youth services across canada who are emerging as critical spaces for street youth to heal from the ravages of ~treet cultur~. as young people increasingly make up a substantial proportion of the homeless population in canada, it becomes urgent to explore the multiple ways in which we can support them to regain a sense of wellbeing and "citizenship." p - (c) health and livelihood implications of marginalization of slum dwellers in provision of water and sanitation services in nairobi city elizabeth kimani, eliya zulu, and chi-chi undie . ~ntrodfldion: un-habitat estimates that % of urban residents in kenya live in slums; yet due to their illegal status, they are not provided with basic services such as water sanitation and health care. ~nseque~tly, the services are provided by vendors who typically provide' poor services at exorbitant prices .. this paper investigates how the inequality in provision of basic services affects health and livelihood circumstances of the poor residents of nairobi slums . . methods: this study uses qualitative and quantitative data collected through the ongoing longitudmal .health and demographic study conducted by the african population and health research center m slum communities in n ·rob" w d · · · · ai . e use escnpnve analytical and qualitative techmques to assess h~w concerns relating to water supply and environmental sanitation services rank among the c~mmumty's general and health needs/concerns, and how this context affect their health and livelihood circumstances. results: water ( %) and sanitation ( %) were the most commonly reported health needs and also key among general needs (after unemployment) among slum dwellers. water and sanitation services are mainly provided by exploitative vendors who operate without any regulatory mechanism and charge exorbitantly for their poor services. for instance slum residents pay about times more for water than non-slum households. water supply is irregular and residents often go for a week without water; prices are hiked and hygiene is compromised during such shortages. most houses do not have toilets and residents have to use commercial toilets or adopt unorthodox means such as disposing of their excreta in the nearby bushes or plastic bags that they throw in the open. as a direct result of the poor environmental conditions and inaccessible health services, slum residents are not only sicker, they are also less likely to utilise health services and consequently, more likely to die than non-slum residents. for instance, the prevalence of diarrhoea among children in the slums was % compared to % in nairobi as a whole and % in rural areas, while under-five mortality rates were / , / and / respectively. the results demonstrate the need for change in governments' policies that deprive the rapidly expanding urban poor population of basic services and regulatory mechanisms that would protect them from exploitation. the poor environmental sanitation and lack of basic services compound slum residents' poverty since they pay much more for the relatively poor services than their non-slum counterparts, and also increase their vulnerability to infectious diseases and mortality. since iepas've been working in harm reduction becoming the pioneer in latin america that brought this methodology for brazil. nowadays the main goal is to expand this strategy in the region and strive to change the drug policy in brazil. in this way harm reduction: health and citizenship program work in two areas to promote the citizenship of !du and for people living with hiv/aids offering law assistance for this population and outreach work for needle exchange to reduce damages and dissemination of hiv/aids/hepatit is. the methodology used in outreach work is peer education, needle exchange, condoms and folders distribution to reduce damages and the dissemination of diseases like hiv/aids/hepatitis besides counseling to search for basic health and rights are activities in this program. law attendance for the target population at iepas headquarters every week in order to provide law assistance that includes only supply people with correct law information or file a lawsuit. presentations in harm reduction and drug policy to expand these subjects for police chiefs and governmental in the last year attended !du and nidu reached and . needles and syringes exchanged. in law assistance ( people living with aids, drug users, inject drug users, were not in profile) people attended. lawsuits filed lawsuits in current activity. broadcasting of the harm reduction strategies by the press helps to move the public opinion, gather supporters and diminish controversies regarding such actions. a majority number of police officer doesn't know the existence of this policy. it's still polemic discuss this subject in this part of population. women remain one of the most under seviced segments of the nigerian populationand a focus on their health and other needs is of special importance.the singular focus of the nigerian family welfare program is mostly on demographic targets by seeking to increase contraceptive prevalence.this has meant the neglect of many areas of of women's reproductive health. reproductive health is affected by a variety of socio-cultural and biological factors on on e hand and the quality of the service delivery system and its responsiveness on the other.a woman's based approach is one which responds to the needs of the adult woman and adolescent girls in a culturally sensitive manner.women's unequal access to resources including health care is well known in nigeria in which stark gender disparities are a reality .maternal health activities are unbalanced,focusi ng on immunisation and provision of iron and folic acid,rather than on sustained care of women or on the detection and referral of high risk cases. a cross-sectional study of a municipal government -owned hospitalfrom each of the geo-political regions in igeria was carried out (atotal of ce~ters) .. as _part ~f t~e re.search, the h~spital records were uesd as a background in addition to a -week mtens ve mvesuganon m the obstemc and gynecology departments. . . . : little is known for example of the extent of gynecological morbtdtty among women; the little known suggest that teh majority suffer from one or more reproductive tr~ct infect~ons. although abortion is widespread, it continues to be performed under ilegal and unsafe condmons. with the growing v poster sessions hiv pandemic, while high riskgroups such ascomn;iercial sex workers and their clients have been studied, little has been accomplished in the large populat ns, and particularly among women, regardmgstd an hiv education. . . conclusions: programs of various governmentalor non-governmental agen,c es to mvolve strategies to broaden the narrow focus of services, and more importan~, to put wo~en s reproducnve health services and information needs in the forefront are urgently required. there is a n~d to reonent commuication and education activities to incorprate a wider interpretation of reproducnve health, to focus on the varying information needs of women, men, and youth and to the media most suitable to convey information to these diverse groups on reproductive health. introduction: it is estimated that there are - youths living on the streets, on their own with the assistance of social services or in poverty with a parent in ottawa. this population is under-serviced in many areas including health care. many of these adolescents are uncomfortable or unable to access the health care system through conventional methods and have been treated in walk-in clinics and emergency rooms without ongoing follow up. in march , the ontario government provided the ct lamont institute with a grant to open an interdisciplinary and teaching medical/dental clinic for street youth in a drop-in center in downtown ottawa. bringing community organizations together to provide primary medical care and dental hygiene to the streetyouths of ottawa ages - , it is staffed by a family physician, family medicine residents, a nurse practitioner, public health nurses, a dental hygienist, dental hygiene students and a chiropodist who link to social services already provided at the centre including housing, life skills programs and counselling. project objectives: . to improve the health of high risk youth by providing accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. . to model and teach interdisciplinary adolescent care to undergraduate medical students, family medicine residents and dental hygiene students. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative:a) semi-structured interviews b) focus groups with youth quantitative:a) electronic medical records for months b) records (budget, photos, project information). results: in progress-results from first months available in august . early results suggest that locating the clinic in a safe and familiar environment is a key factor in attracting the over youths the clinic has seen to date. other findings include the prevalence of preventative interventions including vaccinations, std testing and prenatal care. the poster presentation will present these and other impacts that the clinic has had on the health of the youth in the first year of the study. conclusions: ) the clinic has improved the health of ottawa streetyouth and will continue beyond the initial pilot project phase. ) this project demonstrates that with strong community partnerships, it is possible meet make healthcare more accessible for urban youth. right to health care campaign by s.j.chander, community health cell, bangalore, india. introduction: the people's health movement in india launched a campaign known as 'right to health care' during the silver jubilee year of the alma ata declaration of 'health for all' by ad in collahoration with the national human rights commission (nhrc). the aim of the campaign was to establish the 'right to health care' as a basic human right and to address structural deficiencies in the pubic health care system and unregulated private sector . . methods: as part of the campaign a public hearing was organized in a slum in bangalore. former chairman of the nhrc chaired the hearing panel, consisting of a senior health official and other eminent people in the city. detailed documentation of individual case studies on 'denial of access to health care' in different parts of the city was carried out using a specific format. the focus was on cases where denial of health services has led to loss of life, physical damage or severe financial losses to the patient. results: _fourte_en people, except one who had accessed a private clinic, presented their testimonies of their experiences m accessing the public health care services in government health centres. all the people, e_xcept_ one person who spontaneously shared her testimony, were identified by the organizations worki_ng with the slum dwellers. corruption and ill treatment were the main issues of concern to the people. five of the fourteen testimonies presented resulted in death due to negligence. the public health cen· n:s not only demand money for the supposedly free services but also ill-treats them with verbal abuse. five of these fourteen case studies were presented before the national human right commission. the poster sessions v nhrc has asked the government health officials to look into the cases that were presented and to rectify the anomalies in the system. as a result of the public hearing held in the slum, the nhrc identified urban health as one of key areas for focus during the national public hearing. cond#sion: a campaign is necessary to check the corrupted public health care system and a covetous private health care system. it helps people to understand the structure and functioning of public health care system and to assert their right to assess heath care. the public hearings or people's tribunals held during the campaign are an instrument in making the public health system accountable. ps- (a) violence among women who inject drugs nadia fairbairn, jo-anne stoltz, evan wood, kathy li, julio montaner, and thomas kerr background/object ives: violence is a major cause of morbidity and mortality among women living in urban settings. though it is widely recognized that violence is endemic to inner-city illicit drug markets, little is known about violence experienced by women injection drug users (!du). therefore, the present analyses were conducted to evaluate the prevalence of, and characteristics associated with, experiencing violence among a cohort of female idu in vancouver. methods: we evaluated factors associated with violence among female participants enrolled in the vancouver injection drug user study (vidus) using univariate analyses. we also examined self-reported relationships with the perpetrator of the attack and the nature of the violent attack. results: of the active iou followed between december , and may , , ( . %) had experienced violence during the last six months. variables positively associated with experiencing violence included: homelessness (or= . , % ci: . - . , p < . ), public injecting (or= . , % ci: . - . , p < . ), frequent crack use (or= . , % ci: . - . , p < . ), recent incarceration (or = . , % cl: . - . , p < . ), receiving help injecting (or = . , % cl: . - . , p < . ), shooting gallery attendance (or = . , % ci: . - . , p < . ), sex trade work (or = . , % cl: . - . , p < . ), frequent heroin injection (or= . , % cl: . - . , p < . ), and residence in the downtown eastside (odds ratio [or] = . , % ci: . - . , p < . ). variables negatively associated with experiencing violence included: being married or common-law (or = . . % ci: . - . , p < . ) and being in methadone treatment (or = . , % ci: . - . , p < . ). the most common perpetrators of the attack were acquaintances ( . %), strangers ( . %), police ( . %), or dealers ( . %). attacks were most frequently in the form of beatings ( . %), robberies ( . %), and assault with a weapon ( . %). conclusion: violence was a common experience among women !du in this cohort. being the victim of violence was associated with various factors, including homelessness and public injecting. these findings indicate the need for targeted prevention and support services, such as supportive housing programs and safer injection facilities, for women iou. introduction: although research on determinants of tobacco use among arab youth has been carried out at several ecologic levels, such research has included conceptual models and has compared the two different types of tobacco that are most commonly used among the lebanese youth, namely cigarette and argileh. this study uses the ecological model to investigate differences between the genders as related to the determinants of both cigarette and argileh use among youth. methodology: quantitative data was collected from youth in economically disadvantaged urban communities in beirut, the capital of lebanon. results: the results indicated that there are differences by gender at a variety of ecological levels of influence on smoking behavior. for cigarettes, gender differences were found in knowledge, peer, family, and community influences. for argileh, gender differences were found at the peer, family, and community l.evels. the differential prevalence of cigarette and argileh smoking between boys and girls s therefore understandable and partially explained by the variation in the interpersonal and community envi.ronment which surrounds them. interventions therefore need to be tailored to the specific needs of boys and girls. introduction: the objective of this study was to assess the relationship between parents' employment status and children' health among professional immigrant families in vancouver. our target communmes v poster sessions included immigrants from five ethnicity groups: south korean, indian, chine~e, ~ussian, and irani~ with professional degrees (i.e., mds, lawyers, engineers, ma?~ger~, and uru~ers ty professors) w h no relevant job to their professions and those who had been hvmg m the studied area at least for months. methodology: the participants were recruited by collaboration from three local community agencies and were interviewed individually during the fall of . ra#lts: totally, complete interviews were analyzed: from south-east asia, from south asia, from russia and other eastern europe. overall, . % were employed, . % were underemployed, % indicated they were unemployed. overall, . % were not satisfied with their current job. russians and other eastern europeans were most likely satisfied with their current job, while south-east asians were most satisfied from their life in canada. about % indicated that their spouses were not satisfied with their life in canada, while % believed that their children are very satisfied from their life in canada. in addition, around % said they were not satisfied from their family relationship in canada. while most of the responders ranked their own and their spouses' health status as either poor or very poor, jut % indicated that their first child's health was very poor. in most cases they ranked their children's health as excellent or very good. the results of this pilot study show that there is a need to create culturally specific child health and behavioral scales when conducting research in immigrant communities. for instance, in many asian cultures, it is customary for a parent either to praise their children profusely, or to condemn them. this cultural practice, called "saving face," can affect research results, as it might have affected the present study. necessary steps, therefore, are needed to revise the current standard health and behavioral scales for further studies by developing a new scale that is more relevant and culturally sensitive to the targeted immigrant families. metboda: database: national health survey (ministry of health www.msc.es). two thousand interviews were performed among madrid population ( . % of the whole); corresponded to older adults ( . % of the . million aged years and over). study sample constitutes . % ( out of ) of those older adults, who live in urban areas. demographic structure (by age and gender) of this population in relation to health services use (medical consultations, dentist visits, emergence services, hospitalisation) was studied using general linear model univariate procedure. a p . ), while age was associated with emergence services use ( % of the population: %, % and % of each age group) and hos~italisation ( % .oft~~ population: %, % and %, of each age ~oup) (p . ) was fou~d with respect to dennst v s ts ( % vs %), medical consultations ( % vs %), and emergence services use ( % vs %), while an association (p= . ) was found according to hospitalisation ( % vs %). age. an~ g~der interaction effect on health services use was not found (p> . ), but a trend towards bosp tal sanon (p= . ) could be considered. concl.uions: demographic structure of urban older adults is associated with two of the four health se~ices use studi~. a relation.ship ber_ween age. and hospital services use (emergence units and hospitalisanon), but not with ~ut-hosp tal sei:vices (medical and dentist consultations), was found. in addition ro age, gender also contnbutes to explam hospitalisation. . sexua experiences. we exammed the prevalence expenences relation to ethnic origin and other sociodemographic variables as wc i as y j die relation between unwanted sexual experiences, depression and agreuion. we did so for boys and prts separately. mdhods: data on unwanted sexual expcric:nces, depressive symptoms (ce.s-d), aggrc:uion (bohi-di and sociodemographic facron were collected by self-report quescionnairc:s administettd to students in the: nd grade (aged - ) of secondary schools in amsterdam, the netherlands. data on the nature ol unwanted sexual experiences were collected during penonal interviews by trained schoolnursn. ltaijtj: overall prevalences of unwanted sexual experiences for boys and girls were . % and . % respectively. unwanted sexual experiences were more often ttported by turkish ( . %), moroc· an ( . %) and surinamese/anrillian boys ( . %) than by dutch boys ( . %). moroccan and turkish girls, however, reported fewer unwanted sexual experiences (respectively . and . %) than durch girls did ( . %). depressive symptoms(or= . , cl= . - . ) covert agression ( r• . , cl• . - . ) and cmrt aggression (or= . , cl• . - . ) were more common in girls with an unwanted sexual experi· met. boys with an unwanted sexual experience reported more depressive symptoms (or= . ; cl• i . .l· . ) and oven agression (or= . , cl= . - . ) . of the reported unwanted sexual experiences rnpec· timy . % and . % were confirmed by male and female adolescents during a personal interview. cond sion: we ..:an conclude that the prevalence of unwanted sexual experiences among turkish and moroccan boys is disturbing. it is possible that unwanted sexual experiences are more reported hy boys who belong to a religion or culture where the virginity of girls is a maner of family honour and talking about sexuality is taboo. more boys than girls did not confirm their initial disdosurc of an lllwalltc:d sexual experience. the low rates of disclosure among boys suggcsu a necd to educ.:atc hcahh care providen and others who work with migrant boys in the recognition and repomng of exu.il ... iction. viramin a aupplc:tmntation i at .h'yo, till far from tafl'eted %. feedinit pracn~:n panku· lerty for new born earn demand lot of educatton ernpha a• cxdu ve hrealt fecdtnit for dnared rcnoj of months was observtd in only .s% of childrrn thoulh colckturm w. givm n rn% of mwly horn ct.ildrm. the proportion of children hclow- waz (malnounshrdl .con" a• h!jh •• . % anj "rt'i· acimy tc.. compared to data. mother's ~alth: from all is womm in ttprod~uvr •ill' poup, % were married and among marned w~ .\ % only w\"rt' u mic wmr cnntr.-:cruve mt h· odl % were married bdorc thc •ar of yean and % had thnr ftnc prcicnancy hcftitt dlt' •icr nf yean. the lt'f'vicn are not uutfactory or they arc adequate but nae unh ed opumally. of thote' l'h mothen who had deliverrd in last one year, % had nailed ntmaral eum nat on ira" oncc, .~o-... bad matt rhan four ttmn and ma ortty had heir tetanus toxotd tnin,"t or"'" nlht "'"'"· ljn r ned rn· win ronductrd . % dchvcnn and % had home deh\'t'oc'i. ~md~: the tervtcn unbud or u led are !tu than dnarame. the wr· l'kft provided are inadequate and on dechm reprcwnttng a looun t ~p of h hnto good coytti\#' ol wr· ncn. l!.ckground chanpng pnoriry cannoc be ruled out u °"" of thc coatnbutory bc f. ps-ii ia) dcpn:wioa aad anuccy ia mip'mu ia awccr._ many de wn, witco tui~bmjer. jack dekker, aart·jan lttkman, wim gonmc:n. and amoud verhoeff ~ a dutch commumry-bucd icudy thawed -moarh•·prc:yalm«i al . ' . kw anx · ay daorden and . % foi' dqrasion m anmttdam. nm .. p tficantly hlllhn than dwwhrft .. dw ~thew diffamca m pttyalcnca att probably rdarcd to tlk' largr populanoa of napaan ..\mturdam. <turkish %, moroccan %, and surinam % . lndttd. ic'wt'll ltudla hatt ~ ~ high prevalena rata among migrant poupi in rbe ncdwrlands. howc'ytt au ttlluchn iuffenod from wry low raporne rara, or med screnung talel thac lack a ~y yabdarcd ~ in order to study the prevalence of depression and anxiety, and the (barriers to) use of mental health care among the different ethnic groups the following study was recently conducted: . the study consisted of a two-step approach. the first step was mcl~ded m the ~ h ith survey of (ahs), and consisted of three screening scales for depression and aruaety (klo, g::q- and mhl- ). in this survey all respondents were asked_ permission for~ second app~ :' t consisted of a structured interview containing the cidi for aruaety and depression, and questtollllalres on health care seeking, amongst others. all respondents who gave permission for a second approachwere invited by jetter for a suuctured interview with multilingual interviewers at home at a preset date and time in the following week. . in total, dutch, turkish, moroccan and surinam respondents took part in the ahs and gave permission for a second approach. in the second step, fo~ ~ tur~h, m~roc can surinamese and dutch respondents, information from the extensive interview was available (res~nse rates between and % ). since the data collection was completed only recently (june ), prevalence estimates can be presented at the conference for the first time. we have shown that with this approach it is feasible to achieve an acceptable response rate in a study on mental health among migrants. therefore we expect that this study will provide reli· able estimates of depression and anxiety in the turkish, moroccan and surinam migrants in amstw! ~· for the first time. in addition, insight into mechanisms underlying the differences between and within ethnic groups and into barriers to mental health care will provide pretexts for the improvement of pre· vention and mental health care for migrant groups. this study aimed to determine spatial patterns of mortality and morbidity of five major health problems in an urban environment: homicides, pregnancy among adolescents ((< years old), asthma hospitalization among young children(< years old) and two mosquito-borne diseasesdengue and visceral leishmaniasis, during - . all events were obtained through the city health database and, subsequently, geoproccsscd using the address of residence and the geographical and administrative division of the municipality, composed by unit of planning (up), which in tum were formed, each one, by census tract units. two research questions were investigated: are there spatial patterns to the events dis· tribution, and moreover, are these patterns overlapping across space? we use thematic maps, index of comparative mortality/morbidity by up and the overlapped rank of the th worse up rates for each event. a spatial pattern of high rates of homicides, proportion of young mothers and hospitalization of asthma were overlapping in areas social and economically disadvantaged. for mosquito-borne diseases, high rates with great dispersion were found in unprivileged areas in contrast with very low rares among privileged ones. these results pointed toward a coexistence of heavier burden of diseases for those living in areas of the city where misery, poverty, lack of political public health may be modulating social health problems. a possible environmental intervention in one mosquito•bome disease might be playing a role in the occurrence of other. although with limitations, this study may provide useful information for a joint urban planning under the public perspective, articulated for use in health impact assessment. jalil safaei bdrod#aion: the association of socioeconomic status (ses), usually measured by income, and health status is an established result in bcalth studies. the poor and low income individuals have lower health sta· tus then_ those with higher incomes. in general. such finding has been usually obtained from sample surveys on speafic populations. a problem with many sample survey$ is that their results are not comparable aaoss ~ndaries as they may use different sampling methods, ask different questions, categorize the answers differently, or define groups differently. moreover, the sample data need to be standardized using the demographic: katurea of a ~ population. this study, however, uses the national population health survey (nphs) cycle public use mictodata files which is based on a common survey template ·~~three~ area in canada, namely montreal, toronto, and vancouver. it also utili .es the built-m stanclatdizaaon of the nphs data which accounts for its complex survey design. . ~:the stu~ usc:s two well-known measures of health inequalitythe relative index of meqaality and die concentranon indexto capture the extent of income related health inequality among poster sessions v urban female and male populations in each of the three metropolitan areas. personal income is classified into ten groups by the nphs with "no income" as the first group and "more than $ , " as the last. health status is measured by three variables -having a chronic condition (chc), self assessed health (sah), and health utility index (hui) -using appropriate indices. alternative formulations are used to calculate the standard deviations of the estimated or calculated measures. the findings of the study suggest that the measured health inequality depends on the health measure used. for chc and hui the measured inequality indices do indicate poorer health for lower income individulas, however, they are not statistically insignificant. health inequalities are more pronounced when health is measured by sah. the results do not support any systematic ranking of the three metropolitan areas in terms of health inequalities. they do not reveal any systematic pattern of inequality between men and women, either. conclusions: despite the use of highly aggregated nphs data, income related health disparities are observed in the three metropolitan areas in canada. this is more the case with self perceived (sah) health. such disparities are preventable and call for broader health policies that address poverty and low income among other social determinants of health. introduction: the analysis of health indicators under the spatial perspective is configured as an important instrument in the detection of intra-urban differentials. this study aimed to examine the spatial distribution of the births occurred in belo horizonte, in , analyzing the presence of spatial clusters of health indicators for newborns (rn) and their mothers, using data from the information system on live birth database (sinasc). method: for each covered area of the basic units of health (ubs), we calculated the proportion of: adolescent mothers, mothers with less than years of schooling, first pregnancy, mothers with four or more pregnancies, dead babies born on previous pregnancies, stillbirths, cesarean section, less than four prenatal care attendance, moderate and severe hypoxemia in the st and th minutes of life, low or very low birth weight. we used empiric bayesian methods for smoothing the estimates. for spatial analysis, the indicators obtained from the global moran (i) index and local indicators of spatial association (lisa) were used. maps were built to allow the visualization of the spatial clusters. in all analysis, significance statistics was considered p~ . . results: a total of , births of residents in belo horizonte were registered in i. the estimated bayesian proportions for the entire municipality was close to the one observed for all variables. analysis using lisa showed the presence of relevant spatial clusters for adolescent and low educated mothers, dead babies form previous pregnancies, cesarean section, low attendance to the prenatal care especially in area with low socio-demographic characteristics. three areas presented consistent clusters, with important spatial auto-correlation for almost all studied indicators. conclusion: the used methodology was configured as a great instrument of detection risk areas where clustering occurs. it can easily be incorporated in any surveillance system as a mechanism for controlling events related to births in the municipality. moreover, it can be applied to discriminate target areas for prompt public health interventions, such as improving health services access and the consolidation of better obstetric practices. introduction: gentrification, the displacement of low income and non-majority people out of longtime neighborhoods and residences is a global phenomenon. it has been identified as occurring in both developed and less developed countries and as inequality persists or increases, many communities are vulnerable to disruption and loss. while there may be some benefits to gentrification, these benefits are less likely to impact those who have been forced to move out of a gentrifying community or those who remain but economically stressed. . . . . this paper lays out a theoretical framework for dent fymg and ~ddressm~. the_ health consequences of gentrification on residents living in a community prior .to o.r durmg gent~ ~ cat. n. by drawing on the literature of housing, sociology, health and urban plannmg, t places genmf catt~n and neighborhood change into the context of other forces affecting th~ .hea.lth of vulnerable populations. it then proposes solutions to prevent or mitigate the impacts of genmf cat on. results: four main categories of consequences potentiallr re~ult from ~entr~fica~~n: !'°°r housing· related issues, spatial effects, mental health impacts and contr bunons to racial ~spanttes m heal~. the housing issues include increased susceptibility to asthma, lead exposure, allergiesl~topy an~. acetdents/ injuries. spatial effects include reduced access to health ~are, reduce~ access to obslttadinonal food sources, decreased physical activity, and increased obesity. the __ pnmary mental health effects_ :ire increased stress increased risk of depression and disruption of trad t onal support networks. in addinon to the above he~lth issues, gentrification has the potential to increase racial disparities in health by reduc· ing access to long term and multi-culturally experienced health care provide~s. conclusions: public health practice provides a framework for addressmg the health consequences of gentrification. in this context primary prevention would involve preventing gentrification in the first place along with a renewed commitment to helping distressed communities a~~ im_proving the quality ~f life for long term residents. the next layer of meeting the challenges of gentrification would be to assjst long rime residents to stay in a community and thus potentially allowing them to participate in the bene~ts of gentrification (such as better public services). only if all these efforts fail -and these other prevennon strategies must be a priority, public policy should then work to help people and instirutions move to other communities through grants and the provision of alternative safe affordable housing and neighborhoods. sarah romans, marsha cohen, and tonia forte lnh'odlletion: there has been sustained interest in urban rural (ur) differences in mental health over the last years of epidemiological research, with most studies reporting higher urban rates of mor· bidity, particularly when psychotic disorders have been studied. most recently, in britain, urban rates of non-psychotic disorder were greater than rural and semi-rural rates, both before and after the more adverse circumstances of urban dwellers were considered (paykel et al ) . surprisingly, there were no ur differences in help seeking. in canada, wang ( ) found greater urban rates for major depression only after he controlled for the confounding effects of race, immigration, employment and marital status, a result reminiscent of work from the us (blazer et ) . rural participants were less likely to have sought help for their mental health problems. in this study, we sought to examine urban/rural differences in rates of depression and help seeking in canada. method; data came from the canadian community health survey . , a community survey conducted by statistics canada of people aged and older, with the total sample size of , respon· dents, % response. analyses used weighted data; differences were assessed by chi-squared. ra.its: bivariate cross-tabulations showed a modest increase in month depression rates for urban ( . %) over rural ( . %, p= . ) dwellers; there were no ur differences when the sample was examined separately by gender and age group ( - , - , - ) . in general, more urban ( . %) than rural people ( . %, p= . ) had sought mental health treatment in the past year. there was no ur difference in helping seeking amongst those with depression (u . %, r . % ns). amongst the whole population, helping seeking was gendered with more urban men accessing help ( . %) than rural men ( . %, p= . ); this did not apply for women ( . % vs . % p= . ). ~ons: the urban-rural demographic continues to generate intriguing findings, even recently when internal migration is common and people can seek out the environment most conducive to their health, ~th physical and mental. people with depression are a disadvantaged, frequently stigmatized group, with ~r quality of life a_nd often impaired function. unlike many other factors associated wi~h urban or rural hfe per se, depression can be treated. the low help seeking rates is a cause for concern, m both the ur~n and_ rural populations. it behooves researchers, policy makers and service planners to ensutt effective services are available for both humane and economic reasons. methods: using united states census income data, we assigned the manhattan community districts to two major socioeconomic groups, manhattan i and ii. manhattan i is composed of community districts with average household incomes above the median for new york city; manhattan ii is those below. with public new york city department of health death records and us census data, we calculated a "standard" new york city population and estimated mortality rate distributions for manhattan i and ii. we then compared these age-adjusted actual mortality distributions with a standard t-test. results: we explored premature deaths using several cut-off points (before the ages of , , and ), and with subcomparisons for males and females. every comparison showed the wealthier area, manhattan i, to have significantly lower premature mortality rates than the lower income manhattan ii. further, we compared age-adjusted mortality rates among the city's five boroughs, and found no significant differences based on local geography alone. conclusions: these findings suggest that in manhattan, characterized by its extremes of wealth and poverty, health status, as measured by premature mortality, does vary significantly with the local income level. in manhattan, the relative average income by community district varies as much as : . this ratio is greater than that found in the other cities we have studied: for example, the range among tokyo's kus is half that in manhattan, or about : . paris has shown the longest life expectancy and changing premature mortality rates. from our preliminary work, we expect to find less variation in premature mortality rates in comparable cities. this study will continue to explore the relationship of premature mortality rates and life expectancy to income levels and different health systems among wcp cities with a view to measuring health policy options. introduction: according to the world health organization (who), smoking-related illness is currently the world's second major cause of death, currently responsible for one out of ten adult deaths worldwide. the who's framework convention on tobacco control (fctc) aims to reduce tobaccorelated disease and deaths by changing national public policies. mexico, which, according to the who, had smoking prevalences of % among adults in and % among health care providers (hcps) in , ratified the fctc in . objective: to examine knowledge of and attitudes towards cigarette smoking and smoking cessation among hcps, and clinical practices regarding smoking cessation. methods: in june , a convenience sample of hcps from one public clinic in urban oaxaca, mexico, part of mexico's national network of public health care clinics, were interviewed in spanish using a verbally administered questionnaire that was standard among all participants. during primary care outpatient visits, hcps were observed treating patients to assess the relative importance of smoking cessation as a health care priority. results: of the hcps interviewed, including ten physicians, three nurses, and five medical students, % reported smoking regularly. all hcps reported assessing patients' history of smoking, knowledge of the health risks associated with smoking, and feeling qualified to discuss these risks with patients. all hcps reported counseling patients who currently smoked to quit. all hcps reported recommending nicotine replacement therapy (eg., patch and/or gum) and/or behavioral therapy (eg., psychologist, support groups) to patients who smoked. all hcps reported that there was no government funding for smoking cessation, and that all costs associated with smoking cessation were patients' out-of-pocket expenses. observation of hcp interaction with patients revealed that hcps always inquired about smoking history with new patients and rarely inquired about smoking history with returning patients. hcps were not observed counseling patients who reported current smoking on smoking cessation methods and its benefits. observation of the clinical environment suggested a focus on preventative child health (eg., immunization, water-borne illnesses), family planning, and chronic diseases (eg., diabetes, hypertension). conclusions: while the mexican government has made smoking cessation a public health priority and hcps report addressing smoking cessation, observation of hcps suggests: ) smoking status is assessed only in new patients; and ) smoking cessation methods are not addresse~. observ_atio~ of hcps and the clinical environment in a public clinic in oaxaca suggests that smoking cessation s of lower priority than other heath care issues. p - (a) urban agriculture and food and nutrition security in kampala, uganda fiona yeudall, renee sebastian, abdelrahman lubowa, selahadin ibrahim, and donald cole introduction: urban agriculture is an important livelihood strategy contributing to household food security by increasing access and availability to food in urban settings (koc et al., ) . the purpose of poster sessions v rhis study was to examine relationships between child nutritional securiry outcomes, household food security, and urban agriculture activiries in kampala, uga~da. . . questionnaires assessing socio-demographic, farmmg and household food secunry (hfsi characreristics were administered to households. food diversiry was ~lculate~ from ~e number of foods consumed over hours for one child ( - years) per household. heigh~ weight,. nud-upper·ann· circumference (muac) and tricep skinfolds (tsf) were measured for the mdex child. z-sc.ores for height-for·age (haz), weighr-for-age (waz) and body mass index (zbmi) were ~~ulated usmg cen· rres for disease control and prevenrion reference data. z-scores for body composition measures were calculated using nhanes i and ii data for african americans. the lms method was used to c~.t for skewed z·score indices. all dara was checked for normaliry and univariable and backward mulnvanablc linear regression analysis conducted. ruwlts: household food securiry was significantly associated with wealth (b= . , p< 'a acre were more dependenr on assets for hfs. although sex of head of household was ~ot related to j-:ifs, it modi· fied relationships in rhar female headed households had greater food securtry when fai:mmg less than , acre compared ro male headed households, and vice versa. hfs was significantly associated with food diversiry (s= . , p). urbanization, especially in developing countries, has substantially increased the vulnerability of rhe mass of low-income urban dwellers. the livelihoods and quality of life for many of the poor espe· cially in larin america, asia, and africa, have deteriorated significantly over the years. urban areas are increasingly unable to provide for their populations, resulting in poverry, massive unemploymenr, job cuts, poor housing, lack of or poor public services, and a compromised health status. botswana, a country rhat lies in the sourhern parr of africa, has had its share of urban problems such as rhe mush· rooming of squarters and low-income urban sertlements. despite efforts to address the substandard living conditions in low-income urban areas, these problems have continued to grow. these living con· diuons are porenrially stressful to rhe residenrs and likely affects their health. the primary aim of the udy wa to examine the complex relationship between communiry-level stressors and interveners and health-related quality of life among residents of low-income neighborhoods in francistown, botswana. u i"" a croa -icctional quantitative design (both descriptive and explanatory) and using primarily cloae-mded interview• with a random sample of residents, this study examined the role of chrome life trnson and environmental quality on overall health status qualiry of life) and the physical, psy· chological and level of independence domains of health. the major hypothesis of the study was that community-levrl stre sor would influence health-related quality of life and that social capital would moderate these relationships. findings indicate that neighborhood quality is a powerful predictor of healrh tatu rhan socioeconomic status and individual life stressors. social capital was also found to he a ificant positive predictor of healrh and also moderator of structural factors. social capital moderated the effects of low environmental quality on level of indrpendence and on physical health outcomn, but nor on psychological and global health outcomes. these findings suggest that as the environment get betttr. stresson are reduced, hence promoting berter health outcomes. the study ends with implication• for social justice, public health and social work practice, and research, focusing mostly on the ~ole of social capital and the environmental quality in predicting health outcomes. spt· cafically • anenhon should be focused on political and civic society's commitment for social justice and poveny alleviation, ~uction of the threat of insecuriry and violence; cultivating social capital and good governance; and improving the health and social environments, especially housing and environ· mental aiutanon to name a few. urban and other uprisings by non-elites that lead to transitions, can disrupt sexual and injection "risk" networks that transmit infectious diseases by changing mixing patterns. they can also weaken urban social networks, their associated protective norms and their informal social control mechanisms which can lead to increased sexual and drug risk behaviors and violence (fullilove ; wallace & wallace , aral , friedman & reid hankins et al ) . for example, the revolution and transition to theocratic rule, and subsequent urban and national conflicts, have been followed by many urban youth in iran engaging in clandestine high-risk sexual and drug behaviors. in palestine, conflicts and restrictions on movement have led to increased fatalities from chronic diseases due to limited access to hospitals and modern medical facilities (union of palestinian medical relief committees); and heroin use and violence-related blood exposure have also increased. social movements "from below" that are rooted both in urban social network dynamics and in underlying patterns of injustice can have both protective and risky effects. for example, the social movements that led to the collapse of the ussr and its dependent governments in other countries-with subsequent increases in sex trade, alcoholism, drug use, tuberculosis, hiv, stis, and mortality in many localities-were based originally on such city-based movements in eastern europe. their impacts on health were mediated by urban social dynamics and structures. some urban social movements have improved health by prevent· ing the spread of hiv, hepatitis and other diseases. examples include movements of (a) gays and lesbians and (b) drug users. these have been rooted in social networks that overlap with risk networks. theories of urban health should include social conflict as a core concept. mechanisms that generate conflicts and the pathways by which conflicts affect health should be a major part of urban health research agendas. p - (c) demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital (lasuth) chest clinic john bako, adewale akeredolu, and wale alabi tuberculosis has become a resurgent public health problem in recent times in the world. because resources are limited, control programmes frequently must target population at greatest risk. the purpose of this study was to study the demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital. a total of patients who have been both radiologically and bacteriologically confirmed tuberculosis patients were used for this study between january and march. ( %) were males, while ( %) were females. notable risk factors among patients with tuberculosis were overcrowding ( . % ), homelessness ( . %) cigarette smoking ( . % ), alcoholism ( . %), non vaccination ( %), secondary contact ( . %) and poor knowledge ( . l 'x,). man· agement history patterns among the patients were herbs ( . 'yo), orthodox medicine ( .h . .l'x.). intervention targeting early-identified groups may be an effective way to reduce the incidence of tuber· culosis. such intervention should focus on health education, modification of life style and improvement of standard of living. p - (c) profiles in urban health in cities of the americas in the countries of the americas, there is an increasing migration of national and international populations to urban centers. this presentation will focus on some of the issues created by this influx of populations, the ways that cities in countries are dealing with them, and the efforts to promote local participation and solutions in management and decision-making. the methodology used to collect this information has been to draw upon and analyze information produced by the mayor's and ministry of health and development offices in each of the cities under consideration. an analysis of the impact of urbanization on health and health determinants will be presented. the information covers issues such as health status by geographic areas within the cities, highlighting issues such as marginality, barriers and physical, economic and cultural constructs and inequities in the delivery of and access to essential services (such as health, education, water, and basic sanitation). issues of governance and citizen participation will be highlighted to provide insight in~o the balance of power and mechanisms for decision-making at the local level. part of the analysis will show the relationship between democratic processes and social participation. public ~olicies will be reviewed to indicate those that are most beneficial in promoting health and overcoming barriers to it, as well as ways of capitalizing on local assets and resources. final~y, evidence of effectiveness of various strategies will be indicated. the presentation will conclude wuh suggesuons for future strategic directions to improve the quality of life and the promotion of health in large urban centers of the americas. introduction: much of the illicit drug in mexico is concentrated in northern border areas. the mile border between the u.s. and mexico is also characterized by migration; the border crossing between tijuana, baja california, mexico and san diego, california, u.s.a. is rep~rt~dl~ the busiest land border crossing in the world. we attempt to describe the migration scene among m ect on drug users (idus) m tijuana and investigate service needs. methods: migration trends were investigated in a cross-sectional study conducted from february to june among idus in tijuana. enrollment criteria included informed consent, being years or older, and having injected drugs within the prior month. subjects were recruited by respondent-dnven sampling and were administered a quantitative survey and serology for hiv, hcv, and syphilis. logistic regression was used to compare idus who had migrated to the u.s. versus those who had not. results: of idus enrolled, % were male and median age and age at first injection were and , respectively. drug combinations injected most frequently in the past months were heroin ( % and crystal methamphetamine mixed with heroin ( %). of those enrolled, responded to quesnons on migration and drug treatment and were included in this analysis. although % had resided in tijuana for at least years, % of users were born outside of baja california. working outside of mexico was common, with % working abroad in the last years ( % in u.s.), and % in the past year. in the last months, % of idus had crossed the border to the u.s., with % crossing at least once per month. those working outside of mexico in the past year were less likely to have ever received substance abuse treatment, [ % vs. %, or . , ] and were marginally less likely to have received drug treatment in the past months [ % vs. %, or . , % ci ( . - . )]. drug use patterns, age and gender did not differ between migrants and non-migrants, although migrants were more likely to report being in need of substance abuse treatment ( % vs. %, respectively). conclusions: migration is common among idus in tijuana. maintaining drug treatment regimens and determining how to best target education and services to a highly mobile population pose challenges to officials on both sides of the border. these data underscore the need to develop coordinated binational prevention and treatment efforts. introduction: despite the expanding literature on the important role public policy plays in influencing the broader determinants of the public\'s health, profound differences exist among jurisdictions in rhe attention placed upon such activities. we take an international perspective on health by examining rhe d?minant public _health paradigms of canada, usa, uk, and sweden and exploring how these paradigms shape public health practice. _method: we carefully analyze governmental and public health agencies documents to discern ~he dommant para~igms driving public health approaches and practices. we also consider the unique paht · cal and economic contexts within each nation and consider how these contexts drive public health pahcy and approaches. . . ~u~: the canadian and usa public health communities -with some exceptions --focus upon m~ividuahzed approaches to risk management. in contrast, the uk and swedish public health scenes are oriented toward broader approaches to health determinants. we find that the extent to which govern· ments, public health agencies and public health workers concern themselves with public policy approaches £<_> ~ddress ~ro.ad~r .determinants of health depends upon the particular health parad'.~ adhered. ~o withm each urisd ctton. and whether a paradigm is adopted depends upon the ideologi~a and pol~ncal context of each nation. nations such as sweden that have a long tradition of public policies promonng social jus~ce an~ equity are naturally receptive to evolving population health concepts. '[he usa represen~ a ~bey en~ro~~t where such is~ues are clear!~ subordinate. ., our findings mdicate that there s a strong political component that influences pubh ~ealth a~proaches and practi~ within the jurisdictions examined. the implications are that those seek· m~ to raise the broader detennmants of the public's health should work in coalition to raise these issues with non-health organizations and age · ca d d th · - badrgrollnd: in developed countries, social inequalities in health have endured or even worsened comparatively throughout different social groups since the s. in france, a country where access to medical and surgical care is theoretically affordable for everyone, health inequalities are among the high· est in western europe. in developing countries, health and access to care have remained critical issues. in madagascar, poverty has even increased in recent years, since the country wenr through political crisis and structural adjustment policies. objectives. we aimed to estimate and compare the impact of socio· economic status but also psychosocial characteristics (social integration, health beliefs, expectations and representation, and psychological characteristics) on the risk of having forgone healthcare in these dif· fercnt contexts. methods: population surveys conducted among random samples of households in some under· served paris neighbourhoods (n= ) and in the whole antananarivo city (n= ) in , using a common individual questionnaire in french and malagasy. reslllts: as expected, the impact of socioeconomic status is stronger in antananarivo than in paris. but, after making adjustments for numerous individual socio-economic and health characteristics, we observed in both cities a higher (and statically significant) occurrence of reponed forgone healthcare among people who have experienced childhood and/or adulthood difficulties (with relative risks up to and .s respectively in paris and antananarivo) and who complained about unhealthy living conditions. in paris, it is also correlated with a lack of trust in health services. coneluions: aside from purely financial hurdles, other individual factors play a role in the non-use of healthcare services. health insurance or free healthcare seems to be necessary hut not sufficienr to achieve an equitable access to care. therefore, health policies must not only focus on the reduction of the financial barriers to healthcare, but also must be supplemented by programmes (e.g. outreach care ser· vices, health education, health promotion programmes) and discretionary local policies tailored to the needs of those with poor health concern .. acknowledgments. this project was supported by the mal>io project and the national institute of statistics (instat) in madagascar, and hy the development research institute (ird) and the avenir programme of the national institute of health and medical research (inserm) in france. for the cities of developing countries, poverty is often described in terms of the living standard~ of slum populations, and there is good reason to believe that the health risks facing these populations are even greater, in some instances, than those facing rural villagers. yet much remains to be learned ahour the connections between urban poverty and health. it is not known what percentage of all urban poor live in slums, that is, in communities of concentrated poverty; neither is it known what proportion of slum residents are, in fact, poor. funhermore, no quantitative accounting is yet available that would sep· arare the health risks of slum life into those due to a househoid•s own poverty and those stemminic from poveny in the surrounding neighborhood. if urban health interventions are to be effectively targeted in developing countries, substantial progress must be made in addressing these cenrral issues. this paper examines poverty and children's health and survival using two large surveys, one a demographic and health survey fielded in urban egypt (with an oversampling of slums) and the other a survey of the slums of allahabad, india. using multivariate statistical methods. we find, in both settings: ( substan· rial evidence of living standards heterogeneity within the slums; ( strong evidence indicating that household-level poverty is an imponant influence on health; and ( ) staristically significant (though less strong) evidence that with household living standards held constant, neighborhood levels of poverty adversely affect health. the paper doses with a discussion of the implications of these findings for the targeting of health and poverty program interventions. p - (a) urban environment and the changing epidemiological surfacr. the cardiovascular ~ &om dorin, nigeria the emergence of cardiovascular diseases had been explained through the concomitants o_f the demographic transition wherein the prevalent causes of morbidity and monality ~hangr pr~mmant infectious diseases to diseases of lifestyle or chronic disease (see deck, ) . a ma or frustration m the v poster sessions case of cvd is its multifactural nature. it is acknowledged that the environment, however defined is the d · f · t' b tween agents and hosts such that chronic disease pathogenesis also reqmre a me an o mterac ion e . spatio-temporal coincidence of these two parties. what is not clear is which among ~ever~( potennal fac· · h b pace exacerbate cvd risk more· and to what extent does the ep dem olog cal trans · tors m t e ur an s ' . . . . tion h othesis relevant in the explanation of urban disease outlook even the developmg cities like nigeri~: thesis paper explorer these within a traditional city in nigeria. . . . the data for the study were obtained from two tertiary level hospitals m the metropolis for years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the data contain reported cases of cvd in the two facilities for the period. adopting a series of parametric and non-parametric statistics, we draw inferences between the observed cases of cvds and various demographic and locational variables of the patients. findings: about % of rhe cases occurred in years ( ) ( ) ( ) coinciding with the last year of military rule with great instability. . % occurred among male. . % also occurred among people aged - years. these are groups who are also likely to engage in most stressful life patterns. ~e study also shows that % of all cases occurred in the frontier wards with minor city areas also havmg their •fair' share. our result conformed with many empirical observation on the elusive nature of causation of cvd. this multifactoral nature had precluded the production of a map of hypertension that would be consistent with ideas of spatial prediction. cvd -cardiovascular diseases. mumbai is the commercial capital of india. as the hub of a rapidly transiting economy, mumbai provides an interesting case study into the health of urban populations in a developing country. with high-rise multimillion-dollar construction projects and crowded slums next to each other, mumbai presents a con· trast in development. there are a host of hi-tech hospitals which provide high quality care to the many who can afford it (including many westerners eager to jump the queue in their healthcare systems-'medical tour· ism'), at the same time there is a overcrowded and strained public healthcare system for those who cannot afford to pay. voluntary organizations are engaged in service provision as well as advocacy. the paper will outline role of the voluntary sector in the context of the development of the healthcare system in mumbai. mumbai has distinct upper, middle and lower economic classes, and the health needs and problems of all three have similarities and differences. these will be showcased, and the response of the healthcare system to these will be documented. a rising hiv prevalence rate, among the highest in india, is a challenge to the mumbai public healthcare system. the role of the voluntary sector in service provision, advocacy, and empowerment of local populations with regards to urban health has been paramount. the emergence of the voluntary sector as a major player in the puzzle of urban mumbai health, and it being visualized as voices of civil society or communiry representatives has advantages as well as pitfalls. this paper will be a unique attempt at examining urban health in india as a complex web of players. the influence of everyday socio·polirical-cultural and economic reality of the urban mumbai population will be a cross cutting theme in the analysis. the paper will thus help in filling a critical void in this context. the paper will thus map out issues of social justice, gender, equiry, effect of environment, through the lens of the role of the voluntary sector to construct a quilt of the realiry of healthcare in mumbai. the successes and failures of a long tradi· tion of the active advocacy and participation of the voluntary sector in trying to achieve social justice in the urban mumbai community will be analyzed. this will help in a better understanding of global urban health, and m how the voluntary sector/ngos fir into the larger picture. ba~und: o~er. half _of n~irobi's . million inhabitants live in illegal informal settlements that compose yo of the city s res dent al land area. the majority of slum residents lack access to proper san· iranon and a clean and adequate water supply. this research was designed to gain a clearer understand· mg of what kappr · · · h f . . opnate samtanon means or the urban poor, to determine the linkages between gender, hvehhoods, and access to water and sanitation, and to assess the ability of community sanitation blocks to meet water and sanitation needs in urban areas. m~tbojs_: _a household survey, gender specific focus groups and key informant interviews were conducted m maih saba, a peri-urban informal settlement. qualitative and quantitative research tools were u~ to asses~ the impact and effectiveness of community sanitation blocks in two informal settlements. results ropna e samtarmn me u es not only safe and clean latrines, but also provision ° adequate drainage and access to water supply for cleaning of clothes and homes. safety and cleanliness poster sessions v were priorities for women in latrines. levels of poverty within the informal settlements were identified and access to water and sanitation services improved with increased income. environmental health problems related to inadequate water and sanitation remain a problem for all residents. community sanitation blocks have improved the overall local environment and usage is far greater than envisioned in the design phase. women and children use the blocks less than men. this is a result of financial, social, and safety constraints. the results highlight the importance a need to expand participatory approaches for the design of water and sanitation interventions for the urban poor. plans need to recognize "appropriate sanitation" goes beyond provision of latrines and gender and socioeconomic differences must be taken into account. lessons and resources from pilot projects must be learned from, shared and leveraged so that solutions can be scaled up. underlying all the challenges facing improving water and sanitation for the urban poor are issues of land tenure. p - (c) integrating tqm (total quality management), good governance and social mobilization principles in health promotion leadership training programmes for new urban settings in countries/ areas: the prolead experience susan mercado, faren abdelaziz, and dorjursen bayarsaikhan introduction: globalization and urbanization have resulted in "new urban settings" characterized by a radical process of change with positive and negative effects, increased inequities, greater environmental impacts, expanding metropolitan areas and fast-growing slums and vulnerable populations. the key role of municipal health governance in mitigating and modulating these processes cannot be overemphasized. new and more effective ways of working with a wide variety of stakeholders is an underpinning theme for good governance in new urban settings. in relation to this, organizing and sustaining infrastructure and financing to promote health in cities through better governance is of paramount importance. there is a wealth of information on how health promotion can be enhanced in cities. despite this, appropriate capacity building programmes to enable municipal players to effectively respond to the challenges and impacts on health of globalization, urbanization and increasing inequity in new urban settings are deficient. the who kobe centre, (funded by the kobe group( and in collaboration with regional offices (emro, searo, wpro) with initial support from the japan voluntary contribution, developed a health promotion leadership training programme called "prolead" that focuses on new and autonomous structures and sustainable financing for health promotion in the context of new urban settings. methodology: country and/or city-level teams from areas, (china, fiji, india, japan, lebanon, malaysia, mongolia, oman, philippines, republic of korea, tonga and viet nam) worked on projects to advance health promotion infrastructure and financing in their areas over a month period. tools were provided to integrate principles of total quality management, good governance and social mobili .ation. results: six countries/areas have commenced projects on earmarking of tobacco and alcohol taxes for health, moblization of sports and arts organizations, integration of health promotion and social health insurance, organizational reforms, training in advocacy and lobbying, private sector and corporate mobilization and community mobilization. results from the other six areas will be reported in ..;obcr. conclusions: total quality management, good governance and social mobilization principles and skills are useful and relevant for helping municipal teams focus on strategic interventions to address complex and overwhelming determinants of health at the municipal level. the prolead training programmes hopes to inform other processes for building health promotion leadership capacity for new urban settings. the impact of city living and urbanization on the health of citizens in developing countries has received increasing attention in recent years. urban areas contribute largely to national economies. however, rapid and unplanned urban growth is often associated with poverty, environmental degradation and population demands that outstrip service capacity which conditions place human health at risk. local and national governments as well as multi national organizations are all grappling with the challenges of urbanization. with limited data and information available, urban health characteristics, including the types, quantities, locations and sources in kampala, are largely unknown. moreover, there is n? basis for assessing the impact of the resultant initiatives to improve health ~onditions amo~g ~o": ": um ties settled in unplanned areas. since urban areas are more than the aggregation ?f ~?pie w~th md_ v dual risk factors and health care needs, this paper argues that factors beyond the md v dual, mcludmg the poster sessions v · i d h · i · ment and systems of health and social services are determinants of the health soc a an p ys ca environ . of urban populations. however, as part of an ongoing study? ~s pape~ .addresses the basic concerns of urban health in kampala city. while applying the "urban hvmg conditions and the urban heal~ pen· alty" frameworks, this paper use aggregated urban health d~ta t~ explore the role of place an~ st tu· tions in shaping health and well-being of the population m kampala by understanding how characteristics of the urban environment and specific features of the city are causally related to health of invisible and forgotten urban poor population: results i~dica~e that a .range o~ urb~n he~l~h hazards m the city of kampala include substandard housing, crowdmg, mdoor air poll.ut on, msuff c ent a~d con· taminated water, inadequate sanitation and solid waste management services, vector borne .diseases, industrial waste increased motor vehicle traffic among others. the impact of these on the envtronment and community.health are mutually reinforcing. arising out of the withdra"'.al of city pl~nning systems and service delivery systems or just planning failure, thousands of people part cularl~ low-mc~me groups have been pushed to the most undesirable sections of the city where they are faced with ~ va_r ety ~f envj· ronmental insults. the number of initiatives to improve urban health is, however, growing mvolvjng the interaction of many sectors (health, environment, housing, energy, transportation and urban planning) and stakeholders (local government, non governmental organizations, aid donors and local community groups). key words: urban health governance, health risks, kampala. introduction: the viability of urban communities is dependent upon reliable and affordable mass transit. in particular, subway systems play an especially important role in the mass transit network, since they provide service to vast numbers of ridersseven of the subway systems worldwide report over one billion passenger rides each year. surprisingly, given the large number of people potentially affected, very little is known about the health and safety hazards that could affect both passengers and transit workers; these include physical (e.g., noise, vibration, accidents, electrified sources, temperature extremes), biological (e.g., transmission of infectious diseases, either through person-to-person spread or vector-borne, for example, through rodents), chemical (e.g., exposure to toxic and irritant chemicals and metals, gas emissions, fumes), electro-magnetic radiation, and psychosocial (e.g., violence, workstress). more recently, we need to consider the threat of terrorism, which could take the form of a mass casualty event (e.g., resulting from conventional incendiary devices), radiological attack (e.g., "dirty bomb"), chemical terrorist attack (e.g., sarin gas), or bioterrorist attack (e.g., weapons grade anthrax). given the large number of riders and workers potentially at risk, the public health implications are considerable. methods: to assess the hazards associated with subways, a structured review of the (english) litera· ture was conducted. ruults: based on our review, non-violent crime, followed by accidents, and violent crimes are most prevalent. compared to all other forms of mass transit, subways present greater health and safety risks. however, the rate of subway associated fatalities is much lower than the fatality rate associated with automobile travel ( . vs. . per million passenger miles), and cities with high subway ridership rates have a % lower per capita rate of transportation related fatalities than low ridership cities ( . versus . annual deaths per , residents). available data also suggest that subway noise levels and levels of air pollutants may exceed recommended levels. . ~: there is a paucity of published research examining the health and safety hazards associated with subways. most of the available data came from government agencies, who rely on passively reported data. research is warranted on this topic for a number of reasons, not only to address important knowled~ gaps, but also because the population at potential risk is large. importantly, from an urban perspecnve, the benefits of mass transit are optimized by high ridership ratesand these could be adversely affu:ted by unsafe conditions and health and safety concerns. veena joshi, jeremy lim. and benjamin chua ~ ~rban health issues have moved beyond infectious diseases and now centre largely on chrome diseases. diabetes is one of the most prevalent non-communicable diseases globally. % of adult ¥ benefit in providing splash pads in more parks. given the high temperature and humidity of london summers, this is an important aspect and asset of parks. interviewed parents claimed to visit city parks anywhere between to days per week. corrduion: given that the vast majority of canadian children are insufficiently active to gain health benefits, identifying effective qualities of local parks, that may support and foster physical activity is essential. strategies to promote activity within children's environments are an important health initiative. the results from this study have implications for city planners and policy makers; parents' opinions of, and use of city parks provides feedback as to the state current local parks, and modifications that should be made for new ones being developed. this study may also provide important feedback for health promoters trying to advocate for physical activity among children. introdt clion: a rapidly increasing proportion of urban dwellers in africa live below the poverty line in overcrowded slums characterized by uncollected garbage, unsafe water, and deficient sanitation and overflowing sewers. this growth of urban poverty challenges the commonly held assumption that urban populations enjoy better health than their rural counterparts. the objectives of this study are (i) to compare the vaccination status, and morbidity and mortality outcomes among children in the slums of nairobi with rural kenya, and (ii) to examine the factors associated with poor child health in the slums. we use data from demographic and health survey representative of all slum settlements in nairobi city carried out in by the african population & health research center. a total of , women aged - from , households were interviewed. our sample consists of , children aged - months. the comparison data are from the kenya demographic and health survey. the outcomes of interest include child vaccination status, morbidity (diarrhea, fever and cough) and mortality, all dichotomized. socioeconomic, environmental, demographic, and behavioral factors, as well as child and mother characteristics, are included in the multivariate analyses. multilevel logistic regression models are used. l'nlimin ry rest lts: about % of children in the slums had diarrhea in the two weeks prior to the survey, compared to % of rural children. these disparities between the urban poor anj the rural residents are also observed for fever ( % against %), cough ( % versus %), infant mortality ( / against / ), and complete vaccination ( % against %). preliminary multivariate results indicate that health service utilization and maternal education have the strongest predictive power on child morbidity and mortality in the slums, and that household wealth has only minor, statistically insignificant effects. conclruion: the superiority of health of urban children, compared with their rural counterparts, masks significant disparities within urban areas. compared to rural residents, children of slum dwellers in nairobi are sicker, are less likely to utilize health services when sick, and stand greater risk to die. our results suggest policies and programs contributing to the attainment of the millennium development goal on child health should pay particular attention to the urban poor. the insignificance of socioeconomic status suggests that poor health outcomes in these communities are compounded by poor environmental sanitation and behavioral factors that could partly be improved through female education and behavior change communication. introduction: historic trade city surat with its industrial and political peace has remained a center of attraction for people from all the comers of india resulting in to pop.ulatio~ explosio~ a~d stressed social and service infrastructure. the topography,dimate and demographic profile of the city s threat to the healthy environment. aim of this analysis is to review the impact of managemt'nt reform on health indicators. method: this paper is an analysis of the changing profile of population, sanitary infr~s~rucrure, local self government management and public health service reform, secondary health stat st cs data, health indicator and process monitoring of years. . . health of entire city and challenge to the management system. plague outbr~ak ( ) was the turning point in the history of civic service management including p~blic ~e~lth service management. ~ocal self government management system was revitalized by reg~lar_ field v s ts o~ al~ cadre~, _decentraltzanon of power and responsibility, equity, regular vigilant momtormg, commumcanon facility, ream_approach and people participation. reform in public health service management was throu_gh stan~~rd zed intervention protocol, innovative intervention, public private partnership, community part c panon, academic and service institute collaboration and research. sanitation service coverage have reached nearer to universal. area covered by safe water supply reached to %( ) from % ( ) and underground drainage to % ( ) from % ( ) the overhauling of the system have reflected on health indicators of vector and water born disease. malaria spr declined to . ( ) from . 'yo(! ) and diarrhea case report declined to ( ) from ( ). except dengue fever in no major disease outbreaks are reported after . city is recipient of international/national awards/ranking for these achievements. the health department have developed an evidence and experience based intervention and monitoring system and protocol for routine as well as disaster situation. the health service and management structure of surat city have emerged as an urban health model for the country. introduction: the center for healthy communities (chc) in the department of family and com· munity medicine at the medical college of wisconsin developed a pilot project to: ) assess the know· ledge, attitudes, and behaviors of female milwaukee public housing residents related to breast cancer; develop culturally and literacy appropriate education and screening modules; ) implement the developed modules; ) evaluate the modules; and ) provide follow-up services. using a community-based participatory research model the chc worked collaboratively with on-site nurse case management to meet these objectives. methods: a "breast health kick off event" was held at four separate milwaukee public housing sites for elderly and disabled adults. female residents were invited to complete a -item breast health survey, designed to accommodate various literacy levels. responses were anonymous and voluntary. the survey asked women about their previous physical exams for breast health, and then presented a series of state· ments about breast cancer to determine any existing myths. the final part gathered information about personal risk for breast cancer, the highest level of education completed, and whether the respondents h;td ever used hormone replacement therapy and/or consumed alcohol. responses were collected for descriptive analysis. results: a total of surveys (representing % of the total female population in the four sites) were completed and analyzed. % reported that they had a physical exam in the previous rwo years. % of respondents indicated they never had been diagnosed with breast cancer. % reported having had a mammogram and % having had a clinical breast exam. those that never had a mammogram reported a fear of what the provider would discover or there were not any current breast problems ro warrant an exam. % agreed that finding breast cancer early could lower the chance of dying of cancer. over % reported that mammograms were helpful in finding cancer. however, % believed that hav· ing a mammogram actually prevents breast cancer. % indicated that mammograms actually cause cancer and % reported that a woman should get a mammogram only if there is breast cancer in her family. conclusion: this survey indicates that current information about the importance of mammograms and clinical breast exams is reaching traditionally underserved women. yet there are still critical oppor· tunities to provide valuable education on breast health. this pilot study can serve as a tool for shaping future studies of health education messages for underserved populations. located in a yourh serv· ~ng agency m downtow~ ottawa, the clinic brings together community partners to provide primary medical care. and dent~i hygiene t? the street youths of ottawa aged - . the primary goal of the project is to provide accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. these efforts respond to the pre-existing body of evidence suggesting that the principle barrier in accessing such care for these youths are feelings of intimidation and vulnerability in the face of a complex healthcare system. the bruyere fhn satellite clinic is located in the basement of a downtown drop-in and brings together a family medicine physician and her residents, a dental hygienist and her nd year students, a nurse practitioner, a chiropodist and public health nurses to provide primary care. the clinic has been extremely busy and well received by the youth. this workshop will demonstrate how five community organizations have come together to meet the needs of high risk youths in ottawa. this presentation will showcase the development of the clinic from its inception through its first year including reaction of the youths, partnerships and lessons learned. it will also focus on its sustainability without continued funding. we hope to have developed a model of service delivery that could be reproduced and sustained in other large cities with faculties of medicine. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative-a) semi structured interviews with providers & partners b)focus groups with youth quantitative a)electronic medical records for months records (budget, photos, project information). results: ) successfully built and opened a medicaudental clinic which will celebrate its year anniversary in august. ) over youths have been seen, and we have had over visits. conclusion: ) the clinic will continue to operate beyond the month project funding. ) the health of high risk youth in ottawa will continue to improve due to increased access to medical services. p - (a) health services -for the citizens of bangalore -past, present and future savita sathyagala, girish rao, thandavamurthy shetty, and subhash chandra bangalore city, the capital of karnataka with . million is the th most populous city in india; supporting % of the urban population of karnataka, it is considered as one of the fastest growing cities in india. known as the 'silicon valley of india', bangalore is nearly years old. bangalore city corporation (bmp), is a local self government and has the statutory commitment to provide to the citizens of bangalore: good roads, sanitation, street lighting, safe drinking water apart from other social obligations, cultural development and poverty alleviation activities. providing preventive and promotive heahh services is also a specific component. the objective of this study was to review the planning process with respect to health care services in the period since india independence; the specific research questions being what has been the strategies adopted by the city planners to address to the growing needs of the population amidst the background of the different strategies adopted by the country as a whole. three broad rime ranges have been considered for analysis: the s, s and the s. the salient results are: major area of focus has been on the maternal and child care with activities ranging from day-care to in-patient-care; though the number of institutions have grown from to the current day , their distribution has been far from satisfactory; obtaining support from the india population projects and major upgradarions have been undertaken in terms of infrastructure; over the years, in addition to the dispensaries of modern system of medicine, local traditional systems have also been initiated; the city has partnered with the healthy cities campaign with mixed success; disease surveillance, addressing the problems related to the emerging non-communicable diseases including mental health and road traffic injuries are still in its infancy. isolated attempts have been made to address the risks groups of elderly care and adolescent care. what stands out remarkably amongst the cities achievements is its ability to elicit participation from ngos, cbos and neighbourhood groups. however, the harnessing of this ability into the health sector cannot be said totally successful. the moot question in all the above observed development are: has the city rationally addressed it planning needs? the progress made so far can be considered as stuttered. the analysis and its presentation would identify the key posirive elements in the growth of banglore city and spell a framework for the new public health. introduction: anaemia associated with pregnancy is a major public health problem all over the world. different studies in different parts of india shown prevalence of anaemia between - %. anaemia remains a serious health problem in pregnancy despite of strong action taken by the government of india through national programmes. in the present study we identified th~ social beha~iors, responsible for low compliance of if a tablets consumption in pregnancy at community level and intervention was given with new modified behaviors on trial bases. . in vadodara urban. anganwadies out of were selected from the list by random sampling for tips (trials of improved practices) study. . . participants: pregnant women ( , intervention group+ , control. group) registered m the above anganwadies. study was conducted in to three phases: phase: . formative research and baseline survey (frbs). data was collected from all pregnant women to identify behaviors that are responsible for low compliance of ifa tablets. both qualitative and quantitative data were collected. haemoglobin was estimated of all pregnant women by haemo-cue. phase: . phase of tips. behaviors were identified both social & clinical for low compliance of ifa tablets consumption in pregnancy from frbs and against those, modified behaviors were proposed to pregnant women in the intervention group on trial bases by health education. trial period of weeks was given for trial of new behaviors to pregnant women in the interven· tion group. phase: . in this phase, feedbacks on behaviors tried or not tried were taken from pregnant women in intervention group. haemoglobin estimation was carried out again in all pregnant women. at the end of the study, messages were formulated on the bases of feedbacks from the pregnant women. results: all pregnant women in the intervention group had given positive feedback on new modified behaviors after intervention. mean haemoglobin concentration was higher in intervention group ( . ± . gm%) than control group ( . ± . gm%). ifa tablets compliance was improved in intervention group ( . %) than control group ( . %). conclusion: all pregnant women got benefits after trial of new modified behaviors in the intervention group. messages were formulated from the new modified behaviors, which can be used for longterm strategies for anaemia control in the community. introduction: in order to develop a comprehensive mch handbook for pregnant women and to assess its effect among them, a pilot study was carried out at the maternal and child health training institute (mchti), in dhaka, bangladesh. methods: from mchti a sample of pregnant women was selected and all subjects were women who were attending the first visit of their current pregnancy by using a random sampling method. of the subjects, women were given the mch handbook as case and women were not given the handbook as control. data on pre and post intervention of the handbook from the cases and controls were taken from data recording forms between the st of november and st of october, and data was analysed by using a multilevel analysis approach. this was a hospital-based action (case-control) research, and was applied in order to measure the outcome of pre and post intervention following the introduction of the handbook. data was used to assess the effects of utilisation of the handbook on women's knowledge, practice and utilisation of mch services. results: this study showed that the change of knowledge about antenatal care visits was . % among case mothers. knowledge of danger signs improved . %, breast feeding results . %, vaccination . % and family planning results improved . % among case. results showed some positive changes in women's attitudes among case mothers and study showed the change of practice in antenatal care visits was .u. % in the case. other notable changes were: change of practice in case mother's tetanus toxoid (ti), . %; and family planning . %. in addition, handbook assessment study indicated that most women brought the handbook on subsequent visits ( . %), the handbook was highly utilised (i.e. it was read by . %, filled-in by . %, and was used as a health education tool by . %). most women kept the handbook ( . %) and found it highly useful ( . %) with a high client satisfaction rate of . %. conclusion: pregnant women in the case group had higher knowledge, better practices, and higher utilisation of mch services than mothers in the control groups who used alternative health cards. if the handbook is developed with a focus on utilising a problem-oriented approach and involving the recomendations .of end~users, it is anticipated that the mch handbook will contribute significantly to ensuring the quahry of hfe of women and their children in bangladesh. after several meetmgs to identify the needs of the community, a faso clinic was opened at ncfs. health care professionals from smh joined with developmental and social service workers from ncfs to implement the faso diagnostic process and to provide culturally appropriate after-care. the clinic is unique in that its focus is the high risk urban aboriginal population of toronto. it accepts referrals of not only children and youth, but also of adults. lessons learned: response to the faso clinic at native child and family services has been overwhelming. aboriginal children with f asd are receiving timely diagnosis and interventions. aboriginal youth and adults who have been struggling with poveny, substance abuse, and homelessness are more willing to enter the ncfs centre for diagnosis and treatment. aboriginal infants prenatally exposed to alcohol born at st. michael's hospital or referred by other centres have access to the developmental programs located in both of the partnering agencies. the presentation will describe the clinic's development, and will detail the outcomes described, including interventions unique to the aboriginal culture. p - (c) seeds, soil, and stories: an exploration of community gardening in southeast toronto carolin taran, sarah wakefield, jennifer reynolds, and fiona yeudall introduction: community gardens are increasingly seen as a mechanism for improving nutrition and increasing food security in urban neighbourhoods, but the evidence available to support these claims is limited. in order to begin to address this gap in a way that is respectful of community knowledge and needs, the urban gardening research opportunities workgroup (ugrow) project explored the benefits and potential risks of community gardening in southeast toronto. the project used a community-based research (cbr) model to assess community gardens as a means of improving local health. the research process included interviews, focus groups, and participant observation (documented in field notes). we also directly engaged the community in the research process, through co-learning activities and community events which allowed participants to express their views and comment on emerging results. most of the research was conducted by a community-based research associate, herself a community gardener. key results were derived from these various sources through line-by-line coding of interview transcripts and field note review, an interactive and iterative process which involved both academic and community partners. results: these various data sources all suggest that enhanced health and access to fresh produce are important components of the gardening experience. they also highlight the central importance of empowering and community-building aspects of gardening to gardeners. community gardens were thought to play a role in developing friendships and social support, sharing food and other resources, appreciating cultural diversity, learning together, enhancing local place attachment and stewardship, and mobilizing to solve local problems (both inside and outside the garden). potential challenges to community gardens as a mechanism for communiry development include bureaucratic resistance to gardens, insecure land tenure and access, concerns about soil contamination, and a lack of awareness and under· standing by community members and decision-makers of all kinds. conclusion: the results highlight many health and broader social benefits experienced by commu· nity gardeners. they also point to the need for greater support for community gardening programs, par· ticularly ongoing the ongoing provision of resources and education programs to support gardens in their many roles. this research project is supported by the wellesley central health corporation and the centre for urban health initiatives, a cihr funded centre for research development hased at the univer· sity of toronto. p - (c) developing resiliency in children living in disadvantaged neighbourhoods sarah farrell, lorna weigand, and wayne hammond the traditional idea of targeting risk reduction by focusing on the development of eff~ctive coping strategies and educational programs has merit in light of the research reportmg_ that_ ~ lupl.e forms of problem behaviour consistently appear to be predicted by increasing exposure to den_uf able risk factors. as a result, many of the disadvantaged child and youth studies have focused on trymg to better _unde.r· stand the multiple risk factors that increase the likelihood of the development of at nsk behaviour m ch ldren/youth and the potential implications for prevention. this in turn has led t_o. the conclus on that community and health programs need to focus on risk reduction by helpm~ md v duals develop more effective coping strategies and a better understanding of the limitations of cenam pathologies, problematic v poster sessions coping behaviours and risk factors potentially inheren~ in high needs co~unities. ~owever, another ai:ea of research has proposed that preventative interventions should cons de~ .~rotecnve fa~ors alo~~ with reducing risk factors. as opposed to just emphasizing problems, vulnerab ht es, and deficits, a res liencybased perspective holds the belief that children, youth and their families. have strengths, reso~ce.s and the ability to cope with significant adversity in ways that are not only effective, but tend to result m mcreased ability to constructively respond to future adversity. with this in mind, a participatory research project sponsored by the united way of greater toronto was initiated to evaluate and determine the resiliency profiles of children - years (n = ) of recent immigrant families living in significantly disadvantaged communities in the toronto area. the presentation will provide an overview of the identified protective factors (both intrinsic and extrinsic) and resiliency profiles in an aggregated format as well as a summary of how the children and their parents interpreted and explained these strength-based results. as part of the focus groups, current community programs and services were examined by the participants as to what might be best practices for supporting the development and maintaining of resiliency in children, families and communities. it was proposed that the community model of assessing resiliency and protective factors as well as proposed best strength-based practice could serve as a guide for all in the community sector who provide services and programs to those in disadvantaged neighbourhoods. p - (c) naloxone by prescription in san francisco, ca and new york, ny emalie huriaux the harm reduction coalition's overdose project works to reduce the number of fatal overdoses to zero. located in new york, ny and san francisco, ca, the overdose project provides overdose education for social service providers, single-room occupancy hotel (sro) residents, and syringe exchange participants. the project also conducts an innovative naloxone prescription program, providing naloxone, an opiate antagonist traditionally administered by paramedics to temporarily reverse the effects of opiate overdose, to injection drug users (idus). we will describe how naloxone distribution became a reality in new york and san francisco, how the project works, and our results. the naloxone prescription program utilizes multiple models to reach idus, including sro-and street-based trainings, and office-based trainings at syringe exchange sites. trainings include information on overdose prevention, recognition, and response. a clinician conducts a medical intake with participants and provides them with pre-filled units of naloxone. in new york, funding was initially provided by tides foundation. new york city council provides current funding. new york department of mental health and hygiene provides program oversight. while the new york project was initiated in june , over half the trainings have been since march . in san francisco, california endowment, tides foundation, and san francisco department of public health (sfdph) provide funding. in addition, sfdph purchases naloxone and provides clinicians who conduct medical intakes with participants. trainings have been conducted since november . to date, nearly individuals have been trained and provided with naloxone. approximately of them have returned for refills and reported that they used naloxone to reverse an opiate-related overdose. limited episodes of adverse effects have been reported, including vomiting, seizure, and "loss of friendship." in new york, individuals have been trained and provided with naloxone. over overdose reversals have been reported. over half of the participants in new york have been trained in the south bronx, the area of new york with the highest rate of overdose fatalities. in san francisco, individuals have been trained and provided with naloxone. over overdose reversals have been reported. the majority of the participants in san francisco have been trained in the tenderloin, th street corridor, and mission, areas with the highest rates of overdose fatalities. the experience of the overdose project in both cities indicates that providing idus low-threshold access to naloxone and overdose information is a cost-effective, efficient, and safe intervention to prevent accidental death in this population. p - (c) successful strategies to regulate nuisance liquor stores using community mobilization, law enforcement, city council, merchants and researchers tahra goraya presenta~ion _will discuss ~uccessful environmental and public policy strategies employed in one southen: cahf?rmna commumty to remedy problems associated with nuisance liquor stores. participants ~ be given tools to understand the importance of utilizing various substance abuse prevention str~tegi~ to change local policies and the importance of involving various sectors in the community to a~_ st with and advocate for community-wide policy changes. recent policy successes from the commultles of pa~ad~na and altad~na will highlight the collaborative process by which the community mobilized resulnng m several ordmances, how local law enforcement was given more authority to monitor poster sessions v nonconforming liquor stores, how collaborative efforts with liquor store owners helped to remove high alcohol content alcohol products from their establishments and how a community-based organiz,uion worked with local legislators to introduce statewide legislation regarding the regulation of nuisance liquor outlets. p - (c) "dialogue on sex and life": a reliable health promotion tool among street-involved youth beth hayhoe and tracey methven introduction: street involved youth are a marginalized population that participate in extremely risky behaviours and have multiple health issues. unfortunately, because of previous abuses and negative experiences, they also have an extreme distrust of the adults who could help them. in , toronto public health granted funding to a non governmental, nor for profit drop-in centre for street youth aged - , to educate them about how to decrease rhe risk of acquiring hiv. since then the funding has been renewed yearly and the program has evolved as needed in order to target the maximum number of youth and provide them with vital information in a candid and enjoyable atmosphere. methods: using a retrospective analysis of the six years of data gathered from the "dialogue on sex and life" program, the researchers examined the number of youth involved, the kinds of things discussed, and the number of youth trained as peer leaders. also reviewed, was written feedback from the weekly logs, and anecdotal outcomes noted by the facilitators and other staff in the organization. results: over the five year period of this program, many of youth have participated in one hour sessions of candid discussion regarding a wide range of topics including sexual health, drug use, harm reduction, relationship issues, parenting, street culture, safety and life skills. many were new youth who had not participated in the program before and were often new to the street. some of the youth were given specific training regarding facilitation skills, sexual anatomy and physiology, birth control, sexually transmitted infections, hiv, substance use/abuse, harm reduction, relationships and discussion of their next steps/future plans following completion of the training. feedback has been overwhelmingly positive and stories of life changing decisions have been reported. conclusion: clearly, this program is a successful tool to reach street involved youth who may otherwise be wary of adults and their beliefs. based on data from the evaluation, recommendations have been made to public health to expand the funding and the training for peer leaders in order ro target between - new youth per year, increase the total numbers of youth reached and to increase the level of knowledge among the peer leaders. p - (c) access to identification and services jane kali replacing identification has become increasingly more complex as rhe government identification issuing offices introduce new requirements rhar create significant barriers for homeless people to replace their id. new forms of identification have also been introduced that art' not accessible to homekss peoplt-(e.g. the permanent resident card). ar rhe same time, many service providers continue to require identifi· cation ro access supports such as income, housing, food, health care, employment and employmt·nt training programs. street health, as well as a number of other agencies and community health centres, h, , been assisting with identification replacement for homeless peoplt· for a number of years. the rnrrt·nr challenges inherent within new replacement requirements, as well as the introduction of new forn ' of identification, have resulted in further barriers homeless people encounter when rrring to access t:ssential services. street health has been highlighting these issues to government identification issuing offices, as well as policy makers, in an effort to ensure rhar people who are homeless and marginalized have ac'ess to needed essential services. bandar is a somali word for •·a safe place." the bandar research project is the product of the regent park community health centre. the research looks ar the increasing number of somali and afri· can men in the homeless and precariously house population in the inner city core of down~own toronto. in the first phase of the pilot project, a needs assessment was conducted to dennfy barners and issues faced by rhe somali and other african men who are homeless and have add cr ns issues. th_e second phase of rhe research project was to identify long rerm resources and service delivery mechamsms that v poster sessions would enhance the abiity of this population to better access detox, treatment, and post treatment ser· vices. the final phase of the project was to facilitate the development of a conceptual model of seamless continual services and supports from the streets to detox to treatment to long term rehabilitation to housing. "between the pestle and mortar" -safe place. p - (c) successful methods for studying transient populations while improving public health beth hayhoe, ruth ewert, eileen mcmahon, and dan jang introduction: street youth are a group that do not regularly access healthcare because of their mis· trust of adults. when they do access health care, it is usually for issues severe enough for hospitalization or for episodic care in community clinics. health promotion and illness prevention is rarely a part of their thinking. thus, standard public health measures implemented in a more stable population do not work in this group. for example, pap tests, which have dearly been shown to decrease prevalence of cer· vical cancer, are rarely done and when they are, rarely followed up. methods to meet the health care needs and increase the health of this population are frequently being sought. methods: a drop-in centre for street youth in canada has participated in several studies investigating sexual health in both men and women. we required the sponsoring agencies to pay the youth for their rime, even though the testing they were undergoing was necessary according to public health stan· dards. we surmised that this would increase both initial participation and return. results: many results requiring intervention have been detected. given the transient nature of this population, return rates have been encouraging so far. conclusion: it seems evident that even a small incentive for this population increases participation in needed health examinations and studies. it is possible that matching the initial and follow-up incentives would increase the return rate even further. the fact that the youth were recruited on site, and not from any external advertising, indicates that studies done where youth trust the staff, are more likely to be successful. the presentation will share the results of the "empowering stroke prevention project" which incor· porated self-help mutual aids strategies as a health promotion methodology. the presentation will include project's theoretical basis, methodology, outcomes and evaluation results. self-help methodology has proven successful in consumer involvement and behaviour modification in "at risk," "marginalized" settings. self-help is a process of learning with and from each other which provides participants oppor· tunities for support in dealing with a problem, issue, condition or need. self-help groups are mechanisms for the participants to investigate existing solutions and discover alternatives, empowering themselves in this process. learning dynamic in self-help groups is similar to that of cooperative learning and peertraining, has proven successful, effective and efficient (haller et al, ) . the mutual support provided by participation in these groups is documented as contributory factor in the improved health of those involved. cognizant of the above theoretical basis, in the self-help resource centre initiated the "empowering stroke prevention project." the project was implemented after the input from health organizations, a scan of more than resources and an in-depth analysis of risk-factor-specific stroke prevention materials indicated the need for such a program. the project objectives were:• to develop a holistic and empowering health promotion model for stroke prevention that incorporates selfhelp and peer support strategies. • to develop educational materials that place modifiable risk factors and lifestyle information in a relevant context that validates project participants' life experiences and perspectives.• to educate members of at-risk communities about the modifiable risk factors associated with stroke, and promote healthy living. to achieve the above, a diverse group of community members were engaged as "co-editors" in the development of stroke prevention education materials which reflected and validated their life experiences. these community members received training to become lay health promoters (trained volunteer peer facilitators). in collaboration with local health organizations, these trained lay health promoters were then supported in organizing their own community-based stroke prevention activities. in addition, an educational booklet written in plain language, entitled healthy ways to prevent stroke: a guide for you, and a companion guide called healthy ways to pre· vent stroke: a facilitator's guide were produced. the presentation will include the results of a tw<>tiered evaluation of the program methodology, educational materials and the use of the materials beyond the life of the project. this poster presentation will focus on the development and structure of an innovative street outreach service that assists individuals who struggle mental illness/addictions and are experiencing homelessness. the mental health/outreach team at public health and community services (phcs) of hamilton, ontario assists individuals in reconnecting with health and social services. each worker brings to the ream his or her own skills-set, rendering it extremely effective at addressing the multidimensional and complex needs of clients. using a capacity building framework, each ream member is employed under a service contract between public health and community services and a local grassroots agency. there are public health nurses (phn), two of whom run a street health centre and one of canada's oldest and most successful needle exchange programs, mental health workers, housing specialists, a harm reduction worker, youth workers, and a united church minister, to name a few. a community advisory board, composed of consumers and professionals, advises the program quarterly. the program is featured on raising the roors 'shared learnings on homelessness' website at www.sharedlearnings.ca. through our poster presentation participants will learn how to create effective partnerships between government and grassroots agencies using a capacity building model that builds on existing programs. this study aims to assess the effects of broadcasting a series of documentary and drama videos, intended to provide information about the bc healthguide program in farsi, on the awareness about and the patterns of the service usage among farsi-speaking communities in the greater vancouver area. the major goals of the present study were twofold; ( ) to compare two methods of communications (direct vs. indirect messages) on the attitudes and perceptions of the viewers regarding the credibility of messengers and the relevance of the information provided in the videos, and ( ) to compare and contrast the impact of providing health information (i.e., the produced videos) via local tvs with the same materials when presented in group sessions (using vcr) on participants' attitudes and perceptions cowards the bc healrhguide services. results: through a telephone survey, farsi-speaking adults were interviewed in november and december . the preliminary findings show that % of the participants had seen the aired videos, from which, % watched at least one of the 'drama' clips, % watched only 'documentary' clip, and % watched both types of video. in addition, % of the respondents claimed that they were aware about the program before watching the aired videos, while % said they leaned about the services only after watching the videos. from this group, % said they called the bchg for their own or their "hildren's health problems in the past month. % also indicated that they would use the services in the future whenever it would be needed. % considered the videos as "very good" and thought they rnuld deliver relevant messages and % expressed their wish to increase the variety of subjects (produ\:e more videos) and increase the frequency of video dips. conclusion: the results of this study will assist public health specialists in bc who want to choose the best medium for disseminating information and apply communication interventions in multi\:ultural communities. introduction: many theorists and practitioners in community-based research (cbr) and knowledge transfer (kt) strongly advocate for involvement of potential users of research in the development of research projects, yet few examples of such involvement exist for urban workplace health interventions. we describe the process of developing a collaborative research program. methods: four different sets of stakeholders were identified as potential contributors to and users of the research: workplace health policy makers, employers, trade unions, and health and safety associations. representatives of these stakeholders formed an advisory committee which met quarterly. over the month research development period, an additional meetings were held between resc:ar~h~rs and stakeholders. in keeping with participant observation approaches, field notes of group and md v ~ ual meetings were kept by the two co-authors. emails and telephone calls were also documented. qu~h tative approaches to textual analysis were used, with particular attention paid to collaborattve v poster sessions relationships established (as per cbr), indicators of stakeholders' knowledge utilization (as per kt), and transformations of the proposed research (as per cbr). results: despite initial strong differences of opinion both among stakeho~ders .an~ between stakeholders and researchers, goodwill was noted among all involved. acts of rec~proc ty included mu.rual sharing of assessment tools, guidance on data utilization to stakeho~der orga~ zat ns, and suggestions on workplace recruitment to researchers. stakeholders demonstrated mcreases m concep~ual. un~erstand ing of workplace health e.g. they more commonly discussed more complex,. psychosocial md cators of organizational health. stakeholders made instrumental use of shared materials based on research e.g. adapting their consulting model to more sophisticated dat~ analysis. sta~ehol?~rs recogni_zed the strategic use of their alliance with researchers e.g., transformational leadership trainmg as a~ inducement to improve health and safety among small service franchises. stakeholders helped re-define the research questions, dramatically changed the method of recruitment from researcher cold call to stakeholderbased recruitment, and strongly influenced pilot research designs. owing a great deal to the elaborate joint development process, the four collaboratively developed pilot project submissions which were all successfully funded. conclusion: the intensive process of collaborative development of a research program among stakeholders and researchers was not a smooth process and was time consuming. nevertheless, the result of the collaborative process was a set of projects that were more responsive to stakeholder needs, more feasible for implementation, and more broadly applicable to relevant workplace health problems. introduction: environmental groups, municipal public health authorities and, increasingly, the general public are advocating for reductions in pesticide use in urban areas, primarily because of concern around potential adverse health impacts in vulnerable populations. however, limited evidence of the relative merits of different intervention strategies in different contexts exists. in a pilot research project, we sought to explore the options for evaluating pesticide reduction interventions across ontario municipalities. methods: the project team and a multi-stakeholder project advisory committee (pac), generated a list of potential key informants (kl) and an open ended interview guide. thirteen ki from municipal government, industry, health care, and environmental organizations completed face to face or telephone interviews lasting - minutes. in a parallel process, a workshop involving similar representatives and health researchers was held to discuss the role of pesticide exposure monitoring. minutes from pac meetings, field notes taken during ki interviews, and workshop proceedings were synthesized to generate potential evaluation methods and indicators. results: current evaluation activities were limited but all kls supported greater evaluation effons beginning with fuller indicator monitoring. indicators of education and outreach services were imponant for industry representatives changing applicator practices as well as most public health units and environmental organizations. lndictors based on bylaw enforcement were only applicable in the two cities with bylaws, though changing attitudes toward legal approaches were being assessed in many communities. the public health rapid risk factor surveillance system could use historical baseline data to assess changes in community behaviour through reported pesticide uses and practices, though it had limited penetration in immigrant communities not comfortable in english. pesticide sales (economic) data were only available in regional aggregates not useful for city specific change documentation. testing for watercourse or environmental contamination might be helpful, but it is sporadic and expensive. human exposure monitoring was fraught with ethical issues, floor effects from low levels of exposure, and prohibitive costs. clinical episodes of pesticide exposure reported to the regional poison centre (all ages) or the mother risk program (pregnant or breastfeeding women) are likely substantial underestimates that would be need to be supplemented with sentinel practice surveillance. focus on special clinical populations e.g., multiple chemical sensitivity would require additional data collection efforts . . conc~ons: broad support for evaluation and multiple indicators were proposed, though con-s~raints associate~ with access, coverage, sensitivity and feasibility were all raised, demonstrating the difficulty of evaluating such urban primary prevention initiatives. interventionists. an important aim of the youth monitor is to learn more about the health development of children and adolescents and the factors that can influence this development. special attention is paid to emo· tional and behavioural problems. the youth monitor identifies high-risk groups and factors that are associated with health problems. at various stages, the youth monitor chancrs the course of life of a child. the sources of informa· tion and methods of research are different for each age group. the results arc used to generate various kinds of repons: for children and young persons, parents, schools, neighbourhoods, boroughs and the municipality of rotterdam and its environs. any problems can be spotted early, at borough and neigh· bourhood level, based on the type of school or among the young persons and children themselves. together with schools, parents, youngsters and various organisations in the area, the municipal health service aims to really address these problems. on request, an overview is offered of potentially suitable interventions. the authors will present the philosophy, working method, preliminary effects and future developments of this instrument, which serves as the backbone for the rotterdam local youth policy. social workers to be leaders in response to aging urban populations: the practicum partnership program sarah sisco, alissa yarkony, and patricia volland "'" tliu:tion: across the us, . % of those over live in urban areas. these aging urban popu· lations, including the baby boomers, have already begun encounter a range of heahh and mental hcahh conditions. to compound these effects, health and social service delivery fluciuates in cities, whit:h arc increasingly diverse both in their recipients and their systems. common to other disciplines (medicine, nursing, psychology, etc.) the social work profession faces a shortage of workers who are well-equipped to navigate the many systems, services, and requisite care that this vast population requires. in the next two decades, it is projected that nearly , social workers will be required to provide suppon to our older urban populations. social workers must be prepared to be aging-savvy leaders in their field, whether they specialize in gerontology or work across the life span. mllhotu: in , a study conducted at the new york academy of medicine d<> :umcntcd the need for improved synchroniciry in two aspects of social work education, classroom instruction and the field experience. with suppon from the john a. hanford foundation, our team created a pilot proj~"t entitled the practicum pannership program (ppp) in master's level schools of social work, to improvt" aginr exposure in field and classroom content through use of the following: i) community-university partnrr· ships, ) increased, diverse student field rotations, ll infusion of competcn ."}'·drivm coursework, enhancement of field instructors' roles, and ) concentrated student recruitment. we conductt"d a prr· and post-test survey into students' knowledge, skills. and satisfaction. icarlja: surveys of over graduates and field inltnk."tors rcflected increased numlk-n of . rrm:y· univmity panncrships, as well as in students placed in aging agencin for field placements. there wa marked increase in student commitments to an aging specialization. onr year por.t·gradu:nion rcvealrd that % of those surveyed were gainfully employed, with % employed in the field of aginic. by com· bining curricular enhancement with real-world experiences the ppp instilled a broad exposurr for llu· dents who worked with aging populations in multiple urban settings. coltdtuion: increased exposure to a range of levels of practicr, including clinical, policy/ajvocaq, and community-based can potentially improve service delivery for older adulh who live in elfin, and potentially improve national policy. the hanford foundation has now elected to uppon cxpantion of the ppp to schools nationwide (urban and rural) to complement other domntic initiatives to cnhalk"c" holistic services for older adults across the aging spectrum. bodrgnn.ntl: we arc a team of rcscarcbcn and community panncn working tcj c(her to develop an in"itepth understanding of the mental health needs of homeless youth ~ages to ) (using qualiutivc and quantitative methods ' panicipatory rncarch methods). it is readily apparmt that '-neless youth cxpcricnce a range of mental health problems. for youth living on the street, menul illnew may be either a major risk factor for homelessnal or may frequently emcsge in response to coping with rhe multitudinous stressors associated with homclcslllcsi including exposure to violence, prasutt to pamaplte in v poster sessions survival sex and/or drug use. the most frequent psychiatric diagnoses amongst the homeless gencrally include: depression, anxiety and psychosis. . . . the ultimate ob ective of the pr~am of rei:e~ is to ~evelop a plan for intervention to meet the mental health needs of street youth. prior t_o pl~nnmg mtervenbons, .it is necessary to undertake a comprehensive assessment ~f mental health needs m this ~lnerable populanon. thus, the immediate objective of this research study is to undertake a comprehensive assessment of men· tal health needs. . . melbotlology: a mixed methodology triangulating qualitative, participatory acnon and quantitative methods will capture the data related to mental health needs of homeless youth. a purposive sample of approximately - subjecrs. ages to , is currently being ~ted ~participate from the commu.nity agencies covenant house, evergreen centre fo~ srrc;et youth, turning p? ?t and street ~ serv~. youth living on the street or in short -term residennal programs for a mmimum of month pnor to their participation; ages to and able to give infonned consent will be invited to participate in the study. o..tcomes: the expected outcome of this initial survey will be an increased understanding of mental health needs of street youth that will be used to develop effective interventions. it is anticipated that results from this study will contribute to the development of mental health policy, as well as future programs that are relevant to the mental health needs of street youth. note: it is anticipated that preliminary quantitative data ( subjects) and qualitative data will be available for the conference. the authors intend to present the identification of the research focus, the formation of our community-based team, relevance for policy, as well as preliminary results. p - (a) the need for developing a firm health policy for urban informal worken: the case of despite their critical role in producing food for urban in kenya, urban farmers have largely been ignored by government planners and policymakers. their activity is at best dismissed as peripheral eveo, inappropriate retention of peasant culture in cities and at worst illegal and often some-times criminal· ized. urban agriculture is also condemned for its presumed negative health impact. a myth that contin· ues despite proof to the contrary is that malarial mosquitoes breed in maize grown in east african towns. however, potential health risks are insignificant compared with the benefits of urban food production. recent studies too rightly do point to the commercial value of food produced in the urban area while underscoring the importance of urban farming as a survival strategy among the urban poor, especially women-headed households. since the millennium declaration, health has emerged as one of the most serious casualties consequent on the poverty, social exclusion, marginalisation and lack of sustain· able development in africa. hiv/aids epidemic poses an unprecedented challenge, while malaria, tuber· culosis, communicable diseases of childhood all add to the untenable burden. malnutrition underpins much ill-health and is linked to more than per cent of all childhood deaths. kenya's urban poor people ~ace ~ h~ge burde~ of preventable and treatable health problems, measured by any social and bi~ medical md cator, which not only cause unnecessary death and suffering, but also undermine econonuc development and damage the country's social fabric. the burden is in spite of the availability of suitable tools and re:c=hnology for prevention and treatment and is largely rooted in poverty and in weak healah •rstems. this pa~ therefore challenges development planners who perceive a dichotomy instead of con· tmuum between informal and formal urban wage earners in so far as access to health services is con· cemed. it i~ this gap that calls for a need to developing and building sustainable health systems among the urban mformal ~wellers. we recommend a focus on an urban health policy that can build and strengthen the capacity of urban dwellers to access health services that is cost-effective and sustainable. such ~ health poli<=>: must strive for equity for the urban poor, displaced or marginalized; mobilise and effect ~ely use sufficient sustainable resources in order to build secure health systems and services. special anenti_on. should ~ afforded hiv/aids in view of the unprecedented challenge that this epidemic poses to africa s economic and social development and to health services on the continent. methods: a review of the literature led us to construct three simple models and a composite model of exposure to traffic. the data were collected with the help of a daily diary of travel activities using a sample of cyclists who went to or come back from work or study. to calculate the distance, the length of journey, and the number of intersections crossed by a cyclist different geographic information systems (gis) were operated. statistical analysis was used to determine the significance between a measure of exposure on the one hand, and the sociodemographic characteristics of the panicipants or their geographic location on the other hand. restlltj: our results indicate that cyclists were significantly exposed to road accidents, no matter of where they live or what are their sociodemographic characteristics. we also stress the point that the fact of having been involved in a road accident was significantly related to the helmet use, but did not reduce the propensity of the cyclists to expose themselves to the road hazards. condlllion: the efforts of the various authorities as regards road safety should not be directed towards the reduction of the exposure of the vulnerable users, but rather towards the reduction of the dangers to which they could face. keywords: cyclist, daily diary of activities, measures of exposure to traffic, island of montreal. p - (a) intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods olumuyiwa akinbamijo intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods abstract urbanization panicularly in nigerian cities, ponends unprecedented crises of grave dimensions. from physical and demographic viewpoints, city growth rates are staggering coupled with gross inabilities to cope with the consequences. environmental and social ills associated with unguarded rapid urbanization characterize nigerian cities and threaten urban existence. this paper repons the findings of a recent study of the relationship between environmental health across inrraurban residential communities of akure, south west nigeria. it discuses the typical urbanization process of nigerian cities and its dynamic spatial-temporal characteristics. physical and socio-demographic attributes as well as the levels and effectiveness of urban infrastructural services are examined across the core residential districts and the elite residential layouts in the town. the incidence rate of cenain environmentally induced tropical diseases across residential neighborhoods and communes is examined. salient environmental variables that are germane to health procurement in the residential districts, incidence of diseases and diseases parasitology, diseases prevention and control were studied. field data were subjected to analysis ranging from the univariate and bivariate analysis. inferential statistics using the chi-square test were done to establish the truthfulness of the guiding hypothesis. given the above, the study affirms that there is strong independence in the studied communities, between the environment and incidence of diseases hence health of residents of the town. this assertion, tested statistically at the district levels revealed that residents of the core districts have very strong independence between the environment and incidences of diseases. the strength of this relationship however thins out towards the city peripheral districts. the study therefore concludes that since most of the city dwellers live in urban deprivation, urban health sensitive policies must be evolved. this is to cater for the urban dwellers who occupy fringe peripheral sites where the extension of facilities often times are illegally done. urban infrastructural facilities and services need be provided as a matter of public good for which there is no exclusive consumption or access even for the poorest of the urban poor. many suffer from low-self esteem, shame and guilt about their drug use. in addition, they often lack suppon or encounter opposition from their panners, family and friends in seeking treatment. these personal barriers are compounded by fragmented addiction, prenatal and social care services, inflexible intake systems and poor communication among sectors. the experience of accessing adequate care between services can be overwhelming and too demanding. the toronto centre for substance use in pregnancy (t-cup) is a unique program developed to minimize barriers by providing kone-stop" comprehensive healthcare. t-cup is a primary care based program located in the department of family medicine at st. joseph\'s health centre, a community teaching hospital in toronto. the interdisciplinary staff provides prenatal and addiction services, case management, as well as care of newborns affected by substance use. regular care plan meetings are held between t-cup, labour and delivery nurses and social workers in the y poster sessions maternity and child care program. t-cup also connects "'.omen with. inpatient treatment programs and community agencies such as breaking the cycle, an on-site counselmg group for pregnant substance users. · f · d d h ith method: retrospective chart review, qualitative patient ~ans action stu ~· an ea care provider surveys are used to determine outcomes. primary outcomes mclude changes m maternal su~tance use, psychosocial status and obstetrical complications (e.g. pre-rupture of membrane, pre-eclampsia, placen· ral abruption and hemorrhage). neonatal measures ~~nsisted of .bir~h pa_rame~ers, length of h~spital st.ay and complications (e.g. feral distress, meconium stammg, resuscitation, aund ce, hypoglycemia, seventy of withdrawal and treatment length). chart review consisted of all t-cup patients who met clinical cri· reria for alcohol or drug dependence and received prenatal and intra-partum care at st. joseph's from october to june . participants in the qualitative study included former and current t-cup patients. provider surveys were distributed on-site and to a local community hospital. raulb: preliminary evaluation has demonstrated positive results. treatment retention and satisfaction rates were high, maternal substance use was markedly reduced and neonatal outcomes have shown to be above those reported in literature. conclusion: this comprehensive, primary care model has shown to be optimal in the management of substance use in pregnancy and for improving neonatal outcomes. future research will focus on how this inexpensive program can be replicated in other health care settings. t-cup may prove to be the optimal model for providing care to pregnant substance users in canada. lntrod ction: cigarette smoking is one of the most serious health problems in taiwan. the prevalence of smoking in is . % in males . % in females aged years and older. although the government of taiwan passed a tobacco hazards control act in , it has not been strongly enforced in many places. therefore, community residents have often reported exposure of second hand smoke. the purpose of the study was to establish a device to build up more smoke-free environments in the city of tainan. methods: unique from traditional intervention studies, the study used a healthy city approach to help build up smoke-free environments. the major concept of the approach is to build up a healthy city platform, including organizing a steering committee, setting up policies and indicators, creating intersectoral collaboration, and increasing community participation. first, more than enthusiastic researchers, experts, governmental officers, city counselors and community leaders in tainan were invited in the healthy city committee. second, smoke-free policies, indicators for smoke-free environments, and mechanisms for inter-departmen· tal inspections were set up. third, community volunteers were recruited and trained for persuading related stakeholders. lastly, both penalties and rewards were used for help build up the environments. raults: aher two-year ( aher two-year ( - execution of the project, the results qualitatively showed that smoke-free environments in tainan were widely accepted and established, including smoke-free schools, smoke-free workpla~es, smoke-free households, smoke-free internet shops, and smoke-free restaurants. smoke~s were. effectively educated not to smoke in public places. community residents including adults and children m the smoke-free communities clearly understand the adverse effects of environmental tobacco smoke and actively participated anti-smoking activities. conclruions: healthy city platform is effective to conquer the barrier of limited anti-smoking rc:sources. nor. only can it enlar:ge community actions for anti-smoking campaigns, but also it can provide par_merships for collaboratjon. by establishing related policies and indicators the effects of smoke· free environments can be susta ·ned a d th · · · ' · n e progression can be monitored m a commuruty. these issues are used ~· oi::c it~ goals, weuha identifies issues that put people's health at risk. presently, team com~u:c: ran ee~tion !earns. (iats) that design integrative solutions ~tesj'°~ g om six to fifteen members. methods in order to establish wo-poster sessions v projects for weuha, the following approach was undertaken: i. a project-polling template was created and sent to all members of the alliance for their input. each member was asked to identify thdr top two population groups, and to suggest a project on which to focus over a - month period for each identified population. . there was a % response to the poll and the top three population groups were identified. data from the toronto community health profile database were utilized to contextualize the information supplied for these populations. a presentation was made to the steering committee and three population-based projects were selected, leaders identified and iats formed. three population-based projects: the population-based projects and health care issues identified are: newcomer prenatal uninsured women; this project will address the challenges faced by providers to a growing number of non-insured prenatal women seeking care. a service model where the barrier of "catchments" is removed to allow enhanced access and improved and co-ordinated service delivery will be pilot-tested. children/obesity/diab etes: using a health promotion model this team will focus on screening, intervention, and promoting healthy lifestyles (physical activity and nutrition) for families as well as for overweight and obese children. seniors health promotion and circle of discharge: this team will develop an early intervention model to assist seniors/family unit/caregivers in accessing information and receiving treatment/care in the community. the circle of discharge initiative will address ways of utilizing community supports to keep seniors in the community and minimize readmissions to acute care facilities. results/expected outcomes: coordinated and enhanced service delivery to identified populations, leading to improved access, improved quality of life, and health care for these targeted populations. introduction: basic human rights are often denied to high-risk populations and people living with hiv/aids. their rights to work and social security, health, privacy, non discrimination, liberty and freedom of movement, marriage and having a family have been compromised due to their sero-positive status and risk of being positive. the spread of hiv/aids has been accelerating due to the lack of general human rights among vulnerable groups. to formulate and implement effective responses needs dialogue and to prevent the epidemic to go underground barriers like stigma need to be overcome. objective: how to reduce the situation of stigma, discrimination and human rights violations experienced by people living with hiv/aids and those who are vulnerable to hiv/aids. methodology and findings: consultation meetings were strm.-rured around presentations, field visits, community meetings and group work to formulate recommendations on how govt and ngos/cbos should move forward based on objective. pakistan being a low prevalence country, the whole sense of compl;u:enc.:y that individuals are not subject to situations of vulnerable to hiv is the major threat to an explosion in th•· epidemic, therefore urgent measures are needed to integrate human rights issues from the very start of the response. the protection and promotion of human rights in an integral component of ;tll responses to the hiv/aids epidemic. it has been recognized that the response to hiv/aios must he multi sectoral and multi faceted, with each group contributing its particular expertise. for this to occur along with other knowlcdg<" more information is required in human rights abuses related to hiv/ aids in a particular scenario. the ~·on sultarion meetings on hiv/aids and human rights were an exemplary effort to achieve the same ohj<..:tivc. recommendations: the need for a comprehensive, integrated and a multi-sectoral appro;u.:h in addressing the issue of hiv/aids was highlighted. the need social, cultural and religious asp•·ct' to he: prominently addressed were identified. it was thought imperative measures even in low prevalence countries. education has a key role to play, there is a need for a code of ethics for media people and h<"alth care providers and violations should be closely monitored and follow up action taken. p - (c) how can community-based funding programs contribute to building community capacity and how can we measure this elusive goal? mary frances maclellan-wright, brenda cantin, mary jane buchanan, and tammy simpson community capacity building is recognized by the public health agency of canada (phac) as an important strategy for improving the overall health of communities by enabling communities to addre~s priority issues such as social and economic determinants of health. in / phac.:, alberta/nwf region's population health fund (phf) supported community-based projects to build community capacity on or across the determinants of health. specifically, this included creating accessible and sup· portive social and physical environments as well as creating tools and processes necessary for healthy policy development and implementation. the objective of this presentation is to highlight how the community capacity building tool, developed by phac ab/nwf region, can demonstrate gains in v poster sessions · · the course of a pror· ect and be used as a reflective tool for project planning and community capacity over . . . . i · a art of their reporting requirements, pro ect sites completed the community caparny eva uanon. s p . . th t i ii i'd d . building tool at the beginning and end of their ~ne-year prorect. e oo ~o ects va an reliable data in the context of community-based health prorects. developed through a vigorous ~nd collabora ve research process, the tool uses plain languag~ to expl~re nine key f~atures o~ commuruty cap~city with 't ch with a section for contextual information, of which also mdude a four-pomt raong ems, ea f fu d · scale. results show an increase in community capacity over the course o the nde prorects. pre and post aggregate data from the one-year projects measure~ statistic.ally si~n~ficant changes for of the scaled items. projects identified key areas of commumty capacity bmldmg that needed strengthemng, such as increasing participation, particularly among people with low incomes; engaging community members in identifying root causes; and linking with community groups. in completing the tool, projects examined root causes of the social and economic determinants of health, thereby exploring social justice issues related to the health of their community. results of the tool also served as a reflec· cion on the process of community capacity building; that is, how the project outcomes were achieved. projects also reported that the tool helped identify gaps and future directions, and was useful as a project planning, needs assessment and evaluation tool. community capacity building is a strategy that can be measured. the community capacity building tool provides a practical means to demonstrate gains in community capacity building. strengthening the elements of community capacity building through community-based funding can serve as building blocks for addressing other community issues. needs of marginalized crack users lorraine barnaby, victoria okazawa, barb panter, alan simpson, and bo yee thom background: the safer crack use coalition of toronto (scuc) was formed in in response to the growing concern for the health and well-being of marginalized crack users. a central concern was the alarm· ing hepatitis c rate ( %) amongst crack smokers and the lack of connection to prevention and health ser· vices. scuc is an innovative grassroots coalition comprised of front-line workers, crack users, researcher! and advocates. despite opposition and without funding, scuc has grown into the largest crack specific harm reduction coalition in canada and developed a nationally recognized sarer crack kit distribution program (involving community-based agencies that provide outreach to users). the success of our coalition derives from our dedication to the issue and from the involvement of those directly affected by crack use. setting: scuc's primary service region is greater toronto, a diverse, large urban centre. much ofour work is done in areas where homeless people, sex trade workers and drug users tend to congregate. recently, scuc has reached out to regional and national stakeholders to provide leadership and education. mandate: our mandate is to advocate for marginalized crack users and support the devdopmentof a com.p.rehensive harm reduction model that addresses the health and social needs facing crack users; and to fac htare the exchange of information between crack users, service providers, researchers, and policy developers across canada. owrview: the proposed workshop will provide participants with an overview of the devdopment of scuc, our current projects (including research, education, direct intervention and consultation), our challenge~ and s~ccesses and the role of community development and advocacy within the coalition. pre-senter~ will consist of community members who have personal crack use experience and front-line work· ers-, sc.uc conducted a community-based research project (toronto crack users perspectives, ) , in w~ich s focus groups with marginalized crack users across toronto were conducted. participants iden· t f ed health and social issues affecti h b · · · d " red . . ng t em, arrsers to needed services, personal strategies, an oue recommendations for improved services. presenters will share the methodology, results and recommen· datmns resulting from the research project. conc/usio": research, field observations and consultations with stakeholders have shown that cradck shmoke~s are at an. increased risk for sexually transmitted infections hiv/aids hepatitis c, tb an ot er serious health issues health · ff, · ' ' · · . · issues a ectmg crack users are due to high risk behavmurs, socio· economic factors, such as homeless d. · · · · d · . . ness, scrsmmat on, unemployment, violence incarceraoons, an soc a so at on, and a lack of comprehe · h i h · ' ns ve ea t and social services targeting crack users. · · sinct · s, owever arge remains a gross underesurnaoon. poster sessions v these are hospital-based reports and many known cases go unreported. however teh case, young age at first intercourse, inconsistent condom use and multiple partnersplace adolescents at high risks for a diverse array of stls, including hiv. about % of female nigerian secondary school students report initiating sexual intercourse before age years. % of nigerian female secondary school students report not using a condom the last time they had sexual intercourse. more than % of urban nigerian teens report inconsistent condom use. methods: adolescents were studied, ages to , from benin city in edo state. the models used were mother-daughter( ), mother -son( ), father -son ( ), and father-daughter( ). the effect of parent-child sexual communicationat baseline on child\'s report of sexual behavior, to months later were studied. greater amounts of sexual risk communication were asociated with markedly fewer episodes of unprotected sexual intercourse, reduced number of sexual partners and fewer episodes of unprotected sexual intercourse. results: this study proved that parents can exert more influence on the sexual knowledge attitudes and practise of their adolescent children through desired practises or rolemodeling, reiterating their values and appropriate monitoring of the adolescents\' behavior. they also stand to provide information about sexuality and various sexual topics. parental-child sexual communication has been found to be particularly influential and has been associated with later onset of sexual initiation among adolescents, less sexual activity, more responsible sexual attitudes including greater condom use, self efficacy and lower self -reported incidence of stis. conclusions: parents need to be trained to relate more effectively with their children/wards about issues related to sex and sexuality. family -based programs to reduce sexual risk-taking need to be developed. there is also the need to carry out cross-ethnicaland cross-cultural studies to identify how parent-child influences on adolescent sexual risk behavior may vary in different regions or countries, especially inthis era of the hiv pandemic. introduction: public health interventions to identify and eliminate health disparities require evidence-based policy and adequate model specification, which includes individuals within a socioecological context, and requires the integration of biosociomedical information. multiple public and private data sources need to be linked to apportion variation in health disparities ro individual risk factors, the health delivery system, and the geosocial environment. multilevel mapping of health disparities furthers the development of evidence-based interventions through the growth of the public health information network (phin-cdc) by linking clinical and population health data. clinical encounter data, administrative hospital data, population socioenvironmental data, and local health policy were examined in a three-level geocoded multilevel model to establish a tracking system for health disparities. nj has a long established political tradition of "home rule" based in elected municipal governments, which are responsible for the well-being of their populations. municipalities are contained within counties as defined by the us census, and health data are linked mostly at the municipality level. marika schwandt community organizers from the ontario coaliti~n again~t pove~, .along ":ith ~edical practitioners who have endorsed the campaign and have been mvolved m prescnbmg special diet needs for ow and odsp recipients, will discuss the raise the rates campaign. the organizati~n has used a special diet needs supplement as a political tool, meeting the urgent needs o.f .poor ~ople m toront~ while raising the issues of poverty as a primary determinant of health and nutrtnous diet as a preventative health mea· sure. health professionals carry the responsibility to ensure that they use all means available to them to improve the health of the individuals that they serve, and to prevent future disease and health conditions. most health practitioners know that those on social assistance are not able to afford nutritious foods or even sufficient amounts of food, but many are not aware of the extra dietary funds that are available aher consideration by a health practitioner. responsible nurse practitioners and physicians cannot, in good conscience, ignore the special needs diet supplement that is available to all recipients of welfare and disabiliry (ow and odsp). a number of toronto physicians have taken the position that all clients can justifiably benefit from vitamins, organic foods and high fiber diets as a preventative health measure. we know that income is one of the greatest predictors of poor health. the special needs diet is a health promotion intervention which will prevent numerous future health conditions, including chronic conditions such as cardiovascular disease, cancer, diabetes and osteoporosis. many communiry health centres and other providers have chosen to hold clinics to allow many patients to get signed up for the supplement at one time. initiated by the ontario coalition against poverty, these clinics have brought together commu· niry organizers, community health centers, health practitioners, and individuals, who believe that poverty is the primary determinant of poor health. we believe that rates must be increased to address the health problems of all people on social assistance, kids, elders, people with hiv/aids -everyone. even in the context of understaffing, it could be considered a priority activity that has potentially important health promotion benefits. many clients can be processed in a two hour clinic. most providers find it a very interesting, rewarding undertaking. in the ontario coalition for social justice found that a toronto family with two adults and two kids receives $ , . this is $ , below the poverty line. p - (c) the health of street youth compared to similar aged youth beth hayhoe and ruth ewert . lntrod~on: street youth are at an age normally associated with good health, but due to their risky ~hav ours and th~ conditions in which they live, they experience health conditions unlike their peer~ an more stable env r~nments. in addition, the majority of street youth have experienced significant physical, sexual ~nd em.ot onal abuse as younger children, directly impacting many of the choices they make around their physical and emotional health. we examined how different their health really is. . , methodl: using a retrospective analysis of the years of data gathered from yonge street mis· ~ • evergreen health centre, the top conditions of youth were examined and compared with national tren~s for similar aged youth. based on knowledge of the risk factors present in the group, rea· sons for the difference were examined. d' ~its: street youth experience more illness than other youth their age and their illnesses can bt . irect t ·~kc~ to the. conditions in which they live. long-term impacts of abus~ contribute to such signif· ~~nt t e t d~slpl air that youth may voluntarily engage in behaviours or lack of self care in the hope at t cir ve~ w perhaps come to a quicker end. concl non: although it has ion b k h th' dy clearly shows d'fi . h g ee~ no~n t at poverty negatively affects health, ~siu be used to make ; erence m t .e health of this particular marginalized population. the infonnanon can relates to th . ecommendatio.ns around public policy that affects children and youth, especially as it e r access to appropriate health care and follow up. p - (cl why do urban children · b gt . tarek hussain an adesh die: how to save our children? the traditional belief that urban child alid. a recent study (dhs d fr r~n are better off than rural children might be no longer v urban migrants are highata th om h c~untn~s i demonstrates that the child survival prospects of rural· er an t ose m their r j · · ·grants. in bangladesh, currently million ~r~ ~ gm and lower than those of urban non-idi million. health of the urban ~ p~e are hvmg m urban area and by the year , it would be so the popu at on s a key a eals that urban poor have the worse h h . concern. recent study on the urban poor rev ea t situation than the nation as a whole. this study shows that infant poster sessions v mortality among the urban poor as per thousand, which are above the rural and national level estimates. the mortality levels of the dhaka poor are well above those of the rest of the city's population but much of the difference in death rates is explained by the experience of children, especially infants. analyzing demographic surveillance data from a large zone of the city containing all sectors of the population, research showed that the one-fifth of the households with the least possessions exhibited u child mortality almost three times as high as that recorded by the rest of the population. why children die in bangladesh? because their parents are too poor to provide them with enough food, clean water and other basic needs to help them avoid infection and recover from illness. researchers believed that girls are more at risk than boys, as mothers regularly feed boys first. this reflects the different value placed on girls and boys, as well as resources which may not stretch far enough to provide for everyone. many studies show that housing conditions such as household construction materials and access to safe drinking water and hygienic toilet facilities are the most critical determinants of child survival in urban areas of developing countries. the present situation stressed on the need for renewed emphasis on maternal and child healthcare and child nutrition programs. mapping path for progress to save our children would need be done strategically. we have the policies on hand, we have the means, to change the world so that every child will survive and has the opportunity to develop himself fully as a healthy human being. we need the political will--courage and determination to make that a reality. p - (c) sherbourne health centre: innovation in healthcare for the transgendered community james read introduction: sherbourne health centre (shc), a primary health care centre located in downtown toronto, was established to address health service gaps in the local community. its mission is to reduce barriers to health by working with the people of its diverse urban communities to promote wellness and provide innovative primary health services. in addition to the local communities there are three populations of focus: the lesbian, gay, bisexual, transgendered and transexual communities (lgbtt); people who are homeless or underhoused; and newcomers to canada. shc is dedicated to providing health services in an interdisciplinary manner and its health providers include nurses, a nurse practitioner, mental health counsellors, health promoters, client-resource workers, and physicians. in january shc began offering medical care. among the challenges faced was how to provide responsive, respectful services to the trans community. providers had considerable expertise in the area of counselling and community work, but little in the area of hormone therapy -a key health service for those who want to transition from one gender to another. method: in preparing to offer community-based health care to the trans community it was clear that shc was being welcomed but also being watched with a critical eye. trans people have traditionally experienced significant barriers in accessing medical care. to respond to this challenge a working group of members of the trans community and health providers was created to develop an overall approach to care and specific protocols for hormone therapy. the group met over a one year period and their work culminated in the development of medical protocols for the provision of hormone therapy to trans individuals. results: shc is currently providing health care to registered clients who identify as trans individuals (march ) through primary care and mental health programs. in an audit of shc medical charts (january to september ) female-to-male (ftm) and male-to-female (mtf) clients were identified. less than half of the ftm group and just over two-thirds of the mtf group presented specifically for the provision of hormones. based on this chart audit and ongoing experience shc continues to update and refine these protocols to ensure delivery of quality care. conclusion: this program is an example of innovative community-based health delivery to a population who have traditionally faced barriers. shc services also include counselling, health promotion, outreach and education. p - (c) healthy cities for canadian women: a national consultation sandra kerr, kimberly walker, and gail lush on march , the national network on environment and women's health held a pan-canadian consultation to identify opportunities for health research, policy change, and action. this consultation also worked to facilitate information sharing and networking between canadian women working as urban planners, policy makers, researchers, and service workers on issues pertaining to the health of women living in canadian cities. methods: for this research project, participants included front-line service workers, policy workers, researchers, and advocates from coast to coast, including francophone women, women with disabilities, racialized women, and other marginalized groups. the following key areas were selected as topics for du.bnes i alto kading .:auk of end·sugr ieaal clileue ia singapore, accounting for more than so% of new can singapore (nkfs) to embark on a prevention program (pp) empo~r d ahc j u f dieir condition bttter, emphasizing education and disease sdf·managemen lkilla a. essennal camponenn of good glycaemic control. we sought explore the effects of a pecialijed edu.:a on pro· pun od glycacmic conuol, as indicated by, serum hba ic values budine serum hba ic values were determined before un<k-rgmng the education progr ;am, which couisted of comprehensive dietary advice, ideal weight goals, and improving lipid profiln. serum hbaic values were obtained ar , , months later to determine impact of the program. analy • wu done uling paired !·tests significant reduction in hba le levels from ro month• was observed in females, chinese race, older age group(> so yean). ohew-ibmi ~ .nwm , wai hip ratio> l),up to primary and above secondary level education and those having om urine iclt showed that increasing hbalc levels ( ) had increasing urmary protein ( .± ; . ±i ih so± ) and crearinine (s .s ± s ± ; ioi± s) levels fbg rnults showed that the management nf d abetn m the nkfs preven· tion programme is effec;rive. results also indicated har hba le leve have a linnr trend wnh unnary protein and creatinine which are imponant determinants of renal diseate tal family-focused cinical palbway promoce politivc outcollln for ua inner city canu allicy ipmai jerrnjm care llctivirits in preparation for an infanr'' dilchargr honlr, and art m endnl lo improve effi.:k'fl.:tn of c.are. lere i paucity of tttran:h, and inconsi trncy of rnulta on ht-•m!*- of f m ly·fc"-'uw d nm a: to determinr whrthrr implrmentation of family.focuted c:pt n ntnn.tt.tl unit w"n mg an inner city ;ommunity drcl't'aki leftarh of lf•y (i.osi and rromclll'i family uo•fkllon and rt. j nest for dikhargr. md odt: family-focuk"d cpi data wm coll«ted for all infant• horn btrwttn and wft"k• t"lal mi atr who wrtt . dm ed to the ntonatal unit lmgdl of -.y . n. . day'o p c o.osi ind pma . d•mr., ho.nr . t . n. . ± i. i wb, p < o.os) wett n« fiamly f.lfrt n the pre.(]' poup. ~ .fxtmon icofn for famihn wrre high. and families noctd thc:y wnr mott prepued to ah thrar t..lby "'-· thett was .a cosi uving of s , (cdn) per patient d teharpd home n the pmi-cp poap c.-pated the p"''lfoup· cortclaion· lmplrmrnr.rion of family·foanrd c:p. in a nrona . i umt tc"fyidi an nnn an com· muniry decre.ned length of'"'" mft with a high dcgrft of family uujamon, and wrre coll~nt at least % percent of the kathmandu population lives in slum like conditions with poor access to basic health services. in these disadvantaged areas, a large proportion of children do not receive treatment due to inaccessibility to medical services. in these areas, diarrhea, pneumonia, and measles, are the key determinants of infant mortality. protein energy malnutrition and vitamin a deficiency persists and communicable diseases are compounded by the emergence of diseases like hiv/aids. while the health challenges for disadvantaged populations in kathmandu are substantial, the city has also experienced various forms of innovative and effective community development health programs. for example, there are community primary health centers established by the kathmandu municipality to deliver essential health services to targeted communities. these centers not only provide equal access to health services to the people through an effective management system but also educate them hy organizing health related awareness programs. this program is considered one of the most effective urban health programs. the paper/presentation this paper will review large, innovative, and effective urhan health programs that are operating in kathmandu. most of these programs are currently run by international and national ngos a) early detection of emerging diseases in urban settings through syndromic surveillance: data pilot study kate bassil of community resources, and without adequate follow-up. in november shelter pr.oviders ~et with hospital social workers and ccac to strike a working group to address some of th~ issues by mcre.asing knowledge among hospital staff of issues surrounding homelessness, and to build a stro?g workmg relationship between both systems in hamilton. to date the hswg has conducted four w~lkmg to~ of downtown shelters for hospital staff and local politicians. recently the hswg launched its ·~ool.k t for staff working with patients who are homeless', which contains community resources and gu dehnes to help with effective discharge plans. a scpi proposal has been submitted to incre~se the capacity of the hswg to address education gaps and opportunities with both shelters and hospitals around homelessness and healthcare. the purpose of this poster presentation is to share hamilton's experience and learnings with communities who are experiencing similar issues. it will provide for intera~tion around shared experiences and a chance to network with practitioners across canada re: best practices. introduction and objectives: canadians view health as the biggest priority for the federal government, where health policies are often based on models that rely on abstract definitions of health that provide little assistance in the policy and analytical arena. the main objectives of this paper are to provide a functional definition of health, to create a didactic model for devising policies and determining forms of intervention, to aid health professionals and analysts to strategize and prioritize policy objectives via cost benefit analysis, and to prompt readers to view health in terms of capacity measures as opposed to status measures. this paper provides a different perspective on health, which can be applied to various applications of health such as strategies of aid and poverty reduction, and measuring the health of an individual/ community/country. this paper aims to discuss theoretical, conceptual, methodological, and applied implications associated with different health policies and strategies, which can be extended to urban communities. essentially, our paper touches on the following two main themes of this conference: •health status of disadvantaged populations; and •interventions to improve the health of urban communities.methodology: we initially surveyed other models on this topic, and extrapolated key aspects into our conceptual framework. we then devised a theoretical framework that parallels simple theories of physkal energy, where health is viewed in terms of personal/societal health capacities and effort components.after establishing a theoretical model, we constructed a graphical representation of our model using selfrated health status and life expectancy measures. ultimately, we formulated a new definition of health, and a rudimentary method of conducting cost benefit analysis on policy initiatives. we end the paper with an application example discussing the issues surrounding the introduction of a seniors program.results: this paper provides both a conceptual and theoretical model that outlines how one can go about conducting a cost-benefit analysis when implementing a program. it also devises a new definition and model for health barred on our concept of individual and societal capacities. by devising a definition for health that links with a conceptual and theoretical framework, strategies can be more logically constructed where the repercussions on the general population are minimized. equally important, our model also sets itself up nicely for future microsimulation modeling and analysis.implications: this research enhances one's ability to conduct community-based cost-benefit analysis, and acts as a pedagogical tool when identifying which strategies provide the best outcome. p - (a) good playgrounds are hard to find: parents' perceptions of neighbourhood parks patricia tucker, martin holmes, jennifer irwin, and jason gilliland introduction: neighbourhood opportunities, including public parks and physical activity or sports fields hav~ been. iden.tified as correlates to physical activity among youth. increasingly, physical activity among children s bemg acknowledged as a vital component of children's lives as it is a modifiable determinant of childh~d obesity. children's use of parks is mainly under the influence of parents; therefore, the purpose of this study was to assess parents' perspectives of city parks, using london ontario as a case study.m~~: this qualitative study targeted a heterogeneous sample of parents of children using local parks w thm london. parents with children using the parks were asked for minutes of their time and if willing, a s.hort interview was conducted. the interview guide asked parents for their opinion 'of city parks, particularly the one they were currently using. a sample size of parents is expected by the end of the summer.results: preliminary findings are identifying parents concern with the current jack of shade in local parks. most parents have identified this as a limitation of existing parks, and when asked what would make the parks better, parents agree that shade is vital. additionally, some parents are recognizing the v poster sessions focused discussions during the consultation: . women in _poverty . women with disability . immi· grant and racialized women . the built and _physica_l environment. . . . . r its· participants voiced the need for integration of the following issues withm the research and policy :::na; t) the intersectional nature of urban women's health i~sues wh~ch reflects the reality of women's complex lives ) the multisectional aspect of urban wo_m~n s health, ss~es, which reflects the diversity within women's lives ) the interse~roral _dynamics within _womens hves and urban health issues. these concepts span multiple sectors -mdudmg health, educat n, and economics -when leveraging community, research, and policy support, and engaging all levels of government.policy jmplicatiom: jn order to work towards health equity for women, plans for gender equity must be incorporated nationally and internationally within urban development initiatives: • reintroduce "women" and "gender" as distinct sectors for research, analysis, advocacy, and action. •integrate the multisectional, intersectional, and intersecroral aspects of women's lives within the framework of research and policy development, as well as in the development of action strategies. • develop a strategic framework to house the consultation priorities for future health research and policy development (for example, advocacy, relationship building, evidence-based policy-relevant research, priority initiatives}.note: research conducted by nnewh has been made possible through a financial contribution from health canada. the views expressed herein do not necessarily represent the views of health canada.p - (c) drugs, culture and disadvantaged populations leticia folgar and cecilia rado lntroducci n: a partir de un proyecto de reducci n de daiios en una comunidad urbana en situ· aci n de extrema vulnerahilidad surge la reflexion sobre el lugar prioritario de los elementos sociocuhurales en el acceso a los servicios de salud de diferentes colectivos urbanos. las "formas de hacer, pensar y sentir" orientan las acciones y delimitan las posibilidades que tienen los individuos de definir que algo es o no problema, asf como tambien los mecanismos de pedido de ayuda. el analisis permanenre del campo de "las culturas cotidianas" de los llamados "usuarios de drogas" aporta a la comprension de la complejidad del tema en sus escenarios reales, y colabora en los diseiios contextualizados de politicas y propuestas socio-sanitarias de intervenci n, tornandolas mas efectivas.mitodos: esta experiencia de investigaci n-acci n que utiliza el merodo emografico identifica elementos socio estructurales, patrones de consumo y profundiza en los elementos socio-simb icos que estructuran los discursos de los usuarios, caracterizandolos y diferenciandolos en tanto constitutivos de identidades socia les que condicionan la implementaci n del programas de reduccion de daiios.resultados: los resultados que presentaremos dan cuenta de las caracteristicas diferenciadas v relaciones particulares ~ntre los consumidores de drogas en este contexto espedfico. a partir de este e~tudio de caso se mtentara co ? enzar a responder preguntas que entendemos significativas a la hora de pensar intcrvcnciones a la med da de poblaciones que comparten ciertas caracteristicas socio-culturales. (cuales serian las .motivaciones para el cambio en estas comunidades?, cque elementos comunitarios nos ayudan a i:nnstnur dema~~a? • cque tenemos para aprender de las "soluciones" que ellos mismos encuenrran a los usos problemat cos? methods: our study was conducted by a team of two researchers at three different sites. the mapping consisted of filling in a chart of observable neighbourhood features such as graffiti, litter, and boarded housing, and the presence or absence of each feature was noted for each city block. qualitative observations were also recorded throughout the process. researchers analyzed the compiled quantitative and qualitative neighbourhood data and then analyzed the process of data collection itself.results: this study reveals the need for further research into the effects of physical environments on individual health and sense of well-being, and perception of investment in neighbourhoods. the process reveals that perceptions of health and safety are not easily quantified. we make specific recommendations about the mapping methodology including the importance of considering how factors such as researcher social location may impact the experience of neighbourhoods and how similar neighbourhood characteristics are experienced differently in various spaces. further, we discuss some of the practical considerations around the mapping exercise such as recording of findings, time of day, temperature, and researcher safety.conclusion: this study revealed the importance of exploring conceptions of health and well-being beyond basic physical wellness. it suggests the importance of considering one's environment and one's own perception of health, safety, and well-being in determining health. this conclusion suggests that attention needs to be paid to the connection between the workplace and the external environment it is situated in. the individual's workday experience does not start and stop at the front door of their workplace, but rather extends into the neighbourhood and environment around them. our procedural observations and recommendations will allow other researchers interested in the effect of urban environments on health to consider using this innovative methodology. introduction: responding ro protests against poor medical attention for sexually assaulted women and deplorable conviction rates for sex offenders, in the late s, the ontario government established what would become over hospital-based sexual assault care and treatment centres (sactcs) across the province. these centres, staffed around the clock with specially trained heath care providers, have become the centralized locations for the simultaneous health care treatment of and forensic evidence collection from sexually assaulted women for the purpose of facilitating positive social and legal outcomes. since the introduction of these centres, very little evaluative research has been conducted to determine the impact of this intervention. the purpose of our study was to investigate it from the perspectives of sexually assaulted women who have undergone forensic medical examinations at these centres.method: women were referred to our study by sactc coordinators across ontario. we developed an interview schedule composed of both closed and open-ended questions. twenty-two women were interviewed, face-to-face. these interviews were approximately one-to-two hours in length, and were transcribed verbatim. to date, have been analyzed for key themes.results: preliminary findings indicate that most women interviewed were canadian born ( 'yo), and ranged in age from to years. a substantial proportion self-identified as a visible minority ( 'x.). approximately half were single or never married ( %) and living with a spouse or family of origin ( %). most were either students or not employed ( %). two-thirds ( %) had completed high school and onethird ( %) was from a lower socio-economic stratum. almost two-fifths ( %) of women perceived the medical forensic examination as revictimizing citing, for example, the internal examination and having blood drawn. the other two-thirds ( %) indicated that it was an empowering experience, as it gave them a sense of control at a time when they described feeling otherwise powerless. most ( %) women stated that they had presented to a centre due to health care concerns and were very satisfied ( % ) with their experiences and interactions with staff. almost all ( %) women felt supported and understood.conclusions: this research has important implications for clinical practice and for appropriately addressing the needs of sexually assaulted women. what is apparent is that continued high-quality medical attention administered in the milieu of specialized hospital-based services is essential. at the same time, we would suggest that some forensic evidence collection procedures warrant reevaluation. the study will take an experiential, approach by chroruclmg the impa~ of the transition f m the streets to stabilization in a managed alcohol program through the techruque of narrative i~:uiry. in keeping with the shift in thinking in the mental health fie!~ ~his stu~y is based on a paradigm of recovery rather than one of pathology. the "inner views of part c pants hves as they portray their worlds, experiences and observations" will be presented (charm~z, , ~· ~)-"i?e p~ of the study is to: identify barriers to recovery. it will explore the exj?cnence of ~n~t zanon pnor to entry into the program; and following entry will: explore the meanmg ~nd defirutto~s of r~overy ~~d the impact of the new environment and highlight what supports were instrumental m movmg pan apants along the recovery paradigm.p -st (a) treating the "untreatable": the politics of public health in vancouver's inner city introdudion: this paper explores the everyday practices of therapeutic programs in the treadnent of hiv in vancouver's inner city. as anthropologists have shown elsewhere, therapeutic programs do not siinply treat physical ailments but they shape, regulate and manage social lives. in vancouver's inner city, there are few therapeutic options available for the treatment of -ilv. public health initiatives in the inner city have instead largely focused on prevention and harm reduction strategies such as needle exchange programs, safe injection sites, and safer-sex education. epidemiological reports suggest that less than a quarter of those living with hiv in the downtown eastside (dtes) are taking antiretroviral therapies raising critical questions regarding the therapeutic economy of antiretrovirals and rights to health care for the urban poor.methods: this paper is drawn from ethnographic fieldwork in vancouver's otes neighborhood focusing on therapeutic programs for hiv treatment among "hard-to-reach" populations. the research includes participant-observation at inner city health clinics specializing in the treatment of hiv; semi· structured interviews with hiv positive participants, health care professionals providing hiv treatment, and administraton working in the field of inner city public health; and, lastly, observation at public meetings and conferences surrounding hiv treatment.r.awlts: hiv prevention and treatment is a central concern in the lives of many residents living in the inner city -although it is just one of many health priorities afflicting the community. concerns about drug resistance, cost of antiretrovirals, and illicit drug use means that hiv therapy for most is characterized by the daily observation of their medicine ingestion at health clinics or pharmacies. daily observed treatment (dot) is increasingly being adopted as a strategy in the therapeutic management of "untreatable" populations. dot programs demand a particular type of subject -one who is "compliant" to the rules and regimes of public health. over emphasis on "risky practices," "chaotic lives," and "~dh~rence" preve~ts the public health system from meaningful engagement with the health of the marginalized who continue to suffer from multiple and serious health conditions and who continue to experience considerable disparities in health.~ the ~ffec~s of hiv in the inner city are compounded by poverty, laclc of safe and affordable houamg, vanous llegal underground economies increased rates of violence and outbreaks of ~~~·~ly tr~nsmitted infections, hepatitis, and tuberculosi: but this research suggests 'that public health uunauves aimed at reducing health disparities may be failing the most vulnerable and marginal of citiztl s. margaret malone ~ vi~lence that occurs in families and in intimate relationships is a significant urban, ~unity, and pu~hc health problem. it has major consequences and far-reaching effects for women, ~~--renho, you~ sen on, and families. violence also has significant effects for those who provide and ukllc w receive health care violence · · i · · . all lasses, · is a soc a act mvolvmg a senous abuse of power. it crosses : ' : ' ~ s;nden, ag~ ~ti~, cultures, sexualities, abilities, and religions. societal responseshali ra y oc:used on identificatton, crisis intervention and services for families and individuajs.promoten are only "-"--:-g to add h · ' · i in intimate relationshi with"-~"'.". ress t e issues of violence against women and vjoence lenga to consider i~ m families. in thi_s p~per, i analyze issues, propose strategies, and note c~· cannot be full -...l'-~ whork towards erad canng violence, while arguing that social justice and equity y -. ucvcu w en thett are people wh mnhod: critical social theory, an analysis that addresses culturally and ethnically diverse communities, together with a population health promotion perspective frame this analysis. social determinants of health are used to highlight the extent of the problem of violence and the social and health care costs.the ottawa charter is integrated to focus on strategies for developing personal skills, strengthening community action, creating supportive environments, devdoping healthy public policies, and re-orientating health and social services. attention is directed to approaches for working with individuals, families, groups, communities, populations, and society.ratdts: this analysis demonstrates that a comprehensive interdisciplinary, multisectoral, and multifaceted approach within an overall health promoting perspective helps to focus on the relevant issues, aitical analysis, and strategies required for action. it also illuminates a number of interacting, intersecting, and interconnecting factors related to violence. attention, which is often focused on individuals who are blamed for the problem of violence, is redirected to the expertise of non-health professionals and to community-based solutions. the challenge for health promoters working in the area of violence in families and in intimate relationships is to work to empower ourselves and the communities with whom we work to create health-promoting urban environments. social justice, equiry, and emancipatory possibilities are positioned in relation to recommendations for future community-based participatory research, pedagogical practices for health care practitioners, and policy development in relation to violence and urban health. the mid-main community health center, located in vancouver british columbia (bc), has a diverse patient base reflecting various cultures, languages, abilities, and socio-economic statuses. due to these differences, some mid-main patients experience greater digital divide barriers in accessing computers and reputable, government produced consumer health information (chi) websites, such as the bc healthguide and canadian health network. inequitable access is problematic because patient empowerment is the basis of many government produced chi websites. an internet terminal was introduced at mid-main in the summer of , as part of an action research project to attempt to bridge the digital divide and make government produced chi resources useful to a broad array of patients. multi-level interventions in co-operation with patients, with the clinic and eventually government ministries were envisioned to meet this goal. the idea of implementing multi-level interventions was adopted to counter the tendency in interactive design to implement a universal solution for the 'ideal' end-user [ ), which discounts diversity. to design and execute the interventions, various action-oriented and ethnographic methods were employed before and during the implementation of the internet terminal. upon the introduction of the internet terminal, participant observation and interviews were conducted using a motion capture software program to record a digital video and audio track of patients' internet sessions. this research provided insight into the spectrum of patients' capacities to use technology to fulfil their health information needs and become empowered. at the mid-main clinic it is noteworthy that the most significant intervention to enhance the usefulness of chi websites for patients appeared to be a human rather than a technological presence. as demonstrated in other ethnographic research of community internet access, technical support and capacity building is a significant component of empowerment ( ). the mid-main wired waiting room project indicates that medical practitioners, medical administrators, and human intermediaries remain integral to making chi websites useful to patients and their potential empowerment. ( ) over the past years the environmental yo~th alliance has been of~ering a.youth as~t. mappin~ program which trains young people in community research and evaluation. wh ~st the positive expenenc~ and relationships that have developed over this time attest to the success of this program, no evaluations has yet been undertaken to find out what works for t.he youth, what ~ould be changed, and what long term outcomes this approach offers for the youth, their local community, and urban governance. these topics will be shared and discussed to help other community disorganizing and uncials governments build better, youth-driven structures in the places they live.p - (a) the world trade center health registry: a unique resource for urban health researchers deborah walker, lorna thorpe, mark farfel, erin gregg, and robert brackbill introduction: the world trade center health registry (wfchr) was developed as a public health response to document and evaluate the long-term physical and mental health effects of the / disaster on a large, diverse population. over , people completed a wfchr enrollment baseline survey, creating the largest u.s. health registry. while studies have begun to characterize / bealth impacts, questions on long-term impacts remain that require additional studies involving carefully selected populations, long-term follow-up and appropriate physical exams and laboratory tests. wtchr provides an exposed population directory valuable for such studies with features that make ita unique resource: (a) a large diverse population of residents, school children/staff, people in lower man· hattan on / including occupants of damaged/destroyed buildings, and rescue/recovery/cleanup work· ers; (b) consent by % of enrollees to receive information about / -related health studies; (c) represenration of many groups not well-studied by other researchers; (c) email addresses of % of enrollees; (d) % of enrollees recruited from lists with denominator estimates; and (e) available com· parison data for nyc residents. wfchr strives to maintain up-to-date contact information for all enrollees, an interested pool of potential study participants. follow-up surveys are planned.methods: to promote the wtchr as a public health resource, guidelines for external researcher.; were developed and posted on (www.wtcregistry.org) which include a short application form, a twopage proposal and documentation of irb approval. proposals are limited to medical, public health, or other scientific research. researchers can request de-identified baseline data or have dohmh send information about their studies to selected wfchr enrollees via mail or email. applications are scored by the wtchr review committee, comprised of representatives from dohmh, the agency for toxic subst~nces and disease registry, and wtchr's scientific, community and labor advisory committees. a data file users manual will be available in early fall .~suits: three external applications have been approved in , including one &om a non-u.s. ~esearcher, all requesting information to be sent to selected wtchr enrollees. the one completed mail· mg~~ wtchr enrollee~ (o , wfc tower evacuees) generated a positive survey response rate. three additional researchers mtend to submit applications in . wfchr encourages collaborations between researchers and labor and community leaders.conclusion: studies involving wtchr enrollees will provide vital information about the long· term health consequences of / . wtchr-related research can inform communities, researcher.;, policy makers, health care providers and public health officials examining and reacting to and other disasters. t .,. dp'"f'osed: thi is presentation will discuss the findings of attitudes toward the repeat male client iden· ie as su e a and substance us'n p · · · · i · 'd . . - g. articipants will learn about some identified effective strategies or service prov ers to assist this group of i · f men are oft · d bl men. n emergency care settings, studies show that this group en viewe as pro emaric patient d i r for mental health p bl h h an are more ikely to be discharged without an assessmen !) ea rofr ems t. an or er, more cooperative patients (forster and wu · hickey er al., · r y resu ts om this study suggest th · · ' ' l · d tel' mining how best to h . d at negative amtudes towards patients, difficu nes e · as well pathways l_e_ p patientsblan ~ck of conrinuity of care influence pathways to mental health care. • uc\:ome pro emat c when p ti k · che system. m a ems present repeatedly and become "get stuc id methods: semi-structured intervie d . · (n= ), ed nurses (n= ) other ed ;s were con ucted with male ed patients (n= ), ed phys oans ' sta (n= ) and family physicians (n= ). patients also completed a poster sessions v diagnostic interview. interviews were tape-recorded, transcribed verbatim and managed using n . transcripts were coded using an iterative process and memos prepared capture emergent themes. ethics approval was obtained and all participants signed a detailed informed consent form.introduction: urban settings are particularly susceptible to the emergence and rapid spread of nt•w or rare diseases. the emergence of infectious diseases such as sars and increasing concerns over the next influenza pandemic has heightened interest in developing and using a surveillance systt·m which detects emerging public health problems early. syndromic surveillance systems, which use data b, scd on symptoms rather than disease, offer substantial potential for this by providing near-real-rime data which are linked to an automated warning system. in toronto, we are piloting syndromic data from the · emergency medical services (ems) database to examine how this information can be used on an ongoing basis for the early detection of syndromes including heat-related illness (hri), and influenza-like-illness (ill). this presentation will provide an outline of the planned desi_gn of this system and proposed evaluation. for one year, call codes which reflect heat-related illness or influenza-like-illness will be selected and searched for daily using software with a multifactorial algorithm. calls will he stratified by call code, extracted from the -ems database and transferred electronically to toronto public health. the data will be analyzed for clusters and aberrations from the expected with the realtime outbreak and disease surveillance (rods) system, a computer-based public health tool for the early detection of disease outbreaks. this -ems surveillance system will be assessed in terms of its specificity and sensitivity through comparisons with the well-established tracking systems already in place for hr! and ill. others sources of data including paramedic ambulance call reports of signs and . this study will introduce complementary data sources t~ the ed ch e~ complamt an~ o~~rthe-counter pharmacy sales syndromic surveillance data currently bemg evaluated m ~ther ontar~o cltles. . syndromic surveillance is a unique approach to proactive(~ dete~tmg early c.hangesm the health status of urban communities. the proposed study aims to provide evidence of differential effectiveness through investigating the use of -ems call data as a source of syndromic surveillance information for hr! and ili in toronto. introduction: there is strong evidence that primary care interventions, including screening, brief advi<:e, treatment referral and pharmacotherapy are effective in reducing morbidity and mortality caused by substance abuse. yet physicians are poor at intervening with substance users, in part because of lack of time, training and support. this study examines the hypothesis that shared care in addictions will result in decreased substance use and improved health status of patients, as well as increased use of primary care interventions by primary care practitioners (pcps). methods: the addiction medicine service (ams) at st. joseph's health centre's family medicine department is in the process of being transformed from its current structure as a traditional consult service into a shared care model called addiction shared care (asc). the program will have three components: education, office systems and clinical shared care. as opposed to a traditional consult service, the patient will be booked with both a primary care liaison worker (pcl) and addictions physician. patients referred from community physicians, the emergency department and inpatient medical and psychiatric wards will be recruited for the study as well as pcps from the surrounding community. the target sample size is - physicians and a similar number of patients. after initial consult, patient will be recruited into the study with their consent. the shared-case model underlines the interaction and collaboration with the patient's main pcp. asc will provide them with telephone consults, advice, support and re-assessment for their patients, as well as educational sessions and materials such as newsletters and informational kits.results: the impact of this transition on our patient care and on pcp's satisfaction with the asc model is currently being evaluated through a grant provided by the ministry of health & long term care. a retrospective chart review will be conducted using information on the patient's substance use, er/clinic visits, and their health/mood status. pcp satisfaction with the program will be measured through surveys and focus groups. our cost-effectiveness analysis will calculate the overall cost of the program per patient..conclusion: this low-cost service holds promise to serve as an optimal model and strategy to improve outcomes and reduce health care utilization in addict patients. the inner city public health project introduction the inner city public health project (icphp) was desi.gned to explore new an~ innovative ways to reach marginalized inner city populations that par-t c pate m high health-nsk beha~ ors. much of this population struggles with poverty, addictions, mental illness and homelessness, creatmg barriers to accessing health services and receiving follow-up. this pro ect was de~igned to evaluat~ .~e success of offering clinics in the community for testing and followup of communicable diseases uuhzmg an aboriginal outreach worker to build relationships with individuals and agencies. v n(demographics~ history ~f testi~g ~nd immunization and participation in various health-risk behaviors), records of tesnng and mmumzat ons, and mterviews with partner agency and project staff after one year.. results: t~e chr ~as i~strumental in building relationships with individuals and partner agencies ' .° the c~mmun_ ~ re_sultmg m req~ests for on-site outreach clinics from many of the agencies. the increase m parnc pat n, the chr mvolvement in the community, and the positive feedback from the agen? staff de~onstrated that.the project was successfully creating partnerships and becoming increasingly integrated m the community. data collected from clients at the initial visit indicated that the project was reaching its target populations and highlighted the unique health needs of clients, the large unmet need for health services and the barriers that exist to accessing those services. ~usion: the outreach clinics were successful at providing services to target populations of high health-nsk groups and had great support from the community agencies. the role of the chr was critical to the success of the project and proved the value of this category of health care worker in an urban aboriginal population. the unmet health needs of this disadvantaged population support the need for more dedicated resources with an emphasis on reducing access barriers. building a caring community old strathcona's whyte avenue, a district in edmonton, brought concern about increases in the population of panhandlers, street people and homeless persons to the attention of all levels of government. the issue was not only the problems of homelessness and related issues, but feelings of insecurity and disempowerment by the neighbourhood residents and businesses. their concerns were acknowledged, and civic support was offered, but it was up to the community itself to solve the problem. within a year of those meetings, an adult outreach worker program was created. the outreach worker, meets people in their own environments, including river valley camps. she provides wrap-around services rooted in harm reduction and health promotion principles. her relationship-based practice establishes the trust for helping clients with appropriate housing, physical and/or mental health issues, who have little or no income and family support to transition from homelessness. the program is an excellent example of collaboration that has been established with the businesses, community residents, community associations, churches, municiple services, and inner-city agencies such as boyle street community services. statistics are tracked using the canadian outcomes research institute homes database, and feedback from participants, including people who are street involved. this includes an annual general meeting for community and people who are homeless. the program's holistic approach to serving the homeless population has been integral, both in creating community awareness and equipping residents and businesses to effectively interact with people who are homeless. through this community development work, the outreach worker engages old strathcona in meeting the financial and material needs of the marginalized community. the success of this program has been surprising -the fact is that homeless people's lives are being changed; one person at a time and the community has been changed in how they view and treat those without homes. over two years, the program has successfully connected with approximately seventy-five individuals who call old strathcona home, but are homeless. thirty-six individuals are now in homes, while numerous others have been assisted in obtaining a healthier and safer lifestyles by becoming connected with other social/health agencies. the program highlights the roots of homelessness, barriers to change and requirements for success. it has been a thriving program and a model that works by showing how a caring community has rallied together to achieve prosperous outcomes. the spn has created models of tb service delivery to be used m part~ers~ p with phannaceunca compa-. · · -. t' ns cooperatives and health maintenance orgamzanons (hmos). for example, the mes, c v c orgamza , . · b tb d' · spn has established a system with pharmaceutical companies that help patients to uy me cmes at a special discounted rate. this scheme also allows patients to get a free one-_month's worth of~ dru_g supply if they purchase the first months of their regimen. the sy_s~e~s were ~es gned to be cm~pattble with existing policies for recording and documentation of the ph hppme national tuberculosis program (ntp). aside from that, stakeholders were also encouraged to be dots-enabled through the use of m~nual~ and on-line training courses. the spn initiative offers an alternative in easing the burden of tb sc:rv ce delivery from rhe public sector through the harnessing of existing private-sector (dsos). the learnmgs from the spn experience would benefit groups from other locales that _work no~ only on ~ but other health concerns as well. the spn experience showcases how well-coordinated private sector involvements help promote social justice in health delivery in urban communities.p - (c) young people in control; doing it safe. the safe sex comedy juan walter and pepijn v. empelen introduction: high prevalence of chlamydia and gonorrhoea have been reported among migrants youth in amsterdam, originating from the dutch antilles, suriname and sub-sahara africa. in addition, these groups also have high rates of teenage-pregnancy (stuart, ) and abortions (rademakers ), indicating unsafe sexual behaviour of these young people. young people (aged - ) from the so· called urban scene (young trendsetters in r&b/hip hop music and lifestyle) in amsterdam have been approached by the municipal health service (mhs) to collaborate on a safe sex project. their input was to use comedy as vehicle to get the message a cross. for the mhs this collaboration was a valuable opportunity to reach a hard-to-reach group.mdhods: first we conducted a need assessment by means of a online survey to assess basic knowledge and to similtaneously examine issues of interest concerning sex, sexuality, safer sex and the opposite sex. second, a small literature study was conducted about elements and essential conditions for succesful entertainment & education (e&e) (bouman ), with as most important condition to ensure that the message is realistic (buckingham & bragg, ) . third a program plan was developed aiming at enhancing the stl/hiv and sexuality knowledge of the young people and addressing communication and educational skills, by means of drama. subsequently a safe sex comedy show was developed, with as main topics: being in love, sexuality, empowerment, stigma, sti, hivand safer sex. the messages where carried by a mix of video presentation, stand up comedy, spoken word, rap and dance.results: there have been two safe sex comedy shows. the attendance was good; the group was divers' with an age range between and year, with the majority being younger than year. more women than men attended the show. the story lines were considered realistic and most of the audients recognised the situations displayed. eighty percent of the audients found the show entertaining and % found it edm:arional. from this %, one third considers the information as new. almost all respondents pointed our that they would promote this show to their friends.con.clusion: the s.h<_>w reached the hard-to-reach group of young people out of the urban scene and was cons d_ered entert~mmg, educational and realistic. in addition, the program was able in addressing important issues, and impacted on the percieved personal risk of acquiring an sti when not using condoms, as well as on basic knowledge about stl's. introduction: modernity has contributed mightily to the marginality of adults who live with mental illnesses and the subsequent denial of opportunities to them. limited access to social, vocational, educational, and residential opportunities exacerbates their disenfranchisement, strengthening the stigma that has been associated with mental illness in western society, and resulting in the denial of their basic human rights and their exclusion from active participation in civil society. the clubhouse approach tn recovery has led to the reduction of both marginality and stigma in every locale in which it has been implemented judiciously. its elucidation via the prism of social justice principles will lead to a deeper appreciation of its efficacy and relevance to an array of settings. methods: a review of the literature on social justice and mental health was conducted to determine core principles and relationships between the concepts. in particular, fondacaro and weinberg's ( ) conceptualization of social justice in community psychology suggests the desirability of the clubhouse approach in community mental health practice. a review of clubhouse philosophy and practice has led to the inescapable conclusion that there is a strong connection between clubhouse philosophy-which represents a unique approach co recovery--and social justice principles. placing this highly effective model of community mental health practice within the context of these principles is long overdue. via textual analysis, we will glean the principles of social justice inherent in the rich trove of clubhouse literature, particularly the international standards of clubhouse development.results: fondacarao and weinberg highlight three primary social justice themes within their community psychology framework: prevention and health promotion; empowerment, and a critical pnsp<"<·tive. utilizing the prescriptive principles that inform every detail of clubhouse development and th<" movement toward recovery for individuals at a fully-realized clubhouse, this presentation asserts that both clubhouse philosophy and practice embody these social justice themes, promote human rights, and empower clubhouse members, individuals who live with mental illnesses, to achieve a level of wdl-heing and productivity previously unimagined.conclusion: a social justice framework is critical to and enhances an understanding of the clubhouse model. this model creates inclusive communities that lead to opportunities for full partic pil!ion civil society of a previously marginalized group. the implication is that clubhouses that an· based on the international standards for clubhouse programs offer an effective intervention strategy to guarantee the human rights of a sizable, worthy, and earnest group of citizens. to a drastic increase in school enrollment from . million in to . million in .s. however, while gross enrollment rates increased to °/., in the whole country after the introduction of fpe, it remained conspicuously low at % in the capital city, nairobi. nairobi city's enrollment rate is lower .than thatof all regions in the country except the nomadic north-eastern province. !h.e.d sadvantage of children bas_ed in the capital city was also noted in uganda after the introduction of fpe m the late s_-many_ education experts in kenya attribute the city's poor performance to the high propornon of children hvmg m slums, which are grossly underserved as far as social services are concerned. this paper ~xammes the impact of fpe and explores reasons for poor enrollment in informal settlements m na rob city. methods: the study utilizes quantitative and qualitative schooling data from the longitudinal health and demographic study being implemented by the african population and health research center in two informal settlements in nairobi. descriptive statistics are used to depict trends in enrollment rates for children aged - years in slum settlements for the period - . results: the results show that school enrollment has surprisingly steadily declined for children aged - while it increased marginally for those aged - . the number of new enrollments (among those aged years) did not change much between and while it declined consistently among those aged - since . these results show that the underlying reasons for poor school attendance in poverty-stricken populations go far beyond the lack of school fees. indeed, the results show that lack of finances (for uniform, transportation, and scholastic materials) has continued to be a key barrier to schooling for many children in slums. furthermore, slum children have not benefited from fpe because they mostly attend informal schools since they do not have access to government schools where the policy is being implemented.conclusion: the results show the need for equity considerations in the design and implementation of the fpe program in kenya. without paying particular attention to the schooling needs of the urban poor children, the millennium development goal aimed at achieving universal primary education will remain but a pipe dream for the rapidly increasing number of children living in poor urban neighborhoods.ps- (c) programing for hiv/aids in the urban workplace: issues and insights joseph kamoga hiv/aids has had a major effect on the workforce. according to !lo million persons who are engaged in some form of production are affectefd by hiv/aids. the working class mises out on programs that take place in communities, yet in a number of jobs, there are high risks to hiv infection. working persons sopend much of their active life time in workplaces and that is where they start getting involved in risky behaviour putting entire families at risk. and when they are infected with hiv, working people face high levels of seclusion, stigmatisation and some miss out on benefits especially in countries where there are no strong workplace programs. adressing hiv/aids in the workplace is key for sucessfull responses. this paper presents a case for workplace programing; the needs, issues and recommendations especially for urban places in developing countries where the private sector workers face major challenges. key: cord- -eahx cy authors: fleischack, anne; macleod, catriona; böhmke, werner title: the conundrums of counselling women in violent intimate partner relationships in south africa: implications for practice date: - - journal: int j adv couns doi: . /s - - - sha: doc_id: cord_uid: eahx cy little research focuses on how counsellors experience counselling encounters concerning intimate partner violence. this study reports on narrative research conducted with eight south african non-governmental organisation counsellors. participants spoke of creating productive and caring counselling dynamics, and providing non-directive counselling. however, they also indicated providing moral guidance, particularly in cases where pregnancy or children were involved. success was viewed rather narrowly as the women leaving the relationship, setting up ‘all-or-nothing’ outcomes. such ‘success’ led to counsellor happiness, whilst failure in this regard led to counsellors experiencing anger and burn-out. we conclude that the conundrums evident in these data are grounded in patriarchal systems, limiting the efficacy of counselling based on a bondage and deliverance narrative. implications for practice and training are also outlined. local and international research has shown that counselling for women who have experienced relationships characterised by intimate partner violence (ipv) can have many positive effects. these include women gaining confidence to leave a violent/abusive relationship (hatcher et al. ; jewkes et al. ; rhodes and mckenzie ) , considering options for solving problems within the relationship, and increasing their emotional wellbeing (iverson et al. ; rhodes and mckenzie ) . counselling, however, may also be challenging. for example, research into a latino community in the usa revealed that counsellors sometimes did bnot consider some potentially important personal barriers to reporting^, such as the victim's shame (lewis et al. , p. ) . various models of conducting counselling in relation to ipv have been suggested in the literature. these include: viewing ipv relationships as developing in stages, and modelling therapy based on this perspective; a client-centred approach in which the counsellor facilitates the client in choosing solutions and actions that are compatible and appropriate for themselves (the client) (mchattie ); and a competency framework that focuses on counselling skills, specialist knowledge and specific personal characteristics needed for working with this client group (roddy and gabriel ) . research on the experiences of receiving counselling for ipv has been used to refine recommendations for the counselling encounter (roddy ) . little research has been conducted, however, on how counsellors themselves experience and describe their own positioning within the counselling encounter. given the high level of gender-based violence in many countries (including south africa, the site of this study), and that counsellors tend to be women, how the counsellors experience the counselling encounter in regard to ipv is an important aspect of understanding such counselling. in this paper, we report on a study in which we interviewed counsellors, using narrative interviews, about their understandings of relationships characterised by ipv and how they, as counsellors, worked with ipv in their practice. all of the counsellors interviewed were women. we report, in this paper, on these counsellors' experiences of providing counselling within the context of the study. south africa has one of the highest prevalence rates of ipv in the world (britton ; joyner and mash ; modiba et al. , p. ; ntaganira et al. ) . ipv cuts across all ethnic groups regardless of education or income level, or the victim's or perpetrator's line of employment (modiba et al. ) . south african research reveals that % of women have experienced a lifetime prevalence of domestic victimisation (seedat et al. ) and . % of south african men reported abusing their current or most recent partner (gupta et al. ) . there are many barriers that women face in south africa when reporting ipv, related to resource constraints and social issues. the resource-related barriers include the relative lack of availability of healthcare or service provision facilities in the first place (mbokota and moodley ; modiba et al. ; njuho and davids ) . other reasons include lack of adequate assistance due to problematic interactions with counsellors (rasool bassadien and hochfeld ) . that is, counsellors may sometimes view ipv as a private matter, or that it is a normal phenomenon, possibly leading to lack of action or non-interference (rasool bassadien and hochfeld ); they may misdiagnose ipv (joyner and mash ) , be afraid to intervene on behalf of the community (lewis et al. ) , and may not have received adequate or appropriate primary care training (noted locally, mash et al. , and globally, watts and mayhew ) . in terms of social issues, some women may not report abuse due to conservative gender roles; e.g., the belief that the man is the head of the household and that his authority, and manner in which he runs the household, should not be questioned (sugarman & frankel , cited in jewkes et al. . as a result of the relatively widespread acceptance of such conservative and traditional gender roles within south african society, ipv has, in many respects, become normalised within relationships. women may either accept such violence as an everyday feature of their intimate relationships, or may see themselves as deserving of violent treatment from their partners for failing to adhere to culturally-located gendered expectations regarding their relationship roles (kim and motsei ; wood et al. ) . as a result, many women who experience ipv may feel that their violent partners were justified in their actions or that they did not harm them intentionally (silverman et al. ) . women may also feel reluctant or ashamed about reporting ipv (lewis et al. ) due to the personal, and sometimes sexual nature of the assault (vogelman and eagle ) . cultural and contextually mediated understandings of violence in intimate relationships, as well as subjective interpretations of the relative harm sustained, may also play a role. for example, anthropological research in south africa has described violence in interpersonal relationships as being understood by those involved as a demonstration of love, depth of feeling, or emotional investment in the relationship, with women victims of ipv consequently downplaying the harm caused (wood et al. ) . as noted earlier, ipv is also often not recognized by primary care providers and when it has been identified, the treatment has often been badly coordinated, fragmented, missed important aspects and/or lacked continuity (joyner and mash ) . this may be due to the lack of appropriate or adequate training that healthcare workers receive, both globally (watts and mayhew ) and locally . the south african non-governmental organisation (ngo) sector has played a role in addressing ipv. there are a number of safe houses available for abused women within south africa (kaldine ) often linked to ngos. the south african ngo sector also has many organisations linked to women's movements, examples of which include family welfare society and living hope. these ngos offer various services including counselling for domestic violence, women's upliftment, empowerment programmes, interventions, legal support and shelter services. in essence, these organisations specifically aim to bengage masculinities within 'feminist' frameworks^due to bthe growing institutionalisation and ngo-isation of the south african women's movement^ (britton , p. ) . due to the various problems surrounding access to counselling for ipv as noted above, effective help from counsellors and healthcare professionals is vital when ipv is reported. indeed, b[a]chievement of an efficient healthcare system which enhances respect for women and children is likely to contribute to a reduction of violence in communities and [will] subsequently boost the quality of life in south africa^ (njuho and davids , p. ) . research shows that women who have utilised the services of counselling centres are able to consider options for solving problems within the relationship, increase their emotional wellbeing (iverson et al. ; rhodes and mckenzie ) and also develop an enhanced ability to physically remove themselves from the abuse (hatcher et al. ; jewkes et al. ) . a variety of models for conducting effective counselling for those experiencing ipv have been developed. for example, the care guidelines by miller et al. ( ) outline addressing decision-making, which clinical services should be considered, and timelines for when intervention and assessment should occur. feminist principles proposed by mwau ( ) include helping women to explore options, acknowledging their strengths, assisting them with coping with shame or guilt, educating them about ipv dynamics and validating women's feelings. research conducted on clients' experiences of counselling has been used to enhance counselling dynamics. for example, women have emphasised the need to share their stories with counsellors within a safe and trustworthy environment (mchattie ; roddy ) where there was sufficient time to explore issues (roddy ) . other important factors are clients having their agency supported, being able to complete certain tasks, learning skills, having access to information, the importance of empowerment (mchattie ), and counsellors recognising diversity (e.g., same-sex partnerships) and nuances within relationships (oswald et al. ) . overcoming shame in relation to ipv within a non-judgemental environment was also linked to feelings of acceptance and validation (roddy (roddy , . however, very little research has been conducted on the experiences of counsellors who work with ipv, with research of this kind being useful for enhancing the quality of counselling. exceptions include zust et al.'s ( ) study with evangelical pastors, who indicated that they were ill-prepared to deal with domestic violence, and that counselling focused mainly on keeping the children safe and helping victims/survivors to understand that the violence was not their fault. iliffe and steed ( ) found that counsellors in their study who were involved in ipv issues experienced vicarious trauma, reported changes in their views of safety and gender power issues, as well as feelings of isolation and powerlessness as a result of the involvement. this study used a narrative-oriented inquiry (hiles and Čermák ) , based on the 'lightly-structured biographic-narrative interview structure' by wengraf ( ) see further details belowto investigate the micro-narratives elicited from counsellors when they spoke about their understandings of ipv and their practice in relation to it. narratives are bstories with words and meanings^that are linked to certain social groups and communities and provide information about the experiences and ways of life of these groups and communities (jovchelovitch and bauer , p. ) . micro-narratives can be defined as bshort bursts of narrative interactionally embedded in question-answer sequences: several stories produced often in intricate relations to one another^ (blommaert , p. ) . they often take the form of smaller, personal stories (fok ) and are bprovisional, contingent, temporary, and relative^ (barry , cited in o'donovan . although each person's narrative is idiosyncratic to their life experiences (hiles and Čermák ) , narratives also benable human experiences to be seen as socially positioned and culturally grounded^ (hiles and Čermák , p. ; young and collin ) . thus it is suggested that people construct narratives by drawing upon culturally-available social and discursive resources. data were collected by means of interviewing counsellors, using wengraf's ( ) method, who were based at two ngos, one located in an urban and the other in a peri-urban area in the eastern cape, south africa. these areas were chosen to ensure some diversity in the micronarratives. the clients who approach these ngos are from a lower socio-economic bracket. the agencies offer a variety of services including individual, couple and family counselling, women's empowerment initiatives and working in conjunction with the magistrates' court and the police to process safe house referrals and protection orders, as well as handling divorce and maintenance orders. the counsellors also intermittently enter the local communities to share knowledge and information on human rights. across the two sites, eight counsellors were interviewed for this research; owing to the relative size of the organisations, two were recruited at the peri-urban site and six at the urban site. the participants all had experience counselling people who had experienced ipv. seven of the counsellors were lay counsellors who had received in-house training and the other had a degree in social work. some of the counsellors themselves had been abused by their partners and thus could be seen as 'wounded healers'. counselling by 'wounded healers' may be beneficial as the counsellors are able to identify with the clients' traumatic experiences, and, through self-disclosure, can de-stigmatise the clients' experiences. on the negative side, however, counsellors may become too emotionally involved in their clients' situations, be unable to manage the countertransference set up in the encounter, and suffer from compassion fatigue (zerubavel and wright ) . at both sites, a client-centered, solution-based approach to counselling is adopted. after listening to the clients' stories, the counsellors, in a private, one-on-one setting, probe for more information, offer clients a variety of options for action, provide emotional support for the particular path chosen by the client, and offer to link the clients directly to places where they can get help. the study was granted ethical clearance by the rhodes university psychology department's research projects and ethics review committee. counsellors all provided their consent for the interviews to be conducted, including the fact that the interviews would be digitally recorded. the participants were assured that they would not be asked to divulge sensitive personal issues (e.g. their own histories in relation to ipv), as our research was focused on their experiences of their counselling. locations and names mentioned in the interviews were kept non-specific and the participants were asked to choose pseudonyms so as to ensure that the information could not be linked back to them. all of the participants were women; seven were black and spoke isixhosa as a home language; one was white with english as a home language. all were fluent in english. the first author and a co-researcher together conducted three separate interviews with each of the eight participants, using wengraf's ( ) method. this interview method allows the content of the narratives to guide further questions that the interviewers might ask. during the interviews, the co-researcher took notes, specifically focusing on topics that emerged during the elicitation of counsellors' micro-narratives. in the first interview, the counsellors were asked, using an open-ended narrative-inducing question, to share their understandings of ipv, and their experiences with conducting counselling sessions with clients who were in relationships characterised by ipv. in the second interview, held min after the first one, the researcher asked questions based on topics that had emerged during the first interview. the third and final session was conducted two months later, once the data had been transcribed and after a preliminary analysis had been conducted on the data, so as to determine which topics would be suitable for follow-up questions in the final interview. the data were transcribed verbatim using parker's ( ) transcription conventions (see appendix). these conventions were selected as they provide details of the talk (pauses, interruptions, etc.) without being too technical. the data were analysed using aspects of taylor and littleton's ( ) narrative-discursive method in order to examine the micro-narratives that emerged during the interviews with the counsellors. taylor and littleton's ( ) approach focuses, inter alia, on how micro-narratives enable subject positioning (the depiction of people within particular roles and responsibilities) to take place. the interview recordings were listened to several times and the transcription read at the same time. the transcribed data were imported and coded using qsr nvivo , a qualitative data analysis software program. coding centred on the identification of micro-narratives. in the analysis, we examined common micro-narratives occurring across the interviews and at different times in the same interview, which allowed us to see patterns in the counsellors' micro-narratives. all three authors engaged with the analytical process, and the findings were presented to peers in order to refine the analysis. the following micro-narratives were identified across the interviewees' data: 'we develop good counselling dynamics', 'we use non-directive counselling', 'when things go well, we feel positive', 'counselling ipv victims is emotional labour' and 'we provide moral guidance and suggestions'. with regard to each of these, the subject positions enabled by the micronarratives, and the implications for counselling are discussed below. the counsellors shared that they utilised a variety of session management tools (praise for clients; listening deeply; building trust) in order to create a positive environment and appropriate counsellor-client session relationships/dynamics. in this way they positioned themselves as professional, and as following well-established counselling techniques. some of the counsellors indicated that they praised their clients for coming to see them. this, they explained, formed a positive relationship between the client and counsellor, as can be seen in the following extracts: extract : duvi (p ): ...so the woman straight away she's going to be straight and say that 'enough is enough /hmm/ ja 'when i am looking at myself … i see that i'm going nowhere' /hmm/ hmm …i even congratulate her /mmm/ saying that 'no-one forced you to come here' /mmm::/ meaning that you are ready to take any step. extract : lwando (p ): ...as for us at [name of ngo] (.) once a woman take[s] a step forward =/mmm/ (.) to look at herself =/mmm/ (.) we see that as a survivor person =/mmm/= because once you find that … you need i-advice =/yes/= you need i-solution /mmm/ you need to find out what will work for you /mmm/ so once you take a step (.) we take you … as a great survivor. in the above extracts, duvi spoke of attempting to build a positive relationship with her client by bcongratulat[ing]^her for coming to see her, and lwando by bsee[ing] that [person] as a survivor^. these affirmations are seen as important to the process of taking bsteps^in the right direction; i.e., the women moving towards solving the problem. across the dataset, interventions were viewed by the counsellors as something that should help the women leave their ipv situation. these extracts reveal how a story of bondage and then of deliverance (see haaken ) , or at least the possibility of deliverance (byou are ready to take any step^; bwe take you as a great survivor^), provided a positive framing that counsellors encouraged in the session. the client's movement from victim to survivor through extracting herself from the relationship was viewed by the participants as an essential element of successful counselling. counsellors acknowledged that the movement from victim to survivor requires counselling labour. some of the counsellors mentioned providing a space to listen empathetically and attentively to their clients as an important counselling management tool, seen in the extracts below. intervention. this is because trust and confidentiality are important aspects of effective intervention as they provide the safe space in which the client can share her stories. the counsellors mentioned that they educate their clients about their rights and available intervention options. within this micro-narrative, the participants saw the counsellor's job as being non-directive, simply assisting the client to make the best decision for her amongst the options presented, as exemplified in the extract below. however, this micro-narrative stands in contrast to the counsellors' stated orientation of working towards the client leaving the ipv relationship. certain examples of subject positioning, however, show the slippage from nondirective to directive counselling. shelly (p ): i always tell them (.) it's very good to talk =/mmm/= not to keep inside you mmm/= talk about it so that …when you are talking …you're also getting the answers …because the answer is not coming from people … that you are sharing with (.) it's also coming with from you =/mmm./… you started to do this by yourself =/mmm/= you have to be strong for that. in extract , despite indicating that she does not say bdo these things^, amandisa takes up the subject position of beducator^in relation to her clients, narrating how she informs them of their rights and the options open to them. in this way, she suggests that women are victims of ignorance: they are less knowledgeable than the counsellor or are un(der)educated and in need of information in order to best decide how to manage their ipv situation. as the counsellors are speaking from an institutional space of helping women with ipv situations, they are considered qualified to speak about interventions because of their skills, expertise and knowledge in the field. furthermore, being in an institutional 'space of helping' may reinforce counsellors' narrative of bondage/deliverance of which they see themselves as facilitators. they thus act as facilitators of deliverance by representing apparently neutral options to their clients. this might in turn obscure the contradiction between their stated neutrality and their practice of providing options that follow a restrictive narrative of successful counselling outcomes. nevertheless, these options are presented, according to shelly, in a neutral way, with the client having to make her own decisions, as seen in extract . in this extract, shelly outlines that an element of counselling is women providing their own answers through talking with the counsellor. shelly constructs her clients as having their own agency and responsibility for their futures. interestingly, amandisa initially indicates that she gives badvice^. this is quickly corrected to giving boptions^because telling clients what to do is viewed as problematic. work undertaken to promote the perception of neutrality seems to be a defining feature of the first micro-narrative of 'good practice'. we will take up the slippage between non-directive and directive counselling in a later analytical section. counsellors spoke of positive experiences when reflecting on successful outcomes. examples of these positive reflections can be seen in the following extracts: extract : lwando (p ): women … they (.) becoming brave to report these cases that makes me very happy =/mmm/= and even if the case has been taken to court and then the perpetrator is being sentenced =/yes/= that makes me very happy. shelly's extract above expresses emotional satisfaction (bfeel[ing] good^) at essentially helping clients (to leave relationships characterised by ipv). similarly, lwando expresses happiness at women being 'brave' and reporting cases as well as the outcome of a perpetrator being sentenced in court. importantly, lwando's extract emphasises the view that successful interventions, as mentioned earlier, are those where the women leave relationships characterised by ipv. clients are seen to change from the subject position of victim to survivor in the extracts as the women in these cases have been bbrave^: they have become survivors by taking the cases to court and having the perpetrator sentenced (extract ). it is in these circumstances that the counsellors experience positive emotions and feel that they are successful in their work of helping their clients. a clear micro-narrative that emerged in the interviews concerned the emotional labour that goes into providing counselling for ipv clients. counsellors spoke about the sessions evoking strong emotions in them, the difficulty at times to remain objective as a result and thus the need to look after themselves. this can be seen in the extracts below: extract : shelly (p ): i got angry when … (.) a woman is staying … in an abusive relationship /mmm/ i got angry very angry =/okay/ … because … i stayed (.) but i don't want someone to stay there because i know (.) how it's pain … yho i know that in extract , shelly's struggle to remain objective can be seen in her revealing that she felt angry when her clients chose not to leave relationships characterised by ipv. in constructing this micro-narrative, shelly positioned herself as caring, as she is concerned for her clients and interested in their well-being. this can be seen in her remark that she understood and identified with the bpain^that the woman in this case was going through. the anger shelly felt at her client's inability to see the necessity of leaving the relationship links to work on wounded storytellers; frank ( , p. xv) suggests that anger or bchaos [is] in the claustrophobia of confronting others' inability to see what [one] so clearly feel[s]^. shelly, as the wounded healer, managed, eventually, to accomplish the situation most desired by the counsellorsthat women leave abusive relationships. as such, she feels compelled to assist the client along the same path, and thus experiences the countertransference of anger when this does not occur. while confessing to anger, shelly also positioned herself as knowledgeable (through the experience of not leaving at first). in this way, the woman client is positioned as a victim with little agency. as a result of their work being emotionally taxing, the counsellors spoke about trying to look after themselves and one another in order to continually carry out their work effectively, as can be seen in the following extracts: extract : nomsa (p ): we still have the [weekly] supervision … so each week we bring … all those worrying cases /mmm/ and also we … get … advices from the:: other … colleagues /okay/ …we … present your [our] case [p claps] and all other … colleagues will intervene in your case /that's great/= [we] discuss discuss discuss (.). extract : amanda (p ): i have in the past (.) organised … (.) consultations with:: … a private person or someone =/mmm::/= … to deal with that =/yes/= … to make sure that it doesn't overwhelm [me] . nomsa indicates that she and her colleagues were interested in supporting one another and were concerned about one another's wellbeing in light of the emotionally taxing work that they do. they discuss ball those worrying cases^, providing input and advice. nomsa alluded to the idea that the helper needs help to navigate the bworry^, and suggested that the counsellors take on the burden of their clients' ipv experiences by feeling empathy for the clients. amanda expressed concern over the real possibility of the work overwhelming her emotionally, and pointed, therefore, to the need to consult a person outside of the ngo for professional supervision. as was noted earlier, the counsellors indicated that they provide non-directive counselling, in particular presenting their clients with options for resolving the problems they are facing. however, the counsellors also spoke at times about encouraging their clients to engage in certain practices/behaviours through providing moral guidance or suggestions. this occurred mostly when discussing matters involving pregnancy or children. these moral suggestions included encouraging women to look after themselves during pregnancy and to consider the children: not to leave them behind if the woman was thinking of leaving a relationship characterised by ipv. this stance is opposed to letting the woman freely choose their options without such suggestions. in relation to this, it is important to note that the moral suggestions and guidance offered by the counsellors were largely influenced by culturallylocated and socially-sanctioned constructions of gendered roles and subjectivities, especially those around the concept of motherhood. these ideas can be noted in the extracts below: extract : mrs. x (p ): i always remind them that it's only temporary that your tummy is big. you're going to have your baby in your arms no more in your:: tummy after nine months so for the nine months that the baby is depending on you for survival you need to take better care of yourself . mrs. x (participant's chosen pseudonym) is attempting to reassure her client that the pregnancy is temporary and that her client must btake better care of [her]self^. in this way, mrs. x was positioning the woman as a nurturer with a responsibility towards her children. while not problematic in and of itself, this positioning leads to the moral injunction of self-care. in providing this moral injunction, mrs. x was subtly implying that failure to attend to this self-care could result in damage to the children. preventing damage to the children thus becomes the sole responsibility of the woman; failure to engage in self-care results in the woman being positioned as wilfully refusing to prevent damage. shelly stated that if a woman was thinking of leaving a relationship characterised by ipv, she bmust think about [her] children^. as with mrs. x, shelly was placing herself in a superior subject position as she seemed to feel that she had the status, knowledge and expertise in order to provide this moral guidance. the micro-narratives the counsellors related of their experiences of counselling women in ipv relationships, and the associated subject positions, point to a number of conundrums or double binds. the counsellors positioned themselves as professionals who implement good counselling practices (praise, listening, confidentiality, trust); at the same time, they could not help but feel angry, burnt-out and overwhelmed. when counselling was successful, the counsellors felt positive, but there were often failures, which they reported led to anger. this anger could be viewed as the countertransference of wounded healers, who, having suffered similar abuses, simultaneously empathise with the client, feel righteous anger towards the perpetrator, and dismay at the lack of 'success' (zerubavel and wright ) . throughout the data, 'success' was described by the counsellors as the woman removing herself from the ipv relationship. as such, the classic narrative of women being delivered from bondage formed the foundation of counselling. within this narrative, women who remain are regarded as victims and women who leave are considered survivors. this creates a dichotomy or an 'all-or-nothing' position within the counselling dynamic. the counsellor's emotional investment in the client and relationship building (such as ensuring confidentiality and thus building trust, listening attentively, displaying empathy where possible, promoting strength) was seen as worthwhile when the woman leaves the relationship (see also lewis et al. ) . however, the counsellors indicated becoming discouraged when the woman remained within the relationship. counsellors indicated that they used non-directive counselling, informing women of their rights and options and assisting them in making decisions. in this, however, the counsellors positioned themselves as experts on the options open to women, and regarded the women as experts on their own lives. however, there were limits displayed to simply allowing women to make their own decisions. when it came to matters to do with pregnancy or children, the counsellors felt it imperative to provide moral guidance on the correct form of action; i.e., that women must engage in self-care and take their children with them if they were to leave the relationship characterised by ipv. the fact that these counsellors invested in a narrative of female survivorhood, that implied leaving violent intimate relationships, is perhaps not surprising, given the high rates of abuse in the country and that all counsellors interviewed were women. counsellors who have experienced abuse themselves (some voluntarily revealed this in the interviews, as can be seen in one or two extracts here) may create an emotional weight or responsibility if their female clients choose not to leave the relationship. we argue that the conundrums evident in the counsellors' talk stem from the fact that they counsel the women within already entrenched patriarchal and structural power relations. there is no guarantee that the women will be able to successfully leave their current relationship characterised by ipv, or avoid another one in the future, and the counsellors were painfully aware of this. they nevertheless held onto the narrative of bbondage to deliverance^or bvictimhood to survivorhood^as the only valid outcome of counselling. this singular narrative regarding what constitutes a 'successful' outcome of counselling women who have had experiences of ipv during pregnancy, does not take into account the sometimes very real structural and/or cultural obstacles that frequently prevent women from leaving relationships characterised by ipv (e.g., economic dependency on their partners for survival, or culturally-located customs and traditional practices regarding marriage bonds) (see fleischack et al. ). this 'narrow' view of counselling outcomes may, therefore, be more likely to fail than not. indeed counsellors' insistence on clients' adherence to patriarchal and culturally-entrenched forms of motherhood may unwittingly constitute a barrier to successfully leaving an ipv relationship, thereby undermining their own criterion for a successful outcome (that is, leaving the ipv relationship). the counsellors indicated that they felt overwhelmed, fatigued and disappointed if their clients did not leave the ipv relationship. this emotional cost suggests that the counsellors as well as the clients were victims, working against a patriarchal system. in this tough and challenging environment, the counsellors often turned to one another for help, support and guidance. our research illustrates the importance of studying not only clients' but also counsellors' experiences so as to improve counselling concerning ipv. the conundrums illustrated above point to a number of implications in terms of the counselling process. firstly, to obviate counsellors feeling that their emotional investment has not been worthwhile, a useful perspective would be to see clients as complex beings: somewhere between victim and survivor, slipping between the two depending on circumstances, or as neither. this may also allow the counsellors to see and value small gains in their counselling process. examples include: when the women come to counselling in the first place, because they feel hopeful that they can receive some assistance; valuing women having a comfortable space to share their stories to gain some insight (which also links to moon's idea that story telling is a means to healing); and the notion of women engaging in everyday practices that serve to increase their agency and reduce the ipv, even if it involves remaining in the relationship. thus, secondly, the narrative of bondage and delivery (i.e., being in an ipv relationship followed by leaving) needs to be nuanced to allow for other narratives of success, including changing dynamics within the household or simple mechanisms to reduce the possibility of abuse. this is particularly important in circumstances where, as mentioned earlier, some women feel unable, for a range of reasons (e.g., financial, childcare), to leave the relationship. research into ipv risk factors and reduction interventions have highlighted key risks and aspects that, if addressed, might lower the likelihood of ipv occurring. these include addressing, for example, poor relationship communication and conflict management skills (abrahams et al. ; hatcher et al. ) , as well as economic and social empowerment initiatives (jewkes et al. ; kim et al. ; pronyk et al. ) . these all aim to alter and/ or develop troubling dynamics within relationships to reduce ipv, rather than arguing that women should simply leave situations of ipv. thirdly, recognising that counsellors and clients are both steeped in patriarchal power relations that, in the first place, foster ipv and, in the second place, make resolving the situation very difficult is important. the kind of support received from colleagues that was spoken about by participants is essential. peer support as well as sensitive clinical supervision go a long way in developing growth and self-care in counsellors, as identified by friesema ( ) . equally, though, counselling needs to be supplemented with a focus on accountability or collective responsibility for ipv in communities. this, thus, suggests the need for widerscale interventions and advocacy. running these kinds of interventions alongside counselling may assist counsellors in feeling less burnt-out and despondent about what is and is not achievable in this context. finally, the conundrums evidenced in the 'wounded healer' position need to be taken up in training and clinical supervision. as noted above and in the literature (zerubavel and wright ) , 'wounded healers' have the potential to empathise with clients and to de-stigmatise being the victim of abuse. on the flip side, uncontained emotions such as anger may surface and may interfere with the sessions. this is particularly pertinent when, as in this case, the 'success' of the counselling is narrowly defined. training and supervision, thus, could concentrate on: ( ) allowing the counsellors to reflect on and work through countertransference emotions, and ( ) ensuring that the client's options and choices are taken seriously and supported without the implication that counsellor-led outcomes are better. ian parker's ( ) transcription conventions (adapted) round brackets ( ) indicates doubts arising about the accuracy of material ellipses … to show when material is omitted from the transcript square brackets [ ] to clarify something for the reader forward slashes / / indicates noises, words of assents and others equals sign = indicates the absence of a gap between one speaker and another at the end of one utterance and the beginning of the next utterance round brackets with number inserted, e.g. ( ) indicates pauses in speech with the number of seconds in round brackets round brackets with full stop (.) indicates pauses in speech that last less than a second colon :: indicates an extended sound in the speech underlining ______ indicates emphasis in speech single inverted commas b indicates words or phrases which have been quoted; either the counsellor quoting themselves or quoting their clients, in this research intimate partner violence: prevalence and risk factors for men in cape town applied ethnopoetics. narrative enquiry organising against gender violence in south africa bthe man can use that power^, bshe got courage^and binimba^: discursive 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africa qualitative research interviewing bshowing roughness in a beautiful way^: talk about love, coercion, and rape in south african youth sexual culture binjuries are beyond love^: physical violence in young south africans' sexual relationships introduction: constructivism and social constructionism in the career field the dilemma of the wounded healer evangelical christian pastors' lived experience of counseling victims/survivors of domestic violence publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest the authors declare that they have no conflict of interest. key: cord- -mfe oajn authors: suehiro, tamy taianne; damke, gabrielle marconi zago ferreira; damke, edilson; de azevedo ramos, paloma luana rodrigues; de andrade pereira silva, marcela; pelloso, sandra marisa; huh, warner k.; franco, ricardo argemiro fonseca; da silva, vânia ramos sela; scarinci, isabel cristina; consolaro, marcia edilaine lopes title: cervical and oral human papillomavirus infection in women living with human immunodeficiency virus (hiv) and matched hiv-negative controls in brazil date: - - journal: infect agent cancer doi: . /s - - -y sha: doc_id: cord_uid: mfe oajn background: despite the demonstrated role of human papillomavirus (hpv) in the etiology of cervical cancer and the strong evidence suggesting the importance of hpv in the development of oropharyngeal cancer, several aspects of the interrelationship between hpv infection in both body sites remain unknown, specifically in female human immunodeficiency virus (hiv)-positive (hiv+) patients. we aimed to assess the prevalence, distribution, and concordance of cervical and oral hpv in hiv+ women and matched hiv-negative (hiv-) controls in brazil. material and methods: cervical and endocervical samples for cytological screening and hpv detection and oral samples were collected from hiv+ women using highly active antiretroviral therapy (haart) and hiv-matched controls (hiv-) in maringá city, brazil. risk factors were assessed using a standardized questionnaire, and the data regarding hiv infection were obtained from the patients’ medical records. hpv detection and typing were performed using the kit multiplex xgen multi hpv chip hs . results: hiv infection was well controlled in this cohort, but women who exhibited detectable hiv loads were significantly associated with hpv-positive status overall (p = . ) and in cervical mucosa (p = . ). hiv+ women had significantly more abnormal cytological findings (p = . ) than hiv- women. of the hiv+ women, . % were positive for cervical and/or oral hpv dna; of the hiv- women, % were positive for cervical and/or oral hpv (p = . ). both hiv+ and hiv- women had a statistically higher prevalence of cervical hpv infection than oral infection. the concurrent hpv infection in two anatomical sites was similar in hiv+ and hiv- women; however, hpv type concordance was not observed. hpv type distribution was different between the anatomical sites in both groups, and hiv+ women presented less common types, mainly in oral mucosa. conclusion: our data support the importance of testing hpv infection in hiv+ women, even when the hiv infection is well controlled. prospective studies are required to better understand the natural history of hpv infection in both anatomical sites, specifically in hiv+ women. the association between persistent high-risk human papillomavirus (hrhpv), squamous cervical cancer (cc), and some vaginal and anal cancers has been well-established [ ] [ ] [ ] . additionally, recent data demonstrated that hpv is also associated with a subset of head and neck cancers (hncs), including a worldwide range~ - % of oropharyngeal cancers (opcs) [ , ] . individuals living with human immunodeficiency virus (hiv+) are more susceptible to infection, less likely to clear the virus and have a higher risk of hpv-related cancers than hiv-negative (hiv-) individuals [ , ] . although the incidence of overall cancer has decreased in hiv+ individuals with the advent of highly active antiretroviral therapy (haart), hpvrelated cc risk is higher among hiv+ individuals [ , ] . moreover, in hiv+ women, cc tends to respond poorly to recommended therapies, becomes more aggressive, and may have a worse prognosis [ ] . with the increase in survival of hiv+ women due to haart, progression of oncogenic viral infection into malignancy may result in an increased incidence of hpv-associated oropharyngeal, genital, and anal cancers [ ] [ ] [ ] . currently, the hiv/acquired immunodeficiency syndrome (aids) pandemic impacts the poorest and the youngest in low-resource settings [ ] . hiv+ young women are key populations at high risk for developing hpv-related cancers, particularly in low-and middle-income countries such as brazil [ , ] . with the recent approval of the valent hpv vaccine, the risks of persistent hpv infection and hpv-related cervical precancerous lesions and malignancies are expected to decrease significantly [ ] . with the appropriate vaccination rate thresholds, this vaccine provides a logical rationale for increasing screening intervals considering the anticipated decrease in the burden of disease [ ] . therefore, understanding the specific prevalence, distribution and concordance of cervical and oral hpv in at-risk women in specific geographic locations will provide further insight into the effectiveness of this new vaccine against oral hpv infection, which has not been proven yet. considering the high burden of hpv-related cancers among hiv+ women and the possible effectiveness of a -valent hpv vaccine [ ] , it is critical to understand the prevalence and types of hpv infections in oral and cervical mucosa in hiv+ women (and matched controls). however, while several studies on hiv+ women have reported cervical, oral, or anal hpv type distribution [ ] [ ] [ ] [ ] [ ] [ ] [ ] , only a few studies have addressed concurrent cervical and oral hpv prevalence [ ] [ ] [ ] . despite the demonstrated role of hpv in the etiology of cc and the strong evidence suggesting the importance of hpv in the development of opc [ ] [ ] [ ] [ ] , several aspects of the interrelationship between oral and cervical infections remain unknown, specifically in hiv+ female patients. the present study aimed to assess the prevalence, distribution, and concordance of cervical and oral hpv in hiv+ women and matched hiv-controls in the southern region of brazil, a geographic area with a high incidence of hiv and cc. participants included hiv+ women receiving haart and hiv-aged to years who attended the specialized assistance service (sae) for sexually transmitted diseases (std/aids in maringá, southern brazil) from september to may . women with the following characteristics were included in this study: women with confirmed hiv/aids diagnosis using two different methods were included in the hiv+ group and women with two hiv/aids negative results using two different methods were included in the hiv-group. exclusion criteria include: women with previous hysterectomy, pregnant, younger than years, and women with no history of sexual intercourse. of the hiv+ women enrolled in the sae, were eligible for the study. the sample size was calculated with a hpv cervical prevalence of % in hiv+ women [ ] , a % confidence interval (ci), and an error estimate of %. with an increase of % for possible participant losses, the total sample size was fixed at randomly selected women. sae also provides other services and hiv screening. therefore, to obtain a comparable sample, matched controls from the list of patients served by the sae were identified. the controls were matched by age. written informed consent was obtained from women, and based on their hiv serology status, participants were assigned to the hiv+ (n = ) or hiv-group (n = ). participants were interviewed using a standardized questionnaire to obtain demographic information (e.g., age, educational attainment, household income, race/ethnicity); tobacco and alcohol use/abuse; obstetric and gynecologic history (e.g., nursing staff contacted all women, administered the questionnaire, and collected the cervical and oropharyngeal samples. ecto−/endocervical samples were collected using an ayre's spatula and cytobrush for cervical cytology and polymerase chain reaction (pcr) for hpv; the samples for hpv testing were stored in thinprep® pap test solution. the conventional cytological smears were sent to the clinical cytology laboratory at state university of maringá (uem) and were graded according to the bethesda system [ ] . full-mouth oral/oropharyngeal scraping, including the cheeks, tongue, palate, tonsils, and oropharynx, was performed using a sterile brush with soft bristles; samples were stored in thinprep® pap test solution. moreover, a gargle sample was obtained by having the participant gargle with ml of . % sterile saline for a total of s ( s, rinse; s, gargle; s rinse; s, gargle), collected in a sterile cup and stored at − °c [ , ] . all oral/oropharyngeal samples will be referred as "oral samples." detection and typing of hpv were performed using the kit multiplex xgen multi hpv chip hs (mobius life science), following the manufacturer's instructions. ). an additional hpv universal probe was used to detect other, non-specified types of hpv. samples with invalid outcomes were retested, and the second result was considered definitive. women were considered positive for oropharyngeal hpv if one of the samples, oral and/ or scraping, was positive for hpv. furthermore, women were considered negative for oropharyngeal hpv if their oral and scraping samples were negative for hpv. statistical analyses were performed using the graph-pad prism . (san diego, california, usa) software. all variables were expressed as absolute and relative frequencies. for univariate analysis (unadjusted odds ratios [ors]), categorical variables were compared with hpv infection using the chi-squared and fisher's exact test. crude ors and % confidence intervals (cis) were calculated. a p-value < . was considered significant. a total of ( hiv+ and hiv-) women were included in the study, with all cervical and oral samples (oral scraping and gargle) having sufficient dna for hpv assessment. all ( %) participants had conclusive hpv test results from both anatomical sites. hiv diagnosis (years) yes ( . ) --- haart, highly active antiretroviral therapy; or = odds ratio; ci = confidence interval demographic and clinical characteristics of the two groups of patients are presented in table . the median age was . ± . years old for hiv+ women and . ± . years old for hiv-women. compared to hiv-women, hiv+ women were significantly more likely to have less than years of schooling (p = . ), non-white skin color (p = . ), their first sexual intercourse at < years old (p = . ), more than two sexual partners (p = . for - partners and p = . for > partners), and a higher number of parities (p = . for - parities and p . for ≥ parities), and were less likely to report screening for cc within the past three years (p = . ). hiv-women were, however, more likely to be a widowed (p = . ). most hiv+ women presented excellent control of the hiv infection based on their compliance with haart ( . %), preserved cd + t lymphocyte count ( . % with > cells/mm ), and suppressed current viral loads ( . % undetectable). additionally, most of the hiv+ women had had documented hiv infections for < years ( . %) ( table ) . cytology showed no signs of malignancy in most women from both groups. overall, . % of hiv+ women and . % of hiv-women presented abnormal cytological findings (p = . ). atypical squamous cells of undetermined significance (asc-us) were observed in . % of hiv+ women and in . % of hiv-women (p = . ); lowgrade squamous intraepithelial lesions (lsil) were observed in . % of hiv+ women and in . % of hivwomen (p = . ); high-grade squamous intraepithelial lesions (hsil) were observed in . % of hiv+ women and . % of hiv-women (p = . ). overall, ( . %) of the hiv+ women were positive for cervical and/or oral hpv dna, while ( %) of the hiv-women were positive for cervical and/or oral hpv (p = . ). both hiv+ and hiv-women had a statistically higher prevalence of cervical hpv infection than oral infection, including higher rates of hrhpv, lrhpv, universal hpv, and infection by multiple hpv types in cervical samples compared to oral ones, as shown in table . hpv dna was detected in oral samples from ( . %) hiv+ women and ( . %) hiv-women (p = . ) ( table ) . multiple hpv infections were detected in five samples ( . %) from hiv+ women and in four samples ( . %) from hiv-women (table ). statistical analysis did not reveal an association between hiv+ status and the presence of hpv dna in the oral mucosa (p = . ). fifty-one ( . %) hiv+ women and ( . %) hivwomen had hpv-positive cervical samples (p = . ) ( table ) . multiple hpv types were detected in ( . %) of hiv+ and in ( . %) of hiv-patients (table ) . there was no significant difference between the hiv+ and hiv-women with regard to hpv types. to better understand the association between cervical and oral hpv infection, the prevalence of concurrent hpv infection in this population was investigated. eight ( . %) hiv+ women and ( . %) hiv-women had concurrent hpv infection in their cervical and oral samples (p = . ) ( table ) . concordance between hpv types in the cervical and oral samples was not observed in either group. in the hiv+ group, the most frequent cervical hrhpv types observed were hpv , hpv , and hpv ( . % each). in the oral site, the most prevalent hrhpv was hpv ( . %) followed by hpv , hpv , hpv , and hpv ( . % each). the most prevalent cervical lrhpv found in this group was hpv ( . %), followed by hpv ( . %), and in oral mucosa, the most prevalent lrhpv was also hpv ( . %), followed by hpv and hpv ( . %) (fig. ) . in the hiv-group, the most prevalent hrhpv in the cervical mucosa was hpv ( . %), followed by hpv and hpv ( . % each). in the oral site, hpv and hpv were the most prevalent hrhpv ( . % each). the most prevalent lrhpvs in the cervical site were hpv ( . %) and hpv and hpv ( . % each), and the most prevalent lrhpv in the oral site was hpv ( . %), followed by hpv ( %) (fig. ) . hiv+ women with recent detectable hiv loads were significantly associated with hpv-positive status overall (or = . ; ci = . - . ; p = . ) and in cervical mucosa (or = . ; ci = . - . ; p = . ) ( table ) . when the characteristics of the hiv+ women were analyzed in relation to hpv status, only current smoking was associated with overall (or = . ; ci = . - . ; p = . ) and cervical hpv-positive status (or = . ; ci = . - . ; p = . for both), as shown in table . in the present study, we aimed to determine the hpv prevalence, distribution, and type concordance between cervical and oral samples of hiv+ women and hivmatched controls in the southern region of brazil, a geographic area with high incidences of hiv and cc. our data demonstrated that hiv+ and hiv-women had a similar and high hpv prevalence in cervical and in oral sites. however, hiv+ women had higher prevalence of abnormal cytological findings than hiv-women. hpv type distribution was different between the anatomical sites within both groups, and hiv+ women commonly presented with narrower hpv type distributions, mainly in the oral mucosa. finally, the frequency of concurrent hpv infection in both sites was low, and hpv type concordance was not observed. our results showed that the prevalence of cervical hpv infection was . % in hiv+ women and . % in hiv-women. studies across different populations present varying rates of hpv infection: . % in hiv+ women and . - . % in hiv-women in the cervical site [ , , , ] . the high prevalence of hpv in hiv-negative women in this study can be explained, at least in part, by the fact they were recruited from a specialized assistance service (sae) for sexually transmitted diseases, and were therefore at higher risk for sexually transmitted infections, including hpv. additionally, the rates of oral hpv infection in hiv+ women and hiv-control were . and . %, respectively. other studies have shown that the prevalence of hpv infection in the oral site can vary significantly ( - . % in hiv+ women and - . % in hiv-women) [ , , ] . although hiv infections were well controlled and cytology results showed no malignancies, abnormal cytological findings were significantly higher in hiv+ women than in hiv-women. these data are consistent with the results of the previous studies showing that hiv+ women are less likely to eliminate the virus, have subsequent persistent hrhpv infections and have higher risk of developing precancerous lesions and malignancies, even with the appropriate use of antiretroviral therapy, than hiv-women [ , , , , ] . our results demonstrated no significant difference in hpv detection in the uterine cervix or oral mucosa between hiv+ women and hiv-women; however, hpv infection was significantly higher in the cervical mucosa than in the oral site in both groups. these findings are consistent with previous studies suggesting that the natural history of hpv infection varies by anatomical site, and a higher prevalence of hpv infection is observed in the cervical mucosa than in the oral mucosa in hiv+ women [ ] [ ] [ ] . this can be explained, at least in part, by the evidence that the oral cavity is a hostile environment for the establishment of infectious agents due to the presence of both mechanical and molecular mechanisms related to digestion [ ] . more specifically, fakhry et al. [ ] conducted a study that directly compared the local immunologic profiles of the oral cavities and cervices of healthy women using paired secretion specimens. this study showed that the oral cavity contained significantly higher concentrations of immunoregulatory factors that were related to the adaptive and cellmediated immune response than the cervix, which may in part explain the significantly lower burden of sexually transmitted infections such as chlamydia trachomatis, hpv, and hiv- in the oral cavity than in the cervix. according to the authors, these findings provide additional information to better understand the differences in the etiology and natural history of pathogenic agents that are capable of colonizing both the oral cavity and female reproductive tract. the most prevalent hpv types in the cervical samples from both hiv+ and hiv-women were hrhpv and hrhpv ; however, hrhpv and hrhpv were frequently detected in hiv+ women and hiv-women, respectively. prevalence studies around the world have shown that hrhpv types , , , , , , and are the most commonly detected hrhpvs in cc, with hrhpv being the most common in all populations, with the exception of hiv+ people [ ] . data have consistently shown that hiv+ women are frequently more infected with other hrhpv types than hrhpv and hrhpv , such as hrhpv and hrhpv [ ] . the high prevalence of non-vaccine hrhpv types of -valent and -valent vaccines in the cervical and oral mucosa found in our study suggests that the -valent hpv vaccine is significantly required, which is considered important to reduce the risk of developing hpv-related cancers, specifically in the hiv+ population. unlike the distribution of hpv types in cervical samples, hpv type concordance between the hiv+ and hiv-groups was not observed in oral samples. hrhpv was the most common hrhpv detected in oral samples of hiv+ women, followed by hrhpv , hrhpv , hrhpv , and hrhpv , with these types being also frequently found in cervical samples in the same group. however, in hiv-women, the oral hrhpv types observed were totally different, with hrhpv and hrhpv being the most frequently detected hrhpv. current evidence has shown that hrhpv and hrhpv contribute to the majority (approximately %) of hnc cases worldwide, while the remaining cancers are caused by hrhpv , hrhpv , hrhpv , hrhpv , hrhpv , and hrhpv [ , ] . examination of concurrent hpv infections in different anatomical sites has been limited. hence, we concurrently investigated the prevalence of hpv infection and hpv type distribution in cervical and oral sites to better understand their clinical significance. simultaneous hpv cervical and oral infection was low in both hiv+ and hiv-women. moreover, hpv type concordance was not observed, a finding consistent with previous studies [ , ] . taken together, these observations suggest that various hpv types are more likely to occur in a different anatomical sites, and/or that the two anatomical sites can clear certain hpv types or distinct exposures, while allowing other hpv types to cause persistent oral and cervical hpv infections. prior investigations have demonstrated that engagement in some high-risk behaviors may facilitate hpv infection and act as a cofactor for viral persistence, contributing to cancer progression in the oral and cervical mucosa. in the present study, we found that current smoking was associated with overall and cervical hpv infection in hiv+ women. several studies have already demonstrated that smoking status acts as a predictor and cofactor in cervical hpv infection, which is possibly due to the alteration of the mucosa cells, making them more susceptible to infection, changing the immune mediators, causing dna damage, and promoting the integration of hpv dna into the host genome [ ] [ ] [ ] [ ] . our study demonstrated that hiv+ and hiv-women in southern brazil had high hpv prevalence in cervical and oral sites. in this population, hiv+ women had more abnormal cytological 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and p ink a detection in head and neck cancers: a systematic review and meta-analysis worldwide burden of cancer attributable to hpv by site, country and hpv type carcinoma of the cervix and tobacco smoking: collaborative reanalysis of individual data on , women with carcinoma of the cervix and , women without carcinoma of the cervix from epidemiological studies response to therapy and outcomes in oropharyngeal cancer are associated with biomarkers including human papillomavirus, epidermal growth factor receptor, gender, and smoking differential effect of smoking on gene expression in head and neck cancer patients all the authors contributed to the manuscript. tts, gmzfd, ed, and melc searched the literature and prepared the manuscript. smp collected the biological samples from the women. tts and melc wrote the manuscript. melc, wh, rf, vrss, smp, llrar, maps, and ics participated in the research design and execution. tts and ed performed the statistical analysis. gmzfd, ed, wh, raaf, vrss, smp, and ics were involved in revising the manuscript to include critically important intellectual content. melc revised the final version of the manuscript and provided information and suggestions. all the authors read and approved the final draft of the manuscript. this work was supported through a research grant from the nci (p ca - s ). the funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.availability of data and materials all data are included in the manuscript. the study involves human participants. this study was approved by the local ethics committee ( each author gives consent for publication. the authors declare that they have no competing interests.author details publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -i h ob n authors: salem, haya; daher-nashif, suhad title: psychosocial aspects of female breast cancer in the middle east and north africa date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: i h ob n breast cancer, the most common cancer among women in the middle east and north africa (mena) region, is associated with social and psychological implications deriving from women’s socio-cultural contexts. examining articles published between and , this literature/narrative review explores the psychosocial aspects of female breast cancer in the mena region. it highlights socio-cultural barriers to seeking help and socio-political factors influencing women’s experience with the disease. in of arab countries, common findings emerge which derive from shared cultural values. findings indicate that women lack knowledge of breast cancer screening (bcs) and breast cancer self-examination (bse) benefits/techniques due to a lack of physicians’ recommendations, fear, embarrassment, cultural beliefs, and a lack of formal and informal support systems. women in rural areas or with low socioeconomic status further lack access to health services. women with breast cancer, report low self-esteem due to gender dynamics and a tendency towards fatalism. collaboration between mass media, health and education systems, and leading social-religious figures plays a major role in overcoming psychological and cultural barriers, including beliefs surrounding pain, fear, embarrassment, and modesty, particularly for women of lower socioeconomic status and women living in crises and conflict zones. breast cancer is the leading type of cancer for females across the arab (mena) region. adib et al. [ ] noted that . % of female cancer cases are breast cancer, while el-attar [ ] found that breast cancer comprises between . % and . % of all types of cancer. in second place on the prevalence scale is non-hodgkin lymphoma ( . %), followed by rectal ( . %) and thyroid ( . %) cancers. the least prevalent are buccal, gallbladder, and bladder cancers ( . %). meanwhile, earlier studies found that colorectal cancer is the second most prevalent after breast cancer among women in some arab countries [ , ] . while many studies in the mena region focused on prevalence, epidemiology, and etiology of female breast cancer, several studies highlighted the psychosocial experiences of the women who had been diagnosed. this study aims to review these studies and identify the main socio-cultural and demographic factors affecting arab women's psychosocial experiences through their journey with breast cancer. in their study of the epidemiology and management of breast cancer in arab countries, el saghir et al. [ ] reported that people in the region are reluctant to speak openly about cancer and that it is highly stigmatized, to the extent that many refrain from mentioning it by name. hence there is a need to better understand the cultural and religious landscape in which breast cancer patients undergo their treatment, the specificities of which may influence their subjective experiences. recent studies have shown a positive impact of early examination, which leads to early diagnosis and breast-conserving surgery [ ] . bener et al. [ ] found that health workers rarely recommend examinations, resulting in women having inadequate knowledge about breast cancer screening [ , ] . despite breast cancer being one of the most common cancers among women, the uptake of breast cancer screening (bcs) and breast cancer self-examination (bse) is still relatively low. donnelly et al.'s [ ] multicenter cross-sectional quantitative survey conducted amongst arab women in qatar reported that in addition to the low levels of awareness and participation in bcs, only one-quarter of the participants reported that their doctors discussed and recommended bcs. women who did not undergo bcs cited as reasons the lack of physicians' recommendation, fear, and embarrassment [ , ] . donnelly et al. [ ] attribute late diagnosis of the disease to the low awareness of the importance of bcs. they link this low awareness to a variety of factors, mainly age, education, and the absence of a doctor's recommendation. a diagnosis of breast cancer can be disruptive to an individual's physical, psychological, interpersonal, and financial states [ ] . breast cancer and its treatment are associated with a broad range of symptoms that impact physical, social [ ] , mental (especially when self-esteem is influenced by changes in the body), and cognitive functioning. this upheaval can have a profound impact on women's well-being and quality of life. within clinical domains, quality of life has become an important health outcome measure, used to indicate which facets of an individual's life are most affected by a disease and its treatment [ ] . wisloff et al. [ ] demonstrate a link between compromised quality of life and clinical outcomes, including survival. sociodemographic factors emerge as an important theme in the quality of life literature [ ] . past studies found that factors such as a patient's educational level, age, amount of spousal and familial support, employment and financial status, and stage of disease progression can predict the quality of life of patients with breast cancer [ , , ] . in this paper, we present the main psychosocial aspects of being a woman with breast cancer in the mena region. this study is a narrative literature review, in which the researchers reviewed existing studies on the psychosocial aspects of female breast cancer in the mena region published between and . we chose a literature review because we aimed to document the main findings by thematically analyzing and integrating the knowledge gained over a whole decade by several researchers in all arab countries. in this type of review, researchers can summarize shared themes across existing studies, bringing together their conclusions into a holistic interpretation contributed by the reviewers in doing so, we can also summarize similarities and differences, meaning that while we consider the socio-cultural similarities shared by the arab countries, we can also explore the uniqueness of a specific country that results from its local circumstances. literature review studies' results are narrative and qualitative rather than quantitative, and they enable the researcher to acknowledge, reflect, and assist the reviewed data. using a literature review allows us to analyze the psychological and socio-cultural barriers, needs, and challenges facing arab women with breast cancer. we began by searching academic databases including pubmed, scopus, ebsco, and jstor. we used the keywords "society", "culture", "breast cancer", "women", "screening", "quality of life", "attitudes", "stigma", "women", "arab", "muslim", "family", "coping", "mental health", and "religion". the study included only english language articles and covered both qualitative and quantitative studies. chapters in books, research reports, arabic articles, and studies and information published as abstract only were excluded. both authors, with the assistance of two students, reviewed the titles and abstracts gathered. we found candidate articles, which were further reviewed and reduced to articles ( figure ; table s ). we included only research papers where the main topic was psychosocial experiences and psychosocial aspects of female breast cancer in the mena. in order to analyze and categorize the content of the articles included, we used conventional content analysis whereby identifying the main concepts and categories is derived directly from the text data [ ] . in this type of analysis, researchers determine the presence of certain themes or concepts within the given qualitative data (i.e., text), that repeat themselves across the data. by using content analysis, researchers can identify the presence of certain themes and concepts, as well as identify meanings and relationships between the identified themes and concepts. for credibility assurance, the authors debriefed and discussed the methods and results with experts in the topic of this review from different health sciences fields. the team of experts included two public health researchers, a psychologist, a psychiatrist, a social sociologist, and a medical anthropologist. furthermore, the researchers evaluated the quality of their review by using the sanra scale. sanra scale is a validated tool developed to evaluate the quality of narrative and literature reviews [ ] . the scale includes six items: justification of the article's importance, statement of concrete aims of the review, description of the literature research, referencing, scientific reasoning, and appropriate presentation of data. each item includes three levels, zero, one, and two, where two indicates that the review meets the criteria for quality. we evaluated the manuscript individually and then met to discuss gaps and ways to improve the manuscript in order to meet sanra's criteria. in reviewing the papers on our final list, we identified five main themes that highlight the psychosocial aspects of female breast cancer in the mena region. these themes are . . who cares? . . sociodemographic and cultural determinants associated with breast cancer, . . awareness and sources of knowledge, . . quality of life of women with breast cancer, and . . family support and relationships of women who have breast cancer. . . who cares? states, themes, types, and subjects of the studies included bsc/bse was the most frequent topic, discussed in % of studies. this was followed by the topic of quality of life of women with breast cancer ( %). the least discussed topic was sexual functioning ( %). other prevalent themes included attitudes and beliefs regarding breast cancer, its examination and its treatment ( %); health care providers' roles ( %); and family support and mental health issues ( %) (figure ). some countries conducted a higher number of studies than other countries. egypt, lebanon, palestine, qatar, and saudi arabia were amongst those who published the highest number of studies on the addressed issues. libya, syria, yemen, and sudan were amongst those who published the lowest numbers of studies. north africa's countries such as tunisia and morocco were in the middle. north african countries (tunisia, morocco, algeria, and mauritania) are considered francophone countries, and researchers in these countries publish in french more than in english. it is therefore likely that these countries have additional studies published in french, but these were not included in our review due to the exclusion criteria. among the middle eastern countries, syria, libya, and iraq had the lowest number of studies. this can be explained by the political crises and conflicts these countries have been experiencing since , which have made conducting research more difficult. the most frequent research participants were diagnosed women, included in % of studies, healthy women ( %), health care workers ( %), the general population ( %), and family members ( %) (figure ) . most of the studies were quantitative ( %), % were qualitative, and % were review studies. we argue that the number of the studies, the subjects, and the topics indicate who cares about which aspect of psychosocial experiences of female breast cancer. the studies reviewed in this paper indicate that an alarming number of women received their breast cancer diagnoses later in the course of their disease (stage iii and iv). socio-cultural and political factors, family values, and religious beliefs were consistently mentioned by the studies as the main factors contributing to women being late in seeking help and thus receiving a late diagnosis. economic status and political situation were reported as the most influential factors with regard to access to health care. the reviewed studies indicated that a lack of health insurance, low economic status/income, and distance from health care facilities (being unable to pay for transportation or accommodation near hospitals) seemed to be the most prominent causes of late diagnosis [ , [ ] [ ] [ ] . conflicts and political crises were an additional reason for lack of access to healthcare systems. for example, palestinian women living in the west bank faced hardships passing military checkpoints. as a result, they considered the journey to a hospital for screening worthless and postponed seeking diagnosis until the late stages of the disease [ , ] . religious beliefs were also found to have an impact on women's experiences. when women were questioned about their assumptions with respect to the causes of breast cancer, many linked it to religious causes, such as a test or punishment from god for previously committed sins [ ] [ ] [ ] . in some contexts, women mentioned unique beliefs regarding the causes of breast cancer, including the increased use of hormonal birth control pills and not breastfeeding. women believed that islam promotes and encourages women to breastfeed and utilize natural birth controls for several reasons. one is to protect against breast cancer [ , ] . furthermore, cultural norms and religious beliefs constituted barriers to early diagnosis and treatment [ , ] religious practices, such as becoming more devout and praying much more often, as a means of coping with their illness were reported by women, as well as references to tawakkul (trust in god) [ ] [ ] [ ] [ ] . in addition, screening and early diagnosis were perceived to be worthless and futile since god is the only protector and healer, even though, opposingly, treatment was claimed to be necessary since "our bodies are lent to us by god" and must be taken care of [ , , ] . a moroccan study that interviewed nurses and doctors showed that % of nurses believed that breast cancer can be cured by adhering to prayer without any kind of therapy [ ] . moreover, screening was considered to be a breach of a woman's islamic modesty [ , ] . some cultural values in the mena region necessitated having a female doctor for clinical breast examinations (cbe) and mammograms, which resulted in a delay in diagnosis of approximately months among libyan, palestinian, and egyptian women [ , , ] . furthermore, culturally, the term "cancer" has been shown to be associated with either death or baldness due to chemotherapy [ , ] . this seemed to be a more common conception among arab women, leading them to avoid mentioning it to their families. for example, palestinian women living inside israel reported that they felt more comfortable communicating with jewish women during their chemotherapy sessions than with fellow palestinians who also suffered from breast cancer [ ] . their comfort speaking about their diagnosis with strangers resulted from the social stigma and the way that cancer is perceived and framed by their close community. cancer was also linked to being attacked by someone's "evil eye", and was believed to be able to be resolved on its own or through the use of home remedies, such as rubbing the lump with olive oil [ , , , [ ] [ ] [ ] [ ] . knowledge about breast cancer risk factors and clinical features is a vital indicator of conducting regular bse, seeking cbe, and pursuing treatment. women, mostly working mothers, who had knowledge about bse practice lacked general information about the frequency and best time of their menstrual cycle to perform bse [ ] [ ] [ ] [ ] . knowledge of some indicators of breast cancer risk factors, such as the absence of non-lump breast signs, nipple retraction or changes in breast size and/or shape, other health symptoms like weight loss or fatigue, and denial of and fear of finding a lump, made women less likely to perform bse or undergo a cbe or mammogram [ , , , , , [ ] [ ] [ ] . furthermore, women who successfully underwent a bse, cbe, or mammogram once did not repeat the screening tests regularly since they believed that the initial negative results accompanied by no breast changes made a second screening unnecessary [ , , ] . for example, it was found that in the palestinian authority, more than % of women above the age of had never undergone a mammography and did not know about the need for regular screening tests, while % had never had a cbe [ ] . women who underwent cbe also performed bse regularly, which was also a common trend among qatari women [ ] . it was also noted that women who performed screenings were motivated to do so because they knew someone (a family member or friend) who had suffered from breast cancer [ , , , , ] . the gap between initial occurrence of symptoms and diagnosis among women of different arab nationalities living in the uae ranged from months to years, and this was largely explained by the inappropriate information that women had about the presentation of breast cancer [ ] . a huge gap in the knowledge of the risk factors of breast cancer was also noticed among women in northern saudi arabia, which may have resulted in delayed diagnosis, as in the uae [ ] . on the other hand, . % of libyan women reported that they had been falsely reassured by their physicians that their breast lump was benign [ ] . the impact of level of education on breast cancer awareness is very debatable. despite the expectation or hypothesis that women who attended university or who had higher levels of education would have had more knowledge about breast cancer diagnosis, screening, and risk factors, the actual correlation varied between countries. for example, female students attending the university of assuit and ain shams in egypt and taibah university in saudi arabia were found to have poor knowledge about breast cancer risk factors and clinical features [ , , ] . even among those students who had a good level of knowledge about breast cancer and were aware of the existence of bse, the majority did not recognize the need to perform screenings regularly because of their young age or lack of knowledge on how to perform it. this lack related to a low interest in learning about the topic. similar results were found in a study of sudanese medical students who were trainees in the ob/gyn department at omdurman maternity hospital [ ] . likewise, among omani women who had completed postgraduate studies, almost half had poor knowledge about breast cancer. similar results were also observed among jordanian female students of different majors and departments [ ] . in addition to the deficiency in information, women reported that their primary source of information was not from health care providers but rather from the media, including the internet, social media, and television [ , , , , , , [ ] [ ] [ ] [ ] [ ] . more than half of the subjects in the papers who underwent bse, cbe, and/or mammograms were advised by the doctors whom they trusted the most. in iraq, although both students and teaching staff at the technical institute of shatra showed a high percentage of awareness, % and %, respectively, only . % and . %, respectively, performed bse [ ] . the participants of this study also reported that their principal sources of information (from the most to least popular) were the internet and television ( %), health care providers ( %), and family ( %) [ ] . in palestine, only % of doctors recommended breast exams to their patients; % of them remarked that they did not know if radiotherapy was available to women in gaza. similarly, only % of female practitioners in saudi arabia ordered a mammogram for women over years of age despite their high level of knowledge about breast cancer risk factors [ ] . therefore, the lack of physicians' recommendations for screening was highlighted in most of the countries. researchers attributed this lack to the embarrassment and shame that derive from gender and body values within the discussed societies [ , ] . researchers found that the patient's level of education influenced the level of knowledge of risk factors as well as the way women coped with the diagnosis. women who had a university degree or higher, especially those who were working, tended to experience less severe episodes of depression and anxiety and had better physical functioning [ , [ ] [ ] [ ] [ ] [ ] . in other words, knowledge and education were found to be helpful in improving women's quality of life (qol). hence, we can conclude that increasing awareness and knowledge around breast cancer can be an alternative to physician recommendation. according to the who, quality of life (qol) is defined as an individual's perception of their position in life within the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns [ ] . when arab women were asked about their definition of quality of life, they generally described their ability to fulfill their roles as mothers and wives [ , , , , ] . lower income and higher financial stress were associated with a poor quality of life in addition to higher pain severity [ ] . in yemen, younger women had worse scores on the quality of life scales [ ] . this could be due to the socio-political crisis in which they live, which is described by many human rights organizations as the worst crisis of the century. adverse effects related to treatment interfered with general activity and social functioning and hindered women from performing their day-to-day chores as mothers and wives [ , , , , ] . women described physical symptoms, including fever, nausea, fatigue, vomiting, dyspnea, poor appetite, and arm pain, which greatly impacted them psychologically, leading to depression, constant anxiety, sleep disturbances, and social difficulties. the reverse effect was also evident [ , [ ] [ ] [ ] [ ] . studies revealed that the extent of pain was influenced by the time of diagnosis as well as the mode of treatment. women who underwent radiation and/or immunotherapy scored best on a spiritual well-being scale [ , ] . studies in egypt and jordan showed that physical and psychosocial symptoms were statistically significantly better in those who underwent breast-conserving surgery rather than modified radical mastectomy [ , ] . in jordan, lumpectomy surgeries had better outcomes compared with mastectomies [ ] . the studies indicated that the progression of women's psychiatric symptoms was significantly associated with advanced stages of the disease, such as metastasis, breast cancer relapse, and multiple tumors, and with continuous post-treatment pain [ , , , , ] . hence, the stage of the disease was a direct factor in shaping their perception of quality of life. some of the issues commonly reported by women as consequences of therapy, that their physicians failed to mention, were loss of what represented their femininity, such as breast resection, hair loss, breast pain, lack of desire to engage in sexual activities, and vaginal dryness [ , , , , , ] . in morocco, for example, % of women with breast cancer who continued sexual activity described it as being increasingly uncomfortable/unenjoyable, painful, and undesirable [ , , ] . this was substantiated by research done in bahrain in which women were interviewed about their spouses' reactions to their illness. the women expressed that they felt rejected and weak [ ] . another study in bahrain showed that husbands sometimes even interfered with the type of treatment their wives were to undergo by insisting on less aggressive forms of treatment or none at all [ ] . this indicates that women's quality of life is partially shaped by gender hierarchies within their society. some women tried to tackle the decline in their quality of life caused by breast cancer by resorting to alternative medicine (such as special foods, herbs, supplements, spiritual activities) in parallel with, and sometimes instead of, their treatment plans due to a fear of the toxicity caused by chemotherapy. a high percentage of those women did so without consulting their doctors [ , ] . the studies that were reviewed showed the importance of the role of the family in both diagnosis and treatment stages. for example, divorced and widowed saudi women scored lower on social well-being than their married counterparts [ ] . patients were affected by the presence or absence of familial support as well as their families' reactions to the illness. an example of the importance of familial support was illustrated in a study performed by adib et al. [ ] , which showed that iraqi migrants living in lebanon suffered from depression and anxiety more than lebanese women. this was mainly due to the lack of nuclear family, extended family, and community support, in addition to other factors such as economic status. furthermore, family structures often change when women are unable to perform their roles as wives and/or mothers [ , ] . while the majority of women shared the news of their diagnosis with their closest family members, other women felt obliged to hide the news from their family members for various reasons. for example, some hid it from their husbands due to the fear of divorce or being forced to accept their husbands marrying a second wife [ , ] . this behavior resulted from the impact of the breast cancer diagnosis and its implications for women's femininity, marriage, intimate relationships, and body image [ , ] . women hid their diagnosis from their friends due to their fear of becoming a burden and of the social stigma associated with "that" disease. this made women hesitant about mentioning their hospital visits to avoid questions from people who knew them [ , ] . hiding their diagnosis from family and friends led women not to receive the appropriate treatment in time because they were unable to hide the side effects of ongoing treatment [ ] . some studies mentioned that women hide their diagnosis from their children to protect them from worry and grief. for example, mothers in saudi arabia who revealed their diagnosis to their children, despite experiencing a stronger mother-child bond, admitted that the news negatively affected their children's academic performance, which in turn increased the burden on the women [ ] . hiding a diagnosis from children is a protective act resulting from mothers' fear of negatively impacting their children's emotional and academic performance. this is a mothering value, protecting the child despite being in need of support oneself. this review found that several socio-cultural and political factors affect arab women's quality of life when they are diagnosed with and treated for breast cancer. one of the interesting findings was that few studies addressed sexual functioning, family support, and mental health. these are essential needs that can be reflected directly in women's qol in the process of healing and facing cancer. we argue that researchers and health care workers should give these factors as much attention as they do the physical symptoms. we assume that the absence of studies on sexual functioning indicates that the sexuality, sexual health, and sexual functioning of women and their ability to express their attitudes and feelings toward it are still considered inappropriate or taboo [ ] . similarly, the social stigma surrounding mental health constitutes a barrier to seeking help for the patient, and a barrier to researchers in asking patients about the issue [ ] . in arab societies, family members tend to hide illness and disease from both their close community and strangers because the cultural value is to keep family issues in the home [ ] . this can be explained by the fact that illness and disease are considered weaknesses that society must not see, because if they are seen, the family will be perceived as weak and vulnerable by society. the political events since , beginning with the "arab spring", led to continuous crises in several countries, including syria, libya, yemen, and iraq. we assume that these events have affected women's life in general and have influenced the research agenda within these countries, which reflected by the scarcity of studies on women and breast cancer. in general, in times of conflict women become more vulnerable and women's issues are pushed to the bottom of national priorities [ ] . sidel and levy [ ] argue that armed conflicts may be associated with poor health and poor access to quality medical care, especially for women, children, and the elderly, that is, the vulnerable and those most affected by wars and conflicts. political conflicts have a direct impact on women's qol, healing processes, and the general ability to cope with breast cancer. hence, these women are essentially facing three battles: political, medical, and social. wars reproduce patriarchy within and between genders and thus require a focus on those institutions that are crucially responsible for the production of masculine identity [ ] . almost half of the studies we reviewed focused their research on women who had been diagnosed with breast cancer, while one-third studied the experiences and attitudes of healthy women. this reflected the patient-centered approach in the studies, where women's voices were the main voices. despite this, most of the studies were quantitative. while quantitative methodologies tend to analyze phenomena in terms of prevalence and frequencies, qualitative methodologies aim to determine the meaning of a phenomenon and develop concepts that help in our understanding of the phenomenon through those who are involved in it, that is, the human participants. we attest that there is a need for more qualitative or mixed-methods studies in order to better understand women's experiences and needs. this will help to better implement the patient-centered approach in healthcare systems, which highlights patients' perspectives as a basic principle in health care [ ] . socio-cultural factors, such as religion and cultural values, were found to play a major role in bse and bcs behaviors. the term "cancer" has a negative connotation because it is associated with death and end of life. in her work illness as metaphor ( ), susan sontag clarifies how fatalistic social perceptions and the framing of cancer, reflected in the language and metaphors used to refer to the disease, negatively influence women's perceptions, experiences, and healing processes [ ] . the health belief model [ ] considers cultural values and religion as significant variables affecting perceptions of illness and health, with a major impact on managing health and sickness in certain societies. in arab-muslim societies, that is all mena states, religion plays a role on three levels: the holy text (quran and hadith), the belief system that derives from the text, and the social-religious practices that derive from both [ ] . in several contexts, there may be gaps between the holy text, the belief system, and the religious practice. in our review, the gap was between the perception of illness as a punishment or test that only god can heal, and the belief that our bodies are a gift from god and we have to take responsibility and care for them. this contradiction is reflected in women's screening behavior whereby they say that god gave us our bodies and it is our duty to care for them, yet they also engage in late screening behaviors resulting from fear, embarrassment, and rejection of the idea of being sick. another example of a gap between the quranic text and social beliefs is that envy is mentioned in the quran, the holy book for muslims, as something people should protect themselves from, but it is not referred to or based on the concept of the "evil eye." arab-muslim societies use the evil eye to refer to envy of others and every bad event they cannot explain. abu-rabia argues that the belief in the evil eye is embedded in the folklore of fallahin (peasant) societies throughout the middle east [ ] . we argue that this belief in the evil eye influences perceptions of disease and illness, and affects the way women with breast cancer, and indeed other ill arab-muslim people, manage their diseases. religious and social leaders, as well as awareness campaigns in all platforms and forms, play a crucial role in re-structuring belief systems and encouraging women to seek early diagnosis and care for their health. the primary factor to consider in preparing these awareness campaigns is the access of women. access, in this context, refers to language and location. studies that considered the role of breast cancer awareness campaigns and investigated their impact on women reflect that these campaigns were ineffective in countries where they occurred abundantly. women in our review, such as women living in qatar and saudi arabia, recommended using the arabic language to distribute information. another common recommendation was to make the campaigns more culturally sensitive by locating informational booths in female-restricted areas instead of public malls, so that women would feel less exposed while visiting the booths [ , , ] . in addition, in lebanon it was found that public information campaigns were occurring at a much lower rate in rural areas compared with in the cities [ ] . women in rural areas were found to use more alternative and herbal medicine due to their distance from main health care centers. few studies mentioned alternative medicine, especially herbal remedies, as a tool women use during their trials to promote healing in parallel to the clinical treatment. azaizeh et al. [ ] found that the eastern region of the mediterranean has been distinguished from other regions through a rich inventory of complementary alternative medicine, in particular herbal medicine. our review found that being a working and educated mother does not necessarily indicate better self-care or better awareness of bse; in fact, we found that knowing someone, such as a family member or friend, who was diagnosed with breast cancer had a stronger impact on self-health management, resulting from fear that prompted women to perform self-or clinical screening. similar results were found in non-arab countries, such as in serbia [ ] . we assume that many eastern and western societies may express fear as an emotional reaction associated with the diagnosis of a close friend or family member. the difference between societies is in the way their culture shapes an individual's reaction to it. one of the cultural factors found to create delay in seeking diagnosis was a woman's preference in having a female doctor perform the clinical breast examination. the best way to counter this factor is to seek out female doctors. the healthcare system should also construct a culturally tailored system by providing more female doctors. in addition to a lack of female doctors available, our review found that the lack of a physician's recommendation for breast examination was significant. indeed, this is one of the major reasons women were unaware of the importance of bse and bce. some researchers attributed this lack of physician recommendation to the gender dynamics and cultural values of arab societies, which can result in embarrassment and avoidance by doctors who would be recommending bse or bce to their patients. lack of doctors' support and women's preference not to discuss health concerns with family members led them to rely on the media, social media, and the internet as their main resources of knowledge. although some cultural values created barriers to seeking early diagnosis, other cultural values promoted the healing processes. for example, the arab cultural structure is characterized by collectivism and patriarchy, which was found to play a positive role in the way women were able to deal with treatment. women reported relying on support from their extended families that lived nearby when they were in need. extended family members filled the woman's roles in mothering, housekeeping, and managing the daily lives of her nuclear family. studies from other regions in the world found the same results in terms of extended family support [ , ] . furthermore, we found that migrant women fleeing war, such as iraqis, syrians, and yemenis who lived in other arab countries far from their extended families, lacked the necessary support and this was reflected in their poorer quality of life. socioeconomic and socio-cultural factors are important in shaping the quality of life of arab women with breast cancer. these factors are combined with clinical factors, such as the stage of disease and treatment modality. while all women with breast cancer generally share these experiences and impacts, the features of the society that arab women inhabit make the development of these experiences unique to them. gender hierarchies and patriarchy, family values and tribal mentality, cultural practices that contradict the holy religious texts, and cultural perceptions of cancer and women's bodies may make the experience of being diagnosed with and treated for breast cancer harder for women living in the mena. a limitation of this study is that it may not have included all relevant studies because the search was limited to four databases. indeed, literature reviews cannot include every study on the topic, and this is one limitation of this type of review. we also think that including the studies published in arabic and french, especially on north africa's countries, could enrich this review. further qualitative studies are recommended to explore women's 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family's role and strengths after a young woman is diagnosed with breast cancer: views of women and their families the impact of culture and sociological and psychological issues on muslim patients with breast cancer in pakistan we thank amna al-sada and manwa al-shamari for their valuable help in collecting and reviewing part of the articles included in this study. the authors declare no conflict of interest. key: cord- -mljywm p authors: jain, amisha; sami-zakhari, iman r. title: pulmonary complications of obstetric and gynecologic conditions date: - - journal: pulmonary complications of non-pulmonary pediatric disorders doi: . / - - - - _ sha: doc_id: cord_uid: mljywm p the respiratory and the female reproductive systems are not embryologically or functionally related. however, the reproductive system can exert significant effects on the respiratory system as a result of the various hormonal changes that occur during a woman’s menstrual cycle and especially during pregnancy. in addition, there are several unique gynecologic and/or obstetric conditions that can directly affect the respiratory system. the following chapter reviews the effects of pregnancy on the respiratory system, as well as the special issues concerning the management of common respiratory conditions (e.g., pneumonia, asthma) during pregnancy. in addition it reviews several gynecologic disorders with unique pulmonary complications. a fundamental difference between the female reproductive system compared with virtually every other organ system in the body is that it goes through significant changes on a regular basis during the woman's healthy menstrual cycle and not only in a state of disease as is the case for virtually any other organ system. even more significant are the changes that occur during pregnancy when the entire body changes to accommodate the developing fetus. although none of these changes are directly related to the respiratory system, they do exert a significant effect in the mechanics of breathing. thus, the physician who cares for a woman with respiratory symptoms has to consider if and to what extent they are caused, complicated, or exacerbated by an underlying gynecologic or obstetric condition. this chapter focuses on the normal alterations in pulmonary physiology during pregnancy and how it may affect the natural history of specific respiratory diseases and of course how the respiratory disease may affect the pregnancy outcome. lung disorders related to gynecologic conditions are also described. profound physiological changes occur in both the pulmonary and cardiovascular systems during pregnancy. understanding these changes and how they may affect other underlying disorders helps in the management of respiratory disease during pregnancy. in the upper respiratory tract, edema of the nasal mucosa resulting in symptoms of rhinitis ("rhinitis of pregnancy") has been reported in as many as - % of pregnant women. it characteristically appears during the last weeks of pregnancy in the absence of any infectious or allergic trigger, and it completely resolves within - weeks after delivery. its exact cause is not known. various factors have been implicated in its pathogenesis including the effect of placental growth hormone on the mucosa and increases in the circulating blood volume. other alterations in the upper airways include increases in the mallampati score (that assesses the space between the base of the tongue and the roof of the mouth) and in the neck circumference. the decrease in the size of the upper airways is assumed to be caused by the overall alterations in the lung volumes that affect the caudal traction, and by fat infiltration of the tissues, and it is exacerbated in supine position. during pregnancy the configuration of the chest wall is altered in order to accommodate the enlarging uterus. the changes include increases in the transverse diameter of the thorax that results into an increase of approximately % in the subcostal angle. as a result, the diaphragm is elevated by - cm. this would significantly impair the ability of the diaphragm to move during inspiration, but it is compensated by an increase in the anteroposterior diameter as well that allows the diaphragm to maintain a fairly normal excursion. however, the overall chest wall compliance decreases. there appears to be no effect on the respiratory muscle strength although the changes in the chest wall configuration probably puts the muscle at a mechanical disadvantage, thus contributing to the increased work of breathing that pregnant women experience. interestingly, most of the alterations in the chest wall occur primarily during the first trimester of the pregnancy when the uterus is still too small to have any substantial mechanical effect. it is believed that the chest wall configuration changes as a result of hormonal action, especially of relaxin that relaxes the ligaments of the lower rib cage, thus allowing the increase in the diameters. the alterations in the configuration of the chest wall confer surprisingly relatively little change in lung volumes and even less in lung function ( table ). the most substantial change occurs in the functional residual capacity (frc) that is usually decreased by about % primarily due to a decrease in the expiratory reserve volume (erv) and residual volume (rv). this is due to elevation of the diaphragm and increased pulmonary blood volume in pregnancy. the inspiratory capacity (ic) remains essentially the same or even increases, and as a result, the total lung capacity (tlc) is only marginally decreased. there are changes in the respiratory drive and minute ventilation, both of which increase under hormonal influence. the increase in minute ventilation offsets the increased carbon dioxide production, so primary respiratory alkalosis with ph ranging from . to . and pco ranging from to is a normal finding in pregnancy. asthma asthma is one of the most common chronic respiratory diseases complicating pregnancy with an estimated prevalence of . - . % of all pregnancies. asthma is clinically characterized by recurrent episodes of reversible bronchoconstriction. there is a bidirectional interaction of asthma and pregnancy where asthma influences pregnancy outcomes and pregnancy affects asthma severity. poorly controlled asthma is associated with adverse perinatal outcomes; however, when asthma is well controlled, pregnancy is not adversely affected. the course of asthma during pregnancy improves in about one-third of women, worsens in one-third, and remains the same in the other one-third. the course is determined by the baseline asthma severity with more severe asthma prior to pregnancy conferring a higher risk of worsening during pregnancy. there is evidence that the course of asthma is similar in subsequent pregnancies. there is evidence that female fetuses are associated with worsening of the maternal asthma, suggesting the influence of hormonal causes. uncontrolled asthma increases the risk of severe maternal and fetal complications including preeclampsia, preterm birth, low birth weight, intrauterine growth restriction, and increased perinatal mortality. immunological mechanisms in asthma influence pregnancy. it has been shown that poorly controlled asthma in pregnant women is associated with immune reactions that influence fetal growth. the focus of management is to maintain adequate control of asthma during pregnancy that will improve both maternal and fetal outcomes. the diagnosis of asthma is usually known prenatally, but the symptoms may occur for the first time during pregnancy. spirometry showing lower airway obstruction that is reversible with bronchodilators is very useful in confirming the diagnosis. however, the absence of an obstructive pattern is not a contraindication to treating the patient if there is sufficient clinical suspicion. bronchial challenge tests are contraindicated during pregnancy due to the lack of safety data. performing a skin prick test during pregnancy for the possibility of allergic asthma is also not recommended due to the risk of systemic reactions. fractional nitric oxide (feno) concentration in exhaled breath is a relatively new tool to monitor asthma control. according to a recent study, feno levels are not altered in pregnancy, and they correlate with the level of asthma control. however, as in the nonpregnant population, the limitation of the feno is that it reflects primarily the eosinophilic asthma and not all types of asthma. monthly assessment of asthma control during prenatal visits is strongly recommended as well as patient education. despite the concern about administering medications during pregnancy and their effect on the fetus, it is safer for pregnant women with asthma to be treated with asthma medications than to experience exacerbations that may increase the risk of perinatal mortality. most studies have shown no increased perinatal risk with the use of beta-agonist and inhaled corticosteroids. some epidemiologic studies have shown an increased risk of congenital abnormalities (cleft palate with oral corticosteroids, gastroschisis with bronchodilators) in the offsprings of asthmatic women, but the evidence is far from conclusive. it should be noted that congenital abnormalities develop very early in pregnancy (sometimes before the woman realizes that she is pregnant), and therefore withholding the medications later in pregnancy would confer no benefit. albuterol is the preferred reliever medication because of its overall excellent safety profile. inhaled corticosteroids (ics) are the preferred controller medication with budesonide being the preferred choice due to the availability of reassuring data in pregnant women. it is important to note that no data indicates that other ics are unsafe during pregnancy, and if a patient was well controlled before, she should continue taking the same asthma medications during pregnancy. long-acting beta-agonists (labas) may be used as an alternative controller medication if clinically warranted by symptoms not controlled with ics. a recent retrospective study showed no difference in the risk profile of step-up therapy with low-dose ics/laba inhalers or high-dose ics in terms of major congenital malformations. leukotriene receptor antagonists (ltras) seem to be safe based on the animal safety data submitted to fda; however, availability of human data is scarce. the use of asthma medications should be continued during labor and delivery. lumbar epidural anesthesia is preferred over general anesthesia, if cesarean section is required, and ketamine is the preferred anesthetic. the key in asthma management is remembering that adequate control of asthma can improve the health of both mothers and their babies. cystic fibrosis (cf) is an autosomal recessive disorder affecting the body's exocrine glands, including the pancreas, sweat glands, and lungs. it is the most common life-shortening genetic disorder in caucasians with a carrier frequency rate of in and an incidence of in live births in caucasians. it is present in other races albeit less commonly with an incidence of in and in , live births in hispanic and african-american populations in the united states. the most common gene deletion in % of genes is the delta f , which leads to a misfolded cf transmembrane conductance regulator protein resulting in impaired movement of water and electrolytes across epithelial surfaces. in the last few decades, there have been improvements in treatment and survival, and the median life expectancy is now years. about - % of female patients become pregnant. malnutrition and thick cervical mucus may impair female fertility. despite the concern that pregnancy would have an adverse impact on the mother, a large us review of pregnant women with cf enrolled in the us cystic fibrosis foundation national patient registry ( to ) demonstrated that survival was actually better in the pregnant female group than in the matched control patients with cf. they had higher predicted percentages of fev and higher weights. after adjustment of age, colonization with pseudomonas aeruginosa, pancreatic function, and prepregnancy fev , the pregnancy did not appear harmful. in another case-control study, pregnancy had little effect on patients with stable cf, although poor outcomes were seen in those with severe disease. the presence of pulmonary hypertension, cor pulmonale, or fev < % predicted is a relative contraindication to pregnancy. prior to pregnancy, genetic counseling should be offered and should include a risk estimate of having a child with cf as it can be as high as % if the father is heterozygous for the gene. during pregnancy, fetal surveillance to detect early signs of growth restriction is essential. pregnant women with cf need regular monitoring by a dedicated team, to achieve favorable pregnancy outcomes. commonly reported adverse events are fetal growth restriction and prematurity which includes iatrogenic early delivery because of maternal health deterioration. women with cf are also at an increased risk of developing gestational diabetes. so screening for diabetes, baseline lung function tests as well as dietary supplementation, enzyme supplements, and chest physical therapy are important. pulmonary exacerbations should be treated aggressively with antibiotic therapy paying attention to the class of medications and using those approved for use during pregnancy. there is no contraindication to vaginal delivery; however, there is a small risk of pneumothorax if the second stage is very prolonged. general anesthesia should be minimized. there is no contraindication to breastfeeding, but mothers will need to use nutritional supplements in the postnatal period to ensure adequate caloric intake. the frequency of pneumonia in pregnancy is similar to that in the general population. infants born to women who develop pneumonia during pregnancy have a higher risk of being low birth weight and small for gestational age. pneumonia may also precipitate preterm labor. intrauterine and neonatal deaths have also been reported. poor maternal and fetal outcomes occur primarily in mothers with underlying chronic respiratory illnesses. pregnancy increases the risk of complications of pneumonia including respiratory failure, and the mortality is higher. the most common pathogens causing bacterial pneumonia in pregnancy are streptococcus pneumoniae, haemophilus influenzae, and mycoplasma pneumonia. the clinical features are similar to those in nonpregnant patients with fever, cough, dyspnea, and rigors as the presenting symptoms. a chest radiograph may be obtained to confirm the diagnosis. penicillin, cephalosporins, and macrolides are safe antibiotics for use during pregnancy. tetracyclines should be avoided as they may cause teeth discoloration in the fetus. influenza epidemics have shown that the morbidity and mortality rate in pregnant women is higher compared with nonpregnant women. influenza vaccination has been shown to reduce hospitalization rates among pregnant women; therefore, the centers for disease control and prevention (cdc) recommends inactivated influenza vaccine during the second and third trimesters of pregnancy. in , a previously unrecognized strain of influenza a (h n ) virus emerged and caused increased morbidity and mortality in pregnant women. treatment with oseltamivir in pregnant women provided better protection against maternal-fetal transmission. maternal varicella pneumonia is associated with high mortality rates. antiviral therapy with acyclovir reduces the mortality rates in pregnant patients and should be considered in the treatment of active disease. passive immunization with varicella zoster immune globulin (varizig) has been shown to reduce the risk of congenital varicella syndrome and is also effective in preventing maternal complications of varicella. the live attenuated vaccine against varicella is contraindicated in pregnancy. fungal pneumonias are not common during pregnancy. coccidioidomycosis is the most extensively studied fungal infection in pregnancy and can affect the outcome if it is disseminated. compared with the general population, the risk of disseminated infection is higher in pregnant women, especially in the third trimester of pregnancy. possible reasons are impairment of cell-mediated immunity and a stimulatory effect of progesterone on fungal proliferation. amphotericin is the preferred antifungal for disseminated coccidioidomycosis. azoles should be avoided during pregnancy due to an association with branchial cleft abnormalities. there is no evidence that other fungal infections, including blastomycosis, histoplasmosis, sporotrichosis, and cryptococcosis, are more severe during pregnancy. pneumonia complicating hiv infection in pregnancy is most commonly caused by a yeastlike fungus pneumocystis jirovecii; it should be suspected in the presence of hypoxia that is out of proportion to the chest x-ray findings. treatment is with high-dose co-trimoxazole/pentamidine with folate supplementation. pregnancy and tuberculosis have little effect on one another. patients are often asymptomatic but can present with typical symptoms of cough, night sweats, hemoptysis, and weight loss. tuberculin skin testing can be used for screening patients, and treatment should not be delayed during pregnancy. rifampicin, isoniazid, and ethambutol are standard antitubercular drugs approved by the cdc due to their acceptable safety profile. streptomycin is associated with congenital deafness and is contraindicated. guidelines for the evaluation and management of newborns born to mothers with tuberculosis should be followed. aspiration pneumonia is a major cause of maternal morbidity and mortality. the pregnant woman is predisposed to aspiration during labor and delivery due to increased intra-abdominal pressure from the gravid uterus, relaxed gastroesophageal sphincter due to the effect of progesterone, delayed gastric emptying, vigorous abdominal palpation during examinations, and sedation and analgesia given in the delivery room. aspiration of the acidic gastric contents with a ph less than . induces chemical pneumonitis and pulmonary edema. most cases of aspiration occur at the time of delivery. if general anesthesia or endotracheal intubation is needed, prophylaxis in the form of h blockers, metoclopramide, or sodium citrate is often given before intubation. the clinical presentation includes tachypnea, bronchospasm, hypoxemia, and hypotension with chest radiograph findings of either isolated or diffuse infiltrates. the timing of presentation depends on the volume of the aspirate with large volumes causing immediate asphyxiation and smaller volumes becoming apparent - h after the event. respiratory failure can sometimes manifest in the postpartum period. management is supportive and includes oxygen, bronchodilators, and ventilatory support. antibiotics should be considered early if there is suspicion of bacterial infection. the common bacterial pathogens are staphylococcus aureus, gramnegatives, or anaerobes originating from the oropharynx. restrictive lung diseases are characterized by a decrease in total lung capacity. this can be caused by abnormalities in the pleura, chest wall, and neuromuscular apparatus or alterations in the lung parenchyma. in most cases, due to the large pulmonary reserve, pregnancy is unaffected; however, in severe restriction, problems may arise during pregnancy and labor due to impaired reserve and higher oxygen demands. the gravid uterus pushes the diaphragm upward, thereby further worsening the restriction. as a general rule, patients with a fvc of < l or < % of predicted fvc and those who have pulmonary hypertension are at greater risk of cardiopulmonary complications and hence should consider avoiding pregnancy or consider a therapeutic termination. kyphoscoliosis is an abnormality of the spine characterized by posterior or lateral curvature or both. almost half of the cases are idiopathic. depending on the site of primary curvature in pregnant females, there can be cardiopulmonary complications or obstetrical complications such as cephalopelvic disproportion. other obstetrical complications experienced by pregnant women with kyphoscoliosis include prematurity and low birth weight. it is controversial if spinal curvature will worsen during pregnancy. studies have shown that the risk of progression of the curvature is low unless the scoliosis is unstable at the time of pregnancy. the presence of kyphoscoliosis during pregnancy may cause back pain. sarcoidosis is a multisystem disorder of unknown etiology that is characterized by noncaseating epithelioid granulomas. the most common site of granuloma formulation is the lungs. other organs include the lymph nodes, eyes, skin, liver, heart, and nervous system. since the disease can involve any organ system, clinical manifestations are variable ranging from dyspnea, nonproductive cough, and chest pain to fever, joint/ muscle aches, visual changes, and erythema nodosum. the disease has a variable course with spontaneous remissions occurring in nearly two-thirds of patients. sarcoidosis has not been found to adversely affect pregnancy outcomes. it is not transmitted to the fetus and does not increase the incidence of maternal or fetal complications. improvement in sarcoidosis occurs during pregnancy with a tendency to relapse in the postnatal period. factors that indicate a poor prognosis in pregnancy include parenchymal infiltrates on chest radiograph, advanced radiographic staging, low inflammatory activity, advanced maternal age, requirement for drugs other than steroids for disease control, and the presence of extrapulmonary disease. except for severely affected patients, sarcoidosis is not a contraindication to pregnancy. the diagnosis usually warrants a tissue biopsy of the involved organ that shows noncaseating granulomas. the patient may also have other laboratory abnormalities including an increased angiotensin-converting enzyme (ace) level, elevated liver enzymes, and hypercalcemia. pulmonary function tests are abnormal in many patients and generally show a restrictive pattern but may be normal or obstructed if there is endobronchial involvement, stenosis, or airway distortion from parenchymal disease. there may also be a reduction in diffusion capacity. systemic steroids are the main stay of therapy and should be continued in pregnancy. acute respiratory distress syndrome (ards) is a severe form of acute lung injury characterized by severe hypoxemia and bilateral pulmonary infiltrates resulting from increased alveolar-capillary permeability. ards in pregnancy can develop from obstetric and non-obstetric complication. the common obstetric causes are chorioamnionitis, amniotic fluid embolism, trophoblastic embolism, and placental abruption. the most common non-obstetric causes are pneumonia, sepsis, and aspiration. due to the changes in the definition of ards, it has been difficult to determine the true prevalence of the condition with estimates ranging from . to cases per , population. the prevalence of ards during pregnancy is comparable to the number in the general population: however, the mortality rates of ards for both the mother and the fetus are high. there is not enough evidence available regarding the management of ards in pregnancy, and treatment strategies are extrapolated from the studies on the general population. a multidisciplinary approach is necessary to optimize maternal and fetal outcomes and manage ards in pregnancy. acute pulmonary edema in pregnancy is an uncommon yet significant cause of morbidity and mortality with an estimated incidence of . - . %. it was reported as the fourth most common form of maternal morbidity in the scottish confidential audit of severe maternal morbidity, which is one of the largest maternal morbidity audits. acute pulmonary edema may occur during the antenatal, intrapartum, or postpartum periods. pregnant women are at an increased risk for pulmonary edema due to the hypervolemia and high cardiac output of pregnancy, the occasional need for tocolytic drugs that affect the vascular bed, and some clinical conditions unique to pregnancy. it is now recognized that in addition to fluid accumulation and retention, fluid redistribution from the systemic circulation to the pulmonary circulation also plays an important role in causation of pulmonary edema. clinically, the patient presents with acute onset of breathlessness, orthopnea, cough, tachycardia, tachypnea, and hypoxemia. chest x-ray, ecg, and echocardiography may help establish the diagnosis. in contrast to nonpregnant women, serum concentration of b-type natriuretic peptide is not widely utilized in pregnancy. transthoracic echocardiography is very helpful in diagnosis and management of the pulmonary edema as it enables assessment of cardiac systolic function. treatment is supportive and includes fluid restriction, circulation control with vasodilators, oxygenation, mechanical ventilation if needed, and close monitoring. pulmonary embolism (pe) is a leading cause of maternal mortality accounting for % of maternal deaths in the united states. the estimated incidence of pulmonary embolism is . per , with the highest risk during the postpartum period. pregnant patients are predisposed to thromboembolic disease for several reasons including ( ) an increase in several coagulation factors and a decrease in fibrinolytic activity, leading to a hypercoagulable state, ( ) venous stasis caused by uterine compression of the inferior vena cava and the left iliac vein, and ( ) trauma to pelvic veins at the time of delivery. this might account for the peak incidence of thromboembolism in the postpartum period, especially after cesarean section. other risk factors for developing thromboembolism include a past history of thromboembolism during pregnancy or while taking oral contraceptives, patients more than years of age, prolonged bed rest, complicated or cesarean delivery, and inherited coagulation defects. clinical symptoms of pulmonary embolism (pe) include acute onset of dyspnea, tachypnea, tachycardia, and pleuritic chest pain that can rapidly progress to arrhythmias, syncope, and cardiovascular collapse if the pe is massive. despite the current availability of an array of diagnostic tests, diagnosis of a pregnant woman with suspected pe is very challenging. recent ats guidelines from the american thoracic society for evaluation of suspected pe in pregnancy recommend performing a chest radiograph (cxr) as the first test; if the chest x-ray is normal, then lung scintigraphy/ventilation-perfusion (v/q) scan is recommended and finally computed tomographic pulmonary angiography (ctpa) rather than digital subtraction angiography (dsa) if the ventilation-perfusion (v/q) scan is negative. the patient can also be evaluated for the presence of a deep venous thrombosis (dvt), the presence of which increases the likelihood that the patient has a pe. again, it is very difficult to diagnose dvt during pregnancy since contrast venography, which is the diagnostic test for dvt in nonpregnant patient, is usually performed in a limited manner to minimize the radiation exposure, thus decreasing the sensitivity of the test. treatment of dvt and pe necessitates the use of anticoagulants. heparin is the drug of choice since warfarin crosses the placenta and can cause fetal dysmorphism, congenital heart defects, and growth retardation. low-molecular-weight heparin (lmwh) is an alternative to standard heparin treatment and appears to be safe in pregnancy with fewer adverse effects such as thrombocytopenia and osteoporosis. treatment should be given throughout pregnancy and continued for about - weeks after delivery. if thrombosis occurs late in the pregnancy, treatment may be required for up to months after delivery. thrombolytic therapy has also been used successfully in life-threatening thromboembolism during pregnancy. other management options for a massive pulmonary embolism in pregnancy include surgical embolectomy and catheter-directed therapy. during uncomplicated pregnancies, small amounts of amniotic fluid may enter the maternal circulation. amniotic fluid contains fetal debris, including desquamated squamous cells, meconium, lanugo hair, and mucin. in a very small percentage of deliveries (estimated at . per , deliveries), amniotic fluid embolism develops with high maternal mortality rates of - %. clinical signs include sudden onset of severe dyspnea, hypoxemia, cyanosis, cardiovascular collapse, seizures, and coma that may occur during labor and delivery. this may progress to ards and disseminated intravascular coagulation (dic). risk factors for developing amniotic fluid embolism include premature rupture of membranes, advanced maternal age, meconium staining of amniotic fluid, multiparity, and cesarean section. disruption of the uterine veins has a role in pathogenesis. two possible sites of entry are at the site of placental separation and small tears in the lower uterus and endocervix. it is unclear how much amniotic fluid is required to initiate the syndrome. the diagnosis can be made by the presence of a large amount of fetal squamous cells, mucin, and lanugo in the blood removed from the distal lumen of a wedged pulmonary artery catheter. treatment is primarily supportive for disseminated intravascular coagulation and cardiopulmonary failure. venous air embolism results from entrapment of air in the venous system. it is an infrequent complication of pregnancy but can occasionally occur during labor and delivery especially during cesarean sections, induced abortions, manual extraction of placenta, and vacuum and forceps delivery. it has been also reported as a possible complication of oro-genital sex during pregnancy. air passes beneath the fetal membranes and into the circulation of the subplacental sinuses. nonfatal air embolism during cesarean section may be more common than appreciated (studies suggest an incidence as high as %). a lethal air embolism may follow a bolus of - cc/kg of air. the clinical presentation is acute onset tachypnea, chest pain, and gasping due to obstruction of pulmonary arterial blood flow. diagnosis is very difficult and requires a high index of suspicion. transesophageal echocardiogram offers the most sensitive measurement of air trapped within the right atrium or ventricle; however, it has the limitation of being invasive. precordial doppler is less sensitive but noninvasive. management includes optimum patient positioning, aspiration of air, discontinuation of nitrous oxide, administration of % oxygen, and flooding the surgical site with saline to prevent further air entry. there are case reports of maternal and fetal death with venous air embolism, so familiarity with this syndrome is important if prompt and appropriate therapy is to be provided. pulmonary arteriovenous malformations (pavms) are abnormal communications between the pulmonary and systemic circulation, which cause a right-to-left shunt. more than half of the cases reported during pregnancy are associated with hereditary telangiectasia, an autosomal dominant disorder characterized by the development of multiple arteriovenous malformations in the skin, mucous membranes, and/ or visceral organs. these pavms may expand during pregnancy because of the increase in blood volume, cardiac output, and venous distensibility, which increases the likelihood of rupture leading to life-threatening hemoptysis and hemothorax. diagnosis is based upon transthoracic contrast echocardiography and ct scan that also help to plan percutaneous embolization, which is the treatment of choice during pregnancy. spontaneous pneumothorax is primary when it occurs in a person with no apparent lung disease or secondary as a complication of preexisting lung disease. it is rare in pregnancy. it can occur in the pre-or postpartum period but is most common during labor when the increase in alveolar intrathoracic pressure causes rupture of previously unrecognized blebs in the subpleural space. common predisposing factors for pneumothorax in pregnancy are previous respiratory infections, asthma, or a previous pneumothorax unrelated to pregnancy. the diagnosis may be obscured due to other causes of dyspnea in pregnancy or the discomfort of parturition. this is a potentially serious situation since any impairment in ventilation during pregnancy can have detrimental effects on both the mother and fetus. spontaneous pneumothorax should be considered in a pregnant woman with acute onset dyspnea, chest pain, or history of prior pneumothorax. prompt recognition and timely treatment of pneumothorax can prevent complications. the diagnosis can be confirmed with a chest radiograph with an abdominal shield. initial management is generally based on the size of the pneumothorax and may involve observation, drainage with a chest tube, or video-assisted thoracotomy (vats). if the pneumothorax occurs close to term and is large enough to require placement of a chest tube, induction of labor should be considered with the chest tube in place to avoid recurrence during labor. there is no evidence that cesarean section is necessary, and it should be performed for obstetric indications only. patients with recurrent pneumothorax, who require vats, should undergo surgery after the period of organogenesis and before the pregnancy is too far advanced. improvement in survival and quality of life in patients with lung transplants has prompted them to consider pregnancy. successful pregnancy is possible after lung transplantation, but it requires planning and a multidisciplinary team approach involving maternofetal medicine, respiratory and transplant medicine, anesthesia, neonatology, genetics, and social services. since the first successful pregnancy reported in in a patient with single lung transplant, there have been several successful pregnancies. the report of the national transplantation pregnancy registry reported pregnancies in lung transplant recipients, of which were live births. cystic fibrosis was the most common cause of lung transplant in out of recipients. according to the most recently (in ) published management update on pregnancy after solid organ transplantation, it is recommended that pregnancy should be avoided for at least year after transplant to minimize the episodes of acute rejection. it is also recommended that adequate and stable graft function should be achieved before pregnancy. patients should be counseled regarding the increased risk for both maternal and neonatal complications including prematurity and low birth weight. of note is that the frequency of congenital malformations is similar to that of the general population ( - %). the risk of rejection in patients who have stable graft function is not increased, except for patients with lung transplants who have a higher incidence of acute rejection compared with other organs (lung, %; heart, %; liver, %; kidney, %). lung transplant recipients are at a higher risk of developing hypertension and renal dysfunction. these comorbidities increase the risk of preeclampsia and preterm delivery, ( - % vs. - % in the general population). vaginal delivery is acceptable unless cesarean section is indicated for obstetric reasons. breastfeeding should be avoided to prevent exposure of the newborn to immunosuppressive drugs. physiological and hormonal changes of pregnancy may predispose pregnant women to developing osa. however, the prevalence of osa among women of reproductive age is estimated to be - %, but the exact prevalence of osa among pregnant women is not known. there is some evidence suggesting that osa is associated with adverse maternal and fetal outcomes, due to low oxygen levels during apneic episodes. there are some protective mechanisms against osa during pregnancy. high levels of progesterone have a stimulatory effect on the respiratory system, a decrease in rem sleep in later stages of pregnancy, and the rightward shift of the oxyhemoglobin dissociation curve. osa generally occurs in obese patients and is precipitated by the estrogen-induced airway mucosal edema and vascular congestion. snoring is the most common symptom of osa, but it is less specific than witnessed apneas and choking sensations during sleep for a diagnosis of osa. there are no specific guidelines for screening pregnant women for osa; however, it is prudent to evaluate pregnant women with loud snoring and witnessed apneas with overnight polysomnography. nasal continuous positive airway pressure (cpap) is generally well tolerated during pregnancy. patients should also be encouraged to follow conservative measures such as sleeping in the side position, elevation of the head of the bed, and avoiding the use of alcohol and sedatives. postpartum withdrawal of therapy with close follow-up should be considered due to rapid improvement of sleep apnea symptoms in the postnatal period. rare diseases are defined as conditions affecting less than in people (in europe) or less than , individuals (in the united states). rare lung diseases (rld) constitute % of these rare diseases. rld are chronic in character and often have a poor prognosis. advances in medicine have improved the survival and the quality of life in these patients, so they seek medical advice in planning their reproductive life. however, in certain conditions, pregnancy is contraindicated due to the adverse effect on the course of the disease. in lymphangioleiomyomatosis (lam), there is a very high risk of pneumothorax and loss of lung function, and in primary pulmonary hypertension (pph), there is a high risk of mortality. the contraceptive method should be individualized based on the personal choices of the patients and on the underlying disease process. all patients can safely use condoms. oral contraceptives should be used cautiously in patients with cystic fibrosis due to poor absorption; they are absolutely contraindicated in lam due to disease progression from exogenous estrogen. since pregnancy is contraindicated in lam, surgical sterilization should be considered in patients with lam and pph. consideration should also be given to the future possibility of lung transplantation; therefore, combined hormone contraceptives should be avoided due to the risk of pulmonary thromboembolism. currently, the experience in managing the reproductive health of women with rld is limited, but based on the current experience, individualized and multidisciplinary approach is recommended to assist patients in making the best decisions about contraception and pregnancy. endometriosis is a condition characterized by the presence of endometrial tissue outside of the uterine cavity or myometrium. it is encountered most commonly in pelvic structures such as the ovary, uterine ligaments, pelvic peritoneum, cervix, labia, and vagina. thoracic endometriosis syndrome (tes) is defined as the presence of endometrial tissue in or around the lung. endometrial tissue may be present in the lung parenchyma, visceral and parietal pleura, diaphragm, and endobronchial sites. there are four distinct clinical entities: (a) catamenial pneumothorax (b) catamenial hemothorax (c) hemoptysis (d) pulmonary nodules the clinical manifestations of tes imply the presence of endometrial tissue in the thoracic cavity that undergoes cyclical sloughing in response to the physiologic hormonal variations, and the clinical presentation depends on the affected structures. how endometrial tissue migrates to the thoracic cavity has remained elusive; however, three theories have been proposed to explain it: (a) retrograde menstruation with subsequent transperitoneal-transdiaphragmatic migration of endometrial tissue (b) coelomic metaplasia (c) lymphatic or hematogenous embolization from the uterus or pelvis the disease probably has a multifactorial etiology, since none of these theories can fully explain all the clinical manifestations of tes. since tes is a rare condition, a high index of suspicion is the key to timely diagnosis. the clinical presentation is of a woman in her reproductive years (with a peak incidence between the ages of and years), who reports recurrent episodes of chest pain, dyspnea, or cough around the time of her menstrual cycle. catamenial pneumothorax accounts for only . - % of cases of spontaneous pneumothorax in women even though it is the presenting symptom in % of cases of tes, followed by hemothorax in % and hemoptysis in %. physical examination findings are nonspecific. ct and mri have been shown to be helpful in the diagnosis. mri may be superior to ct since it helps in differentiating pleural from parenchymal implants. bronchoscopy has a limited role in diagnosis due to the peripheral location of the disease and the low diagnostic yield of bronchial washings. in the era of endoscopic surgery, vats allows direct visualization of the lung and diaphragmatic surfaces for endometrial implants. the size of the implants usually ranges from a few millimeters to a centimeter, and depending on the timing during the menstrual cycle, their color varies from brown to violet. exploratory thoracotomy now has a limited role in the diagnosis and is used in cases of failure of vats exploration. catamenial pneumothorax (cp) refers to the occurrence of spontaneous pneumothorax during mensuration. it is also known as menstruation-related spontaneous pneumothorax (msp) which was first reported in the s by maurer et al., who defined it as pneumothorax occurring within - h after onset of menses. in , lillington et al. introduced the term catamenial pneumothorax for spontaneous pneumothorax associated with menses. previously considered to be rare, current knowledge suggests that cp is a more common reason for spontaneous pneumothoraces in women of reproductive age. as mentioned in the previous section, cp is frequently associated with thoracic endometriosis syndrome (tes), but there might be other etiological mechanisms. the etiology of the remainder is obscure, but a number of theories have been proposed. during menstruation, the absence of the normal cervical mucus plug provides a connection between the ambient air and the abdominal cavity through the uterus and fallopian tubes, hence allowing the air to move across the diaphragm through right-sided diaphragmatic fenestrations into the pleural space. this may account for the fact that - % of msps are right-sided. a second theory is that bronchospasm with air trapping and pneumothorax may occur due to high levels of prostaglandin f during menstruation. the third theory is that pleural blebs or bullae are more prone to rupture during menstruation because of hormonal changes. for cases that are not clearly associated with systemic endometriosis, thoracoscopy during menstruation helps determine the etiology. successful treatment necessitates a combined medical and surgical approach. the medical therapy of tes primarily focuses on blocking the hormonal support from the ovaries that fosters the growth of the endometrial tissue. it consists of oral contraceptives, progestational agents, danazol, and gonadotropin-releasing hormone (gnrh) agonists. surgical approaches include excision, local laser ablation, or pleurodesis. the recurrence rate with medical treatment exceeds % and subsequently requires surgical management. conversely, there are reports of recurrence after surgical treatment of msp that responded to subsequent hormonal therapy, so the current opinion is a sequential medical-surgical or surgical-medical approach. lymphangioleiomyomatosis (lam) was a disease of unknown origin in the mid- s, with no effective treatment. during the last decade, substantial progress has been made in understanding the natural history of the disease with support from nhlbi (national heart, lung, and blood institute). once defined as a fatal disease of women of childbearing age, it is now known that lam occurs in postmenopausal women as well. lam is a rare, slowly progressive, multisystem disorder of women characterized by proliferation of abnormal smooth muscle-like cells (lam cells) associated with cystic lesions in the lungs and in the axial lymphatics (lymphangioleiomyomas) and angiomyolipomas. in the lungs, the cells are present along the pulmonary blood vessels, lymphatics, and bronchioles. lam occurs in association with tuberous sclerosis complex (tsc) which is an autosomal dominant syndrome characterized by multisystem hamartoma-like tumor growths or sporadically with no evidence of a genetic abnormality. sporadic lam is rare with a prevalence of - /million. in both cases, lam is caused by a mutation in one of the two tumor suppressor genes tsc or tsc that produce hamartin and tuberin, respectively. lam most frequently presents with progressive breathlessness, recurrent pneumothorax, hemoptysis, or chylothorax. extrapulmonary manifestations include an intra-abdominal hemorrhage or an abdominal mass. patients who present with dyspnea and hemoptysis generally have a more severe disease and higher mortality than those presenting with pneumothorax. lam histology score (lhs), quantitative ct scan, and pulmonary function testing including exercise testing assist in assessing severity of the disease. airflow obstruction and decreased lung diffusion capacity are the most frequent lung function abnormalities in lam. exercise tests are frequently abnormal in lam patients who have low-grade pulmonary hypertension which worsens on exercise. currently the best methods to assess the severity and progression of lung disease are frequent monitoring of fev and dlco and the -min walk test. the focus of current research is to identify possible treatment targets. studies have shown a potential role for sirolimus (rapamycin), an immunosuppressant drug that inhibits the hyperphosphorylation of ribosomal protein s and p s kinase activation which is unregulated in lam cells in the absence of tuberin (protein product of tsc gene). another potential drug doxycycline is an inhibitor of matrix metalloproteinase (mmp) and has shown improvement in fev and dlco when used in the treatment of patients with severe lam. antiestrogen therapy and oophorectomy, which were once considered conventional therapies, are no longer universally recommended. gestational trophoblastic disease (gtd) is a term used for a rare group of pregnancyrelated disorders ranging from benign, partial, and complete hydatidiform mole, invasive and metastatic mole, and malignant choriocarcinoma. trophoblastic pulmonary embolization is a rare complication of gtd and can occur following abdominal hysterectomy for invasive mole as well as after molar evacuation. the clinical course is dramatic with acute onset dyspnea, tachypnea, bilateral pulmonary infiltrates, and low oxygen levels. possible etiologies for pulmonary findings include pulmonary trophoblastic embolization, hypervolemia, aspiration, dic, and hyperthyroidism. although not very common, pulmonary trophoblastic embolization should be considered part of the differential diagnosis if a patient has acute onset respiratory distress in the postoperative period. malignant choriocarcinoma is associated with metastases to the lungs, which is the most common site of metastases. ovarian hyperstimulation syndrome (ohss) is an exaggerated response to the use of exogenous gonadotropins to induce ovulation for in vitro fertilization. the syndrome has a broad spectrum of clinical presentations ranging from abdominal pain from ovarian enlargement, ovarian cysts, ascites, dyspnea, intravascular volume depletion, and acute renal failure. ohss is characterized by increased capillary permeability resulting in fluid shift from the intravascular space to third space compartments. various factors have been previously implicated in the process including estrogen, prolactin, histamine, and prostaglandins, but recently it is thought to be related to vasoactive mediators such as interleukins, tumor necrosis factor-α, endothelin- , and vascular endothelial growth factor (vegf). risk factors to developing ohss include young age, low body weight, polycystic ovary syndrome (pcos), use of higher dose of exogenous gonadotropins, and previous episodes of ohss. pulmonary manifestations include dyspnea that may result from decreased diaphragmatic movement due to abdominal enlargement. other rare complications include pleural effusion, pulmonary edema, atelectasis, and acute respiratory distress syndrome (ards). pulmonary embolism is a life-threatening complication and may occur due to hypercoagulable state. treatment is supportive and directed at maintaining intravascular blood volume. ohss is a self-limiting disease, so most patients respond to medical therapy, and surgical intervention is required only for complications such as ruptured ovarian cyst or ovarian torsion. thoracocentesis may be needed for bilateral or persistent pleural effusions. polycystic ovarian syndrome (pcos) is a common endocrine disorder affecting almost - % of females and characterized by menstrual irregularity, hyperandrogenism, obesity, and polycystic ovaries. patients with pcos are at increased risk of various metabolic derangements such as insulin resistance, glucose intolerance, dyslipidemia, and hypertension. obstructive sleep apnea (osa) has been recently recognized as a significant contributing factor to the pathophysiology of metabolic derangements in pcos. recent studies have shown that there are two distinct clinical entities: pcos with osa and pcos without osa. pcos women with osa may be at much higher risk for the development of diabetes and cardiovascular disease than pcos women without osa. the risk for osa in pcos is -fold higher than in similarly obese women. it is proposed that osa possibly triggers one or more of three major hormonal responses that contribute to the metabolic abnormalities associated with it. they are: (a) activation of the hypothalamic-pituitary-adrenal (hpa) axis with increased cortisol production and secretion (b) increased catecholamine output from sympathetic nervous system stimulation (c) increased release of adipokines from the adipose tissue treatment of patients with osa in pcos with cpap is important as it improves the metabolic profile. pregnancy and the lung respiratory physiology in pregnancy pregnancy and the lungs asthma in pregnancy respiratory disease in pregnancy respiratory disease in pregnancy prescribing for the pregnant patient national asthma education and prevention program asthma and pregnancy working group. naepp expert panel report. managing asthma during pregnancy: recommendations for pharmacologic treatment- update asthma in pregnancyimmunological changes and clinical management pregnancy in cystic fibrosis. fetal and maternal outcome pregnancy in cystic fibrosis lung transplant recipients: case series and review report from the national transplantation pregnancy registry (ntpr): outcomes of pregnancy after transplantation pregnancy after lung transplant pregnancy after lung transplant: case report. breathe (sheff) acute pulmonary edema in pregnancy sleep-disordered breathing during pregnancy circadian variation of sleep during the follicular and luteal phases of the menstrual cycle polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance death due to air embolism during sexual intercourse in the puerperium acute pulmonary oedema in pregnant women progression of pulmonary arteriovenous malformation during pregnancy: case report and review of the literature pulmonary arteriovenous malformations. a state of the art review thoracic endometriosis: current knowledge thoracic endometriosis syndrome: case report and review of the literature gestational trophoblastic disease trophoblastic pulmonary embolization after hysterectomy for invasive complete mole. a case report update on the diagnosis and management of gestational trophoblastic disease sirolimus for angiomyolipoma in tuberous sclerosis complex or lymphangioleiomyomatosis catamenial pneumothorax revisited: clinical approach and systematic review of the literature spontaneous pneumothorax contraception, pregnancy and rare respiratory diseases of thoracic radiology clinical practice guideline-evaluation of suspected pulmonary embolism in pregnancy obstructive sleep apnea and metabolic dysfunction in polycystic ovary syndrome a national heart, lung, and blood institute history and perspective on lymphangioleiomyomatosis practice committe of the american society for reproductive medicine. ovarian hyperstimulation syndrome key: cord- -ro nhody authors: louis, mariam; oyiengo, d. onentia; bourjeily, ghada title: pulmonary disorders in pregnancy date: - - journal: medical management of the pregnant patient doi: . / - - - - _ sha: doc_id: cord_uid: ro nhody pregnancy is associated with some profound changes in the cardiovascular, respiratory, immune, and hematologic systems that impact the clinical presentation of respiratory disorders, their implications in pregnancy, and the decisions to treat. in addition, concerns for fetal well-being and safety of various interventions complicate the management of these disorders. in many circumstances, especially life-threatening ones, decisions are based upon a careful assessment of the risk benefit ratio rather than absolute safety of drugs and interventions. in this chapter, we review some of the common respiratory disorders that internists or obstetricians may be called upon to manage. asthma is the most common respiratory disease during pregnancy. asthma affects - % of pregnancies in the united states and up to % in the united kingdom and australia. difference in prevalence around the world may be related to reporting methods, diagnostic methods, or possibly some environmental or genetic infl uences. pregnancy is a state of important physiological changes in the respiratory system. these physiological changes vary across the course of the pregnancy and are summarized in table . . • - in fi rst trimester and - by third trimester paco (mmhg) • - in fi rst trimester and - by third trimester ph • . hco (meq/l) • - tlc total lung capacity, erv expiratory reserve volume, rv residual volume, frc functional residual capacity, vc vital capacity, ic inspiratory capacity, irv inspiratory reserve volume, fev forced expiratory volume in s, fvc forced vital capacity, pao partial arterial pressure of oxygen, paco partial arterial pressure of carbon dioxide the course of asthma during pregnancy is variable. the majority of patients who improve in pregnancy tend to worsen in the postpartum period and vice versa [ ] . in general, asthma improves toward the end of the pregnancy, including labor and delivery. however, the rate of asthma exacerbations is increased between gestational weeks and [ , ] . this may in part be due to medication noncompliance during the earlier part of the pregnancy upon discovery of the pregnancy but may also have to do with other pregnancy-related factors such as esophageal refl ux, nasal congestion, hormonal factors, and alterations in immunity that may result in increased susceptibility to infections. the major predictor of disease course is the severity of asthma prior to the pregnancy, but race and obesity may also play a role. african american and hispanic women are more likely to have asthma exacerbations. poor compliance with medications and diffi culties with access to medical services may be important confounders. additionally, obese women tend to have more severe asthma as both asthma and obesity share a common infl ammatory pathway at the cellular level. asthma also tends to behave in a similar fashion in subsequent pregnancies. while well-controlled asthma does not appear to have adverse consequences during pregnancy, poorly controlled asthma may negatively impact some maternal and fetal outcomes. in the largest study performed to date on over , women with asthma and over , controls, asthmatic women were more likely to have pregnancies complicated by miscarriage, antepartum and postpartum hemorrhage, anemia, and depression [ ] . however, the risk of other negative outcomes such as gestational hypertensive disorders and stillbirths was not signifi cant in this study. in other large studies, a small, but statistically signifi cant risk of perinatal mortality, preeclampsia, and preterm deliveries have been reported [ , ] . a more recent retrospective cohort study performed in clinical centers in the united states has shown increased risk of preeclampsia, gestational diabetes, and all preterm births [ ] . secondary analysis of a recent randomized controlled trial showed that women with perception of good asthma control had a reduced risk of planned cesarean deliveries, asthma exacerbations, and preterm birth [ ] . in the same study, women with increased anxiety had a higher risk of exacerbations. there is some evidence suggesting that poorly controlled asthma also confers an increased risk of small for gestational age, and low birth weight [ ] . growth restriction may, however, be confounded by smoking. babies born to severe asthmatics are possibly more likely to have congenital anomalies [ ] . the treatment of asthma involves assessment and management from preconception to the postpartum period. please refer to table . and figure . for a general overview of the classifi cation and management of chronic asthma. there are four general components of asthma care, irrespective of gestational age. these are ( ) monitoring of respiratory status, ( ) avoidance of possible triggers, ( ) patient education, and ( ) pharmacological treatment. patients should get a baseline spirometry and be instructed in how to follow their peak expiratory fl ow rate (pefr) at home. ideally, this should be done twice a day in patients with persistent disease. since pregnancy does not affect fl ow rates, reductions in these numbers usually indicate a worsening degree of airfl ow obstruction and should prompt quick medical evaluation. second, it is critical that patients avoid their known triggers to asthma including tobacco, dust, extreme temperatures, and allergens such as pollen and pet dander. third, patients need to be educated about their disease. pregnancy constitutes a perfect window to educate women given the multiple contacts with providers increased motivation due to concerns for fetal well-being. trigger control from washing bed sheets to vacuuming to rodent control are important strategies to review, especially since in most circumstances, women are more likely to be exposed to these triggers. important topics that need to be reviewed also include inhaler technique, early recognition of symptoms of worsening asthma, an action plan for acute asthma exacerbations, as well as an overview of how poorly controlled asthma can affect the pregnancy. patients should also be provided with the opportunity to express their concerns and ask questions. in a multi-institutional prospective study, lower forced expiratory volume in s (fev ), but not asthma symptom frequency, was shown to be associated with adverse perinatal outcomes [ ] . these data may be a refl ection of the effect of asthma severity or poor asthma control on perinatal outcomes and emphasize the possibility of discrepancies between symptom-based assessment and more objective measurement of lung function in pregnant women with asthma. finally, women with asthma need to receive the appropriate pharmacological treatment to achieve disease control. populationbased data do show that well-controlled asthmatics without exacerbations have better outcomes than women with exacerbations, but for obvious reasons, there are no randomized controlled trials evaluating this particular question. although most clinical practices use symptom-based, guideline-directed assessments to decide on medication use, recent data from a randomized controlled trial suggest lower rates of exacerbation, improved quality of life, and reduced neonatal hospitalization when management decisions were based on measurements of exhaled nitric oxide in pregnancy [ ] . it is likely that this improvement in outcomes is due to improved control, rather than the method of assessment itself. table . provides an overview of the asthma medications that are used in pregnancy. as in the nonpregnant population, the choice of pharmacological agent depends on disease severity. a frank discussion with the expectant mother and her partner should occur to encourage them to voice their concerns regarding asthma treatment in pregnancy. most women are told to stop their inhalers at the time of pregnancy diagnosis because of fda category listing. for that reason, a good amount of time should be spent on counseling about the use of asthma drugs in pregnancy. explaining to women that asthma control is key to the health of the pregnancy and their baby is an important part of counseling and may have to be done repeatedly during the course of pregnancy. in general, most asthma medications are justifi able in pregnancy, and some have adequate safety data. as noted in table . , many of the drug choices are category c according to the fda classifi cation; however, these drugs are used routinely in the care of pregnant women with asthma. in addition, although leukotriene inhibitors are listed as category b, safety data are less reassuring than other drugs classifi ed as category c. omalizumab is classifi ed as category b by the fda despite the fact that all of the initial trials have excluded pregnant women. these safety data are based on animal studies which are limited by the fact that teratogenicity may be species specifi c. in addition, although prednisone may be associated with a small risk of cleft palate when administered in early pregnancy, the benefi t of this drug in an acute exacerbation of asthma by far outweighs the small risk of malformation. table . reviews the classifi cation of asthma severity, which includes not only symptoms but also peak fl ow meter measurements. other coexisting diseases may worsen asthma and may have to be treated in order to achieve optimal control. the most common of these disorders are allergic rhinitis, gastroesophageal refl ux disease (gerd), sleep apnea, and psychiatric illnesses. allergic rhinitis occurs in - % of nonpregnant asthmatics and worsens asthma symptoms. management of the allergic rhinitis with drugs such as steroidal nasal sprays often improves asthma symptoms. women who are pregnant can also develop a different form of rhinitis, called rhinitis of pregnancy. this typically occurs in the latter part of pregnancy and resolves completely within weeks after delivery. the prevalence of gerd among nonpregnant asthmatics varies between and %. in pregnant women with asthma, this number is likely higher given that gerd has been reported to be present in nearly % of all pregnant women [ ] . gerd can worsen bronchoconstriction via increased vagal tone, heightened bronchial reactivity, and microaspiration of gastric contents into the upper airway. patients who have symptoms of gerd benefi t from treatment. although proton pump inhibitors are not expected to increase the risk of congenital malformation in experimental animal studies and limited human pregnancy exposures, ranitidine constitutes a safer fi rst choice. finally, asthma and psychiatric comorbidities may coexist. stress and mental illness can worsen asthma in the pregnant women and may also complicate compliance. during labor, the general management of asthma is not signifi cantly different than above. most patients with asthma do not require a labor and delivery plan. however, patients with more severe disease or those who suffered an exacerbation close to term would require a detailed plan. stress dosing with steroids during labor can be considered in patients who have been on prolonged periods of systemic steroids during the pregnancy. patients with active symptoms or more severe asthma may benefi t from regional anesthesia. epidural anesthesia reduces minute volume and oxygen consumption and may help prevent hyperinfl ation in patients with active symptoms and reduce oxygen consumption. if general anesthesia is to be considered, then ketamine and halogenated anesthetics are preferred. it is safe to use oxytocin and prostaglandin e . however, ergotamine and ergot derivatives, -methyl prostaglandin f alpha, morphine, and meperidine should be avoided in pregnant women with asthma as they may be associated with an increased risk of bronchospasm. an overview of the management of acute asthma exacerbations in the pregnant woman is detailed in fig. . . more detailed information can be found in national heart lung and blood institute guidelines on asthma and pregnancy published in . the treatment is similar to nonpregnant women with a few key differences that need to be highlighted. the fi rst is to remember that during pregnancy, the normal paco is lower than in the nonpregnant state. therefore, a normal or high paco heralds worsening respiratory failure and should be acted upon quickly. second, hypoxia during asthma exacerbations can lead to fetal distress and decelerations. therefore, immediate bronchodilators and supplemental oxygen should be administered. finally, it should be noted that while the indications for airway intubation are the same in the pregnant asthmatic as the nonpregnant asthmatic, intubation during pregnancy, especially in the third trimester, can be more diffi cult. this is due to increased airway edema, low frc and oxygen reserve, and a more profound response to sedatives from decreased venous return. hence, the most experienced member of the team should perform the intubation and be familiar with diffi cult airway management procedures. airway intubation is discussed in more detail in the critical care chap. . pneumonia is one of the leading causes of non-obstetric maternal deaths in the united states [ ] . there are several categories of pneumonia based on the likely spectrum of pathogens: community-acquired pneumonia (cap), healthcareassociated pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia as well as pneumonia in the immune-compromised host. as pregnant women are usually young and healthy, cap predominates. the overall rate of cap in pregnant women is . - / , pregnancies depending on the population being studied [ - ] . the risk of pneumonia is notably increased in gravidas with comorbid conditions such as asthma, anemia, and human immunodefi ciency virus [ ] . tobacco and substance abuse have also been independently associated with an increased risk for pneumonia. infl uenza increases the risk for development of bacterial pneumonia by denuding the respiratory epithelium and predisposing the host to infection. in adults, the causative agents for cap are identifi ed in - % of cases when advanced testing techniques are utilized [ , ] . the yield is much lower, in the range of - %, with regular testing. though specifi c studies in pregnant women are lacking, the likely pathogens are not considered to be signifi cantly different • less severe symptoms • pefr between - % predicted [ ] . pregnant women may be more likely to contract viral infections and tend to have more severe disease than the nonpregnant population. therefore, the estimates above may be somewhat different in pregnancy. gingival hyperplasia in pregnancy may promote changes in oral fl ora and promote growth of anaerobic bacteria. aspiration risk and heartburn [ ] may be increased in pregnancy, especially when undergoing sedative procedures or general anesthesia. whether these changes and increased gastroesophageal refl ux disorders are associated with increased risk of pneumonia is not clear. immune alterations in pregnancy that promote maternal tolerance to the fetus may impair optimal function of host defense mechanisms and increase the risk of infections. pregnant women have decreased lung capacity and decreased erv and rv resulting in a reduction in functional residual capacity. a state of compensated respiratory alkalosis is established by increasing minute ventilation. this is largely secondary to an increase in tidal volume and to a lesser extent an increase in respiratory rate. healthy gravid subjects have increased cardiac output and decreased oncotic pressure which peaks in the third trimester that promotes transudation of fl uid into the pulmonary interstitium. these changes diminish oxygen reserve, increase the risk of development of pulmonary edema with fl uid resuscitation, and predispose to respiratory failure and predispose women to more severe disease. pneumonia may be complicated by hypoxia, respiratory failure, or death, and preterm delivery appears to be the most common obstetric complication associated with maternal pneumonia. while intrauterine infection is known to cause preterm delivery, a causal relationship between pneumonia in pregnancy and preterm delivery is not well established. it is possible that higher levels of cytokines and other mediators such as tnf-α and prostaglandin f reported in bacterial infections may lead to preterm delivery and low birth weight. other reported complications include placental abruption, preeclampsia and eclampsia, and low apgar scores [ - ] . it is unclear, however, whether these complications are related to the actual infection or to other host factors. common causes for respiratory distress in pregnancy include infection such as urinary tract infection, pulmonary edema, asthma, aspiration, and pulmonary embolus. the clinical spectra of pneumonia caused by different pathogens overlap considerably. thorough history and examination along with microscopic examination of respiratory secretions may narrow the differential diagnosis and identify the offending pathogen. urine pneumococcal and legionella antigen may also aid in guiding antibiotic therapy and should be considered for patients requiring admission. during infl uenza seasons, respiratory viral panel should be sent. though blood cultures are usually negative and of low yield, they may add value in the patient requiring admission to the intensive care unit (icu). arterial blood gas should be done for all patients with hypoxia or those requiring admission to the icu and interpreted according to pregnant status. chest x-ray should be performed in patients suspected of having pneumonia and helps confi rm the diagnosis or show evidence of a complicated pneumonia such as lung abscess or pleural effusion. computed tomography scan is unlikely to add value in the management of pneumonia, unless empyema is suspected. ultrasound guidance likely reduces the risk of complications with thoracentesis in pregnancy given the cranial displacement of the diaphragm in pregnancy. bronchoscopy though rarely needed can be performed safely in pregnancy and should not be withheld when indicated. general supportive measures are similar in patients with various types of pneumonia. for patients with a viable fetus who require admission, the obstetric team should be consulted for fetal monitoring as well as timing of delivery in the event of fetal distress. hypoxia, acidosis, and fever should not be tolerated as they are independently associated with poor fetal outcomes. oxygen should be supplemented for goal saturations > % or pao above . fever should be treated aggressively for a goal temp of less than °c. in cases of severe pneumonia associated with respiratory failure, early intubation should be considered. intubations in pregnancy have a higher failure rate than the general surgical population (see chap. on airway intubation ). attempts to maintain co within an acceptable range may be challenging in the event of acute respiratory distress syndrome (ards) and the use of lung protective strategies. low tidal volume ventilation strategy with a target tidal volume of ml/kg is recommended for ards [ ] . though pregnant women were excluded in the acute respiratory distress network studies on lung protective strategies, low tidal volume ventilation should be attempted, initially with a higher respiratory rate to maintain ventilation given the survival benefi t observed in the nonpregnant population. however, higher tidal volumes may be required to correct acidosis that may compromise the fetus, in such instances attempts should still be made to keep the plateau pressure below cm of water as barotrauma is thought to contribute signifi cantly to lung injury. paco levels need to be watched closely, and given the mmhg gradient between fetal and maternal, maternal paco should be kept at mmhg or lower. use of bicarbonate to correct the ph has been suggested in the nonpregnant population though clinical studies to support this approach are limited. it is thought that the transfer of bicarbonate across the placenta is slow and may not be adequate to correct fetal acidosis. while the decision to admit patients to the icu is complex and should be individualized, clinicians should have a lower threshold when evaluating pregnant mothers. antibiotic therapy should be initiated empirically while awaiting confi rmatory tests that may aid in narrowing the antimicrobial coverage. in infl uenza season, antiviral (usually oseltamivir) should be started empirically as well. decisions about antibiotic choice should address the most likely pathogen, adverse effect on the mother, and should also weigh the risk of the specifi c drug to the fetus against the risk of inappropriately treated disease. an optimal drug would be one with maximal efficacy against the known pathogen and no risk to the fetus. however, such drugs are scarce, and in most circumstances, a drug with more benefi t than risk can be selected. other than concern for fetal safety, preferred antibiotics are not different from those in nonpregnant women, but dosing should take into account increased hepatic and renal clearance and increased volume of distribution. there is a theoretical concern that aminoglycosides and vancomycin may be associated with hearing and kidney dysfunction in the offspring, but this possibility has not been confi rmed clinically. penicillins, clindamycins, and most macrolides except clarithromycin have a good safety profi le. fluoroquinolones are usually avoided in pregnancy due to a theoretical risk of arthropathy in the offspring. however, some experts argue that this issue is not clinically signifi cant in humans. tetracyclines should be avoided as they may cause permanent dental discoloration. varicella (chicken pox) is caused by varicella zoster virus (vzv). varicella is predominantly a childhood illness that is usually self-limited and rarely results in severe disease. in adults, however, it is much more likely to be severe. vzv is not only likely to have increased morbidity and mortality in pregnancy but may also be associated with congenital abnormalities and poor fetal outcomes. varicella pneumonia is among the most severe maternal complication of vzv infection [ - ] . viral particles are shed from varicella-associated vesicles and get airborne. inhalation or contact with the conjunctiva results into contraction of the infection with entry of the virus through the respiratory mucosa. crusting over of the last crop of vesicles usually marks the end of the contagious period. patients are known to be infectious - days prior to development of the vesicular rash; for this reason, an alternative viral shedding site such as the respiratory tract is believed to exist [ ] . varicella is highly contagious with seasonal variation in incidence, being most prevalent in the winter and spring. it has a very high clinical attack rate of - % following exposure to susceptible individuals [ ] . following a primary infection with varicella, lifelong immunity is usually established in the majority of subjects; in a few people, however, second attacks of varicella may occur [ ] . while varicella follows a benign course in children, adults have up to times increased risk of severe disease [ ] . pregnant women are at a uniquely increased risk for infection. in the united states, the incidence of primary varicella averages . - cases/ , pregnancies. varicella pneumonia complicates - % of all cases, and % of mothers with pneumonia require mechanical ventilation [ , ] . maternal mortality from varicella pneumonia used to be high at - % before the introduction of antiviral therapy but is currently estimated at less than - % [ , ] . changes in physiology and immunity associated with pregnancy may increase the risk of infection and severe outcomes in the pregnant women. in an effort to promote maternal tolerance to fetal antigens, pregnancy is associated with a shift from th to th lymphocyte responses and associated cytokines at the maternal fetal interface. macrophage and lymphocyte-secreted th cytokines stimulate b lymphocytes promoting a humoral response while suppressing cytotoxic lymphocytes. while pregnancy may not necessarily be an immune-suppressed state in the real sense, immunity against vzv infection is primarily cell mediated, and a systemic shift away from cell-mediated immunity may increase susceptibility to intracellular viral pathogens, parasites, and bacteria. primary varicella (chicken pox) is associated with several adverse effects in pregnancy such as preterm delivery and low birth weight. in one study involving pregnant women with varicella compared to a similar number of noninfected controls, . % of pregnant women with chicken pox had a preterm delivery as compared to . % of controls [ ] . low birth weight and intrauterine growth restriction have been described. nearly - % of cases of maternal primary vzv infection result in congenital varicella syndrome (cvs), which is associated with a mortality of up to % in the fi rst few months of life and severe disability in survivors. primary vzv infection prior to the th week of pregnancy is associated with the highest risk for cvs [ , ] . clinical features of cvs include skin lesions in a dermatomal distribution that may lead to eventual scarring in up to % of cases, muscle and limb hypoplasia in up to % of cases, chorioretinitis and cataracts in up to % of cases, and abnormalities of gastrointestinal, genitourinary, and cardiovascular system in - % of cases [ , ] . neurological abnormalities such as mental retardation, microcephaly, and hydrocephalus occur in - % of cases resulting in learning diffi culties and developmental delays [ ] . the pathobiology of cvs is thought to be in utero reactivation similar to that of herpes zoster with a shortened latency period that is likely due to immature fetal cell-mediated immunity. while up to % of babies born to mothers with primary vzv infection have serologic evidence of infection, there is no serologic evidence of infection in babies born to mothers with herpes zoster. similarly, infants do not appear to be at risk of infection if maternal zoster occurs near delivery [ ] . unless disseminated, herpes zoster is thus not associated with a signifi cant increase in adverse fetal outcomes [ , ] . peripartum varicella infection places the infant at risk for neonatal varicella, which is associated with mortality rate as high as %. following a -to -week incubation period, fever, headache, malaise, anorexia, and other constitutional symptoms precede the occurrence of the rash by - days. the rash is typically vesicular, generalized, and intensely pruritic. varicella pneumonia can develop anywhere from day to day after the onset of the rash. late onset of respiratory symptoms with recurrence of fevers is suggestive of bacterial coinfection rather than primary viral pneumonia. skin superinfection with staphylococcal bacteremia and neurological involvement with encephalitis may occur. a thorough history and skin exam may strongly suggest the diagnosis of varicella. chest radiograph pattern in varicella pneumonia is nonspecifi c and may be normal or show unilateral or patchy areas of consolidation or nodular opacities. ct fi ndings include multicentric hemorrhage and necrosis centered around the airways and small nodular opacities surrounded by ground glass which may coalesce to form consolidations. healed and calcifi ed pulmonary nodules may persist [ ] . skin lesion (rather than bronchoscopic) sampling offers a high yield and should be attempted fi rst. the base of newly erupted vesicles has the highest yield and should be sampled. specimens can then be sent for viral culture, polymerase chain reaction (pcr), and immunofl uorescence (dfa). direct fl uorescent antibody test is rapidly available in most institutions. though bronchoscopy in most cases is not necessary, varicella may be recovered from bronchial washings by viral pcr and viral culture techniques. pregnant women suspected of having varicella should be admitted for initiation of antivirals and other supportive treatment. chest imaging should be performed on admission to evaluate for pulmonary involvement. antiviral therapy is associated with a reduction in the duration of symptoms when initiated within the fi rst h of onset of the varicella rash. due to the high risk of varicella pneumonia in pregnancy, empiric antiviral therapy should be initiated while awaiting confi rmatory results. acyclovir or valacyclovir are the antivirals of choice. oral acyclovir has low bioavailability that requires it to be administered in frequent doses to achieve therapeutic levels. valacyclovir has high oral bioavailability and less frequent dosing intervals and is an alternative oral formulation. there is however less experience with valacyclovir compared to acyclovir. presence of pulmonary symptoms should prompt admission to the icu and initiation of intravenous acyclovir which has a guaranteed and higher bioavailability. antiviral therapy is associated with significantly less morbidity and mortality when initiated prior to h. late presentation with varicella pneumonia should not obviate the initiation of antiviral therapy. a dose of - mg/kg intravenously every h for - days is recommended for vzv pneumonia. pulmonary bacterial superinfection may occur. studies characterizing bacterial pathogens likely to cause superinfection are lacking. thus, empiric broad-spectrum antibiotic coverage should be initiated in pregnant women with pneumonia. despite acyclovir crossing the placenta in signifi cant amounts, there appears to be no reduction in congenital varicella syndrome with treatment. the neonate should be isolated from the mother in the peripartum period until the mother is deemed noncontagious. consultation with high-risk obstetrics and neonatology would be useful given the risk of preterm labor and growth restriction. immunity to varicella consists of both vzv-specifi c neutralizing antibodies and cell-mediated immunity. immunity against vzv can be assessed by the use of antibody serologic assays. though there are no adequate controlled trials examining the effectiveness of vzig prophylaxis, vzig is associated with more than - % reduction in risk of contracting varicella and a signifi cant reduction in risk of severe disease [ ] . vzv can be prevented by vaccination. vzv vaccine is a live attenuated vaccine and is generally not recommended in pregnancy and in immune-suppressed individuals. varicella can be contracted from herpes zoster lesions as well. family members with such lesions should minimize contact and cover their lesions to decrease the risk of transmission. healthcare workers who deal with pregnant women should be screened and vaccinated, and similarly pregnant healthcare workers should avoid contact or exposure to patients with varicella. infection with infl uenza virus can result in an acute respiratory illness of varying severity. the majority of healthy individuals infected with infl uenza is asymptomatic or has minimal symptoms. however, adults with comorbidities, elderly subjects, and healthy pregnant women are at increased risk of severe disease and death. in addition, infl uenza infection during pregnancy increases the risk of adverse fetal outcomes. in a regular endemic season, infl uenza is estimated to result in , hospitalizations and , deaths in the united states. pregnant women are at increased risk for morbidity (including cardiorespiratory complications) and mortality from infl uenza compared with nonpregnant controls [ - ] that is more pronounced in the second and third trimester of pregnancy [ ] . in , the pandemic h n infl uenza in pregnancy working group reported on pregnant women in the united states with infl uenza a(h n ). among those, died ( % of all reported infl uenza a (h n ) infl uenza deaths in this period). most hospitalizations and deaths occurred in the third trimester [ ] . pregnant women with comorbidities or those who smoke have an increased risk for severe disease requiring hospital admission compared to those without comorbidities [ , ] . as discussed above, these physiological changes make pregnant women more susceptible to acquiring viral infections and subsequent development of severe disease. apart from direct effects to the mother, infl uenza has been associated with undesirable effects to the fetus. risks of adverse fetal outcomes vary with the severity of maternal disease. preterm delivery appears to be the most common and consistent complication associated with infl uenza pandemics. in the pandemic of and , higher rates of pregnancy loss, premature delivery, preterm deliveries, as well as other adverse effects were reported. in several reports during the pandemic infl uenza of among pregnant women requiring admission, preterm delivery was close to % and was even higher among mothers who were admitted to the icu [ , , ] . several other adverse fetal outcomes of maternal infl uenza have been reported especially during pandemics, including abortion, fetal distress, and placenta abruption [ , ] . symptoms of infl uenza in pregnancy are similar to symptoms outside of pregnancy. infl uenza virus-mediated leukopenia may make the host more susceptible to bacterial infections. secondary bacterial pneumonia is characterized by the appearance of a new fever and productive cough during early convalescence. radiologic fi ndings are generally similar to other viral pneumonias, and more extensive fi ndings are associated with more severe complications. tree in bud opacities may also be seen. laboratory fi ndings may include an elevated or low white count, lymphopenia, and hyponatremia. myoglobinuria and renal failure can occur rarely. cardiac muscle damage with associated electrocardiographic changes, disturbances of rhythm, and high levels of cardiac enzymes have been reported after infl uenza virus infection. sputum cultures may be revealing in the event of bacterial superinfection. streptococcus pneumoniae , staphylococcus aureus , haemophilus infl uenzae , and group a hemolytic streptococci are the bacterial pathogens most commonly isolated in adults with infl uenza. a defi nitive diagnosis of infl uenza requires laboratory confi rmation. diagnostic tests for infl uenza fall into four broad categories: virus isolation [culture], detection of viral proteins, detection of viral nucleic acid, and serological diagnosis. detection of viral nucleic acid allows for typing and subtyping of the specifi c virus strain. treatment of infl uenza consists of supportive management and specifi c antiviral therapy. optimizing supportive treatment is central to the management of infl uenza and probably of more benefi t than specifi c antiviral therapy. supportive therapy is similar to other types of pneumonia as discussed above. as with most drugs, information about safety and effectiveness of anti-infl uenza drugs during pregnancy is scarce. in view of potential severe maternal disease from infl uenza and adverse fetal outcomes, benefi ts of treatment with antivirals likely outweigh the potential risks to the fetus. there are two classes of antiviral drugs currently in general clinical use: adamantanes, (examples of which include amantadine and rimantadine) and neuraminidase inhibitors such as oseltamivir, zanamivir, and peramivir . adamantanes are active against infl uenza a only, increase infl uenza a resistance to adamantanes, and are associated with embryotoxicity in animal studies. as such they are not recommended in pregnancy. neuraminidase inhibitors are active against infl uenza a and b viruses. they are preferred in all adults and in pregnancy. though studies in pregnancy are inadequate, extensive use of oseltamivir in pregnancy during the hin pandemic was not associated with adverse effects specifi c to the drug. neuraminidase inhibitors reduce the duration and severity of symptoms and duration of viral shedding when initiated within h of symptom onset [ , , , ] . there is also evidence to support reduction in complication rate, duration of hospitalization, and mortality in adults. observational studies published during the pandemic demonstrated that, among pregnant women hospitalized with pandemic h n infection, treatment with oseltamivir was associated with fewer intensive care unit admissions, less use of mechanical ventilation, and decreased mortality [ , ] . empiric treatment should always be initiated in the gravid woman when infl uenza is suspected while awaiting confi rmatory results as delay in initiation of treatment is associated with an increased risk of severe outcomes, icu admission, and death [ , , ] . pregnant mothers presenting after h of symptom onset should still be initiated on therapy as there is evidence of benefi t even when initiated after days of symptom onset. initiation of antiviral therapy within the fi rst h is associated with the most benefi t [ , , , , ] . there is less experience with zanamivir which is administered by inhalation route. zanamivir is also contraindicated in patients with asthma as it has a potential of worsening respiratory symptoms [ ] . for patients requiring admission to icu for infl uenza pneumonia or in cases of suspected secondary bacterial infection, empiric antibiotic therapy should be initiated. sputum culture may be helpful in the case of isolation of resistant bacteria that may warrant changes or broadening of antibiotic coverage. in pregnant women, infl uenza vaccination induces an antibody response similar to that in nonpregnant women. cdc and who recommend pregnant women or women who will be pregnant during the winter or peak infl uenza season to be prioritized for vaccination. in addition to protection to the mothers, infl uenza vaccination may offer protection to the neonate as well as contribute to herd immunity in other family members. pregnant mothers who have not been vaccinated or those with comorbidities such as asthma who have been exposed to infl uenza may benefi t from antiviral prophylaxis. oseltamivir is preferred for prophylaxis due to its ease of administration. sleep-disordered breathing (sdb) is a spectrum of disorders that encompasses snoring and upper airway resistance, obstructive sleep apnea (osa), and other disorders. osa is a disorder characterized by periodic and recurrent collapse of the upper airway during sleep. obesity, age, and upper airway and facial abnormalities are the most recognized risk factors for the disorder. osa is prevalent in patients with chronic hypertension, cardiovascular disease, and metabolic disorders such as diabetes mellitus. the pregnant population appears to be at risk for the disorder given anatomic upper airway changes that occur in pregnancy as well as physiological changes and hormones. snoring occurs in close to % of pregnant women [ ] . the prevalence of osa in pregnancy is not well known, but preliminary data suggest that close to % of loud snorers in pregnancy have at least mild osa. the natural history of snoring around pregnancy is, however, unclear. there are some data suggesting that osa actually improves in untreated postpartum women around months after delivery. data on osa predating pregnancy is missing and pregestational and gestational osa may have different clinical consequences. there is a signifi cant lack in screening for the disorder by obstetric providers according to a recent study, even in obese patients [ ] . notably, the berlin questionnaire, a widely used screening tool in the nonpregnant population, appears to have poor positive and negative predictive values in pregnancy [ ] . snoring and excessive daytime sleepiness may be important predictors [ ] . chronic hypertension, age, obesity, and snoring appear to have a good predictive value for osa in high-risk populations [ ] . further validation of this potential predictive model in different pregnant populations is needed. snoring and osa have been shown to be associated with a variety of adverse pregnancy outcomes including gestational hypertension, gestational diabetes, and cesarean deliveries. gestational hypertension is the most studied link with numerous studies on snoring as well as osa showing a two-to threefold increased risk of gestational hypertension in snorers, even after adjusting for confounders such as body mass index [ ] . mechanistic studies are lacking and the directionality of the association not well clarifi ed, but it is possible that intermittent hypoxia, fl ow limitation, poor sleep, and arousals may play a role in causing endothelial dysfunction, infl ammation, and hypercoagulability that are common to the two disorders. a few studies to date have also shown worse abnormalities in glucose metabolism and a higher prevalence of gestational diabetes in women complaining of loud snoring and poor sleep [ , ] . gestational diabetes has been associated with a fi vefold increase in the risk of type ii diabetes at years and a ninefold risk at years [ ] . snoring, poor sleep, and osa have all been associated with a higher risk of unplanned cesarean deliveries. this association may be harder to explain and may depend on the actual reason leading to unplanned cesarean delivery such as obstetric, fetal, or medical causes. the impact of sdb on fetal and neonatal outcomes has also been studied, but the results of such studies have been more confl icting. growth restriction has been reported to be associated with snoring in some studies but not in others. the effect on apgar scores also appears to be controversial. there are some case reports and case series suggesting fetal decelerations secondary to sleep apnea, but a recent study evaluating synchronized limited sleep studies and fetal monitors have failed to show a signifi cantly higher prevalence of late decelerations [ ] . once diagnosed, treatment of osa is approved in patients with an apnea hypopnea index ahi > or those with ahi > who have symptoms that are known to respond to therapy such as daytime sleepiness. there are no specifi c guidelines on therapy initiation in pregnancy yet for various reasons. as stated above, the natural history of the disorder around the perinatal period is not well known. thus, it is possible that, with weight loss and reversal of pregnancy physiology, the disorder may resolve or at least improve in the postpartum period. in addition, there have been no trials to date that have shown that treatment of osa in pregnancy would improve pregnancy or fetal outcomes. this reason likely contributes to the fact that the disorder remains underscreened and underdiagnosed [ ] . based on current data, weight loss is unlikely to be an option in pregnancy because of concern that it may affect the nutritional status of the mother and therefore fetal well-being. alcohol and cigarette smoking avoidance is another therapeutic strategy in pregnancy that carries additional pregnancy-specifi c benefi ts. outside of pregnancy, cpap therapy has been shown to improve quality of life and daytime sleepiness with some data suggesting improvement in cardiovascular outcomes such as hypertension. it is likely that these effects of cpap are also true in pregnancy. observational studies have shown improvement in daytime fatigue and daytime somnolence in pregnant women with osa treated with cpap and re-titrated around midpregnancy [ ] . in women with preeclampsia, small, randomized trials have shown that in-laboratory positive airway pressure therapy improves hemodynamics, uric acid, and cardiac output compared to untreated women [ , ] . until future studies of cpap therapy are available in pregnancy, indications for therapy are likely the same as in the nonpregnant population. we are awaiting trials evaluating the effect of pap therapy on pregnancy-specifi c outcomes to be able to determine the "urgency" of starting pap therapy in pregnancy. the type of pap therapy that is most benefi cial in pregnancy is unknown. however, auto-titrating pap therapy has the advantage of avoiding repeat re-titration of pressure requirements. in summary, pregnant women with the above disorders need to be managed with pregnancy physiology and fetal effects of the disease and the therapy in mind. the course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis acute asthma during pregnancy a comprehensive analysis of adverse obstetric and pediatric complications in women with asthma asthma during pregnancy-a population based study infant and maternal outcomes in the pregnancies of asthmatic women obstetric 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adult--nited states managing varicella zoster infection in pregnancy treatment with acyclovir of varicella pneumonia in pregnancy use of acyclovir for varicella pneumonia during pregnancy outcome after maternal varicella infection in the fi rst weeks of pregnancy varicella and herpes zoster in pregnancy and the newborn neurodevelopmental follow-up of children of women infected with varicella during pregnancy: a prospective study congenital varicella syndrome: the evidence for secondary prevention with varicella-zoster immune globulin intrauterine infection with varicella-zoster virus after maternal varicella high-resolution ct fi ndings of varicella-zoster pneumonia risk factors for severe illness with pandemic infl uenza a (h n ) virus infection in china pandemic infl uenza a (h n ) virus infection in postpartum women in california maternal morbidity and perinatal outcomes among pregnant women with respiratory hospitalizations during infl uenza season deaths from asian infl uenza associated with pregnancy pandemic infl uenza a(h n ) virus illness among pregnant women in the united states infl uenza virus infection during pregnancy in the usa pandemic infl uenza a (h n ) in pregnancy: a systematic review of the literature pandemic infl uenza a (h n ) in critically ill pregnant women in california infl uenza a/h n v in pregnancy: an investigation of the characteristics and management of affected women and the relationship to pregnancy outcomes for mother and infant novel infl uenza a(h n ) virus among gravid admissions california pandemic working g. severe h n infl uenza in pregnant and postpartum women in california antiviral agents for the treatment and chemoprophylaxis of infl uenza --recommendations of the advisory committee on immunization practices (acip) severe, critical and fatal cases of h n infl uenza in china severity of pandemic infl uenza a (h n ) virus infection in pregnant women product information: relenza(r) oral inhalation powder, zanamivir oral inhalation powder. glaxosmithkline (per fda) pregnancy and fetal outcomes of symptoms of sleep-disordered breathing patient and provider perceptions of sleep disordered breathing assessment during prenatal care: a survey-based observational study prospective trial on obstructive sleep apnea in pregnancy and fetal heart rate monitoring excessive daytime sleepiness in late pregnancy may not always be normal: results from a cross sectional study development of a pregnancy-specifi c screening tool for sleep apnea sleep-disordered breathing in pregnancy glucose intolerance and gestational diabetes risk in relation to sleep duration and snoring during pregnancy: a pilot study type diabetes mellitus after gestational diabetes: a systematic review and meta-analysis pregnancy, sleep disordered breathing and treatment with nasal continuous positive airway pressure reduced nocturnal cardiac output associated with preeclampsia is minimized with the use of nocturnal nasal cpap nasal continuous positive airway pressure reduces sleep-induced blood pressure increments in preeclampsia key: cord- - o g q authors: polychronakis, ioannis; riza, elena; karnaki, pania; linos, athena title: workplace health promotion interventions concerningwomenworkers' occupational hazards date: journal: promoting health for working women doi: . / - - - - _ sha: doc_id: cord_uid: o g q nan in the european labor market, women today constitute an increasing part of the working population, equaling about percent of the european workforce (european agency for safety and health at work a) as a result of their dynamic entrance in the labor market during the last few decades. while women have occupied posts even in professions that so far have been considered as "traditionally male," the european labor market retains a high degree of segregation regarding women's participation rates in certain occupational sectors (european agency for safety and health at work a; ) . the european union (eu) has so far applied a gender-neutral approach (european agency for safety and health at work a; ) to policies and legislation concerning occupational safety and health (osh) to comply with world health organization (who) guidelines for equality in health standards and access to health service. however, this approach does not seem to suffice for effectively meeting gender-specific issues of occupational hygiene and safety that have emerged concerning female workers in particular. the female working population carries certain characteristics that have to be taken into consideration through the process of design and implementation of osh policies, because their interaction with the occupational environment may produce additional hazardous effects for women employees: women's workday concerns arising from their roles as mothers, spouses, or carers for the elderly, add an extra load on the mental and physical fatigue they sustain in their workplace (artazcoz et al. ; artazcoz, borrell & benach ) . everyday household tasks amount to hours of unpaid overtime on top of the -hour working day, increasing their total physical and psychological strain. as a consequence, women workers are more easily affected by burnout effect or suffer more frequently from work-related stress than their male colleagues, who continue to participate significantly less than women in house tasks. working conditions in terms of ergonomics, working pace, managing heavy workloads, and using tools or personal protective equipment (ppe) (tapp ; murphy, patton, mello, bidwell, & harp ) are often designed according to the size and the physical strength of an average male worker. this is a consequence of the fact that many occupational sectors were, until recently, almost exclusively staffed by men, and even today employ an overwhelming majority of male workers. despite the increase in the participation of female workers in many professional fields, the high cost of adequate interventions still constitutes a forceful barrier to adjusting the modern workplace to female employee's needs for health and safety. because women of child-bearing age constitute a significant part of the female workforce, the protection of women's reproductive health is an issue of great concern for eu policymakers, in terms of legislation. this applies to factors and working conditions that both directly and indirectly influence the female reproductive system, including fertility (biological, physical, or chemical hazards-e.g., endocrine disruptors that affect women's ability to conceive), pregnancy (detrimental factors for the foetus during intrauterine development), and lactation. one also has to underline the fact that pregnant women are in need of specially designed ergonomic workplaces (niedhammer, saurel-cubizolles, piciotti & bonenfant ) , that consider changing physical and biological conditions and needs throughout the gestation and post-partum period. biological predisposition determines that women employees have reduced physical strength in comparison with their male colleagues (hooftman, van der beek, bongers, & van mechelen ) . this fact creates a comparatively higher burden for female workers who perform the same tasks as men, and creates a greater risk for musculoskeletal strain. furthermore, women's reduced average muscle force places them in an unfavorable position in cases of bullying and physical violence at their workplace, both from co-workers or the public (e.g., psychiatric ward nurses). women workers are still a minority group in certain professional fields (e.g., construction, mineral extraction, heavy industry), and in most cases they remain in lower managerial positions in comparison with men. under these circumstances, women employees have limited control over administrative decisions (european agency for safety and health at work ) concerning occupational health and safety, and often lack access to the appropriate communication channels to report cases of bullying, mobbing, or even sexual harassment-especially when superiors are involved. in certain areas of industrial production (e.g., the textile industry), the female working population consists predominantly of immigrant workers with poor literacy skills, or difficulty communicating. this language barrier may, in some situations, cause work-related accidents, as well as expose workers to occupational hazards due to misconception or ignorance of safety instructions or warning labels and signs. women in europe present higher percentages of part-time employment than men, as shown in figures . and . . in many occupational sectors (e.g., cleaning industry, cashiers), the overwhelming majority of women work part time. in addition, female employees show a higher turnover rate during their career and seem to spend shorter periods, on average, in the same position (mcdiarmid & gucer ) . because of this effect, women's occupational diseases are, in many cases, significantly underreported, introducing a systematic bias in many studies on occupational hazards and creating the misperception that female workers generally occupy safer jobs. to make matters even worse, women in this kind of unstable employment pattern have, in most cases, only limited access to occupational health services and workplace health promotion activities, even though they constitute a high-priority group for similar interventions. it should be underlined, however, that under no circumstance does this genderspecific approach lead to the false conclusion that women workers constitute a (jouhette & romans ) high-risk group requiring preferential treatment over issues of occupational safety and health in comparison to male workers. such a misinterpretation could cause unacceptable discrimination against women and, in some cases, their exclusion from occupational sectors where female workers have for a long time now proven their worthiness as employees. even though available research data in the literature may suggest that certain traits or characteristics connected with gender could possibly influence the occupational risk of female employees, they fail to identify occupational hazards that are selectively or exclusively harmful to women. at this point, it is useful to categorize all gender-related parameters that have been identified as distinguishing occupational health and safety issues between male and female workers. according to previous studies, three fields of possible gender influence (kennedy & koehoorn ) on estimated occupational risk can be identified. because of job and task segregation observed among the european workforce, osh studies based on occupational categorization alone have been insufficient in assessing potential health risks for women, because their tasks may vary significantly from men's even if they carry the same professional title (Östlin ) . women follow different time patterns of exposure through part-time or shift work, and usually carry out tasks requiring more precise, repetitive movements than male workers (hooftman et al. ; stellman ) . • female workers have smaller (on average) body dimensions (hooftman et al. ) , which differentiates their occupational exposure: a. in professions involving manual handling, greater physical workload may be required by women to perform the same tasks as men. b. in cases of chemical exposure through the skin, the female body provides smaller available surface for absorption. c. protective equipment is often ineffective for women employees (protective clothing, gloves, masks, and respirators) (han dh ) . protective equipment originally designed for male workers does not fit appropriately to the shape and size of the female body and does not fully prevent exposure to hazardous agents. • under normal conditions, women present lower alveolar ventilation rate and cardiac output (brown, shelley & fisher ) , which reduces the input rate of volatile chemicals into their body • in the case of benzene (a proven carcinogen) and other volatile organic compounds (vocs), it has been experimentally demonstrated that women present higher blood/air partition coefficients (brown et al. ) (greater blood / air concentration fraction), increasing the amount of chemicals diffused from alveoli to the blood compartment • concerning the metabolism of chemical compounds, potential gender-related disparities in enzymic activity (gandhi, aweeka, greenblatt & blaschke ) (e.g., cytochromes p , transporting enzymes) have been reported, although research results are contradictory • in the case of exposure to metals, women appear to absorb greater amounts of cadmium through digestion, possibly due to a common absorption pathway for iron and cadmium (vahter, berglund, Åkesson & lidén ) (especially for menstruating women with low body-iron storage) • chemicals absorbed into the bodies of women workers are distributed in a relatively smaller body mass than men, because their body mass index (bmi) is lower (gandhi et al. ) . as a further consequence: a. women present a relatively higher organ blood flow, which increases the rate at which chemical substances circulating in blood compartment are delivered to the tissues. b. women's renal clearance (gandhi et al. ) (a parameter that is directly related to body weight) is slower in comparison with men's, and therefore their capacity to excrete toxic compounds, as well as their metabolites, through daily production of urine is low. • bodily distribution of chemicals in women also differs in regard to their concentration in plasma. experiments on gender influence on the distribution of certain drugs, indicate that (gandhi et al. ): a. plasma volume is generally lower in females (the same total-body chemical burden may produce more toxic plasma concentrations in women). a. the concentration of certain binding proteins for drug metabolites or other chemicals in plasma depends heavily on hormonal status-especially estrogens (e.g., pregnancy, menstrual phase, and menopause). • the female body carries a greater proportion of adipose tissue than that of males (brown et al. ; gandhi et al. ) , and as a result it demonstrates a different pharmacokinetic response to lipophilic metabolites (e.g., prolonged retain and increased metabolism of benzene). • in professions involving exposure to inorganic lead, blood concentrations do not provide a reliable criterion of chronic exposure in the case of female employees. as the metal gradually accumulates in the bone tissue, demineralization of women's skeleton during periods of increased bone turnover (as in pregnancy or menopause) releases significant quantities of lead into their bloodstream (vahter m et al. ) . • women present different social and dietary habits, such as smoking (e.g., cadmium absorption) (vahter m et al. ) and alcohol or coffee consumption (mcgovern ) , which may act as modifiers to environmental exposures • the use of chemical substances for household tasks (e.g., cleaning products), hobbies (e.g., fertilizers in gardening), or other activities involving application of potentially harmful agents (including cosmetics and artificial hair dyes) may subject women to further exposure outside their daily work hours • wearing jewelery is an additional nonoccupational source of skin exposure to metals for women (e.g., nickel) (vahter m et al. ) , increasing the burden of metal-induced occupational dermatitis for women employees • female employees in occupations involving manual tasks may also have to sustain additional workloads arising from family demands, especially in large families with children under years old, or elderly persons over years old (artazcoz et al. ) , which may contribute to producing symptoms of physical fatigue or musculoskeletal strain. • increased family demands of female workers, combined with strenuous job tasks may also have a serious impact on women's mental health (disturbed work-life balance, inadequate leisure time, lack of personal life) (artazcoz et al. ) • besides the immediate toxic effects of certain metals such as cadmium on humans (affecting both men and women), there is ongoing research on possible estrogenlike activity as well as its potential association with breast cancer through the activation of estrogenic receptors (brama m et al. ) • the manifestation of certain gender-specific cancers (e.g., breast cancer, which occurs almost exclusively in women) seems to involve among others, interaction between genetic expression (e.g. atm tumor suppressors) (mcgovern ) and environmental exposures • the manifestation of autoimmune diseases (highly frequent among the female population) might be triggered or accelerated by substances or agents commonly used in certain professions (as in the case of lupus erythematosus and mercury exposure) (mcgovern ) • the varying composition of the labor force in different occupational sectors may have introduced a significant bias in epidemiological studies concerning occupational hazards for women: a. especially in the heavy industry and construction sectors, which employ almost exclusively male employees, the small minority of women who work alongside their male co-workers in various positions may have been overlooked (niedhammer et al. ) in osh studies, introducing exclusion bias (concerning women workers) because of the difficulties researchers had in finding women employees to participate in their studies. b. on the other hand, women-focused osh research has concentrated on the relatively small number of professions that master the majority of the female work-force. this fact probably explains the relatively large volume of studies on health-care professions (which are easily accessible to research), while women workers remain heavily underrepresented in osh studies in other sectors (messing & stellman mager ) c. the majority of studies that focus exclusively on women workers deal with mental health issues and psychological parameters (messing & stellman mager ; niedhammer et al. ) , while other work-related hazards such as exposure to chemicals, radioactive material, biological factors, electromagnetic fields, noise, or ergonomic factors are either indirectly examined by surveys on mixed working populations (where results are adjusted for gender), or even worse, by generalizing epidemiological evidence of osh conducted among male employees. • the segregation of tasks performed within the same job department or even under the same occupational title, may introduce misclassification bias when the influence of gender on occupational risk is under study. any observed excess risk among women workers (e.g. musculoskeletal injuries) in comparison with men, should not necessarily be attributed to the role of gender, especially when such results are based only on job title (hooftman et al. ). in such cases, further quantification of exposure (job exposure matrices, stratification according to tasks) is essential in determining whether the declination in study results arises from differences in performed tasks, or is truly related to gender-e.g., the excess risk for developing carpal tunnel syndrome in female workers seems to be eliminated in professions with strictly defined tasks (mcdiarmid, oliver, ruser & gucer ) . • other forms of bias related to gender have been identified in the design of clinical, as well as osh, studies: a. an observer error due to adopting "male perspective and way of thinking" (pinn ) in interpreting epidemiological data. b. the "male norm" bias, arising from the use of male workers as standard (pinn ) , even for occupational health and safety issues where both sexes are affected (e.g., occupational cancer). • there are indications that many of the existing studies on women workersespecially those concerning occupational musculoskeletal injury-may suffer from perceptual bias (the increased likelihood of employees to report injuries), or overrating the severity of related symptoms in questionnaire surveys according to the way they perceive their working environment or their degree of job satisfaction (strazdins & bammer ) . taking into account that female workers are generally occupied in less satisfactory, underpaid jobs with repetitivemonotonous tasks (hooftman et al. ) , over-reporting may contribute significantly to the excess risk found by many relevant studies for female employees. • for the majority of female workers employed outside the dangerous industrial or construction sectors, there is little public awareness of the occupational exposures they sustain from their working environment because they usually do not face immediate danger of acute toxic effects or death. this fact may introduce a significant recall bias in relative studies because women workers are either unable to identify potentially harmful agents they have been exposed to, or tend to underestimate the extent of such exposures (e.g., unawareness of types of agents involved in their tasks that may constitute reproductive hazards) (bauer, romitti & reynolds ) . • in mixed working populations, the healthy worker effect appears stronger for male than female employees , which is possibly attributable to the fact that men are hired to perform more physically demanding tasks than women and are therefore subjected to more rigorous selection during the hiring process. the existing research evidence indicates a widely accepted false sense of safety in many of the professional sectors employing predominantly women, which has been recognized in earlier occupational health and safety studies in the united states as the so-called generally recognized as safe (gras) status (mcdiarmid & gucer ) for most of the female professions. this is partially due to the fact that male workers, especially in heavy industry (construction workers, miners, welders, heavy machinery operators), are expected to face a higher number of severe or even fatal incidents or occupational diseases (niedhammer et al. ) , than those in the safe tertiary sector. gras reflects the commonly held belief that certain drugs and chemicals are safe if empirical knowledge obtained by their wide use over a period of years does not indicate they are detrimental to the population. as a consequence, this approach is also adopted in occupational sectors, where such materials have been widely used-the majority of which involve femaledominated professions where, until recently, osh research has been considered nonessential. contemporary evidence-based medicine, however, requires more solid epidemiological data to conclude whether this group of occupations is as safe as is currently presumed. in addition, there is an increasing need to study the possible sideeffects on health from exposure to thousands of chemical compounds present in jobs generally considered as nonhazardous (cleaning agents, drugs, cosmetics, food preservatives). the latter translates as a need to expand the field of occupational health and safety research and place the so-called female professions under a more thorough and systematic investigation. according to official statistics of the european agency for safety and health at work, certain occupational sectors (health professionals, education workers) employ mostly females while the percentage of women in other professions (construction workers, heavy industry) (european agency for safety and health at work ) remains relatively low. figure . presents the distribution of the female working population in different occupational activities, in the european union. for many of the professions where women are highly represented, research has explored specific occupational hazards. in tables . in the health services sector, women are employed in various positions (e.g., nurses, laboratory technicians, emergency room technicians) and face a multitude of occupational risks, some of which are cited in table . . women are also often employed in the education sector, especially in nursery and primary education, and therefore face diverse occupational risks, some of which are specific to the profession (e.g., voice disorders). table . presents some of the related occupational hazards for this category of workers. while affected by many occupational hazards, some of which are cited in table . , women working in the cleaning industry are also disadvantaged due to the fact that (gavana, tsoukana, giannakopoulos, smyrnakis, & benos, ; gyorkos et al., ; nakazono, nii-no, & ishi, ; skillen, olson, & gilbert, ; valeur-jensen et al., ) • vascular problems (kovess-masfety, sevilla-dedieu, rios-seidel, nerriere, & chee, ) of the lower extremities due to extended standing (sandmark, wiktorin, hogstedt, klenell-hatschek, & vingard, ) in upright position • voice disorders due to overuse of vocal chords duff, proctor, & yairi, ; kooijman et al., ; kosztyla-hojna, rogowski, ruczaj, pepinski, & lobaczuk-sitnik, ; roy, ; sliwinska-kowalska et al., ; sulkowski & kowalska, ; thibeault, merrill, roy, gray, & smith, ; williams, ) • exposure to increased levels of noise (behar et al., ) • musculoskeletal problems (fjellman-wiklund, brulin, & sundelin, ; sandmark, ; yamamoto, saeki, & kurumatani, ) (handling and lifting small children in day care centres, physical education teachers, inadequate body posture) • work-related stress (fjellman-wiklund et al., ; zidkova & martinkova, ) • children's or adolescent's violent behavior (lawrence & green, ) • exposure to infectious agents • dermatitis due to direct skin contact with irritating substances (weisshaar et al., ) • dermal infections (staphylococcus, fungi) (mcbryde, bradley, whitby, & mcelwain, ) • inhalation of irritating vapours and airborne micro-particles containing dust or other allergens (j. j. jaakkola & jaakkola, ) • musculoskeletal disorders due to handling or lifting heavy objects, inadequate body posture (balogh et al., ; mondelli et al., ) • fall injuries (stairs, slippery floors) (kines, hannerz, mikkelsen, & tuchsen, ) • workplace violence (chen & skillen, ) • sexual harassment table . food production industry workers workplace hazards • inhalation of airborne allergens emitted from food processing (e.g., artificial dyes, flour, animal proteins) • dermal infections (staphylococcus, b-haemolytic streptococcus, bacillus anthracis, fungi) • dermatitis (allergic or irritating) from skin contact to foods themselves or substances used for their processing (jappe, bonnekoh, hausen, & gollnick, ; kanerva, estlander, & jolanki, ) • exposure to zoonoses (processing animal products) • musculoskeletal disorders (handling and lifting excessive loads, inappropriate body postures, poor ergonomic design of workstations, repetitive strain) (chyuan, du, yeh, & li, ) • injuries (falls due to slippery floors, burns, lacerations from knives or used tools) (courtney et al., ) • exposure to extreme temperatures (cold in refrigerators, excessive heat in kitchens) their occupation is often unregulated, and thus no occupational safety and health services are available to them. the food production sector involves various types of work, from food preparation to packaging, storing, and more, involving mainly biological and chemical hazards due to immediate contact with food. table . presents a non-exhaustive lists of related occupational hazards. a large number of women are employed in the sector of hospitality services (e.g., waitresses, cooks, bar attendants) and are subject to a number of risks, some of which are listed in table . . the textile sector is heavily industrialized, and women working in this sector face many and serious risks, some of which are cited in table . . laundry workers are also faced with heavy tasks such as long hours on their feet, exposure to extreme temperatures, and lifting heavy loads, as can be seen in table . . table . hospitality services industry-restaurant workers' workplace hazards • exposure to extreme temperature conditions (excessive heat in cookers) • musculoskeletal injury due to handling or lifting heavy objects-repetitive movementsstrenuous workload (chyuan et al., ; dempsey & filiaggi, ) • dermatitis induced by skin contact with foods or cleaning agents (jappe et al., ; kanerva et al., ) • dermal infections (skin contact to infected food surfaces, development of fungal infections due to extended exposure to humidity) • injuries (falls due to slippery floors, falling objects, skin lacerations from sharp objects, burns from heat-emitting objects or appliances) (courtney et al., ; horwitz & mccall, ) • inhalation of micro-particles (food-cooking, passive smoking, poor ventilation) (svendsen, jensen, sivertsen, & sjaastad, ) • workplace violence (graham, bernards, osgood, & wells, ) • sexual harassment • work-related stress (low levels of job satisfaction, stressful working conditions) table . textile industry-clothing manufacture workplace hazards • exposure to increased levels of noise (weaving machines) (bedi, ; cardoso, oliveira, silva, aguas, & pereira, ) • increased concentration of fibres, micro-particles and organic solvents (artificial dyes, chemicals used in textile processing) in workplace environment (bakirci et al., ; ghio et al., ) • musculoskeletal injury (poor ergonomic design (choobineh, lahmi, hosseini, shahnavaz, & jazani, ) of the production line, repetitive movements (bjorksten, boquist, talback, & edling, ) , lifting and handling heavy objects) • visual fatigue • injuries (entanglement in moving parts of equipment, skin lacerations by sharp objects) • intense work-related stress (strenuous workload, intense work pace in production lines, low level of job satisfaction) ceramic and pottery workers face a series of specific occupational risks connected with the nature of their profession, as presented in table . . light manufacturing includes many types of industries, employing mainly nonspecialized workers and therefore involving diverse types of exposure. table . presents some of the hazards involved in these occupational activities. (dorevitch & babin, ) • musculoskeletal injury due to poor ergonomic design, handling heavy loads, repetitive muscle strain, vibrations (martinelli & carri, ) • stressful working conditions -strenuous work pace in production lines table . light manufacture workers' workplace hazards • musculoskeletal injury due to poor ergonomic design (equipment, tools and workstations that don't fit the physical dimensions of female workers), handling and lifting heavy loads, repetitive movements (bjorksten et al., ; roquelaure et al., ) • visual fatigue (untimanon et al., ) • exposure to chemical agents (e.g., metals & solvents in electronic circuits manufacture, drug by-products in the pharmaceutical industry) (clapp, ; ladou, ) • stressful working conditions in production lines call center work is a newly developed sector that employs mostly women who are faced with risks such as visual fatigue, musculoskeletal disorders, and other hazards as presented in table . . hairdressing is a female-dominated sector that, until recently, has been regarded as a safe occupation. however, current literature associates this profession with various hazards, some of which are included in table . . the tertiary sector-especially office workers-are faced with hazards arising mainly from poor ergonomic design and poor indoor air quality, as shown in table . . hazards in agriculture are linked mainly to a high risk of injuries and to the use of chemical substances such as pesticides, herbicides, and others, as shown in table . . (best et al., ) (inadequate body postures (osteras, ljunggren, gould, waersted, & bo veiersted, ) , poor ergonomic design (boyles, yearout, & rys, ) ) • vascular problems of the lower extremities due to prolonged standing in upright position • dermal infections (ballas, psarras, rafailidis, konstantinidis, & sakadamis, ; schroder, merk, & frank, ) (skin lacerations from scissors or other sharp tools (moghadam, mazloomy, & ehrampoush, ) , dermal fungi from continuous exposure to humidity) • dermatitis (khrenova, john, pfahlberg, gefeller, & uter, ; perkins & farrow, ) (irritating or allergic) (cavallo et al., ; doutre, ) induced by contact to cosmetics (amado & taylor, ; iorizzo, parente, vincenzi, pazzaglia, & tosti, ; katugampola et al., ; sosted, hesse, menne, andersen, & johansen, ) , artificial hair dyes (belinda thielen, ; rastogi, sosted, johansen, menne, & bossi, ) or even protective gloves (foti et al., ) • allergic asthma (akpinar-elci, cimrin, & elci, ; allmers, nickau, skudlik, & john, ; macchioni et al., ; moscato et al., ) induced by exposure to volatile substances (baur, ; berges & kleine, ; gala ortiz et al., ; hoerauf, funk, harth, & hobbhahn, ; hollund & moen, ; labreche, forest, trottier, lalonde, & simard, ; piipari & keskinen, ) and particles (cosmetics, hair sprays (albin et al., ; montomoli, cioni, sisinni, romeo, & sartorelli, ) , dryers • job-related stress (strenuous working conditions, low job satisfaction) (mcbride, firth, & herbison, ; perry & may, ) • exposure to zoonoses due to close contact with animals or animal products (bacillus anthracis, mycobacterium, brucellosis, viral infections e.g. avian influenza) • exposure to chemical compounds during transportation, storage, mixing or application of fertilizers, pesticides or herbicides (buranatrevedh & roy, ; garcia, ) • exposure to allergens through inhalation or direct skin contact (pollen, animal proteins, fungi) (linaker & smedley, ) • exposure to natural phenomena (extreme heat, frost, thunderstorms, floods) • job related stress (stressful working conditions, job insecurity, low income, low job satisfaction) • violence at the workplace (verbal or physical abuse) • sexual harassment this section will focus on how theories and models of health promotion can be put into practice for the design and implementation of workplace interventions concerning osh issues targeted at female workers. the example that will be used is work-related reproductive disorders. the specific health topic has been selected as an example for three primary reasons: • reproductive disorders have been associated with a wide range of occupational hazards (e.g. physical, chemical, biological agents) • a large number of professions employing women involve exposure to hazards such as those mentioned in the above point • further research is needed on this topic because many of the traditionally female professions considered generally safe may involve unidentified risks for women's reproductive health reproductive hazards constitute a field of increasing interest for occupational hygienists and health professionals across the world. there is little or no information at all about the possible effects on female reproductive health of the vast majority of chemical substances introduced by the thousands every year in industrial production (lawson et al. ) . even in cases of widely used chemicals, the existing literature of their possible detrimental effects on women's reproductive physiology is relatively poor. for most of the agents considered as hazardous for the reproductive system, their causal relationship to problems in human reproduction has not been adequately documented and gender differences in exposure or toxicity have not been thoroughly examined. because female workers constitute a nonhomogenous population of diverse occupational categories, various physical, chemical, and biological exposures are under examination concerning their potential risks on the reproductive health of women. a non exhaustive list of factors under investigation concerning their potential harmful effects on female reproductive health is presented in table . . the precede-proceed model of planning will be used as a framework to guide the diagnostic phase of the suggested intervention (gielen & mcdonald ; green & kreuter ; green, kreuter, deeds & partridge ; national cancer institute b; ransdell. ) . the outline of this theoretical model is presented in figure . . • precede provides the methodological framework for the design of tailored educational interventions targeting specific populations. it is based on the medical model, involving an initial diagnostic approach to the needs of a patient, before prescribing a specific treatment. as an analogy, precede constitutes a tool to design a specific educational plan, according to the identified needs of the target group. • proceed has been an addition to the original model, to further include environmental determinants (e.g., policies, managerial and economic issues) that influence human attitudes towards specific health behaviors. this model follows a reverse course, towards the origin of certain health behaviors to target interventions for the causal factors themselves, rather than just the symptoms. the outline of the process that takes place in nine stages is presented in figure . . for our example, only the diagnostic part of the model will be analyzed. despite the fact that we have already chosen occupational reproductive hazards as our intervention subject in this case, the stage of social diagnosis is supposed to have taken place before making our choice. for any workplace health promotion effort to be effective, the key issue must be tailored according to the needs of the predefined target population. even though women's reproductive health may seem like a scientifically important field of intervention, our target group of women employees may not consider it to be a highpriority issue-either because they consider having more important health problems or because they are not adequately informed on the possible impact of similar disorders on their personal health status. the main focus of health professionals at this stage is to investigate: • the target group's perception of their quality of life • the most important determinants of their quality of life (e.g., career, family, health) • their expectations and concerns about their health status • whether reproductive health issues are considered an important enough factor for women that an intervention through a whp program is valuable the focus of health professionals during this phase is to identify-through analyzing epidemiological evidence-the impact of the specific problem on the predefined target group (e.g., female workers in a factory, women employed in a specific profession). furthermore, this procedure aims at prioritizing the specific subgroups that face the highest risk of exposure to reproductive hazards and need more immediate preventive measures. this stage includes: • identification of work-related parameters, as well as individual behaviors that may influence the reproductive health status of women employees • evaluation of specific indicators of reproductive health disorders in our target population. some of these indicators are listed in table . one of the specific interests of health professionals at this stage is to locate groupings of reproductive disorder indicators in certain subgroups (specific job tasks, worksite-specific reproductive hazards) of the population, to prioritize them as intervention groups (e.g., focusing a whp program for the prevention of reproductive disorders on oncology unit nurses in case they present higher incidence of congenital defects compared to the rest of health care personnel) table . potential indicators of reproductive disorders (lawson et al. ) . increased infertility rates among women of a specific industry . a prolonged conception period among female workers . frequent reports of menstrual disorders and early menopause by female employees in the company's medical files . male/female ratio of births . reported pregnancy complications among employed pregnant workers (e.g., diabetes, hypertension, pre-eclampsia, etc.) . reduced (or increased) average birth-weight of infants . increased rates of pre-term deliveries (and miscarriages) . number of sick-leave days among pregnant employees (for problems related to pregnancy) . increased rates of congenital defects among infants of female workers . increased incidence of neoplasms of reproductive organs among employed women it is imperative during the initial design of a tailored whp intervention program for the prevention of occupation-induced female reproductive disorders, to incorporate a set of behavioral and environmental change indicators that serve as general objectives for the program. whp professionals, prior to the development of an intervention plan, should conduct behavioral and environmental diagnosis to identify existing key issues concerning osh attitudes and beliefs and practices in the organization (employees, executives, and company administration) and the safety status of facilities, procedures, and equipment. these key issues may include (state of alaska ): • personal accountability: this parameter is crucial for the success or failure of any prevention program, both on worksites and in the general population. it is important to adjust the program's aims and methods according to women's perceptions of its personal influence on their health status. female employees should be able to recognize their personal responsibility and contribution to the effective implementation of the preventive measures and practices by the completion of the whp intervention. • attitude towards change: a key component for the design of an effective intervention prevention program is taking into account the degree to which women agree with the proposed changes (safety behavior, practices, osh regulatory environment), so that invention methods can be modified accordingly. at this stage, therefore, health professionals should evaluate the awareness status and the ability of female employees to adopt the desired safety practices introduced by the whp program on both personal and collective levels to determine the kind of messages and strategies appropriate for the specific population. • participation: one of the primary targets of the whp intervention is to achieve a high degree of participation in the program's activities, as it is one of the key elements that significantly influences results. it is important at this stage to recognize and alleviate barriers that are driving women to abstain from similar programs. furthermore, there is a need to identify the subgroups of female workers where the focus of the intervention needs to be to promote their involvement. • occupational hazard identification: apart from recognizing that female workers are at a high risk for reproductive disorders, the whp program should also concentrate on specific protective measures and proposals for these groups of employees. it is essential, therefore, to identify and record existing working conditions of women in the specific organization in detail, to determine their possible detrimental effect on the reproductive physiology of those same women, and assess the existent osh status of their job tasks. this process includes recording: . procedures (production line, manual tasks, strenuous work pace, extreme climate conditions, emission of fumes/particles, and stressful conditions) . hazardous agents (physical, chemical, and biological) involved in female workers' tasks or working environment . equipment used in specific tasks (radiation sources, vibrating parts, electromagnetic fields) . existing protective measures (ventilation systems, separate mixing chambers for chemicals, lifting devices for manual handling, radiation shields, ppe, rotation of night shift workers, etc.) for women employees . potential for osh improvement (substitution of procedures or agents, automatization of tasks, amelioration of working conditions, change of job post, or rotation of workers) this part of the diagnostic process involves the identification of the educational needs of female employees, as well as the structural changes that are needed in the specific organization to effectively introduce the whp interventions for the protection of women worker's reproductive health. this process will be used to shape our strategic approach towards the target population, through the analysis of determinants of compliance with safety practices at individual, collective, and organizational levels. three categories of such factors may be identified-namely, predisposing, enabling, and reinforcing factors, that will be further analyzed: predisposing factors: health professionals may recognize multiple potential fields of intervention on which to focus the whp program: the whp program may introduce certain interventions to promote the desirable change to compliance in osh practices. • personalized information on female reproductive system and occupational risks involved • health awareness building on reproductive health issues and their importance • wide dissemination of existing scientific evidence on reproductive hazards for women employees (population awareness) • creation of peer support systems among groups of women workers to promote compliance with safety procedures • detailed recording of job tasks for female employees and identification of sources of exposures to known or potential reproductive hazards • introduction of specific safety guidelines and policies for the prevention of reproductive disorders • establishment of clear communication channels between employees and administration to report their concerns or personal experience on relative issues • improvement of the existing surveillance system for reporting suspicious cases among women workers reinforcing factors whp program officials may utilize numerous tactics to support the desired prevention strategy at this field. • provision of access to supplementary information resources on reproductive health issues and available prevention methods to the population of women employees • application of periodic follow-up sessions and use of frequent reminders (letters, telephone calls, e-mail messages) to retain an increased awareness level among female workers • dispensation of easily accessible screening services for exposure of employees to reproductive hazards • building a support network for the compliance of individuals with occupational safety practices by appointing safety committees that include female workers at risk for reproductive hazards • organization of group discussions among workers of specific occupational categories to share common experiences and concerns on related issues • projection of specific employees as models of good conduct in osh issues involving reproductive hazards prevention • presentation of statistics on results of exposure level reduction, or outcomes, if available (e.g., reduction on rate of miscarriages) organizational level- • active participation of women employees in the decision-making process concerning applied safety policies in the company • representation of female workers from different occupational sectors within the organization in administrative issues regarding the design of workstations and job tasks, and the introduction of new technologies, materials, and procedures • introduction of incentives for the compliance of employees with safety policies whp professionals should conduct this final diagnostic procedure before the implementation of the prevention program, to determine whether the program's scope and activities are compatible with the administrative and policy framework of the organization. the main issues to be identified at this stage are: • whether the policies and safety regulations related to potential reproductive hazards are in accordance with the program's requirements and the existence of requisite modifications or complementary arrangements • whether the program introduces any interventions that are in conflict with the organization's operational framework • whether the selected form of intervention (information campaign, skill building sessions, group activities) is appropriate for the existing company culture in osh issues • which of the existing structures and activities in the organization are useful to the program's strategic planning. some examples of similar structures and activities are presented in table . . • whether the company's administration is sufficiently flexible to adopt the participatory decision model proposed by the program for the resolution of osh issues • whether the organization's field of activities and operational status allows for alternative practices, procedures, and materials. table . sites an indicative list of similar practices and procedures. . systematic record of occupational medical history of workers . safety committees appointed by company's employees . trade-union department specialized in osh issues for female employees . registry of recognized occupational reproductive disorders . official forms for reporting employees remarks on working conditions and related hazards . detailed registry of materials, substances and processes utilized in each department of the organization (toxicity, carcinogenicity, potential for endocrine disrupting activity) . regular group meetings among workers and administration representatives . periodic screening of working population for hazardous occupational exposures the primary concern of whp professionals in the design of an educative intervention for women workers is to provide a tailored program according to the specific target population and its educational needs. the selection of a specific approach for this educational needs assessment depends heavily on the available resources (staff, time, expenditure limitation) of the program. listed below are some of the available techniques, and the form in which they may be employed, to obtain related information from the female workers' population (national cancer institute a; pfizer ; younger, wittet, hooks & lasher ) : women employees can be accessed individually, either at their worksite or through telephone or internet surveys, to fill in specifically designed questionnaires. some of the questions that may be included in such a questionnaire are listed in table . . this approach involves two-hour sessions of small work groups of six to ten women employees who testify their individual concerns, experiences, and percep- tions on work-related reproductive health issues. the activity takes place under the continuous supervision of an expert facilitator (health professional). the workgroup is selected on the basis of common socioeconomic and ethnic characteristics (e.g., representation of low literate immigrant female workers) as well as their specific job tasks. the application of this technique offers the whp program a more comprehensive insight into the target population profile (younger et al. ) , as well as the specific needs of certain special subgroups of womens workers (e.g., effective approach and training techniques, use of appropriate educative material). women employees are interviewed in the form of open-ended questions, where they are encouraged to identify themselves and their educational needs by trained professionals (instead of being guided by specific queries). even though this technique is the most time-consuming, it offers the most in-depth needs identification (younger et al. ) . these committees are formed by women employee representatives of specific at-risk populations, and consult whp professionals on specific issues related to reproductive health disorders among certain categories of workers, contributing their own experiences and concerns. the ecological model (mcleroy, bideau, steckler & glanz ) that was presented in the first chapter of this book offers the opportunity to identify the determinants of individual behavior within the wider context of social groups or organizations to which a person belongs. this perspective can therefore be useful for implementing comprehensive whp programs addressing specific health issues. analyzing the profile of a specific organization according to the five individual levels of the ecological perspective model-intrapersonal, interpersonal, institutional, community, and policy-one can identify multiple and multi-component potential interventions for the protection of female workers from the main categories of reproductive hazards recognized in the existing literature. at the intrapersonal level, workplace health promotion activities focus on individual skill building for female workers in the form of personal counseling on issues of reproductive health. the general scope of these interventions, some of which are presented in table . , is the introduction of a number of issues including: • identification of occupational reproductive hazards, personal risk factors, and related symptoms • requested behavioral changes towards prevention • skill-building in the correct use of equipment, materials, and safety practices • access to scientific resources and specialized health services workplace health promotion interventions at this level appeal to groups of working women instead of individuals. this stage of whp involves skill-building sessions, team collaboration and support activities, and health education, which may vary in group size or duration according to the educational needs of a specific working population. these groups can be selected according to common epidemiological or social characteristics of the workers (e.g., age, education, ethnicity) to adequately tailor any intervention. table . presents some of the group activities that may take place within the context of whp: cited in table . is a list of available interventions at the institutional (or company) level concerning organizational measures, practices, and policies that may be implemented for the protection of women worker's reproductive health. to implement effective workplace health promotion programs for the protection of female reproductive health, health professionals should not neglect the fact that the female working population in a specific worksite acquires certain characteristics that • group training sessions on radioactive material safe handling, and protective measures against ionizing radiation • group skill-building on stress management techniques, workplace design for the protection of pregnant women employees, safe manual handling methods • group education on infectious agents hazardous for female reproductive health, their transmission pathways, methods for prevention generic: • creation of employee's groups to constitute models of "best practice" and provide a supportive environment for the adoption of safety techniques (or "healthy behaviour") among women workers • creation of idea-exchanging groups, for identification of specific workplace reproductive hazards and special issues of concern for women workers define a community. the main focus of a successful whp project at this level is to incorporate the issue of reproductive health in the safety culture of female workers. this involves organizing targeted group activities for female workers that addresses the problem of reproductive hazard prevention through the community's system of "group norms, inner rules and beliefs" (edlich, winters, hudson, britt & long ) , and create a climate of awareness on issues related to female employees. at this level, workplace health promotion programs involve contacts with stakeholders (trade union members, employee representatives, company executives) and policymakers to propose measures, policies, and legal provisions for the protection of female workers' reproductive health, some of which are listed in table . . whp programs may utilize multiple channels of communication to deliver messages related to women's reproductive health protection. the approach may take various forms (prevention ): • proposals (by health professionals) for specific changes in the production line -substitution of chemical factors which are detrimental for female reproductive health with "safer" compounds • proposals for specific design changes in facilities, to isolate chemical procedures • frequent measurements by health technicians in the workplace to record concentration of chemicals, and identification of high risk population • training of occupational physicians and nurses in: a) identification of chemical reproductive hazards b) available preventive measures c) early diagnosis of reproductive disorders • re-positioning of pregnant employees to reduce potential exposure to chemicals • provision to all staff members of specific company's guidelines on occupational safety and reproductive hazards prevention (official forms, leaflets, electronic mail), as well as standard operating procedures for using chemicals • rotation of workers to reduce potential exposure • definition of a strict company's policy on health protection for non-smokers • placement of warning signs to prohibit smoking in the company • provision of adequate outdoor spaces, and timebreaks for smokers • funding of campaigns and incentives on smoking cessation for employees • proposals for specific design changes (e.g. armoring improvement, isolation of radioactive material) to avoid exposure of personnel to radiation • frequent radiation measurements in the workplace environment to identify potential sources of exposure and high risk employees • provision (to all staff) of specific directives on safe use of radiation emitting equipment (instruction sheets, official forms, leaflets, electronic mail) • re-positioning of pregnant employees to reduce potential exposure. rotation of workers to reduce potential exposure • proposals to administration to conduct adequate modifications in ergonomic design and provision of special equipment table . (continued) potential hazard intervention opportunities • proposals to administration for the introduction of specific safety regulations concerning female employees (especially during pregnancy): a) time-schedule modification, b) maximum working hours, c) mandatory time-breaks, d) provision of sick-leave days, e) maximum allowed weight for manual handling, f) re-positioning of pregnant employees, g) zero-tolerance policy on aggressive behavior against employees • providing staff with the organization's safety guidelines for preventing physical strain (instruction sheets, official forms, leaflets, electronic mail). rotation of workers to reduce physical strain • provision to all staff of educative material on potential effects of infectious agents to female reproductive health • introduction of collective safety guidelines for all health-care personnel • provision of adequate safety equipment to prevent accidental transmission of infectious agents (safety syringe mechanisms, syringe disposal vessels, goggles, masques, gloves) • extensive vaccination program for child-bearing age personnel (health care workers, teachers, nursery workers) lectures constitute single courses or one-shot education interventions (prevention ) providing general information on the topic of occupational reproductive hazards for women (risk factors, generic preventive measures). presentations and lectures may be used as well to carry health messages among the staff in an effort to establish general acceptance and support for the company's pertinent safety regulations and policies. (lawson et al., ) • systematic occupational exposure assessment to identify high risk female employees • proposal for legislative regulation to substitute hazardous agents with "safer" chemical compounds • promotion of scientific research on gender specific reproductive issues for female workers • obligatory reproductive health surveillance of women workers in high risk for reproductive disorders • systematic registry of birth defects according to maternal occupational exposures • production of specifically designed protective equipment for female workers this form of communication is able to provide wide-scale access to the population of working women (e.g., access to agricultural workers in distant areas, low-literacy skill employees) through billboards, magazines, and newspapers published by the company, or items of special interest to certain professional sectors, such as leaflets referring to reproductive safety issues. health professionals may utilize this channel to address generic guidelines for prevention on issues of reproductive health either to female workers themselves or to their coworkers, which may effect women employees through their tasks or behavior (e.g., men employees smoking indoors, safe storage or handling of hazardous chemicals in the workplace). this form of health promotion is based on establishing an interactive information service for the prevention of occupational reproductive disorders (prevention ) . this service should incorporate a telephone center with the ability to provide personal telephone counseling to women employees, as well as a hotline for answering women's questions concerning reproductive health issues. furthermore, this service should develop an electronic library, accessible through the internet, for all female workers and the general public, providing official safety guidelines for reproductive hazards and answers to related questions. finally, it enables continuous sensitization of high-risk female employees through frequent electronic reminders and their activation in safeguarding their reproductive health. media has proven to be one of the most effective communication channels for many health issues and health promotion activities. it can be utilized to address messages on a larger scale, mostly by health professionals who work in workplace health promotion programs on community, national, or european level. it uses public announcements, short messages, and commercials to address reproductive health hazard prevention issues through radio, television, and newspapers. in some cases, this form of health promotion may be useful for approaching female workers who are not easily accessible by other workplace health promotion programs, such as occupations in small enterprises, part-time employment, and female agricultural workers in remote areas. • violent behavior intense psychological stress (artazcoz lazcano, cruz i cubells, moncada i lluis, & sanchez miguel exposure to ionizing radiation (x-ray & computed tomography departments, nuclear laboratories, patients treated with radioactive drugs) anaesthetic gases, cytotoxic drugs • infectious diseases airborne, blood borne • dermatitis (allergic, irritative) • disturbance of the regular circadian -metabolic rhythm gimeno, felknor, burau, & delclos, ) and micro particles indoor air quality and health in offices and other non-industrial working environments prevalence and risk factors of occupational asthma among hairdressers in turkey incidence of asthma in female swedish hairdressers current findings about the development of obstructive airway diseases in hairdressers (bk numbers: / ) women's occupational dermatologic issues associations of self estimated workloads with musculoskeletal symptoms among hospital nurses combining job and family demands and being healthy: what are the differences between men and women? gender inequalities in health among workers: the relation with family demands stress and work-related tension in the nurses and clinical aides of a hospital predictors of early leaving from the cotton spinning mill environment in newly hired workers interdigital pilonidal sinus in a hairdresser self-assessed and directly measured occupational physical activities-influence of musculoskeletal complaints, age and gender evaluation of reports of periconceptual occupational exposure: maternal-assessed versus industrial hygienist-assessed exposure work-related obstructed airway diseases by irritative noxae in the low concentration range evaluation of occupational environment in two textile plants in northern india with specific reference to noise noise exposure of music teachers laundry workers: cleaning up an industry. we can do it: protecting women workers hazardous substances in the air at hairdressers' workplaces work-related musculoskeletal disorders in hairdressers the hazards of surgical smoke. not to be sniffed at! british journal of perioperative nursing : the journal of the neck and 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and challenges. aaohn journal : official journal of the american association of occupational health nurses workstation design in carpet hand-weaving operation: guidelines for prevention of musculoskeletal disorders nurses confronting sexual harassment in the medical environment musculoskeletal disorders in hotel restaurant workers mortality among us employees of a large computer manufacturing company factors influencing restaurant worker perception of floor slipperiness handle with care: the american nurses association's campaign to address work-related musculoskeletal disorders prioritizing safe patient handling: the american nurses association's handle with care campaign epidemiology of voice problems in dutch teachers cross-sectional investigation of task demands and musculoskeletal discomfort among restaurant wait staff work-related violence and the ohs of home health care workers working in clients' homes: the impact on the mental health and well-being of visiting home care workers. home health care services quarterly health hazards of ceramic artists occupational contact urticaria and protein contact dermatitis are health care providers who work with cancer drugs at an increased risk for toxic events? a systematic review and meta-analysis of the literature prevalence of voice disorders in african american and european american preschoolers prevention of disabling back injuries in nurses by the use of mechanical patient lift systems gender issues in safety and health at work -a review. luxembourg: office for official publications of the european communities european agency for safety and health at work ( b) including gender issues in risk assessment [electronic version mainstreaming gender into occupational safety and health. luxembourg: office for official publications of the european communities eurostat ( ) european social statistics: labour force survey results : office for official publications of the european communities fjellman-wiklund a, brulin c, and sundelin g ( ) physical and psychosocial work-related risk factors associated with neck-shoulder discomfort in male and female music teachers prevalence of sensitivity to rubber additives and latex in hairdressers with hand and/or forearm contact dermatitis diagnostic approach and management of occupational asthma by persulfate salts in a hairdresser. allergy and asthma proceedings : the official journal of regional and state allergy societies sex differences in pharmacokinetics and pharmacodynamics pesticide exposure and women's health adequacy of vaccination coverage at school-entry: cross-sectional study in schoolchildren of an urban population pulmonary fibrosis and ferruginous bodies associated with exposure to synthetic fibers the precede-proceed planning model organisational and occupational risk factors associated with work related injuries among public hospital employees in costa rica bad nights or bad bars? multi-level analysis of environmental predictors of aggression in late-night large-capacity bars and clubs health promotion planning: an educational and environmental approach knowledge, attitude and practices among health care workers on needle-stick injuries high rubella seronegativity in daycare educators fit factors for quarter masks and facial size categories the risk of adverse reproductive and developmental disorders due to occupational pesticide exposure: an overview of current epidemiological evidence traumatic injuries in agriculture haz-map ( b) cadmium and compounds. occupational exposures to hazardous agents retrieved glycol-ethers. occupational exposure to hazardous agents occupational exposure to sevoflurane, halothane and nitrous oxide during paediatric anaesthesia. waste gas exposure during paediatric anaesthesia chemical exposure in hairdresser salons: effect of local exhaust ventilation gender differences in self-reported physical and psychosocial exposures in jobs with both female and male workers quantification and risk analysis of occupational burns: oregon workers' compensation claims, to environmental factors in infertility risk factors for neck pain in office workers: a prospective study allergic contact dermatitis in hairdressers: frequency and source of sensitisation professional cleaning and asthma office work, sbs and respiratory and sick building syndrome symptoms garlic-related dermatoses: case report and review of the literature principal results occupational allergic contact dermatitis from spices a multicentre review of the hairdressing allergens tested in the uk occupational risk for hepatitis a: a literature-based analysis exposure assessment in epidemiology: does gender matter? development of hand eczema in hairdressers, to years after the start of training -a follow-up study of "posh-studie" participants perilous work: nurses' experiences in psychiatric units with high risks of assault industrial sectors with high risk of women's hospital-treated injuries risk factors for voice problems in teachers an analysis of occupational dysphonia diagnosed in the north-east of poland do teachers have more health problems? results from a french cross-sectional survey work practice and some adverse health effects in nurses handling antineoplastic drugs case report: occupationally related recurrent varicella (chickenpox) in a hospital nurse characterization of chemical exposures in hairdressing salons printed circuit board industry perceiving classroom aggression: the influence of setting, intervention style and group perceptions workgroup report: implementing a national occupational reproductive research agenda-decade one and beyond gender differences in the healthy worker effect among synthetic vitreous fiber workers voice symptoms of call-centre customer service advisers experienced during a work-day and effects of a short vocal training course respiratory illness in agricultural workers making manufacturing a safe work environment for women workers. we can do it: protecting women workers evaluation of the exposure to biomechanical overload of the upper limbs and clinical investigation in a female population employed in the manual loading of production lines in ceramics factories noise exposure and hearing loss in agriculture: a survey of farmers and farm workers in the southland region of new zealand an investigation of contact transmission of methicillin-resistant staphylococcus aureus women in agriculture: risks for occupational injury within the context of gendered role male and female rate differences in carpal tunnel syndrome injuries: personal attributes or job tasks? the "gras" status of women's work sex matters: exploring differences in responses to exposures an ecological perspective of health promotion programs workplace violence in health care: recognized but not regulated sex, gender and women's occupational health:the importance of considering mechanism ovarian intrafollicular processes as a target for cigarette smoke components and selected environmental reproductive disruptors the effect of health education in promoting health of hairdressers about hepatitis b based on health belief model: a field trial in yazd carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners occupational asthma among hairdressers occupational asthma and occupational rhinitis in hairdressers energy cost of physical task performance in men and women wearing personal protective clothing rubella infections of the school teachers in sapporo municipal schools after their employment adapting osha ergonomic guidelines to the rehabilitation setting theory at a glance: a guide for health promotion practice theory at a glance" a guide for health promotion practice how is sex considered in recent epidemiological publications on occupational risks? muscle pain, physical activity, self-efficacy and relaxation ability in adolescents gender inequalities in occupational health: harvard school of public health accidental exposure to biological risk among health care workers of a sanitary area prevalence of occupational hand dermatitis in u.k. hairdressers noise and chemical induced hearing loss: special considerations for farm youth pfizer principles for clear health communication nd edition agents causing occupational asthma in finland in - : cow epithelium bypassed by moulds from moisture-damaged buildings sex and gender factors in medical studies: implications for health and clinical practice lik sprava safe handling of hazardous drugs needlestick injuries among health care workers. a literature review designing and evaluating intervention plans evaluating cdc-funded health department hiv prevention programs occupational risky business: injury prevention behaviors of farm women and children using the precede-proceed model to increase productivity in health education faculty [electronic version unconsumed precursors and couplers after formation of oxidative hair dyes labour market latest trends - rd quarter data active epidemiological surveillance of musculoskeletal disorders in a shoe factory histology and pathology laboratories. chemical hazard prevention and medical/health surveillance musculoskeletal dysfunction in physical education teachers physical work load in physical education teachers barber's hair sinus in a female hairdresser: uncommon manifestation of an occupational dermatosis framing personal risk in public health nursing the prevalence and risk factors for occupational voice disorders in teachers glutaraldehyde exposure and its occupational impact in the health care environment contact dermatitis to hair dyes in a danish adult population: an interview-based study division of labor standards and safety, occupational safety and health ( ) the manager's handbook: a reference for developing a basic occupational safety and health program for small businesses women, work and musculoskeletal health occupational voice disorders: an analysis of diagnoses made and certificates issued in - exposure to cooking fumes in restaurant kitchens in norway effects of glutaraldehyde exposure on human health occupational risk factors associated with voice disorders among teachers health risks of occupational exposure to anticancer (antineoplastic) drugs in health care workers assessment of dna damage in nurses handling antineoplastic drugs by the alkaline comet assay assessment of dna damage in nurses handling antineoplastic drugs by the alkaline comet assay visual problems among electronic and jewelry workers in thailand association between occupational asthenopia and psycho-physiological indicators of visual strain in workers using video display terminals please put this in the proper format and move this reference to its alphabetical place in the "p's" weaver vm secondary individual prevention of occupational skin diseases in health care workers, cleaners and kitchen employees: aims, experiences and descriptive results. int arch occup environ health williams nr ( ) occupational groups at risk of voice disorders: a review of the literature chemical occupational risks identified by nurses in a hospital environment work-related musculoskeletal disorders and associated factors in teachers of physically and intellectually disabled pupils: a self-administered questionnaire study seroprevalence of varicella, measles and hepatitis b among female health care workers of childbearing age immunization and child health materials development guide zidkova z and martinkova j ( ) psychic load in teachers of elementary schools key: cord- -ex ahuc authors: brooks, deborah jordan; saad, lydia title: double whammy: why the underrepresentation of women among workplace and political decision makers matters in pandemic times date: - - journal: nan doi: . /s x sha: doc_id: cord_uid: ex ahuc in this article, we explore whether women's underrepresentation among political and workplace decision makers may subject female citizens and employees to covid- -related decisions that are at odds with their preferences. we find that women overall, as well as female political party members, workers, and workplace leaders in particular, share a distinctively female perspective that more heavily emphasizes caution with respect to covid- compared with men. given the limited representation of women leaders across most industries and in politics, covid- regulations are thus likely to be less cautious than would be the case if there were an equitable representation of women across leadership roles. we argue that female employees, in particular, face a representational “double whammy” for covid- : gender imbalances in workplace leadership create inequities that are compounded—rather than redressed—by unequal political representation. we conclude by addressing how this dynamic may enhance the movement of women away from republican candidates moving forward. i n recent months, covid- has upended normal daily life, education, and work across the globe. decisions about school and workplace closures and reopenings have substantial implications for nearly everyone, often pitting health concerns against consumer preferences and economic considerations. in this article, we explore whether the lack of representation of women among both political and workplace decision makers may cause the covid- -related interests of female citizens and female workers to be discounted. we find that women tend to share distinctive perspectives regarding covid- that emphasize caution far more than is the case for their male counterparts, and we show that the gender difference tracks across political parties. we also demonstrate that both female workers and female workplace leaders have fundamentally different preferences than men concerning covid- in the workplace. in light of the poor representation of women among decision makers in most u.s. industries and in politics, the results of this analysis suggest that regulations about covid- -related issues are likely to be less focused on the protection of individuals from the coronavirus than might otherwise be the case if women were equally represented in leadership roles in the united states. ultimately, we argue that covid- creates a form of interaction of the political and business realms that may be especially harmful to women. specifically, we conclude that women face a representational "double whammy" regarding covid- : their lack of representation among workplace leaders creates problems that are being compoundedrather than redressedby unequal political representation. we conclude the article by discussing suggestive signs that women have recently been moving away from president donald trump at disproportionately higher rates, potentially because of his positioning on covid- . we examine these issues using large random national samples of americans collected by gallup via web surveys. the gallup panel is a nationally representative, probability-based survey panel of adults, and the data are weighted according to demographic characteristics to reduce nonresponse bias and improve the representation of the u.s. population. studies indicate that probability-based panel polls can provide estimates of public opinion that tend to be at least as accurate as those of traditional telephone polls (macinnis et al. ; yeager et al. ) . we use these data for all the analyses that follow, with the analyses of workers and workplace leaders making up a subset of the total sample. we included data collected from may to june , , a time when initial reopening decisions were actively being implemented in many parts of the country. the questions asked in the survey were largely focused on covid- concerns, individual preferences, and workplace structure; there were no questions specifically about covid- -related policy on the survey. especially as an emergent policy area, it seems unlikely that there would be a substantial discrepancy between personal preferences and policy preferences that would further diverge by gender, but this is a potential caveat to note. the divergence between women and men across a wide range of questions concerning covid- is striking. table shows that women express substantially greater levels of concern than men on a wide variety of covid- dimensions. these patterns are notable given that women seem to be carrying a disproportionately greater share of the covid- -related care-giving load at home, such as child care and remote schooling (see, e.g., cohen and hsu ; miller ) . of course, it is also the case that women tend to be democrats, and democrats tend to have more cautious views on covid- relative to republicans. as such, we examine whether the gender differences shown are a reflection of the partisan gender gap. table shows that is not the case. across both parties and among political independents men tend to be substantially less concerned and cautious about covid- compared with their female copartisans. appendix a in the supplementary material online shows a corresponding pattern of results based on multivariate analyses with the inclusion of a series of control variables. % * * indicates differences between women and men that are significant at . or bett our results match up with research on previous respiratory diseases across the globe. specifically, moran and del valle ( ) conducted a meta-analysis of studies of responses to respiratory outbreaks around the world and found that women were approximately % more likely to practice nonpharmaceutical preventative behaviors (i.e., using masks, extra handwashing, etc.) during outbreaks than men. establishing why sex differences exist in responses to epidemics is beyond the scope of this article, although our findings suggest some possibilities. studies have found that the views of men and women tend to differ when risk is involved. in particular, scholars have found that women have a greater preference for risk reduction on environmental issues when safety risks are involved (bord and o'connor ; norrander ) . our results seem consistent with a lower perception of risk by men than by women, since we find that women are not just more likely to prefer a cautious approach to covid- but also more concerned than men about catching the coronavirus, even though men are far more likely die from it (reeves and ford ). given the rapid spread of covid- , workplace decisions have critical importance for the economic livelihood and safety of employees. as a result, we examine whether there is a gender gap among workers regarding responses to covid- and, in turn, whether differences exist between workplace leaders versus nonleader employees. questions regarding covid- in the workplace were asked of a subset of the gallup panelists represented in the analyses who had been employed over the seven days prior to the day the survey was taken. when asked which option describes their role or job responsibilities at work, % of employed male respondents and % of employed female respondents selected "i am a leader who manages others" (coded as "leaders"), while the balance selected nonleadership descriptions of their role at work (coded as "workers"). the "workers" column of table shows a persistent gender gap. female workers are significantly more concerned about the safety of . the specific options presented to respondents were: . "i am a leader who manages others"; . "i am a manager/supervisor whose main responsibilities are the work output of other people"; . i am a project manager who is responsible for other people's work; . "i am an individual contributor responsible for my own work or output." in our analyses, = "leader" and , , and = "worker." double whammy returning to work, are more likely to prefer to continue working at home because of covid- -related concerns, and anticipate a longer duration of continued disruption. a related question is whether the preferences of female workers would be better represented by female workplace leaders as decision makers, which requires first identifying whether a similar gender gap regarding caution toward covid- is also observed among their leaders. table confirms that female workplace leaders are also more likely than their male counterparts to take a cautious approach to covid- . the multivariate analyses in appendix b allow us to confirm that gender is a significant determinant of covid- views in the workplace both with and without interactions between sex and leadership. controls were included for partisanship (as dummies for "republican" and "independent"), low-density population (rural/small town), married, parent, college graduate, race/ethnicity (dummy coded as white, non-hispanic), age or older, high health risk for covid- , high income (household income of $ , or more) and low income (household income of $ , or less), essential worker, and week of survey administration. in short, all of the analyses point in the same direction: male workers are far more bullish about returning to work life as usual than their female colleagues, and similarly gendered patterns exist among workplace leaders. from the foregoing analyses, we can conclude that female business leaders would be likely to voice different perspectives on covid- -related workplace policies than their male colleagues. but how likely are they to have an effective platform for doing so? just % of the self-described workplace leaders in our sample were female, reflecting a strong male skew in leadership across the majority of u.s. industries and workplaces; moreover, gender imbalances in leadership tend to be even greater at the highest levels of decisionmaking for the largest employers. for example, just . % of the ceos of . men and women, on average, tend to hold different types of roles in different industries; that could be a confound if women are more likely to be represented in the ranks of frontline workers. by controlling for "essential workers" based on self-report (i.e., "is your job something your state government considers an essential job function that is exempt from stay-at-home orders?"), we are able to show that it does not negate the gender gap. moreover, its presence in the equation does not significantly affect any of the core findings. fortune companies are female (hinchliffe ; see also yanosek, ahmad, and abramson ) . it is notable as well that even in fields that are mostly composed of female workers, the leadership still skews heavily male: for example, only % of health care ceos and medical division chiefs are female (compared with % of health care workers), and only one-quarter of school district superintendents are female, while just over three-quarters of k- teachers are women (rotenstein ; superville ) . those mostly male workplace leaders are probably unlikely to feel strong pressure to factor in the distinctive covid- -related preferences of female workers. leaders outside of politics do not tend to be democratically elected, generally holding powers more akin to autocrats or even dictators (wadhwa ) . ultimately, the exclusion of women from leadership across so many industries strongly suggests that female employees are likely to find themselves pressured or even required to return to workplaces sooner than it feels safe to them, and, by extension, once returning, they may also find fewer safety precautions in place than they prefer. the political realm could potentially serve as a bulwark to prevent female workers from working under conditions they deem unsafe. unfortunately, women are also descriptively underrepresented across all levels of politics; moreover, the vast majority of female office holders hail from the democratic party (for the most recent numbers, see cawp ). there is active debate about the degree to which co-partisanship versus shared gender most effectively promotes the interests of women. but to the extent that descriptive representation does matter, there is reason to think that healthcare might be one of the policy arenas where it might matter a good deal (swers ) . might this pandemic cause womenand perhaps republican-leaning working women in particularto become especially concerned about the relative lack of female decision makers both at work and in politics? if republican leaders continue to minimize the need for safety measures around covid- (hellmann ; wildermuth ), could it lead to a further shift among women in the short term toward a vote for joe biden over trump, or away from the republican party in the long term? partisanship tends to be "sticky," and candidate preference tends to be closely tied to partisanship (see, e.g., green, palmquist, and schickler ) . these are not normal times, however, and covid- is not a normal issue. the degree to which this pandemic creates what for many may feel like fundamental concerns about economic and corporeal survivalnot just for individuals but for entire households and communitiesshould not be underestimated. it is thus interesting that some early indications have emerged that trump has been losing support among women to an even greater extent in recent months. for example, some polls found that the drop in those preferring trump over biden was particularly marked between march/april and may/june (cohn ) . with other factors in play during that same time period, a clear causal relationship cannot be isolated; moreover, those results do not isolate female employees specifically. however, results such as those provide some suggestive evidence that the republican party may be facing a new cleavage that may further peel away female support for republican candidates, thereby potentially expanding an already considerable partisan gender gap. to view supplementary material for this article, please visit https://doi.org/ . /s x deborah jordan brooks is associate professor of government at dartmouth college: deborah.j.brooks@dartmouth.edu; lydia saad is director of u.s. social research at gallup: lydia_saad@gallup.co the gender gap in environmental attitudes: the case of perceived vulnerability to risk women in elective office pandemic could scar a generation of working mothers wave of new polling suggests an erosion of trump's support partisan hearts and minds: political parties and the social identities of voters mask-wearing becomes political even as some governors ease resistance the number of female ceos in the fortune hits an all-time record the accuracy of measurements with probability and nonprobability survey samples: replication and extension nearly half of men say they do most of the home schooling. percent of women agree a meta-analysis of the association between gender and protective behaviors in response to respiratory epidemics and pandemics the history of the gender gaps covid- is much more fatal for men, especially taking age into account fixing the gender imbalance in health care leadership stubborn gender gap in the top job pursuing women's interests in partisan times: explaining gender differences in legislative activity on health, education, and women's health issues democracy is a great thing, except in the workplace mask or no mask? democrats, republicans find new battleground how women can help fill the oil and gas industry's talent gap comparing the accuracy of rdd telephone surveys and internet surveys conducted with probability and nonprobability samples key: cord- - n zs authors: strong, adrienne e.; schwartz, david a. title: effects of the west african ebola epidemic on health care of pregnant women: stigmatization with and without infection date: - - journal: pregnant in the time of ebola doi: . / - - - - _ sha: doc_id: cord_uid: n zs following the end of the ebola virus outbreak in west africa in march , the lingering effects of stigma on ebola survivors, as well as children orphaned by the disease, have become evident. however, there was little scholarly attention paid to stigma while the outbreak was still active. this chapter explores the effects of stigmatization on the health care services that pregnant women, both with and without ebola, were able to access and receive during the outbreak. we propose three primary ways in which stigma operated to reduce pregnant women’s access to health care services during the outbreak: ( ) women and their relatives were afraid to go to health facilities for fear of being infected with ebola while there, i.e., stigmatization of health care facilities; ( ) health care workers frequently died due to their occupational exposure to evd while caring for others, i.e., they were stigmatized as carriers or transmitters of ebola; and ( ) pregnant women themselves were refused services at health facilities due to fears that they were infected with ebola, i.e., the physiological processes of birth, which involve high levels of potential for exposure to bodily fluids, led to health care workers’ stigmatization of these women when they sought services during pregnancy or, particularly, at the time of giving birth. in several of the countries that experienced the worst of the outbreak, women already faced some of the world’s highest rates of pregnancy-related death even prior to the advent of the epidemic. we argue that the high fatality rate for pregnant women with ebola, the drastic effects of the epidemic on countries’ health care workforce, and the inherent messiness of birth, all coalesced to create heightened discrimination and stigma around seeking care during pregnancy and birth. multivalent meanings for social relations within communities that would, ultimately, disrupt containment efforts. the ways in which local and international organizations enacted many of these containment protocols both engendered and exacerbated community resentment, mistrust, and, at times, hostility that transformed into outright violence directed at the people working to implement public health measures (calain and poncin ) . when faced with rapidly deteriorating health infrastructure, there is some evidence to suggest, as do blair et al. ( ) from their work in liberia, that people with low confidence in formal state functions, institutions, and structures were more likely to ignore recommendations meant to control the spread of evd. this could, in turn, suggest that countries in which citizens have low confidence in state structures might experience greater levels of evd-related stigma; as a population at risk, with little other recourse (in the absence of confidence in the state to be able to protect them), began ostracizing the members of society they considered to be the greatest threat to them. pregnant women, having unpredictable bodily fluids and, upon delivery, ebola-infected amniotic fluid, hemorrhage, and placental tissue, would certainly fall into that category. the health care workers involved in the care of evd patients also fell into this category, as well as those people thought to be even remotely affiliated with health facilities or locations in which evd patients had been. in their discussion of hiv/aids stigma, castro and farmer ( ) argue that a driving force behind the stigma is a lack of access to treatment. stigma is not the determining factor in treatment seeking but, instead, economic and logistical barriers decide who will be able to avail themselves of care (castro and farmer ) . in the case of evd, poor infrastructure and weak public health systems were undeniable contributors to the spread of the disease. additionally, as castro and farmer ( ) indicate, evd differentially affected people based upon economic resources. in one of the stories we analyze later in this chapter, the family was able to pay an exorbitant sum for the pregnant wife to access care, but many others did not have the economic means to pursue even regular obstetric care at any cost. these infrastructure and economic constraints, when combined with a high case fatality rate and rapid progression of clinical evd, dramatically set ebola apart from hiv/aids. taken together with the criteria of maman et al. ( ) for stigma, particularly as related to the fears of suffering and death and the fear of transmission, the weak state in many of the affected countries provided the perfect storm for the development of strong and pervasive ebola stigma. we argue here that it is likely that health care workers and community members fell back on stigmatization as, what they saw as, one of only a few possible ways of protecting themselves. pregnant women, even those unaffected by the virus, suffered the consequences of people's fears, which took the form of increased stigma that caused many women to be refused care at health facilities. the health care system was undeniably overwhelmed by the number of ebola patients and the particular needs for quarantine and supplies these patients presented. the fact that an ebola epidemic was able to effectively shut down any and all routine health care services, particularly vital functions related to obstetric care, is a testament to the long-standing weaknesses of these systems (chothia ) . while others have begun to write about the lasting stigmatization that ebola survivors (karafillakis et al. ; van bortel et al. ) or ebola orphans (denis-ramirez et al. ) have been experiencing since the end of the outbreak, we are most interested here in examining stigma that occurred during the active phase of the outbreak. likewise, we have chosen to limit our discussion to the experiences of women who were pregnant at the time of ebola. in this chapter, we argue for a reexamination of stigma in the context of transient, acute crises. without first understanding more about the ways in which people use or suffer from the effects of stigmatization under these circumstances, it will be impossible to mitigate the effects of stigma in similar situations. we use a meaning-centered approach to stigma, thinking through what is at stake for both the stigmatized and stigmatizing groups. next, we put forth examples of three ways in which pregnant women were particularly affected by stigma in the health care setting during the - ebola virus outbreak in west africa: ( ) women/community stigmatization and avoidance of health care facilities; ( ) stigmatization of health care workers due to association with ebola; and ( ) stigmatization directed toward pregnant women (or perceived stigma), which prevented women from receiving care when pregnant or during delivery and in the postpartum period. we then explore the consequences of this stigmatization, seeking to answer questions such as: how did women and/or their family members seek to combat stigmatization? how did pregnant women's stigmatization of other parties (namely health care workers) affect their access to obstetric care? what were the intended effects of stigmatizing health workers? what were the protective effects of stigmatizing pregnant women and for whom? how did reluctance to care for pregnant women result in compounding adverse effects for a segment of the population that was already at far greater risk for death-both from pregnancy-related causes, and ebola virus itself? the residual effects of evd, even in people who have survived and recovered, are bound to increase the chances that any similar future outbreak of evd could generate even more severe stigma because people will have the collective memory of the previous outbreak and its devastating effects. in outbreaks of infectious diseases, sex, gender, and age all play important roles. women typically have different gender-assigned roles than do men-even when they are pregnant. they prepare meals, are caregivers for the sick, and often help to prepare the dead, in addition to the daily work of childcare, and, in many areas of africa, fetching water and firewood, washing clothes, and ensuring the availability of daily provisions for the family, as well as engaging in subsistence farming (avotri and walters ; who ) . broader structural factors and power relations influence women's ability to access health care services even under normal conditions. women who are pregnant are at an especially high risk for becoming infected with evd, and then having poor clinical outcomes, for several reasons. depending on the community norms of their particular ethnic group, women, and pregnant women perhaps even more so, typically have less mobility than do other members of the society, are often dependent upon men or more senior women for decisions related to seeking health care, are poorer than men, and have less access and control over economic resources (coulter ). there are frequently concomitant biological factors which may make pregnant women even more susceptible such as anemia, altered immunity due to pregnancy or reduced health over their life course, low body mass index (bmi), malnutrition and poor nutritional quality of the diet, and other complications of pregnancy including diabetes and hypertensive diseases. pregnant women may spend more time in health care settings, such as clinics and hospitals, due to the pregnancy itself or due to monthly visits with their young children, or as they accompany others seeking care, and thus have greater exposure to nosocomial transmission of all diseases, not simply ebola. pregnant women may also have fewer treatment options or choice of medications because of potential teratogenic effects on the fetus and, if postpartum, due to breastfeeding. as was seen in previous ebola outbreaks in uganda and democratic republic of the congo, women are often placed at greater risk for infection due to gender specific roles and activities, particularly those related to funerary practices, which have been well-studied in these previous outbreaks and have taken on a prominent role in gender-specific risk (anoko ; barbato ; hewlett and amola ; segers ; world health organization ) . infants and children are another vulnerable part of society in these countries. in previous outbreaks of the ebola virus, there have been no documented neonatal survivors from pregnant women infected with the virus (cdc a). the most recent data from the west african epidemic indicate that there are very few infants born to ebola-infected mothers who survived as neonates for even a few days (howard ; jamieson et al. ) . those newborns who have survived following their mother's ebola virus infection have been highly profiled in the media (awford ; chicago tribune ; martel ; médecins sans frontières ) . women and children are also vulnerable to the continued effects of destabilization within their countries after the official termination of the outbreak. we are now seeing the beginning signs of lasting physiological and psychological effects of ebola even on those who made a full recovery after initial infection (clark et al. ; maron ) . in these instances, it is clear that ebola survivors will continue to face the continuing impact of their infection for years to come in the form of the physiological effects mentioned above, but also in the form of social effects. early findings suggest survivors and children left orphaned due to the outbreak may suffer from on-going stigmatization (denis-ramirez et al. ) . it is also expected that comorbid diseases, especially those that are vaccine-preventable such as measles and meningitis, may now have a resurgence as a result of interruptions of routine immunization practices caused by the ebola epidemic, which further weakened already strained health systems (takahashi et al. ). during the - outbreak, women in liberia, sierra leone, and guinea faced the unwelcome prospect of a triple burden of death-they could die from ebola virus, during pregnancy, or during childbirth. early during the development of this outbreak, a preponderance of women were affected, with infected women outnumbering infected men by a to ratio in liberia, and to in both guinea and sierra leone (barbato ; bofu-tawamba ; hogan ; life for african mothers ). this was the result of customs which have been well-described-women had the major roles in providing care for the ill and preparing the dead for burial (menéndez et al. ) . it was not until much later in the epidemic that the ratio of new cases normalized to equal numbers of both sexes being infected by early (saul ; thomas ; who ) . while it has not been systematically confirmed, this equalization perhaps represented effective education concerning modes of transmission, risk behaviors, and an increase in resources coming from governments, volunteers, and nongovernmental organizations (ngos), and their assistance in the removal and burial of the dead. with the onset of the ebola outbreak, the progress which liberia, sierra leone, and guinea had made in the improvement of maternal health prior to the epidemic had all but disappeared. the few hospitals and clinics that were in existence in these countries were converted largely, or in some cases exclusively, into ebola treatment centers (etcs). this had dire consequences even for women who were not infected with the virus-during the height of the epidemic from october to october , it was estimated that , women would give birth in liberia, sierra leone, and guinea, and that up to , mothers could die if denied access to emergency obstetrical care; this is equivalent to almost women dying from pregnancy each day (boseley ; hayden ; unfpa c, d) . at that time, the united nations population fund (unfpa) had estimated that, unless sufficient emergency obstetrical care was provided, the maternal death rates in these three countries could effectively double to levels seen in the s during times of political unrest, civil war, and violence. this increase would represent a maternal mortality ratio (mmr) of in guinea and liberia, and over in sierra leone (unfpa ) . there is no evidence to demonstrate that pregnant women are biologically more susceptible to acquiring ebola virus infection following exposure; however, there are studies which suggest that the ebola virus is much more deadly to pregnant women and their infants than it is to the general population (mupapa et al. ; doucleff ; jamieson et al. ; sieff ) . the ebola virus epidemic in west arica had a case fatality rate (cfr) among people of all ages and sexes of from to %, depending upon the specifics of the group evaluated. data from the centers for disease control and prevention reported a total of , confirmed cases of evd occurring in liberia, sierra leone, and guinea, with a total number of , deaths-a mortality rate of % (cdc b). among pregnant women and their infants, however, there is evidence to suggest that the mortality rates are higher. in an analysis of published studies of pregnant women and fetal outcomes following ebola virus infection in guinea, liberia, and sierra leone, there were maternal deaths, a case fatality rate of . %, and only one surviving fetus (garba et al. ) . in a study of reported cases of evd among pregnant women in all three west african countries, bebell et al. ( ) found an aggregate maternal death rate of % (bebell et al. ) . the fetus from a pregnant woman with ebola virus disease (evd) will almost certainly become infected, likely via the virus passing through the placenta, and be stillborn or die shortly after birth. dr. denise jamieson, an obstetrician with the division of reproductive health of the centers for disease control and prevention (cdc) in atlanta, stated, "there have been no neonatal survivors" (sieff ) . during the kikwit, zaire (currently democratic republic of congo), outbreak of ebola virus infection in , the case fatality rate (cfr) among infected pregnant women was . % (as compared with a case fatality rate of % for nonpregnant women). in this kikwit outbreak, the infection was uniformly fatal to all unborn infants (cfr = %) (mupapa et al. ). liberia, sierra leone, and guinea all had a severe shortage of health workers before the outbreak began in . in liberia, a nation with . million people, there were only physicians, nurses and midwives, and pharmacists in the country. sierra leone, a more populous country with six million inhabitants, had doctors, nurses and midwives, and pharmacists (chothia ) . health care resources in the most affected countries were already stretched thin, with guinea having physicians per , people, sierra leone having physicians per , people, and liberia having only . physicians per , people (in contrast, sweden has physicians per , people) to assist in the treatment of infected persons, as well as the treatment of endemic illnesses and chronic conditions (cia ) . and among these limited contingents of physicians present at the beginning of the epidemic, only a very few were obstetricians, or had even received any additional specialized training in obstetrics. it has been estimated that there were only six obstetricians in all of liberia, some of whom also had administrative roles, and many health facilities lacked a single midwife (sepkowitz and haglage ). to make matters worse, as the epidemic continued in these three countries, the small contingent of physicians became even smaller as a result of exposure to infected patients. in just months, the total number of physicians in sierra leone was reduced by . %-a total of doctors in that nation had died from ebola virus infection as of december (frankel ) . as of november , , there were cases of ebola infection among all types of health care workers in liberia, resulting in deaths; cases of ebola infection in guinea among health care workers resulting in deaths; and, in sierra leone, infections among health care workers causing deaths (statista ) -a total of infected health care workers and deaths as of january , (the economist ). according to the cdc, the confirmed incidence of ebola virus infection was -fold greater in health care workers than in the general population of sierra leone (kilmarx et al. ) . because of these grim statistics, health care workers became associated with ebola, death, and the spread of the disease. after the end of the outbreak, many health care workers continued to experience the social repercussions of carrying out their professional duties-they have been ostracized and stigmatized in their communities (mcmahon et al. ) . the health care workers themselves lamented the drastic changes in patient-provider interactions that the ebola outbreak necessitated; gone were many of the small gestures that communicate closeness and caring in these contexts, such as sitting in close proximity, touching a patient's arm or hand, or helping a breastfeeding mother with her baby's latch (mcmahon et al. ) . quarantines imposed on health facilities that experience compromised contact with people with evd "induced panic within facilities and the broader community" (mcmahon et al. (mcmahon et al. : and health care providers in such communities reported that many people delayed seeking treatment because they associated facilities with points of ebola transmission (mcmahon et al. ) . mcmahon et al. ( mcmahon et al. ( : additionally state that one provider told them, "'if we have not done triage, we are not going to take care of that person even if she is in labor…we have to abandon her on the street. '" mcmahon et al.'s ( ) findings clearly demonstrate the ways in which all three forms of stigma were at play in these communities-people came to associate facilities with transmission points for ebola; health care workers were stigmatized due to their work caring for patients and for changed behavior necessitated by the outbreak; and even when pregnant women did elect to seek health care services, they might not be treated but left on the street to give birth alone, no one willing to risk assisting her. pregnant women avoided going to clinics and hospitals where ebola patients were concentrated for fear of becoming infected with ebola, despite the need for antenatal and intrapartum care. this behavior presents one way in which ebola stigma affected maternal health-by not seeking care for fear of infection or contact with possible ebola patients, pregnant mothers put themselves at risk for complications left undetected or untreated. there was also fear of physicians, nurses, and other health workers among some people, fueled by rumors and conspiracy theories including that health personnel and aid organizations were responsible for spreading the virus. in one occurrence in guinea, these fears resulted in the deaths of eight health workers who were killed by members of the community during a health education campaign (bbc ). the murder of these health care workers was, arguably, an extreme example of enacted stigma as community members killed those thought responsible for the disease and its effects. the deaths of health care workers in countries that already suffered from a severe health worker deficit further limited the number of those who would have been able to serve pregnant women, when pregnant women overcame their fears of health facilities and providers. as a result of the murders, governments and agencies organized attempts to educate the populace about the need to seek medical attention, especially targeting pregnant women. for example, the united nations population fund (unfpa) distributed the following radio message-"pregnant women: health workers are there for you, to give you all the care and advice you need for a safe pregnancy and delivery… they ensure your safety and the safety of your child during the ebola outbreak" (unfpa b). in the face of strong ebola stigma and fears of infection, the effects of such an announcement were debatable, particularly when paired with low levels of local confidence in state structures or outsiders (in the form of aid and humanitarian organizations). prior to the outbreak, the maternity ward at the west point clinic, located in an impoverished residential area outside of monrovia, would have - births each week-during the height of the outbreak, the clinic saw one or two pregnant women per week, and not all stayed to deliver. "people won't go to the hospital, the clinic," according to a -year staff member there, comfort tapeh, "they say that when you go to the hospital, the nurses kill you. i tell them, 'so who's killing the nurses?'" (moore ) . at the same maternity ward, a pregnant women developed a fever, but the woman resisted attempts by the staff to medicate her. she yelled to the staff, "my husband told me i shouldn't take any injections here!" when the staff spoke with her husband, he refused to permit them to treat his pregnant wife and brought her home. jemimah kargbo was on duty at the maternity ward when the woman left. "she will die. with a fever like that, she will definitely die. maybe the baby too," she said (moore ) . these quotes raise a number of other issues related to the differential effect of the ebola virus outbreak on pregnant women, as well as the effects of stigma associated with evd itself, and the stigma those people in close contact with ebola victims attracted in the course of caring for them-be they biomedical health workers, red cross volunteers, or family members caring for relatives in their homes. the stigma associated with working in proximity to ebola patients, or associated with the perception that one was working with ebola patients, effectively led some pregnant women, such as comfort tapeh above, to reject assistance from health care workers. comfort's case demonstrates, too, the ways in which stigma contributed to comfort's desire to risk possible death due to infection instead of, what she perceived to be, the worse fate of risking infection from the ebola virus while in the hospital. even in the best of circumstances, in communities with resource-poor health facilities there is often a deep mistrust and suspicion of health care providers (strong ) ; throughout many resourcepoor communities, people speculate that there are no medications or even gloves, because the nurses were selling these supplies in their own shops. in those instances, people became reluctant to seek care in the frontline health facilities, preferring to go further afield or stay at home with local birth attendants for economic, logistic, or social reasons. if the situation were to deteriorate further, as it did during the ebola outbreak, this suspicion and mistrust would easily multiply. data from the cdc in atlanta have confirmed that fewer pregnant women were seeking care in clinics and hospitals- dynes et al. ( ) and luginaah et al. ( ) state the evidence suggests the outbreak most likely eroded recent gains in utilization of prenatal and delivery care in libera. in the kenema district of sierra leone, a high prevalence area for ebola virus infections, during the period may to july , there were % fewer antenatal care visits and % fewer postnatal care visits than occurred prior to the outbreak. the cdc researchers conducted a focus group among pregnant and lactating women and they found that these declines in care-seeking behavior were motivated by fear of becoming infected with ebola at the facilities and mistrust of the physicians (dynes et al. ) . here, we see both the first and second forms of stigma we proposed above-women and their relatives were stigmatizing health care workers and the facilities in which they worked. this stigmatization or discrimination was motivated by fear and a lack of trust. returning to parker and aggleton's ( ) assertions that stigma reveals power relations and social processes, we can read women's stigmatization of health care facilities and workers as a different form of power relations. the stigmatization of these health care providers during the ebola outbreak had roots in a much longer history of distrust of state institutions and health care workers who were unable to provide consistently high quality care due to a persistently weak health care system in many of these countries (blair et al. ) . while the pregnant women themselves may not have had any real form of power over health care workers, we suggest that their stigmatization of health providers and facilities, leading to avoidance of services, was a result of systemic and on-going disempowerment of women and community members in the biomedical system, produced by weak state institutions. it is also possible that pregnant women were acting out of perceived, or internalized, stigma (luginaah et al. ), a fear of being stigmatized when they reported to health facilities, as we discuss further below. according to the chief executive of actionaid, justin forsyth, "ebola is having a huge impact on wider health issues like maternal healthcare. no children have gone to school since march and pregnant mums are avoiding health clinics and hospitals. one clinic i went to said the admissions had plummeted from a day to -a worrying stat when the un estimates that , mums will give birth in the coming year across the region" (boseley ) . the clinics and hospitals were so overwhelmed with caring for victims of the ebola outbreak that providing obstetrical services for noninfected women became less of a priority. an important result of this was decreased prenatal care for pregnant women, placing them and their unborn children at higher risk for undetected complications such as other infectious diseases including malaria, hiv and tuberculosis, hypertensive diseases of pregnancy, anemia, and obstructed labor. "the lack of access by women, especially pregnant women, to reproductive health services is a major health disaster in waiting," said john k. mulbah, chairman of the obstetrics and gynaecology department at the university of liberia (unfpa a). "as a result of the outbreak, there has been an increase in pregnant women dying from preventable causes, including antepartum and post-partum hemorrhage, ruptured uterus, as well as hypertensive disease," said dr. mulbah. pregnant women had to give birth without medical supervision, often without a midwife, and occasionally even alone. in monrovia, year-old comfort fayiah went into labor and was taken by her husband to four different clinics and hospitals to deliver her twins, but she was refused admittance to all four. her husband, victor fayiah, said, "i begged them, i cried, but they bluntly refused." on the final day of hospitalization, an up-front payment of $ for a surgical delivery was demanded. "the hospital administration requested a cash down payment of $ before my wife would be touched," said her husband. "upon realizing that we did not have the money, and for fear that my wife could pass away in their premises, a man acting on the order of the hospital physically pushed my wife out. he said, 'get outside! do you think this is a free hospital?'" after leaving in the rain, they hadn't walked more than m before mrs. fayiah fell onto the street and began to deliver her twins. she received no care from the hospital staff, but instead was assisted by people passing by and onlookers. a nurse assistant on a motorbike stopped to help deliver the twins (unfpa d). hayden ( ) relates another situation in which a laboring woman was left to give birth alone in the back of an ambulance in liberia. when the mother arrived at an msf ebola management center, the obstetrician found that the woman's placenta and now-dead baby were still between her legs; tests later determined neither the mother nor baby had had ebola (hayden ) . despite the fact that the woman was not infected with the ebola virus, health care workers had been too afraid of contamination from the copious bodily fluids involved in birth to chance assisting her without full-body protective equipment. other obstetric causes of hemorrhage could simulate the effects of the ebola virus infection during pregnancy. during the ebola outbreak in liberia, mamie tarr arrived at a clinic in her fifth month of pregnancy while hemorrhaging, holding her abdomen and complaining of severe pain. her husband edwin was ill and previously had been brought to an ebola treatment center for care. "my wife saw me being carried to the ebola treatment center as a suspected ebola case, and she thought i was going to die," he stated. but mamie did not want to raise the infant without her husband. so, without informing her sick husband, the -year-old mother sought out an illegal and unsafe abortion from a "backstreet abortionist" who performed the procedure using a combination of herbs, a rusty syringe, and chalk, known in liberia as "spoiling the belly." her husband said "she got scared about raising the child without me, so she spoiled her belly. then she just closed her mouth, she said nothing, until she started bleeding." mamie died as a result of the unsafe abortion; her husband edwin was released from the etc without ever having had the ebola virus infection (thomas ) . the ebola crisis became more severe and, as it spread during and into , country officials diverted critical resources away from pregnant women, who already faced limited access to adequate health care in these nations. the majority of ebola units in these countries did not have staff trained in obstetrics or midwifery. for example, in bong, one of the most populous counties in liberia, the ambulance that was used for obstetric emergencies was instead being used for the ebola response, diverting this already scarce and much-needed resource from its original purpose, which had not disappeared, only been overwhelmed by a louder, more urgent disaster. and the surgical and emergency departments at jfk hospital in monrovia, one of the country's major referral hospitals, were closed during part of the outbreak (sepkowitz and haglage ). giving birth at home is dangerous-there is a risk of hepatitis or hiv infections being transmitted because instruments are not sterilized, as well as life-threatening hemorrhage from a placental abruption, uterine rupture, placenta previa, velamentous cord, retained placenta, or coagulopathy (schwartz ) . giving birth at home also generally takes place with the assistance of untrained relatives or perhaps local midwives who may or may not have had any experience or training related to pregnancy or delivery complications, and may not be able to recognize and deal with an emergency should one arise. this further endangers the lives of both the mother and her baby; a woman can live with hepatitis or hiv, but without proper emergency treatment, will most likely not recover from hemorrhage leading to hypovolemic shock. should an obstructed delivery occur, which is one of the most frequent causes of maternal death in sub-saharan africa, there is no provision for performance of a life-saving cesarean section at home (schwartz ) . social stigmatization can result from the fear of disease, as well as the fear of people who are understood to be different, often due to perceived connections with the contagion. during an infectious disease outbreak, these two fears can occur simultaneously, resulting in the stigmatization of strangers with or without the disease. this stigmatization creates numerous problems for both care givers and care seekers, increasing the suffering of infected people and interfering with public health measures to control the outbreak, as well as the provision of health care (des jarlais et al. ; goffman ) . from a contemporary historical perspective, stigmatization has been an important sociological aspect of many infectious diseases including hansen's disease (leprosy), aids, tuberculosis, and sars (severe acute respiratory syndrome) to name but a few (obilade ) . during the - ebola epidemic, besides the problem of pregnant women intentionally avoiding health care facilities, many others were stigmatized when seeking treatment at a clinic or hospital due to the widespread general fear regarding the ebola outbreak. as a result, when pregnant women sought health care, in some cases they were turned away for fear that they were infected with ebola virus. for example, in august , sierra leonean filmmaker arthur pratt was working in freetown to educate people about the ebola outbreak. because all hospitals there were closed to non-ebola-infected cases, he was forced to drive his -month pregnant wife to her mother's village, many hours distant, in order to give birth. "a lot of women are having to give birth in the house now," he said during an interview, "all of the hospitals are closed. they have nowhere to go" (sepkowitz and haglage ). in the case of aminata, a young pregnant woman who presented to a health care facility in sierra leone with a life-threatening obstructed labor, medical staff at the health care facility were afraid to treat her because she might have ebola virus disease. while waiting for the results of her blood test for the infection, she was transferred to an ebola holding center so that she could be rushed for a cesarean section if her test was negative. aminata and her unborn fetus died from complications of the obstructed labor while waiting for the test results-they were found to be negative for ebola virus hours later (farmer and koroma ) . childbirth is a messy process in the safest of circumstances-hemorrhage, amniotic fluid, secretions, sweat, and expulsion of a bloody placenta are all normal processes in childbirth, except that all of these fluids and tissues may contain the virus in infected women. pregnant women infected with the ebola virus have been found to have high levels of the viral nucleic acid persisting in amniotic fluid even following the clearance of the virus from maternal blood (baggi et al. ) . even in the first author's field site in southwestern tanzania, there was great fear in that ebola cases from democratic republic of congo (drc) or uganda would jump borders and the virus could find its way into tanzania. the maternity ward nursing staff repeatedly discussed a deficiency of personal protective equipment (ppe) available at the hospital under normal circumstances and wanted to know why the maternity ward staff had not been the first to be trained in proper techniques for isolating ebola patients and recognizing the virus's early symptoms. the nurses were of the opinion that the maternity ward staff, with their intimate and nearly continual contact with vast quantities of bodily fluids, would be the first to be infected and die from ebola in the event that the virus became an issue in their region. under normal conditions, these midwives expressed a concern with their greater than average exposure to bodily fluids and a lack of vaccines for diseases such as hepatitis b (strong ) . this fear and concern most certainly was multiplied exponentially for midwives working in the areas most heavily affected by the evd epidemic. surely, any amount of money to deal with bodily fluids that may or may not be infected was poor incentive for providers to expose themselves to infection and a terrifying death as they watched or heard of their colleagues dying around them. compounding the stigmatization of pregnant women due to their potential ebola infection was a much older, geographically widespread stigma that ties women's bodily fluids to concepts of pollution, dirt, and contamination. in some places, only women from groups which are already constructed as polluted or polluting are considered suitable birth attendants in order to contain the stigma associated with contamination from the bodily by-products of birth. in india, for example, the local birth attendants, dais, are generally from the lowest caste (rai : ; van hollen ) . even in western biomedical settings, health care providers and a woman's relatives act to mitigate their contamination from women's bodily fluids due to concerns about germs or infection, but callaghan ( ) argues, also due to much older, ingrained ideas about the inherently polluting nature of women's bodies that continue to float below the surface of action and thought. in west africa, a history of menstrual taboos or seclusion practices and other taboos related to sex or reproduction may hint at beliefs regarding the underlying dangers of exposing others to the products of women's bodies (sterner and david ; strassmann ) , even if these practices are not in place any longer. it should be noted that restrictions related to menstruation, for example, are not universally damaging to women (buckley and gottlieb, ) . with the spread of biomedicine and its conceptions of microscopic agents of infection (viruses and bacteria) has come a newer understanding of what might be hiding in the substances produced by bodies, particularly women's bodies-in this case, infectious, potentially deadly pathogens such as hiv, ebola, hepatitis, and others. exacerbating the potential stigmatization of caring for pregnant women during an ebola outbreak were data indicating that some women who were pregnant and infected with ebola virus may not have had symptoms of the infection at the time of labor. a -year-old woman was presented to a monrovia hospital in the late stage of pregnancy with suspected premature rupture of membranes (prom), abdominal pain, and mild uterine contractions. she was afebrile, reported no contact with persons having ebola virus disease, and did not meet the existing case criteria for having ebola infection. subsequently, her blood was found to contain a high viral titer of ebola virus. three days after admission, she became febrile, and both she and her unborn fetus died of ebola virus disease on the seventh day (akerlund et al. ) . those women with ebola infection who are pregnant can have copious hemorrhaging. compounding the hemorrhaging that accompanied delivery in women with ebola infections was the occurrence of obstetric emergencies that could occur in any cohort of women during pregnancy or in labor. these included such hemorrhagic events as placental abruptions (or abruptio placentae; the premature separation of the placenta before or during labor), placenta previa, retained products of conception, rupture of the uterus, cervical lacerations, ruptured ectopic pregnancy, incomplete abortions, and others (bolkan ) . there are no statistics available detailing the prevalence of the problem of obstetrical hemorrhage with ebola infection, but there are published reports. the chief of actionaid in liberia, korto williams, has stated, "but we know that many women have had to give birth on their own because people were afraid they had ebola and women have died because of a lack of care" (boseley ) . korto williams also said that there are online videos showing women giving birth in the streets alone and without assistance because bystanders were scared they were infected with ebola (feminist newswire ). some women were unable to leave quarantine to give birth (boseley ) . the inexperienced staff members found themselves having to risk contamination by caring for a pregnant woman who they believed would die regardless of treatment, thus also wasting valuable supplies and medicines (lang ) . the conditions in many clinics and hospitals, overwhelmed with providing care and housing for patients with ebola, resulted in providers discouraging pregnant women from receiving antenatal care or giving birth within their walls as a result of fear of bodily fluids (feminist newswire ). there were reports of some clinics and hospitals refusing to admit ebola-infected pregnant women into their ebola wards with other patients. at the west point maternity ward in monrovia, the staff turned away pregnant women with red eyes and weakness, symptoms of ebola infection, who were seeking maternity care. a staff nurse there, tarpeh, said "we are afraid-o, sister. if i had money to sustain my family for six months, i would go home. i'm not lying to you" (moore ) . based upon interviews with nurses caring for ebola patients in sierra leone, the magazine new yorker reported that an unofficial protocol developed among health workers in that nation: deny infected pregnant women access to ebola wards, or if entry was permitted, triage them last (lang ) . it was reported from liberia that rumors were common that most health workers who became infected with ebola virus contracted the disease as a result of caring for pregnant women-it is well-known that this is how the american physician, dr. rick sacra, who was equipped with full personal protective equipment, became infected in august (dantzer ) . speaking on the condition of anonymity, a sierra leonean nurse told joshua lang, a medical student at the university of california san francisco, "the hospitals are neglecting [pregnant women]they won't even allow them in." gabriel warren, who runs west african medical missions, a nonprofit organization in sierra leone, saw the effect of this exclusion at a variety of treatment centers. he told joshua lang, "they aren't given preferential treatment," he said, "they aren't even given beds. they get put in an area where they get no interventions. they are assumed to die" (lang ) . the fear of infection compounded with previously existing poor quality maternity care, which was evidenced by the outstandingly high mmr even before the outbreak had begun. any tendency towards neglect or abuse (bohren et al. ) could then be amplified by providers' fears of infection and contamination, which were taken out on the women for whom they cared. the equipment in many of the maternity wards and clinics was insufficient to properly protect the staff, especially in the earlier stages of the outbreak, similar to previous outbreaks in central african countries. lucy barh, the president of the liberia midwifery association, said that feelings about inadequate protection were common to the midwives she led, "that's why some of the clinics are closed-fear, fear, fear. there's no protective equipment, and the lives of those health care workers are threatened" (moore ) . in addition to the lack of personal protective equipment, nurses often faced stigma within their own families or communities due to their exposure or potential exposure to the deadly virus (hewlett and hewlett ; mcmahon et al. ) . in monrovia, fatuma fofana was a -year-old mother of five who was pregnant with her sixth child when she developed severe abdominal pain. her brother sheriff took her to a nearby clinic, but they refused to see her-the staff was terrified that she might have ebola infection. her brother took her to two other clinics, where she was also refused treatment. finally, a fourth clinic let them in, but by that time her baby had died-and she did not have ebola. the staff member did not have the supplies to further treat her and the retained dead infant, so sheriff called numerous doctors, prepared to offer them a large sum of money ($ usd). but no doctor answered his calls, and his sister died, adding to the maternal mortality of the epidemic (moore ). stories abound of uninfected pregnant women who died as a result of pregnancy complications or miscarriages because they could not get health care. fatuma's story, similar to comfort fayiah's above, also demonstrates an additional burden on poor women; even though her brother was prepared to offer a very large sum of money for her care, it was still impossible to get appropriate medical attention. for many other women and their families, such sums of money would be absolutely out of their reach. under more normal circumstances (i.e., without the added stressors of a highly fatal epidemic), a family might fundraise from relatives and/or neighbors and friends to acquire enough money for treatment. however, with so many people infected, and rapidly deteriorating infrastructure making daily life more difficult than normal, this network might, logically, rapidly start to fray and become less reliable. it must be considered that women coming from wealthier families would not only have more cultural capital to exert when trying to access care during pregnancy or while giving birth, but would have more physical capital to put on the line in the search for care, as well. women and families with more funds would be able to pay higher costs that might be charged for scarce medical supplies or that might be given as incentives for transportation or health care services. this differential access to capital would further enlarge the already present gap between those women living at a subsistence level and those who might be considered more middle or upper middle class in these countries. being able to put resources on the line in the effort to attain care could possibly have helped to mitigate the stigma associated with pregnant women and treating them. however, the story of fatuma suggests that pregnant women were so highly feared and stigmatized that even large sums of money could not induce health care workers to overcome this stigma. in some cases of pregnant women who arrived at a clinic or hospital with an urgent pregnancy complication which included bleeding, a common pregnancy-related occurrence with or without ebola infection, there was a delay in their initial evaluation and treatment. the staff were hesitant to expose themselves to potentially infectious bodily fluids, and there were delays while waiting for the results of testing for the ebola virus. dr. benjamin black, an obstetrician, has said that poor infrastructure and limited access to laboratory services meant that test results for suspected ebola patients could take more than h to arrive, during which time a woman and her fetus could die (guilbert ) . poor infrastructure was one of the significant factors in these countries that caused them to be ripe for the spread of this epidemic. while many knew this weak infrastructure was already a barrier to significant improvement in a diverse array of health outcomes in these countries, the ebola outbreak threw this into stark relief, drastically highlighting the shortcomings and inefficiencies of the preexisting weak health care sector. the existing social inequalities and health system weaknesses helped contribute to the forms of stigma affecting pregnant women, which we have discussed here. despite many of the representations, if we look deeper, pregnant women were not only victims of stigma, but perpetrators, as well. they avoided health facilities and health care workers due to their associations with the disease and its spread. avoidance of facilities and distrust of health care workers thought to have almost certainly been exposed to ebola led to the almost complete erasure of previous gains in maternal health outcomes. in a mutually reinforcing cycle, health care workers feared and shunned pregnant women and pregnant women avoided providers and facilities. these forms of stigmatization had fertile ground in which to prosper due to the preexisting health system weaknesses in guinea, liberia, and sierra leone, compounded by the rapid spread of the epidemic. gender inequalities meant women had, at least during the first part of the epidemic, a greater risk of contracting ebola and worse outcomes when they became infected. pregnant women, both in - and moving forward in time, perhaps suffered the greatest burden through near % fatality when infected, but also through the reduction in obstetric services of any kind. it will doubtlessly take these countries several years to recover from the impact of the epidemic and pregnant women will continue to suffer the consequences via a decimated health care profession and weakened networks of care and services. in what was perhaps the most shocking example of the stigma related to pregnant women, health care workers, and ebv infection, one of time magazine's "people of the year" from , an "ebola fighter," salome karwah, who was a nursing assistant and herself an ebola survivor, died on february , , due to complications following the cesarean delivery of her third child (baker ) . karwah used the lasting immunity from her previous ebola infection to care for patients during the epidemic whom no one else would touch. the outbreak also claimed many of her immediate relatives, including her father who was also a physician (baker ) . of salome's death following her son's birth, baker ( ) writes, "within hours of coming home, karwah lapsed into convulsions. her husband and her sister rushed her back to the hospital, but no one would touch her. her foaming mouth and violent seizures panicked the staff. 'they said she was an ebola survivor,' says her sister by telephone. 'they didn't want contact with her fluids. they all gave her distance. no one would give her an injection.'" salome's sister directly pointed to stigma associated with ebola as a cause of salome's death. an msf health promoter, ella watson-stryker, who worked with salome during the outbreak said, "to survive ebola and then die in the larger yet silent epidemic of health system failure… i have no words" (baker ) . news of salome's death spread around the world due to her appearance on the cover of time, but she holds a place for the unknown number of pregnant women who died during, and after, the - epidemic due to the effects of stigma and fear. factors affecting perceived stigma in leprosy affected persons in western nepal shedding of ebola virus in an asymptomatic pregnant woman individual, household, and community level factors associated with keeping tuberculosis status secret in ghana communication with rebellious communities during an outbreak of ebola virus disease in guinea: an anthropological approach. ebola response anthropology platform you just look at our work and see if you have any freedom on earth woman who became the first to survive ebola in sierra leone but lost relatives to the disease gives birth to a baby boy. daily mail management of pregnant women infected with ebola virus in a treatment centre in guinea dimensions and process of stigmatization in leprosy liberian ebola fighter, a time person of the year, dies in childbirth most ebola victims are women, for one big reason self-mortification and the stigma of leprosy in northern india stigma in the time of influenza: social and institutional responses to emergencies ebola outbreak: guinea health team killed ebola virus disease and pregnancy: a review of the current knowledge of ebola virus pathogenesis, maternal, and neonatal outcomes public health and public trust: survey evidence from the ebola virus disease epidemic in liberia african women face ebola triple jeopardy the mistreatment of 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experience of stigma among african men with tb diagnosis in london ebola drains already weak west african health systems the world factbook long-term sequelae after ebola virus disease in bundibugyo structural forces and the production of tb-related stigma among haitians in two contexts bush wives and girl soldiers: women's lives through war and peace in sierra leone tuberculosis and stigmatization: pathways and interventions the history of tuberculosis reproductive health: the biggest casualty of the ebola epidemic? addressing ebola-related stigma: lessons learned from hiv/aids in the midst of a 'perfect storm': unpacking the causes and consequences of ebola-related stigma for children orphaned by ebola in sierra leone stigmatization of newly emerging infectious diseases: aids and sars an exploration of the causes of tuberculosis stigma in an urban district in ghana first newborn baby to receive experimental therapies survives ebola virus disease dangerous deliveries: ebola leaves moms and babies without care. national public radio arcade africa. ebola's history perceptions of the risk for ebola and health facility use among health workers and pregnant and lactating women pih, sierra leone address needs of pregnant women amid ebola maternal death rate in west africa expected to rise due to ebola ebola virus disease in children imagine a disease wiping out , u.s. doctors. now, you understand ebola in sierra leone ebola virus disease and pregnancy outcome: a review of the literature the stigma and prejudice of leprosy: influence on the human condition how ebola got its name stigma: notes on the management of a spoiled identity ebola health workers face life or death decision on pregnant women-experts ebola's lost ward: a hospital in sierra leone has struggled to continue its research amid the worst ebola outbreak in history the dynamics of stigma in leprosy cultural contexts of ebola in northern uganda providing care and facing death: nursing during ebola outbreaks in central africa ebola striking women more frequently than men. the washington post viral haemorrhagic fevers what obstetriciangynecologists should know about ebola: a perspective from the centers for disease control and prevention leprosy stigma once there is life, there is hope' ebola survivors' experiences, behaviours and attitudes in sierra leone ebola virus disease in health care workers-sierra leone ebola in the maternity ward a serological survey of ebola virus infection in central african nonhuman primates most victims of ebola virus are women conceptualizing stigma timing and utilization of antenatal care services in liberia: understanding the pre-ebola epidemic context understanding the stigma of leprosy a comparison of hiv stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings thousands of ebola survivors face persistent joint pain and other problems two-week-old baby girl survives ebola in sierra leone healthcare providers on the frontlines: a qualitative investigation of the social and emotional impact of delivering health services during sierra leone's ebola epidemic. health policy and planning nubia. first newborn to survive ebola ebola crisis: the unequal impact on women and children's health. the lancet global health how ebola can kill you-even when you don't have ebola ebola hemorrhagic fever and pregnancy ebola virus disease stigmatization; the role of societal attributes hiv and aids-related stigma and discrimination: a conceptual framework and implications for action no time to lose: a life in pursuit of deadly viruses listening to dais speak about their work in gujarat, india study on differences and similarities in the concept and origin of leprosy stigma in relation to other health-related stigma insights from clinical research completed during the west africa ebola virus disease epidemic ebola crisis: this is why ' %' of victims are women. the independent 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deeply spoiling the belly': the dangers of backstreet abortions in liberia liberia's ebola outbreak leaves pregnant women stranded fear of health workers fuels ebola crisis in guinea ebola wiping out gains in safe motherhood pregnant in the shadow of ebola: deteriorating health systems endanger women $ million needed to provide services in ebola-affected countries to avoid maternal death toll of civil wars years psychosocial effects of an ebola outbreak at individual, community and international levels birth on the threshold: childbirth and modernity in south india ebola virus disease among children in west africa addressing sex and gender in epidemic-prone infectious diseases ebola situation report - world health organization (who) key: cord- -f hf plf authors: madsen, tracy e.; dobiesz, valerie; das, devjani; sethuraman, kinjal; agrawal, pooja; zeidan, amy; goldberg, elizabeth; safdar, basmah; lall, michelle d. title: unique risks and solutions for equitable advancement during the covid- pandemic: early experience from frontline physicians in academic medicine date: - - journal: nejm catal innov care deliv doi: . /cat. . sha: doc_id: cord_uid: f hf plf given the demands facing physicians working on the frontlines in academic health centers, heightened attention to gender inequities in the context of home and workplace stressors, research and authorship projects, and academic/professional advancement opportunities require focused strategies. burdens. not only are frontline women physicians on the frontlines at work, but they are more often on the "frontline" at home as well -serving as the primary caregivers for children or aging parents during the pandemic -and, as a result, are experiencing major barriers to academic productivity. further, long-standing inequities in the workforce of frontline physicians in academics have resulted in a system where women are paid less and are less likely to advance through the ranks of academic medicine. , highlighting pre-existing inequities in the academic medicine workforce is critical to understanding the differential impact of covid- on physicians by gender. for example, women are more likely to hold educational roles as opposed to funded research roles or administrative roles, the latter yielding more protected time from clinical duties. as a result, faculty in education leadership positions (often women) have higher clinical workloads, subsequent higher exposure to infections, and can therefore, in this catch- cycle, devote less time to pursue opportunities associated with academic work. furthermore, because women physicians do not hold the majority of executive leadership positions, they are less likely to get asked or chosen for even temporary leadership positions during a health care crisis, and they are often not in positions to advocate for new policies to break these catch- cycles. for physicians facing pay cuts due to covid- , women and more junior faculty may be disproportionately impacted given they have lower baseline salaries. , here, we explore these areas of concern in greater detail. health risks for frontline workers are numerous, and women make up % of the total health care workforce globally, including nurses and non-physicians. although recent cdc data show that % of the health care workers infected with covid- were female, there is no current data on infection rates in physicians by gender. , further, though infection rates by gender among frontline physicians have not been published, the length of exposure and proximity to patients with covid- are the primary contributors to a physicians' risk of infection. though men make up a greater proportion of the physician workforce, women are disproportionately likely to hold junior faculty positions, which often include more clinical hours and thus higher risks of direct exposure to covid- . in addition, there are known issues with respirator and personal protective equipment (ppe) fit for women, which further increases the risk of infection. as we can only speculate regarding potential gender differences in either individual-or population-level infection rates for frontline physicians, future reports of covid- infections and deaths among health care workers should be reported by job title (i.e., physicians, nurses, technicians), gender, race, and ethnicity. women and men who are primary caregivers for children or older family members are likely disproportionally burdened by protecting their families from infection, and we know that the majority of primary caregivers are women. not only do shortages of ppe increase the risks to the physical health and psychological well-being of physicians, but following risks of exposures at work, they must then choose how to best protect their families from possible infection. data regarding effective disease prevention within family units is lacking, especially for asymptomatic health care workers. while the decision to self-isolate after shifts carries significant psychological burden for both physicians and their family members, physicians who are the primary caregivers for their children or other family members often do not have the option to self-isolate, further adding to the physical and psychological risks for all involved. although it is too soon to know whether the psychological distress experienced by health care workers during the initial wave of the covid- outbreak will persist, data from the sars outbreak is concerning. these data demonstrated that health care workers who are sars survivors showed significantly higher stress levels one year after the outbreak and had higher depression, anxiety, and posttraumatic symptoms than non-health care worker survivors of infection. emerging data show that not only are the psychological impacts of covid- more pronounced among women in the general population, but even more so on women health care workers. studies looking at the impact on women physicians specifically have not been published to date, but will be critical in order to assess the long-term psychological impact of covid- . finally, dual physician families face unique challenges due to unpredictable clinical schedules in the setting of covid- surges as well as an elevated risk of infection for both partners. emerging data show that not only are the psychological impacts of covid- more pronounced among women in the general population, but even more so on women health care workers." physicians who are pregnant or nursing face sex-specific health care risks as well. little data exist on morbidity and mortality for pregnant women with covid- , and concerns for nursing mothers include potential infectious risks around pumping in the hospital and the possibility of needing to self-isolate from nursing infants. because this is a novel virus and our understanding of its impacts continue to evolve, there has been no unified policy to guide pregnant physicians on the frontlines. early in its course, it was thought that the impact on pregnancies was minimal, leaving many pregnant women working as usual. only now are we starting to gather that there could be a pro-thrombotic impact on the placenta. other early data suggest that infected women, especially those with pneumonia or severe maternal illness, may have increased risk of preterm labor, premature rupture of membranes, preterm birth, preeclampsia, and cesarean delivery for fetal distress, , which has obvious implications for pregnant physicians on the frontlines. few policies exist to mitigate work exposure for women who are pregnant or nursing, though evolving data points to the need to direct pregnant physicians away from the direct care of covid- -positive patients when possible. other countries have instituted protections such as allocating pregnant health care workers to patients and duties with reduced exposure to covid- and offering pregnant staff the choice of whether to work in direct patient-facing roles. based on evolving data in this area, we suggest that institutions take all precautions necessary to reduce risk to pregnant physicians, including giving pregnant physicians a choice to avoid working in high-risk areas defined by a high prevalence of covid- -positive patients. as more evidence about how to reduce risk of transmission and the safety of pregnant women on the frontlines is established, employers could recommend pregnant women return to clinical interactions with patients with suspected covid- . finally, an increase in gender-based violence in the setting of social isolation poses a major health threat to women: physician and non-physician alike. " many women physicians are disproportionately managing the dramatic changes in the lives of families and children due to covid- . for example, for many families with young children, utilizing outside childcare facilities and home childcare professionals is no longer an option due to the need for social distancing or factors such as stigmatization of frontline health care workers due to the perceived risk of covid- . it is well known that women physicians provide more childcare and spend more time on parenting and domestic tasks than their male counterparts, responsibilities that have been exacerbated due to stay-at-home orders and pandemic-related closures. families with school-aged children are now tasked with homeschooling, which includes not only keeping up on daily academic work but also keeping track of virtual learning schedules and helping children to adapt to distance learning. in addition, challenges for physicians caring for aging parents include increased concern for the health of aging parents, worry about infecting older family members who may live with them, and not being able to visit aging parents due to the potential for disease transmission. further, some physicians are expected to help manage the medical care of their parents; navigating this from afar to reduce infection risk places an undue burden on both the aging parent as well as the physician caregivers. finally, tasks that are typically outsourced can no longer be outsourced, further adding to the burden for physicians. these may include cooking, meal planning, grocery shopping, laundry, house cleaning, assisting with schoolwork, and managing children's extracurricular activities. for women physicians working on the frontline and continuing academic careers, the covid- pandemic has given literal meaning to doing it all. while many of these issues place increased burden on physicians, the increasing demands on the partners of physicians is also substantial and may add to increased stress on families. for women physicians working on the frontline and continuing academic careers, the covid- pandemic has given literal meaning to doing it all." despite new challenges in both the home and work environment, the role of academic physicians and their responsibilities in research, administration, and education remain, and the covid- pandemic has resulted in the creation of countless new opportunities to contribute to the advancement of science and education. these roles and opportunities, however, create additional challenges for front-line women physicians, who often are also serving as caregivers at home. whether one is caring for young children, aging parents, or partners, the combination of increasing clinical challenges with new caregiving responsibilities is creating major barriers for continued academic productivity including " reduced work hours and frequent interruptions. new data, though early, support evidence for a disproportionate decrease in submissions from female authors, especially those in first author roles and in manuscripts pertaining to covid- . - for many women, the first sacrifice in times of difficulty is their personal health and their professional work. the impact of this will likely be studied in hindsight by gender equity researchers. similar challenges will likely arise for physicians with personal health issues or who become infected with covid- . for many younger physicians and particularly women working toward academic promotion, even temporary changes in productivity and momentum have the potential to have significant detrimental effects on career trajectories. additionally, many schools have already declared they will remain closed for inperson learning in the fall and expect all children with any signs of illness to remain home. because women continue to bear the majority of home and childrearing responsibilities, we anticipate that decreased productivity due to school and daycare absences will continue for the foreseeable future. as a result of cancelled academic conferences and meetings, many faculty have lost speaking and in-person networking opportunities, both locally and nationally, that are critical for promotion and career advancement. in addition, many non-covid- research projects and clinical trials have been put on hold in the u.s. and elsewhere, delaying scientific inquiry and risking future funding. further, the rapid creation of new covid- task forces and leadership roles are at risk of being affected by the same gender biases that have consistently affected our workforce, with a potential to exclude women from such opportunities. in sum, these factors have the potential to substantially widen the gender disparities in promotion and advancement that women have faced for decades. academic medicine has well-documented challenges for women (and caregivers) in the workforce that are being exacerbated by covid- . when addressing covid- -related challenges, it is essential to include primary caregivers in high-level decision-making processes to address such disparities. further, there are many strategies that could be implemented to reduce health risks, mitigate the effects of lost productivity, and support physicians caring for their families (table ) . while some of these recommendations may be applicable to both women and men, the recommendations chosen include those that will help mitigate worsening gender disparities in academic medicine. to reduce health risks to physicians and families, in addition to providing adequate ppe (including sizes that fit both women and men), practices such as providing scrubs and changing/showering areas for post-shift decontamination as well as frequent testing of physicians are needed. it is also critical at this time to provide a clean area in which nursing physicians may pump and store their breast milk in a sterile environment. to relieve some of the burden from increased responsibilities at home, and to allow women to be active leaders in their departments and institutions, flexibility in meeting times should be encouraged to avoid conflict with homeschooling or childcare responsibilities. institutions should also work to provide alternative childcare options for their staff. the highly transmissible nature of the virus puts families of physicians at risk. • provide adequate personal protective equipment (ppe), with options for appropriate sizes for both women and men • provide access to a post-shift decontamination area in hospital (or in proximity) with: • a shower • scrub machine or hospital scrub laundry service • frequently cleaned locker room • secure decontaminated area to store personal belongings in proximity • provide off-shift housing options for physicians who may need to isolate themselves from family members the dynamic situation of evolving knowledge and administrative guidelines around clinical protocols during the pandemic contributes to a greater workload and work stress. • reassurance and frequent open communications from leadership/ administration to address rationale and change in policies in real time • regularly scheduled virtual townhall meetings with recordings available to review for those who are unable to attend due to childcare or other commitments • daily email updates with new information highlighted • regular feedback mechanisms for those directly engaged on the frontlines high stress of an unpredictable pandemic, lack of good treatment options, scarcity of resources, high clinical acuity, and personal risk can challenge the wellbeing of even the more resilient physicians. • support for physician mental health, resilience, and post-traumatic stress: • clean and well-stocked faculty break rooms with snacks/coffee/ water • adequate clinical coverage to support faculty who need time to adapt to new information • forums to encourage peer support (virtual support groups, open and closed group chats through social media, acknowledgement of the stress of new roles and environments) • increased vigilance for burnout from peers and leadership with frequent check-ins • professional help encouraged for all (efforts to make mental health services available during non-business hours (i.e., opt out : sessions for all faculty) • encourage and develop models for medical or personal leave when needed for physicians at higher risk for complications of covid- (pregnant physicians, physicians who are immunocompromised, physicians in older age groups), implications of infection are not fully understood. • give physicians shift flexibility to avoid high-risk exposures (e.g., intubation) • consider changing to telemedicine shifts • additional administrative or education time • flexibility to work in "cold" zones of the ed lactating physicians need a secure and clean place to pump.* • designated lactation room with refrigeration, frequent surface disinfection, and access to soap and water for hand hygiene • designated break times to allow for appropriate doffing and time to pump academic productivity and career advancement while other specialties may defer elective procedures or routine clinic visits allowing physicians more time to be academically productive, frontline academic physicians may experience a decline in scholarly productivity with a need to rapidly adapt to a new clinical environment, changing protocols, and similar or even increased clinical volume in response to a pandemic. • university leadership should recognize and adapt promotion and compensation guidelines to support frontline academicians. • support those who are ready for promotion to continue forward in the process to support the academic careers of women physicians during this unprecedented time, it is paramount to understand the tasks competing for physicians' time and mental energy. potential solutions include offering bridge funding and grant extensions for researchers and forming collaborations between clinical and non-clinical faculty to help keep projects moving forward while clinicians are needed on the front lines. women should be equitably considered and actively sponsored for new leadership roles. with regard to career advancement, the potential adverse effects of the covid- pandemic should be considered. although stop-the-clock policies have been implemented in some institutions, it would be preferable to continue the promotions process for those who are qualified to go forward, but also take into account decreased productivity during this time period for others. it is critical to not widen pre-existing disparities in promotion and rank. although stop-the-clock policies have been implemented in some institutions, it would be preferable to continue the promotions process for those who are qualified to go forward, but also take into account decreased productivity during this time period for others. it is critical to not widen pre-existing disparities in promotion and rank." the current covid- pandemic has created many career challenges for frontline academic physicians. using innovative solutions to support academic careers and prevent exacerbating existing gender inequities in the system, steps must be taken to ensure all faculty have adequate support during this time. a diverse group of voices should be sought to design strategies and solutions to best support all academic physicians working on the frontline. continuation of gender disparities in pay among academic emergency medicine physicians current status of gender and racial/ethnic disparities among academic emergency medicine physicians are women disproportionately represented in education compared to other roles in academic radiology? characteristics of health care personnel with covid- -united states why women may face a greater risk of catching coronovirus promotion of alternative-sized personal protective equipment gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers psychological impact of novel coronavirus ( -ncov) outbreak in health workers in china stress and psychological distress among sars survivors year after the outbreak prevalence and predictors of ptss during covid- outbreak in china hardesthit areas: gender differences matter impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study placental pathology in covid- positive mothers: preliminary findings coronavirus in pregnancy and delivery: rapid review coronavirus disease (covid- ) and pregnancy: what obstetricians need to know characteristics of women of reproductive age with laboratory-confirmed sars-cov- infection by pregnancy status -united states pregnant health care workers at risk for coronavirus are being force to keep working. propublica the pandemic paradox: the consequences of covid- on domestic violence challenges for the female academic during the covid- pandemic meta-research: is covid- amplifying the authorship gender gap in the medical literature? the decline of women's research production during the coronavirus pandemic clinical trials suspended in uk to prioritise covid- studies and free up staff breast practices: strategies to support lactating emergency physicians key: cord- -sar ej authors: stone, sophia; nelson-piercy, catherine title: respiratory disease in pregnancy date: - - journal: obstet gynaecol reprod med doi: . /j.ogrm. . . sha: doc_id: cord_uid: sar ej breathlessness in the absence of an underlying pathology is common in pregnancy. asthma affects about % of women of childbearing age. treatment is the same as for the non-pregnant population and most drugs are safe in pregnancy. educating women to continue preventer inhaled corticosteroid therapy will reduce the risk of attacks. respiratory infections are associated with a higher morbidity in pregnancy and should be treated aggressively. most chronic pulmonary diseases do not alter fertility. large reserves in respiratory function allow the fetus and mother to survive without compromise in most cases. the use of chest x-rays should not be avoided in pregnancy. women with a chronic respiratory disease should receive pre-pregnancy counselling and education. women should be managed in a multidisciplinary setting with the respiratory team. the presence of pulmonary hypertension and cor pulmonale is associated with a high risk of death in pregnancy. severe chest disease leading to respiratory failure is uncommon in women of childbearing age but respiratory symptoms are extremely common in pregnancy. this is in part an effect of the physiological adaptation of the respiratory and vascular systems to pregnancy and in part because of limited functional capacity and mobility from diaphragmatic elevation by the gravid uterus in late gestation. oxygen consumption is increased by % from early pregnancy, minute ventilation by - % secondary to tidal volume increase, and maternal hyperventilation results in a mild fully compensated respiratory alkalosis (increased arterial po and decreased arterial pco , compensatory fall in serum bicarbonate to - mmol/l; arterial ph . ). the commonest respiratory symptom in pregnancy is breathlessness. although not the subject of this article, pulmonary embolus and cardiac causes are important differential diagnoses, but it is most commonly the increased awareness of the physiological hyperventilation of pregnancy which leads to a subjective feeling of breathlessness. women most often present in the third trimester but may become symptomatic at any gestation. classically physiological breathlessness of pregnancy is present at rest or while talking and paradoxically improves with activity. table summarises other causes. other presenting symptoms of respiratory disease include chest pain, cough, sputum production, haemoptysis, fever or cyanosis. on examination, respiratory rate is unchanged by pregnancy. presence of raised temperature should be noted. expansion on inspiration reflects tidal volume and is reduced in many respiratory diseases. percussion note may be dull in the presence of pleural effusion, consolidation, collapse or fibrosis. it is enhanced in the presence of a pneumothorax. auscultation may reveal wheezes indicative of asthma, fine crepitations in the presence of pulmonary oedema and pleural rubs indicative of inflammatory conditions of the pleura in pneumonia or pulmonary infarction; and bronchial breathing+coarse crackles suggest consolidation. absent breath sounds occur with pneumothorax or extensive collapse. a simple non-invasive investigation is transcutaneous oxygen saturation. the normal oxygen saturation is %. a fall in saturation on exercise, e.g. climbing stairs, indicates some form of cardiopulmonary disease and should be investigated further. measurement of arterial blood gases should be reserved for those who are markedly breathless, those whose oxygen saturations are low at rest or which drop on exercise, and those who appear unwell. reluctance to perform a chest x-ray in pregnancy may delay a diagnosis. ionising radiation from a chest x-ray is approximately . rad (o % of the maximum recommended exposure in pregnancy) and abdominal shielding will reduce fetal exposure further. sputum should be sent for microbiological examination. asthma is a common chronic inflammatory condition of the lung airways characterised by episodes of reversible bronchoconstriction as a result of various stimuli. it affects up to % of women of childbearing age. it may present with episodes of wheeze, shortness of breath, chest tightness or cough. signs classically include a diffuse, bilateral, expiratory ( inspiratory) wheeze and tachypnoea but are often absent. there may be an associated personal or family history of atopy and recognised triggers include pollen, dust, animals and infections. objectively the diagnosis may be confirmed by measuring the peak expiratory flow rate (pefr) or forced expiratory volume in s (fev ) as an indication of the degree of bronchoconstriction. a % diurnal variation on x days in a week for weeks on pef diary or fev x % increase after a trial of a b agonist or steroid tablets or a similar decrease after minutes of exercise are diagnostic. pefr and fev are unaffected by pregnancy. atopy is often associated with asthma. it has no effect on pregnancy and drugs used in the treatment of hayfever (the antihistamines most commonly used with best safety profile are chlorpheniramine and intranasal beclomethasone) may be safely prescribed. effect of asthma on pregnancy: although a number of small studies have suggested an association of asthma with the development of pre-eclampsia, intrauterine growth retardation (iugr), preterm birth and low birthweights, most pregnancies are unaffected by the effects of asthma. severe poorly controlled asthma resulting in episodes of maternal hypoxaemia could, however, give rise to such complications. it is therefore of concern that many women stop their medication at the start of the pregnancy because of concerns regarding the safety profile of these drugs for the fetus. in a recent us study, between and weeks' gestation there was a % reduction in use of inhaled corticosteroids, % reduction in short-acting b -agonists and a % reduction in rescue steroids. effect of pregnancy on asthma: asthma can worsen, improve or remain unchanged in pregnancy. endogenous steroids in labour ensure that acute asthma attacks are very uncommon during labour and delivery. there may be a deterioration postpartum. management: pregnancy is an ideal opportunity to optimise therapy. ideally, this should occur pre-pregnancy. a pre-conceptual visit would allow time to optimise therapy and educate women regarding the importance and safety of continuing their medication to ensure good asthma control throughout pregnancy. inhaler techniques should be checked and home peak flow monitoring encouraged. pregnant women should be monitored closely so that any change in course can be matched by an appropriate change in therapy. smoking should be discouraged. drug therapy in pregnancy is essentially the same as for the non-pregnant population and should follow the british thoracic society guidelines on the management of asthma. a stepwise approach is recommended (figure ). inhaled b -agonists, inhaled and oral steroids, oral and intravenous theophyllines and intravenous magnesium sulphate should be used as normal. only leukotriene antagonists are not recommended because of limited data, although the guidelines suggest that it is safer to continue these in women who are already taking them and who are resistant to the other therapies. acute asthma attacks should be managed aggressively as an emergency in hospital. multidisciplinary care from obstetricians, respiratory physicians and, in severe cases, itu staff will ensure that appropriate treatment as for the non-pregnant patients is administered (table ) . continuous oxygen to maintain saturation above % and continuous fetal monitoring should be instigated. a pefr of - % best/predicted indicates acute severe asthma attack;o % is life-threatening. other concerning signs are spo o %, po o kpa with normal pco , silent chest, cyanosis, feeble respiratory effort, hypotension, altered consciousness and exhaustion. if caesarean section is required, regional blockade is preferable to general anaesthesia in women with asthma and opiates should be avoided for pain relief, especially in the presence of an acute physiological diagnosis by exclusion and typical history anaemia full blood count asthma pefr -response to bronchodilators pulmonary embolus arterial blood gases (kpo and kpco )/ vq scan ctpa mitral stenosis, cardiomyopathy ecg, echocardiogram, chest x-ray chest x-ray, sputum culture, serology pneumothorax chest x-ray hyperventilation/ anxiety arterial blood gases (kpco but not kpo ) table obstetrics, gynaecology and reproductive medicine : attack. prostaglandin e does not cause bronchoconstriction and may used for induction of labour. prostaglandin f a should be used only in extreme circumstances in the management of postpartum haemorrhage and with caution since it may precipitate an acute attack. likewise aspirin and non-steroidal anti-inflammatory drugs should be avoided, although if aspirin is indicated for pre-eclampsia prophylaxis, and there is a history of aspirin exposure without problems, then it should be safe to use. encourage women to continue their regular medication in labour. those women taking . mg prednisolone tablets for weeks prior to the onset of labour require parenteral hydrocortisone mg - hourly during labour. ergometrine has been reported to cause bronchospasm but syntometrine routinely used for active management of the third stage does not. postpartum, breastfeeding may reduce the incidence of asthma in the child and should be encouraged. none of the medications for asthma is contraindicated in breastfeeding. pneumonia occurs in the pregnant population with a frequency equal to that in the general population. effects of pregnancy on pneumonia: pneumonia in pregnancy is often more virulent and mortality is higher than in the nonpregnant population. the spectrum of pathogens is similar to that in the non-pregnant population and the management does not differ. coexisting maternal disease, including asthma and anaemia, and immunosuppressive therapy increase the risk of contracting pneumonia. effect of pneumonia on pregnancy: severe pneumonia may precipitate preterm delivery and result in low birthweight infants. there is an increased risk of serious maternal complications, including respiratory failure. clinical features: women may present with cough, fever, rigors, breathlessness and pleuritic pain. signs include fever, purulent sputum, coarse crackles on auscultation and signs of consolidation. diagnosis may be confirmed with a chest x-ray. blood and sputum cultures should be taken. bacterial pneumonia is associated with a raised white blood cell count, although mycoplasma pneumonia is not. knowledge of the increased mycoplasma activity in the community during an epidemic period may help guide the clinician to the increased likelihood of mycoplasma infection. mycoplasma and chlamydial pneumonias are diagnosed on serological assays with complement fixation tests. management: supportive measures in the management of pregnant women with pneumonia include oxygen administration if there is evidence of hypoxia, and rehydration especially in the presence of fever. chest physiotherapy will help clear secretions and aid oxygenation. oral antibiotic therapy should be commenced for community acquired bacterial infections -oral amoxicillin ( . - g t.d.s.) and clarithromycin ( mg b.d.) are the current recommended strategies. for severe community acquired or hospital acquired infections intravenous cefuroxime and clarithromycin should be used. tetracyclines cause discolouration of the teeth in the fetus and should be avoided after weeks' gestation. community-acquired pneumonia is most commonly caused by streptococcus pneumoniae, haemophilus influenzae and mycoplasma pneumoniae. b-lactam and macrolide antibiotics are safe in pregnancy and are effective in treating community acquired infections. viral pneumonia viral respiratory infections, including varicella, influenza a and severe acute respiratory syndrome (sars), may present in pregnancy and are associated with a worse outcome than in the non-pregnant population. current antiviral and respiratory therapies can reduce maternal morbidity and mortality. the royal college of obstetricians and gynaecologists' guidelines on the treatment of varicella infection in pregnancy recommend that all non-immune pregnant women exposed to varicella should be given zoster immunoglobulin (zig) as soon as possible. those who develop clinical varicella should be treated with aciclovir if within hours of the onset of the rash and after weeks' gestation since mortality and morbidity is higher at advanced gestations. hospital admission should be arranged in the event of respiratory deterioration, neurological symptoms, haemorrhagic rash and bleeding, or in the presence of a dense rash with mucosal lesions. delivery during a viraemic period is hazardous with maternal risks of bleeding, thrombocytopenia, disseminated intravascular coagulation and hepatitis. supportive treatment and intravenous aciclovir may be necessary. there is a high risk of varicella transmission to the newborn with significant morbidity and mortality. therefore, vzig should be given to the newborn after delivery (if maternal infection occurred within days pre and days post-delivery). if the neonate develops varicella, aciclovir should be commenced. influenza vaccination can reduce the prevalence of hospitalisations among pregnant women during the influenza season and is not contraindicated in pregnancy. give high flow oxygen b -agonist bronchodilators high-dose inhaled b -agonists by oxygen-driven nebuliser ipratropium bromide add nebulised ipratropium bromide ( . mg - hourly) if poor response to bronchodilators or severe acute asthma steroid therapy systemic steroids ( - mg/day) in all cases for at least days or until recovery other therapies consider single dose intravenous magnesium sulphate ( . - g infusion over minutes) routine antibiotics are not recommended pneumocystis pneumonia in association with hiv pneumocystis pneumonia (pcp) is the most common opportunistic infection in patients progressing to acquired immunodeficiency syndrome (aids) and continues to carry significant maternal risk to the immunocompromised population. it should be suspected in the presence of profound hypoxia out of proportion to the chest x-ray findings, and bronchoscopy should be considered. treatment is with high-dose co-trimoxazole (septrin) pentamidine, usually contraindicated in pregnancy because of the theoretical risks of neonatal kernicterus and haemolysis. however, in the presence of pcp the benefits of treatment outweigh these risks and women with hiv and a past history of pcp or with a cd + cell count ofo cells/ml should receive prophylactic septrin or nebulised pentamidine when embarking on pregnancy. this is an infection caused by mycobacterium tuberculosis which characteristically causes caseating granulomas, usually involving the lungs as the primary site. the incidence of tuberculosis (tb) worldwide is rising, in part due to the susceptibility to tb of hivinfected patients, and in the uk is more prevalent amongst asian and african immigrants. in pregnancy recent studies have suggested a high prevalence ( %) of extrapulmonary tb (at sites such as lymph nodes, bone, liver, spleen, bone marrow, caecum, nervous system and eye). the patient is often asymptomatic but typically can present with a cough, haemoptysis, weight loss and night sweats. the diagnosis is confirmed with sputum examination for acid-fast bacilli (ziehl-neelsen stain). although pregnancy and tb have little effect on each other, treatment should not be delayed in pregnancy. because of a rising incidence of drug-resistant tb, treatment is often with prolonged courses of multiple chemotherapeutic agents at the advice of the respiratory physicians. the usual drugs given are rifampicin (no proven adverse fetal effects but risk of maternal hepatotoxicity), isoniazid (in combination with pyridoxine mg/day to reduce the risk of peripheral neuritis), pyrazinamide and/or ethambutol. liver function should be monitored monthly. streptomycin is associated with eighth nerve damage and should therefore be avoided. after delivery the neonate should be given prophylactic isoniazid treatment if the mother is sputum positive. the infant should also be vaccinated as soon as possible. breastfeeding is not contraindicated since very little of the drugs are excreted in breast milk. this is a complication of gastric regurgitation often at the time of a general anaesthetic in late pregnancy (usually at caesarean section). it may also occur in the event of an excessively high regional block. increased intra-abdominal pressure, delayed gastric emptying and reduced gastro-oesophageal sphincter tone contribute to the risk. ranitidine, an h antagonist, which reduces gastric acid secretion and an antacid which neutralises the gastric acid are now routinely prescribed for women in labour with risk factors for caesarean section or prior to an elective procedure. the last confidential enquiry into maternal deaths ( ) ( ) ( ) reported one death from gastric aspiration in an obese woman (bmi ) following failure to intubate the trachea after induction for general anaesthesia. cystic fibrosis (cf) is an autosomal-recessive disorder affecting the body's exocrine glands, including the pancreas, sweat glands and lungs. it results from a gene deletion in % of cases and has a carrier frequency of in caucasians. a resultant defect in the cf transmembrane conductance regulator protein causes impaired movement of water and electrolytes across epithelial surfaces. formerly, cf patients rarely lived to adulthood, but improvements in treatment have meant more women with cf are now reaching reproductive age and wish to become pregnant. the signs and symptoms of cf vary, depending on the severity of the disease and the degree of bacterial infection. some cases are very mild and may not be diagnosed until adulthood. cf is characterised by the production of very thick and sticky mucus. the ducts leading from the pancreas become obstructed, causing pancreatic insufficiency, diabetes and malnutrition. about % of cf cases involve the lungs with recurrent or persistent infections, development of bronchiectasis and respiratory failure. a productive cough is almost always present, and very often patients appear barrel-chested. frequent hospitalisations are a result of recurring respiratory, gastrointestinal and nutritional problems. effect of cystic fibrosis on pregnancy: female fertility may be impaired because of malnutrition or thickened cervical mucus but is usually normal. men are usually sterile. most reported series of pregnancies in women with cf have shown that with careful planning and close monitoring by a dedicated cf team, pregnancy outcomes are favourable. commonly reported adverse events are iugr and prematurity, which includes iatrogenic early delivery in unwell women. effect of pregnancy on cystic fibrosis: pregnancy does not affect disease severity or cause deterioration in the patient's condition. maternal mortality is not significantly greater than non-pregnant age-matched women with cf except in the presence of pulmonary hypertension, cyanosis, arterial hypoxaemia (oxygen saturationo %), severe lung disease (fev o % predicted) and/or malnutrition when both maternal and fetal outcome may be poor. management: the risk of a child being born with cf is - . % if the carrier status of the father is unknown (based on the uk carrier status of in ) and % if the father is heterozygous for the gene. therefore pre-conceptual genetic counselling is important. during the pregnancy, regular assessment of fetal growth should be planned to detect early signs of fetal growth restriction. ideally women with cf planning a pregnancy should be seen and assessed pre-conceptually. women with mild disease can then be reassured that pregnancy is safe and liaison may be planned ahead between a cf centre and an obstetrician with a special interest in cf. screening for diabetes and baseline lung function tests can be performed. dietary supplementation and enzyme supplements can be commenced to optimise the patient's condition prior to conception and continued throughout pregnancy. women with cf are at increased risk of developing gestational diabetes. chest physiotherapy and prophylactic antibiotics may be implemented prior to conception and continued throughout the pregnancy. infective chest exacerbations should be treated aggressively with antibiotic therapy. conversely, if pre-conceptually the patient is found to have pulmonary hypertension complicating the cf, cor pulmonale or an fev o - %, she may be counselled regarding the associated high risk and be strongly advised against pregnancy. effective contraception should also be discussed in such cases. in order to achieve a successful outcome, multidisciplinary management aims to ensure adequate maternal nutrition, control of pulmonary infection and avoidance of prolonged hypoxia. women may develop symptoms of breathlessness or evidence of hypoxia in late pregnancy. admission for bed rest and oxygen therapy should be arranged. delivery should be planned if their clinical condition deteriorates further. there is no contraindication to vaginal delivery but a prolonged second stage should be avoided because of the susceptibility of these patients to pneumothoraces. general anaesthesia should be avoided. there is no contraindication to breastfeeding but women may need to continue nutritional supplements postpartum. bronchiectasis is a sequela of cf, pneumonias and rarer causes such as kartagener's syndrome. it is characterised by irreversibly dilated damaged bronchi predisposing to persistently infected mucus and bacterial infections. a cough productive of large amounts of sputum is characteristic. the condition is uncommon in the childbearing years but there is some evidence to suggest an association with iugr when present in pregnancy. women should be managed jointly with respiratory physicians and their condition can deteriorate in pregnancy. close attention to postural drainage and physiotherapy will help. regular sputum cultures and treatment of chest infections are necessary intermittently or continuously if recurrent infections are frequent. the use of bronchodilators may help. as in cf, the presence of pulmonary hypertension and/or hypoxaemia adversely affects prognosis. there are few data regarding pregnancy outcome in women following lung transplant. of a series of pregnancies in women who were cf lung transplant recipients, five with a long stable interval of years between transplant and the pregnancy had favourable outcomes; the remaining five had preterm deliveries. all , however, showed progressive decline in lung function and all died of chronic rejection within months of delivery. restrictive ventilatory defects characterised by a reduction in lung volumes and an increase in the ratio of fev to forced vital capacity (fvc) occur when lung expansion is limited because of alterations in the lung parenchyma or because of abnormalities in the pleura, chest wall or neuromuscular apparatus. the majority of pulmonary diseases do not alter fertility. a large reserve in respiratory function allows fetus and mother to survive without compromise in most cases. fvc of l or % of predicted have been suggested as a cut-off for successful pregnancies and although more severe cases can negotiate pregnancy, patients with severe restrictive lung disease should be advised to avoid pregnancy or consider a therapeutic termination. associated polycythaemia causing hyperviscosity may add to the thrombotic risk during a pregnancy. women with an associated kyphoscoliosis are often delivered prematurely because of deterioration in lung function. mode of delivery tends to be caesarean section because of abnormal fetal presentation. each case should be assessed individually. sarcoidosis is characterised by non-caseating epithelioid granulomas that may affect any organ system. the aetiology of the disease remains unknown. the disease most commonly involves granuloma formation in the lungs. other commonly involved organ systems include the lymph nodes (especially the intrathoracic nodes), skin, eyes, liver, heart, and nervous, musculoskeletal, renal and endocrine systems. the course of sarcoidosis is variable, ranging from self-limited acute disease to a chronic debilitating disease that may result in death. spontaneous remissions occur in nearly two-thirds of patients, but - % of patients have a more chronic or progressive course. because sarcoidosis can involve any organ system, the clinical presentation is often variable. many patients are asymptomatic but there may be chest symptoms. other features include erythema nodosum, anterior uveitis, hypercalcaemia, arthropathy, fever or central nervous system symptoms. effect of pregnancy on sarcoidosis: according to reported series, sarcoidosis either does not change in pregnancy or if it changes, improves, possibly because of the increased circulating cortisol. however, there is a tendency to relapse in the puerperium. this should not be a contraindication to pregnancy except in severely affected cases pre-pregnancy. factors indicating a poor prognosis include parenchymal lesions on chest x-ray, advanced radiographic staging, advanced maternal age, low inflammatory activity, requirement for drugs other than steroids and presence of extrapulmonary sarcoidosis. effect of sarcoidosis on pregnancy: sarcoidosis does not adversely affect pregnancy and is not transmitted to the fetus. there is one report of sarcoid granulomata found in the placenta of one patient. management: ideally patients require evaluation before pregnancy to establish chronicity, baseline pulmonary function, inflammatory activity, staging and response to treatment. systemic steroids should be continued in pregnancy. angiotensin converting enzyme levels, used as a marker of disease activity, are unreliable in pregnancy. women should be advised to avoid vitamin d because of the risk of hypercalcaemia. intravenous hydrocortisone should be administered in labour in women taking . mg/day of prednisolone. wegener's granulomatosis this is a rare form of systemic vasculitis in which necrotising granulomatous lesions affect the upper respiratory tract, lungs and kidneys. without treatment the condition has a poor prognosis. remission may be achieved with prednisolone and cyclophosphamide, a teratogenic drug. women should be advised to avoid pregnancy until remission has been achieved and to wait at least months following cessation of cyclophosphamide before conceiving. cyclophosphamide may also cause ovarian failure. pregnancy has been associated with exacerbation of disease activity and cyclophosphamide has been used in the latter half of pregnancy, causing a fetal leucopenia. antineutrophil cytoplasmic antibody (anca) titres are markers of disease activity but their reliability in pregnancy has not been evaluated. amniotic fluid embolism is fortunately rare ( in ) but should be suspected when a woman presents with a sudden onset of hypoxia (with dysnoea, cyanosis or respiratory arrest), collapse, an acute hypotensive crises or disseminated intravascular coagulation or haemorrhage in the absence of any other explanation. onset is usually during labour, caesarean section or within minutes of delivery. it has also been described during dilatation and curettage procedures. management is supportive with early involvement of the intensive care team. the aim is to achieve adequate oxygenation with ventilatory support, invasive monitoring to maintain good cardiac output and correction of a coagulopathy. mortality rate is %. the pathogenesis is not entirely clear. it is thought to be due to the passage of amniotic fluid and debris into the maternal circulation, precipitating an anaphylactic-like reaction. fetal squames are however present in the circulation of healthy pregnant women without any consequences. bronchial carcinoma accounts for % of all primary tumours of the lungs. although the incidence continues to rise in women, few cases have been reported in pregnancy. the commonest presenting symptoms are cough, chest discomfort and haemoptysis and chest x-ray may demonstrate round shadows. metastasis has been reported in the pericardium and placenta. lymphomas may also present with respiratory symptoms. the strength of association between cigarette smoking and bronchial carcinoma overshadows any other aetiological risk factors and - % of pregnant women report smoking in the developed world. few will stop on becoming pregnant but focused counselling by specialist staff has been shown to be more effective than other measures, with more than doubling of cessation rates. the effectiveness and safety of nicotine replacement therapy in pregnancy have yet to be established. besides maternal morbidity, smoking adversely affects the pregnancy by doubling the risk of premature delivery, both spontaneous and iatrogenic, as a result of placental abruption and lowers the mean birth weight. reduced ovarian and tubal function and implantation predispose to subfertility, miscarriage and ectopic pregnancy. breathlessness in the absence of an underlying pathology is common in pregnancy, especially in the second and third trimesters. the use of chest x-rays when underlying disease is suspected should not be avoided in pregnancy and most drugs can be used safely in pregnancy. it is important that women with a chronic respiratory disease should receive pre-pregnancy counselling and education regarding the risks of pregnancy and the importance of continuing their medications. it also provides the opportunity to optimise their condition and so reduce adverse pregnancy outcomes. women should be managed in a multidisciplinary setting with regular review by chest physicians and access to chest physiotherapy if necessary. liaison with obstetric anaesthetists in the antenatal period will optimise care at delivery with regard to pain relief and reduce anaesthetic risks. respiratory diseases complicated by pulmonary hypertension and cor pulmonale have a poor prognosis in pregnancy.f pneumonia in pregnancy is often more virulent and therefore should be treated aggressively all non-immune pregnant women exposed to varicella should be given zoster immunoglobulin ( british thoracic society: scottish intercollegiate guidelines network. british guideline on the management of asthma british thoracic society: guidelines for the management of community acquired pneumonia respiratory disease cessation of asthma medication in early pregnancy pregnancy in cystic fibrosis lung transplant recipients: case series and review restrictive lung disease in pregnancy tuberculosis and pregnancy-results of a study in a high prevalence area in london asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes handbook of obstetric medicine key: cord- -p gyyl c authors: hsu, albert l.; guan, minhui; johannesen, eric; stephens, amanda j.; khaleel, nabila; kagan, nikki; tuhlei, breanna c.; wan, xiu‐feng title: placental sars‐cov‐ in a pregnant woman with mild covid‐ disease date: - - journal: j med virol doi: . /jmv. sha: doc_id: cord_uid: p gyyl c background: the full impact of covid‐ on pregnancy remains uncharacterized. current literature suggests minimal maternal, fetal, and neonatal morbidity and mortality.( ) covid‐ manifestations appear similar between pregnant and non‐pregnant women.( ) objectives/study design: we present a case of placental sars‐cov‐ virus in a woman with mild covid‐ disease, then review the literature. rt‐pcr was performed to detect sars‐cov‐ . immunohistochemistry staining was performed with specific monoclonal antibodies to detect sars‐cov‐ antigen or to identify trophoblasts. results: a year‐old multigravida presented at ‐ / weeks for labor induction. with myalgias two days prior, she tested positive for sars‐cov‐ . we demonstrate maternal vascular malperfusion, with no fetal vascular malperfusion, as well as sars‐cov‐ virus in chorionic villi endothelial cells, and also rarely in trophoblasts. conclusions: to our knowledge, this is the first report of placental sars‐cov‐ despite mild covid‐ disease (no symptoms of covid‐ aside from myalgias); patient had no fever, cough, or shortness of breath, but only myalgias and sick contacts. despite her mild covid‐ disease in pregnancy, we demonstrate placental vasculopathy and presence of sars‐cov‐ virus across the placenta. evidence of placental covid‐ raises concern for placental vasculopathy (potentially leading to fetal growth restriction and other pregnancy complications) and possible vertical transmission – especially for pregnant women who may be exposed to covid‐ in early pregnancy. this raises important questions of whether future pregnancy guidance should include stricter pandemic precautions, such as screening for a wider array of covid‐ symptoms, increased antenatal surveillance, and possibly routine covid‐ testing throughout pregnancy. this article is protected by copyright. all rights reserved. this raises important questions of whether future pregnancy guidance should include stricter pandemic precautions, such as screening for a wider array of covid- symptoms, increased antenatal surveillance, and possibly routine covid- testing throughout pregnancy. as of july , the coronavirus disease (covid- ) pandemic has resulted in , , cases and , deaths in the united states. the full impact of covid- on pregnancy remains to be fully characterized, especially as women who were exposed to covid- early in their first trimester have yet to reach full term, as of the time of writing this manuscript. the current literature suggests minimal maternal, fetal, and neonatal morbidity and mortality for women with covid- in pregnancy. this article is protected by copyright. all rights reserved. women, until a recent publication from the us cdc morbidity and mortality weekly report (mmwr). before this study, we searched pubmed and medline on may (updated on june ) for articles describing the impact of covid- in pregnancy, using the search terms "covid- " or "sars-cov- " and "pregnancy" or "placenta" with no time or language restrictions. we found only previously published research that describes finding sars-cov- virus in the placentas of women with moderate-to-severe covid- disease. we found no published work about sars-cov- virus in the placentas of women with mild covid- disease. two reports suggest that pregnant women with covid- may be more likely to be admitted to the icu and more likely to be intubated, but all reports consistently state that severe covid- disease during pregnancy is uncommon. we found six manuscripts which describe sars-cov- virus in the placentas of women with moderate-to-severe covid- disease. we found no published work about sars-cov- virus immunohistochemistry in the placentas of women with mild covid- disease. in this case study, we present a case of placental sars-cov- virus in a woman with an uncomplicated pregnancy and mild covid- disease. here, we review the literature on covid- disease and pregnancy, and subsequently discuss the key messages of this case. this article is protected by copyright. all rights reserved. a pregnant woman was evaluated at university of missouri women and children's hospital. institutional review board approval was obtained; information was obtained from medical records. reverse transcriptase-polymerase chain reaction (rt-pcr) was performed to detect sars-cov- . a gynecological pathologist examined the placenta and performed histolopathology. sections were formalin-fixed and paraffin-embedded; slides were cut and subjected to hematoxylin-and-eosin or immunohistochemistry (ihc) staining. ihc was performed with sars-cov- nucelocapsid-specific or cytokeratin- specific monoclonal antibody to detect sars-cov- antigen or to identify trophoblasts, respectively. in april , a year-old multigravida presented at - / weeks for labor induction. she had tested positive for sars-cov- , with her only symptoms being myalgias two days prior. her parents and siblings had been in self-isolation for covid- positivity; her husband was asymptomatic and tested negative for covid- , but he had been exposed to a workplace (meatpacking facility) outbreak. her prenatal course was uncomplicated, with no gestational hypertension or any other pregnancy complications. her myalgias improved prior to admission. she was afebrile and asymptomatic with normal vital signs throughout hospitalization. consistent with other reports of laboratory abnormalities associated with covid- , her inpatient labwork showed some mild elevations in her lfts and c-reactive protein, but were otherwise unremarkable (table ) . this article is protected by copyright. all rights reserved. a liveborn male infant was delivered vaginally. newborn course was uneventful; with routine resuscitation and newborn apgars of and at and minutes; points were taken off for color only. birthweight was g ( th percentile), length was cm ( th percentile) and head circumference was cm ( th percentile), all appropriate for gestational age. his physical was unremarkable, with a small skin tag on his right cheek and dermal melanocytosis on buttock, appropriate for ethnicity. he passed hearing screen and screen for critical congenital heart defects (normal-preductal %, postductal %). he was discharged home at hours of life, with a plan for close follow-up from his pediatrician. covid- reverse transcriptase-polymerase chain reaction (rt-pcr) test was negative at hours. at one-week follow-up, newborn was breastfeeding well, with no fevers or respiratory distress. two months later, mother and baby are doing well. a gynecological pathologist examined the placenta and performed histolopathology. sections were formalin-fixed and paraffin-embedded; slides were then cut and subjected to hematoxylin-and-eosin or immunohistochemistry (ihc) staining. placenta had a marginally-inserted three-vessel umbilical cord; placental membranes were thin and transparent. placental weight was grams, at the th percentile for gestational age. no gross lesions were seen on fetal or maternal placental surfaces; parenchymal sections were unremarkable. on histology, placental membranes showed decidua with scattered arterioles with thickened smooth muscle, consistent with hypertrophic arteriolopathy ( figure a ) and subchorionic laminar necrosis ( b). placental disc showed focal lympho-histiocytic inflammation consistent with chronic villitis ( c) and scattered islands of extravillous trophoblasts ( d). no evidence of fetal thrombi (villous sclerosis or villous karyorrhexis) were seen. overall histology is consistent with acute this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. system in new york state and found that pregnant women were not at an increased risk for icu admission compared with nonpregnant women (p= . ); in this study, . % of nonpregnant females were admitted to the icu compared to . % of pregnant patients. positive cases). fortunately, none of these studies reported any maternal deaths. two other studies, , suggest that pregnant women with covid- have a higher risk of severe disease than nonpregnant women. a swedish study showed pregnant swedish women were times more likely to be admitted to the icu and times more likely to receive mechanical ventilation than were nonpregnant women. also, a us cdc report reviewed , women of reproductive age ( - pregnant women in this study had an even lower overall risk of icu admission than the previous case series. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] all of these studies agree upon a low level of maternal mortality ( deaths, or . % according to mmwr) from covid- . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] while this is reassuring overall, more data is needed, especially regarding pregnancies with exposure to covid- in the first trimester. there are also several reports suggesting a potential low risk of in utero vertical transmission from mother to fetus. in an italian series of women affected by covid- were all positive for sars-cov- by pcr testing. symptoms. baud et al describe a second-trimester miscarriage in which the mother (nasopharyngeal swab) and placental submembranes and placental cotyledons were positive for sars-cov- on rt-pcr. hosier et al describe sars-cov- localization to syncytiotrophoblast cells at the maternal-fetal interface of the placenta, with no evidence of vasculopathy. chen et al describe patients who had a caesarean section, with amniotic fluid, cord blood, neonatal throat swab, and breastmilk samples from six patients all testing negative for sars-cov- . this article is protected by copyright. all rights reserved. ferriaolo et al describe an asymptomatic woman with a positive nasopharyngeal swab for covid- in italy, who had a caesarean section and positive placental swabs for sars-cov- rna. dong et al report a case of sars-cov- igm in a neonate born to a covid- positive mother. collectively, this literature suggests that there may be a low risk of vertical transmission of covid- from mother to fetus in utero. in our report, sars-cov- was found throughout the placenta on immunohistochemistry, and newborn was covid- negative. as this patient was exposed to covid- in her third trimester of pregnancy, it remains unclear whether women who are exposed to covid- earlier in pregnancy (or multiple times during malperfusion in of placentas. in a study at northwestern university, shanes et al found that the most common findings in covid-positive placentas were decidual arteriopathy and intervillous thrombi. however, it is notable that signs of fetal and maternal malperfusion are non-specific and can be seen in other conditions, such as hypercoagulable states, like lupus anticoagulant and protein c or s deficiency, gestational hypertension, pre-eclampsia, as well as in patients with no specific medical history. the inexorable rise in covid- cases in the united states amid decreasing adherence to public health recommendations raises concern for the possibility of viral mutations. in light of the cdc's mmwr report, the us cdc also issued updated ( / / ) recommendations regarding pregnancy and covid- , encouraging pregnant women to "limit interactions with other people as much as possible," to "take precautions to prevent getting covid- when you do interact with others," and to be aware that "some babies have tested positive for the virus shortly after birth. it is unknown if these babies got the virus before, during, or after birth." while two reports suggest that pregnant women with covid- may be more likely to be admitted to the icu and more likely to be intubated than non-pregnant women, , all reports consistently state that severe covid- disease during pregnancy is uncommon. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] we found six manuscripts which describe sars-cov- virus in the placentas of women with moderate-to-severe covid- disease. to date, there is still no other published work about sars-cov- virus by immunohistochemistry in the placentas of women with mild covid- disease. this article is protected by copyright. all rights reserved. to our knowledge, this is the first report of placental covid- despite mild covid- disease in pregnancy (with no symptoms of covid- aside from myalgias); specifically, this patient had no fever, cough, or shortness of breath, but only myalgias and sick contacts. evidence of placental covid- raises concern for possible placental vasculopathy (potentially leading to fetal growth restriction, pre-eclampsia, and other pregnancy complications) as well as for potential vertical transmission -especially for pregnant women who may be exposed to covid- in early pregnancy. despite her having mild covid- disease in pregnancy, we demonstrate placental vasculopathy and presence of sars-cov- virus across the placenta. while our case shows features of maternal vascular malperfusion (extra-villous trophoblastic lesions and subchorionic laminar necrosis), no evidence of fetal vascular malperfusion were seen. as this patient was exposed to covid- in her third trimester of pregnancy, it remains unclear whether women who are exposed to covid- earlier in pregnancy (or multiple times during pregnancy) may have a greater risk of fetal vascular malperfusion, which may result in pre-eclampsia, fetal growth restriction, or other obstetric complications. further studies are needed, especially from pregnancies with exposure to covid- in the first trimester. this report also raises important concerns regarding the possibility of birth defects, miscarriages, and stillbirths with covid- infection, as well as the question about potential protective or detrimental effects of breastfeeding. data responsive to these critical issues remain limited and preliminary. of note, women who were exposed to covid- in their first trimester in the united states still have not had any full-term this article is protected by copyright. all rights reserved. deliveries, and remain in early stages of their pregnancies; thus, we are not able to comment on the possibilities of birth defects with covid- at the current time. regarding miscarriage, one early meta-analysis noted cases of miscarriage out of pregnant women with covid- ; most related studies similarly lack a wellcharacterized control group for appropriate comparative analyses. there are also isolated case reports suggesting that late miscarriage may be a presenting manifestation of covid- . , finally, an early report from the united kingdom demonstrated a concerning increase in stillbirth rates during the covid- pandemic; specifically, those authors report " stillbirths among completed pregnancies" in women with confirmed covid- , for a rate of . vs . per births (p=. ), with multifactorial causes likely. regarding breastfeeding, early data suggest that transmission of covid- through breastmilk is possible but rare. cumulative data from six separate studies , , [ ] [ ] [ ] [ ] found that out of mothers with covid- , only two had their breastmilk test positive with pcr. of those two cases, one breastfed newborn tested positive for sars-cov- by pcr, and the other newborn tested negative for sars-cov- ; it is unclear whether that newborn breastfed or received expressed breastmilk. ferrazi et al reported that, of two women with covid- who breastfed without a mask, both had newborns who tested positive for covid- postpartum. in contrast, eight other covid- positive mothers in this study breastfed while mask-wearing, and those eight newborns did not contract covid- ; there was no mention of whether or not the breastmilk was tested for sars-cov- . this suggests that close contact associated with breastfeeding may increase the risk of transmission of infected respiratory secretions, and that mask-wearing may decrease this risk. questions about birth defects, miscarriage, stillbirth, and this article is protected by copyright. all rights reserved. breastfeeding with covid- remain critical areas for future research, but at the current time, data is limited, preliminary, and continually-evolving. to our knowledge, this is the first report of placental covid- despite mild covid- disease in pregnancy (with no symptoms of covid- aside from myalgias). all other reports have shown placental covid- in pregnancies with moderate-to-severe disease. this patient had no fever, cough, or shortness of breath, but only myalgias and sick contacts. in this report, sars-cov- was found in the placenta, but the newborn was covid- negative. our case shows maternal vascular malperfusion, with no features of fetal vascular malperfusion. evidence of placental covid- raises concern for placental vasculopathy and potential vertical transmission. our report raises the question of whether future pregnancy guidance should include even stricter pandemic precautions, such as prenatal screening for a wider array of covid- symptoms, increased antenatal surveillance recommendations, and possibly covid- testing on a regular basis throughout pregnancy. covid- cases in the u.s effects of coronavirus disease (covid- ) on maternal, perinatal and neonatal outcomes: a systematic review analysis of maternal coronavirus infections and neonates born to mothers with -ncov; a systematic review characteristics of women of reproductive age with laboratory-confirmed sars-cov- infection by pregnancy status -united states covid- infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals coronavirus disease in pregnancy: early lessons american journal of obstetrics & gynecology mfm intensive care unit admissions for pregnant and non-pregnant women with covid- clinical findings and disease severity in hospitalized pregnant women with coronavirus disease vaginal delivery in sars-cov- -infected pregnant women in northern italy: a retrospective analysis bjog re: novel coronavirus covid- in late pregnancy: outcomes of first nine cases in an inner city london hospital screening for covid- at childbirth: does it deliver? clinical characteristics of pregnant women with a sars-cov- infection in washington state coronavirus disease among pregnant chinese women: case series data on the safety of vaginal birth and breastfeeding bjog neonatal late onset infection with severe acute respiratory syndrome coronavirus coronavirus disease in pregnancy coronavirus disease (covid- ) in pregnant women: a report based on cases public health agency of sweden's brief report: pregnant and postpartum women with sars-cov- infection in intensive care in sweden has sweden's controversial covid- strategy been successful? vertical transmission of covid- : sars-cov- rna on the fetal side of the placenta in pregnancies with covid- positive mothers and neonates at birth detection of sars-cov- in placental and fetal membrane samples second-trimester miscarriage in a pregnant woman with sars-cov- infection sars-cov- infection of the placenta clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records report of positive placental swabs for sars-cov- in an asymptomatic pregnant woman with covid- possible vertical transmission of sars-cov- from an infected mother to her newborn covid- and its implications for thrombosis and anticoagulation placental pathology in covid- positive mothers: preliminary findings placental pathology in covid- fetal vascular malperfusion if you are pregnant, breastfeeding, or caring for young children late miscarriage as a presenting manifestation of covid- change in the incidence of stillbirth and preterm delivery during the covid- perinatal transmission of covid- associated sars-cov- : should we worry? detection of sars-cov- in human breastmilk the lancet coronavirus disease among pregnant chinese women: case series data on the safety of vaginal birth and breastfeeding bjog vaginal delivery in sars-cov- -infected pregnant women in northern italy: a retrospective analysis bjog this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. immunohistochemistry (ihc) staining of sars-cov- virus in a covid- negative patient, delivery prior to the covid- outbreak (figure a) . ihc of sars-cov- from three placental sections ( b: under umbilical cord, c: central placental disc, d-e: peripheral placental disc at x and x). ihc of cytokeratin- (ck- ) marker in control ferret nasal turbinate tissue ( figure f ). ihc of ck- from three placental sections ( g: under umbilical cord, h: central placental disc, i-j: peripheral placental disc at x and x). arrows or brown staining indicate immunoreactive antigens. bars = / / µm shown at the right bottom corner of each panel. ihc was performed with sars-cov- nucleocapsid-specific rabbit monoclonal antibody (sino biological, wayne, pa) and goat anti-rabbit igg (vector lab, burlingame, ca). to identify trophoblasts, ihc was performed using rabbit recombinant anti-cytokeratin (ck ) monoclonal antibody (abcam, cambridge, ma) and goat anti-rabbit igg (vector lab, burlingame, ca). key: cord- -f g r nv authors: bahri, amrita title: women at the frontline of covid- : can gender mainstreaming in free trade agreements help? date: - - journal: nan doi: . /jiel/jgaa sha: doc_id: cord_uid: f g r nv health pandemics affect women and men differently, and they can make the existing gender inequalities much worse. covid- is one such pandemic, which can have substantial gendered implications both during and in the post-pandemic world. its economic and social consequences could deepen the existing gender inequalities and roll back the limited gains made in respect of women empowerment in the past few decades. the impending global recession, multiple trade restrictions, economic lockdown, and social distancing measures can expose vulnerabilities in social, political, and economic systems, which, in turn, could have a profound impact on women’s participation in trade and commerce. the article outlines five main reasons that explain why this health pandemic has put women employees, entrepreneurs, and consumers at the frontline of the struggle. it then explores how free trade agreements can contribute in repairing the harm in the post-pandemic world. in doing so, the author sheds light on various ways in which the existing trade agreements embrace gender equality considerations and how they can be better prepared to help minimize the pandemic-inflicted economic loss to women. the unprecedented pandemic of covid- has strained and overstretched the health systems worldwide, including in the most advanced economies of the world. it has upended the global economy, and with it the international trade, creating enormous shocks to supply and demand. as a response to this pandemic, countries have increased trade restrictions and closed down their borders, and this has cut the supply chain, that is, 'the fuel line to the engine' of international trade. the world trade organization (wto) economists predict that covid- can cause a bigger collapse of global trade than what we had seen during the - economic crises. the economic contagion has grown as fast as this health pandemic itself. amidst all this, something else is happening that we need to take an account of. covid- has put women employees, women entrepreneurs, and women consumers at the frontline of this struggle. ' across every sphere, from health to the economy, security to social protection, the impacts of covid- are exacerbated for women and girls simply by virtue of their sex. ' this article sheds light on the key reasons that explain why women, working women in particular, are placed at the frontline of this struggle. this article is not attempting to show how or why more working women than working men (in absolute numbers) can get affected due to this pandemic; this may not be the case as much more men than women are involved in the economies and hence men may be impacted more in absolute terms moreover, we need sex-disaggregated data on the economic impact of covid- to better understand its gendered impact. the article seeks to underline how this pandemic could roll-back the limited gains made in respect of women empowerment over the past few decades. the post-pandemic world will require multiple interventions at domestic and international levels to repair this harm. international trade law and policies can form an important part of this recovery, as they can trigger changes at the domestic levels. this crisis presents a unique opportunity to build back the economy in an inclusive manner and explore how trade policies can contribute in this respect through existing and future free trade agreements (ftas). ftas can play an instrumental role in reducing gender gap. two reasons in particular support this claim. first, the existing and future trade agreements between countries can increase trade flows and hence lead to more business and employment opportunities and a better standard of life for all including women. second, through regional or bilateral trade accords, countries can encourage their trade partners to create laws and procedures that may encourage women's participation in trade and commerce. as will be discussed in section ii, more and more countries are employing this 'topdown' approach to deal with gender inequality as they are increasingly including gender considerations in their trade agreements. this article sheds light on different types of gender-responsive provisions found in existing ftas that can play a part in reducing gender inequality. it will also present some discussion on how future ftas can take a step further in this respect, so they are able to better respond to the pandemic-inflicteddisruptions to inclusive growth. these discussions will provide an understanding of how ftas can help women participate in the economy and the elements that existing ftas lack in this respect. a. reason : loss of employment for women in service sectors trade in services seems to be most directly affected by this pandemic due to its very special nature. the loss of services (in the form of cancellation of sports events, travel plans, other recreational services) is permanent as, unlike goods, there are no inventories of services and services cannot be stored or restocked for future consumption. hence, the impact of this pandemic on trade in services is much harsher than its impact on trade in goods. globally, almost % of women workforce is employed in service-based industries. women are mostly employed in labor-intensive services that require physical proximity between providers and consumers. in this pandemic where social distancing has become a global norm, service industries such as tourism, finance, and education are set to suffer a significant loss of revenue. women workers employed in these sectors stand at an economically vulnerable position. moreover, women are overrepresented in low-paid, part-time, and temporary employment, often without job protection, maternity benefits, health benefits, or pensions commensurate with their working life. in any industry that is hit hard by the pandemic, women are more likely to feel the impact as compared to men who tend to have higher representation at senior, well-paid, and permanent roles (often with stronger job protection and employment benefits) than women. recent studies show that two billion people in the world work in the informal sector, majority being in emerging and developing countries. this means that more than % of the world's employed population makes their living from the informal economy. if we only look at the world's informal employment in emerging and developing countries, the number goes up to %. out of two billion workers in the informal employment worldwide, over million are women. in south asia, over % of women in nonagricultural jobs are in informal employment. this number is over % in sub-saharan africa and % in latin america and the caribbean. women in this sector, which is often referred to as a 'gray economy,' frequently work without decent salaries, protection from labor laws, insurance or health cover, maternity benefits, or paid sick leave. with the 'stay at home' orders and social distancing norms, petty services traders, street-vendors, seasonal workers, and industrial outworkers will be left out of their already poorly paid employments. in the current era of globalization and trade liberalization, small and medium-sized enterprises (smes) play an instrumental role in the economy. smes account for almost % of the global gross domestic product (gdp) and over % of the employment worldwide. smes drive economic growth, but they tend to be vulnerable to changes in the economy or markets forces beyond their control, such as a health pandemic which can alter the market dynamics and supply chain for a considerable period of time. they may not have the capacity and resources to survive a global economic meltdown or a recession as compared to large multinational companies. this would especially be the case with smes that are engaged in export and import of goods as well as services, mainly because of the disruptions in service economies and temporary export restrictions imposed on multiple products including drugs, medical equipments, agricultural products, and cereals. these export restrictions could alter the consumption patterns, disrupt supply chains, and hence change the very nature of multiple industries worldwide. women own close to million of the world's smes. this means that more than % of smes in the world are owned by women entrepreneurs. in the state of lockdown, it is a hard reality that many smes will have to close or scale down their operations. smes dealing with trade in services, in particular those working in tourism, retail, education, hospitality, and finance, could suffer a gigantic jolt. moreover, women who are employed by smes might also be uprooted from the economy as a result of this pandemic. globally, approximately % of working women are employed in service-based smes. this number goes as high as % if we look at female employment in service sectors in advanced economies. hence, loss of employment for women in smes could be quite significant. d. reason : women entrepreneurs may require longer times to reactivate their businesses women entrepreneurs may require longer times to reactivate their businesses due to several reasons. one of the reasons that could impede the process of reactivating women-owned businesses is their lack of access to productive resources such as assets and capital. approximately % of women in the world do not have bank accounts or access to other financial services. in the rural areas of low-income countries, only about % of bank account holders are women. women without bank accounts have no credit history. also, women generally have less access to assets such as land or other property due to multiple reasons including men-favoring inheritance laws in many countries. lack of credit history and assets would mean that women entrepreneurs could face significant difficulties in securing credit for reviving their businesses post pandemic. another reason that could slow down the process of recovery for women might be the decrease in access to family planning services such as abortions. difficulty and fear in approaching medical services for having an abortion or accessing contraceptives could cause untimely and unwanted pregnancy to many women professionals, which, in turn, could increase their time constraints. lack of access to medical services could also lead to an increase in the numbers of maternal mortality and sexually transmitted diseases. moreover, women may be disconnected further from the economy due to increased household responsibilities and domestic violence during the great lockdown. against women women professionals tend to take a bigger chunk of domestic responsibilities as compared to men even during their working hours. lockdown implies that children across the world are at home, which would mean an increase in child-care work for women and higher time-poverty for them. time-poverty is one of the barriers that impede women's participation in economies, as it implies for them lack of time to receive education, skill development, vocational training, employment prospects, and business opportunities. moreover, most of this household work is largely invisible and unpaid. this puts women a step farther from being economically empowered. moreover, for some women, staying at homes could also mean being locked down with their physically abusive family members. france has reported a spike of % in domestic violence cases against women during the lockdown. in the united kingdom, calls to the national abuse hotline have increased by % during the lockdown. a similar spike in the numbers of domestic abuse cases is noticed in other countries including china, spain, and india. this shows how global this problem is, and these reports do not even take into account the actual numbers as many instances of domestic violence remain unreported. domestic violence can lead to loss of lives for some; for the survivors, it could cause physical injuries, anxiety, and distress. women can be psychologically scarred due to increased domestic violence and household responsibilities; this could jeopardize their confidence or psychological set-up to succeed or progress in their professional endeavors. due to the aforementioned reasons, this pandemic might reverse the gains we have made in respect of women's economic empowerment. international trade can serve as a tool to minimize this damage, as it can create more economic opportunities for women. it can also be used to deconstruct or minimize the formidable barriers (in the form of domestic laws, policies, practices, and perceptions) that impede women's participation in the economies. as discussed in the following section, international trade instruments can play an instrumental role in guiding countries on conducting trade in a manner that can lead to equal benefits and opportunities for women and men. the pandemic has forced governments to take unprecedented measures to protect human health and lives. some of these measures have caused an unavoidable decline in trade of goods and services, leading to painful suffering for the global economy. the increasing protectionism and nationalism seems to be reversing the trend of economic globalization. in these testing times, international trade is emerging as a 'necessary evil. ' some scholars in the past have shed light on its 'evil' effects because in addition to the rapid transmission of virus to different countries partly aggravated due to globalization, trade has fostered interdependence among countries even for essential products such as food items, drugs, medical equipments, and clothing. this interdependence becomes an acute problem when countries increase their restrictions on trade as a response to crisis-like situations such as a health pandemic. does this mean that countries postpandemic might not remain as open to trade as they were before the pandemic in order to be more self-sufficient? the answer seems to be a 'no,' as although trade flows might reduce for a period of time, trade is 'necessary' because no country-powerful, developed, or developing-has resources to produce everything it needs. nevertheless, countries might want to revisit the way and the extent to which they trade and how this trade might be regulated in the future. this crisis presents a unique opportunity for countries to explore how trade policies can contribute in 'building back better' and in an inclusive manner in the post-covid- world. inclusive growth is the cornerstone for sustainable development. foreign trade needs to be sustainable to ensure that countries can harmonize trade liberalization with their important national interests. it needs to be inclusive so as to better include and benefit marginalized players. a recent study has found that if women play an equal role in labor markets to that of men, the global gdp will increase by % in . these numbers may not hold in the post-covid- world, but they certainly make inclusive trade a compelling business case for the post-pandemic economic recovery. encouraging women participation in trade and commerce has a two-fold benefit. on one hand, increased participation of female workforce can lead to faster economic recovery for the world; on the other hand, it could help minimize the extent of economic and social harm women might have suffered during this pandemic. multiple interventions are required to undo the harm, and international trade could arguably be one of the required and effective interventions in this respect. women's economic empowerment and international trade share an intricate and complex relationship as the former could be enhanced through an effective regulation of the latter. this is not a new realization. one of the first acknowledgments of the interrelationship between gender and commerce can be traced back to the treaty on the functioning of the european union. moreover, the addis ababa agenda of action and the un's agenda for sustainable development recognize foreign trade as an important instrument to reach development objectives including gender equality. the addis ababa agenda of action builds a clear nexus between international trade and gender. it reads as follows: 'recognizing the critical role of women as producers and traders, we will address their specific challenges in order to facilitate women's equal and active participation in domestic, regional and international trade. ' the sustainable development goals also directly address the need to achieve full and effective participation of women for furthering economic growth and sustainable development. almost % of the wto membership, reaffirms that 'international trade and investment are engines of economic growth for both developing and developed countries, and that improving women's access to opportunities and removing barriers to their participation in national and international economies contributes to sustainable economic development. ' the following section explores this relationship further, as it provides a discussion on how ftas can enhance women empowerment and hence help with rebooting the economy in an inclusive manner in the post-pandemic world. examples and the road ahead ftas can play an important role in reducing gender inequality. through ftas, countries can encourage their trade partners to create laws and procedures that can eliminate or reduce the barriers that impede women's participation in trade. this can be seen as a 'top-down' approach to deal with gender inequality at the domestic levels. certain countries (such as canada) are emerging champions of this approach, as they have offered their market access to other countries through negotiating some of the world's most gender-responsive trade agreements so far. ftas create different outcomes and opportunities for women and men. some argue that trade agreements can exacerbate existing gender inequalities. it can put livelihoods and employment of women at risk. trade liberalization can disrupt economic sectors where women are most active, thereby depriving them of employment and business opportunities. it can increase gender wage gaps and create poorer working conditions for women in developing countries. scholarship, on the other hand, observes that trade agreements can translate into more job opportunities and better business connections for enhanced market access for women. mainstream economics' literature notes that there is a positive correlation between the increase in production for exports in developing countries and the increase in levels of female employment in various sectors including manufacturing. these observations show that the scholarship is divided on how trade agreements can impact gender equality; moreover, we need sex-disaggregated data to understand the impact the existing agreements have had on men and women in different sectors of different countries and regions. however, in the meantime, it is crucial to promote gender mainstreaming in trade agreements to ensure that these agreements do not perpetuate gender inequalities as they are put back to operation in the post-covid- world. mainstreaming gender in ftas entails the inclusion of gender equality considerations in the drafting and implementation of ftas. the process of gender mainstreaming affirms a party's commitment, understanding, and political will to reduce gender inequality through trade policies and instruments. the process also aims to maximize the positive impact and minimize the negative impact of trade agreements on women's empowerment. in the recent years, we have witnessed a sharp increase in the number of ftas mainstreaming gender considerations. gender equality is gradually emerging as a policy norm in trade agreements. out of ftas currently in force, almost have at least one gender-explicit provision. the last three years have been phenomenal in this respect. in , two ftas were enforced with a dedicated chapter on gender. the european parliament in passed a resolution to include gender equality consideration in all future eu trade agreements. by doing this, the eu has committed itself to ensuring that trade-related aspects of gender are adequately addressed in its future trade agreements. these developments affirm that neither international trade nor gender equality is a zero-sum game. everyone benefits from making trade fair and inclusive. the following subsection takes a look at some examples that further clarify how existing trade agreements may serve to strengthen women empowerment in the post-pandemic world. more and more countries are including gender considerations in their trade agreements, albeit in very different ways. some ftas have a whole chapter on gender, but no legal obligations. some ftas have a single provision, but that single provision creates a strong legal obligation related to gender equality or nondiscrimination based on sex. several agreements include these provisions in their main text ; others load them in a side agreement or an annex or a protocol. in some agreements, all we find are general statements where parties acknowledge the importance of inclusive trade and the role of women in trade and commerce. in other agreements, we find reaffirming provisions, wherein parties reaffirm their commitments made under other international instruments such as convention on the elimination of all forms of discrimination against women (cedaw) or international labor organization conventions. however, one thing is common: almost in every agreement, implementing gender-related commitments is left to the parties' willingness and available resources. at one end of the spectrum, we have agreements that merely show the parties' awareness in this respect as they acknowledge the importance of gender concerns as a social value amongst other noneconomic concerns. for example, article . of chile-vietnam fta mentions gender equality as one of the issues for cooperation and capacity building. a relatively more gender-responsive agreement is the cotonou agreement, which explicitly acknowledges the importance of gender equality for economic development of the region. the chile-uruguay and chile-canada agreements take a step further. in addition to acknowledging the importance of gender issues for economic development and international trade, they provide a list of cooperation activities and institutional mechanisms that can enable parties to carry out trade in a gender-sensitive manner. at the other end of the spectrum, we have the canada-israel fta which is perhaps the most advanced fta in this respect. in canada-israel fta, parties make explicit affirmations to work on gender issues and reaffirmations to implement the commitment they have undertaken under other international instruments such as the cedaw. what makes this agreement unique in this respect is the possibility parties have to enforce these commitments, as it is perhaps the only fta which explicitly subjects gender-related provisions to the agreement's dispute settlement mechanism with a binding (but not compulsory) jurisdiction. the parties in this fta commit themselves to various activities directly related to women empowerment, and these activities envisage women not merely as an employee or labor but also as an entrepreneur, leader, decision-maker, and scientist. the cooperation activities also focus on enhancing education or skill development opportunities in the fields that can translate to high-paid job opportunities for women (such as stem and ict focused education). in this respect, this fta is more of an exception, as most ftas that make a mention of education or skill development opportunities for women limit these opportunities to fields that have traditionally been reserved for women (such as farming, handicraft, textile, and fisheries). as discussed earlier, the pandemic has made women more time-poor as it has drowned them in increased household responsibilities, taking them further away from the possibility of availing educational opportunities they might have otherwise availed. the physically locked-down academic institutions have worsened this situation particularly for those women that have no or insufficient technological abilities to seek online education due to the existing digital gap between men and women. women's access to education is a crucial commitment that policymakers may consider to better prepare their agreements to work for women in the post-covid- world. efforts directed at women's access to education should also include increasing their access to technology and internet, which is crucial to reconnect women back to the economy and help them reap the benefits of trade digitization. another remarkable development in this respect is the recent african continental free trade agreement. in its preamble, the agreement recognizes the importance of gender equality for international trade and development. including gender equality considerations in the preamble is an effective way of mainstreaming gender perspective in trade agreements, as it can be instrumental in determining the intentions of the negotiators or drafters of the agreement at the time when it was concluded. article of the agreement outlines gender equality as one of the general objectives of the agreement, frontloading gender concerns even further in the agreement. in article , parties commit to mobilizing resources to improve the export capacity of women entrepreneurs and women-owned smes. this provision is a best practice example, as identifying or mobilizing funds for gender-related commitments is fundamental for their implementation. identification of funding options alongside these commitments can bring such promises a step closer to their implementation. in the absence of finance made available for this purpose, the resource-constrained pandemic-hit countries may not have sufficient resources to invest in the women-favoring promises they might have made in trade instruments. the eu-central america is another accord that provides a best practice example for future trade negotiations for two reasons. first, it gives particular attention to initiating programs that could address violence against women. this is a unique provision, not found commonly in other agreements. with increased cases of violence against women during the pandemic, policymakers in future trade negotiations could trigger their trade partners' commitment to work on this issue. second, the parties in this agreement commit to improving women's maternal health and address other health priority areas such as sexual and reproductive health and the care for and prevention of sexually transmitted diseases and unwanted pregnancies. insufficient protection of health requirements such as maternity needs, childcare, and prevention of unwanted pregnancy have been an impediment to women empowerment even before the onset of this pandemic. the pandemic has exacerbated these preexisting concerns, as medical services worldwide are now focused on tackling the virus-inflicted patients and patients with nonurgent issues are reluctant or even fearful to approach the medical establishments. this can lead to complications in birth and higher rates of unwanted pregnancy. hence, covid- has reduced women's access to crucial health services. to top it all, women that work in informal sectors mainly in developing countries are putting their lives at risk as they still have to venture out in search for their livelihood. a focus on access to health services is therefore crucial in the future trade negotiations to undo the repercussions this pandemic might have on women's access to health services. the discussion brings to light a number of ways in which the existing ftas can help connect more women to the economy in the post-covid- world. the cooperationbased provisions in canada-israel, for example, have shown how countries can encourage their trade partners to create laws and procedures that can reduce barriers that women face such as lack of access to finance, business opportunities, and technology. discussion on eu-central america has shown how parties can endeavor to increase women's access to health services and reduce or eliminate violence against women. canada-chile is a leading example where parties have shown how ftas can include commitments on increasing women's access to education and skill development. parties in this agreement also seek to create encouraging conditions for women entrepreneurs; such a commitment if put to action might help women revive their businesses post pandemic, for example, by pushing for the creation of business networks and improved infrastructure in relevant sectors and industries. however, to ensure that these promises are put to action, it is crucial to ensure implementation of these provisions. the following section provides some observations on how policymakers can plan the road ahead to ensure that the gender-responsive provisions are indeed put to action. as discussed in the previous section, a number of agreements mainstream gender considerations in their own unique ways; however almost no fta so far contemplates how gender-related commitments could be implemented, financed, or enforced. for the implementation of gender-related commitments, countries in their future ftas need to create dedicated procedures and institutions that can put their long list of commitments into action. ftas need to spell-out the functions of the institutions, milestones and objectives they are expected to achieve, and a timeline by which to achieve these milestones. the most important in this regard is to provide for funding arrangements to finance gender-related activities if we genuinely intend these commitments to be put into action. as of today, even the most advanced ftas in gender concerns such as the ones signed between canada and chile or canada and israel do not clarify precise procedures or identify channels to finance these activities. moreover, almost all ftas have explicitly and unambiguously excluded gender-related provisions and chapters from the application of their dispute settlement machineries. in the absence of applicable dispute settlement procedures, enforcement of genderrelated commitments remains a distant reality. this implies that a country's failure to comply with these obligations or commitments or affirmations has no direct consequence. the only exception is the canada-israel fta that provides (for the very first time) a binding dispute settlement procedure that is applicable to its chapter on trade and gender. unfortunately, this also seems to be a cosmetic attempt to provide for an enforcement mechanism as the parties have subjected the binding jurisdiction of this mechanism to their consent, making its jurisdiction noncompulsory in nature. future trade agreements should consider going a step further by subjecting gender provisions to binding and compulsory dispute settlement provisions. parties could subject gender provisions either to the agreement's dispute settlement chapter or create a specialized mechanism to enforce gender-related commitments. this recommendation should be considered with a word of caution. while gender-related provisions need to be enforceable, their enforcement often requires deep societal changes and long-term cooperation between different stakeholders. ensuring enforcement through dispute settlement provisions may be a top-down approach to trigger societal changes; however, the long-term solution to the problem of gender inequality lies in changing the domestic laws, cultures, beliefs, and stereotypes in a given community. another way to drastically increase the gender-responsiveness of ftas is by negotiating a gender-specific exception. countries have in the past included or incorporated by reference the gatt-like exceptions in their ftas for the protection of public morals, human health or animal life or environment. in the same manner, a new exception for gender can be designed and employed by ftas in the future. no such exception exists to date in ftas. countries may hesitate to employ such an exception as it could enable other countries to enact new rules and regulations which could pose as a barrier to trade. it could also enable countries to violate the provisions of the given fta under the justification of gender exception. this hesitation is understandable, but it is not justifiable. if countries can allow fta-inconsistent practices and laws to operate if they are important to protect their public morals, or animal health or life, or even plant health or life, how can countries oppose an exception that can reduce gender inequality and include humankind's half population in the journey towards economic growth and development? are gender considerations and removal of barriers women face any less important than the conservation of exhaustible natural resources (such as sea-turtles) or protection of public morals (including religious beliefs)? the answer seems to be a categorical 'no. ' a gender exception could allow a party to pursue an otherwise fta-inconsistent measure if it is necessary to protect or empower female entrepreneurs or employees. in this uncertain environment, more governments than ever may be looking to extend various support measures mainly to those industries that are most severely hit by the pandemic. the proposed exception can allow countries to provide such favorable support for domestic industries that particularly impact women employees and entrepreneurs in the form of state-aid, government bail-outs, loans, or subsidies. for a temporary period of time post this pandemic, countries may also consider crafting women-favoring government procurement measures. according to the international trade centre, only one percent of the global government procurement market is currently offered to women-owned businesses. adoption of gender-responsive government procurement initiatives may help in increasing the participation of womenowned enterprises in the bidding process, which, in turn, could help in reviving the women-owned smes that might have had to scale down or face closures during the pandemic. in addition, countries may consider mandating or encouraging several industries to employ supplier diversity programs through these programs, they can obligate or somehow incentivize their multinational companies to make a percentage amount of their purchases from marginalized vendors such as women entrepreneurs. these are a few examples to show how a gender exception may allow countries to take a measure that might otherwise entail inconsistency with other obligations of an agreement. alternatively, it may be possible to invoke public morality exception to protect the economic interests of women stakeholders. this seems to be a very ambitious interpretation of gatt article xx (a), and there is no jurisprudence which supports such an interpretation. however, we can find some support in favor of such an interpretation in the existing jurisprudence. in us-gambling, the panel found that the term 'public morality' denotes standards of good and bad conduct on the part of or on behalf of a community or nation and that the meaning of this concept for members may vary over time and space, depending on various factors, including prevailing social, cultural, ethical, and religious values. the panel also stated that members should be given certain freedom to define and apply the concepts of 'public morality' in their respective territories, in accordance with their own systems and scales of values. in ec-seals, the appellate body found that the term 'to protect' when used in relation to 'public morals' did not require the panel to identify the existence of a risk to eu public moral concerns regarding seal welfare. in light of these interpretations, a country could argue that the protection of women's business and employment prospects in a particular industry that might have been severely hit by the pandemic is a public moral concern for its nation. the defending country could argue that this concern amidst the pandemic amounts to a clear legitimate objective, provided the 'design, architecture, and revealing structure' of the measure reflects a genuine public moral concern in this respect. the discussions in this section show that there is a half-opened door in ftas that countries need to push upon further by finding different ways of implementing or enforcing their gender-related commitments. moreover, due to the covid- triggered wave of protectionism, the operation of ftas might be significantly hindered. lesser exports and imports between canada and israel, for example, would mean that canada-israel fta would result in less business and employment opportunities for both men and women in their respective economies. it would also mean that companies may not have the funds to engage in gender-responsive corporate social responsibilities encouraged in this agreement. also, public authorities may not invest the required resources and time in expanding the promised access to education and skill development and creation of business networks for women in business as countries during and in the post-covid- world would have shifted priorities of saving human lives and their country's economy. the issue of gender equality could take a back seat in the minds of many policymakers. this intervention seeks to reiterate the role trade policymakers and negotiators can play in rebooting an inclusive economy in the post-covid- world by connecting more women to the global economy. populism and nationalism have made themselves obvious during covid- crisis. wild enthusiasm against international trade, including by pioneers of trade such as the eu member states and canada, is unprecedented. majority of wto members have imposed export restrictions. the good news is that all restrictions so far are imposed with an expiration date. however, this expiration date could be revised, depending upon how the pandemic unfolds in the future. on a positive note, the wto economists have projected that if the pandemic is brought under control relatively soon and the right policies are in place, trade and output could revive to their pre-pandemic trajectory by as early as . the fast-approaching economic recession, disruption in international trade, changing supply and demand patterns, and the social distancing mode can jeopardize jobs and business opportunities for many. women are positioned to bear a disproportionate burden of this pandemic, in terms of health, employment, business, consumption, and social protection. the limited gains made in the past decades in respect of achieving gender equality are at the risk of being rolled back as the pandemic is deepening the preexisting inequalities. ftas may play an important role in minimizing this loss, as they can help restart the economy in the post-covid- world. ftas can provide the architecture for sustainable and inclusive economic growth. through gender mainstreaming, ftas can help in reducing the formidable barriers that impede women's participation in the economy. they can encourage countries to carry out ex-post and ex-ante gender impact assessments of trade agreements that they are party to. countries can bind themselves to certain minimum legal standards for improving the employment conditions for women or prohibiting sex-based discrimination. countries can also endeavor to increase women's access to health services, education, and skill development. they can also create encouraging conditions for women businesses to flourish, for example, by the creation of business networks and improved infrastructure in relevant sectors and industries. countries in ftas could also commit to increasing the representation of women in decision-making and policymaking roles. the base line is: countries can use trade agreements as laboratories where they can experiment with different legal provisions and commitments regarding gender equality. the wto also has an important role to play. with members and observers, wto can play an instrumental role in preparing a framework for the regulation of inclusive and sustainable trade. the wto can encourage its members to remove the export restrictions as promptly as possible. this would allow the trade volumes to go up again, having a trickle-down impact on employment, businesses, and the overall global economy. the trade and gender focal point can play a role in encouraging more research in this area and gathering different stakeholders for future discussions on inclusive economic growth. moreover, the wto trade outlook may also conduct research on the gendered impact of covid- , that is, the extent to which this pandemic might roll-back the progress made in gender equality and the loss of employment and business opportunities to women. in this manner, the wto could regain relevance as a forum to redesign and reshape economic and trade cooperation during/after the crisis caused by the pandemic. before this crisis is over, policymakers and international organizations should work together and prepare action plans for repairing the harm. governments, international organizations, and policymakers need to be aware of the loss it could cause to women as employees, employers, and consumers. the world economy will suffer even more if women-who account for one half of the world's working-age population-are further excluded from the economy and hence impeded from contributing to economic growth and economic recovery post-covid- recovery. women will be the hardest hit by this pandemic; however, they will also form the backbone of the economic recovery in almost every country. hence, future trade policy response must recognize this and include women at the heart of the covid- response. placing women at the center of economies will lead to a more rapid recovery; this recovery will put us back on track to achieve the sustainable development goals. empirical research finds that due to covid- , more than half of smes now already face severe losses in revenues, with many having only a few months smes and the credit crunch: current financing difficulties, policy measures and a review of literature small and medium enterprises and global risks: evidence from manufacturing smes in turkey temporary export ban on certain personal protective equipment amendments introduced to the export policy of active pharmaceutical ingredients (apis) and formulations made from these apis temporary restrictions on the non-commercial export of personal protective equipment and sanitizer products temporary decrease of import tariffs on certain products, for example, medical supplies, raw materials, agricultural products, meat [the general office of the ministry of commerce issued the circular on actively expanding imports to combat against novel coronavirus epidemic temporary elimination of import certification requirements on imports of onions and garlic [permanent delegation of indonesia to the wto ( april ) and ministry of trade regulation no temporary export ban on certain dried leguminous vegetables tackling covid- together: the trade policy dimension' , global trade alert filling the gap: how technology enables access to finance for small-and medium-sized enterprises see note ) [the authors explain how natural disasters and global recessions can impact smes, with a special focus on smes in turkey.] 'global employment trends : the risk of a jobless recovery', international labour organization economic restructuring, gender and the allocation of time discussion on gross distribution of unpaid care work between and men discussed in eclac recasting women in the global economy: internationalization and changing definitions of gender infographic: the shadow pandemic-violence against women and girls and covid- ', un women coronavirus: i'm in lockdown with my abuser', bbc news a new covid- crisis: domestic abuse rises worldwide covid- : a gender lens violence against women (vaw) in the context of covid- : lessons and tools for latin america and the caribbean' , idb buenos aires joint declaration on trade and women's economic empowerment' (wto ministerial conference domestic laws and policies also have an important role to play in this respect; however this discussion remains outside the scope of this article. for more information on programs and policies countries have initiated as a response to covid- , see 'policy brief: the impact of covid- on women measuring the gender-responsiveness of free trade agreements: using a self-evaluation maturity framework top-down' approach in this respect could be seen as an approach that uses international trade instruments to trigger changes at the domestic levels see bahri (note ) north-south trade and female labour in manufacturing: an asymmetry trade policies in developed countries employment responses to international liberalization in chile gender justice in trade policy -the gender effects of economic partnership agreements global defeminization? industrial upgrading, occupational segmentation and manufacturing employment in middle-income countries', schwartz center for economic policy analysis working paper gender justice in trade policy' (see note ) an examination of the gendered effects of trade liberalisation for the case of north america, see philip sauvé and hosny zoabi, 'international trade, the gender wage gap and female labor force participation increased employment for women in pakistan discussed in asma hyder and jere r behrman, 'international trade openness and gender gaps in pakistani labor force participation rates over years north-south trade and female labour in manufacturing: an asymmetry trade liberalisation and the feminisation of poverty: the mauritian scenario', ( ) agenda: empowering women for gender equity the eu's trade policy: from gender-blind to gender-sensitive?', directorate for external policies, european parliament gender-related provisions in regional trade agreements' , wto economic research and statistics division modernized canada-chile free trade agreement (ccfta) (enforced modernized canada-israel free trade agreement (cifta) (enforced eca policy brief spotlights women's wellbeing and health care systems amidst covid- pandemic some examples of these provisions in the agreement are the following: 'access to, and ownership of, economic resources' (art . ); 'promoting financial inclusion for women, including financial training, access to finance, and financial assistance' (art . (b)); 'promoting female entrepreneurship and women's participation in international trade articles n bis- (d), (e), (g) article . . 'mainstreaming gender in free trade agreements' (international trade centre usmca, article . is one example of such a provision proposal mentioned in 'mainstreaming gender in free trade agreements members may need to assess this proposal's compatibility with the wto agreement on government procurement if they are party to this plurilateral agreement supplier diversity programs can allow multinational companies to make a percentage amount of their purchases from marginalized vendors such as women entrepreneurs. for an example of walmart us and the supplier diversity initiative it has employed, see deborah abrams kaplan marrakesh agreement establishing the world trade organization united states-measures affecting the cross-border supply of gambling and betting services, wt/ds /r, adopted european communities-measures prohibiting the importation and marketing of seal products countries can the unctad's toolbox on trade and gender for conducting these assessments. more details at unctad, 'unctad trade and gender tool box world trade organization key: cord- -pjrutidu authors: funk, kendall d. title: local responses to a global pandemic: women mayors lead the way date: - - journal: nan doi: . /s x sha: doc_id: cord_uid: pjrutidu even before the novel coronavirus, covid- , was declared a pandemic, prominent women mayors in the united states enacted proactive and innovative policies to prevent local outbreaks and soften the social and economic repercussions. several black women mayors, in particular, have led the way in local pandemic response efforts. this article identifies four major features of these and other women mayors’ early responses. first, women mayors demonstrated proactive leadership even when faced with pushback. second, these mayors advocated for transparent and evidence-based decision-making at all levels of government. third, they enacted measures to protect vulnerable communities and reduce disparities. fourth, they actively shared advice on best practices and lessons learned, and provided examples for other local leaders to follow. the article concludes by situating these responses in the larger research on gender and leadership and asks whether these women's actions are unique or part of a systematic trend of gendered responses to the pandemic. w hen the world health organization declared covid- a pandemic in march , the u.s. federal government did little to stymie the virus's spread. several subnational governments, however, responded quickly. among those leading the way in response efforts are women mayors (dittmar ) . several black women mayors in particular, including san francisco mayor london breed, chicago mayor lori lightfoot, and atlanta mayor keisha lance bottoms, have demonstrated remarkable leadership and ingenuity. these women mayors and others have not only provided leadership for their cities but also serve as role models for other leaders. this article uses hypothesis-generating case studies (levy ) of democratic women mayors of large u.s. cities to theorize about potential systematic gendered responses to the pandemic. while these women may represent "extreme" cases (seawright and gerring ) given the underrepresentation of women, especially women of color, among u.s. mayors, the final section offers theoretical reasons why other women mayors may produce similar responses to the women featured here. a focus on local governments is prudent as governors continue to reopen states and public health experts warn that local hotspots will emerge. elected mayors and other local officials can implement policies to prevent local outbreaks and soften the pandemic's social and economic fallout. examining mayors' early responses to covid- can provide an indication of how local leaders mightor shouldrespond in the future and whether mayors' gender might affect their responses. four major features stand out among these women mayors' responses. first, they demonstrated proactive leadership by quickly implementing preventive measures even as they received pushback from various stakeholders. second, their decisions were transparent, evidence-based, and effectively communicated to the public. third, they sought to not only prevent outbreaks but also protect vulnerable communities and reduce disparities. fourth, they were generous in sharing best practices and lessons learned, providing models for others to emulate. in an interview with glamour, san francisco mayor breed said that she realized the seriousness of covid- in january (kahn ) . following her realization, breed acted quickly. she declared a state of emergency before a single case had been confirmed in san francisco. she banned large gatherings in early march, effectively ending major sporting events. shortly thereafter, she issued a citywide shelter-in-place order. breed's early actions were criticized as overreaching and alarmist (kahn ), but her swift actions undoubtedly prevented many deaths (berman ) . chicago mayor lightfoot and atlanta mayor bottoms echoed breed's impulse for action. in the same interview with glamour, lightfoot admonished, "i'm a black woman in america. nobody's coming to rescue me. i've got to get it for myself, and i feel the same way with what we need to do here in our city." bottoms urged, "we've got to be prepared for this regardless of what the federal preparations and the state preparations will be" (kahn ) . these women mayors are not the only ones who responded proactively when federal and state responses seemed inadequate. women mayors in arizona, including tucson's regina romero, phoenix's kate gallego, and flagstaff's coral evans, implemented preventive measures weeks before arizona's governor issued a statewide stay-at-home order. these mayors then pushed back against governor doug ducey's order for being too lax (hassan ) ; ducey responded with an executive order prohibiting local governments from closing businesses he deemed essential. women mayors have also advocated for transparent, evidence-based decision-making. when seattle became an early epicenter in the united states, mayor jenny durkan was transparent with her constituents. she reasoned, "people are scared, confused, and getting mixed messages from the national and local level. i think people will trust their local leaders. you have to be transparent about the seriousness of the situation" (bloomberg harvard ). while the majority of the country was proceeding with business as usual, durkan restricted large gatherings and engaged seattle's research community to ramp up testing and epidemiological modeling (durkan ) . in arizona, when the statewide stay-at-home order was set to expire, mayors romero, gallego, and evans issued a statement urging the governor to follow all centers for disease control and prevention guidelines and to present clear data showing a decline in cases before reopening the state. even more recently, mayor latoya cantrell stated that new orleans would not enter phase of reopening along with the rest of louisiana. cantrell explained her decision, stating, "we are watching the data, not the date. we don't yet have sufficient data to authorize opening up further at this point. all of our decisions must be grounded in science" (city of new orleans mayor's office ). women mayors have also expressed concerns over how the pandemic will affect vulnerable communities and exacerbate existing inequalities. atlanta local responses to a global pandemic mayor bottoms asked herself, "who is going to be the most vulnerable? what will their needs be?" (kahn ) . these are questions that other women mayors seem to be askingand answeringas well. in a letter to congressional leaders, the african american mayors association warned that the pandemic will produce racial disparities (owens ) . this warning became a reality in chicago, where black residents make up a disproportionate share of covid- cases and deaths (wetli ) . mayor lightfoot deemed these disparities "unacceptable" (wetli ) and responded by adapting public transit, requiring health care providers to report demographic data with covid- testing, and deploying a racial equity rapid response team. in similar fashion, tucson mayor romero established the somos uno resilience fund to provide resources to members of the latinx community regardless of their immigration status (arce ). securing food and shelter for vulnerable communities and child care for essential workers was also integrated into their response plans. breed and durkan quickly issued moratoriums on evictions (berman ; durkan ). breed increased shelter capacity to facilitate social distancing among san francisco's homeless population (berman ) . durkan, along with bottoms and cantrell, initiated programs to address food insecurity (dittmar ; kahn ). durkan, breed, and lightfoot also launched child care programs for essential workers (dittmar ; kahn ) . early innovators, notably durkan and breed, have been generous in sharing their best practices and lessons learned. after managing seattle's early outbreaks, durkan wrote an op-ed for the washington post advising other mayors to act quickly, be transparent and honest, engage their research community, and anticipate outbreaks in vulnerable communities (durkan ) . breed, meanwhile, shared her policies and resources with other cities, explaining, "as soon as someone asks, we send it. we're here to help" (kahn ) . cities nationwide have replicated breed's innovative policies, from her rigorous shelter-in-place order to the fee cap on delivery services. atlanta mayor bottoms confirms she watched breed and reproduced breed's stay-at-home order "almost word for word" (kahn ) . indeed, these women mayors have produced national models of effective pandemic responses. among the first cities listed in the u.s. conference of mayors' "city guidelines and best practices" for covid- are san francisco, seattle, chicago, and atlanta. are these women anomalies or part of a systematic trend? while not all women mayors have demonstrated praiseworthy leadership -las vegas mayor carolyn goodman, for example, offered up her city as a "control group"there are several reasons why other women mayors might act similarly to the ones highlighted here. research finds that women tend to be more risk averse (byrnes, miller, and schafer ) and supportive of government intervention (schlesinger and heldman ) , and they prioritize social policy to a greater extent than men (barnes, beall, and holman ; funk and philips ) . if women hesitate to risk overrunning hospitals, prioritize health care over economic interests, and view government intervention favorably, then these characteristics might help explain women mayors' proactive shutdown decisions. there is also evidence that women mayors increase municipal transparency (araujo and tejedo-romero ) , and at least two reasons why they may support evidence-based health care policies. first, women politicians are more likely to have experience in the health care sector, and this can factor into their policy decisions (barnes, beall, and holman ) . second, women are more likely to acknowledge limitations in their qualifications (fox and lawless ) and thus may be more likely to seek outside expertise to inform their decisions. women's greater emphasis on social issues (barnes, beall, and holman ; funk and philips ) might also explain why these mayors' response plans included social protections. and, insights from research on policy diffusion (einstein, glick, and palmer ) and political role models (stokes-brown and dolan ) suggests women mayors may look to one another for guidance. thus, other women mayors may model their pandemic responses after these innovative leaders. finally, we must also acknowledge the role of intersectionality, especially the way partisanship and race factor into women mayors' . available at https://www.usmayors.org/issues/covid- / (accessed july , ). . carolyn goodman, interview with anderson cooper on cnn, april , , https://www.cnn.com/ videos/politics/ / / /las-vegas-control-group-coronavirus-mayor-goodman-vpx.cnn (accessed august , ). responses. partisanship is major determinant of covid- responses in the united states (adolph et al. ) , and the responses of non-democratic women mayors have been notably less commendable than their democratic counterparts. the women featured in this article are also trailblazersoften the first black woman or lesbian woman to be elected mayor. the responses of black women politicians, in particular, might be unique given their hypervisibility, progressiveness, and prioritization of "intersectionally marginalized populations" (brown and banks ) . thus, it is incumbent on future research to determine whether other women of color, white women, and conservative women leaders across contexts have also responded in proactive, transparent, evidence-based, and socially minded ways or whether these women mayors are truly anomalies. kendall d. funk is an assistant professor of political science in the school of social and behavioral sciences at arizona state university. her research focuses on women's political representation, especially in local governments: kendall.funk@asu.edu pandemic politics: timing state-level social distancing responses to covid- does gender equality affect municipal transparency: the case of spain mayors of tucson, los angeles urge federal government for more help for latinos pink-collar representation and budgetary outcomes in us states the city that has flattened the coronavirus curve q&a with seattle mayor jenny durkan: on the front lines since january, seattle mayor shares her take on responding to an outbreak black women's agenda setting in the maryland state legislature gender differences in risk taking: a meta-analysis orleans parish monitoring data closely, will remain under 'phase one' guidelines beyond women on the front lines in cities' fights against covid- what every mayor needs to know about this virus city learning: evidence of policy information diffusion from a survey of us mayors gendered perceptions and political candidacies: a central barrier to women's equality in electoral politics representative budgeting: women mayors and the composition of spending in local governments arizona mayors slam covid- stay-at-home order that allows hair salons, golf courses to remain open the women leading the coronavirus response from city hall case studies: types, designs, and logics of inference black mayors warn covid- could hit our communities especially hard gender gap or gender gaps? new perspectives on support for government action and policies case selection techniques in case study research race, gender, and symbolic representation: african american female candidates as mobilizing agents lightfoot activates rapid response team to stem 'unacceptable' racial disparity in covid- deaths key: cord- -er lvhn authors: farewell, charlotte v.; jewell, jennifer; walls, jessica; leiferman, jenn a. title: a mixed-methods pilot study of perinatal risk and resilience during covid- date: - - journal: j prim care community health doi: . / sha: doc_id: cord_uid: er lvhn introduction/objectives: national guidelines underscore the need for improvement in the detection and treatment of mood disorders in the perinatal period. exposure to disasters can amplify perinatal mood disorders and even have intergenerational impacts. the primary aim of this pilot study was to use mixed-methods to better understand the mental health and well-being effects of the coronavirus disease (covid- ) pandemic, as well as sources of resilience, among women during the perinatal period. methods: the study team used a simultaneous exploratory mixed-methods design to investigate the primary objective. thirty-one pregnant and postpartum women participated in phone interviews and were invited to complete an online survey which included validated mental health and well-being measures. results: approximately % of the sample reported high depressive symptomatology and % reported moderate or severe anxiety. forty percent of the sample reported being lonely. the primary themes related to stress were uncertainty surrounding perinatal care, exposure risk for both mother and baby, inconsistent messaging from information sources and lack of support networks. participants identified various sources of resilience, including the use of virtual communication platforms, engaging in self-care behaviors (eg, adequate sleep, physical activity, and healthy eating), partner emotional support, being outdoors, gratitude, and adhering to structures and routines. conclusions: since the onset of covid- , many pregnant and postpartum women report struggling with stress, depression, and anxiety symptomatology. findings from this pilot study begin to inform future intervention work to best support this highly vulnerable population. pregnancy and the first months postpartum (perinatal period) can be inherently challenging, often leading to lack of sleep, relationship tensions, and feelings of isolation. these challenges result in the development of mood disorders for many women. for example, the prevalence of prenatal and postpartum depression is estimated at % and %, respectively. [ ] [ ] [ ] exposure to environmental stressors, such as natural disasters, can amplify perinatal mood disorders and even have intergenerational impacts on child health and development outcomes. [ ] [ ] [ ] [ ] health care providers are often the primary source of mental health resources and care for women during the perinatal period, indicating a significant role of providers in helping to identify and manage (eg, treat/refer) perinatal mood disorders. , however, a prior study found that maternal depression is assessed in primary care settings less than % of the time, and the use of screening tools is even lower ( %- %). national guidelines underscore the need for improvement in the detection and treatment of mood disorders in the perinatal period, particularly among those vulnerable to environmental stressors. , many studies have explored the impacts of disasters, or events that cause disruption exceeding the adjustment capacity of the affected community, on mental health and have found that prenatal and postpartum women may experience significantly higher rates of mood disorders during disasters compared with the general population. , in january , the world health organization (who) declared the outbreak of a new coronavirus disease, covid- , to be a public health emergency of international concern. according to similar epidemics and pandemics, stress coupled with feelings of loneliness and anger can develop among people who are quarantined. additionally, social isolation during environmental disasters, such as covid- , may lead to decreased social connections, which can further exacerbate feelings of isolation and perinatal mood disorders. although current studies are exploring the specific impacts of covid- on population mental health, less is known about the mental health implications specifically related to perinatal mental health during covid- . additionally, better understanding of potential factors that may be protective for perinatal women during a pandemic, such as social supports and/or coping strategies is warranted. resilience in the face of disasters is likely to result from a combination of resources that foster the ability to cope well despite extraordinarily severe demands. the primary aim of this pilot study was to use mixed-methods to better understand mental health and well-being, as well as sources of resilience, for women in the perinatal period during the covid- pandemic. these findings have implications related to prenatal and postpartum health care among women exposed to disasters and large-scale traumatic events. ethical approval for this pilot study was obtained from the colorado multiple institutional review board (# - ). rolling recruitment for this study occurred between march and april using a purposive, nonprobabilistic sampling method. the targeted audience for this study included mothers who met the following criteria: ( ) over the age of years, ( ) english-speaking, ( ) currently living in colorado, and ( ) being pregnant or within the first -months postpartum. women were recruited through advertisements posted on social media outlets (eg, facebook, mom listservs). women who met the eligibility criteria and who were interested in participating in the study completed an online consent form. women were contacted by a member of the study team to schedule a time for a phone interview within hours of completing the online consent form. the study team used a simultaneous exploratory mixedmethods design to investigate the primary objective. qualitative methods. prior to the interview, participants were provided information about how the interview would be conducted. two members of the research team conducted the phone interviews (first, cvf, and last author, jal); interviews averaged minutes, ranging from to minutes. the interview protocol consisted of a semistructured tool including a combination of open-ended questions related to sources of stress, sources of support and coping, self-care and well-being, beliefs around covid risks, and impacts on care plans. example questions included, "in general, how has the covid- pandemic impacted your pregnancy experience thus far?" and "how has the pandemic changed your expectations around parenting?" participants were provided mental health resources at the conclusion of interviews. qualitative analysis. the interviewers took extensive notes throughout the phone interviews. qualitative data analysis followed best practice methods for qualitative research, including a deductive, theory-driven approach, and an inductive, data-driven approach. , one of the interviewers (first author, cvf) coded the interviews using nvivo software and constant comparison analysis. the codebook contained a priori codes that aligned with sources of stress (eg, social isolation) and resilience (eg, social supports) from the literature. inductive coding was also used to allow for discovery of unique sources of risk and resilience. a second coder (jal) reviewed all transcripts, summarized themes and subthemes and compared findings with the first coder. if disconcordance on the meaning of the codes and themes were present, a discussion occurred between the coders to reach consensus on the coding structure. quantitative methods. after completing the interview, participants were sent an electronic link to a -item online survey. the survey took approximately minutes to complete. the survey included measures of sociodemographic factors, coping behaviors, and several validated measures for mental health and well-being, including: the patient health questionnaire- (phq- ), which is a brief measure of depression with a range of to and a cutoff score of ≥ ; the generalized anxiety disorder- (gad- ) scale, which is a brief measure of anxiety with a range of to and a cutoff score of ≥ ; the brief resilience scale (brs), which measures resilience and ranges from to with higher scores indicating more resilience; the warwick-edinburgh mental wellbeing scale (wemwbs), which measures subjective well-being and ranges from to with higher scores indicating higher well-being; and the -item loneliness scale, which measures loneliness and has a cutoff of ≥ and a range of to . after completion of both the phone interview and online survey, participants were randomly selected to receive of usd gift cards. quantitative analysis. descriptive statistics were conducted to investigate the primary variables of interest in the quantitative data, including demographics, mental health and well-being measures and reported coping behaviors. thirty-one interviews were conducted and of the participants completed the online survey. approximately half of the interview participants were pregnant ( %) and half were within months postpartum ( %). fifty percent of the pregnant sample were primigravid and % of the postpartum sample had only one child. table displays sample characteristics of the participants who completed the survey and descriptives related to the primary variables of interest. approximately % of the sample reported high depressive symptomology and % reported moderate or severe anxiety symptomatology. about two-thirds of the sample ( %) reported experiencing at least moderate stress, and participants scored an average of on the well-being scale (range = - ) and an average of . on the resilience scale (range = . - . ). forty percent of the sample reported being lonely. participants reported that the most common ways they were coping included texting with friends ( %), video/phone calls with friends ( %) and sleeping ( %). the primary themes, subthemes, and illustrative quotes from the qualitative data are summarized in table . pregnant women most commonly expressed stress surrounding "unknowns" related to prenatal care appointment rules, birth plan expectations, and prenatal exposure risk. for example, one woman shared, "i anticipate the birthing experience will be quite different, and i'm just hoping the hospital i'm delivering in will allow my husband to be there. it's just not knowing what's going to happen right now." among new mothers, uncertainty and stress were related to newborn risk exposure. one mother said, "and when it comes to health, like with having a new baby, i'm not an expert and i don't know how worried i should be. i need someone to tell me . . ." lack of consistent messaging and clear guidance surrounding recommendations and care appointments from providers was a concern shared by both pregnant women and new mothers. one pregnant woman said, "i feel like we get all these mixed-messages about it." another pregnant woman said, "i mean online appointments have been fine, but i guess the healthcare system doesn't really know what they're doing, and they are trying to be nimble and they haven't let me know in advance about who i'm seeing or if i'm allowed to come in until the last minute." pregnant women reported feelings of isolation and loneliness as well as lack of postpartum support networks. women shared that being pregnant during covid- resulted in less excitement surrounding the pregnancy because of social isolation. one woman said, "it's made it definitely a more somber experience and it has been difficult to be excited because you can't share it with people." pregnant women also talked about concerns over postpartum supports. one woman shared, "well, we were counting on support from grandparents on both sides and we can't anymore." new moms frequently cited stressors related to lack of daycare and caregiver supports, and social isolation. one mother said, "it has made it a lot harder, mainly that i don't have childcare and i was planning on going back to work but now i can't." new moms shared that social isolation was significantly affecting their postpartum mental health. a mother said, "and now feeling even more isolated than normal because if we go for a walk now i use the ergobaby instead of the stroller so i can keep her covered." pregnant women and new moms shared that partner support was the primary factor that helped them cope. one new mom shared, "we [partners] are alternating like some days he's stressed and anxious and sometimes i will be. and we're like we need to get through this together." emotional support was cited as the most helpful source of support among all mothers. one mom said, "being able to connect with newer moms with similar aged babies and go around and share with everyone on zoom." all women shared that getting outdoors and being in nature was helping them cope. one pregnant woman said, "just being outside. i always go to the park and just breathe." women also said that focusing on gratitude promoted their mental health. for example, one new mom said, "feeling grateful for all this special time with my kids and to have all this intense family time." finally, women in both the prenatal and postpartum periods shared that managing expectations was protective. one pregnant woman shared, "just sort of having to adjust expectations because none of this is how we imagined pregnancy would be." among new mothers, structures and routines were cited as a factor that helped them cope. one mom said, "so completely resetting daily routines and coordinating work schedules and full-time parenting" and "staying on schedule has helped with staying mentally well too." participants shared a variety of positive impacts related to the covid- pandemic. pregnant woman said that being able to work from home allowed for more time to prioritize self-care, which improved their mental and physical health. new mothers highlighted numerous positive benefits including increased connection and bonding with their immediate family unit, partner supports in the home to share caregiving responsibilities, and increased access to remote postnatal and postpartum care. one mom said, "my husband is home full-time and that has been so helpful just to not be alone. i can really focus on her and my husband and our family time." another mother shared, i've been connected with postpartum behavioral health support and that has been virtual which is really great actually because i'm not sure how otherwise i would be able to go. in that way it has allowed me to seek those types of services more. both pregnant women and new mothers shared additional positive impacts of the covid- pandemic including not missing out on social activities and spending less money. one mom said, "i think the biggest positive is that i didn't have that feeling of missing out . . . my friends weren't posting cool things that i was missing out on," and a pregnant woman said, "we are spending less because we aren't going out." these findings highlight the additional toll of the covid- pandemic on perinatal mental health in the united states. the quantitative findings suggest that the pandemic has resulted in elevated rates of mood disorders for this sample of pregnant and postpartum women. perinatal anxiety rates were approximately six times higher in this sample compared to pre-pandemic perinatal rates in colorado. additionally, participants reported lower well-being and lower levels of resilience compared to pre-pandemic scores. the qualitative component of this study illustrated sources of stress that further explain these quantitative findings. the burden of uncertainty related to health care services and risk exposure for all women was a salient theme. harville et al similarly found that after hurricane katrina, stressors experienced by perinatal women included the interruption of health care services, clinical infrastructure and referrals and the lack of knowledge surrounding early term exposure. alternative studies found that uncertainties lead to heightened fears of contracting or transmitting infection and fears surrounding separation from the infant at birth. almost half of the sample reported feeling lonely, and this social isolation may explain the high rates of anxiety and poor well-being and resilience reported in this sample of pregnant and postpartum women. social isolation was a common theme shared by both pregnant and postpartum women in the qualitative data and align with the prevalence of loneliness reported in the sample. social distancing and isolation during disasters, coupled with lack of access to health care professionals, can lead to heightened intimate partner violence, , which can affect maternal mood disorders and adverse pregnancy and birth outcomes. additionally, lack of caregiver social supports in the postpartum period are linked to poor maternal psychological well-being. sources of resilience were identified in these data and are supported by past research that has explored resilience among perinatal women during disasters. virtual media platforms (texting, video calls), , and engaging in selfcare behaviors such as getting recommended sleep and exercise were identified as protective coping behaviors in the quantitative data. qualitative data suggested that social support, and specifically partner and emotional support, gratitude and optimism, , and the management or shifting of expectations were significant protective factors for pregnant and postpartum women, particularly during exposure to significant environmental stressors. however, the high rates of depression, anxiety, and stress identified in this sample suggest that quarantine and social isolation regulations may increase need for supports and protective coping behaviors. limitations of this pilot study include the small sample size, minimal diversity, lack of consideration of pregnancy and birth complications, and the recruitment strategy, which relied solely on social media platforms and may limit the generalizability of these findings. additionally, approximately half of the pregnant sample were pregnant with their first baby and over a third of the postpartum sample were first-time moms. mental health and associated factors may vary by primigravid and multigravida women. [ ] [ ] [ ] larger studies are needed to increase generalizability and to compare the unique experiences of stress during covid- among these different groups. however, this study may have implications for health care providers who are providing care for pregnant and postpartum women during the covid- pandemic. table displays provider recommendations to help mitigate perinatal mood disorders and promote resilience based on these preliminary findings. examples include screening all perinatal women for depression and anxiety during healthcare visits and providing positive coping behavior recommendations via hand-outs during prenatal and postpartum care visits. collectively, these data suggest that covid- has amplified the rates of perinatal mood disorders among this sample of perinatal women. • alert pregnant women to information regarding appointment rules and regulations (eg, supports) as early as possible in the pregnancy • • address uncertainty surrounding covid- and impacts on perinatal health and direct to evidence-based sources of information • • screen all prenatal and postpartum women for depression/anxiety during health care visits promote perinatal resilience and positive coping • • provide coping suggestions and recommendations in the form of hand-outs/one-pagers during prenatal and postpartum care visits. recommended topics include remote and safe ways to promote social connection, outdoors benefits, gratitude, managing expectations related to birthing/delivery, and self-care behaviors (physical activity, stress management, sleep) • • increase opportunities for social connection during prenatal and postpartum tele-health classes • • provide resources related to mental health supports and care for all prenatal and postpartum women exposure to prenatal psychobiological stress exerts programming influences on the mother and her fetus prevalence and incidence of postpartum depression among healthy mothers: a systematic review and meta-analysis a 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methods, barriers, and recommendations for practice disasters and perinatal health: a systematic review psychiatric disorders in pregnant and postpartum women in the united states timely mental health care for the novel coronavirus outbreak is urgently needed recommended psychological crisis intervention response to the novel coronavirus pneumonia outbreak in china: a model of west china hospital iranian mental health during the covid- epidemic transactional theory and research on emotions and coping simultaneous and sequential qualitative mixed method designs qualitative methods for health research. sage designing a qualitative study nvivo qualitative data analysis software validation of phq- and phq- to screen for major depression in the primary care population a brief measure for assessing generalized anxiety disorder: the gad- the brief resilience scale: assessing the ability to bounce back the warwick-dinburgh mental well-being scale (wemwbs): development and uk validation a short scale for measuring loneliness in large surveys: results from two population-based studies societal costs of untreated perinatal mood and anxiety disorders in the united states associations between social support, mental wellbeing, self-efficacy and technology use in first-time antenatal women: data from the babbles cohort study postpartum mental health after hurricane katrina: a cohort study the psychological impact of quarantine and how to reduce it: rapid review of the evidence should infants be separated from mothers with covid- ? first, do no harm the encyclopedia of child and adolescent development danger in danger: interpersonal violence during covid- quarantine a systematic review and meta-analysis of intimate partner violence during pregnancy and selected birth outcomes intimate partner violence during pregnancy and the risk for adverse infant outcomes: a systematic review and meta-analysis grandparent support of mothers caring for a child with a disability: impacts for maternal mental health disaster resilience among war-affected people resettled in northern sri lanka: challenges revisited mental health and worries of pregnant women living through disaster recovery psychological first aid: a model for disaster psychosocial support for the perinatal population social support-a protective factor for depressed perinatal women? keeping it together, keeping their heads above water": western australian child health nurses' understanding of resilience in postpartum mothers dialectical behavior therapy-based psychological intervention for woman in late pregnancy and early postpartum suffering from covid- : a case report posttraumatic growth: conceptual foundations and empirical evidence anxiety on primigravid women attending antenatal care: a hospital based cross-sectional study primigravid and multigravid women: prenatal perspectives fear of childbirth in primiparous italian pregnant women: the role of anxiety, depression, and couple adjustment we acknowledge all pregnant and postpartum women who participated in this study and shared their experiences. key: cord- -e yk a authors: lozano-medina, jessica ivonne; hervert-escobar, laura; hernandez-gress, neil title: risk profiles of financial service portfolio for women segment using machine learning algorithms date: - - journal: computational science - iccs doi: . / - - - - _ sha: doc_id: cord_uid: e yk a typically, women are scored with a lower financial risk than men. however, the understanding of variables and indicators that lead to such results, are not fully understood. furthermore, the stochastic nature of the data makes it difficult to generate a suitable profile to offer an adequate financial portfolio to the women segment. as the amount, variety, and speed of data increases, so too does the uncertainty inherent within, leading to a lack of confidence in the results. in this research, machine learning techniques are used for data analysis. in this way, faster, more accurate results are obtained than in traditional models (such as statistical models or linear programming) in addition to their scalability. in latin america and the caribbean (lac), approximately one in four are poor and one in ten cannot meet their basic food needs. the latter being especially true for children. according to the world bank [ ] , even the most equal country in lac (uruguay) is more unequal than the most unequal country of oecd (portugal). but it has been found that women have been important in the reduction of poverty across lac countries. according to the study [ ] , it was found that women made crucial contributions to extreme and moderate poverty reduction between to . growth in female income translated to % reduction in extreme poverty along with % reduction by male income. overall, female labor market income was twice as effective in reducing the severity of poverty compared to male labor market income. some benefits of the inclusion of women include: -more resiliency against poverty and better coping mechanisms during economic shocks, especially in cases of dual-income households. -increases in female labor income and labor market participation seem proportional to higher enrollment rates and a higher education (closer to men). some of those studies, have found that women tend to be more risk-adverse than men in their financial management [ ] . though there is much controversy if the difference is significant or invalid [ ] , the issue of understanding the financial attitudes of people is of interest for many institutions. such institutions include governmental organizations, who wish to increase the involvement of women in the finance industry [ ] , and also of financial institutions that wish to classify better the profiles of their clients. currently, banks manage their finance portfolio clients depending on a risk profile. these profiles are unique for every client. what this means is that every client has a different risk tolerance. that is the level at which they are still comfortable risking money, and it depends on the lifestyle, age and personality of the person. classifying these profiles correctly helps the client have decent earnings while having peace of mind [ ] . in the past, many studies have been done to determine if there are differences in risk management between genders. for example, there has been numerous studies to prove or disprove such claim [ ] . this included data gathering from experiments meant to measure that difference, and from experiments that were not meant to measure it. yet these studies prove time and again that there is truth to the claim. on the other hand, there has been previous attempts to model, the classification of woman financial habits. studies include analysis on household income census from italy [ ] , sweden [ ] and united states [ ] . the majority of these studies use linear programming techniques [ , , ] and probit models [ , ] . one of the studies has used an unsupervised machine learning technique. simms [ ] used cluster analysis to analyze women habits on financial advice and was able to identify two prominent groups. cluster analysis is useful for unlabeled data, that is instances that don't have a class assigned. and these type of techniques can benefit the study of risk profiles due to being able to create complex models, manage the amount of features and classify them with high accuracy. therefore as a means to understand the segment better, this research seeks to generate an adequate profile of women segment and explain the variables and indicators of the profile. if this model proves to be efficient identifying risk and classifying, it will provide a better understanding of the client risk profile of the target segment and a better-tailored product. this will help develop entrepreneurial woman in mexico that seek to grow their financial assets and generate a reasonable income from their investments. for the financial institution it will help to provide a better product, a safer investment, and aid in its decision-making as a better way of classifying and understanding user risk profiles. the rest of the document is organized as follows: problem definition and context are given in sect. . section presents methods and approaches used. finally sect. presents the conclusions and future work. modelling human behavior is a complicated task. some examples are the modelling market price movements [ ] , manage credit card customers [ ] , and forecasting financial risk [ ] . most of them are done with statistical and operational techniques [ ] . in finance, the modeling of the behavior of potential clients and their risk, in general, does not distinguish gender. however, analyzing the women's segment separately represents an opportunity for financial companies to expand their portfolio and contribute to gender equality. women are among the most vulnerable groups and provide much concern for governments in the world. according to the un [ ] , at least % of the women in the world have a paid wage and salary employment, which is an increase of % compared to the s. yet women earn % less than men when having the same work. therefore there is still much work to do to provide gender equality, poverty eradication and inclusive economic growth. women make enormous contributions to economy either by working in a business, on a farm, as entrepreneurs or employees, or by doing unpaid care work at home, and still there is much to do to aid women in their development. in the context of mexico, the national institute of statistics and geography (inegi) released the results of a survey that reveals the differences between being men or women in mexico [ ] . the survey contains information on population between and years old. the analysis was made for rural and urban areas and includes some topics related with habits in the expenses management. some examples are: having a savings account, having an expense record book, source of your income (foreign or national), etc. saving accounts. mexican women overall use less financial instruments such as retirement savings accounts. being the participation of % in urban areas and . % in rural areas. this result is due to they have less presence in the workforce. typically, mexicans contribute to their retirement account through contributions from their salary. this contribution is made automatically (by law) to each salaried worker. people who do not have an employer should look for ways to save for retirement. women overall did not have a saving account due to not having a job ( . %) or not knowing about the benefit ( . %). type of savings. three options were considered: formal savings (within a financial institution), informal savings and a combination of both. overall, out of mexicans have informal savings. also, out of do not have savings and about the same amount have formal savings. in urban areas, men combined informal and formal savings, while women prefer informal savings. contrary so, in rural areas, men prefer informal savings while women choose formal savings, or a combination of both. additionally, in rural areas, women have more access to formal credits than men, while in urban areas it is the opposite. national business trends. businesses in mexico can be divided in four categories: commerce ( . %), services ( . %), manufacturing ( . %) and other types of economic activities ( %). while . % of the workforce can be found in the areas of commerce and services in , the best paid jobs can be found in the areas of manufacturing with an average of , . dollars per year per worker. men have the largest presence in the areas of manufacturing, where . % of the men in the workforce can be found. while women have the largest presence in the areas of commerce, with . %. the states with the highest participation of women are the ones in south-center of the country, specifically in guerrero ( . %) and oaxaca ( . %). some problems facing companies in mexico are the insecurity ( . %), very high costs ( . %), and the unfair competition . %. mexico has a dominant type of business, named micro-businesses. they are the most common type found in all the country. they give employment to more than a third of the citizens. usually, the workforce is maximum people or less. they represent % of all businesses, contribute % of the total employed workforce and . % of the incomes. from census, it has been found that most businesses are located in the state of mexico ( . %), mexico city ( . %), puebla ( . %), jalisco ( . %), and veracruz ( %). but most of the workforce can be found in mexico city ( . %), state of mexico ( . %), jalisco ( . %), nuevo león ( . %), guanajuato ( %), veracruz ( . %), and puebla ( . %). out of people work in any of these: state of mexico, mexico city, jalisco or nuevo león. this means that places with low in number of businesses but higher workforce are those with a lower proportion of micro-businesses. so this research proposes to use this stereotype, and use it as an advantage for women in the financial industry. as their profile provide a better case study for financial portfolios. next section, we introduce the methods ans strategies used to generate the woman profile. high dimensional data is problematic due to high computational costs and memory usage. it can consist of irrelevant, misleading or redundant features that are the ones increasing the search space size. they make it harder to process the data and therefore do not contribute to the learning process [ ] . there are methods to reduce dimensionality: feature selection and feature extraction. in the former, the features that contain the information necessary to solve the problem are the only ones selected; in the latter, it consists of methods that seeks a transformation of the input space into a lower dimensional subspace that still contains most of the relevant information. both or only one of these methods can be used as a preprocessing step. the need for feature selection and extraction is due to the information of a dataset falling in either of three categories: relevant, irrelevant and redundant. by means of the method to remove the majority of irrelevant and redundant features, the objective is to create a subset with the least amount of features that still retains the most information and contributes to the learning accuracy [ ] . some advantages of feature selection [ ] include: -reduce storage requirements and increase algorithm speed. -removes redundant, irrelevant or noisy data. -improves data quality. -increases accuracy of the resulting model. -reduction of feature set and therefore faster future recollections. -improved performance in predictive accuracy. -better visualization and understanding about the dataset. there is a major difference between feature selection and feature extraction. in selection, when a dataset is complex with many relevant features, choosing only a small selection of them, means that information will be lost by the omission. whereas in feature extraction, the size of the feature space can be decreased without discarding features, but the transformation done to linearly combine them makes them harder to interpret as individual features. among these techniques, the most common and popular one is principal component analysis (pca) developed by karl pearson in . it consists of a linear transformation of data that minimizes the redundancy, which is measured by the covariance, and maximizes the information, which is measured by the variance. pca uses orthogonal transformations to convert samples of correlated variables into samples of linearly uncorrelated features [ ] . these new features are called principle components (pc) and describe the same or less amount of information. principle components are new features with two properties: -each principle component is a linear combination of the original variables. -and the principle components are uncorrelated to each other and redundant information is discarded. the principle components are ordered in terms of information gain. that is, the first principle component contains the most observed variability, and the last principle component contains the least. pca reduces the number of original features by eliminating the last principle components. the main applications of pca are data compression, image analysis, visualization, pattern recognition, regression, and time series predictions. pca also has assumptions which limits its use [ ] : -relationship between variables is linear, -variables are normalized, -and it lacks a probabilistic model structure which is important in many statistical tests. k-means. k-means is an unsupervised clustering algorithm whose objective is to assign data points into clusters, thus the overall distance between points and cluster centroids is minimized [ ] . it tries to separate samples into groups of equal variance, minimizing a criterion knows as inertia or within-cluster sum of squares [ ] . equation shows the expression k-means minimizes: one of the advantages of this algorithm is that it scales well with data size and its flexibility allows it to be applied to many different fields. the most common way to choose the number of clusters for k-means is using the elbow method. this is done by fitting k-means models for a range of consecutive numbers starting from , and plotting the total within sum of squares value for each number of clusters versus that cluster number. the elbow or turning point in the line plot, and therefore an adequate number of clusters, is where the reduction in sum of squares seems to drop off [ ] . in this section, the techniques used will be discussed. among the candidate methods for classification we used decision trees (dts) which is a non-parametric supervised learning method used for classification and regression. the goal is to create a model that predicts the value of a target variable by learning simple decision rules inferred from the data features. some advantages of decision trees are: -simple to understand and to interpret. trees can be visualised. -requires little data preparation. -the cost of using the tree (i.e., predicting data) is logarithmic in the number of data points used to train the tree. -able to handle both numerical and categorical data. the disadvantages of decision trees include: -decision-tree learners can create overfitting. -decision trees can be unstable. -the problem of learning an optimal decision tree is known to be np-complete under several aspects of optimality and even for simple concepts. -there are concepts that are hard to learn because decision trees do not express them easily, such as xor, parity or multiplexer problems. -decision tree learners create biased trees if some classes dominate. it is therefore recommended to balance the dataset prior to fitting with the decision tree. accuracy is the most used measure to assess the performance of a credit evaluation model [ ] , and was seen throughout different studies [ , ] other variations exist where the former measure was considered incomplete, such as in the study of danenas and garsvas [ ] . where the accuracy performance was represented using three different measures: -accuracy defined as the proportion of correct prediction shown in eq. . total number of instances the population of interest in this research is focused on mexican woman. then, three sets of data were used in order to define the financial profile for this segment. the first dataset is from the mexican national institute of statistics and geography (inegi). this data provide information about location and density of population in mexico. the data was generated during the population and dwellings census (iter). a locality is any settlement where a community of people live. it can range from a small number of dwellings to a large urbanized area. an example of how a locality looks like can be seen in fig. . the dataset contains information on the localities for the thirty-two states found in fig. . the original dataset contained , localities and attributes. the attributes contain demographic information of each locality. usually in the form of counts or averages. among these, attributes were chosen as relevant: - attributes related to coordinates - related to men-women ratio - related to child mortality - related to education - related to economic activity - related to civil status - related to household decisions - related to dwellings. it can consist of irrelevant, misleading or redundant features that are the ones increasing the search space size. they make it harder to process the data and therefore do not contribute to the learning process. the programming language used was python. four steps were done to tidy and prepare the dataset for the next subsection: -coercing data types into floats -transforming attributes into proportions -scaling variables -removing nulls by the end of the process, instances and attributes remained. to reduce dimensionality, pca was applied. % of the information was retained, and principle components were created. the principle components percentages can be seen in table . the weight of the variance for each principle component is of . , . , . , . , . , . , . , . , . , . , and . , respectively. clustering. to identify the best number of clusters found in the data, three different scores were used: the elbow method, the davies-bouldin score and the calinski-harabasz score. the results obtained in fig. show that four clusters was the best option overall. in the elbow method, it is were the distances start decaying; in davies-bouldin score is the lowest score; and in calinski-harabasz score is the highest value. applying the silhouette score gives us a value of . . the reduced data then is used for clustering the population. results show that the country is divided into four clusters as fig. shows: a north cluster (blue), a south cluster (red), a central cluster (cyan) and small populations clusters (yellow). by seeing them individually, such as in fig. , we can appreciate the size of each cluster without the overlapping. as such, the small populations cluster is a very big cluster, which defining characteristic is the small size of the population in the localities. and contrary to the other clusters found, this can be found all over the country. but as we are dealing with proportions, it gives very inflated values as its population size is very small. which also make the populations with very large populations have smaller proportions overall, and thus is excluded for further analysis to concentrate on the bigger localities. an interesting trend found was within the proportion of household heads found in the country found in fig. , where the proportion of household heads and the economically active population per locality are plotted. it is shown that the household authority of men grow proportionally with their economic activity. whereas the household authority of women decreases with theirs. women as mentioned in literature, are not as economically active as men, but when the economic activity of women increases the trend seems to grow positively. another trend can be seen in married people per locality and economic activity. the economic activity of men increases as the percentage of married men increases per locality. the case of of women is a bit trickier though as shown in fig. . as the economic activity of women increases, the proportion of married women per locality stays averaged approximately in %. on the other hand, the average academic grade per locality is pretty even between genders, just as mentioned in literature about lac countries. a linear regression shows that both levels are similar just as shown in fig. . decision trees. the decision tree was created using an implementation found in scikit-learn. the inputs were the attributed without pca reduction and the a training and testing set of % and %, respectively was used. the parameters used were a criterion of entropy, a max depth of and minimum samples per leaf of . the score obtained was of . . in most cases, the coordinates and altitude of the locality where used to separate the clusters. but in cases where overlapping existed between clusters, variables such as the level of education and percentage of houses with more than three rooms were the deciding factors. the north cluster has a higher level of education per locality and houses with more than three rooms than the other clusters, the center cluster has a higher proportion as well than the south cluster. we can observe localities are defined by their location, altitude, average level of education and the percentage of houses with more than three rooms. the north cluster was found to have a higher level of education and number of rooms than the center and south cluster where overlapping existed. the center cluster had as well a higher level of education and rooms than the south cluster. many trends found in literature could also be found in the data such as an even education, a smaller proportion of female household heads and some trends with economic activity and civil status between genders. the small populations cluster is another interesting result. it was the only cluster that was not defined strongly by its geography and could be found around all the country. still, the small sample size brought along many overestimated proportions and could not be used to compare against the clusters with larger localities. the results provide more knowledge on the partition of the mexican population using state-of-the-art machine learning techniques. prior studies made using census data on the mexican population do not make use of them, whereas other countries [ , , , ] have started implementing them on their own data with good results. señales de gentrificación a través de la inteligencia artificial: identificación mediante el censo de vivienda the effect of women's economic power in latin america and the caribbean. latin america and the caribbean poverty and labor brief portfolio choices, gender and marital status data mining in census data with cart barriers to women achieving their entrepreneurial potential: women and risk strong evidence for gender differences in risk taking selection of support vector machines based classifiers for credit risk domain da survey of popular r packages for cluster analysis a fuzzy logic control using a differential evolution algorithm aimed at modelling the financial market dynamics an integrated data mining and behavioral scoring model for analyzing bank customers mujeres y hombres en méxico . instituto nacional de estadística y geografía (méxico) self-directed pensions: gender, risk, and portfolio choices a survey of feature selection and feature extraction techniques in machine learning feature selection methods and algorithms factors that every financial advisor must consider when doing a client's risk profile scikit-learn: machine learning in python a fuzzy rate-of-return based model for portfolio selection and risk estimation gender differences in portfolio risk across birth cohort and marital status an ai based approach to multiple census data analysis for feature selection data analytics to predict the income and economic hierarchy on census data investor profiles: meaningful differences in women's use of investment advice? financ a survey of credit and behavioural scoring: forecasting financial risk of lending to consumers economic empowerment of women credit risk assessment with a multistage neural network ensemble learning approach support vector machine based multiagent ensemble learning for credit risk evaluation analysis of risk in linear multiobjective model and its evaluation for selection of a portfolio of investment in the mexican stock exchange this research provide a methodology for analyzing several datasets using machine learning techniques in order to define a financial profile of mexican woman. the methodology includes first the preprocessing of the data, to then reduce the dimensionality using a pca. followed by a clustering analysis, and finally the use of decision trees to define the profile. the main contribution of this research is the definition of the mexican financial profile for women segment. highlighting that women segment has been partially attended by the financial entities, missing the opportunity to offer financial products according to the risk involved. the methods applied in this research have been proof to be more flexible and accurate than traditional statistical approaches. future work includes the risk calculator for specific financial products, as well as the extension for population of other countries of interest. key: cord- -qtfx qp authors: scott, jodie; oxlad, melissa; dodd, jodie; szabo, claudia; deussen, andrea; turnbull, deborah title: creating healthy change in the preconception period for women with overweight or obesity: a qualitative study using the information–motivation–behavioural skills model date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: qtfx qp worldwide, half of women begin a pregnancy with overweight or obesity, which increases the risk of pregnancy and birth complications and adversely affects the lifelong health of the offspring. in order for metabolic changes to influence the gestational environment, research suggests that weight loss should take place before conception. this study aimed to understand women’s emotional and social contexts, knowledge, motivations, skills and self-efficacy in making healthy change. semi-structured interviews conducted with twenty-three women with overweight or obesity, informed by the information–motivation–behavioural skills (imb) model, were analysed using reflexive thematic analysis. information-related themes identified included poor health risk knowledge, healthy food decisions and health versus convenience. the motivation themes comprised taking responsibility, flexible options, social expectations, interpersonal challenges and accountability. behavioural skills entailed themes such as the mental battle, time management, self-care and inspiration. an environmental factor was identified in affordability—limiting access to healthier alternatives. women wanted simple, flexible options that considered family commitments, time and budgetary constraints. unprompted, several mentioned the importance of psychological support in managing setbacks, stress and maintaining motivation. strategies for enhancing self-efficacy and motivational support are required to enable longstanding health behaviour change. findings will inform intervention mapping development of an ehealth solution for women preconception. worldwide, half of all women of childbearing age have overweight (body mass index (bmi) ≥ . to . kg/m ) or obesity (bmi ≥ kg/m ) [ ] . this figure is significant as retrospective, case-control and cohort studies have found that women who enter pregnancy with obesity are at higher risk of gestational diabetes mellitus (gdm) [ ] and pre-eclampsia [ , ] -both associated with long-term morbidities [ ] . a review of reviews on the risks of maternal obesity also found these women are more traditional weight-loss interventions across all life stages have included advice and strategies to adopt healthy behaviours via diet and/or physical activity. those adopting an interdisciplinary approach using behavioural strategies and psychological techniques, and specifically targeting the preconception period are almost non-existent. there are also significant barriers to behaviour change regarding healthy lifestyle. within the target group of women for this study, there is low health literacy, and they are often from low-income families. in a large stratified study on the socioeconomic differences in health behaviours, those with lower socioeconomic status (ses) also displayed less health consciousness (thinking about ways to keep healthy), stronger beliefs about the role of chance on their health and lower rates of thinking about the future [ ] . a qualitative study focused on improving health in women of childbearing age identified that dietary knowledge, cooking skills and the time and cost of preparing healthy food were significant barriers to adopting a healthier diet [ ] . a lack of support from partners and family members was also cited as a significant barrier to healthy change, likewise, finding the time and inclination to exercise. while preconception care largely focusses on women's health and care, fathers are increasingly becoming involved in pregnancy planning and lifestyle changes in efforts to conceive. however, little is known about partners' attitudes and roles in supporting positive preconception health behaviours [ ] . a high bmi category is associated with a range of co-morbidities, and poorer general health may affect motivation and perceived ability to adhere to healthy lifestyle recommendations [ ] . behavioural programs have the potential for substantial weight loss, yet significant problems remain due to program attrition and poor maintenance of healthy habits-with authors citing the lack of innovation as a factor in this area [ ] . significant gaps in knowledge exist, with further research exploring women's perspectives required to inform effective preconception health promotion strategies [ ] . this study aims to develop an understanding of preconception health awareness, potential barriers to adopting a healthier lifestyle, motivations, current behaviours and the practical skills required to change behaviour, for women with overweight or obesity. we sought to understand experiences from the women's perspectives [ ] consistent with the aims of the study in fostering empathy with their desires, needs and challenges. the intent is to understand the women's emotional and social contexts, to inform which behaviour change techniques and intervention components are likely to be most engaging. this qualitative study explored the perceptions and experiences of women related to healthy lifestyle change and weight management before conception. the information-motivation-behavioural skills (imb) model [ ] addresses some of the existing attitudes, beliefs and values that may impact behaviour [ ] and was used as the theoretical model for the interview topics. the model, which asserts that when individuals are well-informed, motivated to act, and hold the necessary behavioural skills, they will likely initiate and maintain a health behaviour [ ] , is highly applicable to obesity management [ , ] . the imb model is based on a critical review and integration of relevant constructs in social and health psychology theories and seeks to address limitations to these [ ] . the constructs are supported in the literature to improve healthy lifestyle behaviours and have been tested and used successfully in obesity prevention [ ] [ ] [ ] and in improving dietary and physical activity behaviours [ , ] . this model was chosen for its simplicity of structure and the fact that the constructs can be easily translated into intervention components. the imb model's elicitation-intervention-evaluation approach to the promotion of health behaviour, begins with seeking to identify this cohort's existing weight management knowledge, motivation and behavioural skills assets and deficits [ ] . individual determinants of behavioural change were explored: information, including behaviour-related information, knowledge about the impact of obesity, but also heuristics that permit automatic decision-making; motivation, comprising personal motivation (beliefs about intervention outcome and attitudes towards obesity prevention behaviours) and social motivation (including perceived social support for engaging in that behaviour); and behavioural skills (individual skills and self-efficacy) [ ] . qualitative investigation enables a deep and thorough understanding of the topic, yielding rich data [ ] , and is recommended to develop effective interventions [ ] . the relevant literature informed the development of the interview schedule, with probes allowing for exploration of topics driven by participants. under the belief that knowledge is socially situated [ ] , demographic information was also gathered, allowing the researchers to reflect on the relationship between the results and the sample [ ] . the present research, drawing on the problem-solving principles of design thinking [ ] , uses a human-centred approach that holds the emotional, functional and motivational needs of the user at the centre of the development process [ ] . this study represents the first phase of this process in empathic engagement-with these findings being used to inform the development of an ehealth solution using the intervention mapping approach. interview participants were a sample of women who have participated previously in diet and lifestyle intervention studies (the limit [ ] and/or grow [ ] randomised trials) at the women's and children's hospital-a high-risk specialty hospital with approximately deliveries annually-and who had given their consent to be contacted about future research. a purposeful sampling frame was adopted, with eligibility limited to those of reproductive age ( - years) [ ] , who were above the healthy weight range (bmi > kg/m ) and identified that they would like to lose weight. intention to become pregnant was not a prerequisite. women were contacted via telephone, with the purpose and methods of the study explained, and eligibility confirmed. those who expressed an interest in the research were emailed an information sheet and consent form, with interview times confirmed via email or telephone. the primary researcher (js) conducted twenty-three interviews during september . eight participants attended face-to-face interviews at the university of adelaide robinson research institute, with the remaining conducted via telephone. the interviews lasted - min (mdn = ). written consent was obtained from those attending a face-to-face interview, with verbal consent gained from those participating via telephone. the interviews followed after the consent process. the interviewer was a psychology researcher (js) trained in qualitative methods and interviewing skills, with knowledge of pre-pregnancy health and wellbeing, and no previous connection with any participants. a pilot interview was conducted with an eligible woman to determine the level of comprehension and natural flow of the intended questions, with this data excluded from the dataset as the interviewee was known to the researcher. after several interviews, some questions were revised for greater understanding, with others modified to broaden the scope for response. no further changes were made after the seventh interview. this process of revision is accepted as best practice within qualitative interviewing [ ] . each interview commenced with broader questions about lifestyle to build rapport. more sensitive and descriptive questions were asked later when participants were more comfortable. the interview schedule closed with questions that empowered the women to give their opinions and advice on the broader issue. questions were formulated to address the imb model constructs yet allowed scope for participants to speak freely outside of these topics. indicative topics included awareness of maternal and neonatal health risks, previous experience of weight loss, lifestyle and social factors, motivations, challenges and self-efficacy. a sample of questions is provided in table . participants who attended a face-to-face interview received a aud gift card as reimbursement for travel costs. after the interview, all women were provided with information on the maternal and neonatal health risks associated with overweight or obesity in pregnancy. all interviews were digitally recorded and transcribed verbatim by the first author. data analysis software nvivo ® [ ] was used to store and manage the transcripts, with each participant given a pseudonym and identifying information removed from the transcripts. despite recurring patterns indicating that code saturation was reached after participants, additional women were interviewed to provide meaning saturation-thereby identifying further insights and the nuances of issues required to understand this complex topic [ ] . it is believed that depth requires further data, especially for codes that are conceptual in nature [ ] . the analysis followed the six-phase process of reflexive thematic analysis set out in braun and clarke ( ) [ ] : familiarisation, generating codes, constructing themes, revising themes, defining themes and producing the report. this recursive process begins with repeatedly reading the data in an immersive manner to gain a sense of the whole. the analysis took both a deductive and inductive approach [ ] . while guided by the imb model and obesity literature, the coding process ensured that concepts falling outside of this were also captured. key concepts relating to the research aims were coded, then sorted into meaningful clusters that were assessed for applicability to the imb model constructs. two additional members of the research team (mo, dt) co-coded several transcripts to ensure rigour and transparency of interpretation, with the researchers working collaboratively to ensure the codes and candidate themes fit both the evidence, and the constructs of the imb model. the themes were then defined and named, with compelling extracts selected to illustrate the findings. perspectives that differed from the dominant beliefs were not excluded, with counter-instances considered to add rigour [ ] . the study was conducted in accordance with the declaration of helsinki, with the research approved by the women's and children health network (hrec/ /wchn/ ) and the university of adelaide human research ethics committee. this research was reported as per the consolidated criteria for reporting qualitative studies (coreq) [ ]-a -item checklist across three domains governing reflexivity, study design and analysis. each author approached the research from their respective positions and biases. while the primary researcher (js) who conducted the interviews, is not above the healthy weight range, she has an understanding of preconception health. the research team also comprised: a clinical and health psychologist (mo) with extensive experience in preconception care and health literacy; an obstetrician and academic researcher (jd) with extensive experience in maternity care; a digital technology specialist (cs) with an interest in its practical application within the health domain; a clinical trials manager (ad) within reproductive health and preventive medicine; and an academic researcher (dt) with a specialist interest in health psychology and maternity care. all authors are women with children of their own. a triangulated review process was used, with codes and candidate themes discussed by three researchers (js, mo, dt). an audit trail was maintained throughout data collection and analysis [ , ] , and participant confidentiality ensured by assigning pseudonyms. participants were able to review their transcripts to verify accuracy [ ] and were sent a summary of the findings [ ] . due to the sensitive nature of the topic, and participants not providing consent for sharing of their data beyond the current research, data will not be made publicly-available. a total of women, aged between and years (m = . , sd = . ) participated. each had between one and four children, with two women intending to conceive in the next months and three unsure on pregnancy intentions. participants self-reported their weight and height-most considered themselves above the healthy weight range (n = ), with bmi categories ranging between overweight ( . kg/m ) and obese class iii ( . kg/m ). all women expressed a desire to lose weight, with amounts ranging between five and kg. demographic characteristics of the participants can be seen in table . the themes identified in the data reflect the individual perspectives of participants concerning healthy lifestyle changes. these comprise four overarching themes: the imb model constructs (information, motivation, behavioural skills) and one issue beyond the scope of these (environmental factors) that encompass the diverse experiences of these women. within these, several themes were derived from the data, depicted in figure . the themes identified in the data reflect the individual perspectives of participants concerning healthy lifestyle changes. these comprise four overarching themes: the imb model constructs (information, motivation, behavioural skills) and one issue beyond the scope of these (environmental factors) that encompass the diverse experiences of these women. within these, several themes were derived from the data, depicted in figure . information-related themes included poor health risk knowledge, making healthy food decisions and health versus convenience. motivation-related themes-divided into personal and social motivation-included concepts such as taking responsibility, flexible options, interpersonal challenges and accountability. behavioural skills themes covered concepts such as the mental battle, time management, self-care and inspiration. the women conveyed their feelings and attitudes as they discussed previous experiences, their social environments, and aspects they considered presented barriers to adopting a healthy lifestyle. themes are presented in greater detail below. knowledge of the potential maternal and neonatal health risks associated with overweight or obesity before pregnancy was alarmingly low. while many participants had some knowledge of the risks to their health, most commonly gestational diabetes and pre-eclampsia, others expressed this knowledge in more general terms. of those who knew some of the risks, several disclosed they had experienced these in a previous pregnancy. information-related themes included poor health risk knowledge, making healthy food decisions and health versus convenience. motivation-related themes-divided into personal and social motivation-included concepts such as taking responsibility, flexible options, interpersonal challenges and accountability. behavioural skills themes covered concepts such as the mental battle, time management, self-care and inspiration. the women conveyed their feelings and attitudes as they discussed previous experiences, their social environments, and aspects they considered presented barriers to adopting a healthy lifestyle. themes are presented in greater detail below. knowledge of the potential maternal and neonatal health risks associated with overweight or obesity before pregnancy was alarmingly low. while many participants had some knowledge of the risks to their health, most commonly gestational diabetes and pre-eclampsia, others expressed this knowledge in more general terms. of those who knew some of the risks, several disclosed they had experienced these in a previous pregnancy. knowledge of neonatal health risks and outcomes was much less evident, with only half the participants able to recall any at all. of these, the majority were unable to describe them in detail or they were based on false information. while several women knew the risk of high birthweight, only two participants mentioned that the child may be at risk of having weight issues over their life course. however, some women did express informed knowledge of longer-term health risks for their child. "yeah well, stillbirth, um, high birth weight, um, i might be pulling this out of thin air, but i believe it puts your child at higher risk of having diabetes themselves." (amber, obese class ii) even those women who knew some of the risks to their health or their baby's health were unaware of the genetic traits they may pass on to their child, by entering a pregnancy with overweight or obesity. in many instances, participants only followed a healthy lifestyle after conception-discussing the more immediate effects of the foods they ate during the pregnancy and how this may impact the baby. " . . . you want what's best for your kids, and that starts from the second you see those two pink lines." (annie, obese class iii) when asked about the benefits of losing weight before pregnancy, some women expressed that they may fall pregnant more easily, and many conceded the healthier they were, the easier the pregnancy and birth would be, with less strain on their body and fewer complications. some requested information be freely available on the benefits, for themselves and their baby, of being a healthy weight before conception. many of the women had inadequate information on nutrition to make autonomous healthy food decisions for themselves or their families. while no participants were currently on an intensive weight loss program, some foods they reported consuming were carbohydrate-laden or high in sugar or fat-suggesting poor nutritional knowledge and self-monitoring of eating habits. for some, knowledge was based on misinformation such as considering some high sugar or "light" version of foods as healthy. " . . . i suppose an example is when i had gallstones and i wasn't supposed to be eating fat, i ate kabana [high-fat cured sausage], not realising that it was full of fat, and i ended up in the hospital with a gall bladder attack. it was just a . . . you know, a lack of information i suppose, i just didn't know." (erin, overweight) portion control, snacking, willpower and knowledge of consumption norms were among the greatest food challenges-even for those who considered their current diet to be healthy. positive health knowledge and behaviours were also displayed, with some reporting a good understanding of nutrition to aid weight loss. several women recognised the value in clean eating and shopping the perimeter of the supermarket to avoid heavily processed foods. "don't do fad diets, just eat clean. your food is % of it. if you've got your food under control, then . . . other things will fall into place." (elizabeth, overweight) while over half of the participants read the ingredients list and/or nutritional information panels, there appeared to be confusion around interpreting these. many appeared overwhelmed by the volume of nutrition advice available and whether it could be trusted. "there's a whole confusing world out there when it comes to diet" (mary, obese class iii) several women requested information being more freely available on healthy substitutions for unhealthy ingredients or dishes, plus alternatives to processed foods. participants emphasised the complexity of their lives, with busy schedules a contributing factor in choosing convenience meals over healthy ones. many women spoke of being too exhausted to cook and often relied heavily on processed foods or take-away, while half of the women reported cooking from scratch most of the time. physical and emotional exhaustion, general busyness and a lack of forward planning were cited as reasons for making poorer choices. when asked about their primary motivators for losing weight, some of the women expressed aesthetic motivators over health ones, in wanting to feel good about themselves and more confident. "almost entirely aesthetic. like i don't like the way i look in photos. and i understand the health risks, you know, the higher, higher incidence of diabetes, heart disease, all of the fat diseases, but that's not my main motivator if i'm honest." (amber, obese class ii) a powerful motivator for nearly all participants was role modelling healthy behaviours to their children, so they can also make good choices. several women did not want their children to focus on weight or dieting; instead, they wanted to set an example with positive health talk. within this, a couple of women conceded that the food they fed their children was much healthier than what they ate themselves. several women expressed their primary motivation was to improve their overall health, with some conceding that co-morbidities they suffered were an added incentive to lose weight. "just to feel healthier in myself. also to kick my depression a bit." (lucinda, obese class iii) most women cited several reasons for wanting to lose weight-even those with aesthetic motivators also wanted to provide a good example to others and see their children grow up. other reasons cited were to improve self-esteem, have more energy, feel proud next to their partner or to simply be a normal bmi. some women looked to the future, in wanting a long healthy life for their children, or more self-sufficient as they age. several expressed motivators related to the health of their potential baby or having an easier pregnancy. most women held positive beliefs about how important it was for them to manage their weight. it was widely recognised that they needed a "lifestyle" rather than a "diet"-having had negative experiences of weight loss programs in the past. many women attributed their excess weight to unhealthy behavioural patterns and felt a responsibility, whether trying to conceive or not, for managing their weight and health. " . . . trying to conceive, or have already had children and trying to conceive again, you know, you've got another body to look after, like it's not just you any more" (sasha, obese class ii) many women felt a sense of personal autonomy in choosing to improve their health-recognising that their lifestyle choices were modifiable and to have a healthy life, they had to take stock of their habits and change their mindset. "i don't blame my kids or my husband and i don't think that i don't have enough time." (mary, obese class iii) many were ready to change their lifestyle but perceived a barrier in making that first step-not knowing where to start in a task that seemed overwhelming. beliefs about other parts of women's lives often affected their motivation to begin a program of change. some women conceded they had no reason to eat unhealthily and were ignoring satiety cues or lacking in motivation. all participants had previous experience with trying to lose weight. these included meal replacement shakes, the ketogenic (or other low carbohydrate) diet, duromine or other diet pills, the "healthy mummy" app, intermittent fasting, weight watchers and counting calories. most had tried at least two of these methods. although some women had experienced success, many failed to lose weight or found the programs too restrictive, costly, or rigid to maintain with other responsibilities. women required options for both healthy eating and exercise that were flexible enough to accommodate family commitments. "i like taking the ideas from it, but i need the flexibility, with the family . . . for what's best to eat for us." (chloe, overweight) women talked about establishing a new routine that became an automatic habit. several women noted that they wanted a program that they could use long term to manage their weight. some noted that small steps and achievable goals would make women more motivated to succeed, along with devising a program that was simple to follow. social motivation many women reported feeling that societal norms dictated how they should look and feel and felt judged when they did not fit the "social" mould. some felt they were perceived differently due to their weight and did not want to shame their children or partners. . ] there's always going to be that voice in the back of your head that there is someone judging you, that doesn't even know you." (annie, obese class iii) a handful of participants could not relate to some of the advice or services they had accessed in the past, believing they target women who were already fit and a healthy weight, and found this de-motivating. despite experiencing hostility from others, or feeling out of place in fitness classes, some women were still able to push forward to improve their health. several women noted their partners were a barrier to eating more healthily, despite how supportive they may be in other ways. either they prepared unhealthy foods or ate unhealthy food in front of them. more than half of the women reported that their children were fussy eaters-which provided an added barrier to motivation, in that mothers preferred to cook food they knew their children would eat, at the expense of their own health. some struggled to strike a balance between healthy foods and the nutritional needs and preferences of their children, so as not to have to cook separate meals. "i've got two kids that are fussy eaters, to try and provide foods that are easy and carb-loaded for them [ . . . ] so that's where i've had issues with putting on weight, because trying to motivate the kids to eat and put on a bit of weight, you have to eat what they're eating. so, it's just trying to get that balance." (ella, obese class ii) some had difficulty convincing others of the need for healthy eating and felt this attitude sabotaged any efforts to lose weight. many women reported ongoing encouragement as holding power to maintain motivationregardless of whether they saw results-citing it as a significant reason not to abandon a healthy lifestyle program. "just nice words of encouragement, like you know 'you're doing a good job, and well done on you know, getting through the day, and you know, reaching your goal of however many steps' or 'it's ok you didn't get there today, but, you know, you're still doing good'." (olivia, overweight) women often find motivation wanes when "life gets in the way" and wanted gentle encouragement to keep on track after a setback. methods were highly individualized-while some wanted strategies that challenge on an individual level with personal messages, others found a group setting or competitive environment more motivating in that they saw others push themselves. the most powerful motivational support for women was seeing results-several had abandoned previous weight loss attempts due to not seeing results quickly enough. overwhelmingly, women felt they needed to be held accountable-some preferred a real person rather than goals set in an app, feeling they may be more likely to move the goalposts or lose motivation if they could not reach them. "i can fool myself pretty easily and make excuses for why i haven't done what i've done. it's different when you've got to explain to someone else your pathetic reasons for not having done something." (amber, obese class ii) several participants saw value in family members also committing to improving their health habits, to create an environment more conducive to success. some saw reciprocal benefits in encouraging others-such as peer interaction within an online support forum-and valued the camaraderie with those on the same journey. behavioural skills unprompted, several women mentioned psychological support in managing setbacks, stress and maintaining motivation-knowing the difficulties that can be encountered. " . . . mental health is a huge thing when you're trying to lose weight. [ . . . ] [it] can be really demoralising, especially if you're not achieving those goals. or if people around you are achieving them, and you're not." (elizabeth, overweight) weight management was viewed as much more complicated than just calorie input versus output. one participant noted that for most, obesity is about more than just food, and she would value being able to talk to someone about other issues that may impact behaviours. some women talked about their mental barriers and expressed the need to change their thinking around old habits. "you've really got to sort of train yourself mentally as well, to . . . um, eat better and to exercise more. it's kind of a mental battle as well." (olivia, overweight) participants overwhelmingly had stressful lives, with factors such as juggling work and caring for children, financial difficulties, children with complex health issues, or managing a hectic schedule contributing to this. for some, exercise was noted as being particularly beneficial for stress, with several women requesting stress management or mindfulness approaches within an intervention. some also valued a holistic approach incorporating increasing self-esteem too, with the belief it would help maintain good health decisions. most women recognised time as one of the biggest barriers to a healthier lifestyle. prioritising their health over other responsibilities proved difficult and contributed to the abandonment of previous weight loss attempts. some participants recognised that exercising would be easy if they were able to manage their time better. "i feel like it's just managing my time better isn't it? just getting up, even like a little bit earlier, i can do it in the morning . . . " (alex, obese class ii) some felt that time spent cooking from scratch or exercising meant that other priorities in their lives piled up and left them further behind. several women conceded that they do not really have an excuse not to eat well or exercise, but probably do not make the best use of their time, with "perceived busyness" often an excuse. "i think if someone can help you plan your whole day, so you can fit it in." (mary, obese class iii) exercise proved more of a challenge than healthy eating, and women wanted ideas for how to integrate physical activity into their lifestyle with small changes. women often felt a trade-off between spending time with their children and exercising, with the unpredictable nature of family life a barrier to maintaining physical activity and healthy eating regimes. many women also recognised other benefits, beyond weight management, in eating well and exercising. participants noted these self-care behaviours were rewarded with improvements in sleep, energy, clearer skin, mental clarity, less digestive issues, and some felt it gave them more motivation in other areas of their lives. overwhelmingly, women assigned greater importance to eating well than physical activity. "when i eat well, i feel well if that makes sense." (erin, overweight) some noted it took longer to notice the health benefits of physical activity, yet several women placed higher importance on exercise than healthy food, for the additional psychological benefits. "for me it's got the stress relief component, it's my 'me' time, it feels good, i feel good afterwards, i tend to be . . . i find the flow on effects, so when i exercise that's when i do tend to be less likely to go to straight the cupboard because i'm still feeling motivated." (chloe, overweight) it was also mentioned that, as mothers, they often prioritised everything else before their health. some found value in exercise as it allows them to focus on themselves, rather than just taking care of their families. many women lacked skills such as nutrition planning and meal preparation. participants indicated they often found healthy food boring or repetitive and wanted ideas to make meals more interesting and attractive to themselves and their families. " . . . knowing how to make foods interesting so you're not eating the same old things continuously [ . . . ] how to make vegetables more interesting [ . . . ] without adding massive amounts of calories to them." (lucinda, obese class iii) around half the women regularly cooked meals from scratch with fresh produce. while not always intentional with their meal planning, a handful of women noted they were skilled in creating basic meals, based on ingredients at hand and their personal preferences. some participants noted that what they needed was inspiration to implement changes. " . . . oh gosh, i need more inspiration than information" (amber, obese class ii) several women expressed a desire for basic meal plans and simple, quick recipes that were within their skillset, using easily accessible, cost-effective ingredients. women knew their old, unhealthy patterns of eating, and highly restricted regimes were not sustainable in helping them establish healthy patterns for weight loss. many wanted a more structured plan with interesting ideas for both nutrition and exercise. . . . theme: believing in myself to change my lifestyle several women noted they felt confident to make healthy changes to their diet and exercise levels, but motivation held them back. many placed caveats on their ability-contingent upon managing their time better, managing exhaustion, or finding adequate motivation. for some, previous successful experience of weight loss gave them confidence that they could make the changes required. "reasonably confident. i know i can do it. i know i can, because i've done that with little things, like the soft drink as i said. so i know i could do it." (erin, overweight) women often reported better results with changing their diet than exercising and expressed more confidence in being able to modify their diet. several cited the / rule-believing that weight loss is % diet and % exercise. given the correct information, many felt confident about easily integrating healthy foods into their daily life. however, a handful of women recognised that their lack of cooking skills might hinder their progress. some felt it would be easy to include physical exercise in their daily life, but only after attending to other responsibilities. environmental factors several women considered healthy food to be more expensive than convenience foods, and some cited this as a reason for their poor diet at times. they noted that the foods on special offer were the "cheat" foods, not the healthier options, and this influenced their purchase choices. "so it's more about finding the alternate to those expensive things [ . . . ] because it's very expensive starting a diet and that can sometimes put a lot of people off, because budget-wise you just can't fit it in. and i find that's why people go for the easy foods, because it is cheaper." (april, overweight) especially for families with limited income, cost encouraged reliance on cheaper fat-, sugar-or carbohydrate-laden foods. frozen or packaged food was sometimes bought in favour of fresh, as it could be relied upon if money was tight. leaner cuts of meat were also seen as less affordable. " . . . that makes it a bit harder sometimes, especially if we're like, tight on money and the only thing that we can whip up is like sausages and packet pasta and stuff like that." (carla, obese class iii) some were unable to continue with previous weight management programs due to food costs. physical exercise often presented a cost barrier too, with several noting the cost of gym memberships, boot camp and exercise clothing suitable for overweight women. this qualitative investigation examined the experiences and beliefs of women with overweight or obesity related to managing their weight before pregnancy. in general, the participants displayed poor health literacy on the impact of entering pregnancy with overweight or obesity. while some women were aware of the risks to their health, few recognised the potential risks to their future baby. this finding corresponds with previous research noting a poor understanding of neonatal outcomes for pregnant women with overweight or obesity [ ] . while preconception care and counselling may include advice about smoking, alcohol intake, nutritional supplementation and immunisations, less attention has been paid to diet and lifestyle advice for women with overweight or obesity [ ] . the topic holds such sensitivity that it is often not raised by doctors during consultations. previous systematic review research has found that the beliefs and attitudes of partners, peers and family exert a powerful influence on women's health behaviours that may undermine the advice of health professionals [ ] . the fact that many women reported interpersonal challenges suggests that partners need greater involvement in the process of preconception counselling and creating and supporting a healthy lifestyle. pregnancy is considered a powerful "teachable moment" [ ] for weight control and health behaviour change, which enhances the perceived value of nutrition and exercise. while the focus of the current study has been on efforts women can undertake in the preconception period to maximise outcomes for their child, pregnancy is often a joint endeavour and partners are becoming increasingly involved in preconception planning. it is evident that partners can help or hinder women in their efforts to make lifestyle changes. it is crucial that any future intervention consider the impact of partners including ways to foster social support by making lifestyle or behavioural changes themselves, and to reduce social pressure by lifting the stigma around weight. this would provide a supportive environment to initiate healthy change within the whole family. interestingly, many of the women conceded they were motivated more by aesthetics and social expectation than health considerations. this finding reiterates previous research that found motivations beyond health, such as self-image, may be more engaging for some women [ ] , and enable those not yet considering pregnancy to be captured by the public health messages. while it has been reported that between % [ ] and % [ ] of pregnancies are planned, it is thought that women with overweight or obesity are more likely to have unplanned pregnancies [ ] and therefore are less able to optimise their health before conception. thus, interventions may need to target not just those intending to conceive, but all women of childbearing age. for many women in the study, the prime consideration was being healthy during the pregnancy, rather than in preparation for conception. greater understanding of the health implications of weight status may provide an added motivation to improve lifestyle. while the current study is concerned with behaviour change on an individual level, interactions with surrounding influences-family, community, plus social, environmental and policy contexts-exert a powerful force on health behaviours, as noted by many of the women in this study and previous research [ ] . a two-pronged approach is required-empowering women with the tools to change the way they respond to the environment, and also changing their environment, where possible, to make healthier choices easier to make. the sugar tax, intended to create shifts in consumer behaviour, has reduced sugar consumption in the united kingdom and mexico [ ] , with higher effects for lower-income households. while food taxes and subsidies have not yet been implemented in australia [ ] , it stresses the importance of giving women evidence-informed guidance they can trust, but also individual support to counteract obesogenic environments [ ] . unsurprisingly, nutrition knowledge was relatively poor amongst participants, with many consuming processed foods high in sugar or fat. it is known that unconscious and instinctual processes can prompt poorer eating practices, with people relying on heuristic cues to make food decisions which often lead them to choose larger and less nutritious options [ ] . heuristics are mental shortcuts-in this instance, made in response to contextual food cues and are thought to reduce the cognitive depletion associated with making health decisions [ ] -especially salient in a population with lower health literacy. many women had requested simple solutions, rather than complex calorie-counting and food logging. these findings emphasise the need for interventions to respond to the preference for heuristic processing, to help people make better choices with regard to food, portion control, even leisure activities, as suggested in a previous study [ ] . previous experience of dieting practices meant that many of the women were wary of highly restrictive eating regimes, which often affected adherence and success. this result corresponds with previous research on barriers to following a mediterranean style diet for women of childbearing age [ ] , with women perceiving the term "diet" to have negative connotations. the language used will be critical to the success of any future intervention, a sentiment shared by previous research on public perceptions of the terms used to improve eating habits [ ] . this information highlights the need to frame the intervention with clear communication and a positive focus, along with making guidelines more flexible to accommodate busy lifestyles and families, as noted by previous research [ ] . accessibility was also problematic, with the perception that healthy food was more expensive-a finding common to other studies [ , ] . this finding points to the need for education on better food choices and substitutions-being mindful of budgetary constraints. women had stressed the importance of social support, encouragement and accountability, suggesting the need for an inclusive community to be created, where women feel empowered and supported to reach their goals-as noted in previous research on mutual-help groups [ ] . avenues for peer support have never before been so important, with social barriers such as those imposed by the covid- pandemic, along with caring responsibilities for other children, giving women less opportunity to interact with peers and health professionals for encouragement. many participants also recognised the benefits of a healthier lifestyle beyond weight loss itself. a holistic intervention therefore presents an opportunity to promote factors such as stress reduction, increased self-esteem, improved mental health or role modelling. several women in the study expressed a need for psychological support along their weight loss journey. a technology-delivered motivational interviewing approach [ ] could provide tactics to increase self-efficacy through small steps and achievable goals, elicit change talk and garner family support. a regime of establishing and recognising partial success in changing behaviour, plus strategies to manage setbacks, may promote greater motivation to continue. mindfulness-based interventions may have particular relevance for obesity with a meta-analysis suggesting benefit for improving both psychological health and eating behaviours [ ] . likewise, open trial and case series evidence suggests that cognitive behavioural therapy (cbt) [ ] and acceptance and commitment therapy (act) [ ] can provide useful adjuncts to other behavioural techniques for weight management. however, few studies exist that assess these techniques when delivered via digital health intervention. an ehealth intervention offers a solution that is low cost, high reach, with the potential for personalisation and the use of adaptive and agile design to improve efficacy. this study presents an opportunity to understand the behaviour change techniques and digital functionality to which women may best respond. in-depth qualitative research is crucial in understanding the personal experiences and the contexts within which potential intervention users live, and to help tailor interventions to specific life stages. this person-based approach complements the theory-and evidence-based approaches to intervention development [ ] . an intervention mapping approach will be guided by these interviews, the literature on obesity, behaviour change and psychological techniques. it is hoped that themes and subthemes derived from this study, having been identified by the women as important, will directly inform modules to be delivered in the intervention. the intent is to develop an intervention that the women want to engage with, using strategies that address some of the existing barriers to change and help them to create a sustainable healthy lifestyle. to date, there has been little qualitative research conducted into the experiences and beliefs of women regarding weight management before pregnancy-within an australian context. to the authors knowledge, there have been none that use the imb determinants of behaviour within this specific target group. this cohort displayed a diverse profile across age, family circumstance, bmi and socioeconomic factors. credibility was added through the multivocality of the participants, with the authors aware of the empathic understanding required to let this wide range of insights emerge. both the interviews and analysis were conducted with rigour, adhering to best-practice guidelines for qualitative research [ , ] . the research was not without limitations. the women interviewed were not necessarily intending pregnancy (n = intending pregnancy in next months, n = unsure, n = not planning pregnancy in the next months). therefore, motivations may be different from those in the preconception phase. however, it is thought that similar health and role-modelling sentiments would stand for those intending pregnancy, in wanting the best outcomes for their children. the women were recruited from a pool who had previously participated in studies concerning gestational weight gain, so may have prior knowledge of managing their weight through pregnancy in a supported manner. in addition, some women reflected on previous pregnancies in their responses, discussing lived experience of the health risks associated with their weight status. moreover, the cohort was not culturally diverse, in that recruitment was limited to those who spoke english. the cultural implications of dietary and social habits need to be considered and, therefore, future research with diverse populations is recommended. the preconception period is now acknowledged as a critical window in which to intervene for preventing obesity in pregnancy, with significant potential benefits-both health and economic. however, obesity is a complex and challenging issue, with multiple genetic, social, environmental and behavioural influences. promoting meaningful change in this group requires a multifactorial approach, involving a complex interaction between the necessary determinants of behaviour-information, motivation, and behavioural skills. this elicitation study, the first step in the imb approach to health behaviour change, provided insights about the beliefs and psychosocial contexts of women in this particular population. important factors for consideration include psychological support, flexibility, enhancing self-efficacy, motivational support and affordability. a tailored, empathic and collaborative intervention approach will be taken, guided by the perspectives gained from this study. informed by the current findings and the existing literature, we seek to develop an effective digital health intervention, that results in improved multigenerational health outcomes for women and their children. the international weight management in pregnancy [i-wip] collaborative group. effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews does maternal obesity cause preeclampsia? a systematic review of the evidence preconceptional and maternal obesity: epidemiology and health consequences maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review risk factors for severe postpartum 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adolescents: a test of the information, motivation, behavioral skills model an information-motivation-behavioral skills analysis of diet and exercise behavior in puerto ricans with diabetes thematic analysis. in handbook of guidance on how to develop complex interventions to improve health and healthcare qualitative quality: eight "big-tent" criteria for excellent qualitative research successful qualitative research: a practical guide for beginners a design thinking framework for healthcare management and innovation use of the principles of design thinking to address limitations of digital mental health interventions for youth: viewpoint antenatal lifestyle advice for women who are overweight or obese: limit randomised trial effect of metformin in addition to dietary and lifestyle advice for pregnant women who are overweight or obese: the grow randomised, double-blind, placebo-controlled trial reproductive health indicators: guidelines for their generation, interpretation and analysis for global monitoring nvivo qualitative data analysis software ; qsr international pty ltd code saturation versus meaning saturation: how many interviews are enough? qual. health res characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a -year period reflecting on reflexive thematic analysis deviant case analysis. in encyclopedia of case study research consolidated criteria for reporting qualitative research (coreq): a -item checklist for interviews and focus groups overweight and obese women's perceptions about making healthy change during pregnancy: a mixed method study. matern directed preconception health programs and interventions for improving pregnancy outcomes for women who are overweight or obese behavioural interventions for weight management in pregnancy: a systematic review of quantitative and qualitative data a "teachable moment" for weight control and obesity prevention intervention strategies to improve nutrition and health behaviours before conception global, regional, and subregional trends in unintended pregnancy and its outcomes from to : estimates from a bayesian hierarchical model unintended pregnancy amongst an early pregnancy clinic cohort: identifying opportunities for preventative health interventions the effect of food taxes and subsidies on population health and health costs: a modelling study modelled health benefits of a sugar-sweetened beverage tax across different socioeconomic groups in australia: a cost-effectiveness and equity analysis the global obesity pandemic: shaped by global drivers and local environments contextual influences on eating behaviours: heuristic processing and dietary choices language is the source of misunderstandings-impact of terminology on public perceptions of health promotion messages integrating user perspectives into the development of a web-based weight management intervention peer support groups for weight loss technology-delivered adaptations of motivational interviewing for health-related behaviors: a systematic review of the current research mindfulness-based interventions for adults who are overweight or obese: a meta-analysis of physical and psychological health outcomes the effectiveness of cognitive behavioral therapy with mindfulness and an internet intervention for obesity: a case series the person-based approach to intervention development: application to digital health-related behavior change interventions the authors would like to sincerely thank the women who participated for their generosity in sharing their thoughts and experiences with us. we would also like to thank the coordinating team who supported recruitment in this study: deussen a, kannieappan l. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- -pjcskj m authors: piazza, kelly senters; diaz, gustavo title: light in the midst of chaos: covid- and female political representation() date: - - journal: world dev doi: . /j.worlddev. . sha: doc_id: cord_uid: pjcskj m the promotion of gender equality and the empowerment of women are global policy priorities across countries and development institutions. research on gender and politics shows that exceptional environments can activate stereotypes of women as honest, trustworthy, and competent lawmakers in public health and, in doing so, can generate increased public support for female political candidates. we argue that the – coronavirus pandemic has the potential to produce this outcome, as recent public opinion polls highlight widespread discontent with male-led governments’ responses to the pandemic and elevated concerns surrounding public health. recent positive media reports of female world leaders’ responses to the pandemic provide further reason to suspect a forthcoming increase in political support for female candidates. we posit that such an outcome may prove essential not only for enhancing development and improving long-standing gender inequities but also for alleviating the pandemic’s disproportionately allocated hardships. the promotion of gender equality and the empowerment of women is formally recognized as a global policy priority both by the world's countries and by leading development institutions. not only is gender equality morally and ethically just, but scholars and development practitioners agree that the empowerment of women engenders positive political, economic, and social yields for societies writ large. as such, government and nongovernment actors have developed wide-ranging initiatives in pursuit of this goal with varying degrees of success. operating under the belief that political empowerment is an important precursor to gender equality in wide-ranging development metrics, political scientists have worked to understand the factors underlying women's political representation. their research finds that factors ranging from electoral gender quotas (sacchet, ; wylie, ) to proportional representation electoral systems (that permit multiple electoral winners) boost women's electoral prospects (ahn, kim, & kang, ; githens, lovenduski, & norris, ; matland, ; salmond, ) . the caveat is that these factors are less impactful in enhancing women's political representation in the absence of accompanying public support for female candidates (franceschet & piscopo, ) . recent research suggests that exceptional environmentsinvolving conflict and including political corruption scandals accompanied by downturns in public trust as well as public health crises -can generate the public support for female political representation that public policies or institutions alone may not. such unique environments may promote female candidates either because they increase the demand for desirable qualities associated with women or because they focus voters' attention on issues that women are perceived to be especially competent in addressing. we argue that the - coronavirus pandemic may have fostered an environment capable of promoting female representation through both mechanisms. in this piece, we overview key findings from related research and introduce preliminary insight into contemporary global attitudes related to the coronavirus. both help us to weigh in on whether the coronavirus pandemic may lead to favorable electoral outcomes for female candidates. the literature on gender stereotypes asserts that female politicians are perceived to be more empathetic, compassionate, honest, trustworthy, and liberal than their male counterparts (alexander & andersen, ; dollar, fisman, & gatti, ; funk, hinojosa, & piscopo, ; huddy & terkildsen, ; mcdermott, ; world development j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / w o r l d d e v morgan, ) . exceptional environments that are deficient in these areas may generate demands for female inclusion. recent and ongoing scholarship on the exceptional environments associated with conflict and political corruption revelation explores the validity of this claim, seeking to understand the connection between gender stereotypes relating to qualities and personality traits and electoral dynamics. regarding conflict, both a robust literature on peace-building and security council resolution concede that women are fundamental to post-conflict resolutions (see zuckerman & greenberg, ) . underlying calls for increased female representation in post-conflict states is the ''women and peace" hypothesis that women hold more pacific or compromising attitudes than men, plausibly a function of ''traditionally female characteristics such as empathy and caring" (brounéus, ; tessler, nachtwey, & grant, ; tessler & warriner, ) . additionally, some accounts suggest that women improve the process and outcome of peace talks because they build trust and bridge divides (o'reilly, ) . speaking on corruption, funk et al., discern that gender stereotypes work to the political benefit of female political candidates in exceptional latin american environments penetrated with perceived corruption and political distrust. they find that latin american political parties nominate more women when the public lacks trust in the national legislature under the presumption that voters will look more favorably upon female candidates due to their association with the desirable qualities of honesty and trustworthiness. ongoing research corroborates this conclusion, finding that revealing corruption in brazilian municipalities increases the number of women contesting mayoral offices, especially in places where male incumbents were revealed to engage in malfeasance (diaz & piazza, ) . both studies suggest that political environments that spark public distrust, such as those plagued with corruption, can activate gender stereotypes relating to qualities or personality traits that render female candidates more attractive than their male counterparts. similar to post-conflict and corruption-laden environments, the - coronavirus pandemic has ushered in a deficiency in public trust around the world. poor public perceptions of both government responses to covid- and government truthfulness abounded in march and april and were especially acute in countries with male leaders. according to data from the international survey on coronavirus (fetzer et al., ) , as of april , , less than % of respondents in countries ranging from the united kingdom to brazil to indonesia perceived their governments' reactions to the pandemic to be sufficient. per this same source, more than % of respondents in countries ranging from the united states to chile to nigeria perceived their governments to be untruthful in communications regarding the pandemic. though causal tests remain outstanding, other data from the international survey on coronavirus suggests corresponding high levels of distrust in government in a subset of countries, including the united states, colombia, venezuela, and russia. more than % of respondents in these countries have indicated a distrust in government to take care of its citizens in light of the raging pandemic. in line with the previously reviewed literature, the meager levels of public trust in government following from the - coronavirus pandemic may increase demands for female representation, compel political parties to field female candidates, and potentially improve female candidates' chances of electoral success. aside from qualities or personality traits, the literature on gender stereotypes acknowledges differences in perceived issue competencies across male and female politicians. whereas male politicians are perceived as proficient policymakers in the ''high politics" areas of the economy, agriculture, employment, fiscal affairs, crime, and security (herrnson, lay, & stokes, ; lawless, ) , female politicians are generally considered to be especially adept policymakers in the ''low politics" areas of education, health, and other issues relating to ''children and family" (alexander & andersen, ; herrnson, lay, & stokes, ; huddy & terkildsen, ; leeper, ) . recent research has moved beyond documenting these stereotypes to demonstrating their influence on electoral behaviors. most pertinent to this paper, piazza & schneider, assess whether the exceptional environment stemming from the - zika epidemic and the accompanying priming of the ''women's issue" of (infant) health resulted in an electoral boost for female candidates. their difference-in-difference analyses show that if the number of cases of zika per , residents increases by % in the two months leading up to the brazilian municipal elections, then the vote share for female mayoral candidates is predicted to increase by . %. they find that this effect is especially pronounced in brazilian municipalities with high incidences of the zika virus among pregnant women. the authors attribute these results to popular perceptions of female candidates' unique competencies in the area of public health and, more specifically, in infant health and family planning. like the zika virus, the - coronavirus pandemic has primed the ''women's issue" of public health around the world. public opinion polls from mid-march conducted in diverse contexts including the united states, canada, and italy point in this direction. on the basis of mid-march social media surveys, nelson et al., find that . % of americans expressed concerns of getting sick from covid- , and . % expressed concerns of not being able to get medical care. an angus reid institute poll conducted march - found that a similar share of canadians ( %) perceived the coronavirus outbreak to be a serious threat to their country, with % expressing personal concerns about getting sick from the novel coronavirus and % expressing concern for their friends and family members. an ipsos survey of , italian adults conducted from march to march found that % of italians perceived the coronavirus as a threat to italy, with % expressing a perceived personal threat. we interpret the common concern with the - coronavirus pandemic across these diverse global contexts as a strong signal that the public health crisis and evaluations of incumbent responses to it will factor into upcoming electoral decisions world-wide. insofar as both these public health concerns predominate and endure in the lead up to electoral contests and global publics interpret these concerns to correspond with ''women's issues," research on the - zika virus epidemic suggests that female candidates may experience an electoral boost in upcoming political contests. we identify two critiques to our argument. first, research from economics and law finds that organizations appoint more women to ''glass cliff" leadership positions in moments of crisis (ashby, ryan, & haslam, ; haslam & ryan, ) . ryan, haslam, and kulich, selection strategies in politics. in line with this research, the coronavirus pandemic may increase female representation not due to their perceived trustworthiness or competence in public health but because party leaders are more likely to assign women to leadership positions with high risk of failure in moments of crisis. second, though intimately connected with public health, the - coronavirus pandemic is less directly related to the types of health in which women are perceived to have a comparative advantage. this means that the coronavirus pandemic may not increase support for female candidates in the same way that the zika epidemic did. while these critiques are valid, we believe that media reports of female leadership in response to the coronavirus mitigate them and bolster our argument. reports praising german chancellor angela merkel's sciencebased response, widespread testing, transparency, stringent social distancing policies, travel restrictions, and relational appeals to the public to induce compliance and new zealand prime minister jacinda arden's clarity, compassion, strict national lockdown, travel restrictions, and pervasive testing (mahdawi, ) have fostered the narrative that female executives have more effectively, efficiently, and impressively handled the coronavirus pandemic (cherneski, ) . whether a function of over competence, the disproportionate hurdles women need to overcome to be elected in the first place, or a disposition to seek out advice from experts in moments of crisis, the contemporary dynamics suggest that female world leaders are handling the virus in an impressive manner (mahdawi, ; yancey-bragg, ) . there are compelling reasons to suspect that these narratives instill gender stereotypes relating to trustworthiness and/or competence in public health, and insofar as they do, it is plausible to anticipate an improvement in female candidates' prospects in upcoming electoral contests. to summarize, research suggests that exceptional environments may activate gender stereotypes that improve the electoral prospects of female candidates. though distinct from other exceptional climates in its global reach and magnitude, we argue that the - coronavirus pandemic also has the potential to produce an outcome favorable to prospective female politicians. recent public opinion polls highlight both general discontent with how politicians have managed the pandemic and widespread concerns surrounding the ''women's issue" of public health. contemporary public opinion, along with the positive media coverage of female leaders in times of crisis, may lead both party elites and voters to turn towards female candidates. in the midst of chaos, an increase in women's political representation could establish an important foundation from which to protect recent development advances and achieve related goals. it may also prove fundamental in alleviating the pandemic's disproportionately allocated hardships. according to grown and sánchez-páramo, '' there is a high risk that gender inequalities will widen during and after the pandemic and that gains in women's and girls' accumulation of human capital, economic empowerment, and voice and agency, painstakingly built over the past decades, will be reversed" (grown & sánchez-páramo, ) . substantiating grown and sánchez-páramo's fear, recent reports indicate that the coronavirus has hit economic sectors with high female employment shares (e.g. the service and ''essential worker" sectors) especially hard, intensified women's domestic responsibilities, and increased violence against women (alon, doepke, olmstead-rumsey, & tertilt, ; bahn, cohen, & van der meulen rodgers, ; campbell, ; cherneski, ; gausman & langer, ; graves, ; grown & sánchez-páramo, ; o'donnell, peterman, & potts, ; wenham, smith, & morgan, ) . these consequences may be especially pronounced for women of racial and ethnic minority groups, who bear the brunt of enforcement sanctions, job losses, and the adverse public health effects of the virus itself (kirby, ) . in the event that the - coronavirus pandemic increases public support for female political candidates who exude qualities of trustworthiness and uphold their mandates in the realm of public health, there may be some promise for relief. under chancellor angela merkel's leadership, began developing a test for the virus (blackburn & ruyle, ) and required healthcare providers to immediately report suspected cases of covid- to public health authorities (wieler & gottschalk, ) . from the outset, national responses were science-based, and information collected was made transparent. within a month, tests were widely available at no cost to probable carriers of the virus and swiftly rolled out (wieler & gottschalk, ) . shortly thereafter, merkel adopted stringent social distancing policies, mandated the closure of schools and retail businesses, limited public gatherings, and operated with travel restrictions (blackburn & ruyle, ) . in an effort to induce compliance with these policies, merkel ''asked citizens to consider how their behavior impacts those they love" (cherneski, ) . as a result, the number of daily confirmed cases in germany has, at the time of this writing, diminished both in terms of the number of daily confirmed cases and deaths. since the pandemic's outbreak, the media has frequently touted new zealand prime minister jacinda ardern's successes in curtailing the coronavirus. prior to new zealand's first reported case of covid- , prime minister jacinda ardern banned travel from china (blackburn & ruyle, ) . in late-march, one month after new zealand's first reported case, new zealand implemented a strict national lockdown that closed schools and non-essential businesses, banned social gatherings, and mandated a -day self-isolation period for travelers entering the country (blackburn & ruyle, ) . ardern evoked compliance by 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brazil? the role of the electoral system and political finance proportional representation and female parliamentarians further tests of the women and peace hypothesis: evidence from cross-national survey research in the middle east gender, feminism, and attitudes toward international conflict: exploring relationships with survey data from the middle east covid- : the gendered impacts of the outbreak party institutionalization and women's representation in democratic brazil emerging covid- success story: germany's strong enabling environment female world leaders are handling the coronavirus crisis ''in a really impressive manner the gender dimensions of post-conflict reconstruction: an analytical framework for policymakers the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- - w fkd authors: nan title: abstract date: - - journal: eur j epidemiol doi: . /s - - - sha: doc_id: cord_uid: w fkd nan the organisers of the european congress of epidemiology , the board of the netherlands epidemiological society, and the board of the european epidemiology federation of the international epidemiological association (iea-eef) welcome you to utrecht, the netherlands, for this iea-eef congress. epidemiology is a medical discipline that is focussed on principles and methods of research on causes, diagnosis and prognosis of disease, and establishing the benefits and risks of treatment and prevention. epidemiological research has proven its importance by contributions to the understanding the origins and consequences of diseases, and has made major contributions to the management diseases and improvement of health in-patients and populations. this meeting provides a major opportunity to affirm the scientific and societal contributions of epidemiological research in health care practice, both in clinical medicine and in public health. during this meeting major current health care problems are addressed alongside methodological issues, and the opportunities and challenges in approaching them are explored. the exchange of ideas will foster existing co-operation and stimulate new collaborations across countries and cultures. the goal of this meeting is to promote the highest scientific quality of the presentations and display advanced achievements in epidemiological research. our aim is to offer a comprehensive and educational programme in the field of epidemiological research in health care and public health, and create room for discussions on contemporary methods and innovations from the perspective of policy makers, professionals and patients. above all, we want to stimulate open interaction among the congress participants. your presence in utrecht is key to an outstanding scientific meeting. the european congress of epidemiology is organised by epidemiologists of utrecht university, under the auspices of the iea-eef, and in collaboration with the netherlands epidemiological society. utrecht university, founded in , is the largest university in the netherlands and harbours the largest academic teaching hospital in the netherlands. the epidemiologists from utrecht university work in the faculties of medicine, veterinary medicine, pharmacy and biology. the current meeting was announced through national societies, taking advantage of their newsletters and of the iea-eef newsletter. in addition, avoiding the costs and disadvantages of the traditional journal advertisements and leaflets, information about the congress was disseminated via an internet mailing list of epidemiologists, which was compiled from, among other, the meeting in porto in , the european young epidemiologist network (http://higiene.med.up.pt/eye/) and several institutions and departments. many of the procedures followed this year were based on or directly borrowed from the stimulating iea-eef congress in porto in . publication in an international journal of large circulation of the congress programme and abstracts selected for oral and poster presentation, signifies the commitment of the organisers towards all colleagues that decided to present their original work at our meeting, and is intended to promote our discipline and to further stimulate the quality of the scientific work of european epidemiologists. and methods to the objectives and quality of its description; presentation of results; importance of the topic; and originality. a final rating was given on a - point scale. the two junior epidemiologists independently evaluated each abstract. based on ratings of the juniors, the senior epidemiologist gave a final abstract rating. the senior reviewer decided when juniors disagreed, and harnessed against untoward extreme judgements of the juniors. based on the judgement by the seniors abstracts with a final rating of or higher were accepted for presentation. next, in order to shape the scientific programme according to scientific and professional topics and issues of interest for epidemiologists, members of the scientific programme committee grouped the accepted abstracts in major thematic clusters. for these, topics, keywords and title words were used. within each cluster, abstracts with a final rating of or higher, as well as abstracts featuring innovative epidemiological approaches were prioritised to be programmed as an oral presentation. the submitted abstracts had an average final rating of (sd= ). in total abstracts ( %) with a final rating of or lower were rejected. because of the thematic programming some abstracts with a final rating of or higher will be presented as posters, while few with a final rating of are programmed as oral presentation. there were abstracts ( %) accepted and programmed for poster presentation; each poster will be displayed for a full day. in total abstracts ( %) are accepted for oral presentation. these are programmed in parallel sessions. based on the topics of their abstracts the oral sessions were arranged into themes, notably epidemiology of diseases, methods clinical & population research, burden of disease, high risk populations, growth and development, public health strategies, translational epidemiology. sessions from one theme never are programmed parallel. in table we present the submitted and accepted abstracts (oral or poster) according to the distribution of country of origin. in table submitted abstracts are displayed according to their topic, as classified by the authors using the topic long list of the submission form. the scientific programme committee convened in a telephone meeting by the end of the summer of and decided on the above programming process. the scientific programme committee was informed on the result of the programming process by the end of april . fifteen abstracts were submitted for the eye session work in progress. of these abstracts were selected for oral presentation and thereby nominated for the eye award. in total, abstracts were submitted in relation to the student award, of which were programmed for oral presentation and thus nominated. during the congress authors of poster presentations may name themselves as candidate for the poster award. during the closing ceremony the winners of the student award and the poster award will be announced. these awards are an initiative of the netherlands epidemiological society that will fund them in . according to the iea rules expenses of congress participation for applicants from low-income countries will be covered. the board of the iea-eef will select a maximum of candidates; their travel and registration expenses will be (partly) covered from the congress budget. in order to stimulate participation form as many as possible junior researchers and young epidemiologists the congress budget covers registration fee reduction for undergraduate (msc) participants and eye members. this also holds for the registration fee reduction of iea-eef members and nes members. it is years ago ( ) that the iea regional european meeting was held in the hague, the marcon wei leray gehring leray spallek greving laan brussee brussee may- de groot hoefman goettsch posters ordered by abstract number olawuyi de vries uotinen smits gimeno houben de vries de vries ten berg diaconu diaconu streppel belo sauvaget koopman kilsztajn pembrey schmidt kretzschmar scholtens defraye medronho eljedi van de garde mello hosper feleus bayingana de wit stolk teixeira teixeira verhoef capon de boer lazarevska terschu¨ren khosravi boroujeni molag mikolajczyk luijsterburg stolk mirabelli barreto curzio pereira van gageldonk-lafeber van nispen roobol mokkink rava haukka jansen de kraker bogers donalisio behrens borders melis pac muller van den hooven van der sande van den berg novoa van den boogaard vannoord koedijk kuczerowska giorgi rossi vannoord baussano agabiti bierma-zeinstra van wier faustini jarrin juhl miguel maira lindert van den berg mierzejewska fonseca cardoso martens cotton corte ursoniu vernic boer ruskamp szurkowska bijkerk fonseca cardoso mazur ahrens dijkstra ajdacic-gross ajdacic-gross lucas santos gielkens-sijstermans tobi de kraker proteomics and genomics are supposed to be related to epidemiology and clinical medicine, among other because of the putative diagnostic usefulness of proteomics and genomics tests. hence, clinical and sometimes even public health applications are promised by basic sciences. it is debated whether such promises and subsequent expectation are fulfilled. what are at meaningful and consequential examples of current findings in proteomics, genomics and similar approaches in biomedical research? are they different from the ''classic'' tools and frameworks of clinical epidemiology? in the context of proteomics and genomics, etiologic studies, primary prevention, epidemiological surveillance and public health are concerned with the influence of environmental exposures on gene expression and on the accumulation of genetic alterations. proponents and advocates of proteomics and genomics have suggested that their products can yield clinically useful findings, e.g., for early diagnosis, for prognosis, for therapeutic monitoring, without always needing to identify the proteins, peptides or other 'biomarkers' at stake. do we feel comfortable with this ''black-box'' reasoning, i.e. do we question the role of pathophysiological and mechanistic reasoning in clinical medicine? how much sense does it make for epidemiology to play with and scrutinize proteomics and genomics approaches in epidemiology and clinical medicine? what are at present (and in the near future) the main biological, clinical and public health implications of current findings in these research fields? in this plenary session these and other questions regarding the place and role of proteomics and genomics in clinical epidemiological research are discussed from different perspectives. infection diseases: beneficial or disaster for man? infectious diseases pose an increasing risk to human and animal health. they lead to increasing mortality, in contrast to the situation fifty years ago when new control measures still provided hope of overcoming many problems in the future. improved hygiene, better socio-economic circumstances, vaccination and use of antibiotics has led to a gradual decline of tuberculosis, rheumatic fever, measles and mumps in western societies over the last five decades. paradoxically, absence of exposure to infectious agents has a major impact as well. the decline in infectious disease risk is accompanied by a gradual increase of allergic and autoimmune diseases and this association is believed to be causal. exposure to infectious agents from early on in life can markedly boost an individual's natural resistance and hence influence the individual's reaction to future exposure to both biological and non-biological antigens. in this plenary session we want to emphasise both aspects of the effect of infectious agents on human and animal health. evidence based medicine in health care practice and epidemiological research p. glasziou & l. bonneux evidence-based medicine is defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. proponents of evidence-based medicine maintain that coming form a tradition of pathophysiological rationale and rather unsystematic clinical experience, clinical disciplines should summarize and use evidence concerning their practices, by using principles of critical appraisal and quantitative clinical reasoning. for this they should convert clinical information needs into answerable questions, locate the available evidence, critically appraise that evidence for its validity and usefulness, and apply the results of the best available evidence in practice. applying the principles of evidence-based medicine implies improvement of the effectiveness and efficiency of health care. therefore, evidence-based medicine has commonalties with clinical medical and epidemiological research. for integration of evidence-based medicine into health care practice the challenge is to translate knowledge from clinical medical and epidemiological research, for example in up to date practice guidelines. the limitations of using evidence alone to make decisions are evident. the importance of the values and preference judgments that are implicit in every clinical management decision are also evident. critics of evidence based medicine argue that applying best available research evidence in practice in order to improve the effectiveness and efficiency of health care contradicts with the importance of the values and preference judgments in clinical management decisions. in this plenary session we want to contrast these and other viewpoints on evidence based medicine in health care practice. statistical topics i: missing data prof. dr. t. stijnen this workshop will be an educational lecture on missing data by professor stijnen from the department of epidemiology and biostatistics of the erasmus mc rotterdam, the netherlands. every clinical or epidemiological study suffers from the problem of missing data. in practice mostly simple solutions are chosen, such as restricting the analysis to individuals without missing data or imputing missing values by the mean value of the individuals with observed data. it is not always realised that these simple approaches can lead to considerable bias in the estimates and standard errors of the parameters of interest. in the last to years much research has been done to better methods for dealing with missing values. in this workshop first an overview will be given of the methods that are available and their advantages and disadvantages will be discussed. most attention will be given to multiple imputation, to date generally considered as the best method for dealing with missing values. also the available software in important statistical packages such as spss and sas will be shortly discussed. prof. dr. b. van hout suppose that one wants to know how often individuals have a certain characteristic, and suppose that one doesn't have any knowledge -any knowledge at all -how often this is the case. now, suppose that one starts by checking individuals and only finds individual with this characteristic. than the probability that the ' th individual has the characteristic is / . the fact that this is not / (although it will be close to that if the numbers of observations increase) may be counter-intuitive. it will become less so, when realising how it is obtained from the formal integration of the new information with the complete uncertainty beforehand. this formal integration, with a prior indicating that it is as likely to be / as it is to be / as it is / , and with negative and positive observation -is by way of bayes rule. the italian mathematician, actuary, and bayesian, bruno de finetti ( - , estimated that it would take until the year for the bayesian view of statistics to completely prevail. the purpose of this workshop is to not only convince the attendants that this is appealing outlook but also to aid the workshop participants in realising this prediction. after a first introduction of the work of reverend bayes, a number of practical examples are presented and the attendant is introduced in the use of win-bugs. a first example -introducing the notion of noninformative priors -concerns a random effects logistic regression analysis. second, the use of informative priors, is illustrated (in contrast with non-informative priors) using an analysis of differences in quality of life as observed in a randomised clinical trial. it will be shown how taking account of such prior information changes the results as well as showing how such information may increase the power of the study. in a third example, it will be shown how winbugs offers a powerful and flexible tool to estimate rather complex multi-level models in a relatively easy way and how to discriminate between various models. within this presentation some survival techniques (or stress control techniques) will be presented for when winbugs starts to spit out obscure error-codes without giving the researcher any clue where to search for the reason behind these errors. communicating research to the public h. van maanen, prof. dr. ir. d. kromhout, a. aarts most researchers will at some point in their career face difficulties in communicating research results to the public. whereas most scientific publications will pass by the larger public in silence, now and then a publication provokes profound interest of popular press. interest from the general public should be regarded as positive. after all, public money is put into research and a researcher has a societal responsibility of spreading new knowledge. however, often, general press interest is regarded upon as negative by the researcher. the messages get shortened, distorted or ridiculed. whose responsibility is this misunderstanding between press and researchers? should a researcher foresee press reaction and what can be done to prevent negative consequences? is the press responsible background and relevance: patients with a carotid artery stenosis, including those with an asymptomatic or moderate stenosis, have a considerable risk of ischemic stroke. identification of risk factors for cerebrovascular disease in these patients may improve risk profiling and guide new treatment strategies. objectives and question: we cross-sectionally investigated whether carotid stiffness is associated with previous ischemic stroke or tia in patients with a carotid artery stenosis of at least %. design and methods: patients were selected from the second manifestations of arterial disease (smart) study, a cohort study among patients with manifest vascular disease or vascular risk factors. arterial stiffness, measured as change in lumen diameter of the common carotid arteries during the cardiac cycle, forms part of the vascular screening performed at baseline. the first participants with a stenosis of minimally % in at least one of the internal carotid arteries measured by duplex scanning were included in this study. logistic regression analysis was used to determine the relation between arterial stiffness and previous ischemic stroke or tia. results: the risk of ischemic stroke or tia in the highest quartile (stiffest arteries) relative to the lowest quartile was . ( % ci . - . ). these findings were adjusted for age, sex, systolic blood pressure, minimal diameter of the carotid artery and degree of carotid artery stenosis. conclusion and discussion: in-patients with a ‡ % carotid artery stenosis, increased common carotid stiffness is associated with previous ischemic stroke and tia. measurement of carotid stiffness may improve selection of high-risk patients eligible for carotid endarterectomy and may guide new treatment strategies. background (and relevance): patients with advanced renal insufficiency are at increased risk for adverse cardiovascular disease (cvd) outcomes. objectives and question: the aim was to establish whether impaired renal function is an independent predictor of cvd and death in an unselected high-risk population with cvd. design and methods: the study was performed in patients with cvd. primary outcomes were all vascular events and all cause death. during a median follow-up of months, patients had a vascular event ( %) and patients died ( . %). results: the adjusted hazard ratio (hr) of an estimated glomerular filtration rate < vs > ml/min per . m was . ( % ci . - . ) for vascular events and . ( % ci . - . ) for all cause death. for stroke as a separate outcome it was . ( % ci . - . ) . subgroup analysis according to vascular disease at presentation or the risk factors hypertension, diabetes and albuminuria had no influence on the hr's. conclusion and discussion: renal insufficiency is an independent risk factor for adverse cvd events in patients with a history of vascular disease. renal function was a particularly important factor in predicting stroke. the presence of other risk factors hypertension, diabetes or albuminuria had no influence on the impact of renal function alone. background and relevance: patients with hypertension have an increased case-fatality during acute mi. coronary collateral (cc) circulation has been proposed to reduce the risk of death during acute ischemia. objectives and question: we determined whether and to which degree high blood pressure (bp) affects the presence and extent of cc-circulation. design and methods: cross-sectional study in patients ( % males), admitted for elective coronary angioplasty between january and july . collaterals were graded with rentrop's classification (grade - ). ccpresence was defined as rentrop-grade ‡ . bp was measured twice with an inflatable cuff-manometer in seated position. pulse pressure was calculated by systolic blood pressure (sbp) )diastolic blood pressure (dbp). mean arterial pressure was calculated by dbp + / *(sbp-dbp). systolic hypertension was defined by a reading ‡ mmhg. we used logistic regression with adjustment for putative confounders. results: sbp (odds ratio (or) . per mmhg; % confidence-interval (ci) . - . ), dbp (or . per mmhg; % ci . - . ), mean arterial pressure (or . per mmhg; % ci . - . ), systolic hypertension (or . ; % ci . - . ), and antihypertensive treatment (or . ; % ci . - . ), each were inversely associated with the presence of cc's. also, among patients with cc's, there was a graded, significant inverse relation between levels of sbp, levels of pulse pressure, and collateral extent. conclusion and discussion: there is an inverse relationship between bp and the presence and extent of cc-circulation in patients with ischemic heart disease. background and relevance: silent brain infarcts are associated with decreased cognitive function in the general population. objectives and question: we examined whether this relation also exists in patients with symptomatic arterial disease. furthermore, we compared cognitive function of patients with stroke or tia, with cognitive function of patients with symptomatic arterial disease at other sites in the arterial tree. design and methods: an extensive screening was done in consecutive patients participating in the second manifestations of arterial disease (smart) study, including a neuropsychological test. inclusion diagnoses were cerebrovascular disease, symptomatic coronary artery disease, peripheral arterial disease, or abdominal aortic aneurysm. mri examination was performed to assess the presence of silent infarcts in patients without symptomatic cerebrovascular disease. the patients were assigned to one of three categories according to their patient history and inclusion diagnosis: no stroke or tia, no silent infarcts (n = ; mean age years); no stroke or tia, but silent infarcts present (n = ; mean age years); stroke or tia at background and relevance: patients with manifest vascular disease are at high risk of a new vascular event or death. modification of classical risk factors is often not successful. objectives and question: we determined whether the extra care of a nurse practitioner (np) could be beneficial to the cardiovascular risk profile of high-risk patients. design and methods: randomised controlled trial based on the zelen design. patients with manifestations of a vascular disease and who had ‡ modifiable vascular risk factors were prerandomised to receive treatment by a np plus usual care or usual care alone. after year, risk factors were re-measured. primary endpoint was achievement of treatment goals for risk factors. results: of the pre-randomised patients, of ( %) in the intervention group and of ( %) in the control group participated in the study. after a mean follow-up of months, the patients in the intervention group achieved significantly more treatment goals than did the patients in the control group (systolic blood pressure % versus %, total cholesterol % vs %, ldl-cholesterol % vs %, and bmi % vs %). medication use was increased in both groups and no differences were found in patients' quality of life (sf- ) at followup. conclusion and discussion: treatment delivered by nps, in addition to a vascular risk factor screening and prevention program, resulted in a better management of vascular risk factors compared to usual care alone in vascular patients after year follow-up. were used as non-invasive markers of vascular damage and adjusted for age and sex if appropriate. results: the prevalence of the metabolic syndrome in the study population was %. in pad patients this was %; in chd patients %, in stroke patients % and in aaa patients %. patients with the metabolic syndrome had an increased mean imt ( . vs. . mm, p-value < . ), more often a decreased abpi ( % vs. %, p-value . ) and increased prevalence of albuminuria ( % vs. %, p-value . ) compared to patients without this syndrome. an increase in the number of components of the metabolic syndrome was associated with an increase in mean imt (p-value for trend < . ), lower abpi (p-value for trend < . ) and higher prevalence albuminuria (p-value for trend < . ). conclusion and discussion: in patients with manifest vascular disease the presence of the metabolic syndrome is associated with advanced vascular damage. background (and relevance): in patients with type diabetes the progression of atherosclerosis is accelerated, as observed by the high incidence of cardiovascular events. objectives (and question): to estimate the influence of location and extent of vascular disease on new cardiovascular events in type diabetes patients. design and methods: diabetes patients (n = ), mean age years, with and without prior vascular disease were followed through - (mean follow-up years). patients with vascular disease (n = ) were classified according to symptomatic vascular location, and number (extent) of locations. we analyzed occurrence of new (non)-fatal cardiovascular events using cox proportional hazards models and kaplan-meier analysis. results: multivariate-adjusted hazard ratios (hrs) were comparable in diabetes patients with cerebrovascular disease (hr . ; % ci . - . ), coronary heart disease (hr . ; . - . ) and peripheral arterial disease (hr . ; . - . ), compared to those without vascular disease. multivariate-adjusted hr was . ; ( . - . ) in patients with one vascular location and . ; ( . - . ) in those with ‡ locations. the -year risks were respectively . % ( . - . ) and . % ( . - . ) . conclusion and discussion: diabetes patients with prior vascular disease have an increased risk of cardiovascular events, irrespective of symptomatic vascular location. cardiovascular risk increased with the number of locations. data emphasize the necessity of early and aggressive treatment of cardiovascular risk factors in diabetes patients. background (and relevance): despite recent advances in medical treatment, cardiovascular disease (cvd) is still health problem number one in western societies. a multifactorial approach with the aid of nurse practitioners (nps) is beneficial for achieving treatment goals and reducing events in patients with manifest cvd. objectives (and question): in the self-management of vascular patients activated by internet and nurses (spain) pilot study, we want to implement and test a secure personalized website with additional treatment and coaching of a np for hypertension, hyperlipidemia, diabetes mellitus, smoking and obesity in patients with clinical manifestations of cvd. design and methods: interesting patients are going to use the secure patient-specific website. before the use of the web-application, risk factors are measured. realistic treatment goal(s) for elevated risk factors based on current guidelines are made and appointments how to achieve the treatment goal(s) are determined between the patients and the np in a face to face contact. patients can enter his/ her own weight or a new blood pressure measurement for instance, besides the regular exchange information with the responding np through e-mail messages. the np personally replies as quick as possible and gives regular but protocol driven feedback and support to the patient. the risk factors are remeasured after six months. conclusion and discussion: the spain study is aimed to implement and test a patient specific website. secondary outcome is the change in cardiovascular risk profile. the pre-post measurements of risk factors and the amount of corresponding e-mail messages between the patient and the np enhances the feasibility of this innovative way of risk factor management. background (and relevance): modification of vascular risk factors has been shown to be effective in reducing mortality and morbidity in patients with symptomatic atherosclerosis. nevertheless, reduction of risk factors in clinical practice is difficult to achieve and maintain. objectives (and question): in the risk management in utrecht and leiden evaluation (rule) study, a prospective, comparative study, we assess the effects of a multidisciplinary vascular screening program on improvement of the cardiovascular risk profile and to compare this to a setting without such a program that provides current standard practice in patients referred for cardiovascular disorders. design and methods: patients with diabetes mellitus, coronary artery disease, cerebrovascular disease, or peripheral arterial disease ( per disease category in each hospital) referred by the general practitioner will be enrolled, started january . at the umcu, patients need to be enrolled in the vascular screening program or will be identified through the hospital registration system. at the lumc patients will be identified through the hospital registration system. risk factors will be measured in the two hospitals at baseline and one year after their initial visit. a risk function will be developed for this population based on data of the whole cohort. analysis will be performed on the two comparison groups as a whole, and on subgroups per disease category. changes in risk factors will be assessed with linear or logistic regression procedures, adjusting for differences in baseline characteristics between groups. conclusion and discussion: the rule study is aimed to evaluate the added value of a systematic hospital based vascular screening program on risk factor management in patients at high risk for vascular diseases. background: signs of early cerebral damage are frequently seen on mri scans in elderly people. they are related to future manifest cerebrovascular disease and cognitive deterioration. cardiovascular risk factors can only partially explain their presence and progression. evidence that inflammation is involved in atherogenesis continues to accumulate. chronic infections can act as an inflammatory stimulus. it is possible that subclinical inflammation and chronic infections play a role in the pathogenesis of early cerebral damage. objectives (and question): to unravel the role of inflammation and chronic infection in the occurrence and progression of early cerebral damage in patients with manifest vascular disease. design and methods: participants of the smart study with manifest vascular disease underwent an mr investigation of the brain between may and december . starting in january of all patients are invited for a second mr of the brain after an average follow-up period of four years. both at baseline and after follow-up all cardiovascular risk factors are measured and blood samples are stored to assess levels of inflammatory biomarkers and antibodies against several pathogens. occurrence and progression of early cerebral damage is assessed by measuring the volume of white matter lesions, the number of silent brain infarctions, cerebral atrophy, aberrant metabolic ratios measured with mr spectroscopy and cognitive function at baseline and after follow-up. the relation between inflammation, chronic infection and the occurrence and progression of early cerebral damage will be investigated using both crosssectional and longitudinal analysis. abstract monocyte chemoattractant protein (mcp- ) polymorphism and susceptibility for coro-nary collaterals j.j. regieli , , j. koerselman , ng sunanto , , m. entius , p.p. de jaegere , y. van der graaf , d.e. grobbee , p.a. doevendans heart lung institute, dept of cardiology clinical epidemiology, julius center for health sciences and primary care, utrecht, netherlands background (and relevance): collateral formation is an important beneficial condition during an acute ischemic event. a marked interindividual variability in high risk patients is seen, but at present the basis for this variability is unclear and can not be explained solely by environmental factors. a genetic factor might be present that could influence coronary collateral formation. objectives (and question): we have analyzed the association between a single nucleotide polymorphism in mcp- and the formation of coronary collaterals in patients admitted for angioplasty. mcp- has been suggested to play an important role in collateral development. design and methods: this study involved caucasian patients who were admitted for coronary angioplasty. coronary collateral development was defined angiographically as rentropgrade ‡ . polymorphisms in the promoter region of mcp- () ) were identified by pcr and allele specific restriction digestion. this method allows identification of individuals with either aa, ag or gg at mcp- position ) . statistical analysis was performed using a x -test, unconditional logistic regression, likelihood ration and a wald's test. results: we could genotype of the patients. coronary collaterals (rentropgrade > ) were found in patients. the allele frequency for aa, ag and gg was . %, . % and . %, respectively. the dis-tribution of mcp- genotypes in subjects without collaterals was in hardy weinberg equilibrium. we found that individuals with g allele ( %) were more likely to have collaterals than those with homozygous aa (or . , % ci . to . ) adjusted for potential confounders. linear regression shows that the allele g increased the likelihood for collateral presence with a factor . . conclusion and discussion: this study provides evidence for a role for genetic variation of mcp- gene in the occurrence of coronary collaterals in high risk patients. until september patients with recently established clinically manifest atherosclerotic disease with > modifiable vascular risk factors were selected for the study. the mean self-efficacy scores were calculated for vascular risk factors (age, sex, vascular disease, weight, diabetes mellitus, smoking behavior, hypercholesterolemia, hypertension, and hyperhomocysteinemia). results: diabetes, overweight, and smoking, but none of the other risk factors, were significantly associated with the level of self-efficacy in these patients. patients with diabetes had lower self-efficacy scores ( . ) for exercise and controlling weight ( . ) than patients without diabetes ( . p = . ) and ( . p = . ) respectively. overweight patients scored low on controlling weight ( . and . p< . ) and choosing healthy food ( . and . p = . ) than patients who were on a healthy weight ( . and . ). conclusion and discussion: patients with vascular diseases appear to have high levels of self-efficacy regarding medication use ( . ), exercise ( . ), and controlling weight ( . ). in patients with diabetes, overweight and in smokers, self efficacy levels were lower. practice implications: in nursing care and research on developing self-efficacy based interventions, lower self-efficacy levels can be taken into account for specific vascular patient groups. background (and relevance): little is known about the role of serum uric acid in the metabolic syndrome and increased risk of cardiovascular disease. we investigated the association between uric acid levels and the metabolic syndrome in a population of patients with manifest vascular diseases and whether serum uric acid levels conveyed an increased risk for cardiovascular disease in patients with the metabolic syndrome. design and methods: this is a nested case-cohort study of patients originating from the second manifestations of arterial disease (smart) study. all patients had manifest vascular diseases, constituting peripheral artery disease, cerebral ischemia, coronary artery disease and abdominal aortic aneurysm. analyzing the relationship of serum uric acid with the metabolic syndrome, age, sex, creatinine clearance, alcohol and diuretics were considered as confounders. investigating the relationship of serum uric acid levels with the risk for cardiovascular disease, values were adjusted for age and sex. results: the metabolic syndrome was present in % of the patients. serum uric acid levels in patients with metabolic syndrome were higher compared to patients without ( . ± . mmol/l vs. . ± . mmol/l). serum uric acid concentrations increased with the number of components of the metabolic syndrome ( . mmol/l to . mmol/l) adjusted for age, sex, creatinine clearance, alcohol and use of diuretics. increased serum uric acid concentrations showed to be independently associated with the occurrence of cardiovascular events in patients without the metabolic syndrome (age en sex adjusted hr: . , % ci . - . ) , contrary to patients with the metabolic syndrome (adjusted hr: . , % ci . - . ). conclusion: elevated serum uric acid levels are strongly associated with the metabolic syndrome, yet are not linked to an increased risk for cardiovascular disease in patients with the metabolic syndrome. however, in patients without the metabolic syndrome elevated serum uric acid levels are associated with increased risk for cardiovascular disease. the objective of this study is to investigate the overall and combined role of late-life depression, prolonged psychosocial stress exposure, and stress hormones in the etiology of hippocampal atrophy and cognitive decline. design and methods: as part of the smart study, participants with manifest vascular disease underwent an mri of the brain between may and december . in a subsample of subjects, cognitive function and depressed mood were assessed. starting in january , all patients are invited for a follow-up mri of the brain. at this follow-up measurement, minor and major depression, hypothalamic-pituitary-adrenal (hpa) axis function indicated by salivary cortisol, psychosocial stress exposure indicated by stressful life events early and later in life, and cognitive functioning will also be assessed. the independent and combined effects of late-life depression, (change in) hpa-axis activity, and psychosocial stress exposure on risk of hippocampal atrophy and cognitive decline will be estimated with regression analysis techniques adjusting for potential confounders. introduction the netherlands epidemiological society advocates according to good epidemiological practice, that research with sound research questions and good methodology should be adequately published independent of the research outcomes. although reporting bias in clinical trials is fully acknowledged, failure to report outcomes or selective reporting of outcomes in non-clinical trial epidemiological studies is less well known, but most likely occurs as well. in this mini-symposium the netherlands epidemiological society wants to give attention to this phenomenon of not publishing research outcomes, to encourage publication of all outcomes of adequate research. different scopes to this subject will be addressed: the background, an example of occurrence, initiatives to possibly avoid it and an editor's point of view. selective reporting of outcomes in clinical studies (reporting bias) has been described to occur frequently. therefore a registration of clinical trials is started which enables to address this problem in the future since occurrence of not publishing negative or adverse outcomes can be investigated with this registration. in non-clinical epidemiological studies the failure to report outcomes or selective reporting of outcomes most likely occurs as well, but is less studied and reported. again studies with negative outcomes or no associations are the ones most likely not to be reported. the most important obstacles for not publishing no or negative associations are tradition and priorities of researchers and journals. the reviewers might play a role in this as well. the netherlands epidemiological society advocates according to good epidemiological practice, that research with sound research questions and good methodology should be adequately published independent of the research outcomes. however, reality occurs not to be accordingly. therefore we would like to give attention to this phenomenon of not publishing research outcomes in non-trial-based epidemiological studies, to encourage publication of all outcomes of adequate research. in this mini-symposium, firstly the effects of failure or selective publishing of outcomes on subsequent meta-analysis in a non-clinical research setting will be demonstrated. afterwards, initiatives to promote and improve publication of observational epidemiological research will be addressed, the editor's point of view on this phenomenon will be given and finally concluding remarks will be given. background: there are several reasons for suspecting reporting bias in time-series studies of air pollution. such bias could lead to false conclusions concerning causal associations or inflate estimates of health impact. objectives: to examine time-series results for evidence of publication and lag selection bias. design and methods: all published time-series studies were identified and relevant data extracted into a relational database. effect estimates were adjusted to an increment of lg/m . publication bias was investigated using funnel plots and two statistical methods (begg, egger). adjusted summary estimates were calculated using the ''trim and fill'' method. the effect of lag selection was investigated using data on mortality from us cities and from a european multi-centre panel study of children. results: there was evidence of publication bias in a number of pollutant-outcome analyses. adjustment reduced the summary estimates by up to %. selection of the most significant lag increased estimates by over % compared with a fixed lag. conclusion and discussion: publication and lag selection bias occurs in these studies but significant associations remain. presentation and publication of time-series results should be standardised. background: selective non-publication of study outcomes hampers the critical appraisal and appropriate interpretation of available evidence. its existence could be shown empirically in clinical trials. observational research often uses an exploratory approach rather than testing specific hypotheses. results of multiple data analyses may be selected based on their direction and significance. objectives: to improve the quality of reporting of observational studies. to help avoid selective non-publication of study outcomes. methods: ''strengthening the reporting of observational studies in epidemiology (strobe)'' is an international multidisciplinary initiative that currently develops a checklist of items recommended for the reporting of observational studies (http:// www.strobe-statement.org). results: strobe recommends to avoid selective reporting of 'positive' or 'significant' study results and to base the interpretation on main results rather than on results of secondary analyses. discussion: strobe cannot prevent data dredging, but it promotes transparency at the publication stage. for instance, if multiple statistical analyses were performed in a large dataset to identify new exposure-outcome associations, authors should give details and not only report significant associations. strobe could have a ''feedback effect'' on study quality since, ideally, researchers think ahead when a study is planned and consider points that are essential for later publication. good publishing practice begins with researchers considering ( ) whether an intended study can bring added value, irrespective its result, ( ) and whether its methodology is valid to pick up positive and negative outcomes equally well. when reporting ( ) they should adequately discuss the significance of a negative result ( ) and be as eager to publish negative results as positive ones. as to editors, intentional bias in relation to study results is considered editorial malpractice, whatever its motivation. unintentional bias may be more frequent but will not easily be noticed, also by editors. editorial responsibility implies several levels (accepting for review, choice of reviewers, assess their reviews, decision making, and a repeated process in case of resubmission). various designs for process evaluation can be considered. evaluation will be more difficult for journals with few professional support. collaboration between journals can help, and may also avoid 'self evaluation bias'. in line with registering of randomized trials, registers for observational study protocols could facilitate monitoring for bias and searching unpublished results. but practicalities, methodological requirements, and bureaucratic burden should not be underestimated. in principle, in an era of electronic publishing every study can be made widely accessible widely also if not 'accepted', by editors or authors themselves. however, this would need huge changes in culture of authoring and reading, editorial practice, publishing business, and scientific openness. background: high circulating levels of insulin-like growth factor-i (igf-i), a mitogenic and anti-apoptotic peptide, have been associated with increased risk of several cancer types. objective: to study circulating levels of igf-i and igf binding protein- (igfbp- ) in relation to ovarian cancer risk. design and methods: within the european prospective investigation into cancer and nutrition (epic), we compared levels of igf-i and igfbp- measured in blood samples collected at baseline in women who subsequently developed ovarian cancer ( women diagnosed before age ) and controls. results: the risk of developing ovarian cancer before age ('premenopausal' was increased among women in the middle or top tertiles of igf-i, compared to the lowest tertile: or = . [ % ci: . - . ], and or = . [ % ci: . - . ], respectively (p trend = . ). results were adjusted for bmi, previous hormone use, fertility problems and parity. adjustment for igfbp- levels slightly attenuated relative risks. in older women we observed no association between igf-i, igfbp- and ovarian cancer risk. discussion and conclusion: in agreement with the only other prospective study in this field (lukanova et al, int j cancer, ) , our results indicate that high circulating igf-i levels may increase the risk of premenopausal ovarian cancer. background: the proportion of glandular and stromal tissue in the breast (percent breast density) is a strong breast cancer risk factor. insulin-like growth factor (igf- ) is hypothesized to influence breast cancer risk by increasing breast density. objectives: we studied the relation between premenopausal circulating igf- levels and changes in breast density over menopause. design and methods: mammograms and blood samples of premenopausal participants of the prospect-epic cohort were collected at baseline. a second mammogram was collected after these women became postmenopausal. we determined serum igf- levels. mammographic density was assessed using a computer-assisted method. changes in percent density over menopause were calculated for quartiles of igf- , using linear regression, adjusted for age and bmi. results: premenopausal percent density was not associated with igf- levels (mean percent density . in all quartiles). however, women in the highest igf- quartile showed less decrease in percent density over menopause ( st quartile: ) . vs th quartile: ) . , p-trend = . ). this was mostly explained by a stronger decrease of total breast size in women with high igf- levels. conclusion and discussion: women with high igf- levels show a lower decrease of percent density over menopause than those with low igf- levels. background: body mass index (bmi) has been found to be associated with risk of colon cancer in men, whereas weaker associations have been reported for women. reasons for this discrepancy are unclear but may be related to fat distribution or use of hormone replacement therapy (hrt) in women. objective: to examine the association between anthropometry and risk of colon cancer in men and women. design and methods: during . years of followup, we identified cases of colon cancer among , subjects free of cancer at baseline from european countries. results: bmi was significantly related to colon cancer risk in men (rr per kg/ m , . ; %-ci . - . ) but not in women (rr . ; . - . ; p interaction = . ), whereas waist-hip-ratio (whr) was equally strong related to risk in both genders (rr per . , men, . ; %-ci . - . ; women, . ; . - . ; p interaction = . ). the positive association for whr was not apparent among postmenopausal women who used hrt. conclusions: abdominal obesity is an equally strong risk factor for colon cancer in both sexes and whr is a disease predictor superior to bmi in women. the association may vary depending on hrt use in postmenopausal women; however, these findings require confirmation in future studies. background: fruits and vegetables are thought to protect against colorectal cancer. recent cohort studies, however, have not been able to show a protective effect. patients & methods: the relationship between consumption of vegetables and fruit and the incidence of colorectal cancer within epic was examined among , subjects of whom developed colorectal cancer. a multivariate cox proportional hazard model was used to determine adjusted cancer risk estimates. a calibration method based on standardized -hour dietary recalls was used to correct for measurement errors. results: after adjustment for potential confounding and exclusion of the first two years of follow-up, the results suggest that consumption of vegetables and fruits is weakly, inversely associated with risk of colorectal cancer (hr . , . , . , . , . , for quintiles of intake, % ci upper quintile . - . , p-trend . ), with each gram daily increase in vegetables and fruit associated with a statistically borderline significant % reduction in colorectal cancer risk (hr . ; . - . ). linear calibration strengthened this effect. further subgroup analyses will be presented. conclusion: findings within epic support the hypothesis that increased consumption of fruits and vegetables may protect against colorectal cancer risk. a diverse consumption of vegetables and fruit may influence the risk of gastric and oesophageal cancer. diet diversity scores (dds) were calculated within the epic cohort data from > , subjects in european countries. four scores, counting the number of ffq-based food-items usually eaten at least once in two weeks, were calculated to represent the diversity in the overall vegetable and/or fruit consumption. after an average follow-up of . years, incident cases of gastric and oesophageal cancer were observed. cox proportional hazard models were used to compute tertile specific risks, stratified by follow-up duration, gender and centre and adjusted for total consumption of vegetables and fruit and potential confounders.preliminary findings suggest that, compared to individuals who eat from only or less vegetable sub-groups, individuals who usually eat from eight different subgroups, have a reduced gastric cancer risk (hr . ; % ci . - . ). in comparison to all others, individuals who usually eat only the same fruit may experience an elevated risk (hr . ; % ci . - . ). these findings from the epic study suggest that a diverse consumption of vegetables may reduce gastric and oesophageal cancer risk. subjects with a very low diversity in fruit consumption may experience higher risk. g. steindorf , l. friedenreich , j. linseisen , p. vineis , e. riboli for the epic group german cancer research center, heidelberg, germany alberta cancer board, alberta, canada imperial college london, great-britain background: previous research on physical activity and lung cancer risk, conducted predominantly in males, has yielded inconsistent results. objectives: we examined this relationship among , men and women from the epic-cohort. design and methods: during . years of follow-up we identified men and women with incident primary lung cancer. detailed information on recreational, household and occupational physical activity, smoking habits, and diet was assessed. relative risks (rr) were estimated using cox regression. results: we did not observe an inverse association between occupational, recreational or household physical activity and lung cancer risk either in males or in females. we found a modest reduction in lung cancer risk associated with sports in males and cycling in females. for occupational physical activity, lung cancer risk was increased for unemployed men (rr = . ; % confidence interval . - . ) and men with standing occupations (rr = . ; . - . ) compared with sitting professions. conclusion: our study shows no convincing protective associations of physical activity with lung cancer risk. discussion: it may be speculated that the elevated risks for occupational physical activity could reflect the higher probability that manual workers are exposed to industrial carcinogens compared to workers having sitting/office jobs. purposes: epidemiological research almost always means using data and, increasingly, human tissue as well. the use of these resources is not free but is subject to various regulations, which differ in the european countries on several important aspects. usually these regulations have been determined without involvement of active epidemiological researchers or patient organisations. this workshop will address the issues involved in these regulations in the european context. it will serve the following purposes: -to provide arguments and tools and to exchange best practices for a way out of the regulatory labyrinths especially in cross european research projects; -to provide a platform for epidemiologists and patient groups to discuss their concerns about impediments for epidemiological research with other parties, like data protection authorities. targeted audience: the mini symposium is primarily meant for epidemiologists, but provides an excellent opportunity to meet and discuss with other stakeholders, like from patient groups, data protection authorities, the european commission etc. as well. therefore program allows for extra time for discussion. the other stakeholders will be explicitly invited. a special 'day ticket' is available to satellite symposium epidemiology and the seventh eu research framework over the last few years the seventh eu research framework has been drafted. it is now rapidly moving towards the first calls for proposals. previous eu research programmes and frameworks have been criticised because they are considered to include too few possibilities for epidemiological research and public health research. this satellite-symposium will provide an outline of the research framework and inform researchers about the current state of affairs of the seventh eu research framework. special focus will be on the possibilities for epidemiology and public health research. - . welcome by our host prof. jan willem coebergh, rotterdam, introduction, international and national regulations on the use of data and tissue or research in europe, different approaches to: evert-ben van veen l.l.m. (medlawconsult, the netherlands) -'identifiability' of data -consent for using data and tissue for research the tubafrost code of conduct to exchange data and tissue across europe. . - . data and tissuebanking for research in denmark: a liberal approach the danish approach to use patient data for epidemiological research, cooperation of the danish data protection authority, the danish act of to use anonymous but coded tissue for research based on an opt-out system, first experiences hans storm ph.d. (copenhagen, denmark) . - . estonian data protection act: a disaster for epidemiology the story of the birth of the act, implementing the european data protection directive and of its consequences reveal political and administrative incapability resulting in gradual vanishing of register-based epidemiological research. background: non-invasive assessment of atherosclerosis is important. most of the evidence of coronary calcium has been based on images obtained by electron beam ct (ebct). current data suggest that ebct and multi-slice ct (msct) give comparable results. since msct is more widely available than ebct, information on its reproducibility is relevant. objective: to assess inter-scan reproducibility of msct and to evaluate whether reproducibility is affected by different measurement protocols, slice thickness, cardiovascular risk factors and technical variables. design: cross-sectional study. materials and methods: the study population comprised healthy postmenopausal women. coronary calcium was assessed in these women twice at two separate visits using msct (philips mx idt ). images were made using . and . mm slice thickness. the agatston, volume and mass scores were assessed. reproducibility was determined by mean differences, absolute mean differences and intra-class correlation coefficients (iccc). results: the reproducibility of coronary calcium measurements between scans was excellent with iccc of > . , and small mean and absolute mean differences. reproducibilility was similar for . as for . mm slices, and equal for agatston, volume and mass measurements. conclusion: inter-scan reproducibilility of msct is excellent, irrespective of slice thickness and type of calcium parameter. background: it has been suggested that the incidence of colorectal cancer is associated with socioeconomic status (ses). the major part of this association may be explained by known lifestyle risk factors such as dietary habits. objective: to explore the association between diet and ses measured at area-based level. methods: the data for this analysis were taken from a multi-centre case-control study conducted to investigate the association between some environmental, genetic factors and colorectal cancer incidence. the townsend scores (as deprivation index) were categorized into fifths. a linear regression analysis was used to estimate difference in mean of each continuous variable of diet by deprivation fifth. results: the mean of processed meat consumption in the most deprived area was higher compared to the mean of that in the most affluent areas (mean difference = . , % ci: . , . ). by contrast, the mean of vegetables and fruits consumption in the most deprived areas was lower than that in the affluent areas. conclusion: our findings suggest that lifestyle factors are likely to be related to ses. thus any relation between ses and colorectal cancer may direct us to seek for the role of different life style factors in aetiology of this cancer. background: the reason for the apparent decline in semen quality during the past years is still unexplained. objective: to investigate the effect of exposure to cigarette smoke in utero on the semen quality in the male offspring. design and methods: in this prospective follow-up study, adult sons of mothers, who during pregnancy provided information about smoking and other lifestyle factors, are sampled in six strata according to prenatal tobacco smoke exposure. each man provides a semen sample, a blood sample, and answers a questionnaire, which is collected in a mobile laboratory. external quality assessment of semen analysis is performed twice a year. results: until now, a total of men have been included. the participation rate is %. the percentage of men with decreased sperm concentration (< mill/ml) is %. the unadjusted median ( - % percentile) sperm concentration in the non-exposed group (n = ) is ( - ) mill/ml compared to ( - ) mill/ml among men exposed to > cigarettes per day in fetal life (n = aim: to estimate the prevalence of overweight and obesity, and their effects in physical activity (pa) levels of portuguese children and adolescents aged - years. methods: the sample comprises subjects ( females- males) attending basic/secondary schools. the prevalence of overweight and obesity was calculated using body mass index (bmi), and the cut-off points suggested by cole et al. ( ) . pa was assessed with the baecke et al. ( ) questionnaire. proportions were compared using chi-square tests and means by anova. results and conclusions: overall, . % were overweight (females = . %; males = . %) and . % were obese (females = . %; males = . %). prevalence was similar across age and gender. bmi changed with age (p< . ), and a significant interaction between age and gender was found (p = . ): whereas bmi in males increased with aging, in females increased up to years and stabilized onwards. males showed significantly higher values of pa (p< . ). both genders had a tendency to increase their pa until - years. a significant interaction between age and gender (p = . ) points out different gender patterns across age: pa increased with aging in males but in females started to decline after years. no significant differences in pa were found between normal weight, overweight and obese subjects (p = . ). background: atherosclerosis is an inflammatory process. however, the relation between inflammatory markers and extent and progression of atherosclerosis remains unclear. objectives: we studied the association between c-reactive protein (crp) and established measures of atherosclerosis. design and methods: within the rotterdam study, a population-based cohort of , persons over age , we measured crp, carotid plaque and intima-media thickness (imt), abdominal artery calcification, ankle-brachial index (abi) and coronary calcification. using ancova, we investigated the relation between crp and extent of atherosclerosis. we studied the association between progression of extra coronary atherosclerosis (mean follow-up period: . years) and crp using multinomial regression analysis. results: crp levels were positively related to all measures of atherosclerosis, but the relation was weaker for measures based on detection of calcification only. crp levels were associated with severe progression of carotid plaque (multivariable adjusted odds ratio: . , % ci: . - . ), imt ( . , . - . ) and abi ( . , . - . ). no relation was observed with progression of abdominal artery calcification. conclusion and discussion: crp is related to extent and progression of atherosclerosis. the relation seems weaker for measures based on detection of calcification only, indicating that calcification of plaques might attenuate the inflammatory process. background: maternal stress during pregnancy has been reported to have an adverse influence on fetal growth. the terrorist attacks of september , on the united states have provoked feelings of insecurity and stress worldwide. objective: our aim was to test the hypothesis that maternal exposure to these acts of terrorism via the media had an unfavourable influence on mean birth weight in the netherlands. design and methods: in a prospective cohort study, we compared birth weights of dutch neonates who were in utero during the attacks with those of neonates who were in utero exactly year later. results: in the exposed group, birth weight was lower than in the non-exposed group (difference, g, %ci . , . , p = . ). the difference in birth weight could not be explained by tobacco use, maternal age, parity or other potential confounders, nor by shorter pregnancy durations. conclusion: these results provide evidence supporting the hypothesis that exposure of dutch pregnant women to the september events via the media has had an adverse effect on the birth weight of their offspring. objective: asian studies suggested potential reduction in the risk of pneumonia among patients with stroke on ace-inhibitor therapy. because of the high risk of pneumonia in patients with diabetes we aimed to assess the effects of ace-inhibitors on the occurrence of pneumonia in a general, ambulatory population of diabetic patients. methods: a case-control study was performed nested in , patients with diabetes. cases were defined as patients with a first diagnosis of pneumonia. for each case, up to controls were matched by age, gender, practice, and index date. current ace-inhibitor use was defined within a time-window encompassing the index date. results: ace-inhibitors were used in . % of , cases and in , % of , matched controls (crude or: . , % ci . to . ). after adjusting for potential confounders, ace-inhibitor therapy was associated with a reduction in pneumonia risk (adjusted or: . , % ci . to . ). the association was consistent among different relevant subgroups (stroke, heart failure, and pulmonary diseases) and showed a strong dose-effect relationship (p< . ). conclusions: use of ace-inhibitors was significantly associated with reduced pneumonia risk and may apart from blood pressure lowering properties be useful in prevention of respiratory infections in patients with diabetes. background: progressive decline in serum levels of testosterone occurs with normal aging in both men and women. this is paralleled by a decrease in physical performance and muscle strength, which may lead to disability, institutionalization and mortality. objective. we examined whether low levels of testosterone were associated with three-year decline in physical performance and muscle strength in two population-based samples of older men and women. methods: data were available for men in the longitudinal aging study amsterdam (lasa) and men and women in the health, aging, and body composition (health abc) study. levels of total testosterone and free testosterone were determined at baseline. physical performance and grip strength were measured at baseline and after three years. results: total and free testosterone were not associated with change in physical performance or muscle strength in men. in women, low levels of total testosterone (<= ng/dl) increased the risk of decline in physical performance (p = . ), and low levels of free testosterone (< pg/ ml) of decline in muscle strength (p = . ). conclusion: low levels of total and free testosterone were associated with decline in physical performance and muscle strength in older women, but not in older men. background: obesity and physical inactivity are key determinants of insulin resistance, and chronic hyperinsulinemia may mediate their effects on endometrial cancer (ec) risk. aim: to examine the relationships between prediagnostic serum concentrations of cpeptide, igf binding protein (igfbp)- and igfbp- , and ec risk. methods: we conducted a case-control study nested within the epic prospective cohort study, including incident cases of ec, in pre-and post-menopausal women, and matched control subjects. odds ratios (or) and % confidence intervals (ci) were calculated using conditional logistic regression models. results: in fasting women (> h since last meal), serum levels of c-peptide, igfbp- and igfbp- were not related to risk. however, in nonfasting women ( h or less since last meal), ec risk increased with increasing serum levels of c-peptide ( background: tobacco is the single most preventable cause of death in the world today. tobacco use primarily begins in early adolescent. objective: to estimate the prevalence and evaluate factors associated with smoking among high school going adolescents in karachi, pakistan. methods: a school based cross sectional survey was conducted in three towns of karachi from january through may . two-stage cluster sampling stratified on school types was employed to select schools and students. self-reported smoking status of school going adolescents was our main outcome in analysis. results: prevalence of smoking ( days) among adolescents was . %. multiple logistic regression model showed that after adjustment for age, ethnicity and place of residence, being student of a government school (or= . ; % ci: . - . ), parental smoking (or = . ; % ci: . - . ), uncle (or = . ; % ci: . - . ) , peer smoking (or = . ; % ci: . - . ) and spending leisure time outside home (or = . ; % ci . - . ) were significantly associated with adolescents smoking. conclusion: a . % prevalence of smoking among school going adolescents and influence of parents and peers in initiating smoking in this age group warrant the need for effective tobacco control in the country especially among the adolescents. background: individual patient data meta-analyses (ipd-ma) have been proposed to improve subgroup analyses that may provide clinically relevant information. nevertheles, comparison of the effect estimates of ipd-ma and meta-analyses of published data (map) are lacking. objective: to compare main and subgroup effect estimates of ipd-ma and map. methods: an extended literature search was performed to identify all ipd-ma of randomized controlled trials, followed by a related article search to identify maps with a similar domain, objective, and outcome. data were extracted regarding number of trials, number of subgroups, effect measure, effect estimate and their confidence intervals. results: in total ipd-ma and map could be included in the analysis. twentyfive main effect estimates could be compared; of which were in the same direction. although over subgroups were studied in both ipd-ma and map, only effect estimates could be compared; were in the same direction. subgroup analyses in map most often related to trial characteristics, whereas subgroup analyses in ipd-ma were related to patient characteristics. conclusion: comparable ipd-ma and map report similar main and subgroup effect estimates. however, ipd-ma more often study subgroups based on patient characteristics, and thus provide more clinically relevant information. patients with diabetes have an increased risk of a complicated course of community-acquired lower respiratory tract infections. although influenza vaccination is recommended for these persons, vaccination levels remain too low because of conflicting evidence regarding potential benefits. as part of the prisma nested casecontrol study among , persons recommended for vaccination, we studied the effectiveness of single and repeat influenza vaccination in the subgroup of adult diabetic population ( , ) during the - influenza a epidemic. case patients were hospitalized for diabetes, acute respiratory or cardiovascular events, or died and controls were sampled from the baseline cohort. after control for age, gender, health insurance, prior health care, medication use and co-morbid conditions logistic regression analysis showed that the occurrence of any complication ( hospitalizations, deaths) was reduced by % ( % confidence interval % to %). vaccine effectiveness was similar for those who received the vaccine for the first time and for those who received an earlier influenza vaccination. although we did not perform virological analysis or distinguish type i from type ii diabetes we conclude that patients with diabetes benefit substantially from influenza vaccination independent of whether they received the vaccine for the first time or received earlier influenza vaccinations. background: construction workers are at risk of developing silicosis. regular medical evaluations to detect silicosis preferably in the pre-clinical phase are needed. objectives: to identify the presence or absence of silicosis by developing an easy to use diagnostic model for pneumoconiosis from simple questionnaires and spirometry. design and methods: multiple logistic regression analysis was done in dutch construction workers, using chest x-ray indicative for pneumoconiosis (ilo profusion category > / ) as the reference standard (prevalence . %). model calibration was assessed with graph and the hoshmer-lemeshow goodness of fit test; discriminative ability using area under receiver operating characteristic curve (auc); and internal validity using bootstrapping procedure. results: age > years, current smoking, high exposure job title, working > years in the construction industry, 'feeling unhealthy', and standardized residual fev below ) . were selected as predictors. the diagnostic model showed a good calibration (p = . ) and discriminative ability (auc . ; % ci . to . ). internal validity was reasonable (correction factor of . and optimism corrected auc of . ). conclusions: and discussion: our diagnostic model for silicosis showed reasonable performance and internal validity. to apply the model with confidence, external validation before application in a new working population is recommended. background: artemisinin based combination therapy (act) reduces microscopic gametocytaemia, the malaria parasite stage responsible for transmission from man to mosquito. as a result, act is expected to reduce the burden of disease in african populations. however, molecular techniques recently revealed high prevalences of gametocytaemia below the microscopic threshold. our objective was to determine the importance of sub-microscopic gametocytaemia after act treatment. methods: kenyan children (n= ) aged months - years were randomised to four treatment regimens. gametocytaemia was determined by microscopy and pfs real-time nucleic acid sequence-based amplification (qt-nasba). transmission was determined by membrane feedings. findings: gametocyte prevalence at enrolment was . % ( / ) as determined by pfs qt-nasba and decreased after treatment with act. membrane feedings in randomly selected children revealed that the proportion of infectious children was up to fourfold higher than expected when based on microscopy. act did not significantly reduce the proportion of infectious children but merely the proportion of infected mosquitoes. interpretation: sub-microscopic gametocyte densities are common after treatment and contribute considerably to mosquito infection. our novel approach indicates that the effect of act on malaria transmission is much smaller than previously suggested. these findings are sobering for future interventions aiming to reduce malaria transmission. background: adequate folate intake may be important in the prevention of breast cancer. factors linked to folate metabolism may be relevant to its protective role. objectives: to investigate the association between folate intake and breast cancer risk among postmenopausal women and evaluate the interaction with alcohol and vitamin b intake. methods: a prospective cohort analysis of folate intake among , postmenopausal women from the e n french cohort who completed a validated food frequency questionnaire in was conducted. during years follow-up , cases of pathology-confirmed breast cancer were documented through followup questionnaires. nutrient intakes were categorized in quintiles and energy-adjusted using the regression-residual method. cox modelderived relative risks (rr) were adjusted for known risk factors for breast cancer. results: the multivariate rr comparing the extreme quintiles of folate intake was . ( % ci . - . ; p-trend= . ). after stratification, the association was observed only among women whose alcohol consumption was above the median (= . g/day) and among women who consumed = . lg/day of vitamin b . however, tests for interaction were not significant. conclusions: in this population, high intakes of folate were associated with decreased breast cancer risk; alcohol and vitamin b intake may modify the observed inverse association. background: the simultaneous rise in the prevalence of obesity and atopy in children has prompted suggestions that obesity might be a causal factor in the inception of atopic diseases. objective: we investigated the possible role of ponderal index (kg/m ) as marker for fatness at birth in early childhood atopic dermatitis (ad) in a prospective birth cohort study. methods: between november and november , mothers and their newborns were recruited after delivery at the university of ulm, germany. active follow-up was performed at the age of months. results: for ( %) of the children included at baseline, information on physician reported diagnosis of ad was obtained during follow-up. incidence of ad was . % at the age of one year. mean ponderal index at birth was . kg/m . risk for ad was higher among children with high ponderal index at birth (adjusted or for children within the third and fourth compared to children within the second quartile of ponderal index: . ; % ci . respectively) background: the relationship between duration of breastfeeding and risk of childhood overweight remains inconclusive, possibly in part caused by using never breastfeeding mothers as the reference category. objectives: we assessed the association between duration of breastfeeding and childhood overweight among ever breastfed children within a prospective birth cohort study. methods: between november and november all mothers and their newborns were recruited after delivery at the university of ulm, germany. active follow-up was performed at age months. results: among children ( % of children included at baseline) with available body mass index at age two ( . %) were overweight. whereas children ( . %) were never breastfed, ( . %) were breastfed for at least six months, and ( . %) were exclusively breastfed for at least six months. compared to children who were exclusively breastfed less than three months, the adjusted or for overweight was . ( % ci . ; . ) in children who were exclusively breastfed for at least three but less than six months and . ( % ci . ; . ) in children who were exclusively breastfed for at least six months. conclusion: these results highlight the importance of prolonged breastfeeding in the prevention of overweight in children. background: in africa, hiv and feeding practices influence child mortality. exclusive breastfeeding for months (bf ) and formula feeding (ff) when affordable are two who recommendations for safe feeding. objective: we estimated the proportion and the number of children saved with each recommendation at population level. design and methods: data on sub-saharan countries were analysed. we considered saved a child remaining hiv-free and alive after two years of life. a spreadsheet model based on a decision tree for risk assessment was used to calculate this number according to six scenarios that combine the two recommendations without and with promotion then with promotion and group education. results: whatever the country, the number of children saved with bf would be higher than with ff. overall, without promotion, ( background: farming has been associated with respiratory symptoms as well as protection against atopy. effects of different farming practices on respiratory health in adults have rarely been studied. objectives: we studied associations between farming practices and hay fever and current asthma in organic and conventional farmers. design and methods this cross-sectional study evaluated questionnaire data of conventional and organic farmers. associations between health effects and farm exposures were assessed by logistic regression. results: organic farmers reported slightly more hay fever than conventional farmers ( . % versus . %, p = . ). however, organic farming was no independent determinant for hay fever in multivariate models including farming practices and potential confounders. livestock farmers who grew up on a farm had a five-fold lower prevalence of hay fever than crop farmers without farm childhood (or . , % ci . - . ). use of disinfectants containing quaternary ammonium compounds was positively related to hay fever (or . , % ci . - . ). no effects of farming practices were found for asthma. conclusion and discussion: our study adds to the evidence that a farm childhood in combination with current livestock farming protects against allergic disorders. this effect was found for both organic and conventional farmers. background: although a body mass index (bmi) above kg/m is clearly associated with an increase in mortality in the general population, the meaning of high levels of bmi among physically heavily working men is less clear. methods: we assessed the association between bmi and mortality in a cohort of male construction workers, aged - years, who underwent an occupational health examination in wu¨rttemberg (germany) during - and who were followed over a years period. covariates considered in the proportional hazard regression analysis included age, nationality, smoking status, alcohol consumption, and comorbidity. results: during the follow-up deaths occurred. there was a strong u-shaped association between bmi and all-cause mortality, which was lowest for bmi levels between and kg/m . this pattern persisted after exclusion of the first years of follow-up and control for multiple covariates. compared with men with a bmi < . kg/m , the relative mortality was . ( % confidence interval: , - , ), . ( . - . ) and . ( . - . ) for bmi ranges - . , - . and = . kg/m . conclusion and discussion: bmi levels commonly considered to reflect overweight or moderate obesity in the general population may be associated with reduced mortality in physically heavily working men. background: colonoscopy with removal of polyps may strongly reduce colorectal cancer (crc) incidence and mortality. empirical evidence for optimal schedules for surveillance is limited. objective. to assess risk of proximal and distal crc after colonoscopy with polypectomy. design and methods: history and results of colonoscopies were obtained from cases and controls in a population-based case-control study in germany. risk of proximal and distal crc according to time since colonoscopy was compared to risk of subjects without previous colonoscopy. results: subjects with previous detection and removal of polyps had a much lower risk of crc within four years after colonoscopy (adjusted odds ratio . , % confidence interval . - . ), and a similar risk as those without colonoscopy in the long run. within four years after colonoscopy, risk was particularly low if only single or small adenomas were detected. most cancers occurring after polypectomy were located in the proximal colon, even if polyps were found in the sigma or rectum only. conclusion and discussion: our results support suggestions that surveillance colonoscopy after removal of single and small adenomas may be deferred to five years and that surveillance should include the entire colorectum even if only distal polyps are detected. background: a population-based early detection programme for breast cancer has been in progress in finland since . recently, detailed information about actual screening invitation schemes in - has become available in electronic form, which enables more specific modeling of breast cancer incidence. objectives: to present a methodology for taking into account historical municipality-specific schemes of mass screening when constructing predictions for breast cancer incidence. to provide predictions for numbers of new cancer cases and incidence rates according to alternative future screening policies. methods: observed municipality-specific screening invitation schemes in finland during - were linked together with breast cancer data. the incidence rate during the observation period was analyzed using poisson regression, and this was done separately for localized and nonlocalized cancers. for modeling, the screening programme was divided into seven different phases. alternative screening scenarios for future mass-screening practices in finland were created and an appropriate model for incidence prediction was defined. results and conclusion: expanding the screening programme would increase the incidence of localized breast cancers; the biggest increase would be obtained by expanding from women aged - to - . the impacts of changes in the screening practices on predictions for non-localized cancers would be minor. background: new screening technologies are implemented to routine screening in increasing numbers, with limited evidence on their effectiveness. randomised evaluation of new technologies is encouraged but rarely done. objective: to evaluate in a randomised design whether the effectiveness of an organised cervical screening programme can be improved by means of new technologies. methods: since , - , women have been invited annually to a randomised multi-arm trial ran within the finnish organised cervical screening programme. the invited women are randomly allocated to three study arms of different primary screening tests: conventional cytology, automation-assisted cytology and, since , human papillomavirus (hpv) testing. up to , we have gathered information on , screening visits in the automation-assisted arm and , in the hpv arm, and we have compared the results to conventional screening. results: automation-assistance resulted in a slightly increased detection of precancers, but the efficacy based on interval cancers is not known. results on hpv screening suggest higher detection of precancers and cancers compared to conventional screening. conclusion: evidence of higher effectiveness of new screening technologies is needed, especially when changing the existing screening programmes. the multi-arm trial shows how these technologies can be implemented to routine in a controlled manner. introduction: nodules and goitres are important risk factors for thyroid cancer. as the number of diagnosed cases of thyroid cancer is increasing, the incidence of such risk factors has been assessed in a french cohort of adults. methods: the su.vi.max (supple´mentation en vitamines et mine´raux antioxydants) cohort study included middle-aged adults followed-up during eight years. incident cases of goitres and nodules have been identified retrospectively by scheduled clinical examinations and spontaneous consultations by the participants. cox proportional hazards modeling was used to identify factors associated to thyroid diseases. results: finally, incident cases of nodules and goitres were identified among , subjects free of thyroid diseases at inclusion. after an average follow-up of years, the incidence of goitres and nodules was . % in - year old men, . % in - year old women and . % in - year old women. identified associated factors were age, low urinary thiocyanate level and oral contraceptive use in women, and high urinary thiocyanate level and low urinary iodine level in men. conclusion: estimated incidences are consistent with those observed in other countries. the protective role of urinary thiocyanate in both men and women and, in women, oral contraceptives deserve further investigation. background: various statistical methods for outbreak detection in hospital settings have been proposed in the literature. usually validation of those methods is difficult, because the long time series of data needed for testing the methods are not available. modeling is a tool to overcome that difficulty. objectives: to use model generated data for testing sensitivity and specificity of different outbreak detection methods. methods: we developed a simple stochastic model for a process of importation and transmission of infection in small populations (hospital wards). we applied different statistical outbreak detection methods described in the literature to the generated time series of diagnosis data and calculated and the sensitivity and specificity of different methods. results: we present roc curves for the different methods and show how they depend on the underlying model parameters. we discuss how sensitivity and specificity measures depend on the degree of underdiagnosis, on the ratio of admitted colonised patients to colonisation resulting from transmission in the hospital, and on the frequency of testing patients for colonisation. conclusions: modeling can be a useful tool for evaluating statistical methods of outbreak detection especially in situation where real data is scarce or its quality questionable. associated with higher mammographic density and breast pain, has been increased which has bearing on screening performance. objective: we compared the screening performance for women aged - years with dense and lucent breast patterns in two time periods and studied the possible interaction with use of hrt. methods: data were collected from a dutch regional screening programme for women referred in - (n = ) and - (n = ) . in addition, we sampled controls for both periods that were not referred (n = and n = resp.) and women diagnosed with an interval cancer. mammograms were digitised and computer-assisted methods used to measure mammographic density. among other parameters, sensitivity was calculated to describe screening performance. results: screening performance has improved slightly, but the difference between dense and lucent breast patterns still exists (e.g. sensitivity % vs. %). hrt use has increased; sensitivity was particularly low ( %) in the group of women with dense breast patterns on hrt. discussion: in conclusion, the detrimental effect of breast density and the interaction with hrt on screening performance warrants further research with enlargement of the catchment area, more referred women, interval cancers and controls. background: population based association studies might lead to false-positive results if possibly underlying population structure is not adequately accounted for. to assess the nature of the population structure some kind of cluster analysis has to be carried out. we investigated the use of self-organizing maps (soms) for this purpose. objectives: the two main questions concern identification of an either discrete or an admixed population structure and identification of the number of subpopulations involved in forming the structured population under investigation. design and methods: we simulated data sets with different population models and included varying informative marker and map sizes. sample sizes ranged from to individuals. results: we found that a discrete structure can easily be accessed by soms. a near to perfect assignment of individuals to their population of origin can be obtained. for an admixed population structure though, soms do not lead to reasonable results. here, even the correct number of subpopulations involved can not be identified. conclusion: in conclusion, soms can be an alternative to a model-based cluster analysis if the researcher assumes a discrete structure but should not be applied if an admixed structure is likely. background: little is known about the combined effect of duration of breastfeeding, sucking habits and malocclusion in the primary dentition. objectives: we studied the association of breastfeeding and non-nutritive sucking habits on malocclusion on the primary dentition. design and methods: a cross-sectional study nested in a birth cohort was carried out in pelotas, brazil. a random sample of children aged was examined and their mothers interviewed. the foster and hamilton criteria were used to define anterior open bite (aob) and posterior cross bite (pcb). information regarding breastfeeding and non-nutritive sucking habits was collected from birth to years-old. poisson's regression analysis was used. results: non-nutritive sucking habits between months and years of age (pr . [ . ; . ] ) and digital sucking at years of age (pr . [ . ; . ]) were risk factors for aob. breastfeeding for less than months (pr . [ . ; . ] ) and the regular use of a pacifier between months and years of age (pr . [ . ; . ]) were the risk factors for pcb. for pcb an interaction was identified between lack of breastfeeding and the use of a pacifier. conclusion: lack of breastfeeding and longer non-nutritive sucking habits during early childhood were the main risk factors for malocclusion in primary dentition. background: recent, dramatic coronary heart disease (chd) mortality increases in beijing, can be mostly explained by adverse changes in risk factors, particularly total cholesterol and diabetes. it is important for policy making to predict the impact of future changes in risk factors on chd mortality trends. objective: to assess the potential impact of changes in risk factors on numbers of chd deaths in beijing from to , to provide evidence for future chd strategies. design: the previously validated impact model was used to estimate the chd deaths expected in a) if recent risk factor trends continue or b) if levels of risk factors reduce. results: continuation of current risk factor trends will result in a % increase in chd deaths by , (almost half being attributable to increases in total cholesterol levels). even optimistically assuming a % annual decrease in risk factors, chd deaths would still rise by % because of population ageing. conclusion: a substantial increase in chd deaths in beijing may be expected by . this will reflect worsening risk factors compounded by demographic trends. population ageing in china will play an important role in the future, irrespective of any improvements in risk factor profiles. background: since smoking cessation is more likely during pregnancy than at other times, interventions to maintain quitting postpartum may give the best opportunity for a long-time abstinence. it is still not clear what kind of advice or counseling should be given to help prevent the relapse postpartum. objectives: to identify the factors, which predispose women to smoking relapse after delivery. design and methods: the cohort study was conducted in and in public maternity units in lodz, poland. the study population consisted of pregnant women between - weeks of pregnancy who have quit smoking no later than three months prior to participation in the study. smoking status was verified using saliva cotinine level. women were interviewed twice: during pregnancy and three months after delivery. results: within three months after delivery about half of women relapsed into smoking. the final model identified the following risk factors for smoking relapse: having partner and friends who smoke, quitting smoking in late pregnancy, and negative experiences after quitting smoking such as dissatisfaction with weight, nervousness, irritation, loosing pleasure. conclusion. this study advanced the knowledge of the factors that determine smoking relapse after delivery and provided preliminary data for future interventions. introduction: it remains difficult to predict the effect of an particular antihypertensive drug in an individual patient and pharmacogenetics might optimise this. objective: to investigate whether the association between use of angiotensin converting enzyme (ace)-inhibitors or ß-blockers and the risk of stroke or myocardial infarction (mi) is modified by the t-allele of the angiotensinogen m t polymorphism. methods: data were used from the rotterdam study, a population-based prospective cohort study. in total, subjects with hypertension were included from july st, onwards. follow-up ended at the diagnosis of mi or stroke, death, or the end of study period (january st, ) . the drug-gene interaction and the risk of mi/stroke was determined with a cox proportional hazard model (adjusted for each drug class as time-dependent covariates). results: the interaction between current use of ace-inhibitors and the angiotensinogen m t polymorphism increased the risk of mi (synergy index (si) = . ; % ci: . - . ) and non-significant increased risk of stroke (si = . ; % ci: . - . ). no interaction was found between current use of ß-blockers and the agt m t polymorphism on the risk of mi or stroke. conclusion: subjects with at least one copy of the t allele of the agt gene might have less benefit from ace-inhibitor therapy. [ . - . ] to . [ . - . ] in those without ms-idf and . [ . - . ] with ms-idf. ms-ncep had no effect. conclusion and discussion: although cardiovascular disease was self-reported, we conclude that the higher prevalence of cardiovascular disease is partly accounted for by marked differences in the prevalence of metabolic syndrome. the ms-idf criteria seem better for defining metabolic syndrome in ethnic groups than the ms-ncep criteria. background: selenium is an essential trace mineral with antioxidant properties. objective: to perform meta-analyses of the association of selenium levels with coronary heart disease (chd) endpoints in observational studies and the efficacy of selenium supplements in preventing chd in randomized controlled trials. methods: we searched medline and the cochrane library from through . relative risk (rr) estimates were pooled using an inversevariance weighted random-effects model. for observational studies reporting three or more categories of exposure we conducted a dose-response meta-analysis. results: twenty-five observational studies and clinical trials met our inclusion criteria. the pooled rr comparing the highest to the lowest categories of selenium levels was . ( % confidence interval . - . ) in cohort studies and . ( . - . ) in case-control studies. in dose-response models, a % increase in selenium levels was associated with a % ( - %) reduced risk of coronary events. in randomized trials, the rr comparing participants taking selenium supplements to those taking placebo was . ( . - . ). conclusion: selenium levels were inversely associated with the risk of chd in observational studies. the randomized trials findings are still inconclusive. these results require confirmation in randomised controlled trials. currently, selenium supplements should not be recommended for cardiovascular prevention. background propensity score analysis (psa) can be used to reduce confounding bias in pharmacoepidemiologic studies of the effectiveness and safety of drugs. however, confidence intervals may be falsely precise because psa ignores uncertainty in the estimated propensity scores. objectives: we propose a new statistical analysis technique called bayesian propensity score analysis (bpsa). the method uses bayesian modelling with the propensity score as a latent variable. our question is: does bpsa yield improved interval estimation of treatment effects compared to psa? our objective is: to implement bpsa using computer programs and investigate the performance of bpsa compared to psa. design and methods: we investigated bpsa using monte carlo simulations. synthetic datasets, of sample size n = , , , were simulated by computer. the datasets were analyzed using bpsa and psa and we estimated the coverage probability of % credible intervals. results the estimated coverage probabilities ranged from % to % for bpsa, and from % to % for psa, with simulation standard errors less than %. background: several factors associated with low birth weight, such as smoking and body mass index (bmi) do not explain all ethnic differences. this study investigates the effects of working conditions on birth weight among different ethnic groups. methods: questionnaire data, filled in weeks after prenatal screening, was used from the amsterdam born children and their development (abcd) study (all pregnant women in amsterdam [ / / - / / (n = . ), response ( %)]. ethnicity (country of birth). was dichotomised into dutch and non-dutch. working conditions were: weekly working hours, weekly hours standing/walking, physical load and job-strain (karasek-model). only singleton deliveries with pregnancy duration = weeks were included. results: although only . % of the non-dutch women worked during first trimester ( . % of the dutch women), they reported significantly more physical load ( . % vs . %), more hours standing/walking ( . % vs . %) and more high job-strain ( . vs . ). linear regression revealed that only high job-strain lowered significantly birth weight (non-dutch: gram and dutch: gram). after adjusting for confounders (gender, parity, smoking, maternal length, maternal bmi and education), this was only significant in the non-dutch group ( vs. gram). conclusion: job-strain has more effect on birth weight in non-dutch compared to dutch women. background: in panama population was estimated in . million habitants, from which three millions lived in malaria endemic areas. until january malaria control activities were accomplished under a vertical structure. objective: to evaluate the evolution of malaria control in panama, before and after the decentralization of the malaria program. design and methods: average (standard deviation) of the program indexes are described for the last decades. the correlation between positive smears index and per capita cost of the program is analyze. results: in the 's the average (standard deviation) positive smears index per habitants was . % ( . ); in the 's: . % ( . ); in the 's: . % ( . ); in the 's: . % ( . ); and in the first five years of : . % ( . ). after the decentralization of the program was accomplished in , the positive smears index increased . fold. the average per capita cost involved in malaria control activities per decade ranged between . y . us dollars and presented a determination coefficient of . in the reduction of the positive smears index. discussion: the decentralization had significant detrimental implications in the control program capabilities. background: notification rates of new smear-positive tuberculosis in the central mountainous provinces ( / , population) are considerably lower than in vietnam in general ( / , population). this study assessed whether this is explained by low case detection. objective: to assess the prevalence and case detection of new smear-positive pulmonary tuberculosis among adults with a prolonged cough in central mountainous vietnam. design and methods: a house-to-house survey of adults years or older was carried out in randomly selected districts in three mountainous provinces in central vietnam in . three sputum specimens were microscopically examined of persons reporting a cough of weeks or longer. results: the survey included , persons with a response of %. a cough of weeks or longer was reported by , ( . % % ci . - . ) persons. of these, were sputum smear-positive of whom had had anti-tuberculosis treatment. the prevalence of new smear-positive tuberculosis was / , population ( % ci - / , population). the patient diagnostic rate was . per person-year, suggesting that the case notification rate as defined by who was %. conclusion: low tuberculosis notification rates in mountainous vietnam are probably due to low tuberculosis incidence. explanations for low incidence at high altitude need to be studied. background: although patients with type diabetes (dm ) have an increased risk of urinary tract infections (utis), not much is known about predictors of a complicated course. objective: this study aims to develop a prediction rule for complicated utis in dm patients in primary care. design and methods: we conducted a -month prospective cohort study, including dm patients aged years or older from the second dutch national survey of general practice. the combined outcome measure was defined as the occurrence of recurrent cystitis, or an episode of acute pyelonephritis or prostatitis. results: of the , dm patients % was male and mean age was years (sd ). incidence of the outcome was per patient years (n = ). predictors were age, male sex, number of physician contacts, incontinence of urine, cerebro vascular disease or dementia and renal disease. the area under the receiver-operating curve (auc) was . ( % ci . to . ). subgroup analyses for gender showed no differences. there is an increased early postoperative mortality (operation risk) after elective surgery. this mortality is normally associated with cardiovascular events, such as deep venous thrombosis, pulmonary embolism, and ischemic heart diseases. our objective was to quantify the magnitude of the increased mortality and how long the mortality after an operation persists. we focused on the early postoperative mortality after surgery for total knee and total hip replacements from the national registries in australia and norway, which cover more than % of all operations in the two nations. only osteoarthritis patients between and years of age were included. a total of . patients remained for analyses. smoothed intensity curves were calculated for the early postoperative period. effects of risk factors were studied using a nonparametric proportional hazards model. the mortality was highest immediately after the operation ($ deaths per . patients per day), and it decreased until the rd postoperative week. the mortality was virtually the same for both nations and both joints. mortality increased with age and was higher for males than for females. a possible reduction of early postoperative mortality is plausible for the immediate postoperative period, and no longer than the rd postoperative week. background/objectives: single, modifiable risk factors for stroke have been extensively studied before, but their combined effects were rarely investigated. aim of the present study was to assess single and joint effects of risk factors on stroke and transitoric ischemic attack (tia) incidence in the european prospective investigation into cancer and nutrition (epic)-potsdam study. methods: among participants aged - years at baseline total stroke cases and tia cases occurred during . years of follow-up. relative risks (rr) for stroke and tia related to risk factors were estimated using cox proportional hazard models. results: after adjustment for potential confounders rr for ischemic stroke associated with hypertension was . ( % ci, . - . ) and for tia . ( % ci . - . ). the highest rr for ischemic stroke (rr . , % ci . - . , p trend< . ) and tia (rr . , % ci . - . , p trend= . ) were observed among participants with or modifiable risk factors. . % of ischemic strokes and . % of tia cases were attributable to hypertension, diabetes mellitus, high alcohol consumption, hyperlipidemia, and smoking. conclusion: almost % of ischemic stroke cases could be explained by classical modifiable risk factors. however, only one in four tia cases was attributable to those risk factors. background: the investigation of genetic factors is gaining importance in epidemi-ology. most relevant from a public health perspective are complex diseases that are characterised by complex pathways involving gene-gene-and gene-environment-interactions. the identification of such pathways requires sophisticated statistical methods that are still in their infancy. due to their ability in describing complex association structures, directed graphs may represent a suitable means for modelling complex causal pathways. objectives: we present a study plan to investigate the appropriateness for using directed graphs for modelling complex pathways in association stud-ies. design and methods: graphical models and artificial neural networks will be investigated using simulation studies and real data and their advantages and disadvantages of the respective ap-proaches summed up. furthermore, it is planned to construct a hybrid model exploiting the strengths of either model type. results and conclusions: the part of the project that concerns graphical models is being funded and ongoing. first results of a simulation study have been obtained and will be presented and discussed. a second project is currently being applied for. this shall cover the investigation of neural networks and the construction of the hybrid model. this study investigates variations in mortality from 'avoidable' causes among migrants in the netherlands in comparison with the native dutch population. data were obtained from population and mortality registries in the period - . we compared mortality rates for selected 'avoidable' conditions for turkish, moroccan, surinamese and antillean/aruban groups to native dutch. we found slightly elevated risk in total 'avoidable' mortality for migrant populations (rr = . ). higher risks of death among migrants were observed from almost all infectious diseases (most rr> . ) and several chronic conditions including asthma, diabetes and cerebro-vascular disorders (most rr> . ). migrant women experienced a higher risk of death from maternity-related conditions (rr = . ). surinamese and antillean/ aruban population had a higher mortality risk (rr = . and . respectively), while turkish and moroccans experienced a lower risk of death (rr = . and . respectively) from all 'avoidable' conditions compared to native dutch. control for demographic and socioeconomic factors explained a substantial part of ethnic differences in 'avoidable' mortality. conclusion: compared to native dutch, total 'avoidable' mortality was slightly elevated for all migrants combined. mortality risks varied greatly by cause of death and ethnicity. the substantial differences in mortality for a few 'avoidable' conditions suggest opportunities for improvement within specific areas of the healthcare system. warmblood horses scored by the jury as having uneven feet will never pass yearly selection sales of the royal dutch warmblood studbook (kwpn).to evaluate whether the undesired trait 'uneven feet' influences performance, databases of kwpn (n = horses) and knhs (n = show jumpers, n = dressage horses) were linked through the unique number of each registered horse. using a proc glm model of sas was investigated whether uneven feet had effects on age at first start and highest performance level. elite show jumpers with uneven feet start at . years and dressage horses . years of age, which is a significant difference (p< . ) with elite even feet horses ( . respectively . years). at their maximum level of performance horses with even feet linearly scored in show jumping . at regular and . at elite level ( . resp. . with uneven feet), while in dressage horses scores were . at regular and . at elite level ( . resp. . with uneven feet).the conformational trait 'uneven feet' appears to have a significant effect on age at first start, while horses with even feet demonstrate a higher maximal performance than horses with uneven feet. objectives: to identify children with acute otitis media (aom) who might benefit more from treatment with antibiotics. methods: an individual patient data meta-analysis (ipdma) on six randomized trials (n = children). to preclude multiple testing, we first performed a prognostic study in which predictors of poor outcome were identified. subsequently, interactions between these predictors and treatment were studied by fixed effect logistic regression analyses. only if a significant interaction term was found, stratified analyses were performed to quantify the effect in each subgroup. results: interactions were found for: age and bilateral aom, and otorrhea. in children less than years with bilateral aom, a rate difference (rd) of ) % ( % ci ) ; ) %) was found, whereas in children aged years or older with unilateral aom the rd was ) % ( % ci ) ; ) %). in children with and without otorrhea the rd were ) % ( % ci ) ; ) %), and ) % ( % ci ) %; ) %). conclusion: although there still are many areas in which ipdma can be improved, using individual patient data appear to have many advantages especially in identifying subgroups. in our example, antibiotics are beneficial in children aged less than years with bilateral aom, and in children with otorrhea. major injuries, such as fractures, are known to increase the risk of venous thrombosis (vt). however, little is known of the risk caused by minor injuries, such as ankle sprains. we studied the risk of vt after minor injury in a population-based case-control study of risk factors for vt, the mega-study. consecutive patients, enrolled via anticoagulation clinics, and control subjects, consisting both of partners of patients and randomly selected control subjects, were asked to participate and filled in a questionnaire. participants with cancer, recent plastercasts, surgery or bedrest were excluded from the current analyses. out of patients ( . %) and out of controls ( . %) had suffered from a minor injury resulting in a three-fold increased risk of vt (odds ratio adjusted for age and sex . ; % confidence interval . - . ) compared to those without injury. the risk was highest in the first month after injury and was no longer increased after months. injuries located in the leg increased the risk five-fold, while those located in other body parts did not increase the risk. these results show that minor injuries in the leg increase the risk of vt. this effect appears to be temporary and mainly local. introduction: in southeast asia, dengue was considered a childhood disease. in the americas, this disease occurs predominantly in older age groups, indicating the need for studies to investigate the immune status of the child population, since the presence of antibodies against a serotype of this virus is a risk factor for dengue hemorrhagic fever (dhf). objective: to evaluate the seroprevalence and seroincidence of dengue in children living in salvador, bahia, brazil. methods: a prospective study was carried out in a sample of children of - years by performing sequential serological surveys (igg/ dengue). results: seroprevalence in children was . %. a second survey (n = seronegative children) detected an incidence of . % and no difference was found between males and females or according to factors socioeconomic analyzed. conclusion and discussion: these results show that, in brazil, the dengue virus circulates actively in the initial years of life, indicating that children are also at great risk of developing dhf. it is possible that in this age group, dengue infections are mistaken for other febrile conditions, and that there are more inapparent infections in this age group. therefore, epidemiological surveillance and medical care services should be aware of the risk of dhf in children. since , in the comprehensive cancer centre limburg (cccl) region, all women aged - years are invited to participate in the cervical cancer screening programme once every five years. we had the unique opportunity to link data from the cervical screening programme and the cancer registry. we studied individual pap smear testing and participation in the screening programme preceding the diagnosis of cervical cancer. all invasive cases of cervical cancer of women aged - years in the period - were selected. subgroups were based on results of the pap smear and invitation and participation in the screening programme. time interval between screening and detection of tumours was calculated. in - , the non-response rate was %. in total, invasive cervical cancer cases were detected of which were screening and interval carcinomas. in the group of women who were invited but did not participate and women who were not invited, respectively and tumours were detected. these tumours had a higher stage compared to screening carcinomas. in the cccl region, more and higher stage tumours were found in women who did not participate in the screening compared to women with screening tumours. background: pcr for mycobacterium tuberculosis (mtb) has already proved to be a useful tool for the diagnosis and investigation of molecular epidemiology. objectives: evaluation of pcr assay for detection of mycobacterium tuberculosis dna as a diagnostic aid in cutaneous tuberculosis. design and methods: thirty paraffinembedded samples belonging to patients were analyzed for acid fast bacilli. dna was extracted from tissue sections and pcr was performed using specific primers based on is repeated gene sequence of mtb. results: two of the tissue samples were positive for acid fast bacilli (afb). pcr was positive in eight samples from six patients. amongst them, two were suspected of having lupus vulgaris confirmed histopathologically, whom their entire tests were positive. accounting histopathology as gold standard, the sensitivity of pcr in this study was determined as %. conclusion: from cases of skin tuberculosis diagnosed by histopathology, were positive by pcr technique, which shows the priority of previous method to molecular technique. discussion: pcr assay can be used for rapid detection of mtb from cutaneous tuberculosis cases, particularly when staining for afb is negative and there is a lack of growth on culture or when fresh material has not been collected for culture. background: recent epidemiological studies used automated oscillometric blood pressure (aod) devices that systematically measure higher blood pressure values than random zero sphygmomanometer devices (rzs) hampering the comparability of the blood pressure values between these studies. we applied both a random zero and an automated oscillometric blood pressure device in a randomized order in an ongoing cohort study. objectives: the aim of this analysis was to compare the blood pressure values by device and to develop a conversion algorithm for the estimation of blood pressure values from one device to the other. methods: within a randomized subset of subjects aged - years, each subject was measured three times by each device (hawskley random zero and omron hem- cp) in a randomized order. results: the mean difference (aod-rzs) between the devices was . mmhg and . mmhg for the systolic and diastolic blood pressure respectively. linear regression models including age, sex, and blood pressure level can be used to convert rzs blood pressure values to aod blood pressure values and vice versa. conclusions: the results may help to better compare blood pressure values of epidemiological studies that used different blood pressure devices. a form was used to collect relevant perinatal clinical data, as part of a european (mosaic) and italian (action) project. the main outcomes were mortality and a variable combining mortality and severe morbidity at discharge. the cox proportional hazards and logistic regression models were used, respectively, for the two outcomes. results: twenty-two of percent of vpbs were among fbms. comparing to control group, the percentage of babies below weeks and plurality was statistically significant higher among babies of fbms: % vs. . and . % vs. . %. adjusting for potential confounders, no association for mortality among immigrant group was found, whereas a slightly excess of morbidity-mortality was observed (odd ratio, . ; % cis . - . ). conclusions: the high proportion of vpbs among fbms and the slight excess observed in morbidity and mortality indicate the need to improve the health care delivery for the immigrant population. background: high-risk newborns have excess mortality, morbidity and use of health services. objectives: to describe re-hospitalizations after discharge from an italian region. design and methods: the population study consisted of all births with < weeks' gestation discharged alive from the twelve neonatal intensive care units in lazio region during . the perinatal clinical data was collected as part of a european project (mosaic). we used the regional hospital discharge database to find hospital admissions within months, using tax code for record linkage. data were analyzed through logistic regression for re-hospitalization. results: the study group included children; among these, ( . %) were re-hospitalized; overall, readmission were observed. the median total length of stay for re-admissions was d. the two most common reasons for re-hospitalization were respiratory ( . %) and gastrointestinal ( . %) disorders. the presence of a severe morbidity at discharge (odd ratio . : % cis . - . ) and male sex (odd ratio . ; % cis . - . ) predicted re-hospitalization in multivariate model. conclusions: almost one out three preterm infants was re-hospitalized in the first months. readmissions after initial hospitalization for a very preterm birth could be a sensitive indicator of quality of follow-up strategies in high risk newborns. background: self-medication with antibiotics may lead to inappropriate use and increase the risk of selection of resistant bacteria. in europe the prevalence varies from / to / respondents. self-medication may be triggered by experience with prescribed antibiotics. we investigated whether in european countries prescribed use was associated with self-medication with antibiotics. methods: a population survey was conducted in european countries with respondents completing the questionnaire. multivariate logistic regression analysis was used to study the relationship between prescribed use and self-medication (both actual and intended) in general, for a specific symptom/disease or a specific antibiotic. results: prescribed use was associated with selfmedication, with stronger effect in northern/western europe (odds ratio . , % ci . - . ) than in southern ( . , . - . ) and eastern europe ( . , . - . ). prescribing of a specific antibiotic increased the probability of self-medication with the same antibiotic. prescribing for a specific symptom/disease increased the likelihood of self-medication for the same symptom/disease. the use of prescribed antibiotics and actual self-medication were both determinants of intended self-medication in general and for specific symptoms/diseases. conclusions: routine prescribing of antibiotics increases the risk of self-medication with antibiotics for similar ailments, both through the use of leftovers and buying antibiotics directly from pharmacies. background: in the american national kidney foundation published a guideline based on opinion and observational studies which recommends tight control of serum calcium, phosphorus and calcium-phosphorus product levels in dialysis patients. objectives: within the context of this guideline, we explored associations of these plasma concentrations with cardiovascular mortality risk in incident dialysis patients. design and methods: in necosad, a prospective multi-centre cohort study in the netherlands, we included consecutive patients new on haemodialysis or peritoneal dialysis between and . risks were estimated using adjusted time-dependent cox regression models. results: mean age was ± years, % was male, and % was treated with haemodialysis. cardiovascular mortality risk was significantly higher in haemodialysis patients (hr: . ; % ci: . to . ) and in peritoneal dialysis patients (hr: . ; . to . ) with elevated plasma phosphorus levels when compared to patients who met the target. in addition, having elevated plasma calcium-phosphorus product concentrations increased cardiovascular mortality risk in haemodialysis (hr: . ; . to . ) and in peritoneal dialysis patients (hr: . ; . to . ). conclusion: application of the current guideline in clinical practice is warranted since it reduces cardiovascular mortality risk in haemodialysis and peritoneal dialysis patients in the netherlands. background: urologists are increasingly confronted with requests for early detection of prostate cancer in men from hereditary prostate cancer (hpc) families. however, little is known about the benefit of early detection among men at increased risk. objectives: we studied the effect of biennial screening with psa in unaffected men from hpc families, aged - years, on surrogate endpoints (test and tumour characteristics). methods: the netherlands foundation for the detection of hereditary tumours holds information on approximately hpc families. here, nonaffected men from these families were included and invited for psa testing every years. we collected data on screening history and complications related to screening. results: in the first round, serum psa was elevated ( ng/ml or greater) in of men screened ( %). further diagnostic assessment revealed patients with prostate cancer ( . %). compared to population-based prostate cancer screening trials, the referral rate is equal but the detection rate is twice as high. discussion: in conclusion, the results of prostate cancer screening trials will not be directly applicable to screening in hpc families. the balance between costs, side-effects and potential benefits of screening when applied to a high-risk population will have to be assessed separately. background: in industrialized countries occupational tuberculosis among health care workers (hcws) is re-emerging as a public health priority. to prevent and control tuberculosis transmission in nosocomial settings, public health agencies have issued specific guidelines. turin, the capital of the piedmont region in italy, is experiencing a worrying rise of tuberculosis incidence. here, hcws are increasingly exposed to the risk of nosocomial tuberculosis transmission. objectives: a) to estimate the sex-and age-adjusted annual rate of tuberculosis infection (arti) (per person-years [%py]) among the hcws, as indicated by tuberculin skin test conversion (tst) conversion, b) to identify occupational factors associated with significant variations in the arti, c) to investigate the efficacy of the regional preventive guidelines. design and methods: multivariate survival analysis on tst conversion data from a dynamic cohort of hcws in turin, between and . results: the overall estimated arti was . ( % ci: . - . ) %py. the risk of tst conversion significantly differed among workplaces, occupations, and age of hcws. the guidelines implementation was associated with an arti reductions of . ( % ci: . - . ) %py. conclusions: we identify occupational risk categories for targeting surveillance and prevention measures and assessed the efficacy of the local guidelines. background: a positive family history (fh) of breast cancer is an established risk factor for the disease. screening for breast cancer in israel is recommended annually for positive-fh women aged = y and biennially for average-risk women aged - y. objective: to assess the effect of having a positive breast cancer fh on performing screening mammography in israeli women. methods: a cross-sectional survey based on a random sample of the israeli population. the study population consists of , women aged - y and telephone interviews were used. logistic regression models identified variables associated with mammography performance. results: a positive fh for breast cancer was reported by ( . %) participants. performing a mammogram in the previous year was reported by . % and . % of the positive and negative fh subgroups, respectively (p< . ). rates increased with age. among positive fh participants, being married was the only significant correlate for a mammogram in the previous year. conclusions: over % and around % of high-risk women aged - y and = y, respectively, are inadequately screened for breast cancer. screening rates are suboptimal in average-risk women too. discussion: national efforts should concentrate on increasing awareness and breast cancer screening rates. to evaluate the association between infertility, infertility treatments and breast cancer risk. methods: a historical prospective cohort with , women who attended israeli infertility centers between and . their medical charts were abstracted. breast cancer incidence was determined through linkage with the national cancer registry. standardized incidence ratios (sirs) and % confidence intervals were computed by comparing observed cancer rates to those expected in the general population. additionally, in order to control for known risk factors, a casecontrol study nested within the cohort was carried out as well based on telephone interviews with breast cancer cases and controls matched by : ratio. results: compared to . expected breast cancer cases, were observed (sir = . ;non-significant). risk for breast cancer was higher for women treated with clomiphene citrate (sir = . ; % ci . - . ). similar results were noted when treated and untreated women were compared, and when multivariate models were applied. in the nested case-control study, higher cycle index and treatment with clomiphene citrate were associated with significantly higher risk for breast cancer. conclusions: clomiphene citrate may be associated with higher breast cancer risk. smoking is a strong risk factor for arterial disease. some consider smoking also as a risk factor for venous thrombosis, while the results of studies investigating the relationship are inconsistent. therefore, we evaluated smoking as a risk factor for venous thrombosis in the multiple environmental and genetic assessment of risk factors for venous thrombosis (mega) study, a large population-based case-control study. consecutive patients with a first venous thrombosis were included from six anticoagulation clinics. using a random-digit-dialing method a control group was recruited in the same geographical area. all participants completed a questionnaire including questions on smoking habits. persons with known malignancies were excluded from the analyses, leading to a total of patients and controls. current and former smoking resulted in a small increased risk of venous thrombosis (ors adjusted for age, sex and bmi) (or-current: . ci : . - . , or-former: . ci : . - . ). an increasing amount and duration of smoking was associated with an increase in risk. the highest risk was found among young (lowest tertile: to yrs) current smokers; twenty or more pack-years resulted in a . -fold increased risk (ci : . - . ). in conclusion, smoking results in a small increased risk of venous thrombosis, with the greatest relative effect among young heavy smokers. objective: to explore whether the observed association between silica exposure and lung cancer was confounded by exposure to other occupational carcinogens, we conducted a nested case-control-study among a cohort of male workers in chinese mines and potteries. methods: lung cancer cases and matched controls were selected. exposure to respirable silica as well as relevant occupational confounders were evaluated quantitatively based on historical industrial hygiene data. the relationship between silica exposure and lung cancer mortality was analyzed by conditional logistic regression analysis adjusted for exposure to arsenic, polycyclic aromatic hydrocarbons (pahs), radon, and smoking habit. results: in a crude analysis adjusted for smoking only, a significant trend of increasing risk of lung cancer with exposure to silica was found for tin, copper/iron miners, and pottery workers. however, after the relevant occupational confounders were adjusted, no association can be observed between silica exposure and lung cancer mortality (pro mg/m -year increase of silica exposure: or = . , % ci: . - . ). conclusion: our results suggest that, the observed excess risk of lung cancer among silica exposed chinese workers is more likely due to exposure to other occupational carcinogens such as arsenic and pahs rather than due to exposure to respirable silica. background: modelling studies have shown that lifestyle interventions for adults with a high risk of developing diabetes are costeffective. objective: to explore the cost-effectiveness of lifestyle interventions for adults with low or moderate risk of developing diabetes. design and methods: the short-term effects of both a community-based lifestyle program for the general population and a lifestyle intervention for obese adults on diabetes risk factors were estimated from international literature. intervention costs were based on dutch projects. the rivm chronic diseases model was used to estimate long-term health effects and disease costs. costeffectiveness was evaluated from a health care perspective with a time horizon of years. results: intervention costs needed to prevent one case of diabetes in years range from , to , euro for the community program and from , to , euro for the intervention for obese adults. cost-effectiveness was , to , euro per quality adjusted life-year for the community program and , to , for the lifestyle intervention. conclusion: a lifestyle intervention for obese adults produces larger individual health benefits then a community program but, on a population level, health gains are more expensively achieved. both lifestyle interventions are cost-effective. background: in barcelona, the proportion of foreign-born patients with tuberculosis (tb) raised from . % in to , % in . objective: to determine differences in infection by country of origin among contacts investigated by the tb programme in barcelona from - . design and methods: data were collected on cases and their contacts. generalized estimating equations were used to obtain the risk of infection (or and % ci) to account for potential correlation among contacts. results: contacts of foreign born cases were more infected than contacts of natives patients ( % vs %, p< . ) factors related to infection among contacts of foreign cases were inner city residency (or: . , % ci: . - . ) and sputum smear positivity of the case (or: . , % ci: . - . ) and male contact (or: . , % ci: . - . ), but not daily contact (or: . , % ci: . - . ) among natives cases, inner city residency (or: . , % ci: . - . ), sputum smear positivity (or: . , % ci: . - . ) and daily exposure (or: . , % ci: . - . ) increased risk of infection. conclusion: contacts immigrant tb cases have a higher risk of infection than contacts of natives cases, however daily exposure to an immigrant case was not associated with a greater risk of infection. this could be explained by the higher prevalence of tb infection in their country of origin. background: an inverse association between birthweight and subsequent coronary heart disease (chd) has been widely reported but has not been formally quantified. we therefore conducted a systematic review of the association between birthweight and chd. design and methods: seventeen studies including a total of , singletons that had reported quantitative or qualitative estimates of the association between birthweight and chd by october were identified. additional data from two unpublished studies of individuals were also included. in total, the analyses included data on non-fatal and fatal coronary heart disease events in , individuals. results: the mean weighted estimate for the association between birthweight and chd incidence was . ( % ci . - . ) per kg of birthweight. overall, there was no significant heterogeneity between studies (p = . ) or evidence of publication bias (begg test p = . ). fifteen studies were able to adjust for some measure of socioeconomic position, but such adjustment did not materially influence the association: . ( % ci . - . ). discussion: these findings are consistent with one kilogram higher birthweight being associated with - % lower risk of subsequent chd, but the causal nature of this association remains uncertain and its direct relevance to public health is likely to be small. objective: diabetes has been reported to be associated with a greater coronary hazard among women compared with men with diabetes. we quantified the coronary risk associated with diabetes by sex by conducting a meta-analysis of prospective cohort studies. methods: studies reporting estimates of the relative risk for fatal coronary heart disease (chd) comparing those with and without diabetes, for both men and women were included. results: studies of type- diabetes and chd among , individuals were identified. the summary relative risk for fatal chd, diabetes versus not, was significantly greater among women than men: . ( % ci . to . ) versus . ( % ci . to . ), p< . . after excluding eight studies that had only adjusted for age, the sex risk difference was substantially reduced, but still highly significant (p = . ). the pooled ratio of the relative risks (female: male) from the multiple-adjusted studies was . ( % ci . to . ). conclusions: the relative risk for fatal chd associated with diabetes is % higher in women than in men. more adverse cardiovascular risk profiles among women with diabetes, combined with possible treatment disparities that favour men, may explain the greater excess coronary risk associated with diabetes in women. background: malaria in sri lanka is strongly seasonal and often of epidemic nature. the incidence has lowered in recent years which increased the relevance of epidemic forecasting for better targeting control resources. objectives: to establish the spatio/temporal correlation of precipitation and malaria incidence for use in forecasting. design and methods: de-trended long term ( de-trended long term ( - monthly time series of malaria incidence at district level were regressed in a poisson regression against rainfall and temperature at several lags. results: in the north and east of sri lanka, malaria seasonality is strongly positively correlated to rainfall seasonality (malaria lagging one or two months behind rainfall). however, in the south west, no significant (negative) correlation was found. also in the hill country, no significant correlation was observed. conclusion and discussion: despite high correlations, it still remains to be explored to what extent rainfall can be a used as a predictor (in time) of malaria. observed correlation could simply be due to two cyclical seasonal patterns running in parallel, without causal relationship. e.g. similarly, strong correlations were found between temperature and malaria seasonality at months time lag in northern districts, but causality is biologically implausible. background: few studies assessed the excess burden of acute respiratory tract infections (rti) among preschool children in primary care during viral seasons. objective: to determine the excess of rti in preschool children in primary care attributable to influenza and respiratory syncytial virus (rsv). methods: we performed a retrospective cohort study including all children aged - years registered in the database of the utrecht general practitioner (gp) network. during during - , gps recorded episodes of acute rti. surveillance data of influenza and rsv were obtained from the weekly sentinel system of the dutch working group on clinical virology. viral seasons and base-line period were defined as the weeks with respectively more than % and less than % of the yearly number of isolates of influenza or rsv. results: on average episodes of rti were recorded per , child years ( % ci: - ). notably more consults for rti occurred during influenza-season (rr . , % ci: . - . ) and rsv-season (rr . , % ci: . - . ) as compared to base-line period, especially in children younger than two years of age. conclusion: substantial excess rates of rti were demonstrated among preschool children in primary care during influenza-season and particularly during rsvseason, notably in the younger age group. background: many cancer patients who have already survived some time want to know about their prognosis, given the precondition that they are still alive. objective: we described and interpreted population-based conditional -year relative survival rates for cancer patients. methods: the longstanding eindhoven cancer registry collects data on all patients with newly diagnosed cancer in the southeastern part of the netherlands ( . million inhabitants). patients aged - years, diagnosed between and and followed up until january , were included. conditional -year relative survival was computed for every additional year survived. results: for many tumours conditional -year relative survival approached - % after having survived - years. however, for stomach cancer and hodgkin's lymphoma conditional -year relative survival increased to only - % and for lung cancer and non-hodgkin's lymphoma it did not exceed - %. initial differences in survival at diagnosis between age and stage groups disappeared after having survived for - years. conclusion: prognosis for patients with cancer changes with each year survived and for most tumours patients can considered to be cured after a certain period of time. however, for stomach cancer, lymphoma's and lung cancer the odds for death remains elevated compared to the general population. background: systematic review with meta-analysis, now regarded as 'best evidence', depends on availability of primary trials and on completeness of review. whilst reviewers have attempted to assess publication bias, relatively little attention has been given to selection bias by reviewers. method: systematic reviews of three cardiology treatments, that used common search terms, were compared for inclusion/exclusion of primary trials, pooled measures of principal outcomes and conclusions. results: in one treatment, reviews included , , , , and trials. there was little overlap: of trials in the last review only , , , and were included by others. reported summary effects ranged from (most effective to least significant); mortality relative risk . ( . , . ) in trials to . ( . , . ) in , and in one morbidity measure; standardised mean difference from . ( . , . ) in trials ( patients) to . () . , . ) in ( patients). reviewers' conclusions ranged from 'highly effective' to 'no evidence of effect'. conclusions: these examples illustrate strong selection bias in published meta-analyses. post hoc review contravenes one important principal of science 'first the hypothesis, then the test'. selection bias by reviewers may affect 'evidence' more than does publication bias. in the context of a large population based german case control study examining the effects of hormone therapy (ht) on breast cancer risk, we conducted a validation study comparing ht prescription data with participants' self-reports for data quality assurance. included were cases and controls aged - years, stratified by age and hormone use. study participants provided detailed information on ht use to trained interviewers, while gynecologists provided prescription data via telephone or fax. data were compared using proportion of agreement, kappa, intraclass correlation coefficient (icc), and descriptive statistics. overall agreement for ever/never use was . %, while agreement for ever/never use by type of ht was . %, . %, and . % for mono-estrogen, cyclical, and continuous combined therapy, respectively. icc for duration was high ( . ( % ci: . - . )), as were the iccs for age at first and last use ( . ( % ci: . - . ) and . ( % ci: . - . ), respectively). comparison of exact brand name resulted in perfect agreement for . % of participants, partial agreement for . %, and no agreement for . %. higher education and shorter length of recall were associated with better agreement. agreement was not differential by disease status. in conclusion, these self-reported ht data corresponded well with gynecologists' reports. background: legionnaires' disease (ld) is a pneumonia of low incidence. however, the impact of an outbreak can be substantial. objective: to stop a possible outbreak at an early stage, an outbreak detection programme was installed in the netherlands and evaluated after two years. design: the programme was installed nationally and consisted of sampling and controlling of potential sources to which ld patients had been exposed during their incubation period. potential sources were considered to be true sources of infection if two or more ld patients (cluster) had visited them, or if available patients' and environmental strains were indistinguishable by amplified fragment length polymorphism genotyping. all municipal health services of the netherlands participated in the study. the regional public health laboratory kennemerland sampled potential sources and cultured samples for legionella spp. results: rapid sampling and genotyping as well as cluster recognition helped to target control measures. despite these measures, two small outbreaks were only stopped after renewal of the water system. the combination of genotyping and cluster recognition lead to of ( %) patient-source associations. conclusion and discussion: systematic sampling and cluster recognition can contribute to ld outbreak detection and control. this programme can cost-effectively lead to secondary prevention. -up ( - ) , primary invasive breast cancers occurred. results: compared with hrt never-use, use of estrogen alone was associated with a significant . -fold increased risk. the association of estrogen-progestagen combinations with breast cancer risk varied significantly according to the type of progestagen: while there was no increase in risk with estrogen-progesterone (rr . [ . - . ]), estrogen-dydrogesterone was associated with a significant . -fold increase, and estrogen combined with other synthetic progestins with a significant . -fold increase. although the latter type of hrt involves a variety of different progestins, their associations with breast cancer risk did not differ significantly from one another. rrs did not vary significantly according to the route of estrogen administration (oral or transdermal/percutaneous). conclusion and discussion: progesterone rather than synthetic progestins may be preferred when an opposed estrogen therapy is to be prescribed. additional results on estrogen-progesterone are needed. background: although survival of hodgkin's lymphoma (hl) is high (> %), treatment may cause long-term side-effects like premature menopause. objectives: to assess therapy-related risk factors for premature menopause (age < ) following hl. design and methods: we conducted a cohort-study among female year hl-survivors, aged < at diagnose and treated between and . patients were followed from first treatment until june , menopause, death, or age . cumulative dose of various chemotherapeutic agents as well as radiation fields were studied as risk factors for premature menopause. cox-regression was used to adjust for age, year of treatment, smoking, bmi, and oral contraceptive-use. results: after a median follow-up of . years, ( %) women reached premature menopause. overall women ( %) were treated with chemotherapy only, ( %) with radiotherapy only and ( %) with both radio-and chemotherapy. exposure to procarbazine ), cyclophosphamide (hr . [ . - . ] ) and irradiation of the ovaries ]) were associated with significant increased risks for premature menopause. for procarbazine a dose-response relation was observed. procarbazine-use has decreased over time. conclusion: to decrease the risk for premature menopause after hl, procarbazine and cyclophosphamide exposure should be minimized and ovarian irradiation should be avoided. background: casale is an italian town where a large asbestos cement plant was active for decades. previous studies found increased risk for mesothelioma in residents, suggesting a decreasing spatial trend with distance from the plant. objective: to analyse the spatial variation of risk in casale and the surrounding area ($ , inhabitants) focussing on non-occupationally exposed individuals. design/methods: population-based case-control study including pleural mesotheliomas diagnosed between and . information on the cases and controls comprised lifelong residential and occupational history of subjects and their relatives. nonparametric tests of clustering were used to evaluate spatial aggregation. parametric spatial models based on distance between the longest-lasting subject residence (excluding the last years before diagnosis) and the source enabled estimation of risk gradient. results: mesothelioma risk appeared higher in an area of roughly - km radius from the source. spatial clustering was statistically significant (p = . ) and several clusters of cases were identified within casale. risk was highly related to the distance from the source; the best fitting model was the exponential decay with threshold. conclusion/discussion: asbestos pollution has increased dramatically the risk of mesothelioma in the area around casale. risk decreases slowly with the square of distance from the plant. malaria control programmes targeting malaria transmission from man to mosquito can have a large impact of malaria morbidity and mortality. to successfully interrupt transmission, a thorough understanding of disease and transmission parameters is essential. our objective was to map malaria transmission and analyse microenvironmental factors influencing this transmission in order to select high risk areas where transmission reducing interventions can be introduced. each house in the village msitu-wa-tembo was mapped and censused. transmission intensity was estimated from weekly mosquito catches. malaria cases identified through passive case detection were mapped by residence using gis software and the incidence of cases by season and distance to river were calculated. the distribution of malaria cases showed a clear seasonal pattern with the majority of cases during the rainy season (chisquare = . , p< . ). living further away from the river (p = . ) was the most notable independent protective factor for malaria infection. transmission intensity was estimated at . ( % ci . - . ) infectious bites per person per year. we show that malaria in the study area is restricted to a short transmission season. spatial clustering of cases indicates that interventions should be planned in the area closest to the river, prior and during the rainy season. background: the effectiveness of influenza vaccination of elders has been subject of some dispute. its impact on health inequalities also demands epidemiological assessments, as health interventions may affect early and most intensely better-off social strata. objectives: to compare pneumonia and influenza (p&i) mortality of elders (aged or more years old) before and after the onset of a largescale scheme of vaccination in sao paulo, brazil. methods: official information on deaths and population allowed the study of p&i mortality at the inner-city area level. rates related to the period to , during which vaccination coverage ranked higher than % of elders were compared with figures related to the precedent period ( ) ( ) ( ) ( ) ( ) . the appraisal of mortality decrease used a geo-referred model for regression analysis. results: overall p&i mortality reduced . % after vaccination. also the number of outbreaks, the excess of deaths during epidemic weeks, and the proportional p&i mortality ratio reduced significantly after vaccination. besides having higher prior levels of p&i deaths, deprived areas of the city presented a higher proportional decrease of mortality. conclusion: influenza vaccination contributed for an overall reduction of p&i mortality, while reducing the gap in the experience of disease among social strata. background: alcohol's first metabolite, acetaldehyde, may trigger aberrations in dna which predispose to developing colorectal cancer (crc) through several distinct pathways. our objective was to study associations between alcohol consumption and the risk of crc, according to two pathways characterized by mutations in apc and k-ras genes, and absence of hmlh expression. methods: in the netherlands cohort study, , men and women, aged - years, completed a questionnaire on risk factors for cancer in . case-cohort analyses were conducted using crc cases with complete data after . years of follow-up, excluding the first . years. gender-specific adjusted incidence rate ratios (rr) and % confidence intervals (ci) were estimated. results: neither total alcohol, nor beer, wine or liquor consumption was clearly associated with the risk of colorectal tumors lacking hmlh expression or harboring a truncating apc mutation and/or an activating k-ras mutation. in men and women, total alcohol consumption above g/day was associated with an increased risk of crc harboring a truncating apc and/or activating k-ras mutation, though not statistically significant. (rr: . ( % ci: . - . ) in men, rr: . ( % ci: . - . ) in women). in conclusion, alcohol consumption is not involved in the studied pathways leading to crc. background: educational level is commonly used to identify social groups with increased prevalence of smoking. other indicators of socioeconomic status (ses) might however be more discriminatory. objective: this study examines to what extent smoking behaviour is related to other ses indicators, such as labour market position and financial situation. methods: data derived from the european household panel, which includes data on smoking for european countries. we selected data for , respondents aged - years. the association between ses indicators and smoking prevalence was examined through logistic regression analyses. results: preliminary results show that, in univariate analysis, all selected ses indicators were associated with smoking. higher rates of smoking in lower social groups were observed in all countries, except for women in some mediterranean countries. in multivariate analyses, education retained an independent effect on smoking. no strong effect was observed for labour market position (occupational class, employment status) or for income. however, smoking prevalence was strongly related to economic deprivation and housing tenure. conclusion: these results suggest that different aspects of people's ses affect their smoking behaviour. interventions that aim to tackle smoking among high-risk groups should identify risk groups in terms of both education and material deprivation. objective: we investigated time trends in overweight and leisure time physical activities (ltpa) in the netherlands since . intra-national differences were examined stratified for sex, age and urbanisation degree. design and methods: we used a random sample from the health interview survey of about respondents, aged -to- years. self-reported data on weight, height and demographic characteristics were gathered through interviews (yearly) and data on ltpa were collected by selfadministered questionnaires . linear regression was performed for trend analyses. results: during - , mean body mass index (bmi) increased by . kg/m (p = . ). trends were similar across sex and urbanisation degrees. in -to- year old women, mean bmi increased more ( . kg/m ; p = . ) than in older women. concerning ltpa, no clear trend was observed during observed during - and observed during - . however, in year old women spent $ min/wk less on ltpa compared to older women, while this difference was smaller during - . conclusions: mean bmi increased more in younger women, which is consistent with the observation that this group spent less time on ltpa during recent years. although the overall increase in overweight could no´t be explained by trends in ltpa, physical activity interventions should target the younger women. background: prediction rules combine patient characteristics and test results to predict the presence of an outcome (diagnosis) or the occurrence of an outcome (prognosis) for individual patients. when prediction rules show poor performance in new patients, investigators often develop a new rule, ignoring the prior information available in the original rule. recently, several updating methods have been proposed that consider both prior information and information of the new patients. objectives: to compare five updating methods (that vary in extensiveness) for an existing prediction rule that preoperatively predicts the risk of severe postoperative pain (spp). design and methods: the rule was tested and updated on a validation set of new surgical patients ( ( %) with spp). we estimated the discrimination (the ability to discriminate between patients with and without spp) and calibration (the agreement between the predicted risks and observed frequencies of spp) of the five updated rules in other patients ( ( %) with spp). results: simple updating methods showed similar effects on calibration and discrimination as the more complex methods. discussion and conclusion: when the performance of a prediction rule in new patients is poor, a simple updating method can be applied to improve the predictive accuracy. about two million ethnic germans (aussiedler) have resettled in germany since . analyses with a yet incomplete follow-up of a cohort of aussiedler showed a different mortality compared to russia and germany. objectives: we investigated whether the mortality pattern changed after a complete follow-up and whether residential mobility after resettlement has an effect on mortality. we established a cohort of aussiedler who moved to germany between and . we calculated smr for all causes, external causes, cardiovascular deaths and cancer in comparison to german rates. results: with a complete follow-up, the cohort accumulated person years. overall, deaths were observed (smr . , % ci: . - . ). smr for all external causes, all cancer and cardiovascular deaths were . , . and . , respectively. increased number of moves within germany was associated with increased mortality. conclusion and discussion: the mortality in the cohort is surprisingly low, in particular for cardiovascular deaths. there is a mortality disadvantage from external causes and for some selected cancers. this disadvantage is however not as large as would be expected if aussiedler were representative of the general population in fsu countries. mobility as an indicator for a lesser integration will be discussed. background: breast cancer screening (bcs) provides an opportunity to analyze the relationship between lymph node involvement (ln), the most important prognostic factor, and biological and time dependent characteristics. objective: our aim was to assess those characteristics that are associated with ln in a cohort of screen-detected breast cancers. methods: observational population study of all invasive cancers within stage i-iiia detected from to through a bcs program in catalonia (spain). age, tumor size, histological grade, ln status and screening episode (prevalent or incident) were analyzed. pearson chi-square or fisher's exact test, mann-whitney test and stratified analyses were applied, as well as multiple logistic regression techniques. results: twenty nine percent ( % ci . - . %) out of invasive cancers had ln and . % were prevalent cancers. in the bivariate analysis, tumor size and age were strongly associated to ln (p< . ) while grade was related to ln only in incident cancers (p = . ). grade was associated with tumor size (p = . ) and with screening episode (p = . ). adjusting for screening episode and grade, age and tumor size were independent predictors of ln. conclusion: in conclusion, age and tumor size are independent predictors of ln. grade emerges as an important biological factor in incident cancers. background: the evidence regarding the association between smoking and cognitive function in the elderly is inconsistent. objectives: to examine the association between smoking and cognitive function in the elderly. design and methods: in , all participants of a population-based cohort study aged years or older were eligible for a telephone interview on cognitive function using validated instruments, such as the telephone interview of cognitive status (tics). information on smoking history was available from questionnaires administered in . we estimated the odds ratios (or) of cognitive impairment (below th percentile) and the corresponding % confidence intervals (ci) by means of logistic regression adjusting for age, sex, alcohol consumption, body mass index, physical exercise, educational level, depressive symptoms and co-morbidity. results: in total, participants were interviewed and had complete information on smoking history. former smokers had a lower prevalence of cognitive impairment (oradjusted = . ; % ci: . - . ) compared with never smokers, but not current smokers (oradjusted = . ; % ci: . - . ). conclusion: there is no association between current smoking and cognitive impairment in the elderly. discussion: the lack of association between current smoking and cognitive impairment is in line with previous non-prospective studies. the inverse association with former smoking might be due to smoking cessation associated with co-morbidities. background: many studies have reported late effects of treatment in childhood cancer survivors. most studies, however, focused on only one late effect or suffered from incomplete follow-up. objectives: we assessed the total burden of adverse events (ae), and determined treatment-related risk factors for the development of various aes. methods: the study cohort included -year survivors, treated in the emma childrens hospital amc in the netherlands between - . aes were graded for severity by one reviewer according to the common terminology criteria adverse events version . . results: medical follow-up data were complete for . % -year survivors. median follow-up time was years. almost % of survivors had one or more aes, and . % had even or more aes. of patients treated with rt alone, % had a high or severe burden of aes, while this was only % in patients treated with ct alone. radiotherapy (rt) was associated with the highest risk to develop an ae of at least grade , and was also associated with a greater risk to develop a medium to severe ae burden. conclusions: survivors are at increased risk for many health problems that may adversely affect their quality of life and long-term survival. background: studies in the past demonstrated that multifaceted interventions could enhance the quality of diabetes care. however many of these studies showed methodological flaws as no corrections were made for patient case-mix and clustering or a nonrandomised design was used. objective: to assess the efficacy of a multifaceted intervention to implement diabetes shared care guidelines. methods: a cluster randomised controlled trial of patients with type diabetes was conducted at general practises (n = ) and one outpatient clinic (n = ). in primary care, facilitators analysed barriers to change, introduced structured care, gave feedback and trained practice staff. at the outpatient clinic, an abstract of the guidelines was distributed. case-mix differences such as duration of diabetes, education, co-morbidity and quality of life were taken into account. results: in primary care, more patients in the intervention group were seen on a three monthly basis ( . % versus . %, p< . ) and their hba c was statistically significant lower ( . ± . versus . ± . , p< . ). however, significance was lost after correction for case-mix (p = . ). change in blood pressure and total cholesterol was not significant. we were unable to demonstrate any change in secondary care. conclusion: multifaceted implementation did improve the process of care but left cardiovascular risk unchanged. background: we have performed a meta-analysis including studies on the diagnostic accuracy of mr-mammography in patients referred for further characterization of suspicious breast lesions. using the bivariate diagnostic meta-analysis approach we found an overall sensitivity and specificity of . and . , respectively. the aim of the present analysis was to detect heterogeneity between studies. materials and methods: seventeen study and population characteristics were separately included in the bivariate model to compare sensitivity and specificity between strata of the characteristics. results: both sensitivity and specificity were higher in studies performed in the united states compared to non-united states studies. both estimates were also higher if two criteria for malignancy were used instead of one or three. only specificity was affected by the prevalence of cancer: specificity was highest in studies with the lowest prevalence of cancer in the study population. furthermore, specificity was affected by whether the radiologist was blinded for clinical information: specificity was higher if there was no blinding. conclusions: variation between studies was notably present across studies in country of publication, the number of criteria for malignancy, the prevalence of cancer and whether the observers were blinded for clinical information. objective: the aim of this project is to explore variation in three candidate genes involved in cholesterol metabolism in relation to risk of acute coronary syndrome (acs), and to investigate whether dietary fat intake modifies inherent genetic risks. study population: a case-cohort study is designed within the danish 'diet, cancer and health' study population. a total of cases of acs have been identified among , men and women who participated in a baseline examination between - when they were aged - years. a random sample of participants will serve as 'control' population. exposures: all participants have filled out a detailed -item food frequency questionnaire and a questionnaire concerning lifestyle factors. participants were asked to provide a blood sample. candidate genes for acs have been selected among those involved in cholesterol transport (atp-binding cassette transporter a , cholesterol-ester transfer protein, and acyl-coa:cholesterol acyltransferase ). five single nucleotide polymorphisms (snps) will be genotyped within each gene. snps will be selected among those with demonstrated functional importance, as assessed in public databases. methods: statistical analyses of association between genetic variation in the three chosen genes and risk of acs. explorations of methods to evaluate biological interaction will be of particular focus. background: c-reactive protein (crp) has been shown to be associated with type diabetes mellitus. it is unclear whether the association is completely explained by obesity. objective: to examine whether crp is associated with diabetes independent of obesity. design and methods: we measured baseline characteristics and serum crp in non-diabetic participants of the rotterdam study and followed them for a mean of . years. cox regression was used to estimate the hazard ratio. in addition, we performed a meta-analysis on published studies. results: during follow-up, participants developed diabetes. serum crp was significantly and positively associated with the risk to develop diabetes. the risk estimates attenuated but remained statistically significant after adjustment for obesity indexes. age, sex and body mass index (bmi) adjusted hazard ratios ( % ci) were . ( . - . ) for the fourth quartile, . ( . - . ) for the third quartile, and . ( . - . ) for the second quartile of serum crp compared to the first quartile. in the meta-analysis, weighed age, sex, and bmi adjusted risk ratio was . ( . - . ), for the highest crp category (> . mg/l) compared to the reference category (< . mg/l). conclusion: our findings shows that the association of serum crp with diabetes is independent of obesity. background: effectiveness of screening can be predicted by episode sensitivity, which is estimated by interval cancers following a screen. full-field digital or cr plate mammography are increasingly introduced into mammography screening. objectives: to develop a design to compare performance and validity between screen-film and digital mammography in a breast cancer screening program. methods: interval cancer incidence was estimated by linking screening visits from - at an individual level to the files of the cancer registry in finland. these data was used to estimate the study size requirements for analyzing differences in episode sensitivity between screen-film and digital mammography in a randomized setting. results: the two-year cumulative incidence of interval cancers per screening visits was estimated to be . to allow the maximum acceptable difference in the episode sensitivity between screenfilm and digital arm to be % ( % power, . significance level, : randomization ratio, % attendance rate), approximately women need to be invited. conclusion: only fairly large differences in the episode sensitivity can be explored within a single randomized study. in order to reduce the degree of non-inferiority between the screen-film and digital mammography, meta-analyses or pooled analyses with other randomized data are needed. session: socio-economic status and migrants presentation: oral. background: tackling urban/rural inequalities in health has been identified as a substantial challenge in reforming health system in lithuania. objectives: to assess mortality trends from major causes of death of the lithuanian urban and rural populations throughout the period of - . methods: information on major causes of death (cardiovascular diseases, cancers, external causes, and respiratory diseases) of lithuanian urban and rural populations from to was obtained from lithuanian department of statistics. mortality rates were age-standardized, using european standard. mortality trends were explored using the logarithmic regression analysis. results: overall mortality of lithuanian urban and rural populations was decreasing statistically significantly during - . more considerable decrease was observed in urban areas where mortality declined by . % per year in males and . % in females, compare to the decline by . % in males and . % in females in rural areas. the most notable urban/rural differences in mortality trends with unfavourable situation in rural areas were estimated in mortality from stoke, breast cancer in females, and external causes of death (traffic accidents and suicides). background: recent studies indicate that depression plays an important role in the occurrence of cardiovascular diseases (cvd). underlying mechanisms are not well understood. objectives: we investigated whether low intake of omega- fatty acids (fas) is a common cause for depression and cvd. methods: the zutphen elderly study is a prospective cohort study conducted in the netherlands. depressive symptoms were measured with the zung scale in men, aged - years, and free from cvd and diabetes in . dietary factors were assessed with a cross-check dietary history method. results: compared to high intake (= . mg/d), low intake (< . mg/d) of omega- fas, adjusted for demographics and cvd risk factors, was associated with an increased risk of depressive symptoms (or . ; % ci . - . ) at baseline, and non-significantly with -year cvd mortality (hr . ; % ci . - . ). the adjusted hr for a -point increase in depressive symptoms for cvd mortality was . ( % ci . - . ), and did not change after additional adjustment for omega- fas. conclusion: low intake of omega- fas may increase the risk of depression. our results, however, do not support the hypothesis that low intake of omega- fas explains the relation between depression and increased risk of cvd. background: during the last decades the incidence of metabolic syndrome has risen dramatically. several studies have shown beneficial effects of nut and seed intake on components of this syndrome. the relationship with prevalence of metabolic syndrome has not yet been examined. objectives: we studied the relation between nut and seed intake and metabolic syndrome in coronary patients. design and methods: presence of metabolic syndrome (according to international diabetes federation definition) was assessed in stable myocardial infarction patients ( % men) aged - years, as part of the alpha omega trial. dietary data were collected by food-frequency questionnaire. results: the prevalence of metabolic syndrome was %. median nut and seed intake was . g/day (interquartile range, . - . g/day). intake of nuts and seeds was inversely associated with the metabolic syndrome (prevalence ratio: . ; % confidence interval: . - . , for > g/day versus < g/day), after adjustment for age, gender, dietary and lifestyle factors. the prevalence of metabolic syndrome was % lower (p = . ) in men with a high nut and seed intake compared to men with a low intake, after adjustment for confounders. conclusion and discussion: intake of nuts and seeds may reduce the risk of metabolic syndrome in stable coronary patients. background: in epidemiology, interaction is often assessed by adding a product term to the regression model. in linear regression the regression coefficient of the product term refers to additive interaction. however, in logistic regression it refers to multiplicative interaction. rothman has argued that interaction as departure from additivity better reflects biological interaction. hosmer and lemeshow presented a method to quantify additive interaction and its confidence interval (ci) between two dichotomous determinants using logistic regression. objective: our objective was to provide an estimation method for additive interaction between continuous determinants. methods and results: from the abovementioned literature we derived the formulas to quantify additive interaction and its ci between one continuous and one dichotomous determinant and between two continuous determinants using logistic regression. to illustrate the theory, data of the utrecht health project were used, with age and body mass index as risk factors for diastolic blood pressure. conclusions: this paper will help epidemiologists to estimate interaction as departure from additivity. to facilitate its use, we developed a spreadsheet, which will become freely available at our website. background: the incidences of acute myocardial infarction (ami) and ischemic stroke (is) in finland have been among highest in the world. accurate geo-referenced epidemiological data in finland provides unique possibilities for ecological studies using bayesian spatial models. objectives: examine sex-specific geographical patterns and temporal variation of ami and is. design and methods: ami (n = , ) and is (n = , ) cases in - in finland, localized at the time of diagnosis according to the place of residence address using map coordinates. cases and population were aggregated to km x km grids. full bayesian conditional autoregressive models (car) were used for studying the geographic incidence patterns. results: the incidence patterns of ami and is showed on average % ( % ci - %) common geographic variation and significantly the rest of the variation was disease specific. there was no significant difference between sexes. the patterns of high-risk areas have persisted over the years and the pattern of is showed more annual random fluctuations. conclusions: although ami and is showed rather similar and temporally stable patterns, significant part of the spatial variation was disease specific. further studies are needed for finding the reasons for disease specific geographical variation. most studies addressing socio-economic inequalities in health services use fail to take into account the disease the patient is suffering from. the objective of this study is to compare possible socioeconomic differences in the use of ambulatory care between distinct patient groups: diabetics and patients with migraine. data was obtained from the belgian health interview surveys , and . in total patients with self reported diabetes or migraine were identified. in a multilevel analysis the probability of a contact and the volume of contacts with the general practitioner and/or the specialist were studied for both groups in relation to educational attainment and income. adjustment was made for age, sex, subjective health and comorbidity at the individual level, and doctors' density and region at district level. no socio-economic differences were observed among diabetic patients. among patients with migraine we observed a higher probability of specialist contacts in higher income groups (or , ; % ci , - , ) and higher educated persons (or , ; % ci , - , ), while lower educated persons tend to report more visits with the general practitioner. to correctly interpret socio-economic differences in the use of health services there is need to take into account information on the patient's type of disease. background: the suitability of non-randomised studies to assess effects of interventions has been debated for a long time, mainly because of the risk of confounding by indication. choices in the design and analytical phase of non-randomised studies determine the ability to control for such confounding, but have not been systematically compared yet. objective: the aim of the study will be to quantify the role of design and analytical factors on confounding in non-randomised studies. design and methods: a meta-regression analysis will be conducted, based on cohort and case-control studies analysed in a recent cochrane review on influenza vaccine effectiveness against hospitalisation or death in the elderly. primary outcome will be the degree of confounding as measured by the difference between the reported effect estimate (odds ratios or relative risks) and the best available estimate (nichol, unpublished data) . design factors that will be considered include study design, matching, restriction and availability of confounders. statistical techniques that will be evaluated include multivariate regression analysis with adjustment for confounders, stratification and, if available, propensity scores. results the rsults will be used to develop a generic guideline with recommendations how to prevent confounding by indication in non-randomised effect studies. the wreckage of the oil tanker prestige in november produced a heavy contamination of the coast of galicia (spain). we studied relationships between participation in clean-up work and respiratory symptoms in local fishermen. questionnaires including details of clean-up activities and respiratory symptoms were distributed among associates of fishermen's cooperatives, with postal and telephone follow-up. statistical associations were evaluated using multiple logistic regression analyses, adjusted for sex, age, and smoking status. between january and february , information was obtained from , fishermen (response rate %). sixty-three percent had participated in clean-up operations. lower respiratory tract symptoms were more prevalent in clean-up workers (odds ratio (or) . ; % confidence interval . - . ). the risk increased when the number of exposed days, number of hours per day, or number of activities increased (p for linear trend < . ). the excess risk decreased when more time had elapsed since last exposure (or . ( . - . ) and . ( . - . ) for more and less than months, respectively; p for interaction < . ). in conclusion, fishermen who participated in the clean-up work of the prestige oil spill show a prolonged dosedependent increased prevalence of respiratory symptoms one to two years after the beginning of the spill. background. hpv testing has been proposed for cervical cancer screening. objectives: evaluating the protection provided by hpv testing at long intervals vs. cytology every third year. methods: randomised controlled trial conventional arm: conventional cytology. experimental arm: in phase hpv and liquid-based cytology. hpv-positive cytology-negatives referred for colposcopy if age - , for repeat after one year if age - . in phase hpv alone. positives referred for colposcopy independently of age. endpoint: histologically confirmed cervical intraepithelial neoplasia (cin) grade or more. results: overall , women were randomised. preliminary data at recruitment are presented. overall, among women aged - years relative sensitivity of hpv versus conventional cytology was . ( % c.i. . - . ) and relative positive predictive (ppv) value was . ( % c.i. . - . ). among women aged - relative sensitivity of hpv vs. conventional cytology was . ( % c.i. . - . ) during phase but . ( % c.i. . - . ) during phase . conclusions: hpv testing increased cross-sectional sensitivity, but reduced ppv. in younger women data suggest that direct referral of hpv-positives to colposcopy results in relevant overdiagnosis of regressive lesions. measuring detection rate of cin at the following screening round will allow studying overdiagnosis and the possibility of longer screening intervals. background: plant lignans are present in foods such as whole grains, seeds, fruits and vegetables, and beverages. they are converted by intestinal bacteria into the enterolignans, enterodiol and enterolactone. enterolignans possess several biological activities whereby they may influence carcinogenesis. objective: to study the association between plasma enterolignans and the risk of colorectal adenomas. colorectal adenomas are considered to be precursors of colorectal cancer. design and method: the case-control study included cases with at least one histologically confirmed colorectal adenoma and controls with no history of any type of adenoma. associations between plasma enterolignans and colorectal adenomas were analyzed by logistic regression. results: associations were stronger for incident than for prevalent cases. when only incident cases (n = ) were included, high compared to low enterodiol plasma concentrations were associated with a reduction in colorectal adenoma risk after adjustment for confounding variables. enterodiol odds ratios ( % ci) were . , . ( . - . ), . ( . - . ), . ( . - . ) with a significant trend (p = . ) through the quartiles. although enterolactone plasma concentrations were fold higher, enterolactone's reduction in risk was not statistically significant (p for trend = . ). conclusion: we observed a substantial reduction in colorectal adenoma risk among subjects with high plasma concentrations of enterolignans, in particular enterodiol. background: smoking is a risk factor for tuberculosis diseases. recently the question was raised if smoking also increases the risk of tuberculosis infection. objective: to assess the influence of environmental tobacco smoke (ets) exposure in the household on tuberculosis infection in children. design and methods: a crosssectional community survey was done and information on children was obtained. tuberculosis infection was determined with a tuberculin skin test (tst) (cut-off mm) and information on smoking habits was obtained from all adult household members. univariate and multivariate analyses were performed, and odds ratio (or) was adjusted for the presence of a tb contact in the household, crowding and age of the child. results: ets was a risk factor for tuberculosis infection (or: . , % ci: . - . ) when all children with a tst read between two and five days were included. the adjusted or was . ( % ci: . - . ). in dwellings were a tuberculosis case had lived the association was strongest (adjusted or . , % ci: . - . ). conclusion and discussion: ets exposure seems to be a risk factor for tuberculosis infection in children. this is of great concern considering the high prevalence of smoking and tuberculosis in developing countries. background and objective: to implement a simulation model to analyze demand and waiting time (wt) for knee arthroplasty and to compare a waiting list prioritization system (ps) with the usual first-in, first-out (fifo) system. methods: parameters for the conceptual model were estimated using administrative data and specific studies. a discrete-event simulation model was implemented to perform -year simulations. the benefit of applying the ps was calculated as the difference in wt weighted by priority score between disciplines, for all cases who entered the waiting list. results: wt for patients operated under the fifo discipline was homogeneous (standard deviation (sd) between . - . months) with mean . . wt under the ps had higher variability (sd between . - . ) and was positively skewed, with mean . months and % of cases over months. when wt was weighted by priority score, the ps saved . months ( % ci . - . ) on average. the ps was favorable for patients with priority scores over , but penalized those with lower priority scores. conclusions: management of the waiting list for knee arthroplasty through a ps was globally more effective than through fifo, although patients with low priority scores were penalized with higher waiting times. background: we developed a probabilistic linkage procedure for the linking of readmissions of newborns from the dutch paediatrician registry (lnr). % of all newborns ( . ) are admitted to a neonatal ward. the main problems were the unknown number of readmissions per child and the identification of admissions of twins. objective: to validate our linking procedure in a double blinded study. design and methods: a random sample of admissions from children from the linked file has been validated by the caregivers, using the original medical records. results: response was %. for admissions of singletons the linkage contained no errors except for the small uncertain area of the linkage. for admissions of multiple births a high error rate was found. conclusion and discussion: we successfully linked the admissions of singleton newborns with the developed probabilistic linking algorithm. for multiple births we did not succeed in constructing valid admission histories due to too low data quality of twin membership variables. validation showed alternative solutions for linking twin admissions. we strongly recommend that linkage results should always be externally validated. background: salmonella typhimurium definitive phage type (dt) has emerged as an important pathogen in the last two decades. a -fold increase in cases in the netherlands during september-november prompted an outbreak investigation. objective: the objective was to identify the source of infection to enable preventive measures. methods: a subset of outbreak isolates was typed by molecular means. in a case-control study, cases (n = ) and matched population controls (n = ) were invited to complete self-administered questionnaires. results: the molecular typing corroborated the clonality of the isolates. the molecular type was similar to that of a recent s. typhimurium dt outbreak in denmark associated with imported beef. the incriminated shipment was traced after having been distributed sequentially through several eu member states. sampling of the beef identified s. typhimurium dt of the same molecular type as the outbreak isolates. cases were more likely than controls to have eaten a particular raw beef product. conclusions: our preliminary results are consistent with this s. typhimurium dt outbreak being caused by contaminated beef. our findings underline the importance of european collaboration, traceability of consumer products and a need for timely intervention into distribution chains. background: heavy-metals may affect newborns. some of them are presenting tobacco smoke. objectives: to estimate cord-blood levels of mercury, arsenic, lead and cadmium in newborns in areas in madrid, and to assess the relationship with maternal tobacco exposure. design and methods: bio-madrid study obtained cord-blood samples from recruited trios (mother/father/ newborn). cold-vapor atomic absorption spectrophotometry (aas) was used to measure mercury and graphite-furnace aas for the other metals. mothers answered a questionnaire including tobacco exposure. median, means and standard errors were calculated and logistic regression used to estimate or. results: median levels for mercury and lead were . mg/l and . mg/l. arsenic and cadmium were undetectable in % and % of samples. preliminar analysis showed a significant association of maternal tobacco exposure and levels of arsenic (or: . ; % ci: . - . ), cadmium (or: . ; % ci: . - . ), and lead (or: . ; % ci: . - . ). smoking in pregnancy was associated to arsenic (or: . ; % ci: . - . ), while passive exposure was more related to lead (or: . ; % ci: . - . ) and cadmium (or: . ; % ci: . - . ). conclusion: madrid newborns have high cord-blood levels of mercury. tobacco exposure in pregnancy might increase levels of arsenic, cadmium and lead. background: road traffic accidents (rta) are the leading cause of death for young. rta police reports provide no health information other then the number of deaths and injured, while health databases have no information on the accident dynamics. the integration of the two databases would allows to better describe the phenomenon. nevertheless, the absence of common identification variables through the lists makes the deterministic record linkage (rl) impossible. objective: to test feasibility of a probabilistic rl between rta and health information when personal identifiers are lacking. methods: health information came from the rta integrated surveillance for the year . it integrates data from ed visits, hospital discharges and deaths certificates. a deterministic rl was performed with police reports, where the name and age of deceased were present. results of the deterministic rl was then used as gold standard to evaluate the performance of the probabilistic one. results: the deterministic rl resulted in ( . %) linked records. the probabilistic rl, where the name was omitted, was capable to correctly identify ( . %). conclusions: performance of the probabilistic rl was good. further work is needed to develop strategies for the use of this approach in the complete datasets. background: overweight constitutes a major public health problem. the prevalence of overweight is unequally distributed between socioeconomic groups. risk group identification, therefore, may enhance the efficiency of interventions. objectives: to identify which socioeconomic variable best predicts overweight in european populations: education, occupation or income. design: european community household panel data were obtained for countries (n = , ). overweight was defined as a body mass index >= kg/m . uni-and multivariate logistic regression analyses were employed to predict overweight in relationship to socioeconomic indicators. results: major socioeconomic differences in overweight were observed, especially for women. for both sexes, a low educational attainment was the strongest predictor of overweight. after control for confounders and the other socioeconomic predictors, the income gradient was either absent or positive (men) or negative (women) in most countries. similar patterns were found for occupational level. for women, inequalities in overweight were generally greater in southern european countries. conversely, for men, differences were generally greater in other european countries. conclusion: across europe, educational attainment most strongly predicts overweight. therefore, obesity interventions should target adults and children with lower levels of education. background: because incidence and prevalence of most chronic diseases rise with age, their burden will increase in ageing populations. we report the increase in prevalence of myocardial infarction (mi), stroke (cva), diabetes type ii (dm) and copd based on the demographic changes in the netherlands. in addition, for mi and dm the effect of a rise in overweight was calculated. methods: calculations were made for the period - with a dynamic multi-state transition model and demographic projections of the cbs. results: based on ageing alone, between and prevalence of dm will rise from . to . (+ %), prevalence of mi from . to . (+ %), stroke prevalence from . to . (+ %) and copd prevalence from . to . (+ %). a continuation of the dutch (rising) trend in overweight prevalence would in lead to about . diabetics (+ %). a trend resulting in american levels would lead to over million diabetics (+ %), while the impact on mi was much smaller: about . (+ %) in . conclusion: the burden of chronic disease will substantially increase in the near future. a rising prevalence of overweight has an impact especially on the future prevalence of diabetes background: there has been increasing concern about the effects of environmental endocrine disruptors (eeds) on human reproductive health. eeds include various industrial chemicals, as well as dietary phyto-estrogens. intra-uterine exposures to eeds are hypothesized to disturb normal foetal development of male reproductive organs and specifically, to increase the risk of cryptorchidism, hypospadias, testicular cancer, and a reduced sperm quality in offspring. objective: to study the associations between maternal and paternal exposures to eeds and the risks of cryptorchidism, hypospadias, testicular cancer and reduced sperm quality. design and methods: these associations are studied using a case-referent design. in the first phase of the study, we collected questionnaire data of the parents of cases with cryptorchidism, cases with hypospadias and referent children. in the second phase, we will focus on the health effects at adult age: testicular cancer and reduced sperm quality. in both phases, we will attempt to estimate the total eed exposure of parents of cases and referents at time of pregnancy through an exposure-assessment model in which various sources of exposure, e.g. environment, occupation, leisure time activities and nutrition, are combined. in addition, we will measure hormone receptor activity in blood. background: eleven percent of the pharmacotherapeutic budget is spent on acid-suppressive drugs (asd); % of patients are chronic user. most of these indications are not conform to dyspepsia guidelines. objectives: we evaluated the implementation of an asd rationalisation protocol among chronic users, and analysed effects on volume and costs. method: in a cohort study patients from gp's with protocol were compared to a control group of patients from gp's without. prescription data of - were extracted from agis health database. a log-linear regression model compared standardised outcomes of number of patients that stopped or reduced asd (> %) and of prescription volume and costs. results: gp's and patients in both groups were comparable. % in the intervention group had stopped; % in the control group (p< . ). the volume had decreased in another % of patients; % in control group (p< . ). compared to the baseline data in the control group ( %) the adjusted or of volume in the intervention group was . %. the total costs adjusted or was . %. the implementation significantly reduced the number of chronic users, and substantially dropped volume and costs. active intervention from insurance companies can stimulate rationalisation of prescription. background/objective: today, % of lung cancers are resectable (stage i/ii). -year survival is therefore low ( %). spiral computed tomography (ct) screening detects more lung cancers than chest x-ray. it is unknown if this will translate into a lung cancer mortality reduction. the nelson trial investigates whether detector multi-slice ct reduces lung cancer mortality with at least % compared to no screening. we present baseline screening results. methods: a questionnaire was sent to , men and women. of the , respondents, , high-risk current and former smokers were invited. until december , , , of them gave informed consent and were randomised ( : ) in a screen arm (ct in year , and ) and control arm (no screening). data will be linked with the cancer registry and statistics netherlands to determine cancer mortality and incidence. results: of the first , baseline ct examinations % was negative (ct after one year), % indeterminate (ct after months) and % positive (referral pulmonologist). seventy percent of detected tumours were resectable. conclusion/discussion: ct screening detects a high percentage of early stage lung cancers. it is estimated that the nelson trial is sufficiently large to demonstrate a % lung cancer mortality reduction or more. background: due to diagnostic dilemmas in childhood asthma, drug treatment of young children with asthmatic complaints often serves as a trial treatment. objective: to obtain more insight into patterns and continuation of asthma medication in children during the first years of life. design: prospective birth cohort study methods: within the prevention and incidence of asthma and mite allergy (piama) study (n = , children) we identified children using asthma medication in their first year of life. results: about % of children receiving asthma medication before the age of one, discontinued use during follow-up. continuation of therapy was associated with male gender (adjusted odds ratio [aor] . , % confidence interval [ci]: . - . ), a diagnosis of asthma (aor . , % ci: . - . ) and receiving combination or controller therapy (aor , , % ci: . - . ). conclusion: patterns of medication use in preschool children support the notion that both beta -agonist and inhaled corticosteroids are often used as trial medication, since % discontinues. the observed association between continuation of therapy and both an early diagnosis of asthma and a prescription for controller therapy suggests that, despite of diagnostic dilemmas, children in apparent need of prolonged asthma therapy are identified at this very early age. background: this study explored the differences in birthweight between infants of first and second generation immigrants and infants of dutch women, and to what extent maternal, fetal and environmental characteristics could explain these differences. method: during months all pregnant women in amsterdam attending their first prenatel screening were asked to fill out a questionnaire (sociodemographic status, lifestyle) as part of the amsterdam born children and their development (abcd)-study; women ( %) responded. only singleton deliveries with pregnancy duration = weeks were included (n = ). results: infants of all first and second generation immigrant groups (surinam, the antilles, turkey, morocco, ghana, other countries) had lower birthweights (range: - gram) than dutch infants ( gram). linear regression revealed that, adjusted for maternal height, weight, age, parity, smoking, marital status, gestational age and gender, infants of surinamese women ( st and nd generation), antillean and ghanaian women (both st generation) were still lighter than dutch infants ( . , . , . , and . grams respectively; p< . ). conclusion: adjusted for maternal, fetal and environmental characteristics infants of some immigrant groups had substantial lower birthweights than infants of dutch women. other factors (like genetics, culture) can possibly explain these differences. introduction: missing data is frequently seen in cost-effectiveness analyses (ceas). we applied multiple imputation (mi) combined with bootstrapping in a cea. objective: to examine the effect of two new methodological procedures of combining mi and bootstrapping in a cea with missing data. methods: from a trial we used direct health and non-health care costs and indirect costs, kinesiophobia and work absence data assessed over months. mi was applied by multivariate imputation by chained equations (mice) and non-parametric bootstrapping was used. observed case analyses (oca), where analyses were conducted on the data without missings, were compared with complete case analysis (cca) and with analyses when mi and bootstrapping were combined after to % of cost and effect data were omitted. results: by the cca effect and cost estimates shifted from negative to positive and cost-effectiveness planes and acceptability curves were biased compared to the oca. the methods of combining mi and bootstrapping generated good cost and effect estimates and the cost-effectiveness planes and acceptability curves were almost identical to the oca. conclusion: on basis of our study results we recommend to use the combined application of mi and bootstrapping in data sets with missingness in costs and effects. background: since the s, coronary heart disease (chd) mortality rates have halved with approximately % of this decrease being attributable to medical and surgical treatments. objective: this study examined the cost-effectiveness of specific chd treatments. design and methods: the impact chd model was used to calculate the number of life-years-gained (lyg) by specific cardiology interventions given in , and followed over ten years. this previously validated model integrates data on patient numbers, median survival in specific groups, treatment uptake, effectiveness and costs of specific interventions. cost-effectiveness ratios were generated as costs per lyg for each specific intervention. results: in , medical and surgical treatments together prevented or postponed approximately , chd deaths in patients aged - years; this generated approximately , extra life years. aspirin and beta-blockers for secondary prevention of myocardial infarction and heart failure, and spironolactone for heart failure all appeared highly cost-effective (<e , per lyg). less cost effective, however, were revascularisation for chronic angina (cabg surgery e , and angioplasty e , per lyg), or statins for primary prevention (e , per lyg) or for community patients with angina (e , per lyg). conclusions: cost effectiveness ratios generally favoured simple medical treatments for myocardial infarction, secondary prevention, and heart failure. objective: is population-based primary prevention more favourable than secondary prevention (risk factor reduction in coronary heart disease (chd) patients)? methods: the previously validated im-pact model was used to integrate data describing chd patient numbers, specific treatment uptake levels, trends in major risk factors, and the mortality benefits of these risk factor changes in healthy people and in chd patients. results: approximately , fewer deaths were attributable to reductions in the three major risk factors between and . declining smoking prevalence resulted in approximately fewer deaths: in healthy people and in known chd patients. decreasing population total cholesterol concentrations resulted in approximately , fewer deaths attributable to dietary changes ( , in healthy people and in chd patients) plus fewer deaths attributable to statin treatment ( in people without chd and in chd patients). decreasing mean population blood pressure resulted in approximately fewer deaths attributable to secular falls in blood pressure ( in healthy people and in chd patients) plus approximately fewer deaths attributable to antihypertensive treatments in people without chd. conclusions: compared with secondary prevention ( fewer deaths), primary prevention ( , fewer deaths) achieved a three-fold larger reduction in chd deaths. background: carotenoid intake has been positively associated with plasma concentrations in different populations. however, the influence of body mass index (bmi) on this association is mostly unknown. objectives: we explored the relationship between intake of carotenoids and vitamin c, and their plasma concentrations by bmi categories in spanish elderly people. desgin/methods: a dietary interview using a -item food-frequency questionnaire was conducted with men and women, and older, participating in the eureye study in spain. blood samples were collected for measurement of carotenoids and vitamin c. correlation coefficients (r) between energy adjusted nutrient intakes and plasma concentrations were calculated by categories of bmi, adjusting for sex, age and smoking. results: significant correlations between acarotene, ß-carotene, lycopene, ß-cryptoxanthin and vitamin c intakes, and plasma concentrations were observed, r= . ; . ; . ; . , . , respectively (p< . ). correlations for carotenoids changed substantially by bmi categories, with the highest correlations for a-carotene, ß-carotene, and, to a lesser extension, ß-cryptoxanthin and lycopene, in subjects with bmi< ( . ; . ; . ; . respectively), and the lowest, in subjects with bmi= ( . ; . ; . ; . respectively). correlations for vitamin c remained unchanged by bmi. conclusions: our data suggest that carotenoids in plasma may be good markers of dietary intake in elderly subjects with lower bmi. background: reduced heart rate variability (hrv) is associated with an increased mortality, morbidity and worse prognosis of cardiovascular diseases (cvd). there is a lack of population-based data to examine the distribution of hrv, its association with cardiovascular risk factors (cvrf), and its role as a potential mediator of the effect of established risk factors on cvd. objective: to study the distribution of hrv and its association with cvrf in an elderly eastern german population. design and methods: this analysis is based on data of participants ( - years) of an ongoing cross-sectional study. time-and frequency-domain measures of hrv were computed. their association with cvrf was determined by linear regression modelling. results: age-and heart rate-adjusted standard deviation of the durations of nn intervals and high frequency power was significantly higher in women. significant inverse associations of timeand frequency-domain hrv with anthropometric parameters, triglycerides, blood pressure, prevalent diabetes and age were observed in both sexes. there was a graded inverse association of hrv with age except for the oldest age-group. discussion/conclusion: established cvrf are associated with a reduced hrv. therefore reduced hrv could be a mediator between cvrf and cvd, which will be examined in a follow-up study. background: aalen's model and cox's proportional hazard model postulate different relationship between hazard and covariates and the subject matter seldom suggests which of the models are to be preferred. actually the assumption of constant effects, either additive or multiplicative, may be incorrect especially in cancer survival analysis. objectives: the aim of the study is to analyse survival for a breast cancer cohort where typical prognostic factors lack of proportionality. design and methods: the cohort consists of invasive breast cancer cases from turin cancer registry within a high resolution study in co-operation with the breast cancer screening program, diagnosed from through , aged - . an additive-multiplicative cox-aalen model with age at diagnosis, categorized tumour size (t) and nodal status (n) is fitted. results: the prognostic role of age at diagnosis, t and n are confirmed. proportionality assumption holds only for age (hazard ratio = . , p-value< . ). t, particularly the category referring to 'extended to chest wall or skin' versus 'less than cm', has a significant time-varying effect (p-value = . ) after months since diagnosis. discussion: more flexible regression tools than cox model which is routinely used for analyzing cancer survival are needed. cox-aalen proves to be an appealing alternative. background: the major software packages for meta-analysis of causal -notably intervention -research are generally too expensive for developing countries. moreover, interactive educational software for students and teachers is largely unavailable. we recently developed the 'mix' program, an easy-to-maintain, interactive, and educational meta-analysis add-in for excel, available as free download at http://www.mix-for-meta-analysis.info. objectives: to formally establish whether the program's numerical and graphical output is comprehensive and accurate enough for scientific standards. design and methods: the study was designed as a software validation. data sets, primarily intervention studies, with substantially different features were analyzed by three investigators with mix and stata, using the latter program as golden standard. additionally, a feature (software options) comparison was made with modern programs for meta-analysis, such as cma . , metawin . , weasyma . , and revman . . results: the results of the validation project will be fully reported at the congress. preliminary results indicate that the mix program's output is comparable to stata output. it distinguishes itself from other software by the variety of graphical output, the excel-based interface, and free availability. conclusion and discussion: the mix program appears to provide valid output and may be an attractive, feature-rich alternative to existing meta-analysis software. background: an ankle-arm index (aai) < . of systolic blood pressure (sbp) as marker of peripheral arterial disease is a predictor of coronary and carotid artery disease. the present gold standard examination with doppler-ultrasound and sphygmomanometric cuff is subject to observer bias and requires intensive training. for epidemiologic studies, valid and easy-to-use examination methods are needed. objective: to validate the easy-to-use omron hem- cp for sbp measurements in the ankle and for aai determination in epidemiologic studies. design/methods: in a population-based sample of subjects ( - years), arm and ankle sbp measurements by the omron hem- cp and corresponding aai were compared with those using a hand-held doppler and sphygmomanometric cuff. bland-altman plots of sbp and aai differences, validation criteria for use in clinical practice and diagnostic values for the detection of an aai< . were employed. results: omron measured higher sbp than doppler. sbp and aai differences increasing towards higher sbp levels. specificity, sensitivity and negative predictive value for the detection of aai< . were > % (positive predictive value was %). conclusion: omron fails the validation criteria for ankle sbp measurement. however, the ease of use of the device could outweigh the inaccuracy if used as a screening tool for aai< , in epidemiologic studies. background: associations exist between: ) parental birth weight and child birth weight; ) birth weight and adult psychopathology; and ) maternal psychopathology during pregnancy and birth weight of the child. this study is the first to combine those associations. objective: to investigate the different pathways from parental birth weight and parental psychopathology to child birth weight in one model. design and methods: depression and anxiety scores on , mothers and , fathers during weeks pregnancy and birth weights from , children were available. path analyses with standardized regression coefficients were used to evaluate the different effects. results: in the unadjusted path analyses significant effects existed between: maternal (r = . ) and paternal birth weight (r = . ) and child birth weight; maternal birth weight and maternal depression (r=). ) and anxiety (r=). ); and maternal depression (r = . ) and anxiety (r = . ) and child birth weight. after adjustment for confounders, only maternal (r = . ) and paternal (r = . ) birth weight and maternal depression (r=). ) remained significantly related to child birth weight. conclusion after adjustment maternal depression, and not anxiety, remained significantly related to child birth weight. discussion future research should focus on the different mechanisms of maternal anxiety and depression on child birth weight. background: most patients with peripheral arterial disease (pad) die from coronary artery disease (cad). non-invasive cardiac imaging can assess the presence of coronary atherosclerosis and/or cardiac ischemia. screening in combination with more aggressive treatment may improve prognosis. objective: to evaluate whether a non-invasive cardiac imaging algorithm, followed by treatment will reduce the -year-risk of cardiovascular events in pad patients free from cardiac symptoms. design and methods: this is a multicenter randomized controlled clinical trial. patients with intermittent claudication and no history of cad are eligible. one group will undergo computed tomography (ct) calcium scoring. the other group will undergo ct calcium scoring and ct angiography (cta) of the coronary arteries. patients in the latter group will be scheduled for a dobutamine stress magnetic resonance imaging (dsmr) test to assess cardiac ischemia, unless a stenosis of the left main (lm) coronary artery (or its equivalent) was found on cta. patients with cardiac ischemia or a lm/lm-equivalent stenosis will be referred to a cardiologist, who will decide on further (interventional) treatment. patients are followed for years. conclusion: this study assesses the value of non-invasive cardiac imaging to reduce the risk of cardiovascular events in patients with pad free from cardiac symptoms. background: hpv is the main risk factor for cervical cancer and also a necessary cause for it. participation rates in cervical cancer screening are low in some countries and soon hpv vaccination will be available. objectives: aim of this systematic review was to collect and analyze published data on knowledge about hpv. design and methods: a medline search was performed for publications on knowledge about hpv as a risk factor for cervical cancer and other issues of hpv infection. results: of individual studies were stratified by age of study population, country of origin, study size, publication year and response proportion. heterogeneity was described. results: knowledge between included studies varied substantially. thirteen to % (closed question) and . to . % (open question) of the participants knew about hpv as a risk factor for cervical cancer. women had consistently better knowledge on hpv than men. there was confusion of hpv with other sexually transmitted diseases. conclusion and discussion: studies were very heterogeneous, thus making comparison difficult. knowledge about hpv infections depended on the type of question used, gender of the participants and their professional background. education of the general public on hpv infections needs improvement, specially men should also be addressed. background: influenza outbreaks in hospitals and nursing homes are characterized by high attack rates and severe complications. knowledge of the virus' specific transmission dynamics in healthcare institutions is scarce but essential to develop cost-effective strategies. objective: to follow and model the spread of influenza in two hospital departments and to quantify the contributions of the several possible transmission pathways. methods: an observational prospective cohort study is performed on the departments of internal medicine & infectious diseases and pulmonary diseases of the umc utrecht during the influenza season. all patients and regular medical staff are checked daily on the presence of fever and cough, the most accurate symptoms of influenza infection. nose-throat swabs are taken for pcr analysis for both symptomatic individuals and a sample of asymptomatic individuals. to determine transmission, contact patterns are observed between patients and visitors and patients and medical staff. results/discussion: spatial and temporal data of influenza cases will be combined with contact data in a mathematical model to quantify the main transmission pathways. among others the model can be used to predict the effect of vaccination of the medical staff which is not yet common practice in the studied hospital. background: the long term maternal sequelae of stillbirths is unknown. objectives: to assess whether women who experienced stillbirths have an excess risk of long term mortality. study design: cohort study. methods: we traced jewish women from the jerusalem perinatal study, a population-based database of all births to west jerusalem residents ( - who gave birth at least twice during the study period, using unique identity numbers. we compared the survival to - - of women who had at least one stillbirth (n = ) to that of women who had only live births (n = ) using cox proportional hazards models. results: during a median follow up of . years, ( . %) mothers with stillbirths died compared to , ( . %) unexposed women; crude hazard ratio (hr) . ( % ci: . - . ). the mortality risk remained significantly increased after adjustments for sociodemo-graphic variables, maternal diseases, placental abruption and preeclampsia (hr: . , % ci: . - . ). stillbirth was associated with increased risk of death from cardiovascular (adjusted hr: . , . - . ), circulatory ( . , . - . ) and genitourinary ( . , . - . ) causes. conclusions: the finding of increased mortality among mothers of stillbirths joins the growing body of evidence demonstrating long term sequelae of obstetric events. future studies should elucidate the mechanisms underlying these associations. resilience is one of the essential characteristics of successful ageing. however, very little is known about the determinants of resilience in old age. our objectives were to identify resilience in the english longitudinal study of ageing (elsa) and to investigate social and psychological factors determining it. the study design was a crosssectional analysis of wave of elsa. using structural equation modelling, we identified resilience as a latent variable indicated by high quality of life in the face of six adversities: ageing, limiting long-standing illness, disability, depression, perceived poverty and social isolation and we regressed it on social and psychological factors. the latent variable model for resilience showed a highly significant degree of fit (weighted root mean square resid-ual= . ). determinants of resilience included good quality of relationships with spouse (p = . ), family (p = . ), and friends (p< . ), good neighbourhood (p< . ), high level of social participation (p< . ), involvement in leisure activities (p = . ); perception of not being old (p< . ); optimism (p = . ), and high subjective probability of survival to an older age (p< . ). we concluded that resilience in old age was as much a matter of social engagement, networks and context as of individual disposition. implications of this on health policy are discussed. background: there is extensive literature concluding that ses is inversely related to obesity in developed countries. several studies in developing populations however reported curvilinear or positive association between ses and obesity. objectives: to assess the social distribution of obesity in men and women in middle-income countries of eastern and central europe with different level of economic development. methods: random population samples aged - years from poland, russia and czech republic were examined between - as baseline for prospective cohort study. we used body-mass index (bmi) and waist/hip ratio (whr) as obesity measures. we compared age-adjusted bmi and whr for men and women by educational levels in all countries. results: the data collection was concluded in summer . we collected data from about , subjects. lower ses increased obesity risk in women in all countries (the strongest gradient in the czech republic and the lowest in russia), and in czech men. there was no ses gradient in bmi in polish men and positive association between education and bmi in russian men. conclusions: our findings strongly agree with previous literature showing that the association between ses status and obesity is strongly influenced by overall level of country economic development. background: inaccurate measurements of body weight, height and waist circumference will lead to an inaccurate assessment of body composition, and thus of the general health of a population. objectives: to assess the accuracy of self-reported body weight, height and waist-circumference in a dutch overweight working population. design and methods: bland and altman methods were used to examine the individual agreement between self-reported and measured body weight and height in overweight workers ( % male; mean age . +/) . years; mean body mass index [bmi] . +/) . kg/m ). the accuracy of self-reported waistcircumference was assessed in a subgroup of persons ( % male; mean age . +/) . years; mean bmi . +/) . kg/ m ), for whom both measured and self-reported waist circumference was available. results: body weight was underreported by a mean (standard deviation) of . ( . ) kg, body height was on average over-reported by . ( . ) cm. bmi was on average underreported by . ( . ) kg/m . waist-circumference was overreported by . ( . ) cm. the overall degree of error from selfreporting was between . and . %. conclusion and discussion: self-reported anthropometrics seem satisfactorily accurate for the assessment of general health in a middle-aged overweight working population. the incidence of breast cancer and the prevalence of metabolic syndrome are increasing rapidly in chile, but this relationship is still debated. the goal of this study is to assess the association between metabolic syndrome and breast cancer before and after menopause. a hospital based case-control study was conducted in chile during . cases with histologically confirmed breast cancer and age matched controls with normal mammography were identified. metabolic syndrome was defined by atpiii and serum lipids, glucose, blood pressure and waist circumference were measured by trained nurses. data of potential confounders such as, obesity, socioeconomic status, exercise and diet were obtained by anthropometric measures and a questionnaire. odds ratios (ors) and % confidence intervals (cis) were estimated by conditional logistic regression stratified by menopause. in postmenopausal women, a significant increase risk of breast cancer was observed in women with metabolic syndrome (or = . , % ci = . - . ). the elements of metabolic syndrome strongly associated were high levels of glucose and hypertension. in conclusion, postmenopausal women with metabolic syndrome had % of excess risk of breast cancer. these findings support the theory that there is a different risk profile of breast cancer after and before menopause. background: physical exercise during pregnancy has numerous beneficial effects on maternal and foetal health. it may, however, affect early foetal survival negatively. objectives: to examine the association between physical exercise and spontaneous abortion in a cohort study. design and methods: in total, , women recruited to the danish national birth cohort in early pregnancy, provided information on amount and type of exercise during pregnancy and on possible confounding factors. , women experienced foetal death before gestational weeks. hazard ratios for spontaneous abortion in four periods of pregnancy () , - , - , and - weeks) according to amount (min/week) and type of exercise, respectively, were estimated using cox regression. various sensitivity analyses to reveal distortion of the results from selection forces and information bias were made. results: the hazard ratios of spontaneous abortion increased stepwise with amount of physical exercise and were largest in the earlier periods of pregnancy (hrweek - = . (ci . - . ) for min/week, compared to no exercise). weight bearing types of exercise were strongest associated with abortion, while swimming showed no association. these results remained stable, although attenuated, in the sensitivity analyses. discussion: handling of unexpected findings that furthermore challenge official public health messages will be discussed. hemodialysis (hd) patients with a low body mass index (bmi) have an increased mortality risk, but bmi changes over time on dialysis treatment. we studied the association between changes in bmi and all-cause mortality in a cohort of incident hd patients. patients were followed until death or censoring for a maximum follow-up of years. bmi was measured every months and changes in bmi were calculated over each -mo period. with a time-dependent cox regression analysis, hazard ratios (hr) were calculated for these -mo changes on subsequent mortality from all causes, adjusted for the mean bmi of each -mo period, age, sex and comorbidity. men and women were included (age: ? years, bmi: . ? . kg/m , -y mortality: %). a loss of bmi> % was independently associated with an increased mortality risk (hr: . , %-ci: . - . ), while a loss of - % showed no difference (hr: . , . - . ) compared to no change in bmi () % to + % change). a gain in bmi of - % showed beneficial (hr: . , . - . ), while a gain of bmi> % was not associated with a survival advantage (hr: . , . - . ). in conclusion, hd patients with a decreasing bmi have an increased risk of all-cause mortality. background: within the tripss- project, impact of clinical guidelines (gl) on venous thromboembolism (vte) prophylaxis was evaluated in a large italian hospital. gl were effective in increasing the appropriateness of prophylaxis and in reducing vte. objectives: we performed a cost-effectiveness analysis by using a decision-tree model to estimate the impact of the adopted gl on costs and benefits. design and methods: a decision-tree model compared prophylaxis cost and effects before and after gl implementation. four risk profiles were identified (low, medium, high, very high). possible outcomes were: no event, major bleeding, asymptomatic vte, symptomatic vte and fatal pulmonary embolism. vte patients risk and probability of receiving prophylaxis were defined using data from the previous survey. outcome probabilities were assumed from literature. tariffs and hospital figures were used for costing the events. results: gl introduction reduced the average cost per patient from e to () %) with an increase in terms of event free patients (+ %). results are particularly relevant in the very high risk group. conclusion: the implementation of locally adapted gl may lead to a gain in terms of costs and effects, in particular for patients at highest vte risk. background: assisted reproductive techniques are used to overcome infertility. one reason of success is the use of ovarian stimulation. objectives: compare two ovarian stimulation protocols, gonadotropin-releasing hormone agonists/antagonists, assessing laboratorial and clinical outcomes, to provide proper therapy option. identify significant predictors of clinical pregnancy and ovarian response. design and methods: retrospective study (agonist cycles, ; antagonist cycles, ) including ivf/intracytoplasmic sperm injection cycles. multiple logistic and regression models, with fractional polynomial method were used. results: antagonist group exhibited lower length of stimulation and dose of recombinant follicle stimulating hormone (rfsh), higher number of retrieved and fertilized oocytes, and embryos. agonist group presented thicker endometrium, better fertilization, implantation and clinical pregnancy rates. clinical pregnancy has shown positive correlation with endometrial thickness and use of agonist; negative correlation with age and number of previous attempts. retrieved oocytes shown positive correlation with estradiol on day of human chorionic gonadotrophin (hcg) and use of antagonist; negative correlation with rfsh dose. conclusion: patients from antagonist group are more likely to get more oocytes and quality embryos, despite those from agonist group are more likely to get pregnant. background: prevalence studies of the metabolic syndrome require fasting blood samples and are therefore lacking in many countries including germany. objectives: to narrow the incertitude resulting from extrapolation of international prevalence estimates, with a sensitivity analysis of the prevalence of the metabolic syndrome in germany using a nationally representative but partially non-fasting sample. methods: stepwise analysis of the german health examination survey , using the national cholesterol education program (ncep) criteria, hemoglobin a c (hba c), non-fasting triglycerides and fasting time. results: among participants aged - years, the metabolic syndrome prevalence was (i) . % with . % inconclusive cases using the unmodified ncep criteria, (ii) . % with . % inconclusive cases using hba c > . % if fasting glucose was missing, (iii) . % with . % inconclusive cases when additionally using non-fasting triglycerides = th percentile stratified by fasting time, and (iv) . % to . % with < % inconclusive cases using different cutoffs (hba c . %, non-fasting triglycerides and mg/dl). discussion: despite a lower prevalence of obesity in germany compared to the us, the prevalence of the metabolic syndrome is likely to be in the same order of magnitude. this analysis may help promote healthy life styles by stressing the high prevalence of interrelated cardiovascular risk factors. background: epidemiologic studies that directly examine fruits and vegetables (f&v) consumption and other lifestyle factors in relation to weight gain are sparse. objective: we examined the associations between the f&v intake and -y weight gain among spanish adult people. design/methods: the study was conducted with a sub-sample of healthy people aged y and over at baseline in , who participated in a population-based nutrition survey in valencia-spain. data on diet, lifestyle factors and body weight (direct measurement) were obtained in and . information on weight gain was available for participants in . results: during the -y period, participants tended to gain on average . kg (median = . kg). in multivariate analyses, participants with the highest tertile of f&v intake at baseline had a % of lower risk of gaining = . kg compared with those who had the lowest intake tertile after adjustment for sex, age, education, smoking, tv-viewing, bmi, and energy intake (or = . ; % ci: . . ;p-fortrend = . ). for every g/d increase in f&v intake, the or was reduced by % (or = . ; . - . ;p-trend= . ). tvviewing at baseline was positively associated with weight gain, or for- h-increase= . ( . - . ;p-trend= . ). conclusions: our findings suggest that a high f&v intake and low tv-viewing may reduce weight gain among adults. background: diabetic patients develop more readily atherosclerosis thus showing greatly increased risk for cardiovascular disease. objective: the heinz nixdorf recall-study is a prospective cohort-study designed to assess the prognostic value of new risk stratification methods. here we examined the association between diabetes, previously unknown hyperglycemia and the degree of coronary calcification (cac). methods: a population-based sample of , men and women aged - years was recruited from three german cities between - . baseline examination included amongst others a detailed medical history, blood analyses and electron-beam tomography. we calculated adjusted prevalence ratios (pr), adjusting for age, smoking, bmi and %-confidence intervals ( % ci) with log-linear binomial regression. results: the prevalence of diabetes is . % (men: . %, women: . %), for hyperglycemia . % (men: . %, women: . %). prevalence ratio for cac in male diabetics without overt coronary heart disease is . ( % ci: . - . ), for those with hyperglycemia . ( . - . ). in women the association is even stronger: . ( . - . ) with diabetes, . ( . - . ) with hyperglycemia. conclusion: the data support the concept of regarding diabetic patients as being in a high risk category meaning > % hard events in years. furthermore, even persons with elevated blood glucose levels already show higher levels of coronary calcification. background: birth weight is associated with health in infancy and later in life. socioeconomic inequality in birth weight is an important marker of current and future population health inequality. objective: to examine the effect of maternal education on birth weight, low birth weight (lbw, birth weight< , g), and small for gestational age (sga) background: in clinical practice patient data are obtained gradually and health care practitioners tune prognostic information according to available data. prognostic research does not always reproduce this sequential acquisition of data: instead, 'worst', discharge or aggregate data are often used. objective: to estimate prognostic performance of sequentially updated models. methods: cohortstudy of all very-low-birth-weight-babies (< g) admitted to the study neonatal icu < days after birth ( eligible from to ) and followed-up until years old ( . % lost-to-follow-up). main outcomes: disabling cerebral palsy at years ( , . %) or death ( , . % ) % in the first weeks). main prognostic determinants: neonatal cerebral lesions identified with cranial ultrasound (us) exams performed per protocol on days , , and at discharge. logistic regression models were updated with data available at these different moments in time during admission. results: at days , and respectively, main predictor (severe parenchymal lesion) adjusted odds ratio: , and ; us model c-statistic: . , . and . . discussion: prognostic models performance in neonatal patients improved from inception to discharge, particularly for identification of the high risk category. time of data acquisition should be considered when comparing prognostic instruments. in epidemiological longitudinal studies one is often interested in the analysis of time patterns of censored history data. for example, how regular a medication is used or how often someone is depressed. our goal is to develop a method to analyse time patterns of censored data. one of the tools in longitudinal studies is a nonhomogeneous markov chain model with discrete time moments and categorical state space (for example, use of various medications). suppose we are interested only in the time pattern of appearance of a particular state which is in fact a certain epidemiological event under study. for this purpose we construct a new homogeneous markov chain associated with this event. the states of this markov chain are the time moments of the original nonhomogeneous markov chain. using the new transition matrix and standard tools from markov chain theory we can derive the probabilities of occurence of that epidemiological event during various time periods (including ones with gaps). for example, probabilities of cumulative use of medication during any time period. in conclusion, the proposed approach based on markov chain model provides a new way of data representation and analysis which is easy to interpret in practical applications. background: tuberculosis (tb) cases that belong to a cluster of the same mycobacterium tuberculosis dna fingerprint are assumed to be consequence of recent transmission. targeting interventions to fast growing clusters may be an efficient way of interrupting transmission in outbreaks. objective: to assess predictors for large growing clusters compared to clusters that remain small within a years period. design and method out of the culture confirmed tb patients diagnosed between and , ( %) had unique fingerprints while were part of a cluster. of the clustered cases were in a small ( to cases within the first years) and in a large cluster (more than cases within the first years). results independent risk factors for being a case within the first years of a large cluster were non-dutch nationality (or = . % ci [ . - . background: passive smoking causes adverse health outcomes such as lung cancer or coronary heart disease (chd). the burden of passive smoking on a population level is currently unclear and depends on several assumptions. we investigated the public health impact of passive smoking in germany. methods: we computed attributable mortality risks due to environmental tobacco smoke (ets). we considered lung cancer, chd, stroke, copd and sudden infant death. frequency of passive smoking was derived from the national german health survey. sensitivity analyses were performed using different definitions of exposure to passive smoking. results: in total, deaths every year in germany are estimated to be caused by exposure to passive smoking at home (women , men ). most of these deaths are due to chd ( ) and stroke ( ). additional consideration of passive smoking at workplace increased the number of deaths to . considering any exposure to passive smoking and also active smokers who report exposure to passive smoking increased the number of deaths further. conclusions: passive smoking has an important impact on mortality in germany. even the most conservative estimate using exposure to ets at home led to a substantial number of deaths related to passive smoking. des daughters have a strongly increased risk of clear-cell adenocarcinoma of the vagina and cervix (ccac) at a young age. longterm health problems, however, are still unknown. we studied incidence of cancer, other than ccac, in a prospective cohort of des daughters (desnet project). in , questionnaires were sent to des daughters registered at the des center in utrecht. also, informed consent was asked for linkage with disease registries. for this analysis, data of , responders and nonresponders were linked to palga, the dutch nationwide network and registry of histo-and cytopathology. mean age at the end of follow-up was . years. a total of incident cancers occurred. increased standardized incidence rates (sir) were found for vaginal/vulvar cancers (sir = . , % confidence interval ( % ci) . - . ), melanoma (sir = . , % ci . - . )) and breast cancer (sir= . , % ci . - . ) as compared to the general population. no increased risk was found for invasive cervical cancer, possibly due to effective screening. results for breast and cervical cancer are consistent with the sparse literature. the risk of melanoma might be due to surveillance bias. future analyses will include non-invasive cervical cancer, stage specific sirs for melanoma and adjustment for confounding (sister control group) for breast cancer. background: contact tracing plays an important role in the control of emerging infectious diseases in both human and farm animal populations, but little is known yet about its effectiveness. here we investigate in a generic setting for well-mixed populations the dependence of tracing effectiveness on the probability that a contact is traced, the possibility of iteratively tracing yet asymptomatic infectives, and delays in the tracing process. methods and findings: we investigate contact tracing in a mathematical model of an emerging epidemic, incorporating a flexible infectivity function and incubation period distribution. we consider isolation of symptomatic infected as the basic scenario, and determine the critical tracing probability (needed for effective control) in relation to two infectious disease parameters: the reproduction ratio under isolation and the duration of latent period relative to the incubation period. the effect of tracing delays is considered, as is the possibility of single-step tracing vs. iterative tracing of quarantined invectives. finally, the model is used to assess the likely success of tracing for influenza, smallpox, sars, and foot-and-mouth disease epidemics. conclusions: we conclude that single-step contact tracing can be effective for infections with a relatively long latent period or a large variation in incubation period, thus enabling backwards tracing of super spreading individuals. the sensitivity to changes in the tracing delay varies greatly, but small increases may have major consequences for effectiveness. if single-step tracing is on the brink of being effective, iterative tracing can help, but otherwise it will not improve much. we conclude that contact tracing will not be effective for influenza pandemics, only partially for fmd epidemics, and very effective for smallpox and sars epidemics. abstract: infections of highly pathogenic h n avian influenza in humans underline the need for tracking of the ability of these viruses to spread among humans. here we propose a method of analysing outbreak data that allows determination of whether and to what extent transmission in a household has occurred after an introduction from the animal reservoir. in particular, it distinguishes between onward transmission from humans that were infected from the animal reservoir (primary human-to-human transmission) and onward transmission from humans who were themselves infected by humans (secondary human-to-human transmission). the method is applied to data from an epidemiological study of an outbreak of highly pathogenic avian influenza (h n ) in the netherlands in . we contrast a number of models that differ with respect to the assumptions on primary versus secondary human-to-human transmission. session: mathematical modelling of infectious diseases presentation: oral. usually models for the spread of an infection in a population are based on the assumption of a randomly mixing population, where every individual may contact every other individual. however, the assumption of random mixing seems to be unrealistic, therefore one may also want to consider epidemics on (social) networks. connections in the network are possible contacts, e.g. if we consider sexually transmitted diseases and ignore all spread by other than sexual ways, the connections are only between people that may have intercourse with each other. in this talk i will compare the basic reproduction ratio, r and the probability of a major outbreak of network models and for randomly mixing populations. furthermore, i will discuss which properties of the network are important and how they can be incorporated in the model. in this talk a reproductive power model is proposed that incorporates the following points met when an epidemic disease outbreak is modeled statistically: ) the dependence of the data is handled with a non-homogeneous birth process. ) the first stage of the outbreak is described with an epidemic sir model. soon control measures will start to influence the process. these measures are in addition to the natural epidemic removal process. the prevalence is related to the censored infection times in such a way that the distribution function, and therefore the survival function, satisfies approximately the first equation of the sir model. this leads in a natural way to the burr-family of distributions. ) the non-homogeneous birth process handles the fact that in practice, with some delay, it is the infected that are registered and not the susceptibles. ) finally the ending of the epidemic caused by the measures taken is incorporated by modifying the survival function with a finalsize parameter in the same way as is done in long-term survival models. this method is applied to the dutch classical swine individual and area (municipality) measures of income, marital and employment status were obtained. there were , suicides and , controls. after controlling for compositional effects, ecological associations of increased suicide risk with declining area levels of employment and income and increasing levels of people living alone were much attenuated. individual-level associations with these risk factors were little changed when controlling for contextual effects. we found no consistent evidence that associations with individual level risk factors differed depending on the areas characteristics (cross-level interactions). this analysis suggests the ecological associations reported in previous studies are likely to be due in greater part to the characteristics of the residents in those areas than area-influences on risk, rather than to contextual effects. were found to be at higher risk. risk was significantly greater in women whose first full-term pregnancy was at age or more (or . , ). in addition, more than full-term pregnancies would be expected to correlate with an increase in the risk (x . , p< . ). in multivariate analysis, history of breast feeding is a significant factor in decreasing risk (or . , % ci . - . the euregion meuse-rhine (emr) is an area with different regions, regarding language, culture and law. organisations and institutions received frequently signals about an increasing and region-related consumption of addictive drugs and risky behaviour of adolescents. as a reaction institutions from regions of the emr started a cross-border cooperation project 'risky behaviour adolescents in the emr'. the partners intend to improve the efficiency of prevention programmes by investigating the prevalence and pre-conditional aspects related to risky behaviour, and creating conditions for best-practice-public-health. the project included two phases: study. two cross-border (epidemiological) studies where realized: a quantitative study of the prevalence of risky behaviour ( pupils) and a qualitative study mapped preconditional aspects of risky behaviour and possibilities to preventive programmes. implementation. this served bringing about recommendations on policy level as well as on prevention level. during this phase the planning and realisation of cross-border preventionprogrammes and activities started. there is region-related variance of prevalence in risky-behaviour of adolescents in de emr. also there are essential differences in legislation and regulation, (tolerated) policy, prevention structures, political and organizational priorities and social acceptance toward stimulants. cross-border studies and cooperation between institutions have resulted in best-practice-projects in (border) areas of the emr. abstract background: beta-blockers increase bone strenght in mice and may reduce fracture risk in humans. therefore, we hypothesized that inhaled beta- agonists may increase risk of hip fracture. objective: to determine the association between daily dose of beta- agonist use and risk of hip fractures. methods: a case-control study was conducted among adults who were enrolled in the dutch phar-mo database (n = , ). cases (n = , ) were patients with a first hip fracture. the date of the fracture was the index date. four controls were matched by age, gender and region. we adjusted our analyses for indicators of asthma/copd severity, and for disease and drug history. results: low daily doses (dds) (< ug albuterol eq.) of beta -agonists (crude or . , % ci . - . ) did not increase risk of hip fracture, in contrast to high dds (> ug albuterol eq., crude or . , % ci . . - . ). after extensive adjustment for indicators of the severity of the underlying disease, (including corticosteroid intake), fracture risk in the high dd group decreased to . ( % ci . - . ). conclusions: high dds of beta- agonists are linked to increased risk of hip fracture. extensive adjustments for the severity of the underlying disease is important when evaluating this association. abstract salivary nitrate arises from ingested nitrate and is the main source of gastric nitrite, a precursor of carcinogenic n-nitroso compounds. we examinated the nitrate and nitrite levels in saliva of children who used private wells for their drinking water supply. saliva was collected in the morning, from children aged - years. control group (n = ) drank water containing . - . mg/l (milligrams/litre) nitrate. exposure groups consisting of subjects (n = ) who used private wells with nitrate levels in drinking water below mg/l (mean ± standard deviation . ± . mg/l) and above mg/l (n = ) ( . ± . mg/l) respectively. the nitrate and nitrite of saliva samples was determined by high performance liquid chromatographs method. the values of nitrate in saliva samples from exposed groups ranged between . to . mg/l ( . ± . mg/l). for control groups, the levels of . to . mg/l ( . ± . mg/l) were registered. no differences between levels of salivary nitrite from control and exposed groups were found. regression analysis on water nitrate concentrations and salivary nitrate showed significant correlations. in conclusion, we estimate that salivary nitrate may be used as biomarkers of human exposure to nitrate. abstract disinfection of public drinking water supplies produces trihalomethanes. epidemiological studies have associated chlorinated disinfection by-products with cancer, reproductive and developmental effects. we studied the levels of trihalomethanes (chloroform, dibromochloromethane, bromodichloromethane, bromoform) in drinking water delivered to the population living in some urban areas (n= ). the water samples (n= ) were analysed using gas chromatographic method. assessment of exposure to trihalomethanes in tap water has been on monitoring data collected over - months periods and that we averaged over entire water system. analytical data revealed that total trihalomethanes levels were higher in the summer: mean ± standard deviation . ± . lg/l (micrograms/litre). these organic compounds were present in the end of distribution networks ( . ± . lg/l). it is noted that, sometimes, we found high concentrations of chloroform exceeding the sanitary norm ( lg/l) in tap water (maximum value . lg/l). results of sampling programs showed stronger correlations between chlorine and trihalomethanes value (correlation coefficient r = . to . , credible %interval). in conclusion, the population drank water with the law concentration of trihalomethanes, especially chloroform. abstract objective: to determine the validity of a performance-based assessment of knee function, dynaport[rsymbol] kneetest (dpkt), in first-time consulters with non-traumatic knee complaints in general practice. methods: patients consulting for nontraumatic knee pain in general practice aged years and older were enrolled in the study. at baseline and -months follow-up knee function was assessed by questionnaires and the dpkt; a physical examination was also performed at baseline. hypothesis testing assessed cross-sectional and longitudinal validity of the dpkt. results: a total of patients were included for dpkt of which were available for analysis. the studied population included women ( . %), median age was (range - ) years. at follow-up, patients ( . %) were available for dpkt. only out of ( %) predetermined hypotheses concerning cross-sectional and longitudinal validity were confirmed. comparison of the general practice and secondary care population showed a major difference in baseline characteristics, dynaport knee score, internal consistency and hypotheses confirmation concerning the construct validity. conclusion: the validity of the dpkt could not be demonstrated for first-time consulters with non-traumatic knee complaints in general practice. measurement instruments developed and validated in secondary care are not automatically also valid in primary care setting. abstract although animal studies have described the protective effects of dietary factors supplemented before radiation exposure, little is known about the lifestyle effects after radiation exposure on radiation damage and cancer risks in human. the purpose of this study is to clarify whether lifestyle can modify the effects of radiation exposure on cancer risk. a cohort of , japanese atomic-bomb survivors, for whom radiation dose estimates were currently available, had their lifestyle assessed in . they were followed during years for cancer incidence. the combined effect of smoking, drinking, diet and radiation exposure on cancer risk was examined in additive and multiplicative models. combined effects of a diet rich in fruit and vegetables and ionizing radiation exposure resulted in a lower cancer risk as compared to those with a diet poor in fruit and vegetables and exposed to radiation. similarly, those exposed to radiation and who never drink alcohol or never smoke tobacco presented a lower oesophagus cancer risk than those exposed to radiation and who currently drink alcohol or smoke tobacco. there was no evidence to reject either the additive or the multiplicative model. a healthy lifestyle seems beneficial to persons exposed to radiation in reducing their cancer risks. abstract background: clinical trials have shown significant reduction in major adverse cardiac events (mace) following implantation of sirolimus-eluting (ses) vs. bare-metal stents (bms) for coronary artery disease (cad). objective: to evaluate long-term clinical outcomes and economic implications of ses vs. bms in usual care. methods: in this prospective intervention study, cad patients were treated with bms or ses (sequential control design). standardized patient and physician questionnaires , , and months following implantation documented mace, disease-related costs and patient quality of life (qol). results: patients treated with ses (mean age ± , % male), with bms (mean age ± , % male). there were no significant baseline differences in cardiovascular risk factors and severity of cad. after months, % ses vs. % bms patients had suffered mace (p< . ). initial hospital costs were higher with ses than with bms, but respective month follow-up direct and indirect costs were lower ( , ± vs. , ± euro and ± vs. , ± euro, p = ns). overall, disease-related costs were similar in both groups (ses , ± , bms , ± , p = ns) . differences in qol were not significant. conclusions: as in clinical trials, ses patients experienced significantly fewer mace than bms patients during -month follow-up with similar overall costs and qol. abstract background: meta-analyses that use individual patient data (ipd-ma) rather than published data have been proposed as an improvement in subgroup-analyses. objective: to study ) whether and how often ipd-ma are used to perform subgroup-analyses ) whether the methodology used for subgroup-analyses differs between ipd-ma and meta-analyses of published data (map) methods: ipd-ma were identified in pubmed. related article search was used to identify map on the same objective. metaanalyses not performing subgroup-analysis were excluded from further analyses. differences between ipd-ma and map were analysed, reasons for discrepancies were described. we recently developed a simple diagnostic rule (including history and physical findings plus d-dimer assay results) to safely exclude the presence of deep vein thrombosis (dvt) without the need for referral in primary care patients suspected of dvt. when applied to new patients, the performance of any (diagnostic or prognostic) prediction rule tends to be lower than expected based on the original study results. therefore, rules need to be tested on their generalizability. the aim was to determine the generalizability of the rule. in this cross-sectional study, primary care patients with suspicion of dvt were prospectively identified. the rule items were obtained from each patient plus ultrasonography as reference standard. the accuracy of the rule was quantified on its discriminative performance, sensitivity, specificity, negative predictive value, and negative likelihood ratio, with accompanying % confidence interval. dvt could be safely excluded in % ( % in the original study) of the patients, without referral. none of these patients had dvt ( . % in the derivation population). in conclusion, the rule appears to be a safe diagnostic tool for excluding dvt in patients suspected of dvt in primary care. abstract background: long-term exposure to very low concentrations of asbestos in the environment and relation to incidence of mesothelioma contributes to insight into the dose-response relationship and public health policy. aim: to describe regional differences in the occurrence mesothelioma in the netherlands in relation to the occurrence in the asbestos polluted area around goor and to determine whether the increased incidence of pleural mesothelioma among women in this area could be attributed to environmental exposure to asbestos. methods: mesothelioma cases were selected in the period - from the netherlands cancer register (n = ). for the women in the region goor (n = ) exposure to asbestos due to occupation, household or environment was verified from the medical files, the general practitioner and next-of-kin for cases. results: in goor the incidence of pleural mesothelioma among women was -fold increased compared with the netherlands and among men fold. of the additional cases among women, cases were attributed to the environmental asbestos pollution and in cases this was the most likely cause. the average cumulative asbestos exposure was estimated at . fiber-years. . temporal trends and gender differences were investigated by random slope analysis. variance was expressed using median odds ratio (mor). results: ohcs appeared to be more relevant than administrative areas for understanding physicians' propensity to follow prescription guidelines (mor_ohc = . and mor_aa = . ). conclusion and discussion: as expected, the intervention increased prevalence and decreased variance, but at the end of the observation period practice variation remained high. these results may reflect inefficient therapeutic traditions, and suggest that more intensive interventions may be necessary to promote rational statin prescription. abstract background: mortality rates in ska˚ne, sweden have decreased in recent years. if this decline has been similar for different geographical areas have not been examined closely. objectives: we wanted to illustrate trends and geographical inequities in all cause mortality between the municipalities in ska˚ne, sweden from to . we also aimed to explore the application of multilevel regression analysis (mlra) in our study, since it is a relatively new methodology when describing mortality rates. design and methods: we used linear mlra with years at the first level and municipalities at the second to model direct age-standardized rates. temporal trends were examined by random slope analysis. variance across time was expressed using intra-class correlation (icc). results: the municipality level was very relevant for understanding temporal differences in mortality rates (icc = %). in average, mortality decreased by / Ù along the study period but this trend varied considerably between municipalities, geographical inequalities along the years were u-shaped with lowest variance in the s (var = ). conclusion: mortality has decreased in ska˚ne but municipality differences are increasing again. mlra is a useful technique for modelling mortality trends and variation among geographical areas. abstract background: ozone has adverse health effects but it is not clear who is most susceptible. objective: identification of individuals with increased ozone susceptibility. methods: daily visits for lower respiratory symptoms (lrs) in general practitioner (gp) offices in the north of the netherlands ( - , patients) were related to daily ozone levels in summer. ozone effects were estimated for patients with asthma, copd, atopic dermatitis, and cardiovascular diseases (cvd) and compared to effects in patients without these diseases. generalized additive models adjusting for trend, weekday, temperature, and pollen counts were used. results: the mean daily number of lrs-visits in summer in the gp-offices varied from . to . . mean (sd) -hour maximum ozone level was . ( . ) lg/m . rrs ( % ci) for a lg/m increase (from th to th percentile) in the mean of lag to of ozone for patients with/ without disease are: abstract asthma is a costly health condition, its economic effect is greater than that estimated for aids and tuberculosis together. following global initiative for asthma recommendations that require more data about the burden of asthma, we have determined the cost of this illness from - . an epidemiological approach based on population studies was made to estimate global as well as direct and indirect costs. data were obtained mainly from the national health ministry database, the national statistics institute of spain and the national health survey. the costs were averaged and adjusted to e. we have found a global burden (including private medicine) of million e. indirect and direct costs account for , and , %.the largest components within direct costs were pharmaceutical ( . %), primary health care systems ( , %), hospital admissions ( . %) and hospital non-emergency ambulatory visits ( . %). within indirect costs, total cessation of work days ( . %), permanent labour incapacity ( . %) and early mortality ( . %) costs were the main components. pharmaceutical cost is the first component as in most studies from developed countries, followed by primary health care systems unlike some reports that consider hospital admissions in second place. finally, direct costs represent . % of the total health care expenditure. abstract background: it is well known that fair phenotypical characteristics are a risk factor for cutaneous melanoma. the aim of our study was to investigate the analogous associations between phenotypical characteristics and uveal melanoma. design/methods: in our casecontrol study we compared incident uveal melamom patients with population controls to evaluate the role of phenotypical characteristics like iris-, hair-and skin color and other risk factors in the pathogenesis of this tumor. a total of patients and controls matched on sex, age and region were interviewed. conditional logistic regression was used to calculate odds ratio (or) and % confidence intervals ( % ci). results: risk of uveal melanoma was increased among people with light iris color (or = . % ci . - . ) and light skin color was slightly associated with an increased risk of uveal melanoma (or . % . - . ). hair color, tanning ability, burning tendency and freckles as a child showed no increased risk. results of the combined analysis of eye-and hair color, burning tendency and freckles showed that only light iris color was clearly associated with uveal melanoma risk. conclusion: among potential phenotypical risk factors only light iris-and skin color were identified as risk factor for uveal melanoma. abstract background: between-study variation in estimates of the risk of hcv mother-to-child transmission (mtct) and associated risk factors may be due to methodological differences or changes in population characteristics over time. objective: to investigate the effect of sample size and time on risk factors for mtct of hcv. design and methods: heterogeneity was assessed before pooling data. logistic regression estimated odds ratios for risk factors. results: the three studies included mother-child pairs born between and , born between and , and between and . there was no evidence of heterogeneity of the estimates for maternal hcv/hiv co-infection and mode of delivery (q = . , p = . and q = . , p = . , respectively). in pooled analysis the proportion of hcv/hiv co-infected mothers significantly decreased from % before to % since (p< . ). the pooled adjusted odds ratios for maternal hcv/hiv co-infection and elective caesarean section delivery were . ( %ci . - . ), p< . and . ( %ci . - . ), p = . respectively. there was no evidence that the effect of risk factors for mtct changed over time. conclusion: although certain risk factors have become less common, their effect on mtct of hcv has not changed substantially over time. abstract background: the need to gain insight into prevailing eating pattrerns and their health effects is evident. objective: to identify dietary patterns and their relationship with total mortality in dutch older women. methods: principal components analysis on food groups was used to identify dietary patterns among , women ( - y) included in the dutch epic-elderly cohort (follow-up $ . y). mortality ratios for three major principle components were assessed using cox proportional hazard analysis. results: the most relevant principal components were a 'mediterranean-like' pattern (high in vegetable oils, pasta/rice, sauces, fish, and wine), a 'traditional dutch dinner' pattern (high in meat, potatoes, vegetables, and alcoholic beverages) and a 'healthy traditional' pattern (high in vegetables, fruit, non-alcoholic drinks, dairy products, and potatoes). in , person years deaths occurred. independent of age, education, and other life style factors only the 'healthy traditional' pattern score was associated with a lower mortality rate, women in the highest tertile experienced a percent reduced mortality risk. conclusion: from this study a healthy traditional dutch diet, rather than a mediterranean diet, appears beneficial for longevity and feasible for health promotion. this diet is comparable to other reported 'healthy' or 'prudent' diets that have been shown to be protective. parents of (aged - ) and (aged - ) children were sent a questionnaire, as were adolescents (aged - ). to assess validity, generic outcome instruments were included (infant toddler quality of life questionnaire (itqol) or the child health questionnaire (chq) and the euroqol- d). response rate was - %. internal consistency of hobq and boq-scales was good (cronbach's alpha's > . in all but two scales). test-retest results showed no differences in - % of scales. high correlations between hobq-and boq-scales and conceptually equivalent generic outcome instruments were found. the majority of hobq ( / ) and boq scales ( / ) showed significant differences between children with a long versus short length of stay. the dutch hobq and boq can be used to evaluate functional outcome after burns in children. the study estimated caesarean section rates and odds ratios for caesarean section in association with maternal characteristics in both public and private sectors; and maternal mortality associated with mode of delivery in the public sector, adjusted for hypertension, other disorders, problems and complications, as well as maternal age. results: the caesarean section rate was . % in the public sector, and . % in the private sector. the odd ratio for caesarean section was . ( %ci: . - . ) for women with or more years of education. the odd ratio for maternal mortality associated with caesarean section in the public sector was . ( %ci: . - . ). conclusion and discussion: sao paulo presented high caesarean section rates. caesarean section compared to vaginal delivery in the public sector presented higher risk for mortality even when adjusted for hypertension, other disorders, problems and complications, as well as maternal age. we show that serious bias in questionnaires can be revealed by bland-altman methods but may remain undetected by correlation coefficients. we refute the argument that correlation coefficients properly investigate whether questionnaires rank subjects sufficiently well. conclusions: the commonly used correlation approach can yield misleading conclusions in validation studies. a more frequent and proper use of the bland-altman methods would be desirable to improve epidemiological data quality. abstract screening performance relies on quality and efficiency of protocols and guidelines for screening and follow-up. evidence of low attendance rates, over-screening of young women and low smear specificity gathered by the early 's in the dutch cervical cancer screening program called for an improvement. several protocols and guidelines were redefined in , with emphasis on assuring that these would be adhered to. we assessed improvement since by changes in various indicators: coverage rates, follow-up compliance and number of smears. information on all cervix uteri tests in the netherlands registered until st march was retrieved from the nationwide registry of histo-and cytopathology (palga). five-year coverage rate in the age group - years rose to %. the percentage of screened women in follow-up decreased from % to %. fourteen percent more women with abnormal smears were followed-up, and the time spent in follow-up decreased. a % decrease in the annual number of smears made was observed, especially among young women. in conclusion, the changes in protocols and guidelines, and their implementation have increased coverage and efficiency of screening, and decreased the screening-induced negative side effects. similar measures can be used to improve other mass screening programmes. abstract background: it is common knowledge that in low endemic countries the main transmission route of hepatitis b infection is sexual contact, while in high endemic regions it is perinatal transmission and horizontal household transmission in early childhood. objectives: to get insight into what determines the main transmission route in different regions. design and methods: we used a formula for the basic reproduction number r for hepatitis b in a population stratified by age and sexual activity to investigate under which conditions r > . using data extracted from the literature we investigated how r depends on fertility rates, rates of horizontal childhood transmission and sexual partner change rates. results: we identified conditions on the mean offspring number and the transmission probabilities for which perinatal and horizontal childhood transmission alone ensures that r > . those transmission routes are then dominant, because of the high probability for children to become chronic carriers. sexual transmission dominates if fertility is too low to be the driving force of transmission. conclusion: in regions with high fertility rates hepatitis b can establish itself on a high level of prevalence driven by perinatal and horizontal childhood transmission. therefore, demographic changes can influence hepatitis b transmission routes. abstract background: the artificial oestrogen diethylstilboestrol is known to be fetotoxic. thus, intrauterine exposure to other artificial sex hormones may increase the risk of fetal death. objective: to study if use of oral contraceptive months prior to or during pregnancy is associated to an increased risk of fetal death. design and methods: a cohort study of pregnant women who were recruited into the danish national birth cohort during the years - and interviewed about exposures during pregnancy, either during the first part of their pregnancy (n = ) or following a fetal loss (n = ). cox regression analyses with delayed entry were used to estimate the risk of fetal death. results: in total ( . %) women took oral contraceptives during pregnancy. use of combined oestrogen and progesterone oral contraceptives (coc) or progesterone only oral contraceptives (poc) during pregnancy were not associated with increased hazard ratios of fetal death compared to non-users, hr . ( % ci . - . ) and hr . ( % ci . - . ) respectively. neither use of coc nor poc prior to pregnancy was associated with fetal death. conclusion: use of oral contraceptive months prior to conception or during pregnancy is not related to an increased risk of fetal death. abstract background: few studies have been performed to assess if water fluoridation reduces social inequalities among groups of different socioeconomic status, and none of them was conducted in developing countries. objectives: to assess socioeconomic differences between brazilians towns with and without water fluoridation, and to compare dental caries indices among socioeconomic strata in fluoridated and non-fluoridated areas. design and methods: a countrywide survey of oral health performed in - and comprising , children aged years provided information about dental caries indices in brazilian towns. socioeconomic indices, the coverage and the fluoride status of the water supply network of participating towns were also appraised. multivariate regression models were performed. inequalities in dental outcomes were compared in towns with and without fluoridated tap water. results: better-off towns tended to present a higher coverage by the water supply network, and were more inclined to add fluoride. fluoridated tap water was associated with an overall improved profile of caries, concurrent with an expressively larger inequality in the distribution of dental disease. conclusion: suppressing inequalities in the distribution of dental caries requires an expanded access to fluoridated tap water; a strategy that can be effective to foster further reductions in caries indices. objective: to investigate the role of family socioeconomic trajectories from childhood to adolescence on dental caries and associated behavioural factors. design and methods: a population-based birth cohort was carried out in pelotas, brazil. a sample (n= ) of the population of subjects born in were dentally examined and interviewed at aged . dental caries index, care index, toothbrushing, flossing, and pattern of utilization of dental services were the outcomes. these measures were compared among four different family income trajectories. results: adolescents who were always poor showed, in general, a worse dental caries profile, whilst adolescents who never were poor had a better dental caries profile. adolescents who had moved from poverty in childhood to nonpoverty in adolescence and those who had moved from non-poverty in childhood to poverty in adolescence had similar dental profiles to those who were always poor except for pattern of utilization of dental services which was higher in the first group. conclusion: poverty in at least one stage of the lifespan has a harmful effect on dental caries, oral behaviours and utilization of dental services. we assessed contextual and individual determinants of dental caries in the brazilian context. a country-wide survey of oral health informed the dental status of , twelve-year-old schoolchildren living in towns in . a multilevel model fitted the adjustment of untreated caries prevalence to individual (socio-demographic characteristics of examined children) and contextual (geographic characteristics of participating towns) covariates. being black (or = . ; % ci: . - . ), living in rural areas (or = . ; . - . ) and studying in public schools (or = . ; . - . ) increased the odds of having untreated decayed teeth. the multilevel model identified the fluoride status of water supplies (ß=) . ), the proportion of households linked to the water network (ß=) . ) and the human development index (ß=) . ) as town-level covariates of caries experience. better-off brazilian regions presented an improved profile of dental health, besides having a less unequal distribution of dental treatment needs between blacks and whites, rural and urban areas, and public and private schools. dental caries experience is prone to socio-demographic and geographic inequalities. monitoring contrasts in dental health outcomes is relevant for programming socially appropriate interventions aimed both at overall improvements and at the targeting of resources for groups of population presenting higher levels of needs. abstract background: ultraviolet radiation (uvr) is the main cause of nonmelanoma skin cancer but has been hypothesised to protect against development of prostate cancer (pc). if this is true, skin cancer patients should have lower pc incidence than the general population. objectives: to study the incidence of pc after a diagnosis of skin cancer. design methods: using the eindhoven cancer registry, a cohort of male skin cancer patients diagnosed since ( squamous cell carcinoma (scc), basal cell carcinoma (bcc) and melanoma (cm)) was followed up for incidence of invasive pc. observed incidence rates of pc amongst skin cancer patients were compared to those in the reference population, resulting in standardised incidence ratios (sir). results: scc (sir . ( %ci: . ; . )) and bcc (sir . ( %ci: . ; . )) showed a decreased incidence of pc, cm did not. patients with bccs occurring in the chronically sun-exposed head and neck area (sir . ( %ci: . ; . ) had significantly lower pc incidence rates. conclusion discussion: although numbers of scc and cm were too small to obtain unequivocal results, this study partly supports the hypothesis that uvr protects against pc and also illustrate that cm patients are different from nmsc patients in several aspects. abstract introduction: hypo-and hyperthyroidism have been associated to various symptoms and metabolic dysfunctions in men and women. incidences of these diseases have been estimated in a cohort of middle-aged adults in france. methods: the su.vi.max (sup-ple´mentation en vitamines et mine´raux antioxydants) cohort study included volunteers followed-up for eight years since - . the incidence of hypo-and hyperthyroidism was estimated retrospectively from scheduled questionnaires and the data transmitted by the subjects during their follow-up. factors associated to incident cases have been identified by cox proportional hazards models. results: among the subjects free of thyroid dysfunction at inclusion, incident cases were identified. after an average follow-up of . years, the incidence of hyper-and hypothyroidism was . % in men, . % in - year old women, and . % in - year old women. no associated factor was identified in men. in women, age and alcohol consumption (> grams/day) increased the risk of hypo-or hyperthyroidism, while a high urinary thiocyanate level in - would be a protective factor. conclusion: the incidences of hypo and hyperthyroidism observed in our study as well as the associated risk factors found are in agreement with the data of studies performed in other countries. abstract background: lung cancer is the most frequent malignant neoplasm world-wide. in , the number of new lung cancer cases was estimated at . million, which makes over % of all new cases of neoplasm registered all round the globe. it is also the leading cause of cancer deaths. objective: the objective of this paper is to provide a systematic review of life-related factors for lung cancer risk. methods: data sources were medline from january to december , title in the field. search terms included: lung cancer, tobacco smoke, education, diet, alcohol consumption or physical activity terms. book chapters, monographs, relevant news reports, and web material were also reviewed to find articles. results: the results of the literature review suggest that smoking is a major, unquestionable factor of lung cancer risk. exposure to environmental tobacco smoke (ets) and education could also play a role in the occurrence of the disease. diet, alcohol consumption and physical activity level are other important but less extended determinants of lung cancer. conclusions: effective prevention programs against some of the life style-related factors for lung cancer, especially against smoking must be developed to minimize potential health risks and prevent the future cost of health. stedendriehoek twente and south (n = ), additional data (co-morbidity, complications after surgery and follow-up) were gathered. cox-regression analyses were used. results: the proportion resections declined from % of patients < to % of patients aged > = years, whereas primary radiotherapy increased from % to %. in the two regions patients ( %) underwent resection. co-morbid conditions did not influence the choice of the therapy. % had complications. postoperative mortality was %. in multivariate analysis, only treatment had an independent effect.two year survival was % for patients undergoing surgical resection and % for those receiving radiotherapy (p< . ). conclusion: number of co-morbid conditions did not influence choice of treatment, postoperative complications, and survival in patients with nsclc > = years. the epidemiology of oesophageal cancer has changed in recent decades. the incidence has increased sharply, mainly comprising men, adenocarcinoma and tumours of the lower third of the oesophagus. the eurocare study suggested large variation in survival between european countries, primarily related to early mortality. to study potential explanations, we compared data from the rotterdam and thames cancer registry. computer records from , patients diagnosed with oesophageal cancer in the period - were analysed by age, gender, histological type, tumour subsite, period and region. there was a large variation in resection rates between the two regions, % for rotterdam versus % for thames (p< . ). resection rates were higher for men, younger patients, adenocarcinoma and distal tumours. postoperative mortality (pom) was defined as death within days of surgery and was . % on average. pom increased with age from . % for patients younger than years to . % for patients older than years. pom was significantly lower in high-volume hospitals (> operations per year), . % versus . % (p< . ). this study shows a large variation in treatment practice between the netherlands and the united kingdom. potential explanations will need to be studied in detail. abstract russia has experienced tremendous decline in life expectancy after break up of the ussr. surprisingly, im has also been decreasing. less is known on the structure of im in different regions of russia. the official im data may be underestimated partly due to misreporting early neonatal deaths (end) as stillbirths (sb). end/sb ratio considerably exceeding : indicates misreporting. we present the trends and structure of im in arkhangelsk oblast (ao), north-west russia from to as obtained from the regional statistical committee. im decreased from . to . per live births. cause-specific death rates (per , ) decreased from to . for infectious diseases, from to for respiratory causes, from to for traumas, from to for inborn abnormalities but did not change for conditions of the perinatal period ( in both and ) . the end/sb ratio increased from to . . in , im from infections and respiratory causes in the ao are much lower than in russia in general. the degree of misreporting end as sb in the ao is lower than in russia in general. other potential sources of underestimation of im in russia will be discussed. abstract background: epidemiological studies that investigated malocclusion and different physical aspects in adolescents are rare in the literature. objective: we studied the impact of malocclusion on adolescents' self-image regardless of other physical aspects. design and methods: a cross-sectional study nested in a cohort study was carried out, in pelotas, brazil. a random sample of yearsold adolescents was selected. the world health organization ( ) criteria were used to define malocclusion. interviews about self-reported skin colour and appearance satisfaction were administered. the body mass index was calculated. gender, birth weight and socioeconomic characteristics were obtained from the birth phase of the cohort study. poisson regression models were performed. results: the prevalence of moderate or severe malocclusion was . % [ %ci . ; . ] in the whole sample without significant difference between boys and girls. a higher statistically significant difference of appearance dissatisfaction was identified in girls ( . %) than in boys ( . %). a positive association between malocclusion and appearance dissatisfaction was observed only in girls, after adjusting for other physical and socioeconomic characteristics. conclusions: malocclusion influenced appearance dissatisfaction only in young women. abstract background: factors for healthy aging with good functional capacity and those which increase the risk of death and disability need to be identified. objectives: we studied the prevalence of low functional capacity and its associations in a small city in southern brazil. design and methods: a population based cross sectional study was carried out with a random sample size of elderly people. a home-applied questionnaire including socioeconomic, demographic, house conditions, socioeconomic self-perception characteristics was applied. the low functional capacity was defined as the difficulty in the performance of or more activities or inability to carry out of those activities according to scale proposed by rikli and jones. descriptive statistics, association using chi-square test as well as the multiple logistic regression analysis were performed. abstract introduction: assessment of trichiuriasis spatial distribution is important to evaluate sanitation conditions. our objective was to identify risk areas for the trichuris trichiura infection. methods: cross sectional study was held in census tracts of duque de caxias county, rio de janeiro, brazil. collection and analysis of fecal specimens and a standardize questionnaire were carry out in order to evaluate socio-economic and sanitation conditions in a sample of , children between and years old. geoestatistics techniques were used to identify risk areas for trichiuriasis. results: the mean age of the studied population was . years old, which % were females and % were males. the prevalence of trichuris trichiura in the sample was %. children whose mothers studied for years or less had odds ratio (or) = . than children whose mothers studied for more than years old. children who were living in houses without water supply had or = . comparing to children living in houses with water supply. the spatial analysis identified risk areas for infection. conclusion: the results show association between socio-economic conditions and the proliferation of trichuris trichiura infection. the identification of risk areas can guide efficient actions to combat the disease. abstract background: refuge life and diabetes mellitus can affect the healthrelated quality of life (hrqol). objective: to assess how both aspects influence hrqol of the diabetic refugees in gaza strip. methods: overall subjects filled a self-administered questionnaire including world health organization quality of life questionnaire (whoqol-bref) and some socio-demographic information. the sample consisted of three frequency matched groups for gender and sex, each. first group were refugees with diabetes mellitus, second refugees without diabetes and third diabetes patients with no refugee history. the response rate was % on average. global score consisting of all four domains of who-qol-bref was dichotomized by the value of and logistic regression was used for the analysis. results: crude odds ratios (or) for lower quality of life were . ( % ci . - . ) for diabetes refugees compared to diabetes non-refugees and . ( . - . ) compared to non-diabetes refugees. after adjusting for age, gender, education, employment, income status and number of persons depending on the respondents or was . ( . - . ) and . ( . - . ), respectively. additionally, adjusting for length of diabetes and complications reduced the or to . ( . - . ) for diabetes refugees compared to diabetes non-refugees. conclusion: quality of life is highly reduced in refugees with diabetes. abstract background: pesticides have a significant public health benefit by increasing food production productivity and decreasing diseases. on the other hand, public concern has been raised about the potential health effects of the exposure to pesticides on the developing fetus and child. objectives: to review the available literature to find an epidemiological studies dealing with the exposure to pesticides and children health. design and methods: epidemiological studies were identified during search of the literature basis. following health effects were taking into account: adverse reproductive and developmental disorders, childhood cancer, neurodevelopmental effects and the role of pesticides as endocrine disrupters. results: pesticides were associated with wide range of reproductive disorders. the association between exposure to pesticides and the risk of childhood cancer and neurodevelopmental effects was found in several studies. epidemiological studies have been limited by luck of specific pesticide exposure, exposure based on job title, small size of examined groups. conclusions: in the light of existing although still limited evidence of adverse effects of pesticide exposure it is necessary to reduce the exposure. the literature review suggests a great need to increase awareness of people who are occupationally or environmentally exposed to pesticides about its potential negative influence on their children. in order to match local health policy more with the needs of citizens, the municipal health service utrecht started the project 'demand-orientated prevention policy'. one of the aims was to explore the needs of the utrecht citizens. the local health survey from contained questions about needs of information and support with regard to disorders and lifestyle. do these questions about needs give other results compared to questions about prevalence of health problems? in total utrecht citizens aged to years returned the health questionnaire (response rate %). most needs were observed on subjects concerning overweight and mental problems, and were higher among women, moroccans, turks, low educated people and citizens of deprived areas. the prevalence of disorders and unhealthy lifestyles did not correlate well to the needs (majority correlation coefficients: < , ). most striking, of the utrecht population % were smokers and % excessive alcohol drinkers, while needs related to these topics were low. furthermore, higher needs among specific groups did not always correspond to higher prevalences of related health problems in these groups. these results show the importance of including questions about needs in a health survey, because they add additional information to questions about prevalences. abstract background: recent studies associated statin therapy with better outcome in patients with pneumonia. because of an increased risk of pneumonia in patients with diabetes we aimed to assess the effects of statin use on pneumonia occurrence in diabetic patients managed in primary care. methods: we performed a case-control study nested in , patients with diabetes. cases were defined as patients with a diagnosis of pneumonia. for each case, up to controls were matched by age, gender, practice, and index date. patients were classified as current statin user when the index date was between the start and end date of statin therapy. results: statins were currently used in . % of , cases and in . % of , controls (crude or: . , % ci . - . ). after adjusting for potential confounders, statin therapy was associated with a % reduction in pneumonia risk (adjusted or: . , % ci . - . ). the association was consistent among relevant subgroups (stroke, heart failure, and pulmonary diseases) and independent of age or use of other prescription drugs. conclusions: use of statins was significantly associated with reduced pneumonia risk in diabetic patients and may apart from lipid lowering properties be useful in prevention of respiratory infections. abstract introduction: cigarette smoking is the most important risk factor for copd development. therefore, smoking cessation is the best preventive measure. aim: to determine the beneficial effect of smoking cessation on copd development. methods: incidence of copd (gold stage > = ) was studied in smokers without copd who quitted or continued smoking during yr of followup. we performed logistic regression analyses on pairs of observations. correlations within a subject and time, and time between successive surveys were taken into account. abstract objectives: to describe the prevalence and severity of dental caries in adolescents of the city of porto, portugal, and to assess socioeconomic and behavioral covariates of dental caries experience. methods: a sample of thirteen-year-old schoolchildren underwent dental examination. results from the dental examination were linked to anthropometric information and to data supplied by two structured questionnaires assessing nutritional factors, sociodemographic characteristics and behaviors related to health promotion. dental caries was appraised in terms of the dmft index, and two dichotomous outcomes, one assessing the prevalence of dental caries (dmft = ); the other assessing the prevalence of a high level of dental caries (dmft = ). results: consuming soft drinks derived from cola two or more times per week, attending a public school, being girl and having parents with low educational attainment were identified as risk factors both for having dental caries and for having a high level of dental caries. conclusion: the improvement of oral health status in the portuguese context demands the implementation of polices to reduce the frequency of sugar intake, and could benefit from an overall and longstanding expansion of education in society. abstract background: migrant mortality does not conform to a single pattern of convergence towards rates in the host population. to better understand how migrant mortality will develop, there is a need to further investigate how the underlying behavioural determinants change following migration. objective: we studied whether behavioural risk factors among two generations of migrants converge towards the behaviour in the host population. design and methods: cross-sectional interview-data were used including moroccan and turkish migrants, aged - . questions were asked about smoking, alcohol consumption, physical inactivity and weight/height. age-adjusted prevalence rates among first and second generation migrants were compared with prevalence rates in the host population. results: converging trends were found for smoking, physical inactivity and overweight. for example, we found a higher prevalence of physical inactivity in first generation turkish women as compared to ethnic dutch (or = . ( . - . )), whereas among second generation no differences were found (or = . ( . - . )). however, this trend was not found in all subgroups. additionally, alcohol consumption remained low in all subgroups and did not converge. conclusion and discussion: behavioural risk factors in two generations of migrants seem to converge towards the prevalence rates in the host population. although, some groups and risk factors showed a deviant pattern. abstract background/relevance: arm-neck-shoulder complaints are common in general practice. for referral in these complaints, only guidelines exist for shoulder complaints and epicondylitis. besides, other factors can be important. objective: what factors are associated with referral to physiotherapy or specialist in non-traumatic armneck-shoulder complaints in general practice, during the first consultation? design/methods: general practitioners (gps) recruited consulters with new arm, neck or shoulder complaints. data on complaint-, patient-, gp-characteristics and management were collected. the diagnosis was categorised into: shoulder specific, epicondylitis, other specific or non-specific. multilevel analyses (adjustment for treating gp) were executed in procgenmod to assess associated variables (p< . ). results: during the first consultation, % was referred for physiotherapy and % for specialist care. indicators of reference to physiotherapy were: long duration of complaint, recurrent complaint and gp located in a little/not urbanised area. while having shoulder specific or other specific diagnoses was negatively associated. indicators of reference to specialist care were: having other specific diagnosis, long duration of complaint, musculoskeletal co-morbidity, functional limitations and consulting a less experienced gp. conclusion/discussion: most referrals were to physiotherapy and only a minority to specialist care. mainly diagnosis and other complaint variables indicate on 'who goes where'. besides gp-characteristics can play a role. abstract background: the ruhr area has for years been a synonym for a me´gapolis of heavy industry with a high population density. presently, % of the population of the state of north rhine-westphalia live there, i.e. more than five million people. objectives: for the first time, social and health indicators of nrw's health indicator set were brought together for this me´gapolis area. design and methods: new standard tables were constructed for the central area of 'ruhr-city' including seven cities with more than inhabitants/km and the peripheral zone with eight districts and cities. for the pilot phase, four socio-demographic and four health indicators were recalculated. comparability of the figures was achieved by age standardization. the results obtained were submitted to a significance test by identifying % confidence intervals. results: the centre of 'ruhr-city' is characterised by elderly, unemployed, foreign, low-income citizens living closely together. infant mortality lies above nrw's average, male life expectancy is . years lower and female life expectancy . years lower than life expectancy in nrw (without 'ruhr-city'). several avoidable deaths' rate in the ruhr area are significantly higher than the average in nrw. specific intervention strategies are required to improve the health status in 'ruhr-city'. abstract background: general practitioners (gps) have a fundamental role to play in tobacco control, since they reach a high percentage of the target population. objectives: to evaluate specific strategies to enhance promotion of smoking cessation in general practice. design and methods in a cluster-randomized trial, medical practices were randomized following a · factorial design. patients aged - years who smoked at least cigarettes per day (irrespective of their intention to stop smoking) were recruited. the intervention included (ti) the provision of a two-hour physician group training in smoking cessation methods plus direct physician payments for every participant not smoking months after recruitment; and (tm) provision of the same training plus direct participant reimbursements for pharmacy costs associated with nicotine replacement therapy or bupropion treatment. results: in the mixed logistic regression model, no effect was identified for intervention ti (odds ratio (or) = . , % confidence interval (ci) . - . ), but intervention tm strongly increased the odds of cessation (or = . , % ci . - . ). conclusion and discussion: the cost-free provision of effective medication along with improved training opportunities for gps may be an effective measure to enhance smoking cessation promotion in general practice. in europe, little research on international comparison of health surveys has been accomplished, despite a growing interest in this field. smoking prevalence is chosen to explore data comparability. we aim to illustrate methodological problems encountered when comparing data from health surveys and investigate international variations in smoking behaviour. we examined a sample . individuals aged and more, from six european health surveys performed in - . problems met during the comparisons are described. we took the example of current smoking as an indicator allowing a valid comparison of the prevalences. the differences in age and sex distribution between countries were adjusted through direct standardisation. additionally, multivariate analysis will assess variations in current smoking between countries, when controlling for sex, age, and educational level. methodological problems concern comparability of socioeconomic variables. the percentage of current smokers varies from % to %. smoking patterns observed by age groups, sexes and educational level are similar, although rates per country differ. further results will determine if the variations in smoking related to socioeconomic status are alike. this international comparison of health surveys highlights methodological problems encountered when comparing data of several countries. furthermore, variations in smoking may call for adaptations in public health programs. from research it appears that adolescent alcohol use in the achterhoek is much higher than in the rest of the netherlands and rapidly increasing. excessive alcohol use has consequences for health and society. parents play an important role in preventing excessive adolescent alcohol use, but are not aware of the problem and consequences. for this reasons the municipalities in the achterhoek launch an alcohol moderation programme, starting with a regional media campaign to increase problem awareness among parents. the objective of this study is to assess the impact of this media campaign in the achterhoek. three successive independent cross-sectional telephone surveys, interviewing approximately respondents each, will be conducted before, during and after the campaign. respondents will be questioned on knowledge and awareness of excessive adolescent alcohol use, its consequences and the role child raising can play. also the reach and appreciation of the different activities of the campaign will be investigated. results: of the surveys before and during the implementation will be known by may . with these first findings the unawareness of the problem among parents and partly the reach and appreciation of the campaign can be assessed. abstract background: obesity is a growing problem, increasingly so in children and adolescents. overweight is partly 'programmed' during pregnancy, but few comprehensive studies looked prospectively into the changes of body composition and metabolic factors from birth. objectives: the aim of the population-based birth-cohort study within gecko is to study the etiology and prognosis of overweight and the metabolic syndrome during childhood. design and methods: the gecko drenthe will be a population based observational birth-cohort study, which includes all children born from april to april in drenthe, one of the northern provinces of the netherlands. during the first year of life, the study includes repeated questionnaires, extensive anthropometric measurements and blood measurements at birth (cord blood) and at the age of eleven months. results: the number of babies born in the drenthe province is about . per year. the results from a feasibility study conducted in february will be presented. conclusion: gecko drenthe is a unique project that will contribute to the understanding of the development of obesity in childhood and its tracking into adulthood. this will enable early identification of children at risk and opens the way for timely and tailored preventive interventions. abstract background: tunisia is facing an epidemiologic transition with the extension of chronic diseases that share common risk factors. obesity is a leading risk factor and happens to occur frequently in early life. objective: to study the prevalence and the risk factors of obesity and overweight among urban schoolchildren in sousse, tunisia. methods: cross sectional study of a tunisian sample of schoolchildren aged between and years living in the urban area of sousse, tunisia. a representative sample of school children selected by multistage cluster sampling procedure. measurements: weight and height, blood pressure measured by electronic system, fasting blood lipids. questionnaire assessment was used for family history of cardiovascular disease, smoking habits, physical activity and diet. abstract background: quality of life (qol) measurements are acknowledged as very important in the evaluation of health care. objectives: we studied the validity and the reliability of the hungarian version of the whoqol-bref among people living in small settlements. method: a questionnaire-based cross-sectional study was conducted in a representative sample (n = ) of persons aged years and over in south-east-hungary, in . data were analysed by the spss . . the internal consistency was evaluated using cronbach's alpha; for comparison of the qol scores amongst the various groups the two-tailed t-tests were used; convergent validity was assessed by spearman coefficients. results: the male:female ratio was . to . %, and the average age . (sd: . ) years. the domain scores were . (sd: . ) for the physical, . (sd: . ) for psychological, . (sd: . ) for the social, and . (sd: . ) for the environment domains. the cronbach's alpha values ranged from . to . across domains. the whoqol-bref seemed to be suitable to distinguish healthy and unhealthy people. the scores for all domains correlated with the self-evaluated health, and overall quality of life (p< . ). conclusion: our study supported that the whoqol-bref provided a valid, reasonable and useful determination of the qol of people living in hungarian villages. abstract background: further than a cardiovascular disease, arterial hypertension (aht) is the main cardiovascular risk factor. in spain, the aht prevalence reaches %, placed in the third position after germany and finland in affecters percentage. although its high morbi-mortality, the aht is a forecast factor. the treatment's objective (pharmacological and life style modifications) of hypertensive patients is not only to reduce blood pressure levels to optimum levels but also to treat all modifiable vascular risk factors. objective: economic impact evaluation of direct costs due to aht pathology (cie -mc - ) in spain in , according to autonomous region. design and methods: descriptive and transversal study of costs estimation in the period between january to december in spain according to autonomous region. the study is based on data available from the national health ministry database and the national statistics institute of spain. results: the national health service assigned million e to aht treatment. , % of the total cost is owe to pharmaceutical service expenses, , % to primary health care and a , % to hospital admissions. conclusion and discussion: the costs generated by aht are mainly due to the pharmaceutical service. the costs distribution is modified according to the geographical region. abstract background: over the last decades, for low-stage cervical cancer less surgical treatment and for high-stage cervical cancer chemoradiotherapy was recommended in the national guidelines. objectives: to describe changes and variation in treatment and survival in cervical cancer in the regions of the comprehensive cancer centre stedendriehoek twente (cccst) and south (cccs) in the netherlands. design and methods. newly diagnosed cervical cancer cases were selected from both cancer registries in the period - . patient characteristics, tumour characteristics, treatment and follow-up data were collected from the medical records. results: in figo stages ia -ib the percentage hysterectomy decreased from % in - to % in - (p<. ) and survival improved comparing - with - . figo stages iii-ivb had mostly received radiotherapy only ( %). no differences in survival between years of diagnosis were found. in the cccs-region more chemoradiotherapy was given in these stages ( % versus % in the cccst-region in the whole period). conclusion and discussion:. abstract background: the reason for the increased prevalence of depression in type diabetes (dm ) is unknown. objective: we investigated whether depression is associated with metabolic dysregulation or that depression is rather a consequence of having dm . methods: baseline data of the utrecht health project were used. subjects with cardiovascular disease were excluded. , subjects (age: . +/) ) were classified into four mutually exclusive categories: normal fasting plasma glucose (fpg < . mmol/l), impaired fpg (> = . and < . mmol/l), undiagnosed dm (fpg > = . mmol/l), and diagnosed dm . depression was defined as either a score of or more on the depression subscale of the symptom check list- or use of antidepressants. results: subjects with impaired fasting glucose and undiagnosed dm had no increased prevalence of depression. diagnosed dm patients had an increased prevalence of depression (or = . ( . - . )) after adjustment for gender, age, body mass index, smoking, alcohol consumption, physical activity, education level and number of chronic diseases. conclusions: our findings suggest that depression is not related to disturbed glucose homeostasis. the increased risk of depression in diagnosed dm only, suggests that depression is rather a consequence of the psychosocial burden of diabetes. abstract background: breast-conserving surgery (bcs) followed by radiotherapy (bcs-rt) is a safe treatment option for the large majority of patients with tumours less than cm. aim: the use of bcs and bcs-rt in pt (? cm) and pt -tumours ( - cm) was investigated in the netherlands in the period and . methods: from the netherlands cancer registry patients were selected with invasive pt (? . cm) or pt ( . - . cm) tumours, without metastasis at time of diagnosis. trends in the use of bcs and rt after bcs were determined for different age groups and regions. results: in the period - , pt -tumours and , pt -tumours were diagnosed. the %bcs in pt -tumours increased in all age groups. it remained lowest in patients years and older ( % in ). in pt -tumours a decrease was observed in patients years and older (from % to % in ). in both pt and pt tumours the %bcs-rt increased in patients years and older to respectively % and %. between regions and hospitals large differences were seen in %bcs and %bcs-rt. conclusion: multidisciplinary treatment planning, based on specific guidelines, and patient education could increase the use of bcs combined with rt in all age groups. abstract this is a follow-up study on the adverse health effects associated with pesticide exposure among cut-flower farmers. survey questionnaires and detailed physical and laboratory examinations were administered to and respondents, respectively, to determine pesticide exposure, work and safety practices, and cholinesterase levels. results showed that pesticide application was the most frequent activity associated with pesticide exposure, and entry was mostly ocular and dermal. majority of those exposed were symptomatic. on physical examination, or . % of those examined were found to have abnormal peak expiratory flow rate (pefr). eighty-two percent had abnormal temperature, followed by abnormal general survey findings (e.g. cardiorespiratory distress). % had cholinesterase levels below the mean value of . ? ph/hour, and . % exhibited a more than % depression in the level of rbc cholinesterase. certain hematological parameters were also abnormal, namely hemoglobin, hematocrit, and eosinophil count. using pearson's r, factors strongly associated with illness due to pesticides include using a contaminated piece of fabric to wipe sweat off (p.= . ) and reusing pesticide containers to store water (p.= . ). the greatest adverse effect of those exposed is an abnormal cholinesterase level which confirms earlier studies on the effect of pesticides on the body. objectives: this pair-study was performed to find out the rate of spontaneous abortions in female workers exposed to organic solvents from the wood-processing industry. methods: the level of organic solvents was assessed within the workplaces during a year period. exposed female workers from the wood-processing industry were examined. the occupational and non-occupational data associated with their fertility were obtained by applying a standard epidemiological computed questionnaire. the reference group consisted of female workers non-exposed to hypo-fertilizing agents, residing in the same locality. the rate of spontaneous abortions was evaluated in both groups as an epidemiological fertility indicator. results: within the studied period, the organic solvents levels exceeded several time the maximal admissible concentrations in all workplaces. the long-term exposure to organic solvents caused a significant increase in rate of spontaneous abortions compared to the reference group (p< . ). the majority of abortions ( %) have happened in the first trimester of pregnancy. conclusions: the long-term exposure to organic solvents may cause low fertility on female workers because of the spontaneous abortions. it is advised to reduce the organic solvents level in the air of all workplaces, as well as to stop working the pregnant women in exposure to organic solvents. abstract introduction: rio de janeiro city (rj) presents a fast aging of the population with changes in morbi-mortality. cardiovascular diseases are the first cause of death in elderly population. more than a half of ischemic heart diseases (ihd) cases occur in aged people (> years old). objective: describe the spatial distribution of ihd mortality in the elderly population in rj and associations with socio-demographics variables. methods: data were gathered from information on mortality system of the ministry of health and the demographic census of the foundation of the brazilian institute for geography and statistics. the geographic distributions of the standardized coefficient of mortality due to ihd and socio-demographics variables, by districts, in were analyzed in arcgis . . spatial autocorrelation of ihd was assessed by the moran and geary indices. a conditional autoregressive model was used to evaluate the association between idh and socio-demographics variables. results: association between idh mortality and income, educational level, family type and to possess computer, videocassette and microwave was found. conclusion: spatial analysis of the idh mortality and socio-demographics factors influence are fundamental to subsidize more efficient public policies in sense to prevention and control of this important injury of health. abstract purpose: to evaluate the prognostic impact of isolated loco-regional recurrences on metastatic progression among women treated for invasive stage i or ii breast cancer (within phase iii trials concerning the optimal management of breast cancer). patients and methods: the study population consisted of , women primary surgically treated for early stage breast cancer, enrolled in eortc trials , , or , by breast conservation ( %) and mastectomy ( %) with long time of follow-up (median: . range: . - . ). data were analysed in a multi-state model by using multivariate cox regression models, including a state-dependent covariate. results: after the incidence of the loco-regional recurrence, a positive nodal status at baseline is a significant prognostic risk factor for distant metastases. the effects of the young ages at diagnosis and larger tumour size, become less significant after the incidence of loco-regional recurrences. the presence of a locoregional recurrence in itself is a significant prognostic risk factor for distant metastases after loco-regional recurrences. the effect of the time to the loco-regional recurrence is not a significant prognostic factor. conclusion: the presence of local recurrence is an important risk factor for outcome in patients with early breast cancer. abstract background: the relationship between the antral follicles and ovarian reserve tests (ort) to determine ovarian response in ivf is extensively studied. we studied the role of follicle size distribution in the response on the various orts in a large group of subfertile patients. methods: in a prospective cohort study, female patients were included if they had regular ovulatory cycles, subfertility for > months, > = ovary and > = patent ovarian tube. antral follicles were counted by ultrasound and blood was collected for fsh, including a clomiphene challenge test (ccct), inhibin b, and estradiol before and after administration of puregon [rsymbol] . (efort test). statistical analysis was performed using spss . for windows. results: of eligible patients, participated. mean age was . years and mean duration of subfertility was . months. age, baseline fsh, ccct and efort correlated with the number of small follicles ( - mm) but not with large follicles ( - mm). regression analysis confirmed that the number of small follicles and average follicle size contributed to ovarian response after correction for age, while large follicles did not. conclusion: small antral follicles are responsible for the hormonal response in ort and may be suitable to predict ovarian response in ivf. abstract background: dengue epidemics account annually for several million cases and deaths worldwide. the high endemic level of dengue fever and its hemorrhagic form (dhf) correlates to extensive house infestation by aedes aegypti and multiple viral serotype human infection. objective: to describe dengue incidence evolutionary patterns and spatial distribution in brazil. methods: it is a review study that analyzed serial case reports registered since until . results: it was shown that defined epidemic waves followed the introduction of every serotype (den to ) , and reduction in susceptible people possibly responded for downward case frequency. conclusions and discussion: an incremental expansion of affected areas and increasing occurrence of dhf with high lethality were noted in recent years. in contrast, efforts based solely on chemical vectorial combat have been insufficient. moreover, some evidence demonstrated that educational action do not permanently modify population habits. in this regard it was stated that while vaccine is not available, further dengue control would depend on potential results gathered from basic interdisciplinary research and intervention evaluation studies, integrating environmental changes, community participation and education, epidemiological and virological surveillance, and strategic technological innovations aimed to stop transmission. abstract background: patient participation in treatment decisions can have positive effects on patient satisfaction, compliance and health outcomes. objectives: study objectives were to examine attitudes regarding participation in decision-making among psoriasis patients and to evaluate the effect of a decision-aid for discussing treatment options. methods: a 'quasi experiment' was conducted in a large dermatological hospital in italy: a questionnaire evaluating the decision-making process and knowledge on treatments was selfcompleted by a consecutive sample of psoriasis patients after routine clinical practice and by a second sample of patients exposed to a decision-board. results: in routine clinical practice . % of patients wanted to be involved in treatment decisions, . % wanted to leave decisions entirely to the doctor and . % preferred making decisions alone. . % and . % of the control and decision-board group had good knowledge level. at multivariate analysis good knowledge on treatments increased the likelihood of preferring an active role (or = . ; %ci . - . ; p = . ). the decision-board only marginally improved patient knowledge and doctor-patient communication. conclusion and discussion: in conclusion, large proportions of patients want to participate in decision-making, but insufficient knowledge can represent a barrier. further research is needed for developing effective instruments for improving patient knowledge and participation. abstract background: the only available means of controlling infections caused by the dengue virus is the elimination of its principal urban vector (aedes aegypti). brazil has been implementing programs to fight the mosquito; however, since the 's the geographic range of infestation has been expanding steadily, resulting in increased circulation of the virus. objective: to evaluate the effectiveness of the dengue control actions that have been implemented in the city of salvador. methods: prospective design, serologic inquiries were made in a sample population of residents of urban 'sentinel areas'.the seroprevalence and one year seroincidence of dengue are estimated and the relationship between intensity of viral circulation and the standards of living and vector density is analysed. results: there were high overall seroprevalence ( . %) and seroincidence ( . %) for the circulating serotypes (denv- and denv- ). the effectiveness of control measures appears to be low, and although a preventable fraction of . % was found, the incidence of infections in these areas was still very high ( . %). conclusions and discussions: it is necessary to revise the technical and operational strategies of the infection control program in order to attain infestation levels that are low enough to interrupt the circulation of the dengue virus. this study investigates the difference in cancer mortality risks between migrant groups and the native dutch population, and determines the extent of convergence of cancer mortality risks according to migrants' generation, age at migration and duration of residence. data were obtained from the national population & mortality registries in the period - ( person years, cancer deaths). we used poisson regression to compare the cancer mortality rates of migrants originating from turkey, morocco, surinam, netherlands antilles/aruba to the rates for the native dutch. results: all-cancer mortality among all migrant groups combined was significantly lower compared to the native dutch population (rr= . ci: . - . ). mortality rates for all cancers combined were higher among nd generation migrants, among those with younger age at migration, and those with longer duration of residence. this effect was particularly pronounced in lung cancer and colorectal cancer. for most cancers, mortality among nd generation migrants remained lower compared to the native dutch population. surinamese migrants showed the most consistent pattern of convergence of cancer mortality. conclusions: the generally low risk of cancer mortality for migrants showed some degree of convergence but the cancer mortality rates did not yet reach the levels of the native dutch population. abstract background: legionnaires' disease (ld) is a notifiable disease in the netherlands. ld cases are reported to authorities for national surveillance. supplementary, a national ld outbreak detection program (odp) is installed in the netherlands. these two registration systems have their own information exchange process and databases. objectives: surveillance systems are known to suffer from incompleteness of reported data. co-existence of two databases creates the opportunity to investigate accuracy and reliability in a national surveillance system. design and methods: comparison was made between the outcome 'diagnosis by culture' in both databases and physical presence of legionella strains in laboratories for patients. accuracy is described using the parameters sensitivity and correctness. for reliability, cohen's kappa coefficient (?) was applied. results: accuracy and reliability were significantly higher in the odp database, but not optimal in both databases when compared to data in laboratories. the odp database was moderately reliable (? = . ; %ci . - . ), the surveillance database slightly (? = . ; %ci . - . ). conclusion: our findings suggest that diagnostic notification data concerning ld patients are most accurate and reliable when derived directly from diagnostic laboratories. discussion: involvement of data-entry persons in outbreak detection results in higher reliability. unreliable data may have considerable consequences during outbreaks of ld. the aim of the study was to investigate the medical students' plans to emigrate, quantify the scale of migration in the near future and to build a profile of the possible emigrants. data were collected based on anonymous questionnaire delivered to random group of medical students (katowice). we used the binary logistic regression and multivariate analysis to identify the differences between groups preferring to go abroad or stay in poland. % respondents confirmed that considerate the emigration; . % of them declared they are very likely to move and further . % is certain. , % of those considering emigration confirmed having taken practical steps towards moving. binary logistic regression showed no difference between people who were certain or almost certain to go and those who were not considering going for most baseline characteristics: hometown size, socio economic background and having family tradition of the medical profession (p = . ). only marks' mean differentiates between the two groups: . for those who will definitely stay vs . for students who will definitely move (p = . ). the multivariate analysis gave similar results. conclusions: most of the students consider the emigration, but the declarations of will to departure are more frequent among those with the worse marks. abstract background: falls incidence in home resident elderly people varies from % to %. falls induce loss of self-sufficiency and increase mortality and morbidity. objectives: to evaluate falls incidence and risk factors in a group of general practice elderly patients. design : prospective cohort study with year follow-up methods: eight hundreds elderly (> years) were visited by practitioners for a baseline assessment. information on current pathologies and previous falls in the last six months was collected. functional status was evaluated using: short portable mental state questionnaire, geriatric depression scale, activities of daily living (adl), instrumental activities of daily living, total mobility tinetti score. falls were monitored through phone-interviews at and months. data were analyzed through logistic regression. results: twenty-eight percent of the elderly fell in the whole period. sixty percent of falls were not reported to the practitioner. independent predictors for falls were adl score (adl< : or = . ; % ci . - . ) and previous falls (or = . ; % ci . - . ). tinetti score was significantly associated to falls only in univariate analysis. conclusions: practitioners can play a key-role in identifying at-risk subjects and managing prevention interventions. falls monitoring and a continuous practice of comprehensive geriatric assessment should be encouraged. abstract background: oral health represents an important indicator of health status. socio-economic barriers to oral care among elderly are considerable. in the lazio region, a public health program for oral rehabilitation was implemented to offer dentures to elderly people with social security. objectives: to compare hospitalisation between elderly enrolled in the program and a control group. design and methods: for each elderly enrolled in the program living in rome, three controls, matched for sex and age, were selected from rome municipality register. hospital admissions in the two-year period before enrollment were traced by record-linkage with the hospital discharge register. results: totally, , admissions occurred. the annual admissions rate was per elderly among controls and in the program group (incidence rate ratio: irr = . ; % ci . - . ). when comparing diagnosis-specific rates, significant excesses were observed in the program group for respiratory diseases ( abstract background: herpes simplex virus (hsv) type and are important viral sexually transmitted diseases (sti) and can cause significant morbidity. in the netherlands, data about prevalences in the general population are hampered. objective: description of the seroprevalences of hsv- and hsv- and associated factors in the netherlands. design and methods: a population based serum bank survey in the netherlands with an age-stratified sample was used ( ) ( ) . antibodies against hsv- and hsv- were determined using elisa. a questionnaire was used to get information on demographics and risk factors. a logistic regression adjusting for age and full multiple regression were done to establish risk factors. results: questionnaires and sera were available for persons. both hsv- and hsv- seroprevalence increased with age. seroprevalence of hsv- was . % and was amongst others associated with female sex and being divorced. seroprevalence of hsv- was . % and was amongst others associated with being divorced and a history of sti. conclusion: seroprevalence is higher in certain groups like teenagers, women, divorced people and those with a history of sti. prevention should be focused on those groups. more research is needed on prevention methods, which can be used in the netherlands, like screening or vaccination. abstract background: frequently, statistically significant prognostic factors are reported with suggestions that patient management should be modified. however, the clinical relevance of such factors is rarely quantified. objectives: we evaluated the accuracy of predicting the need for invasive treatment among bph patients managed conservatively with alpha -blockers. methods: information on eight prognostic factors was collected from patients treated with alpha -blockers. with phm regression coefficients a risk score for retreatment was calculated for each patient. the analyses were repeated on groups of patients sampled from the original case series. these bootstrap results were compared to the original results. results: three significant predictors of retreatment were identified. the % of patients with the highest risk score had an -month risk of retreatment of only %. analyses of less than half of all the bootstrap samples resulted in the same three significant prognostic factors. the % of patients with the highest risk score in each of the samples experienced a highly variable risk of retreatment of % to %. conclusions: four of the five high risk patients would be overtreated with a modified policy. internal validation procedures may warn against the invalid translation of statistical significance into clinical relevance. background: e-cadherin expression is frequently lost in human epithelium derived cancers, including bladder cancer. for two genetic polymorphisms in the region of the e-cadherin gene (cdh ) promoter, a reduced transcription has been reported: a c/a single nucleotide polymorphism (snp) and a g/ga snp at bp and bp, respectively, upstream of the transcriptional start site. objective: we studied the association between both polymorphisms and the risk of bladder cancer. methods: patients with bladder cancer and population controls were genotyped for the ) c/ a and the ) g/ga promoter polymorphisms using pcr-rflp. results: a significantly increased risk for bladder cancer was found for a allele carriers compared to the homozygous c allele carriers (or . ; % ci: . - . ). the risk for the heterozygous and homozygous a allele carriers, was increased approximately . and -fold, respectively. the association was stronger for more aggressive tumors. we did not find any association between the ) g/ga snp and bladder cancer. conclusion: this study indicates that the ) c/a snp in the e-cadherin gene promoter is a low-penetrance susceptibility factor for bladder cancer. background: health problems, whether somatic, psychiatric or accident-related cluster within persons. the study of allostatic load as a unifying theme (salut) aims to identify risk factors that are shared by different pathologies and that could explain this clustering. studying patients with repetitive injuries might be helpful to identify risk factors that are shared by accident-related and other health problems. objectives: to study injury characteristics in repetitive injury (ri) patients as compared to single injury (si) patients. methods: the presented study included ri patients and si patients. medical records provided information about injury characteristics and patients were asked for possible causes and context. results: ri patients suffered significantly more from contusions than si patients ( % vs %). regarding the context, si patients were significantly more injured in traffic ( % vs %). in both groups most injuries were attributed to 'mere bad luck' (ri %, si %), closely followed by 'clumsiness or inattention' (ri %, si %). ri patients pointed out aggression or substance misuse significantly more often than si patients ( % vs %). conclusion: ri patients seem to have more 'at risk' behavior (i.e. aggression, impulsivity), which will increase their risk for psychiatric health problems. abstract background: breastfeeding may have a protective effect on infant eczema. bias as a result of methodological problems may explain the controversial scientific evidence. objective: we studied the association between duration of breastfeeding and eczema when taking into account the possible influence of reverse causation. design and methods: information on breastfeeding, determinants and outcomes at age one year was collected by repeated questionnaires in mother infant-pairs participating in the koala study ( cases of eczema). to avoid reverse causation, a periodspecific-analysis was performed in which only 'at risk' infants were considered. results: no statistically significant association between the duration of breastfeeding (> weeks versus formula feeding) and the risk of eczema in the first year was found (or . %ci . - . ). after excluding from the analysis all breastfed infants with symptoms of eczema reported in the same period as breastfeeding, also no statistical significant association was found for the duration of breastfeeding and eczema between and months (or . %ci . - . ). conclusion and discussion: in conclusion, no evidence was found for a protective effect of breastfeeding duration on eczema. this conclusion was strengthened by risk period-specific-analysis which made the influence of reverse causation unlikely. abstract background: the internet can be used to meet health information needs, provide social support, and deliver health services. the anonymity of the internet offers benefits for people with mental health problems, who often feel stigmatized when seeking help from traditional sources. objectives: to identify the prevalence of internet use for physical and mental health information among the uk population. to investigate the relationship of internet use with current psychological status. to identify the relative importance of the internet as a source of mental health information. design and methods: self-completion questionnaire survey of a random sample of the uk population (n = ). questions included demographic characteristics, health status (general health questionnaire), and use of the internet and other information sources. results: % of internet users had sought health information online, and % had sought mental health information. use was higher among those with current psychological problems. only % of respondents identified the internet as one of the most accurate sources of mental health information, compared with % who identified it as one of the sources they would use. conclusions: health service providers must recognise the increasing use of the internet in healthcare, even though it is not always regarded as being accurate. abstract old age is a significant risk factor for falls. approximately % of people older than are falling at least once a year, mostly in the own homes. resulting hip fractures cause at least partial immobility in - % of the affected persons. almost % are sent to nursing homes afterwards. in mecklenburg-west pomerania, ageing of the population proceeds particularly fast. to prevent falls and the loss of independent living a falls prevention module was integrated in a community-bbased study conducted in cooperation with a general practitioner (gp). in the patients homes' a trained nurse performed a test to estimate the falls risk of each patient and a consultation how to reduce risk, e.g. eye sight check, gymnastic exercise. in the feasibility study ( %) out of patients (average age years), agreed to a visiting of each room of their homes in search for tripping dangers. the evaluation was assisted by a standardized, computer-based documentation. the prevention module received a considerable acceptance despite the extensive home visiting. within one month the patients started to transfer advice into practice. during the first follow up visits of the nurse three patients reported e.g. to have started gymnastics and/or wear stable shoes. abstract background: the emergence of drug resistant m. tuberculosis (mtb) is an increasing problem in both developed and developing countries. objectives: investigation of isoniazid (inh) and rifampin (rif) susceptibility patterns among mtb isolates from patients. design and methods: in total sputum samples were collected. smears were prepared for acid fast staining and all the isolates were identified as m. tuberculosis by preliminary cultural and biochemical tests. the isolates were examined for inh and rifampin resistance using conventional mic method and pcr technique by using specific inh (kat g) and rifampin (rpo b) resistant primers. results: seven isolates were resistant to both inh and rifampin by mic method. in pcr technique, and out of above mentioned strains showed resistant to inh and rifampin respectively. coclusion: the epidemiology of drug resistance is . % in region of study which is significant. discussion: conventional mic method despite being time consuming is more sensitive for evaluation of drug resistance, however, pcr as a rapid and sensitive technique is recommended additionally to conventional method for having quicker results to start treatment and disease control management. abstract background and objectives: we studied in literature which design characteristics of food frequency questionnaires (ffqs) influence their validity to assess both absolute and relative levels of energy intake in adults with western food habits, and to rank them according to these intakes. this information is required in harmonizing ffqs for multi centre studies. design and methods: we performed a review of studies investigating the validity or reproducibility of ffqs, published since . the included studies validated ffqs against doubly labeled water (for energy expenditure) as a gold standard, or against food records or hour recalls for assessing relative validity (for energy intake). the design characteristics we studied were the number of food items, the reference period, the administration mode, and inclusion of portion size questions. results: and conclusion: for this review we included articles representing the validation of questionnaires. three questionnaires were validated against dlw, ten against urinary n and against -hour recalls or food records. in conclusion a positive linear relationship (r = . , p< . ) was observed between the number of items on the ffq and the reported mean energy intake. details about the influence of other design characteristics on validity will be discussed at the conference. abstract background: high ethanol intake may increase the risk of lung cancer. objectives: to examine the association of ethanol intake with lung cancer in epic. design and methods: information on baseline and past alcohol consumption, lifetime tobacco smoking, diet, and anthropometrics of , participants was collected between and . cox proportional hazard regression was used to examine the association of ethanol intake at recruitment ( cases) and mean lifelong ethanol intake ( cases) with lung cancer. results: non-consumers at recruitment had a higher lung cancer risk than low consumers ( . - . g/day) [hr = . , % ci . - . ]. lung cancer risk was lower for moderate ethanol intake at recruitment ( . - . g/day) compared with low intake (hr = . , % ci . - . ); no association was seen for higher intake. compared with lifelong low consumers, lifelong non-consumers did not have a higher lung cancer risk (hr = . , % ci . , . ) but lifelong moderate consumers had a lower risk (hr = . , % ci: . - . ). lung cancer risk tended to increase with increasing lifelong ethanol intake (= vs. . - . g/ day hr = . , % ci: . - . ). conclusion: while lung cancer risk was lower for moderate compared with low ethanol intake in this study, high lifelong ethanol intake might increase the risk. abstract background: one of the hypotheses to explain the increasing prevalence of atopic diseases (eczema, allergy and asthma) is imbalance between dietary intake of omega- and omega- fatty acids. objectives: we evaluated the role of perinatal fatty acid (fa) supply from mother to child in the early development of atopy. design and methods: fa composition of breast milk was used as a marker of maternal fa intake and placental and lactational fa supply. breast milk was sampled months postpartum from mother-infant pairs in the koala birth cohort study, the netherlands. the infants were followed for atopic symptoms (repeated questionnaires on eczema and wheezing) and sensitisation at age (specific serum ige against major allergens). multivariate logistic regression analysis was used to adjust for confounding factors. results: high levels of omega- long chain polyunsaturated fas were associated with lower incidence of eczema in the first year (odds ratio for the highest vs lowest quintile . , % confidence interval . - . ; trend over quintiles p = . ). wheeze and sensitisation were not associated with breast milk fa composition. conclusion and discussion: the results support the omega- / hypothesis. we suggest that anti-inflammatory activity of omega- eicosanoid mediators is involved but not allergic sensitisation. abstract background: acute myocardial infarction (ami) is among the main causes of death in italy and is characterized by high fatality associated with a fast course of the disease. consequently timeliness and appropriateness of the first treatment are paramount for a positive recovery. objectives: investigate the differences among italian regions of ami first treatment and in-hospital deaths. design and methods: following the theoretical care pathway (from onset of ami to hospitalization and recovery or death), regional in-hospital deaths are decomposed into the contributions of attack rate, hospitalization and in-hospital fatality. hospital discharges, death and population data are provided by the official statistics. results: generally in northern and central regions there is an excess of observed in-hospital deaths, while the opposite occurs in southern regions. conclusion: in northern and central regions the decomposition method suggests a more frequent and severe illness, generally accompanied by a higher availability of hospitals; exceptions are lombardia and lazio, where some inefficiencies in the hospital system are highlighted. in most southern regions the decomposition confirms a less frequent and less severe illness; exceptions are campania and sicilia, where only the less severe patients reach the hospital and then recover, while the others die before reaching the hospital. abstract background: atherosclerotic lesions have typical histological and histochemical compositions at different stages of their natural history. the more advanced atherosclerotic lesions contain calcification. objective: we examined the prevalence of and associations between calcification in the coronary arteries, aortic arch and carotid arteries assessed by multislice computed tomography (msct). methods: this study was part of the rotterdam study,a population-based study of subjects aged years and over. calcification was measured and quantified in subjects. correlation coefficients were computed using spearman's correlation coefficients. results: the prevalence of calcification increased with age throughout the vascular bed. in subjects aged and over, up to % of men had calcification in the coronary arteries and up to % of women had calcification in the aortic arch. in men, the strongest correlation was found between calcification in the aortic arch and the carotid arteries (r= . , p< . ). in women, the relations were somewhat lower, the strongest correlation was found between calcification in the coronary arteries and the carotid arteries (r = . , p< . ). conclusion and discussion: in conclusion, the prevalence of calcification was generally high and increased with increasing age. the study confirms the presence of strong correlations between atherosclerosis in different vessel beds. abstract background: health status deteriorates with age and can be affected by transition from active work to retirement. objective: to assess the effect of retirement on age related deterioration of health. methods: secondary analysis of the german health survey (bundesgesundheitssurvey ) and california health interview survey (chis ) . subjective health was assessed by a single question regarding respondent's health status from = excellent to = poor. locally weighted regression was used for exploratory analysis and b-splines for the effect estimation in regression models. results: subjective health decreased in an obviously non-linear manner with age. in both cases the decrease could be reasonably approximated by two linear segments, however the pattern was different in the german and california sample. in germany, the change point of the slope describing deterioration of health was located at . abstract objective: to assess the effectiveness of physiotherapy compared to general practitioners' care alone, in patients with acute sciatica. design, setting and patients: a randomised clinical trial in primary care with a -months follow-up period. patients with acute sciatica (recruited - ) were randomised in two groups: ) intervention group received physiotherapy (active exercises), and ) control group received general practitioners' care only. main outcome measures the primary outcome was patients' global perceived effect. secondary outcomes were severity of leg and back pain, severity of disability, general health and absence from work. the outcomes were measured at , , and weeks after randomisation. results: at months follow-up, % of the intervention group and % of the control group reported improvement (rr . ; % ci . to . ). at months follow-up, % of the intervention group and % of the control group reported improvement (rr . ; % ci . ; . ). no significant differences in secondary outcomes were found at short-term or long-term follow-up. conclusion: at months follow-up, evidence was found that physiotherapy added to general practitioners' care is more effective in the treatment of patients with acute sciatica than general practitioners' care alone. abstract background: only little is known about the epidemiology of skin melanoma in the baltic states. objectives: the aim of this study was to provide insights into the epidemiology of skin melanoma in lithuania by analyzing population-based incidence and mortality ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) time trends and relative survival based on skin melanoma. methods: we calculated age-standardized incidence and mortality rates (cases per , ) using the european standard population and calculated period estimates of relative survival. for the period - , % of all registered cases were checked by reviews of the medical charts. results: about % of the cases of the period - were reported to the cancer registry indicating a high quality of cancer registration of skin melanoma in lithuania. the incidence rates increased from (men: . , women: . ) to (men: . , women: . ). mortality rates increased from (men: . , women: . ) to (men: . , women: . ). relative -year relative survival rates among men were % lower than among women. the overall difference in survival is mainly due to a more favorable survival among women aged - years. conclusions: overall prognosis is less favorable among men most likely due to diagnoses at later stages. abstract background: only little is known about the epidemiology of skin melanoma in the baltic states. objectives: the aim of this study was to provide insights into the epidemiology of skin melanoma in lithuania by analyzing population-based incidence and mortality ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) time trends and relative survival based on skin melanoma. methods: we calculated age-standardized incidence and mortality rates (cases per , ) using the european standard population and calculated period estimates of relative survival. for the period - , % of all registered cases were checked by reviews of the medical charts. results: about % of the cases of the period - were reported to the cancer registry indicating a high quality of cancer registration of skin melanoma in lithuania. the incidence rates increased from (men: . , women: . ) to (men: . , women: . ). mortality rates increased from (men: . , women: . ) to (men: . , women: . ). relative -year relative survival rates among men were % lower than among women. the overall difference in survival is mainly due to a more favorable survival among women aged - years. conclusions: overall prognosis is less favorable among men most likely due to diagnoses at later stages. abstract background: multifactorial diseases share many risk factors, genetic as well as environmental. to investigate the unresolved issues on etiology of and individual susceptibility to multifactorial diseases, the research focus must move from single determinantoutcome relations to modification of universal risk factors. objectives: the aim of the lifelines project is to study universal risk factors and their modifiers for multifactorial diseases. modifiers can be categorized into factors that determine the effect of the studied risk factor (eg gen-expression), those that determine the expression of the studied outcome (eg previous disease), and generic factors that determine the baseline risk for multifactorial diseases (eg age). design and methods: lifelines is carried out in a representative sample of . participants from the northern provinces of the netherlands. apart from questionnaires and clinical measurements, a biobank is constructed (blood, urine, dna). lifelines will employ a three-generation family design (proband design with relatives), which has statistical advantages, enables unique possibilities to study social characteristics, and offers practical benefits. conclusion: lifelines will contribute to the understanding of how disease-overriding risk factors are modified to influence the individual susceptibility to multifactorial diseases, not only at one stage of life but cumulatively over time: the lifeline. abstract background: obesity-related mortality is a major public health problem, but few studies have been conducted on severely obese individuals. objectives: we assessed long-term mortality in treatment-seeking, severely obese persons. design and methods: we enrolled persons in six centres for obesity treatment in four italian regions, with body mass index (bmi) at first visit => kg/m and age => . after exclusion of duplicate registrations and persons with missing personal or clinical data, persons were followed up; as ( . %) could not be traced, persons ( men, women) were retained for analysis. results: there were ( men, women) deaths; the standardized mortality ratios (smrs) and % confidence intervals were ( - ) among men and ( - ) among women. mortality increased with increasing bmi, but the trend was not monotonic in men. lower smrs were observed among persons recruited more recently. excess mortality was inversely related to age attained at follow-up. conclusions and discussion: the harmful, long-term potential of severe obesity we documented confirms observations from studies carried out in different nutritional contexts. the decrease in mortality among most recently recruited persons may reflect better treatment of obesity and of its complications. abstract background: in finland, every cancer patient should have equal access to high quality care provided by the public sector. therefore no regional differences in survival should be observed. objectives: the aim of the study was to find any regional differences in survival, and to elaborate whether possible differences could be explained, e.g., by differences in distributions of prognostic factors. design and methods: the study material consisted of , patients diagnosed in to with cancer at one of the major primary sites. the common closing date was dec. . finland was divided into five university hospital regions. stage, age at diagnosis and sex were used as prognostic factors. the relative survival rates for calendar period window, - , were tabulated using period method and modelled. results: survival differences between the regions were not significant for most primary sites. for some sites, the differences disappeared in the modelling phase after adjusting for the prognostic factors. for a few of the primary sites (e.g., carcinoma of the ovary), regional differences remained after modelling. conclusion: we were able to highlight certain regional survival differences. ways to improve the equity of cancer care will be considered in collaboration with the oncological community. abstract background: the prevalence of cardiovascular disease (cvd) is extremely high in dialysis patients. disordered mineral metabolism, including hyperphosphatemia and hypercalcaemia, contributes to the development of cvd in these patients. objectives: to assess associations between plasma calcium, phosphorus and calciumphosphorus product levels and risk of cvd-related hospitalization in incident dialysis patients. design and methods: in necosad, a prospective multi-centre cohort study in the netherlands, we included consecutive patients new on haemodialysis or peritoneal dialysis between and . risks were estimated using adjusted time-dependent cox regression modeling. results: mean age was ± years, % was male, and % was treated with haemodialysis. cvd was the cause of hospitalization in haemodialysis patients ( % of hospitalizations) and in peritoneal dialysis patients ( %). most common cardiovascular morbidities were peripheral vascular disease and coronary artery disease in both patient groups. in haemodialysis patients risk of cvd-related hospitalization increased with elevated plasma calcium (hazard ratio: . ; % ci: . to . ) and calcium-phosphorus product levels ( . ; % ci: . to . ). in peritoneal dialysis patients, we observed similar effects that were not statistically significant. conclusion: tight control of plasma calcium and calcium-phosphorus product levels might prevent cvd-related hospitalizations in dialysis patients. abstract background: nurses are at health risk due to the nature of their work. analysis of morbidity among nurses was conducted to provide insight concerning the relationship between their occupational exposure and health response. methods: self reported medical history, was collected from an israeli female-nurses cohort (n = , + years old) and their siblings (n = , age matched +/) years) using a structured questionnaire. to compare disease occurrence between the two groups we used chi-square tests and hazard ratio (hr) was calculated by cox-regression to account for age of onset. results: cardiovascular diseases were more frequent among the nurses compared to the controls: heart diseases . % vs. . , p = . (hr= . , p = . ); hypertension . % vs. . %, p<. (hr= . , p = . ). the frequency of hyperlipidemia was . % among the nurses, and only . % among the controls. (hr= . ,p = . ). for the following chronic diseases the occurrence were significantly higher among the nurses and the hrs were significantly higher than : thyroid, hr= . ; liver, hr= . . total cancer and diabetes rates were similar in the groups (hr$ ). conclusions: the results suggest an association between working as a nurse and the existence of risk factors for cardiovascular diseases. the specific related determinants of their work should be further evaluated. abstract background: early referral (er) to a nephrologist and arteriovenous fistulae as first vascular access (va) reduce negative outcomes in chronic dialysis patients (cdp). objectives: to evaluate the effect of nephrologist referral timing and type of the first va on mortality. design and methods: prospective cohort study of incident cdp notified to lazio dialysis registry (italy) in - . late referral (lr) was a patient not referred to nephrologists within months before starting dialysis. we dichotomized va as fistulae versus catheters. to estimate mortality hazard ratios (hr) a multivariate cox model was performed. results: we observed . % lr subjects and . % catheters as first va; proportion of catheters was . % vs. . % (p< . ) for lr and er, respectively. we found a higher mortality hr for patient with a catheter as first va both for er (hr = . ; %c.i. = . - . ) and lr (hr = . ; %c.i. = . - . ); the interaction between referral and va was slight significant (p = . ). conclusions: the originality of our study was to investigate the influence of nephrologist referral timing and va on cdp mortality using a population registry, area-based: we found that a catheter as first va has an independent effect for mortality and modifies the effect of referral timing on this outcome. abstract patients with idiopathic venous thrombosis (vt) without known genetic risk factors but with a positive family history might carry yet unknown genetic defects. to determine the role of unknown hereditary factors in unexplained vt we calculated the risk associated with family history. in the multiple environmental and genetic assessment of risk factors for vt (mega) study, a large population-based case-control study, we collected blood samples and questionnaires on acquired risk factors (surgery, immobilisation, malignancy, pregnancy and hormone use) and family history of patients and control subjects. overall, positive family history was associated with an increased risk of vt (or ( % ci): . ( . - . )), especially in the absence of acquired risk factors (or ( % ci): . ( . - . ) ). among participants without acquired factors but with a positive family history, prothrombotic defects (factor v leiden, prothrombin a, protein c or protein s deficiency) were identified in out of ( %) patients compared to out of ( %) control subjects. after excluding participants with acquired or prothrombotic defects, family history persisted as a risk factor (or ( % ci): . ( . - . )). in conclusion, a substantial fraction of thrombotic events is unexplained. family history remains an important predictor of vt. abstract background: alcohol may have a beneficial effect on coronary heart disease (chd) through elevation of high-density lipoprotein cholesterol (hdlc) or other alterations in blood lipids. data on alcohol consumption and blood lipids in coronary patients are scarce. objectives: to assess whether alcohol consumption and intake of specific types of beverages are associated with blood lipids in older subjects with chd. design and methods: blood lipids (total cholesterol, hdlc, ldl cholesterol, triglycerides) were measured in myocardial infarction patients aged - years ( % male), as part of the alpha omega trial. intake of alcoholic beverages, total ethanol and macro and micronutrients were assessed by food-frequency questionnaire. results: seventy percent of the subjects used lipidlowering medication. mean total cholesterol was . mmol/l and hdlc was . mmol/l. in men but not in women, ethanol intake was positively associated with hdlc (difference of . mmol/l for = g/d vs. g/d, p = . ) after adjustment for diet, lifestyle, and chd risk factors. also, liquor consumption was weakly positively associated with hdlc in men (p = . ). conclusion and discussion: moderate alcohol consumption may elevate hdlc in (treated) myocardial infarction patients. this is probably due to ethanol and not to other beneficial substances in alcoholic beverages. session: posters session : july presentation: poster. abstract objective: early detection and diagnosis of silicosis among dust exposed workers is based mainly on the presence of rounded opacities on radiographs. it is thus important to examine how reliable the radiographic findings are in comparison to pathological findings. methods: a systematic literature search via medline was conducted. validity of silicosis detection and its influence on risk estimation in epidemiology was evaluated in a sensitivity analysis. results: studies on comparison between radiographic and pathological findings of silicosis were identified. the sensitivity of radiographic diagnosis of silicosis (ilo / ) varied between % and %, and specifity between % and %. under the realistic assumption of silicosis prevalence between % and % in dust exposed workers, % to % of silicosis identified may be falsely diagnosed. the sensitivity analysis indicates that invalid diagnostics alone may lead to the finding of an increased risk of lung cancer among patients with silicosis. it may also lead to findings of % to % of radiographic silicosis even when there is no case of silicosis. however, the risk of silicosis could also be underestimated if the prevalence of silicosis exceeds %. conclusion: epidemiological studies based on patients with silicosis should be interpreted with caution. abstract introduction: epidemics of dengue occurring in various countries have stimulated investigators to seek innovative ways of improving current knowledge on the issue. objective: to identify the characteristics of spatial-temporal diffusion of the first dengue epidemic in a major brazilian city (salvador, bahia). methods: notified cases of dengue in salvador in were georeferenced according to census sector (cs) and by epidemiological week. kernel density estimation was used to identify the spatial diffusion pattern. results: of the cs in the city, cases of dengue were registered in ( %). spatial distribution showed that in practically the entire city had been affected by the virus, with a greater concentration of cases in the western region, comprising cs of high population density and predominantly horizontal dwellings. conclusion and discussion: the pattern found showed characteristics of a contagious diffusion process. it was possible to identify the epicenter of the epidemic from which propagation initiated. the speed of progression suggested that even if a rapid intervention was initiated to reduce the vector population, it would probably have little effect in reducing the incidence of the disease. this finding confirms the need for new studies to develop novel technology for prevention of this disease. abstract background: knowing the size of drug user hidden populations in a community is important to plan and evaluate public health interventions. objectives: the aim of this study was to estimate the prevalence of opiate and cocaine users in liguria region by using the covariate capture-recapture method applied to four data sources. methods: we performed a cross-sectional study in the resident population aged - years ( . people at census). during individual cases identified as opiate or cocaine primary users were flagged by four sources (drug dependence services, social service at prefectures, therapeutic communities, hospital discharges). poisson regression models were fitted, adjusting for dependence among sources and for heterogeneity in catchability among categories of the two examined covariates: age ( - and - years) and gender. results: the prevalence of opiate or cocaine users was , % ( % c.i., , - , %) and , % ( % c.i.= , - , %) respectively. conclusions: the estimated prevalence of opiate and cocaine users is consistent with that found in inner london: . % and . % respectively (hickman m., ; hope v.d., ) . the covariate capture-recapture method applied to four data sources allowed identifying a large cocaine-using population and resulted appropriate to determine drug user hidden populations. abstract background: in - we performed a population based diabetes screening programme. objectives: to investigate whether the yield of screening is influenced by gp and practice characteristics. methods: a questionnaire containing items on the gp (age, gender, employment, specialty in diabetes, applying insulin therapy) and the practice (setting, location, number of patients from ethnic minority groups, specific diabetes clinic, involvement of practice assistant and practice nurse in diabetes care, cooperation with a diabetes nurse) was sent to general practitioners (gps) in practices in the southwestern region of the netherlands. multiple linear regression analysis was performed. outcome measure was the ratio screen detected diabetic patients/known diabetic patients per practice (sdm/kdm). results: sdm/kdm was independently associated with higher age of the gp (regression coefficient . ; % confidence interval . to . ), urban location () . ; ) . to ) . ) and involvement of the practice assistant in diabetes care ( . ; . to . ) . conclusion: a lower yield of screening, assumably reflecting a lower prevalence of undiagnosed diabetes, was found in practices of younger gps and in urban practices. a lower yield was not associated with an appropriate practice organization nor with a specialty of the gp in diabetes. session: posters session : july presentation: poster. background: since few years increased incidence rates for childhood cancer were reported from industrialized countries. these findings were discussed controversial, because increases could be caused by changing of potential risk factors. objectives: the question is: are observed increasing rates due to actual changes in incidence rates or mainly caused by changes in registration practice or artefacts? methods: for europe, data from the accis project (pooled data from european population-based cancer registries, performed at iarc, lyon; responsible: e. steliarova-foucher) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , and for germany, data of the german childhood cancer registry available from onwards were used. results: accis data (based on , cases) show significantly increased data with an overall average annual percentage change of about % and it is seen for mainly all diagnostic subgroups. for germany, increases are seen for neuroblastoma (due to screening programmes) and brain tumours (due to improved registration). for acute leukaemia the observed increase is explained by changes in classification. conclusion and discussion: the increased incidence for europe can only partly be explained by registration artefacts or improved diagnostic methods. the observed patterns suggest that an actual change exists. in germany, from till now the observed increased rates could be explained by artefacts. abstract suicide is the fourth most common cause of death among working age finns. among men socioeconomic status is strongly and inversely associated with suicide mortality, but little is known about socioeconomic differences in female suicide. we studied the direct and indirect effects of different socioeconomic indicators -education, occupation-based social class and income -on suicide among finnish women aged - . also the effect of main economic activity was studied. we used individual level data from the census linked to the death register for the years - . altogether over million person-years were included and suicides were committed. age-adjusted rii conducted using poissonregression model was . ( % ci . - . ) for education, . ( . - . ) for social class and . ( . - . ) for income. however, almost all of the effect of education was mediated by social class. fifteen per cent of social class was explained by education and per cent was mediated by income. the effect of income on suicide was mainly explained by economic activity. in conclusion, net of other indicators occupation-based social class is a strong determinant of socioeconomic differences in female suicide mortality, and actions aimed at preventing female suicide should target this group. abstract c-reactive protein levels (crp) in the range between and mg/ l independently predict the risk of future cardiovascular events. besides being a marker of atherosclerotic processes, high-normal crp levels may also be a sign of a more pronounced response to everyday inflammatory stimuli. the aim of our study is to assess the association between response to everyday stimuli and the risk of myocardial infarction. we will perform a population based case-control study including a total of persons. cases (n = ) are first myocardial infarction (mi) patients. controls (n = ) are partners of the patients. offspring of the mi patients (n = ) are included because disease activity and the use of medication by the mi patients may influence the inflammatory response. in order to assess the inflammatory response in mi patients the mean genetically determined inflammatory response in the offspring will be assessed and used as a measure for the inflammatory response in the mi patients. the offspring is free of disease and medication use. partners of the offspring (n = ) are the controls for the offspring. influvac vaccine will be given to assess crp concentration, i.e. inflammatory response, before and after the vaccination. abstract background:. ischemic heart disease risk may be influenced by long-term exposure to electromagnetic fields (emf) in vulnerable subjects, but epidemiological data is inconsistent. objectives: we studied whether the long-term occupational exposure to emf is related to an increased myocardial infarction (mi) risk. design and methods: we conducted a prospective case-control study, which involved mi cases and controls. emf exposure in cases and controls was assessed subjectively. the effect of emf exposure on mi risk was estimated using multivariate logistic regression. results: after adjustment for age, smoking, blood pressure, body mass index and psychological stress the odds ratios for emf exposure < years was . ; % ci . - . , for emf exposure - years - . ; % ci . - . and for emf exposure > years - . ; % ci . - . . conclusion: longterm occupational exposure to emf may increase the risk of mi. our crude estimates of emf exposure might have impact on excess risk because of nondifferential misclassification in assigning exposure. abstract background: it has been suggested that noise exposure is associated with ischemic heart disease risk, but epidemiological evidence is still limited. objectives: we studied whether road traffic noise exposure increases the risk of myocardial infarction (mi). design and methods: we conducted population-based prospective casecontrol study, which involved mi cases and controls. we measured traffic-related noise levels at the electoral districts and linked these levels to residential addresses. we used multiple logistic regression to assess effect of noise exposure on mi risk. results: after adjustment for age, smoking, blood pressure, body mass index, and psychological stress the risk of mi was higher for the men exposed to - dba ( background: some studies have suggested that patients, depressed following acute myocardial infarction (mi), experience poorer survival. however, i) other studies show no significant association, when adjusted for recognized prognostic indicators and ii) some 'natural' responses to mi may be recorded in questionnaires as indicators of depression. method: depression was assessed in mi patients, by interview on two measures (gwb and sf ) - weeks after discharge, clinical data were abstracted from patients' medical records and vital status was assessed at - years. survivals of depressed, marginally depressed and normal patients were calculated by kaplan meier method and comparisons made by log rank and cox proportional hazard modelling. results: crude survival at years in patients was higher for depressed and marginally depressed ( %) than for normals ( %), although not significantly. in multivariate analysis, four patient characteristics contributed significantly to survival: age (p< . ), previous mi (< . ), diabetes (< . ) and sex (< . ): other potential explanatory variables, including hypertension, infarct severity and depression were excluded by the model. abstract background: the low coronary heart disease (chd) incidence in southern europe could result in lower low density lipoprotein cholesterol oxidation (oxldl). objective. the aim of this study was to compare oxldl levels in chd patients from several european countries. methods: a cross-sectional multicenter study included stable chd male subjects aged to years from northen (finland and sweden), central (germany), and southern europe (greece and spain). lipid peroxidation was determined by plasma oxldl. results: the score of adherence to mediterranean diet, antioxidant intake, alcohol intake, and lipid profile were significantly associated with oxldl. oxldl levels were higher in northern ( . u/l) than in centre ( . u/l) and southern populations ( . u/l), p = . , in the adjusted models. the probability of northern europe to have the highest oxldl levels was . %, and . , % in logarithm of triglyceride-adjusted and fully adjusted models, respectively. the probability of this order to hold after adjustment for country was . %. conclusion: a gradient on lipoperoxidation from north to central and southern europe is very likely to exist, and parallels that observed in the chd mortality, and incidence rates. southern populations may have more favourable environmental factors against oxidation than northern europe. abstract background: whereas socioeconomic status (ses) has been established as a risk factor for a range of adverse health outcomes, little literature exists examining socio-economic inequalities in the prevalence of congenital anomalies. objectives: to investigate the relationship between the ses and the risk of specific congenital anomalies, such as neural tube defects (ntd), oral clefts (oc) and down's syndrome (ds). design and methods: a total of cases of congenital anomaly and non-malformed control births were collected between and from the italian archive of the certificates of delivery care. as a measure of ses, cases and controls were given a value for a level deprivation index. data were analysed using a logistic regression model. results: we found cases of dtn, cases of sof and cases of ds. the risk of having a baby with ntd was significantly higher for women of low ses (or = . ;c.i.: . - . ), as well as for oc (or = . ; c.i.: . - . ). no significant evidence for ses variation was found for ds. conclusion and discussion: our data suggest risk factors linked to ses, such as nutritional factors, lifestyle, and access to health services, may play a role in the occurrence of some malformations. abstract background: general practitioners (gp) are well-regarded by their patients and have the opportunity to play an active role in providing cessation advice. objectives: this study was run to examine whether a public health programme based on a carefully adapted programme of continuing education can increase gps' use of cessation advice and increase the success rates of such advice. methods: the particular context due to a randomization of gp leads us to consider a cluster randomization trial. marginal models, estimated by gee and mixed generalized linear models are used for this type of design. results: the cessation rate is relatively high for all smokers enrolled in the trial (n = ): a total of smokers were ex-smokers at one year ( . %). patients who were seen by trained gps were more likely to successfully stop smoking than those seen by the control gps ( . % vs . %). motivated subjects, aged over , lower had anxiety scores, and confidence in their ability to stop smoking, were predictive of successful cessation at one year follow-up. conclusions: cluster analysis indicated that factors important to successful cessation in this population of smokers are factors commonly found to influence cessation. abstract background: and purpose conventional meta-analysis showed no difference in primary outcome for coronary bypass surgery without (offpump) or with (onpump) the heart-lung machine. secondary outcome parameters such as transfusion requirements or hospitalization days favored offpump surgery. combined individual data analysis improves precision of effect estimates and allows accurate subgroup analyses. objective: our objective is to obtain accurate effect estimates for stroke, myocardial infarction, or death, after offpump versus onpump surgery, by meta-analysis on pooled individual patient data. method and results: bibliographic database search identified eleven large trials (> patients). the obtained data for trials data included patients. primary endpoint was composite (n = ), secondary endpoints were death (n = ), stroke (n = ) and myocardial infarction (n = ). hazard ratio for event-free survival after offpump vs onpump ( % ci) was: composite endpoint . ( . ; . ), death . ( . ; . ) myocardial infarction . ( . ; . ), stroke . ( . ; . ). after stratification for diabetes, gender and age the results slightly favored offpump for high-risk groups. hazard ratios remained not statistically significant. conclusion: no clinical or statistical significant differences were found for any endpoint or subgroup. offpump coronary bypass surgery is at least equal to conventional coronary bypass surgery. offpump surgery therefore is a justifiable option for cardiac surgeons for cardiac bypass surgery. in - an outbreak of pertussis occurred, mostly among vaccinated children. since then the incidence has remained high. therefore, a fifth dose with acellular booster vaccine for -yearolds was introduced in october . the impact of this vaccination on the age-specific pertussis incidence was assessed. mandatory notifications and hospitalisations were analysed for - and compared with previous years. surveillance data show 'epidemic' increases of pertussis in , , and . the total incidence/ , in ( . ) was higher than in the previous epidemic year ( . ). nevertheless, the incidence of notifications and hospitalisations in the age-groups targeted for the booster-vaccination had decreased with respectively % and % compared to . in contrast, the incidence in adolescents and adults almost doubled. unlike other countries that introduced a pre-school booster, the incidence of hospitalised infants < months also decreased ( % compared with ). as expected, the booster-vaccination for -year-olds has decreased the incidence among the target-population itself. more importantly, the decreased incidence among infants < months suggests that transmission from siblings to infants has also decreased. in further exploration of the impact of additional vaccination strategies (such as boostering of adolescents and/or adults) this effect should not be ignored. abstract acute respiratory infections (ari) are responsible for considerable morbidity in the community, but little is known about the presence of respiratory pathogens in asymptomatic individuals. we hypothesized that asymptomatic persons could have a sub clinical infection and so act as a source of transmission. between and all patients with ari who visited their sentinel general practitioner were reported to estimate the incidence of ari in dutch general practices. a random selection of them (cases) and an equal number of asymptomatic persons visiting for other complaints (controls) were included in a case-control study. nose/ throat swabs of participants were tested for a broad range of pathogens. the overall incidence of ari was per , person years, suggesting that in the dutch population an estimated , persons annually consult their general practitioner for respiratory complaints. viruses were detected in % of the cases, ?-haemolytic streptococci group a in % and mixed infections in %. besides, pathogens were detected in approximately % of controls, particularly in the youngest age groups. this study confirms that most ari are viral and supports the reserved policy of prescribing antibiotics. furthermore, we demonstrated that asymptomatic persons might be a neglected source of transmission. abstract background: the baking and flour producing industries in the netherlands agreed on developing a health surveillance system to reduce the burden of and improve prognosis of occupational allergic diseases. objectives: to develop and validate a diagnostic model for sensitization to wheat and fungal amylase allergens, as triage instrument to detect occupational allergic diseases. design and methods: a diagnostic regression model was developed in bakers from a cross-sectional study with ige serology to wheat and or amylase allergens as the reference standard. model calibration was assessed with hoshmer-lemeshow goodness of fit test; discriminative ability using area under receiver operating characteristic curve (auc); and internal validity using bootstrapping procedure. external validation was conducted in other bakers. results: the diagnostic model consisted of four questionnaire items (history of asthma, rhinitis, conjunctivitis, and work-related allergic symptom) showed good calibration (p = . ) and discriminative ability (auc . ; % ci . to . ). internal validity was reasonable (correction factor of . and optimism corrected auc of . ). external validation showed good calibration (p = . ) and discriminative ability (auc . ; % ci . to . ). conclusions and discussion: this easily applicable diagnostic model for sensitization to flour and enzymes shows reasonable diagnostic accuracy and external validation. abstract background: in the netherlands the baking and flour producing industries ( , small bakeries, industrial bakeries, and flour manufactures) agreed to reduce the high rate (up to %) of occupational related allergic diseases. objectives: to conduct health surveillance for early detection of occupational allergic diseases by implementing a diagnostic model as triage instrument. design and methods: in the preparation phase, a validated diagnostic regression model for sensitization to wheat and or a-amylase allergens was converted into score chart for use in occupational health practice. two cut off points of the sum scores were selected based on diagnostic accuracy properties. in the first phase, a questionnaire including the diagnostic predictors from the model was applied in . bakers. surveillance simulation was done in bakers recently enrolled in the surveillance. workers with high questionnaire scores were referred for advanced medical examination. results: implementing the diagnostic questionnaire model yielded %, %, and % bakers in the low, intermediate, and high score groups. workers with high scores showed the highest percentage of occupational allergic diseases. conclusions and discussion: with proper cut off points for referral, the diagnostic model could serve as triage instrument in health surveillance to early detect occupational allergic diseases. abstract background: the prevalence of cardiovascular risk factors in spain is high but myocardial infarction incidence is lower than in other countries. objective: to determine the role of basic lipid profile on coronary heart disease (chd) incidence in spain. methods: a cohort of , healthy spanish individuals aged to years was followed for years. the end-points were fatal and non-fatal myocardial infarction, and angina. results: the participants who developed a coronary end-point were significantly older ( vs ), more often diabetic ( % vs %), smoker ( % vs %) and hypertensive ( % vs %) than the rest, and their average total and hdl-cholesterols (mg/dl) were: vs (ns) and vs , (p< . ), respectively. chd incidence among individuals with low hdl levels (< in men/< in women) was higher than in the rest: . &aeyear- vs . &aeyear- (p< . ) in men, and . &aeyear- vs . &aeyear- (p< . ) in women. hdl-cholesterol was the only lipid related variable significantly associated with chd: hazard ratio for mg/dl increase was . ( % ci: . - . ) in men, and . ( % ci: . - . ) in women, after adjusting for classical risk factors. conclusion: hdl-cholesterol is the only classical lipid variable associated with chd incidence in spain. abstract background: it is widely recognized that health service interventions may reduce infant mortality/imr rate which usually occurs alongside with economic growth. however, there are reports showing that imr decrease under adverse economic and social conditions, indicating the presence of other unknown determinants. objective: this study aims to analyze temporal tendency of infant mortality in brazil during a recent period ( to ) of economic crisis. methods: temporal series study using data from the mortality information system, censuses (ibge) and epidemiological information (funasa). applying arima -autoregressive integrated moving average, it was described series parameters and, spearman correlation coefficients were used to evaluate the association between infant mortality coefficient and some determinants. results: the infant mortality showed a declining tendency () . %) and strong correlation to the majority of the indicators analyzed. however, only correlation between infant mortality coefficient and total fecundity and birth rates differed significantly within decades. conclusions/discussion: fecundity variation was responsible to the persistence of mortality decline during the eighties. in the next period those indicators of life conditions, mostly health care, could be more important. abstract background: across european union (eu) member states, considerable variation exists in the structure and performance of surveillance systems for communicable disease prevention and control. objectives: the study aims to support the improvement of surveillance systems of communicable diseases in europe while using benchmarking for the comparison of national surveillance systems. design and methods: surveillance systems from england & wales, finland, france, germany, hungary and the netherlands were described and analysed. benchmarking processes were performed with selected criteria (e.g. case definitions, early warning systems). after the description of benchmarks, best practices were identified and described. results: the six countries have in general wellfunctioning communicable disease control and prevention systems. nevertheless, different strengths and weaknesses in could be identified. practical examples for best practice from various surveillance systems demonstrated fields for improvement. conclusion and discussion: benchmarking national surveillance systems is applicable as a new tool for the comparison of communicable disease control in europe. a gold standard of surveillance systems in various countries is very difficult to achieve because of heterogeneity (e.g. in disease burden, personal and financial resources). however, to improve the quality of surveillance systems across europe, it will be useful to benchmark surveillance systems of all eu member states. abstract background: therapeutic decisions in osteoarthritis (oa) often involve trade-offs between accepting risks of side effects and gaining pain relief. data about the risk levels patients are willing to accept are limited. objectives: to determine patients' maximum acceptable risk levels (marls) for different adverse effects from typical oa medications and to identify the predictors of these risk attitudes. design and methods: marls were measured with a probabilistic threshold technique for different levels of pain relief. baseline pain and risk levels were controlled for in a x factorial design. clinical and sociodemographic characteristics were assessed using a selfadministered questionnaire. results: for subjects, marls distributions were skewed, and varied by level of pain relief, type of adverse effect, and baseline risk level. given a % baseline risk, for a -point ( - scale) pain benefit the mean (median) marls were . % ( %) for heart attack/stroke; . % ( %) for stomach bleed; . % ( . %) for hypertension; and . % ( . %) for dyspepsia. most clinical and sociodemographic factors were not associated with marls. conclusion: subjects were willing to trade substantial risks of side effects for pain benefits. this study provides new data on risk acceptability in oa patients that could be incorporated into practice guidelines for physicians. background: several independent studies have shown that single genetic determinants of platelet aggregation are associated with increased ihd risk. objectives: to study the effects of clustering prothombotic (genetic) determinants on the prediction of ihd risk. design and methods: the study is based on a cohort of , women, aged to years, who were followed from to . during this period, there were women with registered ihd (icd- - ) . a nested case cohort analysis was performed to study the relation of plasma levels vwf and fibrinogen, blood group genotype and prothrombotic mutations in the gene of a b , gpvi, gpib and aiibb to ihd. results: blood group ab, high vwf concentrations and high fibrinogen concentrations were associated with increased incidence of acute ihd. when the effects of blood group ab/o genotype, plasma levels fibrinogen and vwf were clustered with a score, there was a convincing relationship between a high prothrombotic score and increased incidence of acute ihd: the full-adjusted hr ( % confidence interval) was . ( . - . ) for women with the highest score when the lowest score was taken as reference. conclusions: clustering of prothrombotic markers is a major determinant of increased incidence of acute ihd. abstract background: studies have revealed heart rate variability (hrv) was a predictor of hypertension; however its h-recording has not been analysed with the -hour ambulatory blood pressure. objective: we studied the relationship between hrv and blood pressure. methods: hrv and blood pressure were measured by -hour ambulatory recordings, in randomly selected population without evidence of heart disease. cross-sectional analyses were conducted in women and men (mean age: . ± . ). hrv values, measured by the standard deviation of rr intervals (sdnn), were compared after logarithmic transformation between the blood pressure levels ( / mmhg), using analysis of variance. stepwise multiple-regression was performed to assess on sdnn the cumulative effects of systolic and diastolic blood pressure, clinical obesity, fasting glycaemia, c-reative protein, treatments, smoking and alcohol consumption. results: sdnn was lower in hypertensive men and women (p< . ), independently of drug treatments. after adjustment for factors associated with hypertension, sdnn was no more associated with hypertension, but with obesity, glycaemia and c-reative protein in both genders. sdnn was negatively associated with diastolic blood pressure in men (p = . ) in the multivariate approach. conclusion: whereas blood pressure levels were not related to the sdnn in the multivariate analysis, diastolic blood pressure contributed to sdnn in men. it has been proposed that n- fatty acids may protect against the development of allergic disease, while n- fatty acids may promote its development. in the piama (prevention and incidence of asthma and mite allergy) study we investigated associations between breast milk fatty acid composition of allergic and non allergic mothers and allergic disease (doctor diagnosed asthma, eczema or hay fever) in their children at the age of year and at the age of years. in children of allergic mothers prevalences of allergic disease at age and at age were relatively high if the breast milk they consumed had a low content (wt%) of n- fatty acids and particularly of n- long chain polyunsaturates (lcps), a low content of trans fatty acids, or a low ratio of n- lcps/n- lcps. the strongest predictor of allergic disease was a low breast milk n- lcps/n- lcps ratio (odds ratios ( % ci) of lowest vs highest tertile, adjusted for maternal age, parity and education: . ( . to . ) for allergic disease at age and . ( . to . ) for allergic disease at age ). in children of non allergic mothers no statistically significant associations were observed. abstract background/relevance: to find out about the appropriateness of using two vision related quality of life instruments to measure outcome of visually impaired elderly in a mono-and multidisciplinary rehabilitation centre. objective/design: to evaluate sensitivity of the vision quality of life core measure (vcm ) and the low vision quality of life questionnaire (lvqol) to measure changes in vision related quality of life in a non-randomised followup study. methods: visually impaired patients (n= ) recruited from ophthalmology departments administered questionnaires at baseline ( ) ( ) ( ) ( ) , months and year after rehabilitation. person measures were analysed using rasch analyses for polytomous rating scales. results: paired sample t-tests for the vcm showed improvement at months (p = . ; effect size = . and p = . ; effect size= . ) for the monodisciplinary and the multidisciplinary groups respectively. at year only the multidisciplinary group showed improvement on the vcm (p = . ; effect size = . ). on the lvqol, no significant improvement or deterioration was found for both groups. discussion: although, vcm showed improvement in vision related quality of life over time, the effect sizes appeared to be quite small. we conclude that both instruments lack sensitivity to measure changes. another explanation is that rehabilitation did not contribute to quality of life improvements. abstract background: the natural history of asthma severity is poorly known. objective: to investigate prognostic factors of asthma severity. methods: all current asthmatics identified in / in the european community respiratory health survey were followed up and their severity was assessed in by using the global initiative for asthma categorization (n = ). asthma severity was related to baseline/follow-up potential determinants by a multinomial logistic model, using intermittent asthmatics as reference category for relative risk ratios (rrr). results: patients in the lowest/highest levels of severity at baseline had an % likelihood of remaining in a similar level. severe persistent had a poorer fev %predicted at baseline, higher ige levels (rrr= . ; % ci: . - . ), higher prevalence of chronic cough/phlegm ( . ; . - . ) than intermittent asthmatics. moderate persistent showed similar associations. mild persistent were similar to intermittent asthmatics, although the former showed a poorer control of symptoms than the latter. subjects in remission had a lower probability of an increase in bmi than current asthmatics ( . ; . - . ). allergic rhinitis, smoking, respiratory infections in childhood were not associated with severity. conclusion: asthma severity is a relatively stable condition, at least for patients at the two extremes of the severity spectrum. high ige levels and persistent cough/phlegm are strong markers of moderate/severe asthma. abstract background: thyroid cancer (tc) has a low, yet growing, incidence in spain. ionizing radiation is the only well established risk factor. objectives: this study sought to depict the municipal distribution of tc mortality in spain and to argue about possible risk factors. design and methods: posterior distribution of relative risk for tc was computed using a single bayesian spatial model covering all municipal areas of spain ( , ) . maps were plotted depicting standardised mortality ratios, smoothed municipal relative risk (rr) using the besag, york and mollie`model, and the distribution of the posterior probability that rr> . results: from to a total of , tc deaths were registered in , municipalities. there was a higher risk of death in some areas of canary islands, galicia and asturias. abstract igf-i is an important growth factor associated with increased breast cancer risk in epidemiological and experimental studies. lycopene intake has been associated with decreased cancer risk. although some data indicate that lycopene can influence the igfsystem, this has never been extensively tested in humans. the purpose of this study is to evaluate the effects of a lycopene intervention on the circulating igf-system in women with an increased risk of breast cancer. we conducted a randomized, placebo-controlled cross-over intervention study on the effects of lycopene supplementation ( mg/day, months) in pre-menopausal women with ) history of breast cancer (n = ) and ) high familial breast cancer risk (n = ). drop-out rate was %. mean igf-i and igfbp- concentrations after placebo were . ± . ng/ml and . ± . mg/ml respectively. lycopene supplementation did not significantly alter serum total igf-i (mean lycopene effect: ) . ng/ml; % ci: ) . - . ) and igfbp- () . mg/ml; ) . - . ) concentrations. dietary energy and macronutrient intake, physical activity, body weight, and serum lycopene concentrations were assessed, and are currently under evaluation. in conclusion, this study shows that months lycopene supplementation has no effect on serum igf-system components in a high risk population for breast cancer. abstract introduction: patients who experience burden during diagnostic tests may disrupt these tests. the aim was to describe the perception of melanoma patients with lymph node metastases of the diagnostic tests. methods: patients were requested to complete a self-administrated questionnaire. experienced levels of embarrassment, discomfort and anxiety were calculated, as well as (total) scores for each burden. the non-parametric friedman test for related samples was used to see if there was a difference in burden. results: the questionnaire was completed by patients; response rate was %. overall satisfaction was high. in total % felt embarrassment, % discomfort and % anxiety. overall, % felt some kind of burden. there was no difference in anxiety between the three tests. however, patients experienced more embarrassment and discomfort during the pet (positron emission tomography) scan (p = . and p = . ). conclusion: overall levels of burden were low. however, patients experienced more embarrassment and discomfort during the pet scan, possibly as a result of lying immobile for a long time. the accuracy, costs and patients upstaged will probably be the most important to determine the additional value of fdg-pet and ct, but it is reassuring to know that only few patients experience severe or extreme burden. abstract gastric cancer (gc) is the second most frequent cause of cancer death in lithuania. some intercultural aspects of diet that is related to the outcome could be the risk factors of the disease. the objective of the study was to assess an associations between risk of gc and dietary factors. a case-control study included cases with diagnose of gc and controls that were cancer and gastric diseases free. a questionnaire used to collect information on possible risk factors. the odds ratios (or) and % confidence intervals (ci) estimated by the conditional logistic regression model. after controlling for possible confounders that were associated with gc, use of salted meat (or = . ; % ci = . - . ; > - times/week vs. almost never) smoked meat (or = . ; % ci = . - . ; > - times/week vs. less), smoked fish (or = . ; % ci = . - . ; > - times/week vs. less) was associated with increased risk of gc. higher risk of gc was associated with frequent use of butter, eggs and noodles. while frequent consumption of carrots, cabbages, broccolis, tomatoes, garlic, beans decreased the risk significantly. the data support a role of salt processed food and some animal foods in increasing the risk of gc and plant foods in reducing the risk of the disease. abstract background: standards for the evaluation of measurement properties of health status measurement instruments (hsmi), including explicit criteria for what constitutes good measurement properties, are lacking. nevertheless, many systematic reviews have been performed to compare and select hsmi, using different criteria to judge the measurement properties. objectives: ( ) to determine which measurement properties are reported in systematic reviews of hsmi and how these properties are defined, ( ) which standards are used to define how measurement properties should be assessed, and ( ) which criteria are defined for good measurement properties. methods: a systematic literature search was performed in pubmed, embase and psychlit. articles were included if they met the following inclusion criteria: ( ) systematic review, ( ) hsmi were reviewed, and ( ) the purpose of the review is to identify all measurement instruments assessing (an aspect of) health status and to report on the clinimetric properties of these hsmi. two independent reviewers selected the articles. a standardised data-extraction form was used. preliminary results: systematic reviews were included. conclusions: large variability in standards and criteria used for evaluating measurement properties was found. this review can serve as basis for reaching consensus on standards and criteria for evaluating measurement properties of hsmi. abstract residential exposure to nitrogen dioxide is an air quality indicator and could be very useful to assess the effects of air pollution on respiratory diseases. the present study aims at developing a model to predict residential exposure to no , combining data from questionnaires and from local monitoring stations (ms). in the italian centres of verona, torino and pavia, participating in ecrhs-ii, no concentrations were measured using passive samplers (ps-no ) placed outside the kitchen of subjects for days. simultaneously, average no concentrations were collected from all the mss of the three centres (ms-no ). a multiple regression model was set up with ps-no concentrations as response variable and questionnaire information and ms-no concentrations as predictors. the model minimizing the root mean square error (rmse), obtained from a ten fold cross validation, was selected. the model with the best predictive ability (rmse= . ), had as predictors: ms-no concentrations, season of the survey, centre, type of building, self-reported intensity of heavy vehicle traffic. the correlation coefficient between predictive and observed values was . ( % ci: . - . ). in conclusion, this preliminary analysis suggests that the combination of questionnaire information and routine data from the mss could be useful to predict the residential exposure to no . abstract background: currently only % of dutch mothers comply with the who recommendation to give exclusive breastfeeding for at least six months. therefore, the dutch authorities consider policies on breastfeeding. objectives: quantification of the health effect of several breastfeeding policies. methods: a systematic literature search of published epidemiological studies conducted in the general 'western' population. based on this overview a model is developed. the model simulates incidences of diseases of mother and child depending on the duration that mothers breastfeed. each policy corresponds to a distribution in the duration of breastfeeding. the health effects of each policy are compared to the present situation. results: breastfeeding has beneficial health effects on both the short and the long term for mother and child. the longer the duration of breastfeeding, the larger is the effect. most public health gain is achieved by introducing breastfeeding to all newborns rather than through a policy focusing just on extending the lactation period of women already breastfeeding. conclusion: breastfeeding has positive health effects. policy should focus preferentially on encouraging all mothers to start with breastfeeding. abstract background: constant increase of international trade and travel activities has risen the significance of pandemic infectious diseases worldwide. the / sars outbreak rapidly spread from china to countries, from which were located in europe. in order to control and prevent pandemic infections in europe, systematic and effective public health preparation by every member state is essential. method: supported by the european commission, surveys focusing on national sars (september ) and influenza (october ) preparedness were accomplished. a descriptive analysis was undertaken to identify differences in european infectious disease policies. results: guidelines and guidance for disease management were well established in most european countries. however, the application of control measures, like e.g. measures for mass gatherings or public information policies, had varied among member states. discussion: the results show that european countries are aware of preparing for pandemic infections. yet, the effectiveness of certain control measures is analysed insufficiently. further research and detailed knowledge about factors influencing international spread of diseases is required. 'hazard analysis of critical control points' (haccp) will be applied to evaluate national health response in order to provide comprehensive data for recommendations to european pandemic preparedness. abstract background: influenza is still an important problem for public health. knowing its space-time evolution is of special interest in order to carry out prevention plans. objectives: to analyze the geographical diffusion of the epidemic wave in extremadura. methods: the influenza incidence absolute rates in every town have been calculated, according to the registered cases per week in the compulsory disease declaration system. continuous maps have been represented using a geographical interpolation method (inverse distance weighting (idw) was applied with weighting exponents of ). results: the / season began in the th week of , with a small influenza incidence. there have been concrete cases in those towns until the th week. punctual areas diffusion in the north and southwest of the region between the th and the st weeks. the highest incidence appeared between the nd week of and the rd of . influenza cases started to decrease in the northwest and north of the region from the rd week of , till the th week, when most of the cases were found in the southwest. conclusion: there is a space-time diffusion of influenza, due to the higher population density. we propose to analyze these data combining temperature information. abstract background: acute lower respiratory tract infection (lrti) can cause various complications leading to morbidity and mortality notably among elderly patients. antibiotics are often given to prevent complications. to minimise costs and bacterial resistance, antibiotics are only recommended in case of pneumonia or in patients at serious risk for serious complications. objective: we assessed the course of illness of lrtis among dutch elderly primary care patients and assessed whether gps were inclined to prescribe antibiotics more readily to patients at risk for complications. methods: we retrospectively analysed medical data from , episodes of lrti among patients? years of age presenting in primary care to describe the course of illness. the relation between prescriptions of antibiotics and patients with risk factors for a complicated course was assessed by means of multivariate logistic regression. results: in episodes of acute bronchitis antibiotics were more readily prescribed to patients aged years or older. in exacerbations of copd or asthma gps favoured antibiotics in male patients and when diabetes, neurological disease or dementia was present. conclusion: gp's do not take all high risk conditions into account when prescribing antibiotics to patients with lrti despite recommendations of national guidelines. abstract background: the putative association between antidepressant treatment and increased suicidal behaviour has been under debate. objectives: to estimate the risk of suicide, attempted suicide, and overall mortality during antidepressant treatments. design and methods: study cohort consisted all subjects without non-affective psychosis, hospitalized due to a suicide attempt during the years - , followed up by using nationwide registers. main outcome were completed suicides, attempted suicides, and mortality. main explanatory variable was antidepressant usage. results: suicides, suicide attempts and deaths were observed. when the effect of background variables was taken into account, the risk of suicide attempts was increased markedly during antidepressant treatment (rr for selective serotonin reuptake inhibitors or ssri . , . - . ) compared with no antidepressants. however, the risk of completed suicides was not increased. a lower mortality was observed during ssri use (rr . , . - . ), which was mainly attributable to decrease in cardiovascular deaths. conclusion and discussion: in this suicidal high risk cohort the use of any antidepressant is associated with an increased risk of suicide attempts, but not with the increased risk of completed suicide. antidepressants and, especially, ssri use is associated with a substantial decrease in cardiovascular deaths and overall mortality. abstract background: the quattro study is a rct on the effectiveness of intensified preventive care in primary health care centres in deprived neighbourhoods. additional qualitative research on the execution of interventions in primary care was considered necessary for the explanation of differences in effectiveness. objectives: our question was: can we understand rct outcomes better with qualitative research? design and methods: an ethnographic design was used. in their daily work we observed researchers for months days a week, and practice nurses for days each. two other practice nurses were interviewed. all transcribed observations were analysed thematically. results: from the rct showed differences in effectiveness among the centres and that intensified preventive care provided no additional effect compared to structural physical measurements. ethnographic results show that these differences are due to variations in execution of the intervention among the centres. conclusion: in conclusion ethnographic analysis showed that differences in execution of intervention lead to differences in rct outcomes. the rct conclusion 'no additional effect' is problematic. discussion as variations in primary care influence a rcts' execution they create methodological problems for research. to what extent can additional qualitative research improve rct research. abstract background: acute myocardial infarction is the most important cause of morbidity from ischemic heart disease (ihd) and is the leading cause of death in the western world. objectives: to assess the benefits and harms of 'dan shen' compound for acute myocardial infarction. methods: we searched the cochrane controlled trials register on the cochrane library, medline, embase, chinese biomedical database and the chinese cochrane centre controlled trials register. we included randomized controlled studies lasting at least days. main results: eleven studies with participants in total were included. seven studies compared the mortality in routine treatment plus 'dan shen' compound and single routine treatment. one trial compared the arrhythmia in routine treatment plus 'dan shen' compound injection and single routine treatment. two trials compared the revascularization in routine treatment plus 'dan shen' compound injection and single routine treatment. conclusions: evidence is insufficient to recommend the routine use of 'dan shen' compound because of the small number of included studies and their low quality. no well designed randomized controlled trials with adequate power to provide a more definitive answer have been conducted. in addition, the safety of 'dan shen' compound is unproven, though adverse events were rarely reported. abstract antimicrobial resistance is emerging. to identify the scope of this threat and to be able to take proper actions and evaluate these, monitoring is essential. the remit of earss is to maintain a comprehensive surveillance system that provides comparable and validated data on the prevalence and spread of major invasive bacteria with clinically and epidemiologically relevant antimicrobial resistance in europe. since , earss collects routine antimicrobial susceptibility test (ast) results of invasive isolates of five indicator bacteria, tested according to standard protocols. in , ast results for , isolates were provided by laboratories, serving hospitals, covering million inhabitants in countries. through a biannual questionnaire denominator information was collected. the quality of ast results of laboratories was evaluated by the yearly external quality assessment. currently, earss includes all member and candidate states ( ) of the european union, plus israel, bosnia, bulgaria and turkey. participating hospitals treat a wide range of patients and laboratory results are of sufficient validity. earss identified antimicrobial resistance time trends and found a steady increase for most pathogen-compound combinations. in conclusion, earss is a comprehensive system with sufficient quality to show that antimicrobial resistance is increasing in europe and threatens health-care outcomes. abstract introduction: since chloroform has been detected in drinking waters, the number of studies has increased to identify the presence of trihalomethanes (thms) in drinking waters, as well as to establish the possible effects they may have population health. objectives: to determine thms levels in the water distributing network in the city of valencia. design and methods: over a one-year period, points of the drinking water distributing netowrk have undergone sampling at week intervals. the concentration of these pollutants was determined by gas chromatography. results: our results showed greater concentrations of the species substituted by chlorine and bromine atoms (dichlorobromomethane and dibromochloromethane) in the range of - z lg/l for both, - lg/l for trichloromethane and between - lg/l for tribromomethane. an increase in thms concentration was observed in those points near the sea, although they did not exceed the legal limit of lg/l. conclusion: we established two areas of concentration of these species in water: high and average, according to their proximity to the sea. abstract background: childhood cancer survivors are known to be at increased risk for second malignancies. objectives: we studied longterm risk of second malignancy in -year survivors, according to therapy and follow-up interval. methods: the risk of second malignancies was assessed in -year survivors of childhood cancer treated in the emma children's hospital amc in amsterdam and compared with incidence in the general population of the netherlands. complete follow-up till at least january was obtained for . % of the patients. the median follow-up time was . . results: sixty second malignancies were observed against . expected, yielding a standardized incidence ratio (sir) of ). the absolute excess risk (aer) was . per , persons per year. the sir appeared to stabilize after years of follow-up, but the absolute excess risk increased with longer follow-up (aer follow-up > = years of . ). patients who were treated with radiotherapy experienced the greatest increase of risk. conclusions: in view of the quickly increasing background rate of cancer with ageing of the cohort, it is concerning that even after more than years of follow-up the sir is still increased, as is the absolute excess risk. the chek * delc germline variant has been shown to increase susceptibility for breast cancer and could have an impact on breast cancer survival. this study aimed to determine the proportion of chek * delc germline mutation carriers, and breast cancer survival and tumor characteristics, compared to non-carriers in an unselected (for family history) breast cancer cohort. women with invasive mammary carcinoma, aged < years and diagnosed in several dutch hospitals between and , were included. for all patients, paraffin embedded tissue blocks were collected for dna isolation (normal tissue), and subsequent mutation analyses, and tumor revision. in breast cancer patients, ( . %) chek * delc carriers were detected. chek * delc tumors characteristics, treatment and patient stage did not differ from those of non-carriers. chek * delc carriers had times increased risk of developing a second breast cancer compared to non-carriers. with a mean follow up of years, chek * delc carriers had worse recurrence free and breast cancer specific survival than non-carriers. in conclusion, this study indicates a worse breast cancer outcome in chek * -delc carriers compared to non-carriers. the extension of the presence of the chek * delc germline mutation warrants research into therapy interaction and possibly into screening of premenopausal breast cancer patients. abstract background: for primary or secondary prevention (e.g. myocardial infarction) hormone therapy (ht) is no longer recommended in postmenopausal women. however, physicians commonly prescribe ht to climacteric women as a treatment of hot flashes/night sweats. objective: to assess efficacy and adverse reactions of ht in climacteric women with hot flashes (including night sweats). methods: for our systematic review (sr), we searched databases (medline, embase, cochrane) for randomized controlled trials, other srs and meta-analyses, published to . the quality of the studies was assessed using checklists corresponding to the study type. results: we identified studies of good/excellent quality. they included predominantly caucasian women and lasted - months. in all studies, ht showed a reduction of - % in the number of hot flashes, which was significantly better than placebo. most common adverse events of ht were uterine bleeding and breast pain/tenderness. cardiovascular diseases and neoplasms were reported only sporadically. conclusions: ht is highly effective in treating hot flashes in climacteric women. however, to assess serious adverse events longer studies (including also non-caucasian women) are needed, as there are only sparse data available. abstract igf-i is an important growth factor, and has been associated with increased colorectal cancer risk in both prospective epidemiological and experimental studies. however, it is largely unknown which lifestyle factors are related to circulating levels of the igf-system. studies investigating the effect of isoflavones on the igf-system have thus far been conflicting. the purpose of this study was to evaluate the effects of isoflavones on the circulating igf-system in men with high colorectal cancer risk. we conducted a randomized, placebo-controlled, cross-over study on the effect of a -month isoflavone supplementation ( mg/day) on igf levels in men with a family history of colorectal cancer or a personal history of colorectal adenomas. dropout rate was %, and all but men were more than % compliant. isoflavones supplementation did not significantly alter serum total igf-i () . %; %ci: ) . - . ) and igf binding protein (+ . %, %ci: ) . - . ) concentrations. other covariables, e.g. dietary energy and macronutrient intake, physical activity, and body weight, are currently under evaluation. in conclusion, this study shows that a -month isoflavone supplementation has no effect on serum igf-system components in men with high colorectal cancer risk. abstract background/objective: eurociss-european cardiovascular indicators surveillance set project, funded under the health monitoring programme of european commission, aims developing health indicators and recommendations for monitoring cardiovascular diseases (cvd). methods: prioritise cvd according to their importance in public health; identify morbidity and mortality indicators; develop data collection and harmonizing recommendations; describe data collection, validation procedures and discuss their comparability. population (geographical area, age, gender), methods (case definition, icd codes), procedures (record linkage, validation), morbidity indicators (attack rate, incidence, case fatality) collected by questionnaire. results: the main outcome was the inventory of acute myocardial infarction (ami) populationbased registers in the european partner countries: countries have no register, regional, of which also national. registers differ for: icd codes (only ami or also acute and subacute ischemic forms), ages ( - , - , all) , record linkage (probabilistic, personal identification number), calendar years, validation (monica, esc/acc diagnostic criteria). differences make morbidity indicators difficult to compare. conclusion: new diagnostic criteria led to a more exhaustive definition of myocardial necrosis as acute coronary syndrome (acs). given the high burden of ami/acs, efforts are needed to implement population-based registers in all countries. application of recommended indicators, validated through standardized methodology, will provide reliable, valid and comparable data. abstract objective: the objective of this paper was to compare and discuss the use of odd ratios and prevalence ratios using real data with complex sampling design. method: we carried out a cross-sectional study using data obtained from a two-stage stratified cluster sample from a study conducted in - (n = , ) . odds ratios and prevalence ratios were obtained by unconditional logistic regression and poisson regression, respectively, for later comparison using the stata statistical package (v. . ). confidence intervals and design effects were considered in the evaluation of the precision of estimates. two outcomes of a cross-sectional study with different prevalence were evaluates: vaccination against influenza ( . %) and self-referred lung disease ( . %). results: in the high-prevalence scenario, using prevalence ratios the estimates were more conservative and we found narrower confidence intervals. in the low-prevalence scenario, we found no important differences between the estimates and standard errors obtained using the two techniques. discussion: however, it is the researcher's task to choose which technique and measure to use for each set of data, since this choice must remain within the scope of epidemiology. abstract background: in italy coronary heart disease chd mortality has been falling since the s. objective: to examine how much of the fall between and could be attributed to trends in risk factors, medical and surgical treatments. methods: a validated model was used to combine and analyse data on uptake and effectiveness of cardiological treatments and risk factor trends. published trials, meta-analyses, official statistics, longitudinal studies, surveys are main data sources. results: chd mortality fell by % in men and % in women aged - ; , fewer deaths in . approximately half mortality fall was attributed to treatments in patients and half to population changes in risk factors: in men, mainly improvements in cholesterol ( %) and smoking ( %) rather than blood pressure ( %). in women / mortality fall attributable to improvements in cholesterol ( %) and blood pressure ( %); adverse trends in smoking () %). adverse trends also in bmi () % in both genders) and diabetes () % in men; ) . % in women). conclusion: half chd mortality fall was attributable to risk factors reductions, principally cholesterol in men and women and smoking in men; in women rising smoking rates generated substantial additional deaths. a comprehensive strategy promoting primary prevention is needed. objective: to investigate the efficacy of ni in the post exposure prophylaxis (pep), i.e. in persons who had contact with an influenza case. design and methods: we conducted a systematic electronic data base review for the period between and . studies were selected and graded by two independent reviewers. the proportion of influenza-positive patients was chosen as primary outcome. for all analyses fixed effect models were used. weighted relative risks (rr) and % confidence intervals (ci) were calculated on an intention-to-treat basis. results: randomized controlled trials (n= , ) were included in the analysis. zanamivir and oseltamivir were effective against an infection with influenza (rr= . , % ci . - . and rr= . , % ci . - . , respectively). prophylactic efficacy was comparable in the subgroup of persons who had contact with an index case with lab-confirmed influenza ( studies, all ni, rr= . , % ci . - . ). conclusions: the available evidence suggests that ni are effective in the pep of influenza. discussion: results have to be interpreted with caution when transferred into general medical practice because study populations mainly included young and healthy adults without chronic diseases. abstract an important risk factor of breast cancer, mammographic breast density (mbd) is inversely associated with reproductive factors (age at first childbirth, and lactating). as pregnancy and lactating are highly correlated, whether this decline is induced by pregnancy or lactating is still unclear. we hypothesize that lactation reduces mbd independent of age at first pregnancy and parity. a study was done on women in the third sub-cohort of the dom project who had complete data regarding lactating, dy, had a child but varied by duration of lactating. multiple logistic regression analysis was done using dy (yes/ no) as outcome variable. explanatory variables added into the model were age, bmi, parity and age at first childbirth. a significant univariate relation was seen between lactating of the first child and dy. or . (ci % . ; . ). adjusted for explanatory variables, the or changed to . (ci % . ; . ). lactating seems to contribute independently to the reduction of mbd over and above pregnancy itself. given the limitations of the dichotomous dy ratio scores, additional studies will address which part; either glandular mass or fat tissue is responsible for the observed relation which will be measured from mammograms to be digitized. abstract background: alcohol consumption is common, but little is known about whether drinking patterns vary across geographic regions. objectives: to examine potential disparities in alcohol consumption across census regions and urban, suburban, and rural areas of the united states. design and methods: the data source was the national epidemiologic survey on alcohol and related conditions, an in-person interview of approximately , adults. the prevalence of abstinence and, among drinkers, the prevalences of heavy and daily drinking were calculated by census region and metropolitan status. multivariate logistic regression analyses were conducted to test for differences in abstinence and per drinker consumption after controlling for confounders. results: the odds of abstinence, heavy, and daily drinking varied widely across geographic areas. additional analyses stratified by census region revealed that rural residents in the south and northeast as well as urban residents in the northeast had higher odds of abstinence. rural residents in the midwest had higher odds of heavy drinking. conclusion and discussion: heavy alcohol consumption is of particular concern among drinkers living in the rural areas of the united states, particularly the rural midwest. other nations should consider testing for similar differences as they implement policies to promote safe alcohol consumption. abstract background: long-term exposure to particulate air pollution (pm) has been suggested to accelerate atherogenesis. objective: we examined the relationship between long-term exposure to traffic emissions and the degree of coronary artery calcification (cac), a measure of atherosclerosis. methods: in a population based, crosssectional study, distances between participants' home addresses and major roads were calculated with a geographic information system. annual mean pm . -exposure at the residence was derived from a small scale geostatistical model. cac, assessed by electronbeam computer tomography, was modelled with linear regression by proximity to major roads, controlling for background pm . air pollution and individual level risk factors. results: of participants lived within m of a major road. background-pm . ranged from . to . lg/m (mean . ). mean cacvalues were strongly dependent on age, sex and smoking status. reducing the distance to major roads by % leads to increases in cac by . % ( %ci . - . %) in the unadjusted model and , % ( %ci ) . - . ) in the adjusted model. stronger effects (adjusted model) were seen in men ( , %, %ci ) . - . ) and male non-smokers ( , %, %ci ) . - . ). conclusions: this study provides epidemiologic evidence that long-term exposure to traffic emissions is an important risk factor for coronary calcification. abstract background: this polymorphism has been associated risk factor levels and in one study with a reduced risk of acute myocardial infarction (ami). yet, the risk relation has not been confirmed. objectives: we investigated the role of this polymorphism on occurrence of ami, coronary heart disease (chd) and stroke in healthy dutch women. design and methods: a case-cohort study in a prospective cohort of initially healthy dutch from until january st . results: we applied a cox proportional hazards model with an estimation procedure adapted for case-cohort designs. a lower ami (n= ) risk was found among carriers of the ala allele (n= ) compared with those with the more common pro pro genotype (hazard ratio= . ; % ci, . to . ). no relation was found for chd (n= ;hr . ; % ci, . - . ) and for stroke (n= ;hr . ; % ci, . - . ). in our data little evidence was found for a relation between pparg and risk factors. conclusion and discussion: this study shows the pro ala polymorphism in pparg gene is modestly related to a reduced risk of ami in our study. no statistically significant relation was found for chd and stroke. abstract background: pseudo cluster randomization was used in a services evaluation trial because individual randomization risked contamination and cluster randomization risked selection bias due to expected treatment arm preferences of recruiting general practitioners (gps). gps were randomized in two groups. depending on this randomization, participants were randomized in majority to one study arm: intervention:control/ : or intervention:control/ : . objectives: to evaluate internal validity of pseudo cluster randomization. have gps treatment arm preferences? what is the effect on allocation concealment and selection bias? design and methods: we compared the baseline characteristics of participants to study selection bias. using a questionnaire, gps indicated their treatment arm preferences on a visual analogue scale (vas) and the allocation proportions they believed were used to allocate their patients over treatment arms. results: gps preferred allocation to the intervention (vas . (sd . ); - : indicates strongly favoring the intervention arm). after recruitment % of gps estimated a randomization ratio of : was used. the participants showed no relevant differences at baseline. conclusion and discussion: gps profoundly preferred allocation to the intervention group. few indications of allocation disclosure or selection bias were found in the dutch easycare trial. pseudo cluster randomization proofs to be a valid randomization method. abstract background: epidemiological studies rely on self-reporting to acquire data on participants, although such data are often limited in reliability. the aim here is to assess nuclear magnetic resonance (nmr) based metabonomics for evaluation of self-reported data on paracetamol use. method: four in-depth -hour dietary recalls and two timed -hour urine collections were obtained for each participant in the intermap study. a mhz h nmr spectrum was acquired for each urine specimen (n = , ). training and test sets involved two strata, i.e., paracetamol metabolites yes or no in the urine spectra, selected from all population samples by a principal component analysis model. the partial least squares-discriminant analysis (pls-da) model based on a training set of samples was validated by test set (n = ). the model correctly predicted stratum for of samples ( %) after removal of outliers not fitting the model, sensitivity . %, specificity %. this model was used to predict paracetamol status in all intermap specimens. it identified participants ( . %) who underreported analgesic use, of whom underreported analgesic use in both clinical visits. conclusion: nmr-based metabonomics can be used as a tool to enhance reliability of self-reported data. abstract background: in patients with asthma, the decline in forced expiratory volume in one second (fev ) is accelerated compared with non-asthmatics. objective: to investigate long-term prognostic factors of fev change in asthmatics from the general population. methods: a cohort of asthmatics ( - years-old) was identified in the frame of the european community respiratory health survey ( / ), and followed up in / . spirometry was performed on both occasions. the annual fev decrease (?fev ) was analysed by multi-level regression models, according to age, sex, height, bmi, occupation, familiarity of asthma, hospitalization for asthma (baseline factors); cumulative time of inhaled corticosteroid (ics) use and annual weight gain during the follow-up; lifetime pack-years smoked. results: when adjusting for all covariates, ics use for > years significantly reduced ?fev , with respect to non-users, of . ( %ci: . - . ) ml/year. ?fev was . ( . - . ) ml/year lower in women than in men. it increased by . ( . - . ) ml/year for every additional year in patient age and by . ( . - . ) ml/year for every additional kg/year in the rate of weight gain. conclusion: long-term ics use (> years) seems to be associated with a reduced ?fev over a -year followup. body weight gain seems a crucial factor in determining lung function decrease in asthmatics. abstract background: effectiveness of screening can be predicted by episode sensitivity, which is estimated by interval cancers following a screen. full-field digital or cr plate mammography are increasingly introduced into mammography screening. objectives: to develop a design to compare performance and validity between screen-film and digital mammography in a breast cancer screening program. methods: interval cancer incidence was estimated by linking screening visits from - at an individual level to the files of the cancer registry in finland. these data were used to estimate the study size requirements for analyzing differences in episode sensitivity between screen-film and digital mammography in a randomized setting. results: the two-year cumulative incidence of interval cancers per screening visits was estimated to be . to allow the maximum acceptable difference in the episode sensitivity between screen-film and digital arm to be % ( % power, . significance level, : randomization ratio, % attendance rate), approximately women need to be invited. conclusion: only fairly large differences in the episode sensitivity can be explored within a single randomized study. in order to reduce the degree of non-inferiority between the screen-film and digital mammography, meta-analyses or pooled analyses with other randomized data are needed. according to the literature up to % of colorectal cancers worldwide is preventable by dietary change. however the results of the epidemiologic studies are not consistent across the countries. the objective of the study is to evaluate the role of dietary nutrients on colorectal cancer risk in poland. the hospital-based case-control study was carried out in - . in total, histologically confirmed cancer cases and controls were recruited. adjustment for age, sex, education, marital status, multivitamin use, alcohol consumption, cigarette smoking, family history and energy consumption was done by logistic regression model. low tertile of daily intake in the control group was defined as a reference level. the lower colorectal cancer risk was found in cases with high daily intake of dietary fiber (or = , ; %ci: , - , ) and vitamin e (or = , ; %ci: , - , ). on the other hand, an increased risk for high monosaccharides consumption was observed. the risk pattern wasn't changed after additional adjustment for physical activity and body mass index. the results of the present study support the protective role of dietary fiber and some antyoxidative vitamins in the etiology of colorectal cancer. additionally they suggest that high consumption of monosaccharides may lead to elevated risk of investigated cancers. abstract assessment of nutrition is very difficult in every population, but in children there's additional question if child can properly recognize and recall foods that have been eaten. the aim of this study was to assess if dietary recall administered to adolescents can be used in epidemiological studies on nutrition. subjects were children, - years old, and they caretakers. -h recall was used to evaluate children's nutrition. both, child and caretaker were asked to recall all products, drinks and dishes eaten by child during the day before recall. the statistical analyses were done separately for each meal. we have noticed statistically significant differenced for intake of energy and almost all nutrients from the lunch. the observed spearman rank correlation coefficients between child and his caretaker ranged from . for vitamin c up to . for intake of carbohydrates. only calcium intake ( . vs. . mg/day) differentiated groups for the breakfast and b-carotene for the supper. the study showed that the recall with adolescents could be helpful source of data for the research in the population aspect. however, one shouldn't use such data for the examination of the individual nutritional habit of children, especially information about dinner can be biased. abstract background: acute bronchitis is one of the most common diagnoses made by primary care physicians. in addition to antibiotics, chinese medicinal herbs may be a potential medicine of choice. objectives: this review aims to summarize the existing evidence of comparative effectiveness and safety of chinese medicinal herbs for treating uncomplicated acute bronchitis. methods: we searched the cochrane central register of controlled trials, medline, embase, chinese biomedical database and etc. we included randomised controlled trials comparing chinese medicinal herbs with placebo, antibiotics or other western medicine for treating uncomplicated acute bronchitis. at least two authors extracted data and assessed trial quality. main results: four trials reported the time to improvement of cough, fever, and rales; two trials reported the proportion of patients with improved signs and symptoms; thirteen trials analyzed the data of global assessments of improvement. one trial reported the adverse effect during treatment. conclusions: there is insufficient quality data to recommend the routine use of chinese herbs for acute bronchitis. the benefit found in individual studies and this systematic review could be due to publication bias and study design limitations. in addition, the safety of chinese herbs is unknown, though adverse events are rarely reported. design and methods: patients with a definite ms and classified as dead or alive at st january were included in this retrospective observational study. influence of demographic and clinical variables was assessed with kaplan meier and cox methods. standardised mortality ratios were computed to compare patients' mortality with the french general population. results: a total of patients were included ( men, women). the mean age at ms onset was +/) years and the mean follow-up duration was +/) years ( patients-years). by , deaths occurred ( per patients-years). male gender, progressive course, polysymptomatic onset and high relapse rate were related to a worse prognosis. ms did not increase the number of deaths in our cohort compared to the general french population ( expected), except for highly disabled patients ( observed, expected). conclusion: this study gave precise insights on mortality in multiple sclerosis in west france. mattress dust. methods: we performed nested case-control studies within ongoing birth cohort studies in germany, the netherlands, and sweden and selected approximately sensitised and non-sensitised children per country. we measured levels of bacterial endotoxin, ß( -> )-glucans, and fungal extracellular polysaccharides (eps) in dust samples collected on the children's mattresses. results: combined across countries, higher amounts of dust and higher endotoxin, ß( -> )-glucans, and eps loads of mattress dust were associated with a significantly decreased risk of sensitization to inhalant allergens, but not food allergens. after mutual adjustment, only the protective effect of the amount of mattress dust remained significant [odds ratio ( % confidence interval) . ( . - . )]. conclusion: higher amounts of mattress dust might decrease the risk of allergic sensitization to inhalant allergens. the effect might be partly attributable to endotoxin, ß( -> )-glucans, and eps. it is not possible to distinguish with certainty, which component relates to the effect, since microbial agents loads are highly correlated with amount of dust and with each other. abstract background: postmenopausal hormone therapy (ht) increases mammographic density, a strong breast cancer risk factor, but effects vary across women. objective: to investigate whether the effect of ht use on changes in mammographic density is modified by polymorphisms in the estrogen (esr ) and progesterone receptor (pgr) genes. design and methods: information on ht use, dna and two consecutive mammograms were obtained from ht users and never ht users of the dutch prospect-epic and the english epic-norfolk cohorts. mammographic density was assessed using a computer-assisted method. changes in density between mammograms before and during ht use were analyzed using linear regression. results: a difference in percent density change between ht users and never users was seen in women with the esr pvuii pp or pp genotype ( . %; p< . ), but not in those with the pp genotype ( . %; p = . ). similar effects were observed for the esr xbai and the pgr + g/a polymorphisms. the pgr progins polymorphism did not appear to make women more susceptible to the effects of ht use. discussion and conclusion: our results suggest that specific polymorphisms in the esr and pgr genes may make women more susceptible to the effects of ht use on mammographic density. abstract background: there is a paucity of data on the cancer risk of turkish migrant children in germany. objectives: to identify cancer cases of turkish origin in the german childhood cancer registry (gccr) and to compare the relative incidence of individual cancers among turkish and non-turkish children. design and methods: we used a name algorithm to identify children of turkish origin among the , cancer cases below years of age registered since . we calculated proportional cancer incidence ratios (pcir) stratified for sex and time period. results: the name algorithm performed well (high sensitivity and specificity), and turkish childhood cancers were identified. overall, the relative frequency of tumours among turkish and non-turkish children is similar. there are specific sites and cancers for which pcirs are different; these will be reported during the conference. conclusion: our study is the first to show differences in the relative frequency of cancers among turkish and non-turkish children in germany. discussion: case control studies could help to explain whether observed differences in the relative frequency of cancers are due to differences in genetic disposition, lifestyle or socio-economic status. mutations in the netherlands cohort study on diet and cancer. data from , participants, cases and , subcohort members were analysed from a follow-up period between . to . years after baseline. adjusted gender-specific incidence rate ratios (rr) and % confidence intervals (ci) were calculated over tertiles of folate intake in case-cohort analyses. high folate intake did not reduce overall colon cancer risk. however, in men only, it was inversely associated with apc[csymbol] colon tumours (rr . , % ci . - . for the highest versus the lowest tertile of folate intake), but positively associated with apc+ colon tumours (highest vs. lowest tertile: rr . , ci . - . ). folate intake was neither associated with overall rectum cancer risk, nor with rectum cancer when apc mutation status was accounted for. we observed opposite associations between folate intake and colon cancer risk with or without apc mutations in men, which may implicate a distinct mutated apc pathway mediated by folate intake in men. abstract background and objectives: ten years after completion of the first serum bank of the general population to evaluate the long-term effects of the national immunisation programme (nip) a new serum collection is desirable. the objective is to provide insight into age-specific estimates of the immunity to childhood diseases and estimates of the incidence of infectious diseases with a frequent sub clinical course. design and methods: a two-stage cluster sampling technique was used to draw a nationwide sample. in each of five geographic regions, eight municipalities were randomly selected proportionally to their size. within each municipality, an age-stratified sample of individuals ( - yr) will be drawn from the population register. in addition eight municipalities will be selected with lower immunization coverage to obtain insight into the immune status of persons who often refuse vaccination on religious grounds. furthermore over sampling of migrants will be performed to study whether their immune status is satisfactory. participants will be asked to fill in a questionnaire and to allow blood to be taken. extra blood will be taken for a genetic study. results and conclusion: the design of a population-based serum collection aimed at the establishment of a representative serum bank will be presented. abstract background: during the last decade, the standard of diabetes care evolved to require more intensive management focussing on multiple cardiovascular risk factors. treatment decisions for lipidlowering drugs should be based on cholesterol and blood pressure levels. objectives: to investigate the influence of hba c, blood pressure and cholesterol levels on subsequent intensification of lipid-lowering therapy between - . design and methods: we conducted a prospective cohort study including , type diabetes patients who had at least two consecutive annual visits to a diabetes nurse. treatment intensification was measured by comparing drug regimes per year, and defined as initiation of a new drug class or dose increase of an existing drug. results: between - , the prevalence of lipid-lowering drug use increased from % to %. rates of intensification of lipid-lowering therapy remained low in poorly controlled patients ( % to %;tc/hdl ratio> ). intensification of lipid-lowering therapy was only associated with tc/hdl ratio (age-adjusted or = . ; %ci . - . ) and this association became slightly stronger over time. blood pressure was not found to be a predictor of the intensification of lipid-lowering therapy (or = . ). conclusion: hypercholesterolemia management intensified between - , but therapy intensification was only triggered by elevated cholesterol levels. more attention for multifactorial risk assessment is needed. abstract background: there are no standard severity measures that can classify the range of illness and disease seen in general practice. objectives: to validate new scales of morbidity severity against age, gender, deprivation and poor physical function. design and methods: in a cross-sectional design, morbidity data for consulters in a -month period was linked to their physical function status . there were english older consulters ( years +) and dutch consulters ( years +). consulters for morbidities classified on four gp-defined ordinal scales of severity ('chronicity', 'time course', 'health care use' and 'patient impact on activities of daily living') were compared to consulters for morbidity other than the , by age-groups, gender, and dichotomised deprivation and physical function scores. results: for both countries, on all scales, there was an increasing association between morbidity severity and older ages, female gender, more deprivation (minimum p< . ) and poor physical function (all trends p< . ). the estimates for categories, for example, within the 'chronicity' scale was ordered as follows: 'acute' (unadjusted odds ratio . ), 'acute-on-chronic' ( . ), 'chronic' ( . ) and 'life-threatening' ( . ). conclusions: new validated measures of morbidity severity indicate physical health status and offer the potential to optimise general practice care. hospitalization or death. calibration and discriminative capacity were estimated. results: among episodes of lrti in elderly patients with dm, endpoints occurred (attack rate %). reliability of the model was good (goodness-of-fit test p = . ). the discriminative properties of the original rule was acceptable (area under the receiver-operating curve (auc): . , % ci: . to . ). conclusion: the prediction rule for the probability of hospitalization or death derived from an unselected elderly population with lrti appeared to have acceptable discriminative properties in diabetes patients and can be used to target management of these common diseases. confounding by indication is a major threat to the validity of nonrandomized studies on treatment effects. we quantified such confounding in a cohort study on the effect of statin therapy on acute respiratory disease (ard) during influenza epidemics in the umc utrecht general practitioner research database among persons aged > = years. the primary endpoint was a composite of pneumonia or prednisolone-treated ard during epidemic, non-epidemic and summer seasons. to quantify confounding, we obtained unadjusted and adjusted estimates of associations for outcome and control events. in all, , persons provided , persons-periods, statin therapy was used in . % and in , person-periods an outcome event occurred. without adjustments, statin therapy was not associated with the primary endpoint during influenza epidemics (relative risk [rr] . ; % confidence interval [ %ci]: . - . ). after applying multivariable generalized estimating equations (gee) and propensity score analysis the rrs were . ( % ci: . - . ) and . ( % ci: . - . ). the findings were consistent across relevant strata. in non-epidemic influenza and summer seasons the rr approached . while statin therapy was not associated with control event rates. observed confounding in the association between statin therapy and acute respiratory outcomes during influenza epidemics masked a potential benefit of more than %. abstract background: despite several advances in the treatment of schizophrenia, the currently available pharmacotherapy does not change the course of illness or prevent functional deterioration in a substantial number of patients. therefore, research efforts into alternative or adjuvant treatment options are needed. in this project, called the 'aspirine trial', we investigate the effect of the antiinflammatory drug acetylsalicylic acid as an add-on to regular antipsychotic therapy on the symptoms of schizophrenia. objectives: to objective is to study the efficacy of acetylsalicylic acid in schizophrenia on positive and negative psychotic symptoms, immune parameters and cognitive functions. design and methods: a randomized placebo controlled double-blind add-on trial of inpatients and outpatients with schizophrenia, schizophreniform or schizoaffective disorder is performed. patients are : randomized to either months mg acetylsalicylic acid per day or months placebo, in addition to their regular antipsychotic treatment. all patients receive pantoprazole treatment for gastroprotection. participants are recruited from various major psychiatric hospitals in the netherlands. the outcomes of this study are -month change in psychotic and negative symptom severity, cognitive function, and several immunological parameters. status around participants have been randomized. no interim analysis was planned. abstract background: congenital cmv infection is the most prevalent congenital infection worldwide. epidemiology and outcome are known to vary with socio-economic background, but few data are available on epidemiology and outcome in a developing country, where the overall burden of infectious diseases is high. objective: to determine prevalence, riskfactors and outcome of congenital cmv infection in an environment with high infectious disease burden methods: as part of an ongoing birth cohort study, baby and maternal samples were collected at birth, and tested with an inhouse pcr for the presence of cmv. standardised clinical assessment were performed by a paediatrician. placental malaria was also assessed. follow-up is ongoing till the age of years. preliminary results: the prevalence of congenital cmv infection was / ( . %). the infected children were more often first born babies ( . % vs . %, p< . ). while no seasonality was observed, placental malaria was more prevalent among congenitally infected children ( . % vs . %,p = . ). there were no symptomatic babies detected. conclusion: this prevalence of congenital cmv is much higher than reported in industrialised countries, in the absence of obvious clinical pathology. further follow up is needed to assess impact on response to vaccinations, growth, and morbidities. of wheeze or cough at night in the first years. data on respiratory symptoms and dda were collected by yearly questionnaires. in total, symptomatic children with and without an early dda were included in the study population. results: fifty-one percent of the children with and % of the children without an early dda had persistent respiratory symptoms at age . persistence of symptoms was associated with parental atopy, eczema, nose symptoms without a cold, or a combination of wheeze and cough in the first years. conclusions: monitoring the course of symptoms in children with risk factors for persistent symptoms, irrespective of a diagnosis of asthma, may contribute to early recognition and treatment of asthma. little is known about the response mechanisms of survivors of disasters. objective: to examine selective non-response and to investigate whether attrition has biased the prevalence estimates among survivors of a disaster. design and methods: a longitudinal study was performed after the explosion of a fireworks depot in enschede, the netherlands. survivors completed a questionnaire weeks (t ), months (t ) and years post-disaster (t ). prevalence estimates resulting from multiple imputation were compared with estimates resulting from complete case analysis. results: non-response differed between native dutch and nonwestern immigrant survivors. for example, native dutch survivors who participate at t only were more likely to have health problems at t such as depression than native dutch who participated at all three waves (or = . , % ci: . - . ) . in contrast, immigrants who participated at t only were less likely to have depression at t (or = . , % ci: . - . ). conclusion and discussion: among native dutch survivors, the imputed estimates of t health problems tended to underestimated than the complete case estimates. the imputed t estimates among immigrants were unaffected or somewhat overestimated than the complete case estimates. multiple imputation is a useful statistical technique to examine whether selective non-response has biased the prevalence estimates. session: posters session : july presentation: poster. background: several epidemiologic studies have shown decreased colon cancer risk in physically active individuals. objectives: this review provides an update of the epidemiologic evidence for the association between physical activity and colon cancer risk. we also explored whether study quality explains discrepancies in results between different studies. methods: we included cohort (male n = ; female n = ) and case-control studies (male n = ; female n = ) that assessed total or leisure time activities in relation to colon cancer risk. we developed a specific methodological quality scoring system for this review. due to the large heterogeneity between studies, we refrained from statistical pooling. results: in males, the cohort and case-control studies lead to different conclusions: the case-control studies provide strong evidence for a decreased colon cancer risk in the physically active while the evidence in the cohort studies is inconclusive. these discrepant findings can be attributed to either misclassification bias in cohort or selection bias in case-control studies. in females, the small number of high quality cohort studies precludes a conclusion and the case-control studies indicate an inverse association. conclusion: this review indicates a possible association of physical activity and reduction of colon cancer risk in both sexes but the evidence is not yet convincing. abstract background/objectives: radiotherapy after lumpectomy is commonly applied to reduce recurrence of breast cancer but may cause acute and late side effects. we determined predictive factors for the development of late toxicity in a prospective study of breast cancer patients. methods: late toxicity was assessed using the rtog/ eortc classification among women receiving radiotherapy following lumpectomy after a mean follow-up time of months. predictors of late toxicity were modelled using cox regression in relation to observation time, adjusting for age, bmi and biologically effective dose in the maximum at the skin. results: ( . %) patients presented with telangiectasia and ( . %) patients with fibrosis. we observed a strong association between development of telangiectasia and fibrosis (p< . ). increasing patient age was a risk factor for telangiectasia and fibrosis (p for trend . and . , respectively). boost therapy (hazard ratio (hr) . , % ci . - . ) and acute skin toxicity (hr . , % ci . - . ) significantly increased risk of telangiectasia. risk of fibrosis was elevated among patients with atopic diseases (hr . , % ci . - . ). discussion: our study revealed several risk factors for late complications of radiotherapy. further understanding of differences in response to irradiation may enable individualized treatment and improve cosmetic outcome. doctor-diagnosed asthma and respiratory symptoms (age ) were available for (rint) and (no) children. results: the discriminative capacities of rint and exhaled no were statistically significant for the prediction of doctor-diagnosed asthma, wheeze (rint only) and shortness of breath (rint only). due to the low prevalence of disease in this general population sample, the positive predictive values of both individual tests were low. however, the positive predictive value of the combination of increased rint (cutoff . kpa.l- .second) and exhaled no (cut-off ppb) was % for the prediction of doctor-diagnosed asthma, with a negative predictive value of %. combinations of rint or exhaled no with atopy of the child showed similar results. conclusions: the combination of rint, exhaled no and atopy may be useful to identify high-risk children, for monitoring the course of their symptoms and to facilitate early detection of asthma. abstract background: in a cargo aircraft crashed into apartment buildings in amsterdam, killing people, and destroying apartments. an extensive, troublesome aftermath followed with rumours on toxic exposures and health consequences. objectives: we studied the long-term physical health effects of occupational exposure to this disaster among professional assistance workers. design and methods: in this historical cohort study we compared the firefighters and police officers who were occupationally exposed to this disaster (i.e. who reported one or more disasterrelated tasks) with their nonexposed colleagues (n = , and n = , respectively), using regression models adjusted for background characteristics. data collection took place from january to march , and included various clinical blood and urine parameters (including blood count and kidney function), and questionnaire data on occupational exposure, physical symptoms, and background characteristics. the overall response rate was %. results: exposed workers reported various physical symptoms (including fatigue, skin and musculoskeletal symptoms) significantly more often than their nonexposed colleagues. in contrast, no consistent significant differences between exposed and nonexposed workers were found regarding clinical blood and urine parameters. discussion and conclusion: this epidemiological study demonstrates that professional assistance workers involved in a disaster are at risk for long-term unexplained physical symptoms. abstract background and objectives: recent studies indicate that women with cosmetic breast implants have significantly increased risk of suicide. reasons for elevated risk are not known. it is suggested that women with cosmetic breast implants differ in their characteristics and have more mental problems than women of general population. aim of this study was to find out possible associations between physical or mental health and postoperative quality of life among finnish women with cosmetic breast implants. design and methods: information was collected from patient records of women and structured questionnaires mailed to women of the same cohort. data was analysed by using pearson chi square testing and logistic regression modelling. results: although effects of implantation on postoperative quality of life in different areas were mainly reported as positive or neutral, % of the women reported decreased state of health. postoperative dissatisfaction and decreased quality of life were significantly associated with diagnoses of depression (p = . ) and local complication called capsular contracture (p< . ). conclusion: our results are consistent with previous results finding most of the cosmetic breast surgery patients satisfied after implantation. however, this study brings new information on associations between depression, capsular contracture and decreased quality of life. abstract cancer and its treatments often produce significant persistent morbidities that reduce quality of life (qol) in cancer survivors. research indicates that both, physical exercise and psycho-education might enhance qol. therefore, we developed a -week multidisciplinary rehabilitation program that combines physical training with psycho-education. the aim of the present multicenter study is to determine the effect of multidisciplinary rehabilitation on qol as compared to no treatment and, additionally, to physical training alone. furthermore, we will explore which variables are related to successful outcome (socio-demographic, disease related, physiological, psychological and environmental characteristics). participants are needed to detect a medium effect. at present, cancer survivors are randomised to either the multidisciplinary or physical rehabilitation program or a -month waiting list control group. outcome assessment will take place before, halfway, directly after, and months following the intervention by means of questionnaires. physical activity will be measured before, halfway and directly after rehabilitation using maximal and submaximal cycle ergometer testing and muscle strength measurement. effectiveness of multidisciplinary rehabilitation will be determined by analysing changes between groups from baseline to post-intervention using multiple linear and logistic regression. positive evaluation of multidisciplinary rehabilitation may lead to implementation in usual care. continuous event recorders (cer) have proven to be successful in diagnosing causes of palpitations but may affect patient qol and increase anxiety. objectives: determine qol and anxiety in patients presenting with palpitations, and to evaluate the burden of the cer on qol and anxiety in patients presenting to the general practitioner. methods: randomized clinical trial in general practice. the short form- (sf- ) and state-trait anxiety inventory (stai) were administered at study inclusion, -weeks and months. results: at baseline, patients with palpitations (n = ) reported lower qol and more anxiety than a healthy population for both males and females. there were no differences between the cer arm and usual gp care at -weeks. at -months the usual care group (n = ) showed minimal qol improvement and less anxiety compared to the cer group (n = ). type of diagnosis did not account for any of these reported differences. conclusion: anxiety decreases and qol increases in both groups at -weeks and -month follow-up. hence it is a safe and effective diagnostic tool, which is applicable for all patients with palpitations in the general practice. abstract background: clinical benefits of statin therapy are accepted, but their safety profiles have been under scrutiny, particularly for the most recently introduced statin, rosuvastatin, relating to serious adverse events involving muscle, kidney and liver. objective: to study the association between statin use and the incidence of hospitalizations for rhabdomyolysis, myopathy, acute renal failure and hepatic impairment (outcome events) in real life. methods: in and , , incident rosuvastatin users, , incident other statin users and , patients without statin prescriptions from the pharmo database of > million dutch residents were included in a retrospective cohort study. potential cases of hospitalization for myopathy, rhabdomyolysis, acute renal failure or hepatic impairment were identified using icd- -cm codes and validated using hospital records. results: there were validated outcome events in the three cohorts including one case each of myopathy (other statin group) and rhabdomyolysis (non-treated group). there were no significant differences in the incidence of outcome events between rosuvastatin and other statin users. discussion: this study indicated that the number of outcome events is less than per person years. rosuvastatin does not lead to an increased incidence of rhabdomyolysis, myopathy, acute renal failure and hepatic impairment compared to other statins. the aim: the aim of the study was to assess the influence of insulin resistance (ir) on the coronary artery disease (cad) occurrence in middle aged women with normal glucose tolerance (ngt) material and methods: in - year women aged - , participants of the polish multicenter study on diabetes epidemiology were examined. anthropometric, biochemical (fasting lipids, fasting and after glucose load plasma glucose and insulin) and blood pressure determinations were performed . ir was defined as the matsuda index (irmatsuda) below the lower quartile of the irmatsuda distribution in ngt population the questionnaire examination of the lifestyle, present and past diseases was performed. results: ir was observed in % of all examined women and in . % with ngt. cad was diagnosed in , % of all examined women and in , % of those with ngt. the relative risk of cad related to ir in ngt and normotensive women was , ( % ci: , - , ) (p< . ). regular menstruation was observed in , % of cad women. irmatsuda was not different for cad menstruating and non menstruating women (respectively , ± , and , ± , ). conclusion: in middle aged, normotensive and normal glucose tolerant women ir seems to be an important risk factor of cad abstract background: in germany, primary prevention at population level is provided by general practitioners (gp). little is known about gps' strategies to identify patients at high risk for vascular diseases using standardised risk scores. objectives: we studied gp attitudes and current practice in using risk scores. methods-a cross-sectional survey was conducted among gps in north rhine-westphalia, germany, using mailed self-administered questionnaires on attitudes and current practice in identification of patients at high risk for vascular diseases. results: in , gps participated in the study. . % of gps stated to know the framingham-score, . % the procam-score and . % the score-score. . % of gps reported regular use of standardised risk scores to identify patients at high risk for vascular diseases, most frequently procam-score ( . %), followed by score-score ( . %) and framingham-score ( . %). main reasons for not using standardised risk scores were assumed rigid assessment of individual patients' risk profile ( . %), time-consuming appliance ( . %) and higher confidence in own work experience ( . %). conclusion: use of standardised risk scores to identify patients at high risk for vascular diseases is common among gps in germany. however, more educational work might be useful to strengthen gps' belief in the flexible appliance of standardised risk scores in medical practice. among epilepsy patients than in general population, but effects of specific antiepileptic drugs on birth rate are not well known. objectives: to estimate birth rate in epilepsy patients on aed treatment or without aeds and in a population-based reference cohort without epilepsy. design and methods: patients (n = , ) with reimbursement for aeds for the first time between and and information on their aed use, were identified from the databases of social insurance institution of finland. reference cohort without epilepsy (n = , ) and information on live births were identified from the finnish population register centre. the analyses were performed using poisson regression modelling. results:birth rate was decreased in epilepsy patients in relation to reference cohort without epilepsy in both genders regardless of aed use. in relation to untreated patients, women on any of the aeds had non-significantly lower birth rates. among men, birth rate was decreased in men on oxcarbazepine (rr = . , % ci = . , . ), but was not clearly lower among those on carbamazepine (rr = . , % ci = . , . ) or valproate (rr = . , % ci = . , . ) when compared to untreated patients. conclusion: our results suggest that birth rate is decreased among epilepsy patients on aeds, more so in men. abstract background: hereditary hemochromatosis (hh), characterised by excessive iron absorption, subsequent iron storage and progressive clinical features, can when diagnosed at an early stage be successfully treated. high prevalence of the c y-mutation on the hfe-gene in the hh patient population may motivate genetic screening. objectives: in first-degree relatives of c y-homozygotes we studied the gender and age -related biochemical penetrance of hfe-genotype to define a high-risk population eligible for screening. design and methods: one-thousand-six first-degree family members of probands with clinically overt hfe-related hh from five medical centres in the netherlands were approached. data on levels of serum iron parameters and hfe-genotype were collected. elevation of serum ferritin was defined using the centre-specific normal-values by age and gender. results: among the participating relatives, highest serum iron parameters were found in male c y-homozygous siblings aged > years: % had elevated levels of serum ferritin. generally, male gender and increased age are related with higher iron values. discussion and conclusion: genetic screening for hh is most relevant in male and elderly first-degree relatives of patients with clinically overt hfe-related hh, enabling regular investigations of iron parameters in homozygous individuals. abstract background: nosocomial infection causes increased hospital morbidity and mortality rates. although handwashing is known to be the most important action in its prevention, adherence of health care workers to recommended hand hygiene procedures is extremely poor. objective: evaluation of compliance of hand hygiene recommendations in health care workers of a tertiary hospital in barcelona after a course on hand hygiene was given to all nurses in the hospital during the previous year. methods: by means of nondeclared observation, compliance (handwashing or disinfecting, not solely glove exchange) of recommendations given by the center for disease control related to opportunities for hand hygiene was registered, in procedures of diverse risk level for infection, both in physicians and nurses. results: in opportunities for hand hygiene carried out by health care workers compliance of recommendations was . %. adherence differed between wards ( . % in intensive care units, . % in medical wards and . % in surgical wards) and slightly between health care workers ( . % in physicians, . % in nurses). discussion: in conclusion, after one year of an intervention on education, adherence to hand hygiene recommendations is very low. these results enhance the need of reconsidering the type of interventions implemented. type of comorbidity affects qol most. objectives: we studied whether qol differed in subjects with dm with and without comorbidities. in addition, we determined differences in type of comorbidity. design and methods: cross-sectional data of dm patients, participants of a population-based dutch monitoring project on risk factors for chronic disease (morgen) were analyzed. qol was measured by the short form . we compared the means of subdimensions for dm patients with one comorbidity (cardiovascular diseases (cvd), musculoskeletal diseases (msd) and asthma/copd) to dm patients without this comorbidity, by regression analyses adjusted for age and sex. results: the prevalences of cvd, msd and asthma/copd were . %, . %, and . %. all comorbidities were associated with lower qol, especially for physical functioning. the mean difference ( % ci) was . abstract background: the extent or increase of ueds is suggested repeatedly, but never before the scientific literature was systematic studied. objectives: a systematic appraisal of the worldwide incidence and prevalence rates of upper extremity disorders (ueds) available in scientific literature was executed to gauge the range of these estimates in various countries and to determine whether the rates are increasing in time. design and methods: studies that recruited at least people, collected data by using questionnaires, interviews and/or physical examinations, and reported incidence or prevalence rates of the whole upper-extremity including neck, were included. results: no studies were found with regard to the incidence of ueds and studies that reported prevalence rates of ueds were included. the point prevalence ranged from . - %; the months prevalence ranged from . - %. one study reported on the lifetime prevalence ( %). we did not find evidence of a clear increasing or decreasing pattern over time. it was not possible to pool the date, because the definitions used for ueds differed enormously. conclusions: there are substantial differences in reported prevalence rates on ueds. main reason for this is the absence of a universally accepted way of labelling or defining ueds. abstract background: the absolute number of women diagnosed with breast cancer increased from , in to , in in the netherlands. likewise, the age standardized rate increased from . to . per , women. besides the current screening programme, changes in risk profile could be a reason for the increased incidence. objective: we studied the changes in breast cancer risk factors for women in nijmegen. methods: in the regional screening programme in nijmegen, almost , women aged - years filled in a questionnaire about risk factors in [ ] [ ] . similar questions were applied in the nijmegen biomedical study in , where women of - year participated. the median age in both studies was years. results: the frequency of a first-degree relative with breast cancer was . % and . % in and , respectively . none of the other risk factors, as the age of women at st birth ( . % respectively . %), nulliparity ( . % resp. . %), age at menarche ( . % resp. . %), age at menopause ( . % resp. . %) and obesity ( . % resp. . %), changed in time. conclusion: the distribution of risk factors hardly changed, and is unlikely to explain the rise in breast cancer incidence from onwards. abstract background: a single electronic clinical history system has been developed in the bac (basque autonomous community) for general use for all health centres, thus making it possible to collect information online on acute health problems as well as chronic ailments. method: the prevalence of diabetes, high blood pressure and copd (chronic obstructive pulmonary disease) was estimated using icd- -cm diagnosis performed by primary care physicians. an estimate was also made of the prevalence of cholesterolemia based on the results of analyses requested by physicians. results: in , , patients (out of a total population of , , ) were assessed for serum cholesterol levels. based on this highly representative sample, it was estimated that . % had serum cholesterol levels above mg/dl. the prevalence of diabetes mellitus in people over the age of was . %. the prevalence of high blood pressure in people over was %. discussion: the primary care database makes it possible to access information on problems related to chronic illnesses. knowing the prevalence of diabetes patients enables doctors to analyse all aspects related to services used by the diabetic population. it also makes it possible to monitor analytical data in real time and evaluate health service outcomes. examinations were used to asses risk factors for diabetes. cases (n = ) were matched on age and sex to controls (n = ) who were not treated with antidiabetic drugs. logistic regression was used to calculate odds ratios (or). results: the or of incident diabetes for acei-use versus non-acei use was . ( %ci : . - . ). for ace dd homozygotes the or was . ( %ci: . - . ) and for ace-i allele carriers . ( %ci: . - . ). the interaction or was . ( %ci: . - . ). the agt and at r genotypes did not modify the association between acei use and diabetes. abstract background: lignans have antioxidant and estrogen-like activity, and may therefore lower cardiovascular and cancer risk. objective: we have investigated whether intake of four plant lignans (lariciresinol, pinoresinol, secoisolariciresinol, matairesinol) was inversely associated with coronary heart disease (chd), cardiovascular diseases (cvd), cancer, and all-cause mortality. design: the zutphen elderly study is a prospective cohort study in which men aged - y were followed for years. lignan intake was estimated using a recently developed database, and related to mortality using cox proportional hazards analysis. results: median total lignan intake in was lg/d. beverages such as tea and wine, vegetables, bread, and fruits were the major lignan sources. total lignan intake was not related to mortality. however, matairesinol was inversely associated with chd, cvd, cancer, and all-cause mortality. multivariate adjusted rrs ( % ci) per sd increase in intake were . ( . - . ) for chd, . ( . - . ) for cvd, . ( . - . ) for cancer, and . ( . - . ) for allcause mortality. conclusions: total lignan intake was not associated with mortality. the intake of matairesinol was inversely associated with mortality from chd, cvd, cancer, and all-causes. we can not rule out that this is due to an associated factor, such as wine consumption. abstract despite the drastic increase in the amount of research into neighbourhood-level contextual effects on health, studies contrasting these effects between different domains of health within one contextual setting are strikingly sparse. in this study we use multilevel logistic regression models to estimate the existence of neighbourhood-level variations of physical health functioning (pcs) and mental well-being (ghq) in the helsinki metropolitan area and assess the causes of these differences. the individual-level data are based on a health-survey of - year old employees of the city of helsinki (n = , response rate %). the metropolitan area is divided into neighbourhoods, which are characterised using a number of area-level indicators (e.g. unemployment rate). our results show moderate but systematic negative effect of indicators of neighbourhood deprivation on physical functioning, whereas for mental health the effect is absent. these effects were strongest for proportion of manual workers; odds ratio for poor physical functioning was . for respondents living in areas with low proportion of manual workers. part of this effect was mediated by differences in health behaviour. analyses on cross-level interactions show that individual-level socioeconomic differences in physical health are smallest in most deprived areas, somewhat contradicting the results of earlier studies. abstract background: the second-eye cataract surgery is beneficial, nevertheless, there is a considerable proportion of unmet needs. objective: to estimate the proportion of second-eye cataract surgery in the public health system of catalonia, and explore differences in utilisation by patients' gender, age, and region of residence. methods: a total of , senile cataract surgeries performed between and were included. proportions observed were adjusted through independent logarithmic regression models for each study factor. results: the proportion of second-eye surgery showed an increasing trend (r . %) from . % ( % ci . ; . ) in november to . % ( % ci . ; . ) in december , and its projection to years was , % ( % ci . ; . ). the proportion of second-eye surgery was % ( % ci . ; . ) greater in women than in men. patients years or older had a lowest proportion ( . %; % ic . ; . ), which nevertheless increased during the period, unlike that of patients aged less than years. differences among regions were moderate and decreased throughout the period. conclusions: if the observed trends persist, there will be a substantial proportion of unmet need for bilateral surgery. we predict greater use of second-eye surgery by older patients. abstract background: persistence with bisphosphonates is suboptimal which could limit prevention of fractures in daily practice. objectives: to investigate the effect of long term persistent bisphosphonate usage on the risk of osteoporotic fractures. methods: the pharmo database, including drug-dispensing and hospital discharge records for > two million subjects in the netherlands, was used to identify new female bisphosphonate users > years from jan ' -jun ' . persistence with bisphosphonates was determined using the method of catalan. a nested matched case-control study was performed. cases had a first hospitalization for an osteoporotic fracture (index-date). controls were matched : to cases on year of inclusion and received a random index-date. the association with fracturerisk was assessed for one and two year persistent bisphosphonate use prior to the index-date. analyses were adjusted for di fferences in patient characteristics. results: , bisphosphonate users were identified and had a hospitalization for osteoporotic fracture during follow-up. one year persistent bisphosphonate use resulted in a % lower fracture rate (or . ; % ci . - . ) whereas two year persistent use resulted in a % lower rate (or . ; % ci . - . ). conclusion and discussion: these results emphasize the importance of persistent bisphosphonate usage to obtain maximal protective effect of treatment. abstract background: in the who recommended all countries to add hepatitis b (hbv) vaccination to their national immunization programs. the netherlands is a low hbv endemic country and therefore adopted a vaccination policy targeted towards high-risk groups. methods: during , epidemiological data and blood samples were collected from all reported patients with an acute hbv infection. a fragment of the s-gene was sequenced and phylogenetically analysed to clarify transmission patterns between risk groups. results: of hbv cases reported, % was infected through sexual contact ( % homo-/bisexual, % heterosexual). for patients samples were available for genotyping. phylogenetic analysis identified genotypes: a( %), b( %), c( %), d( %), e( %) and f( %). of men who have sex with men (msm), % were infected with genotype a. among heterosexuals, all genotypes were found. in many cases, genotypes b-f were direct or indirect related to countries abroad. only injecting drug user was found (genotype a). conclusion: genotype a is predominant in the netherlands, including most of the msm. migrant hbv carriers play an important role in the dutch hbv epidemic. genotyping provides insight into the spread of hbv among highrisk groups. this information will be used to evaluate the vaccination policy in the netherlands. abstract background: excess weight might affect the perception of both physical and mental health in women. objective: to examine the relationship between body mass index (bmi) and hrqol in women aged -to -year-old in a rural zone of galicia. design and methods: population-based cross-sectional study covering women, personally interviewed, from villages. hrqol was assessed with sf- questionnaire, through personal interviews. each scale of sf- was dichotomised in suboptimal or optimal hrqol using previously defined cut-offs. odds ratios (or) obtained from logistic regression summarize the relationship of bmi with each scale, adjusting for sociodemographic variables, sedentary leisuretime, number of chronic diseases and sleeping hours. results: a . % of women were obese (bmi = kg/m ) and . % overweight kg/m ) . frequency of suboptimal physical function was higher among overweight women (adjusted or: . ; % ci: . - . ) and obesity (adjusted or: . ; % ci: . - . ). furthermore, obese women had higher frequency of suboptimal scores on the general health scale (adjusted or: . ; % ci: . - . ). no differences were observed regarding mental health scores among women with different bmi categories. conclusion: in women from rural villages, overweight is associated with worse hrqol in physical function and general health. abstract background: pneumococcal vaccination among elderly is recommended in several western countries. objectives: we estimate the cost-effectiveness of a hypothetical vaccination campaign among the + general population in lazio region (italy). methods: a cohort was followed during a years timeframe. we estimated the incidence of invasive pneumococcal disease, in absence of vaccine, based on actual surveillance and hospital data. the avoided deaths and cases have been estimated from literature according to trial results. health expenditures included: costs of vaccine program, inpatient and some outpatient costs. cost-effectiveness was expressed as net healthcare costs per episode averted and life-year gained (lyg) and was estimated at baseline and in deterministic and stochastic sensitivity analyses. all parameters were age-specific and varied according to literature data. results: at baseline net costs per event averted and lyg at prices were, respectively, e , ( % ci: e , -e , ) and , ( % ci: e , -e , ). in the sensitivity analysis, bacteraemic pneumonia incidence and vaccine effectiveness increased the net cost per lyg by % and % in the worst-case scenario, and decreased it to e , in the best-case. conclusions: the intervention was not cost saving. the uncertainties concerning invasive pneumococcal disease incidence and vaccine effectiveness make the cost-effectiveness estimates instable. spain - abstract background: spatial data analysis can detect possible sources of heterogeneity in spatial distribution of incidence and mortality of diseases. moreover small area studies have greater capacity to detect local effects linked to environmental exposures. objective: to estimate the patterns of cancer mortality at municipal level in spain using smoothing techniques in a single spatial model. design and methods: cases were deaths due to cancer, registered at a municipal level nation-wide for the period - . expected cases for each town were calculated using overall spanish mortality rates and standard mortality ratios were computed. to plot the maps, smoothed municipal relative risks were calculated using besag york and mollie`model and markov chain monte carlo simulation methods. as an example maps for stomach and lung cancer neoplasms are shown. results: it was possible to obtain the posterior distribution of relative risk by a single spatial model including towns and the adjacencies. maps showed the singular patterns for both cancer locations. conclusion: the municipal atlas allows to avoid edge local effects, improving the detection of spatial patterns. discussion: bayesian modelling is a very efficient way to detect spatial heterogeneity by cancer and other causes of death. abstract background: little is known about the impact of socioeconomic status (ses) on outcomes of surgical care. objectives: we estimated the association between ses and outcomes of selected complex elective surgical procedures. methods: using hospital discharge registries (icd-ix-cm codes) of milan, bologna, turin and rome we identified patients undergoing cardiovascular operations (coronary artery bypass grafting, valve replacement, carotid endarterectomy, repair of unruptured thoracic aorta aneurysm) (n = , ) and cancer resections (pancreatectomy, oesophagectomy, liver resection, pneumonectomy, pelvic evisceration) (n = , ) in four italian cities, - . an area-based income index was calculated. post-operative mortality (in-hospital or within days) was the outcome. logistic regression adjusted for gender, age, residence, comorbidities, concurrent and previous surgeries. results: high income patients were older and had fewer comorbidities. mortality varied by surgery type (cabg , %, valve , %, endartectomy , %, aorta aneurysm , %, cancer . %). low income patients were more likely to die after cabg (or = . abstract background: an important medical problem of renal transplant patients who receive immunosuppression therapy, is the development of a malignancy during the long term follow-up. however, existing studies are not in agreement over whether patients who undergo renal transplantation have an increased risk of melanoma. objective: the aim of this study was to determine the incidence of melanoma in renal transplantation patients in the northern part of the netherlands. methods: we linked a cohort of patients who received a renal transplantation in the university medical centre groningen between and with the cancer registry of the comprehensive cancer centre north-netherlands, to identify all melanoma patients in this cohort. results: only patient developed a melanoma following the renal transplantation; no significant increase in the risk of melanoma was found. conclusion: although several epidemiologic studies have shown that the risk of melanoma is increased in renal transplantation patients who receive immunosuppression therapy to prevent allograft rejection, this increased risk was not found in the present study. the lower level of immunosuppressive agents given in the netherlands might be responsible for this low incidence. abstract background: socio-economic health inequalities are usually studied for self-reported income, although the validity of self-reports is uncertain. objectives: to compare self-reports of income by respondents to health surveys with their income according to tax registries, and determine to what extent choice of income measure influences the health-income relation. methods: around . respondents from the dutch permanent survey on living conditions were linked to data from dutch tax and housing registries of . both self-reported and registry-based measures of household equivalent income were calculated and divided into deciles. the association with less than good self-assessed health was studied using prevalence rates and odds ratios. results: around % of the respondents did not report their income. around % reported an income deciles lower or higher than the actual income value. the relation between income and health was influenced by choice of income measure. larger health inequalities were observed with selfreports compared to registry-based measures. while a linear healthincome relation was found using self-reported income, a curvilinear relation (with the worst health in the second lowest deciles) was observed for registry-based income. conclusion: choice of the income source has a major influence on the health-income relation that is found in inequality research. abstract background: while many health problems are known to affect immigrant groups more than the native dutch population, little is known about health differences within immigrant groups. objectives: to determine the association between self assessed health and socioeconomic status (ses) among people of turkish, moroccan, surinamese and antillean origin. methods: data were obtained from a social survey held among immigrants - years in the netherlands, with almost respondents per immigrant group. ses differences in the prevalence of 'poor' self-assessed health were measured using prevalence rate ratios estimated with regression techniques. results: within each immigrant group, poor health was much more common among those with low ses. the health of women was related to their educational level, occupational position, household income, financial situation and (to a lesser extent) their parents' education. similar relationships were observed for men, except that income was the strongest predictor of poor health. the health differences were about as large as those known for the native dutch population. conclusion and discussion: migrant groups are not homogenous. also within these groups, low ses is related to poor general health. in order to identify subgroups where most health problems occur, different socioeconomic indictors should be used. abstract background: genetic damage quantification can be considered as biomarker of exposure to genotoxic agents and as early-effect biomarker regarding cancer risk. objectives: to assess genetic damage in newborns and its relationship with anthropometrical, sociodemographic variables, maternal tobacco consumption and pollution perception. design and methods: the bio-madrid study recruited trios (mother/father/newborn) from areas in madrid to assess the impact of pollutants in humans. parents answered a questionnaire about socio-economic characteristics, pregnancy, life-style and perception of pollution. genetic damage in newborns were measured with the micronucleus(mn) test in peripheral lymphocytes poisson regression models were fitted using mn frequency per binucleated cells as dependent variable. explanatory variables included sex, parents age, tobacco, area and reported pollution level. results: the mean frequency of mn was . per (range: - ). no differences were found regarding area, sex and maternal tobacco consumption. mn frequency was higher in underweighted newborns and in those residing near heavy traffic roads. in recent years minimally invasive surgery procedures underwent rapid diffusion and laparoscopic cholecystectomy has been among the first to be introduced. after its advent, increasing rates of overall and laparoscopic cholecystectomy have been observed in many countries. we evaluated the effect of the introduction of laparoscopic procedure on the rates of cholecystectomy in friuli venezia giulia region, performing a retrospective study. from regional hospitals discharge data we selected all records with procedure code of laparoscopic (icd cm: ) or open ( ) cholecystectomy and diagnosis of uncomplicated cholelithiasis (icd cm: . ; . ; , ) or cholecystitis ( , ; , ), in any field, from to . in the year study period, the number of overall cholecystectomies increased from to (+ , %), mainly for the relevant increase of laparoscopic interventions from procedures, ( , % of overall cholecystectomies), to ( , %). rates of laparoscopic cholecystectomies increased from , to , per admitted patients with diagnosis of cholelithiasis or cholecystitis. the introduction of laparoscopic cholecystectomies was followed not only by a shift towards laparoscopically performed interventions but also by an increase in overall cholecystectomies in friuli venezia giulia region. abstract background: although a diminished doses scheme of -valent pneumococcal conjugate vaccination (pcv ) may offer protection against invasive pneumococcal disease, it might affect pneumococcal carriage and herd immunity. long term memory has to be evaluated. objective: to compare the influence of a and -doses pcv -vaccination scheme on pneumococcal carriage, transmission, herd immunity and anti-pneumococcal antibody levels. methods: in a prospective, randomized, controlled trial infants are randomly allocated to receive pcv at ages and months; ages , and months and the age of months only. nasopharyngeal (np) swabs are regularly obtained from infants and family members. the np swabs are cultured by conventional methods and pneumococcal serotypes are determined by quellung reaction. antibody levels are obtained at and months from infants in group i and ii and from infants in group iii. one thousand infants are needed to detect a % difference in pneumococcal carriage (a = . , ß = . ) between the three groups. results: so far, infants have been included. preliminary results show that prior to vaccination pneumococcal carriage was %. conclusion: this trial will provide insight into the effects of a diminished dose scheme on herd immunity and long-term antipneumococcal antibody development. abstract background: oil-spills cause important environmental damages and acute health problems on affected populations. objectives: to assess the impact of the prestige oil-spill in the hrqol of the exposed population. design and methods: we selected residents in coastal areas heavily affected by the oil-spill and residents in unaffected inland villages through random sampling, stratified by age and sex. hrqol was measured with the sf- questionnaire in personal interviews. individual exposure was also explored. mean differences in sf- scores > points were considered 'clinically relevant'. odds ratios (or) summarized the association between area of residence (coast vs inland) and suboptimum hrqol (lower than percentile th), adjusting for possible confounders. results: neither clinically relevant nor statistically significant differences were observed in most of the sf- scales regarding place of residence or individual exposure. worse scores (inland = , ; coast = , ; p< , ) abstract background: patient comorbidities are usually measured and controlled in health care outcome research. hypertension is one of the most commonly used comorbidity measures. objectives: this study aims to assess underreporting of hypertension in ami patients, and to analyze the impact of coding practices among italian regions or hospitals' type. methods: a cohort of ami hospitalisations in italy from november to october was selected. patients with a previous hospital admission reporting a diagnosis of complicated hypertension within the preceding months were studied. a logistic model was constructed. both crude and adjusted probability of reporting a hypertension in ami admissions, depending from the number of diagnosis fields compiled in discharge abstracts, and presence of other diseases were estimated. results: in . % of patients hypertension was not reported. probability of reporting hypertension increased with the number of compiled diagnosis fields (adjusted ors range: . - . ). there were no significant differences among italian regions, while private hospitals' reporting was less accurate. disorders of lipoid metabolism were more probably coded with hypertension (adjusted or: . ). conclusions: information from both ami and previous hospitali-sations would be needed to include hypertension in a comorbidity measure. abstract background: the angiotensin converting enzyme inhibitors (acei) should be considered the standard initial treatment of the systolic heart failure. this treatment is not recommended in patients with hypotension, although figures of systolic blood pressure around - mmhg during the treatment are allowed if the patient remains asymptomatic. objectives: to know the proportion of patients with systolic heart failure receiving treatment with acei, and the proportion of these patients with signs oh hypotension. design and methods: the electronic clinical records of all the patients diagnosed of systolic heart failure were reviewed. the electronic information system covers a % of the population of the basque country, approximately. diagnosis of heart failure was defined as the presence of any of the following cie- codes: or . or . . to evaluate the blood pressure, the last available determination was considered. results: out of patients with left heart failure, ( . %) have been prescribed acei. among the patients with blood pressure lower than mmhg (systolic) or than mmhg (diastolic), ( . %) were also receiving this treatment. conclusions: acei are clearly underprescribed in the basque country for the treatment of heart failure. attention should be given to the group at risk of hypotension. abstract background: epidemiologic studies have shown an association between c-reactive protein (crp) and cardiovascular endpoints in population samples. methods: in a longitudinal study of myocardial infarction (mi) survivors, crp was measured repeatedly (up to times) within a period of months. data on disease history and life style were collected at baseline. we examined the association between different variables and the level of crp using a random effects model. results: in total crp samples were collected in athens, augsburg, barcelona, helsinki, rome and stockholm. mean levels of crp were . , . , . , . , . , . [mg/l] respectively. body mass index (bmi) and chronic bronchitis (ever diagnosed) had the largest effect on crp ( % (for kg/m ) and % change from the mean level, respectively, p< . ). age classes showed a cubic function with a minimum at ages to . glycosylated hemoglobin (hba c) < . % as a measure of long-term blood glucose control and being male were found to be protective () % and ) % respectively, p< . ). conclusion: it was shown that bmi and history of bronchitis are important in predicting the level of crp. other variables, like alcohol intake, play a minor role in this large sample of mi patients. abstract background: during the last decades a remarkable increase in incidence rates of malignant lymphoma was seen. although some reasons are known or suspect underlying risk factors are not well understood. objectives: we studied the influence of medical radiation (x-ray, radiotherapy and szintigraphy) on the risk of malignant lymphoma. methods: we analysed data from a population-based case-control study with incident lymphoma cases in germany from - . after informed consent cases were pair-matched with controls recruited from registration office by age, gender and study region. data was collected in a personal interview. we analysed data using conditional logistic regression. results: the linear model shows an or = . /msv due to x-ray exposure and or = . ( %-ci = . - . ) comparing higher with lower exposure. radiotherapy shows an or = . (n = cases). there is no association between all lymphomas and szintigraphies but in the subgroup containing multiple myeloma, cll, malt-and marginalcell lymphoma we found an or = . ( %-ci = . - . ) in the multivariate model. discussion: no excess risk was observed for x-ray examinations. ionising radiation may increase risk for specific lymphoma subgroups. however, it should be noted that numbers in the subgroups are small and that radiation dose may be somehow inaccurate as no measures were available. abstract background: varus-alignment (bow-leggedness) is assumed to correlate with knee osteoarthritis (oa), but it is unknown whether varus-alignment precedes the oa or whether varus-alignment is a result of oa. objective: to assess the relationship between varusalignment and the development, as well as progression, of knee oa. methods: , participants in the rotterdam study were selected. knee oa at baseline and at follow-up (mean follow-up . years) was defined as kellgren & lawrence (k&l) grade , and progression of oa as an increase of k&l degree. alignment was measured by the femoro-tibial angle on baseline radiographs. multivariable logistic regression for repeated measurements was used. results: of , knees, . % showed normal alignment, . % varus-alignment, and . % valgus-alignment. comparison of high varus-alignment versus normal, low and mediate varus-alignment together, showed a two-fold increase in the development of knee oa. (or = . ; %ci = . - . ). the risk of progression was higher in the high varus group compared to the normal, low and mediate varus group (or = . ; %ci = . - . ). stratification for overweight gave similar odds ratio's in the overweight group, but weaker odds ratio's in the non-overweight group. conclusion: a higher value of varus-alignment is associated with the onset and progression of knee oa. abstract background: echocardiographic image quality in copd patients can be hampered by hyperinflated lungs. cardiovascular magnetic resonance imaging (cmr) may overcome this problem and provides accurate and reproducible information about the heart without geometric assumptions. objective: to determine the value of easily assessable cmr parameters compared to other diagnostic tests in identifying heart failure (hf) in copd patients. design and methods: participants were recruited from a cohort of copd patients = years. a panel established the diagnosis of hf during consensus meetings using all diagnostic information, including echocardiography. in a nested case-control study design, copd patients with hf (cases) and a random sample of copd patients without hf (controls) received cmr. the diagnostic value of cmr for diagnosing hf was quantified using univariate and multivariate logistic modelling and roc-area analyses. results: four easily assessable cmr measurements had significantly more added diagnostic value beyond clinical items (roc-area . ) than amino-terminal pro b-type natriuretic peptide (roc-area . ) or electrocardiography (roc-area . ). a 'cmr model' without clinical items had an roc-area of . . conclusion: cmr has excellent capacities to establish a diagnosis of heart failure in copd patients and could be an alternative for echocardiography in this group of patients. abstract background: the prevalence of overweight (i.e, body mass index [bmi] > = kg/m ) is increasing. new approaches to address this problem are needed. objectives: ) to assess the effectiveness of distance counseling (i.e., by phone and e-mail/internet) on body weight and bmi, in an overweight working population. ) to assess differences in effectiveness of the two communication methods. design and methods: overweight employees ( % male; mean age . ± . years; mean bmi . ± . kg/m ) were randomized to a control group receiving general information on overweight and lifestyle (n = ), a phone based intervention group (n = ) and an internet based intervention group (n = ). the intervention took months and used a cognitive behavioral approach, addressing physical activity and diet. the primary outcome measures, body weight and bmi, were measured at baseline and at six months. statistical analyses were performed with multiple linear regression. results: the intervention groups (i.e., phone and e-mail combined) lost . kg (bmi reduced by . kg/m ) over the control group (p = . ). the phone group lost . kg more than the internet group (p = . ). abstract objective: although an inverse gradient education-mortality has been shown in the general population, little is known about this trend in groups with higher risks of death.we examine differences in mortality by education and hiv-status among injecting drug users (idus) before and after introduction of highly active antiretroviral therapy (haart) in . methods: communitybased cohort study of idus recruited in aids prevention centres ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) abstract background: pancreatic cancer is an aggressive cancer with low survival time, with health-related quality of life (hrqol) being of major importance. objectives: the aim of our study was to assess both generic and disease-specific hrqol in patients with pancreatic cancer. methods: patients with suspected pancreatic cancer were consecutively included at admission to the hospital. hrqol was determined with the disease-specific european organization for research and treatment of cancer (eortc) health status instrument and generic euroqol (eq- d). results: a total of patients (mean age years ± , % men) were admitted with suspected pancreatic cancer. of these patients, ( %) had pancreatic cancer confirmed as final diagnosis. hrqol was significantly impaired in patients with pancreatic cancer for most eortc and eq- d scales in comparison to norm populations. the ed- d visual analogue scale (vas) and utility values were significantly correlated to the five functional scales, to the global health scale and to some but not all of the eortc symptom scales/items. conclusions: hrqol was severely impaired in patients with pancreatic cancer. there was a significant correlation between most eortc and eq- d scales. our results may facilitate further economic evaluations and aid health policy makers in resource allocation. abstract background: organised violence has health impact both on those who experience the violence directly and indirectly. the numbers of people affected by mass violence is alarming. substantial knowledge on the long-term health impact of organized violence is of importance for public health and for epidemiology. objectives: to investigate research results of long term mental health impact of organised violence. design and methods: a search of papers for the keywords genocide, organised violence, transgenerational effects, mental health was carried out in pubmed, science citation index and psychinfo. results: the systematic review on the long-term health impact of genocide showed that exposure to organised violence has an impact on mental health. methodological strenghts and weaknesses varied between studies. the found mental health consequences were associated with the country of research and the time of study. overall data showed organised violence has transgenerational impact on mental health of individuals and societies. conclusion: longitudinal studies have to be carried out to get further insight into the long-term health effects of organised violence. discussion: research results on mental health effects of organised violence have to be analysed in the context of changing concepts of illness. overweight is increasing and associated with various health problems. there are no well-structured primary care programs for overweight available in the netherlands. therefore, we developed a -month multidisciplinary treatment program in a primary care setting. the aim of the present study is to determine the feasibility and efficacy of a multidisciplinary treatment program on weight loss and risk profile in an adult overweight population. hundred participants of the utrecht health project are randomised to either a dietetic group or a dietetic plus physiotherapy group. the control group consist of another participants recruited from the utrecht health project and receives routine health care. body weight, waist circumference, blood pressure, serum levels, energy-intake and physical activity are measured at baseline, halfway and at the end of the treatment program. feasibility of the treatment program is assessed by response, compliance and program-associated costs and workload. efficacy is determined by analysing changes in outcome measures between groups over time using t-tests and anova repeated measurements. the treatment program is considered effective with at least a % difference in mean weight change over time between groups. positive evaluation of the multidisciplinary treatment program for overweight may lead to implementation in routine primary health care. abstract background: examining patient's quality of life (qol) before icu admission will permit to compare and analyze its relation with other variables. objectives: analyze qol of patients admitted to a surgical icu before admission and study its relation with baseline characteristics and outcome. design and methods: the study was observational and prospective in a surgical icu, enrolling all patients admitted between november and april . baseline characteristics of patients, history of co morbidities and quality of life survey score (qolss) were recorded. assessment of the relation between each variable or outcome and the total score of qolss was performed by multiple linear regression. results: total qolss demonstrated worse qol in patients with hypertension, cerebrovascular disease, renal insufficiency, severely ill (as measured by saps and asa physical status), and in older patients. there was no relation between qol and longer icu los. conclusions: preadmission qol correlates with age, severity of illness, comorbidities and mortality rates but is an able to predict longer icu stay. discussion: qolss appears to be a good indicator of outcome and severity of illness. abstract background: transient loss of consciousness (tloc) has a cumulative lifetime incidence of %, and can be caused by various disorders. objectives: to assess the yield and accuracy of initial evaluation (standardized history, physical examination and ecg), performed by attending physicians in patients with tloc, using follow-up as a gold standard. design and methods: adult patients presenting with tloc to the academic medical centre between february and may were included. after initial evaluation physicians made a certain, likely or no initial diagnosis. when no diagnosis was made additional cardiological testing, expert history taking and autonomic function testing were performed. the final diagnosis, after years follow-up, was determined by an expert committee. results: patients were included. after initial evaluation, % of the patients were diagnosed with a certain and % with a likely cause for their episodes. overall diagnostic accuracy was % ( %ci - %); % ( %ci - %) for the certain diagnoses and % ( %ci - %) for the likely diagnoses. conclusion and discussion: attending physicians make a diagnosis in % of patients with tloc after initial evaluation, with high accuracy. the use of abundant additional testing can be avoided in many patients. abstract background: the possibility of an influenza pandemic is one of the major public health challenges of today. risk perceptions among the general public may be important for successful public health measures to better control an outbreak situation. objectives: we investigated risk perception and efficacy beliefs related to an influenza pandemic in the general population in countries in europe and asia. design and methods: telephone interviews were conducted in . risk perception of an influenza pandemic was measured on a -point scale and outcome-and self-efficacy on a point scale (low-high). the differences in risk perception by country, sex and age were assessed with a general linear model including interaction effects. results: , persons were interviewed. the mean risk perception of flu was . and was significantly higher in europe ( . ) compared to asia ( . ) (p< . ) and higher in women ( . ) than men ( . ) (p< . ). outcome-and self-efficacy were lower in europe than asia. conclusion: in europe higher risk perceptions and lower efficacy beliefs were found as compared to asia. in developing preparedness plans for an influenza pandemic specific attention should therefore be paid to risk communication and how perceived self-efficacy can be increased. abstract background: increased survival of patients with cf has prompted interest towards their hrqol. objectives: .to measure hrqol and its predictors in cf patients cared for at the bambino gesuc hildren's hospital in rome; . to assess the psychometric properties of the italian version of the cf specific hrqol instrument (cystic fibrosis questionnaire, cfq). design and methods: crosssectional survey. all cf patients aged years or more were asked to complete the cfq (age-specific format). psychological distress was assessed through standardized questionnaires in patients (achenbach and general health questionnaire, ghq) and their parents (ghq and sf- ). results: one-hundred-eighteen patients ( males, females, age range to years) participated in the study (response rate %). internal consistency of cfq was satisfactory (cronbach alpha from . to . ); all item-test correlation were greater than . . average cfq standardized scores were very good in all domains (> on a - scale), except perceived burden of treatments ( ) and degree of socialization ( ). multiple regression analysis was performed to identify factors associated with different hrqol dimensions. conclusion: support interventions for these patients should concentrate on finding a balance between need to prevent infections and promotions of adequate, age-appropriate social interactions. abstract background: the metabolic syndrome (metsyn) -a clustering of metabolic risk factors with diabetes and cardiovascular diseases as the primary clinical outcomes -is thought to be highly prevalent with an enormous impact on public health. to date, consistent data in germany are missing. objective: the study was conducted to examine the prevalence of the metsyn (according to ncap atp iii-definition) among german patients in primary care. methods: the german-wide cross-sectional study run two weeks in october with randomly selected general practitioners included. blood glucose and serum lipids were analyzed, waist circumference and blood pressure assessed, data on smoking, dietary and exercise habits, regional and sociodemographic characteristics collected. abstract background: excessive infant crying is a common and often stress inducing problem than can ultimately result in child abuse. from previous research is known that maternal depression during pregnancy is related to excessive crying, but so far little attention is paid to paternal depression. objective: we studied whether paternal depression is independently associated to excessive infant crying. design and methods: in a prospective multiethnic population-based study we obtained depression scores of , mothers and , fathers at weeks pregnancy using the brief symptom inventory, and information on crying behaviour of , infants at months. we used logistic regression analyses in which we adjusted for depression of the mother, level of education, smoking and alcohol use. results: paternal depressive symptomatology was related to the widely used wessel's criteria for excessive crying (adusted odds ratio . , . - . ). conclusion: our findings indicate that paternal depressive symptomatology might be a risk factor for excessive infant crying. discussion genetic as well as other direct (e.g. interaction between father and child) or indirect (e.g. marital distress or poor circumstances) mechanisms could explain the found association. abstract background: in studying genetic background of congenital anomalies the comparison of affected cases to non-affected controls is popular method. investigation of case-parent triads uses observation of cases and their parents exclusively. methods: both casecontrol approach and log-linear case-parent triads model were implemented to spina bifida (sb) cases and their parents ( triads) and controls in analysis of impact of the c t and a c mthfr polymorphisms on occurrence of sb. results: observed frequencies for tt genotype were , % in sb children, , % in mothers, , % in fathers, , % in controls and for cc genotype were , % of sb children, , % of mothers, , % of fathers and , % of controls. both genotype frequencies in sb triads did not differ significantly from controls. case-control approach showed nonsignificant increase in risk of having sb for t allele carriers either in homozygous (or = , ) or heterozygous form (or = , ) and for c allele carriers in heterozygous form (or = , ). log-linear model revealed significant relative risk of sb in children with both tt and ct genotype (rr = , and rr = , respectively). child's genotype at a c and mother's genotypes did not contribute to the risk. conclusions: caseparent triads approach adds new information regarding impact of parental imprinting on congenital anomalies. abstract background: previous studies showed an association of autonomic dysfunction with coronary heart disease (chd) and with depression as well as an association of depression with chd. however, there is limited information on autonomic dysfunction as potential mediator of the adverse effect of depression on chd. objectives: to examine the role of autonomic dysfunction as a potential mediator of the association of depression with chd. design/ methods: we used data of participants aged - years of the ongoing population-based cross-sectional carla study ( % male). time-and frequency-domain parameters of heart rate variability (hrv) as a marker of autonomic dysfunction were calculated. prevalent myocardial infarction (mi) was defined as selfreported physician-diagnosed mi or diagnostic minnesota code in the electrocardiogram. depression was defined based on the cesd-depression scale. logistic regression was used to assess associations between depression, hrv and mi. results: in ageadjusted logistic regression models, there was no statistically significant association of hrv with depression, of depression with mi, or of hrv with mi in men and women. discussion/conclusion: the present analyses do not support the hypothesis of an intermediate role of autonomic dysfunction on the causal path from depression to chd. abstract background: hypertension is an established risk factor for cardiovascular disease. however, prevalence of untreated or uncontrolled hypertension is often high (even in populations at high risk). objectives: to assess the prevalence of untreated and of uncontrolled hypertension in an elderly east german population. design and methods preliminary data of a cross-sectional, populationbased examination of men and women aged - years were analysed. systolic (sbp) and diastolic blood pressure (dbp) were measured and physician-diagnosed hypertension and use of antihypertensive drugs were recorded. prevalence of hypertension was calculated according to age and sex. results: of all participants, . % were hypertensive ( . % of men, . % of women). of these, . % were untreated, . % treated but uncontrolled, and . % controlled. women were more often properly treated than men. the prevalence of untreated hypertension was highest in men aged - years ( . %) and lowest in men and women aged > = years ( . %). uncontrolled hypertension increases with age in both sexes. conclusion and discussion: in this elderly population, there is a high prevalence of untreated and uncontrolled hypertension. higher awareness in the population and among physicians is needed to prevent sequelae such as cardiovascular disease. abstract background: exposure to pesticides is a potential risk factor for subfertility, which can be measured by time-to-pregnancy (ttp). as female greenhouse workers constitute a major group of workers exposed to pesticides at childbearing age, a study was performed among these and a non-exposed group of female workers. objectives: to measure the effects of pesticide exposure on time-topregnancy. design and methods: data were collected through postal questionnaires with detailed questions on ttp, lifestyle factors, and work tasks (e.g. application of pesticides, re-entry activities, and work hours) during six months prior to conception of the most recent pregnancy. associations between ttp and exposure to pesticides were studied in cox's proportional hazards models among female greenhouse workers and referents. results: the initial fecundability ratio (fradjusted) for greenhouse workers versus referents was . ( %ci: . - . ). this fr proved to be biased by the reproductively unhealthy worker effect. restricting the analyses to fulltime workers only gave an fradjusted of . ( %ci: . - . ). among primigravidous greenhouse workers, an association was observed between prolonged ttp and gathering flowers (fr = . , %ci: . - . ). conclusion and discussion: this study adds some evidence to the hypothesis of adverse effects of pesticide exposure on time-topregnancy, but more research is needed. abstract background: hfe-related hereditary hemochromatosis (hh) is an iron overload disease for which screening is recommended to prevent morbidity and mortality. however, discussion has risen on the clinical penetrance of the hfe-gene mutations. objective: in the present study the morbidity and mortality of families with hferelated hh is compared to a normal population. methods: c yhomozygous probands with clinically overt hfe-related hh and their first-degree relatives filled in a questionnaire on health, diseases and mortality among relatives. laboratory results on serum iron parameters and hfe-genotype were collected. the self-reported morbidity, family mortality and laboratory results were compared with an age and gender matched subpopulation of the nijmegen biomedical study (nbs), a population-based survey conducted in the eastern part of the netherlands. results: twohundred-twenty-eight probands and first-degree relatives participated in the hefas. serum iron parameters were significantly elevated in the hefas population compared to the nbs controls. also, the morbidity within hefas families was significantly increased for fatigue, hypertension, liver disease, myocardial infarction, osteoporosis and rheumatism. mortality among siblings, children and parents of hefas probands and nbs participants was similar. discussion: the substantially elevated morbidity within hefas families justifies further exploration for a family cascade screening program for hh in the netherlands. abstract objectives: to evaluate awareness levels and effectiveness of warning labels in cigarette packs, among portuguese students enrolled in the th to the th grades. design and methods: a cross sectional-study was carried out in may ( ) in a high school population ( th- th grades) in the north of portugal (n = ). a confidential self-reported questionnaire was administered. warning labels effectiveness was evaluated by changes in smoking behaviour and cigarette consuption, during the period between june/ (before the implementation of the tobacco warnings labels in portugal) and may/ . continuous variables were compared by the t-test for paired samples and kruskal-wallis test. crude and adjusted odds ratios and confidential intervals were calculated by logistic regression analysis. results: the majority of students ( . %) have a high level of awareness about warning labels content. this knowledge was significantly associated with school grade and current smoking status. none of these variables was significantly associated with changes in smoking behaviour. although not reaching statistic significance, the majority of teenagers ( . %) increased or kept their smoking pattern. awareness level was not associated with smoking prevalence or consumption decreases. conclusions: current warning labels are ineffective in changing smoking behaviour among portuguese adolescents. abstract background: injuries are an important cause of morbidity. the presence of pre-existing chronic conditions (pecs) have been shown to be associated with higher mortality. objectives: aim of this study is to evaluate the association between pecs and risk of death in elder trauma patients. methods: an injury surveillance, based on the integration between emergency, hospital, and mortality databases of lazio region, year , was used. patients were the elder people visited at the emergency departments, and hospitalised. pecs were evaluated on the basis of the charlson comorbidity index (cci). to measure the effect of pecs on the probability of death, we used logistic regression. results: patients were admitted to the hospital. the . % of the injured subjects were affected by one or more chronic conditions. risk of death for non urgent and urgent patients increased at increasing cci score abstract background: c-reactive protein (crp) was shown to predict prognosis in heart failure (hf). objective: to assess variability of crp over time in patients with stable hf. methods: we measured high-sensitivity crp (hscrp) times ( -week intervals) in patients with stable hf. patients whose hscrp was > mg/dl or whose clinical status deteriorated were excluded. two consecutive hscrp measurements were available for patients: men, mean(sd) age . ( . ) years, % depressed left ventricular systolic function. forty-four patients had a third measurement. using the cutoff point of . mg/dl for prediction of adverse cardiac events we assessed the proportion of patients who changed risk category. results: median(p -p ) baseline hscrp was . mg/dl( . - . ). hscrp varied largely particularly for higher levels. the th and th percentiles of differences between first two measurements were ) . mg/dl and + . mg/dl. correlation coefficient between these measurements: . , p< . . eleven ( %) patients changed risk category, kappa = . , p< . . among patients whose first two measurements were concordant, . % changed category in third measurement, kappa = . , p< . . conclusion: large variability in hscrp in stable hf may decrease the validity of risk stratification based on single measurements. it remains to be demonstrated whether the pattern of change over time adds predictive value in hf patients. abstract background: instrumental variables can be used to adjust for confounding in observational studies. this method has not yet been applied with censored survival outcomes. objectives: to show how instrumental variables can be combined with survival analysis. design and methods: in a sample of patients with type- diabetes who started renal-replacement therapy in the netherlands between and , the effect of pancreas-kidney transplantation versus kidney transplantation on mortality was analyzed using region as the instrumental variable. because the hospital could not be chosen with this type of transplantation, patients can be assumed to be naturally randomized across hospitals. we calculated an adjusted difference in survival probabilities for every time point including the appropriate confidence interval (ci %). results: the -year difference in survival probabilities between the two transplantation methods, adjusted for measured and unmeasured confounders, was . (ci %: . - . ) favoring the pancreas-kidney transplantation. this is substantially larger than the intention-to-treat estimate of . (ci %: . - . ) where policies are compared. conclusion and discussion: instrumental variables are not restricted to uncensored data, but can also be used with a censored survival outcome. hazard ratios with this method have not yet been developed. the strong assumptions of this technique apply similarly with survival outcomes. . ] . sir of coronary heart disease was . [ %ci: . - . ] and remained significantly increased up to years of follow-up. cox regression analysis showed a . -fold ( % ci, . - . ) increased risk of congestive heart failure after anthracyclines and a . -fold ( % ci, . - . ) increased risk of coronary heart disease after radiotherapy to the mediastinum. conclusion: the incidence of several cardiac diseases was strongly increased after treatment for hl, even after prolonged follow-up. anthracyclines increased the risk of congestive heart failure and radiotherapy to the mediastinum increased the risk of coronary heart disease. abstract background: the concept of reproductive health is emerging as an essential need for health development. objectives: to know the opinions of parents, teachers and students about education of reproductive health issues to students of mid and high schools. design and methods: focus group discussions (fgd) as a qualitative research was chosen. a series of group discussions with participation of persons ( students, teachers, and parents) was held. each group had included to persons. results: all the participants noted to a true need in education of puberty health in order to provide essentials for pre-adolescent students to adopt the psycho-and somatic changes of puberty. however, a few fathers and a group of mothers believed that education of family planning is not suitable for students. a need for education of aids and marital problems for students was the major concern in all groups. the female students emphasized a need for programming counseling in pre-marital period. conclusion: essentials in puberty health, family planning, aids and marital problems should be provided in mid-and high schools in order to narrow the knowledge gap of the students. abstract background: the association between social support and hypertension in pregnancy remains controversial. objective: the objective of this study was to investigate whether level of social support is a protective factor against preeclampsia and eclampsia. design and methods: a case-control study was carried out in a public high-risk maternity hospital in rio de janeiro, brazil. between july -may , all cases, identified at diagnosis, and controls, matched on gestational age, were included in the study. participants were interviewed about clinical history, socio-demographic and psychosocial characteristics. the principal exposure was the level of social support available during the pregnancy, using the medical outcomes study scale. adjusted odds ratios were estimated using multivariate conditional logistic regression. results: multiparous women with a higher level of social support had a lower risk of presenting with preeclampsia and eclampsia (or = . ), although this association was not statistically significant ( % ci . - . ). in primiparous women, a higher level of social support was seen amongst cases (or = . ; % ci . - . ). an interaction between level of social support and stressful life events was not identified. these results contribute to increased knowledge of the relationship between preeclampsia and psychosocial factors in low-income pregnant and puerperal women. abstract background: current case-definitions for cfs/me are designed for clinical-use and not appropriate for health needs assessment. a robust epidemiological case-definition is crucial in order to achieve rational allocation of resources to improve service provision for people with cfs/me. objectives: to identify the clinical features that distinguish people with cfs/me from those with other forms of chronic fatigue and to develop a reliable epidemiological case-definition. methods-primary care patient data for unexplained chronic fatigue was assessed for symptoms, exclusionary and comorbid conditions and demographic characteristics. cases were assigned to disease and non-disease groups by three members of the chief medical officer's working group on cfs/me (reliability-cronbach's alpha . ). results: preliminary multivariate analyses were conducted and classification and regression tree analysis included a -fold cross-validation approach to prevent over fitting. the results suggested that there were at least four strong discriminating variables for cfs/ me with 'post-exertional malaise' being the strongest predictor. risk and classification tables showed an overall correct classification rate of . %. conclusion: the analyses demonstrated that the application of the combination of the four discriminating variables (the defacto epidemiological case-definition) and predefined comorbid conditions had the ability to differentiate between cfs/me and non-cfs/me cases. abstract background: infection with high-risk human papillomavirus (hpv) is a necessary cause for cervical cancer. vaccines against the most common types (hpv , hpv ) are being developed. relatively little is known about factors associated with hpv or hpv infection. we investigated associations between lifestyle factors and hpv and hpv infection. methods: uk women aged - years with a recent abnormal cervical smear underwent hpv testing and completed a lifestyle questionnaire. hpv and hpv status was determined using type-specific pcrs. associations between lifestyle factors and hpv status were assessed by multivariate logistic regression models. results: . % ( %ci . %- . %) of women were hpv -positive. . % ( % ci . %- . %) were hpv -positive. for both types, the proportion testing positive decreased with increasing age, and increased with increasing grade of cytological abnormality. after adjusting for these factors, significant associations remained between (i) hpv and marital, employment, and smoking status and (ii) hpv and marital status and contraceptive pill use. gravidity, ethnicity, barrier contraceptive use and socio-economic status were not related to either type. conclusions we identified modest associations between several lifestyle factors and hpv and hpv . studies of this type help elucidate hpv natural history in different populations and will inform development of future vaccine delivery programmes. in ageing men testosterone levels decline, while cognitive function, muscle and bone mass, sexual hair growth, libido and sexual activity decline and the risk of cardiovascular diseases increase. we set up a double-blind, randomized placebo-controlled trial to investigate the effects of testosterone supplementation on functional mobility, quality of life, body composition, cognitive function, vascular function and risk factors, and bone mineral density in older hypogonadal men. we recruited men with serum testosterone levels below nmol/l and ages - years. they were randomized to either four capsules of mg testosterone undecanoate (tu) or placebo daily for weeks. primary endpoints are functional mobility and quality of life. secondary endpoints are body composition, cognitive function, aortic stiffness and cardiovascular risk factors and bone mineral density. effects on prostate, liver and hematological parameters will be studied with respect to safety. measure of effect will be the difference in change from baseline visit to final visit between tu and placebo. we will study whether the effect of tu differs across subgroups of baseline waist girth, testosterone level, age, and level of outcome under study. at baseline, mean age, bmi and testosterone levels were (yrs), (kg/m ) and .x (nmol/l), respectively. abstract at a student population, the carie's prevalence was , %. objectives: to evaluate the efficiency between two types of oral health education programmes and the adherence towards tooth brushing. study design: case control study: youngsters took part, in the case group. an health education programme was carried out in schools and included two types of strategies: a participative strategy (learning based on the colouring of the dental plaque) towards a case group; and a traditional strategy (oral expository method) towards a control group. during the outcome of the programmes, the oral health condition evaluation was done through cpo index, the adherence towards tooth brushing and the (iho's) oral hygiene index. results: in the initial dental exam the (iho) average was of , . three months after the application of the oral health programme, there was a general decrease in the average of iho's to , . discussion and conclusion: in the case group the decrease was higher: , to , . the students submitted to a session of oral health education based on the colouring of the dental plaque showed an lower iho's average and higher knowledge. this can be due to the teaching session being more active, participative and demonstrative. abstract background: violence perpetuated by adolescents is a major problem in many societies. objectives: the aim of this study is to examine high school students' violent behaviour and to identify predictors. design and methods: a cross-sectional study was conducted in timis county, romania between may-june . the sample consisted of randomly selected classes, stratified proportionally according to grades - , high school profile, urban and rural environment. the students completed a self administered questionnaire in their classroom. a weighting factor was applied to each student record to adjust for non-response and for the varying probabilities of selection. results: a total of students were included in the survey. during the last months, . % of adolescents got mixed into a physical fight outside school and . % on school property. abstract background: drug use by adolescents has become an increasing public health problem in many countries. objectives: the aim of this study is to identify prevalence of drug use and to examine high school students' perceived risks of substance use. design and methods: a cross-sectional study was conducted in timis county, romania between may-june . the sample consisted of randomly selected classes, stratified proportionally according to grades - , high school profile, urban and rural environment. the students completed a self administered questionnaire in their classroom. eighteen items regarding illicit drug use suggesting different intensity of use were listed. the response categories were 'no risk', 'slight risk', 'moderate risk', 'great risk' and 'don't know'. results: a total of students were included in the survey. the lifetime prevalence of any illicit drug was . %. significant beliefs associated with drug use are: trying marijuana once or twice (p< . ), smoking marijuana occasionally (p = . ), trying lsd once or twice (p = . ), trying cocaine once or twice (p = . ), trying heroine once or twice (p = . ). conclusion: the overall drug use prevalence is small. however, use of some drugs once or twice is not seen as a very risky behaviour. abstract background: the health ombudsman service was created in ceara´, brazil, in , with the objective of receiving user opinions about public services. objectives: to describe user profiles, evaluating their satisfaction with health services and the ombudsman service itself. design and methods: a transversal and exploratory study with a random sample of users who had used the service in the last three months. the data were analyzed with the epi info program. results: women were those who used the service most ( . %). the users sought the service for complaints ( . %), guidance ( . %) and commendation ( . %). users made the following complaints about health services: lack of care ( . %), poor assistance ( . %) lack of medication ( . %). in relation to the ombudsman service, the following failures were mentioned: lack of autonomy ( . %), delay in solving problems ( . %) and few ombudsmen ( . %). conclusion: participation of the population in use of the serviced is small. the service does not satisfy the expectations of users, it is necessary to publicize the service and try to establish an effective partnership between users and ombudsmen so that the population finds in the ombudsman service an instrument to put into effect social control and improve the quality of health services. in chile, the rates of breast cancer and diabetes have dramatically increased in the last decade. the role of insulin resistance in the development of breast cancer, however, remains unexplored. we conducted a hospital-based case-control to assess the relationship of insulin resistance (ir) and breast cancer in chilean pre and postmenopausal women. we compared women, - y, with incident breast cancer diagnosed by biopsy and controls with normal mammography. insulin and glucose were measured in blood and ir was calculated by homeostasis model assessment method. anthropometric measurements and socio-demographic and behavioural data were also collected. odds ratios (ors) and % confidence intervals (cis) were estimated by multivariate logistic regression. the risk of breast cancer increased with age. ir was significantly associated to breast cancer in postmenopausal women (or = . , %ci = . - . ), but not in premenopausal (p> . ). socioeconomic status and smoking appeared as important risk factors for breast cancer. obesity was not associated with breast cancer at any age (p> . ). in these women, ir increased the risk of breast cancer only after menopause. overall, these results suggest a different risk pattern for breast cancer before and after menopause. keywords: insulin resistance; breast cancer; chile. abstract background: previous european community health indicators (echi) projects have proposed a shortlist of indicators as a common conceptual structure for health information. the european community health indicators and monitoring (echim) is a -year project to develop and implement health indicators and to develop health monitoring. objectives: our aim is to assess the availability and comparability of the echi-shortlist indicators in european countries. methods: four widely used health indicators i) perceived general health ii-iii) prevalence of any and certain chronic diseases or conditions iv) limitations in activities of daily living (adl) were evaluated. our evaluation of available sources for these indicators is based on the european health interview & health examination surveys database ( surveys in chile, breast cancer, obesity and sedentary behaviour rates are increasing. the role of specific nutrients and exercise in the risk of breast cancer remains unclear. the aim of the present study was to evaluate the role of fruits and vegetables intake and physical activity in the prevention of breast cancer. we undertook an age matched case-control study. cases were women with breast cancer histologically confirmed and controls were women with normal mammography, admitted to the same hospital. a structured questionnaire was used to obtain dietary information and measurement of physical activity was obtained from the international physical activity questionnaire. odds ratios (ors) and % confidence intervals (cis) were estimated by conditional logistic regression adjusted by obesity, socioeconomic status and smoking habit. a significant association was found with fruit intake (or = . , %ci = . - . ). the consumption of vegetables (or = . , %ci = . - . ), moderate (or = . , %ci = . - . ) and high physical activity (or = . , %ci = . - . ) were not observed as protective factors. in conclusion, the consumption of fruit is protective in breast cancer. these findings need to be replicated at chile to support the role of diet and physical activity in breast cancer and subsequence contribution in public health policy. keywords: diet; physical activity; breast cancer; chile. the role of trace elements in pathogenesis of liver cirrhosis and its complications is still not clearly understood. serum concentrations of zinc, copper, manganese and magnesium were determinated in patients with alcoholic liver cirrhosis and healthy subjects by means of plasma sequential spectrophotometer. serum levels of zinc were significantly lower (median . vs . lmol/l, p = . ) in patients with liver cirrhosis in comparison to controls. serum levels of copper were significantly higher in patients with liver cirrhosis ( . vs . lmol/l, p< . ) as well as manganese ( . vs . lmol/l, p = . ). concentration of magnesium was not significantly different between patients with liver cirrhosis and controls ( . vs . mmol/l, p = . ). there was no difference in trace elements concentrations between child-pugh groups. zinc level was significantly lower in patients with hepatic encephalopathy in comparison to cirrhotic patients without encephalopathy ( . vs . lmol/l, p = . ). manganese was significantly higher in cirrhotic patients with ascites in comparison to those without ascites ( . vs . lmol/l, p = . ). correction of trace elements concentrations might have beneficial effect on complications and maybe progression of liver cirrhosis. it would be recommendable to provide analyzis of trace elements as a routine. abstract background: respiratory tract infections (rti) are very common in childhood and knowledge of pathogenesis and risk factors is required for effective prevention. objective: to investigate the association between early atopic symptoms and occurrence of recurrent rti during first years of life. design and methods: in the prospective prevention and incidence of asthma and mite allergy birth cohort study, children were followed from birth to the age of years. information on atopic symptoms, potential confounders, and effect modifiers like passive smoking, daycare attendance and presence of siblings was collected at ages months and year by parental questionnaires. information on rti was collected at ages , , , and years. results: children with early atopic symptoms, i.e. itchy skin rash and/or eczema or doctordiagnosed cow's milk allergy at year of age had a slightly higher risk to develop recurrent rti (aor . ( . - . ); and . ( . - . ), respectively). the association between atopic symptoms and recurrent rti was stronger in children whose mother smoked during pregnancy and who had siblings (aor . ( . - . ) the aim : the aim of the study was to assess the relative risk (rr) of obesity and abdominal fat distribution on the insulin resistance (ir), diabetes, hyperlipidemia and hypertension in polish population. materials and methods: subjects at age - , were randomized and invited to the study. in participants anthropometric and blood pressure examination was performed. fasting lipids, fasting and after glucose load glucose and insulin were determined. ir was defined as the upper quartile of the homa-ir distribution for the normal glucose tolerant population. results: overweight and obesity was observed in , % and , % of subjects. visceral obesity was found in subjects ( , %-men and , %-women). rr of ir in obesity was , ( % ci: , - , ), for obese subjects at age below was , ( % ci: , - , ). in men with visceral obesity rr of ir was the highest for men aged below . rr of diabetes was increasing with the increase of body weight, in obese subjects with abdominal fat distribution was , ( %ci: , - , ). the same was observed for the hypertension and hyperlipidemia. conclusions: obesity and the abdominal fat distribution seems to be an important risk factor of ir, diabetes, hypertension, hiperlipidemia, especially in the younger age groups. abstract background: age as an effect modifier in cardiovascular risk remains unclear. objective: to evaluate age-related differences in the effect of risk factors for acute myocardial infarction (ami). methods: in a population-based case-control study, with data collected by trained interviewers, consecutive male cases of first myocardial infarction (participation rate %) and randomly selected male control dwellers (participation rate %) were compared. effect-measure modification was evaluated by the statistical significance of a product term of each independent variable with age. unconditional logistic regression was used to estimate ors in each age stratum (< years/> years). results: there was a statistically significant interaction between education (> vs. < years), sports practice, diabetes and age: the adjusted (education, ami family history, dyslipidemia, hypertension, diabetes, angina, waist circumference, sports practice, alcohol and caffeine consumption, and energy intake) ors ( %ci) were respectively . ( . - . ), . ( . - . ) and . ( . - . ) in younger, and . ( . - . ), . ( . - . ) and . ( . - . ) in older participants. conclusions: in males, age has a significant interaction with education, sports practice and diabetes in the occurrence of ami. the effect is evident in the magnitude but not in the direction of the association. abstract there are few studies on the role of diet in lung cancer etiology. thus, we calculated both, squamous cell and small cell carcinoma risks in relation to the frequency of consumption of vegetables, cooked meat, fish and butter in silesian male in industrial area of poland. in the case-control study, the studied population comprised men with squamous cell carcinoma and men with small cell carcinoma, and healthy controls. multivariate logistic regression was employed to calculate lung cancer risk in the relation to simultaneous influence of dietary factors. the relative risk was adjusted for age and smoking. we observed a significant decrease in lung cancer risk related to more frequent consumption of raw vegetables, cooked meat and fish. however, stronger protective effect was reported for squamous cell carcinoma. frequent fish consumption significantly decreases the risk especially in cigarette smokers. the frequent consumption of pickles lowers squamous cell carcinoma risk in all cases but small cell carcinoma risk only in smokers. the presence of butter, cooked meat, fish and vegetables in diet significantly decreases the lung cancer risk especially in smokers. the association between diet and lung cancer risk is more pronounced for squamous cell carcinoma. abstract background: in functional disease research selection mechanisms need to be studied to assure external validity of trial results. objective: we compared demographic and disease-specific characteristics, history, co-morbidity and psychosocial factors of patients diagnosed, approached and randomised for a clinical trial analysing the efficacy of fibre therapy in irritable bowel syndrome (ibs). design and methods: in primary care patients were diagnosed with ibs by their gp in the past two years. characteristics were compared between ( ) randomised patients (n = ); ( ) patients who did not give their informed consent (n = ); ( ) patients who decided not to participate (n = ); and ( ) those not responding to the mailing (n = ). results: the groups showed no significance differences in age and gender ( % females, mean age years, s.d. ). patients consulting their gp for the trial compared to patients not attending their gp showed significant more severe ibs symptoms, more abdominal pain during the previous three months, and a longer history of ibs (p< , ). patients randomised have more comorbidity (p = , ). conclusion and discussion: patients included in this ibs trial differ from no participating and excluded patients mainly in ibs symptomatology, history and comorbidity. this may affect the external validity of the trial results. abstract objectives: to evaluate smoking prevalence among teenagers and identify associated social-behavioral factors. study design and methods: a cross sectional-study was carried out in may ( ) in high school population ( th- th grades) in the north of portugal (n = ). a confidential self-reported questionnaire was administered. crude and adjusted odds ratios and confidence intervals were calculated by logistic regression analysis. results: overall smoking prevalence was . % (boys = . %; girls = . %) (or = . ; ci % = . - . ; p< . ). smoking prevalence was significantly and positively associated with gender, smoking parents, school failure and school grade; in the group of students with smoking relatives, smoking was significantly associated with parents who smoke near the student (or = . ; ci % = . - . ; p< . ); in the group of the secondary grade ( th- th grades) smoking was significantly associated with belonging to 'non science-courses' (or = . ; ci % = . - . ; p = . ). conclusions: smoking is a growing problem among portuguese adolescents, increasing with age, prevailing among males, although major increases have been documented in the female population. parents' behaviours and habits have an important impact in their children's smoking behaviour. school failure is also an important factor associated with smoking. there is a need for further prevention programmes that should include families and consider students' social environment. abstract background: social environment of school can contribute to etiology of health behaviors. objective: to evaluate the role of school context for substance abuse in youth. design: a cross-sectional study was carried out in , using self-completed classroomadministered questionnaire. subjects: from a representative sample of students, a sub-sample of students was selected (including / classes with at least persons without missing data)*. methods: substance abuse was measured by: tobacco smoking at present, episodes of drunkenness and marijuana use in the lifetime. overall index was created as main independent variable, ranging - (cronbach's alpha = . ). class membership, type of school, gender, place of domicile, and school climate were included as contextual variables, measured on individual or group level. results: on individual level, the mean index was equal to . (sd = . ), and ranged from . in general comprehensive schools to . in basic vocational schools and from . to . for separated classes. about . % of total variance in this index may be attributed to differences between classes. conclusion: individual differences in substance abuse in youth could be partly explained by factors at school level. * project no po d . abstract background: rates of c-section in brazil are very high, . % in . brazil illustrates an extreme example of medicalization of birth. c-section, as any major surgery, increases the risk of morbidity, which can persist long after discharge from hospital. objectives: to investigate how social, reproductive, prenatal care and delivery factors interact after hospital discharge, influencing post partum complications. design and methods: a cross-sectional study of women gathered information through home interviews and clinical examination during post-partum. a hierarchical logistic regression model of factors associated with post-partum complications was applied. results: physical and emotional post partum complications were almost twice as high among women having c-section. most of this effect were associated with lower socioeconomic conditions which influences, were mainly explained by longer duration of delivery (even in the presence of medical indications), and less social support when returning home. conclusion: risk of c-section complications is higher among women from the lower socioeconomic strata. social inequalities mediate the association between type of delivery and postpartum complications. discussion: c-section complications should be taken into account when decisions concerning type of delivery are made. social support after birth, from the public health sector, has to be provided for women in socioeconomic deprivation. the relationship between unemployment and increased mortality was previously reported in western countries. the aim of this study was to assess the influence of the changes in unemployment rate on survival in general population in northern poland at the time of economic transition. to analyze the association between the unemployment and risk of death we collected survival data from death certificates and data on rates of unemployment from regions of gdansk county from period - . kaplan-meier method and cox proportional hazard model were used in univariate and multivariate analysis. a change of unemployment (percentage) in the year of death in the area of residence, sex and educational level ( categories) were included into multivariate analysis. the change of unemployment rate was associated with significantly worse overall survival: hazard ratio . % confidence interval . to . . the highest risk associated with the change of unemployment in the area of residence was for death from congenital defects (hazard ratio . % confidence interval . to . ) and for death from cardiovascular diseases (hazard ratio . % confidence interval . to . abstract background: there is no evidence from randomized trials as to whether or not educational interventions improve voluntary reporting systems in terms of quantity or quality. objectives: evaluation of the effectiveness of educational outreach visits aimed at improving adverse drug reaction (adr) reporting by physicians design and methods: cluster-randomized controlled trial covering all health system physicians in northern portugal. four spatialclusters assigned to intervention group (n = ) received outreach visits tailored to training needs detected in previous study and clusters were assigned to the control (n = ). the main was the total number of reported adr; the second was the number of serious, unexpected, high-causality and new-drug-related adr. a follow-up was conducted for a period of months. results: the intervention increased reports as follows: total adr, . -fold (p< . ); serious adr, . -fold (p = . ); high-causality adr, . -fold (p< . ); unexpected adr, . -fold (p< . ); and newdrug-related adr, . -fold (p = . ). the intervention had its maximum effect during the first four months ( . -fold increase, p< . ), yet the effect was nonetheless maintained over the four month periods post-intervention (p = . ). discussion and conclusion: physician training based on academic detailing visits improves reporting quality and quantity. this type of intervention could result in sizeable improvements in voluntary reporting in many countries. there were no evidence of differences in absolute indications between the years. conclusion: most of the increase in rates in the period may be attributable to relative and non-medical indications. discussion policies to promote rational use of c-sections should take into account the role played by obstetrician's convenience and the increased medicalization of birth on cesarean rates. abstract background: the changing environment has led to unhealthy dietary habits and low physical activity of children resulting in overweight/obesity and related comorbid conditions. objective: idefics is a five-year multilevel epidemiological approach proposed under the sixth eu framework to counteract the threatening epidemic of diet-and lifestyle-induced morbidity by evidence-based interventions. design and methods: a population-based cohort of . children to years old will be established in nine european countries to investigate the aetiology of these diseases. culturally adapted multi-component intervention strategies will be developed, implemented and evaluated prospectively. results: idefics compares regional, ethnic and sex-specific distributions of the above disorders and their key risk factors in children within europe. the impact of sensory perception, genetic polymorphisms and the role of internal/external triggers of food choice and children's consumer behaviour are elucidated. risk profile inventories for children susceptible to obesity and its co-morbid conditions are identified. based on controlled intervention studies an evidencebased set of guidelines for health promotion and disease prevention is developed. conclusions: provision of effective intervention modules, easy to implement in larger populations, may reduce future obesity related disease incidence. discussion: transfer of feasible guidelines into practice requires involvement of health professionals, stakeholders and consumers. abstract background: non-medically indicated cesarean deliveries increase morbidity and health care costs. brazil has one of the highest rates of caesarean sections in the world. variations in rates are positively associated with socioeconomic status. objectives: to investigate factors associated with cesarean sections in public and private sector wards in south brazil. design and methods: cross sectional data from post partum interviews and clinical records of consecutive deliveries ( in the main public and in a private maternity) was analyzed using logistic regression. results: multiple regression showed privately insured women having much higher cesarean rates than those delivering in public sector wards (or = . ; ci %: . - . ). obstetricians individual rates varied from %- %. doctors working in both, public and private sectors had a higher rates of cesarean in private wards (p< . ). wanting and having a cesarean was significantly more common among privately insured women. conclusion: women from wealthier families are at higher risk of cesarean, particularly those willing this type of delivery and whose obstetrician works in the private sector. discussion: women potentially at lower clinical risk are more like to have a caesarean. the obstetricians' role and women's preferences must be further investigated to tackle this problem. abstract background: in the netherlands, bcg-vaccination is offered to immigrant children and children of immigrant parents in order to prevent severe tuberculosis. the effectiveness of this policy has never been studied. objectives: assessing the effectiveness of the bcg-vaccination policy in the netherlands. design and methods: we used data on the size of the risk population per year (from statistics netherlands), number of children with meningitis or miliary tuberculosis in the risk population per year, and vaccination status of those cases (from the netherlands tuberculosis register) over the period - . we estimated the vaccine efficacy and annual risk of acquiring meningitis or miliary tuberculosis by log-linear modelling and treating the vaccination coverage as missing data. results: in the period - cases of meningitis or miliary tuberculosis were registered. the risk for unvaccinated to children to acquire such a serious tuberculosis infection was . ( %ci . - . ) per per year; the reduction in risk for vaccinated children was % ( %ci - %). conclusion and discussion: this means that, discounting future effects with %, a ( %ci: - ) extra children should be vaccinated to prevent one extra case of meningitis or miliary tuberculosis. given that bcg-vaccination is relatively inexpensive, the current policy could even be cost-saving. abstract background: psychotic symptom experiences in the general population are frequent and often longlasting. objectives: the zurich cohort study offered the opportunity of differentiating the patterns of psychotic experiences over a span of years. design and methods: the zurich study is based on a stratified community sample of persons born in (women) and (men). the data were collected at six time points since . we examined variables from two subscales of the scl- -r -'paranoid ideation' and 'psychoticism' -using factor analysis, cluster analysis and polytomous logistic regression. results: two new subscales were derived representing 'thought disorders' and 'schizotypal signs'. continously high symptom load on one of these subscales (both subscales) was found in % ( . %) of the population. cannabis use was the best predictor of continuously high symptom load in the 'thought disorders' subscale, whereas several variables representing adversity in childhood / youth were associated with continuously high symptom load in the 'schizotypal signs' subscale. conclusion and discussion: psychotic experiences can be divided at least in two different syndromes -thought disorders and schizotypal signs. despite similar longitudinal course patterns and also similar outcomes these syndromes rely on different risk factors, thus possibly defining separate pathways to psychosis. abstract background: the reasons for the rise in asthma and allergies remain unclear. to identify influential factors several european birth cohort studies on asthma and allergic diseases have been initiated since . objective: the aim of one work package within the global allergy and asthma european network (ga len), sponsored by the european commission, was to identify and compare european birth cohorts specifically designed to examine asthma and allergic diseases. methods: for each study, we collected detailed information (mostly by personal visits) regarding recruitment process, study setting, follow-up rates, subjective/objective outcomes and exposure parameters. results: by june , we assessed european birth cohort studies on asthma and allergic diseases. the largest recruited over children each. most studies determined specific immunoglobulin e levels to various allergens or used the isaac questionnaire for evaluation of asthma or allergic rhinitis symptoms. however, the assessment of other objective and subjective outcomes (e.g. lung function or definitions of eczema) were rather heterogeneous across the studies. conclusions due to the unique cooperation within the ga len project a common database was established containing study characteristics of european birth cohorts on asthma and allergic diseases. the possibility to pool data and perform meta-analyses is currently being evaluated. abstract background: birth weight is an important marker of health in infancy and health trajectories later in life. social inequality in birth weight is a key component in population health inequalities. objective: to comparatively study social inequality in birth weight in denmark, finland, norway, and sweden from to . design and methods as part of the nordic collaborative project on health and social inequality in early life (norchase), register-based data covering all births in all involved countries - was linked with national registries on parental socioeconomic position, covering a host of different markers including income, education and occupation. also, nested cohort studies provide opportunity to test hypotheses of mediation. results: preliminary results show that the social inequality in birth weight, small for gestational age, and low birth weight has increased in denmark through out the period. also, preliminary results from finland, norway and sweden will be presented. discussion: crosscountry comparisons pose several methodological challenges. these challenges include characterizing the societal context of each country so as to correctly interpret inter-country differences in social gradients, along with dealing with differences in the data collection methods and classification schemes used by different national registries. also, strategies for influencing policy will be discussed. abstract background: modifying the availability of suicide methods is a major issue in suicide prevention. objectives: we investigated changes in the proportion of firearm suicides in western countries since the 's, and their relation to the change of legislation and regulatory measures. design and methods: data from previous publications, from the who mortality database, and from the international crime victims survey (icvs) were used in a multilevel analysis. results: multilevel modeling of longitudinal data confirmed the effect of the proportion of households owning firearms on firearm suicide rates. several countries stand out with an obvious decline in firearm suicides since the s: norway, united kingdom, canada, australia, and new zealand. in all of these countries legislative measures have been introduced which led to a decrease in the proportion of households owning firearms. conclusion and discussion: the spread of firearms is a main determinant of the proportion of firearm suicides. legislative measures restricting the availability of firearms are a promising option in suicide prevention. abstract background: fatigue is a non-specific but frequent symptom in a number of conditions, for which correlates are unclear. objectives: to estimate socio-demographic and clinical factors determining the magnitude of fatigue. methods: as part of a follow-up evaluation of a cohort of urban portuguese adults, socio-demographic and clinical variables for consecutive participants were collected through personal interview. lifetime history of chronic disease diagnosis was inquired (depression, cancer, cardiovascular, rheumatic, and respiratory conditions), anthropometry was measured, and haemoglobin determined. krupp's -item fatigue severity scale was applied and severe fatigue defined as mean score over . mean age (sd) was . ( . ) and . % of participants were females. logistic regression was used to compute adjusted odds ratios, and attributable fractions were estimated using the formula ar = -s(?j/orj). results: adjusted for age and clinical conditions, female gender (or = . , %ci: . - . ) and education (under -years schooling: or = . , %ci: . - . ) were associated with severe fatigue. obesity (or = . , %ci: . - . ) and diagnosed cardiovascular disease (or = . , %ci: . - . ) also increased fatigue. attributable fractions were . % for gender, . % for education, . % for obesity, and . % for cardiovascular disease. conclusion: gender and education have large impact on severe fatigue, and, to a lesser extent, obesity and cardiovascular disease. abstract introduction: analysis of infant mortality allows identification of death contributing factors and assessment of child health care quality. objective: to study characteristics of infant and fetal mortality using data from a committee for prevention of maternal and infant mortality, in sobral, brazil. methods: all cases of infant deaths between and were analyzed. medical records were reviewed and mothers, interviewed. using a tool to identify preventable deaths (seade classification -brazil) the committee characterized causes of death. meetings with governmental groups involved in family health care took place to identify death contributing factors. results: in , infant mortality decreased from . to . . in the next years there was an increase from . to . . the increase in was due to respiratory illnesses. in , was due to diarrhea. analysis of preventable deaths indicated a reduction from to deaths that could have been prevented by adequate gestational care, and an increase in preventable deaths by early diagnosis and treatment. conclusion: pre-natal and delivery care improved whereas care for children less than yr old worsened. analysis of death causes allowed a reduction of infant mortality rate to . abstract objective: to identify dietary patterns and its association with metabolic syndrome. design and methods: we evaluated noninstitutionalised adults. diet was assessed using a semi-quantitative dietary frequency questionnaire, and dietary patterns were identified using principal components analysis followed by cluster analysis (k-means method) with bootstrapping (choosing the clusters presenting the lowest intra-cluster variance). metabolic syndrome (mets) was defined according to the ncep-atp-iii. results: the overall prevalence of metabolic syndrome was . %. in the population sample clusters were identified in females - .healthy, .milk/soup; .fast food; .wine/low calories; and in males - .milk/carbohydrates; . codfish/soup; .fast food; .low calories. in males, using milk/carbohydrates as the reference and adjusting for age and education, high blood pressure (or = . ; %ci: . - . ) and high triglycerides (or = . ; %ci: . - . ) were associated with the fast food pattern, and low calories pattern presented higher frequency of high blood pressure (or = . ; %ci: . - . ). in females, after age and education adjustment, no significant association was found either with metabolic syndrome or its individual features and the dietary patterns identified. conclusion: we found no specific dietary pattern associated with an increased prevalence of metabolic syndrome. however, a fast food diet was significantly more frequent in males with dyslipidemia and high blood pressure. abstract aim: to determine the prevalence of stress urinary incontinence (sui) before, during pregnancy and following childbirth, and also to analyse the impact of a health education campaign about sui prevention, following childbirth in viana district, portugal. methods: participants (n = ), interviewed during hospitalization, after birth and two months later at health centres, were divided into two groups: a first group of non-exposed and a second exposed to a health education campaign. this second group was encouraged to perform an exercise programme and given a 'suiprevention-treatment' brochure, approved by the regional health authority. results: sui prevalence was . %( %ci: . - . ) before pregnancy, . %( %ci: . - . ) during pregnancy and . ( %ci: . - . ) four weeks after birth. less than half of the women with sui sought help from healthcare professionals. statistical significant differences were found between groups: sui knowledge level and practice of pelvic floor muscles re-education exercises were higher in the exposed group ( . and . times, respectively). conclusions: sui affects a great number of women but only a small percentage reveals it. this campaign improved women knowledge and modified their else behaviors. healthcare professionals must be aware of this reality, providing an early and continuous intervention that would optimise the verified benefits of this campaign. abstract background: social inequalities have been associated with poorer developmental outcomes, but little is known about the role of the area of residence. objectives: examine whether the housing infrastructure of the area modifies the effect of socio-economic conditions of the families on child development. design and methods: community-based survey of under-fives in southern brazil applied hierarchical multi-level linear regression to investigate determinants of child development, measured by a score from the denver developmental screening test. results: in multivariable models, the mean score of child development increased with maternal and paternal education and work qualification, family income and better housing and was higher when the mother was in paid work (all p< . ). paternal education had an effect in areas of lower housing quality only; the effect of occupational status and income in these areas were twice as large as in better-provided areas (likelihood test for all interactions p< . ). this model explained % of the variation in developmental score between the areas of residence. conclusion: the housing quality and sanitation of the area modified the effects of socioeconomic conditions on child development. discussion: housing and sanitation programs are potentially beneficial to decrease the negative effect of social disadvantage on child development. abstract background: it is known that both genetic and environmental factors are involved in the early development of type diabetes (t d), and that incidence varies geographically. however we still need to explain why there is variation in incidence. objectives: in order to better understand the role of non-genetic factors, we decided to examine whether prevalence of newborns with high risk genotypes or islet autoantibodies varies geographically. design and methods: the analysis was performed on a cohort of newborns born to non-diabetic mothers, between september and august , who were included in diabetes prediction in ska˚ne study (dipis) in sweden. neighbourhoods were defined by administrative boundaries and variation in prevalence was investigated using multi-level regression analysis. results: we observed that prevalence of newborns with islet autoantibodies differed across the municipalities of ska˚ne (s = . , p < . ), with highest prevalence found in wealthy urban areas. however there was no observed difference in the prevalence of newborns with high risk genes. conclusion and discussion: newborns born with autoantibodies to islet antigens appear to cluster by region. we suggest that non-genetic factors during pregnancy may explain some of the geographical variation in the incidence of t d. abstract background: risk assessment is a science-based discipline used for decision making and regulatory purposes, such as setting acceptable exposure limits. estimation of risks attributed to exposure to chemical substances are traditionally mainly the domain of toxicology. it is recognized, however, that human, epidemiologic data, if available, are to be preferred to data from laboratory animal experiments. objectives: how can epidemiologic data be used for (quantitative) risk assessment? results: we described a framework to conduct quantitative risk assessment based on epidemiological studies. important features of the process include a weight-of-theevidence approach, estimation of the optimal exposure-risk function by fitting a regression model to the epidemiological data, estimation of uncertainty introduced by potential biases and missing information in the epidemiological studies, and calculation of excess lifetime risk through a life table to take into account competing risks. sensitivity analyses are a useful tool to evaluate the impact of assumptions and the variability of the underlying data. conclusion and discussion: many types of epidemiologic data, ranging from published, sometimes incomplete data to detailed individual data, can be used for risk assessment. epidemiologists should better facilitate such use of their data, however. abstract background: high-virulence h. pylori (hp) strains and smoking increase the risk of gastric precancerous lesions. its association with specific types of intestinal metaplasia (im) in infected subjects may clarify gastric carcinogenesis pathways. objectives: to quantify the association between types of im and infection with highvirulence hp strains (simultaneously caga+, vacas and va-cam ) and current smoking. design and methods: male volunteers (n = ) underwent gastroscopy and completed a self-administered questionnaire. participants were classified based on mucin expression patterns in biopsy specimens (antrum, body and incisura). hp vaca and caga were directly genotyped by pcr/reverse hybridization. data were analysed using multinomial logistic regression (reference: normal/superficial gastritis), models including hp virulence, smoking and age. results: high-virulence strains increased the risk of all im types (complete: or = . , %ci: . - . ; incomplete: or = . , %ci: . - . ; mixed: or = . , %ci: . - . ) but smoking was only associated with an increased risk of complete im (or = . %ci: . - . ). compared to non-smokers infected with lowvirulent strains, infection with the high-virulence hp increased the risk of im similarly for smokers (or = . , %ci: . - . ) and non-smokers (or = . %ci: . - . ). conclusion: gastric precancerous lesions, with different potential for progression, are differentially modulated by hp virulence and smoking. the risk of im associated with high-virulence hp is not further increased by smoking. abstract background: in may , the portuguese government created the basic urgency units (buu). these buu must attend at least . persons, be open hours per day, and be at maximum minutes of distance to all the users. objectives: determine the optimal location of buu, considering the existing health centers, in the viseu district, north portugal. methods: from a matrix of distances between population and health centers an accessibility index was created (sum of distances traveled by population to reach a buu). the location-allocation models were used to create simulations based on p-median model, maximal covering location problem (mclp) and set covering location problem (sclp). the solutions were ranked by weighting the variables of accessibility ( %), number of doctors in the health centers ( %), equipments ( %), distance/time ( %) and total number of buu ( %). results: the best solution has buu, doctors, attends users and the accessibility index is . km. conclusions: it was proved that it is impossible to attend all the criterion for creation of a buu. in some areas with low population density, to sum at least persons in a buu, the travel time is necessarily more than hour. background: a prospective observational study of fatigue in staff working a day/ off/ night/ off roster of hour shifts was conducted at a fly-in/fly-out fertilizer mine in remote northern australia. objectives: to determine whether fatigue in staff increased: from the start compared to the finish of shift; with the number of consecutive shifts; and from day-compared to nightshift. methods: data of sleep diaries, the mackworth clock test and the swedish occupational fatigue inventory were obtained at the start and finish of each shift from august to november . results: a total of staff participated in the study. reaction times, sleepiness and lack of energy scores were highest at the finish of nights to . the reaction times increased significantly at both the start and finish of day onwards, and at the finish of night . reaction times and lack of motivation were highest during nightshift. conclusions: from the above results, a disturbed diurnal rhythm and decreased motivation during night-shift; and a roster of more than eight consecutive shifts can be inferred as the primary contributors to staff fatigue. discussion: the implications for changes to workplace practices and environment will be discussed. the aim of this survey was to assess the impact of a meta-analysis comparing resurfacing with nonresurfacing of the patella on the daily practice of experts. participants in this study were experts which had participated in a previous survey on personal preferences regarding patella resurfacing. these experts in the field of patella resurfacing were identified by a thorough search of medline, an internet search (with googletm search engine), and personal references from the identified experts. participants of the 'knee arthroplasty trial' (kat) in the united kingdom were also included. two surveys were sent to the participants, one before and one after the publication of the meta-analysis. the response rate is questionnaires or %. the vast majority of responders are not persuaded to change change their practice after reading the metaanalysis. this is only in part due to the fact that best evidence and practice coincide. other reasons given are methodology related, an observation which is shared by the authors of the review, which force the orthopedic community to improve its research methodology. reasons such as 'i do not believe in meta-analysis' either demands a fundamental discussion or demands the reader to take evidence based medicine more seriously. abstract background: patients with type diabetes (dm ) have a - fold increased risk of cardiovascular disease. delegating routine tasks and computerized decision support systems (cdss) such as diabetes care protocol (dcp) may improve treatment of cardiovascular risk factors hba c, blood pressure and cholesterol. dcp includes consultation-hours exclusively scheduled for dm patients, rigorous delegation of routine tasks in diabetes care to trained paramedics, and software to support medical management. objective: to investigate the effects of dcp, used by practice assistants, on the risk of coronary heart disease for patients with dm . design and methods: in an open-label pragmatic trial in general practices with patients, hba , blood pressure and cholesterol were examined before and prospectively one year after implementation of dcp. the primary outcome was the change in the year ukpds coronary heart disease (chd) risk estimate. results: the median year ukpds chd risk estimate improved significantly from . % to . %. hba decreased from . % to . %, systolic blood pressure from . to . mmhg and total cholesterol from . to . mmol/l. (all p< . ). conclusion: delegating routine task in diabetes care to trained paramedics and using cdss improves the cardiovascular risk of dm patients. tuberculosis in exposed immigrants by tuberculin skin test, ifn-g tests and epidemiologic abstract background: currently immigrants in western countries are only investigated for active tuberculosis (tb) by use of a chest x-ray. recent latent tuberculosis infection (ltbi) is hard to diagnose in this specific population because the only available test method, the tuberculin skin test (tst), has a low positive predictive value (ppv). recently interferon-gamma (ifn-g) tests have become available that measure cellular responses to specific m. tuberculosis antigens and might have a better ppv. objective: to determine the predictive value of tst and two different ifn-g tests combined with epidemiological characteristics for developing active tb in immigrants who are close contacts of smear positive tb patients. methods in this prospective cohort study close contacts will be included. demographic characteristics and exposure data are investigated. beside their normal examination they will all have a tst. two different ifn-g tests will be done in those with a tst induration of ? mm. these contacts will be followed for years to determine the occurrence of tb. results since april , municipal health services have started with the inclusion. preliminary results on the predictive value of tst, both ifn-g tests and epidemiological characteristics will be presented. abstract background: different factors contribute to the quality of ed (emergency department) care of an injured patient. objective: determine factors influencing the disagreement between er diagnoses and those assigned at hospital admission in injuried patients, and evaluate if disagreement between the diagnoses could have worsened the outcome. methods: all the er visits of the emergency departments of lazio region for unintentional injuries followed by hospitalisation in . concordant diagnoses were established on the basis of the barell matrix cells. logistic regression was used to assess the role of individual and er care factors on the probability of concordance. a logistic regression where death within days was the outcome and concordance the determinant was uses. results: , injury er visits were considered. in . % cases, the er and discharge diagnoses were concordant. higher concordance was found with increasing age and less urgent cases. factors influencing concordance were: the hour of the visit, er level, initial outcome, length of stay in hospital. patients who had non concordant diagnoses had a % higher probability of death. conclusions: a correct diagnosis at first contact with the emergency room is associated with lower mortality. methods: a cohort of consecutive patients treated for secondary peritonitis were sent the posttraumatic stress syndrome inventory (ptss- ) and impact of events scale-revised (ies-r) - years following their surgery for secondary peritonitis. results: from the patients operated upon between and , questionnaires were sent to the long-term survivors of which % responded (n = ). ptsd-related symptoms were found in % of patients by both questionnaires. patients admitted to icu (n = ) were significantly older, with higher apache-ii scores, but reported similar ptsd symptomology scores compared to non-icu patients (n = ). traumatic memories during icu and hospital-stay were most predictive for higher scores. adverse memories did not occur more often in the icu group than in the hospital-ward group conclusions: longterm ptsdrelated symptoms in patients with secondary peritonitis were very barthé lé my c cabanas ruiz-carrillo de la cruz den boon jimé nez-moleó n mü ller-nordhorn national evaluation team rich-edwards in the netherlands. design and methods we used the populationbased databases of the netherlands cancer registry, the eindhoven cancer registry (ecr) and the central bureau of statistics. patients from the ecr were followed until - - for vital status and relative survival was calculated. results: the number of breast cancer cases increased from in to . in , an annual increase of . % (p< . ). the death rate decreased , % annually (p< . ), which resulted in deaths in . the relative -yr survival was less than % for patients diagnosed in the seventies, this increased to over % for patient diagnosed since , patients with stage i disease even have a % -yr relative survival. conclusion: the alarming increase in breast cancer incidence is accompanied with a serious improvement in survival rates. this results in a large number of women (ever) diagnosed with breast cancer, about , in of whom % demand some kind of medical care. abstract background: nine % of the population in the netherlands belongs to non-western ethnic minorities. perceived health is worse and health care use different from dutch natives. objectives. which factors are associated with ethnic differences in self-rated health? which factors are associated with differences in utilisation of gp care? methods: during one year all contacts with gps were registered. adult surinam, antillean, turkish, moroccan and dutch responders were included (total n: . ). we performed multivariate analyses of determinants of self-rated health and on the number of contacts with gps. results: self-rated health differ from native dutch: surinam/antillean (or . ) and turkish/moroccan patients (or . / . ) , especially in turkish/moroccan females. more turks visit the gps at least once a year (or . ). less surinamese (or . ) and antillean patients (or . ) visit their gps than the dutch do. people from ethnic minorities in good health visit their gps more often ( . - . consults per year vs. . ). incidence rates of acute respiratory infections and chest complaints were significantly higher than in the dutch. conclusions: ethnicity is independently associated with self-rated health. higher use of gp-care by ethnic minorities in good health, points towards possible inappropriate use of resources. the future: do they fulfil it? first results of the limburg youth monitoring project abstract background: incidence of coronary heart disease (chd) and stroke can be estimated from local, population-based registers. it is unclear, to what extent local register data are applicable on a nationwide level. therefore, we compared german register data with estimates derived with who global burden of disease (gbd) method. methods: incidence of chd and stroke was computed with the gbd method using official german mortality statistics and prevalences from the german national health survey. results were compared to estimates from the kora/monica augsburg register (chd) and the erlangen stroke project in southern germany. results: gbd estimates and register data showed good agreement: chd (age group - years) , (gbd) versus , (register) and stroke (all ages) , versus , incident cases per year. chd incidence among all age groups was estimated with the gbd method to be , per year (no register data available). chd incidence in men and stroke incidence in women were underestimated with the gbd method as compared to register data. conclusions: gbd method is a useful tool to estimate incidence of chd and stroke. the computed estimates may be seen as lower limit for incidence data. differences between gbd estimates and register data are discussed. abstract background: children with mental retardation (mr) are a vulnerable not much studied population. objectives: to investigate psychopharmacotherapy in children with mr and to examine possible factors associated with psychopharmacotherapy. methods: participants were recruited through all facilities for children with mental retardation in friesland, the netherlands, resulting in participants, - years old, including all levels of mental retardation. the dbc and the pdd-mrs were used to assess general behavior problems and pervasive developmental disorders (pdd). information on medication was collected through a parent-interview. logistic regression was used to investigate the relationship between the psychotropic drug use and the factors dbc, pdd, housing, age, gender and level of mr. results: % of the participants used psychotropic medication. main factors associated with receiving psychopharmacotherapy were pdd (or . ) and dbc score (or . ). living away from home and mr-level also played a role whereas gender and age did not. dbc score was associated with clonidine, stimulants and anti-psychotics. pdd was the main factor associated with anti-psychotics use (or . ). discussion: psychopharmacotherapy is especially prevalent among children with mr and comorbid pdd and general behavior problems. although many psychotropic drugs are used off-label, specific drugs were associated with specific psychiatric or behavior problems. abstract background: increased survival in children with cancer has raised interest on the quality-of-life of long-term survivors. objective: to compare educational outcomes of adult survivors of childhood cancer and healthy controls. methods: retrospective cohort study including a sample of adult survivors ( ) treated for childhood cancer in the three existing italian paediatric research hospitals. controls ( ) were selected among siblings, relatives or friends of survivors. when these controls were not available, a search was carried out in the same area of residence of the survivors though random digit dialling. data collection was carried out through a telephone-administered structured questionnaire. results: significantly more survivors than controls needed school support (adjusted odds ratio -oradj- . , % ci . - . ); failed at least a grade after disease onset (oradj . , % ci . - . ); achieved a lower educational level (oradj . , % ci . - . ) and did not reach an educational level higher than their parents' (oradj . , % ci . - . ). subject's age, sex, parents' education and area of residence were taken into account as possible confounders. conclusions: these findings suggest the need to provide appropriate school support to children treated for childhood cancer. abstract background: in italy supplementation with folic acid (fa) in the periconceptional period to prevent congenital malformations (cms) is quite low. the national health institute has recently launched ( ) a programme to improve awareness about the role of fa in reducing the risk of serious defects also by providing . mg fa tablets free of charge to women planning a pregnancy. objectives: we analysed cms that are or may be sensitive to fa supplementation in order to establish an adequate baseline to allow a fa impact assessment in the next years and to investigate spatial differences among cms registries, time trends and time-space interactions. design and methods data collected over - by the italian registries members of eurocat and icbdsr on births and induced abortions with neural tube defects, ano-rectal atresia, omphalocele, oral clefts, cardiovascular, limb reduction and urinary system defects. results: all the cms showed statistically significant differences among registries with the exception of ano-rectal atresia. the majority of cms by registry showed stable or increasing trends over time. conclusions results show the importance of fa intake during the periconceptional period. differences among registries indicate also the need of having a baseline for each registry to follow trends over time. abstract country-specific resistance proportions are more biased by variable sampling and ascertainment procedures than incidence rates. within the european antimicrobial resistance surveillance system (earss) resistance incidence rates and proportions can be calculated. in this study, the association between antimicrobial resistance incidence rates and proportions and the possible effect of differential sampling of blood cultures was investigated. in , earss collected routine antimicrobial susceptibility test data from invasive s. aureus isolates, tested according to standard protocols. via a questionnaire denominator information was collected. the spearman correlation coefficient and linear regression were used for statistical analysis. this year, of hospitals and of laboratories from of earss countries responded to the questionnaire. they reported of, overall, , s. aureus isolates. in the different countries, mrsa proportions ranged from < % to % and incidence rates per , patient days from . ae - to . ae - . overall, the proportions and rates highly correlated. blood culturing rates only influenced the relationship between mrsa resistance proportions and incidence rates for eastern european countries. in conclusion, resistance proportions seem to be very similar to resistance incidence rates, in the case of mrsa. nevertheless, this relationship appears to be dependent of some level of blood culturing. . key: cord- - dh jv authors: liu, fang; liu, huanhuan; hou, liang; li, jinning; zheng, hui; chi, runmin; lan, weishun; wang, dengbin title: clinico-radiological features and outcomes in pregnant women with covid- pneumonia compared with age-matched non-pregnant women date: - - journal: infect drug resist doi: . /idr.s sha: doc_id: cord_uid: dh jv purpose: to investigate the clinico-radiological findings and outcomes in pregnant women with covid- pneumonia compared to age-matched non-pregnant women. methods: a retrospective case-controlled study was conducted to review clinical and ct data of pregnant and age-matched non-pregnant women with covid- pneumonia. four stages of ct images were analyzed and compared based on the time interval from symptom onset: stage ( – days), stage ( – days), stage ( – days), and stage (> days). the initial and follow-up data were analyzed and compared. results: compared with age-matched non-pregnant women, initial absence of fever ( / , %) and normal lymphocyte count ( / , %) were more frequent in pregnant group. the predominant patterns of lung lesions were pure ground-glass opacity (ggo), ggo with consolidation or reticulation, and pure consolidation in both groups. pure consolidation on chest ct was more common at presentation in pregnant cases. pregnant women progressed with a higher consolidation frequency compared with non-pregnant group in stage ( % vs %). improvement was identified in stages and for both groups, but consolidation was still more frequent for pregnant women in stage . most patients ( / , %) were grouped as mild or common type. the length of hospitalization between the two groups was similar. conclusion: pregnant women with covid- pneumonia did not present typical clinical features, while developing a relatively more severe disease at imaging with a slower recovery course and experiencing similar outcomes compared with the non-pregnant women. the ongoing outbreak of coronavirus disease (covid- ) caused by the "severe acute respiratory syndrome coronavirus " (sars-cov- ) has rapidly spread worldwide. [ ] [ ] [ ] the basic reproductive number (r ), defined as the expected number of people who will become infected by an infectious case in a susceptible population, is estimated to be . . it is important to be vigilant about the spread of covid- and implement timely effective measures to control the ongoing global outbreak. epidemiological, clinical, and radiological characteristics of patients with covid- have been preliminarily reported. [ ] [ ] [ ] [ ] [ ] [ ] [ ] according to the previous studies, initial symptoms of fever and cough, male-predominance, and lymphopenia were clinically typical and chest ct characteristics included peripherally distributed ground-glass opacity (ggo) and ggo with consolidation and/or reticulation. however, to the best of our knowledge, most publications involved the non-pregnant adults. pregnant women, as a special population with immune suppression, are reported at a higher risk to infectious diseases. the increased risk of complication with the pandemic h n influenza virus, and the higher casefatality rate with sars-cov and mers-cov infections was found in pregnant women compared with nonpregnant adults. , to date, limited data are available about covid- pneumonia during pregnancy. previous studies have described the clinical characteristics and intrauterine vertical transmission potential in pregnant women with covid- pneumonia and compared their outcomes with those of general population. [ ] [ ] [ ] the clinical and radiological characteristics as well as the outcomes of pregnant women with covid- pneumonia in comparison with the gender-and age-matched population have not been reported in detail. the pregnancy complications and adverse outcomes have been reported more common among pregnant women with sars and mers than the age-matched non-pregnant women. however, the outcomes for pregnant women with covid- pneumonia remained unclear. in this case-controlled study, we aimed to investigate the clinical features, serial chest ct findings, and outcomes in pregnant women with covid- pneumonia by comparing with age-matched non-pregnant women, which are crucial for profiling the disease in the special populations seeking the early detection, accurate diagnosis, and timely obstetrical management. clinical and ct data of pregnant women and nonpregnant women with laboratory-confirmed covid- pneumonia between and years old from january to march , in the two enrolled centers were retrospectively reviewed. the exclusion criteria were as follows: (a) lack of complete clinical records (n= ); (b) lack of follow-up data (n= ); (c) simultaneous infection with any other common pathogen such as mycoplasma pneumonia, chlamydia pneumonia, respiratory syncytial virus, adenovirus, coxsackie virus b, influenza a, influenza b, or human parainfluenza virus (n= , co-infection with influenza a); (d) insufficient image quality due to the severe artifacts affecting the image assessment (n= ). finally, pregnant and age-matched non-pregnant women were recruited in this study. one was from xinhua hospital affiliated to shanghai jiao tong university school of medicine and the others from maternal and child health hospital of hubei province. reverse-transcription polymerase chain reaction (rt-pcr) tests were performed using pharyngeal swab samples twice for each patient at to days after symptom onset by the local center for disease prevention and control following the who guideline. clinical characteristics, ct features, and outcomes were compared between the two groups. according to the chinese management guideline for covid- (version . ), the clinical severity of covid- was grouped into four types: ) mild type, slight clinical symptoms but no imaging presentations of pneumonia; ) common type, fever, respiratory symptoms and imaging presentations of pneumonia; ) severe type, any of the following: respiratory distress with respiratory rate ≥ breaths per minute, oxygen saturation ≤ % in a resting state or arteria oxygen tension (pao )/inspiratory oxygen fraction (fio ) ≤ mmhg ( mmhg= . kpa); ) critically severe type, any of the following: respiratory failure needing mechanical ventilation, shock, or combination with other organ failure needing intensive care unit (icu) monitoring and treatment. all patients underwent non-enhanced chest ct scans in the supine position during end-inspiration, using one of the section multi-detector ct scanners (uct , united imaging, shanghai, china, or optima , ge medical system, milwaukee, wi, usa). the ct scan covered from thoracic entrance to the level of posterior costophrenic angle. the parameters were as follows: tube voltage kv, automatic tube current ( - ) ma, thickness ( - ) mm, slice interval mm, rotation speed . s or . s, and helical pitch . : or . : . the noise index (ni) and dose-length product (dlp) were and - mgy·cm for pregnant women, while . and - mgy·cm for non-pregnant women. thyroid, abdomen, and pelvis were protected by lead sheath during ct examinations. lung window images at . to mm thickness were reconstructed. iterative reconstruction technique was implemented. the informed consents for ct examination were obtained from all patients. experience in thoracic imaging, respectively). the disputes between the radiologists were resolved by consulting another experienced radiologist (dw or wl, with more than years of experience in thoracic imaging, respectively). the radiologists were blinded to the pregnancy status of patients. ct features consisted of lesion number, distribution, and density. the lesion was counted as the involved lung segments if a lesion extends across multiple lung segments. distribution included unilateral or bilateral lungs, and peripheral or central locations. density included pure ggo, ggo with consolidation, ggo with reticulation (intralobular/interlobular septal thickening), pure consolidation, air bronchogram, and cavitation. lymphadenopathy within the mediastinum and pleural effusion were also analyzed. peripheral distribution was defined as the outer one-third of the lung and lymphadenopathy as the size of lymph node more than mm in short-axis diameter. a ct scoring method was used to quantify the extent of lesions. each of the lung lobe involvement was scored from to as follows: as none involvement; as < % involvement; as %- % involvement; as %- % involvement; as %- % involvement; and as > % involvement. the total ct score was obtained by summing the scores of the five lobes ranging from to . according to the previous reported time intervals of disease progression stages, , the baseline images (stage , - days) and serial follow-up images including stage ( - days), stage ( - days), and stage (> days) were comparatively analyzed based on the time intervals from symptom onset. the imaging parameters were the same as the initial baseline ct imaging. the images were reviewed by the same radiologists in consensus (hl and fl). the ct scores of both lungs and presence of lesions were assessed and compared with previous ct findings to evaluate the recovery course. the clinical characteristics and outcomes of female patients are demonstrated in table . the pregnant and casecontrolled groups were matched for gender, age, and underlying illness. the mean age of the pregnant and non-pregnant groups was ( ± ) years and ( ± ) years. there were no underlying chronic diseases among all patients, but two pregnant women had gestational diabetes and three had gestational hypertension with two accompanied by mild preeclampsia or abnormal liver and cardiac function. the gestational age on admission was weeks for one pregnant woman, and the others were in their third trimester at presentation ranging from weeks to weeks plus days (median gestational age, weeks). the common symptoms were fever, cough, and fatigue in both groups. compared with non-pregnant women, initially normal body temperature, leukocytosis, elevated neutrophil ratio, and normal lymphocyte count were more frequent in the pregnant group. none had leukopenia. all pregnant women lived in wuhan and eight of them were associated with familial clusters. totally pregnant women underwent delivery, ten of whom delivered ten full-term infants. among them, five underwent cesarean sections and the other five were vaginal delivery. seven neonates (five singletons and two twins) born to the remaining six mothers were delivered premature between - weeks of gestation. the -min and -min apgar scores for all the neonates were - and - . the causes of premature birth were as follows: intrauterine distress (n= , %), premature rupture of dovepress membrane (n= , %), and premature labour at or weeks of gestation (n= , %). one pregnant woman was admitted to the icu after cesarean section. in the nonpregnant group, one patient used non-invasive mechanical ventilation. six pregnant women with symptoms occurring after delivery received antibiotics and antivirals treatment. other pregnant women with prepartum symptoms onset received only antibiotics before delivery and then combination of antibiotics and antivirals therapy after delivery. for the non-pregnant women, all the patients received antiviral treatment and ten received combination antibiotics treatment. antibiotics included cephalosporins, quinolones, and macrolides, and the antivirals included oseltamivir and ganciclovir. by the end of this study, two pregnant and three non-pregnant women were still sars-cov- positive and hospitalized for treatment. for the other patients, the length of hospitalization between the pregnant and non-pregnant women was similar. initial ct features of the patients are summarized in table . the median intervals of the initial ct scans from symptom onset were two days (inter-quartile range [iqr] - , range - ) and two days (iqr - , range - ) in the pregnant and non-pregnant groups. seven pregnant women underwent initial ct scans after delivery and the others prior to delivery. there were lesions detected in involved lobes and segments in the pregnant cases, while , , and in the non-pregnant group. peripheral and lower lobe distributions were predominant in both pregnant ( %, %) and non-pregnant groups ( %, %). bilateral distribution ( %) and five lobes involvement ( %) were relatively common in the pregnant cases, whereas unilateral distribution ( %) and one lobe involvement ( %) were more frequent in the non-pregnant group. the most common lesions were pure ggo, ggo with consolidation or reticulation, and pure consolidation in both groups. ggo lesions were the predominant pattern; however, pure consolidation had a higher incidence in the pregnant cases (figure ), whereas ggo with consolidation and reticulation were more frequent in the nonpregnant group (figure ). initial normal ct was found in two pregnant and one non-pregnant woman. minimal pleural effusion was present in seven pregnant women after delivery. pulmonary edema was not detected in those two patients with mild pre-eclampsia. no cavitation and mediastinal lymphadenopathy were identified. the mean ct scores for the whole cohort, pregnant, and nonpregnant women were . ± . , . ± . , and . ± . , respectively. the ct score for pregnant group seemed to be higher compared with that for non-pregnant women. besides the baseline chest ct study in all women (stage ), serial follow-up ct studies were performed in , , and patients for stages - , respectively. for the pregnant women after delivery, follow-up ct was usually performed on approximately , , , or days after treatment according to the disease severity. for the pregnant women prior to delivery, follow-up ct was performed at approximately or days after treatment. the incidences of ggo, ggo with reticulation, and consolidation (including mixed and pure consolidation) of the four stages are demonstrated in figure . incidence of consolidation or reticulation in the initial pure ggo lesions, more pure consolidation lesions, or larger extent of lesions indicated more severity during the follow-up. in stage , ggo was predominant in both groups. the ct scores were . ± . and . ± . for pregnant and nonpregnant groups, respectively. in stage , / ( %) pregnant and / ( %) non-pregnant women presented progression. more ggos, mixed ggos with consolidation, and more pure consolidations were identified during follow-up (figures and ) . ct scores for the pregnant and non-pregnant women were . ± . and . ± . . however, the consolidation increased to % and % from % and % in stage for the pregnant and nonpregnant groups. in stage , / ( %) pregnant and / ( %) non-pregnant women harvested improvement. ct scores for the pregnant and non-pregnant women were . ± . and . ± . , and incidence of consolidation was % and %. continuous improvement was observed in / pregnant and / non-pregnant women in stage , in which ct scores were . ± . and . ± . and the consolidation frequency decreased to % and % in the above groups. notably, consolidation was still more common in the pregnant group in the final stage. to the best of our knowledge, this case-controlled study is the first case series to compare the clinico-radiological features and outcomes between pregnant and agematched non-pregnant women. our study found that initial absence of fever and normal lymphocyte count were more frequent for pregnant women compared with the controlled cases. more severe covid- pneumonia was initially identified at imaging in pregnant women with more frequent pure consolidation. regarding the recovery, pregnant women experienced comparatively more severe progression and a slower recovery course while there were no significant adverse outcomes for the pregnant women. for pregnant women, specific physiological and anatomical changes during pregnancy involved almost all organ systems, such as increased heart rate and oxygen consumption, decreased functional residual capacity of lungs, immunologic adaptations, etc. as demonstrated in our study, although pregnant women presented post-partum fever, the initial fever was detected in only % of patients compared with % in the non-pregnant group, which could be contributed to the slow or weak response to the virus in the immunosuppressive condition during pregnancy. leukocytosis and elevated neutrophil ratio were presented in % and % of pregnant women, while the incidence of lymphopenia was lower in the pregnant group, which was not characteristic in patients with covid- pneumonia. these discrepancies could be ascribed to physiological phenomena in pregnancy. during this ongoing outbreak, fever is the principal surveillance index for covid- , and laboratory results including leukopenia or normal blood white cell count as well as lymphopenia were listed as the typical clinical findings. therefore, the physiological adaptions to pregnancy make it challenging to early identify the covid- in pregnant women if without any additional evidence. hence, early diagnosis, isolation, and treatment are crucial for the pregnant women and neonates. ct plays an important role in the surveillance for covid- with a higher sensitivity and time efficiency superior to rt-pcr, which can be regarded as the modality of choice for pregnant women in the third trimester with high suspicion of covid- , especially in the epidemic area. in our cohort, of pregnant women were performed chest ct imaging prior to delivery. low dose technique was implemented with dlp ranging from to mgy·cm for diagnostic imaging, which was safe for the fetuses. the mean age of enrolled patients was younger ( years, rang - ) and the mean ct score was lower ( . ) than the older patients ( years, . ). most patients ( / , %) were grouped as the mild or common types except two patients developed severe pneumonia using mechanical ventilation in our cases. our results were consistent with previous studies reporting that younger patients experienced less severe covid- pneumonia compared with the old-age people (> years) with comorbidities. , , when compared between the pregnant and aged-matched non-pregnant groups, the patterns of lesions were similar, including pure ggos, ggos with consolidation or reticulation, and pure consolidations. the presence of lesions was also similar to the general population as our previous study reported. these imaging features were in concordance with the pathological findings of covid- , manifesting that diffuse type ii alveolar epithelial proliferation, intra-alveolar serous exudates, hyaline membrane formation, and alveolar septum edema, along with intraluminal bronchial mucous plug, mononuclear inflammatory infiltrates (dominated by lymphocytes), and fibrosis in pulmonary interstitium. however, the lung involvement was a bit more severe for pregnant women with a higher incidence of consolidation compared to the age-matched group. some reasons could be responsible for this phenomenon. for one thing, the immunosuppressive status of pregnant women and the physiological adaptive changes in pregnancy such as dilatation of respiratory airways, and hyperemia and edema of the mucosal surfaces mediated by elevated progesterone, and decreased functional residual capacity increased the risk to covid- infection. for the other, the asymptomatic status and laboratory tests could delay the recognition and diagnosis of this disease. as for the recovery course, the progression stage of - days from symptom onset was similar in both groups, which could be reflected by the elevated ct scores and increased proportion of consolidation. the improvement was observed during stage ( - days), which was depicted by the decreased ct scores and frequency of consolidation in both groups. the pregnant women experienced more severe progression and a slower recovery course. the incidence of consolidation was higher for the pregnant group in stage after antiviral treatment, and the frequency of consolidation was also higher in stage (> days) after continuous treatment. we speculated that the immunosuppressive status may affect the recovery course with superimposition of compromised medications for treatment, which were supposed to avoid impairment on fetuses in pregnancy. fortunately, there was no evidence that the clinical outcomes were obviously worse for pregnant than the age-matched non-pregnant women. in our study, ct was proved as a useful tool in diagnosing and monitoring covid- pneumonia in pregnant women under the extraordinary circumstances during covid- pandemic for better maternal and fetal outcomes. although the low dose technique and a relatively long time interval for follow-up ct were implemented, and the total radiation dose was less than mgy, which was reported to be not associated with the possible dosedependent adverse outcomes such as fetal demise, growth restriction, organ malformations, and cognitive deficits. anxiety could be raised among certain pregnant women due to the increased radiation dose during serial follow-up ct scans. recently, lung ultrasound, a radiation-free tool, was found to be useful in screening and diagnosing covid- in pregnant women, especially for the asymptomatic patients on presentation accounting for approximately onethird of all pregnant women in the united states. [ ] [ ] [ ] effective screening of covid- in asymptomatic pregnant women could avoid the delayed diagnosis and management. however, lung ultrasound plays a limited role in detecting lesions located in the central or inner zone areas. furthermore, the treatment assessment of covid- pneumonia could be affected by the lack of standardized patient's positions and different experiences of operators. hence, an applicable screening, diagnostic, and monitoring process of covid- pneumonia can be developed by choosing the best modality of lung ultrasound or ct examination for better maternal and fetal outcomes. when compared to the reported outcomes of pregnant women with sars or mers infections, the prognosis of patients with covid- in our study was better. wong et al reported that % of pregnant women with sars died, and % were admitted to icu. besides, % of pregnancy with first-trimester infections and % with third-trimester infections ended in spontaneous abortion and preterm delivery. mechanical ventilation was applied three times more than that in non-pregnant women with sars. for pregnant women with mers, % of patients were admitted to icu, while % required ventilator support, and % died after delivery. in our study, one case in each group developed severe covid- pneumonia requiring mechanical ventilation, which was mostly dissipated at follow-up chest ct after and days from admission. no patient died in either group. preterm delivery occurred in six pregnant women ( %), and intrauterine distress occurred in one fetus ( %), whereas the premature rupture of membranes in three cases with suspected infection ( %), which were less common compared with previous studies. , our study had several limitations. firstly, the sample size was relatively small, larger population from more centers should be warranted to validate our preliminary results. secondly, we tried our best to match the time intervals of follow-up ct from symptom onset in two groups. however, the initial prepartum absence of fever occurred in some pregnant women and the complicated status of pregnant women made it difficult to match the follow-up time for each patient. thirdly, the treatment strategies were different for pregnant women, which could affect the evaluation of clinical outcomes. however, although the pregnant women did not receive antiviral treatment before delivery, all the pregnant women achieved good outcomes similar to the non-pregnant women. finally, as for the outcomes, the follow-up term in our study was relatively short. the longterm follow-up for the effects of covid- should be further investigated. our preliminary study revealed that the clinical symptoms and laboratory tests of covid- in pregnant women were not characteristic compared with the age-matched nonpregnant women, which was challenging in a battle for screening the covid- in pregnancy. lung involvement was a bit more severe in the pregnant women at presentation and the patients were supposed to take a relatively longer recovery course, even though the prognosis was not poorer than that of the non-pregnant women. therefore, early detection, diagnosis, and timely obstetrical management are crucial for better maternal and fetal outcomes. ground-glass opacity; rt-pcr, reverse-transcription polymerase chain reaction; iqr, inter-quartile range. all data generated or analyzed of this study are included in this published article. raw and processed data during the current study are available from the corresponding authors upon reasonable request. this study was conducted in accordance with the declaration of helsinki and approved by the institutional ethics committee of maternal and child health hospital of hubei province ( / / , -iec-lw ) and xinhua hospital affiliated to shanghai jiao tong university school of medicine ( / / , xhec-c- - ). we performed a retrospective analysis of patient clinical information and did not conduct experiments on patient specimens. all patient data were 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computed tomographic findings in pregnant woman with covid- pregnancy and perinatal outcomes of women with severe acute respiratory syndrome a case-controlled study comparing clinical course and outcomes of pregnant and non-pregnant women with severe acute respiratory syndrome all authors declare no potential conflict of interest relevant to this article. all authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.infection and drug resistance : submit your manuscript | www.dovepress.com infection and drug resistance is an international, peer-reviewed openaccess journal that focuses on the optimal treatment of infection (bacterial, fungal and viral) and the development and institution of preventive strategies to minimize the development and spread of resistance. the journal is specifically concerned with the epidemiology of antibiotic resistance and the mechanisms of resistance development and diffusion in both hospitals and the community. the manuscript management system is completely online and includes a very quick and fair peerreview system, which is all easy to use. visit http://www.dovepress.com/ testimonials.php to read real quotes from published authors. submit your manuscript here: https://www.dovepress.com/infection-and-drug-resistance-journal key: cord- - s u dl authors: nan title: inaugural meeting of the international society of obstetric medicine: – october , fremantle, western australiarefereed abstracts of original oral presentations at the meeting date: - - journal: aust n z j obstet gynaecol doi: . /j. - x. . .x sha: doc_id: cord_uid: s u dl nan the aim of this review was to examine the pregnancies and their outcomes in women with an autoimmune disease at nepean hospital over the past years and to compare these to the nonautoimmune women. to achieve this, a retrospective review of the obstetric database of all births from to (inclusive) was performed. comparisons included medical conditions, medications during pregnancy and pregnancy outcomes. sub analyses were used to explore differences in the various autoimmune disease groups and also medication regimes in all women. there were a total of births with births to women with an autoimmune disease. there was a significantly higher incidence in autoimmune women compared to nonautoimmune women of cardiac ( vs %; p < . ), valvular ( vs . %; p < . ), renal ( vs %; p < . ), haematological ( vs %; p < . ), respiratory ( vs %; p = . ), skin ( vs %; p = . ), endocrine ( vs %; p < . ) and hypertensive ( vs %; p < . ) disorders. the major measure of pregnancy outcome was the stillbirth rate which was significantly higher (p = . ) in the autoimmune women ( . %) than in the nonautoimmune women ( . %). this review confirms the high-risk status of pregnant women with an autoimmune disease and will be the basis for future prospective studies directed at those factors that can be modified. the recent worldwide outbreak of severe acute respiratory syndrome (sars) has been implicated in the development of a life-threatening, atypical pneumonia in humans. several cases have been reported in pregnant women in hong kong, and isolated cases have been reported in singapore and canada. recent microbiological evidence points to a novel coronavirus that is spread via contact or droplet transmission. limited data are available regarding the epidemiology and natural history of this disease, and there is no published information regarding the outcomes associated with pregnancy. given the apparent virulence of the sars organism and the decrease in cell-mediated immunity associated with pregnancy, disease progression in pregnant women may be comparable to the more severe types of viral pneumonia that result in high maternal and perinatal morbidity and mortality rates. given the significant maternal and perinatal morbidity and mortality of viral pneumonia in pregnancy, sars may impose greater risk in pregnant compared to non-pregnant individuals. caring for sars-affected pregnant women also poses several questions regarding labour and delivery management, as well as the protection of health care providers. we report outcomes of women diagnosed with sars during pregnancy from collaborating centres in canada and hong kong. the clinical presentation of sars in pregnant women is described. sixty percent of pregnant women with sars required intubation. thirty percent of patients were delivered preterm. the rate of caesarean section was %. three maternal deaths were reported. we also describe our centre's approach to labour and delivery suite organisation in view of caring for sars-exposed and affected pregnant individuals, as well as the management of exposed neonates. the physiologic adaptations to pregnancy can potentially worsen the prognosis in women whose pregnancy is complicated by heart disease. a comprehensive systematic approach to risk identification is desirable. the ability to predict a subgroup of women that are at a particularly increased risk of pregnancyrelated complications can enhance the obstetric care we provide to this population. a retrospective review of pregnancies associated with pre-existing heart disease was undertaken in three toronto teaching institutions. during the course of the pregnancy, ( %) out of completed gestations were complicated by adverse cardiovascular events (congestive heart failure, arrhythmia, and stroke). poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events were predictive of maternal cardiac complications. these prior predictors were converted into a point score. if a point score was , , or more than , the risk of a patient developing an adverse cardiac event, was , , and %, respectively. the canadian prospective multicentre study allowed validation and simplification of this prediction rule. in this study, centres prospectively recruited patients with australian and new zealand journal of obstetrics and gynaecology ; : - completed gestations. similar factors were identified that predicted adverse cardiac events. in addition neonatal complications ( % of pregnancies) were associated with poor functional class or cyanosis, left heart obstruction, anticoagulation, smoking, and multiple gestation. a sample of this prospective cohort ( pregnancies) was compared to matched pregnancies with no underlying heart disease. the neonatal complication rate was higher in the study group when compared to controls, verus %, respectively. the highest neonatal complication rate ( %) was seen in gravidas with underlying heart disease, who had previously identified cardiac risk factors, who were at both extremes of reproductive age, who had obstetrical risk factors, who smoked, or who received anticoagulants. both maternal and neonatal morbidity is significantly increased in gravidas with pre-existing heart disease, although mortality is low. factors that place the mother and the neonate at risk can be identified prior to pregnancy. this allows informed counselling and development of patient-specific management plan. to evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country, a retrospective analysis was carried out of pregnancies in women with cardiac disease who delivered at ≥ weeks of gestation from june to december at a tertiary care centre. rheumatic heart disease (n = , %) with isolated mitral stenosis (n = ) was the predominant cardiac problem. septal defects were the most common form of congenital heart disease (n = ). in ( . %) women, the diagnosis of cardiac disease was made during pregnancy. cardiac complications were noted in ( . %) and fetal complications in ( . %) pregnancies. patients in new york heart association (nyha) class i-ii (n = , . %) had fewer maternal complications and their babies had a higher birthweight than those in nyha class iii-iv (n = , . %). cardiac intervention was performed prior to pregnancy in ( . %) patients with rheumatic heart disease: ptmc/cmv in and valve replacement (vr) in . maternal and fetal outcome was better in patients with prosthetic valves (n = ) and the majority ( . %) of them remained in nyha class i-ii. cardiac intervention was safely carried out during pregnancy in women (ptmc in seven, cmv in one, and vr in two). one of them developed congestive cardiac failure during labour. none of the newborns of the women who had received anticoagulants had any congenital malformation. rheumatic heart disease was the predominant type. patients in nyha class i-ii had a better maternal and fetal outcome than those in nyha class iii-iv. surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. pregnant women with prosthetic valves tolerated pregnancy well. the chips trial will determine if 'less tight' (vs 'tight') control of mild-moderate non-proteinuric hypertension in pregnancy will decrease adverse perinatal outcome without increasing maternal risk. first, the chips pilot trial will determine compliance with the trial intervention of differential bp control. the chips pilot will recruit women ( per arm) internationally over year. inclusion: dbp - mmhg due to preexisting or gestational hypertension; live fetus(es); and - + week. exclusion: severe hypertension; proteinuria; contraindication to either arm or to pregnancy prolongation; or known major fetal anomaly. treatment: randomisation to either 'less tight' control (target dbp ± mmhg) or 'tight' control (target dbp ± mmhg) of bp. interventions follow-up: standardised bp measurement. dbp and bp therapy will be recorded in a patient-held diary. at , , and weeks, the trial co-ordinator will meet with women to review the diary and bp management, and have dbp measured independently. other outcomes will be assessed during delivery admission when women will complete a questionnaire about their views. cihr funded. recruitment from apr/ . interested centres should contact l magee (lmagee@cw.bc.ca) for chips study group. maternal pulse pressure in severe early onset pre-eclampsia steyn w assessment and management of hypertension in pregnancy depend on systolic blood pressure (sbp) and diastolic blood pressure (dbp). relatively little has been published about pulse pressure. we assessed the characteristics of maternal pulse pressure (pp) in severe early onset pre-eclampsia (pe). blood pressure in mothers with severe pe before weeks' gestation who were managed expectantly was also measured every min on alternative days with the pregnancy validated spacelabs ambulatory monitor. these results were not available to managing clinicians. women were managed according to departmental policy. the mean pp of measurements obtained from women was . ± . mmhg. the pp correlated significantly with the sbp (r = . ; p < . ), the dbp (r = − . , p < . ) and the mean arterial pressure (map) (r = . , p < . ). this correlation between pp and sbp remained significant for all pp values. the correlation between pp and dbp was not significant when only the upper quartile of pp was considered. pp was also significantly influenced by parity (multipara = . mmhg; primipara = . mmhg, p < . ), medication used and gestational age (ga) (ga - weeks = . mmhg; ga - weeks = . mmhg, p < . ). the mean pp was higher at night ( . ± . vs . ± . ; p < . ). mean sbp and mean map were significantly higher in the upper quartile of pp compared with the lower quartile ( . vs . mmhg and . vs . mmhg, respectively), while dbp decreased ( . mmhg vs . mmhg). pulse pressure changes in women with severe pre-eclampsia are compatible with increased arterial stiffness and seem to be influenced more by sbp than dbp. the implications of these findings should be further investigated. objectives: both elevated mid-trimester maternal serum hcg and abnormal uterine artery doppler flow velocimetry waveforms have been associated with adverse pregnancy outcomes but neither test has been demonstrated to have adequate utility as a predictive marker. we set out to assess the predictive capacity of a two step screening process. methods: in our institution women with an unexplained elevated mid-trimester hcg level (= . mom) are offered uterine artery doppler assessment at - weeks' gestation. we have audited the utility of this practice by reviewing the prevalence of the adverse outcomes of gestational hyertension, intrauterine growth restriction (iugr) and preterm birth. results: sixty-two women had a serum hcg = . m m and underwent doppler study of uterine artery flow velocity waveform (ut afvw). notching of the ut afvw afforded better predictive utility for any outcome than the resistance index (ri) alone or in combination with notching. for a composite adverse outcome of gestational hypertension, birthweight = th centile and preterm delivery (< weeks) the presence of a uterine notch alone had sensitivity of . %, specificity of . %, a positive likelihood ratio of . and a negative likelihood ratio of . . for the identification of severe fetal growth restriction, < th centile, and pre-eclampsia, the presence of a notch offered a sensitivity of %, specificity of . %, a positive likelihood ratio of . and a negative likelihood ratio of . . conclusions: the identification of uterine artery notching by doppler ultrasound as a component of the surveillance of women with unexplained elevated hcg levels significantly improves the prediction of pre-eclampsia and severe iugr. low-molecular-weight (lmw ) heparins have been shown to be at least as effective as unfractionated (uf) heparin in the treatment of deep venous thrombosis (dvt) in non-pregnant subjects. lmw heparins have been shown to be safe when used during pregnancy as they do not cross the placenta. up to now they have been used mainly in thromboprophylaxis during pregnancy and rarely in the treatment of acute dvt in pregnant women. in a prospective observational study we compared the effectiveness and safety of the lmw heparin dalteparin versus uf heparin as initial treatment (first week) of dvt during pregnancy. after confirmation of dvt by ultrasonography, women were treated with uf heparin ( iu/day, mean) and women with dalteparin ( iu/day, mean) for days and thereafter all women were given treatment doses of lmwheparin for another weeks. the dose was then gradually decreased and kept at high prophylactic dose until delivery. one patient in the dalteparin group had recurrence of dvt weeks after starting the treatment. no differences were observed between the groups in symptoms or bleeding complications during pregnancy and delivery. our results indicate that lmw heparin is as effective and safe as uf heparin for the first week of treatment, but lmw heparin has the advantage that it is easily administered and few laboratory controls are required. metastatic paraganglioma and pregnancy: a case report of a successful pregnancy outcome adair s, ellwood d, yip d, carney g, kecskes z and tucker k metastatic para-ganglioma is a very rare condition, recently shown to be sometimes due to autosomal, dominantly transmitted mutations in sdhb, d and c genes. the patient ( years old) presented with recurrent abdominal pain and a year history of hypertension. ct scan demonstrated a para-aortic mass, and mibg scan revealed three intra-abdominal foci. surgical resection of the tumours followed and histology confirmed metastatic parganglioma. she subsequently developed additional lesions in her thorax and left hip, and was treated with ablative mibg therapy. she became inadvertently pregnant in early , and underwent further mibg and ct scans in early pregnancy prior to the diagnosis. she was seen for antenatal care at weeks and counselled about the risks of continuing the pregnancy, as well as the risks to the fetus. blood pressure medication initially was with phenoxybenzamine, but this was changed to labetalol mg b.d. at weeks with good control. ultrasound scans at , , , and weeks were normal. after corticosteroid administration, she underwent elective caesarean section at weeks to allow for further mibg ablative therapy to take place. the infant was female, weighed g and required only short-term ventilation for hyaline membrane disease. this case illustrates a successful pregnancy outcome in a woman with a serious, and potentially lethal condition. there were particular unknown fetal risks, both teratogenic and genetic, as well as potentially serious maternal risks of severe hypertension and disease progression. a multidisciplinary approach to management was an essential ingredient in this case. case reports have shown that pre-eclamptics with visual disturbances can have retinal detachments. the aim of this study was to identify the nature of ophthalmological abnormalities in patients with pre-eclampsia and persistent visual disturbance beyond delivery. all women with pre-eclampsia and visual disturbance persisting beyond the first postnatal day at groote schuur hospital over a year period underwent formal ophthalmological review. twenty-two pre-eclamptic women required ophthalmological assessment for persisting visual disturbance postpartum. all women had severe pre-eclampsia with at least + proteinuria australian and new zealand journal of obstetrics and gynaecology ; : - and a mean highest antenatal blood pressure of / . twentyone ( . %) women had an abnormality identified at fundoscopy or ct scan. seventeen ( . %) women had exudative serous retinal detachments ( of which were bilateral). eight ( . %) women had elshnig's spots (ischaemic infarcts in the choroid). all those with elshnig's spots had retinal detachments. three ( . %) women had parieto-occipital infarcts identified on ct scan. one patient had cortical blindness and one had optic atrophy. fundoscopically defined retinal abnormality occurs in most pre-eclamptic women with visual disturbances persisting beyond the first postnatal day. the most common abnormalities are exudative serous retinal detachment, which are usually reversible, and elshnig's spots. these are both manifestations of choroidal ischaemia. parieto-occipital infarction, cortical blindness and optic atrophy can also occur. blackburn ca, powrie ro, sauve n, sung j, eidson e, henry d and rosene-montella k like all aspects of healthcare, management of pregnancy induced hypertension (pih) in hospital is subject to errors and ineffectiveness. we conducted process improvement strategy known as failure mode and effect analysis (fmea) to identify potential problems and improve the management of pih in our hospital. from october a multidisciplinary team was formed to perform the fmea. we reviewed all aspects of the process of management of pih from referral to hospital until discharge. for each activity we identified potential problems (failure modes), defined their causes and surmised the effects if failures occurred. numerical scores were assigned for the likelihood of failure occurrence and the severity of the effects. these scores were multiplied and reported as a risk priority number (rpn) for each failure mode. solutions and monitoring plans were developed to address the failure modes with the highest rpns. four top areas needing improvement were: (i) accuracy of blood pressure measurement; (ii) patient education; (iii) evaluation of proteinuria; and (iv) assessment and treatment of severe hypertension. each of these initiatives, with the changes implemented and their monitoring processes, will be described. the fmea is a useful process for identifying and implementing institutional change in regards to the management of pih. our process may serve as a model initiative to other institutions with similar needs. fertility returns within months of successful liver transplantation. by june approximately liver transplants had been performed on australian women of potentially child-bearing age. the course and outcome of seven pregnancies in four liver transplant recipients is described. four of the pregnancies in three mothers were complicated by intrahepatic cholestasis, and one pregnancy was complicated by acute on chronic renal failure requiring dialysis. the literature on pregnancy outcome in liver transplant recipients and the management of acute on chronic renal failure in pregnancy is discussed. until recently the diagnosis of obstetric cholestasis (oc), if made at all, was made on the basis of clinical observation, with apparent considerable inaccuracy. however, while the condition can increase risk of perinatal mortality and maternal morbidity, the current treatment of ursodeoxycholic acid to reduce bile acid level in blood, involve use of this medication which is said to be potentially teratogenic and not licensed for use in pregnancy. hence, it is extremely desirable to be able to identify with accuracy those cases really need of such treatment. accordingly, we are attempting to identify a suitable local protocol for management of these. we have carried out a review of all pregnant women who had had serum total bile acid levels measured during the whole of . they were identified from the biochemistry database, and individual case notes were reviewed. an initial review was carried out on women who had had serum bile acid levels measured on one or more occasions during the last quarter of . a total of tests had been performed on cases during the period. eighteen cases were found to have levels within normal limits, four required ursodeoxycholic acid, and labour was induced in three women who were approaching term and remained symptomatic (but serum bile acid levels were only slightly raised). the remaining six cases resolved spontaneously, with raised initial bile acid levels falling to within normal in subsequent tests. we shall present the outcomes of the review of all cases, with reference to our own normal range, and on the basis of this, we shall make recommendations for a protocol for diagnosis and management of oc, with a view to reduce perinatal mortality and maternal morbidity. serum glutathione s-transferase alpha - , an index of hepatocellular damage, is raised at weeks' gestation in women who develop obstetric cholestasis girling j, dann a, kenyon a, seed p, nelson-piercy c, williamson c, shennan a and tribe r statement of purpose: glutathione s-transferase alpha - (gsta - ) is a highly sensitive and early indicator of hepatocellular damage. to determine in a longitudinal study whether gsta - is a useful marker for obstetric cholestasis (oc) and whether it distinguishes between oc and pruritus gravidarum (pg). statement of method: serum gsta - was measured in women who developed oc at a median gestation of . weeks (range - . ) (those on ursodeoxycholic acid were excluded); with pg and with normal pregnancy. serum was sampled at least three times between weeks' gestation and delivery. summary of results: gsta - increased with gestation in the oc group (but not the other groups) and was significantly greater by weeks' gestation than in normal pregnancy and pg. in the oc group there was a highly significant correlation (p < . ) between gsta - level and alanine aminotransferase (spearman's rank correlation: r = . ), and total gsta - was not related to severity of pruritus specificity . % (ci: . - . %), positive predictive value . % (ci: . - . %), negative predictive value . % (ci: . - . %), and the likelihood ratio for a positive conclusion: this is the first series of gsta - measurement in oc or pg. gsta - is a useful marker of liver dysfunction in distinguishing women with oc from those with pg. interactive case presentation. no abstract available. key: cord- - el uxr authors: berkhout, suze g.; richardson, lisa title: identity, politics, and the pandemic: why is covid- a disaster for feminism(s)? date: - - journal: hist philos life sci doi: . /s - - - sha: doc_id: cord_uid: el uxr covid- has been called “a disaster for feminism” (lewis in the coronavirus is a disaster for feminism, ) for numerous reasons. in this short piece, we make sense of this claim, drawing on intersectional feminism(s) to understand why an analysis that considers gender alone is inadequate to address both the risks and consequences of covid- . calls to track disproportionate risks and consequences of the coronavirus disease (covid- ) pandemic for women have come from a range of sectors. globally, limited gains in gender equality since the beijing platform for action have been flagged as at risk of being rolled back as the pandemic deepens preexisting inequalities (united nations policy brief, april ). early in the pandemic, nature published a commentary discussing how social restrictions impact women especially, given that they are disproportionately responsible for family care work and also make up the majority of single parents (minello ) . unpaid care responsibilities have increased dramatically as covid- has closed schools, overwhelmed health services, and heightened the care needs of older persons-these have both disproportionately burdened women and exposed the fragility of women's roles in the paid economy (power ) . in the popular press, covid- has been called "a disaster for feminism" (lewis ) as heightened care obligations within the pandemic context negatively impact many women's financial and employment security. in this short piece, we make sense of how covid- has been considered a disaster or crisis for feminism(s) and why an analysis that considers gender alone is inadequate to address the issues. in answering this question, it is crucial to emphasize "women" are not a uniform demographic group. feminist discourses surrounding the pandemic that fail to locate intersections of racism, patriarchy, ableism and heteronormativity (amongst other axes of social power) will be inadequate for understanding and addressing vulnerability: an intersectional analysis is needed along with a response that centres the experiences of multiply positioned community members. we bring to this analysis our own positionalities: suze berkhout is an urban, white, settler woman; she is a clinician-investigator in feminist science and technology studies (sts) and philosophy whose research is embedded in ethnographic methodologies and she is a practicing psychiatrist. lisa richardson is a mixed anishinaabe kwe who is a clinician-educator and education researcher with a focus on the integration of critical, indigenous and feminist perspectives in medical education; she practices as a general internist and leads numerous indigenous health initiatives at the local and national level. as physicians as well as researchers, each of us brings our understandings of intersectionality to our clinical and academic work. intersectionality refers to the multiple ways in which oppressive systems overlap: injustices are based not only on gender, but on race, ethnicity, sexuality, economic background, (dis)ability, geography, and religion, as well as other sources of discrimination and subordination. an intersectional analysis offers a way of thinking about how such systems intersect and interact, impacting individuals who are differently positioned with respect to their social identities (cho et al. ) . with origins in critical race theory and black feminist scholarship, intersectionality was developed as an alternative to forms of identity politics that ignore or conflate intra group differences (crenshaw ) ; it focuses instead on the shifting webs of relationships that our identities are tied to (woods ) .taken up within social justice discourses in a range of scholarly fields, intersectionality is also a critical praxis as much as an analytic strategy. what do intersectional approaches to the pandemic reveal? early in the pandemic, the notion that covid- was a "great equalizer" was frequently touted. this view, that risks from the virus could impact anyone regardless of their positionality, has been roundly criticized as the pandemic amplifies existing health inequality (mein ). an intersectional feminist analysis helps to understand how disproportionate risks are materialized as lived reality. elevated infection and fatality rates have devastated long term care settings across north america and europe. these settings have been flagged as a gender crisis: women are two-thirds of residents and more than % of paid staff (estabrooks and keefe ) . but it is often women racialized as minorities who are engaged in frontline care work, particularly in positions structured by parttime contracts leading to jobs across multiple sites and roles with high exposure and patient contact. in general, long term care settings have had less access to personal protective equipment compared to hospitals, contributing to higher rates of infection amongst staff and residents. many westernized health care systems have emphasized acute services while deprioritizing community care. but it is notable that safety standards decrease along with pay scales when a workforce is racialized and feminized (das gupta ) . and although workplace safety rights are guaranteed through law, non-professionalized care workers are often less able to assert those rights. black, indigenous, latinx, and southeast asian women in these workplaces are also more likely to be caregivers for multigenerational kin or to send financial support to family abroad. they are more likely to depend on their work for subsistence survival. these factors limit their ability to refuse unsafe work (lopez ) . intersections of race, gender, economic position, and migration overlap to heighten risks for particular women especially, within a larger context of funding priorities. prison settings have also experienced notably higher infection rates. an intersectional analysis asks us to consider gender in relation to race, economic background, migration status, and disability, amongst other identities. certainly, covid- exposure in prisons overwhelmingly impacts men racialized as minorities (black men especially), who bear the brunt of police attention, are more likely to receive stiffer judicial penalties, and less likely to access plea bargaining than white men with comparable offenses (nellis ) . but when we consider gender in relation to other axes of social oppression, it is also clear that in canada and in the united states, for instance, indigenous, black, and latinx women are incarcerated at disproportionate rates, even as the white female prison population has grown (kajstura ) . undiagnosed as well as untreated learning disorders, mental health challenges, and physical health concerns are prevalent for racialized women in prison settings (annamma ) ; incarcerated women are much more likely to have had prior mental health hospitalizations and women prisoners have disproportionately experienced past and current abuse compared to both the general community and wider prison populations. we see greater intersections of identity-related vulnerability for women within this context, but such dynamics often remain hidden from public scrutiny. an intersectional analysis offers us a way to understand important aspects of risk for both men and women in carceral settings, including where there are overlapping versus divergent vulnerabilities. when disaggregated data is available, community outbreaks have been clearly shown to be clustered in lower income communities where ethnoracial minority groups reside-groups more likely to have precarious employment in lower paid essential fields, higher density living arrangements, as well as pre-existing chronic illness due to the effects of systemic forms of oppression. an intersectional lens sheds critical light on both the distribution of infection as well as the risks of worse outcomes for those infected. economic precarity, intergenerational trauma, limited access to clean water or nutritious food, greater exposure to pollution are distributed along lines of social power and contribute to a priori illness burden. systemic forms of discrimination often lead to delayed presentations to health services, limiting a person's access to high quality care even where universal healthcare is available. morbidity and mortality due to covid- infection increase with a range of underlying medical conditions, the risks for which are driven by social injustice in ways that are imbricated with individual biologies. when health care resource scarcity results from demand exceeding supply, triage protocols that rely on seemingly objective clinical criteria (e.g. age, underlying respiratory status, presence of underlying medical conditions) can inadvertently reinforce these structural forms of disadvantage, shaped by assumptions about health status, quality of life, and social utility (carrieri et al. ; scully ) . within the larger context of racialized health inequity, gender, economic disadvantage, age, and (dis)ability intersect in ways that lead to differential access to the supports that assist individuals in coping with the sequelae of the pandemic. thinking about intersectionality can contribute to a more robust pandemic response, particularly when embraced within health and social policy. there have been calls, for instance, to ensure that covid- -related data (e.g. infection rates) is disaggregated. failing to collect information about racialized or other relevant social groups obscures disproportionate impacts and contributes to what charles mills has called an epistemology of ignorance (mills ) . but, as has been abundantly clear from the pejorative usages and distortions of scientific data stemming from research on indigenous communities in canada, data cannot be collected and wielded without community involvement. as feminist science and technology studies (sts) scholars have emphasized, data pedagogies need to be re-imagined, and the issue of good relations and trust is central to data governance (coleman ) . who has a voice at the table is a critical issue in policy discussions and decisions relating to how data will be collected and utilized. at a broader level, an intersectional response means supporting and promoting leaders from a range of national and community organizations as well as from local or regional first nations, inuit, and metis governments, where their involvement as advisors, liaisons, or in governance roles is formalized and accountable. non-tokenistic engagement entails that structurally disadvantaged communities are part of developing and implementing solutions-not prescribed them. attending and responding to the intersections of race, gender, economic situation, disability, sexuality, and other axes of oppression meaningfully is crucial to the goals of equity and justice within the covid- pandemic. funding none. conflict of interest the authors declare that they have no conflict of interest. the pedagogy of pathologization: dis/abled girls of colour in the school-prison nexus covid- : a plea to protect the older population toward a field of intersectionality studies: theory, applications, and praxis activating context: disruptive data pedagogies and smart infrastructure mapping the margins: intersectionality, identity politics, and violence against women of color precarious employ-ment: understanding labour market insecurity in canada covid- crisis in nursing homes is a gender crisis women's mass incarceration: the whole pie . prison policy initiative why we capitalize 'black' (and not 'white'). columbia journalism review the coronavirus is a disaster for feminism. the atlantic we are not a machine": personal support workers' (ante)narratives of labour, leisure, and hope amidst politics of genderacialised care in long-term care homes covid- and health disparities: the reality of 'the great equalizer white ignorance the pandemic and the female academic the colour of justice: racial and ethnic disparity in state prisons. the sentencing project the covid- pandemic has increased the care burden of women and families. sustainability: science, practice and policy disability, disablism, and covid- pandemic triage standing in the intersection: feminist voices, feminist practices in communication studies publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -hxxa y authors: nichols, carly e.; jalali, falak; ali, syed shoaib; gupta, divya; shrestha, suchita; fischer, harry title: the gendered impacts of covid- amid agrarian distress: opportunities for comprehensive policy response in agrarian south asia date: - - journal: nan doi: . /s x sha: doc_id: cord_uid: hxxa y covid- and its associated disease control measures have greatly altered everyday life. the burden of these challenges has fallen disproportionately on women. drawing on qualitative inquiry in agrarian north india and nepal, this research note analyzes how south asian covid- lockdowns have affected women's labor responsibilities in sometimes surprising ways. we find increased responsibilities for caregiving within the household, substantial stress in responding to food insecurity, and growing expectations to fulfill public roles in disease response measures. however, we also find that the return of male migrants and youth has, in some cases, reduced women's farming responsibilities and created opportunities for household togetherness at a time of great uncertainty. we conclude that more research is needed to examine the nuanced aspects of covid- 's gendered labor impacts to create comprehensive policy responses to address the multiple and sometimes conflicting effects the lockdown has had on agrarian women's informal labor and well-being. a s covid- and associated movement restrictions upend life around the world, it is well known that the responsibility for responding to these challenges has fallen disproportionately on women (kamdar ; wenham, smith, and morgan ) . globally, care work has long been highly feminized (rai and waylen ) , and the shutdowns of schools, businesses, and transport that occurred in response to covid- have intensified and shifted women's roles globally (wenham, smith, and morgan ) . in the mid-himalayan hills of rural india and nepal, women's unpaid labor has also acted as a shock absorber during the covid- lockdown, which was both strict and sudden. across south asia, women's unpaid labor burden is stark, with women averaging six hours per day compared with men's one hour (oecd ) . these disparities are attributable not only to strictly enforced patriarchal labor roles but also to the fact that large numbers of men and children work and study in cities, so women assume more responsibility for agriculture and livestock. while this is often referred to as the "feminization of agriculture," south asian scholars have argued compellingly that a more apt conceptual frame is the "feminization of agrarian distress," given the poorly remunerative state of agriculture in south asia along with poor village services and infrastructure (pattnaik et al. ) in this research note, we draw on qualitative data collected in nepal and the indian state of himachal pradesh (hp) to explore the complex impacts that covid- and lockdown policies are having on women's labor roles within the context of agrarian distress. our data suggest while the mass sheltering in place of families significantly expanded women's unpaid care work, the presence of returned family members also diminished women's agricultural labor burdens and created opportunities for familial togetherness. in highlighting these themes, our aim is to contribute to policy discussions on how looking at relief efforts in south asia through a feminist lens must entail a more nuanced examination of the ways lockdowns have impacted women within the ongoing crisis of feminized agrarian distress. our data are drawn from qualitative fieldwork conducted from march to june in villages in nepal and hp, india. our sites are socioeconomically diverse, including districts more integrated into urban centers with commercial agriculture (sirmaur, hp, and kavre, nepal), as well as remote areas with higher levels of subsistence agriculture (chamba, hp, and ramechhap, nepal). data were collected by trained field assistants from an existing research project that was disrupted by the pandemic. at the lockdown's onset, field staff returned to their homes with detailed instructions to document how the lockdown was affecting their own families, as well as their neighbors and individuals they could contact by phone. data collection was directed by a series of open-ended questions; assistants were instructed to keep extensive notes throughout the day and reflect on events in daily journals. participating researchers also conducted remote interviews with research subjects identified by field assistants. field assistants were evenly split between men and women, yet all were general category castes (i.e., not low castes) with relatively high education. since sampling relied on their social networks, privileged groups are more represented in our data. to help limit this bias, assistants were instructed to the gendered impacts of covid- amid agrarian distress make explicit efforts to get in touch with marginalized social groups. despite these limitations, we feel our data provide an invaluable view of the gendered impacts of covid- in mid-himalayan agricultural communities. given strong patriarchal gender roles across study sites, it was not surprising that women shouldered additional care work as family members stayed at home. while women had increased responsibilities for cleaning, laundry, and water and fuelwood hauling, the most dramatic impacts related to their role as food preparers. women were faced with a double burden of having to feed more people amid a period of unprecedented food scarcity. the lockdown began at the end of march, when monthly rations were almost depleted, and although all impoverished families in hp received two months of advance rations in april, the increased number of mouths to feed caused stress and rationing. in times of household food scarcity, it is typically the women who eat "last and least" (lentz, narayanan, and de ) , and we heard many reports of similar scenarios across field sites. one nepali woman stated she used to eat at a.m., but since her household had swelled to people, she was too busy cooking for others, so she now ate alone at noon (sunita, gokulganga, may , ). although the risk of contracting the coronavirus through food supplies is minimal, there were widespread perceptions in the villages that vegetables and rations that came from distant market towns could be holding virus particles. one woman in hp lamented, the vegetables come from the mandis [markets], which are very crowded. who knows how many hands it has passed through? if one person gets corona the whole village will get it. (santosh, india, june , ) these anxieties around virus contraction, some unfounded, meant that there were marked declines in dietary diversity, and women had to go to extra lengths to secure vegetables within the village. moreover, women sought to quell household anxiety through more arduous food preparations typically reserved for festivals. this was also something that family members demanded. this was especially true in nepal, which has higher rates of urban out-migration than india. in one nepal site, a . nepal does not have a national food subsidy program like india, so families there received no rations. . pseudonyms are used for all interviews to protect anonymity. woman reported feeling highly stressed because her children had returned from kathmandu and would "get irritated to eat maize every meal," instead requesting common street food snacks and fruit, which she could only sometimes provide (sunita, gokulganga, may , ). women derive much intra-household bargaining power through their roles as food provisioners, and their inability to meet family members demands in a time of scarcity and stress caused them great anxiety. it is critical to note that although most respondents we spoke to had some agricultural lands from which to procure foods, many spoke of marginalized landless households who were suffering because of the shutdown of their daily labor jobs (birbal, sirmour, june , ). alongside more food preparation, women also had to make more trips to haul water and collect fuelwood for their cookstoves. because of fears around both the virus and the police, women reported having to haul water from more distant, less utilized water springs or taking circuitous routes to the forest to avoid roadways where police were strictly enforcing lockdown. women were also responsible for enacting disease prevention measures and attending to the emotional needs of family members fearful about the pandemic. most villagers got information about covid- from television news and forwarded whatsapp messages. given the dearth of information from state or local officials, our respondents took conservative approaches to disease prevention. these included ensuring their children wore masks and practiced proper hand hygiene as well as preparing heated water throughout the day to ensure good immunity against the virus. as most women operated wood-burning cookstoves, this necessitated more frequent trips to forests for firewood. finally, with transport shutdown, there was little ability to go to the hospital or clinic so if householders got ill, the women were responsible for caring for them with traditional remedies. in hp, women also became schoolmasters for children, receiving daily homework assignments via whatsapp to distribute to their children, whom they also supervised. women largely reported that their children were unable to focus on or complete school work. this caused them stress as they mourned a lost year of their children's education. scholars have found that rural parents in india often sustain their own hope for the gendered impacts of covid- amid agrarian distress the future through investing in children's education (jakimow ) . perhaps a more enduring yet subtle impact will be on women's diminishing emotional resources to sustain hope through their children's education: one year of my son's life is lost and as per age he will be behind because in the future if he sits for tests for army, etc., then it will be problematic. . . . even if they pass the child but he does not know anything that a class student should know and it will cause problem later. half the year has passed now and doesn't look like the disease will get over anytime soon. (sunita, sirmour, may , ) moreover, the ability of children to complete schoolwork was dependent on having a working smartphone in the house, leading to further marginalization of the poor. while women faced significant expansions in the burden of care labor, our data also suggest a reduction in agricultural labor because of the presence of more people at home. for example, in hp, one woman explained there are more people at home so work was completed faster. she said, everyone helps in harvesting wheat in the farm. work that took two days now takes one day. now we have a lot more free time. now, we have - hours of rest [whereas] earlier [we had] had only hour of rest. (kiran, sirmour, may , ) experiences similar to kiran's were observed and reported in every field site. while in some households, girl children were tasked with greater work while boys focused on their studies, most respondents reported that boys would attend to fields and animals while girls assisted with cleaning and cooking. these findings highlight how agrarian distress has been shouldered by women as men increasingly seek labor work and children pursue studies in both nearby and distant towns. the data resonate with other scholars' assertion that the so-called feminization of agriculture seen across the global south might be more aptly called the feminization of agrarian distress as women's increased responsibility is not due to empowerment but to other family members' eagerness to escape the drudgery of smallholder farming. interestingly, some women also expressed happiness that their families were together, highlighting how the presence of additional household members not only reduced the agriculture work burden but also sometimes improved psychosocial well-being. while feminist scholarship has long highlighted the exploitation that occurs in the paid and unpaid care economy, there has been slow movement to structure a comprehensive policy approach to address this within south asia. however, as policies to mitigate covid- have been disproportionately subsidized by women's unpaid care labor, relief efforts offer an opportunity to begin to recognize and compensate women's substantial contributions to the economy. similarly, the impacts shed light on the ongoing phenomenon of rural distress being shouldered by women. a comprehensive policy solution would include social support (e.g., cash entitlements) to women as subsidies for unpaid labor but also create a broader investment portfolio into agrarian india to reduce the need for out-migration and reduce the drudgery of women's work. women's concerns around food, water, and fuel security alongside adequate transport for health service need to be addressed through provisions by state and local government councils. in the medium term, however, we concur with wenham, smith, and morgan ( ) that for any response to be effective, women's voices must be better represented within all relief policies. this resonates with policy recommendations put forth by feminist collectives both in india (dasgupta and mitra ) and globally (https://www.feministcovidresponse.com). while covid- and the lockdown have exacerbated gender inequities, they have also highlighted how during "normal" times rural women are individually responsible for an untenably broad range of activities in the home and agricultural fields. an effective feminist relief policy, therefore, should not only compensate and acknowledge the central role women are playing in the covid-response but should seek to learn from these . we do not wish to depict an overly sanguine picture, as there is substantive evidence of increased domestic violence across india and other countries throughout the lockdown. however, our data suggest a more complex picture in which many women also sincerely expressed improved well-being as their families were unexpectedly reunited. . wenham, smith, and morgan ( ) rightly caution that while women should have a larger say in policy and governance, this need not be another (unpaid) responsibility and proper compensation should be rendered. labor dynamics to produce policies that can shift gender inequities across the longer term. carly e. nichols is assistant professor in the department of geographical and sustainability sciences and global health studies at the university of iowa: carly-nichols@uiowa.edu; falak jalali is a phd student at the university of iowa: falak-jalali@uiowa.edu; syed shoaib ali is a phd candidate at ambedkar university: ssali. @stu.aud.ac.in; divya gupta is a senior research fellow at the indian school of business: divya_gupta@isb.edu; suchita shrestha is a researcher at the southasia institute of advanced studies: suchita@sias.-southasia.org; harry fischer is associate senior lecturer at the swedish university of agricultural sciences: harry.fischer@slu.edu a gender-responsive policy and fiscal response to the pandemic clinging to hope through education: the consequences of hope for rural laborers in telangana, india india's covid- gender blind spot last and least: findings on intrahousehold undernutrition from participatory research in south asia the feminization of agriculture or the feminization of agrarian distress? tracking the trajectory of women in agriculture in india feminist political economy: looking back, looking forward covid- : the gendered impacts of the outbreak this research would not have been possible without the untiring efforts of our field staff in india and nepal. we express our deep gratitude for their patience in helping us understand what their communities, families, and friends have experienced were going through in the midst of the global pandemic. this research was supported by the swedish research council (vetenskapsrådet) research project - . key: cord- -igp g l authors: mahmood, shereen n.; blanco, irene title: the road to equity for women in academic rheumatology date: - - journal: nat rev rheumatol doi: . /s - - - sha: doc_id: cord_uid: igp g l gender disparities persist in many aspects of working life for women in academic rheumatology. to move forward, we must find ways to address the gender gap in rheumatology with the goal of creating a workforce as diverse as the patient population it serves. in their brief report, jorge et al. analysed data from a cohort of rheumatologists derived from an online database of physicians in the usa with a valid national provider identifier . they found that women in this cohort were less likely to have been promoted to the rank of associate or full professor, had fewer publications and were awarded fewer federal grants than men. however, when they looked at the likelihood of holding leadership positions, women were just as likely as men to have the title of programme director or division director. as acknowledged by jorge et al. , women are predicted to comprise the majority of the rheumatology workforce by (ref. ). therefore, although it is heartening that women have achieved parity in holding leadership roles within their divisions, it is concerning that they continue to lag behind men in several other important academic metrics. in their analysis of the nature of gender disparities in academic rheumatology, one thing that jorge et al. did not investigate (but is roles and that women who are programme or division directors are supported, compensated and sponsored in the same way that men would be in the same positions. although this fine detail has not been fully studied in rheumatology, lessons can be learnt from academic cardiology, where an increasing proportion of women are programme directors and division directors . despite this increase, on average, cardiology programme directors who are men were of higher rank, had more publications in total and had publications in higher impact journals than those who are women. this discrepancy was not true for cardiology division directors, as women seem to have achieved parity with men in the same metrics . again, given that programme directors have a predominantly educational role, it behoves deans, department chairs and division chiefs to evaluate how education is valued on the track for promotion, especially if we are to retain women in academia. the majority of women might be on clinician-educator tracks in academic rheumatology; however, we must also acknow ledge the experience of women on research-focused tracks. bagga et al. conducted a study looking at the percentage of women in lead and senior author positions in articles that report rheumatology-related research . overall, they found gender parity in first authorship for publications reporting investigator-lead research. however, despite this finding, there were still fewer women than men listed as senior authors, and women were under-represented as first and last authors for publications reporting industry-sponsored studies and random ized controlled trials. although it is encouraging that women are well represented as lead authors, the reason for the lack of women in senior authorship positions in clinical trials and industry-led studies is unclear. this discrepancy might reflect the relative lack of women in advanced research careers. as noted by bagga et al. , women face gender bias in publishing and funding mechanisms, thus potentially stalling promotion along important to note) was the promotion track that an academic rheumatologist might find herself on. women in academic medical centres in the usa tend to be on clinician-educator tracks , whereas jorge et al. used metrics that are predominantly associated with traditional, research-focused tenure tracks to analyse the career advancement of the rheumatology workforce . although it is crucially important that women are adequately represented in research careers, it could be that the majority of women in rheumatology are not on traditional tenure tracks, and as such, their path to career advancement will be different. this fact is especially important given that women on clinician-educator tracks are at a higher risk of leaving academia than women on research tracks , . as noted in a review article , the role of the clinician-educator is crucial for the education of resident physicians and especially for rheumatology fellows; however, given that the metrics for promotion often rely on the publication of basic, clinical and translational research, clinician-educators often lag behind their peers in other tracks. as the author of the review recommends, promotion tracks should be modified, and clinician-educators should be championed and provided with sufficient faculty development to not only become master educators, but also scholars in medical education. the finding that women are just as likely to have leadership roles as men in the cohort studied by jorge et al. is incredibly encouraging. as we investigate this finding further, we need to ensure that there is equity in these s c i e n c e a n d s o c i e t y the road to equity for women in academic rheumatology gender disparities persist in many aspects of working life for women in academic rheumatology. to move forward, we must find ways to address the gender gap in rheumatology with the goal of creating a workforce as diverse as the patient population it serves. women face gender bias in publishing and funding mechanisms, thus potentially stalling promotion nature reviews | rheumatology research tracks. in addition, it remains to be seen how the covid- pandemic will affect female investigators and leaders within rheumatology. not only are women publishing fewer articles than expected during this time, but they are also shouldering increased burdens secondary to the pandemic, including increased patient care, intensified work-life imbalance and sacrificed positional duties and title advancements . lastly, we must acknowledge the intersectional experience of women in academia. women of colour with rheumatic diseases, especially those with connective tissue diseases, have a high burden of disease activity and are also disproportionately affected by health disparities. nevertheless, rheumatology has a workforce that, like much of medicine, does not reflect those patients who are most affected. in the acr workforce study, few adult rheumatologists identified as hispanic/latinx ( . %), black ( . %) american indian/alaska native ( . %) or native hawaiian/pacific islander ( . %), and there were comparable numbers in paediatric rheumatology . the proportion of these rheumatologists that are women is unknown. as we think about how to address gender equity in rheumatology, we must also continue to consider how else we can diversify the field to provide long-term equity for patients, practitioners and investigators. as the future of rheumatology unfolds, and as we strive for excellence in patient care, research and education, we need to address the barriers that lead to inequities faced by patients and practitioners. the studies by jorge et al. and bagga et al. highlight a gender disparity in academic rheumatology that persists despite having been under discussion for many years . although major gains have been made in the number of women in rheumatology, further work must address the possible causes of inequity between women and men to ensure that women are not only adequately represented and advocated for, but also retained within academic divisions. the association between physician gender and career advancement among academic rheumatologists in the united states representation of women as authors of rheumatology research articles american college of rheumatology workforce study: supply and demand projections of adult rheumatology workforce gender distribution of u.s. medical school faculty by academic track type factors impacting the departure rates of female and male junior medical school faculty: evidence from a longitudinal analysis the role of the clinician educator in rheumatology women in leadership positions in academic cardiology: a study of program directors and division chiefs women physicians and the covid- pandemic workforce study of rheumatology specialists in the united states women in academic rheumatology the authors acknowledge the association of women in rheumatology and all of the female mentors that they have had over the years who have paved the way for them. the authors declare no competing interests.we must also continue to consider how else we can diversify the field to provide long-term equity key: cord- -mb y jf authors: baird, barbara; millar, erica title: abortion at the edges: politics, practices, performances date: - - journal: womens stud int forum doi: . /j.wsif. . sha: doc_id: cord_uid: mb y jf abstract this article provides a brief overview of the state of discourse, politics and provision of abortion in the anglophone west, including developments in the wake of the covid- pandemic. it then surveys three promising directions for feminist abortion scholarship. the first is work inspired by the reproductive justice movement, that points to the intersectional axes of inequality that shape abortion discourse and position us in relation to reproductive choice and access issues. the second is work that examines the particularity of the constitution of the aborting body, reflecting the particularity of the pregnant body. this is a specific body, with a specific history; abortion discourse draws from and makes a significant contribution to the meaning and lived experience of this body. the third area of scholarship we highlight is that which seeks to amplify the meaning of abortion as a social good. much abortion scholarship is attuned to a critique of negative aspects of abortion—from its representation in popular culture to restrictive law and access issues. this is critical work but/and the performative nature of abortion scholarship, like all discourse, means that it can amplify the association of negativity with abortion. the article concludes by introducing the articles contained in the special section of women's studies international forum, ‘abortion at the edges: politics, practices, performances’. j o u r n a l p r e -p r o o f ( ), the covid- pandemic has already led to widespread contraceptive shortages and the reduced availability of abortion worldwide; the organisation warns that the resulting ‗loss of health, autonomy and life' will have ‗catastrophic' consequences for women and girls. restrictions on abortion within the anglophone west also bear most directly on the most marginal women. for example, the closure of abortion clinics resulting from us trap (targeted regulation of abortion providers) laws is felt most acutely by minority women, who in pre covid- times were having abortions at later gestations because of difficulty accessing the necessary resources to travel to obtain an abortion (solazzo ) . the closure of clinics in the wake of covid- (abrams ) will likely have similarly stratified consequences for those seeking abortion. in canada, which became the first country to completely decriminalise abortion in , access to abortion in rural and remote areas is virtually non-existent, and women requiring abortions post weeks must travel to the us (shaw & norman ) . women in many other countries also face the burdens of the need to travel (sethna & davis ). while illegality and low socioeconomic status remain major obstacles in accessing abortion, the increasing accessibility of medical abortion is making clandestine abortion safer (singh et al. ) . sydney calkin ( ) argues that medical abortion, especially in conjunction with feminist activist strategies to make it available (often illegally), means that 'abortion access is becoming less connected to physical clinic spaces and, by extension, less tethered to national legal frameworks' ( ). the impact of medical abortion is also significant in overcoming geographical barriers when legality is not an issue (hyland, raymond & chong ; upadhyay j o u r n a l p r e -p r o o f uk-founded, now international, journal feminism and psychology produced a special issue on abortion in , as did the harvard university based health and human rights journal which has subsequently devoted more special issue space to abortion. in the social sciences the concept of abortion stigma has been a dense site of scholarship since kumar, hessini and mitchell's ground-breaking work over a decade ago ( ). the turnaway study in the us, the first longitudinal comparison of the outcomes of women who received an abortion with those who were turned away, is another noteworthy contribution (ralph, foster & rocca (sheldon et al. ) . elsewhere in the humanities contemporary feminist theory about affect and emotion has been brought to bear on the ways that the political construction of the emotions frames abortion discourse (millar (ross : ) . it also draws attention to the relationship of abortion to other norms and practices of reproduction: the choice of abortion can only be considered autonomous in a meaningful way if the alternative choice of motherhood is viable, materially, socially and discursively (ross & solinger ) . disability is one node of inequality that intersects with others to shape the material and discursive worlds of reproduction. australian disability activist nicole lee ( ), who uses a wheelchair, writes of how her decision to have an abortion was, in a reversal to the stated norm, interrogated far less than her decision to become a mother. the stigma of disabled parenting can manifest in coercive practices, most notoriously in sterilisation, which women with disabilities continue to experience disproportionately compared to the able-bodied (wu et al. ). discourses of able-bodiedness also variegate abortion stigma. claire mckinney ( ) argues that women who are otherwise nonstigmatised (white, heterosexual, married, economically stable, able-bodied mothers) can deploy the ‗tragic narrative of fetal abnormality' to recuperate their choice of abortion to narratives of ‗fit motherhood': thus, their status as deviant reproductive subjects is avoided at the expense of re-stigmatising disability. projection of anxieties about ‗whose subjectivity, whose forms of intimacy and interests, whose bodies and identifications, whose heroic narratives-will direct america's future ' ( : ) . barbara baird ( ) reads theoretical work on white patriarchal supremacy, a mode of governmentality that can only be maintained through ‗constant ritual repetition' ( ), alongside a history of maternal citizenship for white women in australia to argue that ‗debate over abortion (like debate over immigration), particularly during times of intensified race politics, is both a displacement activity where anxious white nationalists can performatively reinstate white power and also the literal performance of the control of national reproduction, the forceful attempt to make like reproduce like' ( ). the nostalgic longing for the past that animates many contemporary restatements of white national belonging contains a powerful reproductive dimension that is only beginning to be theorised. in an important contribution to this project, sarah franklin and fay ginzburg argue that trump's reproductive politics do not signify a break with the past but are, rather, a particularly virulent rearticulation of a ‗tragically familiar grammar' that draws powerful links between ‗traditional gender roles and family values, opposition to gay marriage, the right to gun ownership, and opposition to abortion within an overarching white settler narrative of lost american greatness' ( : - ). race and gender form nodes in a more complex arrangement, which is inflected with class, (dis)ability, and the other axes of identity that form the idealised family arrangements under the neoliberal state, stripped of public health and social services. in the contemporary era, the fusion between race, reproduction and nation in relation to abortion politics is also acutely waged in the process of creating and recreating borders. scholars have documented how, across several different contexts, state restrictions on the reproductive autonomy of asylum seekers is particularly draconian. ruth fletcher ( ) documents a case of an acutely suicidal asylum seeker and survivor of rape who was refused an abortion by the public health authority in ireland in . her asylum status prevented her from following the route to britain then routinely taken by irish abortion-seeking women. the woman was forced to continue with the pregnancy until she was weeks' pregnant, when she was forced to undergo a caesarean delivery. writing before the important constitutional amendments of , fletcher argues that this ‗abortion refusal … reiterates just how unethical and rights-violating the substance of irish abortion law is … [and how it] discriminates against women in general, and women with mentalhealth issues, women with few economic resources and women with limited mobility options, in particular ' ( : ) . kevin and agutter ( ) ( ) documents, the reproductive coercion enacted at the level of the state towards asylum seekers extends beyond abortion to other areas of reproductive health; in, for example, creating conditions that make continuing with a pregnancy and raising a child unviable. unhygienic and unsafe birthing conditions and policies of indefinite detention punish parents and children alike. scholars and activists must continue to examine and unpack the multiple modalities of power that delineate access to reproductive choices, the broader social and cultural significance and meaning of reproductive choices, and reproductive politics more broadly. such work forms an important critique of neoliberalism, a mode of governmentality that works to camouflage the oppressive structures that continue to act on and through individual subjects (millar ) . dissection of the multiple and complex battles that are waged through the politics of reproduction also has much to tell us about the social and cultural worlds that we inhabit, including, as we have emphasized here, projects of nation building and the making of national communities. the politics of abortion contribute to the creation of states and nations and they also where women's access to abortion is largely dependent on wealth and the distance needed to travel. like gleeson on the past, and indeed common observation of the present, oberman points out that it will be ‗individual actors, rather than official policies' that will make the difference in a post-roe future ( ). both authors challenge readers to identify the political mythologies that shape our thinking about the past, present and future, and open space for greater complexity. the work of critiquing dominant discourses, conservative political developments and problematic assumptions does not, however, exhaust analysis of all possible experiences or ways to think about abortion. we mention a handful of texts here to illustrate some of the possible ways in which abortion scholarship that focuses on the ‗positive' and innovative pushes conceptual boundaries and creates pathways that might lead us beyond current epistemological, political and service provision regimes. there is a rich (if minority) vein of scholarship which has focused on successes in the struggle for abortion rights and access to services. one such example is kirtz and lundy's documentary film ( ) and laura kaplan's history ( ) of the chicago based feminist abortion service jane (of which kaplan was a member). jane operated for four years in the period before the roe v wade decision; it began as a referral service, offering counselling and support, and transformed into a service that offered abortions performed by women it had trained. jane assisted over ten thousand women, many who would not have been able to afford an abortion anywhere else, many of them black. kaplan wrote to record the history of a little- two contributions to the collection examine the strategies and discourses of anti-abortion activists. prudence flowers provides a historical account of a foundational tension between two groups of us anti-abortion activists: ‗extremists' who argue that abortion should be banned entirely, and ‗moderates' who argue for exceptions on grounds such as rape and fatal foetal anomaly. by arguing that this tension is irresolvable, flowers dispels any notion that the anti-abortion movement is a united political force, thus demystifying some of the power and authority with which it is often invested. pam lowe and sarah-jane page examine the rhetoric and framing devices that motivate anti-abortion activists to picket abortion clinics in the uk. they argue that this form of activism (or, seen differently, harassment) is driven by the idea that women need to be ‗saved' from service providers who are motivated by profit, and that the discourse of ‗saving women' they deploy is rooted in christian beliefs aimed at ensuring souls go to heaven. their work adds to scholarship that demonstrates the gendered paternalism that runs through much abortion law, politics and discourse and views women as vulnerable and in need of protection. our final pair of articles contribute research to knowing about and working with women who have abortions in the second and third trimesters of pregnancy. in different ways, the articles provide space for the voices of individual women who have had this experience. trish hayes, suzanne hurley and chanel keane are counsellors who work with women seeking abortion in melbourne, australia. they write about some of the major psychosocial issues faced by women who are seeking an abortion between - weeks of pregnancy and ways in which they help women navigate having a procedure that is highly stigmatised. like all contexts for abortion, those around second/third trimester abortions are diverse and contested. hayes, j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f covid- could permanently make abortions harder to access nationwide advancing new standards in reproductive health) . abortion onscreen in who seeks abortions at or after weeks? rethinking reproductive politics in time, and time in uk reproductive politics reproductive politics in the age of trump and brexit trauma of rape‖ discourse: a double-edged template for everyday understandings of the impact of rape? the other abortion myth-the failure of the common law cultural conceptions: on reproductive technologies and the remaking of life reproductive coercion and the australian state: a new chapter hospitals providing abortion services coronavirus: gp visits regarding abortions to take place remotely. irish times visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate the agnotology of abortion: a history of ignorance about women's knowledge of fertility control. outskirts: feminisms along the edge abortion "can now be carried out fighting to choose: the abortion rights struggle in a good abortion is a tragic abortion: fit motherhood and disability stigma happy abortions: our bodies in the era of choice relaxation of abortion rules welcomed by experts. the guardian, march talkin' up to the white woman: aboriginal women and feminism laws/document/bill_ /abortion-legislation-bill. access date her body, our laws: on the front lines of the abortion war, from el salvador to oklahoma reproducing jane: abortion stories and women's political histories sexual violence and the border: colonial genealogies of us and australian immigration detention regimes abortion and woman's choice: the state sexuality and reproductive freedom fetal images: the power of visual culture in the politics of reproduction experiences of reproductive coercion in queensland women comparing prospective and retrospective reports of pregnancy intention in a longitudinal cohort perspectives on sexual and reproductive health quarter of us abortion clinics have closed over last five years, report says. the guardian, february killing the black body: race, reproduction, and the meaning of liberty reproductive justice as intersectional feminist activism reproductive justice: an introduction abortion across borders: transnational travel and access to abortion services dirs when there are no abortion laws: a case study of canada. best practice & research clinical obstetrics & gynaecology beyond control: medical power and abortion law the abortion act ( ): a biography abortion worldwide : uneven progress and unequal access abortion worldwide : uneven progress and unequal access after tiller: the impact of a documentary film on understandings of third-trimester abortion different and not equal: the uneven association of race, poverty, and abortion laws on abortion timing feminism and the technological fix when the punishment is pregnancy: carceral restriction of abortion in the united states queering abortion rights: notes from argentina unintended pregnancy in australia: what more can we do? uk abortion law: reform proposals, private members' bills, devolution and the role of the courts. the modern law review innovative models are needed for equitable abortion access in the usa. the lancet public health characteristics of women who present for abortion beyond the legal limit in flanders rethinking the mantra that abortion should be -safe, legal, and rare‖ abortion: a review of south australian law and practice looking back while moving forward: a justice-based, intersectional approach to research on contraception and disability key: cord- -etli c a authors: magee, laura a.; khalil, asma; kametas, nikos; von dadelszen, peter title: towards personalized management of chronic hypertension in pregnancy date: - - journal: am j obstet gynecol doi: . /j.ajog. . . sha: doc_id: cord_uid: etli c a abstract objectives chronic hypertension complicates - % of pregnancies and it is increasingly common. women with chronic hypertension are easily-recognized and in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. we reviewed recent data on management to inform current care and future research. study design narrative review of published literature. results compared with normotensive women, women with chronic hypertension are at increased risk of maternal and perinatal complications. women wish to be involved in their care and are capable of measuring blood pressure (bp) at home. accurate devices for home bp monitoring are now available. the diagnostic criteria for superimposed preeclampsia remain problematic, as most guidelines continue to include deteriorating bp control in the definition. it has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely-available clinical data and laboratory results. while chronic hypertension is a strong risk factor for preeclampsia and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. it is unclear whether calcium has an independent effect in preeclampsia prevention in such women. treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been demonstrated; however, the latter lack of evidence is possibly due to few events. also, treating chronic hypertension neither reduces nor increases fetal/newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. at present, bp treatment targets used in clinic are the same as those used at home; although bp values tend to be inconsistently lower at home among hypertensive women. while starting all women on the same antihypertensive medication is usually effective in reducing bp, it remains unclear whether there is an optimal agent for such an approach, or how best to use combinations of antihypertensive medications. an alternative approach is to individualize care, using maternal characteristics and bp features beyond bp level (e.g., variability) that are of prognostic value. outcomes may be improved by timed birth between + - + weeks based on observational literature; confirmatory trial evidence is pending. postnatal care is facilitated by the acceptability of most antihypertensives (included angiotensin converting enzymes inhibitors) for use in breastfeeding. conclusions the evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning international guidance. addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy. personal characteristics, symptoms, bp features beyond the bp level, and other physiological characteristics are associated with adverse outcomes and offer opportunities to personalize care. shortened title: personalized care of chronic hypertension has been questioned. it is unclear whether calcium has an independent effect in preeclampsia prevention in such women. treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been demonstrated; however, the latter lack of evidence is possibly due to few events. also, treating chronic hypertension neither reduces nor increases fetal/newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. at present, bp treatment targets used in clinic are the same as those used at home; although bp values tend to be inconsistently lower at home among hypertensive women. while starting all women on the same antihypertensive medication is usually effective in reducing bp, it remains unclear whether there is an optimal agent for such an approach, or how best to use combinations of antihypertensive medications. an alternative approach is to individualize care, using maternal characteristics and bp features beyond bp level (e.g., variability) that are of prognostic value. outcomes may be improved by timed birth between + - + hypertension complicates up to % of pregnancies, and potentially twice that when considered per woman ( ). chronic hypertension complicates - % of pregnancies, and rates are rising ( ). while this has been attributed to secular trends in age and body mass index ( ), a relationship with black race and rising maternal age, but not obesity or smoking, could be demonstrated in a population- based cross-sectional study of more than million hospital deliveries in the united states ( ). this is a global phenomenon, with rates at least as high in resource-limited settings ( ). definition clinical practice guidelines define chronic hypertension as a blood pressure (bp) ≥ / mmhg preconception or before weeks' gestation ( ). while this is consistent with how hypertension is generally defined outside pregnancy, the american college of cardiology/american heart association (acc/aha) have lowered their threshold for diagnosis to / mmhg, with - / - mmhg designated as stage hypertension and ≥ / mmhg as stage ( ). if / mmhg were the threshold for diagnosing chronic hypertension in pregnancy, more women would be identified who have a heightened risk of preeclampsia (with risk being intermediate between those with bp < / mmhg [defined as normal if < / mmhg and 'elevated' if systolic is - ] and stage chronic hypertension), preterm birth, and gestational diabetes ( ). furthermore, women with stage hypertension would benefit from low-dose aspirin, based on a secondary analysis of a larger trial ( ). women with chronic hypertension experience increased maternal and perinatal complications. by systematic review ( studies, , pregnancies), women with chronic hypertension have high rates of superimposed preeclampsia ( %), cesarean delivery ( %), preterm delivery ( %), low birthweight ( %), perinatal death ( %), and neonatal unit (nicu) admission ( %) ( ). stillbirths occur earlier, at a median of vs. weeks, with an absolute risk at weeks ( / births) that equates to that among low-risk nulliparae at weeks ( , ). chronic hypertension is a singular clinical risk factor for preeclampsia ( ), that itself accentuates risk for adverse pregnancy outcomes ( - ); however, development of preeclampsia, defined traditionally by new proteinuria, inadequately accounts for the excess of complications. for example, preeclampsia accounts for < % of chronic hypertension-associated prematurity, small-for-gestational age (sga) infants and nicu care ( - ). early pregnancy evaluation over % of pregnant women with chronic hypertension have underlying primary (formerly called 'essential') hypertension, related to genetics or lifestyle factors ( ), and most will have been identified preconception. extensive genetics studies have revealed two types of abnormalities: (i) < rare mutations that are primarily genes regulating mineralocorticoid or renal pathways, associated with substantial hypertension, and useful in a small number of families; and (ii) hundreds of genetic variants associated with a very small increase in bp (i.e., ≈ mmhg) that contribute to our understanding of the pathogenesis of hypertension but not to the care of individuals ( ). excessive intake of sodium (i.e., > g/d of sodium chloride) or alcohol, or a sedentary lifestyle are all modifiable, lifestyle risk factors for hypertension outside pregnancy; while little is known about altering salt intake in women with chronic hypertension in pregnancy and pregnant women are advised not to drink alcohol, encouraging physical activity is emerging as an important intervention in pregnancy to prevent pre-eclampsia ( ). while less likely to be an issue in pregnancy, it is noteworthy that many medications can increase bp; oral contraceptives and non-steroid anti- inflammatory drugs [nsaids] will have been stopped in pregnancy, but women may take over-the- counter decongestants, prescription drugs for medical indications (such as immunosuppressants or antidepressants), or consume illicit drugs like cocaine. an underlying, 'secondary', cause of hypertension may be related to problems in renal (e.g., chronic kidney disease or renal artery stenosis), vascular (e.g., coarctation of the aorta), endocrine causes (e.g., primary aldosteronism, pheochromocytoma, cushing syndrome, hypothyroidism or thyrotoxicosis), or respiratory (e.g., obstructive sleep apnea) systems. while collectively, they are thought to account for less than % of cases of hypertension, primary aldosteronism may be underrecognized. with systematic screening, including aldosterone to renin ratios, hyperaldosteronism is prevalent among individuals within stage ( %) or stage ( %) hypertension, compared with normotensive individuals ( %) ( ). it is not cost-effective to perform a work-up for secondary causes of hypertension in all pregnant women or all adults outside pregnancy. however, it is considered prudent to perform a basic work- up in early pregnancy if not performed before pregnancy. the objective is to rule-out obvious secondary causes of hypertension and evaluate baseline cardiovascular risk, although most tests for the latter are not recommended in pregnancy given differences in normal ranges and/or no resultant change in management in pregnancy (table ) . additional baseline tests may be useful for later comparison when superimposed preeclampsia may be suspected (table ) . of note, this screening does not include hyperaldosteronism as associated hypertension usually improves in pregnancy and the most commonly-used mineralocorticoid receptor antagonist (spironolactone) is not recommended for use in pregnancy because of potential anti-androgen effects on male fetuses. hypertension secondary to renal, vascular, or endocrine causes are suggested by age of onset < years, uncontrolled blood pressure with three antihypertensives, or condition-specific symptoms; however many symptoms are associated with normal pregnancy (e.g., dizziness the baseline risk of fetal malformations should be clarified numerically, as many women may not appreciate that - % of all pregnancies are complicated by major birth defects. additionally, untreated chronic hypertension may further increase that risk, particularly for cardiovascular defects, cleft lip or palate, and hypospadias ( - ). while the mechanism is not understood, antihypertensive agents do not appear to be responsible (as discussed below), nor do they appear to alter miscarriage risk (≈ %) ( , ), although information is limited. as approximately half of pregnancies are unplanned, women with chronic hypertension who are of reproductive age would ideally be treated with antihypertensives that are safe in pregnancy. while no antihypertensive medication is a proven human teratogen, initial associations between angiotensin converting enzyme inhibitors (aceis) and birth defects may have suffered from residual confounding from the underlying hypertension, as discussed above ( ). subsequent work has not been consistently reassuring. in a prospective cohort (n= women), aceis and angiotensin receptor blockers (arbs) were associated with miscarriage (but not malformations), compared with both hypertensive and normotensive controls; most women ( . %) were exposed to aceis ( ). however, aceis, arbs, and other antihypertensive agents have been associated with teratogenicity in a meta-analysis of five controlled cohort studies ( infants exposed to aceis or arbs, to other antihypertensives, and , , unexposed) ( ). the uk clinical practice guideline suggests that thiazides are teratogenic ( ), but this statement is not supported by animal or limited human studies ( ). given the inconsistent literature, it is acceptable to continue antihypertensive agents, including aceis and arbs, until conception; this practice may be particularly important for women taking aceis for renoprotection in chronic kidney disease (ckd). conception may normally take up to months, and women over years of age suffer more subfertility, so replacing medication prepregnancy can mean that such women's medication is suboptimal for - years. the safety of antihypertensive agents beyond early pregnancy is further discussed below, under 'antihypertensive therapy'. home blood pressure monitoring (hbpm) hbpm is recommended by most guidelines for care of hypertension outside pregnancy, based on improved links between diagnoses and adverse outcomes, convenience, antihypertensive compliance, and bp control ( ). therefore, women with chronic hypertension may have used hbpm preconceptionally; the covid- pandemic has broadened pregnancy hbpm implementation ( ). in pregnancy, women using hbpm report greater awareness of risks and empowerment ( , ). currently, similar bp targets should be used for hbpm and office bp to inform care pathways. while systematic review ( studies, up to women in late pregnancy) found that home bp is widely variable and probably lower than in clinic for hypertensive women ( ). importantly, subgroup analyses before weeks involved fewer than women, and differences were seen primarily in systolic bp (up to mmhg vs mmhg for diastolic bp [dbp]). second, when multivariable screening identified women at high risk of preeclampsia, and they were administered mg/evening of aspirin, the risk of preterm preeclampsia was substantially reduced ( ), but women with chronic hypertension were the only subgroup not to benefit ( ). this observation is consistent with subgroup analyses in the relevant individual participant data meta- analysis ( ) and two randomised trials, although aspirin was used in low dose ( , ) and/or often started after weeks ( ); a trial is planned (nct ). no practice guideline currently recommends against administering aspirin to these women ( ). these issues are discussed in detail elsewhere( ). calcium increasing calcium intake to ≥ g/day reduces the likelihood of preeclampsia in women with low intake( - ); most women in more-developed countries have adequate intake ( ) 'tight' bp control in chips was achieved by a simple algorithm of antihypertensive up-or down- titration (figure ) , using single or multiple medications. importantly, antihypertensive therapy was decreased if dbp fell to mmhg or below, as frequently encountered in mid-pregnancy, and therapy increased if systolic bp were ≥ mmhg, regardless of dbp, for safety. the mean bp achieved in the 'tight' control group, / mmhg ( ), was in the lower half of the acc/aha 'stage hypertension' range ( ), and increasing antihypertensive medication when bp is 'high normal' concurs with guidance from the royal college of obstetricians and gynaecologists ( ). also of note is that the bp achieved in 'less tight' control was not particularly high, at / mmhg; the dbp goal of mmhg was designed to minimize use of antihypertensives which were nevertheless required by % of women post-randomization. while adherence to these algorithms was similar in 'less tight' ( %) and 'tight' control ( %), adherence based on adjusting according to a range of ± mmhg around the target dbp was lower in 'less tight' ( %) than 'tight' control ( %, p= . ), as clinicians tended to leave current dosing of medication in 'tight' control when dbp was - mmhg and tended to increase medication in 'less tight' control when dbp was - mmhg ( ). it seems unlikely that clinicians would be comfortable keeping bp below / mmhg if acc/aha thresholds were adopted. four national/international practice guidelines (canada, uk, poland, isshp) now endorse 'tight' bp control for all forms of pregnancy hypertension, based on the results of the chips trial ( ). other (smfm) considers as acceptable both 'tight' and 'less tight' control, by giving advice to maintain bp at - / - mmhg in women with low-risk chronic hypertension. the american college of obstetricians and gynaecologists recommends treating bp emergently when it reaches severe levels (i.e., ≥ / mmhg), but not at all before then unless there are comorbidities pending the results of the chap trial (control of hypertension and pregnancy, nct ), as below ( ). there are two ongoing trials of an oral antihypertensive vs. another for non-severe pregnancy hypertension. one is studying nifedipine vs. labetalol initiation to achieve 'tight' bp approach in each group (giant panda, nihr ), with randomization minimized by race. there is one ongoing trial of antihypertensive therapy vs. 'treatment only when bp is severe' (chap) for women with chronic hypertension randomized to treatment approaches similar to chips, with a primary composite maternal and perinatal outcome and a co-primary of birthweight < th centile ( ). smfm is looking to chap to address two concerns. first, the average gestational age at recruitment to chips was > weeks (i.e., weeks); while this was related in part to % of women recruited having gestational hypertension, the adverse effects of 'less tight' control were seen in particular before weeks ( ). second, most women in 'less tight' control ( %) received an antihypertensive before birth; this should be anticipated in chap as the interventions are similar. reporting in , chap will be powered to address whether 'tight' control benefits the mother (i.e., fewer serious maternal complications) and baby (i.e., fewer preterm births), or causes more newborn side effects (i.e., more sga infants). initial antihypertensive therapy should be monotherapy from accepted first-line drugs; ≥ % of women take only one agent prenatally ( ). the most commonly-used and recommended antihypertensive medications come from different drug classes. all cross the placenta. labetalol is a combined alpha-and (nonselective) beta-blocker, used in oral and parenteral forms; beta-blockade predominates, particularly when labetalol is administered parenterally. the overall effect is vasodilatation without reflex tachycardia or a reduction in cardiac output. labetalol should be used with caution in women with mild-moderate asthma (or another contraindication to nonselective beta-blockade) and not at all in women with severe or decompensated asthma. (including placebo/no therapy) ( ), many agents decreased the incidence of severe hypertension compared with placebo/no therapy: nifedipine, methyldopa, pindolol, and ketanserin; nifedipine decreased severe hypertension compared with furosemide, as did pindolol compared with furosemide or amlodipine. both nifedipine and methyldopa decreased the incidence of placental abruption compared with placebo/no therapy. atenolol increased the incidence of sga infants compared with placebo/no therapy and other antihypertensives (labetalol, nifedipine, methyldopa, and ketanserin). no differences were seen in preeclampsia, cesarean, preterm birth, or perinatal death. the % cis around estimates of effect were often very wide, and one trial was counted twice ( , ). however, the results suggest that nifedipine and methyldopa are most beneficial. vitamin d may enhance the effectiveness of nifedipine ( ). these data concur with the broader systematic review of antihypertensive vs. placebo/no therapy in pregnancy ( trials, women) and head-to-head comparisons of different antihypertensives ( trials, women); generally the type of hypertensive disorder was unspecified ( ). multiple agents reduce the incidence of severe hypertension compared with no antihypertensive. however, neither nifedipine nor methyldopa had previously been recognized to reduce abruption. while comparison with methyldopa as the gold standard, has been reported to show that beta-blockers (any, including labetalol) and calcium channel blockers taken together may reduce the risk of severe hypertension, results were more different than could be expected by chance alone. also, beta- blockers, but not calcium channel blockers, may decrease the risk of preeclampsia compared with placebo/no therapy, but when beta-blockers and calcium channel blockers were compared directly, beta-blockers did not decrease preeclampsia as anticipated. of note, in the chips trial, women treated with methyldopa (vs. labetalol) may have had better maternal and perinatal outcomes, although there may have been residual confounding ( ). other relevant short-and long-term outcomes have been understudied. an example is an unsubstantiated belief that both oral labetalol and methyldopa may alter fetal heart rate ( although more efficiently with nifedipine than iv hydralazine ( ). using a minimally important relative risk reduction of % between groups, an associated trial sequential analysis concluded that there was no difference in effectiveness between iv labetalol and oral nifedipine or iv hydralazine, but more data were needed to compare nifedipine and hydralazine. a second network meta-analysis of first-line agents ( trials, women) found that nifedipine more successfully treated severe hypertension than iv hydralazine ( ). oral labetalol and oral methyldopa compared favorably to oral nifedipine in a recent indian trial for severe pregnancy hypertension ( ); an in-target bp (i.e., - / - mmhg) was achieved without fetal compromise at hours in ≥ % of women in each group, similarly in the nifedipine ( %) and labetalol ( %) groups, but slightly more often in the nifedipine vs. methyldopa comparison ( %, absolute difference · %, % ci · , · ). however, more nifedipine group babies received nicu care (for low birthweight) ( %) than labetalol ( %) or methyldopa ( %). table presents a dose-escalation protocol consistent with recommendations by the society of obstetricians and gynaecologists of canada and acog, and incorporating oral treatment ( , , ). the protocol is more conservative in places with regards to dosing (at the lower limit of published ranges) and/or time for repeat dosing (at or beyond the upper limit of recommendations) to harmonize between medications for ease of implementation in urgent care and to minimize the risk of maternal hypotension. of note, a third dose of oral nifedipine capsules is given at min because a dose of mg is not used, and when another agent is needed, one should choose from a different drug class, and not hydralazine if nifedipine failed (or vice versa). successful treatment is resolution of severe hypertension. consistent with acog guidance, routine antihypertensive therapy should be instituted to avoid further episodes of severe hypertension( ). no antihypertensive medication is a proven human teratogen. however, some agents may be best avoided in pregnancy, given possible or proven concerns about fetotoxicity and the availability of alternative agents. atenolol, a cardioselective beta-blocker, may reduce fetal growth velocity ( , , - ) . many practitioners are uncomfortable using thiazides and thiazide-like diuretics due to theoretical concerns about reducing gestational plasma volume expansion ( ); however, diuretics were not associated with adverse outcomes when used throughout pregnancy for preeclampsia prevention. their use is probably best limited to specific circumstances (e.g., medullary sponge kidney). aceis and arbs should not be used in women once pregnant (grades c and d, respectively) ( ); while they do not appear to be teratogenic ( , , ) , there may be an excess of miscarriage, fgr, and neonatal morbidity following use in early pregnancy, even when the medication is stopped in early pregnancy ( ). however, such associations have been based on low-quality data (e.g., case reports and series), inconsistently observed, and may relate to underlying hypertension ( , , individualized antihypertensive therapy outside pregnancy, age and race reflect different hemodynamic profiles in hypertension and response to antihypertensive therapy ( , ); high renin hypertension is associated with young age and higher hr, or volume expansion, and low renin hypertension is associated with black race ( ). antihypertensive therapy guided by these phenotypes halves poor bp control, by giving aceis or arbs to young and white patients, and calcium channel blockers to black patients ( ), and is recommended outside pregnancy for adult hypertension ( ). in observational work, demographic and hemodynamic parameters identify individual pregnant women less likely to achieve bp control with oral labetalol ( ). these women were more often black, with lower hr and cardiac stroke volume (sv) ('vasoconstricted' or 'high resistance' phenotype associated with more severe hypertension and fgr) and more likely to respond to a vasodilator. in contrast, women with non-black race and higher hr and sv ('hyperdynamic' phenotype) were more successfully treated with oral labetalol. importantly, maternal race alone was a poor predictor of bp response to labetalol (area-under-the-receiver-operator curve only . ). in a subsequent observational study of hypertensive pregnancies, initiation and titration of antihypertensive therapy (for bp ≥ / mmhg) guided by this model resulted in a change in care for % of women taking oral labetalol; % initially given labetalol required additional nifedipine, and % initially given nifedipine required additional labetalol. severe hypertension requiring admission to a high dependency unit was reduced by %, without fgr ( ). personalized hemodynamic assessment holds promise to deliver 'tight' bp control while optimizing fetal growth and highlighting potential perinatal benefits. neither of two ongoing trials of were associated with a greater likelihood of preeclampsia (defined by new proteinuria), preeclampsia that was more severe, early delivery, and adverse maternal and perinatal outcomes ( - ); one study confirmed the observations in a cohort of women with chronic hypertension and ckd ( ). as angiogenic imbalance is associated with risks for both placental fgr and stillbirth, it is possible that defining preeclampsia broadly would improve the diagnostic test performance of angiogenic markers ( - ) . detecting progression to preeclampsia when it occurs is why many professional organizations emphasize evaluating maternal symptoms ( ). in a systematic review of maternal risk stratification in pregnancy hypertension ( studies), minipiers (preeclampsia integrated estimate of risk score) was the only model for all pregnancy hypertension types, has been externally validated ( ), and quantifies the risk of adverse maternal outcome by bp, symptoms, urinalysis (if performed), gestational age and parity (of particular importance for nulliparous women). 'high-risk' women have a predicted risk ≥ %, as a 'rule-in' test for adverse maternal outcome within hr (likelihood ratio of . ) and correct classification ( %). an online calculator is available ( ). if preeclampsia develops, the adverse maternal outcomes can be predicted by the fullpiers model, incorporating: gestational age, chest pain/dyspnea, pulse oximetry, platelet count, serum creatinine, and ast/sgot or alt/sgpt) ( ). using ≥ % to define high risk, fullpiers can be used as a 'rule-in' test for adverse maternal outcome within hr, based on a good lr ( . ). an online calculator is available ( ). determining the added value of angiogenic markers is warranted ( , ). practise related to the timing of birth for women with chronic hypertension varies widely. in a previously unpublished site survey of chips trial investigators, respondents highlighted variable practice, with delivery currently offered at ( %), ( %), ( %), ( %), and ( %) weeks gestation. observational data suggest that delivery between + - + weeks may optimize perinatal outcomes, by balancing stillbirth and neonatal morbidity risks ( , ). these observational data are complemented by limited trial data related to egyptian women with chronic hypertension ( ), that suggest that earlier term delivery may benefit women without increasing perinatal risks or cesarean deliveries. however, there are insufficient data available to assess the impact of planned delivery at term (i.e., between + to + weeks) on maternal morbidity or cesarean delivery ( ). the will trial (when to induce labour to limit risk in pregnancy hypertension; isrctn ) is randomizing both chronically-and gestationally-hypertensive women to either a policy of delivery at - weeks or expectant care until ≥ + weeks (or as clinical need dictates). the co-primary outcomes are maternal death or serious morbidity (fullpiers outcome( ); superiority) and nicu admission for ≥ hours (non-inferiority); cesarean delivery rate is the core secondary outcome. as most trials have evaluated antepartum, rather than postpartum, antihypertensive therapy, evidence is insufficient to guide clinical practice; however, it is reasonable to continue 'tight' bp control postpartum. bp is likely to rise after a woman leaves hospital (peaking on days three to six postpartum), postnatal stroke is increasing in incidence, and most antihypertensives are acceptable for use in breastfeeding (searchable information in lactmed ( ) women with chronic hypertension are at high-risk of pregnancy complications, but an easily- recognized group in touch with a wide variety of healthcare providers before, during, and after pregnancy. we know that these women are at increased risk of maternal and perinatal complications, that they are capable of measuring their bp values at home with accurate devices, that treating their hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, and that they wish to be involved in their care. priorities for future research include whether or not: additional characteristics of bp and other physiological variables can be used to predict preeclampsia; low-dose aspirin reduces their risk of preeclampsia specifically and/or calcium has an independent preventative effect; use of angiogenic markers with clinical factors and routine laboratory testing improves care; hemodynamically-guided care improves outcomes in comparison with antihypertensive therapy titrated to bp level and, if the latter, with which antihypertensive agent is best to initiate treatment from among labetalol, nifedipine, and methyldopa; and optimal timing of birth. all of this will bring us closer to offering women more personalized care of their chronic hypertension in pregnancy. medications or illicit substances that can increase bp (e.g., decongestants, nsaids, immunosuppressants, antidepressants, cocaine) * not performed in pregnancy as the normal range is higher and management would not be changed. † 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diagnosis, management, and research in preeclampsia angiogenic marker prognostic models in pregnant women with hypertension timing of delivery in women with chronic hypertension pregnancy outcomes of expectant management of stable mild to moderate chronic hypertension as compared with planned delivery planned early delivery versus expectant management for hypertensive disorders from weeks gestation to term. cochrane database syst rev drugs and lactation database (lactmed) bethesda: national library of medicine (us) furosemide in postpartum management of severe preeclampsia: a randomized controlled trial key: cord- -w sxap p authors: pierce-williams, rebecca a.m.; burd, julia; felder, laura; khoury, rasha; bernstein, peter s.; avila, karina; penfield, christina a.; roman, ashley s.; debolt, chelsea a.; stone, joanne l.; bianco, angela; kern-goldberger, adina r.; hirshberg, adi; srinivas, sindhu k.; jayakumaran, jenani s.; brandt, justin s.; anastasio, hannah; birsner, meredith; o’brien, devon s.; sedev, harish m.; dolin, cara d.; schnettler, william t.; suhag, anju; ahluwalia, shabani; navathe, reshama s.; khalifeh, adeeb; anderson, kathryn; berghella, vincenzo title: clinical course of severe and critical covid- in hospitalized pregnancies: a us cohort study date: - - journal: am j obstet gynecol mfm doi: . /j.ajogmf. . sha: doc_id: cord_uid: w sxap p abstract background the covid- pandemic has had an impact on healthcare systems around the world with . million infected and , resultant mortalities as of this writing. information regarding infection in pregnancy is still limited. objectives to describe the clinical course of severe and critical infection in hospitalized pregnant women with positive laboratory testing for sars-cov . study design this is a cohort study of pregnant women with severe or critical covid- infection hospitalized at us institutions between march , and april , . severe infection was defined according to published criteria by patient reported dyspnea, respiratory rate > per minute, blood oxygen saturation ≤ % on room air, partial pressure of arterial oxygen to fraction of inspired oxygen < and/or lung infiltrates > % within to hours on chest imaging. critical disease was defined by respiratory failure, septic shock, and/or multiple organ dysfunction or failure. women were excluded if they had presumed covid- infection but laboratory testing was negative. the primary outcome was median duration from hospital admission to discharge. secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. the clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. treatment and neonatal outcomes are also reported. results of pregnant women hospitalized with covid- , ( %) had severe and ( %) critical disease. the following pre-existing comorbidities were observed: % had a pulmonary condition, % had cardiac disease and the mean bmi was kg/m . gestational age at symptom onset was at a mean ± weeks and at hospital admission a mean of ± weeks, on a median day of disease since first symptoms. eighty-one percent of women were treated with hydroxychloroquine; % of women with severe disease and % of women with critical disease received remdesivir. all women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. the median duration of hospital stay was days ( days for severe, . days for critical, p= . ). for those who required it, intubation usually occurred around day , and peak respiratory support for women with severe disease occurred on day . in women with critical disease, prone positioning was performed in % of cases, the rate of ards was %, and re-intubation was necessary in %. there was one case of maternal cardiac arrest, but no cases of cardiomyopathy and no maternal deaths. thirty-two ( %) women in this cohort delivered during their covid- hospitalization ( % of severe and % of critical women). eighty-eight percent ( / ) of pregnant women with critical covid- who delivered during their disease course were delivered preterm, % of them via cesarean; in all, % ( / ) of critically ill women delivered preterm. there were no stillbirths or neonatal deaths, or cases of vertical transmission. conclusion in hospitalized pregnant women with severe or critical covid- infection, admission typically occurred about days after symptom onset, and the duration of hospitalization was days ( severe versus critical). critically ill women had a high rate of ards, and there was one case of cardiac arrest, but there were no cases of cardiomyopathy, or maternal mortality. hospitalization for severe or critical covid- infection resulted in delivery during the course of infection in % of this cohort, usually in the third trimester. there were no perinatal deaths in this cohort. the novel coronavirus , sars-cov , has caused a pandemic of covid- infection, with . million infected people and , deaths globally at the time of this writing (april , ) . covid- infection is usually mild in %, severe in %, and critical in % of nonpregnant patients , percentages which are similar ( %, %, and %) to pregnant women in early knowledge of the maternal course of disease is vital to answering questions about the management for pregnant women infected with covid- . the physiologic changes in pregnancy affect lung volumes and immune response and therefore have the potential to impact the clinical course of covid- in pregnancy. to be able to answer questions about optimal management, timing of delivery and various medications used for obstetric indications, the course of maternal disease must be understood. the physiologic changes of pregnancy, particularly those related to disease severity, progression, and outcomes, also need to be more clearly elucidated. the objective of this study was to describe the clinical course of pregnant women admitted with severe and/or critical covid- infection. this is a multi-center cohort study on pregnant women admitted to the hospital for treatment of severe and/or critical covid- infection from march to april , . to maximize the number of cases included, this study was of both retrospective and prospective nature. it was designed in accordance with the strobe guidelines for cohort studies prior to data collection . irb approval was obtained from the primary site, thomas jefferson university (irb control number e. ). data use agreements were obtained for collaboration between sites. inclusion criteria were all pregnant and immediately postpartum women confirmed sars-cov positive by laboratory testing meeting criteria for diagnosis of severe or critical covid- as defined by the chinese center for disease control and prevention . severe covid- was defined as dyspnea, respiratory rate of ≥ breaths per minute, blood oxygen saturation ≤ % on room air, partial pressure of arterial oxygen to fraction of inspired oxygen < and/or lung infiltrates > % within to hours of symptom onset . for the purpose of the definition of severe disease in this study, "dyspnea" was defined as patient reported dyspnea at rest. critical covid- was defined as respiratory failure requiring mechanical ventilation, septic shock, and/or multiple organ dysfunction or failure . respiratory failure was defined as a need for invasive mechanical ventilation. septic shock was defined as ≥ sepsis-related organ failure assessment (sofa) criteria [decline in partial pressure of oxygen/fraction of inspired oxygen, decline in platelets, rising bilirubin, decline in mean arterial pressure (map), decline in glasgow coma scale, and rise in serum creatinine] and with need for vasopressors to maintain map > and serum lactate > mmol/l even with sufficient volume resuscitation . women were considered to have multiple organ dysfunction or failure if they had evidence of at least of the following: r renal impairment or failure (defined as a threefold increase in baseline creatinine or need for dialysis ), liver failure (inr > . ), refractory hypoglycemia as diagnosed by the treating institution, or hepatic encephalopathy . women with inconclusive or negative covid testing (even if clinical suspicion was high), and those diagnosed with covid- diagnosis > days postpartum were excluded. the primary outcome was median duration (from hospital admission to discharge) overall and for women with severe versus critical covid- infection. this outcome was chosen as a surrogate for the length of illness requiring support. secondary maternal outcomes focus on the clinical course of covid- , with the day of symptom onset being defined as disease day number one. the variables of the clinical course examined included disease day of oxygen supplementation, other respiratory support, intubation and extubation, day of peak respiratory support, and day of return to room air. data were also recorded on new onset cardiomyopathy, cardiac arrest, and death. disease day of delivery, if applicable, was included. peak levels of various serum labs markers were recorded, as well as the peak day of that lab value if it was drawn > times in that patient. additional data were collected on duration of hospitalization, treatment modalities, obstetric outcomes, and neonatal outcomes. investigators at each institution reviewed their electronic medical record of the mother and any delivered neonate and de-identified data were recorded and stored in a standardized computer spreadsheet. data were reviewed by co-investigators and compiled for analysis. statistical analysis included means and standard deviations for normally distributed data, medians with interquartile ranges and percentages. the groups were compared using the t-test, analysis of variance, mann-whitney u, χ and fisher exact test. analysis was performed for severe and critical illness separately, as well as for the entire cohort. twelve institutions, in pennsylvania (n= ), new york (n= ), new jersey (n= ), and ohio (n= ), maternal demographics are shown in table . overall, the mean age was years old; critically ill women were significantly older than severely ill women. average body mass index (bmi) was kg/m , and % women were hispanic, % non-hispanic black, and % non-hispanic white. pre-existing pulmonary conditions (i.e. obstructive sleep apnea, asthma, chronic obstructive pulmonary disease) were present in % of women and pre-existing cardiac disease (i.e. chronic hypertension, cardiomyopathy) in % of women. the average gestational age at symptom onset of covid- infection was . ± . weeks (range . - . weeks), with hospital admission at . ± . weeks. no patients included in this study were postpartum at the onset of symptoms or hospitalization. twenty-three percent of women with severe disease experienced symptom onset at < weeks, whereas all women with critical disease were > weeks (p= . ). sixty-nine percent of all women developed symptoms < weeks, and % at < weeks. ninety-eight percent had disease confirmed by nasopharyngeal testing. two critically ill women initially tested negative; one subsequently tested positive by bronchoalveolar lavage (after negative nasopharyngeal swabs over days, and the other by repeat nasopharyngeal testing, table . the vast majority of women in this study were treated with hydroxychloroquine ( %) ( table ) . remdesivir was used in % of all women ( % of critically ill women). convalescent serum was used in one critically ill patient. twenty-three percent of women ( % of women with critical disease) received steroids for maternal indications (rather than for fetal maturity). all ( %) of women with critical disease received either prophylactic or therapeutic anticoagulation during their admission ( / , % prophylactic, / , % therapeutic), while / ( %) of women with severe disease received anticoagulation, ( / , % prophylactic, / , % therapeutic) ( table ). in this cohort, % of women with severe disease required o supplementation, while % ( of ) of the critically ill women required intubation (table ). in women with critical disease, % ( of ) developed ards, % (n= ) were placed in prone positioning (gestational ages - weeks), and % required re-intubation. at the time of writing, there were no cases of cardiomyopathy and no maternal mortality. one woman experienced cardiac arrest after a prolonged disease course. she was hospitalized days after symptom onset, intubated days later at days from symptom onset. she remained intubated for approximately week, with initial signs of recovery and extubation; however, she again developed respiratory failure and experienced cardiac arrest on day . cardiopulmonary resuscitation (cpr) was performed, she was re-intubated and return of spontaneous circulation (rosc) was achieved. she was delivered via cesarean after rosc. she was intubated for over weeks postpartum before she underwent tracheostomy placement. in this cohort and at the time of writing, we observed that the median day (with interquartile range, iqr) of events from the first day of reported symptoms were as follows (table , figure ): hospital admission on day (iqr - ), initiation of supplemental o on day (iqr - ), intubation (among critical women) on day (iqr - . ), peak respiratory support on day . (iqr - ), hydroxychloroquine treatment started on day (iqr - ), remdesivir treatment on day . (iqr . - . ), discontinuation of supplemental o on day (iqr - ) ( severe and critical remain on o at the time of writing), symptom resolution on day (for those who have achieved resolution). of those who were delivered during the disease course, delivery occurred on a median disease day (iqr - ). when comparing severe and critical women, the clinical course was longer for the critical group, requiring the use of invasive if the laboratory studies typically utilized to predict disease severity are used as a proxy for the most severe point in the course of the infection, the average peak disease day was (table ) . subjects with critical disease had higher interleukin- levels (il- ), ferritin, fibrin split products, platelets, procalcitonin, troponins, c-reactive protein (crp), creatine phosphokinase (cpk) and lactate dehydrogenase (ldh) compared to those with severe disease. the median duration of covid- infection for the women for whom complete hospital disease course data are available are shown in table . symptoms lasted days for those whose symptoms have resolved, (n= , versus days for women with severe versus critical disease, p= . ). for the primary outcome, the length of hospital stay was on average ± days (median duration days). women with severe disease were hospitalized for days (iqr . - ), and women with critical disease for (iqr - ) days (p= . ). at the time of writing, several women remain hospitalized (n= , severe and critical). women required supplemental o for a duration of days ( [iqr - ] days for severe disease and [iqr [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for critical disease, p= . ). of the women who were intubated and have been discharged, the median duration of intubation was days (iqr - ). among all women who delivered, preterm birth < weeks and < weeks occurred in ( . %) and women ( . %), respectively; however, when evaluating only women with critical disease who delivered (n= ), ( %) were delivered preterm (table ) . spontaneous preterm labor occurred in only women, both in the critical group ( %). during the course of covid- , % of women were delivered ( % of the women with severe disease and % of those with critical disease), table . maternal status was the primary indication in most cases ( % overall, % of severe, % of critical). the remainder were for fetal indications. critical covid women were delivered at an earlier mean gestational age than those with severe disease ( ± weeks versus ± , p < . ). there were no cases of intrauterine fetal demise. delivery route was cesarean for % and % of women with severe and critical disease, respectively. preeclampsia or gestational hypertension occurred in only women ( %), though % of our cohort remains undelivered. the rate of postpartum hemorrhage, defined as blood loss > cc at time of vaginal or cesarean delivery or symptomatic hypovolemia within hours associated with blood loss, was % overall ( % among subjects in the severe disease group, % of those in the critical disease group. the rate of presumed intrauterine infections (chorioamnionitis and/or endometritis) was % ( % among subjects in the severe disease group, in the critical disease group). the average neonatal birth weight was , . ± . grams ( , . ± . grams severe and , . ± . grams critical), though this difference is likely attributed to the earlier gestational age of delivery in the critical disease group. sixty-four percent of neonates required intensive care unit admission ( % of severe, % of critical). additional neonatal outcomes are reported in table . detailed data on neonatal testing and/or method of testing were not available. one of neonates was diagnosed with covid- ; in this newborn, the first test for sars-cov at hours of life was negative, but a repeat test at hours returned a positive result. the neonate showed no signs or symptoms of covid- . in this cohort, pregnant women hospitalized with severe or critical covid- infection were typically admitted on day of disease (as measured from the first day of symptoms), and the median duration of hospitalization was days ( versus . for severe and critical, respectively). for those who require it, intubation usually occurs around disease day (approximately days after hospital admission), and peak severity of non-intubated (severe) disease, judging by highest oxygen use, was approximately day . fifty percent of women were delivered during their covid- hospital course, the majority of these due to maternal disease. about half of the severe cases delivered vaginally, while over % of the critical ones delivered via cesarean. the average gestational age at delivery was weeks for severe and weeks for critical cases. the majority of preterm births were due to maternal status; however, data on exact etiologies were not collected. there were no maternal deaths as of this manuscript submission. the clinical course of disease in hospitalized pregnant women with severe or critical covid- infection seems to be similar to non-pregnant persons in the limited available studies. notably, these comparisons are limited as comparison patients include a broad age range, an international community, non-pregnant patients, men, and varied indications for admission. in a series of non-pregnant patients in china, hospital admission occurred on disease day with onset of dyspnea on day . ards occurred on day , and icu admission and mechanical ventilation on day . . in another study of non-pregnant patients from china, the length of hospital stay was days . in a cohort of hospitalized non-pregnant patients, ards and icu admission occurred on day , and death on day . or discharge on day . in a cohort of pregnant women in china, the interval from symptom onset to admission was - days. notably, this cohort does not include any patients who required invasive mechanical ventilation . it is important to note that these non-pregnant populations were mostly older men, and an appropriate non-pregnant reproductive age control group is not yet available in the literature. a current challenge lies in the prediction of patients presenting with covid- infection who will progress to develop critical disease. consistently across studies in non-pregnant populations, the risk of adverse outcomes increases with age and comorbidities, as well as certain laboratory values and radiologic findings , - . in one study, patients requiring icu care were more likely to have comorbid hypertension, cardiovascular disease, diabetes, and cerebrovascular disease . in terms of prognostic lab parameters, more severe lymphopenia has been noted in patients with worse outcomes , , , [ ] [ ] [ ] . other lab markers linked with severe illness include elevated d-dimer, interleukin- , and serum ferritin levels , , . as there are currently few reports of severe or critical covid- infections in pregnant women, this study seeks to describe these patients and their clinical progression. in previous outbreaks of respiratory pathogens, pregnant populations experienced increased severity of illness and mortality. however, current data in the covid- pandemic suggests that pregnant women experience similar, or even lower, rates of severe disease as compared to non-pregnant individuals , . despite these early findings, there is concern that pregnant women may still be at a higher risk for complications. for example, case reports have indicated cardiomyopathy in the setting of covid- . further data are needed on when this occurs and what predicts its occurrence. it is therefore critical to determine the unique factors in pregnant women that predict a more severe disease course to guide clinical management as well as the optimal time of delivery. these data can help guide obstetricians in deciding when a patient should be symptomatically improving or at risk for deterioration. this is particularly important for the obstetrician who needs to consider timing and mode of delivery for patients with severe or critical covid- . typically, attempts should be made to support the mother with oxygen as needed to maintain an oxygen saturation > % and reassuring fetal testing. markers of developing critical infection seem to be valid in pregnancy as well (table ), but further research is needed given that the physiology of pregnancy changes the normal ranges of several of these markers, with the ultimate aim of developing a tool to predict those who would benefit from delivery. one useful variable is time: in our data, pregnant women with covid- who developed critical disease and needed intubation progressed quickly from admission on day from symptom onset to intubation on day . as the standard deviation for time to intubation is . days, this means that % of women requiring intubation will do so within days of symptom onset; this is still a long period, when management is most difficult. as most women with severe disease do not develop critical illness, expectant supportive management is probably reasonable for most. on the other end of the spectrum, for those women at > weeks with several risk factors for critical disease such as advanced age, comorbidities including obesity, pulmonary or cardiac disease, diabetes and others, predictive laboratory abnormalities, and predictive respiratory requirements, delivery may be indicated before onset of critical disease. these are challenging cases to manage, often requiring individualized decisions, particularly given that we do not know whether cesarean delivery increases the severity of the clinical course, particularly given the significant fluid shifts. a predictive tool to determine those who would benefit from delivery during covid- hospitalization could be developed as we acquire more data. to date, we are not aware of a larger cohort study examining specifically the disease course of pregnant women hospitalized with molecular test confirmed severe or critical covid- . a recent report of covid- in pregnant women from wuhan, china examined pregnant women with covid- . of this cohort, only women had severe or critical disease, and no data were described for disease course . our study is limited by the nature of the cohort study (non-randomized, lack of control group for comparison). additionally, management of covid- varied across institutions. due to the urgency of obtaining information on covid- in pregnancy, in order to guide physician management during this pandemic, we are unable to report on long-term pregnancy or neonatal outcomes at this time. these data are also limited by the fact that women ( severe and critical) remained hospitalized, with several still on invasive mechanical ventilation, at the time of data collection; therefore, data on complete hospital courses and complete covid- courses and pregnancy outcomes are limited. fifty percent of women are undelivered, which can be seen as a strength in that in the appropriate setting, delivery can be delayed; however, complete outcomes on pregnancy cannot be reported. specifically, effects of covid- on pregnancy, including fetal growth restriction and amniotic fluid abnormalities, could not be elucidated due to the timing of data collection. longer term analysis will be required in the future. recommendations on pharmacotherapy cannot be made based on these data. larger case-control studies of the course of covid- in pregnancy, and randomized-controlled trials (rcts) of interventions, are necessary to best determine prognosis and management of these women. hydroxychloroquine was used in % of women in our study; however, current recommendations are for its use only in the setting of clinical trials due to unclear risks and benefits . based on limited data from an rct on treatment of ebola virus with remdesivir, the medication appears safe in pregnancy . twenty-five percent of our cohort received remdesivir. rcts are on-going on the efficacy of remdesivir for covid- infection. at some of our institutions, rcts on the use of convalescent plasma are ongoing, and include pregnant women. anticoagulation remains controversial, with more research needed. by study design, no data are provided for mild covid- disease. pregnant women hospitalized with severe or critical covid- infection are typically admitted on day of disease , and stay days. for those who require it, intubation usually occurs around day and peak severity of non-intubated disease occurs on day as well. laboratory and treatment management can reasonably follow non-pregnant guidelines, though differing normal ranges for some laboratory values in pregnancy must be considered. this clinical course is not markedly different from that of non-pregnant hospitalized patients with covid- , except that days in hospital are less, with lower mortality, albeit this comparison is made with non-pregnant patients who are much older on average. this suggests that perhaps pregnancy should not be considered an independent risk factor for severe or critical covid- disease. maternal characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention covid- infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals clinical features of patients infected with novel coronavirus in wuhan clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study clinical characteristics of coronavirus disease in china pregnancy and perinatal outcomes of women with coronavirus disease (covid- ) pneumonia: a preliminary analysis the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- )-china smfm consult series # : sepsis during pregnancy and the puerperium society for maternal-fetal medicine (smfm) defining acute renal failure acute liver failure clinical progression of patients with covid- in shanghai clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical course and outcomes of patients with severe acute respiratory syndrome coronavirus infection: a preliminary report of the first patients from the korean cohort study on covid- hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease (covid- ): a meta-analysis clinical characteristics of pregnant women with coronavirus disease in wuhan, china. ssrn electron j two cases of covid- related cardiomyopathy in pregnancy severe ards in covid- -infected pregnancy: obstetric and intensive care considerations clinical characteristics of pregnant women with covid- in wuhan infectious diseases society of america guidelines on the treatment and management of patients with covid- high flow nasal cannula all gestations < weeks to < weeks to < weeks ≥ weeks ( - ) ( . - . ) . ( . - . ) ( - . ) ( . - ) ( . - . ) . ( - ) na ( - ) na ( . - ) ( . - . all gestations < weeks to < weeks to < weeks ≥ weeks ( - ) ( . - ) ( . - ) . ( - . ) ( . - . ) ( - ) ( . - ) . ( - . ) ( - . ) ( . - . ) . ( - . key: cord- -z rb adi authors: traylor, claire s.; johnson, jasmine; kimmel, mary c.; manuck, tracy a. title: effects of psychological stress on adverse pregnancy outcomes and non-pharmacologic approaches for reduction: an expert review date: - - journal: am j obstet gynecol mfm doi: . /j.ajogmf. . sha: doc_id: cord_uid: z rb adi both acute and chronic stress can cause allostatic overload, or long-term imbalance in mediators of homeostasis, that results in disruptions in the maternal-placental-fetal endocrine and immune system responses. during pregnancy, disruptions in homeostasis may increase the likelihood of preterm birth and pre-eclampsia. expectant mothers traditionally have high rates of anxiety and depressive disorders and many are susceptible to a variety of stressors during pregnancy. these common life stressors include financial concerns and relationship challenges and may be exacerbated by the biologic, social and psychologic changes occurring during pregnancy. in addition, external stressors such as major weather events (e.g., hurricanes, tornados, floods) and other global phenomena (e.g., the covid- pandemic) may contribute to significant stress during pregnancy. this review investigates recent literature published about the use of non-pharmacologic modalities for stress relief in pregnancy and examines the interplay between psychiatric diagnoses and stressors, with the purpose of evaluating the feasibility of implementing non-pharmacologic interventions as sole therapies or in conjunction with psychotherapy or psychiatric medication therapy. further, the effectiveness of each non-pharamacologic therapy in reducing symptoms of maternal stress is reviewed. mindfulness meditation and biofeedback have shown effectiveness in improving one’s mental health such as depressive symptoms and anxiety. exercise, including yoga, may improve both depressive symptoms and birth outcomes. expressive writing has successfully been applied post-partum and in response to pregnancy challenges. though some of these non-pharmacologic interventions can be convenient and low cost, there is a trend towards inconsistent implementation of these modalities. future investigations should focus on methods to increase ease of uptake , ensure each option is available at home, and a standardized way to evaluate whether combinations of different interventions may provide added benefit. both acute and chronic stress can cause allostatic overload, or long-term imbalance in mediators of homeostasis, that results in disruptions in the maternal-placental-fetal endocrine and immune system responses. during pregnancy, disruptions in homeostasis may increase the likelihood of preterm birth and pre-eclampsia. expectant mothers traditionally have high rates of anxiety and depressive disorders and many are susceptible to a variety of stressors during pregnancy. these common life stressors include financial concerns and relationship challenges and may be exacerbated by the biologic, social and psychologic changes occurring during pregnancy. in addition, external stressors such as major weather events (e.g., hurricanes, tornados, floods) and other global phenomena (e.g., the covid- pandemic) may contribute to significant stress during pregnancy. this review investigates recent literature published about the use of non-pharmacologic modalities for stress relief in pregnancy and examines the interplay between psychiatric diagnoses and stressors, with the purpose of evaluating the feasibility of implementing non- pharmacologic interventions as sole therapies or in conjunction with psychotherapy or psychiatric medication therapy. further, the effectiveness of each non-pharamacologic therapy in reducing symptoms of maternal stress is reviewed. mindfulness meditation and biofeedback have shown effectiveness in improving one's mental health such as depressive symptoms and anxiety. exercise, including yoga, may improve both depressive symptoms and birth outcomes. expressive writing has successfully been applied post-partum and in response to pregnancy challenges. though some of these non-pharmacologic interventions can be convenient and low cost, there is a trend towards inconsistent implementation of these modalities. future investigations should focus on methods to increase ease of uptake , ensure each option is stress is a frequently used, ambiguous term. the 'allostatic model' has been developed to help clarify these ambiguities and explain the effects of acute versus chronic stress responses. initial conceptions of stress response were centered around homeostasis, a concept referring to self-regulating processes that maintain the stability of an individual's essential systems. cohen et al. provide a working definition of stress as "when environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological and biological changes that may place persons at risk for disease." these environmental demands may be internal, relating to an individual's disposition, or external, relating to an individual's life circumstances. acute stress is an intense, but relatively short-lived response to stressors whereas chronic stress is the result of unresolved stressors that are experienced for a longer period of time. repeated or chronic stress contributes to the cumulative allostatic load-the "wear and tear on the body," or a sum of the lifetime stress exposure. , allostatic load increases over time and represents physiologic consequences of heightened neural or neuroendocrine responses. hypothalamic-pituitary-adrenal (hpa) axis hormones -including cortisol, catecholamines such as epinephrine, and cytokines -are all primary mediators impacting allostasis. when these primary mediators go beyond the limits of homeostatic mechanisms and become unbalanced, the body is only able to sustain this state without negative effects for a limited time. a prolonged imbalance of these primary homeostatic mediators results in allostatic overload. additionally, chronic stressors or repeated acute stressors may result in changes related to glucocorticoid genes, by alterations of the epigenome and/or transcriptome, and hasten disease. however, though the initial stressful insult cannot always be prevented, epigenetic and transcriptomic effects are dynamic, and potentially reversible through treatment. - stress is common among pregnant women. in - , data from the us-wide centers for disease control pregnancy risk assessment monitoring system found that nearly % of j o u r n a l p r e -p r o o f postpartum mothers reported at least one major stressful event in the year leading up to delivery of their baby. the most commonly cited stressors experienced during pregnancy included moving to a new address, arguing with a partner more than usual, serious illness and hospitalization of a family member, and inability to pay bills. in addition, external stressors such as extreme weather events (e.g., hurricanes, tornados, floods) and other global adverse events (e.g., the covid- pandemic) may contribute to significant acute and chronic stress during pregnancy. reports of perceived stress varied widely by race and ethnicity, with non-hispanic american indian/alaska native women reporting highest levels of stress and non-hispanic asian women reporting the lowest. chronic stress may be associated with adverse pregnancy outcomes via a positive feedback loop. maternal-placental-fetal neuroendocrine interaction and immune responses are stress- sensitive, and thus may affect birth outcomes. maternal stress is associated with cortisol release. , high cortisol levels reduce lymphocyte sensitivity to glucocorticoids by binding to glucocorticoid receptors; subsequently, as steroid resistance is developed, there is an increased release of pro-inflammatory cytokines. furthermore, maternal stress influences circulating levels of inflammatory markers by increasing pro-inflammatory cytokines interleukin- β, interleukin- , and tumor necrosis factor α, and decreasing anti-inflammatory cytokine interleukin- . these inflammatory markers dampen the immune system response, increasing the susceptibility to adverse pregnancy outcomes, such as ptb. women who develop adverse pregnancy complications requiring early delivery or resulting in other maternal or neonatal morbidities may then experience additional stress, furthering the loop. previous studies have found that minority and low-income pregnant women may have higher baseline levels of cortisol compared to women of other situations, supporting the association between chronic stress, increased allostatic load, and higher rates of adverse pregnancy outcomes among these high risk obstetric populations. one stressor of particular j o u r n a l p r e -p r o o f concern to pregnant women of color in the us is racism. racism (and/or discrimination) is typically defined as differential treatment based on ones' skin color or racial identity. racism affects over % non-hispanic black women in the u.s. it is hypothesized that racism may be a significant contributor to the disparities in adverse birth outcomes (e.g., ptb and preeclampsia) among non-hispanic black women compared to non-hispanic white women. the chronic stress associated with racism contributes to an increased allostatic load and a more rapid decline in health during an individual's lifetime-it is a major contributing factor to the 'weathering hypothesis.' weathering is the premature aging of the body due to endurance of adverse events -this can be both physically and psychological. this hypothesis is supported by studies suggesting that age-related increases in preterm birth are higher among non-hispanic black women compared to non-hispanic white women and that racial and ethnic disparities in ptb and other adverse pregnancy outcomes persist among women of high socioeconomic status. acute stress, chronic stress, and allostatic overload have all been associated with a variety of adverse pregnancy outcomes, including spontaneous ptb, preeclampsia, neonatal morbidity, and low birth weight (table ) . , , in turn, ptb (regardless of indication) is associated with a higher risk of short-term neonatal morbidities (including neurologic, pulmonary, cardiovascular, gastrointestinal, immune and metabolic complications) and long-term complications among survivors (e.g., cerebral palsy, neurodevelopmental delay, visions problems, and hearing loss). - as the total allostatic load increases, the likelihood of adverse pregnancy outcomes may also increase ( figure ) . natural disasters and adverse national and international events (e.g., pandemics) provide a unique opportunity to study the effects of a 'universally stressful' exposure on pregnancy outcomes. while it can be difficult to navigate ethical considerations of human research involving an imposed stress variable, populations and individuals intrinsically experience varying j o u r n a l p r e -p r o o f levels of impact, and thus stress exposure, in the event of a population-wide stressor. these stressful experiences -including destructive weather events (e.g., hurricanes, earthquakes) and more chronic population-wide stressors (e.g., local political unrest, war, pandemics) may also activate both the acute and chronic stress response feedback loops in pregnant individuals. depression and anxiety during pregnancy is very common. one in five women will have an anxiety disorder in pregnancy, and - % of women in the general obstetric population meet criteria for major depression during pregnancy. however, anxiety and depressive symptoms are as high as - % in pregnancy, when symptoms are present but insufficient to meet full diagnostic criteria for a specific anxiety or depressive disorder. - in a study of pregnant low- income black women engaging in home-visiting programs in an urban environment, over % met full criteria for major depressive disorder in pregnancy, further supporting that non- hispanic black women who face higher stress also have higher rates of depression. women with a previous diagnosis of depression or anxiety prior to pregnancy, past pregnancy or delivery complications including pregnancy loss and stillbirth, history of adverse life events (e.g., abuse), and particularly those with multiple traumatic events have a higher allostatic load and higher rates of antenatal depression and anxiety. similar to biologic findings seen in those with chronic stress, women with major depressive disorder during pregnancy have increased pro-inflammatory cytokines and a blunted cortisol awakening response. further, prenatal anxiety is associated with increased cortisol levels and pro-inflammatory cytokines. women with both severe depression and severe anxiety during the third trimester had higher levels of il- , il- , il- and il- a. though many pregnant women are exposed to both acute and chronic stressors, not all women who are exposed have adverse pregnancy outcomes. this may explain, in part, why j o u r n a l p r e -p r o o f pregnancy outcomes remain variable in the setting of more widespread adverse events. the sum of an individual's prior social experiences (both positive and negative), and their reaction to these experiences influence whether exposure to new acute or chronic stressors disrupts homeostasis and results in disease or adverse outcomes. hogue and colleagues positioned racial discrimination and spontaneous ptb within a stress and coping framework whereby effective coping may reduce the negative impact of the stress of discrimination, but ineffective coping may allow the stress to cause a disruption in homeostasis and contribute to adverse birth outcomes. others report that though women have elevated risk of spontaneous ptb when reporting lifetime racism (or . , % ci . - . ) and racism in the past year (or . , % . - . ), this risk can be abrogated by "active coping." finally, though one study of , women in canada found that stress was a significant risk factor for ptb (or . , % ci . - . ), the risk of prematurity was highest among those with low levels of social support or optimism. based on these data, the successful reduction on the biological effects of stress during pregnancy has the potential for profound impacts on maternal health and pregnancy outcomes for certain populations. though pharmacologic therapy including selective serotonin reuptake inhibitors (ssris) and benzodiazepines have a role in treating depression or anxiety in pregnancy, pharmacologic treatments for the different alterations in stress responses that have built up over time are more elusive, and the effect on pregnancy outcomes remains under- investigated. of concern, benzodiazepine use in combination with ssri therapy has been associated with worse adverse behavioral effects in the infants. furthermore, though rates of depression are high, only . % receive adequate treatment in pregnancy, and data regarding remission rates of depression with medication during pregnancy are limited. finally, women may be taking appropriate doses of pharmacotherapy but need or desire an additional adjunct therapy. psychotherapy also has a role in the treatment of stress during pregnancy through cognitive behavioral therapy and other approaches, but is excluded from this review because access to psychotherapy may be limited due to provider availability or financial concerns. therefore, the objective here is to review the available use of low-cost, logistically feasible, non-pharmacologic therapies to reduce stress during pregnancy (figure ), and to discuss future avenues for research and clinical care in this area. section : interventions to reduce stress during pregnancy meditation is a mental exercise that improves attention and emotional self-regulation. some types of meditation include mindfulness, breathing, mantra recitation, and visualizations. grounded in buddhist origins, mindfulness is described as attention to and awareness of present perceptions. it is a form of experiential processing in which instances are observed from a wider perspective that recognizes influential judgements and associations. in contrast, during conceptual processing, an individual evaluates situations within the context of self- concern. in recent literature, mindfulness has been of prominent interest as a potential j o u r n a l p r e -p r o o f therapeutic tool because it is low cost and only requires a relatively short investment of time each day. an integrative review of mindfulness in the workplace reported improvements in attention, cognitive capacity, emotional reactivity, self-regulation, and stress response. as a targeted intervention for stress, mindfulness has shown effectiveness in reducing negative outcomes such as anxiety, depression, and chronic pain. in pregnancy, mindfulness has potential as a therapy to reduce stress and improve birth in a randomized controlled trial of non-pregnant students with chronic, pain, and anxiety, mindful breathing facilitated by a -minute smartphone-based task is proposed to decrease hrv. similarly, hrv biofeedback is a non-invasive technique that utilizes metronomic breathing while monitoring one's parasympathetic activity to improve hrv measures. hrv biofeedback has been shown to improve control in response to negative situations, and has been associated with reductions in self-reported perceived stress and anxiety. two studies of perinatal women, one including women with threatened preterm labor and the other including women in the early postpartum period utilized hrv biofeedback versus control groups. [ ] [ ] [ ] in the study of antenatal women with threatened preterm labor, women were randomized to hrv biofeedback vs. standard care at an average weeks' gestation; those randomized to hrv biofeedback had a decrease in their perception of chronic stress during the study period, and the rate of ptb was lower than in the control group ( % vs. %; p value=not significant, exact value not provided in manuscript). in the early postpartum study, use of hrv biofeedback was associated with significant improvements in hrv measures and in scores on the edinburgh postnatal depression scale compared to those who did not use hrv feedback. in anxiety symptoms and improvement in psychological well-being. taken together, these data suggest that biofeedback -particularly when linked to hrv monitoring -may be a method of determining who is responding physiologically to mindfulness and deep breathing practices. studies have already shown efficacy in reducing perceived stress and anxiety during pregnancy, including among pregnant women with threatened preterm labor. according to the national center for health statistics, over million american adults actively practiced yoga in , and this number is still growing. yoga is the most commonly used complementary health approach in the u.s. and consists of three aspects: physical postures (asanas), breathing techniques (pranayama), and meditation (dhyana). originating from india as a spiritual practice, yoga has grown and evolved into many different styles such as hatha, iyengar, bikram, and integrated approaches. while hatha yoga is the most popular form, these different styles do not significantly differ in the probability of reaching positive conclusions in recent research (p= . ). yoga is a popular non-pharmacologic intervention available to pregnant women that may improve both birth outcomes and mental health. prenatal yoga classes are commonly available across the united states. in addition, yoga instruction specifically tailored for pregnant women is available for 'free' online through smartphone apps and on publicly available websites. in a study investigating the effects of prenatal yoga on birth outcomes, women with depressive symptoms were randomized to yoga, massage therapy, or standard prenatal care from to weeks' gestation. a greater improvement in depression scores, decreased anxiety scores, decreased anger scores, decreased back and leg pain scores, and increased relationship scores were seen for those in both the yoga group and the massage therapy group, but not the control group. in addition, those in the yoga and massage group delivered later (mean . and . weeks', respectively) than those in the control group (mean . weeks' gestation). a taiwanese study evaluating the effects of prenatal yoga on stress and immune function intervention. however, it is it important to note that the trials evaluated in both analyses were typically preliminary with small sample sizes. as defined by the american college of sports medicine, exercise is "a type of physical activity consisting of planned, structured, and repetitive bodily movement" that is produced by skeletal muscle contraction and leads to increased energy expenditure. exercise is known to help prevent and treat metabolic or cardiovascular diseases; it has also been shown to reduce depressive symptoms. the american college of obstetrics and gynecology recommends women with uncomplicated pregnancies should complete moderate-intensity physical activity for at least - minutes on most or all days of the week. historically, intense exercise has been assumed to have negative consequences for mother and child. in fact, women tend to reduce their physical activity during pregnancy and less than half of pregnant women meet exercise recommendations. while there may be a theoretic concern regarding vigorous exercise in some situations (e.g., women with premature cervical dilation or threatened preterm labor), there is minimal evidence to suggest harm, and one observational study of women with short cervix suggested a higher risk of preterm birth among women with activity restrictions compared j o u r n a l p r e -p r o o f to those without such restrictions. an analysis of exercise and pregnancy loss referencing cohort studies and reviews including over , women found that regular exercise for up to hours a week, including low-and high-intensity activity, is not associated with increased rates of miscarriage. the benefits of exercise during pregnancy span both physical and mental capacities. a systematic review and meta-analysis of low-impact physical activity in pregnancy evaluated randomized-controlled trials and cohort studies for maternal-child health outcomes. regular exercise was associated with lower weight gain during pregnancy, a lower likelihood of gestational diabetes mellitus, and a lower risk of preterm delivery. less is understood about the relationship between stress and exercise in pregnancy. however, there is a direct association between low exercise frequency and higher reports of stress-related symptoms. , one randomized controlled trial of women explored depression reduction and exercise during pregnancy. women randomized to the exercise group completed three -min sessions of supervised physical activity per week throughout pregnancy. compared to the control group, women in the exercise intervention group scored significantly lower on the center for epidemiologic studies depression scale ( . ± . vs. . ± . , p = . ) at the end of the study. expressive writing involves a personal and often emotional reflection of thoughts or memories; it focuses on detailing one's feelings while writing with the purpose of potentially easing emotional trauma. it was developed as a type of therapy by james w. pennebaker in the late s after his research found that writing for minutes a day for at least consecutive days about previous distressing experiences was associated with significantly fewer visits to a physician in the following months. subsequently, various medical disciplines have started using expressive writing; it is an attractive therapeutic option as it is accessible, customizable, does not require significant time commitment, and is low cost. additionally, it may be more convenient compared with traditional psychotherapy given the lack of mental health professionals in many areas, though it may also be effective if the pregnant woman is able to share some of her writing with a health care professional. although a quantitative survey of pregnant women found that women preferred video telehealth therapy compared to computer-assisted therapy and self-guided online therapy, psychotherapy access is limited for many individuals due to lack of providers and other barriers including financial and scheduling logistics. pregnant women rated computer-based support as acceptable, meditation and mindfulness, biofeedback, yoga, exercise, and expressive writing have not been explored as possible stress therapy options until recent years. therefore, research conducted on these interventions is largely preliminary and prospective. support for these interventions, particularly expressive writing, could benefit from more randomized, controlled trials with larger sample sizes. likely there may be characteristics that make some women more responsive to on over another (e.g., anxious depression versus non-anxious depression). in addition, combining some of these might also lead to greater results, e.g., a mindfulness practice that also includes expressive writing. non-pharmacologic interventions -including, but not limited to those discussed here - have the potential to be affordable and widely available. additionally, with the rising popularity of online classes and support groups, all of the above interventions can be completed at-home. this holds great potential for times when leaving one's home is not possible-a period where situational stress can even be elevated. for example, the methods for stress reduction outlined here provide a safe and potentially effective way for women to reduce stress during pregnancy during a pandemic. non-pharmacologic interventions also provide patients with a choice of preference; patient autonomy will likely improve participation and engagement. expressive writing, mindful meditation, biofeedback, yoga, and exercise provide a broad range of options in terms of metacognition and physicality. finally, these interventions are novel strategies that may be readily available to women of all social and racial / ethnic backgrounds, and the benefits of such could help to close the health disparities gap with respect to maternal and fetal health outcomes. these may also augment pharmacologic treatment of depression and anxiety just as therapy and pharmacotherapy combined can be most effective for those with severe depression or anxiety. , thus, non-pharmacologic interventions for stress reduction provide a viable option available to women during pregnancy. nevertheless, improvements in the implementation of these options should be explored. providers must also take into consideration the unique situation and variable social determinants of health that may make some stress reducing modalities difficult to routinely practice -such as one's work schedule, caregiver needs, unstable housing and/or internet access, etc. in one study, the viability of using expressive writing was studied through agreement of participation and completion of full intervention. around , eligible women were contacted, approximately , replied to the study invitation, and agreed to participate. however, by the -month follow-up, only women remained. additionally, less than % of the women in both writing groups fulfilled the intervention conditions completely. most of the women who did not choose to participate marked "too busy" as the reason for their decline. these results reveal that although expressive writing is theoretically more convenient than other interventions, many patients struggled to complete the intervention conditions to the full extent. horsch's study supports this idea as although of the eligible mothers contacted agreed to participate, only completed the study through to the -month follow-up. further, it is unknown whether combinations of these approaches -e.g., expressive writing and yoga or exercise -might improve pregnancy outcomes. finally, incentivizing the use effective non-pharmacologic therapies for providers could also help with update of the modalities discussed in this review. in the future, ways to incentivize completion and emphasize the potential importance of writing therapy and meditation should be researched for all stakeholders. expressive writing, meditation, mindfulness, biofeedback, yoga, and exercise are effective therapies for emotional and physical health. while these methods have not always been considered for medical treatment of individuals, new research is continually revealing the potential of these interventions to improve health outcomes. for example, other non- pharmacologic approaches to reduce stress in pregnancy -including music therapy and a smartphone app specifically designed to reduce stress in pregnancy -have also been evaluated, but more data are needed to determine the effectiveness of these additional modalities. , the application of these accessible and widely available interventions to reduce stress during pregnancy. in turn, by limiting the negative implications associated with stress in pregnancy, these non-pharmacologic options could help improve birth outcomes. research should continue to expand on the strengths of each intervention as effective, affordable, adaptable to make them a more convenient option for stress alleviation in addition to research on how these non-pharmacologic methods could further enhance the effects of pharmacologic therapies to treat psychiatric conditions. the stress reaction: a historical 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risk for preterm birth key: cord- -higq wje authors: bahn, kate; cohen, jennifer; van der meulen rodgers, yana title: a feminist perspective on covid‐ and the value of care work globally date: - - journal: gend work organ doi: . /gwao. sha: doc_id: cord_uid: higq wje the shared response to the covid‐ crisis demonstrates that the vast majority of society believes human well‐being ‐ not economic growth ‐ should be at the center of policy. covid‐ exposes the foundational role of care work, both paid and unpaid, to functioning societies and economies. focusing on "production" instead of the sustainable reproduction of human life devalues care work and those who perform it. women's physical and mental health, and the societies that rely on them, are at stake. when these policies are formulated, the field of feminist economics has valuable lessons for mitigating hardships as countries navigate the related economic fallout. a comprehensive response to the covid‐ crisis must recognize this gendered work as an integral part of the economic system that promotes human well‐being for all. natural disasters and health crises have gendered dimensions, a point repeatedly demonstrated across disciplines and an important argument raised in this publication by boncori ( ) in the case of the coronavirus pandemic and academic lives. early evidence of a gender disparity in mortality in china indicates a disadvantage for men, who are more likely to have a laboratory-confirmed case, but the gender differential is reversed for other, less clear-cut dimensions of the disease (chen et al., ; guan et al., ) . of particular concern is the overrepresentation of women among low-wage workers on the frontlineincluding home health aides, nurses, and nursing assistantsand at the other end of the supply chainincluding those employed in the logistics and packing industry (himmelstein and venkataramani, ) . women also stand to face the starkest employment losses, as retail, food service, and hospitality are among the industries already hardest hit. in most developed countries, low-wage workers at risk of unemployment are disproportionately minority women, particularly women of color (averett, argys, and hoffman, ) . the gendered dimensions of this crisis also apply within the home, where the gendered division of work has been slow to change. women still do more of the unpaid care work than men around the globe (ilo, ; sayer, ) . the covid- outbreak has increased the need for home-based caring labor not only because of the closing of schools and childcare facilities, but also because more people are sick and need care. women's physical and mental health, and by extension, the societies that rely on women and the work they do, are at stake (cohen and venter, ; geurts et al., ) . this crisis points a spotlight on the need for care, both medical care by paid healthcare personnel as well as care in the home. yet care work is often undervalued and invisible (himmelstein and venkataramani, ; sayer ) . the perceived low value of care work paid and unpaid -and women's disproportionate responsibility in performing this work is an issue that has garnered long-term attention in the field of feminist economics, with valuable lessons for understanding how women are impacted by covid- and mitigating hardships as countries navigate the related economic fallout (power, ) . feminist research in economics has consistently highlighted the ways production depends on paid and unpaid work (laslett and brenner, ; power, ; vogel, ) . social reproduction includes the day-to-day work assigned largely to womenhousehold labor, physical and emotional caregiving, and other work to meet human needsrequired to "maintain existing life and to reproduce the next generation" (laslett and brenner, ) . without the day-to-day work of social reproduction, entire social systems would collapse. the value of women's paid and unpaid labor is increasingly apparent with the spread of covid- : as school close, the role of teachersdisproportionately womenand public education as a mechanism of support and care-giving for families is laid bare, as women working for pay scramble to arrange childcare. across many countries, womenespecially women of colorare overrepresented among low-wage workers on the front line during the covid- crisis. many have no choice but to go to work even when they are at risk of contracting the virus or they are sick, and they cannot telecommute. nursesdisproportionately womenand other first responders must continue to work for pay. women in grocery stores, where task segregation often places them in face-to-face interactions with customers, are essential workers and are newly being recognized as such (tolich and briar, ) . time-use surveys show that, as a group, women work longer than men in total, and they perform more unpaid work than men (ilo, ; sayer, ) . because women bear responsibility for social reproduction, during crises they may face increased pressure to substitute unpaid work for lost income, for example taking care of an ill relative at home rather than taking them to a clinic (ilo, ). all over the world, women are also more likely to be single parents, meaning that women and their households are often more dependent on a single source of income and women provide financial support to more dependents on that income (cohen, ) . intensified pressure is likely to impact women's mental and physical health (cohen and venter, ; geurts et al., ) . gender-aware policies recognize women's work outside of paid employment. more broadly, policy responses from national to local levels should be developed with a feminist perspective that puts due emphasis on the value of care and the power of interdependency, as the interchange of care and resources can sustain families and communities through difficult times (banks, ; power, ) . in wealthier countries, a key policy response is to expand paid sick leave and family leave benefits. in the u.s., the second federal covid- relief package passed march includes for the first timepaid family and medical leave during this crisis to care for a sick or at-risk family member or oneself. this emergency paid leave policy applies to employees who need to care for children whose schools or daycare facilities closed. this legislation helps to meet the needs of some workers who are balancing care responsibilities, but almost half of the u.s. private sector workforce is not eligible. other oecd countries are well ahead of the u.s. in terms of paid leave benefits. further stimulus policy responses being implemented or considered across developed countries include expanded unemployment insurance, targeted cash transfers, universal basic income, and support for small businesses. in poorer countries, the impacts of covid on care-takers will be dire. the "social distancing" recommended in developed countries will be difficult to observe in overcrowded households, and may be impossible for women to adopt. information advising people how to care for ill household members and themselves must be made available, along with hand sanitizer in urban areas, and tippy taps in rural areas. assistance with obtaining food, medications, and maintaining access to utilities is likely to be needed. community health workers and friendship bench-type mental health support for care providers may be valuable interventions for helping people cope with psychological distress (chibanda et al., ) . efforts to mitigate intimate partner violence as tensions mount within households from the health crisis and associated economic insecurity should be prioritized. domestic violence intensifies during disasters and crises (gearhart et al., ) . the covid- crisis is longer term, more people are confined to their homes, there is an uncertain endpoint, many are struggling financially, and people are scared and grieving. it is difficult to overstate the scale of this problem for those who are subject to abuse of all kinds. this article is protected by copyright. all rights reserved. moreover, the crisis cannot be used as an excuse to divert resources away from women's reproductive health care and maternal and child health. for example, under directives to free up hospital beds and medical supplies, legislators in several u.s. states have classified abortions as elective and nonessential procedures that need to be postponed until the crisis is over. however, these restrictions do little if anything to divert necessary resources toward hospital care for coronavirus patients. using covid- as a rationale to limit women's access to reproductive health care services is a political maneuver that defies numerous studies in public health and social sciences showing the beneficial effects of investing in reproductive health. such benefits, which include women's economic empowerment, expanded choice, and a sense of greater control over their lives, are critical in times of crisis (bärnighausen et al., ; gammage, joshi, and rodgers, ) . conclusion covid- is not only a major economic and health shock, it may also be a major shock to social norms around the gendered distribution of work at home. like natural disasters, a public health crisis alters daily living in such a way that may re-entrench gender norms, but also offers the opportunity to disrupt them. more parents are staying home due to workplace closures, with many employees in white collar jobs telecommuting if that is feasible. the home, usually a black box in neoclassical economics, has suddenly become a sphere of close scrutiny in academic and media discourse around caring labor and its power relations. in twoparent households, the allocation of work within the home depends not only on gendered social norms but also bargaining power and the opportunity cost of time allocated to domestic work. these issues have garnered attention during the covid- crisis as families have been confined to their homes while attempting to work and care for children at the same time. changing the gender distribution caring labor within the home and causing conflict in negotiating boundaries between work and family. we expect that telecommuting in the context of covid- places disproportionate burdens on women. this question fits into the broader goal of seeking to understand how the nature of workboth paid and unpaidis changing during the enormous social and economic upheaval caused by the covid- pandemic. the institutionalization of telecommuting may bring wider acceptance and adoption of other workplace policies such as job sharing and flex-time that place value on labor within the home. covid- exposes how the usual functioning of the labor market combines with gender roles to require more work from women than from men. although many of the challenges for women are not unique to this time, covid- exacerbates their impacts, and making this an important moment to advocate for policies that support their wellbeing, and that of the society their work sustains. economic policy should be constructed within a broader, feminist framework of human wellbeing and justice, rather than being solely concerned with the achievement of output-based metrics such as financial stability and economic growth. at minimum, in addition to capabilities (the ability to do or be) and self-efficacy, human well-being requires adequate provisioning through three interconnected channels: paid labor, unpaid care activities, and support from the government (nussbaum, ; sen, ) . paramount in this approach is the need to address other types of injustice that may intersect with gender inequality, especially by race and class. hence a comprehensive response to the covid- crisis the oxford handbook of women and the economy women of color and unpaid community work. pathways to gender equity conference this is mine, this is for me': preexposure prophylaxis as a source of resilience among women in eswatini the neverending shift: a 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vulnerability among us female health care workers: potential impact of a $ -per-hour minimum wage care work and care jobs for the future of decent work gender and social reproduction: historical perspectives capabilities as fundamental entitlements: sen and social justice social provisioning as a starting point for feminist economics gender, time and inequality: trends in women's and men's paid work, unpaid work and free time development as freedom just checking it out: exploring the significance of informal gender divisions amongst american supermarket employees marxism and the oppression of women: toward a unitary theory key: cord- -xihpfidg authors: ford, julian d.; grasso, damion j.; elhai, jon d.; courtois, christine a. title: social, cultural, and other diversity issues in the traumatic stress field date: - - journal: posttraumatic stress disorder doi: . /b - - - - . -x sha: doc_id: cord_uid: xihpfidg this chapter describes how the impact of psychological trauma and posttraumatic stress disorder (ptsd) differ, depending on individual differences and the social and cultural context and culture-specific teachings and resources available to individuals, families, and communities. a social-ecological framework is used to differentiate the impact of exposure to traumatic stressors and the development of (or resistance to) ptsd, based on the individual’s or group’s (i) personal, unique physical characteristics, including skin color, racial background, gender, and sexual orientation; and (ii) family, ethnocultural, and community membership, including majority or minority group status, religious beliefs and practices, socioeconomic resources, and political and civic affiliations. while personal, familial, social, and cultural factors can be a positive resource contributing to safety and well-being, they also can be a basis for placing the person, group, or entire community or population in harm’s way or at heightened risk of developing ptsd. this is an adaptive response in one sense, providing an awareness and readiness to respond should the genocide or any associated forms of stigma, discrimination, or violence ever recur with impunity. however, it can also become a form of persistent hypervigilance similar to that seen in ptsd, placing a strain upon the individual's or group's daily life that may compromise their well-being. our discussion of the impact of exposure to traumatic stressors and ptsd on ethnoracial groups and individuals whose forebears have experienced historical trauma will bear this fact in mind. in addition, gender-based biases and beliefs, many of which are based on longstanding religious and cultural traditions, have caused women to be systematically discriminated against and subject to routine physical and sexual assault. genderbased discrimination and violence against females (whether intra-or extrafamilial) have been so widespread as to be implicated in what kristof and wudunn ( ) term "gendercide." in their recent book, they cite examples of selective abortions based on a fetus's gender and differential nutrition and care beginning in infancy also based on gender preference. they are then often followed by lifelong major disparities in education and restricted role and career opportunities for females as compared to males. unfortunately, even today, with all the advances that have occurred predominantly in western societies, these same issues remain in place around the world. the increased recognition of the underclass status of the majority of women and girls and the discrimination they face, along with the violence perpetrated against them (often seemingly with impunity), in countries around the world (whether industrialized and "advanced," or relatively primitive) has led to the recent development of major initiatives against global violence and discrimination against women. malala yousafzai, who was shot by the taliban for her espousal of universal education for girls, was awarded the nobel peace prize, the youngest recipient to date. the brutality of the attack against her was shocking, yet it served to highlight the traumatic threat to which many girls and women across the world are exposed when targeted for hateful acts by those who believe this is necessary to maintain the status quo and the subservience of females. discrimination and violence based on sexual orientation and transgender/intergender status are yet other sources of traumatic victimization that must be well recognized. sexual orientation is both a personal and social characteristic that is more complex than the gender that a person inherits based on inborn sexual characteristics. when socially ascribed gender and culturally promulgated expectations for gender-based activities, such as mating, are a mismatch to an individual's sense of his or her own true sexual preferences and identity, the conflict can be psychologically devastating. global initiatives therefore are underway to prevent or ameliorate the adverse impact of discrimination, stigma, and violence based on sexual orientation and identity providing an essential foundation for the basic liberties, freedom from assault, and the right to marry to gay, lesbian, bisexual, and transgendered (glbt) individuals. it should also be noted that boys and men are also subject to abuse and assault at rates that are not yet adequately researched. males may be more subject to violence when they are in a position of vulnerability of some sort due to being a member of a group that is targeted and/or of lesser status/lesser strength. depending on social, cultural, and other diversity issues in the traumatic stress field their cultural background and its traditions and beliefs, individuals may also have "multiple vulnerability status"-that is, to be members of more than one group or to have characteristic that cause them to be even more susceptible to discrimination or victimization (i.e., adolescent black male in the united states; a baby born with physical or developmental disabilities in a culture that endorses selective resources to the ablebodied; a gay man or lesbian woman of color in a highly homophobic and racist society). age is yet another vulnerability factor dimension that has not received adequate recognition, with individuals at either end of the life span as most vulnerable. research has substantiated that children and adolescents are the most at-risk segment of the population globally (finkelhor, ) . victimization of the elderly and the lessabled/disabled members of the population is now documented as widespread in many societies and is increasingly under investigation. like other forms of abuse, victimization of the elderly and less-abled is often based on the victim's relative degree of dependence and his powerlessness to defend himself. the extent and impact of exposure to traumatic stressors experienced by each of these vulnerable populations is discussed in this chapter, as are the efforts of international non-governmental organizations (ngos) to provide them with resources to reduce their exposure to traumatic stressors or to mitigate the adverse effects of traumatic exposure and ptsd (box . ). box . key points . culture, ethnicity, gender, sexual orientation, and disability are potential sources of resilience, but they also may lead to chronic stressors such as social stigma, discrimination, and oppression, which can increase psychological trauma and ptsd. . cumulative adversities are faced by many persons, communities, ethnocultural minority groups, and societies that may lead to-as well as worsen the impact of-ptsd: • persons of ethnoracial minority backgrounds; • persons discriminated against due to gender or sexual orientation; • persons with developmental or physical disabilities; • economically impoverished persons and groups, including the homeless; • victims of political repression, genocide, "ethnic cleansing," or torture; • persons chronically or permanently displaced from their homes and communities due to catastrophic armed conflicts or disasters. . members of ethnoracial minority groups have been found to be more likely in some cases to develop ptsd than other persons, but in other cases they are less likely to develop ptsd (e.g., persons of asian or african descent). . members of ethnoracial minority groups often encounter disparities in access to social, educational, economic, and health care resources; it is these disparities that are the most likely source of the increased vulnerability of these persons to psychological trauma and ptsd. (continued ) to psychological trauma in the immediate or most distant past, or both. psychological trauma and ptsd occur across the full spectrum of gender, racial, ethnic, and cultural groups in the united states (pole, gone, & kulkarni, ) . psychological trauma and ptsd are epidemic internationally as well, particularly for ethnoracial minority groups (which include a much broader range of ethnicities and cultures and manifestations of ptsd than typically recognized in studies of ptsd in the united states; de jong, komproe, spinazzola, van der kolk, & van ommeren, ; de jong, komproe, & van ommeren, ) . the scientific and clinical study of ptsd and its treatment among gender and ethnoracial majority and minority groups is of great importance, especially given the disparities, adversities, and traumas to which they have been subjected historically (miranda, mcguire, williams, & wang, )-and to which they are still exposed in health and health care, education and income, and adult criminal and juvenile justice (ford, ) . although latinos (and possibly african americans) persons are at greater risk than european americans for ptsd based on available research findings (pole, gone, & kulkarni, ) , it is possible that the elevated prevalence may be due to differences in the extent or types of exposure to psychological trauma (including prior traumas that often are not assessed in ptsd clinical or epidemiological studies; eisenman, gelberg, liu, & shapiro, ) or to differences in exposure to other risk or protective factors such as poverty, education, or gender-based violence (turner & lloyd, , . in addition, there is sufficient diversity (in norms, beliefs, values, roles, practices, language, and history) within categorical ethnocultural groups such as african americans or latinos to call into question any sweeping generalizations about their exposure and vulnerability or resilience to psychological trauma (pole et al., ) . race, ethnicity, gender and sexual identity, and culture tend to be described with shorthand labels that appear to distinguish homogeneous subgroups but that actually obscure the true heterogeneity within as well as between different groups (marsella, friedman, gerrity, & scurfield, ) . one partial antidote for this problem is for clinicians and researchers to be curious about these issues and to ask study participants or clinical patients to self-identify their own racial, ethnic, and cultural background and to essentially educate them about their unique characteristics and associated belief systems and traditions (brown, ; brown, hitlin, & elder, ) . it also is important to carefully assess factors that are associated with differential exposure to adverse experiences (such as racial-ethnic discrimination) or differential access to protective resources (such as income, health care, education, police protection), rather than assuming that each member of an ethnocultural group is identical on these crucial dimensions. however, when systematic disparities in exposure to stressors or deprivation of resources are identified for specific groups, such as persons from indigenous culturesthe original inhabitants of a geographic area who have been displaced or marginalized by colonizing national/cultural groups-are found to have a generally increased risk of discrimination, poverty, addiction, family violence, and poor health (harris et al., ; liberato, pomeroy, & fennell, ) , it is crucial not to mistakenly conclude that those persons are less resilient than others when they are confronted with traumatic stressors. commonly, the very opposite is true: persons and groups who are subjected to chronic stressors or deprivations tend to be more resilient than others, but they also are more exposed to and less protected from traumatic stressors (pole et al., ) . racism and associated discrimination and mistreatment are particularly chronic stressors faced by many members of ethnoracial and other minority groups. racism may constitute a form of psychological trauma in and of itself, increasing the risk of exposure to psychological trauma, and exacerbating its impact by increasing the risk of ptsd (ford, ) . as of yet, few systematic studies have directly examined racism as a risk factor for exposure to psychological trauma, although the connection is increasingly recognized (carter & forsyth, ; hunter & schmidt, ; miller, ) . perhaps, the holocaust and other forms of genocide have been the most investigated to date. studies of survivors of the holocaust and other types of ethnic annihilation provide particularly graphic and tragic evidence of the infliction of psychological trauma en masse in the name of racism (staub, ; yule, ) . studies are needed that systematically compare persons and groups who are exposed to different types and degrees of racism in order to test whether (and under what conditions) racism is a form of, or leads to exposure to other types of, traumatic stressors (ford, ) . when racism leads to the profiling and targeting of ethnoracial minority groups for violence, dispossession, dislocation, or annihilation, the risk of ptsd increases in proportion to type and degree of the traumatization involved (pole et al., ) . for example, studies based in the united states (pole et al., ) and internationally (macdonald, chamberlain, & long, ) suggest that racial discrimination may have played a role in placing military personnel from ethnoracial minority groups at risk for more extensive and severe combat trauma exposure. one study found that self-reported experiences of racial discrimination increased the risk of ptsd among latino and african american police officers (pole, best, metzler, & marmar, ) . another study with asian american military veterans from the vietnam war era showed that exposure to multiple race-related stressors that met ptsd criteria for psychological trauma was associated with more severe ptsd than when only one or no such race-related traumas were reported (loo, fairbank, & chemtob, ) . this study more precisely operationalized racism than any prior study, utilizing two psychometrically validated measures of race-related stressors and ptsd. however, as in the pole et al. ( ) study, the stressors/traumas and ptsd symptoms were assessed by contemporaneous self-report, so the actual extent of racism experienced by the participants cannot be definitely determined. the loo et al. ( ) study also did not control for traumatic stressor exposure other than that which was related to racism. in order to extend the valuable work these studies have begun, it will be important to utilize measures based on operationally specific criteria for categorizing and quantifying exposure to discrimination (e.g., wiking, johansson, & sundquist, ) as a distinct class of stressors that can be assessed separately as well as concurrently with exposure to psychological trauma. research also is needed to determine to what extent the adverse outcomes of racial disparities are the direct result of racism as a stressor (e.g., racially motivated stigmatization, mistreatment, subjugation, and deprivation resulting in personal and community depression and destabilization), as opposed to the indirect effects of racism (such as microaggressions that accrue over time). racism can also indirectly reduce access to protective factors (adequate nutrition and other socioeconomic and community resources) that protect against the adverse effects of stressors (such as poverty, pollution, disaster) and traumatic stressors (such as accidents, crime, or violence). hurricane katrina and its aftermath provided just such an example. it is important to determine whether ptsd is the product of either the direct or indirect effects of racism, or both, particularly given its demonstrated association with other psychiatric conditions (such as depression, anxiety, and addiction) and with increased risk of physical illness (such as cancer and cardiovascular disease) in ethnoracial minorities (e.g., among american indians; sawchuk et al., ) . education is a particularly relevant example of a socioeconomic resource to which ethnoracial minorities often have restricted access as that as a protective factor mitigating against the risk of ptsd (dirkzwager, bramsen, & van der ploeg, ) and overall health status (wiking et al., ) . racial disparities in access to education are due both to direct influences (such as lower funding for inner-city schools that disproportionately serve minority students) and indirect associations with other racial disparities (such as disproportionate juvenile and criminal justice confinement of ethnoracial minority persons). racial disparities in education are both the product of and a contributor to reduced access by minorities to other socioeconomic and health resources (such as income, health insurance, adequate nutrition) (harris et al., ) . when investigating risk and protective factors for ptsd, it is essential therefore to consider race and ethnicity in the context not only of ethnocultural identity and group membership but also of racism and other sources of racial disparities in access to socioeconomic resources. although all ethnoracial minority groups tend to be disproportionately disadvantaged with regard to the more privileged majority population, particularly severe disparities in access to vital resources often are complicated by exposure to pervasive (both intrafamilial and community) violence and by the loss of ties to family, home, and community. when family and community relationships are severed-as occurs with massive political upheaval, war, genocide, slavery, colonization, or catastrophic disasters-racial and ethnocultural groups may find themselves scattered and subject to further victimization and exploitation. for example, there continue to be massively displaced populations in central and south america, the balkans, central asia, and africa. when primary social ties are cut or diminished as a result of disaster, violence, or political repression, the challenge expands beyond survival of traumatic life-threatening danger to preserving a viable life, community, and culture in the face of lifealtering losses and suppression of those very factors needed to maintain (garbarino & kostelny, ; rabalais, ruggiero, & scotti, ) . ethnoracial groups that have been able to preserve or regenerate core elements of their original cultural norms, practices, and relationships within intact or reconstituted families may actually be particularly resilient to traumatic stressors and protected against the development of ptsd. for example, persons of asian or african descent have been found to be less likely than those of other ethnocultural backgrounds to develop ptsd. whether this is due to factors other than ethnicity per se, such as having cultural practices and beliefs that sustain family integrity and social ties, is a question that has not been scientifically studied and should be a focus for research (pole et al., ) . a recurring theme is that the psychological trauma inflicted in service of racial discrimination may lead not only to ptsd but also to a range of insidious psychosocial problems that result from adverse effects upon the psychobiological development of the affected persons. when families and entire communities are destroyed or displaced, the impact on the psychobiological development of children and young adults may lead to complex forms of ptsd that involve not only persistent fear and anxiety but also core problems with relatedness and self-regulation of emotion, consciousness, and bodily health that are described as "complex ptsd" (herman, ) or "disorders of extreme stress" (de jong et al., ) . a critical question not yet answered by studies of ptsd and racial discrimination (pole et al., ) and race-related stress (loo et al., ) , as well as by the robust literature that shows evidence of intergenerational transmission of risk for ptsd (kellerman, ) , is whether racism constitutes a "hidden" (crenshaw & hardy, ) or "invisible" (franklin, boyd-franklin, & kelly, ) form of traumatization that may be transmitted across generations. recent research findings demonstrating highly adverse effects of emotional abuse in childhood (teicher, samson, polcari, & mcgreenery, ) are consistent with a view that chronic denigration, shaming, demoralization, and coercion may constitute a risk factor for severe ptsd and associated psychobiological problems. research is needed to better describe how emotional violence or abuse related to racism may (along with physical violence) constitute a form of traumatic stress and how this may adversely affect not only current but also future generations. a fully articulated conceptual model for the scientific study and social/clinical prevention and treatment of the adverse impact of psychological trauma and ptsd requires principles and practices informed by this diversity of factors, rather than a "black and white" view of race, ethnicity, or culture that misrepresents the individual's and group's heritage, nature, and needs. treatment preferences, in terms of characteristics of the therapist as well as the therapy model, differ substantially not only across but also within ethnoracial groups (pole et al., ) . as a result, it is not possible as yet-and may never be possible-to precisely prescribe how best to select or train therapists and design or adapt therapies to fit different ethnocultural groups and the individuals within them. a culturally competent (brown, (brown, , a (brown, , b approach to treating ptsd (ford, ) begins with a collaborative discussion in which the therapist adopts the stance of a respectful visitor to the client's outer and inner world-clarifying the client's expectations and preferences, and the meaning of sensitive interpersonal communication modalities (such as spatial proximity, gaze, choice of names, private versus public topics, synchronizing of talk and listening, use of colloquialisms, providing advice or education). ptsd therapists thus must avoid stereotypic assumptions and become both a host and guest in the client's psychic world in order to ensure that assessment and treatment are genuinely collaborative and sensitive to each client's ethnocultural traditions, expectations, goals, and preferences (parson, ; stuart, ) . at times, it is helpful to involve other members of the family or culture in assisting with the treatment. religious beliefs and spirituality are other dimensions of culture that have not yet been given sufficient focus in most psychotherapy but must also be assessed and understood by the therapist (walker, courtois, & aten, ) . cultural competence means many things to many people, and unfortunately, it is often mistakenly equated with being of the same racial, ethnic, cultural, religious, or national background as the persons involved in a study or receiving services, or knowing in advance exactly what each person believes and expects, how they communicate with and are most receptive to learning from others, and what their experience has been in relation to sensitive matters such as psychological trauma or ptsd. this is likely to be a serious mistake for several reasons. sharing some general racial, ethnic, cultural, or national features (or an apparently identical language or religion) is not synonymous with shared identity, knowledge, or history. even persons from as virtually identical backgrounds as monozygotic twins raised in the same family have substantial differences in physical and temperamental characteristics as well as often quite distinct social learning histories, and thus rarely if ever can reliably read one another's minds or exactly know one another's vulnerabilities and strengths. therefore, cultural competence should not be defined in terms of stereotypic assumptions about identity or prescience but instead based upon a respectful interest in learning from each person and community what they have experienced and how they understand and are affected by psychological trauma and ptsd. we should also note that the idioms of distress can differ by culture and tradition. professionals from industrialized nations and anglo cultures must be cautious and respectful in working with individuals and communities from other cultures that are challenged by ptsd in the aftermath of exposure to violence or disasters. before offering or providing education or therapeutic assistance, it is essential to become aware of how the potential recipients understand and prefer to communicate about traumatic stress and the process of healing from traumatization. the implication for psychometric assessment of psychological trauma and ptsd with clients of ethnocultural minority groups (hall, ; marsella et al., ) is that it is essential to carefully select protocols that do not confront individuals with questions that are inadvertently disrespectful of their values or practices (e.g., including peyote as an example of an illicit drugs in a native american tribe that uses it for religious rituals), irrelevant (e.g., distinguishing blood family from close friends in a group that considers all community members as family), or incomplete (e.g., limiting health care to western medical or therapeutic services, to the exclusion of traditional forms of healing). a systematic assessment of trauma history and ptsd thus should include not only a recitation of events in a person's life and symptomatic or resilient responses in the aftermath but how the person interpreted these events and reactions based on their cultural framework, beliefs, and values (manson, ) . interventions for prevention or treatment of ptsd typically have been developed within the context of the western medical model (parson, ; but see andres-hyman, ortiz, anez, paris, & davidson, ; hinton et al., ; hwang, , for examples of culturally sensitive adaptations). evidence-based ptsd treatment models are not necessarily incompatible with culturally specific healing practices and have in common the goal of fostering not just symptom reduction but a bolstering of resilience and mastery (see chapters and ). the integration of culturally specific methods and rituals in prevention or treatment interventions for ptsd, however, requires careful ethnographic study (i.e., observing and learning about the values, norms, beliefs, and practices endorsed and enforced by different cultural subgroups and their particular idioms (ways of describing and explaining) traumatic stress and ptsd) so the ptsd clinician and researcher can truly work collaboratively withrather than imposing external assumptions and standards upon-the members of the wide range of ethnic and cultural communities. in most cultures, girls and women are subject to discrimination in the form of limitations on their access to crucial socioeconomic resources. women earn - % lower wages or salaries than men in most job classes in the united states (http://www.payequity.org/info.html) and europe (http://www.eurofound.europa.eu/ewco/ / / es i.htm). although girls and women are approaching parity with boys and men in access to education in most areas of the world (and exceed the enrollment of boys or men in secondary and college/university education), in sub-saharan africa and asia, women and girls are as much as % less likely to be able to enroll in education and to have achieved literacy as adults (http://www.uis.unesco.org/template/ pdf/educgeneral/uisfactsheet_ _no% _en.pdf). girls and women also may be systematically subjected to extreme forms of psychological and physical trauma as a result of their gender being equated with second-class citizenship and social norms that permit or even encourage exploitation. sexual exploitation of women and girls is an international epidemic, including abuse and molestation, harassment, rape and punishment of rape victims, forced marriage, genital mutilation, and sex trafficking or slavery (box . ). physical abuse or assault of women and girls is tolerated-and in some cases actually prescribed as a form of social control-in both mainstream cultures and subcultures that span the globe and include most religions and developed as well as developing or preindustrial societies. similar potentially traumatic forms of violence are directed at many glbt persons as a result of both formal and informal forms of social stigma and discrimination. epidemiological studies have been conducted with samples of glbt youth (d'augelli, grossman, & starks, ) and adults (herek, ) in the united states, suggesting that they are often subjected to potentially traumatic violence as a result of their nontraditional sexual orientation and behavior. instances of violence specifically related to sexual orientation include: • - % of gay men and % of lesbians who were physically assaulted in the past year; • - % of glb adults who were subjected to actual or threatened violence toward their person or a property crime at some point in their lives; • - % of glb adolescents reported past incidents of physical or sexual violence. in contrast to the general pattern of stigma-related violence being directed toward girls and women, gay and bisexual boys (d'augelli et al., ) and men (herek, ) were more likely to report violent victimization or threats than lesbian or bisexual women or girls. the findings from the survey of glb adolescents suggest that stigma and victimization begin early in life, with physical and sexual attacks occurring as early as ages - years old. one in eleven glb adolescents met criteria for ptsd, box . "making the harm visible": sexual exploitation of women and girls women from every world region report that the sexual exploitation of women and girls is increasing. all over the world, brothels and prostitution rings exist underground on a small scale, and on an increasingly larger scale, entire sections of cities are informally zoned into brothels, bars, and clubs that house, and often enslave, women for the purposes of prostitution. the magnitude and violence of these practices of sexual exploitation constitute an international human rights crisis of contemporary slavery. in prostitution: a form of modern slavery, dorchen leidholdt, the coexecutive director of the coalition against trafficking in women, examines the definitions of slavery and shows how prostitution, and related forms of sexual exploitation, fit into defined forms of slavery. in some parts of the world, such as the philippines, prostitution is illegal but well entrenched from providing "recreational services" to military personnel. in "blazing trails, confronting challenges: the sexual exploitation of women and girls in the philippines," aida f. santos describes the harmful conditions for women and girls in prostitution in the philippines, with problems related to health, violence, the legal system, and services. in other regions, such as northern norway, organized prostitution is a more recent problem, stemming from the economic crisis in russia. in "russian women in norway," asta beate håland describes how an entire community is being transformed by the trafficking of women for prostitution from russia to campgrounds and villages across the border in norway. political changes combined with economic crises have devastated entire world regions, increasing the supply of vulnerable women willing to risk their lives to earn money for themselves and their families. aurora javate de dios, president of the coalition against trafficking in women, discusses the impact of the southeast asian economic crisis on women's lives in "confronting trafficking, prostitution and sexual exploitation: the struggle for survival and dignity." economic globalization controlled by a handful of multinational corporations located in a few industrialized countries continues to shift wealth from poorer to richer countries. in her paper "globalization, human rights and sexual exploitation," aida f. santos shows us the connection between global economics and the commodification and sexual exploitation of women and girls, especially in the philippines. structural adjustment programs implemented by international financial institutions impose loan repayment plans on poor countries, which sacrifice social and educational programs in order to service their debt to rich nations and banks. fatoumata sire diakite points to structural adjustment programs as one of the factors contributing to poverty and sexual exploitation in her paper "prostitution in mali." zoraida ramirez rodriguez writes in "report on latin america" that the foreign debt and policies of the international monetary fund are primary factors in creating poverty for women and children. these forces leave women with few options, increasing the supply of women vulnerable to recruitment into bride trafficking and the prostitution industry. (continued ) social problems such as sexual and physical abuse within families force girls and women to leave in search of safety and a better life, but often they find more exploitation and violence. physical and sexual abuse of girls and women in their families and by intimate partners destroys girls' and women's sense of self and resiliency, making them easy targets for pimps and traffickers who prey on those who have few options left to them. these factors are evident in many of the papers from all world regions in this volume, such as jill leighton and katherine depasquale's, "a commitment to living," and martha daguno's, "support groups for survivors of the prostitution industry in manila." government policies and practices also fuel the demand for prostitution, as they legalize prostitution or refuse to enforce laws against pimps, traffickers, and male buyers. in making the harm visible, we see how countries with governmental structures and ideological foundations as different as the netherlands and iran, both promote and legalize sexual violence and exploitation of girls and women. in "legalizing pimping, dutch style," marie-victoire louis exposes the liberal laws and policies that legalize prostitution and tolerate brothels in the netherlands. at the other extreme, religious fundamentalists in iran have legalized the sexual exploitation of girls and women in child and temporary marriages and the sexual torture of women in prison. sarvnaz chitsaz and soona samsami document this harm and violation of human rights in "iranian women and girls: victims of exploitation and violence." global media and communication tools, such as the internet, make access to pornography, catalogs of mail-order brides, advertisements for prostitution tours, and information on where and how to buy women and girls in prostitution widely available. this open advertisement normalizes and increases the demand by men for women and girls to use in these different forms of exploitation. donna m. hughes describes her findings on how the internet is being used to promote the sexual exploitation of women and children in "the internet and the global prostitution industry." in this milieu, women and girls become commoditiesbought and sold locally and trafficked from one part of the world to another. how do we make the harm of sexual exploitation visible? in a world where sexual exploitation is increasingly normalized and industrialized, what is needed to make people see the harm and act to stop it? the women in making the harm visible recommend four ways to make the harm of sexual exploitation visible: listen to the experiences of survivors, expose the ideological constructions that hide the harm, expose the agents that profit from the sexual exploitation of women and children, and document harm and conduct research that reveals the harm and offers findings that can be used for policy initiatives. reprinted with permission from the introduction to making the harm visible, edited by d. hughes - times the prevalence of children (copeland, keeler, angold, & costello, ) and adolescents (kilpatrick et al., ) in national samples in the united states. although gender and sexual orientation may seem intuitively to be simpler phenomena than race or ethnicity, in reality they are quite complex in terms of referring to not just biological characteristics but many aspects of psychological identity and social affiliations. being a female or a male, let alone gay, lesbian, bisexual, or transgendered/ intergendered, means many different things to different people. although more stable than changeable, sexual orientation and even gender may be changed for the same person over time. it is inaccurate to assume that all or even most people of a given gender or sexual orientation are identical or even similar without careful and objective assessment of how they view themselves and how they actually act, think, and feel. in relationship to psychological trauma and ptsd, therefore, the broad generalizations that have been suggested by research concerning gender and sexual orientation relate more to the way in which people of a gender or sexual orientation are generally viewed and treated (which varies, depending on the society and culture) than to inherent qualities of a given gender or sexual orientation (which is highly individual across all societies and cultures). the finding that girls and women are more often subjected to sexual and intrafamilial traumatic stressors, while boys and men more often experience physical, accidental, combat, and assaultive traumatic stressors is consistent with stereotypic sex roles that are found in many (but not all) cultures that assign females to the role of subservient helper and caregiver, while males are assigned to the role of leader and warrior. there are biological foundations for these differences-such as due to distinct levels of the sex-linked hormones estrogen and testosterone, and brain chemicals that differentially affect females and males (oxytocin and vasopressin; see chapter ). however, biology need not dictate a person's or a group's destiny, so it is inaccurate to assume that males or females must always fill these sex role stereotypes, particularly when there are severe adverse consequences, such as the epidemics of abuse of girls and women and of boys and men killed as violent combatants or as the "spoils of war." stereotypes can be even more insidious and damaging in relation to sexual orientation. only in the past decades has homosexuality been rescued from the status of a psychiatric disorder (as it was in the first three editions of the diagnostic and statistical manual). stigma and harassment evidently are still experienced, potentially with traumatic results when violent acts are tolerated or even encouraged, by glbt adults and youth. it is not surprising that the prevalence of ptsd is greater among persons with other than heterosexual sexual identities, and the extent to which this is the result of the pernicious stigma directed at such individuals in most cultures or of outright traumatic violence, or both, remains to be tested. persons with physical or developmental disabilities are another group of persons who unfortunately may be subjected to stigma and discrimination. physical disabilities are more common in developing countries than in more industrialized and affluent nations in which medical technology and accident and illness prevention have reduced the risk of severe injury or genetically based physical disabilities (mueser, hiday, goodman, & valentini-hein, ) . persons with physical disabilities may be at risk for exposure to traumatic accidents or maltreatment as children and as adults due to limitations in their abilities to care for themselves and live independently, particularly if they have cognitive impairment due to conditions such as mental retardation or serious mental illness. only one study that examined the prevalence of exposure to potentially traumatic events among physically disabled persons could be located. that was a national survey of women with physical disabilities by the center for research on women with disabilities (nosek, howland, & young, ) . on the one hand, the study found that disabled women were no more likely to report exposure to physical or sexual abuse than women without physical disabilities. however, in more detailed interviews with a subsample, more than % reported instances of abuse, on average two incidents per woman (each often lasting for a lengthy time period). for example, the report provides verbatim quotations: more than half of all respondents ( % with disabilities, % with no disability) reported a history of either physical or sexual abuse, or both, which is a substantially higher prevalence than that reported in epidemiological surveys of nationally representative samples of women. notably, women with disabilities were more likely than women without disability to report emotional abuse from a caregiver or family member and to have experienced all forms of abuse for a longer time period than women without disability. although ptsd was not assessed, women younger than years old with spina bifida ( %), amputation, traumatic brain injury (tbi), or multiple sclerosis (> %) were highly likely to be diagnosed with depression than women with no disability. in light of the extensive histories of potentially traumatic abuse and of depression, it appears that women with physical disabilities-particularly those in early to midlife adulthood with disabilities that involve progressive deterioration or mental or psychological disfiguration-may be at risk for having experienced traumatic interpersonal violence and other forms of abuse and suffering from undetected ptsd. tbi is a special case of physical disability because it involves physical injury that specifically compromises mental functioning. tbi ranges from mild (no more than minutes of unconsciousness and hours of amnesia) to severe (coma of at least hours or amnesia for more than hours). studies with adults and children of both genders who have sustained tbi demonstrate that they are as likely to develop ptsd as persons in equally severe accidents or assaults who have not (mcmillan, williams, & bryant, ) . fewer studies have been conducted with persons with severe than mild tbi, but they have not been found to be less likely to develop ptsd, as was originally hypothesized-due to not being able to experience or later recall the psychologically traumatic aspects of the injury as vividly as a person who does not lose consciousness or have amnesia. a subsequent study confirmed that adults with tbi were less likely to report acute traumatic stress symptoms immediately after the injury and to recall having felt helpless when interviewed several weeks later but that months after the accident, they were equally likely to report ptsd symptoms as injury survivors with no tbi (jones, harvey, & brewin, ) . tbi definitely exacerbates, and indeed may cause, ptsd, as tragically is illustrated by the extremely high estimates of prevalence of ptsd among military veterans of the iraq and afghanistan wars with tbi. thus, ptsd warrants careful assessment when tbi has occurred. concerning developmental disabilities, similarly, only one published study of ptsd could be located (ryan, ) . in that study, adults receiving services for learning disability were more likely than other adults (kessler, sonnega, bromet, & hughes, ) to report exposure to traumatic stressors ( % prevalence, on average two past traumatic events). however, they had no greater risk than adults in the general population when exposed to traumatic stressors. the most frequently reported types of traumatic exposures were multiple experiences of sexual abuse by multiple perpetrators (commonly starting in childhood), physical abuse, or life-threatening neglect. traumatic losses involving a caregiver or close relative or friend (including witnessing the death in several instances (such as witnessing a sibling dying in a fire, a close friend die during a seizure or an accident, or a parent commit suicide by shooting himself in the head with a gun)) were also reported by at least % of the participants. most of the learning-disabled adults who met criteria for ptsd had been referred for treatment for violent or disruptive behavior, typically with no psychiatric diagnosis or a diagnosis of schizophrenia, autism, or intermittent explosive disorder. when ptsd was diagnosed, major depression was a frequent comorbid disorder; yet, neither ptsd nor depression typically had been identified prior to the clinical assessment study. the findings of this study suggest that adults with developmental disorders often have been targets for abuse or neglect in childhood or have sustained severe traumatic losses and that their ptsd and depression tend to go undiagnosed as clinicians make their behavioral difficulties the focus of treatment services (box . ). poverty is an adverse result of having low "social status." this does not mean that a person or group is objectively deficient but rather that he or she is identified socially and politically as either not deserving or not possessing the social mandate to have access to resources such as money, safety, housing, transportation, health care and nutrition, education, and gainful employment. kubiak's ( ) social location theory states that each individual possesses identities within their society that are defined ( ) show the adverse impact of undetected ptsd: "a -year-old girl with a learning disability has suffered early abuse of a physical and sexual nature, including neglect. she presented [for medical evaluation] in early childhood with behavioral problems of aggression. she settled in a residential school from age to before an act of arson. she later revealed that she had experienced inappropriate sexual behaviors with peers at school. she complained of intrusive thoughts and images, along with depressive symptoms. at times she shows sexually inappropriate behavior and self-harm." "a -year-old man with a moderate learning disability who had been sexually assaulted by a care[giver] presented [for medical evaluation] in [an] acute state with disturbance of appetite, sleep, loss of skills, and emotional numbness, but the abuse was revealed only months later. on being exposed to the perpetrator at a later date, he showed a deterioration in mental state with acute symptoms of anxiety, and later developed a depressive disorder requiring medication. his level of functioning never returned to that prior to the traumatic event." a third case illustrates the therapeutic gains that a ptsd perspective can provide: a -year-old woman with learning disabilities and pervasive developmental disorder had been diagnosed at age with schizophrenia and subsequently had been diagnosed with schizoaffective disorder, bipolar disorder, and borderline personality disorder. for years after the first psychiatric diagnosis and hospitalization, she had been psychiatrically hospitalized more than times due to episodes of acute suicidality complicated by auditory command hallucinations (i.e., she believed she was hearing voices telling her to kill herself) and compulsive self-harm behavior (she used sharp objects to cut virtually every area on both arms and legs). treatment included high doses of antipsychotic, antiseizure, antidepressant, and antianxiety medications and two courses of electroconvulsive therapy, with periods of relative stabilization sufficient for her to live in an assisted living residential home and on two occasions to live in an independent apartment with in-home daily case management and nursing care. each period of improvement was relatively brief, lasting no longer than - months, at which time she experienced severe worsening in the apparently psychotic, depressive, and anxiety symptoms, requiring multiple rehospitalizations and progressive loss of social and cognitive abilities. for several years, family therapy was conducted, and the patient's history of traumatic stressors was assessed gradually in order not to lead to further destabilization. in addition to potential episodes of sexual assault as an adolescent and young adult, her mother disclosed that her biological father had been severely domestically violent during the patient's first years of life, until the mother ended that relationship. when ptsd was confirmed and accepted by the treatment team and the patient and her family as the primary diagnosis, the patient felt that she finally understood why she was experiencing the cyclic surges in distress and was able to utilize affect by factors such as their race, socioeconomic class, gender, age, residential status, and legal status. the greater the number of oppressed identities that one possesses, the more likely one will be "poor," including not only low income but also living in neighborhoods plagued with high crime, gang violence, abandoned buildings, drugs, teen pregnancy, high unemployment rate, underfunded schools, housing shortage, food of limited nutritional value, and unresponsive police. thus, poverty fundamentally is a breakdown of the social order as well as a resultant deprivation of resources for some people. the relationship between low income and exposure to psychological trauma and ptsd has been studied primarily in relationship to women and families, including those who currently have stable housing and those who do not. morrell-bellai, goering, and boydell ( ) identify poverty as a core risk factor for homelessness, because the socioeconomic benefits provided by a diminishing societal safety net and the typically insufficient employment wages provided by marginal jobs force people to rely on an increasingly limited pool of subsidized housing or to become homeless. associated risk factors include a lack of education, lack of work skill, physical or mental disability, substance abuse problem, minority status, sole support parent status, or the absence of an economically viable support system (fischer & breakey, ; morrell-bellai et al., ) . snow and anderson ( ) found that the most common reasons for homelessness reported in a survey of men and women living "on the street" were family-related problems such as marital breakup; family caregivers becoming unwilling or unable to care for a mentally ill or substance-abusing family member; escape from a dysfunctional and/or abusive family; or not having a family to turn to for support. poverty and homelessness involve a vicious cycle in which socioeconomic adversities are compounded by the experience of homelessness, leading to psychological disaffiliation, hopelessness, and loss of self-efficacy, and often substance dependence (bentley, ; hopper & baumohl, ; morrell-bellai et al., ) -which thus tends to perpetuate poverty and homelessness. a recent study by frisman, ford, lin, mallon, and chang ( ) reported that % of a sample of very low-income homeless women caring for children had experienced at least one type (and on average, five different types) of psychologically traumatic events, usually repeatedly and over long periods of time, with one in three having experienced full or partial ptsd at regulation skills (taught using dialectic behavior therapy and trauma affect regulation: guide for education and therapy; see chapter ). over the next year, her medications were carefully reduced to the lower therapeutic range for attentional problems and anxiety, with a sustained improvement in mood and social and cognitive functioning such that she was able to successfully work as a skilled volunteer in an assisted living center for older adults. some time in their lives. in addition, ford and frisman ( ) found that one in three of these homeless women with children had experienced a complex variant of ptsd involving problems with dysregulated affect or impulses, dissociation, somatization, and alterations in fundamental beliefs about self, relationships, and the future (i.e., "complex ptsd" or "disorders of extreme stress"; ford, ) . more than half of the sample had a history of either or both ptsd and its complex variant. exposure to violence and other forms of victimization begins in childhood for many homeless individuals, in part due to their exposure and the vulnerability of their living conditions (north, smith, & spitznagel, ) . rates of childhood physical abuse as high as % among homeless adolescents have been reported (maclean, paradise, & cauce, ) , and this figure may be on the low end. extremely poor women, whether homeless or not, have elevated rates of lifetime ptsd or other mental illness, and a history of such disorders is associated with having grown up in family and community environments with violence, threat, and anger (bassuk, dawson, perloff, & weinrub, ; davies-netzley, hurlburt, & hough, ) . however, homelessness per se may confer additional risk: homeless mothers and their children have higher lifetime rates of violent abuse and assault than equally impoverished housed mothers (bassuk et al., ) . thus, poverty puts people at risk for traumatic violence, but not having a stable residence compounds this risk and the likelihood of developing ptsd. victims of political repression, genocide ("ethnic cleansing"), and torture when political power is used to repress free speech and citizens' self-determination, there is an increase in the risk to members of that nation or community and its neighbors and associates of psychological trauma. domestic violence (see box . ) is a microcosm that shares much in common with large-scale political repression, because physical, psychological, and economic power is used to entrap, systematically break down, and coercively control the thoughts as well as the actions and relationships of the victim. on a larger scale, political repression involves similar psychological (and often physical as well) assaults by the people and institutions in power on the people, families, communities, and organizations that are deprived of access to political power and socioeconomic resources-and therefore also on their fundamental freedoms and values. without access to self-determination and the resources necessary to sustain independence, people are vulnerable to not just traumatic exploitation and violence but also to the traumatic loss of their intimate relationships, their families, their way of life, and their values (box . ). genocide (also described as "ethnic cleansing") involves the planned and systematic elimination of an entire collectivity of people, based on discrimination against them. historically, genocide has occurred often when conquering nations not only dominated and subjugated other nations but sought to eradicate their core culture and its leaders and teachers and to kill off or enslave the entire population. examples in the twentieth century include the armenian genocide in turkey, the holocaust box . the lost boys of sudan: complex ptsd in the wake of societal breakdown in the book what is the what?, by dave eggers ( ), valentino achak deng (a fictional character based upon a real person) provides an autobiography that includes his trials and tribulations in his current home in atlanta, georgia, after a traumatic journey of many years as a "lost boy" fleeing from his family's home in a rural village in southern sudan to refugee camps in ethiopia and kenya. valentino graphically describes a relentless series of traumatic experiences that include his village becoming a war zone, the deaths of family and friends, starvation and continual threats of being killed while traveling by foot with thousands of other "lost" children to escape sudan, witnessing brutal acts of violence by children as well as adults (e.g., a boy beating another boy to death in a fight over food rations), and being robbed and beaten unconscious in his own home in atlanta by a predatory african american couple. valentino is a good example of a person who suffers from chronic and complex ptsd, yet is extremely articulate, intelligent, and resourceful. valentino struggles with both unwanted memories and the need to keep his memories so that he ultimately can make sense of what has happened to him: what is the what? by writing his autobiography, he did what the therapy for children or adults with ptsd is intended to do: making sense of, rather than attempting to avoid, memories and reminders of traumatic experiences as a part-albeit horrible or tragic-of one's complete life story (see chapters and ). for example, in trauma-focused cognitive behavior therapy, the therapist helps the child to write (or in other creative ways to depict, such as by drawing pictures; using puppets, dolls, or action figures; or using collage or music) a "story" of what happened to them before, during, and after traumatic experience(s) and to share this "story" with a parent who can help the child with feelings of guilt and fear so that the traumatic memory can be "over" in the child's mind. because valentino was not able to get that kind of help, his autobiography as an adult (the book) is a kind of second attempt to achieve a sense of resolution by telling his story. but we see how this is very difficult to do when current life involves new problems and dangers that interfere with achieving a sense of safety. whether valentino succeeds in achieving some degree of emotional resolution about what he and his loved ones have suffered is an open question. what is clear is that he never stops trying to do so. it also is apparent that valentino's ethnic identification and heritage as an african man from the dinka tribe is very important as a protective factor enabling him to retain a small but significant fragment of his sense of personal identity and his intimate ties to his family and community. he experiences an odyssey as a victim fleeing the scene of horrific trauma, an initially reluctant but eventually drug-induced savage combatant, and a refugee "stranger in a strange land" when he is able to escape to what seems like an entirely different planet in the cosmopolitan urban setting of atlanta and the southern united states. it is the psychological trauma that he experiences on this odyssey, and the chronic stressors and societal breakdown and oppression that led him-and millions of others of all ages and a multiplicity of ethnocultural groups-on this journey of crisis and survival, and not his ethnicity or cultural background that is responsible for the profound symptoms of ptsd that he develops. inflicted on jewish people in europe by the nazis, the "ethnic cleansing" in bosnia and serbo-croatia in the s, and the massacres and mass starvation and epidemics perpetrated in rwanda in , in sudan beginning in , and in somalia, kenya, and zimbabwe most recently. genocide was first used as a term in by raphael lemkin, combining the words genos, from the greek for "race" or "kind," and cidere, which is latin and can be translated as "kill" (brom & kleber, ) . in , the term was adopted by the united nations general assembly and defined by the united nations convention on the prevention and punishment of the crime of genocide (cppcg) as follows: gregory stanton, the president of genocide watch, described " stages of genocide"; http://www.genocidewatch.org/aboutgenocide/ stagesofgenocide.htm. accessed / / : . classification-earliest stage, dividing people into "us" and "them" (the victim group). . symbolization-assigning particular symbols to designate the victim group members. . dehumanization-equating certain people with subhuman animals, vermin, or insects. . organization-militias or special units created for the purpose of genocide. . polarization-broadcasting of propaganda aimed at marginalizing the out-group. . preparation-out-group members are physically separated or confined in a "ghetto." . extermination-murder, starvation, infection, or other forms of inflicting pain and death. . denial-refusal to accept responsibility or admit wrongdoing, maintaining the self-righteous position that the victim group deserved annihilation and were subhuman. these stages are approximate and vary in each separate incident, but they demonstrate how genocide differs from other forms of even very horrific violence (such as war) because the aim is not simply to subdue, harm, or exploit but to dehumanize, exterminate, and annihilate. genocide thus involves several traumatic features, including loss of self-worth and allegiance to core values and institutions; prolonged pain and suffering; bereavement; terror and horror of annihilation; injury; helplessness while witnessing demeaning, cruel, and violent events; and confinement. survival responses to genocide are described by brom and kleber ( ) as: … a narrowing of functioning and awareness in order to maximize the chances of survival [often involving] psychic closing off (also called robotization-that is, acting and feeling emotionally and mentally empty or on "automatic pilot" like a "robot"), [and] regression-that is, feeling, thinking, and acting like a child (or in the case of children, like a much younger age than actual chronological age). often victims also experience a strong dependence on perpetrators who decide on life and death. the "muselman effect" … manifested by complete physical decrepitude, apathy, slowing of movement, and gradual disintegration of personality (including loss of the capacity for rational reasoning) may result when individuals have been exposed to long-term and extreme circumstances. an additional phenomenon that is well documented is the so-called "death imprint" resulting when substantial witnessing of death continues to haunt the survivor. these reactions closely parallel the symptoms of both asd (such as dissociation and regression) and ptsd (such as intrusive reexperiencing and emotional numbing). the adverse long-term effects of experiencing genocide are severe and pervasive. more than one in three survivors become clinically depressed and develop ptsd. the social support of caring family members (and for children, parents, or other caregivers) and relationships and activities that individuals to retain their spiritual or religious beliefs and their sense of self-respect are crucial protective factors against ptsd and depression. however, even the most resilient and socially supported person is likely to experience distressing memories and survivor guilt years or even decades later. studies with elderly holocaust survivors who are physically and emotionally very hardy (often well into their s and s) have documented significant persisting emotional distress and ptsd symptoms or more years later (brom & kleber, ) . moreover, the offspring of holocaust survivors with ptsd are more likely than offspring whose parents do not have ptsd to themselves experience ptsd as adults (yehuda et al., (yehuda et al., , . genocide often involves physical hardships that compromise physical health and may lead to long-term illnesses and depletion of the body's immune system. for example, the physical exertion and pain involved in torture, untreated physical illnesses, insufficient sleep, starvation, exposure to extreme temperatures, and forced labor may accelerate the aging process (brom & kleber, ) . genocide also often includes separating individuals from their families and community groups. this not only deprives the survivor of crucial social support but engenders a sense of isolation, distrust, and shame and of being permanently psychologically damaged (herman, ) . survivors also are faced with a choice of holding to their allegiance to their family, nation, culture, and racial identity, despite the punishment inflicted by the perpetrators, or abandoning these basic commitments and rejecting themselves and people like them. faced with this impossible choice (as epitomized in william styron's classic novel, sophie's choice), survivors often believe that they failed utterly and let down not only themselves but their family and culture no matter how resiliently they coped and the integrity of their efforts. survivor guilt is an expression of a sense of grief, powerlessness, and failure, including questioning why they survived and others did not. torture. torture is a terrible special case of political repression that involves "malicious intent and a total disregard for the recipient's dignity and humanity. thus, torture is among the most egregious violations of a person's fundamental right to personal integrity and a pathological form of human interaction" (quiroga & jaranson, ) . the united nations (un) office of high commissioner for human rights established a "convention against torture and other cruel, inhuman or degrading treatment or punishment (cat)," which has been endorsed by nations and defines torture as follows: for the purpose of this convention, the term "torture" means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purpose as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed, or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by, or at the instigation of, or with the consent or acquiescence of, a public official or other person acting in an official capacity. it does not include pain or suffering arising only from, inherent in, or incidental to lawful sanctions. (http://www.unhchr.ch/html/menu /b/h_cat .htm accessed / / ) an amnesty international worldwide survey found that % of countries practice torture systematically, despite the absolute prohibition of torture and cruel and inhuman treatment under international law. torture may be euphemistically referred to as "enhanced interrogation techniques" and condoned in order to obtain "intelligence" from designated enemies of the nation, although this is completely prohibited by the un resolution (quiroga & jaranson, ) . widespread controversy has attended the use of such techniques by the us central intelligence agency in response to the september , , terrorism incidents, controversy that peaked in with the presidential decision to close the guantanamo bay military prison, and the release of the us senate report revealing and questioning the legality and morality of torture tactics used in interrogation and incarceration. basoglu, livanou, and crnobaric ( ) , in a sample from the balkan war ( - ) studied from to , showed that the torture need not inflict physical pain in order to produce ptsd. psychological assessment of torture survivors was systematized by the istanbul protocol, a manual on the effective investigation and documentation of torture and other cruel, inhumane, or degrading treatment or punishment that includes modules for medical, psychological, and legal professionals united nations resolution / on december , (quiroga & jaranson, ) . the psychological problems most often reported by torture survivors are emotional symptoms (anxiety, depression, irritability/aggressiveness, emotional liability, self-isolation, alienation from others, withdrawal); cognitive symptoms (confusion/disorientation, memory and concentration impairments); and neuro-vegetative symptoms (lack of energy and stamina, insomnia, nightmares, sexual dysfunction) (quiroga & jaranson, ) . the most frequent psychiatric diagnoses are ptsd and major depression, other anxiety disorders such as panic disorder and generalized anxiety disorder, and substance use disorders. longer-term effects include changes in personality or worldview, consistent with complex ptsd (quiroga & jaranson, ) . the greater the degree of distress and loss of sense of control during torture, the greater the likelihood of ptsd and depression. resilience, through being able maintain a sense of personal control, efficacy, and hope while enduring torture, is associated with less distress during torture and lower risk of ptsd (quiroga & jaranson, ) . social, cultural, and other diversity issues in the traumatic stress field however, quiroga and jaranson ( ) cited a study by olsen showing that years after torture, physical pain was still prevalent even if torture was primarily psychological in nature. based on this finding and related studies, they conclude the following (p. ): the most important physical consequence of torture is chronic, long-lasting pain experienced in multiple areas of the body. all [physical] torture victims show some acute injuries, sometimes temporary, such as bruises, hematomas, lacerations, cuts, burns, and fractures of teeth or bones, if examined soon after the torture episode. permanent lesions, such as skin scars on different parts of the body, have been found in % to % of torture victims. … falanga, beating the sole of the feet with a wooden or metallic baton, has been studied extensively. survivors complain of chronic pain, a burning sensation. … acute renal failure secondary to rhabdomyolysis, or destruction of skeletal muscle, is a possible consequence of severe beating involving damage to muscle tissue. this condition can be fatal without hemodialysis. … a severe traumatic brain injury that is caused by a blow or jolt to the head or a penetrating head injury may disrupt the function of the brain by causing a fracture of the skull, brain hemorrhage, brain edema, seizures, and dementia. the effects of less severe brain injury have not been well studied. treatment for torture survivors must be multidisciplinary and involves a long-term approach. several treatment modalities have been developed, but little consensus exists concerning the standard of practice, and treatment effectiveness has not been scientifically validated by treatment outcome studies (quiroga & jaranson, ) . a key element that is widely agreed upon is to pay careful attention to not inadvertently replicating in benign ways aspects of torture in the treatment (such as by pressing a survivor to recount traumatic memories without the survivor's informed and voluntary consent; by encouraging or discouraging political, family, and social activities except as initiated by the survivor; or by behaving in authoritarian ways rather than seeking to be collaborative with the survivor). it also is best to use medical, psychiatric medication, and psychotherapy modalities to address the ptsd symptoms of impaired sleep, nightmares, hyperarousal, startle reactions, and irritability. quiroga and jaranson ( ) also recommend using groups for socializing and supportive activities to reestablish a sense of family and cultural values, and supporting the traditional religious and cultural beliefs of the survivor. currently, nearly torture survivor treatment centers exist worldwide, of them accredited by the international rehabilitation council of torture victims (quiroga & jaranson, ) . most of these centers also involve the survivors' families and communities in developing shared approaches to recovery and reparation of the harm done to all. the controversy concerning the use of torture on detainees in the so-called "war on terror" has led to deep concern on the part of not only the public at large but specifically by mental health professionals. the issue is that psychiatry and psychology professionals who are in the military or consult to the military have been involved in the detention and interrogation of suspected terrorists at high-security facilities such as the military base at guantanamo bay and the military prison in iraq, abu ghraib. as a result, guidelines for mental health professionals working in these or similar facilities in which prolonged detention and interrogation may involve practices that constitute torture have been developed by a special committee of the american psychological association's division ( ) on trauma psychology (box . ). the apa council of representatives … included in its "unequivocal condemnation" all techniques considered torture or cruel, inhuman or degrading treatment or punishment under the united nations convention against torture and other cruel, inhuman, or degrading treatment or punishment; the geneva conventions; the principles of medical ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel, inhuman, or degrading treatment or punishment; the basic principles for the treatment of prisoners, the mccain amendment, the united nations principles on the effective investigation and documentation of torture and other cruel, inhuman, or degrading treatment or punishment an "absolute prohibition against mock executions; waterboarding or any other form of simulated drowning or suffocation; sexual humiliation; rape; cultural or religious humiliation; exploitation of fears, phobias, or psychopathology; induced hypothermia; the use of psychotropic drugs or mind-altering substances; hooding; forced nakedness; stress positions; the use of dogs to threaten or intimidate; physical assault, including slapping or shaking; exposure to extreme heat or cold; threats of harm or death; isolation; sensory deprivation and overstimulation; sleep deprivation; or the threat [of these] to an individual or to members of an individual's family. psychologists are absolutely prohibited from knowingly planning, designing, participating in, or assisting in the use of all condemned techniques at any time and may not enlist others to employ these techniques. we have come to the conclusion that the united states' harsh interrogationdetention program is potentially trauma-inducing both in general (e.g., indefinite detention, little contact with lawyers, no contact with relatives or significant others, prolonged absence of due process, awareness that other prisoners have been tortured, lack of predictability or control regarding potential threats to survival or bodily integrity) and in terms of some of its specific components (e.g., prolonged isolation, waterboarding, humiliation, painful stress positions). in other words, these potentials for trauma extend beyond the narrow procedures that meet international definitions of torture. the evidence for risk of psychological trauma to detained enemy combatants is particularly compelling and well grounded in formal research, but there is also suggestive anecdotal and theoretical evidence of trauma induction in interrogators and the broader society. we were particularly struck by the fact that the potentially traumatic elements include not only activities designed to extract information from prisoners but also much of the detention process as it is currently conceived, beyond much oversight, or compliance with international law. given the pervasiveness of these traumatogenic elements, it is questionable whether psychologists can function in these settings without participating in, or being adversely affected by, heightened risk for trauma. nonetheless, as a group of psychologists with expertise in preventing traumatic stress and ameliorating debilitating posttraumatic sequelae, we believe that certain steps could … minimize the risk of psychological trauma. they are as follows: . we believe that the risk of traumatic stress and negative posttraumatic sequelae will be reduced if psychologists adhere to both the apa ethical standards and subsequent refinements of apa policies pertaining to interrogation, detention, and torture. such adherence would be more likely if the apa ethics code were revised to incorporate, as enforceable standards, the specific interrogation and torture-related policy refinements that have occurred since . psychologists should promote situations that maintain the risk of traumatic stress at acceptably low levels and avoid situations that heighten the risk for traumatic stress occurring. among other things, this means that psychologists should not provide professional services in secret prisons that appear to be beyond the reach of normal standards of international law or in settings in which torture and other human rights abuses have been credibly documented to be permitted on the basis of local laws. it also suggests that psychologists should not support or participate in any detention or interrogation procedure that constitutes cruel or inhumane treatment or that otherwise has been shown to elevate risk of traumatic stress (e.g., prolonged isolation). . if psychologists work in settings in which detention and interrogations are conducted, then they should conduct or seek an assessment of the potential traumatic features of the treatment of detainees before, during, and after interrogation. this assessment can be informal or formal, depending on whether other systems of oversight are in place. this assessment should include an examination of the social psychological factors that could elevate risk of trauma. because not all psychologists have expertise in assessing traumatic stress risk and/or social psychological (continued ) factors, the assessment should be conducted by psychologists who have this specific expertise. such assessments could inform decisions not only by psychologists but also by others working in facilities in which detention and interrogation occur. it is recommended therefore that apa advocate for appropriate governmental authorities to appoint an independent oversight committee for each facility of this type and that the oversight committees include psychologists identified by apa as having relevant expertise. . if psychologists work in settings in which risk of traumatic stress is found to be elevated then they should (i) formally recommend alterations that could reduce the traumatogenic potential of the detention and interrogation process (n.b. some recommendations may be aimed at policy makers rather than local authorities); (ii) conduct or seek an assessment of posttraumatic stress symptoms and associated features (e.g., depression, dissociation) in detainees, interrogators, and other directly or indirectly involved staff; (iii) recommend appropriate psychological interventions for any detainees or personnel found to be suffering from clinically significant psychological difficulties; and (iv) refuse to participate in any activities that significantly increase risk of traumatic stress. if a psychologist working in such settings does not have specific expertise required to meet some of the above recommendations, then she or he should consult with psychologist(s) who have this expertise to make the appropriate determination. . because some detainee abuses have been credibly linked to an absence of appropriate training and/or expertise, psychologists should advocate for, participate in designing, and/or assist with providing appropriate and comprehensive training to all personnel involved in interacting with detainees. this training should include (i) clear ethical guidelines emphasizing the prohibition of causing harm and the importance of protecting detainee rights, (ii) a research-based overview of the nature and consequences of traumatic stress and posttraumatic impairment as they relate to the interrogation and confinement process and all parties involved in layperson terms with practical implications, and (iii) detailed review of research on false confessions, in layperson terms, with practical implications for enhancing the validity and utility of information gathered in the course of interrogation and detention. because not all psychologists have expertise in these specific matters, apa should develop standardized training materials that cover the current state of psychological knowledge and practices on these important topics, and ensure that these materials are regularly updated by qualified psychologists in consultation with experts from other fields such as law enforcement, the military, and human rights. . because protecting human rights reduces the risk for traumatic stress and posttraumatic impairment, psychologists should collaborate with legal, military, and other colleagues to advocate for due process for all detainees, including providing clear guidelines about finite lengths of detention prior to formal hearing or trial and enforcing the recent supreme court decision to reinstate habeas corpus and other international standards of human rights. psychologists' support for these actions should not come from a blanket support for adherence to law but rather from an informed judgment that these … laws reduce the risk for harm. psychologists should be prepared to disagree with any future international laws or us supreme court decisions that heighten risk for traumatic stress. box . continued . psychologists should support increased transparency during the detention and interrogation process. such increased transparency could reduce the likelihood of traumatizing practices, increase the likelihood that traumatizing practices will be identified and stopped as early as possible, and protect ethical psychologists and other workers within the system from being falsely accused of acting unethically. we recognize that this recommendation raises an apparent conflict with the goal of secrecy commonly endorsed by national security organizations. we concur that full transparency is unreasonable and counterproductive. yet, we do believe that increased transparency is a safeguard against traumatizing practices. though the details of resolving this conflict are beyond the scope of this task force's expertise, we believe that reasonable, knowledgeable intelligence experts, in consultation with psychologists, can construct a system of oversight that will both retain credible independence from the military chain of command and guard classified information. one suggestion may be to establish a greater presence of psychological expertise within a framework of oversight protection. . if psychologists are going to continue to be involved in interrogations, then it will be important to continue to segregate the function of interrogation consultant from that of mental health provider to reduce risk of perceived or actual betrayal by the detainee. it is unknown whether betrayal of trust due to dual roles can constitute a direct form of traumatization under these circumstances, but it is likely that betrayal in this context could exacerbate traumatic stress that occurs of other aspects of detention and interrogation (especially in light of the ways that such detention appears to disrupt attachment as outlined in the body of our report). maintaining separate roles also may enable the psychologist to more effectively assist detainees with traumatic stress reactions by fostering a trusting therapeutic relationship. . psychologists should advocate for extra protections for detainees who are from vulnerable populations such as minors, ethnic minorities, or other groups that have limited access to socioeconomic or political resources or are potentially subject to societal discrimination or prejudice because such groups may be more likely to receive coercive interrogations and/or excessive force and less likely to be sympathetically viewed by the general public. for this purpose, psychologists may work within sponsor/authorizing organizations to institute developmental, gender, and culture sensitivity trainings for interrogators and should review evidence concerning the impact of different forms of traumatic stressors and differential sensitivity to the interrogation/detention setting/process on different (and particularly vulnerable) ages, genders, and cultural backgrounds. such psychologists should, to whatever extent possible, guard against such information being used to exploit vulnerable populations and instead emphasize ways to enhance safety and psychological wellbeing in the interrogation process. if psychologists lack relevant expertise to meet the recommendations, … they should seek or advocate for outside expert consultation. . psychologists should collaborate with colleagues from a variety of professions and organizations, including the military and intelligence organizations, to conduct ethical research on several aspects of the detention and interrogation process, especially its potential for inducing trauma. recent reviews suggest that most of the interrogation procedures used today have not received recent rigorous study (intelligence science board, ) . furthermore, very little of the recent study has been directed toward understanding the psychological effects of interrogation on not only the detainees but also the people working within and outside the interrogation and detention system. political violence not only leads to traumatic harm to people while they are living in their communities but also often when victims are forced to flee their homes either to another country or while remaining within their country. refugees are defined by the united nations high commissioner for refugees (unhcr) as persons who have left their nation of origin to escape violence. article one of the united nations convention relating to the status of refugees defines a refugee as someone who "owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it" (unhcr, p. ; http:// www.unhcr.org/home/publ/ b e ea .pdf; accessed . . ). therefore, refugees are distinct from both legal and illegal immigrants, economic migrants, environmental migrants, and labor migrants (weine, ) . refugees must involuntarily leave home, community, and family and friends, often with limited resources or preparation and usually without knowing whom they can trust and where they can find safe passage and a safe haven. thus, both prior to and during the displacement, refugees often suffer psychologically traumatic experiences, including having their community or homes attacked or destroyed due to war; racially, genderbased, or ethnically targeted genocide or terrorism; institutionally orchestrated deprivation and violence; along with torture, atrocities, rape, witnessing violence, fear for their lives, hunger, lack of adequate shelter, separation from loved ones, and destruction and loss of property (weine, ) . estimating the number of refugees is very difficult. a minimum estimate that is probably much lower than the actual number is calculated by the united nations based on the number of persons in resettlement camps or individually recognized by a host country. based on this definition, there were million refugees worldwide in (www.unhcr.org) (figure . ). in côte d'ivoire, and was quickly followed by others in libya, somalia, sudan, and elsewhere. in all, . million people were newly displaced, with a full , of these fleeing their countries and becoming refugees. " saw suffering on an epic scale. for so many lives to have been thrown into turmoil over so short a space of time means enormous personal cost for all who were affected," said the unhcr antónio guterres. "we can be grateful only that the international system for protecting such people held firm for the most part and that borders stayed open. these are testing times." worldwide, . million people ended either as refugees ( . million), internally displaced ( . million), or in the process of seeking asylum ( , ). despite the high number of new refugees, the overall figure was lower than the total of . million people, due mainly to the offsetting effect of large numbers of idps returning home: . million, the highest rate of returns of idps in more than a decade. among refugees, and notwithstanding an increase in voluntary repatriation over levels, was the third lowest year for returns ( , ) in a decade. viewed on a -year basis, the report shows several worrying trends. one is that forced displacement is affecting larger numbers of people globally, with the annual level exceeding million people for each of the last years. another is that a person who becomes a refugee is likely to remain one for many years-often stuck in a camp or living precariously in an urban location. of the . million refugees under unhcr's mandate, almost three-quarters ( . million) have been in exile for at least years awaiting a solution. overall, afghanistan remains the biggest producer of refugees ( . million), followed by iraq ( . million), somalia ( . million), sudan ( , ), and the democratic republic of the congo ( , ) . around four-fifths of the world's refugees flee to their neighboring countries, reflected in the large refugee populations seen, for example, in pakistan ( . million people), iran ( , ) , kenya ( , ), and chad ( , many people displaced from their communities by violence remain in their home country. they are not considered refugees, but "idps": "people or groups … who have been forced to leave their homes" due to "armed conflict, situations of generalized violence, violations of human rights, or natural-or human-made disasters, and who have not crossed an international border" (www.unhcr.org). as of , there were more than three times as many idps as refugees, an estimated million worldwide, million social, cultural, and other diversity issues in the traumatic stress field due to armed conflict and million due to mass natural disasters (www.unhcr.org). between one and more than million idps were known to be in several countries in , including colombia, congo, iraq, somalia, sudan, and uganda. azerbaijan, cote due n'orde, and sri lanka had more than , known idps each. at least another million persons are considered "stateless"-that is, to not be citizens of any nation, in . nepal and bangladesh have the majority of the stateless persons in the world, although nearly million persons in those two countries were made citizens in . palestine and iraq are the other countries with large numbers of stateless persons. there may be millions more stateless individuals, because only countries assisted the united nations in its census of stateless persons in (www.unhcr.org). the impact of forced displacement often is not just extremely stressful but traumatic. refugees, idps, and stateless persons have few protections and often must live in confined camps or crowded public shelters, where they are vulnerable to assaults (including rape), robbery, and illness. many have witnessed horrific violence associated with wars, genocide, or other forms of mass armed conflict that caused them to flee. loss of family and friends due to violence or illness is common, as well as due to being separated with no way to communicate. studies have documented high prevalence levels of ptsd and depression among refugees or idps from armed conflicts in central america, southeast asia, the middle east, and the balkans (fazel, wheeler, & danesh, ; marshall, schell, elliott, berthold, & chun, ) at least times higher than the - % prevalence estimates from epidemiological surveys (see chapter ). ptsd prevalence estimates that are more than three times higher than these very high levels, as high as - %, have been reported among disabled central american refugees (rivera, mari, andreoli, quintana, & ferraz, ) and among afghan mothers (seino, takano, mashal, hemat, & nakamura, ) . other studies have more specifically investigated physical displacement in the traumatic stress experienced by refugees. displacement may involve many stressors, and a research review found that "living in institutional accommodation, experiencing restricted economic opportunity, [being] displaced internally within their own country [or] repatriated to a country they had previously fled or whose initiating conflict was unresolved" were particularly problematic. this review of reports involving , participants ( , refugees and , persons who were not displaced) showed that displacement alone was associated with more severe mental health problems, including ptsd (porter & haslam, ) . in contrast to most research findings on the etiology (see chapter ) and epidemiology (see chapter ) of ptsd, "refugees who were older, more educated, and female and who had higher predisplacement socioeconomic status and rural residence also had worse outcomes" (porter & haslam, , p. ) . people become "internally displaced" as often due to mass natural disasters as to armed violence. in the united states, several hundred thousand people had to leave the new orleans area following hurricane katrina in august . almost , received medical care at american red cross shelters within the next month (mills, edmondson, & park, ) . many displaced persons already were severely disadvantaged due to living in poverty (roughly % of the population of new orleans), having limited access to quality health care, and exposure to community violence (mills et al., ) . in a study of adult evacuees from new orleans and surrounding parishes ( % men, average age years old, % black, % low income (annual income less than $ , ), % reporting a prehurricane psychiatric disorder ( % depression, % anxiety disorder, % bipolar disorder)), most ( %) waited several days to be evacuated, and a majority reported sustaining minor to severe injuries ( %) and mild to severe illness ( %) in the hurricane or evacuation process. one in seven lost a loved one due to death in the hurricane or its aftermath, and most ( %) were separated from a family member for a day or more. many ( %) lost their home, two-thirds of whom were without property insurance. almost two in three ( %), particularly women, people with a prior psychiatric disorder, and those who recalled feeling their lives were in danger during the hurricane or its aftermath, were injured physically, or felt they had limited control over their current life circumstances, reported symptoms sufficient to qualify for a diagnosis of asd. natural disasters of several magnitudes greater have occurred in less developed and affluent areas of the world. for example, the tsunami that struck on december , , in the wake of the sumatra-andaman earthquake killed an estimated , people along the coastlines of the indian ocean, including , indonesians. another half a million indonesians were displaced from their communities. studies of survivors of this tsunami from indonesian areas such as aceh and north sumatra (frankenberg et al., ) , as well as from thailand (van griensven et al., ) and sri lanka (hollifield et al., ) , have demonstrated that posttraumatic stress, anxiety, and depression are suffered by hundreds of thousands, and perhaps millions, of people who experienced psychological trauma due to the tsunami (box . ). box . refugee posttraumatic stress in the wake of mass natural disaster frankenberg et al. ( ) reported a unique study of the impact of a massive natural disaster: the indian ocean tsunami that struck the day after christmas . unlike most research on mental health after disasters, this study began with a survey of a representative sample of persons in the host country (indonesia) almost years before the disaster. this "national socioeconomic survey (susenas)" provided a registry of respondents and predisaster data on health and socioeconomic characteristics of people throughout indonesia. the "study of the tsunami aftermath and recovery (star)" attempted to recontact , persons interviewed in communities by the susenas. the study also was able to determine the extent of damage caused to each community by the tsunami. the researchers got data from the national aeronautics and space administration's moderate resolution imaging spectroradiometer sensor collected year prior to the tsunami, and again immediately after the tsunami, to assess the degree to which the pretsunami ground cover visible in the first image had been replaced by bare earth in the second image. communities with at least % loss of ground cover were classified as heavily damaged ( % of the surveyed communities). those with some loss of ground cover were categorized as moderately damaged ( % of all locales), and % with no loss of ground cover were classified as undamaged by the tsunami. community leaders' and field observers' estimates of damage strongly correlated (r= . and . ) with these satellite-based estimates. one in three of the survey respondents (average age years old) heard the tsunami wave or people screaming. fewer sustained injuries ( %), lost a spouse ( %), lost a parent or child ( %), or witnessed family or friends "struggle or disappear" ( %), but % lost a family member or friend, % lost their home, and % lost their farming land, livestock, or equipment. posttraumatic stress was assessed by asking every respondent years or older to answer seven of the items from the ptsd checklist (see chapter ), as follows: since the tsunami, have you ever experienced (never, rarely, sometimes, or exposure to probable traumatic stress due to hearing the wave or screams, being injured, or seeing friends or family members "struggle or disappear," doubled the severity of pcl-c scores. consistent with this finding, compared to the sleep difficulties reported before the tsunami, after the tsunami, there was a large increase in the likelihood of sleep difficulties only in the most heavily damaged areas. pcl-c scores increased the most in the worst damaged locales, followed by the moderately damaged ones, with little change in the nondamaged communities. pcl-c scores averaged . , . , and . for the heavily, moderately, and undamaged areas, respectively, at the time of the interview and had been % higher at their peak after the tsunami (based on respondents' recollections). this is consistent with other studies that have reported persistent ptsd symptoms among the worst exposed persons but a substantial decline in ptsd symptom severity over time even among heavily exposed persons (see chapter ). women reported higher pcl-c scores than men, but primarily only in the heavily damaged areas. age was a factor in all communities: persons younger than years reporting an increase after the tsunami and persons years and older reporting lower pcl-c scores after the tsunami. interestingly, respondents who had a parent alive before the tsunami had lower pcl-c scores after the tsunami, but marital status, education, and income were not related to posttsunami pcl-c scores. property damage also correlated with posttsunami pcl-c scores. (continued ) as frankenberg et al. ( ) noted, these findings probably understate the severity and widespread nature of the harm, including posttraumatic stress, caused by a massive disaster such as this tsunami. however, the study provides the strongest evidence to date that a disaster that is not only life threatening for many but that displaces tens or hundreds of thousands of persons from their homes, families, neighbors, and way of life has the strongest adverse impact on communities that are most directly affected. another study (van griensven et al., ) conducted weeks after the tsunami in six southwestern provinces of thailand (where more than persons died or were unaccounted for and another were injured) included random samples of displaced persons and nondisplaced persons from the most heavily hit area and persons from less damaged areas. even though the extent of death and destruction was less in the worst-hit areas of thailand than in indonesia, symptoms of ptsd were reported by % of displaced and % of nondisplaced persons in the most damaged area of thailand (and by % in the less damaged areas). anxiety or depression symptoms were reported by three times as many persons, with similar proportions depending on displacement and the severity of damage to the community. thus, this study adds to the findings of the study from indonesia by demonstrating that displacement from home and community was a factor in ptsd and related symptoms soon after a mass natural disaster. the thailand study also resurveyed participants from the worst-damaged area months later ( months after the tsunami) and confirmed that displaced persons continued to be more likely than nondisplaced persons to suffer from ptsd, anxiety, and depression symptoms. consistent with other studies (ford, adams, & dailey, ) of postdisaster recovery (including the indonesia study), as the first anniversary of the disaster approached, about % of each group had recovered sufficiently to no longer report severe symptoms. whereas the indonesia study examined the extent of damage to participants' homes and (for most) the source of their incomes (farmland, animals, and equipment), the thailand study inquired directly as to whether respondents had lost their source of income and found that loss of livelihood was the strongest correlate of ptsd, anxiety, and depression symptoms. thus, the thailand study showed that losing not only home or community but also one's ability to generate an independent income through gainful work may contribute to the development and persistence of ptsd and related anxiety and depression symptoms. the defining characteristics of becoming a refugee in the wake of disaster therefore include (i) exposure to life-threatening catastrophe; (ii) loss of or separation from family and friends, (iii) loss of home and community; and (iv) loss of one's personal or family livelihood. each of these factors may result in acute posttraumatic distress, and the combination of several places people at risk for persistent ptsd. as weine ( ) describes, resettlement of refugees is a substantial challenge not only for displaced persons themselves but also for the host country. relatively stable and affluent countries in asia (such as pakistan, due to afghan refugees), the middle east (such as lebanon and syria, due to palestinian refugees), and africa (such as kenya and south africa), as well as most european and british commonwealth nations and the united states, have had a large influx of refugees. the half of all refugees who are resettled in cities experience economic pressures due to poverty and low-wage work and must live in communities that are crowded, segregated economically and culturally, and often adversely affected by crime, gangs, drugs, aids, and troubled schools (weine, ) . another half of all refugees are resettled in suburban and rural areas, which are more isolated (www.unhcr.org). in either case, refugees often face prolonged separations from family, friends, and loved ones, as well as the burden of having to find a way to subsist while saving money to bring others to their new home and to provide support to those back home who have stayed behind. refugee children have additional needs and challenges, including having to survive life-threatening experiences without adult help or guidance and then, if they are fortunate enough to be permanently resettled, having to return to being a "child" with a new family, community, and culture (henderson, ) . refugee children often display not only the symptoms of ptsd but also behavior problems (such as control, aggression, or defiance of authority), profound bereavement, and developmental, learning, or educational delays or deficits that are understandable in light of their often chronic deprivations before and during displacement. however, children also can be particularly resilient in the face of the psychological losses and traumas of being a refugee, and often they are a key source of hope for their families in the resettlement process (weine, ) . many refugees have opportunities to receive mental health services, either in the context of a refugee camp or after resettlement, but many do not seek or utilize these services. survival; getting stable and predictable access to food, money, housing, transportation, and safety; renewing communication with friends and family; and sustaining or regaining connection to cultural and religious traditions, values, and practices may take precedence over mental health treatment (and may in fact be the best form of therapy for many, under the circumstances). in resettlement settings, clinical treatment for refugee trauma is typically organized through refugee mental health clinics or specialized torture victim treatment centers, with services including crisis intervention, psychopharmacology, individual psychotherapy, group psychotherapy, and self-help groups and activities (weine, ) . to deliver culturally appropriate services, many programs involve traditional healers, socialization or mutual support groups, multifamily groups, and culturally based activities (weine, ) . services also tend to be provided by staff who themselves are members of the refugees' ethnic community, in collaboration with traumatic stress specialists and mental health professionals. the traditional model of western professional "expert" doctor or consultant who unilaterally tells local staff or clients how best to do assessment, diagnosis, or treatment has been justly criticized as culturally insensitive and potentially harmful rather than helpful (weine, ) . instead, the joint experience and expertise of the refugee client, local professional and paraprofessional alike, traditional healers, and traumatic stress professionals are taken together in a team approach that validates the client's and local helpers' cultures and traditions. this approach enhances the providers' ability to make a true cross-cultural assessment of symptoms and diagnoses, to adapt interventions to reflect different cultural beliefs and practices, and to engage not just individual clients but families and communities in recovery from ptsd. such an approach is consistent with new theoretical views of refugee traumatic stress, which include "the concepts of cultural bereavement, cultural trauma, family consequences of refugee trauma, community trauma, and social suffering" (weine, ) . this more culturally grounded view of refugees' experiences of traumatic stress and recovery from ptsd has led to the development of innovative therapy approaches (such as incorporating personal testimony and reconciliation into treatment) that address refugees' psychological vulnerabilities but strongly acknowledge their (and their families' and communities') hopes and strengths (weine, ) . when mass catastrophes, whether human-made or "acts of god" in origin, including natural disasters such as tsunamis, tornadoes, hurricanes, floods, or earthquakes, or public health emergencies, such as aids, severe acute respiratory syndrome (sars), pandemic influenza, ebola, or human-made disasters such as terrorist attacks, airline crashes, ferry capsizes, and train derailments, cause tens or hundreds of thousands or even millions of people and families to experience psychological trauma, the resultant suffering and needs are generally beyond the capacities of traditional mental health services and other forms of government-sponsored services. ngos play a critical role supporting and assisting persons and communities affected by catastrophic disaster or violence, including providing psychological support through clinical and nonclinical behavioral health services (hamilton & dodgen, ) . ngo responses to the mental health needs of mass-disaster survivors are based on the core belief that "all disasters are local" (hamilton & dodgen, ) . this means that local responders such as law enforcement, police, emergency medical teams, and professionals from the health care facilities, schools, and government are invariably first on the scene and frequently remain involved for months or years afterward. when insufficient resources are available, a local community may request help from the country, state, or provincial governments, which in turn may request regional or national assistance from both government and private sectors. for that reason, ngos that provide assistance following disasters, such as the american red cross, the national voluntary organizations active in disaster (nvoad), the united way, and the salvation army do so through their local chapters, which organize the initial relief efforts to provide shelter, food, legal aid, health and mental health care, and humanitarian assistance. organized in , nvoad is the umbrella organization coordinating all disaster relief services provided by volunteer organizations such as the american red cross throughout the united states. ngos also work closely with faith-based organizations (fbos) in the united states (such as catholic charities united states, church world service, lutheran disaster response, national association of jewish chaplains) within the national response framework of the federal emergency management agency (fema), which guides the nation's "all-hazards incident response" (hamilton & dodgen, ) . for example, american red cross disaster mental health (dmh) volunteers provide mental health services to people in shelters, while the church of the brethren provides crisis intervention to young children through their disaster child care program (hamilton & dodgen, ) . the american red cross is the most widely recognized ngo providing dmh services in the united states. in , congress chartered the american red cross to "carry on a system of national and international relief in time of peace" to reduce and prevent the suffering caused by national calamities program (hamilton & dodgen, ) . in , the american red cross established a formal dmh services program and began training licensed and certified mental health professionals to volunteer and assist other red cross workers to cope with and recover from the traumatic stress (or "vicarious trauma") of their disaster relief work. initially only licensed psychologists and social workers were permitted to become red cross dmh volunteers, but recently professionals from other disciplines, such as psychiatry and masters-level marriage and family therapy or counseling professions, also have become eligible. the american red cross has set up formal agreements with the american psychiatric association, the american psychological association, the national association of social workers, the american counseling association, and the american association of marriage and family therapy. the agreements provide that in the event of a mass disaster, the red cross will notify each professional associations to put out a call to their memberships for professionals who have completed red cross preparatory training and who can take time out from their ordinary work to serve as dmh volunteers for weeks or more at red cross disaster services sites. the american red cross sets up and oversees family assistance centers for disaster-affected communities, provides crisis and grief counseling through its dmh volunteers, and coordinates with federal agencies such as fema and the national transportation safety board (for airline or mass transportation disasters) to provide child care services and interfaith memorial services. the red cross also works closely with disaster-focused ngos such as the national organization for victim assistance, disaster psychiatry outreach, and the international critical incident stress foundation, inc. (icisf). founded in , the icisf trains mental health professionals, emergency responders, clergy, and chaplains to conduct critical incident stress management (see chapter ) teams to support disaster services personnel. in , the american red cross broadened the scope of dmh services to include assisting disaster-affected persons who are seeking red cross assistance, as well as red cross volunteers. all dmh volunteers now are trained in psychological first aid (see chapter ) so that they will provide mental health services to disaster victims in an appropriately circumscribed manner that is therapeutic without attempting to conduct psychotherapy at a disaster relief site. two other freestanding programs participating in a dmh response are the green cross assistance program, which provides trained traumatology specialists and the association of traumatic stress specialists, an association of mental health professionals and paraprofessionals who assist survivors of psychological trauma (hamilton & dodgen, ) . a number of us ngos also work internationally to provide psychosocial support and traumatic stress counseling to survivors of disasters and mass conflicts. these include the international services of the american red cross, the united methodist committee on relief, church world services, green cross, action aid-the united states, the american refugee committee, the center for victims of torture, and doctors without borders (hamilton & dodgen, ) . the international federation of red cross and red crescent societies also assist many nations' red cross organizations in serving their own and neighboring countries. a analysis by the united states homeland security institute found that fbos and ngos had a significant beneficial impact during and after hurricanes katrina and rita, with mental health and spiritual support among types of services (hamilton & dodgen, ) . the study reported that while fbos and ngos faced significant limitations and challenges in providing services, mental health and spiritual support was one of the three best-applied special practices, particularly services designed to preserve family unity within disaster relief shelters. hamilton and dodgen ( , p. ) describe how ngos can work together to meet critical needs in times of mass crisis, using the september , , terrorist attacks in new york, washington, and pennsylvania, as a case in point: local mental health providers working in mental health settings mobilized quickly, but needs were expected to surpass local capability. the american red cross dispatched dmh providers from local and adjacent communities to provide mental health support and stress reduction assistance. national volunteers recruited from across the country arrived within a few days to augment that mission. concurrently, icisf-trained volunteers, some of whom were already part of military mental health systems, also arrived to provide assistance. other agencies, such as fbos, also organized support for victims. in washington, the military was the gatekeeper for volunteers and worked closely with the american red cross to coordinate mental health support. in new york, civilian authorities collaborated with the american red cross. as family assistance centers were set up to aid grieving families, national dmh volunteers continued providing mental health support. because the terrorist attacks created a crime scene, access was controlled and ngos needed official standing to provide assistance. incorporating lessons learned from / , a similar event today would be different in several ways: all ngos and government agencies would organize their response under the national incident management system (nims) and the nrf, thus creating a more centralized, coordinated response and reducing overlapping or competing activities on the part of nvoads. because of ongoing coordination and outreach efforts since / , a greater array of disciplines and specific types of expertise would be available through ngos. the benefits of these efforts were seen during the responses to hurricanes katrina and rita in . personal and community characteristics that reflect ethnocultural, national, gender, age, and disability factors are crucial in defining the identity of every human being. when traumatic stress occurs in a person's or community's life, its impact is influenced by these identity factors. when identity is used as a basis for stigma, discrimination, or socioeconomic disadvantage, those stressors compound the effect of traumatic stressors and can be traumatic in and of themselves. by addressing the vulnerability that this combination in a scientifically and clinically responsible manner (alcantara, casement, & lewis-fernandez, ; c'de baca, castillo, & qualls, ; ghafoori, barragan, tohidian, & palinkas, ) to assist rather than stigmatize persons and communities (ruglass et al., ) , the traumatic stress professional can play a crucial role in our society's quest for social justice. 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oriented psychotherapy for trauma refugees ethnicity, acculturation, and self reported health. a population based study among immigrants from poland, turkey, and iran in sweden low cortisol and risk for ptsd in adult offspring of holocaust survivors from pogroms to "ethnic cleansing": meeting the needs of war affected children key: cord- -crvnzr authors: mascarenhas, victor hugo alves; caroci-becker, adriana; venâncio, kelly cristina máxima pereira; baraldi, nayara girardi; durkin, adelaide caroci; riesco, maria luiza gonzalez title: care recommendations for parturient and postpartum women and newborns during the covid- pandemic: a scoping review date: - - journal: revista latino-americana de enfermagem doi: . / - . . sha: doc_id: cord_uid: crvnzr objective: to map the current knowledge on recommendations for labor, childbirth, and newborn (nb) care in the context of the novel coronavirus. method: scoping review of papers identified in databases, repositories, and reference lists of papers included in the study. two researchers independently read the papers’ full texts, extracted and analyzed data, and synthesized content. results: papers were included, the content of which was synthesized and organized into two conceptual categories: ) recommendations concerning childbirth with three subcategories – indications to anticipate delivery, route of delivery, and preparation of the staff and birth room, and ) recommendations concerning postpartum care with four categories – breastfeeding, nb care, hospital discharge, and care provided to nb at home. conclusion: prevent the transmission of the virus in the pregnancy-postpartum cycle, assess whether there is a need to interrupt pregnancies, decrease the circulation of people, avoid skin-to-skin contact and water births, prefer epidural over general anesthesia, keep mothers who tested positive or are symptomatic isolated from nb, and encourage breastfeeding. future studies are needed to address directed pushing, instrumental delivery, delayed umbilical cord clamping, and bathing nb immediately after birth. the world health organization (who) declared the human infection caused by the novel coronavirus severe acute respiratory syndrome-coronavirus (sars-cov- ), named covid- ", a public health emergency of international concern" ( ) . this infection has been acknowledged as the most disturbing event since world war ii and has put health systems worldwide under unprecedented stress. this context has led the entire population, health workers, and government officials to experience an atmosphere of fear and emotional stress, because of its severity and high mortality rates as well as the lack of sufficient services and equipment to meet the large demand of patients requiring hospitalization in intensive care units and mechanical ventilators. on april th, , infectious disease experts reported that this pandemic may last between and months and that everyone should be prepared for its resurgence after the first wave of contamination ( ) ( ) ( ) ( ) ( ) ( ) ( ) . to decrease infection or prevent the majority of the population from being infected at the same time, causing the health system to collapse, the who and brazilian ministry of health have recommended social isolation, early detection, reporting, as well as investigation and appropriate case management ( , ) . the novel coronavirus is transmitted through droplets and respiratory secretions of individuals infected by the disease or through contaminated objects; this virus can be also transmitted through contaminated feces ( ) . health workers are advised to observe contact and droplet precautions, according to the procedures performed. hence, complete personal protective equipment (ppe) has to be worn, such as disposable waterproof aprons or gown, goggles, head covers, gloves, and n masks or pff respirators. care is advised when removing ppe ( ) . symptoms of sars-cov- may range from mild symptoms such as fever, runny nose, nasal congestion, dyspnea, malaise, myalgia, and loss of taste up to severe symptoms such as severe acute respiratory syndrome (sars). complications are most common, and more frequently lethal, among elderly individuals and those with comorbidities ( - ) . the brazilian ministry of health classified women in the pregnancypostpartum cycle and newborns (nb) to be risk groups ( ) ( ) ( ) , considering that the clinical condition of these individuals may be aggravated by the infection due to low immunity and poor tolerance to hypoxia, which culminate in worse outcomes, compared to the population in general ( ) ( ) . the number of pregnant women and nb infected is much lower than that of the general population, however, pregnant and puerperal women are more vulnerable to covid- and, when they become infected, the symptoms may be more severe. transmission may occur from mother to nb in the postpartum and, the nb's immunological system being still immature, they are believed to be more susceptible to sars-cov- infection. hence, it is recommended to prevent infection of nb through contact with mothers, close family members, and health workers who are sick or carry the virus ( , , ) . one study conducted by chinese researchers analyzed , cases of children younger than years, of whom were confirmed and , considered suggestive due to their clinical condition, imaging tests, and the fact they had been exposed to individuals with the virus. the study's results show that children younger than one year had their clinical condition worsened ( ) . decisions concerning the route of childbirth also need to take into account individual characteristics. as usual, c-sections should be indicated depending on the maternal and fetal conditions ( ) . note that even amidst this pandemic, good practices concerning labor, birth and postpartum care should continue among women who are not suggestive of being infected or had a confirmed diagnosis of covid- , as well as women who have recovered from the infection ( ) . there is little scientific evidence for the development of a protocol addressing the best treatment against the novel coronavirus. therefore, this study is intended to map the body of knowledge ( ) identification of relevant studies; ( ) selection and inclusion of studies; ( ) data organization; and ( ) collection, synthesis, and report of results ( ) ( ) . these stages are individually described, as follows. ( ) . the population includes parturient and postpartum women and newborns. the the search strategy used with the selected terms was ("postpartum women" or "postnatal women" or "perinatal women" or "pregnant women") and ("covid- " or "severe acute respiratory syndrome coronavirus " or "severe acute respiratory syndrome coronavirus " or " -ncov" or "sars-cov- " or " ncov" or "coronavirus") and (parturition or "labor, obstetric" or "labor stage, third" or "labor stage, fourth" or childbirth or delivery or postpartum or puerperium or "period, postpartum"). the sources included met the following criteria: due to the method's specificity, there was no need to formally assess the methodological quality of the studies included. this review followed the prisma checklist to ensure methodological rigor and content of the report ( ) . in total, papers were identified in the databases, while were identified in reference lists and unpublished research repositories. of these, appeared more than once and were removed. regarding the methodological designs of the papers included in this review, these include six retrospective descriptive studies, five reviews, four opinion papers, three case studies, and one experience report. to facilitate the presentation of information collected from the manuscripts, after reading and analyzing recommendations, the content was grouped into two it is recommended to: keep the clinical condition of the mother-fetus pair stable as long as possible and consider that the ideal time for childbirth should be determined by gestational age. high-risk pregnancies: decisions regarding the course of the pregnancy should: ) be individualized and based on underlying comorbidities (preeclampsia, gestational diabetes, heart diseases, among other obstetric conditions); ) obstetric history; ) in addition to the factors mentioned for low-risk pregnancies. it should be considered that: given a steady progression with clinical conditions within expectations, a pregnancy may proceed under rigorous periodic assessment. normal childbirth: • mild clinical conditions; • there are no contraindications, especially due to a lack of evidence on vertical transmissions; • if pregnant women infected with sars-cov- * present spontaneous labor and good cervical conditions, normal childbirth is advised, provided that the health service has the apparatus necessary to promote appropriate precautions; • to shorten the duration of the second stage of labor, directed pushing is recommended and parturient women are supposed to wear a surgical mask. • avoid delayed umbilical cord clamping and skin-toskin contact to reduce the most potential sources of contamination in the immediate postpartum; • nb † bathing and drying should be performed immediately after birth to avoid exposure and neonatal hypothermia. • clinical instability considering critical conditions and/or obstetrical factors; • obstetrical indications for a c-section presented in the retrospective studies included: • severe preeclampsia; premature rupture of membranes; prematurity; irregular uterine contractions; prior c-section history; changes in the volume of amniotic fluid; placenta previa; umbilical cord abnormalities; acute fetal distress; uncertainty about the risk of transmission during vaginal delivery. • anesthesia: epidural is preferred over general anesthesia to reduce the chance of exacerbating pulmonary complications due to intubation/extubation and to avoid the side effects of general anesthesia on nb † , both on muscle tone and respiratory rate at birth. rev. latino-am. enfermagem ; :e . recommendations regarding care provided to childbirth in the context of the sars-cov- * infection one must choose a negative pressure birthing isolation room, isolated room, or a surgery room for respiratory diseases. avoid regularly used birthing rooms or rotate among individuals with and without flu syndrome; obstetricians, pediatricians, and nurses need to work together and be notified minutes before delivery to plan the care that will be provided to the nb † ; the childbirth staff has to include a minimum number of workers (two to three health workers at most) and remain inside the room, avoiding the circulation of people; all those involved in childbirth care need to observe a strict personal protection protocol, wearing the following ppe ‡ : head covers, gowns, props, surgical masks, goggles or facial shields, and gloves. additionally, perform rigorous hand hygiene before and after leaving the room; during c-sections, the women under the effect of general anesthesia must wear surgical masks during the entire procedure; restrict to the presence of a single companion during labor and birth to decrease the levels of transmission to the community. attention to mother's fever, which may indicate ongoing sars-cov- * infection, some physiological symptom that is characteristic of this period, or some pathology, such as breast engorgement, mastitis, urinary tract infection, genital infection, or even common colds. • there is no evidence that sars-cov- * is transmitted through breast milk; • breastfeeding should be encouraged because its benefits outweigh potential risks of contamination; • there is no consensus regarding the initiation and maintenance of breastfeeding among mothers with covid- . this decision should be taken together with the mother and health workers involved in care delivery; • there is a risk of mothers transmitting sars-cov- * to their nb † through respiratory droplets at the time of breastfeeding, even when wearing a surgical mask; • women who opt not to breastfeed during the period of the disease should be encouraged to express breast milk to feed their nb † ; • the use of a breast pump is recommended. • instruct mothers to perform rigorous hand hygiene before and after feedings or when pumping breast milk and providing care to nb † , always wearing a surgical face mask; • recommend a healthy caregiver to feed the baby in the case of mothers pumping milk. • nb † present signs and symptoms that are similar to those exhibited by infected adults: dyspnea, fever, tachycardia, vomiting, and thrombocytopenia. • when caring for an nb † , rigorously monitor the following signs: • respiratory frequency; • body temperature; • heart rate; • gastrointestinal signs and symptoms. • these should be the main focus of care provided after birth. early intervention is recommended as soon as abnormal patterns are observed. consider that: the studies conducted in china recommend isolating mothers from infants for days whenever mothers present a positive rt-pcr ‡ . isolation ceases when the mother presents a negative rt-pcr ‡ twice in a row. nb* need to remain in an isolated ward and have their clinical condition monitored rigorously. • normothermia is sustained for at least three days; • good breathing pattern or significant improvement; • chest radiography shows acute exudative lesions healed or obvious absorption of lung inflammation; • rt-pcr ‡ appears negative twice in a row with an interval above hours between testing. • keep the bedroom at appropriate temperature and humidity levels. • keep the bedroom airy, preferably with windows open; • minimize visits and physical contact; • sanitize hands and face frequently when establishing contact; • clean and disinfect the floor and furniture with alcohol at % or dissolved chlorinated compounds; • pacifiers and bottles made of heat resistant material should be disinfected at high temperatures. consider that: whenever health workers perform home visits, they should assess general aspects such as weight gain, height, reflexes, breastfeeding, and vital signs. ( ) . women, greater deterioration of the health condition of mothers has been observed in brazil. therefore, the brazilian ministry of health included pregnant women, those who gave birth recently, and those who experienced an abortion or fetal death in the group of risk and provided specific guidelines ( ) ( ) ( ) . one recent study ( ) therefore, greater care is recommended with this group given the potential of positive cases for sars-cov- to become more severe. in this context, a suggestive or confirmed diagnosis of covid- has promoted changes in the context of childbirth and obstetric care that is provided to women with the infection. there was a need for a rigorous evaluation of pregnancy and fetal status due to the tendency to fetal growth restriction and greater chances of prematurity ( , , ) . decisions regarding the course of pregnancy or its resolution should take into account: the mother's clinical condition, fetal wellbeing, gestational age, and the mother's autonomy. as long as the clinical condition of both mother and fetus is ensured, the ideal time for delivery should be determined by gestational age ( , , , ) . if, however, the safety of either mother or fetus is compromised due to sars or there is no satisfactory response to the therapy implemented against covid- , or yet, in the presence of severe pneumonia or critical condition, a premature delivery should be considered to safeguard mother and infant, as an anticipated birth decreases fetal hypoxemia and the maternal condition is expected to improve ( ) ( ) ) . in some cases, the interruption of pregnancy should be considered, even before fetal viability is achieved, seeking to improve the mother's clinical condition, considering that there is evidence showing rapid recovery of maternal oxygenation after the procedure ( ) ( ) ). any decision by the health staff should consider the mother's and family's principles and desires, without disregarding ethical principles ( ) . these precepts are endorsed by the international confederation of midwives, which reinforce the need of women and fetuses to be treated with dignity, compassion, and respect ( ) . regarding the birth route, studies ( , , , ) show that there is no contraindication for vaginal deliveries if clinical and obstetrical assessments are favorable. greater surveillance of both mother and fetus is recommended through cardiotocography or intermittent auscultation in a short period. water births are contraindicated due to the possibility for the mother's fecal elimination and water contamination, and consequently, greater risk of contamination of nb ( ) . c-sections should be indicated when there is clinical or obstetrical instability in addition to changes in fetal vitality ( , , , , ) . these recommendations are corroborated by obstetricians in wuhan, china, who state that c-sections indicated for women with the infection should be flexible, as the objective is to decrease the length of hospitalization of mothers to minimize cross-infection and avoid physical exertion, which is characteristic of normal deliveries ( ) . the staff providing childbirth care must be informed about a suspected or confirmed diagnosis of covid- to prepare for and implement biosafety measures, as well as to grant priority for these deliveries to occur in labor, childbirth and postpartum rooms reserved for those with a suspected or confirmed diagnosis of the sars-cov- infection ( , ( ) ( ) . at the time of delivery, a minimum team of essential workers should be considered; hygiene measures and protective equipment guidelines should be rigorously observed; parturient women should wear surgical or n masks; and only one companion should be recommended during labor, childbirth and postpartum ( , , , ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ) . this companion should be someone who lives with the mother, does not belong to a risk group, does not present any signs and symptoms of the flu; and wears a mask during his/her entire permanence in the service ( ) . recommendations to hasten the expulsive period by promoting directed pushing or instrumental delivery demand caution because there is no consensus and rev. latino-am. enfermagem ; :e . this procedure may increase the risk of exposure, as it decreases the efficacy of face masks in preventing the propagation of particles ( ) . furthermore, there is a lack of evidence on whether the abbreviation of labor improves maternal and fetal outcomes. epidural analgesia is preferred in the case of mothers wishing pharmacological analgesia during childbirth ( ) . this option should also be offered in the case of c-sections, considering that general anesthesia may cause pulmonary complications related to intubation/extubation, in addition to side effects for nb ( , , ) . it is important to highlight one review addressing the guidelines concerning pregnant women and nb in the context of covid- , reporting that there is no consensus among the practices adopted in the different countries and that these recommendations may differ between countries, as each can give priority to follow local health government agencies or international organizations ( ) . the chinese studies included in this review recommend isolating the mother-infant pair after birth, as this procedure is believed to decrease nb contamination by sars-cov- . for this reason, these studies recommend delayed umbilical cord clamping and skin-to-skin contact to be avoided. therefore, nb should be placed in a warm crib in an environment different from that of mothers ( , , , ) . one review ( ) , a guide providing guidelines for pregnancy, labor and childbirth ( ) , and a technical note from the brazilian ministry of health ( ) report, however, that umbilical cord clamping among asymptomatic women, and even among women with symptoms, does not need to be immediate. because there is no evidence of vertical transmission, optimal timing for umbilical cord clamping may be chosen instead of immediate clamping. it is important to consider that the pandemic demands that health workers and health services exercise good judgment and assess each case individually, encouraging and adopting good practices to promote a positive experience for mothers. the desire and clinical conditions of women should be taken into account, and physical structures should be adapted, observing biosafety maneuvers necessary to decrease the chances of virus transmission ( ) ( ) ) . vigilant attention should be intensified in the postpartum period to monitor the mother's signs and symptoms and detect any worsening of the mothers' health conditions early ( ) . even though hyperthermia is the symptom most frequently reported in the sars-cov- infection, a differential diagnosis should be made, considering that other pathologies may be associated, while other specific signs and symptoms of the respiratory infection caused by covid- should be also investigated ( ) . ( ) ( ) ) . evidence, however, shows that there is no virus in human breast milk. therefore, breastfeeding should be encouraged, especially when we consider the benefits of immunization for the nb ( , , , , , , ) . currently, the greatest concern with breastfeeding lies in the possibility of infants being contaminated by the mothers' respiratory droplets ( , ) . to decrease this risk, mothers are recommended to wear surgical masks during breastfeeding to protect against coughing or sneezing, in addition to constantly performing proper hand hygiene. if mothers opt not to breastfeed while the symptoms remain, health workers should encourage them to pump breast milk and allow another caregiver, who lives in the same home, to feed the infant ( , , , ) . bottles, dosing spoons, or glasses used to feed infants with breast milk have to be sterilized ( ) . a multicenter retrospective study conducted in italy addressing women, recommend physicians and midwives, working in regions with high contamination rates by covid- , to encourage women to wear face masks, both during labor and childbirth and when providing care to infants and breastfeeding, aiming to decrease mascarenhas vha, caroci-becker a, venâncio kcmp, baraldi ng, durkin ac, riesco mlg transmission to nb, considering that individuals with the infection may be asymptomatic ( ) . as for the nb in general, neonatal variables immediately after birth were satisfactory in terms of weight, height, and apgar indexes, while no asphyxia or neonatal death was reported ( , ( ) ( ) ( ) , , ( ) ( ) . even though infection due to the covid- is less frequent in this population, attention should be paid to the risk of infection with greater severity among nb and children under three months of age ( ) . therefore, one should monitor for signs and symptoms, such as dyspnea and tachypnea, hyperthermia or hypothermia, tachycardia, emesis, gastrointestinal symptoms, and thrombocytopenia. in the case of infection, early intervention and differential diagnosis should apply ( , , , , ) . after hospital discharge, the routine and care provided at home are important to prevent the infant and other family members from becoming infected with sars-cov- . hence, mothers are recommended to be isolated until the symptoms disappear or present negative rt-pcr; keep at least two-meter distance from nb when not breastfeeding or providing childcare; keep bedrooms airy and with appropriate temperature and humidity levels; minimize or completely disallow visits and physical contact. it is also important to clean and disinfect the floor and furniture with alcohol or dissolved chlorinated compounds ( ) . the brazilian ministry of health reports an acceptable distance of one meter between mother and nb ( ) . the general health aspects of mother and infant should be assessed during home visits, childcare, and postpartum consultations. also, checks should include anthropometric measures, weight gain, reflexes, breastfeeding, contraceptive methods, how the mother is adapting to the postpartum period, and vital signs ( , ) . additionally, reproductive planning is indicated to ensure the safety of contraceptive methods. it should even be intensified, considering that there is a lack of strong evidence concerning vertical transmission, premature labor, and restricted intrauterine growth. it is also noteworthy that parturient and postpartum women and newborns have been included in vulnerable groups. the choice of the contraceptive should consider the desires of women and their families, although the intrauterine device is an option that can be offered in the immediate postpartum period ( , , ) . rev. latino-am. enfermagem ; :e . in some cases, women are advised to keep a distance from nb, though each case should be considered individually, taking into account the desires of women and their companions. breastfeeding is recommended even among women infected with covid- , provided that they wear surgical masks and observe hand hygiene. when breastfeeding is impossible, mothers are recommended to express or pump breast milk. vital signs should be rigorously assessed and symptoms of this infection identified during childcare consultations. also, support such as medication, oxygen, and guidance concerning sleeping, resting, hydration, feeding should be provided in case of worsened symptoms, along with multidisciplinary care. further studies with greater methodological rigor are needed to resolve controversies regarding directed pushing, instrumental delivery, delayed umbilical cord clamping and bathing nb immediately after birth. because this content is new, some recommendations may change as new knowledge and guidelines emerge in each country. novel coronavirus ( -ncov) coordenadoria de controle de doenças. plano de contingência do estado de são paulo para infecção humana pelo novo coronavírus - ncov recomendações para cuidados e assistência ao recém-nascido com suspeita ou diagnóstico de covid- 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gravídico puerperal -covid : referência e contra referência para a região metropolitana de são paulo ministério da saúde (br). nota técnica nº / -covid- e amamentação vilelas jms. o novo coronavírus e o risco para a saúde das crianças key: cord- -rtqkvf authors: padberg, stephanie title: anti-infective agents date: - - journal: drugs during pregnancy and lactation doi: . /b - - - - . -x sha: doc_id: cord_uid: rtqkvf infections may be hazardous to the health of the mother, the course of pregnancy, and the unborn child. they can lead to premature labor or premature rupture of membranes and thereby increase the risk for spontaneous abortion and prematurity. furthermore, certain germs can pass to the unborn child and harm it directly. therefore, an anti-infective treatment which should be both effective and safe for the mother and the unborn child is often required. the use of penicillines and older cephalosporines is well documented and considered to be safe. consequently, they are the drug of choice during pregnancy. in selected cases of bacterial resistance or intolerance to first-line antibiotics, other anti-infective agents might be recommended. especially for life-threatening infections, a therapy with not so well-tried agents might be needed. the potential benefit of treatment in such cases most often outbalances the potential risk for the unborn child. infections may be hazardous to the health of the mother, the course of pregnancy, and the unborn child. they can lead to premature labor or premature rupture of membranes and thereby increase the risk for spontaneous abortion and prematurity. furthermore, certain germs can pass to the unborn child and harm it directly. therefore, an anti-infective treatment which should be both effective and safe for the mother and the unborn child is often required. the use of penicillins and older cephalosporins is well documented and considered to be safe. consequently, they are the drug of choice during pregnancy. in selected cases of bacterial resistance or intolerance to first-line antibiotics, other anti-infective agents might be recommended. especially for life-threatening infections, a therapy with not so well-tried agents might be needed. the potential benefit of treatment in such cases most often outbalances the potential risk for the unborn child. stephanie padberg . . . erythromycin and other macrolides pharmacology erythromycin and other macrolides inhibit bacterial protein synthesis and are bacteriostatic. macrolides are primarily applied in the treatment of infections with gram-positive germs, but are also effective against haemophilus influenzae and intracellular pathogens such as chlamydia. macrolides offer an alternative for patients with penicillin allergy. erythromycin is the oldest medication of this group. its resorption can be delayed in the third trimester. gastrointestinal side effects can lead to lower than therapeutic plasma concentrations, resulting in treatment failure (larsen ) . only - % of the maternal erythromycin concentration is obtained in the fetus. therefore, erythromycin is not a sufficiently reliable drug for fetal or amniotic infections. the newer macrolide antibiotics azithromycin, clarithromycin, dirithromycin, josamycin, midecamycin, roxithromycin and troleandomycin have a similar antibacterial spectrum as erythromycin, but to some degree less gastrointestinal side effects. spiramycin is used for toxoplasmosis in the first trimester. telithromycin is the first ketolide antibiotic for clinical use. it is structurally related to erythromycin. erythromycin has always been considered a safe and effective antibiotic during pregnancy. data on several thousand first trimester exposures do not support an association between erythromycin and congenital malformations (e.g. czeizel a ). however, an analysis of the data from the swedish birth registry showed a weakly significant increase in malformations in , children whose mothers took erythromycin in early pregnancy compared to offspring whose mothers used phenoxymethylpenicillin (källén a ). this was based on an increased rate of cardiovascular malformations, especially ventricular and atrial septal defects. an update of the swedish data verified an association between the use of erythromycin during early pregnancy and cardiovascular defects (källén ). an increased incidence of pyloric stenosis was discussed by the same author (källén a) . this observation after intrauterine exposure in the first trimester is biologically not plausible; but it should be mentioned that a link has been suggested between a neonatal treatment with erythromycin during the first two weeks and the development of pylorus stenosis (e.g. mahon ) . other studies have failed to find a higher rate of septum defects, pyloric stenosis or other malformations (bahat dinur , lin , romøren , malm , cooper , louik . in summary, the experiences argue against an increased embryo-and fetotoxic risk for erythromycin. there are several reports of maternal hepatotoxic changes when erythromycin estolate was administered in the second half of pregnancy. these women developed a cholestatic icterus during the second week of treatment that abated within weeks when the treatment was discontinued, without evidence of permanent damage or signs of fetal compromise (e.g. mccormack ) . azithromycin, clarithromycin and roxithromycin have also been studied in several publications without any indication of embryo-or fetotoxic effects (bar-oz , bar-oz , chun , sarkar , drinkard , einarson ). in the case of clarithromycin, there was some . anti-infective agents pregnancy initial concern as animal experiments demonstrated teratogenic effects, and for instance, in some studies cardiovascular defects were induced in rats. recently a danish cohort study based on a prescription register observed an increased risk of miscarriage after clarithromycin in early pregnancy, but no increased risk for major malformations (andersen a) . experience with dirithromycin, josamycin, midecamycin, spiramycin, and troleandomycin is very limited (czeizel b) . spiramycin has been used in many first trimesters for the treatment of toxoplamosis. although these reports did not focus on a possible teratogenic effect, numerous normal births after spiramycin exposure are reassuring. there is no published experience with the use of the ketolide telithromycin in the first trimester. the animal experiments did not show that this agent is teratogenic. a local treatment with macrolides is quite safe for the fetus. yet, because resistance develops quickly and allergies are frequent, macrolides should be used with some reservation. clindamycin and lincomycin belong to the lincosamide group. they inhibit bacterial protein synthesis and can be bactericidal or bacteriostatic depending on concentration and sensitivity. after an oral dose the resorption is almost complete. about half of the maternal concentration can be attained in the umbilical veins. there were no signs of embryo-or fetotoxic effects in several hundred pregnant women treated with lincomycin at different points in pregnancy (czeizel c , mickal . there were also no problems found for clindamycin. pseudomembranous enterocolitis is a dangerous maternal complication of clindamycin treatment that may also happen after vaginal application. pregnancy complications due to bacterial vaginosis are not sufficiently preventable by vaginal clindamycin therapy (joesoef ) . it should be noted though, that other investigators found a reduction in late abortions and prematurity when treating several hundred patients with oral clindamycin for an abnormal vaginal flora (ugwumadu ) . recommendation. erythromycin, clarithromycin, azithromycin, and roxithromycin may be used in pregnancy when the resistance spectrum requires them, or in cases of an allergy to penicillin. because of hepatotoxicity, erythomycin estolate should not be given during the second and third trimester. spiramycin is the treatment of choice for toxoplasmosis in the first trimester. telithromycin and other makrolides should only be given during pregnancy when no alternatives are available. recommendation. clindamycin and lincomycin should only be used when penicillins, cephalosporins and macrolides have failed. clindamycin should not be routinely used after dental procedures. the bacteriostatic effect of tetracyclines is based on an inhibition of the bacterial protein synthesis. these broad-spectrum antibiotics, especially tetracycline itself, form stable chelates with calcium ions. the standard agent today is doxycycline. minocycline is especially lipophilic and displays a somewhat wider antibacterial spectrum than doxycycline. the older derivatives such as oxytetracycline and tetracycline are now rarely used as they are poorly resorbed. chlortetracycline, demeclocycline, and meclocycline are only used as local agents. tigecycline is a minocycline derivative that belongs to the glycylcyclines; it has a very broad-spectrum and is especially effective against multi-resistant pathogens such as mrsa. tetracyclines cross the placenta. according to current knowledge an increased risk of malformation is not expected when tetracyclines are used (cooper , czeizel . the results of a population-based case-control study suggested that oxytetracycline was associated with an increased incidence of congenital malformations (czeizel d) . however, the number of cases in this study was small, and there are no other studies confirming this suspicion. a danish cohort study found an association between oral clefts and maternal tetracycline exposure in the second month, but this result was based on only two exposed cases (mølgaard-nielsen ) . from the sixteenth week of pregnancy when fetal mineralization takes place, tetracyclines can bind to calcium ions in developing teeth and bones. in the s numerous publications described the brown/yellow discoloration of teeth in children who were prenatally exposed to tetracyclines. such dental discoloration is the only proven prenatal side effect of tetracyclines in humans. under discussion were also enamel defects leading to an increased risk of caries, inhibition of the growth of the long bones, specifically the fibula and further, cataracts due to depositions into the lens. as doxycycline has a weaker affinity to calcium ions than the older tetracyclines, the risk appears to be lower for doxycycline exposures. a discoloration of milk teeth is not to be expected prior to the sixteenth week of gestation. even thereafter, at worst, only the first molars of the permanent teeth would be affected when the usual therapeutic regimens if current dosings are adhered to. a bigger risk for the described development abnormalities can possibly expected with higher tetracycline doses during the second and third trimester that are necessary, for example, in malaria treatment. in the past, the use of tetracyclines, especially in high doses or via intravenous administration in the second half of pregnancy, has been associated with severe maternal hepatic toxicity (e.g. lewis ) . in most cases these were patients with kidney problems whose serum concentrations were markedly above the therapeutic range. no untoward effects have been described in pregnant women who applied tetracyclines locally during pregnancy. there is a lack of experience with tigecycline; no statement can be made about its tolerance in pregnancy. for local application silver sulfadiazine is used for burn injuries and sulfacetamide for eye infections. sulfonamides attain - % of the maternal concentration in the fetus and compete with bilirubin for binding sites on albumin. today, sulfonamides are seldom used as monotherapy because their spectrum is limited and resistance develops rapidly. combined with a folate antagonist such as trimethoprim or pyrimethamine (section . . ), sulfonamides are indicated among others in the treatment of toxoplasmosis and malaria. the fixed combination of the sulfonamide sulfamethoxazole and trimethoprim is available as co-trimoxazole. both agents in this combination are not subject to pregnancy-induced variation in clearance that would require dose modifications. trimethoprim is effective as a monotherapy in uncomplicated urinary tract infections with sensitive pathogens. to date, there are no indications that sulfonamides, trimethoprim, and their combinations have a teratogenic potential in humans (nørgård , czeizel ). an embryotoxic potential has been discussed from time to time, because antagonists to folic acid can lead to malformations in animal experiments, and in humans the spontaneous incidence of neural tube defects (spina bifida) can be decreased by the administration of folic acid during early pregnancy (chapter . ). the fact that human folic acid reductase is much less sensitive to trimethoprim than the bacterial enzyme, could explain that teratogenic problems have so far not been documented in humans when antibiotics with folic acid antagonists were used. trimethoprim has been used for many decades in pregnant women. at present, there is an ongoing discussion concerning the association between the use of folic acid antagonists and an increased risk of congenital malformations. a retrospective case-control study discusses the causal relationship between treatment with trimethoprim and other folic acid antagonists, and the development of neural tube defects, cardiovascular abnormalities, cleft lip and palate, and urinary tract anomalies (hernandez-diaz ) . authors' views on a preventative dose of multivitamin and folic acid preparations vary. additional case-control studies, some of them with notable methodological problems, found weakly recommendation. all tetracyclines are contraindicated after the fifteenth gestational week. prior to this, they are antibiotics of second choice. doxycycline should be preferred in such cases. inadvertent use of tetracyclines, even after the fifteenth week, is not an indication for termination of pregnancy (chapter . ). if really necessary, a local application to a small area may be conducted throughout pregnancy. tigecyclin is reserved for special situations when sufficiently tested antibiotic are not effective. significant evidence for the development of cardiovascular defects, urinary tract anomalies, anencephaly, limb defects, and orofacial clefts (e.g. mølgaard-nielsen , crider , czeizel c ). an increased risk for preterm birth and low birth weight has also been observed after exposure to trimethoprim/sulfamethoxazole (santos , yang . a danish cohort study based on a prescription register found a doubling of the hazard of miscarriage after trimethoprim exposure in the first trimester (andersen b ). based on the same prescription register, an increased risk of heart and limb defects was observed after preconceptional exposure (during the weeks before conception) to trimethoprim (andersen c) . beside methodological problems, such an association seems unlikely because a short-term therapy with trimethoprim does not usually lead to a relevant folic acid deficiency as a possible cause for birth defects. trimethoprim and sulfonamides are not drugs of first choice, but they exhibit no established teratogens. according to current knowledge the teratogenic risk of a trimethoprim and sulfonamide therapy is negligible. actually, there are no sufficiently convincing arguments to support the recommendation of an additional folic acid administration during an antibiotic therapy with the discussed medications, see chapter . . for additional discussion concerning folic acid usage. extensive, generally reassuring experiences in the use of co-trimoxazole for common urinary tract infections during pregnancy, do not include the conclusion that this medication is safe when used at a much higher dose for opportunistic infections such as a pneumocystis pneumonia in the context of an hiv infection. so far, there have been no reports of malformations when such therapy was used in pregnant women. there are no systematic studies about the local application of sulfonamides during pregnancy. as sulfonamides compete with bilirubin for binding sites with plasma proteins, it has been argued that the risk of neonatal kernicterus is increased when sulfonamides are given at the end of gestation. with current surveillance, the danger of kernicterus is not tangible. however, a rise in bilirubin, especially in premature infants, cannot be excluded when sulfonamides have been used until birth. a danish population-based study could not find an association between sulfamethoxzole exposure near term and an increased risk of neonatal jaundice (klarskov ). quinolones inhibit the bacterial enzymes topoisomerase ii and iv that are important for the nucleic acid metabolism of bacteria. quinolones recommendation. sulfonamides, trimethoprim, and co-trimoxazole are antibiotics of second choice throughout pregnancy. if high dose co-trimoxazole is used for a pneumocystis pneumonia during the first trimester, based on theoretical grounds, folic acid should be supplemented and a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. if a premature birth is threatening, sulfonamides should be avoided in view of the bilirubin levels of the newborn. a short-term local treatment is acceptable, especially if the site is small. have a high affinity for cartilage and bone tissue which is highest in immature cartilage. pipemidic acid and nalidixid acid belong to the group of older quinolones. they have been displaced by the newer fluoroquinolones. the most important fluoroquinolones include ciprofloxacin, enoxacin, levofloxacin, moxifloxacin, norfloxacin, and ofloxacin. several substances have been removed from the market because of severe side effects. garenoxacin, lomefloxacin, pefloxacin, rosoxacin, and sparfloxacin are still available in some countries. gatifloxacin and nadifloxacin are only used as local agent. quinolones cross the placenta and are found in the amniotic fluid at low concentrations.when moxifloxacin is used about % of the maternal serum concentration can be measured in the amniotic fluid, and with lovofloxacin about % (ozyüncü ) . quinolones have not been found to be teratogenic in animals but severe, irreversible damage to joint cartilages was noted in young dogs treated after birth with quinolones (e.g. gough ). such alterations have not been described in prenatally exposed children. many publications failed to show indications of joint cartilage damage or an increased risk of malformations (bar-oz , cooper , larsen , loebstein , schaefer , berkovitch . one study expressed concern that the prenatal use of fluoroquinolones may be associated with an increased risk of bone malformations (wogelius ) . although not resembling each other, in three out of four birth defects the skeleton was affected. however, in this study of women who redeemed a prescription for fluoroquinolones during the first trimester, or days before conception, the total malformation rate was not increased (wogelius ) . in a prospective cohort study with women who were exposed to a fluorquinolone during the first trimester, neither the rate of major birth defects, nor the risk of spontaneous abortion were increased compared to a control group (padberg ) . altogether, most data are available for norfloxacin and ciprofloxacin and, to a lesser extent, for levofloxacin, moxifloxacin, ofloxacin and pefloxacin. there are few or no data for the other fluoroquinolones. there have been no reports of undesirable side effects after topical use of quinolones during pregnancy. nitrofurantoin is a chemotherapeutic agent for drug-resistant urinary tract infections (utis) and for the prevention of recurrent utis. it acts as a bacteriostatic, but is also bactericidal at higher concentrations. details of its mechanism of action remain to be clarified. after an oral dose, therapeutic effective levels are attained only in the urinary tract. several publications do not support an association between nitrofurantoin and congenital malformations (nordeng , goldberg quinolones are antibiotics of second choice during pregnancy. in well-founded situations, when better studied antibiotics are ineffective, those quinolones that are well documented may be preferred such as norfloxacin or ciprofloxacin. a detailed ultrasound examination may be offered after exposure with the other fluoroquinolones during the first trimester. local treatment with quinolones is acceptable throughout pregnancy. czeizel d , ben david , although in a number of studies, some of them with methodological faults, weakly significant findings were noted for craniosysnostosis, ophthalmic malformations, oral clefts, and cardiovascular defects (crider , källén b , källén . a case-control study observed an increased risk of craniosynostosis after intrauterine exposure to nitrosatable drugs (gardner ) . as nitrofurantoin lowers the activity of glutathione reductase, discussions arise periodically as to whether an intrauterine exposure could trigger a fetal hemolysis. bruel ( ) reported a mature newborn with hemolytic anemia whose mother took nitrofurantoin during the last gestational month. nitrofurantoin is often used during pregnancy, and fetal hemolysis has not been commonly observed; therefore, a relevant risk is not likely. however, nordeng ( ) observed an increased risk of neonatal jaundice after maternal nitofurantoin treatment in the last days before delivery. there is a case report of a pregnant woman who developed a toxic hepatitis after having been exposed to nitrofurantoin in her thirty-sixth week (aksamija ). in another case a woman took nitrofurantoin in her thirty-third week and was interpreted to present a gestational nitrofurantoin-induced pneumonia (mohamed ) . the nitrofurantoin derivative nifuroxazide is used for the treatment of diarrhea. there are no documented reports of its tolerance in pregnancy nor evidence of effectiveness. nifurtimox is a nitrofuran used for treatment of chagas disease. experience for pregnancy is very limited and the world health organization recommends that nifurtimox should not be taken by pregnant women (who a). one study about safety included pregnant women, but did not give information about the pregnancy outcome (schmid ) . for local treatment the nitrofurans furazolidone, nitrofural, and nifuratel are available. there has been no evidence of embryo-or fetotoxic risk in local applications. the use of local nitrofurans, especially as vaginal therapy, remains controversial and needs to be critically assessed not only during pregnancy. methenamine is a uti medication that releases the antiseptic formaldehyde into the urine. methenamine mandelate had been used for chronic utis due to e. coli and unproblematic germs. effectiveness and tolerance of the agent remain controversial. embryo-or fetotoxic problems have not been reported. there are no reports about the use of the hydroxy-quinolone derivative nitroxoline in pregnancy. fosfomycin is a broad-spectrum antibiotic that is bactericidal by inhibiting the synthesis of the bacterial cell wall. it is used as an intravenous injectable and as a reserve antibiotic in severe infections such as osteomyelitis. fosfomycin tromethamine is an orally taken salt of fosfomycin used for the treatment of uncomplicated utis. some authors also recommend the oral use during pregnancy (e.g. falagas , bayrak . these studies, however, are primarily focused on the effectiveness of fosfomycin tromethamine, not on the risk for the newborn. overall, the experience argues against a teratogenic and fetotoxic potential in humans. nitroimidazoles are effective bactericidal agents against anaerobes and protozoa. they are converted into metabolites that impede intracellular bacterial dna synthesis. the main representative of the nitroimidazoles is metronidazole. metronidazole is now being recommended by some investigators for the treatment of bacterial vaginosis in pregnancies at high risk for preterm delivery, as a strategy to decrease this risk (review by joesoef ) . others, however, failed to notice an improvement in the incidence of prematurity ( shennan , andrews , klebanoff . after oral and intravenous administration, concentrations as high as those in the mother are reached in the embryo/fetus. significant systemic absorption occurs after vaginal application, exposing the fetus as well. the pharmacokinetic profile of metronidazole did not change at the different time points assessed during pregnancy, and did not differ from nonpregnant patients (wang ) . like all nitroimidazoles, metronidazole displays an experimentally mutagenic and cancerogenic potential (review by dobias ) that has not been confirmed in humans. an investigation that ranged over years did not show any indication of an increased risk of cancer when metronidazole was used (beard ) . on the basis of over , analyzed pregnancies, it can be stated that metronidazole has no teratogenic potential in humans (e.g. koss , diav-citrin , czeizel . suggestions from the hungarian malformation registry of a link between vaginal therapy with metronidazole and miconazole during the second and third month, and an increased appearance of syndactylies and hexadactylies have not been confirmed by other investigators (kazy a) . nimorazole and tinidazole, both registered for the treatment of trichomonas infections, amebiasis, and bacterial vaginosis, cannot be evaluated sufficiently because of the lack of human data -the same applies to ornidazole. so far, there are no reports of human teratogenicity. the aminoglycoside antibiotics amikacin, framycetin, gentamicin, kanamycin, neomycin, netilmicin, paromomycin, ribostamycin, streptomycin, recommendation. nitrofurantoin can be given during pregnancy to treat urinary tract infections when the antibiotics of choice have been ineffective. if possible, it should be avoided towards the end of pregnancy. the use of nifuroxazide, nifurtimox, local nitrofurans, methenamine, and nitroxoline should be avoided during pregnancy. when the antibiotics of choice in pregnancy cannot be used, fosfomycin tromethamine may be used to treat urinary tract infections in pregnancy. the intravenous application of fosfomycin should be restricted to severe bacterial infections with problematic germs. recommendation. metronidazol may be used in pregnancy when indicated. a single oral dose of g is preferable to vaginal administration spread over several days, particularly as there are doubts about the effectiveness of the vaginal application. a parenteral administration is only indicated for a serious anaerobic infection. metronidazole is to be preferred to the less examined nitroimidazoles. and tobramycin inhibit protein synthesis and are bactericidal primarily for gram-negative germs. after oral administration only a minimal portion of aminoglycosides is resorbed. after parenteral administration of about - % of the maternal plasma concentration is detectable in the fetus. spectinomycin is an aminocyclitol antibiotic closely related to the aminoglycosides. oto-and nephrotoxic side effects are also known to occur in nonpregnant patients when aminolgycosides are used parenterally. there are case reports about the parenteral use of kanamycin and streptomycin during pregnancy describing auditory problems, even deafness, in children exposed in utero (e.g. jones , conway , robinson . a similar case was reported in connection with gentamicin (sánchez sainz-trápaga ). an investigation of the hearing ability of children whose mothers had received gentamicin intravenously during pregnancy found no deficiencies. this argues against a major ototoxic risk of gentamicin when used in pregnancy (kirkwood ) . theoretically, a fetal nephrotoxic risk exists because aminoglycosides concentrate in the fetal kidneys. a case report about a connatal kidney dysplasia after maternal gentamicin therapy (hulton ) does not prove a clinically relevant human risk, nor does a case of a hydronephrosis and suspected stenosis at the uteropelvic junction with lethal outcome, where the mother had been treated for uti first with ciprofloxacin and then with gentamicin at weeks - (yaris ) . except for these case reports, studies argue against a high oto-or nephrotoxic risk of gentamicin in the fetus and newborn. there has been no increase in the observation of malformations (czeizel e) . no untoward effects have been described with aminoglycosides as local treatment during pregnancy. experience with spectinomycin is insufficient to analyze a risk in pregnancy. glycopeptide and polypeptide antibiotics  glycopeptide antibiotics the glycopeptides vancomycin and teicoplanin are bactericidal only for gram-positive pathogens by inhibiting their cell wall synthesis. they are considered reserve antibiotics to be used against msra and multiresistant enterococci. to avoid the development of resistance, their application should be critically appraised, and possibly limited only to fighting problematic pathogens. oral glycopeptides are hardly resorbed. this is useful when treating pseudomembranous enterocolitis with vancomycin. however, in this situation metronidazole (section . . ) should be considered as an alternative, as vancomycin therapy is more expensive, and to prevent the selection for vancomycin-resistant enterococci. vancomycin crosses the placenta reaching the fetus in relevant quantities (laiprasert ) . it has not shown teratogenic effects in animal studies. experience with treatment in human pregnancy is limited to a recommendation. aminoglycosides should only be used parenterally in life-threatening infections with difficult gram-negative pathogens and when firstchoice antibiotics fail. the serum levels need to be monitored regularly during the treatment. a risk-based termination of pregnancy or invasive diagnostic are not required (chapter . ). if the parenteral therapy had been extensive, renal function should be monitored in the neonate and an auditory test should be performed. if local or oral application of aminoglycosides is indicated, they can be given because systemic absorption is minimal by these routes. pregnancy few case reports. there were no observations of malformations, kidney damage, or hearing deficits (reyes ) . experience with teicoplanin and the new lipoglycopeptides dalbavancin, oritavancin and telavancin is insufficient to analyze a risk in pregnancy. in vitro telavancin crosses the human placenta, with fetal concentrations reaching less than % of maternal concentrations (nanovskaya ) . daptomycin belongs to a new class of cyclic lipopeptides and is effective exclusively against gram-positive bacteria. it works by interfering with the bacterial cell membrane and protein synthesis, and is indicated to treat complicated infections with difficult pathogens. in animal experiments, daptomycin crossed the placenta and was not teratogenic. two children whose mothers took daptomycin in the fourteenth and twentyseventh weeks were unremarkable (stroup , shea ). polymyxins belong to the polypeptide antibiotics that are bactericidal by interfering with the transport mechanism of the cell wall. while the polymyxin colistin is today mostly used locally, it can also be applied parenterally where there is an infection with multi-resistant gram-negative germs. in patients with mucoviscidosis it is used as an inhalative. enterally colistin is not resorbed; therefore its oral administration is used to selectively decontaminate the intestinal tract. the polypeptide antibiotics bacitracin, polymyxin b, and tyrothricin are used locally. only limited experience is available in the application of polypeptide antibiotics during pregnancy and do not indicate a substantial risk (kazy b ). other antibiotics chloramphenicol and tiamphenicol inhibit bacterial protein synthesis and have bacteriostatic activity. chloramphenicol is relatively toxic, and can cause severe agranulocytosis. it crosses the placenta well and can reach therapeutic concentrations in the fetus. in premature and term births it may lead to the grey baby syndrome. chloramphenicol can reach toxic levels in the neonate even when only the mother has been treated. there have been no suggestions of malformations (czeizel f ). recommendation. glycopeptides should only be used in cases of life-threatening bacterial infections; vancomycin should then be preferred. recommendation. the use of daptomycin is limited to cases of life-threatening bacterial infections. recommendation. the parental use of colistin is limited to cases of lifethreatening bacterial infections. the local and oral application of polypeptide antibiotics need to be critically assessed. experience with thiamphenicol is insufficient to analyze a risk in pregnancy. dapsone, used among other indications against leprosis, apparently has no teratogenic potential (e.g. lush , bhargava . however, cases of hemolytic anemia have been reported in mothers and newborns. as dapsone bears a structural similarity to the sulfonamides, it has been argued that it might compete with bilirubin for protein binding, and thus could lead to hyperbilirubinemia in the newborn. fidaxomicin is a macrocyclic antibiotic which is approved for the treatment of infections with clostridium difficile. enterally fidaxomicin is very poorly resorbed. no experiences have been reported about its use during pregnancy. linezolid is a member of the oxazolidinone class, a new group of antibiotics. it acts bactericidally by inhibiting bacterial protein synthesis and is indicated in the treatment of multi-resistant pathogens. there is just one case report about the use of linezolid during pregnancy. after intrauterine exposure from gestational weeks to a healthy infant was delivered at term (mercieri ). the antiprotozoal agent pentamidine, among others effective in pneumocystis pneumonia, has not been evaluated sufficiently in pregnancy to recommendation. the systemic use of chloramphenicol and thiamphenicol is contraindicated throughout pregnancy. exceptions are life-threatening maternal infections that do not respond to less toxic antibiotics. when systemic treatment is absolutely necessary before birth, it is important to observe the newborn for toxic symptoms. a local application is also to be avoided during pregnancy. recommendation. during pregnancy, dapsone should be reserved for specific indications. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. fidaxomicin should be avoided in pregnancy. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. with the lack of experience, linezolid should only be used for severe infections with problematic germs. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. pregnancy estimate its embryotoxic potential for humans. usually it can be replaced by other antibiotics, e.g. co-trimoxazole (section . . ). rifaximin is an antibiotic to treat travelers' diarrhea. there is not enough experience regarding its use in pregnancy. minimal enteral resorption and negative animal testing suggest that a high embryotoxic risk is unlikely. streptogramins are a group of cyclic peptide antibiotics that inhibit, like macrolides and lincosamides, the synthesis of bacterial proteins. they are derivatives of the naturally occurring pristinamycin. the later developed derivatives quinupristin and dalfopristin are used in a fixed combination. streptogramins should only be applied as reserve antibiotics for infections with highly resistant gram-positive germs. reports about use in pregnancy have not been available. active tuberculosis (tb) requires treatment in pregnancy, as the disease endangers not only the mother, but also the fetus. pregnancy does not seem to affect the course of tb. the prevalence of congenital tb is less than % where no treatment is initiated. lin ( ) investigated newborns of mothers who had received treatment for tb during the gestation. their children were smaller and had lower birth weights than the control group of children of healthy mothers. there are slight differences in the recommendations of the different organizations in the world, such as the who ( a), the international union against tuberculosis and lung disease (iuatld), and several national organizations (e.g. blumberg ) . treatment considerations depend on disease status and drug resistance. first-line drugs for the treatment of tb during pregnancy are isoniazid (+pyridoxine), rifampicin, ethambutol and pyrazinamide. these standard medications have not shown teratogenic or fetotoxic effects in humans (e.g. bothamley ) . as far as we know today, tb drugs reach the fetus in relevant quantities. an increasing development of resistance makes it harder to choose the right medication in pregnancy. pregnant women with multidrugresistant tb (mdr-tb) may also require second-line antituberculous recommendation. pentamidine is to be reserved in pregnancy for special situations when better tested antibiotics are not effective. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. if possible, rifaximin should be avoided during pregnancy. recommendation. streptogramins are to be avoided during pregnancy. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. drugs; the necessity for treatment should be weighed against the risk for the fetus on an individual base. current experiences in the management of mdr-tb argue against a high risk of the reserve drugs for the newborn (drobac , shin . streptomycin, however, should be avoided because of its ototoxic potential. ethambutol is a bacteriostatic drug used against tuberculosis. it can cross the placenta, but the risk of congenital malformations when used during pregnancy appears to be low. there are no reports indicating that ethambutol can cause ocular toxicity in the fetus, as it does in adults, when given in higher doses. isoniazid (inh) has proven to be a highly effective drug against many strains of mycobacterium, and can be used for tuberculous prophylaxis and for treatment of an active disease during pregnancy. although inh can cross the placenta, it does not appear to be teratogenic, even when given during the first trimester. the older literature contains case reports of different malformations and neurological damages in prenatally exposed children. inh intake, lack of pyridoxine, co-medication, and even the tb disease itself was blamed. newer publications did not confirm a teratogenic risk (e.g. taylor . in summary, experiences speak against a major risk. inh increases pyridoxine metabolism, which may be responsible for cns toxicity. to prevent a possible vitamin b deficiency, inh should be given during pregnancy in combination with pyridoxine. pyrazinamide (pza) is an antibiotic with specific effectiveness against mycobacterium tuberculosis. as its structure resembles nicotinamide, it is assumed that it intervenes with the nucleic acid metabolism of the bacterial cell. pza has effective bactericidal properties. systematic studies of its tolerance in pregnancy are lacking. so far, there has been no evidence of embryo-or fetotoxic effects in humans. the use of pza during pregnancy is recommended in several guidelines (e.g. who a). the american thoracic society recommends in its guidelines to hold pza as a reserve drug during pregnancy, as there are currently insufficient data about its teratogenicity (blumberg ) . if pza is not used, treatment may be prolonged. recommendation. ethambutol is a first-line drug for treatment of tuberculosis during pregnancy. recommendation. isoniazid is a first-line drug for treatment of tuberculosis during pregnancy. it needs to be given together with pyridoxine. rifampicin also called rifampin, inhibits bacterial rna polymerase and is effective as a bactericidal agent against different pathogens, particularly mycobacteria. rifampicin can cross the placenta. in animal experiments, teratogenic effects were seen with doses - times higher than in human treatment. because rifampicin inhibits dna-dependent rna polymerase, there has been concern that it might interfere with fetal development. until now, no reports in the literature have confirmed this fear. there is apparently no increased risk of malformations. a long-term therapy of the mother could result in inhibition of vitamin k synthesis, and result in a higher bleeding tendency in neonates. streptomycin is an aminoglycoside that is used parenterally in the treatment of tb. it is bactericidal, particularly affecting germs that proliferate extracellularly. its ototoxicity can also hurt the fetus (section . . ). aside from the above discussed first-line drugs for tb, reserve medications are available and used in cases of resistance or intolerance. no systematic studies exist on the tolerance of -aminosalicylic acid (p-aminosalicylic acid; pas). so far, no evidence for embryo-or fetotoxic effects has been found in humans (e.g. lowe ) . capreomycin, ethionamide, protionamide, rifabutin, rifapentine, thioacetazone, and terizidone, a prodrug of cycloserine, are all second-line agents used internationally for mdr-tb. the extent of documented experiences in pregnancy is limited, and insufficient for a differentiated risk assessment. single case reports argue against a high teratogenic risk of these drugs (e.g. lessnau , drobac . for additional reserve drugs for multi-resistant tb such as amikacin, see section . . , and diverse quinolones, see section . . ; for other anti-infective agents, view the relevant sections of this chapter. recommendation. pyrazinamide may be used during pregnancy to treat active tb. recommendation. rifampicin is a first-line drug for treatment of tuberculosis during pregnancy. when used near term the newborn should receive an extended vitamin k prophylaxis (chapter . ). regarding other infections such as mrsa, rifampicin should only be administered when the drugs of first choice for pregnancy cannot be used. recommendation. streptomycin is contraindicated during pregnancy because of its ototoxic properties. inadvertent exposure does not require risk-based termination of pregnancy or invasive diagnostic procedures, but hearing tests should be performed after birth (chapter . ). generally, each external antibiotic treatment needs to be examined carefully to see whether or not the bacterial infection is more effectively treated with systemic medication. the potential of local treatment is often overestimated. further, with topical therapy, sensitization and resistance development need to be considered. fusafungine has bacteriostatic and anti-inflammatory effects and is used as a spray for the treatment of infections of the nose and throat area. there is insufficient experience about its application in pregnancy. fusidic acid is an antibiotic that is almost exclusively used externally; its prenatal tolerance has not been examined systematically, although the medication has been available for a long time. it has a narrow spectrum of effectiveness against gram-positive bacteria (staphylococci) and is not recommended for an untargeted treatment. mupirocin is primarily bacteriostatic, affecting staphylococci and streptococci by inhibiting bacterial protein synthesis. it is especially used as a nasal ointment to eliminate mrsa. mupirocin has not been examined systematically, but there is no evidence of undesirable effects in pregnancy. retapamulin is the first representative of the pleuromutilins that is approved for human treatment. it is applied as an ointment for short-term treatment of superficial skin infections. retapamulin inhibits bacterial protein synthesis and is bacteriostatic, primarily for gram-positive germs. systemic resorption is minimal with topical use, but nevertheless, as experience in pregnancy has been limited, its application needs to be critically examined. taurolidine is an antimicrobial solution that can be used for lavage in peritonitis and for the prevention of infections with catheters. as a bactericidal agent, its mechanism of action is only partially clarified. there are no reported experiences in pregnancy. see the corresponding sections for the local application of aminoglycosides (section . . ), chloramphenicol (section . . ), quinolones (section . . ), macrolides (section . . ), nitrofurans (section . . ), nitroimidazoles (section . . ), polypeptide antibiotics (section . . ), sulfonamides (section . . ), and tetracyclines (section . . ). apart from pregnant women living in malaria areas, pregnant women are increasingly traveling to tropical countries and need a suitable malaria prophylaxis. increased resistance of malaria pathogens make it more difficult to suggest a general recommendation. the guidelines of tropical medicine recommendation. the reserve drugs discussed here should only be used for multi-resistant tuberculosis when standard therapy is not indicated. an inadvertent exposure during pregnancy does not require a risk-based termination or invasive diagnostic, but a detailed ultrasound examination should be carried out (chapter . ). recommendation. externally used antibiotics are not suspected to be teratogenic. nevertheless, the application of local antibiotics needs to be critically assessed. antibiotics that are safe when used systemically may also be used locally. if another local antibiotic is absolutely necessary, it may be used in pregnancy. should be followed, also in pregnancy, according to the travel destination. especially difficult is the management of malaria tropica caused by plasmodium falciparum. pregnancy enhances the clinical severity of falciparum malaria, especially in the primiparous and non-immune woman. pregnancy alters a woman's immunity to malaria, making her more susceptible to malaria infection and increasing the risk of illness, severe anaemia, and death. maternal malaria increases the risk of spontaneous abortion, stillbirth, prematurity, and low birth weight, and thus results in excess infant mortality (e.g. bardaji , shulman . therefore, mosquito-bite prevention, prophylaxis, and treatment of malaria should not be shortened or omitted in an ongoing pregnancy. traveling to areas with multidrug-resistant malaria should be avoided if possible. the choice of drug for malaria prophylaxis and treatment during pregnancy depends on the local pattern of antimalarial drug resistance, the severity of the malaria, and the degree of pre-existing immunity. it is important to be well informed about the current recommendations for prophylaxis and treatment of malaria in the area to be visited. for travelers to malaria-endemic areas, a general recommendation is difficult because of increasing resistances. depending on the drug, the chemoprophylaxis must be continued for up to weeks after leaving the malarial region. for women living in falciparum-endemic areas with stable transmission, the world health organization recommends the use of insecticide-treated nets (itns) and intermittent preventive treatment (ipt) with sulfadoxine-pyrimethamine during pregnancy (who b , nyunt . ipt reduces maternal malaria episodes, maternal anaemia, placental parasitaemia, low birth weight, and neonatal mortality (review by mcclure ). a prompt diagnosis and effective treatment of malaria infections is vital. although data from prospective studies are limited quinine, chloroquine, proguanil, and clindamycin (section . . ) are considered safe during early pregnancy. pregnant women in the first trimester with uncomplicated malaria tropica should be treated with quinine plus clindamycin (if available) (who b). for the second and third trimester the world health organization recommends artemisinin derivatives. the choice of combination partner is difficult because of limited information. reserve medications include the following: amodiaquine, atovaquone, dapsone (section . . ), lumefantrine, mefloquine, piperaquine, and pyrimethamine plus sulfadoxine. doxycycline is contraindicated after the sixteenth gestational week (section . . ). halofantrine and primaquine should be avoided. see the relevant sections of this chapter about the specific active substrates. during gestation plasma concentrations of many antimalaria agents are lower and their elimination is enhanced. this can result in treatment failure. thus, in each patient dose and dose interval need to be assessed individually. recommendation. generally, the physician should discuss with a patient if the trip to a tropical region could be postponed (section . . ). the risk of exposure can be reduced by long clothes, mosquito netting, and repellents. in no case should medications be denied for prophylaxis or treatment on behalf of a pregnancy, as the potential risk for the unborn child predominates. if medications with inadequate pregnancy experience are used in the first trimester, a detailed ultrasound examination should be offered. a risk-based termination is not justified when the above-described medications have been used in pregnancy (chapter . ). amodiaquine, like chloroquine, belongs to the group of -aminoquinolines. it can cause severe side effects such as liver damage and agranulocytosis, and for this reason, is unsuitable for prophylaxis. its use is limited as a reserve medication for malaria. there has been no evidence of tetatogenicity (review by thomas ) , but experiences are limited. with regard to early pregnancy, only single case reports have been published. one study found only mild maternal side effects in pregnant women who had been treated in the second or third trimester. an increase in miscarriages, prematurity, stillbirth, or malformations was not observed (tagbor ). artemisinin and its derivatives artemether, artemotil, artesunate, and dihydroartemisinin, are increasingly used against malaria as plasmodium falciparum has developed resistance to other drugs. these compounds combine rapid blood schizonticide activity with a wide therapeutic index. artemisinins should be given as combination therapy to protect them from resistance. typical combinations of such artemisinin-based combination therapy (act) are artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, and dihydroartemisinin plus piperaquine first trimester experiences with the use of artemisinin derivatives are limited. a number of studies contain data of more than pregnant women treated with an artemisinin derivative during the first trimester, without showing evidence of a teratogenic risk (mosha , adam , clark , who . manyando ( ) more commonly found umbilical hernias in an additional children whose mothers had been treated with artemether and lumefantrine. after months most of these hernias were not detectable anymore. there are experiences with more than , pregnant women who used artemisinin derivatives in the second and third trimester (e.g. piola , bounyasong , deen , mcgready , phillips-howard . in summary, these studies did not find an increased risk in miscarriages, stillbirths, and malformations. to some degree the artemisisin derivatives were better tolerated by pregnant women, and were more effective than treatments of the control group. as plasma levels of artemether are decreased during pregnancy, it has been suggested that the dose and the dose interval may have to be adjusted (e.g. tarning , morris ). these reassuring data led the who ( b) to recommend using artemisinin derivatives as medications of choice for malaria tropica in the second and third trimester. it does not specify what combination is recommended in the context of act. during the first trimester, based on a lack of experiences, the who views artemisinin derivatives as reserve medications that should not be withheld in an individual case where needed. recommendation. amodiaquine may be used as a reserve medication for the treatment of malaria. atovaquone is a broad-spectrum anti-protozoal drug that is also used in pneumocystis pneumonia. monotherapy quickly leads to resistance, thus it is combined with proguanil when used for malaria prophylaxis and treatment. experience with atovaquone is limited in pregnancy. a danish cohort study based on a prescription register with women exposed during their first trimester to atovaquone, of them exposed at any time in weeks through after conception, found no increased risk for birth defects (pasternak ) . when used in the second and third trimester, small studies observed no adverse effects (mcgready , na-bangchang . available data are insufficient for a differentiated risk assessment, but do not suggest a teratogenic risk. mcgready ( ) discusses the need of a dose adjustment as clearance increases and levels decrease during pregnancy. chloroquine, an antimalaria drug of the group of -aminoquinolines, works well and effectively as a schizonticidal drug against the erythrocytic forms of all types of plasmodia. today though, almost all pathogens of the potentially lethal malaria tropica have become resistant to this rather well tolerated, and for many decades, useful medication. resistance has also been noted for plasmodium vivax, the pathogen of the less severe malaria tertiana. plasmodium ovale and plasmodium malariae still remain mainly sensitive to chloroquine. chloroquine is not embryo-and fetotoxic when used at the usual dose for malaria prophylaxis or for a three-day treatment of a typical malaria attack (mcgready , phillips-howard . current evidence does not suggest fetal ocular toxicity when chloroquine was used as antimalarian medication during pregnancy (review by osadchy ). lee ( ) examined pregnant women and nonpregnant controls, and did not find any changes in the pharmacokinetics or the serum level of chloroquine. the anti-inflammatory properties of chloroquine are used also for antirheumatic therapy (section . . ). antirheumatic doses of chloroquine are higher than those used for malaria prevention. recommendation. artemisinin derivatives may be used in the second and third trimester. in the first trimester they are reserve medications for the treatment of malaria. recommendation. atovaquone may be used as a reserve medication for the treatment of malaria. recommendation. chloroquine may be used throughout pregnancy for the prophylaxis and treatment of malaria. if chloroquine resistance of the parasite is likely or has been demonstrated, other drugs must be used. halofantrine has a rapid schizonticidal effect upon the erythrocytic forms of those plasmodia that are resistant to chloroquine and other antimalarials. halofantrine prolongs the qt interval in the ekg. becauses it can provoke life-threatening cardiac arrhythmias in patients with heart disease, or in conjunction with other arrhythmogenic medications, halofantrine is no longer recommended. the limited experiences in pregnancy allow no differentiated risk analysis. lumefantrine belongs to the group of arylamine alcohols like quinine, mefloquine, and halofantrine. artemether plus lumefantrine is currently a popular artemisinin-based combination therapy. few experiences are available regarding its application in the first trimester without showing evidence of a teratogenic risk (e.g. mosha ) . for the second and third trimester, studies with several hundred patients have been reported and do not indicate a major risk (piola . manyando ( ) found only a mild increase in umbilical hernias in children whose mothers took artemether and lumefantrine during the first trimester. most of these had disappeared when follow-up examination was conducted months later. in summary, current experiences do not suggest a major embryo-or fetotoxic risk of lumefantrine. during pregnancy, the plasma concentration is lower and the elimination enhanced, thus increasing the risk of treatment failure (e.g. tarning ). mefloquine displays an effective and rapid activity against the erythrocytic forms of all plasmodia. current experiences with more than , treated pregnant women, several hundred of them in the first trimester, do not suggest a teratogenic or fetotoxic potential in humans (e.g. schlagenhauf , bounyasong , mcgready . one single study of the use of mefloquine has been debated as finding an increased rate of stillbirths. this study compared pregnant women who received mefloquine for malaria, and found them to have a significantly higher rate of stillbirth than those who had been treated with quinine and other antimalarials (nosten ) . other studies, however, have not confirmed this risk, and mefloquine has been an established medication in pregnancy for some time. recommendation. halofantrine is only to be used in cases of acutely threatening malaria that cannot be managed with better tested and less toxic drugs. when cardiac problems are an issue, other antimalaria medications must be used. recommendation. lumefantrine may be used as a reserve medication for the treatment of malaria. recommendation. mefloquine may be used throughout pregnancy for the prophylaxis and treatment of malaria if there is no resistance. a fixed oral combination of the bisquinolone piperaquine and dihydroartemisinin (dhp) is a new and promising artemisinin-based combination therapy. the mechanism of action of piperaquine is unknown. an indonesian observational study detected a higher rate of abortion after first trimester exposure to dihydroartemisinin-piperaquine (poespoprodjo ) . this observation was based on five abortions among eight pregnancies ( %). the same study found a lower risk of perinatal mortality after dihydroartemisinin-piperaquine in the second and third trimester compared to quinine-based regimens. the limited experiences in pregnancy allow no differentiated risk analysis. no significant pharmacokinetic differences between pregnant and nonpregnant women were reported in two small studies , hoglund ). primaquine, an -aminoquinoline derivative, is effective against the intrahepatic permanent forms of plasmodium vivax and plasmodium ovale. it is used for the complete elimination of pathogens in combination with a blood schizontocide for the erythrocytic parasites. primaquine should not be used in pregnancy because of the potential risk of hemolytic effects in the fetus. as yet, there are no studies that permit a well-grounded risk assessment. however, there is no substantial evidence for a teratogenic potential in humans (phillips-howard ). proguanil, an older medication for malaria prophylaxis belonging to the folic acid antagonists, is experiencing a renaissance as it has become useful in the face of increasing chloroquine resistance. most often it is applied in combination with the synergistic atovaquone. there is no evidence of an embryotoxic potential in humans (e.g. pasternak , mcgready . mcgready ( ) discuss the need to adjust the dose as clearance is increased and blood levels decreased during pregnancy. pyrimethamine is an inhibitor of folic acid synthesis that is also used in the treatment of toxoplasmosis and pneumocystis pneumonia. in malaria recommendation. piperaquine may be used as a reserve medication for the treatment of malaria. recommendation. primaquine is not a therapeutic option during pregnancy. a prophylactic elimination of hepatic spores should usually be postponed for a time after birth. recommendation. proguanil may be used throughout pregnancy for prophylaxis and treatment of malaria provided there is no resistance. treatment it is only applied in combination with another folic acid antagonist such as sulfadoxine (section . . ). this particular combination is used for intermittent preventive treatment (ipt) during pregnancy. however, increasing resistance has started to limit the effectiveness of this popular combination (newman ) . as animal experiments indicated embryotoxic effects, concerns had been raised about the use of these folic acid antagonists in early pregnancy. numerous investigations, however, have not demonstrated an increased malformation risk in humans (e.g. manyando , phillips-howard . some studies suggest that pregnancy adversely alters the pharmacokinetics of pyrimethamine and sulfadoxine (e.g. karunajeewa , green . as data are inconsistent, a general recommendation about dose adjustments in pregnancy is difficult. when sulfadoxine-pyrimethamine is given in early pregnancy, it should be supplemented by folic acid until the tenth week. the who recommends . - . mg per day, as a coadministration of high dose ( mg daily) compromises the efficacy of sulfadoxine-pyrimethamine in pregnancy (who b). quinine is the oldest antimalarial agent. it works well and effectively as a schizonticidal drug against the erythrocytic forms of all plasmodium species. despite a relatively high toxicity and a narrow therapeutic range, it is used again increasingly in the treatment of chloroquine-resistant malaria. in combination with clindamycin (section . . ) its effectiveness is increased. concentrations in the fetus are just as high as in the mother, and are potentially toxic. in some case reports it was observed that children had auditory or visual defects after the use of quinine in pregnancy. however, in those cases considerably higher doses had been administered than currently in use. there is no evidence of an increased risk of abortion or preterm delivery with the use of a standard dosage of quinine for treatment of acute malaria (phillips-howard ) . these findings were confirmed by other studies with several hundred pregnant women exposed during the first trimester, where no increased rates of spontaneous abortion, congenital malformations, stillbirth or low birth weight were found (e.g. adam b , mcgready . quinine increases the secretion of insulin (elbadawi ) . especially in the last part of pregnancy, severe maternal hypoglycaemia has been induced by quinine therapy. due to the risk of hypoglycemia, the who ( b) guidelines prefer to use an artemisinin combination for the management of malaria tropica from the second trimester on. a study of the metabolism of quinine in pregnant and nonpregnant women failed to show significant pharmacokinetic differences. the authors concluded that dose adjustment is not necessary during pregnancy (abdelrahim ) . induction of contractions with high doses of quinine cannot be excluded. recommendation. pyrimethamine in combination with sulfadoxine may be administered for the treatment of malaria. for toxoplasmosis it is the drug of choice when combined with a long-term sulfonamide, especially after the first trimester. when pyrimethamine is given in early pregnancy, it should be supplemented with folic acid, see also chapter . . . quinine is a component of some analgesic compounds and of certain beverages, although in lower and apparently nonembryotoxic doses. azole antifungals azole derivatives inhibit the ergosterol biosynthesis, thereby causing disturbances in the permeability and functions of the fungal cell membrane. azole antifungals include two broad classes, imidazoles and triazoles. in animal experiments azole antifungals cross the placenta and are teratogenic at high doses. with regard to the use of the triazole derivative fluconazole in pregnancy, there was a report of three children (two of them siblings) with craniofacial, skeletal, and cardiac malformations, similar to those seen in animal studies (pursley ) . because of meningitis, their mother had used high doses of fluconazole ( - mg daily) through or beyond the first trimester on a long-term basis. additional case reports have described two births involving craniofacial, limb, and cardiac defects in two mothers who used fluconazole (lopez-rangel , aleck ). those cases shared some characteristics with the antley-bixler syndrome. however, there was no evidence of an increased risk of malformation in a prospective cohort study with women exposed during the first trimester (mastroiacovo ) . in several other studies, first trimester exposure to low-dosage regimens of fluconazole for vaginal candidiasis did not appear to cause an increased risk of malformations (e.g. jick , campomori , inman . danish cohort studies based on a prescription register also could not find an increased risk of birth defects after first trimester exposure in several thousand pregnant women (nørgaard , sørensen ). an extended analysis of the danish data observed an increased risk for tetralogy of fallot based on seven cases (prevalence . %) compared to unexposed pregnancies (or . ; % ci . - . ). the rate of major birth defects was not increased (mølgaard-nielsen ). in most cases the low and single dose consisted of mg fluconazole usually used for a vaginal yeast infection. itraconazole is a triazole derivative with wide-spectrum activity. there has been no evidence of teratogenicity in prospective studies examining several hundred women with first trimester exposure (e.g. de santis , bar-oz ; most of the exposures were short-term. a danish register analysis did not find an increased risk of birth defects among women with a first trimester prescription of itraconazole (mølgaard-nielsen ). recommendation. despite its toxicity, quinine belongs to the drugs of choice when dealing with chloroquine-resistant malaria tropica in pregnancy. in this situation the potential risk of treatment is much smaller for the fetus than the danger of a severe maternal disease. attention needs to be paid to possible maternal hypoglycemia. even though embryotoxic effects due to quinine in analgesic compounds are not to be expected, these agents should be avoided because they do not conform to good therapeutical practice. the same holds for the regular or excessive consumption of quinine drinks. the imidazole derivative ketoconazole is usually avoided in systemic use because it is poorly tolerated and has many suitable alternatives. ketoconazole is administered on occasion for the treatment of cushing syndrome as it inhibits steroid synthesis. theoretically, by decreasing testosterone synthesis, it might impede the sexual development of male foetuses; however, this has not been described. ketoconazole has been used in several cases in pregnancy with good maternal and fetal outcome (e.g. boronat , berwaerts , amado . a retrospective study from data of the hungarian malformation registry based on exposed subjects shows no evidence of an increased risk of malformations after systemic use of ketoconazole (kazy c ). an analysis of a danish register did not observe a significantly increased risk of birth defects among pregnant women with a prescription for this agent during first trimester (mølgaard-nielsen ). for posaconazole and voriconazole which are used for aspergillosis and other invasive mycoses, information is lacking about use during pregnancy. there is only one published case report of a normal child, born after voriconazole treatment of the mother in the second and third trimester (shoai tehrani ). a multitude of poorly resorbed topical azole derivatives are available for the treatment of superficial fungal infections. the drugs of this group that had been introduced first, namely clotrimazole and miconazole, are most thoroughly investigated for use in pregnancy. regarding clotrimazole, there are extensive studies about the treatment of vaginal yeast infections that do not indicate an embryotoxic potential (e.g. czeizel b , king . also, there is no suggestion that there is an increase in miscarriages. czeizel ( a) noted a decrease in prematurity when vaginosis was treated locally with clotrimazole. experiences with several thousand pregnant women are available for miconazole (e.g. czeizel b , mcnellis . a suggestion by the hungarian malformation registry about a link between vaginal therapy with miconazole plus metronidazole during the second and third gestational month, and an increase in syndactyly and hexadactyly, has not been substantiated by other studies (kazy a ). an israeli report describes two cases of severe skeletonal anomalies after the use of bifonazole that are reminiscent of anomalies seen after systemic use of fluconazole. in the first case, bifonazole was taken orally from week to , in the second case mg/d vaginally throughout pregnancy and clearly at a higher dose than recommended (linder ) . at dose levels which are reached with nomally recommended topical application no teratogenic risks have been noted, yet systematic studies are lacking. for ketoconazole see above (azole antifungals for systemic use). recommendation. if a systemic treatment with an azole derivative becomes absolutely necessary, fluconazole and itraconazole are to be preferred as the better-tested medications. if possible, treatment should start after the first trimester. an inadvertent exposure during pregnancy does not require a risk-based termination or invasive diagnostic, but a detailed ultrasound examination should be carried out (chapter . ). clearly less experience has been collected about the local applications of butoconazole, croconazole, econazole, fenticonazole, isoconazole, omoconazole, oxiconazole, sertaconazole, sulconazole, terconazole, and tioconazole. teratogenic effects have not been observed (king ) . this was confirmed for vaginal econazole treatment in a study of pregnant patients (czeizel a ). amphotericin b is a broad-spectrum antifungal agent of the polyene group. it binds to ergosterol at the cell membrane of fungi and disturbs cell wall permeability. it can be used intravenously, orally, and locally. with oral application, it is poorly resorbed and thus has only a local effect in the intestinal tract. conventional amphotericin b given parenterally has a number of side effects, primarily nephrotoxicity. newer lipid formulations of amphotericin b such as liposomal amphotericin b are characterized by a markedly better tolerance and less nephrotoxicity. amphotericin passes the placenta. relevant plasma concentrations could be measured in a newborn, although the mother had taken her last dose four months prior (dean ). this could be due to placental accumulation or delayed elimination by the fetal kidneys. several case reports do not indicate an increased risk of malformations with amphotericin b (e.g. costa , ely , king ). more than pregnancy courses with liposomal amphotericin b also argue against an embryo-or fetotoxic risk (e.g. mueller , pagliano , pipitone ). these experiences are insufficient for a differentiated risk assessment. as resorption is minimal with oral or local use, a risk appears unlikely. echinocandins are a new antifungal medication group. these parenteral synthetic lipopeptides inhibit the synthesis of , -β-d-glucan, a key ingredient of the fungal cell wall. anidulafungin, caspofungin, and micafungin are currently approved. in animal experiments echinocandins cross the placenta. there have been no reports of their use in pregnancy. yalaz ( ) described the successful postnatal application of caspofungin in a dystrophic premature newborn of the twenth-seventh gestational week. recommendation. clotrimazole and miconazole belong to the local antifungal medications of choice in pregnancy. the other azole derivates are antimycotic drugs of second choice. recommendation. amphotericin b should only be used parenterally in cases of serious disseminated fungal infections. the liposomal formulation may be preferred. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. oral and local use of amphotericin b is acceptable in pregnancy. flucytosine is effective against cryptococcus neoformans and many candida species. it inhibits the dna synthesis. within the mycotic cell flucytosine is partially converted into the cytostatic -fluorouracil. to a smaller degree this reaction has to be expected in humans as well. due to a high incidence of resistance, flucytosine should only be administered in combination with another antifungal drug such as amphotericin b. in animal experiment, fluycytosine has a teratogenic effect at doses below those used in humans. as yet, no malformations have been reported in humans; however, there is, as yet, no published experience with the use of flucytosine in the first trimester. case reports about application in the second and third trimester for dangerous disseminated cryptococcosis have not shown evidence of fetal damage (e.g. ely ). griseofulvin is an organically derived antifungal agent that is used orally for several weeks against fungal infections of the skin, hair and nails. as it is deposited within the keratin, it is especially suited for the management of fungal infections of nail mykoses. in animal experiments griseofulvin is teratogenic and, at high doses, cancerogenic. it crosses the placenta at term (rubin ) . one publication, based on birth defects data, reported two pairs of conjoined twins after the use of griseofulvin in early pregnancy (rosa ) . this observation could not be confirmed in other publications (knudsen , metneki . a population based case-control study with some exposed pregnant women did not demonstrate an increased risk of malformations (czeizel c ). these experiences are insufficient for a differentiated risk assessment. recommendation. as there is insufficient data regarding the use of echinocandins in pregnancy, they should only be used where no alternatives are available and the mycosis is life-threatening. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. flucytosine should only be used for life-threatening disseminated fungal infections during pregnancy. as it is not indicated as a monotherapy, it needs to be assessed critically if its use as a second mycotic drug is really necessary. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. as griseofulvin is not used to treat life-threatening fungal infections, its application in pregnancy should be avoided. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. terbinafine is used for both oral and topical treatment of fungal infections of the nails and other dermatophytoses. a prospective study reported on pregnant women exposed to terbinafine which showed no evidence of a teratogenic potential (sarkar ) . of these women were exposed during the first trimester and had an oral exposure. these data are insufficient for a differentiated risk analysis. when used topically, less than % is resorbed making a risk unlikely. regarding the topical use of azole derivatives such as clotrimazole and miconazole, see section . . ; for amphotericin b, section . . ; and for terbinafine, section . . . nystatin is an antifungal drug from the polyene group. like the closely related amphotericin b it binds with ergosterol of the mycotic cell wall and interferes with its function. nystatin is an effective local antifungal drug for candidiasis of the skin or mucosa. when taken orally, it is poorly resorbed and only works locally in the intestinal tract. the indication for intestinal cleansing needs to be critically assessed in immunocompromized patients. nystatin is used frequently, and there is no evidence of embryo-or fetotoxic effects (e.g. king ) . a population-based case control study did not show an increased risk of malformation after first trimester exposure. when treatment was performed in the second and third trimester, slightly more cases of hypospadia were noted (czeizel b ). however, a low resorption rate, methodological weaknesses of the study, and the low number of only pregnant women place the result in question. a retrospective study of the hungarian malformation register, with exposed subjects, did not reveal signs of an increased risk of malformation when natamycin was applied vaginally (czeizel c) . based on the same register, a case-control study discussed a possible association between cardiovascular malformations and maternal use of tolnaftate in pregnancy (czeizel d) . this observation was based on exposed cases, of which four cases had varying types of cardiac defects (or . , %; ci . - . ). these data are insufficient for a differentiated risk analysis. amorolfine, butenafine, ciclopirox, haloprogin, naftifin, and tolciclate are insufficiently investigated with regard to prenatal human toxicity. as yet, there is no substantial indication for an increased risk of malformations after local use. recommendation. terbinafine should be avoided during pregnancy as safety data are lacking and fungal nail infections do not require urgent treatment. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. a topical application is likely to be harmless. recommendation. nystatin, like clotrimazole and miconazole is an antifungal drug of choice during pregnancy. where possible, these drugs should be preferred. external treatment with amorolfine, butenafine, ciclopirox, haloprogin, natamycin, naftifin, tolciclate, and tolnaftate should be avoided during pregnancy. more than billion people are infected with helminths worldwide. soil-transmitted helminths have been recognized as an important public health problem in many developing countries. severe hookworm and other helminth infections during pregnancy may cause anemia, reduced birth weight and increased perinatal mortality. a routine application of anthelmintics during the second and third trimester for women in areas endemic for hookworm infection has been suggested, with the argument that this may improve maternal anemia, birth weight, and neonatal mortility (e.g. who c, christian ). however, a randomized placebo-controlled study showed no advantage for newborns whose pregnant mothers had received albendazole or praziquantel . recently, it has been discussed if routine anthelmintic treatment during pregnancy might lead to an increased risk for allergies in infancy (mpairwe ). the benzimidazole derivatives albendazole, flubendazole, mebendazole, thiabendazole, and triclabendazole inhibit the uptake of glucose and thereby kill the parasites. in animal experiments benzimidazole derivative with anthelmintic activity showed teratogenic effects. albendazole and mebendazole are poorly resorbed from the gastrointestinal tract, except when there is an inflammation. however, enteral absorption may be increased due to high-fat diet. mebendazole is a highly effective and well tolerated anthelmintic drug used against nematodes (such as pinworms, roundworms, whipworms, and hookworms). there have been reports describing children with various malformations after in utero exposure to mebendazole, but a distinct pattern of malformations could not be discerned (review by schardein ) . an increased risk of congenital malformations was not observed in a study of over pregnant women exposed to mebendazole in the first trimester (de silva ) . this was confirmed in a controlled prospective study covering first trimester exposed pregnant women (diav-citrin ) . another study with first trimester exposures also found no increased risk for malformations or miscarriages ( mcelhatton ) . although numbers are too small for any definite conclusion, mebendazole does not appear to represent a major teratogenic risk. significantly more experience has been collected with exposure during the second and third trimester showing no evidence of a fetal risk (e.g. gyorkos ) . albendazole is a newer, highly effective broad-spectrum anthelmintic which combined with operative interventions has become the treatment of choice for alveolar and cystic echinococcosis. limited experience in the first trimester has not shown evidence of a major risk (gyapong , cowden . there are several thousand pregnancies with the use of albendazole in the second or third trimester without any obvious adverse reactions reported (e.g. , ndyomugyenyi . two abstracts from korea which reported the outcome of pregnant women after the first trimester exposure to flubendazole showed no evidence of a teratogenic potential (choi (choi , . however, the data is insufficient for a differentiated risk assessment. there are no reports of thiabendazole and triclabendazole use during human pregnancies. ivermectin is a broad-spectrum anthelmintic agent which is mainly used in humans in the treatment of onchocerciasis (river blindness), lymphatic filiriasis and strongyloidiasis. it is also effective against other worm infections and some epidermal parasitic skin diseases, such as scabies. ivermectin is well resorbed after oral administration. animal experiments do not suggest a teratogenic potential, although at maternally toxic exposures malformations were noted in rodents. a number of case reports describing accidental treatments during the first trimester have not shown malformations in the children (gyapong , chippaux , pacque ). however, data are insufficient for a differentiated risk assessment. a study encompassing more than women who took ivermectin during the second trimester found no significant anomalies in the newborns (ndyomugyenyi ). niclosamide is an anthelmintic that is effective against tapeworms (cestodes). it affects the energy metabolism of the parasites and is practically not resorbed by the intestinal tract. this agent had been used extensively in the past and is not suspected to cause malformations, but has not been systematically studied in humans. praziquantel is a highly effective broad-spectrum anthelmintic agent against many trematodes and cestodes. it is mainly used for the treatment of schistosomiasis (bilharziosis). no teratogenicity has been reported in animal studies. over the last decades millions of pregnant women have been inadvertently treated with praziquatel during routine anthelmintic programs without an obvious adverse reactions reported. a few publications recommendation. mebendazole may be used during pregnancy to treat relevant worm diseases. albendazole may be used in cases of echinococcosis. the other benzimidazole anthelmintics should only be used with a compelling indication, and when more established anthelmintics are ineffective. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. with a compelling indication ivermectin may be used in pregnancy. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. niclosamide may be given during pregnancy to treat relevant tapeworm infections. application in the first trimester needs to be critically assessed as tapeworm infections are generally not a great hazard to the mother or unborn child. after first trimester exposure, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. also found no evidence of a teratogenic potential after mothers had been treated in the first trimester (adam a , paparone . in a study from uganda encompassing more than , pregnant women, treatment with praziquantel in the second and third trimester was not associated with an increase in adverse outcomes (ndibazza ) . the who ( ) recommends the use of praziquantel for schistosomiasis during pregnancy. pyrantel is a broad-spectrum anthelmintic that acts by inhibition of cholinesterase, causing spastic paralysis and subsequent death of the parasite. no teratogenicity has been reported in animal studies. pyrantel is poorly absorbed from the gastrointestinal tract. published experience on its use during pregnancy is not sufficient to determine risk. pyrvinium is effective against pinworms (enterobius). after oral administration it is hardly absorbed. therefore, it is unlikely to reach the fetus in relevant amounts. there are no reports of embryo-or fetotoxic effects. however, there has been no published experience with the use of pyrvinium during pregnancy. a danish cohort study based on prescription registers identified women redeeming a prescription for pyrvinium ( during first trimester). the pregnancy outcome was not considered in this article (torp-pedersen ). diethylcarbamazine is used for the treatment of filiriasis and onchocercosis. no teratogenicity was reported in animal studies. no publications regarding its use during human pregnancies have been located. levamisole is used as anthelmintic and as an immunomodulator. a retrospective study with data from the hungarian malformation registry based on subjects (four first trimester exposures), shows no evidence of an increased risk of malformations after use of levamisole (kazy ) . oxamniquine is used for the treatment of schistosomiasis. no experiences have been reported about its use during pregnancy. recommendation. praziquantel should be reserved for specific severe indications like schistosomiasis. usually for other indications better-established anthelmintics are available. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. pyrantel should be avoided in pregnancy because better tested alternatives are available for all indications. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. pyrvinium may be used during pregnancy. the standard agent of this group is acyclovir which is used against the varicella-zoster virus (vzv) and herpes simplex virus (hsv) type and . the manufacturer's case collection contains over , women treated systemically with acyclovir during pregnancy, of them during the first trimester; with no evidence of embryo-or fetotoxic risk (stone ) . a study of a danish registry with , women with prescriptions in the first trimester, showed no increased risk after acyclovir (pasternak ) . although these studies had some methodological weaknesses, the experiences argue against the risk of acyclovir in pregnancy. valacyclovir, the prodrug of acyclovir, is converted quickly and completely to acyclovir in the body. orally it is distinctly better resorbed than acyclovir of which only about % is resorbed. the manufacturer did not find an increased risk of malformation in women who had received valacyclovir during pregnancy, of these during the first trimester (glaxo wellcome ) . also, the above cited study of the danish registry did not show evidence of embryo-or fetotoxic risk in pregnancies, in which the mother filled a prescription for valacyclovir during the first trimester (pasternak ) . ganciclovir and its prodrug valganciclovir are effective in cytomegalus virus infections (cmv). in animal experiment, teratogenic effects were only seen with plasma levels that were twice as high as those recommended in human therapy. there are a few case reports describing normal pregnancy outcome after the first trimester treatment during early pregnancy (pescovitz ) . puliyanda ( ) describes a successful oral treatment with ganciclovir for an intrauterine cmv infection after the nd week. these experiences are insufficient to evaluate the safety of ganciclovir in pregnancy. famciclovir is quickly converted after enteral resorption into the virostatic penciclovir. neou ( ) reported a newborn whose mother took mg famciclovir daily in her fifth week. the boy who succumbed to a severe neonatal infection had a hypoplastic thymus, a mild stenosis of the pulmonary valve, an ostium secundum defect, and an enlarged liver with stenotic extrahepatic biliary ducts. a retrospective study of data from the danish birth registry contained women who took oral famciclovir during the first trimester, and showed no increase in the malformation rate (pasternak ) . there is insufficient data about the use in pregnancy for brivudine, cidofovir, foscarnet, and fomivirsen. in animal experiments, small doses of foscarnet sodium trigger skeletal anomalies in rats and rabbits. no experience is reported for the combination therapy of dimepranol and inosine that is used to stimulate the immune system against viruses of the herpes group. recommendation. diethylcarbamazine, levamizole and oxamniquine should be avoided during pregnancy as better tested alternatives are available for most indications. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus.  herpes medication for local use acyclovir, foscarnet, ganciclovir, idoxuridine, penciclovir, trifluridine, and tromantadine are locally applied in hsv infections. none of these agents has been suspected to give rise to teratogenic effects. acyclovir may be used in pregnancy systemically and is harmless in local application. in the above cited danish registry study , women had used acyclovir and women penciclovir locally during the first trimester, and no increased malformation risk was noted (pasternak ) . the other agents lack studies about local application. docosanol is a newly approved agent for topical application in herpetic cold sores. the mechanism of action is unknown. there has been no experience about its use in pregnancy; however, a risk is unlikely with its minimal resoption. the local application of zinc sulfate and of patches containing hydrocolloid particles is harmless in pregnancy. antiviral drugs for hepatitis  antiviral drugs for hepatitis b nucleoside/nucleotide analogs and α-interferon (chapter . ) are used for the management of chronic hepatitis b. a general therapeutic recommendation cannot be made for pregnancy as data are inadequate. experience so far did not reveal serious signs of teratogenic or fetotoxic damage in humans. if there is a very active hepatitis b or cirrhosis, antiviral treatment might be considered. passive-active immunoprophylaxis of infants have reduced mother-to-child-transmissions. however, in high viremic mothers immunoprophylaxis might fail. no consensus has been reached if pregnant women who are hbsag positive, and highly viremic should be treated in the third trimester to prevent a perinatal transmission to the infant (e.g. pan ). for lamivudine and tenofovir see section . . . adefovir dipivoxil, the prodrug of adefovir, is an orally-administered nucleotide analog. no teratogenicity has been reported in animal studies. the antiretroviral pregnancy registry ( ) received reports of births after a maternal adefovir dipivoxil regimen in the first trimester. no birth defects were observed in the infants. entecavir has shown teratogenic effects in animal studies where, in high doses, more vertebral and tail malformations occurred. of recommendation. if an antiviral therapy is indicated for a severe maternal disease, or to protect the fetus from an intrauterine infection, acyclovir or valacyclovir should be used as the best evaluated medication whenever possible. the other antiviral agents are only indicated in infections where they have a therapeutic advantage over acyclovir. after the application of one of the less well examined drugs during first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. where indicated, local remedies for herpes may be used during pregnancy. drying agents and patches for herpes are harmless. where possible, acyclovir should be preferred as the best evaluated antiviral drug. infants whose mothers were exposed to entecavir during first trimester, two babies were born with birth defects (no details available) (antiretroviral pregnancy registry ). one case report describes a healthy baby born after entecavir exposure for days in the second trimester (kakogawa ) . telbivudine raised no suspicions for teratogenicity in animal experiments. among pregnancies of women who received telbivudine before or in early pregnancy the abortion rate was . %. fifty mothers delivered infants. one pregnancy was terminated because of cleft lip and palate and one infant showed right ear accessories, no other birth defects were reported (liu ) . in the antiretroviral pregnancy registry ( ) no birth defects were observed in infants after first trimester exposure to telbivudine. in a prospective study, infants were born after maternal treatment with telbivudine in late pregnancy to prevent perinatal transmission. exposure took place from the twentieth to thirty-second gestational week until at least month after delivery. there were no significant differences in infant outcomes compared to a control group. no serious adverse events were noted in the infants . there is an ongoing discussion as to whether telbivudine should be given to women with a high virus load during late pregnancy to prevent intrauterine transmission (review by deng ). the nucleoside analog ribavirin inhibits both dna-and rna-viruses, displaying a relatively broad antiviral spectrum experimentally. among other applications, it is used to treat respiratory syncytial virus (rsv) infections in infants, and, combined with α-interferon (chapter . ), against hepatitis c. ribavirin has teratogenic and mutagenic effects in animal experiments. nine women who were treated during the second half of pregnancy for severe measles delivered healthy infants (atmar ) . a woman treated for sars (severe acute respiratory syndrome) in the first trimester with ribavirin by injection for days gave birth to a normal child (rezvani ) . in its pregnancy registry, the manufacturer noted eight women with ribavirin exposure in the first trimester, and women with exposure within months of the last menstrual period (roberts ) . the authors found no evidence of a teratogenic risk for humans. in summary, current data is insufficient for a risk assessment for ribavirin. an embryo-or fetotoxic risk is not apparent with the available case reports. the level of ribavirin is twice as high in seminal fluid as in sperm. there has been no increased risk of malformations after paternal ribavirin treatment and interferon in pregnancies reported as case reports (review by hofer ), and pregnancies of the ribavirin pregnancy registry (roberts ) . these numbers are inadequate to assess a possible risk after paternal exposure. the protease inhibitors boceprevir, simeprevir and telaprevir have been approved for the treatment of chronic hepatitis c. there are no experiences with their use in pregnancy. the same applies to sofosbuvira recently approved polymerase inhibitor for the treatment of chronic hepatitis c. amantadine enhances dopamine activity at the receptor and thus is also used as an antiparkinson drug. as an antiviral medication, it inhibits the membrane protein hampering the ability of the virus to enter the cell nucleus. because of rapid resistance and frequent neurologic side effects, it is not recommended any more as an antiviral agent. for amantadin in parkinson disease, see chapter . . the neuraminidase inhibitors oseltamivir, peramivir and zanamivir are used to treat patients whose influenza requires therapy. oseltamivir has not shown teratogenic effects in animal studies. a prospective investigation at two japanese centers did not see an increase in malformations where women had been treated in the first trimester (review by tanaka ). another study involving exposed offspring, of them in the first trimester, also did not find a higher risk (greer ) . the manufacturer, too, noticed no increased risk in women who had used oseltamivir during pregnancy, of these during the first months (donner ) . one study with pregnant women exposed to oseltamivir, in the first trimester, found an increased risk of late transient hypoglycaemia compared to an unexposed control group. no other increased risks of adverse birth outcomes among the infants have been observed. one child had a ventricular septal defect. this was the only major malformation after exposure in the first trimester (svensson ) . another publication included pregnant women exposed to oseltamivir, of them in first trimester. the overall rate of major malformation after first trimester exposure was . % (saito ) . in a french publication, a total of mothers received at least one prescription of oseltamivir during pregnancy. one congenital heart defect was observed among infants who were exposed during first trimester. no significant association between adverse fetal outcomes and exposure to oseltamivir during pregnancy could be found (beau ) . dunstan ( ) could also find no signs of embryo-or fetotoxic effects in exposed pregnant women. no birth defects were observed in eight first trimester exposures. a population-based retrospective cohort study analyzed data from , women who received oseltamivir during pregnancy. compared to a control group, there were no associations between maternal use of oseltamivir with preterm birth and low apgar score. women who recommendation. ribavirin and the other antiviral agents discussed here should only be used during pregnancy when compellingly indicated. treatment during the first trimester is not a justification for a risk-based termination of pregnancy (chapter . ). in such a situation a detailed ultrasound examination should be offered to ascertain normal fetal development. pregnancy took oseltamivir during pregnancy were less likely to have a small for gestational age infant. however, birth defects and time of exposure were not mentioned (xie ) . two studies looked into the pharmacokinetics of oseltamivir and its active metabolite oseltamivir carboxylate during gestation. greer ( ) compared the pharmacokinetics of pregnant women in each group during the last trimester and found no significant differences. beigi ( ) examined the pharmacokinetcs in pregnant women (average gestational age . weeks) in comparison to nonpregnant women, and found the pregnant group to have lower oseltamivir carboxylate level. however, it remains unclear if the dose needs to be adjusted during pregnancy. zanamivir is applied by inhalation and very little is resorbed. no teratogenicity was found in animal experiments. a case series study from japan reported infants born after intrauterine zanamivir exposure, of them were exposed in the first trimester. no malformations have been observed (saito ) . a prospective surveillance study did not provide a case that use of zanamivir in pregnancy is associated with an increased risk of adverse pregnancy outcomes among women exposed to zanamivir during pregnancy. no major malformations were reported in zanamivir first trimester exposures (dunstan ) . experience and the presence of low systemic concentrations, make it unlikely that there is an increased embryo-or fetotoxic risk. experience during pregnancy with peramivir is insufficient for a risk assessment. the aim of antiretroviral therapy (art) during pregnancy is the prevention of a vertical transmission of the human immunodeficiency virus (hiv) from mother to child, and also the optimal management of the hiv-infected mother, whereby unwanted side effects are to be kept at a minimum for her and the child. art in pregnancy has become an integral part in the prophylaxis of hiv transmission after data revealed the protective effect of perinatal prophylaxis, with the nucleoside analog reverse transcriptase inhibitor (nrti) zidovudine that could prevent a possible vertical transmission during the last trimester and labor (connor ) . national and international guidelines recommend a standard therapy for both nonpregnant and pregnant hiv-infected women take a combination of at least three antiretroviral medications (eacs , oarac , who c . this highly active antiretroviral therapy (haart) typically consists of two nrtis and either a protease inhibitor (pi), or a non-nucleoside analog reverse transcriptase inhibitor (nnrti). the intention is that the suppression of the plasma hiv load (hiv-rna) should be as close to < copies/ml at least by the end of the pregnancy. when an effective haart is applied during pregnancy and lactation, the hiv rate of transmission can be decreased from its former levels of recommendation. if indicated, neuraminidase inhibitors oseltamivir and tanamivir may be used in pregnancy. peramivir should be avoided. amantadine is no longer recommended for the treatment of influenza. when used during the first trimester, a detailed ultrasound examination should be offered to ascertain normal fetal development. - % to < % (townsend , warszawski . the decision of what regimen to use is already complicated in nonpregnant patients, but more so in pregnancy. how to balance individual needs and risks should be considered, especially in view of the timing of the start of treatment, a possible interruption of therapy during the first trimester in women already under treatment, and the selection of appropriate antiretroviral medications. the risks from intrauterine exposure to combinations of antiretroviral agents are difficult to assess, as data are limited concerning the pharmakinetics and the developmental toxicity for most of the drugs. there is no data about the long-term toxicity of the exposure to intrauterine retroviral substances. information about the safety of retroviral drugs in pregnancy are limited to experiments in animals, single case reports, a few clinical studies, and analyses of registries such as the antiretroviral pregnancy registry ( ) in the usa that contains most of the information about the safety of antiviral substances in pregnancy. overview of the antiretroviral medications , darunavir, fosamprenavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir, and tipranavir. . entry inhibitors: enfuvirtide and maraviroc. . integrase inhibitors: raltegravir, dolutegravir and elvitegravir. data currently available do not allow for a summarizing differentiated risk analysis for antiretroviral medications in pregnancy. with the exception of efavirenz, there have been no serious signs of teratogenic or fetotoxic damages in humans (e.g. watts , ecs . prospectively documented pregnancies do not demonstrate a higher risk of malformations and, like retrospective case reports, fail to reveal any distinct pattern of anomalies. when antiretroviral agents are used in the first trimester, the embryotoxic risk appears to be generally small (phiri , floridia , antiretroviral pregnancy registry , joao . nevertheless, substances that might be embryotoxic should be eschewed in early pregnancy. common side effects in children treated in utero or after birth with zidovudine or antiretroviral combinations consist of hematologic problems, especially anemias and neutropenias (dryden-peterson , feiterna-sperling , le chenadec . it is being debated if antiretroviral treatment with or without protease inhibitors favors prematurity (chen , patel , kourtis , cotter , tuomala . the maternal risks of therapy are discussed with the specific medications. the medical treatment of hiv infection during pregnancy is a prime example for the need to sometimes utilize insufficiently tested medications -because of the acute danger for mother and child. in individual cases it needs to be critically assessed if an ongoing or maternally indicated treatment is absolutely necessary during the time of embryogenesis, or if it can be temporarily suspended. data from clinical studies during pregnancy in women are available for abacavir, didanosine, emtricitabine, lamivudine, stavudine, tenofovir, and zidovudine. with the exception of didanosine, the nrtis showed comparable levels in the maternal serum, and the umbilical cord blood suggested an easy placental passage (pacifici ) . having an affinity to mitochondrial γ-dna polymerases, nrtis can induce mitochondrial dysfunction. the greatest risk for mitochondrial toxicity is exhibited in vitro for didanosine, stavudine, and zidovudine. the question if a perinatal nrti exposure could lead to mitochondrial problems in children is currently under discussion; a final consensus has not been reached (benhammou , blanche . lamivudine and zidovudine are the nrtis that should be preferred during pregnancy because of extensive experience. abacavir, emtricitabine and tenofovir are alternative nrtis which also might be used. didanosine and stavudine should only be used in special circumstances (oarac ). abacavir can lead to skeletal anomalies when given to rats at a high dosage. there is no evidence of teratogenicity in humans. abacavir readily crosses the placenta (chappuy ) . data from the antiretroviral pregnancy registry ( ) with birth defects in cases, indicate a malformation rate of . % after exposure during the first trimester, similarly as seen in the general population of the usa. in animal experiments didanosine given at high doses did not show teratogenic effects. didanosine crosses the placenta only in limited recommendation. antiretroviral medications may be used in pregnancy. specific risks for the prophylaxis of transmission and the therapy of maternal hiv infection need to be observed. the choice of medication and the timing of treatment have to be decided on an individual basis. when choosing medications it should be noted that some of the retroviral substances should be avoided during pregnancy, if possible. this concerns efavirenz (teratogenic effects) and the combination stavudine/didanosine (lactic acidosis). for newer medications such as maraviroc, raltegravir and etravirine, few or no data are available concerning their use in pregnancy. caution is called for when nevirapine is used in women with cd cell counts of < /mm mm (hepatotoxicity). if nevirapine is used during pregnancy, transaminases need to be checked regularly, especially during the first weeks of treatment; also, clinical symptoms are to be watched. the short-term use of nevirapine for transmission prophylaxis does not seem to carry a similar risk. when exposure occurs during the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. it is recommended that the pregnant patient is cared for in a specialized center. physicians should report pregnancies involving the use of hiv medications shortly after diagnosis to the antiviral pregnancy registry (www.apregistry.com). amounts (wang ) . the data of the antiretroviral pregnancy registry ( ) show a slightly increased malformation rate after first trimester exposure at . % ( of births), in comparison to . % in the general us population. however, no distinct pattern of birth defects has been discovered. in a study where hiv infected women were treated at - weeks with didanosine, neither maternal nor neonatal side effects were noted (wang ) . cases of lethal lactic acidosis have been described in pregnant women treated with a combination of stavudine and didanosine (mandelbrot , sarner . due to the risk of fatal lactic acidosis, combination treatment with didanosine and stavudine should only be used in cases where no alternatives are available (bristol-myers squibb ) . emtricitabine has not shown evidence of teratogenicity in animal experiments or in humans. it crosses the placenta readily (stek , hirt b ). among cases of first trimester exposures reported to the antiretroviral pregnancy registry ( ), the prevalence of birth defects was . % ( of , births), similar to the rate in the general us population. lamivudine, one of the best evaluated nrtis, is also approved for the treatment of chronic hepatitis b. levels measured in the umbilical cord blood correspond to those of the mother. data from the antiretroviral pregnancy registry ( ) indicate an unsuspicious malformation rate of . % ( of , births). a larger study to prevent perinatal transmission was conducted in france where pregnant women received zidovudine and lamivudine after gestational week , and their newborns were also given the combination for weeks ( mandelbrot ) . in this study newborns displayed significant side effects that included lethal mitochondriopathies. however, lamivudine and zidovudine are medications that are preferred in pregnancy because of extensive experience. there is no evidence that stavudine leads to teratogenic effects in animal experiments or humans. stavudine crosses the placenta easily ( chappuy ) . the malformation rate after exposure in the first trimester is . % ( of births) according to data from the antiretroviral pregnancy registry ( ), thus similar as in the general us population ( . %). good tolerance of a staduvine-lamivudine combination has been described in a small phase i/ii study with mother-child pairs (wade ) . cases of lethal lactic acidosis have been described in pregnant women treated with a combination of stavudine and didanosine (mandelbrot , sarner . due to the risk of a fatal lactic acidosis, combination treatment with didanosine and stavudine should only be used in cases where no alternatives are available (bristol-myers squibb ). in animal experiments, offspring of monkeys that received high doses of tenofovir have a decreased fetal growth rate and diminished fetal bone density (tarantal ) . during pregnancy tenofovir crosses the placenta easily (flynn , hirt a . there is no evidence that tenofovir is teratogenic in humans. according to the data of the antiretroviral pregnancy registry ( ) the malformation rate after exposure during the first trimester is . % ( of , births), similar to the . % rate in the general us population. in clinical studies hiv patients, primarily children, displayed decreased bone density when treated with tenofovir. the clinical significance of these findings is still unclear. one study did not reveal any risk for adverse effects of in utero tenofovir exposure in pregnant women (gibb ). however, tenofovir should be used with caution during pregnancy, because of the risk of fetal bone changes and the paucity of other data about its pregnancy-related risks. zidovudine, also known as azidothymidine (azt), is the oldest antiviral drug used for antiretroviral therapy. it readily crosses the placenta. in rats, maternal toxic doses lead to an increased malformation rate during organogenesis, an effect not seen with lower doses. there are no signs of teratogenicity in humans. according to data from the antiretroviral pregnancy registry ( ) the malformation rate of . % ( of , births) was not significant higher than that of the general us population. the application of zidovudine has been well studied in pregnancy and is considered to be safe in regard to shortterm and medium-term toxicities. a common side effect, when zidovudine is used in the perinatal period, is a transient anemia in newborns (sperling , connor . a follow-up study of children who had been exposed to zidovudine in utero did not display any physical, immunological, or cognitive anomalies. the median age of children at the time of last follow-up was . years (range, . - . years) (culnane ) . also, there was no evidence of an increased risk for neoplasia in more than children after pre-and perinatal exposure (culnane , hanson . there are no data regarding long-term toxicity, especially for cancerogenicity. data from clinical studies about the safety in human pregnancy for nnrt is are limited. nevirapine is the agent that should be preferred if a nnrti is required during pregnancy. efavirenz might be used in special circumstances. for etravirine and rilpivirine the data are insufficient to recommend use during pregnancy (oarac ). delavirdine is not recommended as part of an initial therapy. delavirdine caused an increased incidence of ventricular septal defects in rats. experience in humans is limited to births after first trimester exposure reported to the antiretroviral pregnancy registry ( ). although no birth defects have been observed, these data allow no differentiated risk analysis. most guidelines do not recommend delavirdine as a part of antiretroviral regimens for initial treatment of hiv infection because of inferior efficacy. in animal experiments efavirenz showed evidence of teratogenicity. three of prenatally exposed cynomolgus monkeys showed malformations when plasma levels were similar to the therapeutic levels in humans. anencephaly with unilateral anophthalmia was observed in one fetus, microphthalmia in another, and cleft palate in a third. there are case reports in humans about neural tube defects in children whose mothers had received efavirenz during the first trimester (de santis , fundaro . according to the data of the antiretroviral pregnancy registry ( ) the malformation rate of . % ( of births) after first trimester exposure is comparable to the background rate of . % in the general us population. the birth defects included one infant with myelomeningocele. another child was born with anophthalmia, severe facial cleft and amniotic banding. in total, the antiretrorviral pregnancy register received six retrospective reports of neural tube defects; four of them were exposed to efavirenz. a meta-analysis, including nine prospective studies together with , live births, did not detect an increased risk of overall birth defects after exposure to an efavirenz-containing regimen during the first trimester. including retrospective studies, one neural tube defect was reported in , live births (ford ). an update of this meta-analysis which included additional subjects had similar results (ford ) . in contrast to these reassuring findings, another study analyzes data of , infants born between and . a significantly increased risk of congenital anomalies after exposure to efavirenz during first trimester was observed. six of infants with first trimester exposure to efavirenz had congenital anomalies (adj.or . , %; ci: . - . ) (knapp ) . however, the six observed major and minor defects (patent foramen ovale, gastroschisis, postaxial polydactyly, arnold-chiari malformation, talipes equinovarus, plagiocephaly), do not present a distinct pattern. with the available published experience, the british hiv association guidelines panels concluded that there are insufficient data to support the former position and furthermore recommend that efavirenz can be both continued and commenced in pregnancy (taylor ) . however, the united state guidelines are more restrictive. they recommend that an efavirenz-based regimen may be continued in women who present for antenatal care in the first trimester, provided the regimen produces virologic suppression (oarac ). animal experiments have not shown that etravirine is teratogenic. experience in pregnancy is limited to case reports (jaworsky , furco ). according to the data of the antiretroviral pregnancy registry ( ) no birth defects were reported in infants born after first trimester pregnancy exposure to etravirine. experiences are insufficient to analyze a possible risk in pregnancy. there is no evidence in animal experiments or human experience that nevirapine is teratogenic. nevirapine crosses the placenta easily and attains levels in the neonate that correspond to those of the mother ( benaboud , mirochnick . according to the data of the antiretroviral pregnancy registry ( ) the malformation rate after first trimester exposure is . % ( of , births), which is no higher than that of the general us population. studies indicate that viral transmission is blocked when mg p.o. nevirapine is given to the mother at the beginning of labor, and the newborn receives a single dose of mg/kg to hours after delivery (guay ) . there is a high risk of developing viral resistance even after a single dose (low resistance barrier and long half-life of nevirapine), thus nevirapine should only be administered in a combination regimen. reports have been published describing single cases of liver toxicity in pregnant women who took nevirapine (e.g. knudtson ). this event is often rash-associated and potentially fatal. liver toxicity is primarily observed in patients with higher cd cell counts (> /mm ); in these patients the risk of symptomatic hepatic events is twelve times greater than in women with lower cd cell counts (< /mm ). studies indicate that pregnancy per se is a risk factor for liver toxicity. pregnant patients using haart that includes nevirapin have no higher risk of hepatotoxicity than those who use haart without nevirapine (ouyang , ouyang ). these data suggest that the risk of liver toxicity of nevirapine is similar in pregnant and nonpregnant patients. however, if nevirapine is used in pregnancy, physicians should be aware of hepatotoxicity. animal experiments failed to show that rilpivirine is teratogenic. in the antiretroviral pregnancy registry ( ) no birth defects were reported in infants born after first trimester exposure to rilpivirine. one publication describes two healthy infants after rilpivirine exposure during pregnancy (colbers ) . experiences are insufficient to analyze a possible risk in pregnancy. pis are being used increasingly in pregnancy. they are recommended in regimens combined with two nrti drugs. pi therapy can lead to the disturbance of glucose tolerance and even to the manifestation or exacerbation of diabetes mellitus. it remains unclear if pregnancy itself increases the risk even further. generally, pis pass the placenta poorly ( gingelmaier , marzolini , mirochnick . therefore, fetal toxicity would seem to be unlikely. lopinavir/ritonavir and atazanavir with low-dose ritonavir boosting are the preferred pis during pregnancy. alternative pis include ritonavir-boosted saquinavir and darunavir. indinavir and nelfinavir should only be used in special circumstances. data is too limited to recommend the routine use of fosamprenavir and tipranavir in pregnant women (oarac ). atazanavir has not shown evidence of teratogenicity in animal experiments or human experience. according to the data of the antiretroviral pregnancy registry ( ), the malformation rate of . % ( of births) after first trimester exposure is comparable to the rate of . % in the general us population. a number of studies are available, including pharmacokinetic evaluations in pregnant women using haart with atazanavir , ripamonti . some experts recommend an increased dose in late pregnancy. the umbilical cord blood of neonates shows atazanavir levels of - % of those seen in the maternal serum. atazanavir inhibits the uridin glucuronosyl transferase that metabolizes indirect bilirubin. thus, as a common side effect, atazanavir treatment may lead to higher indirect bilirubin levels. while case numbers are relatively small, investigations showed that neonates of atazanavir-treated mothers did not show pathological elevations of indirect bilirubin. , ripamonti ). darunavir did not demonstrate evidence of teratogenicity in animal experiments. some case reports demonstrated a limited placental transfer. like with other pis a reduction in plasma levels has been observed in late pregnancy (pinnetti ) . in the antiretroviral pregnancy registry ( ) five birth defects were reported in infants born after first trimester exposure to rilpivirine (prevalence . %). few experiences about its use in pregnancy are available (e.g. jaworsky , ivanovic ). these data are insufficient for a differentiated risk assessment. in animal experiments no evidence was found that fosamprenavir leads to teratogenicity. human data about its use in pregnancy are very limited. transplacental passage analyzed in seven cases was relatively high compared to other pis. the authors detected a median ratio of . of cord blood to maternal amprenavir level (the active metabolite of fosamprenavir) (cespedes ) . one publication did not report adverse effects in nine infants after intrauterine exposure to fosamprenavir (martorell ) . two birth defects among births were reported to the antiretroviral pregnancy registry ( ) after first trimester exposure to fosamprenavir. these data are insufficient for a differentiated risk assessment. evidence for teratogenicity is not evident for indinavir in animal experiments or human reports. little of indinavir crosses the placenta ( mirochnick ) . according to the data of the antiretroviral pregnancy pregnancy registry ( ) the malformation rate of . % ( of births) after first trimester exposure is comparable to that in the general us population. these data are insufficient for a differentiated risk assessment. there is a theoretical concern that physiologic hyperbilirubinemia might be exacerbated due to indinavir. lopinavir is used in conjunction with its pharmacological booster ritonavir. in animal experiments with high doses of lopinavir, rats displayed evidence of embryotoxicity with an increased rate of miscarriages, less fetal viability, lower fetal weight, and skeletal changes. these problems were not apparent in rabbits. there is no evidence of teratogenicity in humans. like most pis, lopinavir/ritonavir crosses the placenta poorly (gingelmaier ) . according to the data of the antiretroviral pregnancy registry ( ) the malformation rate is . % ( of , births) after first trimester exposure, and thus not increased in comparison to the general us population. studies with hiv-infected pregnant women indicate that the treatment with lopinavir/ritonavir is well tolerated. pharmacokinetic investigations show lower plasma levels, primarilty in the last trimester (best ) . it is unclear if pregnant women require a higher dose or just a continuation of the pi standard therapy. a report of infants who received lopinavir/ ritonavir after birth observed an association with transient adrenal dysfunction in the infants (simon ) . a systematic review about the safety and efficacy of lopinavir/ritonavir during pregnancy included nine studies involving , pregnant women. no concerns with the use of these agents were suggested (pasley ). nelfinavir did not display evidence of teratogenicity in animal experiments. according to the data of the antiretroviral pregnancy registry ( ), the malformation rate is . % ( of , births) after first trimester exposure which is a modest evaluation compared to the general population ( . %). no distinct pattern of birth defects defects has been discovered. in studies with hiv-infected pregnant women it was noted that a small amount crosses the placenta (bryson , mirochnick . when nelfinavir is used as an unboosted pi in pregnant women who need treatment for hiv, it is inferior to newer, low-dose ritonavir boosted pis, but is useful as an alternative pi in combination with nrtis for the prophylaxis of hiv transmission. however, nevirapine should only be used under special circumstances during pregnancy. ritonavir should be used in combination with other pis as a low-dose booster to increase levels of a second pi. only a small amount crosses the placenta (mirochnick ) . there is no evidence that ritonavir is teratogenic in animal experiments or humans. according to the data of the antiretroviral pregnancy registry ( ) the malformation rate is . % ( of , births) after first trimester exposure, thus similar to the general us population. saquinavir has not demonstrated evidence of teratogenicity in animal experiments or human experience. like with other pis only small amounts of the drug cross the placenta (mirochnick ) . pharmacokinetic studies indicate that the newer tablet formulation that has replaced the former capsule formulation, leads to plasma concentrations similar to nonpregnant patients (van der lugt ). thus, it is not necessary to adjust the doses in pregnancy. seven birth defects among first trimester exposures were reported to the antiretroviral pregnancy registry ( ). these data are insufficient for a differentiated risk assessment. tipranavir shows no teratogenicity in animal experiments. there are no data about its ability to cross the placenta. aside from single case reports of pregnant patients with multiple resistances (weizsaecker , wensing , there are no other data about the use of tipranavir in pregnancy. no birth defects were reported to the antiretroviral pregnancy registry ( ) among four first trimester exposures to tipranavir. experiences are insufficient to analyze a possible risk in pregnancy. entry inhibitors are antiretroviral agents that inhibit viral binding or fusion of hiv to the cell, either by inhibition of the fusion of the viral capsule with the cell membrane or by blocking cd -or co-receptors. data about the use of enfuvirtide or maravorioc during pregnancy are insufficient to recommend their use during pregnancy (oarac ). in animal experiments no evidence was observed that enfuvirtide is teratogenic. a number of single case reports suggest that enfuvirtide apparently does not cross the placenta (weizsaecker , brennan-benson . according to the data of the antiretroviral pregnancy registry ( ) no birth defects have been reported among first trimester exposure to enfuvirtide. thus, it can be assumed that the risk of fetal toxicity is likely to be small. enfuvirtide may be used in pregnant women with multi-resistent hiv in combination with other potent agents as a therapeutic option, but current experience in pregnancy is very limited. maraviroc is a ccr inhibitor that is used to treat pretreated hivinfected adults in combination with other antiretroviral medications, when exclusively ccr -tropic hiv type- have been proven to be present. animal experiments using rats and rabbits did not show evidence of teratogenicity for maraviroc. there are no data indicating to what degree pregnancy maraviroc crosses the placenta. while there has been no indication that the use of maraviroc leads to a higher rate of malignancy, a theoretical concern remains based on the method of its action. maraviroc should only be used when the benefit justifies the potential fetal risk. there is a lack of data about its application in pregnancy. among cases with first trimester exposure reported to the antiretroviral pregnancy registry ( ) no birth defects have been observed. integrase inhibitors block integrase, a hiv-coded enzyme, and thereby hiv replication. the use of raltegravir during pregnancy can be considered in special circumstances when preferred and alternative agents cannot be used (oarac ) . there is insufficient data for the new integrase inhibitors dolutegravir and elvitegravir. in animal experiments no evidence was seen that dolutegravir is teratogenic. placental transfer has been described in animals. no experiences have been reported about its use during human pregnancy. there are also no reports about the use of dolutegravir to the antiretroviral pregnancy registry ( ). elvitegravir is combined with colbicistat which has no known antiretroviral activity. colbicistat is a pharmacokinetic enhancer which inhibits enzymes that metabolize elvitegravir. animal studies of elvitegravir have shown no evidence of teratogenicity. only one report about the use of elvitagravir during the first trimester has been reported to the antiretroviral pregnancy registry ( ). no birth defects were observed in this case. development studies in rats and rabbits did not show raltegravir to be teratogenic. however, there was a slightly increased incidence of supernumerary ribs in the offspring of rats that had received raltegravir at doses about . times higher than those recommended in human treatment. potential human risks are not known at this time. according to the few data about its use during pregnancy, raltegravir crosses the placenta well (mckeown ). in a case series of five women raltegravir was well tolerated (taylor ) . three birth defects were observed among pregnant women with first trimester exposures reported to the antiretroviral pregnancy registry ( ). because experience is increasing, the united states guidelines recommend allowing a regimen including raltegravir in special circumstances, when preferred and alternative agents cannot be used (oarac ) . however, the data on the use of raltegravir during pregnancy allow no differentiated risk analysis. more than years ago animal experiments demonstrated that an increase in the body temperature can cause malformations (review by graham , edwards , miller . this problem has also been discussed for humans. neural tube defects, in particular (suarez , shaw ), but also kidney, heart and abdominal wall defects (abe , chambers , have been reported in association with febrile infections in early pregnancy, even though the overall malformation risk is absent or only mildly increased. moretti ( ) performed a meta-analysis about the risk of neural tube defects and hyperthermia. they included studies with , cases and found a significant correlation (or . ; %; ci . - . ), both in the nine case-control studies and the six cohort studies. lowering fever in pregnant women seems to reduce the risk (suarez ) . it has been debated if the use of sauna, electric blankets, or other factors that bring about a short-term increase in body temperature could lead to similar effects as high fever (suarez ) . in finland, where this issue had been investigated repeatedly, visits to saunas occur frequently during pregnancy and is considered safe. the use of electric blankets and heated water beds has not shown, in other investigations, that they are linked to an increased malformation risk. one study observed that children between the ages of and had more frequent emotional and cognitive deficits where there were reports about high fever during the second and third trimester (dombrowski ) . in summary, it appears that there is a slightly higher risk of malformations when high fever (> °c and > hours) occurs, especially during the first weeks after conception. during long-distance travel and flights during pregnancy, a number of potential risks need to be considered: □ prevention of infections (malaria prophylaxis, see section . . .; vaccinations, see chapter . ). □ the risk of other infections (fever, fluid loss), and required therapy. □ during long-distance flights: -risks of thrombosis -ionizing cosmic radiation recommendation. if there is an infection with high fever, especially during early pregnancy, the fever should be controlled with acetaminophen (paracetamol) or ibuprofen (chapter . ). ibuprofen should not be taken after gestational weeks. non pharmacological measures of fever control such as cool wrappings, and sufficient fluid intake should also be considered. in cases of high fever episodes in early pregnancy, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. a fever episode does not justify a risk-based termination of pregnancy (chapter . ). visits to a sauna should be limited to less than minutes, and hot or long baths need to be avoided as well as other sources that can overheat the body. -decrease of the partial oxygen pressure equivalent to an altitude of , m -dry air. □ physical and psychological stress. specific developmental anomalies have not been found in pregnant women undergoing vaccinations or recommended malaria prophylaxis, nor were such problems seen as a result of long-distance flights. however, it needs to be noted that the stress of a long-distance trip, especially in predisposed women, might increase the risk of miscarriage. also, aside from typical infectious diseases, "common" infections may be more prevalent due to altered hygienic standards in the destination country. the accompanying dehydration, fever, or other complications may also endanger the fetus. the dose of cosmic radiation on a long-distance flight varies markedlydepending on solar activity. yet, according to current knowledge, no doses are reached that are high enough to lead to an increased risk of malformations. pharmacokinetics of quinine and its metabolites in pregnant sudanese women with 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pregnant women soil-transmitted helminth infections further analysis of the risk of adverse birth outcome after maternal use of fluoroquinolones infant outcomes among pregnant women who used oseltamivir for treatment of influenza during the h n epidemic successful caspofungin treatment of multidrug resistant candida parapsilosis septicaemia in an extremely low birth weight neonate exposure to trimethoprim/sulfamethoxazole but not other fda category c and d anti-infectives is associated with increased risks of preterm birth and low birth weight gentamicin use in pregnancy. a renal anomaly key: cord- -oin m uq authors: ferreira, cristine homsi jorge; driusso, patricia; haddad, jorge milhem; pereira, simone botelho; fernandes, ana carolina nociti lopes; porto, debora; reis, bianca manzan; mascarenhas, lilian rose; brito, luiz gustavo oliveira; ferreira, elizabeth alves gonçalves title: a guide to physiotherapy in urogynecology for patient care during the covid- pandemic date: - - journal: int urogynecol j doi: . /s - - - sha: doc_id: cord_uid: oin m uq introduction and aim: physiotherapy in urogynecology faces challenges to safely continuing its work, considering the adoption of social distancing measures during the covid- pandemic. some guidelines have already been published for urogynecology; however, no specific documents have been produced on physiotherapy in urogynecology. this article aimed to offer guidance regarding physiotherapy in urogynecology during the covid- pandemic. methods: a group of experts in physiotherapy in women’s health performed a literature search in the pubmed, pedro, web of science and embase databases and proposed a clinical guideline for physiotherapy management of urogynecological disorders during the covid- pandemic. this document was reviewed by other physiotherapists and a multidisciplinary panel, which analyzed the suggested topics and reached consensus. the recommendations were grouped according to their similarities and allocated into categories. results: four categories of recommendations (ethics and regulation issues, assessment of pelvic floor muscle function and dysfunction, health education and return to in-person care) were proposed. telephysiotherapy and situations that need in-person care were also discussed. regionalization is another topic that was considered. conclusion: this study provides some guidance for continuity of the physiotherapist's work in urogynecology during the covid- pandemic, considering the world health organization recommendations and the epidemiological public health situation of each region. telephysiotherapy can also be used to provide continuity of the care in this area during the covid- pandemic, opening new perspectives for physiotherapy in urogynecology. the covid- pandemic has changed all health care scenarios, and many institutions have interrupted patient care. women's health physiotherapy focused on urogynecology has been almost completely interrupted, and thousands of patients have been left unattended. if we consider the number of patients that would have needed care, we can find data indicating that about % of women have symptomatic pfds [ ] . although the problems treated are generally not urgent, the level of discomfort can be severe, creating a negative impact on quality of life. social distancing during the pandemic could increase pfd-related suffering and other morbidities affecting women's quality of life because of multiple factors such as increased obesity, physical inactivity, stress and difficulty having access to safe and comprehensive health care, including physiotherapy [ , ] . an early initiation of the rehabilitation process in urogynecology is considered a crucial factor for women's health [ ] . physiotherapy is a profession that focuses on human movement and functionality [ ] , basing its interventions on thorough evaluation of general aspects regarding symptoms and specific aspects related to pelvic floor muscle (pfm) function and dysfunctions in the field of women's health. telehealth services can facilitate public health strategies during the pandemic, offering guidance to patients while preserving social distancing [ ] . according to the world confederation for physical therapy, "digital practice is a term used to describe health care services, support and information provided remotely via digital communication and devices" [ ] . it includes telephone calls, platforms for video calls, video recordings and other forms of contact with technological assistance. the term adopted throughout this manuscript to refer to the practice of digital physiotherapy is telephysiotherapy, although other terms such as virtual physiotherapy can be found in the literature. a number of randomized controlled trials (rcts) have tested the efficacy of telephysiotherapy for some health conditions [ ] . however, pfd in-person physiotherapy treatment involves some specificities, such as dealing with intimate issues, patients' embarrassment regarding their symptoms and the need to perform a pelvic floor muscle examination. these specificities make privacy and ethical issues in this area especially relevant, as there are limitations and concerns when considering telephysiotherapy in urogynecology. nonetheless, telephysiotherapy could provide safe continuity to physiotherapy care in urogynecology. despite this, there are only a few studies addressing telephysiotherapy in the treatment of pfds, and they present promising results [ , ] . although grimes et al. [ ] published excellent guidelines for treating urogynecological patients during the pandemic, their article was not specifically focused on physiotherapy. therefore, this article aims to offer specific guidance regarding physiotherapy in urogynecology during the covid- pandemic. this was a descriptive study proposing guidance and recommendations based on a literature review and a group of experts' opinions about the topic. this document was coordinated by a group of experts who are members of the brazilian association of physiotherapy in women's health (associação brasileira de fisioterapia em saúde da mulher -abrafism). it included representative consultants from the brazilian association of urogynecology and the pelvic floor (associação de uroginecologia e assoalho pélvico -uroginap) and the latin american association of the pelvic floor (associación latino americana de piso pelvico-alapp). the process of discussing and writing the document followed a three-step modified delphi method and took place in june and july . the first step was a literature review, conducted from june to july , , in the following databases: pubmed, pedro, web of science and embase. all searches were restricted to the english and portuguese languages. for all topics, we sought existing systematic reviews and primary studies. we also consulted the guidelines of international associations, such as the world confederation for physical therapy (wcpt), international urogynecological association (iuga) and international continence society (ics). two independent reviewers (acnlf and bmr) performed the selection process for primary studies by reviewing titles, abstracts and reading full texts, based on the previously described proposed inclusion criteria. the reference lists of included studies were screened independently to identify possible studies not retrieved by the electronic search. any disagreements during the selection process were resolved by discussion until a consensus was reached by the group of specialists. the terms used in the search strategy in the pubmed, web of science and embase databases were: (physiotherapy* or "physical therapy*" or rehabilitation) and ("pelvic floor dysfunctions" or "pelvic floor symptoms" or "pelvic floor" or "pelvic floor muscle" or "lower urinary tract symptoms" or "urinary incontinence" or "urinary leakage" or "anal incontinence" or constipation or "fecal incontinence" or "bowel symptoms" or incontinence or "pelvic organ prolapse" or "rectal prolapse" or "vaginal prolapse" or "pelvic prolapse" or "sexual dysfunction" or vaginismus or dyspareunia or "pelvic pain") and ("mobile health*" or e-health or "mobile app*" or "digital health*" or telemedicine or "tele rehabilitation" or telehealth or "telephone-delivered care" or "telephone health*" or "home treatment" or "home-based" or covid- or "covid " or covid or coronavirus). the strategy for the advanced search in pedro was limited by anatomical regions (perineum or genito-urinary system) and discipline (continence and women's health). the following terms were used in "abstract & title": covid, coronavirus, e-health, mobile app, mobile health, digital health, telemedicine, tele rehabilitation, tele health, telephone-delivered care, telephone health and home-based treatment. one search was generated for each term. the second step was performed by a group of experts that discussed issues related to the digital practice of physiotherapy in the treatment of pfd, while another group read the identified manuscripts and guidelines related to the topic. the first group was composed of two women's health physiotherapists (chjf and lrm) and current members of the executive board of abrafism. both professionals have > years of experience working in the area as clinicians and researchers. furthermore, two women's health physiotherapists (eagf and pd) with extensive experience in the field complemented the initial draft with additional modifications. the second group was composed of three clinical physiotherapists with experience of between and years working in the area, who participated in the preparation of the document. in this step, the experts had several online meetings to discuss the findings and vote for the recommendations, with careful attention to the items that presented a disagreement rate > %. the third step involved a final meeting to thoroughly revise the document and propose the final recommendations. in this step, after consensus was reached, the recommendations were grouped according to their similarities and assigned to categories. subsequently, a group of consultants, including two urogynecologists, members of the executive board of uroginap (jh and lgob) and iuga (international urogynecological association), and a physiotherapist specializing in women's health and representing alapp (sb), made additional contributions and approved the recommendations. due to the covid- pandemic, no face-to-face meetings were scheduled. finally, expert consensus was used to create and summarize the following topics: ( ) recommendations about the continuity of physiotherapy care during the covid- pandemic, ethics and regulation issues; ( ) recommendations on physiotherapeutic assessment of pfd symptoms and pfm function using telephysiotherapy; ( ) health education recommendations and specific recommendations about physiotherapeutic interventions for women with pfd during the pandemic; ( ) returning to in-person clinical care. the electronic search returned a total of references and, after the selection process, studies were included in the final analysis (fig. ) . the guidelines proposed four categories of recommendations, as presented below: . recommendations about the continuity of physiotherapy care during the covid- pandemic, ethics and regulation issues. & to provide continuity of care using digital physiotherapy modalities whenever possible. remote monitoring should be considered, especially for women who were already undergoing physiotherapy treatment of urogynecology and proctological symptoms [ , ] . & to discuss with patients the feasibility of performing physiotherapeutic care using digital physiotherapy. & to observe all norms and rules contained in the codes of ethics and deontology of physiotherapy and take into consideration that this may be influenced by each country's specifics as well as specific regulations and/ or standards of service involved and possible new regulations related to the pandemic, even when using digital physiotherapy [ ] . & to consider cultural aspects, technological and personal limitations on the use of technology, patient availability and access to technology, and familiarity of physiotherapists and patients with technological tools [ ] . & to choose the most appropriate digital method, considering the specific case to be treated as well as patient access and preferences. & to be more cautious about privacy of care and storage of patient data. the registration of information and therapeutic exercises must be maintained with extra care, considering the vulnerability of some digital platforms [ ] . & to ensure patient privacy, information accuracy, security and confidentiality. information about the benefits and disadvantages of online care should be made clear to patients [ ] . & to share written guidelines with patients prior to or after the session [ ] . & to comply with privacy and ethics regulations when using any photos of the patient for assessment purposes [ ] . & to inform the patient in advance when recording remote physiotherapy sessions and when recording videos of the body and the posture in general for movement analysis. & to align patient expectations with services and be clear in establishing the specific goals, outcomes and indicators for each virtual meeting, so that the patient also feels in control of their health and involved with the treatment [ ] . recommendations on physiotherapeutic assessment of pfd symptoms and pfm function using telehealth. & history should be taken with a focus on: obtaining as many details as possible about pelvic floor functionality, adding to the voiding diary and validating questionnaires to assess pelvic floor symptom severity and impact on quality of life [ ] . & voiding diary apps can be recommended to women who are willing to use them. the quality of apps should be considered when choosing them as well as translation and validation into the languages to be used [ ] . & attempts to guide complete and accurate remote pfm assessment in clinical practice should be avoided because of the lack of evidence at this time and the impossibility of assessing tonus, strength and endurance of the pelvic floor without an internal examination. & it is important to avoid requesting images and videos involving exposure of women's bodies for remote synchronous or asynchronous evaluation unless their consent is obtained and they are clearly informed about all the limitations and uncertainty regarding the accuracy of the evaluation and the privacy risks involved. & information about women's capacity to contract their pfms can be investigated using alternative methods such as the stop test. it can be explained to women and used cautiously as a means for them to self-assess their pfm contraction capacity as well as the use of terms that can facilitate their capacity to perceive their pfm contraction [ , ] . & the stop test should not be used routinely to perform pelvic floor muscle training (pfmt) [ ] . & instructions for self-palpation can be given to women who culturally accept it, and they should be told to perform it in a private environment and that it should be avoided during real-time video calls [ , ] . & self-estimation of women's ability to contract their pfms seems to be poor, especially in women with weak pfm contraction, meaning that the results should be interpreted with caution [ ] . & to instruct women about general health issues and their influence on pfd using different types of illustrative resources. & to give detailed information about the importance and benefits of physical exercise for weight control, healthy diet, appropriate water intake and prevention of constipation. & to provide women with general self-perception, stretching and relaxation exercises and strategies, considering the anxiety issues involved in this time of the pandemic and their need for strategies to promote their health and well-being. & to counsel women about the use of protectors (absorbents, diapers) and hygienic issues. & to provide women with essential information about pelvic floor function and dysfunction and options for treatment prior to implementing physiotherapy and to educate the general community in order to increase women's knowledge about these topics [ ] . & to use educational illustrations, videos and other resources that can facilitate women's comprehension of pelvic floor contraction. & to consider possible adherence modifiers while conducting health education aiming to improve treatment adherence. the use of health behavior theories is suggested. & women who are able to contract their pfms should be advised to start or continue their pfmt program, considering the same parameters prescribed for them based on exercise physiology principles (frequency, intensity and duration). & whenever possible, sessions should be remotely supervised by the physiotherapist, using synchronic video calls to answer questions, clear up any possible doubts for patients and reinforce instructions for proper exercises [ ] . & if women have limited or no internet access, adherence can be monitored using telephone calls, and motivation could be provided by sending written instructions using e-visits (e-mails). & different options to facilitate pfmt adherence,such as training diaries, phone calls, apps and others, should be indicated based on women's cultural and socioeconomic background, especially when supervised training is not possible. & the use of apps can be an adjunct method for the physiotherapeutic treatment prescribed, based on physiotherapy assessment of patients' profiles. consider patient access, familiarity with the use of technologies, autonomy, level of education and, especially, how much patients like and feel confident in the use of technology. & the quality of pfmt apps should be considered when making recommendations [ ] and should be discussed with women for shared clinical decision-making, considering clinical evaluation and physiotherapeutic objectives [ ] . & physiotherapists must know the functionalities of the many paid and unpaid apps to be able to guide women throughout the entire therapeutic process. & in recommending the use of apps, consider the possibility of performing data extraction, their educational features, availability of reinforcements/reminder systems, self-monitoring, whether the app is free on download platforms and the cost benefit for patients to acquire an app, especially considering their socioeconomic status [ , ] . & consult rcts and the systematic reviews on the topic that investigated different mobile technologies and apps for urinary incontinence. one systematic review concluded there is level evidence of benefits in using mobile technologies to improve ui, patient satisfaction, adherence and costs [ ] . another systematic review included three rcts of low to moderate quality and concluded that mobile apps reduced urinary symptoms [ ] . & give preference to the use of well-evaluated apps according to validated scales for assessing app quality and with demonstrated effectiveness in rcts of good methodological quality [ ] . & women who are not able to contract their pfms need to be informed about the limitations of using all physiotherapeutic resources when receiving telephysiotherapy. the remote options available should be discussed, including giving instructions exclusively using analogies such as videos simulating pfm contraction, self-visualization, self-palpation and the stop test. & prescriptions and instructions for home self-applied electrostimulation, biofeedback and vaginal cones should be carefully analyzed, considering the low level of evidence showing risks and benefits [ , ] . & before recommending the use of any probes or equipment for home use, physiotherapists must pay attention to possible required registration with regulatory agencies in their countries. in addition, clear instructions must be given about issues around cleaning and preventing infection. & bladder training and behavioral treatment should be provided and supervised by physiotherapists, including any types of intervention to delay urination, programmed urination and patient education to modify urination habits. this article offers a list of recommendations for practicing physiotherapy in the treatment of urogynecological conditions throughout the covid- pandemic. the most important recommendation is to, as much as possible, offer continuity of physiotherapy care, using some type of remote service. although this is already part of physiotherapy practice in some places, it might be limited because of physiotherapy regulations or restrictions on internet access and technology in many countries. at this time, the most important thing seems to be the possibility of making contact with patients using whatever remote technology enables physiotherapists to get information about patients' situations and monitor implemented therapies. in many places, the only way to do this is by telephone. another option that should be considered is the use of free platforms for video calls, taking into consideration local physiotherapy regulations and privacy and ethical issues. ethical issues should be looked at very carefully, considering that physiotherapy in women's health deals with sensitive issues that can lead to patients' embarrassment if there are breaches of confidentiality. despite the many challenges, the literature has described many advantages of telephysiotherapy, including encouragement of self-management, increases in flexibility for healthcare delivery and decreases in sick-leave duration [ ] . other possible advantages include reduced costs to transport patients and physiotherapists to health services, a possible increased number of sessions if necessary, time saved for patients waiting to be treated and being able to assist patients from distant locations. it is an opportunity for physiotherapists to work creatively using technology, valuing the evaluation of aspects of the patients' history and habits, communication skills and provision of instructions to help them change life habits and adhere to treatment [ , ] . furthermore, the accuracy of assessment tests and efficacy of treatment have been investigated and confirmed in different areas of physiotherapy [ ] . however, only a few studies have investigated the efficacy of telephysiotherapy in the treatment of pfd. although small rcts have shown promising results for some remote interventions, such as home pfmt and lifestyle interventions, there is not strong evidence about the efficacy of this format for treatment. a few small studies on the use of home electrostimulation and biofeedback to treat urinary and fecal incontinence in women have achieved good results, but they present high risk of bias, and the patients had previously been trained to self-use the devices [ ] . additionally, the devices have established protocols, allowing patients to manipulate only current intensity. it is essential for physiotherapists to know patients' profiles and include them in the clinical decision-making process and to balance the cost-effectiveness of treatments. the role of physiotherapists includes more than the use of therapeutic resources, such as electrical stimulation and manual therapy; it also involves aspects related to interactions with patients, communication skills, and selection and use of combined therapeutic resources based on the physiotherapist's assessment of patients. all these comprehensive aspects have the potential to impact the results of telephysiotherapy compared to in-person sessions. future pragmatic rcts should further investigate the efficacy of telephysiotherapy in the treatment of uroginecological problems, since the literature related to this topic is still scarce. pelvic floor muscle training is the first-line treatment for non-neurogenic ui and mild and moderate pelvic organ prolapse [ ] . there are many remote synchronous and asynchronous ways for physiotherapists to prescribe and monitor individualized digital sessions of pfmt. however, it does not seem to currently be possible to accurately and completely carry out pfm assessment using digital technologies. the most critical limitation when using telephysiotherapy is assessment of women's capacity to contract their pfms. even with this limitation, pfmt should be prescribed, since at least a proportion of women who are not able to contract their pfms in the first assessment will acquire this ability by receiving proper instructions on how to do so exclusively in this format [ ] . when considering the use of the stop test or any devices, such as vaginal cones and all types of home biofeedback, physiotherapists must provide very clear instructions to patients regarding proper use and safety issues. patients should be informed that performing pfmt by stopping the urine stream is not recommended, because it can potentially disturb the neurophysiological bladder voiding mechanism and increase the risk of urinary infection [ ] . the return to in-person physiotherapy will require additional care to protect physiotherapists and patients. this article offered some guidance related to this issue. however, local epidemiological situations and sustained declines in the number of covid- cases must be taken into account for a safe return of face-to-face care. some limitations of these guidelines must be highlighted, starting with the short time during which the study was carried out and the absence of specific studies on the topic. this led to recommendations based on expert opinion, combined with no or low levels of evidence. however, it was possible to offer some guidance to professionals working in the area and also indicate some directions for future research on telephysiotherapy in urogynecology. telephysiotherapy will not be a feasible option for all patients, but it provides opportunities to offer continuity of care to at least some patients and to advance knowledge and clinical practice in this field. the challenges imposed by the pandemic may lead to greater appreciation of the communicative and educational abilities of physiotherapists. the present study provided some guidance for continuity of the work of physiotherapists in urogynecology during the covid- pandemic, considering the world health organization recommendations and the epidemiological public health situation of each region. telephysiotherapy is an option for continuity of care during the pandemic, especially considering that education is a large component in physiotherapy, opening new perspectives for the development of practice and research in urogynecology and pelvic health. funding coordenação de aperfeiçoamento de pessoal de nível superior -(capes)-finance code . prevalence of symptomatic pelvic floor disorders in us women association of all-cause mortality with overweight and obesity using standard body mass index categories dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis a guide for urogynecologic patient care utilizing telemedicine during the covid- pandemic: review of existing evidence using telehealth to reduce all-cause -day hospital readmissions among heart failure patients receiving skilled home health services report of the wcpt/inptra digital physical therapy practice task 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urinary incontinence: effectiveness of two treatment programmes focused on pelvic floor muscle training, one booklet and one internet-based. scand j prim health care pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women content and functionality features of voiding diary applications for mobile devices in brazil: a descriptive analysis physiotherapy methods to facilitate pelvic floor muscle contraction: a systematic review chapter : pelvic floor and exercise science: motor learning do women have an accurate perception of their pelvic floor muscle contraction? a cross-sectional study an education program about pelvic floor muscles improved women's knowledge but not pelvic floor muscle function, urinary incontinence or sexual function: a randomised trial effectiveness of pelvic floor muscle training and bladder training for women with urinary incontinence in primary care: a pragmatic controlled trial evaluation of smartphone pelvic floor exercise applications using standardized scoring system appsolutely fabulous? -the quality of pfmt smartphone app content and design rated using the mobile app rating scale, behaviour change taxonomy, and guidance for exercise prescription home-based versus office-based biofeedback therapy for constipation with dyssynergic defecation: a randomised controlled trial mobile technologies for the conservative self-management of urinary incontinence: a systematic scoping review use of mobile apps for controlling of the urinary incontinence: a systematic review digital physical therapy in the covid- pandemic the efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis effects of three interventions in facilitating voluntary pelvic floor muscle contraction in women: a randomized controlled trial publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations disclosures the authors completed the icjme form for disclosure of potential conflicts of interest and reported no conflicts of interest.ethics approval not applied. key: cord- -igo dbs authors: sweida, gloria; sherman, cynthia l. title: does happiness launch more businesses? affect, gender, and entrepreneurial intention date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: igo dbs in one of the first studies to examine how positive affect, negative affect, gender, and gender roles interact with entrepreneurial intention, we conducted an online survey of adults from the western, midwestern, and southern regions of the united states. a higher positive affect was associated with greater intention to start a business, however, lower levels of negative affect were not. as in previous studies, women showed less entrepreneurial intention than men, however, the presence of positive affect had a larger positive impact on women’s entrepreneurial intention than men’s. contrary to expectations, acceptance of traditional gender roles interacted with entrepreneurial intention such that women’s entrepreneurial intention increased as their support of traditional gender roles increased, and for men, entrepreneurial intention decreased slightly as acceptance of traditional gender roles increased. as we explore the myriad of ways that affect, emotion, and mood drive human behavior, particularly in the workplace [ , ] , we also find ways by which they drive entrepreneurial behavior. many research teams have investigated the role played by the broad construct of affect in entrepreneurship. while many studies conflate the states of emotion and mood with trait-level affect, some researchers have argued that an individual's frequent experience of positive emotions and positive moods is not meaningfully distinguishable from dispositional or trait-level affect [ ] [ ] [ ] . in their study, watson et al. [ ] asked respondents to estimate their mood states across both short and long time frames, and because of the strong relationship between trait-level affect and emotional experiences based on shorter time frames, we feel confident in drawing upon the literature that includes measures of emotion, mood and affect, which we will include under the general term "affect". baron [ ] considered the role of affect in decision-making, opportunity identification, and coping with adversity, all of which are important aspects of the entrepreneurial process. cardon et al. [ ] considered positive affect a key component of entrepreneurial passion, which is connected to persistence and creative problem solving, and therefore positive outcomes for nascent ventures. further, other research teams have found that entrepreneurs report high work and life satisfaction [ ] [ ] [ ] . affect may also play a role in successive entrepreneurial endeavors because of the connection to entrepreneurial passion and persistence [ , ] . stenholm and nielsen's [ ] study looked at how entrepreneurial passion was created from emotional support. they found that emotional support helped to create positive emotions that helped entrepreneurs to engage with their environment, changing their perceptions of the environment, ideas, and persons more favorably, as described by fredrickson's broaden and build theory [ ] . human behavior is guided by emotion, mood, and more broadly by affect [ , ] . affect, emotion, and mood are often conflated; however, affect refers to a more general state of consciously accessible feelings [ , ] . in contrast, emotions are defined as a response to a stimulus, unfolding over a relatively short time [ , ] . moods are defined as somewhat stable background sensations that are not associated with a particular stimulus [ , ] . affect, more generally, can be considered the accumulation of the experience of positive or negative moods and emotions. the creators of the widely used positive and negative affect scale (panas), watson and colleagues [ ] , created the panas as a two-factor construct, therefore, one can have positive and negative emotions at the same time. they also determined that emotions and moods are indeed generally reflective of one's dispositional-level affect. as such, even though both positive and negative affect can be conceived as both a state and trait, in this study, we study trait/dispositional-level affect. [ , ] . affect is a form of information that influences cognitive processes such as perception, judgment, decision, memory, creativity, and coping with stress [ ] . schwarz and clore's [ ] affect as information theory suggests that positive or negative affect act as categories for organizing experiences and making similar material easier to retrieve. several researchers have utilized this theory [ , , ] to posit that affect impacts cognition by priming memories and associations, and by serving as a heuristic for classifying and responding to objects, ideas, and people. positive affect includes emotions such as joy, hope, and inspiration [ ] . positive affect facilitates approach behavior and prompts people to engage with their environment. engaging with one's environment tends to facilitate the acquisition of resources in the external world [ ] . the resources accrued during states of positive emotions outlast the transient emotional states that led to their acquisition. the positive emotions can lead to the urge to explore the environment, take in new information, and expand the self [ , ] . from an entrepreneurial perspective, for instance, this could lead to creative ideation or a playful investigation that might lead to a new product or business. therefore, the often-incidental effect of experiencing a positive emotion has the impact of leading to an increase in one's resources [ ] which can positively impact one's overall personal, psychological, professional, and physical well-being. positive affect also helps build social capital and psychological well-being, which leads to personal growth, meaningful goals, and self-acceptance [ ] . additionally, those with more positive affect experience more positive outcomes in work, health, and relationships [ , , ] . this may be because positive affect serves as a conduit for the integration of new ideas into current knowledge. the new knowledge can inspire innovative and creative thinking about goal attainment. positive affect broadens thinking and enhances resilience and the ability to cope with challenging situations [ , ] . positive emotions, over time, may loosen the hold that negative emotion has on one's reactions to events, such as the flee response to something fearful. positive affect can broaden a person's momentary thought-action repertoire to include ideas of play or exploration. positive affect also yields better health outcomes, as the frequent experience of positive emotions yields a faster recovery time from cardiovascular stress, lessening damage to the body over time [ ] . positive affect influences several key entrepreneurial processes. trope and colleagues [ ] found that positive affect positively impacted general decision making. george and zhou [ ] revealed a relationship between positive affect and entrepreneurial creativity and ideation. positive affect also positively predicts opportunity recognition [ , ] . positive affect influences outcomes for business, as well. baron and tang [ ] found that higher degrees of positive affect predicted sales growth and innovation. they also found that the benefits of positive affect influenced smaller entrepreneurial ventures more than larger ventures. cardon and colleagues' model of entrepreneurial passion emphasizes the role of high-activation positive affective states such as joy, energy, excitement, and enthusiasm. these states lead to key performance outcomes for the health of the nascent organization. furthermore, an entrepreneur's energy leads to persistence in the face of adversity [ ] . the entrepreneur's absorption in the activities of venture creation results in higher quality products and services. the entrepreneur's ability to solve problems also creatively helps the organization carve its niche in the marketplace. the mechanism behind these outcomes can be explained through broaden and build theory [ ] . building on affect-as-resource theory and affect-as-information theory [ , ] broaden and build theory suggests that positive affect broadens thought-action repertoires and acts as a resource that helps one persist and learn from negative information [ ] . entrepreneurship entails risk and reward and is fraught with dangers and uncertainty. however, positive affect is not the only source of information for entrepreneurs; negative affect may also play a role. brundin and gustafsson [ ] found that entrepreneurs' likelihood to persist in a failing project increased with increased positive emotion (hope, self-confidence, and challenge in their study) and decreased with stronger feelings of embarrassment, frustration, and strain. negative affect includes emotions such as anger, fear, shame, and nervousness [ ] . negative emotions exist independently of positive emotions and can, therefore, be experienced at the same time as positive emotions [ ] . affect-as-information theory suggests that negative affect informs a person that things are not going well [ ] . negative information represents a potential threat to survival, as it is attended to and processed more thoroughly than positive emotions [ ] . even though entrepreneurs experience fewer negative emotions than those who work for wages [ ] , successful management of negative emotions is a key factor in successful entrepreneurship [ ] . because entrepreneurs have more decisional autonomy than people who are employed by others, they can use more problem-focused coping mechanisms to overcome adversity [ ] . overall, a mix of positive and negative emotions may be optimal for entrepreneurship. mixed and conflicting emotions are an important predictor of risk perception, which helps people avoid the common trap of overconfidence [ ] . baron [ ] found that an excess of positive affect yielded diminishing returns, with a medium amount of positivity being optimal. while positive affect enhanced leaders' abilities to recognize entrepreneurial opportunities, too much positive and negative affect both lowered their likelihood of acting on those opportunities [ ] . birthed by bird's [ ] conception, eints shape the form, direction, and development of an organization. it links the entrepreneurs' ideas and attitudes to their entrepreneurial behavior. thompson [ ] added that while conviction and planning are essential to eint, actual venture creation is not. this is because entrepreneurial activities are rare and difficult to measure. for example, what constitutes "planning"? is it the spark that ignites the thought or feeling that starting a business would be desirable or does a formal business plan need to be in place? even though business start-up may not be the inevitable outcome, eint is a strong predictor of behaviors [ ] and is measured as a continuous versus dichotomous variable. this explains its use not only as a proxy for entrepreneurial behavior but also, as thompson [ ] suggests, as a construct that can stand on its own and be used as an independent and control variable. the theory of planned behavior (tpb) [ ] is one of the most cited unidirectional models of intention. according to tpb, three factors, social norms, attitudes and perceived control, work in concert to influence the intention to act. social norms refer to the perceived acceptance or aversion toward a specific behavior of those the target deems important in their immediate social environment. attitudes are the target's judgments and evaluations of the behavior. lastly, perceived control is consistent with self-efficacy, the belief in one's capability to perform specific tasks. using the tpb framework to describe conscious intent, we define eint as the desire and plan to start a business. affect-as-information theory [ ] suggests that affect attunes people to the safety of conditions in their environment. positive affect tells people all is well and they can relax, while negative affect leads people to search their environment for threats. therefore, positive affect may tend to make people approach new situations more confidently, making them more likely to move forward with starting a business. this leads us to the hypothesis: hypothesis a (h a): higher positive affect is correlated with higher eint. further, negative affect may heighten people's estimation of threats to successful entrepreneurship, making would-be entrepreneurs less willing to trust their vision, and therefore less likely to create new ventures. therefore, we propose that: hypothesis b (h b): higher negative affect is correlated with lower eint. an extant amount of research highlights interest in investigating the role of gender in entrepreneurial processes [ ] [ ] [ ] [ ] [ ] . even though research has resulted in some mixed findings [ , ] when comparing women and men's eint, copious research indicates that women report lower eint compared to men [ , , , ] . the main reasons cited for differences between men and women's eint are ( ) perceptions that the characteristics necessary for successful entrepreneurship are stereotypically male, ( ) lack of training for women, ( ) unfavorable economic and social environments for women, ( ) lack of education for women, and ( ) a lack of entrepreneurial self-efficacy among women [ , ] . regardless of why this occurs, we have no reason to expect this study to be inconsistent with the abundance of past studies supporting a lower reported eint of women compared to men. however, a better understanding of influential factors on eint is an important step to closing the gap. hypothesis a (h a): women will report lower eint than men. social constructivist theories suggest that social norms and roles regulate emotions by signaling appropriate and valued responses [ ] . social roles held by men and women heighten sex differences in emotions and social behavior between men and women [ ] . as suggested by eagly and wood [ ] , men and women are likely to possess sex-differentiated skills, beliefs, and subjective experiences that enhance the enactment of sex-typed social roles [ ] . for example, women are socialized at an early age to be nurturing and develop verbal skills whereas men are encouraged to be aggressive and develop math skills. these socialization norms are reinforced through parents, media, and peers [ ] [ ] [ ] [ ] [ ] [ ] . consistent with social role predictions, women experience and display emotions congruent with expectations of their gender. women report experiencing pleasant stimuli such as happiness more intensely than do men [ ] [ ] [ ] . additionally, women also suppress negative emotions and display positive emotions more than men [ ] . alexander and wood's [ ] review of research highlights that women report more intense positive emotions than men, they more frequently express such emotions to others, and they respond more extremely to certain psychophysiological measures. thus, if women experience positive emotions more intensely, suppress negative emotions, and display positive emotions more than men, we suggest that they will confer the benefits of an approach mindset and process opportunities more readily than men. the benefits of positive affect, such as broadening one's mind to possibilities, may open them to the idea of starting a business more easily than men. therefore, we expect positive affect to enhance eint. however, we expect this relationship to be greater for women than men because women's socialization and past gender-role-related experiences are likely to instill subjective positive emotions and ways to respond to emotions that are congruent with their gender. hypothesis b (h b): positive affect will moderate the relationship between gender and eint, such that it will be more influential on women's eint than men's. role congruity theory suggests that entrepreneurship would be challenging for women because the role of the entrepreneur is male-typed [ , ] and contrary to that of the stereotypical female gender role, whereas the male stereotype of entrepreneurship would confer a benefit for men. numerous gender stereotypes surround women and are based on perceptions of what women's roles are: from women's views on education [ ] to having nurturing personalities [ ] , which construct the way women approach career-related decisions. examples of traditional gender roles would be that males are breadwinners and leaders of the family, whereas women are the homemakers and caretakers of the family. consequently, acceptance of traditional gender roles may provide a boost for entrepreneurial men but a hindrance for women. therefore, we hypothesize the following: hypothesis (h ): acceptance of traditional gender roles moderates the relationship between gender and eint such that stronger acceptance of traditional gender roles increases men's eint and decreases women's eint. the data used for this paper were part of a larger study that utilized an internet-based survey and examined multiple constructs including eint, acceptance of traditional gender roles, career choice, entrepreneurial industry interest, positive and negative affect, marketing strategies, and kidpreneur activities. the present study explored positive and negative affect, eint, gender, and acceptance of traditional gender roles. the following is the full set of procedures used to administer the survey in the original study. a convenience sampling method was used to recruit participants for the original study in . recruitment efforts included posts on social media such as facebook and linkedin, referrals from friends, family, associates, as well as undergraduate and graduate students from four colleges in the midwest, south, and western parts of the united states. all students (n = ) were offered a maximum of % extra-credit to take the survey. upon completion of data collection, the sample consisted of n = subjects. cases were examined for missing data and cases were removed because of missing responses. the sample was narrowed to those responding as male or female, as only three participants identified as bigender. this left a usable sample size of n = cases. the ethnic diversity of the sample was homogeneous in that most participants ( . %) identified as caucasian. the ages of the participants ranged from to years with a mean of . years (sd = . ). only about a quarter of the participants had earned an undergraduate or graduate degree ( . %), % had completed some college, and about % had earned an associate's degree. lastly, participants had attempted to start at least one business or made at least one attempt to earn money in a self-employed way as an adult (m = . , sd = . , ra = - or greater). dispositional affect was measured using the -item international positive and negative affect scale (i-panas-sf; thompson, ) , an international shortened version of the panas [ ] . the stem question, "thinking about yourself and how you normally feel, to what extent do you generally feel:" was followed by five items for the positive affect scale and five items for the negative affect scale. eint was measured using thompson's -item eint measure [ ] , which has three items reverse-coded and four filler items and was assessed on a five-point likert scale ( = does not describe me; = describes me extremely well). two sample items include: i intend to set up a company in the future, and i never search for business startup opportunities. the cronbach alpha was . for this measure. brown and gladstone's [ ] short version of the gender role beliefs scale was used to assess the strength of participants' acceptance of traditional gender role ideology. this measure has ten items. one of the ten items is reverse-coded. the measure used a one (strongly disagree) to (strongly agree) likert scale. examples of items from this measure include: ( ) women should be concerned with their duties of childbearing and house tending, rather than with the desires for professional and business careers, and ( ) swearing and obscenity are more repulsive in the speech of a woman than a man. cronbach alpha for this measure reached . . the analysis (see table ) showed several significant correlations among the independent, dependent, and two demographic variables. positive and negative affect were negatively correlated with each other, r = − . , p < . . eint had a significant and positive correlation with positive affect r = . , p < . . and a significant negative correlation with negative affect r = − . , p < . . this suggests that both higher levels of positive affect and lower levels of negative affect are associated with greater intention to start a business. of note in the demographic variables, the number of business started was significantly and positively correlated with age (r = . , p < . ), education (r = . , p < . ), and eint (r = . , p < . ). in all the following analyses, the number of businesses started as an adult was the only control variable. this was done because age, education, the number of businesses started were correlated and because research shows prior business ownership to be predictive of eint [ , ] . as shown in [ ] , centering variables to mitigate potential threats of multicollinearity in unnecessary. however, we have done this to alleviate concerns. furthermore, as can be seen in table , the correlations between variables are fairly small. therefore, the threat of multicollinearity is mild at best. hypothesis a stated that positive affect would lead to higher levels of eint and hypothesis b stated that negative affect would lead to lower levels of eint. hierarchical linear regression was conducted to test these hypotheses. eint was entered as the dependent variable, positive and negative affect were entered as the independent variables, and the number of businesses was the control variable. the overall model was significant f( ) = . , p < . . as can be seen in table , the model explained twelve percent of the variance in eint, r = . , p < . . positive affect was a significant predictor of eint, unstandardized b = . , se b = . , t( ) = . , p < . . however, negative affect did not predict eint (p > . ). therefore, we found support for hypothesis a but not for hypothesis b. hypothesis a stated that women will report lower eint than men and hypothesis b argued that positive affect will moderate the relationship between gender and eint, such that it will be more influential on women's eint than men's. ordinary least squares regression was used to test these hypotheses by employing hayes process macro-regression analysis (model ). a -bootstrap sample was conducted to test this hypothesis [ ] . gender was coded zero for male and one for female. controlling for the number of businesses, eint was entered as the dependent variable and gender as the independent variable and positive affect as the moderator. the overall model was significant f( , ) = . , p < . , and explained sixteen percent of the variance r = . (see table ). examination of the unstandardized coefficients revealed a significant main effect for the number of businesses started, b = . , se b = . , t( ) = . , p < . . this result suggests that for each additional attempt at business ownership, eint is predicted to rise . (one-tenth) of a unit. there was also a significant main effect for gender, b = − . , se b = . , t( ) = − . , p < . . lastly, the interaction was also significant b = . , se b = . , t( ) = . , p < . . based on the negative coefficients, the mean scores for eint by gender (male mean = . , sd = . ; female mean = . , sd = . ) and the regression slopes which show a steeper slope for women than men, shown in figure , show that women report lower levels eint and that positive affect positively influences this relationship. therefore, hypothesis a and hypothesis b were supported. hypothesis stated that stronger acceptance of traditional gender norms would moderate the relationship between gender and eint, such that, as acceptance of traditional gender roles increases, men's eint also increases, and women's eint decreases. ordinary least squares regression was used to test these hypotheses by employing hayes process macro-regression analysis (model ). a -bootstrap sample was conducted to test this hypothesis [ ] . gender was coded zero for male and one for female. controlling for the number of businesses participants started as adults, eint was entered as the dependent variable, gender as the independent variable, and acceptance of gender roles as the moderator. as can be seen in table , the overall model was significant f( ) = . , p < . and explained percent of the variance in eint, r = . , p < . . examination of the unstandardized coefficients revealed that there was a significant main effect for gender b = − . , se b = . , t( ) = − . , p < . and acceptance of gender roles b = . , se b = . , t( ) = . , p < . . this result suggests that for each additional step in acceptance of traditional gender roles eint is predicted to rise . (one-seventh) of a unit. a significant interaction was found between acceptance of traditional gender roles and gender, b = . , se b = . , t( ) = . , p = . . the interaction explained an additional five percent of variance (p = . ). however, the interaction was in the opposite direction (see figure ) than hypothesized. for men, eint decreased slightly as acceptance of traditional gender roles increased. the slope was steeper for women and was also in the opposite direction, as predicted. women's eint increased as their support for traditional gender roles increased. therefore, hypothesis was not supported. . *** note: business started as adult response range , , , , , , , , , +; stgr = support for traditional gender roles. * p < . , ** p < . , *** p < . . this study adds to the research about entrepreneurial affect by relating positive and negative affect to eint. this approach considers positive and negative affect to be relatively independent dimensions [ ] . our results extend the few other studies examining affect and eint, by demonstrating that higher positive affect is associated with higher eint and that positive affect influences women's eint more than men's. positive affect fuels resilience, which helps entrepreneurs to persevere in deciding if a problem is worth solving, and then solving it [ ] . the ability to persevere and decide where to spend your personal and financial resources is a critical factor in entrepreneurial success. using the broaden and build theory, the development of emotional and interpersonal relationships is consistent with long-term success in entrepreneurship. congruent with affect-as-information theory, positive affect can act as a resource for perseverance through adversity, which is critical to entrepreneurial success. however, our results did not show that higher levels of negative affect were related to lower eint. the relationship of negative affect to eint has not been well studied in previous work. when positing on the relationship, we thought that a higher negative affect may deter potential entrepreneurial motivation. however, in this study, higher negative affect was not related to lower eint. the correlational analysis revealed a statistically small and negative relationship between the two constructs, however, enough variance was consumed by prior business experience during the regression analysis, for it to become not significant. opportunities to engage in entrepreneurship may counteract the effects of negative affect, by providing mastery experiences. mastery experiences allow people to learn and improve and thereby increase confidence [ ] and motivation. in this way, negative affect may support systematic thinking that enables more focused attention on problem solving and opportunity recognition [ ] [ ] [ ] . as negative affect is an inevitable part of the journey of entrepreneurship, successfully coping with negative emotions is an important part of the successful entrepreneurship trajectory [ ] . our result showing that women's eint is lower than men's eint is consistent with previous work [ , , , ] . however, our novel finding that positive affect has more impact on the eint of women than of men suggests that women can confer a benefit from stereotyping. women are socialized to display more positive affect, therefore experiencing positive affect allows them more congruency with their gender role, making the road to entrepreneurship smoother. as for the surprising result regarding the non-relationship between acceptance of gender roles and eint, we recognize three possible explanations. first, women may report the belief that traditional gender roles should exist [ ] yet consider entrepreneurship from a feminized perspective. for example, entrepreneurship can be used to supplement the household income. based on the larger dataset from which these data were drawn [ ] , it was found that women tended to report the desire to start businesses in more feminized industries that are amenable to income replacement versus wealth generation. second, a shift in entrepreneurship may allow for easier entry and the ability for women to start a business and maintain a more traditional female gender-role. technology has democratized internet access, which enables entrepreneurs to tap into a larger audience of potential buyers than ever before and has made the location of the business almost irrelevant. both factors allow women more flexibility to work around family duties. perhaps this shift is changing entrepreneurship from a rarefied pursuit, only for the well-financed and well-connected, to one enabling women to connect with entrepreneurship in a way that is more congruent with stereotypical female gender roles. third, meta-analysis shows that gender roles and stereotypes are changing around perceptions of women's roles [ ] . as such, staying at home to take care of the family and home as women's only responsibility may be fading from the female stereotype. additionally, it may be that stereotypes about women in entrepreneurship are changing [ ] , or at least being cognitively neutralized [ ] . the women in gupta and colleagues' study [ ] showed that women, unlike their male counterparts, perceive entrepreneurs to have male and female characteristics. imbuing the idea of entrepreneurship with female characteristics may allow women to reconcile cognitive dissonance between their gender-role and the entrepreneurial role. these results are relevant for leadership and entrepreneurial training programs, especially those aimed at women. building positive emotions over time can lead to more positive affect [ , ] . focusing on providing positive experiences and producing higher positive affect within programs can help women increase their self-efficacy and increase the chances for successful entrepreneurship, thereby, increasing benefits to society such as job creation, new markets, and innovation. for example, an examination of emotion in leadership training sessions for entrepreneurs [ ] revealed that when entrepreneur participants spoke of their companies, they used language that was more emotive than rational, particularly if they were speaking about their fear of failure. part of the emotional salience sprang from the fact that the entrepreneurs' identity was entwined with their business. in the second day of training, the entrepreneurs engaged in difficult and potentially frustrating activities. during the debrief, the participants realized that they were being manipulated in order to understand their emotions and that, framed appropriately, the experienced emotions became an impactful and remembered part of the training [ ] . early entrepreneurial training which teaches the core tenets of business ownership (e.g., market research, strategy, or finance) can include stories of and learning from other successful women who are small business owners, entrepreneurs, or serial entrepreneurs. some research shows that the development of women's entrepreneurial self-efficacy can be contextual to size of business, industry of the business, and the level of female representation within an industry [ ] . understanding the lessons learned from successful launches by other women entrepreneurs will encourage positive affect through hope and inspiration. the increase in positive affect will increase self-efficacy via vicarious learning and social persuasion [ , ] . furthermore, positive affect can lead to more openness to new ideas, in turn building resources to use in future problem-solving. women entrepreneurs can use those resources in new and creative ways to implement feasible solutions and in opportunity recognition or venture creation [ , ] . building positive affect during training is the start of what can flourish into positive outcomes for the would-be business, such as sales growth and innovation. this is an important factor because many women tend to migrate to industries with little growth that are not attractive candidates for financing [ ] . negative affect is not a barrier to future action, but rather information about challenges that need solving. focusing attention on negative affect in training can include role-playing of difficult emotional conversations and discussions of venture failure [ ] . in this way, would-be entrepreneurs are not blind-sided by the intensity of feelings that they may experience in creating their business. in sum, opportunities to broaden thought repertoire can lead women to consider new ideas and ways of doing business and help dispel the myths about women entrepreneurs [ ] , such as not having the financial savvy or resources to start high-growth businesses, or that women do not have the right kinds of experiences. the main strength of this research is that we add to the literature examining positive and negative affect, eint, and gender which, to our knowledge, have never been studied simultaneously. another strength can also be considered a limitation: the utilization of a homogeneous sample. our sample was predominately students from state universities and professional adults across the united states. according to a study from the ewing marion kauffman foundation, most entrepreneurs find that a college education is important [ ] and most entrepreneurs have studied in college, even if they have not received a degree. therefore, our sample may be representative of would-be entrepreneurs. when researchers are limited to convenience samples, homogeneous samples convenience samples are a positive alternative because they can generalize to a subpopulation [ ] . however, this strength is, of course, also a limitation, as we discuss. a convenience sampling procedure was used to recruit participants and a large portion of the sample were students from state universities and professional adults across the united states. as with all samples of convenience, the benefits of ease of access to participants and relatively low cost for researchers on a shoe-string budget must be weighed against the disadvantages of lack of generalizability to the population as a whole, under-or over-representation of the population, and biased results based on participants' willingness to take part in the research. as stated earlier, entrepreneurs consider education important and have engaged in some higher education [ ] . therefore, the sample for this study is reasonably generalizable to an american college-educated population and would-be entrepreneurs but not to the population as a whole. another limitation of the study, as with survey studies, is the potential for common methods bias. common methods bias has been defined as "response tendencies that raters apply across measures, similarities in item structure or wording that induce similar response, the proximity of items in an instrument and similarities in the medium, timing, or location" ( [ ] , p. ). since positive and negative affect and eint data were collected at the same time in this study, temporal separation was not available between the measurement of positive and negative affect and eint variables. future research can provide more granularity on why women are less likely than men to engage in entrepreneurial activities. a longitudinal study to better assess eint and positive and negative affect over time could help disambiguate how affect, emotion, and mood impact eint. the current economic environment in response to covid- shows women's unemployment to be . %, while men are at . % [ ] . although many men are stepping up to increased responsibilities in the home during lockdown, including childcare and schooling, women still bear the largest burden for these tasks [ ] . this pandemic may change how women see entrepreneurship, create opportunity for online learning situations, as mentioned in the practical implications, and even provide more opportunity for digitally based businesses. entrepreneurs are necessary to both global and local economies in that the personal risks they take create new jobs, explore new markets, and contribute to innovation. by any measure, entrepreneurship is stressful. more positive affect can help entrepreneurs build resilience, positively adapt to stressful situations, and tolerate ambiguity. potential entrepreneurs, and particularly women, will have more tools to use in uncertain times. by casting more light on the ways that affect impacts entrepreneurship, we can help create stronger companies, more meaningful work, and reap the full benefits of entrepreneurship. emotions in the workplace affective events theory: a theoretical discussion of the structure, causes and consequences of affective experiences at work intraindividual and interindividual analyses of positive and negative affect: their relation to health complaints, perceived stress, and daily activities development and validation of brief measures of positive and negative affect: the panas scales the role of affect in the entrepreneurial process the nature and experience of entrepreneurial passion negative emotions of an entrepreneurial career: self-employment and regulatory coping behaviors entrepreneurs' mental health and well-being: a review and research agenda health of entrepreneurs versus employees in a national representative sample understanding the emergence of entrepreneurial passion. the influence of perceived emotional support and competences the role of positive emotions in positive psychology: the broaden-and-build theory of positive emotions beyond hubris: how highly confident entrepreneurs rebound to venture again the importance of being emotional: how do emotions affect entrepreneurial opportunity evaluation and exploitation? entrepreneurial intention: the role of gender gender-role orientation as a determinant of entrepreneurial self-efficacy affect, mood, and emotions mood, misattribution, and judgments of well-being: informative and directive functions of affective states want information: how mood and performance perceptions alter the perceived value of information and influence information-seeking behaviors feelings as information: informational and motivational functions of affective states groundbreaking research reveals how to embrace the hidden strength of positive emotions, overcome negativity, and thrive flow: the psychology of optimal experience self-determination theory and the facilitation of intrinsic motivation, social development, and well-being employee well-being in organizations theoretical model, scale development, and cross-cultural validation will you be there for me when things go right? supportive responses to positive event disclosures the benefits of frequent positive affect: does happiness lead to success? stress, positive emotion, and coping mood-as-a-resource in processing self-relevant information understanding when bad moods foster creativity and good ones don't: the role of context and clarity of feelings the integrating self 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entrepreneurial propensity of women does gender matter? our entrepreneurial future: examining the diverse attitudes and motivations of teens across gender and ethnic identity asian and minority ethnic female business owners: discrimination and social support influences of gendered institutions on women's entry into entrepreneurship the social construction of emotion: with special reference to love explaining sex differences in social behavior: a meta-analytic perspective the origins of sex differences in human behavior: evolved dispositions versus social roles gender schema theory and its implications for child development: raising gender-aschematic children in a gender-schematic society the sex-typing of children's household labor: parental influence on daughters' and sons' housework how parents raise boys & girls social cognitive theory of gender development and differentiation understanding women's educational and occupational choices: applying the eccles et al. model of achievement-related choices gender constructs and career commitment: the influence of peer culture on women in college the role of culture and gender in the relationship between positive and negative affect gender and emotions a multilevel field investigation of emotional labor, affect, work withdrawal, and gender the making of the female entrepreneur: a discourse analysis of research texts on women's entrepreneurship how ideology shapes women's lives structure of gender stereotypes: interrelationships among components and gender label development of a short version of the gender role beliefs scale evaluating the impact of prior experience in entrepreneurial intention impact of prior entrepreneurial exposure on entrepreneurial intention-cross-cultural evidence multicollinearity is a red herring in the search for moderator variables: a guide to interpreting moderated multiple regression models and a critique of iacobucci introduction to mediation, moderation, and conditional process infusing positive emotions into life: the broaden-and-build theory and dual-process model of resilience self-efficacy: toward a unifying theory of behavioural change how affect relates to entrepreneurship: a systematic review of the literature and research agenda affective influences on judgments and behavior in organizations: an information processing perspective mood as information development of the gender role beliefs scale (grbs) lemonade and lawns: gendered kidpreneur activities and gendered adult entrepreneurial intentions. unpublished work gender stereotypes have changed: a cross-temporal meta-analysis of us public opinion polls from the role of gender stereotypes in perceptions of entrepreneurs and intentions to become an entrepreneur an investigation into the role of emotion in leadership development for entrepreneurs comparing the development of entrepreneurial self-efficacy of female entrepreneurs in male-and female-dominated industries the diana project: women business owners and equity capital: the myths dispelled a symbol of women entrepreneurs' hunt for knowledge, money, and the rewards of entrepreneurship the anatomy of an entrepreneur: making of a successful entrepreneur to prosper, organizational psychology should overcome methodological barriers to progress this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord- - hy uxpf authors: nelson, anita l. title: pulling back the curtain on trends in contraceptive use in recent years: what can we predict for the future? date: - - journal: f s rep doi: . /j.xfre. . . sha: doc_id: cord_uid: hy uxpf nan ( ) they report increases in the utilization of both contraceptive implants (particularly by adolescent women) and intrauterine devices, and decreases in the use of oral contraceptives and permanent contraception. they also report that the percent of sexually active women who use no method remained stubbornly unchanged at %. the overall % increase in use of iuds and implants seen in this study between - extends the . % increase seen between - . it would be reasonable to ask if these trends predict future increases in women's use of these highly effective and safe methods. however, analyzing the forces that were responsible for this observed growth, one wonders if these rates might actually represent a high-water mark. enthusiasm for iuds and implants clearly grew in the wake of the choice study, which demonstrated high rates of acceptance of iuds and implants, their superior pregnancy protection and their high continuation rates. three quarters of subjects chose iuds or implants. it was suggested that if their efficacy-based structured counselling approach were adopted elsewhere, uptake of these methods would significantly expand. about that same time, the affordable care act progressively removed many of the financial barriers to long-acting methods, which measurably increased iud use by privately insured women. implants placed immediately following delivery before discharge home were highly successful. women provided those devices in hospital were far more likely to still be using them months postpartum compared to women who delayed their initiation until the -week postpartum visit. in relatively short order, the medicaid programs in dozens of states started reimbursing hospitals and providers for postpartum provision. enthusiasm for implants and iuds was palpable. every study that resulted in increased utilization of these methods was hailed a success. at one point, family planning programs were debating what usage percentages should be adopted as targets. the thought was that "appropriate counselling" could be documented if a greater percentage of patients in a clinic chose these "top tier" methods. at a more fundamental level though, many thought leaders have progressively moved away from structured counselling that stressed efficacy as the most important variable in method selection. they saw that it did not promote patient autonomy and had begun to rekindle distrust with the medical system. what has emerged to replace that model is the person- centered framework for high-quality, equitable contraception care.( ) this approach does not merely focus on reducing unintended pregnancies, but adds prioritizing the individual's wellbeing and promoting positive experiences with care. from a utilitarian viewpoint, the idea is that women, who, based on their own preferences and priorities, choose the methods they want to use, will be more successful users. echoes from the history of some family planning experiences seem to be heard today around iuds and implants. studies have shown that these more effective methods may not meet the preferences of many people of color. the mistrust of the medical system becomes even more important when women must rely on clinicians not only to place the device but also to remove it on demand. enthusiasm clinicians express for the iuds and implant may be interpreted as pressure, which violates a woman's autonomy. and when women's requests for removal are resisted or ignored, clinician-patient relationships are jeopardized and the appeal of the method is undermined.( ) whether it is related to these concerns or not, calls for women- controlled methods are increasing. some new methods such as the -cycle ee/segestrel vaginal ring and vaginal ph regulators for contraception still require clinicians to prescribe them, but their use is controlled by the woman. newer apps and biometric devices that can be used for fertility awareness methods may be appealing precisely because they require no interaction with the medical system. covid- pandemic has also accelerated the introduction of non-traditional avenues to contraception. telemedicine has enjoyed a huge jump start that enables women access to contraception without needing an office visit. in many states, pharmacists can both prescribe and dispense pills, patches, vaginal rings and injections. by increasing easier access to these methods, we may be biasing the choices women make. similarly, increasing the number of cycles of pills, patches and rings dispensed at once further enhances the convenience (and effectiveness) of those methods but may well inhibit the use of methods that require office visits (and procedures) with a clinician. over-the-counter access to hormonal methods has been endorsed by acog and other groups to diminish access barriers, which may further diminish relative attractiveness of iuds or implants. while women may be able to remove their own iuds, they cannot place them themselves. finally, the critical ongoing problem that kavanaugh and pliskin remind us of in their article is the persistently high proportion ( %) of sexually active women who use no method of birth control even though they do not desire to become pregnant. studies show that this % contributes disproportionately to the unintended pregnancies, abortions and unintended births. we still do not seem to understand what motivates these women. it is apparently not a problem with the survey tool; nsfg specifically asks about traditional methods of contraception, such as fertility awareness and coitus interruptus, which other surveys often neglect. it is quite conceivable that some of these women rely on abortion as their method of family planning where the procedure is safe, legal and available. but there are clearly other forces at work. indifference and ambivalence about both pregnancy and contraception are common. it may not be socially acceptable for a woman to admit that she wants to become pregnant when she does not have the social and financial resources to support a child. traditional women's roles may call for them to view the pregnancy as a gift or at least as something to accepted. perhaps these women should be given ongoing preconception care to insure they are ready for pregnancy when they conceive. some may need education; surveys use of contraception among reproductive-aged women in the united states early impact of the affordable care act on uptake of providing quality family planning services: recommendations of cdc and the u.s. office of population affairs beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care she just told me to leave it": women's experiences discussing early elective iud removal key: cord- -i q olv authors: cobos-sanchiz, david; del-pino-espejo, maría-josé; sánchez-tovar, ligia; matud, m. pilar title: the importance of work-related events and changes in psychological distress and life satisfaction amongst young workers in spain: a gender analysis date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: i q olv a relentless stream of social, technological, and economic changes have impacted the workplace, affecting young people in particular. such changes can be a major source of stress and can cause a threat to health and well-being. the aim of this paper is to understand the importance of work-related events and changes in the psychological distress and life satisfaction of young workers in spain. a transversal study was carried out on a sample comprising men and women aged between and years old. the results showed that there were no differences between the men and women in the number of work-related events and changes experienced in the last months, nor in terms of job satisfaction. the results from the multiple regression analysis showed that a greater number of work-related events and changes experienced during the last months were associated with increased psychological distress and reduced life satisfaction amongst men, but this was not the case for women. although job satisfaction was independent from the men and women’s psychological distress when self-esteem and social support was included in the regression equation, greater job satisfaction was associated with greater life satisfaction for both men and women. it concludes that work-related events and job satisfaction are important for the health and well-being of young people, even though a larger number of work-related events and changes is associated with increased psychological distress and reduced life satisfaction for men only. profound social change has been taking place in recent decades in technological and economic terms, having an impact on work and workers. these changes are taking place at increasingly faster speeds and affect most countries across the world. from the late s and, in particular, in the s, researchers supporting different theoretical perspectives have recounted the consequences of the changes in manufacturing systems; the move from an industrial to post-industrial society. these changes go beyond the methods of organizing production, having a clear impact on working conditions and employment opportunities [ ] . there is discussion around an environment characterized by volatility, uncertainty, complexity, and ambiguity (vuca) where companies, in response to almost unpredictable social expectations, undergo constant and rapid change [ ] . among the effects of globalization, it is worth highlighting that economic, social, and health crises are no longer confined to just one country, but rather they spread to other countries-sometimes more quickly than others. within this context, working life has experienced significant changes, caused by an ever more global and flexible system [ ] ; these are changes that are contributing to a significant loss of work, with an increase in unemployment, underemployment, and precarious employment throughout the world [ ] . according to the international labor organization (ilo), the main problem in the world's labor markets is poor quality employment. millions of people are compelled to accept poor working conditions. recent data show that, in , the majority of the total global working population of . billion did not have an adequate level of economic security, material well-being, and equal opportunities [ ] . this tends to affect young people most of all, as individuals that are extremely vulnerable to an ever-changing environment, where situations of abnormal employment, temporary employment, part-time work, outsourcing, individual contracts, and self-employment prevail. the changes in the world of work that young people are facing, whether due to the introduction of new technologies or the type of employment in itself, take place in such a way that young people often do not have the chance to adapt to the position [ ] . for millions of young people in the european union, finding a job is extremely difficult. in some southern european countries, more than half of all young adults are unemployed, a situation that was made even worse by the last financial crisis. this entails problems of a psychosocial nature, but can also have devastating consequences for the countries concerned-and the european union itself [ ] in a post-brexit context, due to the social tensions that can arise from unemployment. in spain, in particular, youth unemployment rates double those of the adult population and affect more than half of the population [ ] . the most relevant aspect has been the change in the industrial trend of male employment: stable jobs for life have made way for constant change with periods of unemployment, instability, and precariousness throughout one's working life. in addition to the difficulty of entering the labor market for the first time, replicated across europe, the problems arising from the spanish economy based on unstable productive industries must also be considered [ ] . it could be assumed that this dynamic reflects the stamina of young people, but in reality it shows an overwhelming situation that hinders them in their daily routine, characterized by an uncontrolled flow of new demands that constantly force them to search for new jobs, which consistently fail to meet their expectations due to their temporary nature. according to vendramin [ ] , switching jobs is part of a "normalized" journey of employment instability for young people. these changes are involuntary for . % of women and % of men. the reality of young workers has been put in the spotlight by different visions. according to data from the ilo [ ] , women are more likely to take casual work, and just like young people, they are prone to establishing weak ties with the employment market. it is undeniable that working is fundamental for the economic and psychological well-being of an individual, and of society in general [ ] . in current day society, a person's job is one of their most important sources of identity and it plays a vital economic and social role for the majority of people [ ] . however, employment and working conditions can involve factors that are not people-oriented, and this affects their well-being. the links between work and health have become a central issue in organizational literature, and workers are becoming more and more aware of the importance of health in their work-life balance [ , ] . in terms of young workers, it is particularly important to understand that their initiation into the world of work is taking place under adverse circumstances; due to the lack of jobs currently on offer on the market and also due to the lack of appreciation for their personal conditions due to inexperience [ ] . although work can be a source of stress, it is a fundamental aspect of life, as working age adults spend the majority of their waking hours at work [ ] . work is particularly important for a young person's personal development, and due to the restricted possibilities of entering the labor market, they can end up accepting precarious employment with unfavorable conditions that put their physical and mental integrity at risk. it is worth nothing that, despite the employment crisis and the aforementioned changes in production systems, the vision and expectations of young spanish people with regard to work and professional life continue to be largely similar to those of previous generations. for them, work is a fundamental part of their lives, whether it is more instrumental and utilitarian (young people from an industrial background or from peripheral rural and semi-rural areas), or more self-fulfilling (young urbanites) [ ] . in this respect, despite the fact that, among the realistic expectations of young spanish people is just how difficult it is to gain a foothold in the labor market, this does not mitigate a major psychological and social impact, which can trigger severe and significant consequences for individuals that endure over time [ ] . such circumstances may be, in fact, an important source of stress that can alter the physiology and mental well-being of individuals [ ] . work-related events and changes thus pose a threat to the health and well-being of women and men alike. in recent decades ample research has been carried out on the psychosocial risks of work, such as stress in the workplace, and a link was found between psychosocial risks and their consequences on physical, mental, and social health [ ] . in accordance with data from the quebec national institute for public health [ ] , there are several scientific studies that have shown that the presence of one or more psychosocial risks in the workplace can impinge upon workers' mental and physical health, increasing the risk of accidents. it was also stressed that workers with a low level of education working in precarious employment have to face increased psychosocial risks at work, which affects their health and hinders the possibility of improved life conditions. likewise, it was highlighted that men and women are not exposed to the same psychosocial risks in the workplace, but that women tend to be more exposed. it is important to understand that when assessing work-related psychosocial factors, analyzing job satisfaction is also important. although there is no sole definition, it is believed that job satisfaction reflects a pleasant emotional state where people value their work or work experience positively [ ] . job satisfaction is a global concept that covers several aspects and is determined by specific work elements, such as the workplace or the job's characteristics, by specific personal factors such as skill or psychological status, and by non-specific factors such as demographic, cultural, and community aspects [ , ] . there is evidence that job satisfaction has an impact on individual performance and company results, as well as affecting the health and lifestyle quality of the worker. for example, it has been found that job satisfaction is associated with trust in the company [ ] , work performance [ ] , and self-efficacy [ ] , whilst workers that are unsatisfied can see their mental and physical health suffer due to mood changes or psychosomatic complaints, reduced efficiency, more time off, and more requests for a change in role [ ] . symptoms of depression and anxiety have been named collectively as psychological distress [ ] , although other symptoms such as somatic issues or insomnia are also included within psychological distress [ ] [ ] [ ] . both clinically and in research, psychological distress is a commonly used indicator for mental health and psychopathologies [ ] , as well as being associated with physical health. there is evidence showing that psychological distress is associated with higher mortality rates for various reasons [ ] , and with several inflammatory markers [ ] . it has also been found to increase the risk of diseases such as arthritis, cardiovascular disease, and chronic obstructive pulmonary disorder [ ] . many of these effects have been studied less in young people than they have been in adults, perhaps due to morbidity and mortality rates being comparatively lower in the former group. it should be noted, however, that various health issues onset at a young age, which may affect the individual throughout the rest of their life [ ] . self-esteem and social support stand out amongst the psychosocial factors related to health and well-being [ ] [ ] [ ] [ ] . self-concept refers to describing and evaluating oneself, including one's psychological and physical characteristics, qualities, skills, and roles. self-esteem is the degree to which such qualities and characteristics are perceived as being positive [ ] . there are many factors that determine a person's self-esteem, including individual values, attitudes, wishes, family issues, and social factors related to work and the type of work [ ] . there is evidence that self-esteem has consequences on central aspects of life and high self-esteem leads to good mental and physical health, satisfaction with close relationships, and social support [ , ] , as well as being associated with job performance [ ] and professional prestige and income [ ] . across all societies, gender is fundamental in organizing work, and work is fundamental for socially constructing gender. although there is empirical evidence that men and women are similar in the majority of their psychological features [ , ] , most societies believe that differences remain, and that they should take on different roles; and they are treated differently depending on the gender assigned to them at birth. gender is a social construct [ ] that restricts people and gives them different roles and positions. traditional gender roles consider women as carers and men as the backbone of the family [ ] , assuming that working is vital for a man's mental health, but somewhat secondary for women, whilst the opposite assumption occurs within family roles [ ] . these assumptions are not supported by the empirical evidence that shows that the quality of job positions is associated with less psychological distress amongst men and women [ , ] , and that the similarities between men and women are clearer than the differences, amongst a series of factors that are important for the family-work association [ ] . despite this, it is still believed that the commitment of a woman to work is lower than that of a man, and the classification of gender is an important deciding factor when it comes to professional interests [ ] . although there has been a trend towards more equal gender roles in recent decades [ ] , gender stereotypes that present significant differences between men and women in terms of their features, occupations, and behavior still exist [ , ] . in spite of a woman's role in the workplace having become more widespread in recent years in many countries [ ] total working equality has not yet been achieved, with salary gaps and job segregation remaining [ ] [ ] [ ] . an example of this is that men still dominate the more prestigious and creative roles, as well as the technical positions [ ] . although the importance of research in the psychological aspects of work has received more recognition in recent decades, and research has been done on the psychosocial risks inherent to the workplace and the working environment [ ] , the impact on health due to stress at work understood as work-related events and changes has been studied less. furthermore, the positive aspects of work such as job satisfaction or the presence of personal resources such as self-esteem, and social resources such as social support, are rarely considered in these studies. these are all variables that can differ from men to women and can be important in determining health and well-being. the aim of this paper is therefore to understand the importance of work-related events and changes experienced in the last year in psychological distress and life satisfaction for young people in spain, including satisfaction with the job role, self-esteem, and emotional and instrumental social support in the prediction model, all of which will be assessed by analyzing men and women separately. the hypotheses are: men and women who have experienced a greater number of work-related events and changes, and who report low job satisfaction, low self-esteem, and low social support will also report greater psychological distress. men and women who have experienced a lesser number of work-related events and changes, and who report high job satisfaction, high self-esteem, and high social support will also report greater life satisfaction. the sample consisted of men and women aged between and years old. the average age of the men was . (sd = . ) and for women was . (sd = . ), the difference was not statistically significant, t( ) = . , p = . . their professions were different: % was non-manual labor, . % was manual labor, and . % had professions that required university studies. there were also differences in their level of education, even though it was most common for them to have studied at university ( . %), . % had secondary school education and . % had only basic education. more than half of the sample ( . %) was single, % was married or in a civil partnership, and . % was separated or divorced. psychological distress was assessed using scales of somatic symptoms, anxiety and insomnia, and severe depression as per the ghq- [ ] , each of which includes items that gathers information on general health over recent weeks. example items are "been feeling nervous and strung-up all the time?", "felt constantly under strain?", "felt that life isn't worth living?", and "felt that life is entirely hopeless?". the likert scale was used, allocating weightings from (no symptoms) to (greater discomfort). the internal consistency in the sample group of this paper for the items is . . life satisfaction was assessed with the satisfaction with life scale (swls) [ ] . it is made up of items with a likert-style -point response scale ranging from (completely disagree) to (completely agree). it is a tool that has been used in many countries, spain included, and has shown suitable psychometric properties for men and women [ , ] . the internal consistency in the sample group of this paper was . . the work-related events and changes were assessed using four items where participants were asked whether in the last months they had experienced the following: ( ) change of employment, ( ) loss of employment, ( ) starting new employment; and ( ) change in employment conditions. each item was scored with a if the person had not experienced it in the previous months and with if they had. the total score for work-related events and changes was obtained by adding together the responses from the items, so the score range is between (for the complete absence of work-related events and changes) and , which is the maximum score. job satisfaction was assessed using the job satisfaction questionnaire [ ] . it is an open response test where there are questions about whether the person is satisfied in their job, if it is the job they chose, if they want a change, and to what extent they feel fulfilled. the responses to each of the questions were scored quantitatively by applying a code created and approved by matud [ ] . the internal consistency for the sample group in this paper was . . self-esteem was assessed using the spanish version of the york self-esteem inventory [ ] , a questionnaire made up of items that takes an overall measurement of self-esteem, reflecting the assessment of several skills including personal, interpersonal, family, achievement, physical attractiveness, and the assessment of the degree of uncertainty in themselves. the answer format is on a -point scale that ranges from "never" (scored with a ) to "always", which is scored with a . with this sample group in this paper the internal consistency was . . social support was assessed using the social support scale [ ] . it is made up of items, answers to which are given on a -point likert scale that ranges from (never) to (always), and they assess the social support perceived emotionally ( items) and instrumentally ( items). the internal consistency of the sample in this paper was . for emotional social support and . for instrumental social support. furthermore, each participant was given a sociodemographic and employment data collection sheet. participants were volunteers and were not paid for their participation in this study. the sample was chosen through various work centers of spanish companies all over spain, from all production sectors. to collect data, the social networks of psychology and sociology students at spanish universities were analyzed, who were trained for the testing step and received course credits for this task. after verbal informed consent was received, the questionnaires were completed individually on paper by people that met the following criteria: ( ) aged between and years old; ( ) with work experience and either working (work experience means having, or having had, a formal employment contract) or not; and ( ) able to understand and speak spanish. this study is part of broader research on the importance of personal and social factors in men and women's well-being, and it was assessed positively by the animal research and well-being ethics committee at the university of la laguna (study approval no. - ). descriptive analyses were carried out to understand the socio-demographic characteristics of the participants. the reliability of the internal consistency of the study factors was calculated using cronbach's alpha coefficient. the comparisons between men and women were calculated using the student's t-test. the bivariate associations between variables were calculated using pearson's r correlation coefficient except for the educational level where spearman's rho was used as it is an ordinal variable with levels, from (for no studies) to (for university studies spanning years). to test the hypotheses and determine the importance of the number of work-related events and changes, job satisfaction, self-esteem and social support in psychological distress, and life satisfaction amongst men and women, hierarchical multiple regression analyses were made. the age and level of studies were incorporated at the first step (model ) to control their effect. at step (model ), the number of work-related events and changes and job satisfaction. finally, at step (model ), self-esteem and emotional and instrumental social support were incorporated. the correlations and the multiple regression analyses were made independently for the sample of women and the sample of men. the statistical analyses were performed using the ibm spss statistics for windows software, version . (ibm corp., armonk, n.y., usa). sectors. to collect data, the social networks of psychology and sociology students at spanish universities were analyzed, who were trained for the testing step and received course credits for this task. after verbal informed consent was received, the questionnaires were completed individually on paper by people that met the following criteria: ( ) aged between and years old; ( ) with work experience and either working (work experience means having, or having had, a formal employment contract) or not; and ( ) able to understand and speak spanish. this study is part of broader research on the importance of personal and social factors in men and women's well-being, and it was assessed positively by the animal research and well-being ethics committee at the university of la laguna (study approval no. - ). descriptive analyses were carried out to understand the socio-demographic characteristics of the participants. the reliability of the internal consistency of the study factors was calculated using cronbach's alpha coefficient. the comparisons between men and women were calculated using the student's t-test. the bivariate associations between variables were calculated using pearson's r correlation coefficient except for the educational level where spearman's rho was used as it is an ordinal variable with levels, from (for no studies) to (for university studies spanning years). to test the hypotheses and determine the importance of the number of work-related events and changes, job satisfaction, self-esteem and social support in psychological distress, and life satisfaction amongst men and women, hierarchical multiple regression analyses were made. the age and level of studies were incorporated at the first step (model ) to control their effect. at step (model ), the number of work-related events and changes and job satisfaction. finally, at step (model ), selfesteem and emotional and instrumental social support were incorporated. the correlations and the multiple regression analyses were made independently for the sample of women and the sample of men. the statistical analyses were performed using the ibm spss statistics for windows software, version . (ibm corp., armonk, n.y., usa). in table are the correlation coefficients between the age, level of studies, number of workrelated events and changes, job satisfaction, self-esteem and social support with the psychological distress, and life satisfaction amongst men and women. as it is possible to observe, age is independent from the psychological distress and life satisfaction amongst men and women, and although for men said variables are also independent from the level of studies, women with a higher level of studies have less psychological distress and greater life satisfaction. for both men and women, a higher number of work-related events and changes are associated with increased psychological distress and less life satisfaction, whilst more job satisfaction, self-esteem, and social support are associated with more life satisfaction and less psychological distress. table . correlations between the dependent and independent variables amongst men and women. table shows the main results from the hierarchical multiple regression analysis in which the dependent variable was psychological distress for the male sample, with table showing the female sample. as it is possible to observe, model was only statistically significant in the female sample, albeit with the only statistically significant predictor being the level of studies (β = − . , p < . ). including the number of work-related events and changes and job satisfaction in model produced a statistically significant increase in r , with the beta weights being statistically significant for both variables amongst men but only job satisfaction amongst women. including self-esteem and emotional and instrumental social support in model also produced a statistically significant increase in r , although for the female sample only self-esteem was statistically significant (β = − . , p < . ), whilst in the male sample self-esteem (β = − . , p < − ) and instrumental social support (β = − . , p < . ) was. model , with all the independent variables in the equation, predicted % in table are the correlation coefficients between the age, level of studies, number of work-related events and changes, job satisfaction, self-esteem and social support with the psychological distress, and life satisfaction amongst men and women. as it is possible to observe, age is independent from the psychological distress and life satisfaction amongst men and women, and although for men said variables are also independent from the level of studies, women with a higher level of studies have less psychological distress and greater life satisfaction. for both men and women, a higher number of work-related events and changes are associated with increased psychological distress and less life satisfaction, whilst more job satisfaction, self-esteem, and social support are associated with more life satisfaction and less psychological distress. table shows the main results from the hierarchical multiple regression analysis in which the dependent variable was psychological distress for the male sample, with table showing the female sample. as it is possible to observe, model was only statistically significant in the female sample, albeit with the only statistically significant predictor being the level of studies (β = − . , p < . ). including the number of work-related events and changes and job satisfaction in model produced a statistically significant increase in r , with the beta weights being statistically significant for both variables amongst men but only job satisfaction amongst women. including self-esteem and emotional and instrumental social support in model also produced a statistically significant increase in r , although for the female sample only self-esteem was statistically significant (β = − . , p < . ), whilst in the male sample self-esteem (β = − . , p < − ) and instrumental social support (β = − . , p < . ) was. model , with all the independent variables in the equation, predicted % of the variability in psychological distress amongst men and % of psychological distress amongst women. for the male sample, psychological distress was associated with lower self-esteem, a higher number of work-related events and changes in the past year, and less instrumental social support whilst for the females it was only associated with a lower self-esteem. . ( , ) ** . ( , ) *** . ( , ) *** note: β = standardized regression coefficient. * p < . ; ** p < . ; *** p < . . table shows the main results from the hierarchical multiple regression analysis in which the dependent variable was life satisfaction for the male sample, with table showing the female sample. as it is possible to observe, model was only statistically significant in the female sample where a higher level of study was associated to greater job satisfaction. including the number of work-related events and changes that had taken place in the last year and job satisfaction in model produced a statistically significant increase in r for men and women, with the beta weights being statistically significant for both variables, and showing that greater life satisfaction was associated to greater job satisfaction and a lower number of work-related events and changes in the previous year. including self-esteem and emotional and instrumental social support in model produced a statistically significant increase in r for men and women, with the beta weights for self-esteem and emotional social support in the male sample and self-esteem and instrumental social support in the female sample being statistically significant. model , with all the regression variables, predicted % of the variance in life satisfaction for men and % for women. for men, increased life satisfaction was associated with increased job satisfaction, greater emotional social support, higher self-esteem, and less work-related events and changes during the last year. for women, increased life satisfaction was associated to higher self-esteem, more job satisfaction, and greater instrumental social support. the aim of this paper was to understand the importance of work-related events and changes experienced in the last year in assessing psychological distress and life satisfaction for male and female young workers in spain, including these factors in the prediction model together with the number of work-related events and changes, and job satisfaction. self-esteem and emotional and instrumental social support were also included in the regression equation, with the aim of understanding the relative weight that social, personal, and work factors have on psychological distress and life satisfaction. a hierarchical regression model was used, and men and women were analyzed separately, given the evidence that gender is an important distinction in the workplace. it highlights that, in regression analysis, work-related events and changes experienced in the previous year and job satisfaction were statistically significant for men, but for women, only job satisfaction, was statistically significant. this coincides with what has been reported in literature [ , ] ; for both men and women, the quality of job positions is associated with less psychological distress and better health. the fact that only job satisfaction was statistically significant for women could be a reflection of women facing situations of inequality, segregation, imbalances, and gender stereotypes in the labor market [ , ] , which is still happening regardless of the academic level reached by this group in recent years. it is well known that gender places young men and women unequally in both the education and the labor market [ ] . there is extensive literature on the gender gap, in general and in the spanish labor market in particular, which looks at employment discrimination, its evolution throughout the life cycle and, specifically, pay discrimination [ ] [ ] [ ] [ ] . employers still hold stereotypes about women's productivity and, in general, tend to regard women as being less committed to paid work than men [ , ] . this reality is reported in studies that reveal the distribution of roles in accordance with gender in workplaces [ ] [ ] [ ] , aspects, which are often highlighted in female working environments. with regard to the predictors of psychological distress and life satisfaction, there were some significant differences between men and women. in both groups, age was independent from psychological distress and life satisfaction, as was the case with the level of studies for men. for women, a higher level of studies was associated with less psychological distress and greater life satisfaction, despite the small size of the effect and its greatly reduced statistical significance when self-esteem and social support were included in the regression equation. the first hypothesis, proposing that men and women who have experienced a greater number of work-related events or changes, and who report low job satisfaction, low self-esteem, and low social support would also report greater psychological distress, was only partially supported. although in the male sample a larger number of work-related events and changes taking place in the last year and less job satisfaction predicted psychological distress (model ), when self-esteem and social support (model ) were included in the regression equation, job satisfaction ceased to be statistically significant in predicting psychological distress. for women, although in model less job satisfaction predicted increased psychological distress, job satisfaction ceased to be statistically significant in predicting psychological distress when self-esteem and social support (model ) were included in the regression equation. self-esteem ended up being an important predictor of psychological distress for the male sample and the only predictor for the females. these results coincide with those of other studies [ , ] and confirm the importance of self-esteem on psychological well-being for both men and women. these results force us to consider the value of self-esteem and psychological well-being as health contributors, as highlighted by some authors in studies on psychological distress and the workplace [ ] [ ] [ ] [ ] . the results highlight the lack of importance of social support in predicting psychological distress, as it was only statistically significant in the male group, despite literature reporting social support as a protective factor of psychological distress. the second hypothesis, which proposed that men and women who have experienced a lesser number of work-related events and changes, and who report high job satisfaction, high self-esteem, and high social support would also report greater life satisfaction, was also only partially supported. in fact, in the male group, greater life satisfaction was associated with greater job satisfaction, increased emotional social support, higher self-esteem, and less work-related events and changes. however, for women, in the final model, when self-esteem and social support were incorporated, the number of work-related events and changes ceased to be statistically significant, and the social support, which was associated in a statistically significant way with greater life satisfaction, was instrumental and not emotional. this suggests that self-esteem and social support are valuable factors when surveying disrupting situations in life satisfaction for both groups. it should be noted that the perceived social support in particular has been considered by several authors as an element that facilitates protection against situations that create psychological distress. the results found highlight that there are differences between men and women in the predictive value of work-related events and changes in psychological distress, with job events and changes being much more associated with psychological distress in young men rather than women. this could perhaps be a consequence of traditional social practices and gender stereotypes that further underscore working roles amongst men more so than women [ , , , ] , and therefore work-related events and changes could equate to a bigger threat for men's mental health than for women's. in any case, it also highlights that there were no differences between men and women in terms of their job satisfaction, and this was important for predicting life satisfaction for both sexes. the results allow us to broaden our knowledge about the relevance of work-related events and changes on the health and well-being of women and men. in this respect, the findings of our research serve as a basis for further studies aimed at the in-depth research into distress in young workers, including looking into factors that implicate the work environment as a potential trigger of psychological distress. in particular, the difference between men and women in the predictive importance that work-related events and changes have in psychological distress and life satisfaction (a construct that refers to the feeling of well-being with oneself in one's surroundings) has been highlighted, with this being much greater amongst young men than young women. in conclusion, work-related events and changes and job satisfaction are important for the health and well-being of young workers, even though a larger number of work-related events and changes amongst only men are associated with greater psychological distress and reduced life satisfaction. it is important to highlight that, for young workers, life satisfaction, social support, and self-esteem were shown to be important factors to considered in research in relation to the psychological distress created by adverse circumstances in the working environment. the study has some limitations and it should be noted that a convenience sample was used, so there can be no guarantee that this is representative of young spanish people. moreover, the study is transversal, so we cannot speak of cause-effect relationships. in addition, the percentage of variance explained in psychological distress and in life satisfaction does not exceed %. certain aspects could have been studied in greater depth, and remain open to subsequent study in greater detail. in particular, it would be interesting to use the holmes-rahe life stress scale, a psychological scale used to measure susceptibility to stress-induced health problems, as well as to introduce the locus of control as a study variable. finally, there should be some mention of the recent covid- pandemic. this study was carried out using the data of young spanish people collected in the last year. obviously, conditions have changed since the data were used, in a dynamic and changing context. we understand that the main results are still valid in this context, however, it is reasonable to consider highly likely that the socio-economic situation may be aggravated in light of the current situation, which may have an impact on the psychosocial occupational risks to which young people are exposed. empleabilidad de l@s jóvenes: formación, género y territorio (eject): informe final de proyectos de i+d+i; cso - -p the strategic position of human resource management for creating sustainable competitive advantage in the vuca world predisposition to change is linked to job satisfaction: assessing the 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discrimination when professionals become mothers, warmth doesn't cut the ice this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- -ulj gtn authors: sattari, mahtab; bashirian, saeed; masoumi, seyedeh zahra; shayan, arezoo; jenabi, ensiyeh; ghelichkhani, samereh; shirzadeh, azam ali; jalili, ebrahim; alimohammadi, shohreh title: evaluating clinical course and risk factors of infection and demographic characteristics of pregnant women with covid- in hamadan province, west of iran date: - - journal: j res health sci doi: . /jrhs. . sha: doc_id: cord_uid: ulj gtn background: covid- is a new viral disease with a rapid outbreak. pregnant women are at a higher risk of contracting viral infections including covid- . we aimed to evaluate the clinical course and risk factors of pregnant women diagnosed with covid in hamadan province, west of iran. study design: a retrospective cohort study. methods: the convenience sampling was performed using papers and electronic files of pregnant women diagnosed with covid- according to the who’s temporary guidelines. they were hospitalized in health centers and clinics of hamadan province. the data-collecting tool employed was a researcher-made questionnaire. the data were analyzed via spss software version . results: the mean age of pregnant women with covid was estimated to be . ± . yr and their average gestational age estimated to be . ± . weeks. about % of them had an underlying disease, % a history of influenza, and % recently traveled to infected areas. the most common findings were ct scans and multiple mottling and ground-glass opacity chest radiology. the most common symptoms were fever, cough, and shortness of breath. about % of the women required icu hospitalization and the average length of hospital stay was . ± . and % had premature births. moreover, % of infected mothers had a normal delivery and % had a cesarean section. conclusion: early diagnosis of covid- disease is essential in pregnant women. because there is a possibility of worsening complications in the mother and fetus. oronavirus (covid- ) is a relatively new disease with a high outbreak rate. the virus causes severe pneumonia such that who has recognized it as a global public health emergency , . coronavirus is a coated single-stranded ribonucleic acid called solar corona due to the presence of - -nm-long spikes on its surface . there are four main structural proteins on the coating encrypted by the virus genome. one of these proteins is spike (s), which binds to the angiotensin enzyme converter enzyme (ace ) receptor and mediates further fusion between the host cell membrane and the virus' coating, leading to virus entry into the host cell , . coronavirus can cause a variety of illnesses observed in the forms of a mild cold to severe respiratory illness and even death . at present, primary epidemiological risk factors for covid- include traveling to the infected and high-risk areas or close contact with the infected individuals within days from the onset of symptoms , . common symptoms include fever, cough, myalgia, headache, and diarrhea. abnormal tests also include chest radiographs, lymphopenia, leukopenia, and thrombocytopenia. preliminary reports of acute respiratory distress syndrome (ards) have also been observed in - % of hospitalized patients . the virus spreads via infected respiratory droplets, usually through individual to individual(s) or through the contact of mucus with infected surfaces. this virus can lead to pneumonia, ards, kidney, and several other organ failures. elderlies with chronic and severe illnesses such as asthma, diabetes, heart failure, and immune system disorders are more prone to be infected with covid- . besides, due to immunophysiological changes during pregnancy, pregnant women are at a higher risk for contracting viral infections, including covid- , . consequently, the pathogenesis of covid- infection may be similar to sars-cov- and the risk of vertical covid- transmission may be as high as sars-cov- . sars infection during pregnancy has adverse maternal and neonatal complications associated with adverse complications including spontaneous abortion, preterm delivery, intrauterine growth restriction, tracheal intubation, intensive care unit hospitalization, renal failure, and intravascular coagulation , . nevertheless, the complications and deaths resulting from covid- in pregnant women and their infants are less compared to those of other viruses in the corona family such as sars and mers , . two reports of pregnant women with covid- respectively confirmed that they were all infected in the third trimester and had clinical findings similar to those of non-pregnant infected adults. there were also cases of fetal distress and preterm delivery . symptomatic care along with an early diagnosis of the disease in pregnant mothers, a strong immune system, and general well-being can be effective determinants in improving maternal and fetal prognosis . there is no conclusive evidence of complications, symptoms, and risk factors for pregnant mothers, especially in iran, which is one of the countries with the highest prevalence of the disease. we aimed to evaluate the clinical course and risk factors of pregnant women diagnosed with covid in hamadan province, west of iran. the present study was conducted as a retrospective cohort on pregnant mothers hospitalized diagnosed with covid- in hospitals of hamadan province, iran, in . sampling of all pregnant women suspected of having coronavirus disease was performed in the obstetrics and gynecology department from january , to june , . the name lists of all pregnant mothers who were diagnosed with a temporary who guideline for covid- were provided via the infection control center, in coordination with the departments and security office of each hospital. the convenience sampling was carried out among cases of hospitalized pregnant women diagnosed with covid- . to gather the needed information, the electronic files along with the paper copies of the files in each hospital's archive were scanned. a few professionals familiar with midwifery and clinical cases of covid- visited the hospitals several times to observed and maintain health protocols and prevention orders. these professionals carefully examined the files, extracted the necessary information, and registered them. patients' files were examined for demographic information, symptoms, and clinical course of the disease and risk factors. to this end, these mothers' information was examined through their electronic files and paper copies of the files. the collection of epidemiological, demographic, clinical, laboratory, therapeutic, and results from medical records data were extracted using a standard data set. the results of the chest radiology and pcr tests were also examined. fever, secondary infection, pneumonia, acute kidney damage, and ards were assessed based on the following criteria. the minimum fever was defined as an armpit temperature of at least . ℃. sepsis and septic shock are examined according to the definition for sepsis and septic shock the third international consensus . secondary infection was assessed based on patients with clinical signs or post-hospitalization blood sample . acute renal impairment was also assessed based on kdigo clinical practice guidelines . acute myocardial infarction was diagnosed if the serum level of cardiac biomarkers (e.g., high-sensitivity cardiac troponin i) was higher than % or new evidence was available on the electrocardiography . finally, ards was assessed based on the berlin definition . data were analyzed using spss software version (chicago, il, usa) and descriptive statistics including mean and standard deviation and relative frequency and percentage in the form of frequency tables. the present study was conducted to evaluate hospitalized pregnant women with an age range of - yr diagnosed with covid- . besides, their average gestational age was . ± . yr. among these women, mothers gave birth, of whom were multi-pars, . had a history of cesarean section, and . had a history of normal vaginal delivery. moreover, of them had a background of underlying diseases and influenza and % had an account of recent travel to high-risk and infected areas. the most-reported findings in ct scans were patients with multiple mottling and ground-glass opacity. other demographic characteristics of the infected pregnant mother, the severity of the disease, the type of the underlying disease, and the chest radiographic findings are shown in table . examination of the signs and symptoms of pregnant women with covid- upon admission to the hospital showed that the average oxygen saturation percentage was . ± . and their most common symptoms at the time of admission were fever ( . %). coughing and dyspnea were % each. pneumonia was also observed in % of pregnant women at the time of admission to the hospital ( table ) . laboratory findings showed an increase in white blood cell counts, c-reactive protein, and alanine aminotransferase, and a decrease in platelet, hemoglobin, and red blood cell counts (table ) . furthermore, regarding the effect of covid- on the complications of pregnancy in infected women, the results showed that infected pregnant women were hospitalized for an average of . ± . days and % of them required hospitalization in the icu. there were two maternal deaths due to covid- . of the studied population, infected mothers gave birth during this period, babies were born, and seven cases of covid were reported among the newborns according to covid- . (table ). details of pregnancy results and the birth rate of neonatal apgar score are shown in table . the most commonly used drugs to treat pregnant women with covid- were hydroxychloroquine, oseltamivir, kaletra, azithromycin, and vancomycin. covid- has spread rapidly in most parts of the world, infecting and even killing many people. pregnancy is a physiological condition that exposes women to viral infections . beyond the impact of covid- infection on pregnant women, there are concerns about the potential impact on the fetus and the infant. accordingly, the pregnant women should be examined more closely due to physiological and immunological changes during pregnancy, childbirth, the presence of the fetus, and even the possibility of the fetus or infant infection. in this regard, all pregnant women diagnosed with covid- in hamadan province referred to hospitals or were hospitalized during different periods of pregnancy with different gestational ages were examined. mothers were in the different stages of pregnancy, ranging from early first trimester to the late third trimester. several mothers referred only for the delivery. according to the patients' files, clinical, and laboratory evidence, the women were in the suspected and infected category, receiving medical treatment, care, and support. the average age of pregnant women admitted to hospitals was . ± . yr and their gestational age average was approximately weeks. most of the infected pregnant women were young; most of them had experienced previous pregnancy; and % had a history of cesarean delivery. . studies on the history of the disease showed that among women with covid- , there was a history of underlying diseases such as diabetes, hypertension, and cardiovascular disease and about one-third of the women surveyed had a history of the influenza disease. other studies have looked less strictly at maternal morbidity, which may be due to younger mothers having a lower risk of underlying diseases. given that the initial prevalence of covid- had increased dramatically in some iranian cities, about % of the infected women had recently traveled to these areas. therefore, it can be suggested that traveling to the high-risk areas pose them to a higher risk of infection. wang et al. presented a case report from a -yr-old pregnant mother diagnosed with covid- who had an ongoing -weeks pregnancy. they showed that the mother had recently traveled to the infected areas . according to clinical evidence, examinations, and tests, most cases of the disease, or nearly half of all pregnant mothers, showed only mild symptoms, with only % experiencing severe illness symptoms. in other studies, most women did not have severe symptoms, and only one pregnant woman within the zhang study had severe disease, and the rest were asymptomatic [ ] [ ] [ ] . sixteen percent of pregnant women had no symptoms at all . in many cases, chest radiography and ct scans were carried out to confirm the diagnosis of covid- . in this regard, most of the cases were reported with multiple mottling and groundglass opacity. the infiltration method is the second most frequently used method in this regard. in line with these results, other studies have regularly reported these two findings in the ct scan and examination of the lungs of infected pregnant women while hospitalized , , , . pregnant women infected with covid- were suffering from a wide range of symptoms upon admission to the hospital. these symptoms included fever, cough, muscle aches, fatigue, diarrhea, nausea, vomiting, and dyspnea, tachycardia, pneumonia, and ards. a small number of patients also had hypoproteinemia, coagulopathy, and acute heart damage. among them, fever, cough, shortness of breath, and pneumonia were the most common symptoms of covid- infection in pregnant women, respectively. in most studies, fever, cough, and shortness of breath have been reported in pregnant women [ ] [ ] [ ] . moreover, the symptoms of pregnant women infected with the covid- virus do not seem to be different from those infected of other backgrounds and nonpregnant adults. however, other studies did not report severe pneumonia in pregnant women , . the yang et al study also found no evidence of greater susceptibility to covid- infection in pregnant women and that people with covid- infection were more likely to develop severe pneumonia . oxygen saturation percentage in these women during admission and hospitalization was . ± . , although these values increased or decreased in different patients during regular inspections. in patients with increased severity of symptoms and worsening of the disease, the oxygen saturation percentage declined. unfortunately, among postpartum women, there were two cases of maternal death from covid- , with an acute decrease in oxygen saturation in the later stages of the disease. the pregnant mother admitted to the emergency had an oxygen saturation percentage above % (i.e., %) . despite two cases of maternal death in our study, in most studies, not maternal mortality from covid was reported , , , , and only one case of maternal and neonatal death was reported . the rank of covid- is th among major causes of death. unfortunately, the rank of covid- is th among major causes of death . examining laboratory indicators of patients also revealed an increase in white blood cells, thrombocytopenia, lymphopenia, c-reactive protein, and alanine aminotransferase (u / l). laboratory data from the chen and yang study also showed that most pregnant women diagnosed with covid- had lymphopenia and increased c-response protein , . the infected women were hospitalized for only about days and required clinical care and just few needed icu hospitalization. similarly, the most common drugs used to treat pregnant mothers with covid- infection were hydroxychloroquine, oseltamivir, kaletra, azithromycin, and vancomycin , . of all the referred women, were transferred to medical centers for delivery, of which required cesarean delivery and the rest went into labor naturally. the results showed that about % of women gave birth prematurely. in addition to our results, several studies, have noted an increase in preterm labor, which should be considered as a significant issue , , . apparently, in most studies, due to instability of the maternal and fetal status, cesarean delivery is preferred , , , . although timely termination of pregnancy in pregnant women with covid- does not increase the risk of preterm delivery and neonatal asphyxia, it is beneficial for the treatment and rehabilitation of the mother . in studies on infants [ ] [ ] [ ] [ ] , the results determined that the average score of apgar in the first and fifth minutes was optimal; however, the score of apgar in the fifth minute improved compared to that of the first minute. in the present study, the results of the neonatal pcr test showed that seven infants were infected with the coronavirus postpartum and thus were monitored in the nicu. nevertheless, the general condition of all infants was satisfactory. in most studies, the condition of newborns and their postpartum apgar score was reported to be optimal in preterm deliveries of infected mothers , [ ] [ ] [ ] [ ] . contrary to our results, there is no evidence of breast milk infection. transmission of the disease through breast milk has still been studied in another study . apparently, the disease will worsen and even lead to death in mothers diagnosed with covid- , as well as infant infection. furthermore, despite the similarity of the symptoms of pregnant women with other non-pregnant women, it seems that the possibility of premature delivery, cesarean delivery, fetal distress, and the effect on the apgar score of newborns is not far-fetched. consequently, understanding the symptoms, clinical course, and paraclinical findings in these patients can be practical in diagnosis, treatment, and medical measures to improve prognosis in mothers, fetuses, and infants. coronavirus disease (covid- ) and pregnancy: what obstetricians need to know the sars, mers and novel coronavirus (covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? description of the first strain of -ncov, c-tan-ncov wuhan strain-national pathogen resource center coronavirus disease (covid- ): a perspective from china pre-fusion structure of a human coronavirus spike protein molecular immune pathogenesis and diagnosis of covid- severe acute respiratory syndrome coronavirus (sars-cov- ) and corona virus disease- (covid- ): the epidemic and the challenges a case of novel coronavirus in a pregnant woman with preterm delivery risks of novel coronavirus disease (covid- ) in pregnancy; a narrative review a controversial debate: vertical transmission of covid- in pregnancy middle east respiratory syndrome coronavirus (mers-cov) infection during pregnancy: report of two cases & review of the literature coronavirus in pregnancy and delivery: rapid review and expert consensus clinical features of patients infected with novel coronavirus in wuhan management of adults with hospital-acquired and ventilator-associated pneumonia: clinical practice guidelines by the infectious diseases society of america and the kdigo clinical practice guidelines for acute kidney injury acute respiratory distress syndrome novel coronavirus infection and pregnancy clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records analysis of the pregnancy outcomes in pregnant women with covid- in hubei province coronavirus disease in pregnancy the authors are grateful to the support of hamadan university of medical sciences, hamadan health center, the participants of the study, and all those who contributed to this research. key: cord- -nqq ieyg authors: safdar, muhammad; yasmin, musarat title: covid‐ : a threat to educated muslim women's negotiated identity in pakistan date: - - journal: gend work organ doi: . /gwao. sha: doc_id: cord_uid: nqq ieyg this study attempts to explore how the lockdown/containment measures taken by the government during the covid‐ pandemic have threatened educated muslim women's negotiated identity regarding wifehood and motherhood in urban pakistan and how they struggle to reposition to reconstruct it. through semi‐structured interviews, making an in‐depth comparative study of three differently situated cases (muslim women), this study argues that the abnormal situation that has ensued from the pandemic has reinforced the vulnerability of women's nascent negotiated identity by landing them in a space where they are supposed by the normative structures to step back to carrying out their traditional responsibilities as ‘good’ wife and mother during the crisis. it has found that the pandemic has similarity in its impacts for the women in their familial lives, despite their being variously situated and resistive, due to the general religio‐culturally defined patriarchal social behaviour of the place (pakistan) toward women and lack of action on the part of the state for implementing its laws of women's empowerment. this study attempts to explore how the lockdown/containment measures taken by the government during the covid- pandemic have threatened educated muslim women's negotiated identity regarding wifehood and motherhood in urban pakistan and how they struggle to reposition to reconstruct it. through semi-structured interviews, making an in-depth comparative study of three differently situated cases (muslim women), this study argues that the abnormal situation that has ensued from the pandemic has reinforced the vulnerability of women's nascent negotiated identity by landing them in a space where they are supposed by the normative structures to step back to carrying out their traditional responsibilities as 'good' wife and mother during the crisis. it has found that the pandemic has similarity in its impacts for the women in their familial lives, despite their being variously situated and resistive, due to the general religio-culturally defined patriarchal social behaviour of the place (pakistan) toward women and lack of action on the part of the state for implementing its laws of women's empowerment. covid- , identity, motherhood, muslim women, pakistan, wifehood the world has scrambled to deal with the multidimensional impacts of the cataclysmic covid- pandemic which first erupted in wuhan, china in december and spread across the world within weeks (at the time of writing in the last week of march the virus has claimed about , lives and has infected hundreds of thousands of people across the globe; the virus is still spreading and casualties multiplying with no medicine to cure it so far). though statistics reported in the media have shown men in greater number as victims of the pandemic, the effects of the virus cannot be taken as limited to just physical illness or mortality. there is a need to study the outbreak with reference to its impact on women in terms of increased aggravation of unpaid labour, domestic and sexual violence, reproductive health, issues of pregnancy and maternity, and economic burden. there is hardly any published academic research on the impact of covid- on women regarding how it has worsened gender issues. pandemics like covid- can have severe and long-term gender impacts for women, especially in religio-culturally inspired patriarchal societies like pakistan. informed by the little feminist research focused on the impacts of the zika and ebola epidemics (the diseases that struck south and north america and africa during [ ] [ ] [ ] [ ] , this study, from the feminist perspective, attempts to explore the impact of the covid- pandemic on muslim women in pakistan. ebola in africa resulted in long-term destructive consequences for women by affecting their life chances as many of them had to drop out of school; teenage-pregnancy rates increased, domestic and sexual violence grew, women's health deteriorated and the rate of women dying due to obstetric complications rose (farmer, ; lewis, ; marindo, ) . zika epidemics, in latin america, were exacerbated due to the lack of reproductive rights of women in that patriarchal society which had deep structural economic inequalities for its women (velez & diniz, ) . to contain the spread of the highly contagious covid- virus, pakistan's federal and provincial governments closed down all schools, colleges and universities across the country from march to may . all types of international, national, inter-city and intra-city travel were banned; shopping malls, businesses and all types of public gatherings were prohibited; along with other law enforcement agencies, the army was deployed to force people to stay at home. the lockdown period was extended to april , which could further be increased in view of the spread of the virus. muslim women in pakistan have long struggled to negotiate their gender identity in the religiously inspired patriarchal sociocultural structures of the postcolonial globalized nation state that came into existence (in ) in the name of islam (details in the following section). this study attempts to explore how the lockdown/containment measures taken by the government during the covid- pandemic have threatened educated muslim women's negotiated identity regarding wifehood and motherhood in urban pakistan and how they struggle to reposition to reconstruct it. through semi-structured interviews, making an in-depth comparative study of three differently situated cases (muslim women), this study argues that the abnormal situation resulting from the pandemic has reinforced the vulnerability of the women's nascent negotiated identity by landing them in a space where they are supposed by the normative structures to step back to carrying out their traditional responsibilities as 'good' wife and mother during the crisis. it has been found that the pandemic has similarity in its impacts for the women in their familial lives, despite their being variously situated and resistive, due to the general religio-culturally defined patriarchal social behaviour of the place (pakistan) toward women and lack of will and action on the part of the state for implementing its laws of women's empowerment. the pandemic for the women has resulted in the form of increased burden of unrecognized unpaid domestic labour and domestic violence which, as a result, has caused them mental stress and apprehension regarding the loss of the identity that they had long negotiated their religio-traditional structures to achieve. within the framework of the case study methodology, the data from the interviews is properly coded and categorized for their thematic analysis. though gender-defining intersectional factors like social status, class, education, economic independence, locality, interpretation of religion and physical beauty usually intervene to influence a woman's empowerment in the family, this study finds that, in addition to the influence of these factors, the general dominant social behaviour toward women and the lack of will and action/infrastructure on the part of the government to ensure women's empowerment are major factors which even worsen their condition during a crisis like covid- . muslim women in pakistan have never been able to get rid of being viewed as symbols of the religiously rooted national and postcolonial culture in which they have to embody and enact the modest and pious muslim lady as a daughter, sister, mother and wife. they are supposed by the nationalist and dominant social discourse to look 'muslim' and not 'western'; westernization is deemed as being vulgar and obscene. social, political, cultural, religious and economic structures of pakistan see its women as caregivers at home and have deep gender disparities. however, cultural and economic globalization and increasing geographic and non-geographic physical and intellectual mobility of women can also be felt through its effects on changing lifestyles and social spaces (safdar & ghani, ) . though a number of factors like class, region, locality, ethnicity, social status, age and historical specificity have intersected to define and position gender of muslim women in pakistan, the intervention of religion and state discourses has always had, throughout the country's history, a major influence on the construction of the perceptions and expectations associated with gender (jafar, ; jamal, ; julia, ; mumtaz & shaheed, ; shaheed, ; yasmin, naseem & sohail, ; yasmin, naseem & raza, ; zia, ) . religious and state discourses, though varied across various government configurations (democratic and dictatorial), have been key to forming general social behaviour and the state's policy toward determining female spaces. the moderate social space women gained through their active participation in the struggle for independence of the nation during the s reduced after independence in and then was drastically curtailed in the name of islam by the dictatorship of general zial-ul-haq in the s (saigol, ; suleri, ) . the state promulgated such legislations (including zina and hodood ordinances) and initiated such public discourses (people could act as vigilantes to judge and police the character of women) that have continued to victimize women. women action forum (waf), led by upper-class women following the politics of secular feminism, protested against the regime of zia for its women-biased public discourse and policies, and demanded equality of women. waf, though struggled hard for the democratic rights of women and other suppressed communities, failed to attract common women largely due to the dominant religiously inspired social behaviour toward women. its problems in forwarding its agenda multiplied in the aftermath of / , when it became usual in pakistan to label secular feminist struggles with the stigma of westernization of the society. feminism, having been ambivalently interpreted by the majority of people in the country, has been in retreat; instead, a third space enabling women to negotiate the oppressive indigenous religio-cultural patriarchal structures and western notions of women's equality has increasingly opened for women to negotiate their space (akhtar, ; mansoor, ; safdar & ghani, ; zubair & zubair, ) . as a reaction to secular perceptions of gender, religion-based struggle for women's rights has been advocated by academics as the alternative indigenous agency that does not necessarily mean to subvert patriarchy in the sense that secular feminism means (iqtidar, ; mahmood, ; syed, ) . the pre-and post-zia era state policies exploited relatively moderate versions of religious interpretations to forward their political and economic agendas. general pervez musharraf's regime ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) included religious political parties in the coalition government and advocated cultural enlightenment and women's rights. successive governments after musharraf have also introduced several women-friendly legal measures. however, the recently reignited discursive conflict between secular and religious viewpoints about muslim women's gender roles and rights in pakistan by the marvi sarmad (a pakistani feminist activist) and khalil ur rehaman (a playwright) episode (dawn, a (dawn, , b has revealed that the majority of people in pakistan view gender of muslim women through the perspectives of their religion and local culture rather than secularism. women's visibility and mobility have been growing across the country, and as a result, their intellectual mobility as well in the form of an increasing sense of reasoning and critical thinking. however, they mostly seek their agency from interpretations of religion, especially in the case of middle-class women (khurshid, ) . the state, in the last two decades, has also passed a number of pro-women legislations to punish the perpetrators of honour killings, domestic violence and sexual harassment, and to empower women in matters related to divorce and marriage (dawn, ; mirza, ) . however, what is missing is the will, readiness, proper training and consistency in action on the part of the state institutions to implement these laws (dawn, a (dawn, , b . it has resulted in scattered, disorganized and haphazard growth in social behaviours towards gender in the contemporary pakistan which is globalized and also always mindful of the reason of its being (that is, religion). the covid- pandemic and the asymmetric condition of gender in hardcore patriarchal societies like pakistan form the background of this study. the study conducts purposive sampling to explore the impact of the pandemic on the familial life of those pakistani muslim (single parent and double parent) women who are highly educated, comparatively less educated (grade - ), economically independent/dependent and located in urban areas in pakistan. it is generally assumed that educated and economically independent women located in urban areas exercise comparatively greater agency than uneducated and economically dependent women who are located in rural/remote areas. this is why this study attempts to explore the experience of the educated and economically independent (and dependent as well) women who are located in urban areas to understand how the women have to struggle to maintain their relatively better position regarding their rights/agency in the times of pandemics like covid- . all the three cases selected for this study are from sialkot. sialkot is an industrial city located in the province of punjab in pakistan; after the metropolises: karachi, lahore and faisalabad, it is the forth city in the country that has high per capita income. case study methodology, as explained in hood ( ) , provides a useful entry point to explore the experiences of the women through their personal narratives; narratives constitute and can help understand one's identity (neitz, ; wuthnow, ) . since the authors are also married and going through similar experiences as the cases are in their familial life during the containment measures, self-reflexivity as a method, which is often employed by feminist research (alldred, ; birch, ; parr, ; zubair, ; zubair & zubair, ) , is also used to feel a connection with the research participants and to research with rather than on them. as typical with linguistics and discourse studies, language is constitutive and expressive of one's identity; this study therefore attempts to investigate and capture the lived experiences of the muslim women through their talks. the following prompt was used to initiate the semi-structured individual interviews which lasted over an hour each and also included informal irrelevant exchanges of ideas and gossip: how are you doing during these lockdown/containment measures by the government? since the interviews were recorded, the relevant material was later noted down and transcribed for the study. two of the cases (both of them women and coded as nisa and rida) and the authors have been serving as colleagues in the same university in sialkot for several years, and have visited each other's families many times. therefore, the authors position themselves with respect to the two participants as colleagues and friends who have a deep understanding of each other's familial situations and can share their experiences confiding in each other. the third case (also a woman coded as nayab) for this study is a relative of ours with whom also we can position ourselves in a situation where there is mutual confidence and trust and deep knowledge of each other's familial experiences. though the authors' positionalities with the participants are such that they have mutual confidence, trust and deep knowledge of each other's familial and personal lives, the first author, being a male, may have to be more reflective and empathetic to understand the women participants' sensibilities. however, this sexual opposition of the author enables him to be more interested and curious to explore the experiences of the women. the second author, being a woman, can better feel with the women participants and helps the first author to feel the same by explaining to him the situations of the participants. rida is a single parent, parenting her five-year-old daughter after her divorce two years ago. she is in her thirties, living with her parents in their own home after her divorce. she is the only daughter of her parents and has no siblings. her parents are over years of age and need someone to take care of them. her family environment is not that strict in religious matters like dress and rituals, etc. she wears cultural (shalwar qameez) and modern dress also (like pants and loose shirts). however, she wears a scarf which is a symbol of modesty and piety in pakistan. being a senior management officer, her monthly salary is sufficient to lead a respectable middle-class life. her father's retirement pension also adds a considerable amount to her monthly budget. for household chores like cooking, washing and cleaning, she has a female servant. during workdays, she spends nine hours a day at the university campus, and back at her home the servant takes care of her household chores and parents; her daughter is dropped off and picked up from school by the school van. during the covid- outbreak, she has spent all of her time at home looking after her daughter and parents. as culturally and religiously expected, she personally takes care of most of the services of her parents and daughter even when the servant is also available. nisa is a double parent having three sons and no daughter. she is in her forties and lives with her husband, father-inlaw and mother-in-law. she is highly educated ( years of education) but the level of her husband's education ( years education) is lower than hers. being a university lecturer she is financially independent; her husband also runs his own small private business. she belongs to the middle class. her eldest son is years old and the youngest ; all three of them are students at different levels and can travel to and back home from their schools on their own. her family environment is religiously and culturally fundamentalist. with the purpose of avoiding obscenity and irreligiousness, they do not even have a television at home. though she is allowed to travel alone to the university campus, which is only a mile away from her home, she first used to wear a full head-to-toe veil (abaya), however, latter, for a few years she has negotiated her veil and now wears a complete head scarf instead of the head-to-toe veil. the authors have never seen her wearing pants and shirts; she dresses according to religious and cultural norms. for household chores, she has a female servant. during workdays, she usually spends five to six hours a day at the university campus and the rest of the time she spends with her family at home. during the covid- pandemic, she has had to spend all of her time at home with her family. the third case coded as nayab is a woman in her thirties with two children (a five-year-old daughter and a two-yearold son). she is comparatively less educated (she has ten years of schooling) than the other two cases in this study and is not financially independent. she is a housewife. however, her husband is highly educated (he has years of education) and has a job as a senior management officer in a local private organization. her family environment is not culturally and religiously fundamental, however, she has always been seen wearing culturally appropriate clothing and is traditional in her views about lifestyle. she does all the household chores herself, however, during the last few weeks of her pregnancy and the initial weeks after giving birth to her two children, she hired a female servant for the household chores. during the covid- pandemic, her husband spends most of his time at home doing his professional work online through internet and mobile phone services. to study the experiences of the participants, the authors have come from the position of moderate, educated pakistani muslims who believe in the progressively negotiated identity of muslim women that resists universalist as well as indigenous traditional oppressions. in the following sections, major themes that were identified through regressive and recursive readings of the transcripts are analysed. our analysis is informed by the feminist assumption that the non-traditional agency of women, like the one that comes from their mobility and economic independence, in patriarchal societies, easily falls vulnerable to curtailment during moments of national crisis, and they are mostly supposed to step back to their conventional gender roles. one of the major themes that transpired from the data is the compromised identity and frequent mental stress that all the three cases under study have experienced in their respective familial environments during the lockdown period. doing jobs, nisa and rida had become accustomed to such an environment which they considered was professional and in which they used to think and act professionally as useful and empowered persons of the society. but the lockdown shut them in homes rendering them traditional mothers and caregivers while facing harsh behaviours of their male life-partners which added to the mental stress they were already suffering from because of the widespread fear of the pandemic. nisa says: it is signified by the above excerpt that though nisa has multiple coexisting positions and identities as an educated, economically independent, professional muslim married woman, what ultimately dominates her, during these times of national calamity, is her identity as a 'good' wife and mother; the rest have to be compromised and even suppressed, at least for the time being. though the educated, professional and economically empowered positionalities and identities enable her to discern the patriarchal suppression and negotiate the religioculturally defined 'pari likhi' (educated) wife and mother makes her behave patiently and modestly, corresponding with the findings of khurshid ( ) about educated muslim women in an ethnographic study in pakistan. being an educated muslim woman in pakistan implies a privileged social position entitled to claiming power in decision-making in familial matters, but these educated women feel greater social pressure to abide by the islamic morality and struggle within rather than without the institutions of family, culture and religion (khurshid, ) . zubair and zubair ( ) argue through personal narratives of their research participants (muslim women educated in english literature in pakistan) that multiple positionalities and identities, like the one seen in nisa, enable women to negotiate in the third space by being resistive to the local religioculturally defined patriarchal structures and the western concepts of women's autonomy. however, the situation wherein nisa is operating is unusual which has triggered reinforcement of traditional norms in familial environments which expect her to conform rather than to resist or negotiate. people have turned more religious, intended to please god to forgive them and end his wrath that has struck them in the form of the pandemic; this general behaviour of the society also makes its imprint on familial environments. being a 'bad' wife or mother by resisting her traditional normative duties may not be afforded in these times of hyperreligiosity of the society. fighting against and suppressing her identity as an empowered and intellectually mobile woman while embodying like a good wife and mother has created unusual psychological pressure for her. similarly, rida says: rida, though a single parent who divorced her husband years ago and has only one daughter and parents to take care of, has started feeling like the traditional woman who is just supposed to stay at home and look after familial domestic matters. she feels that the identity that she had negotiated for herself as an independent professional woman has come under threat through the containment/lockdown measures. i feel as if this disease is the new super authoritarian man that has been fast rendering me powerless and reduced to femininity. i do try to find some time to read books, and to answer the queries of my students who keep sending me messages through whatsapp about their studies. however, you really have to grapple to find some time for such things. nisa personifies covid- as the super authoritarian man that has continuously been rendering her deprived of her power to negotiate the traditional patriarchal norms and assert herself. she has to continuously remind herself to situate her thinking, feelings and actions within the sociocultural structures of her family which are hyper-conservative. her mobility for her paid job does not mean that the social and familial norms have undergone some drastic and established change. though cultural fluidity giving rise to women's mobility and less conservative social spaces in the contemporary globalized pakistan cannot be denied, its effects are still restricted mostly to the private lives of people rather than seen generally in the society (safdar & ghani, ) . despite shifts in their identity due to their multiple social positions, women in pakistan have to embody traditional gender perceptions while in public spaces. the identity of these women is precarious and vulnerable to challenges due to their being in multiple social positions, locations and roles that are contradictory. as mouffe ( ) notes: the identity of such a multiple and contradictory subject is therefore always contingent and precarious, temporarily fixed at the intersection of those positions and dependent on specific forms of identification. it is therefore impossible to speak of the social agent as if we were dealing with a unified, homogeneous entity. we have rather to approach it as a plurality, dependent on the various subject positions through which it is constituted within various discursive formations. (p. ) zubair and zubair ( ) call it frontstage and backstage identities when educated muslim women in pakistan have to behave and act differently in their public and private lives and/or while in different social spaces. but being at frontstage and backstage is not devoid of mental stress, at least in the cases of nisa and rida who, after having learnt to think critically and negotiate their identity, have to step back and dormant their faculties of reasoning and negotiating just to conform to the traditional and dogmatic normative structures. nayab's situation, however, is pretty different from nisa and rida. being an average educated housewife with a husband who is more interested and involved in his professional matters than those of home, she is happy performing her household responsibilities regarding looking after and feeding her two children, and cooking, washing and cleansing. she has negotiated her position as a responsible wife and mother and therefore claims a considerable decisive power in household matters. this negotiated position comes under threat when her husband has to stay at home all the time due to the lockdown/containment measures of the government. before the covid- pandemic, nayab used to use her ability and skills of taking care of her home, husband and children as her agency to negotiate and resist the domineering influence and superiority of her husband's education and provision of financial resources. with a few exceptions, her husband too regarded her for her skills as a good caregiver. however, the newly emerged situation in which they have to live together inside the home for weeks has made her husband even question her very ability that had enabled her to negotiate her identity. all the three women, though situated differently and having different positionalities and identities, have similarity in the perceived threats to the identity that they had taken years to develop; and these perceived threats are a cause of their mental stress. however, they do not simply submit as a way of surrendering, rather they reposition themselves and re-resist through various changed tactics. understanding the sensitivity of the unusual circumstances under the pandemic lockdown and taking her husband's stay at home as just temporary, nayab uses her silence, submission and even greater consciousness of her wifely and motherly duties as a wilful strategy to counter the domineering behaviour of her husband. her silence is not a helpless or unthoughtful surrender but a strategy to pull herself off the conflict and prove through her behaviour and action that she is more in control of her temperament, behaviour and treatment to others. however, she does feel the pain her husband's growing misbehaviour has caused her. nayab says: worsen. my silence silences him. though i feel upset but i mind my own business even more carefully. the use of silence by nayab to silence her raging husband is strategic, agentive and resistive. it is in correspondence with the findings of bartkowski and read ( ) about wifely submission of christian female participants; it is also resonant of the findings of zubair and zubair ( ) regarding agentive silence of muslim women to their husbands in the patriarchal religio-cultural society of pakistan. if not discursively, psychologically and behaviourally she resists the patriarchal oppressive measures of her husband. perhaps due to being positioned in the financially and socially disadvantaged position, nayab (as she is economically dependent on her husband and is less educated) makes comparatively greater use of silence as agency than nisa and rida. they have been found using their knowledge and information of the updated developments in pakistan and across the world regarding the pandemic as a strategy to negotiate and resist the sudden patriarchal clampdown on them. though nisa endeavours to comply with the heightened religio-cultural traditional responsibilities of her as a wife and mother, she, as a way to be agentive, finds time to take part in informative discussions with her husband, sons and in-laws. rida also often keeps updating her parents of the latest impacts of the pandemic and what the government is doing as a result. it enables them to resist against the patriarchal structures that have pushed to narrow their gender space. they discursively open and expand a space for them in which they have power in the form of information, knowledge and critical thinking which agentively repositions them against the traditional expectations of the patriarchy. being situated in a socially advantageous position (highly educated and economically independent), nisa and rida are agentive not only psychologically but also discursively, through silence as well as discourse. further, nisa being the mother of three sons (giving birth to a son in a patriarchal society empowers the mother by enhancing her respect and value in her family and society) possesses another point of leverage. on the one hand, her religio-culturally fundamentalist family environment curtails many of her human rights; on the other hand, she, being very knowledgeable in islamic teachings about muslim women's rights, embeds her agency in religion. she resists her husband's oppressive manoeuvres through silence as well as discourse that are supported by her stance in religion. her agency is neither of the type that mahmood's ( ) women exercise through their piety, nor is it of the type of islamic feminism which reinterprets quranic text from a feminine perspective (barlas, ) . rida's comparatively less conservative environment than that of nisa and her having no husband to domineer her also enables her to easily create a space for herself. however, being a divorced middle-aged woman she also has to be careful regarding her modesty and piety in society as she is more likely to be seen by others to be having an illicit relationship. nayab's domestic environment is also not conservative; also, she is not in a socially disadvantageous position regarding the sex of her children as she has given birth to a daughter and a son. however, perhaps what makes her seek recourse to silence rather than to discourse is her being comparatively less well equipped with knowledge that could have empowered her in discourse as well. the identity of each of these three women is contingent on the conjuncture of a number of intersecting factors defining their gender. being (re)situated in their respective historical specificities, they appropriate and reconstruct their religious, cultural and feminist ideals to negotiate their gender space. nisa supposes men, the state and the dominant social behaviour toward women as being in connivance with each other in the form of a nexus to ensure enforcement of patriarchal power structures. though by her religious and cultural orientation she does not consider it appropriate for a muslim woman in pakistan to complain to state institutions against her own husband for minor abuse or torture, she highlights the need for the availability of and ease of access to such state institutions whom a woman can conveniently approach for justice if she feels she is being seriously tormented by her husband or in-laws. despite being highly educated and being in professional jobs, both nisa and rida do not know the existence of any state institution or even a helpline in their city that is especially available to rescue a woman if she is under threat of any kind. it corresponds with the observations of dawn ( a dawn ( , b that the state has introduced several legislations over the previous two decades to protect women's rights. however, due to the lack of proper planning and allocation of resources for the implementation of these legislations, the condition of women has not changed much; even a dominant majority of women is unaware of these laws. it seems the patriarchal core of the nature of the state institutions has not changed; consistent implementation, training of state institutions and change in social behaviours are still things a long way off. the pakistani state being actively involved in defining and shaping the gender of its muslim women became glaringly obvious during general zia's regime, whose impact can still be felt in its various forms including extremist religious ideologies regarding muslim women's identity in public spaces (jamal, (jamal, , rouse, ; saigol, ; suleri, ; zia, ) . in the last few decades, the state has passed several such legislations (perhaps under the pressure of its western donors that want to see gender equality) that are pro-women, but lack of coherence in their implementation indicates the level of seriousness on the part of the state. even in normal situations in the country, the appropriated and reconstructed identity of educated, working, mobile muslim women remains vulnerable to the patriarchy's whims; abnormal situations like covid- just add to its vulnerability in which women find no option other than to succumb and/or reposition themselves depending on their own specific situations. in a society where there does not exist in normal conditions the generally accepted social practice to approach the state for matters like domestic violence, women perhaps cannot even imagine doing so during the pandemic-like national crisis which traditionally demands them to be more 'cooperative' to their men. it is good that there should be some institution to complain; at least we are also human beings. i've heard about some women who were even killed by their husbands and in-laws. when asked if she would complain against her husband, she says: no, not at all. i do not mean to complain against my own husband when i talk about these laws. i was just talking about them, not meaning to actually approach them. it is not fair. i can't even imagine it. it's not a practice here in our society. these are hard times on us. doing so will be highly unfair. though nayab is aware of her rights as a human being and is worried about the mental torture given to her by her husband's growingly oppressive and insulting behaviour, she does not think it appropriate to complain about it to the state because doing so is socially unacceptable. like most other states, the pakistani state has also played a major role in shaping the social behaviour of its people; in pakistan, patriarchal interpretations of religion and culture have greatly inspired the state's policies focused to regulate social behaviours. nayab's predicament can be described as a typical example of many of those muslim women in her situation who are conscious of their oppression but are unarmed and revert back (by the overtly/covertly state-supported social behaviours) to their traditional strategies of resistance that are silence and psychological agency, rather than 'rhetorical agency' which is seen on the part of nisa and rida to re-construct new subject positions for them (sinha, , p. ) . this study reveals that the chances of vulnerability of the negotiated identity and social space of middle-class educated muslim women in urban pakistan get heightened in situations like covid- mainly due to the religiously inspired dominant patriarchal social behaviours and the state's inability to practically empower its women during normal conditions. though neither the abnormal pandemic conditions are to stay as permanent, nor the women in these situations, what gets exposed is the nascence of their negotiated identities and social spaces which are contingent on the intersectional social structures and conditions. the psychological scars of nayab and nisa due to their husbands' oppressive and even insulting behaviour may get stored in their unconscious and not be healed for a long time, and can also leave a long-lasting impression on their children's psyche and behaviour as well. given the dominant general social behaviour towards the state's treatment of gender, what is considered of paramount importance by all the three women, during the abnormal pandemic circumstances, is to conform to the normative structures while innovating new forms of re-positioning and re-negotiating their identity in their respective contexts. gendered social behaviour, the state's policies and women's identity are interlinked. the study also reveals that awareness, education, mobility, religiosity and economic self-dependence intersect (variously according to their contextual setups) to re-enable the women to re-negotiate their traditional gender identity as wife and mother, re-position and reconstruct their subjectivities even during the stressful times. they take care of their families and perform their wifely and motherly duties as well as innovate ways to re-position themselves to seek agency. this study indicates that if educated urban women feel the social pressure to step back to their traditional patriarchal roles while bearing domestic violence as well, the situation of those living in remote/rural areas or less empowered women could be much worse. the nexus of religiously inspired patriarchal social behaviour and the state's callousness regarding implementation of its laws renders women suppressed. given the religiously disguised violent reaction of the local patriarchal elements to feminist voices in pakistan, the authors, throughout this study have felt the normative pressure not to speak about the issues related to the women participants' sexuality which are cultural taboos. the findings and conclusion of this study enable the first author, whose gendered perspective repeatedly intervened to demand closer insights and empathy in order to feel and understand the participants' situations, to get insight into the underlying religio-culturally disguised patriarchal oppressions of which he himself, consciously or unconsciously, at least partly, had been a part. however, the author has progressively been moderate, advocated and voiced for the rights of muslim women in pakistan. the authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article. https://orcid.org/ - - - musarat yasmin https://orcid.org/ - - - we were muslims but we didn't know islam': migration, pakistani muslim women and changing religious practices in the uk. women's studies international forum ethnography and discourse analysis: dilemmas in representing the voices of children does the qur'an support gender equality? or, do i have the autonomy to answer this question veiled submission: gender, power and identity among evangelical and muslim women in the us re/constructing research narratives: self and sociological identity in alternative settings pakistan passes anti-honor killings and anti-rape bills khalil ur rehman, please sit march ). violence against women the largest ever epidemic of ebola case study secularizing islamists? jamaat-i-islami and jama'at-ud-da'wa in urban pakistan women, islam, and the state in pakistan 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marginalization of gender: a discourse analysis of advertisements in pakistani newspapers faith and feminism in pakistan: religious agency or secular autonomy? just a time-pass: acknowledgement/denial (?) of sexual harassment in young women's discourse situating islamic feminism(s): lived religion, negotiation of identity and assertion of third space by muslim women in pakistan. women's studies international forum he graduated from pakistan, the united kingdom and the united states. his research areas include gender and sexuality, identity, displacement, cultural hybridity, postcoloniality and english language teaching.his research has been published in peer-reviewed international journals which have impact factor since , she has been an assistant professor with the university of gujrat, pakistan. she has the highest impact factor(thomson reuters) in the field of english language in pakistan. she has authored more than peer-reviewed international journal papers with an h-index . her research interests include discourse analysis, language, education and adult education. she serves as a co-editor of hayatian journal of linguistics and literature(hjll) key: cord- - pf mj authors: thomason, bobbi; macias‐alonso, inmaculada title: covid‐ and raising the value of care date: - - journal: gend work organ doi: . /gwao. sha: doc_id: cord_uid: pf mj in this opinion piece, we argue the current pandemic is shining a light on caregiving as critical work that is under‐valued and under‐paid. we call upon national lawmakers to raise the value of care work. doing so would also make progress in solving another national crisis: closing the gender wage gap. we explore how the gender wage gap is driven primarily by the fact that men and women sort into different work, with women being over‐represented in work where they care for others and in work that allows them to care for their families. senate democrats have called for a 'heroes fund' within the coronavirus relief bill of up to $ , pay for frontline healthcare and service industry workers caring for our country during the coronavirus (the associated press, ). we hope this is the first of many ways the current pandemic will make national leaders, regardless of party affiliation, recognize caregiving as critical work that is under-valued and under-paid. doing so would also make progress in solving another national crisis: closing the gender wage gap. in the united states, women are paid percent less than men on average. the gap is even worse for black women and latinas, paid and percent less than white men on average (hegewisch & tesfaselassie, ) . this gap is driven primarily by the fact that men and women sort into different work, with women being over-represented in work where they care for others and in work that allows them to care for their families (blau & kahn, ; goldin, ; reskin, ) . women are concentrated in so-called heed professionshealth care, early education and domestic roles (block, croft, & schmader, ) . as of in america, women make up . percent of registered nurses, . per cent of kindergarten and preschool teachers and percent of maids and housekeepers. women also dominate caregiving roles in other industries: women make up . percent of administrative assistants and secretaries and . percent of social workers (us bureau of labor statistics, ). many of these jobs are low-paid (center for the study of child care employment, ). in fact, women make up the majority of minimum wage workers in almost every state (national women's law center, ). these are precisely the jobs that have been laid-off and furloughed in the wake of the coronavirus (alon, doepke, olmstead-rumsey, & tertilt, ) . they are also the jobs saving lives, comforting those in their last moments and riskingor even losingtheir lives to care for others (schwirtz, ) . women are also over-represented in part-time, temporary and informal work (un women, ; williams, ; world health organization, ) . many women turn to part-time work to have more time to care for their families (grant-vallone & ensher, ; higgins, duxbury, & johnson, ; hochschild, ) . however, working part-time means women earn less and are promoted less frequently (stone, ; stone & lovejoy, ) . it also means they are less likely to have employer benefits when a crisis hits, such as paid time off (boesch, ) . that the current situation is making care work more precarious is also problematic for many families. over percent of american families depend on a mother's earning for their economic wellbeing and about percent depend solely on a female breadwinner (joint economic committee, united states congress, ; us bureau of labor statistics, ). given women's over-representation in low-wage work, it is no surprise that their savings are on average less than men's (perez, ) , making them even more vulnerable during economic shocks. it is important to note that markets do not inherently value some jobs over others. rather, professions dominated by women have lower prestige and pay than those dominated by men. we know this because gender composition and compensation of particular occupations changes over time. take computer programmers in the united states for example. when programming was predominantly female, status and pay used to be low. as it became an increasingly male occupation, status and compensation went up. similarly, when women move into male-dominated professions, those jobs begin to pay lesseven controlling for factors such as education, work experience, skills and race (cohen & huffman, ; levanon, england, & allison, ). even when men and women work in the same professions, they continue to be sorted into high-and low-status positions. for example, men in care occupations tend to reach management and supervisory roles faster than women, a phenomenon known as the 'glass escalator' (williams, ) . this, together with sorting into different specialties, partially explains the . percent gender pay gap for doctors (kavilanz, ) . the lack of compensation for care work is particularly visible during the current crisis, when care work is exceptionally valuable and consequential. under covid- , women represent the majority of the health workforce, provide the majority of home-based care (smith, ) and take on most of the domestic burden (graves, ; hochschild, ; moen & sweet, ) . as children are now home from school (donner & purtill, ) , parents across the country are reminded not only that teachers' jobs are difficult, but also that they are critical for continuing every other job. closing the gender wage gap is a complicated, multi-level undertaking that requires the federal government's commitment to raising the value of care. this means legislating paid family leave so both mothers and fathers are equally available for caregiving, universal health care so part-time, temporary and informal workers have access to basic medical care, and protecting the rights of vulnerable workers to organize. it is critical our federal government sets aside party lines to support caregivers and care work in the midst of this pandemic. lawmakers should act quickly to pass the 'heroes fund' legislation and recognize, on even ground, the outsized contributions of care by frontline healthcare and service industry workers. and, when our country returns to normal, it is also critical that our federal government remember that caregiving is hard, valuable and crucial work and pass further legislation to ensure care workers receive the compensation and protection they deserve moving forward. since moments of rupture allow new ways of being, let's not rush back to pre-covid- normal, let's find a new normal in which we care about those who care for us. the authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article. https://orcid.org/ - - - the impact of covid- on gender equality (nber working paper series: economic fluctuations and growth, ) the gender wage gap: extent, trends, and explanations worth less?: why men (and women) devalue care-oriented careers rhetoric vs. reality: not all paid leave proposals are equal why do parents pay so much for child care when early educators earn so little? occupational segregation and the devaluation of women's work across u.s. labor markets figuring out home schooling in the age of coronavirus. the new york times a grand gender convergence: its last chapter opting in between: strategies used by professional women with children to balance work and family women's domestic burden just got heavier with the coronavirus. the guardian earnings differences by gender, race, and ethnicity (no. c ) part-time work for women: does it really help balance work and family? human resource management gender pay inequality: consequences for women, families and the economy the gender pay gap for women doctors is big -and getting worse. cnn business occupational feminization and pay: assessing causal dynamics using - u.s. census data women and the minimum wage, state by state savings by gender: who's saving more, women or men? magnifymoney sex segregation in the workplace nurses die, doctors fall sick and panic rises on virus front lines gender and the coronavirus outbreak. think global health opting out?: why women really quit careers and head home fast-track women and the 'choice' to stay home paying attention to women's needs and leadership will strengthen covid- response. un women: news and events the glass escalator: hidden advantages for men in the 'female' professions unbending gender: why family and work conflict and what to do about it gender equity in the health workforce: analysis of countries (health workforce working paper ) bobbi thomason is an assistant professor of applied behavioral science at pepperdine graziadio business school. her research explores how individuals of traditionally under-represented social categories work and pursue their careers globally inmaculada macias-alonso is a postdoctoral fellow at the women and public policy program at the harvard kennedy school. her research focusses on the effects of gender on labor market access and various organizational processes how to cite this article: thomason b, macias-alonso i. covid- and raising the value of care key: cord- -k osvkd authors: johnson, carol; williams, blair title: gender and political leadership in a time of covid date: - - journal: nan doi: . /s x x sha: doc_id: cord_uid: k osvkd the covid- pandemic has undermined the division between the private sphere of the home and the public sphere of politics that has traditionally disadvantaged women political leaders. whereas male political leaders historically drew on their traditional role as the male head of household to display forms of masculine protectionism toward citizens, women leaders are now able to draw on their traditional motherly role—for example, as the member of the household who traditionally cares for the sick—to display forms of feminine protectionism. as a result, international women leaders have managed to leverage women's role in the home to their advantage in the political sphere. significantly, an appreciation of traditionally feminine attributes in women political leaders has been displayed in much media coverage, providing more favorable coverage of female political leaders than was previously the case. such as aggression and toughness, on the one hand, and satisfying expectations of feminine traits such as empathy and caring, on the other (schneider and bos , - ; see also jamieson ) . voters generally prefer stereotypically male traits in political leaders, although when women leaders display these traits, they are often devalued in comparison with their male counterparts (dolan and lynch ) . schneider and bos ( , ) note a distinction between the feminine stereotypes faced by women inside and outside of politics, arguing that women leaders are often seen to lack stereotypically feminine strengths as well as the masculine qualities deemed necessary for leadership. however, we argue that the pandemic has opened up particular opportunities for perceived everyday feminine traits in the private sphere to be valued in women leaders, including by the media. conforming to gendered stereotypes, male politicians commonly depict themselves as strong leaders who will protect their citizens from both internal and external threats while promising economic security. this depiction can be seen as a form of protective masculinity (c. johnson ; c. johnson , - ) , in which male leaders draw on traditional conceptions of the male head of household and breadwinner who protects and cares for their family to suggest that they have the necessary masculine characteristics to protect their nation. for example, donald trump depicts himself as the strong alpha male who will defend americans from threats such as undesirable immigrants and the loss of jobs overseas to "make america great again." by contrast, protective femininity (c. johnson , - ) draws on forms of protectiveness, often incorporating caring and empathy and associated with women's role in the family, to suggest that women politicians have feminine characteristics that will facilitate their looking after citizens. however, the coronavirus has had an impact on political leaders' attempts to evoke forms of protective masculinityor, more rarely, protective femininityto make citizens feel safe and secure. in particular, trump has faced a potential masculinity fail as his administration faces major criticism for neglecting to protect americans from covid- . consequently trump has tried to portray the image of a strong leader fighting "a war against the invisible enemy" from communist china while opening up an economy that weaker politicians want to unnecessarily close down (trump and pence ) . other male leaders, such as boris johnson ( ) , have also resorted to masculine war metaphors, given that defense is normally seen as a stereotypical area of male leaders' strength (schneider and bos , ) . meanwhile, joe biden ( ) has attempted to counter trump by mobilizing both war metaphors and compassion. however, the covid- pandemic has provided unusual opportunities for women leaders to display forms of protective femininity. while male leaders have built on the role of male head of household and warrior defender in honing their gender performance, women leaders have been able to draw on traditional conceptions of women's roles. after all, it is traditionally mothers, not fathers, who look after sick members of the family. it is traditionally mothers who take charge of household hygiene and ensure that children and recalcitrant males wash their hands. it is also women who are traditionally caring and empathetic in times of trauma. as a result, the pandemic has undermined the traditional divide between the (feminine) private sphere of the home and the (masculine) public sphere of politics (celis et al. ) that has traditionally disadvantaged women leaders, allowing them to leverage women's role in the home to their advantage in the political sphere. such an opportunity is not unprecedented. for example, there have been situations in which women leaders in postconflict and postdictatorship societies have argued that their experience as women and mothers has equipped them with much-needed additional attributes, such as empathy and conciliation skills, that their male opponents lacked (franceschet, piscopo, and thomas ; thomas and adams ) . perceived feminine leadership attributes are also sometimes valued more in times of crisis (ryan et al. ) , though male political leaders are still generally favored to handle crisis situations (dolan and lynch , ) . however, the health nature of the current crisis, combined with the focus that lockdown places on being confined to the (feminized) sphere of the home, has arguably facilitated the leveraging of women's role to an even greater extent. consequently, various women leaders have exhibited strength in confining citizens to the home while simultaneously displaying motherly feelings of caring, empathy, and compassion. after an emergency horn announcing a lockdown sounded on mobile phones, new zealand prime minister jacinda ardern appeared live on facebook direct from her home to both comfort citizens and urge compliance. ardern ( b) apologized for her "casual attire," an old sweatshirt, because "it can be a messy business putting toddlers to bed." she warmly and sympathetically answered livestream questions, giving useful practical advice, including avoiding touching playground equipment. she urged new zealanders to be kind and caring (ardern a) . the norwegian prime minister, erna solberg ( ), held a press conference specifically for children, empathizing that "many children are finding this scary" but gently explaining the measures taken to protect their families. german chancellor angela merkel, who has a phd in quantum chemistry, won plaudits for her clear explanation of infection spread rates. however, merkel ( ), nicknamed "mutti" (mommy), also expressed compassion for how painful social distancing and isolating the elderly would be, because in hard times: "we show affection by staying close, and by reaching out to each other. but at this time, we must do the exact opposite." in short, styles of leadership during the pandemic have often reflected particular performances of gender. significantly, the opportunities opened up for performances of protective femininity, especially the valuing of perceived feminine traits in the private sphere of personal life, have also facilitated favorable media coverage. women politicians, particularly leaders, commonly experience far more gendered and personalized critical media coverage than their male counterparts (see hall and donaghue ; trimble ; williams ). yet, for the reasons suggested earlier, what has often disadvantaged women leaders previously is now working to their advantage. the media have largely portrayed women leaders positively in their effective responses to the pandemic, from the washington post headline declaring "female world leaders hailed as voices of reason" to the times headline arguing that "women are the stronger sex in this crisis" (hassan and o'grady ; phillips ) . leaders such as ardern, merkel, and taiwan's president tsai ing-wen have been praised for their "effective messaging and decisive action," which has contrasted starkly with "the bombastic approaches of several of the world's most prominent male leaders" (hassan and o'grady ) . indeed, some "strongman" leaders such as trump, johnson, xi jinping, and jair bolsonaro have come under scrutiny for their inadequate pandemic response. media coverage has labeled them as "self-interested" (hartcher ) and "weak" (lewis ), displaying a "reckless insouciance" and a "lethal incompetence" (tisdall ). this sentiment is even shared by the conservative press (see leach ; stewart ; tominey ), which, prior to the pandemic, generally portrayed women leaders through a stereotypically traditional gendered lens (williams ) . in fact, analyzing english-language media articles published in april and may reveals little negative media coverage of women leaders' responses to the crisis, other than broader conservative critiques of the impact of lockdowns on nations' economies (e.g., creighton ). nonetheless, the mainstream media continue to draw from gender stereotypes in the personal, private sphere. the same articles that praise women leaders describe their leadership style using stereotypically feminine adjectives, such as "kind," "caring," "sincere," and "thoughtful." likewise, media coverage of women political leaders continues to focus on their appearance and personal lives (ross , ) . for example, articles noted that ardern was "wearing a sweater" (sparrow ) and "look[ed] tired" (cave ) . however, unlike previously, women's difference from toxically masculine leaders is now celebrated, and their casual home attire is embraced as a sign that they are more relatable and sincere. pre-pandemic media coverage of women leaders regularly focused on their decisions to have or not have children. now the media uses this gendered trope to depict a maternal form of protective femininity; they are mothers of the nation protecting their "children." merkel, for example, has older stepchildren but no biological children. one article argued that merkel's effective response had "return[ed her] to the role of the nation's mutti" (chazan ) , while another noted that she is not a "touchy-feely" mum but a "disciplinarian" (lewis ) . media coverage of ardern repeatedly mentioned her maternal status. articles noted that she was "only the second world leader to give birth in office" (looms ) , that she is a doting "mother and world leader" (cave ) , and that her baby, neve, is often audible in her facebook live videos (sparrow ) . like merkel, ardern has also been portrayed metaphorically as the maternal protector of new zealand: she "held kiwis' hands through the lockdown" (henley and roy ), blended "epidemiology . . . with empathy, law leavened with mom jokes" (cave ) and, after putting her toddler to bed, "empathized with citizens' anxieties" (taub ) . like so many other women political leaders, ardern is depicted as providing the maternal comfort that we seek when we are illthe one to comfort us and lessen our anxieties. whether such an appreciation of the stereotypically feminine will continue remains to be seen. in particular, turning attention to reopening damaged economies may reemphasize traditional divisions between the feminized private (home) and the masculine public (economy). women political leaders could be regarded as less appropriate for economic crises (blanton, blanton, and peksen , ) . more traditional gender relations have often been normalized again after crises are over (kaufman and williams , ) . there is a clear need for further analyses, including into the question of whether problematic gender stereotypes have been reinforced during the pandemic or whether conceptions of good leadership are now more inclusive of traditionally feminine traits. however, for the moment, women leaders seem to be experiencing a level of appreciation that has rarely been seen before. relations at the university of adelaide, australia: carol.johnson@adelaide.edu.au; blair williams is an associate lecturer at the australian national university, canberra, australia: blair.williams@anu.edu.au covid- alert level increased facebook live vice president joe biden questions trump's covid response the gendered consequences of financial crises: a cross-national analysis jacinda ardern sold a drastic lockdown with straight talk and mom jokes introduction: gender and politics: a gendered world, a gendered discipline angela merkel: germany's crisis manager is back a feminised style of politics? women mps in the house of commons flightless economy will land with a thud the impact of gender stereotypes on voting for women candidates by level and type of office motherhood and politics in latin america: continuity and change nice girls don't carry knives': constructions of ambition in media coverage of australia's first female prime minister xi and trump: insecure 'strongmen' who had nothing to offer in a crisis but vanity female world leaders hailed as voices of reason amid the coronavirus chaos are female leaders more successful at managing the coronavirus crisis beyond the double bind: women and leadership playing the gender card: the uses and abuses of gender in australian politics pm statement on coronavirus gender, emotion and political discourse: masculinity, femininity and populism introduction lead the way: while strongmen let us down, women show us the virtue of competence the pandemic has revealed the weakness of strongmen jacinda ardern praised for wearing coat with nappy cream on it feminizing politics an address to the nation by federal chancellor merkel women are the stronger sex in this crisis gender, politics, news: a game of three sides getting on top of the glass cliff: reviewing a decade of evidence, explanations, and impact measuring stereotypes of female politicians the interplay of candidate party and gender in evaluations of political candidates introduction at press conference for children what makes jacinda ardern such a special political presence? trump's most dangerous test why are nations led by women doing better? breaking the final glass ceiling: the influence of gender in the elections of ellen johnson-sirleaf and michelle bachelet trump, putin and bolsonaro have been complacent. now the pandemic has made them all vulnerable leaders in lockdown: who are the winners and losers remarks by president trump and vice president pence in roundtable with industry executives on the plan for opening up america again a gendered media analysis of the prime ministerial ascension of gillard and turnbull: he's 'taken back the reins' and she's 'a backstabbing' murderer key: cord- -yw zlucc authors: aghababaei, soodabeh; bashirian, saeed; soltanian, alireza; refaei, mansoureh; omidi, tahereh; ghelichkhani, samereh; soltani, farzaneh title: perceived risk and protective behaviors regarding covid- among iranian pregnant women date: - - journal: middle east fertil soc j doi: . /s - - -z sha: doc_id: cord_uid: yw zlucc background: despite the vulnerability of pregnant women, few studies have been conducted on their perceived risk and protective behaviors during the covid- pandemic. the present cross-sectional study aims to investigate the perceived risk and protective behaviors regarding covid- among pregnant women, in hamadan, iran. using a two-stage cluster sampling method, pregnant women referring to the health centers completed the questionnaires. data were analyzed using the kruskal-wallis and spearman correlation tests as well as a stepwise linear regression model at % confidence level. results: . % of pregnant women had a high level of knowledge, . % had a high performance in protective behaviors, and . % had a moderate level of risk perception related to covid- . the highest mean score of knowledge was observed in women who had a history of influenza in their previous pregnancies ( . ± . ). the mean score of protective behaviors was significantly higher in women with a high economic level ( . ± . ), and the highest level of risk perception was observed in nulliparous women ( . ± . ). risk perception was an independent predictor of protective behaviors related to covid- (p < . ). conclusions: pregnant women had a high level of knowledge, high performance in protective behaviors, and a moderate level of risk perception related to covid- . history of influenza in previous pregnancies, high economic level, and nulliparity were associated with higher levels of knowledge, protective behaviors, and risk perception, respectively. risk perception of pregnant women regarding covid- can predict their protective behaviors. in the last days of , an unknown outbreak of pneumonia was reported in eastern china, which was recognized by the world health organization as covid- [ ] . the most important route of transmission agreed by all is respiratory droplets or direct human-to-human contact [ ] [ ] [ ] . covid- , which has now become a pervasive epidemic, is a serious public health emergency that is deadly, especially in vulnerable populations and communities where health systems are not sufficiently prepared to manage the infection [ ] . pregnant women and their fetuses are at high risk during the outbreak of infectious diseases [ ] . in general, physiological and mechanical changes during pregnancy increase susceptibility to infections. researchers have shown that emerging infections have a significant impact on pregnant women and their fetuses [ ] . previous data from sars and mers infections show that clinical findings during pregnancy can range from mild symptoms to severe illness and death [ ] . it seems that coronavirus infection in the third trimester of pregnancy increases the risk of premature rupture of the membranes, preterm labor, fetal tachycardia, and fetal distress [ ] [ ] [ ] . therefore, it is important that pregnant women and their families, as well as health care providers, receive as much accurate information as possible. during the corona epidemic, it is recommended that pregnant women take care of personal and social hygiene and avoid unnecessary trips, crowded places, public transportation, and contact with sick people [ ] . pregnant women have different attitudes toward the recommendations of health care providers. some evaluate the given instructions based on their views and experiences and change them if they do not feel useful, but some women carefully follow the treatment plans and welcome health care to reduce the risk [ ] . in pandemic diseases, perceived risk encourages people to engage in protective behaviors to reduce potential risks [ ] . globally, risk is defined as the probability of loss and is thought to be composed of two components: probability and severity of negative outcomes [ , ] . meanwhile, risk perception is defined as a person's expectation of a particular event occurring [ ] . risk perception as an important determinant of healthy behaviors plays an important role in designing interventions to change behaviors [ ] . in the study of ackerman et al. on the iranian pregnant women, the higher fear of covid- was associated with higher preventive behaviors. covid- pandemic is the most intense and emotional experience of pregnant women's lives. in this regard, health care providers should pay more attention to pregnant women who have health concerns at the same time about themselves and their fetuses. currently, the mortality rate from covid- is lower than previous epidemics such as sars and mers. however, stress and anxiety may be the most important challenge in the covid- pandemic [ ] . transmitting large amounts of information and overuse of the media can lead to overreaction, irrational fear, and overperception of risk, which in turn might affect pregnant women's behaviors [ ] . psychobehavioral surveillance is critical during communicable disease outbreaks because it affects risk awareness strategies targeting high-risk groups such as pregnant women [ ] . measuring the level of risk perception as well as its determinants in pregnant women is essential for the transmission of information and health protocols. despite the vulnerability of pregnant women during the covid- pandemic, few studies have been conducted on their risk perception and protective behaviors. the present study aims to investigate the perceived risk and protective behaviors regarding covid- among iranian pregnant women. this cross-sectional study was conducted on pregnant women referring to the health centers to receive prenatal care in hamadan, iran, . the inclusion criteria included normal singleton pregnancies, without medical or obstetrical complications, and the ability to read and write. pregnant women who did not answer more than % of the questionnaire items were excluded from the study. considering the standard deviation of the knowledge of covid- in women (about . ), % confidence level, and maximum error equal to % standard deviation, the sample size was calculated to be pregnant women. the sample was drawn through a two-stage cluster sampling method. first, hamadan city was divided into four geographical regions (north, south, east, and west), and then two health centers were randomly selected from each region using the list of health centers ( health centers in total). thirty eligible pregnant women were randomly selected from each center, and after obtaining the informed consent of the participants, the self-administered questionnaires were completed with observing health protocols. the questionnaire consisted of sections including the following: . socio-demographic and obstetrics characteristics: including age, education level, place of residence, housing status, economic situation, gestational age, parity, pregnancy status, history of abortion, number of children, history of influenza in the previous pregnancies, and sources of information about covid- . . covid- -related knowledge ( items): the items were designed based on the health protocols by the world health organization [ ] , as well as the ministry of health and medical education, iran ( table ). the aspects of knowledge included etiology, symptoms, transmission, and public prevention. correct answers were assigned point, and incorrect answers or "i do not know" were assigned points. the total score was converted into a percentile. a score ≥ % was designated as high, - % as moderate, and ≤ % as low level of knowledge. . covid- -related risk perception ( items): using the visual scale measure [ , ] , perceived risks of maternal infection, fetal infection, fetal anomalies, abortion or fetal death, preterm delivery, hospitalization the newborn in the neonatal intensive care unit, and maternal death due to coronavirus infection were measured. responses were given based on a lickert range from (no perceived risk) to (high level of perceived risk). the total score, which was between and , was calculated from the score of . in this study, a score of less than was considered the low perceived risk, a score between and was considered the moderate perceived risk, and a score higher than was considered the high perceived risk. the items were designed based on the health protocols by the world health organization [ ] , as well as the ministry of health and medical education, iran ( table ). the aspects of preventive behaviors included social distancing, personal hygiene and frequent hand washing, public transportation, out-of-home prepared foods, and shopping. responses were "yes" or "no," and the participant was assigned point for each appropriate behavior and point for inappropriate behaviors. the total score was converted into a percentile. a score ≥ % was designated as high, - % as moderate, and ≤ % as low level of knowledge. the validity of the questionnaire was assessed using different experts' opinions, and its reliability was calculated using the cronbach α coefficient ( . ). statistical analysis was performed using spss/ . , at the % significance level. using the kolmogorov-smirnov test, none of the major outcomes followed a normal distribution and was analyzed using the kruskal-wallis and spearman correlation tests. stepwise multivariate linear regression analysis was performed to determine the most predictive indicator for preventive behaviors. the frequencies and percentages were computed for categorical variables, and the means and standard deviations were calculated for numerical variables. a total of pregnant women were enrolled in this study, and people responded to the questionnaires. the mean age of women was . years. the majority of participants had college education ( . %), were unemployed ( . %), had a moderate economic situation ( . %), and lived in their personal houses ( . %). the mean gestational age was . weeks. the majority of participants were primigravida ( . %), had a wanted pregnancy ( . %), had regular prenatal care ( . %), and did not have a history of abortion ( . %) or influenza in the previous pregnancy ( %); . % of pregnant women said that television was the main source of their information about covid- . table shows the distribution of participants' responses to the items of knowledge and preventive behaviors related to covid- . the average of correct answers was . % in the knowledge section. the lowest scores pertained to q (children do not get the disease), q (everyone in the community should wear a mask), q (coronavirus can be treated with common antiviral drugs), q (the flu vaccine can be given every year to prevent the coronavirus). in the preventive behaviors section, the average of correct answers was . %. the lowest score ( . %) pertained to "i keep my distance from others at home." according to the results, . % of pregnant women had a high level of knowledge related to covid- . . % of the participants had high performance in preventive behaviors, and . % of pregnant women had a moderate level of risk perception related to the disease ( table ). the mean score of knowledge in women who had a university education, their source of information was an obstetrician, had two or more children, and had a history of influenza in the previous pregnancy was significantly higher (p < . ) ( table ) . the highest mean score of knowledge was observed in women who had a history of influenza in their previous pregnancies ( . ± . ), and even in these women, the average level of risk perception and preventive behavior was higher than in pregnant women who did not have a history of influenza. the mean score of preventive behaviors was significantly higher in women with a high economic level (p < . ), so the highest score of preventive behaviors ( . ± . ) also belonged to this group of women. the mean score of risk perception in nulliparous women and those without a history of abortion was significantly higher (p < . ). the highest level of risk perception was observed in nulliparous women ( . ± . ), and the lowest level was observed in pregnant women who experienced two or more abortions ( . ± . ). the spearman correlations between knowledge, protective behaviors, and risk perception related to covid- are presented in table . risk perception was positively associated with protective behaviors (r = . , p = . ). the knowledge negatively associated with protective behaviors, but this relationship was not statistically significant (r = − . , p = . ). we also performed a linear regression analysis considering all studied risk factors to determine the most predictive indicator for protective behaviors. in table , we present the final multivariate linear regression model. stepwise multivariate linear regression analysis revealed that risk perception was an independent predictor of protective behaviors (β = . , p = . ). although the effect of covid- on pregnant women is still unclear, there are concerns about its potential impact on maternal and perinatal outcomes due to suppression of the immune system during pregnancy [ ] . however, few studies have been conducted on perceived risk and protective behaviors among pregnant women during the covid- pandemic. the present study addressed this important issue and measured the level of risk perception, knowledge level, and protective behaviors of pregnant women, as well as the relevant determinants. the present study showed that the level of knowledge related to the covid- and its transmission and mann-whitney u value *significant at the level of p < . prevention was high among pregnant women, so this level of awareness about the symptoms of the disease, and in particular the ways in which it is transmitted, has been almost above %. it seems that the awareness of pregnant women, both through the mass media and by health care providers, has increased significantly. in a study by nwafor et al., . % of pregnant women had sufficient knowledge of preventive measures against covid- [ ] . yassa et al., in their study on pregnant women near childbirth, found that pregnant women have a positive attitude toward quarantine. at the same time, they expressed their progressive anxiety and concern for the pregnancy and the baby due to the pandemic and also believed that they had been given insufficient counseling or limited information about the relationship between pregnancy and pandemic [ ] . in the present study, the majority of pregnant women [about %] believed that the general population should use masks to prevent disease; nearly % opposed it, and about % said they were unaware. it should be acknowledged that the unknown nature of covid- , and even its transmission, along with the different policies of different countries on disease protection, can have a significant impact on people's responses. besides, researchers have noted the sensitivity and concern of pregnant women about their vulnerability to infectious diseases. for example, an interview study conducted during the h n influenza pandemic revealed that the individuals most concerned for the possibility of getting infected or transmitting the virus to others were pregnant women and those with young children [ , ] . in the present study, % of pregnant women did not know that children could also develop covid- . about % of women did not know that the disease could not be treated with common antiviral drugs, and about % of pregnant women thought that the flu vaccine could be given every year to prevent the covid- . while the clinical evidence was growing rapidly, this data may guide to perceive what accurate information should be provided to pregnant women. our results showed that more than half of pregnant women obtained their information through tv. similar to our findings, other studies reported that participants usually obtained their information about infectious diseases through the internet and watching tv. olapegba and ayandele in a study in nigeria reported that traditional media [tv/radio] was the source of information regarding covid- for more than . % of people [ ] . in a similar manner, sasaki et al. found that television, the internet, and newspapers were the most common sources of information about the h n outbreak [ ] . according to our study, women with a university education were significantly more aware of the disease than women with less education. in the recent study of nwafor et al., one of the factors associated with inadequate knowledge of preventive measures regarding covid- was no formal education [ ] . the level of knowledge of pregnant women who had more children was significantly higher, and although nonsignificant, their risk perception was lower and their preventive behavior was better. contrary to our study, in the study of nwafor et al., pregnant african women who had given birth five or more times had lower levels of awareness about preventive measures related to covid- [ ] . the greater awareness of pregnant women with a previous history of influenza in the present study can be related to the increased sensitivity of this group of women to the risk of contracting viral diseases during pregnancy and its complications. pregnant women in our study reported high levels of protective behaviors related to covid- . it seems that during acute conditions such as epidemics, due to extensive training and information transition, high preventive behavior can be expected from individuals. in the usa, over the course of a few days, people became increasingly aware of the dangers of covid- and performed well on protective behaviors [ ] . in our study, pregnant women with better economic status had better protective behaviors. in a study by chandrasekaran et al. [ ] , knowledge and behavior related to zika disease were lower in women with poor economic status compared to women with moderate to high status. therefore, special attention should be paid to women with low economic status, especially during pandemics. nulliparous women in our study had a higher level of risk perception related to covid- than multiparous women. similar to the risk perception in other fields, pregnancy risk perception is highly individualized and several factors may influence the perception of pregnancy risk [ ] . risk perception is the subjective response based on previous life experiences, coping strategies, the context in which the risk occurs, and the degrees the risk obtained from a variety of sources [ ] . little is known about how risk impacts a woman's perception and experience of pregnancy [ ] . however, it seems that the experience of pregnancy and childbirth can reduce the perceived risk. the results of the present study showed that risk perception can predict preventive behaviors significantly. in contrast to our study, taghrir et al., in the recent study on the medical students, reported a negative correlation between preventative behaviors and risk perception related to covid- [ ] . risk perception as a determinant of protective behaviors is often positively associated with preventative behaviors, although in some cases negative interactions with preventive behaviors have been shown, for example, when the perception of risk is high, but the chance of success in dealing with it is considered low, preventive behaviors are reduced [ ] . the main strong point of the present study is addressing pregnant women as a vulnerable group during the covid- pandemic. yet, the causal relationships among the variables could not be assessed due to the cross-sectional design of the study. iranian pregnant women had a high level of knowledge, high performance in protective behaviors, and a moderate level of risk perception related to covid- . history of influenza in previous pregnancies, high economic level, and nulliparity were associated with higher levels of knowledge, protective behaviors, and risk perception, respectively. risk perception of pregnant women can predict their protective behaviors against covid- . the results of the present study, as one of the first study on the risk perception and protective behaviors of iranian pregnant women during the covid- pandemic, can be used by researchers and health planners in similar future crises. abbreviation covid- : coronavirus disease of a novel coronavirus from patients with pneumonia in china transmission of -ncov infection from an asymptomatic contact in germany epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study coronavirus disease (covid- ) coronavirus disease (covid- ) pandemic and pregnancy public health approach to emerging infections among pregnant women coronavirus disease (covid- ) and pregnancy: what obstetricians need to know novel corona virus disease (covid- ) in pregnancy: what clinical recommendations to follow? experience of clinical management for pregnant women and newborns with novel coronavirus pneumonia in tongji hospital, china analysis of the pregnancy outcomes in pregnant women with covid- in hubei province factors influencing pregnant women's perceptions of risk the effects of social media use on preventive behaviors during infectious disease outbreaks: the mediating role of selfrelevant emotions and public risk perception risk perception among women at risk for hereditary breast and ovarian cancer the risk perception paradox--implications for governance and communication of natural hazards perceptions of risk characteristics of earthquakes compared to other hazards and their impact on risk tolerance risk perceptions and health behavior the novel chinese coronavirus ( -ncov) infections: challenges for fighting the storm data for understanding the risk perception of covid- from vietnamese sample behavioral responses to the influenza a (h n ) outbreak in malaysia world health organization ( ) coronavirus disease (covid- ) advice for the public psychometric testing of the perception of pregnancy risk questionnaire difference in perception of pregnancy risk in two maternal age groups clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study okedo-alex in ( ) pregnant women's knowledge and practice of preventive measures against covid- in a low-resource african setting near-term pregnant women's attitude toward, concern about and knowledge of the covid- pandemic understanding the school community's response to school closures during the h n influenza pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence survey data of covid- -related knowledge, risk perceptions and precautionary behavior among nigerians. data brief : attitudes about the h n influenza pandemic among pregnant japanese women and the use of the japanese municipality as a source of information changes in risk perception and protective behavior during the first week of the covid- pandemic in the united states socioeconomic disparities in knowledge and behaviors of zika virus in pregnant women how can doctors communicate information about risk more effectively? high-risk pregnancy after perinatal loss: understanding the label covid- and iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception factors associated with preventive behaviors regarding lyme disease in canada and switzerland: a comparative study the authors sincerely appreciated the financial support from the research deputy of hamadan university of medical sciences. in addition, all participants and personnel in health care centers who helped in the research process are appreciated.authors' contributions sa and fs contributed to the proposal development, interpretation of the data, and drafting of the manuscript. sb and mr contributed to the preparation of the manuscript draft. sgh gathered the data. as and so analyzed the data and contributed to the manuscript development. all authors read, commented, and approved the final manuscript. this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. received: july accepted: september the authors declare that they have no competing interests. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -q g vw y authors: o’neil, adrienne; russell, josephine d.; thompson, kelly; martinson, melissa l.; peters, sanne a.e. title: the impact of socioeconomic position (sep) on women's health over the lifetime date: - - journal: maturitas doi: . /j.maturitas. . . sha: doc_id: cord_uid: q g vw y the “social gradient of health” refers to the steep inverse associations between socioeconomic position (sep) and the risk of premature mortality and morbidity. in many societies, due to cultural and structural factors, women and girls have reduced access to the socioeconomic resources that ensure good health and wellbeing when compared with their male counterparts. thus, the objective of this paper is to review how sep - a construct at the heart of the social determinants of health (sdoh) theory - shapes the health and longevity of women and girls at all stages of the lifespan. using literature identified from pubmed, cochrane, cinahl and embase databases, we first describe the sdoh theory. we then use examples from each stage of the life course to demonstrate how sep can differentially shape girls’ and women’s health outcomes compared with boys’ and men’s, as well as between sub-groups of girls and women when other axes of inequalities are considered, including ethnicity, race and residential setting. we also explore the key consideration of whether conventional sep markers are appropriate for understanding the social determinants of women’s health. we conclude by making key recommendations in the context of clinical, research and policy development. in almost all countries, women live longer than men yet experience poorer mental health, greater disability and greater comorbidities. this paradoxical female advantage in life expectancy is, however, expected to decrease worldwide by [ ] . the excess mortality rates of men, especially those under age , have historically been explained by accidents and injuries. however, changing risk factor profiles observed globally, particularly from smoking cessation, have conferred greater survival gains in men. at the same time that these mortality risk factors have changed, the global economic climate has changed dramatically, particularly in recent times in the context of the covid- pandemic. austerity measures in response to economic downturns have and will continue to exacerbate socioeconomic inequalities for all. these widening socioeconomic inequalities may help explain the weakening female survival advantage [ ] . a social determinants of health (sdoh) framework seeks to understand how materialist and structuralist health inequities persist throughout life. this is a useful framework for understanding how the health and longevity of females differs relative to males and each other. a sdoh approach purports that health outcomes depend on the organisation and distribution of socioeconomic resources across any given society [ ] . the "social gradient of health" refers to the steep inverse associations observed between sep and mortality/morbidity [ ] . measures of sep (e.g., individual and household income, employment conditions) that are used to determined socially graded patterns are being thought of as inherently gendered. moreover, some have argued that the role of gender has subsequently been neglected in discussions of how sep influences health across the life course [ ] . this is despite the fact that, in almost all societies, women and girls, when compared with their male counterparts, have reduced access to the socioeconomic resources -namely education and/or employment -that ensure good health and wellbeing. this can stem from cultural biases and practices that can commence early in the life course (e.g., discriminatory feeding patterns, gender-based violence, uneven labour divisions) and persist across middle and later life (e.g., the gender pay gap, political impotence [ ] ). the ways in which sep is measured may affect interpretation of the social gradient of health for females. moreover, sep may exert its influence on the outcomes of women and girls differently to boys and men at specific stages of the life course. these concepts will, thus, be explored in this paper. the objective of this paper is to review how, what and when sep -a construct at the heart of the sdoh theory -shapes the health and longevity of women and girls. we first describe sdoh theory and then use examples from each life course stage to demonstrate how sep can differentially shape girls'/women's health outcomes compared to boys'/men's. these stages aligning with important sep transitions rather than those associated with biological development. we also consider differences in outcomes between sub-groups of girls/women when other axes of inequalities like ethnicity and residential setting are considered. we discuss how the timing and trajectory of sep across the life course may be important in these determinations and conclude by making key recommendations in the context of clinical, research and policy development. given the broad scope of our aims, it was not feasible to conduct a systematic review. rather, we conducted a narrative review based on targeted search of the research literature and author expertise. using keywords including "gender", "sex", "women", "girls", "social gradient", "socioeconomic status", "education", and "health", we searched pubmed, cochrane, cinahl and embase databases to identify articles published after the year . articles published within the last decade, systematic reviews, and primary studies with population-wide or crosscountry samples were preferentially included. we have focused on health conditions that are most pertinent to the lifespan stage in question, e.g., cognitive development in early life, overweight/obesity in adolescence, premature cardiovascular disease (cvd) in adulthood, and frailty in older age. where possible, we have included studies from non-western countries. throughout this review we have exclusively used the term "gender" in order to improve readability, but acknowledge that "gender" and "sex" are two separate but interrelated constructs with differential effects on sdoh [ ] . may underpin the association between low sep and poorer health outcomes. conventionally, "social class" and "socioeconomic status" (ses) have been employed as constructs for understanding how health outcomes are socially graded. while useful in illustrating the social gradient of specific health conditions, different indicators will produce varying slopes [ ] . "social class" as a socioeconomic measure has been argued to more accurately reflect "occupational class", while "ses" conflates different sep constituents like actual resources and status/prestige [ ] . sep instead exerts its influence on health via numerous exposures, resources, and vulnerabilities including income, poverty, and education. sep will be used henceforth. the sep-health relationship has been demonstrated repeatedly. a systematic review of studies [ ] found that people of lower sep have greater risk of mortality, cvd, cancer, amongst other health conditions, than those of higher sep. when data were disaggregated by gender, women of lower sep were especially vulnerable to coronary heart disease. however, it has been argued that, in the main, sdoh theory is often discussed without considering the inherent gender differences in sep and its measurement. this is in spite of the fact that women and girls are most disadvantaged by institutional policies and provisions that govern the labour market and family experiences that drive socioeconomic inequalities [ ] . with this in mind, we now consider how sep shapes morbidity and mortality of women and girls at critical life stages that align with important sep transitions. given the focus of women's health across the life course has often been centred around sexual and reproductive health, we have selected stages based on sep transition (e.g., educational attainment in adolescence and young adulthood), acknowledging that they may not occur in the same sequential manner for all women and girls and may vary across countries and settings. a sdoh framework is often guided by life course epidemiology; a field largely concerned with the timing of exposures, mechanisms, intermediary factors and resources that drive health inequalities across the life course [ ] . the enduring effects of early life exposures (economic, social, behavioural) from gestation to young adulthood on health outcomes in later life has been extensively examined. indeed, sep-graded health outcomes observed in adulthood have antecedents in early life [ , ] . however, the evidence shows gender differences are not always apparent in early childhood. for example, birth outcomes are shaped by parental socioeconomic factors and impact upon health across the life course. studies from industrialised countries have demonstrated that socioeconomic disadvantage at individual (e.g., parental ses), neighbourhood (e.g., poverty, unemployment) and national (e.g., gdp) levels increases the likelihood of adverse birth outcomes, including small-forgestational age, preterm birth, and low birth weight [ , ] . the way in which gender modifies the sep-health gradient appears dependent on the outcome of interest and the comparator group. for example, lower childhood sep is known to predict poorer physical and cognitive outcomes and acute medical conditions [ ] . for girls, the impact of poverty (as determined by parental income and mother's education) on cognitive developmental delays appears to be pronounced, especially when compared to boys [ ] . in australia, the most stark sep differences in -year old's development are within gender groups, with language and cognitive developmental delay more common for both male and female indigenous children than non-indigenous children [ ] . data from india suggest that although girls appear to be inoculated against the sep gradient in early childhood development, this is reversed after age , with boys (particularly those in the upper classes) performing better [ ] . indeed, lowmiddle income country status is highly correlated with indices that measure gender j o u r n a l p r e -p r o o f inequalities in reproductive health, political empowerment and economic status. thus country-level sep indicators including gender equality is an important predictor of survival. data from countries [ ] shows that the more gender unequal a society is, the lower the survival rate of girls compared to boys. again, using the example of india, girls under years with cardiac defects are less likely to have their guardians agree to cardiac surgery when compared to boys ( % vs. %). social class greatly influences access to treatment, with % of girls in the "upper class" receiving the surgery versus . % in the "upper-lower class". deep-seated social factors perpetuating gender biases, such as the customs of arranged marriages and "dowry", appeared to drive these poorer outcomes for girls [ ] . sep remains a powerful predictor of health in adolescence [ , ] , during which time parental employment, family affluence and composition are commonly constituents of an adolescent's sep. cognition outcomes continue to be socially patterned from childhood into adolescence [ ] and the same is true of physical health outcomes like weight. in the us, an inverse association exists between sep and overweight in adolescent girls (particularly white) but not boys [ ] . in other studies, sep and ethnicity interact to confer risk for physical health conditions like cvd and protective effects on mental health. data from the uk showed sep patterning for psychological well-being in girls [ ] , with low sep asserting a stronger influence on black compared to white girls. systolic blood pressure increased with level of disadvantage amongst black caribbean girls; a trend that was exacerbated in subsequent years [ ] . but cross-country comparisons reveal the complexity of the sep patterning of health of boys and girls, indicating it is largely context-specific. for example, in a national comparison of russian, us and chinese children/adolescents aged - , higher overweight/obesity was observed for: urban boys in china; urban girls from low-and highincome groups in russia; and african-american and mexican-american girls in the us (especially those aged ≥ years) [ ] . in zambia, one of the countries with the highest hiv burden in the world, young women have higher rates of hiv infection than young men. yet the gender gap is narrowing in both urban and rural areas [ ] attributed primarily to higher educational attainment of both sexes. an increasing proportion of young women enrol and stay in school, thus, delaying their sexual debut [ ] . in addition to preventing sexually transmitted infections, education can help prevent precocious pregnancy. a cross-national comparative study showed evidence of a strong, negative educational gradient in early childbearing in all high-income countries included. there was also an increase in the prevalence of early childbearing amongst lower educated females born between and in of the included countries, with only one country (poland) showing a decrease in the educational gap [ ] . paradoxically, gender bias can compromise educational attainment and result in early attrition from the education system. in some developing countries in which resources are scarce and girls may be required to earn money for their families, education deprivation is a significant issue affecting girls health and safety, especially in rural regions [ ] . the period from adolescence to young adulthood sees a transition from parental level sep affecting an individual's health to their own educational status shaping access to socioeconomic resource (e.g. higher income, stable employment) that protect against both the onset and consequences of ill health. higher levels of education attainment provide a basis for enhanced self-control and problem-solving skills in adulthood, that can facilitate both the adoption of lifestyle behaviours and entry into environmental contexts that promote health and wellbeing. data from the us show that women's self-rated health, which is typically poorer than men's, improved from - , and that this improvement could be largely accounted for by increased educational attainment across this same time period [ ] . in contrast, men did not experience a linear increase in self-rated health in this study, which suggests that women may reap greater health benefits from increased educational attainment. this is supported by evidence showing the deleterious health effects of having low educational attainment are more potent for women than men for cvd [ ] . this is even true in countries in which a greater number of women are graduating with university degrees than men [ ] . for many, this period of the lifespan sees individuals in gainful employment for the first time. studies utilising employment related markers like income as a measure of sep provide some insight into the health inequalities faced by women. in a cross-sectional survey of working-age catalonian residents, individual income showed a graded association with self-rated health for both men and women, whereby individuals with lower monthly incomes reported worse health. individual income accounted for women's poorer self-rated health compared to men's, with analyses adjusting for individual income abolishing this gender difference in health [ ] . occupational class has also been used to examine gender differences in sep and health outcomes. in a cross-sectional study of , barcelona residents, self-rated health was poorer for men in lower occupational classes, compared to that of managers and skilled supervisors. in contrast, only women in unskilled jobs had worse self-rated health than the reference category. rather, the number of hours per week of domestic labour was an important determinant of self-rated health in women, whereas it was not for men [ ] . the impact of children and family composition will be discussed in more detail in the following section. income and education continue to shape women's health into mid-life. with respect to the former, the whitehall study ii shows that men and women with the lowest individual income were significantly more likely to have metabolic syndrome, compared to those with the highest. although the magnitude of this effect was similar for both genders, the use of household income as a measure of sep revealed a relatively steeper social gradient of health for women than men [ ] . with respect to the latter, the gap in self-rated health between the lowest and highest educational levels appears to be widening in many western countries. this is somewhat dependent upon age, gender and race. in us citizens aged - , the education health gap remained relatively stable for men from - , whereas educational disparities in selfrated health diverged for white women and converged for black women [ ] . similar temporal trends have been found when examining mortality. in a study using us mortality data, middle aged ( - years old), white women experienced the greatest increase in the educational gradient of mortality, due to substantially increased mortality rates amongst those with high school diplomas or less [ ] . as discussed previously, educational attainment is a key indicator of age of first pregnancy which, along with family composition and relationship status, is of particular relevance both to women's ability to earn money and their individual health outcomes during this stage of the lifespan. during this period of adulthood whereby partnerships are formed and families are started, the role of household and partners' sep can begin to influence a woman's health. in general, marriage appears to be a protective factor for many health conditions [ ] . while married women have a survival advantage over unmarried women, the premium afforded to married men may be more pronounced [ ] . over recent decades, however, the marriage advantage appears to have increased. the assumption was that people with lower education were marrying less frequently while those of comparable levels of education tended to marry later. yet, us [ ] and norwegian [ ] data show that temporal changes in educational status of married people contributed little to the steepening health gradient. interestingly, data from hungary show that in middle-age, a married woman's sep has greater influence on her husband's mortality than his sep on her mortality [ ] . a population-wide norwegian study demonstrated that older men's mortality across all causes of death was strongly associated with their wife's educational status. meanwhile, a husband's income and occupation were related to few causespecific mortality outcomes in women [ ] . women with higher education levels tend to be more likely to engage in health-promoting behaviours [ ] . it is thus plausible they influence the diet, exercise, and smoking/drinking habits of their partners [ ] . while a recent metaanalysis of over million individuals found that being unmarried led to a greater risk of stroke and mortality for men compared to women [ ] , other meta-analyses have found no significant gender differences in the marriage advantage for cvd risk [ ] and mortality [ ] . changes in family composition owing to reproduction, child rearing and relationship breakdowns, are defining features of women's adult years. these factors have an important effect on professional attainment, employment conditions and career advancement and financial independence, and therefore how sep shapes women's health. while parity (i.e. motherhood) has been positively associated with better cvd risk [ ] ) across sep categories [ ] , other studies show that mothers have poorer self-reported health (in spite of similar rates of chronic conditions) particularly those living at or near the poverty line [ ] . part of the reason may be that motherhood is associated with financial penalties in the form of time out of the workforce (due to maternity and carers leave), but also potentially wage reductions [ ] . single mothers appear to be particularly disadvantaged in terms of sep and its impact on health outcomes [ ] . for example, despite greater opportunities for educational and employment attainment over recent generations, there are widening sep disparities for us women, especially for mothers without partners. since the s, the number of single-parent us households headed by women has tripled. ten percent of us women aged - years live in poverty, a plausible driver of increasing premature mortality rates. women aged - [ ] are the only sub-population in the us to have experienced large increases in coronary heart disease mortality since the early s. compared to same-age women in england, us women show earlier risk markers of chronic disease [ ] . differences for younger us women ( - years) are as pronounced as their older female counterparts for cvd risk factors such as obesity, cholesterol, heart attack, angina and stroke. us health inequalities clinically evident at early ages are best ascribed to socio-political influences rather than conventional risk factors [ ] . as women reach older age with greater disability and comorbidities, having accumulated less wealth due to relatively fewer employment-related opportunities, it stands to reason that older women are susceptible to the social gradient of health. there is evidence to suggest that indeed women's sep is more precarious over the life course for reasons discussed in previous sections (e.g., extended periods out of the workforce, reduced access to independent wealth) compared with men's which exhibits greater stability [ ] . data from the survey of health, ageing and retirement in europe (share) study (n= , ; + years of age) showed that while both childhood and current sep exerted strong and independent effects on self-rated health in older age, their relative influence differed by gender. for example, current sep explained less of the variance in self-rated health than childhood sep for men, whereas current sep was more important than childhood sep in explaining variance in self-rated health for women. in addition, all current sep indicators had a significant influence on self-rated health in older j o u r n a l p r e -p r o o f women, whereas being employed and household net wealth were not significantly associated with self-rated health in older men. thus, the authors concluded that sep in childhood was more predictive of older men's self-rated health, while current sep in older age was more important for women's self-rated health [ ] . conversely, poor health can also influence material wealth in later life. in new zealand, the odds for entering their s with material hardship were greater for women and māori, yet this association was attenuated by mid and late life adverse events such as onset of serious illness [ ] . interestingly, having children may provide protective health related effects. the sep of one's grown children has been shown predictive of risk of parental death, potentially independent of parent's own sep [ ] . of course, the gendered nature of sep-health trends in this age group are likely to be both outcome and country-specific. in south korea, a longitudinal study of aged + years found wealth was inversely associated with depressive symptoms (measured using the center for epidemiologic studies of depression scale) in men, whereas low education and income predicted depression in women [ ] . on the other hand, in england, data from the first two waves of the english longitudinal study of ageing (elsa) found no gender differences for wealth as a predictor of functional impairment (measured using six activities of daily living) in those above years of age [ ] . interventions and policies that mitigate deleterious effects of sep on girls' and women's health should target micro-, meso-, and macro-levels. whilst policies that provide universal health coverage is one obvious initiative, coordinated interventions targeting these levels are required to address gendered health inequities in underprivileged populations. in india, women of low sep have a lower share of hospital care than men, even when provided free access. this suggests that free hospital care alone is not sufficient to guarantee gender equity in healthcare access [ ] . it is well established that interventions reliant upon individual resources will preferentially advantage those of higher sep and thus maintain health inequalities [ ] . a key consideration is the socio-political environment in which individuals live, work and age, including the state-provided resources available. national social security provisions can insulate women's disease and mortality risk. this includes the extent to which a nation's welfare provisions allow for an acceptable standard of living independent from family relationships (defamilisation) and insulated from market dependence (decommodification). in countries with welfare systems that promote greater financial autonomy for women, a weaker social gradient of health for women would be expected. a longitudinal analysis of data comparing different welfare regimes within europe indeed support this hypothesis. the social gradient of health, as measured by the impact of education, income and wealth on -year change in frailty, was steepest for older women residing in southern european countries that are characterised by less defamilising and decommodifying welfare systems. conversely, this gradient was flattest for those living in northern european countries; typically characterised by comparatively high levels of gender equality and social democratic politics [ ] . whether these results are generalisable to other western nations or low-to-middle income countries is unclear. however, there is good evidence that the strength of association between women's sep and their life expectancy varies with level of economic development [ ] . conventional sep markers were developed by and for men and are generally not well-suited to assessing women's socioeconomic circumstances [ ] and associated health outcomes. here, we have provided examples showing specific measures may produce differential health gradients between women and men. if employment markers alone are used to assess women's engagement with the workforce and thus sep, disengagement with the workforce may be a marker of extreme wealth, child rearing, studying, disability or extreme poverty at different points of the life course. alternatively, using household income assumes women have equal access to pooled resources, which in many cultures is not the case [ ] . this might help explain why some studies using conventional measures show that sep-related health differences are more pronounced for men [ ] . studies where the mortality gradient was stronger for men than women have used employment [ ] and occupational exposures [ ] . yet classifying women's sep based on occupation is problematic given that women cannot always be classified appropriately using census data [ ] . thus, appropriate weighting and consideration of interactions between conventional markers of sep for women (e.g. education, marriage and number of children) may be required to acknowledge women's unique health circumstances. as such, there has been a push to broaden sep to include important inputs like social isolation, pessimism, childhood adversity, or domestic situation [ , ] . for example, the influence of childhood adversity [ ] and psychological strain/job satisfaction [ , ] is stronger for women than men. a study that investigated gender, mortality and sep by using both social disadvantage (defined by social distance from high sep [ ] ) and occupational class demonstrated that the social gradient of mortality was greater for women when using the former, and greater for men when using the latter [ ] . this suggests that the use of conventional, occupational based sep indicators may be underestimating the social gradient of health for women. ultimately the best sep marker by which to assess health inequalities between women/girls and men/boys and amongst women and girls requires consideration of life course epidemiology. this field seeks to understand the temporal trajectories, patterns and mechanisms by which sep drives health inequalities. applying a life course epidemiology framework that considers these assumptions is critical for determining research design and data collection as well as to guide resource allocation (examples of which are provided in the following section). to date, there is a lack of consensus regarding the exact trajectory of health inequalities over time; some argue the data show they widen, others purport they converge while others suggest they remain stable over time [ ] . while we have discussed the influence of sep in each life stage as discrete periods, they cannot be separated in our attempts to understand the relationship between sep, gender and health. this review highlights the complexities of these trajectories; they may be somewhat dependent upon stage of the lifespan, the health outcome of interest, setting and referent group. for example, an sep marker like educational attainment may not yield mortality benefits for women when compared to white men but may when compared to non-white women or when considering other inequality axes like age, race, disability or rurality. an added incentive for developing an approach that uses multiple and contextual sep indicators is that it may help to further disentangle the gender paradox of women's health. in clinical practice, medical practitioners require robust tools and clinical aids by which to assess and tailor patient care according to sep. there remains an absence of such tools much less those which consider the nuanced issues pertaining to gender or other axes of inequality discussed herewith [ ] . in the united kingdom and scotland, the qrisk [ ] and assign [ ] algorithms used in clinical practice to determine -year absolute cvd risk of j o u r n a l p r e -p r o o f patients include a measure of area-level material deprivation; one of the few such tools to do so. whether this measure of sep is most appropriate for utility in women of different ages, ethnic and other backgrounds remains unclear in the context of the issues discussed in this paper. this is largely because these tools have been developed and populated by data from male-dominated historical cohorts. nevertheless, the advantage of using and further developing and refining risk assessment tools that contain sep measures is not only critical for greater discrimination between cases and non-cases but for the purpose of equity. in the clinical context, the provision of lifestyle advice, counselling and interventions for preventing and managing chronic physical and mental conditions requires clinicians to appreciate that individuals living under conditions of scarcity cannot freely make decisions about their own health and investments that may, in fact, afford them the opportunity to escape those very circumstances [ ] . where low sep is identified, an understanding of how limited economic resources restrict decision making can help guide the implementation of health promoting incentives -especially for those on welfare who have high material deprivation. from a public health perspective, investment in early life education of all, and especially girls in settings of marked gender inequality, is critical to lifelong health. in conjunction with other interventions, education (both formal attainment and health literacy) appears to be the key to improving sep and is a strong determinant of future employment and income [ ] . . skills and knowledge obtained from greater education may enhance confidence, adeptness or receptiveness to health education [ ] . however, the greatest reduction to the social gradient of health can arguably be achieved by developing interventions that minimise the extent to which socioeconomic resources confer a health benefit [ ] . this notion has underpinned many public health initiatives, which have aimed to overcome differences in sep. one pertinent example is the fortification of flour with folic acid in over countries worldwide. this is opposed to recommending that women take folic acid supplements during pregnancy, which disadvantages women of lower sep due to issues of cost and access. preliminary evidence suggests that folic acid fortification of flour at a population-level reduces the risk of neural tube defects in foetuses and improves the folate status of women of reproductive age [ ] . acknowledging the heterogeneity both between women and men and amongst women in the context of analytic frameworks is critical. pragmatically, research in this area should consider interactions between gender and both conventional and non-conventional sep markers to ensure that health inequalities for sub-populations are not concealed. consensus on genderspecific sep indicators across the life course are required. of note, there has been work developing tools by which to assess adolescents' material circumstances and family affluence as a measure of self-reported family socioeconomic status [ ] . further research is necessary to develop indicators specific to developing countries, given that the majority of this research has been generated in developed countries. the role of sep on the health and longevity of women and girls is complex and fluctuates throughout the life course. this trajectory appears dependent upon (i) the outcome of interest and setting in which the research is conducted; (ii) how sep is defined and the level (macro or micro) at which it is measured; and (iii) the extent to which other axes of inequality are considered (ethnicity, residential setting, indigenous status). how sep is measured and applied is an important consideration given that many women are likely to have variable engagement with the workforce and possible financial reliance on others at various stages of the life course. it is likely that the conventional concept of sep itself may inherently misrepresent genderbased inequalities in health. taking a broader view of sep, that includes psychosocial inputs and considers sep as a web of interconnected variables, may 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extent of restrictive measures, the reciprocal duties to healthcare workers, the allocation of scarce resources, and the need for research. while policy and ethical frameworks are being developed to face these problems, the gender perspective has been largely overlooked in most of the issues at stake. domestic violence is the most prevalent form of violence against women, which can be exacerbated during a pandemic: stress and economic uncertainty are triggers for abuse, and confinement limits access to support networks. confinement also exacerbates the unfair distribution of unpaid labor, which is disproportionately assigned to women and girls, and highlights inequality in the overall labor market. lack of security measures has resulted in attacks towards health workers, particularly female nurses, due to fear of contamination. finally, resource results in lack of access to other health necessities, including sexual and reproductive health services. research across all disciplines to face—and to learn from—this crisis should be done through a gender lens, because understanding the realities of women is essential to understand the pandemic’s true effects in mexico and the world. this year's international women's day was a historic occurrence in mexico (el universal ). tens of thousands of women took to the streets on the eighth of march and then chose to vanish on the ninth (averbuch ) . each day in its own way, the socalled m and m were meant to raise awareness about femicides and the foundation of structural violence against women on which they stand. women all across the country sought to generate a widespread debate and called for active commitment from key stakeholders and decision-makers. but while they marched through the streets in mexico, the rest of the world was beginning to become paralyzed by a virus which has claimed over , lives globally, confining individuals and families to their homes, and overwhelming already fragile health systems (world health organization ). and in this unprecedented situation, girls and women in mexico find themselves caught between a rock and a hard place of two public health crises-the pandemic and gender-based violence-in a country where misogyny seems part of our cultural heritage (htun and jensenius forthcoming) . in the mexican context, structural violence against women is normalized and spans every sphere of society. even the written press has played a role in this normalization, particularly through femicide coverage (tiscareño-garcía and miranda-villanueva ). that is why a gender perspective should be included when analyzing issues, to find solutions that do not exacerbate inequality. during this pandemic, a lot of significant ethical and social issues have been raised, such as: the extent of restrictive measures, the reciprocal duties to healthcare workers, the allocation of scarce resources, and the need for research (palacios-gonzález ). while policy and ethical frameworks are being developed to face these problems, here we will try to show how the gender perspective has been largely overlooked in practice during the pandemic response in mexico. understanding the realities of women is essential to understand the true effects of this pandemic. similarly, we believe including feminist approaches to the many ethical and social issues would allow decision-makers in mexico to reach more optimal solutions. this is because traditional approaches tend to be abstract and based on universal absolutes, which ignore the diverse realities of women's experiences. further, these absolutes tend to focus on individualistic principles like autonomy, ignoring other ethical principles like solidarity, compassion, and communitarian values which are essential (medina-arellano ). indeed, solidarity has been made a cornerstone of the global pandemic response, but how this principle is translated to practice both internationally and within our borders necessitates the recognition of power dynamics, including the prevalence of gender inequality. the first topic of discussion is the deployment of restrictive public health measures. social distancing measures, such as shelter-in-place orders, have become essential to counteract the rapid spread of sars-cov- . however, besides seeming incompatible with the socioeconomic reality in mexico where many people live day-to-day (padrón innamorato, gandini, and navarrete ), isolation and confinement at home are extremely concerning for women's safety. in our country, domestic violence is the most prevalent form of violence against women, also impacting the lives of children (scolese et al. ) . further, a considerable number of femicides is perpetuated in family, couple, or friendship environments (lara olmos ). in fact, the rate of femicides has increased by . per cent in the period of january to june compared to (urrutia and jiménez ) . as the data shows, athome violence and violence against women in general can be exacerbated during a pandemic: stress and economic uncertainty are triggers for abuse, and confinement pulls women away from their existing support networks or makes it difficult for them to find new ones. ideally, public programmes would have been set in place to respond to these issues before the general population was asked to stay at home. there are indeed existing programmes, like hotlines for gender violence. however, we need to realize that those measures are not sufficient in the current context and ask questions like: how can i call for help if there is constant forced coexistence with my aggressor? where should i go to find shelter without being exposed to contagion? how can i file a lawsuit, or follow-up on one, while staying at home? who ensures that i can have access to justice when the government workforce is not at full capacity? developing mobile applications to serve as panic buttons could be an effective solution (ministerio de las mujeres & géneros y diversidad ). importantly, access to mental health support should be fully guaranteed, since suicide rates, especially among married women, are intricately linked to conflict within the household (beleche ). however, we must always remember that violence against women is an intersectional issue. for example, socioeconomic status is a contributing factor to domestic violence, and the women who need the most help might be the same women who have less access to technology; the same is true for other marginalized women, such as indigenous or racialized women. therefore, to be effective, these tools must be part of more widespread, cohesive policy efforts, relying on interinstitutional cooperation among relevant agencies. another consequence of confinement is that it highlights the existing inequality, based on misogynistic stereotypes, in the distribution of unpaid labor (i.e. household chores and care) (salgado-galicia et al. ). this inequality was normalized when authorities stated that women at home would have no issue looking after the health of elders, affirming that men tend to be "more detached" (morales, miranda, and villa y caña ). during quarantine, most women will be responsible for: increased household chores; caring for children, including aid in schoolwork and education due to schools closing down; tending to family members with any physical or mental disability; caring for the elderly; and, in some cases, looking after family sick with covid- . importantly, we should also be thinking about how the unequal distribution of domestic chores will affect young girls and teenagers during confinement (wang et al. ) . it is likely that having to do school from home will force them to put their education aside, since they will be expected to help with chores or care for their siblings, for example. girls have less access to education and less academic opportunities than boys as it is, and we need to start thinking about ways to avoid this reality being exacerbated in our country post-pandemic. in that sense, we think it is also important that more women who work in the pandemic relief are showcased, especially those in top positions, to serve as role models. it is sadly unsurprising, but very illustrative of the inequality in our country, that most of the spearheads giving press conferences and shown on media are male, partly explained by the persistence of male directors and executives at the national institutes of health in mexico (rivera-romano et al. ). on top of the difficult situation at home, a lot of women will also take on professional responsibilities. this is made harder in a labour market where already they deal with increased job insecurity-including lack of access to health insurance-and lower salaries. these situations once again highlight the importance of an intersectional perspective, since indigenous women and women living in poverty are disproportionally affected; for example, those who participate in paid but exploitative domestic labor (rojas-garcía and toledo gonzáles ). regarding healthcare workers, an important ethical issue is the scope and limitations of their duties during the pandemic. they will unavoidably face increased risk of contracting covid- , but this is only acceptable when there are reciprocal obligations from the state. this includes providing sufficient resources like face masks and other protective gear, including strategies to prevent burnout syndrome which is more prevalent on female medical students (miranda-ackerman et al. ). broader security measures should also be provided, since healthcare workers, particularly female nurses, have sadly been attacked for fear of contamination. it must be stressed that women make up most of the healthcare workforce at the frontlines (world health organization ); therefore, governments, should ensure access to care facilities and school aids for their children, as well as services to aid in the care of any other dependents. similarly, even though it is expected that the health system will be overwhelmed, female health workers who are in special situations, such as maternity leave or those who are breastfeeding, should not be, under any circumstance, expected to risk exposure and should not face any penalties. finally, the public debate should avoid using hierarchical language based on sexist stereotypes when speaking about the healthcare workforce-médicos (male doctors) and enfermeras (female nurses)-which contributes to existing power dynamics. another ethical issue relates to the distribution of scarce resources. the fair allocation of ventilators is a particularly hot topic at this time, and the ethical framework developed in mexico appropriately included a gender perspective (guía bioética ). however, medical resources and health staff being diverted to face the crisis will also affect health beyond covid- . this issue has been internationally recognized by the release of a joint statement regarding the protection of sexual and reproductive health and rights of women during the pandemic response (klasing ) . while mexico signed said statement, there is still more work to be done in practice. the concern arises partly because rates of obstetric violence in mexico are already high (calvo aguilar, torres falcón, and valdez santiago ), and it took some time to issue a special protocol regarding access to healthcare for pregnant women before, during, and after childbirth to prevent covid- infection (secretaría de salud ). another concern emerges from the lack of access to family planning and contraception methods. in particular, access to emergency health services for victims of sexual violence, such as safe means to interrupt a pregnancy resulting from rape, which is a recognized right in all of mexico (nom- -ssa - ) . the provision of abortion services must be ensured in a timely manner, given that these procedures cannot be postponed and should be considered urgent, especially when they are legally recognized rights. indeed, in addition to the rape causal nationwide (nom- -ssa - ; ministry of health, mexico ), the decision to interrupt a pregnancy on any grounds has been recently decriminalized in the state of oaxaca, and abortion services are constitutionally guaranteed for any reason by the public health system in mexico city. beyond any moral opposition to abortion, these services are at risk of being set aside because they are sometimes thought to only pertain to women, and women's interests are considered secondary. women's right to health is linked to their rights to life, free development of personality, human dignity, and sexual and reproductive freedom. all of these constitute undisputed human rights which cannot be discarded by any measure of exceptionality, even in the face of scarcity in the health sector. women's independence is inextricably linked to control over their bodies and reproduction, and any argument to justify taking away that right is undeniably a form of discrimination against women, especially towards women already marginalized in mexico due to racism and classism. one final issue raised by the pandemic is the need for research. we affirm that focused research must be done with a gender perspective. this includes: biomedical research about any differential responses to treatment; public health research to look at the effects of resource deviation on women's physical health and of confinement on women's mental health; economic research to look at the impact on the female informal workforce; and social research to see whether more girls are made to drop out of school and how rates of violence respond to social distancing. these approaches to research will prove invaluable not only to face this pandemic but to have reallife data in place to inform decision-makers in the future. among everything that has happened, this pandemic has managed to highlight and exacerbate the existing inequalities and flaws in our social structure (papp and hersh ) . even though the th of march and the women's march seem like another lifetime, the demands remain current. the topics we have discussed about women's access to health, justice, and a life free of violence must be fundamental issues in any and every plan to face this pandemic. yes, we are all worried about the pandemic and what is to come, but we must remember that the structural violence women face every day remains itself an unattended public health crisis. indeed, while social distancing to reduce transmission, women are stuck at home with their aggressors. while the health system struggles to provide life-sustaining services, eleven women are still dying every day in this country just for being women (xantomila ) . the government must not consider this a secondary issue, because women in mexico sure do not have the option of forgetting. acknowledgements this work was supported by unam-papiit ig . open access this article is licensed under a creative commons attribution . international license, which 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(covid- ). last modified onudh: en méxico se cometen en promedio . feminicidios al día publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -r w lb authors: schwartz, david a title: the effects of pregnancy on women with covid- : maternal and infant outcomes date: - - journal: clin infect dis doi: . /cid/ciaa sha: doc_id: cord_uid: r w lb nan m a n u s c r i p t outbreaks of new and emerging viral diseases have always caused anxiety among persons and societies at risk for infection. in particular, this has been especially true for pregnant women, who fear not only for themselves but often even more so for their unborn infants. pregnant women, their fetuses and infants are generally the most vulnerable members of society during an infectious disease outbreak. the normal physiological, anatomical and immunological changes that accompany pregnancy may increase a pregnant woman's susceptibility to newly emergent viral pathogen as well as increase the severity of infection. these changes, including an adaptive immune state including local suppression of cell-mediated immunity, changes in the maternal cardiovascular and respiratory systems including increased oxygen consumption, heart rate, stroke volume, decreased lung capacity and other physiological changes, may increase the likelihood for severe maternal disease from an infectious disease, and especially with those that have respiratory transmission [ , ] . recent history is replete with examples of new and reemergent viral diseases that have adversely affected pregnant women, often causing greater harm to them as a result of their condition than among infected but non-pregnant women. such infectious diseases as influenza, ebola virus, hepatitis e and varicella may have a more severe clinical course, increased complication rate, and higher casefatality rate among pregnant women than in non-pregnant individuals. the impact of emerging infections on the embryo or fetus is difficult to predict and varies depending on such factors as the agent, gestational timing of infection, and such host factors as the maternal-fetal interface. during the recent ebola virus epidemics non-vaccinated pregnant women were especially prone to excess morbidity and mortality, and the effects on their unborn infants were worse -only newborns having the infection survived [ ] . in contrast, some pregnant women might be asymptomatic or have only mild or nonspecific symptoms from an infectious disease, resulting in their escaping detection as having infection even when the embryo or fetus is severely affected. during the zika virus pandemic, infected pregnant women were typically asymptomatic, or at most had mild symptoms, which were unconcerning. however, the virus stealthily crossed the placenta without even inducing an inflammatory response, to produce a tragic spectrum of fetal malformations, neurological injuries, and even death [ ] . an important aspect of the current covid- pandemic is its effect on pregnant women and their infants. there have now been numerous publications addressing the adverse effects of covid- on pregnant women, as well as examining the infection status and clinical characteristics of their newborn infants [ ] [ ] [ ] [ ] . however, there have been no data available to determine whether pregnancy itself has any consequences on the health of reproductive aged women with covid- . in order to investigate this important question, li et al. [ ] evaluated for the first time the effects of being pregnant on covid- disease and pneumonia using a case-control experimental design conducted at the maternal and child health hospital of hubei province, a -bed tertiary medical center in wuhan, china. to accomplish this, the authors enrolled two cohorts of pregnant women with covid- and pneumonia -one consisting of pregnant women with pneumonia and rt-pcr confirmed sars-cov- infection, and the other with pregnant women with pneumonia who were clinically and radiologically suspected of having covid- but had negative rt-pcr test results. these pregnant women with confirmed or suspected covid- pneumonia were compared with two cohorts of control cases. the first control cohort consisted of non-pregnant women who were also infected with sars-cov- -this group included non-pregnant women with rt-pcr confirmed a c c e p t e d m a n u s c r i p t infection and non-pregnant women with clinical and radiographic evidence of the disease but who had negative rt-pcr testing. the second control cohort consisted of two groups of randomly selected women of reproductive age from different time periods with no pneumonia and not having covid- - women in each group -for a total of women. their results showed that covid- typically caused mild respiratory symptoms in pregnant women, most of whom were asymptomatic upon hospital admission. when compared with nonpregnant women with covid- pneumonia, the infected pregnant women generally had absent or mild respiratory symptoms, and none developed severe respiratory compromise or required intensive care. among their findings was a higher incidence of premature delivery in pregnant women with confirmed covid- , although this was not the result of severe maternal respiratory disease. in analyzing the neonatal outcomes from the cohort of pregnant women with covid- , there was no evidence for intrauterine transmission of sars-cov- . this latter observation was similar to a multitude of studies of pregnant women with covid- and their infants from china ( ) ( ) ( ) ( ) and is typical of intrauterine maternal-fetal transmission patterns of other respiratory rna viruses [ ] . this important case-control investigation by li et al. significantly expands our knowledge of the effects of pregnancy and covid- infection and the infection status of neonates from infected mothers. the clinical outcomes of pregnant women with covid- from wuhan, china discussed in this article were all favorable, and are similar to reports of all (but one) pregnant women from that country. however, this should not be understood to indicate that infection with sars-cov- is not capable of causing severe and even life-threatening disease among pregnant women. in the single case of an obstetric near-miss event reported from china, a woman who developed severe pneumonia from covid- at weeks gestation delivered a stillborn infant, had deterioration of cardiopulmonary status and subsequently developed multiple organ system dysfunction syndrome requiring extracorporeal membrane oxygenation [ ] . in countries outside of china there are increasing reports of poor clinical outcomes arising from covid- disease among pregnant women. in new york city pregnant women who were initially thought to be uninfected with sars-cov- developed severe postpartum medical complications requiring admission to intensive care and were found to have covid- [ ] . a study of pregnant women with covid- presenting to new york city hospitals, ( . %) women developed severe disease, and ( . %) had critical disease requiring intensive case treatment [ ] . cardiomyopathy occurring in pregnant women with sars-cov- infection has also been described [ ] . covid- is now recognized to cause the death of pregnant women. there have recently been cases of mortality among pregnant women from iran reported [ , ] , none of whom had preexisting comorbid conditions that were above the baseline population risk. in response to the increasing seriousness of covid- as a threat to maternal and infant health, national registries of pregnant women with covid- have been established in many parts of the world -these include the priority study in the united states, ukss registry in great britain, nethoss in netherlands, itoss in italy, chopan in australia, and others. data obtained from these registries will be of immense significance in further understanding the effects of sars-cov- infection during pregnancy and its effects on clinical outcomes of mothers and their infants. the author has no potential conflicts to disclose. emerging infections and pregnancy pregnancy and susceptibility to infectious diseases maternal and infant death and the rvsv-zebov vaccine through three recent ebola virus epidemics -west africa, drc Équateur and dr.c kivu: four years of excluding pregnant and lactating women and their infants from immunization viral infection, proliferation and hyperplasia of hofbauer cells and absence of inflammation characterize the placental pathology of fetuses with congenital zika virus infection an analysis of pregnant women with covid- , their newborn infants, and maternal-fetal transmission of sars-cov- : maternal coronavirus infections and pregnancy outcomes clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records covid- infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals maternal and perinatal outcomes with covid- : a systematic review of pregnancies maternal and neonatal outcomes of pregnant women with covid- pneumonia: a case-control study infections in pregnancy with covid- and other respiratory rna virus diseases are rarely, if ever, transmitted to the fetus: experiences with coronaviruses, hpiv, hmpv, rsv, and influenza clinical manifestations and outcome of sars-cov- infection during pregnancy the babies were delivered. no one realized the mothers had the virus. the new york times two cases of covid- related cardiomyopathy in pregnancy maternal death due to covid- disease mortality of a pregnant patient diagnosed with covid- : a case report with clinical, radiological, and histopathological findings a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t key: cord- - r gavbq authors: kajdy, anna; feduniw, stepan; ajdacka, urszula; modzelewski, jan; baranowska, barbara; sys, dorota; pokropek, artur; pawlicka, paulina; kaźmierczak, maria; rabijewski, michał; jasiak, hanna; lewandowska, roksana; borowski, dariusz; kwiatkowski, sebastian; poon, liona c. title: risk factors for anxiety and depression among pregnant women during the covid- pandemic: a web-based cross-sectional survey date: - - journal: medicine (baltimore) doi: . /md. sha: doc_id: cord_uid: r gavbq introduction: the article presents a protocol of a cross-sectional study of mental health of pregnant women in relation to the coronavirus disease (covid- ) pandemic. the primary aim is to compare differences in anxiety and depression scores of pregnant women between countries affected by the covid- pandemic. the secondary aim is to assess demographic, economic, and social aspects affecting maternal anxiety and depression scores among pregnant women worldwide in the time of the covid- pandemic. finally, we will be able to compare differences in perception of the different aspects of the covid- pandemic (social distancing, restrictions related to delivery) between countries and according to the epidemic status (number of infected patients, number of reported deaths). the comparisons will also be done according to the covid- status of the participants. methods and analysis: it is a web-based anonymous survey of pregnant women living in countries affected by the covid- pandemic. the survey is comprised of sections: ).. questions related to general demography, pregnancy health history, mental health history, socioeconomic factors, as well as perception of fear, burden and restrictions related to the covid- pandemic; ).. general anxiety disorder- (gad- ) questionnaire for anxiety assessment and; ).. patient health questionnaire– (phq- ) for depression assessment. web-based recruitment for health research has proven to be cost-effective and efficient. at current times with the covid- pandemic, limited resources and social distancing restrictions, performing a mental health study involving pregnant women on a large international scale cannot be safely conducted without involving social-media. the fears of pregnant women fall into categories: the medical condition, the economic status and the organization of daily activity. the study has received approval of the medical ethics committee and has been registered on clinicaltrials.gov. results will be published in peer-reviewed journals and made public through all available media. anxiety is a feeling of worry, nervousness, or unease about something with an uncertain outcome and it can co-exist, predispose or cause depression. [ ] the unpredictability of the coronavirus disease (covid- ) pandemic makes people prone to severe anxiety. [ ] research has shown that pregnant women are especially prone to anxiety [ , ] with prevalence of gestational anxiety between % and %, [ ] in comparison with to % of anxiety symptoms in the general population. [ ] risk factors for anxiety are similar in the general population and during pregnancy, including bad childhood experiences (overprotective or harsh parenting, maltreatment, and physical punishment). parental history of mental disorders and low socioeconomic status have also been described to increase the risk of anxiety. [ , , ] about % of pregnant women experience perinatal depression globally. [ ] [ ] [ ] [ ] untreated perinatal depression may result in adverse obstetric outcomes and is a risk factor for poor maternal health, inadequate prenatal care, and postnatal depression. [ , ] in addition to the potential negative impact on pregnancy outcomes, perinatal depression is associated with disrupted maternal-infant bonding, increased irritability, and decreased activity. children born to depressed mothers are at risk for delayed cognitive and language development, lower iq, and increased prevalence of psychiatric and emotional problems. depression that begins during pregnancy frequently continues or worsens after delivery. [ , , ] mothers have a strong desire to provide their children with a stable environment, however, the situation of the growing pandemic with strict limitations regarding social contacts and economic instability does not make a secure situation for procreation. [ ] based on the current data, it seems that the severe acute respiratory syndrome coronavirus (sars-cov- ) does not cause a severe course of infection in pregnant women as they are usually young and without co-morbidities. [ ] it is worth to underline that the covid- pandemic is not only a public health crisis but also a social, demographic and economic one and it has a substantial negative psychosocial effect on everyone, including pregnant women. the resulting anxiety of pregnant women has a negative impact on pregnancy, such as increased risk of preeclampsia, depression, nausea, vomiting and could even cause preterm labor or miscarriage. [ ] what is more, maternal anxiety may lead to adverse effects of the newborns, like low birth weight, growth restriction or low apgar score. [ , ] the primary aim of our study is to compare differences in anxiety and depression scores of pregnant women between countries affected by the covid- pandemic. the secondary aim is to assess demographic, economic, and social aspects affecting maternal anxiety and depression scores among pregnant women worldwide in the time of the covid- pandemic. finally, we will be able to compare differences in perception of the different aspects of the pandemic (social distancing, restrictions related to delivery) between countries and according to the epidemic status (number of infected patients, number of reported deaths). the comparisons will also be done according to the covid- status of the participants. this is a cross-sectional study. data will be collected through an anonymous web-based survey made up of closed questions with multiple choice answers. the survey has three parts: ) questions related to general demography, pregnancy health history, mental health history, socioeconomic factors, as well as perception of fear, burden and restrictions related to the covid- pandemic and ) general anxiety disorder- (gad- ) questionnaire for anxiety assessment ) patient health questionnaire- (phq- ) for depression assessment. . . . survey development. the survey will be conducted using the research and electronic data capture (redcap) tool. it is a secure application that provides an interface for data entry. [ , ] all data will be collected anonymously, and the answers will not be attributed to a specific individual. the survey has been developed by a multidisciplinary team comprised of physicians, midwives, psychologists, and sociologists. all experts have proposed questions from their field. the questions, in turn, have been reviewed by a second group of field experts. the second group of experts also proposed questions, and their feedback has been included in the final version of the survey. a pilot study was performed on ten polish, chinese and english-speaking pregnant women, and their feedback was obtained to enhance the readability and the content of the survey. in the following stage of the study, this will be done for all participating languages. description of the survey. the survey collects information on demography, socioeconomic situation, general health history, pregnancy risk assessment, mental health history, and specific aspects related to the covid- pandemic. both gad- and phq- scales are used to assess anxiety and depression. the survey consists of questions, and it has the following structure: screening questions, consent form, demographic and socioeconomic questions, mental health history questions, general health history questions, pregnancy risk assessment questions, covid- specific questions, and the gad- and phq- scales. supplemental digital content (appendix . full survey in english), http://links.lww.com/md/e . . . screening questions. the survey has screening questions, of which the first asks if the woman is pregnant or not. it is followed by questions regarding last menstrual period and estimated date of delivery, type of provided care (midwife, doctor, shared, none), and if the pregnancy has been confirmed by a medical professional. this is aimed at decreasing bias created by women claiming to be pregnant to complete the survey. demographic and socioeconomic questions ask about place of residence, education, number of people in household, sources of income, marital status, and family/partner support. pregnancy risk assessment questions include parity, previous mode of delivery, pre-pregnancy chronic diseases, pregnancy-related complications, and infertility treatment. mental health history questions cover pre-pregnancy and current mental health issues. covid- specific questions cover fear and burden related to covid- pandemic and the restrictions imposed in order to limit the spread of the virus. once participants are deemed eligible to participate, a consent form appears that explains the purpose of the study, what the data will be used for, how the data will be stored, requirements of the participant, and any potential benefits or risks incurred by participating, and that consent for participation can be withdrawn at any point before submission of the questionnaire. because of the questionnaire's anonymous nature, the participant information cannot be withdrawn after data has been submitted. the researchers will not know which data belong to which participant. participants will be informed of this in the consent form. . . . gad- scale. generalized anxiety disorder -item (gad- ) questionnaire measures the severity of anxiety over the past two weeks. the gad- questionnaire is a -question scale. there are four choices regarding the severity of symptoms: "not at all", "several days", "more than half the days" and "nearly every day", which correspond to , , , and points score, respectively (minimum total score , maximum ). [ ] the summarized score is used to assess anxiety intensification. the scale is commonly used to diagnose generalized anxiety disorder in the general population. national institute for health and care excellence (nice) recommends using this tool as a measurement of prenatal anxiety. [ ] the gad- scale is the only scale besides the state-trait anxiety inventory (stai) that is validated for women in the prenatal period. [ ] the advantages of the gad- scale are that it is more straightforward, easy to complete and that the interpretation is easier with fewer questions: in gad- vs. in stai. moreover, the gad- scale is available without cost and is easier to use on social media. in the general population a score of ≥ allows diagnosis of generalized anxiety disorder. [ ] nevertheless, in pregnant women, the cut-off point has been established as ≥ with a sensitivity of . % and specificity of . %. [ ] (table ) . . . phq- scale. nice also recommends using the phq- scale with the gad- scale to measure the depression risk in pregnant women. [ ] phq- has a similar grading system to gad- and consists of nine questions exploring the depression symptoms over the past two weeks with four possible answers: "not at all," "several days," "more than half the days" and "nearly every day," which correspond to , , , and points score, respectively (minimum total score , maximum ). [ ] according to american college of obstetricians and gynecologists (acog), edinburg postnatal depression scale (epds) and phq- are appropriate tools to measure antepartum depression. [ , ] the advantage of the phq- scale is that it has fewer questions: questions vs in epds. participants that achieve a score of ≥ meet diagnostic criteria of perinatal depression. [ ] ( table ) . . . follow-up, disclaimers and data storage. after completing the questionnaire, women will be given the option of providing their contact information (first name and email address). this database of contacts will be used to update participants on the results of this study and invite them to future studies and activities. neither the women who participate in giving their data nor those that provide contact information in the study will receive any compensation. this study has received no funding and is a non-profit initiative of an international perinatal medicine community to better understand the burden of covid- pandemic on maternal mental health worldwide. contact information will be collected using a separate form so that personal information cannot be linked to the data provided in the web-based survey. in the consent section of the survey, participants will be warned that some questions might be of a sensitive nature, and they can skip any question that they do not feel comfortable answering. the only parts of the survey that need to be fully answered are the gad- and phq- scale. all data will be stored on secure internal servers at the st. sophie's obstetrics and gynecology hospital, warsaw, poland, and will be directly downloaded from the redcap tool and stored on a password-protected computer in a locked room at the department of reproductive health of the centre of postgraduate medical education located on the hospital grounds. data will be stored in this location for years before it is destroyed. principles outlined in the data protection act are considered to ensure proper handling of the collected personal data. exclusion criteria are the following: not providing online informed consent for participation or if the participant does not click on the submit button at the end of the survey, and women who do not answer all the gad- and phq- scale questions. . . . sample size. the estimated sample size is for each country. this has been calculated using the cincalc.com sample size calculator. [ ] results of gad- for the general population vary between , (+/À . ) to , (+/À . ). [ , ] for phq- , the scores vary from , (+/À , ; for population in age of - ) to , (+/À . ). [ , ] to detect a % difference separately in anxiety (gad- scale) and depression levels (phq- scale) between the studied countries using a power of % and a margin error of . , [ ] the calculated sample size for gad- is in every single country and for phq- calculated sample size is in every single country. values yielding higher sample sizes will be used. this sample size will allow us to compare reported anxiety and depression levels among pregnant women in different countries around the world affected by the pandemic. group was formed, and a website was constructed for the international promotion of the study (www.pregmind.org). [ ] data collection will begin with an initial social media post created on the the pregmind facebook fan page. the post will be prepared in the predefined languages and shared publicly. campaigns will be set up to promote the study. advertisements and posts will be shared on pages targeted towards pregnant women on every continent in the world in the predefined languages. we will also target closed pregnancy orientated groups via private messages on facebook and invite them to post the study advertisement with the link to the survey on their pages. the recruitment target will be reached when the desired sample size per region is achieved. we hope to collect data from at least one country from every continent. the survey will be translated into languages, out of which (english, spanish, chinese, arabic) are widely spoken around the world and are not nationality related. for this study, the recruitment rate is difficult to predict. we expect data collection to take place at least six months for each language, based on similar previous studies of mental health. [ ] recruitment rates may vary in different regions. recruitment will not start simultaneously for all regions. . . . statistical analysis. data will be kept anonymous and non-identifiable. for the statistical, analysis, r software [ ] and the mplus computer program will be used. [ ] data collection will include the most relevant demographic variables allowing us to compare collected data within a population. reweighting and other techniques will allow adjustment for known or expected discrepancies between sample populations. [ ] to ensure comparability reweighting techniques, measurement invariance analysis will be performed. for the reweighting, we will use procedures suggested by gelman and carlin. [ ] we will collect external information about the distribution of age, place of residence, education level of pregnant women in the population, and adjust our sample to match the proportion in each country. if this is not possible because of the shortage of data, we will use propensity score matching [ ] and regression technique to balance the groups' demographic distributions and make comparisons justifiable. additionally, to ensure a valid comparison between countries, we will conduct a detailed measurement invariance analysis. [ ] furthermore, we plan to perform regression analyses to explore potential associations between the reported anxiety, depression levels, and medical, sociodemographic, and pandemic related variables (including burdens related to social distancing). altogether there will be different variables. according to a rule of thumb "n > +m", where n is the number of participants and m is the number of variables, the sample size will allow us to perform all planned analysis. [ ] our main variables (gad- and phq- scale) are measured by multiple indicators (questions), this opens the possibility to use confirmatory factor analysis (cfa). this technique will allow us to assess the comparability of variables and, if necessary, address the problem of comparability using different latent variable modeling strategies. [ ] principal analysis will be conducted using structural equation modeling framework which allows us to account not only for comparability problems but as well for measurement error. [ ] . . . ethics and dissemination. the study protocol is in accordance with and was based on the helsinki declaration. ethics approval was obtained from the medical bioethics committee of the centre of postgraduate medical university (decision no. / pb/ ). the study has been registered at clinicaltrials.gov, registration number nct . participation in the study is voluntary and anonymous. participants consent to the study by filling a web-based survey and clicking the submit button at the end. before beginning they are informed that they can withdraw at any time and none of the information will be stored in the database. participants may provide their personal information for participation in future research, but this information will not be linked with the data provided in this study. the results of the study will be presented at local, national and international conferences related to mental health, pregnancy and covid- . data will be published in peer-reviewed journals. the main findings of the study will also be shared and disseminated to researchers, health service providers, healthcare professionals and the public, especially pregnant women through all forms of media and communication. web-based recruitment is not free of problems, but it is timeefficient and allows for fast data collection in cross-national settings. typical survey procedures require months of preparation, and realization is not free of obstacles. despite the potential problems, web-based surveys have proven to be useful in many types of projects, [ ] including assessment of mental health as well as other aspects of pregnancy, for example, nutritional habits. [ ] in this study data collection procedures are designed to maintain the highest degree of cross-country comparability. web-based recruiting for health research has proven to be costeffective and efficient. [ ] at current times with the covid- pandemic, because of limited resources, and social distancing restrictions, performing a mental health study involving pregnant women on a large international scale cannot be safely conducted without involving the social-media. a web-based survey can be prone to several types of bias, such as non-response bias, response bias, selection bias, recall bias, and volunteer bias. [ ] although the medium used to propagate the survey is available both in developed and underdeveloped countries, there is a risk that our survey will reach more women of a higher socioeconomic status and from larger agglomerations. to some extent, we could control this bias using historical data collected by conventional methods. in our study, additionally, bias will be accounted for by planning the campaigns for the dissemination of the survey to reach populations in various settings. response-bias, on the other hand, is a situation when there is a systematic distortion in the way respondents answer the questions. this kind of bias is mainly a problem in surveys that investigate socially unacceptable/embarrassing behavior, that is, alcohol consumption or illegal drug use. although this is not the case, there is a risk that pregnant women are particularly worried about the covid- pandemic and will be more likely to respond to the advertisement of a survey assessing mental health related to the covid- pandemic. this type of bias is also defined as recall bias, which is often the case in medical surveys where respondents who are prone to a specific sickness, are sick, or are more interested in the disease, are more likely to respond to a survey. [ ] for this reason, we will collect background information regarding mental health problems and previous treatments to distinguish such responses. we expect a higher incidence in difficulties with coping with the covid- pandemic in women with a previously diagnosed mental health problem. it has been described that the experience of having the studied condition encourages an 'effort after meaning.' the participant in such a case has already gone over his/her life history to understand why he/she has become ill. this clearly predisposes to recall bias. [ ] again, this is not the case in our study. volunteer bias would have occurred if there is a systematic difference between those who volunteer to be part of the study (completed the survey) and the population. in this case, we use a convenience sampling method, which involves sampling participants who are available to be approached at the time of recruitment. also, we are approaching a specific part of the populationpregnant women. if there were a significant difference between those patients selected for the survey and those who are not, this would result in a sample that is not representative of the population. convenience sampling is a proven, efficient, cost-effective method of recruitment for a web-based survey. [ ] the study aims to assess differences between countries resulting from the covid pandemic. it will be hard to assess if the presented views will reflect the views of the general population of pregnant women in specific countries. this can be accounted for by analyzing the spread of the demographic and socioeconomic factors in the studied populations. the strength of the study is that we are targeting unselected pregnant women. as a result of covid- related mortality and morbidity, the rapid spread of the virus worldwide, who (world health organization) announced a pandemic state on march . as a result of the announcement, but also prior to the announcement, governments worldwide implemented measures to avoid further spread of the virus and reduce the number of causalities. [ ] because of the pandemic, many essential services that usually make life easier, like banking, shopping facilities, all kinds of services, including medical, childcare, schools, sports and entertainment are unavailable due to new regulations. many people are asking themselves questions such as: "how long will all this last?", 'how will it impact my life in the long-term?", "will i have a job when this is over?", "will i have an employer to return to?", "will all my family members survive?" and many more. isolation and social distancing are important risk factors of mental health. [ ] [ ] [ ] fetal well-being is one of the main maternal concerns. although the possibility of vertical transmission has not been confirmed with concrete evidence, women may feel worried about such risk or infection of the infant in the peripartum period. pregnancy is also the time of increased medical observation, which is difficult to facilitate during the pandemic. [ ] the difficulty in accessing professional medical help may also be a source of anxiety for pregnant women. [ ] besides, pregnant women may feel insecure about exposure risk to the coronavirus when accessing medical facilities. since schools have been closed, the -hour presence of children at home is an additional source of stress because of the additional time dedicated to looking after them, the lack of physical/outdoor activities and the need to provide home-schooling. financial problems and newfound duties related to family care can potentially lead to misunderstandings between family members. the support of the partner has a significant influence on maternal well-being and therefore single mothers may be more prone to anxiety. [ ] the covid pandemic has resulted in increased fear and uncertainty. this in turn may lead to negative societal behaviors. this may include behaviors aimed at regaining control of the situation, such as clearing shelves at supermarkets resulting in temporary shortages of food or other essentials such as toilet paper. [ ] more and more countries are implementing mass quarantines. the experience of isolation, fear of being trapped and rumors spread on social media can all result in growing anxiety and social panic. [ ] other aspects of social life are being severely affected as well, such as family gatherings, participation in holidays, religious celebrations, births, funerals and many more. all of these can lead to growing anxiety and depression. [ ] another important social aspect is the fear of blame, guilt and stigmatization related to being infected with covid- . infected people may become a target of discrimination. there have been documented incidents of suicide due to guilt related to being infected as well as to social media bullying of medical professionals. [ , ] the covid- pandemic has affected the job market. salaries have often been reduced and many people have lost their jobs leading to difficulties in paying bills and loans, and problems with daily survival costs. measures to contain the virus directly influence economy. in china where the outbreak struck first, production fell by . % and some sectors have collapsed completely, such as car sales by % and restaurant sales by %. the predicted decrease of the us economy in the second quarter of is % as a result of the covid- pandemic. [ ] more than a decade ago the world suffered an economic crisis similar to the one we are expecting to happen now. that global financial crisis resulted in declining mental health worldwide with a rising number of suicides, alcohol and drug related deaths. [ ] the intricate vine of dependencies between the safety of all people, economy, health and political systems shows how vulnerable we have all become during these difficult times. the covid- pandemic has shown us that in an extreme environment mental health is a major public issue. the crisis that we are facing now, if appropriately managed, may become an opportunity for a global social transformation of perceptions, and interventions are needed to address mental health. [ ] we hope that our study, with its international reach, issues to be addressed and data to be gathered, will play a role in this process. attitudes about the h n influenza pandemic among pregnant japanese women and the use of the japanese municipality as a source of information incidence, prevalence and risk factors related to anxiety symptoms during pregnancy prevalence and identification of anxiety disorders in pregnancy: the diagnostic accuracy of the two-item generalised anxiety disorder scale (gad- ) anxiety scales used in pregnancy: systematic review risk factors of transient and persistent anxiety during pregnancy anxiety and depression during pregnancy in central america: a cross-sectional study among pregnant women in the developing country nicaragua effects of depressive and anxiety symptoms during pregnancy on pregnant, obstetric and neonatal outcomes: a follow-up study association of panic disorder, generalized anxiety disorder, and benzodiazepine treatment during pregnancy with risk of adverse birth outcomes maternal anxiety, depression and sleep disorders before and during pregnancy,; ; and preschool adhd symptoms in the ninfea birth cohort study anxiety during pregnancy and postpartum: course, predictors and comorbidity with postpartum depression clinical pharmacology during pregnancy effectiveness of psychoeducational counseling on anxiety in preeclampsia the comorbidity of low back pelvic pain and risk of depression and anxiety in pregnancy in primiparous women the redcap consortium: building an international community of software platform partners research electronic data capture (redcap)-a metadata-driven methodology and workflow process for providing translational research informatics support a brief measure for assessing generalized anxiety disorder: the gad- antenatal and postnatal mental health: the nice guideline on clinical management and service guidance potential maternal and infant outcomes from (wuhan) coronavirus -ncov infecting pregnant women: lessons from sars, mers, and other human coronavirus infections diagnostic validity of the generalized anxiety disorder - (gad- ) among pregnant women validation and utility of a selfreport version of prime-md: the phq primary care study. primary care evaluation of mental disorders. patient health questionnaire screening for perinatal depression acog releases recommendations on screening for perinatal depression depression: an exploratory parallel-group randomised controlled trial of antenatal guided self help for women (dawn): study protocol for a randomised controlled trial sample size calculator psychometric analysis of the generalized anxiety disorder scale (gad- ) in primary care using modern item response theory stability of the distribution of patient health questionnaire- scores against age in the general population: data from the national health and nutrition examination survey emental health experiences and expectations: a survey of youths' web-based resource preferences in canada r: a language and environment for statistical computing. r foundation for statistical computing mplus user's guide. seventh edition. muthén & muthén propensity score analysis: statistical methods and applications a monte carlo simulation study to assess the appropriateness of traditional and newer approaches to test for measurement invariance how many subjects does it take to do a regression analysis principles and practice of structural equation modeling bit by bit: social research in the digital age what do pregnant women know about the healthy eating guidelines for pregnancy? a web-based questionnaire web-based recruiting for health research using a social networking site: an exploratory study questionnaire surveys: sources of bias recall bias -an overview j sciencedirect topics a manual for selecting sampling techniques in research the covid- emergency response should include a mental health component traumatic stress in the age of covid- : a call to close critical gaps and adapt to new realities the mental health consequences of covid- and physical distancing: the need for prevention and early intervention isuog safety committee position statement on safe performance of obstetric and gynecological scans and equipment cleaning in the context of covid- effects of ultrasound on anxiety and psychosocial adaptation to pregnancy course and risk factors of maternal pregnancy-related anxiety across pregnancy in ma' anshan city the covid- pandemic and mental health impacts factors associated with pregnancy-related anxiety in tanzanian women: a cross sectional study as if a storm hit": more than italian health workers have died since crisis began [internet]. the guardian prokuratorskie dochodzenie w sprawie smierci prof if the world fails to protect the economy, covid- will damage health not just now but also in the future covid- pandemic: a public and global mental health opportunity for social transformation? medicine ( ) : www.md-journal we would like to thank _ zelazna medical centre for their support in this project. akconceived the study, designed the study protocol, drafted the manuscript; sf -drafted the manuscript; ua -designed the study protocol, drafted the manuscript; jm -designed the study protocol, drafted the manuscript; bb -conceived the study, designed the study protocol, ds -conceived the study, designed the study protocol, drafted the manuscript, organized and implemented the redcap program; apdesigned, revised the study protocol, planned and wrote the statistical analysis of the study; mrparticipated in drafting and revising the manuscript; hj -designed the study protocol; rl -designed the study protocol; db -conceived the study, designed the study protocol, participated in the local networking of the study sk -conceived the study, designed the study protocol, drafted the manuscript, participated in the international networking of the study; lp -drafted and critically revised the study protocol and manuscript, participated in the international networking of the study key: cord- -gifwg ho authors: bender, whitney r.; hirshberg, adi; coutifaris, paulina; acker, alexandra l.; srinivas, sindhu k. title: universal testing for sars-cov- in two philadelphia hospitals: carrier prevalence and symptom development over two weeks date: - - journal: am j obstet gynecol mfm doi: . /j.ajogmf. . sha: doc_id: cord_uid: gifwg ho background the covid- pandemic caused by the sars-cov- virus has challenged obstetric care providers. universal testing on labor and delivery units has been implemented by many hospitals to ensure patient and staff safety. asymptomatic carrier rates are expected to vary based on geographic differences in disease prevalence, although differences within the same city have not previously been reported. additionally, clinical follow-up of women testing negative for sars-cov- during obstetric hospitalization have not been included in any prior reports. objectives to describe the prevalence of positive sars-cov- tests among asymptomatic pregnant women at two philadelphia obstetric hospitals, characterize the clinical course of those testing positive, and report symptom development among all women tested in the two weeks post-hospitalization. study design this is an observational study of asymptomatic pregnant women who underwent sars-cov- testing at two academic health centers (hup and pah) in philadelphia, pa between april , and april , . all women tested were contacted via telephone for symptom follow-up at one and two weeks post-discharge. asymptomatic positive test rates are reported for the overall population and by hospital. the hospital and two-week post-hospital course are described for women testing positive for sars-cov- . post-hospital symptom development among women testing negative for sars-cov- is also described. results three hundred and eighteen asymptomatic women underwent sars-cov- testing during this two-week period. eight women tested positive. the overall asymptomatic test positive rate was . %. the rate at hup was . % compared to . % at pah (p = . ). three women ( . %) who were initially asymptomatic developed mild symptoms in the two weeks after positive test. repeat sars-cov- testing was performed in of the women ( . %) who initially tested negative; two women ( . %) were positive on repeat testing. ( . %) and ( . %) of the women who were sars-cov- negative at time of initial hospitalization were reached for telephone follow-up at one and two weeks post-admission, respectively. viral symptoms, including fevers, chills, shortness of breath, or cough, were self-reported in . % and . % of these women at one and two weeks post-discharge, respectively. conclusions the asymptomatic positive sars-cov- test rate among an obstetric population in philadelphia differed between two hospitals and was lower than described in other geographic regions. this supports the importance of institution-specific testing protocols. the development of symptomatic sars-cov- infection post-hospitalization among women with initial negative testing is uncommon. after positive test. repeat sars-cov- testing was performed in of the women ( . %) who initially tested negative; two women ( . %) were positive on repeat testing. ( . %) and ( . %) of the women who were sars-cov- negative at time of initial hospitalization were reached for telephone follow-up at one and two weeks post-admission, respectively. viral symptoms, including fevers, chills, shortness of breath, or cough, were self- reported in . % and . % of these women at one and two weeks post-discharge, respectively. the asymptomatic positive sars-cov- test rate among an obstetric population in philadelphia differed between two hospitals and was lower than described in other geographic regions. this supports the importance of institution-specific testing protocols. the delivery, however, often cannot be delayed nor considered elective. due to the necessity of contact with the health system and the inability to delay such contact, many hospitals have implemented universal testing for sars-cov- on labor and delivery. implementation of universal testing has raised many process-related questions regarding isolation, use of personal protective equipment (ppe), accuracy of the test results and implications for newborn and post-discharge care. much of the information regarding universal sars-cov- testing has focused on the obstetric population in new york city. the asymptomatic positive rate has been reported as . %. symptom development occurred in - % of women during the course of their hospitalizations or shortly thereafter. [ ] [ ] [ ] [ ] geographic differences in asymptomatic carrier rates have not been widely reported, although rates are likely to be based on disease prevalence. to date, one additional report outside of new york suggested lower asymptomatic sars-cov- test positive rate of < %. in each of these studies, the follow-up period for asymptomatic test positive patients was variable as delivery hospitalizations are typically short. therefore, it remains unclear whether these women were truly asymptomatic or pre-symptomatic. further, no studies to j o u r n a l p r e -p r o o f date have reported follow-up of asymptomatic women who tested negative during their hospitalization. the objectives of this study are to describe the prevalence of positive sars-cov- tests at time of admission for delivery among asymptomatic pregnant women in philadelphia within two large academic hospitals, characterize the in-hospital clinical course for those who tested positive, and report the development of viral symptoms in all women tested for two weeks after hospital discharge. this is an observational study of pregnant women presenting for obstetric care at two hospitals within a large academic health system in philadelphia, pennsylvania between april , and april , . given its retrospective nature, this study was deemed exempt by the university of pennsylvania institutional review board. all women presenting for delivery at the hospital of the university of pennsylvania (hup) and pennsylvania hospital (pah) were approached for testing for sars-cov- via nasopharyngeal and oropharyngeal swab as part of a universal testing clinical protocol. women admitted for other obstetrical indication and deemed likely to deliver during the admission were also tested. collection of these specimens was performed by physicians and advanced practice providers at hup and by registered nurses at pah. all staff received hands- on training on specimen collection at the start of this clinical protocol. a real-time pcr assay was performed for the qualitative detection of nucleic acid of the sars-cov- virus. women who reported viral symptoms, were febrile at the time of presentation, or had a known sars- cov- exposure were deemed persons under investigation and were excluded from this study test results, demographic, obstetric, and neonatal data were abstracted from the electronic medical record (emr) by a single investigator (wb). the development of viral symptoms among those women who tested positive was also recorded. telephone calls were made to all of these patients at - days and - days post-hospital admission and test date as part of routine clinical follow-up. a total of two weeks of follow up was obtained given the j o u r n a l p r e -p r o o f reported potential for gradual symptom onset over this time period. , during these calls, patients were asked about the need for personal medical care or the development of viral symptoms in themselves or their family since hospital discharge. the development of viral symptoms was assessed using standardized scripting. viral symptoms included in the standard script were fever, shortness of breath, anosmia, cough, headaches, sore throat, rhinorrhea, nausea, vomiting, diarrhea, and muscle aches. sample size was fixed based on the number of women admitted during the prespecified timeframe. descriptive statistics were calculated for the population at large. comparisons were made between hospitals and between women testing positive and negative for sars-cov- . the association of categorical variables with binary outcomes were analyzed using fisher exact test or chi squared analyses as appropriate. the associations of continuous variables with binary outcomes were analyzed using student's t-test or wilcoxon rank-sum tests for non- normally distributed variables during the specified two-week timeframe, testing was not completed on seven women across both sites. three hundred and eighteen women were tested for sars-cov- ; were tested at hup and were tested at pah. complete demographic data for the population by hospital site is listed in table . of note, black women accounted for % of the total population. women delivering at pah were less likely to be black or publically-insured. between the two hospitals. six women ( . %) were positive for sars-cov- at hup compared to only . % ( / ) of women testing positive for sars-cov- at pah (p = . ). as seen in table , there were no differences in demographic characteristics or delivery outcomes between asymptomatic women with positive and negative sars-cov- test results. seven of the eight women who tested positive for sars-cov- were without medical comorbidities; one woman had chronic hypertension. details of the hospital course for the eight asymptomatic women with a positive sars-cov- test are shown in table . six women delivered a full-term living neonate, with negative sars-cov- testing on all of these infants. one woman was discharged undelivered after a trauma observation. cov- during their admission. repeat testing was performed for patients as shown in table . repeat testing was done on the index hospitalization for an unexplained fever on postpartum day one for one patient and again resulted negative. another patient had repeat testing prior to delivery four days after initial admission testing. the remaining repeat tests were performed at either a subsequent emergency evaluation or hospital readmission. in this retrospective cohort study, the asymptomatic sars-cov- test positive rate among pregnant women in philadelphia was . %. however, it is important to note that the asymptomatic test positive rates differed between the two hospitals ( . % v. . %) despite only four miles separating the two sites. eight asymptomatic women tested positive, only one of whom developed a fever during the hospitalization; the other seven remained asymptomatic during their hospitalization. none of the women required additional care during the two week follow up period. in addition to the patient who developed a fever while in the hospital, two women subsequently developed mild symptoms within one week of being tested. therefore, five of the eight women ( . %) with positive sars-cov- testing remained asymptomatic. women who tested negative for sars-cov- were also followed for two weeks post- hospitalization. two women developed fever and respiratory symptoms during this timeframe and were diagnosed with covid- on repeat testing; in both cases, this occurred more than days after initial negative test. this study adds to the growing body of literature on asymptomatic testing for sars-cov- in the obstetric patient. our rate of asymptomatic positive tests is lower than reported for similar programs in new york city, likely secondary to differences in local disease prevalence. additionally, the development of symptoms in our asymptomatic test positive population ( / ; . %) is lower than that described in the new york city cohort (over %). interestingly, however, two hospitals within the same city and health system had clinically though not statistically different asymptomatic positive test rates during the same time frame. the reason for this difference could be several fold. although all providers received similar instructions on specimen collection, testing was performed by different personnel at each site. additionally, there are some notable differences in patient population. the difference in rates despite close proximity of the hospitals supports the need for institution-driven testing rather than reliance upon regionally or nationally-reported information. j o u r n a l p r e -p r o o f the inclusion of follow-up data from sars-cov- negative women allows us to comment upon the potential for false negative test results, negative test results during a potential presymptomatic period, or the risk of viral acquisition during hospitalization. less than % ( / ) of women developed sars-cov- during their two-week follow-up. while we cannot ascertain when or how these infections were acquired, the low rate of symptomatic infection following discharge may be useful for counseling and providing reassurance to women who have anxiety about disease exposure during their delivery hospitalization throughout the pandemic. while an additional - % of women reported viral symptoms including chills, shortness of breath, or cough in the two-week follow-up period, none of these women were tested for sars-cov- infection. therefore, the true significance of these symptoms remains unknown. five of the eight women who tested positive for sars-cov- remained asymptomatic during the two week follow-up period. repeat testing was not performed routinely in this population in the weeks post-delivery, and as such, the possibility for false positive test results cannot be adequately addressed with the data available. as additional testing becomes available, future research is needed to determine the true significance of any viral symptoms post-hospitalization. as this study is among the first to report clinical follow-up from asymptomatic negative women, additional studies are warranted to confirm its findings. further work to confirm geographic variations within cities and investigate the reasons for their existence is also warranted. lastly, additional studies are warranted to determine the impact of universal sars-cov- testing on population spread as well as patient and provider anxiety. this study has several strengths. this was a large cohort study of all asymptomatic pregnant women presenting for care at two hospitals in an academic health system. data describing hospitalization was abstracted by a single author. the inclusion of telephone-call derived data until two-weeks post-hospitalization for both sars-cov- -positive and negative women allows us to comment upon symptom development in both populations. this study is not without limitations. as this study was conducted within a single academic health system, the data may not be generalizable to the population at large. follow- up information regarding interval symptom development was based on patient report. however, this is the most accurate way to comprehensively assess this information. lastly, the vast majority ( %) of patients were not re-tested in a short interval to determine conversion of asymptomatic test negative patients to test positive. this is particularly important for the . % and . % of women who reported viral symptoms at one and two weeks postpartum, respectively. seroconversion of these women to sars-cov- positive would not have been noted given they did not all undergo repeat sars-cov- testing. therefore, it remains possible that the rate of infection development post-hospitalization is higher than the reported less than % in this cohort. if these were true sars-cov- infections, however, they were likely mild in nature. overall, the absence of development of symptoms in the vast majority of women ( %) during the two weeks postpartum is reassuring. in summary, this retrospective cohort study found an asymptomatic carrier rate ranging from . % to . % in the philadelphia obstetric population. the differences found between the two hospitals highlights the importance of institution-specific information and approaches to universal testing and ppe protocols. less than % of the test negative women developed sars- cov- in the two weeks following hospitalization. this information may be an important component of provider counseling as obstetricians continue to determine the best means of providing high quality care in the pandemic. j o u r n a l p r e -p r o o f universal screening for sars-cov- in women admitted for delivery coronavirus disease infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentation to an affiliated pair of new york city hospitals critical illness among obstetric patients with coronavirus disease online ahead of print outcomes of births to women with severe acute respiratory syndrome coronavirus (sars-cov- ) infection at five new york city medical centers online ahead of print clinical findings in a group of patients infected with the novel coronavirus (sars-cov- ) outside of wuhan china: retrospective case series the authors report no conflicts of interest. the authors have no financial disclosures to report. key: cord- -iy vjpuh authors: schwartz, david a.; graham, ashley l. title: potential maternal and infant outcomes from coronavirus -ncov (sars-cov- ) infecting pregnant women: lessons from sars, mers, and other human coronavirus infections date: - - journal: viruses doi: . /v sha: doc_id: cord_uid: iy vjpuh in early december a cluster of cases of pneumonia of unknown cause was identified in wuhan, a city of million persons in the people’s republic of china. further investigation revealed these cases to result from infection with a newly identified coronavirus, initially termed -ncov and subsequently sars-cov- . the infection moved rapidly through china, spread to thailand and japan, extended into adjacent countries through infected persons travelling by air, eventually reaching multiple countries and continents. similar to such other coronaviruses as those causing the middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars), the new coronavirus was reported to spread via natural aerosols from human-to-human. in the early stages of this epidemic the case fatality rate is estimated to be approximately %, with the majority of deaths occurring in special populations. unfortunately, there is limited experience with coronavirus infections during pregnancy, and it now appears certain that pregnant women have become infected during the present -ncov epidemic. in order to assess the potential of the wuhan -ncov to cause maternal, fetal and neonatal morbidity and other poor obstetrical outcomes, this communication reviews the published data addressing the epidemiological and clinical effects of sars, mers, and other coronavirus infections on pregnant women and their infants. recommendations are also made for the consideration of pregnant women in the design, clinical trials, and implementation of future -ncov vaccines. coronaviruses are spherical, enveloped, and the largest of positive-strand rna viruses. they have a wide host range, including birds, farm animals, pets, camels, and bats, in which they primarily cause respiratory and gastrointestinal disease. belonging to the order nidovirales, family coronaviridae, and the subfamily orthocoronaviridae there are four genera of coronaviruses-alphacoronavirus, betacoronavirus, deltacorona virus, and gammacoronavirus [ ] [ ] [ ] [ ] . in humans, they are a cause of mild illnesses including the common colds occurring in children and adults, and were believed to be of modest medical importance. however, two zoonotic coronaviruses-including the severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov)-can produce severe lower respiratory in the beginning of december , a cluster of persons with a pneumonia of unknown cause was identified in wuhan, the capital of hubei province and a large city of approximately million persons located in the central region of the people's republic of china [ , ] . between and december there were cases of pneumonia identified whose clinical features resembled that of a viral pneumonia. the outbreak was initially believed to be linked to the wuhan huanan (south china) seafood wholesale market. this market, termed a "wet" market, sells a variety of seafood, cuts of meat, and both live and dead animals in over one thousand stalls in constant close contact; however, whether this market was the origin of the outbreak remains unknown [ ] . on december , the chinese center for disease control and prevention (china cdc) sent a rapid response team to hubei to work alongside health personnel from the provincial and wuhan city health departments to conduct an epidemiologic investigation. as the disease was spreading through secondary and tertiary cases, the world health organization (who) china country office was informed on december of the occurrence of these cases of pneumonia of unknown etiology. during the period from december to january , patients with pneumonia of unknown etiology were reported by the chinese authorities to the who. on january investigators in china identified the etiological agent of the epidemic as a previously unknown coronavirus, and it was given the designation -ncov (for novel coronavirus) [ ] . analysis of the clinical features of hospitalized patients with laboratory-confirmed -ncov infection revealed that were men ( %); less than one-half had underlying co-morbid conditions ( ; %) which included diabetes ( , %) , hypertension ( , %), and cardiovascular disease ( ; %); and the average age was . years old. the most common symptoms at the beginning of their illness included fever ( , %) , cough ( , %) , and fatigue or myalgia ( , %) , sputum production ( , %) , and headache ( , %) [ ] . among these initial cases of -ncov infection there were patients ( %) who developed acute respiratory distress syndrome (ards), ( %) required intensive care and ( %) died. during the first weeks of january the infection spread rapidly through china and extended to adjacent countries where cases began to appear- january in thailand, january in japan, january in the republic of korea, and taiwan and the united states on january [ ] . infected travelers, mostly via commercial air travel, are known to have been responsible for introducing the virus outside of wuhan. the new coronavirus continued to spread throughout multiple countries and continents, and by february the who reported , confirmed cases in china that resulted in deaths, surpassing the number of deaths that occurred during the - sars epidemic. an additional cases of -ncov infection have occurred among other countries outside of china [ ] . (figure ) at the meeting of the emergency committee of the who on january, the novel coronavirus epidemic was declared a public health emergency of international concern (pheic) [ , ] . viruses , , of epidemic. an additional cases of -ncov infection have occurred among other countries outside of china [ ] . (figure ) at the meeting of the emergency committee of the who on january, the novel coronavirus epidemic was declared a public health emergency of international concern (pheic) [ , ] . this newly recognized coronavirus, producing a disease that has been termed covid- , is rapidly spreading throughout china, has crossed international borders to infect persons in neighboring countries, and humans infected by the virus are travelling via commercial airlines to other continents. it is certain that -ncov will infect women who are pregnant, leaving the question open as to whether the novel coronavirus will have a similar or different effect on them compared with sars-cov and mers-cov. in order to address the potential obstetrical outcomes of infection to both mother and infant, the present communication describes the current state of knowledge regarding the effects of other coronavirus infections in pregnancy. pneumonia arising from any infectious etiology is an important cause of morbidity and mortality among pregnant women. it is the most prevalent non-obstetric infectious condition that occurs during pregnancy [ ] [ ] [ ] . in one study pneumonia was the rd most common cause of indirect maternal death [ ] . approximately percent of pregnant women who develop pneumonia will need to be hospitalized in critical care units and require ventilatory support [ ] . although bacterial pneumonia is a serious disease when it occurs in pregnant women, even when the agent(s) are susceptible to antibiotics, viral pneumonia has even higher levels of morbidity and mortality during pregnancy [ ] . as with other infectious diseases, the normal maternal physiologic changes that accompany pregnancy-including altered cell-mediated immunity [ ] and changes in pulmonary function-have been hypothesized to affect both susceptibility to and clinical severity of pneumonia [ ] [ ] [ ] . this has been evident historically during previous epidemics. the case fatality rate (cfr) for pregnant women infected with influenza during the - pandemic was %-even higher when exposure occurred during the rd trimester and upwards of % if pneumonia supervened [ ] . during the - asian flu epidemic, % of all deaths occurred in pregnant women, and their cfr was twice as high as that of infected women who were not pregnant [ ] . the most common adverse obstetrical outcomes associated with maternal pneumonias from all causes include this newly recognized coronavirus, producing a disease that has been termed covid- , is rapidly spreading throughout china, has crossed international borders to infect persons in neighboring countries, and humans infected by the virus are travelling via commercial airlines to other continents. it is certain that -ncov will infect women who are pregnant, leaving the question open as to whether the novel coronavirus will have a similar or different effect on them compared with sars-cov and mers-cov. in order to address the potential obstetrical outcomes of infection to both mother and infant, the present communication describes the current state of knowledge regarding the effects of other coronavirus infections in pregnancy. pneumonia arising from any infectious etiology is an important cause of morbidity and mortality among pregnant women. it is the most prevalent non-obstetric infectious condition that occurs during pregnancy [ ] [ ] [ ] . in one study pneumonia was the rd most common cause of indirect maternal death [ ] . approximately percent of pregnant women who develop pneumonia will need to be hospitalized in critical care units and require ventilatory support [ ] . although bacterial pneumonia is a serious disease when it occurs in pregnant women, even when the agent(s) are susceptible to antibiotics, viral pneumonia has even higher levels of morbidity and mortality during pregnancy [ ] . as with other infectious diseases, the normal maternal physiologic changes that accompany pregnancy-including altered cell-mediated immunity [ ] and changes in pulmonary function-have been hypothesized to affect both susceptibility to and clinical severity of pneumonia [ ] [ ] [ ] . this has been evident historically during previous epidemics. the case fatality rate (cfr) for pregnant women infected with influenza during the - pandemic was %-even higher when exposure occurred during the rd trimester and upwards of % if pneumonia supervened [ ] . during the - asian flu epidemic, % of all deaths occurred in pregnant women, and their cfr was twice as high as that of infected women who were not pregnant [ ] . the most common adverse obstetrical outcomes associated with maternal pneumonias from all causes include premature rupture of membranes (prom) and preterm labor (ptl), intrauterine fetal demise (iufd), intrauterine growth restriction (iugr), and neonatal death [ ] [ ] [ ] . the sars epidemic began quietly at the turn of the st century. in november , a cook in guangdong province, china, died from an unidentified illness. he had worked at a restaurant in which meat from wild animals was served. on november chinese-language media and internet reports were picked up by canada's global public health intelligence network (gphin) that indicated a flu-like illness was occurring in china [ , ] . unfortunately, the reports were not translated, and china failed to report the occurrence of this illness to the world health organization (who) until february . the disease spread to other countries where it primarily infected healthcare workers. one of these was dr. carlo urbani, a who physician investigating a patient with the new disease in hanoi. he recognized that the pneumonia was probably caused by a new, highly infectious agent, and rapidly notified the who. he contracted the sars-cov while there, became febrile and later died after traveling to thailand to attend a conference. on march , who issued a global alert regarding the disease that was occurring primarily among health care workers in hanoi, vietnam and hong kong. the disease continued to spread, and by july there were probable cases, leading to deaths in countries, with the majority of cases occurring in mainland china and hong kong. approximately % of infections occurred in healthcare workers. by the termination of the epidemic the global cfr was % [ ] . although there were relatively few documented cases of sars occurring during pregnancy, several case reports and small clinical studies have described the clinical effects in pregnant women and their infants. in reviewing these reports describing pregnant women with sars in china it is possible, and perhaps even probable, that some of the same patients were included in more than one publication. however, even if this is the case, there is no doubt that sars coronavirus infection was found to be associated with severe maternal illness, maternal death, and spontaneous abortion [ , [ ] [ ] [ ] [ ] . martha anker, an expert in statistics formerly with the who and the university of massachusetts, estimated that more than cases of sars-cov infection occurred in pregnant women, which warrants closer inspection [ ] . the clinical outcomes among pregnant women with sars in hong kong were worse than those occurring in infected women who were not pregnant [ ] . wong et al. [ ] evaluated the obstetrical outcomes from a cohort of pregnant women who developed sars in hong kong during the period of february to july . four of the women ( %) that presented during the st trimester sustained spontaneous miscarriages, likely a result of the hypoxia that was caused by sars-related acute respiratory distress. among the women who presented after weeks gestation, had preterm deliveries ( %). a case-control study to determine the effects of sars on pregnancy compared pregnant and non-pregnant women with the infection at the princess margaret hospital in hong kong [ , ] . there were deaths among the pregnant women with sars (maternal mortality rate of %) and no deaths in the non-pregnant group of infected women (p = . ). renal failure (p = . ) and disseminated intravascular coagulopathy (p = . ) developed more frequently in pregnant sars patients when compared with the non-pregnant sars group. six pregnant women with sars required admission to the intensive care unit (icu) ( %) and required endotracheal intubation ( %), compared with a . % intubation rate (p = . ) and . % icu admission rate (p = . ) in the non-pregnant group. maxwell et al. [ ] reported pregnant women infected with sars-cov who were followed at a designated sars unit- of the died (cfr of %), and ( %) required icu hospitalization and mechanical ventilation. in contrast, the mortality rate was less than % and mechanical ventilation rate less than % among non-pregnant, age-matched counterparts who were not infected with sars-cov. two women with sars recovered and maintained their pregnancy but had infants with iugr. among the live newborn infants, none had clinical or laboratory evidence for sars-cov infection. the new mothers who had developed sars were advised not to breastfeed to prevent possible vertical transmission of the virus. zhang et al. [ ] described sars-cov infections in primagravidas from guangzhou, china at the height of the sars epidemic. two of the mothers became infected in the nd trimester, and developed infection in the rd trimester. two of the pregnant women had hospital-acquired sars infections, and the other were community-acquired. all pregnant women had fever and abnormal chest radiographs; had cough; developed hypoalbuminemia; had elevated alanine aminotransferase levels (alt), had chills or rigor, had decreased lymphocytes, and had decreased platelets. one pregnant woman required intensive care, but all recovered and there were no maternal deaths. the infants were clinically evaluated, and none had evidence of sars. two pregnant women with sars were reported from the united states. in a detailed case report, robertson et al. [ ] described a -year-old pregnant woman with an intermittent cough of approximately days duration and no fever. while travelling in hong kong during the epidemic, she was exposed at her hotel to a person subsequently known to be infected with sars-cov. at weeks gestation she developed fever, anorexia, headache, increasing cough, weakness, and shortness of breath. upon returning to the united states she was hospitalized with pneumonia. obstetrical ultrasounds revealed a low-lying placenta (placenta previa) but were otherwise normal. following her discharge home and clinical recovery, she was found to have antibodies to sars-cov. she underwent cesarean section at weeks gestation because of the placenta previa and a healthy baby girl was delivered [ , ] . the placenta was interpreted as being normal. at days post-maternal illness, maternal serum and whole blood, swabs from maternal nasopharynx and rectum, post-delivery placenta, umbilical cord blood, amniotic fluid, and breast milk were collected for analysis-no viral rna was detected in specimens tested by reverse transcriptase polymerase chain reaction (rt-pcr). antibodies to sars-cov were detected from maternal serum, umbilical cord blood, and breast milk by enzyme immunoassay (eia) and indirect immunofluorescence assay. no clinical specimens (except for cord blood) were available for testing from the infant. the second case in the usa occurred in a -year-old woman who had travelled to hong kong at weeks gestation where she was exposed to sars-cov in the same hotel as the aforementioned american woman [ ] . following her return to the united states, her husband developed the clinical onset of sars, and days later she became ill with fever, myalgia, chills, headache, coryza, and a productive cough with shortness of breath and wheezing. following her hospitalization for sars she recovered, serum samples taken on days and post-onset of illness were positive for antibodies to sars-cov by enzyme immunoassay and immunofluorescent assays. her pregnancy continued and was unremarkable except for developing elevated glucose levels. a cesarean section that was performed at weeks gestation due to preterm rupture of membranes and fetal distress resulted in a healthy baby boy. at the time of delivery, the mother's serum samples were positive for antibodies to sars-cov, but samples taken of umbilical cord blood and placenta were negative. breast milk sampled and days after delivery were also negative for sars-cov antibodies. specimens evaluated from maternal blood, stool, and nasopharynx samples, as well as umbilical cord blood of the infant, were all negative for coronavirus rna by rt-pcr. neonatal stool samples obtained on days-of-life and were also negative for viral rna. from canada, yudin et al. [ ] reported a -year-old pregnant woman who was admitted to the hospital at weeks gestation with a fever, dry cough, and abnormal chest radiograph demonstrating patchy infiltrates. she had acquired sars from contact with an infected family member. following a -day stay in the hospital, during which she did not require ventilatory support, her convalescent antibody titers were positive for coronavirus infection. she had a normal labor and delivery and her newborn girl had no evidence of infection. in a study of liveborn neonates who were delivered to women infected with sars-cov during the hong kong epidemic, results from multiple tests-including serial rt-pcr assays, viral culture, and paired neonatal serological titers-were negative for sars-cov [ ] . none of the neonates developed any clinical signs or symptoms of respiratory infection or compromise. fortunately, there were no cases of vertical transmission identified among pregnant women infected with sars-cov during the - asian epidemic [ , , , , ] , and with the exception of a small cluster of cases that recurred in late , no new cases of sars have occurred. in the only reported study of the placental pathology of mothers with sars, ng et al. [ ] reported the findings from pregnant women infected with sars-cov. in the case of women who were convalescing from sars-cov infection during the st trimester of pregnancy, the placentas were found to be normal. three placentas were delivered from pregnancies in which the mothers had acute sars-cov infection-these were abnormal and demonstrated increased subchorionic and intervillous fibrin, a finding that can be associated with abnormal maternal blood flow to the placenta. in the placentas of women who were convalescing from sars-cov infection in the rd trimester of pregnancy the placentas were highly abnormal. they showed extensive fetal thrombotic vasculopathy with areas of avascular chorionic villi-chronic findings of fetal vascular malperfusion. these pregnancies also were complicated by oligohydramnios and had poor obstetrical outcomes-both infants had developed iugr. it is interesting that villitis, the microscopic finding of inflammation of the chorionic villi that is the histologic hallmark of many maternal hematogenous infections that are transmitted through the placenta to the fetus, was not identified in any of these placentas. similar to other coronavirus infections, sars-cov is easily spread from person-to-person via respiratory droplets and secretions as well as through nosocomial contacts [ , ] . in addition to transmission of sars-cov through natural aerosols from infected patients, it was found that in hong kong the sars-cov could also be transmitted by mechanical aerosols [ ] . environmental factors had an important role when it was discovered that during the amoy gardens housing estate outbreak as many as two-thirds of infected persons had diarrhea, sars-cov was excreted in their stools, and that aerosols arising from the flushing of toilets could transmit the virus [ ] . healthcare facilities were also an important source of new sars infections during the - epidemic, and healthcare workers were also at high risk for acquiring the infection. in order to address the safety issues for the obstetrical management and delivery of pregnant women with sars, guidelines were prepared by the canadian task force on preventive health care and the society of obstetricians and gynaecologists of canada [ ] . these recommendations include: . "all hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for sars or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit. at times of sars outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for sars. upon arrival in the labour triage unit, pregnant patients with suspected and probable sars should be placed in a negative pressure isolation room with at least air exchanges per hour. all labour and delivery units caring for suspected and probable sars should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation. if possible, labour and delivery (including operative delivery or caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear. . either regional or general anaesthesia may be appropriate for delivery of patients with sars. neonates of mothers with sars should be isolated in a designated unit until the infant has been well for days, or until the mother's period of isolation is complete. the mother should not breastfeed during this period. . a multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of sars management protocols. . staff caring for pregnant sars patients should not care for other pregnant patients. staff caring for pregnant sars patients should be actively monitored for fever and other symptoms of sars. such individuals should not work in the presence of any sars symptoms within days of exposure to a sars patient. . all health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the sars virus. . regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centers, to care for patients with sars or similar illnesses." middle east respiratory syndrome (mers) was first reported in september in saudi arabia, following isolation of mers-cov from a male patient who died months earlier from severe pneumonia and multiple organ failure [ ] . in the years since then, there have been more than confirmed cases of mers resulting in upwards of deaths globally [ ] . while countries have reported cases of mers, approximately % of confirmed cases originated in saudi arabia [ ] . to date, all known cases of mers can be linked to travel or residence in countries along the arabian peninsula-that is, bahrain; iraq; iran; israel, the west bank, and gaza; jordan; kuwait; lebanon; oman; qatar, saudi arabia; syria; the united arab emirates (uae); and yemen [ ] . the largest documented outbreak outside of this region occurred in in the republic of korea, in which infections occurred, resulting in deaths [ ] . the index case in this outbreak reportedly returned from the arabian peninsula just prior to onset of illness [ ] . mers-cov is characterized by sporadic zoonotic transmission events as well as spread between infected patients and close contacts (i.e., intra-familial transmission) [ ] . nosocomial outbreaks in health care settings-the result of poor infection control and prevention-are widely recognized as the hallmark of mers [ ] . superspreading events have been recorded in healthcare settings in jordan, al hasa, jeddah, abu dhabi and south korea [ , [ ] [ ] [ ] [ ] . like other coronaviruses, mers-cov can be spread through person-to-person contact, likely via infected respiratory secretions [ ] . transmission dynamics, however, are otherwise poorly understood [ ] . bats are believed to be the natural reservoir of mers-cov, and dromedary camels can have the virus and have been suggested as possible intermediary hosts as well as a source of infection to humans [ , , ] . there are no clinical or serological reports of perinatal transmission of mers, though vertical transmission has been reported for non-coronavirus respiratory viruses including influenza and respiratory syncytial virus (rsv) [ ] . researchers have not yet discovered ongoing transmission of mers-cov within communities outside of health care settings. the clinical presentation of mers varies from asymptomatic to severe pneumonia with acute respiratory distress syndrome (ards), septic shock, and multiple organ failure, often resulting in death. most patients with mers develop severe acute respiratory illness accompanied by fever, cough, and shortness of breath [ ] . progression to pneumonia is swift-usually within the first week -and at least one-third of patients also present with gastrointestinal symptoms [ ] . mers progresses much more rapidly to respiratory failure and has a higher case fatality rate than sars [ ] . unlike sars, however, infection with mers-cov is generally mild in healthy individuals but more severe in immunocompromised patients and people with underlying comorbidities [ ] . the overall cfr of mers is approximately . % [ ] . most fatalities have been associated with pre-existing medical conditions like chronic lung disease, diabetes, and renal failure, as well as weakened immune systems [ ] , making such individuals high risk. as a result of the immunological changes that occur during pregnancy, women who are pregnant are included in this high-risk group. pregnant women may develop severe disease and fatal maternal and/or fetal outcomes as a result of mers-cov infection; however, little is known of the pathophysiology of this infection during pregnancy. limited data exists on the prevalence and clinical features of mers during pregnancy, birth, and the postnatal period. it is likely, however, that the immunological changes that normally occur in pregnancy may alter susceptibility to the mers-cov and the severity of clinical illness [ ] . pregnant women infected with sars-cov, a related coronavirus, appear to have increased morbidity and mortality when compared to non-pregnant women, suggesting that mers-cov could also lead to severe clinical outcomes in pregnancy. to date, however, very few pregnancy-associated cases (n = ) have been documented, with % having adverse clinical outcomes. between november and february , there were cases of mers reported by the saudi arabia ministry of health (moh). of these, patients were pregnant, according to a retrospective study by assiri et al. [ ] , and all resulted in adverse outcomes. patient ages ranged from to years, with occurrence of exposure in either the nd or rd trimester. all cases received intensive care. two women died and there were cases of perinatal death- stillbirth and neonatal death shortly after emergency cesarean section. these instances of severe maternal and perinatal outcomes are consistent with other reports of mers-cov infection in pregnant women, as well as outcomes associated with sars-cov infection. the authors of the retrospectives study concede that unreported cases of mers in pregnancy are likely due to lack of routine pregnancy testing [ ] . they conclude that pregnancy testing for women of reproductive age should be considered for those who test positive for mers-cov, to contribute to overall understanding of pathogenesis and epidemiological risk. additionally, of the patients were healthcare workers, which corresponds with existing knowledge of higher risk of exposure to mers-cov in healthcare settings. in a separate case report of mers occurring in pregnancy, alserehi et al. [ ] described a -year-old critical care nurse who became infected during the rd trimester in the midst of a large hospital outbreak. in the days following hospital admission, she developed respiratory failure necessitating mechanical ventilation and administration of dexamethasone as prophylaxis for the fetus. following an emergency cesarean section at weeks gestation, she was transferred to the intensive care unit (icu) and later recovered. the preterm but otherwise healthy infant was kept in the neonatal unit for observation and later released along with his mother. in contrast to other reported cases, this patient had a successful outcome, perhaps due to the timing of mers-cov exposure, her young age, the use of steroids, and differences in immune response. alfaraj et al. [ ] described cases of maternal infection with mers-cov at the prince mohammed bin abdulaziz hospital (pmah) in saudi arabia. maternal infection in both cases was confirmed by nasopharyngeal swab testing by rt-pcr. one patient was a -year-old woman at weeks gestation with no underlying medical conditions. the second patient, a -year-old at weeks gestation, had several comorbidities, including end stage renal disease, hypertension, and hemodialysis. this woman presented to the hospital after contact with a mers-cov-infected person during an active outbreak. both patients later tested negative for mers-cov and were subsequently discharged. the younger patient delivered a healthy, full-term infant. the status of the other delivery is unknown. neither fetus was tested for mers-cov. according to payne et al. [ ] , epidemiologic investigation of the mers outbreak in zarqa, jordan, revealed that a nd trimester stillbirth ( months gestational age) had occurred as a result of maternal exposure to mers-cov. the mother experienced fever, fatigue, headache and cough, concurrently with vaginal bleeding and abdominal pain. on the th day of symptoms, she had a fetal death. the mother was confirmed to have antibody to mers-cov, and she self-reported having had unprotected contact with family members who later tested positive for the virus. this was the first documented occurrence of stillbirth during maternal infection with mers-cov. on november , a -year-old pregnant woman in the united arab emirates (uae) developed ards following admission to the icu after suspected community-acquired pneumonia advanced to respiratory failure and hypotension [ ] . later that day, her baby was delivered by caesarean section and subsequent apgar scores were within healthy range. the next day, rt-pcr evaluation revealed that the mother was positive for mers-cov. despite rigorous intervention, including oral ribavirin-peginterferon-α therapy and ventilator support, the woman continued to deteriorate, developed septic shock, and died. while the outcome for this mother was fatal, malik et al. noted that virus shedding ceased during therapy with ribavirin and peginterferon-α and radiographic evidence indicated clinical improvement before her death [ ] . more research is needed to determine safety, efficacy, and dosage of these therapies in the general population but also in pregnant women. while few data exist on the effects of these treatments in pregnant humans, ribavirin is generally contraindicated during pregnancy [ ] . outside of the middle east the only confirmed case of mers in pregnancy occurred in in south korea. jeong et al. [ ] reported that a -year-old patient was exposed during the rd trimester following contact with a patient having mers. despite abrupt vaginal bleeding and rupture of membranes, the patient recovered fully and delivered a healthy infant at weeks and days gestation. subsequent testing of the infant's blood did not detect any igg, igm, or iga antibodies to mers-cov. the mean maternal age of the confirmed maternal sars cases described above was . years, with a mean gestational age of . weeks. the source of infection in of the cases was attributed to contact with family members who tested positive for mers-cov, unknown in cases, likely due to animal exposure in case, and were healthcare-associated ( of these patients were healthcare workers). six patients required intensive care and died. of those who died, were exposed to mers-cov in the rd trimester, and was exposed during the nd trimester. the infant death rate for all cases was %. fetal survival did not appear to correlate with the timing of maternal infection and gestational age; however, more data are needed to draw conclusions about this relationship. according to alfaraj et al. [ ] , the cfr for the infected women-also %-was not statistically different from the overall cfr of mers in the general population ( %) (p = . ). only case resulted in both maternal and fetal death. similar to sars in pregnancy, more research is needed to understand the pathogenesis and epidemiology of mers in pregnancy including the relationship between the timing of maternal infection, gestational age of the fetus, the effects of comorbid factors, and the occurrence of adverse outcomes. few studies documented the presence of mers-cov antibodies in the umbilical cord or neonatal blood, making it difficult to assess perinatal transmission. as such, future studies should involve the collection of samples from relevant specimens including amniotic fluid, placenta, and umbilical cord [ ] . mers prevention should be high priority for high-risk exposures such as healthcare workers, pregnant women and individuals working with camels, camel meat-milk processors and in abattoirs [ ] . since , the saudi arabia moh has recommended that pregnant women postpone travel to saudi arabia for the hajj and umrah [ ] . to further reduce risk of exposure among pregnant women, additional measures such as avoiding contact with camels and sick persons-particularly in healthcare settings-are also recommended. pregnant women who present with symptoms of pneumonia, influenza-like illness (ili), or sepsis on the arabian peninsula may also benefit from mers-cov screening to expedite early diagnosis and improve disease management [ ] . while multiple agents have been used to treat mers, none have been tested in large clinical studies. available data are limited to the use of combination therapies of interferon and other agents in case reports and case series [ ] . a prospective or randomized study may prove difficult given the sporadic nature of mers-cov outbreaks. due to a gap in research on the treatment of mers in pregnancy, there are no therapeutic options currently recommended for pregnant women [ ] . therapies under development and testing may be considered inappropriate for pregnant women due to the unknown potential for teratogenic effects. for example, during the sars outbreak, ribavirin was administered to pregnant women with severe cases of the disease, but ribavirin therapy has been documented to increase the risk of teratogenic effects in newborns [ ] . the alphacoronaviruses hcov e and nl , as well as the betacoronaviruses hku and oc , can infect humans and cause the common cold. in order to investigate the potential maternal-fetal transmission of human coronaviruses during pregnancy, gagneur et al. [ , ] evaluated types of maternal-infant paired specimens that included maternal vaginal and respiratory specimens that were obtained during labor, as well as gastric samples from the newborn infants. these specimens were evaluated for the presence of hcov e, oc- , nl and hku using rt-pcr methodology. between the period from july to august the authors examined mother-infant dyads. human coronaviruses were identified in samples (hcov e: ; hku : ) from mother-child pairs. in mother-infant dyads only maternal respiratory samples were positive; in other pairs all of the samples tested positive for human coronavirus; in case only the maternal vaginal and newborn gastric samples were positive; and in another case the maternal vaginal sample alone was positive. there were no signs of clinical infection in any of the neonates that had positive gastric samples for human coronavirus. it is beyond the scope of this communication to discuss the various technical challenges inherent in developing a safe and efficacious vaccine for coronavirus infections in humans. there are clearly challenges to this endeavor-protective antibodies to coronaviruses are not long-lasting, tissue damage has been reported to occur as a result of exposure to sars-cov, development of animal models that closely resemble human infection are limited, and the extensive time and expense necessary to perform clinical trials in humans, to name a few [ ] [ ] [ ] . it is vitally important that pregnant women be considered in the design, clinical trial, and implementation of vaccine candidates for -ncov. in examining the history of vaccine design, it is clear that the needs of pregnant women have rarely been prioritized in either the preclinical development or the clinical trial phases of production. today, pregnant women are usually excluded from experimental trial of drugs and vaccines that do not target obstetric conditions [ ] . excluding pregnant women and their infants from participation in vaccine development and implementation undermines ethical principles of justice-fairness, equity, and maximization of benefit-and potentially places their health at risk during outbreaks and other health emergencies [ ] [ ] [ ] . on january the coalition for epidemic preparedness innovations (cepi) announced three programs to develop a vaccine against the novel wuhan coronavirus. the chief executive officer of cepi, richard hatchett, said [ ] : "given the rapid global spread of the ncov- virus the world needs to act quickly and in unity to tackle this disease. our intention with this work is to leverage our work on the mers coronavirus and rapid response platforms to speed up vaccine development." the novel coronavirus is the first epidemic disease to emerge since the formation of cepi in davos in . cepi was created with the express intent to enable speedy research and development of vaccines against emerging pathogens. in may , who released the target product profile (tpp) for mers-cov vaccines, following the prioritization of mers-cov as one of eight priority pathogens for prevention of epidemics [ ] . cepi and partners aim to use existing platforms-that is, the existing "backbone" that can be adapted for use against new pathogens-that are currently in preclinical development for mers-cov vaccine candidates. following the who declaration on january that the current -ncov outbreak is a public health emergency of international concern (pheic), global health organizations and researchers will be further mobilized-bolstered by new mechanisms for action and greater resources-to stop the spread of disease. a critical question that must be answered at this stage-with a clear view of the potential deleterious effects of a new coronavirus in pregnancy-is will maternal immunization be a priority in research and development? as of the pheic declaration, groups have announced that they are developing new vaccines against -ncov and seven others announced initiatives to develop new therapies [ ] . safe testing of experimental vaccines in a pregnant population is difficult and, as a result, vaccines are not typically developed with pregnant women in mind. to date, very few clinical trials for vaccines have proactively included pregnant women [ ] , and the exclusion of pregnant and lactating women from receiving the rvsv-zebov vaccine through ebola virus epidemics serves as a recent example [ ] [ ] [ ] . given the potential severity in pregnancy, as demonstrated by this review of maternal infections of sars and mers, women who are pregnant should be considered a priority population in all efforts to prepare for and prevent infection by novel coronaviruses. on february it was reported by multiple media outlets that a newborn infant delivered during the epidemic in wuhan had tested positive for -ncov at the wuhan children's hospital in hubei province hours following its birth. according to the official xinhua news agency, the infant was delivered on february to a mother who had tested positive for the virus. reports have stated that the infant had stable vital signs, no fever or cough, but had shortness of breath together with abnormal chest radiographs and abnormalities of liver function [ ] [ ] [ ] . dr. zeng lingkong, chief physician at the neonatal medicine department of the hospital, said [ ] , "this reminds us to pay attention to mother-to-child being a possible route of coronavirus transmission" the hospital also provided information about a previous case of a baby that had been delivered on january . following its birth, the infant's nanny was diagnosed with -ncov, and the mother was diagnosed days later [ ] . on january the baby began to develop symptoms. according to dr. zeng lingkong [ ] , "whether it was the baby's nanny who passed the virus to the mother who passed it to the baby, we cannot be sure at the moment. but we can confirm that the baby was in close contact with patients infected with the new coronavirus, which says newborns can also be infected" in considering whether these and future cases of neonatal infection are acquired prior to delivery, it is important to remember that newborn infants can acquire an infection in other ways beyond intrauterine maternal-fetal transmission. in some cases, viral infection can be acquired when the infant passes through the birth canal during a vaginal delivery or through post-partum breast feeding, although these mechanisms would be highly unusual for a respiratory virus. neonatal infection from respiratory viruses can occur after delivery through such mechanisms as inhalation of the agent through aerosols produced by coughing from the mother, relatives or healthcare workers or other sources in the hospital environment. based upon past experience with pregnant women who developed mers and sars, and realizing that the numbers are limited, there has never been confirmed intrauterine coronavirus transmission from mother to fetus. discussing the most recent baby to be diagnosed with the -ncov infection, dr. stephen morse, an epidemiologist at the mailman school of public health at columbia university stated [ ] , "it's more likely that the baby contracted the virus from the hospital environment, the same way healthcare workers get infected by the patients they treat," "it's quite possible that the baby picked it up very conventionally-by inhaling virus droplets that came from the mother coughing." and according to dr. paul hunter, professor of medicine at the university of east anglia [ ] , "as far as i am aware there is currently no evidence that the novel coronavirus can be transmitted in the womb. when a baby is born vaginally it is exposed to the mother's gut microbiome, therefore if a baby does get infected with coronavirus a few days after birth we currently cannot tell if the baby was infected in the womb or during birth." there is limited knowledge regarding coronavirus infections that occur during pregnancy-what is known has, for the most part, been the result of epidemics resulting from two different diseases, sars and mers. these previous experiences with coronavirus infections in pregnancy indicates that these agents are capable of causing adverse clinical outcomes including life-threatening maternal disease that in some cases requires hospitalization, intensive care and ventilatory support. both of these coronaviruses can result in maternal death in a small but significant number of cases, but the specific risk factors for a fatal outcome during pregnancy have not been clarified. coronaviruses can also result in adverse outcomes for the fetus and infant including intrauterine growth restriction, preterm delivery, admission to the icu, spontaneous abortion and perinatal death. unlike some viral infections, notably ebola virus [ ] and zika virus [ ] , the likelihood of intrauterine maternal-fetal transmission of coronaviruses is low-there have been no documented cases of vertical transmission occurring with either sars or mers. it remains to be seen during the current wuhan -ncov epidemic how this newly-emergent coronavirus affects pregnant women and their infants, as well as which factors may modulate obstetrical disease and outcomes including the timing of maternal coronavirus exposure by gestational age, the effects of medications or other treatment regimens, differences in host immune responses, occurrence of coexisting medical and obstetrical conditions, and other covariables. however, pregnant women should be considered to be at high risk for developing severe infection during this current outbreak of -ncov. additional clinical research on the treatment of sars, mers, and the new coronavirus -ncov is necessary if we are to understand the potential risks and benefits of novel therapies and new vaccines in pregnancy. this research will be critical in improving the care, and even saving the lives, of pregnant women in the current as well as future outbreaks. epidemic and emerging 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doctors fear pregnant women can pass on illness after newborn baby is diagnosed expert reaction to newborn baby testing positive for coronavirus in wuhan zika virus infection in pregnancy, microcephaly and maternal and fetal health-what we think, what we know, and what we think we know this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -omsc a k authors: chen, lian; jiang, hai; zhao, yangyu title: pregnancy with covid‐ : management considerations for care of severe and critically ill cases date: - - journal: am j reprod immunol doi: . /aji. sha: doc_id: cord_uid: omsc a k pregnant women are a potentially highly vulnerable population due to anatomical, physiological and immunological changes under the covid‐ pandemic. issues related to pregnancy with covid‐ attracted widespread attention from researchers. a large number of articles were published aiming to elaborate clinical characteristics and outcomes of pregnant women infected with covid‐ , in order to provide evidence for management. the existing data suggest that the overall prognosis of pregnancy with covid‐ is promising when compared with that of other previous coronaviruses. there is still maternal morbidity and mortality related to covid‐ reported. however, the optimal management of severe and critically ill cases of covid‐ ‐infected‐pregnancy is poorly clarified. the possibility of postpartum exacerbation in pregnancy with covid‐ is also worthy of attention for obstetricians. this review makes further elaboration of the above issues. pregnant women may be different from that of sars and mers. it is well known that most pregnancy complications, such as hypertensive disorders of pregnancy, will be relieved after the termination of pregnancy. but for covid- , we found that postpartum exacerbation presented due to short-term pathophysiological changes immediately after delivery. gestational weeks of infection, the maturity of the fetus, disease severity and postpartum exacerbation make the management of severe and critically ill cases of pregnant women with covid- more difficult. this article is mainly to explore those issues and make some clinical suggestions. as all we know, pregnant women may be more susceptible to respiratory pathogens and pneumonia in pregnancy compared with non-pregnant women due to the physiological adaptations of pregnancy, such as diaphragmatic elevation, edema of the respiratory tract mucosa, and increased oxygen consumption, as well as pregnancy-related immune alterations. [ ] [ ] [ ] [ ] these adaptive changes also make women less tolerant of hypoxia. over the last several decades, it has been shown that coronaviruses and influenza viruses can cause severe respiratory disease in pregnant women with a high fatality rate. for example, the mortality rate for pregnant women infected with influenza during the pandemic was %. similarly, regarding the sars virus, the mortality rate for the general population was %, while the maternal rate was %, and % need mechanical ventilation. in the h n influenza virus outbreak, pregnant women were four times more likely to be hospitalized and were at increased risk of complications when compared to the general population. however, based on available reports from different countries so far, it seems that sars-ncov- does not follow the same pathogenic pattern. in the correspondence we published previously, the information of infected pregnant women in wuhan from the epidemic reporting system of the national health commission showed a rate of severe maternal disease at . %. another report from china which collected data of infected pregnant women came to the same conclusion with a relatively lower severe disease rate ( . %). in a recently published article from new york city, breslin et al reported that among pregnant women confirmed with covid- , the estimated rate of severe maternal disease approximated that of the non-pregnant population at . %. covid- does not appear to have a higher risk of severe disease in pregnancy than in the general population. however, although there are limited but several reports of severe and critically ill cases with this article is protected by copyright. all rights reserved covid- . one report from china described a gravida at weeks with severe covid- pneumonia who was performed cesarean section for stillbirth and deteriorated with requiring extracorporeal membrane oxygenation (ecmo). another report from iran still described critically ill patients infected with covid- , of which cases of maternal deaths and cases of pregnancy loss (stillbirth or neonatal death). these reports suggest that sars-ncov- infection still has the potential to cause maternal death and adverse outcomes, despite encouraging early experiences, which deserves the attention of obstetricians. in addition, it is worth noting that asymptomatic infections are presented in pregnant women. sutton et al conducted a universal screening for sars-cov- in women admitted for delivery in a hospital of new york city, and showed an asymptomatic infectious rate at . % (among patients). in the report from breslin et al, ( . %) of pregnant women were asymptomatic with a positive result of sars-cov- . during the pandemic, maternity care delivered has remained a high priority and pregnant women had to visit doctors for obstetric factors. the presence of asymptomatic infections reminds obstetricians to consider a reasonable screen test to guide the management of pregnancy with covid- . one of the most difficult yet crucial issues of the management is the determination of delivery timing, especially in the severe and critically ill cases. in the review of the literature, he et al reported a case admitted at weeks gestation with severe covid- pneumonia in guangdong, china. what is remarkable is the rapid speed of disease development of covid- in the severe and critical cases. in this case, the fetal heart rate pattern was reassuring hours before operation without evidence of hypoxia. at the same time, the maternal blood gas analysis showed hypoxemia with balanced acid-base status. after hours, the operation was performed with a severe asphyxia baby born (apgar score at minute was ). the neonate cord blood gas analysis suggested severe metabolic acidosis with a ph value of . . similarly, the mother developed acidosis minutes after the beginning of operation according to blood gas analysis (ph . ). the baby died of severe asphyxia and acidosis which may relate to the mother's rapidly progressing respiratory failure and metabolic disorders. a similar situation also occurred in a critically ill case confirmed with covid- reported by schnettler et al from cincinnati, usa, with the development of severe covid- ards within hours of admission. hantoushzadeh et al from iran presented critically ill cases with maternal deaths. among them, patients progressed to require mechanical ventilation within week of onset, which highlighted the rapidity of covid- infection in pregnancy. based on the above limited reports, we learned that for some severe cases, after the onset of disease, they may progress to require mechanical ventilation and intensive care, even result in maternal death within a very short time ( to weeks). the incidence of fetal or neonatal death was quite high in critically ill cases. this rapidly progressing ards puts the fetus at great risk. therefore, the time window left for us to decide to terminate the pregnancy is relatively short, which also brings great difficulties to our decision-making. therefore, we recommend to organize a multidisciplinary team in a short period of time after maternal hypoxemia occurs, to assess fetal maturity combined with the evaluation of progression speed of the disease, and make a decision of delivery in time. it is commonly accepted, based on extremely limited data, that delivery does not improve the respiratory status of pregnant patients with acute respiratory failure. in cases which the fetus is not mature enough to survive, especially less than weeks, and the maternal cardiopulmonary conditions are unstable, the decision to proceed toward delivery may be deferred to avoid the mother's condition deteriorated furtherly. if the pregnant patient's respiratory status is so dire to manage, especially after weeks of gestation, we recommend proceeding with a controlled delivery (like cesarean) to avoid the occurrence of fetal death and achieve possible improvement in maternal cardio-pulmonary function. but before the pregnancy termination, it should be necessary to monitor the fetal condition closely due to an extremely high rate of fetal death in the setting of severe systemic infection. for pregnant women who are stable on conventional oxygen therapy, we suggest a daily nonstress test for fetal monitoring. but for patients who require mechanical ventilation, we suggest continuous monitoring after weeks of gestation to find out the signs of non-reassuring fetal status in time. regarding the use of steroids for fetal lung maturity in the setting of covid- infection, despite no more data available, we still believe a single course of steroids may be reasonable to give for patients at high risk of preterm birth within seven days. what indicators can be used to predict the occurrence of rapid ards has not yet been determined. in some studies of pregnancy with community-acquired pneumonia, anemia, hypoproteinemia, and low bmi were proved as risk factors for severe community-acquired pneumonia. among the patients with covid- , we also this article is protected by copyright. all rights reserved found that level of hemoglobin and albumin was significantly lower in severe cases than that of mild cases, which reminds us to attach importance to the above indicators. but whether correcting the anemia and hypoproteinemia status can benefit, more research evidence is needed. recently, a risk score based on characteristics of covid- patients at the time of admission to the hospital was developed that may help predict a patient's risk of developing critical illness. in this risk prediction model, variables were independent predictive factors and were included in the risk score. the mean auc in the development cohort was . ( % ci, . - . ) and the auc in the validation cohort was . ( % ci, . - . ). although, whether this risk score is applicable in maternal populations with equal predictive effectiveness is unknown. but this result provides a possibility for clinicians to estimate an individual hospitalized patient's risk of developing the critical illness, which can provide obstetricians with essential information for delivery decision-making. in our correspondence, six cases who were mild and one case who was severe at admission all aggravated in one week after delivery. the same phenomenon was observed in other reports through sorting out the timeline of cases. several severe case reports from henan and hubei also manifested postpartum exacerbation. one patient in new york was admitted to hospital because of obstetric factors with mild covid- illness, and was discharged after delivery. but she was re-admitted to the hospital days after delivery due to aggravation of the covid- pneumonia. in the report of critically ill cases in iran, all women have deteriorated after delivery. but we need to be cautious to understand that this condition may attribute to changes in the maternal cardiopulmonary system shortly after delivery or be a part of the natural disease course. it is indeed worth noting that the physiologic adaptations to delivery and the immediate postpartum period had occurred. one of the most unstable periods of perinatal hemodynamics is three days after delivery. the fluid retention began to return to the body circulation with auto transfusion of up to ml of blood volume, which increased the perfusion of the viscera and the pressure of the pulmonary circulation. in addition, with a surge of catecholaminergic and release of inflammatory mediators within the endothelium, considerable fluid shifts between the interstitial, intracellular, and intravascular compartments which may result in pulmonary edema. this article is protected by copyright. all rights reserved on the other hand, due to hemodilution and excessive consumption and demand, the level of basic albumin in pregnant women is lower than that of non-pregnant women, and studies have shown that the colloidal osmotic pressure after delivery is significantly decreased. hypoalbuminemia was common in severe cases. due to the hypoalbuminemia, colloid osmotic pressure decreases furtherly, and excessive amount of fluid outside the pulmonary vessels even infiltrates into the alveoli. fluid retention in the stroma and alveoli can reduce the gas diffusion and decrease the ratio of ventilating blood flow. combined with pulmonary injury by virus, pulmonary edema and other pathological changes can serve to exacerbate illness leading to ards. third, the delivery itself can increase the level of some cytokines such as il- which high expression is related to the increase of incidence rate and mortality of influenza virus during pregnanc. studies have shown that in sars-ncov- infected patients, cytokine secretion increases, such as il- , and the immune system of severe patients will have a fatal cytokine storm. childbirth may be a promoter of cytokine secretion to affect the illness development. [ ] [ ] taking into account the above reasons, in the short period after birth, some patients, especially severe patients, will suffer from an increased risk of illness exacerbation. this provides us with more information on the management of covid- in pregnancy. on the one hand, for severe and critically ill maternal covid- infection, it is necessary to fully consider that the pathophysiological changes in the delivery and postpartum stages may aggravate the condition. therefore, close observation and timely treatment after birth should be conducted with the change of disease condition in pregnant women with covid- . as described in the first part of this article, covid- infection manifested less severe illness than the other coronaviruses which attributed to many factors. one explanation is the different immune states activated by virus infection. the th /th immune balance is one of the important immune regulatory mechanisms. th cytokines have antimicrobial and pro-inflammatory properties, while th cytokines have anti-inflammatory properties. in the case of sars-cov infection, the immune response of th type is highly activated and lasts for a long time, resulting in a consistently high level of pro-inflammatory cytokine expression for more than accepted article weeks since the onset of the disease. the persistence of this intense inflammatory state may be responsible for extensive lung damage. however, unlike sars-cov infection, the intensity and duration of th and th immune responses in sars-cov- infection are very similar. not only ifn-γ and il- , but il- and il- are also present in the blood. in the pregnant population, the pregnancy itself does not appear to be an aggravating factor, and may also be related to the unique immune status during pregnancy. as we all know, maternal-fetal immunity is the only paradox that contradicts the classical immunological principles. fetus is regarded as a semi-allograft, and successful pregnancy depends on the mother's sustained and stable immune tolerance to the fetus. meanwhile, a series of changes on the status of maternal anti-infective immunity also occur during pregnancy. during pregnancy, the maternal immune system will make real-time adjustments to resist the invasion of pathogens, manifested as an enhanced response on natural immunity and a decrease in adaptive immune response. this specific change of immune state is believed to be related to the tilt of the immune balance of th /th to th which induce immune tolerance to the fetus and placenta. meanwhile, some studies believe that the immune balance of th /treg also plays an important role in this process. [ ] [ ] therefore although, the risk of developing into severe cases in pregnant women with covid- is not higher than that of the general population, the management of severe and critically ill cases still deserves more attention. rapid clinical decompensation, the occurrence of adverse maternal and neonatal outcomes, and postpartum exacerbation highlight the delivery timing and management considerations during pregnancy and the postpartum period. for the care of severe and critically ill cases, we recommend to organize a multidisciplinary team as soon as possible after maternal hypoxemia occurs, to assess fetal maturity combined with the evaluation of progression speed of the disease, and make a decision of delivery in time. when the fetus is not mature enough to survive, the decision to proceed delivery should be deferred in the setting of severe and critical maternal covid- infection until maternal cardiopulmonary stability can be achieved. in the postpartum period, close observation and timely treatment after birth should be conducted with the change of disease condition in pregnant women with covid- . in addition, the immune status of pregnant women infected with covid- should also be considered to provide evidence for optimizing current treatment measures. all authors have no conflict of interest to declare. the study was supported by grants from the national key research and development program of reproductive accepted article who coronavirus disease (covid- ) dashboard pregnancy and perinatal outcomes of women with severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome world health organization. middle east respiratory syndrome coronavirus (mers-cov) effects of coronavirus disease (covid- ) on maternal, perinatal and neonatal outcomes: a systematic review clinical findings and disease severity in hospitalized pregnant women with coronavirus disease (covid- ) clinical characteristics of pregnant women with covid- in wuhan, china pneumonia complicating pregnancy pneumonia during pregnancy pneumonia in the pregnant patient pneumonia complicating pregnancy effects of influenza on pregnant women and infants pandemic influenza a (h n ) in pregnancy: a systematic review of the literature accepted article this article is protected by copyright. all rights reserved coronavirus disease in pregnant women: a report based on cases covid- infection among asymptomatic and symptomatic pregnant women: two weeks ofconfirmed presentations to an affiliated pair of new york city hospitals report of a case of neonatal death caused by severe covid- infection during pregnancy maternal death due to covid- disease universal screening for sars-cov- in women admitted for delivery severe ards in covid- -infected pregnancy: obstetric and intensive care considerations clinical course of severe and critical covid- in hospitalized pregnancies: a us cohort study management of acute respiratory failure in pregnancy early acute respiratory support for pregnant patients with coronavirus disease (covid- ) infection anemia and low albumin levels are associated with severe community-acquired pneumonia in pregnancy: a case-control study clinical features of patients infected with novel coronavirus in wuhan development and validation of a clinical risk score to predict the accepted article this article is protected by copyright. all rights reserved occurrence of critical illness in hospitalized patients with covid- report of the first cases of mother and infant infections with novel coronavirus in xinyang city henan province postpartum exacerbation of antenatal covid- pneumonia in women physiologic changes during normal pregnancy and delivery the use of colloid osmotic pressure in pregnancy pathological findings of covid- associated with acute respiratory distress syndrome pregnant women infected with pandemic influenza a(h n ) pdm virus showed differential immune response correlated with disease severity characteristics of lymphocyte subsets and cytokines in peripheral blood of hospitalized patients with novel coronavirus pneumonia (ncp) immune cell and transcriptomic analysis of the human decidua in term and preterm parturition investigating stress response during vaginal delivery and elective cesarean section through th and th responses: what are they? plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome relationship between pregnancy and coronavirus: what we know accepted article this article is protected by copyright. all rights reserved mother's little helpers: mechanisms of maternal-fetal tolerance an immune clock of human pregnancy th /th /th and regulatory t-cell paradigm in pregnancy dynamic function and composition changes of immune cells during normal and pathological pregnancy at the maternal-fetal interface immunological environment shifts during pregnancy may affect the risk of developing severe complications in covid- patients is covid- receiving ade from other coronaviruses? accepted article key: cord- -z qn b authors: serge, rozenberg; vandromme, jean; charlotte, martin title: are we equal in adversity? does covid- affect women and men differently? date: - - journal: maturitas doi: . /j.maturitas. . . sha: doc_id: cord_uid: z qn b background & objectives: this article examines whether women are less prone than men to covid- infections and their complications. data sources: we reviewed available databases and searched systematically for publications. to be taken into account, data had to be broken down by gender. there was no study evaluation nor quantification synthesis, due to the large heterogeneity of the studies. nineteen databases were selected. publications were considered and were selected, to which more were added. results: globally, the proportion of men and women who tested positive is comparable. however, men are about % more likely to be severely ill or to die from the complications of covid- than are women. limitations: the study was hampered by a large heterogeneity in testing and reporting of the data. conclusions: although in the pandemic men die more frequently than women from covid- , it is not clear whether this is due to biological differences between men and women, differences in behavioral habits, or differences in the rates of co-morbidities. implications of key findings: countries and studies should report their data by age, gender and co-morbidities. this may have implications in terms of vaccination strategies, the choice of treatments and future consequences for long-term health issues concerning gender equality. unfortunately, it is well known that we are not all equal in adversity. it has been reported that older people and those with preexistent co-morbidities are at higher risk of dying from covid- in the pandemic ( ) ( ) ( ) . it is also possible that ethnic origin influences the prognosis of the covid- infection, since diseases like diabetes and hypertension are more frequently found among patients of african origin ( ) . currently, it is unclear whether there is a direct link j o u r n a l p r e -p r o o f between race or ethnicity and the outcome of covid- infection or whether race is a confounding factor due to the hidden effects of diabetes or hypertension, which are more prevalent, for instance, in the afro-american population. ( ) . the availability of health care resources may also play a major role, since access to health care systems may vary between countries or regions, but may also vary within a region according to socioeconomic factors or the presence of chronic diseases ( ) . analyses stratified by those factors should be carried out for the pandemic's data. the first publications from china and italy reported higher fatality rates, due to the pandemic, in men than in women ( , ). following these publications, some authors suggested that the reduced susceptibility of women to viral infections could be attributed to the protection from the x chromosome as well as from sex hormones, which play an essential role in innate and adaptive immunity ( ) . therefore the current gender difference in the response to the pandemic raises a number of questions: here are a few of them. are women and men similarly vulnerable or is there a difference in susceptibility? are the biological and clinical immune responses identical? are symptoms in women and men similar? what is the proportion of men and women who are hospitalized and transferred to intensive care units (icu)? are the responses to treatment and the recovery patterns similar in men and women? are the fatality rates identical? and finally will the response to vaccines be comparable in men and women? we review only some of the currently available data, notably the sex-difference in susceptibility to the covid- infection and the concomitant risk of death. indeed, it will not be possible to determine whether biological and clinical immune responses are the same in women and men until data becomes available regarding the cytokine release syndrome (crs) and the production of antibodies are identified and systematically measured. similarly there are not enough data to determine whether symptoms and imaging are comparable in women and men. j o u r n a l p r e -p r o o f we conducted a thorough research of epidemiological databases, available in english, french, german, spanish, italian, and dutch ( , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . we collected data from websites, such as "our world on data", https://coronavirus.jhu.edu/us-map and "https://globalhealth .org/covid / », (which are freely accessible websites presenting research, data or actions for gender equality in global health) ( , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . we selected only the countries where data were presented by sex, either for prevalence of positive tests, or hospitalization or deaths. we completed the search on pubmed using the mesh terms: "covid- " and "sex" or "gender". our search retrieved items, but only of these were related to the subject through other articles were added to this review (figure )( - ). finally, we added personal data from our hospital (an inner-city, university, tertiary hospital located in brussels) concerning the first hospitalized covid- patients (personal communication). the study was accepted by the ethical review board of the chu st pierre. statistics: we used only descriptive data from which we calculated the men to women death ratio for europe. the only way to answer this question would require universal screening of men and women with a breakdown of data by age and gender. according to "our world on data", not all countries provide testing data ( ) ( ) ( ) . most countries only provide incomplete data and these j o u r n a l p r e -p r o o f concern analyses of tests for the presence of the virus thereby determining whether an individual is infected and not whether he or she has developed immunity (the presence of antibodies). furthermore, it is often unclear how to interpret tests ( ) ( ) ( ) ). some people are tested more than once, some countries report the number of tests performed, others the number of individuals that have been tested. there is also extensive heterogeneity in the number of false positive and negative results, among tests ( - ). in some countries systematic virus testing by pcr, of large segments of the population, has begun, in others, mildly symptomatic patients were tested, in some others, only severely ill or hospitalized patients were tested. moreover, the attitude towards testing geriatric patients and health providers who work with infected patients, varied considerably. this explains that the range in testing coverage differs tremendously between countries (while iceland was testing close to out of people, the uk was testing / people) and demonstrates why the comparison of prevalence between countries is difficult ( - ). the pandemic started in china, spread to other asian countries, before reaching italy and then other european countries and the us. consequently, diverse countries are at different stages of the epidemic trajectory, and it is difficult to compare or to pool data before the epidemic curve has been completed in the respective countries. this is well illustrated by dynamic graphs ( , ). the presented data originate therefore from selected, non-random samples, and are characterized by considerable heterogeneity. very few countries provide categorization of their numbers by gender ( ). in table i, we show the number of patients tested per one thousand habitants, as this reflects whether tests are largely available or only available in specific, limited circumstances. we report the proportion of positive tests in men or women when available ( ( ) . the proportion of males tested positive to j o u r n a l p r e -p r o o f covid- was higher as compared to females in asia (with the exception of south korea), in south america, in the new york area ( - , , ) , but not in canada and in some european countries (estonia and in belgium) ( - , , , ) where more women tested positive than men ( table ). the proportions were quite comparable when considering global europe, and were also comparable on board of the diamond princess cruise ship (table ) ( , ) . currently, the incidence, the prevalence and the covid- fatality ratios are not well known. the reasons are, first, that the denominators of incidence and prevalence are not defined, mainly because random sampling of the population has not been carried out (samples are selective as mentioned previously) and secondly, multivariate analyses are needed to determine the exact effect of covid- on adverse outcomes, given other risk factors such as gender, age or comorbidities. we did however search national databases and registries that presented data in relation to gender. when possible, we further sought to classify the data by age and comorbidities. male hospitalization rates were higher than female ones, in all countries which reported them, ranging from % to % (table ) ( , , , , , ). the proportion of male admissions to the icu was even higher ranging from % to % ( , ). throughout europe, % of all icu admissions were for men (table )( - ). most, but not all, of early publications from china reported that men presented three times more often prolonged sars-cov- rna shedding, had twice the risk of developing kidney disease as well as more frequent refractory pneumonia and metabolic associated fatty liver disease (mafld) ( ) ( ) ( ) ( ) ( ) ( ) . similarly, in the seattle and new york areas more men ( % and %) were admitted to the j o u r n a l p r e -p r o o f icu ( , ) . in our own hospital the first patients that were admitted had a median age of years; % had hypertension, % diabetes and % cardiovascular diseases. sixty-six percent of these patients were men. fifty seven out of were admitted to the icu, of which % were men (personal communication). reported death rates vary tremendously between countries. but almost all of the data that broke numbers down by gender, reported a higher proportion of deaths among men than among women (ranging between % and %). (table ). with the exception of india and pakistan, all other countries reported a male to female death ratio ranging between and . . even in countries where fewer male than female cases were reported the death rates were still higher for males ( table ). the first report from china quoted a death rate of . % in men and . % in women ( ). in other series in china, more men than women died ( % vs %), and had higher fatality rates ( . % vs . %) ( ) ( ) ( ) ( ) ( ) . this was also the case in australia, austria, belgium, denmark, france, germany, italy, europe (in general), seattle and new york ( in new york, men accounted for . % of deaths and women for . %. an even higher proportion of men were admitted to the icu ( . % vs . %), while more women were being discharged and more men died in each age class. ( ) . nevertheless, there is still a lack of data classified by age, sex and comorbidities. earlier publications reported that men were more frequently infected with covid- than women, with men accounting for % of infected patients ( ) ., this has also been reported for mers-cov and sars-cov ( ) . nevertheless, these data should be interpreted with great caution. indeed, other publications did not report sex differences among people with seasonal coronaviruses and respiratory illnesses: among , episodes of respiratory illness, in scotland, between and , the global sex distribution was approximately equal, with . % of patients being female ( ). however, these authors reported greater numbers among males than females for certain infections such as cov- e, cov-oc , cov-nl and influenza, with higher hospitalization and mortality rates in men ( ). furthermore, there is a marked heterogeneity concerning the current pandemic as to who is being tested. in iceland, a large proportion of the population has been tested ( people per thousand inhabitants), whereas in other countries only severely symptomatic patients have been tested ( per thousand in france). the number of tests is constantly increasing. the "picture" that we report here, therefore only reflects the situation at the beginning of may . but if we rely on the most comprehensive available data, there seems to be no important difference in terms of infection prevalence between men and women (women have a % - % lower exposure rate than men in some countries). the south korea data are an exception. indeed, in this series of . patients, only . % of the infected ones where male ( ) . but the authors provided an explanation: the discrepancy was probably due to an increase of infected women, in a religious group of daegu ( ) . the belgian data also are somewhat particular because they present data by sex and age group. they found a higher rate of infections in women before the age of and a lower rate thereafter. it is possible, however, that these data are biased by the higher rate of women working in hospitals and more prone to be infected therefore ( , ) . about % of confirmed infected health workers were found to be women, in spain, the usa, italy and germany ( - , - ). we don't know much yet about the spectrum of symptoms in men and women. one series of ( . %) women and men ( . %) mildly-to-moderately affected patients, by covid- , reported that women were significantly more affected by olfactory and gustatory dysfunctions than men ( ) . we did find data broken down by sex, for patients requiring hospitalization in some countries or areas (denmark, france, new york, belgium) ( , , , , ) . in these areas, more men were hospitalized than women (between % and %). similarly, in all countries reporting death rates from covid infections, by sex, more men died than women ( %- % of men) ( these data need also to be interpreted cautiously. there are many diverse ways to evaluate covid- related mortality. for instance, the fatality ratio (the number of deaths divided by the number of confirmed cases) depends on how many tests are performed. when extensive screening occurs, the fatality ratio is lowered (austria, germany, finland)( - , , ). on the other hand, the mortality rate will rise, when deaths suspected to be related to covid - , in patients untested for the presence of the virus, are attributed to the pandemic (this is what happened in belgium where about half of the deaths occurred in geriatric living facilities, but only % of the patients who died had been tested for covid )( ). the fatality rate also depends on the country's age pyramid (the older the population the higher the rate). this was the case in italy ( ). as suggested by others, the difference in vulnerability towards the pandemic could be due to biological differences between men and women. but whether men are more susceptible to an j o u r n a l p r e -p r o o f infection or its increased severity, or whether woman have some natural protection against these viruses, is not clear ( ) . it has been previously reported that men suffering from all-cause infectious sepsis have a % higher mortality rate than women and this is also the case for sars and mers respiratory infections ( . % vs . %) ( ) ( ) . women seem to have a more robust immune system ( ) . it has been reported that women have stronger immune responses to infections and vaccinations than men. this is, among other factors, due to the documented effects of estrogens, progestogens and androgens ( ) . for instance, estrogens suppress t and b cell lymphopoiesis and activates b cell function. estrogen enhances humoral responses, b cell differentiation and immunoglobulin (ig) production ( ) . the difference in gender immune responses may also have a role in why women have a higher incidence (up to times more for thyroiditis) of autoimmune diseases ( ) . the presence of two x chromosomes in women emphasizes the immune system even if one is inactive. the immune regulatory genes encoded by x chromosome in women has been associated with lower viral load levels, and less inflammation in women than in men, with better immune responses and higher levels of cd + t cells, higher levels of antibodies that persist longer, higher levels of tlr , which result in an increased resistance toward viral infections ( ) . the production of inflammatory il- after viral infection is lower in women than in men. other genes involved in the immunological answer have been implicated and are localized on the x chromosome, like foxp ( ) . in any case, if estrogen decreases the risk of covid- , it is unlikely to do so by reducing the susceptibility rate, but rather by decreasing the severity of the disease. the worsening of the disease could also be associated with differences in ace polymorphism. indeed, a significant correlation was found between ace d/i polymorphism and covid- prevalence, when data from countries were extracted (r = . ) ( ) .it should be noted that in that study, ace d/i polymorphism was j o u r n a l p r e -p r o o f also correlated with covid- mortality, when the data were corrected for the onset of mortality (r = . ) ( ) . these data suggest that ace d/i polymorphism may be a confounder in the spread of covid and the outcome of the infection ( ) . the d/i polymorphism of intron of ace , located on chromosome , is associated with alterations in circulating and tissue concentrations of ace. the deletion is associated with a reduced expression of ace ( ) . sars-cov- uses the sars-cov receptor ace for entrance into the cell ( ) . sex differences in the expression of ace genes have been reported ( , ) . in animal models, estradiol reduces renal ace activity (it is increased in males and in ovarectomized mice) ( ) data from epidemiologic-, in vitro-, and knock-out studies, in mice, suggest that sars-cov- infection involves the role of the transmembrane serine protease (tmprss ). the latter is a cell-surface protein, expressed by epithelial cells among others of the aerodigestive tract ( ) . coronaviruses may depend on tmprss for viral entry and spread in the host. first viral hemagglutinin protein attaches to the angiotensin-converting enzyme (ace ), encoded, by the ace gene ( ) .. hemagglutinin is thereafter cleaved to activate internalization of the virus. this step may be dependent on tmprss . tmprss was first identified in prostate cancer, where its expression is upregulated by prostate cancer cell lines in response to androgens ( ) . often there is a gene fusion between the tmprss and erg genes ( ) . this gene fusion is consequently controlled by androgen receptor signaling. in men, tumors with the tmprss -erg fusion have higher insulin/insulin-like growth factor signaling, and tmprss -erg may modify how hormonal risk factors such as obesity influence the risk of metastasis ( ), although there seems to be no difference in expression of tmprss in lung tissue between men and women. low levels of androgens in women may suffice to sustain tmprss expression, and .tumors with tmprss -erg fusion may be responsive to estrogen signaling. further studies should evaluate tmprss polymorphisms and whether androgen modulators modify the tmprss expression and respiratory consequences of sars-cov- ( ). aside from biological differences between men and women, there are also environmental differences that may play a role. it has also been documented that women are more attentive to hygiene measures such as hand washing than are men ( ) . while this may be the case, it should probably influence rather the infection rates, rather than complication rates of the disease. alternatively, since the prevalence of infection seems to be quite similar between sexes, but the severity of the disease, the complications and the deaths rates much higher in men than women, it is also plausible that this may be due to a higher rate of co-morbidities in infected men than women, or to differences in behaviors between them. not all of the reports support smoking as a predisposing factor in men or any subgroup for infection with sars-cov- , since they reported only small proportions of smokers among the affected patients (actually much lower than the smoking prevalence in china) ( , ) . nevertheless, it should be noted that worldwide a third of men smoke, whereas about % of women do ( ) . this difference in smoking habits results in much higher rates of disease and co-morbidities that are influenced by smoking ( ) . there are, for instance, almost four times as many lung cancers in men than in women in france, germany, italy and south korea, ( ) . men develop cardiovascular disease, hypertension and diabetes more frequently and at a younger age than women. these co-morbidities have been associated with an increased rate of death associated with covid- infection ( ) . bots et al reported that while the gap between sexes, in cases of cardiovascular disease narrowed between and , coronary heart disease (chd) mortality was still on average about five times higher in men and the stroke mortality was twice as high. ( ) . the pattern of the case fatality rate, seen for covid- , may therefore be comparable to that j o u r n a l p r e -p r o o f of other major causes of mortality in the elderly, such as heart disease, diabetes, or combined influenza and pneumonia ( ) . this review is hampered by several limitations, as mentioned before: there is a marked heterogeneity concerning who is being tested, the tests that are used and the number of tests are increasing constantly. we only selected databases that presented data by sex and in languages that we understood. to conclude : a breakdown of hospitalization rates in the icu and death rates by sex, age and co-morbidities is necessary in order to answer the question of whether men are more at risk for covid- than women ( , ) . these results may also have implications as treatments and vaccines are currently being tested on men and women ( ) . although women seem to die less frequently than men from the immediate consequences of the covid- pandemic, women may be more exposed, given their predominant roles as caregivers within families and as front-line health-care workers ( ) . moreover, we do not yet know what the long-term consequences will be on women's health. for instance, the pandemic will have dramatic consequences on economic issues, which often affect women more than men ( , ) serge rozenberg collected and analysed the literature data, and drafted the manuscript. jean vandromme checked the literature data. charlotte martin checked the literature data, and collected and analyzed data in the chu st pierre. the manuscript was reviewed and approved by all co-authors. the authors declare that they have no present conflict of interest.. in the past s rozenberg received fees for advisory boards and lectures (gedeon, abbot, mylan, ucb), or research grants (amgen, gedeon, and mylan). jean vandromme: advisory boards and lectures (gedeon). charlotte martin has nothing to declare. the study was not funded. our use of personal data 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differences in renal angiotensin converting enzyme (ace ) activity are β-oestradiol-dependent and sex chromosome-independent epub ahead of print tmprss and covid- : serendipity or opportunity for intervention? cancer discov sex differences in public restroom handwashing behavior associated with visual behavior prompts sex difference and smoking predisposition in patients with covid- smoking association of inpatient use of angiotensin converting enzyme inhibitors and angiotensin ii receptor blockers with mortality among patients with hypertension hospitalized with covid- sex differences in coronary heart disease and stroke mortality: a global assessment of the effect of ageing between a geroscience perspective on covid- mortality covid- worldwide: we need precise data by age group and sex urgently demographic science aids in understanding the spread and fatality rates of covid- prediction models for diagnosis and prognosis of covid- infection: systematic review and critical appraisal covid- : the gendered impacts of the outbreak sex and gender disparities in the covid- pandemic we thank "global health / info@globalhealth .org" for the permission to reproduce their table. key: cord- -reoa kcw authors: botreau, hélène; cohen, marc j. title: gender inequality and food insecurity: a dozen years after the food price crisis, rural women still bear the brunt of poverty and hunger date: - - journal: nan doi: . /bs.af s. . . sha: doc_id: cord_uid: reoa kcw the global food price crisis of – had devastating impacts for the world's poorest people, especially for smallholder farmers and in particular for women, who face discrimination and a heavy burden of household responsibility. the international policy response to the crisis saw the launch of numerous new initiatives and instruments, but funding has been insufficient and policies have failed to address the structural deficiencies in the global food system. a dozen years on, in light of climate change and increased conflict, new policies are needed to reorient the food system so that it prioritizes smallholder communities, with a renewed focus on the needs and aspirations of women. . introduction . underlying structural factors and their impacts on women . what led to the food price crisis? . impacts and long-term effects on women smallholder farmers . how effective was the global response in tackling the structural causes of the crisis? . the global response after - . responding to the crisis with business as usual . a lack of coherent governance for global food security . addressing women's food insecurity in a (more) unstable and broken food system . increased challenges for food and nutrition security for women . what changes have there been in the institutional and funding agenda to address women's food insecurity? . closing the gender gap: transforming rather than mainstreaming . conclusion and recommendations . guarantee participation and inclusiveness . increase aid to agriculture . increase national public investments in agriculture in developing countries . ensure women's access to resources, competitive markets and farmers' rights the global food price crisis of - underscored how fragile livelihoods are among the world's extremely vulnerable people, as it drove million people in developing countries into poverty (world bank, ) . in the aftermath of the crisis, in the food and agriculture organization of the united nations (fao) estimated in a that almost billion people worldwide were undernourished (fao, a) . as this chapter will show, the crisis disproportionately affected women. in the un world food programme (wfp) calculated that women and girls accounted for % of chronically hungry people around the world (wfp, ; see also scott-villiers et al., ) . the flurry of policy action in the months and years following the price spike brought some hope that the world's governments were prepared to tackle the structural factors behind the crisis, which had a severe impact on vulnerable people's resilience to shocks. the effects proved especially severe for women small-scale agricultural producers. a dozen years later, despite the international commitment to sustainable development goal (sdg) of zero hunger, too many of the policies that precipitated the food price crisis remain in place (wise and murphy, ) . the united nations food, agriculture, and health agencies estimate that the number of hungry people in the world increased by million in , and rose by million over the preceding years (fao et al., ) . viewing food insecurity through a somewhat different lens, the agencies also a following these estimates of hunger, the committee on world food security (cfs) recommended that fao revise its much-criticized methodology for counting the number of undernourished people. this new methodology included updated population estimates and household surveys on food consumption, and took into account food waste at the distribution level. it was used for the first time in the state of food insecurity security in the world (sofi ) (fao, ) report, and the hunger trends observed showed significant changes. the methodology has been under constant revision since then, with new indicators added to make it more complete. therefore, it is not possible to compare figures across annual volumes of the sofi report. estimated that over billion people ( . % of the world's population) cannot afford a healthy diet (fao et al., ) . women smallholder farmers are among the worst affected, and remain far from realizing their human right to adequate food. looking back in , reconsideration of the long-term impacts of the food-price crisis and the impacts of the policy response is long overdue. it has become clear that we will not achieve sdg , given that the structural causes of hunger remain unaddressed and that additional issues have become more salient since . this chapter will proceed as follows: • reflecting on how the existing challenges faced by women smallholder farmers were exacerbated by the structural causes of the food price crisis; • examining major policy responses from governments and the private sector and analyzing their effectiveness in addressing the structural causes of the crisis; • setting out the lessons learned from the major failures of this policy response; • identifying key challenges and gaps in financial aid to women smallholder farmers and, more specifically, looking at the level of official development assistance (oda) targeted to them since ; and • providing policy recommendations to address all of these issues. the challenges and questions raised by this chapter remain substantial, diverse and context-specific. although we cannot explore these topics exhaustively, we hope to contribute to renewed calls for justice and the right to food for the hundreds of millions of people who remain hungry in a time of plenty. their impacts on women . what led to the food price crisis? the term "global food price crisis" usually refers to one of the biggest price surges (de schutter, ) in a period of extreme volatility for primary commodities, mainly the most widely consumed cereals, which had peaks in the second half of and the first half of and another spike in - . between march and march prices rose %, those of soybeans jumped % and wheat prices ballooned % (fao and oecd, ) . the price of rice climbed fourfold during january-april , as several major exporters embargoed foreign sales of this lightly traded commodity (fao and oecd, ) . b global food prices declined from their peak in june , as the world economy fell into recession (fig. ) . prices remained relatively stable until the first half of and then began rising again, reaching an all-time high in february (fao, ) (fig. ). severe drought in major exporting countries was the key short-term factor contributing to this second spike (trostle, ) . as a study by the institute of development studies conducted for oxfam noted, the rise in prices pushed low-income people, who precrisis frequently spent % or more of their incomes to buy food, further into poverty and increased their difficulties in maintaining basic consumption levels: people for whom securing food has already absorbed a large share of their resources and energies before the food crisis came under intense pressure to alter their relationship to food and thus to the economy-to spend more time earning more money to cover basic provisioning and to extract more value from whatever they consumed. scott-villiers et al. ( ) . in other words, the crisis posed a severe threat to the right to adequate food for millions of people (de schutter, ) . . . a broad variety of causes led to the - food price crisis, and views on the weight to give to long-term trends vary in the literature (scott-villiers et al., ) . nevertheless, as olivier de schutter, then the un special rapporteur on the right to food, observed in , "the disaster which results from the increase of international prices of food commodities is a man-made disaster. the causes are identifiable" (de schutter, ) . the agri-food system and its contradictions contain a number of hidden causes of the crisis, what we call "structural factors": liberalization of agriculture and trade, concentration of distribution and inputs marginalizing smaller production units and decreases in investments in agriculture and development assistance to the sector in a context of increasing climate change. these long-term trends made smallholder farmers more vulnerable to shorter-term "conjunctural factors" experienced in the more immediate run-up to the crisis. these conjunctural factors consist mainly of an evolution of fundamentals of the market-supply and demand (bricas and goïta, ; clapp and cohen, )-and marked an increased level of globalization (scott-villiers et al., ) , creating an even more unfavorable economic context for smallholder farmers. in the decade prior to the crisis and following adoption of the world trade organization (wto) agreement on agriculture of and the world food summit in , there was a major shift in global food and agriculture, with lower trade barriers and more open markets. however, countries with weak market infrastructures and those that relied on a small number of export commodities did not gain from liberalization and faced risks associated with increases in world food prices, which would mean considerably higher import bills, potentially requiring them to spend their foreign-exchange reserves (trueblood and shapouri, ) . for farmers, this shift encouraged less production of traditional food cropswhich frequently were the crops that women farmers produced-in favor of crops for domestic and export markets, increasing their exposure to the volatility of those markets and their dependence on purchased inputs (un women, ) . most low-income countries moved rapidly away from self-sufficiency in food and in turn opened their domestic markets to external produce. from , sub-saharan africa became a net food importer (fig. ) , despite an impressive increase in regional production of major crops. between and , only one-fifth of african food exports stayed in african countries, and % of agricultural imports came from other continents (rakotoarisoa et al., ) . west africa tripled its rice imports in the s (fig. ) (oecd, ) . outside of africa, haiti reduced its tariff on imports of rice-the daily staple for most haitians-from % to %. from near self-sufficiency, the country went to importing % of its rice consumption, and has now become the second largest market for us rice (cohen, ; oxfam, ) . liberalization policies have also facilitated the overwhelming market supremacy of a small number of large companies, from farm inputs to sales of food to consumers. as mckeon ( ) has observed, "corporate power in food chains has continued to grow unabated, with the mega-mergers of major agribusiness multinationals threatening a further concentration'" over the past few decades, four firms, known as the abcd companies-archer daniels midland (adm), bunge, cargill and louis dreyfus-have come to virtually control trade in grain and oilseeds plume, ) . such concentrated market power is often seen in low-income countries that typically have at best insubstantial market regulation. in the agrochemical sector in the late s, the top companies accounted for % of global sales. by , seven companies controlled the same market share (humphrey and memedovic, ) . in , as a result of the mega-mergers that mckeon highlights, three companies (bayer, dowdupont c and chemchina) stood poised to claim a % share of global commercial seed and agro-chemical sales (friends of the earth europe et al., ). however, the ability of these firms to administer the prices of seeds, for example, varies according to crop and country context (cavero and galiá, ; oecd, a) . the rate of growth of public spending on agriculture slowed dramatically during - , and it stagnated in africa. however, spending rose steadily in asia, and doubled during the two decades after . in the absence of public funding, smallholder producers, particularly women farmers, had little ability to bargain with large agribusiness firms, middlemen or credit providers (un women, research is unlikely to address the problems facing low-income farmers, given the unlikelihood of a sufficient return on investment in the shortto-medium term. . . . decreased aid to agriculture the public expenditure trend was not offset by oda to agriculture. the period between and was marked by low food prices and a sharp reduction in aid to agricultural development and investments from oecd countries and multilateral agencies ( fig. ; see also hlpe, ) . most of the aid that there was continued to focus on staples productivity; greater support for fruits, vegetables and legumes could have benefited smallholders (pingali, ) . by , agriculture's share of bilateral aid had fallen to a quarter of its former level, and the trend was similar for multilateral agencies: agriculture fell from % of world bank lending in to just % in - (brock and paasch, ). climate change is resulting in more frequent and more severe heat waves, droughts and floods, which can decimate farm production. its effects contributed to food price increases in - and also in , with severe droughts in australia, canada, argentina and the united states, all major cereals producers (fao and oecd, ) . there were droughts in east africa in , (bailey, . the last of these affected more than million people and resulted in the famine in somalia that killed , people (news centre, crops to weather indicate that global maize and wheat yields between and may have been, respectively, . % and . % lower than they would have been without the effects of climate change (lobell et al., (mittal, )-growth in food crop production slowed from the mid- s. for cereals, which cover over half of the world's farm land, yield growth fell from % annually in the s to a little more than half of that in the s, then increased to nearly % in the s (fao, a). . . . . escalating crude oil prices have led to rising farm production costs in the st century, increases in the prices of fertilizer and oil, which are key farm inputs, have exceed those for agricultural produce (fig. ). this has created further financial difficulties for farmers, as most developing country governments have reduced or eliminated subsidies on inputs and assistance with credit and marketing for smallholders (un women, (world bank, ) , and this was associated with a growing urban middle class. food consumption habits evolved and all regions in the world saw increased meat consumption and thus a rising demand for grains for animal feed (see fig. ). during this same period, global food trade concentrated on just four main crops: rice, maize (this, in particular, is an important animal feed as well as a major direct source of human food in sub-saharan africa and parts of latin america) and wheat, plus soybeans (directly consumed by humans, an input into processed foods, an animal feed and also a source of biodiesel) (mccreary, ) . the trends of dependence on the three major global cereals and on imports for food supplies have been simultaneous and mutually reinforcing. in sub-saharan africa and south asia-which are home to the majority of the world's food insecure people and thus constitute hunger's center of gravity-consumption of these cereals has steadily displaced traditional staples such as millet, sorghum, bananas, cassava, potatoes, sweet potatoes and beans over a long period. the trend was remarked on by people interviewed during the - crisis, who repeatedly mentioned the decline of "traditional" foods due to reduced availability, higher cost and longer preparation time (scott-villiers et al., ) . . . . . rapid expansion of biofuels production the expanded production of biofuels was a key driver of the food price crisis: increased biofuel demand in the united states, due to legal mandates to blend ethanol into petrol, pushed up maize prices and probably also those of soybeans, while eu and european expansion of oilseed production for biofuel led to higher wheat prices ( fig. ; see also headey and fan, ) . governments across the world attempted to reduce dependency on oil, increase the use of renewable energies and halt declines in farm income, and approved legislative instruments that encouraged the biofuels industry. those policies, led mainly by rich countries, created a demand shock in international markets (wise and murphy, ) . during a very short period before the crisis, % of the global maize supply was diverted to the us ethanol program. moreover, biofuels have direct impacts on land use and land rights, compromising food security. the eu's bio-energy policy helped biofuels industries to prosper, but the , km of eu land devoted to biofuels crops in could have grown enough food for million people that year (herman and mayrhofer, ) . . . . . declining stocks a low "stock-to-use" ratio due to low stocks, high demand or both creates upward price pressure (fao, b) . low stocks are a vulnerability factor, especially for countries already at high risk vis-à-vis prices, since reserves provide a buffer against both rising prices and poor harvests (wise and murphy, ) . in - the world cereal stockto-use ratio stood at an all-time low of . % (fao, b). . . . . dollar devaluation depreciation of the us dollar also played a role in food price escalation. in general, a weaker dollar is associated with commodity price increases (fao, b; headey and fan, ) . for countries that tie their currency to the dollar or that have a weaker currency, dollar depreciation makes food imports more expensive (fao, b). . . . . increasing speculation in commodities dollar depreciation also made food commodities attractive to investors, especially as technology and housing "went bust" (clapp, ). the growth of food commodities investment became mixed up with the financial crisis of - , which persuaded many noncommercial traders (whether considered "investors" or "speculators") to move their money away from collapsing stock, bond and property markets and into the commodity futures trade (fao, b) . such large-scale speculation contributes to commodity price volatility and gives inappropriate market signals to agricultural producers (fao, b). from the beginning of the food price crisis, the rice market came under pressure because some governments imposed bans on exports (such as restrictions on non-basmati exports by india, e a leading exporter) (usda/fas, ) and major importers such as the philippines made large-scale purchases, seeking to lock in prices as a hedge against further increases (childs and kiawu, ) . like the diversion of maize to biofuels, all this created distrust on the global markets and exacerbated upward pressure on prices. because of the large amount of international trade in wheat and maize at a time of extremely low global stocks, the price increases quickly spread to many national markets. however, transmission of world market prices to domestic markets varied greatly from country to country: in china and india, domestic prices were virtually unaffected; in brazil and south africa e india lifted this ban, imposed in april , in . during the period of the ban, thailand, pakistan and vietnam, among others, moved in to replace indian exports. it served to keep rice affordable for indian consumers, but adversely affected (albeit marginally) india's foreign exchange earnings. since lifting the ban, india has become the world's largest exporter of rice. the authors are grateful to ranu bhogal of oxfam india for pointing this out. prices increased in line with international markets; but in ethiopia and nigeria domestic prices increased dramatically. in general, according to one analysis, there were "higher price transmission rates for import dependent countries, including rice in senegal, mali, burkina faso, niger… and uganda, maize in malawi and uganda, and wheat in ethiopia" (baltzer, ) . the degree of price transmission was affected by domestic and trade policies in importing countries. f the events of - brought into plain view the cracks in an unsustainable food system that was already having severe negative effects on the basic livelihoods of smallholder farmers (murphy and schiavoni, ) . the structural factors outlined above (liberalization of the agri-food system, concentration in input and output markets, a decrease in public investments in agriculture, declining aid to agriculture) showed how unbalanced the system had become, privileging big agri-food businesses and making low-income people even more vulnerable to the conjunctural factors of the crisis. these short-term factors triggered the crisis and further impoverished the poorest people, denying them their human right to adequate food and nutrition and illustrating the global food system's failures (murphy and schiavoni, ) . rural people, and especially farmers, were on the front line. people living in rural areas are among the poorest in the global south and at the time of the crisis three-quarters of them were living on less than the equivalent of $ a day, and spending up to % of their earnings on food (coon, ) . already precarious rural livelihoods (due to geographic, economic and political isolation, poor access to markets, limited opportunities for work, low productivity and seasonal and long-term migration) (coon, ) amplified the threat of soaring agricultural prices, which affected not only consumers and urban dwellers but also food producers. the overwhelming majority of small-scale farmers are also net food purchasers, with very high exposure to price increases (murphy and schiavoni, ) . in theory, higher prices offered opportunities to farmers who are net food sellers, but price increases for agricultural inputs (fertilizers, fuel etc.) offset this possibility (quisumbing et al., ) . f according to baltzer ( ) , 'much of this variation [in the price transmission patterns] can be explained by price stabilization policies, public policy failure, incomplete market integration, and coinciding domestic shocks.' . . women smallholder farmers have been disproportionately affected because gender inequalities remain very strong in agriculture, women farmers are particularly at risk of food insecurity, especially in times of crisis (fao, ). rural women account for one in four people on earth and on average for nearly half the agricultural labor force in developing countries (fao, a) . women play crucial food-security roles, which include farming, food processing, marketing and ensuring household consumption and nutrition (fao, a) . nevertheless: • they face discrimination and frequently are in a weak bargaining position. in addition, other forms of discrimination (based on, e.g., race, class, caste or religion) often intersectionally reinforce gender inequality (un women, ). • the diminished state role in agriculture in the s and s added to female farmers' marginalization, as it reduced their access to inputs, resources and services (un women, ) . rural women also face unequal power relations within both the household and wider society, which have impacts on many aspects of food security. at the level of society: social inequalities come from socially constructed barriers to accessing productive and financial resources that also hinder social participation and political representation. patriarchal norms leading to power imbalances between women and men create disadvantages for women in agriculture, specifically in land rights (small plots, difficulties accessing ownership, discriminatory inheritance rights), productive resources (no access to credit markets, extension services or inputs), unpaid work, insecure employment and low levels of participation in decision making (sexsmith et al., ) . in the household: cultural practices and intra-household bargaining power can also determine the allocation of household incomes to food and care needs. women's weaker position within the family and social standards that favor boys over girls lead to poorer nutrition among women and girls (fao, a; lourme-ruiz et al., ) . . . . the challenges already facing women smallholder farmers were exacerbated by the food price crisis even though there is as yet inadequate research on the gender differentiated impacts of the food price crisis, it is clear that women bore the brunt of it and came under the most pressure to cope with its effects (quisumbing et al., ) . as hossain and green ( ) have observed: the effects differ by gender…women come under more pressure to provide good meals with less food, and feel the stresses of coping with their children's hunger most directly. these stresses push women into poorly paid informal sector work, competing among themselves for ever more inadequate earnings. the crisis really was a matter of inequalities in achieving the right to adequate food and nutrition, and the short-term factors involved in it exacerbated all the gendered dynamics of the food system (un women, ). discrimination against women at these different levels affects their capacity to respond to shocks and cope with food crises (fao, ; un women, ) . because of the constraints they face in accessing extension services and financial and agricultural resources, limited legal benefits and protection, heavy time burdens and limited decision-making power, women have fewer options for overcoming any crisis and face more risks than men of losing their assets or formal sector jobs. price spikes have particularly negative effects on women heads of household, for several reasons: they suffer labor market discrimination, which confines them to informal, vulnerable and casual employment; they often receive less pay than men doing the same work and they usually spend a higher share of their income on food than male household heads (holmes et al., ) . when looking at intra-household dynamics, it is crucial to highlight women's food-security roles: they usually have the primary responsibility for procuring and preparing food within the household (ford, ) . with regard to nutrition, they play an important role in providing dietary diversity through their vegetable gardens (which are often not considered "agriculture"), and also because they grow a large share of the cereal or root crops that the household consumes (doss et al., ) . during - , improvements in women's education and social status accounted for more than % of the substantial reductions in child malnutrition that occurred (smith and haddad, g ). in times of crisis, poor rural households face losses in assets, productivity and income. men use their income to pay past debt and seek new farm production loans. when women's intra-household bargaining position is weak, g here is the methodology used: 'ifpri…examined the factors that helped reduce child malnutrition by % in the developing world between and . the evidence shows that increases in women's education accounted for % of the total reduction in child malnutrition, by far the largest contribution. improvements in women's status accounted for another %. improvements in food availability came in a distant second to women's education, contributing % to the rate of reduction.' the frequent result is less spending on nutrition and children's wellbeing. indeed, when poor households face a decline in food purchasing power, their coping strategies often include buying cheaper items and moving to less diverse diets, depriving pregnant and nursing women and young children of essential nutrients (holmes et al., ) . women often turn to extreme coping strategies: reducing their food consumption to make more available to others in the family (quisumbing et al., ) , collecting wild food or even migrating in distress or selling assets (holmes et al., ) . during the food crisis in chad, khadija khazali, a widow with seven children from azoza village, said, "we have reduced the number of meals daily, and women are digging in anthills to recover grainsa practice which our community has not had to resort to for a very long time" (ford, ) . women may also take unsafe jobs to boost their incomes, at the expense of their own security and health, e.g. working in mines (quisumbing et al., ) or going into prostitution (cohen and smale, a) . men have more access to social capital and have more pathways out of a crisis, whereas women often face severe time burdens, given the pressure on them to ensure the household's food security. therefore they do not enjoy the same opportunities (ford, ) . men can migrate more easily to find a job in urban areas, and this affects the coping capacity of the women who are left behind: they now must manage the family farm, but may still have to get approval from their absent husbands on key agricultural decisions (coon, ) . the structural causes of the crisis? . . putting food security back on the political front burner the crisis and the subsequent media coverage created an opportunity to put food and agriculture back at the core of global development policies, following years of neglect. after - there was a flurry of action, from countries and regions on the front line of the crisis to oda, multilateral initiatives for reinvestment in agriculture and intergovernmental action, to elevate the place of food security on the global policy agenda. as noted in table , in the first years following the crisis the global policy responses and funding commitments focused on macro-level relief such as support for production, food aid and preventing export bans (quisumbing et al., ) . help million africans get out of poverty by . source: authors' analysis; specific sources for each initiative indicated in the relevant row. the fao was the first institution to react, establishing the initiative on soaring food prices in december , with a budget of $ . bn. this provided countries with technical advice through fao's guide for policy and programmatic actions at country level to address high food prices (maetz et al., ) . then in april world bank president robert zoellick pushed for a "new deal for a global food policy" and established the global food crisis response program (gfrp), with a view to the "expedited processing" of assistance and an initial budget of $ . bn. similar to fao's initiative, the gfrp provided technical and policy advice to severely affected, low-income countries (world bank, ). the first coordinated international response was the high-level conference on world food security, held in rome in june and attended by over heads of state from the global south and north. a group of international organizations produced the comprehensive framework for action (cfa), which was launched at the conference; this called for an additional $ bn-$ bn per year for food aid and oda for agriculture and social protection, and advocated allocating % of international aid to agriculture for the next years. the conference resulted in greater collaboration among the rome-based un food and agriculture agencies, but it also led to greater fragmentation of food-related international institutions as yet more new ones were created. then the world summit on food security in rome in november agreed to the rome principles for sustainable global food security, which called for better coordination and more stable funding (fao, c) . both the group of (g ) "leading" countries and the larger group of (g ) then agreed to food security initiatives, including at every annual g /g summit meeting from to . at the g summit in l'aquila, italy member governments pledged $ bn, but it turned out that a large part of this consisted of recycled promises or even money previously spent. in september the pittsburgh g summit asked the world bank "to work with interested donors and organizations to develop a multilateral trust fund to scale-up agricultural assistance to low-income countries" (g information centre, ). the resulting global agriculture and food security program (gafsp) (world bank, a) currently is providing $ . bn to countries through two windows: one focused on supporting public sector action in developing countries, and the other providing loans, guarantees and equity to the private sector to support investment in agricultural development (gafsp, ). following the second spike of the crisis in , there was an additional set of global responses. this time there was a greater focus on long-term agricultural investments, especially through partnerships with other actors like the private sector, whereas in - the response was mainly through the public sector. reflecting on the policy responses to soaring food prices, de schutter ( ) commented: today, too many [governments] continue to see hunger as a problem of supply and demand, when it is primarily a problem of a lack of access to productive resources such as land and water, of unscrupulous employers and traders, of an increasingly concentrated input providers sector, and of insufficient safety nets to support the poor. too much attention has been paid to addressing the mismatch between supply and demand on the international markets […] while comparatively too little attention has been paid both to the imbalances of power in the food systems and to the failure to support the ability of small-scale farmers to feed themselves, their families, and their communities. . responding to the crisis with business as usual . . addressing supply and demand factors: increasing productivity as a major solution, but neglecting the issue of marginalization the marginalization of whole segments of the population in attaining food security and nutrition throughout the food price crisis made it clear that the main issues were access and inequality, rather than food production. however, the policy discussion tended to focus on the need to double production, both to dampen short-term price increases and also to meet projected population growth through to . efforts and plans tended to focus on this perceived need for increased production, even though supplies were already in substantial surplus (bricas and goïta, ) . between june and july , wfp provided short-term food aid valued at $ . bn, nearly double the $ . bn in agricultural aid mobilized by the world bank, fao and the international fund for agricultural development (ifad) (brock and paasch, ). wfp's big fundraising push sought to compensate for the effects of rising food prices on its ability to procure commodities (golay, ) , but in fact global food aid volumes in - were below those of - , as a direct result of the and price spikes (brock and paasch, ) . although some of the early initiatives did provide resources to smallholder agriculture, not all smallholders benefitted equally. thus, these programs fell short on delivering fully on the promise that smallholder-led agricultural development was back prominently on the development agenda. for example, an actionaid assessment showed that gafsp projects successfully targeted small-scale food producers. some projects emphasized women's empowerment, through income-generating opportunities for women and strengthening women's organizations. however, the study also pointed out that women were not adequately consulted in project design and activity planning, and their under-representation prevented them from receiving information about projects (actionaid, ). in addition, much of the funding provided to address the crisis aimed to promote the growth of productivity in staple grains. this was true of the majority of grants from gafsp and the us feed the future (ftf) program for example, with much less attention paid to horticulture crops (pingali, ) , even though horticulture production had the potential to boost the livelihoods and food security of smallholders, including women farmers (ulrich, ) . as table shows, targeting women was not a priority for most of the initiatives that sought to address the food price crisis. for those that did aim to make gender equality a high priority, such as the cfa, the gafsp and ftf, the impacts were limited because these initiatives focused on enhancing the productivity of "market-ready" farmers, who frequently tend to be male. although the cfs champions tackling gender inequalities in food security and nutrition, some member states have sought to weaken it over the past decades, leaving it with less influence. the g responded to the price spikes by encouraging the development of the agricultural marketing information system (amis). this initiative seeks more transparent commodity markets and information exchange among producer and consumer countries. however, amis has no control over many of the drivers of price volatility, and it is not able to monitor privately held stocks (e.g., those of grain traders) (murphy and schiavoni, ) . equally, it cannot tackle all the major market failures that lay behind the crisis. global policy makers largely failed to enact needed reforms to financial markets to prevent destabilizing speculation in commodity markets, due to pressure from industry lobbyists to maintain the status quo (see, for example, fang, ) . the high-level conference on world food security in , the g summit and the world food summit all pointed to the potential table attention to gender issues in initiatives undertake to tackle the food price crisis. gender focus? no mention of gender inequalities or specific focus on women in the guide. comprehensive framework for action (cfa) recognizes the disadvantages that women face in the food price crisis and their disproportionate vulnerability, especially to the long-term effects. the "menu of actions" recommends that "channeling food assistance via women should be encouraged and opportunities to improve program efficiency should be pursued." global food crisis response program (gfrp) no information found. purchase for progress (p p) takes a "gender transformative approach, directly focusing on women to ensure that they benefit from the project source." hokkaido, japan g summit no mention of gender inequalities. committed to a rights-based approach to support small-scale food producers, gender mainstreaming and ecological sustainability. feed the future the usaid forward policy framework and the feed the future guide, which support ftf operations, emphasize gender equality. the policy framework seeks to ensure women's engagement throughout the project cycle. the guide makes gender a cross-cutting priority, and aims to recognize women's often unsung contributions in agriculture, rights to resources and needs as food producers. l'aquila, italy g summit only one mention of women farmers as food security actors. makes "gender, food security and nutrition" a pillar of cfs work. the committee urged member states to undertake policy reforms to ensure gender equality in achieving the right to adequate food and nutrition, and to include women in food security decision making at all levels. it also asked member states to produce gender-disaggregated data. continued role that food reserves could play in the international response to the crisis (gubbels, ) . in the early s, under pressure from the international financial institutions due to the high cost, many developing country governments had abandoned the use of food stocks to counter physical shortages or reduce price fluctuations (see, for example, devereux, ) . but as prices rose in - , some countries sought to collaborate on a regional basis to create reserves to dampen the effects: new regional stocking systems were set up in west africa by the economic community of west african states (ecowas) and in southeast asia by the association of southeast asian nations (asean) (lines, ) . many governments reacted to the crisis, sometimes without efforts to coordinate their actions. however, many low-income, food-importing countries had limited capacity to respond (golay, ) and they also suffered impacts from the actions of other countries, such as export bans. gafsp directly supports achievement of sdg , encouraging gender equality. beyond increasing productivity and linking farmers to markets, gafsp's sustainable agriculture interventions have an impact on gender equality issues, such as women's agricultural empowerment, job creation on and off the farm and the enhancement of women's and girls' nutritional status. agricultural action plan mostly gender-blind, with a single "add women and stir" line in the action plan: "focus on the ultimate client, especially women." gender-blind: does not address gender issues, and evaluated by fao as "neutral" on gender, with no specific gender component or strategy. no mention of gender. weak on the recognition of women's rights and women's empowerment. source: authors' analysis; see table for specific sources for each initiative. in west africa in the majority of states lowered tariffs and taxes on some cereals, and some decided to control their domestic prices. although such measures can ease the food price burden on consumers, including politically restive urban populations, they cannot ensure efficiency and sustainability or target all vulnerable people, and may be very costly to maintain (cohen and smale, b; hathie, ) . most of the programs implemented after the crisis only targeted cereal production to reach national sufficiency and did not target other segments of the value chain. this strategy was conducted through national agricultural investment plans (naips), which originally were meant to tackle structural constraints and encourage sustainable agricultural growth as part of national development planning processes but which led to dependency on input subsidies and created a higher dependence on external markets (hathie, ) . fao examined the measures taken in more than countries from to , and found that policy decisions paralleled those of - ( fig. ) (see also maetz et al., ) . these measures included support for farmers' access to inputs and facilitating access to credit. however, such policies do not necessarily favor smallholder production, and many of the policies that on paper targeted small-scale producers excluded those considered to be nonviable economically, leaving many out (wise and murphy, ) . moreover, some of the policies emphasized inclusion of small-holders in export value chains without evaluating the environmental and economic risks (wise and murphy, ) . such policies often had disastrous impacts on small-scale farmers, especially on women farmers who relied on production of non-staple crops. these are key sources of micronutrients, but were crowded out by efforts to promote staple production with fertilizer and credit subsidies and price supports. in many instances, this led to increased prices for non-staples, such as fruit and vegetables (pingali, ) . . . . . liberalization of agricultural trade trade-oriented measures evolved as a medium-term trend. some exporting countries still observed export restrictions after to keep their domestic prices low but several countries, in contrast, put in place export facilitation measures (maetz et al., ) . h in addition, some governments lowered tariffs on imported food in order to improve food access (maetz et al., ) . overall, the policy responses did not reverse the direction of global agricultural trade liberalization. governments continued to reduce agricultural tariffs, and many offered preferential market access via bilateral agreements. world agricultural trade grew an average of . % per year during the two decades following enactment of the wto agreement on agriculture, i.e., (beckman et al., . . . . . acquisition of large tracts of land and biofuel policies one consequence of the food price crisis was a scramble to gain control of large tracts of land in developing countries. wealthy-country governments and private companies acquired much of the land in question. between and , the five leading investor countries were malaysia, singapore, cyprus, the united kingdom and china (grain, ; nolte et al., ) . large-scale land acquisitions (in excess of hectares) often dispossessed smallholders (geary, ; wise and murphy, ) . in most instances, these investments focused on export production rather than growing food h these countries included argentina, brazil, chile, ecuador and paraguay in south america, syria and yemen in the middle east and asian nations including china, pakistan and thailand, as well as india to some extent. countries limiting exports included cambodia, china, india, pakistan and vietnam. crops for local consumption, often with little regard to environmental consequences (geary, ) . two-thirds of these acquisitions occurred in countries facing significant food insecurity (geary, ) . usually, investors sought to acquire land in order to produce biofuel crops such as sugarcane, soy and jatropha for export (geary, ) . meanwhile, biofuels policies in rich countries remain largely unchanged. the united states, the main producer of maize-based ethanol, continues to require the blending of ethanol into petrol (bracmort, ) . legislative work to install a ceiling on the share of biofuels coming from food crops has continued at the eu level over the past decade. however, the eu's renewable energy directive (red ii) of still allows member states to burn massive amounts of food as fuel (oxfam international, ) . . . . . national public investments in agriculture continue to fall short food security and agriculture also gained regional and national policy salience after the food price crisis. for example, the comprehensive africa agriculture development program (caadp) (see box ), the comprehensive africa agriculture development program (caadp) (au, a) seeks to promote agricultural development, food security and good nutrition on the continent. it was endorsed at the au's summit meeting under the maputo declaration in (au, b) . from the start, it grabbed headlines by setting a target for every african government to devote a minimum of % of its budget to agriculture. the program is intended to end a long-ingrained habit of dependence on external resources. as a oxfam report noted, "international aid has long represented the bulk of agricultural sector financing in many west african countries. in , it accounted for % of the domestic agriculture budget of niger [and] over % in ghana…." (guereña, ) . oda remains a key source of finance for burkina faso's agriculture budget. i this situation has led the work of governments in unusual directions. thus, "national agriculture co-ordination bodies do exist…, but they serve more to exchange information than to actually co-ordinate interventions on the ground" (guereña, ) . by agriculture's share of public expenditure by african governments was just . %, although the share differed greatly from country to (anisimova, ) , and few have done so consistently. the au agreed to a new agenda in , marking years since the foundation of the organisation of african unity. its call to action for the next years included the following among its targets for african agriculture and agro-businesses by the time of the th anniversary: • achieve zero hunger; • lower food imports while boosting intra-africa food and agricultural trade to % of total agricultural trade; and • increase women's access to land and agricultural inputs, and allocate at least % of agricultural finance to women (au, ) . one year later in , the malabo declaration introduced a system of biennial reviews of countries' achievements under caadp (au, ). the first review, covering and , found that au members' expenditure on agriculture ranged from . % to . % of their budgets. ten countries met the % target, but this was no more than in , when the star performers were zimbabwe, malawi and ethiopia. however, malawi had fallen back from . % in to . %, ethiopia to . % and zimbabwe to . % (au, ). there are concerns that the review process is excessively "state-centric." popular narratives dwell on the argument that if the review process is there to ensure accountability, it must provide for inclusivity and the participation of all stakeholders. j indeed, the caadp framework remains very weak in terms of gender inclusion: the only caadp commitment related to gender is about women's involvement in agribusiness. in other words, the caadp commitments themselves are largely gender-blind. and although the technical guidance of caadp asks countries to collect gender-disaggregated data, there is minimal reporting on how women smallholder farmers are progressing under these commitments. . % of their expenditures that year to the military (world bank, ), despite the role played by conflict in increasing hunger in the region. despite renewed policy attention to agriculture, current public investment levels remain woefully inadequate. the un conference on trade and development (unctad) estimates an annual investment gap in developing country agriculture of $ bn over the period - (out of a total annual sdg financing gap of $ . trillion) (unctad, ). an analysis of national government and aid donor investments in ethiopia, ghana, nigeria, pakistan, the philippines and tanzania was unable to trace the flow of funds to women farmers. it found diversion of resources away from smallholders, and a lack of government capacity to ensure support for small-scale producers (either men or women) (mayrhofer and saarinen, ) . social safety nets put in place by governments are often efficient in targeting vulnerable populations; however, their efficiency is limited depending on the objective (e.g., assistance through cash transfers during lean periods) and there are multiple approaches (a short-term approach providing food assistance or long-term approaches aimed at strengthening resilience and fighting poverty). while donors' efforts to target support for social protection programs based on poverty criteria show decent results (schnitzer, ) , there could be better inclusion of women by adding gender-specific requirements (e.g., direct inclusion of female heads of household or women with children under the age of five). investments in r&d and in infrastructure have often focused on export agriculture and cereals at the expense of food crops oriented toward the consumption of local communities (de schutter, ) . the consultative group for international agricultural research's (cgiar) r&d expenditures on wheat, maize and rice, for example, more than doubled from $ m in to $ m annually during - (pingali, ) . the share of oda dedicated to food security and nutrition (fsn) has remained largely constant (fig. k ) : oecd data show that this kind of aid grew at the same rate as total oda, without major increases in response to the food price spikes. k we use the same methodology as presented in mowlds et al. ( ) to calculate gross oda disbursements for food and nutrition security (fns). we therefore consider all aid reported under agriculture, agro-industries, forestry, fishing, nutrition and development food aid/food security assistance as being aid for fns. while this approach will include some aid that is not specifically targeted to fns and will also exclude some that is, we feel that in the absence of a specific fns classification it provides a reasonable picture of trends in aid in this area. although the $ bn pledge made in l'aquila in did lead to additional oda resources for agriculture, the increase in funds for fsn was modest, as less than one-third of the pledges ($ . bn) represented additional money above spending that donors had already planned. also, the funds promised at l'aquila were one-time pledges, not multiyear commitments of additional money (mowlds et al., ; wise and murphy, ) . as the global economy fell into recession in the second half of , donors turned to austerity measures that limited oda increases (wise and murphy, ) . analyzing two major donors, the eu and the us, over a period of years shows that they are far from delivering. smallholders are central to the eu's international food security policy (ec, ) and its $ bn food facility, launched in , had a specific focus on small-scale producers. however, mayrhofer and saarinen ( ) found that less than one-quarter of eu aid for agriculture between and explicitly targeted small-scale producers. only %- % of eu agricultural funding promoted gender equality, and there was little attention to environmental sustainability. furthermore, with the exception of just year ( due to the food facility), the eu's agricultural oda has consistently supported industrial and export crops with significantly higher budgets than food crops. the destination of oda can also contradict aid effectiveness principles when it does not match policy commitments. in contrast with the eu commitment to target a substantial share of its aid to africa, oda for agricultural fig. ). the us created a -year, $ . bn agriculture, food security and nutrition initiative, feed the future (ftf), after l'aquila. since , the program has continued with funding of about $ bn annually. ftf has attempted to integrate the principles of aid effectiveness, particularly country ownership, into its programming, along with women's empowerment and sustainable natural resource management. its main emphasis is on working with "market-ready" smallholders who have high potential to engage in commercial agriculture, often however at the expense of farmers who have the least access to resources (land, labor, capital). also, the focus is more often on approaches to yield gains that require high levels of external inputs. the gains have been impressive: farm outputs in ftf focus countries over the period - exceeded those of other low-and low-middle-income countries by $ bn (feed the future, ). however, it is not clear whether these gains are sustainable once us aid ends. there also appears to be a real trade-off between aligning aid with national development plans missing out on small is beautiful: the eu's failure to deliver on policy commitments to support smallholder agriculture in developing countries. oxfam briefing paper. https://policy-practice.oxfam.org.uk/publications/missing-out-onsmall-is-beautiful-the-eus-failure-to-deliv-er-on-policy-commitme- . on the one hand and some other aspects of country ownership on the other, such as broad consultation with stakeholders and provision of resources through local systems and actors (muñoz and tumusiime, ) . . . . . growing role for multinational enterprise since the food price crisis, global policy has given more space to the private sector: for instance, the g launched its new alliance for food security and nutrition in africa in may , with a goal of "unleashing the potential of the private sector." developing country governments, bilateral and multilateral aid agencies, and multinational firms have all joined in promoting private investment in agriculture in the global south. but there is a big risk that this emphasis will bypass smallholder farmers (see box ). the g launched the new alliance on the eve of its camp david meeting in . this initiative represents a major scaling back of public funds provided by g countries for global agricultural development, leaving africa much more reliant on public-private partnerships (ppps) and private capital. the alliance has been denounced as "the new colonialism" by some organizations in the region (provost et al., ) . the new alliance has benefited the biggest agribusiness multinationals through legal changes and new investor frameworks in african countries, while family and smallholder farming is to a great extent excluded. of new alliance projects, only three are led by producers' organizations (one each in burkina faso, benin and malawi). the agricultural model supported resembles that of the green revolution of the s and s, i.e., monoculture, mechanization, very heavy dependence on purchased inputs, long distribution channels and production for export. it also puts considerable emphasis on the role of biotechnology. by focusing narrowly on technology-driven productivity gains, this approach misses much of the complexity that underlies hunger, and ignores the ways that the interests of powerful actors affect food and agriculture. there is evidence that the alliance has supported the enactment of laws conferring intellectual property rights to plant breeders; this impinges on traditional farming practices such as saving, reusing and trading seeds (qiu, ) . a uk government fact sheet on the new alliance makes no mention of gender or women's roles in food security (dfid, n.d.), and a new alliance progress report published in points out that only % of smallholder farmers taking part in new alliance projects are women (acf et al., ) . a new trend in development finance is private finance (pf) blending: during the past years, donors and international agencies have increasingly sought to engage the private sector in development, using oda to "leverage" private finance through "blending" the latter with public resources. the data on how much oda is going into pf blending arrangements remain unclear (eurodad, ) . although the absolute figures appear still to be relatively low, it is expected that they will increase rapidly over the coming years. such a financing mechanism could benefit smallholders in low-income developing countries, including women, by de-risking the provision of credit for on-and off-farm activities. for example, ftf in ghana has worked with a local financial institution to expand the provision of microcredit in the northern part of the country, which has higher poverty rates than the national average (saarinen and godfrey, ) . a study of pf blending programs in agriculture found serious data limitations (both quantitative and qualitative). it concluded that "donors have more work to do to ensure that private finance blending is an effective tool for financing smallholder agriculture and promoting inclusive and sustainable transformation in the sector" (saarinen and godfrey, ). the following broad conclusions have been drawn from a analysis by eurodad and oxfam (which is not specific to agriculture and food security). pf blending poses risks to the quality of aid (eurodad, ): • it is less transparent and accountable than other forms of aid. • development finance institutions (dfis) that engage in pf blending often do not operate according to the principles of development effectiveness, particularly country ownership. • so far, there is inadequate evidence on impacts and inadequate monitoring and evaluation. • pf blending opens up the possibility of supporting donor-based commercial interests, rather than local smallholders. this increases the risk that it will support tied aid. blending also could drain oda resources from high priority development programs and is unlikely to offer an effective means to finance development in poorer countries or for the poorest farmers. based on return on investment considerations, pf blending resources tend to go to middle-income countries and are geared toward better-off farmer groups who already have access to resources and knowledge (eurodad, ; see also saarinen and godfrey, ) . a recent study by the overseas development institute (odi) reinforces these concerns. it found that, despite donor claims of high leverage ratios, each $ . of blended development finance from multilateral development banks and dfis in fact leverages just $ . in private finance. the figure falls to $ . for lowincome countries (attridge and engen, ). adaptation to climate change is also an issue that needs high-level funding if the world is to reach zero hunger. the united nations environment program (unep) has found that developing countries' annual adaptation costs could reach $ bn-$ bn by (unep, ), with much of those costs agriculture-related. pearl-martinez ( ) found that adaptation finance still accounts for less than half of all climate finance. only a very small share is targeted to smallholders; in , the figure was just $ m. the food price crisis of - generated a strong reaction and opened the door to civil society and the scientific community to push for a radical transformation of agri-food systems that would take account of environmental, social and health challenges and would promote fairness and sustainability, through balanced governance (bricas and goïta, ) . despite these opportunities, however, the governance of global food security is under threat and its shake-up after the food price crisis has not led to smooth coordination, coherence or convergence among the multiple stakeholders. multilateralism and global governance are more and more hybrid and fragmented: numerous parallel and overlapping initiatives and platforms deal with food security and operate without coordination. so far, they have not proved able to converge to attain sdg (zero hunger), (gender equality) or (combat the impacts of climate change). since the food price crisis, the decision-making center has shifted uncertainly between the cfa, the high-level task force on global food and nutrition security (hltf), the g , the g and the world bank and the international monetary fund (imf), with strong influence from the private sector. the decision-making power of the cfs has been reinforced since its restructuring, but its recommendations to member states remain purely advisory. paradoxically, food security governance has also been more concentrated among just a few actors since the food price crisis. after the crisis, we can identify four relevant types of international agency involved in food security governance: • general political direction: the g /g and the g . these groupings are powerful as they are dominated by richer countries, include all the main aid donors and can take big decisions at moments of crisis. even in the more broadly based g , the representatives of the global south are either bigger countries (e.g., indonesia), members of the brics group (e.g., south africa) or both (e.g., brazil, china and india). africa is represented only by south africa, while small island states, which are extremely vulnerable economically and climatically, are not represented at all. • development aid: e.g., wfp, the world bank, ifad, usaid, eu institutions, such private foundations as the bill & melinda gates foundation and the rockefeller foundation and private ventures like the alliance for a green revolution in africa (agra). the world bank and the imf wield outsized influence on countries through their loans, conditionalities, policy advice and technical assistance, much of which is followed by bilateral aid agencies as well (eurodad, ; stichelmans, dispute settlement mechanism is currently in crisis due to a withdrawal of cooperation by the us, which is seen in some quarters as an effort to undermine the organization (bey, ) . other analysts see us obstruction as part of that country's negotiating posture tied to its trade disputes with china, and note that the us continues to win a substantial share of the complaints it brings to the disputes body (hanke and von der burchard, ; lamy, ) . this fragmentation leads to a lack of coordinated policies and coherent governance, with strong competing perspectives. the un system has promoted a rights-based approach to food security through the cfs, encouraging the implementation of more holistic tactics to achieve the sdgs, advocating for sustainable food systems and agroecology, launching the un decade of family farming ( - ) and, in , adopting the un peasants' rights declaration ( un news, ) . on the opposite side, some aid donors have provided short-term responses that have not always been consistent with long-term needs. and in terms of policy, the response to the food price crisis served to reinforce the emphasis on productivity and producing more food "to feed billion by ," failed to address ecological challenges and the rights and practices of small-scale farmers and practically ignored gender inequalities (duncan and margulis, ) . increased multinational corporate influence within the governance landscape has resulted in a limited interpretation of sustainability. for example, some global supermarket firms include in their sustainability plans the integration of smallholder farmers into their value chains, including training in sustainable agriculture techniques. at the same time, the growing market power of these firms allows them to enforce production standards within those value chains and to determine contract terms (barling and duncan, ) . such private power often contradicts and undermines efforts undertaken by civil society actors and some states to promote a rights-based approach to food security (duncan and margulis, ) , and raises accountability questions. states continue to play a key role in global food security governance across the different platforms of engagement and at multiple scales (duncan and margulis, ) . however, the increased complexity of governance can permit states to pursue contradictory policy goals. they may place food security high on their policy agendas, strongly advocate for it in forums like the g or the g and provide contributions of aid for agriculture, but at the same time they may try to limit the political influence of the cfs and its multi-stakeholder process, prevent institutionalization of the human right to food as a fundamental principle of food security and pursue aggressive trade liberalization policies vis-à-vis developing countries (duncan and margulis, ) . the body that was supposed to give general political direction is the cfs, which was reformed in the wake of the food price crisis to be a broad, multistakeholder platform for food security governance, incorporating civil society organizations, in particular organizations and movements of the people seriously affected by hunger and undernutrition, as part of the decisionmaking procedures with the status of empowered (though non-voting) participants (mckeon, ) . this process is facilitated through the civil society and indigenous peoples' mechanism (csm). member states remain the principal decision makers and accountable stakeholders (mckeon, ) . this structural reform qualifies as a significant effort to address the underlying causes of the food crisis. however, the cfs faces a multitude of challenges, despite evaluations that find its work positive and pertinent; this is symptomatic of a global contraction of civil-society space in all governance platforms. the challenges concern (mckeon, ): • the actors-some governments do not wish to be held accountable; big corporate actors seek a privileged place at the expense of smallholders and civil society organizations (csos). • the process-some states favor technical and institutional solutions that privilege investments over public policies and make extra use of their red lines to prohibit discussion of certain topics. • the finances-inadequate funding of the platform constrains its potential. • the content-the agenda is overly influenced or controlled by a few states with strong vested interests in expanding current agriculture models while civil society voices and farmers organizations are marginalized. it took the csm several years to bring agro-ecology before the cfs, and debate on contentious questions such as food sovereignty, climate change, biofuels and the food and nutrition impacts of international trade liberalization remain taboo. in contrast, the g expanded its area of influence after the food price crisis, seeking to coordinate the global response. the g action plan did not address the root causes of the problem, however, and au countries criticized it for fostering continuing dependence on food imports in an era of volatile global prices. these countries demanded policies to support food self-reliance (wise and murphy, ) . the g includes the governments of some of the world's wealthiest and most powerful countries, as well as those of middle-income and developing countries that have no mandate to speak for other countries. this arrangement poses a problem of legitimacy, especially when the countries representing the global south in the group are major net food exporters, such as brazil (wise and murphy, ) . since the food price crisis the private sector, another key player, has acquired increasing influence over food security governance, adding another layer of complexity to the panorama of actors and decision making. the rhetoric of mobilizing "billions to trillions" to finance achievement of the sdgs (world bank, ) elevates the private sector and private finance to an ever more privileged position. a analysis examined the key elements of the growing influence of agri-food multinationals in discussions on the fight against hunger at a governance level (acf et al., ) and syngenta (now owned by bayer and chemchina, respectively) established or ramped up their philanthropic arms to engage in advocacy in international forums, including the cfs, as well as in discussions on trade and the environment. • multinational firms have proved influential in development discussions through their corporate social responsibility activities. their public relations efforts highlight the convergence of corporate and government interests and priorities. a good example is the food company nestl e's decade-long emphasis on "creating shared value" which, according to the firm, reflects "our ongoing commitment to achieving the un sustainable development goals…." (nestl e, ). • undertakings such as the new alliance and grow africa seek to mobilize private funds to overcome public sector disinvestment in the agricultural sector in developing countries. donors have established these entities to offer the private sector vehicles to promote their approaches, technologies and policy prescriptions. large philanthropies such as the rockefeller foundation and the bill & melinda gates foundation in particular have a great deal of financial clout: between and private foundations spent $ . bn on agricultural development, and % of these funds went to africa. over the same period, private foundations spent $ . bn on agricultural research, primarily on inputs and specifically seeds (mainly hybrids and genetically modified organisms (gmos)) (inter-r eseaux, ). their financial clout and investment mean that they exert influence over the agricultural models that developing countries adopt. organizations that have received substantial foundation funding, such as agra, have sought to shape the design of policies in africa: in ghana, the agra working group on seeds drafted corporateoriented amendments to the national seed policy that were submitted to the ministry of food and agriculture (inter-r eseaux, ). as the influence of private sector actors in food security policy has grown, it has tended to overwhelm that of small and family-owned business. corporate actors usually promote technological approaches to development, including high-external-input agriculture, and generally steer clear of any holistic rights-based approach. multinational firms also structure their own governance along top-down lines, leaving out farmers' organizations, organizations of rural women and women's rights organizations, national private sectors and civil society in general (inter-r eseaux, ). unstable and broken food system the lack of progress on realization of the right to adequate food for all-and specifically for women smallholder farmers-and thus on achieving sdg by results from instability in the factors that contribute to achieving food security, and this has led to food price volatility. all this is largely the consequence of gender-blind political choices that have failed to tackle the broken agri-food system. twelve years after the - food price spike, the main structural factors that marginalized women smallholder farmers have still not been addressed and the most likely food security scenarios do not seem to have become any more optimistic. according to the un report on the state of food security and nutrition in the world (sofi ), the number of hungry people globally rose by million in and by million over a -year period. looking at food insecurity thorough a different optic, the report also found that more than billion people ( . % of the world's population) cannot afford a healthy diet (fao et al., ) . the number of people facing acute food insecurity rose to million in (fsin, ). the number of african countries relying on external food aid rose from in to in (caramel, ) . early projections of the effects of the coronavirus pandemic suggest that it will have catastrophic food security consequences. sofi reports that covid- could add million- million people to the ranks of the hungry, depending on the depth and duration of the resulting global recession (fao et al., ) . the virus, combined with insecurity, extreme weather, desert locusts and economic instability will likely contribute to increased acute food insecurity as well (fsin, ) . violent conflict is the key factor in the severe food crises in south sudan and yemen (fsin, ) . according to the latest intergovernmental panel on climate change (ipcc) report (ipcc, ), there is already evidence of farmers migrating as temperatures increase, exacerbating inequality as those least able to cope are forced to uproot their lives. marginalized communities-including indigenous, pastoral, agricultural and coastal communities-will suffer the most as food and water become less available, health risks increase and their lives and livelihoods are jeopardized. women farmers remain on the razor edge of extreme shocks to the system and in a warming world, with a growing number of hungry people and more conflicts, they face ever greater risks. indeed, according to fao, "women are slightly more likely to be food insecure than men in every region of the world" (fao et al., : ) , especially if they live in rural areas, where poverty and food insecurity are very much linked, and especially in a context of increased reliance on markets and a decrease in subsistence agriculture. current food stresses are linked to prices and access to markets rather than to production (gaye et al., ) , but women are vulnerable in all dimensions of food security: availability, access, utilization and stability. twelve years on, food production has increased and remains adequate to feed all of the increased population in all of the world's regions. per capita food availability has increased globally over the past years (un women, ). nevertheless, climate change and its impacts on agriculture constitute a substantial threat to food availability. fao projects that global average cereal yields will decrease by %- % for each degree of warming . africa and a belt stretching from the middle east through south asia to mainland south-east asia and on into indonesia and the philippines are forecast to be the regions worst affected by disasters caused by natural hazards associated with climate change . this is likely to cause severe harm to harvests and external trade, among other things . it is also forecast to increase food prices, most of all in west africa and india; people's purchasing power is expected to decline by nearly % in west africa and . % in india (fao, ). reduced buying power will have severe impacts on rural poor people . climate variability and extreme weather events can have negative local impacts even when overall national food production figures look good, and this can lead to serious hunger problems in the affected areas . rural people in developing countries, who usually have low carbon footprints (pearl-martinez, ) and depend on renewable natural resources, are acutely vulnerable to climate shocks and natural hazards, which can result in devastating production losses and undermine their food security and nutrition . women have especially high vulnerability as they tend to have less access than men to the resources that can facilitate climate change adaptation, such as social capital, land, finance, credit, health, education, information, mobility and formal employment, and they frequently lack a seat at the decision making table pearl-martinez, ; quisumbing et al., ) . climate change related drought and water scarcity add to their gender-related workloads, such as collecting fuel wood and water (fao, ). even when food is available, poor and marginalized people may lack the resources to access it through purchase or production, and too often neither public social protection programs nor private charity reach them, if these even exist in poor countries (drèze and sen, ) . most often women are expected to find ways to cope with their families' hunger (un women, ) . within concentrated global and domestic value chains, women farmers are at risk because of their weak bargaining position: global food industries and supermarket chains play an increasingly prominent role in food supply, and access to food depends on income, price levels and social transfers, factors over which women have no power or in which they face discrimination (un women, ) . smallholders find that they are being driven out of markets, squeezed by corporate entities on both the input side (seeds, machinery) and the buyer side (traders, food industry, supermarket chains). willoughby and gore ( ) found that in the context of patriarchal norms and social practices, women feel the effects most severely. they are relegated to low-paying and often informal work within agri-food systems, are denied most socioeconomic and political rights and are under the threat of sexual harassment and violence. all these factors constrain their ability to access food. a survey of south african grape farm workers in found that over % said that they did not have enough to eat during the prior month. nearly a third said that they or someone in their family had missed at least one meal in that month (willoughby and gore, ) . when policies have been implemented to give women better access to markets, they have not necessarily been beneficial. entering into market relations usually brings large changes-negative or positive-to the ways that people live. these changes can alter relations within the household, to the benefit or detriment of women. in general, it is widely thought that direct access to income increases a woman's autonomy, but in the household economy it is not always that simple (britwum, ) . within farming households, there are often gender differences in revenue earning from crops. men tend to produce high-value crops, leaving women to cultivate traditional produce which may be rich in critical micronutrients but has been neglected by post-crisis policies that have primarily targeted cereal production to reach national sufficiency. an fao analysis of gender and cash crop production in ghana found that women cocoa farmers are as productive as men. but because they tend to be more cash strapped than male producers, women cultivators tend to use more labor-intensive and less high-tech approaches than men, which adds to their workloads (fao, c) . conflict also has gendered impacts on food security (fao et al., ) : • men tend to do the bulk of the fighting, leaving women in charge of household livelihoods and wellbeing. • violence can directly harm women, and can also reduce their capacity to provide for their families. • conflict related displacement also is a major reason for food insecurity, and affects women and children disproportionately. at the household level, women are frequently the ones who eat least, last and least well. increased poverty in female-headed households affects women's nutrition: to adjust to the decline in their capacity to purchase or grow highquality, diverse foods, they often shift to cheaper and less diverse diets, which frequently lack the key nutrients that pregnant women and young children require. as fao (n.d.) has observed, "more often than not, the face of malnutrition is female." in , global food insecurity rose for the third consecutive year , and women were the most affected: a third of the world's women of reproductive age suffer from anemia, usually due to iron-deficient diets. this also means risks for the health and nutrition of their children (fao et al., ) and has long-term impacts on development. worldwide, anemia is a contributing or sole cause of %- % of maternal deaths. anemic women are twice as likely to die during or shortly after pregnancy as nonanemic mothers . because anemia caused by iron deficiency results in reduced learning capacity and less productive workers, it is estimated to reduce gross domestic product (gdp) by % annually, particularly in african and south-east asian countries (world bank, ) . women's malnutrition frequently stems from poverty and unequal intrahousehold relations. women who have access to financial resources enjoy greater dietary diversity, and in rural areas women farmers who control resources tend to have better-quality diets (lourme-ruiz et al., ) . even when food is available and relatively accessible, people may not fully meet their nutritional needs. in countries where the calorie supply is adequate, there are still high levels of child stunting, e.g., bangladesh, burkina faso, ghana, mali and nepal (dury and bocoum, ; un women, ) . climate shocks, conflicts and social factors that increase women farmers' work burdens put their own health at risk and limit their ability to engage in recommended feeding practices for infants and young children . in many developing countries staples price volatility has persisted, with fresh spikes in and , and prices have remained above the level of the early s. in the face of volatile prices, people shift their income from other necessities to maintain their access to food, and this means that stable prices are a crucial element of food security (fao, ; murphy and schiavoni, ) . instability on the dimensions of food security over the past years has driven the failure to attain the right to adequate food. this is largely due to political choices concerning food security but also to funding, in terms of quantity, quality, targets and accountability. funding agenda to address women's food insecurity? . . an institutional step forward some major institutions have shifted their narratives to factor gender into their policies and strategies. the un agencies in particular have worked toward the empowerment of rural women and have helped reframe the agricultural development narrative. after the food price crisis, the rome-based un agencies developed their own gender strategies: • wfp-in wfp implemented its policy on gender equality for all its programs and projects through an action plan for operability in the field. the objectives were to bring an adapted approach to food aid considering specific needs, increase women's participation in program design, empower women and girls in decision making and protect women from sexual and gender-based violence (wfp, ). • fao-in march fao adopted its policy on gender equality. the objective was to better target women across all programs through disaggregated gender data and norms and standards in project formulation (fao, b). • ifad-ifad's gender strategy implemented in was articulated around three objectives: promote women's economic empowerment, ensure equal participation and influence within institutions and rural organizations and guarantee equity in workloads and in the share of extension services and economic value (ifad, ) . • in the cfs produced gender and nutrition policy recommendations (cfs, ), which included: affirmative action for women. enhancing women's role in food security decision making. enacting legislation to guarantee women's access to resources and services. • in october , fao, ifad, un women and wfp launched their joint initiative on accelerating progress toward the economic empowerment of rural women (un women, ) . it seeks greater leadership opportunities, better food security and higher incomes for women, as well as to foster greater gender awareness. in the face of inaction by governments, the un has taken a step further in legislating around gender inequalities in rural and agricultural sectors over the past years: the committee on the elimination of discrimination against women (cedaw) recognized the myriad challenges facing rural women in , noting that in many cases, the situation has worsened. the committee also indicated that states should therefore ensure, among other things, that macroeconomic policies, including trade, fiscal and investment policies, as well as bilateral and multilateral agreements, are responsive to the needs of rural women and strengthen the productive and investing capacities of small-scale women producers. they should address the negative and differential impacts of economic policies, including agricultural and general trade liberalization, privatization and the commodification of land, water and natural resources, on the lives of rural women and the fulfillment of their rights. the cfs forum on women's empowerment has pointed to significant gaps in policy implementation: countries have at least one law restricting women's economic opportunities, countries exclude women altogether from certain jobs and leave it to husbands to determine if their wives can work. this forum has urged states to uphold their commitments to rural women's rights under the convention on the elimination of all forms of discrimination against women (fao, c) . in , the cfs began work on a set of voluntary guidelines on gender equality and women's empowerment in the context of food security and nutrition. the un declaration on the rights of peasants and other people living in rural areas, adopted by the general assembly in , calls on states to take all appropriate measures to eliminate all forms of discrimination against peasant women and other women working in rural areas and to promote their empowerment in order to ensure, on the basis of equality between men and women, that they fully and equally enjoy all human rights and fundamental freedoms and that they are able to freely pursue, participate in and benefit from rural economic, social, political and cultural development. the world bank's world development report : agriculture for development recognized the importance of smallholder farmers, and especially women. it emphasized the significance of investment in smallholder-led agricultural development for poverty reduction after decades of development processes bypassing small-scale farmers, particularly women cultivators (world bank, ) . in the ensuing years, two broad agendas have emerged, with tools that call for more responsible investment in agriculture and tackling gender inequalities: the voluntary sustainability standards (vss), targeting mainly the private sector, and the responsible investment frameworks in agriculture (rifs), targeting mainly governments. important gaps remain in addressing gender inequality and empowering women farmers, and these tools have to be used in the appropriate context so that they work (sexsmith et al., ) . also in , the bill & melinda gates foundation established a gender policy for the agricultural projects that it supports. this seeks to ensure that women benefit and to track project impacts on women and their children and communities (coon, ) . however, since the food price crisis, there is scant evidence that policy responses have taken gender differentials into account, and research in this area is still patchy. decades of rhetoric about the greater vulnerability of women have borne limited results in policy action. this neglect is reflected in aid expenditures. oecd data show that overall bilateral aid targeting gender equality and women's empowerment as either a significant (secondary) or principal (primary) objective in all sectors combined was higher than ever before in - , corresponding to % of total aid. however, the aid activities marked with the principal objective remained consistently below a total of $ bn per year, representing only % of total bilateral allocable aid from development assistance committee (dac) members in - . dedicated support focused on gender equality and women's empowerment as the principal objective in the economic and productive sectors-which encompass agriculture and rural development-decreased from $ m on average annually in - to only $ m on average in - , representing less than % of aid to these sectors (oecd, b) . nevertheless, it is worth noting that out of that $ m, more than half ($ m) was committed to agriculture and rural development. even though agriculture is the main economic and productive sector for targeting gender equality, making gender a principal objective of aid to agriculture and rural development is still not high on donors' agendas. furthermore, it is important to bear in mind that even when donors tag their aid projects with the oecd gender equality markers, this does not necessarily mean that the projects advance gender equality or empower women. grabowski and essick examined aid projects carrying the markers and found that only two of them actually met all of the oecd's minimum criteria for using the gender equality project marker (grabowski and essick, ) . also, although strong women's rights organizations and movements are recognized as being particularly effective actors in bringing about sustained changes toward gender equality, aid going to these organizations remains extremely modest. in - , an annual average of $ m went specifically to women's nongovernmental organizations (ngos), and women's organizations in developing countries received just $ m of this (oecd, b). in agriculture in - , there was little attention to the gender-disaggregated effects of the food price crisis, including its nutritional impact, coping strategies such as withdrawing girls from school and worsening poverty among female-headed households. the work of agnes quisumbing and ruth meinzen-dick and their colleagues at ifpri (quisumbing et al., ) and fao's ( ) sofi are major exceptions. there is still no access to sex-disaggregated data in food security programs (see box ) (un women, ) . of fao's indicators on food security determinants and outcomes, just one is gender related (anemia among pregnant women) (un women, ) . lack of sex-disaggregated data on rural populations also hampers implementation of cedaw's provisions on the rights of rural women. data are also lacking in terms of donors' actual funding to support women in farming and adapting to climate change, and not all donors systematically report to the oecd creditor reporting system. moreover, oecd gender equality markers only indicate if a project targets gender equality and whether it is a mainstreamed objective or fundamental to a project's design and expected results. the markers do not distinguish the nuances between projects that target resources to women and those that aim to transform gender relations (grabowski and essick, ) . as pearl-martinez notes, because aid recipient countries fail to gather sexdisaggregated data, it is impossible to track whether oda reaches women box collecting high-quality, sex-disaggregated data for better prevention tools: the case of the harmonized framework. l since , the permanent interstate committee for drought control in the sahel (comit e permanent inter-etats de lutte contre la s echeresse dans le sahel, or cilss) has been developing and refining its harmonized framework (cadre harmonis e) for the analysis and identification of risk areas and vulnerable groups in the sahel and west africa. the framework is a tool for food crisis prevention and management, and can identify and analyze zones with populations at high risk of food and nutrition insecurity. the results of these analyses allow the classification of food insecurity on a severity scale and estimates of the most affected populations, as well as projections for lean periods. this tool, targeted at decision makers, could be more qualitative with the inclusion of gender analysis, for example by systematically collecting sex-disaggregated data and evidence. this first step could help characterize food insecurity through a gender lens, and thereby help to better target vulnerable populations. farmers (pearl-martinez, ) . tools exist that can be used to measure gender empowerment, e.g., the women's empowerment in agriculture index, which the us ftf initiative helped create. m such empowerment is essential for transforming rural women's roles in agriculture and food security, as well as for addressing the structural causes of hunger (coon, ) . more investments in agricultural development, even if they target small family farms, do not automatically benefit women and food security. the key questions related to whether agricultural development promotes gender equality include whether women are able to access resources, whether they actually can make decisions about the fruits of productivity and income gains and whether development efforts help them to meet their needs and aspirations (huyer, ) . the international institute for sustainable development (iisd) showed in that men and women do not benefit equally from foreign investments in agriculture (sexsmith et al., ) . though its analysis looks at private investments, some of the faults detailed are also found in publicly funded development programs: • foreign investors tend to reinforce existing inequality in land ownership and control by working only with men who have formal land rights. this can reduce rural women's ability to use common lands to meet household needs. • women frequently have difficulties accessing credit and extension services, and so may be excluded from contract farming schemes. these factors also prevent them from benefitting from agricultural innovations. • investors tend to overlook women's needs and thereby increase their workload, including their unpaid labor. foreign investments can increase household incomes, helping women to ensure that their families are food-secure, but if this requires producing export crops instead of food crops for the household's own consumption, it entails new food security risks, e.g., greater vulnerability to volatile global commodity prices and increased competition. • investment projects reinforce rather than transform gender divisions of labor, with women remaining in insecure and often informal jobs. m for further detail, the weai resource center at http://weai.ifpri.info/. • projects also tend to fail to change women's under-representation in cooperatives and agricultural worker organizations, and particularly in leadership roles in these groups. gender integration in agricultural development and food security policies and programs requires ex ante impact assessment to ensure respect for the "do no harm" principle, considering local social and cultural contexts and how these shape women's ability to participate in development activities. in particular, projects must consider who controls assets within the household and seek to redress inequities. failing to do so will simply reinforce existing gender norms and inequalities (quisumbing et al., ) . poorly designed agricultural development interventions can lead to the increased marginalization of women in decision making. too often, projects require beneficiaries to have minimum levels of education and access to credit, for example, prerequisites that wind up excluding women (dury et al., ) . a gender strategy can help project staff better understand the potential gendered impacts of their interventions, and who is likely to benefit (quisumbing et al., ) . boxes and discuss gender integration efforts in rural development projects in haiti and nigeria. haiti is the poorest country in the western hemisphere and has one of the most unequal income distributions on the planet. agriculture remains central to development in the country, accounting for % of employment and % of gdp. yet poverty pervades the haitian countryside, with % of the population living below the poverty line (compared with an overall national poverty rate of %) (ifad, n.d.; world bank, ). hunger and malnutrition go hand in hand with low incomes: % of all haitian households experience food insecurity and % of pre-school children are chronically malnourished (usaid-haiti, ) . rural women in haiti are especially vulnerable. according to a study for usaid, % of all haitian women are anemic. women are percentage points more likely than men to be unemployed, and on average they earn more than % less than men. in the countryside, rural women have inadequate access to land and participate less than men in high-value agricultural activities. box case study-food insecurity among rural haitian women. n -cont'd this affects the quantity and quality of the food that they are able to consume. in addition, nearly half of rural haitian women should be considered "not empowered," due to their heavy workloads (including many unpaid household responsibilities), lack of ability to make decisions related to agriculture and lack of membership in groups such as farmers' associations or cooperatives (rames et al., ) . in , the us government made haiti one of its ftf "focus countries." according to an assessment of avanse, the feed the future north project in haiti, the project provided women with %- % of the benefits (anglade et al., ) . so avanse can be characterized as "gender-sensitive," in that project staff explicitly sought to mainstream gender and include women and their organizations in activities (avanse, ). however, the project was not gender-transformative, as it did not challenge traditional gender roles in rural northern haiti. it engaged women in what is locally considered "women's work," e.g., small-scale, wholesale marketing of farm produce and the heavy manual labor of building soil and water conservation structures such as terraces and retaining walls. participating farmers at various project sites told the assessment team that "kek grenn fanm" (just a few women) were engaged in growing rice through avanse. the assessment recommended that agricultural development efforts in rural haiti such as avanse make more concerted efforts to consult with women farmers about their needs and priorities, and give them the opportunity to participate in all project activities, including production of all kinds of crops and livestock. box increasing disposable income for women's food security and empowerment in nigeria. food prices in nigeria have trended upwards since (samuels et al., ) , reaching a peak in that negatively affected poor consumers' access to food. in a country very dependent on imports of commodities, the agriculture sector represents a large part of the economy, employing % of working nigerians, mainly as smallholders with below poverty line incomes (matemilola and elegbede, ) . women farmers have less access than male cultivators to land, inputs, paid labor and extension services, and this means that they tend to grow and earn less. in response, many national and international programs have been implemented in nigeria (matemilola and elegbede, ) , but not many have targeted smallholder farmers and women. at a national level, nigeria is far from the % caadp target for agriculture's share of the national budget, with the figure remaining below % as of (mwanzia, ) . very little attention is given box increasing disposable income for women's food security and empowerment in nigeria.-cont'd to specific budget lines for women, youth and marginalized segments of communities. in , gender and youth were lumped together in the budget and only % of proposed projects for them were funded (mwanzia, ) . international initiatives have not tackled this issue either, but some programs, like the one described below, have tried to recognize the productive capacity of female small-scale producers and empower them to significantly reduce food insecurity. since , oxfam has led a village savings and loans (vsl) o program in nigeria, allowing small groups of - villagers to create a common savings fund from which all group members can take loans. one of the main goals of these groups is to increase women's access to financial resources, and eventually to empower women economically, socially and politically. women represent % of program participants. a - baseline study examined the vsl program's impacts on women's empowerment. one of the direct impacts is on community food security. in , some of the respondents, mostly women, reported having fewer than three meals per day in some villages, but in all respondents in all villages reported three meals per day. this improvement can be directly linked to the increased financial capacities of women participants. the following assertion from a woman beneficiary in the village of kebbi shows that vsl allowed her to diversify her household's sources of income, and gave her more choices in buying food to ensure household food security: "before joining the vsl group, i needed to seek permission to buy even soup condiments because the money comes from my husband. but after joining vsl, i am empowered and don't need to seek permission before making little purchases." the program has indeed had a positive impact on joint decision making at the household level because women now contribute fully to expenditures. "i now contribute with money to support my husband, and this is possible because i joined vsl," said a woman from adamawa state. another, from guyuk village, added: "when my husband sells a goat, we discuss how to spend that money. i am very happy, everything has changed." vsl has also contributed to a change of perceptions on women's social role and has reinforced their participation in community political decision making. a woman from kebbi reported: "since i joined vsl, i am being respected by all. often times, i am being included as an executive member of most committees constituted in my community." o the vsl is a methodology invented by care international in . since then, the vsl methodology has been implemented worldwide by several ngos, including oxfam. the authors are grateful to oxfam in nigeria for providing information on the program used here. a study analyzing policy documents in uganda found that the rhetoric of "gender mainstreaming" was well integrated, but that this was insufficient to advance gender equality, given the lack of concrete implementation efforts. the study also found that the documents used mainstreaming in a way that tended to depoliticize gender (acosta et al., ) . multiple food supply and demand factors triggered the food price crisis of - . price spikes also revealed how the structural evolution of the global food system has fomented inequalities in accessing food. the food price crisis denied the right to adequate food to whole categories of people who have suffered long-term impacts. women have experienced disproportionate effects because they face discrimination at both the societal level and within their own households, with profound effects on their right to food. the global response to the crisis has been very visible, with many actors involved and numerous commitments, new initiatives and instruments launched by intergovernmental bodies, countries, global donors and private stakeholders. however, funding has been insufficient and the policy response has mainly targeted production issues instead of focusing on the right to food, especially of women. after years, global food security governance is highly fragmented, with the power of a small number of actors increasing dramatically. those actors include major multinational corporations, the world bank and the imf and the g governments. the voices of the people who have been left food-insecure are seldom heard in policy discussions. funding targeted at women in agriculture is insignificant compared with other official funding, and this public disinvestment opens the door to other actors, such as multinational companies, which have taken a "business as usual" approach and make gender equality in agriculture a low priority at best. especially in light of climate change and increased conflicts, failing to address the structural causes of the food price crisis has put women even more at risk on all dimensions of food security. in order to start tackling these challenges, we offer the following recommendations: • developing country governments and donors should support inclusive agricultural transformation and create an enabling environment for both female and male farmers to exercise their rights. this should include reducing power imbalances and supporting national-level land reforms. • governments and donors must make women's economic empowerment in agriculture a high priority. actions should include greater support for women farmers' organizations and for developing markets for crops that women tend to produce. p • local communities, farmer organizations, rural women's organizations and other relevant civil society actors should be involved in the design of food and agricultural policies. governments and donors need to take a rights-based approach, including ex ante target group identification, ex ante gender analyses and affirmative action addressing the needs of women (e.g., extension services reaching out to them and employing female extension agents). special attention should be paid to ensuring that women participate in decision making at all levels. • policies and funding should support and promote women smallholder farmers in achieving sdg by facilitating the self-organization of women and women's organizations. • donors should encourage multilateral agencies, such as the world bank and ifad, to increase the share of their agricultural spending that supports gender equality. • development aid providers should increase the quantity and quality of aid and support to focus on women smallholders, promoting low-input, climate-resilient practices, particularly soil restoration, crop diversification and water conservation and management. • investments in small-scale agriculture should be combined with and complementary to other initiatives that seek to restore the rights and decision-making power of women smallholder farmers, including initiatives that seek to increase women's access to education and encourage families to share the responsibilities of unpaid care work, as well as legal efforts to give women the same rights as men. • developing country governments should increase public investment in agriculture, with a focus on both women and men smallholder farmers and sustainable, climate-resilient approaches to agricultural p for more on this recommendation, see willoughby ( ) . development, and should include specific line items in their agriculture budgets to support women farmers. • governments should ensure that women farmers' associations and women's rights organizations are able to participate in budget decision making. • african governments should make meeting and then exceeding their caadp pledges on allocating % of national budgets to agriculture a top priority. these budgets should emphasize public investment rather than recurrent spending such as salaries for public officials. • developing country governments should adopt national policies that prioritize food production and discourage the diversion of farmland to large-scale production of crops for export and biofuels. q • governments should create public databases on land ownership and the terms and conditions of large-scale land transactions. • donors should help strengthen developing country governments' capacity to negotiate with investors in large-scale land transactions. • governments should facilitate the participation of civil society, farmers' organizations and women's organizations in the development and governance of food reserves. bilateral and multilateral donors should provide financial and technical assistance to establishment of reserves. • agriculture policies should facilitate women's access to inputs, resources and services. • governments should develop accountability mechanisms to ensure that national and transnational companies do not violate land rights and should ensure gender equality in land governance. • governments should enact or enforce existing competition or antitrust legislation to regulate excessive private power in markets. governments should cooperate on a regional and global basis to enforce competition policies. • national seed policies and legislation on plant breeders' rights should ensure the right of women and men smallholder farmers to save, reuse, exchange and sell seeds. q for more detail, see bernabe ( ) . • developed country governments should increase climate change adaptation financing. • donors should increase efforts to promote gender equality through their bilateral climate adaptation finance by significantly increasing the share of adaptation projects that have gender equality as a principal (dac marker ) or significant (marker ) objective. collect sex-disaggregated data to assess gender inequalities in agriculture • research institutions and agrarian and economic policy forums should seek quality sex-disaggregated data, with strong gender indicators, from all actors, and especially from governments and donors reporting on gender policy markers. they should also lead robust qualitative research to understand women's and men's experiences in agriculture, rural development, food security and nutrition. • fao member states should defend the cfs by refocusing the governance of food security on this platform, reaffirming its sole legitimacy in global food security governance, guaranteeing the decision making and accountability of states and reinforcing the participation of csos. they should also allocate adequate funding to its activities to provide sufficient leverage for action, and adopt its recommendations into national laws and policy frameworks. ccfd-terre solidaire and oxfam france agriculture africaine: l'impasse des pôles de croissance agricoles discursive translations of gender mainstreaming norms: the case of agricultural and climate change policies in uganda is gafsp reaching small-scale food producers in malawi usaid's avanse project in haiti: an assessment of its conformity with aid 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partnerships in african agriculture ripe for change: ending human suffering in supermarket supply chains institute for agriculture and trade policy and the global development and environment institute (gdae) world bank framework document for a global agriculture and food security program (gafsp) food price hike drives million people into poverty global food crisis response program from billions to trillions: transforming development finance post- , financing for development: multilateral development finance the world bank in haiti world bank databank the authors wish to acknowledge the assistance of ranu key: cord- - swrn rv authors: einav, sharon; ippolito, mariachiara; cortegiani, andrea title: inclusion of pregnant women in clinical trials of covid- therapies: what have we learned? date: - - journal: br j anaesth doi: . /j.bja. . . sha: doc_id: cord_uid: swrn rv nan admission for % of pregnant women . there have been also case reports of severe covid- related cardiomyopathy, multiorgan failure and deaths in pregnant women . as the covid- pandemic spreads globally, an increasing number of patients are receiving experimental treatments, some within the framework of randomised controlled trials, and others as off-label or compassionate use. off-label or compassionate drug treatment is a recent editorial on drug use during pandemics stated that the "tragedy of not discovering new therapies during an outbreak cannot be repeated" . it also elaborated that "by participating in an rct, both patients and clinicians can benefit from the unique opportunity to directly contribute to the discovery of new therapies". however, there is ongoing tension between the bioethical and research consensus that pregnant women should be included in clinical trials and actual implementation of such inclusion in a reality where one in four medical lawsuits may be an obstetric case. we studied the approach towards recruitment of pregnant women to interventional clinical trials for covid- . to this end we searched the us national library of medicine registry (clinicaltrial.gov) for studies including the terms 'covid or coronavirus or sars-cov- ' up to th april . overall registered trials were identified. after applying a filter for study type ('interventional' trials), we identified trials which were retrieved and screened. duplicate trials, withdrawn or suspended trials and trials unrelated to the covid- pandemic were excluded. the data on the final included trials are presented in the table (table) . among the interventional trials registered, most declare pregnancy an exclusion criterion ( / , %). this is most striking in trials investigating the use of drugs ( / , . %). many trials altogether avoid mention of pregnant women in their inclusion/exclusion criteria ( / , %). several trials (including those on the use of chloroquine) suggest referring to "known" contraindications in order to determine whether a pregnant patient may be included. this tactic effectively deflects all responsibility (and liability) to the clinician. even trials investigating drugs with a relatively favorable safety profile (e.g. ascorbic acid), interventions or drugs already being used in pregnant women (e.g. ecmo, steroids) or those investigating low-risk non-pharmacological interventions (e.g. biological sampling for diagnostic/basic science purposes) exclude pregnant women. most importantly, there is a global lack of differentiation between the risk at various developmental stages of pregnancy (table) . a commonly cited excuse for non-inclusion of pregnant women in clinical trials is that pregnant women would be unwilling to participate. adult women and their families should not be patronized because they are pregnant; they should be given the choice to participate. they may be willing to participate if the intervention is presented favourably, it is not available outside the trial and when their contribution to scientific research is highlighted. as with any other patient, fulfilment of inclusion/exclusion criteria and informed consent are mandatory to safeguard the patient. on the one hand, experimental drugs are being used to treat pregnant women with covid- anyway . on the other hand, pregnant women with covid- are dying, perhaps with no treatment attempted. declarations regarding the need to include pregnant women in clinical research and obvious concerns for the wellbeing of this population time and time again fail to translate to actual practice. what should we learn from this situation? clarification of the approach to pregnant women should be mandatory during trial registration. trials excluding pregnant women should be required to justify doing so. referral to alternative sources with regards to risk should not be allowed. industry should be expected to cover insurance for all patients, including pregnant women. in the specific context of the covid- pandemic, experimental treatments offered to deteriorating patients within the context of a clinical trial in the hope that they may be of benefit should also be offered to pregnant women who deteriorate. we could learn much from the management of pregnant women whose lives are at stake during this pandemic wave. this opportunity should be embraced lest we need to explain to our daughters why we have learned nothing of use to them during this pandemic wave when they are pregnant during the next pandemic. the authors have no conflicts to declare. maternal and perinatal outcomes with covid- : a systematic review of pregnancies mode of delivery and clinical findings in covid- infected pregnant women in northern italy ( / / ) clinical manifestations and outcome of sars-cov- infection during pregnancy covid- infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals treating covid- -off-label drug use, compassionate use, and randomized clinical trials during pandemics we would like to thank hen y sela and carolyn weiniger for sharing with us their insights on the topic. key: cord- -f imrltt authors: weimer, louis h. title: neuromuscular disorders in pregnancy date: - - journal: handb clin neurol doi: . /b - - - - . -x sha: doc_id: cord_uid: f imrltt many neuromuscular disorders preexist or occur during pregnancy. in some cases, pregnancy unmasks a latent hereditary disorder. most available information is based on case reports or series or retrospective clinical experience or patient surveys. of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. anesthesia for cesarean section surgery requires special precautions in many disorders. the types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. disorders include carpal tunnel syndrome and other focal neuropathies, bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions. numerous neuromuscular conditions develop or preexist in women of childbearing age. some are immune or inflammatory disorders that may be influenced by pregnancy; processes can be incited, improved, or unaffected. some of the most common and most important conditions are reviewed (sax and rosenbaum, ; guidon and massey, ; massey and guidon, ; edmundson and guidon, ) . categories include focal and generalized neuropathy, neuromuscular junction disorders, acquired and hereditary muscle disorders, channelopathies, motor neuronopathies, and autonomic disorders. there are no rigorous studies to rely on with regard to most conditions; treatment advice is also often based on anecdotal case series or on retrospective chart data or patient survey. many conditions cause difficulty because of skeletal muscle but not uterine smooth muscle weakness that impacts labor and delivery. decisions to wean or continue medication treatments are important considerations-most commonly used treatments have animal but no reliable human information on pregnancy safety. the fda class for some examples is listed in table . . however, the fda removed this alphabet system effective mid- in favor of a narrative summary of drug risks during pregnancy and lactation and discussion of the evidence. however, the category system is still referenced and useful to many physicians and patients. the new system was intended to be phased in by , but that review process continues. therefore, a combination of details is presented in this section. some conditions, such as orthostatic intolerance or postural orthostatic tachycardia syndrome (pots), are often paradoxically lessened during pregnancy. episodic, recurrent numbness and tingling in the fingertips of the first three digits, characteristically more at night. nocturnal awakening that triggers hand shaking is highly characteristic. thenar muscle weakness or atrophy occurs only in severe or untreated cases. incidence varies considerably in published reports based on ascertainment methods. hand symptoms are relatively common, affecting up to % of pregnant women, but some older estimates are much lower. the italian cts study group surveyed women in their last trimester: % had a clinical diagnosis of cts, but only % had a positive electrophysiologic diagnosis (padua et al., (padua et al., , a . a common belief is that cts exclusively occurs in the third trimester; however, symptoms and findings can occur at any stage including the postpartum period. other risk factors include multiple births and age over (ekman-ordeberg et al., ; wand, ) . gestational diabetes was not a risk factor in one study (turgut et al., ) . also, contrary to common belief, symptoms often improve but do not resolve after delivery but can develop or persist postpartum. symptoms starting earlier in pregnancy are more likely to persist after delivery. one study noted frequent postpartum symptoms, but only % remained symptomatic at months and % at year (turgut et al., ) . however, a multicenter prospective italian study found % remained symptomatic at the same timepoint (pazzaglia et al., ) . in some cases, lactation can trigger cts symptoms that improve after weaning (wand, ) . conservative nonsurgical treatments including neutral angle or degrees cock-up wrist splinting or local steroid injections are often sufficient. one case of us fda category designations were removed june in favor of description and narrative discussion. however, the replacement system is incomplete, and these designations retain usefulness: (a) adequate and well-controlled studies found no increased risk; (b) no risk found in animal studies but insufficient human studies; (c) adverse fetal animal studies but no adequate human studies; treatment benefits may warrant use despite potential risk; (d) evidence of human fetal risk based on studies or marketing experience but benefit may outweigh risk; and (x) animal or human studies or other experience find fetal abnormalities so that potential benefit in pregnancy is outweighed by risk. na, not assigned. prospective and multiple sequential nerve conduction studies during pregnancy found early onset and symptom resolution with conservative measures during pregnancy, but responses took between and months postpartum to return to baseline values (weimer et al., ) . neuropathic pain medication is generally avoided during pregnancy. severe or refractory cases can be considered for carpal tunnel release surgery, done under local anesthesia, especially earlier in the pregnancy or after delivery. back pain is quite common during pregnancy and can be severe; about % of women are affected. sciatica is much less common, occurring in approximately % (ostgaard et al., ; padua et al., b) . in one patient-reported symptom-based study, a male fetus and prior back pain were positive risk factors but prior pregnancy was not. symptomatic root injury, producing sensory loss or weakness, however, is very uncommon-one older study estimated the incidence to be in , pregnancies (laban et al., ) . pregnancy-related pelvic pain and sacroiliac-induced pain can mimic a radicular pattern. exaggerated lumbar lordosis, direct uterine pressure, and hormonally induced ligamentous laxity are possible factors. pain often improves after delivery but can persist postpartum. treatment is generally conservative unless overt root injury develops. mri scans are feasible in more severe cases. successful and uncomplicated lumbar laminectomy is reported in refractory, severe cases (ostgaard et al., ; garmel et al., ; ng and kitchen, ) . neuropathic pain medications are generally avoided. the risk of idiopathic or a rare hereditary form of brachial neuritis increases mostly in the postpartum period (lederman and wilbourn, ) . typically, severe shoulder or neck pain occurs without provocation. as the pain subsides, muscle weakness is noted; certain patterns are typical, including scapular winging and anterior interosseous neuropathy. weakness is expected to slowly improve but recovery is sometimes incomplete. a rare hereditary cause of recurrent brachial neuritis, known as hereditary neuralgic amyotrophy, can be unmasked. a mutation in the septin (formerly sept ) gene is causative. one case of in the cleveland clinic series suggested that pattern (lederman and wilbourn, ) . entrapment or injury to the lateral femoral cutaneous nerve produces sensory loss or paresthesia in the lateral thigh known as meralgia paresthetica-the neuropathy produces purely sensory symptoms and no objective weakness. weight change, compressive bands, low belts or constrictive garments are recognized risk factors. hip hugger jeans are an example. the nerve is also vulnerable during hip flexion during delivery and by retractors during cesarean section surgery. identification and behavior or garment changes can help. neuropathic pain medications are avoided while pregnant. femoral neuropathy rarely occurs during pregnancy. rates of nerve injury have declined over time with refinements in obstetric care, such as better attention to prolonged lithotomy positioning (al hakim and katirji, ) . one retrospective study found femoral neuropathy affected . % of live births. nerve injury causes isolated thigh and medial lower leg numbness (saphenous nerve), quadriceps weakness, and reduced or absent knee deep tendon reflex (wong et al., ; guidon and massey, ) . the iliopsoas muscle that controls hip flexion variably arises from the proximal femoral or distal lumbar plexus and may be affected. if hip adduction is also affected, a more proximal plexus or root injury is supported. risk factors include primiparous women and prolonged labor. recovery time depends on the severity of axonal injury but often takes weeks to months to improve (rowland et al., ) . obturator neuropathy is rare and primarily occurs during delivery. the nerve travels very deeply in the pelvis and innervates most of the hip adductors and a sensory patch on the medial thigh and occasionally in the upper medial calf. obturator neuropathy can cause medial thigh numbness and pain and hip adductor weakness. because of the deep position, injury is otherwise quite rare, except in severe trauma or infiltrative processes. during labor and delivery, the fetal head can compress the nerve against the pelvic wall; forceps can also cause injury. prognosis is related to the degree of injury and nerve axonal loss. electrodiagnostic studies can distinguish this neuropathy from radiculopathy, plexopathy or femoral neuropathy. however, obturator nerve studies are more challenging because of the deep location. bell palsy is an acute unilateral peripheral facial neuropathy that is typically idiopathic. reduced lacrimation, hyperacusis, or loss of taste sensation may accompany facial muscle weakness. involvement of the forehead muscle (frontalis) can help distinguish from central causes of facial asymmetry. the course may progress to maximum weakness over days, followed by recovery of some, if not all, functions over several months. more severe cases develop complete paralysis. most studies support an increased incidence in pregnancy, especially in the third trimester and immediate postpartum periods. the condition must be separated from central conditions that occur in late pregnancy or immediately afterwards; examples include ischemic or hemorrhagic stroke and venous sinus thrombosis. bell palsy rates range from to times that of nonpregnant women of childbearing age. hilsinger in reported rates of and . per , in pregnant and nonpregnant women, respectively (hilsinger et al., ) . a more recent prospective italian series found pregnancy to have an increased odds ratio of . , compared to the general population, but only two pregnancy-related cases were included (monini et al., ) . some reports suggest that pregnancy-associated facial neuropathy is more severe and more likely to be complete, leading to a worse prognosis. one retrospective study found about half of pregnant women with severe or complete facial paralysis significantly improved, compared to % of others (gillman et al., ) . in contrast, a very large and recent retrospective korean study found no association with bell palsy and pregnancy or postpartum periods (choi et al., ) . that study compared over , pregnancies to over , controls employing the national korean health insurance review and assessment service. the extrapolated annual incidence of bell's palsy per , women during pregnancy was . %, and in the control group, it was . %; postpartum rates were . % in the patient group and . % in the control group. pathogenic mechanisms that may differ in pregnancyrelated bell palsy include altered immune tolerance, hormonal effects on fluid shifts, increased herpes simplex or varicella viral susceptibility, and vasa nervorum thrombosis (hilsinger et al., ; falco and eriksson, ; shmorgun et al., ) . risk factors include essential or gestational hypertension, preeclampsia, and obesity (falco and eriksson, ; shmorgun et al., ) . not surprisingly, treatment considerations are more complicated. the american academy of neurology treatment guidelines concluded that corticosteroids are highly likely to be effective and should be offered in the acute setting (level a); antiviral agents may provide modest benefit (level c) (gronseth et al., ) . however, understandably, pregnant women were excluded from all studies considered for this consensus recommendation. corticosteroids, including prednisone, are prescribed to pregnant women with bell palsy and other conditions despite some concerns of fetal toxicity, especially at high dose. prognosis is dependent on the degree of nerve injury; however, the facial nerve typically recovers better than most other peripheral nerves. one study found further evidence that facial neuropathy is more severe in pregnancy-associated cases despite corticosteroid treatment (phillips et al., ) . antiviral treatments are more controversial given the unproven benefit. one danish study found no increase in birth defects in a large cohort of women exposed to acyclovir, valacyclovir, and famciclovir, compared to other pregnant women in the first trimester (pasternak and hviid, ) . eye patching or lubricating drops and nocturnal ointment should be used in cases of severe eye closure weakness to prevent ocular dehydration injury. fibular (peroneal) neuropathy causing acute foot drop must be distinguished from acute l radiculopathy or lumbosacral plexopathy. nerve stretch can occur due to several factors, including prolonged squatting during childbirth, external compression by inappropriate stirrup leg positioning, or hyperflexion of the mother's knees (babayev et al., ; wong et al., ) . prognosis for recovery is generally good unless the nerve injury is severe. a rare condition, hereditary neuropathy with tendency for pressure palsy caused by a deletion of the pmp gene-the same gene that causes charcot-marie-tooth (cmt) type a discussed later-is particularly vulnerable to fibular neuropathy and related foot drop. radial neuropathy was reported in two unusual situations. one case was attributed to compression from prolonged use of a birthing bar (roubal et al., ) ; another case was caused by a compressive synovial cyst that required surgical intervention (hsiao et al., ) . intercostal neuropathy causing isolated pain and numbness in a thoracic dermatome is described sometimes as thoraconeuralgia gravidarum or intercostal neuralgia (pleet and massey, ; skeen and eggleston, ) . the condition is said to spontaneously improve or resolve-autoimmune or inflammatory causes similar to brachial neuritis are suspected. pregnancy does not specifically cause generalized or polyneuropathy. most forms of polyneuropathy affect the longest nerves exclusively or more severely, leading to the stocking-glove distribution. most neuropathy cases affect sensory more than motor fibers. there are many exceptions that include disproportionate sensory ataxia, weakness, or asymmetry. the exceptions are often caused by inflammatory or immune mechanisms. glucose intolerance and gestational diabetes can signal the start of longstanding blood sugar issues and later diabetic neuropathy. autoimmune or inflammatory conditions in general may change during pregnancy-both acute inflammatory demyelinating polyneuropathy or gbs is an acute or subacute onset of ascending weakness, sensory loss, and areflexia-a nadir by definition occurs within weeks after onset. incidence is about . - cases per , population. patients may progress to severe weakness or paralysis. facial, cranial, and autonomic nerve involvement occur in severe cases that can progress to respiratory insufficiency, autonomic instability, and protracted recovery. there is no evidence that the condition is more common during pregnancy, but many pregnant women develop gbs by coincidence, usually in the second and third trimesters. however, incidence seems to be about three times higher in the days postpartum (chan et al., ) . before the advent of immune treatments, such as intravenous immunoglobulin and plasmapheresis, significant morbidity and mortality occurred in pregnant women with gbs (chan et al., ) . typical infectious triggers such as campylobacter jejuni gastroenteritis occur but may be less common in pregnant women (rees et al., ) . cytomegalovirus (cmv), a known gbs trigger, seems to more problematic. pregnant women have a similar underlying seropositivity to the general population, roughly %; however, mothers with cmv and gbs may have more severe respiratory involvement and worse neonatal outcomes (araki et al., ; lupo et al., ) . some advocate testing all pregnant women with gbs for cmv. zika virus is associated with increased gbs risk (krauer et al., ; muñoz et al., ) . a systematic review of zika-related complications during pregnancy found one report of a pregnant woman with confirmed zika infection who developed gbs at weeks gestation; she recovered and delivered a healthy infant (chibueze et al., ). an association of gbs to the novel coronavirus covid- is suspected but not yet established. standard treatment using either plasmapheresis or intravenous immune globulin (ivig) is generally safe; significant treatment-related complications are rare. both are effective. some prefer to avoid plasmapheresis because of fluid shifts that can trigger hypotension and potentially endanger the fetus. a large italian series reviewed plasmapheresis complications of procedures during pregnancies; treatment indications were various and included some for myasthenia gravis (mg). they found only % had significant adverse events; none required hospitalization or extended ongoing hospitalization (colpo et al., ) . fewer risks and complications are present for ivig during pregnancy but concerns include volume overload, hyperviscosity, and hypercoagulability. termination of pregnancy does not shorten gbs disease duration or improve maternal outcome (chan et al., ) . interestingly, cases that progress to complete paralysis continue to demonstrate normal fetal movements, supporting a lack of placental transmission of the causative factors in most cases. one notable exception reported hypotonia and respiratory distress in a newborn that received successful treatment of both mother and child (luijckx et al., ) . gbs does not significantly affect uterine contractility so that vaginal delivery remains the preferred route. epidural anesthesia is considered to be generally safe in this setting, though one case of acute worsening was reported (brooks et al., ; wiertlewski et al., ) . succinylcholine should be avoided for cesarean section induction (brooks et al., ) . induced preterm delivery is common- % in one large series-mostly because of maternal neurologic decline (chan et al., ) . the need for cesarean section surgery should be based on obstetric indications. prevention of complications from infection and venous thromboembolism is critical, especially in the postpartum period. chronic inflammatory demyelinating neuropathy (cidp) of various subtypes causes proximal and distal weakness, sensory loss, and reduced deep tendon reflexes; most forms are relatively symmetric but an asymmetric form is well known. the syndrome is distinct from gbs but many features overlap. the course may be relapsing or progressive; immune treatments are typically highly effective. onset is most common between and years, but onset also occurs in younger ages, including in childhood and teenage. cidp in pregnancy is uncommon but described. one study reviewed women of childbearing age with cidp; became pregnant. of these , developed cidp during pregnancy, and the disease flared in the other with-the authors concluded that cidp risk increases during pregnancy (mccombe et al., ) . a tendency for symptoms to worsen during the third trimester or during the immediate postpartum period was noted. corticosteroids can be used in cidp but are often not necessary. steroid-sparing therapies such as azathioprine (category d) are generally avoided during pregnancy. plasmapheresis can be used for refractory cases. multifocal motor neuropathy (mmn) is a separate and distinct syndrome that causes chronic and multifocal, typically distal weakness in specific nerve territories. a minority of cases are associated with gm ganglioside igm antibodies. conduction block is demonstrated on electrodiagnostic testing in many. intravenous immunoglobulin is the preferred and fda-approved therapy. exacerbation of existing weakness or new weakness is known to occur during pregnancy despite treatment; findings generally return to baseline after delivery (chaudhry et al., ) . ivig is generally continued during and after pregnancy. corticosteroids and plasmapheresis are contraindicated in this disease. one case of suspected transplacental transfer of pathogenic gm ganglioside antibodies was reported (attarian et al., ) . the mother had mmn and underlying iggl monoclonal gammopathy. the fetus had decreased movement; the infant had distal weakness and hyporeflexia; and weakness and atrophy persisted at age years. hereditary motor and sensory neuropathy also known as cmt is a prevalent condition affecting roughly in individuals. many subtypes and specific genetic forms are known but cmt a, caused by a duplication of the pmp gene is by far most common. that condition causes progressive distal weakness, areflexia, pes cavus, and associated orthopedic issues. onset is generally in the teens or soon afterwards so that the condition is often known prior to pregnancy. penetrance is variable. autosomal dominant inheritance is most common, though x-linked and recessive forms are known. data on pregnancy effects are sparse. in general, cmt patients demonstrate no increased risk of miscarriage, fetal malformations, or hypertensive complications. about % of patients self-report worsened weakness while pregnant that tends to improve in about a third and not improve or worsen in others afterwards (rudnik-sch€ oneborn et al., ; awater et al., ) . women with cmt have a higher occurrence of presentation anomalies and postpartum bleeding (hoff et al., ) . the rate of operative delivery or forceps requirement was - times more frequent than for others. the majority of cmt cesarean sections were emergencies. epidural anesthesia is employed when needed. succinylcholine should be avoided if intubation is needed because of concerns that it may induce hyperkalemia. most other forms of hereditary neuropathy are too rare or severe to have sufficient pregnancy data. myasthenia gravis (mg) the autoimmune condition mg causes fluctuating and fatigable muscular weakness-bulbar muscles are particularly vulnerable. ptosis, diplopia, dysarthria, and dysphagia are common manifestations. ocular myasthenia is the term used for isolated ptosis and diplopia but without any other impairment. more severe cases demonstrate muscle weakness, notably proximal. myasthenic crisis is characterized by severe weakness, severe dysphagia, aspiration, and respiratory insufficiency that requires urgent or emergent intervention. the majority of cases, up to %, demonstrate antibodies to the alpha subunit of the nicotinic acetylcholine receptor (binding antibodies). additional cases are associated with muscle-specific kinase (musk), agrin, or lipoprotein receptor-related igg (lrp ) antibodies. the remainder of cases supported by clinical and electrodiagnostic features are seronegative, roughly %. the overall incidence estimates range from about to per , (macdonald et al., ) ; an estimated excess of , people worldwide are affected (sanders et al., ) . a bimodal age distribution is well documented but is, overall, more common in women. women of childbearing age constitute one large spike peaking in the second and third decades; older men make up the other group, who more often have an underlying thymoma. as a result, pregnancy and mg are a relatively common cooccurrence. congenital myasthenic syndromes are rare genetic defects affecting components of the neuromuscular junction, nerve terminal, or muscle. these conditions are quite rare and distinct from autoimmune mg. transient neonatal mg is a relevant topic discussed later. pregnancy-induced disease severity alterations and treatment adjustments are important clinical considerations; a multidisciplinary medical approach that includes an obstetrician and neurologist is best (norwood et al., % of mildly affected patients became relatively severe. about % paradoxically improved, and the remainder did not change. exacerbations tended to be early or late in the course, though one review found the second trimester most critical (ducci et al., ) ; alterations within months postpartum were also noted. in the same review, transient neonatal mg occurred in . % of live-born infants-no predictors were found. mg associated with musk antibodies demonstrates some clinical and treatment differences. the entity represents about %- % of mg cases overall. african americans and women overrepresent with musk, compared to other mg forms. onset in women tends to be slightly later than achr seropositive patients, peaking in the s but still overlapping with childbearing age. patients tend to demonstrate more proximal limb, bulbar, and ocular weakness but typically do not have purely ocular disease; tongue atrophy, muscle cramping, and twitching can occur. respiratory involvement and disease crises are a risk. one portuguese series retrospectively examined the pregnancy course in musk positive women, of which had more than one pregnancy ( total pregnancies studied) (santos et al., ) . all were on steroids at the time of conception, one on azathioprine and another on ivig maintenance infusions. only mild pregnancyinduced changes were noted, but some required medication titration. no changes were considered to be relapses. mg onset during pregnancy is also well described. seropositive patients with typical symptoms and signs are straightforward to diagnose, but treatment options are narrowed. seronegative patients may require additional testing such as repetitive nerve stimulation or single fiber electromyography to confirm the diagnosis, in part to consider treatment and to guide delivery management. to assess for thymoma, an increased risk in mg patients, a chest ct is typically the care standard. during pregnancy, a chest mri may be indicated depending on the pregnancy stage; if late in pregnancy, the study is often deferred until after delivery. the treatment of mg is more complex than other neuromuscular disorders, in part because so many effective therapeutic options are available. family planning in known mg patients should be proactive so that treatments can be optimized or tapered prior to conception. counseling in advance is prudent, including the risks for individual ongoing and potential therapies. thyroid status should be addressed and optimized prior to pregnancy. some options are strictly contraindicated, but many have limited available medical evidence for pregnancy risks. pyridostigmine (mestinon) is an initial and effective treatment for all mg stages. it has been used for decades. because of pregnancy-induced changes in intestinal absorption and renal clearance, the pyridostigmine dose may need titration. no fetal risk is known despite longstanding use in pregnancy. prednisone or prednisolone is typically continued during pregnancy. corticosteroid risks are discussed earlier, but an optimized dose prior to pregnancy is prudent. some early studies suggested steroids increased cleft palate risk, but later case-controlled studies did not replicate the findings. treatment can also suppress normal adrenal output so that stress steroids may be needed during labor and delivery to avoid acute adrenal insufficiency. in general, initiating a new steroid-sparing agent is avoided, if possible, by most practitioners. azathioprine (imuran) is the most common steroid-sparing agent. the agent, previously rated category d by the us fda, is generally avoided in the united states primarily because of teratogenic effects in laboratory animals and reported hematologic effects in some newborns. because of this concern, use during pregnancy is rare in the united states. however, azathioprine remains a recommended option in europe (norwood et al., ) , mostly based on experience treating various rheumatologic conditions (ostensen et al., ) and using similar agents such as -mercaptopurine to treat inflammatory bowel disease (francella et al., ) . no detectable drug was found in neonates of breastfeeding mothers who had been treated (sau et al., ) . because of some ongoing use during pregnancy, this drug and others discussed are part of a national transplantation pregnancy registry to track effects. a recent meta-analysis including a large cohort of contributors concluded that available human studies are lacking to answer the question of azathioprine exposure risk during pregnancy (belizna et al., ) . mycophenolate mofetil (cellcept) was initially classified as category c but was downgraded to category d in prior to elimination from the fda rating system in ; birth defects and serious teratogenic concerns during pregnancy were recognized. a typical clinical syndrome includes hypoplastic nails, shortened fifth fingers, diaphragmatic hernia, microtia, micrognathia, cleft lip and palate, and congenital heart defects-quoted risk is as high as % (sifontis et al., ; ostensen et al., ; norwood et al., ; perez-aytes et al., ) . in general, treatment is tapered off prior to pregnancy. calcineurin inhibitors such as cyclosporin or tacrolimus are occasionally used to treat mg and show no known teratogenic effects, but there is some concern for spontaneous abortions, prematurity, and low birth weight; the agent may also aggravate gestational diabetes. methotrexate is strictly contraindicated during pregnancy (former category x). thymectomy is demonstrated to benefit mg course, reduce steroid dosage, and increase remission likelihood; the benefit persists for multiple years (wolfe et al., , . thymectomy during pregnancy is rarely indicated unless a benign or malignant thymoma is discovered. because of the long-term potential benefit, surgery prior to a planned pregnancy is a consideration in generalized seropositive mg patients. mg crisis or inadequate steroid control may require rescue or more aggressive treatment. for mg crisis both plasmapheresis and ivig are indicated. the risks for each were reviewed earlier with reference to gbs treatment. clinical use for maintenance therapy with ivig has steadily increased, but mg is not an indication recognized by the us fda, so that use is technically off-label. rituximab (rituxan) is an option in refractory seropositive mg, especially for musk positive cases. treatment is generally considered to be safe despite some animal toxicity concerns. the newest and most expensive treatment option is the humanized anti-c antibody, eculizumab (soliris). treatment is reserved for refractory seropositive mg patients that are uncontrolled despite all other options, including ivig and plasmapheresis. pregnancy risk information is limited. however, usage is currently generally regarded to be safe (sarno et al., ) . experience from use in various hematologic conditions is available, mostly hemolytic uremic syndrome. vaccination for meningococcal meningitis is required prior to treatment. some differences are evident in musk mg patients. pyridostigmine is less often helpful. the course tends to be less responsive to ivig, but that treatment is still used. patients often respond to plasmapheresis. musk positive patients were specifically excluded from thymectomy trials. in addition, a lack of benefit is generally accepted, so surgery is not indicated for these patients. agrin and lpr seropositive patients seem to respond to treatment similar to achr positive patients. ongoing prenatal care, including fetal monitoring is expected. spontaneous delivery at term is the goal, provided there is no deterioration in the mother's myasthenic control (norwood et al., ) . of all potential labor and delivery difficulties, only premature membrane rupture is more common. infection-induced disease flares are a concern, notably urinary tract infections, especially in women on immune suppression. infections should be treated; however, aminoglycosides, fluoroquinolones, and macrolides can aggravate the condition. for delivery, conventional epidural or spinal is accepted and preferable to general anesthesia, including women that need cesarean section (c-section). opiates should be avoided because of potential respiratory depression in mother or fetus. calcium channel blockers and b-blockers are also generally avoided. stress steroids for women on ongoing steroid therapy were previously discussed. mg affects skeletal muscle and not smooth muscle uterine contractions, so that impairment in early labor stages is not expected. mothers can fatigue in later stages so that assisted delivery may be needed. in one study c-sections were more common in mg patients, but assisted vacuum or forceps deliveries were no more common (hoff et al., ) ; another taiwanese study found no difference in c-section rates between mg patients and others (wen et al., ). magnesium sulfate is generally avoided for eclampsia prevention because of potential interference with calcium influx in the nerve terminal and aggravating acetylcholine release. one case of severe magnesium-induced muscular weakness in a previously minimally affected patient was reported (bashuk and krendel, ) . if eclampsia-induced seizures develop, magnesium sulfate can be given with extreme caution but intubation is expected. appropriate anticonvulsants can be used instead. if a c-section is required, general anesthesia presents potential concerns. typical intubation utilizes a muscle relaxer, such as succinylcholine. mg patients are particularly sensitive to these agents; so they should be used at low dose or not at all. if needed, a peripheral nerve stimulator must be used to monitor the effect. other agents to initiate or maintain anesthesia, such as propofol and volatile anesthetics, are used. despite these delivery concerns, there is no evidence of increased rates of premature birth, reduced birth weight, congenital malformations, or infant mortality (hoff et al., ; wen et al., ; guidon and massey, ) . breast feeding is not contraindicated, including for women on active immune therapies. transmission of antibodies to newborns is well recognized; this can transiently complicate functions. hypotonia, dysphagia, and respiratory difficulties are most concerning-other findings include ptosis, eye muscle weakness, and other bulbar weaknesses. the incidence of transient neonatal mg ranges from % to %, depending on the series, though most infants demonstrate transient antibodies in seropositive mothers. because the mother's mg disease severity seems to bear no predictive value for this entity, neonatologists must screen newborns carefully. in some cases, transplacental passage of antibodies occurs, resulting in reduced fetal movement and postnatal weakness. there are some exceptional cases of antibodies to the fetal achr g subunit that can result in severe or sometimes fatal fetal arthrogryposis (vincent et al., ; oskoui et al., (lee et al., ) . she delivered a normal infant who quickly developed hypotonia and respiratory failure requiring mechanical ventilation for weeks. the mother later worsened, and musk antibodies were uncovered on further evaluation. anti-musk-mediated transient neonatal mg was presumed. this form appears to be less common but more severe (niks et al., ) . autoimmune lambert-eaton myasthenic syndrome (lems), not from a lung cancer associated paraneoplastic syndrome, can occur in women of childbearing age. three notable cases have been reported. one patient had an uncomplicated, successful delivery; another had a child with a week of severe neonatal weakness and infant voltage gated calcium channel antibody seropositivity reuner et al., ) . another previously asymptomatic woman developed third trimester weakness that led to a new lems diagnosis (bayrak et al., ) . the only fda-approved therapy amifampridine (firdapse), previously known as , -diaminopyridine, is highly effective and, often, transformative for affected patients. the drug is associated with fetal animal toxicity but no documented human pregnancy-related concerns. autoimmune forms of myositis are uncommon, representing about . - cases per , population (munira and christopher-stine, ) . the most common forms, polymyositis and dermatomyositis cause symmetric proximal limb weakness, variably increased creatine kinase, and sometimes dysphagia, head drop, or respiratory compromise. the pathophysiology differs between the two. polymyositis is almost always a component of a generalized rheumatologic or systemic condition, such as mixed connective tissue disease, systemic lupus erythematosus, or rheumatoid arthritis; some have antisynthetase syndrome. dermatomyositis is distinct and manifests as variably impacted muscular and characteristic skin manifestations. muscle pathology shows differing and distinctive features. both occur during childbearing ages. in general polymyositis tends to have more severe weakness, but most pregnancy-related literature lumps the two conditions. sporadic inclusion body myositis is often classified in this group but is not a simple autoimmune condition and almost always occurs after age ; so that entity will not be discussed further. necrotizing myositis is a more aggressive and severe form that requires aggressive immune treatment. fortunately, the combination of necrotizing myositis and pregnancy is rare. pregnancy does not appear to affect disease activity for the mother. however, disease activity and general health of the mother greatly impacts fetal risk. patients with controlled disease or remission have low risk of complications and generally good outcomes for both mother and child. in contrast, active disease is associated with increased fetal mortality, low birth weight, and prematurity (silva et al., ; váncsa et al., ; nagy-vincze et al., ; zhong et al., ; che et al., ) . a large and recent retrospective series from india reviewed pregnancies resulting in only live births, though some were voluntarily terminated (gupta et al., ) . mothers also have longer hospital stays, more hypertensive complications, and higher c-section rates but no other labor or delivery complications (kolstad et al., ) . neither condition is transmitted to the newborn but interestingly, two asymptomatic newborns were noted to have elevated creatine kinase levels for a few months (messina et al., ) . initial disease onset during pregnancy is rare, but that group may have the highest infant mortality, nearing % (silva et al., ; munira and christopher-stine, ) . similar to mg patients, uterine smooth muscle is unaffected but voluntary muscles necessary for labor can fatigue, requiring c-section in some cases. transient spikes in creatine kinase can indicate muscle breakdown after excessive muscular activity. treatment considerations during pregnancy are similar to mg. corticosteroids are the mainstay of treatment. ivig can be used in refractory patients (williams et al., ; nozaki et al., ; linardaki et al., ) . other usual immune therapies or steroid-sparing agents are highly problematic and discussed earlier, such as azathioprine (category d), methotrexate (category x), mycophenolate (category d), and cyclophosphamide (category d). in refractory cases, severe disease may require aggressive treatment. one was a case of a -year-old woman with myositis associated with antisignal recognition particle antibody. she was in remission on a combination of oral prednisolone and rituximab every months that was stopped prior to a planned pregnancy. treatment was restarted at weeks gestation without complication, despite concerns for rituximab treatment later in pregnancy increasing the risk of neonatal b-cell depletion and cytopenia (mehta et al., ) . similar to other autoimmune diseases, patients on prednisone at the time of delivery should be treated with stress steroids to prevent acute adrenal insufficiency (briemberg, ) . hereditary and genetic entities represent a higher percentage of muscle disorders than most other areas of neurology. a variety of types of conditions that impact pregnancy are considered in this chapter. there are too many individual conditions to address all, but some groups are detailed. dystrophinopathies caused by multiple different mutations or deletions in the dystrophin gene are the most common form of muscular dystrophy. both duchenne and becker muscular dystrophy are x-linked disorders that overwhelmingly affect males. however, female carriers can manifest symptoms and signs (ishizaki et al., ) . information on pregnancy and delivery of these symptomatic patients, however, is very limited. myotonic muscular dystrophy is the second most common muscular dystrophy and most common starting in adulthood. prevalence is - per , (guidon and massey, ) . myotonic dystrophy type i (dm ) is a multisystem disease caused by an excess of ctg repeats in the dystrophia myotonica protein kinase (dmpk) gene. the number of repeats correlates with disease severity and onset age. typical symptoms include muscle weakness, cramps and stiffness (myotonia), cardiac conduction delay, endocrine dysfunction, and early cataracts. of note, mothers with this condition often have children with more severe disease and expanded repeats that can present in infancy (anticipation). in that instance, the term congenital myotonic dystrophy is employedthe risk for affected mothers is approximately one-third (rudnik-sch€ oneborn and zerres, ; johnson et al., ) . congenital dm is quite severe and includes respiratory insufficiency, hypotonia, generalized weakness, poor feeding, and mental retardation. only % live to months, and % reach adulthood. congenital arthrogryposis can occur because of severe prenatal weakness. one study of women found % were unaware of the diagnosis prior to discovery of the affected infant, and fewer were aware of their diagnosis prior to pregnancy (rudnik-sch€ oneborn and zerres, ). obstetric complications of various types were increased. a registry-based review of pregnancies of women with dm found a % miscarriage rate and various delivery complications, including preterm labor ( %), preeclampsia ( %), and peripartum hemorrhage ( %) (johnson et al., ) . polyhydramnios due to reduced fetal swallowing is a prime cause attributed to the premature labor and delivery. many women reported disease progression that did not return to the prior baseline during pregnancy. despite the overt clinical myotonia, that phenomenon often needs no specific treatment. in contrast to other discussed muscular conditions, smooth muscle including uterine contractions are affected, so that assisted delivery may be needed and hemorrhage risks increased (sax and rosenbaum, ) . the tocolytic ritodrine used to arrest labor is reported to cause rhabdomyolysis, but that agent is no longer available in the united states but is used in japan (ogoyama et al., ) . depolarizing muscle relaxants are avoided because of the risk of triggering severe and dangerous myotonic spasms. spinal block and epidural anesthesia have been successfully used; general anesthesia should be avoided if possible (hopkins et al., ) . despite these concerns a series of dm patients that underwent general anesthesia for other surgeries found no instances of malignant hyperthermia (mh) or problematic spasms (mathieu et al., ) . however, case reports of both complications are known (edmundson and guidon, ) . myotonic dystrophy type (dm ), previously known as proximal myotonic myopathy (promm), is an autosomal dominant multisystem disorder whose clinical manifestations resemble dm but often starts at later ages. proximal weakness, early cataracts, and myotonia are present but as lesser systemic features. a different repeat sequence (cctg) of the zinc finger protein (znf ) gene is causative. anticipation is not prominent. a congenital form is not described. retrospective data from pregnancies in women with dm found that previously pregnant women had symptom onset at an earlier age than the general population of men and other women (rudnik-sch€ oneborn et al., ) . of pregnancies, % ended early and % as late miscarriages. roughly % had initial symptoms during pregnancy and symptomatically worsened in later pregnancies. although not muscular dystrophies, there are several hereditary conditions that have prominent myotonia and some similar delivery recommendations. autosomal dominant (thomsen disease) and autosomal recessive (becker disease) are forms of myotonia congenita caused by mutations in a muscle chloride channel (clcn ). both have prominent and symptomatic myotonia and abundant myotonic discharges on electromyography. mild weakness may be present more commonly in the more severe and recessive becker disease. paramyotonia congenita is another related condition characterized by either paralysis spells or myotonia, most commonly caused by a sodium channel defect (scn a). labor and delivery concerns are much less than for myotonic dystrophy (lacomis et al., ) . myotonic symptoms l.h. weimer can worsen during pregnancy (gorthi et al., ) . cold is a prominent myotonia trigger; one case of cold inducing a spontaneous abortion was reported in a mother with paramyotonia congenita (chitayat et al., ) . similar precautions as for myotonic dystrophy are important for medications and anesthesia concerns. mexiletine, a common medication used to treat symptomatic myotonia, may be stopped during pregnancy if possible. the third most common muscular dystrophy is the autosomal dominant condition, facioscapulohumeral muscular dystrophy (fshd). prevalence is approximately - per , ; however, many patients are minimally symptomatic or asymptomatic. unlike many hereditary conditions, weakness is often asymmetric or selective. facial, shoulder girdle, and proximal arm and foot dorsiflexion weakness are common. weak abdominal muscles can impact labor. contraction of d z repeats in the double homeobox protein (dux ) on chromosome is causative and represents % of cases. a second form accounting for the remainder of cases is linked to a similar process on chromosome (type fshd). males are more symptomatic; so some women of childbearing age are unaware of their diagnosis. a survey of women with fshd reported pregnancies and live births (ciafaloni et al., ) . only about half knew their diagnosis prior to pregnancy. records found that outcomes were generally favorable, but birth weight was lower, instrument delivery rates higher, and c-section rates higher than the general population. one quarter noted increased weakness during pregnancy that did not resolve postpartum. miscarriage, preterm labor, and adverse neonatal outcome rates were not increased. another series included fshd patients; reported symptom aggravation that resolved after delivery (rudnik-sch€ oneborn et al., ) . rapid prenatal diagnosis of d z repeat numbers was reported (zheng et al., ) . a multitude of additional inherited muscular diseases are known resulting from mutations of several dozen different genes. in general, muscular dystrophy is used for progressive conditions. congenital myopathy is employed for conditions that have distinctive neuropathology and static or very slowly progressive weakness. most have proximal arm and leg weakness but few other distinctive features. autosomal recessive forms are most common (lgmd type ). type lgmd is autosomal dominant and often associated with allelic disorders. one series included lgmd patients and live births (rudnik-sch€ oneborn et al., ) . no miscarriages or preterm births were noted. five had prolonged labor that required assisted vaginal delivery or c-section. all infants were normal except one that had a likely unrelated neural tube defect. over half noted increased weakness during pregnancy that did not recover but many attributed that change to expected disease progression. the majority needed more family assistance for child care but retained a positive attitude for the pregnancy. the same series included women and pregnancies in patients with congenital myopathy of various forms. the small numbers make conclusions problematic, but findings were similar to the lgmd patients (rudnik-sch€ oneborn et al., ) . additionally, some forms of congenital myopathies, such as multiminicore myopathy and central core disease, have an increased risk of anesthesia-induced mh. during delivery, halogenated inhaled anesthetics and succinylcholine must be avoided, and monitoring must be more detailed. dantrolene can be used to treat mh associated with c-section. if the diagnosis is known, additional information about individual genetic conditions or even the specific mutation should be sought prior to delivery. additional conditions related to lipid, carbohydrate, or mitochondrial metabolism can produce specific muscle disorders. either fixed or exercise-induced weakness depends on the disorder. fixed or exercise-induced weakness can occur depending on the specific disorder. myophosphorylase deficiency (mcardle disease) characterized by autosomal recessive inherited bouts of myoglobinuria, is one of the most common conditions. two case reports noted no specific pregnancy or delivery issues other than one exercise-induced bout of myoglobinuria during the first trimester; both deliveries were successful (cochrane and alderman, ; giles and maher, ) . acid maltase disease (pompe disease) is caused by a-glucosidase deficiency; enzyme replacement therapy is well established for this disease. fixed weakness starting at variable ages, ranging from early childhood to the old age, is characteristic. there are a growing number of reports detailing successful pregnancies during ongoing enzyme replacement (kłos et al., ; santos et al., ; van houtte and de bleecker, ) . no specific complications were noted. treatment was interrupted during the first trimester in one case because of organogenesis toxicity concerns, but the mother's weakness progressed and treatment resumed (zagnoli et al., ) . a european consensus panel recommended that treatment should be continued during pregnancy (van der ploeg et al., ). mitochondrial encephalomyopathies are relatively rare, but some published experience during pregnancy in some syndromes is available. multiple syndromes are known and caused by various underlying genetic defects, including mitochondrial genome mutations or deletions or somatic mutations-overall prevalence is about in . mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (melas) is a discrete but rare multisystem disorder caused by various mitochondrial gene mutations. onset of myopathy and neuropathy symptoms during pregnancy led to the initial diagnosis in one case (yanagawa et al., ) . severe worsening in one case included severe pulmonary edema, intensive care needs, and fetal demise at weeks (sánchez and romero, ) . a european survey of women with the most common m. a > g melas mutation reported on pregnancies (de laat et al., ) . results listed % preterm delivery ( % prior to weeks), % preeclampsia, and % gestational diabetes. deficiency of cytochrome oxidase can cause myopathy and weakness; severely reduced maternal strength to the point of immobility was noted in one patient. despite this risk others advocate to attempt vaginal delivery (blake and shaw, ; soccio et al., ) . a survey of women with various mitochondrial disorders included women who were pregnant at least once ( pregnancies and live births) (karaa et al., ) . one-third had myopathy. overall, some increases in common obstetric complications occurred as expected but there was no notable worsening of fetal outcomes, other than various congenital anomalies. several forms of channelopathies causing intermittent bouts of paralysis are known. hypokalemic periodic paralysis bouts can be severe-triggers include carbohydrate load, glucose and insulin infusion, cold, stress, b-agonists, and potassium-lowering medications. a calcium channel mutation is most common. specific reports noted attacks during pregnancy triggered by betamethasone, new onset grave disease, glucose tolerance testing, and excessive caffeine (damallie et al., ; appel and myles, ; donovan et al., ; teagarden and picardo, ) . of note, the patient with new onset thyrotoxic form of the disease responded well to thyroid treatment. asians are highly overrepresented in this subtype including the case described (donovan et al., ) . spinal muscular atrophy (sma) sma is the most common fatal autosomal recessive disorder and results in severe progressive weakness. subtypes - are based on onset age and motor milestones. weakness onset ranges from prenatal to adulthood. prevalence is approximately - per , persons and incidence is around in , live births. the condition is caused by a mutation in the survival motor neuron (smn ) gene; copy numbers of the smn gene affect the phenotype severity. two current fda-approved treatments altered the expectations of future prognosis of this condition; additional agents are in the pipeline. nusinersen (spinraza) is an intrathecal infusion approved for all ages but is mostly given to infants and children; onasemnogene abeparvovec-xioi (zolgensma) is a single dose adenovirus vector gene therapy approved for patients under years. the expectation is that the most severe type i patients that previously expired prior to child bearing ages will have a much better prognosis. there is current limited information on pregnancy mainly for later onset types ii and iii that will hopefully change as children currently treated reach adulthood. a number of successful pregnancy reports have been published (carter et al., ; pugh et al., ; yim et al., ) . a recent literature review found that the incidence of maternal and fetal complications was not higher than the general population, but not surprisingly, premature labor and c-section rates were higher (abati and corti, ) . similar to conditions already discussed, regional anesthesia is preferred, and depolarizing muscle blockers avoided. weakness exacerbation was reported in a notable percentage of women. respiratory muscle weakness can hamper delivery and anesthesia management; spinal deformities and surgical hardware can complicate epidural or spinal anesthesia and respiratory management during c-section (carter et al., ) . als is typically a late-onset sporadic progressive fatal disorder-mean age of onset is years. about %- % are inherited conditions that start at younger ages. however, onset during pregnancy occurs (chiò et al., ; lunetta et al., ) . successful pregnancies are also reported (chiò et al., ; sarafov et al., ; kawamichi et al., ; pathiraja and ranaraja, ). an italian group reviewed all registered als patients of childbearing age and found examples of disease onset during or soon after five pregnancies (lunetta et al., ) . two had genetic forms, namely, superoxide dismutase one mutations. the authors noted a vascular endothelial growth factor promoter genotype that they theorize might impair oxidative stress mechanisms and promote als onset. the original fda-approved treatment is riluzole; several reports note no recognized negative fetal effects (kawamichi et al., ) . the most recently approved infusion, edaravone (radicava) is l.h. weimer associated with some adverse animal effects. both vaginal and c-section deliveries are reported, mainly based on the degree of impairment, especially muscular weakness and respiratory capacity. delivery and anesthesia concerns are similar to other discussed conditions. autonomic neuropathy, orthostatic intolerance, and postural orthostatic tachycardia syndrome (pots) pregnancy affects autonomic responses in multiple ways. various studies have documented various differences, which are further altered by preeclampsia (chaswal et al., ; da corrêa et al., ; garg et al., ) . autonomic neuropathy is uncommon but can occur in young women. significant autonomic neuropathy can create challenges, such as vomiting from gastroparesisdiabetes is the most common cause (macleod et al., ) . much more common is general dysautonomia, often termed orthostatic intolerance or pots. about . - million cases in the united states, predominantly affecting women, are estimated (garland et al., ) . common symptoms include orthostatic lightheadedness and tachycardia, syncope or presyncope, gastrointestinal disturbance, cognitive dysfunction, nausea, exercise or heat intolerance, and fatigue. symptoms can be disabling. onset can occur after an acute infection or other monophasic event or progress gradually; a minority of patients have signs of mild but painful small fiber neuropathy, suggesting underlying sensory and autonomic neuropathy following a viral syndrome. the condition must be distinguished from chronic fatigue syndrome, anxiety disorders, simple deconditioning, and cardiac-induced tachycardia. a variety of risk factors are known but most common are various forms of ehlers danlos syndrome. that condition can create additional pregnancy and delivery challenges, predominantly from joint hyperextensibility concerns (karthikeyan and venkat-raman, ) . contrary to many of the neuromuscular conditions already discussed, these patients often paradoxically improve during pregnancy, most commonly in the second trimester. however, given the heterogeneous nature of this syndrome, no consistent or reliable patterns are present. a review of available reports of pregnancy publications, mostly case reports, highlighted this variability (morgan et al., ) . volume expansion and weight gain during pregnancy can help and reduce the need for supplemental fluids and salt loading. even significant neurogenic orthostatic hypotension from diabetic autonomic neuropathy can improve in this setting (scott et al., ) . weaning helpful medications, such as fludrocortisone, midodrine, pyridostigmine, b-blockers, and others prior to pregnancy can be problematic in some patients. most are category c, but no examples of deleterious fetal medication events in this population are published. special considerations during delivery can include excess responses to epinephrine and stimulants and inappropriate tachycardia. some patients improve postpartum, but most return to baseline symptoms after delivery. pregnancy outcomes in women with spinal muscular atrophy: a review femoral mononeuropathy induced by the lithotomy position: a report of cases with a review of literature caffeine-induced hypokalemic paralysis in pregnancy two cases of guillain-barr e syndrome in late pregnancy neonatal lower motor neuron syndrome associated with maternal neuropathy with anti-gm igg pregnancy course 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patient with amyotrophic lateral sclerosis: a case report alglucosidase alfa therapy for pompe disease in pregnancy-case report pregnancy outcomes in adult patients with dermatomyositis and polymyositis zika virus infection as a cause of congenital brain abnormalities and guillain-barr e syndrome: systematic review pregnancy and the herniated lumbar disc fluctuating clinical myotonia and weakness from thomsen's disease occurring only during pregnancies postpartum neuralgic amyotrophy transient neonatal myasthenia gravis due to a mother with ocular onset of anti-muscle specific kinase myasthenia gravis intravenous immunoglobulin treatment for pregnancy-associated dermatomyositis guillain-barr e syndrome in mother and newborn child amyotrophic lateral sclerosis in pregnancy is associated with a vascular endothelial growth factor promoter genotype guillain-barr e syndrome and cytomegalovirus infection during pregnancy the incidence and lifetime prevalence of neurological disorders in a 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alglucosidase alfa pregnancy outcome in idiopathic inflammatory myopathy arthrogryposis multiplex congenita with maternal autoantibodies specific for a fetal antigen carpal tunnel syndrome in pregnancy and lactation serial studies of carpal tunnel syndrome during and after pregnancy no increased risk of adverse pregnancy outcomes for women with myasthenia gravis: a nationwide population-based study worsening of neurologic symptoms after epidural anesthesia for labor in a guillain-barr e patient successful treatment of dermatomyositis during pregnancy with intravenous immunoglobulin monotherapy randomized trial of thymectomy in myasthenia gravis long-term effect of thymectomy plus prednisone versus prednisone alone in patients with non-thymomatous myasthenia gravis: -year extension of the mgtx randomised trial incidence of postpartum lumbosacral spine and lower extremity nerve injuries mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes with deterioration during pregnancy successful pregnancy in a patient with spinal muscular atrophy and severe kyphoscoliosis pregnancy during enzyme replacement therapy for late-onset acid maltase deficiency rapid prenatal diagnosis of facioscapulohumeral muscular dystrophy by combined bionano optical mapping and karyomapping pregnancy in polymyositis or dermatomyositis: retrospective results from a tertiary centre in china key: cord- -xfg iczd authors: zhong, yajuan; cao, yacong; zhong, xiaozhu; peng, zhihang; jiang, sushi; tang, tiantian; chen, hai; li, xiaojia; xia, yankai; cheng, yanxiang; zhao, xiaomiao title: immunity and coagulation/fibrinolytic processes may reduce the risk of severe illness in pregnant women with covid- date: - - journal: am j obstet gynecol doi: . /j.ajog. . . sha: doc_id: cord_uid: xfg iczd background there are specific physiologic features regarding the immunity and coagulation among pregnant women, which may play important roles in the illness development of covid- . objective to determine the key factors associated with the deterioration of patients with covid- and the differentiating clinical characteristics of pregnant women with covid- , to interfere with the progression of covid- . study design a retrospective study of chinese han adult patients with covid- was conducted, of which cases were pregnant women. pregnant women without covid- were recruited as the control. the characteristics of severe and critical illness which were differentiated from mild and moderate illness in patients with covid- were analyzed using a machine learning algorithm. additionally, major differences between pregnant women with covid- and age-matched non-pregnant women with severe/critical covid- , paired with pregnant women without covid- , were explored to identify specific physiological features of pregnant women with covid- . results for the total patient population, the lymphocyte, cd +, cd +, cd +, cd + and cd + + cell counts were significantly lower, and white blood cell (wbc), neutrophil and neutrophil-to-lymphocyte ratio (nlr) were higher in those with severe/critical illness than those with mild/moderate illness (p< . ). the plasma levels of il- , il- and il- to il- ratio (il- / ) were significantly increased in critical patients, compared to mild, moderate and severe patients (p< . ). the above immunological co-clusters achieved an auc of . ( % ci: . - . ); and its combined model with the coagulation and fibrinolysis index (prothrombin time, d-dimer) achieved an auc of . ( % ci: . - . ) using the random forest regression model to predict severe or critical illness. for the pregnant women with covid- , none had pre-existing diseases. they displayed increased wbc, neutrophil count, nlr, and levels of d-dimer and fibrinogen, along with decreased lymphocyte and il- level (p< . ), compared with non-pregnant women with mild/moderate covid- . although they presented similar changes of immunological markers of lymphocyte, wbc, nlr, cd +, cd +, cd +, cd + + cell count and il- / compared with non-pregnant women with severe/critical covid- , none of the pregnant women with covid- deteriorated into severe or critical illness. there were no significant differences in comparison to wbc, lymphocyte, neutrophil, nlr, immunological markers or coagulation fibrinolysis markers between pregnant women with covid- and pregnant women without covid- . as for the discrepancy of pathophysiological features between pregnant women with covid- and non-pregnant women with severe/critical covid- , the immunological markers achieved an auc of . ( % ci: . - . ); and its combined model with coagulation and fibrinolysis index achieved an auc of . ( % ci: . - . ). conclusions immune dysregulation was identified as a crucial feature of covid- patients which developed severe or critical illness, and pregnant women with covid- presented with similar immune responses but rarer incidences of severe or critical illness. immune dysregulation is related to the risks of deterioration into severe or critical illness. the specific coagulation/fibrinolysis system of pregnancy may reduce pregnant women with covid- without pre-existing disease from the development of severe illness. the pandemic of coronavirus disease (covid- ) caused by severe acute respiratory syndrome coronavirus (sars-cov- ) has infected more than . million people in most of the countries worldwide, and up to september , , people have died, as reported by the world health organization (who) . despite tremendous efforts to combat this novel infectious disease globally, only a few medications have shown potentially curative effects. the coexistence of sars-cov- with human beings seems inevitable . finding a way to interfere with the development of illness to severe or critical stages and reducing the mortality as much as possible may be another strategy . according to the current reports which provide information regarding pregnant patients, the illness severity of pregnant women with covid- is similar with the common population or even lighter - . in a study conducted in wuhan city, only of pregnant lymphocytopenia along with an elevated neutrophil-to-lymphocyte ratio (nlr) were reported to be associated with hospitalization rate, severity of illness and/or mortality. on the other hand, dysregulated coagulation and diffuse thrombosis have been observed in lungs and extra-pulmonary organs in deceased patients with acute respiratory distress syndrome (ards) - . however, during pregnancy, the neutrophil, nlr and d-dimer also increase with the progression of gestational age. the microcirculation will undergo modifications during the course of pregnancy to aid adaptation to ensure adequate oxygen supply to the fetus . we hypothesize that the specific immunity response and coagulation-fibrinolysis state among pregnant women covid- may play important roles in progression of illness in herein, the clinical characteristics and laboratory indicators in chinese han covid- patients including pregnant women were analyzed. vital pathological features distinguishing severe or critical illness from mild or moderate illness were identified via machine learning algorithms. the physiological features between pregnant women with covid- and their counterpart controls were then compared to determine the key factors that may hint the potential mechanism of illness development of covid- . the clinical, laboratory and outcome data for patients with covid- were obtained from the electronic medical records during the time of admission and discharge for mild illness; admission, improvement and discharge for moderate illness; as well as admission, exacerbation, improvement and discharge for severe or critical illness. additionally, laboratory data for pregnant women in the control group were collected on the date of admission. the data collection forms were independently reviewed by two researchers. for laboratory assessments, blood samples were collected in the morning after fasting overnight to examine the following indexes: complete blood count (photoelectric colorimetry, xn- ), coagulation and fibrinolysis index (immunoturbidimetry, cs- ), n-terminal pro-brain natriuretic peptide (nt-probnp) (electrochemical laser method, e ), creatine the severity of the disease process is determined according to the diagnosis and moderate illness is defined as fever, respiratory tract symptoms, and imaging displaying signs of pneumonia. severe illness is defined as tachypnoea (≥ breaths/ min) or an oxygen saturation (sao ) of ≤ % on room air at sea level, or a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (pao / fio ) of ≤ mmhg, or progression of lesions > % within - hours, as determined by pulmonary imaging. critical illness is defined as respiratory failure requiring mechanical ventilation, shock or other organ failure that requires intensive care. considered statistically significant. violin plots were generated with graphpad prism version . program (graphpad software inc., san diego, ca, usa). for the methodology of grouping, firstly, a total of patients with covid- were divided into four sub-groups: mild (n= ), moderate (n= ), severe (n= ) and critical (n= ), according to the severity of illness. then, pregnant women with covid- and their counterparts of non-pregnant women with covid- aged - years old which were age-matched were extracted from the total patients. the sub-groups were categorized into pregnant women with covid- (n= ), age-matched non-pregnant women with mild/moderate covid- (n= ) and non-pregnant women with severe/critical covid- (n= ) to analyze the biochemical characteristics. in addition, considering the multiple repeated times of blood investigations performed in this study, generalized mixed models and generalized estimating equation models were also used to assess the difference of laboratory characteristics between different sub-groups . these data were analyzed using stata software (version . ; stata corporation). a random forest (rf) regression model was further used to evaluate the distinguishing abilities of clinical and laboratory markers. the data set was randomly split into a training set containing % of the samples, and a validation set containing the remaining %. variables used for distinguishing were selected based on comprehensive consideration of ranking of importance ( figure s ). the rf was implemented using r software version . . (r core team ) using the "random forest" package. the graphical roc (receiver operating characteristic) curve was produced along with area under the roc curve (auc). statistical significance was defined as p< . . results the clinical and biochemical features of all patients were first analyzed, as shown in table s . on admission, lymphopenia was detected in ( . %) patients with covid- , as shown in table s . the lymphocyte count, cd + , cd + , cd + , cd + and cd + + cell counts were significantly lower in severe and critical patients compared with mild and moderate patients (p< . ). serum white blood cell (wbc), neutrophil count and nlr were significantly higher in severe and critical patients than moderate patients (p< . ), as shown in table s . corresponding with the cellular immune dynamic in the aggravating severity of (il- / ) were significantly increased in critical patients, compared to the mild, moderate and severe patients (p< . ), as shown in table s . however, it is noteworthy that the incidence of more than triple the normal cut-off value of il- (> . pg/ml) was . % ( / ) in critical patients and . % ( / ) in severe patients. no significant differences were found in the serum levels of the other cytokine co-cluster (i.e. il- , il- , tumor necrosing factor (tnf)-α, and interferon (ifn)-γ) among the four sub-groups. the median age of the pregnant women with covid- was . years old (iqr . - . ). the gestational age was from weeks to weeks and . % women were in the rd trimester of pregnancy. . % ( weeks. no individual in control group had comorbidity ( table ) . pregnant women with covid- displayed similar changes of immunological markers of wbc, lymphocyte, wbc, nlr, cd + , cd + , cd + , cd + + cell count and il- / compared with non-pregnant women with severe/critical covid- (figure a and b) , and had increased wbc, neutrophil count, nlr, and levels of d-dimer and fib, as well as decreased lymphocyte and il- level (p< . ), compared with non-pregnant women with mild/moderate covid- (table and table s ). non-pregnant women with severe/critical covid- , there are significant difference in immunological and coagulation/fibrinolysis indicators. in this retrospective study with the clinical outcomes of covid- patients, the immune dysregulation was identified as a vital feature of covid- patients which developed severe or critical illness, and pregnant women with covid- presented similar immune response with non-pregnant women with severe/critical covid- but rare incidence of severe or critical illness. digging deeper into the discrepancy between the pregnant women with covid- and non-pregnant women with severe/critical covid- , the coagulation fibrinolysis index (pt, d-dimer) showed remarkable differences. however, for pregnancy itself, the pregnant women without covid- also demonstrated similar changes of immunological markers, consisting of wbc, lymphocyte, neutrophil and nlr, as the pregnant women with covid- . in our study, pregnant women with covid- presented with milder symptoms and mild illness, compared to the non-pregnant women with covid- of reproductive age. the result is partly consistent with a meta-analysis including pregnant and non-pregnant women with covid- which demonstrated that pregnant women with covid- had milder symptoms. although the meta-analysis indicated that pregnant women with covid- were more likely to require admission to an intensive care unit (icu) ( . , . to . ; i = %) at first glance, it was further elucidated that severe covid- or requirement of admission to an icu were actually associated with older age, obesity and pre-existing maternal comorbidities like hypertension, diabetes, etc . our data also indicated that risks of severe and critical covid- were associated with the above factors, in accordance with these reports on the other hand. the majority of the pregnant patients in our study had no comorbidities or complications, which may partly explain their mild to moderate illness. the maternal immune system is unique during normal pregnancy. however, to date, in general, normal maternal immune system is actively modulated at different gestational stages. the first trimester is a pro-inflammatory state in favor of embryo implantation, the an anti-inflammatory state benefiting fetal growth, and the third trimester changes to a second pro-inflammatory state featured by a th -type immune environment necessary for labor. viral invasion switches the immune environment from the th -type to th -type and activates inflammation by overproduction of cytokines including il- . the pregnant women with covid- in the third trimester composed nearly % of the whole pregnant population in our study. this may explain why the immunological files are similar between pregnant women with covid- and pregnant women without our data indicated that for the general covid- women population, the immune dysregulation mainly manifesting as increased il- , il- and il- / levels and a decreased lymphocyte count and its subsets, along with increased nlr, is related to the risks for severe and critical illness. the pregnant women with covid- demonstrated similar immune changes but none severe illness occurred. the most dramatic discrepancy between pregnant women with covid- from non-pregnant women with covid- was the coagulation fibrinolysis index variance. the significant increase of il- (pro-inflammatory cytokine), il- (an anti-inflammatory cytokine) and il- / ratio in severe or critical illness indicated that the host immune system switches to a predominantly pro-inflammatory state. it was reported that infection with sars-cov- triggers a pro-inflammatory response characterized by the production of il- , c-x-c motif chemokine (cxcl ) and type interferons, which attract macrophages, monocytes, and t lymphocytes to infection sites . however, in our study, there were no significant differences in terms of serum il- , il- , tnf-α, and ifn-γ levels within comparisons among defined sub-groups. it demonstrates the heterogeneity of the host immune response to sars-cov- . it is notable that pro-inflammatory cytokines (mainly il- ) are common triggers to besides, lymphopenia as a factor related to severe covid- illness has been reported - . our data indicated that the absolute counts of total lymphocyte and its subsets were decreased and sustained in severe and critical patients, along with increased nlr, predicting the risks for severe or critical covid- illness, in accordance with qin's study that lymphopenia, especially reduction of cd + and cd + t cells, was related with deterioration and signs of poor prognosis , . additionally, neutrophil extracellular traps therefore, immunity disorders mainly consisting of increased il- , neutrophil and nlr, may trigger thrombotic events by extrinsic and intrinsic pathways simultaneously, promoting the pathological process to severe covid- . the main finding of our study is the association between excessive immune response, coagulation-fibrinolysis dysregulation, and severity of the disease in both general population and pregnant sub-group. given the unique immune state in pregnancy, as described before, a deeper investigation need to be performed to figure out the exact mechanism between sars-cov- -induced inflammation and coagulopathy. in addition, in a series of autopsy cases of patients with severe covid- from australia, all cases were found pulmonary arterial obstruction by thrombotic material at both the macroscopic and microscopic levels. interestingly, ten of these cases received pharmacologic venous thrombus embolism (vte) prophylaxis, and vte was not clinically suspected in any cases before autopsy as a contributor of death . a method to evaluate microcirculation disorders and identify early alert biomarkers is needed. early anticoagulant therapy is implicated according to our study. vasodilating, pro-secretory, and anti-inflammatory effects, which might be assumed to be potential protective mechanisms against the physiological process of covid- and need to be further evidential. furthermore, the presence of pregnancy may lead to adaptive changes in maternal immunity to accept the existence of the fetus as a semi-alien. likewise, it is also possible that there is an unknown mechanism temporarily in mater compromising the invasion of sars-cov- . therefore, long-term follow-up of pregnant women with covid- and their offspring is necessary. besides, we are also concerned about microcirculatory impairments related to endothelialitis and microangiopathy, since some adverse pregnant outcomes, e.g. preeclampsia and hellp syndrome, are caused by this physiological change . the strengths of the study include that using machine learning algorithm to clinical data sets for the purpose of developing robust risk models of covid- ; and compared pregnant women with covid- and age-matched non-pregnant women with severe/critical the pregnant women with covid- and non-pregnant women with covid- (a) or non-pregnant women with severe/critical covid- (b) were extracted for this analysis. roc curves for immunological markers of nlr, cd + , cd + , cd + , cd + + cell count, il- , il- / , lymphocyte count, and wbc (a); immunological markers and ldh (b); j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f mmwr morbidity and mortality weekly report report of the who-china joint mission on coronavirus disease an inflammatory cytokine signature predicts covid- severity and survival epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study. the lancet clinical course and risk factors for mortality of adult inpatients with china: a retrospective cohort study. the lancet clinical characteristics of coronavirus disease in china pulmonary arterial thrombosis in covid- with fatal outcome clinicopathologic case series autopsy findings in patients with single-institution experience microcirculation in pregnancy. physiological research team r. a language and environment for statistical computing author contributions: d. zhao and cheng had full access to all of the data in the study and key: cord- -hhp ygq authors: ticconi, carlo; pietropolli, adalgisa; specchia, monia; nicastri, elena; chiaramonte, carlo; piccione, emilio; scambia, giovanni; di simone, nicoletta title: pregnancy-related complications in women with recurrent pregnancy loss: a prospective cohort study date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: hhp ygq the aim of this prospective cohort study was to determine whether women with recurrent pregnancy loss (rpl) have an increased risk of pregnancy complications compared to normal pregnant women. a total of singleton pregnancies were followed, in women with rpl and in normal healthy women. the prevalence of the following complications was observed: threatened miscarriage, miscarriage, cervical insufficiency, chromosomal/genetic abnormalities, fetal anomalies, oligohydramnios, polyhydramnios, fetal growth restriction, intrauterine fetal death, gestational diabetes mellitus (gdm), preeclampsia, placenta previa, abruptio placentae, pregnancy-related liver disorders, and preterm premature rupture of the membranes. the odds ratio and % ci for each pregnancy complication considered were determined by comparing women with rpl and normal healthy women. women with rpl had an overall rate of pregnancy complications higher than normal women (or = . ; % ci: . – . ; p < . ). their risk was increased for nearly all the conditions considered. they also had an increased risk of multiple concomitant pregnancy complications (or = . ; % ci: . – . , p < . ). considering only women with rpl, women with ≥ losses had a higher risk of pregnancy complications than women with two losses (or = . ; % ci: . – . , p < . ). no differences were found in the overall risk of pregnancy complications according to the type, explained or unexplained, of rpl. women with secondary rpl had an increased risk of gdm than women with primary rpl. pregnancy in women with rpl should be considered at high risk. recurrent pregnancy loss (rpl), defined as the spontaneous loss of two or more pregnancies (according to the american society for reproductive medicine [ ] ) or the loss of two or more pregnancies before the th week of gestation (according to the european society of human reproduction and embryology [ ]), presents several still incompletely defined aspects. among these is the outcome of the successive pregnancy in women with a history of rpl. indeed, there is considerable discrepancy between the reported birth rates and the rates of gestational complications of the successive pregnancy in women with rpl. the likelihood of a live birth in the successive pregnancy in untreated women with rpl has been reported to range - % after three miscarriages and decreases with increasing the number of pregnancy losses, reaching only - % after ≥ losses [ ] . this observation suggests that the number of miscarriages-a likely indicator of the gravity of the condition-is a major determinant of the reproductive success of women with rpl; in fact, it has been reported that the live birth rates in the successive pregnancy in women with two consecutive losses is around % [ , ] . on the other hand, several studies and reviews investigating the outcome of the successive pregnancy in women with rpl found that it was burdened by many obstetric and perinatal complications which occurred more frequently than in normal control women without rpl [ ] [ ] [ ] [ ] , even though this finding has not been observed in all studies [ ] . therefore, it is difficult for the clinicians to ensure a clear counseling, in terms of prognosis, to women with rpl about the subsequent pregnancy once the diagnostic workup has been completed. whereas the outcome of the subsequent pregnancy in women with rpl in terms of live birth, labor, and perinatal complications is well established [ , , ] , less information is available on the obstetric risks that can occur in these women during their pregnancy before labor. moreover, limited information is available concerning the gestational complications in women with rpl with regard to their specific features (primary/secondary or explained/unexplained rpl). the present study was carried out to investigate the outcome of the first pregnancy in women with rpl after their referral compared with healthy pregnant women without rpl, with specific application to the gestational complications and to the particular characteristics of these women. further information on this issue could allow a more comprehensive counseling of women with rpl and could help to better clarify whether these women actually need a more thorough monitoring throughout their pregnancy. this prospective, observational, study has been carried out to investigate the occurrence rates of major gestational complications in a cohort of women with rpl compared to normal healthy women without rpl followed during their first subsequent pregnancy after referral. the study subjects were enrolled from january to january . overall women were initially enrolled in the study. they attended as outpatients the gynecology and obstetrics unit of the policlinico tor vergata university hospital or the università cattolica of the sacred hearth at the policlinico gemelli hospital of rome, italy. in both hospitals, the women with rpl were followed at the rpl units, whereas the control women were followed throughout their pregnancy in the low-risk obstetric clinics. the study subjects were divided into two groups: group , rpl (n = ): non-pregnant women with rpl, enrolled at their first visit carried out to investigate the possible causes/risk factors of the rpl. the women of this group who entered in pregnancy were followed during their gestation. group , control (n = ): pregnant normal women with low risk pregnancy who had at least one uncomplicated pregnancy at term with any previous pregnancy loss. they were followed throughout their gestation. all the control women have had at least two pregnancies at term without any losses and were selected consecutively. of the initial population of enrolled women, women ( . %) with rpl were lost at follow-up without any information on whether they get pregnant. of the remaining women followed-up, ( . %) become pregnant; of these women, ( . %) were lost at the successive follow-up while pregnant, whereas ( . %) were followed-up during their pregnancy. ninety-one women ( . %) of the control group were lost at follow-up during their pregnancy, while women ( . %) were followed up. therefore, the final number of pregnant women included in the study was . these numbers have been reported for clarity in figure . j. clin. med. , , x for peer review of up, ( . %) become pregnant; of these women, ( . %) were lost at the successive follow-up while pregnant, whereas ( . %) were followed-up during their pregnancy. ninety-one women ( . %) of the control group were lost at follow-up during their pregnancy, while women ( . %) were followed up. therefore, the final number of pregnant women included in the study was . these numbers have been reported for clarity in figure . the final number of pregnant women to be included was calculated by taking into account the following conditions: (a) the null hypothesis (cases and controls have the same pregnancy complications) is refused if the difference between the means of the cases and of the controls (size effect) is > . % of the jointed variance of the two distributions; (b) the verification test is two-tailed student's t-test in which α = . and β = . , with a power = %. with the above conditions, the overall number of women to be included (cases and controls) is no less than . the women with rpl were investigated according to a standardized diagnostic protocol already reported in detail [ , ] which included the collection of general and obstetrical history, gynecologic examination with a pelvic ultrasound scan, karyotype of both partners, hysteroscopy, hormonal profile, autoantibodies panel, metabolic evaluation, and screening for coagulation and thrombophilic disorders. the diagnostic workup was aimed to identify defined and probable causes of rpl. the women with rpl with treatable causes (medical and/or surgical) were treated according to the the final number of pregnant women to be included was calculated by taking into account the following conditions: (a) the null hypothesis (cases and controls have the same pregnancy complications) is refused if the difference between the means of the cases and of the controls (size effect) is ≥ . % of the jointed variance of the two distributions; (b) the verification test is two-tailed student's t-test in which α = . and β = . , with a power = %. with the above conditions, the overall number of women to be included (cases and controls) is no less than . the women with rpl were investigated according to a standardized diagnostic protocol already reported in detail [ , ] which included the collection of general and obstetrical history, gynecologic examination with a pelvic ultrasound scan, karyotype of both partners, hysteroscopy, hormonal profile, autoantibodies panel, metabolic evaluation, and screening for coagulation and thrombophilic disorders. the diagnostic workup was aimed to identify defined and probable causes of rpl. the women with rpl with treatable causes (medical and/or surgical) were treated according to the european society of human reproduction and embryology (eshre) guidelines [ ] . treatments in women who were enrolled before the publication of these guidelines were changed accordingly. the women in the control group were followed throughout the pregnancy until term in the low-risk pregnancy unit according to the standardized protocol used in our units, which complies with the national institute for health and clinical excellence (nice) clinical guidelines [ ] . the present study was carried out in accordance with the declaration of helsinki, modified tokyo , and was approved by the institutional review board (irb) of policlinico tor vergata university hospital (protocol number: / ). all women gave their informed written consent to the study. rpl was defined according to the eshre guidelines [ ]. rpl was defined as unexplained when no definite cause could be found at the end of the diagnostic workup. primary rpl was defined as the absence of previous pregnancy at term or beyond the weeks of gestation; secondary rpl was defined as the presence of two or more consecutive losses occurring in women with a previous child or whose previous pregnancy reached the weeks of gestational age. all the women of both groups with pre-existing diabetes and hypertension before the onset of pregnancy were excluded, in order to avoid confounding factors as much as possible, since the objective of the study was to investigate with specific attention the pregnancy-related complications in relation to rpl. women with multiple pregnancies were also excluded from the study. the following additional inclusion criteria were followed for control women: absence of any pre-existing medical conditions, no previous gynecologic surgery, no assumption of drugs before pregnancy. the definitions of the pregnancy complications of interest for the present study are reported in table . table . definitions of pregnancy complications. threatened miscarriage an abnormal vaginal bleeding and abdominal pain occurring before the weeks in an otherwise ongoing pregnancy miscarriage a spontaneous pl occurring before the weeks gestation cervical insufficiency cl < mm by transvaginal ultrasound, or cervical changes detected on physical examination before weeks of gestation [ ] chromosomal abnormalities any detected alteration of the fetal karyotype and/or dna fetal anomalies any structural/morphological abnormality detected by ultrasound oligohydramnios afv < % for ga, or afi < cm or mdp < cm [ ] polyhydramnios a deepest vertical pocket of > cm or an afi > cm [ ] fetal growth restriction fetus with an uefw - th percentile for ga, calculated using the igc according to snijders and nicolaides [ ] intrauterine fetal death fetal death at weeks gestation or late gdm gdm was defined following who criteria [ ] preeclampsia preeclampsia was defined according to acog [ ] placenta previa/low-lying placenta defined according to the criteria of rcog [ ] placental abruptio the premature separation of the placenta before delivery [ ] pregnancy-related liver disorders all the collected data of interest for the present study were reported in a preconceived template. a computerized database available for the successive analyses was then constructed. any collected information was anonymized and de-identified prior to analysis. data are presented as means ± standard deviation (sd) or percentages or proportions, or odds ratios (or) and % confidence intervals (ci) as appropriate. statistical analysis was carried out by using student's t-test and chi-square test. bravais-pearson coefficient was determined to analyze correlations. the software used was the statistical software spss release (ibm ® , armonk, ny, usa). the effect of age and bmi for each complication is counted as percentages of the total population of women (cases and controls); the data were elaborated by using the method of analysis of the averages; by using this approach, the "effect size" expressed in percentages maintains the same dimensional magnitude of the original data. this statistical elaboration has been applied separately for the two above factors in relation to each complication; the results have been analyzed by student's under the usual hypotheses of normality and homogeneity of the corresponding distributions. significance was set at p < . . overall singleton pregnancies were followed ( in women with rpl and in normal healthy controls). the major clinical characteristics of the study women are reported in table . ethnicity distribution was not different between the two study groups (chi-square test = . , p = . , not significant difference). no difference was found between the rates of women with two ( . %) or ≥ ( . %) losses in the population of women with rpl (chi-square test = . , not significant). conversely, significant differences were found in the rates of women with primary vs. secondary rpl (chi-square test = . , p < . ), as well as in the rates of women with explained vs. unexplained rpl (chi-square test = . , p < . ). no differences were found between the two groups in the rates of pregnant women lost at follow-up (figure ; chi-square test = . , not significant). the mean length of follow-up was similar in the two groups (table ) . table . general characteristics of study women. no maternal deaths were observed in the overall study population. live births were / ( %) in women with rpl and / ( . %) in women of control group. women with rpl during their subsequent pregnancy after referral, had a significantly increased risk of not having a live birth compared with control women (or = . , % ci: . - . , p < . ). women with rpl also had a significantly higher overall rate of pregnancy complications ( / , ( . %) than control women ( / , . %): or = . , % ci: . - . ; p < . ). the rates by specific complications are reported in table . the factorial analysis (reported in detail in supplemental tables s and s ) has been carried out to ascertain the effect of age and bmi, that were higher in rpl than in control women; it revealed that both age and bmi had a significant effect on the distribution of nearly all of the above considered complications. this effect was particularly relevant in: (a) the case of age for spontaneous miscarriage; and (b) the case of bmi, for spontaneous miscarriage, chromosomal abnormalities, fetal growth restriction, gestational diabetes mellitus, and preeclampsia. table . pregnancy complication rates in women with rpl and control women. the factorial analysis of the effect size of age and bmi is reported as ∆% of the whole study population. women with rpl (%) the fetal chromosomal abnormalities detected were: trisomy ; trisomy ; monosomy , x ; trisomy , xxy; autosomal triploidy. the fetal anomalies detected during prenatal ultrasonography were: clinodactyly, pre-axial polydactyly, hydrops fetalis, interventricular septal defect, tricuspidal insufficiency, micrognathia, trigonocephaly, femoral heterometry, liver calcifications, cystic hygroma, bilateral pyelectasis, alterations of head circumference, persistence of the right umbilical vein. the detail of the pregnancy-related liver disorders is reported as supplementary material (supplementary table s ). the effect of the number of previous losses on the risk for each specific pregnancy complication was also investigated and the results have been reported in table . a "gravity-response" effect was clearly evident in the case of spontaneous miscarriage, cervical insufficiency, chromosomal abnormalities and preterm prom. the number of women who had more than one pregnancy complication was higher in the rpl group ( / , . %) than in the control group ( / , . %; or = . , % ci: . - . , p < . ). the detailed rates of concomitant pregnancy complications in study women are reported in table . two hundred and nine women with rpl had two previous pregnancy losses and had three or more previous losses. when the women with rpl were stratified in two major groups according to the number of previous losses (two and ≥ ) the pregnancy complication rate in the women with ≥ losses ( / , . %) was higher than that of women with two losses ( / , . %; or = . ; % ci: . - . , p < . ). the detailed rates of pregnancy complications by the number of previous losses are shown in supplementary table s . the pregnancy complications in women with rpl were then stratified by the main diagnostic categories, i.e., explained and unexplained. one hundred and thirty-seven ( . %) out of the women who had an explained rpl and ( . %) out of the women who had an unexplained rpl had a pregnancy complication, respectively. this overall difference was not significant (or = . ; % ci: . - . ; p = . ). however, when the two populations of women with rpl were analyzed by specific type of complications, women with unexplained rpl had an increased risk to develop preeclampsia (or = . , % ci: . - . , p < . ) and pregnancy-related liver disorders (or = . , % ci: . - . , p < . ). these findings are illustrated in detail in supplementary table s . in women with explained rpl the following causes were detected: anatomic causes, . %; endocrine causes, %; thrombophilias (hereditary and acquired), %; immunologic causes, . %; parental chromosomal disorders, . %; and environmental and health behaviors causes, . %. finally, the pregnancy complications in women with rpl were stratified by the other main diagnostic categories, i.e., primary and secondary. in our study, women had primary rpl and women had secondary rpl. women with secondary rpl had a higher rate of pregnancy complications ( / , . %) than women with primary rpl ( / , . %; or = . , % ci: . - . , p < . ). however, no differences between women with primary and secondary rpl were found for any of the specific complications considered, with the exception of gestational diabetes mellitus that was more frequent in women with secondary rpl (or = . ; % ci: . - . , p < . ). these findings are shown in detail in supplementary table s . the results of the present study show that women with rpl during their first gestation after the completion of the diagnostic workup had a significantly higher rate of several pregnancy complications than normal healthy women without rpl. nearly all the pregnancy complications considered in our study occurred more frequently in women with rpl and that women with rpl had an increased risk to have multiple pregnancy complications than control women. to our knowledge, this aspect has been scarcely explored in women with rpl. these observations suggest that pregnancy in women with rpl could be considered high-risk in its entirety and support the general concept that these women could have a wide reproductive disorder not limited to early pregnancy establishment and maintenance; rather, it can be extended also to late gestation, once the implantation of the embryo and its initial development have been successfully established. however, this hypothesis could be in contrast with the high rate ( %) of live births observed in our study. there are several potential explanations for this. it is known that the final outcome of the successive pregnancy in women with rpl in terms of live births could be considered, all in all, satisfactory, particularly in those women with a limited number of previous losses [ , , ] . this is the case of our study, in which the majority of women studied ( / , . %) had two or three previous losses, while the women with ≥ previous losses, those at highest risk of an unfavorable outcome, were / , ( . %), i.e., less than one quarter of the overall population of women with rpl). it is also possible that the high rates of live births in our study women, albeit are within or near the high range reported in previous studies [ , , ] , are linked to complications of moderate severity; moreover, our live birth rates could be to some extent overestimated, since a part of our cohort of pregnant women ( . % of women with rpl and . % of control women) was lost at follow-up and this is a limitation of the present study. the rate of spontaneous miscarriage in women with rpl was much higher than that found in control women. the risk of miscarriage increased by increasing the number of previous losses. the higher risk of fetal anomalies in women with rpl is in substantial accordance with the observations of previous studied carried out on this issue [ , ] , even though other more recent studies could not find this association [ , ] . however, the postnatal genetic follow-up of the newborns was incomplete in our series and this limitation does not allows to draw firm conclusions on this issue. in our study, women with rpl had an increased risk of fetal growth restriction and intrauterine fetal demise compared to control women. these findings are in accordance, although to a variable extent, with many of the studied previously carried out [ , , , ] . however, several other studies could not demonstrate the above associations with rpl [ , ] . similar considerations can be made for gestational diabetes mellitus, preeclampsia, placenta previa and abruptio placentae, conditions for which the association was either found to variable extent or not found at all [ ] [ ] [ ] [ ] [ ] [ ] , [ ] [ ] [ ] [ ] [ ] . pregnancy-related liver disorders were found to be more frequent in women with rpl than in control women. this finding is in accordance with what has been observed by cozzolino et al. [ ] . in the present study there are additional major findings related to the specific population of women with rpl. ( ) by increasing the number of previous losses, the rates of women who became pregnant decreased, however the rates of women with pregnancy complications have the tendency to increase. since the number of previous losses is considered an indicator of the severity of the rpl condition [ , ] , it is possible that the biological factors underlying multiple pregnancy losses can continue to act by impairing the successive pregnancies, even though they have the strength to evolve towards advanced gestational ages. further research is needed to check this hypothesis. a clear effect of the gravity of rpl condition, in terms of number of previous losses, has been shown in the case of selected pregnancy complications (table ). ( ) when the women with rpl were stratified according to the two major diagnostic categories, explained and unexplained, the rates of overall pregnancy complications were similar. however, the analysis carried out by specific complication revealed that the risk of preeclampsia and abruptio placentae was higher in women with unexplained rpl. a possible, plausible explanation for this finding-taken into account that the above conditions are linked since preeclampsia is a known major risk factor for abruptio placentae-is that in some or several women with unexplained rpl a disorder in the placentation could occur. ( ) when the women with rpl were stratified according to the other two major diagnostic categories, primary and secondary rpl, the rates of overall pregnancy complications were similar. however, the analysis carried out by specific complication revealed that the risk of gdm was higher in women with secondary than in women with primary rpl. a possible explanation for this finding could be that women with secondary rpl have been more exposed than women with primary rpl to the well-known diabetogenic effect of pregnancy that is exerted mainly in the second half of pregnancy, making them more susceptible for gdm in a successive pregnancy. this possibility is also supported by recent observation showing the association between high numbers of pregnancies and the increased prevalence of gdm [ ] . on the basis of all the above consideration, it is clear that assessing the outcome of the first pregnancy after referral with the aim to establish a clear prognosis is highly problematic [ ] . in fact, it is very difficult to make comparisons and fully explain the differences in the specific pregnancy complications observed between the studies, including the present one. this can be due to multiple reasons, including the heterogeneity of the studies with regard to the study design (retrospective/prospective), the inclusion/exclusion criteria, the different specific complications taken into account and their clear definitions, the stratification of women with rpl in specific subgroups, the potential impact of different therapeutic managements; in several studies a control group is lacking [ , , , ] . on the other hand, the major limitations of our study are the incomplete follow-up of the initially included women, particularly the pregnant ones, and the limited number of women with multiple pregnancy losses, i.e., ≥ . another limitation of the present study is that the intrapartum complications of pregnancy, as well as the neonatal complications, have not been reported because they were not included in the design of the present study, whose aim was to gain and report as much information as possible on the prepartum outcome of the investigated subjects. finally, there is evidence suggesting that women with rpl are at increased risk of long-term cardiovascular complications [ ] , so that recently figo had published guidelines regarding long-term follow up on these women in order to decrease this risk [ ] . we believe that this issue is worth to be investigated in depth. the results of the present study show that women with rpl have an increased risk to develop pregnancy-related complications during the first gestation after their referral; their pregnancy should be considered at high-risk and deserves special attention and care, even though caution is needed before drawing firm conclusions on this relevant issue, as it has recently reported [ ] . clearly, further investigation is needed to fully clarify still many aspects of this important issue. recurrent 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increased prevalence of gestational diabetes mellitus: results from the healthy baby cohort study recurrent pregnancy loss: a risk factor for long-term maternal atherosclerotic morbidity? international federation of gynecology and obstetrics) postpregnancy initiative: long-term maternal implications of pregnancy complications-follow-up considerations this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: this article has been written during the so far hardest time of the covid- outbreak in italy. our thanks to all our colleagues who died in fighting the infection. the authors declare no conflict of interest. the following are available online at http://www.mdpi.com/ - / / / /s , supplementary key: cord- -awtp mpg authors: mccartney, stephen a.; kachikis, alisa; huebner, emily m.; walker, christie l.; chandrasekaran, suchi; adams waldorf, kristina m. title: obesity as a contributor to immunopathology in pregnant and non‐pregnant adults with covid‐ date: - - journal: am j reprod immunol doi: . /aji. sha: doc_id: cord_uid: awtp mpg the ongoing coronavirus disease (covid‐ ) pandemic has led to a global public health emergency with the need to identify vulnerable populations who may benefit from increased screening and healthcare resources. initial data suggests that overall, pregnancy is not a significant risk factor for severe coronavirus disease (covid‐ ). however, case series have suggested that maternal obesity is one of the most important co‐morbidities associated with more severe disease. in obese individuals, suppressors of cytokine signaling are upregulated and type i and iii interferon responses are delayed and blunted leading to ineffective viral clearance. obesity is also associated with changes in systemic immunity involving a wide range of immune cells and mechanisms that lead to low‐grade chronic inflammation, which can compromise antiviral immunity. macrophage activation in adipose tissue can produce low levels of pro‐inflammatory cytokines (tnf‐α, il‐ β, il‐ ). further, adipocyte secretion of leptin is pro‐inflammatory and high circulating levels of leptin have been associated with mortality in patients with acute respiratory distress syndrome. the synergistic effects of obesity‐associated delays in immune control of covid‐ with mechanical stress of increased adipose tissue may contribute to a greater risk of pulmonary compromise in obese pregnant women. in this review, we bring together data regarding obesity as a key co‐morbidity for covid‐ in pregnancy with known changes in the antiviral immune response associated with obesity. we also describe how the global burden of obesity among reproductive age women has serious public health implications for covid‐ . the emerging coronavirus disease (covid- ) pandemic caused by infection with the novel betacoronavirus sars-cov- continues to challenge public health systems globally. although the majority of patients with covid- have self-limited disease consisting predominantly of mild respiratory symptoms, approximately - % develop acute respiratory distress syndrome (ards) [ ] [ ] [ ] [ ] . the centers for disease control have recently refined their risk categories for covid- to state that obesity was a major risk factor . in pregnant women, severe covid- disease is also associated with obesity , . over the last decade, non-communicable metabolic diseases such as hypertension, diabetes and obesity have increased in prevalence globally . in the united states, more than one-third of reproductive age women are considered to be obese [body mass index (bmi) ≥ kg/m ) . at the same time, the immunology and pathophysiology associated with covid- in pregnancy and especially in the setting of other comorbidities such as obesity is poorly understood. this review is directed towards summarizing how obesity affects the severity of covid- clinical disease and negatively impacts the antiviral immune response. in non-pregnant populations, obesity has been associated with severe covid- disease. a retrospective review of patients with covid- from the two medical centers in new york found that obese patients were more likely to present with symptoms; obese patients also had a significantly increased risk of icu admission or death (rr . ) even after adjusting for race, age and troponin levels . another retrospective study from a third medical center in new york including patients with covid- found that a bmi ≥ kg/m was independently associated with higher in hospital mortality compared to a bmi of - kg/m (adjusted odds ratio . ; % ci: . - . ). similarly, bmi ≥ kg/m was a significant predictor for increasing oxygenation requirements and intubation . an italian retrospective study demonstrated similar findings with overweight or obese patients more often requiring ventilation and a higher level of care despite younger age than older patients with normal bmi . obese pregnant women are at increased risk for complications of viral infection from influenza, cytomegalovirus, and sars-cov- and related complications such as ards - . the increased risk of severe respiratory viral disease due to obesity and pregnancy was most strikingly noticed with the accepted article h n pandemic in . in a study of hospitalized patients with a confirmed h n influenza a viral infection in the united states, class iii obesity was associated with hospitalization regardless of whether the patient had chronic medical conditions . immune changes in obesity have also been associated with increased susceptibility of viral infection including increased peak viral loads and delayed clearance in influenza . several case series and cohort studies have reported an increased severity of covid- in pregnancies complicated by elevated bmi and obesity (table ). an early report of two pregnant women with severe covid- necessitating icu admission in the postpartum period was notable for a bmi of and kg/m in these cases . in a cohort study of pregnant women with covid- in washington state, obesity emerged as a key co-morbidity in women with severe covid- ; of five pregnant women with severe disease in which information to calculate the body mass index was available, four were overweight or obese prior to pregnancy . in a study of pregnant women in italy, it was reported that of women with severe disease, the median bmi was kg/m , which was significantly elevated compared to women with mild disease (p= . ) . another cohort study from medical centers in the united states included pregnant women hospitalized due to covid- ; of women with severe or critical covid- disease, the average bmi was . kg/m . this study also demonstrated that critically ill pregnant women with covid- had a lower bmi than severely ill women, suggesting that while obesity may be a risk factor for severe disease, obese women may have lower mortality than lean women. interestingly, the idea that obese women may have a greater disease severity, but lower mortality than lean women mirrors other studies from the critical care literature, which have coined this finding as the "obesity paradox" . maternal deaths have been linked with obesity, however. a case series from iran including nine pregnant women with severe covid- disease of which seven died, three women had a bmi > kg/m . a case series of maternal deaths from brazil found that obesity (undefined) was significantly associated with mortality . further, several case reports or series from the united states and the united kingdom have reported maternal deaths or severe maternal morbidity in women with obesity - . finally, the largest series of pregnant women with covid- to date including cases in the united kingdom demonstrated that % of cases were obese compared to % of controls . this article is protected by copyright. all rights reserved understanding the immunopathology of infection with this novel virus is rapidly evolving. sars-cov- shares % rna sequence homology with sars-cov- , allowing extrapolation of likely shared pathophysiology and immune response [ ] [ ] [ ] . both viruses enter the cell via angiotensinconverting enzyme-related carboxypeptidase (ace ) receptor, though the sars-cov- spike protein binds ace with significantly higher affinity than sars-cov- . healthy individuals have higher concentrations of ace in lung tissues, specifically bronchial smooth muscle cells, alveolar epithelium, type ii pneumocytes and alveolar macrophages , . extrapulmonary expression of ace occurs in myocardial cells , enterocytes in the ileum and jejunum , proximal tubular cells in the kidney , oral mucosa , and arterial and venous endothelium . in contrast, the strongest evidence suggests negligible placental expression of ace and tmprss , a serine protease that acts as a canonical mediator of cell entry for sars-cov- in conjunction with ace . multiple cells, predominantly within the lung, but also within other target organs (e.g. heart, kidney) express the canonical receptor for sars-cov- entry. during the initial stage of most viral infections, the type i and type iii interferon (ifn) response is the primary mechanism leading to viral clearance. immune cells detect viral nucleic acids through pattern this article is protected by copyright. all rights reserved inflammatory response by producing pro-inflammatory cytokines (tnf-, il- , il- ), which, in turn, lead to additional lung injury and immune cell recruitment , . cytokines and chemokines result in activation of adaptive immune t and b cells as well as recruitment of neutrophils and monocytes. viral-specific cd t cells are cytotoxic primarily to infected cells and serve to limit the release of additional viral particles, while neutrophils non-specifically release reactive oxygen species and leukotrienes, which are directly toxic to pneumocytes and endothelial cells. additionally, high levels of ifn and pro-inflammatory cytokines also lead to cell death directly with and without viral infection through induction of apoptosis. patients with severe covid- typically have high levels of systemic pro-inflammatory cytokines, lymphopenia, and inflammatory lung infiltrates, which is consistent with a maladaptive patterns of cytokine production and inflammatory misfiring - . elevated cytokines are also associated with multiple pathologic effects in the lung including endothelial apoptosis and vascular leaking, an ineffective antiviral response, diffuse alveolar damage, inflammatory cellular infiltrates and intravascular thrombosis [ ] [ ] [ ] . adipose tissue is an active endocrine and immune organ consisting primarily of adipocytes, but also multiple immune cell types, which represent the second most frequent type of cells in this tissue , . macrophages are the most common immune cell type in adipose tissue and, in lean individuals, produce type cytokines (il- , il- ) and anti-inflammatory molecules , . however, in obese individuals, activated macrophages in adipose tissue produce pro-inflammatory cytokines tnf-, il-  and il- , which results in recruitment and activation of additional monocytes, as well as nkt cells and mast cells. adaptive immune cells also play a role in obesity-associated inflammation. adipose tissue from lean individuals is composed primarily of cd + th cells and regulatory t cells (treg), which promote an anti-inflammatory environment, while obese adipose tissue is enriched for cd + th and th cells as well as cytotoxic cd + t cells [ ] [ ] [ ] . changes in t cell polarization may be due to altered metabolite availability in obesity, which contributes to t cell differentiation and response to pulmonary infection , . in addition to changes in t-helper cell phenotype, obesity is also associated with t cell dysfunction. obesity results in increased production of memory t cells, and in a mouse model of viral infection, the memory t cell response to viral infection in obese animals resulted in increased pathogenesis rather than a protective response this article is protected by copyright. all rights reserved also been associated with t cell exhaustion, which may be responsive to treatment with biologic therapies , . adipose tissue and cytokine-like hormone released from adipocytes, called adipokines, may directly and indirectly impair the pulmonary immune response. the adipocyte overflow hypothesis suggests that when an adipocyte can no longer hypertrophy to accommodate storage of new lipids, an "overflow" of fatty acids occurs into the body , ; lipids may then be recognized by innate immune pathogen recognition receptors at ectopic sites to stimulate a low-grade inflammatory response . adipose tissues also release adipokines that can act as powerful regulators of the immune response. leptin is a key adipokine and can regulate both innate and adaptive immunity to mediate a proinflammatory immune response . an inflammatory microenvironment can also downregulate production of adiponectin by adipocytes, which impairs the anti-inflammatory response. interestingly, high-levels of leptin that are typical in obese individuals increase the risk of the severity of respiratory infections in both humans and mouse models . high circulating leptin levels were associated with mortality in non-pregnant adults hospitalized for acute respiratory distress syndrome due to pneumonia, even after adjusting for bmi . the placental trophoblast and amnion also secrete leptin, which may further impair the pulmonary immune response in pregnant women . finally, adipose tissue is present in subcutaneous, visceral, and omental locations; the cellular and metabolic properties of each type of tissue are unique. alterations in visceral adiposity have been associated more closely with adverse metabolic and health outcomes and immunologic dysfunction , . in addition to inducing immunologic dysfunction, excess adipose tissue also changes the mechanics and physiology of respiration. the increased metabolic requirements in obesity results in higher oxygen consumption and increased work of breathing . obesity also results in greater production of carbon dioxide, which leads to decreased respiratory drive. mechanically, increased fat deposits within the abdominal cavity reduce the compliance of the respiratory system . increased abdominal adipose tissue mass leads to elevated abdominal pressure and lower lung volume by reducing expiratory reserve and functional residual capacity . obesity is also associated with airway narrowing which can lead to gas trapping . the combination of decreased lung volumes, increased abdominal pressure and narrowing of the airway leads to increased work of breathing with early fatigue of respiratory muscles. this article is protected by copyright. all rights reserved pregnancy provides both a physiologic and immunologic challenge for the maternal host during which it must balance providing access to nutrition, protection from infection, and tolerance of a genetically foreign fetus. to accommodate these functions, there is dynamic regulation of the maternal immune system, both systemically and at the maternal-fetal interface during pregnancy. pregnancy requires both pro-inflammatory and tolerogenic immune responses at specific times during gestation [ ] [ ] [ ] . during the early first trimester, a localized inflammatory response is necessary for embryonic implantation into the uterine decidua , . at the time of human parturition, a functional progesterone withdrawal in humans coupled with an inflammatory response direct the cascade of biological events that culminate in birth [ ] [ ] [ ] [ ] accepted article levels are one of the strongest clinical correlates for severe covid- disease , . in addition, a change in cd + t cell polarization from th and treg cytokines (il- , il- , il- ) to a proinflammatory th and th response observed in obese individuals is associated with production of pro-inflammatory cytokines, such as tnf-, il- , il- , and il- , which provides a potential mechanism for an earlier initiation of cytokine release and inflammatory misfiring in obese patients. the expression of ace by adipocytes and immune cells also suggests the possibility that adipose tissue may represent a potential reservoir for viral infection and may lead to increased viral burden or persistence; however, no studies to date have demonstrated that adipocytes can be directly infected with sars-cov- . these obesity-driven alterations in the immune response likely contribute to the severity of covid- in obese pregnant women. maternal obesity has emerged as a key risk factor increasing susceptibility of pregnant women to severe covid- disease. this is likely the result of complex immunologic, metabolic, endocrine and physiologic changes associated with obesity, which affect the immune response to viral infection. the increasing global burden of obesity may lead to more severe pregnancy morbidity and has the potential to regress decades of progress in global health and, by extension, to improvements in reproductive and pregnancy care worldwide. analyses comparing obesity rates in over the last three decades show that obesity among pregnant women has increased drastically worldwide . in - , obesity among women years and over was . % in the united states . currently the us also has the highest number of covid- infections worldwide . in light of the global covid- pandemic, there has been a call for renewed prioritization of non-communicable diseases such as obesity that increase susceptibility of women with sars-cov- infection to severe disease or mortality . carefully designed epidemiologic studies are required to assess the linkage between covid- disease severity, obesity and associated socioeconomic factors. there is also an urgent need to focus research on how risk factors, like obesity, alter the immune response to sars-cov- and influence disease pathogenesis of covid- (box ). finally, given global trends in the rise of obesity over the last decades, urgent action is needed to address this critical health condition for global health . clinical features of patients infected with novel coronavirus in wuhan presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the new york city area clinical, laboratory and imaging features of covid- : a systematic review and meta-analysis clinical characteristics of , covid- patients: a meta-analysis covid- ): people with certain medical conditions clinical characteristics of pregnant women with a sars-cov- infection in washington state characteristics and outcomes of pregnant women hospitalised with confirmed sars-cov- infection in the uk: a national cohort study using the uk obstetric surveillance system (ukoss). medrxiv facing the noncommunicable disease (ncd) global epidemic--the battle of prevention starts in utero--the figo challenge prevalence of obesity and severe obesity among adults: united states obesity is associated with worse outcomes in covid- : analysis of early data from severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality obesity and covid- : an italian snapshot cytokine release syndrome in severe covid- clinical characteristics of deceased patients with coronavirus disease : retrospective study the many faces of the anti-covid immune response longitudinal immunological analyses reveal inflammatory misfiring in severe covid- patients pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology post-mortem examination of covid patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction autopsy findings and venous thromboembolism in patients with covid- . annals of internal medicine the role of adipose tissue immune cells in obesity and low-grade inflammation adipocytes properties and crosstalk with immune system in obesity-related inflammation inflamed fat: what starts the fire? inflammatory mechanisms in obesity association between specific adipose tissue cd + t-cell populations and insulin resistance in obese individuals the obesity-related pathology and th cells th and treg lymphocytes in obesity and type diabetic patients accepted article this article is protected by copyright. all rights reserved immunometabolism and pulmonary infections: implications for protective immune responses and host-directed therapies t cells in adipose tissue: critical players in immunometabolism obesity expands a distinct population of t cells in adipose tissue and increases vulnerability to infection t-cell exhaustion in chronic infections: reversing the state of exhaustion and reinvigorating optimal protective immune responses obesity induced t cell dysfunction and implications for cancer immunotherapy lipid overload and overflow: metabolic trauma and the metabolic syndrome adipose tissue expandability, lipotoxicity and the metabolic syndrome inflammation and lipid signaling in the etiology of insulin resistance fat mass and immune system: role for leptin hyperleptinemia is associated with impaired pulmonary host defense nonadipose tissue production of leptin: leptin as a novel placenta-derived hormone in humans the concept of metabolic syndrome: contribution of visceral fat accumulation and its molecular mechanism metabolically healthy obesity: facts and fantasies the impact of morbid obesity on oxygen cost of breathing (vo( resp)) at rest accepted article this article is protected by copyright. all rights reserved the effect of obesity on lung function total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients airway closure and distribution of inspired gas in the extremely obese, breathing spontaneously and during anaesthesia with intermittent positive pressure ventilation the unique immunological and microbial aspects of pregnancy the inflammation paradox in the evolution of mammalian pregnancy: turning a foe into a friend immunological basis for recurrent fetal loss and pregnancy complications the role of inflammation for a successful implantation inflammation and pregnancy: the role of the immune system at the implantation site gestational tissue inflammatory biomarkers at term labor: a systematic review of literature physiologic uterine inflammation and labor onset: integration of endocrine and mechanical signals myometrial cytokines and their role in the onset of labour interplay of transcriptional signaling by progesterone, cyclic amp, and inflammation in myometrial cells: implications for the control of human parturition accepted article this article is protected by copyright. all rights reserved immune responses at the maternal-fetal interface immunology of the maternal-fetal interface sterile inflammation and pregnancy complications: a review an immune clock of human pregnancy the influence of pregnancy on systemic immunity th /th /th and regulatory t-cell paradigm in pregnancy influenza, immune system, and pregnancy. reproductive sciences (thousand oaks, calif) plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome influenza virus-related critical illness: pathophysiology and epidemiology viral infections and interferons in the development of obesity and inflammation: the linking mechanism and the complications inflammation in maternal obesity and gestational diabetes mellitus dysregulation of immune response in patients with covid- in wuhan, china. clinical infectious diseases : an official publication of the infectious diseases society of america covid- ) situation report - . world health organization maternal health and non-communicable disease prevention: an investment case for the post covid- world and need for better health economic data symptoms and critical illness among obstetric patients with coronavirus disease (covid- ) infection %) maternal deaths / iatrogenic ptb, ( %) due to covid- . iufd, nnd lokken et al. usa (wa) ( . %) ( %) severe covid- box . research questions . what is the mechanism of increased risk for severe covid- disease in obese nonpregnant and pregnant women? does the second and third trimester of pregnancy represent a time of increased risk for severe covid- ? if yes, how does gestational age modify the effect of obesity on covid- disease severity? is preterm birth more common in obese pregnant women with covid- due to concern for respiratory compromise? are certain therapies more effective for treatment of severe covid- in obese pregnant women compared to lean or non-pregnant women? does increased surveillance for covid- in obese pregnant women improve health outcomes? can adipose tissue serve as a reservoir for sars-cov- viral infection through adipocyte ace expression? are viral loads higher of sars-cov- in obese versus lean pregnant women? are the kinetics of viral clearance different in obese versus lean pregnant women? can we design epidemiologic studies to further assess whether the risk of severe covid- infection in obese pregnancy is directly related to obesity itself or to associated socioeconomic factors? accepted article key: cord- -z l rsm authors: kline-fath, beth m.; victoria, teresa title: revisiting gender workspace blind spots date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: z l rsm nan we applaud the articles from pfeifer et al. [ ] and joshi [ ] with regard to gender balance in pediatric radiology. these data are important for the society for pediatric radiology (spr) as it demonstrates that change definitely needs to occur to support leadership by women in our field. we are in complete agreement with the comments from sandberg that "it will be quite a day when we look at each other without attention to gender and diversity" [ ] . the statistics provided by pfeifer et al. [ ] open the door to understanding the disparity, yet they do not quite describe the problem at hand. why do women find themselves primarily in the middle of the pyramid rather than at the top [ ] ? first of all, gender stereotypes are still a part of the global culture [ ] . women, while working, are the ones who generally take on most of the family responsibilities, and there is often little flexibility in their work schedules. in addition, there are definitely negative labels and frank discrimination that act as barriers for women to achieve leadership positions. these come from both genders: it is not just men who need to recognize gender bias; women need to be more assertive and support other women as well. to illustrate this point, ms. sandberg [ ] discussed how women, when offered a new position, only accept it if they feel they are % qualified, whereas men do so if they meet % of the qualifications, with the thinking that they will acquire the missing % on the job. in addition, aware of discrimination and insecurities, women often prefer to remain on the periphery of the room, protecting themselves from unwarranted criticism but crucially limiting their input and growth. there are problematic societally sanctioned biases about what constitutes leadership that highlight different styles between men and women. traditionally, the characteristics most admired in a leader have been those typically identified as masculine, including showing assertiveness, demonstrating individualism, and being single-task-oriented. however, many of the traits of a transformational leader, such as collaboration and empowerment, are traditionally thought of as feminine attributes. women are often more emotionally driven and less aggressive, tend not to act as authoritarian, are more supportive and creative, and are often more quick to give credit to others for their success [ ] . in fact, a review of the fortune companies shows that those with female leadership have much higher productivity in general than those with predominantly male leadership [ ] . look at the current crisis with covid- : women are at the top of leadership in handling this pandemic. in new zealand, for example, as a result of her bold response to the virus, prime minister jacinda ardern has nearly eradicated the virus from her country [ ] . "blind spots are getting in our way," sandberg wrote. "it's hard to solve a problem we don't fully see or understandand when it comes to gender in the workplace, too often we miss the scope and scale of the issue [ ] ." in our society, inequalities with regard to gender need to be acknowledged and changed. differences in salary between men and women should be transparent and either amended or explained. these inequalities occur at the highest levels of leadership in medicine, with women department chairs earning . cents per dollar received by men [ ] . a lack of transparency in salary between men and women only conceals persistent inequality. we should engage in a dialogue about this matter openly and not pretend that it is a taboo subject to discuss salary. just as pediatric radiology is gender-balanced in the united states, leadership in the spr and work environments should reflect similar equity. presidents of medical societies should include women leaders at an even percentage with men. chair positions in our hospitals should be balanced, and women should have the opportunity to pursue and accept any leadership position, even when applying from outside the hiring institution. this is not merely an issue for the applicant: employees deeply care about fairness. in a recent survey, workers noted that fairness and opportunity are the most important factors in determining satisfaction at work [ ] . we need to model fairness and opportunity. one possible impediment in the growth of junior women faculty is that mentorship has been deficient. both women and men in leadership positions should make it a point to act as mentors for young physicians and support them on their journey. mentors may advise when a junior faculty member is at a crossroad and might inspire at times when the junior mentee fails to see her full potential. discrimination and stereotyping of women in society has been brought into the light of day by the "me too" movement. we dislike the label because it again emphasizes a gender difference. we need to work as a team to change how women are treated, viewed and appreciated. we challenge each one of us to take these thoughts forward in our practices so that one day, gender and diversity are not descriptors in leadership. the movement for gender equality should be more of a "we too" inclusive movement of women and men. together, we can do this. advancing from gender equity to women in leadership in pediatric radiology gender balance in pediatric radiology: it benefits everyone lean in: women, work, and the will to lead female leaders: injurious or inspiring role models for women? jepson school of leadership studies articles, book chapters and other publications leadership and gender differences -are men and women leading the same way? the white house project report. benchmarking women's leadership female world leaders hailed as voices of reason amid the coronavirus chaos sex differences in salaries of department chairs at public medical schools publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflicts of interest none key: cord- -vqurc pj authors: metitieri, tiziana; mele, sonia title: women in neuroscience: a short time travel date: - - journal: reference module in neuroscience and biobehavioral psychology doi: . /b - - - - . - sha: doc_id: cord_uid: vqurc pj about half of graduate and postgraduate students and one-third of faculty in the field of neuroscience are women. the proportion of women neuroscientists tend to decrease as they progress through the career ladder. their responsibilities and their opportunities to secure research funding also tend to be lower compared to men, as in most scientific disciplines and professions. the multiple factors contributing to the under-representation of women in higher-level roles have historical, social, and cultural roots. a process of forgetfulness of pioneer women from the last century prevented the field from having role models in which upcoming generations of women neuroscientists could have identified. maria manasseina, cécile vogt, augusta dejerine klumpke are only some early pioneers who have recently been rediscovered. the available data show that the profiles of women neuroscientists are overlooked and their remarkable findings receive less recognition. conscious and unconscious gender biases also affect the evaluation and recruitment process. the presence of cultural and institutional barriers continues to hinder equal opportunities in all aspects of the scientific and academic career. the initiatives launched so far to increase awareness of such barriers and diversity in the workplace have produced a slight improvement but further action should be taken and supported to improve the condition of women in neuroscience. the shaded side of the history of neuroscience shows how women took part to the development of this modern interdisciplinary field from the beginning, despite the plain hurdles in accessing higher education. their contribution, acknowledged and sometimes awarded by the scientific community of the time, has been forgotten and in some cases actively removed so as to leave only faint traces in the reference handbooks and academic student textbooks. this scarce presence led to the thesis that women were not inclined to scientific research, and above all they would remain focused on their predisposed role: the care of husband, children, older people. embarking on a scientific path would have prevented women from stay at home and take care of the family. furthermore, science required the intellectual abilities of which women were believed to be lacking and it is not necessary to go far back in the years to hear echoes of this belief in university classrooms and lecture halls. "women are so grossly under-represented in modern science because, for most of history, they have been treated as intellectual inferiors and deliberately excluded from it" wrote angela saini in her book inferior (saini, ) , which encouraged international awareness campaigns on gender discrimination in the scientific world. as for women inferiority, the story begins with charles darwin who explained his thesis in the book the descent of man and summarized his thought in the correspondence with caroline kennard, to whom he wrote in : "i certainly think that women though generally superior to men [in] moral qualities are inferior intellectually, and there seems to me to be a great difficulty from the laws of inheritance, (if i understand these laws rightly) in their becoming the intellectual equals of man" (saini, ) . the thesis then found fertile ground in the following decades and became increasingly structured in the academic and general communities. still today, some maintain that the small proportion of women in major international scientific awards (nobel prizes, fields medals, etc.) can be explained with the supposed female lower aptitude for abstraction, mathematics, and physics. female nobel laureates are not lacking but they are very few indeed. between and , the nobel prizes were awarded to women (marie curie received it in physics in and in chemistry in ) out of scientists. however, cases of women who have been denied the recognition they deserved have emerged in recent years. lise meitner, marguerite vogt, and more recently jocelyn bell burnell are just a few examples of women who made essential contributions to discoveries that led to nobel prizes awarded to their male colleagues. the impact of removing women from science is still evident today in the small number of celebrations dedicated to the pioneer women of neuroscience, in the limited access to the top positions of departments and laboratories, as well as to the highest academic positions. scientific errors, cultural barriers, and gender segregation have led to this removal. gender bias and discrimination prove to be very effective in leaving women's innovation potential unexpressed through horizontal and vertical segregation (chiofalo and metitieri, ) . in the next four sections we will illustrate the condition of women in neuroscience through a temporal dimension: recovering the stories of some representative women neuroscientists from the past; referring to the transition from sources sought in the hidden historical archives to the autobiographies accessible online; summarizing the current situation of women in neuroscience; and, finally, tracing the unknowns of the future that with the covid- pandemic are likely to cancel the slightest changes made to diversity in the last few years. until the early s, it was widely believed that the lower physical strength of women than men implied similar mental weakness and a more delicate nervous system. in the th century, different fields in brain research highlighted that sexual differences were reflected in exaggerated gender distinctions: from biology to psychology, to phrenology and evolutionary theory, the scientists claimed that women had fewer intellectual abilities than men (houghtaling, ) . moreover, being at the mercy of their hormones, it was said, women were thought to be emotionally unstable and unable to make decisions. in medicine, this belief justified the idea that women could not reach high standards in their studies and was the excuse with which they were prevented from accessing post-graduate specialization courses and hospital traineeships, which in france remained exclusive to men until (digby, ) . despite social and cultural barriers, some women managed to enter the academic world, a world for men only, and there to find their place. among these are five pioneer women of neuroscience born in the late s who produced seminal works in the first half of the last century. maria mikhailovna manasseina ( manasseina ( - was one of the first women to graduate in medicine in europe (kovalzon, ). she published important contributions to biochemistry, physiology, and sleep deprivation. she discovered that the negative effects of prolonged sleep deprivation originated in the brain and demonstrated that sleep is more important than food for the preservation of life (bentivoglio and grassi-zucconi, ) . manasseina published the first comprehensive handbook on sleep in , in russian. the book was then translated in english (de manacéïne, ) and widely distributed in europe, becoming the sleep encyclopedia, a reference book in those times. manasseina stated that sleep represents a definite state of brain activity which is different from the absence of activity, as it was commonly seen at the time: a remarkable intuition, considering that the objective recording of brain electrical activity through the electroencephalogram would have been introduced after more than years. before studying sleep, manasseina worked at the polytechnic university of vienna, where she had the opportunity to study the alcoholic fermentation process by discovering that it is due to specific components that can be isolated from yeast cells (she called them "unorganized enzymes") rather than the living yeast per se (lagnado, ) . the same results were replicated by eduard buchner after years and, although he was aware of manasseina's work, he did not even mention her in his publications. buchner was awarded the nobel prize in chemistry in for this discovery and manasseina's name obliterated. laura forster and manuela serra were the first two women working at the spanish neurological school of santiago ramon y cajal in madrid (giné et al., ) . although almost all cajal's collaborators were men, forster and serra appeared on the official list of school members drawn up by cajal in , on the occasion of the echegaray medal reception by the royal spanish national academy of physics, exact and natural sciences (giné et al., ) . laura elizabeth forster ( - ) was born and initially studied in australia. she moved to england after the death of her father, and, in , she entered the university of bern in switzerland as a medical student and graduated in . she remained working at the institute of pathology for the next six years and devoted her research to the study of muscle spindle fibers. returning to the united kingdom, she settled in oxford and attended the physiological laboratory under the supervision of gustav mann. there, she published a scientific paper on the histology of the lymph nodes of a patient suffering from tuberculosis. to gain more mastery in neurohistological techniques, forster went to madrid in , in the cajal laboratory, where she stayed a few months. her research focused on the degeneration of nerve fibers after a traumatic lesion of the spinal cord in birds, to compare its effects with what was observed in the previous studies on mammals conducted by cajal and others. forster was the first to apply the neurofibrillary techniques to birds and her findings were published in august in a long scientific paper written in spanish and elegantly illustrated by six drawings in the style of the cajal school. cajal cited forster's work in his laboratory at least three times. laura forster's scientific career ended in when at the outbreak of the first balkan war, she enlisted as a nurse, since women could not serve as doctors on the war front. she also served at the outbreak of the first world war. biographical information regarding manuela serra is scarce, as reported by giné et al. ( ) . despite being neither a doctor nor a senior researcher, manuela serra conducted her studies on the intracellular fibrils of ependymal cells and astrocytes in the spinal cord of the frog and published a paper in the cajal laboratory's journal in . in this publication, illustrated by ten drawings, serra reported for the first time the presence of microglia, which she called "mesoglia", in the white matter. the women neuroscientists in the cajal school were admitted as independent researchers or collaborators, a role not as prominent as that of female scientists in other countries, despite their outstanding findings and their relevance for the development of neuroscience. augusta marie dejerine-klumpke ( - was born in the united states to german parents. she spoke english, german and french, and knowing these languages was a considerable advantage to access scientific literature, since, during the first decades of the th century, many scientists still wrote in their native language. only after the second world war english became the main language of science. in , following the published work of the german neurologist wilhelm heinrich erb, which described the clinical signs following the injury of the brachial plexus (bogousslavsky, ) , dejerine-klumpke characterized the paralysis of the lower brachial plexus, that was named after her klumpke's palsy. during the first world war, together with her daughter yvonne, she treated soldiers with spinal cord injuries, and founded a professional rehabilitation center near fontainebleau, thanks to donations from family and friends (schurch and dollfus, ). dejerine-klumpke contributed significantly, with her husband jules dejerine ( dejerine ( - , to the two-volume anatomie des centres nerveux [anatomy of the central nervous system] (dejerine, (dejerine, , , one of the most significant works in the field of neurology. in , she took part in the -day scientific meeting of the french society of neurology in paris, during which a dispute took place between jules dejerine and pierre marie, charcot's most important pupil. the first supported a differential classification of aphasias, while the second claimed the existence of only one type of aphasia (wernicke's aphasia). for pierre marie, broca's aphasia consisted of adding anarthria to wernicke's aphasia, and its neuroanatomical basis was to be localized in the "quadrilateral space" which included the basal ganglia and internal capsule. augusta dejerine-klumpke, through neuroanatomical data, proved that marie's assumptions were incorrect due to the fact that a lesion within the quadrangle is capable of causing aphasia only if it affects the anterior, upper and external parts of the area, thus sectioning the third frontal convolution foot and cap devoted to language skills (lecours and caplan, ) . after jules dejerine's death, pierre marie took over the chair of clinical neurology and fired augusta, asking her to free the laboratory from all dejerines' documents and personal effects. dejerine-klumpke, then, together with her daughter, created the "fondation dejerine" to collect all their clinical and research works in a museum and a laboratory. the foundation collection is currently located in the basement of the sorbonne university in paris under the management of the library. in her career, augusta dejerine-klumpke received many prizes and awards: the anatomy prize for free teaching in - , the godard prize of the academy of medicine in , the silver medal from the faculty of medicine in paris, the lallemand prize of the prestigious académie des sciences for her doctoral thesis in , a first legion of honor for her scientific studies in , and a second in with the rank of officer for her strong commitment in the care of wounded soldiers during the first world war. she was the first woman to become president of the french society of neurology in (berhoune et al., ) . augustine marie cécile mugnier vogt ( vogt ( - was one of the first women admitted to medical school in paris. she studied under the neurologist pierre marie and his research team at the bicêtre hospital and graduated in with a dissertation in neuroanatomy. in paris, cécile met oskar vogt ( vogt ( - , who worked for some time in the laboratory of augusta and jules dejerine at la salpêtrière hospital. after getting married, they settled in germany, berlin, and at the neurobiological laboratory (neurobiologische laboratorium), the vogts began a long and productive scientific collaboration that would lead them to landmark discoveries in the field of neuroanatomy and neuropathology. in , oskar and cécile vogt started to work at the new kaiser wilhelm institute for brain research (kwi), in berlin, which later became the max planck institute for brain research, as appointed director and head of the anatomy department, respectively. cécile vogt's work on the morphology of the nervous system contributed to a new understanding of the interactions between the different regions of the brain. she conducted systematic clinical-anatomical research and published important studies on the myeloarchitectonic organization of the thalamus, on the pathology of the corpus striatum, and the cytoarchitecture of the cerebral cortex (klatzo, ; vogt and vogt, ) . in her first work on thalamus myeloarchitecture, she identified several thalamic nuclei and their connections. it was a pioneering work for the modern understanding of the thalamus' physiology. cécile vogt was among the very few scientists in europe, together with sherrington in the united kingdom, to use cortical electrical stimulation. she countered, also through her research, the pervasive prejudice that women were intellectually inferior to men. in the s, vogt explicitly stated that her research did not support the hypothesis of a difference between male and female brains (akkermans, ) . cécile and oskar vogt worked also with korbinian brodmann, and they were recognized as "key figures in establishing modern brain research" (klatzo, ) . in the years following , they became the target of inspections and accusations by the national socialists and were forced to leave the kwi. from they moved to neustadt in the black forest and continued to work in their privately funded institut für hirnforschung und allgemeine biologie (institute for brain research and general biology). cécile vogt had a very productive scientific career for over years, despite the two world wars and the very tough social and economic situation in germany. before they met, cécile had given birth to a girl, claire, whom oskar adopted once married. they had two other daughters: marthe and marguerite. we are in the presence of an entire and unique family of scientists, and remarkable women, since claire ( claire ( - conducted and published research about pediatric neurology in paris, and was a pioneer in child neuropsychiatry (poirier and poirier, ); marthe ( marthe ( - was a leading neurophysiologist and pharmacologist, conducted, in the united kingdom, pioneering research on neuropharmacology for the treatment of mental illness, and was elected a fellow of the royal society (wright, ); and marguerite ( - ) was an outstanding cancer biologist and virologist, worked at the california institute of technology (caltech), in pasadena, united states, with renato dulbecco, and they were the first researchers to observe that polio virus formed plaques in tissue culture (rubin, ) . vogt and dulbecco founded the field of molecular virology. despite her high reputation in the scientific community, marguerite vogt never received major awards and honors and was not bothered by the fact that dulbecco received many awards for their joint work (including the nobel prize in ) (wunderlich, ) . in his nobel lecture, renato dulbecco acknowledged the assistance of many researchers but forgot the name of marguerite vogt, despite the inclusion of five of their joint publications in the reference section. many other names can be listed, among those sought in the historical archives or brought to light by historians. the crossed paths between augusta dejerine klumpke and cécile vogt were recounted at the annual history of neuroscience meeting in paris, dedicated for the first time to pioneer women in medicine and neuroscience. that event revealed, among others, the lives and careers of the italian anatomist anna morandi manzolini ( - ); two french neurologists from la salpetrière, chiriachitza athanassio-benisty ( - ) and gabrielle lévy ( - ; and the nobel laureate rita levi montalcini . the meeting was also attended by nicole le douarin, pioneer of microbiology, who is also the author of a fascinating chapter in the history of neuroscience in autobiography, volume (le douarin, ). volume of this collection includes the autobiography of brenda milner (milner, ) "the renowned neuroscientist who changed our understanding of brain and behavior" (watkins and klein, ) . milner was recently celebrated on occasion of her th birthday, the july , , with a ceremony and a series of conferences at the montreal neurological institute. she continues to conduct research and to support "troops" of scientists from all over the world (watkins and klein, ) . for her discovery of multiple brain systems for memory she was awarded the kavli prize in with john o'keefe and marcus raichle. the awards ceremony was captured in a very representative image in which brenda milner was the only woman to stand out with her blue dress among many white men in black (fig. ) : the non-diversity in science at its peak. although unintentionally, brenda milner continues to be a role model for several generations of women neuroscientists as well as for young students who want to pursue a scientific career. her work has also become popular through a comic book and the children's book good night stories for rebel girls (watkins and klein, ) . the place reserved for women in neuroscience is well illustrated in the indices of the ten volumes of the above-mentioned collection the history of neuroscience in autobiography, published by the society for neuroscience (sfn) from to : . out of essays are authored by distinguished women neuroscientists, corresponding to about % of all chapters by seniors, singles or couples. in recent years many initiatives have been launched to move toward gender diversity in the field of neuroscience. society for neuroscience provides opportunities to empower women scientists and increase awareness for gender bias, through the women in neuroscience initiative (win), created in . win is an international organization that aims at promoting professional advancement and facilitating communication between women working in neuroscience (haak, ) . women neuroscientists are still underrepresented in books, conferences, and various aspects of academic life. data from the women in neuroscience repository (winrepo) show that women: author significantly fewer papers as first or last contributor than men; -are awarded significantly fewer prizes; -and appear significantly less as speakers in departmental seminar series and conferences (schrouff et al., ) . winrepo is an initiative aimed at increasing the visibility of women in neuroscience, addressing gender bias through proposed solutions at different levels of intervention, and taking responsibility for promoting equal opportunities to new generations of neuroscientists. conscious and unconscious gender bias, combined with widespread sexual harassment in both academia and laboratories, can raise barriers that drive young women away from academic careers (national academy of science, ). awareness of any gender biases can be increased by getting data periodically. this is the aim of bias watch neuro, an initiative carried out through a website that tracks the gender ratio among speakers in conferences and authors of papers published in key journals, to raise awareness among the organizers and the neuroscientific community. under-represention of women in neuroscience also has implications for the general population, biasing the studies in the medical field, where: women's health is understudied, women are less represented in clinical trials, and many neuroimaging studies come from groups of highly educated white subjects. female invisibility begins in animal studies on brain disorders, which are more likely to be conducted on male animals (criado perez, ) , and comes to the diagnosis of head injury whose outcomes in women are historically attributed to chronic emotional disorders and, therefore, less investigated with neuroradiological tests, compared to men (casper and o'donnell, ) . adequate representation of women in neuroscience can improve by acting on institutional, organizational, cultural, and historical levels. the achievement of women awaits to be recognized and celebrated to strengthen the tradition of women who pursue research or academic paths and offer new generations equal opportunities in the field of neuroscience. the scenario that will follow the health emergency of the sars-cov- pandemic could neutralize the small progress made in recent years to promote a greater presence of women and in general a greater diversity in opportunities to study stem (science, technology, engineering, and mathematics) disciplines, to devote to scientific research, to pursue an academic career, to take part in conference panels, and to be awarded international prizes. the closure of schools and universities to control covid- transmission in countries could have a differential impact on high education and job opportunities of women, who provide the majority of informal care at home (wenham et al., ) . the response policies and practices to the indirect impact of outbreaks such as covid- must, therefore, be effective to not perpetuate or exacerbate gender, cultural and socio-economic inequalities in education and professional career. although the world health organization (who) executive board recognized the need to include women in the decisionmaking process for planning outbreak responses (who, ) , there is currently inadequate representation of women on scientific committees and task forces for covid- appointed by national governments. this makes it uncertain whether long-term investments are made to foster diversity. however, without any targeted intervention, data on publication records, allocated funds, and career advancements over the next two years will show that women in academia who are also engaged in informal home care were disadvantaged in (minello, ; viglione, ) . despite visible and invisible social and cultural barriers, women have reached pioneering milestones in neuroscience since the dawn of this modern discipline. the women neuroscientists who conducted their outstanding research in the early s have been almost completely forgotten and, with rare exceptions, there is no trace of their work in science handbooks or university textbooks. few women neuroscientists have been awarded major international awards, just as the percentage of women in the historical collections of eminent senior neuroscientists that extends to the present day is small. some initiatives have been undertaken to address gender bias, discrimination, harassment, lack of support for work-life balance, and to increase diversity and equal opportunities in accessing scientific research and academic career advancements. a cultural change, institutional actions, and the promotion of historical projects are among the needed solutions to increase awareness of bias and barriers, and to continue building a safer, diverse, collaborative, and innovative environment for the whole neuroscientific community. building a more inclusive environment is not an enterprise that can be left to individuals, it must be planned through a competent, integrated and widespread decision-making process (chiofalo and metitieri, ) , that is even more important to address in light of the new challenges posed by the covid- pandemic. the pioneering experimental studies on sleep deprivation augusta dejerine-klumpke ( - ): an extraordinary neurologist and an inspiration for all women in medical careers the klumpke family -memories by doctor déjerine, born augusta klumpke the punch-drunk boxer and the battered wife: gender and brain injury research the lesson we can learn from the canadian documentary "ms. scientist" to have more women in science exposing data bias in a world designed for men . avec la collaboration de madame dejerine-klumpke, anatomie des centres nerveux vols becoming a physician: medical education in great britain, france, germany, and the united states women in neuroscience (win): the first twenty years sex in mind: the gendered brain in nineteenth-century literature and mental sciences cécile and oskar vogt: the visionaries of modern neuroscience was the first biochemist a woman? the history of neuroscience in autobiography augusta dejerine-klumpke or "the lesson in anatomy brenda milner the pandemic and the female academic sexual harassment of women: climate, culture, and consequences in academic sciences, engineering, and medicine une neuropsychiatre infantile injustement oubliée the vogt family: creators of diverse paths for women in biological research inferior: how science got women wrong and the new research that's rewriting the story the "déjerines": an historical review and homage to two pioneers in the field of neurology and their contribution to the understanding of spinal cord pathology are women publishing less during the pandemic? here's what the data say allgemeine ergebnisse unserer hirnforschung brenda milner on her th birthday: a lifetime of 'good ideas gender and covid- working group. covid- : the gendered impacts of the outbreak strengthening preparedness for health emergencies; implementation of international health regulations key: cord- - wefotwe authors: johann, alexandra; ehlert, ulrike title: the study protocol: neuroendocrinology and (epi-) genetics of female reproductive transition phase mood disorder - an observational, longitudinal study from pregnancy to postpartum date: - - journal: bmc pregnancy childbirth doi: . /s - - - sha: doc_id: cord_uid: wefotwe background: postpartum depression is considered to be one of the most common health threats during pregnancy and postpartum, affecting not only the woman herself but also the offspring and the whole family system. evidence for a conclusive etiopathological model with distinct risk and resilience factors is still broadly lacking. therefore, the aim of the present study is to investigate numerous health-related markers to obtain greater insight into which biopsychosocial profiles render women more vulnerable to ppd or facilitate a healthy transition from pregnancy to postpartum. methods: the observational, longitudinal study aims to include a total of physically healthy women, aged – years. a multitude of relevant parameters, of an (epi-) genetic, endocrinological, physiological and psychological nature, will be assessed over a period of months, following the participants from the rd trimester until three months postpartum. discussion: the ultimate goal of the present study is to ameliorate mental health care during pregnancy and postpartum, by gaining a better understanding of the underlying biopsychosocial mechanisms that women undergo during the transition from pregnancy to postpartum. depression is projected to become the leading contributor to the global burden of disease worldwide by [ ] . it causes severe impairments to quality of life, and the adverse effects often extend to the whole family system of the affected individual [ ] . for instance, maternal depression is associated with unfavorable neonatal birth outcomes, and the offspring can show an up to threefold increased risk of developing a depressive disorder throughout later life [ , ] . it is well known that women's lifetime risk of suffering from major depression is twice as high as that of men [ ] . this sex difference emerges during early adolescence and leads to a lifetime prevalence of . - . % for women in the us and europe, compared to . - . % for men [ , ] . even though pregnancy and childbirth mark a period filled with joy and excitement for most women, there is a substantial group of women who are prone to develop mood disturbances throughout pregnancy and the postpartum period. as such, the transition phase from pregnancy to postpartum depicts an exceptionally vulnerable phase in a woman's reproductive life, given prevalence rates of - % for peri-and postpartum depression [ ] . previous research, including recent work by our own group, points to different trajectories of the onset and development of depressive symptoms during pregnancy and postpartum [ ] . in a large, community-based longitudinal online survey (n = ), we found a remarkably high incidence of antenatal and postpartum depressive symptoms ( . % and . %, respectively) as well as recurrence rates ( . % and . %, respectively) in healthy women and women with prior depression. it is well established that women with a history of non-puerperal depression show a greater risk of developing depressive symptoms during pregnancy and postpartum [ ] . to our knowledge, the aforementioned study was the first in a large swiss sample to clearly differentiate between recurrent and de novo episodes of depressive symptoms in pregnancy and postpartum. as such, we assume that there might be distinct biopsychosocial profiles, following different etiopathological pathways, which render some women more vulnerable to depression during pregnancy and postpartum compared to women who remain mentally healthy throughout the peripartum period. potential mechanisms that render these women more vulnerable might be found in the reported stressprovoked dysregulation of the hpa axis linked to nonpuerperal depression [ ] . in line with these findings, higher placental corticotropin-releasing hormone (pcrh) levels in mid to late pregnancy have been found to be a strong predictor of postpartum depression (ppd) [ ] . a potential explanation may be that the prolonged elevation of pcrh in pregnancy leads to greater residual hypothalamic suppression and hpa axis hypoactivity in women after giving birth [ ] . therefore, women with prior nonpuerperal depression might show a phenotype of greater vulnerability to the substantial changes of the hpa axis during pregnancy and postpartum. a further, hormone-sensitive phenotype has been discussed in previous research in women with a history of premenstrual syndrome/premenstrual dysphoric disorder or prior ppd. these women show a greater risk of developing depressive symptoms during pregnancy and postpartum [ ] . sex steroids rise exponentially during pregnancy, with a sharp drop following delivery and the associated displacement of the placenta [ ] . the rapid withdrawal of sex steroids can also be found in other reproductive phases, for example the luteal phase of the menstrual cycle or the perimenopause in later life. it has been shown that some women react particularly sensitively to sudden withdrawal and fluctuations of estrogen and progesterone, resulting in mood disturbances [ , ] . a notable key player associated with postpartum depression might also be one of the metabolites of progesterone, allopregnanolone: lower rates in the second and third trimester have been linked to an elevated risk of ppd [ ] . women prone to hormonal sensitivity are also more likely to experience somatization; for instance, hot flushes have been associated with depressive symptoms during pregnancy and in the postpartum period [ ] . there is an additional group of women who may show symptoms of depression during pregnancy but find themselves in remission after giving birth. these women might show greater physiological, psychological and psychosocial resources and resilience. specific genetic predispositions and epigenetic mechanisms seem to influence the likelihood of suffering from mood disturbances during pregnancy and postpartum, and might even differentiate between women with a history of non-puerperal depression versus women with prior pms/ppd on a (epi-) genetic level. in non-puerperal and peripartum depression, polymorphisms of the glucocorticoid receptor gene (gr ), the crh receptor (crhr ), the short version of the serotonin transporter-linked polymorphic region genotype ( -httlpr), as well as the serotonin a receptor (htr a) and protein kinase c (prkcb) have been found [ ] [ ] [ ] [ ] [ ] . distinct biomarkers for ppd focus on polymorphisms that implicate reproductive hormones, e.g. in the estrogen receptor alpha gene, and suggest an enhanced sensitivity to estrogen-based dna methylation reprogramming [ ] . in one study, the development of ppd was predicted with an accuracy of % in women with a higher expression change in response to erα signaling [ ] . research regarding the epigenetic mechanisms of the g protein-coupled estrogen receptor gene is still lacking. so far, despite extensive research, evidence for a conclusive etiological model for ppd, including potentially distinct biopsychosocial profiles and phenotypes, is largely absent, most likely due to the lack of combined assessments of biopsychosocial markers relevant for pregnancy and the postpartum period. the present study proposes an integrative etiopathological model with distinct trajectories including (epi-) genetic vulnerability, chronic stress or adverse life events, which result in a potential dysregulation of the hpa and hpg axis and their counter-regulation and render some women more sensitive to the fluctuations of sex steroids throughout pregnancy and the postpartum period. as such, the study seeks to provide an etiopathological model that contributes to explaining the higher prevalence of depressive disorders in women, with the ultimate aim of improving prevention, diagnosis and treatment of peri-and postpartum depression. design the present study will be an observational, longitudinal, single-center, national study. data will be collected between june and potentially december , depending on the current situation regarding covid- . pregnant women interested in participating will be screened for eligibility using both ) an online tool to screen for current depressive symptoms and prior depression with a short questionnaire using validated cutoff scores, and ) a telephone interview to verify the inclusion criteria. before completing the screening questionnaire, potential participants will be presented, on an online platform, with the inclusion criteria for study participation, general information about participation and a declaration of consent for the screening. potential participants will also be provided with a privacy statement, which refers to the relevant privacy aspects of the screening and the online surveys, and to which they must also explicitly agree. the online screening will compromise an examination of the general inclusion and exclusion criteria of the study, the edinburgh postnatal depression scale (epds) and an assessment of prior depressive episodes according to dsm- criteria. if the inclusion criteria will be met, participants will be invited to the first of two appointments at the laboratory (lab visit ) between and weeks of gestation ( rd trimester of pregnancy). all lab appointments will take place at the lab of the institute of psychology at the university of zurich. during these visits, sociodemographic as well as health-and pregnancy-related information will be obtained. additionally, the women will respond to psychological selfreport questionnaires (see table ). as part of the lab visits, participants will undergo the screening for the structured clinical interview for dsm-iv (scid-dsm-iv). if necessary, this will be followed by the scid-iv interview, conducted by a trained clinical psychologist. during both laboratory visits, capillary blood samples (dried blood spots) will be taken from the fingertip using a lancet (accu-chek safe-t-pro plus), based on the model of blood glucose measurement in diabetic patients. the blood spots will be absorbed by a special filter paper (whatman ) and dried for - hours at room temperature before being stored. in addition, peripheral physiological measures (blood pressure) will be taken at both laboratory appointments. at the end of the first lab visit, all women will receive a study material package and both oral and written instructions on how to collect the study parameters on their own. following lab visit , the pregnant women will be asked to provide saliva samples and to complete short questionnaires regarding perceived stress, quality of sleep and mood state on two consecutive weekdays between + and + weeks gestation, and then again as close to the due date as possible (i.e., weeks gestation) in order to capture the steep hormone increase as close to delivery as possible. on the evening before sampling, the women will receive a reminder by email. in total, each participant will collect saliva samples (using salicaps, ibl) at home, on two consecutive weekdays at - weeks of gestation, at weeks of gestation, at - weeks pp, and at - weeks pp (t -immediately after awakening; t - min after awakening; t - min after awakening; t -in the evening). the women will additionally wear a smart sensor bracelet to collect psychophysiological data during the days of saliva sampling. at - weeks postpartum, the women will be invited to a second and final lab visit (lab visit ). the procedure of the second visit will be comparable to the first (i.e., scid screening, dried blood spot sampling, measurement of psychological and psychophysiological parameters). additionally, birth-and postpartum-specific information will be obtained. all women will be compensated with gift vouchers as well as maternity and infant care products (in total worth approximately chf .-). moreover, the women will receive a summary of all major research findings. an overview of the study design can be found in fig. . the study will include a total of physically healthy pregnant women aged between and years. both women who were mentally healthy prior to pregnancy and women with a history of depression according to dsm- will be eligible for participation. the women will fig. study design. t = - weeks ;t = weeks ;t = - days postpartum; t = - weeks; postpartum; t = - weeks postpartum be examined beginning from the rd trimester of pregnancy onwards and followed into the postpartum period - weeks after giving birth. the following exclusion criteria will be applied: multifetal gestation; pregnancies achieved through assisted reproductive technology; medical complications (e.g., hypertension, diabetes mellitus, hyperemesis gravidarum, (pre)eclampsia, suspected fetal growth restriction, fetal structural abnormalities); medical condition or surgical intervention that might have affected ovarian function prior to pregnancy or may affect ovarian function during the postpartum period (e.g., polycystic ovary syndrome, endometriosis, breast cancers); current or past history of psychosis, bipolar disorder, posttraumatic stress disorder, eating disorder, substance abuse or dependency; current intake of hormones (e.g., corticosteroids), diuretics, hypertensives, vasodilators; treatment with psychotropic substances within the last months preceding study inclusion; drug use and/or smoking; alcohol intake of more than one standard unit a day; pre-pregnancy body mass index (bmi) > or < ; protein-restricted diet, and/or regular consumption of soy products. for the sample size estimation, we performed an a priori sample size estimation analysis using gpower . [ ] . the analysis was computed taking a middle effect size of . with α = . and power = . ( -β a) into account. since only pregnant women who will give birth to a healthy child will be included into the statistical analyses, and in order to take a drop-out rate of approximately % into account, a sample size of n = was estimated to obtain comparable subgroups of women with/without prior depression and with/without ppd according to recent prevalence rates. recruitment began directly after approval of the proposal by the ethics committee of the canton of zurich, switzerland. data of the study participants will be collected continuously for months. information about the study will be published on the research team's website, www.ichbinschwanger.ch, which was developed seven years ago with the goal of providing pregnant women with helpful material and knowledge about the current state of research on psychobiological health during pregnancy. study information leaflets will be handed out to all pregnant women receiving prenatal medical care at the obstetric departments of all major outpatient clinics of hospitals in and around zurich, switzerland. the study information leaflets will also be placed in as many outpatient clinics for gynecology and obstetrics in the zurich area as possible, and will be handed out to midwives and antenatal classes. additionally, study information leaflets will be offered to pregnant women visiting psychosocial counseling institutions regarding pregnancy and birth. moreover, recruitment will also be conducted via various mailing lists, online and newspaper advertisements, specific offers for pregnant women (e.g. prenatal yoga) and social media (e.g. facebook). informed consent will be first obtained electronically for the online screening tool, and written informed consent will be obtained prior to any data collection. in order to measure relevant psychological parameters, the participants will complete validated german versions of questionnaires regarding the following clusters of variables: psychological state and trait variables such as anxiety, depression and stress; potential risk factors such as early trauma and adverse life events; potential protective factors such as relationship quality; sociodemographic characteristics; and health-, pregnancy-, and birthspecific characteristics. online data will be collected using the unipark platform (www.unipark.com/de, certificate iso , ), which is reliably protected from any external access. the bsi-certified data center is subject to requirements of high data protection and safety in conformity with iso , based on the it basic protection. a comprehensive overview of all self-report questionnaires can be found in table . neuroendocrine parameters will be measured using saliva and dried blood spot sampling, with blood obtained from finger prick. with regard to saliva, the hpg hormones of interest will include salivary e, p, and allo. salivary cortisol, the end product of the hpa axis, will also be analyzed. saliva samples will be collected via salicaps (a passive drooling device; ibl international gmbh, hamburg, germany). salivary e, p, and cortisol concentrations will be quantified by luminescence immunoassay with commercial immunoassay kits (ibl-hamburg, germany). analyses will be conducted in our own laboratory. allo will be analyzed from the first measurement time point at morning awakening using an enzyme-linked immunosorbent assay (elisa). blood samples will be collected through finger prick. the participants' finger will be pricked with a sterile, disposable lancet (commonly used by diabetics, accu-chek safe-t-pro plus), and up to five drops of blood (about µl per drop) will be spotted onto standardized filter paper (no. whatman, dbs protein saver card). serotonin and crh will be assessed from dried blood samples obtained during lab visit and kept at − °c until analysis [ , ] . gaba, lh, and fsh will be measured in dried blood spots collected during lab visits and [ ] . the filter paper samples will be air-dried after collection and stored in an airtight plastic bag at − °c until analysis. biochemical analyses will be conducted at our own laboratory and the cytolab laboratory in regensdorf, switzerland. an overview of the assessed biological parameters can be found in table . methylation will be assessed using an established next generation sequencing (ngs) method: medium throughput bisulfite sequencing [ ] , which has been previously used by our research group in close cooperation with the lab of prof. dr. turecki, mcgill university, canada. the assay (e.g., primer design) for the methylation analyses of the nr c , fkbp , erα, erβ, and gper are already established in the lab, while the assay development for the crhr gene is currently ongoing and will be fully operational by the projected time of analysis. tagsnps selected in the candidate genes, according to the previously reported tagsnps selection procedure [ ] , and snps showing evidence of association, will be included in a custom genotyping array and analyzed at the genetic diversity center (gdc), eth, zurich. variable length tandem repeats (vntrs) will be analyzed by polymerase chain reaction (pcr) followed by capillary electrophoresis [ ] . to assess relevant psychophysiological data, participants will wear a smart sensor bracelet, the everion cd, developed by the medical technology company biovotion (https://www.biovotion.com). the everion cd is a noninvasive physiological monitor that is ce-certified as a class iia medical device. it provides parameters and features measured in very short intervals (every second) with medical-grade quality. measured psychophysiological parameters that are influenced by both the hpg and hpa axis hormones include the following: heart rate (hr), heart rate variability (hrv), resting respiratory rate (rr), skin temperature, electrodermal activity (eda), skin blood perfusion, steps, activity, barometric pressure, blood pulse wave, and blood oxygen saturation. the large collected dataset will permit us to address multiple research questions, such as associations between perceived sleep quality, objective amount of sleep, and the development of ppd. additionally, the sensor bracelet will be able to track participants' sleep duration and awakening time, which is essential for the statistical analyses and interpretation of the morning awakening response [ ] . these data will be transferred to a smartphone app, which the women will download and install on their smartphone upon study enrollment. besides big data analyses in cooperation with the mobile devices center of the urpp healthy aging, the collected data everion cd -bracelet psychophysiological parameter -heart rate -heart rate variability -skin blood perfusion -resting respiratory rate -activity -steps -skin temperature -barometric pressure -electrodermal activity -blood oxygen saturation will be investigated with specific algorithms provided by biovotion. for data security, each woman will receive a unique identification code. biovotion handles customer data in compliance with the gdpr. finally, participants' blood pressure will be assessed during the two lab visits in order to control for cardiovascular parameters in addition to the measurements with the everion cd bracelet. the statistical analyses will be conducted using the statistical package for the social sciences (spss . , armonk, ny, usa) and the open-source software r (the r foundation for statistical computing, vienna, austria) amongst others. multivariate analyses of variance, multivariate regression analyses, cluster analyses, multilevel/ mixed models, and mediator and moderator analyses will be used to analyze the neuroendocrine, psychological, (epi-) genetic and physiological parameters [ , ] . hypothesis-free data-mining approaches will be used to analyze the large amounts of data collected via the smart sensor bracelet in combination with the repeatedly assessed neuroendocrine and psychological parameters [ ] . with these analyses, the associations between biorhythms and depressive symptoms will be explored. to minimize the risk of over-interpreting incidental findings, split-half procedures will be used to compare hypothesisdriven analyses with data-mining models [ ] . moreover, all statistical analyses will be corrected for multiple testing as appropriate. the two-sided significance level will be set at p < . . the study population will be homogenous in terms of pregnancy/pp status (from to weeks of pregnancy until - weeks pp). from june to march , a total of women expressed an interest in participating by clicking on the online screening questionnaire, and ( . %) women completed the online screening questionnaire. after reassessment of the inclusion criteria by telephone, ( . %) participants were found to be eligible for the the present study aims to provide further insight into the etiopathological mechanisms that render some women more vulnerable to mood disturbances and anxiety throughout pregnancy and the postpartum period. to the best of our knowledge, previous research has mostly focused on either biological or psychological factors, whereas a comprehensive investigation of all relevant factors is still lacking. the main goal is to assess and evaluate specific health-related markers, such as (epi-) genetic factors, hormonal patterns, and psychosocial and physiological parameters that contribute to a healthy transition or maladaptation from pregnancy to postpartum. given the prevalence rates and multiple possible negative outcomes for the affected individual and the whole family system, it is of utmost importance to gain deeper insight into the underlying mechanisms of ppd. previous research has pointed in the direction of possibly different trajectories, meaning that not all women are affected equally by the same hormonal changes or risk factors. therefore, this study aims to find not only an overall etiopathological model, but also different trajectories of ppd, consisting of specific subgroups of vulnerable women who show a distinct biopsychosocial profile. the strengths of the present study design lie in its longitudinal nature, the application of strict inclusion criteria and the large set of relevant markers being assessed. a further strength is the inclusion of women with prior depression, women with current depression and/or anxiety, and mentally healthy women, which will enable us to follow up different pathways and their underlying mechanisms during pregnancy and the postpartum period. since distinct (epi-) genetic markers of ppd are still largely missing, we hope to obtain greater insight into possibly relevant gene-environment interactions regarding ppd. to gain objective physiological data, we will use smart sensor bracelets in order to monitor physiological symptoms in addition to self-assessment questionnaires (e.g. regarding sleep and stress). in conclusion, the present study aims to fill the gap in terms of achieving a conclusive etiopathological model regarding ppd by assessing numerous relevant biopsychosocial parameters in a longitudinal design and large sample. this should ultimately enable us to distinguish which women tend to have a high risk for mood disturbances during pregnancy and the postpartum period and thereby enhance prevention, diagnosis and treatment of ppd. so far, no declarations can be made, since the study is still ongoing. cross-national epidemiology of dsm-iv major depressive episode parental depression, child mental health problems, and health care utilization parental depression and depression in offspring: evidence for familial characteristics and subtypes? the contribution of psychiatric illness on perinatal outcomes cross-national associations between gender and mental disorders in the world health organization world mental health surveys neurodevelopment and ages of onset in depressive disorders magnitude and risk factors for postpartum symptoms: a literature review longitudinal assessment of symptoms of postpartum mood disorder in women with and without a history of depression psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: the role of the hypothalamus-pituitary-adrenal axis risk of postpartum depressive symptoms with elevated corticotropin-releasing hormone in human pregnancy sundström poromaa i, skalkidou a. mid-pregnancy corticotropinreleasing hormone levels in association with postpartum depressive symptoms associations between premenstrual syndrome and postpartum depression: a systematic literature review steroid hormones in the development of postpartum depression estrogen-related mood disorders -reproductive life cycle factors effects of gonadal steroids in women with a history of postpartum depression lower allopregnanolone during pregnancy predicts postpartum depression: an exploratory study prospective evaluation of nighttime hot flashes during pregnancy and postpartum association of glucocorticoid and type corticotropin-releasing hormone receptors gene variants and risk for depression during pregnancy and post-partum a serotonin transporter gene polymorphism predicts peripartum depressive symptoms in an at-risk psychiatric cohort role of mother's genes and environment in postpartum depression a pilot study evaluating genetic and environmental factors for postpartum depression association study of candidate genes with depressive and anxiety symptoms in post-partum women antenatal prediction of postpartum depression with blood dna methylation biomarkers the -httlpr polymorphism modulates the influence on environmental stressors on peripartum depression symptoms statistical power analyses using g*power . : tests for correlation and regression analyses blood serotonin levels in adults, autistic and non-autistic children -with a comparison of different methodologies quantitation of gammahydroxybutyric acid in dried blood spots: feasibility assessment for newborn screening of succinic semialdehyde dehydrogenase (ssadh) deficiency medium throughput bisulfite sequencing for accurate detection of -methylcytosine and -hydroxymethylcytosine marker selection for genetic case-control association studies association study of the estrogen receptor gene esr with postpartum depression-a pilot study assessment of the cortisol awakening response: summary of the ispne expert consensus guidelines mmpi- : cluster analysis of personality profiles in perinatal depression-preliminary evidence assessment of the cortisol awakening response: expert consensus guidelines bioinformatics mining and modeling methods for the identification of disease mechanisms in neurodegenerative disorders tutorial in biostatistics: data-driven subgroup identification and analysis in clinical trials we wish to thank the participants who have contributed to our study so far, the entire study team for collecting the data, and sarah mannion for proofreading the manuscript. the authors declare that they have no competing interests. authors' contributions ue developed the concept and provided critical revision of the manuscript. aj is responsible for acquisition of data and drafting the manuscript. all authors have read and approved the final manuscript. the study is funded by the swiss national science foundation (reference number: _ / ). the funding body had no influence on the design of the study, the collection, analysis, and interpretation of data and in writing the manuscript.availability of data and materials not applicable. ethical approval for the study protocol of this study was provided by the cantonal ethics committee zurich, health department, switzerland, reference number: kek-zh-nr. - . approved written informed consent forms will be obtained from each study participant. not applicable. key: cord- - kjlcakt authors: fogacci, silvia; fogacci, federica; favari, elda; toth, peter p; borghi, claudio; cicero, arrigo f g title: management of pregnancy-related hypertensive disorders in patients infected with sars cov- : pharmacological and clinical issues date: - - journal: eur heart j cardiovasc pharmacother doi: . /ehjcvp/pvaa sha: doc_id: cord_uid: kjlcakt aims: coronavirus- disease (covid- ) continues to spread throughout the world. it is known that among patients with hypertension, diabetes, chronic respiratory disease, or cardiovascular diseases, covid- is associated with greater morbidity and mortality compared with patients without these conditions. this correlation is of great importance in pregnant women affected by covid- , since it usually leads to the development of a serious clinical complication. in particular, managing hypertensive disorders in pregnancy can be problematic because antihypertensive medications may interact pharmacologically with drugs used to treat covid- . this review focuses on the safety of drug treatment for covid- in pregnant women treated with antihypertensive medication. methods and results: several databases were searched to identify relevant literature. a few antihypertensive drugs and antithrombotic treatments are known for having a beneficial effect in the management of hypertension and hypertensive disorders in pregnancy. in this review, we focus on the expected drug–drug interactions with the experimental agents most often used to treat covid- . conclusions: the current indications for the management of hypertension-related disorders in pregnancy maintain their validity, while the risk of pharmacological interaction with the currently tested anti-sars-cov- medications is relatively low. coronavirus disease , caused by the highly transmissible severe acute respiratory virus coronavirus (sars-cov- ), continues to spread throughout the world [ ] . the virus is primarily spread through close human contact via aerosolized droplets of saliva or mucus secretions [ ] . its main feature is infection of the respiratory system in association with cough, fever and typical changes in radiographic studies that can lead to acute respiratory distress syndrome, cardiovascular (cv) events such as myocardial infarction, myocarditis, fulminant heart failure and lethal arrhythmias, and such neurovascular events as ischemic stroke and encephalopathy. pregnant women are considered a high-risk group due to their altered immunological and physiological status [ ] [ ] [ ] . viral respiratory illnesses frequently develop during pregnancy; hence, pregnant women have greater vulnerability for contracting a sars-cov- infection [ , ] . as a matter of fact, physiological hormonal changes in pregnant women, such as the progesterone-mediated action on nasal mucosa, have been demonstrated to increase the probability of contracting the disease compared to the general population [ ] . very few studies are available concerning the effect of covid- on pregnancy and fetal outcomes [ ] . the maternal-fetal interface was analyzed in different clinical settings, and no evidence of vertical covid- transmission was seen in pregnant women in the third trimester of pregnancy [ ] [ ] [ ] . due to limited scientific evidence regarding pregnancy and covid- , some official statements have been made referring to sars cov- [ ] . some previous studies about sars suggest women may need prioritized medical care sincecovid- infection during pregnancy may lead to maternal and fetal complications, such as spontaneous miscarriage, preterm birth, intrauterine growth restriction, premature rupture of membranes, fetal tachycardia and fetal distress, multiple organ injury and admission to intensive care units [ , [ ] [ ] [ ] . nevertheless, what is clear is that more studies are needed regarding covid- and pregnancy, considering the fact that it affects the well-being of mothers and their babies [ ] . for this reason, accurate hygiene and social information must be guaranteed to pregnant women and their families in order to prevent sars-cov- infection [ ] . it is known that among patients with hypertension, diabetes, chronic respiratory disease, or cv diseases, sars-cov- infection is associated with greater morbidity and mortality compared to patients without these conditions [ , ] . this correlation is of great importance in pregnant women affected by covid- , since it usually leads to the development of a serious clinical complication [ ] . regarding hypertensive disorders in pregnancy there are very few drugs available with a controversial security profile, that sometimes pharmacologically interact with the ones tested to treat covid- [ ] . in particular, the anti-covid- medications for which there are currently more evidence are low molecular weight heparin (lmwh), lopinavir/ritonavir, hydoxychloroquine and chloroquine [ , ] . the purpose of the current review is to highlight the safety of drug treatment for covid - in pregnant women treated with anti-hypertensive medications. a few anti-hypertensive drugs and antithrombotic treatments are known for having a beneficial effect in the management of hypertension and hypertensive disorders in pregnancy. in this review, we focus on the expected drug-drug interactions with the experimental agents most often used to treat sars-cov- infection (figure ). in accordance with the european society of cardiology (esc) guidelines for the management of cv diseases during pregnancy, - mg/day acetylsalicylic acid (aspirin) should be recommended to pregnant women with a high or moderate risk to develop pre-eclampsia (class i; level of evidence a) [ ] . similarly, the american college of obstetricians and gynecologists (acog) recommends that these patients take mg/day of aspirin (level of evidence a) [ ] . in the general population, non-steroidal anti-inflammatory drugs (nsaids), such as ibuprofen, are reported to negatively affect the lungs, worsening a pre-existing pulmonary infection [ , ] . for this reason, some investigators brought into question the safety of aspirin treatment in pregnancy during the covid- pandemic [ ] . taking into account that significant data about aspirin intake and aggravation of covid- symptoms in pregnancy are lacking, the same authors agree that the benefits of aspirin prophylaxis in high risk women for hypertensive disorders outweigh the potential dangers posed by the virus [ ] . in this perspective, it is also worth to evidence a possible effect of nsaids on induction of map kinase phosphatase , leading the inhibition of inflammatory gene expression [ ] . moreover, we have also to consider a possible interaction between aspirin and lmwh on risk of bleeding [ ] . on the other side, there is no evidence that aspirin interacts with medications currently being evaluated for treating sars-cov- infection methyldopa is an alpha- adrenergic agonist with both central and peripheral nervous system effects. together with labetalol and calcium antagonists, methyldopa is one of the drugs of choice recommended by esc for the treatment of hypertension in pregnant women (class i; level of evidence b) [ ] . in accordance with the american heart association (aha) recommendations [ ] , methyldopa should only be prescribed in cases of severe hypertension during pregnancy, considering potential maternal and fetal side effects (class i; level of evidence a). in vitro, chloroquine and hydroxychloroquine are aminoquinolone derivatives that have antiviral activity against the sars-cov- [ ] [ ] [ ] [ ] ; however, efficacy data in humans are still preliminary. compared to chloroquine, hydroxychloroquine has a much better safety profile [ ] , and has demonstrated promising capacity to prevent pre-eclampsia [ ] . in clinical practice, methyldopa is often prescribed to women affected by systemic lupus erythematosus treated with hydroxychloroquine to prevent flares [ ] ., the coadministration of methyldopa and hydroxychloroquine is considered to be safe in hypertensive pregnant women infected with sars-cov- . among beta-adrenergic receptor blockers, esc recommends the use of labetalol as first-line therapy in pregnant women with hypertension (class i; level of evidence c) [ ] , while aha suggests atenolol (class iii; level of evidence b), pindolol, metoprolol and labetalol as first-line therapies (class iia; level of evidence b) [ ] . acog recommends labetalol therapy in urgent blood pressure control in pregnancy [ ] . thirdgeneration beta-blockers have also been shown to prevent bronchial asthma attacks and respiratory dysfunction. the release of nitric oxide, antioxidant action and other mechanisms underlying the vasodilating action of these drugs may be responsible for the beneficial therapeutic effects of these agents [ ] . however, these agents have never been tested in pregnant women. in pregnant women, the combination of beta-blockers and lmwh is the recommended treatment for atrial fibrillation [ ] . in this context, we can reasonably expect the combination of beta-blockers and heparin to be safely administered in hypertensivetreated pregnant women infected by sars-cov- . this is certainly of great interest, since lmwh seems to mitigate the pulmonary coagulopathy often promulgated by the virus [ , ] . in contrast, the simultaneous administration of beta-blockers and hydroxychloroquine (or chloroquine) requires close electrocardiographic monitoring due to the risk of qt prolongation [ ] . hydralazine hydrochloride is a hydrazine derivative vasodilator drug. in light of the acog recommendations, hydralazine is one of the drugs used for urgent blood pressure control in pregnancy [ ] . aha also recommends it in hypertensive-treated women (class iii; level of evidence b) [ ] . to date, there is a lack of validated studies evaluating the interaction between hydralazine and investigational drugs used for treating sars-cov- infection while nsaids could reduce its efficacy by inhibiting the prostacyclin-related vasodilation [ ] . anti-hypertensive drugs recommended by esc (level of evidence c) [ ] and aha (class i; level of evidence a) [ ] , whereas acog advises nifedipine administration only in the setting of hypertensive urgency [ ] . during the current pandemic, questions have been raised about potential drug-to-drug interactions with treatments for sars-cov- infection. a variety of antiretroviral therapies are being tested to treat covid- [ , [ ] [ ] [ ] . the co-administration of nifedipine and lopinavir/ritonavir is potentially toxic linked, to their common cytochrome p a related metabolism [ , ] , occasionally causing serious sides effects such as tachycardia, hypotension, headache and peripheral edema [ ] . considering the safety profile of combining nifedipine and lopinavir/ritonavir in non-pregnant women, we can reasonably expect a toxic effect in pregnancy as well [ ] . high-risk pregnant women by improving endothelial function in the vasculature [ , ] . moreover, lmwh inhibits endothelial inflammation [ ] , making it potentially useful for treatment of sars-cov- infection. in accordance with the latest esc guidelines for the management of cv disease during the covid- pandemic, drug-drug interactions should be considered before administering azithromycin in patients treated with lmwh [ ] , despite possible beneficial effects by azithromycin in patients infected with sars-cov- [ ] . in contrast, chloroquine, hydrochloroquine and lopinavir/ritonavir do not have any clinically significant interactions with lmwh [ ] . intravenous magnesium sulfate is recommended for preventing eclampsia and treating seizures as suggested by acog (level of evidence a) [ ] and esc [ ] guidelines. according to a case-control study, its co-administration with lmwh shows better results than magnesium sulfate alone in treating severe pre-eclampsia [ ] . there are no no contraindications to combined treatment in hypertensive pregnant women infected with sars-cov- [ ] . guidelines, a recent meta-analysis shows it may prevent pre-eclampsia in pregnancy [ ] . from the covid- point of view, it seems to have a role in the pre-clinical phase in strengthening the immune system, especially in cases of deficiency [ ] . furthermore, several studies have shown antiviral effects of vitamin d, which can interfere directly with viral replication, but also can act in an immunomodulatory and anti-inflammatory way [ ] . in addition to vitamin d, vitamin c is not included in international recommendations, though its deficiency has been associated with an increased risk of pre-eclampsia [ ] . its role in preventing hypertensive disorders in pregnancy is still unclear and needs to be further investigated [ ] . in the course of the sars-cov- pandemic, vitamin c serum levels are reported to decrease during infection and the requirement for supplementation increases accordingly [ ] . a number of ongoing clinical trials will provide additional information on the impact of vitamin administration as a component of supportive care in sars-cov- infection [ , ] . the general advice for pregnant women is to avoid pharmacological treatments, in particular since rarely the safety profile of drugs has been systematically evaluated in this frail patient population [ ] . considering that available data on covid- in pregnant patients do not provide a clear conclusion as regards clinical implications for mother and fetus [ ], decision-making processes in clinical practice need to be based on well-known similar prognostic models. in this context, in order to study the potential drug-drug interactions it is possible to refer to particular affections in pregnancy in which the anti-hypertensive treatment has just been tested along with drugs currently used against sars-cov- . for example, cohorts of hypertensive pregnant women affected by hiv can be taken into exam to predict the clinical outcome of protease inhibitors and ccb association [ ] . in the same way chloroquine and hydrochloroquine effect along with methyldopa can be usefully considered in cohorts of pregnant women with rheumatological diseases and gestational hypertension [ ] . there is no doubt that data on long-term safety regarding all the above-discussed treatment combinations are needed, but until more evidence become available, it is necessary to rely on previous clinical experience and not prioritize the treatment of covid- over that of hypertension, as it can also result in potentially fatal complications [ ] . on the other side, even if renin-angiotensin system inhibitors seem to improve the clinical outcomes of sars-cov- patients with hypertension [ , ] , they are contraindicated during pregnancy because of teratogenesis risk [ ] . finally, it must be taken into account that even though several clinical trials have been initiated to assess potentially promising therapies for covid- , pregnant and breastfeeding women were excluded from almost all these studies [ ] . obviously, this will cause a delay in identifying the most appropriate treatment, though the choice is in some respects understandable. future research should focus on drugs protecting the endothelium from the damage induced by sars-cov- infection. [ ] in particular, cell adhesion molecules (cams), including cd l/l-sign and cd /dc-sign, could be a relevant role in sars-cov- infection and other related viruses, consequently been possible therapeutic targets. [ ] inhibition of il- and the janus kinase, signal transducer and activator of transcription proteins pathway (jak/stat), could be also favorable targets. 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- journal: transl psychiatry doi: . /s - - -x sha: doc_id: cord_uid: w lfv e coronavirus disease (covid- ) is rapidly spreading worldwide, with a staggering number of cases and deaths. however, available data on the psychological impacts of covid- on pregnant women are limited. the purposes of this study were to assess the prevalence of psychiatric symptoms among pregnant women, and to compare them with non-pregnant women. from february to march , , a cross-sectional study of pregnant and non-pregnant women was performed in china. the online questionnaire was used to collect information of participants. the mental health status was assessed by patient health questionnaire, generalized anxiety disorder scale, insomnia severity index, somatization subscale of the symptom checklist , and post-traumatic stress disorder (ptsd) checklist- . totally, respondents were enrolled, including pregnant women and non-pregnant women. in this study, . %, . %, . %, . %, and . % of pregnant women were identified to have symptoms of depression, anxiety, physical discomfort, insomnia, and ptsd, respectively. however, the corresponding prevalence rates among non-pregnant women were . %, . %, . %, . %, . %, respectively. after adjusting for other covariates, we observed that pregnancy was associated a reduced risk of symptoms of depression (or = . ; % ci: . – . ), anxiety (or = . ; % ci: . – . ), insomnia (or = . ; % ci: . – . ), and ptsd (or = . ; % ci: . – . ) during the covid- epidemic. our results indicate that during the covid- epidemic in china, pregnant women have an advantage of facing mental problems caused by covid- , showing fewer depression, anxiety, insomnia, and ptsd symptoms than non-pregnant women. in december , unexplained pneumonia occurred in wuhan, china and then became an epidemic. now it is well-known as the coronavirus disease (covid- ) epidemic, which is spreading rapidly around the world, causing a high incidence and heavy economic burden , . on january , , the novel coronavirus was identified as the pathogen of the epidemic by genome sequencing . due to the rapid spread of the epidemic in many countries, the emergency committee of the world health organization (who) called an emergency meeting on january, declaring the novel coronavirus (sars-cov- ) epidemic as a public health emergency of international concern (pheic) . subsequently, the who officially named covid- on february . moreover, accumulating evidence has shown that person-to-person transmission has occurred between close contacts , . according to the official website of the chinese national health commission, as of february , , china had , confirmed cases and deaths, with a fatality rate of . % . as a major public health emergency, the covid- outbreak not only poses a great threat to human life , but also has a significant psychological impact on public health . wang et al. reported that . % of the general public rated the psychological impact as moderate to severe . yang et al. conducted a survey of teenagers aged - years during epidemic period, and found that . % of them had anxiety disorders and . % had severe depressive symptoms . lai et al. investigated heath care workers from fever clinics or hospital wards in china during the covid- outbreak, and found that a considerable number of them had symptoms of depression, anxiety, insomnia, and distress . however, to our best knowledge, no research has focused on the psychological impact of covid- epidemic on pregnancy women. previous studies have shown that pregnancy women who bear significantly psychological burden are more likely to develop mental disorders and impaired social function in the future , . further, the mental problems during pregnancy can also adversely affect the cognitive, emotional, and physical development of children [ ] [ ] [ ] . therefore, more attentions should be paid to the mental health of this special population. moreover, pregnant women are at high risk of sars-cov- infection due to suppression of immune system functions . during the covid- epidemic, it is difficult for pregnant women to receive routine prenatal examinations or delivery, which may further increase the psychological burden of pregnant women. recently, a retrospective review reported nine pregnant women contracted covid- pneumonia in late pregnancy, and showed that almost half of patients ( / ) had preterm birth , similar to previous studies that pregnant women infected with severe acute respiratory syndrome coronavirus (sars-cov) or middle east respiratory syndrome coronavirus (mers-cov) had an increased risk of adverse pregnancy outcomes, including preterm birth and neonatal death , . therefore, during covid- epidemic, pregnant women may face greater psychological pressure and more complicated psychological problems. we conducted this mental health survey among pregnant and non-pregnant women in china during the covid- outbreak to assess the prevalence of depression, anxiety, physical discomfort, insomnia, posttraumatic stress disorder (ptsd) in both groups, and to explore whether pregnant women have more serious mental symptoms than non-pregnant women. a cross-sectional survey was performed to assess the psychological status of pregnant and non-pregnant women in several maternal and child health hospitals in beijing during the epidemic of covid- . as the chinese government requires the general public to stay at home, our study adopted anonymous online surveys to collect data. the link to the survey was disseminated through social networks and through notifications from the maternal and child health hospitals. the notice required participants to be pregnant or non-pregnant women of childbearing age. pregnant and non-pregnant women were invited electronically through the widely used social media app wechat (wechat, tencent inc, china). because the notifications were spread through the maternal and child health hospitals, and pregnant women paid close attention to the health of their fetuses, they had received antenatal check-ups on time. therefore, during the covid- epidemic, they may pay more attention to hospital information than non-pregnant women, resulting in more pregnant women participating in the study. data collection was completed during february -march , . the present study was approved by the institutional review board of the institute of psychology, chinese academy of sciences. all participants provided the informed consent before participating in the study. the structured questionnaire was used to collect sociodemographic data, mental health information, and additional information about covid- . socio-demographic data included age, nationality, marital status, occupation, education, height, weight, place of residence, smoking and drinking, annual family income and history of chronic diseases. in addition, respondents were asked to answer whether they followed the epidemic information every day, and whether any of their relatives or friends were infected with covid- . the mental health status of the participants was assessed by the chinese version of various scales, including the patient health questionnaire (phq- ), generalized anxiety disorder scale (gad- ), insomnia severity index (isi), somatization subscale of the symptom checklist (scl- ), and post-traumatic stress disorder checklist- (pcl- ). our study used phq- to measure depressive symptoms. each phq- question asks the respondents how many days they have experienced depressive symptoms in the past two weeks. the scores for each item are as follows: point (not at all), point (a few days), points (more than half the days), and points (almost every day). the total score of phq- ranges from to and is used to identify women who meet the criteria for depressive symptoms. the validity and reliability of the chinese version of phq- were reported, with a sensitivity of . and a specificity of . . the cronbach's alpha value of this study was . . in this study, women with a phq- score of more than were considered to have depressive symptoms. the gad- was used to assess the anxiety level of participants. gad- has items, and each item is scored on a -point scale ranging from to . the total score ranges from to , and the higher score reflects the increased risk of gad. gad- has been previously validated among pregnant chinese women . participants have anxiety symptoms with a cutoff of or higher . in this study, the cronbach' s alpha value was . . the scl- somatization subscale was applied to measure the severity of somatic symptoms. the reliability and validity of the chinese version of the scl- have been established in previous studies . it has items, mainly reflecting the subjective physical discomfort over the past week. each question is rated on a -point likert scale. the total score of the subscale is between and . an individual with a cutoff of or higher indicates that he or she has obvious somatic symptoms. in this study, the cronbach's alpha coefficient of the scale was . . insomnia was assessed by the chinese version of the item isi. participants were asked to answer these questions on a -point scale, with a score range of - . the total score ranges from to . a cutoff of or higher indicates insomnia symptoms. the tool has been proven to have good reliability and validity . in this study, the cronbach's alpha coefficient of this scale was . . ptsd was evaluated by using the ptsd checklist- (pcl- ). pcl- includes items that reflect the standards of diagnostic and statistical manual of mental disorders (dsm-iv). participants were asked how troubled they were with each item in the past month, on a - likert scale. the total score ranges from to , and a score of or higher indicates the presence of ptsd. in this study, the cronbach's alpha value was . . continuous variables were expressed as mean ± standard deviation (sd) and compared using student's t-tests. due to non-normal distributions, the scores of the measurement scales were expressed as the median of interquartile ranges (iqrs), and the difference in symptom scores between the two groups was compared by mann-whitney u test. categorical data was expressed as a percentage and compared by chi-square test. multivariable logistical regression was used to measure the independent association between pregnancy and mental health status. statistical significance was evaluated at % level (two-tailed test). all analyses were performed using spss software version . (spss, chicago, il, usa). totally, we received completed questionnaires, and respondents with a diagnosis of mental illness were excluded from this study. finally, women ( pregnant and non-pregnant women) were included in the analysis. they were from cities in china. since the link to the survey was spread through social networks and through notifications from several maternal and child health hospitals in beijing, three quarters of them came from beijing. however, due to the traditional chinese festival "spring festival" at the end of january, most of outsiders had left beijing to be reunited with their families. some people also participated in this study through the internet link disseminated by the hospitals, resulting in our subjects coming from cities in china except for beijing. in addition, the participants had an age range of - years, with han nationality accounting for . %, and the married rate of . %. table compares the socio-demographic and behavior characteristics of pregnant and non-pregnant women. pregnant women were more likely to be younger, get married, have higher weight and body mass index (bmi) and have a job than non-pregnant women. on the contrary, non-pregnant women had a higher proportion of current smokers, drinkers, and low family incomes than pregnant women. in addition, the proportion of pregnant women suffering from chronic diseases was significantly higher than that of non-pregnant women. however, there was no significant difference between pregnant and nonpregnant women in terms of nationality, education, height, and attention to epidemic information. compared with non-pregnant women, pregnant women had lower scores of symptoms of depression, anxiety, and ptsd (all p < . ). however, there was no significant difference in scl- somatic symptoms and insomnia symptoms between the two groups. in addition, we analyzed the relationships between socialdemographic factors (education, income, job occupation) and the scores of psychiatric conditions in the pregnant group, non-pregnant group, and the whole participants. however, there was no significant difference between these social-demographic factors and the scores of psychiatric conditions except for the scores of somatization symptoms among the participants with different education levels and occupations in the whole participants. among the non-pregnant women, . % ( / ) had depression symptoms and . % ( / ) had anxiety symptoms, which were significantly higher than those of pregnant women ( . % and . %, respectively; both p < . ). moreover, insomnia ( . % vs. . %, p < . ) and ptsd ( . % vs. . %, p < . ) were more common in non-pregnant women than those in pregnant women. however, there was no significant difference in somatic symptoms between the two groups ( . % vs. . %, p > . ). after adjusting other covariables with statistical significance in univariate analysis, including age, married status, weight, bmi, employment, smoking, drinking, annul family income, and history of chronic diseases, we observed that pregnancy was associated with a reduced risk of depression (or = . ; % ci: . - . ; p < . ), anxiety (or = . ; % ci: . - . ; p < . ), insomnia (or = . ; % ci: . - . ; p = . ) and ptsd (or = . ; % ci: . - . ; p = . ) ( table ) . however, after adjusting for other variables, there was no significant difference in the prevalence of somatic symptoms between the two groups. to the best of our knowledge, this study is the first investigation to assess and compare the prevalence of psychiatric symptoms including depression, anxiety, somatic symptoms, insomnia, and ptsd between pregnant and non-pregnant women during covid- epidemic. interestingly, our study showed that pregnant women had fewer psychiatric symptoms including depression, anxiety, insomnia, and ptsd than nonpregnant women. in the current study, a small percentage of pregnant women displayed symptoms of depression, anxiety, physical discomfort, insomnia, and ptsd during the covid- epidemic. however, a study by hawryluck et al. showed that the detection rates of depressive symptoms and ptsd were . % and . % , respectively, during the epidemic of severe acute respiratory syndrome (sars) in , which were significantly higher than our survey results in this study. compared with covid- , more serious psychological effects may be attributed to higher mortality of sars. moreover, the chinese government has taken many effective measures to control the further spread of the epidemic, such as city closure, traffic control, and self-isolation, which have enhanced public confidence in winning the fight against the epidemic. a study recently published by lai et al. showed that . %, . %, . %, and . % of medical staffs reported symptoms of depression, anxiety, insomnia, and distress, respectively . another study by wang et al. reported that . % of the respondents had moderate to severe depressive symptoms, . % had moderate to severe anxiety symptoms, and . % had moderate to severe stress levels . the reported prevalence rate was significantly higher than that in our current study. the differences in prevalence estimates may be explained by the variation of the study however, leach et al. reported that the levels of depression, anxiety, and stress of pregnant and non-pregnant women were similar . in addition, contrary findings have been reported. for example, adewuya et al. reported that anxiety disorders were more common among pregnant women ( . % vs. . %) than non-pregnant women , which was confirmed by uguz et al. . this discrepancy in results may be due to differences in the study population, diagnostic tool and criteria, and the impact of the covid- epidemic. compared with pregnant women, non-pregnant women may have fewer opportunities to keep in touch with medical staff, and are more disappointed with limited activities because of self-isolation. as for the decreased risk of psychological effects on pregnant women, there may be several reasons. first, pregnant women decided to become pregnant when they had better mental health and financial situation. therefore, they had better health mental condition than nonpregnant women. second, pregnant women, as the focus of family attention, may obtain more emotional support from family members during covid- epidemic. third, increased contact with medical workers can provide support and decrease stress symptoms. fourth, pregnant women reduce the processing of chemosensory anxiety signals, thereby reducing the perception of anxiety . in addition, there is accumulating evidences that elevated hormone levels during pregnancy reduced the symptoms of ptsd . this study has several limitations. the first limitation is that our study is a cross-sectional survey and lacks longitudinal follow-up, which prevents us from exploring its impact on pregnancy outcomes. therefore, the long-term psychological impact on this population is worth further investigation. second, most participants were from 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controlled study is pregnancy associated with mood and anxiety disorders? a cross-sectional study pregnancy reduces the perception of anxiety symptoms of posttraumatic stress disorder in a community sample of lowincome pregnant women we are particularly grateful to the participants agreed to participating in our study. the authors declare that they have no conflict of interest.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.received: june revised: september accepted: september key: cord- - uqpro authors: cafferata, gail title: gender, judicatory respect and pastors’ well-being in closing churches date: - - journal: rev relig res doi: . /s - - - sha: doc_id: cord_uid: uqpro this study of over clergy in five old-line protestant denominations (episcopal, lutheran, united methodist, presbyterian and ucc) who dissolved their congregations examines the relationships of gender, judicatory respect and pastors’ well-being in their experience of closing a church and vocational transition afterwards; respondents completed a written survey and most also participated in in-depth interviews. survey results show significant gender differences in the experience of respect from and satisfaction with relationships with the middle administrative part of the wider church called here the judicatory (e.g., synod, conference, diocese or presbytery), and with the experience of stress after their churches closed. women clergy experienced greater loneliness and isolation, financial strain and thinking that closure affected their job search; their job search was also significantly longer than that of men. respectful judicatory relationships are negatively related to many but not all vocational stresses. comparisons with the experience of secular professionals suggest the stigma of closing a church adversely affects women clergy’s vocational journey more than men’s. the paper closes with implications for judicatory support of clergy leading churches to closure. the challenges and rewards of clergy serving protestant churches spring from the intersection of their divine call to ordained ministry with the sacred communities called "church" (both local and wider), and the broader social culture in which pastors and their congregations are embedded. a pastor's experience of vocational risks like precarious finances, church conflict, and rural isolation, as well as vocational rewards like deepened faith in god, collaborative relationships with church members, and respect by colleagues and superiors such as bishops, depend not only on the presence of god, but also the commitments and practices of institutional systems within which they work, not only congregations, but also denominational institutions. social scientists know little of how the wider, administrative bodies that coordinate local congregations, called judicatories, affect a pastor's experience of vocational challenges and rewards. these middle administrative bodies (such as dioceses or synods) are both the "body of christ" and modern bureaucracies. as such, they are hybrid structures with inherent tensions between communal norms such as equality, transparency and respect, and institutional demands such as a hierarchy of authority, effectiveness, efficiency and sustainability. as well, a diverse mosaic of inner-city/rural, large/small, majority-anglo/majority-ethnic, working-class/white collar, theologically conservative/progressive congregations in the same body may strain a judicatory's capacity to support pastors serving vulnerable churches (cafferata ). although earlier research has documented a gender gap among clergy in compensation, full-time placements, attainment of higher-level leadership positions, and acceptance of their leadership, we still do not understand whether access to judicatory, as well as congregational support, differs among men and women pastors serving congregations that eventually close (zikmund et al. ; price ). this paper draws on survey and interview data from a five-denomination national study of pastors who had the experience of closing their churches (cafferata ) . this point of church crisis and vocational vulnerability offers a unique opportunity to examine whether career challenges such as spiritual or emotional stress, health issues, or access to resources such as financial or spiritual support from a judicatory differ among women and men. further, it enables us to examine how the demise of their congregation subsequently affects the vocations of men or women clergy, for example, whether they are equally able to secure their next position and experience satisfaction with their new ministries and lives. this research is important because the rate of church decline is rising across mainline protestant denominations and more pastors, both men and women, will experience this ministry in their vocation (voas and chaves ; roozen ; pew research center ) . for example, the episcopal church lost almost a quarter of its members between and (goodhew ) . old-line protestant churches like those in this study are becoming older and more fragile as congregations fail to replace themselves with newer generations (mckinney ; funk and smith ) . economic displacement associated with the covid- pandemic may accelerate this trend. even when not closing a church, serving as a pastor can be challenging (chaves and eagle ; ellison et al. ; francis et al. ; lewis et al. ; pepinster ; proeschold-bell and byassee ) . serving when a church's future is threatened by congregational aging, declining income, culturally shifting neighborhoods, and the inability to replace leaving or dying members with young families is even more so (bendroth ; berry et al. ; darling et al. ; ellison et al. ; francis and brewster ; gledhill ; peyton and gatrell ; rudgard ; willimon ; wuthnow ; united church of christ ; gaede ; irwin ; olson ) . in these demanding circumstances, the "living human web" of supportive relationships should be important in buffering clergy's spiritual and emotional stress and nurturing wholeness (miller-mclemore ) . a wholistic health approach posits that this "living human web" of personal and professional support affects clergy health (proeschold-bell et al. ) . although women in historic protestant denominations have been ordained for decades, women clergy must work harder than men to obtain a position, keep a position, get equal pay, and get promoted (greene and robbins ; froschauer ; chang ; executive council's committee on the status of women et al. ; hoegeman ; hughes ; lehman ; zikmund et al. ) . similarly, in non-religious job sectors, a cultural presumption of male superiority or dominance has been shown to affect hiring, job evaluation and promotion, pay, and access to in-group and mentoring supports in occupations such as nursing, science, law, medicine or business (heilman ; eagly and heilman ; carli and eagly ; vial et al. ; lerchenmueller and sorenson ) . in secular occupations, roles that require a high degree of agentic behavior such as authoritative decision-making, commitments to effectiveness and efficiency, self-advocacy and emotional distance are more difficult for women to negotiate successfully (ridgeway ; zheng et al. ) , resulting in greater job stress. in the profession of ministry, women the risk being called "cold" or "aggressive" when they exercise structural authority. like women in other occupations, women pastors may be more inclined to exercise charismatic or inspirational personal authority and to see themselves as empathic, transformational leaders (brescoll ; ramsay ; zikmund et al. ) . a transformational leadership style is built on relationships of respect, trust and communality; it is emotionally expressive, inspires motivation for others to participate and contribute, and values the development and mentoring of community members. in contrast, prevailing gender norms make it easier for male clergy to exercise a transactional or laissez-faire leadership style where relationships are more formal, exchange-based, and focused on task completion. one study found that nearly a third of women pastors view their role primarily as one of empowering laity to implement decisions that laity have made, whereas only % of clergy men chose this style (carroll ) . research has confirmed that women leaders are seen as more effective when they exercise both inspirational motivation (seen as agentic) and individual consideration (that is seen as communal) (zheng et al. ) . this study therefore expects women pastors may be more likely than men to be disappointed when denominational colleagues and superiors fail to respect their dignity by not accepting their identity, including them as much as their male colleagues in professional work, being fair, understanding them, recognizing them, or, in other words, when judicatories fail to exercise inclusive, transformational leadership. failure to accept their pastoral identity, or unfair demeaning of their competence may be a unique source of stress for women pastors. for example, managerial literature has shown that women walk a "razor's edge" in balancing expectations for agentic behavior with cultural expectations for women's communality such as being caring, participatory, other-serving, and approachable (zheng et al. ) . evaluations of competence are shaped by a leader's capacity to exercise both agentic and communal behavior; traditional gender expectations assume women's agency and competence to be lower than men's, with women being less likely to be perceived as leaders despite the same qualifications; when they succeed, women are more likely than men to attribute it to hard work and less likely to attribute it to innate ability (ridgeway ; lerchenmueller and sorenson ; pickett ) . when things aren't going well, as in the throes of church closure where there is grief and even conflict about what to do and how to do it, a cultural presumption of male dominance or superiority may be able to buffer the attribution of failure or incompetence to male but not female clergy, especially in denominations such as the church of england, the episcopal church, and others where formal hierarchical leadership has been historically male (greene and robbins ; ridgeway ) . although one study found women pastors find greater social support in their congregations and among colleagues and the church hierarchy than men (mcduff and mueller ) , that research was confined to clergy in two non-hierarchical denominations (doc and ucc). other studies show that women pastors find less support in their work than men. for example, women priests in the church of england reported overt and hidden congregational hostility to their leadership as well as a lack of respect among colleagues in the wider church such as being talked about behind their backs, openly criticized, belittled in public, overly scrutinized, and not being listened to (greene and robbins ) . they reported being placed in appointments at a higher risk of failure as well as in congregations lacking empathy for the constraints of motherhood and work-life balance. in the u.s., a national study of methodist clergy found women pastors more likely than men to report occupational stress, hostility of church environment and perceived stress (wespath ) . in the episcopal church, men reported greater assistance from bishops in their job search than women, and gender inequalities persist in income, access to senior positions, and the ability to achieve work-life balance (price ). an essential quality of pastoral relationships with congregations and judicatories, the "living human web," is mutual respect. respect is a nearly universal dimension of ethics. respect for the other, as in the golden rule ("do unto others and you would have them do unto you"), is a foundational value in the fields of education (deutsch and jones ) , the law (lawrence-lightfoot ), nursing (parse ) , medicine (sarsons ) , feminist studies (farley ) , business (van quaquebeke and eckloff ) , and entire societies (dyck ) . respect is key to reconciliation efforts as described in the "dignity" model of hicks ( ) , spanning dimensions such as acceptance of identity, inclusion, safety, acknowledgement, recognition, fairness, benefit of the doubt, understanding, independence and accountability. following this model, this study measured clergy satisfaction with these dimensions of respect from their congregations and their judicatories. although mutually respectful relationships may deter the formation of shame and stress among clergy closing churches (lawrence-lightfoot ), "second generation gender bias" against women, that is, widespread "cultural beliefs about gender as well as workplace structures, practices and patterns that inadvertently favor men," (ibarra and petriglieri ) may intrude in the church, increasing stress for women clergy serving a closing congregation. the persistence of gender bias even after acceptance of women into professions such as science has been well noted (pickett ). such bias may shrink support by judicatories as well as congregations considering them for positions after their church closes. in the heat of conflict or the pain of grief, cultural and structural resistance to women's leadership may prove stronger than any theological commitment to dignity, respect and fairness or, for that matter, bureaucratic norms of efficacy, efficiency, and accountability. on the basis of previous research, this study hypothesizes that: . satisfaction with respect from their congregations and judicatories will differ by gender, with male pastors being more satisfied than women pastors; . lower satisfaction with respect from their congregations and judicatories will be associated with the experience of "worsening health" while serving the church that closes as well as the experience of a difficult, even tragic, closing, measured by a pastor's description of it as like "good friday" or "holy saturday," rather than a "reflective" church season (advent, lent) or a "festive" church season (christmas, epiphany, easter, pentecost, all saints). . satisfaction with respect from congregations and judicatories will be associated with mental health of pastors one to three years post-closure (when the written survey was completed). . the experience of overall vocational stress such as difficulty finding a new position will be associated with lower satisfaction with mutually respectful relationships with congregations and judicatories. . women will have more difficult vocational trajectories following a church closure than men, i.e., longer job search time, less support from judicatories in their job search, less satisfying relationships with their judicatories after closure. this study examines the experiences of a universe of women and men clergy in five mainline protestant denominations (episcopal, lutheran, methodist, presbyterian and united church of christ) who closed their churches over a span between and , depending on the denomination. after pastors' names and contact information were received from the national research offices of each of these denominations, -page surveys were mailed in - (with postage-paid envelopes), with follow-up surveys and reminder postcards at appropriate intervals. surveys were completed by ( %); there were no significant differences in response rates by gender; the only non-response bias was race, with non-whites less likely to respond than whites. table shows measures used in statistical analyses. clergy variables include age, gender, marital status, church experience (first or second appointment vs. longer experience), whether the pastor had a multi-church appointment, whether they were bi-vocational, whether the pastor or the judicatory initially expected the pastor to "revitalize a congregation" and religious coping (positive rcope scale) (pargament et al., ) , and health post-closure. challenges when serving the church were measured by two variables-first, a ten-item pastoral challenges scale with dimensions such as: dealing with members' difficult emotions, initiating discernment, the process of discernment, the actual decision to close, disposition of church property, spiritual care of the congregation, and self-care, and a second, pastoral stress scale based on the question: "when you served the church that was closing, how often did you (very often/fairly often/rarely/never): experience stress because of the challenges in that congregation? feel lonely and isolated in your work? have doubts about your abilities as a pastoral minister? seriously think of leaving for a secular occupation? seriously think of leaving for another type of ministry?". to assess satisfaction with life and ministry one to three years after the church closed, two scales were used: satisfaction with personal life, a two-item scale including satisfaction with family life and with personal life (rated on a scale: very satisfied/somewhat satisfied/somewhat dissatisfied/very dissatisfied), and satisfaction with ministries is a -item scale including satisfaction with current ministry, effectiveness as a pastor in their present congregation, and relationships with members and leaders of your current church. to assess congregational context, independent variables included the perceived level of conflict when the pastor entered the church, congregational laity and leadership initiative in closing the church, emotional skill of the congregation ( items, "members of congregations may express a range of emotions in the process of closing. how skillful were members in communicating:" fear, anger, sadness, tenderness, acceptance, gladness, rated on a -point scale "inadequate to excellent"), and congregational respect. both congregational and judicatory respect were measured with a series of items derived from the "dignity" model (hicks ) . the two overall scales of satisfaction with congregational respect and satisfaction with judicatory respect (very satisfied/somewhat satisfied/somewhat dissatisfied/very dissatisfied) span a variety of dimensions shown in fig. . table shows reliability coefficients. binary judicatory independent variables included polity (bishops/none) and appointment (vs. call) system. dependent variables included: "health worsened," measured by "in your opinion, how did serving in this church affect your health? my health improved/my health remained stable/my health worsened/i don't know if it affected my health." because it measured what happened when the pastor served the church, this was also an independent variable in several post-closure regressions of stress. a binary variable indicating a closing experience like "good friday/holy saturday" was based on the question: "if the process of closing your congregation was like a church season or holy day, it would be: (advent/christmas/epiphany/ lent/good friday/holy saturday/easter/pentecost/other: specify)." pastors imputed their own understanding of these words. a brief -item "mental health" scale was based on a series of questions used in another clergy survey (carroll ) . "the following questions are about how you feel and how things have been with you during the past four weeks. for each question, please give the one answer that comes closest to the way you have been feeling. (table ) . multivariate analysis used backwards stepwise regression for two dependent variables: mental health and overall vocational stress. logistic regressions were used to assess fit for the variables "health worsened," and "good friday/holy saturday." and a power test with g*power demonstrated adequate sample size for all final regressions. in summary, the research shows that women clergy who experience the closing of their churches report are less satisfied with respect from their judicatories (but not from their congregations) than men clergy. pastors reporting greater satisfaction with respect from congregations and judicatories are less likely to report that their "health worsened," a closing like "good friday," or "holy saturday," or to report poor mental health - years after the church closed. further, their overall vocational stress after closing was lower. however, the correlation of judicatory respect with mental health ( - years post-closure) is attenuated by the inclusion of selfrated physical health and measures of satisfaction with current relationships with the "living human web" of family, colleagues and denominations. the study also demonstrates that among the vocational consequences of closing a church, a job search for women takes longer than men, is accompanied by women's greater reporting of have a sense of shame? experience financial strain?** feel lonely and isolated?** stigma associated with church closure, and is complicated by women's more difficult relationships with judicatory executives and colleagues in their new ministries. relating to hypothesis , fig. shows that women clergy report consistently less satisfaction than men with respect from their judicatories, but not their congregations (p < . ). for example, nearly twice as many men as women were "very satisfied" with the judicatory's "speaking honestly with you." women also lamented the lack of compassion, understanding and accountability they experienced from their denominational colleagues, that is, women perceive less inclusive, respectful leadership than do men among judicatory leaders. this research explores whether mutually respectful relationships with colleagues and judicatory leadership are associated with pastors' experiences of personal and vocational outcomes. one possible consequence of work stress is worsening health (hypothesis ). zero-order correlations reveal that gender is unrelated to worsening health but respect is significant (p < . ). figure shows that nearly seven in ten women clergy with low judicatory respect reported worsened health compared with no pastors with high judicatory respect, with a similar pattern for men (nearly six in ten compared with %). logistic multivariate regression of whether a pastor's "health worsened" while serving the church that closed reveals that younger pastors, and pastors experiencing lower respect from congregations and/or their judicatories were more likely to report worsening health (table ) . relating to hypothesis , fig. shows that congregational respect is associated with a less tragic outcome (not good friday/holy saturday) for women, but not men; judicatory respect decreases the experience of good friday or holy saturday for both genders. in a logistic regression, gender was not significant. the only significant variables were pastoral stress associated with serving the church that closed, and judicatory respect (nagelkerke r square = . ). hypothesis expects that respect from the judicatory might have overall mental health consequences beyond the closure. zero-order correlations reveal that mental health scores at the time of the survey ( - years post-closure) were not related to gender or respect but to age and church experience, stress encountered while serving the church that closed, and also, what happened after the church closed. for example, mental health scores were higher among older clergy (p < . ), those with better overall physical health (p < . ). they were also higher for those with more church experience, i.e., not first/second call (p < . ) and clergy reporting less stress while serving the church that closed (p < . ). scores were also higher among clergy not stressed by needing to find a new position (p < . ), with a lower sense of shame (p < . ), and with higher satisfaction with personal life and new ministry at the time of the survey (all p < . ). in stepwise regression (table ) , however, the scale of mental health was significantly related only to pastors' current overall health, and more importantly to satisfaction with current relationships with denominational officials, and with their current life and current ministries. thus, their current health and context were more important to mental health than the stresses of serving a declining church. hypothesis relates respectful relationships with overall vocational stress after the church closed. table shows that men and women were equally stressed by the need to find another position but significantly more women than men congregaƟonal respect judicatory respect reporting their "health worsened" while serving the church that closed by congregational and judicatory respect and gender experienced financial strain from losing their position. women were more likely than men to be single, and therefore unable to rely on a spouse's financial support. importantly, women clergy are significantly more likely than their male counterparts to perceive signs of stigma associated with a church closing. four times as many women as men ( % compared with %) reported hearing "that closing a church would hinder your search for another position." moreover, twice as many women pastors as men ( % compared with %) "think the experience of closing a church hindered your job search." women ministers also felt more lonely and isolated than men clergy, which is not surprising given their greater dissatisfaction with respect from the judicatory or wider church when serving their congregation. there were no gender differences in reporting of shame. women clergy reported higher overall vocational stress after closing than men (r = − . , p < . ) but in a stepwise regression (table ) , younger pastors, those reporting more pastoral stress while serving their churches before closing, and those with lower judicatory respect had higher overall vocational stress. vocational stress was also significantly less among pastors in a multi-church appointment. gender is not a significant variable when respect and these other sources of stress and supports are taken into account. relating to hypothesis , women experienced greater difficulty than men securing their next position. figure shows that among men, respect by the judicatory is associated with lower job search time, but for women this does not hold. although women are more vulnerable financially than men because they are more often single, nearly two-thirds of men clergy found a new pastoral position within the first month, compared with % of women, with an average search for men of . months, and for women, . months. the differences are significant (p < . ) and profound for pastors in a national call system where clergy enter an often-competitive job market (all denominations except the united methodist church, which appoints clergy). hypothesis suggested that gender differences in satisfaction with judicatory relationships might persist after serving and finding new positions. the study confirmed that women clergy reported less satisfaction than men clergy with relationships with the wider church (denominational officials and other clergy) when the survey was conducted (one to three years after closing). for example, three times as many men ( %) report they are presently "very satisfied" with denominational officials in their current ministry compared with only % of women (p < . ). similarly, nearly six in ten ( %) of men clergy reported they are "very satisfied" with present relationships with other clergy in their current ministry compared with less than one-third ( %) of women (p < . ). these differences may reflect gender differences in current access to denominational support as well as any difficult experiences serving their churches that closed and vocational transitions. in the face of economic fallout from the pandemic, an increasing number of mainline protestant clergy may serve congregations "on the brink," so challenged by ebbing financial and human resources they will feel called by god to close; some will be closed by the judicatory. this means leading a congregation, and oneself, on a journey into grief and hope of new life. this experience is therefore a crucible for leaders of any gender, a context in which pastors risk loneliness and isolation from colleagues and superiors, feelings of shame, worsened health, and challenges in finding their next position. previous literature has suggested that mutually supportive relationships with congregations and judicatories, a "living human web," can provide spiritual, material and emotional resources for grieving and stressed pastors. women men the aim of this research was to learn whether these affect vocational and personal outcomes among clergy closing churches, and whether there are gender differences in access to these resources. this study confirms that being embedded in a mutually respectful living human web of relationships with both congregations and judicatories is related to positive outcomes after a church closes such as less experience of "worsened health" while serving their churches, fewer closing experiences like the mournful season of good friday-holy saturday, and less overall vocational stress like challenges looking for their next position. interestingly, mental health appears to be more responsive to the pastor's current context than what happened in the past, that is, to present physical health, and satisfaction with current relationships with the wider church, ministry and personal life. all of these are true for both women and men clergy. thus a "living human web" of superiors and colleagues may mediate the stress of serving a dying congregation as well as healthy ones. vocational stress after closing a congregation is also significantly higher for younger pastors and lower for those in multi-church calls. younger pastors may lack mutually respectful long-term relationships with colleagues and superiors available to older, more experienced clergy. surprisingly, younger clergy are more at risk of "worsened health" than older clergy. perhaps younger pastors are more likely to be blind-sided and hurt by an early career disappointment; in this study, only % of clergy who closed churches entered them expecting to. on the other hand, clergy called to serve more than one church at a time (multi-church appointments) suffer significantly less post-closure vocational stress, possibly because they may continue to serve their "other" congregation(s). the study also found gender differences in satisfaction clergy colleagues and superiors such as bishops, with greater disappointment among women pastors that judicatories fail to engage in mutually respectful relationships and transformational leadership. this was true as they served their closing churches, and also - years after their churches closed. as well, the study also found significant gender differences in vocational concerns and trajectories after churches close. not only are men more likely to find a position in a timely manner than women, with the difference greatest among pastors in a call system (not united methodist). women are nearly twice as likely as men to believe that the experience of closing a church affected their job search, that is, to perceive a kind of stigma. this is akin to research findings that women managers and executives in secular occupations perceive persistent gender bias in access to vocational rewards such as esteem, inclusion in decisionmaking, mentoring and networking, and opportunities for advancement. secular management literature suggests that stigma may affect a woman's job placement more than a man's because male privilege and expectations of higher male competence pre-empt men from this form of discrimination. in medicine, one study showed that after a patient death, female surgeons experience a greater drop in referrals than male surgeons; after a bad experience with one female surgeon, male surgeons are less likely to refer to any female surgeons. there are no such spillovers to men after a bad experience with a male surgeon (sarsons ). an executive consultant, joelle emerson, remarks that, "if women make one mistake, their career gets stalled… men are able to make multiple mistakes and not suffer career consequences" (lublin ) . the presumption of superior male competence appears to mediate failure and stigma for men but not for women leaders whether secular or ordained. one possible consequence of women's difficulty in finding a congregational position in denominations that don't appoint clergy is leaving congregational ministry for another vocation. the written survey confirms that more than twice as many women as men ( % compared with %, p < . ) have a position following the church that closed that they categorize as "other (than solo or senior pastor, associate or assistant clergy, co-pastor, interim or bridge pastor)." this includes vocations such as hospital chaplain, senior facility chaplain, university chaplain, management of a non-profit, seminary administration, teaching, or work in a secular field. although women pastors in subsequent pastoral positions may experience less respect than men from their judicatory, they successfully negotiate leadership challenges by leaning on their faith, family, friends and other supports. for example, the greater the stresses such as health worsening, or a good friday closing, the more pastors, both men and women, turned to god for consolation (cafferata ) . as well, difficulties women pastors may have experienced in finding their next job such as a lengthier search, or not finding a position at all, which are correlated with mental health, appear to be eased by satisfying relationships with denominational officials, new and current ministries and others such as family, friends and colleagues. in the long run, if faith in god and the living human web of current relationships are strong, the stress of closing a church and a difficult job search appear to be mitigated for both women and for men. the research raises the question of why respect, a core element of the "living human web," appears weaker for women pastors than for men despite the church's theological commitment to respect the dignity of every human being. for this, scholars may look not only to women's preference for inclusive, transformational leadership but also to structural answers such as cultural bias against female leadership, lack of institutional norms that reflect a commitment to equality and justice for men and women, or theological/geographic/economic cleavages that weaken the capacity of judicatories to understand, trust, or support women pastors in difficult cures. many judicatories are also historical bureaucracies with inertia or "benign neglect" of past injustices and inequalities. judicatories led by hierarchical authorities such as bishops run the risk of exercising authority over clergy and congregations in accordance with church law but lacking compassion that transformational pastors of both genders value and expect of their leaders. further research is needed to explore these possibilities more systematically. among the limitations of this study is the relative lack of non-white pastors; this is an opportunity for future research. as well, the research was not designed to examine gender differences in clergy leadership style, although it did allow examination of gender differences in the role of clergy and laity in making the actual decision to close. further, it was not a longitudinal study, and causal inferences must be taken with caution. other studies are needed to correct these limitations. although women have been ordained for decades in every historic protestant denomination, in this study of closing churches, women clergy report less respect from their denominational bodies-conferences, dioceses, presbyteries and synods-than their male colleagues. thus, this research confirms previous studies among clergy and other professions showing gendered differences in access to valuable vocational supports and resources. this matters to clergy wellness because respect from peers and denominational superiors decreases untoward personal and vocational consequences such as worsened health, the experience of a tragic "good friday" or "holy saturday" closing process, financial stress, or an extended or unsuccessful congregational job search. satisfaction with relationships with current denominational officials when serving in a new call, as well as with new ministries and family life are associated with better well-being following a church's closure. although the wider church is a sacred community like the congregations that comprise it, its structure as a historical bureaucracy risks compromising its theological commitment to and institutional embodiment of gender equality and justice. how it negotiates those challenges will matter for the increasing number of men and women called to serve and possibly close a church in the coming years. interim ministry in action: a handbook for churches in transition ministry and stress: listening to anglican clergy in wales leading with their hearts? how gender stereotypes of emotion lead to biased evaluations of female leaders respect, challenges, and stress among protestant pastors closing a church: structural and identity theory perspectives the last pastor: faithfully steering a closing church gender, hierarchy, and leadership: an introduction god's 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the lutheran church: a discourse analysis nones" on the rise: one-in-five adults have no religion ending with hope: a resource for closing congregations rural vicars struggling with multiple churches and dying congregations facing episcopal church decline. living church the cost of a calling? clergywomen and work in the church of england gender stereotypes and workplace bias dignity: its essential role in resolving conflict job status of women head clergy: findings from the national congregations study clergy employment in the episcopal church-a new landscape impossible selves: image strategies and identity threat in professional women's career transitions toward the better country: church closure and resurrection respect: an exploration clergy women's world: musings of a fox research: junior female scientists aren't getting the credit they deserve the gender gap in early career transitions in the life sciences clergy work-related psychological health, stress, and burnout: an introduction to this special issue of mental health, religion and culture women managers have little margin for error; one mistake can stall a woman's career, while men's flaws or bad ideas are minimized social support and compensating differentials in the ministry: gender differences in two protestant denominations crunching the numbers the living human web: a twenty-five year retrospective claiming resurrection in the dying church: freedom beyond survival. louisville religious coping among the religious: the relationships between religious coping and well-being in a national sample of presbyterian clergy, elders, and members feeling respected: a parse method study stressed out anglican prieststurn to trade unions for support. religion news service decline of christianity continues at rapid pace the sacrificial embrace: exploring contemporary english parish clergy lives i want what my male colleague has, and that will cost a few million dollars. the new york times called to serve: a study of clergy careers, clergy wellness, and clergy women in faithful and fractured: responding to the clergy health crisis truth, power, and love: challenges for clergywomen across the life span framed by gender how gender inequality persists in the modern world why status matters for inequality a decade of change in american congregations pressure to grow congregations leads to 'clergy self-harm' says christ church dean interpreting signals in the labor market: evidence from medical referrals living legacy: church legacy and closure resource defining respectful leadership: what it is, how it can be measured, and another glimpse at what it is related to a bed of thorns: female leaders and the self-reinforcing cycle of illegitimacy is the united states a counterexample to the secularization thesis? clergy well-being survey: well-being survey of the united methodist church active u.s. clergy- the tough truth about our small churches the crisis in the churches: spiritual malaise, fiscal woe dancing on the razor's edge: how top-level women leaders manage the paradoxical tensions between agency and communion clergy women: an uphill calling publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -esttc z authors: kayem, gilles; alessandrini, vivien; azria, elie; blanc, julie; bohec, caroline; bornes, marie; bretelle, florence; ceccaldi, pierre-françois; chalet, yasmine; chauleur, céline; cordier, anne-gael; deruelle, philippe; desbrière, raoul; doret, muriel; dreyfus, michel; driessen, marine; fermaut, marion; gallot, denis; garabédian, charles; huissoud, cyril; lecarpentier, edouard; luton, dominique; morel, olivier; perrotin, franck; picone, olivier; rozenberg, patrick; schmitz, thomas; sentilhes, loïc; sroussi, jeremy; vayssière, christophe; verspyck, eric; vivanti, alexandre j.; winer, norbert title: a snapshot of the covid- pandemic among pregnant women in france date: - - journal: j gynecol obstet hum reprod doi: . /j.jogoh. . sha: doc_id: cord_uid: esttc z objective: to describe the course over time of severe acute respiratory syndrome coronavirus (sars-cov- ) infection in french women from the beginning of the pandemic until mid-april, the risk profile of women with respiratory complications, and short-term pregnancy outcomes. methods: we collected a case series of pregnant women with covid- in a research network of french maternity units between march and april , . all cases of sars-cov- infection confirmed by a positive result on real-time reverse transcriptase polymerase chain reaction tests of a nasal sample and/or diagnosed by a computed tomography chest scan were included and analyzed. the primary outcome measures were covid- requiring oxygen (oxygen therapy or noninvasive ventilation) and critical covid- (requiring invasive mechanical ventilation or extracorporeal membrane oxygenation, ecmo). demographic data, baseline comorbidities, and pregnancy outcomes were also collected. results: active cases of covid- increased exponentially during march - , ; the numbers fell during april - , after lockdown was imposed on march . the shape of the curve of active critical covid- mirrored that of all active cases. by april , among the pregnant women with covid- , women ( . %; %ci . - . ) had required oxygen therapy and others ( . %; %ci . - . ) had had a critical form of covid- . the severity of the disease was associated with age older than years and obesity, as well as preexisting diabetes, previous preeclampsia, and gestational hypertension or preeclampsia. one woman with critical covid- died ( . %; %ci - . ). among the women who gave birth, rates of preterm birth in women with non-severe, oxygen-requiring, and critical covid- were / ( . %), / ( . %), and / ( . %) before weeks and / ( . %), / ( . %), and / ( . %) before weeks, respectively. one neonate in the critical group died from prematurity. conclusion: covid- can be responsible for significant rates of severe acute, potentially deadly, respiratory distress syndromes. the most vulnerable pregnant women, those with comorbidities, may benefit particularly from prevention measures such as a lockdown. , few maternal complications have been reported, and most information so far comes from china ( ) ( ) ( ) ( ) . for now, the absence of comparisons with appropriate controls means we cannot know whether pregnant women are at higher risk of developing severe complications than the general population ( , ) , although their risk factors for respiratory complications are suggested to mirror those in the general population ( , ) . there is however no data from a large series about the general and obstetric risk factors for developing respiratory complications, especially critical covid- or about the obstetric consequences of these complications. we therefore undertook a national survey with a followup ending on april , , through a french research network: the groupe de recherche en obstétrique et gynécologie (grog). our main objectives were to describe the course over time of sars-cov- infection in french pregnant women, the clinical profile and risk factors for women with maternal respiratory complications, and short-term pregnancy outcomes. this case series came from a research network of french maternity units (including tertiary referral centers representing around deliveries annually, % of french births). aggregated data, extracted from medical files by local physicians, from all diagnosed cases of covid- in pregnant women in these hospitals (for prenatal care, illness, or delivery) from march to april were merged and analyzed to provide a snapshot of the pandemic's consequences in this population. during this period, the french health authorities recommended diagnostic tests only in women with symptoms or diagnosed contacts ( ). infections were diagnosed by the real-time reverse transcriptase polymerase chain reaction (rt-pcr) test for sars-cov- nucleic acid (from nasal swabs) and/or a computed j o u r n a l p r e -p r o o f tomography (ct) chest scan. women were considered, as proposed by french health authorities ( ), to have recovered from covid- if, days after diagnosis or days after symptoms began, they were asymptomatic for more than hours. otherwise, covid- cases were considered active. we first describe the temporal trends of covid- , the reasons for and the gestational age at diagnosis, as well as covid- respiratory complications in the overall population. we then report maternal characteristics and maternal, pregnancy, and neonatal outcomes according to the severity of the respiratory disease, categorized in exclusive groups: non-severe (no respiratory support), requiring oxygen (nasal oxygen therapy or noninvasive ventilation), or critical (invasive mechanical ventilation or extracorporeal membrane oxygenation, ecmo). maternal and neonatal characteristics and outcomes were described as frequencies and percentages. linear trends of categorical variables were tested by the chi-squared trend test developed by royston ( ) . differences between women with non-severe covid- and those with any respiratory support (oxygen-requiring and critical) were expressed as risk ratios (rr) with their % confidence intervals (ci). data were analyzed with stata/se . (statacorp lp, college station, texas). this study received irb approval (cerog -obst- ). active cases of covid- increased exponentially during the entire month of march; the numbers fell during april - ( figure a table ). the most frequent symptoms leading to diagnosis were cough, fever, anosmia, and dyspnea. shortness of breath led to nasal oxygen therapy for women, noninvasive ventilation for , invasive mechanical ventilation for , and ecmo for ( table ) the severity of the disease was associated with age over and obesity, as well as preexisting diabetes, previous preeclampsia, and gestational hypertension or preeclampsia ( table ) symptoms and of admission to neonatal intensive care unit increased with severity. two ( . %; %ci . - . ) neonates had positive sars-cov- rt-pcr. there was one ( . %; %ci . - . ) neonatal death in the critical group due to prematurity. initial reports of covid- during pregnancy did not describe any serious maternal or neonatal complications ( ) ( ) ( ) ( ) . in this large cohort of pregnant women with covid- , more than one fifth required respiratory support, with % categorized with severe and % with critical disease. although these rates may be overestimated because the study took place j o u r n a l p r e -p r o o f mainly in tertiary referral centers and included mostly symptomatic women, maternal respiratory morbidity related to covid- appears notably higher than previously reported among symptomatic pregnant women ( , ) . a more precise estimate of the prevalence of the pulmonary complications would be provided by population-based studies; however, even those studies will not provide a "true" estimate because far from all pregnant women have been tested for sars-cov- in france during this period. indeed, a recent uk populationbased study of women hospitalized for covid reported % ( / ) of the women needed critical care ( ) . our study shows that women with the most serious disease are those with the highest rates of comorbidities. some, like obesity, diabetes, hypertension, or advanced age, have already been identified in general chinese and us populations and among pregnant women in the uk ( , ( ) ( ) ( ) . in this cohort, however, gestational hypertensive diseases were also associated with severity. risk factors for preeclampsia match those for covid- severity ( ) . the use of aggregated data makes it impossible to show an independent association between preeclampsia and covid- severity. however, placental angiotensin-converting enzyme (ace ) is highly expressed at the maternal-fetal interface and its dysregulation by sars-cov- might be involved in the high rates of preeclampsia associated with severe and critical covid- ( , ) . we also showed higher rates of preterm delivery than the chinese studies ( ) ( ) . in the uk study that included only hospitalized women, the rate of preterm birth before weeks was % among the % of women whose pregnancy was completed by the end of follow-up ( ). in our series, because the women with the most severe illness are likely those who have already delivered, the rates of preterm births we report might be lower once all these women with covid- during pregnancy have given birth. however, because more than % of the women with critical covid- have already delivered, the preterm delivery rates before j o u r n a l p r e -p r o o f and weeks in this group will not drop below % and %, respectively, even if all the other women of the group give birth after weeks gestation. finally, two weeks after the imposition of lockdown, the number of pregnant women with active covid- cases and with respiratory failure requiring invasive mechanical ventilation or ecmo decreased. lockdown in france has been associated with a reduction of the estimated reproduction number from . to . ( ) , as also reported in china ( ) . because no treatment has yet been shown to be effective against sars-cov- infection ( ), the temporal association between lockdown and the decrease in critical covid- cases suggests that prevention measures such as lockdown could represent the only available policy for reducing the incidence of covid- respiratory complications, especially among pregnant women with comorbidities. this preliminary report has several limitations. all the data come from a research hospital network, of which more than two third are referral centers. consequently, the morbidity observed is not an accurate estimate of the severity of covid- in pregnant women because some cases were followed in other centers and referred because they already required oxygen therapy or were in critical condition. regarding the risk factors of severity, because we used aggregated and not individual data, we were unable to perform adjustments with multivariate models to establish the independence of these associations; other studies, preferably population-based, are necessary to confirm these findings. in conclusion, covid- in french pregnant women can be a serious condition and may be responsible for severe acute, potentially deadly respiratory distress syndromes. the most vulnerable pregnant women, those with comorbidities, may particularly benefit from prevention measures such as a lockdown. ) -all data are expressed as n (%). *non-severe compared with any respiratory support (oxygen-requiring + critical); ** as only of women had given birth by april , , rrs were not calculated for maternal, pregnancy and neonatal outcomes; *** eight multiple pregnancies (one triplet). there were no missing values for maternal characteristics, previous medical history, or outcomes. gestational diabetes was considered to be present if diagnosed and positive and otherwise was assumed to be negative. smoking during pregnancy was assumed to be negative if it not reported. clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records clinical characteristics of pregnant women with covid- in wuhan, china coronavirus disease in pregnant women: a report based on cases clinical features and obstetric and neonatal outcomes of pregnant patients with covid- in wuhan, china: a retrospective, single-centre, descriptive study covid- infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals characteristics and outcomes of pregnant women hospitalised with confirmed sars-cov- infection in the uk: a national cohort study using the uk obstetric surveillance system (ukoss) ptrend: stata module for trend analysis for proportions comorbidity and its impact on patients with covid- in china: a nationwide analysis clinical characteristics of coronavirus disease in china presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the coronavirus disease (covid- ): do angiotensin-converting enzyme inhibitors/angiotensin receptor blockers have a biphasic effect? physiological and pathological regulation of ace , the sars-cov- receptor distribution of angiotensin-( - ) and ace in human placentas of normal and pathological pregnancies estimating the burden of sars-cov- in france association of public health interventions with the epidemiology of the covid- outbreak in wuhan, china pharmacologic treatments for coronavirus disease (covid- ): a review jo ann cahn for editing the manuscript. key: cord- -yj uwiu authors: el morr, christo; layal, manpreet title: effectiveness of ict-based intimate partner violence interventions: a systematic review date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: yj uwiu background: intimate partner violence is a “global pandemic”. meanwhile, information and communication technologies (ict), such as the internet, mobile phones, and smartphones, are spreading worldwide, including in low- and middle-income countries. we reviewed the available evidence on the use of ict-based interventions to address intimate partner violence (ipv), evaluating the effectiveness, acceptability, and suitability of ict for addressing different aspects of the problem (e.g., awareness, screening, prevention, treatment, mental health). methods: we conducted a systematic review, following prisma guidelines, using the following databases: pubmed, psycinfo, and web of science. key search terms included women, violence, domestic violence, intimate partner violence, information, communication technology, ict, technology, email, mobile, phone, digital, ehealth, web, computer, online, and computerized. only articles written in english were included. results: twenty-five studies addressing screening and disclosure, ipv prevention, ict suitability, support and women’s mental health were identified. the evidence reviewed suggests that ict-based interventions were effective mainly in screening, disclosure, and prevention. however, there is a lack of homogeneity among the studies’ outcome measurements and the sample sizes, the control groups used (if any), the type of interventions, and the study recruitment space. questions addressing safety, equity, and the unintended consequences of the use of ict in ipv programming are virtually non-existent. conclusions: there is a clear need to develop women-centered ict design when programming for ipv. our study showed only one study that formally addressed software usability. the need for more research to address safety, equity, and the unintended consequences of the use of ict in ipv programming is paramount. studies addressing long term effects are also needed. intimate partner violence includes physical violence, sexual violence, stalking, and psychological harm inflicted by a current or former partner or spouse [ ] . violence against women (vaw) has been described as a "global pandemic" by the united nations [ ] . it is considered both a violation of women's human rights [ ] and a public health issue [ ] . in low-and middle-income countries, violence against women is widespread and often involves pregnant women [ , ] . however, violence against women occurs in high-income countries as well [ , ] . nearly one in three women have experienced intimate partner violence or sexual violence [ ] ; therefore, it is important to disseminate as widely as possible the knowledge and tools related to ipv prevention and to intervention to empower the women subjected to ipv. information and communication technologies (ict) present an opportunity for such dissemination. ict are being adopted at unprecedented rates in high-income as well as low-and middle-income countries [ ] . moreover, the use of the internet , mobile phones, and smartphones [ , [ ] [ ] [ ] [ ] [ ] [ ] for health purposes has been well documented in research. it has been used to address chronic disease management [ , ] , mental health challenges [ , ] , and hospital readmissions [ ] , encompassing applications that target the public (i.e., public health informatics), interactions between patients and healthcare professionals, and applications for individual use through smartphone apps (i.e., consumer health informatics). however, little is known about the use of icts in the context of violence against women, and only a few articles on the subject have been published recently [ , , ] . at the same time, there is a solid increase in phone ownership and access to the internet in low-and-middle-income countries [ ] , which suggests the possibility of implementing ict-based interventions to address ipv in these countries. recent systematic reviews showed that the efficacy of ict-based mobile apps for health (mhealth) is still limited, as research in the field lacks long-term studies and existing evidences of impact are inconsistent [ ] . also, mhealth in the domain of violence against women (vaw) showed an abundance of apps addressing one-time emergency or avoidance solutions, and a paucity of preventative apps, which indicates the need for studies addressing data security, personal safety, and efficacy of interventions using apps to address vaw [ ] . by extension, investigating the situation of ict in ipv seems a necessary step. given the existing ipv interventions challenges, the evidence demonstrating effectiveness of online interventions in health, the rise of research on online ipv interventions, the risks inherent in ict use for ipv programming, it is important to synthesize the available evidence regarding the use of ict-based ipv interventions. to our knowledge, there is no systematic review of such work. to address this knowledge gap, we initiated a systematic review of literature on ict-based ipv interventions. the study objectives were to examine whether ict could become acceptable for effective ipv interventions, we reviewed the literature on the use of ictbased interventions to address ipv issues. the questions that guided us in examining the were as follows: ( ) "what type of objectives did ict based interventions tried to address?", ( ) "were ict based interventions effective in addressing ipv?", and ( ) "what type of strategies did they implement to mitigate ict risks (e.g. safety, data security)". the results will inform future ict-based ipv interventions. in total, articles were identified, among which articles were duplicates. out of the unique articles, were excluded based on the content of their abstracts. the inclusion criteria were then applied to the remaining articles after reading their full text. four articles were then excluded, and articles were kept for analysis [ , (fig. ) . table (see appendix) lays out the studies in terms of population, intervention, comparison groups, and outcomes (pico). table presents the authors, publication year, study country, study type, recruitment space, theme, outcomes, sample size, sample size per arm, control group, and the type of ict used for the studies. out of the , ( %) took place in north america ( studies ( %) in the united states and ( %) in canada), study ( %) took place in australia, and ( %) in new zealand. most studies focused on women with potential vulnerability to, past experience of, and/or current experience of intimate partner violence, with the exception of one [ ] , which included both men and women as study participants. four studies included women who were pregnant [ , , , ] ; two of these studies included women up to months postpartum who had history of ipv [ , ] . two studies focused on women with a history of ipv and who were active substance(s) users [ , ] , and study on women who were at risk of hiv through unprotected intercourse [ ] . out of the , studies ( %) were solely desktop-or laptop-based [ , , , , , , , - , , , - , - ] , studies ( %) were solely tablet-based [ , ] , study ( %) used computer and telephone [ ] , study ( %) used tablet and telephone [ ] , ( %) implemented a kiosk system [ ] and ( %) were not reported and supposed any type of ict [ , , ] . table shows the characteristics of the included studies. the studies included randomized controlled trials ( two-arm and four three-arm studies), four pre-post designs, two cross-sectional studies, two prospective studies, and one diagnostic case-control study (i.e. retrospective data with known disease-positive and disease-negative cases [ ] ). control groups varied widely, and wait-list controls were used in five rct studies [ , , , , ] . four studies allowed control groups to access websites with static, or non-interactive, or non-tailored content [ , , , ] , while two studies used irrelevant information for control groups [ , ] , seven control groups used faceto-face (or paper-based self-reported) screening [ , , , , , , ] , four had the intervention group play the role of control (i.e. pre-post design) [ , , , ] , and three studies had no control groups [ , , ] . the sample size in the rct studies varied extensively from participants to a high of . the interventions implemented had various foci. ict was used for screening and disclosure in ( %) of the studies. five studies ( %) aimed at ipv prevention, four ( %) studies used ict to address the mental health of female victims of ipv, and two ( %) studies used ict to provide support for decision aid. only one ( %) study assessed mainly the suitability of ict for use in an ipv context. the studies had five types of interventions and varied study settings. in terms of settings, studies were conducted in medical services facilities [ , , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ] such as emergency departments, clinics, community health centers, trauma treatment centers, and family practices. six studies were conducted in the community [ , , , , , ] , four in social services facilities [ , , , ] , and one in legal services facilities [ ] . the studies represent a range of uses of ict in the context of ipv, addressing screening and disclosure, ipv prevention, ict suitability, empowerment and support, and women's health. in three studies, ipv screening using ict was found to be as effective as using the usual face-to-face/paper method [ , , ] . one study reported that computerized screening was more sensitive and less or similarly specific compared to face-to-face staff screening [ ] . one study reported high self-disclosure of ipv using computers vs in person ipv screening with health professionals; out of female patients who participated in both screening methods. ( %) patients out of the disclosed some form of ipv in person compared to ( %) who disclosed ipv via a computer. out of those patients, ( %) also disclosed ipv to their doctors in person and patients ( %) disclosed via a computerized tool but not with the doctor [ ] . one study that included african american women in a women, infants, and children (wic) services setting found that women were less likely to disclose ipv using a computerized intervention than in person [ ] . a study that used a tablet for disclosure during perinatal home visitation found the tablet to be a conduit through which interpersonal connection between women and home visitors was facilitated [ ] . one study found that women were more likely to disclose ipv using ict, leading to higher rates of screening and disclosure [ ] . one study reported that . % of women disclosed using the ict intervention, and only . % women disclosed using usual care [ ] . another study found that implementing ict-based disclosure in an emergency department was successful and reliable [ ] . two studies addressed ipv prevention [ , ] . one study showed that % of the participating women who used ict were less likely to report experiencing physical ipv at a follow-up ( months later), % were less likely to report ipv with injury, and % were less likely to report severe sexual ipv [ ] . the study by braithwaite et al., which targeted both males and females using ict, reported less physical aggression committed by females at postintervention, as well as less physical aggression committed by both males and females at a -year follow up; also, the study showed a large reduction in expected counts for female-and male-perpetrated physical aggression at the year follow-up ( and %, respectively) [ ] . our systematic review showed that ict has been used to address two aspects in the lives of some women experiencing ipv: substance use and mental health. six studies used online tools to address the mental health of women experiencing ipv [ , , , , , ] . depression was measured in five studies [ , , , , ] , anxiety was measured in three [ , , ] and stress in two [ , , ] . in all studies, mental health showed improvement compared to intervention. one study reported that women found it easier and safer to report drug use and partner abuse through a computer than in person [ ] . the study by hassija et al. addressed the treatment of ipv-related trauma through video conferencing, and found the method effective at reducing post-traumatic stress disorder (ptsd) symptoms, with high users' satisfaction [ ] . ict was used to empower women by enabling them to create safety and action plans and by providing them with tools for enhanced decision making and self-efficacy. three studies focused on women creating a safety and/or action plan in the event of a future partner abuse incident [ , , ] , with two interventions providing additional local resources [ , ] . in one study, % of the participating women who used ict reported leaving their abusive partner within the year [ ] , and in another study % of the participating women reported the intention to make changes in regard to their ipv within days to months [ ] . moreover, in a single study focused on using online tools to teach participants about behaviours and/or actions related to safety [ ] , researchers reported a % significant increase in safety behaviours for the ict-based intervention group, compared to a % increase for the control waitlist [ ] . in addition, a study reported that participants found using a computer survey to disclose ipv safer than a face-to-face survey [ ] . in terms of decision-making and self-efficacy, two studies reported that more than % of the participants acquired general skills through the ict-based interventions [ ] , and two other studies reported that participants gained decision-making skills through the ict-based interventions [ , ] . additionally, using their new skills, women experienced lower decisional conflicts and had an overall less difficult time deciding on their actions [ , ] . only study has a formal testing for the usability of ict software as a major focus using the systems usability scale [ ] . the results indicate high satisfaction with the software usability. table (appendix) summarizes the outcomes measured by each study. our review revealed a wide variation among studies in terms of outcomes measured for studies that address the same focus. in total, measurement tools were used in the studies (see table in appendix). among the studies that address screening and disclosure, five studies used a simple disclosure count [ , , , , ] . two studies used non-validated questionnaires [ , ] , and two studies used the partner violence screen (pvs) and the abuse assessment screen (aas) [ , ] . three studies had no common outcome measurement tools. the four studies [ , , , ] that focus on mental health used eight different outcome measurement tools; only the ptsd checklist (pcl) was common to two studies [ , ] . in terms of suitability of ict, the systems usability scale (sus) was used in one study only to assess software usability [ ] . out of the five studies [ , , , , ] focusing on ipv prevention, three studies [ , , ] used the revised conflict tactics scale (cts ). the two studies that addressed support [ , ] had no common measurement tools. our review revealed the emerging nature of ict use in ipv research. while there is a growing interest in the use of ict in ipv interventions, there are virtually no studies examining its challenges. while most of the studies used ict to enhance screening and increase the disclosure rate, few studies targeted ipv prevention and even fewer aimed at improving support. suitability of ict was seldom assessed in a formal way using a validated usability scale (e.g. systems usability scale) or methodology [ ] . in addition, while most of the studies used rct design, the number of arms, the population, the control groups used, the sample sizes, and the outcome measures varied widely among the studies, which makes it hard to compare those results. with the exception of two large sample sizes that were used in two non-rct studies (one that accessed electronic health records for an artificial intelligence application [ ] , and another that used the emergency department [ ] ), the sample sizes per arm were generally low. the sample size per arm was less than in four studies. only six studies had a sample size per arm between and , and only four studies had a sample size per arm between and . this suggests that the current ict-based ipv interventions have limited generalizability and comparability-especially because only six studies were conducted in the community. twenty-three ( %) of the studies were conducted in north america, ( %) of which were in the united states, which is an additional limitation to the generalizability of the findings since they lack diversity in terms of ethnicity, race, language, and cultural backgrounds. diversity is crucial in ipv. research shows that foreign-born immigrant as well as indigenous women are more likely to experience ipv [ , ] and intimate partner homicide than other women [ , ] ; hence, addressing diversity in ipv is critical. it is encouraging that one recently published rct protocol laid out a plan for culturally tailored intervention targeting immigrant, refugee, and indigenous survivors of ipv [ ] . technology is costly in terms of hardware, software and data plan costs. consequently, while access to ict by women experiencing ipv is a challenge in high income countries, including the united states [ , ] , it is even more difficult in low-and middle-income countries (lmics). this creates inequity in access to technology, and a digital divide among women subject to ipv. this inequity challenge and its impact on outcomes has long been observed in electronic health (ehealth) [ , ] and needs to be addressed in ictbased ipv interventions; it was not addressed in the studies covered by our review. also, involvement of users in software design is a well-known need that is effective in producing software that works for users and aligns with their priorities and is suitable for their environments [ , [ ] [ ] [ ] [ ] [ ] . hence, involving women experiencing ipv in the research team and in the ict software design process is paramount to ensure usability and accessibility of the software and as a matter of equity [ ] . there is a lack of research in this area in the studies covered by our review. a recent study protocol is promising that ict will ensure lower access barriers [ ] , which is the traditional unchecked point of view; this is another demonstration of the need to shed a critical light on the use of ict for women experiencing ipv, analyzing equity as well as the safety and ethical challenges involved. our review shows that studies [ , , , , , , , ] reported that women found ict interventions suitable for ipv disclosure; three of those studies found it particularly suitable in terms of confidentiality, usefulness, and satisfaction [ , , ] . stigma is an important factor associated with intimate partner violence [ ] limiting agency in help-seeking for ipv [ ] ; ict seems to be a tool that provide an opportunity for women subject to ipv. with the exception of one in which participants preferred a face-to-face discussion [ ] , ipv disclosure through ict was found to be most appropriate in most of the studies compared to face-to-face disclosure and was perceived as non-judgemental and more anonymous than face-to-face discussion, which facilitated more disclosure. the increase in phone ownership and internet access in low-and middle-income countries [ ] , coupled with the ability to use ict to target individuals through health informatics tools that targets individuals (i.e. consumer health informatics) [ ] such as apps, makes ict a flexible tool to address ipv in multiple languages, embedding different cultural cues, and overcoming the cultural stigma related to disclosing ipv from the convenience of a personal ict device (e.g. cell phone, smart phone). simple ict tools such as cell phones are available in rural areas and proved to be successful tools in the health domain (e.g. chronic disease management) [ ] [ ] [ ] . however, it is important to note that one challenge of ict-based interventions is that only women with basic literacy and it knowledge can benefit; also, some victims may not have access to ict, and some abusers may restrict their partners' access to ict. therefore, in addition to the traditional security considerations related to the use of ict, such as maintenance of privacy [ ] and confidentiality [ ] , there are ethical issues related to the unintended consequences of ict [ , ] , including safety risks. in the ipv domain, sharing cell/smart phones at home or with neighbors is a common practice [ , ] , which might increase the risk of ipv if the perpetrators notice that women are using these devices to address ipv [ ] . the studies covered by this review were located in high income countries; there is little to no examination of the problem of access to ict (i.e. cost), nor of the risks inherent in the use of ict (e.g. sharing devices, ability to access browsing history) in addressing ipv programming in a variety of contexts. ethical challenges related to the safety of women increase when women are sharing cell/smart phones with perpetrators; in such contexts special considerations should be taken care of, including "safety by design" [ ] . safety challenges involved in the use of ict in health have recently attracted much attention [ , ] . moreover, recent reflections related to the ethical challenges of using web-based rct show the need to equip participants with information about internet safety [ ] ; likewise, identifying and managing safety risks within ictbased ipv research remains a perspective to be explored. this raises ethical questions related to the use of ict, for example in the case of referral embedded in the ipv programming, as was the case in three studies included in this review [ , , ] . poor quality services are well documented in low-resource and rural areas [ ] , so referring women to such services might have negative consequences for them. while this is not an ict issue, ict facilitates communication of information and has the potential to exacerbate current challenges. this is part of the well-known unintended consequences of the use of information technology in health [ ] [ ] [ ] . of the studies that explicitly mentioned their settings, were in urban settings, only three were in urban and suburban areas, and two were in suburban settings, suggesting a need to test ict use for ipv in rural settings [ , ] and uncover any particularities compared to the urban context. it is also worth noting that our systematic review has not included search terms regarding the user of ict tools to address ipv for women with disabilities. however, in a quick assessment, when we searched in pubmed for research that addresses the use of ict to address violence in the context of women with disabilities, our search revealed only two papers [ , ] . the use of ict to address ipv for this particular group of women is important to address in a separate study, as ict accessibility may be challenging for women with certain types of disabilities, especially since there is evidence that ipv occurs at higher rates in this population compared to the general population [ ] [ ] [ ] [ ] [ ] [ ] , and that ict can play a major role in empowering people with disabilities [ ] . the use of ict tools to address ipv for women with disabilities, and the accessibility of these tools, remains an important area for future studies. moreover, our review indicated that there is a paucity of research addressing ict use for ipv prevention and ipv treatment. there is a clear need for more research on ictbased interventions to prevent ipv and to address post-ipv challenges, such as mental illness and the integration and coordination of mental and social services (e.g., employment, housing), which has never been addressed in the reviewed literature. in this context, virtual communities may play an important role in integrating and coordinating mental health services and social services [ ] . while the studies showed different aspects of ict use for ipv, a more integrative approach can be taken if researchers approach ipv using a virtual community framework. a virtual community (vc) is defined as a community of individuals cooperating using online tools to attain an objective [ ] . health vcs have been used in healthcare to provide patients with education, health education, and remote support; that proved to be an enabling and empowering factor, which allowed patients to become active participants in managing their health conditions [ , ] . support was not provided solely by health professionals; instead, health vcs connected individuals with common experiences (e.g., similar health conditions), which enabled them to interact and mutually support each other [ ] . healthcare providers could provide validated evidence-based health information, coupled with strategies for effective chronic disease management [ ] [ ] [ ] . ample evidence exists demonstrating that virtual tools are effective and efficient for addressing health issues experienced by patients with various health conditions (chronic kidney disease, pulmonary hypertension, cancer) [ , [ ] [ ] [ ] . there is also ample evidence that health vcs are effective in engaging individuals managing their own health condition [ , ] . moreover, vcs can be patient-centred, customizable to individual preferences, and responsive to individuals' needs and values [ ] . in terms of mental health, an important factor for women experiencing ipv, vcs provide a secure, private way for women to communicate privately and securely and to access information tailored to their situation in a personalized manner. this privacy facilitates access and assists in overcoming stigma, especially for women from visible minority groups [ ] . vcs have a proven potential to engage participants [ ] . there is ample evidence that health vcs are associated with positive mental and social benefits, such as reduced loneliness and increased emotional well-being, self-esteem, and self-empowerment [ , , ] . it is important to explore an integrative approach to ict-based intervention in ipv using vcs, especially since vcs enable a community dimension that facilitates mutual support and empowerment among its members (e.g., abused women). in a study that screened for ipv, while women preferred computerized over face-to-face disclosure, computerized screening did not increase prevalence, so ict did not lead to increase in disclosure. also, when women disclosed by answering paper-based questionnaires, the self-completed paper-based questionnaires had less missing data collected than both computer-based and face-to-face interviews [ ] , which shows the advantage of having for paper-based screening (i.e. less missing data). likewise, while ict allowed considerably higher ipv detection, this did not always lead to charting for ipv or to a follow-up by treating physicians [ ] ; more research is needed to understand the factors, such as continuing medical education [ ] , that increase the chances of charting and follow-up. detection is not enough. we have noted above the lack of research regarding equity, safety, and the ethical challenges involved in the use of ict, as well as the lack of culturally, ethically, and racially sensitive ict programs. ict might be able to support and enhance more traditional on-the-ground program delivery; however, ensuring that effective ictbased interventions reach the most vulnerable in equitable, ethical, and safe ways remains a research agenda to be undertaken. current results suggest that face-to-face and paperbased approaches should not be discarded, and that the computer-based software design must be user-centred and must follow usability principles [ , ] . limiting the search to english language is one of the limitations of this study. another limitation was the difficulty to compare the results, since the tools used to measure the same outcome varied widely between the studies. various questionnaires were used to detect ipv, assess decisional conflict, assess mental health challenges, assess treatment efficacy, and assess different primary and secondary outcomes. an illustrative example is the varied questionnaires that researchers used to measure ipv [ , , , , , , [ ] [ ] [ ] , which included the use of an artificial neural network to identify ipv automatically via analysis of the notes stored in the electronic health records [ ] . our review shows that there are limits for comparing the effectiveness of the interventions in terms of mental health (e.g., reduction in stress, anxiety, or depression levels), given the great variety of mental-healthrelated measurement tools that have been used. the evidence reviewed suggests that ict-based interventions have the potential to be effective in spreading awareness about and screening for ipv. ict use show promise for reducing decisional conflict, improving knowledge and risk assessments, and motivating women to disclose, discuss, and leave their abusive relationships. however, there is lack of homogeneity among the studies' outcome measurements, and the sample sizes, the control groups used (if any), the type of interventions and the study recruitment space. the use of ict-based interventions seems to be an attractive option for disseminating awareness and prevention information [ ] , due to the wide availability of ict (including simple mobile phones) in both high-income and low-and middle-income countries. ict may also present an opportunity to deliver culturally sensitive multilingual interventions using consumer health informatics. however, there is a clear need to develop womencentred ict design when programming for ipv. our study showed only one study that formally addressed software usability. moreover, research directly addressing safety, equity, and ethical challenges in using ict in ipv programming are virtually non-existent; the need to find answers to equity, and the unintended consequences of the use of ict use for ipv programming is necessary. in this context, virtual communities may play an important role in providing a sense of community and in integrating and coordinating the services around women experiencing ipv. future longitudinal follow-ups could help determine the long-term effects of the use of ict in ipv programming. 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springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge the work of kanchi uttamchandani in searching for some of the articles. authors' contributions ml contributed in searching for articles, analysing their content, completing a first categorization of themes. ce contributed to searching for articles and analysing their content, comparing ml results with his, he finalized the themes, interpreted the results, designed and populated the figures and tables and wrote the current version of the paper. ce supervised and coached ml during the process. all authors read and approved the manuscript. not applicable. data sharing not applicable to this article as no datasets were generated or analysed during the current study.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord- -rtilfnzi authors: lambelet, valentine; vouga, manon; pomar, léo; favre, guillaume; gerbier, eva; panchaud, alice; baud, david title: sars‐cov‐ in the context of past coronaviruses epidemics: consideration for prenatal care date: - - journal: prenat diagn doi: . /pd. sha: doc_id: cord_uid: rtilfnzi since december , the novel sars‐cov‐ outbreak has resulted in millions of cases and more than , deaths worldwide. the clinical course among non‐pregnant women has been described but data about potential risks for women and their fetus remain scarce. the sars and mers epidemics were responsible for miscarriages, adverse fetal and neonatal outcomes and maternal deaths. for covid‐ infection, only cases of maternal death have been reported as of april , and pregnant women seem to develop the same clinical presentation as the general population. however, severe maternal cases, as well as prematurity, fetal distress and stillbirth among newborns have been reported. the sars‐cov‐ pandemic greatly impacts prenatal management and surveillance and raise the need for clear unanimous guidelines. in this narrative review, we describe the current knowledge about coronaviruses (sars, mers and sars‐cov‐ ) risks and consequences on pregnancies and we summarize available current candidate therapeutic options for pregnant women. finally, we compare current guidance proposed by rcog, acog and the who to give an overview of prenatal management which should be utilized until future data appear. this article is protected by copyright. all rights reserved. severe cases of covid- infection in pregnant women are not frequent as with the previous coronavirus infections described above. nevertheless, nine ( . %) maternal deaths have been reported among eleven iranian patients with rd trimester infections ( - ). all women presented with typical symptoms, including dyspnea. they were previously healthy except two patients known for hypothyroidism and one patient with suspected gestational diabetes. maternal age was between and y.o. and two women had dichorionic/diamniotic twin gestations. all women were admitted to the icu, intubated and ventilated and died from cardiopulmonary collapse or multiple organ failure (mof). one had septic shock and disseminated intravascular coagulation (dic) before progressing to heart failure. intrauter ine fetal death (iufd) were described among four patients ( / ) with gestational ages between and wg. cs were performed in other cases ( / ) with gestational age between and wg. cohort studies have reported a rate of severe disease requiring icu admission of . - % (n= / ; n= / ), including requiring mechanical ventilation among chinese patients. in the italian cohort, a total of % of pregnant women (n= / ) required either oxygen supplementation through continuous positive airway pressure (cpap) or icu admission, while in the american cohort, ( . %) presented with severe disease and ( . %) required icu admission without mechanical ventilation. severe complications in pregnant women are similar to what has been described in the general population and include multiple organ failure, respiratory failure requiring mechanica l ventilation, and even extracorporeal membrane oxygenation, as described in a patient at wg ( ). in the latter, the patient required an emergency cesarean section for maternal resuscitation and the newborn unfortunately died due to an intrauterine asphyxia. the mother had multiple organ failure, needed mechanical ventilation before extracorporeal membrane oxygenation for a total of days. she was discharged from hospital weeks later. two cases of cardiomyopathy related to covid were reported by juusela and al. ( ) . the first pregnant woman was y.o., had a bmi of . m /kg and was diagnosed with dietcontrolled gestational diabetes. she delivered via cesarean at wg for severe preeclamps ia and tested positive to sars-cov- on postpartum day with evidence of fever, tachypnea and suspicious chest imaging. she was then diagnosed with acute heart failure after an echocardiogram was performed, showing a moderately reduced left ventricular ejection fraction (lvef) of % with global hypokinesis. on day postpartum, the mother required this article is protected by copyright. all rights reserved. mechanical ventilation and was still intubated at the time of publication. the second patient was a y.o. women with no relevant medical history. she was admitted for respiratory symptoms necessitating nasal oxygen support. due to the previous experience, an echocardiogram was completed and showed a moderately reduced lvef of - % with global hypokinesis. she rapidly developed severe features leading to a cesarean section at wg. at the time of publication, she was postpartum day and did not require oxygen support. though current data suggest that most pregnant women with covid- will have an uncomplicated clinical course, severe complications must be anticipated. nevertheless, the observed rates appear similar to those for non-pregnant patients between - years old. in a recent analysis based on a chinese cohort, the actual rate of severe disease was / ( . %) among - y.o. patients; after adjusting for demographic factors, the expected rate of severe disease was . - . % ( ) . breslin et al. also reported a similar rate of complications in pregnant women compared to nonpregnant adults ( ) : vs % with mild clinical symptoms, . vs % with severe symptoms and . vs % requiring icu admission respectively. we should point out, however, that complications in the general population mainly impacted the elderly and patients with comorbidities. when comparing pregnant woman to their typical age group, they qualify as a high-risk group for adverse maternal outcomes ( ). therefore, although the majority of infected pregnant women seems to demonstrate a mild clinical course, pregnancies should be approached with caution considering the potential critica l complications reported in several cases published so far report. more exhaustive data, however, this article is protected by copyright. all rights reserved. are needed to understand the additional risk pregnancy may pose to women with a covid- infection. sars-cov- and mers-cov infections during pregnancy were associated with adverse fetal and neonatal outcomes. a report on twelve pregnant women suffering from sars-cov- ( - pandemic) was published ( ) and the rate of adverse fetal / neonatal outcomes was % ( / ) in this series. four of the seven patients ( %) infected during the first trimester experienced miscarriages. two others decided to terminate their pregnancy after recovering from sars, and the last had an uncomplicated pregnancy. among the five patients infected during the second or third trimester, four ( / , %) had a preterm delivery, including one for fetal distress ( / , %) . two neonates exhibited respiratory distress syndrome and other complicatio ns related to prematurity (necrotizing enterocolitis). all placentas of these patients ( / , %) weighed below the th percentile, of which had abnormal anatomo-pathology results (thrombotic vasculopathy with avascular fibrotic villi and / or placental infarct) ( ). when the infection occurred during the week before birth, no fetal growth restriction was noted ( / ). when the infection occurred one month or more before birth, two fetuses ( / , %) had fetal growth restriction (fgr) with oligohydramnios, related to the abnormal placentas presented above. another chinese series ( ) reported fetal demise in one of five ( %) fetuses exposed to sars-cov- during the second or third trimester of pregnancy. this article is protected by copyright. all rights reserved. eleven fetuses / neonates from mothers infected with mers-cov have been described ( )( )( ). among them, ( / , %) had fetal or neonatal demise: two intrauterine fetal deaths at and weeks, and one neonatal demise at weeks due to extreme prematurity ( )( ). abruption was identified on placental examination from these fetuses, and from another liveborn neonate who presented with fetal distress at weeks ( ). with regards to sars-cov- infection during pregnancy, several case-series and case reports show that similar adverse fetal and neonatal outcomes could occur. overall, we included cases with fetal and/or neonatal outcomes available at the time of this review. among them, ( %) were born prematurely (< w) and ( %) had adverse outcomes (fgr, fetal or neonatal demise, severe symptoms at birth). congenital or perinatal transmiss io n was suspected in of ( %) newborns tested. details of all cases available are presented in table . in a case-control study ( ), among fetuses from sars-cov- infected mothers, exhibited fgr ( / , %), had fetal distress ( / , %), and four were born prematurely ( / , %) due to prom or placental bleeding. the rates of low birth weight and premature birth were significantly higher when compared to the control groups. one of these fetuses also exhibited sinus tachycardia that persisted after birth. zhu and colleagues ( ) described the outcomes of neonates from sars-cov- infected mothers. two of them were small for gestational age ( / , %), and had a pediatric critical illness score (pcis) below with shortness of breath ( / , %), fever ( / , %), thrombocytopenia accompanied by abnormal liver this article is protected by copyright. all rights reserved. function ( / , %), tachycardia ( / , %), vomiting ( / , %), and pneumothorax ( / , %). neonatal radiography showed abnormalities in of them ( / , %): had signs of infection, respiratory distress syndrome and pneumothorax. among these neonates, two ( / , %) had disseminated intravascular coagulation and one ( / , %) refractory shock with multiple organ failure leading to death at day of life. liu y. ( ) presented the outcomes of other newborns exposed during pregnancy: none which were positive for sars-cov- at birth, ( / , %) were premature (for fetal distress in cases, / , %), and one was stillborn ( / , %). chen and colleagues ( ) described a series of newborns from infected mothers during the third trimester. two ( / , %) had a low birthweight and four ( / , %) were premature (for fetal distress in cases), none experienced a severe adverse outcome. yu and colleagues also reported a series of newborns from infected mothers during the third trimester, without adverse outcomes. one of these neonates had a positive sars-cov- pcr hours after birth, leading to the suspicion of a perinatal transmission. liu d. and colleague s ( ) described briefly the outcomes of newborns from infected mothers. induced prematurity was noted in % ( / ), but none had neonatal complications. in the new-york series ( ), which presented the outcomes of infants from infected mothers, all but one had negative neonatal testing for sars-cov- . one infant had an 'indeterminate' test result, which was clinically managed as a 'presumptive negative' diagnosis, as this result may reflect low level detection. in this series, ( / , %) instances of fetal distresses were noticed, one infant ( / , %) was premature and one ( / , %) presented with rds with a concern for sepsis. zeng and colleagues ( ) reported the largest series to date, with newborns included. a perinatal infection was suspected in three of them ( / , %), with a positive pcr at day and of life. infected newborns presented with higher rates of fgr, prematurity and complicatio ns at birth (fever, pneumonia, rds, shortness of breath) than non-infected newborns: % vs %, % vs %, % vs %, respectively. wang ( ) reported one case with a positive pcr in both the mother and her newborn (whereas placental and umbilical blood samples were negative). this newborn had lymphocytopenia, abnormal liver function and elevated creatine kinase, although was clinically stable. congenital or perinatal transmission was also suspected in three other cases ( ) ( ) . sars-cov- igm antibodies were elevated in these three newborns, although their nasopharyngeal pcrs were negative. in an editorial related to these cases, kimberlin ( ) pointed out that false-positive results due to cross-reactivity of igm could occur and perinatal testing remains a challenge. interestingly, zamaniyan and al.( ) , described a case of positive sars-cov- amniot ic sample from a newborn, raising concern about potential vertical transmission in mothers with serious illness. indeed, possible vertical transmission has been questioned by other authors ( , ) and remain unclear. a case of second trimester miscarriage was reported by baud and al.( ) in a patient at wg positive for sars-cov- . virological findings confirmed the presence of the virus in the placenta, but not in fetal tissue or maternal samples, suggesting a potential impact of sars-cov- early in the pregnancy. in other cov infections during the second or third trimester of pregnancy, it is interesting to note that placental changes seem to precede fgr. severe maternal respiratory illness related to cov infection may lead to a circulatory insufficiency in both the placenta and the fetus. thus, this article is protected by copyright. all rights reserved. a maternal covid infection could affect the oxygen supply, leading to placental insufficienc y, iugr, fetal distress and / or fetal demise. a direct impact of the virus itself, by increasing fibrin deposits or thrombo-embolic events in the placenta, cannot be excluded and warrants further investigation. similarly, maternal sars related to cov- infection during the first trimester of pregnancy could disrupt the uterine placental flow, leading to miscarriage. although the risk of miscarria ge has been described with sars-cov- infection, no cases have yet been reported with sars-cov- infection. currently, no curative agent has been found for covid- . studies conducted so far (includ ing randomized controlled trials = rcts) have been plagued by poor methods and reporting, such as exclusion of patients with worse outcome from the treated group, different endpoints between protocols and published reports, premature stopping of rct (leading to lack of statistical power), use of endpoints of no clinical value (such as viral load), degrees of severity of enrolled patients (so that the benefit of a treatment or lack thereof in a cohort of patients may not generalizable to patients with different degrees of severity, lack of optimization of treatment dose or duration of treatment, to name but a few). this article is protected by copyright. all rights reserved. several drugs are currently being evaluated as potential treatment for sars-cov- includ i ng hydroxychloroquine, lopinavir-ritonavir combination, remdesivir, oseltamivir, interferon alpha, darunavir, baricitinib, tocilizumab and immunoglobulin therapy. hydroxychloroquine use in pregnant women has raised concerns in the past especially for an increased risk of cardiac malformation ( ) and its retinal and ototoxicity ( )( ), related to the use of chloroquine and not hydroxychloroquine, findings which were not confirmed in more recent case series ( )( )( ) ( ) . in the most recent systematic review and meta-analys is conducted in , kaplan yc et al ( ) , found no increase "in the rates of major congenita l craniofacial and cardiovascular, nervous system and genitourinary malformations in the infants." however, there was a significant increase in the spontaneous abortion rate, which could be associated with the underlying disease activity rather than the treatment. that being said, (hydroxy)chloroquine is one of the antimalarial drugs considered compatible with pregnancy in all trimesters for prophylaxis and treatment of malaria ( , ) . a recent article gathered evidence on its use during lactation and found that it was compatible with breastfeeding ( ), concluding that hydroxychloroquine could be used for the treatment of covid- infection, in usual rheumatological doses ( - mg/day) if proven to be effective. the lopinavir ritonavir combination is used as part of the haart regimen to treat hiv infected women during pregnancy ( ) . in a systematic review that included , lpv/r-exposed pregnancies, the authors reported the rate of congenital abnormalities to be similar to that of the general population. however, the stillbirth rate was higher than in the general population in the uk ( . per infants against . per infants in ) ( ). there has been general concern regarding protease inhibitor exposure in utero and its association with an increased risk of preterm birth ( ), however, to our knowledge this risk has not been evaluated specifica lly for lopinavir and ritonavir alone, and could be associated with the underlying disease activity rather than the treatment. finally, moderate adverse events such as gastro-intestinal symptoms ( ) and an increased risk for alteration in fasting glycemia ( ) were reported. lopinavir and ritonavir are drugs considered compatible with pregnancy in all trimesters for hiv treatment and has been associated with very low excretion into breastmilk ( , ) . regarding remdesivir, no adverse effect was reported in pregnant participants in a randomized controlled trial on ebola virus ( ). safety data on remdesivir in pregnancy are still scarce. oseltamivir was used during the influenza a/h n pandemic and notably in pregnant mothers. in the most recent population-based study ( ) conducted on , pregnancies in denmark from to of which were exposed to oseltamivir during pregnancy, ehrenstein.v and colleagues found no increased risk of any major congenital malformatio n, fetal death, preterm birth, sga or low -min apgar score. this confirmed previous observations from the european registry study ( ) and the roche global safety database ( ). oseltamivir could be considered compatible with pregnancy in all trimesters if proven effective in covid- treatment and has been associated with very low excretion into breastmilk ( , ) . the interferon alpha drug (infα) is used to treat essential thrombocythemia, chronic myelocytic leukemia or hepatitis b and c in pregnant women. in a recent review including exposed women, sakai k et al. found that no adverse event had required discontinuation of the this article is protected by copyright. all rights reserved. treatment but alerted physicians to "pay attention to (…) rare adverse events, such as impaired liver function, interstitial pneumonia, and attempts at suicide" ( ). safety data on infα in pregnancy are scarce but its similarity to beta interferon, of which safety data during pregnancy are substantial and reassuring, makes it compatible in pregnancy if proven effective for covid- infection. regarding darunavir, no embryotoxicity or teratogenicity of this molecule was found in anima l studies ( ). in a brief review of darunavir use in pregnant women, the authors concluded that it is a well-tolerated molecule which has few minor adverse effects ( ). darunavir is considered compatible with pregnancy in all trimesters for hiv treatment despite its lack of safety data in pregnancy as its maternal benefit outweighs the potential unknown risks ( , ) . animal studies have demonstrated embryotoxicity of baricitinib ( ) and no safety data are available in human. analysis of the roche global safety database does not suggest a substantially increased risk of malformations with the use of tocilizumab. however, an increased rate of preterm birth and low birth weight children was possibly associated with tcz exposure and could be associated with the underlying disease activity rather than the treatment ( ). safety data in pregnancy are limited and due to treatment-induced immunosuppression, an increased risk of maternal-feta l infections is theoretically possible in pregnant women treated with tocilizumab. in a systematic review assessing the benefits and safety of hyperimmune globulins to prevent hbv mother to child transmission in pregnant women, only one study mentioned adverse events consisting in swelling in two women ( ). more recently, convalescent serum to treat the ebola virus disease was evaluated in a non randomized comparative study of patients which included eight pregnant women. no serious adverse reaction were associated with the transfusion ( ). two cases of pregnant women report the use of convalescent serum to treat sars-cov- infection ( , ). in the first case of a years old pregnant woman, no serious adverse event related to the use of convalescent plasma was reported but its relative contribution to surviva l could not be determined due to other concomitant treatments. the authors concluded that its clinical benefit remained unknown ( ). in the second case of a year old pregnant woman with severe co morbidities who received both convalescent serum and remdesivir, no conclusion regarding safety or benefit of convalescent plasma could be drawn by the authors ( ). data on the use of specific hyper immunoglobulins to prevent infections in pregnant women seem reassuring as well as those on the use of convalescent serum although they are more scarce. if they proved to be effective in covid- treatment, convalescent serum and specific hyper immunoglobulins directed against sars-cov- could be considered compatible with pregnancy in all trimesters. this article is protected by copyright. all rights reserved. (table ) regarding potential asymptomatic infected pregnant women, the who recommends careful monitoring of patients with epidemiological history of contact with infected individuals, while the american college of obstetricians and gynecologists (acog) suggests routine antenatal care in this situation. an algorithm for assessment and management of symptomatic parturients has been proposed by acog, classifying them in three categories of risk: low, moderate and elevated. for mild presentations, women without comorbidities (low risk) should self-isolate at home, whereas those with health problems, obstetrical issues or the inability to care for themselves (moderate risk) should be seen in an ambulatory setting. according to the royal college of obstetricians and gynaecologists (rcog), pregnant women with moderate symptoms should self-isolate, unless they attend a maternity unit where patients in the nd or rd trimester meeting phe criteria ( ≥ of: ( ) clinical/radiological evidence of pneumonia, ( ) acute respiratory distress syndrome (ards), ( ) fever ≥ . and at least one of acute persistent cough, hoarseness, nasal discharge/congestion, shortness of breath, sore throat, wheezing or sneezing) should be tested for covid- and treated as infected until results are available. when pregnant women present with severe symptoms (high risk), they should immediately go to an emergency department according to acog algorithm. all guideline s agree that administration of corticosteroids for fetal lung maturity is still recommended per protocol for in the setting of a high risk of preterm birth when the mother's condition is stable. regarding fetal growth surveillance, rcog recommends an antenatal ultrasound fourteen days after acute illness resolution for hospitalized patients, while acog suggests a rd trimester ultrasound for covid- pregnant women infected in nd and rd trimester. a detailed anatomy ultrasound could be considered for st trimester infections (acog). data suggest that covid- may be associated with an increased thromboembolic risk with a rate of venous thromboembolism (vte) of % in icu patients ( ). therefore, routine vte other coronavirus epidemics, such as sars-cov- had a higher impact on pregnant women encompassing % of icu admissions and % of mortalities. the mers-cov epidemic was even more lethal with a % mortality without significant difference of severity between pregnant and non-pregnant women. in this review, we gathered more than cases of sars-cov- in pregnancy and identified a maternal mortality of . % ( cases) among those described in the literature. icu admissions were between . % and %. the proportion of this article is protected by copyright. all rights reserved. severe complications seem to be equal to the non-pregnant population, however these must still be anticipated in pregnant women. these rates will have to be reviewed when the true denominator (number of infected pregnant women) is known, as a significant proportion of patients remain asymptomatic. past coronavirus epidemics were associated with adverse outcomes for the fetus and/or newborns including miscarriages ( %), preterm birth, fetal distress and fgr with sars-cov- infection during the nd and rd trimesters. also, mers-cov infection resulted in fetal and neonatal demise in % of cases. in this review, we found that of cases of sars-cov- infections in pregnancy, % experienced preterm birth and % had adverse fetal/neonata l outcomes (fgr, fetal/neonatal demise, severe symptoms at birth). potential mechanis ms include placental changes, as observed with sars-cov- , and severe respiratory maternal illness, which could lead to placental insufficiency, iugr and fetal distress/demise. the role of sars-cov- in early adverse pregnancy outcomes needs further investigation. with regards to pharmacological management, most agents currently tried are safe in pregnancy. as of april , , prenatal management should be adapted to the patient's condition as indicated by acog and other algorithms ( ). there is currently no agreement on specific prenatal ultrasound surveillance, but due to the potential risk of iugr, it would seem reasonable to assess fetal growth surveillance during the third trimester of pregnancy. administration of corticosteroids in pregnant women at risk of preterm birth should be administered per protocol, with consideration for the patient's condition. we recommend this article is protected by copyright. all rights reserved. considering parental preferences, the severity of illness and obstetrical indications when addressing the mode of delivery. guidelines for pregnancy management will continue to be updated and professionals should stay informed about new guidelines. the acquisition of robust data on the impact of emergent pathogens on pregnant women is often lacking or only available after a considerable delay ( ) this article is protected by copyright. all rights reserved. . covid- and vte-anticoagulation -hematology.org [internet] . this article is protected by copyright. all rights reserved. this article is protected by copyright. all rights reserved. suspected perinatal infection * ( %) * / * ( %) / * ( %) ( %) ( %) / * ( %) * / * ( %) ( %) ( %) / * ( %) ( %) ( %) / * ( %) the nucleic acid test from the mother's amniotic fluid, vaginal secretions, cord blood, placenta, serum, anal swab, and breast milk were also negative. the most comprehensively tested case reported to date confirmed that the vertical transmission of covid is unlikely. the current data show that the infection of sars-cov- in late pregnant women does not cause adverse outcomes in their newborns, however, it is necessary to separate newborns from mothers immediately to avoid the potential threats. vlachodimitropoul ou koumoutsea e, covid and acute coagulopathy in pregnancy. journal of thrombosis and haemostasis none the laboratory derangements may be reminiscent of hellp syndrome, and thus knowledge of the covid relationship is paramount for appropriate diagnosis and management. in addition to routine measurements of d-dimers, prothrombin time, and platelet count in all patients presenting with covid as per isth guidance, monitoring of aptt and fibrinogen levels should be considered in pregnancy, as highlighted in this report. li l, [ ] and their efforts to point out the error in table . after consideration of the information presented by moradi et al., we have corrected the contents of although vertical transmission of sars-cov has been excluded thus far and the outcome for mothers and fetuses has been generally good, the high rate of preterm cesarean delivery is a reason for concern. these interventions were typically elective, and it is reasonable to question whether they were warranted or not. in mothers infected with coronavirus infections, including covid- , > % of whom also had pneumonia, ptb is the most common adverse pregnancy outcome. miscarriage, preeclampsia, cesarean, and perinatal death ( - %) were also more common than in the general population. it seems that the data in the second and third columns in table have been transposed, which needs correction. we present here the best evidence available to address many of these challenges, from making the diagnosis in symptomatic cases, to the debate between nucleic acid testing and chest imaging, to the management of the unwell patient in labor. this article is protected by copyright. all rights reserved. khan s, impact of covid- infection on pregnancy outcomes and the risk of maternal-toneonatal intrapartum transmission of covid- during natural birth. infection control and hospital epidemiology we report a case report study of pregnant women with laboratory-confirmed covid- pneumonia. all pregnant women had vaginal deliveries. these patients presented with symptoms manifested by people with covid- . of patients, only patient delivered a preterm baby. saccone g, the novel coronavirus ( -ncov) in pregnancy: what we need to know. european journal of obstetrics, gynecology, and reproductive biology none in conclusion, strict monitoring of women with suspected -ncov is firmly recommended. obstetricians should promptly recognize the symptoms of -ncov, and adequately assess severity and fetal well-being. with interest, we read the guidelines by guillaume favre and colleagues on the management of pregnant women with suspected severe acute respiratory syndrome coronavirus (sars-cov- ) infection. therefore, we propose a translated algorithm for spanish-speaking countries (appendix). we also suggest that the new breastfeeding recommendations and the option to use dexamethasone as an alternative to betamethasone are adopted in latin america. this article is protected by copyright. all rights reserved. khan s, association of covid- infection with pregnancy outcomes in healthcare workers and general women. clinical microbiology and infection in summary, we found two neonates suspected for covid- infection and five neonates with neonatal pneumonia, suggesting the possibility that adverse pregnancy outcomes may be linked to covid- infection. shah ps, classification system and case definition for sars-cov- infection in pregnant women, fetuses, and neonates. acta obstetricia et gynecologica scandinavica none at present the evidence for intrauterine transmission from mother to fetus or intrapartum transmission from mother to the neonate is sparse. there are limitations associated with sensitivity and specificity of diagnostic tests used and classification of patients based on test results has also been questioned. deprest j, feto-placental surgeries during the covid- pandemic: starting the discussion. prenatal diagnosis none fetal diagnosis and pregnancy care need to be maintained, and we should strive to preotect the vulnerable population of pregnant women as well as their fetus, as much as possible. this includes both sars-cov -negative and positive patients with fetal anomalies that may benefit from prenatal intervention. mimouni f, perinatal aspects on the covid- pandemic: a practical resource for perinatalneonatal specialists. journal of perinatalogy none vertical transmission from maternal infection during the third trimester probably does not occur or likely it occurs very rarely. consequences of covid- infection among women during early pregnancy remain unknown. we cannot conclude if pregnancy is a risk factor for more severe disease in women with covid- . little is known about disease severity in neonates, and from very few samples, the presence of sars-cov- has not been documented in human milk. this article is protected by copyright. all rights reserved. wilson an, caring for the carers: ensuring the provision of quality maternity care during a global pandemic. women and birth none this article provides an overview of important considerations for supporting the emotional, mental and physical health needs of maternity care providers in the context of the unprecedented crisis that covid- presents. cooperation, planning ahead and adequate availability of ppe is critical. thinking about the needs of maternity providers to prevent stress and burnout is essential. palatnik a, protecting labor and delivery personnel from covid- during the second stage of labor. american journal of perinatology none we recommend that labor and delivery personnel have the utmost caution and be granted the protection they need to protect themselves and other patients. this includes providing labor and delivery personnel full ppe including n for the second stage of labor. this is critical to ensure the adequate protection for health care workers and to prevent spread to other health care workers and patients. in summary, at present it must be stated that the general care recommendations that also apply to non-covid- patients are initially valid with regard to obstetric anesthesia. nevertheless, the special requirements on the part of hygiene and infection protection result in special circumstances that should be taken into account when caring for pregnant patients from an anesthetic point of view. mcintosh jj, corticosteroid guidance for pregnancy during covid- pandemic. american journal of perinatology none it is necessary that obstetricians adjust practice to carefully weigh the fetal benefits with maternal risks. therefore, our institution has examined the risks and benefits and altered our corticosteroid recommendations. gonzalez-brown vm, operating room guide for confirmed or suspected covid- pregnant patients requiring cesarean delivery. american journal of perinatology none this is a suggested protocol which may not be applicable to all health care settings but can be adapted to local resources and limitations of individual l&d units. this article is protected by copyright. all rights reserved. parazzini f, delivery in pregnant women infected with sars-cov- : a fast review. international journal of gynaecology and obstetrics the rate of vertical or peripartum transmission of sars-cov- is low, if any, for cesarean delivery; no data are available for vaginal delivery. low frequency of spontaneous preterm birth and general favorable immediate neonatal outcome are reassuring. huang x, epidemiology and clinical characteristics of covid- . archives of iranian medicine none the basic strategy for controlling the epidemic is early detection, early isolation, early diagnosis and early treatment. covid- cases are insidious and transmissible in the incubation period, and multiple clusters have been reported in china. the causal role of covid- in these cases is therefore uncertain and larger studies are needed in the future to describe the prevalence, clinical characteristics and course of the disease. pérez-lópez fr, severe acute respiratory syndrome coronavirus and human pregnancy. gynecological endocrinology none outcomes of pregnants delivering in the upcoming months will provide more information on this particular new disease and its relation to pregnancy. in the meantime, it seems best that women should be encouraged to delay becoming pregnant until more evidence related to risks associated to covid- infection during pregnancy is available. in addition, women susceptible to be submitted to assisted reproductive technology should take some additional precautions as recently recommended by la marca et al. pregnant women in shanghai critically concern about the risk of -ncov infections, and highly demand knowledge and measures on prevention and protection from covid- . they ask for having time-lapse appointments for anc and online access to health information and services. maternal and child care institutes should understand the demands of pregnant women, optimize the means of anc service, and provide tailored and accessible health education and service for the safety of mother and child. the manuscript outlines the precautions and steps to be taken before, during, and after resuscitation of a newborn born to a covid- mother, including three optional variations of current standards involving shared-decision making with parents for perinatal management, resuscitation of the newborn, disposition, nutrition, and postdischarge care. the availability of resources may also drive the application of these guidelines. this article is protected by copyright. all rights reserved. bourne lancet . infectious diseases the maternal, fetal, and neonatal outcomes of patients who were infected in late pregnancy appeared very good, and these outcomes were achieved with intensive, active management that might be the best practice in the absence of more robust data. the clinical characteristics of these patients with covid- during pregnancy were similar to those of nonpregnant adults with covid- that have been reported in the literature. given that patients were diagnosed by mar. th in shenzhen and tens of cases was diagnosed in our hospital, yet no nosocomial infection has occurred and none of the pregnant woman registered in our hospital was reported to be infected, this management should be effective to an extant, however mathematical model may be needed to quantify the effectiveness of these methods. on january , we published "guidance for maternal and fetal management during pneumonia epidemics of novel coronavirus infection in the wuhan tongji hospital (first edition)" [ ] . based on the clinical characteristics, diagnosis and treatment progress of the recently discovered diseases, we offered an updated clinical management for pregnant women and newborns with ncp. for ordinary covid- patients intraspinal anesthesia is preferred in cesarean section, and the influence on respiration and circulation in both maternal and infant should be reduced; while for severe or critically ill patients general anesthesia with endotracheal intubation should be adopted. the safety of medical environment should be ensured, and level-Ⅲ standard protection should be taken for anesthetists. special attention and support should be given to maternal psychology. we therefore updated the guidelines according to the data available at the beginning of march, (appendix). it is our responsibility, as specialists working in different fields of perinatology, to improve our own recommendations and that of others for the benefit of our patients. clinical features of patients infected with novel coronavirus in wuhan, china. the lancet a novel coronavirus from patients with pneumonia in china zika virus infection -after the pandemic sars and mers: recent insights into emerging coronaviruses aerosol and surface stability of sars-cov- as compared with sars-cov- first experience of covid- screening of health-care workers in england. the lancet who | summary table of sars cases by country this article is protected by copyright. all rights reserved who | middle east respiratory syndrome coronavirus (mers-cov) early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the hospitalized patients with novel coronavirus-infected pneumonia in coronavirus disease (covid- ) and pregnancy: what obstetricians need to know guillain-barré syndrome related to covid- infection presumed asymptomatic carrier transmission of covid- a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster. the lancet real estimates of mortality following covid- infection authors' reply. the lancet infectious diseases estimates of the severity of coronavirus disease : a model-based analysis. the lancet infectious diseases clinical manifestations and outcome of sars-cov- infection during pregnancy clinical 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transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records. the lancet clinical features and obstetric and neonatal outcomes of pregnant patients with covid- in wuhan, china: a retrospective, single-centre, descriptive study. the lancet infectious diseases clinical analysis of neonates born to mothers with -ncov pneumonia pregnancy and perinatal outcomes of women with coronavirus disease (covid- ) pneumonia: a preliminary analysis neonatal early-onset infection with sars-cov- in neonates born to mothers with covid- in wuhan, china. jama pediatr clinical manifestations and outcome of sars-cov- infection during pregnancy clinical features and outcomes of pregnant women suspected of coronavirus disease perinatal transmission of covid- associated sars-cov- : should we worry? a case report of neonatal covid- infection in china a case of novel coronavirus in a pregnant woman with preterm delivery covid- in pregnancy with comorbidities: more liberal testing strategy is needed an uncomplicated delivery in a patient with covid- in the united states emergency cesarean section on severe acute respiratory syndrome coronavirus (sars-cov- ) confirmed patient covid- ), practice advisory. the american college of obstetricians and gynecologists covid- ) infection in pregnancy, information for healthcare professionals version . royal college of obstetricians & gynaecologists covid- -guidance for neonatal settings. royal college of paediatrics and child health current criteria phe criteria(correct at the time of publishing this update) are: women who are being/are admitted to hospital with one of the following: • clinical/radiological evidence of pneumonia, • acute respiratory distress syndrome (ards), • fever ≥ . and at least one of acute persistent cough, hoarseness, nasal discharge/congestion, shortness of breath national institute for health and care excellence this article is protected by copyright. all rights reserved.accepted article this article is protected by copyright. all rights reserved. this article is protected by copyright. all ten key recommendations were provided for the management of covid- infections in pregnancy.this article is protected by copyright. all rights reserved.accepted article zhou d, covid- : a recommendation to examine the effect of hydroxychloroquin e in preventing infection and progression.review article the journal of antimicrobial chemotherapy none in summary, we propose that hydroxychloroquine (hcq) could serve as a better therapeutic approach than chloroquine (cq) for the treatment of sars-cov- infection. there are three major reasons for this: (i) hcq is likely to attenuate the severe progression of covid- through inhibiting the cytokine storm by reducing cd expression in t cells; (ii) hcq may confer a similar antiviral effect at both pre-and post-infection stages, as found with cq; (iii) hcq has fewer side effects, is safe in pregnancy and is cheaper and more highly available in china. if there is an indication for obstetric surgery or critical illness of covid- in pregnant women, timely termination of pregnancy will not increase the risk of premature birth and asphyxia of the newborn, but it is beneficial to the treatment and rehabilitation of maternal pneumonia. preventive use of long-acting uterotonic agents could reduce the incidence of postpartum hemorrhage during surgery. -ncov infection has not been found in neonates deliverd from pregnant women with covid- . journal of infection the report showed pregnant women are also susceptible to sars-cov- infection. sars-cov- may increase health risks to both mothers and infants during pregnancy. efforts should be taken to reduce the infection rate of sars-cov- both in pregnant and perinatal period, and more intensive attention should be paid to pregnant patients. review article international nursing review none the next decade is likely to produce any number of global challenges that will affect health and health care, including pan-national infections such as the new coronavirus covid- and others that will be related to global warming. nurses will be required to react to these events, even though they will also be affected as ordinary citizens. the future resilience of healthcare services will depend on having sufficient numbers of nurses who are adequately resourced to face the coming challenges. none not about coronavirus - therefore, p c potentially could be tested as a priming vaccine or be further modified using reverse genetics. it also can be administered in multiple doses or be combined with inactivated or subunit vaccines and adjuvants as a pedv vaccination regimen, whose efficacy can be tested in the future.this article is protected by copyright. all rights reserved. not about coronavirus - mers-cov remains an uncommon disease among children, and its course follows a milder path among children than those of adults. majority of cases were asymptomatic and were diagnosed during the course of contact investigation. not about coronavirus - ifn-based drugs enhance the protective effect of vaccination against associative infections in the newborn calves. they stimulate a rise in the titer of antibodies to rotavirus, coronavirus, vd, and mucosal disease complex as well as an increase in immunoglobulins a, m, and g. key: cord- - tt k authors: chauhan, priyanshi title: gendering covid- : impact of the pandemic on women’s burden of unpaid work in india date: - - journal: gender issues doi: . /s - - -w sha: doc_id: cord_uid: tt k the covid- pandemic has exacerbated the already existing gender inequalities with substantial implications on women. with the closure of offices and educational institutions, and the emerging norm of work from home and online education, along with the lack of services of domestic worker, the need to perform unpaid chores in the household has increased. simultaneously, the requirements of social distancing and sanitization have created new unpaid chores. owing to the sexual division of labour, and gendered roles and social norms of performing domestic and care work, the burden of unpaid work falls disproportionately on women. in this context, the objective of the paper is to study the impact of covid- on time spent on unpaid work and the underlying gender differences in the urban centres in india. specifically, the paper will do a comparative analysis of the gender differences in time spent on unpaid work before and during the lockdown, and analyse the reasons for the same. the covid- pandemic has wreaked havoc across the world and brought the world to a standstill with unprecedented changes in our society and economy. as has been the case, the novel coronavirus spread with such a speed and intensity across the world due to the interconnectedness of the globalized world that most countries imposed temporary shutdowns as a strategy to contain its spread. the government of india imposed a nationwide lockdown on march , initially for days only, which was eventually extended till may in various phases. the impacts of the lockdown have been disruptive and changed the way in which humans perform their daily activities and go about their routine lives. such impact has however not been the same across all social groups, with the most vulnerable and marginalized groups being affected differently due to the already existing social inequalities [ ] . specifically, the lockdown has widened the existing gender inequalities and limited the opportunities for women [ , ] . one of the ways in which the pandemic has affected women differently than men is through increased burden of unpaid work. owing to the sexual division of labour, and gendered roles and social norms of performing domestic and care work in a household, the burden of unpaid work falls disproportionately on women. such tasks are time-consuming and physically tiring, and subject women to time poverty, leaving little or no time for them to undertake productive activities like education or employment, or leisure. the pandemic has worked to exacerbate the already existing gendered nature of unpaid work at home [ , ] . with the closure of offices and educational institutions, and the simultaneously emerging norm of work from home and online education, along with the lack of services of domestic workers, the need to perform unpaid chores like cooking, cleaning, washing, child care among others by household members has increased [ ] . for working women, the lockdown has meant the collapse of the demarcation of their professional spaces and domestic life which has led to the simultaneous performance of their office work and household responsibilities. in this context, the objective of the paper is to study the impact of covid- on time spent on unpaid work and gender differences for the same in the urban centres in india. specifically, the paper will do a comparative analysis of the gender differences in time spent on unpaid work before and during the lockdown. furthermore, the paper will study the gendered impact of lockdown on unpaid labour of women on various parameters like marital status, employment status, income levels and average weekly office hours. finally, the paper will analyse the reasons for the observed gendered differences in unpaid household chores. the term unpaid work, as given by the international labour organization [ , p. ] , is the 'non-remunerated work carried out to sustain the well-being and maintenance of other individuals in a household or the community, and it includes both direct and indirect care (i.e. routine housework)'. the ilo estimates show that time spent in unpaid work accounted for ' . billion hours per day, with women contributing more than three-fourths of the total' which is 'equivalent to . billion people working on a full-time basis without pay' [ , p. ]. in india, women spend an average of . min/day on unpaid work as compared to an average of . min/ time poverty is the burden of competing claims on an individual's time that reduce their ability to make unconstrained choices in how they allocated their time leading to trade offs among various tasks. the burden of unpaid work causes time poverty as it prevents women from participating in paid labour and social activities, thus feeding back to their low status [ , pp. - ] . day by men [ ] . in addition, data show that time spent on total paid and unpaid work by women in india is . min/day as compared to an average of . min/ day being spent by men [ ] . this implies that for women engaged in paid employment, the drudgery of unpaid work is so high that they work longer than men. overall, the data highlight the gendered nature of unpaid work and shows that the burden of such activities falls disproportionately on women (table ) . there are two theoretical strands in the existing literature that explain the gendered nature of unpaid work and its disproportionate burden on women, namely the economic perspective and the gender perspective. the economic perspective emphasizes the principles of rationality and comparative advantage. accordingly, it states that women's engagement in unpaid labour depends on the comparative advantage relative to the paid work which can be changed with changes in various factors like educational attainment and wages [ ] . within the economic perspective, there are two models, namely the unitary model and intra-household bargaining model that explain the burden of unpaid work. as originally given by becker [ ] , the unitary model assumes household as the basic unit of analysis with common preferences and common utility curve of all members. the argument in the unitary model leads to role specialization where one partner invests more time in producing income and the other spends more time in non-market work [ ] . the feminist economists however reject the unitary model as it does not consider the role of gender as a factor in different preferences for women [ , , ] . the basis for this is that gender plays a significant role in determining power relations within a household where men are often more privileged than women, and the allocation of resources is in favour of men leaving women worse-off who could be effectively in poverty, even when the household aggregates indicate otherwise [ , ] . in addition to determining the intra-household allocation of resources, gender also affects the decision making power and responsibilities within a household [ , ] . as such, households are sites where gender roles are both produced and performed through various means like the sexual division of labour. going further, the assumption of unitary models that the household is a rational unit is criticized as it not only neglects the gendered nature of household and the consequent inequalities in resource distribution but also justifies them in "favour of economic rationality" [ , p. ] , thereby seeing intrahousehold power dynamics and inequalities across genders as excusable and even preferable. according to the intra-household bargaining models, the partner with greater resources, who are generally men owing to power dynamics of gender, will use these resources to avoid unpaid work [ ] . the gender perspective derives from the sociological understanding of gender as a power relation. accordingly, the approach emphasizes reinforcing masculine and feminine behaviour through unpaid labour. specifically, by avoiding unpaid work men tend to display masculinity whereas performing unpaid household chores is considered integral to being an 'ideal' wife or mother [ , ] . interestingly, this is evident in situations where both men and women in a household are engaged in full time employment and earn equal incomes, there is a tendency for women to do more household work [ , , ] . this is because, women making more money than the husband is considered as a deviance from the gender norm where a husband is to provide for the household, and therefore to neutralize this deviance women take more responsibility of the unpaid household chores, thereby reinforcing the gender norms [ ] . since the burden of unpaid work is relatively greater on women as compared to men, it raises various concerns for them. the chores that fall into the category of unpaid labour are physically exerting and time consuming. as such, the unpaid work of women takes away most of their time and subjects women to time poverty, leaving little or no time for them to engage in productive activities like education and paid employment [ , , ] . in india, women's labour force participation is dismal and has been showing a declining trend for more than a decade. according to the world bank data, female labour force participation has decreased from % in to % in [ ] . simultaneously, women's time poverty has increased manifold [ , p. ], despite the drop in their labour force participation, clearly suggesting that women experience extreme time poverty due to their responsibilities of unpaid labour. consequently, lack of personal income affects their economic status, financial independence, bargaining power and decision making within the household, thereby affecting the intra-household distribution of resources in favour of men as guided by the power dynamics of gender relations. furthermore, women's lower labour force participation also disincentivizes investment in education and skill development of girls and young women, and they further get pushed into undertaking unpaid labour. thus, disproportionate burden of unpaid work pushes women out of the labour force which not only affects their financial status but also makes education and skill upgradation less attractive which reduces their opportunities of participating in formal economy, therefore raising equity concerns for women's participation in the process of development. simultaneously, the designation of household chores as 'women's work' does not include the element of choice and is instead governed by the norms of gender division of labour and norms, and feeds into the existing power relation across genders [ , p. ] . for women in paid employment, the drudgery of unpaid work is so high that they work longer than men owing to the triple burdens of unpaid work, reproductive work and paid employment. consequently, there are only limited opportunities for social and political participation, which has significant bearing for their empowerment, and for leisure which affects their overall well-being [ ] . this also affects their opportunities for career advancement, as women's participation in paid work reduces the time spent on unpaid work but less than proportionally as compared to the increase in time in paid work, thereby effectively increasing the number of hours women spend working which is often compensated from the time spent for leisure, sleep, or personal care activities [ , ] . finally, the unpaid labour performed by women in not accounted for in the national accounting systems, and are therefore excluded from the realm of policy making [ , p. ]. efforts to integrate women in the development process to make it inclusive have not considered the drudgery of unpaid work on women. for instance, the much recognized 'efficiency approach' that calls for integration and increased participation of women in the development process on grounds of costs of excluding women from the formal economy and the resulting inefficiencies in the markets, seeks to bring women into the ambit of development without considering the impact on their overall well-being. the literature highlights that such development, though inclusive, is bound to put stress on women, increase their drudgery and affect their overall well-being [ , p. ; ] . the research follows a qualitative approach and primary data is collected in two stages. in the first stage, a survey is conducted with the objective to understand patterns of time spent on household chores for men and women, both before and during the lockdown. at the second stage, semi-structured interviews are conducted with the objective to understand the reasons for responses received in stage one. since the objective is to do a gender analysis of the impact of covid- on unpaid work, the unit of analysis for the research is the individual, with focus on two genders, namely men and women. the chores included in the unpaid work comprise of cleaning the house, cleaning the dishes, cooking, childcare, elderly care and laundry among others. non-probability sampling techniques were used to make decision regarding the sample population. specifically, convenience sampling techniques and judgemental sampling techniques were used for the purpose of the survey and interviews respectively. for interviews, a sub-sample from stage one was taken based on the characteristics like marital status, employment status, use of services of domestic help, and the responses received on change in time spent on unpaid chores during the lockdown. the total sample size for survey comprised of and individuals for stage one and two respectively. the geographical scope of the research is limited to urban and semi-urban areas in india. owing to the conditions of lockdown and the social distancing norms, the data have been collected through virtual mode only, via the internet and telephonic conversation only. further, the survey was conducted in english language, and the interviews were conducted in both english and hindi language based on the preferences of the interviewee. details of the descriptive characteristics of the respondents who participated in the survey are presented in table . out of the total sample population of respondents for the survey, % are men and % are women. based on the marital status, % of the population is married and % is unmarried. the employment status of the respondents is such that % of them are employed and % are unemployed. sixty-four percent of the respondents have stated post-graduation as their highest qualification, followed by % being graduates, % with m.phil. and above, and % who studied till class . based on the educational qualifications and the average monthly income, all the respondents to the survey are from the middle class. furthermore, % of the total population, and approximately % and % of men's and women's population respectively availed the services of domestic workers before the lockdown to perform multiple household chores like cooking, cleaning, child care, elderly care, laundry among others which are otherwise unpaid when performed by a member of the household. it should be noted that the category of 'unemployed men' includes only two respondents, and therefore does not provide sufficient information regarding their time-use patterns and how the lockdown has affected their burden of unpaid labour. figure shows the comparative burden of household chores on men and women, and is consistent with the theoretical exposition that the burden of unpaid work fell disproportionately on women. it can be observed from fig. that the highest percentage of both men and women spent a maximum of h/week to perform unpaid work. however, more men spent up to h/week as compared to women. specifically, % men spent a maximum of h/week on unpaid work as compared to % women before the lockdown. furthermore, there is a virtual absence of men from the higher time intervals spent on domestic work as compared to a significant presence of women in these time intervals. approximately, % women spent - h/week on domestic chores as compared to zero men, and . % women spent - h/week on domestic chores as compared to . % men. interestingly, no man spent more than h/week on unpaid work as compared to approximately % women. this is significant considering the fact that spending more than h/week on unpaid work is greater than the maximum limit of h/week for paid employment set by the law but do not get remunerated for the same. figure , therefore clearly highlights that despite a comparable use of the services of domestic workers for domestic chores in the survey sample, it is women who bear a higher and disproportionate burden of unpaid household chores as compared to men. differences in the burden of unpaid work are observed based on the marital status of the respondents. to assess the same, the respondents have been categorized as -married men, married women, unmarried men and unmarried women. as shown in fig. , the highest percentage of population from all the four categories spent up to h/week on unpaid chores. however, there are differences in the percentage of population of each category spending - h per week on such tasks, with the least percentage of married women ( . %), followed by married men ( %) and unmarried women ( %) and the highest percentage of unmarried men ( %). all unmarried men spent only a maximum of h/week on household chores. simultaneously, % of unmarried women and % of married men spent a maximum of h/week on household chores. this stands in stark contrast to the burden of unpaid household chores on married women, with % spending - h/week, and . % spending more than h/week on domestic chores in the household. marital status is therefore a key determinant of the burden of unpaid labour in a household, with survey respondents showing that married women share the highest burden. other than the marital status, the gendered burden of unpaid domestic chores also depends on the employment status of each individual. as shown in fig. , approximately % of employed men and % of employed women spent a maximum of h/week on unpaid work, as compared to only % of unemployed women. ninetyfive percent of employed men and % of employed women spent a maximum of who identified themselves as 'housewives/homemaker' are married, meaning that the employment status and marital status intersect, and affect women's burden of unpaid labour in a household. for employed respondents, the gender-wise burden of unpaid labour is similar across different income groups, and average office hours as shown in figs. and respectively, and these variables did not significantly affect the burden of unpaid labour across genders in the pre-covid period. the following inferences can be drawn from the above for the burden of unpaid work and its gendered nature before the lockdown. first, despite a similar and comparable use of the services of domestic workers in the sample population, the burden of unpaid work fell disproportionately on women. second, marital status and employment status are key determinants of time spent on domestic work. third, in the context of marital status being a variable, married women share the highest burden of unpaid labour at home. fourth, based on the employment status, it is the unemployed women, particularly those who identify themselves as housewives/ homemakers, who share the highest burden of domestic work. fifth, for employed individuals, no significant gendered differences in the pattern of sharing the load of household chores is found based on their average monthly income or average weekly office hours. during the lockdown, % of the total survey population reported to avail no services of the domestic workers as compared to % before the lockdown. therefore, the domestic work including cleaning, cooking, laundry, child care, elderly care among others which were earlier performed by the domestic workers for income, are now performed by the household members without any remuneration. therefore, the burden of unpaid work during the lockdown increased for all. a comparison of the time spent on such tasks before and during the lockdown in terms of change in percentage points is shown in fig. . highest decrease has been observed for the percentage of population spending up to h/week on unpaid work during the lockdown for both men ( . percentage points) and women ( . percentage points). however, the disparity across genders has increased. approximately, only . % of women now spend a maximum of h/week on unpaid household chores as compared to . % men during the lockdown. furthermore, for men the highest increase in population of . percentage points is observed in the time interval of ( - ) h/week whereas highest increase for women of percentage points has been observed for more than h/week being spent on unpaid work. interestingly, no man in the survey population spent more than h on household tasks during the lockdown. it should be further highlighted that during the lockdown, % men dedicated up to h/week on unpaid household responsibilities as compared to only . % women. simultaneously, % and % women spend more than h/week and h/week respectively on unpaid work during the lockdown as compared to % and . % women before the lockdown. therefore, the conditions of lockdown to contain the spread of covid- has increased the burden of household work for all, but the responsibility has increased relatively more and disproportionately for women who were already spending more time in unpaid work than men before the lockdown. based on the marital status, a comparison of time allocated to unpaid work before and during the lockdown, is shown in fig. . there has been a highest decrease in the percentage of population spending up to h/week on unpaid work during the lockdown, being approximately percentage points for married men, percentage points for married women, percentage points for unmarried men, and percentage points for unmarried women. while the decline has been greater for unmarried individuals, it should be noted that the percentage of unmarried men and women spending a maximum of h/week is % and % respectively, which is higher than that of married individuals. in addition, the data also highlight that the percentage of both married and unmarried men spending up to h/week on unpaid work is greater than that of married and unmarried women. furthermore, % unmarried men spent up to h/week on such tasks during the lockdown which is the same as before the lockdown, as compared to approximately % unmarried women. for married men, the highest increase in population of percentage points and . percentage points has been observed in the time interval of ( - ) h/week followed by ( ) ( ) ( ) ( ) ( ) ( ) ( ) h/week. all this is in stark contrast to the increase in the percentage of women who spent more than h/week and has observed an increase of percentage points during the lockdown. not only has the increase been the largest, the highest percentage of married women, approximately . %, worked for more than h/ week. before the lockdown, the highest percentage of married women worked maximum of h/week on household chores. interestingly, no men and unmarried women worked for more than h/week during the lockdown. in addition, one-fourth of married women spent more than h/week to unpaid household activities as compared to zero unmarried men and women, and only % married men. based on the employment status, fig. shows that there has been a highest decrease in the percentage of population spending a maximum of h/week on household tasks during the lockdown, for both employed men ( . percentage points) and employed women ( . percentage points). however, the percentage of men ( %) spending a maximum of h/week is more than double than that of women ( week interval during the lockdown and highest increase of . percentage points for those who spent more than h/week on unpaid work. it has been observed that all those unemployed women who spent - h/week on domestic work before the lockdown now spent more than h/week during the lockdown. interestingly, a significant population of unemployed women also spent a maximum of h/week on household chores. it has been found that all the unemployed women respondents who spent less than h/week on unpaid work are students, and all the unemployed women respondents who spent more than h/week on unpaid work identify themselves as housewives/homemakers. for the employed respondents, similar patterns were observed in the burden of unpaid labour for men and women across all income groups before the lockdown. however, during the lockdown, the burden of unpaid labour has increased more for women as compared to men across all income groups. for instance, in the highest income group for the survey of > , inr/month, . % women now spend - h/week on unpaid work as compared to % before. this is also significantly higher as compared to men in the same income group, only . % of whom spend - h/week on domestic chores. similarly, in the income group of , - , inr, % and . % women spend - h/week and > h/week on household chores respectively as compared to % men during the lockdown. similar observations have been made in the context of average weekly office hours, where there was no significant gendered burden of unpaid work before the lockdown. during the lockdown, the burden has increased for all, but disproportionately so for women. for instance, for the respondents whose average office hours are more than h/week, lockdown has increased the percentage of such women spending - h/ week on household chores to . % as compared to . % before the lockdown. simultaneously, the percentage of men in the same interval of - h/week has been increased to . % as compared to % before the lockdown. similarly, for respondents whose average office hours are - h/week, lockdown has increased the percentage of women who spend - h/week and - h/week on household chores to . % and . % respectively during the lockdown from % before the lockdown. interestingly, only . % men with same working hours spend - h/week on household chores and no man spends more than h/week on such tasks during the lockdown. in a nutshell, the lockdown has increased the burden of unpaid work for all members of the household. however, there are differences in the share of such burden across gender lines when explored within the household. first, despite an increase in the time spent for everyone on unpaid work, the burden has increased more for women. second, marital status and employment status are key determinants of the gendered nature of such an increase of women's labour on unpaid chores during the lockdown. as such, the burden has increased the largest for married women and unemployed women, who already spent the highest time on domestic work even before the lockdown. third, for unemployed women, it is those who identify themselves as the housewives/ homemakers who spent maximum time on unpaid household chores during the lockdown. fourth, for the individuals who are employed, the burden has increased more for employed women. fifth, based on changes in average monthly income and average weekly office hours, there was a similarity in trends on the burden of household labour for men and women before the lockdown. however, during the lockdown, stark differences are observed where women spend more time on household chores than men in the same income groups and average weekly office hours groups. overall, women are more burdened across all parameters including marital status, employment status, average monthly income and office hours. it would be fair to say that the burden of unpaid work has increased for all, but increased more for women who were already responsible for such chores even before the lockdown, thus exacerbating the already existing inequalities. based on the interviews conducted, it is observed that the covid- pandemic and the consequent lockdown have created needs of social distancing, hygiene and care, and sanitization. simultaneously, the lockdown has imposed new restrictions on the mobility of individuals with emerging norms of work from home, and online education, accompanied by no services of domestic workers to perform the household chores. the responsibility to perform these tasks both directly or indirectly facilitate them has fallen more on women as is discussed below: along with the restrictions on mobility, the covid- pandemic has shifted the office spaces and classrooms to the homes of the people, meaning that individuals who would go out of their homes into the professional spaces for the purpose of income earning or educational opportunities now spend more time at home doing the same activities. young people who were living away from their hometowns in pursuit of education and jobs have also returned to their homes due to the flexibility of performing these activities from within the house. this implies that the services including buying cooked meals and snacks, the entire process of cooking, and finally cleaning the dishes that were earlier purchased to facilitate working and studying are now to be procured within the house. furthermore, the activities like laundry and cleaning the house which were earlier performed by domestic workers for a wage while the members of the household were allocating the same time for other activities, for example, preparing for office, are now to be performed by the members of the household at a time that does not conflict with the office hours. thus, the norms of work from home and online education increased the demand for services that were earlier purchased both within and outside the household, and are to be now performed without pay during the lockdown, therefore increasing the burden of unpaid work which is gendered in nature. as amrita, a -year old homemaker and a mother of two adults who reported to work for more than h/work during the lockdown states, "before the lockdown, i was living with my husband and my son and my daughter was staying away to pursue her education and later job. the lock down has permanently moved all their work to home. i cook for all of them which takes longer than earlier. but cooking is not the most time-consuming activity. with four of us living in the house all the time, cleaning the dishes has to be done multiple times during the day." akriti, a -year old single woman working in delhi, who has moved back to her hometown in uttar pradesh and reported spending a maximum of h/week on unpaid work during the lockdown narrates, "work from home has increased my working hours. the concept of weekend has almost collapsed with my organization assuming that work from home means being available × . and with no domestic help, it was getting very difficult for me to manage professional space and household chores. so, i came back home at the first opportunity. now cooking and food needs are taken care of by my mother, and i can focus on my job." meera, a -year old woman, who is married and is working in an it firm and has two school going children, has to spend more time with her children during their online classes, cater to their personal needs and also keep them constantly engaged in fun activities as they cannot go to public places to play anymore. she states, "with schools being shut and education being done through online mode, i have to constantly look after my children, get involved in their virtual classes and also do my office work. in the pre-covid world, we all used to spend time together in the evening, and go out on weekends. now, i have to devote a lot more time to child care. it has started affecting my professional life as i am missing deadlines and am constantly tired. my husband is a big support, but his working hours are more rigid than mine." another manifestation of the lockdown is visible in the recurring need to maintain social distancing and hygiene through sanitising everything that has physically been in the public space, which has created a new set of activities that need to be performed daily and are time consuming. as amrita states, "since the onset of the pandemic, i sanitize all the vegetables and grocery items that are purchased for the household. other than that, i separately wash and sanitize all the footwear and clothes that are used while going to the supermarket." akriti highlights a similar concern and narrates, "the pandemic has created so much extra work in terms of sanitizing everything from milk packets to vegetables and fruits. after buying vegetables and fruits we soak them in a tub of water for about - h, then wipe them with a sanitized cloth, and then use for consumption. it is time-consuming considering we are a family of five people." not only this, the pandemic has also created the need to boost immunity and promote intake of herbal products or home-made kadha. this has also added to the burden of the unpaid household chores. as meera states, "i make sure all of us consume kadha two times a day. we have also increased consumption of indian herbs and immunity boosting products like cinnamon, raw turmeric, basil, ginger and honey, and we either consume it with milk, tea or make a paste of some of it. as me and my husband are particularly concerned about the well-being of our children, we make sure that we buy it only in solid form and grind it at home to get a powdered form. it has added to some of my original kitchen work, but i think this is inevitable." in her interview, akriti also highlighted the increase in care work due to probable covid- suspect at home that increased everyone's time spent at home, but more so of the mother in the kitchen work. as stated by her: "the assumption that my brother might be infected with covid- increased all our workloads, and most of all my mother's. she was making him kadha, boiling water for the purpose of steaming and drinking, making separate immunity boosting food items for him, serving him food, cleaning his clothes and maintaining everything related to his cleanliness and hygiene. plus, she was also regularly monitoring his overall health and her own health in isolation to all of us, in case the infection spread to her as well. me and my dad were busy procuring medicines, consulting doctors, and preparing for the day if things got worse." the requirements to maintain social distancing and hygiene in the pandemic, has also led to procuring luxury eating and leisure eating within the house that was earlier done in restaurants and was paid for. as rita, a -year old school teacher who lives with her husband and has school going child highlights: "i love eating out. before the onset of the pandemic, all of us would go out every weekend and try some new food or place to eat. with the lockdown, my daughter and my husband crave for that kind of food, so i cook it at home. during the first month of the lockdown itself, i made gulab jamun thrice, samosas twice and other items like chilli potatoes, rasgullas, momos, barfi, cakes and brownies." an examination of the perception regarding gender roles and the responsibility of unpaid work highlighted that while none of the interviewees believed that women are more responsible for household chores than men just because of their gender, two observations are significant in this context. first, is the fixation on unemployed women who are housewives/homemakers to share a greater burden of household chores for every member in the family. the reason most cited for this is that since these women are not engaged in any type of income generating activities, they have more time available to perform the domestic work. in addition, the interviewees also stated that since other members of the household are working full time, they do not have any spare time to contribute to domestic chores, which are therefore inadvertently taken up by the unemployed women of the house, either mothers or wives. this has been observed in the interviews with both men and women. as amrita states, "all the other members of my family are working full-time jobs and do not have much time available to help me with household chores. so, they help me as and when they can. i am a housewife, it is my responsibility to keep the house running. and the house will come to a halt if i stop doing the domestic work." aman, a -year old single working professional states that, "the lockdown has increased all our work at home, particularly so for my mother. but considering that she is a homemaker, she was already doing many of these chores even before the pandemic. i try to help her as much as i can, particularly with work that is more physically demanding like cleaning the house. but i cannot take full time responsibility of running the house as i have professional commitments as well." second, is the inefficiency argument where the interviewees have stated that they do not contribute much to the household as they take longer to perform the same activity as compared to other member of the household who is more responsible for the domestic work. akshay, a -year old working man, who lives with his wife, son and daughter states that, "i do not think that women are more responsible for running the house because of their gender. i can pursue all the household activities on my own including cooking, cleaning the house, laundry and doing the dishes. but i have not done these things for a long time on regular basis. i take much longer than my wife to complete the same household chores." similar perceptions have been observed in interviews with both men and women. however, the inefficiency argument is just an extension of the gender roles and norms which have to be fulfilled with the performance of certain activities like domestic work. since, women have been fulfilling these roles and responsibilities even in normal situations before the pandemic set in, they are more efficient at these activities as compared to individuals, generally men, who are new at these activities during the lockdown. related with this are the results around the independence in taking employment related decisions. as shown in fig. , for employed respondents, approximately % of employed men take such decisions by themselves as compared to only % employed women. furthermore, approximately % employed women's work-related decision making is influenced by the spouse and family members as compared to only % employed men. this is indicative that men have relatively more control and independence in decision making related to employment as compared to women who are more influenced by their family. this becomes significant, considering that time spent on paid work and the inefficiency argument is an important determinant of the burden of unpaid work shared in the household as is highlighted above. gender norms and roles are therefore constantly working and making women share a greater burden of unpaid work. however, there is also a growing perception where it is acknowledged that men and women should equally share the burden of unpaid work. as ritu, a -year old working woman living with her husband and a -year old kid states: "i don't think that me being a woman is enough for me to contribute more to the household. my husband and i are both working, and live in the same house, so we share the tasks based on our interests and work hours, and also help each other in case there are some other engagements, particularly at work similar perceptions regarding sharing of household chores were observed among other respondents, particularly among married individuals where their partner is also engaged in full-time employment. none of the interviewees endorsed women quitting their jobs to take greater responsibility of unpaid household chores that had increased manifold during the lockdown. this, therefore, creates an opportunity to bring a change in gender norms regarding unpaid household chores, particularly when women are engaged in full-time employment and are financially independent. however, such perceptions are limited to individuals where all their household members are employed. in households where one or more member is unemployed, the interviewees suggested that the unemployed member, generally a woman (housewife/homemaker), should take up greater burden of unpaid work. this paper highlights the impact of covid- on gender equality, specifically on the burden of unpaid work for women. the paper shows that women were already sharing a higher burden of unpaid work, and covid- and the consequent lockdown has worked to exacerbate the existing gender inequalities and increased their burden of unpaid work even more. among women, marital status and employment status are the key determinants of women's burden of unpaid work where time spent on unpaid work has increased the highest for married women and unemployed women, who were already spending the highest time on such work even before the lockdown. specifically, during the lockdown, approximately . % of married women, as compared to zero men and unmarried women, worked for more than h/ week. similarly, unemployed women witness the highest increase of . percentage points for those who spent more than h/week on unpaid work as compared to employed women who show the highest increase of . percentage points for those spending - h/week and - h/week each. the emerging norms of work from home and online education, and the new needs of sanitization are responsible for the increased burden. for unemployed women, particularly the housewives/homemakers, the excessive burden is due to the perception that their share of responsibility for unpaid work should be more due to not being engaged in full-time employment and is more efficient in performing these tasks. as such, unemployed women have to perform the unpaid domestic work for all members of the household. for employed women, the collapse of the distinction of the professional and personal lives, both of which are now confined to the household, means that office commitments and domestic responsibilities are to be fulfilled simultaneously. this has created time poverty for most women which impacts their opportunities for engaging in employment, professional performance, career advancement, and leisure, thereby affecting their overall well-being and empowerment. in the context of perceptions regarding gender roles for unpaid work, while it was found that individuals did not overtly believe in putting the burden on women by the virtue of their gender, but rationalized it with the time spent on full-time paid work (for unemployed women) and their own inefficiencies in performing such tasks. in addition, the results on employment related decision-making shows that gender roles and responsibilities, though overtly rejected, remain entrenched in the social norms of the society. however, there is a ray of hope in reversing gender roles in the household work during the pandemic as both men and women are looking for gender equality in performing unpaid work, particularly when all members of the household are engaged in full-time employment. for this, it is suggested that the work from home norms and online education becomes more flexible and suits requirements of the employees. furthermore, such flexibility needs to be extended not only to women, but also to men to facilitate their contribution in the unpaid domestic work. however, caution should be exercised in terms of policy making as flexibility in working will not automatically translate into gender equality in unpaid work and will have to be catalysed through awareness, knowledge and opportunities. finally, the new norms of work and related policy, by both the government and the private players should focus on gender mainstreaming, where gender perspectives are integrated into the designing, implementation, and monitoring and evaluation of policies, rather than addressing these concerns in isolation. conflict of interest the author declares that there is no conflict of interest. informed consent was obtained from all individual participants included in the study. the survey respondents had consented to their data being used for the purpose of the study and verbal informed consent was obtained prior to the interview. participants have consented to the submission of the case report to the journal. however, names of the interviewees have been changed for the purpose of anonymity with the consent of the participants. see tables , , , , , , , and . invisible work invisible workers: the sub-economies of unpaid work and paid work action research on women's unpaid labour bargaining" and gender relations: within and beyond the household the impact of covid- on gender equality altruism, egoism, and genetic fitness: economics and sociobiology when does gender trump money? bargaining and time in household work economic dependency, gender, and the division of labor at home time to care: unpaid and underpaid care work and the global inequality crisis intrahousehold bargaining and resource allocation in developing countries no work is easy! notes from the field on unpaid care work for women unpaid care work: the missing link in the analysis of gender gaps in labour outcomes ways we lack gender balance in the workplace economic dependence, gender, and the division of labor in the home: a replication and extension the coronavirus is not gender-blind, nor should we be missing labour force: an explanation care work and care jobs for the future of decent work international labour organization (ilo). (n.d.). gender equality tool the intra-household economics of voice and exit gender inequalities in time use the: distribution of caring, housework and employment among women and men in ireland. dublin: the equality authority and the economic and social research institute gender planning and development: theory, practice and training employment: time spent in paid and unpaid work, by sex gender equality perceptions, division of paid and unpaid work, and partnership dissolution in sweden household decisions, gender, and development: a synthesis of recent research wid, wad, gad: trends in research and practice gender, time and inequality: trends in women's and men's paid work, unpaid work and free time the impact of covid- on women moving from the household to the individual: multidimensional poverty analysis doing gender gender dimensions of the covid- pandemic the world bank data. labor force participation rate, female (% of female population ages +) (modeled ilo estimate)-india acknowledgements i thank my supervisor, prof. amita batra, chairperson, centre for south asian studies, jawaharlal nehru university for her support and guidance. i also thank pratiksha singh, parvendra kumar, prayrit and kaushik for their support and assistance. i also extend my gratitude to all the individuals who participated in the survey and interviews. please note that this research has not received any external funding.funding the research has not received any external funding. the data have been collected through surveys and interviews, as is provided in the manuscript. key: cord- -xjy chia authors: wu, y; liu, c; dong, l; zhang, c; chen, y; liu, j; zhang, c; duan, c; zhang, h; mol, bw; dennis, c‐l; yin, t; yang, j; huang, h title: coronavirus disease among pregnant chinese women: case series data on the safety of vaginal birth and breastfeeding date: - - journal: bjog doi: . / - . sha: doc_id: cord_uid: xjy chia objective: to assess whether vaginal secretions and breast milk of women with coronavirus disease (covid‐ ) contain severe acute respiratory syndrome coronavirus (sars‐cov‐ ). design: single centre cohort study. setting: renmin hospital of wuhan university, wuhan, hubei province, china. population: we studied sars‐cov‐ ‐infected pregnant women diagnosed between january and march . methods: we collected clinical data, vaginal secretions, stool specimens and breast milk from sars‐cov‐ ‐infected women during different stages of pregnancy and collected neonatal throat and anal swabs. main outcomes and measures: we assessed viral presence in different biosamples. results: of the women with covid‐ , five were in their first trimester, three in their second trimester and five in their third trimester. of the five women in their third trimester who gave birth, all delivered live newborns. among these five deliveries, the primary adverse perinatal outcomes included premature delivery (n = ) and neonatal pneumonia (n = ). one of nine stool samples was positive; all vaginal secretion samples, and five throat swabs and four anal swabs collected from neonates, were negative for the novel coronavirus. however, one of three samples of breast milk was positive by viral nucleic acid testing. conclusions: in this case series of pregnant women with covid‐ , we observed negative viral test results in vaginal secretion specimens, suggesting that a vaginal delivery may be a safe delivery option. however, additional research is urgently needed to examine breast milk and the potential risk for viral contamination. tweetable abstract: new evidence for the safety of vaginal delivery and breastfeeding in pregnant women infected with sars‐cov‐ , positive viral result in a breast‐milk sample. in december of , wuhan, in hubei province, china, experienced an outbreak of pneumonia caused by the severe acute respiratory syndrome coronavirus (sars-cov- ). on march the world health organization declared that the spread of coronavirus disease (covid- ) was a pandemic, which is now disrupting health and public life around the world. sars-cov- shares % nucleotide sequence identity with sars-cov and % with middle-east respiratory syndrome coronavirus (mers-cov). previous studies have suggested that sars-cov infection during pregnancy may carry severe complications including maternal death, spontaneous miscarriage, preterm delivery and intrauterine growth restriction; and mers has been associated with intrauterine fetal demise and stillbirth. , human transmission is through droplets and direct contact, though recent investigations have demonstrated that sars-cov- is also detectable in stool and blood. no evidence of vertical transmission was demonstrated in nine pregnant women, and amniotic fluid, cord blood and breast milk samples of six women were all negative. however, one newborn was diagnosed with sars-cov- infection within hours of delivery, which raised the concern of vertical transmission. viral analysis of the vaginal mucosa or secretions has not been reported, so there may be a clinical tendency to promote caesarean delivery to avoid intrapartum transmission. furthermore, data on breastfeeding are scarce and no one has examined the effect of covid- in the first and second trimesters of pregnancy. in view of these clinical gaps, we performed the retrospective study. all pregnant women with sars-cov- admitted to renmin hospital of wuhan university in china between we extracted demographic information, clinical course, laboratory indices and imaging results of infected pregnant women from the medical records, maternal throat swabs were collected upon admission. samples of vaginal secretions from nine women were collected during pregnancy and samples from four women were collected after delivery. neonatal throat and anal swabs were collected on the st and rd days after birth. breast milk samples from three women were collected on the st, th and th days after delivery and stool specimens were taken from nine women between and march. the details of sample collection are shown in the supplementary material (tables s and s ) . we collected throat swabs, anal swabs, vaginal secretions and stool specimens using sterile polyester swabs. after collection, samples were placed in sterile tubes and transported to the laboratory at °c. for breast-milk collection, iodine was used to disinfect the patient's breast. breast milk was expressed into a sterile container. maternal samples were processed at the laboratory of renmin hospital of wuhan university, and neonatal samples were processed at the laboratory of wuhan children's hospital. both laboratories met the world health organization standard. we reviewed the medical records of pregnant women with sars-cov- infection; where five were infected in the first trimester, three in the second trimester and five in the third trimester. one of the infants included here has been previously reported. all women had a history of viral exposure in the central epidemic area in and around wuhan. the women were between and years of age, with parity ranging from to ; hospital admission for infection occurred between and weeks of gestation. all women were diagnosed as having mild covid- without severe complications, and none was admitted to the intensive care unit. all women were provided with oxygen support, antiviral therapy assisted by antibacterial treatment was administered to eight women, and corticosteroid treatment was given to three women. all women are currently virus free (see supplementary material, table s ). in terms of clinical manifestations, fever was the most common symptom (n = ); followed by cough (n = ), dyspnoea (n = ), myalgia (n = ) and diarrhoea (n = ). three women demonstrated an increased leucocyte count, two women had lymphopenia and five women had elevated c-reactive protein levels. impaired liver function was observed in three women (with elevated levels of alanine aminotransferase), and two women had increased aspartate aminotransferase levels. eight women manifested patchy ground-glass opacities or consolidation shadows, with peripherally distributed computed tomography imaging features. in the five women in the first trimester of pregnancy, one (patient ) had a biochemical pregnancy with serum human chorionic gonadotrophin concentrations dropping from . iu/l to < iu/l. the other four women (patients , , and ) had ongoing pregnancies. all five women in their third trimester (patients - ) delivered, with only one (patient ) undergoing vaginal birth. while patient experienced dyspnoeawith fetal heart rate monitoring that suggested fetal distressthe other three women exhibited no clear medical indication for a caesarean section. lack of knowledge regarding covid- and concerns about potential mother-to-child transmission as a 'social factor' became an indication for caesarean section in these last three pregnant women ( table ). the gestational age at delivery ranged from + to + weeks. two neonates (babies of patients and ) were born prematurely (at + and + weeks), with birthweights of g and g, respectively. the pregnancy of patient was ended prematurely because of fetal distress, and patient underwent a spontaneous preterm birth. the neonate of patient was large for gestational age (at g) (see supplementary material, table s ). two of the five women had increased leucocyte counts, and three of the five women continued to show elevated c-reactive protein levels after delivery ( table ) . all five women delivered a live newborn; the infant of patient had a -min apgar score of and -min apgar score of , but the other four infants had normal apgar scores. two neonates (babies of patient and patient ) were born prematurely and diagnosed with neonatal pneumonia by chest x-ray (see supplementary material, figure s ). sars-cov- nucleic acid tests of neonatal throat and anal swabs were all negative on the st and rd days after birth. all vaginal secretions samples were negative for viral nucleic acids and only one stool sample was positive (patient ) (see supplementary material, table s ); the viral nucleic acid tests of throat swabs of ten women were positive on the day of vaginal secretion collection (see supplementary material, table s ). we assessed breast milk in three women; the breast-milk sample of one woman (patient ), collected on the st day after delivery, was positive using the real-time reverse transcription-polymerase chain reaction test for the open reading frame ab of sars-cov- (see supplementary material, table s ), but subsequent re-examination on the rd day after delivery was negative. the other breast-milk samples, collected on the th and th days after delivery, were negative for the virus (see table . supplementary material, table s ). the viral-detection results for all participants are summarised in figure . data from neonate , born in renmin hospital, suggested no diagnosis of sars-cov- infection; this newborn had four negative swabs, no clinical symptoms or signs and received no treatment. however, the newborn was subsequently found to have igm and igg seroconversion. this newborn has been previously reported elsewhere. in this study, the clinical characteristics of the pregnant women were mild compared with the general chinese population, and none of them progressed to severe pneumonia. sars-cov- was not found in the vaginal swabs, and none of the five newborns was infected, although one of the three breast-milk samples was positive for the virus. our study is the first to report on women at various stages of pregnancy with laboratory-confirmed sars-cov- infection, and on the ensuing safety of a vaginal birth and breastfeeding. our study has some limitations. first, only pregnant women with sars-cov- infection and five newborns were included in our study; therefore, additional studies with larger sample sizes are required to confirm our preliminary results. furthermore, there were no pregnant women with severe symptoms requiring intensive care in our study, limiting the clinical implications. also, all women in our study were from the renmin hospital of wuhan university, so it is not known if our results are applicable to other medical centres. given the widespread nature of this global public health emergency, there may be different clinical characteristics in different covid- epidemic areas due to differences in race, culture, policies and medical conditions. further studies involving additional populations and multiple centres are required to confirm our results. finally, this was a retrospective study, which limited our ability to examine the long-term health effects on infants born to mothers with covid- . vertical transmission is a key concern for pregnant women with sars-cov- infection. none of the newborns delivered in our study was infected, a result consistent with previous reports (e.g. negative tests for the novel coronavirus nucleic acid in pharyngeal swab samples from neonates born to mothers with covid- pneumonia, and for three placental samples , ) . two newborns with neonatal coronavirus pneumonia were confirmed in wuhan , as of february ; one of them was diagnosed with sars-cov- infection hours after birth. expert clinical opinion suggests that this sars-cov- infection was the result of close contact with an infected individual rather than to vertical transmission. in our study, one woman gave birth vaginally and the newborn's viral nucleic acid test was negative. however, it is unclear whether intrauterine transmission of sars-cov- occurs, and additional research is therefore warranted. intrapartum transmission is another concern that may affect mode of delivery. many types of virusesincluding herpes simplex virus, human papillomavirus and hivcan be spread to neonates by intrapartum transmission. [ ] [ ] [ ] an important mechanism for viral intrapartum transmission is through swallowing of infected vaginal secretions during vaginal delivery. in this study, three of four caesarean sections were performed without any medical indications in an attempt to avoid potential intrapartum transmission. importantly, we collected vaginal secretions from the women for viral nucleic acid testing to clarify whether sars-cov- could be transmitted via vaginal delivery; and our test results were negative in amniotic fluids and placentae from nine women, which should reassure women who wish to deliver vaginally and can do so. , the results of our study support the recommendation that all infected pregnant women with covid- who do not have a medical indication for a caesarean section should have a vaginal delivery. some pathogenssuch as herpes simplex virus and chlamydia trachomatiscan travel along the genital tract and spread to the uterus, causing adverse neonatal outcomes such as stillbirth and premature birth. [ ] [ ] [ ] our negative results of vaginal secretions from women, however, suggest that ascending infection in covid- was low. an important mechanism underlying the entry of sars-cov- into human cells has been demonstrated through the interaction between viral s-protein and angiotensin-converting enzyme (ace ) in the host. , therefore, the distribution of ace expression may be closely associated with targetorgan damage and viral transmission. although rna and protein expression levels for ace are very low in the vagina, uterus and cervix, the ace receptor is expressed in the digestive tract and oral mucosa. , this may explain why sars-cov- can be found in human saliva and faeces rather than in vaginal secretions. while we could not find evidence for intrapartum transmission of sars-cov- , a previous case report from our series indicated intrauterine seroconversion of a neonate. this neonate showed no signs of sickness after birth. seroconversion was found only in this pregnancy. advice regarding breastfeeding is clearly a matter of concern. previous studies have found that hiv and hepatitis b virus appear in breast milk and cause mother-to-infant transmission; , and that mothers with covid- can transmit the virus through respiratory droplets or skin contact during breastfeeding. in contrast to a study that did not find sars-cov- in the breast milk of women with covid- , we found a positive viral nucleic acid test in one breastmilk sample. although we retested the breast milk from this infected women days later and found it to be negative, the possibility of viral transmission through breast milk cannot be excluded. until large studies have demonstrated the safety of breast milk, our advice is against the use of breastfeeding even through breast expression; mothers with covid- should not breastfeed until after full recovery, when breast milk tests negative for the virus. our study confirms that pregnant women with sars-cov- are not at high risk of severe illness and adverse pregnancy outcomes, which is in accordance with previous studies. , previous studies have shown that pregnant women with sars are prone to adverse maternal and neonatal complications, including miscarriage, preterm birth, intrauterine growth restriction, use of intubation and admission to the intensive care unit, and have a mortality rate of %. in the present study, pregnant women with covid- , in contradistinction, exhibited far fewer adverse maternal and neonatal complications and outcomes. one reason for the discrepancy may be that sars-cov has a significantly greater virulence than sars-cov- , causing sars-cov-infected patients to generally manifest more severe signs and symptoms than sars-cov- -infected patients; and pregnant women have a poor prognosis when suffering from severe pneumonia. we also observed one pregnancy failure, raising concerns that sars-cov- infection may induce early pregnancy loss. the aetiology of a biochemical pregnancy is diverse and may be the result of thrombophilic disorders, chromosomal anomalies, various endocrine disturbances, immune dysfunction or disrupted endometrium. in addition, infection is a major cause of miscarriage; overall, % of early miscarriages and % of late miscarriages are related to infections. the association between a systemic infection such as malaria, dengue fever, brucellosis, cytomegalovirus, hiv, influenza or bacterial vaginosis, and an increased risk of miscarriage has been well documented. the mechanisms of termination of pregnancy caused by the influenza virus, sars cov or mers cov comprise maternal respiratory difficulties and insufficient delivery of oxygen to the embryo, and are not due to direct viral infection of the fetus. , , the woman in our study who experienced the biochemical pregnancy did not experience dyspnoea, so fetal oxygenation was probably sufficient. it is unclear whether the biochemical pregnancy was associated with maternal infection, and therefore additional research is warranted. in summary, in our study we found no evidence for vertical or intrapartum transmission of the novel coronavirus, with negative test results for all of our vaginal samples. one infected women gave birth vaginally to a healthy newborn, providing additional evidence that a vaginal delivery among infected women is a safe option. however, sars-cov- could potentially be transmitted through breast milk, and therefore further research is urgently needed. the impact of sars-cov- infection on embryo health during the first trimester of pregnancy also requires further investigation. with the global outbreak of covid- , we believe that our findings provide health professionals with important clinical information when treating infected pregnant women and providing perinatal care. bwm is supported by an nhmrc investigator grant (gnt ). bwm reports consultancies for obseva, merck kgaa, igenomix and guerbet, with no potential conflicts of interest. the other authors have no conflicts of interest. completed disclosure of interests forms are available to view online as supporting information. hh, jy and ty contributed to concept and design. yw, cjz, cz, cd, hz, bwm and cld drafted the manuscript. cz and cd performed the statistical analyses and cl, ld, yc and jl collected the data. this work was supported by the national key research and development programme of china ( yfc , yfc ). the funders had no role in the design or conduct of this study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit this manuscript for publication. additional supporting information may be found online in the supporting information section at the end of the article. figure s . imaging examination of the four delivered women and their neonates. table s . data of maternal sample collection. table s . data of neonatal sample collection. table s . samples of clinical and laboratory characteristics. table s . neonatal outcomes. & world health organization. who director-general's opening remarks at the mission briefing on covid- - genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding pregnancy and perinatal outcomes of women with severe acute respiratory syndrome middle east respiratory syndrome coronavirus (mers-cov) infection during pregnancy: report of two cases and review of the literature middle east respiratory syndrome coronavirus infection during pregnancy: a report of cases from saudi arabia john wiley & sons ltd on behalf of royal college of obstetricians and gynaecologists epidemiologic features and clinical course of patients infected with sars-cov- in singapore clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records transcript of press conference on general office of the national health commission of china, general office of the state administration of traditional chinese medicine. diagnosis and treatment protocol for the novel coronavirus pneumonia laboratory testing for novel coronavirus ( -ncov) in suspected human cases. interim guidance possible vertical transmission of sars-cov- from an infected mother to her newborn jama clinical characteristics of coronavirus disease in china clinical analysis of neonates born to mothers with -ncov pneumonia pregnant women with new coronavirus infection: a clinical characteristics and placental pathological analysis of three cases wuhan tongji hospital diagnoses first case of neonatal infection with new coronavirus mother-to-child transmission of herpes simplex virus rate of vertical transmission of human papillomavirus from mothers to infants: relationship between infection rate and mode of delivery hiv/aids epidemiology, pathogenesis, prevention, and treatment guidelines for pregnant women with suspected sars-cov- infection acquisition of herpes simplex virus during pregnancy adverse pregnancy and neonatal outcomes associated with neisseria gonorrhoeae, mycoplasma genitalium, m. hominis, ureaplasma urealyticum and u. parvum: a systematic review and meta-analysis protocol sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries a pneumonia outbreak associated with a new coronavirus of probable bat origin tissue-based map of the human proteome high expression of ace receptor of -ncov on the epithelial cells of oral mucosa a review of evidence for transmission of hiv from children to breastfeeding women and implications for prevention mother-to-infant transmission of hepatitis b virus: challenges and perspectives epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study a case-controlled study comparing clinical course and outcomes of pregnant and non-pregnant women with severe acute respiratory syndrome new insights into mechanisms behind miscarriage the role of infection in miscarriage perinatal and maternal outcomes in critically ill obstetrics patients with pandemic h n influenza a the authors we wish to thank the women, researchers and clinical staff who provided significant contributions to this study. key: cord- -f i k f authors: espinel-flores, verónica; gotsens, mercè; puig-barrachina, vanessa; león-gómez, brenda biaani; peralta, andrés; pérez, glòria title: trends in teenage motherhood in ecuador: challenges and inequalities date: - - journal: int j public health doi: . /s - - -w sha: doc_id: cord_uid: f i k f objectives: to describe trends in teenage motherhood (tm), based on the socioeconomic groups teenagers belong to, and factors related to their first experience of heterosexual intercourse (fehi). we took into consideration women aged – years, comparing three surveys from , , and . methods: we obtained data from the ecuadorian demographic and health surveys about , women aged – years who had given birth as teenagers. prevalence ratios and their confidence intervals ( % ci) were calculated to estimate changes in socioeconomic inequalities and factors related to the fehi. results: the prevalence of tm increased from % in to % in among women with complete primary education. the social gradient among socioeconomic groups were sustained. we detected no changes in the socioeconomic inequalities characterizing tm, and in the factors related to the fehi across the three studies in ecuador. conclusions: socioeconomic inequalities in tm and disadvantageous circumstances at fehi remained unchanged for years. some factors are vital for reducing teenage motherhood in ecuador: gender-equitable economic development, access to comprehensive-sexual education, contraception, health services, and safe abortion. since , when the international conference on population and development, icpd was held, reducing adolescent childbearing has been a global priority. more than two decades later, reducing tm remains an aim of political and societal activity worldwide (un ), as a global indicator of sustainable development (sdg ). another important global indicator of sustainable development (sdg ) is women's access to the means to prevent tm. tm is associated with a variety of adverse outcomes for both women (tabet et al. ) and children. these outcomes involve high risk of neonatal mortality ) and long-term developmental issues (falster et al. ) . moreover, tm is considered a symptom of socioeconomic disadvantage, often leading women into a circle of poverty (unfpa ) . also, it aggravates disadvantageous conditions for women in modern societies, by accentuating gender and socioeconomic inequalities (rodríguez-vignoli ) . this is especially true in countries lacking policies to overcome potential tm effects. tm is influenced by interlinked social, structural, interpersonal and behavioural factors. risk of tm is increased by low educational attainment (islam et al. ; kunnuji et al. ; wado et al. ) , income inequalities, poverty and material deprivation (mccall et al. ) . from to , there was a global decrease in the adolescent birth rates (abr), with the largest regional declines in south asia. declines closely followed rising socioeconomic status and where grater where income inequalities were lower in . on the contrary, long-term socioeconomic and gender inequalities have been shown to have an important impact in slowing down the decline in adolescent birth rates across countries (santelli et al. ; decker et al. ) . adolescents' first sexual intercourse is also a factor that influences tm trends (manlove et al. ). early sexual intercourse is less likely to be consensual or to involve the use of contraception, increasing the risk of pregnancy (woog and kågesten ) . also, the age of the first sexual partner is inversely linked to women's consent for sexual intercourse, degree of control and agency over this experience, and use of contraception (kaestle et al. ) . these factors are strongly influenced by societal and socioeconomic factors. on the latter subject, empirical evidence on structural and intermediate factors associated to tm has been mostly developed in high-income countries. also, most of the studies on risk and protective factors for adolescent sexual and reproductive health are focused in sub-saharan african low-and middle-income countries (mmari and sabherwal ) . among latin americans, % of all pregnancies occur among girls younger than years (united nations et al. ) . in low-and middle-income countries, there is also a high number of age-specific births among girls aged - years (benova et al. ; liang et al. ) . in contrast, in western europe and other high-income countries, abr are now very low among adolescents (younger than years), representing % of all births (eurostat ) . in ecuador, a south american country, rates of tm have increased in the last two decades, while global fertility has declined (rodríguez-vignoli ). the country has one of the highest rates of teenage pregnancy in the south american region, with % of women getting pregnant between and years (senplades ). the proportion of unplanned childbearing increased from % in % in to % in % in in adolescents aged - years (ishida et al. ). risk of teenage pregnancy was greater in women living in very poor households, those not enrolled in school, or who had experienced sexual abuse during childhood and adolescence (goicolea et al. ). in the country, social structures are related to gender norms that constrain adolescents' agency and control over their sexuality (varea ; goicolea et al. a; santillana and castello ) . indeed, such structures have a strong influence over women's use of contraception and decision-making during the first heterosexual intercourse. however, this evidence is representative of adolescents attending public facilities in the biggest cities of ecuador (guijarro et al. ; chedraui et al. ). they do not explore the influence on tm of interpersonal factors related to adolescents' first sexual experience, and how this influence changes over time. the ecuadorian policy for the prevention of pregnancy in girls and adolescents defines tm as ''a social and public health problem, revealing inequalities, social injustice and a violation of human rights …'' nevertheless, evidence is lacking on the effects of structural and intermediate factors with tm for benchmarking, policy, and public health decision-making in the country. thus, this study aims to describe trends in teenage motherhood (tm), based on the socioeconomic groups teenagers belong to, and factors related to their first experience of heterosexual intercourse (fehi). we took into consideration women aged - years, comparing three surveys from , , and . social determinants of health, defined as the conditions in which people are born, live, learn, work, play, worship, and age (office of disease prevention and health promotion ), are shaped by families, communities, and the distribution of money, power, and resources. all these aspects are affected by policy choices at each level (world health organisation ). social inequalities in health refer to ''systematic differences in health between different socioeconomic groups within a society. as they are socially produced, they are potentially avoidable and are widely considered unacceptable'' (whitehead and dahlgren ) . the construct socioeconomic position (sep) is an aggregate concept that includes both resource-based and prestige-based measures, as a link to both childhood and adult social class position (krieger et al. ) . it can be measured through educational level (galobardes et al. ), a structural determinant of adolescents' health and well-being (viner et al. ; maness et al. ) , and an empowerment factor for girls (williamson ) . following carpenters' gendered-sexuality framework (carpenter ) , the factors related to the fehi are capable of capturing social gendered patterns. such patterns include specific sexual conducts and attitudes, encouraging sexual scripts grounded on hegemonic masculinity for men v. espinel-flores et al. (connell ) , and the passive/submissive attitude for women. tm inequalities can be understood as the unequal distribution of maternity during adolescence according to educational attainment (sep), which reflect material, resources, and other resources of the family of origin. the fehi factors are social determinants of tm as they influence women's agency to freely consent to sexual intercourse, and decide on contraception use to avoid early motherhood. we analysed secondary data from the ecuadorian demographic survey, the maternal and child health survey from endemain (cepar , and the national survey on health and nutrition from ensanut- (freire et al. ) . these are three countrywide serial surveys conducted periodically (approximately every years) in a non-institutionalized population. they collected information on fertility, contraceptive use, infant and child mortality, and sexual and reproductive health. the endemain surveys were conducted in a representative sample of women of fertile age (wfa, - years old) in ecuador, and were carried out by the centre for studies on population and social development (cspsd). the ensanut- edition was representative of the ecuadorian population aged b years. in each dwelling, women in their fertile age were considered eligible for the application of the wfa questionnaire, which was administered by the national institute of statistics and census of ecuador (inec). the surveys are representative at the national and provincial levels, and the participation rates in , , and were . %, . %, and . %, respectively. all databases and complete information about the survey methods are available online: https://microdata.worldbank. org/index.php/home https://www.ecuadorencifras.gob.ec/ institucional/home/. the questionnaires were anonymised and administered in face-to-face interviews at the women's homes by a team of interviewers trained by the cspsd and inec. the participants gave written informed consent. the individual wfa questionnaire was used to collect information on sociodemographic characteristics, fertility, and reproductive preferences, with no substantial changes in the formulation and content between the three survey editions. only women aged - years were asked to provide detailed retrospective information about their first experience of heterosexual intercourse (cepar (cepar , inec ) . the study population consisted of women aged - years who were born and resident in ecuador, and who reported having ever had sex. we considered women in this age range because: ( ) younger cohorts were still at risk of teenage pregnancy and needed a different assessment of the factors related to their maternity; ( ) we wanted to better capture socioeconomic position measured through educational attainment; and ( ) we constructed the dependent variable, teenage motherhood, using data from the history pregnancies and births section of the three surveys. this variable was dichotomised into two categories, ''yes'' and ''no'', using the definition of adolescence of the world health organization in : people aged between and years. thus, all women who reported having given birth aged between and years were considered adolescent mothers. educational attainment was categorised at three levels: ( ) no schooling or incomplete primary education; ( ) complete primary education; ( ) complete secondary education or higher. the factors related to the fehi were ( ) age at first heterosexual intercourse: we grouped women according to the legal definition for women's consent to sexual intercourse and statutory rape in ecuador ( - year olds, - year olds, and - year olds, (ministerio de justicia derechos humanos y cultos ); ( ) use of contraceptive methods (yes/no); and ( ) age of the first sexual partner (b years or c years). the proportion of missing data was \ % for all the independent variables in the three surveys. we carried out an analysis of missing data and observed random distribution of the independent variables among women who were teenage mothers and those who were not. all analyses were weighted to maintain the representativeness of the population. first, we performed a univariate analysis of the distribution of the outcome and explanatory variables. next, we conducted a chi-square test to determine differences in the prevalence of tm according to educational attainment and individual and interpersonal factors related to the fehi across surveys. then, we wanted to study the association between tm, educational attainment, and each psychosocial and individual factor. we therefore calculated crude prevalence ratios (cpr) and their confidence intervals ( % ci) through bivariate weighted poisson regression models with robust variance (espelt et al. ) . we considered that pr was better suited to our study than other measures of inequality, such as the relative index of inequality, because the socioeconomic variable included in the models are not strictly hierarchical (garcia-subirats et al. ) . we analysed the interaction between year of the survey and each independent variable: proxy of socioeconomic position -educational attainment and psychosocial individual and interpersonal factors related to the fehi. a significant interaction between the year of the survey and each variable was interpreted as a change over time in socioeconomic inequality and in individual and interpersonal factors associated with tm across the years. individuals with missing data were removed from the analyses. the analyses were run in stata (statacorp ). the proportion of tm in ecuador was . % in , . % in , and . % . most of the women in the study sample had low educational attainment. in all three studies, more than half of the women experienced their fehi between the age of and years, with a sexual partner aged c years. a total of . % of teenage mothers in the sample did not use contraception at fehi in ; this percentage decreased to . % in , and . % in (table ) . we found differences in the prevalence of tm among women from the most disadvantaged socioeconomic groups in the three surveys. indeed, the percentages of women with no studies or incomplete primary studies experiencing tm were . %, . %, and . % in , and , respectively (p \ . ). moreover, . %, . % and . % of women with complete primary studies experienced tm in tm in , tm in , and , respectively (p \ . ). we also analysed the prevalence of tm by factors related to the fehi. our results revealed that differences between periods were statistically significant among women who had their fehi when aged - years: . % in . % in , and . % in (p \ . ). moreover, the prevalence of tm was highest in women who reported having had their fehi at the age of or earlier. we found no statistically significant differences according to the age of the first sexual partner, but did find significant differences for women who did not use contraception at fehi ( table ). the results of the bivariate poisson regression models (table ) showed that the social gradient among socioeconomic groups remained unchanged across the three periods. women with no schooling or incomplete primary education showed the highest probability of tm in the three studies: from (cpr = . ; % ci: . - . ) to (cpr = . ; % ci: . - . ) and (cpr = . ; % ci: . - . ). additionally, the probability of tm increased from (cpr = . ; % ci: . - . ) to (cpr = . ; % ci: . - . ) in women with complete primary education. on the contrary, factors related to the fehi revealed different results between the study periods. among women who reported having had their fehi aged - years, the likelihood of tm remained steady between and , and showed a slight decrease in (cpr = . ; % ci: . - . ). among women aged - years at fehi, an increasing trend in tm was observed between (cpr = . ; % ic: . - . ) and (cpr = . ; % ci: . - . ), followed by a decrease in (cpr = . ; %; ci: . - . ). we also calculated the likelihood of tm according to the age of the first sexual partner, and found that it decreased slightly from to , and was steady from to . finally, we found a steady trend across all three studies in the probability of tm according to the use of contraception. however, none of these results was statistically significant during the study period. this study describes trends in tm and how these trends differ by socioeconomic group and factors related to fehi in women aged - years in ecuador in ecuador in , ecuador in , and . although the prevalence of tm declined slightly between and , more than % of these women gave birth during adolescence in and . except for , women from the most deprived socioeconomic groups showed an upward prevalence of tm, with the most striking increase occurring in women with complete primary education in . furthermore, the prevalence of tm increased from to in women aged - years at fehi, and was higher in women not using contraception during the fehi in the three studies. the bivariate analyses showed that the social gradient among socioeconomic groups was sustained in all three studies. most importantly, analysis of the interaction showed that there were no changes in the socioeconomic inequalities of tm in ecuador or in the factors related to the fehi in the -year period across the three studies. previous studies have reported that the adolescent birth rate (abr) declines more slowly in low-, middle-and highincome countries (sedgh et al. ) with longstanding socioeconomic inequalities, than in those with lower initial inequalities (santelli et al. ) . moreover, decreases in the abr have been associated with increase in the level of national wealth, a leap in socioeconomic status, and decreased income inequalities. on the contrary, unequal gender development has been strongly related to early adolescent childbearing in low-and middle-income countries (decker et al. ) . in ecuador, a history of long-term and deep-rooted socioeconomic and gender-based inequalities has diminished the potential impact of reducing inequalities among historically oppressed groups. for instance, women's salaries are between and % lower than their male peers. also, unpaid domestic and care work by women represents % of the domestic growth product in ecuador (inec ; salazar et al. ) . consequently, the economic growth may not have been inclusive, and therefore may not have reduced the prevalence of tm in the last decade. indeed, the results of the present study showed that the socioeconomic gradient in tm held steady across the period of the three studies, and it increased for women with complete primary education in . tm increased between and in women aged - years at fehi and in those not using contraception. moreover, although not statistically significant, in all the three surveys women who experienced their fehi aged - years and - years were more likely to have been teenage mothers. this striking finding underscores the perpetuation of sexual abuse suffered by girls aged \ years in ecuador. even though ecuadorian legislation criminally penalises sexual contact with girls under years old as statutory rape (ministerio de justicia derechos humanos y cultos ), such crime still occurs. similarly, in a recent report on the determinants of teenage pregnancy in colombia, it was found that sexual abuse is a major risk factor for tm. this risk is associated with lower probability of condom use. thus, sexual abuse and related lack of use of contraception is a shared risk for tm in the south american region. in ecuador, there are strong cultural and social values regarding sexuality and the idealisation of motherhood, even during adolescence. these values intersect with structural violence and power, undermining women's collective and individual agency (goicolea et al. ). there are major barriers to avoid an early pregnancy: ( ) double standards for adolescent boys' and girls' sexual behaviour; ( ) the influence of romantic love on contraceptive use in young couples; and ( ) the reluctance of healthcare personnel to provide counselling and contraception for adolescents (varea ; goicolea et al. a; santillana and castello ) . additionally, in ecuador sexual education is mainly delivered in public schools through isolated talks based on a biological approach (sen-plades ) . moreover, sexual education is not provided in a context of gender-relations and human rights. these limitations diminish the potential of sexual education to lessen traditional gender norms and reduce sexual and reproductive health risks. at the macro level, political tradition is grounded in a conservative perspective of all issues related to sexuality and sexual autonomy (cifuentes ruiz ) . this resulted in abolishment of forward-thinking policies, in interventions implemented without previous effectiveness assessment, and in conservative proposals (paz ) . consequently, in the -year study period, the effectiveness of interventions has been impaired in ecuador. in contrast, interventions clearly enhanced adolescents' ability to achieve better sexual and reproductive health and reduced teenage pregnancy rates and motherhood in other countries. importantly, although there are two grounds for legal abortion in ecuador, access to safe and informed procedures is not currently available. therefore, women from the most deprived socioeconomic groups have no alternative but to undergo an unsafe abortion, or to continue with an unplanned or unwanted pregnancy. furthermore, the national assembly has recently rejected to ease the law in rape cases, and women are criminalized for interrupting pregnancies in unsafe conditions (zaragocin sofía et al. ) . our study has a limitation related to the characteristics of cross-sectional data. indeed, our indicator to measure socioeconomic position is susceptible to reverse causality (i.e. lower educational levels could result from tm). however, we consider women's education to be a potentially useful indicator of early life circumstances, thus measuring material and social resources in the family of origin. therefore, we believe that the differences observed between educational attainment groups also reflect women's socioeconomic position during their adolescence. our assumption is based on the fact that women with better resources and social support have access to higher educational levels. the latter is especially accurate for the and surveys, considering that access to universal education was not guaranteed in those periods. this limitation was unavoidable given the characteristics of our information source. the surveys included no other socioeconomic indicators for the time when the events analysed in our study took place. also, our data can be susceptible to a social bias for questions on a sensitive matter such as sexual behaviour, which may have inhibited some women from answering. nevertheless, the selection of women aged between and years intended to reduce this bias. despite these limitations, we believe that our results are of paramount importance for further policy planning and resource allocation. in the last years, ecuador has not achieved the reduction of socioeconomic inequalities in tm prescribed in local policies. women in the country still endure adverse circumstances at the time of the fehi, and this fact may partially explain the sustained inequalities in tm. furthermore, gender structures constraining women's agency and power may be considered as a consequence of: • a political tradition based on a conservative-religious perspective that has continuously rejected sexual and reproductive health policies; • a dominant heteropatriarchal social context, with negative attitudes towards adolescents' sexuality and freedom of choice; • barriers to access means of early pregnancy prevention: comprehensive sexual education, contraception, and legal and safe abortion. these barriers derive from a negative social image of teenage involvement in sexual practices at the societal and health personnel level and they need to be tackled (goicolea et al. b ). in order to reduce inequalities in tm in ecuador, gender-based strategies should be implemented to improve women's socioeconomic conditions: ( ) providing fair employment conditions and opportunities; ( ) offering equal salaries for equal jobs; ( ) relieving women from the exclusive responsibility of unpaid domestic labour that impoverishes them; ( ) avoiding inequalities in access to material and social resources, mainly caused by place of residence and ethnicity. such improvements would give girls and young women a sense of better life opportunities, other than motherhood. moreover, they would decrease the powerful influence of a social context that idealises maternity, even at young ages. it would be necessary to again support the construction and follow-up of adolescent-friendly services, which have been disrupted since (svanemyr et al. ) . also, it is necessary to reintroduce the financial support to the national strategy for adolescent pregnancy and genderbased violence prevention, which has recently been retired by the current government. additionally, policies must be further developed and implemented on compulsory sexualaffective education. such policies must be based on a gender perspective and provided in a human rights framework. finally, legal reforms are vital to provide informed and safe abortion to reduce tm. future policies and strategies should be assessed at each step of the planning and implementation phases. heavy resources were invested in policies across the -year period analysed, but they were cancelled without evidence of their success or lack thereof. also, resources should be allocated on continued capacity building of the health staff to decrease the influence of personal bias and beliefs related to sexuality. finally, there is a need to enhance the existing surveys in order to collect more accurate information on women socioeconomic, sexual and reproductive trajectories. in conclusion, this study deepens in the social, interpersonal and individual factors influencing tm. certain recommendations can be inferred from these results regarding necessary changes on structural, education and health services factors to tackle tm. strategies and policies to overcome the possible effects of early motherhood should be implemented in ecuador. these strategies are increasingly relevant considering that the lockdown measures applied during the covid- emergency have increased exposure to sexual abuse and pregnancy for girls and adolescent women in their households (plan internacional ). using three indicators to understand the parity-specific contribution of adolescent childbearing to all births gendered sexuality over the life course: a conceptual framework encuesta demográfica y de salud materna e infantil: endemain encuesta nacional de demografía y salud materno infantil endemain determinant factors in ecuador related to pregnancy among 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sexual and reproductive health needs of very young adolescents aged - in developing countries: what does the evidence show? new york world health organisation ( ) closing the gap in a generation: health equity through action on the social determinants of health mapeando la criminalización del aborto en el ecuador acknowledgements this article forms part of the doctoral dissertations of verónica espinel-flores, at universitat pompeu fabra (upf) in barcelona, spain. this work was supported by the national scholarship program from the ecuadorian government-national secretary of higher education, science, technology and innovation (senescyt-convocatoria abierta -segunda fase). conflict of interest the author(s) declare that they have no conflict of interest.ethical approval considering that this study implied no testing on human subjects, it is exempt of being considered by an ethic panel. nevertheless, an informed consent form was fulfilled, and the participants were informed of the nature of the study. importantly, the data base used in our study are freely available on the web site of the national institute of statistics and census and protected by the data protection law of ecuador. key: cord- - aakik a authors: sayres, lauren; hughes, brenna l. title: contemporary understanding of ebola and zika virus in pregnancy date: - - journal: clin perinatol doi: . /j.clp. . . sha: doc_id: cord_uid: aakik a understanding the pathophysiology, management, and prevention of emerging infectious diseases among pregnant women is imperative to achieve a successful response from the medical community. ebola and zika viruses represent infections with profound public health implications. in particular, ebola virus is associated with high case fatality and pregnancy and neonatal loss rates, while zika virus has been associated with multiple congenital anomalies; these features present critical clinical dilemmas for management of pregnant and reproductive aged women. the objective of this article is to summarize key background information and best practices for management of ebola and zika virus in pregnancy. the past decade has yielded the emergence of several infectious diseases of critical importance in pregnancy. in particular, the ebola resurgence of to resulted in infection of at least women of reproductive age and a pregnancy loss rate of nearly %. the to outbreak of zika virus captured widespread media attention as , women of childbearing age became infected, and the significant associated teratogenicity became apparent. both diseases were determined to be public health emergencies of international concern by the world health organization (who). this article seeks to review the epidemiology, transmission, pathogenicity, and management of ebola and zika viruses as among the most important emerging infectious diseases in modern history. our objective is to provide clinically relevant background information and guide best practices for obstetricians as they approach these novel infections. the natural reservoir of ebola virus is unknown, although evidence is accumulating to implicate bats as the most likely source. most outbreaks in people have been traced back to single spillover events from an infected source. human-to-human spread of the virus is via direct contact with infected blood and bodily fluids including urine, saliva, stool, vomit, and semen, or from surfaces that have been contaminated with infected fluids. ebola virus has specifically been identified in amniotic fluid, placental and fetal tissue, and breastmilk. [ ] [ ] [ ] pregnant women are not thought to be at greater risk of acquiring ebola virus. pathogenicity ebola virus effectively targets host immune cells, which allows reproduction and dissemination of the virus. the virus inhibits both the innate and adaptive immune responses via inhibition of interferons, impairment of antigen presentation, and neutralization of antibodies against viral glycoproteins. the viral glycoproteins then induce cytopathic effects by damaging endothelial cells and disrupting coagulation pathways, while the activated immune mediators induce cellular apoptosis or necrosis. in particular, these effects result in hepatic, renal, and gastrointestinal injury and coagulopathy. clinical findings are initially nonspecific and include malaise, myalgia, and fever. as the viral rna load rises, progression to asthenia, vomiting, secretory diarrhea, and hemorrhage occurs, which without adequate resuscitation can result in hypovolemic shock, multiorgan dysfunction, and death. there is poor understanding of the specific mechanisms of ebola pathogenicity in pregnancy. in pregnancy, the effects of hypovolemia and immune dysregulation become exaggerated because of a need for expanded blood volume and an already-altered immune state, respectively. hypoperfusion of the placenta may represent the mechanism by which miscarriage or intrauterine fetal demise occur. furthermore, transplacental viral transmission to the amniotic fluid and fetus can result in fetal infection and therefore interruption of normal development and growth. , diagnosis diagnosis of ebola virus can be made presumptively based on symptoms and history of exposure and should be confirmed with molecular testing. testing typically includes reverse transcriptase polymerase chain reaction (rt pcr) for the detection of viral rna in serum, although it is important to note that such tests can be negative for up to hours after symptom onset. alternatively, enzyme-linked immunoassay (elisa) testing for immunoglobulin m (igm) specific to the virus is available, although it is less commonly used, because positive results can be delayed up to weeks in acutely symptomatic patients. novel rapid diagnostic tests are currently under study but not yet available. testing strategies remain the same for pregnant women, although rapid testing should be even more imperative given the overlap of the presentation of pregnancy-related conditions and ebola virus and the potential need for acute obstetric intervention. the mainstay in management of individuals infected with ebola virus is supportive management, namely massive fluid resuscitation. additional measures include frequent monitoring for and correction of electrolyte, glucose, and acid-base imbalances, antiemetic and antidiarrheal therapy, nutritional support, vasopressor support, intubation and ventilation, and continuous renal replacement therapy in the setting of renal dysfunction. additionally, broad-spectrum antibiotics may be necessary for concomitant infections such as gastroenteritis secondary to bacterial translocation in the setting of gut inflammation or malaria, a frequent coinfection. there has not been significant research as to the specific care for ebola virus infections among pregnant women. in , the who released guidelines for the management of pregnant women with ebola virus, which represent the first comprehensive guidelines on specific strategies for their care. when possible, specifically trained providers should be available to care for pregnant women and their neonates, and care should be provided at a private, high-risk facility. shared decision making for women infected by or recovering from ebola virus is of necessity. generally, maternal rather than fetal indications should take precedent in management decisions. aggressive fluid resuscitation of up to l per day is particularly important among pregnant women given their significantly increased volume of distribution. there is no strong evidence to suggest that induced abortion, labor induction, or invasive procedures for fetal indications are of benefit to pregnant women with ebola virus. in fact, fetal monitoring is generally not recommended. there may be benefit to delaying delivery when possible because of the risk of coagulopathy in the setting of high viral load. a decision for surgical delivery should be made on a case-by-case basis, as there is unlikely to be fetal benefit, and women with severe disease may not survive an operation. fundal massage and administration of uterotonic medications should be strongly prioritized over surgical management of postpartum hemorrhage. for survivors of ebola virus who plan pregnancy continuation, comprehensive counseling regarding the risks of fetal or neonatal demise and risk of transmission from pregnancy tissues should be performed. regular prenatal care with a high-risk obstetrician is recommended for pregnant women who recover from ebola virus. expectant management is considered most appropriate. there is no current approved treatment for ebola virus. several therapeutics are undergoing phase i and ii clinical trials; these include zmapp, regn-eb , and mab (chimeric monoclonal antibodies) and remdesivir (a broad-spectrum antiviral). additional antivirals, some of which were designed to target other viruses, are under investigation for use with ebola virus but have not held as much promise as the aforementioned agents. convalescent plasma treatment has also demonstrated possible benefit in treatment. the monitored emergency use of unregistered and investigational interventions ethical framework recommends that vulnerable contemporary understanding of ebola and zika virus populations including pregnant women be offered similar treatments to the nonpregnant population when potential benefits can outweigh risks. to date, reports describe use of investigational therapeutics in pregnant women with ebola virus. a % mortality rate was noted among women who received convalescent plasma. additionally, a report details pregnant woman who received favipiravir, a broadspectrum antiviral, but subsequently died of hemorrhagic shock during labor. however, her newborn is the first reported survivor of congenitally acquired ebola after receiving zmapp and remdesivir as well as a buffy coat transfusion from an ebola virus survivor. , prevention critical to the prevention of ebola virus is interruption of community and healthcareassociated spread. this includes isolation and contact tracing of infected individuals, appropriate containment of infectious material, and protection for those in contact with infected individual. even if an individual recovers from ebola virus, a person's bodily fluids may be infectious for months or longer. in particular, pregnancy-related tissue including amniotic fluid, placenta, and fetus are highly infectious even if the pregnant woman has recovered from acute illness. handling of tissues should be avoided when possible, and potentially infectious waste should undergo proper disposal. autopsies should be avoided. personal protective equipment should include a face mask with head cover and eye protection, a gown, double gloves, and boots. minimization of sharps and invasive procedures can mitigate risk to health care providers. multiple trials are underway to study candidate vaccines against ebola virus. the most promising is the live replicating rvsv-zebov-gp vaccine, which is manufactured by merck under the trade name ervebo and has been prequalified by the who. , although no vaccine, including rvsv-zebov-gp, has been specifically evaluated in pregnant women, an analysis of available data on women who became pregnant during the rvsv-zebov-gp study time frame suggests there to be no significant increase in pregnancy loss or congenital anomalies among vaccinated women. it has been strongly recommended by multiple international public health and humanitarian organizations that pregnant women be included in vaccine clinical trials and compassionate use protocols. , after years of exclusion from vaccination, pregnant women in the democratic republic of the congo, the location of a widespread ebola outbreak, were able to start receiving the vaccine in . zika virus is a member of the family flaviviridae, which also includes dengue, west nile, yellow fever, and japanese encephalitis viruses. zika virus was first isolated in in a rhesus macaque in the zika forest of uganda. human infection was identified in . there were only cases identified over the next years, until an outbreak affecting people occurred in micronesia in . subsequent outbreaks occurred in pacific islands, with sporadic cases occurring across southeast asia. , most recently, a pandemic occurred in brazil, with virus spreading across the americas to affect greater than million individuals between and . recognition of the more serious complications of zika virus began to emerge during the pandemic in brazil. in particular, approximately cases of microcephaly were detected in infants of women infected with zika virus. it has been estimated that % to % of infected pregnant women will transmit zika virus to their fetus. , approximately % to % of cases of vertical transmission will result in fetal loss, and % to % will result in congenital zika syndrome including microcephaly. vertical transmission can occur in any trimester and regardless of maternal symptomatology. zika virus is spread by multiple species of aedes mosquito to mammalian hosts, including people. the geographic distribution of these mosquito species is expanding secondary to climate change. more recently, it has been discovered that in addition to vectorborne transmission, zika virus can be spread via sexual contact, perinatal transmission (both during pregnancy and delivery), blood transfusion, and bone marrow and organ transplantation. although breastmilk has been shown to contain zika virus, there is no conclusive evidence that the virus can be transmitted by breastfeeding. pathogenicity zika virus exhibits broad tropism in human cells, undergoing replication and widespread distribution after cell entry by endocytosis. zika virus preferentially targets neural stem cells and progenitor cells. zika inhibits the ability of interferons and other cellular signaling pathways to produce an innate immune response to the virus. in pregnancy, hofbauer macrophages and other immune cells of the placenta that usually serve as a maternal-fetal barrier provide a mechanism for the virus to infect fetal cells. zika virus has an incubation period of to days. most infected individuals are asymptomatic or display mild symptoms such as fever, rash, and myalgias lasting up to week. however, a minority of people will suffer severe neurologic symptoms including meningoencephalitis or guillain-barré syndrome because of neurotropism or postinfectious immune response. given this predilection for neural cells, congenital zika syndrome is primarily a constellation of central nervous system abnormalities. in particular, fetal brain disruption sequence results in microcephaly and cortical atrophy, intracranial calcifications, other neural and ocular abnormalities, and growth restriction. , in infants, this manifests with developmental delay, visual or hearing impairment, seizures, and movement and behavioral disorders. it is important to note that asymptomatic pregnant women can still vertically transmit zika virus to their neonates. zika virus infection is typically detected by serum and urine rt pcr nucleic acid molecular screening and/or serologic igm elisa screening. molecular testing should be performed within weeks of onset of symptoms, whereas serologic testing can be accurately used up to weeks after symptom onset. of note, serologic testing is subject to significant cross-reactivity with antibodies to other flaviviruses, in particular dengue virus, and to persistence of antibodies for many months after the resolution of the acute infection. in nonpregnant individuals with a possible exposure to zika virus yet without severe symptoms, serum and urine molecular testing are recommended. in the setting of concern for guillain-barré , molecular testing of the serum and urine as well the cerebrospinal fluid is recommended as soon as possible. if the index of suspicion for zika virus infection is high but molecular testing is negative, serum testing for igm should be performed within to weeks to evaluate for seroconversion. for pregnant women, the screening paradigm shifts. , for those with symptoms, serum and urine molecular testing and serologic testing are recommended as soon as contemporary understanding of ebola and zika virus possible. if there is a discrepancy with a negative molecular result and positive serologic result, a plaque reduction neutralization serologic test is recommended to confirm infection. pregnant women with ongoing exposure but no symptoms should be screened with molecular testing every trimester. dedicated zika virus testing is not routinely recommended as a routine part of preconception screening or in the setting of a single asymptomatic exposure for pregnant women. detailed anatomy ultrasound is recommended at to weeks of gestation for women with symptoms or recurrent exposure, and serial scans should be performed every to weeks thereafter to evaluate for development of evidence of congenital infection. should there be evidence of fetal anomalies consistent with congenital zika syndrome on ultrasound, amniotic fluid should be sent for nucleic acid testing if amniocentesis is already being performed for diagnostic purposes. however, amniocentesis is not universally recommended, as a negative result cannot rule out congenital infection caused by the transient and sometimes delayed nature of shedding of the virus into amniotic fluid. if microcephaly or other complex central nervous system abnormalities are noted on routine ultrasound in the absence of alternate explanation and with possible zika exposure, molecular and serologic testing should be undertaken. in the setting of suspected congenital zika infection, newborn or fetus and placenta should be tested after delivery. treatment of zika virus consists of supportive management including antipyretics, analgesics, and rehydration, typically with good response. severe cases involving guillain-barré syndrome may require plasma exchange or immunoglobulin. there is no approved targeted treatment for zika virus infection, although several agents are being investigated. these include both host-and virus-targeting antivirals or antibodies, either repurposed from drugs in use for other diseases or screened from compound libraries. , for example, drugs that upregulate the interferon innate immune pathway or suppress viral replication have shown therapeutic promise. as of yet, no medication has completed phase ii clinical trials. , additionally, although there is no drug that is proven to mitigate the effects of zika infection during pregnancy, studies of neutrally active compounds such as nmda blockers can potentially modulate the fetal neuronal damage that occurs with vertical transmission. prevention primary prevention strategies against zika virus include vector control. to prevent mosquito bites, high-risk outdoor areas and in particular bodies of standing water should be avoided. long sleeves and pants, mosquito repellant, and mosquito netting should be used in endemic regions. insect repellants, when used per manufacturers' guidelines, are safe for use among pregnant women. individuals who may have a zika virus exposure or have a known infection should also undertake measures to avoid mosquito bites and therefore reduce spread. standard precautions to prevent nosocomial transmission of zika virus are also important, although as of , no cases of occupational infection have been documented. travel guidelines have evolved as the zika virus epidemic progressed, and additional research is needed to appropriately inform travel restriction policy. general recommendations have been to avoid travel to high-risk regions during pregnancy or while attempting conception. , couples residing in affected areas are advised to delay pregnancy. those with a known exposure or infection should delay attempts at conception for months for female partners and months for male partners. a pregnant woman whose partner has had an exposure or infection with zika virus should practice abstinence or consistent condom use for the remainder of the pregnancy. efforts are underway to develop a vaccine against zika virus, although none has yet been approved for use. the most promising vaccine candidates have been shown to induce effective antibodies in mice, and phase i and ii clinical trials are in process. [ ] [ ] [ ] among the candidates are dna vaccines, synthetic peptide vaccines, nanoparticles, and live recombinant and purified inactivated viruses. as one faces emerging infectious diseases such as the novel coronavirus first identified in late , the details of the recent ebola and zika virus outbreaks can provide a framework for an approach to new diseases. understanding of the transmission, maternal and fetal effects, and effective treatment, vaccination, and containment methods are imperative to achieving a successful response from the public health and scientific research communities. specifically addressing emerging infections in pregnancy is important because of the potential differential impact of infections among pregnant women, the possible effects on the fetus, and the unique prophylaxis and treatment strategies necessary for efficacy and acceptability among pregnant women. attention must be paid to the successes and failures of the response to the ebola and zika outbreaks as physicians strive to provide excellent care for pregnant women who are affected by or at risk for emerging infectious diseases. what is current practice? molecular testing is standard of care for both ebola and zika viruses. supportive care including rehydration and antipyretics is necessary for individuals infected with ebola and zika virus; there are no targeted therapeutics. no vaccines are available. prevention of ebola virus includes containment of infected substances and personal protection equipment use, and prevention of zika virus entails protection against mosquito bites, avoidance of high-risk regions, and delay of childbearing. what changes in current practice are likely to improve outcomes? development of targeted therapeutics and vaccines can decrease the burden of disease and in particular reduce risk for pregnant women and their offspring. test individuals who have traveled to endemic areas or have been in contact with individuals infected with ebola or zika virus who display associated symptoms. there is a role for testing of asymptomatic individuals with recurrent zika virus exposure also. successful management of ebola virus includes aggressive rehydration and intensive care. delivery timing should be based on maternal rather than fetal indications. properly dispose of all infected substances and use necessary personal protective equipment to prevent nosocomial and community transmission. pregnant women with zika virus should undergo serial ultrasounds to evaluate for congenital zika syndrome, although vertical transmission cannot be prevented once a woman has been infected. uninfected women who are pregnant or considering childbearing should avoid travel to zika virus endemic areas or unprotected intercourse with infected or exposed partners. ebola virus is associated with high mortality and a very high pregnancy or neonatal loss rate. zika virus carries a risk of congenital zika syndrome. treatment of both is limited to management of 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other human coronavirus infections addressing the effects of established and emerging infections during pregnancy key: cord- -uj fe y authors: nan title: scientific abstracts date: - - journal: reprod sci doi: . / sha: doc_id: cord_uid: uj fe y nan by reduced placental oxygenation, hypoxia-induced oxidative stress is a predominant mechanism. we investigated the effect of hypoxic pregnancy, with and without antioxidant treatment, on placental and maternal circulatory indices of oxidative stress in rats. methods: on pregnancy day , wistar rats were randomised into: normoxia ( % o litters), hypoxia ( % o litters) and hypoxia + vit c ( % o + mg. ml - vit c in water, litters). on day , dams were anaesthetised, maternal blood taken, pups measured and weighed, placentae weighed and frozen. only placentae from two male pups from any one litter were investigated. blood was processed for ascorbate, urate, l-cysteine and glutathione (gsh) measurement. placental protein was analysed for heat shock protein (hsp ; western). results: hypoxia + vit c did not affect maternal food or water intake. vit c elevated maternal ascorbate by % of baseline; a similar increment to human trials (poston et al. ) . hypoxia elevated placental hsp and maternal plasma urate and l-cysteine, but decreased gsh. vit c in hypoxic pregnancies prevented all stimulated effects, but the reduction in gsh persisted. hypoxic pups had a reduced ponderal index and elevated head diameter: body weight ratio; effects also prevented by vit c. fetal oxygen uptake in normal and gdm pregnancies. emanuela taricco, tatjana radaelli, veronica cozzi, gabriele rossi, danila puglia, giorgio pardi, irene cetin. department of obstetrics gynecology "l. mangiagalli", irccs policlinico, mangiagalli e regina elena, milan, italy. background. diabetes in pregnancy has been associated with alterations of fetal growth probably due to increased nutrient availability and placental transport. fetal hypoxia and acidemia have been reported in pregestational diabetic pregnancies with poor glicemic control but this is still uncertain in well controlled patients. the role of placental function and the relationship between maternal and fetal circulation is crucial for efficient exchanges of oxygen and nutrients. since umbilical blood flow can be obtained by us in utero, we studied normal and gdm pregnancies in order to evaluate fetal oxygen uptake. methods. normal (n) and gdm pregnancies were studied at term, at the time of elective caesarean section. umbilical vein volume flow (qumb) was measured by us before caesarean section and blood samples from umbilical vein (uv) and artery (ua) were obtained. blood gases and acid-base balance were evaluated. results. average fetal weights were similar in both groups (n= ± ; gdm= ± g) while placental weights were significantly different (n= ± ; gdm= ± g). n and gdm pregnancies showed similar values of qumb and qumb/kg of fetal weight. (qumb: . ± . in n and . ± . ml/min in gdm; qumb/kg: . ± . in n and . ± . ml/min/kg in gdm). in fetuses from gdm pregnancies a significant reduction in o sat, o cont and po and a significant increased lactate conc was found in both uv and ua compared to n (table ) . o umb uptake (n= . ± . ; gdm= . ± . mmo/l/min) and o umb uptake/kg (n= . ± . ; gdm= . ± . mmo/l/ min/kg) were significantly lower in gdm compared to n fetuses. conclusions. our data indicate that fetuses from gdm pregnancies show a significant reduction in oxygen supply despite a normal blood flow/kg of fetal weight. these data may suggest that a good maternal metabolic control is not sufficient to ensure normal placental oxygen supply and/or utilization by the gdm fetus. background: synthetic glucocorticoids (sgc) are given to mothers at risk of preterm delivery to promote fetal lung maturation. evidence is emerging indicating long-term effects of such treatment on endocrine function and behavior in offspring. however, virtually nothing is known concerning potential transgenerational influences on growth, endocrine function and behaviour. we hypothesize that repeated treatment of grandmothers (f ) with sgc will alter hypothalamic-pituitary-adrenal (hpa) function in f offspring with no manipulation of the f pregnancy. methods: pregnant guinea pigs (f ) were subcutaneously injected with betamethasone (beta; mg/kg) or vehicle (veh) on gestational days / , / / . adult f female offspring from each group were mated with control males. hpa function was assessed in adult f offspring by non-invasive measurement of salivary cortisol concentrations: ) under basal conditions, ) during and following exposure to psychological stress (high frequency strobe light) or psychological/physical stress (forced swim) and, ) following dexamethasone suppression. results: there was no effect of beta (f ) on bodyweight from birth to adulthood in f offspring. basal salivary cortisol in the betaf females was lower than in the vehf group in the morning but not the afternoon; there were no differences in male f offspring. in contrast, both male and female betaf failed to mount adrenocortical responses to psychological stress compared to vehf offspring that mounted robust responses (p< . ). swim stress induced robust adrenocortical responses in all groups (p< . ), however, the response was consistently lower in betaf offspring. beta exposure also led to a significant difference (p< . ) in the cortisol response to dexamethasone suppression in female (f ) offspring, with a similar trend in males. conclusion: prenatal exposure to sgc (f ) causes transgenerational programming of adrenocortical function in adult f offspring. grand maternal exposure to beta results reduced basal adrenocortical activity in betaf female offspring, and caused stress hypo-responsiveness in both males and females. dexamethasone suppression tests indicate altered central glucocorticoid feedback. these findings have important ramifications for the management of human preterm labor. support: canadian institutes of health research. in the uterine and umbilical vasculatures, we hypothesized that their remodeling would also be blunted in pregnant enos -/-mice, leading to an elevated vascular resistance and decreased blood flow to the placenta contributing to fetal growth restriction. methods: utero-and umbilical-placental blood velocity waveforms and umbilical arterial diameters were measured using mhz ultrasound biomicroscopy in control (c bl/ j) and enos -/-mice at . days of pregnancy (n= mothers). spiral artery and fetal capillary morphologies, and uterine arterial diameters were evaluated from vascular corrosion casts. tissues were collected for hydroxyprobe- and actin immunohistochemistry to identify hypoxic and smooth muscle regions. we calculated resistance index ((s-d)/s) from systolic (s) and diastolic (d) velocities, and blood flow from mean velocity and vessel area. results: calculated uterine blood flow normalized to the weight of the uterus and its contents was % lower (p< . ) in pregnant enos -/-mothers due to large reductions in uterine artery diameter (- %, p< . ) and mean velocity (- %, p< . ). uterine arterial resistance index was % higher (p< . ), and the spiral arteries were less coiled and contained more smooth muscle actin in enos -/-mice than controls. more intense hypoxic immunoreactivity was detected in the spongiotrophoblast and trophoblast giant cell layers of the junctional zone of enos -/-placentas, whereas fainter staining was only detected in the spongiotrophoblast cell layer in controls. in the umbilical circulation, flow normalized to fetal weight was not significantly changed although the resistance index was slightly elevated ( %, p< . ) and capillary lobule length was reduced by (- %, p< . ). fetal organs showed increased hypoxic immunoreactivity suggesting reduced organ oxygen delivery in enos -/-fetuses. conclusions: results suggest that enos plays an important role in uterine and spiral artery remodeling and in augmenting utero-placental blood flow during pregnancy. it also appears to enhance oxygen delivery to the placenta and fetus. enos may contribute to normal fetal growth by these mechanisms. integrin methods: hpmcs isolated from term placentas were assessed for their phenotype markers, mutilineage capacity, and the expression of integrin molecules. the hpmcs were induced to endothelial cell differentiation in the presence of endothelial cell growth medium with % of fcs and ng/ml vegf for to days. the angiogenesis ability of these cells was demonstrated by using an in vitro angiogenesis kit and in vivo chick chorioallantoic membrane assay from ten-day-old embryos. blocking antibodies specific to integrin , associated with gdm. this study was adequately powered to detect association in the caucasian and asian group. the absence of association suggests that gdm and t dm may have more divergent molecular pathophysiology than previously suspected. background: uterine endometrium has a unique cycle of physiological angiogenesis. in mice, endothelial progenitor cells (epc) contribute to endometrial angiogenesis being incorporated after oestradiol administration. objective: to determine whether circulating © epc number and function vary through the menstrual cycle in response to changes in circulating sex steroid concentrations. methods: ten healthy, nulliparous, pre-menopausal, non-smoking women (mean age years) with regular menses ( - days) were studied. venous blood was collected during menstrual, follicular, periovulatory and luteal phases of a single cycle (days - , - , - , - ) . cepcs, serum oestradiol (e) and progesterone (p) were measured at each phase. cepcs were quantified by phenotype using flow cytometry (leukocytes co-expressing cd , kdr and cd ) and function by the epc-colony forming unit (cfu) assay. epc-cfus were stained for endothelial markers including uptake of acetylated low-density lipoprotein, binding of lectin (ulex europaeus) and endoglin. results: luteal p was > nmol/l in all women. cepc numbers increased in the menstrual and follicular phases being -fold higher in the follicular compared to periovulatory phase (p< . ). there was no significant variation in cepc function over the menstrual cycle. there was no correlation between serum e or p levels and cepc number or function. conclusion: cepcs number but not function (epc-cfu assay) vary during the menstrual cycle with numbers increasing during the menstrual and follicular phase and falling in the periovulatory and luteal phase of the menstrual cycle. this may represent mobilisation of cepcs from the bone marrow and subsequent incorporation into the endometrium. neither function nor cepc number correlate with serum p or e. our previous studies demonstrated that tissue factor (tf), which binds factor vii to act as a potent pro-coagulant and angiogenic factor, is over-expressed in endometriotic lesions. thus, we determined whether tf could serve as a target for the elimination of pre-established ectopic human endometrial growth in a mouse model. icon is composed of a mutated factor vii (fvii) domain targeting tf and an igg fc (fvii/igg fc) effector domain that activates antibody-dependent immune responses against tf bearing endothelial cells. methods: athymic, ovariectomized and estrogen-treated mice received intraperitoneal (i.p.) injections of . mg of proliferative phase human endometrial tissue derived from normal (disease-free) women. twelve days after inoculation to establish lesions, icon protein ( ug) was delivered i.p. once a week for weeks. after sacrifice, animals were subject to gross inspection. residual endometriotic tissue was formalin fixed, paraffin embedded and immunostained for von willebrand's factor (vwf) and tf. results: compared to control mice, treatment with ug of icon abolished all lesions in of mice and reduced both size ( . to . mm) and number of lesions ( . to per diseased mouse) in the remaining mice. moreover, residual lesions from icon treated mice were atrophic and displayed significant reductions in vessel areas of % +/- % (p= . , mean +/-sem, n= ) as determined by vwf immunostaining. no hemorrhagic or thrombotic sequelae were observed in icon treated mice. conclusions: unlike other treatments that target developing angiogenesis, icon can target both developing and established human endometriotic lesions in athymic mice. the gross and microscopic vessel analysis suggests that icon directly or indirectly destroys endometriotic vessels. thus, icon presents a novel, non-toxic therapy for endometriosis. compared to the miscarriage and top groups. ihc for crisp demonstrated increased secretion of crisp in the glandular epithelium and expression in the leucocytes of the tubal uterine decidua. conclusions: there are differences in decidual gene expression in tubal compared to iu pregnancies. we believe that potential biomarkers of tubal pregnancy can be discovered by focusing on secreted proteins associated with uterine decidualization. one of these proteins, crisp , is significantly increased in decidua of tubal ectopic pregnancies and we are currently investigating its expression pattern in sera from women with tubal compared to iu pregnancies. progesterone and hoxa regulate gaba-a pi receptor expression, membrane translocation and activation. homayoun sadeghi, hugh s taylor. obstetrics, gynecology and reproductive sciences, yale school of medicine, new haven, ct, usa. objective the expression of the gaba-a pi receptor has been previously described in the human endometrium in both luminal epithelium and stroma. it is upregulated during stromal decidualization in the rat and in the implantation window of human endometrium. the gaba receptor is modulated by progesterone metabolites, with the resultant opening of the receptor ion channels which allow the water flux necessary for trophoblast attachment. here we identified regulators of pi subunit receptor gene expression and activity. the well-differentiated human endometrial adenocarcinoma cell line (ishikawa) and human endometrial stromal cells (hesc) were transfected with hoxa , treated with progesterone, or treated with vehicle or empty plasmid controls. gaba-a pi receptor mrna upregulation was evaluated by real time rt-pcr. protein expression was evaluated using immunohistochemistry. results gaba-a pi receptor mrna expression was increased with either progesterone treatment ( %, p= . ) or hoxa transfection ( %, p= . ). coadministration of progesterone along with increased hoxa transfection had no additive effect on the expression of gaba-a pi receptor mrna (p= . ). gaba-a pi receptor protein expression was similarly increased by each treatment. either hoxa or progesterone independently caused translocation of the gaba receptor from the cytoplasm to the cell membrane in ishikawa cells. conclusion gaba-a pi receptor expression is increased in the human luminal epithelium and stroma in the window of implantation. activation of the pi subunit leads to opening of ion channels, likely allowing flux of water into the epithelial cells and out of the uterine lumen. progesterone and hoxa each increase both pi subunit receptor expression and membrane translocation. the lack of additive effect suggests progesterone induced pi subunit receptor expression is likely mediated indirectly through progesterone's regulation of hoxa expression. finally, after receptor expression and translocation, progesterone mediated gaba receptor ion channel activation mediates water resorption necessary for implantation. cancer. suzy davies, donghai dai, kimberly k leslie. obstetrics and gynecology, university of new mexico, albuquerque, nm, usa. objectives: endometrial cancer is the most frequent gynecologic cancer in women. it affects an estimated , women in the us every year, and long term outcomes for patients with advanced stage or recurrent disease are poor. targeted molecular therapy against the vascular endothelial growth factor (vegf) and its receptors constitute a new therapeutic option for patients that is now under study by the gynecologic oncology group in a phase trial, gog e (now in second stage accrual). the goal of our work was to assess the potential effectiveness of vegf/vegfr blockade in preclinical endometrial cancer models. methods: these studies employed two agents, bevacizumab (avastin, a vegfa blocking antibody) and vandetanib (zactima, a tyrosine kinase inhibitor of egfr and vegfr ). ic experiments were performed on endometrial cancer cells in culture using four established cell line models. xenografted athymic mice were also employed to test the ability of compounds to inhibit tumor growth in vivo. tumors were isolated from controls and treated animals, mrna was extracted, and affymetrix gene expression arrays were performed to determine the genes consistently modulated by treatment. results: compared to vandetanib with an ic of . m, bevacizumab showed little activity on cell proliferation in vitro, and cell numbers were not reduced by % using concentrations up to . m. however, bevacizumab demonstrated robust activity in the athymic mouse model, resulting in a significant decrease in tumor formation and growth compared to vehicle treated animals when dosed bi-weekly in a concentration of . mg/mouse ip. tumors from this model demonstrated that eighteen genes were consistently up or down regulated in the presence of bevacizumab. among the regulated transcripts was microrna , which was significantly down-regulated. microrna is an anti-apoptotic factor, and its inhibition by bevacizumab predicts for increased expression of the tumor suppressor pten, decreased cell proliferation, and a reduced capacity for metastasis. conclusions: these studies confirm that the vegf pathway is a good target for new therapies against endometrial cancer. blocking this pathway not only inhibits angiogenesis, but also results in changes in gene expression that enhance apoptosis and reduce cellular proliferation and tumor invasion. we collected fibroid and adjacent normal tissues following hysterectomy with patient consent and institutional irbs. to date, data points for each gene from arrays have been collected from patients. the fluorescence readings were log-transformed and normalized with the robust quartile normalization method. quality control of the normalized data was performed to remove arrays that deviated from twice the inter-quartile range calculated from the array signals. results: the custom microarray profiling identified genes that were differentially expressed between normal and fibroid tissues (p < . ; fdr< . ). among them, genes encode receptor tks, genes encode tk ligands, and genes encode cell cycle and apoptosis proteins. clustering analysis of the mean log ratios of these genes has led to the division of the patients into two major groups. thirty four ( %) belong to a group characterized by the significant downregulation of the cyr (ccn ) gene in fibroid tissues. the cyr -down group can be further divided into two sub-groups based on the expression of another tk ligand, efn a. other receptor differentially expressed tk did not segregate with the three defined sub-groups. finally, there was no sub-group segregation based on age of the patient, menstrual phase, or weight of the fibroid. conclusion: our results have demonstrated that tyrosine kinases and their ligands are uniquely differentially expressed between normal and fibroid tissues. unique tyrosine kinase ligands in our population were cyr and efn a, and these markers created three molecular classification groups based on their differential expression. these results support the hypothesis that tyrosine kinase ligands are involved in fibroid growth, and may offer targets for a strategy to avoid hysterectomy. microvascular perfusion sonographic imaging to detect early stage ovarian cancer. joanie mayer hope, arthur c fleischer, brian day, stephanie v blank, bhavana pothuri, robert wallach, john p curtin, david a fishman. gynecologic oncology, new york university school of medicine, new york, ny, usa; radiology, vanderbilt university medical center, nashville, tn, usa. objective: epithelial ovarian cancer (eoc) is the th leading cause of death in us women due to the inability to detect early stage disease. recent sonographic developments involving harmonics, pulse inversion, and the use of contrast agents justify the hope that depiction of aberrant tumor microvascularity associated with early disease can occur. this study utilizes these new techniques to assess the unique microvascularity associated with early stage eoc. methods: we used pulse inversion harmonic microvascular imaging (mvi) technology to depict differences between benign and malignant ovarian lesions. contrast enhanced harmonic transvaginal (tv) sonography was performed using the philips iu scanner after intravenous injection of g of definity (bristol-myer-squibb). split screen real-time images were acquired displaying conventional sonographic views adjacent to harmonic, low mechanical index images. morphologic features (thickened wall, papillary excrescence, calcifications) and aberrant vascularity were noted. q-lab quantification of wash-in, peak enhancement, and wash-out times as well as area-under-thecurve (corresponding to microvessel perfusion) were compared using student's t-tests. results: to date, contrast enhancement patterns of ovaries have been analyzed, benign and malignant. of the malignancies ( fallopian tube, ovarian: stage i, stage iii), / women were correctly identified using conventional tv imaging and others were identified using mvi / . all benign lesions were correctly identified by mvi / while tv detected normals ( false negatives). the lesions detected as malignant by mvi were -stage i fallopian tube and -stage i eoc. contrast enhancement kinetics of malignant lesions demonstrated similar wash-in ( . ± . vs . ± . , p = . ), greater peak enhancement ( . ± . vs . ± . , p < . ), longer wash-out ( . ± . vs . ± . (p < . ), and greater perfusion ( . ± . vs . ± , p < . ) when compared to benign lesions. conclusion: contrast enhancement patterns are significantly different in benign vs. malignant ovarian masses. this technique has clear potential in differentiating benign from malignant lesions and for detecting occult stage i disease. identification and characterization of mir- a as regulator of ikk expression and its function in ovarian cancer cells. rui chen, ayesha b alvero, thomas rutherford, gil mor. department of obstetrics and gynecology, yale university school of medicine, new haven, ct, usa. introduction: the proinflammatory environment associated with tumor growth and chemoresistance is produced by both immune cells and cancer cells. the nf-b pathway plays a critical role mediating the capacity of cancer cells to produce pro-inflammatory cytokines. recently, we described a group of epithelial ovarian cancer (eoc) cells characterized by ikk expression as the main factor promoting nf-b activation and cytokine production. in this study we evaluated the regulation of ikk in eoc cells. we describe the identification and characterization of mir- a as a regulator of ikk expression, thus indirectly of nf-b activity and function. materials and methods: human eoc cell lines were established from malignant ovarian cancer ascites. protein expression were determined by western blotting. ikk mrna was measured by rt-pcr. cytokines were profiled by the luminex system. ikk transfection was done with roche fugene transfection reagent. mirna microarray was done with invitrogen ncode multi-species mirna microarray kit. mir- a qrt-pcr was performed with invitrogen ncode sybr greener mirna qrt-pcr analysis kit. mirna transfection was done with ambion siport neofx agent. the ikk '-utr luciferase reporter plasmid was established based on ambion pmir-report mirna expression reporter vector. results: ikk expression was associated with nf-b cyclic activity and the ability of type i eoc cells (but not type ii) to produce inflammatory cytokines. transfection of ikk into type ii eoc cells reversed their phenotype. mirna microarray identified mirnas differentially expressed in type i versus type ii cells, one of which, mir- a, had putative binding sites in the '-utr of ikk mrna. mir- a introduction into type i cells inhibited ikk expression, and direct inhibition through ikk 's '-utr was confirmed by luciferase assay. conclusion: we describe for the first time the identification of ikk as a potential key switch between chemo-resistant and chemo-sensitive phenotypes, by regulating nf-b activity in eoc cells. furthermore, we identified mir- a as a direct regulator of ikk expression. ikk expression may represent an adaptational stage in tumor progression allowing cancer cells to create their own inflammatory environment. these findings may provide novel molecular targets and potential markers for individual therapy selection. regulation of cd in the rat uterus by nitric oxide and the involvement of p kinase pathway. uma yallampalli, rebakah elkins, pawel goluszko, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. objective. cd is expressed in many cell types including uterine cells and has been shown to play an important role in protecting against compliment attack. we have previously shown in endometrial cell lines that cd levels were down regulated by nitric oxide (no) . in this study we extend our previous observations to determine if no down regulates cd in rat uterine tissues and assess its mechanisms of action. methods. non pregnant rats ( g; b wt) were bilaterally ovariectomized under ketamine anesthesia. groups of ovariectomized rats were implanted with alzet mini pumps to deliver nitro-l-arginine melthylester (l-name) at or /mg/rat/day in saline or saline alone. uteri were obtained from these rats at or hours after infusion. in another set of experiments uteri were obtained from ovariectomized rats and cut in to small pieces and incubated in vitro with either l-name ( mm), diethylenetriamine-no mm) or worthmanin ( . m) in mem without phenol red for hours. uterine tissues were homogenized in trizol and mrna levels for cd were measured using rt-pcr and expressed as a ratio to s. results. results show that in vivo treatment with l-name to ovariectomized rats caused elevations in uterine cd mrna levels in a time and dose dependent manner with maximal responses seen with mg l-name and at hours. in vitro studies show that deta-no suppressed cd mrna levels in the rat uterus. both l-name and pi kinase inhibitor, worthmanin caused increases in cd levels in these tissues and the effects of worthmanin are reversed by deta-no. these results suggest that cd levels in the rat uterus are down regulated by no and are upregulated when no synthesis is inhibited by l-name. further, pi kinase appears to be involved in cd regulation in the rat uterus and no donor appears to modulate this response. lung. lakeitha r foster, daniel b hardy, carole r mendelson. dept of pediatrics; depts of biochemistry and ob/gyn, ut southwestern medical center, dallas, tx, usa. during % of human pregnancy, the maternal uterus is maintained in a state of almost complete quiescence by elevated circulating levels of progesterone (p ). we previously observed that p acting through the progesterone receptor (pr) serves an anti-inflammatory role and inhibits uterine contractility by antagonizing nuclear factor b activation and cyclooxygenase- (cox- ) expression (hardy et al., ) . our previous findings also suggest that the fetus provides an important signal for the initiation of labor near term through augmented secretion of the major lung surfactant protein, sp-a, into amniotic fluid (condon et al., ) . secreted sp-a, in turn, activates fetal macrophages which migrate to the maternal uterus where they release cytokines and promote an inflammatory response, leading to labor. in the present study, we tested the hypothesis that maternal p also maintains uterine quiescence by inhibiting sp-a production by the fetal lung. age matched icr mice were injected s.c. once daily either with sesame oil (control) or p ( mg/ml) from to days post-coitum (dpc). as expected, treatment with p delayed parturition by - h. this also was associated with a decrease in uterine cox- mrna expression, as compared to the vehicle-injected controls. interestingly, maternal p treatment caused a marked decrease in the levels of immunoreactive sp-a protein secreted by the fetal lungs into in amniotic fluid at dpc. furthermore, sp-a protein and mrna levels were reduced in the fetal lungs of p -injected mothers, as compared to controls. this was associated with an inhibitory effect of p treatment on cox- protein and mrna levels in the fetal lungs. these findings were of interest, since cox- expression is markedly upregulated during differentiation of human fetal lung (hfl) explants in culture (hardy et al., ) and endogenous and exogenous prostaglandins increase sp-a expression in hfl (acarregui et al., ) . collectively, these findings suggest that maternal p treatment prevents increased uterine contractility, in part, by inhibiting inflammatory response pathways within the fetal lung. this, in turn, blocks the developmental induction of sp-a expression and its secretion into amniotic fluid. in this manner, maternal p inhibits an important fetal signal leading to labor. supported by nih p hd ; nih r hl . recent evidence suggests that leukocytes infiltrate uterine tissues at the time of parturition implicating inflammation as a key mechanism of human labor. ccl- is a pro-inflammatory cytokine that may contribute to the development of inflammatory reaction in the myometrium. previously we showed upregulation of rat ccl- gene expression in myometrium during term and ru -induced preterm labor. also ccl- was elevated specifically in the gravid horn of unilaterally pregnant rats suggesting that mechanical strain imposed by the growing fetus controls its expression in the myometrium. the objective of this study was to investigate the role of mechanical stretch as a possible regulator of myometrial leukocyte infiltration and ccl- as a mediator of this stretch response. we also studied the effect of progesterone (p ) on the myometrial secretion of ccl- . methods. we used primary culture of rat myometrium smooth muscle cells (smcs) to study in vitro ccl- gene and protein induction by static mechanical stretch. ccl- gene expression analysis was performed by real-time rt-pcr and immunoreactive (ir) protein content was measured by elisa assay. we used primary rat monocytes to access whether stretch-induced ccl- production by myometrial smcs resulted in enhanced monocyte chemotactic activity. results. myometrial cells were stretched for - hours and the supernatants collected. analysis of media conditioned by primary myometrial smcs revealed that static mechanical stretch ( % elongation for hours) caused a significant accumulation in ir ccl- which was repressed by pretreatment with p ( um). the rise in ccl- protein levels was preceded by a transient increase on ccl- mrna. the migration of primary rat monocytes in response to conditioned medium from stretched myometrial smcs was much greater than that of conditioned medium from control non-stretched cells. co-incubation with a neutralizing antibody to ccl- significantly reduced the chemotaxis of monocytes in response to the stretch-conditioned medium. conclusion: uterine smcs play an active role in uterine inflammation by producing chemokines and promoting the chemotaxis of immune cells into the myometrium. the blockade of this effect by p offers a potential explanation for the therapeutic actions of this hormone in the prevention of preterm birth. membranes during human labor. nardhy gomez-lopez, , guadalupe estrada-gutierrez, lourdes vadillo-perez, felipe vadillo-ortega. direction of research, instituto nacional de perinatologia, mexico city, df, mexico; escuela nacional de ciencias biologicas, ipn, mexico city, df, mexico. introduction. leukocytes arriving to the choriodecidua (chd) during labor are capable to secrete cytokines and matrix metalloproteinases that may play a role in the fetal membranes (fm) extracellular matrix degradation. objective. the aim of this work was to identify changes in the leukocyte subpopulations in the chd and fm during human labor. methods: fm were obtained from two groups of women: ) term without labor (n= ) and ) term with spontaneous labor (n= ). chd cells were isolated and analyzed by flow cytometry. explants of fm were embedded in paraffin and analyzed by confocal microscopy. in both techniques, cd , cd , cd , cd and cd subpopulations of leukocytes were identified. intracellular mmp- was also identified in these cells. results: major changes in leukocytes subpopulations during labor involved a higher amount of cd +, cd+ and cd + cells, both in the chd and inside the fm. mmp- was associated to cd + cells. cd + exhibited a more widespread localization in the fm and cd + cells were localized in the contact with the trophoblast layer during labor. conclusions: leukocyte populations changes both in the chd and fm during labor and are characterized by arrival and infiltration of specific subpopulation of lymphocytes and monocytes. nk cells are enriched in mmp- , which may be related to a role in extracellular matrix degradation leading to the rupture of fetal membranes. women with a history of a pregnancy complicated by preeclampsia or intrauterine growth restriction (iugr) have an increased risk of future cardiovascular disease. excessive weight, particularly abdominal fat mass, is associated with cardiovascular morbidity and mortality. objectives: the aim of this study was to investigate differences in body composition and fat distribution between women with a history of preeclampsia or iugr and uncomplicated pregnancies. methods: from a genetically isolated population in the southwest of the netherlands, non-pregnant women with a history of preeclampsia (n= ), iugr (n= ) and uncomplicated pregnancies (n= ) were recruited at a mean follow up time of . years after pregnancy. body composition and fat distribution were assessed by dual energy-x-ray absorptiometry (dxa) and anthropometric measurements. results: women with a history of preeclampsia compared to controls had higher mean total-, fat-and lean mass (p < . ) as well as higher mean indices of body mass, fat mass and lean mass (p< . ). no significant differences were found for these variables between women with a history of iugr and controls. women with a history of preeclampsia had higher waist circumferences and waistto-hip ratios (p< . ) as well as excess of android fat mass and increased android-to-fat ratios (p< . ). women after pregnancies complicated by iugr had higher waist-to-hip ratios (p < . ). after controlling for body mass index, both women with a history of preeclampsia or iugr had higher waist circumferences (p < . ) and waist-to-hip ratios (p < . ) as well as smaller hip circumferences (p < . ). conclusion: despite differences in body mass index, both women with a history of preeclampsia and women after pregnancies complicated by iugr have a metabolically adverse fat distribution, marked by an excess of fat deposition in the abdominal region relatively to the hip region. these findings may explain, at least partly, their increased cardiovascular risk. women with a history of preeclampsia. marc ea spaanderman, timo h ekhart, robert aardenburg, louis lh peeters. obstetrics and gynecology, radboud university medical center, nijmegen, netherlands; obstetrics and gynecology, university medical center maastricht, maastricht, netherlands. background: a history of preeclampsia is associated with persistent short-term alterations in circulatory function and remote cardiovascular disease. in this study we tested the hypothesis at least years after preeclamptic pregnancy renal and central hemodynamic function is impaired as compared to women with uncomplicated pregnancy. methods: in formerly preeclamptic women (pe) and healthy parous controls (control) who were normotensive at weeks post-partum follow up, we assessed at least years after delivery blood pressure (mmhg), cardiac output (co, doppler ultrasonography, l/min) and effective renal plasma flow (erpf, pah clearance, ml/min/ . m ) after which we calculated total peripheral vascular resistance (. dyne.s/cm ) and renal vascular resistance (. dyne.s/cm ). data were analyzed parametrically (p< . ). results: age and bmi were comparable between groups. blood pressure was higher in formerly pe. moreover, % of formerly pe women and % of control were hypertensive (p< . ). although cardiac out was comparable between groups, total peripheral and renal vascular resistance were about % higher and erpf % lower in formerly pe women as compared to control. conclusion: at least years after gestational hypertensive disease, women who were normotensive at direct follow up have impaired renal and central hemodynamic function and developed more often chronic hypertension. long-term follow up may also be warranted in apparently healthy formerly pe women who are normotensive at post-partum follow up. circulatory function in formerly preeclamptic women and healthy parous controls co erpf tpvr rvr formerly pe . ± . ± * ± * ± * control . ± . ± ± ± * = p< . pregnancy increases blood-brain barrier permeability coefficient (l p ) to lucifer yellow: role of estrogen. marchien j wiegman, , marilyn j cipolla. neurology, ob/gyn and pharmacology, university of vermont, burlington, vt, usa; ob/gyn, university medical center groningen, groningen, netherlands. background: eclampsia is similar to posterior reversible encephalopathy syndrome in which an acute rise in blood pressure causes breakthrough of autoregulation, blood-brain barrier (bbb) disruption, and cerebral edema formation. we previously showed that late-pregnant (lp) animals developed cerebral edema during breakthrough, a response that was absent in nonpregnant (np) animals. in the current study we hypothesized that pregnancy predisposes the brain to edema during acute hypertension by enhanced bbb permeability. we further hypothesized that the underlying effect of pregnancy on the bbb permeability is due to elevated estrogen levels. methods: permeability coefficients (l p ) to lucifer yellow (ly), a polar compound that does not pass through tight junctions, were compared in posterior cerebral arteries (pca) from groups of sprague dawley rats: np (n= ), lp (d ; n= ), ovariectomized and implanted with -estradiol ( . mg, -day release) and estriol ( . mg, -day release) pellets for days (ovx+e; n= ), and ovariectomized and implanted with placebo pellets for days (ovx; n= ). pcas were isolated, pressurized in an arteriograph, and perfused with . mg/ml ly in saline. concentration changes of ly outside the vessel wall were determined at pressures from - mmhg. the slope of the pressure vs. permeability curve is the rate of flux, or l p for ly. results: l p for ly was significantly increased in pcas from lp and ovx animals vs. np (p< . ; figure ). estrogen was protective of the bbb only in ovariectomized animals, decreasing l p % in ovx+e vs. ovx. however, pregnancy did not afford protection and had a l p that was % greater than np. conclusions: pregnancy significantly increases bbb permeability to ly, an effect that may predispose the brain to edema formation during acute hypertension. these data also show that estrogen modulates l p in ovariectomized animals differentially than pregnancy, suggesting that the increased bbb permeability in pregnancy is caused by a mechanism other than elevated estrogen levels. in both pre-and early pregnancy, the sympathoinhibitory response to volume expansion is blunted in formerly preeclamptic women with low plasma volume. ineke krabbendam, marc ea spaanderman, dorette a courtar, robert aardenburg, ben j janssen, fred k lotgering, louis lh peeters. obstetrics and gynecology, radboud university nijmegen medical centre, nijmegen, netherlands; obstetrics and gynecology, university hospital maastricht, maastricht, netherlands; pharmacology and toxicology, university of maastricht, maastricht, netherlands. background: the circulation of formerly preeclamptic women with a low plasma volume (lpv) is characterized by sympathetic dominance. these women respond to a new pregnancy with an aberrant rise in atrial natriuretic peptide (anp) and a times higher chance to develop recurrent gestational hypertensive disease compared to their counterparts with normal plasma volume (npv). anp has sympathicomimetic capacity. we postulate that the sympathetic overdrive in lpv-women is associated with a reduced venous capacitance. to this end, we compared the response to volume expansion (ve) in women with lpv and npv, both before and in pregnancy. method: in non-pregnant normotensive formerly preeclamptic women, we measured pv (hsa i indicator dilution method) at least months post partum. we intravenously infused ml of iso-oncotic fluid over minutes. during the infusion, we recorded changes in heart rate (hr, bpm), blood pressure (bp, mmhg), cardiac output (co, l/min), sympathetic activity (lfsys, mmhg , low frequency component of spontaneous fluctuations in systolic bp, portapress) and anp (nmol/l). eight women became pregnant within year and were evaluated at weeks gestation. changes in circulatory and autonomic function between and within groups were analyzed non-parametrically (p< . ). results: before pregnancy, ve leads to comparable changes in hr, bp and co in women with lpv ( / ) and npv ( / ). in npv, lfsys decreased %, but only % in lpv (p< . ). anp remained unaltered in npv, but increased in lpv. in the pregnant group, women had lpv and had npv. in both groups, pregnancy did not alter the response to ve. conclusion: irrespective of pregnancy, the sympathoinhibitory response to ve is diminished in lpv. these data suggest that in these women ve leads to venous overfill, giving rise to anp-release and consequently sympathetic activation, flattening the normal baroreceptor-mediated sympathoinhibitory response. we speculate that this mechanism contribute to circulatory maladaptation to pregnancy, sympathetic dominance and subsequent gestational hypertensive disease. in both pe and ht, serum sflt- was increased, and plgf reduced at all gestations (p< . ). seng levels were also increased in pe. after weeks (but not before) antihypertensive treatment was associated with a significant fall in serum sflt- and seng, in pe only. the concentrations of both sflt- and seng were significantly higher in the placentas of women with pe, but not ht, compared with controls (p= . ). only sflt- was significantly reduced in the placenta in women who received antihypertensive therapy. conclusion in pe, antihypertensive therapy after weeks' gestation is associated with a significant fall in serum sflt- and seng, and in placental sflt- . these findings raise the possibility that these drugs may have an effect on the pathophysiology of pe other than their known antihypertensive action. the synergistic effect of soluble vegf receptor pre-treatment and small doses of tnf-on endothelial cells. tereza cindrova-davies, debbie a sanders, olivera spasic-boskovic, graham j burton, d stephen charnock-jones. dept of pdn, university of cambridge, united kingdom; dept of obstetrics and gynaecology, university of cambridge, united kingdom. introduction: preeclampsia is marked by an enhanced endothelial inflammatory response manifested by maternal endothelial activation. soluble fms-like tyrosine kinase- (sflt- , svegf-r ), a naturally occurring circulating antagonist of vegf-a and plgf, is one of the secreted factors implicated in the pathogenesis of preeclampsia. in women who develop preeclampsia, sflt rises sharply, preceding the onset of the clinical disease. the aim of this study was to examine the effect of a combined treatment with recombinant sflt- and tnf-on the activation of human umbilical cord endothelial cells (huvec) by examining leukocyte adhesion, and the expression of icam, vcam, endothelin and vwf. methods: huvec were seeded, grown overnight and pre-treated with recombinant sflt ( - ng/ml) in a basic % fbs-dmem medium for hr. on day , low doses of tnf-( . ng/ml) were applied to pre-treated cells for hr. antagonism of the vegf-a action was mimicked at the protein level by pre-incubating huvec with anti-flt antibody ( - g/ml), anti-kdr antibody ( g/ml), anti-vegf antibody ( g/ml), or vegf receptor inhibitor su ( m). at the rna level, the effect of sflt was mimicked by sirna transfection of huvec with siflt or sikdr. at the end of each experiment cells were either harvested for western blotting, fixed in % pfa for immunofluorescence or incubated with labelled hl leukocyte cells, followed by fluorescent detection of adhesion. results: pre-incubation of huvec with sflt and subsequent treatment with low doses of tnf-increased the adhesion of hl leukocytes and increased icam- , vcam- , endothelin and vwf, compared to tnf-treatment alone. similar results were obtained when cells were pre-treated with su , anti-flt, anti-kdr or anti-vegf. transfection knock-down of flt or kdr gene also significantly increased leukocyte adhesion when small doses of tnfwere added. conclusions: pre-incubation with recombinant sflt, anti-flt, anti-kdr, anti-vegf, su or knocking-down flt or kdr transcripts all antagonised the autocrine actions of vegf and/or plgf. this predisposes huvecs to be more sensitive to the effect of tnf-. our study shows that sflt and tnfcombine to induce an enhanced synergistic effect, activating endothelial cells. maternal obesity is associated with increased production of inflammatory cytokines and risk of poor perinatal outcome. inflammatory cytokines can stimulate production of reactive oxygen (ros) and nitrogen (rns) species, which can covalently modify protein function. placental oxidative and nitrative stress are increased in pathological pregnancies and associated with altered placental function. objectives: determine the effect of increasing body mass index (bmi) on placental nitrative stress, measured by the expression and localization of nitrated (nitrotyrosine) and oxidized proteins. methods: placental tissue was collected at term ( - wks) from lean kg/m ), overweight ( - . kg/m ) and obese ( - kg/m ) patients (n= or /group). tissue was sectioned for immunostaining with nitrotyrosine antibody. protein samples were either dot blotted onto nitrocellulose membrane, probed with nitrotyrosine ab, and nitrated proteins detected using ecl, or derivatized using , -dinitrophenylhydrazine (dnph) (oxyblot® kit), separated on sds-page, probed with anti-dnph ab ( : ) and oxidized proteins detected using ecl. protein band intensity was measured by densitometry. oxidized proteins were selected for maldi mass spectrometry analysis. results: nitrotyrosine residues were immunolocalized primarily in the fetal capillary endothelial cells and the villous stroma, but were almost absent in the syncytiotrophoblast. by dot blot, nitrotyrosine expression differed across the three groups (p< . , anova) with expression in tissue from obese women being significantly increased compared to lean (p< . ) and overweight (p< . , tukey test). several oxidized proteins were detected with significantly greater expression seen in the lean versus overweight groups (p< . , mann-whitney u). one oxidized protein was identified by maldi-ms with four peptide matches and . % coverage as -beta hydroxysteroid dehydrogenase ( bhsd). discussion: with increasing bmi, an increase in nitrative stress appears to occur in parallel with a decrease in oxidative stress. oxidative stress is apparently reduced as ros are consumed by the interaction with rns to give nitrative stress. bhsd is involved in the biosynthesis of steroid hormones and glucocorticoids. its activity and hence steroid metabolism in the placenta may be regulated by oxidation with implications for fetal development. background teenagers are susceptible to delivering small-for-gestationalage (sga) infants. previous studies implicate continued maternal growth as a causal factor . growing adolescent sheep have reduced fetal birthweight due to impaired placental development and nutrient transfer . we hypothesized that placental function is impaired in human teenage pregnancy if there is maternal growth. methods placentas were collected from teenagers ( - years) and adults. activity of the amino acid transporter, system a, was quantified by the sodium-dependent uptake of c-methylaminoisobutyric acid into placental fragments. teenagers were defined as growing (> mm increase in kneeheight per days) or non-growing. system a activity was analysed in relation to individualised birthweight centile and maternal growth. results placental system a activity was significantly lower in teenage compared to adult pregnancies (p< . ). this was unrelated to birthweight; teenagers who delivered infants appropriate-for-gestational age (aga) had significantly lower placental system a activity compared to aga infants delivered to adults (p< . ). growing teenagers did not deliver lower birthweight infants than non-growing teenagers (median birthweight g and g respectively). furthermore, system a activity in placentas from growing teenagers was significantly elevated compared to that in non-growing teenagers (p< . ), and was similar to placental activity in adults. conclusions system a activity was reduced in placentas from teenagers compared to adults. this suggests that inherently lower placental function predisposes teenagers to sga, but that other factors (e.g. adequate nutrition) can compensate in those teenagers delivering aga infants. in contrast to our hypothesis, placental system a was elevated in growing teenagers and mimicked that of adults. this may be related to a hormonal-milieu in growing teenagers that is conducive to fetal growth, in part through stimulating placental transport. homocysteine inhibition of system a amino acid transport activity in human placenta. eleni tsitsiou, susan l greenwood, colin p sibley, stephen w d'souza, jocelyn d glazier. maternal and fetal health research group, st. mary's hospital, university of manchester, manchester, united kingdom. background: elevated plasma levels of the amino acid homocysteine (hcy) during pregnancy are associated with vascular-related complications and adverse neonatal outcomes including a reduced birthweight. fetal and maternal plasma hcy concentrations are positively correlated suggesting placental transport of hcy may be an important determinant of fetal plasma hcy. the mechanisms involved in placental hcy transport are uncharacterised. evidence that the system a amino acid transporter, which transports neutral amino acids in a na + -dependent manner, is important in promoting fetal growth and that a reduced system a activity is associated with intrauterine growth restriction (iugr), led to our hypothesis that system a provides one mechanism for placental hcy transport. this hypothesis was tested by measuring the ability of hcy to inhibit system a activity in isolated microvillous plasma membrane (mvm) vesicles and placental fragments. materials and methods: mvm vesicles and placental fragments were isolated from placentas of normal pregnancies at term. system a activity was measured at initial rate ( s and min respectively) as na + -dependent cmethylaminoisobutyric acid (meaib) uptake into mvm vesicles ( . mm) or fragments ( . mm) in the absence (control) or presence of l-hcy and dl-hcy or model substrates. results: mm l-hcy (custom-synthesised) and dl-hcy (commercial source) significantly (p< . ) inhibited na + -dependent c-meaib uptake into mvm vesicles compared to control; comparable in magnitude to other model substrates (meaib, l-ala, l-ser, l-met; n= , kruskal-wallis with dunn's multiple comparison test). l-hcy, l-met and meaib ( . - mm) caused a dose-dependent inhibition of na + -dependent c-meaib uptake into mvm with ec values (in mm; mean ± se) of . ± . , . ± . , and . ± . respectively, n= ). na + -dependent c-meaib uptake into fragments was reduced substantially in the presence of mm l-hcy or dl-hcy causing a ± and ± % reduction (mean ± sd, n= - ) of control respectively. conclusion: these observations suggest that hcy is a relatively high affinity substrate for system a in the human placenta. we speculate that inhibition of placental amino acid uptake by hcy could impact on fetal growth and development. supported by the mrc and action research endowment fund. glucose regulates placental mtor activity and glucose deprivation down-regulates placental system l activity in an mtor-dependent manner. sara roos, theresa l powell, thomas jansson. department of physiology, institute of neuroscience and physiology, gothenburg, sweden; department of obstetrics and gynecology, university of cincinnati, cincinnati, oh, usa. placental amino acid transporters are down-regulated in intrauterine growth restriction (iugr). we have previously shown that mammalian target of rapamycin (mtor) regulates placental system l transporter activity and that placental mtor activity is decreased in iugr. however, the upstream regulators of placental mtor are unknown. in iugr, fetal hypoglycemia and reduced maternal glucose levels are common and the placenta may therefore be exposed to low glucose levels. hypothesis: we hypothesized that glucose availability regulates placental amino acid transporter activity mediated by changes in mtor signaling. methods: cytotrophoblast cells were isolated and cultured until syncytialization at hours. cells were cultured for an additional hours in culture media containing . mm, . mm, or mm glucose (control), which corresponds to standard culture media. at hrs, the activity of the mtor signaling pathway was assessed by measuring the protein expression of s k phosphorylated at thr- , the primary site of mtor phosphorylation. in another set of cells, system l activity was assessed by measuring the bchinhibitable uptake of h-leucine. results: as compared to control, phospho-thr- -s k expression was reduced by % in cells incubated in . mm results: fgr pregnancies were delivered earlier ( ± . v ± . w; p< . ), weighed less ( . ± . v . ± . kg; p< . ) and had higher s/d ratios ( . ± . v . ± . ; p< . ). eaa concentrations were similar between groups, but there were differences (non-parametric testing; p< . ) in transport rates between groups with his crossing considerably faster and ile crossing slower in fgr . the table shows fetal vein/maternal (fv/m) ratios standardized to the leu fv/m ratio for all eaa for both groups. amino acids fell into groups for fgr pregnancies: ) his (ratio . ), ) leu, phe, met (ratios ), and ) val, thr, ile, trp, lys with intermediate ratios ( . ns conclusion: this is the st study to compare the relative rates of in vivo placental transport for all eaa between normal and fgr human pregnancies showing striking differences in the transport rates of two eaa. in the absence of eaa concentration differences between groups, the higher his transport rate in fgr suggests higher utilization by the placenta. vasculature of women who received exogenous estrogen compared to those who received placebo. the purpose of this investigation was to identify the gene expression in response to the estrogen, equilin, as the major component of conjugated equine estrogen and genistein, a phytoestrogen in human coronary artery endothelial cells. human coronary artery endothelial cells from a -year old female were used. cells were treated with estradiol [e ], equilin [eq] ( . nm) or genistein [gen] ( micromolar) for hours. focused oligomicroarrays for cardiovascular disease and endothelial cell function were used to study gene expression. rt-pcr was used to confirm the transcription of genes analyzed in oligoarrays. vascular adhesion molecules and genes involved in the inflammatory response were most affected with the three estrogen sources. significant reduction of integrin alphae was seen with all three . , . and . for e , eq and gen respectively. similarly nfkb was also reduced . , . and . fold compared to controls. significant reduction of ccl was demonstrated with eq ( . fold) and gen ( . fold). tnfreceptor a and b were only significantly decreased by gen. vcam- which is regulated by proatherogenic factors and upregulated mainly at atherosclerosis -prone sites, was significantly reduced ( . -fold) with genistein, and a slight reduction was seen with e and no change was observed with eq. our data support the clinical findings that estrogen has favorable effects on the genes involved in atherosclerotic disease. while e has been shown to be slightly more effective than equilin in the modulation of gene expression, genistein was significantly more effective in the favorable expression of genes involved in particularly the inflammatory response. olga n lekontseva, sandra t davidge. physiology and obstetrics/gynecology, university of alberta, edmonton, ab, canada. introduction: the prevalence of cardiovascular disease in women dramatically rises in the postmenopausal period. although deficiency of estrogen has been implicated in the pathophysiology of systemic vascular dysfunction, the effects of estrogen on vasculature are complex and not completely understood. we have previously shown that estrogen exerts a beneficial effect on the aging vascular system by reducing circulating levels of the inflammatory cytokine tnf . tnf is a known regulator of matrix metalloproteinases (mmps), proteolytic enzymes that may modulate vascular tone through cleavage of vasoactive peptides such as big endothelin- (et- ). the role of estrogen in this pathway is unknown. we tested the hypothesis that in aging/estrogen deficiency, tnf -induced mmp activity mediates greater vasoconstriction, in part, through the et- pathway. we further hypothesized that estrogen replacement reduces vascular sensitivity to the constriction by preventing mmp activation. methods: aged ( month old) female sprague dawley rats were ovariectomized and treated with either placebo [ovx] , -estradiol [ovx+e ], or the tnf inhibitor etanercept [ovx+etan] . after four weeks, resistance mesenteric arteries were isolated and studied on the pressure arteriograph. concentrationresponse to exogenous big in the absence or presence of mmp inhibitor (gm , μm) was assessed in the vessels. results: treatment of "menopausal" [ovx] rats with either estrogen or the tnf inhibitor reduced sensitivity of arteries to big et- (ec = . ± . μm in ovx versus . ± . μm in ovx+e or . ± . μm in ovx+etan groups; p< . ). although mmp inhibition attenuated maximal constriction in all of the arteries, there was a significantly greater (p< . ) role of mmps in big et- -induced vasoconstriction in the ovx+e group (reduction in max constriction= . ± . %) compared to ovx ( . ± . %) and ovx+etan groups ( . ± . %). conclusions: both estrogen and tnf inhibition reduced big et- vasoconstriction. however, contrary to our hypothesis, tnf is not contributing to mmp modulation of et- vasoconstriction. interestingly, our study demonstrates a novel role for estrogen to increase mmp contribution to big et- vasoactivity with the net effect being less vasoconstrictive. understanding this unique pathway of regulation by estrogen in the aged vasculature will allow for development of new therapeutic options for women. mo, usa. introduction: the etiology of pelvic organ prolapse is multifactorial, with both inherited and acquired components. the molecular mechanisms of prolapse have not been established yet. we have previously shown that lysyl oxidase (lox) expression is suppressed in uterosacral ligaments of women with pelvic organ prolapse. it has also been shown that lox is a tumor suppressor gene inactivated by methylation in human gastric cancers. hypothesis: the aim of this study was to analyze the dna sequence of the promoter region of the lysyl oxidase gene in tissues from women with pelvic organ prolapse and identify whether methylation is present. our hypothesis is that the promoters of the lox gene in women with pelvic organ prolapse have significantly more methylation sites than women without prolapse. materials and methods: genomic dna was isolated from the uterosacral ligaments of eight women with pelvic organ prolapse and women without prolapse (controls). genomic dna samples were treated with ez dna methylation kit (zemo research, orange, ca). the lox gene promoter region of - to + was amplified by pcr and then cloned into pcr . -topo (invitrogen, carlsbad, ca) and transformed into an e. coli dh a strain. amplified plasmid dna samples containing the lox gene promoter region from each woman were sequenced and methylated cpg islands were identified by sequence comparison. results: a total of methylated cpg sites were found in the patient group with pelvic organ prolapse while only methylated cpg site was found in the non-prolapse control group. conclusion: these findings suggest that methylation in the promoter region suppresses lox gene expression in women with pelvic organ prolapse. background: reports from case-control and cohort studies have suggested an inverse association between lactation and breast cancer risk, but findings have been inconsistent. methods: we conducted a prospective observational cohort study of , parous women participating in the nurses' health study ii from to . our primary outcome was incident premenopausal breast cancer. results: during the study period, cases of premenopausal breast cancer were diagnosed during , person-years of follow-up. women who had ever breastfed had a % lower incidence of premenopausal breast cancer ( % confidence interval [ci] - %) compared with women who never breastfed, adjusting for parity, age at first birth, year of first birth, height, body mass index (bmi), bmi at age , family history, personal history of benign breast disease, participant birth weight, preterm birth, age at menarche, oral contraceptive use, physical activity, and alcohol consumption. no trend was observed with duration of lactation (p= . ). the association between ever-breastfeeding and premenopausal breast cancer was modified by use of medication to suppress lactation (p= . ); in analyses restricted to women who had never used suppressive medication, ever-breastfeeding was associated with a % ( %ci - %) reduction in incident disease. the association between lactation and premenopausal breast cancer was further modified by family history of breast cancer (p= . ). among women who had never used suppressive medication and reported a family history, those who had breastfed had a % lower covariate-adjusted risk of premenopausal breast cancer ( % ci - %) than women who had never breastfed. among women without a family history, ever-breastfeeding was not associated with breast cancer incidence (hazard ratio . , % ci . - . ). among women who had ever breastfed, we observed no association between breast cancer risk and duration of lactation amenorrhea or exclusive breastfeeding. conclusion: in a large, prospective cohort study, ever-breastfeeding was inversely associated with risk for premenopausal breast cancer. at the durations observed in our cohort, we observed no trend with duration of breastfeeding or lactation amenorrhea. the inverse association with ever-breastfeeding was stronger among women with a family history of breast cancer. regulatory and nkt cells at the maternal-fetal interface. thomas f mcelrath, rachael a clark. brigham women's hospital, boston, ma, usa; harvard skin disease research center, brigham women's hospital, boston, ma, usa. introduction: pregnancy represents an immunologically challenging event requiring maternal tolerance of the fetal semi-allograft. an increase in decidual cd + cd + t cells has been documented but it is unclear if these represent foxp + t cells (tregs) . the possibility also exists that other cd + lineages with potential regulatory function exist within the decidua parientalis. we examined if cd + cd + cells are true foxp + tregs and evaluated the frequency of other t cell subsets with possible regulatory potential. methods: we extracted t cells from term deciduas of planned cesarean deliveries. cells were stained with directly conjugated monoclonal antibodies and were analyzed on a six color flow cytometer. results: we found that only a subset (median %) of cd + t cells were true foxp + regulatory t cells. from donors, foxp + tregs accounted for a median of . % of all cd + cells. these cells were memory cd ro + t cells lacking ccr , and l-selectin but expressing cd , ctla- , gitr, and hla-dr. additionally we found that a median % of cd + t cells expressed the nkt marker cd . these cells were a mixture of cd and cd -cd -t cells, with variable numbers of cd t cells, suggesting they do not represent merely recently activated t cells. there was enrichment for t cells with nkt markers after culture on hela cells expressing cd d, suggesting that these cell represent true nkt cells. nkt cells were of the non-classical type, with a diverse t cell repertoire ( . % iv jq) and also expressed cd , hla class ii, cd ro but were ccr and l-selectin low. comments: we find that only a minority of cd -expressing t cell in the decidua are true foxp + tregs. because much of the work on treg in pregnancy has used cd as a treg marker, this suggests additional studies are needed to confirm the role of these cells in pregnancy. we find that a novel population of non-classical nkt cells exists in the human decidua. nkt cells can either promote or antagonize tolerance, depending on the immunologic context. the large number of these cells in the decidua suggests they may play a role equal or exceeding that of regulatory t cells. prolapse. marsha k guess, kathleen a connell, richard bercik, lloyd g cantley. obstetrics, gynecology reproductive sciences, yale university school of medicine, new haven, ct, usa; internal medicine/neprhology, yale university school of medicine, new haven, ct, usa. objectives: thy- is a cell surface glycoprotien expressed in human fibroblasts, neurons, hematopoetic stems cells and endothelial cells. thy- expression affects fibroblast proliferation and migration, cell-cell, as well as, cell-matrix interactions. moreover, thy- expression has been shown to play a critical role in fibroblast dedifferentiation into myofibroblasts, as well as in extracellular matrix (ecm) production and fibrosis. women with pelvic organ prolapse (pop) have alterations in vaginal ecm protein expression and metabolism, as well as decreases in smooth muscle fractional content. in the current study, we evaluated thy- as well as the smooth muscle markers alpha-smooth muscle actin (asma) and desmin expression in women with pelvic organ prolapse compared to women with normal pelvic support (controls). methods: anterior apical vaginal wall specimens from women with pop and controls were collected at the time of hysterectomy. messenger rna and protein expression of thy- , asma and desmin were evaluated using semiquantitative rt-pcr, real-time pcr and western blot analysis. gapdh and beta actin were used as internal controls. results: rt-pcr demonstrated the presence of thy- , asma and desmin in vaginal tissue from women with pop and controls. further, thy- mrna expression was downregulated % in women with pop compared to controls (p = . ). a parallel decrease in thy- protein was seen in women with pop compared to controls (p= . ). although a % and a % decease were seen in asma and desmin mrna, these differences were not statistically significant. similarly, no differences were seen in asma and desmin protein expression. conclusion: we demonstrate that there is significantly less thy- expression in vaginal tissue from women with pop compared to controls. differential expression of thy- in prolapsed vaginal tissues suggests that thy- may have a functional role in mediating ecm metabolism in the female genitourinary tract. hur expression is altered in ectopic endometrium. s karipcin, t altun, ua kayisli, e seli. ob gyn, yale u., new haven, ct, usa. introduction: cytokines and growth factors contribute to cyclic turnover of the normal endomterium and to the pathogenesis of endometriosis. cytokine and growth factor messenger rnas (mrnas) undergo rapid turnover that is primarily mediated by au-rich elements (are) that consist of multiple stretches of adenylate and uridylate residues located in the ' untranslated region ( '-utr) of their mrnas. hur is a ubiquitously expressed rna-binding protein that stabilizes are containing mrnas and prolongs their expression. we hypothesized that hur may play a role in the regulation of cytokine expression during normal menstrual cycle and in endometriosis. methods: tissue sections obtained from normal (n= ) and ectopic (n= ) endometrium were immunostained for hur. staining intensity was evaluated by hscore and grouped according to menstrual cycle phase. statistical analysis was done with one-way anova. cultured stromal cells isolated from normal endometrium were treated with vehicle, estradiol (e ; - m), or progesterone (p, - m) for and h, and hur expression was determined using western analysis and normalized to ß-actin. results: hur immunostaining was nuclear in endometrial cells. hur immunoreactivity was significantly lower in the early proliferative and late secretory phases ( . ± . and . ± . , respectively), compared to the mid-late proliferative ( . ± . ) and early-mid secretory phases ( . ± . )(p< . ). moreover, hur expression was significantly lower in ectopic endometrial cells when compared to normal endometrium in midlate proliferative and early and mid-secretory phases (p< . ). progesterone suppressed hur levels significantly in cultured endometrial stromal cells at both and h compared to control (p< . ) while estrogen did not cause a significant change. discussion: decreased hur levels in the late secretory and early proliferative phases are likely to contribute to degradation of cytokines and result in lower cytokine levels observed mid-cycle. late secretory decrease in hur levels may be mediated by progesterone as suggested by in vitro findings. in ectopic endometrium, persistent low expression of hur compared to normal endometrium most probably results from elevated cytokine levels associated with endometriosis. the effect of lower hur expression in ectopic endometrium on other are-containing transcripts, and on the pathogenesis of endometriosis remains to be elucidated. tissue. hong zhao, joy innes, scott reierstad, mehmet bertan yilmaz, serdar e bulun. department of obstetrics and gynecology, northwestern university, chicago, il, usa. background: aromatase is the key enzyme for estrogen biosythesis, and is encoded by the cyp a gene. thus far, only three unique untranslated first exons associated with distinct promoters in the mouse cyp a gene were described (brain-, ovary and testis-specific exon i). however, it remains unknown whether aromatase is expressed in other mouse tissues via previously unknown tissue-specific promoters activating new exon is. methods: real-time pcr was used to examine the aromatase expression levels in various c bl mouse tissues. '-rapid amplification of cdna ends ( '-race) was used to determine the transcriptional start sites of cyp a transcripts. promoter activity was measured using serial deletion mutants of dna fused to the luciferase reporter gene. results: real-time pcr results showed that aromatase was expressed in male gonadal fat and the expression level is lower than that in testis. the adipose tissue-specific untranslated exon i of cyp a transcript was isolated using '-race and this novel gonadal fat-specific exon i of cyp a mrna did not show sequence similarities to previously reported ones. this new adiposespecific exon i was mapped to kb upstream of the translation start site in the coding exon ii. the genomic region upstream of the adipose-specific exon i was cloned into luciferase plasmids. transfection of murine t -l cells with these plasmids showed that promoter activity was conferred by the sequence located at - to - bp upstream of the transcriptional start site. dexamethasone significantly induced activity of the adipose-specific promoter region. conclusion: taken together, our results suggest that a novel cyp a transcript is regulated by a tissue-specific promoter in male murine gonadal fat. these sacrificed; reproductive and selected other organs were removed, weighed and evaluated histologically by an observer blinded to treatment. results: the table below shows that tcc augmented effects of tp on weights of accessory sex organs. histological assessment revealed that tcc induced greater glandular distention with more secretions compared to the effects of tp alone; furthermore, mitotic figures were seen only in prostates from rats exposed to tp+tcc. conclusions: tcc is a newly identified endocrine disruptor with unique and novel actions resulting in potentiation of androgen effects on sex organs. these observations underscore possible environmental risks related to exposure to tcc. background: blastocyst implantation is dependent on the differentiation of human endometrial stromal cells (hesc) into decidual cells. transforming growth factor family members have well defined roles in cell differentiation and proliferation. activin a, a tgf superfamily member, enhances hesc decidualization and localizes to decidualized cells in human endometrium. other tgf superfamily members, including bmp , bmp , bmp , gdf , gdf (myostatin), gdf and nodal, may also be present in decidual cells and therefore may also play a role during this important process. this study aimed to determine whether activin is the major family member driving decidualization or whether other family members contribute to the process. methods: broad ranging activin inhibitors (activin-m a and sb ) that effect receptor-ligand interactions of other tgf superfamily members were used in hesc decidualization. protein localization was examined in secretory phase endometrium and first trimester decidua by immunohistochemistry and mrna expression was examined in an ex vivo model. the secretion of candidate proteins was measured during hesc decidualization and certain recombinant proteins added during decidualization to examine their effect. results: m a ( nm) and sb ( m) significantly reduced decidualization ( % and % respectively) demonstrating that activin and possibly other tgf family members are involved in decidualization in vitro. bmp , gdf and tgf protein were detected in decidual cells of mid-late secretory endometrium and first trimester decidua whilst all ligands except nodal, were expressed by hesc. both bmp and tgf secretion increased during hesc decidualization and administration of both these proteins significantly enhanced decidualization in vitro. conclusions: these data support a role for activin a, bmp and tgf in hesc decidualization. this is important as the elucidation of factors involved during decidualization will aid in better understanding implantation and fertility. abnormal chromatin remodeling in diabetic murine oocytes. laura lawrence, ann ratchford, cybill esguerra, qiang wang, kelle moley. ob/ gyn, washington university, st. louis, mo, usa. background: diabetic women experience increased miscarriages and adverse pregnancy outcomes. previous studies suggest adverse diabetic outcomes may occur earlier than the preimplantation period, particularly during oogenesis. we hypothesize that diabetes affects chromatin remodeling and chromosomal condensation in murine oocytes. methods: mii oocytes from diabetic and control mice were fixed with % pfa, permeabilized with . % triton x- for min, and immunostained against a-tubulin and the nucleus for hr at rt. images were obtained with laser confocal scanning microscope. protein expression levels of chromatin with dimethyl h k modifications were measured in nondiabetic and diabetic denuded murine oocytes at hours post pmsg ( hour) and at six hours post hcg ( hour) via western immunoblots. mature nondiabetic denuded oocytes were fixed in %pfa and permeabilized with . % triton x- . they were stained via immunohistochemistry against histone protein h at lysine (h k me ) and heterochromatin. results: immunohistochemistry reveals that diabetic mii oocytes have aberrant spindle formations and metaphase chromosome alignment. approximately / ( %) diabetic oocytes examined had abnormal spindles and metaphase alignments compared with only about / normal oocytes ( . %). western blot demonstrated times higher expression of dimethylated chromatin in diabetic oocytes at time compared with nondiabetic oocytes. at time hours, diabetic oocytes had significantly fewer h k modifications than the controls. when staining mature murine nondiabetic oocytes for dimethylation of h k me by immunohistochemistry, we demonstrated h k me expression in a condensed heterochromatin ring surrounding the nucleolus, consistent with transcriptional silencing. conclusions: diabetic mii oocytes have a significant increase in abnormal spindle formation and metaphase chromosome alignment. they also have increased dimethylation compared with normal oocytes at a time point when they should be transcriptionally active, storing maternal mrna in preparation for the silencing period. in addition, after hcg injection to trigger maturation and gene silencing, the diabetic oocytes had decreased dimethylated chromatin changes. our findings suggest that diabetic oocytes may be exiting the transcriptionally active period prematurely and may ultimately experience decreased, partial, and incomplete gene silencing. and xenopus epab genes and proteins were performed. expression of human epab and pabpc mrna was tested in ten different somatic tissues, testes, and ovaries by rt-pcr. amplification with actin primers provided a positive control and allowed semi-quantitative analysis. epab and pabpc expression in human prophase i (pi) and metaphase ii (mii) oocytes, -cell embryos and blastocysts was evaluated using quantitative real time pcr. results: human epab is a aa protein with % identity and % similarity to mouse epab and contains rna recognition motifs and a pabp domain. human epab mrna is detected in ovaries and to a lesser extent in testes and several somatic tissues including kidney, liver, and muscle. similar to its mouse orthologue, human epab mrna is expressed in pi and mii oocytes, but not in -cell embryos or blastocysts. pabpc mrna is ubiquitously present in all tissues as well as -cell, and blastocyst stage embryos. however, its levels are significantly lower than that of epab in oocytes. conclusions: in this study we report the identification of human epab. similar to that observed in xenopus and mouse, human epab is the predominant poly(a) binding protein in oocytes and it is replaced by pabpc following zga, which occurs at -to -cell stage in human. our findings suggest that the unique translational regulatory pathways that control gene expression during oogenesis and early embryo development may be common between model organisms and humans. objective: c-jun nh -terminal kinase (jnk), a member of mitogen-activated protein (map) kinase family, is involved in cell proliferation, differentiation, and survival. fsh is required for granulosa cell proliferation and antral follicle growth but its mechanism of action in preantral stages is not well defined. we previously showed that pharmacological inhibition of jnk pathway halts invitro growth of murine preantral follicles in serum free media supplemented with fsh ( miu/ml). sigcs (spontaneously immortalized rat granulosa cell line) have characteristics similar to preantral granulosa cells and hence they were used in this study to determine whether the jnk pathway plays a key role in preantral granulosa cell proliferation. our specific aims were to determine whether: a) fsh activates jnk pathway in granulosa cells; b) the inhibition of jnk pathway blocks cell cycle progression. material and methods: sigcs were treated with miu/ml recombinant fsh in serum free media two days after serum starvation. activation of jnk pathway was analyzed with if and wb using phospho-jnk and phospho-cjun expression, respectively. fsh receptor expression (fshr) was analyzed with if. the inhibition of jnk pathway on cell cycle progression was analyzed by facs using a jnk inhibitor sp . results: fshr protein was expressed in sigc indicating that they can respond to fsh (fig a) . likewise by if, phospho-jnk expression was significantly increased in sigc hour post fsh exposure (fig- a) . similarly on wb, phospho-cjun expression increased as early as min after fsh exposure and peaked at hrs. cjun phosphorylation was abolished hr after treatment with sp ( mm) (fig b) . facs analysis showed that the inhibition of jnk by sp resulted in cell cycle arrest at g /m transition in a dose dependent fashion (fig c) . conclusion: these results strongly suggest that the proliferative effect of fsh on immature granulosa cells is mediated through the activation of jnk pathway. this is the first experimental observation implicating jnk signaling in granulosa cell cycle control. (nichd - ). the induction of {alpha}-hydroxylase (cyp ) expression in granulosa cells. satin s patel, victor e beshay, william e rainey, bruce r carr. reproductive endocrinology and infertility, university of texas at southwestern medical center at dallas, dallas, tx, usa; physiology, medical college of georgia, augusta, ga, usa. according to the traditional two-cell two-gonadotropin hypothesis of the ovary, androgen production arises exclusively from theca cells. the granulosa cells, in turn, utilize androstenedione, which is aromatized eventually to estradiol. studies involving immunohistochemical analysis of normal ovaries have shown that granulosa cells express significantly higher levels of the activator protein- (ap- ) transcription factor, cfos compared to theca cells, where cfos expression is virtually absent. we hypothesize that cfos functions to inhibit the expression of cyp in granulosa cells, thereby suppressing androgen production. hence, the inhibition of cfos activity might result in cyp expression in the granulosa cell. our objective was to define the role of cfos, in the regulation of cyp expression in granulosa cells. transformed human luteinized granulosa (hgl ) cells were utilized for all experiments. hgl cells were cultured in monolayer for h. cells were treated for h with and without pd (pd), a mapkk inhibitor, which also blocks cfos expression. rna was isolated and real time rt-pcr was performed for cyp . cfos rna interference experiments were carried out using rnaifect, cfos smartpool sirna and scrambled sirna for h. rna was isolated and rt-pcr was also performed for cyp . immunochistochemical studies were performed on normal ovaries, staining for cfos and cyp . treatment of hgl cells with the mapkk inhibitor pd for h, resulted in a -fold increase in cyp mrna expression compared to basal conditions. in cfos gene silenced cells, cyp mrna expression also increased by -fold compared to control sirna conditions. immunohistochemical staining for cfos and cyp showed significant staining of cfos in the granulosa cell layer, but absent staining for cyp . conversely, the theca cell layer did not stain for cfos, but staining was evident for cyp . these results suggest that the ap- transcription factor, cfos, may play a role in the inhibition of cyp expression in granulosa cells. this may provide an explanation for the lack of cyp expression in granulosa cells. the g /m stages of the granulosa cell cycle. as clip- has been identified as an mtor substrate, we hypothesized that its function at the mitotic spindle would be positively regulated by mtor during the late g and m phases of the cell cycle in granulosa cells. during periods of stress (e.g., mtor inhibition), mtor would fail to phosphorylate clip- , leading to spindle checkpoint failure and follicle undergrowth. objectives: the expression of clip- and mtor were evaluated. computational analysis of potential clip- phosphorylation sites and comparison with residues on known mtor targets were performed. clip- threonine and serine were chosen and evaluated as bona fide mtor phosphorylation sites. a preliminary assessment of the effects of mtor inhibition upon clip- function was performed. methods: for protein expression analyses, western blots, immunostaining of tissues and primary granulosa cells in culture were performed. computational analysis of potential clip- phosphorylation sites was followed by in vitro assessment of mtor kinase activity upon clip- and a peptide substrate. results: clip- was expressed in the ovarian stroma, blood vessels (including the endothelial cells of both arteries and veins), granulosa cells, and in the oocytes of primordial and growing follicles. overlapping expression was found between clip- , mtor, and the mtor cofactors raptor and rictor in granulosa cells. this expression was conserved between the mouse and the human. evaluation of clip- phosphorylation supported thr as a bona fide mtor target. conclusions: clip- was supported as an mtor substrate protein during granulosa cell mitosis. the mechanism of mtor action during granulosa cell growth and survival is likely to include the phosphorylation of clip- and subsequent positive regulation of mitotic spindle function. the effect of a selective oxytocin antagonist (barusiban) in threatened preterm labour: a randomised, double-blind, placebo-controlled trial. steven thornton, thomas m goodwin, gorm greisen, morten hedegaard, joan-carles arce. warwick medical school, university of warwick, coventry, united kingdom; maternal-fetal medicine, university of southern california, los angeles, usa; dept of neonatology, rigshospitalet, copenhagen, denmark; dept of obstetrics, rigshospitalet, copenhagen, denmark; clinical research development, ferring pharmaceuticals, copenhagen, denmark. objective: a mixed oxytocin/vasopressin v a antagonist, atosiban, has been shown to reduce uterine contractions in placebo-controlled clinical trials and is useful in the management of preterm labour. the objective of this study was to determine the effect of a selective oxytocin antagonist, barusiban, in delaying delivery and reducing uterine contractions in women with threatened preterm labour at a late gestational age and relatively high risk of delivery. methods: this was a randomised, double-blind, placebo-controlled multicentre study in countries. a total of women between + and + weeks gestation, and with uterine contractions of sec duration during min, cervical length mm, and cervical dilatation > and < cm were randomised to receive a single intravenous bolus dose of either barusiban . mg, mg, mg, mg or placebo. rescue tocolytics were prohibited. the primary end-point was percentage of women who did not deliver within h. uterine contractions were monitored by cardiotocography. obstetrical and neonatal outcomes were determined. results: there were no significant differences between the placebo and any barusiban group in percentage of women who did not deliver within h ( % in the placebo group and % to % in the barusiban groups). there was no dose-effect relationship nor an effect at or h. none of the barusiban groups were associated with a significant reduction in number of uterine contractions compared to placebo at any time point up to h post-dosing. postpartum blood loss and time to established lactation were not significantly increased with barusiban. barusiban was well tolerated and was not associated with safety concerns for the women, fetus or neonates. conclusion: a single intravenous bolus of a selective oxytocin antagonist, barusiban (dose range . - mg), did not delay delivery or reduce uterine contractions compared to placebo in women with preterm labour at late gestational age and with short cervical length. the results contrast those of the mixed oxytocin/vasopressin v a antagonist, atosiban. prolonged delivery intervals in triplet gestations. tracy a manuck, heather l mertz, leah passmore, david c merrill. obstetrics and gynecology, wake forest university health sciences, winston-salem, nc, usa. objective: delayed interval delivery is one management strategy for previable preterm labor affecting multiple gestations. prior reports of asynchronous deliveries have examined twins and higher-order multiples as a group. this study was conducted to analyze the unique situation of asynchronous triplet deliveries. study design: cases of asynchronous triplet deliveries resulting in an ongoing twin gestation were ascertained through medline. data were abstracted and combined with two similar previously unpublished cases. patients were grouped by management with and without rescue cerclage. variables compared included use of tocolytics, antibiotic administration, gestational age at delivery of each fetus, interdelivery interval, delivery mode, birthweights, and short and long term outcomes. chi-square or t-test analyses were used where appropriate. results: fifty-one cases of asynchronous triplet deliveries met inclusion criteria and were analyzed. twenty-three patients ( . %) underwent placement of a rescue cerclage following delivery of the first infant. these patients delivered the first fetus at a significantly earlier gestational age as compared to those patients without a cerclage ( . +/- . weeks vs. . +/- . weeks, p= . ). patients with a rescue cerclage had a significantly longer prolongation of the remaining twin gestation ( . +/- . days vs. . +/- . days, p= . ). no significant differences in use of tocolytics or antibiotics, gestational age at delivery of triplets "b" and "c," mode of delivery, short term outcome (alive at hours), or long term outcome (alive at discharge) were noted, despite delivery of triplet "a" at a significantly younger gestational age. conclusion: rescue cerclage, particularly when placed following previable delivery of a first triplet, may significantly prolong the delivery interval for the remaining twin gestation. mean pregnancy prolongation (days). objective the aim of our study was to evaluate the role of amnioinfusion in pregnancies complicated by pprom. we studied singleton pregnancies with pprom at < weeks gestation. all patients were managed conservatively with bed-rest, prophilactic antibiotics, tocolytics and steroids. only patients without vaginal bleeding and/or contractions were included: patients showed an amniotic fluid pocket (afp) persistently cm and did not undergo amnioinfusion (group b) whereas had a maximum afp < cm and were offered amnioinfusion to restore an adequate amount of amniotic fluid (group a). in patients of group a amnioinfusion was successful (afp cm for hours following the procedure: group a ) whilst in it was unsuccessful (afp< for hours: group a ) and repeated. results were analized with the student t test for unpaired samples and with the when appropriate. p values < . were considered significant. results the group where amnioinfusion was not successful (group a ) showed the worst outcome (see table) . there were intrauterine deaths, all in this group. pulmonary hypoplasia was present in / ( . %) newborns (both survived and deceased) newborns, / in group a . no maternal complications were recorded. conclusions our data confirm that a conservative-active management with amnioinfusion can be considered a reasonable option in women with pprom. in our series it was effective in preventing both neonatal death and pulmonary hypoplasia. group a (infusion successful) background. synthetic progestogens are effective in reducing the risk of spontaneous preterm birth in high risk singleton, but not multiple, pregnancy. we hypothesized that myometrial stretch may inhibit the response of human myometrium to progestogens. methods. myometrial strips obtained with written consent at the time of term planned cesarean section were studied using a modification of the method of young and zhang (jsgi ; : - ) . strips were maintained in individual tubes in tissue culture media in an incubator for a period of three days. the effect of prolonged stretch was assessed by comparing strips connected to a . g weight with those connected to a . g weight. the effect of prolonged exposure to progestogen was studied by adding medroxyprogesterone acetate (mpa, nm or nm). following the day incubation, myometrial strips were transferred to an organ bath containing kreb's solution. all were placed under g tension and responses obtained to mm potassium then oxytocin. contractility was expressed as the ratio of the maximum response to potassium or oxytocin to the wet weight of the tissue (units = g.tension per gram), summarized as the mean (sem) and compared using student's paired t test. prolonged stretch increased the maximum response to both potassium ( . g weight = . [ . ]; . g weight = . [ . ], n= , p= . ) and oxytocin ( . g weight = . [ . ]; . g weight = . [ . ], n= , p= . ). in strips with a . g weight, incubation in mpa for three days reduced the maximum response to potassium (vehicle = . [ . ]; mpa = . [ . ], n= , p= . ) and there was a trend towards a reduced maximum response to oxytocin (vehicle = . [ . ]; mpa = . [ . ], n= , p= . ). in strips with a . g weight, incubation in mpa for three days had no effect on either the maximum response to potassium . prolonged stretch increases human myometrial contractility in vitro. . prolonged exposure to a progestogen inhibits the contractility of human myometrium but this effect is blocked by prolonged stretch. these properties of human myometrium may explain the failure of oh progesterone caproate to reduce the incidence of spontaneous preterm birth in multiple gestations. sangeeta jain, william l maner, janet l brandon, gary dv hankins, robert e garfield. obstetrics and gynecology, the university of texas medical branch, galveston, tx, usa. objective: to determine if transabdominal uterine electromyography (emg) correlates with parturition factors such as measurement-to-delivery time (mtdt), cervical dilation (cd), cervical effacement (ce), and station (s) for preterm labor patients with and without tocolysis. materials and methods: pregnant preterm labor women were included. uterine electromyography (emg) was measured for minutes. cd, ce, and s were assessed at or near the time of uterine emg measurement. the power density spectrum peak frequency (pdspf) was calculated on emg. patients were grouped (g : tocolysis, n= ; g : no tocolysis, n= ). pearson-product-moment test was used for correlation. significant differences were sought between groups using student-t test. p< . significant. results: there was a significantly higher uterine emg activity (pdspf: . ± . vs. . ± . ), but no difference in cd ( . ± . vs. . ± . ), for patients delivering within days of emg recording compared to those who delivered later, regardless of tocolysis. there was no apparent difference in uterine emg in tocolytic vs. non-tocolytic patients, regardless of mtdt (table ) . conclusions: uterine emg activity is significantly greater in patients in preterm labor who delivered within days of measurement, making it a viable alternative diagnostic parameter for assessing the state of parturition. tocolytics may not affect uterine emg, but this should be further verified with larger studies. supported by grant nih r -hd . objective: calcium sensitizers are a novel class of drugs with unique molecular and phsiological actions. levosimendan, the best characterized of these compounds and is used in the treatment of acute and chronic heart failure. levosimendan can exert an inotropic effect via sensitization of myofilaments to calcium. it also exerts a relaxant effect on vascular smooth muscle through the opening of atp-dependent potassium channels and has been shown to be a potent inhibitor of human uterine contractions in vitro. for these reasons we investigated the effects of levosimendan on uterine contractions, both spontaneous and agonist induced, in the presence of glibenclamide, a k-atp channel blocker. method: biopsies of human myometrium were obtained at elective caesarean section (n= ). dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to glibenclmide ( mmol) followed by cumulative additions of levosimendan in the concentration range of nmol/l to mmol/l. control experiments were performed simultaneously. results: levosimendan exerted an inhibitory effect on spontaneous and oxytocin induced contractions in human m yometrium in vitro, in comparison to control experiments. the effect of levosimendan was significantly antagonized by glibenclamide with the mean maximal inhibition seen due to levosimendan greatly reduced (n= , p< . ). conclusion: the calcium sensitizer levosimendan exerted a potent relaxant effect on human uterine contractility in vitro. this action was antagonized by glibanclamide and this study demonstrates that the effect of levosimendan on uterine smooth muscle is mediated at least in part through the k-atp channel. introduction: the determination of the beginning and ending points for "bursts" of electrical activity occurring during uterine contractions is sometimes difficult. if bursts cannot be discerned, the preferred burst-by-burst analysis cannot be performed. one solution to is to analyze any given electrical recording in its entirety. but this approach has often lead to meaningless results when traditional analytic methods are applied. chaos analysis, using lyapunov exponents, may provide an answer. materials and methods: term patients were included in the analysis: were in labor (group ), while were non-labor (group ). minute recordings were analyzed using "lyapunov exponent." for each pair of subsequent trajectories in phase space, only the most positive lyapunov exponent was calculated. the mean largest exponent was found by averaging over all of the trajectories in the recording. the lyapunov exponent is given in units of bits per data sample. thus a value of + means that the separation of nearby orbits doubles on the average in the time interval between data samples. the mean largest exponent was found for each patient recording. these values were compared using t-test (p < . considered significant). results: the mean and sd of the lyapunov exponent for all the patients was . ± . . moreover, the lyapunov exponent calculated for each patient was positive. comparing lyapunov exponents of the two groups showed a statistically low value (low chaos) for the laboring group, compared to the non-laboring group (figure) . conclusions: there is a chaotic component associated with uterine emg traces, since small but non-negative lyapunov exponents were found in all the traces observed. the lyapunov exponent indicated significantly lower chaotic behavior in the whole emg traces of patients who were in labor than found in those who were not in labor, implying that this measure could be a good diagnostic parameter for labor, possibly eliminating the need for tedious burst-by-burst analysis. supported by grant nih r -hd . comparing uterine emg to tocodynamometer for monitoring contractions. robert e garfield, lynette b mackay, sangeeta jain, william l maner. obstetrics and gynecology, the university of texas medical branch, galveston, tx, usa. objective: to determine whether uterine electromyography (emg) plots contractions similarly to tocodynamometer (toco). study design: pregnant term labor patients were recorded using both uterine emg and toco simultaneously. uterine emg signals were sampled at hz and band-pass filtered in the . to . hz range. root-mean-square (rms) function was calculated from the uterine emg signals in order to produce a "toco-like" trace from the original emg trace. emg-generated rms contraction plots were then compared to toco contraction plots using the following criteria: contractions were assigned a marker value of " ." in-between contraction periods were assigned a " ." from these marker values, contraction rates were established. correlation was found between the contraction rates of rms and toco. temporal overlap of contractions plotted by the two methods was used to find overall percent agreement (opa), positive percent agreement (ppa), and negative percent agreement (npa). these parameters were corrected for within-patient variation using a bootstrap method. results: uterine rms contraction plots were seen to correspond with toco contraction plots (fig. ) . corrected opa, ppa, and npa were high at . %, . %, and . %, respectively. there was a large, statistically significant correlation between uterine emg and toco contraction frequency (fig. ) . conclusions: the similarity between toco and uterine emg contraction plots (specifically, using rms to convert) will allow emg to be used interchangeably with toco in the clinic. supported by grant nih r -hd . introduction -this is a secondary analysis of women participating in a center randomized placebo controlled trial (rct) evaluating the impact of -ohpc in preterm birth (ptb) prevention among women with twins. objective -to evaluate the relationship between plasma -ohpc concentrations and gestational age (ga) at delivery in women with twins receiving weekly injections of -ohpc. methods -women with twins were randomized between - weeks to receive weekly im injections of either -ohpc ( mg) or placebo until weeks. after a minimum of five consecutive injections had been administered to assure steady state concentrations a plasma sample was collected between - weeks. the sample drawn just prior to the next scheduled injection was analyzed for -ohpc by hplc-ms in a blinded manner. the lower limit of quantification of -ohpc was ng/ml. we conducted univariate analyses to assess the association of -ohpc concentration and ga at delivery. we also conducted a proportional hazards model to evaluate the time from sample draw to spontaneous delivery (censoring indicated preterm deliveries), and a logistic regression to evaluate ptb< weeks; in both analyses we adjusted for bmi, race and ga at sample draw. results - women assigned to -ohpc were included; all received all of their scheduled injections. the concentration of -ohpc was significantly higher in women delivering < weeks compared with those women delivering > weeks (p= . , table) . concentration of -ohpc was significantly correlated with ga at delivery (r = - . , p= . ). each unit increase of -ohpc was associated with a % increased odds of delivering < weeks (odds ratio . , % ci, . - . , p= . ) and a % increase in hazard of spontaneous delivery (hazard ratio . , % ci, . - . , p= . ) after adjusting for confounders. gestational age at delivery mean (sd) -ng/ml < weeks (n= ) . ( . ) > weeks (n= ) . ( . ) conclusion plasma -ohpc concentrations after weekly injections were inversely related to ga at delivery in women with twins. since -ohpc induces its own metabolism it is possible that higher concentrations during initial treatment are associated with lower plasma concentrations and reduced efficacy in later pregnancy . clearly more studies are needed. objective: in many non-human species, maternal circulating progesterone levels fall prior to delivery, leading to the theory that in humans progesterone withdrawal occurs on a local and/or functional level. our objective was to characterize maternal and fetal progesterone in human preterm and term labor. methods: women between . and . weeks' gestation (cases) or term controls ( - weeks) with either labor with intact membranes or premature rupture of the membranes prior to labor (prom) were enrolled in a prospective case-control study. progesterone was measured by immulite assay in maternal serum collected upon enrollment and again within minutes after delivery and in umbilical cord serum obtained at delivery. maternal progesterone treatment was not used in any subjects. results: cases and controls were studied (see table for comparisons). controls p value ga at enrollment, weeks . ± . . ± . < . interval to delivery, days (median, range) ( - ) ( - . ) < . maternal progesterone at enrollment, ng/ml ± ± < . maternal progesterone after delivery, ng/ml ± ± . cord progesterone, ng/ml ± ± . among cases, fetal but not maternal progesterone was significantly lower in preterm labor with intact membranes ( ± ng/ml, n = ), as compared to prom ( ± , n = ), p< . . this difference increased further when cases of clinical chorioamnionitis were excluded. conclusions: serum progesterone in laboring patients prior to delivery is higher at term than in the preterm period, which may be attributable to increased placental mass in late pregnancy. this disparity disappears shortly after delivery of the fetus and placenta. fetal progesterone levels are several-fold higher than peripartum maternal levels. preterm labor with intact membranes is associated with diminished fetal progesterone, a phenomenon unrelated to clinical infection. these findings suggest the possibility of fetally regulated progesterone withdrawal as a mechanism underlying preterm labor with intact membranes. [snps] and ptb. however, many of these studies are inconclusive and non reproducible. the challenge of identifying robust associations between genetic variation and either susceptibility or protection from ptb is enormous. a systematic review of literature followed by metaanalysis was performed to understand true associations between snps and ptb. methods: for systematic review, articles were chosen based on medline and embase searches ( ( -april and relevant articles were chosen based on stringent inclusion criteria. primarily, studies reporting genetic associations between snps in maternal dna in singleton pregnancies and spontaneous ptb were included. other criteria included, but not limited to, provided genetic data in a complete enough format so that it could be evaluated in meta-analysis and defined the clinical outcome clearly. meta-analysis was performed wherever > replication data sets were available results: a total of abstracts were reviewed and were selected for full text review. data were extracted from articles. over associations were reported between snps on various candidate genes and ptb; however only had replication dataset. meta-analysis documented significant association between pon a g (odds ratio [or]= . ( %ci . - . ), pon (rs# )(or= . ; ci- . - . ), tnfrsf - a/g (fas) (or= . ; ci- . - . ) and ptb. two snps pon s c (or= . ; ci- . - . ) and ifn gamma (rs ; or- . ; ci- . - . ) documented protective effect. conclusions: systematic review concludes significant heterogeneities leading to lack of reproducible data in genetic association studies of ptb. heterogeneities are contributed predominantly by lack of adequate power, poor phenotype selection, and population admixture. the functional relevance of the risk and protective alleles needs to be verified. jignesh parvadia, mounira habli, jeff livingstone, william polzin, foong lim, timothy crombleholme. pediatric and thoracic surgery, cincinnati children's hospital medical center, cincinnati, oh, usa; obstetric and gynecology, university of cincinnati, cincinnati, oh, usa; obstetric and gynecology, good samaritan hospital, cincinnati, oh, usa. objective little is known about the response of ttts to treatment either by amnioreduction or selective fetospopic laser in triplet pregnancy, particularly the survival of the bystander fetuses. in order to define the response of triplet pregnancies to treatment for ttts we reviewed our experience with higher order multifetal gestations complicated by ttts. study design retrospective chart review of patients diagnosed with in high order gestation from - was performed. results among cases of ttts / ( . %) patients with high order gestations were identified (n= ) with a mean ga at diagnosis of . ± . weeks. pregnancies ( . %) were dichorionic triamniotic and ( . %) were monochorionic triamniotic. cincinnati modification of quinterro staging was utilized to characterize recipient cardiomyopathy as mild (stage iiia, n= ), moderate (stage iiib, n= ) and severe (stage iiic or iv, n= ) categories. / ( . %) were treated with amnioreduction alone (ar), / ( . %) with selective fetoscopic laser photocoagulation (sflp) alone, / ( . %) with ar followed by sflp and / ( . %) with ar followed by intrafetal radio frequency ablation (rfa). / ( . %) patient had a cervical cerclage. / ( . %) patients were treated but remain undelivered. mean ga at delivery was . ± . weeks. overall survival was / ( . %) with bystander survival was / ( %), donor survival / ( . %), recipient survival was / ( . %). conclusion triplet pregnancies treated for ttts have % survival rate for bystander fetuses and have . % survival rates for donor and recipients comparable to twins treated for ttts. ga at diagnosis . ± . weeks cincinnati modification of quinterro (i), (ii), (iii), (iiia), (iiib), (iv) ga at delivery . ± . weeks live birth -donor / ( . %)* # -recipient / ( . %)*# -bystander / ( %) # birth weight -donor to assess the effect of breast feeding (bf) on perinatal outcome in relation to maternal antenatal methadone dose. study design a retrospective chart review study of methadone dependent mother and infant pairs. patients were categorized into groups based on maternal dose at time of delivery: group : dose mg, group : dose - mg, group : dose > mg. the finnegan's scoring system was used to monitor neonatal abstinence syndrome(nas). treatment for nas was initiated if there were scores of . neonatal outcome data included:% nicu admission, % of babies discharged(d/c) at time of maternal d/c, % nas, % treated for nas and total hospital stay. data were analyzed by t-test and fisher's exact test. maternal characteristics between the groups were similar. regardless of maternal methadone dose, bf infants have shorter hospital stays and higher rates of d/c at time of maternal d/c, lower incidence of nas and fewer nicu admission (table) . in all three groups, breast feeding did not impact the severity of nas as reflected in finnegan's score(fs). (table) conclusion regardless of maternal methadone dose, breast feeding improves perinatal objective: to evaluate the effects of preventive collagen plugging of the fetoscopic access port at the time of balloon removal on pregnancy outcome in fetoscopic endoluminal tracheal occlusion pregnancies. study design: fifty-one pregnancies involving fetuses with severe congenital diaphragmatic hernia (cdh) were studied. all patients underwent feto between - weeks gestational age (ga) and fetoscopic balloon removal around weeks ga. at the time of balloon removal, a purified dried collagen plug was inserted through the fetoscopic access port in consecutive pregnancies but not in the first pregnancies considered as controls. all patients underwent post-plugging ultrasound and magnetic resonance imaging studies to evaluate for membrane dehiscence, amniotic fluid volume and fetal well being. ga at delivery, incidence of premature rupture of the membranes (pprom), bleeding at port retrieval and adverse fetal effects were compared in both groups. results: mean (sd) ga at feto [ . ( . ) vs. . ( . ) weeks; p= ns] and balloon removal [ . ( . ) vs. . ( . ) weeks; p= ns] was similar in the treatment and in the control group. incidence of pprom following the second fetoscopy was / in the study group compared to / in the control group (p< . ). mean (sd) ga at delivery was . ( . ) weeks in the study group, compared to . ( . ) in the control group (p= . ). bleeding from the trocar insertion site occurred in cases in both groups, but clinically significant bleeding occurred only in one of the controls. membrane dehiscence was noted in patient in the treatment group compared to in the control group (p=ns). conclusion: preventive collagen plugging of the fetal membrane defect created by the fetoscopic access resulted in a significant reduction in pprom rates and a trend towards increased ga at birth without adverse fetal effects in feto pregnancies. wider application of this technique should be considered, but needs evaluation in larger, randomized trials. hydrops fetalis is an uncommon fetal condition characterised by the abnormal accumulation of fluid in two or more body cavities, traditionally associated with a poor prognosis. the relative rarity of this presentation has meant that published case series have consisted of small numbers. a retrospective review of case notes of all cases managed at kemh between and was performed. in western australia, kemh is the only tertiary maternity hospital incorporating a maternal-fetal medicine unit. cases were obtained from the mfm database. in the period to there was a total of pregnancies affected by hydrops (incidence . per births). the average maternal age was years. in cases a fetal abnormality had occurred in a previous pregnancy. the median gestational age at diagnosis was weeks (range - weeks). in just over half ( %) of cases, the diagnosis was confirmed prior to delivery. a post-mortem was performed on all but of the babies not born alive. edema was present in at least cavities in over half of cases (n= ). chromosomal anomalies included trisomy , trisomy and turners syndrome. in all cases of infection, parvovirus b was implicated. cardiac arrythmias included svt and atrial flutter. cases classified as other included alpha thalassemia and syndromic disorders. in cases an interruption of pregnancy was performed at a mean gestational age of weeks. of those who did not elect to terminate the pregnancy, there were fetal deaths in utero, live borns with neonatal death. for the live borns, the median gestational at delivery was . weeks (range to . weeks). the causes of hydrops in live birth cases included cardiac arrythmia (n= ), infection (n= ), chromosomal abnormality (n= ), unknown (n= ) and other (n= (dmv) have been noted to play a role in the development of hemorrhagic and periventricular leukomalacic lesions in premature babies. since deep vein drainage system is relatively more prominent in the developmental brain than adult brain, we investigated if dmv anomalies could be associated with clastic lesions in-utero. methods two senior neuroradiologists reviewed fetal brain exam performed between and , seeking for unequivocal anomalies in dmv, such as periventricular venular engorgement. all mr scanning is performed at . tesla, using surface abdominal coils and single-shot fast spin-echo t -weighted - mm thick sections, with . - . mm in planar spatial resolution. we found cases with dmv anomalies (tab. ). most of the dmv engorgement is located at frontal lobes level. from this limited preliminary series it appears that dmv involvement plays a role in the development of periventricular leukomalacia and periventricular hemorrhagic necrosis. the observation that these lesions are mostly located at frontal level may suggest that some of the term neonates carrying sequelae of atypically located leukomalacia (i.e. deep frontal lobe) might have developed these lesions in-utero. it is of interest to notice that most of our cases were related to heart failure. therefore, central venous hypertension affecting immature deep cerebral venous system has to be taken into account. in our center, patients with an estimated risk for chromosomal abnormalities at term greater that in after st trimester combined screening test (ft) are offered non-directive genetic counseling. the aim of this study was to evaluate the responses of women younger than attending this genetic counseling session. material and methods: data from patients referred for a positive ft from september , to july , was retrieved from our database. information concerning women younger than years of age at the estimated date of delivery was extracted and tabulated. results: during the study period women had genetic counseling for positive ft. thirteen patients were excluded from further analysis ( had incomplete clinical documentation and had spontaneous miscarriages prior to weeks gestation). four hundred and twenty-five patients were older than and were younger than at the estimated date of delivery. table depicts summary statistics for studied variables in this younger group of women. conclusions: overall this data suggests that approximately % of this younger group of women opted for chorionic villous sampling (cvs), % for amniocentesis and more than % declined prenatal genetic testing. moreover, this data also suggests that: ) these women opted for cvs when the ft risk (mean = in ) almost doubled the cvs procedure related risk quoted at % and, ) when the ft risk is between in and in almost half ( out of ) declined not only the st trimester cvs but also the nd trimester amniocentesis. we believe that understanding our patient population is important to optimize both the efficiency and efficacy of the alternative prenatal screening programs. acceptance for prenatal genetic testing after a positive first trimester combined screening test in women of less than to determine the optimal diagnostic test using prenatal ultrasonography and mri for predicting pulmonary hypoplasia in fetuses with congenital diaphragmatic hernia. methods: relevant papers were identified by searching medline ( medline ( - , embase ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and the cochrane library ( issue ). in addition, the specialist literature on the topic and reference lists were hand searched for relevant articles. studies were selected if they examined diagnostic tests for the prenatal prediction of pulmonary hypoplasia in fetuses with congenital diaphragmatic hernia. the primary outcome measure was perinatal survival. study selection, quality assessment and data abstraction were performed independently and in duplicate by separate observers. results: of a total number of articles (published studies), there were eighteen studies that fulfilled the entry criteria. six examined entirely unique heterogeneous parameters. of the remainder, all examined the ultrasound measurement of lung to head ratios (lhr) at a 'cut-off of greater than or less than the thresholds of . , . , . , . . in addition, the presence of liver in the fetal thorax was included (if present) as a co-variable (liver "up"). a lhr > . compared to < . provided the strongest association with perinatal survival (peto or . , % ci . - . ). the finding of "liver up"in the fetal thorax had a negative association with survival (peto or . , % ci . - . ). only three studies provided data for lhr in conjunction with the presence of liver in the fetal thorax (peto or survival for lhr > . compared to < . was or . , % ci . - . ). data was also available for liver up and lhr > . which had a peto or of . ( % ci . - . ). discussion: the data supports the view that lhr may be a useful prognostic indicator of perinatal survival in fetuses with congenital diaphragmatic hernia. however, heterogeneity still exists regarding the timing of ultrasound measurement and the use of mri. the majority of studies have small sample sizes. objective: to estimate, in fetal anaemia, the diagnostic value of fetal ultrasonography and doppler blood flow in the evaluation of fetal anaemia methods: literature from to was identified using medline and embase, the cochrane library and relevant specialist register of the cochrane collaboration, and by checking reference lists of known primary studies and review articles. studies were selected if the accuracy of the fetal ultrasound parameters or doppler studies of blood flow in the fetal vessels was estimated compared with a reference standard. diagnostic tests evaluated were ultrasound measurement of the fetal spleen and liver length and doppler studies from the umbilical vein and middle cerebral artery. data from the selected studies were abstracted as x tables comparing the diagnostic test result with the reference standard. results were pooled where appropriate. diagnostic accuracy was expressed as sensitivity and specificity. twenty-nine primary studies were identified containing suitable data. twentyone of these gave data on middle cerebral artery doppler peak systolic velocity (mca-psv) and could be pooled in the meta-analysis giving a sensitivity of . ( . - . ) and a specificity of . ( . - . ) for cases in detecting severe anaemia. four studies gave data on spleen perimeter and it was possible to pool three of these giving a sensitivity of . ( . - . ) and a specificity of . ( . - . ) for cases. three studies had data for liver length measurements and two were pooled. the sensitivity was . ( . - . ) and the specificity was . ( . - . ) but only cases were used in the analysis. there were three studies on umbilical vein maximum velocity doppler studies and all were suitable for meta-analysis giving a sensitivity of . ( . - . ) and a specificity of . ( . - . ) with cases analysed. two studies gave data on middle cerebral artery time-averaged mean velocity score giving cases. the sensitivity was . ( . - . ) and specificity was . ( . - . ). discussion: middle cerebral artery peak systolic velocity dopplers remain the gold standard for non-invasive screening of fetal anaemia. middle cerebral artery time-averaged mean velocity scores require further investigation. other tests perform poorly when diagnostic accuracy is assessed. cochrane review of treatment in twin to twin transfusion syndrome. twin-twin transfusion syndrome is a condition affecting monochorionic twin pregnancies associated with a high risk of perinatal mortality and morbidity. the objective of this review was to evaluate the impact (maternal,fetal and pediatric)of treatment modalities in twin-twin transfusion syndrome. register and cochrane controlled trials register. we also searched conference proceedings and made personal contact with experts active in the area of the review. randomised and quasi-randomised studies of amnioreduction versus laser coagulation, septostomy versus laser coagulation or septostomy versus amnioreduction. eligibility was assessed by one reviewer. study authors were contacted for additional information. two studies were included. this review shows that laser coagulation of anastomotic vessels results in less fetal (rr . ; % ci . , . ) and neonatal deaths (rr . ; % ci . , . ) than amnioreduction ( figure ). there is no difference in perinatal outcome between amnioreduction and septostomy. more babies in the laser arm are alive without neurological abnormality at six months of age (developmental delay at < years rr . , % ci . , . )( figure ). conclusions: endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of twin twin transfusion syndrome to improve perinatal outcome. further research on the effect of treatment on milder forms of twin twin transfusion syndrome (quintero stage and ) are required. (produced in collaration with the cochrane collaboration, uk). (cvs) concluded that although the risks of pregnancy loss are relatively low, lack of adequate controls tends to underestimate the true added risk of prenatal invasive procedures (obstet gynecol. ; ( ): - ). the west midlands is a large region within the uk containing approximately % of the total uk population. the congenital anomaly register for this region is able to monitor pregnancy outcomes with accurate deminator data. results: there were first trimester cvs performed, by ten operators, in the west midlands (uk) in . this equates to . procedures per births. significantly higher rates were noted in areas of high socioeconomic status. the median number of procedures performed per operator was (range - ). all operators were performing other invasive tests such as amniocentesis or cordocentesis,etc. the most common indication for cvs was: i) fetal anomaly on dating scan ( . %) ii) abnormal (> in ) risk on combined first trimester screening ( . %) iii) molecular genetic diagnosis ( . %) and iv) maternal request ( . %). using a combination of first trimester scanning and cvs, % had abnormal karyotype/structural anomaly.the corrected loss rate (background and procedure-related) following cvs in normally formed, singleton pregnancies was . % ( thci . - . %) up to days postnatal (perinatal loss) and . % ( thci . - . %) with days of procedure. the proportion of cvs in which an adequate sample was not obtained was . % ( th ci . - . %). conclusions: this epidemiological study using accurate demoninator data provide interesting statistics relating to the uptake and prenatal risks of first trimester cvs. with the increasing prevalence of obesity in the last two decades, we have seen a tremendous increase in bariatric procedures in reproductive aged women. malnourishment and vitamin deficiency are common complications after gastric bypass which may impact on fetal development. we present the case of a yo who underwent a duodenal switch procedure in . she was discovered to be pregnant during evaluation for persistent malnutrition in . multiple prenatal ultrasounds were performed; the first at weeks gestation was unremarkable. the week sono revealed a male fetus with shortened femurs and humeri bilaterally, nasal bridge hypoplasia, macroglossia, poorly defined hands, and possible clubbed feet. amniocentesis revealed a normal karyotype. d ultrasound redemonstrated the abnormal facial findings. a fetal echocardiogram was normal. the lagging long bone measurements continued to worsen, ultimately with femurs weeks behind. the fetal thoracic circumference was two standard deviations below the mean, giving rise to concern for pulmonary sequelae. growth restriction was noted at the wk sonogram. delivery by cesarean section was at / weeks secondary to nonreasuring fetal status. the birthweight was gm; apgars were , , and . postnatal radiographs confirmed antenatal ultrasonographic findings and demonstrated evidence of epiphyseal stippling. the infant remained intubated until weeks of life, after which it died secondary to respiratory complications associated with pulmonary hypoplasia. gene mapping studies have not found any point mutations on the recessive gene as an etiology of this disorder. rhizomelic chondrodysplasia punctata refers to a heterogeneous group of bone dysplasias with a familiar radiographic phenotype involving punctate calcifications and epiphyseal stippling. the etiology of this may be secondary to chromosomal abnormalities, mendelian gene disorders, or teratogens, notably warfarin. this case may be explained by vitamin k deficiency of the embryo due to maternal malabsorption after bariatric surgery. the maternal vit k level was <. ng/dl at time of delivery(normal > . ). the teratogenic effects of vitamin k deficiency in this instance highlight the need for strict counseling and screening for vitamin deficiency in those women undergoing bariatric surgery since previous obesity-related anovulation is reversed as patients lose weight, resulting in unexpected pregnancies and potentially preventable fetal abnormalities. term preeclampsia: any risk for the neonate? sindhu k srinivas, jamie bastek, christina m andrela, emmanuelle pare, michal a elovitz. obstetrics and gynecology; crrwh, university of pennsylvania, philadelphia, pa, usa. introduction: preeclampsia continues to be a major contributor to maternal morbidity and mortality worldwide. preeclampsia at term is not associated with the same risk of neonatal morbidty and mortality as preterm preeclampsia . however, neonatal outcomes in term women with preeclampsia have not been adequately studied. we sought to compare short term neonatal outcomes in term infants born to women with and without preeclampsia. methods: this study was part of a large case control study. women with preeclampsia (n= ) and term controls (n= ) were prospectively identified. infants with congenital anomalies were excluded. hospital length of stay (los), admission or transfer to the nicu, and use of mechanical ventilation or cpap within first week of life were assessed. associations between neonatal outcomes and preeclampsia were evaluated using chi-square analysis and wilcoxon rank sum test. significant confounders were controlled for using multivariable logistic regression. results: discharge day of life was significantly different between neonates born to women with preeclampsia (median = ; mean = . ) versus those born to women with uncomplicated term deliveries (median = ; mean = . , p< . ). this difference persisted even when neonates with iugr and those born to diabetic mothers were excluded (p< . ). term infants born to women with preeclampsia have a higher odds of being admitted or transferred to the nicu (aor= . [ . - . ], p= . ) after controlling for iugr, delivery mode, race, and gestational age at delivery. these infants also have a higher odds of mechanical ventilation (aor= [ . - . ], p= . ) and cpap use (aor= . [ . - . ], p= . ) after controlling for the same confounders. there was no difference in ivh or nec between the two groups. conclusion: neonates born to women with preeclampsia have differences in short-term morbidity when compared to neonates born to women without preeclampsia, despite being born at term. whether this increase in neonatal morbidity is attributable to medications used in preeclampsia, such as magnesium sulfate, is unclear. these findings may have implications for patient counseling as well as hospital resource allocation. further investigation correlating these findings with long-term morbidity is warranted. could confined placental mosaicism account for adverse perinatal outcomes in ivf pregnancies? benoit c jacod, gh schuring-blom, kd lichtenbelt, jse laven, d van opstal, mjc eijkemans, nick s macklon. reproductive medicine gynaecology, university medical centre, utrecht, netherlands; clinical genetics, university medical centre, utrecht, netherlands; obstetrics gynaecology, erasmus medical centre, rotterdam, netherlands; clinical genetics, erasmus medical centre, rotterdam, netherlands. background: ivf singletons have poorer perinatal outcomes than singletons from spontaneous conceptions. this may be due to the influence of ovarian stimulation on the chromosomal constitution of the embryos which could be translated into localized chromosomal anomalies in the placenta. aim: to compare the incidence of confined placental mosaicism (cpm) in ivf/icsi pregnancies and spontaneous conceptions. methods: multicentre retrospective analysis of karyotype results obtained by chorionic villus sampling (cvs) performed because of advanced maternal age ( years at weeks of gestation) in the netherlands between and . results: from a total of pregnancies, cvs results were analysed: in the ivf/icsi group and in the control group. the mean age of women in both groups was . years (mean difference - . , % ci - . - . ). foetal karyotype was missing in cases of possible cpm, all in the control group. when taking into account missing data, the incidence of cpm was lower in the ivf-icsi group than in the control group, . % vs. . % (odds ratio . , % ci . - . ) whereas the incidence of foetal chromosomal anomalies was increased . % vs. . % (odds ratio . , % ci . - . ) although both differences are not significant. conclusions: the incidence of confined placental mosaicism is not increased in ivf/icsi pregnancies compared to spontaneous conceptions. cpm probably does not account for the adverse perinatal outcomes following ivf/icsi. fetal rh d, cc and ee genotyping using fetal dna from maternal blood is not impaired by the presence of maternal alloimmunization. chad a grotegut, stacey l jeronis, john p gaughan, enrique hernandez, ossie geifman-holtzman. obstetrics and gynecology, duke university, durham, nc, usa; obstetrics, gynecology and reproductive sciences, temple university, philadelphia, pa, usa; biostatistics, temple university, philadelphia, pa, usa. this study was conducted to assess the impact of maternal alloimmunization on the accuracy of fetal rh d, cc and ee genotyping from maternal blood. we performed a literature search of english-written articles describing fetal rh d, cc and ee determination from maternal blood (am j obstet gynecol ; : - ) . using this database, we determined the accuracy of rh d, cc and ee genotyping in the presence of maternal alloimmunization. for each subgroup, % confidence intervals for a proportion were calculated and compared between groups. we found english-written publications reporting non-invasive rhd genotyping and reporting non-invasive rh ce genotyping from maternal blood. fourteen ( . %) of the rh d articles and three ( %) of the rh ce articles provided accuracy results in the setting of alloimmunization. the accuracy results are reported as follows: . % of the samples were determined correctly in the presence of alloimmunization.* this accuracy was significantly lower than the accuracy reported for all rh cc samples. when only studies utilizing free fetal dna for rh cc genotyping were used (vs fetal cells), fetal cc genotype was determined correctly in / ( %, % ci . , ), which was similar to the overall success rate for rh cc determination. overall, there were no differences in the success of rh d, cc or ee determination in the setting of alloimmunization compared to the overall accuracy seen when free fetal dna was used. the presence of maternal alloimmunization does not reduce the accuracy of fetal rh d, cc or ee non-invasive genotyping from maternal blood utilizing free fetal dna. further research into structure and rearrangements of the rh d, cc and ee genes may further improve diagnostic accuracy of free fetal dna from maternal blood. fetal dna, most likely of trophoblast origin, is present in both the plasma of pregnant women and provides a potential basis for non-invasive fetal diagnostic tests. however, fetal dna in maternal plasma is highly contaminated with maternal dna, and this contamination is the main technical challenge in trying to accomplish non-invasive detection of fetal chromosome abnormalities. existing methods for the selective amplification of fetal dna have generally relied on specific sequence differences between the mother and fetus. as an alternative, we have developed a method for selective amplification of fetal dna that makes use of observation that trophoblast dna is globally hypomethylated in comparison with dna from other sources. in this method, a dna mixture is first digested with a methylation sensitive restriction enzyme and then amplified by linker-mediated pcr. after an initial amplification, a second isothermal rolling-circle amplification is performed. this procedure results in the differential amplification of short, relatively hypomethylated fragments. after amplification, the resulting "representations" are comparatively hybridized to a microarray consisting of oligonucleotides that correspond to restriction fragments generated by the initial digest. copy number differences are then detected through statistical analysis of array addresses that show significant amplification. to test the feasibility of this method for detecting aneuploidy, we have prepared mixtures of peripheral blood dna and first trimester trophoblast dna from either normal or from samples with trisomy and trisomy . we present data showing that aneuploidy can be detected even when % of the starting dna sample was derived from a euploid source and only % was from an aneuploid trophoblast sample. two different approaches to data analysis are presented. one relies on prior analyses of trophoblast methylation and the second is independent of any prior knowledge or analysis. both methods provide similar ability to detect aneuploidy. future work will focus on testing whether this approach can be used for non-invasive prenatal diagnosis. chromatin immunoprecipitation and emsa analysis of nf-b and c/ ebp synergism on the otr promoter. shirin khanjani, yun s lee, vasso terzidou, mark r johnson, phillip r bennett. institute of reproductive developmental biology, imperial college, london, united kingdom. we have shown, the transient transfections of the transcription factors nf-bp and c/ebp leads to a synergistic increase in otr promoter activity in human myocytes. this effect is mediated through a bp region of the promoter between - to - from tss. we now report that this sequence binds both nf-bp and c/ebp in vitro and chip studies show binding of both transcription factors to be increased by il- in vivo. materials and methods: emsa studies were performed using a bp oligonocleotide sequence (- to - ) , containing the bp region responsible for the synergistic activation of the otr promoter and nuclear extracts from primary human myocytes treated with il- ng/ml for hours. for chip analysis, dna protein complexes were crosslinked and antibodies recognizing p , c/ebp and h (positive control) and igg (negative control) were used for immunoprecipitation. primers were designed to amplify the region - to - , which includes the bp response sequence. to further confirm the interaction between nf-bp with c/ebp a xnf-b consensus/luc reporter construct was cotransfected with an expression vector for either nf-bp or c/ebp . results: specific nf-bp and c/ebp binding was seen in the emsa study. preincubation with antibodies to nf-bp and c/ebp led, not to supershift, but to elimination of dna binding for both nf-kb p and c/ebp . chip analysis confirmed increased in vivo binding of nf-b p and c/ebp to this region of the otr promoter following stimulation with il- . transfection of the nf-b/luc reporter construct with an expression vector for c/ebp caused a significant reduction in the basal promoter activity suggesting that c/ebp is binding to nf-kb. this interaction was further confirmed using a tf-tf interaction array. conclusion: these data support the role of nf-b and c/ebp in regulation of otr. the bp region contains a c/ebp but not a nf-b dna binding site suggesting that c/ebp primarily binds to this part of the otr promoter but also interacts with nf-b. the emsa data shows that the bp region binds both nf-b and c/ebp . the loss of the supershift observed in previous emsa studies suggests that the antibodies inhibit the interaction between c/ebp and nf-b, therefore inhibiting dna binding. chip analysis supports the concept that il- leads to binding of nf-b and c/ebp to the bp region. regulation of pro-labour genes by c/ebp, nf-b and ap- in human uterine myocytes. suren r sooranna, shirin khanjani, yun s lee, phillip r bennett, mark r johnson. imperial college parturition research group, imperial college, london, united kingdom; irdb, imperial college, london. introduction: the transcription factors c/ebp (lap), nf-b (p ) and ap- (c-fos and c-jun) are implicated in inflammatory processes such as parturition. the promoter regions of the pro-labour genes il- , pghs- and otr contain putative transcription factor-binding sites for these transcription factors. our aim was to determine the effect of transfecting these transcription factors either alone or in combination into uterine myocytes and to determine their effects on the expression of pro-labour genes including il- , pghs- , otr, connexin- and fp. methods: primary cultures of human uterine myocytes (n= ) were grown from myometrial samples obtained at the time of elective lscs. cells were cultured in well plates to % confluence at which point expression constructs for c/ ebp (lap), nf-b(p ), ap- (c-fos and c-jun) were transfected either alone or in different combinations. the empty expression vector psg was used as a filler construct. cells were cultured for and h after which culture medium was collected for elisa and cells frozen at - °c prior to rna extraction. copy numbers of il- , pghs- , otr, fp, connexin- and gapdh were measured by qpcr using a rotor-genetm (corbett research). results: h post transfection with c/ebp (lap), nf-b (p ), c-fos and c-jun alone or in combination showed no significant changes in pghs - , otr and connexin- expression. over expression of p alone or together with either c-fos or c-jun increased fp expression by , and % respectively (p= . ). nf-bp consistently increased il- expression either alone (by %; p= . ) or in combination with lap, c-fos or c-jun (by , and % respectively; n= ; p= , ). rel a, lap, c-fos and c-jun together also increased il- expression (by %; p= . ) and a small but significant increase was seen with a combination c-fos and c-jun (by %; p= . ). the changes observed in il- expression were reflected in the medium il- concentration at h post transfection. in the presence of rela and c-fos il- increased from . ± . to . ± . pg/ml of culture medium (mean ± sem; n= ). conclusions: nf-b (p ) consistently increased fp and il- expression in human myometrium. the data suggest that pghs- activation has greater dependence upon other transcription factor(s) in addition to p . true identity of myometrial pr-c: fact or fiction? yun s lee, suren r soorana, mark r johnson, jan brosens, phillip r bennett. imperial college parturition research group, hammersmith campus, london, united kingdom. progesterone is thought to be central to maintenance of pregnancy. multiple progesterone receptor (pr) isoforms underlie complex and diverse biological action of progestins. previously two human pr isoforms have been identified: pr-b and pr-a. pr-a is n-terminally truncated form of pr-b (initiation site methionine ). in some cells pr-a inhibits pr-b. it has been proposed that increased expression of pr-a in myometrium underlies a 'functional progesterone withdrawal'. the breast cancer cell t d contains a kda progestin-specific binding protein that is not found in pr negative cells. it was proposed that there is a downstream methionine (met ) which serves as a translation initiation site for the generation of a pr isoform of kda. based on such findings condon et al (mol endo ) have focused on the possible role of kda pr-c in human parturition. they found that expression of "pr-c" using pr antibody (sc- santa cruz, sc) is increased in upper segment myometrium with labour and that overexpression of this protein inhibits pr-b function. we cloned the same human pr cdna into psg expression vector. in vivo translation produced a protein of only kda. furthermore overexpression of pr-c did not significantly decrease pr-b activity in human myocytes. we examined other downstream initiation sites, which may produce a kda protein. we constructed potential pr isoforms in psg vector with initiation sites at met and . in vivo translation produced proteins of approximately and kda respectively. to determine the effect of pr isoforms on pr-b function, myocytes were co-transfected with pr-a, pr-c , pr-c and pr-c with constant amounts of pr-b. the progesterone dependent pre/luc was used as reporter. unlike pr-c both pr-c and pr-c significantly inhibited ligand dependent pr-b mediated transcriptional activity. we found in western analysis that the antibodies pgr- (nc) and the sc- (sc) detected both endogenous and overexpressed pr-a and pr-b but none of the pr-c isoforms. the sc- antibody detected only pr-a and pr-b very poorly. our data suggests that the sc- antibody would not detect any pr-c protein and that none of the commercially available antibodies in the uk do so. great care needs to be taken when over-expressing pr isoforms to ensure that proteins are of the expected size. if pr-c does exist in vivo then the kda but not the kda isoform might inhibit pr-b function. tnf receptor antibody (tnf ri ab), nf-b inhibitor (nf-b activation inhibitor) and erk inhibitor (u ) (p< . ), but not by tnf receptor antibody (tnf rii ab), p mapk inhibitor (sb ) and jnk inhibitor (sp ). by western blot analysis, we found that the protein level of tnf receptor associate factor (traf ) was higher than that of tnf receptor associate factor (traf ) (traf >traf ) in untreated ct cells. however, after tnf treatment for h to h, traf protein level was increased, but traf protein level was reduced (traf >traf ). the increase of traf and decrease of traf were blocked by tnf ri ab, but not by tnf rii ab. we also found that tnf rapidly (within - min) and significantly increased phosphorylation of ikk , erk / and jnk / / and the phosphorylation of these protein kinases by tnf was reduced significantly by tnf ri ab, but not by tnf rii ab. moreover, we found that the changes of increased traf and decreased traf in ct cells (traf >traf ) resulted in a dramatic deficiency in phosphorylation of the above protein kinases induced by tnf compared with the normal ct cells (traf >traf ). nuclear localization of nf-b p in tnf treated cells was increased compared to untreated controls. conclusion: we have demonstrated for the first time that tnf stimulates mmp- production in ct cells through tnf ri-trafs-ikk /erk-nf-b signaling pathways, but not through the jnk/p -ap- pathway. these studies reveal steps within this pathway as possible therapeutic targets to inhibit mmp- expression potentially attenuating tnf -induced degradation of extracellular matrix and pre-term rupture of the fetal membranes. objective: women with preterm birth are at elevated risk of cardiovascular disease, but mechanisms that might relate these conditions are not understood. we hypothesized that women with spontaneous preterm vs. term births may have early gestation evidence of activation of the fibrinolytic cascade, as measured by the thrombin-antithrombin iii (tat) complex. we also tested if this relation may be associated with inflammation. methods: tat was measured in plasma collected < weeks gestation (mean . weeks, sd . ) among women without chronic medical conditions, preeclampsia or growth restriction who delivered singleton liveborn infants. inflammation was assessed by c-reactive protein (crp) measured in serum from the same samples. women with spontaneous preterm birth (sptb) < weeks (n= ) and -< weeks (n= ) were compared to women with term births >= weeks (n= ). high tat was defined as > . ng/ml (highest quartile among women with term births) and high crp was defined as >= ug/ml. multinomial logistic regression was utilized to relate elevated tat and inflammation to risk of sptb subtypes. results: women with sptb were more likely to have tat concentrations in the highest quartile compared to women with term births (< weeks, . %; -< weeks, . %; >= weeks . %, p< . ). women with high tat concentrations had a . -fold ( % ci: . - . ) increased risk for sptb < weeks, after adjustment for body mass index, race, age and gestational age at sampling. there was no relation between high tat and sptb -< weeks (or . , % ci . - . ). additional adjustment for elevated crp (>= ug/ ml) did not effect the estimates associated with tat, and elevated crp was independently related to risk for both sptb subtypes (< weeks, or . [ . - . ]; -< weeks, or . [ . - . ]). thus, women with high tat and elevated crp appeared to be at particularly elevated risk of sptb < weeks (or . , % ci . - . ). conclusions: the thrombin-antithrombin iii complex was elevated early in gestation among women with sptb < weeks, perhaps secondary to microvascular injury. this effect was independent of inflammation, suggesting that the elevated fibrinolytic cascade may function independently from inflammation among women with sptb. plasma cortico-releasing hormone and cortisol concentrations and psychological stress among pregnant women. katherine p himes, hyagriv n simhan. obstetrics and gynecology, university of pittsburgh medical center, magee womens hospital, pittsburgh, pa, usa. objective: many studies have found an association between psychological stress and preterm birth. we sought to determine if women with greater psychological stress during pregnancy had higher concentrations of plasma cortico-releasing hormone (crh) or cortisol. study design: this is a secondary analysis of a multicenter case-control study, nested within an observational cohort. of , participants, plasma crh and cortisol concentrations at and weeks gestation were available in controls who delivered after weeks and cases who delivered before weeks. the abbreviated scale for the assessment of psychosocial status in pregnancy (asaps) was available for all women. concentrations of crh and cortisol were compared between women above and below the lowest quartile score on the asaps among cases and controls. the same analysis was done for the portion of the scale related to psychological stress. concentrations of crh and cortisol and psychological stress were also compared between black and non-black cases and controls. univariate analysis was performed with kruskal wallis or chi-square. results: there was no difference in crh or cortisol concentrations at or weeks among women above or below the lowest quartile on the asaps (controls:p= . - . cases:p= . - . ). greater psychological stress was not associated with higher concentrations of crh or cortisol at or weeks(controls:p= . - . cases:p= . - . ). crh concentrations were not different between blacks and non-blacks. among both cases and controls, cortisol concentrations at and weeks were lower in black women than non-black women (controls:p< . cases:p< . ). the median cortisol concentration among control black women was . g/ml at weeks compared to . g/ml among non-black women and . g/ml compared to . g/ml at weeks. black women reported less psychological stress than non-black women (p= . ) conclusion: we found no relationship between psychological stress and plasma crh or cortisol. furthermore, while stress is hypothesized to play a role in the racial disparity of preterm birth, black women reported less psychological stress and had lower cortisol concentrations than non-black women. improved assessments of psychological stress and additional biomarkers involved in the stress response may broaden our understanding of how stress contributes to preterm birth. expression, tissular traffic and activation of mmp- in human fetal membranes during labor. rodrigo vega-sanchez, arturo flores, marisol castillo, nardhy gomez, felipe vadillo-ortega. direction of research, instituto nacional de perinatologia, mexico city, df, mexico. introduction. rupture of the fetal membranes (fm) during human labor occurs as a consequence of extracellular matrix degradation. this process is controlled by increased secretion and activity of matrix metalloproteinases, particularly mmp- .several evidences suggest that mmp- is mainly produced by infiltrating choriodecidual leukocytes that could arrive from placental circulation. characterization of the synthesis, transport and activation of mmp- within the fm is critical to understand the process of membrane rupture during human labor. objectives. expression and secretion of mmp- in placental leukocytes, trafficking of the enzyme through the fm and one possible mechanism for its activation were analyzed. methods. leukocytes were isolated from placental blood of women after active labor. maternal leukocytes were used as controls. cells were cultured for h. relative expression of mmp- by rt-pcr and enzyme secretion by elisa and zymography were followed at different times. to analyze the traffic of mmp- through the fm, fluorescein-conjugated prommp- was added to the choriodecidual side of the fm in an in vitro system that allows the separation of amnion and chorion. labeled mmp- was localized at distinct times by confocal microscopy. the protease responsible for the activation of mmp- was identified using neutralizing antibodies and specific inhibitors. results. no difference in the relative expression of mmp- in leukocytes throughout the culture was found. however, secretion of the enzyme significantly increased since h (p< . ). experiments using labeled mmp- , repeatedly showed that after h in culture, the enzyme was mainly localized within the amniotic epithelium. specific inhibition of mmp- significantly decreased the activation of pro-mmp- . conclusions. our results demonstrate that the increased secretion of mmp- by placental leukocytes is not associated to increased gene expression, suggesting that homing of a specific leukocyte subpopulation to the choriodecidua is occurring during labor. mmp- can be trafficked from the choriodecidua to the amnion, suggesting a transmembranal pathway that may regulate the tissular localization of the enzyme to the area of the fm with high content of connective tissue. once secreted by the placental leukocytes, activation of mmp- depends mainly on mmp- , which seems to be derived from the same leukocytes. objective: preterm labour is a major problem in terms of perinatal morbidity and mortality. the histone-deacetylase inhibitor (hdaci), trichostatin a (tsa) has been shown to have an inhibitory effect on myometrial contractility. the aim of this study was to evaluate the effect of the hdaci's suberic bishydroxymate (sbha) and valproic acid (vpa) on human uterine contractions and hence their potential role as tocolytic agents. methods: biopsies of human myometrium were obtained at elective caesarean section (n= ). dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to cumulative additions of sbha in the concentration range of nmol/l to mmol/l and vpa ( nmol/l- mmol/l). control experiments were run simultaneously. results: sbha and vpa exerted a potent and cumulative inhibitory effect on spontaneous and oxytocin-induced contractions, compared to control strips. the mean maximal inhibition (mmi) values for sbha were . % for spontaneous contractions (n= ; p< . ), and . % for oxytocin-induced contractions (n= ; p< . ). the mmi values for vpa were . % for spontaneous contractions (n= ; p< . ), and . % for oxytocin-induced contractions (n= ; p< . ). conclusion: these results raise the possibility that hdaci's may have tocolytic potential, in addition to their current clinical indications. the inhibitory effect observed may be linked to the ability of hdac inhibitors to induce the expression of genes involved in the maintenance of myometrial quiescence via epigenetic mechanisms but may potentially also involve non-epigenetic pathways. progestin suppresses thrombin-enhanced interleukin- expression in term decidual cells: implications for abruption-induced preterm delivery. edward kuczynski, lynn f buchwalder, frederick schatz, charles j lockwood. obstetrics/gynecology reprod. sciences, yale university school of medicine, new haven, ct, usa. background and objective: decidual hemorrhage (abruption) promotes binding of factor vii to decidual cell (dc)-expressed tissue factor to generate thrombin. thrombin in turn induces several biological effects leading to preterm delivery via activation of cell surface protease-activated receptors (pars). interleukin- (il- ) is a pleiotropic proinflammatory cytokine induced by pars. this study assessed the separate and interactive effects of thrombin and medroxyprogesterone acetate (mpa) on il- expression in term dcs. methods: term decidua from stripped fetal membranes were isolated and the dcs were purified on a percoll gradient, grown to confluence and passaged until leukocyte-free. confluent dcs were primed in - m estradiol (e ) of e + - m mpa for days, then incubated in a defined medium (dm) with corresponding steroids ± thrombin. after hours, il- levels in conditioned dm were measured by elisa and western blotting. in parallel -hour incubations, il- mrna levels were assessed by quantitative rt-pcr and normalized to -actin mrna. results: secreted il- levels were similar in cultures maintained in e alone ( . ± . ) and e + mpa ( . ± . pg/ml/ug protein; mean ± sem; n = ). the addition of thrombin ( . u/ml) enhanced secreted il- levels by . ± . fold (p< . ) in incubations with e and by . ± . -fold (p< . ) in incubations with e + mpa. the inhibitory effect of mpa was statistically significant (p< . ). in confluent dcs incubated with e + mpa, exogenous thrombin ( . - . u/ml) elicited a concentration-dependent increase in secreted il- levels. hirudin acted as a pure thrombin antagonist, exerting no agonist effects alone, but counteracting thrombin-enhanced il- secretion. western blotting confirmed the elisa results. quantitative rt-pcr confirmed that il- m-rna levels corresponded to protein changes. conclusion: thrombin enhances il- mrna and protein expression in term dcs and progestin blunts these effects. since thrombin-generating abruption is closely associated with preterm delivery, anti-inflammatory effects induced by progestin inhibition of dc-derived il- may contribute to the protection against ptd, and may explain the reported protective effects of administration of -oh-progesterone in recent clinical trials. introduction: catechol-o-methyltransferase (comt) catalyzes the methylation of the phenolic hydroxyl groups in a variety of catechols. during estrogen metabolism, this enzyme converts the catechol estrogen, -hydroxyestrogen ( ohe ), to -ethoxyestrogen ( meohe ). the comt substrate, -ohe , can exhibit an anti-estrogenic effect in multiple biologic assays while the methoxyestrogen ( -meoe ) can exhibit an estrogenic effect. the biologic activities of these estrogen metabolites ( ohe meoe) depend upon their concentrations and tissue type. since comt activity ultimately controls levels of these metabolites, it appears to be a key factor in regulating the cellular estrogenic milieu. we have recently reported that amnion layers of human fetal membranes from laboring women exhibited folds higher comt mrna expression when compared to non-laboring women (wentz et. al. sgi ) . objective: to investigate the impact of comt inhibition on prostaglandin e (pge ) production by human amniotic membrane explants. study design: explants consisting of -cm circular sections of the amnion layer (obtained from term pregnant women who underwent elective repeat cesarean section) were prepared and placed in tissue culture explants media at ºc. after a -hour incubation, explants were treated with the selective comt inhibitor ro - , at and m concentrations. the incubation media was harvested after and -hour intervals. the levels of prostaglandin e (pge ) in the media were measured by sensitive elisa and were normalized against total protein concentration. results: ro - comt inhibitor induced major reductions in pge production in media collected from amnion explants of human fetal membranes. in the group treated with m of ro - for hours there was %± % reduction of pge after hours compared to untreated control (p< . ). in the amnion explants treated with m of ro - , there was %± % after hours and %± % after hours of treatment compared to untreated control (p< . ). conclusions: this finding indicates that comt activity in the amnion layer of human fetal membranes affects pge production. by facilitating a pro-estrogenic milieu in human fetal membranes in late gestation, increased comt activity may indirectly increases production of factors associated with labor such as pge . hypothesis: an extensive remodeling of the human cervical connective tissue takes place throughout pregnancy with a decrease in the total concentration of collagen and proteoglycans due to an altered higher metabolic turnover. we hypothesize that the profound changes in proteoglycan production in the human pregnant cervix can be seen in corresponding cervical fibroblasts as well. we also hypothesize that proteoglycan production in cervical fibroblasts from preterm partal women are simmilar to the production in fibroblasts from partal women. method: cervical biopsies were obtained from non-pregnant women, women during elective cesarean section, woman after spontaneous parturition and after a preterm vaginal delivery. by explant technique fibroblasts were cultured from the biopsies. produced proteoglycans were metabolically labeled with s during hours and then purified by ion-exchange chromatography and separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. results: the total proteoglycan production decreases with approximately % in partal and preterm partal cell cultures. the reduction of proteoglycans in preterm partal and partal cell cultures is significant compared to non pregnant fibroblast cultures. the distribution of biglycan and perlecan are similar in partal and preterm partal cells. biglycan are significantly reduced by around % and perlecan are significantly increased by around % compared to non pregnant cultures. preterm partal cervical fibroblasts secreates significantly more heparan sulfate proteoglycans compared to non pregnant cultures. the changes in total proteoglycan production in the human pregnant cervix can be seen in corresponding cervical fibroblasts as well. both partal and preterm partal cell cultures differ in their proteoglycan production compared to their non pregnant counterpart, suggesting a role for proteoglycans in cervical ripening. the role of the oxytocin/oxytocin receptor system is not well defined in human amnion. previous studies in rabbit amnion have demonstrated an up-regulation of oxytocin receptors in the end of pregnancy and have shown that there is a large increase in the ability of ot to stimulate pge production. we and others have previously shown a role for nf-b in otr regulation. in whole genome array analysis of human amnion we found that otr was the gene with the second highest increase associated with activation of nf-b (the highest being cox- ). the present work was directed towards further understanding of otr expression and function in human amnion at term. we have shown that pge release by pre-labour primary human amnion cells is significantly increased after oxytocin treatment for hrs (ot: - m; n= ; triplicate samples; fold increase p< . ). the expression of otr in labour (+) and labour (-) primary amnion cells was measured with real time rt-pcr. we found a significantly higher level of expression in the labour (+) cells (n= ; duplicate samples; p< . ). western blot analysis confirmed the upregulation of otr in labouring amnion. treatment with il- b resulted in a significant upregulation of otr which peaked with a fold induction after hours (p< . ). il- caused a fold increase in otr mrna levels in labour (-) cells, bringing the expression level up to that found in labour (+) cells. our findings provide further evidence for a role of otr in human amnion. expression of otr in human amnion is significantly increased after the onset of labour. term non laboured amnion can be stimulated with il- to increase otr expression to levels of laboured amnion. one of the functions of otr in amnion cells is stimulation of prostaglandin synthesis. expression of antioxidant defence proteins in human myometrium before and after the onset of labour. vasso terzidou, mandeep s kandola, shirin khanjani, jan j brosens, phillip r bennett. parturition reserach group, irdb, imperial college, london, united kingdom. background oxidative stress is a result of an imbalance between the production of reactive oxygen species (ros) and the antioxidant defence mechanisms present in biological systems. parturition and infection-induced preterm labour resemble inflammatory processes that are linked to the production of ros including super-oxide (o -), hydrogen peroxide (h o ) and peroxynitrite. low concentrations of ros can act as second messengers in the regulation of several cellular functions. in an attempt to maintain redox homeostasis cells are equipped with machineries to both produce and scavenge ros. enzymatic scavengers include superoxide dismutase (sod), glutathione peroxidise and catalase. sod is the first enzymatic step in the defence system against oxidative stress. nuclear factor-kappa b (nf-b), a transcription factor family classically associated with inflammation, is activated in response to infection and proinflammatory cytokines, such as those prevalent during labour. labour is associated with an increase in nf-b activity in human myometrium and in fetal membranes. nf-b is known to regulate a range of genes associated with the onset of labour. in a study using affymetrix whole genome arrays analysis nf-b overexpression was associated with increased expression of sod- ( . fold). to determine changes in ros scavenging potential upon onset of labour, lower segment myometrial biopsies were taken at term before and after the onset of labour (n= ; each group). cdna was extracted from the tissues and real time rt-pcr was performed for sod- , serum/glucocorticoidinduced protein kinase- (sgk- ) and the dna repair enzyme gadd a. we found that labour onset is associated with a two fold increase in the levels of expression of each. oxidative damage at the fetomaternal interphase has been extensively studied in the placenta as part of investigations for first trimester pregnancy losses, iugr and pre-eclampsia. the role of ros is less well defined in human decidua and the underlying myometrium. our results suggest a role for oxidative stress and redox homeostasis in the maintenance of myometrial quiescene during pregnancy and onset of labour. plasma anandamide levels increase during labour induction and appear to delay labour progression. vijianitha nallendran, anthony h taylor, patricia mw lam, stephen c bell, david j taylor, justin c konje. cancer studies and molecular medicine, university of leicester, leicester, united kingdom. background: the evidence for a role of the endocannabinoid, anandamide (aea) in labour is conflicting. we previously showed elevated aea plasma levels in labouring women whilst another group showed that activation of functional receptors for anandamide actually inhibited uterotonin-induced contractions through an adenylate cyclase pathway . the aim of this study was to explore further the relationship between labour and plasma aea levels. methods: plasma aea levels in women undergoing induction of labour for various indications at term, were measured by a sensitive isotope dilution method using hplc-ms/ms. each volunteer had an assessment of her cervix prior to the start of the induction when the first sample for aea was collected. once active labour was established (cervix cm dilated; contractions every - minutes), a second sample was collected. results: seventeen ( %) of the subjects were multigravida. the inductions were for postdates(n= ); decreased fetal movements(n= ), fetal growth restriction(n= ), symphysis pubis dysfunction(n= ), diabetes mellitus(n= ), pre-eclampsia(n= ), fetal cardiac complication(n= ), spontaneous rupture of newborn offspring with persistent pulmonary hypertension, despite enhanced fetal membranes(n= ). plasma aea levels increased significantly once labour was established (figure) and demonstrated in ( %) of the cases. the median (interquartile range) plasma aea level increased from . nm ( . - . ) at induction to . nm ( . - . ); *p= . ; mann-whitney u-test) at active labour. there was a positive correlation between plasma anandamide levels taken before induction and the time taken for the women to enter into active labour (r = . , p= . pearson correlation). plasma aea levels were higher in labouring women compared to non-labouring women after the induction of labour confirming our previous observations and suggesting a direct role for this endocannabinoid in labour. further studies are required to elucidate this role. nuclear factor-kappa b (nf-b) is a transcription factor family classically associated with inflammation, activated in response to infection and proinflammatory cytokines, such as those prevalent during labour. as a cytokineinducible transcription factor it plays a key role in the expression of a variety of genes involved in inflammatory responses and cell survival. nf-b dna binding and transcriptional activity plays an important role in labour associated gene expression in myometrium. in this study we examined the range of genes regulated by nf-b in myometrium using transient transfections and wholegenome array analysis. myometrial cells were extracted from myometrial biopsies taken at the time of elective caesarean sections at term. transient transfections of primary myocytes were performed using expression vectors for nf-b p .the amount of dna was constant and psg was used as a control construct. cdna was made from myocytes transfected with either nf-b or psg . affymetrix genechip u microarray was performed (n= , each group). we found that genes were significantly differentially expressed between control and overexpressed nf-b samples. twenty eight of these genes were upregulated with nf-b and were down regulated. several chemokines and cytokines were identified in the upregulated group. interleukin demonstrated the highest, fold, induction in the upregulated group, followed by tumor necrosis factor, a-induced protein (tnfaip ), chemokine ligand (ccl ), chemokine ligand (ccl ), pentaxin related gene (ptx ), interleukin (il ) and superoxide dismutase (sod- ). nine genes were present in the nf-b group that were absent in the control group. these included chemokine ligand (ccl ), chemokine ligand (ccl ), chemokine ligand (cxcl ) and il . ingenuity pathway analysis demonstrated that immune response, inflammatory, cell growth and proliferation and cell death were the main pathways involved. standardisation experiments have been performed, and the microarray results were confirmed with real time rt-pcr in several candidate genes. our results provide further support in the role of nf-b in human labour and suggest its direct link in upregulation of inflammatory genes, cytokines and chemokines, consistent with the imflammatory nature of the biochemistry of labour. inflammation is widely accepted to be a key feature of human labor. secretory leukocyte protease inhibitor (slpi), an innate immune molecule, has been shown to be an antimicrobial and anti-inflammatory protein. the aims of this study were to verify its expression and localization in human myometrium methods: specimens were obtained at time of cesarean delivery with or without labor. expression and localization of slpi was detected using immunohistochemistry. slpi expression pattern relative to nf-b p subunit was compared between not in labor and in labor subjects, between different tissue sections as well as in in vitro model systems including myometrial explants, uterine smooth muscle cells (usmc) and ishikawa endometrial adenocarcinoma cells. slpi was predominantly localized to the nuclei of myocytes. the observed nuclear immunoreactivity of myocytes was increased during the labor relative to not in labor, paralleled with p nuclear translocation. the nuclear pattern of slpi is specific to myometrium since slpi immunostaining was present exclusively in the cytoplasm of all other tissues examined, including amnion, chorion, decidua and endometrium. slpi staining was also positive in macrophages, indicated by co-localization of slpi with cd positive cells. treatment with il- or tnf-induced nuclear translocation of p in myometrium explants and usmc, but not in ishikawa cells. in human myometrium, slpi is predominantly localized in the nuclei of myocytes and in macrophages. the nuclear expression pattern of slpi is myometrium-specific and increased following the onset of labor and correlated with nf-b activation. further understanding of its physiological significance may suggest new strategies aimed at preventing preterm birth. application of a new proteomic technology on amniotic fluid in prom. sara consonni, niccolo bosso, marianna andreani, agnese pizzardi, fulvio magni, anna locatelli. obstetrics and gynaecology, university of milano-bicocca, monza, italy; experimental medicine, university of milano-bicocca, monza, italy. objective: mass spectrometry (ms) is the obligatory tool for proteomics studies. biological samples must be purified before ms analysis due to the matrix complexity. a recent approach combines active surface prepurification with maldi-tof (matrix assisted laser desorption) analysis. clinprot technology provides the prepurification of the sample through the use of magnetic beads (mb) with activated surface. this technique can be carried out by robot in an automated way on a large number of samples. a unique example of the use of mb before maldi-tof analysis to determine proteomic profiles of amniotic fluid (af) is reported for rapid detection of fetal aneuploidies (wang ) . the objective of our study was to verify the applicability of clinprot prepurification before maldi-tof analysis on amniotic fluid collected noninvasively in premature rupture of membranes (prom). methods: we sampled af from vaginal posterior fornix of women with preterm prom (group , n= ) and term prom (group , n= ). samples were prepared with mb and analyzed with ms maldi-tof in order to generate proteomic profiles. results: it was possible to generate average proteomic profiles in the two study groups and the observed profiles were different. samples of af non invasively collected in prom can be analyzed by ms maldi-tof after preparation with mb. this technique allows to retain part of the eluted sample for characterization of protein peaks of interest. due to the less laborious characteristics of this method in comparison with techniques based on bidimensional electrophoresis its application can be useful in clinical proteomics. progestins accentuate the maternal but not fetal inflammatory response of women with intra-amniotic inflammation. sonya abdel-razeq, irina a buhimschi, michael cackovic, guoyang luo, antonette dulay, victor rosenberg, mert bahtiyar, errol norwitz, edmund funai, catalin buhimschi. ob./gyn. reprod.sci., yale university, new haven, ct, usa. introduction: data from animal research suggests that progestins have a marked pro-inflammatory capacity. recent studies support the administration of -hydroxyprogesterone caproate in women at risk for preterm birth. we sought to determine the impact of progestins during gestation on the extent of maternal and fetal inflammatory responses in pregnant women with intraamniotic inflammation. methods: amniotic fluid, placenta and cord blood were obtained from women who delivered preterm (median[range], ga: [ - ] wks). an amniocentesis was done to rule out infection. women exposed to progestins (n= ) within one week prior to amniocentesis were matched to controls (crl) by age, parity, history of preterm birth ga, membrane status and interval to delivery. proteomic profiling of amniotic fluid [mass restricted (mr) score] identified the presence or absence of intra-amniotic inflammation. an mr score of or confirmed intra-amniotic inflammation. amniotic fluid and umbilical cord interleukin- (il- ) levels were measured by elisa. histological chorioamnionitis was graded based on recognized criteria. results: overall, women and their fetuses exposed to progestin did not exhibit an increased inflammatory response (table) . however, sub-analysis restricted to women with mr or (n= ) showed that in the context of intraamniotic inflammation, progestins were associated with significantly elevated amniotic fluid il- levels compared to unexposed women (progestins (n= ): vs. crl (n= ): [ . - ] ng/ml, p= . ). these relationships were maintained after correction for steroid and antibiotic exposure. such significance was not found for amniotic fluid glucose, ldh, wbc count or cord blood il- . conclusion: our results suggest that progestins may amplify the maternal, but not the fetal inflammatory response of women with intraamniotic inflammation. objective: recently progestins have been shown to reduce the incidence of recurrent preterm labor in women. progestins have long been known to inhibit preterm labor in some species including rats and are also known to delay term labor. nitric oxide (no) donors, including ng, inhibit uterine contractility and have been used as tocolytics. the aim of this study was to examine the inhibitory effects of r on preterm labor in rats induced with a progesterone antagonist (onapristone, zk) with and without ng. materials and methods: charles river s-d timed pregnant rats (n= /group) were treated with zk ( mg/rat, s.c.) alone or vehicle (controls) on day of gestation. other groups of rats were treated with zk in combination with various doses of r ( . , or mg/rat s.c) with and without ng ( mg s.c. pellet) from days to of gestation. all rats were sacrificed on day of gestation and the number of fetuses and implantation sites were counted to determine the preterm delivery rate. one way anova was used for statistical analysis. p< . was considered significantly different. results: rats treated with zk alone delivered all their fetuses prematurely compared with controls (p< . ) treated with vehicle only (ca. % fetuses delivered). ng treatment alone did not affect the delivery rate (p> . ) compared to controls. similarly zk + ng did not reduce the preterm delivery rate compared to zk alone (p> . ). however r dose dependently reduced (p< . at all doses) the number of fetuses delivered prematurely in response to zk and the premature delivery rate was further reduced when treatment included the combination of r plus ng (p< . ). conclusions: zk effectively induces premature delivery. premature delivery produced by zk can be effectively reduced with a r , a progestin known to bind with high affinity to nuclear progesterone receptors. ng by itself, at the dosage used, does not reduce the prematurity rate caused by zk. however, r and ng act synergistically to reduce the preterm delivery rate. this study indicates that combinations of a progestin with an no donor may be an effective treatment for preterm labor and delivery. monkeys. pl grigsby, jp rasanen, , dw sadowsky, m bertolino, m carbonatto, e gillio tos, s canali, j lacy, a chollet, mj novy. reprod sci, oregon primate res ctr, beaverton, or; ob/gyn, oregon health sci univ, or, usa; rbm, merck serono, italy; merck serono, switzerland. objective: to investigate the pharmacokinetics (pk) and pharmacodynamics (pd) of as , a novel orally active non-peptide oxytocin (ot) antagonist in rhesus monkeys. study design: dose finding and pk/pd studies were done in chronically instrumented non-pregnant (n= ) and pregnant ( - dga, term d; n= ) monkeys. maternal and amniotic fluid compartments were serially sampled during dosing and washout. treatment phases included: ot infusion control, ot infusion + as , and ot rescue therapy. ot infusions ( - mu/kg/hr, iv) were given to determine the lowest dose required to produce stable, sub-maximal uterine contractions in each animal. as was administered p.o. at , , mg/kg and the effects on inhibition of uterine activity (hca, mmhg.sec/hr) were compared. to verify antagonist reversibility, objectives: infection such as chorioamnionitis is thought to be the cause of premature rupture of the membrane and induce uterine contractions leading to preterm delivery. however, the mechanism for enhancement of uterine contractility is not well understood. we have reported that non-selective cation channels (nsccs) regulate pacemaker potentials to generate rhythmical contractions and should be targets of magnesium ions used for tocolysis. the purpose of this study is to investigate the changes of the expression of nsccs during normal pregnancy and the effect of inflammation in preterm. methods; atp receptors (p x) and transient receptor potential canonical (trpc) channels were examined as uterine nsccs. the mrna was extracted from the rat myometrium of non-pregnant and pregnant rats at days , , and . the expression of each subtype of p x and trpc channels was measured by real time rt-pcr (abi ) with taqman probes (abi). as an inflammatory model lipopolysaccharide (lps; . mg/kg) was injected into intraperitoneal cavity at day and the tissue was sampled after six hours. results; p x and p x were determined to be dominant subtypes of p x channel. the expression of p x was increased by % at day , compared with day and that of p x was enhanced by %. on the other hands, trpc and trpc were detected dominantly. the expression of trpc was increased three times in the late stages of gestation. however, trpc was suppressed by %. in the lps treated rat myometrium cox- mrna expression was measured to be fold higher than that of the control rat, showing inflammatory effects in the myometrium. in this model the expressions of p x , p x and trpc were enhanced by . , . and . times, but trpc was not changed. the mrna expression of p x , p x and trpc channels in rat myometrium was increased in the late stages of pregnancy. these channels are suggested to be concerned with onset of labor. in the inflammatory model the expression of these channels was accelerated dramatically and these values were much higher than those in normal pregnancy. this finding supposed inflammation may enhance some types of nsccs to accelerate uterine contractility and induce preterm delivery. anandamide ( to determine the mechanism of rho protein activation during oxytocin and carbachol induced contraction, freshly prepared myometrial strips in krebs henseleit buffer were treated with oxytocin ( nm) and carbachol ( μm) under isometric and tension free conditions. control strips were exposed to buffer only. treated myometrial strips were solubilised and separated into membrane and cytosolic extracts and equal aliquots were immunoblotted with rhoa and rhob antibodies. rhoa translocated to the membrane after oxytocin and carbachol stimulation under both isometric and tension free conditions (p< . ). there were no significant changes in rhob membrane to cytosol ratios relative to control. agonist induced contraction in human myometrium is associated with rhoa but not rhob membrane translocation. during pregnancy components of the intracellular camp signalling pathway show increased gene expression resulting in the maintenance of myometrial quiescence until term where a substantial decrease in expression of these genes is observed. protein kinase a regulatory subunit riia (rii ) is upregulated at both the mrna and protein levels in the human myometrium during pregnancy. this particular subunit is membrane-bound and by directing phosphorylation to myometrial cytoskeletal proteins may affect contractile machinery thus playing a role in maintaining uterine relaxation. acetylation of histones promotes a favourable chromatin environment for transcriptional activity of many genes. this process is largely inhibited by histone deacetylases (hdacs), whereby its activity leads to transcriptional repression. hdacs can be recruited to the promoter region of a gene by other transcription factors such as sp proteins. since the rii promoter contains three sp - consensus binding sequences in its proximal part, we investigated whether this gene is a target for transcriptional regulation by hdacs. using dna precipitation assays we found that sp , and as well as hdac and form complexes with biotin-labelled fragments relating to sp - elements in the promoter region of rii . additionally, treatment of myometrial primary cell cultures with hdac inhibitor trichostatin a (tsa), or with the methyltransferase inhibitor -azac resulted in increased mrna and proteins levels. further studies with full and truncated luciferase constructs of the promoter region of the rii gene in transiently transfected myometrial cells confirmed that all three sp - elements are involved in the transcriptional regulation of the gene. this process involves hdacs, as h treatment with tsa significantly increased the luciferase signal. changes in the binding of sp proteins and hdacs to the promoter after tsa and azac treatment were investigated employing chromatin immunoprecipitation assays. alterations in the methylation status of the promoter after treatment were examined by bisulfite modification and dna sequencing. together, this study highlights the importance of chromatin modifications in the maintenance of uterine quiescence during pregnancy as well as identifying a potential mechanistic target for drugs that may reduce the incidence of preterm labour. objective: progesterone maintains pregnancy by promoting myometrial quiescence. typically progesterone effects are thought to be mediated through the classic genomic pathway. there is evidence, however, that progesterone also acts via a non-genomic pathway by interacting with specific membrane progesterone receptors (mprs) and in particular progesterone receptor membrane component - (pgrmc- ). the role of non-genomic progesterone actions in human pregnancy and parturition is not clearly understood. the goal of this study was to measure the extent of mpr expression in biopsy specimens of human myometrium obtained at cesarean delivery, and to determine whether expression changes with advancing gestation or the onset of labor. study design: lower uterine segment myometrial biopsies were obtained at the time of delivery from consenting women who were at term and not in labor (n= ), preterm and not in labor (n= ) and term and in labor (n= ). protein extracts were prepared and subjected to polyacrylamide gel electrophoresis and immunoblot analyses for pgrmc- and gapdh. abundance of pgrmc- protein relative to gapdh was determined by digital densitometry. we also performed immunohistochemistry (ihc) to determine the cellular localization of pgrmc- in the human pregnancy myometrium. results: pgrmc- protein was identified in each biopsy specimen. there was a -fold increase in pgrmc- protein in term compared with preterm biopsies (relative to gapdh p< . ). the relative level of pgrmc- protein was not different between biopsy specimens from laboring and non-laboring women at term (compared to gapdh, p= . ). pgrmc- immunoreactivity was localized to granular cytoplasmic staining. conclusion: this is the first description of the presence of pgrmc- protein in the human myometrium during pregnancy. its presence suggests that progesterone may influence contractility non-genomically via these receptors. the functional significance of the gestational age associated two fold increase in pgrmc- is unclear. changes in expression of this receptor during pregnancy may be important for the hormonal control of parturition and can be the focus of future studies. (ruddock et. al., abstract smfm, ) . the aim was to examine the mechanism of p inhibition. methods: uterine tissues from women (n= ) at term with cesarean section, were suspended in organ chambers and exposed to various agents or solvents. contractility was registered, stored, analyzed and compared before and after addition of agents or kcl. tissues were treated with p alone ( - to - m) or p bound to bovine serum albumin (bsa/p , - to - m p ), a progestin with low affinity to mpr (r , - - - m), or a non-sex steroid (cholesterol, - to - m). other tissues were pretreated with selective inhibitors of adenylate cyclase (sq , - m), guanylate cylase (odq, - m), phosphodiesterase (rolipram, - m), nitric oxide (no) synthases (l-name, - m) or a nuclear p receptor antagonist (mifepristone, mif, - m), followed by p . data were analyzed by anova for statistical differences (p< . ). results: p rapidly (< hour), effectively ( %) and dose-dependently inhibits spontaneous and kclinduced contractility (ed of < - m incubation of strips with zd- , at concentrations up to m for one hour prior to the experiment, led to no significant reduction in the total work done. however, incubation of strips with l- with a concentration of nm for one hour prior to the experiment, led to a statistically significant reduction in the total work done after one and a half hours. furthermore, when increasing concentrations of pge ( - to - ) were added to l- ( nm) pre-treated strips, total work done per contraction was comparable to that of non-treated controls. similar effects were not observed in zd- ( nm) pre-treated strips. since the reduction in contractility caused by l- was greater than that caused by zd- , it is likely that the stimulating effect of pge acts predominantly via ep receptors. taken together with our previous data showing an increase in ep at labour, this data shows that targetting an ep receptor may be a useful strategy in managaing pre-term labour. recently a truncated kda isoform of the er-has been described in human endothelial and testicular cells. we describe the presence of this kda erisoform in pregnant and immortalized non-pregnant human myometrial cells. methods: myometrial tissue obtained from non-laboring pregnant women undergoing cesarean section at term (n= ) was dissected prior to being finely minced. a portion of the tissue was placed in pbs and sonicated, while the remainder of the tissue was dissociated with collagenase prior to filtration and placement on culture plates. cells were then cultured in mem w/ % fetal bovine serum (fbs) until confluence. cultured cells were then dissociated with . % typsin/edta, subsequently re-plated and grown to confluence. immunohistochemistry directed toward smooth muscle protein was used to verify myometrial phenotype.) protein was extracted and quantified. western blot was performed with mouse monoclonal anti-er-receptor antibody (santa cruz biotechnology) to the f- domain of the human er-receptor. an immortalized non-pregnant human myometrial cell line provided by ann word, htert, was cultured and isolated as described above. results: htert cells expressed both the truncated ( kda) and the full length ( kda) er-isoforms. fresh and cultured myometrial cells from non-labored term pregnant patients also expressed both isoforms of er-. subsequent subcultures of myometrial tissue continued to express the kda erisoform, yet the expression of the kda isoform was lost. a representative blot is below. conclusions: we demonstrate, for the first time, the presence of a kda erisoform in cultured and non-cultured pregnant and cultured nonpregnant human myometrial tissue. discovery of this isoform of er-in myometrial tissue could provide insight into the molecular mechanisms involved in parturition. the action of prostaglandin f (pgf ), a potent uterotonic stimulant that is associated with labour at term and preterm, is mediated by its receptor, ptgfr. myometrial ptgfr mrna levels fall during pregnancy and this likely plays a role in uterine quiescence. however, the mechanisms by which this occurs are poorly understood. we previously reported that pgf downregulates fp mrna expression in cultured human myometrial ultr cells in a protein kinase c (pkc) dependent manner. in addition to the downregulation of mrna levels, receptor desensitization may also represent another mechanism of decreasing ptgfr activity because ligand binding to g protein coupled receptors often results in receptor internalization. we therefore hypothesized that pgf treatment of ultr cells also results in pkc dependent ptgfr internalization. methods: near confluent cultured human myometrial ultr cells were treated +/- - m or - m pgf for , , or hr. cells were fixed with formaldehyde and visualized for localization of ptgfr by immunofluorescence. to examine the potential involvement of pkc in the process, ultr cells were treated +/- - m pgf and +/- m myristoylated pkc inhibitor ( - ) and examined for ptgfr cellular localization as described above. results: pgf treatment resulted in a dose dependent decrease in ptgfr membrane signal at , , and h. this decrease was dependent on pkc as cotreatment with the myristoylated pkc inhibitor ( - ) prevented the pgf induced decrease in membrane ptgfr at h treatment. there was no visible effect of the pkc inhibitor on ptgfr membrane signal on its own. conclusion: we conclude that pgf decreases membrane levels of ptgfr protein in human myometrial ultr cells in a pkc dependent manner. these results suggest that pkc may be required for both the pgf induced internalization and desensitization of ptgfr protein and downregulation of ptgfr mrna in human myometrial ultr cells. therefore pkc may play a crucial role in downregulating ptgfr expression and activity and maintaining uterine quiescence during pregnancy. rhoa is a small gtpase that acts as a molecular switch to control a variety of signalling pathways in smooth muscle, including contractility. it is thought that increases in rhoa-gtp levels facilitates phosphorylation of target proteins such as cpi- , promoting contractility at pre-term and term labour in humans. however, in situations of acute or chronic hypoxia in the uterus, it is important that myometrial contractility and subsequent labour is not facilitated prematurely. given the importance of rhoa to a cell's response to hypoxia in other cell types, it was hypothesised that rhoa plays a central role in the mechanism controlling smooth muscle contraction in the uterus too. following acute hypoxia ( . % o ) for one to six hours, rhoa mrna, total protein and activation (rhoa-gtp) levels were analysed, using semi-quantitative pcrs and western blot, and compared to normoxic non-pregnant human uterine smooth muscle control cells. next, we investigated whether reduced oxygen conditions affected oxytocin induced activation of rhoa, following a two hour treatment of nm oxytocin. firstly, our results demonstrate that the rhoa itself is significantly activated under low oxygen conditions, resulting in phosphorylation of myosin phosphatase, myosin light chain and cofilin, three proteins known to be central in contraction and actin filament organisation. secondly, hypoxia significantly reduced the coupling of oxytocin to rhoa activation under the conditions examined. we observed a significantly reduced level of rhoa expression and activation which correlated with an increase in the level of another rhogtpase protein, rhoe. we propose that rhoa inactivation occurs through a rhoe-mediated mechanism, suggesting a balance in the activity of these two antagonistic rhogtpases in oxytocin-induced hypoxic human uterine smooth muscle cells. these results provide a possible explanation for the reduced coupling of oxytocin as a stimulant of myometrial contractions during slowly progressing labours. oxytocin-induced release of calcium ions (ca + ) from sarcoplasmic reticulum (sr) and sensitisation of contractile proteins to ca + have been suggested to mediate the oxytocin-induced potentiation of myometrial contractions. objective: we investigated the effects of oxytocin in the presence of nifedipine, a known inhibitor of the l-type calcium channel (ltcc). method: samples of myometrium were obtained from women undergoing term caesarean section with the approval of the local ethics committee. a standard organ bath system (ad instruments, uk) was employed to analyse contractile activity. stable spontaneous contractions were recorded for - minutes before addition of nifedipine. results: in agreement with our previous findings, application of oxytocin to spontaneously active strips produced a two-component effect: a transient tetanus-like contraction, followed by prolonged augmentation of phasic contractions. nifedipine ( um) rapidly abolishes spontaneous contractions, subsequent addition of nm oxytocin produced an initial, transient rise in force, approxiamately % compared to oxytocin alone, followed by high frequency oscillations in > % of strips. calcium-free solutions were used to confirm that oscillations were due to ca + entry. disabling the sr store using thapsigargin ( um) had no effect on oscillations, confirming the sr not to be involved. the t-type calcium channel blocker, mibefradil ( um ) showed no inhibition of oscillations. an ip receptor and store-operated calcium channel inhibitor, -aminoethyldiphenylborate ( -apb) um also had no effect on oxytocin-induced oscillations. the store-operated calcium channel inhibitor skf- ( um) showed partial inhibition of oscillations. conclusions: based on these results, we propose that the most likely mechanism of ca + entry producing oxytocin-induced oscillations in the presence of nifedipine is the transient receptor channel-c (trpc) channel, known to be present in the human myometrium. further work needs to be completed to clarify this further. identification of stim and orai in human myometrium. a new paradigm in store-operated calcium signaling. evonne c chin-smith, mark r johnson, rachel m tribe. division of reproduction and endocrinology, king's college london, london, united kingdom; department of maternal fetal medicine, imperial college school of medicine, chelsea and wesminster hospital, london, united kingdom. background: recent reports have suggested that two novel proteins, stim and orai, are involved in the regulation of store-operated calcium entry. we have previously reported that members of the trpc family, putative basal and store operated calcium entry channels, are present in human myometrium and regulated by labour associated stimuli il- beta and mechanical stretch. although stim and orai isoforms have been reported in other smooth muscle cell types, there are no published reports of stim and orai expression in human myometrium. the aim of this study was to identify mrna expression of stim , stim , orai and orai in human myometrium. methods: human myometrial biopsies were obtained from women undergoing elective caesarean section at term (prior to labour) with informed written consent and institutional ethics committee approval. whole myometrial tissue was either snap frozen and stored at - o c or used for cell culture. rna was extracted from whole tissue (n= ), primary cultured myometrial cells (n= ) and passaged (p ) myometrial cells (n= ) and stim , stim , orai and orai mrna expression was assesed by quantitative real-time pcr. results: all four genes were expressed in whole myometrial tissue and cells. stim and stim mrna expression in cultured myometrial smooth muscle cells (primary and passaged) was significantly reduced compared to myometrial tissue expression (p< . ). however, there was no significant difference in either orai or orai expression in whole tissue versus cultured myometrial smooth muscle cells. conclusion: to our knowledge this is the first report of stim / and orai / mrna expression in human myometrium. these genes may contribute to the regulation of calcium signalling in human myometrium, but the functional significance of their expression remains to be determined. funded by the bbsrc. obstetrics and gynecology, national university of ireland, galway, galway, ireland. objective: the ability of uterine smooth muscle cells to stimulate collagen contraction has been well established as an in vitro model of myometrial contractility. devost and zingg ( ) reported that the contractility of human myometrial cell lines layered onto collagen matrices was increased by oxytocin while another group described the stimulation of human uterine smooth muscle cell contractility, cultured within collagen lattices, with endothelin- (dallot et al., ) . our study investigated the response of human primary uterine smooth muscle cells cultured within collagen lattices, to various compounds, including the non-specific depolarizing agent potassium chloride (kcl), the inflammatory cytokine tnf , the rock- inhibitor y- , oxytocin, and oxytocin plus its clinically used antagonist, atosiban. methods: human primary uterine smooth muscle cells (utsmc) (lonza) were maintained in dmem high glucose media. cells ( , per well) passage - , were embedded in . mg/ml collagen, in . ml aliquots, in dmem-f media on well plates (invitrogen) (dallot et al., ) . effects on contraction were studied by monitoring changes in gel area (alpha innotech imager, image j software (nih)). statistical significance was determined by the student t test. results: the utsmcs displayed basal contraction of the collagen gels while the non-contractile cell line hek cells, did not. kcl ( nm) stimulated an % increase in contractility (n= , p= . ) while nm tnf resulted in an . % increase (n= , p= . ), in comparison to unstimulated cells embedded in gel. the rock inhibitor y- ( m) inhibited contractility, with a . % decrease in collagen gel contractility (n= , p= . ). a % increase (n= , p= . ) in utsmc embedded collagen contractility was observed with nm oxytocin, which was antagonized by atosiban ( m) (n= ). conclusion: this study highlights the importance of the development and optimisation of a reproducible human in vitro myometrial contractility model, to evaluate the effect of various known labor-associated, and also unknown compounds. this should aid in our understanding of the many complex biochemical pathways involved in myometrial contractility at labor, and ultimately contribute to the prevention of preterm labor. changes in intra-mural myometrial blood flow during spontaneous labour using d power doppler angiography (pda). nw jones, , nj raine-fenning, h mousa, mj taggart, k jayaprakasan, gj bugg. nottingham university hospitals nhs trust, united kingdom; nottingham university, united kingdom; university of newcastle upon tyne, united kingdom. methods d pda was used to measure the percentage (%) change in the vascularization index (vi), the flow index (fi) and the vascularization flow index (vfi) in a volume of myometrium at the uterine fundus of nulliparous women at term, in the first stage of uncomplicated spontaneous labour. d data sets were obtained during a single cycle of uterine relaxation (r ), contraction and subsequent relaxation (r ). measurements were made independantly by two authors (nwj and gjb) using vocal® (ge kretz) and the mean value was used for analysis. the results from each woman are presented as a % change of r . data is presented as medians [interquartile range (iqr)] and analysed using non-parametric tests. the median volume (cm ) of interest for r was . cm ( . - . cm ), for the contraction was . (fig. ) . the % change for all three indices between r and r was not significantly different. however, there was a significant difference between the contraction and r (p< . ). the mean intra-class correlation coefficient and % confidence interval (ci) of vi, fi and vfi for the authors (nwj and gjb) were . ( . - . ), . ( . - . ) and . ( . - . ), indicative of good inter-observer reliability. conclusion d pda is a useful and reliable tool in the assessment of changes in intramural myometrial blood flow, which was found to reduce significantly during a contraction but increase again during the following uterine relaxation. . raine-fenning nj, et al. the inter-observer reliability of d pda acquisition within the female pelvis. ultrasound obstet gynecol. ; : - . the role of pgf on myometrial contractility; studied with a selective fp antagonist. shankari arulkumaran, andre chollet, phillip r bennet. imperial college parturition research group, institute of reproductive and developmental biology, hammersmith hospital campus, london, united kingdom; merck serono, geneva, switzerland. objectives: human myometrial strips established in culture will usually begin contracting after one hour. we have previously shown that stretch upregulates prostaglandin synthesis and have therefore hypothesized that spontaneous contractions occur because of stretch-related prostaglandin synthesis. methods: experiments were performed using x mm human pre-labour, lower uterine segment myometrial strips in a dmt myograph ms in oxygenated kreb's solution, with adi powerlab software. spontaneous contractions required stretch force and initial experiments determined that the maximum number of strips attaining spontaneous contractions was greatest at a force of - g. a novel antagonist to pgf (fpa) was studied in this model. the fpa has a ki of nm for fp and is - fold selective for fp compared with other prostanoid receptors. results: addition of pge and pgf after the commencement of spontaneous contractions caused a statistically significant increase in the total work done by the strips. the effect of pge was being greater than that of pgf . pre-incubation of the baths with a novel and selective fp antagonist (fpa) with concentrations up to m ( - ) did not affect the total work done by spontaneous contractions compared to non-treated controls. however, increasing concentrations of the fpa ( - to - ) decreased the total work done by -fold on strips treated with pgf beforehand in comparison the pgf -treated strips alone. conclusion: these data suggest that stretch and synthesis of prostaglandins is essential for spontaneous contractility in human myometrial strips. since fpa is able to block pgf induced but not spontaneous contractions, it is likely that pgf does not play a role in spontaneous myometrial contractility in vitro, although it may do so in vivo. because other factors may combine to increase contractility, the combination of an fp antagonist with other inhibitors may therefore, be a more effective strategy in reducing pre-term deliveries. objectives: brain natriuretic peptide (bnp) is synthesized in fetal membranes and inhibits oxytocin-induced contraction of preterm human myometrium. we hypothesized that bnp may be a paracrine mediator of human myometrial quiescence. we showed bnp content is higher in membranes from preterm pregnancies absent labor and significantly decreased with idiopathic preterm labor. while bnp activates natriuretic peptides receptors a (npr-a), b (npr-b), and its clearance receptor (npr-c), we have shown bnp does not inhibit myometrial contraction via npr-a or npr-b. herein, we test in part the hypothesis that bnp inhibits myometrial contractions by activating npr-c by quantitating npr-c in human myometrium at different gestations and labor status. methods: myometrial samples were obtained at the time of cesarean section after informed consent from groups of patients: preterm not in labor (pt-nl), preterm in labor (pt-l), term not in labor (t-nl) and term in labor (t-l). myometrial samples were obtained from women - weeks' gestation, and term between and weeks. mrna for npr-a, b and c were semiquantitated by realtime pcr (normalized by s mrna), and npr-c protein by western blot. results: natriuretic peptide receptors a, b and c mrnas were identified in all groups. while there were no differences in mrna levels among groups, npr-c protein was increased in samples from term laboring women. conclusion: since bnp inhibits the contraction of human preterm but not term myometrium independent of npr-a and npr-b, we have previously speculated that bnp activates another "unknown" receptor. herein we find that myometrial npr-c protein but not mrna increases during human labor at term. the increase in npr-c at term could compete with the unknown quiescent receptor to functionally reduce the availability of bnp and thus permit or promote myometrial activation/contraction. (supported by a grant from chilean government fondecyt ). objective: bnp is synthesized within human chorion and amnion and inhibits oxytocin-induced contraction of human myometrium. bnp activates guanylate cyclase (gc) natriuretic peptides receptors a (npr-a) and b (npr-b). bnp also stimulates the clearance receptor (npr-c) whose action is not mediated by gc. the intracellular pathway of bnp/npr-c inhibition is not known. we determined that bnp does not inhibit myometrial contraction via npr-a or -b. we hypothesized that bnp inhibits myometrium by npr-c activation. we test aspects of our hypothesis by determining whether bnp/npr-c pathway inhibits myometrial contractions via myometrial nos pathway. methods: bnp and canp (specific npr-c agonist) were added to primary human myometrial cell cultures and enos/inos activity/expression determined. cell cultures (n= ) were prepared from myometrial samples of nonlaboring, term pregnant women. after confluence ( d), the cells were incubated ( h) with nm bnp and/or canp. nos activity was measured ( l-citruline assay) and transcription/translation semi quantitated (realtime pcr and western blotting). results: bnp had no effect on either nos expression or activity. canp significantly reduced inos but not enos mrna level. canp did not alter the protein level of nos but significantly reduced nos activity. co-incubation with bnp and canp reduced both mrna levels (p< . ) and significantly decreased enos, but not inos, protein without change in overall nos activity. within the female pelvis. ultrasound obstet gynecol. ; : - . conclusion: the activation of npr-c by canp reduces nos activity and expression. the same effect was not observed by bnp. the difference may be explained because bnp (but not canp) activates all natriuretic peptide receptors, and they may have opposite actions on nos pathway. we conclude unlikely bnp inhibits human myometrial contraction by npr-c activation via the nos pathway. ( introduction: ultr is a retroviral immortalized human uterine smooth muscle cell line which we use as a model for uterine hypertrophy studies. however, this cell line has limited usage due to a reduced rate of cell division and eventually replicative senescence in culture. one of the mechanisms of human somatic cellular senescence is un-compensated shortening of telomeres, the specialized dna structures located at the ends of eukaryotic chromosomes. introduction of human telomere reverse transcriptase (htert) has been shown to induce telomerase activity and telomere elongation, and extend life-span of normal human cells. objective: to recover ultr cell division without altering the phenotypic characteristics of smooth muscle cells by introducing htert, therefore improving ultr cell line. methods: ultr cells were transfected with a modified htert expression vector at a relatively early stage (passage ) in the presence of selective antibiotic. ultr cell growth rate, with (ultr-ht) or without transfection, was determined by plating cells in multiple plates at a fixed density and counting cell numbers after days. single cell clones of stably transfected cells were further isolated by plating in well plates. expression of htert, smooth muscle specific genes (smc-sgs), and target genes was identified by rt-pcr of total rna extracted from ultr and ultr-ht cells. results: rt-pcr demonstrated successful introduction of htert into ultr cells. the growth rate of ultr-ht cells was increased and cell morphology was improved (free of the typical aneupoid appearance). at passage , ultr-ht cells grew . fold (p< . ) and . fold (p< . ) faster than ultr cells at passages and , respectively. currently single cell clones have been selected. ultr-ht cells express a set of smc-sgs, including -actin, caldesmon, calponin, myosin heavy chain, sm , and smoothelin, confirming that the smooth muscle phenotype is preserved. a panel of genes involved in angiotensin ii signalling, including angiotensin ii receptors (at / ), nox family (nox , , and duox ), nox-associated genes (p phox, p phox, p phox, and rac / ), was also preserved. conclusion: this is the first report of rescuing uterine smooth muscle cell replicative senescence via activation of telomerase. we have established a human uterine smooth muscle cell line which will provide an improved in vitro model for studying human myometrium. at term, myometrium is characterized by spontaneous contractions which vary in the amplitude, frequency and duration depending on specie and hormonal status. repetitive depolarization of plasma membrane followed by transient elevation in [ca + ] i is thought to underlie the contractions. however, the detailed pathways which regulate the spontaneous contractility remain unclear. objective: this study was designed to elucidate the effect of protein kinase c (pkc) on the spontaneous contractions and [ca + ] i transients in the myometria from term pregnant mice and women. methods: the human samples were obtained from women undergoing cesarean section with the approval from the institutional review board committee while mice myometria were dissected from the days pregnant mice sacrificed according to the animal study protocol. the isometric force and [ca + ] i were measured simultaneously in fura- loaded myometrial strips using spectrofluorometer equipped with force transducer. results: the pkc activator phorbol , -dibutyrate (pdbu) applied at - m first stimulated the amplitude of spontaneous contractions in mice and human myometria followed by their inhibition. under the pdbu treatment the frequency of the contractions was first increased and then decreased in both species. at the same time, pdbu didn't initially increase the amplitude of [ca + ] i transients but attenuated it over time. however, the frequency of the transients was first increased and later decreased upon the pdbu exposure. in addition, pkc activation with pdbu resulted in the elevation of the uterine basal tone without corresponding changes in the basal level of [ca + ] i in human myometrium. in mice myometrium, on the contrary, pkc activation didn't result in an increase of the muscle tone and the basal level of [ca + ] i . conclusions: we propose that pkc causes bi-phasic effect on uterine spontaneous contraction in mice and human first to potentiate the amplitudes and the frequencies and later decreases them. the amplitude of [ca + ] i was not initially potentiated by pdbu suggestive of the dissociation of the contractile and [ca + ] i response. the stimulatory effect of pdbu on the basal muscle tone in human myometrium and the absence of the effect in mouse suggest different mode of pkc action on uterine contraction in human and mice. introduction: mechanical stretch of uterine myocytes is detected through integrins on the cell surface which form part of the focal adhesion complex, this signals through mapk, ultimately leading to the up-regulation of various pro-labour genes including pghs- and il- . on integrin activation fak is recruited to the focal adhesion complex and activated by autophosphorylation at tyr- , creating a src binding site. this promotes further fak phosphorylation at tyr- , and , enhancing fak catalytic activity. however fak can also act as a scaffold protein and its exact role in the expression of pro-labour genes is uncertain. in this study we used inhibitors for the kinase activity of fak and mek / in order to test the affect of fak kinase activity on expression on pghs- mrna. methods: primary human myometrial cell cultures were grown from myometrial biopsies taken from women undergoing elective caesarean section. cells were plated onto -well flexible bottom plates coated in type i collagen. cells were subjected to % static stretch for up to minutes. cells were also incubated with either the rho kinase inhibitor y or the mek / inhibitor u prior to being stretched. western blots were performed using antibodies to fak phospho- , fak phospho- and erk / phospho- / , -actin was used as a loading control. rna was also extracted and levels of pghs- measured using q-pcr. results: stretch increased levels of phosphorylation at both tyr- and tyr- with the greatest increases occurring at and minutes. however the increase at tyr- appeared to be greater than at tyr- . incubation with the rho kinase inhibitor reduced phosphorylation of fak- , however this did not affect phosphorylation of erk / or stretch induced up regulation of pghs- mrna. in contrast incubation with the mek / inhibitor reduced erk / phosphorylation and expression of pghs- mrna, whilst also reducing fak phosphorylation (n= ; p= . ). conclusions: fak has previously been shown to be important in activation of the stretch induced mapk cascade and pghs- expression. however these data suggest that while stretch causes fak phosphorylation fak kinase activity is not essential to pghs- expression. this suggests fak may be acting as a protein scaffold. . our aim was to examine the effects of both natural progesterone and hp on spontaneous myometrial contractions. myometrial biopsies were taken with informed consent and ethics approval from non-labouring women at elective caesarean section weeks gestation. strips of myometrium mm long , mm wide were cut and suspended under a resting tension of mn in organ baths of krebs gassed with % o / % co within hours of collection. progesterone or hp were added in a cumulative manner at -minute intervals. changes in amplitude were recorded. results were compared using anova. following equilibration for hours, myometrial strips contracted in a rhythmic manner (amplitude . ± . mn, n= pairs). progesterone ( nm- m) produced a concentration dependent inhibitory effect on myometrial contractions (fig ), which was greater than that of vehicle (p< . ). maximum inhibition measured . ± . % and . ± . % for progesterone and vehicle, respectively. hp exerted an inhibitory effect, this was not significantly different from the vehicle (p> . ). progesterone exerts an inhibitory effect on myometrial contractility in vitro. this is apparent within minutes suggesting a nongenomic action. our data are in agreement with some reports in the literature but conflict with others[ ]. this acute inhibition of myometrial contractility may contribute to the mechanism by which progesterone prevents preterm birth. in contrast, we were unable to demonstrate an inhibitory effect of hp on contractility despite its demonstrated ability to reduce the incidence of preterm delivery [ ] . our data suggest that natural progesterone may be a more effective tocolytic agent in the acute setting than hp. obstetrics and gynecology, ramathibodi hospital, mahidol university, bangkok, thailand; pathology, ramathibodi hospital, mahidol university, bangkok, thailand; obstetrics and gynecology, samuel lunenfeld research institute, toronto, canada. objective: chemokines has been shown to play an important role in regulating uterine function. recent evidence demonstrates that monocyte chemotactic protein (mcp) level in amniotic fluid increases during spontaneous labor. the aim of this study was to examine the expression of mcp in human myometrium. methods: myometrial biopsies were taken from nonpregnant women undergoing hysterectomy and term pregnant women undergoing cesarean section followed written consent and local ethics committee approval. elective cesarean section was performed before the onset of labor while emegency section was done after the onset of labor. immunolocalization (n = each) was performed on paraffin sections by avidin biotin complex (abc) technique using monoclonal antibody specific to human mcp . reverse transcriptionpolymerase chain reaction (n = each) using gene specific primer against mcp and mcp receptor was performed to identify mcp messenger(m) rna in human myometrium . results: immunohistochemical findings demonstrated mcp in human myometrial cells from nonpregnant, term pregnant women before and after the onset of labor. mcp was labelled on plasma membrane and cytoplasm of myocytes from these three groups of women. similarly, mcp and mcp receptor mrna were found in nonpregnant and term pregnant women before and after the onset of labor. in this prospective study a group of fetuses was consecutively enrolled. one ultrasound examination was performed to each patient within days from delivery. we considered fetal macrosomia a birthweight g and big babies a birthweight g. cut-off points for identifying the best value of fetal abdominal circumference for fetal macrosomia prediction were chosen by receiving operator characteristics' curve (roc) analysis. using the best cut-off indicated by roc analysis, specificity and sensitivity were calculated. mean gestational age at delivery was + weeks ( + sd). neonates weighted less than g, had a weight range between and g and weighted more than g. the fetal ac measurement was the selected criterium to evaluate the risk of fetal macrosomia. to identify macrosomic fetuses the roc curve analysis identified a cut off of ac > mm which allowed to select fetuses. analysing this population we found true negative cases, false negatives, false positives and true positives, with a sensitivity of . % and a specificity of %. to detect big babies the roc curve analysis identified a cut off of ac > mm (n. fetuses), reaching a sensitivity of % and a specificity of %, without false negative cases and with false positives ( true positives, true negatives). the cases that weighted between and g, were included in the cases considered false positives by this cut-off. conclusions. these results clearly indicated that ultrasounds alone can not be used to manage a pregnancy suspected for fetal macrosomia or big babies. in fact, to avoid shoulder dystocia and all other complications strictly related to macrosomic fetuses, clinicians should perform a large number of useless elective cesarean sections. . pathway analysis of differentially expressed genes (pa; z-score . ) showed up-regulation of axon guidance, folate biosynthesis, nitrogen metabolism and down-regulation of steroid biosynthesis, insulin signaling, oxidative phosphorylation, tgf-beta signaling, and ubiquinone biosynthesis pathways in cm vs cf. comparison of mnr vs c in f showed genes up-and down-regulated (n= , ; p< . ). pa showed up-regulation steroid biosynthesis, fatty acid metabolism, glycolysis/gluconeogenesis, phosphatidylinositol signaling, ketone body metabolism, and ubiquinone biosynthesis pathways and down-regulation of bile acid biosynthesis, cell adhesion molecules, dna polymerase, notch signaling and ti diabetes mellitus pathways in mnr vs c. comparison of mnr vs c in m showed genes up-and down-regulated (n= , ; p< . ). pa showed up-regulation of jak-stat signaling, autophagy, renin-angiotensin system (ras), and ubiquinone biosynthesis pathways and down-regulation of apoptosis, basal transcription, folate biosynthesis, nitrogen metabolism, protein export, and snare interaction pathways in mnr vs c. only the ubiquinone biosynthesis pathway up-regulation of mnr vs. c was common to both m and f. conclusions: ta and pa demonstrate sex-specific transcriptome expression in fetal kidneys at . g. in addition, these results show sexspecificity in response to mnr. we have seen similar effects of mnr on gene expression for autophagy, apoptosis, ras, ubiquinone and cell adhesion pathways at . g, suggesting these pathways may contribute to persistent affects of mnr. finally, we postulate that stress in utero may contribute to sex differences in risk of hypertension in adult life. leptin and neuropeptied y protein expression paradoxally increased in gestationall food restricted dams. louiza belkacemi, chun-hung chen, andrea jelks, michael g ross, mina desai. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: placental insufficiency is associated with marked increase in placental leptin production. this results in a rise in maternal leptin levels that serves as an early index of placental dysfunction. further increased placental leptin and suppressed neuropeptide y (npy) are associated with preeclampsia. leptin, an anorexigenic hormone and npy, an orexigenic peptide regulate food intake. importantly, leptin also serves as a placental and fetal growth factor. we have shown that maternal food restriction (mfr) results in intrauterine growth ... sf ()to:!)) df(,..)l) ...._ bf(jtolo) ... -m bf(,..lj) =- ( . ) <(u.)) ( . ) )( . )"" ' ~. ) !( . )' d.'cbom< ( ) f( ))""" s( l) background teenagers are more likely to deliver small-for-gestational age (sga) infants than adults, even after adjustment for socioeconomic factors , . previous studies of mostly black and hispanic subjects in the usa have suggested that maternal growth may contribute to reduced infant birthweight, due to preferential nutrient partitioning to the mother . the impact of maternal growth on birthweight and nutrient partitioning in pregnant teenagers in the uk has not been examined. methods skeletal growth (change in knee-height from st to rd trimester), weight gain and skinfold thicknesses were measured in pregnant teenagers (n= , % non-white) in london and manchester. key mediators of nutrient partitioning and metabolism: insulin-like growth factor(igf)- , igf binding protein(bp)- and leptin, were measured in maternal plasma ( weeks gestation). results maternal growth (defined as increase in knee-height > mm/ days) was detected in % of pregnant teenagers. this growth was not associated with sga birth; in fact these mothers were more likely to deliver large-forgestational age (lga) infants (p< . ). maternal weight gain and fat accrual at peripheral and central sites were greater in growers (p< . ). these parameters correlated positively with maternal igf- and leptin but negatively with the igf inhibitor, igfbp- (p< . for all). subjects delivering sga infants gained significantly less weight (p< . ) and had lower igf- levels (p< . ) than those delivering non-sga infants. conclusion maternal growth in teenage pregnancy was not associated with reduced birthweight. indeed the increased weight gain and fat accrual observed in growing teenagers may protect against sga birth and promote fetal growth. igf- and leptin promote fetal growth, primarily through effects on maternal metabolism and nutrient partitioning to the fetoplacental unit. these data suggest that higher maternal igf- and leptin in growing teenagers may provide an anabolic drive for both maternal and fetal growth. background. umbilical oxygen uptake (o umb uptake) has been estimated in human pregnancies only in acute experiments at the time of caesarean section. the recently developed possibility to measure umbilical blood flow by ultrasound in utero, prompted us to study normal and iugr pregnancies in order to evaluate fetal oxygen uptake utilizing the fick principle, i.e. uptake equals umbilical blood flow times (a-v) differences. methods. thirty-six iugr pregnancies were studied at the time of elective caesarean section and compared to twenty-one controls (c) (gestational age: c= . ± . and iugr= . ± . wks). an ultrasound examination was performed within hours from the caesarean section in all the recruited patients. umbilical vein absolute volume flow (qumb) was measured as the result between umbilical vein area and the time-averaged peak velocity * . . blood samples from umbilical vein (uv) and artery (ua) were obtained after the delivery and blood gases and acid-base balance were evaluated. umbilical oxygen uptake was calculated as o umb uptake = qumb*(uv-ua) o content. results. as expected, average fetal and placental weights were significantly different in the studied groups ( ± and ± g in iugr vs ± and ± g in n) . iugr pregnancies showed a significant reduction in qumb ( . ± . vs . ± . ml/min; p< . ) but no differences in the qumb/kg of fetal weight. iugr fetuses showed a significant reduction in o sat, o cont and po in both uv and ua compared to n. (uv-ua)o content ( . ± . vs . ± . mmol/l; p< . ) and o umb uptake/kg ( . ± . vs . ± . mmol/min/kg; p< . ) were significantly reduced in iugr. conclusions. we here report an evaluation of fetal oxygen uptake that proved surprisingly similar to the values reported in chronically catheterized animals. however, iugr fetuses showed a significant reduction in both blood and oxygen supply: this latter was reduced more that % on a per kg basis. iugr fetuses therefore utilize less oxygen than normally grown fetuses. circulating levels of vitamin d and il- in pregnancies with iugr. calvin j hobel, chander p arora, adegoke adeniji, priya arora, susan e jackman, olga miadel, baldjyan lilit. ob-gyn, cedars-sinai medical center, burns ans allen research institute, los angeles, ca, usa; university of california los angeles, los angeles, ca, usa. background: any condition resulting in under exposure to sunlight, including the use of sun block or poor nutrition may result in insufficiency ( . - nmol/l) or even deficiency of vitamin d (< . nmol/l).vitamin d regulates placental development and function. vitamin d deficiency has been linked to increased risk of serious chronic and inflammatory diseases. objective: to determine if the circulating levels of vitamin d and interleukin - (il- ) in maternal plasma correlates to pregnancies resulting in fetus with intrauterine growth restriction (iugr). hypothesis: the metabolism of vitamin d initiates the biochemical cascade of events leading to the expression of il- and the inflammatory response in iugr births. study design: in a behavior in pregnancy study, plasma samples at all three time points were analyzed in a cohort of women for (oh)d using elisa. the samples were also analyzed for il- at three stages of pregnancy: t ( - weeks), t ( - weeks) and t ( - weeks). iugr was defined as birth weight below the tenth percentile for gestational age. none of the iugr cases had spontaneous preterm birth. results: iugr was diagnosed in of women with available samples from a behavior in pregnancy study (bips) . out of these subjects, were selected as matched case controls. circulating levels of vitamin d ( (oh)d) were significantly lower in iugr cases at each visit (p<. ). the levels indicated deficient ( . ± . nmol/l) vitamin d in iugr group at t but sufficient vitamin d levels ( . ± . nmol/l) in controls. subsequent visits also showed lower levels in the iugr cases compared to the control group (t : ± . nmol/l vs ± . nmol /l; t : ± . nmol/l vs ± . nmol /l). at all three time intervals, significantly (p<. ) higher levels of il- were associated with the iugr cases ( pg/ml, pg/ml and pg/ml respectively) as compared to the controls ( pg/ml, pg/ml and pg/ml respectively). conclusions: vitamin d deficiency or even insufficiency may be an unrecognized cause of iugr. it is possible that a primary non-infectious inflammatory process is activated by vitamin d deficiency. combined assessment of vitamin d deficiency and il- expression during different stages of pregnancy may facilitate the resognition of the risk of developing iugr. response to global % maternal nutrient restriction (mnr). nathan drever, thomas j mcdonald, peter w nathanielsz, cun li. obstetrics and gynecology, university of texas health science center at san antonio, san antonio, tx, usa. background: igf-ii is a major growth factor in the developing pancreas and studies in the human fetus demonstrate that the peptide localizes to b cells of the islets (j endocrinology : ). rodent studies show decreased fetal pancreatic growth and igf-ii and ins abundance and increased apoptosis with mnr (j endocrinology : ). we previously demonstrated a fall in most components of the placental and fetal baboon liver igf systems with mnr. here we have evaluated fetal pancreatic igf-ii and ins changes in response to mnr. methods: pregnant baboons were fed ad lib (ctr, n= ) or % of wt adjusted ctr diet (mnr, n= ) from . gestation (g) and fetuses were recovered at c-section under general anesthesia at . (n= ; ctr and mnr) and . g (n= ; ctr and mnr). igf-ii and ins expression were determined by immunohistochemistry (ihc) and quantified by image analysis for fraction (area immunostained/area of the field x %) and density. data are expressed as mean + sem; ctr data are expressed] first; comparison made with two tailed t-test. results: at . g there was no difference in igf-ii or insulin fraction or density between groups. at . g, igf-ii fraction ( . ± . vs . ± . ,p< . ) and density ( . x ± . x vs . x ± . x , p< . ) and insulin fraction ( . ± . vs . ± . , p= . ) were reduced. conclusion: moderate mnr decreases abundance of fetal pancreatic igf-ii and ins at . g. in the fetal baboon and supports the extant evidence for impaired pancreatic development with mnr seen in rodents. maintenance of liver growth in the hypoxic growth restricted fetal sheep: a role for intrahepatic glut ? sheridan gentili, janna l morrison, i caroline mcmillen. sansom institute, unisa, adelaide, south australia, australia. objective: we have previously demonstrated that there is a differential tissue response to chronic placental and fetal growth restriction. growth of fetal tissues such as the brain and the adrenal are consistently spared in the face of chronic substrate restriction, whilst we have demonstrated that the growth of the fetal liver may be either maintained or reduced. it is unclear whether the growth response of the fetal liver to hypoxia and hypoglycemia are determined by intrahepatic metabolic adaptations. hypothesis: we hypothesize that there will be a differential profile of hepatic expression of glut , hsd , the gluconeogenic and glycolytic enzymes pepck and g pdh and the transcription factors pgc and ppar in animals in which liver growth is maintained or reduced. methods: carunclectomy was performed in non-pregnant ewes to induce placental restriction (pr). vascular catheters were inserted in pr and control (c) fetuses at - d and arterial blood samples were collected for blood gas analysis. mean gestation po < mmhg was defined as hypoxic (h; normoxia, n). post mortem was performed at - d. hepatic mrna expression of glut , hsd , pepck, g pdh, pgc and ppar was determined using qrt-pcr. results: four experimental groups were defined by fetal po and liver growth (c-n, pr-n, pr-h and pr-h-reduced liver growth). fetal weight correlated with mean gestational po (r = . , y= . x+ . , p< . ). liver weight was significantly lower in a cohort of pr-h fetuses (c, . ± . ; pr-n . ± . ; pr-h . ± . ; pr-h-rlg . ± . g:kg; p< . ). glut expression was highest in those pr-h fetuses in which liver growth was maintained, whilst the expression of hsd , pgc , ppar and pepck was highest in the pr-h fetuses in which liver growth was reduced (p< . ). conclusions: in the pr-h fetuses in which liver growth was reduced, the increase in hsd expression may be associated with an increase in hepatic exposure to cortisol and an associated increase in pepck, pgc and ppar . interestingly the compensatory increase in hepatic glut expression did not occur in fetuses in which liver growth was reduced. predicting the trajectory of fetal growth. racine n edwards-silva, jeffrey gornbein, calvin j hobel. obstetrics gynecology, los angeles, ca, usa; biomathematics, david geffen school of medicine at university of california, los angeles, ca, usa; obstetrics gynecology, david geffen school of medicine at university of california, los angeles, ca, usa. objective: to evaluate twelve potential predictors of fetal growth trajectory defined as the rate of fetal weight change over time. study design: a longitudinal prospective study of singleton fetal growth trajectory. the twelve potential predictors considered were: fetal gender, gestational age, parity, race, bmi, age, weight at st clinical exam, cumulative weight gain at each exam, smoking, and alcohol use. estimated fetal weight was computed using the hadlock formula and sonographic fetal biometric parameters at - weeks, - weeks, and - weeks. the rate of change in fetal weight was defined as x (fetal wt at exam j -fetal wt at exam i )(j > i)/ (gestational age at exam j -gestational age at exam i ). bivariate statistical analysis included the non-parametric spearman rank correlation and wilcoxon rank sum test. all factors were assessed multivariately using multiple linear regression. results: there were multi-ethnic women included in the study, after were excluded. they underwent a total of , exams. fetal gender (p= . ), maternal weight at st exam (p= . ), and cumulative maternal weight gain at exam (p < . ) were significant predictors of fetal growth trajectory. in this model, male fetuses had an average rate of fetal weight change of . grams per days higher than females. the rate of fetal weight change increased by an average of . grams per days for each lb increase in maternal weight at the st exam. the fetal growth rate increased . grams per days for each lb of cumulative weight gain at the rd exam. conclusions: in this study, maternal weight at the st exam and cumulative maternal weight gain were the significant determinants of fetal growth trajectory. adequate initial maternal weight and cumulative gestational weight gains probably ensure sufficient nourishment for normal placental growth, uteroplacental blood flow, and fetal nutrient uptake. this supports the emphasis on periconceptual nutritional counseling for all pregnant women. the implication of this study is that similar to fetal programming of adult diseases, there is nutritional programming of fetal growth trajectory. high risk patients. other predictors include the known risk factors of age < and > , single, tobacco/alcohol use, and african american race. interestingly, hispanic and native american patients have a lower lbw rate compared to other groups. introduction: catecholamines released by the sympathetic nervous system and adrenal medulla act via b-ars to regulate glucose and insulin function in liver, pancreas, adipose and muscle tissue. b-ar knock out mice show increased fat mass and glucose intolerance (asenslo et al.,diabetes, ) . mnr animal models have increased sympathetic activity. we, therefore, evaluated effects of mnr on baboon fetal liver b -ar. methods: baboons were fed as ad lib controls (ctr) or % of wt adjusted ctr diet (mnr) from . gestation(g) with fetuses retrieved at c-section under general anesthesia at . or . g. protein expression determined by immunohistochemistry for b -ar in the central liver lobule was quantified by image anaysis and expressed as fraction = area immuno-stained/area of the field x %. all data are expressed as mean + sem with ctr data presented first. liver glycogen expression was determined by the periodic accid schiiff (pas) method. comparisions were made with student's t-test with alpha level set at . . results: fetal body and liver wts were not changed by mnr at either age. pas stained liver glycogen at . g = . ± . vs. . ± . %, p< . . b -ar fraction was lower following mnr at . g and at . g (p< . ; fig ) conclusions: mnr decreased b -ar over % at . g and % at . g. decreased fetal liver b -ar in mnr alters glucose metabolisam and may result in reduced lipolysis predisposing to fatty liver. infection with noncytopathic bovine viral diarrhea virus (ncpbvdv) during early bovine pregnancy (< d gestation) results in fetal immunotolerance, persistent infection (pi) and intrauterine growth restriction (iugr). in contrast, infection after the development of adaptive immune competence (> d gestation or postnatal) results in a transient infection (ti). we have previously reported an iugr in pi fetuses presenting as decreased body weight and ponderal index. a growth defect can be the result of many factors, including placental insufficiency and nutrient restriction, however it was hypothesized that the iugr seen in bvdv pi fetuses may be an immunopathological effect caused by the persisting virus. our two part experimental design examined the relationship between bvdv and its pi host. in experiment (exp) , blood cell mrna was collected from pi steers (n= ; confirmed by virus isolation), or uninfected control steers (n= ) and used to identify differentially expressed genes using microarray (affymetrix) and qtrt-pcr approaches. in exp , bvdv naïve pregnant heifers (n= per group) were not infected (control) or infected with ncpbvdv on d. or d. of pregnancy creating pi and ti fetuses, respectively. fetuses were collected by c-section on d. ; infection was confirmed by elisa and qtrt-pcr. histology of placental tissue revealed no placentitis or pathology, and glucose and lactate levels in fetal serum were normal. microarray analysis revealed genes that were differentially regulated in pi vs. controls (p< . , > . fold). qtrt-pcr of steer and fetal blood revealed a significant upregulation of activators and products of the antiviral type-i interferon (ifn-i) pathway. as ifn-i can act as a growthsuppressive cytokine, a long-term upregulation may contribute to the iugr seen in persistent bvdv infection and in other viral infections observed during pregnancy. nricg - from the csrees. patients with a short cervix are at an increased risk for spontaneous preterm delivery. therefore, it is possible that women with a short cervix during pregnancy are also at risk to deliver an sga neonate. this study was conducted to address this question. study design: patients > weeks of gestation were prospectively enrolled into an observational study ( / to / ). transvaginal sonographic examinations were performed every weeks until delivery. the shortest cervical length between - weeks was used for analysis. sga was defined as less than the tenth percentile of birth weight. results: asymptomatic patients were studied. . % of patients delivered an sga neonate ( / ). the median cervical length was mm ( to mm); patients had a cervical length < mm. of these, % ( / ) delivered an sga neonate. similarly, % ( / ) patients with a cervical length < mm had an sga neonate. no relationship was found between a short cervix and sga (short cervix was defined as either < mm and < mm). the frequency of sga was not significantly different between women with a short cervix and those with a long cervix [ % ( / ) vs. % ( / ); p= . ]. newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced background folate is an essential micronutrient for cellular growth. recommendations on periconceptional folic acid use are mainly focussed on prevention of neural tube defects, despite growing evidence that folic acid use may have positive effects on birth weight. objective to examine associations between folic acid use, intrauterine fetal growth and birth weight. design the study was embedded in the generation r study in rotterdam, the netherlands, a population-based prospective cohort study from early pregnancy onwards. methods information on folic acid use was obtained by questionnaires and categorized into three groups: ) preconception start of folic acid use; ) start of folic acid use in first ten weeks of gestation; ) no folic acid use at all. fetal growth measurements included head circumference, abdominal circumference and femur length measured in mid-and late pregnancy, i.e., gestational age - and > weeks, respectively, and birth weight. fetal weight in mid-and late pregnancy was estimated using the haddock method. results data from , pregnant women were available. overall, folic acid use was positively associated with fetal growth. preconceptional folic acid use resulted in an increased growth of grams ( %ci . - . , p< . ) per week from late pregnancy to birth, compared to no folic acid use. similarly, start of folic acid use in the first ten weeks of gestation resulted in an increased growth of grams ( %ci . - . , p= . ) per week from late pregnancy to birth. both preconceptional folic acid use and folic acid use started in the first ten weeks of gestation resulted in higher birth weights of grams ( %ci - ) and grams ( %ci - ), respectively, compared to no folic acid use. a tendency was found for an increased risk of birth weight less than grams when folic acid was not started preconceptionally (or . , %ci . - . ). conclusion periconceptional folic acid use is significantly associated with increased fetal growth resulting in a higher birth weight. ductus venosus isovolumetric relaxation in severely premature growth-restricted fetuses. jason l picconi, katherine drennan, farhan hanif, michael kruger, giancarlo mari. obstetrics and gynecology, wayne state university/dmc, detroit, mi, usa. objective: ductus venosus (dv) doppler waveforms are characterized by two periods in which blood velocity decreases. the first represents the isovolumetric relaxation (ir) at the end of ventricular systole and the second represents atrial contraction at the end of ventricular diastole (a). ductus venosus reversed flow (dvrf) occurring at the time of the a-wave is considered a risk factor for intrauterine fetal demise (iufd). we have previously reported that absent or reversed a-wave flow can be present for weeks before iufd occurs or delivery is performed for non-reassuring fetal testing. the guiding hypothesis for this study is that decreased flow at the time of ir in combination with absent or reversed a-wave flow allows a more accurate prediction of fetal outcome than a-wave absent or reversed flow alone. material and methods: ductus venosus doppler was serially studied in severely premature iugr fetuses (estimated fetal weight < th percentile and umbilical artery pulsatility index > th percentile) from diagnosis until demise or delivery. ductus venosus waveforms were assessed quantitatively for peak systolic velocity (psv), isovolumetric relaxation velocity (irv), and end diastolic velocity (edv). the psv/irv + edv were compared to fetal and neonatal outcome. a kruskal-wallis one way anova, mann whitney u post-hoc test, and a roc, were used for statistical analysis. a p < . was considered statistically significant. results: all fetuses were delivered at < weeks. six cases resulted in iufd, five cases resulted in neonatal demise (nd), and six cases resulted in neonatal survival (ns) at the time of discharge from the hospital. the psv/irv+edv correlated better than a-wave reversal of flow with perinatal outcome. a psv/irv+edv score less than - . resulted in iufd, whereas a score greater than - . resulted in live birth. live births segregated based on estimated gestational age, where those fetuses at less than weeks resulted in nd and those fetuses at or greater than weeks resulted in ns. all results were statistically significant. conclusions: the isovolumetric relaxation velocity is a novel doppler parameter in the assessment of severely premature iugr fetuses. these data indicate that assessment of irv should be considered part of the evaluation of severely iugr fetuses. background: fetal growth restriction has been linked to an increased incidence of chronic hypertension, which may be the result of extracellular matrix changes (ecm) within the vascular tree. in previous studies, ecm changes were observed in the umbilical arteries of preterm growth restricted infants. objective: to determine if there are alterations in collagen subtypes within the umbilical cords from growth restricted fetal rat pups after a period of maternal nutrient restriction. methods: timed pregnant sprague-dawley rats were fed either a % food restricted diet (mfr; n= ) or were fed ad libidum (control; n= ) from d until d of gestation. litter size, fetal weights and placental weights were then noted and umbilical cords from randomly selected pups in each litter were snap frozen. gene expression for collagens i, iii, xiv and decorin was evaluated by real-time rt-pcr with normalization to the gadph housekeeping gene. data were analyzed from fitting general linear regression models with estimation based on the quasi-likelihood estimation (generalized estimating equations) to account for clustering of responses within litters. data are shown as cycles to amplification (ct), which is inversely proportional to mrna levels. results: no difference in median litter size was detected. however, fetal and placental weights in the mfr group were significantly less than those from control dams. no significant differences in umbilical cord gene expression for collagens i, iii, xiv or decorin were detected between mfr and control pups. conclusions: maternal food restriction does not result in any detectable alterations in collagen or decorin expression within the intact umbilical cord, despite causing significant reductions in fetal growth. control (n= ) p-value litter size (median, range) ( , ) ( , ) . fetal weight (mean ± sd) g . ± . . ± . < . placental weight (mean ± sd) g . ± . . ± . . collagen i (mean ± sem) ct . ± . . we have previously demonstrated that the restriction of placental and fetal growth results in fetal hypoxia and fetal brain sparing suggesting a redistribution of cardiac output. furthermore, placentally restricted (pr) hypoxic fetuses are more dependent on their sympathetic nervous system for the maintenance of blood pressure during late gestation. nerve growth factor (ngf) plays a significant role in sympathetic innervation. hypothesis: we hypothesize that the expression of ngf will be higher in the aorta and femoral artery of the pr hypoxic compared to the control fetus. method: carunclectomy was performed in non-pregnant ewes to induce pr. vascular catheters were inserted in pr and control (c) fetuses at - d and arterial blood samples were collected for blood gas analysis. all pr fetuses introduction elevated sflt- levels have been shown to be a feature of pre-eclampsia and is considered to play a significant role in the pathogenesis of the condition. the role of angiogenic factors in fetal growth restriction has not been as well established. this study evaluated the levels of circulating vascular endothelial growth factor (vegf) and its soluble receptor sflt- , in normal pregnancies and isolated placental vascular disease without evidence of pre-eclampsia. method maternal peripheral venous samples were collected antenatally from two groups of pregnant women between - weeks of gestation. group a: uncomplicated normal pregnancies (n = ) and group b: pregnancies complicated by isolated placental vascular disease( n = ) as defined by birth weight less than th centile for gestation and umbilical artery doppler s:d ratio above the th centile for gestation, with no evidence of maternal preeclampsia or pre-existing hypertension. plasma vegf and sflt- levels were measured using standard eliza techniques. comparison between groups were performed by using one way analysis of variance. the maternal plasma sflt- levels (figure ) in group a: normal pregnancies increased with gestation (p < . ). the sflt- levels in group b: isolated placental vascular disease were significantly higher throughout all gestations (p = . ) and did not show a significant variation with gestation ( p = . ). the plasma vegf levels were below the detectable levels of the assay in all samples except normal pregnancies. the significantly increased maternal plasma sflt- levels in established isolated placental vascular disease without evidence of pre-eclampsia suggest a disease of placental origin. the dysregulation of angiogenic factors may be part of a repair and regeneration process in the placenta. objectives: production of -reduced neurosteroids is critical for reducing fetal vulnerability to stressors in pregnancy and inhibition of -reductases ( r) increase acute hypoxia-induced apoptosis in the fetal brain (yawno et al neurosci : . we have developed a model of placental insufficiency that results in fetal growth restriction (gr) in the guinea pig (palliser et al repro sci # ). the aim of the present study was to determine the effects of suppression of -reduced steroid synthesis on apoptosis in vulnerable regions of the fetal brain and on neurosteroid synthetic enzymes in pregnancies compromised by chronic placental insufficiency. methods: placental insufficiency was induced in guinea pig dams by surgical ablation of uterine artery branches at mid gestation (term d). sham operated or gr dams received finasteride (a r inhibitor; mg/kg/day) during late gestation ( d until term). activated caspase- , a marker of apoptotic cell death, was measured by immunohistochemistry and steroidogenic enzymes, r and cytochrome p side chain cleavage (p scc) were measured by real time pcr and western blotting in fetuses ( d) and neonates h after birth. results: placental insufficiency significantly reduced fetal body and organ weight by % whilst sparing brain weight. the number of activated caspase- positive cells was significantly increased in the fetal hippocampus of gr fetuses and further increased in the cortex of gr fetuses receiving finasteride. the neonatal brain also exhibited changes in caspase- activation following gr and finasteride treatment. the fetal adrenal and the placenta responded to the compromise with increased expression of p scc mrna and r protein, respectively. conclusion: the combination of placental insufficiency and suppressed neurosteroid system leads to markedly increased apoptotic cell death in the fetal brain which continues to affect the neonatal brain. the fetus responds to these conditions by increasing steroid synthetic enzyme expression in the placenta and adrenal glands suggestive of a possible neuroprotective feedback process. to study the effect of smoking by mothers on the fetal and neonatal brain using non-invasive magnetoencephalography technique (meg). materials and methods: using fetal magnetoencephalography, cortical auditory evoked responses (aer) were measured from fetuses ranging from to weeks gestational age for a total of recordings. measurements were taken from mothers with a history of smoking (sm) and from mothers with no smoking history (ns). after delivery, five sm and five ns newborns had meg aer measurements twice for a total of recordings. aer was quantified by cross-correlation analysis and its significance was assessed by boot-strap technique. results: aers were detectable in out of fetal recordings in the ns group and of in the sm group. the neonatal response rate was % for each group. the latencies were divided into three components: c ( - ms), c ( - ms) and c ( - ms). in both fetuses and neonates as well, there was a statistically significant difference (p< . ) between the two groups in the c -component and the sm group showed faster aer compared to the lr group. conclusion: meg technique provides a non-invasive approach to study the effects of smoking on developing fetal and neonatal brain. the observed decrease in the latency of fetuses and neonates of the smoking mothers could indicate a hypersensitive cortical response to auditory tone. adenosine (ado) modulates metabolism in adult mammals through multiple mechanisms that involve ado a and a a receptors. objective: this study was designed to test the hypothesis that ado a and a a receptors participate in fetal metabolic homeostasis. methods: experiments were performed in chronically catheterized fetal sheep (> . term). intravascular infusion for h of dpcpx (a receptor antagonist) or zm (zm, a a receptor antagonist) was performed alone or in concert with ado administration. the highly selective ado receptor antagonists were also infused in fetuses in which hypoxia was induced for h by having the ewe breathe a hypoxic gas mixture (fio = . ). data were analyzed by two-way repeated measures of anova. results: blockade of ado a receptors (n= ) increased significantly (p < . ) fetal concentrations of glucose [control (c): . ± . (se)]; experiment (e): . ± . mg/dl] and lactate (c: . ± . ; e: . ± mg/dl) without significantly altering insulin levels and arterial blood gases or ph. antagonism of ado a a receptors (n= ) did not affect plasma levels of glucose, lactate, or insulin. intravenous infusion of ado (n= ), which did not alter pao or paco , increased concentrations of glucose (c: . ± . ; e: . ± . mg/dl) and lactate (c: . ± . ; e: . ± . ). zm (n= ), but not dpcpx (n= ), abolished ado-induced rise in glucose and lactate concentrations. isocapnic hypoxia (pao torr), which increases ( - fold) fetal plasma ado levels to those similar to ado infusion, decreased arterial ph (c: . ± . ; e: . ± . ), and increased fetal levels of glucose (c: . ± . ; e: . ± . mg/dl) and lactate (c: . ± . ; e: . ± . mg/dl) without altering changing insulin concentrations. these effects of hypoxia were not altered by dpcpx or zm. conclusions: ) a receptors modulate plasma levels of glucose and lactate in normoxic fetuses; ) a a receptors mediate the adoinduced rise in plasma glucose and lactate; and ) a and a a receptors are not significant modulators of hypoxia-induced changes in plasma levels of glucose and lactate. supported by usphs hd- . objective: to investigate the dynamic changes of the relationship between leptin, adiponectin and resistin in maternal and fetal circulation during pregnancy and in the early post-natal period. materials and methods: thirty pregnant women with uncomplicated singleton pregnancy delivered at term. maternal and fetal/neonatal venous blood samples were obtained at delivery and at hours from birth. leptin, adiponectin and resistin were measured by specific elisa assays. neonatal anthropometric measurements, glucose metabolism and lipid profile, blood pressure information were obtained. statistical analysis was performed by anova followed by student t test or duncan's test whenever appropriate. correlations were calculated by using the pearson coefficient. results: adipokines concentration at birth and at h from birth was showed in table. multivariate regression analysis showed that fetal leptin levels were positively associated with female gender and adiponectin levels, but not with anthropometric characteristics. fetal leptin and adiponectin levels were not correlated with maternal concentration, whereas fetal and maternal resistin levels were. fetal and maternal resistin concentration was positively associated with gestational age and birth weight and fetal resistin levels correlated negatively with lipid profile. after birth leptin concentration in maternal and neonatal circulation decreased dramatically and the correlation between leptin and adiponectin levels was lost. a positive correlation between resistin and leptin concentration in neonatal circulation was found at h from birth. conclusions: in contrast to adult life a positive correlation between leptin and adiponectin is present in fetal life. placental secretion of leptin, but not of adiponectin and resistin, contributes significantly to maternal and fetal circulating levels. significant changes in the relationship among adipokines occurred immediately after birth and may affect growth and development in early post-natal period. adipokines concentration in maternal and fetal circulation ) antagonism has been shown to normalize placental perfusion and fetal growth in several rat models of fetal growth restriction. however, direct administration of et a antagonists to newborn rats within hours of delivery has been consistently associated with neonatal demise due to failure of the ductus arteriosus to close, raising concerns about the safety of their use late in pregnancy. perinatal exposure to et a antagonists (maternal administration in late gestation) and its impact on rat pup survival and oxygen saturation has not been investigated. objective: to determine the impact of a maternally administered et a antagonist on oxygen saturation in newborn and -day-old rat pups. methods: timed pregnant sprague-dawley rats were treated with fr ( mg/kg/day; et a antagonist) or . % nahco vehicle, by subcutaneous osmotic pump connected to an intravenous catheter, from gestational day (term= days) through parturition. all five pregnant rats in each group delivered spontaneously and nursed their pups through postpartum day . oxygen saturation of each rat pup was measured by pulse oximeter on postpartum days and . results are presented as means ± se. newborn -day neonate vehicle . ± . . ± . eta antagonist . ± . . ± . there were no statistically significant differences between the treatment groups. maternal administration of an et a antagonist from gestational day through parturition, at a dose sufficient to ameliorate fetal growth restriction, has no adverse impact on oxygen saturation in neonatal rat pups. helen l torrance, jan b derks, martijn a oudijk, avnesh s thakor, tereza cindrova-davies, frank van bel, gerard ha visser, graham j burton, dino a giussani. perinatal center, university medical center utrecht, netherlands; department of physiology, development neuroscience, university of cambridge, united kingdom. introduction: the management of perinatal asphyxia remains a major concerns in obstetrics. umbilical cord compressions (ucc) induce fetal asphyxia and ischaemia-reperfusion (i/r). i/r increases reactive oxygen species, for instance via activation of the xanthine oxidase (xo) pathway, which may promote oxidative stress in the fetal circulation. while treatment with allopurinol of asphyxic human neonates reduced free radicals and improved cardiovascular status, treatment started postnatally was deemed too late to prevent oxidative damage (benders et al. arch dis child : , ) . consequently, in complicated pregnancy, recommendations to treat the fetus via the mother, rather than the neonate, with allopurinol are being entertained today. we investigated the effects of maternal allopurinol treatment on indices of oxidative stress in the fetal heart following repeated ucc in sheep. methods: at . of gestation, surgically instrumented sheep fetuses were submitted to i/r ( x min repeated ucc) under maternal allopurinol (n= ) or saline vehicle (n= ) infusion. fetal hearts were collected h after i/r and snap frozen for measurement of (anti)oxidant proteins by western blot. hearts from uninstrumented fetal sheep at . gestation served as controls. statistical comparisons were made using one-way anova. results: i/r episodes led to increased expression of cox- , enos, hsp and decreased expression of sod and gluthatione peroxidase (gpx) in the fetal heart, findings consistent with cardiac oxidative stress. maternal treatment with allopurinol ameliorated these effects (fig. objectives: hypoxic-ischemic fetal brain injury (hie) is a major cause of neonatal death and morbidity. evidence suggests that the brain cell injury associated with chronic hpx (in contrast to an acute ischemic reperfusion injury) is a complex process reflecting a series of adaptive intracellular events that are duration and gestational age dependent. we applied advanced proteomic tools as a next step toward ascertaining a more complete understanding of the impact of hpx on the fetal brain proteome. methods: time-mated guinea pigs were housed in a chamber beginning on day for d, breathing either room air (nmx), or . % or % o ( % o hpx or . % o hpx). on day (term), the fetal brains were removed and preserved for study. total protein was extracted, and the proteome first characterized by d gel electrophoresis. the density of the resulting protein spots were acquired and analyzed using the gs densitometer and pdquest software. identified spots of interest were trypsin digested and subject to maldi mass spectrometry using the proteomics analyzer mass spectrometer for peptide mapping or sequencing. the hpx-induced protein spots were identified based on a minimum of a x change from nmx. results: hpx had a clear effect on the fetal brain proteome. superoxide dismutase (sod), heat shock protein (hsp ), actin (actg ), interleukin- (il- ), and glutamine synthetase (gs) were each up regulated, while cofilin- , brain-type creatine kinase (bb-ck), and - gtp binding protein were each down regulated. all protein changes were proportional to the hpx ( % o hpx vs nmx, % o hpx vs . % o hpx, p< . ). conclusions: this initial application of proteomic techniques confirms that fetal brain damage secondary to chronic hpx (in contrast to acute hpx) is a complex processes characterized by fetal adaptations mediated by multiple protein activations and inactivations. while sod, il- , and gs have each been previously investigated, the potential roles of actg , bb-ck, beta- gtp binding protein, and cofilin- in the fetal response to hpx and the associated brain damage are unclear and represent strong candidates for future investigation. acknowlegement: this study was supported by grants from the phs (r hl - , cpw) and cdc grant (u dp - , cpw). intermittent umbilical cord occlusion occurs in % of human pregnancies.given that elastogenesis within the vascular wall is in part mediated by hemodynamic conditions during development, the blood pressure response to acute hypoxic insults such as cord occlusion may alter arterial composition. elastin content of a central and peripheral artery and blood pressure responses in fetal sheep exposed to varying degrees of cord occlusion were determined. methods: over a day period, near term fetal sheep received total umbilical cord occlusion (uco) lasting min/ hour (mild group; n= ), min/hour (moderate group; n= ), min/hour (severe group; n = ) or no occlusion (control group; n= ). fetal arterial blood samples were drawn min prior to and at the end of cord occlusions. mean arterial pressure (map) was monitored continuously. the carotid and superior mesenteric arteries were excised and a colorimetric assay (biocolor) performed for determination of elastin content. results are presented as mean ± sem. results:umbilical cord occlusions produced decreases in fetal arterial oxygen pressure and oxygen saturation that were progressively more pronounced across mild, moderate and severe uco groups (p < . ). lactate concentration rose during occlusions in the moderate and severe groups, but not the mild group (p < . ).elastin content of the superior mesenteric artery did not differ between the experimental groups and the control group. elastin content of the carotid artery and map response elastin content (μg/mg tissue) max ∆ in map duration of rise in map (min) control . ± . . ± . -mild . ± . . ± . ** . ± . moderate . ± . . ± . ** † . ± . † severe . ± . * . ± . ** † † . ± . † † * p < . ; ** p < . : experimental groups compared to control † p < . ; † † p < . : compared to mild group the max in map was positively correlated with elastin content (r = . , p < . ). conclusions:the transient rise in blood pressure and preferential blood flow to the brain that occur in response to acute hypoxemia during severe intermittent umbilical cord occlusion induce an increase in elastin synthesis in the carotid artery.this may give rise to adaptive programming of postnatal central arterial compliance. electrocortical activity during repetitive umbilical cord occlusions (uco) with worsening acidemia in the ovine fetus near term. martin g frasch, roy mansano, michael g ross, robert gagnon, bryan s richardson. obgyn, chri, univ of western ontario, london, canada; obgyn, harbor-ucla med ctr, torrance, ca. objective: uterine contractions during labour can restrict umbilical blood flow compromising fetal oxygenation and leading to adverse neonatal outcome including newborn encephalopathy/subsequent cerebral palsy. while electronic fetal heart rate (fhr) monitoring is widely used for assessment during labour, abnormal fhr patterns as used clinically have a poor positive predictive value for concerning/significant acidosis at birth. there is limited study of fetal electrocortical activity (ecog) in animal models with induced hypoxia/ acidemia as might be seen during labour. thus, we aimed to induce repetitive ucos in fetal sheep leading to worsening acidemia to determine the predictive value of ecog activity for fetal compromise. methods: near-term fetal sheep (n= ) underwent chronic preparation with artery catheters, ecg/ecog electrodes and placement of an inflatable umbilical cord occluder. following a baseline recording period, fetuses underwent a series of mild ( min every min), moderate ( min every min) and severe ( min every min) ucos with each series lasting h or until fetal arterial ph decreased to < . . fetal arterial blood samples for blood gases and ph were taken at selected time points during the baseline, ucos, and recovery periods. arterial blood pressure (abp) and fhr were continuously monitored and spectral edge frequency (sef) was calculated from ecog. correlation of sef with fhr change was calculated for time intervals using sef maxima and fhr minima during uco series. data are presented as means±sem. results: repetitive ucos led to development of a marked acidosis (ph . ± . to . ± . , p< . ). ± min prior to fetal ph drop < . , the sef of ecog began to increase abruptly during each fhr deceleration from ± hz up to ± hz (p< . ) and was correlated to both fhr change and a decrease in fetal abp during each fhr deceleration at this time (p< . ). conclusion: our findings suggest that in the animal model studied ( ) fetal ecog activity is impaired with progressive acidemia accompanied by fhr decelerations and pathological abp decreases; ( ) there is a consistent temporal relationship between the occurrence of ecog alterations and the subsequent critical drop of ph < . . these findings could contribute to improvement in the clinical ability to predict fetal compromise during labour using ecog/fhr monitoring. background: the ductus arteriosus (da) plays a pivotal role in fetal development and circulation. during gestation, patency of the fetal da is maintained by nitric oxide (no) and prostaglandins (pg). no and pgs are downstream effectors of estrogen (e ) and progesterone (p ). however, the roles of e and p in da regulation have not been studied. objective: we hypothesized that: e and p have opposite effects in the da; that rising e and falling p levels help trigger da closure via specific hormone receptors; and that no and/or pgs mediate da responses to e and p . methods: expression of er , er , pra, prb, and the putative membrane receptors mpr-, -, -, pgrmc- , - , and serbp- was examined by rt-pcr and qpcr on days , , (term), and p . the effects of e and p ( - - - m) on the d fetal da were examined in a cannulated microvessel myography system. e and p effects were also studied in the presence of receptor antagonists (ici , ru ) and no and pg inhibitors (l-name, indomethacin). results: er and pr receptors were expressed at low levels; pgrmc- expression was stronger than other membrane prs, and increased with advancing gestation. under fetal o conditions, e induced rapid, concentrationdependent dilation at - - - m (n= ); p induced progressive vasodilation at all doses (n= ). e and p -induced dilation occurred within - seconds of exposure. while e -dilated das did not respond to ici, ici-pretreated das failed to dilate to the same dose of e (n= ) suggesting antagonism of e effects. the vasodilatory effects of e were partially inhibited by pretreatment with l-name. p -dilated das did not respond to ru , whereas ru pretreated das showed a small, significant response to p (n= ), suggesting partial antagonism or signaling via alternative, ru -independent pathways. pre-treatment with indocin did not block the vasodilatory effects of p . conclusions: contrary to our expectation, both e and p have dilating effects on the fetal da, via no, pgs and non-no, non-pg pathways. expression studies and the rapid response of ex vivo das are consistent with non-genomic actions via membrane receptors. hormone shifts in parturition may have longterm effects on da preparation for postnatal closure, but strategies to maintain fetal da patency or treat newborns with pda will require better understanding of this process. background. for the fetus, arterial blood gases are critical in the regulation of cerebral blood flow (cbf) and cerebral oxygenation. however, the relation of cbf, cortical tissue po (tpo ), and electrocorticographic (ecog) activity to arterial o tension (pao ) are not well defined. in an effort to elucidate these interrelations, we tested the null hypothesis that in the near-term fetus, acute hypoxic-associated cerebral oxygenation and related variables are not closely associated with ecog state. methods. by use of a laser doppler flowmeter with a fluorescent tissue o probe, and with fluorescent-labeled microspheres, and with ecog electrodes, in near-term fetal sheep (n = ) we measured laser doppler cbf (ld-cbf), tpo , ecog (root mean square (rms) voltage with high voltage low frequency, hvlf versus low voltage high frequency, lvhf) and spectral edge frequency- % (sef ) in response to min moderate isocapnic hypoxia. results. ld-cbf, cerebral o delivery, tpo , and several other variables correlated highly with ecog state. in the normoxic control fetus, in association with a shift from hvlf to lvhf ecog activity, tpo decreased briefly to ± from a control value of ± torr; however, as ld-cbf increased ± %, and sef increased to ± from ± %, tpo returned to near normal value. with acute hypoxia (pao = ± torr) when in the lvhf state ld-cbf increased only ± %, as opposed to a ± % increase when in hvlf ecog state. with this degree of hypoxia, tpo decreased to ± torr, sef remained at ± %, and cerebral metabolic rate for o (cmro ) decreased ± % (p< . ). conclusions. for the near-term fetus, normoxia with changes in ecog state was associated with brief periods of decrease in tpo , which were restored quickly by increased ld-cbf. in contrast, acute hypoxia was associated with a significant depression of cortical tpo , cmro , and ecog state, with increased ld-cbf failing to restore cortical tpo . thus, we reject the null hypothesis that in such fetuses, hypoxia demonstrates no compromise in cerebral oxygenation. (supported by usphs hd- ). releasing hormone and arginine vasopressin in the ovine fetus. charles a ducsay, kanchan m kaushal, malgorzata mlynarczyk, kimberly hyatt, dean a myers. ctr. for perinatal biol., loma linda univ., loma linda, ca; ob/gyn, univ. oklahoma hlth. sci. ctr., oklahoma city, ok. background: long term hypoxia (lth) profoundly affects the hypothalamicpituitary-adrenal axis of the fetal sheep. we previously showed that lth causes augmented corticotrope function. the present study was designed to test the hypothesis that lth enhances sensitivity to the acth secretagogues; cortiocotrophic releasing hormone (crh) and arginine vasopressin (avp) resulting in increased anterior pituitary corticotrope secretion of acth. methods: pregnant ewes were maintained at high altitude ( , m) from day to - of gestation (dg), when they were returned to the lab and a maternal tracheal catheter was implanted. maternal po was maintained at a level comparable to that observed at altitude ( mmhg) by nitrogen infusion. on dg, lth (n = ) and age-matched, normoxic control (n = ) fetuses were implantated with vascular catheters. each fetus received a min infusion of either saline vehicle, ng/kg of ovine crh or ng/kg of avp (estimated body weight/min) in a randomized order over consecutive days ( - dg). blood samples were collected at min (baseline prior to infusion), , , and min following the start of the infusion and analyzed for acth, as well as the acth precursors pro-opiomelanocortin and the major processing intermediate kda proacth. results: vehicle had no effect on any of the measured parameters. with crh infusion, acth (pg/ml) increased in both groups over the course of the study. however, peak concentrations (at min) were significantly higher in the lth group compared to control ( ± vs. ± , respectively; p< . ). acth precursor secretion (pm) was greater in lth fetuses compared to controls during the experiment (p< . ). in response to avp, peak acth concentrations were also higher in the lth fetuses compared to control ( ± vs. ± respectively; p< . ), however peak levels were reached at between and min after start of infusion with levels in both groups returning to pre-infusion values. a similar pattern was observed with precursor levels ( . ± . vs. . ± . , p< . , lth vs. control). conclusions: lth significantly increases pituitary sensitivity to both crh and avp. this enhanced sensitivity may be mechanism of our previously observed enhanced corticotrope function. (supported my nih grants hd and hd ). martin g frasch, roy mansano, michael g ross, robert gagnon, bryan s richardson. ob/gyn, chri, university of western ontario, london, canada; ob/gyn, harbor-ucla med. ctr., torrance, ca. objective: repetitive uco leading to worsening fetal acidosis with fetal heart rate (fhr) decelerations (fhr dec ) are accompanied by pathological decreases of fetal arterial blood pressure (bp). we hypothesized this bp change may be caused by the bjr, a vagally mediated reflex with bradycardia and hypotension to reduce cardiac workload, via stimulation of cardiac chemoreceptors during systemic acidemia. methods: ten near-term fetal sheep ( ± dga) underwent chronic preparation with brachial artery catheters and placement of an inflatable umbilical cord occluder. after a control period, fetuses underwent a series of mild ( min every min), moderate ( min every min) and severe ( min every min) uco each lasting h or until ph decreased to < . . fetal arterial blood samples were taken at selected time points during the control and uco periods. bp and fhr were continuously monitored. individual fhr nadir during each fhr dec and accompanying bp change ( bp = [bp at the time of a fhr nadir] -[bp at baseline preceding a uco series]) were determined during all uco. data are presented as means±sem. results: control period ph ( . ± . ), fhr ( ± bpm) and bp ( ± mmhg) were within the physiological range. average depth of fhr dec for all uco was ± bpm and increased with higher lactate concentrations (r = . , p < . ) and lower ph (r = . , p = . ). bp during all uco demonstrated an initial hypertensive response to fhr dec , which decreased with lower ph (r = . , p < . ). bp increased ± mmhg (p < . ) during mild uco (ph to . ± . ), ± mmhg during moderate uco (ph to . ± . , p < . ) and ± mmhg during severe uco (ph to . ± . , p < . ). conclusion: these results suggest that bjr, a short-acting, ph dependent depressor reflex, blunts the physiologic hypertensive response to cord occlusion insults leading to worsening acidemia as might be seen in the human fetus during labour with repetitive variable fhr dec . the failure to increase bp may prevent optimal blood flow distribution responses necessary for preservation of vital organs. role of nos and pde in placental dysfunction following fetal bypass. mitali basu, r scott baker, christopher t lam, kenneth e clark, pirooz eghtesady. cardiothoracic surgery, cincinnati children's hospital, cincinnati, oh, usa; ob/gyn, university of cincinnati, cincinnati, oh, usa. introduction rising placental vascular resistance following fetal cardiopulmonary bypass (bypass) remains the achilles' heel of fetal cardiac surgery. we have previously shown in real-time that nitric oxide (no) production rises during bypass and falls post-bypass, while cgmp levels rise throughout. using immunohistochemical and western analysis of placenta, we examined the involvement no pathway components in this placental vascular pathophysiology. ovine fetuses at - days gestation were placed on bypass for minutes and followed post-bypass for hours. placental samples were collected immediately prior to bypass and at and min post-bypass (n= ) and compared to a group of similarly instrumented controls, (n= ). placental enos, inos and pde protein expression was measured using standard methods and relative expression normalized to beta-actin. statistical analysis utilized students t-test, and anova for trend and group-wise analysis, (significance at p= . ). pre-bypass protein expression did not differ between groups. pde protein levels and phosphorylated pde- expression were both elevated min post bypass, and reduced min post bypass compared to sham, (p= . ). enos levels in the bypass group increased linearly from pre-bypass to min postbypass (p< . ), and were also elevated compared with shams (p< . ), while shams had declined significantly by min post bypass, (p< . ). similarly, phosphorylated enos expression in the bypass group increased linearly from pre-bypass to min post-bypass, (p= . ), while shams trended towards decline by min post-bypass. simultaneously, placental inos expression remained stable within groups, but was lower in the bypass group at and min post-bypass, (p< . ). the preceding data correlated with observed immunohistological changes in the same placental cotyledons. fetal bypass leads to significant increases in placental protein levels of pde , phosphorylated pde- , enos and ostensibly phosphorylated enos. increased pde expression may be a response to increased no and the generated cgmp. this data suggests a compensatory upregulation of pde and enos that eventually fails, leading to increasing placental vascular resistance and subsequent lethal placental dysfunction. angiotensin receptors (rat-ii) in neuronal nuclei of the brainstem have been implicated in integration of baroreceptor responses. in near term fetal sheep, we have previously shown that days of mild chronic hypoxemia increases heart rate (hr) and blood pressure (bp). the aim of the present study was to investigate the effects of chronic mild hypoxemia on the expression of rat-ii in the medulla oblongata and on baroreflex control of the circulation. methods: at days of gestational age, pregnant sheep were submitted to days of hypoxemia ( % of fetal arterial po ; at day fetus ± vs ± . ; mother ± vs ± mmhg). hr and arterial bp were continuously recorded from mother and fetus in control (n= ) and hypoxemic (n= ) animals. baroreflex sensitivity (brs) as well as hr and diastolic bp variability were analyzed (nevrokard software). brainstem was collected and rat-ii expression in the nucleus tractus solitarius (nts) and dorsal motor nucleus of the vagus (dmnx) was measured by autoradiography using i-sarthran labeling. data are shown as mean±sem and were analyzed by t-test. results: hypoxemia induced a greater total binding of i-sarthran in nts and dmnx resulting from an increased expression of at receptors. in the time-domain analysis of brs hypoxemia induces lower baroreflex sensitivity in the fetus (brs in ms/mmhg; . ± . vs. . ± . , p< . ). in the frequency domain, hypoxemia changes the relative power of low frequencies (lf: . - . hz) and high frequencies (hf: . - . hz) of rri and dbp with an increased value of the lf/hf ratio (rri lf/hf . ± . vs ± . , p< . ; dbp lf/hf . ± . vs . ± . , p< . ). also the alpha index for baroreflex sensitivity is decreased in hypoxemic animals (alpha lf . ± vs . ± . , p< . ; alpha hf . ± . vs . ± . , p< . ). no differences were observed in maternal variables. conclusions: our results suggest a link between a prenatal insult, alterations in cns receptors and functional alterations of baroreflex responses. a higher sympathetic outflow, suggested by a greater lf/hf ratio, and impaired reflex gain, both possibly mediated by increases in nts rat , may have potential long-term consequences for the development of hypertension. hd ;hd ;hl . objective : we evaluated velocity profiles, relative wall distension rate (rwdr), and wall shear rate (wsr) of fetal descending aorta (fda) in uncomplicated singleton gestations. study design: ninety seven uncomplicated singleton fetuses were studied throughout gestation using multigate spectral doppler analysis (msda) working with gasp software. this consists of a personal computer (pc) add-on board including a single high-speed digital signal processor. the analysis of echo-signals backscattered from range cells located along the axis of the interrogating ultrasound (us) beam. post-processing was accomplished using gasp software. statistical analysis consisted of spearman correlation and chi-square test. results: velocity profiles, wall distension, wall shear rate were obtained from fetal descending aorta throughout gestation establishing gestational age specific norms. wdr[%] is highly correlated with gestational age in appropriate growth fetuses ( . ± . , rs= . p< . ) with linear regression with standardized coefficient of . (p< . ). in contrast, wsr ( ± ) is unchanged during the first , second and third trimesters (p= . ).conclusion: we speculate that the relative wdr changes observed during gestation, in normally grown fetuses, may be secondary to adaptive vascular and autonomic responses and the evolving composition of the vessel wall, particularly with respect to elastin. conversely, the mean wsr for the study group was independent and constant throughout the gestation. these findings suggest that there is an increase in the diameter of the fetal aorta, which provides adaptation to the progressive flow demands, while preserving other key hemodynamic parameters. in this study, we have established normative values of rwdr and wsr, which are new rheological parameters that may be useful in distinguishing normal and pathologic hemodynamic states. objective: placental dysfunction is a key barrier to successful fetal cardiopulmonary bypass (cpb) for repair of congenital heart defects in utero. endothelial cells regulate vascular tone during fetal cpb through interactions of vasodilation by nitric oxide (no) and endothelin- (et- )-mediated vasoconstriction. the objective was to determine the time during fetal cpb when endothelial cell-mediated changes occur. methods: human umbilical vein endothelial cells (huvec) were cultured in media containing % serum collected from ovine fetuses (n= ) that underwent min of cpb, then were maintained for min. serum was collected before cpb, from pump prime before initiation of cpb, min on cpb, or and min after fetal cpb. control cells were cultured in normal fetal serum. cells were harvested and hr after addition of fetal serum. no production was measured in real time with an electrochemical detection system (inno-t, harvard apparatus). et- was measured in the culture media by elisa. results: no production by huvec after and hr was stimulated above control levels by fetal serum collected during and up to min after fetal cpb (p< . ). serum collected from fetuses that were surgically instrumented, but not yet subjected to cpb, decreased no levels below controls (p<. ). stimulation of et- after and hr of huvec culture peaked with serum collected at min after fetal cpb (p<. compared with control), but was elevated above control levels at each collection time point (p<. , table ). conclusions: fetal cpb releases serum proteins that elevate endothelial cell no and et- production during and for at least min after cpb. although the specific regulatory proteins remain to be identified, the no and et- pathways share circulating mediators and participate in a feedback loop to modulate vascular tone. to test the hypothesis that hypoxia-induced upregulation of no is linked to cardiac inos expression, a selective inos inhibitor, l-nil (l-n -( -iminoethyl)-lysine), was administered in vivo to fetal guinea pigs and no levels measured in fetal hearts. methods: pregnant guinea pigs were exposed to either normal room air (normoxia; %o ) or . %o (hypoxia) in a hypoxic chamber for days prior to term (term= d). l-nil was administered to pregnant normoxic and hypoxic guinea pigs via their drinking water at a dose of - mg/kg/d for days. at d gestation, pregnant sows were anesthetized and near-term fetuses removed via hysterotomy. the fetal hearts were excised, weighed, and normalized to their respective fetal body weights. left cardiac ventricles were obtained and frozen in liquid n and stored at - o c until ready for analysis. the effect of total no product (no and no -, nox) of left ventricles of fetuses exposed to normoxia (n= ), hypoxia (n= ) and hypoxia plus l-nil (n= ) was quantified by a commercial fluorometric no assay kit. results: intrauterine hypoxia significantly reduced fetal body weight by % and increased placenta/fetal body wt by % as expected for hypoxic stress. hypoxia induced a slight increase in heart/fetal body wt by %. fetal cardiac nox levels (pmoles/mg) were increased by hypoxia ( . + . ) by . fold compared to normoxic controls ( . + . ). l-nil significantly decreased (p< . ) nox levels in hypoxic hearts by % ( . + . vs . + . ; hypoxic vs hypoxic+l-nil, respectively). conclusion: l-nil inhibits inos-derived no generation in the hypoxic fetal guinea pig heart. since previous study in our lab showed a significant increase in inos expression but a decrease in enos and no change in nnos expression, we hypothesize that hypoxia upregulates cardiac no generation via the inos pathway. further study is needed to identify the important role of cardiac inos in the adaptive response of fetal hearts to chronic intrauterine hypoxia. objective: fetal asphyxia-mediated metabolic acidosis results in a ph decrease and an increase of lactate and base deficit in blood (bd blood ) and extracellular fluid (bd ecf ). it is not clear whether bd blood and bd ecf are similarly altered with worsening fetal acidosis. in the present study we sought to study the dynamic relations of bd blood and bd ecf to lactate in the ovine fetus subjected to repetitive uco with worsening acidemia. methods: ten near-term fetal sheep ( ± dga) underwent chronic preparation with brachial artery catheters and placement of an inflatable umbilical cord occluder. following a baseline recording period, fetuses underwent a series of mild ( min every min), moderate ( min every min) and severe ( min every min) uco with each series lasting h or until fetal arterial ph decreased to < . . fetal arterial blood was sampled at baseline, immediately before and during the first mild, moderate and severe uco and at min intervals during the moderate and severe uco. bd gap (bd blood -bd ecf ) was studied in relation to lactate. presented as means±sem. results: lactate correlated to bd blood (r= . , p< . ). bd ecf correlated strongly with bd blood (r= , p< . ). bd ecf increased by . ± . mmol/l more than bd blood from baseline to ph nadir, with bd gap therefore decreasing with increasing lactic acidemia ( fig. ) . lactate, bd blood , bd ecf and bd gap correlated to ph (r= . , r= . , r= . and r= , respectively, all p< . ) and ph could therefore be predicted with any of the four acid-base parameters. conclusion: the increases of bd blood and bd ecf and the decrease of bd gap with increasing lactic acidemia suggest a relatively more rapid accumulation of [h+] in ecf during uco of increasing severity. this may be because the metabolic build-up of acidosis occurs primarily in the tissues and the endothelial permeability for [h+] is impeded during increasing acidosis with atp depletion thus decreasing [h+] movement from ecf to plasma. previous studies have shown that intraperitoneal transplantation of human umbilical cord blood (hucb)-derived mononuclear cells led to the specific 'homing' of these cells to a hypoxic-ischemic brain lesion in perinatal rats. motor deficits resulting from the lesion were alleviated upon transplantation. thus, the presence of hucb cells at the lesion site seems to be a major prerequisite for their potential beneficial effect. however, the mechanisms of cell 'homing' are still unclear. in this study, we focused on elucidating mechanisms underlying the specific migration of hucb-derived mononuclear cells to the brain lesion. one possibility to induce cell 'homing' are chemotactic signals present at the lesion site. the cxc chemokine stromal derived factor- (sdf- ), which was previously shown to be a potent chemoattractant for directed migration of other stem and progenitor cells, is a putative candidate in our lesion paradigm. therefore we investigated the spatial and temporal expression of sdf- in brain hemispheres with or without hypoxic-ischemic lesion. sdf- expression was substantially increased at the lesion site during the investigated period of fourteen days after the insult. furthermore, hla-positive hucb cells were mainly detected in sdf- expressing brain regions and we were able to show that these cells express the sdf- receptor cxcr on their surface. the functional implication of sdf- in directing hucb cell migration was determined by application of neutralizing sdf- antibodies in vivo, resulting in a reduced number of hucb-derived mononuclear cells at the lesion site. with these functional effects, together with the observed timing and location of its expression, the involvement of the chemokine sdf- in hucb cell 'homing' seems conceivable. novel pathways in inflammation-induced fetal brain injury. michal a elovitz, jinghua chai. obstetrics and gynecology; crrwh, university of pennsylvania, philadelphia, pa, usa. intro: while survival of extremely preterm infants continues to improve, the number of children with cognitive impairment and/or cerebral palsy is increasing. if preterm birth (ptb) cannot be prevented, then strategies to identify and treat fetal brain injury in the setting of a ptb must be investigated. these studies were performed to explore novel pathways involved in fetal brain injury in the setting of inflammation-induced ptb. methods: cd- mice on e receive intrauterine injection of lipopolysaccharide (lps) or saline. hours after injection, fetal brains from the left upper horn were harvested. fetal brains were removed from each dam with dams per treatment group. separate rna samples were prepared and used for microarray (ma) analysis. all protocols were conducted as described in the affymetrix genechip expression analysis technical manual in the ma core facility using the moe av chip. data analysis was performed using significance analysis for microarray (sam). the brain samples from the same dam were considered as dependent samples. pathway analysis and functional annotation clustering tools were used with david. validations studies using qpcr with fetal brain samples (n= - per group) were performed. results: while there was significant differences in gene expression between lps and saline exposed fetal brains, variability existed even between pups from the same dam. genes were significantly differentially expressed between lps and saline brains (p< . ). with a p value of < . , genes were differentially expressed. pathway analysis revealed significant involvement of ) the cadeherin, cadherin-like, cell fraction and calcium binding (enrichment score . ) and ) ribosomal processing, rna metabolism, pyrimidine metabolism (enrichment score . ). specifically, genes involved in neurogenesis, synaptic function, and neuronal and glial metabolism were most differentially regulated. qpcr confirmed observed fold changes in / genes analyzed. inflammatory pathways were not differentially regulated. conclusions: current theories regarding fetal brain injury in ptb focus on activation of inflammatory processes as essential events. this data suggests that long-term neurological injury in a ptb may be secondary to altered neuronal function, metabolism and/or communication. disruptions in these pathways should be explored as key mechanisms to adverse neurological outcomes in preterm neonates and should be targets for future investigations. regulation of microglial activation in the developing murine brain. mariya hristova, virginia zbarsky, daniel cuthill, adam wallace, donald peebles, gennadij raivich. institute for women's health, university college london, london, united kingdom. introduction: the aim of this study was to assess the process of microglial differentiation in developing white matter, an area of the brain that is particularly vulnerable to damage pre-myelination (approx weeks gestation). microglia form a distinctive non-neuronal component. although related to peripheral macrophages they undergo highly specific processes of regional maturation and differentiation inside the brain with a slimming of the cell body, development of very elaborate crenulated arborised branches and downregulation of most macrophage activation markers. this process is relatively rapid in most grey matter brain regions, but is retarded in and around the subcortical white matter (swm) giving rise to the phagocytic fountains of microglia (fom). methods:we examined the process of deactivation and morphological differentiation in the cortex and swm of mice - days after birth (p -p ) using confocal microscopy for monoclonal antibodies against alpha and beta integrin subunits and the costimulatory factor b . , colocalised with standard microglial marker iba . results: strikingly, only the fom macrophages, but not cortical microglia, strongly expressed typical activation markers alpha- , alpha- , alpha-m, alpha-x, beta- and b . . the data for alpha-x are shown as an example in the figure; cortical microglia are shown in the grey bars and swm in black. fom activation was maximal at p , decreased linearly over p and p and disappeared at p . this process followed the presence of ingested phagocytic material but correlated only moderately with ramification, demonstrated by non-ramified but inactive p cortical microglia and formation of stubby processes in p fom. conclusion: these data describe strong and selective biochemical activation of fom phagocytes in p -p swm, roughly equivalent to early rd trimester human foetal development. this presence of highly active phagocytes in the neighbourhood of vulnerable wm could play an important role in the genesis of axonal damage in the foetus and premature neonate. , pp. - ) . mbp is expressed in mature oligodendrocytes (jakovcevski and zecevic, glia ) . although myelination in the fetal sheep brain, a model extensively used to evaluate fetal development, has been described using conventional staining techniques (barlow, j comp neurol ) the use of specific mbp staining allows a more precise determination of the onset of myelination (antonow-schlorke et al., reprod sci . , , a) . aim: to use mbp expression to determine the trajectory of development of different white matter tracts of fetal sheep brain. methods: the ontogenetic profile of mbp expression was estimated in healthy fetuses at . (n= ), . (n= ), . (n= ), . (n= ), . (n= ), . (n= ) and . (n= ) of gestation (term days). after brain fixation and embedding in wax, sections at the level of the optic chiasm were stained with a monoclonal anti-mbp antibody using the abc-technique. immunohistochemical distribution of mbp was morphometrically assessed in the dorsal internal capsule and cortical white matter tracts, i.e. the lateral centrum semiovale, superficial white matter and median corpus callosum using an image analysis system (scion image . , nih, usa). results: mbp expression of various fetal white matter structures started at different time points; initially in the internal capsule at . of gestation followed by the cortical white matter structures at . of gestation. cortical myelination advanced from the cortical deep white matter via superficial white matter to the corpus callosum reflecting different rates of progression. conclusions: the onset of mbp expression estimated here explicitly antedates previous observations in sheep (barlow, ) the way the embryonic heart functions before cardiac morphogenesis is completed is still subject of many studies. to gain more insight into the early cardiac structure-function relationship, doppler blood flow velocity waveforms at four different locations in the embryonic chicken heart during cardiovascular development were assessed. we collected waveforms using high frequency ultrasound biomicroscopy with a -mhz transducer at hh stages , and which are comparable to humans at to weeks of gestation. waveforms were obtained at the inflow tract, the primitive left ventricle, the primitive right ventricle, and at the outflow tract in ten different embryos per stage. by exploring the time relation between the waveforms, cardiac cycle events were outlined. our results demonstrate that stage and location dependent, intracardiac blood flow velocity waveforms can be obtained in the chicken embryo which reflect stage dependent pumping mechanisms. the blood flow profiles assessed at the four locations in the embryonic heart demonstrated a developmental related increase in velocity. in the primitive ventricle the passive filling wave decreased, whereas the active filling wave increased resulting in a decreased p to a ratio in the course of time. high frequency derived cardiac blood flow velocity characteristics support previous findings that the embryonic heart functions like a suction pump at early development and transforms towards another pumping mechanism at later developmental stages. these findings are of importance for the interpretation of human first trimester cardiac velocimetry studies. figure a . changes in the perimeter of the thymus with gestational age by fetal gender are depicted in figure b . background. for the fetus, the roles of arterial blood gases are recognized to be critical in the regulation of cerebral blood flow (cbf) and cerebral metabolic rate for oxygen (cmro ), cortical tissue po (tpo ), and electrocorticographic (ecog) activity. in addition, metabolites such as adenosine (ado) are important in this regard. nonetheless, the relation of adenosine and its metabolites to these indices of cerebral oxygenation are not well defined. in an effort to elucidate these interrelations, we tested the null hypothesis that acute hypoxic-associated cerebral oxygenation and related variables are not closely associated with adenosine. the most common cause of perinatal brain injury is chronic hypoxia/ischemia. the mechanisms are complex and poorly understood. applying proteomics tools, we identified a set of hypoxia-related proteins in the fetal guinea pig (gp) brain (companion abstract). one protein, cofilin- , which regulates the rapid cycling of actin assembly and disassembly, was dramatically altered by chronic brain hpx. herein, we test the hypothesis that confilin- modifications during hpx contributes to brain damage via apoptosis and is an example of an adaptive response that becomes maladaptive. methods: time-mated gps were housed in a chamber from d to d (term) with either room air (nmx) or . % or % o . fetal brains were removed and sections prepared for double staining specific to bax and dephosporylated cofilin- . total protein was isolated and equal amounts loaded on a sds gel, separated by electrophoresis, and transfered to pvdf membranes probed with primary antibodies to dephosphorylated and phosphorylated cofilin- , bax and bcl-xl, and incubated with second antibody. protein signals were detected, quantified by densitometry, and normalized to -actin. total rna was isolated, reverse-transcribed, and quantified by real-time pcr using sybr green i labeling. expression was calculated by the ct method using s for control. melt analysis was performed to confirm specificity of the amplification, and efficiency determined by the slope of the standard curve. the mitogen activated protein kinase (mapk) signalling pathway is upregulated in perinatal hypoxic-ischaemic brain. the role of the extracellular signal-regulated kinase (erk) cascade, a pivotal component of mapk signalling, remains unclear with reported actions ranging from mitogenic and trophic effects to a neuronal death-promoting role. the aim of this study was to assess the role of neuronal erk activity using selective neuronal inhibition in a perinatal model of hypoxic-ischemic brain injury. methods: we explored the effects of selective neuronal inhibition of erk activation using transgenic mice expressing dominant-negative (dn) mek , the upstream activator of erk / , which was under the control of the pan-neuronal talpha alpha-tubulin promoter. p-erk immunoreactivity was quantified following a hypoxic inschemic (hi) insult in p c bl/ mice, caused by unilateral occlusion of the carotid artery, followed by hypoxia with % oxygen for mins at °c. the volume of surviving brain on the affected hemisphere was expressed as a % relative to the control side. results: expression of the mek dn was associated with a reduction in erk / activation following hypoxia ischaemia, as assessed by p-erk immunoreativity. compared with the wild type, littermate controls, mek dn animals exhibited significantly decreased volume of forebrain damage brain following unilateral, min hi insult (*p< . , **p< . , anova). similar protective effects of mek dn were observed in cerebral cortex, hippocampus, thalamus and striatum when compared to wild type littermate controls and correlated with a significant reduction in microglial activation in all brain areas. conclusion: overall, these results suggest that neuronal mek and its downstream signals have an important death-inducing role in this model of perinatal brain injury and could serve as potential targets for therapeutic intervention. oup, ) . however, whether melatonin protects placento-fetal development during hypoxic or undernourished pregnancy is unknown. we investigated in rats the effects on placental and fetal growth of maternal treatment with melatonin in hypoxic and undernourished pregnancy. methods: on pregnancy day , wistar rats were divided: control ( % o ) + melatonin ( g.ml - drinking water), hypoxia ( % o ) + melatonin, and undernutrition ( % reduction in food intake) + melatonin (n= per group). on day , dams were anaesthetised, the pups, placentae and fetal brain were weighed. results: relative to controls (fetal weight: . ± . g; brain/body weight ratio: . ± . mg/g; n= ), both hypoxic ( . ± . g; . ± . mg/g, n= ) and undernourished pregnancy ( . ± . g; . ± . mg/g, n= ) promoted asymmetric iugr (p< . ), without affecting placental weight. melatonin treatment had no effect on iugr, but it decreased placental weight in normoxic ( . + . , n= ), hypoxic ( . ± . , n= ) and undernourished ( . ± . , n= ) pregnancies relative to untreated controls ( . ± . , n= ; p< . ). when fetal body weight was expressed relative to placental weight, a measure of placental efficiency, melatonin prevented the fall in the ratio in undernourished, but not hypoxic pregnancies (fig. objective: midkine (mk) is a -kda heparin-binding growth factor with various functions including cell proliferation, migration, differentiation and angiogenesis. mk expression is strictly regulated in temporal sequence; it is highly expressed during midgestation. we recently studied mk expression in the midgestation human fetus, and showed that the highest mk expression were observed in the adrenal gland, brain, lung and kidney. in the present study, we investigated the profile of mk in human amniotic fluid (af) and amnion (am). methods: amniotic fluid and amniotic membranes were collected at diagnostic amniocentesis, preterm no labor, and term no labor. mk protein levels were analysed by western blot. expression of transcripts encoding mk and putative mk receptors were examined by rt-pcr and real-time quantitative rt-pcr (qpcr). results: ) western blot analysis demonstrated abundant mk protein in the human am; mk levels were higher at midgestation than at term ( -fold: wks vs. wks). ) tissue transglutaminase known to polymerize mk was abundant in af. ) qpcr revealed that mk mrna was not expressed in am whereas it was highly expressed in the fetal adrenal, kidney and lung (positive controls). ) among the receptors implicated in mk signaling, lowdensity lipoprotein receptor-related protein and syndecan- were expressed in am while protein-tyrosine phosphatase, anaplastic lymphoma kinase, and syndecan- were not. conclusions: abundant mk protein in the midgestation af is likely to be derived from the fetus. mk in af may play a role in feto-amniotic communications and/or development of fetal organs exposed to af. short term hfix expression. we hypothesized that long term hfix expression could be achieved in fetal sheep using an aav vector, without stimulating an immune response to the transgenic hfix protein. we injected aav hfix vector ( - x p/kg) into the peritoneal cavity of fetal sheep under ultrasound guidance in early (n = ) or late (n = ) gestation. fetal blood was retrieved by ultrasound guided sampling from the intra-hepatic umbilical vein. fetal and lamb blood was tested for hfix expression using elisa, antibody responses using functional assays, and for liver damage up to a year after birth. vector spread was detected in maternal and fetal tissues by quantitative pcr analysis. results: the highest level hfix was detected days after late ip injection ( % and % normal human levels). early gestation ip injection gave . % and . % at and days after injection. hfix levels dropped rapidly correlating with the increase in size of the fetal liver and lamb. however, hfix was detectable at a low levels ( . %) year after birth in early and months after birth in late gestation injected lambs. up to year after birth, liver function tests and bile acid levels were normal, showing no evidence of liver pathology. no functional antibodies to the hfix protein or aav vector were detectable. high vector levels were detected in the fetal liver, and other peritoneal organs; no vector was present in fetal gonadal tissue. conclusion: hfix expression is detectable up to year after delivery of aav vector to the fetal sheep using a clinically applicable method. this is the first study to show long term hfix expression after fetal gene therapy in a large animal. further work will include testing for immune tolerance to exogenous hfix protein in these animals. objective: placental estrogens play a pivotal role in the endocrine control of pregnancy and may be involved in the key changes occuring during parturition. it has been established that crh interacting with crh receptor has a positive effect on estrogen production throughout pregnancy. urocortin (ucn ), a novel peptide of the crh family binding exclusively crh receptor , is expressed by human placenta and the aim of the present study was to evaluate the influence of ucn on estrogen biosynthesis in cultured trophoblast cells. methods: cultured term placental cells were treated with various concentrations of ucn in the presence of the estrogens precursors dehydroepiandrosterone sulphate (dhea-s), androstenedione or testosterone. estradiol secretion was measured in the culture medium using a specific elisa, p arom mrna and protein expression were evaluated by real time pcr and western blot analysis respectively. results: the addition of ucn , in presence of dheas significantly increased e levels at , and hours treatment, while in presence of androstenedione and testosterone an increase in e secretion was detected only at , and hours (at different ucn doses). both p arom mrna and protein were up-regulated in presence of each estrogen precursor and the addition of ucn caused a synergistic increase. anti-sauvagine (a crh type receptor antagonist) resulted in a significantly attenuated ucn effects on e secretion and on p arom mrna and protein expression. conclusions: the present study supports a possible role of ucn on placental e biosynthesis: e secretion and p arom transcript and protein expression were significantly increased after ucn treatment. in conclusion, the crf family may play a major role on placental steroidogenesis, stimulating dheas secretion in fetal adrenals by crh and controlling placental estrogen biosynthesis through ucn . a possible influence on the mechanisms of parturition may be hypothesized. increased expression of kiss- gene in preterm placenta. letizia galleri, michela torricelli, chiara voltolini, fernando m reis, felice petraglia. department of pediatrics, obstetrics and reproductive medicine, university of siena, siena, italy. introduction placenta expresses a large number of peptides involved in delivery. neuropeptides, cytokines, are expressed and secreted by human placenta at the time of preterm delivery. human placenta is a major source of kiss- , a -amino-acid peptide encoded by a putative metastasis suppressor gene. kiss- acts on its placental g protein-coupled receptors (kiss- r); this peptide stimulates release of oxytocin in rats, the most potent known uterine stimulant, suggesting a possible role of kiss- in the mechanisms of labor. aim of study the aim of this study was to evaluate placental expression of kiss- at preterm labor. material and methods placental tissue and plasma samples (both maternal and fetal) were collected at term in the absence of labor (tnl), at term spontaneous vaginal delivery (tl), and at preterm labor (ptl). changes in placental mrna expression were determined by real-time quantitative rt-pcr analysis. kiss- protein levels were measured by specific immunoenzymatic assay (elisa). results placental kiss- mrna expression was significantly higher (p< . ) in ptl than in tnl and in tl. however, maternal and fetal plasma kiss- levels did not differ among tnl, tl, and ptl samples. conclusion the present study showed that placental kiss- mrna expression is increased in preterm delivery. further studies are needed to better understand the role of kiss- on cascade leading term and preterm labor. placental angiogenesis is essential for placental development, which occurs under a hypoxic environment ( - % o ) during normal pregnancy. it has been reported that in transformed human dermal microvascular endothelial cells, hypoxia activates erk / , which stabilizes hypoxia-inducible transcription factor- (hif- ). however, signaling mechanisms governing placental angiogenesis under hypoxia is largely unknown. herein, we tested whether hypoxia affected fgf -and vegf-stimulated cell proliferation partly via activating erk / and stabilizing hif- protein levels in human placental artery endothelial (hpae) and transformed human placental microvascular endothelial (hpme) cells. methods: cells cultured under normoxia ( % o ) or hypoxia ( % o ) for days were treated with fgf and vegf. after days, the number of cells was determined. activation of erk / and levels of hif- protein were determined by western analysis. results: under normoxia, fgf and vegf stimulated (p < . ) cell proliferation and induced ( min, p < . ) erk / phosphorylation in hpae and hpme cells. hypoxia promoted (p < . ) fgf -and vegf-stimulated cell proliferation in hpae cells, whereas hypoxia blocked (p < . ) such actions in hpme cells. hypoxia enhanced fgf -, but not vegf-induced erk / phosphorylation in hpae cells. in contrast, hypoxia promoted (p < . ) vegf-, but not fgf -induced erk / phosphorylation in hpme cells. hypoxia increased (p < . ) hif- levels in the hpae cells: first detected at . hr and maintained up to hr. hpme cells had high basal levels of hif- ( folds; p < . ) compared with hpae cells. hypoxia did not alter hif- levels up to hr and decreased (p < . ) hif- levels at hr in hpme cells, conclusions: in hpae cells, hypoxia enhances fgf -and vegf-stimulated cell proliferation possibly partially via promoting activation of different protein kinases. this stimulatory effect is associated with increased hif- protein levels. however, inhibition by hypoxia on fgf -and vegf-stimulated hpme cell proliferation is associated with relatively high hif- levels in the first hr and decreased hif- levels at hr. thus, these data suggest that different signaling mechanisms are involved in hypoxia-modulated growth factor-induced placental angiogenesis in which an increase in hif- levels plays a critical role. objective: corticotrophin releasing factor (crf) is a well established neurohormone involved in the initiation of the stress response. we recently documented that rat placenta is analogous to human placenta in the expression of crf-mrna and protein, and that placental crf release may contribute to in utero meconium passage. time-of-day variation in crf expression is a highly recognized phenomenon at the brain cellular sites of crf synthesis. we sought to determine whether crf expression in rat placenta is subject to time-of-day variation. method: time-dated pregnant rats were obtained on day of gestation (term= days), housed in under h- h light-dark conditions (lights on ). lab chow and water were continuously available. on day , pregnant rats were quickly anesthetized by exposure to isoflurane, abdomen opened and fetuses and placenta exteriorized either at - hr (zeitgeiber time, zt ) or - hr (zt ). individual placentas were processed either for rna extraction or immunohistochemical investigation. the levels of crf-mrna were assessed by pcr using rat specific pcr primers. pcr bands were subsequently cloned and sequenced. bouin's solution fixed paraffin sections of placenta were subjected to crf immunohistochemistry with antibodies specific to rat species and intensity of immunostaining was analyzed using image pro-plus software and expressed in arbitrary units (au). results: one specific pcr band of bp size was consistently identifiable in placenta harvested at zt but not at zt . nucleotide sequence of the pcr band confirmed its identity as crf-mrna. intensity of crf-immunostaining was significantly greater at zt in giant trophoblast (gt) cells (gt-crf: zt = . ± . au, zt = . ± . au, p= . ) but not in spongiotrophoblast cells (stc) (stc-crf: zt = . ± . au, zt = . ± . au, p=ns) or labyrinth cells (lbc) (lbc-crf: zt = . ± . , zt = . ± . au, p=ns) . conclusion: similar to adult brain, rat placenta expresses crf mrna and protein. time-of-day variation of crf expression originally seen in central nervous system neurons is also identifiable in giant trophoblasts cells at zt . these findings suggest that stress-mediated placental crf release, and potentially fetal meconium passage, may be dependent upon time-of-day. objectve: transplacental water flow is essential for the provision and maintenance of fetal body water and amniotic fluid. water flow across membranes is regulated by aquaporin (aqp) water channels in many tissues. thus aqp , expressed in the placenta, is a candidate to regulate maternal to fetal fluid exchange. maternal beta-mimetics have been hypothesized to augment fetal growth by increasing the availability of nutrients and perhaps water. as camp acts as a second messenger to increase expression of selected aqps in other tissues, we sought to determine if betamimetics acting through camp could modulate placental aqp , and potentially influence placental water transfer. methods: trophoblastic cell cultures were established in first trimester-derived extravillous htr- /svneo cells and term placenta-like trophoblast carcinoma cell line jeg- . cultures were treated with sp-camp, a membrane-permeable and phosphodiesterase resistant camp, and forskolin, an adenylate cyclase stimulator, in doses of . , and m for hrs (aqp mrna expression) and hrs (aqp protein expression). for time course experiments, cells were incubated with μm of either sp-camp or forskolin for , and hrs at °c, % co . after cell harvest, mrna and protein expression were assayed using real time pcr and western blotting. results: sp-camp and forskolin increased aqp mrna expression in both cell lines after hrs (p< . ) in a dose-dependent manner. protein expression paralleled the increase seen in the mrna. m of sp-camp and forskolin stimulated aqp mrna expression after hrs in htr- /svneo cells and after hrs in jeg- cells (p< . ). m of either sp-camp or forskolin stimulated aqp protein expression in both cell lines after hrs (p< . ) and the expression remained high at hrs. conclusion: aqp gene expression in trophoblast cells is up-regulated by camp agonists. these results suggest that maternal beta-adrenergic agonists or antagonists may modulate maternal-fetal water flux via modulation of aqp water channels. rat placenta expresses corticotrophin releasing factor-binding protein and mrna. jayaraman lakshmanan, thomas r magee, bindu cherian, sharon k sugano, hanalise huff, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: corticotrophin releasing factor-binding protein (crf-bp), a kda secreted glycoprotein, was originally isolated from human plasma. it binds crf and urocortin i with an equal or greater affinity than does the crf receptor. crf-bp expression has been reported in target tissues such as brain and placenta. based on its ability to inhibit crf actions in vitro, it is speculated to function as a "gate keeper" for crf-initiated stress responses. we recently documented expression of crf and urocortin- in rat placenta. in the present study we sought to establish the expression of crf-bp in rat placenta by immunohistochemical and pcr-analyses. methods: placental tissues (n= ) collected from sprague-dawley pregnant rats on day of gestation (term= ) were either fixed in % paraformaldehyde solution (ph . ) and paraffin embedded or processed for total rna extraction. paraffin sections of five micron thickness were subjected to immunohistochemical analysis with goat polyclonal antibodies to human crf-bp precursor (sc- santa cruz biotechnology, ca) by avidinbiotin-peroxidase complex technique. the structure of cloned human crf-bp precursor exhibit significant amino acid sequence homology among all species studied. immunoreactivities on the sections were quantified using image pro . software and staining intensity (od/area) expressed as arbitrary units (au). all values are expressed as mean±sem. for pcr, cdna was synthesized and pcr amplified with a one step rt-pcr kit. fragments were gel purified, clone into plasmid vector and dna sequenced. results: the crf-bp antibody elicited strong positive staining in decidua, giant trophoblasts, spongiotrophoblasts and labyrinth cells. the results of image analyses revealed (au): decidua: . ± . , giant trophoblast cells: . ± . , spongiotrophoblasts: . ± . , fetal membranes: . ± . . pcr analyses identified a single bp band, consistent with crf-bp. conclusion: our study establishes for the first time that rat placenta is analogous to humans in that both express crf-bp mrna and protein. immunohistochemical findings reveal that crf-bp protein expression occurs at multiple sites within the placenta. expression of per clock protein in rat placenta: an internal timer for placental functions. jayaraman lakshmanan, reuben lakshmanan, sharon k sugano, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: corticotrophin releasing factor (crf) expression time-of-day variation occurs in giant trophoblast cells on the maternal side of the rat placenta. this temporal change in crf expression pattern is very similar to that of central nervous system neurons, suggesting that placental cells may use a similar mechanism to read time of the day. the self-sustaining rhythm generating capacity of the suprachiasmatic nuclei is believed to be derived from cell-autonomous, transcriptional feed-back loops dependent on a number of canonical clock genes. in the present study we sought to determine whether rat placenta expresses period gene (per ), one of the clock/cycle related genes. methods: time-dated pregnant sprague-dawley rats were received on day of gestation and housed in a controlled environment ( - h lights on) with free assess to food and water. placentas collected on days and of gestation (term= days) between and . am were fixed in % paraformaldehyde and paraffin embedded. for each gestational ages a total of placentas from different pregnant rats were used. paraffin sections ( sections per placenta) were subjected to immunohistochemical analysis with antibody to per ( : , santa cruz biotechnology, ca) by abc technique and , 'diaminobenzidine as a chromagen. sections were examined under microscope, imunostaining quantified by image pro . software and expressed in arbitrary units (au). data are presented as mean ± sem. statistical significance was analyzed by anova with a p value < . as significant. conclusion: the present results indicate that rat placental cells, devoid of any neural innervations, express per clock protein, similar to central nervous system neurons. based on the differences in the relative intensities between trophoblasts and labyrinth cells on day of gestation, we conclude that fetalmaternal interactions in per regulation disappear at term (or at the time of birth.). our findings imply that per may function as internal physiological modulator in placenta. to determine the mechanism(s) underlying placental time-of-day crf variation, we examined the effect of maternal administration of betamethasone (a synthetic glucocorticoid) on nuclear gc receptor expression in placental cells. method: time-dated pregnant rats (n= ) on day of gestation were given a single subcutaneous injection (at : am) of betamethasone ( μg/kg body weight) while control pregnant rats (n= ) received saline. dams were exposed to isoflurane anesthesia at : am, and placentas harvested, fixed in bouin's solution and paraffin embedded. sections were subjected to immunohistochemical analysis with gc-receptor antibody (sc- , santa cruz biotechnology), with immunoreactive material identified by abc technique using , ' diaminobenzidine as a chromagen. percentages of gc-nuclear receptor (gc-nr) positive cells and their intensities (od/area) were quantified using image pro . plus software. all values are expressed as mean ± sem. statistical analysis was by anova with p< . considered significant. results: in placentas of saline exposed pregnant rats, isolated labyrinth (lb) cells (< %) were positive to gc-nr. no positive staining for gc-nrs was seen either in giant trophoblasts (gt) or in spongiotrophoblasts (st). betamethasone administration was associated with a significant and marked increase in gc-nr staining in all three placental cell types (p< . ). among the cells, gt ( ± %) demonstrated a greater percentage of cells expressing gc-nr than did st ( ± %) or (lb= ± %) (p< . ), though there was similar immunoreactive intensities (gt: . ± . , st: . ± . , lb: ± . au; p=ns) conclusion: our findings indicate that all placental cells respond to gc with upregulation of gc-nr with an enhanced response among gt cells. these results suggest that endogenous or exogenous maternal stress-induced gc exposure may influence signaling responses within both maternal and fetal placental compartments. ovine placenta at very-preterm gestation expresses corticotrophin releasing factor (crf), crf-binding protein (crf-bp) and glucocorticoid receptors (gr). jayaraman lakshmanan, john d richard, guo l liu, sharon k sugano, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: in humans, the placenta is the major source of maternal and fetal plasma crf. based on its critical functions, crf is considered as a "placental clock" of parturition. we recently reported that ovine fetal as well as maternal plasma contain measurable amounts of crf at near-term but not at very preterm gestation. we interpret the absence of crf in plasma at very preterm gestation is either due to lack of placental crf expression and/or placental crf release. here, we examined the expression status of crf, crf-bp (a known specific binding protein for crf and a known regulator of crf functions in human placenta) and gr (a known positive regulator of crf expression in human placenta) in ovine placenta collected at very-preterm gestation. method: placenta harvested from time-dated pregnant ewes on ± days gestation were fixed in bouins's solution and processed for paraffin embedding. paraffin sections were subjected to immunohistochemical analysis with polyclonal antibodies specific to ovine crf( : - : , phoenix pharmaceuticals, ca,) crf binding protein ( : - : , sc ) and gr ( : - : , sc: , santacruz biotechnology, ca). immunoreactive material on the sections were identified as brown staining by abc technique using diaminobenzidine as chormagen. immunoreactive material was quantified by image analysis using image pro . plus software and the immuoreactive intensity (od/area) expressed as arbitrary units (au). results: strong positive staining for crf ( . ± . au), crf-bp ( . ± . au) and nuclear-gr ( . ± . au) were noticed in syncytiotrophoblast cells in all placental sections obtained from pregnant ewes at days gestation. control sections exhibited no positive staining. conclusion: our findings indicated that ovine placenta at very-preterm gestation expresses crf, crf-bp and gr. these results suggest that absence of measurable crf in maternal and fetal plasma at very-preterm gestation is not due to lack of placental crf expression but rather due to the absence of regulated crf secretory mechanisms. rat placenta expresses urocortin i protein and mrna. thomas r magee, michael g ross, john d richard, sharon k sugano, jayaraman lakshmanan. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: urocortin i (ucn- ), a amino acid neuropeptide belongs to corticotrophin releasing factor (crf) stress hormone family. in humans, the placenta and several gestational tissues have been reported to express ucn- protein and ucn- mrna. a number of published studies indicate that ucn- is similar to crf in expression pattern and biological functions. we recently reported that rat placenta is a site of crf protein and crf mrna expression. in the present study we sought to determine whether rat placenta expresses ucn- protein and ucn- mrna. methods: placenta (n= ) collected from pregnant rats at day gestation were either fixed in bouin's solution and processed for paraffin embedding or placed in rna later preservative and frozen for rna extraction. for immunohistochemical localization, five micron thickness paraffin sections were cut and immunostained with rabbit polyclonal antibodies to ucn- ( : to : , sigma) by standard abc technique. control sections were incubated with omission of ucn- antibody. immunoreactive materials on the sections were identified using , ' daminobenzidine as chromagen. immunostaining intensity (od/area) was quantified by image-pro plus software and expressed in arbitrary units (au). for pcr, cdna was synthesized and pcr amplified with a one step rt-pcr kit. fragments were gel purified, cloned into a plasmid vector and dna sequenced. all values are given as mean ± sem. results: ucn- polyclonal antibody elicited strong immunostaining in placental trophoblast cells with variable intensity. the pattern of immunostaining is as follows: giant trophoblast cells: . ± . au, spongiotrophoblast cells: . ± . au and labyrinth cells: . ± . au. the relative intensity in labyrinth cells was significantly lower than the other two cell types (p< . ). pcr analyses revealed the presence of a single band of bp, consistent with ucn- mrna. conclusion: similar to human placenta, rat placenta expresses ucn- protein and ucn- mrna, with most expression localized to the maternal side trophoblast cells. these results support our hypothesis that rat placenta can be used as a model to understand the role of this peptide in feto-maternal stress. the role of the nuclear hormone receptors fxr, pxr and car in placental bile acid homeostasis in normal and pathological pregnancy. victoria geenes, peter dixon, selina raguz, jenny chambers, kishore bhakoo, catherine williamson. imperial college, london, united kingdom. background: obstetric cholestasis (oc) is a pregnancy specific liver disorder characterised by raised maternal serum bile acid levels and associated with adverse fetal outcome. the aetiology of oc is complex and not fully understood, but the fetal complications are likely to result from an accumulation of bile acids in the fetal circulation. bile acids are the toxic end products of hepatic cholesterol metabolism and are synthesised from weeks gestation. in common with other waste products, accumulation in the fetal compartment is prevented by excretion across the placenta into the maternal compartment. however, studies of maternal and cord serum from normal and oc pregnancies have suggested that bidirectional transfer of bile acids is possible. hepatic bile acid transport and metabolism is regulated by members of the nuclear hormone receptor family, namely fxr, pxr and car, but the mechanisms for regulating placental transfer are unknown. objectives: this study used placenta from normal and cholestatic pregnancies to investigate the expression of genes involved in hepatic bile acid homeostasis. methods: villous trophoblast samples from oc and normal pregnancies (np), and human livers were collected and preserved in rnalater. explant cultures were prepared from a further np placentas and cultured for days at % oxygen. on day they were treated with chenodeoxycholic acid, lithocholic acid or vehicle for hours prior to fixing in rnalater. total rna was extracted using trizol, and reverse transcribed to cdna. quantitative real-time pcr was performed using sybr green. target gene mrna abundance was calculated from a standard curve and normalised to l . results: the expression of fxr, pxr and car, the nuclear hormone receptors responsible for hepatic bile acid homeostasis and several fxr target genes (shp, mdr and bsep) was found to be very low in np, and unaffected by the presence of maternal cholestasis. furthermore, the expression of these genes could not be induced by bile acid treatment in an in vitro model. here we have shown that the nuclear hormone receptors (fxr, pxr and car) involved in hepatic bile acid homeostasis are expressed at very low levels in normal and pathological pregnancy and are thus likely to be of limited importance in placental bile acid transfer. a placental phenotype for obstetric cholestasis. victoria geenes, jenny chambers, jo wyatt-ashmead, kishore bhakoo, catherine williamson. imperial college, london, united kingdom; hammersmith hospital, london, united kingdom. background: obstetric cholestasis (oc) is a pregnancy specific liver disorder that affects . % of pregnant women in the uk. biochemically, oc is characterised by liver dysfunction with elevated maternal serum bile acids (sba), and clinically by an increased risk of fetal complications including fetal distress, meconium staining of the amniotic fluid, preterm labour and sudden intrauterine death. the aetiology of oc is complex and not fully understood, but the fetal complications are likely to result from the toxic effects of bile acids, which can cause vasoconstriction in the placenta and fetal cardiac dysrrhythmias. furthermore, in a rodent model of oc, bile acids cause oxidative stress in the placenta and a reduction in litter size. these changes are absent in animals treated with ursodeoxycholic acid (udca), a drug used to treat oc. however human data are lacking. objectives: this study used whole placenta and explant cultures to investigate the effects of bile acids on human placental architecture and to establish whether udca protects the placenta against bile acid induced damage. methods: villous trophoblast samples were collected from oc and normal pregnancies (np) and fixed in formalin. explant cultures were prepared from a further np placentas, and cultured for days at % oxygen. on day a subset were treated with udca overnight, and on day the explants were treated with taurocholic acid, taurochenodeoxycholic acid or vehicle for hours prior to fixing. m sections were stained with haematoxyllin and eosin. slides were reviewed by a perinatal pathologist and syncytial knots (sk) counted. results: oc tissues showed marked alterations in morphology, including congestion of the terminal villi, and loosening of the stroma and fibrotic change of the membranes of the stem villi. there were significantly more sk the oc samples (mann-whitney u test p= . ). furthermore, sk were increased in explants treated with bile acids, but not those treated with udca prior to the addition of bile acids. conclusions: here we describe several morphological abnormalities of the placenta associated with maternal cholestasis. these changes were confirmed using a placental explant model, which also showed that udca protects the placenta against bile acid induced damage. in summary, this study indicates that udca is likely to protect the fetus in oc. the placenta has complex metabolic and endocrine activities and is essential for the growth and survival of the fetus in utero. ultrasound is the most sensitive and less invasive method to evaluate placental size, morphology and function. the three-dimensional approach allows to calculate placental volume in the i and ii trimester of pregnancy. pregnancies from assisted reproduction technologies (art) show an increased rate of pathologies potentially related to placental insufficiency such as intrauterine growth restriction and preterm delivery. aim. to determine placental volume in art pregnancies in a cross sectional study in the first trimester of gestation. design. using three-dimensional ultrasound machine (ge ) placental volume measurement from art pregnancies (n= ; - wks) were compared with data from normal controls (n= ) matched for gestational age. data were analysed with software stata . results. mean placental volume was . ml (sd± . ) in art pregnancies and . ml (sd± . ) in normal controls. mean difference resulted in . ml (- - . ) and was statistically different (p= . ). multiple linear regression analysis showed a statistically significant interaction (p= . ) between gestational age and case status, i.e. differences in placental volume increase significantly with advancing gestational age between cases and normal controls. mean gestational age at birth was not essentially different between the two subsets ( . weeks ± . ) however a statistically significantly lower mean fetal birthweight was found in art pregnancies: g (sd± ) vs .(sd± . ) (p= . ). conclusions. placental volume is slightly decreased in art pregnancies. measurements of placenta volume by d ultrasound may play a role in identifying the degree of placental growth early in gestation in a risk population. in vitro effects of adenovirus-mediated gene transfer of insulin like growth factor- (ad-igf- ) in trophoblast cells. mounira habli, datis alae, foong yen lim, jignesh parvadia, timothy crombleholme. obstetrics and gynecology; pediatric surgery, university of cincinnati/children's hospital, usa. objective:recently, ad-igf- corrected both fetal and placental weights in rat model of fetal growth restriction (fgr) . to elucidate the mechanism of action of ad-igf- ;we examined the effect of ad-igf- on trophoblast proliferation, differentiation and invasion. methods: rcho- trophoblast cell line derived from rat choricarcinoma was used. ad-igf- and galactosidase transgene (ad-lacz) were given at moi of : and : in all the experiments.transduction efficiency was assessed hr after infection with ad-lacz by galactosidase enzyme activity. the invasiveness of rcho- was measured by using bdmatrigel invasion chamber kit. rcho- proliferation cell density was assessed by crystal violet assay. morphologic analysis of rcho- differentiation in response to treatment (differentiated cells are multinucleated giant cells) was assessed byimunocytochemistry staining using placental lactogen- antibodies(specific hormone produced by giant cells). results: % efficiency of gene transfer of ad-lacz to rcho- cells was observed at both moi's.there was no significant difference in proliferation between treated control group regardless of the dose at and hrs. ad-igf- induced morphologic differentiation of trophoblast cells compared to control (fig ) at hrs.ad-igf- induced higher rate invasion in a dose dependent fashion as compared to control(ad-lacz) group( % at moi vs . % in control p< . )(fig ). conclusion: ad-igf- gene transfer induces differentiation and invasiveness of trophoblast cells. these may be the mechansim of correction of fgr in rat model of placental insufficiency. placental gene transfer may be an effective treatment strategy for placental insufficiency. types of human placenta. martina dieber-rotheneder, ursula hiden, gernot desoye, mila cervar-zivkovic. department of obstetrics and gynaecology, medical university graz, graz, austria. background and hypothesis: endothelin- is a polypeptide with a wide range of functions. in the placenta it acts as a potent regulator of vasotonus on endothelial and smooth muscle cells, whereas on the trophoblast it regulates cell proliferation, invasion and apoptosis. endothelin- action is differently signaled through two endothelin receptor (etr) subtypes, etr-a and etr-b. several alternative splice variants of etr were identified. here we hypothesize that the etr-a splicing varies with gestational age and is different in trophoblast vs endothelial cells of the human term placenta. methods: mrna of placental tissue from first trimester (pregnancy terminations, missed abortions) and term of gestation, first trimester and term trophoblasts, arterial and venous placental endothelial cells as well as cell lines representing first trimester trophoblast (ach p) and term placental endothelial cells (hpec) were analyzed for full length etr-a and known as well as unknown splice variants by sqrt-pcr using primers spanning the exons - . the predominant dna bands in agarose gel were excised and sequenced. results: all tissues and cells expressed full length etr-a. in all tissues an additional -deletion variant was identified which was not found in the isolated cells. trophoblasts expressed another yet unidentified splice variant. the endothelial cells expressed a -deletion variant and a novel splice variant, which was identified as partial -partial deletion. this novel splice variant was found regardless of the arterial or venous origin of the cells as well as in the cell line (sv -transformed). in tissues und trophoblast no difference in splicing was found between first trimester and term. conclusion: gestational age does not alter splicing of endothelin receptor-a. splicing is different between trophoblasts and endothelial cells. the endothelial cells contain a novel splice variant. the differential splicing may allow maternal and fetal endothelin- to induce different effects on the two major cell types of the placenta. (supported by grant , jubilee fund, austrian national bank, vienna). adrenomedullin production and secretion by human trophoblast cells are regulated by glucocorticoids and hypoxia. francesca ciardo, katia pacioni, emanuela marinoni, giovanna corona, massimo moscarini, alfredo patella, romolo di iorio. department of gynecology, perinatology and child health, university "la sapienza", rome, italy; department of obstetetrics and gynecology, university of ferrara, ferrara, italy. objectives: adrenomedullin (am) is produced by intrauterine tissues and is involved in the regulation of implantation, placental hemodynamics and endocrine function. circulating am is increased in pregnancy complications such as preeclampsia and intrauterine growth retardation. we investigated whether am output by human trophoblast cells is regulated by hypoxia and/or glucocorticoids. study design: trophoblast cells obtained by human placentas at term (n= ) were cultured in presence or absence of hypoxia ( % o ) and treated with or without betamethasone at the dose of - , - , - m. media and cells were collected at h and at , and h from syncytiotrophoblast cultures. am was measured in cultured media by specific ria kit. protein expression in trophoblast cells was evaluated with immunohistochemistry and western blot. results: hypoxia stimulated am output and protein expression by cytotrophoblast and syncytiotrophoblast cells. betamethasone induced an increase in am production and secretion in a time-and dose-dependent manner (figure). effects of hypoxia were partially reversed by betamethasone in a dose and time-dependent fashion. conclusions: am production in trophoblast cells is up-regulated by hypoxia and glucocorticoids, independently. increased am levels in pregnancy complications characterized by placental insufficiency might derived by an increase in am placental secretion stimulated directly by hypoxia or indirectly by an increase in fetal cortisol levels. preeclampsia complicates - % of pregnancies, and while associated with significant maternal and fetal morbidity and mortality, the mechanisms responsible for preeclampsia are not completely understood. recent advances suggest there are imbalances of pro-and antiangiogenic factors, present from the time of implantation affecting vascular responsiveness of the fetal placental unit and maternal vasculature. in this study, we investigate vasomotor responsiveness of placental arteries from normal and preeclamptic (pet) pregnancies using an in vitro muscle bath contractility assay. transverse rings of placental arteries were cut and equilibrated in the muscle bath containing a bicarbonate buffer aerated with % o / % co at °c. viability was demonstrated by contraction to mm kcl prior to all experiments. cumulative logarithmic dose dependent responses to four different contractile agents: pgf , serotonin, carbochol, and norepinephrine were compared. placental arteries precontracted with pgf at half maximal concentration were relaxed with three vasorelaxants: sodium nitroprusside (snp), forskolin (fsk) and lactate (lct). agonist studies revealed contraction to both pgf and serotonin but not to carbochol or norepinephrine. there were no statistically significant differences between the responses of normal and pet arteries. both normal and pet arteries demonstrated heightened responsiveness to sodium nitroprusside compared with forskolin and lactate. this study reveals that the placental vessels are more sensitive to sodium nitroprusside, that mediates relaxation through nitric oxide -cyclic gmp signal transduction pathway, than forskolin that induces relaxation through the cyclic amp pathway. cancer complicates approximately one in , pregnancies. depending on the type of cancer and trimester, patients can terminate the pregnancy or choose treatment such as chemotherapy. since there is limited knowledge on the safety of chemotherapy on fetal tissues in utero, clinicians cannot efficiently analyze the risks of particular anticancer agents when deciding on a course of therapy. since carboplatin is among the most common anticancer agents used for treatment of cancer during pregnancy the primary objective of this study was to evaluate if carboplatin will readily cross to placental barrier and determine total potential platinum fetal exposure. this project utilizes an ex vivo placenta perfusion model to determine the concentration of carboplatin that crosses the human placental barrier. placentas are obtained within minutes of spontaneous delivery and re-perfused. two carboplatin concentrations were selected of ng/ml and ng/ml to represent clinically relevant maternal plasma concentrations. antipyrine was used as the internal control. serial samples were collected every minutes for total minutes in open-open model then experiment repeated with closed circuit model. antipyrine concentrations were determined by hplc methods. platinum concentrations in media samples were determined with a validated atomic absorption assay. a cell culture-based approach will be used to determine whether cell cycle or apoptotic proteins are altered (p , bax, bcl- , aif, and pro-caspase- ) using western blotting as a detection method. a total of two placentas have been completed at the low carboplatin concentration and one at the high concentration. the mean carboplatin clearance was . +/- . ml/min and . +/- . ml/min at the low and high carboplatin concentrations, respectively. an estimated % increase in the transport fraction was observed in the high concentration experiments compared to the low concentrations model. fetal carboplatin exposure ranged from to ng/ml. the placental perfusion experiments conducted at carboplatin and ng/ml indicate that carboplatin crosses the placenta through simple diffusion. the toxicology assays are ongoing to determine potential effect on fetal tissues. preterm delivery represents one of the predominant causes of perinatal mortality and morbidity, and is one of the most unpredictable gestational disturbances. urocortin is a peptide expressed by trophoblast and gestational tissues (amnion and chorion), whose maternal levels correlate with gestational length, since they are increased at preterm delivery and decreased in post-term pregnancy, when compared to term pregnancy. the addiction of urocortin enhances contractility of human myometrial strips, suggesting a possible role on uterine contractility. high maternal urocortin levels in threatened preterm delivery correlates with the timing of delivery, suggesting a possible role in the predictivity pf preterm delivery. in the present study urocortin concentrations in amniotic fluid collected at mid gestation for amniocentesis were correlated with gestational age at delivery. a case-control study with amniotic fluid obtained from healthy women undergoing amniocentesis for genetic indications was performed; urocortin concentrations were measured by a specific elisa. amniotic fluid urocortin concentrations resulted significantly lower (p= . ) in women delivering preterm (n= ; ucn= . ± . pg/ml) (m ± se) than in those delivering at term (n= ; ucn= . ± . pg/ml). in conclusion, the present preliminary data showed that amniotic fluid urocortin concentrations at mid gestation may represent predictive marker of preterm delivery. human placentas throughout pregnancy. annunziata mastrogiacomo, elisabetta federico, francesca caprio, maria teresa schettino, gabriele coppola, antonio de luca, luigi cobellis. department of obstetrics and gynecology, second university of naples, naples, italy; department of medicine and public health, section of anatomy, second university of naples, nales, italy. hypothesis apoptosis is intimately involved in placental homeostasis, growth and remodeling and the apoptotic rates increase progressively during normal pregnancy as part of normal placental development. moreover, apoptosis increases in pregnancies complicated by some pathologies such as preeclampsia, fetal growth restriction, diabetes. in the present study, we describe differences in the expression of pro-apoptotic protein bax, in first trimester voluntary termination of pregnancy, first trimester abortion (reserved abortion), caesarean birth, spontaneous birth, preeclampsia and diabetes. material and methods human placental samples were obtained with informed consent from patients undergoing surgery such as first trimester voluntary termination of pregnancy (n= ), first trimester abortion (miscarriage) (n= ), delivery section (n= ), spontaneous birth (n= ), preeclampsia (n= ) and diabetes (n= ). the gestation period ranged from to weeks. the specimens were immediately fixed in formalin for immunohistochemistry. we first observed a strong increase of bax expression in the cytotrophoblast, stroma, endothelial cells and decidua of placentas of the first trimester abortion compared to the low/moderate bax immunopositivity in all the placental compartments during the first trimester voluntary termination of pregnancy. secondly, we showed a more intense immunopositivity for bax in the third trimester spontaneous birth respect to the third trimester caesarean birth. thirdly, we observed an increase of bax expression in preeclamptic placentas compared to the normal full-term placentas. on the contrary, we observed a moderate bax expression in diabetic placentas only slightly decreased compared to the normal full-term placentas. our results seem to suggest that deregulation of apoptotic turnover may lead to placental dysfunction and pathologies. objectives: maternal endothelial activation in preeclampsia (pe) is attributed to the release of unknown factors from a hypoperfused placenta. the application of proteomic technologies such as mass spectrometry promises the reward of identifying and characterising these factors. using a placental explantconditioned culture media model system we have developed a proteomics workflow to obtain relative quantification of proteins released into placental explant culture media. methods: term villous explants were cultured in serum-free conditions and exposed to differing oxygen concentrations ( % %) to mimic physiological and non-physiological intervillous o tensions. the d media was concentrated, immunodepleted to remove fibrinogen (using beckman igy- columns) and proteins labelled using an itraq (applied biosystems) kit following the manufacturer's protocol. labelled peptides were fractionated by strong cation exchange and then analysed using lc-maldi on a maldi-tof/tof (applied biosystems) mass spectrometer. data was analysed using protein pilot . (applied biosystems). results: when matched pooled (n= ) media samples were subjected to our proteomics workflow over proteins were identified with a calculated false positive identification rate of < %. of these proteins a total of display a statistically significant difference in protein levels between the % % o samples (p=< . ). from a list of proteins of interest we selected proteins for validation using elisa/western blotting to measure their relative abundance in both pooled and individual explant media samples. interleukin is an example of a low-abundance differentially expressed protein identified in our proteomic workflow and subsequently validated by elisa; il- (pg/ml) in % o : . , range . to . ; % o : . , range . to . ; values are median with interquartile range. *** p< . , mann-whitney test (n= ) conclusions: we demonstrate a successful reduction to practice of a relative quantitative proteomics strategy applied to placental explant-conditioned culture media. having optimised and validated this proteomic workflow we will apply the same methods to compare proteins released by normal and preeclamptic placentas. a proteomics screen of human placental microvillous syncytiotrophoblast (stb) revealed the expression of dysferlin (dysf), a membrane repair protein associated with certain muscular dystrophies (vandré et al., ) . a second ferlin protein, myoferlin (myof), was also discovered which has not yet been characterized in the placenta. in human c c myoblasts, dysf and myof are reciprocally expressed as a function of differentiation into multinucleate syncytial myotubes, with dysf predominating in differentiated cells. we hypothesized that dysf and myof would show a similar reciprocal expression pattern in human trophoblasts as a function of syncytialization. methods term placentas from uncomplicated pregnancies were obtained with informed consent (n= ) and either fixed for immunofluorescence (if) labeling or flash frozen for subsequent immunoblotting (ib). human trophoblastic (bewo, jar, and jeg- ) and other cell lines (mrc- , hl- , huvec) were cultured in the absence or presence of μm forskolin or solvent control for - days. dysf and myof expression was examined by rt-pcr, ib, and if. results ib validated proteomics data showing myof expression in term placenta. by if, myof labeling was predominant in apical and basal stb plasma membranes. myof was expressed in trophoblastic cell lines (bewo, jar, and jeg- ), cultured endothelium (huvec), and a fibroblast cell line (mrc- ), but was not detected in a leukemic cell line (hl- ). dysf was constitutively expressed in jar, but minimally expressed in unstimulated bewo. following forskolin-induced syncytialization, we observed a time-dependent increase in dysf expression in bewo concomitant with increasing syncytin- levels. by if, dysf expression was restricted to bewo cells in syncytial structures. in contrast, myof expression was robust in mononuclear bewo cells and not down-regulated over the course of days of differentiation. conclusions two ferlin-family genes are expressed in trophoblasts. fusion-competent bewo cells behave similarly to cultured myoblasts and ctbs with regard to dysf expression, which is restricted to syncytializing cells. myof, in contrast, is expressed constitutively in bewo and other models. while both proteins are likely to function in stb plasma membrane repair (e.g., following syncytial sprouting), the relative contributions of each to this process awaits clarification. features of chronic placental insufficiency are significantly more common in small for gestational age placentas from infants with intrauterine growth retardation. emily king, violetta kolesnikova, carri tillotson, jean-marie guise, terry morgan. pathology; center for biostatistics; obstetrics and gynecology, ohsu, portland, or, usa. background: there is a strong association between intrauterine growth restriction (iugr) and small for gestational age (sga) placentas (heinonen et al. placenta ( ), : - ) . the cause is likely multifactorial, but we hypothesize that chronic uteroplacental insufficiency may play a role. our objective was to test whether sga placentas from human neonates with iugr show significantly more pathologic features of placental insufficiency compared to controls. design: we performed a retrospective review of consecutive singleton placentas submitted to ohsu pathology ( - ), excluding elective terminations and spontaneous abortions before weeks gestation. clinical records were reviewed and pregnancy outcomes recorded, including: ) neonatal sex; ) weight (iugr calculated by routine methods), ) trimmed weight of the placenta (sga calculated by routine methods), ) gross placental infarctions, ) gestational age at delivery, and ) maternal features (e.g. race, gravida). controls were defined as cases within the series without sga or iugr (e.g. submitted for meconium, infection, etc). histologic sections were scored by two pathologists while blinded to clinical diagnoses as positive or negative for features of placental insufficiency, including accelerated villous maturation (avm), chorangiosis, and microscopic infarctions. significant associations were tested by analysis and logistic regression for multiple variables. results: similar to prior reports, we observed a strong association between iugr and sga placentas ( . ; p < . ). this relationship was independent of maternal race, fetal sex, and parity, although it was more common in primigravidas. avm and placental infarctions were significantly more frequent in sga placentas with superimposed iugr. controls ( introduction: messenger rna expression peripheral blood cells (pbc) has been recently used as biomarkers of environmental exposures (ionizing radiation or tobacco), physiological conditions (stress) and diseases (hypertension, neurological disorders). pbc evaluation is a useful diagnostic tool in an era of individualized medicine. since there is an urgent need for non-invasive methods for determination of fetal (f) and placental (p) function, this study was designed to evaluate the genes differently and commonly expressed in p tissue and leukocytes in maternal (m) and f circulation.material and methods. p (n= ), f (n= ) and m blood (n= ) were obtained during cesarean section in pregnant baboons at term. total rna from a buffy coat pellet was isolated using a modified procedure of the qiagen rneasy mini kit (qiagen). anti-sense rna (arna) was synthesized and purified using the illumina rna amplification kit (ambion, usa). hybridization of arna to illumina sentrix human whole genome (wg- )beadchips and subsequent washing, blocking and detection was performed using illumina's beadchip ´ protocol. samples were scanned on the illumina beadarrayer gx reader using illumina beadscan image data acquisition software (ver. . . . ). differential gene expression data analysis was performed using illumina beadstudio software (ver. . . . ). results. the detection level of gene transcripts using illumina methodology with control human rna was - at p< . . gene transcripts were detected in f blood and in maternal blood. transcripts were uniquely expressed in fetal blood. transcripts were found in m, but not in f leukocytes. the number of gene transcripts expressed in p tissue was and of these genes were not expressed in m leukocytes. conclusion. despite white blood cells trafficking through the p barrier there is a set of unique genes expressed only in p or in the m or f circulation. the application of these genes as the biomarkers of p barrier function still need to be evaluated. objective: to evaluate if a relationship exists between duration of placental exposure to meconium in vivo and histologic evidence of severity and extent of meconium uptake by macrophages. study design: from a cohort of / ( %) consecutive singleton liveborn infants delivered at term with thick meconium-stained fluid, ( %) had placental histologic examination performed, and in / the timing of meconium appearance after membrane rupture was documented. placental histologic examination quantitatively evaluated the intensity of meconium uptake by resident macrophages based on the number of macrophages/field, and the extent of uptake based on histologic location, graded in a score to . results: mean interval between meconium appearance and delivery was . ± . min (range - ). after exclusion of cases in which severe placental inflammation interfered with analysis, meconium uptake by macrophages was documented in / cases at the level of amniochorionic membranes, in / cases at the placenta, and in / cases at the umbilical cord. there was no correlation between the interval meconium appearance-to-delivery in relation to presence of meconium in the membranes (p= . ), in the placenta (p= . ), in the cord (p= . ), or score of severity of meconium uptake (p= . ). the results did not change after correcting for gestational age, oligohydramnios, presence of placental acute inflammatory or vascular lesions. conclusion: there is no relationship between duration of placental exposure to meconium and the extent and intensity of its uptake by macrophages in cases with exposure up to . hours. transfer of bisphenol a across the human placenta. biju balakrishnan, , kimiora henare, , eric thorstensen, , murray d mitchell. , the liggins institute, university of auckland; national research centre for growth and development, auckland, new zealand. introduction: there are growing concerns over the effects of developmental exposure to the xenoestrogen bisphenol a (bpa). animal studies have shown that bpa is transferred through the placenta and can cause deleterious effects to the fetus. the presence of bpa in feto-placental tissues in humans has also been reported. however, a detailed study of the time-course of bpa transfer across the human placenta has not been performed. the aim of this research was to study the transfer of bpa in ex-vivo perfused human placental tissues. methods: a dual recirculating single cotyledon perfusion was used to monitor the placental transfer of bpa. bpa ( ng/ml), antipyrine (ap) ( μg/ml), and fitc dextran (fitc-dx) ( . μg/ml) were added to the maternal perfusate, and perfusion was continued for hours. perfusate samples were collected from both reservoirs at timed intervals and analysed. bpa, ap, and fitc-dx were determined by hplc with fluorescent detection, hplc with uv detection, and spectrofluorometry respectively. the viability and metabolic activity of the placentae were assessed by measuring -hcg (elisa), glucose utilization, and lactate production (autoanalyzer). fetal pressure, ph, flow rates and fluid shifts were monitored continuously. results: the biochemical validation parameters (glucose consumption, lactate production and -hcg secretion) indicated that the placental tissue was metabolically active and viable throughout the -hour perfusion period. the physical parameters observed (fetal pressure < mmhg, ph range . - . ) were in concordance with other published works for placental perfusion. membrane integrity was confirmed by fluid shifts from either circuit of < ml/hr, and by < % materno-fetal transfer of fitc-dx. an observed ap transfer of - % further validated our model. bpa first appeared in the fetal compartment within minutes of perfusion and reached a peak of about - % of maternal concentration within hours of perfusion. this figure is likely to be an underestimate since it does not include conjugated bpas. conclusion: this first study of bpa transfer in ex-vivo perfused human placental tissue shows that our model can serve as a useful tool to study the transfer kinetics and metabolism of bpa in human term placentae. we found that bpa rapidly crosses the human placenta at environmentally-relevant doses, with potentially harmful effects on the human fetus. angiogenic growth factor secretion by uterine natural killer cells in co-culture with extravillous trophoblast. gendie e lash, katsu naruse, , barbara a innes, stephen c robson, judith n bulmer. institue of cellular medicine, newcastle university, newcastle upon tyne, tyne and wear, united kingdom; obstetrics and gynaecology, nara medical university, nara, japan. objectives. uterine natural killer (unk) and extravillous trophoblast (evt) cells have been proposed to play roles in remodeling of uterine spiral arteries through secretion of various angiogenic growth factors. we have previously demonstrated that unk cells are a significant source of angiogenic growth factors within the decidua, many of which alter with gestational age. however whether the secretion of these proteins is altered by interactions of unk cells with evt is unclear. hypothesis. unk cell angiogenic growth factor secretion is regulated by evt in early pregnant decidua. methods. placental and decidual samples were collected from women undergoing termination of pregnancy with written informed consent ( - and - weeks gestation, n= each group). . × cd + unk cells were positively selected from decidua and co-cultured with evt ( . × ) or cytotrophoblast (ctb; . × ) purified from the same placenta for h in direct or indirect contact (n= each group). angiogenin, ang , pdgf-bb, fgf-basic, timp , icam and vegf-a were measured by fast quant ® angiogenesis multiplex assay system, and vegf-c, ang and plgf by elisa. results of unk co-culture with evt or ctb (negative control) at each gestational age were analyzed with wilcoxon rank test. in addition, the effect of direct and indirect co-culture of unk cells with evt at each gestational age was compared with mann whitney u test. results. at - weeks gestation unk secretion of ang (p= . ), icam (p= . ) and plgf (p= . ) was increased in the presence of evt compared with ctb. no differences were observed at - weeks gestation. in addition, at - weeks gestation unk secretion of ang (p= . ), vegf-c (p= . ) and ang (p= . ) was increased in direct co-culture with evt compared with indirect co-culture. at - weeks gestation unk secretion of timp- (p= . ) was reduced in direct co-culture with evt compared with indirect co-culture. conclusions. unk cell secretion of several key angiogenic growth factors was altered by direct culture with evt. these data suggest that a membrane bound molecule (such as hla-g) mediates this modulation of unk cell activity. abnormalities in placentation and impaired placental circulation can lead to fetal growth restriction. -d ultrasound can be used to evaluate this through the quantification of the power doppler signal that may be expressed as a percentage of colour voxels within a user-defined volume (vi: vascularisation index). we aimed to test the hypothesis that increased fetoplacental blood flow correlates with an increased vi, using the in vitro dual perfusion model of the human placental lobule. three term lobules were dually perfused through both circulations with earles bicarbonate buffer (ebb), and supplemented on the fetal-side only with adult erythrocytes, prepared to a % haematocrit. following initial equilibration perfusion at normal flow values, fetal-side flow was varied between and ml/min, whilst maternal-side flow was held at ml/min. images were obtained with a 'voluson i' ultrasound machine and a neonatal transducer (pulse repetition frequency = . hz, wall motion filter = low , and gain = . ). three -d datasets were acquired at each flow rate from each placental lobule and these were measured in triplicate using vocal. a sphere was centred on a visibly perfused cotyledon along the chorionic-decidual axis, with a diameter corresponding to placental thickness. linear regression analysis was used to assess the relationship between the total fetal-side flow and mean vi. the mean vi showed a high degree of correlation with total fetal-side flow for each lobule ( figure ) suggesting increased vascular perfusion and the inclusion of perfused vessels that cross the detection threshold with increased flow. this data provides qualifying information for translation to a clinical application, where early gestational fetoplacental blood flow will be assessed to predict the onset of fetal growth restriction. anthony n imudia, brian a kilburn, anelia petkova, samuel s edwin, roberto romero, d randall armant. objective survival of first trimester cytotrophoblast cells depends on their upregulation of heparin-binding egf-like growth factor (hbegf), which is downregulated in placental tissues diagnosed with preeclampsia. we have examined the expression and cytoprotective activity of hbegf in term villous explants subjected to hypoxic stress in vitro. non-pathological placentas were collected by cesarean section at term (n= ). chorionic villous explants were prepared and cultured at either % or % o and treated with the hbegf antagonist crm or recombinant hbegf. paraffin sections were assayed for trophoblast cell death by the tunel assay, proliferation by immunohistochemical labeling of nuclear ki and hbegf expression by semi-quantitative immunohistochemistry. data were compared using anova and the student-newman-keuls posthoc test. results crm ( mg/ml) increased trophoblast cell death after culturing villous explants h at % o (p< . ), but only slightly affected proliferative capacity. culture at % o increased trophoblast cell death % above explants incubated at % o (p< . ). trophoblast cell proliferation decreased after h in explants cultured at either % or % o (p< . ). exogenous hbegf ( nm) prevented the elevation of cell death during hypoxia (p< . ) and maintained nuclear ki expression at %, but not %, o . contrary to first trimester trophoblast, hbegf was not upregulated by hypoxia in term trophoblast. the failure of term trophoblast to elevate hbegf expression in response to hypoxia could contribute to their decreased survival at low o compared to early gestation. endogenous hbegf signaling appears to facilitate survival of term trophoblast during villous explants culture. exogenous hbegf supplementation prevented cell death due to hypoxia and maintained trophoblast proliferation rates under in vitro conditions. therefore, hbegf, which is downregulated in preeclampsia, could have significant impact on trophoblast survival during late gestation. supported by the intramural research program of nichd. conspicuous meconium-laden macrophages in the chorionic plate are an independent predictor of clinically significant fetal distress. violetta kolesnikova, emily king, carrie tillotson, jean-marie guise, terry morgan. pathology; center for biostatistics; obstetrics and gynecology, ohsu, portland, or, usa. background: meconium is a common indication for placental examination, present in approximately % of placentas routinely submitted to pathologists (beebe et al. obstet gynecol ; : - ) . prolonged meconium exposure leads to accumulation of meconium-laden macrophages in the chorionic plate (estimated to require at least hours). our objective was to test whether prolonged meconium exposure is associated with clinically significant fetal distress. design: retrospective review of consecutive singleton placentas submitted to ohsu pathology ( - ) was performed, excluding abortions before weeks gestation, and placentas without representative sections of the chorionic plate. clinical records were reviewed and pregnancy outcomes recorded, including: ) evidence of fetal distress prompting c-section (non-reassuring fetal heart rate), ) gestational age, ) maternal diagnosis, ) apgar scores, and ) neonatal length of hospital stay. routine histologic sections were independently scored by two pathologists while blinded to clinical diagnoses and outcomes. cases were scored as positive or negative for: ) diffusely conspicuous meconium-laden macrophages in the chorionic plate (at least / hpf), ) chorioamnionitis, and ) features of placental insufficiency. significant associations were tested by the mann-whitney u test for paired comparisons, x analysis, and logistic regression for multiple variables. results: conspicuous meconium staining of the chorionic plate was common ( / , %) and was significantly more frequent in c-sections performed for fetal distress ( / cases, %) (x . ; p-value < . ). logistic regression modeling showed that this association was independent of chorioamnionitis and features of placental insufficiency. there was no association between meconium and neonatal outcome, including no difference in apgar scores or length of hospital stay. conclusions: our data support the hypothesis that meconium-laden macrophages in the chorionic plate are associated with fetal distress prompting c-section. whether meconium is the cause or consequence of this distress is uncertain. however, given the acute time frame between clinical diagnosis and c-section, we suspect prolonged meconium exposure may be a significant cause of non-reassuring fetal heart rate changes. apoptotic index in normal and intrauterine growth-restricted rat placentas. elissa scotland, tri nguyen, s chiang, radmila runic. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: intra-uterine stress caused by maternal food-restriction may have adverse fetal and placental effects. we sought to assess the effect of maternal food restriction during pregnancy on placental apoptosis. methods: rat placentas were analyzed from control dams fed ad libitum and dams % food-restricted from day of gestation. placentas were harvested at embryonic days and (n= ). placentas were fixed in % pfa and two methods of analysis were utilized to determine the proportion of apoptotic to non-apoptotic cells within maternal food restricted and control rat placentas: immunohistochemistry (ih) using fas-ligand and in situ tunel (terminal deoxynucleotidyl transferase biotin-dutp nick end labeling). tunel: after rehydration, slides were subjected to tdt enzyme. dab was used to visualize brown apoptotic nuclei. dna-se treated slide was used as a positive control. ih: primary rabbit polyclonal fas-ligand antibody was used at : dilution, after which secondary antibody linked to peroxidase and dab staining was performed. results: food-restricted placentas demonstrated . % relative apoptotic index when compared to . % in the control group. the iugr iod (integrated optical density) per unit area in the placental membrane was higher than in the control group. fasl demonstrates an iod of . + . in food restricted placentas as compared to . + . per μm surface area in controls. apoptosis was seen in the amnion as well as trophoblast (syncytialtrophoblasts and some cytotrophoblasts). conclusion: the increased apoptotic index in maternal food restricted placentas suggests that the accompanying iugr may be a result of both maternal/fetal nutrient restriction and increased fetal stress. this study found that maternal food restriction during pregnancy affects placental apoptosis. there is more apoptosis in the iugr placental bed at e than at e , with the reverse being true for the placental membrane. more research is required to statistically validate the data. the suggested next step is to evaluate fas and fas-l and to address possible mechanisms of placental apoptosis. cord. jayaraman lakshmanan, avish arora, lilit baldjyan, sharon k sugano, olga miadel, adegoke adeniji, michael g ross, calvin j hobel. ob-gyn, harbor-ucla medical center, torrance, ca, usa; ob-gyn, cedars-sinai medical center, los angeles, ca, usa. background: crf-bp is a kda protein, that specifically binds corticotrophin releasing factor (crf). the structure of cloned crf cdnas in all species examined predicts that the precursor is larger than the kda in size and contains one n-glycosylation site. marked reductions in plasma crf-bp levels seen in pregnant women prior to both preterm and term delivery led to the notion that crf-bp is a "gatekeeper" of crf responses. recently we identified crf-bp expression in term human umbilical cord (uc) by immunohistochemical analyses. objective: to characterized the expression of crf-bp by immunohistochemical and biochemical analyses in human uc. methods: freshly obtained human preterm ( to < weeks, n= ) umbilical cord ( pieces of mm thickness taken at - cm intervals close to placenta) were fixed in bouin's solution and paraffin embedded. also, pieces of ucs were dissected, arteries and vein separated, weighed and frozen at - c. for immunohistochemical localization, uc sections were subjected to immunostaining with polyclonal antibodies to human crf-bp precursors. for western blot analyses, whole uc as well as isolated arteries and vein were homogenized in a buffer containing detergents and protease inhibitors. the homogenate supernatant proteins were subjected to western analyses by standard protocol. immunoreactive protein bands were identified by chemiluminescent reagent. results: both goat and rabbit crf-bp polyclonal antibodies elicited weak to moderate positive staining in uc epithelial layers, vascular musculature and barely endothelial cells. they identified a strong kda band in whole uc as well as in isolated artery and venous preparations. in addition minor immunoreactive protein bands of , , kda in size were noticed in all three preparations. conclusion: we conclude that preterm uc expresses crf-bp. we postulate that the kda major band is either glycosylated crf-bp precursor or glycosylated kda mature protein. the low molecular weight immunoreactive proteins likely represent proteolytically processed, glycosylated crf-bp precursor or a proetolytically processed mature da crf-bp. uc obtained at delivery could be useful as a tool to understand the critical functions of crf-bp in feto-placental unit. objective: adenosine, known to be released from inflammatory sites and tisse ischemia, has many important biologic roles. four specific adenosine receptors have been cloned to date, termed a , a a, a b, and a . recently our study has shown that increased a receptor in the trophoblast of preeclamptic pregnancy was noted and non-vascular and trophoblast-mediated a receptor may play an important role in the pathogenesis of preeclampsia. there are evidences of impaired trophoblast invasion related to matrix metalloproteinase (mmp) in preeclampsia and the relationship between adenosine receptor and mmp in other fields. the objective of this study is to evaluate the effect of mmp expression by adenosine a receptor in preeclamptic villous explants at different oxygen conditions. methods: placental villous explants from normal (n= ) and preeclamptic (n= ) pregnancies were cultured at high ( %) and low ( %) oxygen levels for days. explants were analyzed for mmp- /- and timp- /- by rt-pcr and western blot. preeclamptic villous explants in hypoxic culture condition were treated with a receptor agonist, cl-ib-meca and a receptor antagonist, mre. mmp- / - expression was determined in a time-and dose-dependent manner by rt-pcr, western blot. also mmp- /- activity was evaluated by zymogram assay. results: there were significantly increased a receptor intensity and reduced mmp- /- and timp- /- expression at low oxygen level in normal and preeclamptic villous explants. interestingly, in preeclamptic villous explants, after high oxygen culture mmp- /- and timp- /- expression were recovered to almost same level compared to those in normal villous explants. treatment of preeclamptic villous explants with cl-ib-meca in low oxygen level resulted in a time-and dose-dependent enhanced expression of mmp- /- . this cl-ib-meca-induced expression of mmp- /- was inhibited by pretreatment with mre. conclusion: to our knowledge, this study is the first to evaluate modulation of mmp secretion by adenosine a receptor in preeclamptic villous explant. our results provide evidence for the existence of functional adenosine a receptors in the trophoblast and suggest that adenosine a receptor will be investigated as a therapeutic target in preeclampsia. murray d mitchell, timothy a sato, anderson wang, jeffrey a keelan, anna p ponnampalam, michelle glass. liggins institute; department of pharmacology and clinical pharmacology, university of auckland, auckland, new zealand. introduction: it is well established that prostaglandins play critical roles in multiple aspects of pregnancy and that the fetal membranes are an important site of intrauterine prostaglandin production. endocannabinoids have been implicated in the maintenance of pregnancy and parturition in women and are a source of arachidonic acid which is a substrate for the production of prostaglandins. the aim of the present study was to determine the effects of endocannabinoids on the production of prostaglandins in extraplacental membranes -amnion, chorion and decidua. methods: explants of term amnion and choriodecidua were established and treated with endogenous endocannabinoids -arachidonoyl glycerol ( ag) and anandamide (aea) and with the synthetic cannabinoid cp , , to determine the ability of these substances to modulate prostaglandin e (pge ) production. pge was measured by radioimmunoassay. the explants were also treated with cp , in the presence of either sr a (a selective antagonist of the cannabinoid receptor cb ) or ns (a cox- inhibitor), to determine whether any observed stimulation of pge production was mediated through cox- activity and/or the cb receptor. cox- , cox- , cpla and pgdh protein levels were measured by western blotting. results: all three cannabinoids caused a significant increase in pge production in amnion but not in choriodecidua. however, separated fetal (chorion) explants responded to cannabinoid treatment in a similar manner to amnion, whereas maternal (decidual) explants did not. the enhanced pge production caused by cp , was abrogated by co-treatment with either sr a or ns , illustrating that the cannabinoid action on prostaglandin production in fetal membranes is mediated by cb agonism and cox- . preliminary data from western blotting show that cannabinoid treatment results in the up-regulation of cox- expression. however, there was no change in cox- expression and no evidence either for up-regulation of cpla or for down-regulation of pgdh expression. conclusion: this study demonstrates a potential role for endocannabinoids in the modulation of prostaglandin production in late human pregnancy, with potentially important implications for the timing and progression of term and preterm labour and membrane rupture. inactivation of vegf receptor- , but not vegfr- or vegfr- , during the peri-implantation period prevents normal pregnancy development in the rodent through disruption of uterine angiogenesis. nataki c douglas, hongyan tang, raul gomez, bronislaw pytowski, daniel j hicklin, jan kitajewski, mark v sauer, ralf c zimmermann. division of reproductive endocrinology and infertility, columbia university, new york, ny, usa; imclone systems, inc., new york. objective: vegf is involved in the regulation of uterine angiogenesis and implantation in both rodents and non-human primates. vegfr- , r- , and r- are expressed in the uterine decidua and are involved in the regulation of vessel formation in many systems. to determine if these receptors have a functional role in the regulation of post-implantation angiogenesis and pregnancy development, we examined the effects of blocking vegfr- , r- , and r- function. design: prospective animal laboratory material and methods: to avoid effects of vegf receptor neutralization on ovarian function, we utilized a progesterone replaced, ovariectomized mouse model. vegf receptor blocking antibodies were administered on ed . , prior to embryonic expression of these receptors. embryonic development was evaluated on ed . , blood vessel density and apoptosis on ed . , and cellular proliferation on ed . (n= per time point in each group). anova with bonferroni correction was used to compare sample means. results: see tables. conclusions: neutralization of vegfr- and vegfr- , but not vegfr- resulted in a significant reduction in cellular proliferation and decidual angiogenesis. vegfr- mediates decidual angiogenesis, but is not required for normal pregnancy development. in contrast, an intact vegf/vegfr- pathway is required for the decidual angiogenesis that mediates early pregnancy development. effect of vegfr neutralization on ed . control anti r- anti r- anti r- no. of implantation sites . +/- . +/- . . +/- . . +/- . hoxa encodes a transcription factor required for endometrial receptivity and embryo implantation. our objective was to identify and to characterize those molecular markers regulated by hoxa in multiple cellular model-systems. using microarray technologies, we identified putative hoxa target genes involved in early implantation. liposome-mediated transfection delivering either empty vector or the same plasmid constitutively expressing hoxa was introduced into newly impregnated mice during laparotomy or layered onto cultured human endometrial stromal-cells (hescs). rna products from these in vivo and in vitro transfections were used to identify targets and to validate the microarray screen employing semi-quantitative real-time pcr (qrt-pcr). we identified statistically-significant genes regulated by hoxa overexpression of which genes were down-regulated greater than -fold when compared to controls. cellular ontogenies of differentially-expressed genes include: cell adhesion molecules, signal transduction factors as well as metabolic regulators. furthermore, we identified the -phosphoglycerate dehydrogenase gene, (pgdh) whose products are regulated by hoxa during implantation in both murine model systems in and cell culture. this genes codes for an enzyme critical to de novo l-serine biosynthesis via a phosphorylation-dependent pathway. microarray analysis demonstrated a fold expression decrease when hoxa is overexpressed. this diminution in pgdh expression was noted in the validation experiments using qrt-pcr and corroborated in hesc cells where the mrna levels decreased to % when compared to controls. the repression of pgdh during the implantation window may represent a conservation of activity as secretory-phase protein synthesis may be suppressed in order to promote cellular differentiation and resultant implantation. these regulatory relationships identified in mouse implantation likely function to enhance uterine receptivity and may have a role in human implantation. objective: hoxa is expressed in endometrium, where it is regulated by sex steroids and is necessary for endometrial receptivity and implantation. hoxa is also expressed in leukocytes. here we hypothesized that hoxa would be regulated by sex steroids in both cell types. we further hypothesized a correlation between expression of hoxa in peripheral blood cell (pbcs) and endometrium in both mice and in humans. methods: real-time pcr was used to determine differential expression of hoxa mrna in u cells, a monomyelocytic cell line, in response to increasing concentrations of estradiol. to determine if hoxa is expressed in leukocytes in vivo, peripheral leukocyte hoxa mrna expression was measured over sequential estrus cycles in mature cd nulliparous mice and correlated to vaginal smear-cytology. additionally, peripheral leukocytes were isolated either from pregnant or normally-cycling women to assess hoxa mrna expression. results: there was a direct, dose-responsive correlation between exposure to increasing estradiol and hoxa mrna expression levels in u cells. in a murine model, we demonstrated that hoxa mrna expression-levels varies throughout the estrus cycle with a marked increase in expression following vaginal plug detection. the nadir of hoxa expression is prior to proestrus and increased up to -fold during the receptive phase. this increased expression continues throughout gestation. the heightened expression in murine leukocytederived hoxa mrna also is demonstrated across species. our preliminary data suggests that the greatest fold-increase of expression occurs during the window of implantation of the secretory phase in normal, cycling women. this level was sustained in pregnancy. there appears to be a trend with the highest levels of expression associated with viable gestations. women with attenuated expression profiles had non-viable gestations. conclusions: hoxa expression is regulated by sex steroids in both leukocytes and endometrium. the temporal pattern of peripheral hoxa transcript expression demonstrated in mice and humans mimics the differential rna expression documented within the uterus. leukocyte hoxa expression during the reproductive cycle in mice and humans is a marker of endometrial receptivity. peripheral leukocyte expression of hoxa mrna may correlate with implantation success. carolien m boomsma, annemieke kavelaars, marinus jc eijkemans, gijs teklenburg, bart cjm fauser, cobi heijnen, nick s macklon. reproductive medicine and gynaecology and laboratory of psychoneuroimmunology, university medical center, utrecht, netherlands. the purpose of this study is to assess the association between the intra-uterine cytokine expression profile at the time of embryo transfer and successful embryo implantation following ivf/ icsi treatment. materials and methods women undergoing ivf/ icsi underwent endometrial secretion aspiration prior to embryo transfer. known soluble mediators of implantation were measured using a multiplex immunoassay, namely il ß, il , il , il , il , il , il , il , tnf , vegf, ifn , eotaxin, mcp- , ip- , dkk- and hbegf. mif was determined using an elisa. the total protein concentration was measured for normalization purposes. data were log transformed to obtain normal distribution. multivariable logistic regression analysis with a backward elimination procedure (p< . ) was used, potential confounders (age, blood contamination, embryo quality) were included in a forward stepwise model. ten mediators of the analysed were detectable in - % of the samples. il was detectable in % of samples, dkk- %, il- %, il- %, il- % and hbegf was detectable in % of samples. ifn-was not detectable in any of the samples. multivariable logistic regression showed only logmif concentrations to have a significant correlation with achieving clinical pregnancy (p = . ). higher mif concentrations were correlated with a higher chance of conceiving. endometrial secretion analysis represents a novel means of assessing the intra-uterine milieu encountered by the embryo and offers new perspectives in the study of endometrial receptivity. in this large prospective study assessing an array of cytokines, mif was found to be significantly correlated with pregnancy. mif, macrophage migration inhibitory factor, is a cytokine with numerous proinflammatory, immunomodulatory, angiogenic and tissue remodelling properties. mif induces the synthesis and secretion of matrix metalloproteinases by endometrial cells, which may contribute to embryo invasion. its expression is particularly increased during the secretory phase, suggesting a role in reproductive processes. analysis of aspirated endometrial secretions offers a direct clinical test of endometrial receptivity which can be applied during treatment cycles without disrupting implantation. endometrial receptivity and secretory differentiation require progesterone (p). it has been hypothesized that low p levels result in delayed endometrial differentiation and infertility due to reduced receptivity. objective: test the effects of low luteal p on histologic and molecular markers of differentiation and function. methods: normal cycling women (n= ) were treated with daily leuprolide ( . mg/d) beginning in the midluteal phase and continuing through the protocol. after menses, subjects received transdermal estradiol (e, . mg/d) for days. after day of e, subjects also received daily i.m. injections of p, randomized to mg/d (sub-physiological) or mg/d (physiological). endometrial biopsy was performed after days of combined e and p treatment. additional untreated women had biopsies performed days after spontaneous lh surge. endometrial histologic dating was performed by two individuals according to the criteria of noyes et al. mrna levels were assessed using real-time rt-pcr. results: mean(s.d.) of peak and trough p serum concentrations in the mg/d p group were . ( . ) and . ( . ) ng/dl, respectively, while those in the mg/d group were . ( . ) and . ( . ) ng/dl. there were no differences between treatment groups for histologic dating; the mean(s.d.) histologic date was . ( . ), . ( . ), and . ( . ) for the mg, mg, and spontaneous cycle groups, respectively. there also were no differences among the three groups in mrna levels of ten functional markers (er , pr, integrin subunit, osteopontin, cyr , egr- , fkb , c-fos, and cd ), although variability of gene expression was greater in those who received mg/d p than in those who received mg/d p. there was also no correlation between serum progesterone level and gene expression or histologic date. conclusions: sub-physiological levels of progesterone, in the range seen in ovulatory women, do not induce detectable changes in expression of marker genes or histological dating, although low p levels were associated with greater variability of gene expression. these data suggest that abnormalities in endometrial histologic development and function likely result from intrinsic abnormalities rather than from low levels of p secretion. (supported by unc nova carta fund and nih u hd- ). endometrial ip attracts trophectoderm through cxcr interaction. simcha yagel, caryn greenfield, hen sela, jacob hanna, irit manaster, orna singer, ronit haimov-kochman, shira natanson-yaron, diana prus, benjamin reubinoff, debra s goldman-wohl, ofer mandelboim. obstetrics and gynecology, hadassah-hebrew university medical centers, jerusalem, israel; lautenberg center for immunology, jerusalem, israel; human embryonic stem cell research center, jerusalem, israel. introduction: implantation is initiated in part by attraction of the blastocyst to the endometrium lining the uterus. we hypothesized that this process is partly accomplished by chemokines expressed by the endometrium interacting with chemokine receptors on the blastocyst, suggesting that they play an important role in implantation. materials and methods: chemokine receptors were characterized in jeg cells, placental villi, primary trophoblast cell culture, trophectoderm cells derived from human es cells, blastocyst trophectoderm, and st trimester placental tissue sections. expression of chemokines was tested in decidua, endometrium, and ishikawa and hec- cell lines. immunohistochemistry, intracellular staining, elisa, facs analysis, and rt-pcr were employed to characterize chemokine receptor and ligand expression. functional testing was performed using transwell migration assays and in a nude mouse model using a matrigel gel plug cell attraction assay followed by facs analysis. results: trophoblasts demonstrated expression of various chemokine receptors, most prominently cxcr and cxcr . immunohistochemistry of trophoblast from placental villi plated on matrigel expressed cxcr and cxcr as well as hla-g. noteworthy is that trophectoderm cells derived from hes cells treated with bmp- and jeg cells, and blastocyst trophectoderm expressed principally cxcr . elisa and immunohistochemistry showed that decidua and endometrium expressed chemokines ip and il . migration assays demonstrated that ip significantly attracted various trophoblast and trophectoderm cells in vitro, and in the mouse model in vivo. taken together these results demonstrate the interaction between trophoblasts and endometrial cells is mediated by cxcr and cxcr , and il and ip . these interactions are important in the attraction of trophoblasts at the feto-maternal interface. however, ip -cxcr is the most relevant to early implantation as only cxcr is expressed consistently by trophectoderm. the endometrial proteome: changes from proliferative to secretory phase. lois a salamonsen, jenny i-c chen, xian mak, peter j stanton, david m robertson, andrew n stephens. prince henry's institute of medical research, melbourne, vic, australia. global gene analyses have demonstrated major changes across the menstrual cycle, but which of these are reflected in the proteome is not known. this study aimed to globally assess proteins differentially expressed in the endometrium between the proliferative and. secretory phases. d page analysis with dige minimal dye labelling was conducted across the pi range - on endometrial tissue from either the mid-proliferative or midsecretory phases (n= /group). profiles were assessed using samespots software. differentially expressed proteins were identified using maldi-tof ms and the interrelationship of proteins examined using ingenuity software. a total of spots were detected: were differentially expressed (p < . ) with spots having an overall false discovery rate < % (q < . ). hierarchical clustering analysis revealed that these proteins lay within three main branches in the protein dendrogram. one cluster had proteins upregulated in the proliferative phase and two contained proteins up-regulated in the secretory phase. the unique protein profiles were also revealed using principle component analysis (pca): proteins clustered into two main groups, according to cycle phase. pca thus indicated similar unique protein signatures as suggested by hierarchical clustering. thirty one of the differentially expressed proteins were identified using maldi-tof ms. these proteins could be grouped into seven categories, which included structural ( ), transport ( ), regulatory ( ), membrane ( ), enzyme ( ), motor ( ) and others ( ). proteins involved in matrix assembly and those needed for subsequent establishment of secretory endometrium were up-regulated in proliferative endometrium. proteins important for cellular organisation and communication as well as products responding to environmental stress and the immune system were highly up-regulated during the secretory phase. biological pathways were constructed based on the proteins identified. the top network for secretory endometrium clustered around tgf-b. others related to inhibition of cell death / cell viability and leukocyte extravasation. these studies provide a global approach to the cyclic changes of the endometrium and highlight the complex dynamics of protein expression in human endometrium. hormonal regulation of prokineticins in the human fallopian tube: potential regulators of embryo transport. aw horne, hn jabbour, p lourenco, s wright, s battersby, arw williams, hod critchley. reproductive and developmental sciences, university of edinburgh, edinburgh, united kingdom; mrc human reproductive sciences unit, queen's medical research institute, edinburgh, united kingdom. background: understanding the factors regulating embryo transport in the fallopian tube (ft) has important clinical implications. embryo retention in the tube due to ft dysfunction is thought to lead to tubal pregnancy, a considerable cause of morbidity and occasional mortality. transport of the embryo through the ft is, for the greater part, accomplished by smooth muscle contraction. a group of multi-functional proteins and their receptors, called prokineticins, have been shown to affect smooth muscle function in other tissues, such as the intestine. the expression pattern of prokineticins, and their receptors, was examined in normal human ft obtained throughout the menstrual cycle, and the effect of the sex steroids on prokineticin expression was examined in an in-vitro model of the ft. methods: ft biopsies (n= ) and sera (for measurement of oestradiol and progesterone for endocrine staging) were collected from women undergoing gynaecological procedures for benign conditions. using a combination of quantitative taqman rt-pcr and immunohistochemistry, the mrna and protein expression pattern of prokineticins, and their receptors, were examined in the ft throughout the menstrual cycle. tubal explant culture was established using surgical tissue from the biopsies and exposed to varying concentrations, and time courses, of oestrogen and progesterone. results: prokineticin (pk ) and prokineticin receptor (pkr ) mrna are up-regulated in the progesterone-dominant mid-secretory phase. pk and pkr protein are expressed in the epithelium, smooth muscle and around the blood vessels of the ft. stimulation of tubal explant cultures with a physiological concentration of progesterone showed an up-regulation of pk and pkr . conclusions: prokineticins show temporal variation in expression in human ft and appear to be regulated by progesterone. their role in embryo transport needs to be investigated to further understanding of pregnancy complications, such as tubal pregnancy. translating mouse to human: a dynamic model of xenografted human endometrium. alex j polotsky, liyin zhu, nanette santoro, jeffrey w pollard. albert einstein college of medicine, bronx, ny, usa. in the mouse endometrium, the hormonal environment controls cellular proliferation and cell cycle activity. estradiol (e ) inhibits glycogen synthase kinase beta (gsk- ), resulting in nuclear accumulation of cyclin d and progression of the cell cycle, as well as dna replication licensing. in utero administration of the gsk- inhibitor, licl, results in epithelial cell proliferation in the absence of e (zhu, pollard. pnas. ; : ) . in this study, we derived a functional model of xenografted human endometrium to perform mechanistic studies of human endometrial proliferation. methods: human endometrial samples were obtained from volunteers aged - . immuno-compromised mice were transplanted with disaggregated/ recombined human epithelial glands and stroma under the kidney capsule. after weeks of out-growth, mice were ovariectomized, and replaced with e or licl. xenografts were harvested and processed for immunohistochemistry (ihc) and glandular labeling index (li). t test was used to compare group means. results: - % of engraftments were successful, resulting in a vascularized endometrium with characteristic architecture (a, b). hoechst staining confirmed that xenografts were made up of human cells ©. e (e) induced significantly greater proliferation compared to control (d) as assessed by ihc for ki , with li of . ± . and . ± . , respectively, p = . ). minichromosome maintenance- , a protein involved in dna replication licensing, was more sensitive for e -treated cells synthesizing dna than was ki staining (i). estrogen (g) and progesterone receptors (h) were expressed in xenotransplant tissue, the latter being up-regulated by e . licl (f) induced proliferation similar to e and greater than control (li = . ± . , p= . for e vs. licl). conclusion: xenografted human endometrium provides a dynamic model of endometrial proliferation that is well suited for translational studies. administration of licl in the absence of e induced glandular proliferation, supporting the notion that similar mechanisms are operative in human proliferation as in the mouse. gnrh analogs have been extensively used in assisted reproduction. although the main effects of gnrh analogs are via gnrh receptors on the pituitary gonadotrope, gnrh and gnrh receptors have been identified in many reproductive tissues including human endometrium, suggesting their potential action at endometrial level. in the present study, we examined the potential regulatory action of gnrha, la on sex steroid mediated gene expression in human endometrium. human endometrial surface epithelial (hes) cells and isolated endometrial stromal (esc) cells were used as in vitro models. all experiments lasted for h. the cells were treated with estradiol (e , nm, h), progesterone (p , nm, h), gnrha (la μm, h), e ( h) followed by p (last h) and gnrha plus e plus p where, gnrha added either first, second or last in order at h intervals. total rna was extracted, reversed-transcribed and subjected to real-time pcr simultaneously, measuring the expressions of il- , il- , il- , il- , il- , il- , il- , il- p , il- p , il- , ifn-and tnf . both hes and esc expressed majority of these cytokines with the exception of low to undetectable levels of il- , il- , il- and ifn-. treatment with e and p , either alone, or in combination significantly upregulated the expression of many of these cytokines at varying extend as compared to controls. however, gnrha either alone or in combination with e and p significantly diminished e , p or e plus p induced mrna expression of cytokines. the suppressive effects of gnrha on some of the cytokines varied significantly by the order which gnrha was introduced into the culture medium. we conclude that gnrha by acting directly on the endometrial cells effectively suppresses the mrna expression of several key proinflammatory cytokines upregulated by ovarian steroids. our results imply that gnrha therapy during assisted reproduction may modify endometrial receptivity via downregulation of proinflammatory cytokines induced by estradiol and progesterone. supported by nih grant hd . introduction: endometrial angiogenesis is characterized by a rapid increase during the early proliferative phase that peaks midcycle, followed by a gradual decrease in the secretory phase, while menses involves generalized endometrial inflammation, necrosis, and vascular thrombosis. vascular endothelial growth factor (vegf), whose expression is regulated by sex steroids, is a mediator of endometrial angiogenesis. recently, myoferlin, a kd transmembrane protein, was identified in endothelial cells where it mediates vegf-dependent endothelial cell proliferation, migration, and nitric oxide synthesis by affecting vegf receptor- function and stability. myoferlin also appears to play a role in vesicle trafficking and membrane repair. objective: to characterize myoferlin protein expression in endometrium. methods: western analysis of cultured human endometrial stromal cells (hesc) and human endometrial endothelial cells (heec) treated with physiologic concentrations of estradiol and progesterone was performed using a polyclonal rabbit antibody against myoferlin. subsequently, immunohistochemistry (ihc) was performed on human endometrium samples obtained from various stages of the menstrual cycle. results: myoferlin protein was expressed in hescs and heecs, but expression was not affected by sex steroids. ihc staining for myoferlin was specific, intense, and localized to the apical membrane of glandular epithelial cells and endothelial cells, with less intense staining in the stroma. h-score quantification showed that in endometrial endothelial cells, myoferlin protein expression was highest during the early proliferative and early secretory phases, while glandular and stromal myoferlin expression peaked during the late proliferative/early secretory phase. conclusion: myoferlin expression in human endometrium correlates with periods of greatest endometrial angiogenesis, and expression is not limited to endothelial cells, but also includes glandular and stromal cells. given the involvement of myoferlin in vegf signaling as well as membrane repair, understanding its role in human endometrium may further elucidate an understanding of endometrial development both under physiologic and pathologic conditions. the human embryo is the primary regulator of embryo-endometrial molecular cross talk during early implantation. gijs teklenburg, , cobi heijnen, esther baart, karima amarouchi, carolien boomsma, janet carver, helen mardon, annemieke kavelaars, nick macklon. reproductive medicine and gynaecology, and laboratory of psychoneuroimmunology, university medical center, utrecht, netherlands; nuffield department of obstetrics and gynaecology, university of oxford, women's centre, john radcliffe hospital, oxford, united kingdom. introduction: uterine receptivity and implantation are controlled by locally acting trophic factors and cytokines. in humans, the regulation of the embryo-endometrial dialogue beyond the early blastocyst stage is poorly understood. we hypothesized that the interaction between a healthy conceptus and the receptive endometrium is associated with a distinct local regulation of cytokine production favouring implantation. methods: human embryos, cryopreserved at day after fertilization and donated for research, were thawed and cultured under standard conditions until day five. forty-two embryos from donors developed to the blastocyst stage. following removal of the zona pellucida, they were placed in individual coculture on a confluent monolayer of endometrial stromal cells. on day , the developmental potential of each embryo was assessed as early arrested, late arrested or developing. culture supernatants were analysed for concentrations of il- , il- , il- , il- , il- , il- , il- , il- , tnf-, mcp- , ip- , eotaxin and hb-egf using a multiplex immunoassay. day supernatants from culture systems in which no embryo had been placed were also analysed as controls. results: out of ( %) embryos continued to develop and were able to attach and invade into the stromal cell compartment of the co-culture environment. twelve late arrested embryos showed signs of degradation on day and the totally disintegrated embryos were assigned to the early arrested group. supernatants from both early and late arrested embryo cultures contained significantly lower levels of a number of cytokines and growth factors in comparison to developing embryo cultures. moreover, the levels of these mediators in co-cultures were significantly lower than those in non-embryo control stromal cell culture supernatants. conclusion: these data suggest a pivotal role of the embryo in embryoendometrial cross talk. whether reduced mediator expression in co-cultures reflects a selective down regulation of stromal cell cytokine and growth factor production is now being investigated. epithelial cell dynamics during human implantation. hiroshi uchida, tetsuo maruyama, toru arase, masanori ono, takashi kajitani, maki kagami, hideyuku oda, sayaka nishikawa, yasunori yoshimura. department of obstetrics and gynecology, keio university school of medicine, shinjuku, tokyo, japan. epithelio-mesenchymal transition (emt) is thought to play a role in functional differentiation of endometrial epithelial cells during human implantation. molecular mechanism of epithelial sheet remodeling caused by embryo invasion remains elusive. to address this, we investigated cellular dynamics of n-cadherin and vimentin, the two representative major markers of emt, during implantation. in in vitro implantation assay using a human endometrial epithelial cell line, ishikawa, and a human choriocarcinoma cell line, jar (uchida et al., hum reprod ), we pre-treated human ishikawa cells with or without ovarian steroid hormones ( -estradiol + progesterone; ep), fa- (n-cadherin blocking ab), or suberoylanilide hydroxamic acid (saha), one of histone deacetylase inhibitors, which has a potential to improve in vitro implantation (ibid). implantation or treatment with or without ep or saha enhanced the expression of n-cadherin and vimentin but down-regulated ecadherin. furthermore, treatment with ep or saha accelerated ishikawa cell motility and increased the number and spreading area of jar spheroids. in vitro implantation assay, the most prominent staining intensity of n-cadherin was observed just around the adhered spheroid from which its intensity decreased away. functional blockade of n-cadherin by fa- resulted in the complete suppression of ishikawa cell motility, the unique distribution of n-cadherin around jar spheroids, and the spreading area of jar spheroids, while it did not affect the number of the adhered spheroids. human implantation consists of the multiple steps, including apposition, adhesion and penetration. thus, these results collectively indicate that emt may take place after the apposition and that n-cadherin may be required for the remodeling and emt of the epithelial sheet during embryo invasion. n-cadherin may enhance the recruitment of spheroid-neighboring cells, suggesting its role in the covering-up of the invading embryo through acceleration of epithelial cell motility. endocannabinoid regulation in human endometrium. jessica g scotchie, marc a fritz, steven l young. obstetrics and gynecology, university of north carolina, chapel hill, nc, usa. background: research in mouse models demonstrates two cyclically regulated endocannabinoids produced in murine endometrium, anandamide and -arachidonoyl glycerol ( -ag); both play critical roles in murine embryonic implantation. no studies of endocannabinoids in human endometrium have been performed. objectives: determine menstrual cycle expression and localization of synthetic and degradative enzymes for anandamide and ag in human endometrium. methods: human endometrium was collected from volunteers across the menstrual cycle (n= ). quantitative rt-pcr was performed analyzing the expression of: n-acylphosphatidylethanolamine (nape) and fatty acid amide hydrolase (faah), the synthetic and degradative enzymes for anandamide, respectively; sn- -diacylglycerol lipase-a (dagla), and b (daglb), the synthesis enzymes for ag; and monoacylglycerol lipase (magl) and cyclooxygenase- (cox ), the degradative enzymes for ag. the constitutive gene ppia was used for comparison. immunohistochemical localization of nape protein was performed using nape-pld polyclonal antibody (cayman chemical, # ). anova and student's t-test analysis performed on samples grouped by proliferative (pro), early, mid-, and late secretory (es, ms, ls) phases. results: mrna expression of all enzymes responsible for synthesis and degradation of anandamide and ag was detected throughout the cycle. no significant cyclic change in nape, faah, or daglb gene expression was seen. a decrease in dagla gene expression in the ms and ls phases compared to the pro and es phases (p= . ) was seen. magl gene expression was higher in the secretory phase than the pro phase (p= . ). cox gene expression was detected at low levels in the pro, es and ms phases, with marked increase in the ls phase (p< . for all comparisons). protein localization of nape showed a cytoplasmic epithelial location, with increased staining on pro and es samples compared to ms and ls samples. immunolocalization of remaining proteins is ongoing. conclusion: this is the first report documenting the presence of endocannabinoid synthetic and degradative enzymes in human endometrium. genes controlling anandamide expression do not fluctuate significantly across the cycle. however, ag's degradative enzymes increase in the secretory phase, suggesting that lower ag levels may be advantageous for embryo implantation. our findings suggest that human endometrial endocannabinoid regulation differs from murine regulation. interleukin- beta (il- ) regulates il- signaling in decidua-implication in the pathophysiology of preeclampsia (pe). sj huang, cf yen, cp chen, f schatz, cj lockwood. obstetrics, gynecology and reproductive sciences, yale university, new haven, ct, usa; ob/gyn, chang gung memorial hospital, tao-yuan, taiwan; ob/gyn, mackay memorial hospital, taipei, taiwan. objective: previously, we found much higher cytoplasmic immunoreactive il- levels in the preeclamptic decidual cells than in adjacent interstitial trophoblasts. such decidual cell-derived il- contributes to the systemic endothelial cell dysfunction that elicits the proteinuria and hypertension of the maternal syndrome. il- promotes the transition from innate to adaptive immunity. moreover, by skewing monocyte differentiation from a dendritic to a macrophage phenotype, decidual il- may promote the macrophage excess observed in the preeclamptic decidua. macrophages impair trophoblast decidual invasion to foster incomplete spiral artery remodeling that elicits placental ischemia and hypoxia. the current study: ) localized il- mrna levels in preeclamptic versus normal decidual sections; ) evaluated mechanisms regulating il- synthesis by targeting intracellular signaling pathways with specific inhibitors; ) identified potential il- targets by immunolocalizing the il- receptor (il- r) to specific cell types in placental bed biopsies. methods: in situ hybridization localized il- mrna in normal versus preeclamptic decidua. il- r was immunolocalized in placental bed biopsies. leukocyte-free first trimester decidual cells were incubated with e and mpa ± il- ( ng/ml) ± an inhibitor of p mapk (sb ) or protein kinase c (calphostin c) or nf b (activation inhibitor iii) for hrs. an elisa measured secreted il- levels. results: il- mrna was present primarily in decidual cells with increased il- mrna levels observed in pe. preferential expression of the il- r was observed on decidual cells in placental bed biopsies. compared with basal il- levels ( . ± . pg/ml/ g cell protein) by decidual cells, il- enhanced il- output by decidual cells ( . ± . pg/ml/ g cell protein). only the p mapk inhibitor significantly reduced this output to . ± . pg/ml/ g cell protein (n= , p< . ). our results indicate that inflammatory cytokine enhances il- synthesis in decidual cells of the preeclamptic decidua by a mechanism involving p mapk. such il- is likely to act as an autocrine/paracrine effector via decidual cell-expressed il- r to contribute to the macrophage excess observed in the preeclamptic decidua. heparanase is up-regulated by estrogen and during the secretory phase of the human endometrium. ronit haimov-kochman, shira natanson-yaron, caryn greenfield, achinoam lev-sagie, lichtenstein michal, haya lorberboum-galsky, israel vlodavsky, simcha yagel, arye hurwitz. ob/ gyn, jerusalem, israel; cellular biochemistry human genetics, hadassah hebrew university medical centers, jerusalem, israel; cancer and vascular biology research center, technion school of medicine, haifa, israel. introduction: heparanase is an endoglycosidase that cleaves heparan sulfate (hs) proteoglycan of the extracellular matrix. the full-length proheparanase is activated by cleavage into an active isoenzyme, resulting in the release of hsbound cell-differentiation factors, such as hb-egf. the cycling endometrium involves remarkable steroid hormone-induced tissue remodeling. in vivo, increasing exposure to unopposed estrogen may lead to endometrial malignant transformation. aim: to investigate heparanase expression and regulation in the cycling endometrium. materials and methods: heparanase mrna levels were measured by quatitative rt-pcr in naturally menstruating women and in hec a, estrogen receptor (er)-negative and ishikawa, er-positive endometrial carcinoma cell lines exposed to increasing doses of estradiol. heparanase isoenzymes were localized by immunohistochemistry using specific anitbodies in murine endometrium and human normal, hyperplastic and malignant endometrium. results: heparanase mrna level increased fold in secretory phase (d ) compared to proliferative phase (d ) endometrium. heparanase transcript levels increased fold during hr culture in er positive adenocarcinoma cell line exposed to increasing doses of estradiol, but not in hec a, er negative cell line. both heparanase isoforms were localized to murine glandular endometrium. human glandular endometrium at both proliferative and secretory phases was immunoreactive with the active isoform of heparanase. proheparanase was detected in basal membrane of endometrial glands and endometrial stroma during secretory phase. along with malignant transformation of the endometrium the presence of proheparanase increased dramatically from none in stroma of normal and hyperplastic endometrium to abundance in malignant tumors. conclusions: heparanase gene expression is higher during the window of implantation and up-regulated with estrogen in endometrial cells via er in vitro and vivo. heparanase is differentially localized in the secretory phase of the endometrium compared to the proliferative phase, suggesting a role for this molecule during the window of implantation in man. interleukin- (il- ) system mrna and protein expression in the human fallopian tube with ectopic implantation. hong-yuan huang, , tien-hung huang, chin-jung li, chyi-long lee, , hsin-shih wang, , yung-kuei soong. , obstetrics and gynecology, chang gung memorial hospital, kwei-shan, tao-yuan, taiwan; obstetrics and gynecology, chang gung university and school of medicine, kwei-shan, tao-yuan, taiwan. objective: ectopic pregnancy, an abnormal implantation of a fertilized ovum outside the uterine cavity, has been increasing in number at a staggering pace of all pregnancies. il- system is one of the major cytokines involved in human endometrium during embryo implantation and might perform a defensive role against maternal immune response. very little information is available regarding the expression and synthesis of cytokines in the pathogenesis of fallopian tube with ectopic gestation. the purpose of this study is to investigate il- system expression in human fallopian tubes with ectopic pregnancy. methods: paired segments of human fallopian tubes with ectopic implantation site and side portion close to ectopic gestation (n= ) were collected from women undergoing laparoscopic salpingectomy after informed consent and irb approval. segments of fallopian tubes from women undergoing tubal ligation (n= ) were used as control groups. total extracted rna was reverse transcribed and amplified by pcr using specific primers for gapdh ( bp), il- ( bp), il- bp ( bp) and il- r ( bp). quantitative il- and il- bp mrna expression in human fallopian tube was determined by real-time pcr. to determine the presence of il- system proteins, tissues were fixed and processed for immunohistochemical study. data analysis was done with anova and pearson's correlation. results: il- and il- bp as well as il- r mrna were all expressed in tubal ectopic implantation and normal tubes. according to real-time pcr with c t value quantification and -ct method, a significantly higher il- expression in tubal ectopic implantation and lower ratio of il- antagonist to agonist in portion close to ectopic implantation is demonstrated in comparison to normal tubes (p< . ). immunoreactive il- system at the protein levels was also present in human fallopian tubes with ectopic implantation and normal tubes. conclusions: these results suggest that fallopian tube il- system expression may play a crucial role during the process of early embryonic implantation. the expression and ratio of antagonist to agonist in fallopian tubes may indicate an earlier "dialogue " in human fallopian tubal gestation prior to uterine implantation. replacement. marcia c ferreira, ines kd cavallo, fernando m reis. gynecology, ufmg, belo horizonte, mg, brazil. activin a is a growth factor expressed in the endometrium, where it modulates tissue remodelling and enhances decidualization. the effects of activin a are counteracted by two binding proteins, namely follistatin and follistatin-like (fstl ). while the endometrial expression of activin a increases during the secretory phase of menstrual cycle, the effects of ovarian steroids on these proteins and their mrnas has not been assessed yet in postmenopausal women or in ovariectomized animals. we have evaluated the effects of estrogen alone or estrogen plus progestin on the endometrial expression of activin beta-a subunit, follistatin and fstl in ovariectomized rats. adult female wistar rats (n= ) were ovariectomized and received one week later a single dose of estradiol benzoate ( . mg/kg body weight, i.m. injection), either alone (n= ) or associated with depot medroxyprogesterone acetate ( . mg/kg body weight, i.m. injection, n= ), or oil vehicle (control group, n= ). one week after the hormone or placebo treatment, the animals were sacrificed and their uteri were removed and processed by immunohistochemistry and real-time pcr. data were normalized to the expression of ribosomal phosphoprotein p (rpp ) and analyzed with the delta-delta ct method, anova and newman-keuls test. activin beta-a subunit mrna levels increased significantly in the uteri of rats treated with estradiol alone ( . fold increase over controls, p< . ) and to the same extent in rats receiving estradiol plus medroxyprogesterone ( . fold increase over controls, p< . ). this was accompanied by increase of beta-a subunit immunostaining in estradiol and estroprogestin-treated rats, which was noted only in the surface endometrial epithelium. follistatin mrna expression, conversely, showed a significant decrease in the groups treated with estrogen alone ( . fold compared to controls, p< . ) and estrogen plus progestin ( . fold compared to controls, p< . ), while follistatin immunostaining in the glandular epithelium was weaker in estradiol and estroprotestin-treated rats compared to controls. fstl expression was similar in the groups. in conclusion, the expression of activin beta-a subunit increases and that of follistatin decreases following estrogen replacement in the endometrium of ovariectomized rats, and these effects are not further altered by the addition of progestin. endometrial nk cells are a unique inert nk subset until pregnancy. simcha yagel, irit manaster, jacob hanna, ronit haimov-kochman, miri godin, yuval bdolach, caryn greenfield, shira natanson-yaron, arye hurwitz, debra s goldman-wohl, ofer mandelboim. obstetrics and gynecology, hadassah-hebrew university medical center, jerusalem, israel; lautenberg center for tumor immunology, hadassah-hebrew university medical center, jerusalem, israel. introduction: we recently demonstrated that nk (natural killer) cells play a critical role in trophoblast migration and angiogenesis at the fetal maternal interface. nk cells populate the endometrium at the secretory phase of the menstrual cycle, the time of anticipated blastocyst implantation. peripheral blood (pb) nk cells and decidual nk (dnk) cells express a variety of activating receptors, including nkp , nkp and nkp , collectively known as natural cytotoxicity receptors (ncrs), and nkg d which regulate nk cell killing and growth factor production. to compare endometrial nk cell (enk) activating receptor expression and function to pbnk and dnk cells and endometrial ligand expression, with a focus on their roles in blastocyst implantation. patients and methods: subjects were ivf patients undergoing natural menstrual cycles. endometrium samples were collected on treatment days and . a lymphocyte profile of the endometrial cells and pb was performed. facs analysis was performed on isolated endometrial nk cells, pbnk cells and dnk cells for cd , cd , nkp , nkp , nkp and nkg d. ncr ligand expression was characterized on adherent endometrial cells using ncr-ig fusion proteins and nkgd -ig and nkg d specific ligands as well as control ccmi-ig. redirected killing assays and cytokine secretion assays of ifn , vegf, plgf, and il- with and without il- were performed. results: endometrial lymphocytes of day and in these women are mostly cd bright cd -nk cells, with a significant amount of t cells, similar to pbnk cells and in marked contrast to dnk cells. unlike pbnk and dnk cells, enk receptors do not express nkp , nkp . nkp and nkg d are the only activating enk receptor expressed. like decidual cells, adherent stromal endometrial cells expressed the ligands for nkp , nkp and nkg d, suggesting that these nk cells have potential for activation. finally enk cells could not kill or secrete cytokines. conclusions: these findings of a unique activating receptor profile on endometrial nk cells, unlike that of dnk and pbnk, suggest that enk cells are a special local population of nk cells that change dramatically and are activated at the onset of pregnancy. variation in platelet activation throughout the menstrual cycle. fiona c denison, amy o robb, imogen b smith, nicholas l mills, hilary od critchley, david e newby. centre for reproductive biology; centre for cardiovascular sciences, the university of edinburgh, united kingdom. background: platelet-monocyte aggregation (pma) is a sensitive and novel measure of platelet activation with important proinflammatory consequences including release of cytokines and chemokines. previous studies using less sensitive techniques suggest that platelet activation alters during the menstrual cycle in response to circulating concentrations of sex steroids. the effect of sex steroids on circulating (c) pmas during a single menstrual cycle is not known. objective: to determine whether cpmas, platelet surface (ps) p-selectin and plasma (p) p-selectin vary through the menstrual cycle in response to changes in circulating sex steroid concentrations. methods: healthy, nulliparous, pre-menopausal, non-smoking women (mean age years), with regular menses ( - days) were studied. subjects gave written informed consent and the study had ethical approval. serial venous blood samples were taken at menstrual, follicular, periovulatory and luteal phases of a single cycle (days - , - , - and - ). cpmas (monocytes positive for the platelet marker cd a) were measured by flow-cytometry. psp-selectin expression was calculated on cd a positive cells. isotype-matched controls were used. serum oestradiol (e) and progesterone (p), plasma and pp-selectin were measured by elisas. data were analysed by one-way anova with repeated measures and bonferroni's post-tests for multiple comparisons. results: luteal phase p was > nmol/l in all women. numbers of cpmas and expression of psp-selectin were both significantly higher during menstrual compared with periovulatory phase of the menstrual cycle ( . ± . vs. . ± . %, p= . and . ± . vs . ± . %, p< . , respectively). there was no significant difference in pp-selectin concentration during the menstrual cycle (p= . ). there was no correlation between levels of serum e or p and numbers of cpmas, expression of psp-selectin or pp-selectin concentration. conclusions: numbers of cpmas and expression of pspselectin are maximal at menstruation with neither numbers of cpmas nor expression of psp-selectin correlating with serum e or p levels. this study suggests that activated platelets may potentially contribute to the inflammatory response at menstruation by releasing inflammatory mediators. by angiogenic factors and peri-cellular proteases in decidual secretory endometrium (dse), decidua parietalis (dp), and basalis (db) of miscarriage patients and matched controls. comparison of these parameters between the two groups enabled hypothesizing about their correlation with the occurrence of miscarriages. methods: decidua was obtained during st trimester termination of pregnancy (control group) and vacuum aspiration of missed abortions (case group). vascularization was studied by cd -immunohistochemistry. the expression of vascular endothelial growth factor-a, placental growth factor, flt- , kdr, angiopoietin- , angiopoietin- , tie- and the membrane-type matrix metalloproteinases mt -, mt -, mt -and mt -mmp were determined at mrna and antigen level and cd -positive unk cells, cd -positive macrophages, proliferation (ki ) and apoptosis (activated caspase- ) were evaluated by immunohistochemistry in consecutive serial sections. results: the decidual vascularization pattern showed differences between cases and controls: i.e. fewer vessels with larger circumference in cases, and this correlated with the differential expression of various angiogenic factors and proteases at mrna and antigen level. moreover, the endothelial protein expression of flt , kdr, mt -and mt -mmp was increased at the implantation site of cases. ki and active caspase- showed similar levels in the two groups and also the immune cells, both unk cells and macrophages, showed no differences at the implantation site between both groups. conclusion: differences between cases and controls appeared not to be based on altered proliferation, apoptosis, and/or inflammation. the differences in vascularization pattern and in the expression of angiogenic factors and proteases between both study groups suggest a correlation between decidual vascularization and the occurrence of miscarriages. respond to adrenomedullin. yaun-lin dong, hong y wen, janice endsley, alison hogg, hui-qun wang, manubai nagamani, chandra yallampalli. background: natural killer (nk) cells are the predominant lymphocytes present in human implantation site. decidual nk cells express perforin, an essential molecule required for lysis. formation of the placenta involves cooperation between maternal nk cells and fetal trophoblast cells that remodels the blood supply; however, the interaction between trophoblasts and decidual nk cells is largely unknown. adrenomedullin (adm) has been implicated in regulating early placental function and fetal growth. objective: to determine the role of multifunctional peptide adm in the decidual nk cells and fetal trophoblast cells interactions. methods: decidual and placental tissues were obtained from normal firsttrimester pregnancies terminated for social reasons. ethical approval to use these tissues was obtained from the irb of university of texas medical branch. cell preparations containing all decidual mononuclear cells were isolated by collagenase enzymatic disaggregation. cd decidual nk cells were purified by magnetic bead isolation. results: ) immunohistochemical analysis showed that adm is expressed primarily in decidual cells and trophoblast cells at the human implantation site; ) confocal imaging analysis demonstrated that decidual nk cells, which were identified by anti-cd staining, express adm receptor components crlr/ramp /ramp and their mrna expressions were futher confirmed by rt-pcr; ) k target cell killing assay indicates that adm inhibits cytokine il- /il- -induced decidual nk cell cytotoxicity; and ) immunofluorescent labeling and flow cytometric analysis revealed that adm suppresses perforin expression by decidual nk cells. conclusion: trophoblast-derived adm inhibits decidual nk cell cytotoxicity via suppressing perforin expression, thus, our results provide evidence for a new paradigm of embryonic-maternal communication involving a adm mediated interaction between decidual nk cells and fetal trophoblasts. leandro g oliveira, gendie e lash, judith n bulmer, barbara a innes, roger f searle, stephen c robson. institute of cellular medicine, newcastle university, newcastle upon tyne, tyne and wear, united kingdom. background: we have previously demonstrated that co-culture with extravillous trophoblast cells (evt) (expressing hla-g) alters cytokine secretion by uterine natural killer (unk) cells, particularly at - weeks gestation. we have also reported that unk cells can stimulate evt invasion, but only at - weeks gestation (not at - weeks gestation). in addition, unk cell cytokine profiles alter with increasing gestational age. other reports have suggested that evt or hla-g expressing cells may alter the expression of cytokines and angiogenic growth factors by unk cells. hypothesis: hla-g expressing cells alters unk secretion of cytokines. methods: cd + unk cells were isolated from early pregnancy decidua ( - and - weeks gestation, n= each group) using enzyme digestion and positive immunomagnetic bead separation. the human b lymphoblastoid . transfected with either hla-g ( g) or a mock cdna ( cdna) were obtained as a kind gift from mr r apps (university of cambridge, uk). isolated unk cells were cultured in the presence or absence of the two cell lines in either direct or indirect contact (n= each group and each gestational age) for hours. cell supernatants were analysed for cytokines using a fastquant® th /th multiplex protein assay (il- , il- , il- , il- , il- , tnf-, il- , il- , ifn-) or by standard elisa (tgf- ). the effect of direct co-culture of unk cells with g compared with co-culture with cdna at each gestational age was tested using mann whitney u test. the effect of co-culture of unk cells with g in both direct and indirect contact was also tested using mann whitney u test. results: there was no difference in the level of cytokines secreted by the g or cdna cells. cytokine secretion by unk cells was not altered after direct co-culture with either g or cdna cells at either gestational age. in addition, direct or indirect co-culture of g or cdna with unk did not alter cytokine secretion at either gestional age. conclusions: hla-g does not alter the secretion of cytokines by unk cells from either - or - weeks gestation. other evt or decidua derived factors (including hla-e) may be responsible for the alteration in secretion of cytokines by unks with increasing gestational age. introduction: natural killer (nk) lymphocytes are central to innate immunity and contribute to tissue homeostasis by eliminating altered cells. their nkg d receptor pathway plays a fundamental role in target elimination through binding nkg d ligands on the cell surface. reduction in the nkg d ligand, ulbp , expression is associated with immune resistance in neoplastic processes. we have previously shown that fibroblasts from adhesion tissue (at) are characterized by increased extracellular matrix molecules and inflammatory cytokines compared with normal peritoneal (np) fibroblasts. objective: to determine if there is a difference in nk lymphocyte-mediated elimination between np and at fibroblasts and to investigate potential role of nkg d pathway in this process. material and methods: expression of nkg d ligands; ulbp , ulbp , mica, and micb was evaluated by flow cytometry and western blot in primary cell cultures of fibroblasts from np and at, established from two patients. peripheral blood nk lymphocytes (cd +cd -) from three healthy volunteers were isolated using macs system with purity greater than % and kept in interleukin overnight. fibroblast elimination with and without ulbp blocking was investigated following -hour co-incubation with allogeneic nk lymphocytes using our established flow cytometric cell mediated cytotoxicity assay. paired t test was used in statistical analysis. results: the flow cytometry studies showed that nkg d ligands (ulbp , ulbp , mica and micb) were lower in at compared to np fibroblasts, reaching a statistical significance in ulbp expression (p = . ). western blot analysis also revealed a lower ulbp protein level in at than np fibroblasts. furthermore, nk lymphocyte-mediated elimination was % lower in at in comparison with np fibroblasts. blocking ulbp expression resulted in decreased nk lymphocyte-mediated np fibroblast elimination by %, supporting the role of nkg d receptor pathway in the process. conclusions: our results demonstrate that nkg d pathway is operational in at fibroblast resistance to immune elimination, and extends our prior observations of the potential role of immunological mechanisms in the pathogenesis of adhesion development. objective: galectin- is an anti-inflammatory lectin that has pleiotropic regulatory functions at the crossroad of innate and adaptive immunity. human galectin- is expressed in the placenta and immune privileged sites and it has been implicated in establishing immune tolerance. the aim of this study was to examine the evolution and placental expression of the lgals gene in primates. methods: seven primate nucleotide sequences were generated, aligned to vertebrate orthologs from all classes and subjected to phylogenetic analysis. deduced amino acid sequences were analyzed for functionally important substitutions. placental galectin- expression was studied by immunohistochemistry and western blot. results: ) the lgals gene had high sequence identity among all investigated species. ) phylogenetic analysis revealed that intense purifying selection had been acting on the lgals gene in placental mammals (dn/ds= . ); ) residues responsible for sugar binding or molecule stabilizing were highly conserved in primates. ) immunostaining showed a uniformly abundant and ubiquitous galectin- expression pattern in human, old and new world monkey and prosimian placentas, regardless the type of placentation. the lgals gene has conserved sequence and placental expression pattern in primates that may suggest its important function in maternal-fetal immune interactions. these results support the view that immune interactions at the maternal-fetal interface evolved in concert with invasive placentation and that these interactions have been maintained regardless of the degree of placental invasion in primates and other mammals. expression of interleukin- in human endometrium throughout the menstrual cycle and early pregnancy. yesim h uz, , william murk, umit a kayisli, aydin arici. department of obstetrics, gynecology and reproductive sciences, yale university school of medicine, new haven, ct, usa; department of histology and embryology, trakya university school of medicine, edirne, turkey. background: interleukin- (il- ) is a recently discovered heterodimeric cytokine, comprised by a novel p subunit and a p subunit shared by il- . it has biological activities that are similar to but distinct from il- , and is known to be involved in th /th cell class switching and the regulation of cytokines such as ifn-gamma, il- , tnf-alpha, and il- . early pregnancy is associated with alterations in the maternal immune response, such as changes in cytokine expression, and leukocyte recruitment and subtype switching. we hypothesized that expression of il- in the human endometrium is menstrual cycle-and pregnancy-dependent. materials and methods: endometrial samples from women (n= ) undergoing surgery for benign gynecologic conditions, and decidual tissues from women (n= ) with clinically normal pregnancies terminated voluntarily in the first trimester, were obtained after receiving informed consent. endometrial samples were grouped according to menstrual phase. paraffin sections were stained with il- p antibodies and evaluated semi-quantitatively with hscore. statistical analysis of the data was done using anova, with p< . considered significant. results: il- immunoreactivity was predominantly located in the cytoplasm of both endometrial stromal (esc) and glandular (egc) cells. escs showed mild il- immunoreactivity without significant changes in intensity throughout the menstrual cycle. on the other hand, first trimester decidual cells showed significantly stronger il- staining compared to escs from non-pregnant endometrium (p< . ). il- immunoreactivity in egcs was high in the late proliferative phase, as compared to other cycle phases and first trimester tissues (p< . ). moreover, egcs from the early secretory phase (p< . ) and first trimester tissues (p< . ) showed higher il- immunoreactivity compared to the early proliferative and late secretory phases. conclusions: this is the first study describing il- expression in the human endometrium and decidua. these results suggest that il- has a cycledependent expression in endometrial cells and may be involved in regulating cytokine expression and immune cell modulation during the menstrual cycle and early pregnancy. gercel-taylor, douglas d taylor. obstetrics, gynecology, and women's health, university of louisville, louisville, ky, usa. objective: estrogen appears appear to be a critical regulator of the immune system. since hypoestrogenism is present in the postmenopausal woman, our objective was to determine whether t cell activation and function, defined as il- production and signaling molecule expressions at the transcriptional and translational levels, were affected by a low estrogen environment. design: prospective study in a university research laboratory. materials and methods: jurkat . t cells, initially grown in estrogen free media, were incubated in pm (representing postmenopausal levels) or pm (premenopausal levels) of estradiol (e ) for hours. cells were either resting or activated with a phorbol ester, -phorbol -myristate -acetate (pma), and ionomycin. enzyme-linked immunosorbent spot assay (elispot) was performed to analyze production of il- . expression of signaling protein components, cd and jak, were determined by western immunoblotting. real time-polymerase chain reaction was performed to quantify cd , jak , and jak gene expression. a p value of < . was considered significant. results: jurkat cells exposed to pm e and activated exhibited significantly diminished numbers of il- producing colonies compared to t cells exposed to pm ( . ± . vs. . ± . colonies, p< . ). analysis of cellular cd and jak protein demonstrated that jurkat cells incubated in pm e expressed a . -fold decrease in cd and . -fold decrease in jak compared with cells incubated in pm e (p< . ). these diminished protein levels appeared to be the consequence of suppressed transcription, as the mrna levels of cd , jak and jak were significantly decreased in jurkat cells incubated in low levels of estrogen ( . , . , and . fold, respectively, compared to pm). conclusions: jurkat cells exposed to low postmenopausal estrogen levels produce significantly less il- following activation, which was associated with a significant decrease in signaling proteins. the diminished levels of signaling proteins appear to result from decreased cd , jak and jak gene expression in the presence of low estrogen. these findings support the observation of decreased cellular immune response in postmenopausal women and may provide a basis for the increased risk of infections and cancer proliferation associated with aging. support: dept. of ob/gyn research seed fund. the expression pattern of novel cytokines (il- and ) in human fetal membranes. judith eckardt, , stephen j fortunato, holger maul, ramkumar menon. the perinatal research center, nashville, tn, usa; womens' hospital, university of heidelberg, heidelberg, baden-wuerttemberg, germany. objective: interleukin (il) and are novel cytokines produced by various immunological cells in response to microbial antigens. the functions of these cytokines in reproductive system is unknown. this study examines the expression pattern of il- and il- in human fetal membranes from preterm and term births and in in vitro in normal term membranes in response to bacterial endotoxin (lipopolysaccharide-lps). methods: fetal membranes collected (n= ) from cesareans at term (normal, not in labor) were placed in an organ explant system for hours and were stimulated with lps for an additional hrs. fetal membranes were also collected (n= ) either at preterm or term after vaginal deliveries. in a case -control study (preterm birth vs. normal term deliveries) amniotic fluids (af) (n= ) were collected to document the role of il- and il- in ptb. tissue expressions of il- and il- were studied by rt-pcr using specific primers. elisa documented culture media and af cytokine concentrations. statistical analysis was performed using non-parametric mann-whitney u test. results: both il- and il - expressions were seen in fetal membranes in culture (in vitro) regardless of stimulation. in vivo in membranes from preterm and term deliveries and membranes at term not in labor also documented the expression of these cytokines. culture media analysis documented higher concentration of il- after lps stimulation (lps- . vs. . pg/ml; p= . ) whereas no difference was noticed in il- concentration (lps- . control- . pg/ml; p= . ) between the two groups. af analysis, regardless of the status, did not document detectable concentrations of either of the cytokines (lower limit . pg/ml for both). conclusion: this is the first study to document the expression of two novel cytokines in laboring and non laboring human fetal membranes and also in membranes from preterm deliveries. il- production was stimulated by lps whereas il- was not affected. these cytokines are not physiological components of af and their role in fetal membranes is unclear. higher il- concentration in response to lps but lack of its presence in term or preterm af is suggestive of an autocrine immune response during pregnancy in response to a microbial antigen. evidence for a selective migration of fetus specific cd + cd bright regulatory t cells from the peripheral blood to the decidua in human pregnancy. tamara tilburg, , dave l roelen, barbara j van der mast, godelieve m de groot, carin kleijburg, sicco a scherjon, frans hj claas. department of obstetrics, leiden university medical centre, leiden, netherlands; department of immunohematologie and bloodbank, leiden university medical centre, leiden, netherlands. during pregnancy the maternal immune system has to tolerate the persistence of fetal alloantigens. many mechanisms contribute to the prevention of a destructive immune response mediated by maternal alloreactive lymphocytes directed against the allogeneic fetus. murine studies suggest that cd + cd + t cells provide mechanisms of specific immune tolerance to fetal alloantigens during pregnancy. previous studies by our group demonstrate that a significantly higher percentage of activated t cells and cd + cd bright t cells are present in decidual tissue in comparison with maternal peripheral blood in human pregnancy ( ) . in this study we examined the phenotypic and functional properties of cd + cd bright t cells derived from maternal peripheral blood and decidual tissue. depletion of cd + cd bright t cells from maternal peripheral blood demonstrates regulation to a rd party umbilical cord blood cells comparable to non-pregnant controls, whereas the suppression capacity to umbilical cord blood cells of her own child is absent. furthermore, maternal peripheral blood shows a reduced percentage of cd + cd bright foxp + and cd + cd bright hla-dr + cells compared to peripheral blood of non-pregnant controls. in contrast, decidual lymphocyte isolates contain high percentages of cd + cd bright t cells with a regulatory phenotype that are able to down regulate fetus-specific and non-specific immune responses. these data suggest a preferential recruitment of fetus-specific regulatory t cells from maternal peripheral blood to the fetal-maternal interface where they may contribute to the local regulation of fetus specific responses. ( ) tilburgs t, roelen dl, van der mast bj, van schip jj, kleijburg c, de groot-swings gm, kanhai hh, claas fh, scherjon sa. differential distribution of cd (+) cd (bright) and cd (+) cd (-) t-cells in decidua and maternal blood during human pregnancy. placenta. apr; suppl a:s - . alicia del toro-arreola, lourdes nunez-atahualpa, juan velazquez-rodriguez, laura gonzalez-lopez, jorge i gamez-nava, adrian daneri-navarro. there is evidence that the maternal immune system is influence by changes in the hormonal levels during the menstrual cycle (mc). so far, the information related to the levels of t, treg, nk cells and receptors of activation and inhibitors is scarce. aim: to analyze the populations of t, treg, nk cells and their receptors of peripheral blood of healthy women and their correlation with hormones during mc. material and methods: we studied to women not using hormonal contraceptives in the day th of the follicular phase and st of the luteal phase of the mc. pbmc subsets and their receptors were determined by flow cytometry and hormone levels by chemiluminescence method. we found that the progesterone and prolactin were positive correlated (rho= . , p< . and rho= . , p< . , respectively) with cd /nkg in t cells and negative correlated (rho= - . , p< . and rho= - . , p< . , respectively) with nk cells. meanwhile cortisol was positive correlated (rho= . , p< . ) with the receptor nkg d expressed in nk cells. the results observed in this study in the luteal phase of mc on the expression of cd /nkg inhibitor receptor and nkg d activator receptor were related to a particular hormone (progesterone, prolactin and cortisol) might contribute to understanding the physiological role of the neuroendocrine axis on the expression of some receptors of the immune system in order to keep the homeostasis milieu of the mc. objective: sp-d, a key component of the innate immune system, is detected in amniotic fluid (af) and believed to originate in the fetal lung. however, sp-d is produced by other cells and therefore extra-pulmonary sources must be considered. the objective of this study was to determine the maternal and fetal plasma and af concentrations of sp-d to gain insight into the behavior of this natural antimicrobial peptide in pregnancy. moreover, we studied sp-d expression in maternal and fetal peripheral leukocytes. methods: maternal and fetal plasma and af samples were obtained from patients in the following groups: ) term not in labor (tnl; n= ); ) term in labor (til; n= ); ) preterm labor without histologic chorioamnionitis (ptl; n= ) and ) preterm labor with histologic chorioamnionitis (ptl-hc; n= ). sp-d concentration was measured by elisa. sp-d mrna expression in maternal and fetal leukocytes was evaluated by real-time qrt-pcr. flow cytometry and confocal microscopy were used to study the localization of sp-d in leukocytes. results: ) the af sp-d concentration increased as a function of gestational age (mean, til: , . ng/ml vs. ptl: , . ng/ml; p< . ); ) in contrast, the maternal and fetal plasma sp-d concentrations decreased with advancing gestational age (mean, til: . ng/ml vs. ptl: . ng/ml; p< . , and til: . ng/ml vs. ptl: . ng/ml; p< . , respectively); ) the maternal plasma sp-d concentration was lower than that of fetal plasma (mean: . ng/ml vs. . ng/ml; p< . ); ) however, sp-d mrna expression in maternal leukocytes was . fold higher than that of fetal leukocytes (p< . ); ) neutrophils (both maternal and fetal) expressed sp-d as demonstrated by flow cytometry and confocal microscopy. conclusion: ) the concentrations of sp-d in the maternal and fetal circulation decreased with gestational age while the af concentration increased; ) the expression of sp-d mrna is higher in maternal leukocytes than in fetal leukocytes; ) we report for the first time that maternal and fetal neutrophils are a source of sp-d and propose that this molecule plays a role in host defense against infection and in the modulation of the maternal and fetal immune response. introduction intrauterine insemination (iui) is a fertility technique that allows for couples to have intercourse after the procedure is performed. it has been postulated that intercourse after iui may increase the pregnancy rate by either endometrial stimulation or because it may represent a second spermatic flow in the periovulatory period. in the present study we evaluate the effect of intercourse on the pregnancy rate of patients undergoing iui. material and methods: from to patients were enrolled in the study. every couple undergoing iui was instructed at the moment of insemination to decide whether to have or not intercourse on the same day of the procedure. all couples were abstinent three to seven days before iui. the information regarding intercourse was recorded the day after treatment. ovulatory, insulin resistant, cervical, male, tubal and endometrial factors as well as parity and time of infertility were compared between the two groups. all these factors were analyzed based on number of follicles that ovulated in each group. our principal outcome was to determine the pregnancy rate. intercourse was practiced by . % of the couples. the global pregnancy rate was . %. the pregnancy rate for the couples who had intercourse was . % and . % for those who did not have intercourse (p< . ). even though age, parity, time of infertility and stimulation protocols were similarly distributed in both groups, the proportion of tubal and endometrial factors were higher among those who had intercourse (p< . ). when subjects with tubal and endometrial factors were excluded, the pregnancy rate between both groups (n= ) was similar ( . % vs . % for positive and negative intercourse, respectively). the average number of ovulatory follicles was . + . for the group that had intercourse and . + . for those who did not. according to our results, intercourse after iui does not improve pregnancy rate after this procedure is performed. furthermore our study indicates that iui does not interfere with sexual intimacy since almost % of the couples decided to have intercourse on the same day of the procedure. . we sought to investigate the effects of gravidity on mmc and fmc in healthy, parous women. methods: mc was assayed in dna extracted from peripheral blood mononuclear cells (pbmc). hla-genotyping was first conducted and mc quantified employing a q-pcr assay targeting a non-shared maternal-or fetalspecific hla polymorphism. gravidity was dichotomized as a history of one pregnancy compared with two or more, and the prevalence of mc was analyzed using logistic regression. possible confounders were included as appropriate, including subject age and time since last pregnancy. adjustment for possible correlation between values was also made when there were repeated measures for the same subject. results: for the mmc analysis, there were subjects with observations. for the fmc analysis, there were subjects with observations. table provides a summary of mmc and fmc by gravidity. mmc was significantly decreased with higher gravidity. fmc was not affected by gravidity. gravida gravida or more adjusted* or ( %ci) mmc / ( %) / ( %) . ( . - . ) fmc / ( %) / ( %) . ( . - . ) *adjusted for possible correlation between values within a subject, subject age, and time from last pregnancy, as appropriate. increasing gravidity is significantly associated with a decreased prevalence of mmc. despite additional sources of fmc, there does not appear to be an increase in fmc prevalence with increasing gravidity. the biology of mc is incompletely understood, and the nature of mmc and fmc are likely to be different given that acquisition of the former, but not the latter, occurs within a nascent immune system. these data raise interesting questions when considered as interactions of acquired grafts within a host, including whether emergence and persistence of one dominant source of mc may be most advantageous for an individual. anti-igd antibody treatment as a novel immunosuppressive agent for autoimmune diseases and its effects on th /th gene expression. tommie g nguyen, eileen d gallery, , jonathan m morris. elevated t-helper cell type- (th ) and type- (th ) cytokine expression have a role in autoimmune diseases, allograft rejection and pregnancy-related complications. thus, molecules that can shift the immunity away from th /th responses toward a th response represent a novel therapeutic treatment for these conditions. we have previously demonstrated that pregnancy is associated with a suppression of t-bet in peripheral t cells. in this study, we examined a novel effect of anti-igd antibody on t-bet expression, th /th gene expression in human peripheral blood mononuclear cells (pbmc) and its therapeutic effects in an animal model of collagen-induced arthritis. methods: human pbmc were isolated and then cultured in the presence of anti-igd antibody at various time points followed by stimulation with pma/ionomycin (p/i) for hrs. gene expression was examined by rt-pcr, western blotting and elisa. for in vivo study, arthritis-prone dba/j mice were induced to undergo joint inflammation by intradermal injections with bovine type-ii collagen. these mice were then given daily doses of mg/kg of intravenous injection with anti-igd antibodies as preventive or therapeutic treatments (n = per group). results: treatment with anti-igd antibodies significantly suppressed p/iinduced expression of t-bet (a master regulator of th immunity), tnf-(a classical pro-inflammatory th cytokine), and il- (a critical proinflammatory th cytokine) in human pbmc. this suppression is highly specific to these genes because anti-igd antibodies have no effects on the expression of ifn-g and il- (two classical th cytokines). in vivo experiment showed that anti-igd antibody treatment markedly reduced clinical severity of joint inflammation when comparing the clinical score of control mice group ( . ± . , mean ± s.e.m), preventive group ( . ± . ) and therapeutic group ( . ± . ) . conclusions: our study has demonstrated that suppression of t-bet by anti-igd antibodies, similar to the changes seen in human pregnancy is a novel in vivo anti-inflammatory effect. given the essential role of t-bet, tnf-and il- in the pathogenesis of human autoimmune diseases, anti-igd antibodies may represent a novel immunosuppressive treatment that needs further studies and evaluation. objective: women with circulating anti-phospholipid antibodies (apl) are at risk for recurrent miscarriage, preeclampsia and preterm labor. apl antibodies directly target the placenta by binding to phospholipids or phospholipid-binding proteins expressed on the surface of viable trophoblasts. the objective of this study was to determine the effects of apl antibodies on first trimester trophoblast cells. methods: two mouse igg anti-human beta -glycoprotein i monoclonal antibodies (mabs), designated id and iic , were used in these studies. the first trimester trophoblast cell line, htr , was incubated with either medium, a mouse igg control, id or iic ( - g/ml), in the presence or absence of unfractionated heparin ( ng/ml). trophoblast cell death and apoptosis was determined using a viability assay, hoechst staining and a caspase activity assay. cytokine production was evaluated by multiplex analysis. results: following a hour incubation, significant trophoblast cell death was induced by iic ( . ± . %) and id ( . ± . %) at the high dose of g/ml, when compared to the medium and mouse igg controls (p< . ). hoechst staining showed that id -and iic -induced trophoblast cell death was a result of apoptosis. moreover, id and iic induced a significant increase in caspase- , - and - activity (p< . ). treatment of trophoblasts with heparin significantly inhibited the effects of iic and id on cell death by . ± . % and . ± . % %, respectively (p< . ). following a hour incubation at lower concentrations ( g/ml), treatment of trophoblast cells with id or iic resulted in a significant upregulation of il- , mcp- , gro production (p< . ), and a significant reduction in il- secretion (p< . ). conclusion: this study demonstrates that at low levels apl antibodies can modulate trophoblast cytokine production, while at higher levels, the same antibodies induce trophoblast apoptosis in a caspase-dependent manner. these findings shed new light on the mechanisms by which apl antibodies may impact placental survival and function. antigenic targets for the diagnosis of premature ovarian failure. hc bohler, c gercel-taylor, lt ku, st nakajima, dd taylor. obstetrics, gynecology, women's health, university of louisville, louisville, ky, usa. objective: premature ovarian failure (pof) is a premature depletion of ovarian follicles before the age of , affecting approximately % of women < years. the involvement of autoimmune mechanisms in pof has been suggested and similar mechanisms have been postulated for other ovarian pathologies, including idiopathic infertility, polycystic ovary syndrome (pcos), or endometriosis. while the association of autoantibodies has been demonstrated for these ovarian pathologies, variation in specificity and frequency of false positivity have limited the diagnostic use of autoantibodies. the objective of this study was to develop an antigen array to differentiate antibody recognition patterns of pof from other infertility pathologies. design: prospective study in a university research laboratory. materials and methods: patients diagnosed with infertility were included in this pilot study: endometriosis (n= ), pcos (n= ) and pof (n= ). autoantibodies were assayed by dot immunoblotting using an antigen array derived from endometrial and ovarian cells. for the cellular antigen preparations, solubilized total proteins were separated by reverse phase-hplcquid chromatography and the individual proteins were blotted onto nitrocellulose membranes and reactivity visualized by peroxidase-labeled antihuman igg. results: patients with pof, endometriosis, and pcos all exhibited autoantibodies reactive with these cellular proteins. while some antigenic reactivities were shared by all infertility patients, the pattern of antigen recognition was distinct for patients with pof. patients with pof all recognized a common antigenic proteins (row , antigens a,b,d-g). conclusions: alterations in autoreactivity are observed in patients with the diagnosis of infertility; however, distinct patterns of autoantibody recognition can be demonstrated for patients with different pathologies. while this study needs to be expanded to reliably establish the specificity, sensitivity and positive and negative predictive values, patients with pof clearly exhibit a shared recognition pattern that may be useful a diagnostic marker. cicek gercel-taylor. ob/gyn, university of louisville, louisville, ky, usa. objective: americans' consumption of nutraceuticals is one of the most rapidly expanding health markets, growing at a rate of % annually. multiple nutraceuticals containing phytoestrogens have been marketed as "immune boosters" despite suboptimal evidence-based medicine to support such statements. as immunomodulatory therapies should affect downstream cytokine expression, the relative effects of estradiol and genistein in regulating expression of cd -and jak were tested. these markers were chosen since they are central to t cell signaling. cd -is a critical transducer of tcr activation and regulates t cell proliferation and cytokine production. jak upregulation is a specific marker for hematopoietic cell stimulation. methods: to test the immunomodulatory effects of phytoestrogens and estrogen, jurkat . (t cell leukemia) cells were grown in estrogen-free, phenol red-free media for hours. these cells were then exposed for hours to pm, pm (postmenopausal), or pm (premenopausual) of estradiol in the presence of increasing concentrations of genistein ( , . , . , . , , and m). cells were then solubilized and cellular protein quantitated. protein concentrations were standardized and western blots for each set of culturing conditions were run in triplicate. cd -and jak expression were quantitated following visualization with chemiluminescence by digital pixel quantification. results: our findings show that in the absence of estradiol and at postmenopausal levels of estradiol, genistein induced a dose dependent increase in cd -reaching a maximum of fold. although cultivation of t cells in pm of estradiol significantly increased the levels of cd -and jak relative to hypoestrogenic conditions, the genistein mediated dose response was not observed. conclusions: these in vitro results indicate that genistein can at least partially reverse suppression of signaling molecules observed in postmenopausal estrogen environments. clinically, this suggests that phytoestrogens may have greater immunomodulatory properties for postmenopausal females than those that are premenopausal. maternal serum il- as a biomarker of acute immunologic rejection of pregnancy. joaquin santolaya-forgas, juan deleon-luis, isabel galan. obstetrics and gynecology, brigham and women's hospital, boston, ma, usa; amarillo women's health research institute, texas tech university health science center, amarillo, tx, usa. objective: markers of acute rejection of pregnancy are very scarce. in this study we aimed at determining if rapid changes in maternal serum concetration of a variety of biomarkers could be used for this purpose. we used an established baboon model for in utero stem cell therapy to introduce at - days from conception and via ultrasound-guided celocentesis, human hematopoietic stem cells with different proportions of natural killer t-cells (nk). maternal blood was collected before and hours after celocentesis for quantification of hormones and il- using solid phase, enzyme labeled, chemiluminescent sequential immunometric assays. pearson correlation analysis was used for determination of significant changes from baseline (p< . ). results: all animals survived their pregnancies. seven animals receiving < % concentration of nk delivered at term ( days gestation) while animal receiving more than % concentration of nk had dead fetuses on ultrasound evaluation hours after celocentesis. table depicts mean maternal serum concentration of the biomarkers investigated (all n.s.). figure shows mean il- changes from baseline in continuing (n.s.) and rejected pregnancies (p< . ). conclusions: we have described a model in which in utero graft vs host disease can be studied. these preliminary results suggest that of all the biomarkers investigated, il- might be the most sensitive for detection of an acute rejection of pregnancy. biomarkers of acute immunologic rejection of pregnancy biomarker unit pre-celocentesis ( ) the activity of cytotoxic cd + t cells during pregnancy protects the mother and fetus from infection. however, pregnancy's effect on the proliferation and apoptosis of cd + t cells has not been clearly defined. objective: to determine if normal pregnancy changes the number of proliferating or apoptotic splenic cd +t cells. methods: female c bl/ mice were used unmated (um) or underwent timed mating. one day prior to harvest, mice were i.p. injected with bromodeoxyuridine (brdu), which is incorporated into replicating dna. harvested spleens were homogenized, enumerated, and stained for cell surface expression of cd and t cell receptor beta chain (tcr ). apoptotic cells were detected by treatment with terminal transferase and fitc-dutp (tunel). the numbers of cd +tcr + cells that were brdu+ or tunel+ were calculated from the percentage of positive cells obtained by flow cytometry and the absolute number of cells counted. for each experiment, the ratio of the number of positive cells in pregnant to um mice was compared by anova with dunnett's post-test. results: at day of pregnancy (n= ), the number of brdu positive cd + t cells was two fold higher than that found in um (n= , p< . ). the number of proliferating cd + t cells continued to be non-significantly elevated at day ( . x, n= ), day ( . x, n= ), and day of pregnancy ( . x, n= ) compared to um. by day of pregnancy (n= ) the number of proliferating cd + t cells returned to the um level, however by this time the total number of splenic cd + t cells was . fold higher than um (n= p< . ). on gestational day , the number of proliferating cd + t cells declined further ( . x, n= ), and the number of splenic cd +t cells returned to the um level (n= , p> . ). compared to um mice, there was no significant difference in the number of cd + t cells undergoing apoptosis at any gestational day examined ( . - . x, p> . ). in normal murine pregnancy, the number of cd + t cells is increased in late gestation, and then returns to baseline at the end of pregnancy. this is due to an early increase then gradual decline in cd + t cell proliferation, accompanied by a steady rate of apoptosis. this argues that the maternal immune system undergoes dynamic homeostatic changes, and is not globally suppressed. supported by nihro hd - niht ai . arturo cerbulo-vazquez, cun li, , gene hubbard, natalia e schlabritz-loutsevitch, , peter w nathanielsz. objectives: early thymocyte (t) maturation occurs in the cortex while later stages occur in the medulla. thymic epithelial cells (tec) synthesize gc and t express gr. tec may influence t cell maturation by regulating apoptosisinduced gc-gr interactions. igf- (also synthesized by tec) may support thymocyte prolifetarion. human fetuses of mothers in premature labor are exposed to gc. gc administered to pregnant baboons at . , . , and . gestation (g) alters fetal lymphocyte populations at . (g) (j repro immunol, , : ) . we determined if fetal gc exposure alters thymic ) structure; ) gr and igf-i protein. methods: pregnant baboons received saline (control ctr; n= ) or betamethasone i.m. ( μg/kg daily for two days at . , . and . g; gc group; n= ), c-sectioned at at . g under general anesthesia and thymic gr and igf-i evaluated by immunohistochemistry. results: gr localized to medulla and a few cortical cells. igf-i localized to cortex with little medullary expression. medullary necrosis was greater in ctr than gc fetuses. t gr was located in cytoplasm. no gross differences were observed between ctr or gc fetuses for either igf-i or gr. conclusions: a) early thymocyte maturation may be supported by igf- , b) later differentiation involves gr, and c) after exposure to gc doses equivalent to human therapy, no gross effects were detected on gr or igf, but d) natural thymic necrosis was inhibited. lindsay s christensen, peyman bizargity, elizabeth a bonney. ob/gyn, university of vermont, burlington, vt, usa. background: the exact mechanism by which bacterial products trigger preterm delivery and the immune cellular circuits involved remain unclear. our recent data in normal c bl/ (b ) or recombinase deficient c bl/ mice (rag-ko) indicates that t and b cells are not critical for lps-induced preterm delivery and stresses the importance of related innate mechanisms. rag-ko mice are more susceptible to lps, suggesting that t or b cells may control the innate response. macrophages are vital to innate immunity and produce proinflammatory cytokines that can activate prostaglandin synthesis and myometrial contraction. we questioned whether differences in susceptibility between the strains are due to differences in the uterine macrophage response to lps and thus examined macrophages at the maternal-fetal interface early after injection. objective: to compare uterine macrophages levels at and hours after lps injection in pregnant b and rag-ko mice. methods: b and rag-ko mice were mated and on gestation day , females were injected intraperitoneally with μg lps in l saline (pbs) or l pbs alone. euthanasia and uterine harvest occurred or hours after injection. frozen uterine sections were stained with the macrophage marker f / or an isotype-matched control followed by an alexafluor -conjugated secondary and a nuclear stain (dapi). sections were visualized by fluorescence microscopy. for each mouse, f / + dapi+ and total dapi + cells were counted in areas of representative section and the percentage of f / + dapi+ cells was calculated. the mean percentage for at least representative areas per experimental group was analyzed by anova. results: two hours post-injection, macrophages levels were similar in b and rag-ko mice injected with pbs (b , n= , . ± . ; rag-ko, n= , . ± . % + per area). lps injection increased macrophages (p< . ) in both strains (b , n= , . ± . ; rag-ko, n= , . ± . ,); no difference was evident between strains. the percentage of f / + cells was similar hours post-injection (b , n= , . ± . v. rag-ko, n= , . ± . ), and not elevated relative to the hour time point. objective. decay-accelerating factor (cd ), is expressed in the plasma membranes and protects mammalian cells against the lytic action of serum complement. phosphoinositide -kinases (pi ks) are involved in the regulation of cell functions by synthesizing a second messenger molecule ptdins ( , , ) p . akt, a serine-threonine kinase acts downstream of pi k and regulates cell survival, growth and proliferation. the pi k-akt activity is controlled by tumor suppressor gene pten. in this study we assessed whether the pi k-akt activity affects the expression of cd in human endometrial and cervical cells. methods. endometrial and cervical cell lines which differ in the constitutive pi k activity were used in this study. ishikawa and rl - endometrial cell lines harbor pten mutation and have high levels of phosphorylated akt (p-akt). hec- -a and kle endometrial cell lines and hela cells express wild-type pten and have minimal or no demonstrable levels of p-akt. the expression of cd was evaluated by rt-pcr, immunoblotting and flow cytometry. the pi k activity was assessed by immunoblotting with anti-p-akt antibodies. the effect of inhibition of pi k-akt pathway on cd expression was evaluated in cells treated with wortmannin ( nm), ly ( mm), or with akt inhibitor sh ( mm). results. immunoblotting densitometry and measurements of mean fluorescence intensities showed that the level of cd expression correlates with the status of pi k-akt pathway. the cd expression was lowest in hec- -a, ishikawa and rl - cells which constitutively express p-akt. higher cd expression was found in hela cells and kle cells which express wild-type pten product and has no detectable phospho-akt. mean fluorescence intensities were . -fold higher for kle cells and -fold higher for hela cells compared to hec- -a cells. treatment of cells with akt inhibitor led to . - . -fold increase in cd expression. the . - . -fold increase following treatment with pi k inhibitor wortmannin was found in ishikawa cells, rl - and kle cells. conclusions. human endometrial cell lines with elevated pi k-akt activity express lower level of cd compared to cell lines with intact pten gene function. these findings may indicate that structural alteration at the dna level and resultant overexpression of pi k-akt pathway are involved in the downregulation of cd . endometrial and cervical cells. pawel goluszko, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. objective. cell shape is determined by the cytoskeleton, which provides the mechanical support and is involved in cellular signaling. apoptotic cells undergo major morphological changes such as rounding and contraction, a process regulated by caspases, the cysteine proteases responsible for events controlling the cell disassembly. the motifs in certain cytokeratins make them substrates for caspase degradation. anti-apoptotic serine/threonine kinase akt provides a survival signal by phosphorylating downstream effector molecules including caspase- . while studying the akt distribution in human endometrial cell line we found that akt shows filamentous pattern of staining resembling cytoskeleton organization. in this study we evaluated whether akt staining correlates with the microfilaments (mf), microtubules (mt) or intermediate filaments. endometrial ishikawa, rl - , hec- -a, kle and cervical hela cell lines were used in the study. incubation with cytochalasin d, ( ug/ml) or nocodazole ( mg/ml) and labeling with bodipy fl phallacidin, anti -tubulin or anti-akt antibody were used to assess whether cytoskeleton disruptors affect akt distribution and mf and mt organization. for colocalization, cells were stained with anti-cytokeratin mouse antibody followed by anti-mouse alexa conjugate, and then stained with anti-akt rabbit antibody and anti-rabbit alexa conjugate. the scans collected with laser scanning confocal microscope from channels filtered for alexa and alexa were combined digitally and evaluated with imaris colocalization analysis software. filamentous pattern of akt staining was most pronounced in ishikawa and less obvious in hec- -a cells. treatment with cytochalasin d or nocodazole resulted in disruption of mf and mt but had no effect on cytokeratin organization and akt distribution. double staining with anti-cytokeratin- and anti-akt antibody showed overlapping staining for cytokeratin and akt. analysis of digitally acquired images showed highest correlation for colocalized channels in rl - cells ( . ) followed by ishikawa ( . ) and hela cells ( . ). lowest correlation was found for kle ( . ) and hec- -a cells ( . ) conclusions. this study indicates a strong colocalization pattern of serine/ threonine kinase akt with cytokeratins, and suggests a mechanism by which cytokeratins might be protected against cleavage by caspase- and caspase- in the early apoptotic stages. background: cd + cd + t regulatory cells (t-reg), express foxp ,suppress antigen-specific immune responses and are important for allograft tolerance. during pregnancy the mother tolerates an allograft expressing paternal antigens (the fetus), requiring substantial changes in immune regulation over a programmed period of time. the presence of t-reg cells (cd + cd highfoxp +) was assessed in the peripheral venous blood of non-pregnant, pregnant and seven postnatal healthy women by flow cytometry. human decidua was obtained by surgical termination of pregnancy in the first (n= ), second (n= ) and third (n= ) trimester of human pregnancy. paraffin sections were immunostained for foxp and cd . foxp +cells were quantified in x fields and results compared between first, second and third trimester samples and according to the presence of extravillous trophoblast. results: fluorometric studies of blood samples indicate an increase % of circulating cd + cd highfoxp t-cells in pregnant ( . % [range . - . %]) vs. non-pregnant controls ( . % [range . - . %]; p< . ). a progression from st, nd and rd trimesters indicated the % of cd + cd highfoxp t-cells was . %, . % and . %, respectively. low numbers of foxp + cells were detected in all decidua samples and their distribution mirrored that of cd + cells. in st trimester samples, foxp + cells were often detected in lymphoid aggregates adjacent to endometrial glands. increased numbers of foxp + cells were detected in st ( . ± . ) compared with nd trimester decidua ( . ± . ; p< . ) but there was no difference between st and rd trimester ( . ± . ), nor between nd and rd trimester decidua. in st trimester decidua, numbers of foxp + cells were increased in areas without extravillous trophoblast. conclusion: normal human pregnancy is associated with an increase in the number of circulating cd + cd highfoxp t-cells. the presence of foxp + cells in early gestation human decidua may be important in the initiation of materno-fetal tolerance at an autocrine level. (supported by mrc). aims: -defensins are small cationic peptides with antibiotic and antimicotic activity. hyaluronan and its degradation products have been described as endogenous ligands for tlr and tlr , whose involvement in -defensin expression has been reported in different epithelial tissues and cell lines. we aim to investigate weather low molecular weight hyaluronic acid induces -defensin release by keratinocytes, via tlr and tlr . methods: the induction of -defensin production following in vitro treatment of human keratinocytes with a low molecular weight hyaluronic acid solution was evaluated by pcr-analysis and elisa techniques. studies on the involvement of tlr and tlr in -defensin production have been performed using specific blocking antibodies. results: pcr and elisa revealed an intense -defensin production following hyaluronic acid treatment in human keratinocytes. the -defensin production induced by hyaluronan was abolished following block of tlr and tlr by specific antibodies, demonstrating the involvement of these receptors. the same hyaluronic acid treatment did not induce activation of inflammatory genes, such as il- , tnf-, il- and il- . conclusion: our data show that hyaluronic acid is an efficient inducer ofdefensin production in keratinocytes, via tlr and tlr . this observation might be important to open new perspectives in the development of possible topical products containing hyaluronic acid, to improve the release ofdefensins by keratinocytes, ameliorating the self-defence of the skin in case of skin infections. therefore, one of the possible applications for this kind of topical products might be the treatment of infective vulvitis, one of the most distressing gynaecological diseases for adult women. pregnancy outcome? kiera von besser, serena wu, mary d stephenson. , obstetrics and gynecology, university of chicago, chicago, il, usa; obstetrics and gynaecology, university of british columbia, vancouver, bc, canada. objective: to investigate whether gender of an ongoing pregnancy impacts the probability of a successful outcome, and, to ascertain whether the gender of prior live birth(s) impacts subsequent pregnancy outcome, among women with rm/aps. materials and method: cohort-control study. rm subjects were evaluated by mds between - (stephenson, . couples who met aps criteria (wilson et al, ) , restricted to rm only, were followed prospectively. cohort data was compared to live birth data from the vital statistics agency of british columbia from - . secondary sex ratios (ssrs) among successful pregnancy outcomes were calculated by dividing the number of male live births by female. sex ratios were calculated for all pregnancies weeks, regardless if they ended in success or demise. pearsons test with yates continuity correction was applied. results: subjects were identified. subjects had prior live births of known gender ( male/ female), giving a ssr of . . there were also prior fetal demises wks of known gender ( / ) giving a sex ratio for all prior pregnancies at wks of . . subjects delivered subsequent live births of known gender ( / ), giving a ssr of . . there were also subsequent fetal demises ( / ) giving a sex ratio for all subsequent pregnancies of . . subjects delivered both prior and subsequent live births. the ssr was . ( / ) among their prior and . ( / ) among their subsequent live births. including fetal demises, subjects had ongoing prior and subsequent pregnancies. the sex ratio was . among their prior pregnancies and . among their subsequent. as the control, a ssr of . ( , / , ) was calculated from vital statistics data. when the prior and subsequent ssrs of the cohort were compared to each other, as well as to the control, there were no statistically significant differences. conclusions: our findings, from the largest study of its kind to date, suggest that, in patients with rm/aps, the gender of an ongoing pregnancy does not significantly affect the probability of a successful outcome, to any greater degree than it does in the general population. also, the gender of a prior ongoing pregnancy does not significantly impact the likelihood of developing rm/aps. oocyte maturation. jk friend, fb bezirci, e seli. ob gyn, yale u., new haven, ct, usa. introduction: oocyte maturation is associated with repression of transcription. during oocyte maturation, fertilization, and early embryo development until the onset of zygotic gene expression, proteins are synthesized from maternallyderived mrnas. the regulation of protein expression from these maternal mrnas is post-transcriptional, and occurs mainly via poly(a)-tail elongation. the embryonic poly(a)-binding protein (epab) is the predominant poly(a)binding protein before the activation of the zygotic genome, and plays a critical role in the activation of certain maternal mrnas, those bound by cpeb and probably pumilio. we are characterizing additional functions of epab during the process of oocyte maturation. methods and results: our model system is the xenopus laevis oocyte where oocyte maturation is induced by the addition of progesterone. our preliminary findings indicate that epab is phosphorylated, and that levels of phosphorylated epab increase upon progesterone-induced oocyte maturation. moreover, glycerol gradient centrifugation revealed that nonphosphorylated and phosphorylated epab are contained in distinct complexes that change mobility upon oocyte maturation. furthermore, oligo-dt selection for poly(a)-containing mrnas strongly suggests that these mrnas are bound exclusively by phosphorylated epab. using affinity purification, we have determined that nonphosphorylated epab exists primarily in a large protein complex prior to oocyte maturation that is later disassembled after the addition of progesterone. conclusions: based on these preliminary findings, we conclude that prior to oocyte maturation, the bulk of epab is nonphosphorylated and is found in a protein-rich complex separate from poly(a)-containing mrnas. upon oocyte maturation (when certain maternally-derived mrnas are activated for translation), the majority of epab becomes phosphorylated, and this phosphorylated form of epab is likely bound to translationally-active mrnas. we are currently investigating what kinase phosphorylates epab and whether this phosphorylation plays a role in translational up-regulation of epab-bound mrnas. introduction: reactive oxygen species (ros) play important roles in all aspects of cellular fate. nadph oxidase isoforms, a family of genetically preserved enzyme complexes, have been shown to be the main sources of ros in various cell types. however, the role of nadph oxidase isoforms in human myometrium proliferation and differentiation has not been defined. in the myometrium, different smooth muscle phenotypes maybe associated with specific physiologic functions. we have shown that angiotensin ii (angii) stimulates hypertrophy but not cell proliferation in ultr cells, an in vitro model of human myometrium. ultr cells at greater than passages display a replicative senescent phenotype. by introducing human telomerase reverse transcriptase (htert) gene, we have obtained a stable cell line (ultr-ht) which has a significantly increased division rate and distinct cellular morphology than the original ultr cells. objective: to determine the relationship of expression of nadph oxidase to ultr cellular fate. methods: early and late passages (p - ) of ultr and ultr-ht (p - ) cells were grown on either plastic or collagen iv (cn )-coated surfaces. ultr-ht cells were further stimulated with angii ( . um) for hrs. expression of nadph oxidase core (nox - and duox / ) and associated subunits (p phox, p phox, noxo , p phox, noxa , p phox, and rac / ), and angii receptors at / was identified by rt-pcr from cellular total rna. fluorescent immunohistochemistry (ihc) was employed to determine protein expression and localization. results: the mrna level of house keeping gene -actin was unchanged by any cellular manipulation. the senescent phenotype of ultr cells was accompanied by an apparent down-regulation of nox , p phox, and noxa genes, and an up-regulation of at / . overexpression of htert did not reverse nox , p phox and noxa expression while cell division rate was increased. however, there was a down-regulation of nox , at / and rac . plating ultr-ht cells on cn induced nox / down-regulation and up-regulation of duox / , with no apparent change of at / . however, exposure to cn re-directed cellular response to angii such that only nox was induced by angii stimulation. conclusion: expression of nadph oxidase isoforms nox , , , and duox / are correlated with ultr cell differentiation and cell fate control. data also suggests that ang ii-induced myometrial hypertrophy involves nox mediated ros generation. fluids from reproductive women -the influence of aging. eriko y fujii, masahiro nakayama. women's health, national center for child health and development, tokyo, japan; aska reproductive clinic, nara, japan. [introduction] receptor for advanced glycation end products (rage) is a multiligand type glycoprotein, and is characterized based on its ability to bind ages, adducts formed by non-enzymatic glycation and oxidation of protein and lipids. this process occurs during normal course of aging. ages/rage interaction regulates various physiological function, such as inflammation, angiogenesis through vegf inducement. a soluble form of rage (srage) works as a decoy in the body and inhibits intracellular signaling. [objectives] the balance of these factors may contribute to reproductive dysfunction by aging. we aimed to measure the ages, srage and vegf concentrations in plasma and follicular fluids from reproductive women, and examined the differences of those factors between young group and old group. [material and methods] patients' plasma and follicular fluid were collected with consent based on regulations of the ethical committee, and we measured ages (pentosidine, cml), srage and vegf in duplicate using commercially available elisa kits (fushimi co, r d and cyelex). concentrations were calculated from each standard curve, and compared between the young group under years old, and the old group over y.o. data were evaluated for the difference in two groups by student's t test , and the significance was determined by p< . . [results] ) srage in plasma, ± pg/ml (mean±sd), n= in the young group was significantly higher than ± pg/ml, n= in the old group. there was no significant difference in plasma vegf. ) vegf in follicular fluid was ± pg /mg protein, n= in the young, and ± pg /mg protein, n= in the old was increased significantly. ) we could not see statistical difference of pentosidine nor cml concentrations between two groups in plasma and follicular fluid samples. [conclusions] it has been reported that higher concentration of vegf in follicular fluid may relate to worse pregnancy rate in art. there was a significant decrease of plasma srage in older group in our result, and because of this decrease of 'decoy', focal ages-rage-vegf signaling might be activated in older women. our results showed the possibility that ages/rage and vegf regulation may contribute to the reproductive dysfunction by aging. and leiomyosarcoma cells. qun pan, xiaoping luo, nasser chegini. ob/ gyn, university of florida, gainesville, fl, usa. as a part of a novel endogenous rna silencing machinery, a noncoding short rna strand referred to as "microrna" (mirna) has been identified to regulate the stability of the target gene expression through mrna degradation and repression. we have identified the expression of many of these mirnas in leiomyoma, myometrium, their isolated smooth muscle cells (lsmc and msmc), transformed lsmc (t-lsmc) and sklm (leiomyosarcoma cell line), including mir- which is predicted to target the expression of many genes, including tgf-b and tgf-b type ii receptor (tgf-brii). however, the biological significance of these mirnas in various cellular processes remains to be established. as such in the present study we examined the expression, regulation and function of mir- in lsmc, msmc, t-lsmc and sklm. we found that mir- is expressed and regulated by b-estridiol and medroxyprogesterone acetate ( - m) in these cells (p< . ). we further assessed the regulatory function of gain of and loss of function of mir- on the expression of tgf-brii. transfection of lsmc, msmc, t-lsmc and sklm with pre-mir-and anti-mir- oligonueclotides resulted in a significant increase and/or inhibition of mir- expression in these cells, respectively as determined by realtime pcr (p< . ). over-expression of mir- resulted in a significant reduction, while transfection with antimir- increased the expression of tgfbrii mrna and protein in these cells as compared to controls (p< . ). we concluded that mir- is expressed in leiomyoma and myometrial cells, its expression is regulated by the ovarian steroids and it functions by targeting the expression of tgfbrii and possibly other genes with key regulatory action on cell growth, angiogenesis, transcription regulation, ecm turnover and apoptosis that results in leiomyomas growth and regression. (supported by nih grant hd ). objective: placenta and a number of gestational tissues are well recognized to express corticotrophin releasing factor (crf), urocortin (ucn ), ucn , ucn and crf -r and crf-r receptor subtypes together with crfbinding proteins locally. ucn and ucn are implicated in the reversal of stress responses initiated by crf. in the present investigation, we evaluated functions of crf and ucns by quantifying their contents in venous smooth muscle layers using image pro . in human umbilical cords collected at preterm and term gestation methods: umbilical cord specimens ( - mm thickness, pieces per umbilical cord) collected at preterm and term (n= each) at delivery were fixed in bouin's solution and paraffin embedded. sections were subjected to immunohistochemical analyses with polyclonal antibodies to crf ( : ), ucn ( : ), ucn ( : ) and ucn ( : ) (peninsula laboratory, pa and sigma aldridge, ms) by standard abc technique. immunoreactive materials on the sections were identified using , '-diaminobenzidine as a chromagen. immunostaining intensities (od/area) on uc-sections were quantified by image pro . software and expressed as arbitrary units (au). all values were expressed as mean ± sem. differences between groups were evaluated by anova, followed by the post-hoc tukey test for multiple comparison. results: antibodies to crf and ucns elicited positive immunostaining of variable intensity in venous smooth muscle layers in uc-sections of preterm and term gestations. immunostaining intensity (au) of venous smooth muscle layers at preterm (pt) and term (t) are as follows: crf-pt= . ± . vs crf-t= . ± . (p< . ); ucn -pt= . ± . vs ucn -t= . ± . (p< . ); ucn -pt= . ± . vs ucn -t= . ± . (p=ns); ucn -pt= . ± . vs . ± . (p< . ). conclusion: crf content in venous smooth muscle layer markedly increased at term, while ucn and ucn contents significantly decreased and no significant change occurred in ucn content. based on the opposing changes in crf vs ucn and ucn immunostaining, we speculate that crf, but not ucn or ucn , is the major key player of vasodilation and function locally at the level of venous smooth muscle cells at term. ucn and ucn may perform cytoprotective functions at preterm. physiol. ; : - , am j physiol. ; : - ) . these studies showed that when ad libitum (al) feeding was resumed in cr females, fertility was sustained well beyond the age at which al-fed females became infertile. however, much of what is known on the effects of cr on fertility derives from models in which cr was initiated at weaning. further, there is large variation in how the experiments were conducted. objective: herein we tested if adult-onset cr could delay age-related infertility in females. methods: cr ( %, nia protocol as described in j geront. a:b -b ) was initiated in c bl/ female mice at months and continued until . months of age, at which time al feeding was resumed. matings were initiated at months of age. for mating during cr, a male mouse was housed overnight in a cage with a female and removed the next morning, so that the female mice could be fed their dietary food ration. al-fed and cr females followed the same mating regimen. the number of offspring born and that survived to weaning (day ) were recorded. results: fertility was lost in of al-fed females by months of age and continued to decline through . months of age. age-matched females maintained on cr during the same period exhibited poor fertility, with a total of pregnancies achieved out of females. although cr females showed poor fertility while on cr, their fertility improved dramatically after the reinitiation of al feeding at . months of age. while only out of , al-fed females achieved a pregnancy between . - . months of age, out of age-matched cr-then-al-fed females achieved a total of pregnancies in this -month time. notably, % of the pups born to cr-then-al-fed females between . - . months of age survived and developed to weaning without complications. conclusions: adult-onset cr allows maintenance of female fertility into advanced maternal age after the reinitiation of al feeding. how long fertility can be maintained and the minimum time needed for the beneficial effects of cr to be realized remain to be investigated. nonetheless, these observations suggest that there may be ways to safely extend fertility in females at ages when reproductive function is suboptimal (nih r -ag ). bile acids in human ovarian follicular fluid. laura p smith, , kaila deiorio-haggar, jason reindollar, alan s penzias, , anny usheva-simidjiyska. ob/gyn reproductive endocrinology infertility, bidmc, boston, ma, usa; boston ivf, boston, ma, usa; endocrinology, bidmc, boston, ma, usa. introduction: bile acids are known to serve important functions in the hepatobiliary and gastrointestinal systems. the presence of bile acids in the human ovary and relation with fertility potential have never been previously evaluated. methods: human follicular fluid (ff) from large follicles and small follicles was obtained at vaginal oocyte retrieval. human serum was obtained before and hours after human chorionic gonadotropin (h-cg). follicular fluid and serum samples were analyzed for total bile acids by spectrophotometry. bile acid concentrations were correlated with age, number of retrieved and mature oocytes, number of fertilized oocytes, and pregnancy. results: bile acid concentrations were analyzed and compared to the normal human serum bile acid concentration which ranges from to micromoles/l. bile acids are present in follicular fluid with a mean concentration of . micromoles/l in large follicles and . micromoles/l in small follicles (p= . ). pre and post h-cg serum bile acid concentrations differed significantly ( . micromoles/l vs. . micromoles/l, p= . ). there was a trend toward higher bile acid concentration in large follicles of young patients < years old compared to older patients years old ( . ± . vs. . ± . , p= . ). there was also a trend toward higher pre h-cg serum bile acid concentrations in older patients ( . ± . vs. . ± . , p= . ). there was no correlation between serum and follicular fluid bile acid concentrations and number of oocytes retrieved or number of mature oocytes, but there did appear to be a positive correlation between pre h-cg serum bile acid concentration and number of fertilized oocytes (spearman's correlation coefficient . , p= . ). conclusions: this is the first demonstration of the presence of bile acids within human ovarian follicular fluid. there may be a relationship between bile acid concentration and fertility potential. the precise function of bile acids in human ovarian follicular fluid is under investigation. objective to investigate the impact of ovarian hyperstimulation treatment on the biomarkers of the homocysteine pathway in blood and follicular fluid, and their association with the follicle diameter as a measure of follicular maturation. methods in women undergoing ivf/icsi treatment blood samples were collected on cycle day and the day of hcg administration. during oocyte retrieval in each woman the diameter of two follicles was measured and the corresponding follicular fluids were collected. in blood and follicular fluid total homocysteine (thcy), folate, cobalamin and pyridoxal' 'phosphate (plp) concentrations were determined. women with a serum folate . nmol/l were classified as folic acid supplemented. results ovarian hyperstimulation significantly decreased thcy and cobalamin blood levels (both p . ). the blood and follicular fluid concentrations of thcy, folate, cobalamin and plp were significantly correlated (all p . ). in the total group, a two-fold increase of thcy in follicular fluid resulted in a . mm decrease of the follicular diameter (p . ). in non-supplemented women this decrease was . mm (p . ). in supplemented women a twofold increase of follicular fluid folate resulted in a . mm decrease of the follicular diameter (p . ). conclusions ovarian hyperstimulation reduces thcy blood levels independent of folic acid supplementation. however, high follicular fluid thcy and folic acid supplementation may have detrimental effects on the maturation of the follicle. ), post-fixed for rain in % w/v osmium tetroxide in the same buffer, quickly dehydrated in a series of ethanol solutions, and embedded in epon. thin sections were stained with uranyl acetate followed by lead citrate and were observed at electron microscope. results: ten blastocysts from each group were collected and analyzed. compared to the in vivo embryos, blastocysts generated in vitro exhibited significant differences. the surface of their trophectoderm (te) layer had a reduced number of microvilli, the number of the apoptotic cells in the inner cell mass (icm) was higher and the presence of non functional mitochondria was elevated. in this study we have, for the first time, compared the ultrastructure of the in vivo and in vitro conceived blastocysts. taken together, these results suggest that both, the higher rate of apoptosis and the morphological alterations in the mitochondrial structure in ivf embryos, are associated with stress during in vitro embryo culture. therefore, these parameters can be used, in the future, as markers for the assessment of the embryo wellbeing in the ivf settings. deteriorating oocyte quality is a critical hurdle in the management of infertility, especially one associated with advancing age.here, we explore a newly discovered role of nitric oxide (no) in the sustenance of oocyte quality. methods: sibling oocytes from superovulated mice were subjected to intracytoplasmic sperm injection (icsi) with cauda-epididymal spermatozoa following exposure to either the no donor, s-nitroso n-acetyl penicillamine (snap, . m/min); a soluble guanylyl cyclase inhibitor, h-[ , , ] oxadiazolo [ , -a] quinoxalin- -one (odq, m) or an no synthase inhibitor, n w -nitro-l-arginine methyl ester (l-name, mm). their sibling oocytes were subjected to icsi either before (young) or after culture for the corresponding period (old). outcomes of fertilization, cleavage and development to the morula and blastocyst stages were compared. some embryos from each subgroup were also subjected to tunel assay for apoptosis. results: oocytes deteriorated in their ability to undergo normal fertilization and development to morulae/blastocysts after aging in culture, as compared to their sibling cohorts subjected to icsi immediately after ovulation (p< . ). this deterioration was prevented after oocyte exposure to snap. while, exposure to l-name or odq resulted in a significant compromise in fertilization and development to the morulae/blastocysts (p< . ) with detection of apoptosis, which was also noted in embryos derived from aged oocytes but not in those from young or snap exposed oocytes. conclusions: no is essential to sustain oocyte fertilizability and developmental ability, and to prevent blastomere apoptosis. objective to investigate the effects of the levels of the biomarkers of the homocysteine pathway on ivf outcome. methods from women undergoing an ivf or icsi procedures, two blood samples and two mono follicular fluid samples were collected for determination of folate, cobalamin, and total homocysteine (thcy). total protein was determined in follicular fluid to adjust the biomarker concentrations for follicular maturation. primary endpoint of the study was oocyte quality measured by fertilization and embryo quality (range - ; with being best quality). secondary endpoint was the occurrence of pregnancy. results % of the included women used a folic acid supplement (serum folate . nmol/l). in non-supplemented women higher cobalamin levels in follicular fluid correlated with a better embryo quality (estimate - . ; p . ) and higher thcy levels (median . mol/l, range . - . ) correlated with a worse embryo quality (estimate . ; p . ). in supplemented women higher follicular fluid thcy (median . mol/l, range . - . ) correlated with better embryo quality (estimate - . ; p . ). the follicular fluid folate level of oocytes that did not fertilize was . -fold higher than in the fluids of a fertilized oocyte ( % ci . - . ; p . ). a two-fold increase of follicular folate corresponded with a . higher chance to achieve pregnancy ( % ci . - . ). conclusions cobalamin levels in follicular fluid are correlated with embryo quality. folic acid supplementation modifies the thcy and folate levels in follicular fluid and thereby affects oocyte quality. the level of folate in follicular fluid is important in the fertilization process. we recently reported that increasing relative oocyte immaturity is associated with worsening outcome, and that cycles with many immature oocytes are more common in younger women. (moore et al, asrm annual meeting, ) to further investigate this trend, we conducted a case/control analysis of patients with repeated cycles of high-level oocyte immaturity (hloi). methods: oocyte maturity data was collected on all icsi cycles starting in . we defined a cycle with hloi as having > % immature oocytes (> sd's above the median). a case was defined as a patient with hloi on more than one cycle. control subjects were age-matched and defined as having </= % ( sd above median) immature oocytes on all cycles. results: from subjects, we identified cases of recurrent hloi (comprising icsi cycles) and control subjects. at baseline, cases had more oocytes retrieved per cycle than controls ( . vs. . , p<. ). all other baseline characteristics were similar. all case subjects were younger than . outcomes are shown in table . discussion: clinical pregnancy and live births were reduced in the case group, but more than expected based on % immaturity. during cycles, there were no live births among the case group. patients with recurrent hloi represent a previously undescribed group of young patients with a very poor prognosis during icsi treatment. this study may suggest that the problem underlying the immaturity may relate to overproduction of oocytes during stimulation, a factor which may be modifiable. however, the additional trend (though not significant) that even the mature oocytes from the case patients tend to have poor outcomes suggests the possibility of a maturation defect and warrants further consideration. data on response to gonadotropins, fert rates, and implantation rates will be presented. amongst those, were performed for an initial diagnosis of premature ovarian aging (poa), for the diagnosis of premature ovarian failure, and for repeated pregnancy loss. in women under age , b-fsh levels over miu/ml and up to < miu/ml denoted a diagnosis of poa, while levels of miu/ml were considered diagnostic for pof. all patients signed consent permitting review of medical records for clinical research purposes. results: day fsh levels ranged from . to . miu/ml (mean . ± . miu/ml). amh levels ranged from < . to . ng/ml (mean . ± . ) and allele repeats ranged from to , (mean for allele- , . ± . ; allele- , . ± . ). mixed model analysis of variance for all patients, adjusted for age, race, and allele- revealed a statistically significant correlation between b-fsh levels and number of repeats in allele- ( figure ; p < . ). we did not observe a significant linear relationship between serum amh levels and cgg repeat counts, however cgg repeat counts above were significantly associated with serum amh levels less than ng/ml (chi square = . ). conclusions: triple repeats above , a level currently considered well within normal, are associated with evidence of premature decline in ovarian function. the evaluation of triple repeats in frm gene offers a first objective assessment of ovarian function and should be predictive of autologous reproductive life span in most women. objective: the levels of mis in the serum and in the ovary have been demonstrated to decrease in response to increasing doses of cisplatin. we hypothesize that ovarian stimulation also will reveal dose related decreases in ovarian and serum mis levels after cisplatin exposure, further demonstrating the follicular damage from chemotherapy. methods: adult female sprague-dawley rats were treated with saline, . mg/kg cisplatin or . mg/kg cisplatin as two weekly injections. five days following the last cisplatin injection, the rats were injected with pregnant mare serum gonadotropin (pmsg) and euthanized hours following the pmsg injection. serum was collected and both ovaries were obtained for protein analysis. serum and ovarian levels of mis were determined using an elisa kit. western blot analysis, immunohistochemical analysis, and tunel analysis were also performed on the ovarian proteins. results: stimulated mis levels declined in a linear fashion in response to increasing cisplatin doses (p< . ). ovarian protein levels measured by elisa and western blot both indicated that stimulated ovarian mis levels also decrease in a linear fashion (p= . and p< . respectively.) immunohistochemical analysis revealed that while the total number of follicles remains the same, both the total number of mis positive follicles, and the percentage of mis positive follicles declines in a linear fashion (p= . for both). tunel analysis reveals that there is no change in the incidence of apoptosis in the stimulated ovaries from any treatment group. conclusions: the administration of pmsg after treatment with cisplatin causes a dose dependent decrease in the levels of mis in both the serum and in the ovary. serum mis levels following ovarian stimulation may be useful as a serum biomarker in this animal model to assess ovarian damage following the administration of cisplatin. correlations of micro-rnas a, b, - pp, and - p with inflammatory and steroidogenic factors in human granulosa/cumulus cells. tannaz toloubeydokhti, orhan bukulmez, kenneth c drury, r stan williams, nasser chegini. obstetrics and gynecology, university of florida college of medicine, gaineville, fl, usa. as part of the novel endogenous rna silencing machinery, noncoding short rna strands, referred to as micrornas (mirnas), have been identified to regulate the stability of the target gene expression through degradation and repression. the expression of many of these mirnas has been identified in human tissues however, their biological significance in various cellular processes remains to be elucidated. in this cross-sectional study of human granulosa cells, we aimed to study the potential correlations between five selected mirnas, mir- a, mir- b, mir- - p, mir- and mir- - p, and mrna expressions of some of their predicted target genes namely, cyclooxygenase (cox)- , il- , steroidogenic acute regulatory protein (star), aromatase and estrogen receptor (er) . granulosa/cumulus cells were obtained from women (age range - ; mean age . ± . ) undergoing oocyte retrieval for assisted reproduction. total rna was extracted from these cells and reversed-transcribed and real-time pcr was performed to measure steady-state levels of mirnas and mrna transcripts. we observed that the expression of mir- a, mir- - p, mir- and mir- - p displayed a significant and positive correlation with the expression of cox- . moreover, mir- b significantly correlated with star mrna expression, but not with other genes tested (p< . ). with advancing age, the expression of mir- - p and cox- was significantly decreased, with cox- expression displaying a positive correlation with aromatase, star and er mrna expressions (p< . ). none of the factors tested showed any significant correlations with peak estradiol levels and number of oocytes retrieved. receiver operating characteristic curve analysis revealed that female age cut-off value of . y best predicted whether mir- - p was below its mean arbitrary value. in conclusion, given the importance of mirnas' regulatory function in gene expression, our results suggest that mir- b may play an important role in gene expression related to granulosa cell luteinization, while variation in mir- - p expression with female age may suggest its potential role as a predictor of oocyte quality and granulosa cell function. given the importance of mirnas in gene regulation, the role of mirnas in ovarian physiology and aging requires further investigation. support: nih grant . introduction: a symbiotic relationship between ovarian granulosa cells (gc) and the enclosed developing oocyte is critical to reproductive efficiency. genetic modulations in gc's can lead to reproductive insufficiency, highlighting the critical role of gc's in reproductive competence. defects in the oocyte-gc repertoire in women with dor include lower e levels, luteal deficiency, poor fertilization rates, higher incidence of aneuploidy, lower pregnancy and higher miscarriage rates. utilizing global gene expression analyses in cumulus gc's, we attempt to enhance our understanding of biological mechanisms that may contribute to poor reproductive capacity in young women with dor. methods: infertile women (< years old) undergoing ivf were prospectively enrolled into two groups based on ovarian reserve (normal reserve, fsh< dor, fsh > miu/ml). at egg retrieval, cumulus gc's were isolated, rna extracted transcribed into cdna. microarray targets were generated cdna hybridized to affymetrix human genome u plus . genechips. microarray data were analyzed (array assist) and normalized (robust multichip analysis). a difference in gene expression of > fold was considered biologically relevant. results: of the , genes identified to be differentially expressed in young women with dor compared to normal reserve, genes demonstrated consistency of expression across five different normalization schema; were down regulated and up-regulated. expression of gremlin, a member of the dan family of genes known for its highly regulated expression pattern during folliculogenesis, was noted to be down-regulated -fold over two probe sets (- . ) in women with dor versus normal reserve; this down-regulation was confirmed by real-time pcr (- . ) . conclusions: this is the first demonstration linking differential expression of gremlin with etiology of infertility in women. gremlin is a downstream effector of oocyte-derived gdf- which facilitates cumulus cell expansion, a critical event in reproductive physiology. our finding of a significant downregulation of gremlin expression in cumulus gc's associated with dor may partly explain the physiology of poor reproductive performance. nih k cd . nih k rr . ferring pharmaceuticals. the objective of the present study was to investigate the effects of the gnrh antagonist ca on expression of mis and aromatase (cyp ) using luteinized human granulosa cells obtained during in-vitro fertilization cycles and an immortalized human granulosa cell line (hgl ). the granulosa cells were cultured +/-dibutyryl camp ( mm) and incubated +/-the gnrh antagonist, ca, for - h. rna was isolated, reversed-transcribed and real-time pcr was performed to measure mrna transcripts for ovary-specific cypiia and mis. we observed that camp markedly induced aromatase mrna in both the primary and immortalized human granulosa cells. interestingly, camp treatment of these cells also caused an upregulation of mis mrna. objectives: bisphenol a (bpa), a known endocrine disruptor, is a chemical used as a plasticizer in the manufacture of polycarbonate plastics and epoxy resins and is present in multitude products, including the interior coating of food cans, milk containers, and baby formula bottles. bpa can leach into foods during heat processing and is known to exert a variety of endocrine-like effects on different cell types acting as an estrogen because it contains two hydroxyl groups in its diphenyl structure. in this study we focused on the effects of bpa on aromatase expression and estradiol production in the human granulosa kgn cell line. we also evaluated its effects on several transcription factors crucial in cyp expression. materials and methods: kgn cells were cultured in f- dmem and were starved for h before experiments. subsequently they were treated for h with vehicle (control), fsh ( ng/ml), and/or bpa ( , , , , um) . messenger rna expression was quantified by real time pcr and estradiol secrection was measured in supernatants by elisa. results: fsh induced a -fold increase in aromatase expression. bpa induced a dose-dependent decrease in cyp production, with the greatest effect at um (p< . ), resulting in +/- % (mean+/-sem) inhibition, compared to aromatase expression induced by fsh alone. bpa also reduced levels of estradiol secretion in a dose-dependent manner, with the greatest inhibition at um (p< . ) resulting in +/- % decrease. we also evaluated expression of transcription factors known to be involved in regulating the activity of the ovary-specific aromatase proximal pii promoter. interestingly factors known for induction of aromatase such us steroidogenic factor- and gata- , mimic the pattern of cyp expression after bpa treatment, whereas, other receptors previously reported to act as aromatase inhibitor, such as ppar gamma were up-regulated by the addition of bpa. moreover, expression of creb remained virtually intact, suggesting that most likely mechanisms governing endocrine disruption by bpa are highly selective. conclusions: bpa inhibited fsh stimulated aromatase expression and downstream estradiol secretion. we propose that constant exposure to this chemical may result in endocrine disruption which may contribute to reduced fertility and early ovarian senescence. oocyte maturation occurs during folliculogenesis as a result of complex cell-tocell communications between the granulosa cells and the oocyte. maintaining the granulosa cells' spherical structure and network of gap junctions surrounding the oocyte is critical. this project tests the ability of a novel substrate-free threedimensional culture system to form viable granulosa cell spheroids. methods: after irb approval, freshly obtained follicular fluid from in vitro fertilization was obtained and granulosa cells were purified by percol gradient. nonadhesive agarose hydrogels, containing cylindrical round bottom recesses m in diameter, were cast from micro-molds designed using computer-assisted rapid prototyping. granulosa cells seeded at a density of , cells per gel were incubated for up to days. cellular viability was assessed with live:dead assay. results: after three days in culture, granulosa cells formed spheroids of densely packed cells that were difficult to disperse with multiple pipettings. the cells remained viable for at least days. conclusions: granulosa cells can be cultured in a novel substrate-free threedimensional culture system. the cells form tightly adherent spheroids that remain viable for extended culture. the cohesiveness of the cells suggests the formation of gap junctions. this is under investigation with immunohistochemistry and electron microscopy. these experiments suggest that a substrate-free threedimensional hydrogel culture system may be ideal to reassemble follicular structure important for future in vitro evidence testing and oocyte maturation. known to function as responders to pathogens, inflammation, and tissue injury. previous studies in our laboratory demonstrated that saa was produced in mouse granulosa and production was regulated by cytokines. ovulation has long been considered an inflammatory reaction and patients with chronic inflammatory conditions often experience infertility. the present study was undertaken to explore the role of saa in human ovarian function. methods: ovarian granulosa and luteal cells were obtained from surgically removed specimens and mural and cumulus granulosa-luteal cells were obtained from ivf aspirates. rna was extracted from fresh or cultured cells. some cells were treated in vitro with tnf or other cytokines for h. expression of saa was assessed by quantitative rt-pcr. in addition, serum levels of saa were determined using a commercial elisa in women undergoing ovulation induction (oi) and art. saa levels were measured at baseline, during oi, on the day of hcg administration and at the time of the pregnancy test. results: saa mrna was expressed in theca, granulosa, and granulosa-luteal cells. in granulosa-luteal cells both saa and saa mrnas were expressed at higher levels in cumulus compared to mural granulosa. expression of saa and saa in theca was increased following treatment with tnf in vitro. serum levels indicated that patients with ovulatory dysfunction had increased levels of saa at the time of hcg injection while patients without ovulatory dysfunction had lower saa levels as compared to the baseline level. in addition, patients undergoing oi who achieved pregnancy exhibited increased levels of saa at the time of the pregnancy test compared to baseline levels, whereas patients who did not become pregnant had lower post-cycle levels of saa. interestingly, saa levels did not change in art patients that became pregnant without undergoing oi (donor egg or frozen embryo transfer) conclusions: human ovarian cells express saa mrnas which can be altered in vitro. serum levels of saa may correlate with the responsiveness of the ovary to gonadotropins as evidenced by altered levels in women with ovulatory dysfunction, and by an increase in pregnant patients following ovarian stimulation. yeh, beom su kim, felicia hercules, jennifer peresie, armando arroyo. gynecology-obstetrics, university at buffalo, buffalo, ny, usa. objective: cisplatin is a common chemotherapeutic agent given to women for treatment for a wide variety of cancers. we hypothesize that one mechanism by which cisplatin may cause damage to ovarian structures is by decreasing the amount of anti-oxidant activity in the ovary. we examined super-oxide dismutase (sod ), a critical anti-oxidant enzyme that has been shown to be affected by cisplatin in other tissues, in the ovaries of cisplatin treated animals. methods: adult female sprague dawley rats were injected with saline, cisplatin . mg/kg or cisplatin . mg/kg as weekly doses. five days following the last injection, the rats were euthanized and both ovaries were excised. one ovary was processed for immunohistochemistry and the other was processed for protein analysis using western blot techniques for sod . the anti-sod antibody was purchased from santa cruz. the immunohistochemical sections were scored using a semiquantitative h scoring method. results: immunohistochemistry analysis of the expression pattern of sod following cisplatin administration revealed that there was a significant linear decrease in a dose response pattern in the expression of sod in antral follicles and in corpora lutea (p< . for both). no change was found in the h score of sod in other ovarian structures. western blot analysis of sod in the ovaries following increasing doses of cisplatin revealed no changes in the overall protein levels of sod in the ovary. conclusions: this is the first report that administration of cisplatin causes changes in the expression pattern of sod in antral follicles and in copora lutea. cisplatin decreases the amount of sod available in these structures, possibly leading to increased oxidative stress and free radical damage, thereby leading to ovarian damage found after cisplatin administration. is there evidence for aromatase activity in the stroma of postmenopausal ovaries? mf landay, rh fogle, rb allen, s patel, fz stanczyk, rj paulson. ob/gyn, usc, keck school of medicine, los angeles, ca, usa. background: following menopause, the ovaries continue to secrete androgens and estrogens. we have recently confirmed the production of androstenedione, testosterone and estradiol (e ) up to ten years after menopause by measuring gradients from ovarian venous effluent and peripheral blood. anti-müllerian hormone (amh) and inhibin b have been shown to be markers of follicular activity. peripheral levels of these hormones have previously been found to be undetectable in menopause, suggesting the absence of follicular activity in the postmenopausal ovary. objective: to investigate if the postmenopausal ovary continues to demonstrate evidence of follicular activity as the source of steroid production. design: observational study materials and methods: eight subjects aged ± . yr (range - ) were enrolled. postmenopausal status was confirmed by preoperative fsh levels of more than u/l and/or amenorrhea greater than months. serum was collected from the ovarian veins during total abdominal hysterectomy and bilateral oophorectomy. peripheral blood was also collected pre-operatively, intraoperatively and postoperatively. all samples were analyzed for amh and inhibin b using elisas with sensitivities of . ng/ml and pg/ml, respectively. androgen and estrogen levels in these samples have previously been reported, and documented a gradient between ovarian venous effluent and peripheral serum in all cases. results: ) six patients had no detectable follicular activity by amh and inhibin b levels. ) one patient demonstrated detectable inhibin b levels with an -fold gradient between ovarian venous effluent ( pg/ml) and peripheral blood ( pg/ml), however no amh was detected. ) in one patient, aged and months postmenopause, both amh and inhibin b were detected. peripheral inhibin b levels were high at pg/ml. amh was detectable at levels of . ng/ml. conclusions: ) in the majority of patients, continued e and androgen production in the ovary occurs in the absence of follicular activity as detected by amh and inhibin b production. ) some patients have evidence of follicular function up to ten years after menopause. ) since e is produced in post-menopausal ovaries in the absence of follicular activity, these data provide evidence for aromatase activity in the stroma of post-menopausal ovaries. to elucidate the process by which prostaglandin f (pgf ) mediates luteal regression, this study examined the role that the transcription factor yin yang (yy ) and histone deacetylase (hdac ) play in altering luteal cholesterol uptake by the scavenger receptor class b type i (sr-bi), intracellular cholesterol transport by steroidogenic acute regulatory protein (star), and cholesterol processing by p side chain cleavage enzyme (p scc) expression. rat luteal cells ( days post-ovulation) were treated with pgf ( hr) and trichostatin a (tsa; hr), a potent hdac inhibitor. protein expression was measured post-treatment by western blot and cholesterol was localized via filipin staining. star and sr-bi promoter activation was also assessed in hek t cells treated with yy , myy , a deletion mutant lacking an essential region required for transcriptional repression, and tsa. pgf caused a significant -fold decline in star (p< . ), and smaller declines in sr-bi and p scc which occurred concomitantly with an increase in yy ( -fold, p< . ) and intracellular lipid staining ( % increase). in contrast, nm tsa treatment caused a dose dependent increase in sr-bi, star, and p scc protein levels, . -fold (p< . ), . -fold (p< . ), . -fold (p< . ), respectively, and a . -fold decline (p< . ) in intracellular lipid levels. tsa prevented the pgf -induced decline in sr-bi, star, and p scc expression. promoter analysis demonstrated that wildtype yy , but not myy , repressed sr-bi and star activation while the addition of tsa overcame the repressive effects. this study shows the critical role that yy plays in pgf induced luteal regression by recruiting a histone deacetylase to block three essential processes in steroid production. in luteal cells yy -mediated global repressive action prevents cholesterol metabolism by inhibiting cholesterol uptake, intracellular transport, and processing thus leading to functional and structural luteal demise. supported by nih hd and nih hl . regulation of intermedin expression in cycling rat ovary. madhu chauhan, rebekah elkins, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. background: intermedin (imd) is a ct/cgrp family peptide involved in a variety of physiological functions, including vasodilatation and fetoplacental growth. this peptide is expressed in a variety of tissues such as stomach, placenta, uterus, pituitary and ovary suggesting its different functions including in reproduction. imd gene has an estrogen response element and we have shown that the plasma concentration of immuno-reactive imd is elevated in rats with pregnancy. however, expression of imd in the ovary and its regulation during estrous cycle is not known. we hypothesize that imd is expressed in the ovary and its expression is hormonally regulated throughout the estrous cycle in rat. objective: ) to assess expression of imd mrna and its receptors components calcitonin receptor like receptor (crlr), and receptor activity modifying proteins, ramp and ramp mrna in rat ovary; on diestrus, proestrus and estrus stages of rat estrus cycle and ; ) to demonstrate immunohistolocalization of imd, crlr, ramp , ramp and ramp in rat ovary. methods: groups of sprague-dawley non-pregnant and pregnant rats on day of gestation were used in this study. non-pregnant rats were sacrificed on diestrus, proestrus and estrus stage. ovaries were collected and total rna was extracted using trizol method. rna was treated with dnase before performing the reverse transcriptase polymerase chain reaction (rt-pcr). immunohistolocalization of imd, ramp , ramp and ramp proteins were assessed in tissue sections of ovaries from pregnant rats sacrificed on day . results: ) imd mrna is regulated in rat estrus cycle and its expression is significantly downregulated in estrus stage compared to the diestrus and proestrus; )expression of imd receptor crlr is highest in the diestrus stage, followed by a decline in proestrus which further declined during estrus; ) expression ramp mrna is higher in proestrus compared to diestrus and estrus (p< . ) but there is no significant change in the ramp expression during the estrus cycle and ; ) imd, ramp , ramp and ramp are immunolocalized in rat ovary in granulose cells of all follicles and granulosa cells of the corpus luteum. conclusion: imd mrna and protein are expressed in rat ovary suggesting a possible role for imd in ovarian function. defining and defying deterioration in oocyte quality with advancing chronological age: role of nitric oxide. pt goud, ap goud, mp diamond, b gonik, hm abu-soud. div reprod endocrinology, dept ob/gyn, wayne state university, detroit, mi, usa; div maternal and fetal medicine, sinai grace hospital, wayne state university, detroit, mi, usa. nitric oxide (no) is a ubiquitous free radical essential for oocyte maturation, function and sustenance of oocyte quality post-ovulation. the current study investigates the role of no insufficiency in the causation of oocyte quality deterioration with advancing chronological age. methods: in set , oocytes were retrieved from the following superovulated b d f mice: (a) young breeders (yb, n= ); (b) retired breeders (rb, n= ), and © old animals (oa, n= ), aged - , - , and - weeks respectively; and studied for zona pellucida dissolution time (zpdt), spindle ( -tubulin fluorescence immunocytochemistry, sigma) and chromosome morphology (dapi, vector), ooplasmic microtubule (mt) dynamics (omd) in response to taxol [ ], and cortical granule (cg) status (rhodamine conjugated lectin, vector). in set (n= ), oocytes from retired breeders were studied after exposure in vitro to an no-donor, s-nitroso acetyl penicillamine (snap in m- , . m no/min , n= , h, °c, % co ), while their sibling control oocytes were cultured for corresponding period under identical conditions without snap. [ ]. zpdt, spindle and chromosome morphology, omd and cg status were assessed with a confocal microscope and compared between the subgroups using anova, chi square and/or fisher's exacts test and appropriate post-hoc tests. results: in set , a significantly fewer oocytes were retrieved per animal (mean) in rb ( ) and oa ( ) compared to yb ( . , p< . ). advancing age was also associated with a significant increase in zpdt, omd and cg loss in rb compared to yb (p< . ). furthermore, significantly fewer oocytes from rb than yb had normal spindle and chromosome morphology (p< . ). oocytes from oa had significant spindle and chromosome disarray, a near total cg loss and significantly harder zp (p< . ). these oocytes also exhibited diminished omd in response to taxol although, metaphases were exquisitely sensitive to disruption with taxol. in set , exposure to snap in oocytes from rb resulted in a significantly lowerzpdt, omd and cg loss, and significantly higher incidence of normal spindles ( the gamma-aminobutyric acid (gaba), its biosnthetic enzyme gad and gaba-a receptors have been found in the oviduct and ovary. objective: this study examined the expression of gaba-a receptor subunit genes and gad and whether the gaba-a receptor could alter cytosolic ca + in gc. methods: for qrt-pcr, both human cumulus and mural gc were obtained at the time of oocyte retrieval for ivf and cultured separately. total rna was isolated separately from each gc type and from human brain ( positive control). the total rna from patients was pooled for each gc type and all rna was treated with dnase i. two-step qrt -pcr was performed using gene-specific lux™ primers for all gaba-a receptor subunits, gad and gad plus gapdh. single and specific qrt-pcr products were verified by melting curve analysis, gel electrophoresis, and dna sequencing. for ca + study, gc were cultured on coverslips. gc were loaded with fura- -am and changes in ca + concentration of gc were studied using a dynamic digital ca + imaging system. gaba-a agonist, muscimol, was used to study any dose-dependent effects on gc. gaba-a antagonist, m bicuculline, were perfused min. prior to and during application of muscimol. the responses were represented as changes in the / nm fluorescence ratio over time. m atp was used as positive control. results: the qrt-pcr results indicated that all gaba-a receptor subunits were expressed to various degrees in both types of gc, with the expressed highest in both cell types. gaba-a receptor subunits showing the next highest expression in both cell types were , and . gad isoenzyme was more abundantly expressed in cumulus and mural gc than gad . ca + imaging showed that muscimol, had the ability to increase ca ++ in gc, about % gc (n= ) cells responded to muscimol. muscimol increased intracellular ca + in a dose-dependent manner. the muscimol responsive cells was reduced by bicuculline, from % to % (n= , p< . ). conclusion: qrt-pcr indicates that gaba-a receptor subunit gene and gad expression occurs in both cumulus and mural gc. the ability of bicuculline to inhibit the ca + response to muscimol suggests the activation of gaba-a receptor. the current study confirms the presence of functional gaba-a in gc for the first time, and suggests that gaba may exert trophic effects in the ovary via gaba-a receptor. the present study test the hypothesis that administration of l-nitro-l-arginine methyl ester (l-name), a nos inhibitor, prior to hypoxia prevents the hypoxiainduced activation of p mapk, erk and jnk in the cerebral cortex of the guinea pig fetus during gestation. to test this hypothesis guinea pig fetuses at and days gestation were assigned to normoxic (nx, n= ), hypoxic (hx, n= ) and hypoxic pretreated with nos inhibitor (hx+l-name, mg/kg i.p., n= ) groups. hypoxia in the fetuses was induced by exposing the pregnant guinea pigs at both gestational ages to an fio of . for min. cerebral tissue hypoxia was documented biochemically by determining the tissue levels of atp and phosphocreatine (pcr). neuronal nuclei were isolated, purified and proteins separated by sds-page, and then probed with specific phosporylated erk, jnk and p antibodies. in the days gestation group: expression of p-p was . ± . (nx), . ± . (hx) . ± . (hx+l-name). p-erk expression was . ± . (nx), . ± . (hx), . ± . (hx+l-name). p-jnk expression was . ± . (nx), . ± . (hx), . ± . (hx+l-name). in the days gestation group: expression of p-p was . ± . (nx), . ± . (hx), . ± . (hx+l-name). p-erk expression was . ± . (nx), . ± . (hx), . ± . (hx+l-name). p-jnk expression was . ± . (nx), . ± . (hx) . ± . (hx+l-name). the data show that administration of l-name prior to hypoxia decreased the expression of phosporylated p , erk and jnk at both gestation ages however expression of phosporylation was higher at term as compared to preterm. since a nos inhibitor prevented the hypoxia-induced phosphorylation of p , erk and jnk in both gestational ages, we conclude that the hypoxia-induced activation of p , erk and jnk in the cerebral cortical nuclei of preterm and term guinea pig fetus is no-mediated. we speculate that no-mediated modification of cysteine residue leading to inhibition of map kinase phosphatases results in increased activation of p , erk and jnk in the guinea pig fetus. (nih-hd , nih-hd and st. christophers foundation for children). the the endocannabinoid, anandamide (aea), is involved in the hormone-cytokine network that regulates implantation and early pregnancy maintenance with levels at the endometrial level considered a major checkpoint . high levels ( nm) in culture are associated with embryo death while plasma levels (> nm) at weeks in women undergoing ivf-et are associated with failed pregnancy . what is uncertain is whether systemic aea levels after spontaneous conception in women presenting with threatened miscarriage are predictive of pregnancy outcome. our aim was therefore to measure plasma aea levels in women presenting with threatened miscarriage and to relate these to outcomes. methods: plasma aea levels were measured using a sensitive and previously validated hplc-ms method at - weeks gestation in women (nonsmokers, bmi < kg/m ) presenting with threatened miscarriage and in whom a viable pregnancy was confirmed by ultrasound scan. results: nine of the women subsequently had a miscarriage. the plasma aea levels in those women who had live births was . -fold lower than that in those who subsequently miscarried ( . ± . nm versus . ± . nm, mean ± sem; respectively; p< . unpaired student's t-test). the roc analysis revealed an area under the curve of . ± . with a sensitivity of % ( %ci of . % to . %) and a specificity of . % ( % ci of . % to . %). using an aea level of . nm as the optimal cut-off point, a single plasma aea measurement provided a sensitivity of % and a specificity of % with a negative predictive value of % and a positive predictive value of % for subsequent miscarriage. conclusion: these findings suggest a possible predictive role for plasma aea in women presenting with threatened miscarriage. the data also indicate that systemic aea levels may reflect local endometrial levels and therefore the local hormonal milieu in the early stages of normal pregnancies and in those complicated by threatened miscarriage. introduction: follicle stimulating hormone (fsh) mediates cyclic follicle growth and development and is widely used for controlled ovarian stimulation. the ovarian response of different women to fsh is variable, ranging from poor response to ovarian hyperstimulation and has been partly attributed to two common variants of the fsh receptor (fshr). we have previously identified four abnormal fshr splicing products ( exon deletions and intron insertion) in women with low and high response to fsh. two of the splice variants, deletion of exon and deletion of exon , showed a correlation with low and high response to fsh, respectively. in the current study, we evaluated the functional competence of the mutant fshrs in vitro. methods: we established stable hek cell lines expressing wild-type (wt) and splice-variant (del) fshr under the control of the inducible tet on/off system. the cells were transfected with a camp-responsive luciferase reporter plasmid and stimulated with fsh. results: the subcellular distribution of all splicing variants was the same as the controls and the protein localized mainly on the cell surface. all four splicing variants showed markedly decreased camp activation compared to controls when stimulated with fsh. however, all variants were able to form functional heterodimers with the wt receptor when co-expressed. interestingly, the heterodimer containing the form of fshr lacking exon , found in patients with decreased response to fsh, resulted in lower intracellular camp compared with the wild-type homodimer. conclusion: our findings suggest that fshr variants can contribute to abnormal response to stimulation in certain women undergoing ivf treatment. the variants require the presence of wild-type receptor in order to initiate signaling in response to fsh. further analysis of this signaling cascade in granulosa cells is underway to estimate the final production of estrogen from these heterodimeric receptors. objective: to compare the proteome of human endometrium in the prereceptive versus the receptive phases of the menstrual cycle. m m: endometrial biopsies were collected and days after urinary lh surge in the same menstrual cycle from three fertile women (n= ). proteins were extracted using sample grinding kit (ge healthcare) and interfering substances removed using -d clean-up kit (ge healthcare). labelling was performed with cydye dige fluors (ge healthcare) and proteins were separated using difference gel electrophoresis (dige). for the isoelectric focusing, cm ipg-strips in the nonlinear range of ph - were used. the second dimension was carried out using sds-page. differentially expressed proteins were detected by image analysis using decyder v . and the statistical module eda (ge healthcare). the spots of interest were subject to protein identification based on in-gel digestion, maldi-tof/tof mass spectrometry and database searching. western blot analysis were performed in the same biopsies in order to validate some candidate proteins. results: table displays the differentially protein abundance between days lh+ and lh+ (> -fold change). of these proteins, were increased at lh+ in comparison with lh+ , whereas only proteins were decreased. stathmin was found more than -fold decrease in lh+ compared to lh+ in the three patients studied in the validation studies performed by western blot. conclusions: this study shows that the human endometrium has a differential protein repertoire during the window of implantation compared to the prereceptive phase. the role of these proteins in the molecular events directed to embryo implantation is under research. differential protein abundance in human endometrium ( the extracellular signal-regulated kinases and (erk / ) are a mitogen-activated protein kinase (mapk) subfamily that act as key links in eukaryotic intracellular signaling transduction. activated by phosphorylation in response to specific stimuli, erk / is known to play a role in the regulation of cellular proliferation and survival. the human myometrium is a tissue known to undergo cycle-dependent proliferative and apoptotic changes in response to sex steroids. we hypothesized that erk / activity is involved in mediating menstrual cycle-dependent changes in the myometrium. materials and methods: immunostaining for phospho-erk and total-erk was performed on myometrial tissues obtained from normal women (n= ) at different phases of the menstrual cycle. staining intensities were evaluated by hscore. myometrial smooth muscle cells were isolated and cultured from normal women and treated with vehicle, estrogen ( - m), and progesterone ( - m) for and minutes, and then subjected to western blot analysis for p-and t-erk. statistical analysis was performed using one-way anova. results: tissue staining revealed that p-erk was mostly nuclear in all tissues, while t-erk was cytoplasmic and nuclear. p-erk staining was significantly stronger in the secretory phase and strongest at the early secretory phase, compared to other phases (p< . ). t-erk staining intensity was moderatehigh without variation across the menstrual cycle. in cultured myometrial cells, progesterone significantly increased p-erk levels within and minutes (p< . ) when compared to control. our results suggest that erk activity in the human myometrium is regulated in a menstrual cycle-dependent manner. the increased phosphorylation in the secretory phase suggests the involvement of progesterone in erk activation, as supported by our in vitro results. this increased erk activity may play a role in regulating myometrial proliferation. measures of insulin resistance (ir) including: fasting serum insulin, gir and homa. measures of plasma levels of endothelin- (et- ), soluble intercellular adhesion molecule- (sicam- ), soluble vascular cell adhesion molecule- (svcam- ) and high sensitivity c-reactive proteins (hscrp). results: women with pcos exhibited significantly higher levels of et- (p < . ), sicamp- (p < . ), svcam- (p < . ) and hscrp (p < . ) as compared with age-matched controls, respectively. positive correlations were evident between et- and fai (r = . ; p < . ) but et- negatively correlated with shbg (r = - . ; p < . ). svcam- positively correlated with total t (r = . ; . ), hscrp correlated with: bmi (r = . ; p < . ), and homa (r = - . ; p < . ), respectively. conclusions: women with pcos exhibited abnormal levels of endothelial and inflammatory markers, which appear to be inter-related to hyperandrogenaemia. ( ), and a higher expression of fatty acid amide hydrolase (faah) in peripheral lymphocytes post-ovulation ( ), suggest an involvement of the endocannabinoid system in menstrual cycle control. our aims were to investigate changes in plasma aea levels and in endometrial faah expression throughout the menstrual cycle. methods: plasma aea levels were measured using a hplc ms/ms method from women, median age yrs (range - ) and bmi kg/m (range - ), with regular menstrual cycles, with no medical problem and not on any medication for the preceding months. the menstrual cycle was divided to early follicular d - (n= ), late follicular d - (n= ), ovulatory d - (n= ), early luteal d - (n- ) and late luteal phases d - (n= ). uterine biopsies were taken from hysterectomy specimens taken for benign conditions and subjected to immunohistochemistry for faah with polyclonal antibodies. results: aea levels were significantly higher around ovulation in comparison to the pre-ovulatory or post-ovulatory phases as shown in the figure. faah expression in the endometrial stroma was unchanged throughout the follicular phase but increased during the mid to late luteal phase reaching a maximum in the late luteal phase. a high aea level in the early follicular phase and during ovulation suggests a role for aea in ovulation. the lower levels of aea in the luteal phase, essential for successful implantation, may be regulated by increased faah expression at the uterine level. the modulation of plasma aea levels during the menstrual cycle strongly suggests that it is regulated by gonadal steroid hormones. ( , , , , , , and , as well as at pregnancy. binding activities of igfbp and their protein levels (igfbp , , , , , ) were assessed by western ligand blot (wlb) and western blot (wb), respectively. the glyscosylation and phosphorylation status of igfbps were examined by deglycosylation treatment. our results showed that both glycosylated and unglycosylated igfbp elevate in fetal and newborn rat and graduately decline to a lower level at day and kept lower constant level since then. interestingly, biding activity of glycosylated igfbp was not detected by wlb assay. the igfbp- cleaved products were observed after rat day age day , which associated with a decrease in full length of igfbp- , suggesting endoproteolytic processing may involved in decreasing igfbp content. igfbp- , with heterogeneous glycosylation, were appeared after age day and disappeared during pregnancy, recurrence again postpartum. glycosylation of igfbp has no effect on its binding activity. unglycosylated and glycosylated igfbp were constant in life time. physiologically constant igfbp were detected by wb in protein, but not by wlb in binging activity. conclusion: highly elevated circulation igfbp suggest physiological role in new born and early postnatal development. its binding activity are well regulated by its posttranslation modification, such as glycosylation of igfbp in inactivating binding activity and possible involvement of active endoproteolytic processing in maintaining binding active igfbp- at low background: cigarette smoking affects hormone biosynthesis, storage, release, binding, transport and clearance, resulting in changes in circulating hormone levels. we used metabolomics to analyze the effects of cigarette smoking and second hand smoke (shs) on changes in hormone levels in women of childbearing age. methods: this is a three arm study; women aged - years who are active smokers, exposed to shs (passive smokers), or non-exposed were recruited from the washington d.c. area. all women completed a detailed staffadministered questionnaire probing their medical history, occupational, lifestyle factors and diet. blood and urine samples were collected at the follicular phase. hormone profiles were determined using metabolomics for serum thyroxine and triiodothyronine and steroid hormones, as well as for cotinine using isotopedilution tandem mass spectrometry (lc/ms/ms-api ). in addition, all samples were analyzed for serum lh, fsh, tsh and creatinine. results: the relationships of cigarette smoking, age, relative weight, and dietary intake to serum thyroxine, triiodothyronine, estradiol (e ), estrone (e ), progesterone (p), -hydroxyprogesterone ( ohp),dehydroepiandrosterone (dhea), dehydroepiandrosterone sulfate (dheas), androstenedione, cortisol, -deoxycortisol, corticosterone, testosterone, aldosterone and vitamin d were analyzed using lc/ms/ms. mean tsh in non-exposed, shs-exposed and smokers: . , . , and . miu/ml respectively. similarly, mean t . , . ( % increase) (p= . ), . μg/dl (- %) in active smokers; (active vs. exposed p= . ). shs increased dhea levels ( % higher, p = . ), dheas ( % higher, p = . ), cortisol ( % lower, p = . ), aldosterone ( % lower, p = . ) and androstenedione ( % higher, p = . ). these data suggest that active smoking and shs can have a profound effect on serum t , adrenal steroid and sex hormone concentrations in women of childbearing age. objective: to determine the prevalence and predictors of the metabolic syndrome (mbs) among in saudi women with polycystic ovary syndrome (pcos) in comparison to women without pcos and to assess the role of androgens and insulin resistance (ir) in mbs development. design: a prospective case control study. setting: tertiary referral university hospital. subjects: six hundreds saudi women living in the jeddah area were classified as follows: with pcos and age-matched women without pcos. interventions: blood samples were collected from all women with or without pcos between : - : , after an overnight fast. main outcome measures: measures of abdominal obesity, blood pressure and that of serum levels of lh, fsh, tsh, ft , -ohp, -a, dheas, total t, free t, shbg, insulin, hdl-c, triglycerides and plasma levels of glucose. measures ir including: fasting serum insulin, gir and homa. results: age-adjusted prevalence of mbs was higher in women with pcos ( . %, % ci: . - . %) as compared with women without pcos ( . %, % ci: . - . %) (p< . ). in the same age group, the risk of mbs in women with pcos was greater than that for women without pcos (p< . ). markers of ir were significantly abnormal in women with both pcos and mbs in comparison to those without mbs (p< . ). the most common abnormal components of mbs in women with both pcos and mbs (after adjustment for age) were: decreased hdl-c ( . ± . %); increased triglycerides ( . ± . %); and increased bmi ( . ± . %), respectively. the prevalence of mbs from lowest to highest tertile of free t level was . , . and . %, respectively; in women with both pcos and mbs. in women with pcos, % exhibited all components of mbs; . % had components, and . % had components. conclusions: women with pcos exhibited significantly higher prevalence of mbs ( . -fold) as compared with age-matched control without pcos. ir is a possible common pathogenetic factor for both mbs and the pcos. it is suggested that more intensive screening and/or therapy monitoring of mbs among women with pcos should be part of the therapeutic modalities of the condition. case of sisters with complete androgen insensitivity syndrome and discordant mullerian remnants. jennifer l nichols, jennifer j gell, eric j bieber. reproductive endocrinology and infertility, geisinger medical center, danville, pa, usa. complete androgen insensitivity is an x-linked recessive disorder resulting in the abnormal expression of the androgen receptor. affected individuals are most commonly phenotypically female but genotypically male. the prevalence of this disorder is in , live male births. we present a case of complete androgen insensitivity in members of the same family with differing residual mullerian tissue. sister a presented at age for evaluation of primary amenorrhea. a karyotype revealed ,xy. an mri of the pelvis showed a hypoplastic uterus but no ovaries. this patient underwent laparoscopic bilateral gonadectomy and hemihysterectomy. on examination under anesthesia, she was noted to have a normal vagina with no cervix noted. at laparoscopic evaluation, she was noted to have bilateral elongated gonads and what appeared to be a remnant of uterine tissue. pathology revealed portions of immature testicles and fragments of smooth muscle in what grossly appeared to be the uterine remnant. the patient's total testosterone following surgery was noted to be elevated at . ng/ml. other laboratory evaluation showed fsh . miu/ml, lh . miu/ml, free testosterone . pg/ml, and estradiol . pg/ml. approximately two years later sister b presented at age for evaluation of primary amenorrhea. no uterus or ovaries were visualized on pelvic ultrasound. again a karyotype revealed ,xy. laboratory evaluation demonstrated fsh . miu/ml, lh . miu/ml, estradiol . pg/ml, total testosterone . ng/ml, and free testosterone . pg/ml. she underwent a laparoscopic bilateral gonadectomy. no uterus, cervix or pelvic masses were identified on exam under anesthesia. at laparoscopy, both gonads were visualized and removed without difficulty but no uterus was visualized. pathology reported two testicular and epididymal-like structures. this case demonstrates the presentation and laparoscopic results of complete androgen insensitivity syndrome discovered in two siblings. although both girls are genotypically male, they differ in the presence of vestigial mullerian tissue. the case shows with complete androgen insensitivity, as an x-linked defect, one should consider apparent sisters of affected individuals, as well as offspring of unaffected individuals with a family member diagnosed. background: anandamide (n-arachidonoylethanolamine, aea) is an endocannabinoid that binds to and activates the cannabinoid receptors, cb and cb and may have important roles in the regulation of human reproduction. the traditional lipid extraction methods used for aea are cumbersome, slow and of low efficiency. the aim of this study was to determine whether the use of a solid phase (spe) method of aea extraction from human plasma would offer any advantages over the traditional liquid phase (lpe) method. methods: pooled human plasma was obtained from the local blood transfusion unit and aliquots stored at - °c prior to extraction. an internal standard of . pmol of deuterated aea (aea-d ) was added to each plasma sample and aea extracted from aliquots on each occasion over three days using the lpe and spe methods. spe was performed with waters oasis hlb cc/ mg cartridges on a waters vacuum manifold. cartridges were activated with methanol and water, the samples applied and washed with % methanol at ml/min. aea was eluted with ml acetonitrile and the eluents dried under a stream of nitrogen before reconstitution in ml acetonitrile. aea levels were measured using uplc-ms/ms against authentic standards. results: these are shown in the table. conclusion: the spe method was -fold more efficient at extracting aea compared to the traditional lpe method. the intra-day and inter-day assay variability were similar for both techniques, although the spe method was quicker, cheaper and required less plasma to generate data similar to that from the traditional lpe method, suggesting that the spe method may be more efficient than the lpe method, and thus making it more suitable for routine analysis of multiple plasma aea samples. background: the precise role of the endocannabinoid, anandamide (narachidonoylethanolamine, aea) in reproduction has been hampered by difficulties in its accurate measurement. aea levels have previously been measured by tlc, gc-ms and hplc-ms but these are laborious. our aim was to improve the analysis of aea using uplc and tandem ms/ms with a standard isotope-dilution method , . methods: authentic non-labelled and deuterium-labelled aea (aea-d ) diluted in acetonitrile were maintained at °c before analysis and separation by uplc on a c ( . x mm) column maintained at °c using a gradient of % a, . min: % a, . min: % a, . min: % a, . min: % a with a flow rate of . ml/min. the mobile phases were a ( mm ammonium acetate, . % formic acid) and b (acetonitrile, . % formic acid). the analytes were quantified using multiple-reaction monitoring in positive ion mode with a quattro premier mass spectrometer. entry, collision and exit energies were - , and - ev, respectively. calibration curves were performed in triplicate with . pmol aea-d as the internal standard. transitions employed were . > . and . > . for aea and aea-d , respectively. results: calibration curves ( . to fmol aea on column; n= ) were linear, producing a mean (±sd) gradient of y = . ± . x, crossing the y-axis very close to the origin ( . ± . units). variability was limited, with an r = . . measurements were precise, fmol aea produced a cv of only . %, and the retention time was consistent at . ± . min (n= ). the limit of quantification (signal/noise> ) was . fmol on column and the limit of detection (lod) was . fmol on column (signal/noise= ). accuracy for . fmol, . fmol and fmol aea was . ± . %, . ± . % and . ± . %, respectively. conclusions: the method described is an improvement over other lc-ms/ms methods , with a lower lod [ . fmol v. fmol or fmol ] and shorter run time [ min v. min or . min ]. thus, an improvement in terms of speed, increased sensitivity and better reproducibility will allow for a more accurate assessment of aea concentrations in a number of biological samples. objectives: the gata family of transcription factors consists of six zinc-finger proteins with a critical role in tissue-specific and developmentally-regulated gene expression. gata factors exert their effects alone and through interactions with cofactors, such as friend of gata (fog), as well as with nuclear hormone receptors, including steroidogenic factor- (sf- ), a well-described activator of gonadotropin gene expression. the objective of these studies was to define the role of gata family members in the gonadotrope. methods: ) total rna was extracted from the gonadotrope cell line, l t , and analyzed by standard rt-pcr analysis. ) the cv- fibroblast cell line was transiently transfected by the calcium phosphate precipitation method with a rat - /+ lh promoterreporter vector as well as cmv-driven expression vectors for gata- , gata- , dngata- , fog- and/or sf- . results: gonadotrope l t cells were found to express transcripts encoding gata- , gata- , and gata- as well as fog- and fog- . gata- and gata- stimulated lh gene promoter activity by approximately -fold (p< . ) and synergistically increased the sf- response ( -fold versus -fold for sf- alone; p< . ). the gata-mediated increase in lh gene expression was nearly eliminated with co-transfection of fog- . similarly, co-transfection with a gata- dominant negative construct blunted wild-type gata- effects in a dose-dependent fashion. conclusions: these data demonstrate expression of both gata and the functionally related fog proteins in a well-characterized gonadotrope cell line. furthermore, they demonstrate a functional role for these factors in regulation of gonadotrope function, specifically expression of the lh gene. low-dose dexamethasone (dex) therapy early in pregnancy is used in fetuses with suspected risk of congenital adrenal hyperplasia. several adverse neurological events in prenatally treated children have been reported and the fetal hypothalamic-pituitary-adrenal (hpa) axis may be involved. aim: to investigate the immediate and long-term effects of early maternal dex administration on fetal growth and pituitary-adrenal activity in sheep. method: pregnant ewes carrying singleton fetuses (total n= ) were randomized to control ( ml saline/ewe) or dex treatment ( . mg/kg ewe weight) consisting of four intramuscular injections at -hourly intervals over hours on - days of gestation (dg). at , , , and dg fetal weights were recorded. i -ria, qrt-pcr and in-situ hybridisation were used to measure fetal plasma cortisol and acth levels and to analyse adrenal and pituitary mrna expression. results: dex-exposed fetuses were lighter than control animals at dg*, but not at other times; in general fetal organ weights were similar between treatment groups. fetal plasma acth was unaffected by dex and did not differ between genders. similarly, pomc and pc- mrna in pars distalis were unaltered after dex. however, fetal plasma cortisol was reduced after dex in both male and females at dg*, was similar at and dg, then elevated at dg*. plasma cortisol in female fetuses in control and after dex was significantly higher than in males. the increases in cortisol after dex at dg* were associated with increased fetal adrenal expression of p c and bhsd mrna in females, reduced expression of mc r in males, but no difference in star mrna. conclusion: we conclude that in sheep, early dex programs the developmental trajectory of the fetal hpa with increased activation directly of the adrenal, but not pars distalis function. in females this effect may be attributed to increased fetal adrenal steroidogenic activity. the effect of dex in increasing cortisol in males, albeit at a significantly lower level than in females, appears to be independent of the enzymes that we have measured.*p< . . synaptophysin and gonadotropin-releasing hormone (gnrh) are colocalized in rat hypothalamus. armando arroyo, beom su kim, amanda biehl, blenna cl bett, , john yeh. gynecology-obstetrics, university of buffalo, buffalo, ny, usa; physiology and biophysics, university at buffalo, buffalo, ny, usa. the cellular and molecular mechanisms that control gonadotropin-releasing hormone (gnrh) release are not completely understood. gnrh is stored in synaptic vesicles and released by exocytosis at gnrh nerve terminals. there are currently nine families of synaptic vesicle proteins that are involved in neurotransmitter release by exocytosis. synaptophysin is one of the most common synaptic vesicle proteins present in synaptic vesicles in neurons. the hypothesis of this study is that synaptophysin is expressed in gnrh neurons. we obtained sections from the hypothalamus of female sprague dawley rats. double-label fluorescence immunohistochemistry was performed on free-floating sections. sections were incubated with a mixture of mouse monoclonal antibody against gnrh ( : -chemicon international) and with a rabbit polyclonal antibody against synaptophysin ( : -santa cruz biotechnology) for h. after incubation the sections were washed and incubated with a mixture of alexa conjugated goat antimouse and alexa conjugated goat antirabbit ( : ; molecular probes) for h. slices were visualized with confocal microscopy (zeiss lsm- ). fifteen out of a total of fifteen gnrh cell bodies in the medial preoptic area and most gnrh neuron terminals in the median eminence showed intense immunostaining for synaptophysin. this is the first study to demonstrate that synaptophysin is expressed in rat gnrh neuron terminals. this suggests that synaptophysin is present in gnrh neuron vesicles. thus, gnrh release by exocytosis may be mediated by synaptic vesicle proteins. objective: our aim was to identify the effects of early gestation gc exposure on fetal and postnatal hpa axis development and function in postnatal life. method: pregnant ewes carrying singleton fetuses were randomized to control ( ml saline/ewe) or dex groups ( . mg/kg), consisting of four at h intervals on days - of pregnancy. at months postnatal age, catheters were implanted; a bolus injection of crh ( . mg/body weight) and avp ( . mg/body weight) were administered and arterial blood samples were taken at - , - , , , , , , , and min. levels of hepatic cbg mrna were determined by qpcr, expressed relative to s rrna. plasma cortisol and cbg levels were measured by radioimmunoassay. results: both total and free cortisol levels in the dex females (n= ) were lower than in dex males (n= ) from to min (p . ) and lower than in control females (n= ) at minutes (p . ), also in the dex-m group were higher than in control males (n= ) at min (p . ). plasma cbg levels and cbg mrna expression were not altered by dexamethasone exposure or sex. conclusions: these findings suggest that prenatal glucocorticoid exposure alters the development of the hpa axis differentially according to the sex of the exposed fetus. to determine maternal injections of synthetic glucocorticoids in early gestation can alter expression of hippocampal corticosteroid receptors at months postnatal age. method: pregnant ewes carrying singleton fetuses were randomized to control ( ml saline/ewe) or dexamethasone treatment ( . mg/kg) consisting of four injections at h intervals on days - . hippocampal was collected from the offspring at months postnatal age. levels of mrna of gr and mr were determined using qpcr and levels relatived to s rrna. results: dexamethasone-treated male animals (n= ) had significantly higher levels of mr gene expression than both control males (n= ; p= . ) and females (n= ; p= . ). gr gene expression levels were higher in treated vs. control males (p= . ), but in females levels in treated and control animals were similar. total body, brain and hippocampus weights were similar. conclusions: maternal dexamethasone administration in early pregnancy resulted in gender-dependent changes in hippocampal gene expression when measured in the offspring seven months after birth. objective: diminished ovarian reserve (dor) affects many younger women. we analyzed superovulation with intrauterine insemination (so) cycles in vitro fertilization (ivf) cycles of women with dor to determine if women < with dor differ from their older counterparts. method: irb approved retrospective review of so ivf cycles from / - / with follicle stimulating hormone (fsh) levels based on age < or . results: so cycles were performed in women. no differences were noted in clinical pregnancy. women < were more likely to have inseminates with a lower mean tms/ins, median tms/ins was . among pregnancy cycles compared to for unsuccessful cycles. for ivf, mean total gonadotropin dosage was significantly lower in women < , mean number of follicles mm peak e were significantly higher in women < . so ivf measures are in tables , respectively. conclusions: similar clinical pregnancy outcomes were seen despite age. in ivf, women < required less gonadotropins and generated more follicles but with no significant difference in number of mature oocytes or clinical pregnancies. of note, pregnancy rates for so in women < with dor are substantially lower than expected in our clinical practice. as ivf yielded a substantially higher chance of pregnancy, consideration should be made to expedite progression to ivf. to assess the effects of intraovarian injection of ad-fshr on the reproductive system of fshr (-/-) mice. methods: about l containing x pfu of ad-hfshr were injected directly into each ovary of treated group and same amount of ad-lacz were injected into the ovaries of control animals. vaginal smears were collected and body weight was measured daily. four weeks after the injection animals were sacrificed and all organs were weighted and evaluated by h e. fsh, e and p measured before and after treatment. results: ad-hfshrtreated mice showed obvious estrogenic changes in vaginal smear while in control animals vaginal smear remained at diestrus stage. significant increase in total body weight and estrogen dependent organs weight (uterus, ovary, vagina) was observed in treated animals compare to control group (p< . ). no significant weight changes were observed in other organs. h e evaluation of the ovaries showed significant increases in both the total number of follicles and the collective diameter of the follicles in treated animals compare to controls. on average follicles/ovary were observed in ad-hfshr-treated group of which follicles were at the antral stage while only follicles observed in ad-lacz control group, with zero follicles at antral stage. a . to folds increase in e and about % decrease of fsh observed in treated animals compared to control mice. there was no significant change in serum progesterone level between treated and control groups. conclusion: intraovarian injection of an adenovirus expressing human fshr gene is able to restore folliculogenesis and resume estrogen hormone production in female forko mice. objective: the sentinel issue surrounding multiple gestations following ivf is the inability to precisely estimate the reproductive potential of individual embryos with the currently used embryo grading systems based on embryo cleavage rate and morphology. recently, metabolomic profiling of spent culture media using raman and near-infrared spectroscopy have been reported to predict reproductive potential of embryos. in this study we applied proton nuclear magnetic resonance (¹h nmr) spectroscopy to analyze metabolomic profile of embryo culture media and to identify components of the media that correlate with reproductive potential. methods: eighteen spent media samples from embryos that failed to implant, and samples from embryos that resulted in pregnancy and delivery were individually collected after embryo transfer on day , and evaluated using ¹h nmr. the spectra obtained were analyzed using a selective genetic algorithm (ga) to determine regions predictive of pregnancy outcome as determined by logistic regression. to avoid random correlations, a leave-one out crossvalidation was used. sensitivity and specificity of predicting pregnancy (described as implantation and delivery) were calculated. results: using the ga, two areas in the ¹h nmr spectral region were identified as most discriminatory between the two groups. viability indices calculated by ¹h nmr using these regions were significantly higher in culture media of embryos with proven reproductive potential ( . ± . ) compared to those that failed to implant ( . ± . ) (p< . ). compiled outcomes from the leave-one-out cross-validation of the logistic regression using the ¹h nmr measurements resulted in a sensitivity of % and a specificity of . %. quantification by integration showed significantly decreased glutamate levels (p= . ) and a trend toward an increase in pyruvate levels (p= . ) in culture media of embryos that did not cause pregnancy. conclusion: metabolomic profile of spent embryo culture media using ¹h nmr correlates with the reproductive potential of embryos. the lower glutamate levels detected in culture media of embryos that failed to implant could potentially be due to the toxicity associated with increased embryonic glutamate uptake. additional studies using complementary approaches are needed to further delineate molecular components associated with reproductive potential. objective: beta-carotene and other carotenoids are known antioxidants previously identified in human follicular fluid (ff). in addition to their inherent antioxidant properties, carotenoids have been identified as precursors of the antioxidant retinol in bovine ff. high retinol levels in bovine ff are associated with non-atretic follicles. this would suggest a possible role for retinol and its carotenoid precursors in follicular heath and the general oxidative state of the follicle. we sought to measure carotenoids and retinol in the ff of women undergoing ivf and correlate these levels with normal fertilization as a marker of follicular/oocyte health. design: prospective cohort study materials and methods: ff from a single - mm follicle was obtained from women (age - ) undergoing ivf and intracytoplasmic sperm injection (icsi). serum was also obtained at the time of oocyte retrieval. retinol, vitamin e ( , , and tocopherol) and carotenoids ( -carotene,cryptoxanthin, lycopene and lutein/zeaxanthin) were measured using hplc. we correlated ff carotenoid and retinol levels with oocyte fertilization status following icsi. results: as previously reported, retinol, vitamin e and carotenoids were all identified in the ff. each fat-soluble vitamin level was significantly lower in ff compared to serum (p< . for all analytes) and the levels were strongly correlated (r > . , p< . for all analytes). mean levels of ff -carotene were significantly higher in those follicles that resulted in a fertilized oocyte ( . +/- . g/ml vs. . +/- . g/ml, p= . ). other carotenoids, retinol, and vitamin e levels did not correlate with fertilization outcomes. conclusions: our finding of a strong association between ff -carotene concentration and subsequent normal fertilization of the oocytes suggests an important antioxidant role for -carotene in the health of the human ovarian follicle/oocyte. the lack of correlation with other carotenoids, retinol and vitamin e suggests that the antioxidant properties of -carotene act by preventing singlet oxygen and scavenging the peroxyl radical and may directly influence oocyte competence. mature oocytes obtained during egg retrieval have been shown to undergo spindle depolymerization as a result of cooling. for this reason, ivf programs strive to maintain constant temperature during follicle aspiration. we sought to elucidate if there was a difference in temperature of fluid aspirated into a hand held (hh) or heating block (hb) encased collection tube. the experiment was performed in an ambient temperature of °c. thermistors, pinhead sized sensors with an accuracy of %, were used to monitor temperature differences between control fluid (cf) (sterile water ºc) and aspirated fluid. data was recorded using an -channel data acquisition system from dataq instruments. one thermistor was placed into the cf, the other was placed into an empty collection tube set in the heating block or held in a gloved hand. a cm, gauge, single lumen needle connected to cm of tubing was used to aspirate into the empty collection tube. temperature was recorded x/second, each experiment was repeated times. baseline empty collection tube temperature was significantly cooler in the hh vs the hb group ( . ± . °c vs . ±. °c, p=. ). two seconds after aspiration, the lowest aspirate temperature was observed, (hh . ±. °c, hb . ±. °c, p>. ) no difference between groups. in both groups, temperature quickly increased as aspiration progressed (hh . ±. °c, hb . ±. °c, p>. ). the hb group took an average of . min to return to baseline ( °c), the hh group never returned to baseline. substantial cooling of aspirated fluid occurs during oocyte retrieval, with a mean temperature decrease of . ±. °c corresponding to . °c. considering this dramatic decrease, the difference between temperatures in the hh vs. the hb group is negligible. current aspiration systems poorly regulate temperature, thus the choice of aspirating into a test tube warmed by hand or by heating block is inconsequential. clinical management of twin gestations with recurrent preterm labor symptoms. lesley de la torre, luis roca, niki b istwan, debbie j rhea, gary j stanziano, victor hugo gonzalez-quintero. obstetrics and gynecology, university of miami medical center, miami, fl, usa; clinical research, matria healthcare, marietta, ga, usa. objective to examine pregnancy outcomes in women with twin pregnancies receiving nifedipine tocolysis (nt) who experienced recurrent preterm labor symptoms (rptlsx). study design twin pregnancies enrolled for outpatient preterm labor (ptl) surveillance services prescribed nt following an initial episode of ptl were identified from a database (n= ). eligible for inclusion were patients later hospitalized with acute rptlsx (n= ). included were those < weeks' gestational age (ga), with intact membranes, remaining undelivered for > hours after rptlsx . pregnancy outcomes of women resuming nt (rnt group, n= ) following hospitalization were compared to those having an alteration in treatment (alttx group, n= ) to continuous subcutaneous terbutaline. per normality assumptions, either independent student´s t or mann-whitney u test statistics were used for continuous variables; pearson´s chi-square for categoric. all p-values presented as two-sided, significant at < . . results overall, ( . %) of twin pregnancies prescribed nt experienced rptlsx; ( . %) were not eligible for continued tocolysis. pregnancy outcomes are presented in table. conclusion rptlsx are common. in twin pregnancies receiving nt, alteration of tocolytic treatment following rptlsx had a positive impact on pregnancy prolongation and neonatal outcomes. routine cervical dilatation during elective cesarean section -is it really necessary? arie koifman, avi harlev, eyal sheiner, fernanda press, arnon wiznitzer. obstetrics and gynecology, soroka university medical center, ben-gurion university of the negev, beer-sheva, israel. objective: the purpose of this study was to examine the necessity of routine cervical dilatation during elective cesarean section. material and methods a retrospective cohort study was performed, including all cases of elective cesarean sections performed at a tertiary medical center during . stratified analysis, using the mantel-haenszel technique, was done to control for confounders. results out of a total of elective cesarean deliveries (cd), underwent routine cervical dilatation. the overall rate of febrile morbidity was . %. no significant differences in postpartum febrile morbidity were noted between the groups ( . and . %; p= . ). in addition, hospitalization duration did not differ between the groups ( . ± . and . ± . days p= . ). about % of all elective operations were repeated cd. there was no difference in febrile morbidity between the groups even in that subgroup of the elective cd. likewise, there was no difference in anemia rate between the two groups (hemoglobin . ± . mg and . ± . mg p= . ). controlling for a previous vaginal delivery, using the mantel-haenszel technique, no significant association was noted between cervical dilatation and fever (weighted or= . ; % ci . - . ; p= . ). nevertheless, in a subgroup of patients following a previous vaginal delivery, cervical dilatation was significantly associated with post-operative fever (or= . the majority of women with an unfavorable cervix undergoing iol at term deliver vaginally, even with a prolonged first stage of labor. this is important information to discuss with women prior to iol when establishing labor expectations. providers should consider the ongoing success of labor induction when contemplating a diagnosis of "failed induction". objective: this study was performed to investigate and compare changes of the lipid peroxide levels and the protein carbonyls formation in the maternal venous plasma of preterm premature rupture of membrane (pprom) during antibiotics administration. materials and methods: thirty-six pregnant women with pprom between and weeks of gestation were chosen for this study. eighteen patients (group ) were treated with amoxicillin and erythromycin for day period while the other patients (group ) were treated with rd generation cephalosporin and erythromycin for the same period. samples of maternal blood were obtained from the two groups at before the antibiotics administration, day , and day after the antibiotics administration. lipid peroxide levels were measured by thiobarbituric acid reaction and protein carbonyl contents were determined by the , -dinitrophenylhydrazine method. results: . the lipid peroxide levels and protein carbonyls formation in the maternal venous plasma of pprom was significantly higher than that of normal pregnancy ( . ± . vs . ± . nmol/mg protein, p< . ), ( . ± . vs . ± . nmol/mg protein, p< . ). . there were no significant differences in the lipid peroxide levels and protein carbonyls formation of the maternal venous plasma with pprom mixed and incubated by amoxicillin, cefodizime, and erythromycin (in vitro). . there were no significant differences in the lipid peroxide levels and protein carbonyls formation of the venous plasma of group among before the antibiotics administration, day , and day after the antibiotics administration. . the protein carbonyls formation in the venous plasma of group was significantly decreased at day and day after the antibiotics administration than that of before the antibiotics administration ( . ± . , . ± . , . ± . nmol/mg protein, p< . ). conclusion: in the maternal venous plasma of pprom, the lipid peroxide levels and protein carbonyls formation were increased. the results suggest that reactive oxygen species formation by inflammatory reaction is suppressed by combined treatment of rd generation cephalosporin and erythromycin. objective: the aim of the present prospective cohort study was to evaluate the correlation between blood flow pulsatility index in fetal middle cerebral artery (mca) and the onset of spontaneous labor. study design: doppler evaluation of fetal mca were performed between and weeks gestation in consecutive pregnant women with a singleton pregnancy and known gestational age. the study population was divided according to the mca pi (< . or >/= . mom) and, using survival analysis and cox regression, the two subgroups obtained were compared. in these analyses, the event was delivery (following spontaneous labor) and the time variable was time elapsed since doppler exam. results: the median time elapsed between doppler evaluation and spontaneous labor was significantly shorter in the women with mca pi lower than . mom ( . days, interquartile range - ) in comparison with the women with mca pi higher or equal than . mom ( . days, interquartile - . days (p< . , mann-whitney test). after correction for birth weight and umbilical artery pi, survival analysis and cox regression confirmed that mca pi was independently associated with the number of days elapsed from doppler to spontaneous labor and delivery (p< . , exp(b) . , ci % . - . ). conclusions: the present data show that, at term of pregnancy, fetal cerebral resistance reduction anticipates the onset of spontaneous labor. novel calcium sensitizers and human uterine contractility. mark p hehir, audrey t moynihan, terry j smith, john j morrison. department of obstetrics and gynaecology, national university of ireland, galway, ireland. objective: the factors regulating contractility of uterine smooth muscle are central to the occurrence of preterm labour and delivery. calcium sensitizers are a novel class of drugs with unique molecular actions. levosimendan, the best characterized of these compounds, is used in the treatment of acute and chronic heart failure and is a compound which exerts a number of effects on smooth muscle. it can exert an inotropic effect via sensitization of myofilaments to calcium and also exerts a relaxant effect by opening atp-dependent potassium channels. for these reasons we hypothesized that levosimendan may have an effect on myometrial contractility and investigated its action on both spontaneous and agonist induced contractions. method: biopsies of human myometrium were obtained at elective caesarean section (n= ). dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to cumulative additions of levosimendan in the concentration range of nmol/l to mmol/l. two sets of control experiments were performed simultaneously as follows: . strips exposed to either physiological salt solution (pss) only, for spontaneous contractions, or . nmol/l oxytocin; . strips exposed to pss/oxytocin and vehicle for levosimendan. results: levosimendan exerted an inhibitory effect on spontaneous and agonist induced contractions, compared to control strips. the mean maximal inhibition values were as follows: . ± . % for spontaneous contractions (n= ; p< . ) and . ± . % for oxytocin-induced contractions (n= ; p< . ). no significant difference was found between control and control for both spontaneous and oxytocin induced contractions. conclusion: the calcium sensitizer levosimendan exerted a potent relaxant effect on uterine contractility in vitro. this action was seen in both spontaneous and agonist induced contractions. the results from this study raise the possibility of calcium sensitizers holding potential tocolytic properties in vivo and further studies are required to investigate the potential benefits of this novel class of drugs. to determine to what degree extensive patient movement affects uterine emg signals and toco signals. study design: pregnant term labor patients were recorded using both uterine emg and toco simultaneously. baseline recordings were obtained when patients were still, and these were used as control records. test recordings for both devices were obtained from all patients by asking the patients to perform movements. area under the rectified-voltage amplitude curve of the uterine emg signals and area under the curve for the toco signals were found. mean %-increase was calculated for the uterine emg and toco devices (each device %-increase values were averaged over all patients). mann-whitney rank-sum test was used to look for any statistical differences in %-increase in area for uterine emg vs. toco methods (p < . considered significant). results: there was a large increase in activity (artifact) on both devices' signals during patient movement (figure ) . both devices' traces eventually returned to baseline after the patient movement stopped. toco movement artifact was significantly higher than emg movement artifact ( table ) . conclusions: both uterine emg and toco signals experience artifact when patients move the uterine emg electrodes and toco pressure transducer, respectively. toco seems to be more adversely affected by such movements. uterine emg may be a preferred method for monitoring contractions of laboring patients in the clinic. supported by grant nih r -hd . results: % of obstetricians completed the questionnaire. none would counsel patients against labour unless there were contraindications. the majority would recommend labour for all indications for previous caesarean section investigated although in all instances, personal preferences were lower (p< . ); after a failed instrumental delivery, % obstetricians would recommend labour but only % would choose that option for themselves (p< . ). overall, female obstetricians would contemplate and recommend labour more readily than male obstetricians. labour augmentation and induction were recommended to patients more frequently ( % and % respectively) than chosen for personal care ( % and %). reluctance for labour augmentation and induction was greatest among younger consultants. conclusion: consultants have responded to consumerism and aim to meet the requests of their patients. they more readily recommend labour than they would choose for personal care, and a majority would recommend labour induction when necessary. informed patient choice is paramount rather than attaining a target figure for women attempting to labour, and the views of those requesting delivery by caesarean section should be respected. (table) . cd increased in nullipara singleton, cephalic, term pregnancy in spontaneous labor, mostly due to dystocia; nullipara singleton, cephalic term pregnancy with induced labor, mostly due to non-reassuring fetal status and dystocia; singleton, cephalic term pregnancy with previous cd, mostly due to elective cd; singleton cephalic preterm. no changes in neonatal outcome were observed. conclusion: clinical audit was useful to keep under control cd rate in our institution in comparison with italian reality, but it was not sufficient to maintain stable cd rate suggesting the need of other, multifaceted strategies. elective delivery at weeks' gestation is a common obstetric intervention. the purpose of this study is to estimate the maternal mortality rates (mmr) associated with this acog -approved intervention. there are no reliable us data describing mmr by mode of delivery. therefore, we base our estimates on british data indicating a procedure related mmr of . / , , . / , and . / , for vaginal, elective cesarean section (c/s) and emergency-unplanned c/s deliveries, respectively. a decision tree model was constructed assuming that all eligible patients (approx. , , /annually in the u.s.) would be delivered at weeks by either an elective c/s or an induction of labor. we further assumed that % of inductions would result in a vaginal delivery. our estimates show that the annual, delivery-related maternal mortality associated with an elective delivery of all patients at weeks would be and for elective c/s and induction of labor, respectively. because vaginal delivery results in the lowest mmr, we performed a oneway sensitivity analysis to identify the impact of changing the success rate of induction on the estimated mmr. the results indicate that once the success rate exceeds %, this intervention would be associated with a lower mmr as compared to elective c/s. our estimates indicate that although the overall mmr associated with elective delivery at weeks is relatively low (approximately . / , deliveries), it is certainly not negligible. in addition, the mmr is highly dependent on the likelihood of a successful vaginal delivery following induction of labor. when the success rate for induction of labor falls below %, an elective c/s appears to be the safer delivery method. background: the first obstetric visit is an opportunity to provide the pregnant patient information regarding substances that can cause potential harm to the pregnancy. little is known about how obstetric care providers handle these topics. objective: to examine patient-provider communication about substance use during the first prenatal visit. methods: we audiotaped first prenatal visits and qualitatively analyzed those tapes in which patients disclosed substance use. we invited patient participants to return for a semi structured interview during which they reviewed their audiotaped conversations and described their reactions to the providers' communication styles. results: providers ( residents, midwives, nurse practitioners) and patients participated. providers asked about smoking, alcohol and drug use in all ( %) visits. patients reported being smokers, reported alcohol use, and reported drug use. provider responses to smoking disclosures included brief discussions of smoking effects on pregnancy, encouragement to quit/cut down, and referral to smoking cessation programs. provider responses to alcohol or drug disclosures included only general statements regarding effects on pregnancy (e.g., "we find that this is bad for babies.") and referral to ultrasound/genetics for reassurance. few alcohol or drug discussions assessed whether the patient had intentions or concerns regarding continued use during the pregnancy. few discussions addressed strategies for behavioral change. none included assessment for motivations, readiness, or barriers to change. in follow up interviews, patient participants said they expected to be asked about substance use but advised providers to ask non-judgmentally. those who used alcohol/drugs wanted more information on potential effects of these substances on the pregnancy/fetus and appreciated the reassurance from referrals to ultrasound/genetics. discussion: counseling for risky behaviors in the first obstetric visits contained only limited discussion of the effects of the risky behaviors and primarily focused on referral-which may be a proxy for avoiding a difficult and time consuming conversations. background. there are conflicting results regarding the association of maternal psychiatric disorders or psychological distress due to stressful life events with pre-term birth and low birth weight. aims. to investigate the association between maternal psychiatric disorders and/or stressful life events and intrauterine growth abnormality, low birth weight or preterm birth. method. three mutually exclusive and homogeneous groups of pregnant women ( with actual psychiatric disorder, with stressful life events, and healthy comparisons) underwent serial fetal ultrasound examinations and uterine and umbilical artery doppler velocimetry at (+ ), (+ ) and (+ ) weeks of gestational age. subjects were recruited from all consecutive women attending two antenatal clinics. the presence of any maternal medical illness, drug treatments, fetal chromosomal and/or structural malformations, were exclusion criteria. all women recruited underwent a structured interview at - weeks for the psychiatric diagnosis (mini international neuropsychiatric interview -mini) (sheehan et al, ) ; moreover, the -item hamilton rating scale for depression and the hamilton rating scale for anxiety were included in the assessment. the person who obtained obstetrical clinical data was blind to the results of psychological evaluations. results. the three groups were comparable for: age, parity, socioeconomic status, smoking, alcohol consumption, body mass index. gestational age at birth was not different in the three groups. infants of women with psychiatric disorders had significantly lower birthweight ( + g) and higher percentage of birth weight below the th centile for gestational age ( %) than infants of healthy mothers ( + g and %, respectively). there was also a trend towards lower mean birth weight ( + g) and higher incidence of birth weight below the th centile ( %) in the stressful life event group. there was no significant difference among groups in the percentage of abnormal uterine or umbilical doppler results. conclusions. maternal psychiatric disorders are associated with a lower birth-weight, but the effect is unlikely to be due to abnormal utero-placental or feto-placental vascularisation. objective: the purpose of this study was to evaluate antenatal ultrasound as a tool for the detection of intrauterine growth restriction (iugr) and small for gestational age (sga) infants among subjects with elevated human chorionic gonadotropin (hcg) levels on second trimester serum screening. although iugr has been linked to elevated hcg levels, the optimal screening regimen for antenatal sonographic surveillance has not been previously established. methods: a retrospective cohort study was performed at saddleback memorial medical center where serial ultrasounds from weeks-delivery are generally recommended for patients with hcg levels > . mom. all pregnancies were dated by second trimester ultrasound ± last menstrual period. subjects with an hcg > . mom, who had at least one antenatal ultrasound evaluation for iugr, were identified from an electronic ultrasound database used for clinical report generation. ultrasound data were then linked to an obstetrical birth outcomes database for relevant demographic/delivery information using unique identifiers. iugr was defined as a sonographic estimated fetal weight (efw) < %ile for the estimated gestational age (ega). sga was defined as an actual birthweight < %ile for the ega at the time of delivery. results: from - , there were subjects with elevated hcg levels who underwent antenatal ultrasound surveillance for iugr and who had known delivery information. a total of ultrasound examinations were performed. the median number of examinations per subject was with a range from - examinations per subject. the incidence of iugr and of sga were . % (n= / ) and . % (n= / ), respectively. no fetus with iugr demonstrated absent or reverse end diastolic umbilical artery doppler flow. antenatal ultrasound examinations only identified . % (n= / ) of sga infants. however, the sensitivity for the detection of sga was % when an efw cut-off of % was used. conclusions: although the majority of sga infants did not demonstrate growth restriction on antenatal ultrasound, a sonographic efw > %ile appears to be a safe cut-off to rule out fetuses at risk for sga. neonatal dry lung syndrome after pprom: reason to change intrauterine referral practice in the netherlands? ellen s hoogakker, christiaan v hulzebos, gerda g zeeman. obstetrics and gynecology, university medical center groningen, groningen, netherlands; pediatrics, division of neonatology, university medical center groningen, groningen, netherlands. background: neonatal dry lung syndrome (dls) is a distinct clinical entity following pprom, mimicking pulmonary hypoplasia but with dramatic respiratory improvement during the first - h . its pathogenesis implies complete collapse of small airways to a degree that capillary forces impede distension by ordinary ventilatory pressures. in the netherlands, women with pprom remain admitted at a level iii nicu perinatal center until they reach wks. when they are referred back to their community hospital, unless they live in the neighborhood of the tertiary center. we question this referral pattern because we still see severe respiratory problems occur > wks. we sought to determine the prevalence of such morbidity, in particular dls, in women with pprom who deliver > wks. methods: retrospective descriptive study of neonatal outcome data of singleton pregnancies complicated by pprom between - wks, who deliver > wks (latency > h) , during the -yr period of - at a single academic center. data were extracted from medical records and electronic department databases. results: pprom pregnancies were identified. all but received at least full course of steroids. ( %) delivered > wks. newborns born at the community hospital needed emergency transportation to a level iii nicu for respiratory morbidity. neonatal outcome data (means ± sd) are listed in the table. there were no cases of late onset sepsis, nec or perinatal mortality. conclusions: respiratory morbidity still occurs after pprom with delivery > wks. further investigation of pregnancy-related characteristics, such as the presence of anhydramnios and the latency period, with regards to dls is needed. modification of current referral practice depends upon complete data derived from all dutch level iii perinatal care centers (n = ). tertiary care center (n = ) to determine if an association exists between macrosomia (birthweight > g) and perinatal outcomes in women with and without gestational diabetes mellitus (gdm). study design: this is a retrospective cohort study of , singleton pregnancies. the study cohort was stratified by the diagnosis of gdm, with the presence or absence of macrosomia as the dependent variable. perinatal outcomes examined included neonatal hyperbilirubinemia, hypoglycemia, respiratory distress syndrome (rds), shoulder dystocia and erb's palsy. chisquare tests were performed as well as multivariable analyses controlling for confounders, using p< . to indicate statistical significance. results: in women diagnosed with gdm, macrosomia is associated with a higher frequency of hypoglycemia, respiratory distress syndrome, shoulder dystocia and erb's palsy. though the prevalence of these outcomes is relatively decreased in patients without gdm, they are still more prevalent in macrosomic patients. macrosomia is associated with a higher prevalence of adverse perinatal outcomes in women with and without gdm. therefore, it is important to evaluate neonates with birthweights greater than grams for hypoglycemia and unrecognized erb's palsy. conclusion a significant proportion of our obstetrical patients are obese and many do not perceive themselves to be obese. while our finding of an inverse correlation between level of education and bmi may be confounded by socioeconomic status, our results suggest that in order to address the problems of obesity in our population an important first step will be improving the education of our reproductive age women regarding normal weight gain and nutrition in pregnancy. this may have a significant impact on improving pregnancy outcomes of today's obstetrical population. objective: the aim of the study was to evaluate the impact of a "flat" oral gct upon the outcome of pregnancy. the gct was considered flat when the difference between the basal value and the after load value was %. methods: we prospectively analyzed the outcomes of pregnancies who delivered at our department. inclusion criteria were singleton pregnancy; bmi < kg/m , absence of major risk factors for diabetes and of pregestational diabetes. g -hour oral gct was performed at - weeks of gestation. women were subdivided into groups according to the result of the gct: group = negative (load glucose > % and < mg/dl) women ( . %); group =flat (load glucose % than basal and < mg/dl) women ( . %); group =positive gct/negative ogtt, women ( . %). data are mean ± sd. differences were calculated with the student t test for unpaired samples and test. regression analysis were performed by the least squared method. p-values were considered significant at p< . . results: the characteristics and obstetric outcomes in the three groups are presented in the table . in all patients there was a significant linear relationship between the load and basal glucose values (load value= . + . basal value; r= . ; p< . ) and between birthweight and load values (birthweight= . + . load value; r= . ; p< . ). the relationships were significant also in group and separately but not in group . in this preliminary study we found no major outcome differences in women with flat gct compared to women with normal and gct positive/ ogtt negative results. it seems important, however, to futher investigate the meaning of a flat curve in a bigger population and/or by means of metabolic studies with the use of stable isotopes. results characteristic of the study population and obstetric outcomes are presented in table . the probability to be primiparous and to deliver babies < ° centile decreased significantly with bmi whereas the risk of cesarean section, of post partum hemorrhage at vaginal delivery and to deliver babies > ° centile increased significantly. also the risk to develop preeclampsia and gestational diabetes was increased, although not significantly, with bmi. compared to lean and normal, obese were more likely to be hypertensive and diabetic before pregnancy (p< . ) and to start pregnancy without any medical and obstetrical risk but obesity ( . % vs . and . %; p< . ). african women exhibited the highest bmi and the highest rate of obesity (table ). conclusions we confirm that obese women have an increased risk of prepregnancy and pregnancy complications: less than % have an uncomplicated pregnancy. at delivery there is an increased risk of cesarean section and post partum haemorrhage. objective: overweight and obese women often give birth to larger babies, which is associated with traumatic birth injuries and an increased risk to develop obesity, diabetes and hypertension in childhood and later in life. the mechanisms underlying fetal overgrowth in obese pregnant women are largely unknown. the aim of this study was to establish a mouse model of obesity/high fat diet in pregnancy. we hypothesized that a moderately high fat diet prior to and during pregnancy would result in increased maternal adiposity, fetal overgrowth and a metabolic profile similar to that of obese newborn offspring with persistent pulmonary hypertension, despite enhanced pregnant women. method: c bl/ j female mice were fed control (c, % of energy from fat) or isocaloric high fat (hf, % of energy from fat) diets ad libitum for weeks prior to mating and during gestation. at gestational day . maternal blood samples were obtained to measure adiponectin, leptin and cytokine levels and maternal fat pads were isolated and weighed. in a sub set of animals measurements of transplacental transport of neutral amino acids and glucose were performed in vivo under ketamine anesthesia using h-meaib, and c-glucose. results: no significant differences were observed in maternal pre-pregnancy bodyweight, total caloric intake, weight of the dam at e . or litter size between treatment groups. fetal weight was increased in the hf group by % (p< . ). maternal adiponectin levels were significantly (p< . , n= ) decreased (hf ± , c ± g/ml) and leptin levels increased by % in animals fed a high fat diet, but this difference did not reach statistical significance (n= ). adiposity (fat pad weight) was increased by % (p< . , n= in the dams fed high fat diet, however no difference was observed in maternal il- levels and neither group had measurable levels of tnf-. maternal red blood cell lipid profiles were altered in high fat animals with an increase in stearic and linoleic acids but decreased oleic acid levels. preliminary data showed that placental uptake and transfer to the fetus of glucose and meaib were increased by at least % in dams fed high fat diet. conclusion: this murine high fat diet model has several features consistent with human obesity in pregnancy and the maternal metabolic environment is similar to that seen in the human. the increase in placental uptake and transfer of nutrients constitute a key mechanism underlying fetal overgrowth in overweight/obesity in pregnancy. objective: epidemiological studies have demonstrated a positive relationship between maternal overnutrition and the development of the metabolic syndrome in the offspring. we previously reported that lambs of well fed ewes have increased plasma glucose levels in early life, this may be a consequence of altered hepatic glucose production. increased hsd expression is associated with an increase in intracellular cortisol, promotion of hepatic insulin resistance and a consequential increase in gluconeogenic activity. hypothesis: we hypothesised that maternal overnutrition in late gestation in the sheep results in increased hepatic expression of hsd in the lamb before and after birth. methods: ewes were provided with either % (control,c) or % (well fed, wf) of maintenance energy requirements from d gestation until delivery. post-mortem was performed on either ± d gestation (c= ,wf= ) or and postnatal day (c= ,wf= ). plasma glucose and leptin concentrations in the fetuses and lambs were determined. the relative hepatic mrna expression of hsd and reference gene rpp were determined by qrt-pcr. results: relative liver weight was significantly higher in lambs of wf ewes compared to c at d (p< . ). the expression of hsd mrna was significantly higher in the postnatal compared to the fetal lamb (p< . ) independent of maternal nutritional treatment. however, there was no effect of maternal overnutrition on the hepatic expression of hsd mrna before or after birth. there was no effect of prenatal nutrition on fetal or postnatal plasma cortisol concentrations. the expression of hsd in the liver of lambs of wf, but not c ewes, was inversely related to plasma glucose concentrations in the first hrs after birth (r =- . , p= . ). we have therefore demonstrated that exposure to prenatal overnutrition results in an inverse relationship between hsd mrna expression in the liver at d and plasma glucose concentrations on the first day of life. this suggests that exposure to high glucose levels before and immediately after birth results in a reduced expression of hepatic hsd . we would expect a reduction, rather than promotion of intra-hepatic cortisol production, and therefore it is unlikely to explain the hyperglycemia present in lambs of wf ewes in early life. ninety-seven ( %) of mothers were classified as obese (bmi> ) based on their first pregnancy weight. glycemic control at weeks was superior in the non-obese group (table ) . there were no differences in glycemic control during the last week of pregnancy. obesity was significantly associated with increased maternal weight gain during pregnancy. mean birth weights, ponderal indices and rates of macrosomia were significantly higher in infants born to obese women when compared to non-obese (table ) . primary cesarean deliveries rates were comparable. the rate of neonatal hypoglycemia, hyperbilirubinemia, phototherapy and neonatal icu admissions did not differ between obese and non-obese diabetic women (table ) . although not statistically significant, there was a trend towards an increased rate of birth injuries in the obese group. a similar comparison between obese and non-obese women treated with medication (glyburide or insulin) demonstrated a higher mean birth weight ( g+ vs. g+ , p=. ) and higher rate of macrosomia ( vs. %, p= . ). there were no differences in glycemic control, cesarean delivery rates and other neonatal outcomes between the obese and non-obese treated with medication. conclusion: obese women with type ii and gdm give birth to larger infants than their non-obese counterparts and have a higher incidence of fetal macrosomia. there was a trend towards increased rate of birth injuries in the obese group. despite these differences other maternal and neonatal outcomes were similar which may be a reflection of glycemic control. introduction: tlrs are key components of the innate immune system which recognize conserved sequences on the surface of pathogens and trigger effector cell functions. the placenta, and more specifically the trophoblast, may play an important role in the response to infection. previously, we described the expression of tlr- by human trophoblast and their ability to respond to polyinosinic-polycytidylic acid (polyi:c), a synthetic double strand rna which mimics viral rna. in the present study we evaluate the effect of polyi:c in mouse pregnancy and characterize the local and systemic response. material and methods: human first trimester trophoblast cell line, htr , was treated with polyi:c. c b/ wild type and tlr- knock out mice were injected intraperitoneally with polyi:c at . gestation day. cytokine and chemokine level were determined in supernatant and lysates using the bio-rad multiplex assay and analysis was done using the bio-plex is. results: polyi:c induced cytokine (il , il and il ) and chemokine (il , rantes, gro , mcp and mip ) secretion and production by human cultured trophoblast in a time ( - h) and a dose ( - g/ml) dependent manner. injection of polyi:c to c b/ wild type mice induced preterm delivery within h at a dose of mg/kg body weight. no effect was observed in tlr- knock out mice. a robust systemic (spleen and serum) and local (placenta and amniotic fluid) inflammatory response was observed and h following polyi:c treatment. trophoblast cell cultures from tlr- ko mice confirmed that the response to polyi:c is tlr- dependent. conclusion: we demonstrate that viral infection may trigger an immune response leading to preterm labor. furthermore we show that the trophoblast is able to recognize and respond to viruses through the expression of tlr- . our findings provide a novel mechanism of pathogenesis of preterm labor associated with tlr- mediated inflammatory response. introduction: adverse neurological outcome is a major cause of neonatal morbidity after a preterm birth (ptb). a growing body of evidence demonstrates the involvement of inflammatory pathways in ptb and implicates these pathways as a causative factor in fetal brain injury. however, activations of cytokine pathways in normal labor (whether iatrogenic preterm or at term) has been observed. what remains understudied is the effect of labor on the preterm fetal brain and whether an inflammatory stimulus is essential for fetal brain injury. methods: mouse models were utilized: ( ) a model of intrauterine inflammation (lps into uterine horn) (n= ); controls received intrauterine saline (n= ) and ( ) autism is a neurodevelopmental disorder with a strong genetic component and several known environmental risk factors, such as infection. in addition, its onset of etiology is likely to occur during prenatal development. we propose that subjecting fetal sheep via amniocentesis to the bacterial endotoxin lipopolysaccharide (lps) injected to the amniotic fluid at gestational day (gd) will result in morphological alterations in the offsprings' cerebellum resembling alterations found in the cerebellum of patients with autism. using high precision design-based stereology, we investigated mean total-and layer-specific volume and mean total granule and purkinje cell (pc) number in the cerebellum of lps infected animals and controls. the results of the present study showed preserved volumes of the total cerebellum as well as of the molecular layer, outer and inner granular cell layers and white matter. interestingly, compared to controls, the lps infected brains showed a statistically significant increase (+ . %) in the mean total number of granule cells, whereas the pcs did not show any difference between the groups. these seemingly paradoxical results might be explained by ( ) the so-called time of origin of these neurons, i.e. the pcs develop prenatally whereas the granule cells develop postnatally or ( ) the direct correlation between pcs and granule cell number in the cerebellum. these results might contribute, as an animal model, to our understanding of the biological basis for interindividual differences in morphological alterations found in the brains of patients with autism. the previous studies have shown that there is a higher incidence of spontaneous preterm birth and poorer neonatal outcome in pregnancies with a male fetus. in vitro studies also report a sex dependent pattern in different placental enzymatic systems. we have shown previously that lactobacillus rhamnosus gr- supernatant is able to antagonize the actions of lps on cytokines and ptgs in placental trophoblasts. we hypothesize that fetal sex will influence the production of cytokines and prostaglandin regulating enzymes in lps and lactobacilli treated placental trophoblast cells. methods: term placentae were collected from women undergoing elective caesarean section. placental trophoblasts were isolated using established primary culture protocols. cells were pretreated with lactobacilli supernatant and subsequently treated with lps. pgdh and ptgs expression levels were measured by western blot analysis and tnf-, and il- concentrations measured by elisa. results: lps stimulation caused a marked increase in production of tnf-( . pg/ml to . pg/ml, n= , p< . ), an effect that was greater in placentae of the male fetuses ( . pg/ml, n= ) compared to female fetuses ( . pg/ml, n= ). lactobacilli supernatant abolished this response in both sexes. lps-activated trophoblasts from placentae of the male fetuses showed an increase in il- production (n= , p< . ) and ptgs expression (n= , p< . ). however, there was no response to lps in placentae of the female fetuses. lactobacilli supernatant up-regulated pgdh (n= ) by %, and this effect was greater in placentae of the female fetuses (n= ). conclusion: we conclude that human placentae from pregnancies carrying male fetuses are more responsive to lps by producing more pro-and anti-inflammatory cytokines, as well as ptgs . conversely, placentae of the female fetuses upregulate pgdh with lactobacilli treatment. these findings may explain the underlying mechanism for the higher incidence of preterm birth and adverse pregnancy outcomes seen with male fetuses in the clinical setting. , ) . this study investigates whether iai is associated also with altered expression of neuropilin- . methods: (i) immunohistochemistry (ihc) was performed on tissue sections of term decidua with or without clinical / histologic evidence of iai (n= for each). neuropilin- expression was scored by an investigator blinded to the identity of the samples. (ii) cultured term dscs were retrieved from elective cesarean (n= ), purified, and depleted of leukocytes. after treatment with - m estradiol (e ), - m medroxyprogesterone acetate (mpa), both, or vehicle for days, dscs were stimulated with il- b ( - ng/ml), tnfa ( ng/ ml), or thrombin ( . iu/ml) for h. since no elisa exists for neuropilin- , protein expression was determined by immunocytochemistry (icc). (iii) total rna was extracted and the effect of il- b on neuropilin- mrna expression measured by real-time rt-qpcr and corrected for b-actin mrna. results: neuropilin- expression in term decidua was increased in tissues with iai vs controls (p< . ), and localized primarily to dscs. using icc, an increase in neuropilin- was noted after stimulation with il- b and tnfa, but not thrombin. il- b increased neuropilin- mrna expression in dscs by . ± . -fold (from . ± . to . ± . neuropilin- mrna/b-actin mrna; p= . ). conclusions: iai is associated with increased expression of the vegf receptor, neuropilin- , in term decidual tissues. il- b and tnfa (but not thrombin) stimulated neuropilin- expression in term dscs, and this effect appears to be mediated at the level of gene transcription. since aberrant vegf function alters vascular permeability, these data provide a mechanism by which iai can promote 'decidual activation' and preterm labor. inflammation, university of glasgow, glasgow, united kingdom. objective: asthma is associated with inappropriate activation of airway smooth muscle, chemokine expression and accumulation of mast cells which drive smooth muscle reactivity. labour is similarly associated with smooth muscle activation and expression of cxcr and cxcr ligands. the role of mast cells in human parturition is unknown; however, mast cell products can stimulate myometrial contractions and preterm labour in animal models. we have quantified mast cells in association with human labour and determined whether they express cxcr and cxcr . methods: lower segment myometrial and cervical biopsies were taken at term caesarean section from women not in labour (nil) (myometrium n= ; cervix n= ) and in labour (il) (myometrium n= ; cervix n= ). mast cells were localised in myometrial and cervical sections by icc with a primary antibody against c-kit. the number of cell transects in randomly selected high-powered fields ( x) was quantified blindly by two observers for each specimen, with median density and interquartile range (iqr) calculated. backto-back icc was performed to determine whether c-kit co-localised with the chemokine receptors cxcr and cxcr . results: mast cells were in close association with myometrial smooth muscle in non-labouring lower segment myometrium. labour was associated with a significant influx and increase in mast cells numbers (nil median . , iqr . - . ; il median . , iqr . - . , p= . ). in contrast no significant increase in mast cells was observed in cervical tissue in association with labour (nil median . , iqr . - . ; il median . iqr . - . , p= . ). analysis of chemokine receptor expression demonstrated co-localisation of cxcr to c-kit positive cells present within the myometrium. conclusions: human labour at term is associated with an increase in mast cells within the myometrium, with close approximation to smooth muscle bundles. these mast cells express the chemokine receptor cxcr , the ligands of which we have previously shown to be up-regulated in labouring myometrium. mast cells are not accumulated in cervix in association with labour suggesting a less critical role in cervical ripening. further analysis of the role of mast cells in modulating myometrial smooth muscle physiology is warranted. progestins and the glucocorticoid receptor in human myometrial and amnion-derived wish cells. alison j tyson-capper, stephen c robson. reproductive sciences, newcastle university, newcastle upon tyne, united kingdom. background and objectives: progesterone (p) can reduce the risk of preterm birth in some high risk women. in this context there is accumulating evidence that this, at least in part, may be due to anti-inflammatory and immunoregulatory properties of p. target tissue responsiveness to p is considered to be determined by the progesterone receptors (pr) and nuclear co-factors that directly interact with pr. pr and glucocorticoid receptors (gr) share several structural and functional characteristics, including similarities in dna sequence recognition by binding to the same hormone response elements. pr and gr interact with similar chaperones in the absence of ligand and with a similar group of co-activators in the presence of hormones; both can display comparable anti-inflammatory activities under specific physiological conditions. in this study we aimed to investigate whether the anti-inflammatory properties of progestins may be mediated by pr and gr signalling. methods: primary cultures of non-pregnant and term pregnant human myometrial (passage - ) and wish cells were serum starved for hrs and treated with -hydroxyprogesterone ( -hp), progesterone (p), dexamethasone (dex) and immunofluorescent staining and immunoblotting analyses performed. in some experiments cells were pre-treated with ru (a pr/gr antagonist) or org (a pure pr antagonist). results: in the absence of hormone gr appeared to be predominantly cytoplasmic, whereas, upon treatment with -hp and p ( and m) and dex ( nm) gr was abundant within the nuclei of myometrial cells. immunoblotting analyses demonstrated that levels of gr progressively increased within the nuclear fractions of both pregnant myometrial and wish cells in response to increasing concentrations of p ( nm to m), and decreased sequentially within cytoplasmic fractions. in the presence of org gr protein levels remained constant within the cytoplasm. there also appeared to be a slight increase in gr expression, though not statistically significant (p> . ) within both cells types in response to p. conclusion: in this study we show that gr is activated by -hp and p and translocates to the nuclei of human myometrial and amnion-derived cells. in addition, levels of gr increase in response to p. whether p and -hp act as agonists or antagonists for gr in the regulation of hormone response genes associated with the onset of term and preterm labour remains to be elucidated. objective: using a mouse model of inflammation-induced preterm birth (ptb), we have demonstrated dramatic cytokine elevations in the uterus and placenta with concomitant, though less dramatic, cytokine elevations in the fetal liver and brain, associated with neuronal injury. because precise mechanisms of fetal injury in ptb remain unclear, we sought to examine inflammatory cell trafficking, and target organ damage by histopathologic assessment of the placenta, fetus, and fetal brain. study design: hours after intrauterine infusion of saline or lps into the right lower uterine horn of cd- mice, the left upper horn, with the gestational sacs(gs) in situ, was removed en bloc(n= per group) each with - gs with fetuses/treatment group. specimens were fixed, bisected and processed for histology and ihc. inflammatory and hematopoietic cells were quantified using pas, gata- (erythroid precursors), cd , and bm (macrophage-mp) within the placenta, liver, extremity mesenchyme, brain and leptomeninges. the presence of hemorrhage, necrosis, and apoptosis (h ax stain) was assessed. erythopoietin (epo) levels were measured in brain and liver by elisa. results: more neutrophils were present in maternal decidual vessels in lps compared to saline (p= . ). in lps-exposed, fetal mp were increased in the placenta (p= . ), fetal extremity mesenchyme (p= . ), fetal liver (p= . ) and leptomeninges (p= . ) but not in the brain or spinal cord compared to saline. no necrosis, hemorrhage or increased apoptosis was noted in the fetal brains. % of lps-exposed fetuses and % of saline-exposed had liver hemorrhages (p< . ). increases in nucleated erythrocytes and erythroid precursors were found in fetal vasculature of the placenta in lps-exposed (p= . ). epo levels were not elevated in either group. conclusion: intrauterine lps infusion induces acute inflammation predominantly in the maternal circulation of the placenta. in the fetus, there is widespread mp activation, liver hemorrhage and increased erythroid precursors seen in the fetal circulation of the placenta. although histologic evidence of cns damage was not evident, the increased mps present in the leptomeninges may play an important role in inflammatory-mediated cns damage. non-toll-like innate immune proteins: do they change during pregnancy? juan m gonzalez, hua xu, ella ofori, michal a elovitz. obgyn; crrwh, university of pennsylvania, philadelphia, pa, usa. introduction: trem- (trigger receptors expressed on myeloid cells) is an important regulator of innate immunity. the natural ligand for trem has not been identified. activation of trem- in the presence of toll-like receptors results in substantial amplification of the host inflammatory response (klesney-tait et al nature immunology ). since inflammatory pathways are implicated in adverse pregnancy outcomes, this novel mediator of inflammation may play a critical role in preterm birth (ptb). therefore, we sought to determine trem- expression in the uterus, cervix, and placenta across gestation and to determine if trem- levels are altered by intrauterine inflammation. methods: in cd- mice, trem- was investigated in non-pregnant (np) and throughout gestation e , e (n= - per group). uterine, cervical, and placental tissues were harvested. using an established mouse model of inflammation-induced ptb, uterine tissue was collected hours after intrauterine infusion of saline (n= ) or lipopolysaccharide (lps) (n= ). for a non-pregnant model, using cd- mice, lps (n= ) or saline (n= ) was injected into the uterine horn following same procedures as with pregnant mice. uteri were harvested hrs later. quantikine ® mouse trem- immunoassay was utilized for these studies. statistical analysis was performed using oneway anova followed by pair-wise comparison if statistical significance was reached (p< . ) results: trem levels are significantly different between np and pregnant uterine tissues (p= . ). e and e trem expression is significantly increased . and . -fold compared to np (p= . and . respectively). trem- levels in the placenta and cervix were not significantly different between e and e . trem levels increased about -fold in the uterus after intrauterine infusion of saline or lps compared to e controls. in nonpregnant, trem levels were significantly different (p= . ) with a -fold increase in trem expression in uteri exposed to lps or saline compared to controls. conclusions: non-toll-like innate immune proteins are differentially regulated during pregnancy compared to the non-pregnant state. the role of trem- in inflammation-induced ptb requires further study. research is warranted to determine if uterine up-regulation of trem in gestation is associated with an increased likelihood of responding to pathogens or severe as a protective mechanism. reduced plasma levels of vitamin d in caucasian women at term are associated with increased rate of infection. chander p arora, adegoke adeniji, susan e jackman, babak forooghi, isaac mostadim, phillip yadegari, calvin j hobel. og-gyn, cedars-siani medical center, los angeles, ca, usa; university of california los angeles, los angeles, ca, usa. background: vitamin d plays an important role in human pregnancy by acting as a regulator of immunity at the fetal-maternal interface. inflammatory changes associated with pro-inflammatory cytokines were reduced by vitamin d while anti-inflammatory cytokines were increased in t lymphocytes. vitamin d status has been defined as deficiency (< . nmol/l), insufficiency ( . to nmol/l) and sufficiency (> nmol/l) . objective: to assess the involvement of vitamin d in the occurrence of maternal infection during pregnacy in women with term deliveries. hypothesis: vitamin d metabolism could affect the rate of infection during pregnancy. study design plasma levels of (oh)d were determined by elisa and the rate of infection was recorded in a behavior in pregnancy study. in this study, ethnically diverse women were evaluated at - weeks (t ), - weeks (t ) and - weeks (t ). maternal infections were documented at each stage as well as at baseline visit with history of infection in current pregnancy. of these subjects who delivered at term two groups ( with no infection during pregnancy, with infection or history of infection) were matched further for non-smoking status, non-diabetics, ethnicity and maternal age. plasma from these were assayed for (oh)d and analyzed for the rate of maternal infection using fisher´s exact test or chi-square test. results although the women delivered at term, the levels of (oh)d in caucasians were significantly lower in the subjects with infection than the ones without (p<. ). women with vitamin d insufficiecy in the first trimester were more likely to develop infection during pregnancy ( . nmol/l ± . at t , . nmol/l ± . at t and . nmol/l ± . at t ; all p<. ) but not subjects with sufficient vitamin d at t ( . nmol/l ± . at t , . nmol/l ± . at t and . nmol/l ± . at t ; all p<. ). conclusion the results reveal a positive association between (oh) d concentrations and greater risk of infection. vitamin d deficiency or even insufficiency may, therefore be involved in the pathogenesis of maternal infection during pregnancy. it is probable that vitamin d deficiency or even insufficiency could modulate the maternal susceptibility to infection during pregnancy by a proinflammatory mechanism. in vitro and in vivo observational data suggest that infection leads to caspase activation and apoptosis in the placenta and membranes, however currently there are no data on the role of apoptosis in the pathogenesis of infection associated preterm delivery. here we used group b streptococcus (gbs) as a model pathogen and examined the role of caspase dependent and independent apoptosis in preterm delivery. methods: we injected ( . x ) heat killed group b streptococcus organisms (hk-gbs) intraperitoneally (i.p.) in . day pregnant c b/l mice. the mice were euthanized at hr (n= ) and hr (n= ), the placentas and membranes were removed and assessed for apoptosis by tunel staining. caspase activation and expression were determined by immuno-histochemistry (ih) and western blotting. the effect of apoptosis on preterm delivery was assessed by i.p. treating the pregnant mice with pbs (n= ), dmso (n= ) or pancaspase inhibitor z-vad-fmk (n= ) prior to hk-gbs and observing the animal for delivery for hrs. results: there was a time dependent, gbs-induced increase in apoptosis by tunel assay and caspase activation in the placenta and membranes. in addition hk-gbs-induced the expression of caspase and caspase independent m-calpain in the placenta. z-vad-fmk ( mg/kg), at the maximum concentration that did not induce maternal illness, did not prevent hk-gbsinduced preterm delivery. conclusions: caspase dependent and independent mechanisms are activated in the placenta upon exposure to gbs. systemic adminstration of a pan-caspase inhibitor did not impact upon the occurance or timing of bacterially induced preterm delivery. further studies are needed to assess the role of apoptosis in the pathogenesis of infection associated preterm delivery. early and ( . %) had a late sptb. the mean + sd gestational age at blood draw was + weeks. the median level of bb was higher in women with early as compared with late sptb or term births (p= . for trend). women with bb in the top quartile were . times more likely to have an early sptb as compared with women who had lower levels of bb ( % ci . to , p = . ). there was no association between bb and late sptb (rr= . , % ci = . to ). the adjusted or of an elevated bb for early sptb was . ( % ci = . to , p= . ). when the analysis was restricted to the women with sptb the rr of an elevated bb for early sptb was . ( % ci . to . , p = . ). conclusions: a significant relationship was found between an elevated bb in early pregnancy and early sptb suggesting inflammatory events in early pregnancy, perhaps infection-related, are part of the pathogenic mechanisms. objective: genital tract infection and/or inflammation appears to contribute to the majority of ptds preceding weeks of gestation. ptd in humans has been associated with colonization and/or infection with a variety of different organisms including gram positive and negative bacteria, mycoplasma, ureaplasma, trichomonads, malaria parasites and viruses. the innate immune response to these pathogens is produced by a family of pattern-recognition cell membrane receptors known as the toll-like receptors (tlrs). these studies sought to characterize the tlr isoforms expressed in the preterm mouse uterus, and their modulation during lipopolysaccharide (lps)-induced ptd. methods: using sterile surgical technique, day- pregnant cd- mice underwent intrauterine injection of g lps. subsequently, the mice were euthanized at , , , , and hours after lps injection. uterine tissue was harvested and placed in rnalater; subsequently total rna was isolated using the trizol reagent and genomic dna was removed using turbo dnafree. cdna was made using iscript cdna synthesis kit. pcr primers were designed using published mouse tlr gene sequences. real-time quantitative rt-pcr was performed using the power sybr green master mix and an abi prism multicycler. to confirm tlr amplicon sizes, the rt-pcr products were visualized on a % agarose/tbe gel stained with gelred. results: these studies have confirmed mrna expression of all of the reported mouse tlr isoforms. these tlr amplicons range in size from to bp as expected; amplicon sequences are pending. quantitative rt-pcr studies performed using uterine tissues from five mice at each time point demonstrated that at hours after lps injection, tlr increased -fold and tlr increased -fold (both p< . ). in contrast, the expression of tlr (the ligand for lps) remained stable during the hours after lps; the expression of tlr , , , , , and also remained stable. tlr expression trended upward and tlr trended downward, although neither was statistically significant. conclusions: these studies have confirmed expression of all tlrs within the preterm pregnant mouse uterus, along with characterization of their modulation during lps-induced ptd. these observations are important because they contribute to our understanding of the immunologic signaling events leading to ptd. (funded by nih hd ). udp-glucose and its receptor p y as a new innate immune system in the female reproductive tract. toru arase, tetsuo maruyama, hiroshi uchida, takashi kajitani, masanori ono, maki kagami, hironori asada, yasunori yoshimura. obstetrics and gynecology, keio university, shinjukuku, tokyo, japan. objective: innate immune system involving toll-like receptors has recently emerged in the female reproductive tract (frt). we hypothesize that there may exist new other mucosal immunity in frt. recently, it has been reported that p y , a g protein-coupled p y receptor for udp-glucose (udp-g), is involved in the lung epithelial immune system. the aim of this study is to investigate whether udp-g and p y have a potential as the defense immune system in frt, in particular endometrium. materials and methods: we obtained human endometrial tissues from consenting reproductive-aged patients. the spatiotemporal expression of p y in human and mouse endometrial tissues was analyzed using rt-pcr and ihc. isolated human endometrial cells and a human endometrial epithelial cell line, ishikawa, were cultured, treated with udp-g, and subjected to rt-pcr analysis for il- mrna expression. we also measured the il- secretion using elisa. small interfering rna was used to knock down p y expression. the chemotactic activity of udp-g on neutrophils was tested using transwell assay with ishikawa cells. lastly, mouse uterine tissues were incubated with udp-g and subjected to rt-pcr analysis for mrna expressions of kc and mip- , the il- homologues in mice. results: p y was exclusively expressed in the glandular and luminal epithelium both in human and mouse uteri. treatment with udp-g induced the secretion of il- in ishikawa and human endometrial glandular cells, but not stromal cells, in a dose-and a time-dependent manner. p y knockdown abrogated udp-g-induced il- production. treatment with udp-g also significantly increased the chemotaxis of neutrophils, which was attenuated by co-addition of anti-human il- neutralizing antibody. in the mouse uterus stimulation of udp-g significantly up-regulated the expressions of kc and mip- mrna. conclusions: udp-g is an endogenous molecule and released into the extracellular environment in a lytic manner after cell damage. taken together, our results collectively substantiate a model in which udp-g released from endometrial cells damaged by infection stimulates il- production via p y in endometrial glandular epithelium, which, in turn, recruits neutrophils thereby preventing the progression of infection. thus, udp-g and its receptor p y may be involved in the trans-species mucosal immune system in frt. (jsgi ; , (suppl) , abst # ) but in utero effects on fetal lung remain to be established. we have examined the relationship between duration of iai and subsequent azi treatment on the severity of fetal lung histopathology. we hypothesized that early treatment would prevent the development of advanced lesions, while late treatment may reduce the severity of lung damage. study design. thirteen chronically instrumented rhesus monkeys received intraamniotic inoculation of u. parvum (serovar ; - x cfu) at ± . days gest. age (dga, mean ± sem, term= d). six of these animals received maternal i.v. azi ( . mg/kg q h or q h for d) either alone (n= ) or in combination (n= ) with dexamethasone (dex; mg/kg/d i.v. for d) and indomethacin (indo; mg/d p.o for d). tissues were obtained at cesarean section for histopathologic assessment. leukocytic infiltration of aveolar spaces and septal walls, type ii pneumocyte hyperplasia and peribronchiolar lymphocytic aggregates were scored as absent ( ), minimal ( ), moderate ( ) and severe ( ). results. inoculation-to-delivery interval was - d for combined treatment groups and was similar to long duration infection without treatment ( - d). treatment effects were tabulated as mean scores and compared as follows: control (n= ), score ; short duration infection ( - d; n= ), score ; long duration infection ( - d; n= ), score ; short duration infection + treatment (n= ), score ; long duration infection + treatment (n= ), score . conclusions. histopathologic findings of fetal pneumonia progressively worsen with duration of u. parvum iai. early maternal azi treatment prevents development of advanced lung lesions, while later treatment may reduce the severity of fetal lung damage. our results suggest that in utero treatment of iai may lower the risk of neonatal bronchopulmonary dysplasia. support: nih hd , rr . brain associated with adverse neurodevelopmental outcome. lps triggers proinflammatory responses through toll-like receptor- (tlr ). mitogen activated protein kinases including c-jun-n-terminal kinase (jnk) have been reported to be implicated in tlr signalling pathways and play important role in both onset of labor and brain injury. in the present study, we used a mouse model of intrauterine infection-associated preterm labor to determine whether the administration of specific inhibitor of jnk signaling, d-jnk inhibitory peptide (d-jnki) can (i) inhibit jnk activity in vivo, (ii) delay lps-induced preterm delivery, and (iii) improve neonatal outcome in the presence of intrauterine inflammation. intrauterine administration of tlr- specific lps to cd pregnant mice at day of pregnancy caused preterm delivery after to h with % pup mortality. in vitro kinase assay demonstrated the activation of jnk in response to lps in the maternal uterus and fetal brain. furthermore, the brain specific jnk was found to be the major jnk isoform activated by lps in the fetal brain. co-administration of d-jnki with lps to pregnant mice delayed significantly (p< . ) lps-induced preterm delivery and reduced pup mortality up to %. this was associated with inhibition of jnk activity in both maternal uterus and fetal brain. in addition, we have found that treatment with lps significantly up-regulated cox- , cxcl (il- equivalent) and ccl in myometrium and this is significantly suppressed after co-administration of d-jnki. we conclude that specific inhibition of jnk signaling may have a potential of controlling preterm labor and preventing fetal brain damage as a result of infection/inflammation. the prostaglandin -deoxy- , -prostaglandin j delays lps-induced preterm delivery and reduces mortality in the mouse. intrauterine infection is a common trigger for preterm birth, and is also a risk factor for the development of neurodevelopmental abnormalities in the neonate. bacterial lipopolysaccharide (lps) binds to toll-like receptor- (tlr ) to activate pro-inflammatory signaling pathways. the transcription factor nuclear factor kappa b (nf-kb) is a key player in the orchestration of the inflammatory response and has a central role in parturition. we have previously shown that exposure to the anti-inflammatory cyclopentenone prostaglandin -deoxy- , -prostaglandin j ( d-pgj ) inhibits il- b-induced nf-kb activity and cox- expression in human myometrial and amnion epithelial cells in vitro. in the present study, we used a mouse model of intrauterine infection-associated preterm labor to determine whether the administration of d-pgj can (i) inhibit nf-kb in vivo, (ii) delay lps-induced preterm delivery, and (iii) improve neonatal outcome in the presence of intrauterine inflammation. intrauterine administration of tlr specific lps to cd pregnant mice at day of pregnancy caused preterm delivery after to h with % pup mortality. co-administration of d-pgj with lps to pregnant mice delayed significantly (p< . ) lps-induced preterm delivery and conferred protection from lps-induced fetal mortality up to %. we have looked at the expression profile of several labor associated genes in myometrium hours after lps administration. (otr, connexin and , cox- , cox- , cxcl (il- equivalent) and ccl ). we have found that treatment with lps significantly up-regulated cox- , cxcl and ccl and this is significantly suppressed after with co-administration of d-pgj . western analysis for ser -phosphorylated p and ikkb in-vitro kinase assay has demonstrated that lps induced activation of nf-kb at both h and h. co-administration of d-pgj was associated with inhibition of nf-kb activation in both the maternal uterus and the fetal brain. conclusion d-pgj may have potential as a therapeutic agent in the management of preterm labor and, by targeting the player nf-kb, may have the added advantage of preventing detrimental effects to the fetus that may result from infection/inflammation. synergistic macrophage response to co-activation of tlr- and tlr- : mechanisms and implications for bacterial/viral co-infection. vladimir ilievski, emmet hirsch. , department of ob/gyn, evanston northwestern healthcare, evanston, il; department of ob/gyn, feinberg school of medicine, northwestern university, chicago, il. background: toll-like receptors (tlrs) recognize structural components of pathogens and initiate host defenses. tlr- responds to gram-positive organisms and peptidoglycan (pgn), a gram-positive cell wall constituent. tlr- is activated by viral infection in response to double-stranded rna. polyinosinic-cytidylic acid (poly(i:c)) is a tlr- ligand. we have shown that pgn and poly(i:c) have a synergistic effect on the expression of downstream genes for both tlr- and tlr- . here we identify mechanisms underlying this synergy. methods: mouse peritoneal macrophages or a mouse macrophage cell line (raw . ) were treated in tissue culture with either pgn ( g/ml), poly(i: c) ( g/ml) or both pgn and poly(i:c) either simultaneously or sequentially for - hours. total rna was extracted and duplex rt-pcr was performed for inducible nitric oxide synthase (inos), interleukin (il- ), tumor necrosis factor (tnf), the chemokine rantes and tlr- , normalized to the housekeeping gene gapdh. results: compared to stimulation with either pgn or poly(i:c) alone, costimulation of raw . cells with both pgn and poly(i:c) resulted in synergistic expression of inos, il- , tnf and rantes (p< . for all) at and hours . sequential stimulation with either pgn or poly(i:c) for h followed by incubation for an additional h with the alternate ligand also induced synergistic expression of the same rnas, albeit at lower levels than were elicited by simultaneous stimulation. in contrast, incubation with either pgn or poly(i:c) for h followed by medium for h induced minimal to no gene expression. both pgn and poly(i:c) induced tlr- mrna after h but not h. tlr- mrna was not detectable by rt-pcr. in primary peritoneal macrophages, similar synergy due to pgn and poly(i:c) was seen. conclusions: simultaneous or sequential exposure to pgn and poly(i:c) exerts a synergistic effect on the expression of inflammatory mediators in macrophages. interestingly, either one of these two tlr pathways can prime cells for activation of the other pathway. a possible mechanism for this effect may be induction of tlr- by either tlr- or tlr- activation. these observations have implications for bacterial/viral co-infection. this is a secondary analysis of a prospective cohort study. after irb approval, daily blood samples were obtained from pprom subjects and analyzed for il- by elisa. paired maternal serum il- levels from subjects were divided into groups: il- levels obtained - hours prior to completion of antibiotics and those obtained - hours after completion of antibiotics. the wilcoxon signed rank test was used to perform the data comparison on the analyze-it statistical software program. statistical significance was defined as p< . . of the pprom subjects, the maternal age was . yrs; gestational age at admission was . weeks; latency was . days; gestational age at delivery was weeks; and infant birth weight was grams. median maternal serum il- levels obtained off antibiotics were significantly higher when compared to those on antibiotics ( . vs. . pg/ml, p< . ). the results of this investigation suggest that maternal serum il- levels rise after discontinuation of antibiotics. the optimal duration of antibiotics administration in the setting of pprom is unknown. this data suggests a role for continuation of antibiotics in women with pprom in order to prolong the latency period and potentially decrease neonatal morbidity. to identify clinical and pathologic factors associated with fetal inflammatory responses in the placenta from term parturients. methods: retrospective cohort study of consecutive term parturients with submitted placentas in . placentas with histologic chorioamnionitis were divided into two cohorts: group -maternal inflammatory responses only, and group -maternal and fetal inflammatory responses. maternal and fetal inflammatory responses in the placenta were classified according to guidelines established by the amniotic fluid infection nosology committee of the perinatal section of the society of pediatric pathologists. selected demographic, intrapartum, newborn and placental characteristics were analyzed with t-tests and chi-square tests as appropriate. multiple logistic regression was used to identify independent predictors of fetal inflammatory responses in the placenta. results: of consecutively submitted placentas, had histologic chorioamnionitis: with maternal inflammatory responses only (group ) and with both maternal and fetal inflammatory responses (group ). fetal inflammatory responses observed in group were associated with higher stages of maternal inflammatory responses (p<. ). % of fetal inflammatory responses were stage i (acute chorionic vasculitis or phlebitis).group patients were more likely to have had amnioinfusion ( % v %, p=. ) and less likely induction of labor ( % v %, p=. ). group was more likely to have had intrapartum fever ( % v %, p=. ) and maternal tachycardia ( % v %, p=. ). newborns from group were more likely to have been observed for sepsis ( % v %, p <. ) and have an apgar score at minutes ( % v %, p=. ). a logistic regression model showed that stage ii or greater maternal inflammatory responses (or . ) and amnioinfusion (or . ) were independent predictors of fetal inflammatory responses. conclusion: higher stages of maternal inflammatory responses in the placenta and amnioinfusion were independent predictors of fetal inflammatory responses in term parturients with histologic chorioamnionitis. objective: previous studies have shown that sulfasalazaine (sasp) inhibits lipopolysaccharide (lps)-induced nf-b activation and decreases lpsstimulated interleukin- (il- ) production by cultured explants of placenta, amnion and choriodecidua with no effect on cell viability. bacteria-induced il- production in the cervix is a potential mechanism for premature cervical ripening that may lead to preterm birth. it is unclear, however, whether sasp can inhibit il- production by endocervical cells. therefore, we performed a series of in vitro studies to determine if sasp inhibits il- production by endocervical epithelial cells stimulated with bacterial pathogens associated with preterm birth. methods: human endocervical epithelial cells were incubated with - . mm sasp overnight and then stimulated with ccu/ml ureaplasma parvum, cfu/ml escherichia coli, or x cfu/ml gardnerella vaginalis for another overnight incubation in -well cultures. conditioned medium was then harvested and production of il- was quantified by elisa. viability of the cells was ascertained at the end of the experiment with the mtt-assay. each treatment was applied in quadruplicate wells and experiments were repeated times using different batches of cells for each pathogen. results were evaluated using the general linear models procedure of sas for a randomized block design. results: sasp had no detectible effect on il- production by endocervical cells not treated with bacteria. at the highest concentration tested ( . mm), sasp significantly inhibited il- production by cultures stimulated with e. coli (p< . ), u. parvum (p< . ), and g. vaginalis (p< . ). viability of the cells, however, was significantly reduced by sasp at . and . mm in the both the presence and absence of bacteria for all experiments. conclusion: although high concentrations of sasp inhibit il- production by cultures of endocervical cells stimulated with pathogens associated with preterm birth, this effect may be due to toxicity of the antibiotic on the cells. the effect of -hydroxyprogesterone caproate on lipopolysaccharide stimulated peripheral blood mononuclear cells from pregnant women. richard h lee, aimin li, frank z stanczyk, jinwen i lin, t murphy goodwin. obstetrics and gynecology, university of southern california, los angeles, ca, usa. introduction: -hydroxyprogesterone caproate ( -ohpc) reduces the rate of recurrent preterm birth in high-risk women. however, there are lines of evidence to suggest that -ohpc alters inflammatory response in the setting of gram-negative infection. in a mouse model, -ohpc decreased the rate of preterm birth but was associated with significantly increased maternal morbidity when mice were exposed to lipopolysaccharide (lps). in non-pregnant women, -ohpc pre-treatment of whole blood exposed to lps significantly increased the production of tnf-. objective: to determine if -ohpc has an effect on the production of proinflammatory cytokines from peripheral blood mononuclear cells (pbmc) in pregnant women. methods: pbmc were isolated from fresh whole blood samples of pregnant women between and weeks. pregnant women had no prior history of preterm birth. cells were treated with -ohpc ( m) and escherichia coli lipopolysaccharide (lps, g/ml) alone or in combination. after and hours of culture, supernatants were collected and tested for tnf-and il- levels by enzyme-linked immunosorbent assay (elisa). statistical analysis was performed using non-parametric tests. p < . was considered significant. results: pbmc exposed to lps significantly increased tnf-and il- secretion compared to untreated controls (p= . and p= . ). tnf-concentrations were not significantly different between lps and lps+ -ohpc treated cells at both and hours (p= . and p= . ). il- production was significantly increased after -hour treatment with lps+ -ohpc compared to lps alone ( , [ , - , ] background. recent clinical trials indicate that progestins reduce the incidence of preterm birth in some high risk pregnancies. it has been proposed that progesterone promotes uterine quiescence, in part, via its antiinflammatory properties with inhibition of pro-inflammatory gene expression. it is intriguing that progestins are clinically effective given the considerably increased background circulating levels of the hormone during pregnancy. we hypothesised that non-classical progesterone signalling pathways contribute towards mediation of the anti inflammatory effects of progestins. to the endotoxin lipopolysaccharide (lps) by activation of inflammatory pathways. myometrial cell cultures were treated with lps ( g/ml)+/progestin ( nm). two progestin compounds were investigated. natural progesterone (p) is known to have a strong affinity with progesterone receptor (pr) analogues in contrast to -hydroxyprogesterone ( -hp) which, in the absence of esterification with caproate or acetate, has been reported to have no progestogenic activity at pr. the effect of p and -hp on the activation of two inflammatory genes known to be associated with labour (cycloxygenase [cox- ], toll-like receptor [tlr- ]) was evaluated. cox- and tlr- were detected at the protein and mrna levels using sds-page and rt-pcr. results. lps-induced expression of cox- and tlr- proteins were significantly inhibited by both p (p< . and p< . , respectively) and -hp (p< . and p< . , respectively). furthermore, preliminary results indicate that co-incubation with the anti-progesterone mifepristone, fail to abrogate the anti inflammatory effect associated with progestin treatment. conclusion. non-classical progesterone signalling pathways have a role in mediating the anti-inflammatory properties of progestins. further elucidation of the molecular actions of progestins may allow novel approaches to ameliorate the inflammatory response associated with preterm labour. detection and transcriptional expression of tlr- , tlr- and tlr- at the maternal-fetal interface. jacqueline p tilak, karen zakharian, alexandra tungol, gabriel o schubiner, david m svinarich. patient care research, providence hospital, southfield, mi, usa. preterm labor and delivery remains a leading cause of neonatal morbidity and mortality and bacterial infection is considered to be the most common etiology. toll-like receptors (tlr's) and the associated components of the innate immune system may represent a first line of defense against these pathogens. tlr's belong to a family of pattern-recognition receptors that bind to highly conserved pathogen-associated molecular patterns (pamps) including lipopolysaccharide (lps), lipotechoic acid (lta) and cpg dna, and are a key component of the innate immune system. this study was undertaken to characterize the transcriptional expression and regulation of tlr- , tlr- and tlr- within gynecologic and gestational tissues. human first trimester trophoblasts, endometrial mesoderm, ectocervix, choriocarcinoma and neonatal epithelium, were cultured in media alone or in the presence of either lps ( mg/ml) or lta ( mg/ml) for , , , , and hours. total rna was isolated and semi-quantitative rt-pcr was performed using intron-spanning amplimers to tlr- , tlr- , tlr- and gapdh. following gel electrophoresis, the integrated optical densities were determined for the corresponding pcr products and normalized with respect to gapdh levels. inducible transcription of tlr- with lta was observed in choriocarcinoma cells ( -fold, h), and endometrial mesoderm cells ( -fold, h). tlr- induction with lps was observed in ectocervical cells ( -fold, h), choriocarcinoma cells ( -fold, h) and endometrial mesoderm cells ( -fold, h). tlr- induction with lps was observed in choriocarcinoma cells ( fold, h) and neonatal epithelial cells ( -fold, h). all cell lines showed at least constitutive levels of transcription for tlr- , tlr- and tlr- . these data demonstrate that tlr- , tlr- and tlr- are transcriptionally expressed either constitutively or inducibly in both gynecologic (endometrial mesoderm, ectocervix) and gestational (chorion, trophoblast), tissues. translation of these receptors suggests that the innate immune system may function at the maternal-fetal interface to help protect the fetus against infection and prevent or diminish the likelihood of prematurity. objective: further to our development of a sheep model of intrauterine ureaplasma spp infection, we aimed to examine the capability of ureaplasma colonization in the amniotic fluid to infect the fetus and alter lung and brain development. methods: at days of gestation (d, term= d) ewes bearing single fetuses were given a single ultrasound-guided intra-amniotic injection of (a) x colony forming units (cfu) of u parvum (serovar , n= ; serovar , n= ), (b) x cfu of u parvum (serovar , n= ; serovar , n= ) or (c) media control (n= ). at d, fetuses were delivered by cesarean section. amniotic fluid and umbilical arterial blood samples were collected. fetal body weight was recorded, fetal cerebrospinal fluid (csf) collected and a descending pressurevolume curve constructed after inflation of the lungs to cmh o. fetal membranes were immersion fixed and the fetal brain was perfusion fixed with % paraformaldehyde. the fetal brain and membranes were blocked, paraffin embedded, stained and viewed under the light microscope. results: chronic intra-amniotic colonisation with u parvum serovar or (ureaplasmas) did not result in fetal abortion or death. amniotic fluid ureaplasma titers at delivery were not dose-dependent. chronic ureaplasma exposure did not affect fetal body or brain weights, or result in a fetal systemic inflammatory response. umbilical arterial blood gases at delivery were similar between ureaplasma-and media-exposed fetuses. chronic intra-amniotic exposure to ureaplasmas resulted in higher inflammatory cell scores in the fetal membranes compared to media controls (p< . ). lung compliance was increased in ureaplasma-exposed fetuses compared to controls (p< . ). there were no gross anatomical changes observed in the white or grey matter in the cerebral hemispheres of fetuses that had been exposed to ureaplasmas; even in animals (n= ) that had csf ureaplasma colonisation. conclusion: chronic ureaplasma colonisation enhances fetal lung compliance without gross anatomical changes in the fetal brain. background: an important source of vitamin d is its synthesis by skin from uv solar radiations. the skin pigment melanin absorbs uv photons thus reducing the vitamin d synthesis by more than % making african americans at high risk for vitamin d deficiency. low maternal vitamin d status during pregnancy has been linked to molecular pathways for adverse outcomes. objective: the nf b transcription factor regulates genes involved in inflammation and immune processes, and is proposed to play a major role in the successful outcome of pregnancy and labor. prior immunohistochemical (ihc) and biochemical studies have been conflicting regarding nf b activation in human intrauterine tissues. the aim of this study was to quantify nuclear localization of p , the major tranactivating nf b subunit, in full-thickness fetal membranes (fm) and myometrium using ihc. methods: a retrospective analysis of paired fm, decidua, and myometrial samples was conducted using tissues collected from women in cohorts: preterm no labor (pnl, n= ), preterm labor (ptl, n= ), spontaneous term labor (stl, n= ), and term no labor (tnl, n= ). subjects were delivered between gestational ages - weeks (preterm) and - weeks (term) by cesarean. paraffin sections were stained with polyclonal (rabbit) anti-human p and microscopically examined. myometrial samples were categorized in a blinded fashion to groups of staining: no nuclear p (-), rare nuclear p (+), and > % nuclear p (++). a p nuclear labeling index (nli; % nuclear p /total cells) was calculated for each histological layer in full-thickness fm specimens using a blinded targeted randomization scheme consisting of non-overlapping low-magnification fields. results: nuclear p labeling was rare in amnion and inconsistently present in chorion. in decidua, p nuclear labeling was observed in all cases; however, decidual nli did not vary significantly across cohorts [pnl- % ( - %); ptl- % ( - %); tnl- % ( - %); stl- % ( - %); all values are median (iqr)]. in myometrium, ++ p nuclear labeling was significantly associated with labor, but present only in a portion of cases (ptl- %; stl- %). despite a trend, decidual nli was not significantly correlated with myometrial nuclear p labeling: myometrial specimens classified as -, +, and ++ corresponded with decidual nli of % ( - %) [median (iqr)], % ( - %), and % ( - %), respectively. conclusions: in a comprehensive ihc analysis, significant nuclear p immunolabeling was observed in myometrial cells following labor. nuclear p labeling in decidua was present in all cases, and did not vary significantly among the cohorts. the inflammatory cytokines interleukin- and tnf-increase g-csf expression in term decidual cells. objectives: chorioamnionitis (cam) elicits premature rupture of the membranes and pre-term delivery. previously, we found that the decidua from cam patients contains much higher neutrophil numbers than control decidua, but macrophage numbers are similar in both groups. granulocyte colony-stimulating factor (g-csf) enhances granulocyte colony formation chemoattraction and activation. the amniotic fluid during cam contains elevated tnf-and il- levels. to account for the marked influx of neutrophils infiltration in cam-complicated decidua, tnf-and il-effects were assessed on g-csf expression in term decidual cell (dc) monolayers. methods: confluent leukocyte-free term dcs from normal term deliveries were primed with - m estradiol (e ) + - m medroxyprogesterone acetate (mpa) for days, then switched to serum-free defined medium (dm) with steroids ± tnf-or il- . after h, aliquots of conditioned dm supernatants, cell lysates and extracted rna from h parallel incubations were frozen. secreted g-csf was measured by elisa in conditioned dm and normalized to cell protein and mrna was assessed by quantitative real time rt-pcr and normalized to -actin mrna. results: in cultured first trimester dcs, basal g-csf levels in conditioned dm were . ± . pg/ml/ug cell protein [mean ± sem, n= ] and did not differ from e +mpa basal levels. the addition of ng/ml of tnf-or il- significantly elevated g-csf output to . ± . and ± respectively (p< . ), representing more than a -fold and , -fold change; respectively. western blotting confirmed the elisa results. quantitative rt-pcr demonstrated corresponding changes in g-csf mrna levels as found for the elisa measurements. concentration-dependent effects for both tnfand il- from . to . ng/ml were observed. conclusions: when extrapolated to the placental milieu of cam, the marked increase in g-csf elicited in term dcs by tnf-and il- may provide a mechanism to account for the selective increase in decidual neutrophils versus macrophages. background. the immunological mechanisms of the female reproductive tract are unclear. toll-like receptors (tlrs), innate immune receptors that combat microbial infections and establish adaptive immunity, may play a role. infection in pregnancy has been associated with preterm birth and tlrs may modulate the host response to such infections. we hypothesised that the distribution of tlr and tlr in cervical epithelial cells may differ with pregnancy, and that oestrogen may contribute to the modulation of these receptors. aims and objectives. . to compare tlr and tlr protein expression, using immunocytochemistry, in the cervical epithelium of pre-menopausal non-pregnant women with pregnant women at term. methods. fresh non-pregnant (n= ) and pregnant (n= ) human cervical cells were obtained by smear and tlr and tlr expression investigated by immunocytochemistry. cervical epithelial cells from nonpregnant women obtained by smears were then coincubated with varying concentrations of estradiol, and tlr and tlr protein expression quantified by immunocytochemistry. results. using pixel-based image analysis software, we demonstrated a reduction in tlr expression in late pregnant compared with non-pregnant cervical epithelium (p= . ), whilst tlr did not appear to differ. there was an apparent up-regulation of tlr protein expression in response to beta-oestradiol (n= ) objective: to evaluate in vitro antimicrobial activity of cranberry-exposed urine against common urinary pathogens. subjects were pregnant women enrolled in a clinical trial evaluating the effect of daily cranberry juice cocktail or matching placebo on asymptomatic bacteriuria and other urinary tract infections. methods: -hour urine samples from pregnant women who were randomized to cranberry or placebo in three treatment arms: a. cranberry two times daily with meals (c, c; n= ), b: cranberry in the am, then placebo at dinner (c, p; n= ), c: placebo two times daily with meals (p, p; n= ). we identified non-pregnant, reproductive-aged controls, randomized them to the same treatment groups and collected -hour urine specimens from them. the ph of all urine specimens was adjusted to ph= and filtered. aliquots of each were independently inoculated with overnight culture of - cell/ml each of single strains of e. coli with fimbriae type i and type ii, k. pneumoniae, and c. albicans. after hours of incubation for e. coli and k. pneumoniae, and hours for c. albicans cfu/ml of each specimen were enumerated by subculture with quantitative plate counts in duplicate. results: there were no differences for any of the antimicrobial activities between pregnant and non-pregnant groups, or based on treatment allocation. we were able to perform antimicrobial assays on the urine of women exposed to cranberry juice or placebo, but unable to demonstrate differences based on treatment allocation or pregnancy. this may be due to beta-error. further studies are planned. supported by r dk - ; clinical trials registration nct . ...,.. e. coli . x .:!: . x . x .:!: . x group a (c, c) group b ( c, p) . x + . x . x + . x . . . group c (p, p) . x o"::!>s x o" . x ~ .ox: o• k. ~neumoniae group a ( c, c) . x + . x . x + . x . . . group b (c, p) . x + . x . x + . x group c (p, pl . x ~ . x . x ~ . x c. al bicans group a (c, c) . x '+ . x . x + . x group b (c, p) . x o•+ . x . x + . x . . . group c (p, p) . x ~ . x . x ~ . x • objective: to measure compliance, we sought to evaluate the use of a bioassay for cranberry in the urine of women enrolled in a clinical trial designed to determine the effect of daily dosing of cranberry juice cocktail or matching placebo on the incidence of asymptomatic bacteriuria (asb) and other urinary tract infections (uti) during pregnancy. methods: we collected -hour urine specimens from pregnant women who were randomized to ingest cranberry or placebo in three treatment arms: a: cranberry two times daily with meals (n= ), b: cranberry in the am, then placebo at dinner (n= ), c. placebo two times daily with meals (n= ). we identified non-pregnant, reproductive-aged controls, randomized them to the same treatment regimens (group a: n= , group b: n= , group c: n= ), and collected -hour urine specimens from them. bacterial anti-adhesion effects of the cranberry-exposed urine were evaluated utilizing a human red blood cell hemagglutination assay specific for uropathogenic p-fimbriated e. coli. activity was quantified as , , and %. results: when combining all subjects and dosing regimens, the sensitivity of the assay was %, range % in the pregnant group assigned single daily dose of cranberry to % in the non-pregnant group assigned to multiple daily doses. the specificity ranged from % to %. conclusions: these data indicate that the bioassay can be applied to the pregnant patient population, although the sensitivity of the assay is variable. higher daily dosing appears to confer greater sensitivity. further studies are needed to evaluate the utility of this bioassay for compliance. supported by r dk - . clinical trials registration nct . objective: increasing evidence suggests that inflammation plays a crucial role in initiation of labour both at term and preterm. we have previously shown upregulation of pro-inflammatory cytokines in myometrium, cervix and membranes at term labour. we have also shown that myometrium and cervix is invaded by leukocytes at the time of labour, and these leukocytes express pro-inflammatory cytokines. in this study, we aimed to test the hypothesis that pro-inflammatory cytokines and toll-like receptor and (tlr and ) mrna expression are up-regulated in circulating leukocytes during term and preterm labour. methods: peripheral blood samples were taken from pregnant women: - weeks gestation (w) preterm not in labour (ptnl) n= ; - w preterm in labour (ptl), n= ; - w term not in labour (tnl) n= ; and - w term in labour (tl) n= . leukocytes were isolated using dextran sedimentation. total rna was isolated and reverse transcribed using high capacity cdna archive kit, and mrna expression determined by real-time pcr (abi, taqman). student's t-test was used to compare outcomes between groups. results: messenger rna expression of il- , icam- , mcp- , tlr and tlr was significantly increased in tl compared to gestation matched tnl. the expression levels of il- b, il- and tlr- were significantly greater in ptl compared with gestation matched ptnl. (table i) . conclusions: we show up-regulation of pro-inflammatory cytokine production in circulating leukocytes in both term and preterm labour. thus, the pathophysiology of labour seems to involve the upregulation of proinflammatory cytokine production in peripheral blood leukocytes, followed by their invasion into the myometrium and cervix. this work further contributes to our understanding of the pathophysiology of parturition, and suggests that peripheral blood leukocytes may be potential targets for therapeutic agents aimed at modifying the time course of parturition. introduction. the mechanisms of innate immunity and tolerance in the female reproductive tract (frt) are ill-understood but involve the pattern recognition toll-like receptors (tlrs). we have previously demonstrated high expression levels of tlr gene and protein in fresh human cervical epithelium. aims. in order to gain insight into the immunological role of cervical epithelial cells (cecs), we sought to determine cec responses to the following tlr- agonists: macrophage-activating lipopeptide (malp- ), pam csk , and peptidoglycan. methods. cecs were isolated by smears and compared between pregnant ( rd trimester) and nonpregnant women. following cell preparation, flow cytometry was performed using a direct staining procedure with mouse anti-human tlr primary antibody and its igg , isotype control, to determine tlr- protein expression. a further nonpregnant smear samples were each prepared, and seeded at a concentration of , cervical epithelial cells/ml into -well cell plates. cells were incubated at °c in % co overnight with the tlr agonists malp- and pam csk (at concentrations of and ng/ml), peptidoglycan( ng/ml), il- ( ng/ml, positive control) and rpmi + -glutamine media only (vehicle). following centrifugation, all resulting supernatants were stored at - °c until the concentration of il- was determined by elisa and an array of cytokines by bead assays. results. both pregnant and nonpregnant cecs expressed tlr (specific mean fluorescence . vs . respectively) but did not differ (p = . ). unstimulated cells incubated with buffer alone demonstrated high il- levels ( pg/ml), which did not differ following stimulation with malp- ( pg/ml), pam csk ( pg/ml) or peptidoglycan ( pg/ml). results of an array of pro-and anti-inflammatory cytokines following incubation of cells stimulated with tlr agonists are pending. conclusion. high basal il- levels suggest constitutive expression by cecs but the physiological relevance of this intriguing observation is unclear. that cec stimulation with tlr- agonists did not lead to further release of il- may epitomise the resistance of these cells to antigenic challenge by the vaginal commensal flora. cecs may play a pivotal role in modulating the immunological tolerance necessary to minimise inappropriate inflammation in the cervix. there are several epidemiological and clinical studies that omega- fatty acids and related fish oils can decrease the premature labor and birth. however, the scientific mechanisms are not well elucidated. this study was carried out to investigate the effects of omega- fatty acids on producing pge and il- , in human umbilical vascular endothelial cell(huvec) media with artificial inflammation as an infection-induced premature labor tissue model. also, if there are some significant effects with omega- fatty acids, we want to investigate the possible mechanisms. materials and methods; human umbilical vascular vascular cell primary culture was done. in the adequate cell confluence in each cell dish, pretreatment with various concentrations of epa, dha and troglitazone (another ppar-ligand) and incubation were done for hours in °c, co incubator. after that, g/ml conc. of lipopolysaccharide(lps) was treated to the each cell dishes and incubated for hours. the cell media were collected, and pge and il- concentration were checked by elisa. the each cell lysates were collected and western blot anaysis for cyclooxygenase(cox)- were done. on the other hand, nuclear factor kappa b (nf b) luciferase vector was transfected and then did the same pretreatment with epa, dha and troglitazone and lps treatment to each cell dishes. after that, nf b luciferase activity was checked with luminometer. statistical analysis was done by student t-test. results: epa, dha and troglitazone decreased the pge (p< . ) and il- (p< . ) significantly in elisa. cox- expression revealed the significant reduction with pretreatment of epa, dha and troglitazone in higher concentration ( , m) in the western blotting (p< . ). nf b luciferase activity were also significantly decresed with pretreatment of epa, dha and troglitazone in higher concentration (p< . ). conclusion; this study offers some scientific mechanisms, by which omega- fatty acids (epa, dha) and troglitazone may be one kind of the preventive medicine for infection-induced preterm labor and delivery. also, these effects may come from the common mechanism of epa, dha and troglitazone, ppar-ligands. the next study would be how the cox- , nf b and pparare related. ( mg/ml). cytokine expression was measured in medium using the bio-plex suspension array system (bio-rad). mean expression was compared between the two groups using t test. results: -aminopurine significantly inhibited lps stimulated cytokine production by human myometrium. in contrast, there were no significant differences in expression after mpa treatment, although a trend towards inhibition of proinflammatory cytokine and an increase in il- production was noted. introduction: intrauterine infection is now recognised as a major antecedent of white matter injury (wmi) in the preterm infant brain, which can manifest later as cerebral palsy or as varying degrees of cognitive dysfunction. wmi in these infants is characterized by damage to immature oligodendrocytes, and has been linked both to microglial activation and to elevated levels of tnfa, il- b and il- . we have developed a fetal sheep model for diffuse and focal wmi, based on repeated administration of e. coli lipopolysaccharide (lps) as the stimulus for an inflammatory response. methods: surgery to implant fetal vascular catheters was performed on pregnant ewes carrying single fetuses at d - of gestation. fetuses received repeated iv injections of lps ( ng/kg estimated fetal weight/day) between d and d . plasma levels of pro-inflammatory cytokines were determined in fetal arterial blood samples taken between d and d . at d ewes and fetuses were euthanized and fetal brain tissue samples collected for histological analysis. results: five days after final administration of lps to fetuses we observed a pattern of wmi similar to that seen clinically, ranging from focal to diffuse injury within the periventricular region, impairment of white matter (cnpase; marker for immature/mature oligodendrocytes) tracts, and thinning of the corpus callosum, characterised by oligodendrocyte disruption and microglial proliferation in the surrounding and sub-cortical white matter. we also found a progressive rise in fetal plasma tnf levels between days and (day two of treatment to third day following final dose of lps). background: plasma fatty acid (fa) levels are associated with altered host inflammatory responses, blood pressure regulation, and insulin resistance, characteristic features of pregnancy-induced hypertension (pih). most studies compare the n- and n- polyunsaturated fatty acids (pufas). in addition, recent data demonstrate that saturated and trans-fas promote inflammation. based on the immunomodulatory activity of various fas, we explored their effects on placenta inflammatory responses ex vivo. methods: placenta cells were isolated from fresh human (anonymous), term placentas and treated with/without lipopolysaccharide (lps) with various fas, including saturated fas, trans-fas, and n- and n- pufas (at physiological concentrations). after an overnight treatment, tnf-alpha (tnf) production was determined. data were analyzed by analysis of variance (anova) followed by the dunnett's test. results: oleic acid ( : n- ), a cis-monosaturated fa common in the mediterranean diet, did not induce significant placenta tnf production (fig. a) . by contrast, elaidic acid ( : n- ), a trans-monosaturated fa, induced tnf production by -fold compared to vehicle (fig. a) . likewise, palmitic acid ( : ), a saturated fa, induced placenta tnf production by -fold (fig. a) . to mimic inflammation, placenta cells were treated with lps ex vivo in the presence/absence of fas. docosahexanoic acid ( : n- , dha) reduced placenta tnf production by up to % following stimulation (fig. b) . similarly, treatment of placenta cells with linoleic acid ( : n- , la) or arachidonic acid (n : n- , aa) suppressed tnf production by up to % and %, respectively (fig. b) . conclusions: both saturated fas and trans-fas, which positively correlate with hypertension, induce placental tnf production. the n- fa precursors to prostaglandins, aa and linoleic acid, reduce placental tnf production following stimulation. likewise, dha, a product of n- fa metabolism commonly consumed in fish oil and associated with improved blood pressure, suppresses tnf production by stimulated placenta cells. vegf and flk mediated glomerulogenesis in offspring exposed to maternal hypernatremia. roy z mansano, mina desai, ahmed abdel-hakeem, thomas r magee, tazmia q henry, cynthia nast, john s torday, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: growth restricted human and animal offspring, resulting from maternal nutrient restriction or uteroplacental insufficiency, consistently demonstrate reduced glomerular number and a predisposition to adult systemic hypertension and renal compromise. in contrast, maternal water restriction (wr) produces newborns with a unique programmed phenotype of increased glomerular number. glomerulogenesis is dependent, in part, on appropriately timed and quantified vascular development. as vegf and its receptor flk have crucial stimulatory effects on renal vasculogenesis, we hypothesized that maternal wr-induced morphologic renal changes are secondary to vegfmediated vasculogenic effects. methods: from day to term gestation, pregnant rats received either ad libitum food and water (control, n= ), or wr to produce an increment of meq/l in plasma sodium (n= ). following delivery, all dams received ad libitum food and water. at d after birth, offspring kidneys were extracted for mrna. vegf and its receptor, flk , mrna levels were determined using real-time rt-pcr (presented as fold difference normalized to s). at d after birth, offspring glomerular number were determined in formalin fixed m sections using histomorphometric analysis. values are means±se. results: wr offspring (day ) had higher glomerular number than control (wr ± , control ± per mm , p< . ). flk mrna expression was increased in wr offspring kidneys (wr . ± . , control . ± . , p< . ) as compared to controls. in contrast, vegf mrna expression in wr offspring kidney was comparable to control (wr . ± . , control . ± . , p= . ). conclusion:prenatally wr offspring demonstrate significantly increased glomerular number. as vegf recruits angioblasts to the developing glomerulus via its receptor flk , increased receptors (flk ) with the same level of the ligand (vegf) suggest that enhanced vasculogenesis may represent a putative mechanism for increased nephrogenesis in wr offspring. modulation of newborn vasculogenesis via vegf and flk expression may represent a therapeutic option for growth restricted offspring with decreased glomerular number. objective: maternal food restriction (mfr) during gestation (embryonic day to birth) reduces rat kidney glomerular number by % at weeks of age. undernutrition during human gestation leads to similar impaired nephrogenesis and increased hypertension in adults. renal development may be delineated into stages including ureteric bud branching, mesenchymal to epithelial transformation and glomerulogenesis. previously, we detected dysregulation of genes controlling nephrogenesis at gestational ages, e -e , suggesting that mfr has significant effects on ureteric bud branching. in the present study we evaluated the effect of this dysregulation on early nephron development in e fetal kidney explants from dams with mfr. methods: e fetal kidneys were collected from % mfr pregnant rats and ad libitum control rats (n= per group and time point), incubated in dmem/f k medium for , , , , and days, and fixed with % paraformaldehyde. kidneys were stained with fluorescein-labeled dolichos biflorus agglutinin (dba), images captured and terminal ureteric buds quantitated. all values are presented as mean ± sem. differences were considered significant at p< . . results: mfr ex-vivo kidneys at day demonstrated an initial moderate reduction in terminal branches versus control (c) samples (mfr: ± vs c: ± terminal branch ends per kidney). both mfr and control (c) kidneys demonstrated significant (p< . ) increases in branching in explant culture to maximum values at days (mfr: ± vs c: ± ). with increasing culture days, the percent reduction in mfr branching increased with terminal branch point decreases of % at day , % at day , % at day , % at day , and % at day (p< . , mfr vs c at day ). conclusion: kidney explant cultures from mfr treated fetuses display basal and culture-based decreased branching compared to controls. this decrease in terminal ureteric buds, in combination with our previous findings of dysregulation of branching-associated kidney transcription and growth factors, suggests mfr induces early (e ) dysregulation of branching as a major mechanism of the associated nephropenia. these results indicate that early programming events in kidney development induce nephropenia and renal disease in adults. intrauterine growth restriction (iugr) has important implications for the neonate not only at the time of birth, but also as an adult. in humans and animals with iugr, the elevated risk of developing hypertension is thought to involve an upregulation of the renin-angiotensin system (ras). however, the link between the intrauterine insult and enhanced ras is not known. a novel mechanism leading to hypertension has emerged recently involving two orphan g-protein coupled receptors (gcr and gcr ) and their endogenous ligands, succinate and -ketoglutarate. infusion of succinate into adult mice induces hypertension, an effect which was eliminated in gcr knockout mice or by pretreatment with ace inhibitors. interestingly, succinate levels have been shown to increase in the circulation under conditions of oxidative stress, one of the hypothesized mediators of developmental programming of hypertension. thus, we hypothesized that gcr and gcr are upregulated in a rat model of iugr and may contribute to in utero programming of hypertension. timedpregnant rats were fed either control (c, % casein) or low protein (lp, % casein) diet throughout gestation. kidneys were collected on embryonic day (e ), post-natal day (d ) or (d ), n . real-time pcr was used to compare gcr , gcr and renin expression. data were standardized to a housekeeping gene (s ) and are expressed as fold increase/ decrease compared to control. a student's t-test was used to determine significance between groups (p< . ). offspring from lp dams were significantly smaller at birth and did not display catch-up growth. in kidneys from lp fetuses, both gcr and gcr were significantly elevated compared with controls ( . fold and . fold respectively; p= . ), whereas renin was . fold lower. on post-natal d , there was a trend towards increased expression of both gcr ( . fold; p= . ) and renin ( . fold; p= . ) in offspring from lp dams. at d , there were no significant differences between groups. in conclusion, these preliminary data suggest that in iugr offspring from lp rats, the gcr / pathway may be enhanced, indicating a novel mechanism for the programming of hypertension. objective: in addition to excess adipose tissue, obesity is accompanied by increased fat storage in organs such as the liver. peroxisome proliferatoractivated receptors (ppars) are ligand-activated transcription factors involved in the regulation of lipid metabolism, and lipid-associated inflammatory response. obesity represents a state of chronic low-level inflammation, with ppar and ppar implicated in this process. we have previously shown that nutrient restriction in pregnancy results in intrauterine growth restricted (iugr) newborns which develop adult obesity with elevated c-reactive protein (crp) levels. as crp is derived from the liver, we hypothesized that iugr-induced obesity inhibition of hepatic ppar and ppar is associated with an increased inflammatory response. methods: control dams received ad libitum food, whereas study dams were % food-restricted from pregnancy day to to produce iugr newborns. all pups were nursed by control dams and weaned at weeks to ad libitum feed. at day and months of age, male offspring were analyzed for hepatic ppar , ppar and crp mrna (real time rt-pcr) and protein (western blot) expression. data was normalized to -actin and presented as fold change for protein levels. at months, hepatic triglyceride content was determined enzymatically. results: at d of age, iugr pups showed significant downregulation of ppar ( . -fold) and ppar ( . -fold) expression, though crp expression was significantly upregulated ( -fold). findings persisted at months of age, with continued downregulation of ppar and ppar ( . -fold) and upregulation of crp expression ( -fold). furthermore, iugr adults had significantly increased hepatic triglyceride content ( ± vs. ± mg/g liver, p< . ). conclusions: reduced expression of hepatic ppar and ppar in iugr offspring may contribute to elevated hepatic crp levels and triglyceride content. thus, developmental hepatic dysregulation leads to programmed obesity-induced inflammation in iugr offspring. offspring. mina desai, ederlen casillas, guang han, darran n tosh, , michael g ross. dept. of ob/gyn, labiomed at harbor-ucla med. ctr., torrance, ca, usa; dept. of physiology, univ. of adelaide, australia. objective: leptin and insulin mediate central anorexigenic signaling responses via different receptor molecules: leptin binds to the obrb receptor activating jak-stat and pi k pathways, whereas insulin activates pi k pathway by binding to its receptor (ir) and substrate (irs ). maternal food restriction in pregnancy results in iugr newborns that develop hyperphagia and adult obesity. the iugr newborns have significantly decreased plasma leptin levels with increased hypothalamic expression of basal obrb, stat and decreased expression of ir and irs , suggesting altered anorexigenic pathways. we studied the response of hypothalamic leptin/insulin signal molecules to peripheral leptin in iugr newborns. methods: control dams received ad libitum food, whereas study dams were % food-restricted from pregnancy day to . day old male offspring were given saline or leptin ( g/g, i.p). hypothalamus was dissected at , and minutes and protein expression of total stat , phosphorylated stat (p-stat ), inhibitor of leptin signal (socs ), ir, irs , total akt and phosphorylated akt was determined by western blot (normalized to -actin). data is compared between leptin and saline treatments in iugr and controls. results: in response to peripheral leptin, iugr newborns showed marked dysfunction in stimulated hypothalamic leptin and insulin signaling responses. ( ) jak-stat : leptin-treated controls show progressively increased pstat ( -fold) with initial suppression of socs ( . -fold) as compared to salinetreated controls. conversely in leptin-treated iugr, the pattern is reversed such that there is sustained decline in pstat expression ( . -fold) with failure to downregulate socs . ( ) pi k pathway: leptin-treated controls showed a significant reduction in irs ( . -fold) and pakt ( . -fold) as compared to saline-treated controls. however, leptin-treated iugr newborns exhibited a paradoxical increase expression of irs ( -fold) and pakt ( -fold). conclusion:the iugr offspring demonstrate persistent upregulation of leptin receptor, a reduced phosphorylated stat (p-stat ) response in conjunction with an enhanced socs- response. the persistent increase in insulin responses indicates a dysfunction in dynamic signaling, leading to altered anorexigenic response and development of programmed obesity. we have previously demonstrated that maternal food restriction (mfr) in rats induces a marked increase in the expression of vegf protein in the aorta and mesenteric arterioles, accompanied by an increase in tgf-and collagen in both vessel types in adult rat offspring (am j physiol, ) . the aim of this study was to determine if this in vivo finding could be reproduced in an in vitro preparation. methods: two types of preparations were used in this study. we isolated endothelial cells from week old male control rat aortas. these cells were used after the third passage. staining with von willerbrand factor demonstrated that these cells were pure endothelial cells. the second type of preparation was aortic explants from week old male control rats. endothelial cells and aortic explants were transfected with a vegf adenovirus ( - viral infective particles) or a -galactosidase-adenovirus as a control. after hours of culture protein was isolated from cells and explants for western blot analysis using rat specific antibodies. culture media was assayed for vegf by elisa. results: transfection of vegf adenovirus induced a dose-dependant increase in the expression of vegf protein in primary endothelial cells and aortic explants. the transfection of vegf into the endothelial cells showed a bell shaped curve, and was accompanied by an increase in media levels of vegf protein. maximal secretion of vegf was found with viral infective particles. vegf adenovirus transfection induced a dose-dependant increase in c-reactive protein (crp) (inflammatory marker), and tgf-protein in both aortic explants and primary endothelial cells. these results indicate that upregulation of vegf in blood vessels induces inflammation and tgf-expression which in turn can induce collagen synthesis. thus the increased collagen expression and reduced compliance previously reported by us in vessels of mfr offspring can be explained by the over-expression of vegf which we reported. therapeutic intervention aimed at prevention of the increase in vascular vegf expression in mfr offspring could potentially prevent programmed hypertension. maternal regulation of high fat nourishment during lactation period reduce a hypertension of male offspring. hidenori takahashi, toshiaki okawa, keiya fujimori, akira sato. obgyn, fukushima med.univ., fukushima, fukushima, japan. objective: exposure to undernutrition or high fat nourishment during fetal life has been proposed as an underlying cause of adult hypertension, but the effect of maternal feeding regulation during lactation period on blood pressure of offspring is unclear. our objective was to investigate the effects of either high-fat diet (hfd) during gestation to lactation period or restrictive fed a hfd during lactation period on blood pressure in male rat offspring. we use types pregnant wistar rats as fed with normal nutrition (group a), with a high fat diet (hfd) during gestation to lactation period (group b) and with hfd nutritionally restricted by feeding with % of the normal lactationmatched dietary intake from the day of delivery to the end of lactation period (group c). the male offspring was measured blood pressure at , and weeks by using indirect tail-cuff method. statically analysis was performed using oneway annova. results: body weight was significantly reduced in c offspring compared to a and b in male offspring at day after delivery (p< . ). at weeks old, the body weight of c offspring was no difference to catch up compared to a and b offspring. systolic and diastolic blood pressures were significantly elevated at all , and weeks in offspring of b > c >a. (p< . , vs. a) conclusions: under high-fat nutrition during gestation to lactation period induced hypertension in male rat offspring. maternal high fat environment make a hypertensive offspring, but regulation of fat feeding during lactation period may reduce adulthood hypertension. background: uterine artery (uta) doppler velocimetry has been validated in populations of heterogeneous parity in the second trimester for prediction of obstetric outcomes requiring preterm delivery to include: fetal growth restriction, fetal demise, hypertensive disorders of pregnancy, abruption, and indicated preterm delivery. understanding that parity may affect uta doppler indices in subsequent pregnancies, we sought to validate these predictive values in the first trimester in a homogeneous population of multiparous women. study design: multiparous women undergoing first trimester screening of singleton pregnancies were enrolled and followed prospectively until delivery (n= ). these women were divided into controls, ri < . (n= ) and cases, ri . (n= ), based on prior studies. demographic, clinical, and sonographic data (including uta indices and assessment of notching) were obtained. statistical analysis included student's t test and chi square. results: cases were not significantly different from controls in terms of maternal age, ethnicity, bmi, or medical history. uta doppler indices were significantly different between the two cohorts in terms of the presence of unilateral or bilateral notching ( % vs, % p< . and % vs. %, p< . , respectively). in contrast to that observed in patients of heterogenous parity previously, ri . was not associated with adverse pregnancy outcomes despite an average ri of . , significantly above this threshold. conclusions: in this multiparous cohort ri was not predictive of adverse obstetrical outcome, in contrast to that observed in cohorts including nulliparous patient. parity may affect uta vasculature and obscure the ability of doppler velocimetry to predict adverse obstetric outcome in multiparous women. presence of uta doppler notching in the first trimester remained a robust predictor of adverse obstetric outcomes in multiparous patients. objective: epidemiological studies have shown that offspring exposed to preeclampsia during fetal development are more susceptible to airway disease later in life. we have shown previously that gender, but not sflt- over-expression during pregnancy determines higher reactivity in the offspring airways at months of age. the objective of this study was to examine the effect of preeclampsia on the trachea from female and male offspring in our model of sflt- induced preeclampsia at year of age and compare responses between the two age groups. methods: cd- mice at day of gestation were injected via the tail vein with adenovirus carrying sflt (adsflt , pfu/ l) or mfc (admfc, pfu/ l). mice were allowed to deliver. tracheas were isolated from female and male offspring at months and year of age, and rings were mounted in organ chambers for isometric tension recording. responses to potassium chloride (kcl, mm), the mast cell degranulating agent compound / ( / , g/ml), and concentration-responses curve to acetylcholine ( - - - m) were obtained. results: there was no significant difference in responses to acetylcholine, kcl, or compound / between year old offspring born to the sflt and mfc groups. when comparing offspring within the same pregnancy exposure groups, responses to acetylcholine in adsflt -treated group were significantly higher in year old females than males. comparison between age groups by pregnancy exposure revealed that in the mfc group, year old male offspring had higher responses to compound / and acetylcholine than months old males. responses to kcl were significantly higher in months old males than year olds independent of maternal treatment during pregnancy. in females, the only difference between age groups was observed in the mfc group, where months old offspring demonstrated significantly higher responses to acetylcholine compared to year old offspring. conclusions: our findings did not show that airways of year old offspring born to mice with a preeclampsia-like syndrome induced by sflt- over-expression have airway hyperreactivity. however, sex and age differences in airway responses dependent on maternal exposure during pregnancy were observed, and needs to be explored further to elucidate underlying mechanisms. objective: maternal food restriction (fr) results in iugr newborns that when normally nursed exhibit rapid catch-up growth and adult obesity. continued fr during nursing delays catch-up growth and prevents adult obesity. igf- , which modulates growth and is secreted by the liver, may contribute to these morbidities. igf- is epigenetically regulated involving two promoters, alternative exon splicing and multiple transcription termination sites. we determined if hepatic igf- mrna levels correlate with obesity, and whether these changes are due to programmed epigenetic modification. methods: control pregnant rats received ad libitum food from gestation day to and lactation, whereas study dams were % fr. fr pups were nursed by either control (fr/adlib) or fr dams (fr/fr) and weaned to ad libitum feed. at day and months, male livers were analyzed for igf- mrna variant levels (real time rt-pcr). chromatin immunoprecipitation (chip) was performed using the antibody for h k trimethyl, and associated levels of each igf- species were measured by pcr. results: at months, obese fr/adlib males showed increased mrna levels of igf- a, igf- b, igf- exon , and igf- exon as compared to controls ( ± , ± , ± , and ± %). comparing fr/adlib month to newborn offspring, h /k was increased at igf -promoter , promoter , exon , utr# and utr# ( ± , ± , ± , ± , and ± %), though there was no differences between control month and newborns. in contrast, month fr/fr males had comparable mrna levels to the controls except for igf- b (% of control: ± ). further, fr/fr month h /k was only different from newborns at utr# (% of newborn: ± ). conclusion: iugr newborns with rapid catch-up growth and adult obesity have increased postnatal hepatic igf- mrna levels, likely a result of igf- histone and chromatin structure modifications to h k trimethylation. conversely, iugr with delayed catch-up growth and absence of adult obesity have levels similar to that of controls. thus, modulation of the rate of iugr newborn catch-up growth may protect against igf- epigenetic modifications. introduction: igf-ii is synthesized as a pro-hormone (proigf-ii; -amino acid peptide) which is then processed into its active forms: "big" igf-ii ( - ) and mature igf-ii ( - ). these active forms are essential for placental and fetal development and have also been shown to persist into postnatal life. since maternal smoking is known to adversely affect feto-placental growth and postnatal development, we postulated that these effects might be mediated through nicotine-induced alterations in igf-ii processing. methods: in the present study, nulliparous female wistar rats ( - g) were given nicotine ( mg/kg/day) or saline for days prior to mating, during pregnancy, and throughout lactation. at gestational day , and , dams were euthanized and we collected serum (fetal and maternal), amniotic fluid and recorded fetal body weight. a subset of dams were allowed to deliver at term. following parturition, serum samples from the offspring were collected at birth (pnd ) and weaning (pnd ). body weight was recorded weekly from birth to weaning. pro, "big" and mature igf-ii levels were determined by western blot analysis. results: maternal nicotine exposure during pregnancy resulted in a significant reduction in fetal body weight by gestational day . however, there was no effect of nicotine on fetal serum or amniotic fluid igf-ii levels at any gestational age examined. in maternal serum, mature igf-ii in control animals decreased with advancing gestational age such that igf-ii levels were lowest at gestational day . nicotine administration prevented this decline, which resulted in significantly higher mature igf-ii levels in nicotine-exposed mothers at gestational day . in postnatal life, nicotine exposed offspring had significantly lower levels of "big" igf-ii expression at weaning (pnd ). conclusions: these data demonstrate that nicotine can alter the amount of the active forms of igf-ii in the mother and the newborn. dysregulation of maternal igf-ii occurs concomitantly with suboptimal fetal growth. results from this study suggest a mechanism by which maternal smoking causes impaired fetal growth and adverse postnatal health outcomes. objective: maternal food restriction in pregnancy results in iugr newborns which develop adult metabolic syndrome. programming of both increased appetite-mediated hyperphagia and enhanced adipogenesis contribute to the development of obesity. transcription factors, peroxisome-proliferatoractivated-receptor (ppar ), ccaat/enhancer binding-protein (c/ebp ), and sterol regulatory element binding-protein (srebp c) regulate adipogenesis and lipogenesis. although iugr offspring exhibit acute upregulation of the adipogenesis signaling cascade prior to the development of obesity, we determined if this increased adipogenic potential was an intrinsic cellular response, and thus maintained in cell culture. we further examined the responses to adipocyte stimulators (ppar activator-ligand rosiglitazone) and inhibitors (ppar repressor-ligand badge). methods: control dams received ad libitum food, whereas study dams were % food-restricted from pregnancy day to term. adipocytes from day old iugr and controls were isolated and cell proliferation rate was determined (mtt). primary adipocyte cell cultures were established and following % confluence, iugr and control adipocytes were treated to two doses ( and m) of either rosiglitazone or badge for h. mrna and protein was extracted for expression of ppar , c/ebp , srebp c. data was normalized to -actin and compared to the respective untreated cells. results: iugr adipocytes had significantly increased protein expression of ppar ( . -fold) and c/ebp ( -fold) as compared to control adipocytes, though srebp c levels were unchanged. mrna levels showed similar changes in iugr newborns. importantly, iugr adipocytes exhibited increased cell proliferation ( % of control, p< . ) and showed greater response to rosiglitazone ( . -fold), though similar response to badge, as the control adipocytes conclusion: iugr primary adipocytes cell culture exhibit basal phenotypic characteristic of programmed upregulation of adipogenic transcription factors which promote adipose cell proliferation. the enhanced response to the adipogenic stimulant is further evidence of the predisposition to obesity. in contrast, the normal suppressive response to the inhibitor suggests that iugr adipocytes may respond to pharmacologic approaches to prevent obesity during this period. objective: maternal nutrient restriction results in intrauterine growth restricted (iugr) newborns which develop programmed obesity despite a normal post-weaning diet. the epidemic of obesity has been attributed in part to programmed "thrifty phenotype" and exposure to "western" diets. hepatic igf- is epigenetically regulated involving two promoters, alternative exon splicing, and multiple transcription termination sites. iugr offspring with normal post-weaning diet have increased postnatal hepatic igf- mrna levels, likely a result of igf- histone and chromatin structure modifications to h k trimethylation. we hypothesized that iugr newborns that develop programmed obesity would demonstrate discernable hepatic igf- changes which are distinct from diet-induced obesity. we determined igf- hepatic mrna levels and epigenetic characteristics in programmed (iugr) and dietinduced (dio) offspring. methods:: control pregnant rats received ad libitum food whereas study dams were % maternal food restricted from day to . all pups were nursed on ad libitum fed dams. controls were weaned to high-fat (fat, %) diet whereas iugr were weaned to normal ad libitum diet (fat, %) to produce diet-induced (dio) and programmed obese groups, respectively. at months, male hepatic igf- were analyzed for igf- mrna variant levels (real time rt-pcr). chromatin immunoprecipitation (chip) was performed using the antibody for h k dimethyl and h k trimethyl, and associated levels of each igf- species were measured by pcr. result: relative to dio control males, iugr had increased mrna of igf- a, exon and exon ( ± , ± , ± %). chip with h k dimethyl showed increased igf- exon ( ± %) and with h k trimethyl, increased igf- promoter and promoter ( ± , ± %) as compared to dio controls. conclusion: adult obese iugr males exposed to normal postweaning diet have increased hepatic igf- a mrna and h k dimethylation and trimethylation of igf- than dio controls. changes in igf- in adulthood from a prenatal insult thus suggest that igf- is programmed during the fetal period and may be associated with programmed adult obesity. rebekah elkins, pandu gangula, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa; internal medicine, university of texas medical branch, galveston, tx, usa. objectives: we previously reported that the offspring of rats fed % protein during gestation develop hypertension at two to four months and that the hypertension is exacerbated in males. this study is to evaluate: ) changes in estrogen receptor (er) angiotensin ii subtype receptor (at -r) and endothelial nitric oxide synthase (enos) in the mesenteric artery and aorta of offspring and assess if these changes, if any, are gender specific. methods: pregnant sprague dawley rats were fed either % protein (ctrl) or % protein (lpd) from day of gestation. the offspring were evaluated for hypertension by means of systolic blood pressure measurements. at four months for the males and nine months for the females, mesenteric artery and aorta were collected in rnalater. expression of estrogen receptor a (er-a) and b (er-b), at -r, and enos were analyzed by western immunoblotting and rt-pcr and expressed relative to b-actin or s. results: mesenteric artery shows no differences between ctrl and lpd female offspring in at -r, enos, er-a or er-b. similarly mesenteric artery shows no diet exposure related changes in at -r, er-a or er-b in male offspring. however, enos expression was lower in mesenteric artery of lpd male offspring. on the other hand, in the aorta both er-a and er-b levels are lower in lpd female offspring while there were no changes in at -r or enos. no changes in at -r, er-a or er-b were observed in male offspring aorta of ctrl and lpd rats. conclusion: the in utero exposure to lpd results in adult hypertension in both male and female offspring. some mechanisms for hypertension include the decrease in er-a and er-b but not at -r or enos in females, and the decrease in enos but not at -r or er in males indicating gender related differences. offspring. hidenori takahashi, toshiaki okawa, keiya fujimori, akira sato. obgyn, fukushima med. univ., fukushima, fukushima, japan. our objective was to investigate the effects of either severe undernutrition during late gestation or lactation period on blood pressure and the development of vascular function in male rat offspring. we use normal pregnant wistar rats (group a), nutritionally restricted by feeding with % of the normal gestation-matched dietary intake from day of gestation to delivery (group b) and % restricted after delivery to the end of lactation period (group c). the offspring was measured blood pressure at and weeks by using indirect tail-cuff method. rings of thoracic aorta with intact endothelium from the male offspring of a and b at weeks, were equilibrated at g passive tension in organ chambers filled with krebs-henseleit solution continuously bubbled with %co in air ( °, ph . ) for isometric tension recording. concentration-response relationships to norepinephrine (ne) and angiotensinii(atii) were obtained in the absence or presence of n(omega)-nitro-l-arginine methyl ester (l-name) or a selective atii type- receptor blocker (valsartan). responses to cumulative concentrations of sodium nitroprusside (snp) and to - m oxyhemoglobin (hb, nitric oxide scavenger) were also determined. contractions were expressed as a percent of the reference contraction induced by potassium chloride ( mm). statically analysis was performed using one-way annova. results: body weight was significantly reduced in b offspring compared to a and c in male offspring at day (p< . ). at weeks the body weight of offspring of b was no difference to catch up compared to a and c offspring. systolic and diastolic blood pressures were significantly elevated at both and weeks in offspring of b > c >a. ne concentration-dependently stimulated tension of aortic rings from in a and b offspring, which was not significantly (n= ). maximal contractions to ne were significantly stimulated by l-name in a (p< . ), but not b offspring. valsartan significantly inhibited aortic contractions by ne in r (p< . ), but not a offspring. there was no significant difference on responses of aortic rings by atii, snp and hb in a and b offspring. conclusions: severe under nutrition during not only late gestation but also lactation period induced hypertension in male rat offspring in adulthood. fetal origin of adult hypertension might be vascular endothelial dysfunction. fujimori, akira sato. obgyn, fukushima med. univ., fukushima, fukushima, japan. objective: exposure to undernutrition during fetal life has been proposed as an underlying cause of adult hypertension, but the effect of either high fat nourishment or undernutrition during lactation period on blood pressure is unclear. our objective was to investigate the most effective maternal nourishment and feeding period for offspring induced adulthood hypertension in using high-fat diet (hfd). study design: we use types pregnant wistar rats as fed with normal nutrition (group a), nutritionally restricted by feeding with % of the normal gestation-matched dietary intake from day of gestation to delivery (group b), % restricted after delivery to the end of lactation period (group c), with a high fat diet (hfd) during gestation to lactation period (group d) and with hfd nutritionally % restricted from the day of delivery to the end of lactation period (group e). the offspring was measured body weight (bw) and measured blood pressure at , and weeks by using indirect tail-cuff method. statically analysis was performed using one-way annova. results: bw was significantly reduced in b offspring compared to another (a, c, d, e) male offspring at day (p< . ). at day after delivery, bw was significantly reduced in c, e offspring compared to a, d in male offspring (p< . ). at weeks old, bw of all type offspring was no difference. systolic and diastolic blood pressures were significantly elevated at weeks in offspring of d> b > e > c >a. (p< . , vs. a). at weeks, hypertensive offspring as b>d>e>c>a (p< . , vs. a). at weeks, d> e > b > c >a (p< . , vs. a). conclusions: maternal high fat environment make a hypertensive offspring, but regulation of fat feeding during lactation period may reduce adulthood hypertension. in case with normal food, restrictive feeding during late gestation is more effective than lactation period for inducing hypertensive male offspring. regulation of maternal feeding not only during late gestation but also lactation period may control adulthood hypertension. the strongest epigenetical factor of maternal nutrition is high fat feeding during pregnancy to lactation period for f blood pressure, respectively. or residence at high altitude, impacts fetal growth and development. in a preliminary study, we observed a significant decrease in birth weight, subsequent compensatory postnatal growth, and an increase in relative right ventricular (rv) weight at postnatal (pn) day in female offspring of rats exposed to hypoxia ( , ft; . % po ) from days thru of gestation (dga). thus, our objective was to further elucidate the impact of prenatal hypoxia on fetal growth and postnatal development. methods: pregnant dams (hx, n= ) were hypoxic from - dga with additional control dams either fed ad libitum (al, n= ), pair-fed with the hx dams throughout gestation (pg, n= ), or only pair-fed during the window of hypoxia (ph, n= ). female offspring from hx, pg, and ph dams were cross-fostered onto additional al dams (n= /litter) by h after birth. results: at birth, there was no difference in litter size; however, body weight (bw) of the hx, pg, and ph pups was lower (p< . ) than that of al pups, and hx pups were lighter (p< . ) than ph pups. weight of hx offspring remained lower (p< . ) than al pups until the termination of the study at pn , while the pg and ph pups reached weights comparable to the al offspring by pn . relative to bw, heart weight and left ventricular/septal (lvs) weight was not different among groups; however, right ventricular weight (rv/bw) was greater (p< . ) in the hx offspring at pn as was rv/lvs (p< . ). cardiac function was evaluated by echocardiography at pn . rv wall thickness was % greater (p< . ) in hx pups as compared to al pups, confirming the significantly higher relative rv weight observed at necropsy. pep, pep/at, and pep/et were %, %, and % higher respectively in the hx offspring relative to the al offspring. lv end diastolic and end systolic diameters were smaller (p< . ) in hx and ph offspring relative to the al group. myosin heavy chain (mhc) and mrna concentrations in the rv were evaluated by qrt-pcr, and the mhc / mrna ratio was greater (p< . ) in the hx pups. conclusion: prenatal hypoxia from - dga impacted both fetal and postnatal growth, altered postnatal heart development and function, with the primary impact being on the rv. supported by nih hd . reproductive sciences; pharmacology experimental therapeutics, university of maryland, baltimore, md, usa. background: exposure to nicotine (nic) is a significant risk to normal fetal development. fetal nic, which readily crosses the placenta, can be acquired from pregnant mothers by smoking or nicotine replacement therapy. the impact of nic on fetal organs may be mediated directly and/or via intrauterine hypoxia (hpx) via constriction of the uterine circulation. in adult hearts, both nic and hypoxia stimulate gene expression of matrix metalloproteinases (mmp), although the study of nic and hypoxia on gene expression in fetal organs remains incomplete. because mmps are involved in the regulation of extracellular matrix turnover and cardiac remodeling, we tested the hypothesis that prenatal nic and intrauterine hpx upregulate protein expression and activity of mmp in the fetal guinea pig heart. methods: pregnant guinea pigs were placed in either normoxia (nmx) or hpx ( . %o in chamber) for d prior to term ( d). in two separate groups, nic was also added to the drinking water ( mg/kg/d) for d at a dose that generates fetal nic levels ( ng/ml cotinine) equivalent to a moderate smoker. anesthetized near-term fetuses ( d) were excised and weighed. left ventricles of hearts were obtained and frozen at - c for storage. mmp protein levels and enzymatic activity were measured by western analysis and gel zymography, respectively. results: nic alone (nmx+nic) decreased (p< . ) fetal body wt by %, increased (p< . ) the relative fetal brain wt (brain wt/fetal body wt ratio) by . % and had no effect on relative placental or fetal heart wts. hpx alone decreased (p< . ) fetal body wt by . %, increased the relative fetal brain wt by % but, in contrast to nic alone, increased relative placental wt by . %. both mmp protein levels (mmp /a-actin density values) and activity (clear band density) were increased (p< . ) by nic alone (by . and . fold, respectively) and hpx alone (by . and . fold, respectively). in addition, both protein and activity levels of hpx hearts were further increased by nic (by . and . fold) compared to hpx alone. conclusion: prenatal nic upregulates mmp expression in nmx fetal hearts and is potentiated by hpx. this suggests that under conditions of intrauterine stress cardiac remodeling by mmp activation may be an important mechanism by which nic and hpx affect fetal heart function. objective: in addition to peripheral hypoglycemic effects, insulin induces central anorexigenic responses via stimulation of the phosphoinositide- kinase (pi k) pathway and cellular growth by mitogen activated protein kinase (mapk) pathway. the pi k signaling cascade is activated by insulin binding to its receptor (ir), recruiting ir substrate (irs- ), and phosphorylating pi k. activated pi k in turn causes phosphorylation of protein kinase b/akt which subsequently modulates hypothalamic anorexigenic responses. in contrast, the mapk (erk /erk ) signaling pathway likely involves irs- . further, insulin signaling is inhibited by the lipid phosphatase pten. we have previously shown that maternal food restriction (mfr) during pregnancy results in iugr newborns that develop hyperphagia, obesity and insulin resistance as adults. we sought to determine if altered hypothalamic basal insulin signaling expression of pi k and mapk pathways contribute to reduced satiety responses and thus enhanced growth in iugr newborns methods: pregnant control dams received ad libitum (n= ) food, whereas study dams were % mfr (n= ) from pregnancy day to to produce iugr newborns. at day , hypothalamic region was dissected and analyzed for mrna levels (real time rt-pcr) of insulin signaling components via pi k (ir, irs , pi k and akt) and mapk (irs , erk , erk ) pathways, and pten. data is presented as fold difference normalized to beta- -microglobulin. results: at d of age, iugr pups exhibited downregulation of the entire pi k pathway with significantly decreased (p< . ) mrna levels of ir ( . -fold), irs- ( . -fold), pi k ( . -fold) and akt ( . -fold). further, iugr pups showed similar decreased mrna expression of erk ( . -fold) and erk ( . -fold). however pten expression was similar to the controls. conclusion: reduced insulin-mediated pi k signaling likely contributes to the suppressed anorexigenic responses and development of obesity in iugr offspring. reduction of central mapk signaling suggests a potential maldevelopment of additional neuronal pathways in iugr offspring. objectives: in the rat, uteroplacental insufficiency restricts fetal growth and impairs mammary development further compromising postnatal growth. both male and female growth-restricted offspring have a reduced nephron endowment but only males develop hypertension with glomerular hypertrophy, which can be reversed by improving the lactational environment. this study used cross-fostering to assess the influence of the prenatal and postnatal environments on renal development and nephrogenesis. methods: bilateral uterine vessel ligation (restricted, r) or sham surgery (control, c) was performed on day of gestation in wky rats. control and restricted pups were cross-fostered onto c or r mothers on postnatal day (pn ). post mortem was carried out on pn (c and r) and pn (c-on-c, c-on-r, r-on-c, r-on-r). results: body and kidney weights were decreased in r and r-on-r pups on pn and pn (p< . ). there was some evidence of accelerated pup growth for r-on-c relative to r-on-r on pn . male, but not female, relative bmp mrna expression on pn was higher in r than c (p< . ) while gdnf, tgf and at receptor were not different. on pn , wnt (but not at r, vegf-a) mrna expression (males only) was relatively higher in r-on-r (p< . ) when compared to c-on-c (p< . ). this and the histological analyses suggests an up-regulation of nephrogenic activity with more immature nephrons (males and females) in r-on-r (p< . ) when compared to c-on-c, while r-on-c remained intermediate. intrauterine growth-restricted pups were born lighter and with smaller kidneys. this was partially rescued by improving lactational nutrition (r-on-c) at pn . higher bmp mrna expression indicates impaired branching morphogenesis in pn r male, but not female kidneys, suggesting the timing and/or molecular mechanisms underlying the nephron deficit may be sex specific. at pn there was evidence of extended and increased nephrogenic activity in r-on-r, however, this was unable to restore the later nephron deficit. improved lactation for r-on-c, which prevented the adult nephron deficit and hypertension, increased and extended nephrogenesis to a lesser degree than r-on-r suggesting that the restoration of nephron endowment was likely to have occurred prior to pn . amy m tetrault, sarah b lieber, marya shanabrough, tamas l horvath, hugh s taylor. obstetrics, gynecology and reproductive sciences, yale university school of medicine, new haven, ct, usa. objective: classically recognized for its role in energy balance, body weight and appetite, ghrelin has also been implicated in reproduction. ghrelin (-/-) mice are infertile while administration of ghrelin to wt mice results in decreased litter size and constrained embryonic growth. here we investigate the effect of maternal ghrelin deficiency on in utero developmental programming of the female reproductive tract. hox genes determine developmental identity of the paramesonephric duct. we determined that hoxa is regulated by ghrelin in vitro and that in utero ghrelin deficency alters f hoxa gene expression and reproductive success. methods: wild-type females mice parented by ghrelin +/-b d f (ghrellin deficient) mice were analyzed for litter size, oocyte, and corpus luteum number. rna was extracted from the uterus of mice exposed to ghrelin deficiency in utero. ishikawa cells were treated with ghrelin with/without receptor (ghsr) antagonist, or saline and rna extracted. in both hoxa expression was analysed by real time rt-pcr normalized to -actin and also determined by ihc. experiments were repeated in triplicate and mrna expression compared by student's t-test. results: wild-type female offspring of ghrelin deficient dams had smaller litter sizes than controls (n= , . ± . pups; n= , . ± . pups, respectively; p< . ). no differences were seen in oocyte or corpus luteum number suggesting a uterine defect. hoxa mrna and protein expression were decreased in the uterus of the f females. ghsr was expressed in uterine endometrium. treatment of ishikawa cells with nm to nm ghrelin resulted in a to % increase (p< . ) in hoxa expression. treatment with ghrelin and ghsr antagonist resulted in similar increases in hoxa expression indicating a non-receptor mediated mechanism. conclusion: ghrelin contributes to reproductive tract developmental programming; in utero ghrelin deficiency compromises reproduction in female offspring. the developmental effects of ghrelin were mediated by alteration in hox gene expression and not through the classic ghsr receptor. obesity and decreased ghrelin may lead to defects in developmental programming of the reproductive tract. these findings demonstrate the importance of nutrition, energy utilization and appropriate ghrelin levels on normal uterine development. we have previously studied the deleterious effects of lack of the endothelial nitric oxid synthase (nos ) in mouse dams and their offspring. our laboratory demonstrated that adaptive responses in subsequent pregnancies may offset the harmful effects of the genetic deficiency of nos . in this study we aimed to determine hepatic and renal histopathologic damage in nos deficient pregnant mice comparing animals carrying their first versus their second pregnancy. study design: gravid nos +/+wt and nos -/-ko mice during their first (p ) or second (p ) pregnancy were sacrificed at day of gestation. livers and kidneys were stained and analyzed for the presence and extent of histopathologic lesions. results: nos +/+wt dams displayed a low incidence of significant renal or hepatic lesions in either the first or the second pregnancy. in nos -/-ko mice the incidence of liver necrosis and inflammation during the first pregnancy was % and %, respectively. in nos -/-ko dams sacrificed during the second gestation the incidence rates for the same lesions were % and %, respectively (p< . ). this correlation persisted when we analyzed the relative severity of hepatic lesions between p and p animals. although a similar trend was observed, the difference between p and p animals with regards to kidney lesions did not reach the level of statistical significance in our study. conclusions: a second pregnancy in this animal model of hypertension was associated with a significantly improved hepatic histopathology compared with the first pregnancy. this observation is consistent with our previous studies showing a decrease in systemic vascular resistance in p versus p nos -/-ko mice. the beneficial effects of a prior pregnancy may partially underlie the phenomenon of a decreased risk of preeclampsia in multiparous versus nulliparous women. further studies are required to delineate the counterregulatory mechanisms leading to improved cardiovascular function in subsequent pregnancies in these genetically modified animals. maternal hypomethylation is associated with congenital heart defects in down syndrome. lmjw van driel, , r de jonge, wa helbing, bd van zelst, j lindemans, eap steegers, rpm steegers-theunissen. , , , obstetrics gynecology; pediatrics; clinical chemistry; epidemiolog y biostatistics; clinical genetics; erasmus university mc, rotterdam, netherlands. background: maternal age and hyperhomocysteinemia are risk factors for having a child with down syndrome (ds) and congenital heart defects (chds), respectively. evidence is rising that ageing is associated with a state of hypomethylation. objectives: to investigate whether the risk of a child with ds and chd is associated with maternal hypomethylation. methods: we conducted a case-control triad study at months after the index-pregnancy. case-children (n= ) were included if they had ds and chd. children (n= ) without a major congenital malformation served as controls. the concentrations of s-adenosyl methionine (sam), s-adenosyl homocysteine (sah), sam/sah ratio, and homocysteine in maternal blood were measured as biomarkers for methylation. the data were analyzed using the mann-whitney u test and a logistic regression model. results: maternal age was included in the model as potential confounder. the levels and the crude and adjusted or( %ci) of the biomarkers are shown in table . an increase of the sam/sah ratio with unit decreases the risk of a child with ds and chd with percent. moreover, every increase of mol/l of homocysteine . fold increases this risk. conclusions: maternal hypomethylation is significantly associated with an increased risk of having a child with ds and chd. since, the effects are confounded by maternal age, hypomethylation can be considered as feature of ageing. the developmental origins hypothesis postulates that during critical ontogenetic periods, transient environmental stimuli perturb developmental pathways and induce permanent changes in gene expression, metabolism, and chronic disease susceptibility. one likely mechanism is via early nutritional influences on epigenetic gene modification consisting of the presence of a methyl group on the carbon of a cytosine residue. this modification is responsible for an important form of gene regulation in eukaryotes. in the present study, we have tested the hypothesis that maternal low-protein diet altered epigenetic regulation of specific gene of the offspring. c bl/ female mice were mated and on the day the plug was detected, these females were then randomly allocated to be fed isocaloric diets consisting % protein or % protein. at delivery, offspring were killed and the livers were removed immediately, frozen in liquid nitrogen and stored at - c. genomic sequencing after bisulfite modification is used to study site-specific dna methylation. dna methylation status of oct- and sphk- gene upstream regions in the mouse liver was analyzed. hepatic oct- or sphk- promoter methylation was not significantly different between both groups. however, dna methylation pattern of the genomic dna is specific in low-protein diet group. aberrant oct- and sphk- gene expression may cause perturbations in cell differentiation. we suggest that the epigenetic mechanism consisting of dna methylation underlies the fetal programming theory. primary human cytomegalovirus (hcmv) infection during pregnancy can have devastating consequences for both the mother and fetus. hcmv infection has been implicated in the development of pre-eclampsia and intrauterine growth retardation (iugr), as well as congenital cmv syndrome in newborns exposed in utero. previously, we have shown that hcmv infection of placental cytotrophoblasts inhibits their normal invasion, proliferation, and migration. however, the mechanisms occurring during early establishment of placental infection are largely unknown. we assessed the impact of hcmv infection on cytotrophoblasts by performing immuno-based assays for various cytokines and cellular growth factors. we detected significant cytokine dysregulation at both and hours after in vitro hcmv infection of cytotrophoblast cells. soluble cytokines involved in recruitment of monocytes and macrophages (gro-a, mcp- ) were downregulated at both and hours after infection. sdf- , which is chemotactic for lymphocytes during early inflammation, was also decreased. these results suggest that recruitment of cells involved in the anti-viral immune response is being interrupted early in the course of infection by hcmv. additionally, a large decrease in the amount of soluble hgf was seen. hgf normally induces migration of cytotrophoblasts along the invasive pathway, and downregulation of this factor could severely affect these processes. finally, we saw increased amounts of soluble icam- , contrasted by decreased amounts of vcam- , indicating dysregulation of adhesion molecules that are necessary for successful placental invasion to occur. all together, these data indicate significant alterations in cytokine profiles as early as hours after hcmv infection, which could provide important clues to the pathogenesis of hcmv in placental invasion and inflammation. additional studies will further elucidate this dysregulation, and determine whether these effects are due to alterations in pre-existing cellular factors or if transcriptional alterations are involved. method: studies were performed in pregnant ewes (n= in each group) with twin fetuses at - days (very preterm) and - days (near-term). neither mother nor fetuses were instrumented prior to the time of blood collection. maternal blood was collected from the jugular vein before sedation. anesthesia was then induced with isofluorane, the abdomen was opened, fetuses exteriorized and blood collected from umbilical cords. blood samples were transferred to plastic tubes containing ethylene-diamino tetraacetic acid and reduced glutathione, plasma separated and stored at - c. commercial radioimmunoassay kits for ovine-crf (phoenix pharmaceuticals, b : . ± . pg/ml) and cortisol (diagnostic laboratory, b : . ± . ng/ml) were used according to the manufacturer's instructions. results: in very-preterm gestations, maternal and fetal plasma crf levels were undetectable. maternal, but not fetal, plasma cortisol levels were measurable ( ± ng/ml). in near-term gestations, both cortisol and crf were measurable in maternal (crf: ± pg/ml; cortisol: ± ng/m) and fetal plasma (crf: ± pg/ml; cortisol: ± ng/ml). plasma crf levels were higher in nearterm fetuses than in their maternal ewes (p < . ). conclusion: ovine plasma crf levels are measurable in maternal and fetal plasma in near-term but not very-preterm gestations. the absence of crf in preterm plasma, perhaps due to reduced placental expression and/or placental crf release, may contribute to the rarity of in utero meconium passage in preterm gestations. interleukin - objectives: interleukin- (il- ) is a pro-inflammatory cytokine produced in adipose cells. recent studies suggest il- may be a marker of maternal obesity and in utero fetal programming. our hypotheses were ) il- correlates with maternal obesity and ) il- mediates the effect of maternal obesity on infant birth weight. methods: the parity, inflammation, and diabetes (pid) study is a longitudinal study of adipokine levels in a diverse sample of pregnant women. we present a cross-sectional analysis of first trimester il- levels from non-diabetic women who underwent a live birth. the independent variable was il- (pg/ml), measured with monoclonal antibody elisa assays. the dependent variable was infant birth weight (gms). maternal bmi categories were: normal/underweight (< kg/m ); overweight ( - kg/m ); and obese (> kg/m ). data on demographic and clinical factors, nutrition and physical activity were collected at baseline. average il- levels were compared across bmi categories using anova. the association of il- levels with infant birth weight was estimated using multiple linear regression, adjusting for covariates. results: average il- levels were significantly higher in obese women ( . ± . ) compared to overweight ( . ± . ) and normal/underweight women ( . ± . ) [p< . ]. after adjustment, il- levels was positively correlated with pre-pregnancy bmi [regression coefficient (rc) . ; % ci: ( . , . )]. as shown in the table below, elevated levels of il- were statistically significantly associated with a . gm higher infant birth weight after full adjustment. each unit increase in pre-pregnancy bmi was associated with a gm higher infant birth weight. table . association of il- with infant birth weight characteristic regression coefficient % confidence interval interleukin- . . , . pre-pregnancy bmi . , gestational weight gain - - , bmi = body mass index; coefficients adjusted for demographics, clinical factors, pre-pregnancy bmi, gestational weight gain, non-fasting first trimester glucose levels, gestational age, nutritional intake and physical activity conclusion: il- and pre-pregnancy bmi were associated with infant birth weight after adjustment for covariates. our findings suggest that the effect of maternal obesity on infant birth weight may be mediated through il- or an alternative independent pathway. we have demonstrated that -tetrahydrocannabinol (thc), in physiologically relevant concentrations, inhibits the growth and tight transcriptional control of the bewo trophoblast cell line . the mechanism involved the decreased expression of the transcriptional regulator histone deacetylase (hdac ). in these experiments we sought to answer the question, 'does anandamide (aea) work in the same manner as thc?' methods: the first trimester human trophoblast cell, bewo were plated at or x cells /well to -well and -well plates for growth and rna experiments, respectively. after growing to - % confluence, cultures were treated with varying concentrations of aea up to a maximum of m for hr. cell numbers were determined using the xtt apoptosis/proliferation assay. total cellular rna was prepared and the relative levels of hdac and gapdh determined by end-point rt-pcr. aea exhibited an inhibitory effect on the bewo cell cultures, but only at concentrations in excess of m where confluency was significantly reduced from % at m to - % at m and m (*p< . ; one-way anova with tukey's hsd test; n= ). cultures treated with m and m aea did not exhibit increased cell death or failure to attach to the substratum, as evidenced by the lack of increase in the shedding of cells into the spent medium. bewo cells treated with aea showed a dose-dependent decrease in hdac mrna expression with a significant effect at . m (*p< . ; oneway anova with tukey's hsd test; n= ). at this dose, the effect of aea had reached an effective maximum decrease in hdac mrna levels ( %) because hdac mrna levels were not decreased further by either m aea ( %) or m aea ( %). the alteration of hdac gene expression by aea in bewo cells with its associated decrease in cell number suggest that the trophoblast cell may be an important target for circulating endocannabinoids during the st trimester of pregnancy. the data indicates that although exocannabinoids and endocannabinoids both inhibit bewo cell growth, they do so using different transcriptional mechanisms. further understanding of the mechanism(s) by which aea alters placental physiology may lead to new strategies for the prevention of pregnancy complications such as st trimester miscarriages. ( ) taylor background: anandamide (aea) exerts its effects by acting on two cannabinoid receptors, cb and cb with the main regulator for aea levels being the metabolising enzyme, fatty acid amide hydrolase (faah). aea, cb , cb and faah constitute the endocannabinoid system and previous studies have shown that faah and cb are expressed in term human placenta( ) suggesting that the endocannabinoid system might be present earlier in gestation. this study aimed to document changes in faah, cb and cb expression in the placenta during the first trimester of pregnancy. methods: first trimester samples ( to weeks gestation) were fixed in % neutral-buffered formalin for days before embedding into paraffin wax or frozen in liquid nitrogen for rna analysis. for immunohistochemistry, faah polyclonal antibodies were used at an optimal dilution of : in pbs, cb at : and cb at : . transcripts were measured using q-pcr with gene-specific primers. results: immunoreactive faah, cb and cb were detected in all samples. faah immunoreactivity in the syncytiotrophoblast increased between the th and th gestational week and by week faah was barely detectable within large parts of the placenta. simultaneously, faah immunoreactivity increased in the mesenchymal core of the developing villi. immunoreactive cb and cb localised to the syncytiotrophoblast, cytotrophoblast and mesenchymal core with cb immunoreactivity showing diminished intensity after week , although this did not reach significance at the transcript level. cb immunoreactivity was absent from fetal blood cells and infiltrating maternal plasma cells, whereas cb and cb immunoreactivity was detected in endothelial cells but not in the vascular smooth muscle cells of blood vessels. the intensity of cb immunoreactivity in the syncytiotrophoblast differed from that of cb and faah in that it remained constant throughout. conclusion: the data suggest that placental faah and cb levels do not alter significantly during the first trimester, but alter their cellular distribution from the syncytiotrophoblast to the mesenchymal core. the significant loss of cb expression from the syncytiotrophoblast after the th week of gestation, a point of critical alteration in the developing placenta, suggests that its retention may be detrimental to normal placental development. reference: park, b. et al., ( ) hankins, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. background: numerous angiogenic proteins synthesized in the placenta are thought to be involved in placental vascularization and development; however, the molecular mechanism modeling the angiogenic process in early pregnancy remains elusive. calatonin gene-related peptide (cgrp) is a multifunctional peptide expressed at the human implantation site; but its influence on in vitro angiogenesis by human micro vascular endothelial cells is not known. objective: the present study was designed to determine the influence of cgrp on angiogenesis by human dermal microvascular endothelial cell (hdmvec) in vitro. methods: hdmvecs (vec technologies) were cultured in mcdb- complete solution containing cgrp ( - m), cgrp plus its antagonist cgrp - ( - m), in well plates with x cells per well. the existence of cgrp receptor components calcitonin receptor-like receptor (crlr) and receptor activity modifying protein (ramp ) was determined using immunofluorescent staining. cell proliferation was examined using methylthiazoltetrazolium (mtt) assay. the pro-angiogenic bioactivity of cgrp was evaluated using cell migration and capillary like tube formation on the matrigel. results: ) immunofluorescent staining showed that cgrp receptor components crlr and ramp are abundantly expressed by hdmvecs. replacement of the primary antibodies with preimmune serum resulted in a negative staining; ) cgrp dose-dependently ( - to - m) stimulated hdmvec proliferation, and this effect was totally blocked by cgrp antagonist, cgrp - ; ) quantitative analysis for cell migration revealed that cgrp increases hdmvec migration in a dose and time-dependant manner; and ) cgrp promotes hdmvec capillary like tube formation, and the length of capillary tube induced by cgrp ( - m) was significantly increased over that of the untreated controls. this increase was observed at hours of treatment and further increase was noted at hours of culture. conclusion: cgrp induces in vitro angiogenesis by promoting microvascular endothelial cell proliferation, migration and capillary like tube formation. therefore, trophoblast derived cgrp at the implantation site may play a role in placental angiogenesis and fetal growth. over-expression of socs- gene promotes il- production by jeg- trophoblast cells. qin dong, , ruping fan, yang gu, david f lewis, yuping wang. biochemistry, harbin medical university, harbin, heilongjiang, china; obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: suppressor of cytokine signaling- (socs- ) plays an important role in negative regulation of inflammatory response in biological cells. evidence has shown anti-inflammatory cytokine il- expression was significantly reduced in trophoblasts of preeclamptic (pe) placentas. we sought to determine if over-expression of socs- in placental trophoblasts could promote il- production. methods: full-length socs- open reading frame (socs- cdna) was generated by rt-pcr from total rna samples isolated from human leukocytes and cloned into a pzsgreen -n vector, which encodes a green fluorescent protein zsgreen . successful socs- cloning was confirmed by sequencing. for transfection, jeg- cells were placed into well/cluster plates at a concentration of . x /well. the tranfection was carried out with . g of socs- /zsgreen plasmid (psocs- /zsgreen ) for hours when cell reached - % confluence. siport lipid were used. jeg- cells transfected with zsgreen plasmid (pzsgreen ) only was used as control. after approximately hours of transfection, cells were treated with il- at and ng/ml. medium was then collected and measured for il- by elisa. il- production was calculated as the percentage of increase by psocs- /zsgreen transfected cells compared to the cells transfected with pzsgreen only. result: il- production was increased by psocs- /zsgreen transfected jeg- cells compared to the cells transfected with pzsgreen only when stimulated by il- , control: . % increase; ng/ml il- : . % increase and ng/ml il- : % increase, p< . , respectively. data are means from three independent experiments. conclusion: over-expression of socs- gene could promote il- production by placental trophoblast cells. reduced sil- r release and increased ratio of sgp /sil- r production by placental tissues from women with preeclampsia. shuang zhao, ruping fan, jingxia sun, yang gu, david f lewis, yuping wang. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa; obstetrics and gynecology, first hospital, harbin medical university, harbin, heilongjiang, china. objective: placental tissue/trophoblasts release more inflammatory cytokines (il- , il- and tnf ) in preeclampsia (pe) than in normal pregnancies. however, the reason for increased inflammatory cytokines released by pe placentas is not clear. soluble il- receptor (sil- r) and membrane receptor il- /gp complex play an important role in the negative regulation of cytokine signaling in suppressor of cytokine signaling (socs) pathway. in contrast, soluble gp (sgp ) is an antagonist for il- /il- r trans-signaling. this study was undertaken to determine sil- r and sgp production by villous tissues from normal and pe placentas. methods: placentas delivered by normal and pe pregnant women were used in this study. placental explants were incubated with dmem for h. the culture medium was collected. placental villous tissue productions of sil- r and sgp were measured by elisa. all samples were assayed in duplicate. data are expressed as mean ± se and analyzed by mann whitney test. a p level < . was considered statistically different. results: placental tissues from pe produced significantly less sil- r than tissues from normal pregnancies, . ± . vs. . ± . pg/mg of wet tissue, p< . . soluble gp production was relatively compatible between pe and normal placental tissues: . ± . vs. . ± . pg/mg of wet tissue. the ratio of sgp /sil- r release was significantly higher in pe than in normal placentas, . ± . vs. . ± . , p< . . conclusion: reduced sil- r production and/or increased ratio of sgp /sil- r production by pe placentas suggest less cytokine inhibitory activity in pe placentas, which may contribute to the increased toxic cytokine production in placentas from pe. using chemiluminescence immunoassays. peter s uzelac, jing dai, frank z stanczyk, daniel r mishell, jr. obstetrics and gynecology, university of louisville, louisville, ky, usa; obstetrics and gynecology, university of southern california, los angeles, ca, usa. objective: characterizing human chorionic gonadotropin (hcg) levels throughout normal pregnancy is critical to its use as a bio-marker for abnormal gestations. there is a paucity of data describing hcg trends during pregnancy and most of the relevant studies use older, less specific assays. our first objective was to characterize hcg levels throughout normal gestation using two different contemporary chemiluminescence immunoassays. our second objective was to compare hcg patterns in healthy gestations with pregnancies affected by diabetes, a common obstetrical complication. methods: a single blood sample was collected from healthy pregnant women and diabetic pregnancies. gestational age was confirmed by ultrasound. serum hcg levels were quantified by chemiluminescence immunoassays using the acs- and immulite systems. data was grouped in -week intervals until weeks of gestation and -week intervals thereafter, with to samples in each interval for healthy women and to samples in each interval for diabetic women. paired t-test and wilcoxon rank sum test were used for statistical analysis. results: using the acs- system, mean hcg levels (miu/ml) for healthy pregnant women were , at - weeks, , at - weeks, , at - weeks, , at - weeks, , at - weeks, and , at - weeks. mean hcg levels obtained from the immulite system were similar. for diabetic pregnancies, mean hcg levels (miu/ml) were , , , , , , , , , and , , respectively. between - weeks of gestation, the hcg levels were significantly lower in diabetic pregnancies (p= . ) compared to healthy controls. ) compared to healthy pregnancies, diabetic gestations have significantly lower peak hcg levels. the cause of this difference is an area deserving further investigation. background: mouse and human placentae share several cellular and molecular features, including a haemochorial interface, allowing the murine labyrinth to be compared with the human fetal placenta. there is an autonomous embryonic ras from at least the time of implantation. ace converts angiotensin i to the active angiotensin ii (angii). angii's actions as a pro-inflammatory agent, in promoting cell migration, angiogenesis and cellular growth and apoptosis, strongly suggest a rôle in placentation. hypothesis: there would be counterregulation of the placental ras if the effect of ace were removed. this study investigated for the first time whether the knockout of somatic ace affected the expression and localisation of various components of the ras in the placentae of wild-type (wt/wt), heterozygous (wt/ ) and ace knockout ( / ) mice. methods: immunohistochemistry (dako envision plus) was used to localise and semiquantify ang type receptor (at r), ang type receptor (at r), ace, and ace- in the three genotypes (n= /group). placental sections were blinded to genotype; a score range of - was used. the test was used (spss version . ) to analyse the difference in staining score by genotype. results: immunoreactivity of all antigens increased in the placental labyrinth of / mice compared to wt/wt and wt/ mice (at r p< . ; at r p<< . ; ace p<< . ; ace- p<< . ). at r and ace- displayed increased staining in the fetal vascular endothelium of / mice (at r p<< . ; ace- p= . ), and in the cells lining the maternal central artery (at r p<< . ; ace- p<< . ). ace- expression was very high in cytotrophoblast lining the maternal blood space in all genotypes. no gross structural differences were seen. comment: the antibody used did not differentiate between ace and the membrane-bound "testicular"-ace (tace). immunohistochemically-identified ace expression was upregulated in / placentae despite the loss of somatic ace, suggesting that t-ace can be expressed placentally. we believe this is the first demonstration of such expression. ace and t-ace are catalyticallysimilar in converting angi to angii. furthermore, angii acting via the at rs is vasodilatory and ace- catalyses production of the vasodilatory ang ( - ); placental blood flow was presumably well-maintained and pregnancy outcome is normal in / mice. it is generally accepted that prostaglandin production plays a crucial role in both term and preterm parturition, and recently the administration of alpha hydroxyprogesterone acetate has been shown useful in preventing preterm labor. what is not clear is the biochemical pathway of prostaglandin production during labor and what, if any, effect alpha hydroxyprogesterone acetate has on this pathway. in order to address this question, we used immunohistochemical staining techniques to evaluate the effect of treating human placental amnion and chorion decidua with alpha hydroxyprogesterone acetate. membranes from unlabored patients were obtained at cesarean section and immediately seperated into control and drug treated specimens. controls were from the same placenta and were subjected to all experimental procedures except for the addition of alpha hydroxyprogesterone acetate to the culture media. specimens were compared at zero, six, and twenty four hour intervals. at the appropriate time, each specimen was formalin fixed and then paraffin blocked. tissue sections were then mounted on slides which were immunohistochemically stained using appropriate primary and secondary antibodies and standard techniques. the slides were then analyzed via light microscopy for changes in staining of three enzymes involved in prostaglandin production--cyclooxygenase (cox- ), cyclooxygenase (cox- ), and -hydroxy prostaglandin dehydrogenase (pgdh). compared to control, the slides treated with alpha hydroxyprogesterone acetate had differing amounts of enzyme expression. cox- was relatively unchanged and pgdh was only slightly increased, but cox- was noticeably decreased in the treated slides. these results were time dependent. this data suggests that alpha hydroxyprogesterone acetate decreases prostaglandin production in fetal membranes primarily by downregulation of the cyclooxygenase enzyme. objectives: in the human placenta, proliferation, differentiation and fusion of cytotrophoblasts (ct) are essential events in the formation of the multinucleated syncytiotrophoblast, however the regulation of these processes is poorly understood. using an explant model of human first trimester placenta we have established that both igf-i and -ii enhance ct proliferation, differentiation and survival mediated via igf r signalling. we have also shown that non-specific inhibition of protein tyrosine phosphatases inhibits igf-mediated signalling in trophoblast; therefore, we have now used sirna-mediated knockdown to investigate the role of the tyrosine phosphatase shp- in this pathway. methods: amaxa nucleofector technology was used to deliver shp- or scrambled sirna ( nm) to bewo cells or first trimester villous tissue fragments. knockdown was confirmed by q-pcr and western blotting. transfected cells and tissue were maintained in culture for hours, then treated with igf-i or igf-ii ( nm) for a further hours before immunohistochemical (ihc) analysis for cell proliferation (ki , brdu) or apoptosis (m ). results: sirna-mediated knockdown of shp- in bewo cells ( % reduction on western blot) demonstrated that igf-induced proliferation was reduced from . ± . % to . ± . % (p< . , n= ). ihc analysis of tissue demonstrated that shp- is localised to ct. following knockdown ( % decrease by q-pcr), igf-i-and igf-ii-induced ct proliferation was decreased by . ± . % and . ± . % respectively (p< . , n= ). furthermore, the ability of igf-i-and igf-ii to prevent ct apoptosis (m staining) was reduced by . ± . % and . ± . % respectively (p< . , n= ) after shp- knockdown. conclusions: igf stimulation of cytotrophoblast proliferation is mediated by shp- . exogenous igf rescues cytotrophoblast from apoptosis, and this pathway is also shp- -dependent. villous endothelial cells. emily j su, zhi-hong lin, ping yin, scott reierstad, joy innes, serdar e bulun. obstetrics and gynecology, northwestern university feinberg school of medicine, chicago, il, usa. background: within the human vascular system, estrogens have been shown to enhance vasodilatation in both normal and abnormal endothelium. estrogenic function occurs by activation of one or both of two estrogen receptors, estrogen receptor-alpha (esr ) and estrogen receptor-beta (esr ). these estrogen receptors are expressed in a wide variety of tissues. within the vasculature, estrogen receptors regulate the expression of multiple vasodilator and vasoconstrictor proteins. specifically, esr has been shown to be critical in maintaining normal vascular physiology in a murine model, where esr knock-out mice demonstrate significant systolic and diastolic hypertension. we hypothesize that within placental endothelium, estrogen plays an important role in maintaining normal vascular function that is critical for normal fetal growth and development. methods: term placentas from uncomplicated pregnancies were obtained, and the decidua was removed. an iv cannula was inserted into the umbilical vein, which was perfused with a collagenase/dispase solution. the perfusate was collected and subjected to further purification. these cells were cultured in complete medium, and after the initial passage of these cells, purity was confirmed via immunofluorescence and flow cytometric studies. estrogen receptor expression was determined in these cells via western blotting. additionally, these endothelial cells underwent treatment with varying doses of estradiol ( - m to - m), and quantitative real-time pcr was performed thereafter for mrna levels of various genes important in prostanoid production. results: western blotting demonstrated that esr is the only estrogen receptor expressed within villous placental endothelial cells. estradiol induced cyclooxygenase- (cox- ) mrna levels -to -fold, as quantified by real-time pcr (p< . ). conversely, there was no effect of estradiol on cyclooxgenase- (cox- ). conclusion: these results suggest that estradiol and esr are important in mediating the balance of prostanoid production that is essential in maintaining placental vascular health. future studies will further delineate estrogenic effects on prostanoid production within placental endothelial cells in health and disease. supported by the smfm/aaogf scholarship award and the nih grant u -hd . previously we established that proteins secreted by the decidua promote the differentiation of extravillous trophoblasts (evt) from a proliferative phenotype (characterized by cx , her- and alpha integrin protein expression) to an invasive phenotype (characterized by her- and alpha protein expression). the ability of decidua-conditioned media (dcm) to induce trophoblast differentiation was inhibited in the presence of the her- receptor antagonist, ag . furthermore, dcm-induced jar cell migration was also attenuated in the presence of ag . thus, the purpose of this study is to define the role of her signaling in evt differentiation and invasion. methods: evt differentiation was assessed in placental villous explant outgrowths and jar cells using antibodies against markers of the proliferative and invasive phenotypes. trophoblast migration was assessed using jar cells in transwell migration assays. results: treatment of placental villous explants with egf, a her- ligand, resulted in the downregulation of her- and an upregulation of her- expression, as well as an induction of alpha integrin expression. pre-treatment of placental villous explants with ag blocked this effect. in the jar cell line, egf treatment mimicked the differentiation-promoting effects of dcm by downregulating her- and upregulating her- expression, effects that were both blocked when jar cells were pre-incubated with ag . in contrast to dcm however, egf stimulation did not induce jar migration. stimulation of jar cells with hb-egf, a her- /her- heterodimer ligand, induced jar migration in a dose-dependent manner. analysis of dcm using antibody arrays confirmed the presence of many members of the egf family including hb-egf. immunohistochemical assessments of placental villous explants verified the expression of her- in evt outgrowths and in jar cells; her- expression was not affected by stimulation with either egf or hb-egf. conclusions: her signaling is an important and necessary component of the invasive evt differentiation cascade. our data supports a role for her- signaling in the induction of the invasive evt phenotype. chandrasekhar thota, chandra yallampalli. obstetrics gynecology, university of texas medical branch, galveston, tx, usa. background: parathyroid hormone related peptide (pthrp) is expressed in trophoblast cells and may play a role in placental growth and function. studies conducted in pregnant rats using pthrp antagonist showed decreases in fetoplacental growth during mid gestation. objective: to assess the effects of pthrp silencing on the expression of growth factors in immortalized first trimester trophoblast cells (htr- /svneo cells). methods: htr- /svneo cells cultured at º c and %co in rpmi- medium supplemented with % fbs were transiently transfected with nm of three different sirna sequences of pthrp, si , auaccuaacucaggaaacuuu; s i , g a g c u g u g u c u g a a c a u c a u u ; a n d s i , caagauuuacggcgacgauuu. for control, a scrambled sirna sequence was used. at % confluency, cells from each well were split and transfected again in triplicates with respective sirna sequences. total rna was isolated using trizol reagent h after transfection, and protein was extracted using lysis buffer h after transfection. the isolated rna and protein were subjected to reverse transcription and polymerase chain reaction (rt-pcr) and western analysis, respectively, using primers and antibodies specific for pthrp, plgf, vegf and lif. the results are expressed relative to either s for changes in mrna expression or -actin for changes in protein expression. results: rt-pcr of total rna obtained from htr cells subjected to double transfection with sirnas for pthrp showed a significant decrease in pthrp expression. expression of growth factors plgf, vegf and lif showed decreases with all the three sirna sequences used compared to the scrambled sequence. western analysis of cell lysates obtained from htr cells subjected to transfection with sirnas for pthrp showed a significant decrease in protein expression of pthrp and vegf. however the protein expression for plgf, and lif decreased in cells transfected with only si sequence of pthrp. conclusions: our studies showed that transient transfection of htr cells with sirna for pthrp caused decreases in both mrna and protein expression of pthrp. our results further suggests that decrease in pthrp peptide in transfected cells resulted in a decrease in vegf, plgf and lif suggesting that pthrp may play role in regulating trophoblast cell functions. objective. maternal obesity poses an increased risk to the fetus during pregnancy, and has long term consequences for the progeny. we tested the hypothesis that maternal caloric excess effects growth-related gene expression changes in the murine placenta. methods. female c bl/ mice were fed a hypercaloric diet ( % fat, % sugar) or standard chow for six weeks prior to mating and throughout pregnancy. near-term (day gestation) the dams ( controls, overfed) were sacrificed. following placental rna extraction, we used the affymetrix mouse a_ . array to measure gene expression changes. we performed pathway analysis on regulated genes. results. maternal overfeeding was associated with a two-fold increase in body fat mass. probe sets, corresponding to genes showed differential expression (p < . ); twenty-seven of which were up-regulated, and ten down-regulated, as compared to the placenta of control fed dams. of note, several genes related to obesity, diabetes, dna methylation, and the tgf beta pathway were differentially expressed. conclusions. diet-induced obesity in mice was associated with altered placental gene expression, including genes involved in tgf beta signaling and dna methylation pathways. these findings may have important implications for placental growth and epigenetic regulation. (supported by usphs hd- , earnest eu framework , tommy's the baby charity, uk). objective. maternal dietary protein restriction has been shown to have deleterious effects on placental development, and has long-term consequences for the progeny. to comprehend more completely stress responses to maternal protein restriction, we measured gene expression changes in the mouse placenta. methods. pregnant fvb/nj mice were fed an isocaloric diet containing % less protein than normal chow ( % vs. % protein content) from embryonic day . (e . ) to e . . following placental rna extraction, we used the affymetrix mouse a_ . array to measure gene expression changes. we performed pathway analysis on the regulated genes, and used both qrt-pcr and immunohistochemistry to verify the results. results. the weights of the e . pups were decreased % (p< . ). probe sets, corresponding to genes, were regulated by protein restriction (p< . ); ninety-one being up-regulated and down-regulated. of particular note, several genes related to the p pathway were up-regulated. along with p itself, positive regulators of p (zmiz , jmy, hipk ) and genes activated by p (inpp d, cebpa) were induced. for selected genes we confirmed these results using qrt-pcr and immunohistochemistry. conclusions. by microarray analysis, we have described the genetic response to maternal protein deprivation in the mouse placenta. we observed that pups were growth restricted, and genes related to the p pathway were regulated. we propose a model through which intrauterine growth restriction is triggered, in part, by activation of the p pathway. (supported by usphs hd- and the sgi medical student grant to cpg). purpose: human placental villous tissue cultures have been underused in the study of placental drug disposition. thus we assessed the utility of this model by studying the effect of time in culture on the viability and integrity of the tissue and the, expression and function of proteins involved in the formation and efflux of -chloro- , -dinitrobenzene (cdnb) conjugate , -dinitrophenyl-s-glutathione (dnp-sg) as a model system for phase ii metabolism and cellular efflux. methods: placental tissue samples were obtained within minutes of cesarean deliveries following normal pregnancies in three patients. villous tissue was cultured in m medium to hr. at , , , , , and hr post culture, villous tissue was preincubated without or with atpase inhibitor sodium orthovanadate, exposed to μm cdnb, rinsed and incubated in buffer at °c to determine formation and efflux of dnp-sg, which was assayed by hplc. changes in expression of gstp - , abc transporter isoforms b , c and g (abcb , abcc , and abcg , resp.) were assessed by immunoblotting. lactate dehydrogenase (ldh) release, methyl tetrazolium thiazolyl blue (mtt) incorporation, and total tissue glutathione content were monitored up to hr. villous tissue morphology was assessed by immunohistochemistry. results: villous tissue structure and protein expression of glutathione-stransferase isoform p - (gstp - ) and abcg remained unchanged over hr in culture. expression of abcb and abcc , and total tissue glutathione decreased with culture time. ldh release was unchanged up to hr and increased at hr, while mtt incorporation remained constant to hr and decreased at and hr suggesting a decline in tissue integrity and viability at hr. however, dnp-sg formation, dnp-sg buffer/tissue ratio, and the extent of inhibition of dnp-sg efflux by sodium orthovanadate remained unchanged through hr. sodium orthovanadate decreased the dnp-sg buffer/tissue ratio by . ± . % (p< . ), consistent with inhibition of apical abc transporters. conclusions: these results support the use of this model to study the coordinated function of metabolizing enzyme gstp - and apical abc transporters in the formation and efflux of the model substrate dnp-sg. the model may be useful to study metabolism and transport of other compounds. syncytiotrophoblast. shauna f williams, ewa fik-rymarkiewicz, stacy zamudio, nicholas p illsley. obstetrics, gynecology and women's health, umd-new jersey medical school, newark, nj, usa. introduction: multiple inputs influence placental protein synthesis. nutritional, endocrine and metabolic factors have been implicated but its regulation has not been investigated. one of the factors shown to be associated with the inhibition of protein synthesis is hypoxia. the goal of this study was to determine the effects of hypoxia on a marker of placental protein synthesis. eukaryotic initiation factor (eif ) is a subunit of eif which is required for initiation of translation however when phosphorylated, eif is unable to participate in the assembly of the initiation complex. hypoxia has been shown previously to cause increased phosphorylation of eif . we hypothesized that hypoxia would increase the levels of phosphorylated eif in term syncytiotrophoblast, thus inhibiting protein synthesis. methods: primary syncytiotrophoblast cultured from term cytotrophoblast were incubated for hr in atmospheres of , , or % o or in the presence of the hypoxia-mimetic, dimethyloxalylglycine (dmog, . - . mm) in % o . cell extracts were analyzed by western blotting to determine the degree of eif phosphorylation. results: incubation in , , or % o did not increase eif phosphorylation relative to the % o control (n= , separate placental preparations). incubation in dmog concentrations up to . mm did not affect eif phosphorylation however incubation in . mm dmog increased eif phosphorylation by ± % (p < . , n= ). conclusions: contrary to our expectations, inhibition of protein synthesis via the eif regulatory pathway was not apparent except when induced by the highest concentration of dmog, consistent with severe hypoxia. thus while eif phosphorylation does occur, we did not observe changes at dissolved oxygen levels of %. these data suggest that a reduction in syncytial protein synthesis via the eif pathway takes place only under severe hypoxic stress. (supported by nih hd ). the increasing prevalence of overweight and obese women of childbearing age is a growing public health concern. the impact of maternal obesity on placental aa transport, which is essential for normal fetal development, remains poorly defined. there are three sub-types of the placental na-dependent system a transporter, snat , and which mediate neutral aa transport. snat is ubiquitously expressed in mammalian tissues and is likely responsible for the majority of placental system a activity. objective: to examine the impact of maternal obesity and over-nutrition on the fetal: maternal (f:m) aa ratio and placental protein abundance for snat . methods: nonpregnant ewes were randomly assigned to a control (c, % of nrc recommendations) or obesogenic (ob, % of nrc) diet from - to days of gestation (dg). under isofluorane anesthesia, maternal and fetal blood samples were collected for aa analysis by hplc from five twin bearing ewes in each dietary group. after euthanasia, placental cotyledonary (cot) tissue was separated from caruncular tissue, frozen in liquid nitrogen and stored at - c for western blot analysis. results: fetuses from ob ewes were % heavier (p< . ) than those from c ewes at dg ( ± vs. ± g). blood concentrations of asn, thr, cit, arg, tau, tyr, trp, val, phe, leu and orn were higher (p< . ), or tended to be higher (met and lys, p< . ) in ob than c ewes. in contrast, f:m ratios, for asn, ser, gln, his, gly, thr, cit, arg, b-ala, tau, ala, tyr, trp, met, val, phe, leu, orn and lys were reduced (p< . ) in ob compared to c ewes. snat content in cot tissue was reduced in ob when compared to c ewes ( . ± . vs. . ± . arbitrary units; p< . ). conclusions: maternal obesity in pregnancy reduced expression of placental snat protein and efficiency of placental aa transport in ewes, providing a mechanism whereby fetuses may mitigate excessive delivery of aa under conditions of maternal obesity and over-nutrition. decreased aa transport to the fetus may play a role in altered cellular structure and function. nih inbre p rr . early gestation utero-placental hemodynamics in an ovine model of fetal growth restriction. lucia dohnal, james s barry, henry l galan, randall b wilkening, russell v anthony. perinatal research center, university of colorado health sciences center, aurora, co. objective: fetal growth restricted (fgr) pregnancies, during late gestation, exhibit altered placental hemodynamics, and reduced capacity for o and nutrient transfer. it was our objective to examine utero-placental hemodynamics and o uptake during early gestation in an ovine model of fgr. methods: singleton-bearing ewes were instrumented with uterine artery flow probes, uterine venous and femoral artery catheters before being placed into a highambient temperature (fgr; n= ) or normothermic (con; n= ) environment at days of gestation (dga). maternal arterial and venous blood, uterine artery flow, heart rate, arterial pressure and respiration rate was collected until dga, at which time umbilical venous blood, fetal weight, placental weight and tissue were harvested. data reported here were analyzed by students t-test. results: maternal respiration rate ( . ± . vs . ± . breaths/min) and arterial po ( . ± . vs . ± . mmhg) were increased (p . ), whereas maternal heart rate ( . ± . vs . ± . beats/min), blood pressure ( . ± . vs . ± . mmhg) and arterial pco ( . ± . vs . ± . mmhg) were reduced (p . ) in fgr pregnancies. at dga, fetal weight was not different (p . ), but placental (total placentome) weight ( . ± . vs . ± . g) was reduced (p . ) in fgr pregnancies. while uterine artery (pregnant horn) flow ( . ± . vs . ± . ml/min) tended (p= . ) to be reduced in fgr pregnancies, relative uterine artery flow ( . ± . vs . ± . ml/min/g fetus; . ± . vs . ± . ml/min/ g placenta) was not different (p . ). uterine o uptake (mmol/min), relative uterine o uptake (ml/min/g fetus or ml/min/ g placenta) and uterine o extraction (%) were not different (p . ) between fgr and con pregnancies. at dga, umbilical vein po (mmhg), o content (mm) and o capacity (mm) were also not different between fgr and con pregnancies. conclusions: reduction in absolute uterine artery flow (ml/min) did not impact utero-placental o uptake or transfer to the umbilical vein, and may have resulted from reductions in maternal cardiac output. relative uterine artery flow was not reduced, suggesting that uterine blood flow and delivery of o to the conceptus does not mediate the ongoing placental growth restriction initiated during early gestation. supported by nih hd . barton c staat, anna maria marconi, cinzia paolini, alex cheung, henry l galan, frederick c battaglia. obstetrics gynecology and pediatrics, univ of colorado at denver health sciences center, aurora, co, usa; dept of obstetrics and gynecology, san paolo institute of biomedical sciences, university of milano, milano, italy. objective: to determine relative contributions of transplacental flux vs fetal production for myo-inositol and mannose in normal term pregnancies using stable isotopic methodolgy. background: myo-inositol and mannose are important in biologic functions. an external supply of mannose may be required for glycoprotein synthesis. low maternal myo-inositol is associated with spina bifida. mannose concentrations are known to be higher in the mother than the fetus. in contrast, myo-inositol concentrations are higher in the fetus than the mother. what remains unknown is whether fetal levels of these polyols are a result of direct maternal transport or from conversion of glucose. design: four term uncomplicated pregnancies undergoing an elective ceasaran section were infused with c labeled isotopes of glucose, myo-inositol and mannose over hours prior to delivery. maternal samples were obtained prior to infusate being administered, and at hour (h), . h and h. fetal concentrations were measured from umbilical artery and vein plasma. the concentrations of labeled and unlabeled glucose, mannose and myo-inositol were measured using high pressure anion exchange chromatogrpahy permitting detection of polyols and sugars at concentrations in the μm range. the feto-maternal molar percent enrichment (mpe) ratio was calculated for each glucose, mannose, and myo-inositol as the ratio between fetal plasma enrichment and the maternal plasma enrichment at steady state. steady state was calculated as the mean of the three maternal samples taken during infusion. results: the feto-maternal mpe ratios of mannose ( . ± . , p= . ) and glucose ( . ± . , p= . ) were not significantly different from . , consistent with transplacental supply. the feto-maternal ratio for myo-inositol ( . ± . , p= . ) indicates little transplacental flux ( % of fetal inositol derived from maternal plasma). conclusion: in normal term pregnancies, fetal mannose and glucose concentrations are dependent upon maternal transplacental supply. in contrast, fetal myo-inositol concentration is not dependent upon transplacental supply, but fetal demands are met by placental conversion, likely from glucose. christian wadsack, manuela augsten, christian guelly, ursula hiden, ingrid lang, manfred moertl, uwe lang, gernot desoye. clinic ob/gyn; center of med res; inst cell biol, histol embryol, med univ graz, austria. background placenta and fetus need lipids for growth and synthesis functions. part of the lipids is supplied from maternal sources by transplacental transfer. recently, we identified in human placenta the high density lipoprotein (hdl) receptor scavenger receptor class b type i (sr-bi). among other functions it mediates hdl-induced ser -phosphorylation of endothelial nitric oxide synthase (enos) resulting in enos activation. this mechanism allows hdl to contribute to regulation of vasotonus in arteries. we hypothesized that term placental endothelial cells (ec) express sr-bi at levels different between arteries and veins. methods sr-bi was localized by ihc and quantified by qrt-pcr in rna isolated from arterial and venous vessels. arterial (eca) and venous (ecv) placental ec were rigorously characterized. sr-bi levels were measured by qrt-pcr and immunoblotting. hdl binding and uptake was measured in eca and ecv with i-labelled hdl. hdl from human donors was used to stimulate ser enos phosphorylation. epigenetic regulation was studied by methylationspecific pcrs for cpg-rich promoter regions of sr-bi. pdzk a key adaptor for sr-bi mediated enos activation was measured by sqrt-pcr. in situ analyses (ihc, qrt-pcr) showed more sr-bi in arteries than in the vein. the differential expression persisted in vitro in isolated eca and ecv even after passages and culture under same conditions suggesting epigenetic mechanisms regulating sr-bi. however, no methylation was found in eca or ecv. sr-bi was functional since hdl cell association was -fold higher in eca than in ecv ( ± . vs ± . ng hdl/mg prot). hdl did not induce ser enos phosporylation in eca or ecv, which was stimulated by ionomycin about -fold in both cell types. pdzk was undetectable in eca and ecv, whereas it was expressed in placental tissue. conclusion more sr-bi is expressed in ec from arteries than from veins in situ and in vitro. this is not the result of different methylation of sr-bi promoter and, hence, unlikely an epigenetic phenomenon. mechanism of differential expression and its functional consequences for vasotonus regulation is yet unknown. the lack of pdzk may account for the failure of hdl to activate enos. (grants , , oenb). cells. juan a arroyo, brad ziebell, mi-hye park, henry l galan. obstetrics and gynecology, university of colorado andgealth sciences center, aurora, co, usa. introduction: mtor is a protein that regulates cell growth in response to nutrients and growth factors. downstream effectors of the mtor pathway include the p and the ebp proteins. activation by phosphorylation of these proteins increases protein synthesis. given that various signaling pathways are regulated by hypoxia in human trophoblast and that mtor is expressed in human trophoblast, our objective was to determine the effects of hypoxia in the activation of mtor, p and ebp in cultured human trophoblast. study designs: trophoblast cell were isolated from term uncomplicated placentas using a trypsin, dnase and disapase solution. cytokeratin immunocytochemistry confirmed trophoblast cells culture purity. trophoblast cells were treated with hypoxia ( % o ) or normoxia ( % o ) for and hours. western blot for p-mtor, mtor, p-p , p , p- ebp , and ebp were done for each time studied. results: trophoblast cells demonstrated: ) positive staining for cytokeratin, ) non significant differences for mtor at either ( . -fold; p= . ) or hours ( . -fold, p= . ), ) no differences in p protein at ( . fold; p= . ) or hours ( . -fold, p= . . ), ) no differences for ebp at either or hour. conclusion: we conclude that the mtor pathway is not regulated under hypoxic conditions in cultured trophoblast, which suggests that hypoxia does not affect protein synthesis in cultured human trophoblast. however, this may not reflect what happens in vivo in iugr. (supported by nih grant r hl - a ). increased expression of phospho-mtor, phospho-p , phospho-akt and phospho-erk in an ovine model of fetal growth restriction. juan a arroyo, brad ziebell, henry l galan. obstetrics and gynecology, university of colorado and health sciences center, aurora, co, usa. objective: both phosphorylated (p) mtor and p are known to be involved in protein synthesis and are regulated by physiological conditions such as fetal growth restriction (fgr). in a hyperthermic (ht) ovine model of fgr we hypothesize that mtor, p , ebp , erk and akt will be phosphorylated (activated) in the placentae of age (dga) animals. study design: ewes were exposed to ht conditions for days to induce iugr and were placed in ambient conditions. at necropsy ( dga), placentomes were separated into the maternal (caruncle) and fetal (cotyledon) components and frozen for western blot analysis with antibodies against (p) mtor, mtor, (p) p , p , (p) ebp , ebp , (p) erk, erk, (p)akt and akt. results: compared to control animals, fgr animals had smaller fetuses ( ± g v. ± g; p= . ) and smaller placentae ( ± g v. ± g; p= . ) at dga. fgr cotyledon showed an increase in p-mtor ( . -fold; p= . ), p-p ( . -fold; p< . ), p-erk ( . -fold; p< . ) and p-akt ( . -fold; p< . ). in contrast, caruncle (maternal) did not show any changes for the mtor pathway. conclusion: in fgr ovine pregnancies, the fetal placental tissues (cotyledons) showed upregulation of the mtor pathway for protein synthesis via phosphorylation of the p but not ebp while this was not seen in the maternal (caruncle) tissues. in addition neither the cotyledon or caruncle tissues at mid-gestation ( dga) showed changes in these endpoints, which is prior to the exponential fetal growth that starts at mid-gestation. (supported by nih grant r hl - a ). hyperuricemia has long been recognized as a common clinical finding in preeclamptic (pe) women. to date, elevated uric acid concentrations in these women have been considered a marker of disease severity. however preeclamptic pregnancies with hyperuricemia, are associated with an increased frequency of preterm birth and fetal growth restriction. over the past decade several pathogenic roles for uric acid have become evident, raising the possibility of a role(s) for uric acid in the altered vascular and placental functions associated with pe. objective: examine the effects of syncytial uric acid uptake on system a amino acid transport across the human placenta using a primary placental villous explant model. methods: placental villous explants from placentae of healthy, term pregnancies were incubated for hours with uric acid ( . mg/dl), corresponding to concentrations of uric acid observed in pe women. these experiments were conducted in the presence or absence of probenecid ( m), a uric acid cellular uptake inhibitor. system a amino acid transport was subsequently assayed using a radiochemical assay in which na+-dependant uptake of radio-labeled system a substrate, [ c] methyl-amino-isobutyric acid, was measured over minutes. data were analyzed using a paired student's t-test and presented as mean ± sem. results: uric acid attenuated system a amino acid placental transport by % (± . %, p< . ). this inhibitory effect of uric acid on system a activity was prevented by probenecid. conclusions: uric acid reduces placental amino acid transport at concentrations observed in pe women. this inhibitory effect of uric acid is dependant upon syncytial uptake of uric acid, being inhibited by the uric acid transporter inhibitor probenecid. these results may be relevant to the increased frequency of fetal growth restriction observed in hyperuricemic pe. additionally the results of this study, indicating a detrimental effect of hyperuricemia on placental function, also suggest a role for uric acid in the pathophysiology of pe. hyperuricemia, a well-documented clinical finding in preeclamptic women, is associated with pre-term birth and intrauterine growth restriction. uric acid is higher in women destined to develop preeclampsia as early as weeks of gestation at a time when cytotrophoblast are invading decidua and myometrium and remodeling uterine spiral arterioles. we propose that elevated concentrations of uric acid may have detrimental effects on placental development in part through inhibition of trophoblast invasion through the decidua. objective: examine the effects of increasing concentrations of uric acid on trophoblast invasion through a reconstituted extracellular matrix. methods: using the in-vitro matrigel invasion assay, the effects of increasing concentrations of dissolved uric acid ( . mg/dl, . mg/dl and . mg/dl) on the ability of immortalized first trimester extravillous trophoblast cells (htr -svneo) to invade through a reconstituted extracellular membrane were assessed. the concentrations of uric acid used were comparable to those measured in healthy pregnant women and preeclamptic women with an increase in uric acid of two or four standard deviations above normal. cells that successfully invaded through the matrigel membrane within hours were fixed with methanol, stained with hematoxylin and counted. data were analyzed using a one-way analysis of variance with fisher's post-hoc analysis. results: uric acid attenuated trophoblast invasion in a dose-dependent fashion (p< . ), with decreases of % (± . %), % (± . %) and % (± . %) respectively compared to untreated controls. conclusions: exogenous uric acid, at physiological and pathological concentrations, is capable of attenuating trophoblast invasion through a reconstituted extracellular membrane in a dose dependent fashion. these results suggest uric acid is a potential contributor to the pathophysiology of altered placental perfusion in preeclamptic pregnancies. previous studies have shown that transforming growth factor (tgf)-is a key inhibitory factors in the invasion of early trophoblast cells, suggesting therefore that overcoming tgf-beta signaling may be necessary for successful implantation. smad ubiquitin regulatory factor (smurf ), a hect type e ubiquitin ligase, is a key regulator of tgf-signaling pathway, targeting tgf-receptors and various smads for proteasome-mediated degradation. in this context, smurf has been shown to play important roles in embryonic development, cell senescence and tumor formation. as a key regulator of tgfbeta signaling, we wished to determine whether smurf has a physiological role during embryo implantation, especially in trophoblast invasion. we have examined the spatio-temporal expression of smurf in human placental villi during pregnancy. we have also investigated the possible function of smurf in trophoblast cell migration and invasion in a model system involving a human extravillous trophoblast cell line, htr /svneo. our results showed that expression of smurf in placental villi was the highest during the first trimester and the expression decreased in the nd trimester. expression of smurf was lowest in placental villi at parturition. overexpression of smurf in htr /svneo cells reduced tgf beta type i receptor levels and attenuated the inhibitory effect of tgf-on cell migration and invasion. conversely, rnai-mediated down-regulation of smurf resulted in significant increase of tgf-type i receptor protein levels. in contrast, the levels of smad , another potential target of smurf , was unchanged. in conclusion, the present study suggests that smurf participates in trophoblast cell migration and invasion by down-regulating the expression of tgf-type i receptor. our previous data demonstrated the extensive expression of mmp- in various kinds of trophoblast cells in human placenta at the early pregnancy. however, the modulation of the enzyme in trophoblasts is largely unclear. in the present study, the effects of the two types of gonadotropin releasing hormone (gnrh) on mmp- expression were examined in an immortalized human cytotrophoblast cell line, b tert- that has been established in this lab. real-time quantitative pcr and western blot analysis revealed that both types of gnrh (gnrh i and gnrh ii) could increase mmp- mrna and protein levels in b tert- cells in time-dependent manners. in particular, regulatory effect of gnrh i on mmp- expression was concentration-independent, whereas that of gnrh ii was dose-dependent. moreover, both gnrh i and gnrh ii could evidently activate jnk kinase, and sp , an inhibitor of a jnk kinase, reversed the up-regulation of mmp- induced by either gnrh i or gnrh ii. on the other hand, it is not likely that erk / pathway participates in the signaling of gnrh i or gnrh ii. collectively, our observations suggest that gnrh i and gnrh ii elicit their modulation effects in human trophoblastic cells through jnk pathway leading to up-regulation of mmp- . during the first trimester of pregnancy, the oxygen tension of the developing trophoblast cells is less than %. however, the majority of studies on primary trophoblast cell development have been performed at % oxygen. primary third-trimester trophoblast cells are believed to be nonproliferative syncytiotrophoblast cells. we have previously demonstrated that low oxygen tension dramatically affects the differentiation pathway of these cells. we now hypothesize that cell culture in low oxygen tension will improve cell growth and restore proliferation. methods: primary trophoblast cells were purified from third-trimester placenta by enzymatic dispersion and cd- negative selection and cultured at %, % or . % oxygen tension for up to days. the number of cells in culture was assessed by cell counting and by measuring genomic dna. live:dead and mtt assays were used to determine viability. proliferation was assayed with brdu and immunohistochemistry for proliferating cell nuclear antigen. to assess cellular activity, radioactivity of protein precipitated from cells cultured in the presence of tritiated leucine was measured. results: there were no obvious morphologic changes in the cells cultured in different oxygen tensions. the amount of cell loss was directly proportional to oxygen tension: at % oxygen % of the cells remain in culture; at . % oxygen tension % of the cells remained. the cells at . % oxygen tension were proliferating and had a five-fold increased metabolic activity. conclusions: it was previously believed that third-trimester trophoblast cells are non-proliferative. we have demonstrated that low oxygen tension increases the survival of primary third-trimester trophoblast cells. this may reflect the change in the differentiation pathway of these cells. however, the cells also begin to proliferate and increase their metabolic activity. trophoblast cells in vivo form a three dimensional structure which promotes critical complex cell-to-cell interactions that cannot be studied with traditional monolayer cell culture. we developed a substrate-free three-dimensional trophoblast culture system capable of studying cellular interactions without a confounding artificial matrix. methods: nonadhesive agarose hydrogels containing cylindrical recesses m in diameter were cast from molds designed using computer-assisted prototyping. tcl trophoblast cells were seeded into the gels ( , cells per) for up to days. viability and cellular stress were assessed and the threedimensional structures of the spheroids were analyzed. results: tcl trophoblast cells formed uniform spheroids within three days of seeding. the spheroids remained intact after being removed from the mold. when placed in traditional cell culture dishes the cells adhered to the plate within one hour and rapidly proliferated into a monolayer. repetitive reseeding allowed easy transition between monolayer and spheroid without affecting cellular morphology. serial sectioning on days , and revealed central vacuolization forming a trophoblast vesicle with an outer rim . m (+/- m) thick. this rim size remained constant for at least days. live:dead assay demonstrated that the outer cells remained viable and staining against proliferating cell nuclear antigen demonstrated that the cells were proliferating. the inner cells undergo apoptosis as demonstrated by caspase- staining. there is an abundance of vegf staining in the cells remaining in the on the inside of the sphere suggesting a gradient of nutrient or oxidative stress. the formation of a vesicle has been confirmed with confocal imaging. em imaging revealed the structure of the rim. conclusions: trophoblast cells cultured in a novel substrate-free three dimensional system form trophoblast vesicles within days of seeding. these vesicles remain viable after long-term culture and can be repeatedly reformed with repetitive seeding. this new cell culture technique allows us to better study placental cell-cell interactions with the potential of forming microtissues. the transcription factor glial cell missing- (gcm ) mediates cell cycle arrest and differentiation of human trophoblast progenitors into villous syncytiotrophoblast and invasive extravillous cytotrophoblast (evt). micro-array analysis of total rna extracted from cultured bewo cells, in which gcm mrna and protein were repressed using sirna, identified tissue inhibitor of metalloproteinase- (timp- ) in the highest ( -fold) upregulated group of genes. confirmatory rtpcr demonstrated a -fold mrna induction. in placental villi, gcm acts as a transcription factor promoting expression of the fusogenic protein syncytin that mediates syncytial fusion into the overlying syncytiotrophoblast. by contrast, syncytial fusion is uncommon in evt. rather these cells invade several millimeters into the distal myometrium where they transform spiral arterioles. to investigate the role of timp and gcm in the trophoblast we assessed its mrna by qrt-pcr and protein by western blot in cellular extracts from both bewo cells grown under standard cultivation conditions (synchronized by prior thymidine exposure) and floating cultured first trimester villous explants cultured in % oxygen with prior exposure to either gcm sirna or anti-sense oligo-nucleotides to gcm . gcm inhibition in the bewo system was associated with a - % increase in timp- protein expression and alteration of cell proliferation and differentiation in both models. we are presently utilizing the explant model of evt invasion (explant tips cultured on matrigel in % oxygen) to test the hypothesis that gcm mediates metallo-proteinase expression and evt invasion via timp- . presently we conclude that gcm -mediated evt differentiation involves more than an arrest of mitosis and may include promotion of invasion via repression of timp- . funding: cihr. scott h purcell, jeremy d cantlon, virginia d winn, russell v anthony. , colorado state university, fort collins, co; university of colorado health sciences center, aurora, co. background: periattachment factor (pf) is a nuclear protein first described in the bovine conceptus. our research in sheep has shown pf mrna concentration peaks when the conceptus is undergoing elongation and initial apposition to the endometrium, and that pf is a nuclear protein localized to the trophoblast. in silico analysis identified a human homolog, hprr . objective: the objective of this experiment was to determine if pf was expressed in the human placenta, and to develop short-hairpin (sh) rnas for hpf to begin investigating its function. materials and methods: immunohistochemistry was performed on paraffin embedded first and second trimester human placental samples. placental sections were immuno-stained using rabbit polyclonal antiovine pf or anti-human cytokeratin- . cytotrophoblasts from first trimester pregnancies (n= ) were subjected to an in vitro invasion assay and rna was harvested following , , and h. quantitative rt-pcr was performed on these samples with intron-spanning primers for hpf, and normalized on hs mrna concentrations. based on the human pf sequence, four putative shrna constructs were generated and cloned into a lentiviral expression vector. bewo human choriocarcinoma cells were treated with one of four shrna contructs or an empty vector for h and then rna was harvested from cells for analysis by quantitative rt-pcr. results: periattachment factor was present in the nuclei of both first and second trimester cytotrophoblasts. hpf mrna concentration increased as invasion occurred from , , to h in all samples; while hypoxia decreased expression at h of invasion compared to h under normoxic conditions. the four lentiviral vectors expressing shrna against hpf resulted in hpf mrna concentrations at , , and % of hpf mrna concentration with the control vector. conclusion: the presence of pf in the human placenta and the increase in pf mrna during cytotrophoblast invasion may indicate this gene plays a role during implantation. we have developed shrnas against pf that result in greater than % mrna knockdown and will be using these to begin to elucidate the function of pf in the human placenta, specifically during the invasion process. recently we demonstrated that infusion of imd antagonist (imd - ) in rat caused distorted labyrinth indicative of a deficient vasculature in placenta. we hypothesize that imd has a role in migration of first trimester trophoblast cell (htr- /svneo) via regulating human leukocyte antigen (hla-g) and stimulating mek / / erk / phosphorylation. objectives: ) to asses the effect of imd on migrating capacity of htr- sv/neo cells using scratch assay in presence or absence of mek and ras/raf inhibitor, u and manumycin a, respectively ; ) to assess the effect of imd peptide on phosphorylation of mek / and erk / in first trimester htr cells ) to analyze the effects of imd on the expression of human leukocyte antigen, hla-g, a critical factor involved in the invasion and vascular remodeling of spiral uterine arteries and subsequent pregnancy in human. methods: htr- sv/neo cells were used to assess the effect of imd ( - m) on the expression of hla-g mrna and phosphorylation of erk / and mek / protein by reverse transcriptase polymeration chain reaction (rt-pcr) and western blot analysis respectively. scratch wound assay was used to determine the migration capacity of htr cells. total rna was isolated from cells using trizol reagent and processed for rt-pcr and results are expressed relative to s mrna. trichloroacetic acid was used for the extraction of total protein for western blot analyses. results: our data demonstrates that, ) imd enhances the migrating capacity of htr cells (compared to the untreated cells) and these effects are inhibited by mek and ras/raf inhibitors, u and manumycin a, respectively; ) imd ( - m ) stimulates phosphorylation of erk / and mek / proteins in htr cells, ) imd increases the expression of hla-g mrna in htr cells. conclusion: imd promotes migration of first trimester htr cells through mek/ erk signaling pathway and modulates the expression of immunoregulatory molecule, hla-g in these cells. chymotrypsin-like protease promotes the placenta tissue release of sflt- . yang gu, shuang zhao, david f lewis, yuping wang. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: the placenta is a major source of soluble vegf receptor- (sflt- ) in the maternal circulation during pregnancy. increased placental release of sflt- is believed to play an important role in the pathophysiology and pathogenesis in pe. however, the mechanism of increased placental sflt- release in pe is unknown. we recently reported increased chymotrypsin-like protease (clp) activity and expression in placental trophoblasts from pe. in this study, we tested if proteolytic effects of chymotrypsin may play a role in promoting sflt- release by placental trophoblasts. methods: placentas delivered by normal pregnant women (n = ) were used. we tested if chymotrypsin could promote sflt- release by placental tissue, in which villous explants were cultured with dmem containing chymotrypsin at . , . , and . g/ml for hours. the culture medium was then collected for measuring sflt- . we then determined the specificity of chymotrypsin induced sflt- release. villous tissues were cultured with or without chymotrypsin inhibitor (ci) in culture and then the medium was collected and measured for sflt- . soluble flt- was measured by elisa. all samples were assayed in duplicate. data are presented as mean ± se and analyzed by anova. a p level < . is considered as statistically different. results: ) sflt- concentrations in the medium were increased when chymotrypsin was present in culture and the increased sflt- release induced by chymotrypsin was in a concentration-dependent manner: control: . ± . ; . g/ml: . ± . ; . g/ml: . ± . ; and . g/ml: . ± . (p< . ) pg/mg tissue/hour. ) ci could attenuate sflt- release. this inhibitory effect was also revealed in a concentration-dependent manner: control: . ± . ; ci . g/ml: . ± . ; and ci . g/ml: . ± . (p< . ) pg/mg tissue/hour. conclusions: increased placental sflt- release stimulated by chymotrypsin and decreased placental sflt- release inhibited by chymotrypsin inhibitor suggest that the proteolytic effect of clp may play a role in sflt- generation. therefore, increased clp activity in placental trophoblasts may contribute to the increased placental sflt- production in pe. (supported nih grants hl and hd ). the change of autophagy-related proteins, lc and beclin- , by tnfa stimulation in cultured primary trophoblasts. soo-young oh, kyung hee kim, suk-joo choi, jong-hwa kim, cheong-rae roh. department of obstetrics and gynecology, samsung medical center, sungkyunkwan university school of medicine, seoul, korea. objective: our previous work have demonstrated that the expression of lc , but not beclin- , was increased in placentas from pregnancies complicated by severe preeclampsia (sgi abstract # ) . to understand the regulatory mechanism of these autophagy-related proteins in trophoblast cells, we investigated the changes in these proteins in response to cytokine or hypoxic stimulation in cultured primary trophoblast. material and methods: primary human cytotrophoblasts obtained from normal term placenta were cultured with stimulation of tnf-a or cocl for a given time and the changes of beclin- and lc were assessed using immunoblot analysis. paired t test was used for statistic analysis. results: tnf-a stimulation induced a significant increase of the expression of lc -ii in cultured primary trophoblasts while decreasing the expression of beclin- (p< . for each). however, cocl stimulation did not induce a significant change of both lc -ii and beclin- . conclusions: our data suggests that tnf-a stimulation in cultured primary trophoblasts is associated with increased autophagic activity. background: thyroid hormones play vital roles in the development of the fetal brain. mutations in mct , recently recognised as a specific thyroid hormone transporter, define a novel syndrome of severe x-linked psychomotor retardation accompanied by elevated serum t . we previously reported that mct expression in n-tera- (nt ) cells (a human embryonal cell line with characteristics of cns precursors), as well as mct -null jeg- choriocarcinoma cells, resulted in markedly reduced cell proliferation. further, the s x mct mutation, as reported in males affected by severe psychomotor impairment, resulted in a similar repression of proliferation to wild type, whereas the l p mutant failed to influence cell turnover compared with control. methods: we now examine the effect of "knocking down" mct via sirna and evaluate the effects of cell proliferation (mtt and [ h]-thymidine assays) and tri-iodothyronine (t ) uptake. results: repression of endogenous mct expression in nt cells by % caused a significant increase in proliferation compared to matched-dose nonspecific sirna treatment, independent of t concentration ( . %, . % and . % induction at , and nm t , n= , p< . ). we also sought to examine the role of mct in t uptake. in jeg- cells, wild type mct induced a . -fold increase in the uptake of i-labelled t . by contrast, mutants s x and l p failed to significantly augment t uptake, though r h caused a mild but significant . fold induction in uptake, hence retaining approximately % of wt activity. in parallel experiments, co-transfection of mu-crystallin, a t binding protein, resulted in a similar increase in t uptake compared with control ( . -fold; n= ; p< . ), implying that mct plays only a minor role in thyroid hormone efflux in jeg- cells. mutants s x, l p and r h showed analogous responses to those in the absence of mu-crystallin. conclusion: these results further extend the evidence of a potential role for mct in the modulation of cell proliferation, independent of t transport. to determine predictors of failure for labor induction in women with preeclampsia. we conducted a retrospective cohort study to examine cesarean delivery rates in all the preeclamptic women at a single institution undergoing labor induction between - with a singleton pregnancy >= weeks gestational age (ga). bivariate analyses informed the creation of multivariable logistic models to predict the risk of cesarean delivery using multiple predictors (maternal age, race/ethnicity, unfavorable cervix, gestational diabetes, diabetes, and gestational age). analyses were stratified by parity. our study population included , preeclamptic women undergoing labor induction. in the bivariate analyses, the risk of cesarean delivery ranged from as low as . % (p= . ) among multiparous women - weeks ga to as high as . % (p< . ) among nulliparous women with diabetes. a total of , women had adequate data to be included in the multivariable analyses. odds ratios of the predictors are presented in the objective: preeclampsia and cardiovascular disease share many risk factors, and women with preeclampsia are at increased risk of cardiovascular mortality later in life. we investigated whether risk factors associated with cardiovascular disease and preeclampsia remain elevated months postpartum. methods: we measured plasma sflt , endoglin, plgf, cellular fibronectin (cfn), uric acid, homocysteine, and asymmetric dimethylarginine (adma) in women with uncomplicated normotensive pregnancies compared to women with preeclampsia in samples collected at pre-delivery and again several months postpartum (average . ± . months). data are mean±sd or median (interquartile range). statistical analysis was by wilcoxin rank-sum or students unpaired t-tests with statistical significance accepted at p< . . results: the mean concentration of sflt , endoglin, plgf, homocysteine, adma, cfn, and uric acid were all significantly different in samples collected pre-delivery in subjects with preeclampsia compared to controls (table). adma, cfn and uric acid remained significantly higher postpartum in subjects with previous preeclampsia compared to postpartum controls (table) . conclusions: biological markers associated with altered vascular function or cardiovascular risk are elevated in women with preeclampsia, and some remain significantly higher in postpartum preeclamptic women. these data suggest that vascular dysfunction persists in women with previous preeclampsia, and may contribute to the increased risk of future cardiovascular disease. funded in part by national institutes of health nih- mo -rr and nih- po -hd . (ajp, ) . as leptin is a known potent angiogenic factor we hypothesized that leptin deficiency and/or resistance to leptin-induced vegf expression might be a mechanism for reduced angiogenesis in mfr offspring. methods: pregnant sprague-dawley rats had % mfr from day of gestation until delivery. mfr and control offspring were sacrificed on day of life (p ). some tissues were used to determine the expression of leptin by western blot analysis. for culture experiments, thoracic aortas were dissected, cut into - mm explants and incubated with leptin ( - ng/ml) in dmem ( % fbs). after hours of culture, rna was extracted from the tissues and subjected to real time rt-pcr using specific rat primers for vegf, vegfr and r , and ob-ra, stat and socs ( s mrna as control). culture media was analyzed for vegf protein by elisa. results: expression of leptin mrna and protein in p mfr aortas was significantly reduced. in culture, leptin significantly increased expression of vegf, vegfr and vegfr mrna in explants of aortas obtained from the control but not mfr tissues. as expected, control but not mfr aortic explants secreted significantly more vegf in vitro. to determine the mechanism for resistance to leptin-induced vegf in mfr offspring, we assessed expression of leptin receptor (ob-ra) in explants treated with leptin. leptin was found to induce the expression of ob-ra in aortas from both dietary groups. this upregulation of leptin receptor was accompanied by significant upregulation of stat and socs mrna in the control tissues. in contrast, in mfr explants only the ng/ml concentration of leptin induced an increase in stat mrna, and the magnitude of socs mrna increase by both concentrations of leptin was significantly less in the mfr explants. conclusion: these results indicate that reduced angiogenesis in mfr vessels is in part due to reduced leptin expression and ability of leptin to stimulate vegf expression. although in vitro leptin induced the expression of its receptor in both groups, it was only in the mfr group in which leptin up-regulated vegf and its receptors. our results suggest that this defect in leptin receptor function in mfr vessels is due, in part, to defects in jak/stat signaling. objective: women with a history of early-onset preeclampsia are at increased risk of developing major cardiovascular disease (cvd) related events, that have a detrimental effect on their long-term health and life expectancy. in this follow-up study, we measured established risk factors predictive of first cvd events after early-onset preeclampsia. study design: over a -year interval, primiparous women with a history of early-onset preeclampsia (delivery < weeks gestation) were included and tested for major cardiovascular risk factors at least six months after delivery, in addition to a population-based control group of healthy non-pregnant women. women with chronic hypertension were excluded. results: mean age was . years for cases compared to . years for controls (p<. ). after adjustment for age, we observed significantly increased mean values for weight (p=. ), body-mass index (p<. ), systolic blood pressure (p<. ), diastolic blood pressure (p<. ), total cholesterol (p=. ), ldl cholesterol (p<. ), triglycerides (p=. ), fasting blood glucose (p<. ), and lower hdl cholesterol (p<. ) in women with previous early-onset preeclampsia. no difference was found for height, smoking, diabetes, and ethnicity. estimated -year risk of first cvd events by framingham risk scores remained < % for all women (low-risk). nonetheless, at mean (sd) . ( . ) years after early-onset preeclampsia, % of women met the criteria for metabolic syndrome, % of women exhibited >= , % of women >= and % of women >= major cvd risk factors. conclusion: the majority of women with a history of early-onset preeclampsia exhibit at least one modifiable risk factor for future cvd. although most of these women are classified as low-risk according to the current aha guidelines, this is mainly due to their young age masking other, mostly modifiable, major risk factors. our data thus support life-style intervention programs aimed at primary prevention of cvd in women with a history of early-onset preeclampsia. it has recently been shown that antihypertensive drugs can stimulate cytokine release in normal and hypertensive pregnancy. there is evidence that these cytokines alter the secretion of inhibin a. inhibin a and activin a levels are increased in pre-eclampsia (pe), but it is not known if antihypertensive therapy can affect their secretion. patients and methods we recruited women with hypertensive disorders in pregnancy ( pe and non-proteinuric hypertension [ht]) and matched normotensive controls. inhibin a and activin a levels, before and - hours after initiating antihypertensives, were measured in serum and urine, using an elisa. the same markers were measured using validated assays in placentas delivered at cesarean section at similar gestational age ( pe, ht and controls). analysis the three study groups were compared using anova multiple comparisons with bonferroni post hoc testing. the data were normally distributed after logarithmic transformation. marker levels before and after antihypertensive therapy were compared using paired t-test. we compared placental concentrations between the group which received antihypertensive therapy and the group which did not, using an independent t-test. data were analysed using spss®. in pe, both serum and urine levels of inibin a and activin a were increased at all gestations (p< . ). activin a (but not inhibin a) level was also increased at all gestations in ht (p< . ). after weeks' gestation (but not before), antihypertensive treatment was associated with a significant fall in both inhibin a and activin a serum levels, and urinary inhibin a, in both pe and ht. the placental concentration of inhibin a, but not activin a, was significantly higher in women with pe compared with controls (p< . ). there was no significant difference in either marker between controls and women with ht. the fall in serum levels of inhibin a and activin a following antihypertensive treatment after weeks' gestation may indicate that these drugs have an effect on the pathophysiology of pe other than their known antihypertensive action. pre-eclampsia (pe) is a placental disease of unknown etiology. anti-angiogenic factors, such as soluble fms-like tyrosine kinase (sflt- ) and soluble endoglin (seng), and pro-angiogenic factors, such as vascular endothelial growth factor (vegf) and placental growth factor (plgf), are believed to play an important role in its pathophysiology. maternal plasma concentrations of these markers are altered in pe, even weeks before the clinical manifestations. the aim of this study was to compare the concentration of these markers in placental extracts of normotensive pregnant women, and women with pe and non-proteinuric hypertension (ht). patients and methods placental samples were collected at cesarean section from women with pe (n = ), ht (n = ) and normotensive pregnancies of similar gestational age (n = ). these samples were stored at - ºc. the frozen tissue samples were homogenised and these four markers measured by specific, validated enzymelinked immunosorbent assays. analysis the three study groups were compared using anova multiple comparisons with bonferroni post hoc testing. the data were normally distributed after logarithmic transformation. data were analysed using spss®. the concentrations of both sflt- and seng were significantly higher in the placentas of women with pe, but not ht, compared with controls (p= . ). there was no significant difference in plgf concentration between controls and women with pe or ht. placental vegf concentrations in both pe and ht were higher than in controls (p< . ); there was no significant difference between the levels in pe and ht (p= . ). the fact that placental concentrations of sflt- and seng mirrored the known rise in serum levels in pe suggests that the placenta is the main source of these circulating factors. although sflt- was significantly raised in pe, plgf was not reduced. this suggests that the lower levels of free plgf found in the serum of women with pe are not the result of impaired placental production or secretion, but are due to increased binding by (the increased levels of) sflt- in the serum. objective. the purpose of this study was to evaluate whether systematic screening with uterine artery doppler (utad) and serum biochemical markers of oxidative stress, endothelial dysfunction and vasculogenesis performed during the first trimester predict efficiently pre-eclampsia (pet), specifically early-onset pet, in an unselected chilean population. methods. this nested case-control study involved asymptomatic pregnancies scanned at + - + week of gestation. the subjects for biochemical testing were women who were delivered due to pet (n= ) and normotensive controls (n= ) that were enrolled during the first trimester scan. mean pulsatility index (pi) of the utad was calculated. blood samples were obtained and stored at - o c until biochemical analysis of oxidative stress, endothelial dysfunction and vasculogenesis were performed. normally distributed data were analysed by the unpaired t test, and non-normally distributed data by the mann-whitney rank sum test. chi-square tests were used for the comparison of categorical variables. a probability level of p< . was considered significant. multiple logistic regressions were used to develop a combined predictive index. results. there was % and % significantly increased of the mean pi utad in women who later developed pet or early-onset pet compared to control pregnancies during the first trimester scan. although oxidative stress and endothelial dysfunction biochemical markers were not different between all pet pregnancies and control groups, plasma levels of sflt ( . ± . vs. . ± . pg/ml, p< . ) and placenta growth factor ( . ± . vs. . ± . pg/ml, p< . ) were significantly higher in women who subsequently developed early-onset pet compared to controls. multivariate logistic regression showed that a combination between abnormal utad and both biochemical markers of abnormal vasculogenesis were the best predictor test for early-onset pet, being its detection rate % with % false positive rate. conclusion. this study has shown early and selective changes in markers of impaired placentation and angiogenic state in women who later developed earlyonset pet, without alteration in oxidative stress and endothelial dysfunction. supported by fondecyt . currently it is unknown whether maternal inflammatory changes are specific to pregnancy or reflect an innate susceptibility to inflammation. c-reactive protein (crp) and interleukin- (il- ) are markers of the acute-phase inflammatory response and predictive of future cardiovascular events. we compared crp and il- levels after influenza vaccination, as an in vivo model for lowgrade inflammation, in non-pregnant women with a history of early-onset preeclampsia and controls with only uneventful pregnancies. methods: forty-four women with a history of early-onset preeclampsia (delivery < weeks' gestation) and twenty-nine controls with at least one uneventful pregnancy received an influenza vaccination. we then compared plasma levels of crp and il- at baseline, . days and . days after vaccination. results: median baseline crp and il- levels of women with a history of early-onset preeclampsia were comparable to controls ( . versus . mg/l; p= . and . versus . pg/l; p= . , respectively). however, high crp and il- responses to vaccination were more common in cases (ors for response > th, > th, > th, > th and > th percentile based on the distribution of control values of . , . , . , . and for crp [p for trend . ] and of . , . , . , . and . for il- [p for trend . ], respectively). the relationship between high il- responses and early-onset preeclampsia persisted after adjustment for body-mass index (p for trend . ). conclusion: women with a history of early-onset preeclampsia more frequently exhibit an innate pro-inflammatory phenotype not specific to pregnancy. background altered maternal inflammatory responses play a role in the development of preeclampsia and the hemolysis, elevated liver enzymes and low platelets (hellp) syndrome. we examined whether allelic variants of the innate immune receptors toll-like receptor (tlr ) and nucleotide-binding oligomerization domain (nod ), that impair the inflammatory response to endotoxin, are related to preeclampsia and hellp syndrome. we determined five common mutations in tlr (d g and t i) and nod (r w, g r and l fs) in primiparous women with a history of early-onset preeclampsia, of whom women developed hellp syndrome and in women with a history of only uneventful pregnancies as controls. in addition, we assessed plasma levels of pro-inflammatory biomarkers c-rp, il- , sicam- , fibrinogen and von willebrand factor in a subset of women included at least six months after delivery. after adjustment for maternal age and chronic hypertension, attenuating allelic variants of tlr were more common in women with a history of early-onset preeclampsia than in controls (or . [ % ci . - . ]). highest frequencies for tlr variants were observed in women who developed hellp syndrome (adjusted or . [ % ci . - . ]). in addition, high levels of il- and fibrinogen were associated with a history of early-onset preeclampsia. combined positivity for any of the tlr and nod allelic variants and high levels of il- was . -fold more common in women with a history of early-onset preeclampsia ( % ci . - . ) compared to controls. we observed an association of common tlr and nod gene variants, and pro-inflammatory phenotype with a history of early-onset preeclampsia and hellp syndrome, that suggests involvement of the maternal innate immune system in severe hypertensive disorders of pregnancy. thus, we sought changes in pbef in the serum of patients with mild and severe pe, compared with matched controls. immunodistribution of pbef in fetal membranes and placentas from similar patients was also studied. methods: serum samples ( ) were collected with clinical data including; gestational age, medications, ethnicity and recognized complications. patients in labor or infection were excluded. the standard bp and proteinuria criteria was utilized to classify cases for pe grouping; no pe (n= ), mild pe (n= bp; / - / , proteinuria; trace to + or - mg/ hr urine) and severe pe (n= bp; > / , proteinuria; > + or > g/ hr, or other associated symptoms). pbef concentration was determined by eia (phoenix pharmaceuticals) in accordance with the manufacturers instructions. fetal membranes and placentas of additional patients, no pe (n= ) and with pe (n= ) were fixed and embedded in paraffin. sections ( um) were immunostained with pbef antibody / (pheonix) and treated with abc reagent (vector labs) followed by dab ( . % mg/ml), washed, counterstained, mounted and viewed under brightfield microscopy. results: the concentrations of pbef in serum were between - ng/ml and were significantly higher in those patients with mild pe (p= . ) and further significantly elevated in those with severe pe (p= . ) compared with the matched controls. pbef was detected by immunocytochemistry in the placental syncytiotrophoblast and in the amnion and choriodecidua of the fetal membranes. conclusions: pbef was elevated in the serum of patients according to the degree of pe severity and may be derived from the placenta and/or fetal membranes. (supported by nih #u rr - to the pacific research center for early human development, university of hawaii). background: platelet-monocyte aggregation (pma) is a novel sensitive measure of platelet activation and indicates a proinflammatory state (cytokine release). less sensitive techniques demonstrate platelet activation during pregnancy and pre-eclampsia (pe) but platelet activation has not been assessed by pma.objective: longitudinal study of pma in normal pregnancy and pe. methods: healthy, non-smoking primigravida with an uncomplicated pregnancy and primigravida women with pe were studied. pe was defined by standard definitions. informed consent was obtained and the study had ethical approval. serial venous blood collected at , , , wks in controls, at time of diagnosis in pe cases and wks post-natal (pn) in all. pma, platelet surface p-selectin (psp-sel) and monocyte cd expression (mcd ) were analysed by flow-cytometry and plasma (p) p-sel by elisa. results: groups were matched for mean age and bmi. in controls, pmas, psp-sel and mcd expression and pp-sel increased with gestation and decreased post-natally (table ) . for pe analysis, data was divided into pre-term (sampled at mean wks), and term (mean wks). pp-sel was lower in pre-term pe than control (normal pregnancy wks; p= . ) there was no significant difference in other measures between pe and control ( objective: much effort has been put into the evaluation of novel markers to identify pregnant women at risk for the development of pre-eclampsia. soluble endoglin (seng) and soluble fms-like tyrosine kinase (sflt ), two antiangiogenic agents, appear to be involved in the pathogenesis of pre-eclampsia. despite several studies describing higher midtrimester serum concentrations of these markers in women with subsequent pre-eclampsia, information on first trimester serum levels is scarce. the aim of this study was to assess seng and sflt as first trimester serum markers for the prediction of pre-eclampsia. methods: sera were obtained between + and + weeks of gestation from women who later developed late-onset pre-eclampsia and from controls matched for gestational age, maternal age, maternal pre-pregnancy weight, and storage. using commercially available microplate enzyme immunoanalytical methods, seng and sflt were determined and the results analyzed using non-parametric statistical tests. results: the serum concentration of seng was found to be increased in women with subsequent pre-eclampsia when compared to controls (mean ± sd, . ± . ng/ml versus . ± . ng/ml, p = . , unpaired mann-whitney test). similarly, the serum levels of sflt were higher in women later developing late-onset pre-eclampsia ( ± ng/ml) when compared to controls ( ± ng/ml, p = . ). sensitivities and specificities for predicting pre-eclampsia were % and % for seng and % and % for sflt- , respectively. the combination of the two markers by multiplication yielded a sensitivity of % and a specificity of %. conclusion: seng and sflt , showing increased first trimester serum levels in women with subsequent pre-eclampsia, might both fulfill the characteristics of first trimester markers to predict pre-eclampsia. the combination of the two, however, did not improve the sensitivity nor the specificity compared to their individual determinations. moderate sensitivities and specifities, however, limit the clinical use of these molecules as single markers. pregnancy is associated with increased monocyte/platelet aggregate formation in whole blood. beth a bouchard, adrienne schonberg, gary j badger, ira m bernstein. biochemistry; obstetrics and gynecology; medical biostatistics, univ of vt, burlington, vt, usa. background preeclampsia is associated with increased rates of platelet clearance, changes in platelet function and platelet activation. the goal of the current study was to examine basal levels of platelet activation through pregnancy beginning prior to conception, and to examine the association of platelet activation with the development of hypertensive complications during pregnancy. methods two indices of platelet activation, platelet cd expression (%cd ) and monocyte/platelet aggregate (%mp) formation, were measured in whole blood by flow cytometry using specific, fluorescentlylabeled monoclonal antibodies in healthy, nonsmoking women during the follicular phase of their menstrual cycle (pp, cycle day . + . ). all women subsequently conceived singleton pregnancies and were re-examined in early (ep, - wks) and late pregnancy (lp, - wks). five of these women were diagnosed with hypertensive complications ( hypertension, preeclampsia) at term although hypertension was not observed at any study time point. data are expressed as mean±sem. p< . was accepted for significance. results subjects were . + . years old with a bmi of . + . kg/m at the time of prepregnancy studies. a significant increase in the %mp formed over time of pregnancy was observed (p= . ). there was little change in the %mp formed between pp and ep (pp, . ± . % and ep, . ± . %, p= . ). however, the %mp increased significantly in lp ( . ± . %) as compared to pp (p= . ) and ep (p= . ). this increase occurred independent of the development of hypertensive complications (p= . ) and independent of pp platelet activation status. although statistically significant increases in cd expression were not observed, the change in cd expression over pregnancy correlated with the change in %mp over pregnancy (r= . , p= . ) and cd expression correlated with %mp in lp (r= . , p= . ). conclusion these combined observations suggest that pregnancy is associated with increases in levels of unstimulated platelet activation and that these increases occur in the presence or absence of subsequent hypertensive complications. furthermore, we observed a correlation between the changes in two distinct platelet activation events, %mp and cd expression, during pregnancy. supported by nih hl . backgound sildenafil citrate (sc) has been proposed as a therapy to improve uterine perfusion in pregnancies complicated by iugr or preeclampsia. we sought to determine the effects of sc on uterine vascular resistance, uterine blood flow and cardiac output in young healthy nulliparous women. methods eleven young healthy nulligravid women were studied during the luteal phase (cycle day + ) of the menstrual cycle. women were randomized in a double-blind fashion to receive placebo (pl), or sc at a dose of or mg. uterine artery vascular resistance, uterine artery volumetric flow, brachial artery volumetric flow and cardiac output were measured at baseline and at and hours post dosing employing color doppler ultrasound. comparisons were made by anova between those randomized to pl (n= ) versus sc (n= ). p< . was accepted for significance. data are expressed as mean + s.e.m. results there were no significant differences in subject age, cycle day, body mass index, uterine blood flow, brachial blood flow or cardiac output at baseline comparing the two groups. there was a tendency towards increased uterine blood flow in subjects randomized to receive sc ( % increase) compared to pl (no change), changes in uterine blood flow, brachial blood flow and cardiac output are outlined in the objective reduced maternal plasma volume in the third trimester has been associated with both fetal growth restriction and preeclampisa. we sought to determine the degree to which third trimester plasma volume is dependent on plasma volume prior to pregnancy. methods sixteen young ( . + . years) healthy nulligravid women had their plasma volume measured during the follicular phase (cycle day . + . ) of the menstrual cycle and subsequently conceived. subjects were predominantly caucasian ( / ) with a mean prepregnancy bmi of . + . kg/m . plasma volume was re-estimated at - weeks gestation. all patients were placed on sodium and total calorie balanced diets for days prior to each plasma volume determination. plasma volume was determined employing evans blue dilution with multiple post injection sampling time points. data are expressed as mean + s.d. results baseline prepregnant plasma volume was , + ml or + ml/unit bmi. third trimester plasma volume was , + ml representing a % increase (p< . ). the range of plasma volume expansion was - % dependent upon prepregnant plasma volume. plasma volume in the third trimester of pregnancy was strongly correlated to prepregnant plasma volume r= . (p= . ). plasma volume expansion was consistent across the range of prepregnancy plasma volume. conclusions pre-pregnancy plasma volume contributes approximately % of the variance in third trimester plasma volume. the observed increase is plasma volume is independent of prepregnancy volume resulting in a greater percentage increase for those starting at the lower end of the plasma volume range. as third trimester plasma volume is strongly associated with pregnancy outcome the correlation of prepregnancy plasma volume to third trimester plasma volume suggests that prepregnancy status contributes to these adverse reproductive events.this work was supported by nih hl . background: hydatidiform mole is a rare disorder of pregnancy and may predispose the mother to severe morbidity. molar pregnancies are known to be associated with high risk for the development of early onset preeclampsia. in recent years, the expression of sflt- (soluble vegfr- ) was found to be increased in preeclampsia, and contributes to the pathogenesis of the maternal systemic disease. the objective of the present study was to examine the expression of sflt- in placentae from molar pregnancies. methods: placental samples from unique cases of twin pregnancies with complete molar pregnancy in one sac and developing fetus in the other sac were prospectively collected (n= ). the first set delivered at weeks due to excessive bleeding. the second set delivered at weeks due to severe iugr and elevated blood pressure. mrna level of sflt- was measured by quantitative real-time pcr using specific taqman primers and probe. protein expression of sflt- in placental tissue lysates were measured by western blot analysis using a polyclonal antibody against flt- . immunohistochemistry of paraffin embedded samples was performed using specific antibody for sftl- . results: mrna level of sflt- was increased by . fold in the molar placentae compared to matched controls. the placentae of the developing fetuses which were growth restricted exhibited . fold increase compared to controls. sflt- protein expression in the molar placentae was increased by . fold compared to controls, while the co-twin placentae exhibited a . fold increase compared to controls. immunohistochemistry revealed strong positive immunoreactivity for sflt- in the trophoblast layer of both molar pregnancies and iugr co-twin relative to controls. conclusion: our data suggest that sflt- expression is increased in placentae from molar pregnancies and thus may explain the increased risk for developing early onset preeclampsia. the expression of sflt- in the growth restricted twin placenta is also increased compared to controls and support our previous observation (supported by cihr and owh/igh). (n= ); ) neonates of patients with pe (n= ); and ) sga neonates (n= ). cord blood was collected immediately after delivery and pz plasma concentrations were measured by elisa. pz deficiency was defined as a cord plasma concentration < th percentile of the normal pregnancy group. non-parametric statistics were used for analysis. results: ) cord plasma pz concentration differed significantly among the study groups (kruskal wallis, p< . ); ) neonates of patients with pe and sga neonates had a significantly lower median cord plasma pz concentration than those delivered after normal pregnancy (pe: median . g/ml, range . - . , p< . ; sga: median . g/ml, range . - . , p= . ; normal pregnancy: median . g/ml, range . - . ); ) there were no differences in the rate of pz deficiency among the groups; and ) there was no relationship between placental histologic findings and median cord plasma pz concentrations between and among the sga and pe groups. conclusions: ) at the time of delivery, the median cord plasma pz concentration was lower in sga neonates and those born to women with pe than in neonates born to normal pregnancies; ) there was no difference in the rate of pz deficiency among the study groups, suggesting that the lower median pz cord blood concentrations in pe and sga groups may result from activation of the coagulation cascade rather than an inherited pz deficiency. objective: periconceptional multivitamin (mv) use may be related preeclampsia risk. we examined the relation between timing and frequency of periconceptional multivitamin use and the risk of preeclampsia. methods: women in the danish national birth cohort who delivered singleton liveborn infants (n= , ) reported upon enrollment at . weeks (sd . ) the number of weeks of regular multivitamin use during a week periconceptional period (lmp- to lmp+ ). preeclampsia cases were identified using icd- codes (n= , . %). logistic regression was used to estimate the effect of frequency (number of weeks of use) and timing of use to lmp+ ] and post-conception [lmp+ to lmp+ ]). results were stratified a priori by overweight status. results: overall, , women ( %) reported mv use in the periconceptional period. after adjustment for bmi, smoking, parity and chronic hypertension, infrequent mv use (< weeks of use) had no relation to risk (or . ; % ci . , . ) but regular use (>= weeks) was associated with modestly reduced risk ( . ( . , . ). similarly, when mv use was modeled as a continuous variable, each additional week of use was related to reduced risk for preeclampsia (or . , % ci . - . ). this potential dose effect of periconceptional mv use appeared to be limited to normal weight women (bmi < kg/m², or . ; % ci . - . ), with no apparent effect among overweight women (bmi kg/m², or . ; % ci . - . ). a total of , women reported regular mv use in both the preconception and post-conception periods, and , women reported regular use only in the post-conception period. among normal weight women, regular use in the preconception period had no effect on preeclampsia risk (or . , % ci . - . ). in contrast, use in the post conception period was associated with reduced risk for preeclampsia (or . , % ci . - . ). conclusions: regular periconceptional mv use was associated with a modestly reduced risk for preeclampsia among normal weight women. if causal, mv use immediately after conception appeared to be the critical exposure window. background: pre-eclampsia (pe), a disorder of pregnancy characterized by maternal inflammation, results in immune, cardiovascular and metabolic dysfunction. in non-pregnant persons, inflammatory disorders are treated with and prevented by pharmaceuticals and lifestyle methods such as physical activity (pa). while most pharmaceuticals are contraindicated for pregnant women, pa during pregnancy has been found safe, healthy and beneficial for both mother and baby. clinical evidence has found pa can beneficially affect pregnancy outcome, decrease excessive inflammation and decrease the risk of pe. epidemiological studies indicate that pa may be useful in preventing pe. unfortunately, previous studies have quantified pa based on recall of postpartum women and have not controlled for differences in women's interpretations of amount, type or intensity of pa. however, investigating pa utilizing a laboratory-based exercise intervention to control these variables inflicts difficulties translating the intervention into a community-based program that attracts and retains pregnant women in order to enhance public health. method: a retrospective study was performed to determine the rates of pe among the , women who gave birth at yale-new haven hospital (ynhh) during and , and a person subset of this group who performed prenatal pa in a community-based program that is evidence-based and standardized, thereby controlling for type and intensity of pa. additionally, the program is established in the community, has been offered to the public for years and is internationally known. results: during during - , the pe rate for the general population at ynhh was . %. for the pa group, the rate was . %. two women in the pa group were diagnosed with pe in the last month of pregnancy and delivered normal infants at term. no pe was observed in this group (pa group) during the second or early third trimesters nor was there any prematurity in this group. significance: these findings support the hypothesis that adequate physical activity provided in a standardized community-based group setting may provide a non-pharmacological approach for preventing pe. growth restriction. margreet plaisier, esther streefland, pieter koolwijk, frans m helmerhorst, jan jaap hm erwich. department of gynecology and reproductive medicine, leiden university medical center, leiden, netherlands; department of obstetrics and gynecology, university medical center groningen, groningen, netherlands; department of physiology, vu univerity medical center, amsterdam, netherlands. objective: disturbances in decidual and placental vascular development may play a role in the pathogenesis of pregnancy complications, like pre-eclampsia (pe) or fetal growth restriction (fgr). whether the regulation of decidual vascular adaptation to implantation is altered in these illnesses, is not elucidated yet. the present study focused on the role of first-trimester angiogenic factors in the pathogenesis of pe and or fgr. methods: first-trimester decidua samples were obtained during routine chorionic villous sampling. the expression of vascular endothelial growth factor (vegf-a), placental growth factor (plgf), flt- , kdr, angiopoietin- (ang- ), angiopoietin- (ang- ) and tie- mrna was determined by rt-pcr. the expression of the angiogenic factors was related to the pregnancy outcome, i.e. uncomplicated, pe or fgr. results: the first-trimester decidual tissues expressed all angiogenic factors. mrna levels of vegf-a, plgf, kdr, ang- , ang- and tie- appeared increased in fgr cases compared to matched controls. in addition, plgf, ang- and tie- mrna appeared increased in pe cases compared to matched controls. the differential expression of angiogenic factors was more pronounced in cases with fgr than pe. the large inter-individual variation disallowed a significant outcome. conclusions: various angiogenic factors showed differential mrna expression in st trimester decidua of patients developing pe or fgr in later pregnancy compared to their matched controls. the first-trimester decidual samples provided a unique opportunity to obtain information regarding the onset of pe and fgr. early st trimester changes in angiogenic factor expression may well occur as a compensatory mechanism. in turn, this may set the stage for increased non-branching angiogenesis and altered decidual and placental vascular adaptation, which may be part of the pathogenesis of pe and/or fgr. complications. beth a bouchard, adrienne schonberg, gary j badger, ira m bernstein. biochemistry; obstetrics and gynecology; medical biostatistics, univ of vt, burlington, vt, usa. background preeclampsia is characterized by endothelial dysfunction. the goal of the current study was to prospectively measure plasma levels of the soluble endothelial cell adhesion molecules, sicam- and svcam- , beginning prior to pregnancy and determine if subjects destined to develop hypertension complicating pregnancy had differences in the concentrations of these molecules. methods serum levels of sicam- and svcam- were measured in healthy, nonsmoking women (cycle day . + . , prepregnancy) by elisa. all women subsequently conceived singleton pregnancies and were re-examined in early (ep, - weeks) and late pregnancy (lp, - weeks). five of these women developed hypertensive complications ( gestational hypertension, pre-eclampsia) near term. all subjects were normotensive at all study time points. data are expressed as mean ± sem. p< . was accepted as significant. results subjects were . + . years old with a mean bmi of . + . kg/m at the time of prepregnancy studies. significant differences in sicam- levels as a function of pregnancy were observed (p= . ) and are outlined in table p= . differences were dependent upon the stage of pregnancy in those women who were not diagnosed with hypertensive complications with a decrease in sicam- levels in ep (p= . ) followed by an increase in sicam- levels in lp (p= . ). in women with hypertension in pregnancy, these differences in sicam- levels were not evident (p= . ). there were no differences in sicam- levels comparing women with or women without hypertensive complications prior to pregnancy (p= . ). in contrast to sicam- , we observed no significant differences in svcam- levels over pregnancy or between those with and without hypertension. conclusions these combined observations suggest that levels of the soluble adhesion molecule sicam- change significantly over time in normal pregnancies. subjects destined to develop hypertension did not demonstrate the early pregnancy reduction in sicam- . supported by nih hl . yuval bdolah, uriel elchalal, shira natanson-yaron, hadas caspi, tali bdolah-abram, angelika bord, caryn greenfield, debra goldman-wohl, ariel milwidsky, franklin h epstein, s ananth karumanchi, simcha yagel, drorith hochner-celnikier. ob/ gyn, jerusalem, israel; ob/gyn medicine, beth israel deaconess medical center, harvard medical school, boston, ma, usa. objectives: nulliparity is a risk factor for preeclampsia (pe) with a reported incidence of up to - times higher than multiparous pregnancies. soluble fms-like tyrosine kinase- (sflt ), a circulating anti-angiogenic molecule of placental origin plays a pivotal role in pe by antagonizing placental growth factor (plgf). increased sflt and sflt /plgf have been shown to antedate clinical signs in pe. we therefore hypothesized, that the higher risk of pe in nulliparous pregnancies is associated with high sflt (or sflt /plgf). methods: maternal serum samples from nulliparous (n= ) and multiparous (n= ) term singleton pregnancies without pe, at the time of admission to delivery room, were used. serum samples were analyzed for levels of sflt and plgf by elisa. statistical analysis was performed applying t-test and the kruskall-wallis test and using spss software. results: for nulliparous and multiparous pregnancies, the mean serum sflt levels were , ± and , ± , (p= . ), the mean serum plgf levels were ± and ± (p= . ), and the mean ratios of sflt- /plgf were ± and ± (p= . ), accordingly. in a subgroup of multigravidous nulliparous pregnancies, sflt levels were , ± . correcting for maternal age did not alter the results. moreover, results did not differ between multiparous pregnancies with a - years interpregnancy interval compared with a - years interval. conclusions: in nulliparous pregnancies, circulating sflt levels and sflt / plgf ratios are significantly higher than in multiparous pregnancies. these findings suggest that the increased risk of pe in nulliparous pregnancies may involve anti-angiogenic imbalance. nulliparity may be more substantial than primigravity, as a risk factor for pe, suggesting that first semester abortions in primigravidas may not protect from pe in a subsequent term pregnancy. nevertheless, even - years intervals from the previous gestation do not increase the risk for pe. different normograms of angiogenesis should be used, when assessing the risk for pe in multiparous versus nulliparous pregnancies. objective: we determined whether maternal serum levels of angiogenic proteins namely soluble fms like tyrosine kinase (sflt- ), soluble endoglin (seng), and placental growth factor (plgf) -measured during the first trimester are associated with the subsequent development of placental abruption. methods: we performed a prospective, nested case-control study of women enrolled in the massachusetts general hospital obstetric maternal study (moms). first trimester serum samples from placental abruption cases and normal pregnancies were measured for angiogenic factors. cases and controls were matched by body mass index and age. placenta abruption was diagnosed by standard clinical findings and pathological examination of the placenta. women with confirmed preeclampsia or chronic hypertension were excluded. results: compared to controls, cases had more pregnancies, delivered infants at an earlier gestational age and with lower birth weight. first trimester levels of seng were significantly increased in cases compared to controls: . ± . ng/ml vs. . ± . ng/ml, p < . . there were no significant difference in serum levels of plgf, . ± . ng/ml versus . ± . ng/ml, p=ns, although sflt levels were lower in cases: . ± . ng/ml vs. . ± . ng/ml, p=ns. in logistic regression analysis adjusted for age, race, smoking, number of pregnancies, gestational age at delivery, gestational age of blood sampling, and blood pressure at first prenatal, seng levels remained independently associated with subsequent risk (odds ratio . , % ci . - . ) of placental abruption. examining this relationship by tertiles of seng, in the unadjusted model, women in the second (or . , % ci . - . ) and third (or . , % ci . - . ) tertiles were at increased risk of developing placental abruption compared with women in the lowest tertile. after adjusting for known risk factors of placental abruption, women in the second (or . , % ci . - . ) and third (or . , % ci . . ) tertiles remained at increased risk for placental abruption. conclusion: increased first trimester maternal serum levels of seng are associated with increased risk of subsequent placental abruption. ob/gyn, univ of vermont. shear stress is the most potent physiologic stimulus for elevating endothelial no production for flow-mediated vasodilatation. we measured in vivo shear stress during the proliferative and secretory phases and at and weeks of gestation hypothesizing that uterine blood flow (ubf) elevations in turn increase shear stress in early and late gestation. methods: during proliferative, secretory phases, and at and - weeks of pregnancy ua blood velocity and internal radius were measured bilaterally using color doppler ultrasound. blood viscosity was measured at shear rates in excess of /sec. results: compared to the proliferative phase viscosity was decreased at weeks and more so at weeks gestation (p< . ). . ± . . ± . nsd . ± . *** . ± . *** ua velocity (cm/sec) . ± . . ± . *** . ± . *** . ± . *** ubf (ml/min) . ± . ± *** . ± . *** . ± . *** shear stress (dynes/cm ) . ± . . ± . *** . ± . *** . ± . *** internal ua radius was not altered by the menstrual cycle, and was greater at weeks (+ %) and weeks (+ %). compared to proliferative, secretory phase showed significant rises in unilateral ubf and velocity that rose progressively during gestation. in contrast, shear stress increased in secretory ( %) and did not rise further in early pregnancy but by weeks shear stresses was further elevated %. conclusions: equivalent rises in shear stress during the secretory phase and weeks gestation demonstrate increases in radius and profound remodeling of uas that reflect the physiologic process of "normalization of shear". by late gestation, continued but modest rises in radius illustrate that further increases in shear stress occur almost solely due to rises in ubf via falls in down stream impedance. continued rises in shear stress into late gestation provide progressive stimuli for no production by ua endothelium. nih hl , hd , hl background: hypertension during pregnancy is associated with altered uterine vascular reactivity and blood flow, although its effects on arterial myogenic behavior have not been explored. the purpose of this study was to evaluate the effects of hypertension and no inhibition on myogenic tone in pregnancy, as the ability of a vessel to constrict and dilate in response to pressure plays a key role in regulating blood flow to the uterus. methods: three groups of sprague dawley late pregnant (day ) rats were used: control (n= ), hypertensive ( . g/l l-name in the drinking water, n= ), and treated with l-name and hydralazine (also in the drinking water, . g/l, n= ) to prevent the blood pressure increase, yet maintain no inhibition. resistance-sized radial arteries (< m) were mounted in a pressure arteriograph and equilibrated at mmhg (in pss containing l-nna and indomethacin) to induce a myogenic response. vessels were then subjected to pressure steps from to mmhg. tone (%) was calculated by comparing the vessel diameter at each pressure with the passive diameter at the same pressure (determined by incubation with . mm papaverine and m diltiazem). results: myogenic tone developed in controls ( ± % maximal), and was maintained over a broad range of transmural pressures . arteries from the l-name group did not develop tone at any pressure. co-treatment with hydralazine reinstated tone ( ± % maximal) over the same range of pressures as in the control group. the reduction in average placental weights in the l-name group ( vs. mg, p< . ) was restored by hydralazine ( mg, p< . vs. l-name). average fetal weights were also reduced in the l-name group ( . vs. . g, p< . ), but only partially restored by hydralazine co-treatment ( . g, p< . vs. control and l-name groups). conclusions: surprisingly, radial uterine arteries from the l-name group did not develop tone over any range of pressures, despite the fact that matched arteries from late-pregnant controls developed significant myogenic tone. this abolishment of tone was reversed by hydralazine, which also had beneficial effects on fetal and placental growth. these results implicate hypertension rather than no inhibition as the key factor in the suppression of myogenicitiy and dysregulation of uterine blood flow. charles r rosenfeld, timothy roy. division of neonatal-perinatal medicine, ut southwestern medical center at dallas, dallas, tx, usa. background: upbf b rises -fold in ovine pregnancy; but the mechanisms responsible for the rise and maintenance are unclear. we (jsgi ) reported that uterine vascular smooth muscle bk ca k + channels contribute to uterine vasodilation and upbf b maintenance; but up-stream activators are unclear. uterine vascular prostacyclin synthesis increases in pregnancy, but cyclooxygenase inhibition does not alter upbf b (ajp ) . vascular nitric oxide synthase (nos) also increases; but acute inhibition with l-name decreases upbf b only % (jci ) . it is unclear if l-name doses were insufficient or if prolonged nos inhibition has a greater effect. objective: to determine if local nos inhibition with l-name dose-dependently decreases upbf b and if prolonged inhibition exerts a greater effect on upbf b . methods: pregnant ewes were studied at - d gestation age (ga). had doseresponse studies with uterine artery l-name infusions to achieve . - . mg/ml over min. had h arterial l-name infusions to achieve and maintain levels of . mg/ml at (n= ), (n= ) and d (n= ) ga, while measuring arterial pressure (map), heart rate (hr) and upbf b before, during ( , , , , , , and h) and after ( , h) infusions. uterine arterial and venous cgmp were measured. data were analyzed by anova. results: acute nos inhibition decreased upbf b - %, but was not doserelated. h arterial l-name infusions decreased upbf b by - h at each ga (p . , anova) and values returned to baseline by h postinfusion. sensitivity did not differ between ga (p= . , anova), upbf b falling - % at each ga. contralateral upbf b was unaffected at all ga. map rose and hr fell during infusions at and d ga, p . ; but were unaffected at d ga. venous-arterial cgmp concentration differences were seen at d and absent at h of l-name infusion, p= . . conclusions: uterine vascular nos increases in ovine pregnancy, but its inhibition decreases upbf b %, suggesting study doses were insufficient to fully inhibit vascular nos activity. alternatively, nos contributes to the maintenance of upbf b , but other mediators, not yet identified, are more important in activating bk ca and regulating upbf b . notably, l-name reached the systemic circulation, and although further diluted, map rose - %, suggesting the systemic vasculature may be more sensitive to nos inhibition than upbf b . charles r rosenfeld, xiao-tie liu. division of neonatal-perinatal medicine, university of texas southwestern medical school, dallas, tx, usa. background: uteroplacental blood flow (upbf) rises -fold in ovine pregnancy, reflecting increases during pre-implantation, placentation and finally, in the last third of gestation. we reported that bk ca density in uterine vascular smooth muscle (uvsm) increases in ovine pregnancy (sgi ) and inhibition with tetraethylammonium ( . mm) dose-dependently decreases basal upbf % in the last third of pregnancy (jsgi ) . it is unclear how bk ca subunit expression changes and activity is regulated in pregnancy; since uterine vascular nitric oxide is increased, signaling via cgmp-dependent protein kinase g (pkg) is one potential pathway. objective: to determine simultaneous changes in uvsm bk ca density and regulatory -subunit expression and the cgmp signaling pathway for activation in ovine pregnancy. methods: endothelium-denuded segments of nd generation uterine arteries obtained from nonpregnant (n= ), pregnant (n= , - d gestation; term d) and postpartum (n= , - d) sheep were used to measure expression of bk ca -and regulatory -subunits and signaling proteins in uvsm by immunoblot analysis and immunohistochemistry. results: uvsm bk ca density, reflected as a change in the kda -subunit, rose % with placentation (p< . ) and was unchanged thereafter. expression of the kda regulatory -subunit paralleled the rise in bk ca density during placentation, increasing % (p< . ), but increased another -fold and exponentially in the last third of pregnancy (p< . , r = . , n= ). changes in subunit immunostaining in uvsm paralleled increases in protein. although uvsm soluble guanylyl cyclase was unchanged in pregnancy (p= . , r= . , n= ), pkg expression rose -fold (p= . , r= . , n= ) and gradually returned to nonpregnant levels by d postpartum (p= . , r= . , n= ). uvsm cgmp is being measured. conclusions: these are the st data suggesting that increases in ovine upbf during placentation involve vascular growth and bk camediated vasodilation. the rise in upbf in the last third of pregnancy reflects bk ca -mediated vasodilation due to enhanced channel activation via increases in uvsm pkg, bk ca phosphorylation and changes in subunit stoichiometry due to an exponential rise in the regulatory -subunit. it is unclear what initiates and directs these changes in bk ca expression and sensitivity. relaxin (rlx) is a hormone traditionally associated with changes in the female reproductive tract during pregnacy. recent evidence suggests that rlx may play a pivotal role in regulating cardiovascular function during gestation. analogous to pregnancy, administration of recombinant human relaxin (rhrlx) to nonpregnant female rats reduces systemic vascular resistance, as well as increases global arterial compliance. additionally, we demonstrated that, concurrent with rlx´s influence on overall cardiovascular function, small renal arteries (sra) from rhrlx-treated mice and rats are characterized by reduced passive stiffness and increased arterial wall area whereas external iliac arteries (eia) are not. we hypothesized that rlx regulates arterial passive mechanical properties by altering the cellular and biochemical composition of the arterial wall. nonpregnant female mice were administered rhrlx for days after which sra and eia were isolated. we measured arterial collagen, elastin, and total protein using the sircol collagen assay, the fastin elastin assay, and the pierce bca protein assay, respectively. additionally, we quantified arterial smooth muscle cell (smc) density using immunofluorescent techniques. sra isolated from rhrlx-treated mice were characterized by a significant reduction in collagen to total protein ratio ( . ± . vs . ± . μg collagen/μg protein; mean±sem; p< . ) as well as a significant increase in smc density ( . ± . vs . ± . cells/ μm ; p< . ) compared to control mice with no significant change in elastin content ( ± vs ± μg elastin/mg dry weight). in contrast, there were no significant changes in collagen to total protein ratio ( . ± . vs . ± . μg collagen/μg protein), smc density ( . ± . vs . ± . cells/ μm ) or elastin content ( ± vs ± μg elastin/mg dry weight) in eia from the rhrlx-treated mice compared to control mice. of note, comparable results were observed for rlx knock-out (rlx -/-) and wild-type mice with rlx -/mice exhibiting increased arterial collagen and decreased smc density. we conclude that the rlx-induced decrease in passive stiffness of sra that we previously reported is, at least in part, due to rlx-induced alterations in arterial wall cellular and biochemical composition. further, our findings suggest that these vessel wall remodeling effects of rlx are artery-type specific. relaxin is a peptide hormone that emanates from the corpus luteum of the ovary and circulates during pregnancy. this hormone plays an important role in renal vasodilation and hyperfiltration, two fundamental maternal adaptations in pregnancy. chronic administration of recombinant human relaxin (rhrlx) to both virgin rats and mice inhibits myogenic reactivity and increases compliance of small renal arteries, thus further mimicking pregnancy. we hypothesize that these arterial responses to rhrlx are mediated by the lgr , and not the lgr receptor. both lgr and lgr receptor-deficient, and wild-type virgin mice were investigated. the mice were chronically infused with rhrlx or vehicle (veh) for days. small renal arteries were isolated and mounted in a pressure arteriograph and myogenic reactivity was assessed (% change in diameter over baseline in response to a mmhg step increase in intraluminal pressure). small renal arteries from rhrlx-infused lgr wild-type mice showed inhibited myogenic reactivity with a . ± . % increase in diameter whereas the arteries from rhrlx-infused lgr knock-out mice exhibited robust myogenic reactivity with only a . ± . % change in diameter (p= . ). in contrast, myogenic reactivity of small renal arteries was inhibited in both the rhrlx-infused lgr knock-out and wild-type mice. the veh-treated lgr and lgr mice, regardless of genotype, exhibited robust myogenic reactivity. arterial compliance was also assessed for each genotype/treatment group. rhrlx infusion increased arterial compliance of small renal arteries from lgr wild-type, but not from lgr knock-out mice (p= . ). in contrast, the arteries from rhrlx-infused lgr wild-type and knock-out mice showed increased compliance relative to veh-infused animals. conclusion: relaxin-induced inhibition of myogenic reacitivity and increase in compliance of small renal arteries is mediated by the lgr , and not the lgr receptor. smoking is associated with adverse pregnancy outcomes including fetal growth restriction. pathologic effects of smoking on maternal vasculature is a potential mechanism leading to fetal growth restriction. the objective of this study was to determine whether cigarette smoke exposure during pregnancy affects the functional properties of uterine and peripheral arteries using a gravid murine model. study design: pregnant and virgin c bl/cj mice were exposed to whole body side stream smoke using an inhalational chamber for hours/day. smoke exposure was increased from day of gestation until late pregnancy (day - ) with mean total suspended particle levels of mg/m , representative of moderate to heavy smoking in humans. control animals were exposed to ambient room air. late pregnant and virgin mice were sacrificed and uterine, mesenteric, and renal arteries were isolated and studied in a pressure arteriograph system (n= - in each group). plasma cotinine was measured by elisa. means were compared using t-test or analysis of variance. results: fetal weights were significantly reduced in mice exposed to smoke compared to control fetuses ( . ± . g vs . ± . g, p= . ), while litter sizes were not different. cotinine levels in smoking mice were significantly elevated compared to control mice ( . ± . vs . ± . ng/ml for virgin mice and . ± vs . ± . ng/ml for pregnant mice). there was no significant difference in phenylephrine responses between groups. endothelial mediated relaxation responses to methacholine were significantly impaired in both the uterine and mesenteric vasculature of pregnant mice exposed to cigarette smoke during gestation. no difference in endothelial-mediated relaxation was seen in isolated renal arteries in pregnant mice exposed to cigarette smoke, however relaxation was significantly reduced in renal arteries from smokeexposed virgin mice. conclusions: passive cigarette smoke exposure is associated with impaired vascular relaxation of uterine and mesenteric arteries in a gravid murine model. functional vascular perturbations during pregnancy, specifically reduced uterine blood flow and impaired peripheral vasodilation, may be a mechanism by which smoking results in fetal growth restriction. human chorionic gonadotropin (hcg) is essential during early human gestation for "rescue" of the corpus luteum. however, its potential contribution to the widespread maternal vasodilation of pregnancy that occurs at this stage of pregnancy remains uncertain. our objective was to use the renal circulation of conscious rats as an experimental model in which to test the vasodilatory potential of hcg. in addition, we investigated both myogenic reactivity and relaxation responses in small renal and mesenteric arteries isolated from rats, as well as in small human subcutaneous arteries using a pressure arteriograph. we chronically instrumented rats for measurement of renal function. five were ovariectomized, and sham-ovariectomized. after days of surgical recovery, baseline glomerular filtration (gfr) and effective renal plasma flow (erpf) were measured on two separate days and the values averaged. then, an osmotic minipump containing hcg ( iu/min) was implanted s.c. and renal function was again assessed and days thereafter. gfr and erpf significantly increased and calculated effective renal vascular resistance decreased from baseline in the intact (p< . vs. baseline), but not ovariectomized (p=ns) rats on both days and of hcg administration. in the intact, but not ovariectomized rats, plasma osmolality declined and progesterone increased (both p< . vs baseline). plasma hcg concentrations were , miu/ml and comparable in both groups of rats. incubation of small renal arteries from rats with recombinant human relaxin (rhrlx, - ng/ml), but not hcg ( , - , miu/ml) in vitro inhibited myogenic reactivity and relaxed phenylephrine (pe)-constricted arteries. in contrast, both rhrlx and hcg inhibited myogenic reactivity and relaxed pe-constricted small mesenteric arteries from rats and small human subcutaneously arteries. in conclusion, consistent with our earlier work showing a virtually exclusive role for relaxin in mediating the renal circulatory changes of pregnancy, hcg is likely to play little or no role. in contrast, hcg and relaxin are both likely to contribute to the vasodilation of other organ circulations during pregnancy. pierre-andre scott, , michele brochu, jean st-louis. , research centre, chu ste-justine, montréal, qc, canada; pharmacology, université de montréal, montréal, qc, canada. uterine vasculature undergoes major structural and functional changes during pregnancy. estrogens have been shown to induce increased uterine blood flow in this circulation. we have reported that estradiol ( -e ) induced direct vasorelaxant response on smooth muscle of the uterine arteries that, for it major part, is not mediated through tissue nitric oxide. to investigate the cellular effectors mediating this vasorelaxant effect of -e , we set-up uterine arteries of non-pregnant rats in wire myograph systems for microvessels. -e and -e were equipotent in relaxing phe ( μmol/l)-preconstricted uterine arteries, although the later produced significant smaller relaxations. genistein, a phytoestrogen presumed to inhibit phosphatases, also produced uterine artery relaxation with significant lower potency. to try interfere with the vasorelaxant effect of -e , tissues were preincubated with different substances. cycloheximide (protein biosysthesis inhibitor), ici , (estrogen receptor modulator), and kt (pka inhibitor) did not significantly influenced the response to -e . rp- -pcpt-cgmps (pkg inhibitor) slightly displaced the concentration-relaxation curve to -e to the right. inhibitors of potassium channels, penitrem a (bkca) and glybenclamide (katp), showed opposite effects for -e concentration-response curve; the former producing a right shift and the latter a small not significant left shift. these data indicated that the direct acute effect of -e in uterine artery is the result of complex interactions within smooth muscle cells, involving potassium channels, and protein kinases and phosphatases. the renin-angiotensin-aldosterone system is paradoxically activated during pregnancy, since blood pressure decreased. earlier data showed that the high levels of aldosterone present during pregnancy may be involved in cardiovascular adaptation to pregnancy. in order to delineate this effect of aldosterone on vascular tone, potassium canrenoate, an antagonist of mineralocorticoid receptors (mr), was administered ( mg/kg/day) to pregnant rats from the day to of gestation. rats were sacrificed at day , and of gestation together with untreated and day pregnant rats. the thoracic aorta was quickly removed and set up in tissue baths as ring ( - mm) preparation. as observed previously, canrenoate enhanced responsiveness to phe for all time of treatment tested, but only at day ( days treatment) for kcl responsiveness. aortic contractile responses to tea (tetraethylammonium) gradually decreased during pregnancy to almost disappear at the end of gestation. in the present results, canrenoate treatment made the response statistically different by day of pregnancy. finally, the activity of na/k-atpase was measured by the relaxant effect of kcl added to physiological solution without potassium. the activity of the pump was decreased when approaching parturition compare to day of pregnancy. canrenoate treatment abolished this effect. the present data show that vascular changes that occurred during pregnancy are markedly modified by treatment of rats with an antagonist of mineralocorticoid receptors, suggesting that aldosterone may be involved in vascular adaptation to pregnancy. background impaired endothelium-dependent vasodilatation has previously been demonstrated in small myometrial arteries from women with gestational diabetes. this impairment may play a role in mediating the complications observed in diabetic pregnancies. it is not known which mechanisms of endothelium-dependent vasodilatation are affected in myometrial arteries by gestational diabetes. aim to investigate mechanisms of endothelium-dependent vasodilatation in uterine arteries using a mouse model of pregnancy complicated by diabetes. methods diabetes was induced in female c bl /j mice (streptozotocin; mg/kg) prior to mating. mice were culled at day of pregnancy (term) and uterine arteries dissected, mounted on a wire myograph, normalised to mmhg and equilibrated ( °c; %co /air). arteries were constricted with phenylephrine ( m) and a concentration-response curve to the endotheliumdependent vasodilator acetylcholine (ach; . nm- m) constructed in the presence and absence of a nitric oxide synthase inhibitor (l-nna; m), a cyclooxygenase inhibitor (indomethacin; m) or a combination of the two to determine the contribution of nitric oxide (no), prostacyclin and endothelium derived hyperpolarising factor (edhf) to vasodilatation. results sensitivity to ach was comparable between diabetic and vehicle treated mice (ec . ± . nm vs . ± . nm). the contribution of individual endothelium-dependent vasodilators was significantly altered in arteries from diabetic mice. at m ach, edhf-mediated relaxation was significantly reduced (p= . , one-way anova) compared with controls ( . ± . vs . ± ). in comparison, no-mediated relaxation was significantly increased (p= . , one-way anova) compared with controls ( . ± . vs . ± . %). conclusions endothelium-dependent relaxation was not reduced in uterine arteries of diabetic mice compared with controls. however, there was a profound change in the contribution of endothelium-dependent vasodilators in arteries of diabetic mice. this may alter compensatory capacity as disease progresses. supported by mfn training grant (cihr). raf- serine/threonine protein kinase has been extensively studied as the upstream kinase linking ras activation to the mek/erk module. mek/erk has been shown to play a role in the modulation of vascular contraction. however, the role of raf kinase in vascular contraction and its possible involvement in alteration of maternal vascular function during pregnancy is not known. objectives: to determine ( ) if raf kinase contributes to phenylephrine (pe)induced contractile response, ( ) the role of raf kinase inhibitor (gw ) in regulating vascular tone during pregnancy, and ( ) mechanism by which gw produces vasodilatation in rat mesenteric arteries. methods and results: conscious non pregnant (np) and pregnant (p) sprague dawley rats received increasing doses of pe in the absence or presence of gw . pe induced a dose-dependent increase in map in both np and p rats but responses were substantially depressed in pregnancy. gw shifted the pe-induced dose response to the right in both np and p rats. gw itself did not affect basal blood pressure. isometric tension studies in mesenteric arteries showed that gw did not change the kcl-evoked contraction but significantly inhibited the contraction to pe in both np and p arteries. interestingly, at a given concentration, gw produced greater inhibition of pe-induced contractile response in p than in np arteries. also, in p arteries the inhibitory effects of gw were greater as the pregnancy progressed from day to day . raf kinase expression and activity was significantly decreased in arteries of p compared to np rats. in mesenteric vascular smooth muscle cells (vsmcs), pe stimulated activation of raf kinase as indicated by phosphorylation of its immediate target, mek / in a time-and dose-dependent manner. measurement of [ca + ] i with fura- showed that gw -mediated inhibition of pe-induced contraction was not associated with decrease in [ca + ] i . vsmcs treated with pe exhibited higher levels of the contractile proteins, p-mypt and p-mlc which was inhibited by gw . conclusion: to our knowledge, for the first time we show that raf kinase plays an important role in the regulation of vascular contractility. decreased expression and/or activity of raf kinase during pregnancy may explain in part, for decreased systemic vascular reactivity during late gestation. the mechanism(s) that contribute to reduced vascular sensitivity to phenyleperine (pe) during pregnancy is not well understood. pe, in addition to activating the classical contractile pathways, also stimulates growth factor pathways that results in activation of ras/mitogen-activated protein kinases. it is not clear whether these pathways play a role in the modulation of vascular contraction. hence, the present study was designed to determine ) if ras is involved in mediating the pressor response to pe in non pregnant (np) and pregnant (p) rats, ) if so, the mechanism by which ras protein contributes to pe-induced vascular contraction, and ) any differential expression and/or activity of ras during pregnancy that might contribute to altered vascular response. methods: ) mean arterial pressure (map) was measured in conscious np and p rats. ) isometric tension was measured in mesenteric arteries of np and p rats. ) expression of contractile proteins, p-mlc and p-mypt were studied in cultured vascular smooth muscle cells (vsmcs). ) expression and activity of ras in mesenteric arteries of np and p rats were measured by western blot analysis. results: ( ) intravenous administration of pe resulted in a dose-dependent increase in map but responses were substantially depressed in pregnancy. inhibiting ras activation with manumycin, decreased pe-induced increase in map in both np and p rats. manumycin by itself had no effects on basal map. ( ) isometric contraction studies in myograph with mesenteric arteries showed that manumycin shifted pe-induced dose response curve to the right with a decrease in e max in np and p rats. higher concentration of manumycin was required to inhibit pe-induced contraction in np ( μm) compared to p ( - μm) rats. ( ) pretreatment with manumycin inhibited pe-induced increase in the extent of phosphorylation of both mlc and mypt in mvsmcs. ( ) compared to p rats, mesenteric arteries of np rats revealed increased basal and pe-induced expression and activity of ras. reduced expression of this contractile ras pathway might contribute to decreased vascular reactivity during pregnancy. conclusion: ras protein plays a role in regulation of vascular contraction. the decreased amount and activity of vascular ras may be a novel mechanism that explains the reduced vascular resistance during pregnancy. overweight affects the relaxin-induced response of mesenteric arteries. joris van drongelen, arianne van koppen, marc ea spaanderman, paul abm smits, frederik k lotgering. obstetrics and gynecology, radboud university nijmegen medical centre, nijmegen, netherlands; pharmacology and toxicology, radboud university nijmegen medical centre, nijmegen, netherlands. objective: overweight affects pregnancy-induced vascular adaptation and predisposes to gestational hypertensive disease. relaxin plays a key role in normal gestational vascular adaptation by increasing endotheliumdependent vasodilation and compliance, and reducing myogenic reactivity. we hypothesized that overweight blunts the vascular response to relaxin. the vascular responses to flow and pressure of mesenteric arteries after pre-treatment to human recombinant relaxin (rlx) or placebo (plac) were examined in overweight (ow) and normal weight (nw) rats in a pressure-perfusion myograph. overweight was established by a high-fat diet. the endothelium-dependent vasodilatation was measured in response to flow: e (flow inducing % dilatation) and e max (maximal dilative effect). active contractile (myogenic reactivity) and passive dilative (compliance) vascular responses to pressure were determined. all vascular responses were calculated as the proportional change in diameter to % precontraction with u . results: in nw rats rlx decreased e and increased e max to flow and attenuated myogenic reactivity without affecting vascular compliance. in ow plac-treated rats, compared to nw rats, an upregulated vasodilative state was present (decreased e and increased e max , and lower myogenic reactivity). in ow rats rlx increased e to flow and unaffected e max . rlx increased myogenic reactivity mildly in absence of changes in vascular compliance. values are presented as mean±sem; * p< . between nw/ow, # p< . within nw/ow. whereas rlx stimulates endothelium-dependent vasodilation to flow and myogenic reactivity in nw rats, ow overturns the flow-induced response and decreases myogenic reactivity to a lesser extent than present in nw rats. we speculate that these overweight-induced adverse effects of rlx prelude to vascular maladaptation and gestational hypertensive disease. compared to the luteal (lut) phase, uterine blood flow is increased in vivo during the follicular (fol) phase and more so during pregnancy (preg). both of these are physiologic states of high estrogen and shear stress. endothelial cells express enos and produce greater amounts of nitric oxide (no) in response to elevations of shear stress. phosphorylation of enos is a signaling marker of activation. we have recently validated lut, fol and preg uaec culture models for evaluating enos phosphorylation responses to shear stress and vascular mediators. we hypothesized that uaecs derived from fol and preg sheep will show greater enos phosphorylation than lut phase uaecs, and with more robust responses in the presence of estrogen (e ). methods: uaecs were cultured until % confluence, and then subjected to (static control), or dynes/cm for hrs in the absence or presence of e ( nm). western analysis was used to compare optical densities of ser -penos (penos) normalized to total-enos (mean + sem). results: in lut uaec penos was equally increased two fold by and dynes/cm (from . + . to . + . and . + . , respectively). compared to lut uaecs, the static control fol uaecs appeared to have higher penos levels ( . + . ) and this was further increased . - . fold with dynes/cm ( . + . ) and dynes/cm ( . + . ). as seen with fol uaecs, preg uaec static penos ( . + . ) appeared higher than lut uaec, but unexpectedly, neither nor dynes/cm significantly raised these levels of penos ( . + . and . + . ). regardless of shear stress level, e replacement in the culture media only increased the penos levels in the nonpregnant, but not the pregnant derived uaecs. conclusions: increasing amounts of shear stress have a corresponding increase in the ratio of enos that is phosphorylated at serine in lut and fol uaecs. pregnant uaecs do not appear to increase the constitutive ratio of serine phosphorylation of enos at either or dynes/cm . in contrast to our hypothesis, chronic treatment with e for hrs did not augment the ratio of enos phosphorylation in pregnancy. nih hl , hd , hl . cells. honghai zhang, wu xiang liao, dong-bao chen. reproductive medicine, university of california san diego, la jolla, ca, usa. s-nitrosylation (sno) is a rapid, reversible, and nitric oxide (no) dependent post-translational protein modification critical for signal transduction. estrogen stimulates endothelial cell (ec) no production but yet to be determined is if this leads to increased formation of sno-proteins in ec. hypothesis: we hypothesize that estrogen stimulates the formation of sno via a receptor and endogenous no dependent pathway in huvec or ovine uterine artery ec. methods: cells on glass coverslips were treated with mm of no donor gsno or dea nonoate, estradiol- ( nm) in the presence of l-name ( mm) for min. the cells were fixed with methanol. in situ sno-proteins were detected by a rapid biotin derivatization method by blocking thiols by methylmethanethiosulfonate (mmts), followed by ascorbate reduction and labeling with texas red-labeled ethylmethanethiosulfonate (mtsea) and examined by fluorescence microscopy. cells ( x /group) were lysed in hen buffer, and then similarly prepared but labeled with biotin-mtsea. a portion of the samples were separated on sds-page and blotted with anti-biotin antibody for total sno-protein patterns. the biotin-labeled sno-proteins were captured by avidin, followed by immunoblotting with specific antibodies. results: basal sno-protein labeling was apparent in both ec types. exogenous no donated by gsno or dea nonoate significantly increased red fluorescence labeling of sno-proteins in the cytosol of both ec types. treatment with estradiol- also increased total sno-protein labeling in both ec types. pretreatment with l-name significantly reduced sno-protein labeling. sds-page and immunoblotting with anti-biotin antibody analyses identified multiple bands of sno-proteins. in avidin captured biotinylated samples, multiple proteins were indentified. conclusion: exogenous no donated by gsno or dea nonoate and endogenous no upon estrogen stimulation increased s-nitrosylated proteins in ec (supported by nih ro hl and ). background and objective: the renin-angiotensin system (ras) functions both systemically and locally as a primary regulator of blood pressure and fluid volume and is therefore involved in the etiopathogenesis of essential hypertension as well as preeclampsia, a pregnancy-induced hypertensive disorder in pregnant women. while much progress has been made in the development of strategies to block the systemic ras and thus treat essential hypertension, relatively less advance has been achieved in the development of effective local ras inhibitors to treat preeclampsia, primarily due to the fact the conventional systemic ras inhibitors generate potential teratogenic risks to pregnant women during critical stages of their pregnancies. ginger has been widely and effectively used in pregnant women to treat pregnancyinduced nausea and vomiting with minimal adverse effects. the present study was designed to investigate whether ginger could down-regulate renin secretion by human decidual cells (the major source of renin in the tissue-based uteroplacental ras), as an initial step toward a long-term goal to develop potential safe and effective ras inhibitors for use in obstetric patients. methods: full-term normal human placentas were obtained within one hour of vaginal deliveries or cesarean sections. decidual cells were isolated from the decidua parietalis. after an initial culture for days in a serum-containing medium, the decidual cells were treated with ginger juice at various doses in a serum-free medium for hours. the culture supernatants were then harvested and subject to western blot analyses of renin protein contents. the ginger juice used was freshly prepared from the ginger roots purchased from a local grocery store and different batches of juice preparations were standardized based on their optical density values at a wavelength of μm on a spectrophotometer. results: a dominant band of renin at approximately kd was detected in all samples. when compared with the control (i.e. %), ginger juice decreased the renin protein contents in the culture supernatants in a dose-dependent manner. no significant difference in the cell morphology was observed between the control and treatment groups. conclusion: ginger root juice down-regulates renin secretion in human decidua, showing a great potential of a novel ras inhibitor, particularly, in obstetric patients. noninvasive quantification of the autonomic nervous system throughout pregnancy. dietmar schlembach, karoline pickel, daniela ulrich, philipp klaritsch, isa alkan, uwe lang, manfred g moertl. obstetrics and gynecology, medical university of graz, graz, styria, austria; cnsystems medizintechnik ag, graz, styria, austria. introduction: the analysis of heart rate variability (hrv), blood pressure variability (bpv), and baroreflex sensitivity (brs) has become a powerful tool for the assessment of autonomic control. although hrv analysis was initially developed for risk stratification in cardiology, the field of clinical application has broadened in recent years. the aim of our study was to investigate the adaptation of autonomic control during pregnancy based on analysis of heart rate variability and baroreceptor sensitivity. methods: patients with uncomplicated pregnancy were measured with the taskforce® monitor i made by cnsystems. all measurements were performed in supine position under standardized resting conditions. autonomic parameters were recorded at rest and within the "deep breathing method" as a "cardiovascular challenge test". results: throughout pregnancy a shift to higher sympathetic activity respectively a lower parasympathetic activity was observed. , and . ± . [> wks]) (figure ). during the deep breathing maneuver we could show an increase of the sympathetic / parasympathetic ratio (figure ). the noninvasive determination of autonomic parameters throughout pregnancy is possible. these results can be used as basic parameters for classifying and assessing autonomic changes in pathological conditions in pregnancy such as hypertensive disorders. how far the characterization and challenge of these autonomic functions can be utilized for diagnosis and prediction of preeclampsia has to be shown in future studies. hemodynamic parameters measured noninvasively throughout pregnancy. daniela ulrich, manfred g moertl, karoline pickel, philipp klaritsch, isa alkan, uwe lang, dietmar schlembach. obstetrics and gynecology, medical university of graz, graz, styria, austria; cnsystems medizintechnik ag, graz, styria, austria. background: hemodynamic changes throughout pregnancy have been measured predominantly by invasive techniques. the discussion on the valence und the low acceptance of these invasive procedures by pregnant women demands a noninvasive method for evaluating and distinguishing cardiovascular adaptative mechanisms throughout normal and especially complicated pregnancy. method: healthy patients with uncomplicated pregnancy were measured with the taskforce® monitor i (cnsystems, austria) at different time points throughout pregnancy. cardiovascular parameters were recorded in supine and left lateral position under standardized conditions. results: throughout pregnancy an increase of global parameters such as heart rate (hr), blood pressure (bp), total peripheral resistance (tpr) and total peripheral resistance index (tpri) were observed. stroke volume (sv), stroke index (si), cardiac output (co), contractility index (ci), acceleration index (aci), and left ventricular ejection time (lvet) decreased throughout pregnancy (table). discussion: the noninvasive determination of cardiovascular parameters throughout pregnancy is possible and the results of this pilot study can serve as basic parameters for classifying and assessing cardiovascular changes in pathological conditions in pregnancy such as hypertensive disorders. assigning pregnant hypertensive women into hyper-and hypodynamic groups may aid in planning individual therapeutic strategies. objective: both gnrh i and gnrh ii are expressed in humans. gnrh i is produced by the hypothalamus under the regulation of gonadal steroids and stimulates pituitary gonadotropins. during pregnancy gnrh i is also produced by the placenta and affects hcg. gnrh ii, the ancient isoform, is produced by numerous human tissues including immune and reproductive tissues and circulates in blood in quantifiable levels. we have demonstrated that gnrh ii analogs directly affect fertilization and uterine function, and propose that it acts via immune regulation. during pregnancy it is known to regulate numerous hormone productions, yet the levels of gnrh ii has not been reported. in these studies we have determined the circulating levels of gnrh ii throughout pregnancy and in early pregnancy loss. study design: thirty-three women having normal pregnancies were followed prospectively. plasma samples were drawn at , , , , , , weeks gestation and during labor. plasma was also collected from patients have spontaneous abortions (n= ). circulating gnrh ii and crh and gnrh i were measured by specific radioimmunoassays. results: circulating gnrh ii increased from non-pregnant levels ( +/- pg/ ml, mean+/-sem) to +/- pg/ml by -week lmp. gnrh ii concentrations continued to increase through weeks gestation over the -week levels, although a significant increase was only attained by weeks. gnrh ii continued to increase in late term, attaining levels of +/- pg/ml which was significantly higher than that of early gestation. during labor and delivery gnrh ii in maternal plasma was further increased to +/- pg/ml, i.e., . times that of -week gestation ( +/- pg/ml). circulating gnrh ii did not parallel gnrh i in early pregnancy but did in late gestation. gnrh ii did correlate with crh in early pregnancy but not in late gestation. patients having spontaneous abortion had increased circulating gnrh ii at -weeks lmp ( +/- pg/ml) as compared to normal pregnancies ( +/- pg/ml). conclusion: gnrh ii increased throughout pregnancy attaining highest concentrations during labor and delivery. patient with early pregnancy loss had increased gnrh ii expression. the function of gnrh ii or factors affecting this increased gnrh ii in normal or abnormal human pregnancy should be investigated. introduction: plasma levels of the endocannabinoid, anandamide (aea) decrease during the luteal phase of the menstrual cycle and early pregnancy and increase during parturition. high plasma aea levels at weeks in women undergoing ivf-et was associated with a failure to achieve an ongoing pregnancy . what is uncertain is what happens to aea levels when the pregnancy has already failed. we aimed to quantify aea levels in women presenting in early pregnancy with a diagnosed non-viable pregnancy and to compare them to those of a viable pregnancy. methods: plasma aea was measured by a sensitive isotope dilution hplc-ms/ms method from women in early pregnancy ( - weeks) of whom had a viable pregnancy and had a non-viable pregnancy. serum hcg and progesterone were measured in blood samples by standard elisa methods. results: the ages and bmi of both groups were similar ( ± . versus ± . years; mean ± sd; p= . ; student's unpaired t-test and ± . versus ± . kg/m ; p= . ) respectively. plasma aea levels in women with non-viable pregnancies were significantly higher than those in women with viable pregnancies ( . ± . versus . ± . nm; p= . ). there was no correlation found between aea levels and hcg or progesterone levels p= . and r= . ; p= . , respectively) , despite progesterone being significantly lower in the non-viable group ( . ± . versus . ± . ng/ml; p= . ). conclusion: higher plasma aea levels were associated with early pregnancy failure, and this association appeared to be independent of serum hcg or progesterone concentrations. these data suggest that plasma aea levels are linked with pregnancy failure through a mechanism that does not involve hcg or progesterone production. the precise involvement of anandamide in early pregnancy needs to be investigated further. n- ) and arachidonic (aa, : n- ) acids, the major brain long-chain polyunsaturated fatty acids (lc-pufa) are generated by elongation-desaturation of dietary essential fatty acids (efa). the maternal liver is principally responsible for efa elongation-desaturation. objetive. we determined effects of protein restriction in pregnancy on expression of d, d and elongases and (elov and ) in the maternal liver rat. methods. pregnant rats were fed control ( % casein; c) or restricted ( % casein; r) isocaloric diets. at day gestation maternal blood and livers were collected. serum triglycerides, cholesterol and glucose were determinate with the synchron cx autoanalyser and leptin and insulin by ria. liver fat determination was performed by the soxhlet method. liver ara and dha were calculated by gas chromatography based upon retention times from methyl ester standards. liver d, d, elov and mrna were measured by rt-pcr and northern blot. data are m ± sem; analysis by t-test. results. liver weights did not differ in c and r. total liver fat ( ± vs ± mg) serum leptin ( ± . vs ± . ng/ml) and insulin ( . ± . vs . ± . ng/ml) differed in c and r respectively (p< . ). serum triglycerides, cholesterol, and glucose did not differ. desaturase and elongase mrna and % of maternal liver aa and dha were lower in r (fig ) . conclusion. low liver fat content and desaturase and elongase mrna in r indicate impaired lc-pufa synthesis which may adversely impact fetal development, especially the brain. objective: to test the hypothesis that obstetrical dic results from an excessive leak of fetal material into the maternal circulation. a secondary objective was to assess maternal morbidity. methods: all cesarean hysterectomy cases for hemorrhage at our hospital from to were included. intravascular presence of fetal material was determined by two pathologists, blinded to each other and any clinical information. the percentage of those with any fetal material in the maternal circulation was calculated for each diagnosis for hemorrhage. for a given diagnosis, the percentage of intravascular fetal material in those with the given diagnosis was compared to those without that diagnosis using fisher's exact test. most patients had multiple hemorrhage diagnoses. a two sample t-test was used to evaluate the difference in mean blood loss between those with and without intravascular fetal material. results: primary outcome* % of patients received blood products and % received clotting agents. the average blood loss was cc. there were no maternal deaths and injuries to adjacent organs, all to the bladder. conclusions: there was no association between the presence of intravascular fetal material and any specific hemorrhage diagnosis or amount of blood loss. although the power to detect a relationship was low, the excessive leakage of fetal material as a specific and exclusive mechanism of obstetrical dic, as postulated, seems unlikely. while % of the population was transfused, there were few intraoperative complications and no maternal deaths. hypertension, tel-aviv university, sheba medical center, ramat-gan, israel. objective: the joint national committee on high blood pressure (jnc ) determined blood pressure of - / - in adults to be prehypertension that requires health promoting life style modifications to prevent cardiovascular disease. similarly, we hypothesize that gestational prehypertension in pregnancy is associated with increased risk of pregnancy complications and its management would improve pregnancy outcome. methods: prospective and retrospective recruitment resulted in a study group consisting of patients who were diagnosed in the first and early second trimester (< weeks) with blood pressure of - / , and a control group consisting of patients with blood pressure < / at similar gestational age. comparisons between the two groups were accomplished for demographic characteristics and outcome measures using the chi-square test statistic and two-sample t-tests for categorical and continuous variables, respectively. results: all outcome measures analyzed resulted in poorer results being associated with the study group compared with control as follows: % versus % of the study and control group pregnancies, respectively, experienced preeclampsia (p= . ); and % versus % of the study and control group, respectively, were associated with gestational hypertension (p= . ). % of the control group deliveries were associated with admission to the nicu, compared to only % in the control group (p= . ); % versus % of the study and control group deliveries, respectively, were preterm (p= . ); twenty-nine percent of the study group were cesarean deliveries, compared to % in the control group (p= . ). on admission mean sbp and dbp was and mmhg, respectively, in the study group, compared to and mmhg in the control group (p= . for sbp and p= . for dbp). conclusions: "gestational pre-hypertension" may be a real pregnancy condition that when is recognized, physician attention, patient close monitoring during prenatal care and delivery and early intervention in patients at risk, may all promote improved pregnancy outcome. larger scale study is in progress to evaluate and confirm these findings in the larger pregnant population. are contractions at - weeks gestation less painful than those at full term? kristy a ruis, karin blakemore, abimbola aina-mumuney, valerie jones. gynecology and obstetrics, johns hopkins hospital, baltimore, md, usa. objective to determine if gestational age plays a role in severity of pain associated with uterine contractions. study design self-reported pain from women in labor, on a scale of - , is assessed and recorded in an obstetrical database by nurses at regular intervals at two hospitals within our medical system and was retrospectively reviewed from - . pain at various dilatations ( - cm) of women who were laboring and then delivered at - weeks' gestation was compared to women in labor at term. maternal demographics of age, race, education level, bmi, presence of support person, request for analgesia at any point in labor, and epidural placement were abstracted from maternal records. categorical data were analyzed using chi square or fisher exact test; continuous variables using student t-test. results laboring patients between - weeks gestation and at term were identified. term and preterm patients did not differ with respect to maternal demographics. pain reported by preterm patients was significantly less at - cm dilatation ( . vs. . ‚ p= . ) and significantly greater at - cm ( . vs. . ‚ p= . ). pain reported at - cm and - cm was not statistically different between the groups. of note, fewer of the preterm patients received an epidural despite the request for analgesia. conclusion preterm laboring patients between - weeks gestation may perceive less pain at - cm dilatation compared to term laboring patients; however, their pain perception at advanced dilatation was comparable to those at term despite the fact that they were less likely to have an epidural in place at the time of pain evaluation. in light of these findings, the widely accepted etiology of labor pain as the result of cervical dilatation may need to be re-examined. also, factoring in the patient's discomfort level into the evaluation for onset of early active labor may not be valid in the preterm patient. background and objective: asthma is a risk factor for adverse pregnancy outcome. this has been attributed to the effect of allergy in pregnancy. mast cell mediators can induce uterine contractility. the objective of the study was to test the hypothesis that pregnant women with asthma have different uterine electrical signals from those generated by normal pregnant women. materials and methods: uterine electromyography (emg) recordings from gestational age matched pregnant women at term were analyzed. the cases consisted of patients with asthma and the controls, those women without asthma. emg was recorded for approximately minutes from surface electrodes placed upon the maternal abdomen, with the electrical signals filtered in the uterine-specific range of . to . hz to remove noise components. the recordings were analyzed in their entirety first by power spectrum analysis and then by lyapunov analysis. the power-spectrum-largest-peak frequency and the largest lyapunov exponent were calculated for each patient, and then the mean and standard deviation of these parameters was compared using student's t-test. results: patients with asthma had significant lower power spectrum frequency and higher lyapunov exponent than women without asthma. see ) the power spectrum frequency and the lyapunov exponent used to analyze uterine emg signals were different in women with and without asthma; ) the results suggest that uterine electrical activity is altered in women affected by asthma; ) these findings may explain the observed increased frequency of preterm birth in women with asthma. further studies are required to dissect the mechanisms. fetal microchimeric cells trafficked into the maternal circulation persist in blood and tissues for years after pregnancy. increasing data suggest that microchimerism occurs after every pregnancy, but the biological role of fetal microchimerism or the cell types involved is unclear. while persistent fetal cells were initially implicated in autoimmune disease, animal studies suggest these fetal cells play a broader role in response to tissue injury. methods: appendix specimens were acquired from women undergoing appendicectomy during pregnancy. detailed reproductive histories were obtained. fluorescence in situ hybridisation (fish) with two different probes allowed investigation of the presence of male presumed-fetal cells and nested pcr amplification of sry gene confirmed male dna in the appendix. immunostaining was used to determine the fetal cell phenotype. results: male cells were identified in appendix tissues from women with known male pregnancies (n= ) and also from a woman with no sons and a previous miscarriage of undetermined gender (n= ). no male cells were observed in the control (n= ), a woman with daughters. male cells of presumed fetal origin were evenly distributed in the muscle, mucosa and submucosa layers of the appendix. morphology and co-localisation analysis suggested the identified male cells had differentiated primarily into muscle cells or lymphocytes. combined immunostaining and y-fish demonstrated male desmin+ muscle cells and cd + and cd + lymphocytes. finally, the presence of male dna in the appendix specimens was confirmed by nested pcr. male cells of presumed fetal origin were identified in the appendix of pregnant women. microchimerism frequency varied according to the reproductive history and the degree of inflammation. microchimerism rates were higher in the appendix from women with current male pregnancies than in those with previous male pregnancies and were higher in those with histological acute inflammation, when compared to milder cases. male microchimeric cells identified were of haematopoietic and mesenchymal origin. this study suggests that fetal cells are present in sites of tissue injury and may participate in tissue repair during pregnancy. collagen i and collagen-binding integrins mrna expression in rat cervix during gestation. huiling ji, tanya l dailey, vit long, edward ks chien. obstetrics and gynecology, maternal fetal medicine, women and infants' hospital of rhode island, providence, ri, usa. objective cervical remodeling is associated with cell proliferation and extracellular matrix (ecm) remodeling. integrins are a family of multifunctional cell adhesion receptors which mediate ecm-cell interactions including binding collagen. of the integrin (i) heterodimers, , , and are primary receptors for collagen. the predominant cervical collagen is collagen type . the purpose of this study is to investigate collagen and integrin expression in the pregnant rat cervix. the cervix was harvested from timed pregnant sprague-dawley rats. non pregnant (np)and timed pregnant day , , , , and animals were euthanized using a protocol approved by the iacuc. four animals were sacrificed on each day of gestation. quantitative rt-pcr was used to evaluate mrna expression and normalized to -actin. a standard curve was generated from a single sample. data was analyzed using anova and multiple comparisons testing. collagen i mrna expression increased through mid-gestation but decreased to np levels on day . a similar pattern was seen with the integrin beta subunit. the pattern of integrin alpha subunit expression was different for each subunit during pregnancy. the changes in collagen, integrin alpha , , and integrin beta were found to be statistically significant. (figure) . the pattern of collagen binding integrin alpha subunit expression during the rat gestation appears to vary independently of each other. the expression of the subunit paralleled col expression. collagen binding integrins may play independent roles in signaling and biomechanics during gestation. funding: women infants' hospital research fund; phs nih-ncrr p rr p rr . background. the effects of chemotherapy on human fetal development are poorly studied, mainly due to the lack of adequate animal models in which placentation and embryological development resembles humans and pharmacokinetic studies, prenatal sonography as well as histological studies can be performed. aim of the study. to test the baboon as model for studying pharmacokinetics and fetal effects of chemotherapy administered during pregnancy. methods. experiments were performed in pregnant baboons at a mean gestational age of (+/- ) days. detailed ultrasound examination (biometry, doppler, screening) was performed days before, at and day after the drug administration. the administration of different schemes of chemotherapy and the fetal samplings occurred under endotracheal anaesthesia. maternal blood samplings, as well as percutaneous ultrasound guided fetal blood ( ml) and amniotic fluid ( ml) samplings were performed at least once immediately after drug administration. in case of fetal demise, the fetus underwent detailed macro-and microscopic examination. in the other animals mother and fetus were euthanized h after the experiments, with collection of blood, amniotic fluid and tissues for further analysis. results. all mothers survived the experiments, one mother developed paralitic ileus. none of the fetuses died during the acute phase of the experiment but / ( %) fetuses died within h following the experiment. none of the animals showed significant clinical or histological signs of infection or anaemia. a total of ultrasound examinations were performed in fetuses, allowing the creation of sonographic growth charts in this model. at the time of drug administration the mean maternal weight was . kg (range . - . ) and the estimated fetal weight was gr (range - ). sixteen out of cordocenteses ( %) and all amniocenteses ( %) were successful in obtaining the required samples for analysis. conclusion. the pregnant baboon can be used as a model for studies on pharmacokinetics and fetal effects of chemotherapy administered during gestation. prenatal ultrasound is comparable to the human situation, and amniocentesis and cordocentesis can be performed with a high success rate and short term survival. therapy to prevent preterm birth is limited". moreover, -hydroxyprogesterone ( ohp) caproate is a category d drug according to the fda (evidence of fetal harm). p is produced in the adrenal glands, gonads and brain. after weeks gestation p is secreted from the placenta independently to the mother and the fetus. p is the precursor of aldosterone and after conversion to ohp, of cortisol and androstenedione. baboons have similar reproductive system and development to humans and are used to study mechanisms of labor and prevention of preterm labor. currently, there are no normative data on the concentration of p, ohp, cortisol ©, estradiol (e ) or inhibin (i) throughout their pregnancy. therefore, a doseresponse or the teratogenic effects of p or ohp caproate cannot be studied in a controlled manner in this animal model. the aim of this study was to generate reference values for these hormones during baboon gestation and early postpartum life. material and methods: hormonal quantitative measurements were performed (immulite analyzer) results: the mean concentrations of these hormones are depicted in figure (maternal serum, from conception to term days) and figure (newborn serum) conclusion: this study provides reference values for hormones quantified during the baboon gestation and early postpartum life. this may be useful for future research concerning the effects of p and ohp administration during pregnancy. ( )non-pregnant women eligible for ivf treatment and ( )pregnant women receiving prenatal care. the pre- / samples were drawn in the year prior to / / ; the post- / samples were drawn within months after. the pre- / and post- / normal pregnant samples were drawn at + weeks' gestation. the non-pregnant samples were from ivf candidates with serum e levels< newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced pg/ml and fsh serum levels< . miu/ml. the samples were assayed for acth and cortisol by a commercially available immulite™ system. hsp and hsp were measured by commercially available elisa. these results were compared in the patient populations before and after / . t-tests were used for analysis. statistical significance was set at p< . . results: in the pregnant subjects, there were no statistical differences in the mean levels of acth, cortisol, and hsp pre-and post- / (table ) . only serum hsp levels were significantly increased in the pregnant women post- / .* mean serum acth, cortisol, hsp , and hsp levels were all significantly different in non-pregnant subjects pre-and post- / . conclusions: except for hsp , serum markers for stress were unchanged in pregnant subjects after the stress of / / in comparison to non-pregnant women whose serum hsp , hsp , cortisol, and acth levels were significantly different. the lack of change in serum markers of stress in pregnant women suggests that the hormonal milieu of pregnancy may buffer against acute environmental stressors. objective: in human pregnancy, maternal body composition provides an indicator of maternal nutritional status and metabolic capacity. previously, we reported that ß hsd- activity was significantly reduced in term placentas from thin women and women with a smaller mid-upper arm circumference before conception. this suggests that these fetuses may have been exposed to inappropriate levels of maternal cortisol, which is a mediator of gestation length. in this study, we hypothesize that the duration of gestation will be shorter in women who tend to be thin and have a lower mid-upper arm circumference prior to conception. methods: within the longitudinal, population-based southampton women's survey (sws), analyses were performed on women whose estimated date of conception was set using an algorithm that combined menstrual and early ultrasound scan data and who had a spontaneous onset of labour and delivered after weeks of gestation. linear regression was used to examine the relationships between maternal body composition and the duration of gestation. results: within the women surveyed, lower maternal body mass index, mid-upper arm circumference and arm muscle area before conception were all associated with shorter duration of gestation at delivery (r= . , p= . ; r= . , p= . ; and r= . , p= . , respectively). a lower subscapular skinfold thickness, sum of skinfolds and height were also associated with shorter duration of gestation (r= . , p= . ; r= . , p= . and r= . , p= . , respectively). mother's age, own birthweight and ratio of subscapular/triceps skinfold thickness were not related to the duration of gestation. conclusions: in this study, we found that thinner women with a lower midupper arm circumference and arm muscle area tended to have a shorter duration of gestation. our findings of shorter gestation length in thinner women are in keeping with our previous observation of lower ß hsd- activity in term placentas from thinner women. we conclude that metabolic capacity prior to conception could influence duration of gestation through mechanisms that include alteration in placental metabolism and fetal cortisol exposure. fecal incontinence (fi) is a debilitating condition affecting - % of the us. our prior studies found that % of women report new onset fi after childbirth. the goal of our study was to examine the impact of fi on postpartum quality of life (qol). women reporting fi on a statewide survey who agreed to participate in a -year study of qol were included in the analysis. women were considered to have fi based upon the nih definition of fi. the quality of life survey was based upon the uebersax incontinence impact questionnaire and was administered every months for years. qol in women with fi was examined using chi square, and impact of severe fi (stool incontinence) was determined by multivariate logistic regression. results women with fi were surveyed and of those, ( %) returned at least survey during the study period, completed all survey questions, and were included in the final analysis. among women with fi, % felt frustrated due to fi, % reported fi impacted their emotional health, . % reported fi impacted child-caring abilities, and . % reported a negative impact on social activities. qol was similar across survey periods. one out of three women with fi reported severe symptoms (incontinence of stool). women with severe symptoms were - times more likely to report negative impacts on qol compared to milder (e.g. flatus) fi after adjusting for age, parity and urinary incontinence. . % felt their stool was stored elsewhere before bowel movements, . % reported using digital defecation and more than half ( %) reported symptoms of urinary leakage. despite the substantial impact on postpartum quality of life, few women sought medical help with only % of women at months, . % at year, and . % at years ever reporting their symptoms to a medical provider. postpartum women report that fecal incontinence has a substantial negative impact on their qol after delivery including their emotional health and ability to care for their newborn. despite this profound impact, few women will discuss fi with medical providers. these data suggests there may be a benefit for providers to inquire about fi at postpartum visits. objective: the objective of this study was to determine what characteristics contribute to racial/ethnic differences in breastfeeding rates. study design: a retrospective cohort study of all women who delivered a viable infant (n= , ) was conducted. the primary outcome was breastfeeding upon discharge of the hospital. we first examined the association between race/ ethnicity and breastfeeding. next, we conducted stratified analyses examining a variety of predictors of breastfeeding within the racial/ethnic groups including maternal demographics, obstetric interventions, and perinatal complications. results: we found that both asians (or . , % ci . - . ) and blacks ( . , % ci . - . ) had statistically significant lower rates of breastfeeding, while latinas (or . , % ci . - . ) showed a trend towards higher rates of breastfeeding. in latinas, we found that rd and th degree lacerations were significantly associated with lower rates of breastfeeding, but were not predictive of breastfeeding in the other racial/ethnic groups. epidural use was predictive of lower rates of breastfeeding in caucasians and blacks, but was not predictive in latinos and asians. some of the other predictors which differed between the racial/ethnic groups were obesity and induction of labor (table ) . conclusion: race/ethnicity is significantly associated with breastfeeding, with blacks and asians having the lowest rates of breastfeeding at discharge. a variety of other factors are associated with breastfeeding and interestingly, their effect appears to differ between the racial/ethnic groups. future studies might elucidate the sociocultural and biomedical reasons that explain the differences. these results help focus our efforts during the peripartum period to advocate for mothers who have factors that might impede breast feeding. epidemiology, erasmus medical centre, rotterdam, netherlands; pediatrics, erasmus medical centre, rotterdam, netherlands; public health, erasmus medical centre, rotterdam, netherlands; clinical genetics, erasmus medical centre, rotterdam, netherlands. background recommendations on folic acid use to prevent neural tube defects are launched in several countries. however, the adequate use of folic acid supplements during the periconception period seems to be low. objective to assess the prevalence of adequate folic acid use, defined as the preconception start of supplements, and to identify its determinants in a multi-ethnic population. design the study was embedded in the generation r study in rotterdam, the netherlands, a population-based prospective cohort study from early pregnancy onwards. methods from all women in the cohort who delivered between april and january information on folic acid use and potential determinants was obtained by questionnaires and physical examination. logistic regression models were used to identify determinants of periconception folic acid use. results. data from , pregnant women were available. of all women % adequately used folic acid supplements. the most important risk factors for inadequate use were unplanned pregnancy (or . , p< . ), nonwestern ethnicity (or . , ci . - . , p < . ) and a low educational level (or . , ci . - . , p< . ). other risk factors were single marital status, smoking, multiparity (all p< . ) and alcohol use (p< . ). prior spontaneous abortion was associated with increased adequate folic acid use (p< . ). conclusion adequate periconceptional folic acid use is low. improved preconception care and public health education programs are necessary to improve the uptake of folic acid. although methamphetamine (ma) use has been front and center of the united states drug control policy since , little attention has been given to ma use in pregnancy, despite the fact that pregnant admissions to drug treatment for ma have been rising sharply. to determine trends in the prevalence of ma treatment admissions during pregnancy, we undertook a secondary analysis of the treatment episode data set (teds), an administrative data set that captures at least % of all known treatment admissions in the us. in particular, we investigated risk factors for ma use and how these characteristics have changed over time. demographic, geographic and substance use data were collected for the , pregnant admissions captured between and . logistic regression models were constructed by year. confounding was assessed via backwards elimination with a change-in-estimate criteria of . considered substantial. trend results were reported as adjusted proportions and represented graphically. overall ma prevalence, reported as the primary drug of use upon admission, rose from . % in to . % in . although white women had times the odds of using ma in (adjusted or ( %ci) . [ . , . ]), this had dropped to . [ . , . ] by , mostly due to an increase in latina ma use in pregnancy. pregnant women admitted for ma had fewer prior treatment admissions, were more likely to be unemployed, and less likely to use alcohol or marijuana. we found great geographic variability in use. ma was more common in the pacific region and least common in new england. there was little change in regional variation over the study time period. less is known about the perinatal effects of ma compared with other substances, yet it is the primary drug of choice for pregnant women admitted into treatment. as pregnant women occupy a unique place in drug treatment, analysis of national trend data is essential to guide both policy and research. background: epidemiologists have grouped the multiple disorders that lead to extremely preterm delivery in a variety of ways. we sought to identify characteristics that would support the combining or dividing of the disorders that lead to preterm delivery. methods: we enrolled , women who delivered a live born singleton infant between and completed weeks gestation at tertiary centers in the united states. each delivery was classified according to the complication that prompted presentation: preterm labor, preterm premature rupture of newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced fetal membranes (pprom), preeclampsia, placental abruption, cervical incompetence, and fetal indication/intrauterine growth restriction (iugr). we compared these entities on the frequency of characteristics identified by standardized interview, chart review, histological examination of the placenta, and culture of placenta parenchyma. results: the percents of women who presented with each antenatal complication were: preterm labor ( ), pprom ( ), preeclampsia ( ), placental abruption ( ), cervical insufficiency ( ), and fetal indication/iugr ( ). after considering antecedents and correlates of the processes leading to preterm delivery, we observed two overarching epidemiologic patterns. the first pattern, characterized by recovery of organisms from the placenta and by histologic chorioamnionitis, tended to be associated with preterm labor, pprom, placental abruption, and cervical insufficiency. the second pattern, characterized by a paucity of organisms and inflammation and the presence of histologic features of dysfunctional placentation, tended to be associated with preeclampsia and fetal indications/iugr. conclusions: disorders leading to preterm delivery can be categorized broadly into two groups: those associated with intrauterine inflammation and those with aberrations of placentation. predictors of compliance with tuberculosis screening in pregnancy. nadav schwartz, sarah wagner, sean keeler, may tam, julian mierlak, , aaron caughey. obstetrics and gynecology, nyu school of medicine, new york, ny; obstetrics and gynecology, ucsf, san francisco, ca; obstetrics and gynecology, gouverneur health care services, new york, ny. objective: poor compliance with tuberculosis screening and treatment is a major obstacle to the containment of this disease. we sought to identify predictors of ppd and cxr compliance during pregnancy. methods: a retrospective cohort study at a single institution which serves a largely immigrant population in nyc, from november , through june , . data on maternal age, ethnicity, country of origin, level of education, ppd and cxr status were collected. results: of the , pregnancies, asian and hispanic race/ethnicities accounted for . % and . % of the population, respectively, with . % being us-born. the mean age was . years and the overall ppd+ rate was . %. there was % non-compliance with ppd testing, and % of ppd+ patients were non-compliant with their chest x-rays. asian women were more likely to be ppd-compliant than hispanic or caucasian women. ppd+ asian women were also more likely to be compliant with cxr. us-born women were significantly less likely to be compliant with their ppd or with their cxr. women > years old were less likely to be compliant with their cxr, while women with an elementary school education or less were more likely to be compliant. (see table for odds ratios and %ci) conclusions: age, education, immigrant status and other cultural and ethnic factors appear to play a role in compliance with tuberculosis screening. further elucidation of these effects may help clinicians target at-risk subpopulations and improve overall compliance, working towards better control of this disease. background: in the us, differential outcomes in cervical cancer among medically underserved women are linked to multiple barriers impacting loss to follow-up and failure or delay in diagnostic resolution. prior studies have found risk factors for acquisition of hpv and for inability to obtain a pap smear. no study has explored health literacy and physician communication as a key factor. methods: this research represents the formative phase of a randomized controlled trial of african american (aa) and hispanic women aimed to improve communication and abnormal pap smear follow-up in chicago. semi-structured interviews and focus groups were conducted face to face in spanish or english. each interview lasted minutes, and each focus group lasted - minutes. we recruited patients ( hispanic, aa) and providers from a purposive sample representative of two large clinics that serve low-income women. results: all interviews were transcribed by two investigators. each interview was coded by two investigators separately and then a third investigator reviewed the transcripts and coding to achieve triangulation. codes for these themes were developed and the responses were tabulated using the coding scheme. atlas ti was utilized to analyze all qualitative data. from these data, we uncovered provider-patient challenges in cancer communication including: the providers' trade off between medical accuracy and/or literacy when communicating with their patients. for the patients, the word cancer was important to hear since they wanted the truth and needed to hear this word in order to encourage them to respond more quickly. however, many providers believed that the word cancer was too "scary" and to "extreme" of a word that may communicate too much exaggerated information. both the hispanic and aa patients did not seem to differ in their responses. conclusion: results exemplify not only the importance of health literacy and patient provider communication, but demonstrate the wealth of information gained from qualitative research-a method of data collection seldom utilized in ob/gyn investigations. funding: women's reproductive health research award: hd - ; r ca (spring). population. kristine beckers, isabelle guelinckx, greet vansant, roland devlieger. obstetrics and gynaecology, university hospital gasthuisberg, leuven, belgium; clinical nutrition, katholic university leuven, leuven, belgium. objective: to generate reference charts for weight gain during pregnancy for the different bmi-categories (underweight, normal weight, overweight, obesity), based on recent data in a homogeneous caucasian population. methods: in a retrospective study at the department of obstetrics of the leuven university hospital (belgium), weight gain and pre-pregnancy bmi were determined in belgian pregnant women with accurately dateable, uncomplicated singleton pregnancies. centile curves for the different bmicategories were constructed using of the linear mixed model, one set of charts based on the absolute weight gain, another set based on the relative (expressed as percentage) weight gain. the effect of parity on weight gain was examined. results: overall mean weight gain was . ± . kg ( . ± . lbs). mean weight gain was . ± . kg ( . ± . lbs) in the underweight population, . ± . kg ( . ± . lbs) in the population with normal weight, . ± . kg ( . ± . lbs) in the overweight population and . ± . kg ( . ± . lbs) in the obese population. weight gain (pattern and amount) of the underweight and normal weight patients differed significantly of the overweight and obese patients. parity had a statistical, but no clinical significant influence on amount and evolution of weight gain. conclusion: by using strict inclusion criteria, bmi-category-specific reference charts were generated representing the optimal gestational weight gain, rather than the mean weight gain. this enables the weight charts to be used as a clinical tool during the counselling of pregnant women. further studies are required to assess the effectiveness of this clinical tool. female fshr(-/-) mice are sterile, because of a block in folliculogenesis at the primary follicle stage, show decrease in e and elevated fsh. this animal model is an appropriate model for studying hypergonadotropic ovarian dysgenesis and infertility, caused by c t mutation in fshr gene. objective: to investigate the effects of bmt on serum hormonal levels, follicular maturation and fertility of fshr(-/-) mice. methods: fshr (-/-) mice at - weeks of age were randomized into treated versus control groups.bm from syngenic female donor was injected into the tails of recipients. control group received vehicle alone. vaginal smears were collected, body weight was measured daily. sample animals were sacrificed at , , , , and weeks post bmt. all organs were weighted and examined by h e. fsh, e , and p were measured before and after treatment. for donor cell tracking, dna was extracted from various organs. specific primer sets were designed for normal and mutant hfshr gene. pcr amplification was done and pcr products were analyzed in % agarose gel. results: total body weight significantly increased in treated animals(p< . ). significant increase in both the total number of follicles, and the collective diameter of the follicles in treated animals observed(p< . and p< . ). six out of treated animals showed estrogenic changes in daily vaginal smear. e level increased . - . times and fsh level dropped to % in treated animals. normal (donor allele) fshr gene was amplifiable in out of recipient mice, and was detected only in the ovaries and uterus but not in any other tested organs.control group did not show any changes in vaginal smear, hormonal level, and normal fshr allele. conclusion: intravenously injected syngeneic bone marrow cells were able to home to the ovaries of female fshr (-/-) mice and restore folliculogenesis and resume steroid hormone production. potential mechanisms for these observations will be discussed. conclusion: neural stem cells (nscs) give rise to progenitors, which expand by rapid proliferation until cell cycle arrest followed by differentiation along one of cns cell lineages: neurons, astrocytes and oligodendrocytes. increased differentiation of neuronal cells with ins and even more with leptin suggests that iugr-associated reduction of these growth factors may contribute to impaired hypothalamic pathway development. objective: to develop a technology of modulating hucb in order to achieve neuronal cells for future potential replacement of damaged neuronal tissue. design: we developed a two-dimensional ( d) tissue culture technology for isolation and differentiation of collagen-adherent hucb neural progenitors (hucbnps). we further used the extracellular matrix protein collagen, organized in a three-dimensional ( d) gel, supplemented with neuronal conditioning medium and nerve growth factor (ngf), to facilitate ex-vivo long term neuronal differentiation of hucbnps. we developed a stable green fluorescence protein (gfp)-pc cell model, to be used as a positive control for monitoring neuronal outgrowth for proper evaluation of the hucbnps growth in the d scaffold, mimicking a neural tissue organization. results: our experimental data indicate that d collagen environment is neuronal biocompatible, supporting attachment, long-term survival, proliferation and differentiation of both hucbnps and gfp-pc cells. conclusions: improvement of the d technology with cultures of hucbnps that is in progress in our laboratory might be the first step in validating the concept for the feasibility of generating a neuronal d tissue construct for future potential treatment of neurodegenerative disorders. piane, justin tsai, gnanaratnam giritharan, emin maltepe, paolo rinaudo. reproductive sciences, university of california san francisco, san francisco, ca, usa. objective: ivf embryos are often used to generate stem cells. however, it is unknown if stem cell lines originated from in vitro generated embryos are different from stem cell originated from in vivo embryos. trophoblastic cells, due to their external position within the embryo, are most susceptible to environmental factors encountered in vitro. furthermore, our previous data showed that trophoblast transport functions may be impaired after culture in vitro and that the number of trophoblastic cells is reduced in the embryo after ivf. in this study, we assess the differentiation characteristics of ts cell lines obtained from in vivo and in vitro fertilized embryos. methods: oocytes were isolated from superovulated c bl/ j female mice and in vitro fertilized with sperm from male c bl/ j mice. the resulting late-cavitating blastocysts were harvested. in vivo controls were obtained by flushing the blastocysts from the uteri of superovulated pregnant mice days post hcg. ts cells from the two groups were allowed to develop and maintained in vitro in the presence of fgf and heparin, using a feeder layer of human placental fibroblasts. ts cells were then allowed to differentiate without fgf and heparin, fixed on day , stained with -tubulin and zo- antibodies and then observed under fluorescence microscopy. three ts cell lines per group were analyzed and their differentiative capacity was evaluated using morphological criteria. results: in vivo and ivf derived ts exhibit a similar differentiation pattern. in particular, the number and timing of trophoblast giant cells and spongiotrophoblasts derivation is similar in the two groups. there are no obvious abnormalities in the immunologic staining morphology of the different cell lines at different time points. conclusion: there are no apparent morphological alterations in ts cells lines derived from ivf embryos as compared to in vivo embryos. this finding in an animal model increases our confidence in the reliability of human stem cells derived from ivf. as a further investigation, markers of trophoblast giant cells, spongiotrophoblast, syncytiotrophoblast and chorionic trophoblast cells will be examined and compared in the two different groups by northern blot hybridization. genomewide high density snp-cgh reveals several new deletion copy number variants on the x chromosome in pof patients. erik ah knauff, cisca wijmenga, ruben van 't slot, lude franke, bart cjm fauser. reproduction gynecology, university medical centre, utrecht, netherlands; complex genetics group, university medical centre, utrecht, netherlands. introduction: around % of women have a post-menopausal hormonal profile before age , referred to as premature ovarian failure (pof). pof could act as a genetic model for accelerated follicle loss and may render useful information about the polygenetic background of major individual differences in menopausal age. macrodeletions on the x chromosome are associated with pof but karyotyping has a maximal resolution of mb. when using genotyping whole genome arrays it is now possible to detect submicroscopic deletions and duplications (copy number variants (cnv)) up to kb effective resolution. we have screened for microdeletions on the x chromosome in a well-phenotyped cohort of pof patients. methods: our study included caucasian, ,xx patients with spontaneous secondary amenorrhea before age , fsh > iu/l and absence of (low) x/ xx mosaicism and fmr premutations. dna analysis was performed using illumina k cnv arrays containing , probes. , probes were located on the x chromosome ( probe for every kb), of which , probes were specifically designed to detect known cnvs. ten samples with call rates < % were removed from the analysis and one sample gave inconsistent x probe intensities. we screened for deletions ( kb) using an algorithm detecting at least five consecutive probes with intensities (logr > - . ) below the mean probe intensity. we identified a total of x chromosomal microdeletions, divided in loci and varying between - kb in size. of the samples showed at least one deletion on the x chromosome. % of the identified deletions had already been recorded in the database of genomic variants. in the newly identified newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced loci, we found coding regions containing genes. eight of these are established or potential pof candidate genes, including five that are clustered on the terminal xq critical pof region. conclusions: we observed abundant variation in the cnv regions, a proof-of-principle for this specially designed cnv-chip. snp comparative genomic hybridization revealed possible new deletions specific to pof on the x chromosome. data on duplications, validation and whole genome cnv analysis, compared to a control cohort, will become available soon and will be presented at the sgi annual scientific meeting. unexplained intrauterine fetal death (iufd) is associated with long qt syndrome. irene cetin, patrizio antonazzo, sabrina cozzolino, stefania calabrese, lia crotti, francesca ferrari, roberto insolia, fabio facchinetti, peter j schwartz. dept. of obst/gynecol, univ. of milano, milano, italy; molec cardiol lab, policlinico san matteo, pavia, italy; mother-infant dept., univ. of modena/reggio emilia, modena, italy. introduction: in developed countries, nearly in every pregnancies ends in late fetal loss. many iufds can be attributed to maternal disorders, fetal pathology, placental pathology and fewer to complications of labor and delivery. however, - % of cases remain unexplained. we recently demonstrated that % of sudden infant death syndrome (sids) cases carry functionally relevant genetic variants in long qt syndrome (lqts) genes. aim of the study was to analyze whether lqts genes are associated with iufd. materials and methods: patients with iufd were enrolled in two years, as part of an italian multicentre study. iufd was defined as fetal death at weeks or more of gestation according to the definition of late fetal death of the who. out of cases were classified as "unexplained stillbirths" according to the wigglesworth and aberdeen classifications. at birth placental and/cord samples were collected and dna extracted. the main lqts genes kcnq , kcnh , scn a, kcne and kcne were screened through dhplc and sequence analysis. any amino-acid substitution identified in the samples was checked for in a control population of caucasian women with uneventful pregnancies. preliminary data on the first cases (gestational age of death: - weeks) are reported. results: a total of missense mutations were identified in of stillbirths ( %), two on scn a and one on kcnh . the two mutations on scn a (v l; p a) were observed in two iufd occurred at term; they had been previously associated to sids and shown to increase the late sodium current. the mutation on kcnh is a novel genetic variant absent in reference alleles, never described in any control populations; this mutations was present in a case of iufd diagnosed at weeks of gestation. we are currently performing the electrophysiological cellular studies to define its functional effect. conclusions: these preliminary data indicate that a potentially significant number of currently unexplained iufd might be caused by ion channel diseases such as lqts. the potential prevention of sids or iufd recurrence and the identification of other affected family members could have important implications for the affected families. alternative splicing of epab is regulated by exonic splicing enhancers. e seli, a yaba, o guzeloglu-kayisli, md lalioti. ob gyn, yale u., new haven, ct, usa. introduction: alternative splicing is an important mechanism by which the genome gives rise to the observed diversity of proteins. embryonic poly(a) binding protein (epab), expressed exclusively in oocytes and early embryos, mediates translation of maternal mrnas. we identified an alternatively spliced form of epab lacking exon (cex del), and investigated its regulation as a model for alternative splicing in early development. specifically, we evaluated: imprinting (expression from maternal or paternal allele only); rna editing (post-transcriptional single nucleotide substitution); and exonic splicing enhancers (eses, exonic sites that bind splicing proteins). methods: a single nucleotide polymorphism (snp) detected in exon (c a/g) served as a marker for the parental origin of the spliced form. snp genotyping was performed by pcr amplification of exon followed by restriction enzyme digestion. to evaluate imprinting, we characterized heterozygous mice (a/g) that inherited the snp from either the mother or the father. to test for rna-editing and exonic enhancer contribution we tested mice homozygous for the exon snp (a/a or g/g). efficiency of alternative splicing in different genetic backgrounds was tested using real-time pcr normalized to actin expression. results: in mice heterozygous (a/g) for the exon snp, cex del was only expressed from the (a) allele. however, this was independent of the parental origin of the allele, ruling out imprinting. in mice homozygous (g/g) for the exon snp, the cex del variant also contained (g). therefore, rna editing did not occur. further sequence analysis led to the identification of an additional snp in exon (c g/c) that co-segregated with the exon snp. presence of c g led to the formation of an ese that binds splicing regulatory protein srp , leading to efficient exclusion of exon . real time pcr revealed a five-fold increase in the expression of the cex del alternative splicing variant in animals carrying the enhancer (homozygous g/g) for the exon snp compared to those that did not (homozygous c/c) at the same locus (p < . ). conclusions: in this study, we found that eses mediate the alternative splicing of oocyte-specific transcripts. our findings suggest that single nucleotide polymorphisms may alter the ratio between alternative splicing variants of oocyte-specific proteins. the role that these subtle differences play in determining individual reproductive outcome remains to be identified. epigenetics and chromosomal abnormalities in human oocytes. ilse van den berg, , joop se laven, robert jan galjaard, j hikke van doorninck. , obstetrics gynaecology; clinical genetics, erasmus medical center, rotterdam, netherlands. humans have a low fertility rate compared to other mammalian species. moreover their fertility declines with increasing age. both phenomena are largely due to an increasing number of chromosomal abnormalities in human oocytes during life. identifying factors that cause aneuploidy in oocytes may offer possibilities to diminish these abnormalities in vitro or in vivo. chromosomal segregation errors can result from aberrant recombination but little is known about epigenetic factors that may cause aneuploidy. epigenetic modifications such as histone acetylation and subsequent de-acetylation in oocytes are necessary for a correct progress through meiosis. if disturbed it may lead to aberrant segregation of chromosomes or chromatids due to decreased kinetochore function and imperfect spindle figures resulting in aneuploidy. mice oocyte data have shown a correlation of abnormal histone de-acetylation and aneuploidy and a correlation between age, remaining histone acetylation and aneuploidy (akiyama et al., ) . our research focused on human oocytes and investigated whether a similar relationship between histone acetylation, age and aneuploidy is present. human oocytes were surplus from standard ivf/icsi treatments (ic+). human oocytes showed immunostaining for histone , lysine acetylation (h k ) at the germinal vesicle stage and complete deacetylation at the mii stage in % of the oocytes, while % keep high levels of h k acetylation. treatment of germinal vesicle oocytes with a histon deacetylase inhibitor (tsa) during in vitro maturation until mii stage resulted in high levels of acetylation. remaining acetylation in tsa treated oocytes was correlated significantly with abnormal spindle figures (tubulin staining), a hallmark of developing aneuploidy. similarly, % of oocytes with naturally remaining h k acetylation showed abnormal spindle figures. in contrast % of the normal de-acetylated oocytes showed normal spindles (p= . ). this suggests that defective de-acetylation of h k in human oocytes leads to abnormal spindle figures and subsequent aneuploidy. advanced maternal age is associated with a reduction in de-acetylation during in vitro maturation and an increase in spindle abnormalities. these results may stimulate the development of assays for histone modifications as biomarkers to follow oocyte quality in in vitro maturation studies or in optimizing general ivf treatments. objective: racial disparity in preterm birth (ptb) is unexplained and genetic risk factors are suspected as a major cause. this large scale candidate gene study examines differences association of single nucleotide polymorphisms [snps] in caucasians (c) and african americans (aa) to help elucidate racial disparity in preterm birth (ptb) methods: in this case (preterm birth < weeks) control study (term birth > weeks) maternal and fetal dna from ( cases and controls) c and ( ptb and term) aa were collected. a high-throughput candidate gene association study was performed examining snps in genes of selected from hypothesized ptb pathways. single locus association analyses were performed separately on maternal and fetal samples. results: snps in genes associated with ptb (p< . ) were common between races with both maternal and fetal dna analyses. however, snps in genes in c and in aa in both maternal and fetal dna differed in its association with ptb. in c maternal dna, the single strongest association between ptb and snp was in plasminogen activator tissue (plat) gene (c- t; rs ) at both allelic (p = . x - ) and genotypic (p= . x - ) level with an odds ratio (or) of . ]. the single strongest effect in c fetal dna was observed in a snp in the interleukin- receptor antagonist gene (a g; rs ) for both allele (p= . ) and genotype (p= . x - ), or . ). in aa, the strongest associations were in interluekin- (c t-rs , allele p= . x - , genotype p= . x - ) in maternal dna with an or= . [ci . - . ] and in fetal dna interleukin- receptor b (a g; rs , allele p= . x - , genotype p= . x - ) with an or . ]. conclusion: large scale high throughput analyses of snps in candidate genes of ptb pathway reveals significant differences between races at both maternal and fetal levels. we found that the strongest single locus associations differed in the two races in both maternal and fetal dna samples. these findings support the hypothesis that underlying genetic predispositions may differ between these populations, perhaps partly explaining racial disparity in preterm birth. candidate gene association study indicates differential etiologies in gdm and in t dm. johann urschitz, tarik sultan, kenneth ward. obgyn, jabsom, university of hawaii, honolulu, hi, usa. objective: recently several genome-wide association studies have associated multiple single nucleotide polymorphisms (snps) in multiple genes with increased risk of type diabetes. as risk factors are similar between t dm and gestational diabetes (gdm), we investigated a possible association of those snps with gdm. study design: blood was collected from caucasian ( cases, controls) women who met coustan-carpenter criteria for gdm and non diabetic controls. dna was extracted and a candidate gene association study was performed (taqman, abi). results: chi contingency tests were used to analyze genotype and allele frequencies in controls and gdm affected pregnancies (see table below). none of the snps showed a significant association after bonferroni correction. conclusion: several polymorphisms which displayed highly significant associations with type diabetes are not associated with gestational diabetes. these results suggest that gdm is not a simple unmasking of a t dm predisposition by the metabolic demands of pregnancy; rather it appears that different biological mechanisms are responsible for the respective diseases. introduction: histone acetylation/deacetylation plays an important role in the regulation of gene expression. histone deacetylase inhibitors (hdaci), in general, maintain gene expression, although in some cases they cause repression of specific genes. in this context we have previously shown that the hdaci tsa suppresses activation of the pro-contractile gene cox- in human myometrial and amnion-derived cells [reproductive sciences, vol , no (supplement, # )]. we have also shown that expression profiles for hdacs ( - , ) differ significantly within upper and lower regions of the myometrium during pregnancy and in labour. objectives: since changes in both acetylation and phosphoryation status can influence the activity of individual hdacs we aimed to define whether there are any changes in the levels of acetylation and phosphoryation of myometrial hdac , and during pregnancy and labour. methods: protein homogenates prepared from non-pregnant, term and labouring myometrium were treated +/-shrimp alkaline phosphatase and subjected to sds-page and western immunoblotting (wb) using antibodies to hdac , and . the acetylation status of the hdacs was assessed by a co-immunoprecipitation assay using anti-hdac and anti-acetylated lysine antibodies. results: distinct patterns of acetylation were observed for the individual hdacs; hdac and appeared to be more acetylated in non-pregnant and labouring lower tissues when compared to pregnant myometrium. in contrast, hdac appeared to be slightly more acetylated in lower uterine samples from pregnant and labouring myometrium. in experiments to evaluate changes in phosphorylation status we observed that ) myometrial hdac appeared to less phosphorylated in both upper and lower labouring samples when compared to non-pregnant and pregnant samples; ) hdac appeared to be more phosphorylated in labouring samples than non-pregnant and pregnant myometrium; ) no changes in phosphorylation levels were observed for hdac using this test system. conclusions: the difference in hdac acetylation and phosphorylation levels in the human myometrium may indicate differential regulation of the activity of the hdacs within the distinct myometrial regions, perhaps leading to the alteration of their epigenetic effect on genes related to myometrial quiescence and contraction and the subsequent onset of both term and preterm labour. objective: native hawaiians and pacific islanders experience a higher perinatal morbidity secondary to the increased incidence and earlier onset of heart failure. this increased incidence is likely multi-factorial and includes co-morbidities and genetic factors. mutations in the human adrenergic receptor gene may play a role in the determination of heart function. mutations in the b -adrenergic receptor (adrb ) located on chromosome have been identified as a cause progressive cardiomyocyte loss leading to a dilated cardiomyopathy. the minor allele frequencies for most of these polymorphisms have been determined for caucasian, japanese, african-american and chinese as part of the hapmap project. the frequencies have not been determined in the pacific islander groups. this study helped determine the hawaiian allele frequency and determine the allele frequency in the presence of cardiac or other vascular co-morbidities such as hypertension, preeclampsia, and gestational diabetes. study design: real time pcr technology (taqman genotyping assays, applied biosystems) was used to screen maternal dna (n= ) from the phenotyping sample core of the pacific center for early human development (prcehd) for the rs single nucleotide polymorphisms (snps). genotype frequencies were also determined in % complete ethnic controls as determined by a four grandparent descent. results: chi square was used to analyze allele and genotype frequencies differences between controls and affected pregnancies. the results are summarized in the following tables. conclusion: the rs snp was not significantly associated with hypertension, preeclampsia or gdm in our overall hawaiian population. the genotype frequency in the % pacific islander group was significantly different from the caucasians (p= . ) and asians (p= . ) in our overall hawaiian population. angiotensin-converting enzyme and -adducin polymorphisms in preeclamptic mothers and fetuses. c mando, p antonazzo, s tabano, f colleoni, a martinelli, s calabrese, c benedetto, l marozio, f facchinetti, m miozzo, i cetin. inst. obstetrics and gynecology, fondaz. irccs policlinico mangiagalli regina elena, univ. milan, milan, italy; dept. biology and genetics, univ. milan, italy; dept.obstetrics and gynecology, univ. torino, italy; univ. modena and reggio emilia, modena, italy. background the genes encoding angiotensin-converting enzyme (ace) and -adducin (add ) share the potential of influencing blood pressure. previous studies demonstrated in humans the association of hypertension with the combined effect of both ace insertion/deletion (i/d) polymorphism, which leads to a different activity of the enzyme, and add g w non-sense single nucleotide polymorphism (snp). ace i-i genotype has been associated with low serum ace activity. controversial studies concerning the association of ace polymorphism with preeclampsia (pe) were reported and the possible combined effect of both ace i/d and add g w polymorphisms yet remains to be investigated. population association study we genotyped polymorphisms (ace i/d and add g w) in women: with pe ( / with severe pe) and controls. moreover, we investigated a subset of their fetuses: from severe pe, from mild pe and controls, in order to identify specific maternal and/or fetal genotypes conferring a higher risk to develop pe. we both evaluated the single and the combined effects of ace and add genotypes on mother-fetus couples and singularly on mothers and fetuses. ace i/d genotype was analyzed using a pcr method; an allelic discrimination approach was performed to detect the add snp. in mother-fetus genotype couples, neither ace nor add polymorphisms are associated with pe, nor are the combination of their genotypes separately in mothers and in fetuses. nevertheless in mothers with mild pe ace i-i genotype is significantly less frequent ( % vs %; p< . ) and ace i-d is significantly more frequent ( % vs %; p< . ) compared to controls. ace i allele frequency is not significantly different in mild pe compared to controls ( % vs %). in women with mild pe the i allele seems to move from i-i to i-d genotype. it leads to the increase in mild pe women of those genotypes with a higher ace activity conferring a higher susceptibility to develop pe. this association with mild pe and not with severe pe could be due to the contribution in the latter of many other genetic and environmental factors. introduction: maternal mrnas stored in the oocyte are critical for early development as transcription ceases upon oocyte maturation, and gene expression until zygotic genome activation (zga) is mediated by translation of maternal transcripts. cytoplasmic polyadenylation element binding protein (cpeb) plays a central role in this process by stabilizing maternal mrnas and regulating their timely activation. this function has been well characterized in xenpous, and a similar role in mammals is suspected as the cpeb knockout mouse displays infertility as a result of arrested oogenesis. in order to investigate if translational regulation of maternal transcripts by cpeb is maintained in mammals, we characterized the spatial and temporal expression of cpeb- in the mouse and human. methods: ten different somatic tissues, testes, and ovaries were tested by rt-pcr for the expression of cpeb mrna in mouse and human. cpeb mrna expression in mouse was also tested in prophase i (pi) and metaphase ii (mii) oocytes, -cell, -cell, -cell, -cell embryos and blastocysts. in human, pi and mii oocytes, -cell embryos and blastocysts were evaluated. sequencing of the pcr products was performed to confirm specific amplification of cpeb. amplification with actin primers provided a positive control and allowed semi-quantitative analysis. results and discussion: highest level of cpeb mrna expression was detected in ovaries and testis of both mouse and human. in addition, differential expression of cpeb in somatic tissues was also observed. among these, prominent expression was present in brain, where a role for cpeb in facilitating gene expression through cytoplasmic polyadenylation has been proposed. these data would suggest that translational control of mrna by cpeb may be a mechanism utilized by multiple somatic tissues to regulate gene expression. in the mouse, cpeb was expressed in pi and mii oocytes and -cell and -cell embryos, and became undetectable in -cell or more advanced embryos. human cpeb was expressed in pi and mii oocytes, but not in -cell embryos or blastocysts. zga occurs at late -cell stage and -to- -cell stage, in mouse and human, respectively. the tightly controlled temporal expression of cpeb prior to zga in both mouse and human is consistent with a conserved role for cpeb in the regulation of maternal mrna expression during early development in mammals. background embryonic stem cells (esc) express specific transcription factors that are indicative of their ability to maintain pluripotency. these factors are activated during preimplantation embryo development. the interplay between the transcription factors pou f (oct / ) and caudal-homeobox domain (cdx ) is thought to regulate inner cell mass (icm) and trophectoderm (te) differentiation; however, the mechanism of cell fate determination in mammalian embryos is poorly understood. genetic ablation of oct / in mice prevents icm development, while cdx knockout embryos fail to implant. esc deficient in nanog, a second key regulator of pluripotency, fail to maintain pluripotency and undergo differentiation. expression of nanog in primate embryos has not been investigated, therefore the localization of oct / , nanog and cdx was determined in rhesus macaque blastocysts. methods oocytes were collected from rhesus macaque females, fertilized and cultured in vitro to the blastocyst stage. embryos were collected hours post insemination, then fixed prior to incubation with primary antibodies directed against oct / , nanog and cdx . following incubation with cy conjugated secondary antibodies, nuclei were counterstained with dapi and embryos visualized using an olympus bx fluorescence microscope. results nanog protein was restricted to the icm of monkey blastocysts. unlike the mouse embryo, oct / protein was detected in both the icm and te, based on two different antibodies. the expression of cdx was localized specifically to the te. conclusions the ubiquitous pattern of oct / expression is consistent with observations in human, cow and pig embryos. significantly, lack of restricted oct / protein, and icm localization of nanog in primate blastocysts, suggests that nanog more specifically determines cell fate in primate embryos. these results contrast markedly with current mechanistic hypotheses, although other factors may lie upstream of nanog. importantly, this difference may underlie observations that regulatory mechanisms in esc differ between mice and primates. further investigations will focus on determining the onset of marker expression, and the upstream regulators of nanog activation. supported by nih grants r hd r rr , and the intramural research program of nichd. in vitro-conceived mice tend to be smaller at birth and throughout their life. luisa delle piane, annemarie donjacour, francesca di sebastiano, gnanaratnam giritharan, paolo rinaudo. obstetrics, gynecology and reproductive sciences, university of california san francisco, san francisco, ca, usa. objective: epidemiological evidence indicates that ivf is associated with an increased incidence of low birth weight. this phenomenon has not been studied in a mouse model; in addition, it is unknown if the resulting offspring show different growth pattern later in life. we therefore created an ivf mouse model to follow growth patterns till adulthood. methods: we generated experimental groups of b mice: one cohort of in vivo generated mice (in vivo group), one cohort of in vitro generated animals (ivf group) transferred to cd foster mothers and one cohort of animals fertilized in vivo and transferred to cd foster mothers (flushed blastocysts group, fb). the fb group was generated because our preliminary results showed that embryo transfer to b foster mothers was not successful. all pups were delivered at term, measured and weighed at birth and then weekly up to weeks. parametric tests (anova with bonferroni correction) were used as appropriate. a mixed model was used to compare growth curves. results: average litter size was . (in vivo), . (fb) and . (ivf). birth weight of male mice both ivf ( . mg) and fb ( . mg) was larger than male in vivo mice ( . mg) (p< . ). ivf mice tended to be smaller than fb mice in both sexes (p= . ). the bmi (body mass index) was not different among all the groups. male fb growth curves were different from in vivo mice (p< . ) and more importantly from ivf growth curves (p= . ) (fig. ) . conclusion: the method of conception and the maternal environment play a significant role in determining birth weight in this mouse model, emphasizing that the fb group is the best control for the effects of ivf in this model. these preliminary results confirmed for the first time an ivf effect on growth and interestingly the ivf males did not show a catch-up growth. the finding of smaller ivf mice when compared to fb is both noteworthy, because it confirms human data, and worrisome, because lower birth weight is associated with long term sequelae according to the barker hypothesis. the effect of betamethasone exposure in mid-gestation on renal sodium excretion in male sheep. lijun tang, luke carrey, nancy valego, philip deibel, james perrott, jorge figueroa, mark chappell, james c rose. obestetrics and gynecology, wake forest university, medical school, nc, usa; hypertension center, wake forest university, medical school, nc, usa. objective: whereas prenatal exposure of ovine fetuses to clinically relevant doses of glucocorticoids during the time of peak nephrogenesis results in a reduction in nephron number in adulthood, there is little information about its effect on sodium excretion. in the present study, we evaluated the effect of exposure to betamethasone on renal sodium excretion in adult male sheep. methods: we studied nineteen conscious adult rams at . years of age which were exposed to either vehicle or betamethasone at - days gestation. we implanted vascular and bladder catheters and then allowed the animals a - days recovery period prior to study. inulin and para-aminohippuric acid (pah) clearances were performed for estimating glomerular filtration rate (gfr) and renal plasma flow (rpf) respectively. following determination under basal conditions, an acute hypertonic sodium load was administrated intravenously by a continuous infusion of nacl ( . meq/kg/min at . ml/min) for minutes. urine was continuously collected for determination of na + excretion. results: basal gfr was decreased in steroid exposed adults ( . ± . ml/min/kg) compared with the vehicle animals ( . ± . ml/min/kg) (p= . ). rpf was similar in the vehicle and steroid exposed group ( . ± . ml/min/kg vs . ± . ml/min/kg). at basal conditions, na + excretion (u na v) was similar in vehicle and steroid exposed group ( . ± . μmol/h vs . ± . μmol/h). this similarity was also present after normalization by body weight ( . ± . μmol/h/kg vs . ± . μmol/h/kg). the vehicle group excreted . ± . % of the dose of na during the experiment while the betamethasone exposed group excreted only . ± . % (p< . ). gfr and prpf did not change during the experiments. these results suggest that prenatal exposure to glucocorticoids affects renal function in adult male sheep which results in a decreased basal gfr and an attenuated ability to excrete on acute sodium load. the elevated blood pressure previously observed associated with this prenatal steroid treatment may be related to the alteration in renal function. the study is supported by nih grants hd , hl and hd . characterisation of human fetal cardiac stem cells. marah alfakir, nicholas dawe, annette meeson, stephen c robson. school of surgical reproductive sciences, newcastle university, newcastle upon tyne, united kingdom. objectives: for many patients with severe cardiac disease treatment is limited to surgical intervention and/or heart transplantation. the heart has a limited regenerative capacity but it is insufficient to repair extensive damage. cellular therapies might provide an alternative treatment. we have identified stem cells (sp cells) in the adult mouse and human heart and have shown that the mouse cardiac sp cells can differentiate along a cardiac lineage. sp cells can be identified using facs combined with hoechst dye efflux. this ability to efflux hoechst dye is due to expression of abcg (an abc transporter). we have hypothesized that the fetal heart would contain more cardiac stem cells, relative to the adult, and the aim of this project was to determine the spatial and temporal expression of known stem cells markers in the embryonic/fetal heart. methods: human fetal hearts were collected aged between - wk. we used rt-pcr, using primers for several stem cell (abcg , cd , cd ) and cardiac specific (mlc- v, mhc) markers, and ihc on frozen and paraffin sections, using a panel of antibodies (abcg , cd , cd , islet ). cdna was generated from the following regions of the heart at different developmental stages: right and left atrium, right and left ventricle, and outflow tract. results: abcg mrna was highly expressed in all regions of the fetal heart between - wk. expression was down regulated at - wk especially in the la and lv. a similar pattern of expression was observed for cd . cd showed low/moderate expression in all heart regions examined; however, this expression was absent in the lv at - wk. mrna and protein analysis showed similar results. whilst protein expression of abcg was robust at wk (approximately - %), it declined with increasing gestational age. cd was also strongly expressed at weeks of age. there was no co-localisation between abcg and islet . conclusion: abcg and cd are both expressed between - wk of age. based on this analysis, further studies are underway to isolate and characterise both the abcg and cd expressing fetal cardiac cells which might be a potential source of cardiac stem/progenitor cells. xanthine oxidase plays a significant role in the fetal cardiovascular defence to hypoxia. ja hansell, a kane, e herrera, da giussani. physiology, cambridge university, united kingdom. prenatal hypoxia remains a major concern in obstetrics. the fetal defence to hypoxia includes redistribution of the cardiac output, away from peripheral and towards essential ciculations, such as those perfusing the brain (cohn et al . ajog : , ) . the physiology underlying this response is well characterised and involves chemoreflex and endocrine responses (giussani et al. fet mat med rev : , ) . more recently, local factors such as nitric oxide (no) and reactive oxygen species (ros), and the interaction between them, have been shown to play a role. antioxidants, such as vitamin c, scavenge hypoxia-induced ros, maintain no high and thereby depress peripheral constriction (thakor et al., sgi ) . in this study, we address the source of hypoxia-induced ros production and investigated the effects on the in vivo fetal femoral constrictor response to hypoxia of maternal treatment with the xanthine oxidase inhibitor allopurinol in sheep. methods: under anaesthesia, sheep at . gestation, were instrumented with maternal and fetal catheters and a fetal femoral transonic probe. five days later, all animals were subjected to h normoxia, . h hypoxia (mat fio to reduce fetal pao to ca. mmhg) and h recovery, either following maternal i.v. treatment with vehicle or allopurinol in low ( mg.kg - over min) or high ( mg.kg - over min ) doses. treatments finished min prior to hypoxia. the low allopurinol dose was adopted from human studies (benders et al. arch dis child : , ) . the timing of the hypoxic challenge coincided with peak concentrations in fetal sheep plasma of oxypurinol (active metabolite). we evaluated the effect of bpa exposure on uterine gene expression in a nonhuman primate model. method: a total of nine vervet monkeys (cercopithecus aethiops sabaeus) were ovariectomized. three monkeys were treated with bpa via alzet pumps ( microgram/kg/day), two with estradiol benzoate and three received combined treatment with bpa and estradiol. the remaining monkey was untreated and served as a control. following days of treatment the monkeys were hysterectomized and immunohistochemistry performed to examine endometrial gene expression. we evaluated hoxa , proliferating cell nuclear antigen (pcna), and caspase iii gene expression as markers of differentiation, proliferation, and apoptosis respectively. differential expression was evaluated by h-score. results: exposure to a combination of estradiol and bpa resulted in increased expression of hoxa and pcna compared to control (p< . ). lower, but increased, levels of hoxa and pcna gene expression were seen in the specimens exposed solely to estradiol (p< . ). those specimens exposed to bpa alone demonstrated a small induction in hoxa expression (p< . ) with no change in caspase iii or pcna expression when compared to the control. conclusion: bpa induced the expression of hoxa in the uteri of a non-human primate. exposure in the presence of endogenous estrogen further augmented estrogenic stimulation confirming that bpa is a xenoestrogen. bpa's effect of developmental gene expression may alter uterine differentiation. bpa acts as an endocrine disruptor by altering estrogen regulation on a gene required for fertility. contractility and meconium passage. jayaraman lakshmanan, john d richard, guo l liu, sharon k sugano, ahmet karadag, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa; dept. of pediatrics, harbor-ucla med. ctr., torrance, ca, usa. objective: endogenous glucocorticoids (gcs) increase with advancing fetal age suggesting that gcs function as a hormonal modulator of organ maturation. although fetal colonic motility and meconium passage primarily occur near term, the role of gc in colonic maturation is poorly understood. we sought to examine gc-nuclear receptor (gc-nr) expression in ovine fetal distal colon smooth muscle from very-preterm to term gestation to define the cascade of gc initiated biochemical changes as a prerequisite for maturation-associated meconium passage. methods: ovine fetal distal colonic segments removed at very-preterm (vpt: - d gestation), preterm (pt: - d), near term (nt: - d) and term (t: - d) (n= fetuses in each group) were fixed in bouin's solution and paraffin embedded. sections were subjected to immunohistochmical analysis with gc-receptor antibody ( : , sc- , santacruz biotechnology, ca) using standard abc regimen. immunoreactive material identified by , 'diaminobenzidine as chromogen. the percentage of gc-nr staining in smooth muscle-enteric unit was analyzed by counting dark brown immunostained nuclei at different fields at x magnification. all values are expressed as mean ± sem. results: the gc-receptor antibody immunostained nuclei both in smooth muscle and enteric units and the observed pattern (expressed as percentage of total nuclei) are as follows: nuclear gc expression varies with gestational age with maximal expression occurring near-term in smooth muscle and enteric neurons, in a synchronized manner. a near total disappearance of gc-nr expression occurs at term. these results suggest that peak gastrointestinal gc-nr mediated effects may occur prior to term with secondary signaling effects resulting in distal colonic motility maturation and meconium passage. the rna-binding protein hud co-localizes with choline acetyl mechanisms of in utero meconium passage. jayaraman lakshmanan, john d richard, guo l liu, sharon k sugano, octavio balbuena, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa. objective: we have previously speculated that crf, acting through its receptor crf-r , increases gastrointestinal (gi) motility and potentiates in utero meconium passage. patients with paraneoplastic syndrome with auto-antibodies to hud, a neuronal rna binding protein, develop severe gi dysmotility, indicating a role for hud in gi motility. hud binds mrna for actylcholinesterase implying a role in the cholinergic neurotransmitter system. based on these known functions, we hypothesized that hud may regulate post-transcriptional activity in fetal colonic cholinergic neurons expressing crf-r . method: bouin's solution-fixed paraffin-embedded sections of distal colonic segments were prepared from very preterm (vpt: - days), preterm (pt: - days), near term (nt: - days) and term ( - days) ovine fetuses (n= at each age). sections were immunostained with anti-human neuronal protein huc/hud antibodies ( : to : ) with abc reagents and examined at x. neurons positive for hud staining were quantified. double immunofluorescence and laser confocal analyses evaluated co-expression of hud in neurons expressing peripheral choline acetyl transferase (pchat) (a marker for peripheral cholinergic neurons) and crf-r receptor. results: hud immunostaining was seen in either entire cytoplasm (c) or cytoplasm and nuclear regions (c+n) in both submucosal and myenteric neurons. a greater percentage of submucosal (vpt: ± , pt: ± , nt: ± , and t: ± %) than myenteric neurons (vpt: ± , pt: ± , nt: ± , t: ± %) exhibited positive staining at all ages. the percentages of neurons with c+n staining in submucosal neurons were significantly lower at very-preterm gestation. confocal studies co-localized the hud staining with pchat and crf-r receptor immunoreactivity both in submucosal and myenteric neurons. conclusion: in the fetal enteric nervous system hud may function both as a rna-binding protein and as a nuclear cytoplasmic shuttling protein. colocalizaion studies suggest that both pchat-mrna and crf-r mrna species are target transcripts for hud in myenteric neurons. we speculate upregulation of hud contributes to in utero meconium passage. meconium passage during mild stressors. jayaraman lakshmanan, guo l liu, john d richard, sharon k sugano, raina khan, octavio balbuena, kimberly chap, virender rehan, michael g ross. dept. of ob/gyn, harbor-ucla med. ctr., torrance, ca, usa; dept. of pediatrics, harbor-ucla med. ctr., torrance, ca, usa. objective: mr exhibit a greater affinity to glucocorticoids (gc) than do glucocorticoid receptors (gr). thus low circulating gc levels may preferentially bind mr during mild-stress periods, while the high gc levels may bind gc-receptors. mr antagonism increases gc-mediated responses, suggesting that mrs have a regulatory impact on gc-mediated stress responses. we recently documented that fetal in utero meconium passage is a neurovisceral stress response. to test our hypothesis that mrs play a primary role in mediating suppressive gc effects, we examined the expression patterns of mr in ovine fetal distal colon. methods: bouin's solution fixed paraffin sections of distal colonic segments collected from ovine fetuses (n= for each gestational ages) at very preterm (vpt: - days gestation), preterm (pt: - days), near term (nt: - days) and term (t: - days) were subjected to immunohistochemistry with polyclonal antibodies to mr. digital photos ( field per colonic ring, rings each gestational age) taken at x were used to count the number of intensely stained neurons, referred to as "mr-capped neurons". differences over time were determined with anova. results: mr antibody elicited a punctate staining pattern in all layers of ovine fetal distal colon. significant immunoreactive intensity was observed in submucosal and myenteric ganglia at all ages: submucosal ganglia: vpt= . ± . , pt= . ± . , nt= . ± . , t= . ± . ; a subpopulation of enteric neurons exhibited dense staining ("mr-capped"). advancing gestation was associated with a significant decreased in the percentage of mrcapped myenteric (vpt = ± , pt = ± , nt = ± , t = ± %; p< . ), though not submucosal ganglia neurons. results indicate a significant decrease in the percentage of mr capped myentric neurons with advancing gestation. in view of the potential inhibitory effect of mr on gc-mediated stress responses, these results suggest that the decrease in mr expression may contribute to near term and term in utero meconium passage. the ambiguity of myometrial progesterone receptor expression in pregnancy and labour. alison j tyson-capper, elizabeth a shiells, stephen c robson. surgical reproductive sciences, institute of cellular medicine, newcastle university, newcastle upon tyne, united kingdom. background and aims: in contrast to many other species, human parturition is not due to a reduction in circulating levels of progesterone (p) but appears to be related to changes in expression, ratios or signalling events of p receptors (pr-a and pr-b). the literature on pr expression in human myometrium in pregnancy and labour remains conflicting. we hypothesise this is due, at least in part, to differing specificities of the various pr antibodies employed. we carried out a comprehensive analysis of pr expression using ten 'pr-specific' antibodies that recognise different amino acid epitopes within the pr proteins. two phosphorylation-specific antibodies for pr were also included to define whether phosphorylation status of myometrial pr changes in pregnancy and in labour. methods: western immunoblotting and semi quantitative rt-pcr were undertaken using protein lysates and rna prepared from myometrial tissue from: -first (n= ) and second (n= ) trimesters, paired upper and lower segment myometrium from preterm ( - wks, n = ), term not in labour (n = ), term spontaneous labour (n = ) and non pregnant (n = ). results: using the same set of myometrial lysates for each antibody, we found that the specificity of individual pr antibodies, in particular those raised against internal and c-terminal epitopes of the pr proteins, varied considerably resulting in different patterns of expression. there also appeared to be temporal and spatial differences in levels of myometrial pr proteins ( - kda/ - kda) in pregnancy and in labour with use of the phosphorylation-specific pr antibodies, however, it remains to be resolved which pr isoforms these may be. in contrast, data using four antibodies all of which react with the amino terminal domain of pr consistently indicated that expression of pr, in particular pr-b, decreased significantly at term (p < . ) and in labour (p < . ) when compared to non-pregnant levels. a decrease in levels of pr-b protein was also observed when comparing preterm levels to non-pregnant levels. rt-pcr using primers specific to pr-b consistently indicated that levels of pr-b mrna decreased at term and in labour. conclusion: interpretation of gestation-related changes in myometrial pr expression and phosphorylation status must take into account the pr antibodies used. further studies are now underway to validate the specificity of the pr antibodies. objective to test the hypothesis that expression of fshr in mural gl cells from ivf follicles varies with the infertility diagnosis and correlates with the outcome of ovulation induction (oi). materials and methods women undergoing ivf were classified as: . "no ovarian factor", (tubal or male factor and egg donors, nof;n= ); . endometriosis (endo; n= ); . poor responders (pr; n= ); . polycystic ovary syndrome (pcos; n= ). ovulation induction was carried out using a long or microflare or antagonist protocol based on clinical parameters and gonadotrophin doses were selected based on ovarian reserve (day fsh and e and basal antral follicle count) and adjusted to the individual response. after ultrasound guided egg retrieval, mural gl cells were isolated from pooled follicular fluids from each patient using a percoll gradient and anti-cd immunobeads to eliminate wbcs, viability was assessed by trypan blue. fshr was measured by rt-pcr as relative expression compared to beta actin. statistical analysis was performed with the spss using pearson´s correlation, one way anova and student´s t-test. results fshr expression in nof ( ± . ) was statistically significantly higher than in pr ( ± . ) and lower than in pcos ( ± . ). both endo ( ± . ) and pr levels of fshr were statistically significantly lower than in pcos. analysis of all cycles showed that fshr expression correlates positively with the number of total (r= , ; p< , ) and mii (r= , ; p< , ) oocytes and negatively with the units of fsh (r=- , ; p< , ) and lh (r=- , ; p< , ) administered for oi. separate analysis of nof showed a positive correlation with the number of total and mii oocytes retrieved and with estradiol levels on day of hcg but not with the total dose of gonadotropins received during oi. fshr expression correlates negatively with day fsh levels in all patients except in pcos (r=- , ; p< , ). conclusions these results suggest that expression of fshr in the hyperstimulated ovarian follicle is "average" in normoresponders, high in high responders (pcos) and low in poor responders (pr and endo). knowledge of the level of expression of fshr might be useful to individualize gonadotrophin doses and oi protocols thus improving pregnancy rates. comparison of intracellular atp levels between non-vitrified and surviving post-vitrification/thawed human oocytes. somjate manipalviratn, zhi-bin tong, eric widra, , alan h decherney. reproductive biology and medicine branch, nichd/nih, bethesda, md, usa; department of obstetrics and gynecology, georgetown university hospital, washington, dc, usa; shady grove reproductive science center, washington, dc, usa. objective: to compare intracellular atp level in non-vitrified and surviving post-vitrification/thawed human oocytes using an atp bioanalysis assay. design: prospective match-controlled laboratory study material and methods: all oocytes were obtained from women undergoing controlled ovarian stimulation for ivf/icsi. oocytes were discarded due to nuclear immaturity at the time of planned icsi. all immature oocytes (gv and mi) were incubated overnight. oocytes from patients with or more discarded eggs which matured to mii stage were used in this study. oocytes from each women were randomly divided into groups. in group , the oocytes were placed in l of ultrapure water and kept at - o c for further atp analysis. in group , the oocytes were vitrified using % ethylene glycol, % dimethyl sulphoxide and . m sucrose as cryoprotectant. these oocytes were kept in liquid nitrogen for - days before thawing with a rapid thawing method. oocyte survival was determined by morphological assessment after minutes of incubation then oocytes were placed in l of ultrapure water and kept at - o c for further atp analysis. intracellular atp level was determined using luciferin-luciferase bioluminescent assay. result: ninety-one discarded human oocytes were obtained from women. oocytes were vitrified/thawed before measuring for atp content. the other oocytes were measured for their atp content without undergoing vitrification/thawing process. oocyte survival rate after vitrification/thawing is . % ( / ). mean oocyte atp levels in non-vitrified oocytes is significantly higher than surviving post-vitrification/thawed oocytes (table ). coefficient of variation of luciferin-luciferase bioluminescent assay is less than %. conclusion: oocyte atp level in surviving post-vitrification/thawed human oocytes is significantly lower than non-vitrified oocytes. objective to study the expression of genes involved in cell proliferation and steroidogenesis in the human follicle (kl , kl , fshr, papp, p ) and its relationship with ivf outcome. materials and methods patients with different infertility diagnosis underwent ovulation induction with either a long or microflare or antagonist protocol based on clinical parameters; the dose of gonadotrophin used for ovulation induction was selected based on the ovarian reserve (day fsh and e and basal antral follicle count) and adjusted to the individual patient response. ultrasound guided egg retrieval was performed hours after administration of . iu of hcg. mural granulosa-lutein cells (gl cells) were isolated from pooled follicular fluids (ff) from each patient using a percoll gradient and anti-cd immunbeads to eliminate wbcs, viability was assessed by trypan blue. the genes under study were measured by rt-pcr as relative expression compared to actin. statistical analysis was performed with the spss statistical software using pearson´s correlation and mann-whitney u. results kl expression correlates positively with kl levels (r= , ; p< , ) and with genes implicated in granulosa cell function such as fshr (r= , ; p< , ), papp (r= , ; p< , ) and p (r= , ; p< , ). the number of mii oocytes obtained is positively correlated with both fshr (r= , ; p< , ) and papp (r= , ; p< , ) expression, but not with the other genes. kl expression in women who became pregnant during the ivf cycle studied was higher ( , ± ) than in non pregnant women ( , ± , ).(n= , mann-whitney u p< , ). conclusions patients who become pregnant have increased expression of kl , which is associated with optimal granulosa cell proliferation and maturation. this is in accordance with the presence of lower apoptosis in granulosa cells in the same patients. syndrome during assisted reproduction treatment. k jayaprakasan, r jayaprakasan, h al-hasie, js clewes, bk campbell, ir johnson, nj raine-fenning. school of human development, university of nottingham, nottingham, united kingdom. objective: to test the hypothesis that an increased pre-treatment ovarian blood flow is associated with the development of ovarian hyperstimulation syndrome (ohss) and to evaluate ovarian vascularity as a predictor of ohss during invitro fertilization (ivf). methods: subjects undergoing first cycle of ivf had d transvaginal ultrasound in the early follicular phase of the menstrual cycle preceding ivf. of them developed ovarian hyper-response, defined as retrieval of oocytes and ohss. subjects had normal ovarian response with retrieval of to oocytes in the absence of ohss. antral follicle count (afc), ovarian volume (ov), and ovarian vascularity (vascularisation index, vi; flow index, fi and vascularisation flow index, vfi) were measured and an unpaired t-test was used to compare these parameters between the ohss and the control groups. multiple logistic regression analysis was used to assess the predictive value of these variables against age, bmi and basal fsh for the development of ohss. results: the ovarian vi ( . ± . vs. . ± . ), fi ( . ± . vs. . ± . ) and vfi ( . ± . vs. . ± . ) were similar in both the groups. afc and ov were significantly higher (p< . ) in the ohss group ( . ± . and . ± . cm respectively) than in the control group ( . ± . and . ± . cm respectively). afc was the only significant (p= . ) predictor of ohss on multiple regression analysis (table ) . conclusion: women developing ohss during ivf do not demonstrate an increased pre-treatment ovarian blood flow as measured by d ultrasound but do have a significantly higher afc, which is the only significant predictor of ohss. compared to other species, little is known about the steroid biosynthetic capacity and gene expression profiles of human cumulus cells. objective: to examine the ability of human cumulus cells in primary and long-term culture to synthesize steroids and respond to gonadotropin or camp-dependent stimulation. methods: human cumulus cells were isolated from cumulusoocyte complexes during assisted reproductive technology (art) and placed in primary culture or propagated to third passage. at subconfluence, cells were transferred into serum-free conditions in the presence of vehicle, forskolin, fsh, or hcg. at h, media was collected and progesterone (p ) and estradiol (e ) levels were determined by eia. aromatase activity was measured by the tritiated water assay. aromatase (cyp ) and cholesterol side-chain cleavage (cyp a ) mrna abundance was determined by quantitative real-time pcr (qrt-pcr). transcriptional regulation of the cyp and cyp a promoters was investigated by transient transfection of cumulus cells with promoter luciferase constructs. results: substantial amounts of p and e were synthesized by cumulus cells in culture, which were further elevated by forskolin, hcg, or fsh treatment. the presence of cyp and cyp a mrna in cumulus cells was confirmed by qrt-pcr, and the relative mrna abundance of both transcripts was induced by forskolin, hcg, or fsh treatment. changes in cyp and cyp a gene expression in response to camp and gonadotropin stimulation were associated with increased transcriptional regulation of both the cyp and cyp a gene promoters. our studies demonstrate that human cumulus cells are sites of significant p and e biosynthesis and respond to camp-and gonadotropin-stimulation in vitro. the ability to examine human cumulus cells in primary and long-term culture provides a unique model system to investigate cumulus cell function, and the paracrine role of cumulus cells in oocyte development, maturation, and subsequent fertilization. background: there is increasing evidence suggesting that events occurring during fetal development may result in increased predisposition to adult conditions, such as diabetes. in vitro fertilization (ivf) is a new environmental stressor and the long-term effects of these manipulations are currently unknown. there is some evidence that lower number of insulin-secreting cells at birth signals predisposition to diabetes later in life. in this study, we compare areas of pancreatic insulin-secreting cells in newborn mice conceived in vivo versus in vitro. methods: oocytes were collected from super ovulated cf- mice and fertilized in vitro with cauda epididymal sperm from b d f /j mice. fertilized eggs were cultured in whitten medium under % co in humidified air at °c for h. blastocysts were transferred to the uteri of pseudo-pregnant recipients. control mice were allowed to conceive in vivo. the newborn animals were sacrificed within hours of birth. pancreases were sectioned, immunostained with anti-insulin, and total areas and stained areas were compared using t-test with two-tailed distribution. p value of < . was considered significant. results: there were total of newborn animals: females ( ivf, controls) and males ( ivf, controls). percentage of total pancreatic area occupied by insulin-secreting cells was lower in female ivf ( . mm , . %) animals compared to female controls ( . mm , . %) and higher in male ivf ( . mm , . %) animals compared to controls ( . mm , . %). the average of males and females was slightly lower for ivf ( . mm , . %) than controls ( . mm , . %). none of these differences were statistically significant. there was a trend in newborn female mice towards lower amount of insulin-secreting cells in the ivf offspring, suggesting possible predisposition to diabetes later in life. this effect was not observed in newborn males. while our study failed to demonstrate consistent and significant differences in the areas of insulin-secreting cells between newborn mice conceived in vitro and in vivo, the number of animals in the study may have been too small to show significant results. larger studies are needed to further investigate this question. peter s uzelac, phyllis risch, kassi shelton, steven t nakajima. obstetrics and gynecology, university of louisville, louisville, ky, usa. objective: several fertility preservation methods currently available may not be viable options to certain patients due to their high cost and limited number of centers offering these services. for women undergoing bilateral oophorectomy, in vitro maturation (ivm) of oocytes retrieved from unstimulated whole ovary specimens may represent a more practical solution. here we describe out initial experience in offering ivm as a fertility-preserving measure to two patients undergoing total abdominal hysterectomy and bilateral salpingo-oophoectomy (tah-bso). case one was a year old nulligravid with chronic pelvic inflammatory disease unresponsive to medical management. case two was a year old nulligravid with stage ia endometrial carcinoma. surgery was planned for the mid-follicular phase in order to collect prophase i oocytes before the onset of late-follicular phase atresia. upon surgical removal, suction aspiration of all identifiable follicles was performed. ovaries were then serially sectioned and all tissue was examined for the presence of prophase i oocytes. results: total number of prophase i oocytes retrieved was and , maturation rate after hours was % ( / ) and % ( / ), fertilization rate after hours was % ( / ) and % ( / ), maturation rate after hours was % ( / ) and % ( / ) and fertilization rates after hours % ( / ) and % ( / ), for case and case respectively. ivm of oocytes retrieved from unstimulated whole ovary specimens may be a simple and inexpensive approach to fertility preservation in women undergoing bilateral oophorectomy. by requiring minimal adjustments to in vitro fertilization protocols, this treatment could easily be implemented in centers which currently have no fertility preservation program. patient age at time of retrieval may be predictive of developmental potential. continued patient enrollment and follow-up studies on the developmental potential of embryos derived from this technique are necessary to fully evaluate its potential for a role in fertility preservation. the routine use of progesterone as luteal phase support in women with a diagnosis of polycystic ovary syndrome (pcos) undergoing ovulation induction cycles with oral agents has not been fully elucidated. we hypothesize that women with pcos utilizing either clomiphene citrate or letrozole, an aromatase inhibitor, should administer intravaginal progesterone in the luteal phase to increase pregnancy rates. design: retrospective chart review. materials and methods: cycle data from women with pcos undergoing ovulation induction with clomiphene citrate or letrozole at the university of cincinnati medical center from to were evaluated. diagnosis of pcos was based on rotterdam criteria and all other infertility diagnoses were excluded. clinical pregnancy rates (presence of fetal cardiac activity on ultrasound at - weeks gestation) in women who received intravaginal micronized progesterone ( mg bid) following ovulation induction (with and without intrauterine insemination) were compared to those who did not receive progesterone. results: no significant differences were noted in demographic parameters, including patient age or bmi. a total of cycles were evaluated in women treated with clomiphene citrate. clinical pregnancies were documented in . % ( / ) of cycles in the progesterone group compared to . % ( / ) of the non-progesterone group (p < . ). forty-three cycles were evaluated in patients treated with letrozole. clinical pregnancies were documented in . % ( / ) of cycles in the progesterone group compared to none ( / ) in the non-progesterone group (p < . ). conclusions: patients with pcos who used letrozole for ovulation induction had superior clinical pregnancy rates when using intravaginal micronized progesterone compared to women who did not receive luteal phase support. there was a trend toward increased clinical pregnancy rates in pcos patients utilizing luteal support following clomiphene citrate for ovulation induction. therefore, in women with pcos undergoing ovulation induction with oral agents, luteal supplementation with progesterone should be strongly considered, especially in those using letrozole. were measured and an unpaired t-test was used to compare these parameters between poor and normal responders. multiple logistic regression analysis was used to assess the predictive value of these variables against age and basal fsh for poor ovarian response. results: the ovarian vi ( . ± . vs. . ± . ), fi ( . ± . vs. . ± . ) and vfi ( . ± . vs. . ± . ) were similar in both poor and normal responders. afc and ov were significantly lower (p< . ) in poor responders ( ± . and . ± . cm respectively) than in normal responders ( . ± . and . ± . cm respectively). afc was the best (p< . ) predictor of poor ovarian response on multiple regression analysis ( objective: gay male couples increasingly seek parenthood through in vitro fertilization using an oocyte donor and a gestational carrier, but no studies describe this unique experience. the purpose of this study was to determine medical and psychosocial issues unique to gay men using art. design: qualitative analysis of semi-structured interviews with gay male couples seeking parenthood through art. materials and methods: sixteen gay males (eight couples) entering an art program were assessed through the use of a semi-structured interview. characteristics evaluated included age, relationship status, duration of their relationship, psychological health and stability, how the decision was made concerning who would donate the sperm, the decision to use an anonymous or known oocyte donor, and whether their gestational carrier was someone previously known to them or not. results: the average age of the men in this study was years. all eight couples were in a committed relationship and had been together for an average of . years. five of the couples ( %) had been joined in a civil union which is legal in the state of connecticut. all subjects were psychologically stable and in good health. six couples ( %) were very clear about which partner would inseminate the oocytes. of those couples, two felt that the older partner should donate; two felt that the partner who cared more about a genetic connection to the child should donate; and two felt that the partner with "better genes" should donate. the remaining two couples chose to inseminate equal numbers of oocytes in order to transfer an embryo from each partner. all couples chose an anonymous oocyte donor, two couples chose relatives as their gestational carriers, while the others chose carriers recruited through an agency. conclusions: participants in this study were determined to become parents through assisted reproduction. they had given thoughtful consideration to the medical and psychosocial issues unique to this process including which partner would be the genetic parent, and why. clomiphene superovulation. rb allen, az steiner, rh fogle, mj kalan, rj paulson. ob/gyn, usc keck school of medicine, la, ca, usa; ob/gyn, unc, chapel hill, nc, usa. intro: micro-dose hcg has been demonstrated to increase ovulation and pregnancy rates following clomiphene administration in women resistant to clomiphene. since micro-dose hcg stimulates growth in follicles expressing the lh receptor, we hypothesized that its use following clomiphene in women with unexplained infertility would increase the number of follicles that ovulate and subsequently, pregnancy rates. m m: irb approval was obtained for this prospective pilot study of women with unexplained infertility. on day # a baseline ultrasound was performed and serum fsh and e levels were measured. subjects were given mg of clomiphene daily from days - and then returned for serial ultrasounds on day # . when at least follicles mm were present, iu of hcg im daily was initiated. cycles were monitored by ultrasound every days until a +lh surge occurred. all subjects had previously undergone a cycle using clomiphene alone for superovulation followed by iui and these cycles were used for comparison. results: subjects, aged . ± . yrs (mean±sem) and bmi . ± . kg/m with . ± . yrs of infertility were enrolled. the mean fsh and e levels were . ± . miu/ml and . ± . pg/ml, respectively. there was an average of . ± . days from starting clomiphene to the attainment of follicles mm. out of the subjects had follicles mm by day # . a mean of . ± . days of treatment were required until ovulation occurred. there were twice as many follicles in the micro-dose hcg cycles, although due to the small sample size this did not reach statistical significance ( . ± . follicles, measuring . ± . mm in the micro-dose hcg cycles, compared to . ± . (p= . ), measuring . ± . mm (p= . ) in the control cycles). there was no difference in the endometrial thickness at the time of ovulation between the micro-dose hcg cycles and the control cycles: . ± . mm vs. . ± . mm (p= . ), respectively. all subjects had at least ovulatory sized follicles in the study cycles. % of subjects had an iui performed, however there were no pregnancies resulting from this study. conclusions: ) the addition of micro-dose hcg to clomiphene may allow more follicles to reach an ovulatory size, which should theoretically increase pregnancy rates ) this pilot study demonstrates that adding micro-dose hcg may increase the effectiveness of clomiphene when given in a superovulatory protocol. jessica salas, donald maier, john nulsen, claudio benadiva, lawrence engmann. obstetrics gynecology, university of connecticut, farmington, ct, usa. objective: to evaluate the antepartum, intrapartum, and neonatal complications in patients undergoing ivf using a gnrh-antagonist protocol where a gnrhagonist was used to induce final oocyte maturation. materials and methods: a retrospective review of data from high responders undergoing their st or nd ivf cycle using a gnrh-antagonist protocol who were triggered with leuprolide acetate (study group) or hcg (control) and achieved at least a singleton pregnancy reaching the third trimester. patients younger than years old were included. both groups received luteal phase support with intramuscular progesterone. the study group received estrogen patch supplementation. outcomes measured were antenatal and intrapartum complications, order of gestation, gestational age at delivery, birth weight, neonatal adverse outcomes, and congenital anomalies. pearson chi square, fisher's exact test, or independent t-test were used as appropriate. results: the baseline characteristics were different (table ) . maternal antenatal and intrapartum complications were similar in both groups ( . % vs . %, p= . ). there were more singletons in the study group ( . % vs . %, p< . ). a subgroup analysis of gestational age at delivery, birth weight, neonatal complications and congenital anomalies in singletons showed no difference (table ) . conclusions: this is the first study reporting the maternal and perinatal outcomes after gnrh-agonist trigger. differences in response to ovarian stimulation may dictate use of gnrh-agonist triggering for prevention of ohss, which may explain the differences in baseline characteristics. maternal and neonatal complications remain unaffected. table lupron (n= ) objective: moderate to severe ovarian hyperstimulation syndrome (ohss) occurs in - % of assisted technology cycles and carries the potential for severe complications. traditional management consists of hospitalization with intravenous fluids (ivf), bedrest, and close monitoring. early and aggressive paracentesis is an alternative method of treatment for ohss in an outpatient setting, but the economic consequences of the two treatment regimens have not been compared. design: cost-effectiveness analysis materials and methods: two scenarios, outpatient management with transvaginal paracentesis and conservative therapy with hospitalization, were compared. potential initial outcomes were analyzed for the conservative group to include hospitalization either in a ward hospital bed or the intensive care unit (icu) for an average of seven days. costs included ivf administration, ultrasound, and daily bloodwork. initial outcomes for the outpatient management group included no further therapy beyond the initial transvaginal paracentesis, bloodwork, ivfs, and ultrasound versus admission for an average of three days to a ward bed with similar management. the probability of the negative outcome for the conservative group was set at % (icu admission) and % for the outpatient group (regular hospitalization). results: the cost of conservative therapy including first tier complications ranged from a low of $ , to a high of $ , . the cost of outpatient management with aggressive paracentesis and its first tier complications ranged from a low of $ to a high of $ , . this resulted in an estimated cost burden of $ , to $ , for conservative management with hospitalization. the main improvement factor was that patients in the outpatient management group had a much lower likelihood for prolonged hospitalization than the conservatively managed group. conclusions: aggressive outpatient treatment of moderate to severe ohss with early paracentesis appears to be a cost-effective strategy. induction. zeynep alpay, michael p diamond, michael l kruger, elizabeth e puscheck. obstetrics and gynecology, division of reproductive endocrinology and infertility, hutzel hospital, wayne state university, detroit, mi, usa. introduction: aromatase inhibitors (ai) are a new method of ovulation induction and is proposed to replace clomiphene citrate (cc) due to their reported advantages. their superior effect is thought to be due to up-regulation of the estrogen receptors and increase in the sensitivity of the endometrium, resulting in better proliferation despite low estrogen levels in the circulation. objective: to compare the effect of different ovulation induction methods, including ai, cc and gonadotropins (gt) on the endometrium in infertility patients. methods: we reviewed ovulation induction cycles performed in our institution in the last one-year period retrospectively. there were gt, cc and ai cycles. age, gravida, day (d et) and midcycle (mcet) endometrial thickness, endometrial pattern (ep) on day of hcg injection, endometrial growth during the induction cycle (d-et), which was calculated by the difference between mcet and d et, and the pregnancy rates (pr) were compared. the ep was categorized as type a (homogenous and hyperechogenic), type b (intermediate isoechogenic pattern and a poorly defined central echogenic line), and type c (multilayered triple-line). chi-square, anova, t test and pearson correlation were used for statistical analysis. results: in all cycles, ep was closely related to the d-et (p < . ). this correlation appeared to be more pronounced when observed ep was compared with d-et (r = . ; p < . ) rather than with mcet (r = . ; p = . ). there was a reverse relationship between the age of the patients and ep (r = - . ; p < . ). a negative correlation was also found between the gravida and ep (r = - . ; p < . ). pregnancy rate was significantly correlated with ep (r = . ; p < . ). pregnancy rate was % in type a ep, . % in b, % in c when all cycles were analyzed. aromatase inhibitors and gt treatments each resulted in % type c pattern in contrast to % with cc (p = . for ai vs. cc; p = . for gt vs. cc). the d-et was greater in gt cycles compared with ai or cc (p < . ). conclusion: these results show that ep has a strong correlation with pr in ovulation induction cycles. additionally, ai and gt treatments have similar effects on ep. both ep and the growth of the endometrium during the induction (d-et) are good prognostic variables for the successful pregnancy initiation. ovarian response in patients undergoing ovarian stimulation after myomectomy. hyacinth browne, , desiree mccarthy-keith, , barbara stegmann, , alicia armstrong. , reproductive biology and medicine branch, nichd, nih, bethesda, md, usa; reproductive endocrinology and infertility, walter reed army medical center, washington, dc, usa. objective: the impact of myomectomy on ovarian function has not been wellstudied. other surgical treatments of fibroids, such as hysterectomy and uterine artery embolization, have shown an increase of fsh into the peri-menopausal range. the objective of this study is to examine ovarian response in infertile women undergoing ovarian stimulation after abdominal myomectomy. design: retrospective analysis. materials and methods: a retrospective analysis of all infertile women with known fibroids who had a failed art cycle, from january to , followed by an abdominal myomectomy and a subsequent art cycle was performed. women served as their own controls. ovarian function pre and post-myomectomy was assessed by age, day and fsh levels, days of stimulation, total gonadotropins used, peak estradiol level, number of oocytes retrieved, embryos obtained, and high-grade embryos, and pregnancy outcome. quantitative results are presented as mean + sd. results: four women had a failed art cycle and underwent an abdominal myomectomy prior to a subsequent art cycle. the mean age was and pre-and post-myomectomy, respectively. all subjects had uterine factor infertility. two of these women also had tubal factor infertility, and one had endometriosis and male factor infertility. we found no difference in ovarian response pre and post-myomectomy. pre-myomectomy post-myomectomy age (years) + . + . day fsh (u/l) . + . . + . day fsh (u/l) . + . . + . objective: anti-mullerian hormone ( amh) is produced by developing primordial follicles. amh levels are stable through the menstrual cycle and therefore can be drawn randomly. the objective of this study was to assess the association of anti-mullerian hormone ( amh) and oocytes obtained at ivf retrieval. design: cross-sectional cohort study. materials and methods: the study cohort is comprised of thirty women in cycles of in vitro fertiization (ivf). serum levels antimullerian hormone (amh) were drawn before starting an ovulation induction cycle for ivf. standard ovulation induction was performed with leuprolide flare and miu/ml per day of follicle stimulating hormone. we performed linear regression of log convert d oocyte number against the log converted amh level. serum amh was measured using an enzymatically amplified two-site immunoassay dsl- - active mis/amh elisa. statistical analysis was performed using spss version . . continuous values are presented as mean std error. results: the log number of oocytes retrieved was directly related to the log value of amh (p = . ). conclusions: our data demonstrate an association between serum amh and oocytes produced in response to ovulation induction. using amh levels in addition to fsh levels in evaluating for ovarian reserve and pregnancy outcome may help improve predictions of reproductive performance. support: foundation for reproductive medicine. context: prediction of outcome after in vitro fertilization (ivf) can be difficult due multiple factors. human chorionic gonadotropin (hcg) levels correlate with pregnancy outcome, but data that can be used to easily counsel patients on their possible outcome is lacking. objective: to investigate the use of hcg levels along with other significant factors to predict the likelihood of an ivf pregnancy progressing to the point of detection of cardiac activity by ultrasound design: retrospective data analysis of ivf cycles performed from january to july resulting in pregnancies. multiple logistic regression analysis modeling was performed to determine the factors most predictive of an ongoing early pregnancy and to assess possible confounding variables. setting: an academic fertility center. patients: patients undergoing in vitro fertilization using autologous fresh embryos. intervention: none main outcome measure: pregnancy continuation to the documentation of cardiac activity by ultrasound. results: maternal age, day (post-oocyte aspiration) hcg level, and day hcg levels were significant in predicting pregnancy outcome. day and day hcg levels were highly correlated and can be considered proxies for each other. the most accurate predictive model used only a single day hcg level and maternal age. the type of fertilization method used, the cycle number for that patient, and the number of embryos transferred were not found to be significantly different. ongoing pregnancy rates were directly proportional to day hcg level, and inversely proportional to maternal age. the incidence of multiple pregnancies also increased proportionally to the initial hcg level. % of ongoing pregnancies had hcg level > miu/ml. conclusions: a single day post-oocyte aspiration hcg level and maternal age are the most predictive of an ongoing ivf pregnancy. there was no difference in outcome between fertilization methods or number of embryos transferred. there is no benefit to obtaining serial hcg levels after the initial one. erk activation with u ( m)) reduced fsh stimulated cyclin d mrna expression by %. fsh has also been shown to stimulate mtor, a regulator of growth and proliferation of many cell types. inhibiting mtor activation with nm rapamycin for min significantly reduced fsh-mediated cyclin d mrna expression. dht exposure for hours also inhibited fsh stimulated mtor signaling, as shown by a % reduction in the phosphorylation of its down stream target p s kinase. furthermore, pretreatment with dht resulted in significantly reduced fsh-mediated tsc- phosphorylation, which is an upstream regulator of mtor pathway. further studies revealed that fsh mediated tsc- phosphorylation and mtor signaling is regulated by erk, but independent of akt. based on these results we conclude that elevated reduced metabolites of androgens inhibit fsh-stimulated pka-erk pathway resulting in the inhibition of multiple mitogenic signaling pathways leading to defective follicle maturation culminating in anovulation. thus, rescuing the erk activation might serve as a potential therapeutic target to restore normal granulosa cell proliferation in hyperandrogenic states. (supported by nih grant hd- ). searching pcos-genes: results of a genome screen for pcos in a dutch founder population. olivier valkenburg, annemarie g mulders, aida bertoli-avella, ben a oostra, joop se laven. department of gynecology and obstetrics, erasmusmc, rotterdam, netherlands; department of internal medicine, erasmusmc, rotterdam, netherlands. context: although the etiology of pcos is not yet fully understood, evidence has accumulated for a complex genetic background i.e. a combination of multiple genetic and environmental factors. to reduce genetic heterogeneity, this study was conducted in a genetically isolated population in the netherlands . objective: in order to identify genomic loci that are associated with pcos, a whole genome screen using highly polymorphic microsatellite markers was performed in a founder population. subjects and methods: pcos patients ( rotterdam criteria) were identified in the founder population (rucphen, the netherlands) of ± . inhabitants. patients underwent a standardized screening procedure that included clinical, ultrasound and endocrine evaluation. all patients plus unaffected first-degree family members were genotyped using polymorphic markers on (microsatellites) from the abi prism ® linkage mapping set md- (average spacing cm). association-analysis was performed with the transmission disequilibrium test (tdt, genehunter software). linkage analysis was performed in clusters of or more closely related patients (simwalk ). results: there was an average number of . alleles per polymorphic marker. the tdt identified two non-adjacent markers on chrome (d s and d s ) that showed significant association with pcos (p , ). other markers that showed significant association were positioned on chromosomes (d s ), (d s ), (d s ) , (d s ), (d s ) and seventeen (d s ) (all p values . ). linkage analysis in sub-pedigrees revealed no significant linkage for these, or other, loci with pcos. moreover the results of a prior report of linkage of a marker on chromosome (d s ) could not be confirmed. conclusions: the lack of consistent results suggests the absence of a consistent genetic background in this select group of pcos patients. this supports the hypothesis of a complex genetic background for pcos that allows relatively small contributions of multiple risk-genes to be involved in the pathogenesis of this syndrome. in this founder-population the genetic heterogeneity was not sufficiently reduced to find risk-loci in a genome wide screen using highly polymorphic markers with an average spacing of cm. objectives: to objectively quantify uterine and endometrial blood flow in women with polycystic ovarian syndrome (pcos) and to examine if this was different in women with different phenotypic expressions of the disease. methods: transvaginal d and d ultrasound was performed in women with pcos, as defined by the rotterdam criteria, and sub-group analysis conducted based on the subjects' body mass index (bmi), ovulation status, and hirsutism score. anova was used to compare the mean values between the groups. results: pcos women with clinical hyperandrogenaemia had significantly lower endometrial and subendometrial blood flow than their anovulatory normoandrogenic counterparts (table ). there were no differences between lean and obese women or between anovulatory and ovulatory women with pcos. the pulsed wave doppler parameters were similar in all three phenotypic groups. conclusions: hirsute women with pcos have impaired endometrial perfusion compared to their normoandrogenic counterparts which is only evident with d ultrasound and not conventional pulsed wave doppler. nusayba a bagegni, jill blaine, anuja dokras. obstetrics gynecology, university of iowa hospitals clinics, iowa city, ia, usa; obstetrics gynecology, university of pennsylvania, philadelphia, pa, usa. background: there is conflicting evidence on the association between pcos and early and late obstetric complications. it is unclear if the reported risks are independent of bmi, preexisting hypertension and diabetes. we examined the risk of early and late obstetrical complications in a large group of women with pcos compared to controls. methods: we reviewed pregnancy records of women with pcos (rotterdam criteria, n= ) and controls (tubal infertility, n= ) after in vitro fertilization at university of iowa from - . the wilcoxon rank sum test and fisher's exact test were used to evaluate differences between variables and logistic regression analysis was used to determine the independent risk of pcos. results: subject demographics and medical history are shown in table. the first trimester miscarriage rate was % in women with pcos and % in controls. after logistic regression analysis pcos was not associated with miscarriage (p= . ). the prevalence of gestational dm (gdm) was similar in both groups % pcos vs % controls. pcos was not associated with gdm after adjusting for age and bmi (p= . ). however, bmi was significantly associated with gdm after adjusting for age and pcos (p= . ). risk of both pre-eclampsia and pih was % in pcos and % in controls, but not statistically significant after adjusting for age, bmi and twin gestation. preexisting htn showed a significant association with preeclampsia (p< . ). there was no significant difference in preterm delivery, cesarean section, twin gestation, intrauterine fetal death and intrauterine growth restriction in the groups. conclusion: despite adequate power, our study did not detect an increased risk of miscarriage in women with pcos. obesity was a significant contributor to late obstetric complications, namely gdm. these findings may warrant aggressive counseling of women with pcos on the potential benefits of weight loss prior to pregnancy. objective: to assess the prevalence of polycystic appearing ovaries (pcao) as defined by the rotterdam criteria; and to determine whether metabolic parameters differ between regularly cycling women with pcao and those with normal ovaries. studies have demonstrated a population frequency of pcao of - %, with - % among women with regular cycles. most were performed in a young reproductive age population; none examined the impact of age. all were performed prior to adoption of the rotterdam criteria. recent studies have shown an increased prevalence of metabolic syndrome among women diagnosed with polycystic ovarian syndrome (pcos). however studies focused on women in their s found no increase in bmi or fasting insulin with pcao but regular menses. participants: women aged - with regular cycles (every - days) enrolled in the ova study, a population-based study of ovarian aging. each subject underwent a transvaginal ultrasound for assessment of ovarian volume and antral follicle count (afc). outcomes collected included waist measurements and hdl, ldl, total cholesterol, triglycerides, fasting glucose and insulin. pcao were determined by the rotterdam criteria (afc of on one ovary or ovarian volume > cc). student's t-test and chi-square tests were used to assess differences between those with and without pcao for continuous and categorical variables, respectively. the prevalence of pcao decreased with increasing age (table ) . of the women with pcao, % met the afc criterion only, while % met the volume criterion only, and % met both. women with and without pcao did not differ in waist measurements, or in fasting lipids, insulin, or glucose. the rotterdam criteria, while less subjective than those described by adams in , have led to an increased prevalence of pcao among women with regular menses, over / of women in their s. women with pcao do not differ from those with normal ovaries in metabolic parameters associated with pcos. consideration should be given to adopting an age-adjusted criterion for afc, or a combination of afc and ovarian volume, for diagnosing pcos. background: pcos, especially accompanied by obesity, has been reported to be associated with a characteristic dyslipidemia comprising elevated triglycerides (tgs) and depressed hdl, especially the hdl- fraction. this is an atherogenic profile; in fact, studies suggest low hdl- may correlate most strongly with cardiovascular disease risk. weight loss is a mainstay of treatment and improves all manifestations of the disease, but the optimal diet to recommend remains undetermined. preliminary studies show a high protein diet may improve total hdl levels and insulin responses. however, the effect of weight loss and dietary composition on hdl- levels in pcos has not been investigated. objective: to evaluate the fasting lipid profile in newly diagnosed obese pcos patients and to determine the effects of a high-protein diet with or without metformin on weight loss, hdl- and other lipoproteins, and menstrual cyclicity. methods: in this pilot retrospective observational study, the fasting lipid profile of obese women newly diagnosed with pcos was determined. they were then placed on a high protein ( - g/day), low carbohydrate ( - g/day) diet with or without metformin ( and %, respectively) and followed monthly for an average of months (range - ). results: at diagnosis, % had low hdl and % had low hdl- ; only % had elevated tgs. on the diet, the patients demonstrated an average weight loss of . lbs ( . to . , p< . ) and decreased bmi of . kg/m ( . to . , p< . ). hdl levels increased significantly ( % increase from . to . , p< . ), especially the hdl- fraction ( % increase from . to . , p< . ). triglycerides decreased as well ( . to . , p< . ). ldl decreased but did not reach statistical significance. resumed menstrual cycles, were started on oral contraceptives, and had a hysterectomy. pregnancies occurred. no difference was seen with metformin use. conclusion: a majority demonstrated decreased hdl and hdl- at diagnosis. the high protein diet resulted in significant weight loss and improvement in hdl- levels, as well as improvements in total hdl, tgs and menstrual cyclicity. metformin produced no added benefit. prospective trials based on these data will help determine the optimal diet to reduce the significant short-and long-term morbidity in the large population of women with pcos. resistin is an adipokine that has been associated with obesity and insulin resistance in animal models. studies on the role of resistin on insulin resistance in humans have been controversial. recently resistin has been shown to exert atherosclerotic effects and elevated resistin levels have been observed in women with coronary heart disease (chd). women with polycystic ovary syndrome (pcos) are at high risk for chd. our present study investigates potential association of resistin and markers of inflammation, c-reactive protein (crp) and insulin resistance in women with pcos. methods: thirty two women with pcos participated in the study. all were hirsute and had irregular cycles. nineteen women with normal ovulatory cycles who matched the pcos patients in bmi served as controls. fasting glucose, insulin, resistin and crp levels were measured in all women. after a high carbohydrate diet for days, a standard oral glucose tolerance test (ogtt) was performed. blood samples were collected for glucose and insulin before and , and hrs after g oral glucose. the area under the curve (auc) for insulin and glucose was calculated. women with overt diabetes were excluded from the study. results: fasting insulin levels ( . + . μu [±se] /ml) and insulin response to oral glucose (auc) ( . + . μu/ml) were higher (p < . ) in women with pcos compared to controls. all were insulin resistant with homa-ir value > . mol x μu / l . resistin levels in women with pcos ( . ± . ng/ml) was significantly (p < . ) higher compared to control women ( . ± . ng/ml). crp levels in women with pcos ( . ± ng/ml) was also significantly (p < . ) higher than the controls ( . ± ng/ml). there was a significant positive correlation between resistin and crp levels (r = . , p < . ). there was no correlation between resistin levels and fasting insulin levels or insulin auc. there was also no correlation between resistin levels and fasting glucose or glucose auc. conclusions: our results indicate that ( )women with pcos and insulin resistance have increased resistin levels, ( ) there is a strong association between resistin and crp ( ) elevated resistin and crp levels may predict women who are at increased risk for chd ( ) ) it is unlikely that resistin plays a major role on insulin resistance in women with pcos. vuk p jovanovic, enrico carmina, prati vardhana, michel ferin, rogerio a lobo. department of obstetrics and gynecology, columbia university, new york, ny, usa; department of internal medicine, university of palermo, palermo, italy. current diagnostic criteria for pcos includes both ovulatory (ov) and anovulatory or "classic" (c) phenotypes. in an effort to further characterize differences and /or similarities between these phenotypes, we studied hyperandrogenic women with pcos (age . ± . , bmi . ± . ) and age matched controls (age . ± . , bmi . ± . ). women with pcos were divided into weight matched (ov) n= and (c) n= groups. fat and weight distribution were assessed by dexa (total fat, r fat, trunk fat) as well as fasting levels of lh, e , mis/amh, kisspeptin and testosterone, the adipocytokines (leptin, adiponectin, visfatin and retinol-binding-protein- rbp ) and serum glucose, insulin and crp. the hyperandrogenic pcos groups had characteristically altered hormone profiles compared to matched controls. although total fat mass was comparable, women with c-pcos had a significantly larger waist circumference ( . . vs. cm, p< . ) trunk fat, r fat and %trunk and %r fat compared to ov-pcos (p< . ). leptin, rbp and visfatin did not significantly differ among the pcos subgroups although adiponectin was lower in the c-pcos group (p< . ). quicki was significantly lower in c-pcos ( . ± . vs. . ± . , p< . ) and insulin was higher ( . ± . vs. . ± . , p< . ). serum lh was also higher ( . ± . vs. . ± . , p< . ) but kisspeptin, testosterone and estradiol were similar. mis/amh ( . ± . vs. . ± . ng/ml, not significant) and crp ( . ± . vs. . ± . , p< . ) were higher in c-pcos. significant correlations (p< . ) were noted among kisspeptin/rbp (r . ), mis/testosterone (r . ), insulin/ %trunk fat (r . , p< , ), total fat/leptin (r . , p< . ), %trunk fat/adiponectin (r - . ). in conclusion, women with c-pcos when compared to similarly hyperandrogenic women with ov-pcos with similar bmi, have increased abdominal fat, and appear to have differences in serum lh, crp and increased insulin resistance. the latter, as well as subtle differences in the adipocytokines may explain these differences in anthropometric findings. problems of normal oogenesis and folliculogenesis but also disturbed oogenesis and folliculogenesis in polycystic ovaries are not fully understood. oocyte specific genes play an essential role in oogenesis and folliculogenesis. there are suggestions about possible role of some oocyte specific genes in etiopathophysiology of pcos. zona pellucida gene (zp ) is recently identified gene, which belongs to zona pellucida genes such as zp , zp and zp . the role of zp , contrary to above-mentioned other zp genes is not well described. the aim of this study was to analyze zp coding sequence and expression in patients with polycystic ovary syndrome. material included blood received from patients (mean age , +/- , years; mean bmi , +/- , kg/m ) with polycystic ovary syndrome. all patients with pcos were diagnosed with the use of eshre/asrm criteria from . dna was isolated from blood cells( after separation of blood cells from serum) using a dna isolation kit (qiagen ). genomic dna was used for in vitro amplification by pcr with a specific set of primers complementary to the coding sequence of the zp gene. products from each pcr reaction were examined by sscp method. samples with changes detected by sscp in comparison to control probes were cloned into plasmid vector and then automatically sequenced from a total of patient samples with pcos, we identified nucleotide changes in the zp coding seguence : silent nucleotide changes in exons , , , , and nucleotide change in the exon ( position , t>g). the mutation in exon ( t>g ) results in substitution of cystein for glycin of amino acid in position of zp protein. in summary, our data demonstrate that zp nucleotide changes account for % of patients with pcos. relationship between serum mullerian inhibiting substance levels and insulin in women with polycystic ovary syndrome. rebecca a chilvers, shilla chakrabarthy, summer james, xin ma, manubai nagamani. ob/gyn, university of texas medical branch, galveston, tx, usa. müllerian-inhibiting substance (mis) is a member of the transforming growth factor-superfamily of growth factors. it is expressed exclusively in granulosa cells and is believed to play a role in the regulation of follicle selection and maturation. women with pcos have anovulation and most of them have hyperinsulinemia. the purpose of our study is to investigate possible association between insulin and mis in the dysregulation of folliculogenesis in pcos. methods: twenty one women with pcos who had anovulatory cycles and hyperandrogenism were recruited for the study. sixteen women with ovulatory cycles and matched the pcos patients in age and bmi served as controls. an oral glucose tolerance test (ogtt) was performed in all women. blood samples were obtained at fasting and , and hours after glucose ingestion for measurement of glucose and insulin. to investigate the effect of hyperinsulinemia on mis secretion, mis levels were measured in ten patients during the ogtt. fasting mis, testosterone, dheas, fsh, and lh levels were measured in all patients. results: fasting insulin levels ( . + . μu/ml) vs . + μ u/ml [+ se]) (p < . ) and area under the curve (auc) of insulin ( . + . vs . + . μu/ml) (p < . ) were significantly increased in women with pcos compared to control women, while the glucose levels were normal indicating insulin resistance. mis levels were significantly (p < . ) increased in women with pcos ( . + . ng/ml) compared to controls ( . + . ng/ml). there was no correlation between age and mis levels in pcos patients while there was a highly significant negative correlation between the age and mis levels in the control women ( r = - . , p< . ). there was significant negative correlation between mis and fasting insulin levels (r = - . , p < . ) and insulin auc during the ogtt (r = - . , p < . ). there were no changes in mis levels during ogtt. conclusions: results of our study indicate that in women with pcos, ( ) there is an increase in secretion of mis, ( ) higher insulin levels are associated with lower mis levels, ( ) acute increase in insulin levels has no effect on mis levels, ( ) lower mis levels in women with severe hyperinsulinemia could be due to associated increased follicular atresia and a decrease in the ovarian reserve. further studies are needed to investigate the role of insulin on mis secretion. hiroyuki asakura, noriko tanaka, kyoko nishio. ohgimachi ladies' clinic, osaka, japan. objective: elevation of serum anti-müllerian hormone (amh) levels among polycystic ovary syndrome (pcos) patients has been reported. however, the regulatory factors of amh in pcos remain unknown. we examined correlations between amh values and various indices of insulin resistance in pcos women. methods: infertile women compatible with rotterdam criteria for pcos were recruited under informed consent. the subjects underwent g oral glucose tolerance test ( ggtt, sampling at , , minutes), and -step elisa for amh (sensitivity . pmol/l, inter intra-assay c.v. : . %, . %, respectively). p< . was considered as statistical significance. results: average amh level of the subjects (age: . + . years, bmi: . + . kg/m , mean+s.d.) was . + . pmol/l, which was higher than normo-ovulatory women ( . + . pmol/l, n= ). amh levels had significant positive correlation with total ovarian volume by ultrasound ( . + . cc), but not with bmi, waist-hip ratio ( . + . ), and levels of serum lh ( . + . iu/l), total testosterone ( . + . ng/dl). although fasting glucose levels ( . + . mg/dl) were positively correlated with total ovarian volume (r= . ), amh levels had no significant correlation with fasting insulin ( . + . iu/l), fasting glucose/insulin ration ( . + . ), homa-ir ( . + . ), and the sum of insulin levels ( . + . iu/l)during ggtt. conclusions: increased serum amh level of pcos and its positive correlation with total ovarian volume implies that determination of serum amh level would aid in confirming diagnosis of the ovulatory disorder. absence of relationship between amh and various clinical indices of insulin resistance suggests alternative regulatory factors of amh gene expression in the follicular compartment. reproductive tissues. amisra a nikrodhanond, keeley l mui, helen h kim. ob/gyn, university of chicago, chicago, il, usa. background: although primarily a neuroendocrine hormone, gonadotropinreleasing hormone (gnrh) is also produced in reproductive tissues, where it acts locally. the study of gnrh regulation in these tissues is limited by low levels of expression. objective: to elucidate mechanisms that regulate gnrh expression in male tissues, our objective was to identify regions of the gnrh gene that target expression in vivo. methods: transgenic mice were generated with different fragments of the mouse gnrh gene promoter (- /+ and - /+ bps), fused to the luciferase reporter gene. in these mice, luciferase activity (detected as light) reflects gnrh promoter activity. using bioluminescent imaging, gnrh promoter activity was assayed in live gnrh-luc mice and in their reproductive tissues ex vivo. to confirm imaging results, luciferase activity was also measured as relative light units (rlu) in tissue homogenates. for each dna construct, male mice were examined. with whole-body imaging, bioluminescence was detected in the genital region of the gnrh-luc transgenic mice (fig.a) . in mice that incorporated the - luc transgene, examination of reproductive tissues ex vivo revealed bioluminescence in the prostate and penis, but not in the seminal vesicles, epididymis, or testes (fig.b) . in contrast, in the - luc mice, bioluminescence was detected in the testes, but not in other tissues (fig.c) . examination of luciferase activity in tissue homogenates from - luc mice confirmed gnrh promoter activity in the prostate ( ± rlu) and penis ( ± rlu) and absence in the testes ( ± rlu). in the - luc mice, however, luciferase activity was detected only in the testes ( ± rlu) and not in the prostate ( ± rlu) or penis ( ± rlu). conclusions: our studies demonstrate that gnrh is present in male reproductive tissues, but may be differentially regulated in the testes vs. prostate/penis. promoter elements, contained within the proximal - bp of the mouse gnrh gene, are sufficient to mediate testicular gnrh expression while - bp of the gene promoter are necessary to direct expression to the prostate and penis. characterization of mouse ringo/speedy homologues. z walton, s uckac, o guzeloglu-kayisli, md lalioti, d sakkas, e seli. ob gyn, yale u., new haven, ct, usa. introduction: ringo/speedy (ringo/spy) is a recently discovered cyclindependent kinase (cdk) activator that functions similar to cyclins in controlling the cell cycle. ringo/spy plays a crucial role during meiotic maturation in xenopus by inducing meiotic g /m progression and germinal vesicle breakdown (gvbd). more recently, padmanabhan and richter demonstrated that ringo/spy mrna is repressed in the xenopus oocyte cytoplasm by pumilio . upon meiotic reactivation, pumilio loses its interactions with ringo/spy permitting its translation. ringo/spy is then expressed, leading to activation of cpeb by phosphorylation, which in turn elicits polyadenylation and translation activation of the mrna for a critical oocyte maturation factor, the mos kinase. in this study, we investigated the expression of ringo/spy in mouse. methods: ten different somatic tissues, testes, and ovaries were tested by reverse transcription-polymerase chain reaction (rt-pcr) for the expression of ringo/spy homologues and their alternative splicing variants. ringo/spy mrna expression was also tested in prophase i (pi) and metaphase ii (mii) oocytes, -cell, -cell, -cell, -cell embryos and blastocysts. amplification with actin primers provided a positive control and allowed semi-quantitative analysis. results: we analyzed the two previously identified homologues of ringo/spy (a and b). the two alternative splicing variants of ringo/spy a (a and a ) were separately studied for their expression profile. we also identified an additional alternative splicing variant of ringo/spy b and evaluated similarly. ringo/spy a ( and ) were expressed in testes, ovaries, and certain somatic tissues including brain, and spleen. ringo/spy b (both variants) were only expressed in testis. ringo/spy a or b were not present in mouse oocytes or early embryos. conclusions: our findings indicate that the previopusly described ringo/spy homologues a and b are not expressed in mouse oocytes or early embryos suggesting that either an alternative cdk-activator or a yet to be identified homologue of ringo/spy may be mediating meiotic g /m progression in mouse. testis specific expression of ringo/spy b, and previously described role of ringo/spy in meiosis suggests a role for this protein in male gametogenesis in mouse. treated with glyburide. jennifer aguayo, gladys a ramos, alethea hanley, carri r warshak, thomas r moore. reproductive medicine, university of california, san diego, san diego, ca, usa. objective: to determine the risk factors that may predict inadequate response to first-line glyburide monotherapy in pregnant women with type diabetes mellitus (dm) or gdm and to assess if non-responders are at increased risk of adverse pregnancy and neonatal outcomes. study design: this was a retrospective cohort of women diagnosed with type ii or gdm initially treated with glyburide at a single institution from - . maternal characteristics, adequate glycemic control defined as more than % of fasting glucose < mg/dl and one-hour post-prandials < mg/dl, and neonatal outcomes were assessed. non-responders were defined as failure to achieve adequate glycemic control on maximum daily doses of glyburide or intolerance due to side effects, necessitating switch to insulin therapy. statistical methods included bivariate analyses. results: of the women initially treated with glyburide, ( %) failed to achieve adequate glycemic control or did not tolerate glyburide. reasons for glyburide non-response were maximum dose ( mg/d) reached ( %), maternal hypoglycemia ( %) and other side effects ( %). there were no statistically significant differences between non-responders and responders with respect to family history of diabetes ( % vs. %, p= . ), prior history of gdm ( % vs. %, p= . ) and macrosomia (> g) ( % vs. %, p= . ) or hour glucose challenge test ( + vs. + mg/dl, p= . ). non-responders had a higher rate of obesity (bmi> ) ( % vs. %, p= . ) and earlier gestational age at initiation of therapy ( + . vs. + . wks, p= . ). there were no differences between the groups in the mean -week fasting ( + vs. + mg/dl, p= . ) and post-prandial glucose values ( + vs. + mg/dl, p= . ). no significant differences were observed in incidence of pre-eclampsia, primary cesarean delivery or birth weight. neonatal outcomes including ponderal index, neonatal hypoglycemia, nicu admission, and birth injuries also did not differ between the groups. conclusion: women who are obese and who require earlier initiation of glyburide therapy are at increased risk of non-response to glyburide monotherapy. however, despite non-response, these women can be managed with subsequent insulin therapy to achieve similar glycemic control and pregnancy and neonatal outcomes. a different diagnostic strategy using the gram, -hour glucose tolerance test for the diagnosis of gestational diabetes mellitus. yvonne w cheng, ingrid block-kurbisch, jennifer lydell, aaron b caughey. obstetrics, gynecology and reproductive sciences, university of california, san francisco, san francisco, ca, usa. objective: to examine whether a simplified strategy using the gm, -hour glucose tolerance test (gtt) may be useful for the diagnosis of gestational diabetes mellitus (gdm). methods: this is a retrospective cohort study of women with singleton pregnancy who received the -gm, -hour glucose challenging test (gct) for initial screening and the gm, -hour gtt as confirmatory tests for the diagnosis of gdm between and . various combinations of the gm, -hour gtt results were examined and compared to the diagnostic criteria for gdm established by the carpenter and coustan criteria using the receiver-operator characteristic (roc) curves. perinatal outcomes of women who would have had a false-positive or false-negative test results were compared to those who did not have gdm using the carpenter and coustan criteria. potential confounding factors were controlled for using multivariable regression models. results: , women had gm, -hour gtt results available for analysis during the study period. using gdm diagnosed by the carpenter and coustan criteria as reference, various diagnostic strategies was compared using roc curves (figure ) . summation of the -hour and -hour gtt results with a diagnostic threshold of mg/dl yielded the most optimal balance between sensitivity ( . %) and specificity ( . %). when compared to women without gdm, women who were diagnosed with gdm by c c criteria but not by summation of -hour and -hour gtts had higher odds of operative vaginal delivery (aor= . , % confidence interval [ci] . - . ) and neonatal birthweight > gm (aor= . , % ci . - . ). conclusion: using only the summation of only the -hour and -hour gtt results of the gm -hour gtt offers an alternative test strategy which may be more convenient and less costly for the diagnosis of gdm. however, women who would have gdm by the carpenter and coustan criteria but not by the summation method have higher odds of having an operative vaginal delivery and neonatal birthweight > gm. outcome of induction of labor indicated for term prom among women with or without a uterine scar. yifat ochshorn, avital skornick rapaport, adi reches, joseph b lessing, ariel many. obstetrics gynecology, lis maternity hospital, tel aviv sourasky medical center, tel aviv, israel. objective: we aimed at comparing the outcome of induced term deliveries presenting with prom with or without a previous uterine scar. methods: the computerized files of women delivered following induction of labor due to term prom, were reviewed. perinatal outcome parameters such as the mode of delivery, indication for cesarean section, rate of low ' apgar scores and nicu admissions were compared between women with and without a previous cesarean. results: during the study period women delivered in our institution following prom and induction of labor , of them had a previous uterine scar. parturients of both groups (with and without a scar) were similar with regard to age, gestational age at delivery and parity. cesarean section rate was higher for the previous scar group ( % vs %, p< . ). the most common indication for cesarean was arrest of dilatation and/or descent among women with previous scar accounting for % and % (p< . ) for women with and with no uterine scar, respectively. no differences were noted in neonatal outcome parameters such as rate of low ' apgar scores and nicu admission rate between the two groups. conclusion: induction of labor due to prom culminates in higher cesarean rate in women with one previous scar compared with parturients with no scar. perinatal outcome is similar between the two groups. acid base balance and immediate perinatal outcome of vertex compared with breech presentation in elective cesarean section. avital skornick rapaport, yifat ochshorn, joseph b lessing, yuval yaron, michael kupferminc, ariel many. obstetrics gynecology, lis maternity hospital, tel aviv sourasky medical center, tel aviv, israel. backround: apgar scores, umbilical blood ph and bicarbonate are generally lower and pco levels are higher in vaginally delivered breech neonates compared to cephalic deliveries. although cesarean delivery improved apgar scores there is a debate wether it improved the acid base status. this retroprospective study compared umbilical cord blood acid-base values and perinatal outcome of elective cesarean breech-delivery with those of elective cephalic cesarean delivery and to determine whether a different metabolic status and perinatal outcome should be expected in neonates in breech presentation. study design: the study group included singleton pregnancies delivered by elective cesarean section at term between january and march . computerized files of singleton breech presentation elective cesarean sections were compared to those of singleton vertex neonates delivered by elective cesarean section. demographic data included: maternal age, pregnancy week at delivery and parity. perinatal outcome measures checked were: birth weight, apgar scores at 'and ', umbilical cord venous and arterial ph and base excess. results: during the period between january and march there were singleton elective cesarean sections, of them were breech and vertex. the mean age, gravida and parity were significantly different between groups ( . vs. . , . vs. . . and . vs. . respectively, p< . ). the birth weight was significantly different - . gram for the vertex and . gram in the breech deliveries (p< . ) there were no differences in either apgar scores or umbilical ph between the breech and vertex neonates delivered by cesarean section at term ( - + w). venous and arterial po and pco levels were significantly different, though the differences were very small and we doubt if these differences have any clinical importance. conclusion: although vaginal breech deliveries are associated with increased risk of asphyxia during delivery, elective cesarean breech deliveries are not at increased risk for lower ph levels or apgar scores. the clinical significance of bleeding during the second trimester of pregnancy. arie koifman, amalia levi, yaron zaulan, avi harlev, eyal sheiner. obstetrics gynecology, soroka university medical center, ben gurion university of the negev, beer-sheva, israel; epidemiology and health services evaluation, faculty of health sciences, ben gurion university of the negev, beer-sheva, israel. objective: this study aimed at investigating clinical importance and pregnancy outcome in women suffering from bleeding during the second half of their pregnancies. methods: a population based study including all deliveries which took place in the soroka university medical center between the years - were examined. comparison was performed between patients with and without second trimester bleeding pregnancies terminated before weeks, multiple gestations and women lacking prenatal care were excluded . stratified analysis, using the mantel-haenszel technique, and a multiple logistic regression model were performed . results: during the study period, , singleton deliveries occurred in our institute. of these, ( . %) were complicated with bleeding upon admission during the second half of pregnancy. the cases were attributed to placental abruption ( . %; n= ) and placenta previa ( . %; n= ). independent risk factors associated with bleeding, were oligohydramnios, polyhydramnions, (odds ratio [or]= . ; % confidence interval [ci] . - . ; p= and . ; . - . ;p< . respectively ), suspected intra uterine growth restriction (iugr, . ; . - . ; p<. ), gestational age, previos abortions and maternal age. these patients subsequently were more likely to deliver by cesarean section (cs, . % vs. . %, or= . ; %ci . - . ; p< . ). perinatal mortality among patients admitted due to second half bleeding was significantly higher as compared to patients without bleeding (p<. ). conclusion: bleeding upon admission during the second half of pregnancy is an independent risk factor for perinatal mortality. careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome. crude and adjusted odds ratios for perinatal mortality among patients with vaginal bleeding. characteristics or % ci p crude or for perinatal mortality . . - . < . or adjusted for: < . iugr . . - . < . oligohydramnios . . - . < . premature rupture of membranes . . - . < . the predictors included neonatal pi, bmi, or birthweight while the outcomes included hypoglycemia, shoulder dystocia, acidemia and hyperbilirubenemia. roc curve analyses were utilized to evaluate the relationship between sensitivity and specificity for each of the predictors and outcomes, with an area under the curve (auc) significantly greater than . indicating a screening test that is better than chance. results: neonatal pi, bmi and birthweight are poor predictors of nicu admission, acidemia and hypoglycemia with all auc values not statistically significantly different than chance alone. they are a reasonable predictor of shoulder dystocia, with birthweight functioning the best (p< . ). in general, neonatal anthropometric measurements do not appear to be good predictors of short term neonatal outcomes. although they are a reasonable predictor of shoulder dystocia, they are not useful clinically for this outcome since they cannot be calculated until after birth. in future studies, new models of neonatal anthropometrics should be created to better predict adverse neonatal outcomes. neonatal anthropometric measurements and their relationship to perinatal outcomes expressed as auc and % confidence intervals history of at least one spontaneous preterm delivery were offered protocolbased prenatal care including first-or second trimester bacterial vaginosis screening, repeated ultrasound cervical length assessment, and supportive care by specialized nurses. women with a positive test for bacterial vaginosis were treated with oral metronidazol therapy, and women with a cervical length below . cm (before weeks of gestation) underwent a vaginal cerclage. progesterone administration was not provided. data on obstetrical and medical history, pregnancy, delivery and neonatal outcome were prospectively collected and evaluated. results: in total, pregnant women were prospectively followedup. eighty-seven women had experienced a preterm delivery in their last pregnancy, of whom had delivered before weeks. three women were diagnosed previously with a bicornual or septal uterus. twelve women received metronidazol therapy and women underwent a vaginal cerclage. eighty-four women ( . %) delivered at weeks or beyond. one-hundred and three women ( . %) delivered no earlier than weeks, and only one woman delivered at weeks. two women gave birth to a twin (at and weeks, respectively). two neonatal deaths due to pulmonary hypoplasia were recorded. conclusion: women at high risk of preterm delivery who were offered protocol-based prenatal care not including progesterone therapy had a better pregnancy outcome than would be expected from previous studies. our findings may question the reported beneficial effects of prenatal progesterone administration. premature rupture of membranes. tracy a manuck, alexandra g eller, m sean esplin, robert m silver. obstetrics gynecology, university of utah health sciences, salt lake city, ut, usa. objective: historically, outcomes following expectant management of midtrimester preterm premature rupture of membranes (pprom) have been uniformly poor. thus, many patients elected pregnancy termination. however, outcomes may be improved with recent advances in neonatal medicine. our purpose was to assess outcomes in expectantly managed early pprom in an era of improved maternal and neonatal care. study design: this is a retrospective cohort of patients from tertiary healthcare systems from - experiencing pprom . weeks gestation. patients electing immediate termination of pregnancy, carrying fetus(es) with lethal anomalies, or delivering within hours of pprom were excluded. survival without major morbidity was the primary outcome. data were analyzed using student t-test and chi-square as appropriate. results: a total of women carrying fetuses ( singleton, twin, triplet, quadruplet) met inclusion criteria. only the fetus in the "ruptured sac" was studied. pprom occurred at a mean of . (+/- . , range . - ) weeks. the average latency period was . (+/- . , range . - ) days, with a mean delivery gestational age of . (+/- . , range . - ) weeks. this communication provides the first report of fundal uterine necrosis following placement of multiple uterine compression sutures. only two previous published cases report occurrence of uterine necrosis following application of a uterine compression suture --both identified as the b-lynch technique --and neither of these cases report necrosis confined to the fundus. in our case, uterine atony was refractory to pharmacologic therapy and manual compression of the uterus appeared to decrease the amount of blood loss. therefore, we applied a traditional b-lynch which effectively contracted the majority of the uterus, while the fundus remained atonic. a second horizontal, square suture was then placed between the cornua and carried over the fundus (see figure one: red reflects b-lynch suture; blue represents second fundal, square stitch). the patient subsequently experienced significant, persistent fevers despite antibiotic therapy. a repeat laparotomy was performed, at which time we found uterine necrosis confined to the uterine fundus (see figure : photograph taken at the time of hysterectomy). the placenta showed no histologic evidence of chorioamniotis --hence, the patient's main risk factor for fundal necrosis was the compression sutures. physicians should be aware of the risk of uterine necrosis, especially after placement of multiple compression sutures and, more specifically, after placement of a compression suture confined to the uterine fundus. background: migraines are far more common in women than in men. the incidence of migraines increases in girls after puberty, reaching an incidence of % in women who experience migraine at least once a year around middle age. migraine has been postulated as one of the major risk factors for stroke during pregnancy and the puerperium.triptans are a class of serotonin receptor agonists used in the treatment of migraine headaches. triptans administered in combination with other drugs have been known to precipitate serotonin syndrome, a rare but potentially life-threatening condition clinically manifested by a triad consisting of mental-status changes, autonomic hyperactivity, and neuromuscular abnormalities. objective: to determine whether triptan monotherapy is associated with serotonin syndrome methods: using data mining techniques we analyzed the entire food and drug administration's (fda) adverse event reporting system (aers) database. results: after excluding reports of concomitant serotonergic medication or other potentially confounding medication, eleven reports remained of serotonin syndrome associated with triptan use without concomitant serotonergic medication. the mean age for these eleven cases was . years; nine cases occurred in females and two occurred in males. there were no apparent instances of overdose among these eleven cases. conclusions: serotonin syndrome is a rare but serious occurrence with the use of triptan monotherapy. such cases were seen with eletriptan, rizatriptan, sumatriptan, and zolmitriptan. because of the spontaneous nature of voluntary reporting to aers, the actual number of occurrences of serotonin syndrome in patients using triptans is probably higher and cannot be assessed from aers data. users of triptan in combination with an ssri or snri should be warned of this rare but serious adverse effect. during periods of drug initiation, dose escalation, or the addition of another serotonergic agent, patients should be particularly vigilant for symptoms of concern and seek urgent medical attention if any occur. the offending agents should be withdrawn and the patients closely monitored and treated with supportive measures as required. rising maternal mortality in the midst of modern technology. oormila p kovilam, jane khoury, padmini c sekar, ralph c buncher. obstetrics gynecology, university of cincinnati, cincinnati, oh, usa; center for epidemiology and biostatistics, cincinnati children's hospital medical center, cincinnati, oh, usa; environmental health, university of cincinnatic, cincinnati, oh, usa. introduction: maternal mortality rate (mmr) is an index of overall wellbeing of the community and safe motherhood should be given utmost priority in obstetric care. as per , who estimates % of maternal mortality occurs in developed countries . this rate has established without much decline in recent years. the mmr for ohio for to was reported by cdc to be . per , live births with % confidence interval . to . . objective: our objective was to audit the trend in maternal mortality in the state of ohio for the last years. methods: information from the death certificates completed by attending physicians, medical examiners, coroners, funeral directors filed with ohio state registration offices were analyzed. we only used women who were residents of the state of ohio at the time of death, and cause of death was coded as a "complication of pregnancy, childbirth and the puerperium", icd codes to and icd codes o to o . five year maternal mortality pattern and long term trend was assessed. results: the number of maternal deaths recorded as due to pregnancy complications varied over the years from a high of in to a low of in and . in general the five-year mortality rate was decreasing over time until the last four years to , when we may be seeing an upward trend compared to to (p= . ). the rates and associated % confidence intervals (ci) are shown in the table below. years mmr % ci ci - ci . . - . ci - . . - . - . . - . - . . - . - . . - . the rate of maternal mortality is on the rise after a period of downward trend. we should develop a multidisciplinary approach to analyze and target the root causes of maternal death. introduction. women with thrombophilia are at higher risk of vte during pregnancy due to the acquired hypercoagulable state. it is likely that not only maternal veins but also placental vessels are more prone to the development of thrombosis. our objective was to compare maternal and fetal placental circulation disorders in women with intra-uterine fetal death (iufd) and thrombophilia and women without thrombophilia. methods. in a dutch multi-centre study on iufd, during the period - we studied singleton deaths > weeks of gestation for which the diagnosis of iufd was determined before labour. factor v leiden and prothrombin g a were tested at induction of labour. panel classification of cause according to the tulip classification was performed by assessors after individual investigation of structured patient information. we studied the cause of death group "maternal and fetal placental circulation disorders": placenta bed pathology with abruption or infarction as origin of mechanism and placental parenchyma pathology with fetal thrombotic vasculopathy and massive perivillous fibrin deposition as origin of mechanism. results. of the women tested for factor v leiden, ( . %) were carriers. of the deaths caused by "maternal and fetal placental circulation disorders" ( . %) mothers were carriers of factor v leiden. of the deaths with another cause of death ( . %) mothers were carriers of factor v leiden (p= . ). of the women tested for prothrombin g a, ( . %) were carriers. of the deaths caused by "maternal and fetal placental circulation disorders" ( . %) mothers were carriers of prothrombin g a mutation. of the deaths with another cause of death ( . %) mothers were carrier of prothrombin g a mutation (p= . ). in women with iufd and factor v leiden or prothrombin g a mutation "maternal and fetal placental circulation disorders" did not seem to cause iufd more often than in non-carriers. , university medical center groningen, groningen, netherlands; pathology, university medical center groningen, groningen, netherlands; trial coordinating center, dept of epidemiology, university medical center groningen, groningen, netherlands; hematology, university medical center groningen, groningen, netherlands. introduction. growing evidence suggests that women with thrombophilic defects may be at higher risk of fetal loss. although some paternal components to the predisposition of preeclampsia have been demonstrated it is not known whether paternal components contribute to intra-uterine fetal death (iufd). our objective was to investigate the relation between paternal thrombophilic defects and iufd. methods. in a dutch multi-centre study on iufd, from - we studied singleton deaths > weeks of gestation for which the diagnosis of iufd was determined before labour. we tested male partners of women with iufd for antithrombin (at), protein c, protein s type i and iii, factor v leiden, prothrombin g a (factor ii) and factor viii: ag. standard tests were performed in one laboratory. normal ranges were determined in healthy male blood donors. we compared prevalence of thrombophilic defects to reference values from the literature. . of the men tested for factor v leiden, ( . %) were carrier versus ( . %) non-carriers. prevalence of factor v leiden in the normal population is % (p= . ). men were tested for prothrombin g a, ( . %) were carriers and ( . %) non-carriers. all were heterozygous. prevalence of prothrombin g a mutation in the normal population is % (p= . ). decreased levels of antithrombin, protein c, protein s type i and iii and increased levels of factor viii: ag were observed significantly more often in male partners of women with iufd compared to the normal population. conclusion. in our iufd group the prevalence of male factor v leiden carriers was comparable to the normal population, prevalence of prothrombin g a mutation was lower. the difference in other factors imply an as yet unexplained association of male thrombophilia with fetal death in their partner. objective fetal macrosomia, the most important complication of gdm, increases the risk of shoulder dystocia, erb's palsy and intrauterine hypoxia. we compared frequencies of fetal macrosomia and erb's palsy in two gdm cohorts with different severity of glycemic disturbance and in healthy controls. methods we studied consecutive gdm women with singleton childbirth and or abnormal values in -h ogtt with g of glucose. abnormal plasma glucose values of the ogtt were: fasting . , -h . and -h . mmol/l. insulin treatment was started when values were . preprandially or . mmol/l postprandially in the -h glucose profile done within days of diagnosis. if the same woman had more than childbirth during the study period, only the last pregnancy was included. the control group consisted of women from a nearby town with singleton childbirth in the same hospital. women with diabetes were excluded from controls. macrosomia was defined as birth weight (bw) > . sd above the mean of a standard population. erb's palsy was diagnosed by pediatric surgeons. results gdm women were older, more obese, had more childbirths and more often a previous child with bw > g than controls. insulin was started in gdm women ( . %). c/s rate was . % in controls, . % in diettreated and . % in insulin-treated gdm women. macrosomia rate was . % in controls, . % in diet-treated and . % in insulin-treated gdm women (p< . compared with controls or diet-treated gdm women). the frequency of macrosomia did not differ between the diet-treated gdm and control women. erb's palsy occurred in . % of controls, in . % of diet-treated and in . % of insulin-treated gdm women. the frequency of erb's palsy was significantly higher in both gdm groups than in controls (p= . ). by regression analysis, previous child with bw > g (p< . ), previous c/s (p= . ), mother's age (p= . ), bmi (p= . ), insulin treatment (p= . ) and fasting plasma glucose of the -h profile (p= . ) were significant independent predictors of fetal macrosomia. conclusions the -h glucose profile done shortly after the diagnosis of gdm clearly distinguishes between low-risk (diet-treated) and high-risk (insulintreated) gdm pregnancies for fetal macrosomia. unfavourable fetal body composition of diet-treated gdm women is the likely explanation for the high rate of erb's palsy in this group. . '-:·:tpartq,-, '-:·:tpartq,-, '-:·:tpartq,-, % p= . ). first trimester uta doppler indices were similar in the two cohorts in terms of the resistance and pulsatility indices (ri . vs. . , p= . ; pi . vs. . , p= . ) . however, bilateral notching was much more common in the cohort of prior adverse outcomes ( % vs. % p= . ) as well as in patients destined to have a subsequent poor outcome (p= . ). conclusions: not surprisingly, prior poor obstetric outcome was strongly associated with recurrent adverse obstetric outcome. uta notching was robustly associated with prior poor obstetric history as well as a recurrent poor outcome. this clinical history had no discernable influence on ri or pi. reassurance may not be offered based on first trimester uta ri and pi. anti-retroviral therapy is associated with increased blood loss and uterine atony for patients undergoing primary cesarean section. carey eppes, alice cootauco, melissa russo, jessica bienstock. gynecology and obstetrics, johns hopkins university school of medicine, baltimore, md, usa. objective: anti-retroviral therapy has been associated with gastrointestinal smooth muscle dysfunction. it has also been hypothesized that myopathies can occur secondary to anti-retroviral therapy due to mitchondrial alterations. in our experience, we have noticed an increased incidence of uterine atony in our hiv patients on anti-retroviral therapy. we sought to examine the incidence of postpartum hemorrhage and uterine atony in patients currently on anti-retroviral therapy. study design: a retrospective case-controlled study was conducted on all hiv positive pregnant women on anti-retroviral therapy undergoing a primary low segment transverse cesarean section from through . these patients were obtained from an irb approved database containing hiv positive patients within our institution. patients' medical records were abstracted for demographic data, use of uterotonics, preoperative and postoperative hematocrits, and incidence of blood transfusions. controls were matched for age, parity, gestational age and surgical indication. data was analyzed using the t-test, fischer's exact test and chi square. results: there were no differences in demographics, incidence of chorioamnionitis or magnesium sulfate use between groups. patients on anti-retroviral therapy had a statistically greater decrease in hematocrit and estimated blood loss compared to controls. they also had an increased need for uterotonics and blood transfusions. conclusion: anti-retroviral therapy may impact uterine smooth muscle contractility in pregnancy, as evident by the increased incidence of uterine atony and change in hematocrit. additional research is needed to elucidate the mechanism. clinicians should be aware of the potential for uterine atony and excessive blood loss in patients on anti-retroviral therapy. background: adolescent pregnancy is frequently associated with adverse outcomes, especially small-for-gestational age (sga) deliveries. some studies have implicated maternal nutritional status in these poor outcomes. methods: in a prospective longitudinal study, ethnically-diverse, pregnant adolescents were studied from booking to parturition, with collection of anthropometric and nutritional variables. blood samples ( - weeks' gestation; n= subjects) were assayed for a spectrum of nutritional biomarkers. logistic regression was used to determine significant associations between studied variables and pregnancy outcomes. results: median age at recruitment was . years (iqr: . - . ). outcome data was available for subjects. ( . %) had uncomplicated pregnancies. median birthweight was , g (iqr: , - , g) and median birthweight centile was . % (iqr: . - . %). ( . %) infants were born sga and ( . %) were preterm. spontaneous vaginal deliveries occurred in . % of cases. there were ( . %) cases of pre-eclampsia and ( . %) admissions to neonatal care. . % of subjects reported smoking at booking. iron deficiency anaemia was prevalent in . % of subjects by - weeks and was strongly associated with higher infant birthweight centile (p< . ). . % had serum -hydroxy vitamin d concentrations < ng/ml, although this was not associated with any outcomes. low folate status, as indicated by low red cell folate (p= . ), low serum folate (p= . ) and high serum homocysteine (p= . ) concentrations, was associated with higher rates of sga birth. conclusion: adolescent pregnancy in inner-city populations is associated with a high risk of sga and preterm birth, increasing the likelihood of health problems in later life and perpetuating social disparities in health. the association between anaemia and higher birthweight is unexplained. impaired maternal folate status may contribute to impaired fetal growth. we suggest that sga birth in this population could be reduced by the use of antenatal supplements or the mandatory fortification of flour with folic acid. amount of cigarette use pre-pregnancy and during pregnancy were self-reported and subgrouped into nonsmokers, quitting during pregnancy, and continued smoking throughout pregnancy. categorical outcomes were compared using chi-square test. multivariable logistic regression analyses were used to control for potential confounders (continued smoking compared to quitting during pregnancy). results: women who quit smoking during pregnancy had higher rates of pregnancy-associated hypertension and cesarean delivery but lower rates of preterm delivery and neonatal birthweight < gm compared to non-smokers. compared to women who quit smoking during pregnancy, those who continue to smoke have lower odds of pregnancy-associated hypertension and cesarean delivery, but higher odds of preterm delivery, neonatal birthweight < gm, and apgar score < at minutes (see table) conclusion: quitting cigarette smoking during pregnancy appears to reduce undesirable neonatal outcomes, though an increase in pregnancy associated hypertension. these findings should be emphasized to women who are smoking during pregnancy. to achieve effective tamponade the balloon was inflated initially up to - ml with incremental increases of volume by ml until bleeding stops. to measure intrauterine balloon pressures we used a standard pressure transducer (edwards lifesciences) connected to the balloon port and to a pressure monitor (ge dash ). the pressure transducer was mounted on the bedrail at uterine level, primed with sterile saline and then connected to the balloon port of the catheter. the system was zeroed to atmospheric pressure, the stopcock of the intrauterine balloon port was opened and the pressure was recorded (p : the total pressure on the fluid). to verify the accuracy of measurements we used another balloon catheter (reference), inflated with the same amount of saline, connected to the pressure transducer and zeroed to atmospheric pressure. the reference balloon measured p (the intrinsic balloon pressure caused by distension at that volume). the system was then zeroed to the reference balloon. the pressure transducer was then reconnected with the intrauterine balloon and the actual intrauterine pressure was recorded (p ). we calculated the correlation coefficient between p and systolic, diastolic and mean blood pressure using a linear regression (statsdirect statistical software there is a growing body of evidence to suggest that peripartum assessment of fetal or neonatal lactate levels are as good as or better than standard blood gas analysis in the prediction of neonatal outcome. in this study we have evaluated the ability of umbilical cord blood gases and lactate levels in the prediction of neonatal hypoxic-ischaemic encephalopathy (hie). department of neonatal paediatrics, king edward memorial hospital, perth, western australia, australia; women and infants research foundation, king edward memorial hospital, perth, western australia, australia. objective: current evidence suggests that umbilical cord ph at delivery provides the most sensitive reflection of birth asphyxia. paired umbilical artery/vein blood gases have been routinely collected at king edward memorial hospital over the last years. the objective of this study was to determine: local reference ranges; accuracy of sampling; and the rates of metabolic acidosis. of the , births ( ) ( ) ( ) ( ) , accurate paired results were available on % of births. over the study period there was a progressive improvements in accuracy rates of paired sampling (p< . ). the median ( . th , . th centile) values for cord arterial blood gases were: ph . ( . , . ); po . mmhg ( . , . ); pco . mmhg ( . , . ); base excess - . (- . , . ); and lactate . mmol/l ( . , . ). there was a progressive improvement in all blood gas measures over the years of this study (all p< . ). moreover, there were significant reductions in all measures of metabolic acidosis (see table) . the progressive improvement in the measures of metabolic acidosis remained significant after multivariate analysis including obstetric, fetal, and demographic factors associated with metabolic acidosis. the introduction of universal umbilical cord blood gas analysis to all births is associated with significant improvements in all markers of metabolic acidosis. together with other compelling evidence in the literature, these data support the routine use of cord arterial and venous gases at all births; however, improved accuracy rates on paired sampling requires an ongoing education program umbilical artery indicators of acidosis, percentage of total ph < . ph < th centile* objective: intrapartum pcn prophylaxis aims to prevent early-onset gbs sepsis by interrupting vertical transmission from colonized mothers to their newborns. however, despite its wide clinical use, systematic pharmacokinetic evidence in support of the current pcn dosage regimen is lacking. current cdc guidelines recommend intensified surveillance and testing of infants exposed to < h of prophylaxis. our goal was to examine the relationship between maternal time of exposure to pcn and fetal serum pcn levels among maternal-fetal dyads exposed to short durations of pcn prophylaxis (< h) compared to those exposed to longer durations. study design: ninety-eight laboring gbs positive women were administered million units (mu) of intravenous pcn to be followed by . mu every hours until delivery (cdc ) . subjects with renal disease, multiple gestation, and preterm delivery (< wks) were excluded. umbilical cord blood samples were collected at delivery and pcn levels measured by high-performance liquid chromatography. intra and inter-assay coefficients of variation were < %. results: the pcn concentrations (mean±sd) by duration of prophylaxis were: < h, . ± . g/ml (n= ); - h, . ± . g/ml (n= ); - h, . ± . g/ ml (n= ); - h, . ± . g/ml (n= ); - h, . ± . g/ml (n= );> h . ± . g/ml (n= ); and for those without a second dose after h, . ± . g/ml (n= ). fetuses exposed to short duration (< h) had higher levels of pcn than those exposed to > h (p= . ). in multivariable linear regression analysis, fetal pcn levels were determined by total duration of exposure, time since last dose, dosage, and number of doses, but not maternal bmi. pcn levels in cord serum increased linearly until hour; thereafter, they decreased rapidly, but all groups were significantly above the minimum inhibitory concentration (mic) for gbs ( . g/ml)(p< . ). furthermore, every sample individually remained - fold above the mic. conclusion: in this study, even short durations of prophylaxis achieved levels above the mic, suggesting a benefit to prophylaxis even in precipitous labors. the data also suggests that the current cdc designation of infants exposed to < h of pcn prophylaxis as particularly at risk for gbs sepsis may be inaccurate from a pharmacokinetic standpoint. objective: -oh aa is a metabolite of tryptophan with pro-oxidant and proapoptotic properties and has been shown to increase in umbilical cord blood in pregnancies with intra-uterine infection. since labour-related events may also activate inflammatory pathways, we sought to determine the placental release of -oh aa into the umbilical circulation in labouring vs non-labouring patients at term. methods: twenty-six patients were studied (term labour n= , and term elective cesarean section n= ) with blood sampling from a clamped segment of umbilical cord after delivery of the fetus and from the cord at its insertion into the placenta after delivery of the placenta, with subsequent measurement of blood gases/ph and -oh aa (isocratic hplc using fluorometric detection with assay sensitivity at pmol). results: -oh aa measurements from respective umbilical and placental cord vessels were all variably higher in the labouring group vs the elective cesarean group patients (table ) . for labouring group patients, the -oh aa levels from the umbilical vein were significantly higher than those from the umbilical artery, indicating net release from the placenta into the fetal circulation. placental vein levels were also significantly higher than those from the umbilical vein, indicating continued placental release of -oh aa into the cord blood after delivery of the fetus. conclusion: labour at term is associated with changes in the placental metabolism of tryptophan resulting in the increased release of -oh aa into the fetal circulation with the potential for pro-oxidative and apoptotic effects in many tissues, including the brain. obstetrics, gynecology, and reproductive sciences, new brunswick, nj, usa; department of obstetrics and gynecology, mineola, ny, usa. objective: ischemic placental disease (preeclampsia, small for gestational age, sga and placental abruption) is a major contributor to pregnancy-related morbidity. although the placenta is considered a fetal organ, it is accepted that ischemic placental disease (ipd) can present clinically with either fetal or maternal manifestations. we hypothesized that the pattern of diagnosis (maternal versus fetal) varies by gestational age and would provide insights in to origins of indicated and spontaneous preterm birth. methods: this was a retrospective cohort study utilizing the maternallylinked reproductive history data for missouri residents , restricted to singleton live births. women who experienced spontaneous onset of labor and subsequently delivered preterm were classified as spontaneous preterm birth. medically indicated preterm birth included women who delivered preterm through a labor induction or (prelabor) cesarean delivery. ipd was classified as maternal (preeclampsia only), fetal (sga only) or both (preeclampsia with sga or abruption, and all conditions). results: among term births with ipd, . % presented as maternal disease only, . % as fetal disease, and the remainder ( . %) as both. among spontaneous preterm births with ipd, a greater proportion were of fetal presentation ( bethesda, md, usa; dept ob/gyn, wayne state univ, detroit, mi, usa; dept pathology, wayne state univ, detroit, mi, usa; dept ob/gyn, soroka univ medical center, israel. objective: hemoglobin (hg) and its catabolic products have been observed in cases of amniotic fluid (af) discoloration, which is a risk factor for intraamniotic infection/inflammation (iai). the study aimed to determine the association between af fetal hg concentration and gestational age, term and preterm labor and iai. study design: this cross-sectional study included: ) mid-trimester (n= ); ) term not in labor (tnl) (n= ); ) term in labor (tin) (n= ); ) preterm labor (ptl) who delivered at term (n= ); ) ptl without iai (n= ); ) ptl with iai (n= ); ) preterm prelabor rupture of membranes (pprom) with (n= ) and without iai (n= ). af fetal hg concentrations were determined by elisa. results: ) fetal hg was detected in . % of all af and . % of mid-trimester samples; ) women at tnl had a higher median af fetal hg concentration than patients at mid-trimester ( . ng/ml, iqr - vs . ng/ml, iqr . - . , p= . ); ) no differences were found in median af fetal hg concentration among patients with and without labor at term (til: . ng/ml, iqr - . ; p= . ); ) median af fetal hg concentration was not significantly different among the ptl subgroups [ptl with iai: . ng/ml, ptl who delivered preterm: . ng/ml, ptl without iai who delivered at term: . ng/ml, p= . (kruskal wallis) ]; ) in pprom, there were no differences among patients with and without iai ( . ng/ml, respectively; p= . ) ; ) median af fetal hg concentrations were significantly higher in ptl or pprom, with or without iai than in pregnant women at term, with and without labor (p< . for all comparisons). conclusions: ) immunoreactive af fetal hg increases with gestational age; ) among women with ptl or pprom, the median af fetal hg concentration is not associated with iai; ) the median af fetal hg concentration is higher in pregnancies complicated with ptl or pprom than in term pregnancies. the impact of latency time to delivery after preterm premature rupture of membranes (pprom) on neonatal outcome. dan nayot, deborah penava, barbra de vrijer, orlando da silva, bryan s richardson. obstetrics and gynaecology; pediatrics, university of western ontario, london, on, canada. objective: there continues to be controversy as to the management of pprom with conservative management to advance gestational age (ga) versus aggressive management with early induction to avoid chorioamnionitis. we have therefore used the perinatal and neonatal databases of a large regional patient population to determine the association of pregnancy variables with latency time to delivery after pprom and the impact of latency duration on adverse neonatal outcomes. methods: the perinatal/neonatal database of st. joseph's health care, london, ontario was used to obtain demographic and neonatal outcome information for all patients with pprom > and < weeks gestation, singleton and no major anomalies, delivering between january , and december , . patients were grouped according to ga at pprom stratified for latency time < hrs vs > hrs with incidences for those pregnancy related variables and neonatal outcomes available from the database then compared with the use of logistic regression analysis. results: there were patients who met the inclusion criteria of whom %, %, and % had pprom at - wks , at - wks, or at - wks, respectively, and with these pprom groupings showing a stepwise decrease in the percentage of patients with latency to delivery > hrs, at %, %, and %, respectively. pregnancy related variables and neonatal outcomes for these patient groupings are as shown in table . conclusion: despite a to fold increase in the incidence of chorioamnionitis with latency to delivery > hrs, a policy of conservative management to advance ga after pprom will result in decreased severe infant morbidity until weeks, and moderate infant morbidity until weeks. hospital. outcomes studied were prolongation of latency period with intact membranes and prom using magnesium sulfate (mgso ), nifedipine, terbutaline and tocolytic agents. secondary outcomes examined were maternal complications. statistical analysis performed were t-test and . comparisons were expressed as odds ratios ( % ci). results: in a -year period, twin gestations were admitted in ptl and administered tocolytic agent(s) with mean gestational age of . weeks. when tocolytic agents were used, maternal complications were: ( . %) with intact membranes and ( . %) with prom had pulmonary edema (or= . , ci . - . ); ( . %) with intact membranes and ( . %) with prom had chorioamnionitis (or= . , ci . - . ); ( . %) with intact membranes and ( . %) with prom had postpartum hemorrhage (or= . , ci . - . ). conclusion: there is no difference in prolongation of latency period achieved in twin gestations in ptl with intact membranes or prom using tocolytic agents. similarly, there is no difference between the groups with latency period hrs. there is an increased likelihood of pulmonary edema and chorioamnionitis with use of tocolytic agents. however, results are not significant due to type ii error. mean latency period and latency ≥ hrs using single or multiple tocolytic agent ( introduction: high sensitivity crp (hscrp) is a serum marker of inflammation and has proven clinical utlility in predicting cardiovascular disease (cvd). considering the hypothesized association between preeclampsia (pre) and inflammation and cvd, it is plausible that hscrp may have utility in predicting pre. prior to widespread utilization of this marker, the affect of labor on levels of crp needs to be clarified. we assessed the association between labor and hscrp levels in term deliveries and between elevated hscrp and adverse perinatal outcomes. a secondary analysis comparing hscrp in women with preeclampsia (pre) to those without was performed. methods: women presenting for term delivery or pre were prospectively identified as part of a case-control study. clinical data and serum were collected for all subjects. a standard immunoturbidimetric assay was used to measure hscrp levels. women presenting for induction of labor or planned cesarean delivery (non-labor) were compared to women presenting in labor. a secondary analysis comparing non labor women with and without pre was performed. serum was collected prior to labor induction in the non-labor group. nonparametric comparisons were made using wilcoxon rank sum tests. mvlr was used to evaluate dichotomous outcomes and control for confounders. results: women were included (non-labor group (n= ), labor group (n= ), non-labor pre (n= )). the median and mean hscrp levels were and and and in the non-labor and labor groups respectively (p= . ). elevated levels of hscrp in these term deliveries were not associated with chorioamnionitis (p= . ), maternal postpartum complications (endometritis, hemorrhage, transfusion) (p= . ), mode of delivery (p= . ), or admission to the nicu ( . ). levels of hscrp were significantly greater in the non-labor pre group compared to non labor without pre (mean . vs. . , median vs. , p< . ). conclusion: use of hscrp as a biomarker may improve clinical prediction of obstetrical complications such as pre. levels of hscrp are affected by labor and this should be taken into account when studying the utility of this biomarker. further, crp levels are elevated in women with pre even after excluding patients in labor. further investigations to determine if crp elevation in term labor is associated with adverse outcomes may be warranted. the role of hscrp as a valid and discriminating biomarker in pre should be assessed. review of the electronic labor record facilitated collection of maternal demographic, intrapartum, and newborn data. data analyzed with t-tests, chi-square tests, and calculated odds ratios with % cis as appropriate. a forward stepwise logistic regression analysis was used to identify predictors of histologic chorioamnionitis. results: of submitted placentas, had histologic chorioamnionitis (cases) and did not (controls). the groups were similar with respect to age, race, gbs status, and mode of delivery. gestational age, birthweight, duration of labor and ruptured membranes, and number of vaginal exams were greater in the cases (p . ). the cases were more likely to have had epidural anesthesia (or . ), internal monitoring (or . ), fever (or . ), maternal tachycardia (or . ) and fetal tachycardia (or . ) and less likely to have had induction of labor (or . ). newborns in the histologic chorioamnionitis group were more likely to have been observed for sepsis (or . severe sepsis defined as sepsis associated with acute respiratory distress syndrome (ards) or cardiovascular dysfunction(cvd) or with or more other organ dysfunction.all patients were resuscitated with fluids and treated with broad spectrum antibiotics and supportive care as needed. outcome data were: etiology, management, maternal complications, duration of icu stay and perinatal survival. results patients were young (mean age= . ± . years) with a mean gestational age at delivery . ± . weeks. etiologies were pyelonephritis(n= ), septic abortion(n= ), endomyometritis (n= ), chorioamnionitis (n= ), ruptured appendix(n= ), pneumonia( n= ) and one unknown. eighteen ( %) were diagnosed during antepartum and ( %) postpartum period.there were ( %) maternal deaths and high rate of major morbidities (table) . among the antepartum patients,there were, abortions, iufd, neonatal death for a perinatal survival rate of only %. conclusion pregnancies complicated with severe sepsis/septic shock are associated with substantial maternal and perinatal morbidities. the low maternal mortality rate in our study as compared to previous reports is attributed to early diagnosis and aggressive management of maternal complications. fetal loss rate, however continues to be high when septic shock develops antepartum. and tnfa levels are elevated. we developed a dynamic computer (in silico) model of pregnancy (uterine myometrial environment -infection/inflammation and endocrine crosstalk). mathematical differential equations were used to describe the interactions between molecules. infection was represented as increased levels of activated, nuclear transcription factor nf-kb. in the model ru inhibited both the glucocorticoid receptor and progesterone receptors. simulations were run adding different concentrations of ru ( . um= dose used in patients, . um, . um) at different time points during infection (before, at the time of or after nf-kb activation). ru degradation kinetics was also included. the effect of ru on nf-kb induced il- and tnfa levels was assessed. results: infection induced nf-kb activation led to increased il- and tnfa levels. there was a subsequent increase in cortisol that led to dampening of nf-kb activation, il- and tnfa levels. in the presence of ru , il- and tnfa levels continued to rise. the effect of ru on nf-kb induced il- and tnfa was dose dependent and was more prominent in slow metabolizers who had ru in the system for a longer time. addition of ru after the onset of nf-kb activation led to increased il- and tnfa levels above those observed without ru . the addition of misoprostol (prostaglandin e analogue), at the concentrations used together with ru for medical abortion, did not add to the effect of ru on nf-kb induced il- or tnf. conclusions: ru has dose dependent effects on infection induced immune activation and may contribute to the pathogenesis of c sordelii induced sepsis syndrome. the increased susceptibility of neonates to infection remains a major clinical problem. we previously found that after intraperitoneal (ip) listeria monocytogenes infection, neonatal mice have an ld that is orders of magnitude lower than adults. we also found that the inflammatory response of neonatal mouse macrophages, but not neutrophils, in the peritoneal fluid was deficient, and that this correlated with low levels of macrophage chemokines mcp- and rantes. given that the liver and spleen are important organs in listeria infection, we sought to characterize the innate immune response in these organs. a sublethal dose of listeria was injected intraperitoneally into balb/c - week old adult mice and - day old neonatal mice. liver and spleen was collected at , , and hours, sectioned serially for staining with hematoxylin-eosin and primary antibodies (rabbit anti-listeria monocytogenes igg; mhc class ii rat anti-mouse igg, a marker for activated macrophages; f / rat antimouse igg, a marker for macrophages) and secondary antibodies (cy- goat anti-rabbit igg; af goat anti-rat igg) were applied. negative controls used only secondary antibody. real time pcr was used to compare the levels of the chemokines mcp- and rantes in adult and neonatal liver. after ip infection, both adults and neonates showed similar influx of neutrophils to the sites of infection within the liver and spleen. at hours post-infection with listeria, adult liver and spleen showed increased staining for f / and class ii, which increased further and became confluent surrounding microabscesses at and hours. in contrast, the listeria infected neonatal mouse showed some increase in f / around microabscesses but no apparent increase in staining for mhc class ii. the neonates showed greater staining for listeria at each time point. mcp- and rantes levels were higher in infected neonatal liver compared to adults. in the neonatal mouse, the innate immune response in the liver and spleen was characterized by a deficiency of activated macrophages. this deficiency was not correlated with hepatic expression of macrophage chemokines. is there a seasonal pattern in the incidence of post-cesarean endometritis? tamula m patterson, alan tn tita, william w andrews. obstetrics and gynecology, the university of alabama at birmingham, birmingham, al, usa. objective: several theories, including one suggesting a peak in july coincident with resident turnover, postulate seasonality in post-cesarean infections. we assessed whether there is seasonal variation in endometritis. a retrospective cohort study of post-cesarean endometritis at our university-based institution using our obstetric computerized database to compare annual variation in monthly incidence patterns from to . prior to establishing an average aggregate seasonal pattern for all years, years were assessed separately for a recurrent pattern of peaks and nadirs in incidence. peak incidence (or nadir) was defined as any monthly incidence that differed from the mean incidence for the year by over %. results: a total of . % ( , ) of , deliveries from to were by cesarean. annual cesarean rates increased by an absolute rate of over %; while, post-cesarean endometritis rates decreased from % to %. monthly incidence of post-cesarean endometritis did not reveal a consistent recurrent pattern of peaks (figure ) or nadirs. the month of july accounted for only out of a total of peaks for all years. the adjacent months of june and august accounted for only each. the month with the highest number of peaks was april with only . these findings contraindicated the establishment of an average aggregate monthly pattern for all years. the incidence of post-cesarean endometritis did not follow a seasonal pattern. chi-square analyses were used to compare associations between race (black (bl) vs non-black (nbl)) and dichotomous characteristics. student´s t-test was used to compare continuous variables. results , patients were evaluated ( cases and controls). % and % of cases and % and % of the controls were bl and nbl respectively. the baseline prevalence of chtn in bl and nbl controls was . % and . % (p= . ). when comparing bl and nbl cases, bl women had a higher mean systolic blood pressure and screening bmi. bl women also had a trend toward being discharged on post partum blood pressure medicine when compared to nbl women. there was no difference in chtn, diabetes, severity of disease, iugr, or delivery < wks between the two groups (table) . to determine the leading causes of death in a case series of stillborn infants examined in a large hospital autopsy service, and to describe the most common post-mortem observations. study design: one hundred and sixty one stillborn infants were examined. gross pathology observations were recorded at autopsy and during the placental exam, and tissue sections were collected and examined microscopically. immediate and underlying cause of death (cod) were recorded, along with contributory cod, concomitant/significant cod, and incidental findings. statistical analysis was conducted using the software spss v. . . results: the immediate anatomic cod could be determined in . % of all infants examined. in over % of these cases, cod was attributable to placental or umbilical cord findings affecting the maternal-fetal blood supply. the most prevalent among these findings were placental lesions (maternal floor infarction, placental abruption, fetal thrombotic vasculopathy), umbilical cord lesions (entanglement, true knot, compression, excessive length/twisting), and infectious/inflammatory processes (chorioamnionitis, chronic villitis objective: advanced maternal age (ama) is associated with increased risk of intrauterine fetal demise (iufd). antenatal testing (at) is widely used in clinical practice to prevent iufd due to uteroplacental insufficiency and has been suggested to reduce the risk of iufd in ama women. we sought to assess the impact of at on obstetrical interventions and compliance with new practice recommendations. methods: retrospective cohort of ama women ( and older at their due date) who delivered at or after weeks. non-exposed women delivered from july to december (when at for ama was not routinely recommended); exposed women delivered from july to december (after at for ama was introduced at our institution). subjects were identified through the perinatal database; records were abstracted for demographics, medical history, and labor/delivery variables. outcomes included rates of at and induction of labor (iol) and mode of delivery. associations between at for ama and outcomes were tested using t test and chi square. assuming a baseline rate of iol of %, we had % power to detect an increase to % after the introduction of at. results: women met the inclusion criteria: delivered before the introduction of at (non-exposed=before at) and delivered after the introduction of at (exposed=after at). baseline clinical characteristics were similar in both groups. as anticipated, at was more common in the after at group than in the before at group ( % vs %; p< . ). women were not eligible for or declined trial of labor, thus not "at risk" for iol and not included in all analyses. ob intervention rates were increased after at compared to before at (table ) . the corrected iufd rates were similar in both groups ( / vs / ). conclusion: at an academic center, compliance with new practice recommendations was excellent. introducing at testing for a new indication seemed to increase iol and cs rates. these findings should be considered when assessing the risks:benefits ratio of antenatal testing. . we stratified indications for cesarean into the following: failed induction (cervix < cm dilated), arrest of dilation, arrest of descent, failed operative delivery, fetal intolerance of labor (fil), and "other" reasons (e.g., pre-eclampsia, abruption, chorioamnionitis, malpresentation). both fil and "other" reasons were more likely to occur among the medically indicated group (rr . , . physicians in solo practice had higher rates of elective inductions (p< . ), but there was no association between cesarean and practice type. conclusions: inductions accounted for . % of cesareans. these results suggest an increased risk for cs for patients undergoing medically indicated inductions at our institution. there was no association between cesarean and type of practice, whether solo or group, suggesting institutional clinical policies may be more important than practice type in determining delivery outcome after induction. further research is needed to understand how age, race/ethnicity, or other unmeasured patient factors may impact these findings. given rising rates of both cesarean delivery and inductions, this information may be pertinent to women considering elective induction prior to weeks. objective: fetal demise can lead to a consumptive coagulophathy ("fetal death syndrome") traditionally attributed to the release of "tissue thromboplastin", now known as "tissue factor" (tf). tf is the most potent activator of coagulation. despite the appeal and acceptance of this proposed pathophysiology, there is no evidence supporting this view. this study was undertaken to determine if fetal death prior to development of fetal death syndrome is associated with changes in maternal plasma concentration of cd l (a marker of platelet activation), tf and its soluble inhibitor (tfpi). methods: a cross-sectional study included the following groups: ) women with normal pregnancy (n= ) and ) patients with fetal demise without disseminated intravascular coagulation (n= ). plasma concentrations of scd l, tf and tfpi were measured by elisa. standard coagulation tests were performed. non-parametric statistics were used for analysis. results: ) patients with fetal demise had a higher median maternal plasma scd l concentration than women with normal pregnancy (median . pg/ml, range - vs. median . pg/ml, range . - . , p< . ); ) there was no significant difference between the groups in the median maternal plasma tf concentration and ) in contrast, the median maternal plasma tfpi concentration was significantly lower in patients with fetal demise than in women with normal pregnancy (median . ng/ml, range . - . vs. median . ng/ml, range . - . , p< . ). conclusions: ) a change in the plasma concentration of tf was not demonstrated; ) a change in the ratio of tf/tf inhibitor pathway may predispose to thrombin generation and activation of the coagulation cascade; ) however, maternal platelet activation is present in patients with a fetal demise without fetal death syndrome and ) the role of tf in fetal death syndrome remains to be proven. lipoic acid inhibits matrix metalloproteinase production, activity and prostaglandin e secretion by cultured amnion epithelial and mesenchymal cells. r moore, j novak, d kumar, j moore. case western reserve university, cleveland, oh, usa. introduction: cytokines, free radicals, matrix metalloproteinases (mmp) and prostaglandins (pg) have been implicated in processes of fetal membrane rupture and labor. dietary anti-oxidant supplementation has been suggested as a possible therapy for high risk patients, however, clincal evidence supporting the efficacy of agents such as vitamin c or n-acetylcysteine remains controversial. in fact, we have previously shown that vitamin c increases matrix metalloproteinase (mmp) activity in isolated fetal membrane fragments and fails to inhibit tumor necrosis factor (tnf) induced fetal membrane weakening in vitro. in this study, we examine the effect of the naturally occurring anti-oxidant, -lipoic acid, on tnf induced mmp activity/protein and pge secretion in isolated amnion epithelial and mesenchymal cells. methods: amnion epithelial and mesenchymal cells were pre-treated with increasing doses of -lipoic acid ( - mm/ h), then with increasing doses of tnf ( - ng/ml/ h). medium and cells were analyzed by gelatin zymography/western blotting for mmp /mmp activities/protein. pge output was determined by immunoassay. results: tnf induced a dose dependent increase in mmp production, secretion and activity in amnion epithelial cells. tnf ( ng/ml) induced an fold increase in cellular active mmp production and fold increase in secreted mmp enzyme activity by amnion epithelial cells. these increases were reduced - % following h pre-treatment with . - . mm -lipoic acid. mmp protein/activity and pge secretion by amnion epithelial cells were barely detectable and unaffected by tnf and/or -lipoic acid treatment. in striking contrast, mesenchymal cells exhibited little basal or tnf induced mmp protein/activity. mmp protein/activity in mesenchymal cells were unaffected by either tnf and/or -lipoic acid. however, tnf treated mesemchymal cells exhibited a dose dependent increase in pge production ( fold increase/ ng/ml tnf/ h) that was inhibited by %- % following . objective: nearly fifty years after the discovery of microphthalmia-associated transcription factor (mitf), its gene was identified as a specialized transcription factor that dictates cell-specific differentiation. unique mitf isoforms are generated from alternative promoter usage. an isoform of mitf (mitf-cx) is down-regulated in cervical stromal cells of the ripened cervix. further, mitf-cx inhibits il- gene expression and thereby suppresses signaling of the final pathway in cervical ripening. since mitf binds to canonical eboxes (canntg) in promoter regions of target genes, we sought to determine if mitf regulated its own promoter through ebox motifs. methods: the kb genomic dna sequence upstream of the mitf-cx transcription start site was cloned into pgl luciferase reporter vectors which were co-transfected with wild type or mutmitf-cx (impaired dna binding) into cervical stromal cells or hek cells. at h, promoter activity was determined and normalized for transfection efficiency. results: gel-shift assays conducted with oligonucleotides corresponding to eboxes in the mitf-cx promoter revealed two strong binding sites (eboxes - to - and - to - ). specific binding was established using oligonucleotides with or without mutated ebox, antibody supershift experiments, competition with cold probe, and absence of binding to mutmitf-cx. binding specificities were confirmed in nuclear extracts from cells that overexpressed mitf-cx, but not control or mutmitf-cx. reporter gene studies indicated that mitf-cx, but not mitf-m, increased mitf-cx promoter activity -to -fold. whereas mutations in ebox or resulted in significant decreases in mitf-stimulated promoter activity, mitfinduced increases in promoter activity were abolished by mutations in both eboxes. conclusions: collectively these experiments indicate that mitf-cx is a vital regulator of its own promoter activity and acts in a positive feedforward loop through two specific binding sites in its promoter. moreover, isoform-specific amino acids are important to mediate mitf-induced mitf-cx promoter activity. decreasing mitf protein or mutating its promoter would interrupt this loop resulting in rapid reduction of mitf synthesis. since mitf-cx suppresses il- gene expression in cervical stromal cells, we suggest that preservation of mitf-cx-induced mitf gene expression is an important mechanism to maintain the "brake" on cervical ripening and ensure cervical competency during pregnancy. the role of cd in cervical remodeling. denisse sanchez, brenda timmons, mala mahendroo. obstetrics and gynecology, ut southwestern medical center, dallas, tx, usa. objective: prior to the onset of parturition, the uterine cervix undergoes a remodeling process from a closed, rigid structure, to one that is soft and dilatable. many changes occur, including increases in hyaluronan (ha), a glycosaminoglycan that facilitates loosening of the collagen matrix. in the postpartum period, the concentration of ha is reduced to that of the nonpregnant state. cd , a transmembrane glycoprotein expressed in hematopoietic and epithelial cells, is a receptor for ha. cd expression by immune cells is important in extravasation of leukocytes into tissue. cd may also be required for ha catabolism through the action of hyaluronidases and . in the cervix, cd is expressed in the endo-cervical epithelia as well as in immune cells localized in the stromal matrix. to study the importance of cd in cervical remodeling, mice with a null mutation for cd (cd -/-) were evaluated during pregnancy, parturition and postpartum. methods: changes in ha amount and size distribution were assessed using ha molecular weight gels and fluorophore assisted carbohydrate electrophoresis. to identify defects in cervical remodeling in the cd -/mice, differences in expression for genes regulated in the cervix were studied by quantitative real time pcr . to determine whether cd plays a role in the recruitment of immune cells during cervical ripening and postpartum repair, immunohistochemistry with antibodies against leukocytes was done. in the postpartum period, there is a higher ratio of high molecular weight ha relative to low molecular weight ha in the cd -/mice. this suggests that postpartum breakdown of ha in cd -/cervices is delayed. as compared to wt cervix, there was a significant increase in hyaluronidase (hyal- ) mrna in the postpartum period. the distribution and relative numbers of immune cells in the cd -/cervix was similar to wt. conclusion: these studies provide evidence that cd may play a role in remodeling of the postpartum cervix back to the nonpregnant state. our current data suggests that the catabolism of ha after birth is delayed in the mutant mice and upregulation of hyal may compensate to allow ha removal. furthermore, the activity of hyal- may be dependent on cd . little difference in the recruitment of immune cells between cd and wt animals suggest that cd expression is not required for this process. these experiments provide a greater understanding for the role of cd and ha in cervical remodeling. in background: during in vitro experiments we have shown that separation of amnion from choriodecidua occurs as an integral part of the process of fetal membrane (fm) rupture. although spontaneous amnion and choriodecidual separation is seen in fm after both svd and elective c/s deliveries, its etiology is uncertain. biochemical degradation at the amnion-choriodecidua interface may be a key contributing factor. our previous biomechanical studies have demonstrated that separated fm require less physical work to rupture than intact membranes. the purpose of this study was to determine whether fm separation was associated with clinical differences in the birth process. hypothesis: during term, normal labor, spontaneous separation of fm is associated with differences in the clinical parameters of labor and delivery. study design: fm from consecutive term deliveries were cut off the placental disk. separated areas of fm were cut from the intact areas. both were weighed and their weight ratios determined. maternal medical, pregnancy, and delivery data were collected and analyzed. results: term fm had the following characteristics: maternal age ± . yr, gravida . ± . , gestation ± . wks, elec. cs . %, duration of rom ± min, duration of contractions ± min, african american %. % of the fm had < % separation; % had more than % separation. srom fm with > % separation (vs. < %) had significantly shorter duration of rom (p= . ) and admission to birth (p= . ) times. srom fm with > % separation (vs. < %) had even shorter rom (p= . ), duration of contractions (p= . ) and admission to birth (p= . ). the > % group (vs. < %) was further along, gestationally (p= . ). srom fm (vs. arom) had shorter admission to birth (p= . ), but longer rom to birth (p< . ) times. absence of epidural (p= . ), srom mode of rupture (p= . ), svd (vs. elec. c/s) (p= . ), and the presence of meconium (p= . ), were all associated with increased fm separation. conclusion: spontaneous separation of fetal membranes is nearly universal and is associated with increased gestation, spontaneous rupture of membranes, shorter duration of contractions, and svd. speculation: we speculate that programmed biochemical changes initiate fm separation which then facilitates rom and childbirth. whole genome array and si-rna investigation of the function of nfkb in human amnion epithelial cells. sheri e lim, shirin khanjani, yun s lee, tg teoh, , philip r bennett. institute of reproductive and developmental biology, imperial college, london, united kingdom; maternal fetal medicine, st. mary's hospital, london, united kingdom. introduction: labour is associated with activation of nfkappab in the amnion. nfkappab increases prostaglandin synthesis through the upregulation of cyclooxygenase- (cox- ), which is essential to the labour process. cox- mrna expression increases with gestation in the amnion. primary amnion epithelial cells cultivated from tissue collected prior to the onset of labour display a spectrum of nfkappab activation, similar to the spectrum of cox- expression presumably relating to the nearness of labour. our aim was to investigate the full range of genes under nfkappab control in amnion epithelial cells by using whole genome arrays. methods: amnion from women undergoing elective caesarean section was collected and primary cell cultures established. total rna and protein were extracted from each culture. nuclear localization of nfkappab is required for its activation. western analysis of nuclear p was therefore performed to identify the samples displaying the lowest and highest nfkappab activity. the corresponding rna samples displaying the three lowest and three highest nuclear p protein concentrations were used for whole genome analysis using affymetrix u arrays. results and conclusions: we identified significantly regulated genes. the gene with the highest fold change was cox- (x . ) followed by oxytocin receptor (x . ), ch orf (x . ), integrina (x . ), and connective tissue growth factor (x . ). other significant genes included interleukin- (il- ) (x . ). pathway analysis revealed the majority of other nfkappab associated genes were involved in cell signaling, turnover and proliferation. we used real-time pcr (rtq-pcr) to validate cox- and il- expression. to prove that cox- is directly regulated by nfkappab, primary amnion epithelial cells were then transiently transfected with nfkappab p sigenome smart pool and sicontrol non-targeting sirna pool. western blot analysis confirmed knockdown of nfkappab p associated with inhibition of cox- demonstrating that nfkappab is essential for cox- expression. objective: premature birth is a major public problem accounting for over , deaths and , surviving infants with life-long morbidity yearly. in order to develop a rational basis for treatment and prevention of premature fetal membrane (fm) failure, we first need to understand the sub-failure fm structural and mechanical behavior at near full term. methods: we utilized planar biaxial mechanical testing, which approximates the physiologic loading state, for mechanical evaluation of the fm, and a structural constitutive model approach was used to offer insight into the structure-strength of the fm by integrating information on tissue composition and structure. small angle light scattering (sals) was used to nondestructively quantify the collagen fiber architecture of both intact and separated fm layers. results: in the stress free state, the gross collagen fiber architecture of the fm and separated layers were not homogenously align but exhibited small regions of fiber alignment. the amnion layer displayed the greatest alignment. the model fit the equi-biaxial strain data well (r = . ) and indicated that fm collagen fibers were rapidly recruited and straightened well below failure stress levels. collagen fibers were gradually recruited followed by a drastic increase in fiber recruitment. conclusion: this study provided the first data on the effective collagen fiber stiffness in the intact fm under physiologic biaxial loading, which was related to quantitative collagen fiber architectural measures. modeling results indicated that the collagen fibers became fully loaded and straighten well below physiological loading levels. failure did not occur during physiological loading, indicating that fibers do not begin to fail until all collagen fibers are fully straightened and bearing load. this result suggested modest structural reserve in the fm collagen architecture, and may be an important aspect of its failure properties. previously, we demonstrated that a physically "weak zone" exists overlying the cervix in the fm, evident of collagen remodeling and cellular apoptosis. we are currently extending the present study to include the "weak zone" tissues, allowing us to elucidate the micro-mechanical mechanisms that facilitate failure in this newly identified fm zone. supported by nih . the extracellular matrix of the cervix undergoes extensive remodeling during parturition. hyaluronan (ha) is a major constituent of the extracellular matrix of the term pregnant cervix. the onset of labor is preceded by an increase in ha and after delivery, the concentration of cervical ha gradually decreases to that of the non-pregnant state. these dramatic changes suggest that ha plays an important role during parturition. hyaluronan synthase (has ) is one of three known ha synthases and the most abundant isoform in the pregnant cervix. transcripts for has are regulated by two alternative promoters, one upstream of the first coding exon (proximal promoter) and another upstream on an untranslated exon (distal promoter). the focus of the current study is to further our understanding of the transcriptional regulation of has during cervical ripening. methods: rna blotting was carried out using transcript specific probes corresponding to the distal and proximal promoter of the mouse has gene. the regulation of has was evaluated in a cervical epithelial cancer cell line (caski cells) which we have previously shown to express endogenous has . regulation of has expression by epidermal growth factor was assessed in the caski cells by western blotting and quantitative real time pcr assessment of transcripts. results: has mrnas in the nonpregnant (np) and pregnant cervix are transcribed from the distal promoter upstream of exon . two transcripts of approximately . kb and . kb were detected that arise from use of polyadenylation sequences. as compared to np, the expression of has is increased , , and fold on gestation days , and shortly postpartum respectively. has mrna expression is increased upon treatment of caski cells with epidermal growth factor ( ng/ml) and is suppressed in cells treated with ag ( m), an inhibitor of egf receptor phosphorylation. maximal stimulation was observed at and hours of treatment. conclusion: has is the major ha synthase expressed during cervical ripening and the majority of transcripts are driven by the distal promoter in the has gene. in vitro studies using caski cells suggest has is regulated in part by the egf signaling pathway resulting in a several fold increase in has expression. these results provide an understanding of has gene regulation at the time of cervical ripening which will ultimately enhance our understanding of the molecular mechanisms important to cervical ripening. chorion and decidua cells. chad a grotegut, bernard j canzoneri, liping feng, phil heine, amy p murtha. obstetrics and gynecology, duke university, durham, nc, usa. objective: preterm premature rupture of the fetal membranes accounts for approximately % of all preterm deliveries. cigarette smoking independently carries a fourfold increase risk for pprom. our laboratory has previously demonstrated that the chorion layer undergoes apoptosis in women with pprom. this study was conducted to determine if extract of cigarette smoke causes cell death in specific cells of the fetal membrane. fetal membranes were collected at the time of elective cesarean section from women without labor and at term. the chorion and decidua layers were separated and purified on a gradient spin column and then plated near confluence. cigarette smoke extract (cse) was collected in cell media and used to treat chorion and decidua cells in culture at concentrations ranging from % to % in -well plates. cell viability was determined at , and hours following treatment with a non-radioactive cell viability assay. data were analyzed using paired t test (analyse-it, leeds, uk). chorion and decidua cells underwent cell death when exposed to cse in a dose dependent fashion. increasing concentrations of cse resulted in increased cell death at hours in both cell types (figure ). at hours, chorion exhibited greater percent cell death compared to decidua at concentrations of , and % cse (p= . , . , and . , respectively). for any given concentration of cse, the degree of cell death increased with increasing length of exposure ( , and hours) for each cell type. chorion cells routinely exhibited greater percentage of cell death following treatment with cse at concentrations ranging from - % compared to decidua cells. human chorion and decidua cells in primary cell culture exhibit a dose-response and time dependent cell death in the presence of cse. human chorion cells show greater sensitivity to cell death when compared to decidua cells. further studies are needed to determine the mechanisms through which these cell types undergo cell death and the implications for the differential sensitivity to cigarette smoke. yoon ha kim, tae-bok song, cheol hong kim, jong woon kim, moon kyoung cho, sung yeul yang, bong whan ahn. obstetrics gynecology, chonnam national university medical school, gwangju, korea; biochemistry, chonnam national university medical school, gwangju, korea. objective: to investigate the lipid peroxide levels and protein carbonyls levels in the amniotic fluid of pregnant women with preterm premature rupture of membranes (pprom). the lipid peroxide levels in the amniotic fluid of normal pregnancy (n= ) and pregnant women with pprom (n= ) were newborn offspring with persistent pulmonary hypertension, despite enhanced newborn offspring with persistent pulmonary hypertension, despite enhanced measured by thiobarbituric acid reaction. the protein carbonyl contents in the amniotic fluid of normal pregnancy (n= ) and pregnant women with pprom (n= ) were determined by the , -dinitrophenylhydrazine method. after amniotic fluid of them were mixed and incubated up to hours with . ml of mm moxalactam, cefodizime, amoxacillin, erythromycin, the lipid peroxide levels and protein carbonyl contents in them were measured. results: . the lipid peroxide levels in the amniotic fluid of pregnant women with pprom was significantly higher than that of normal pregnancy ( . ± . vs. . ± . nmol/mg protein, p< . ). . the protein carbonyl levels in the amniotic fluid of pregnant women with pprom was significantly higher than that of normal pregnancy ( . ± . vs. . ± . nmol/mg protein p< . ). . the lipid peroxide levels and protein carbonyls formation by moxalactam in the amniotic fluid of pregnant women with pprom was significantly higher than basal level ( . ± . vs. . ± . nmol/mg protein, . ± . vs. . ± . nmol/mg protein, p< . ). . the lipid peroxide levels and protein carbonyls formation by cefodizime in the amniotic fluid of pregnant women with pprom was significantly lower than basal level ( . ± . vs. . ± . nmol/mg protein, . ± . vs. . ± . nmol/mg protein, p< . ). . there were no significant differences in the levels of lipid peroxide and protein carbonyls by amoxacillin and erythromycin in the amniotic fluid of pregnant women with pprom between antibiotics-induced and basal levels. background: chorioamnionitis (cam) is a major antecedent of preterm delivery (ptd) associated with elevated amniotic fluid tnf and il . we hypothesized that these cytokines enhance the term decidual cell (dc) expression of the matrix metalloproteinases (mmp) and , which can then promote ptd by degrading the extracellular matrix of the decidua, fetal membranes, and cervix. methods: immunostaining for mmp- , mmp- , and vimentin (a dc marker) was performed on cam-complicated (n= ) and gestational age-matched control decidua (n= ), and staining intensities were evaluated by hscore. confluent, leukocyte-free term dcs were primed with - m estradiol (e ) or e + - m medroxyprogesterone acetate (mpa), and then switched to a defined medium with e +/-mpa with or without ng/ml of il or tnf . secreted mmp- and mmp- levels were measured by elisa (n= ), and quantitative rt-pcr assessed mmp- and mmp- mrna levels (n= ). results: tissue staining revealed that mmp- and mmp- levels in cam-complicated decidua (hscore mean±sem: ± and ± , respectively) were significantly higher than in control decidua ( ± , and ± respectively; p< . ). in cultured term dcs incubated with e , tnf and il significantly increased secreted levels of mmp- compared to e alone (pg/ml/ g protein: . ± . and . ± . , respectively, vs. . ± . ; p< . ). in parallel incubations with e +mpa, basal mmp- output was lowered by %, and tnf -and il -elicited mmp levels were blunted by % and %, respectively. rt-pcr confirmed that tnf and il increased mmp mrna levels (p< . ), although mrna levels in e +mpa incubations were not different from those of e alone. mmp levels in all treatments were similar. conclusions: mmp- and mmp- are elevated in cam decidua compared to controls. our in vitro results suggest that mmp- expression is enhanced by the high levels of il and tnf associated with cam, and that mpa may be able to blunt this effect. we have previously found a similar regulatory mechanism of mmp- and mmp- and their over-expression in cam-complicated tissues. synergy among these mmps may represent a potent pathogenic mechanism of cam that can be targeted through the therapeutic use of progestins in preventing cam-induced ptd. domerudee preechapornprasert, patama promsonthi, wasun chantratita, mana rochanawutanon, patcharee karnsombut, chutatip srichunrusami, stephen j lye, boonsri chanrachakul. obstetrics and gynecology, ramathibodi hospital, mahidol university, bangkok, thailand; pathology, ramathibodi hospital, mahidol university, bangkok, thailand; obstetrics and gynecology, samuel lunenfeld research institute, toronto, canada. objective: cervical ripening is an inflammatory process involving chemokines, cytokines and various mediators. recent study has shown that the level of monocyte chemotactic protein (mcp) , a chemokine, increases in amniotic fluid during spontaneous labor. the aim of this study was to examine the localization and expression of mcp in human cervix before pregnancy, during pregnancy and after the onset of labor. methods: this study was approved by the local ethics committee and written informed consent was obtained from each participant. cervical biopsies were taken from groups of women; nonpregnant women, first trimester pregnant women, term pregnant women with and without labor. tissue samples were fixed in % formal saline for paraffin section. immunohistochemistry (n = each) was performed by avidin biotin complex (abc) technique using monoclonal antibody specific to human mcp . the mcp messenger(m) rna was identified by reverse transcription-polymerase chain reaction using gene specific primer against mcp and mcp receptor (n = each). results: immunohistochemistry demonstrated mcp in cervical tissues from all four groups of women. mcp was localized on plasma membrane and cytoplasm of both squamous epithelial and columnar cell lining of endocervical gland. mcp and mcp receptor mrna were identified in nonpregnant, first trimester and term with and without labor human cervix. conclusion: mcp and mcp receptor were located in cervical tissues of nonpregnant and pregnant women at different gestation both before and after the onset of labor.ongoing studies are investigating the role of this chemokine during pregnancy and labor. whether preterm cervical ripening is just an aberrant regulation in timing or whether divergent mechanisms and pathways are involved in preterm versus term cervical ripening remains to be elucidated. methods: cervical tissue was collected from groups of cd- mice. group : mouse model of ptb that utilizes intrauterine infusion of lipopolysaccharide (lps). group : e dams representing preterm controls. group : e . - dams selected from a timed pregnant batch where half of the dams had delivered representing term cervical ripening. n= dams/treatment group. separate rna samples were used for microarray analysis (ma). significance analysis for ma and partek software was used for biostatistical analysis. pathway analysis was performed using david. quantitative pcr was performed to confirm the most differentially regulated genes. results: using a cut-off of -fold change with p value of < . , genes in the cervix were differently regulated between the groups. principal component analysis revealed three distinct groups (see graph). functional annotation clustering demonstrated the following pathways: ) in preterm cervical ripening (e lps vs e ): immune and inflammation response, defense response ) in term cervical ripening compared to preterm controls: negative regulation of cellular process and biological process, ecm, cell-cell communication. qprc confirmed the highly significant differences found in ma (see table) . conclusions: the molecular mechanisms and pathways governing preterm and term cervical ripening are distinctly different. elucidating these unique pathways can lead to improved therapeutics for prevention of ptb as well as for postdate pregnancies. cervical ripening at term involves activation of apoptotic enzymes. maria kb sennstrom, valentina ciani, gunvor e ekman. obstetrics and gynecology, women and child health, karolinska institute, stockholm, sweden; obstetric and gynecology, university of siena, siena, italy. aim: to investigate if the human cervical ripening at term involves programmed cell death. during the final cervical ripening the extracellular matrix dominated cervix undergoes an extensive remodelling of the tissue. inflammatory mediators such as the cytokines increase in ripening cervical tissue at term. programmed cell death, apoptosis, has been suggested as important in this process. apoptosis can be induced by inflammatory mediators such as cytokines. we also looked upon the distribution of inflammatory cells in cervical tissue. materials and methods: cervical biopsies from pregnant women at term and post partum women with fully ripened cervix were studied. biopsies from non-pregnant women served as controls. immunohistochemical analysis of the apoptotic enzyme caspase- and the inflammatory cell marker cd was performed on paraffin embedded sections of cervical tissue. double staining was performed. mann-whitney u-test was used for statistical analysis. results: there was a significantly higher frequency of caspase- staining in the post partal sections from ripened cervical tissue compared to tissue from term pregnant (p= . ) with unripe cervix and from non-pregnant patients (p= . ). the inflammatory cells staining for cd increased in post partal and term pregnant sections compared to non-pregnant (p= . ). there was a higher frequency of caspase- positive cells in the post partal tissue than of cd positive cells (p= . ). the localization of cd- positive staining was highest in the epithelia and basal lamina while caspase- staining was most pronounced in stromal tissue and around vessels. conclusion: our data show apoptotic activity in stromal tissue in fully ripened human cervix at term of pregnancy, suggesting that apoptotic mechanisms are involved in the extracellular matrix remodelling at term. the apoptotic activity is not co-localized with inflammatory cells suggesting non-infectous inflammation with apoptosis as important for cervical ripening at term. objective: cervical biomechanical responses are important for accommodating the increased stress induced by an enlarging uterus. a mechanical testing system was modified to evaluate the stress relaxation response in the pregnant cervix. methods: tissue harvested from the non pregnant and timed pregnant (days , , , , and ) sprague-dawley rats underwent tensile testing using an instron material testing system. the testing regimen consisted of tissue extension to near maximal strain over seconds followed by a period of constant strain for minutes, then return to rest over seconds. this cycle was repeated additional times with a minute rest period between cycles. strain and force measurements were recorded at second intervals. - animals were used for each time point. in addition, stress and strain at the yield point was also determined for each gestational time point. results: the pregnant and non pregnant samples exhibit marked differences in response in both stress and strain. the timed pregnant tissue demonstrated progressively increased compliance and lower nominal stress compared to non pregnant tissue. peak nominal stress declined with each successive cycle. this was demonstrated in the peak nominal stress and strain values at the yield point. conclusion: the cervix becomes more distensible (compliant) but less resistant to force with increasing gestational age. ...,.. e. coli . x .:!: . x . x .:!: . x group a (c, c) group b ( c, p) . x + . x . x + . x . . . group c (p, p) . x o"::!>s x o" . x ~ .ox: o• k. ~neumoniae group a ( c, c) . x + . x . x + . x . . . group b (c, p) . x + . x . x + . x group c (p, pl . x ~ . x . x ~ . x c. al bicans group a (c, c) . x '+ . x . x + . x group b (c, p) . x o•+ . x . x + . x . . . group c (p, p) . x ~ . x . x ~ . x • introduction: a growing body of evidence supports that inflammatory processes are implicated in spontaneous preterm birth (ptb). using an inflammatory and non-inflammatory mouse model of ptb, we sought to determine if activation of these inflammatory pathways are essential for ptb and/or cervical ripening to occur. methods: timed pregnant cd- mice were used in these two models of ptb: ) a model of intrauterine inflammation where lipopolysaccharide (lps) is injected into the uterine horn (n= ); controls for this model received intrauterine saline (n= ) and ) a non-infectious model of ptb using ru sq ( ugrams/dam) (n= ); controls for this model received no intervention (n= ) were used for these studies. for both models, hours later uterine and cervical tissues were harvested. the tissues were processed for protein and rna studies. elisas were performed to assess il- and tnf-alpha in the uterine tissue. mrna expression of ifn , il- , il- , il- , tnf-alpha were assessed in cervical tissue from both models by quantitative pcr. results: in uterine tissues, both il- and tnf were significantly elevated in the lps-induced ptb when compared to control, saline, and non-infectiousinduced preterm birth (p< . ) (figure ). in cervical tissue, an increase in il- , il- beta and tnf mrnawas observed in both models, while ifn-gamma and il- were only increased in the lps model. (figure ). conclusions: up-regulation of pro-inflammatory cytokines in the uterus do not appear to be essential for ptb. cytokine expression in the cervix is greater in an inflammatory model of ptb but is also present in a non-infectious model. these studies suggest that targeting a cytokine response in the cervix may hold the most promise in prevention of ptb. the initiation of labor at term and preterm is associated with an inflammatory response, with increased interleukins in amniotic fluid (af) and infiltration of the myometrium by neutrophils and macrophages (m ). whereas, in preterm labor, intra-amniotic infection may provide the stimulus for increased af interleukins and inflammatory cell migration, the stimulus for these events at term has remained uncertain. in studies using pregnant mice, we observed that the m that invade the maternal uterus near term arise from the fetus. furthermore, we obtained compelling evidence that surfactant protein-a (sp-a), a developmentally regulated c-type lectin secreted by the fetal lung into af near term, activates af m , which migrate to the uterus where they promote an inflammatory response culminating in labor. we propose that interactions of m surface receptors with sp-a, at term, or bacterial lipopolysaccharide at preterm, initiate changes in m phenotypic properties, resulting in the enhanced expression of genes that promote their migration to the uterus. the objectives of the present study were to analyze the numbers and phenotypic properties of mouse af m during late gestation and to identify their putative tissue source(s) of origin. to assess changes in the number of m in af during late gestation, af cells were isolated and stained for the m marker f / . the density of adherent f / + cells greatly increased in equivalent volumes of af between . and . days postcoitum (dpc) ( . dpc = term). interestingly, the f / + cells at . dpc were highly similar in morphology to those present in . dpc fetal lung, but distinctly different from those in fetal liver, suggesting their pulmonary origin. the af m were foam cell-like, suggesting the presence of lipid inclusions, a property shared by adult alveolar m . to further analyze gestational changes in the m population(s) in mouse af, we used flow cytometric analysis. in our initial studies, cells isolated from af were stained for f / and for cd , a pan-leukocyte marker. we observed that af from . and . dpc mice contained two sub-populations of cd + f / + cells. studies are in progress to analyze these af m populations for expression of cell surface antigens indicative of their maturity, activation state and chemotactic properties in association with the developmental induction of sp-a synthesis and secretion by the fetal lung. april bleich, patrick keller, r ann word. ob-gyn, ut southwestern, dallas, tx, usa. the role of prs, proinflammatory cytokines, cell adhesion molecules, cox- , and toll-like receptors in mediating cervical ripening prior to labor is not clear. the objective of this study was to quantify pr isoforms and determine the relative expression of certain inflammation-related genes in cervical stroma from nonpregnant and pregnant women in early gestation (eg), term before and after cervical ripening, and during labor. methods: standard curves of pr-b, -a, pra+b and qpcr were used to quantify total and pr-b in cervical stroma from nonpregnant (proliferative, n = ; progestin treatment, n = ) and pregnant women undergoing hysterectomy (eg, n = ; term before ripening, n = ; after ripening, n = ; in labor, n = ). cervical status was determined by modified bishop scoring. results: total pr expression was maximal in nonpregnant women in the proliferative phase ( . ± . pg/ug cdna) and decreased % by progestins ( . ± . pg/ug cdna). this level was maintained in stroma from pregnant women before labor ( . ± . , eg.; . ± . before ripening; . ± . after ripening pg/ug cdna). in contrast, total pr was decreased significantly in the dilated cervix ( . ± . pg/ug, p < . ). interestingly, whereas pr-b was ± % that of total pr in the nonpregnant cervix, pr-b mrna levels were ± % to ± % in cervical tissues from all pregnant women and did not vary with labor status. using immunoblot analysis and pr-specific antibodies (pgr ), pr-b immunoreactivity was % that of total pr in all samples from pregnant women, and both pr-a and -b were downregulated significantly in the dilated cervix (from ± to ± units/atub). decreased expression of pr in the dilated cervix was accompanied by significant increases in il- , mcp- , tlr- , cd l, cox- , and s a mrna (all p < . , anova) but not cd b or tlr- . pgdh mrna was decreased significantly in the dilated cervix. with the exception of cox- , expression of these genes was similar before labor regardless of cervical ripening. conclusions: both pr and pr-b are decreased proportionately in the dilated cervix, but not during cervical ripening. further, a number of inflammatory gene products are increased dramatically in the cervix during labor, but not before. taken together, the results suggest that cervical ripening is distinct from cervical dilation and involves upregulation of cox- but not il- , mcp- , or toll-like receptors. ifn-y il- il- , il- tnf- "p value < . lps/saline ru /controls . "" . " . " . * " " . * . . " association between interleukin- (il- ) and il- to examine association of amniotic fluid interleukin (il- ) concentration with il- and its receptor il -r haplotypes in term and preterm caucasians (c) and african americans (aa) samples. methods: in this study case (preterm birth -ptb [< weeks]) and control (term [> weeks]) amniotic fluid (af) il- concentrations were analyzed for association with haplotypes of the il- and il r genes in aa and c separately. in il- , eight, and in il- r, single nucleotide polymorphisms (snps) were examined. aa and c maternal and fetal genotypes were assessed (aa: maternal:cases- controls- fetal: cases- fetal controls-; c: maternal cases- , controls- , fetal:cases- ; controls= ). haplotype associations were performed by using a sliding window with outcome il- concentration. analyses were performed separately on maternal and fetal dna. results: the strongest haplotype associations were observed in il- r rather than in il- . in c fetal dna il- r haplotypes defined by markers - bp from the transcription start site associated most strongly with af il- concentrations (global p= . x - ) and in aa maternal il- r haplotype markers at - - - (global p= . x - associated with il- concentrations. in the c fetal cases the - haplotype with the highest concentration was a-g (log(cytokine) = . pg/ml). in aa maternal samples the highest concentration was observed for haplotype t-t-g-c at - - - .this was seen in both cases and controls at (case log (cytokine) = . ; control log(cytokine) = . pg/ml). significant associations from haplotype analyses converged on three regions of the il- r in both races. no strong differences were observed between the haplotypes of cases with and without microbial invasion of the amniotic cavity (miac), with the exception of aa fetal samples that showed two overlapping haplotypes in il- that associated in cases with miac but not in cases without miac (- and - ; - and - )(both with p < x - ) conclusion: differences in the af il- concentration in ptb do not result from single snp effect on il- but are a result of complex relationships between il- and il- r haplotypes. these associations exhibit racial disparity. the role of tnf-in parturition. helen alexander, amanda tattersall, mark tattersall, suren sooranna, peta grigsby, leslie myatt, mark johnson. obstetrics gynaecology, imperial college, london, united kingdom; obstetrics gynaecology, university of cincinnati college of medcine, cincinnati, oh, usa. introduction: tumour necrosis factor-alpha (tnf-) is thought to play a role in inflammation-induced preterm labour since the decidua produces tnfin response to bacterial products and amniotic fluid tnf-concentrations are increased in the presence of intra-amniotic infection. the aims of this study were to (i) investigate the expression of myometrial tnf-and its receptors in relation to the onset of preterm and term labour; (ii) to identify which intracellular pathways are activated by tnf-; and to investigate the effect of tnf-alone and in combination with il- or il- on gene expression in uterine myocytes. methods: biopsies of human myometrium were taken at caesarean section from women before and after the onset of preterm and term labour and analysed for tnf-and its receptor mrna expression. a further samples were obtained before the onset of labour (n= ) from which myocytes were isolated and cultured in -well plates. when cells were - % confluent either tnf-at a concentration of ng/ml was added to the cells for , , , and min and the cells analysed by western blotting or tnf-at concentrations of , . and ng/ml was added either alone or in combination with similar concentrations of il- or il- to cells for hours and mrna was extracted and converted to cdna to determine il- and gapdh gene expression by qpcr. results: there was no change in tnf-mrna expression in relation to the onset of labour, but the expression of tnfr and tnfr mrna levels were significantly increased with gestation and further increased with the onset of labour. incubation of uterine myocytes with tnf-( ng/ml) activated all three mapk substypes: erk, jnk, and p , activation peaked between - minutes. preliminary data suggest that tnf-induces il- mrna expression but exposure to il- or il- itself did not enhance this response. conclusions: although there is no significant increase in tnf-concentration from baseline during labour we have shown tnf receptor mrna levels do increase with labour at term. exposure of isolated uterine myocytes to tnfcauses activation of all mapk subtypes and an increase in il- mrna expression. this enhanced mapk-dependent il- expression at term may be mediated via increased myometrial sensitivity to tnf-through increased tnf receptor expression. remodeling. brenda c timmons, anna-marie fairhurst, mala s mahendroo. obstetrics and gynecology, ut southwestern medical center, dallas, tx, usa; immunology, ut southwestern medical center, dallas, tx, usa. objective: the molecular mechanisms involved in cervical ripening are not well understood. immunohistochemical studies from our lab report a recruitment of inflammatory cells to the cervical stroma one day before birth in the mouse using a neutrophil/monocyte marker (neutrophil / ). in this study, we sought to identify and quantitate inflammatory cells migrating into the mouse cervix and to determine if this recruitment was affected by changes in progesterone levels. peripheral blood was also evaluated to see if changes in the cervix was paralleled in blood. methods: flow cytometric analysis was performed using cervical cells and peripheral blood obtained before and during cervical ripening along with - h postpartum. dispersion of cervical cells was optimized. these cells were stained with a panel of fluorescent conjugated antibodies directed against leukocyte antigens and analyzed on an lsrii flow cytometer. cells were also sorted and stained to visualize cell morphologies. to determine the effect of progesterone on the migration of leukocytes, gestation d mice were treated for h with a progesterone receptor (pr) antagonist prior to tissue collection. results: neutrophils do not appear to increase in the cervix until after birth. monocyte (mo) numbers do increase during cervical ripening (late day , d . ) and remain high through postpartum (pp). macrophages (mØ) are present prior to cervical ripening and steady state levels are maintained during labor and pp. pr antagonist treatment on d resulted in a premature increase in mo but not neutrophils or mØ. in contrast to the cervix, mo and neutrophil numbers do not significantly increase in the peripheral blood until pp. results from lymphocyte studies suggest a low level of b and t cells in the cervix. in the peripheral blood, b cells remain consistent through parturition and the t cells decrease by d . and continue to decrease pp. conclusion: tissue mo are increased in the cervix during ripening. this recruitment is dependant on loss of pr function. in contrast, neutrophils are increased in the pp cervix while mØ numbers appear constant. timing of changes in mo and neutrophil numbers in the peripheral blood differed from that observed in the cervix suggesting quantitation of these cell types in blood is not reflective of what is occurring in the cervix during ripening, dilation and pp repair. novel interactions between nf-b and other labour-associated transcription factors identified by a tf-tf array. shirin khanjani, yun s lee, suren r sooranna, mark r johnson, phillip r bennett. irdb, imperial college, london, united kingdom. introduction: external stimuli lead to changes in cellular gene expression through activation of inducible transcription factors. nf-b is a ubiquitous transcription factor classically associated with inflammation, which is activated in response to infection and proinflammatory cytokines such as those prevalent during the labour. the tf-tf interaction array uses a novel technology for detecting interactions between transcription factors based on binding of tfs to their own consensus dna binding sequence. materials and methods: primary myometrial cells were grown until - % confluent and stimulated with ng/ml il- prior to nuclear protein extraction. the nuclear extracts were incubated with the provided set of biotin-labeled, double-stranded oligonucleotide probes, which represent a known library of cis-elements. during the incubation step, these tf probes bind to their specific tfs in the nuclear extract. next, immunoprecipitation was performed using an antibody against nf-bp , which pulled out nf-bp and any tfs bound to it, bound to corresponding cis-elements. normal igg was used in a parallel experiment to represent a negative control. free cis-elements and nonspecific binding proteins were washed away and the cis-elements were finally eluted and hybridized to the array membrane, which is spotted with different tf consensus sequences. results: table shows the different tfs interacting with nf-bp based on the degree of binding stimulated by il- compared to no-il- control. conclusion: these data show that il- stimulation causes nf-b to bind to a wide variety of other treansciption factors. of particular interest in the area of parturition is binding to the other pro-inlammatory tfs such as c/ebp and ap- , which are known to regulate labour-associated genes in synergy with nf-b. the lack of association between nf-b and pr without il- stimulation supports the concept that with the onset of labour inflammation leads to functional progesterone withdrawal, rather than pr acting to inhibit inflammation. table high ap- , c/ebp, cbf, creb , c-myb, e f- , ets, ets- /pea ,fast- , gas/isre, hse, mef- , mef- , myc-max, nf- , nfatc, nf-e , nf-e , pax- , objective: pre-partum cervical ripening involves remodeling of collagen structure and inflammatory immune cell activity (jsgi : , ; reprod biol endo : , ) . although parturition is associated with systemic or local progesterone withdrawal (ajog : , ) , effects of a decline in progesterone on cervical ripening is not known. the present study tested the hypothesis that progesterone withdrawal promotes collagen degradation, innervation, and immune cell trafficking in the cervix of nonpregnant mice. methods: adult virgin female c bl mice received capsules (sc) with oil vehicle (v) or estradiol (e) and progesterone (p) to simulate concentrations in pregnancy (hum reprod : , ) . after days, mice in the v and e+p groups were euthanized. the p capsule was removed from some mice on day (e-p) and groups killed on days and . cervix sections were stained for collagen, nerve fibers, macrophages, or neutrophils (n= /group/day; sections/ cervix; biol reprod : , ; jsgi : , ) . stained macrophages and neutrophils were counted (image pro-plus , media cybernetics). results: e+p treatment for days promoted hypertrophy of the cervix compared to v controls, i.e., collagen content and structure diminished, cell nuclei density declined, and nerve fibers increased. removal of p did not affect these endpoints. for immune cells, e+p for , , or days decreased immune cell numbers. by contrast, p removal increased macrophages and neutrophils in the cervix on days and (p< . , e-p vs e+p groups, respectively). the census of resident immune cells in e-p groups at and h after p removal equaled that in the v group. conclusions: mimicking gonadal steroid concentrations in circulation during pregnancy promotes hypertrophy and suppresses immigration of immune cells in the cervix. in this non-pregnant murine model for parturition, progesterone withdrawal recruits immune cells, but fails to promote further remodeling or hyperplasia of nerve fibers in the cervix. the findings raise the possibility that ripening of the cervix requires not only recruitment, but also activation of immune cells. whether proinflammatory activities by specific immune cells affect nerve fiber hypertrophy or neural activity, as part of the mechanism for ripening of the cervix, remains to be determined. we have previously identified and characterized a truncated pr (pr-m), that localizes to the mitochondrion by multiple experimental techniques, including confocal imaging of a recombinant gfp fusion protein, western blot analysis after cellular fractionation of nuclear pr negative t d-y breast cancer cells and western blot analysis of purified human heart mitochondrial proteins. initial studies with nuclear pr negative mcf- a breast epithelial cells shown to express pr-m demonstrated an increase in mitochondrial membrane potential (mmp) with progesterone/progestin treatment. these studies led to the hypothesis that progesterone modulates cellular respiration via the mitochondrial receptor, pr-m. objectives: the present studies sought to further localize pr-m to the outer, inner or matrix portion of the mitochondrion and to correlate the increase in mmp with total cellular atp production. additionally, the potency of progesterone and synthetic progestins on the change in mmp was evaluated. methods: the location of pr-m was determined by western blot analysis after fractionation of human heart mitochondria with digitonin treatment and differential centrifugation. mmp was determined in mcf- a breast epithelial cells and a rhabdomyosarcoma cells by the change in fluorescent emission of jc- . total atp was determined by a bioluminescent assay. results: western blot analysis after mitochondrial fractionation showed pr-m localization exclusively in the outer membrane. a dose-dependent increase in mmp was seen in cell lines with - min treatment with progesterone and r which were inhibited by a specific pr antagonist, rti- - b, and not affected by the translational inhibitor, cycloheximide. similar changes in mmp were seen with the same concentration of progesterone, mpa and r . progesterone/progestin treatment for min led to an increase in total cellular atp without a change in cell number. conclusions: progesterone/progestin treatment results in an increase in cellular respiration in cells expressing an outer mitochondrial membrane pr and known to lack nuclear pr expression. this may represent a mechanism whereby progesterone enhances cellular energy production to meet the demands of pregnancy. introduction pge is a major product of the fetal membranes, decidua and myometrium and plays an important role in cervical ripening and myometrial contractions. there are four pge receptors, ep- and ep- mediate contractions whilst ep- and ep- mediate quiescence. ep- contains multiple consensus sequences for transcription factors known to be of importance in labour, in particular nfkappab. we therefore performed experiments to determine the effect of activation and inhibition of nfkappab upon ep- expression. myocytes plated in well plates were treated with il- ( ng/ml), to activate nfkappab. myometrial cells were also transiently transfected with nfkappab p sigenome smart pool and sicontrol non-targeting sirna to knock down nfkappab p . rna was extracted for amplifying ep- using quantitative rt-pcr with amplification of l as a control to normalise data. il- caused an increase in expression of ep- . knock down of nfkappab using si-rna resulted in a further increase in ep- . this data suggests that although il- stimulates expression of ep- it does so through an nfkappab independent mechanism. the upregulation of ep- with sirna knock down of p suggests that activation of nfkappab would inhibit ep- expression consistent with the concept that activation of nfkappab at term causes the myometrium to adopt a more contractile phenotype. introduction: a role for the pro-inflammatory cytokine il- is suggested in preterm and term birth, independent of the presence of infection. we previously showed that mice with a null mutation in the il- gene (ko) delivered one day later than wild type (wt) mice due at least in part to altered timing of uterine expression of prostaglandin (pg) f receptor, ptgfr, mrna. we also observed differences in mrna expression of other uterine activation proteins (uaps), pg h synthase (pghs)- , oxytocin receptor (otr) and connexin- (cx- ), suggesting multiple physiological effects for il- in term delivery. objective: to examine the effect of il- deficiency on the peri-partal uterine mrna expression of the pge receptors (ep) , and ; the post-partum changes of all uaps; and the relationship of these to serum progesterone (p ) concentrations. methods: gestational length was observed in pregnant c bl/ wt (n= ) and ko (n= ) mice. uap mrna levels were measured by real time rt-pcr in wt and ko dams sacrificed from d through delivery and up to h postdelivery. serum p was determined by ria. data were analyzed by one-way and two-way anova using the holm-sidak test to differentiate treatment effects at p< . . results: birth was delayed in the il- ko mice ( . ± . d vs. . ± . d), and this affected the timing of peri-partal changes for all uaps similarly. both ep and ep (relaxatory receptors) were elevated at d in ko dams, but returned to low levels before delivery and were elevated at delivery (ep ) or afterwards (ep ). ep levels did not change. otr increased several hours before delivery in all dams. cx- increased at delivery, then fell, while pghs- increased at delivery and remained elevated afterwards. ptgfr mrna increased - -fold at delivery and a further - -fold after delivery, suggesting loss of pgf permitted enhanced ptgfr expression. p serum concentrations fell pre-partum in both groups. conclusions: il- ko alters the expression pattern of several pregnancy and parturition-related genes and may delay the pre-partum p fall, suggesting a potential ovarian effect. a uterine role for il- in regulating the timing of normal term parturition cannot be ruled out. objective: recent studies have highlighted the prevalence of vitamin d deficiency in pregnant women, particularly in those from ethnic groups with darker skin who require higher levels of uv light to make parental vitamin d. as the active form of vitamin d, , -dihydroxyvitamin d ( , (oh) d ) is a potent immunomodulator, we postulated that vitamin d deficiency may lead to dysregulated placental immunity. both trophoblast and decidua express the enzyme -hydroxylase (cyp b ) which catalyzes synthesis of , (oh) d from the inactive pro-hormone -hydroxyvitamin d ( ohd ). in view of the role of trophoblast as a barrier site protecting the fetus against infection, we investigated the impact of cyp b , ohd and , (oh) d on innate immune responses in trophoblastic cells. methods: a trophoblast cell line was used to assess the effect of vitamin d on innate immune responses. the cells were treated for hrs with various concentrations of , (oh) d ( - nm) and antimicrobial cathelicidin expression was assessed by real time pcr. to assess whether expression of cyp b was affected by pathogenic stimuli, a cells were treated with ligands for toll-like receptor (tlr) - , cyp b expression (real time pcr) and ohd utilization were assessed. results: a trophoblast cell line; which shows temperature-sensitive differentiation, revealed expression of cyp b with higher levels of enzyme activity under conditions of syncytiotrophoblast development. cells treated for hrs with , (oh) d showed dose-dependent induction of the antimicrobial defensin cathelicidin expression ( . - fold induction), whilst cells treated pro-hormone ohd ( nm) showed . -fold induction of cathelicidin expression. activation of tlr (poly i:c) and tlr (lipopolysaccharide) enhanced the expression of cyp b ( -and . -fold) and increased the sensitivity to ohd as a consequence. conclusion: these data show that autocrine synthesis of , (oh) d from ohd can stimulate trophoblast immune responses in a similar fashion to macrophages. as ohd is the major circulating form of vitamin d, we hypothesize that trophoblast innate immunity may be significantly compromised under conditions of vitamin d deficiency. introduction: secretory leukocyte protease inhibitor (slpi) is a potent -kda protein inhibitor of neutrophil elastase and it is a mediator of mucosal immunity and an inhibitor of nfkb regulated inflammatory responses. however, its source, function and regulation within the uterus during pregnancy and at parturition are not well defined. it has previously been shown to be present in fetal membranes and cervical mucus and in amniotic fluid, where its levels is increased from second trimester to term and with a further increase at parturition. slpi has also been shown to be responsive to progesterone in human epithelial cells. our aim was to determine the effects of il- on slpi gene expression in human myometrium. methods: primary human uterine myocytes were isolated from non labouring myometrium and cultured in well plates and when cells were - % confluent they were serum starved overnight and incubated with m methyl- -hydroxy-progesterone acetate for h and with or without ng/ml il- for a further hours. at the end of incubations rna was extracted and converted to cdna. paired upper and lower segment myometrial tissue was collected at caesarean section either before or after the onset of term or pre-term labour and frozen for extraction of rna (n= for ptnl, ptl, tnl and l). copy numbers of slpi, gapdh and beta-actin were measured by qpcr. results: h incubation of uterine myocytes with ng/ml il- caused a marked increase in slpi by % (n= ; p< . ). incubation of uterine myocytes with m progesterone for h also increased slpi by % (n= ; p< . ). incubation with il- for h in the presence of h with progesterone increased slpi: gapdh mrna ratio from . ± . to . ± . (mean ± sem; p< . ). slpi expression was similar in the upper and lower segment myometrium in preterm patients. in term myometrium the slpi: beta-actin mrna ratio was increased by -and -fold in term labour versus term non labour samples in the lower and upper segment respectively (mean ± sem; p< . ). these data show slpi is present in human myometrium and that it is increased by il- . progesterone also increases its expression. its expression is increased in term labour where its anti-bacterial, anti-fungal and anti-viral properties could allow it to act as an endogenous block to infections. objective: pre-b cell colony-enhancing factor (pbef) downstream mapk signaling and transcription factor activation. introduction: pbef is expressed in all layers of the human fetal membranes and the myometrium and is upregulated by labor, infection, nf-kb, ap- and stretching. pbef has the ability to protect a variety of cells from apoptosis, however it also appears to act as an insulin mimetic via the insulin receptor (fukuhara et al. science : ; - ) . its levels are elevated in obese patients, those with type diabetes and in gestational diabetes. because pbef has poorly understood biological activities an investigation of mapk signaling and transcription factor activation induced by pbef has been undertaken in order to gain insights into its mechanisms of action. methods: primary aec were isolated from fetal membranes and treated with rhpbef ( ng/ml) for h, lysed and the resultant proteins labeled with cy or cy (amersham). there were used on a protein microarray containing constituents of the mapk signaling pathways (sigma). isolated aec were transfected with luciferase constructs for nf-kb, ap- , cre, hse and gre response elements using the exgen reagent. the cells were treated with rhpbef ( . , . , , ng/ml) hrs, lysed and ul of sample was analyzed for luciferase activity with dual-luciferase reporter assay system (promega). co-transfection with gfp and sv luciferase constructs to control for transfection efficiency and cell number (respectively) was also performed for each experiment. results: pbef significantly upregulated mapk signaling components including functioning as part of the erk pathways and belonging to p signaling. it also activated nf-kb and camp response elements. however, it significantly down regulated signaling molecules belonging to the jnk pathway that resulted in decreased c-jun phosphorylation. conclusions: pbef signaling in aec is consistent with its anti-apoptotic ability and its upregulation of the pro-inflammatory cytokines. although some mapk components responsive to pbef could be associated with insulin receptor signaling, some may not. therefore, it appears likely that pbef interacts with another potentially unique, but currently unidentified receptor. was the first effector to be characterised, but camp is now known to have other effectors, including camp receptor protein, cyclic nucleotide-gated channels and camp-guanine nucleotide exchange factor/exchange protein directly activated by camp (camp-gef/epac). two epac's have been identified and they consist of functional domains: camp-binding domains, a dep domain, a ras exchange motif and a gef domain. our aim was to determine the presence of epac's in human myometrium and to study the effect of camp responses on prolabour genes such as il- , pghs- , otr and fp. methods: primary human uterine myocytes were isolated from non labouring myometrium and cultured in well plates until - % confluent. cells were serum starved overnight and incubated with μm methyl progesterone, . mm sodium -bromo-camp, . mm forskolin, μm kt , ng/ml brefeldin a and . mm -pmeopt- 'o-me-camp either alone or in combination for h. rna was extracted and converted to cdna. paired upper and lower segment myometrial tissue was collected at caesarean section either before or after the onset of term or pre-term labour and frozen for extraction of rna (n= for ptnl, ptl, tnl and l). copy numbers of epac , epac , il- , pghs- , otr, fp, gapdh and -actin were measured by qpcr. results: epac and epac were present in the upper and lower segment of myometrium with epac levels being some -fold higher than those of epac . there was no change with the onset of labour at or before term. treatment with il- for h significantly increased epac (n= ; p< . ) but had no effect on epac . when conditions mimicked pregnancy, (the presence of forskolin and progesterone), brefeldin a, an epac antagonist, increased basal pghs- and fp mrna expression (n= ; p< . ), but had no effect on il- and tended to reduce otr. the il- -induced increase in pghs- and il- , but not fp, was greater with the epac antagonist. conclusions: these data show epac's are present in human myometrium and that camp acts via epacs to reduce pghs- and fp expression during pregnancy. background: inflammatory events have been implicated in the process of labour. glucocorticoids mediate strong anti-inflammatory effects through binding to the glucocorticoid receptor (gr), which on activation translocates to the nucleus and either increases or decreases the expression of responsive genes thereby suppressing inflammation. objective: to characterise the expression profile for gr protein and mrna in human myometrium during fetal maturation and parturition. methods: western immunoblotting (wb) was employed to characterise gr protein expression in first (n= ) and second trimester myometrium (n= ), and in paired upper and lower segment pregnant (non-labouring, p, n= ) and labouring (l, n= ) myometrium; as compared to non-pregnant (np, n= ) control samples. immunofluorescence staining with confocal microscopy and rt-pcr were also undertaken. results: detection of gr protein by wb revealed two bands at - kda, representing the alternatively spliced isoforms, gr-and gr-. densitometric analysis showed that gr levels decreased significantly during pregnancy and remained at very low levels at term and in labour when compared with np samples (p< . ); this decrease was seen for gr-and gr-. no significant temporal variations were observed in gr protein levels at term or during labour. gr protein was localised by immunofluorescence staining to the nuclei and cytoplasm of cells. less intense staining was apparent in p compared to np tissues; consistent with wb data. rt-pcr showed a consistent predominance of gr-to gr-mrna in all the tissues used. the observed decrease in protein expression was also mirrored at the mrna level: gr-mrna levels appeared to gradually decrease throughout gestation (p< . ). differences between the upper and lower myometrial regions were only observed in the labouring samples, where gr-mrna levels were significantly decreased in the lower segment (p< . ). nested pcr was additionally used to amplify gr-, but no consistent pattern of mrna expression was obtained. conclusions: these data are the first to characterise gr expression in human myometrium. spatial and temporal variations have been found with expression evolving through the three trimesters of pregnancy and in labour. further studies are now underway to evaluate whether gr contributes to the sequence of inflammatory events implicated in triggering term and preterm labour. these studies sought to determine the mechanism by which pas modulate the immune response. methods: ) an in vitro co-culture model mixed with human cervical epithelial hela cells and pma-induced human macrophage u cells at epithelial/macrophage cell ratio of : was employed. ) the co-culture was pre-treated with medroxyprogesterone acetate (mpa), progesterone (prog) and dexamethasone (dex) at concentrations of , , and nm for hrs followed by day stimulation of g/ml lipopolysaccharide (lps). these experiments were repeated using hela cells transfected with sirna for glucocorticoid receptor (gr). the production of cytokines il- , il- and il- , il- and tnf were determined using elisas. ) the co-culture was pre-treated with nm of each pas for hours prior to lps stimulation at g/ml for . , . , , , and hours. the phosphorylation of p mapk and gr and the expression of mapk phosphatase (mkp ) were determined by western-blotting. results: il- , il- and il- , il- and tnf were elevated by . fold, . fold, fold, . fold and . fold in the co-culture model in response to lps(p< . for all). pretreatment of mpa and dex, but not prog, inhibited the lps-induced cytokine production. the anti-inflammatory effect of mpa occurs in a dose-dependent manner. in the absence of gr, the inhibitory effect of mpa and dex on il- , but not on il- , was lost. mpa and dex, but not prog, induced the phosphorylation of gr and expression of mkp . p mapk was activated by lps for up to hrs and pretreatment of mpa and dex attenuated this response. the ability of mpa and dex to suppress the inflammatory response in cervical tissues appears to be mediated through a gr-dependent pathway, specifically though p mapk. our studies suggest that prog is not a significant immunomodulator in these tissues. background: progesterone (p ) has been shown to play a critical role in maintaining pregnancy and preventing preterm birth. these effects are likely related to its immunomodulatory properties. we investigated whether camp plays a role in the immunosuppressive action of progesterone on fetal mononuclear cells. methods: umbilical cord blood mononuclear cells were isolated using density gradient centrifugation. to establish a p effect and optimize concentrations, cells were pretreated with p ( - m- - m), dexamethasone ( um) or vehicle for hour prior to overnight lps ( ng/ml) stimulation. supernatants were assayed for tnf-using elisa. ldh assays confirmed the absence of a cytotoxic effect. next, cells were pre-incubated with forskolin (adenylate cyclase activator) or db-camp (camp agonist) prior to lps to determine the effects of camp on tnf production. finally, cells were pretreated with rp-camp (camp antagonist) prior to p incubation and lps stimulation to determine whether the p effect was reversed by a camp antagonist. results: p significantly inhibited lps-induced tnf production in a dose dependent manner, with maximum suppression observed at - m. both forskolin and db-camp suppressed lps-induced tnf production in a doserelated manner (fig ) . finally, a dose-dependent partial reversal of tnf production was observed when cells were pretreated with rp-camp. (fig ) conclusions: progesterone suppresses the inflammatory response in fetal mononuclear cells as measured by tnf expression. this effect is mimicked by adenylate cyclase activators and camp agonists and partially reversed by camp antagonists. this implicates the camp pathway in mediating the immunomodulatory actions of p . objectives estrogen improves endothelial function after vascular injury via largely unknown mechanisms. endothelial progenitor cells (epcs) are known to be implicated in various vascular events requiring endothelialization. we hypothesized that estrogen and progesterone could influence the function and the change of epcs in menstrual cycle. material and methods peripheral blood mononuclear cells (pbmcs) were isolated from peripheral blood of healthy young women in each menstrual period by density gradient centrifugation with ficoll separating solution. pbmcs were seeded in endothelial basal medium with or without estrogen or progesterone. on the th day in culture, nonadherent cells were removed. on the th day in culture, adherent cells were incubated with di-ldl, fixed with paraformaldehyde, and stained with fluorescein isothiocyanate-labeled lectin. the number of ldl-and lectin-positive cells was measured as epcs using flowcytometry. the expression of estrogen and progesterone receptor mrna in epcs were measured by real time pcr in menstrual and luteal period. the number of epcs was significantly increased in the menstrual and luteal period compared with the follicular phase. estrogen and progesterone significantly increased the number of adherent epcs dose dependently in menstrual period, but not in luteal period. the expression of estrogen-alpha receptor in menstrual period was higher than luteal period. also, estrogen-beta receptor in luteal period was strongly expressed compared with menstrual period. these results suggest the expression of estrogen receptor and progesterone receptor play important roles to regulate epcs' proliferation during menstrual cycle. objective: elevated levels of fetal plasma avp are associated with the development of oligohydramnios, in part a result of avp-mediated reduction in fetal urine production. as avp urinary concentration effects are mediated via upregulation of renal tubular aqp water channels, we propose that avp modulates placental aqp channels, influencing bidirectional maternal-fetal water flow. we sought to study the effect of avp on trophoblast aqp gene expression using the first trimester-derived extravillous htr- /svneo cells and the term placenta-like trophoblast carcinoma cells jeg- . methods: cultures of both cell lines were treated with a physiological concentration of avp ( . nm) to determine aqp mrna and protein expression. negative controls consisted of cells incubated in medium supplemented with % fbs without avp. to determine whether avp regulation of aqp occurs by a camp signaling pathway, jeg- cells were preincubated with μm -(tetrahydro- '-furyl) adenine (sq ), a cell-permeable camp inhibitor, before being treated with avp ( . nm). cells were incubated for hrs for aqp mrna expression and for hrs for protein extraction at °c. after harvest, real time pcr and western blotting analysis were used to detect the aqp mrna and protein expression levels, respectively. results: avp increased aqp mrna expression in both cell lines by . and . fold after hrs. aqp protein expression paralleled the increase seen in the mrna (p< . ). pretreatment of jeg- cells with sq inhibitor completely blocked the stimulatory effect of avp. conclusion: aqp gene expression is up-regulated by avp in first trimester and term trophoblast cells, with a higher induction in the later. avp activation of aqp gene expression occurs via a camp mediated pathway, as the adenyl cyclase inhibitor blocked avp effects on aqp gene expression. these results suggest that increased fetal plasma avp may contribute to oligohydramnios by an increase in aqp-mediated fetal to maternal water flow. objective: changes in expression, ratio and activity of progesterone receptors within human myometrium have been proposed as potential contributory mechanisms for the functional progesterone withdrawal effect which precedes labour. progesterone receptor c (pr-c) is an n terminally truncated isoform of the full length progesterone receptor; pr-c has been shown to be abundant in fetal membranes, placenta and upper segment of laboring myometrium ( , ). the function and regulation of pr-c is at present unclear. in this study we aimed to investigate the regulation of pr-c in cultured human myometrial and amnion-derived wish cells. methods: myometrial primary cell cultures were prepared from non pregnant and term pregnant uteri. both myometrial and wish cell cultures were treated with natural progesterone ( , nm, mm, mm, mm) for , and hrs. western immunoblotting was employed using nuclear and cytoplasmic extracts prepared from treated cells to observe the effect of progesterone on a) expression and b) subcellular localisation of pr-c within both cell types. immunofluorescent staining and confocal microscopy were also employed. experiments were also undertaken whereby nuclear and cytoplasmic extracts were subjected to shrimp alkaline phosphatase treatment to evaluate the phosphorylation status of pr-c in response to hormone. results: data indicates that a kda cytoplasmic protein, representing pr-c is abundant in myometrial and amnion cell cultures. we show that expression of pr-c increases in both cytoplasmic and nuclear fractions within both cell types in response to progesterone. evidence also suggests that pr-c is phosphorylated in a progesterone-independent manner. concurrent treatment with progesterone and the pr-antagonists ru and organon in amnion-derived cells still led to an increased abundance of pr-c but seemed to alter the phosphorylation status of pr-c. conclusion: pr-c expression and subcellular localisation within myometrial and wish cells alters in response to progesterone. speculation is generated about potential role of pr-c in reproductive tissues and its contribution to functional progesterone withdrawal. . taylor smooth muscle responses have been studied, data on regional blood flow (bf)distribution are scarce. we have studied the effect of a single dex course on relative bf distribution within the brain, skeletal muscle, heart, omental fat, placenta and adrenal in fetal sheep at . g, the equivalent of weeks. methods: fetal sheep received amniotic, jugular, carotid and femoral artery and vein catheters at days g (dg). experiments started at dg in dex ( mg) and saline treated controls (ctr), each receiving injections h apart. fetal blood pressure was recorded continuously (windaq pro+). microspheres ( . x total; sterispheres, biopal) were injected at : am into fetal jugular and femoral veins before maternal i.m. injection (t ) and h after the rd injection (t ) in both groups. tissues were collected hours after the th injection for assessment of bf (biopal). results: fetal bp increased above baseline after dex ( . + . mmhg; p= . ) with no change in ctr (- . + . mmhg). regional bf distribution is presented as a percent of the total counts per g tissue (table ) and after normalization within each animal to placentomal flow, shown previously to be unchanged by dex, in table . no significant differences in flow were found. discussion: although dex altered bp, regional distribution of bf among key organs was unaffected. whether gc does not affect regional bf, or the rise in bp is the result of a non-specific, system-wide vasoconstriction, or the impact of gc on bf is similar in all organs, will be subject of further investigation that will include determination of regional vascular resistance and absolute flow. stimulator while crf-r is an inhibitor of gi motility at times of stress. we recently hypothesized that stress-induced in utero meconium passage in fetuses is analogous to stress-induced defecation in adult rats and likely mediated by crf pathway. in support, we demonstrated hypoxia-induced meconium passage in conjunction with marked increases in fetal plasma crf levels. as the mouse is a common experimental model, with known genome, we sought to determine the presence of crf-r and crf-r receptors in mouse fetuses. methods: time-dated cd- pregnant mouse were anaesthetized and fetuses (n= ) were collected at e (term = e ). whole gi tracts were dissected, fixed in bouin's solution, paraffin embedded and sectioned at five micron thickness. sections were immunostained with rabbit polyclonal antibodies to crf-r and crf-r by abc technique with vector abc reagents. immunoreactivity was identified as brown staining using ', diaminobenzamidine as chromagen. slides were counter stained with mayer's hematoxylin and examined under the microscope. immunoreactive signals in the smooth muscle layers of gi tracts were quantified by image analysis using image pro . plus software. results: immunostaining for both crf-r and crf-r was seen in the smooth muscle layers of all lumens examined ( lumens per section). the immunostaining intensity expressed as intensity over density (iod) in arbitrary units for crf-r (maximal iod: . ± . au and minimal iod: . ± . au) and for crf-r (maximal iod: . ± . au and minimal iod: . ± . au) greatly varied between lumens. the mouse fetal gi tract expressed both crf-r and crf-r receptors, suggesting that the mouse is an appropriate model for fetal-stress induced neurovisceral motor responses. the non-uniform distribution of crf receptors in the fetal gi tract suggests the existence of regional differences in the expression patterns of crf-receptors of both types. we speculate that mouse devoid of crf and crf-r or r receptors will be useful to confirm the participation of crf pathway in stress-induced in utero meconium passage. antenatal exposure to glucocorticoids (gc) is associated with a reduction in nephron number and hypertension in adult life. one of the mechanisms for the development of hypertension is thought to be the long term effect of single nephron hyperfiltration. however, in most studies there is only a - % reduction in nephron number with no change in gfr. thus, although a reduction in nephron number may be a contributing factor it is unlikely the only variable. the aim of the present study was to evaluate nephron mass, renal function and blood pressure in a cohort of adult sheep exposed antenatally to betamethasone. methods: pregnant sheep were treated with two im doses of betamethasone (bm, . mg/kg) or vehicle (ctr) -hs apart at days gestational age and allowed to deliver at term. at . yr of age in female (f) and male (m) offspring, glomerular filtration rate (gfr) was measured as inulin clearance and effective renal plasma flow (erpf) as pah clearance. blood pressure was measured though an indwelling catheter in the femoral artery over a -hour period. nephron number was measured by the acid maceration technique. data mean±sem were analyzed by anova and/or two sample t test. results: antenatal bm was associated with an elevation in arterial blood pressure and a reduction in nephron number in both f and m offspring. in contrast, a reduction in gfr and erpf was present only in males. plasma and urinary electrolytes as well as urinary protein excretion were not different from ctr. conclusion: our data show that prenatal exposure to a single course of gc at . gestation has long-term effects on blood pressure regulation. interestingly, while the decrease in nephron number was of similar magnitude in m and f, evidence of alterations in renal function was present only in males. these suggest that the decrease in renal function observed in males is not solely a consequence of the decrease in nephron number. furthermore, it is possible that different mechanisms are responsible for the elevation in arterial blood pressure observed in m and f. hl ; hd p hd . clr l>t-x to evaluate the effects on blood pressure, urine output, sodium excretion and gfr of the intrarenal infusion of angiotensin - in the male sheep with or without prenatal exposure to b. we studied male sheep which had received either b (n= ) or vehicle (n= ) at - days gestation and were born at term. catheters were placed in the femoral artery, femoral vein, left renal artery and the bladder. the right kidney was removed. after days recovery the sheep received an infusion of ang - ( ng/kg/min) with or without its antagonist, [d-ala ]-ang-( - )(d-ala, ng/kg/min), into the renal artery for hours. blood pressure, gfr, urine output and sodium excretion were measured before and after the infusion. two-way analysis of variance (anova) was used to test mean values between the groups. with or without d-ala, map and urine output didn't change significantly during ang - infusion. however, the infusion of ang - resulted in a decrease (change from baseline) (p= . ) in na + excretion of . ± . meq/kg/ h in the vehicle animals and . ± . meq/kg/ h in the b animals. there was no significant change in gfr during ang - infusion. gfr was lower in the b group during the combined ang - and d-ala infusion ( . ± . ml/min vs . ± in vehicle group, p= . ). intrarenal infusion of ang - at ng/kg/min is followed by a significant decrease in sodium excretion but no significant change in urine output and gfr. the decrease tended to be greater in the vehicle animals and was not markedly attenuated by the antagonist d-ala. this suggests the effect of ang - may be mediated by a receptor other than the mas receptor for ang - and may be of lesser magnitude in animals exposed to b before birth. and norepinephrine ( . - . g/kg/min) and to an l-name ( mg/kg) bolus were studied. vascular reactivity was analyzed by curve fitting of either the blood pressure or hr responses to obtain the maximal response. data are expressed as mean±sem of change from baseline. statistical significance was established using t test. results: bm-exposed animals displayed a higher blood pressure response to at-ii (atii max ± vs ± % of baseline, p< . , figure left panel). no differences in blood pressure or heart rate responses to norepinephrine infusion were detected in bm when compared to control animals (figure right panel) . maximal response to l-name was also elevated in bm-exposed animals but did not reach statistical significance with the current sample size. conclusion: we have shown that antenatal gc treatment significantly increases blood pressure in sheep. here we show an enhanced in vivo response to at-ii. this response may contribute to the increased blood pressure observed. the greater response to l-name most likely represent an increased no production as a compensatory mechanism to the higher blood pressure observed. hl . women at risk of delivering preterm are frequently treated with glucocorticoids to facilitate fetal lung maturation. animal studies have revealed that prenatal exposure to glucocorticoids may alter aspects of hypothalamic-pituitary adrenal functioning in later life. in this study we examined the effects of clinically relevant prenatal betamethasone treatment on the responsiveness of pituitary cells (in terms of adrenocorticotropin, acth, secretion) isolated from adult sheep. time-dated pregnant sheep were injected with betamethasone ( . mg/kg) or vehicle on days and of gestation. thereafter pregnancy was allowed to continue unimpeded and offspring were born. pituitaries were isolated from adult sheep aged between and months and cells were dispersed and plated at a density × cells per well in well plates. after h, cells were stimulated with normal medium, nm arginine vasopressin (avp), nm avp, nm corticotropin releasing factor (crf) or nm crf for h. medium was collected and analyzed for acth using a commercially available kit. acth secretion (given as % increase from untreated cells) was similar between the control and betamethasone groups following nm avp ( . ± . vs. . ± . ) and nm crf ( . ± . vs. . ± . ). at higher stimulatory concentrations of both avp and crf, acth secretion remained similar in control cells ( . ± . and . ± . respectively), but was significantly decreased in betamethasone cells ( . ± . and . ± . respectively). these findings suggest that prenatal exposure to clinically relevant doses of betamethasone can alter pituitary responsiveness to both avp and crf in adulthood. this research was supported by nih grants hd and hd . lcc is supported by an rjr-leon golberg fellowship in pharmacology and toxicology. objective: newborn meconium (mec) passage normally occurs within the first - h after birth. in contrast, more than half a million infants born annually in the us pass mec in utero. neither the physiological mechanism(s) nor causes for in utero mec passage are well understood, though both fetal maturation and stress are associated. we recently reported in utero mec passage and marked increases in plasma crf levels in term fetal rats exposed to maternal hypoxic stress. we hypothesize that stress-induced in utero mec passage is mediated by the crf pathway in a manner analogous to stress-induced defecation in adult rats. in the present investigation we examined placental crf content prior to and following maternal hypoxia, to determine the source of increased plasma crf. methods: time-dated pregnant rats (n= ) were exposed to a paradigm of graded, stepwise hypoxia on day (term= ) (pediatr. res. : - , ) . control pregnant rats were exposed to % oxygen for a similar duration as experimental animals. at the end of the study, placentas were harvested, fixed in % paraformaldehyde and paraffin embedded. sections (n= per placenta) were subjected to immunohistochemical analyses with rat/human crf antibody (peninsula laboratory) by abc technique. immunoreactivities on placental sections were quantified using the image pro . software and intensity expressed as arbitrary unit (au). all values are mean± sem. results: in control maternal rats exposed to normoxia, positive staining for crf was seen in decidua ( . ± . au) and in all three major placental cells types (giant trophoblast cells: . ± . au, spongiotrophoblast cells: . ± . au and labyrinth cells: . ± . au.) in contrast, in animals exposed to hypoxia, there was a total absence of crf staining in the placental cells, with only positive crf staining seen only in the decidua ( . ± . au). conclusion: the total absence of crf staining in both the basal and labyrinth zones in placentas of pregnant rats subjected to hypoxic stress suggests that placental cells rapidly release crf into the maternal and fetal circulation in response to hypoxic-stress. our findings support our hypothesis that the peripheral crf pathway mediates in utero mec passage. offspring. angela g massmann, jie zhang, jorge p figueroa. department of obstetrics and gynecology, wake forest university school of medicine, winston-salem, nc, usa. objective: in rats and sheep, exposure to glucocorticoids (gc) in the perinatal period induces hypertension in adult life. recent evidence suggests that endothelin b (etb) receptor plays an important role in the regulation of sodium balance and blood pressure. renal medulla is an important site of expression and action of etb receptor. furthermore, in kidney it is the medulla (km) where the highest concentrations of immunoreactive et- and etb receptor are found. the aim of this study was to measure eta and etb expression in adult sheep kidney exposed antenatally to gc. methods: pregnant sheep were treated with two im doses of betamethasone (bm, . mg/kg) or vehicle (v) hours apart at days of gestational age and allowed to deliver at term. at . yr of age, male and female offspring exposed to either vehicle or bm were euthanized and the kidneys harvested. kidney medulla (km) was obtained by sharp dissection. eta and etb protein and mrna expression were evaluated by western blot and rnaase protection assay. data are expressed as mean±sem and were analyzed by two way anova. results: a significant decrease in etb (f= . , p= . ) but not eta protein was observed in km of bm exposed male and female adult sheep. at the mrna level, bm exposure also affected etb, but not, eta expression. however, bm treated animals had higher mrna levels than control sheep (f= . ; p= . ). conclusion: our data show that prenatal exposure to a single course of gc at . gestation has long-term effects. the activation of etb receptor by et- inhibits sodium transport function in the collecting duct and the selective gene deletion of the etb in medulla results in hypertension.therefore, our finding of a significant reduction in etb protein suggests that there may be an impairment in the kidney's ability to regulate sodium reabsorption. the functional relevance of the alterations in etb protein expression as well as the discrepancies in mrna regulation need to be established. hl ; hd p hd . in the placenta, -hydroxysteroid dehydrogenase type ( hsd ) regulates the transfer of cortisol. maternal glucocorticoid (gc) administration has been shown to affect the ovine fetal growth trajectory and regulate hsd expression in mid and late gestation. however, little is know about the effects of gc administration in early gestation. we hypothesized that maternally administered low-dose dexamethasone (dex) in early gestation would affect hsd expression, which will subsequently alter fetal birth weight. pregnant ewes were randomized and received intramuscular injections consisting of either saline ( ml saline/ewe) or dex ( . mg/kg) given hours apart starting on days of gestation (dg). the animals were sacrificed at , , , and dg and fetal weights were recorded and placental tissue was collected. qrt-pcr was used to measure hsd placental mrna expression. statistical analysis was done by anova with student's t-test posthoc. overall, there was no significant effect of dex treatment on placental hsd mrna expression across gestation. however at dg, there was a significant increase in hsd expression after dex (p= . ). there was an increase in placental hsd mrna progressively from dg (mean = . ) to dg (mean = . ), independent of treatment. overall, a positive correlation between hsd and fetal weight (r = . ) was apparent at dg and at dg (p= . ) in both control (p= . ) and dex (p= . ). significant positive correlations between placental hsd and fetal weight (r = . ) were found in females (p= . ) and a similar trend was found in male fetuses (p= . ). we conclude that in the sheep placenta, hsd expression increases throughout gestation and may respond, at least transiently in early gestation, to elevations in maternal gc. the positive correlation between hsd and fetal weight is consistent with the thesis that the fetal growth trajectory may be influenced by maternal cortisol levels and that placental hsd is an important mediator of these effects. antenatal gc exposure induces hypertension in the young adult rat (neuroendocrinol; ; : ) and increases femoral vascular resistance in the lamb (jphysiol; ; : ) . unpublished own examinations in preparation of this study have shown age dependency of the vascular reactivity. vascular contractility of the middle cerebral artery (mca) decreased in response to k + and noradrenaline (na) between mo and , y of age (p< . ). vascular relaxation to acetylcholine (ach) but not to pge decreased during the same time (p< . ). vascular contractility of the renal artery (ra) increased in response to k + (p< . ). aims: to examine if antenatal gc alter vascular reactivity in the aged individual when cardiovascular diseases are predominant. we studied the ra because its vascular tone is involved in modulation of arterial pressure control (amjphysiol; ; :r ) and the mca because depressive disorders that are associated with dysregulation of the hpa axis (jcem; ; : ) increase stroke mortality for unknown reasons (amjpsychiatry; ; : ) . to be clinically relevant, we administered dexamethasone at the dose used to enhance lung maturation in babies threaten premature labor. methods: pregnant dams received saline (n= ) or μg/kg dexamethasone (n= ) i.p. at day e / equivalent to x mg dexamethasone administered to a kg pregnant woman. at . years of age, vascular response of the ra and mca to endothelium-dependent and independent mediators was measured using wire myography. vessels were inspected histologically for intact endothelium. results: basal vasoconstrictory and dilatory responses to all mediators were less pronounced in the mca than in the ra probably reflecting autoregulatory properties of cerebral vessels (p< . ). after prenatal dexamethasone exposure, contractility but not sensitivity to k + and na was enhanced in the mca and even more pronounced in the ra (p< . ). relaxation to ach and pge was similarly diminished in both vessels after precontraction with na (p< . ). conclusions: prenatal dexamethasone exposure at the dose used clinically increases renal and cerebral vascular tone in the aged rat by endotheliumdependent and independent mechanisms. this effect may be a potential mechanism of fetal programming of cardiovascular diseases in later life. betamethasone (bmz) therapy during pregnancy to improve fetal lung maturity may result in long term side effects, including hypertension, during adulthood. the kidney is an important organ which regulates systemic blood pressure via the local renin angiotensin system (ras). the major enzymes of the intrarenal ras include angiotensin converting enzyme (ace), angiotensin converting enzyme (ace ), and neprilysin. the hypothesis of this study is that prenatal bmz exposure will result in alterations of the enzymes regulating the intrarenal ras. specifically, sheep that are treated with bmz in utero will have higher amounts of ace activity in kidney cortex compared to control animals. pregnant sheep of known mating date were either treated with vehicle (n= ) or with two doses of bmz (n= ), . mg/kg, hours apart at days of gestation. renal cortex from the male offspring was harvested at - months of age. cortical membranes were then solubilized and incubated at °c with either i-ang i or i-ang ii in the presence or absence of lisinopril to inhibit ace activity, mln to inhibit ace activity, or sch to inhibit neprilysin activity. the metabolic products were separated by reversephase high performance liquid chromatography (rp-hplc). the rate of enzyme activity was quantified by calculating the area under the curve for each product and converted to fmol of product per mg protein per minute of incubation. statistical analysis was performed using student's t-test. p< . was considered significant. results: bmz treatment resulted in a significant increase in ace activity compared to control animals (p= . ). ace and neprilysin levels were not significantly different between treatment groups. when expressed as a ratio of ace/ace activity, bmz treated animals exhibited a . fold greater proportion of ace activity versus control animals (p= . ). this study demonstrates that bmz exposure during fetal life results in a significant increase in renal ace activity during adult life. this increase in enzyme activity would be expected to be associated with increased levels of ang ii in the kidney and na + retention, possibly underlying the development of hypertension. hd , hd . we recently hypothesized that stress-induced in utero meconium passage in term fetuses utilizes peripheral and/or central crf pathways in a manner analogous to stress-induced defecation in adult rats. as participation of central crf pathway requires the crf circuitry system in brain-gut axis, we exploited immunohistochemical techniques to address whether term fetal colon is wired by crf-nerve fibers. methods: fetal distal colon segments (n= ) were dissected from term ovine fetuses ( - d gestation). in addition, lumbosacral spinal cord with spinal roots and dorsal root ganglia (drg) (n= ) were dissected from ovine fetuses, and vagal nerve trunk with nodose ganglia (n= ) were dissected from mouse fetuses. paraffin sections fixed either in bouin's solution or zamboni's were subjected to immunohistochemistry with rabbit polyclonal antibodies specific to ovine-crf (ocrf). immunoreactivity on the sections was identified by standard abc technique, immunostaining quantified by image-pro plus software and expressed (intensity over area) as arbitrary units (au). results: ocrf antibody elicited strong positive staining on the serosal surface (port of entry for extrinsic nerve fibers) in distal colonic segments objective: we hypothesize that stress-induced in utero meconium passage is mediated by the crf pathway. ucn-i, similar to crf, is a potent contractility inhibitor of preterm ovine fetal distal colon, which has abundant crf-r receptors. both ucn- and crf thus may inhibit colonic motility and prevent preterm in utero meconium passage via crf-r receptors. however, ucn-i is reported to stimulate contractility of adult rat colonic smooth muscle strips more strongly than crf. we sought to study the pattern of ucn-i innervation in distal colon of ovine fetuses to delineate whether ucn- functions as a facilitator or inhibitor of colonic propulsive motility. methods: bouin's solution fixed, paraffin sections of very preterm (vpt: - days gestation), preterm (pt: - days), near term (nt: - ) and term (t: - days) ovine fetal distal colon rings were subjected to immunohistochemistry with polyclonal antibodies to human ucn- ( : sigma) by abc system. intensity of ucn- immunostaining in smooth muscle layers and myenteric neurons were quantified by image-pro plus software and expressed (intensity/area) in arbitrary units (au). differences over time were assessed with anova. in all groups very preterm was significantly greater than term (p< . ). conclusion: ucn- immunoreactivity in all three muscle layers, as well as myenteric and submucosal neurons, is highest at very preterm as compared to more mature gestations. these results suggest that the reduction of ucn- inhibitory function may facilitate stress-induced meconium passage at term. to evaluate the effect on blood pressure (bp), urinary output (uop), sodium excretion (nae) and gfr of the intrarenal infusion of ang ii in the male sheep after prenatal exposure to b. methods: we studied male sheep which had received either b (n= ) or vehicle (n= ) at - days gestation. catheters were placed in the femoral artery and vein, left renal artery and in the bladder. a right side nephrectomy was performed. after days of recovery, the sheep were infused with ang ii ( ng/kg/min) with or without candesartan ( ng/kg/day) or pd (pd g loading dose and ng/kg/min infusion) into the renal artery over hours. bp, gfr, uop and nae were measured before and after the infusion. two-way analysis of variance was used to test mean values between the groups. results: bp and uop did not change with ang ii infusion with or without candesartan. the infusion of pd did not affect uop but did increase bp in the b sheep (p= . ). ang ii decreased the nae in both groups(p= . ). candesartan increased nae among controls(controls . and b . meq/kg/h, p= . ). pd infusion decreased nae among controls but this was not significant. baseline gfr was higher among vehicle compared to b animals (p= . ). during ang ii infusion there was a decrease in gfr among control compared to b sheep (- . vs. - . ml/min, p= . ). this difference was not seen during candesartan or pd infusion. conclusion: ang ii infusion led to a decrease in nae in both groups and gfr among controls but not b animals. infusion of ang ii with candesartan increased nae while pd decreased nae among controls but not b animals. this suggests that prenatal steroid exposure can alter at receptor mediated response in renal function by decreasing the effect of ang ii on renal sodium excretion. the differences in gfr suggest that this may be due to an effect on tubular sodium reabsorption rather than glomerular perfusion. antalarmin antagonism of acth-induced cortisol secretion by ovine adrenal cells probably not at acth receptor. nancy k valego, james c rose. center of research for ob/gyn, wake forest u. school of medicine, winston-salem, nc, usa. in addition to regulating the hpa axis, crh and its type receptor (crhr- ) occur peripherally and in the female reproductive system. late in human pregnancy, a surge in placental crh probably stimulates adrenal secretion of cortisol and dheas requisite to parturition. we previously reported that, in dispersed fetal or adult ovine adrenal cortical cells, hour incubation with the specific crh-r antagonist, antalarmin (ant), significantly reduced both cyclicamp and cortisol responses to acth, suggesting an interaction with acth-r (like crh-r , a g-protein-coupled membrane receptor). however, forskolin (fsk; direct stimulant of adenylyl cyclase)-stimulated cortisol secretion was also attenuated by hour co-incubation with ant. our objective was to clarify the effect of ant on binding of acth to its receptor after a short ( . hours) treatment. method: acth binding: the adrenals from adult sheep were obtained at necropsy and the cortex cells dispersed and plated @ cells/well. after hours in culture, wells were rinsed x and refilled with serum-free dmem/ f containing vehicle (dmso) with or without ant. after . hours, wells were washed very gently and the binding assay (adapted from rainey et al; j biol chem, : , ) completed. triplicate vehicle or ant wells were treated with i -tyrosine human acth ( - ) with or without - m acth (for non-specific binding). after hour, wells were chilled, washed, and the cells lysed and counted on a gamma counter. fsk treatment: cells were treated as above except that fsk ( - m) was added to the wells. after . hours, medium was removed and stored @ - ºc for camp eia and cortisol ria. results (mean±se) of . hour incubation on acth binding and fskinduced secretion. vehicle antalarmin acth binding (net cpm) n= ± ± cortisol (ng/ml/ . hr) n= ± ± * (p=. ) camp (pmol/ml/ . hr) n= . ± . . ± . * (p=. ) * indicates significant difference from vehicle alone. conclusion: the crh-r antagonist, antalarmin, attenuates acthstimulated cortisol secretion but not by preventing acth receptor binding. however, its effect is early in the secretory process and is associated with a reduced camp response. objective glucocorticoids are often administered to pregnant women to prevent neonatal respiratory distress syndrome. prenatal steroid treatment increases blood pressure in adult sheep. exposure to excess corticosteroids before birth is hypothesized to be a key mechanism underlying the fetal origins of adult disease hypothesis and effects on the renin-angiotension system (ras) may modulate the steroid-induced increases in blood pressure. we therefore sought to determine if renin processing and secretion were altered in adult female sheep exposed antenatally to betamethasone ( ) and to compare them with data from males studied previously. methods pregnant sheep were randomized to receive doses of . mg/kg of or vehicle, at and days of gestation; the offspring were studied at and months of age. in female offspring, active renin concentration (arc) and total renin concentration in plasma were measured by ria of angiotensin i generated by incubation with excess substrate. prorenin concentration (prc) is the difference between total and active renin. nine or control exposed female animals born at term ( - days of gestation) were brought from the farm at - months of age, and had vascular and bladder catheters placed. five days after surgery, a sodium load of hypertonic nacl ( . meq/kg/min at . ml/min) was given for min. blood samples were obtained. data are expressed as mean sem and were analyzed by t test. the prc was significantly higher in the females than in the males ( . ± . vs . ± . p< . ) but there was no effect of prenatal steroid treatment. arc was similar in both genders. however, arc was a significantly greater percent of the total plasma renin concentration in the males ( . ± . vs . ± . p< . ) during the na infusion experiment, the exposed females had lower arc than did the control females ( . ± . vs . ± . p< . ). conclusion the data suggest that prenatal exposure to didn't alter the processing and secretion of renin in adult female sheep. prenatal steroid treatment does not appear to alter the effect of gender on plasma renin levels in adult sheep.it seems unlikely that the elevated blood pressure seen in adult ewes after prenatal exposure is the result of increased secretion or processing of renin. supported by hd and hd . background: mrap is a recently discovered protein with alpha and beta isoforms, a common amino terminal region and divergent c-terminal sequences generated by alternative splicing. in human and mouse mrap plays an essential role in the generation of a functional, g-protein coupled acth receptor (melanocortin- receptor; mc r) but has not been described for ruminants. we previously reported that lth fetal sheep exhibited elevated basal acth - yet decreased expression of key steroidogenic enzymes and the mc r in the adrenal cortex while basal cortisol levels were not different from control. we hypothesized that mrap could play a key role in mediating the effect of lth as well as developmental regulation of fetal adrenal cortisol synthesis in fetal sheep. the goals of the present study were to determine the ontogenic pattern of mrap expression in the sheep fetus and to determine if lth alters mrap expression. methods: we searched the bovine genomic sequence database (www.ncbi.nlm. nih.gov/genome/guide/cow/) and found a sequence with > % homology to the human mrap n-terminal residues, with partial homology to the beta isoform in the carboxyl region ( %). using primers based on the bovine sequence, we confirmed the presence of mrap in the ovine fetal adrenal cortex. adrenal cortical tissue was collected from sheep fetuses from - (n= ) and near term ( - ; n= ) days of gestation (dg) as well as from lth (n= ) fetuses (exposed to high altitude hypoxia from to - dg) and age-matched normoxic controls (n= ). cyclophilin was used as a housekeeping mrna. data are expressed in fg mrna/ ng total rna. results: the expression of mrap, based on quantitative rt-pcr, was low between - dg ( . ± . ) and increased (p< . ) approx. -fold near term ( - dg; . ± . ). levels of mrna for mrap were highly correlated to cyp mrna in individual samples. mrap expression in control ( . ± . ) and lth ( . ± . ) did not differ between groups. gender differences in hypertension are well described and there is growing evidence that the regulation of the renin angiotensin system (ras) is influenced by sex hormones. the major enzymes of the ras include angiotensin converting enzyme (ace), angiotensin converting enzyme (ace ), and neprilysin. the peptide products of these enzymes have opposing actions. angiotensin ii (ang ii), the product of ace, is a potent vasoconstrictor. on the other hand, the peptide products of ace and neprilysin, ang ( - ) and ang ( - ), exhibit vasodilatory properties. thus, modifications in the relative proportions of these enzymes and their peptide products can result in alterations of systemic blood pressure. the purpose of this study was to describe the gender differences in angiotensin converting enzyme (ace), angiotensin converting enzyme (ace ), and neprilysin (nep) enzyme activities in adult sheep kidney cortex. renal cortex from male (n= ) and female (n= ) sheep were harvested at - months of age. the tissue membranes were solubilized and incubated at °c with either i-ang i or i-ang ii in the presence or absence of lisinopril to inhibit ace activity, mln to inhibit ace activity, or sch to inhibit neprilysin activity. the metabolic products were then separated by reverse-phase high performance liquid chromatography (rp-hplc). the rate of enzyme activity was then quantified by calculating the area under the curve for each product and converted to fmol of product per mg protein per minute of incubation. statistical analysis was performed using student's t-test. p< . was considered significant. results ace activity was over times greater ( ± . vs. . ± . fmol/mg/min, p< . ), ace activity was . times greater ( ± . vs. . ± . fmol/mg/min, p= . ) and nep activity was nearly times greater ( . ± . vs. . ± . fmol/mg/min, p= . ) in female kidney cortex. in adult sheep, key enzymes of the intrarenal ras have signficantly greater activity in female kidney cortex. these findings suggest that there are fundamental, gender specific, differences in the regulation of the enzymes of the intrarenal ras. the physiologic significance of these findings remain to be elucidated. hd , hd . in rats and sheep exposure to glucocorticoids (gc) in the perinatal period is associated with a reduction in nephron number and hypertension in adult life. furthermore, antenatal exposure to gc alters glucose tolerance in animals and in people. the aim of the present study was to determine ) if insulin resistance is a contributing factor for the development of hypertension in adult sheep exposed antenatally to gc and ) if diet-induced obesity has a more pronounced effect in sheep exposed antenatally to gc. methods: pregnant sheep were treated with two im doses of betamethasone (bm, . mg/kg) or vehicle (ctr) -hours apart at days gestational age and allowed to deliver at term. at mo of age, female sheep were randomly allocated to be fed at either % of recommended nutritional allowance or ad libitum for three months. sheep were chronically instrumented under general anesthesia to place intravascular catheters. insulin sensitivity was evaluated both by iv glucose tolerance test (ivgtt) and euglycemic clamp (hec)techniques. for the ivgtt a . g/kg glucose bolus was used and for the hec mu/kg human insulin was used. data mean±sem were analyzed by anova and/or two sample t test. results: ad lib fed sheep gain > % of the original weight. antenatal bm was associated with an elevation in basal and ivgtt plasma insulin values. as shown on the figure, diet-induced obesity significantly increased insulin plasma levels during ivgtt in bm-exposed adult female sheep (f= . ;p< . ). insulin sensitivity derived from hec was significantly decreased by obesity in bm-exposed adult female sheep. conclusion: our data show that prenatal exposure to a single course of gc at . gestation has long-term effects on glucose metabolism regulation. bm-exposed sheep exhibit alterations in glucose tolerance, hyperinsulinemia and insulin resistance. these abnormalities are exagertated by diet-induced obesity. hl . syngergistic induction of -hydroxysteroid deyhdrogenase type expression by cortisol and interleukin- in human fetal lung fibroblasts. z yang, p zhu, cm guo, l myatt, k sun. school of life sciences, fudan university, shanghai, china; obstetrics and gynecology, university of cincinnati, cincinnati, oh, usa. objectives: glucocorticoids acting via glucocorticoid receptor (gr), serve as crucial hormones in fetal lung maturation. glucocorticoids and proinflammatory cytokines to induce b-hydroxysteroid dehydrogenase type ( b-hsd ) which converts inactive cortisone to active cortisol, but their effect on b-hsd expression has not been addressed in human fetal lung. we examined the interactions and mechanism of cortisol and interleukin- b (il- b) effect on b-hsd in human fetal lung fibroblasts (hfl- cells). methods: the expression of b-hsd in hfl- was examined with immunocytochemistry and pcr. b-hsd , prostaglandin h synthase- (pghs- ) and cytosolic phospholipase a a (cpla ) mrna levels in cultured human fetal lung fibroblasts treated with cortisol and il- b were measured with real time pcr. the roles of gr and c/ebps in the effect of cortisol and il- b were studied using a gr antagonist (ru ) and transfection of plasmid carrying c/ebp-specific dominant-negative gene (cmv -a/cebp). results: hfl- cells expressed a high level of b-hsd . both cortisol ( - - - m) and il- b ( . - ng/ml) induced b-hsd mrna expression in a concentration-dependent manner, an effect blocked by the mrna transcription inhibitor , -dichlorobenzimidazole riboside ( μm). ru ( - m) blocked the induction of b-hsd by cortisol. induction of b-hsd mrna expression by cortisol ( - m) was synergistically increased by co-treatment with il- b ( . - ng/ml) in a concentration-dependent manner. in contrast, the induction of cpla and pghs- expression by il- b was inhibited by cortisol, suggesting a different mechanism of interaction. transfection of the cells with c/ebp-specific dominant-negative plasmid attenuated induction of b-hsd mrna expression by either cortisol or il- b. these data suggest induction of b-hsd expression by cortisol is a gr dependent process involving c/ebps, which also mediate induction of b-hsd expression by il- b. conclusions: cortisol and il- b synergistically induce b-hsd expression in human fetal lung fibroblasts. this would lead to greater local cortisol production, perhaps providing either a self-attenuating mechanism for control of inflammation or a mechanism for enhancing fetal lung maturation when the fetus is exposed to cytokines e.g. with infection-induced preterm labor. do alterations in placental -hydroxysteroid dehydrogenase ( hsd) activities explain differences in fetal hypothalamic pituitary adrenal function following periconceptional undernutrition or twinning in sheep? kl connor, pl van zijl, cw rumball, , al jaquiery, , je harding, , mh oliver, , fh bloomfield, , jrg challis. medicine, university of toronto. periconceptional undernutrition (pcun) leads to activation of fetal hypothalamic pituitary adrenal (hpa) function, whereas twinning results in delayed fetal hpa activation. we hypothesized that these differences in fetal hpa activity were the result of altered patterns of expression of placental of hsd isozymes and hence of the maternal glucocorticoid (gc) effect on the fetus. we developed a mass spectrometric assay for the measurement of hsd- and - activities and validated this method against a widely used thin layer chromatography method. sheep were randomly assigned to ad libitum (n control) concentrates throughout gestation or were undernourished (un) from days before until days after mating to reduce maternal body weight by %, with ad libitum feeding thereafter. placentomes were collected on days , , , and of gestation (term, d) and hsd- and - activities were determined by measuring the rate of interconversion between cortisone to cortisol. with un, there was a trend towards lower hsd- activity at d (p= . ), a significant reduction at d (p< . ), but no difference at d or d . hsd- activity was not different between n and un animals at any time. there was no effect of twinning on hsd- or - at d . however, with twins both hsd- (p= . ) and - (p< . ) activities increased at d . hsd- activity was reduced in twins (p= . ) at d but was higher than any singleton pregnancies at d (p= . ). hsd- was not different between singletons and twins at either d or d . overall, hsd- was lower in placentae of male compared to female fetuses in late gestation; hsd- was higher in male than female fetuses. there was no interaction with un in either sex. we conclude that pcun and twinning result in alterations of placental hsd activities in sheep. modifications in these enzymes during critical periods of fetal development may affect transplacental transfer or placental generation of gcs reaching the fetus potentially influencing the timing of activation of the fetal hpa axis, fetal maturation and later life development. methods: pregnant sprague-dawley rats had % mfr from day of gestation until delivery. control animals had ad libitum food. offspring were sacrificed on day of life (p ) and at months (n= - per group). adrenals were dissected and snap frozen in liquid nitrogen for later extraction of rna. real time rt-pcr using specific rat primers was used to quantify mrna levels ( s as control). we evaluated the expression of -beta hydroxylase (cyp b ), aldosterone synthase (cyp b ), acth receptor (mcr ), p side chain cleavage enzyme (cyp a ), star protein, -hydroxysteroid dehydrogenase type (hsd ) and type (hsd ), glucocorticoid receptor (gr), and mineralocorticoid receptor (nr c ). fold changes in mrna expression in controls and mfr offspring was compared by student's t-test. results: there was a marked downregulation in expression of cyp b (p=. ), cyp b (p=. ), hsd (p=. ), p (p=. ), acth receptor (p=. ), star (p=. ) and nr c (p=. ) mrna in p mfr offspring, with no changes in hsd and gr. gender specific differences were found in the adult mfr offspring. in the male mfr offspring the expression of hsd and gr were significantly upregulated with a trend towards an increase in acth receptor (p=. ) whereas in the female mfr the expression of acth receptor (p=. ) was increased and nr c (p=. ) and cyp b were decreased (p=. ). in combined data for adult male and female offspring the expression of acth receptor was significantly (p=. ) increased. conclusion: these results indicate that mfr has a suppressive effect on steroidogenic enzymes of the newborn offspring regardless of gender. this may be an adaptive mechanism in the fetus/newborn to offset the high circulating maternal glucocorticoids in response to undernutrition. in adult male mfr offspring, increased hsd indicates an increase in gc synthesis whereas in the females there were no changes in gc synthesizing enzymes with a suppression of mc synthesizing pathway. the common finding of an increased acth receptor expression in both genders would suggest an increased sensitivity of adult mfr offspring adrenals to the effects of stress. objective: during gestation the fetal adrenal undergoes phases of active growth ( - d), quiescence ( - d) followed by reactivation (> d) before birth. insulin like growth factors play an important role in stimulating adrenal growth throughout late gestation. interestingly the prepartum activation of the adrenal is delayed in the female compared with the male fetus, but the mechanisms underlying this delay are unknown. hypothesis: we hypothesize that there are gender specific differences in the gestational profile of adrenal igf mrna expression between male and female fetuses. methods: a total of twin fetuses were used in this study. post mortem was performed at either - d, - d or - d gestation. adrenal mrna expression of igf , igf , igf r, igf r and cyp was determined by qrt-pcr. results: fetal weight was not different between males and females, and increased (p< . ) with increasing gestational age. the relative adrenal weight was lower however after d when compared to the earlier gestation age group (p< . ). adrenal igf mrna expression was lower (p< . ) at - d when compared to the earlier gestation age groups. interestingly, igf r expression was highest at - d (p< . ). there was an interaction between the effects of age and gender on adrenal igf and igf r mrna expression such that the expression was higher in males compared to females at - d (p< . ), but was not different to either the earlier or later gestational ages. there was no effect of either gender or gestational age on adrenal cyp mrna expression. conclusions: it has been speculated that a delay in prepartum activation of the adrenal in female fetuses may be due to gender specific differences in the intra-adrenal bioavailability of igf . in this study we have demonstrated there is an increase in both igf and igf r mrna expression in males compared to female fetuses. this may be evidence that adrenal igf expression plays a role in the earlier activation of the adrenal gland in male fetuses. we have previously shown that in response to a secondary stressor, in vivo cortisol secretion is elevated in long term hypoxic (lth) ovine fetus despite lower acth receptor mrna expression, and no differences in plasma adrenocorticotropic hormone (acth) levels when compared to normoxic controls. the present study was designed to determine the potential mechanism(s) of this enhanced cortisol secretion. specifically we tested the hypothesis that post receptor signaling events including camp production and expression of steroidogenic acute regulatory protein (star) are enhanced following lth. methods: for the lth group, pregnant sheep were maintained at high altitude ( , m) from day to near term. on days - (term = days), fetal adrenal glands were collected from lth (n= ) and age-matched, normoxic signal transduction pathways that control embryogenesis, cell differentiation, cell proliferation and cell death. the roles of extracellular signal-regulated kinase / (erk / ) and p map kinase in the differentiation and invasion of human trophoblasts have been studied. however, the in vivo expression and activation of erk / and p at the placental bed has not been elucidated. the study group consisted of placental bed biopsy tissues obtained from the pregnancies without preeclampsia (n= ) and with preeclampsia (n= ) between and weeks of gestation. we evaluated the expressions and phosphorylations of erk / and p map kinase in the invasive trophoblasts in the placental bed tissues using immunohistochemistry. results: p and phospho-p map kinase were not detected in invasive trophoblasts in cases or controls. erk / and phospho-erk / were positive in invasive trophoblasts albeit with variable staining. phosphorylation of erk / was significantly less frequent in invasive trophoblasts in placental bed biopsies from women with preeclampsia compared with normotensive controls. conclusion: these findings suggest that preeclampsia is associated with decreased activation of erk / in invasive trophoblasts in vivo. objective: placentae from preeclamptic pregnancies are characterized by an excess of immature hyperproliferative trophoblast cells, however the molecular mechanisms regulating cell cycle progression in this pathology are unclear. our aim was to examine the expression of g phase cell cycle regulators in normal and preeclamptic placentae and to establish whether the hyperproliferative state of trophoblast cells in preeclampsia may result from a developmental delay. methods: human placental samples were collected from normal pregnancies throughout gestation (n= ) and from severe early onset preeclamptic (n= ), and age-matched control placentae (n= ). protein expression of cyclin e , cyclin d , cyclin d and cell cycle inhibitors, p , p , p , and p was assessed by western blot analysis. spatial and temporal localization of cyclins e , d , d , p and p was determined by fluorescence immunohistochemistry. expression of cyclin e and cyclin d mrna was evaluated by qpcr analysis. results: immunohistochemical analysis showed cyclin e and cyclin d to be localized to cytotrophoblast (ct) cells of the chorionic villi; additionally cyclin e was also expressed in the extravillous trophoblast cells of the anchoring columns. in contrast, cyclin d expression was predominantly restricted to the villous stroma. cell cycle inhibitor p was expressed in both ct and syncytiotrophoblast (st) cells whereas p was restricted to the st. during normal placentation, levels of both cyclin e and cyclin d were high in the first trimester and decreased with advancing gestation. the expression of cyclin d , p and p showed an inverse correlation to cyclins e and d whereby their expression increased towards term. levels of p and p remained constant throughout pregnancy. preeclamptic placentae showed a significant increase in both cyclin e and p and a decrease cyclin d and p expression, as compared to age-matched control tissues. interestingly, preeclampsia was associated with an increased number of cyclin e positive progenitor ct cells in the floating villi and an increased expression of p in the endothelial cells lining the villous vessels. conclusion: preeclampsia displays an altered expression of g phase cell cycle regulatory molecules portraying an expression profile that closely resembles that of first trimester placentae. (supported by cihr, owh/igh). we have also demonstrated elevated, hif- -mediated placental and circulating sflt- at high altitude. we sought to correlate circulating levels of plgf, free vegf and sflt- with maternal and fetal oxygen tensions. we hypothesized that circulating sflt- and free vegf would be increased at m, and that plgf, known to be up-regulated by higher oxygen tension, would be decreased. methods: we collected both serum and plasma samples, the latter treated with inhibitors of platelet activation. maternal and umbilical samples were obtained from and healthy mother-infant pairs living at m and m respectively. plgf, free vegf and sflt- were measured in both serum and plasma using commercially available elisa kits (r d). data were log-transformed and analyzed by unpaired student's t test or anova as appropriate. results: plgf did not differ between altitudes. free vegf ( ± pg/ml vs. ± pg/ml, p<. ) and sflt- ( . ± . vs. . ± . ng/ml) were increased at m. however concentrations of all the angiogenic growth factors were reduced when platelet activation was prevented (- ± % plgf; - ± % free vegf; - ± % sflt- , p<. ). cord blood free vegf was -fold greater than in the mothers, but inhibition of peripheral cell activation abolished detectable levels in % of the babies. similar results were obtained for sflt- . thus, while free and total maternal circulating vegf and sflt- are elevated at high altitude, these increases are due to activation of peripheral blood cells. moreover, free vegf does not exist in detectable amounts in human pregnancy. there was no relationship between variation in the angiogenic growth factors and maternal or fetal oxygen tensions. the objective of this study is to identify candidate genes responsible for the variance between severe preeclampsia (spe) and hellp syndrome (hs). placental biopsies from spe (n= ) and hs (n= ) were collected. diagnosis of spe was confirmed by blood pressure and protein criteria. hs was diagnosed in preeclamptic patients who developed characteristic laboratory abnormalities. placental tissues were embedded in oct for sectioning, h e staining and rna isolation (invitrogen, carlsbad). gene expression data was obtained by hybridizing fluorescently labeled reverse transcription products to spotted cdna microarrays. the microarrays were produced by the laboratory of microarray technology at the van andel institute (grand rapids, mi) using a custom microarrayer. microarrays were scanned using an agilent g b scanner. images were analyzed using genepix . (axon). limmagui was used to generate lists of discriminating genes for these data, while david provided functional annotations. there were differentially expressed genes between spe and hs (p<. ). among these candidate genes, were up-regulated and were downregulated. the most up-regulated genes are ( )-deoxyribonucleotidase (dnt- ), superoxide dismutase , hydroxy-delta- -steroid dehydrogenase, caspase , and general transcription factor iih. further analysis of functional groups revealed the most enriched gene categories are related to cellular energy (mitochondria), cell cycle regulation, and protein metabolism. the underlying role of the placenta in the development of hs is currently unknown. this study shows that there is a relatively mdest number of genes that are differentially expressed between hs versus spe placentals. thes data provide the molecular context for placental changes seen in this variant of preeclampsia and provides an opportunity to study the role of the effected genes in disease variance. ( ), severe preeclampsia ( ), hellp syndrome ( ) and eclampsia ( ) and control group ( patients) uncomplicated pregnancies. total rna was isolated and reversely transcribed to c-dna. the mrna level of tert was detected with a probe-specific real-time quantitative pcr assay using ß-actin as the reference gene. crossing point (cp) values were obtained during the pcr amplification and the relative expression level of htert equals to (cp htert -cp ß-actin) . statistical analysis was performed using the student's t test. immunohistochemistry (ihc) staining was employed to localize htert protein on placenta tissue sections using abc method, incubation with rabbit anti-htert antibody followed by application of a goat anti-rabbit antibody with results evaluation using microscope. objective tgf s are involved in the regulation of trophoblast differentiation and invasion, and we have previously reported that tgf- is over expressed in pre-eclamptic placentae. tgf s signal via a receptor complex composed of type ii (t r-ii) and type i (t r-i) receptor. to date, seven type i receptors, designated as activin receptor-like kinase (alk - ) have been identified. our aim was to investigate the expression pattern of alk and alk receptors, known to exert tgf signaling, in preeclamptic and iugr placentae. methods human placental tissue throughout gestation was used in order to determine the development profile of the receptors. in addition, placental tissue from preeclamptic and iugr pregnancies and from age matched controls was collected. all iugr pregnancies were characterized by absence of end diastolic velocity in the umbilical artery and had no evidence of preeclampsia. expression of alk and alk mrna was measured by real-time pcr analysis, and protein by western blot analysis using alk and alk antibodies. immunoblot analysis demonstrated a unique developmental profile whereby alk expression increased with advancing gestation. in preeclamptic placentae alk expression was significantly increased compared to preterm and term controls, whereas alk expression was significantly decreased. preeclamptic placentae also exhibited decreased phosphorylation of smad , a tgf signaling molecule, which is activated by alk and increased phosphorylation of smad , which is triggered by alk . the expression of alk and alk in iugr placentae differed from that of preeclampsia as both alk and alk mrna levels were significantly increased in iugr compared to preterm and term controls. however, only alk expression was significantly increased in iugr placentae at the protein level, while no differences in alk protein levels were noted between iugr and controls. conclusions imbalance between alk and alk signaling pathways might play a role in the pathogenesis of preeclampsia and iugr. as tgf signaling via either alk or alk has been found to differentially regulate vasculogenesis, changes in these signaling pathways may contribute to the altered vasculogenesis found in these pregnancy-related disorders. (supported by cihr and owh/igh). ( ), severe preeclampsia ( ), hellp syndrome ( ) and eclampsia ( ) and patients, the control group who had uncomplicated pregnancies. total protein was isolated from placental tissue. gadd a and its downstream signal proteins--phospo-p , phospho-mkk /mkk were assessed by western blot. immunohistochemistry (ihc) staining was employed to localize the expression of gadd a and sflt- proteins in placenta tissue sections using abc method. huvec cells were cultured to - % confluence and were divided into groups: control, stress induction (sorbitol, . m, h), p inhibition (sb- , ug/ml, ug/ml and ug/ml, hour) + sorbitol ( . m, h). total protein was isolated from cells and the supernatant of huvec was collected. western blot was processed to detect the induction of gadd a and phospho-p . supernatant sflt- was measured with an eia kit and the results were read at nm wavelength. results: gadd a protein was elevated in the preeclamptic placentas with its downstream proteins (mkk and p ) activation compared with control. overexpression of gadd a and sflt- in preeclamptic placentas was observed with ihc staining. in huvec cells, gadd a was induced by sorbitol, triggering the activation of the downstream p- pathway and the accumulation of sflt- in the supernatant. the up-regulation of sflt- secretion by inducing gadd a was depleted when treated with p- inhibitor. conclusions: our study reveals that gadd a and its down stream p- pathway were activated in preeclamptic placentas and this stress inducible signal pathway regulates the secretion of sflt- , which is a key player in preeclampsia. it provides novel evidence that links placental stress to sflt- secretion via the gadd . trophoblast adipose triglyceride lipase (atgl) expression is upregulated in preeclampsia. beth a plunkett, jennifer a doll, emily j su, serdar e bulun, mona cornwell, susan e crawford. obstetrics and gynecology, northwestern university, chicago, il, usa; pathology, northwestern university, chicago, il, usa. objective: preeclampsia is characterized by placental endothelial cell dysfunction and elevated maternal triglyceridemia (tg). tg traverse the placenta in a process of uptake followed by lipolysis with subsequent release of fatty acids to the fetus. although three placental lipases (hormone sensitive lipase, endothelial lipase and lipoprotein lipase) have been identified, they do not account for all lipolytic activity. here, we introduce a new lipase, adipose triglyceride lipase (atgl), which is responsible for the hydrolysis of triglycerides to diglycerides in adipocytes and was recently identified as a receptor for endothelial cell modulator pigment epithelium-derived factor. the purpose of this study is to determine if expression of atgl, a potential modulator of both lipid metabolism and vasculature, is upregulated in preeclampsia. methods: immunohistochemical studies were performed on placental tissues from normal pregnancies (n= ) and those complicated by severe preeclampsia (n= ) with anti-atgl antibodies. the degree of positivity in the trophoblasts and endothelial cell was scored ( =none, =spotty, light, =consistent, dark). to determine if atgl is a product of placental endothelial cells (plec), microvascular cells were isolated from normal placental tissue. purity of the sample was confirmed using flowcytometry (> / positivity for factor antigen). atgl was detected immunohistochemically and via western blot using anti-atgl antibodies. results: mean atgl expression in preeclamptic trophoblast was significantly higher than normal placentas ( . + standard deviation versus . + . , p = . ). endothelial expression was not significantly different in preeclamptic ( . + . ) versus normal placentas ( . + . , p> . ). atgl stained intensely and demonstrated a beaded pattern in the endothelial cells, suggestive of a lipid droplet pattern. immunohistochemistry of plec and western blot analysis of cell lysates revealed strong immunopositivity for atgl, although at a smaller size than anticipated. conclusion: these findings demonstrate that a novel lipase, atgl, is produced by trophoblasts and is upregulated in severe preeclampsia. plec express high levels of atgl, suggesting that atgl could prove to be important in the vascular dysfunction and lipid abnormalities characteristic of preeclampsia. increased endothelial chymotrypsin-like protease (chymase) expression is responsible for endothelial activation in preeclampsia. yuping wang, yang gu, yanping zhang, david f lewis. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: endothelial (ec) activation is an important component of inflammatory phenotypic changes in preeclampsia (pe). our previous study showed enhanced chymotrypsin-like protease (clp)/chymase expression in the maternal vessel endothelium in women with pe. in this study, specific effect of placental-derived clp on ec activation was examined. methods: human uterine microvascular endothelial cells (utmvecs) were used. placental conditioned medium (cm) was prepared by culturing villous explants from normal and pe placentas. confluent utmvecs were treated with placental cm with or without depletion of chymotrypsin. ec adhesion molecule expressions for icam, vcam, p-selectin and e-selectin were determined by a colorimetric assay at od nm. depletion of chymotrypsin from cm was performed by immunoprecipitation. to further determine if activation of endogenous clp/chymase in ecs is responsible for up-regulation of p-selectin and e-selectin expression, chymase sirna was applied to ec culture before the cells were treated with normal or pe cm and then ec adhesion molecule expressions were examined. data was expressed as mean ± se and analyzed by anova. a p level < . was set for statistically different. results: ) expressions of vcam, p-selectin and e-selectin, but not icam, were significantly increased in pe-cm treated utmvecs compared to those of normal-cm treated cells and untreated controls, p< . ; ) there was no difference for adhesion molecule expression in utmvecs between normal-cm treated with untreated controls; ) utmvecs transfected with chymase sirna significantly reduced p-selectin and e-selectin expressions when exposed to pe-cm, p< . . conclusion: placental-derived clp/chymase is responsible for activating ecs and inducing ec adhesion molecule expression. activation of ec chymase may be directly related to the inflammatory phenotypic changes that occur in ecs in pe. (supported nih grants hd and hl ). corin is a transmembrane serine protease that is important in processing natriuretic peptides (nps) and maintaining normal blood pressure. genetically modified mice without corin function develop a syndrome during pregnancy similar to preeclampsia. corin is present in the pregnant uterus and a deficiency in the enzyme may lead to hypertension and preeclampsia. we tested the hypothesis that corin expression was increased in human myometrium from women with preeclampsia. methods: myometrium was obtained from groups of women at the time of primary cesarean section: (i) preterm no labor with preeclampsia (n= , ptspe, . weeks); (ii) preterm labor (n= , ptl, . weeks); (iv) term no labor (n= , tnl, . weeks); (v) term labor (n= , tl, . weeks). microarray gene profiling was performed using affymetrix human genome u plus . arrays. women who were not in active labor at the time of delivery (tnl) served as the control group. conventional and real time pcr was performed to verify corin expression in the arrays was directionally accurate. corin protein expression was examined by western blot. results: compared to tnl control, corin levels decreased nearly -fold in myometrium from women in term labor (tl). there was a small increase in corin gene expression of preeclamptic women (ptspe) and little-to-no change in myometrium from women in preterm labor (ptl). these results were confirmed by pcr analysis. conclusion: blood volume surges during pregnancy, increasing the potential for hypertension and preeclampsia in the mother. the corin-np control system could contribute to this condition. however, there are no reports on corin message or protein levels in women with preeclampsia. our preliminary results suggest that preeclampsia is not a consequence of a corin deficiency (decreased corin preeclampsia). acknowlegement: supported by grants from the phs (r hl - , cpw) and cdc grant (u dp - , cpw). the expression of gp at implantation site: implication for the pathogenesis of preeclampsia. objective: gp is a common shard signal transducing subunit of the il- cytokine family which is critical for implantation, and viewed as marker of endometrial blastocyst receptivity. preeclampsia (pe) is highly related to the restricted trophoblast invasion, which leads to impaired spiral artery remodeling. our hypothesis was that the poor placentation of pe is associated with the altered expression of gp at the implantation site. methods: human decidua from patients with pe and uncomplicated term deliveries (n = , respectively) were immunostained for gp . the intensity and distribution of immunostaining on decidual cells and extravillous traphoblasts were evaluated with hscore. statistical analysis of the data was performed using student's t-test and kruskal-wallis one way anova on ranks followed by post hoc test. results: immunostaining of gp was significantly higher in decidual cells of patients with pe compared with normal specimens, with hscore (median, [interquartile range]) value [ . - . ] and , respectively (p< . ). in pe specimen, the hscore of decidual cells was also significantly higher than that of trophoblast ( [ - ]; p< . ). there were no difference in the comparison of hscore of trophoblasts between the pe and normal specimens, and in normal specimens between decidal cells and trophoblasts. conclusions: the increase of gp expression in the decidual cells of preeclamptic placenta may be implied to the pathogenesis of poor placentation in preeclampsia. we have previously demonstrated that decidual cells are the major source of renin at the human uteroplacental interface, but little is known regarding the human decidual renin expression in hypoxic conditions. therefore, the present study was undertaken to determine the effect of hypoxia on renin secretion by human decidual cells in vitro. methods: full-term normal human placentas were obtained within one hour of vaginal deliveries or cesarean sections. decidual cells were isolated from the decidua parietalis. after an initial culture for days in a serum-containing medium, the decidual cells were exposed to normoxia or hypoxia ( % or % oxygen) in a serum-free medium for hours. the culture supernatants were then harvested and subject to western blot analyses of renin protein contents. a dominant band of renin at approximately kd was detected in all samples. when compared with the cells cultured in the normoxic condition, the cells cultured in both hypoxic conditions (i.e. % and % oxygen) had significantly lower renin protein contents in their culture supernatants. conclusion: our data for the first time show that hypoxia down-regulates renin secretion in human decidua, suggesting a link between the uteroplacental ras and oxygen tension during human gestation. the effect of nucleated fetal red blood cells derived from preeclamptic patients on endothelial progenitor cell proliferation. keiichi matsubara, emiko abe, yuko matsubara, shinji hyodo, masaharu ito. obstetrics and gynecology, ehime university school of medicine, toon, ehime, japan. objectives inadequate uteroplacental circulation results in placental ischemia and the development of preeclampsia (pe). endothelial progenitor cells (epcs) are thought to be a key player in the fetal angiogenesis. vascular endothelial growth factor (vegf), which is up regulated in pe, is involved in epcs proliferation. recently, it was reported that fetal nucleated red blood cells (nrbcs) have the capability to generate vegf. we hypothesized that nrbcs could influence epcs proliferation in the placenta and may be involved in the pathogenesis of pe. material and methods mononuclear cells (mncs) were isolated from the umbilical venous blood of normal pregnant women and preeclamptic patients by density gradient centrifugation. mncs were incubated with anti-cd antibody conjugated with microbeads. nrbcs were collected using a mini macs separator. nrbcs were incubated for hours with or without angiotensin ii (ang ii) and erythropoietin (epo). vegf and placental growth factor (plgf) concentrations in the supernatant were measured using elisa. also, pbmcs without nrbcs were seeded in endothelial basal medium with or without nrbcs using a boyden chamber. these samples were incubated for days with or without ang ii and epo. the adherent cells were incubated with di-ldl, fixed with paraformaldehyde, and stained with fluorescein isothiocyanate-labeled lectin. di-ldl and lectin positive cells was considered to represent epcs and the number was measured using flowcytometry. the number of nrbcs derived from umbilical venous blood was significantly increased in pe. both ang ii and epo significantly increased vegf concentration in the supernatant of nrbcs derived from normal pregnant women. however, ang ii and epo did not influence the nrbcs' vegf production in pe patients. plgf was not detectable in the supernatant. the number of epcs in the umbilical venous blood was significantly decreased in pe and the number was not changed by nrbcs. on the other hand, the number of epcs was significantly decreased in the culture with nrbcs. epo significantly increased the number of epcs in pe at the lower concentration of epo compared with normal pregnant women. conclusions it appears that fetal nrbcs may inhibit fetal epcs proliferation in pe. since epo reduced the inhibitory reaction of nrbcs without vegf production epo may affect epcs proliferation independently of nrbcs. relationship between the hypoxia-inducible factor- (hif- ) and the receptor svegf-r /sflt- : implication for phatophysiology of preeclampsia. julio e valdivia-silva, , juan c gonzalez-altamirano, keisy lopez- the trophoblast invasion is critical for the establishment of the uteroplacental circulation. at early phases of this process local oxygen pressure in the placenta is lower, that pathologically in preeclampsia remain constant. because of this, is important to understand the response of placental cells against these stimuli. in the present work, we use primary cultures of trophoblast cells, fibroblasts of the villous, and human umbilical endothelial cells, isolated of preterm and term placentas (with and without preeclampsia), to explore the effect of the oxygen pressure in the expression and synthesis of vegf, svegfr- /sflt- , hif- and- . our results show that the low pressure of oxygen resulted in a significant increase of the mrna and the protein of the receptor svegf-r selectively in the cts. the vegf's expression and synthesis was raised in three cellular types, but the free protein (not bounded to svegf-r ) of the cts was diminished. on the other hand, the expression of the arnm of hif- or - in cells was comparable in all the types of placentas, nevertheless, the protein hif- was more increased in the cts of preeclamptic placentas. to evaluate the relation of hif- and the increase of the receptor svegfr- , we used sirna-hif . in response to the inhibition, the expression of the receptor svegf-r diminished dramatically. the blockade of hif- did not alter vegf's expression. our data are the first that propose that the protein of the factor of transcription hif- is one of the molecules involved in the selective expression of the receptor svegf-r in trophoblast cells during hypoxia. figure: reduction of the expression to soluble receptor flt- /svegfr- after transfection with sirna-hif in trophoblast cells. sirna= interference rna, lu=luciferase. luc-sirna was used as control. effects of estradiol on synthesis, secretion, and activation of von willebrand factor in endometrial endothelial cell. shumei zhao, chainarong choksuchat, michael s scholfield, todd d deutch, thomas d kimble, david f archer. obstetrics and gynecology, eastern virginia medical school, norfolk, va, usa. objectives: heavy menstrual bleeding (hmb) is a serious clinical condition affecting % of women. due to inefficient and ineffective medical interventions, women with hmb often elect endometrial ablation or hysterectomy to eliminate hmb symptoms. morbidity and loss of fertility linked to these surgical treatments support the search for more effective medical remedies. von willebrand factor (vwf), a principle initiator of blood clotting produced by endothelial cells. women with von willebrand disease (vwd), have a high incidence of hmb indicating poor clotting. these findings suggest vwf heavily impacts the amount of blood loss during menstruation. estrogen stops/reduces hmb and has been used to treat hmb in women with vwd, although the mechanism(s) is unknown. this proposal addresses the hypothesis that estradiol (e ) increases the synthesis and activation of vwf, promoting clotting. materials and methods: immortalized human endometrial endothelia cells (heecs) were used for the studies. to determine if e increases synthesis of vwf, we treated heecs with e at . μm, . μm and . μm for hours. vwf protein and mrna levels were determined by western blotting and real time pcr, respectively. to establish if e can convert vwf from an inactive to an active conformation, the release of activated vwf by cells into culture medium will be assessed by elisa. decreased adamts (a disintegrin and metalloproteinase with thrombospondin type motif) activity results in increased amounts of active vwf. rrelease of activated adamts will be determined by fret. to ascertain if e regulated vwf secretion is by genomic pathway, heecs will be exposed to the estrogen receptor antagonist ici , . elisa and fret will assess the release of active vwf and adamts , respectively. results: western blotting demonstrated e increases vwf mrna and protein levels in a dose-dependent manner in heecs.conclusion: the project will determine if e acts at the heecs to increase synthesis, secretion and activation of vwf. preliminary results show e increases intracellular vwf protein and mrna levels in heecs, supporting our hypothesis that e increases synthesis of vwf in heecs in vitro. if e increases activated vwf, it could reduce/stop hmb by increasing activated vwf, providing justification for a clinical trial of e to treat hmb. over-expression of vegf-d does not induce lymphangiogenesis in the mouse endometrium. peter a rogers, jacqui f donoghue, marc g achen, steven a stacker, jane e girling. obstetrics gynaecology, monash university, melbourne, victoria, australia; ludwig institute for cancer research, melbourne, victoria, australia. background: the human endometrial functionalis has reduced lymphatics compared to the basalis and myometrium . this study examines the distribution of lymphatics in mouse uterus and investigates if over-expression of the lymphangiogenic growth factor vascular endothelial growth factor-d (vegf-d) stimulates growth of new endometrial lymphatic vessels. methods: the distribution of uterine lymphatics was examined in c bl/ jxcba mice collected during the oestrus cycle, early pregnancy and following oestrogen and progesterone treatment. human ebna cells with/without stable transfection of vegf-d were injected into the uterine horn of nod/scid mice. uteri were collected after weeks. serial sections were immunostained with lyve- and/or vegfr (lymphatic endothelial cell markers), cd (blood endothelial cell marker), mab (human vegf-d), mab (human mitochondria) and pcna (proliferative cell nuclear antigen). results: lymphatic vessel profiles were mostly found in the connective tissue between the longitudinal and circular muscle layers of the myometrium. they were rare in the endometrium and only observed in % of the sections. when present in endometrium, lymphatic vessel profiles were usually situated adjacent to the endometrial/myometrial border. ebna tumours formed inside and outside the uterine horn of both the control (n= of ) and vegf-d group (n= of ). localization of ebna cells within the mouse uterus was confirmed by anti-human mitochondrial expression. vegf-d immunostaining confirmed that transfected ebna cells expressed vegf-d in vivo. over-expression of vegf-d did not stimulate endometrial lymphangiogenesis, although there was an increase in vessel diameter of lymphatics in the myometrium adjacent to tumours. initial analysis shows no significant effect of vegf-d ebna cells on endometrial blood vascular density or endothelial cell proliferation. conclusions: minimal lymphatics are present in the mouse endometrium, as is the case for lymphatic vessels in the human endometrial functionalis. the lack of endometrial lymphangiogenesis in response to vegf-d suggests the presence of an inhibitory factor limiting lymphatic growth in this tissue. in early pregnancy, decidual-derived vegf mediates angiogenesis and is required for implantation and placentation. the role of decidual vegf in later pregnancy is poorly understood. decidual hemorrhage (placental abruption) generates excess thrombin and is a major risk factor for pprom and preterm birth. this study compares immunohistochemical (ihc) localization of vegf in decidual tissue sections from term pregnancies complicated by abruption and gestational age-matched controls, and investigates the effect of thrombin on vegf expression by cultured human term decidual stromal cells (dscs). study design: ihc was performed on serial sections of term placental tissues (no labor) with (n= ) and without (n= ) abruption. purified term dscs were passaged until > % free of cd + cells by facs. confluent dscs were primed with - m estradiol (e ), - m medroxyprogesterone acetate (mpa), both, or vehicle for days. after h incubation in defined medium with corresponding steroids ± thrombin ( . - . iu/ml), conditioned supernatants were analyzed for vegf by elisa. extracted total rna was used to assess vegf mrna levels by quantitative rt-pcr using established primers. results: vegf expression was localized by ihc primarily to dscs in placental tissue sections, and was increased in tissues from placental abruption vs controls. in term dscs, thrombin increased vegf secretion in a dosedependent fashion irrespective of the hormonal milieu (eg, . -fold stimulation by . iu/ml thrombin from . ± . to . ± . pg/ml per mcg protein for e +mpa; p= . ). this effect was abrogated by the thrombin inactivator, hirudin. vegf mrna were similarly increased by thrombin with or without steroid hormones (eg, . -fold for e +mpa; p< . ). conclusions: placental abruption is associated with increased vegf expression in term decidual tissues in vivo with thrombin enhancing vegf mrna and protein expression in term dscs in vitro. excess thrombinmediated vegf expression in term decidua aberrantly increases endothelial cell permeability to further generate thrombin by continuous exposure of tissue factor-expressing decidual cells to circulating factor vii. thrombin-enhanced matrix metalloproteinase expression in term dscs would degrade decidual and fetal membrane extracellular matrix to induce pprom and preterm birth. basal directional release of angiotensin ii by endothelial cells stimulated by chymotrypsin-like protease (clp)/chymase. yuping wang, david f lewis, yang gu. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: chymotrypsin-like protease (clp)/chymase is a serine protease which plays a major role in angiotensin ii (ang ii) generation in the human heart. our previous study showed a higher clp activity in the maternal plasma in women with pe than in normal pregnancies. we also found enhanced chymase expression in the maternal vessel endothelium in women with pe. in this study, we determined if clp could promote endothelial cell (ec) generation of ang ii. methods: we specifically examined basal directional release of ang ii by cultured ecs. ecs were grown on cell culture insert ( well/plate, micron pore size). when ecs reached confluence, chymotrypsin (chy) at concentrations of . , . , . , . , and . g/ml were added to the upper chamber of the cell insert. after hours of culture, medium in the lower chamber was collected. medium concentrations of ang ii were measured by enzymelinked immunoassay (eia). all samples were measured in duplicate. data are expressed as mean ± se and analyzed by anova. a p level < . was considered statistically different. results: chymotrypsin produced a concentration-dependent increase in basal directional release of ang ii by cultured ecs, control: . ± . g/ml; chy . : . ± . g/ml; chy . : . ± . g/ml; chy . : . ± . g/ml; chy . : . ± . g/ml (p< . ); chy . : . ± . g/ml (p< . ), respectively. data are means from independent experiments. conclusion: apical exposure of ecs with chymotrypsin-like protease could promote basal directional release of ang ii. our result implicates that in pe, elevated clp levels in the maternal circulation are very likely to affect ec generation of ang ii. basal directional released ang ii may bind to its receptor on underlying vascular smooth muscle cells and contribute to the increased vasoconstriction in pe. (supported nih grants hd and hl ). vegf stimulates angiogenesis and vasodilation critical for dramatic rises in materno-feto interface blood flows directly linked to fetal growth/survival. extracellular signal-regulated kinase (erk / ) pathway mediates partially vegf-induced angiogenic and vasodilatory responses in placental endothelial cells (ec). it is, however, unknown how this vegf-induced signaling is organized in placental ec. objectives: ovine fetoplacental artery ec (ofpaec) and its transformed counterpart, sv -of to test whether: ) vegf-activated erk / signaling is compartmentalized in the caveolae and disruption of caveolae interferes vegf-induced erk / activation and; ) caveolin- , the structure protein of caveolae, regulates vegf-stimulated erk / phosphorylation. methods: ofpaec or sv -of cells were cultured in mcdb- / % fbs/antibiotics. serum-starved subconfluent ( %) cells were treated with rhvegf ( to ng/ml) for various times. caveolae were disrupted by -cyclodextrin ( -cd, mm, min) or caveolin- scaffolding domain (cav-sd, m, hr). sv -of cells were used for fractionation of caveolae membranes by discontinuous sucrose gradient ( %/ %/ %) ultracentrifugation. activation of erk / signaling pathway were analyzed by western-blotting with specific antibodies. results: in total cell extracts, vegf stimulates erk / phosphorylation in a time-and dose-dependent manner. erk / phosphorylation maximized by vegf ( ng/ml) at - min, which was abrogated by -cd or cav-sd. all the molecules for compromising the erk / signaling module, plc , pkc , src, ras, raf- , mek / and erk / , were detectable in purified caveolae membranes positive for various markers including caveolin- , enos, flotillin- , and -adaptin. in caveolae, vegf dramatically increased phosphorylated erk / without altering total erk / in a time-dependent manner similar to that in total cell extracts, which also maximized at - min. pretreatment with -cd or cav-sd blocked vegf stimulation of erk / phosphorylation in caveolae. conclusion: vegf activates the erk / signaling pathway in caveolae and caveolae integrity is essential for vegf-activated erk / signaling pathway. we conclude that caveolae/caveolin- serves as a platform for compartmentalizing the vegf-induced erk / signaling pathway in placental ec (hl and hl ). hypoxia upregulates gcm in human placenta. david mccaig, fiona lyall. institute of medical genetics, university of glasgow, glasgow, united kingdom. introduction: studies in transgenic mice have shown that a variety of genes regulate the differentiation of trophoblast cells. these genes include gcm . gcm is also expressed in the human placenta. placental gcm- protein has been reported to be reduced in pre-eclampsia, in view of the close link between hypoxia, hypoxia-reoxygneation, pre-eclampsia, placental development and the reported reduction in gcm we hypothesised that gcm expression would be affected by hypoxia. aim: the aim of this study was to determine the effects of hypoxia on gcm expression in the human placenta. two model systems were used; ( ) free floating villous explants and ( ) cultured primary cytotrophoblast and syncytiotrophoblast cells as described previously*. methods: explants or cell cultures were exposed to either hypoxia or hypoxia followed by re-oxygenation. western blot analysis was used to assess gcm protein levels. bands on the gels were quantified using scanning densitometry. statistical differences (n= experiments for both models used) were calulated by anova and turkey's post-hoc test. results: gcm protein was detectable at a low level in villous explants maintained for h in % o . a striking increase in gcm protein was observed when villous explants were incubated for h in % o (p< . ). incubation of villous explants for h in % o followed by re-oxygenation for h in % o resulted in a marked decline in gcm protein (p< . ). expression of gcm was also analysed in primary cytotrophoblast and syncytiotrophoblast cultured in % o or reduced oxygen ( % o ) conditions. gcm protein was not detected in any of the experimental conditions used. discussion: the present study has shown that acute hypoxia increases gcm- protein in villous explants. the experiments with purified trophoblast do not support a role for hypoxia increasing gcm- in these cells under the experimental conditions used. the present findings are in keeping with the complex effects of oxygen depending on the conditions used. the observed hypoxic effects on gcm warrant further investigation. the effect of acute alcohol exposure on histone -lys modification in the mid-gestation embryonic lung. xiangyuan wang, debra wolgemuth, , , laxmi baxi. ob/gyn; genetics development; human nutrition, columbia university medical center, new york, ny, usa. objective maternal alcohol abuse during pregnancy produces an array of birth defects comprising fetal alcohol syndrome. lung development depends on a balance between cell proliferation and apoptosis. we have previously shown that the acute alcohol exposure in the mid-gestation embryo can delay lung development and induce apoptosis. acute exposure to ethanol of selected tissues in mouse embryos has been reported by others to initiate apoptosis within hours after exposure and result in histone modifications. specifically, histone acetylation and deacetylation are involved in transcriptional activation and repression, respectively, but can also involve apoptosis. in the present study, we have investigated the effect of alcohol on acetylation of histone at lysine (ach lys ) in the mid-gestation embryonic lung. pregnant c bl/ j mice at day . of gestation (e . ) were injected intraperitoneally with doses of % ethanol ( . g/kg ), hr apart (alcoholexposed: ae) or with ringers solution (controls: c). ae and five c fetuses were retrieved and hr later and the lungs were fixed and processed for morphological evaluation and staining with rabbit polyclonal anti-ach ly antibody. the entire lung tissue field was evaluated for the levels of ach lys staining and scored as (-) to (++++). three areas were selected randomly from each sample and the total number of cells and staining positive cells were counted in the bronchial epithelium and in the mesenchyme. twelve hr after alcohol exposure at e . , the morphology of ae embryonic lungs was normal. however, high levels of ach lys were detected in % of the bronchial epithelial cells and % of the mesenchymal cells. the expression level in both lineages decreased hr after alcohol exposure. in the controls, the expression of ach lys was virtually undetectable in both the bronchial epithelium and the mesenchymal cells. our previous study showed that ae e . lungs significantly increased apoptotic cell in both bronchial epithelium and mesenchyme hours after alcohol treatment. we now observe that elevated expression of ach lys in the embryonic lung preceded the observation of apoptosis, suggesting that alteration in the acetylation of h could be one of the molecular mechanisms involved in the induction of apoptosis following acute alcohol exposure. objective: our purpose was to evaluate the effect of vitamin c and e supplementation on lipid peroxide levels, total antioxidant ability, and antioxidant levels in the umbilical venous plasma. materials and methods: women at risk for preeclampsia (nullipara, previous preeclampsia, chronic hypertension) were recruited at to weeksgestation and randomly assigned to receive either mg of vitamin c and iu of vitamin e (study group, n= ) or placebo (control group, n= ) daily until delivery. umbilical venous blood were collected after full term delivery. lipid peroxide levels, oxygen-radical absorbance capacity (orac) values, antioxidant levels were measured by each method (thiobarbituric acid reaction, cao's method, and high performance liquid chromatography). results: . the lipid peroxide levels in the umbilical venous plasma of study group were significantly lower than that of control group ( . ± . vs. . ± . nmol/mg protein, p< . ). . the orac values in the umbilical venous plasma of study group were significantly higher than that of control group ( . ± . vs. . ± . u/ml, p< . ). . the -tocopherol levels in the umbilical venous plasma of study group were significantly higher than that of control group ( . ± . vs. . ± . nmol/ml, p< . ). . there were no significant differences in the ascorbic acid, uric acid, -carotene, retinol, and -tocopherol levels in the umbilical venous plasma between control and study group. conclusion: this suggested that maternal vitamin c and e supplementation may affect the oxidant-antioxidants balance of the utero-placenta unit and fetus. placental tnf-related apoptosis-inducing ligand (trail) in normal pregnancy and pre-eclampsia. xilian bai, jenny e myers, philip n baker, john d aplin, ian p crocker. maternal and fetal health research group, the university of manchester. introduction: enhanced placental trophoblast apoptosis is well known to occur in pre-eclampsia. however, the potential role of membrane associated or soluble trail, an apoptosis-inducing ligand, and its death receptor, dr , is not known. we tested the hypotheses that the trail/trail-receptor system is compromised in pre-eclampsia and that soluble trail is a circulating factor which triggers the vascular complications of pre-eclampsia. method: this study was conducted on placental samples and plasma (edta) from women with uncomplicated pregnancies (n= ) and with pre-eclampsia (n= ) at - weeks gestation. protein expression levels and tissue localisation of trail and dr were defined in villous tissue by western blotting and immunohistochemistry. soluble trail (strail) was measured in maternal plasma from both groups using a commercial elisa (diaclone). results: placental villous trail and dr protein was unaltered in preeclampsia compared to normal pregnancy. whilst there was differential distribution of trail and dr within the component cells, this also was unaffected in pre-eclampsia. within the villi, trail was mainly confined to the cytoplasm and perinuclear regions of cytotrophoblast, syncytiotrophoblast, stromal cells and the fetal capillary endothelium. conversely, dr was restricted to trophoblast only, distributed evenly between cytoplasm, plasma membranes and nucleus. strail was present in plasma from non-pregnant women of childbearing age [ . ( . - . ) , median (interquartile range), pg/ml, n= ]. however, there was no significant increase either in pregnancy [ . ( . - . ) pg/ml, n= ] or pre-eclampsia [ . ( . - . ) pg/ ml, n= ] (kruskal-wallis test, p> . ). conclusions: these results suggest that placental villous trail is not adversely regulated in pre-eclampsia. the absence of dr in stromal and endothelial cells may increase resistance to apoptotic stimuli in cells of the villous core. the co-localisation of trail and dr in trophoblast suggests a role in autocrine regulation of cell turnover in this cell type. introduction: preeclampsia is associated with apoptosis of the syncytial layer of placenta and the release of particulate and soluble factors which are deleterious to maternal endothelial function. the goal of the current study was to determine whether laser capture microdissection (lcmd) and western blotting could be used to assess levels of syncytial fas ligand (fasl), a key protein in the apoptotic cascade. methods: frozen sections of term placenta delivered from uncomplicated pregnancies at term were used for study (n= ). following staining with mayer's hematoxylin (n= ), lcmd (leica instruments) of an intact terminal villus was carried out using a focused laser pulse directed to the area of interest using a microscope. in the first round of microdissection the placental villus core consisting of fibroblast, macrophages, fetal vessels, and connective tissue, were removed. in the second round of lcmd, the syncytial layer of that same villus was removed and collected in lysis buffer containing detergent and protease inhibitors, and the number of nuclei per sample was recorded. this procedure was repeated until syncytial tissue from - villi were collected. electrophoretic separation of lysate proteins was then carried out, and western blotting and immunodetection using an anti-fasl antibody was performed. results: we observed that fasl was detected in microdissected syncytial specimens at a molecular weight of approximately kda ( figure) , consistent with our previous reports. it is of note, that western blotting of samples containing approximately (lane ), (lane ), (lane ), and (lane ) nuclei revealed that fasl could be reliably detected in specimens containing as few as nuclei. conclusions: since fasl is a cytokine of low to moderate abundance in placenta, this suggests that lcmd coupled with western blotting will be a valuable methodology to elucidate pathways of syncytial apoptosis and pathophysiology in pregnancies complicated by preeclampsia. supported in part by nih grant hd . the placenta of preeclamptic pregnancies shows oxidative and nitrative stress. we have shown low protein abundance but paradoxically high activity of inducible nitric oxide synthase (inos) in the placenta with severe preeclampsia compared with normal pregnancies. protein nitration and phosphorylation are post-translational modifications possibly involved in nos activity. objectives: examine inos localization and tyrosine phosphorylation in the preeclamptic placenta and the effect of a peroxynitrite generator (sin- ) on inos expression in primary human placental microvascular endothelial cell (hpmec) cultures. methods: placental lysates from normal (n= ), mild (n= ) and severe (n= ) preeclamptic pregnancies were western blotted for inos and what are the roles played by peroxynitrite in preeclamptic women? yoshikatsu suzuki, tamao yamamoto, yoshimasa watanabe, takeo itoh, hidetaka izumi. obstetrics and gynecology, nagoya city university, nagoya, japan; pharmacology, nagoya city university, nagoya, japan; obstetrics and gynecology, izumi women's hospital, fukuoka, japan. aim preeclampsia is characterized by hypertension plus proteinuria. it is hypothesized that the endothelial cell function might be activated by placental faculty in early pregnancy and the activation might cause the vascular disease in preeclampsia. peroxynitrite, which is produced by combination with superoxide (o -) and nitric oxide (no), is strong oxidant as well as o -.we investigated whether or not the localization of peroxynitrite in both placenta and resistance artery might play important roles of developing preeclampsia. omental arteries or placentas were obtained from severe preeclamptic and term-normotensive pregnant women at cesarean section. they were stained by ant-nitrotyrosine (nt, a marker of peroxynitrite) antibody. furthermore, the concentration of nt was measured in omental arteries. in formed consent was obtained from all patients in written. preeclampsia was diagnosed according to the criteria of japan society of obstetrics and gynecology. the localization of nt was seen in placentas obtained from sever preeclamptic women ( / ), although it was not seen from normotensive pregnant women ( / ). the localization was also seen in placentas from of severe preeclamptic women with intrauterine fetal restriction. in omental arteries from both groups, the localization of nt was seen to same degree, and the concentration of nt was similar ( . ± . for sever preeclampsia and . ± . for normotensive pregnant women). from these results, it was suggested that an increase in o production, a decrease in no as well as peroxynitrite production in the placentas might cause the vascular dysfunction and subsequently damage uteroplacental blood circulation in preeclampsia. however, the role played by peroxynitrite in resistance artery might be different and more complicated. background: preeclampsia (pe) is associated with shallow cytotrophoblast (ct) invasion of the decidua, leading to impaired vascular transformation and poor uteroplacental perfusion. ct invasion requires the selective proteolysis of the peri-decidual cell (dc) extracellular matrix. we hypothesized that il and tnf , cytokines that have been linked to pe, may induce aberrant expression of the matrix metalloproteinases (mmp) and in dcs, thereby preferentially degrading the decidual ecm and interfering with sequential ct invasion. methods: immunostaining for mmp- , mmp- , and vimentin (a dc marker) was performed on decidua from normal (n= ) and preeclamptic (n= ) women, and staining intensities were evaluated by hscore. confluent, leukocyte-free first trimester dcs were primed with - m estradiol (e ) or e + - m medroxyprogesterone acetate (mpa), and then switched to a defined medium with e +/-mpa with or without ng/ml of il or tnf . secreted mmp- and mmp- levels were measured by elisa (n= ) and confirmed by western blotting. quantitative rt-pcr assessed mmp- and mmp- mrna levels (n= ). results: tissue staining revealed that mmp- and mmp- levels in preeclamptic decidua (hscore mean±sem: ± and ± , respectively) were significantly higher than in normal decidua ( ± and ± , respectively; p< . ). in cultured first trimester dcs incubated with e , tnf increased secreted mmp- and mmp- levels by ± and ± -fold, respectively, while il increased them by ± and ± fold, respectively (p< . ). in parallel incubations with e +mpa, basal mmp- and mmp- output were lowered by approximately % and %, respectively, while tnf -and il elicited mmp- and mmp- levels were blunted by - %. western blotting confirmed the elisa results, and mrna levels corresponded to changes in mmp- and mmp- secreted protein levels. conclusions: over-expression of mmp- and mmp- in decidual cells may promote pe by disrupting decidual ecm and impairing normal ct invasion. the high levels of il and tnf associated with pe may be contributing to this over-expression. our in vitro observations that mpa blunts tnf -and il -elicited mmp expression suggests that exogenous progestin may offer a novel therapeutic approach in preventing pe. to produce -methoxyestradiol ( -me), a compound with diverse biological activities including inhibition of hif- , a transcription factor that mediates cellular response to hypoxia. circulating levels of -me and placental comt activity are significantly reduced in preeclampsia, raising the possibility that reduced production of -me contributes to the pathophysiology of preeclampsia by altering placental response to hypoxia. genetic variation in the comt gene is linked to comt activity and has been associated with intrauterine fetal growth restriction. we determined if a snp in exon of the comt gene (rs ), which does not change amino acid sequence ( leu ), but reduces comt mrna translation, was associated with preeclampsia. we analyzed comt genotypes in paired dna samples extracted from maternal and cord blood from normal pregnancies and pregnancies complicated by preeclampsia by allele discrimination. the study population was predominantly (> %) african-american. the frequency of the minor rs "g" allele, which is associated with low comt activity, was similar in maternal cases and controls (cases: %; controls: %, p= . ), but was significantly greater in fetal dna from pregnancies complicated by preeclampsia compared to control pregnancies (g allele frequency cases: %; control: %; p< . ). likewise, fetal carriage of the rs "g" allele conferred a significantly greater risk of preeclampsia (odds ratio: . ; % c.i.: . , . , p< . ). there was also a significant discordance between paired maternal and fetal rs genotypes with significantly greater discordance for the "g" allele in fetuses hosted in preeclamptic pregnancies (odds ratio: . ; % c.i.: . , . ). we conclude that genetic variation in the comt gene is associated with risk of preeclampsia, possibly through a mechanism involving reduced production of -me. supported by nih p md . smoking is associated with elevated adma in preeclampsia. michael p frank, robert w powers. , magee-womens research institute, pittsburgh, pa, usa; obstetrics gynecology, university of pittsburgh, pittsburgh, pa, usa. objective: cigarette smoke exposure paradoxically reduces the risk of preeclampsia. asymmetric dimethylarginine (adma) is an endogenous competitive inhibitor of nitric oxide synthase (nos), an independent risk factor for cardiovascular mortality, adma is elevated in women who develop preeclampsia, and adma has been reported to be both higher and lower in smokers. the objective of this study was to investigate the concentration of adma in pregnant smokers and nonsmokers with and without preeclampsia. study design: case-control study of women with uncomplicated pregnancy (controls), and women with preeclampsia matched for gestational age at sample collection. adma was measured by hplc. cigarette smoke exposure was determined by questionnaire and confirmed by plasma cotinine. data are mean±sd. analysis was by two factor anova with fishers post-hoc testing, significance accepted at p< . results: as previously reported, maternal plasma adma concentrations were higher in women with preeclampsia compared to controls (p< . ). in addition, the concentration of adma was significantly higher in preeclampsia smokers compared to controls and preeclampsia nonsmokers (p< . ). in contrast, there was no difference in adma concentration between control smokers and nonsmokers. conclusion: these data may suggest a differential effect of cigarette smoke exposure on circulating adma concentrations between women who do and do not develop preeclampsia. previous data has suggested that cigarette smoking is associated with lower adma in low risk elderly patients, and higher adma in high-risk subjects with diabetes. therefore, the data in preeclamptic and non-preeclamptic subjects may be consistent with these studies, however, the underlying biological explanation for this differential effect has yet to be determined. objective: eclampsia is similar to hypertensive encephalopathy in which an acute elevation in blood pressure causes autoregulatory breakthrough, hyperperfusion and edema formation. we previously reported that the pressure of breakthrough was similar between nonpregnant (np) and late-pregnant (lp) rats, but only lp animals developed edema. this study tested the hypothesis that lp animals have decreased in cerebrovascular resistance (cvr) and hyperperfusion in response to breakthrough vs. np. we further hypothesized that acute hypertension would cause greater blood-brain barrier (bbb) permeability in lp rats due to elevated hydrostatic pressure. methods: in vivo models of bbb permeability and cerebral blood flow (cbf) were used in np (n= ) and lp (d - ; n= ) rats that were either normotensive or hypertensive (np-htn, lp-htn) by infusion of phenylephrine to raise mean arterial pressure. permeability was determined in anterior and posterior brain regions by calculating the flux of kd dextran into the brain tissue, measured by a fluorescent spectrophotometer after flushing the vasculature with saline. cbf and cvr were measured by infusion of m fluorescent microspheres and determined based on the flow rate and fluorescence intensity of a reference sample for each animal. animals were ventilated to maintain blood gases within normal ranges (po > mmhg, pco = - mmhg). results: although the pressure change was similar between np and lp ( and mm hg), lp animals responded to acute hypertension with hyperperfusion. cbf increased from ± to ± ml/ g/min in np ( %) and ± to ± ml/ g/min in lp ( %; p< . vs. np). hyperperfusion in lp animals was associate with decreased cvr vs. np ( . ± . vs. . ± . mm hg/(ml/ g/min); p< . ). bbb permeability was significantly increased in lp animals at breakthrough vs. np in both anterior and posterior brain regions. the flux of dextran in anterior and posterior brain regions for np vs. lp animals was: ± vs. ± for anterior (p< . ) and ± vs. ± for posterior (p< . ). conclusions: these data demonstrate that pregnancy decreases cvr and causes hyperperfusion of the brain during acute hypertension. because increases in cvr is a protective function in the brain, impairment of these mechanisms during pregnancy may predispose the brain to edema when blood pressure is elevated, as in eclampsia. introduction: this study used the in vitro dually perfused human placental lobule to test the hypothesese that placental release of vegf and the fetoplacental vasodilatory response to exogenous vegf- are altered by tissue oxygenations that mimic healthy and preeclamptic pregancies. methods: lobules were dually perfused for six hours under one of two oxygenation conditions, representing 'normoxia' and 'hypoxia' (n = each): delivering maternal side inflow perfusate at oxygen concentrations of . % and %, respectively, distributed via cannulae; and fetal side inflow perfusate oxygen concentration of - % in both systems. venous perfusates were sampled and assayed, appropriate to side of release, for erythropoietin (epo), macrophage inflammatory protein- alpha (mip- alpha) (reference oxygen sensitive hormones), free vegf, svegfr- and plgf. in separate perfusions, fetoplacental vasodilation in response to pm vegf was investigated, following preconstriction of the fetoplacental vasculature to steady state fetal-side inflow hydrostatic pressure (fihp) with the thromboxane mimetic, u , (n = each). results: maternal-side mip- alpha release was higher in the 'hypoxic' than the 'normoxic' system ( ± and ± pg/ml, respectively, at hours, mean ± se; -way anova: p< . ). maternal-side epo and fetal-side soluble free vegf and svegfr- release were not different between groups. fetal-side release of plgf was higher in the 'hypoxic' group than the 'normoxic' group ( . ± . and . ± . pm, respectively, at hours, mean ± se; -way anova: p < . ). there was no difference in the vasodilatory response to vegf- in the fetoplacental vasculature between the groups ( . ± . and . ± . % change in fihp, mean ± se). discussion: differences in mip- alpha and plgf release provide evidence for metabolic separation of the adapted systems, caused by a changed oxygen environment. our failure to observe differences in epo, vegf and svegfr- release may be explained by longer lag-times for up regulation of their gene expression. vegf associated endothelial signalling appears to be unaffected by 'hypoxia' in the placenta over the time course studied here. background: there is a placental renin-angiotensin system (ras) from very early pregnancy. ang iv mediates various effects by binding to its specific receptor, the at r, the active site of which is an insulin-regulated aminopeptidase (irap). there is at r expression in both endothelial and smooth muscle cells. ang iv at low concentrations is vasodilatory, increasing blood flow via the at rs; it also stimulates nf-kappa beta and modulates glut- . to date at r expression has not been investigated in the placenta. we propose that at r plays a part in the placental vascular development necessary for successful pregnancy, and that reduced at r expression may be associated with inadequate vascular adaptation contributing to pre-eclampsia (pe). aim: to identify and locate at r expression in both np and pe placentae. methods: the study had hospital ethical approval; written informed consent was obtained from all women. placental samples were obtained from np and pe at delivery (gestational ages: and weeks respectively). samples were taken from areas, near cord, middle and outer edge of the placenta. paraffin embedded sections were immunostained for irap reactivity using a rabbit polyclonal antibody (gift from professor david james, garvan institute, australia). immunoreactivity of trophoblast and uterine cell populations was assessed using a semi-quantitative grading system. grade = no positive labelling, = - %, = - %, = - % and = - % of cells positively labelled. median (max, min) are shown. results: ) at r immunostaining was prominent in the syncytiotrophoblast and hofbauer cells of all placental villi examined, with no differences in expression between sampling sites. ) at r positivity was reduced in near cord pe samples ( . ( . , . )) compared to np ( . ( . , . ) p= . ). conclusion: we have shown for the first time, dense at rs in syncytiotrophoblast and hofbauer cells in np placentae, and their down-regulation in pe. reduced ang iv/at r binding may contribute to increased placental vasoconstriction resulting in increased ischemia/reperfusion. this in turn may stimulate xanthine oxidase, which is itself stimulated by angii, leading to increased superoxide production. further work is needed to clearly define the role of this newly identified component of the renin-angiotensin system in normal pregnancy and pe. pre-eclampsia is associated with lower percentages of regulatory t cells in maternal blood. jr prins, hm boelens, jj hm erwich, j heimweg, s van der heide, ajm van oosterhout, aej dubois, jg aarnoudse. obstetrics, university medical center groningen, groningen, netherlands; laboratory of allergology and pulmonary disease, university medical center groningen; pediatric allergology, beatrix children's clinic, university medical center groningen. pre-eclampsia is a serious disease of human pregnancy and immunological mechanisms play a role in its pathophysiology. normal pregnancy is associated with an increase in regulatory t (treg) cells and with a predominant th immune profile. treg cells are a subpopulation of cd + lymphocytes and are specifically characterized by the lineage specific transcription factor foxp . treg cells seem to induce immunological changes that have a protective role in maintaining normal pregnancy. we hypothesised that percentages of treg cells are decreased in pregnancies complicated by pre-eclampsia. methods in total, women with pregnancies complicated by pre-eclampsia and healthy pregnant controls were enrolled. to obtain control umbilical cord blood as well, control group i consisted of eighteen healthy pregnant women at term. in addition, since women with pre-eclampsia delivered preterm, control group ii (peripheral blood only) consisted of women during normal pregnancy with a gestational age matched for the preterm pre-eclamptic group. treg cells were measured from whole blood using four-color flow-cytometry. women with a pregnancy complicated by pre-eclampsia had a significantly lower percentage of cd + foxp + treg cells ( . vs . %; p< . ). in the pre-term group the pregnancies complicated by pre-eclampsia showed a significantly lower percentage of cd + foxp + cells in the peripheral blood as compared to the healthy pregnant controls. at term this percentage was also lower but not significantly so. between pre-term and term pregnancies both complicated by pre-eclampsia no significant difference was found in the percentage of cd + foxp + treg cells. no difference was found in umbilical cord blood ( . vs . %). conclusions our data suggest that pre-eclampsia is associated with a diminished percentage of treg cells in peripheral blood. we conclude that a deficiency of regulatory t cells may play a role in the pathophysiology of pre-eclampsia. background: preeclampsia and eclampsia are significant causes of maternal and fetal death. however, the pathophysiology of these conditions is unclear. we and others have reported that inhibition of endogenous nitric oxide (no) synthesis produces symptoms similar to preeclampsia in pregnant rats. several studies demonstrate that fetoplacental weights are altered in pregnancies of spontaneous hypertensive (shr) rats. in addition, impaired synthesis of tetrahydrobiopterin (bh ), a major co-factor for endothelial nitric oxide synthase (enos) activity and enhanced expression of enos has been observed in the pathogenesis of hypertension. in the current study, we examined whether supplementation of bh and sepiapterin (sep, a precursor for bh biosynthesis in the salvage pathway) reduces increased blood pressure and improves fetoplacental weights in shr pregnant rats. methods: groups ( - ) of shr pregnant rats were either treated with bh , sep ( mg/k.g body weight/day/rat, oral tablets) or vehicle (normal diet) beginning from day of pregnancy until day of gestation. animals were sacrificed on day of gestation and fetoplacental weights were recorded immediately. western blot analysis was performed to determine vascular enos expression (enos/gapdh). results: significant (p< . ) elevations in blood pressure (bp, mmhg) were observed in shr (shr, ± . vs. wky, ± . mmhg) compared to wistar-kyoto (wky) group. supplementation of either bh or sep ( ± . ), significantly (p< . ) reduced elevated bp beginning from day of pregnancy. fetal but not placental weights were significantly (p< . ) reduced in shr ( . ± . grams) compared to wky ( . ± . ) rats. bh ( . ± . ) treatment partially (p< . ) increased fetal weights compared to the shr group. vascular enos expression is significantly (p< . ) elevated in shr ( . ± . ) compared to wky rats ( . ± . ). further, treatment with bh ( . ± . ) but not sep ( . ± . ) significantly (p< . ) reduced elevated enos protein expression in shr rats. conclusions: bh may be beneficial treatment of preeclampsia to reduce blood pressure and improve fetal perfusion to increase fetal weights. genetic risk factor for severe preeclampsia: significance of endothelial nitric oxide synthase gene t- ->c and missense glu asp variants. toshihiro yoshimura, michihiro yoshimura, masafumi nakayama. obstetrics and gynecology, kumamoto university school of medicine, kumamoto, japan; cardiovascular medicine, jikei university school of medicine, tokyo, japan; cardiovascular medicine, kumamoto university school of medicine, kumamoto, japan. introduction: we recently identified two endothelial nitric oxide synthase (enos) gene polymorphisms, a glu asp missense variant in exon and a t- -->c variant in the '-franking region, which are associated with coronary spasm and myocardial infarction in japanese population. and we also identified a missense glu asp variant is associated with severe preeclampsia and placental abruption. our objective was to analyze the association between the t- -->c and severe preeclampsia. materials and methods: the study participants included patients with histories of severe preeclampsia. this is a preliminary study, therefore, the comparisons were made with the general normal population. results: the analyses revealed that the frequency of the missense glu asp variant (n= / , %) was significantly higher than the general population (n= / , %), as we previously published. however, the frequency of the t- -->c variant (n= / , %) was not different from the general population (n= / , %). interestingly, only one patient had both t- -->c and missense glu asp variants, and she developed placental abruption. conclusion: although our sample size is small, it is very unlikely that the t- -->c variant is associated with severe preeclampsia. the t- -->c variant may not be a genetic susceptibility factor to severe preeclampsia. the t- -->c may have some reproductive significance in combination with missense glu asp variant, however huge number of patients would be needed to analyze such rare ( . %) combination of the variance. the association between the development of preeclampsia and methylenetetrahydrofolate reductase, angiotensinogen, vascular endothelial growth factor single nucleotide polymorphism genotype combinations. hyun soo park, jong kwan jun, chan-wook park, joong shin park, bo hyun yoon, hee chul syn. obstetrics and gynecology, dongguk university international hospital, goyang-si, gyeonggi-do, republic of korea; obstetrics and gynecology, seoul national university college of medicine, seoul, republic of korea. objective this study was conducted to investigate if there exists any genotype combination of multiple single nucleotide polymorphism (snp)s which is frequently found in preeclampsia patients. study design one hundred sixty two preeclampsia patients and normotensive pregnant women were included in this study between jan and jul . diagnosis of preeclampsia and assignment of severity were made according to the criteria by national high blood pressure education working group and american college of obstetricians and gynecologists. the patients were reclassified as early ( weeks or before) and late-onset ( weeks or beyond) disease. genotypes were measured with pcr-rflp for methylenetetrahydrofolate reductase (mthfr) c t, angiotensinogen (agt) m t, vascular endothelial growth factor (vegf) c t with the dna extracted from maternal blood. case-control study for each snp was done and the frequencies of genotype combination were compared. anova, t-test, chi-square test, fisher's exact test and logistic regression analysis were used for statistical analysis. a p value of < . was considered statistically significant. results genotypes of mthfr polymorphism showed significant difference between late onset preeclampsia and control (cc+ct/tt, or: . , p< . ) but agt and vegf polymorphism did not show statistical difference between any case-control combination. only out of possible genotype combinations were found and there was no statistical difference in the frequencies of genotype combination between case and control group. conclusion mthfr polymorphism might be associated with the development of preeclampsia, but there was no combination of mthfr, agt and vegf polymorphisms which is associated with the development of preeclampsia. diffuse staining and vascular smooth muscle (vsm) staining. resistance-sized vessels ( - μm) were evaluated. results: for mpo, the intensity of staining (fig) and the % vessels with neutrophil, diffuse and vsm staining was significantly greater for obese than for overweight or normal weight patients: % diffuse staining ( . ± . vs. . ± . vs. . ± . , p< . ); % vsm staining ( . ± . vs. . ± . vs. . ± . , p< . ). for mmp , obese and overweight patients had a greater (p< . ) % vessels with neutrophil, diffuse and vsm staining than normal weight patients: % diffuse staining ( . ± . vs. . ± . vs. . ± . ); % vsm staining ( . ± . vs. . ± . vs. . ± . ). conclusions: neutrophils infiltrate the systemic vasculature of obese women and release mpo and mmp . speculation: obesity may put women at risk for pe because their vasculature may already be dysfunctional due to neutrophil infiltration and release of mpo and mmp . hl . collagen is an important protein that maintains the structural integrity of tissues. disruption of vascular smooth muscle collagen could result in vascular dysfunction in women with preeclampsia. recently, neutrophil infiltration of the systemic vasculature was demonstrated in preeclamptic women. neutrophils produce inflammatory mediators, such as reactive oxygen species (ros) and tnf-. we hypothesized that neutrophils, ros and tnf-would alter expression of collagen regulating genes. methods: primary cultures of human vascular smooth muscle cells (vsmc) were seeded into t- flasks ( , cells/flask) and grown for days to % confluence. the cells were treated for hours with medium control, ros (hx, . mm + xo . u/ml), tnf-( ng/ml); and neutrophils ( , ) activated with arachidonic acid, μm, ( : ratio of neutrophils to vsmc). rna was extracted from cell homogenates and analyzed for gene expression with an rt profiler pcr array system for human extracellular matrix genes (superarray). to determine the fold-change of gene expression, the results were first normalized to a housekeeping gene and then ct was calculated across two rt-pcr arrays where group was the control and group was the experimental treatment. results: table . conclusions: neutrophils, ros and tnf increased mmp expression. interestingly, genes involved in collagen synthesis (col a ) or inhibition of mmp- activity (timp ) were either not affected or down-regulated. these data suggest that neutrophil infiltration in preeclamptic women could cause vascular dysfunction by creating an imbalance between collagen synthesis and collagen breakdown favoring breakdown. hl , fogarty d tw , p md . objective: hypoxia increases membrane attack complex (mac) binding to cultured human trophoblasts, and mac enhances apoptosis in trophoblasts exposed to low compared to normal fio . trophoblast microparticles and cellular fragments released into the maternal circulation in vivo may contribute to the systemic pathophysiology of preeclampsia. we tested the hypothesis that hypoxia induced mac deposition on cultured human trophoblasts yields microparticles and fragments coated with mac. study design: primary cytotrophoblasts from term human placentas (n= ) were cultured h in % and % oxygen in dmem with % human serum with active mac or heat inactivated serum (control). media were centrifuged to obtain pellets of microparticles and cell debris which were immunostained for mac or exposed - h to confluent, phorbol myristate acetate differentiated u macrophages. the percentage of macrophages that ingested trophoblast debris was quantified by counting the number of macrophages with immunofluorescence for trophoblast cytokeratin filament staining, as assessed by confocal microscopy. results: cultures exposed to normal human serum, but not heat inactivated control serum, showed mac immunofluorescence on microparticles and fragments in medium, with the highest level of mac in cultures exposed to extreme hypoxia. the maximal percentage of macrophages that ingested the trophoblast debris coated with mac from cultures with % oxygen was . %, not different from the . % from cultures exposed a % fio and control serum. conclusion: trophoblasts exposed to hypoxia and active complement release microparticles and cellular fragments coated with mac into the extracellular environment. mac coating does not influence phagocytic removal of the debris by macrophages suggesting that placental derived, membrane bound mac could circulate to yield systemic affects on maternal endothelium. supported by nih hd and hd . is there a role for fatty acids in the pathogenesis of pre-eclampsia? nicola j robinson, laura j minchell, jenny e myers, philip n baker, carl a hubel, ian p crocker. maternal and fetal health research group, the university of manchester; obstetrics, gynecology and reproductive sciences, university of pittsburgh. objectives: women with pre-eclampsia (pe) display altered lipid metabolism as characterized by elevated circulating triglycerides and non-esterified fatty acids (nefa) and these changes are evident before the disease is clinically apparent. we have tested the hypothesis that the increased circulating levels of nefa contribute to endothelial dysfunction in pe. methods: human umbilical vein endothelial cells were incubated for h with pooled plasma ( %) from normal or pe pregnancies, or with palmitic, oleic and linoleic acid in culture media at the concentrations and molar ratios to albumin identified in normal ( , , m, ratio . ) and pe pregnancies ( , , m, ratio . ) , . lipid droplet accumulation was determined using an oil red o absorbance assay. endothelial metabolism was measured using the mtt test and mitochondrial membrane potential determined by jc- assay as a marker of early apoptosis. results: plasma from pe pregnancies increased endothelial cell lipid droplet accumulation compared to normal plasma (p< . , wilcoxon signed ranks, n= ). this change was replicated following exposure to nefa at the combined concentrations found in pe compared to normal pregnant controls (p< . , n= ). plasma from women with pe caused a significant decrease in mitochondrial dehydrogenase activity (mtt test; p< . , n= ) and a reduction in jc- fluorescence (p< . , n= ), compared to normal plasma, suggestive of mitochondrial membrane depolarization and increased cellular apoptosis. again these effects were replicated using nefa in culture medium at the levels found in pe compared to normal pregnancies (mtt test: p< . , n= ; jc- assay: p< . , n= ). conclusions: in endothelial cell cultures, plasma from women with pe caused increased lipid droplet accumulation, decreased cellular metabolism and increased apoptosis. these changes to cellular function were mirrored using nefa in culture medium at the concentrations and molar ratios to albumin previously reported in pe. these findings provide evidence that the changes in endothelial cell function induced by plasma from women with pe may be due to the increased nefa circulating levels and that increased palmitic, oleic and linoleic acid, in combination, could play a role in pathogenesis of pe. lorentzen ( ) bjog; endresen ( ) ajog. background: skewing of the maternal endothelial phenotype in pre-eclampsia (pe) is attributed to the release of unknown factors from a hypoperfused placenta. we hypothesise that factors secreted from pe placental tissue will impair endothelial cell function. we have tested the effect of soluble factors by menopausal status, there was a significant increase in bmi in pre-but not in postmenopausal women. in postmenopausal women there was insufficient power to note a statistically significant change in bmi. results are summarized with the follow-up for each group represented by "n" in the graph below. premenopausal patients were divided into hysterectomy with oophorectomy (pbso) versus hysterectomy alone (ph). the ph group showed an increase in bmi that plateaus at time . in the pbso group the bmi continued to increase over time. subgroup analysis comparing ph to pbso demonstrates initial weight loss in pbso but a significant increase in bmi from baseline at time compared to ph. conclusions: hysterectomy appears to be associated with an increase in bmi over time. subgroup analysis suggests that, in premenopausal women, oophorectomy is more strongly associated with continuing weight gain than hysterectomy alone. purpose: obesity is implicated as a key risk factor in chronic disease, but no studies have associated central obesity to the presence of chronic abdominal and/or pelvic pain. we set out to identify the prevalence of chronic abdominal/ pelvic pain in an underserved, primarily latina population by a cross-sectional study in the olive view-ucla outpatient gynecology clinic. we sought to identify an association between the presence and severity of abdominal/pelvic pain and central obesity. methods: nonpregnant women presenting to the gynecology clinic were prospectively evaluated and grouped according to the presence of abdominal/ pelvic pain ('none-mild' or 'moderate-severe' pain). body mass index (bmi) and abdominal circumference (ac) were measured. patients with 'moderate-severe' pain completed standardized questionnaires for pelvic pain and global health scores. results: / ( %) of patients has 'none-mild' pain, and ( %) had 'moderate-severe' pain. pain prevalence was not significantly associated with bmi (mean: 'none-mild' . + . kg/m ; 'moderate-severe' . + . kg/m , p= . ), nor was pain severity (p= . ). pain prevalence was significantly associated with ac (mean: 'none-mild' . + . inches; 'moderate-severe' . + . , p= . ). a borderline positive association exists between ac and pain severity (p= . ). conclusions: we demonstrate an association between both the presence and severity of chronic abdominal/pelvic pain and central obesity, independent of bmi. ac appears to be a more relevant factor than other traditional measures of habitus in patients with this chronic malady. to improve preventative care in women's health management, further evaluation of the role of central obesity in the pathogenesis of chronic pain is necessary. aims: vulvitis is one of the most frequently diagnosed gynaecological infections. we aim to assess the efficacy against infective vulvitis of a new topical medical device containing low molecular weight hyaluronic acid (lmw-ha). the ability of this molecule to stimulate -defensin release in keratinocytes has been recently shown. methods: we report preliminary data regarding women suffering from infective vulvitis, as assessed by a gyneacologist: patients were randomly selected to receive sphg ( patients), a cream containing low-molecular weigh hyaluronic acid, or vehicle ( patients). patients were asked to apply the cream to the vulva twice-daily for days. at the end of treatment, evaluation of efficacy, tolerability and acceptability of the cream was assessed by a specific questionnaire. results: preliminary results show that patients receiving sphg report a significative improvement of vulvitis symptoms, in terms of itch, redness of the skin and burning, in comparison to vehicle. sphg also showed a good tolerability, cosmetic acceptability and symptomatic relief perceived by patients. conclusion: sphg seems to be efficacious in ameliorating the symptoms of infective vulvitis. this activity may be probably related to the lmw-ha presents in this formulation: in fact, low molecular weight hyaluronic acid has been recently shown to induce -defensin production by human keratinocytes. since this peptide exerts antimicrobial and antimicotic activity, the improvement of symptoms assessed in patients receiving sphg might be linked to a reduced infective charge, attributable to the activity of -defensin . background: allogeneic hematopoietic stem cell transplant (hsct) is a treatment used for many malignant and nonmalignant diseases of the bone marrow and immune system. hsct may be complicated by chronic graft-versus-hostdisease (cgvhd) in to % from matched unrelated donors. genital cgvhd complicates about % of hsct and may uncommonly result in labial fusion. case: year old woman with a history of ewing's sarcoma and acute myelogenous leukemia, had received chemotherapy and total body irradiation (tbi) followed by a matched unrelated donor hsct. menarche occurred at years of age after normal pubertal development. she menstruated regularly until cancer diagnosis. premature ovarian failure resulted after chemotherapy and tbi and oral contraceptive pills were used for hormone replacement. after transplant, she developed chronic gvhd involving the skin, eyes, mouth and joints, and concomitantly complained of vulvar pruritus. she was presumed to have a yeast infection which was treated with fluconazole without a pelvic exam. she was evaluated by a gynecologist when she was unable to insert a tampon. pelvic exam revealed dense labia minora adhesions from the clitoris to urethral meatus and posteriorly leaving a cm opening at the urethra. pelvic mri revealed a normal uterus and ovaries. after weeks of topical estrogen cream, the adhesions remained dense and were lysed under general anesthesia. vaginal examination revealed pale, minimally rugated, normal mucosa. cervical cytology was normal. post-operatively she used daily topical estrogen and hydrocortisone creams. at months after surgery, her urinary stream was stronger. on pelvic exam, the labial opening was cm, but a small posterior forchette adhesion elicited severe pain. after using dilators coated with topical steroids and estrogen, she was able to insert a tampon. conclusion: genital gvhd should be considered in women with genital tract complaints after hsct. labial fusion secondary to chronic gvhd may be treated successfully with surgery and medical therapy. support: rbmb/nichd/nih. dana r ambler, mazen e abdallah, rahi victory, michael p diamond, elizabeth e puscheck, jay m berman. obstetrics and gynecology, wayne state university/detroit medical center, detroit, mi, usa. objective: to determine which factors are predictive of a ruptured ectopic pregnancy, and whether endometrial stripe thickness can be used as an alternative to such criteria in the diagnosis of an ectopic pregnancy. design: retrospectively collected ectopic pregnancy database. setting: detroit medical center, detroit, michigan. patients or participants: women with a diagnosis of an ectopic pregnancy were studied, with surgically confirmed tubal rupture cases. interventions: abstracted data included hcg(iu), gestational age (days), presenting symptoms of pain and/or bleeding, hemoglobin (hgb), hematocrit (hct), historical risk factors, ultrasound-determined ectopic size, endometrial stripe thickness (mm), amount of cul de sac fluid (cds), tubal rupture at time of surgery, and estimated blood loss (ebl)(ml). covariates included demographics. results were significant when p< . . results: chi square analysis revealed that there is a relationship between endometrial stripe thickness and hcg levels. logistic regression models demonstrated that endometrial stripe thickness was not predictive of ectopic rupture, (or . , p= . ) . however, logistic regression, both forced and forward stepwise analysis, demonstrated that hcg (or= . , p< . ), a large volume of cul-de-sac fluid (or= . , p< . ), and increasing pain (or= . , p= . ) were associated with increased risks of rupture. gestational age, and ectopic related risk factors were also not predictive of rupture. conclusions: endometrial stripe thickness is not a useful predictor for the diagnosis of a ruptured ectopic pregnancy. serum hcg measurement, cds fluid volume and the presence of pain are much stronger diagnostic indicators of ectopic pregnancies. clinical profile of migraineurs in a university hospital gynecology department in japan. [objectives] the changes in hormonal milieu associated with menarche, pregnancy, menopause, and post-menopause are frequently accompanied by changes in the patterns and frequency of migraine. little is known on the relationship of women's issues of migraine though the balance between estrogen and progesterone is critical in the elimination of migraine. our aim was to investigate the relations among the prevalence of migraine, the reproductive stage, and gynecologic diseases. [materials and methods] female patients (average age: . years old) who consulted a physician and agreed to answer about the questionnaires during september, -june, . migraineurs were diagnosed with the migraine screener by the japanese headache medical treatment promotion committee in . and the patients answered questionnaires that screened about menopausal disorder and abnormal menstruation at once. they were conducted a survey in the form of a questionnaire and sometimes were taken blood samples. [results] in patients had migraine ( . % average age: . years old). prevalence were . % in one's twenties, higher than another ages. most patients with migraine was complicated by menstruation disorders (premenstrual syndrome %, dysmenorrhea . %), sterility ( . %), and severe menopausal disorder ( %). when trh and the lh-rh test were examined for the sterility patient, migraineurs had higher prolactin basal level and lh level after lord but lower fsh level before and after lord than nonmigraineurs. on the other hand, the prevalence of migraine for postmenopausal women and women who had gynecology cancer treatment was low, and there was no relation between migraine and pregnancy history. [conclusions] this study provides migraine headache is influenced by reproductive stage and that women with migraine are frequently complicated by menstruation disorder. it is thought that migraine account for abnormality of hormone milieu including abnormality of the hypothalamus-pituitary system. objective: this study evaluated the efficacy of doses of estradiol (e ) gel . % (divigel ® ), a novel formulation of e consisting of mg e per g transdermal gel, to reduce frequency and severity of vasomotor symptoms and signs of vulvar and vaginal atrophy (vva) associated with menopause. design: postmenopausal women were evaluated in a -week study comparing placebo to e gel . % at doses of . g/day, . g/day, and . g/day with estimated nominal daily deliveries of . mg, . mg, and . mg of e respectively. endpoints included mean change from baseline in daily frequency and severity of moderate to severe hot flashes (msvs). vaginal ph and % superficial cells were collected at baseline and end of study. results: e gel . % showed statistically significant improvements from placebo gel as early as week (table) that were maintained throughout treatment. signs of vva (vaginal ph and % of superficial cells) showed statistically significant improvements from baseline with all doses of e gel . % compared to placebo. conclusion: e gel . % significantly decreased the frequency and severity of msvs at all doses evaluated in this trial. e gel . % offers multiple dosing options to individualize patient therapy, including the lowest effective dose that was studied ( . mg e , delivering . mg e /day), to treat vasomotor symptoms associated with menopause. estradiol (e ) gel . % (divigel ® ) is a novel formulation of e consisting of mg e per g transdermal gel for the treatment of vasomotor symptoms associated with menopause. safety and tolerability of e gel . % were evaluated in a large placebo-controlled trial. design: postmenopausal women participated in a -week study comparing placebo to . g/day, . g/day, and . g/day of e gel . %. circulating e and estrone (e ) concentrations were measured. safety analyses included the incidence of adverse events (aes) and clinical laboratory evaluations, including plasma levels of sex hormone binding globulin (shbg). application site tolerability was assessed using the draize scale. results: all doses of e gel . % produced physiologic e :e ratios similar to those seen in premenopausal women. e :e increased from a baseline mean of . to . , . , and . with, respectively, the . , . , and . g/day doses of e gel . %. the most frequently reported aes were breast tenderness and postmenopausal bleeding that appeared to be dose-related and would be expected with increased circulating estrogen concentrations. there were no remarkable changes in hematology, blood chemistry, urinalysis, lipid, coagulation, and carbohydrate values following treatment with e gel . %. shbg levels remained unchanged after weeks of treatment at all doses. the vast majority of patients had no evidence of skin irritation throughout the treatment period. mean draise scale scores after , , and weeks of treatment were . for all treatment groups except for a mean value of . ± . for the . g dose group after weeks of treatment. conclusion: e gel . % is a safe and well-tolerated therapy for the treatment of menopausal symptoms. design: pharmacokinetic parameters, dosing, efficacy, and safety information for divigel ® , elestrin ™ , evamist ™ , estrogel ® , and estrasorb ® were obtained from current prescribing information (obtained from manufacturer websites) and the data were compared. results: together, these new transdermal therapies offer multiple dosing/ delivery options and contain a wide range of e ( . mg to . mg), with the lowest systemic daily delivery of e attained by the divigel ® . g dose. following weeks of treatment, across the dosing options, each treatment significantly reduced both the frequency and severity of moderate to severe vasomotor symptoms (msvms) compared to placebo. change in frequency of msvms ranged from - . (divigel ® . g) to - . (estrasorb ® ); change in severity scores for msvms ranged from - . (divigel ® . g) to - . (divigel ® . g). all treatments are safe and well tolerated. breast tenderness was the only adverse event reported in % of subjects, occurring with all therapies. conclusions: current treatment guidelines recommend using the lowest effective dose of estrogen for the treatment of menopausal symptoms. this side-by-side comparison of the recently available e non-patch transdermal options to the standard transdermal therapies is meant to assist physicians in individualizing treatment for their patients. introduction: cdb- (cdb) is a relatively new progesterone receptor modulator being clinically evaluated for contraception and treatment of fibromas. its use in an intrauterine device/system (ius) has not been reported. in this study we prepared cdb-filled intrauterine devices (cdb-ius) and evaluated their effects on endometrial growth and bleeding patterns in rhesus macaques. methods: short ( . - . cm) lengths of silastic tubing (od . mm), either empty (n= ),or filled with silicone rubber matrix containing % of micronized cdb (n= ), were inserted into the uterine lumens of ovariectomized rhesus macaques. animals were induced to cycle by sequential treatment with systemic estradiol and progesterone (p) as reported (brenner et al, ann ny acad, ) . after . cycles, at the end of the follicular phase, the uterus was removed and processed. results: when systemic p treatment was withdrawn at the end of each cycle, animals with empty ius menstruated normally, while animals with cdb-ius bled little or not at all. over the whole . cycles, animals bearing a blank ius bled for an average of . ± . days while cdb treated animals bled for an average of only ± . days. at the end of treatment, animals exposed to blank ius had mean endometrial wet weights of ± mg while the cdb-treated endometria weighed only ± mg. the proliferation markers ki- and phospho-h were substantially lower in the cdb-ius treated than in the blank treated animals. histologically, the cdb exposed endometria were atrophied with evidence of glandular degeneration while the blank controls were proliferative and normal. summary: in cycling rhesus macaques, a cdb-ius prevented progestational development, blocked menstruation after p withdrawal, and suppressed endometrial proliferation. if these effects are confirmed in women, the cdb-ius could provide estrogen-free and bleed-free contraception, and could help control heavy menstrual bleeding. supported by rr , hd and the population council. introduction: irregular uterine bleeding is a major side effect and cause for discontinuation of ltpoc use. while endometria of ltpoc-exposed women display abnormally enlarged, fragile blood vessels (bv), decreased blood flow and evidence of oxidative stress, the mechanisms by which structural and vasomotor endometrial dysfunction occurs remains unknown, in part by the difficulty of manipulating hormone levels in women. the aims of this study were ) to validate the guinea pig (gp) as a model to study uterine effects of ltpoc and ) to investigate ltpoc-effects on endometrial histology and oxidative stress markers. methods: oophorectomized gps were implanted s.c. with time release pellets containing either placebo (crl,n= ); estradiol (e ,n= ); medroxyprogesterone acetate (mpa,n= ) or e +mpa (n= ). after days, uterine horns were weighed and frozen or paraffin embedded. angiogenesis was assessed by quantitative image analysis of vonwillebrand factor staining and included bv density and size. oxidative stress was detected by isoprostane and -oh-deoxyguanosine ( oxog). apoptosis was investigated by the tunel method. statistical analysis was by -way and -way anova. results: gp uteri were enlarged by both e (p< . ) and mpa (p= . ). effects of mpa on uterine weight differed significantly depending on e levels (p< . ), where mpa opposed the e effect in combined treatments. angiogenesis parameters were similarly impacted upon. thus, mpa alone increased bv density (p= . ) and bv average area (p= . ). the presence of e significantly decreased these parameters (bv density mean± sem: crl: . ± . %, e : . ± . %, mpa: . ± . %, e +mpa: . ± . %, p= . ). these changes were associated with highly elevated -isoprostane content in e +mpa-treated uteri compared to all other groups (p< . ). abnormalities in the e +mpa group were consistent with chromatin redistribution, nuclear pyknosis, karyolysis and increased nuclear oxog staining and a marked increase in tunel labeling. conclusions: ltpoc exposure alters endometrial vascular and tissue morphology consistent with oxidative stress and apoptosis in a complex interplay with endogenous estrogens. the gp is an excellent model for the study of ltpoc effects on the uterus. physiologic and psychological symptoms associated with injectable and oral contraceptive use. abbey b berenson, susan odom, carmen r breitkopf, mahbubur rahman. ob/gyn, utmb, galveston, tx, usa. objective: to compare physiologic and psychological symptoms over mo among users of depomedroxyprogesterone acetate (dmpa), an oral contraceptive with micrograms ethinyl estradiol (oc), and non-hormonal (nh) contraception. methods: a total of women reported the presence of symptoms prior to initiating contraception ( dmpa, oc, nh) and every mo thereafter for mo. longitudinal relationships between symptoms and contraceptives (reference: nh), as well as race/ethnicity (non-hispanic black, non-hispanic white, and hispanic) were assessed by gee-analysis after adjusting for age, visits and baseline status of symptoms. persistence, resolution, and new development of symptoms were noted by method in mo increments for mo and compared with that of nh controls. the gee analyses showed that oc was protective against mastalgia (or= . ), cramping (or= . ), hair loss (or= . ), acne (or= . ), nervousness (or= . ) and mood swings (or= . ). when race was considered, oc was protective for all women against acne, for whites against mastalgia and cramping, and for non-whites against nervousness. for whites, it was a risk factor for bleeding between menses. oc use resulted in resolution of acne within mo in nearly % of those with it at baseline, but no significant resolution after mo. also mastalgia ( % at baseline) was less likely to persist at and mo. bleeding between menses was reported for the first time at mo by % of oc users. dmpa users of all races had an increased risk of missed periods (or= . ), bleeding between menses (or= . ), bleeding > d (or= . ) and loss of libido (or= . ) relative to nh users. it reduced cramping (after mo) and bloating (all mo). racial differences were observed with dmpa protective against mastalgia and mood swings in whites, cramping in whites and hispanics, and bloating in non-whites. it was a risk factor for loss of energy in whites only. neither method affected depressive symptoms. conclusion: side effects of these two methods are mostly related to abnormal bleeding. very low dose pills can be protective against symptoms (mastalgia, cramping, hair loss, acne, nervousness and mood swings) commonly associated with pills while dmpa protects against cramping and bloating. knowledge about racial differences will allow physicians to individualize therapy. counseling should include that some symptoms can develop after mo while resolution often occurs within mo. methods: twenty-four women were enrolled in irb approved prospective, randomized, cross-over trial comparing months of oc (ortho cyclen) vs. tc ortho evra). the daily oc administers micrograms of ee; the weekly tc contains . milligrams of ee. each treatment was followed by months of washout and months of the alternative contraceptive. blood was drawn at baseline and final week of treatment for each arm of the study. ee was quantified by ria, with preceding organic solvent extraction and celite column partition chromatography. data were analyzed by t test with boferroni's correction, p < . . results: after two months of treatment the mean (+/-sem) ee levels for tc = . pg/ml (+/- . ) and oc = . pg/ml (+/- . ). the ee level is not significant different for the two medication (p = . ). conclusions: there is no difference in ee levels with the use of these oral and transdermal contraceptives. this suggests the transdermal contraceptive, despite the lack of the hepatic first pass effect, has similar levels of ethinyl estradiol compared to oc. the continuous elevation in ee seen with the tc route of administration, versus the episodic increases seen with the oc route, raises concerns of constant exposure to ee. this may explain the increased risk of estrogen-induced thrombotic events with this tc route of administration. impact of paracervical block, in combination with general anesthesia, on post-abortion pain. gweneth b lazenby, tod aeby. obstetrics and gynecology, university of hawaii, honolulu, hi, usa. objective to evaluate the impact of paracervical block with a long-acting local anesthetic, in conjunction with general anesthesia, on post-operative pain. methods a power analysis determined patients per arm were needed to demonstrate a significant difference of in mean pain scores. seventy-two patients were allocated to one of two arms using urn randomization. all patients received standardized anesthesia; intravenous sedation for gestational age under weeks and general anesthesia for over weeks. thirty-nine patients were randomized to receive a paracervical block with . % bupivacaine and thirtythree were randomized to no local anesthesia prior to surgical abortion. patients completed visual analog scales for pain and anxiety prior to the procedure, upon awaking, and minutes post-operatively, and prior to discharge. data were analyzed using an anova and students t-test the experimental and control groups were equivelent in age, ethnicity, gravidity, parity, prior abortions, prior vaginal deliveries, prior c-sections, gestational age, number of laminaria, pre-operative and intra-operative dilation, operative time, estimated blood loss, and reported complications. pain and anxiety were not significantly affected by placement of a paracervical block. these data do not support the hypothesized benefit of local anesthesia, prior to surgical abortion under general anesthesia, to reduce post-operative pain. we do not recommend the routine use of a paracervical block to decrease post-operative pain. age, parity, history of abortion and contraceptive choices affect the risk of repeated abortion. oskari heikinheimo, mika gissler, satu suhonen. ob gyn, university of helsinki, helsinki, finland; national research and development centre for welfare and health, helsinki, finland. objective the rate of repeat abortion varies from to % in northern europe. however, risk factors for repeat abortion are poorly understood. we characterized risk factors (demographic, as well as those related to abortion and postabortal contraception) of repeat abortion. design a prospective cohort study of women undergoing medical abortion between august and december . the subjects were followed by means of finnish registry on induced abortions until december ; the follow-up time (mean ± sd) was . ± . months. results altogether ( . %) of the subjects requested repeat abortion within the follow-up time. in univariate analysis previous abortion, parity, young age, smoking and failure to attend the follow-up visit were associated with increased risk of repeat abortion. immediate -in contrast to postponed -initiation of any contraceptive method was linked to lower risk of repeat abortion. in comparison to combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. in multivariate analysis the effects of young age, parity, previous abortion and type of contraception on the risk of another abortion persisted. conclusions increased focus on young, parous and those with the history of an abortion may be efficacious in decreasing repeat abortion. contraceptive choices made at the time of abortion have an important effect on the rate of reabortion. postabortal use of intrauterine contraception, specifically that of lng-ius, might decrease the rate repeat abortion. objective. to determine the rate of failure and to analyze factors associated with failure for the essure permanent birth control device at the detroit medical center (dmc). methods. a chart review was conducted on patients who underwent essure placement at the dmc from january through june . patient demographics, past medical and surgical history, anesthesia type, procedure time, intraoperative complications, and procedure failures were noted. data were analyzed for statistical significance using spss. results. there were essure procedures attempted at the dmc from january through june . of the attempted procedures, there were failures ( . %). of the failures were attributed to difficulty visualizing the ostia ( %). other causes of failure included expulsion of the device ( ), tubal spasm ( ), uterine perforation ( ), and tubal ostia too large for the device ( ). there were cases of failed placement for undocumented reasons, one case requiring a laparoscopic tubal ligation secondary to postprocedure tubal patency, and post-procedure pregnancies. age, race, body mass index, gavidity, parity, history of sexually transmitted infections, medical history, history of cesarean section, tobacco or illicit drug use, anesthesia type, and physician experience with the procedure were not significantly associated with placement failure or difficulty visualizing the ostia. a longer procedure time was significantly associated with failure ( . vs . min, p = . ), and history of ectopic pregnancy was significantly associated with difficulty visualizing the ostia ( . % vs . %, p = . ). conclusion. the failure rate for placement of the essure permanent birth control device at the dmc is . % with a pregnancy rate of . %. the majority of failures may be attributed to difficulty visualizing the ostia. a history of ectopic gestation was significantly associated with difficulty visualizing the ostia; thus, it may be reasonable to advise these women that success in essure placement may be reduced. introduction. the essure permanent birth control device is a relatively new form of minimally invasive sterilization for women. under hysteroscopic guidance, a dynamically expanding micro-insert is introduced into the proximal portion of the fallopian tube. the micro-insert induces local fibrosis and ultimately occlusion of the tubal lumen. a hysterosalpingogram (hsg) is performed three months after the procedure to confirm bilateral tubal occlusion. objective. to determine the follow-up rate for the post-essure hsg for a clinic population. methods. a retrospective chart review was conducted on university health center (uhc) patients who underwent placement of the essure permanent birth control device at the detroit medical center from january through june . follow-up for the post-essure hsg as well as the result of the hsg were noted for each patient. results. placement of the essure permanent birth control device was attempted in uhc patients of which were successfully completed. of the patients, ten underwent a post-essure hsg ( . %). the hsg was performed three to six months after placement of the essure permanent birth control device. bilateral tubal occlusion was documented in all ten patients. conclusion. despite counseling patients prior to their procedure that a hsg is needed and providing an information sheet, the follow-up rate for the post-essure hsg for this clinic population is only . %. for those in whom a hsg was performed three to six months after essure placement, bilateral tubal occlusion was confirmed in all. steps and or approaches to improve compliance with post-procedure confirmation of tubal occlusion should be employed to increase follow-up in the future. towards fibroids gene therapy: adenovirus mediated delivery of herpes simplex virus thymidine kinase gene/ganciclovir shrinks uterine leiomyoma in the eker rat model. memy hassan, dong zhang, salama salama, cheryl walker, hala el-mazar, ayman al-hendy. ob/gyn, utmb; md anderson; ob/gyn, meharry medical college, nashville, usa. aim: assessment of the efficacy of gene therapy of uterine leiomyoma in the immune-competent eker rat model using adenovirus mediated delivery of herpes simplex- -thymidine kinase gene followed by ganciclivir treatment (ad-tk/gcv). method: female eker rats with mri-confirmed uterine fibroid lesions were randomized to a single treatment with direct intratumor injection of ad-tk/gcv, ad-lacz/gcv, or medium.the tumor volume was evaluated by serial mri scanning and confirmed with caliper measurement at time of euthanasia. sample rats were selected randomly and killed at the following time points; , and days post treatment. samples were collected from tumors, other body organs and blood to assess the safety and efficacy of the treatment. results: ad-tk/gcv treatment produced dramatic shrinkage of the total uterine fibroid volume by % ± , % ± and %± of pretreatment volume at days , and respectively. the tumor size in negative control animals receiving ad-lacz/gcv continued to grow by + %± , + %± , + % ± while receiving media continue to grow by + % ± , + % ± and + % ± at same time points. ad-tk/gcv induced significant increase in caspase activity, bax expression, decrease in bcl and parp proteins expression and increased tunnel apoptosis index. additionally ad-tk/gcv treatment decreased cyclin d and pcna expressions. ad-tk/gcv did not produce any significant change in liver function tests or relative uterine horns weight to total body weight. the adenovirus transfection did not disseminated significantly to other distal organs except to liver and myometrium in limited number of animals. h e staining of non targeted organs did not revealed any sign of tissue damage. ad-transfection increased local cd and cd expressions as well as serum anti-ad antibodies. conclusion: ad-mediated delivery of hsv tk gene by direct intra-tumor inoculation followed by sc treatment of gcv for ten days effectively shrinks uterine leiomyoma lesions in eker rats. this effect is mediated via induction of apoptosis and decreasing the proliferation. the treatment regimen is well tolerated. these studies provide essential preclinical data for the development of gene therapy as an alternative non-surgical treatment option for women with symptomatic uterine fibroids. inhibitors of catechol o-methyl transferase shrinks uterine fibroids in the eker rat model. memy hassan, dong zhang, hala el-mazar, cheryl walker, ayman al-hendy. ob/gyn, utmb; md anderson; ob/gyn, meharry medical college, nashville, usa. background :the sex hormone dependent pattern of uterine leiomyomas and their high content of catechole -o-methy transferase (comt) raise the possibility for the development of novel treatment option using comt inhibitors.aim : to assess the potential therapeutic utility of a synthetic comt inhibitor (ro - ) in the eker rat model of uterine leiomyoma. methods female eker rat were evaluated by mri to confirm the prescence uterine fibroid lesion, then randomized for sc treatment with ro - mg /kg ,twice/ day for days versus vehicle injection.fibroid tumor burden was evaluated by serial mri measurement and confirmed by direct caliper measurement at time of euthanasia. sample animals were euthanized at and weeks. at that time tumor tissue, blood and most of animal organs including long bones were collected and subjected for further evaluations. hours urine samples were collected for evaluation of estrogen (e ) metabolites and bone resorption marker. results:animals treated with ro - exhibited significantly lower uterine fibroid tumor burden ( % and %) of pretreatment volume at and weeks post treatment respectively. conversely, the tumor size in control animals continued to grow and reached %, and % of pretreatment size at the same time points. ro - treatment resulted in an increase in urinary / hydroxy e metabolite ratio. in addition ro - increased bax expression and decreased parp , pcna and cyclind experssions . all ro - treated animals tolerated the treatment protocol with no signs of toxicity. h e staining of different body organs did not reveal any signs of tissue damage. furthermore, there was no significant change in both liver function tests (alt, ast, billirubin) and bone resorption marker , deoxypyridinoline croslinks, between treated and control rats. conclusion ro - , a synthetic selective comt inhibitor, caused immediate arrest of the growth of eker rat uterine leiomyoma. this effect might be in part due to modulation of various estrogen dependent genes regulating leiomyoma apoptosis (parp, bax) and proliferation (pcna, cyclin d ). this anti-estrogenic effect is due to the accumulation of the the antiestrogenic metabolite hydroxy estrogen secondary to comt inhibition.comt inhibitors might present an alternative non-surgical option for the treatment of women with symptomatic uterine fibroids. background development of uterine leiomyomas (fibroids) is the most common pathological feature in the female reproductive tract. they negatively impact patients of virtually every gynecologist. despite such morbidity, leiomyoma development is poorly understood. we have recently demonstrated that leiomyomas have a genomic expression pattern that limits retinoic acid (ra) exposure. our group and others have demonstrated that tgf-beta regulation is altered as well. these two pathways likely play central roles in leiomyoma development. the central feature of uterine leiomyomas, the extracellular matrix (ecm), is regulated by both all-trans retinoic acid and tgf- , focusing on versican as a critical ecm component. human uterine leiomyoma and patient-matched myometrium were obtained from surgical specimens under an irb-approved protocol. these tissues were immortalized and treated with either all-trans retinoic acid, tgf- , or anti-tgf- antibody. rna was isolated for qrt-pcr. human immortalized leiomyoma cells demonstrated the same increased template expression of tgf- ( . ± . fold), retinoic acid metabolizing protein (cyp a ; . ± . ), and versican variant v ( . ± . fold) as was found in the progenitor tissue. when treated with all-trans ra, expression of versican variant v decreased to levels found in myometrial cells ( . ± . fold). conversely, when treated with tgf- , expression of versican variant v increased . ± . fold. to confirm that tgf- was central to the overexpression of v , we treated leiomyoma cells with anti-tgf- antibody, and found that baseline over-expression of v template was decreased to expression levels similar to untreated myometrial cells. finally, we elucidated a link between the ra and tgf-pathways by assessing the impact of ra treatment of tgf- expression, demonstrating that tgf- template decreased to levels comparable to myometrial cell expression ( . ± . fold). the disrupted leiomyoma ecm, of which versican is a central component, defines the leiomyoma phenotype. in this study, the leiomyoma fibrotic phenotype regressed when treated with ra and increased when treated with tgf- , providing the basis for novel therapeutic interventions directed at cell differentiation and ecm formation. objectives: uterine fibroids are the leading cause for hysterectomies in the us. the lack of an appropriate in vitro cell model for the initiation of fibroid growth has hindered advancement in understanding the cellular and molecular basis for the development and progression of uterine fibroids. fibrosis is the underlying mechanism of uterine fibroid formation and myofibroblasts cells are the principal fibrogenic cell type in the uterus. we sought to develop a myofibroblast in vitro cell model for analyzing the initiating molecular events of uterine fibrosis. methods: smooth muscle cells (smcs) were enzymatically isolated from the myometrium of non-pregnant women and cultured in the presence of % serum until % confluent. for the next h cells were cultured in serum-free media followed by replacement with serum containing media. cells were fixed at , , , , m later. cell fine structure and cytoskeletal organization were evaluated by transmission electron microscopy. smooth muscle specific alpha-actin ( -sma) and progesterone receptors (pr) were detected by western blot. results: we observed smc differentiation into myofibroblasts, marked by the presence of notched nuclei ( figure) and the increased expression of -sma m after serum replacement. pr-a and pr-b were detectable at , and m. conclusions: the development of myofibroblasts is important in wound healing and fibrosis. we show for the first time that uterine myofibroblasts can be derived in culture from myometrial smcs. thus, these cells will be utilized as a model for developing "in vitro fibroids". this model will enable the study of myofibroblast activation, cytokine signaling, intracellular regulation of uterine fibrogenesis, production of extracellular matrix proteins and development of antifibrotic drugs. the presence of prs in our model enables us to evaluate pr mediated events in fibroid pathogenesis and treatment. this model will be more useful in determining the molecular biology of fibroid initiation than cell models derived from established fibroids that are already well past their initial stages of development. novel approach to genome-wide expression profiling analysis. liping feng, morgan walls, insuk sohn, millie behera, sin-ho jung, phyllis leppert. obgyn; biostatistics and bioinformatics, duke university medical center, durham, nc, usa. background: microarray studies have examined the differential gene expression between uterine fibroid and normal myometrium. all previous studies considered the fibroid as a whole and analyzed only fold changes. we have developed a novel statistical approach to genome-wide expression analysis comparing two fibroid tissue sites to myometrium. methods: using affymetrix tm u a genechip, we have compared the gene expression between c and e and matched adjacent m. data has been analyzed by considering the specimens per subject and subjects as individuals. we used a block one-way anova method to test if each gene was differentially expressed among the three sites. the p-value is calculated using a permutation method accounting for possible dependency among three lesions. the multiple testing issue was addressed by controlling the false discovery rate. expression values were calculated using the robust multichip average (rma) method. rma estimates are based upon a robust average of background corrected perfect/mismatch (pm) intensities. normalization was done using quantile normalization. expression values were then transformed by taking logarithm base . confirmatory rt-pcr was performed. results: we applied a hierarchical clustering analysis to all raw data sets and then displayed a dendrogram, where the height of each branch point indicates the similarity level at each generated cluster. identical gene expression among sites clusters together. due to a strong site effect, m tissues clustered separately from e and c combined. genes were differentially expressed when we used a . q-value cut off. expression data revealed concordant changes in genes regulating cholesterol biosynthesis, gene transcription, estrogen and extracellular matrix formation when both e and c were examined. cyp was detected and we report for the first time that scc- (a cell cycle-regulated molecule) folliculin and l-selectin are differentially expressed suggesting that they may be involved in the regulation of cell growth and proliferation of uterine fibroids. conclusions: our novel robust analysis of gene expression provides new clues to the relevant pathways of fibroid development. this new statistical approach that can be used in clinical and/or translational studies to identify differentially expressed genes comparing treatment regimens, cells or tissues. objectives: thrombospondin- (tsp- ) is a large matricellular glycoprotein secreted by many cell types. matricellular proteins modulate interactions between cells and their environment, regulate cell adhesion and are expressed during tissue formative processes. they are especially important in fibrosis. tsp- plays an important role in angiogenesis and is an activator of tgf - . in a previous study, we found that differential expression of tsp- in uterine fibroids may contribute to an altered healing process leading to fibrosis. this alteration in tissue response to injury initiates the development of abundant, nonaligned collagen fibrils and changes in other components of the ecm. methods: we measureed the pattern of mrna and protein expression of tsp- by rt-pcr and western blot in an in vitro serum-deprived differentiated myometrial cell (myofibroblast) model. specifically, smooth muscle cells (smcs) were enzymatically isolated from the myometrium of non-pregnant women and grown in primary culture to % confluence. then smc were serum deprived for h and treated back with % serum for , , , and m. cells were collected for rna and protein, and tsp- expression was evaluated. in addition, cells were stained using the combination of anti-cd and anti-smooth muscle -actin or combination of anti-cd d and anti-smooth muscle -actin as well as the appropriate single and double negative controls. stained sections were analyzed using zeiss axio imager widefield fluorescence confocal microscopy. results: tsp- mrna and protein was present in cells in this serumstarvation model after the addition of serum and the expression level remained elevated for m following the addition of serum. fluorescence staining analysis indicated that these cells were positive for human smooth muscle -actin, but negative for leukocyte antigen cd and platelet marker cd d suggesting that the myofibroblasts cells themselves were the source of the tsp- . conclusions: unlike skin wounds, where tsp- is derived from the blood macrophages, monocytes and platelets, differentiated myometrial cells appear to produce tsp- . elucidating the roles of tsp- in myometrium physiology and pathobiology will increase our understanding of the etiology of uterine fibroids and may lead to improved therapies. further studies utilizing this cell model to determine the role of tsp- in the activation of tgf - are indicated. phospholipid s p via gi, rac and rho pathways. yoel smicun, armando wu pimentel, jennifer gilman, david a fishman. obstetrics gynecology, new york university school of medicine, new york, ny, usa. objectives: sphingosine- -phosphate (s p) levels are elevated in serum and ascites of ovarian cancer patients. we have demonstrated that low concentration s p enhances while high dose s p inhibits invasion of epithelial ovarian carcinoma (eoc) cells in a dose and attachment mode dependent manner. we sought to further dissect the pathways by which s p affects invasion, using specific inhibitors. methods: dov eoc cells were pretreated for -hrs with vehicle, . m or m s p and with inhibitors for gi, p -mapk, rac and rock, thereafter cells were detached and tested for invasion towards m lpa chemoattractant in matrigel-coated chambers. conditioned media from pretreated cells and invading cells were quantified for upa activity using colorimetric assays. the significance of results was calculated by student's t-test. results: inhibition of gi mildly increased invasion of both control ( p= . ) and m s p treated cells ( p= . ). inhibition of both p -mapk and rac did not affect m s p treated cells, in contrast invasion of control cells was mildly increased (p= . , . ). inhibition of rock, a protein effector downstream of rho, highly elevated invasion of both control and m s p treated cells ( fold, p= . , fold, p= . ). both upa and gelatinase activities were higher in conditioned media of invading cells than of attached cells. gelatinase activity was enhanced by both concentrations of s p (p= . , . ). ptx fully inhibited gelatinase activity of control and . m s p treated cells, and partially of the m s p treated cells (p< . ). . m s p significantly increased upa activity of attached (p= . ) but not of invading cells. this increase was sensitive to ptx and rac inhibitor. m s p inhibited upa in both attached and invading cells (p= . ), this inhibition was rock dependent. conclusions: these findings suggest a strong inhibition of invasion and upa by the rho pathway, of both control and m s p treated cells. this inhibition is induced partially by upstream gi protein. increased invasion by . m s p is associated with elevation of gelatinase activity through gi, rac and rock pathways. this suggests that attached cells and invading cells affect upa activity through different pathways. objectives: sphingosine- -phosphate (s p) levels are elevated in serum and ascites of epithelial ovarian cancer (eoc) patients. we have demonstrated that invasion of attached eoc cells differentially react to s p as compared to invading cells. we examined the impact of the inhibitors for gi and rac on attached and invading eoc. methods: dov eoc cells were pretreated for -hrs with vehicle, . m or m s p and with inhibitors for gi (pertussis toxin (ptx)), and rac (nsc , (rac-i)), and cells were detached and assayed for invasion towards m lpa in matrigel-coated chambers. to distinguish the response of attached from invading cells, inhibition of cells pretreated with inhibitors was either continued or not in the invasion chambers. conditioned media (cm) of invading cells were quantified for upa and gelatinase activity by fluorometric and colorimetric assays. significance of results was calculated by student's t-test. results: the significant (p= . ) increase of invasion by . m s p was inhibited by both ptx and rac-i, either by pretreatment alone or by continuous treatment (p= . - . ). however, the invasion was higher in cells inhibited continuously than cells inhibited only in dishes. both inhibitors did not affect cells treated with m s p. control cells invasion was increased ( . fold, p= . ) by continuous rac-i treatment. . m s p increased gelatinolysis in cm of invading cells. this and control cells activity was inhibited by ptx pretreatment. continuous treatment with ptx or rac-i elevated and fold gelatinase activity of control and m s p treated cells. in contrast upa activity was inhibited by both . m and m s p. activity of control cells was inhibited by both pretreatment and continuous treatment with both ptx and raci. upa activity of cells treated with . m s p was increased only by pretreatment with ptx and raci. in contrast, in cells treated with m s p upa was inhibited only by continuous inhibition with ptx and raci. conclusions: invasion of s p induced eoc cells correlated with the gelatinase and upa activities in their microenvironment. ptx and rac-i affect attached and invading cells in different manner, inhibition of invasion and gelatinolysis of attached and increased invasion of invading cells. this suggests a dual effect of the gi-rac pathway, inhibiting attached and stimulating invasion via gelatinolysis of invading cells. lysophosphatidic acid (lpa) levels are elevated in the ascites and plasma of early-and late-stage ovarian cancer patients, underscoring the unique role this bioactive lipid plays in the pathobiology of epithelial ovarian cancer (eoc). lpa binding to its cognate g-protein-coupled receptor can transactivate the receptor tyrosine kinase, egfr, which is often overexpressed in ovarian tumors. in the current study, we investigated the role that lpa activation of egfr plays in the processing of the metalloproteinase, mmp- , and eoc dissemination. lpa stimulates tyrosine phosphorylation of egfr in ovarian cancer cells, and egfr kinase activity is required for optimal lpa induction of pro-mmp- activation. lpa-dependent pro-mmp- activation does not require the egfr ligands, amphiregulin, b-cellulin, egf, hb-egf, and tgf-a. we previously reported that when cells are cultured at high density, lpa represses rhoa activity to induce loss of stress fibers, and these changes in actin microfilament organization contribute to pro-mmp- activation. in the current study, inhibition of rho-kinase/rock with y- reversed the repression of lpa-stimulated pro-mmp- processing observed with treatment of the egfr kinase inhibitor, ag . correspondingly, lpa induced the loss of stress fibers, while inhibition of egfr kinase restored stress fiber formation in lpa-treated cells. this suggests that lpa acts through egfr to modulate microfilament organization and pro-mmp- processing. finally, lpa-induced cellular haptotactic migration and invasion are abrogated when egfr kinase activity is blocked. taken together, these results suggest that egfr signaling plays a critical role in lpa regulation of metastatic pathways by mediating changes in the cytoskeleton which impact protease activity. objectives: membrane-derived vesicles are active modulators of tumor dissemination; they promote and contribute to extracellular matrix degradation and tumor cell invasion. we have isolated vesicles from ascites of ovarian cancer patients and from ovarian cancer cells in vitro. here we analyzed the functional consequences of exposure of cancer cells to vesicles derived from a different type of malignancy in order to evaluate their proinvasive properties. methods: ovarian cancer (dov ), breast cancer (mda mb ) and mesothelioma (hp- ) cells were grown in media supplemented with % fbs. after serum deprivation, % vesicle-free fbs was added for hr to induce vesicle release. vesicles were isolated from media by differential centrifugation and quantified with a bradford assay. fusion to cells was followed by fluorescence of the lipophilic tracer dii. each cell line was stimulated with and g/ml of each type of vesicles and tested in a matrigel invasion assay. changes in proliferation were evaluated in an mts assay. gelatin zymography was used to assess matrix metalloproteinase activity of vesicles. results: zymographic analysis showed that vesicles contained mmp- and . fusion experiments showed that all vesicles fused to all cell types. all vesicles induced the invasion of their respective cell types in a dose-dependent manner. when vesicles were used at g/ml they induced significantly high levels of invasion in all cell types tested. at g/ml they significantly inhibited invasion in different cell types. both concentrations of vesicles stimulated cell proliferation in all cell types tested. conclusions: membrane derived vesicles are potent mediators of invasion for mesothelioma, breast and ovarian cancer cells in vitro. this effect occurs in a dose-dependent manner when vesicles induce invasion of the same cell type from which they were isolated. when vesicles are used to induce a different cell type, low concentrations induce invasion while high concentrations inhibit invasion, this effect was independent of cellular proliferation. these results suggest that a novel mechanism may be at play where activation of recognition of self and non-self specific pathways may determine the invasive potential of the tumor cell upon fusion to microvesicles. the identification of signaling pathways responsible for this heterotypic signaling is a current effort. vegfr- as a potential target to inhibit lpa-induced epithelial ovarian cancer (eoc) invasion. sonia dutta, fengqiang wang, elaine barfield, david a fishman. obstetrics and gynecology, new york university school of medicine, new york, ny, usa. objective: vegf and vegf receptors (vegfrs) play important roles in ovarian cancer metastasis. in this study, we examined the expression profiles of vegf and vegfrs (vegfr , vegfr , co-receptor nrp and nrp ) in established eoc cells lines (dov , r , ovca , skov ) and an immortalized normal ovarian epithelium (iose- ). the effect of lysophosphatidic acid (lpa) on vegf and vegfrs expression and the effect of vegfr- silencing by rnai on lpa-induced invasion were also evaluated. methods: vegf and vegfrs expression in ovarian cancer cell lines and normal ovarian epithelium was quantified by real time pcr. cell invasion differentiate into either a pro-tumor or anti-tumor phenotype depending on the specific tumor microenvironment. previously, we described a subgroup of epithelial ovarian cancer (eoc) cells with a functional tlr- -myd -nf-b pathway (type i eoc cells). these cells have constitutive nf-b activity and constitutively secrete il- , il- , mcp- , and gro . we hypothesize that type i eoc cells, but not type ii, can promote macrophage differentiation into a tumor-supporting immune cell. methods: eoc cell conditioned media (cm) was prepared by incubating eoc cells in log-phase growth in optimem for h. migration assay was done using an in vitro cell culture insert with m-size pore and pkh red fluorescentlabeled thp- . cytokine profile of thp- cells co-cultured with eoc cell cm was determined using xmap technology. modulation of response to apoptotic bodies was determined by "pre-educating" thp- cells with eoc cell cm for h prior to exposure to apoptotic bodies ( : ratio with thp- cells). results: monocytes migrate toward eoc cells. however, migration is significantly higher towards type i eoc cells. type i, but not type ii, eoc cells alter monocytes' cytokine profile by inducing the secretion of high levels of progrowth and angiogenic cytokines il- , il- , mcp- , and gro . furthermore, type i eoc cells modify monocytes response to apoptotic bodies by inducing a significant increase in the secretion of il- , il- , mip- , mip- , and gro ( -fold, . -fold, -fold, -fold, and -fold respectively). conclusion: we demonstrate for the first time a differential interaction between two subtypes of eoc cells and monocytes. we showed that the microenvironment created by type i eoc cells is able to modify the function and differentiation of immune cells towards a tumor supporting phenotype. understanding the molecular mechanisms mediating this tumor-immune interaction will help to design appropriate immune therapies that will take into consideration the tumor microenvironment. objectives: the standard of treatment for patients with ovarian cancer (oc) is intravenous combination chemotherapy (ct) after primary cytoreductive surgery. although initial response is above %, most of these patients experience recurrence. the only approach for these patients is salvage ct which may prolong their lives for months. early detection of patients who are not responding to current therapy or are at risk of experiencing an early relapse of disease might improve response rates and survival if alternative therapy is possible. no single predictive marker has yet been proven sufficiently sensitive or specific to find a place in the daily clinic. in the present study we use a newly described biomarker test for the detection of oc (visintin et al clinical cancer research) and evaluated the ability of the test to monitor ct response methods: patients with oc, figo stage i-iv, were included in this study. all patients recieved postsurgery first line combination ct (paclitaxel/carboplatin). samples were evaluated at ) baseline (mean days after surgery), prior to the first cycle of ct, and ) after cycles of ct. μl serum samples were analyzed by multiplex assay (beadlyte® cancer biomarker panel kit) for six markers. changes during ct and differences in markers between patients with short time to progression (ttp) and patients with long ttp were determined. results: positive test for oc was observed in % of the patients evaluated at baseline. all patients had residual disease after surgery. from patients with long ttp, / patients (specificity %) had a negative test after cycles. from the patients with short ttp, / had a positive test (sensitivity %) p= . ( ²). the risk of experiencing a ttp shorter than months when having a positive test after cycles of ct was %. conclusion: we describe for the first time the use of a panel of biomarkers for oc that might have an application for monitoring ct response and risk of relapse. the test detects the presence of residual disease following debulking surgery, and differentiates between long term and short term progression. a longitudinal study is performed to determine how early during ct the test can identify responder versus non responder. ksp inhibitor (arry- ) as an alternative for paclitaxel in myd -positive epithelial ovarian cancer cells. ki h kim, ayesha b alvero, yanhua xie, david trollinger, gil mor. obstetrics, gynecology, and reproductive sciences, yale university school of medicine, new haven, ct, usa; array biopharma inc., boulder, co, usa. background: we previously described that epithelial ovarian cancer (eoc) cells ubiquitously express tlr- , but not the adaptor protein myd . when treated with paclitaxel, a known tlr- ligand, myd -positive eoc cells exhibited nf-b activation, increased secretion of il- , il- , mcp- , and gro , and increased p-erk levels . since majority of eoc patients are given paclitaxel in combination with a platinum drug, it is not only important to distinguish those patients that should not be given paclitaxel; it is also important to identify alternative chemotherapy agents that would benefit this sub-group of patients. the objective of this study is to determine if the ksp inhibitor, arry- , can be an alternative for paclitaxel in myd -positive ovarian cancer patients. methods: myd -positive and myd -negative eoc cell lines isolated from either ascites or tumor tissue were treated with increasing concentrations of arry- ( to nm) or paclitaxel ( . to m) for , , and hours and cell viability was determined using the celltiter aqueous one solution cell proliferation assay. cytokine profiling was performed from supernatants using xmap technology. nf-b activity was determined using a luciferase reporter system. p-erk levels were measured by western blot analysis. results: arry- and paclitaxel exhibited the same cytotoxic effect on myd -negative and positive eoc cells. the ic at h for myd -negative eoc cells was . m and . um for arry- and paclitaxel, respectively. for myd -positive eoc cells, the ic at h was m and m for arry- and paclitaxel, respectively. however, unlike paclitaxel, arry- did not induce nf-b activation or enhance the secretion of il- , il- , mcp- , and gro , and did not induce erk phosphorylation on myd positive cells. conclusions: administration of paclitaxel to patients with a myd -positive tumor could have detrimental effects due to the paclitaxel-induced enhancement of cytokine production which promotes chemoresistance and tumor growth. arry- has similar anti-tumor activity in eoc cells as that of paclitaxel. however, unlike paclitaxel, it does not induce cytokine production in myd positive eoc cells, and therefore, the ksp inhibitor arry- may represent an alternative to paclitaxel in this subgroup of eoc patients. introduction: nf-b activation has been associated with cell proliferation, angiogenesis, metastasis and suppression of apoptosis in ovarian cancer. in addition, nf-b activity induces the production of pro-inflammatory cytokines which may contribute to chemoresistance. inhibition of nf-b may represent a new approach to prevent tumor growth and reverse chemoresistance. in the present study we described the characterization of a novel nf-b inhibitor, eriocalyxin b (erib) that is able to re-establish the apoptotic cascade in chemoresistant ovarian cancer cells by suppressing pro-inflammatory cytokines and antiapoptotic proteins. materials and methods: eoc cell lines were isolated from malignant ovarian cancer ascites. caspase activity was determined by caspase-glotm assay. cytokine production and secretion were determined using multiplex assay. erib effect on cancer cells was evaluated in a time and dose dependent manner using celltiter cell proliferation assay. protein expression was determined by western blot analysis. combination studies were done with paclitaxel and carboplatin in addition to erib treatment. nf-b activity was determined by monitoring the expression of a nf-b luciferase reporter. results: erib decreased cell viability of ovarian cancer cells with an ic of . - μm in hours and was associated to increasing levels of caspases , and activity. intracellular changes induced by erib included: ) inhibition of nf-b activity; ) decrease in cytokine production; ) down regulation of anti-apoptotic proteins xiap and flip, and reversal of resistance to tnf-and fasl-mediated cell death; and ) chemosensitization to carboplatin and paclitaxel. at present, evidence is accumulating regarding the existence of unique populations of specialized tumor-initiating, stem-like cells within various tumor types of distinct origins. these cancer stem cells (csc), with characteristics reminiscent of normal stem cells, are thought to be responsible for driving tumor growth. we propose that ovarian cancers arise from csc, and are using microarray-based technology to identify specific genes/cell surface markers associated with ovarian csc that will permit distinction of these rare cells from the remaining tumor bulk. to identify unique gene signatures associated with an ovarian tumor-initiating cell population, we have utilized an in vivo serial transplantation model. this model selects for primary human ovarian tumor cells with increased tumorigenic capacity, given that time to tumor formation decreases with successive serial transplant despite fewer cells injected. our initial studies used cells derived from a human ovarian clear cell carcinoma, serially transplanted for three passages in nod/scid mice. rna derived from these transplanted tumors was analyzed on human genome microarrays. from these analyses, several differentially expressed genes were identified. the differential expression noted for potential genes of interest is currently being validated by rt-pcr. of particular interest, expression of the transmembrane glycoprotein muc was found to increase both at the rna and protein level with successive transplant of this clear cell carcinoma. further studies are ongoing to determine the functional significance of muc and other identified differentially expressed genes in ovarian clear cell cancer. in addition, we are carrying out parallel microarray analyses in other ovarian tumor subtypes. background recent observations suggest a decreased incidence of neoplastic lesions in hiv infected individuals treated with highly active anti-retroviral therapy comprised of protease inhibitors, such as ritonavir. the polycomb group protein ezh is associated with aggressive human malignancies via transcriptional suppression of dna repair proteins. objective objective of the present study was to assess the antineoplastic impact of ritonavir on epithelial ovarian cancer (eoc) cell lines. methods eoc cell lines (mdah and skov- ) were treated with serial dilutions of ritonavir ( - mm) dissolved in dmso. normal diploid human fibroblasts served as controls. growth curves, apoptosis and cell cycle analysis were performed with cell counting kit- , annexin v and flow cytometry. signal transduction was studied with western blotting. dna double strand breaks (dsb) were induced with . mm etoposide treatment for hours. homologous recombination (hr) repair of dna damage was measured by assessment of rad foci formation in the nucleus of the cells as visualized by fluorescence microscopy according to previously published criteria. untreated eoc cells expressed higher levels of ezh and lower levels of rad and xrcc as compared to controls and in turn, had lower prevalence of rad repair foci formation in response to dsb. serial treatments of eoc cells with ritonavir resulted in a decrease in expression of ezh and an increase in expression of rad and xrcc when compared to untreated eoc cells. after induction of dsb, the rad repair foci formation was significantly more prevalent in eoc cells treated with ritonavir as compared to untreated eoc cells. in addition, ritonavir induced apoptosis in ovarian cancer cell lines by down-regulation of akt pathway and caused g cell cycle arrest mediated by down modulating levels of prb phosphorylation and depleting the cyclindependent kinase and . ritonavir effectively induces apoptosis, cell cycle arrest and improves repair of dna damage by hr in ovarian cancer cell lines. as impaired hr is a key event in causation and progression of neoplastic lesions, ritonavir may have a role in chemoprophylaxis and treatment of human malignancies. a rare case of ovarian cystic lymphangioma. tomer singer, tamer seckin, noa feldman, susan jormark, michael divon. department of obstetrics and gynecology, lenox hill hospital, n.y., ny, usa; department of pathology, lenox hill hospital, n.y., ny, usa. cystic lymphangioma (cl) is a rare, benign malformation of the lymphatic system whose exact etiology remains uncertain. cl may arise in different sites: the spleen, the mediastinum, the axillary region, the retroperitoneum, and the mesentery. retroperitoneal cl is extremely rare and its true incidence is unknown. the majority of cases are symptomatic during childhood. clinical presentation of adult cl is variable and may be misleading. typically, this is a slow-growing tumor and it remains asymptomatic for a long period of time. it is most often found incidentally during abdominal or pelvic imaging studies, surgeries or autopsies. total surgical removal of the lesions with microscopically clear margins is the best approach when it is possible. we report, for the first time, a case of cystic lymphangioma arising from the ovary in a post-menopausal woman and present the feasibility and the advantages of laparoscopic surgery, allowing accurate diagnosis, optimal treatment and minimal risk for the patient. lgsc) is a chemoresistant ovarian neoplasm that has been molecularly linked to low malignant potential tumor (lmp), which often behaves in a non-invasive fashion. micropapillary features within lmp (lmp-mp) are associated with increased invasive behavior. the aim of this study was to determine the differential gene expression of lmp, lmp-mp, and lgsc to identify genes involved in malignant transformation and carcinogenesis. methods: laser capture microdissection was used to isolate epithelial cells from snap-frozen lmp (n= ), lmp-mp (n= ) and lgsc (n= ). rna was extracted, amplified, reverse transcribed to cdna and hybridized to affymetrix u plus arrays. data was analyzed by significance analysis methods: medical records were reviewed for patients who underwent hysterectomy for all indications at wsu hospitals from / / - / / . pathology reports were reviewed to identify the incidence of adenomyosis. data obtained from medial records included: age, race, insurance, bmi, social history, medical history, and presenting symptoms. the correlation between adenomyosis and all the above factors was tested using the appropriate statistical methods. results: patients were included. adenomyosis was confirmed by pathology in patients, an incidence of . %. incidence was not significantly different among races after controlling for parity. . % in african americans, . % in caucasians, and . % in others. incidence was not statistically different between uninsured( . %), privately insured ( . %), and medicaid ( . %) patients. p=. . incidence of adenomyosis was not different between smokers ( . %) and nonsmokers ( . %). p= . . table i shows the correlation between adenomyosis and different risk factors. conclusion: adenomyosis was diagnosed in . % of hysterectomy specimens. race, socioeconomic status or social habits didn't affect its incidence. diabetes and endometrial cancer were negative risk factors for adenomyosis, whereas htn, hypothyroid, breast cancer, fibroids, polyps and endometriosis didn't affect its incidence. menorrhagia, dysmenorrhea, dyspareunia, and chronic pelvic pain but not metrorrhagia had a positive correlation with adenomyosis. there is a protective adipocytokine profile. we hypothesize that this finding may precede some ill-defined threshold of fat mass and/or insulin resistance after which adiponectin decreases. the objective: to correlate reproductive hormone production with menstrual bleeding patterns among women in the menopause transition. methods: a sub-cohort of the swan study consisting of women age - was studied. each woman collected daily first void urine samples for one complete menstrual cycle or days (whichever came first) once a year for years. urine was assayed for excreted levels of fsh, lh, estrogen metabolites and progesterone metabolites which were normalized for creatinine concentration. ovulation was detected by a validated algorithm. menstrual bleeding parameters were derived from daily calendars. correlations between bleeding characteristics, hormone concentrations, and other potential clinical predictors were analyzed using multivariate logistic regression models. results: the cohort was ethnically diverse with a median age of and with % in the early perimenopause at the start of the study. % of all cycles were anovulatory. short cycle intervals (< days) were associated with the early perimenopause (or . , ci . , . ) and with anovulation (or . , ci . , . ). long cycle intervals ( + days) were associated with late perimenopause (or . , ci . , . )and with anovulatory cycles (or . , ci . , . ). both short ( - days) and long ( + days) duration of menstrual bleeding were significantly associated with anovulation (or . and . , respectively). women with anovulatory cycles were less likely to report heavy menstrual bleeding than women with ovulatory cycles. menorrhagia was not associated with steroid hormone concentrations but was associated with obesity (or . , ci . , . ) and with the self-reported presence of fibroids (or . , ci . , . ). conclusions: among women in the menopause transition, abnormalities in timing of menstrual bleeding (cycle intervals or bleeding duration) have a hormonal basis and are frequently associated with anovulation. in contrast, abnormally heavy periods do not have a hormonal basis and are less likely following anovulatory cycles. heavy periods are associated with obesity and fibroids. to undetectable levels. the use is vaginal e is contraindicated, although these women have even higher rates of av. topical testosterone (tt) has successfully treated vulvar atrophy; testosterone receptors are also present in the vaginal epithelium. objective: assess the effect of tt on vaginal maturation index (mi) and relief of av symptoms. methods: postmenopausal women on aromatase inhibitor with symptomatic atrophic vaginitis were enrolled in prospective, irb approved study. estradiol (e) and testosterone (t) levels, av questionnaires (score - ; none to most severe symptoms of dryness, irritation, and dyspareunia), gynecologic exam, and vaginal smears (for ph and vaginal maturation index, mi, by meisels criteria) were performed at baseline and after month of daily treatment with mcg of tt. data was assessed by t test and fischer's exact test; significant p < . . results: e levels were undetectable at baseline and following treatment. t levels increased (mean +/-sem) from baseline ( +/- . ) to treatment ( +/- . ); the difference was not significant; p = . , although one patient had an appreciable rise in serum t level. two av symptoms improved significantly with tt use; comparing baseline to treatment scores: vaginal dryness ( . vs. . ; p = . ) and dyspareunia ( . vs. ; p = . saliva analysis is a convenient, non-invasive and rapid method for assessing estradiol (e ) levels. however, particularly in postmenopausal women, the low salivary e levels are often near or below the sensitivity of available assays, compromising both accuracy and precision. we present results using an extraction step prior to e assay, which concentrates the sample to increase sensitivity and removes potentially interfering substances. morning saliva samples were obtained from premenopausal (mid-luteal phase, n= , ) and postmenopausal women (n= , ) not taking hormones, and from postmenopausal women receiving oral conjugated equine estrogens (cenestin, n= ; premarin, n= ), oral micronized e (estrace, n= ; compounded e , n= ), transdermal e patches (climara, n= ; vivelle, n= ); or topical e cream (compounded e , n= ). e levels were determined by an automated enzyme immunoassay (eia) after solid phase extraction. the functional sensitivity of the assay was determined to be . pg/ml, compared with > pg/ml without extraction. . . . . . oral conjugated equine estrogens; oral e ; e patch; topical cream salivary e levels corresponded with the hormone dosage, suggesting a reliable assessment of unbound e levels with each formulation, dosage and type of estrogen therapy. extraction prior to eia in an automated assay dramatically increased precision and accuracy at low concentrations. omitting the extraction step may have contributed to poor serum versus saliva correlations in other studies. this method may therefore allow reliable monitoring of estrogen therapy without the need for expensive and inconvenient blood tests. the role of fibulin- in pelvic organ prolapse. david d rahn, jesus f acevedo, patrick w keller, lihua marmorstein, r ann word. ob-gyn, ut southwestern, dallas, tx, usa; visual sciences, univ arizona, tuscon, az, usa. objectives: fibulin- (fib- ) is crucial for normal elastic fibers in the protein showed a statistically significant reduction in its expression (p= . ). lox, loxl , and proteins were detected by immunohistochemistry in all three layers of vaginal skin biopsies: ( ) stratified squamous epithelium; ( ) the lamina propria and ( ) the muscularis layer from both patients with pop and controls. significantly, in both groups we detected a numerous macrophages scattered throughout the vaginal thickness which displayed a very strong immunostaining to loxl . patients with severe pop showed reduced expression of proteins regulating collagen and elastin biogenesis. our finding raises the possibility that failure of ecm homeostasis could underlie the etiology of pop in women. fibroblast proliferation is regulated by hoxa : molecular implications for pelvic organ prolapse. kathleen a connell, marsha k guess, richard bercik, hugh s taylor. obstetrics, gynecology reproductive sciences, yale university school of medicine, new haven, ct, usa. objectives: the integrity of the extracellular matrix (ecm) is maintained by a delicate balance between collagen synthesis and degradation. previously, we have demonstrated that hoxa is essential for the development of the uterosacral ligament in mice and regulates the expression of collagen type iii and mmp . we have also shown that hoxa is deficient in the uterosacral ligament of women with pelvic organ prolapse (pop) compared to women with normal support. the exact mechanisms by which hoxa regulates pelvic organ integrity and repair remains to be elucidated. the aim of this study was to determine the effect of hoxa expression on fibroblast proliferation, and its potential role in pop. methods: nih t cells, a murine fibroblast cell line, were seeded onto a six well plate ( x cells/well) and transfected with either a vector carrying a hoxa cdna or empty vector alone as a control. immunohistochemistry using bromodeoxyuridine (brdu) was performed to evaluate cell proliferation. cell division in the uterosacral ligament (usl) was also compared in women with and without pop. usl specimens were obtained at the time of hysterectomy for benign disease. immunohistochemistry was performed on paraffin embedded sections of the usl to evaluate expression of two mitotic markers, cyclin b and phospho-histone . results: constitutive expression of hoxa in murine fibroblasts resulted in significantly higher proliferation. cells transfected with hoxa had a mean brdu incorporation of . + . cells/ cells compared with . + . cells/ cells in controls (p= . ). in the usl obtained from women with and without pop, cell proliferation as determined by cyclin b and phospho-histone expression was not significantly different. cyclin b and phosphor-histone were expressed in comparable numbers of cells in both groups. conclusion: hoxa is necessary for usl development and promotes proliferation of adult fibroblasts. hoxa may have a similar function in vivo in usl, and may regulate fibroblast proliferation during growth and the acute phase response following trauma when fibroblasts are activated to proliferate and remodel the ecm. it is likely that hoxa mediated proliferation of usl fibroblasts contributes to the tensile strength and resilience of these structures and thereby prevents pop. supported by nichd wrhr: k hd - . connective tissue composition, in term of collagen i, iii and proteoglycans content, in support and nonsupport structures of women with uterine prolapse. elisabetta trabucco, gennaro acone, sara d'avino, marco torella, gennaro trezza, annamaria marenna, nicola colacurci, luigi cobellis. department of obstetrics and gynecology, second university of naples, naples, italy; loreto mare hospital, naples, italy. objective. connective tissue consists mainly of collagen and elastic fibers, glycoproteins and proteoglycans (pgs) and is considered an important factor of the support and nonsupport structures of the genitourinary region. it has been already demonstrated altered morphologic features in the pelvic support connective tissue in women with genital prolapse. however, analysis of nonsupport tissue may provide a more accurate reflection of body collagen. the objective of our study was compare the expression of collagen i, iii and four pgs (decorin, fibromodulin, lumican, biglycan), essential for synthesis and regular assembly and diameter of the collagen fibrils, in uterosacral ligaments and in a nonsupport tissue, the uterine cervix, between premenopausal women with uterine prolapse respect to age matched controls. we characterized uterosacral ligaments and uterine cervix of premenopausal women with uterine prolapse and controls. this immunohistochemical study was performed on paraffin-embedded sections. results. uterosacral ligaments of the prolapsed uteri are characterized by a higher expression of collagen iii, decorin, fibromodulin and byglican and a lower quantity of collagen i. no differences in the immunoreactivity of lumican between the two patients groups. the abnormalities of support connective tissue composition are not observed in the uterine cervix of patients with prolapse. conclusions. our results suggest an altered remodeling of connective tissue in the ligaments of premenopausal patients with prolapse, with a significant decrease in collagen i content and an increase in collagen iii and pgs expression . in the prolapse patients this abnormal collagen metabolism and organization, mainly related to the observed change in pgs expression, might affect significantly the tensile strength of the connective tissue and consequently the support that is provided by the suspensory apparatus to the uterus. the alterd remodeling of support tissues, not detectable in nonsupport tissues, may suggest a predominant role of local biomechanical stresses (childbirth, chronic straining) in the pathogenesis of prolapse respect to systemic connective tissue deficiency. objective: to achieve vaginal delivery with minimal maternal injury, vaginal smooth muscle (sm) contractility likely decreases. the objective of this study was to characterize changes in rat vaginal sm contractility in pregnancy that affords circumferential vaginal distension. methods: a tubular segment of the vagina of virgin, late pregnant , immediate and late post vaginal delivery rats were mounted in an organ bath between a force transducer and an adjustable support block. dose response curves to norepinephrine (ne) and potassium (k+) were used to assess contractility. relaxation capacity was determined in ne preconstricted vagina, using cumulative doses of sodium nitroprusside (snp). differences in active vs. passive length-tension curves were used to measure sm contractility relative to the vaginal wall forces. sm -actin levels were measured using quantitative confocal immunofluorescence. results: cumulative doses of ne induced a maximum constriction force of . ± mn/g in virgin vagina while no measurable force was generated in response to ne in late pregnant or postpartum vaginas. virgin vagina relaxed with cumulative doses of snp; no measurable relaxation response was observed from pregnant or postpartum animals. in the presence of the high dose k+ ( mm), virgin vagina generated the greatest contractile force ( . ± mn/g) vs. late pregnant vagina ( . ± . mn/g, p< . ) or immediate post partum vagina ( . ± mn/g, p= . ). four week postpartum k+ induced forces were similar to virgin levels ( . ± mn/g). sm force generation (difference in active vs. passive length tension curves at mm of displacement) was decreased in late pregnancy ( . ± mn/g) compared with virgin ( ± mn/g, p < . ) and week postpartum vagina ( ± mn/g, p < . ). the expression of sm -actin was lowest in late pregnancy ( ± . , p < . ) and immediate postpartum vagina ( ± . , p < . ) relative to virgin ( ± ) with a return to virgin levels week postpartum ( ± ). conclusions: vaginal sm contractility diminishes in pregnancy. the altered contractility is mirrored by a decrease in sm -actin protein expression. near complete recovery to pre-pregnancy levels occurs by weeks post partum. these functional and biochemical changes likely represent maternal adaptations designed to minimize trauma during passage of the fetus(es). background: diagnosis or exclusion of endometriosis usually requires laparoscopy and peritoneal biopsy. we have described a novel and consistent observation of small nerve fibers in the functional layer of eutopic endometrium in women with endometriosis (tokushige et al, ) . these nerve fibers are not present in women without endometriosis. this finding allows the possibility endometriosis in the nude-mouse and inhibited mmp- expression in human endometrial stroma. the present findings may lead to the development of novel treatments of endometriosis involving statins. supported by nih u hd . k-ras actived immunocompetent retrograde menstruation model of endometriosis. ching-wen cheng, , di licence, , cristin g print, , d stephen charnock-jones. , pathology, university of cambridge, cambridge, united kingdom; obstetric gynaecology, university of cambridge, cambridge; department of molecular medicine pathology, university of auckland, auckland, new zealand. objective: to establish a new murine model of endometriosis that mimics the retrograde menstruation theory using immuno-competent mice. method: ovariectomised donor female k-ras v +/-/cre +/+ /rosa r-lacz +/+ transgenic mice were treated sequentially with steroid hormones. to induce decidualization and activation and k-ras transgene, mg/kg b-nf dissolved in maize oil was injected into the uterine lumen. tissue degeneration mimicking menstruation was induced by hormone withdrawal. menstruating endometrial tissue was collected from donor mice hours after last hormone treatment, re-suspended in matrigel, and implanted subcutaneously in female c bl/ recipients. immunohistochemical and morphometric methods were used to characterize the endometriosis-like lesions. microarray analysis (illumina, n= in each group), was used to study the molecular changes in "menstruating" uteri following k-ras activation. result: simple transplantation of decidualised endometrial tissue into immunocompetent animals does not lead to endometriotic lesion development but using tissue with the genetic modification described here overcomes this. viable endometriosis-like lesions are visible days after implantation. these lesions are histologically similar to those seen in man with intact glands, functional blood vessels, leukocyte infiltration and collagen deposition. statistical analysis revealed that transcripts were differentially regulated in the ras activated and control tissue. gene ontology (go) analysis indicated that transcripts associated with epithelial cell function and differentiation were over represented within this gene set (chloride transport and epidermis development) as were those associated with the acute inflammatory response and neutrophil chemotaxis. we developed a new model of endometriosis using immunocompetent mice to mimic retrograde menstruation induced endometriosis. this permits for the first time, the ready use of transgenic and knock-out tools to investigate the cellular and molecular mechanisms underlying endometriosis. since the animals have an intact immune system it also allows the testing of therapeutic agents that modify the inflammatory response. stra is expressed and induced by progesterone in the endometrium and is absent in endometriosis. mary ellen pavone, serdar e bulun, scott s reierstad, joy innes, magdy p milad, you-hong cheng. obstetrics and gynecology, northwestern univeristy, chicago, il, usa. objective: retinoic acid (ra) plays important roles in development, growth and differentiation by regulating the expression of target genes. in the mouse endometrium, ra deficiency leads to hyperkeratinization, while high concentrations of retinoids promote secretory characteristics. this leads many to believe that ra mediates important actions of progesterone in the endometrium and may account for progesterone resistance in endometriosis. the mechanism for regulation of ra production by progesterone is unknown. moreover, the conversion from retinol to retinoic acid is not different between normal endometrium and endometriotic tissue. we hypothesize that retinol intake into cells rather than conversion of retinol to ra is the critical step that determines ra activity in the endometrium and endometriosis. stra , a widely expressed multitransmembrane domain protein and member of a group of "stimulated by retinoic acid" genes, has been identified as the retinol binding protein receptor. it is strongly expressed in adult mice in several tissues including the female genital tract. we hypothesize that ra activity in the endometrium may be regulated by stra . here we investigate the differential expression of stra in the endometrium and endometriosis. design: we studied primary stromal cells isolated from the eutopic endometrium of disease free women and walls of ovarian endometriomas from women with endometriosis with respect to stra expression and regulation by progesterone. materials and methods primary culture of eutopic endometrial and endometriotic stromal cells were treated with - m estradiol (e ), - m r , a progesterone agonist, or vehicle for hours. real-time pcr was employed to quantify stra mrna levels. we treated cells for hours and quantified protein levels by immunoblotting. results basal mrna of stra levels in endometrial cells (n= ), were > , fold higher than those in vehicle-treated endometriotic cells (n= , p<. ). in endometrial stromal cells (n= ), r stimulated stra mrna levels by . - fold. r induced stra protein levels in endometrial stromal cells (n= ). conclusions stra is highly expressed and regulated by progesterone in endometrial stromal cells, whereas it is practically undetectable in endometriotic cells. stra may mediate important actions of progesterone in endometrium. upregulation of aromatase expression in endometrial cells disseminated into the peritoneal cavity (pc) may influence their survival and persistence via local estrogen synthesis. the inducing factors for the upregulation of aromatase in endometriosis are not well defined, but increased expression of sf- has been suggested to play an important role. given that the aromatase substrate androstenedione (a ) is the predominant steroid in peritoneal fluid, we aimed to determine whether a has a role in the regulation of aromatase expression in human endometrium. we found that culture of primary endometrial stromal cells and explants with a ( - nm) for h significantly upregulated expression of aromatase mrna transcripts containing exon iia at their '-ends. moreover, in human endometrial surface epithelial cells (hes), dose-response studies with a ( - nm) revealed that nm a maximally upregulated expression of both aromatase and sf- . when tissue samples were evaluated from women with endometriosis and control endometrium, expression of aromatase mrna mirrored sf- . treatment of hes cells ( h) with tritiated a demonstrated its metabolism to estradiol (e ), testosterone (t), dihydrotestosterone (dht) and androstanediol (a-diol). although equimolar concentrations of a , t and e upregulated aromatase and sf- mrna expression in hes cells, the nonaromatizable androgens, dht and a-diol, had no effect. a positive feedback role of estrogen in aromatase upregulation was suggested by the finding that the estrogen receptor antagonist, ici , , markedly diminished aromatase and sf- mrna expression induced by a . finally, chromatin immunoprecipitation revealed that a significantly enhanced recruitment of sf- to its response element (- bp) upstream of cyp exon iia. collectively, our findings strongly suggest that exposure of endometrial cells within the pc to c -steroids may cause an acute upregulation of cyp gene expression through their aromatization to estrogens. thus, estrogen may play a critical positive feedback role in the pathogenesis of endometriosis. supported by nih r -dk . the hpa axis and depression/anxiety scores in chronic pelvic pain patients. b stegmann, b frank, j gemmill, g chrousos, m ballweg, p stratton. rbmb, nichd/nih, bethesda, md; som, wake forest university, winston-salem, nc; endometriosis association, milwaukee, wi. stress, pain, anxiety and depression adversely affect the hypothalamic-pituitaryadrenal (hpa) axis. we examined the influence of depression and anxiety on the hpa axis response to corticotropin-releasing hormone (crh) testing in women with and without chronic pelvic pain (cpp). methods: healthy women, aged - , with without cpp, with regular menses and off hormonal contraception were studied. none had pelvic infections, untreated depression, manic depression, fibromyalgia, or chronic fatigue syndrome. after ovine crh injection ( mcg/kg), serial blood samples (- , , + , + , + minutes) were obtained for acth and cortisol measurements. depression and anxiety were scored using the duke quality of life questionnaire. hpa response was abnormal if peak acth levels were > pg/ml without a rise in cortisol levels. subject groups were: no pain and normal acth response (npnr), pain and normal acth response (pnr), no pain with an abnormal acth response (npar) and pain with an abnormal acth response (par). student t-test was used for comparisons. results: women ( cpp, controls) had a mean age of . ± . years (range: - ). women responded normally ( pnr, npnr) and women responded abnormally ( par, npar). peak and absolute rise in acth were significantly higher in abnormal (a) vs normal (n) responders; (peak: . a vs . pg/ml n, p< . ; absolute: . a vs . pg/ml n, p= . ). there was a significant difference within groups: peak acth: . par vs . pg/ml pnr, p= . ; . npar vs . pg/ml npnr, p< . ; absolute acth: . par vs . pg/ml pnr, p= . , . npar vs . pg/ml npnr, p< . ). however, total cortisol level was not different between or within the groups ( . a vs . mcg/dl n, p= . ). mean depression score did not differ among cpp patients ( . par vs . pnr, p= . ), but differed among controls ( npar vs . npnr, p= . ). anxiety scores did not differ between or within groups ( . npar vs . npnr p = . ; par vs . pnr, p= . ). conclusions: chronic pelvic pain is associated with an abnormal hpa response, regardless of anxiety or depression symptoms. abnormal hpa responses in control women, however, appear to be influenced by depression. the mechanism and clinical significance of these findings should be explored. support: rbmb/nichd/nih and endometriosis association. objective: the eutopic endometrium in women with endometriosis demonstrates altered endometrial receptivity and altered gene expression. it is unknow if the endometrium is defective giving rise to a predisposition toward endometriosis or alternativly if the endometriosis causes the altered endometrial receptivity. here we created experimental endometriosis in a mouse model through allotransplantation of the uterus to the peritoneal cavity in immunocompetent mice and examined the expression of several markers of endometrial receptivity in the eutopic endometrium. materials and methods: the uterus of -week-old cd female mice was transected at cervicovaginal junction and each horn divided and transplantated into the abdomidnal cavity of eight cd mice. seven controls received sham surgery only. after weeks the uterus was removed, snap-frozen in trizol. total rna was extracted and cdna generated. quantitative real time rt-pcr using sybrgreen was performed and normalized to -actin. fold changes in normalized hoxa , hoxa , bteb , emx , igfbp , integrin - , total progesterone receptor (pr-ab) and progesterone receptor-b (pr-b) were assessed. all experiments were conducted in duplicate, repeated at least three times and compared using mann-whitney rank sum test. results: hoxa , hoxa , bteb , emx , and igfbp mrna expression showed . -fold (p= . ), . -fold (p< . ), . -fold (p= . ), . fold (p= . ), and . -fold (p< . ) decrease in the uterus of mice with experimental endometriosis compared with controls. pr-ab and pr-b mrna showed . -fold (p= . ) and . -fold (p= . ) increase in endometriosis group compared to controls, respectively, however the ratio of pr-b to pr-ab (b/ab) showed no significant change in both groups ( . vs. . , endometriosis vs. control, p> . ). there was no significant change in integrin - mrna expression ( . -fold, p> . ). conclusion: we demonstrate significant changes in multiple markers of endometrial receptivity in eutopic endometrium after induction of endometriosis. these findings suggest that origionally normal endometrium can develop defects with the creation of endometriosis; an abnormal endometrium is not a prerequisite for the development of endometriosis or associated abnormalities. this data also suggest the existance of a signal conduction pathway from endometriosis that alteres endometrial gene expression. endometrial expression patterns of relaxin and relaxin receptor mrna suggest involvement of relaxin in endometriosis. sara s morelli, felice petraglia, gerson weiss, stefano luisi, pasquale florio, jeff gardner, andrea wojtczuk, laura t goldsmith. obstetrics, gynecology and women's health, new jersey medical school, newark, nj, usa; pediatrics, obstetrics and reproductive medicine, university of siena, siena, italy. objective: in normal endometrium, relaxin is a potent inhibitor of matrix metalloproteinases, which have been implicated in the invasive process of endometriosis. we tested the hypothesis that relaxin plays a role in endometriosis by comparing expression of relaxin and its lgr receptor in normal human endometrium to levels in samples from patients with endometriosis. materials and methods: total rnas, extracted from ectopic (n= ) and eutopic (n= ) endometrium of patients with endometriosis and from endometrium of normal controls (n= ), were reverse transcribed into cdnas. real-time pcr was performed using primers previously shown to identify human lgr relaxin receptor mrna, h relaxin mrna, and beta-actin mrna, with sybr-green detection of double stranded dna products. the comparative c t method ( -ct ) determined relative lgr and relaxin mrna expression (normalized to beta-actin mrna expression). relaxin mrna was detectable in normal endometrium from of ( %) control patients. in contrast, relaxin mrna was detectable in a lower proportion of samples [ of ( . %)] from patients with endometriosis, among whom relaxin mrna was detectable in a lower proportion of ectopic samples [ of ( %)] than in eutopic samples [ of ( . %)]. lgr relaxin receptor mrna was detectable in all samples, with lower expression in endometriosis samples than in endometrium from normal controls. relaxin receptor lgr mrna levels vary with cycle phase, with greater expression in the secretory phase (sp) than in proliferative phase (pp): in normal controls . -fold higher levels in the sp than pp; and in endometriosis patients . -fold higher levels in the sp than pp. in both phases, lgr mrna levels were lower in ectopic samples than in either eutopic samples ( . -fold lower in pp and . -fold lower in sp) or endometrium from normal controls ( . -fold lower in pp and . -fold lower in sp). eutopic endometrium had similar lgr mrna expression to controls throughout the cycle. decreased local expression of relaxin and relaxin receptor mrna in ectopic endometrium from patients with endometriosis throughout the menstrual cycle suggests that relaxin may be protective against endometriosis. ovarian reserve after laparoscopic cystectomy of endometriotic ovarian cysts. shinichi hayasaka, takashi murakami. obsterics and gynecology, tohoku university, sendai, japan. objective laparoscopic ovarian cystectomy is generally recommended for endometriotic ovarian cysts because it has been associated with a higher pregnancy rate and a lower recurrent rate. however, residual ovarian function after laparoscopic cystectomy of endometriotic ovarian cysts has been questioned. in this study, we retrospectively evaluated ovarian response to hyperstimulation in women selected for ivf and icsi cycles who previously underwent laparoscopic cystectomy of a monolateral endometriotic ovarian cyst. methods a retrospective review of the patients between january and september was performed. the operated ovary and contralateral intact ovary were compared in terms of number of oocytes retrieved, number of follicles with a mean diameter > mm at the time of hcg administration. the patients who had recurrent endometriotic ovarian cysts were excluded. in total, ten patients were identified. the mean(±sd)number of oocytes retrieved was . ± . in the control ovary and . ± . in the previously operated ovary(p= . ). the mean(±sd)number of follicles with a mean diameter > mm was . ± . in the control ovary and . ± . in the previously operated ovary(p= . ). the age of patients and diameter of the operated ovary had little influence on the difference between the response of the control ovary and one of the previously operated ovary. laparoscopic cystectomy of endometriotic ovarian cysts is associated with a significant reduction in ovarian reserve. background pre-eclampsia (pe) is associated with systemic maternal endothelial dysfunction, which is thought to result from the presence of circulating factors released following placental damage. it is hypothesised that this occurs as a result of reduced oxygen (o ) delivery. some features of placental pathology seen in pe, such as increased apoptosis, can be reproduced by culture of placental explants in % o . metabolomics operates to study 'all' metabolites within a biological system. this strategy has previously identified differences in maternal plasma between normal pregnancies and those complicated by pe. in these experiments we used metabolomics to investigate differences in the metabolic profile of explants cultured in different o tensions. hypothesis the metabolic profile of placental villous explants is altered by culture in different o tensions. methods placental villous explants were cultured with either % serum (n= ) or in serum-free conditions (n= ) for h in %, % and % o . after h, conditioned culture medium and tissue were collected and snap frozen. tissue was homogenised in % ice cold methanol prior to analysis. samples were analysed using gas chromatography-mass spectroscopy (gc-ms). samples cultured at %, % and % o were compared to identify concentration differences in metabolites in conditioned cultured medium and tissue lysate. kruskal-wallis test was used for statistical analysis. due to the large number of metabolites identified, a p value of . was considered significant. results the mean intra-assay variability was . %. there were no differences in the metabolic profile of conditioned culture medium from % and % o . several metabolites differed in culture medium from % compared to % and % o including: deoxyribose, glycerol and threionic acid. these changes were present in both serum and serum-free conditions. using these metabolites alone, culture in % o could be completely discriminated from % and % o . deoxyribose was also elevated in tissue lysate from % o compared to % o . conclusion this metabolomic strategy can identify differences in metabolic profile in placental tissue cultured in % o . these novel compounds may provide further insight into pathophysiology of pe. objective a strategy of metabolic footprinting (the study of extracellular metabolites, which are related to intracellular metabolism) was used to detect a wide array of low molecular weight metabolites. metabolic profiles were employed to differentiate between placental explants cultured at different oxygen tensions. two separate studies were combined to validate initial observations. methods metabolic footprints of placental villous explants, obtained from uncomplicated pregnancies, (n= ) were cultured for h in %, % and % oxygen. conditioned culture medium was then collected and frozen, prior to analysis by uplc/ltq-orbitrap mass spectrometry in both negative and positive ion mode. samples cultured at %, % and % were compared to identify differences in the metabolic profiles. this procedure was repeated for different explants and the results compared across the studies in order to validate initial findings. approximately unique peaks were detected in both sample sets in negative ion mode and peaks in positive ion mode. a number of metabolites were identified as being significantly different using kruskal-wallis (pval< . ) under different oxygen tensions. some differences were seen between the results obtained from both runs due to separate batch preparation of the medium but good reproducibility was obtained for many metabolites between batches. metabolites of biological interest included amongst others -deoxyribose, valine, tyrosine and aspartic acid. the largest differences were those seen between o % and o %. comprehensive metabolic profiles were detected and employed to identify differences in the metabolic footprints of explants cultured under differing oxygen conditions. a number of biologically interesting metabolites were characterized. objective: brain weight and dna content were reduced in leptin deficient (lep ob /lep ob ) mice postnatally. leptin is detected in the sera and its receptors are expressed in the brain of the mouse fetus. we examined the role of leptin in the proliferation and differentiation of neural lineage cells in the mouse fetus. methods: the number of total cells in the cerebral cortex was compared between (lep ob /lep ob ) and wild type fetuses from embryonic day (e) to . the number of brdu positive cells was also compared on e and e . brdu uptake, the ratio of viable colony number to plated cell number, the proportion of multipotent, neuronal or glial progenitor colonies, and the expression levels of hes mrna were compared between leptin-and non-treated neurosphere cells. moreover, we examined stat phosphorylation by leptin stimulation with elisa to investigate whether or not jak/stat pathway transduces the leptin signal in the prenatal period as in the adult. results: lep ob /lep ob fetuses had reduced total cell numbers in the ventricular zone (vz) on e and e , and in the cortical plate on e . the number of brdu-positive cells was reduced in vz of e and e lep ob /lep ob fetuses. brdu uptake and the number of viable colonies were increased by days-leptin treatment in the neurosphere culture. the proportions of glial-restricted and multipotent precursor colonies were increased by leptin, whereas that of oligodendrocyte precursor colonies were decreased. hes mrna expression was enhanced in neurosphere cells by leptin. neither the amount of phosphorylated stat nor that of stat was increased in neurosphere cells by leptin stimulation. conclusion: our study suggests that leptin maintains the neural stem and glial-restricted precursor cells through upregulation of hes expression and increases the number of cerebrocortical cells in the mouse fetus, however, jak/stat pathway does not mediate the leptin signal in undifferentiated neural lineage cells. a vaginal wall, and > % of fib- knockout (ko) mice develop pelvic organ prolapse by weeks of age. in contrast, fib- and - deficiencies do not result in prolapse, and fib- kos die shortly after birth. herein, we evaluated the role of fib- in pelvic organ support. methods: two observers serially measured the degree of vaginal, perineal, and anal prolapse in fib- ko (fib -/-) and in fib -/-mice severity of prolapse was significantly related to age, but not parity, and the average age at diagnosis was wks. fib -/-animals with advanced prolapse had attenuated uterosacral ligaments and descent of the bladder and uterus caudal to the symphysis. pro-mmp ( -fold, p= . ), active mmp ( -fold, p= . ), and prommp ( -fold, p= . ) were increased in vaginal tissues from mice with gross prolapse compared with age-, strain-, and cycle-matched controls. this increase in protease activity, however, was also accompanied by increased expression of fib- and tropoelastin ( . -fold, p< . ). regardless of prolapse maternal morbidtties tf ards-n(%) ( ) acute ren~m f lure-n (%) ( ) car~tovascular ~ysfunrtion-n ("/o) ( ) hepatc fa..lure-n (%) dt sst'dlm atl:d inlfavascul..-coagul tipalhy-n(%) ( ) durallon of !cu suy (days. mean+sd) :t . hospital my (days.. me +sd) . condon, j. c., hardy, d. b., kovaric, k., and mendelson, c. r. ( ) mol endocrinol ( ), - . objective: innervation of the uterine cervix is important for the process of parturition (physiol beh : , ; j histochem cytochem : , jsgi : , ) . the hypogastric nerve is a major pathway that innervates the uterine cervix, yet its contribution to processes associated with cervical ripening and parturition is not known. the objective of this study was to determine the effect of hypogastric nerve transection on processes associated with cervical remodeling and parturition. methods: time-dated pregnant rats were sham-operated or the hypogastric nerve bilaterally transected just anterior to the inferior mesenteric ganglion on day post-breeding. live pups were born spontaneously by all rats at term on days - post-breeding. on the day of birth, the cervix was excised, postfixed overnight, sectioned, and processed to evaluate collagen content and structure (nih image j). sections were also processed by immunohistochemistry to assess cell nuclei density, the census of resident macrophages, and area of tissue that contained nerve fibers. results: hypogastric neurectomy did not affect cell nuclei density, the number of macrophages, or density of nerve fibers in the cervix. the failure of hypogastric nerve transection to affect indices of cervical remodeling is consistent with the finding that duration of pregnancy and timing of birth were not different in sham-operated and hypogastrectomized rats. conclusions: nerve fibers in the hypogastric nerve that innervate the lower uterus and cervix, including sympathetic and neuropeptidergic projections, are thus not essential for birth. these novel findings provide support for the contention that innervation of the uterine cervix other than through the hypogastric nerve contributes to processes associated with cervical ripening and parturition. receptor system in prostaglandin synthesis in pregnancy. eugenie r lumbers, , della m yates, carolyn m mitchell, jonathan j hirst, , tamas zakar. , school of health sciences, university of newcastle, newcastle, nsw, australia; mothers and babies research centre, hunter medical research institute, newcastle, nsw, australia; obstetrics and gynaecology, john hunter hospital, school of medical practice and public health, university of newcastle, newcastle, nsw, australia. the fetal membranes and decidua contain prorenin, which requires proteolytic activation. ngyuen (j clin invest. : ) described a renin/prorenin receptor that conformationally activates prorenin, so that it can form ang i from aogen. in addition, receptor-bound prorenin can stimulate intracellular pathways directly. prostaglandins (pgs) participate in the control of term and preterm labour, and renin can stimulate pg production by amnion and decidua when angiotensin's action is blocked mitchell placenta : ) . the prorenin receptor may mediate these effects. our aim was to find out if the prorenin receptor gene is expressed and colocalised with prorenin and prostaglandin h synthase- (pghs- ) in human placenta, amnion, chorion and decidua. we have also determined if there is any change in the expression of the prorenin and prorenin receptor genes with labor. placentae with attached membranes were collected after term birth either by elective caesarian section or by spontaneous labor, and prorenin, prorenin receptor and pghs- mrna levels were quantitated relative to beta-actin mrna by real-time rt-pcr in amnion, chorion, decidua and placenta. before labor, mean prorenin mrna levels were . times higher in decidua and . times higher in chorion and placenta than in amnion (p< . ). there were no significant changes with labor. proenin receptor mrna was expressed in all tissues. proenin receptor mrna levels in prelabor amnion, chorion and placenta were similar, while levels in decidua were % of those in amnion (p= . ). this low level of prorenin receptor mrna in decidua persisted after labor (p< . ). pghs- mrna expression was highest in amnion; in decidua and placenta it was only and % of amnion. similar differences were present after labor. we conclude that the decidua is the principal source of prorenin within the pregnant uterus, and all gestational tissues are targets for prorenin. decidual prorenin may affect pghs- expression in amnion through the prorenin receptor forming a maternal-fetal paracrine system that stimulates pg production at labor. the immuno-suppressive effects of progesterone on umbilical cord blood mononuclear cells and the effect of culture media estradiol content. nadav schwartz, xiangying xue, christine n metz. obstetrics and gynecology, nyu school of medicine, new york, ny, usa; feinstein institute for medical research, manhasset, ny, usa. objective: progesterone (p ) is known to supress the maternal immune response and similar effects have been seen with fetal cells. we sought to ascertain whether p action was modulated by the phenol red and/or estrogen content of the culture media. methods: umbilical cord blood mononuclear cells were isolated using a density gradient centrifugation. the cells were incubated with p ( - m) hour prior to overnight stimulation with lps. supernatants were assayed for tnf-using elisa. the following culture media were used: a)'red' media: rpmi+ % fbs, b)'yellow' media: phenol red-free rpmi+ % fbs, and c)'clear' media: phenol-free rpmi+ % dextran/charcoal treated fbs. finally, the 'clear' media experiments were repeated with estradiol add-back. results: p suppressed tnf production in all medias. tnf levels were suppressed to . % (p< . ) of controls using 'red' media and to . % (p< . ) in 'yellow' media. the degree of suppression was not as substantial using 'clear' media where tnf levels were . % (p< . ) of control. (fig ) adding estradiol to the 'clear' media had little or no effect on the degree of tnf suppression. (fig ) conclusions: progesterone exerts an immuno-suppressive effect on lpsstimulated fetal mononuclear cells which is more pronounced when using media containing untreated fetal bovine serum. the phenol-red/estradiol content of the culture media did not modulated the p effect. dextran/charcoal treatment of fbs appears to deplete the media of factors other than estradiol that are necessary for p to exert its full effects. culture conditions should be optimized when studying progesterone's effects on immune response. ovine fetal regional blood flow following prenatal dexamethasone (dex) at . gestation (g). antonine d van heesewijk, jan g nijhuis, susan l jenkins, peter w nathanielsz, mark j nijland. ob/gyn, academisch ziekenhuis maastricht, maastricht, netherlands; ob/gyn, cpnr, uthscsa, san antonio, tx, usa. background: pregnant women at risk for premature labor receive antenatal glucocorticoids (gc) to reduce neonatal morbidity and mortality. while fetal blood pressure (bp), heart rate and vascular endothelial and control fetuses (n= ). dispersed adrenal cortical cells ( . x cells/tube; in duplicate) were challenged with - m acth. samples were collected at time (baseline), , , , and min after acth treatment, and tissue and media samples were frozen for determination of cortisol, camp, and star. results: cortisol output (ng/ . x cells) was higher in the lth group compared to the control, (p< . ) at min ( . ± . vs. . ± . ), min ( . ± . vs. . ± . ), and min ( . ± . vs. . ± . ). peak camp levels (fmol/ . x cells) were observed at min but did not differ between control ( . ± . ) and lth ( . ± . ) adrenal cells. western analysis demonstrated that star protein expression was higher in the lth adrenal cortex compared to control (p< . ) at min ( . ± . vs. . ± . ), and at min ( . ± . vs. . ± . ), relative optical density units. conclusions: results from the present study taken together with those of previous in vivo studies suggest that the enhanced cortisol output in lth fetuses is the result of increased adrenal acth sensitivity. this enhanced sensitivity is not due to differences in camp generation. star, which is a key element involved in cholesterol transfer at the level of the mitochondrial membrane appears to play a key role in the enhanced cortisol response to acth in the lth group. (nih grants hd , hd and llu-nih imsd r gm - ). expression. hiroaki itoh, makoto kawamura, shigeo yura, haruta mogami, tsuyoshhi fujii, norimasa sagawa. obstetrics and gynecology, national hospital organization osaka national hospital, osaka, japan; gynecology and obstetrics, kyoto university graduate school of medicine, kyoto, japan; obstetrics and gynecology, mie university school of medicine, tsu, japan. objective: epidemiological evidences suggested that undernutrition in utero develops risk factors for adult cardiovascular disorders, such as blood pressure increase. the present study was designed to prove the hypothesis that maternal iso-caloric high protein diet alleviates blood pressure increase in the adult offspring by affecting placental beta-hydroxysteroid dehydrogenase type ( beta-hsd ) expression. methods: the % calorie restriction was applied to pregnant mice by using either standard protein diet (spd; % casein protein; spd-un) or high protein diet (hpd; % casein protein; spd-un). in some groups, these pregnant mice were sacrificed at . d.p.c.; then maternal and fetal plasma as well as placental tissues were corrected. while in other groups, systolic blood pressure was measured in the offspring at wks. fetal and maternal corticosterone levels were measured by elisa. the placental beta-hsd gene expression was measured by quantitative taqman pcr. results: systolic blood pressure in the spd-un offspring at weeks ( mmhg) was higher than that in spd-nn offspring ( . mmhg). by contrast, systolic blood pressure in the hpd-un offspring ( . mmhg) was similar to that in spd-nn offspring. maternal calorie restriction with spd and hpd caused similar elevation of maternal plasma corticosterone concentrations. by contrast, fetal plasma corticosterone levels in hpd-un offspring ( ng/ml) was lower than those in spd-un offspring ( ng/ml), indicating the amelioration of fetal exposure to high corticosterone by maternal hpd. the placental beta-hsd gene expression in the hpd-un was % higher than that in spd-un, suggesting that maternal hpd augmented placental beta-hsd gene expression in the placenta and probably facilitated the inactivation of maternal cortocsterone in the process of placental transfer to fetal circulation. conclusion: the preset study suggests that maternal high protein ingestion may elevate placental beta-hsd gene expression and ameliorate blood pressure increase in the adult offspring via modification of fetal exposure to maternal corticosterone. elevated cortisol levels at birth exert critical maturational effects through action at glucocorticoid receptors, gr. in contrast, the low cortisol concentrations in the preterm fetus, before the time of increased fetal cortisol secretion, are near to the kd for cortisol at the higher affinity mineralocorticoid receptor, mr. we hypothesized that endogenous cortisol in the fetus exerts physiologic actions at mr in tissues without appreciable cortisol-inactivating enzyme, hsd , including the fetal lung and brain. we therefore tested the effect of infusion of a mr-antagonist, ru (mra, . mg/h over h) into - day fetal sheep. we tested for effects on lung liquid production rate, lung liquid and plasma electrolytes, plasma acth and cortisol, and hematocrit at - h after start of the infusion. although there was no significant difference in the liquid production rate in fetuses infused with ru , the ratio of na + to k + in lung liquid was significantly greater in mra-treated fetuses than in the control fetuses ( . ± . vs . ± . ). plasma acth was significantly greater in the mra-treated fetuses than in control fetuses at h ( ± vs ± pg/ml); in the mra-treated fetuses, acth concentrations at h were greater than in the same fetuses at h ( ± pg/ml), wheras there was no increase in plasma acth in the control fetuses ( h: ± pg/ml). similarly, plasma cortisol concentrations at and h were greater in the mra infused fetuses than in control fetuses ( h: . ± . vs . ± . ng/ml), and cortisol increased significantly over time in the fetuses infused with mra, but not in control fetuses ( h, mra: . ± . , control: . ± . ng/ml). infusion of mra did not alter fetal plasma electrolyte, fetal blood pressure or fetal heart rate. however, fetal packed cell volume was significantly increased at - h of infusion of mra ( h: ± vs ± %) and fetal pco was significantly greater at h of infusion of mra as compared to control fetuses ( . ± . vs . ± . ). these results suggest that endogenous cortisol concentrations in the preterm fetus exert negative feedback control of acth via action at mr in the fetal brain, and play a role in regulation of fetal lung liquid composition and in fetal fluid balance. preparturient increases in fetal acth secretion are cyclooxygenase- (cox- ) dependent. charles e wood. dept. physiology and functional genomics, university of florida college of medicine, gainesville, fl, usa. maturation of the fetal hypothalamus-pituitary-adrenal axis is critical for the timely somatic development of the fetus and readiness for birth. in sheep, increased preparturient activity of the fetal hpa axis appears to be responsible for triggering parturition itself. this study was designed to test the hypothesis that prostaglandin generation, mediated by cox- in the fetal brain, is critically important for stimulation of the preparturient increase in fetal acth secretion. singleton fetal sheep were chronically catheterized with vascular, amniotic, and lateral cerebral ventricular catheters. nimesulide, a selective cox- inhibitor, was infused ( mg/day, n= ), and vehicle ( % dimethylsulfoxide, n= ) was infused. arterial blood samples were drawn from fetuses at hour intervals for measurement of plasma hormone concentrations and arterial blood gases. in the vehicle-treated fetuses, fetal plasma acth, pomc, and cortisol concentrations increased exponentially (p< . by anova) before spontaneous parturition at ± . days. in the nimesulide-treated fetuses, fetal plasma acth and pomc were constant and did not increase prior to parturition (p=ns by anova). in contrast, fetal plasma cortisol increased independent of acth (p< . by anova) and the fetuses were born spontaneously on ± . days gestation. the slight delay in spontaneous parturition in the nimesulide-treated fetuses was statistically significant (p< . by mantel-cox test). intracerebroventricular nimesulide infusion did not decrease fetal plasma concentrations of prostaglandin e , demonstrating that the action of the nimesulide was restricted to the fetal brain. fetal blood gases were normal in all of the fetuses, and there were no differences in blood gases between groups. we conclude that the spontaneous increase in fetal acth and pomc prior to parturition is cox- dependent. however, we also conclude that the increase in fetal plasma cortisol concentration can occur independent of increases in fetal acth, suggesting that the increase in cortisol can result from increases in adrenal sensitivity to acth. the results of this study demonstrate that the timing of parturition in the sheep is not dependent upon increased acth secretion, and the results suggest that parturition is regulated primarily by changes in adrenal sensitivity. expression of extracellular signal-regulated kinase / and p mitogen-antiphosphotyrosine. immunolocalization of inos was performed in the same tissues. hpmec were used to determine effect of sin- ( mm) on inos protein expression ( min, and h). results: inos protein was detected in microvascular endothelium, smooth muscle and syncytiotrophoblast of the placenta. inducible nos levels in placentas from severe preeclampsia were significantly decreased compared to normal (p< . ) but were not different from mild preeclampsia. aligning western blots of anti-phosphotyrosine and inos revealed a phosphorylated band corresponding to the molecular weight of inos. the proportion of tyrosine phosphorylated inos was reduced by % in severe preeclampsia compared with normotensive. preliminary data with ip for phosphotyrosine and crossblotting with inos confirmed this finding. sin- treatment decreased inos protein abundance at and h in hpmec. conclusions: our results demonstrate decreased tyrosine phosphorylation of inos in preeclamptic placenta. phosphorylation of tyrosine in inos has been reported to negatively regulate its activity. we therefore postulate that decreased phosphorylation of inos may be responsible for the increased catalytic activity of the enzyme that we have previously observed. the decreased levels of inos observed on sin- treatment may be due to nitration, an effect analogous to preeclampsia, where the presence of peroxynitrite has been well established. it remains to be seen if protein nitration has an effect on enzyme stability. objective: -isoprostane ( -iso), a prostaglandin-like compound formed in vivo, is a reliable measure of oxidative stress which occurs in response to many different stimuli, including infection. periodontal disease is a chronic oral infection associated with fetal growth restriction and preeclampsia. our objective was to determine if maternal periodontal disease is associated with oxidative stress as measured by -iso. methods: a secondary analysis was conducted using prospective data from the oral conditions and pregnancy study. a cohort of healthy women enrolled < weeks underwent oral health examination and serum sampling. maternal periodontal disease was categorized as healthy, mild, or moderate-severe by clinical criteria. maternal serum was analyzed for -iso by ultra-sensitive elisa. elevated -iso was defined by a value th %tile. maternal factors associated with elevated -iso were determined using chi-square or t-tests as appropriate. a logistic regression model was created to determine adjusted odds ratios ( th %ci) for elevated -iso. results: women had complete data for analysis. the median -iso level (iqr) was , ( - , pg/dl). using bivariate analysis, moderate-severe periodontal disease, non-white race, use of wic/food stamps, unmarried status, obesity, and lack of insurance were associated with elevated -iso. the logistic regression model for elevated -iso is shown below. adjusted or ( th ci)* mild periodontal disease . maternal periodontal disease and utilization of public assistance are associated with oxidative stress in pregnancy. the relationship between periodontal disease, social hardship, oxidative stress, and adverse pregnancy outcome remains to be determined. antioxidant therapy could represent novel therapy for the prevention of adverse pregnancy outcome. severe transient immunological thrombocytopenia in a preeclampsia patient whose bone marrow production of platelets had been restricted. toshihiro yoshimura. obstetrics and gynecology, ntt-west kyushu general hospital, kumamoto-city, kumamoto, japan. introduction: idiopathic myelofibrosis is a chronic myeloproliferative disorder in which clonal haemopoetic stem cell proliferation is accompanied by reactive fibrosis. case report: a -year-old primiparous woman was referred to our hospital for prenatal care after weeks of gestation. her medical history was significant for idiopathic myelofibrosis, and congenital agenesis of the spleen. the laboratory workup showed the patient's white blood cell count to be , / l; hemoglobin, . gm/dl; and platelet count, , / l. her bleeding time was normal ( min). until the th week, the patient's pregnancy was uneventful. during the th week, however, the patient's platelet count declined to , / l, when proteinuria became evident. her bleeding time was prolonged to min. the coagulation system was normal. by the th week, the patient's blood pressure was elevated to / mmhg, and her urinary protein excretion exceeded g/day. our initial diagnosis was thrombocytopenia due to bone marrow suppression. the patient had no history of platelet transfusion, but we expected it would increase the platelet count, particularly since in the absence of destruction by the spleen, the lifespan of the platelets would be prolonged. this was not the case, however. elective induction of labor was carried out after weeks. at the same time, the patient was transfused with units of platelets, but her platelet count remained unchanged ( , / l). it was then that we realized that immunological thrombocytopenia may be involved, and massive doses ( mg/kg) of gamma globulin were given intravenously for one day. thereafter, platelets ( units) were again transfused, this time raising the platelet count to , / l. cesarean section was promptly carried out under general anesthesia. we later found that the patient's serum platelet associated immunoglobulin (paigg) level was positive, though antiplatelet and antinuclear antibodies were negative. the postoperative course was uneventful. the maternal platelet count declined to the pretransfusion level within days after delivery, but gradually increased to the prepregnancy level by weeks. comment: this idiopathic myelofibrosis patient in whom bone marrow production of platelets had been severely restricted demonstrates that immunological destruction may play a major role in the development of thrombocytopenia in preeclampsia. early l-arginine therapy improves notably the fetal growth in preeclamptic women. a randomized controlled trial. keisy lopez-molina, juan c gonzalez-altamirano, julio e valdivia-silva. , oncoinmunología y biología vascular, facultad de medicina, universidad nacional san agustín, arequipa, peru; cardiología y cirugía de tórax, hospital nacional case essalud, arequipa, peru; inmunología, instituto de investigaciones biomédicas, méxico, distrito federal, mexico. objective: to assess the benefit of early administration to l-arginine, the precursor to nitric oxide, on fetal growth. methods: one hundred women with preeclampsia were randomized to receive either l-arginine or placebo until day postpartum. live singleton infants were born after preeclamptic pregnancies and compared those with other control infants. birth size was expressed as the ratio between observed and expected birth weights, and infants smaller than two standard deviations from expected birth weights were classified as small for gestational age (sga). all the women had neither previous precedents of the preeclampsia nor other factors that they cause sga. results: no significant differences existed between the groups with preeclampsia before randomization. preeclampsia was associated with a % ( % confidence interval [ci] %, %) reduction in birth weight. women with hellp syndrome had to leave the study. the risk of sga was three times higher (relative risk [rr] = . ; % ci . , . ) in infants born after preeclampsia without l-arginine therapy than in control pregnancies, and two times higher (relative risk [rr] = . ; % ci . , . ). in infants born after preeclampsia with l-arginine therapy. conclusion: fetal growth improve markedly with l-arginine therapy in women with preeclampsia. introduction: although the pathogenesis of severe preeclampsia (pe) and intrauterine growth restriction (iugr) is poorly defined, inadequate remodeling of uterine spiral arties may promote reperfusion injury leading to focal infarction and reduced nutrient flow between mother and fetus. our goal was to determine whether an intravillous inflammatory cytokine cascade was associated with pe and iugr. methods: immunohistochemistry (ihc) examined il- and il- expression in preterm placentas with severe pe+iugr, and idiopathic preterm controls (ptc) with no evidence of clinical or histological chorioamnionitis. cultures of fibroblasts (fibs) and syncytiotrophoblasts (scts) from term placentas (n= ) were treated with il- and cytokine levels in conditioned media were determined using elisa or multiplex array. results were analyzed by student's t test or anova. results: the gestational age at delivery was not significantly different in pe+iugr and ptc groups ( . ± . vs . ± . wks). ihc of pe+iugr samples revealed intense villus core staining of il- adjacent to infarcts. villi distal to infarcts stained with a lower intensity. in contrast, staining was virtually undetectable in ptc. the pattern of il- staining was nearly identical in pe+iugr and ptc groups, was localized to the syncytium, and did not differ with respect to distance from infarct. to identify cellular targets of il- action, primary cultures of fibs and scts were incubated for h in serum-free medium ± ng/ml il- . by elisa we observed that il- treatment of fibs increased il- levels from ± to ± pg/ g protein (p< . ). similarly, multiplex array revealed that levels of il- , il- , and il- were induced -, -, and -fold, respectively in fibs. the presence of ng/ml il- receptor antagonist reduced the il- -mediated increase in il- levels ± % (p< . ), indicating that this response was mediated through il- receptor. in marked contrast, il- treatment did not significantly affect levels of il- , il- , il- or il- in scts, indicating that this response was cell type-specific. conclusions: these results indicate that increased expression of il- in the placental villus core in pe and iugr may promote an inflammatory cascade in fibs at this site leading to focal infarction and reduced flow of nutrients to the fetus. introduction: in human pregnancy, decreased responsiveness to angiotensin ii (angii) starts in week , promoting an expanded vascular bed. at the same time levels of the vasodilatory hemopexin increases . during pre-eclampsia the vascular bed is contracted and the responsiveness upon angii persists. this may be due to the increased levels of extra cellular atp, a natural inhibitor of hemopexin . in the present study we tested whether extra cellular atp is toxic in the pregnant condition. methods: pregnant rats were infused with either atp ( g/kg bw; n= ) or saline (n= ) on day of pregnancy (permanent jugular vein cannula/ hr infusion). non-pregnant rats (n= ) were infused with atp identically. one day before and , , days after infusion, hr urine and blood samples (wbc count and hemopexin activity) were collected. seven days after the infusion, rats were sacrificed and kidney tissue processed for immunohistology. results: urinary albumin excretion was increased in pregnant atp infused rats only (fig ) . wbc were also increased only in pregnant rats infused with atp (days and vs pre-infusion value). in pregnant atp infused rats intraglomerular influx of monocytes was increased, which correlated with urinary albumin excretion on the same day (r = . ). staining of glomeruli for the angii receptor (at- r) showed decreased at- r expression in control pregnant rats as compared to non-pregnant rats, while at- r expression in atp infused pregnant rats was increased as compared to control pregnant rats. hemopexin activity was increased on days and in control pregnant rats as compared to all other groups. discussion: these data support the notion that atp is toxic exclusively in the pregnant condition. it may be suggested that atp induced an inflammatory response, although the exact mechanism by which atp induced its effects needs further investigation. background: hepatocyte growth factor (hgf) is a multifunctional cytokine that is known to promote division, motility, invasion and morphogenesis of a wide range of cell types and to inhibit apoptosis. the effects of hgf are mediated through its interaction with the tyrosine kinase receptor c-met. in pregnancy hgf/met system is involved in the physiologic growth and development of the feto-placental unit. hgf/met effects are counteracted by transforming growth factor- (tgf- ), that is known to promote progressive fibrosis in human tissues. moreover tgf- plays a major role in trophoblast growth and differentiation. tgf- inhibits hgf expression as well as hgf inhibits tgf- expression. an understanding of the mechanisms regulating placental balance of these growth factors may provide insights into the processes that occur in complications of pregnancy, such as preeclampsia (pe) and fetal growth restriction (fgr). objective: to verify the hypothesis that hgf, c-met and tgf- are differently expressed in tissues of normal and pe placentas. methods: we studied placentas from pregnancies complicated by pe ( with normal fetal growth and with fgr) and placentas from normal pregnancies. from each placenta random samples were excised and rna was extracted; quantitative real-time rt-pcr analysis was used to investigate mrna expression of hgf, c-met and tgf- in pe (with or without fgr) and in normal placentas. results: gestational age, neonatal weight and placental weight were, as expected, lower in pe groups. the mrna expressions of the three molecules are higher in pe than in normal placentas, but the difference is statistically significant only for c-met. the higher values are mainly due to the increase in the pe group without fgr for c-met and tgf- and the increase in the pe-fgr group for hgf. conclusion: increased levels of expression of hgf/met system in pathological placentas could be explained as an attempt to repair placental damages; nevertheless placental regeneration could be inhibited by the increase of tgf- , that promote fibrosis. placental expression of hgf, c-met and tgf- is increased in all pe placentas, but particularly in placentas of pe with normal fetal growth, where placental tissue is probably less compromised. obesity is a risk factor for preeclampsia (pe), but the reason for this risk is unknown. previously, we found that neutrophils infiltrated into the vasculature of pe women released myeloperoxidase (mpo) and matrix metalloproteinase (mmp ), products that can cause oxidative stress and vascular dysfunction. if neutrophils infiltrate the vasculature of obese women and release mpo and/or mmp , this may help explain why they are at risk of developing pe. hypothesis: systemic vascular tissue of obese women will have a significant presence of mpo and mmp as a result of neutrophil infiltration. methods: subcutaneous fat, which is highly vascularized, was obtained at abdominal surgery from normal weight, overweight and obese women. formalin fixed, paraffin embedded μm sections of fat biopsies were stained using immunohistochemistry with specific antibodies for mpo and mmp . data were evaluated for intensity of vessel staining by visual score ( - ), density of staining using image analysis software, and % vessels with neutrophil staining, liberated from serum-free placental villous explant cultures from normal and pe pregnancies on human endothelial cells, and identified candidate mediators of their differential effects on metabolism and behaviour. methods: term placental villous tissue from normal (n= ) or pe (n= ) pregnancies were explanted for days at % oxygen. conditioned h medium (day - ) was applied to human umbilical vein endothelial cells (huvecs). an angiogenesis assay was conducted in which tubule length and number were measured by morphometric imaging following seeding on % matrigel. the effect of explant conditioned medium on endothelial cell metabolism was determined by mtt and bioluminescent atp assay. the release of vasoactive metabolites (nitrite, endothelin- , prostacyclin) from huvecs exposed to this medium was also measured. finally, a luminex bead array was used to screen the explant media for a panel of chemokines/cytokines. results: in the angiogenesis assay, tubule length (p< . , mann-whitney u test) and number (p< . ) were significantly decreased in pe compared to normal pregnancy medium. there was no change in mtt reduction, but endothelial cellular atp levels were also significantly reduced following exposure to pe explant medium (p< . ). both normal and pe-derived medium stimulated huvecs to produce vasoactive metabolites. the following cytokines were detectable in the explant media: interleukin (il)- , il- , gro-, monocyte chemotactic protein- and macrophage inflammatory protein- (mip- ). higher levels of both il- and gro-were present in the normal medium compared to pe (both p< . ). mip- was present in pe conditioned media but undetectable in media generated from normal placental explants. conclusions: these results suggest that pre-eclampsia stimulates the release of soluble factors from the placenta which have adverse effects on endothelial cell angiogenic potential and metabolism. altered levels of several cytokines were detected in the explant medium, and the effects of these on endothelial cell function are currently being addressed. yang gu, davis f lewis, yuping wang. obstetrics and gynecology, lsuhsc-shreveport, shreveport, la, usa. objective: placentas from women with preeclampsia (pe) release more chymotrypsin-like protease (clp). the purpose of this study was to determine if placenta-derived clp was responsible for altering endothelial (ec) barrier function in pe. approaches: endothelial junctional protein complex ( -catenin/ve-cadherin/ p ) expression and junctional protein ve-cadherin distribution were examined in ecs treated with pe placental conditioned medium. methods: ) confluent ecs were treated with pe placental conditioned medium (cm). the association of ec junctional protein complex ve-cadherin/catenin/p was examined by a combined immuno-precipitation (ip) and immuno-blotting (ib) assay, in which total cellular protein was immunoprecipitated with monoclonal antibody against -catenin and then immunoblotted with antibodies against ve-cadherin or p- . ) confluent ecs grown on cover slips were exposed to pe placental cm with or without depletion of chymotrypsin. ec junction protein ve-cadherin distribution was examined by fluorescent microscopy. results: ) ve-cadherin and p are expressed in control ecs but not in ecs exposed to pe cm, which indicate that the junctional protein complex vecadherin/ -catenin/ p is lost in ecs exposed to pe cm. ) ecs exposed to pe placental cm showed a discontinuous distribution and reduced expression for ve-cadherin at cell contact areas. the zipper like structure was lost and cleft was formed at cell-cell contacts. these observations indicate that the homotypic cell-cell adhesion and junction protein intracellular partner complex are disrupted. these disruptive phenomena in cells treated with pe conditioned medium were not present in control cells and in cells treated with cm after depletion of chymotrypsin. conclusion: clp released by the placenta could be a candidate agent that is responsible for disrupting ec integrity and inducing endothelial permeability in pe. (supported by nih grants hl and hd ). introduction: chronic pelvic pain (cpp) syndromes such as endometriosis, irritable bowel syndrome, and interstitial cystitis are associated with visceral hyperalgesia, and often coexist in the same patient. one possible explanation for this phenomenon is viscero-visceral cross-sensitization in which increased nociceptive input from an inflamed pelvic organ sensitizes neurons that receive convergent input from an unaffected organ to the same dorsal root ganglion (drg). nociception induces upregulation of perk and substance p. the purpose of this study was to determine, in a rodent model, whether uterine inflammation increased the number of perk-and sp-positive neurons in sensory ganglia innervating both uterus and colon. methods: colonic and uterine drgs were retrogradely labeled with fluorescent tracer dyes micro-injected into the colon and uterus. ganglia were harvested, cryoprotected and cut for fluorescent microscopy. results:approximately % neurons were colon-specific and % were uterus-specific. among these uterus-or colon-specific neurons, up to % of labeled drg neurons in the l -s levels innervated both visceral organs. uterine inflammation increased the number of perk and sp-immunoreactive neurons in drg neurons innervating colon, uterus, and those innervating both organs. furthermore, this effect was specific as non-retrograde labeled drg neurons did not manifest a significant increase in perk or sp immunoreactive cells. conclusions: localized uterine inflammation leads to increased expression of sp and perk in uterine afferents as well as dichotomizing afferents innervating both uterus and colon, suggesting that viscero-visceral convergence is present at the level of drg primary afferent cell bodies. this visceral sensory integration may underlie the co-morbidity of female pelvic pain disorders and may provide basic information regarding the etiology of cpp syndromes. purpose: success rates of medical and surgical modalities for the treatment of severe fecal incontinence due to obstetric trauma are modest. we tested whether the intrasphincteric injection of autologous myoblasts is clinically safe and feasible for postobstetric fecal incontinence. methods: using ultrasound guidance a suspension of autologous myoblasts was injected in the anal sphincter muscle complex in three women with severe postobstetric fecal incontinence. main outcome measures were safety, feasibility and the wexner grading score. secondary outcome measures were incontinence episodes, rockwood fecal incontinenece quality of life scale, external anal sphincter morphology and anal pressure values. results: all procurement procedures and injections were performed without complications; there were no clinically or laboratory signs of infection or inflammation. three months post myoblast injection, wexner continence grading scores and rockwood incontinence scales were markedly improved and incontinence episodes reduced in all three patients. no change could be observed in sonographic anal sphincter morphology. mean anal squeeze pressure improved. conclusion: autologous myoblast injection for fecal incontinence is clinically feasible and safe; further studies will evaluate the efficacy of this approach. objective: to evaluate whether hysterectomy is associated with a change in postoperative bmi. methods: a retrospective cohort study was conducted of hysterectomies performed for benign indications from june to june . institutional review board approval was obtained. the data were collected by a medical student blinded to the hypothesis. basic demographic data were recorded. body mass index (bmi) was determined at time points: time (immediately postoperatively), time ( weeks to months postoperatively), time ( months to year postoperatively) and time ( to . years postoperatively). one-way anova was performed using ncss statistical software. a bonferroni multiple comparison test (p< . ) was used to compare median changes in bmi from baseline. the starting bmi served as the control group. results: there was a statistically significant increase in bmi at time compared to baseline in all women ( . to . ). when sorted was measured by matrigel invasion assay. small interference rna targeting vegfr- were predesigned by ambion inc. and cells were transfected using ambion siport neofx according to the optimized protocol. results: of the four receptors (vegfr- , vegfr- , nrp- and nrp- ), vegfr- was the predominant receptor that expressed in the more invasive cell lines (dov , skov and r ). lpa, at - m, significantly induced vegfr- expression in dov and skov cells (p< . ), without significantly affecting vegfr- expression. lpa ( - m) also significantly induced the expression of vegf and vegf (p< . ) in dov and skov cells. by small interference rna (sirna) transfection, we demonstrated that inhibition of vegfr- expression could significantly decrease dov cells' invasiveness (p< . ) and moderately decrease skov cells' invasiveness. moreover, silencing of vegfr- by sirna significantly suppressed lpa-induced dov and skov invasion. conclusion: these results suggest that knocking down vegfr- expression by rnai may be an effective strategy to inhibit lpa-induced ovarian cancer metastasis. cancer. fengqiang wang, david fishman. obstetrics and gynecology, new york university school of medicine, new york, ny, usa. objectives: expression of matrix metalloproteinases, such as mmp- and mmp- , has implicated in epithelial ovarian cancer (eoc) invasion and metastasis. osteopontin (opn) was also expressed in various human cancers and associated with tumor progression, invasion and metastasis. in the present study, we examined the correlation of mmp- , mmp- and osteopontin expression with tumor stage in ovarian tumor tissues and normal ovaries using a commercial tissue scan array. methods: complimentary dna (cdna) from normal ovaries (n = ) and ovarian tumors (n = ) of different stages (stage i, n = ; stage ii, n = ; stage iii, n = ; stage iv, n = ) was amplified by real time pcr using gene specific primer pairs for mmp- , mmp- , and osteopontin. gapdh was also amplified as a reference control. the expression level of mmp- , mmp- and osteopontin was calculated as relative expression normalized to that of gapdh in each tissue sample, and the expression in sample that has the lowest target gene expression was arbitrarily set as . the average expression of mmp- in ovarian tumor tissues ( ± ) is fold of that in normal ovaries ( ± , p = . ). using an arbitrarily set standard, of normal ovaries ( . %) has elevated mmp- expression; in ovarian tumor tissues, the percentage is . % ( of ), significantly higher than in normal tissues (p = . ). in early stage tumors (stage i/ii, n = ), of them have elevated mmp- expression ( . %, p = . vs. normal ovaries), whereh the average expression of mmp- is fold of that in normal ovaries (p = . ) and . fold of that in late stage tumors (stage iii/iv, n = ). the mmp- expression in ovarian tumors (n = , ± ) is fold of that in normal ovaries (n = ), however, the difference is not significant (p > . ) due to the extremely high expression of mmp- in two tumor tissues. osteopontin expression in ovarian tumor tissues is . fold of that in normal ovarian tissues ( ± . , n= vs. . ± . , n = , p< . ). in early stage (i/ii) ovarian tumors, osteopontin expression is . fold of that in normal ovaries, while in late stage (iii/iv) ovarian tumors, its expression is . fold of that in normal ovaries (p< . ), suggesting an increase trend associated with disease stages. conclusions: our results suggest that mmp- , mmp- and osteopontin alone or combined may have clinical value for ovarian cancer detection. objectives: -tubulin acetylation has been proposed to control the dynamic nature of microtubule stability. acetylated -tubulin plays a role in regulating microtubule functions in mitosis and cell migration. here, we sought to identify the relationship between post-translational -tubulin acetylation and the expression of epithelial cell adhesion molecules (ep-cam) after exposure to microtubule interacting agents in ovarian cancer cells. methods: epithelial ovarian cancer cell line, hey was treated with microtubule stabilizing agents (taxol, epothilone b and discodermolide), microtubule-destabilizing agent (vinblastine), hdac inhibitor trichostatin a (tsa), anti-metabolite fluorouracil ( fu), or alkalyting agents (cisplatin and carboplatin). cells were separately treated with either ic or -fold ic of each agent, and incubated at °c for h, h and h. acetylation oftubulin and pan--tubulin were evaluated by western blot analysis followed by protein quantification. cell surface ep-cam expression was examined by flow cytometry. results: increased acetylation of -tubulin was seen with taxol, epothilone b, discodermolide, vinblastine and tsa. -tubulin acetylation was time and dose dependent. the highest level of -tubulin acetylation ( . -fold) was observed with vinblastine at -fold ic after h. exposure to microtubule interacting agents and tsa resulted in increased cell surface expression of ep-cam in a time and dose dependent manner. the highest level of cell surface ep-cam expression ( . fold) was observed with -fold ic of vinblastine at h. the increase in acetylated -tubulin and ep-cam expression was clearly detectable after h treatment. this data reveals a similar dose and time dependent increases between the acetylation of -tubulin and the increase of ep-cam expression. conclusions: these data demonstrate the promotion of -tubulin acetylation and cell surface ep-cam expression by a microtubule destabilizing agent and by microtubule stabilizing agents. interestingly, vinblastine induces the highest -tubulin acetylation and ep-cam expression. acetylation of alpha-tubulin may be associated with redistribution of cell surface antigens in ovarian cancer cells. objective: epothilone b (epob) is similar to taxol in its ability to enhance tubulin polymerization and to stabilize microtubules. epob is currently being evaluated as an antitumor agent and is in phase iii clinical trials. the tumor suppressor gene, p plays an important role in the induction of apoptosis by a variety of anticancer drugs. p mitogen-activated protein kinase is activated by a wide array of stress stimuli including chemotherapeutic agents and promotes apoptosis. since both p and p activation induces apoptosis, we hoped to evaluate the relationship between p , p-p and parp cleavage, an early indicator of apoptosis, in ovarian cancer cells after treatment with epob. methods: hey cells were treated with epob ( to nm) for h. parp cleavage product p as well as p-p , p , phospho-p (ser- ), p and survivin were determined by western blot analysis. a wild type ovarian cancer cell line hey, was treated with or without m sb , a specific inhibitor of p-p , followed by treatment with epob ( or nm) for h. lysates were prepared and western blot analysis was performed with polyclonal phospho-p and anti-phospho-p antibodies. results: epob induces p activation and apoptosis demonstrated by increased parp cleavage product. time course studies indicated that phosphorylation of p precedes phosphorylation of p in hey cells. the expression of p targeted gene, p (survivin) were differentially expressed depending on the dose of epob and the duration of drug exposure. pretreatment with specific inhibitor of p markedly inhibited the p phosphorylation at serine . conclusions: nm epob (a concentration that triggered mitotic arrest) causes a decrease in p expression and an increase in survivin expression. epob induces parp cleavage. p inhibitor sb inhibits epo-b -induced p phosphorylation. these results suggest that phosphorylation of p may lead to p activation and these signaling events may be related to epo-b induced cell death in ovarian cells. conclusions: nf-b has been shown to control the expression and function of anti-apoptotic proteins and pro-inflammatory cytokines. in the present study we demonstrated that specific inhibition of nf-b by erib reversed the anti-apoptotic state of chemoresistant ovarian cancer cells, therefore may provide a new potential venue for the treatment of ovarian cancer patients. expression in cervical cancer. madhu chauhan, chandra yallampalli. gynecology, university of texas medical branch, galveston, tx, usa. background: intermedin (imd)/adrenomedullin is a ct/cgrp family peptide. imd is expressed in a variety of tissues such as pituitary, stomach, placenta, uterus, and ovary .we have shown that imd plays a role in a variety of physiological functions, including vasodilatation and fetoplacental growth regulation. further we have data indicating an angiogenic activity of imd in first trimester trophoblast cells. we hypothesize that imd is expressed in cervix and may have a role in the pathology of cervical cancer objective: ) to analyze expression of imd mrna in human cervix, rat cervix from non-pregnant and pregnant rats; ) to assess the differences in the expression of imd in normal human cervix and cervical carcinoma tissues and ) to analyze the effect of imd on the expression of tnf-alpha and il- beta in human epithelial cervical carcinoma cells (hela). methods: groups of sprague-dawley, non-pregnant and pregnant rats on day of gestation were used in this study. cervical tissues were collected from the non-pregnant and pregnant rats, women undergoing hysterectomy and from women diagnosed with cervical carcinoma. total rna was extracted using trizol method. hela cells were grown to % confluency in rpmi medium supplemented with % fbs. the cells were starved in %fbs for hrs followed by treatment with imd ( - m) in presence or absence of imd antagonist, imda ( - m). cells were further incubated for hrs and total rna was extracted using trizol reagent. rna was treated with dnase before performing the reverse transcriptase polymerase chain reaction (rt-pcr). the rt-pcr data was normalized to that of s. results: ) imd mrna is expressed in rat and human cervix and in hela cells. ) expression of imd is elevated in pregnant rat cervix as compared to the non-pregnant. ) imd has no effect on tnf-alpha expression in hela cells treated with imd but caused a decline in the expression of il- beta mrna and, ) expression of imd mrna is significantly elevated (p< . ) in cervical carcinoma as compared to the normal cervix. conclusion: imd is expressed in both rat and human cervix and is elevated in pregnant rat suggesting that it may have a role in cervical function during pregnancy in rat. in addition we demonstrate that imd is involved in the pathology of cervical carcinoma and thus may have a clinical significance in the pathology of cervical cancer. objective: there is minimal information about the impact of treatment delays or dose reductions on chemotherapeutic treatment responses and overall outcomes in ovarian cancer patients. the primary objective of this study was to quantify the impact of treatment delays and dose reductions in an in vivo xenograft ovarian cancer model and to evaluate if the growth factors could improve overall survival. methods: heya- and skov -ip xenograft mouse models to determine the effect of treatment delays or dose reductions on tumor response. results: the results indicated that full dose of paclitaxel ( mg/kg) and carboplatin ( mg/kg) delivered on timeevery daysachieved better tumor response in both aggressive (heya- ) and metastatic (skov -ip ) human ovarian tumors compared to the non-treatment and vehicle groups. in heya- mice, paclitaxel/carboplatin alone and paclitaxel/carboplatin followed by growth factor support agents including pegfilgrastim ( μg/kg) and darbepoetin ( μg/kg) improved overall survival rate. growth factors also improved the tolerability in heya- model. for skov -ip mice, the treatment delays resulted in a significant reduce in overall survival time compared to full dose, on time treatment (p< . ). for the dose reduction group, there was a significant different survival comparing to full dose, on time treatment (p< . ). conclusion: treatment delays had a negative impact on tumor response and overall survival compare with treatment controls. in addition, use of growth factor agents also improved treatment response and tolerability of chemotherapy and ultimately overall survival. - ) . median age at recurrence was ( - ), and median interval to recurrence . months ( - ). ( %) patients died of recurrent disease and ( %) of other causes. site of recurrence and was local in , groin in and distant in . of the local recurrences were managed with wide local excision (wle) radical surgery ( radical excisions with skin flaps, posterior exenterations, anterior exenteration, total exenteration), wle and radiotherapy (rt)/chemort, chemo/chemort/rt, and palliation. groin recurrences were managed surgically ( adjuvant rt), rt alone, chemotherapy alone, and palliation. patients with distant metastases were managed surgically, with rt/chemo/chemort, and palliation. overall median survival after recurrence was months. median survival (months) by site of recurrence was: local , groin , distant , groin or distant . there was a significant difference in survival in local vs groin node recurrence (p< . ), local vs groin and distant (p< . ), and groin node vs distant (p . ). and years after recurrence survival rates were: local % and %, groin % and % distant , . conclusion patients with vscc remain at risk of recurrent disease therefore long term follow up these patients is essential. patients with local recurrence often have a good prognosis. outcomes for groin and distant recurrences are poor, but a proportion of those with groin recurrences can be salvaged. therefore early identification of local and groin recurrences is essential for improving outcomes in recurrent vscc particularly in cases with more conservative management of primary disease. introduction: endocrine disrupting chemicals (edcs) are environmental agents possessing hormone-like activity. exposure to edcs during differentiation can interfere with hormonal signaling, resulting in predisposition to some cancers. it has been suggested that some of these effects may be epigenetic, mediated by changes in dna and histone methylation. we hypothesized that edcs, diethylstilbestrol (des), and bisphenol-a (bpa), may act by altering the expression of dna and histone methyltransferases (dnmts and hmts). methods: ishikawa (endometrial) and mcf (breast) cells were cultured in steroid-free, phenol-free media with bpa ( m), des ( x - m) or vehicle for hours. pregnant cd- mice were treated with intraperitoneal injections of des ( mg/kg) or vehicle on days - of gestation. weeks after birth, offspring were sacrificed and tissue obtained. mrna was extracted, cdna was generated and quantitative real time rt-pcr was performed and normalized to -actin. all experiments were conducted in triplicate, repeated three times and compared using anova. results: dnmts (dnmt , a, and b) and hmts (mll and ezh ) were screened after in vitro exposure to edcs (table ) . ezh mrna expression was significantly increased in ishikawa cells after treatment with des or bpa. a similar response in ezh expression was seen in mcf cells treated with des or bpa. due to the consistent induction of ezh in all cells with either treatment, we examined the effect of des exposure on ezh expression in vivo. in adult mice exposed to des in utero, ezh expression was persistently increased ( . ± . fold, p< . ). conclusions: breast and uterine cell lines show increased expression of ezh in response to bpa or des exposure. this differential expression persists in the adult offspring of mice exposed to des in utero. ezh has been identified as a risk for neoplastic progression in the breast and for increased proliferation in uterine cancers. des induced ezh expression may be a mechanism for the increased incidence of breast and reproductive tract cancers seen in des exposed women. defects in cellular programs that control apoptosis lead to an imbalance of cell proliferation and cell death in ovarian cancer. recent evidence suggests that the use of some anti-inflammatory drugs decreases risk of ovarian cancer. natural curcumin-based anti-inflammatory therapies were shown to be beneficial in preclinical models of ovarian cancer (lin et al., ) . in this study, we examined the effects of plant derived curcumin on cell proliferation, apoptosis, and vegf expression in cultivated ovarian cancer cells. ovarian cancer igrov cells were cultured under standard conditions to study the effects of curcumin on cell kinetics and on vegf expression. cell proliferation was measured by srb and mtt assays. apoptosis was determined by measuring cytoplasmic histone-associated-dna-fragments (cell death detection elisa, roche, germany). vegf gene promoter-reporter activation and real-time quantitative reverse transcription polymerase chain reaction were used. conditioned media concentrations of vegf were measured with a commercially available enzyme-linked immunosorbent assay (quantikine, r d systems, minneapolis, mn). we observed that curcumin dose-dependently suppressed cell growth in igrov cancer cells (ic = um). treated cells showed a - fold increase in dna fragmentation compared to controls. curcumin also resulted in a significant decrease of vegfmrna expression and vegf protein secretion into the conditioned media in a dose-dependent manner. in this study, we have demonstrated that curcumin induces apoptosis, suppresses growth, and inhibits vegf gene and protein expression in an ovarian cancer cell line. experiments are underway to identify specific mechanism of curcumin action. curcumin may act as a chemosensitizing drug by potentiating the antitumor effects of standard treatments including taxols and platins in ovarian cancer. supported by the caldwell family foundation and the vesa w. and william j. hardman, jr. charitable foundation inc. daniel r christie, faheem m shaikh, john a lucas iii, susan l bellis. obsterics and gynecology, university of alabama at birmingham, birmingham, al, usa; physiology and biophysics, university of alabama at birmingham, birmingham, al, usa. introduction: previous work has shown that an upregulation of the enzyme st gal i, which is responsible for the , sialylation of integrins, confers a more tumorigenic/metastatic phenotype to colon carcinoma cell lines. it is not known, however, if this is unique to colon cancer, or if it is more broadly applicable to other forms of cancers. quantitatively increased expression of st gal i has been reported in ovarian cancers versus controls, but no biochemical or functional assays have been described to date. objective: because integrins are involved in cell adhesion and migration, and because metastasis of epithelial ovarian cancers is largely an intraperitoneal dissemination, we hypothesized that upregulation in the expression of st gal i in an ovarian cancer cell line would enhance binding with the extracellular matrix, increase invasiveness, and alter migration. methods: in the present study we forced a stable transduction of st gal i into the ov ovarian tumor cell line, which we found to be lacking the st gal i enzyme, establishing a parental (par), an empty lentiviral vector (ev), and an st gal i expressing (st ) cell line. a collagen i cell adhesion assay was performed and quantified by staining adherent cells and measuring absorbance. a haptotactic collagen i cell migration assay was performed by seeding cells in boyden chambers lined with collagen i concentration gradient, and quantified with cell staining and absorbance measurement. cell invasion through a reconstituted basement membrane (matrigel) was quantified as previously described for the cell migration assay. results: we were able to demonstrate successful creation of the ov -st gal i cell line by western blot analysis. functional assays demonstrated increased adhesion to collagen i (p < . ), increased haptotactic collagen i cell migration (p < . ), and increased invasiveness (p < . ) in the st cell line as compared to par and ev when analyzed by one-way anova. conclusion: this initial study into st gal i in ovarian cancer may have future therapeutic implications, and, in addition, lend greater insight into the intraperitoneal dissemination of disease.of microarrays (sam), arrayassist and binary tree structured vector quantization. differentially expressed genes were integrated with a database of known predicted protein-protein interactions (ophid) and key genes are being validated with real-time pcr and immunohistochemistry. results: unsupervised hierarchical clustering revealed collective clustering of all tumors, irrespective of their pathological classification. sam analysis has highlighted probe sets as differentially expressed between lmp and lmp-mp, probes between lmp and lgsc, and probes between lmp and lmp-mp+lgsc. no differential gene expression was detected between lmp-mp and lgsc. ophid analysis demonstrated gene members of the egfr and mapk / pathways to be differentially regulated between the non-invasive and the invasive tumors. to date, we have successfully validated members of the mapk / pathway-poly adp ribose polymerase (ppol) and traf family associated nf kappa b activator (tank)-using real-time pcr. conclusion: our data demonstrate that although the tumors have related genetic profiles, lmp-mp and lgsc are similar to each other and different from lmp, in keeping with their clinical behavior. members of the mapk / and egfr pathways appear to play a key role in low grade serous cancer. identification of novel genes associated with malignant transformation, may lead to development of more effective targeted therapy for lgsc. background: approximately % of pap smears with the ambiguous diagnosis of atypical squamous cells, cannot exclude high grade (asc-h), are negative for dysplasia in follow up colposcopic examination and biopsy. although hpv testing provides excellent negative predictive value (npv) ( %), the prevalence of high risk hpv infection is high in young women and the positive predictive value (ppv) in asc-h pap smears is no better than cytologic diagnosis alone ( %). recent studies have shown that immunostaining for p ink a , or proex tm c, supports a diagnosis of dysplasia in surgical biopsies. our objective was to determine whether staining for p or proexc provides sufficient predictive value to reliably distinguish high grade dysplasia in asc-h pap smears. design: we retrospectively collected samples from liquid based pap smears diagnosed as asc-h at either ohsu or portland oregon kaiser permanente ( - ). known hsil and negative pap cases were included as immunostaining controls. asc-h cases with followup cervical biopsies (n= ) were included for subsequent immunostaining according to manufacture's instructions. samples were also sequestered for hpv testing (pending). immunostained slides were scored as positive or negative by two independent cytopathologists (as and tm) while blinded to pap diagnoses and surgical biopsy outcomes. results: we observed excellent agreement between pathologists' scores (pairwise kappa statistic . ). the correlation between p and proexc scores was moderate (kappa . ). chi-square analysis comparing staining to biopsy outcome revealed a significant association between proex c positivity and cervical dysplasia (*** p< . jing lin, zhenmin lei, ch v rao. ob/gyn women health, university of louisville health sciences center, louisville, ky, usa. introduction: matrix metalloproteinases (mmps) are a family of highly homologous zinc-dependent endopeptidases, which degrade all kinds of extracellular matrix proteins. the degradation process is required for tissue growth and remodelling. these enzymes are probably involved in uterine growth and devolopment and its differentiated functions. ovarian steroid hormones, estradiol (e ) and progesterone (p ), are known to regulate some of the uterine mmps. since it is now known that lh/hcg can directly regulate uterine growth and devolopment and its functions, we questioned whether these gonadotropins could also regulate mmps in the uterus. methods: sixty day old wild type (wt) and lh receptor knockout (lhrko) mice and -day e and p treated -day old animals were used. in addition, primary cultures of uterine epithelial cells from wt animals were treated for hrs either with no hormone or with a single or a combination of pg/ml of e or p , ng/ml of hcg. then mmp- , - and - mrna levels were quantified by the semiquantitative rt-pcr. results: while the uterine mmp- mrna levels were unaffected, mmp- mrna levels significantly decreased and mmp- mrna levels significantly increased in lhrko animals as compared with wt siblings. e and p treatment reversed mmp- and mmp- changes in lhrko animals. treatment of wt type primary endometrial epithelial cell cultures with hcg had no effect on mmp- mrna levels, but it did increase mmp- mrna levels. this increase was synergistic with both e or p . conclusion: while lh/hcg do not regulate uterine mmp- and mmp- , they seem to co-regulate mmp- with ovarian steroid hormones. cancer. radhika gogoi, christine ardalan, dorota popiolek, leslie gold, john curtin, stephanie v blank, bhavana pothuri. new york university, new york, ny, usa. objective: megesterol, a synthetic progestin with strong androgenic properties, is used in the medical management of patients (pts) with atypical endometrial hyperplasia (aeh) or endometrial carcinoma (emca). our hypothesis was that androgen receptor (ar) expression in the endometrium of aeh and emca pts would correlate with degree of response to treatment. methods: pre-and post-treatment endometrial biopsy specimens were obtained from pts treated with megesterol for aeh or emca. ar expression was investigated by immunohistochemical (ihc) analysis with appropriate positive and negative controls. ihc staining was scored for intensity ( - ) and percentage of positive cells ( - ) in the glandular and stromal compartments by a pathologist, blinded to clinical response data. a composite score utilizing both intensity and percentage of positive cells was calculated. we evaluated pre-and post-treatment ar expression in responders and nonresponders as well as ar expression in emca, aeh and normal endometrium. the mann whitney u and the wilxocon signed rank tests were utilized for statistical analysis. results: eight pts' pre-and post-treatment samples were obtained; with emca and with aeh. three pts had no response, , a partial response and , complete responses. ar expression in emca samples when compared to the normal endometrium was significantly lower in both the glands (mean . vs. ; p< . ) and the stroma (mean . vs. ; p< . ). although there was no statistically significant difference in glandular ar expression in the pretreatment biopsies of responders compared to nonresponders (mean . vs. . ; p= . ), there was a significantly higher level of glandular ar expression in the post treatment biopsies of responders compared to non-responders (mean . vs. ; p< . ). furthermore, we noted a trend towards higher levels of glandular ar expression in the post-treatment versus the pre-treatment biopsies in the responders (mean . vs. . ; p= . ). we noted a significant decrease in ar expression in emca compared to the normal endometrium. increased ar expression after treatment in responders suggests an important role of the ar in pts treated conservatively with progestational therapy, and needs further prospective validation as a means to predict treatment response in these pts. objectives: study the correlation between adenomyosis and some potential non-surgical risk factors. objective: o -methylguanine-dna methyltransferase (mgmt) acts to repair dna damaged by alkylation of guanine residues. mgmt promoter methylation and gene silencing is seen in a variety of cancers and pre-cancerous changes. the loss of mgmt activity is associated with increased sensitivity to alkylating agents and is a favorable prognostic indicator in gliomas. we sought to determine if mgmt promoter methylation plays a role in endometrial cancer. methods: one hundred and twenty primary endometrial cancers were analyzed for mgmt promoter methylation by combined bisulfite restriction analysis (cobra). the cohort included endometrioid endometrial cancers, endometrial tumors of adverse histologic type, and endometrial cancer cell lines. twenty one endometrioid and mixed endometrioid ovarian cancers were also analyzed. a subset of the primary tumors was analyzed for mgmt expression by immunohistochemistry. results: no mgmt promoter methylation was seen in the endometrial cancers evaluated or the endometrial cancer cell lines. one of the ovarian cancers showed methylation. immunohistochemistry for mgmt expression is ongoing. conclusion: mgmt promoter methylation is an infrequent event in endometrial cancer. mgmt expression in tumor cells and repair of alkylguanine residues could explain in part the limited response of endometrial tumors to alkylating chemotherapy. objective: uterine sarcomas ( % of gynecological malignancies) originate from uterine mesenchyma. patients with high-risk disease (i.e. high grade) or at advanced stages have poor -years overall survival (< - %). pelvic radiation and/or chemotherapy have not demonstrated to improve survival. identification of new therapies for this malignancy is a major goal. few in vitro models have been established to test therapeutic agents for uterine sarcoma. here we sought to establish a new human uterine sarcoma cell line and to test the effects of chemotherapeutic drugs: tnf-related apoptosis inducing ligand (trail) used alone or in combination. methods: tissue sample was obtained from a woman with uterine sarcoma undergoing hysterectomy. sarcoma cell lines were established using a published protocol for endometrial cancer. phenotypic characterization was made through the different passages ( to ) by western blot. levels of estrogen (er), progesterone (pr) and trail receptors were also studied (rt-pcr, w-b). cells were incubated with chemotherapy agents (cisplatin, paclitaxel and doxorubicin and trail) and cytotoxicity (mts assays) and apoptosis (flow cytometry, parp cleavage by w-b, and dna laddering) measured. results: human uterine sarcoma cell line was established from a highgrade uterine sarcoma. through the different passages the cell line remains expressing cytokeratin, vimentin, tissue factor, caveolin- and -actin. this cell line expresses low er and pr levels. trail receptors (r and r ) were also detectable (rt-pcr, w-b). cisplatin, paclitaxel and doxorubicin ( um for h) produced low cell cytotoxicity (< %). trail ( ng/ml for h) induced about % cell cytotoxicity. apoptosis was confirmed by parp cleavage. doxorubicin significantly enhances trail mediated cytotoxicity (up to %), this was demonstrated by a significant increase in the sub g /g region in the dna histogram. conclusions: we establish a human uterine sarcoma cell lines using protocols for endometrial cancer. more importantly, we demonstrated that doxorubicin enhances trail effect on this uterine sarcomas cell line. thus, this combination might be considered as a treatment for high-risk uterine sarcomas. (financial support fondecyt ). defining the tumor initiating capacity of cd + human endometrial cancer cells. anne m friel, petra a sergent, christine l cummings, rosemary foster, current data suggest rare subpopulations of cells with tumor initiating capabilities are a common feature of solid tumors. several investigators have recently identified cd , a cell surface marker expressed on primitive cells of neural, hematopoietic, endothelial and epithelial lineages, as a potential tumor initiating cell (tic) marker in solid tumors of the brain, colon and pancreas. in our efforts to investigate such a population in human endometrial cancers (enca), we developed an in vivo model that is based on serial transplants of tics from endometrial tumor explants. serial transplant experiments were initiated in nod/scid mice that were injected with primary human enca cells. a subset of cells derived from the generated tumor was subsequently transplanted into new recipients. tumors formed following serial transplantation retained the original histological phenotype of the primary enca, and the number of cells required to initiate tumor formation was reduced at each successive transplant stage suggesting an increase in the ratio of tics to non-tics. we exploited this model in our initial efforts to investigate the tumor initiating potential of cd -expressing enca cells. to evaluate the tumorigenic potential of cd + cells, the tumor initiation capacity of xenograft derived cd + and cd cells were compared following subcutaneous injection of each population into nod/scid mice. only the cd + fraction was tumorigenic consistent with the hypothesis that tumors are generated and maintained by a subpopulation of cells with phenotypically distinct profiles. we are further investigating the functional significance and characteristics of this fraction in vitro and in vivo. objectives. central issues in tumor biology are the understanding of factors that control tumor cell proliferation and the identification of extracellular matrix cues controlling the signaling transducing repertoire that make cancer cells proliferate and invade the host tissues. among these factors, small leucine-rich proteoglycans (srlps):decorin, fibromodulin, lumican, biglycan, are emerging as powerful modulators of angiogenesis and cell growth, by affecting several key elements including matrix assembly, growth factor binding, and receptor tyrosine kinase activity. recently has been demonstrated that srlps can act as a pan-erbb ligand and, in doing so, down-regulate the activity of one of the most potent oncogenic proteins, erbb , whose overexpression is linked to poor prognosis and increased cancer mortality in breast, ovary, and prostate. since srlps have not been previously investigated in the endometrial cancer biology, we investigated their role in the benign and malignant endometrial neoplasia. method. the sampling has been obtained in women (n= ; mean age ± . ) with endometrial hyperplasia (n= ), polyps(n= ), and cancer(n= ), during therapeutic and diagnostic procedures (hysterectomy, colpohysterectomy, hysteroscopy). physiological endometrial samples (n= ) were obtained from menopausal women (n= ; mean age ± . ), during procedures for others gynaecologic indications. immunohistochemestry was the biology technique used for the detection of srlps.results. in the physiological endometrial samples immunoreactivity for decorin, fibromodulin and biglycan was intense (+++), while it was weak in polyps and hyperplasia (+) and absent (-) in cancer. no significant difference in the staining of lumican between the physiological and pathological samples. conclusions. these results could provide a mechanism by which naturally occurring proteins normally synthesized by fibroblasts and smooth muscle cells, the two key components of the tumor stroma, may play a protective role in the genesis and progression of endometrial neoplasia counteracting the growth of neoplastic cells and suppressing tumor cell-mediated angiogenesis. although further studies are necessary to understand mechanisms whereby srlps might influence endometrial cell growth and survival, these molecules may represent potential target for pharmacological cancer therapy. myostatin is a member of the tgf-beta superfamily of protein and a wellknown inhibitor of skeletal muscle proliferation. the muscular component of the uterus is the myometrium, a tissue that regulates its mass in response to different physiologic conditions under the influence of steroids. we determined the expression of myostatin mrna in immortalized pregnant human myometrial (phm ) cells and we verified its biological activity. functional assays showed myostatin induced phosphorylation of smad- and reduction of proliferation of phm cells in a time and dose-dependent manner. to investigate the physiological relevance of our in vitro findings, the expression of myostatin in rat uterus was examined at various phases of the estrous cycle. for the first time we report that myostatin is expressed in rat uterus and that levels of myostatin mrna change during distinct phases of the estrus cycle. uterine levels of myostatin peaked during late estrous and were the lowest at pro-estrous. to further examine the role of steroids in myostatin regulation, we examined the effects of gonadal steroid administration in ovariectomized (ovx) rats. ovaryectomy increased myostatin expression compared to normal cycling controls. estrogen treatment strong decreased myostatin levels while progesterone produced less robust effects on myostatin expression. these findings taken together suggest an important role for myostatin in the regulation of myometrial functionality. her neu over-expression and pi kinase/akt pathway activation in paget's disease of the vulva. amy stenson, bita behjatnia, jaime shamonki, jianyu rao, amer karam, jonathan berek, oliver dorigo. ob/gyn and pathology, ucla, los angeles, ca, usa; ob/gyn, stanford university, palo alto, ca, usa. background: paget's disease of the vulva is rare with high recurrence rates. treatment of recurrent disease is challenging due to its extent and location. non-surgical approaches have limited clinical efficacy, obviating the need for novel therapies. in contrast to paget's of the breast with well-described overexpression of her neu, molecular features of vulvar paget's are poorly characterized. our objective was to study therapeutic targets in vulvar paget's, including the her neu protein and the phosphorylated oncoprotein akt (pakt). in addition, detailed clinical characteristics were correlated with molecular expression. methods: specimens with vulvar paget's disease were retrieved from ucla's department of pathology. protein expression was evaluated by immunohistochemistry on slides from paraffin embedded tissue using the hercep test (dako) for her neu expression and a standard protocol to assess expression of activated pakt. slides were scored by two independent pathologists based on a nominal scale of (negative) to (strongly positive). clinical data was retrieved via chart review. results: between and , patients with vulvar paget's were identified. median age was yrs ( - yrs). a family history of cancer was found in / ( %), / ( %) were smokers and / ( %) had a history of hormone use. intraepithelial lesions accounted for the majority ( / , %), while / ( %) demonstrated invasion and / ( %) were associated with underlying gi malignancy. / ( %) had at least one recurrence, with median time to recurrence months. so far, specimens were stained for her neu and pakt. overexpression of her neu was found in / ( %.) positive staining for pakt was evident in / ( %.) statistical analysis suggested a correlation between her neu and pakt expression. conclusions: our study demonstrates that overexpression of her neu and activation of the pi kinase/pakt pathway are important features of vulvar paget's disease. to the best of our knowledge, this is the largest series evaluating these molecular pathways in vulvar paget's. our data suggest that her neu and pakt may be important molecular targets for novel therapies using for example the monoclonal antibody trastuzumab directed against her neu, or a pi kinase pathway inhibitor like rapamycin. introduction: uterine leiomyomas are the most frequent tumor of the female reproductive tract and are the primary indication for hysterectomy in women worldwide. these tumors occur in up to % of adult women, and their prevalence is especially high in africa-american women. currently there is no effective and safe medical treatment for uterine fibroids and surgery is the main stay. epigallocatechin gallate (egcg) constitutes the main solid extract of green tea and is believed to contributes most of the antioxidant and antiinflammation capacity of green tea. egcg has been shown to have beneficial effects on prostate cancer and breast cancer by inducing apoptosis and inhibiting proliferation of cancer cells. in this study, we investigated the ability of egcg to inhibit proliferation of human leiomyoma cells (hlm) in vitro. methods: human immortalized leiomyoma cells were cultured at ºc in a humidified atmosphere of % co - % air in smbm medium supplied with %fbs, . % insulin, . % hfgf-b, . % ga- and . % hegf(lonza). the cells were plated at density of × cells/well in -well plates and grown under the same conditions above. the monolayer cultures at approximately % confluence were treated with various concentrations ( , . , . , , , and μm) of egcg (sigma) for days. a fluorometric assay using hoechst dye (sigma) for dna quantitation was conducted at the following designed time points, day , , , and post egcg treatment. the cells were lysed and dna content was determined using hoechst dye solution ( μg/ml). fluorescence was measured after excitation at nm and emission at nm. results: egcg exhibited marked anti-proliferation effect on the growth of hlm cells. compared with untreated control, the inhibitory effect of egcg on hlm cells was observed at μm and peaked at μm concentration. the difference was statistically significant (p = . ). evaluation of the mechanism of action of egcg is cuurently under investigation in the lab.conclusion: egcg significantly inhibited the proliferation of human leiomyoma cells in a dose-depended pattern. egcg may present a potential effective and safe medicinal treatment for uterine fibroids. objective: choriocarcinoma is an aggressive form of germ cell tumor that exhibits rapid growth with early metastases. choriocarcinomas autonomously secrete hcg which acts as an autocrine/paracrine growth factor in these cancers. we hypothesize that a novel hcg antagonist (hcg-ant) can limit tumor expansion by blocking hcg-induced expression of pro-invasive genes. we investigated if hcg-ant could alter rna expression of matrix metalloproteinases (mmp- and mmp- ), which facilitate basement membrane degradation and hence invasion, and metastin (kisspeptin), a strong suppressant of metastasis, in the choriocarcinoma cell line jeg- . design: in vitro experiments using the jeg- cell line. materials and methods: after plating jeg- cells in a well tray overnight in rpmi media containing % fbs, cells were washed twice with pbs and then cultured in ul of serum-free rpmi media containing one of four treatments: ) saline; ) hcg ( iu); ) hcg ( iu) plus hcg-ant ( iu); or ) hcg-ant ( iu). rna was extracted from each well using trizol and reverse transcribed using sensiscript (qiagen). the relative expression of mmp- , mmp- , and metastin mrna was quantified using sybr-green based real time pcr. the expression of the housekeeping gene hprt was used to normalize expression data. results: treatment of jeg- cells with hcg-ant vs. hcg alone reduced expression of mmp- ( . ± . vs. . ± . ) and . hcg-ant reduced mmp- and mmp- expression by % and %, respectively (p< . ). treatment with hcg-ant vs. hcg increased metastin expression ( . ± . vs. . ± . ). metastin expression was increased by % following hcg-ant treatment. conclusion: treatment of the jeg- choriocarcinoma cell line with hcg-ant reversed the increased expression of mmp- and mmp- following treatment with hcg. metastin expression was increased by hcg-ant. this data suggests that hcg antagonism is capable of altering gene expression thereby inhibiting invasion in a choriocarcinoma cell line. the role of hcg-ant as an adjuvant therapy in hcg sensitive tumors offers promise. retinoids, but not progesterone, directly induce differentiation and apoptosis of endometrial cancer cells. you-hong cheng, serdar e bulun. ob/gyn, northwestern university feinberg school of medicine, chicago, il, usa. objectives: the opposing actions of estrogen and progesterone during the menstrual cycle regulate endometrial proliferation, differentiation and secretion. the unopposed action of estrogen contributes to the development of type i endometrial cancer. however, the mechanisms for progesterone protection of estrogen-induced carcinogenesis in endometrium remain unclear. methods and results: in the current study, we demonstrated that retinoids ( -cis retinoic acid (ra) or all-trans ra (atra)) significantly inhibited basal and hormone-stimulated ishikawa cell proliferation by over % using mtt assay. the same experiment indicated that estrogen had no significant effect, whereas progesterone slightly induced, on cell proliferation. cell cycle analysis indicated that atra significantly increased the g /g cell population by % and decreased s phase cells by %, suggesting that ra induces cell cycle arrest at the s phase. knock-down of rar alone or both rar and rxr significantly increased proliferating cell nuclear antigen (pcna) levels in epithelial ishikawa cells, suggesting that ra signaling via rar/rxr activation is critical for normal endometrial growth and differentiation. to determine whether retinoids are naturally secreted by the endometrial stromal cells, we cultured primary stromal cells and analyzed the culture media using hplc. we found that retinol is the predominant retinoid form secreted by stromal cells. the average concentration of retinol in the cultured media of eutopic endometrial stromal cells was approximately to ng/ml/ cells (n= ). although there was less than . ng/ml/ cells of all-trans retinal or atra in the cultured media, we did find a small peak for all-trans retinal and atra in the media using hplc analysis. furthermore, progesterone significantly increased secreted retinol levels from eutopic endometrial stromal cells, but decreased retinol levels secreted from endometriotic stromal cells. retinol is a precursor for ra that is converted to retinal and then to ra. conclusions: we demonstrated that progesterone signaling via pr induces endometrial stromal cells to secrete paracrine retionids that in turn control the phenotype of adjacent epithelial cells. conversely, this interaction is disrupted in diseased endometrial tissues, such as endometrial cancer and endometriosis. the effects of hormonal contraceptives on antimullerian hormone by obesity status. anne z steiner, frank z stanczyk, stan patel, alison edelman. ob/gyn, university of north carolina, chapel hill, nc, usa; ob/gyn, usc keck school of medicine, los angeles, ca, usa; ob/gyn, oregon health and sciences university, portland, or, usa. background: antimullerian hormone (amh) is emerging as a predictor of reproductive potential. serum levels of fsh, a commonly used measure of ovarian reserve, are suppressed with the use of oral contraceptives (ocs) thereby limiting its use. the impact of ocs and on serum amh levels in normal and obese women is unknown. objective: to examine the impact of ocs on serum amh levels by obesity status in reproductive-age women. materials and methods: ovulatory women, ages - years, of normal (< kg/m ; n = ) and obese (> kg/m ; n = ) body mass index (bmi) received a low dose oc ( mcg ethinyl estradiol/ mcg levonorgestrel) for two cycles. serum was obtained at three time points: after days of active pills (cycle , day ), at the end of the -day hormone-free interval (cycle , day ), and during the first week of active pills in cycle (cycle , day , , or ). amh levels were quantified by elisa; fsh and lh levels were determined by chemiluminescent immunoassay. amh at the three time points was compared using repeated measures anova. models were used to assess the relationship between amh and cycle day by obesity status. amh and gonadotropin levels were compared using spearman's correlation. results: amh levels did not differ by oc cycle day (p anova = . ) or by active versus placebo pill use ( . ng/ml ± . vs. . ng/ml ± . , p= . ) among normal bmi women. among obese women, amh levels differed by oc cycle day (p anova = . ), but not by use of active or placebo pill ( . ng/ml ± . vs. . ng/ml ± . , p = . ). across the cycle, cv(standard deviation/mean) averaged . %± . in the obese and . %± . in the normal bmi women ( p= . ). modeling to determine differences in amh throughout the cycles based on obesity status showed a significant interaction (p = . ) and lower amh levels in the obese group (p< . ). among both bmi groups, serum amh and fsh levels did not correlate during active pills or after days of placebo pills. conclusions: in young, normal bmi women serum amh levels do not appear to fluctuate during oc use. among obese women, amh levels are lower and fluctuate significantly. these fluctuations do not appear to mirror changes in gonadotropins and may complicate clinical interpretation of amh. background: menopausal hormone therapy (ht) is a confusing topic for many clinicians and patients. objective: to assess comprehension of basic clinical trial features among prospective participants for the keeps trial, designed to study the effects of ht initiated within years of menopause on chd markers. methods: screening materials were provided giving an overview of study purpose, duration, medications, likelihood of receiving drug vs. placebo, ht related risks and side effects. at a subsequent interview, a -item questionnaire assessed the participant's level of comprehension. a score of % was adequate to complete the informed consent process. those scoring < % were re-counseled and retested. demographic variables determining the likelihood of an initial score > % were evaluated by univariate and multivariable analyses. results: % ( / ) scored > % on initial testing. all women scored > % after re-counseling and retesting. likelihood of an initial response > % correct was unrelated to age or time since menopause. ability to correctly respond was influenced by highest educational level attained. none of women whose furthest educational level was high school scored > % on initial testing, significantly less than those with a college education (p= . ). a higher proportion of college graduates ( / ) scored > % compared to those attaining further education ( / ) (p= . ). comprehension was greatest for study purpose and duration ( / and / correct responses respectively) and least for questions related to results of the whi hormone trial breast cancer and chd. that e alone was not associated with an increased risk of chd ( %) or breast cancer ( %) was poorly understood. conclusion: comprehension of the risks and benefits of ht by potential research subjects is low despite provision of reading materials prior to the informed consent process. (supported by the montefiore medical center/albert einstein college of medicine site for the kronos longevity research institute and k -hd to ns). variation in menopausal symptoms within a sample of hispanic women: swan, the study of women's health across the nation. robin r green, alex j polotsky, aileen p mcginn, carol a derby, rachel p wildman, lhasa ray, kavitha t ram, gerson weiss, nanette f santoro. albert einstein coll of med, bronx, ny; univ of med and dent of new jersey, newark, nj. background: menopausal symptoms are experienced by over % of women. purpose: to describe symptom frequency in a sample of midlife hispanic women from different countries of origin. methods: the study of women's health across the nation (swan) recruited women at baseline who self-identified as hispanic. their baseline responses to validated questionnaires regarding common menopausal symptomatology were examined. symptoms were reported over the previous two weeks and scored on a frequency scale ranging from (not at all) to (every day). for all analyses, symptoms were dichotomized into "absent" vs. "present" variables. responses were correlated with acculturation ( -item scale: marin, hisp j behav sci : , ) and analyzed by sub-ethnicities: central/south american (c/s am), puerto rican (pr), dominican (dr), and cuban (cu). associations between symptoms and sub-ethnicity were tested by chi-square. logistic regression was used to test for associations with acculturation and being us-born. there was significant variation in several menopausal symptoms. while puerto-rican women had the highest likelihood of reporting trouble sleeping (or= . , %ci: . - . ) and headaches (or= . , %ci: . - . ), dominican women were most likely to report vaginal dryness (or= . , %ci: . - . ) acculturation and being us-born did not explain the variation between subethnicities in any of the models tested conclusion: there appear to be significant differences among hispanic women with respect to menopausal symptomatology. these differences were not readily explained by measures of acculturation. (supported by the study of women's health across the nation (swan) has grant support national institutes of health, dhhs, through the national institute on aging, from the national institute of nursing research and the nih office of research on women's health (grants nr ; ag , ag , ag , ag , ag , ag , ag , ag and cd ). purpose: to compare the relative effects of conjugated equine estrogen, raloxifene, and tamoxifen therapies on cognition among women aged years or older. participants and methods: annual modified mini mental state ( ms) examinations were used to assess global cognitive function among the , women enrolled in the two randomized placebo-controlled clinical trials of the women s health initiative memory study (whims) and women enrolled in co-star, the cognitive substudy of the nsabp's study of tamoxifen and raloxifen (star) trial who had baseline ms testing. associations between baseline cognitive risk factors common to both trials and baseline ms scores were assessed and interactions used to examine whether risk factor relationships differed between cohorts. factors for which relationships were similar were used as covariates in analyses comparing ontrial ms scores. factors for which relationships did not appear to be similar were used to stratify analyses. results: compared to placebo, each of the active therapies was associated with a small mean relative deficit in ms scores of . units or less, which was fairly consistent between women with and without prior hysterectomy. overall, relative deficits appeared to be most marked for tamoxifen (unadjusted p= . ) but were also evident for raloxifene (p= . ) and cee (p= . ). conclusions: while unmeasured differences between trials may have confounded our analysis, these findings suggest that both tamoxifen and raloxifene may adversely affect cognitive function in older women. weight gain and increased abdominal fat have been found in women after menopause and is associated with higher levels of leptin, and decreased levels of the cardioprotective adipocytokine adiponectin. at the same time, bmd characteristically decreases. in an effort to determine the evolution and correlates of these changes, we studied postmenopausal women (pm) within years of menopause (age . ± yrs) of normal weight (bmi . ± ) and compared them to weight matched (bmi . ± ) premenopausal (pre) controls (age . ± yrs.) all subjects had bmd and body composition studies by dexa and measurements of leptin, adiponectin, visfatin and retinol-binding protein (rbp .) while total fat was similar in the groups, pm had more trunk and abdominal fat ( ± ; ± g) compared to pre ( ± g p< . ; ± g p< . ) pm also had greater %trunk fat and %central abdominal fat compared to pre, p< . .serum leptin ( . ± . vs ± pg/ml) and visfatin ( . ± vs. . ± . ng/ml) were similar but adiponectin ( ± vs. . ± g/ml) and rbp ( . ± vs. . ± ng/ml) were higher, p< . in pm. while in pre, abdominal fat correlated negatively with adiponectin (p< . ) in pm only leptin correlated with various parameters of fat mass, p< . , and adiponectin did not correlate but correlated positively with age (r . , p< . .) as expected, pm had reduced bmd at the lumbar spine and hip ( . ± . vs. . ± . g/cm ; . ± . vs. . ± . g/cm , p< . ) but there was a correlation between total and trunk fat in pm and lumbar bmd (r . , . , p< . ) but not with hip bmd; or any correlations in pre. there was a correlation between leptin and lumbar bmd in pm (r . , p< . ) but not in pre. in summary, in normal weight early pm, abdominal fat is increased, but only adiponectin and rbp are altered with an increase in the former correlating with age. lumbar bmd correlated with fat mass in pm and is partially explained by increases in leptin. it is suggested that in spite of increasing abdominal fat in normal weight early pm, (which correlates with a higher lumbar bmd) david d rahn, jesus f acevedo, r ann word. ob-gyn, ut southwestern, dallas, tx, usa. objectives: matrix metalloprotease (mmp) activity is increased in the postpartum vagina of wild type (wt) animals, and this activity is accompanied by a burst in elastic fiber synthesis. the mechanisms that precipitate these changes are unclear. the goals of this study were to determine how vaginal distention (such as in parturition) affects elastic fiber homeostasis in the vaginal wall and the potential significance of these changes in the pathogenesis of pelvic organ prolapse. methods: nonpregnant ( ) and pregnant (d ) wt mice underwent either vaginal distention with a μl balloon x min (to simulate parturition) or sham procedure. tissues were obtained at and h for immunoblot analysis, zymography, and histology. distention was also performed in young fbln -/-, fbln +/-, and wts, and prolapse was quantified for weeks. results: distention resulted in marked increases in mmp activity in nonpregnant animals (prommp , . -fold; active mmp , . -fold; prommp , . -fold; active mmp , . -fold; all p < . compared with sham) which was accompanied by fragmented and disrupted elastic fibers in the vaginal wall. abundant amounts of tropoelastin and fibulin- in the nonpregnant vagina were not increased further by distention. in pregnant animals (which normally have suppressed vaginal wall fibulin- and tropoelastin), however, distention resulted in -fold upregulation of both proteins (p< . ). distention also induced increased mmps in pregnant animals (mmp- , . -fold; prommp- , . -fold; active mmp- , . -fold; all p < . ). thirteen young fbln -/-( - wks prior to age of prolapse development), het siblings, and age-matched wts underwent serial exams after ballooning. distention induced rapid increases in perineal bulge and vaginal diameter (within d) in fbln -/mice which never recovered. conclusions: in pregnant mice, vaginal distention results in increased protease activity in the vaginal wall but also increased synthesis of proteins important for elastic fiber assembly. distention may thereby contribute to the burst of elastic fiber synthesis in the postpartum vagina. the finding that distention results in accelerated pelvic organ prolapse in fbln -/animals, but not wt, indicates that distention results in loss of pelvic organ support if elastic fiber synthesis is compromised. further, the data suggest that elastic fiber synthesis is crucial for recovery of the vaginal wall from parturition/distention-induced increases in vaginal protease activity. the molecular etiology of pelvic organ prolapse (pop) is complex and not yet well understood. defects in the connective tissue, such as a decrease in extracellular matrix (ecm) protein content may predispose women to pop. our objective was to study the expression and the enzymatic activity of matrix metalloproteinases (mmps) and their tissue inhibitor (timps) in vaginal tissue of patients with advanced pop and controls. after informed consent, pre-menopausal caucasian patients affected by pop ( grade by pop-q), and control patients (no pop) matched for age and bmi, undergoing vaginal and abdominal hysterectomy respectively were recruited. full thickness anterior vaginal epithelial tissue was obtained from the surgical cuff of patients and controls in the proliferative phase of the menstrual cycle. total protein was extracted using ripa lyses buffer. western immunoblot analysis was performed (patients: n= , controls: n= ) to study the protein expression of mmp- , - , timp- , - , - . gelatin zymography was used to quantify the activity of mmp- and - . immunohistochemical analysis for timp- and - was performed on pfa-fixed vaginal biopsy tissue (n= ) in each group. both patient and control vaginal biopsy samples expressed latent and active forms of mmp- , and mmp- . the protein expression of the kda active form of mmp- was significantly increased in patients with pop compared to controls (p= . ). zymography detected the enzymatic activity of the proform and active form of both mmp- and mmp- . we found a significant increase in gelatinolytic activity of both kda pro-form and kda active forms of mmp- (p= . and p< . respectively) as well as kda active form of mmp- (p< . ) in patients with pop compared to controls. timp- protein expression in vaginal tissue showed a significant reduction in pop patients compared to controls (p= . ). timp- and - immunostaining were mainly localized in the smooth muscle cells at the muscularis layer of the vaginal biopsies. in vaginal tissue of patients with pop, we have shown a decrease in timp protein expression paralleled by an increase in mmp protein expression and activity. these findings reflect an active ecm remodelling that may compromise the structural integrity of the pelvic floor leading to pop. aberrant elastin and collagen synthesis may play a role in the pathogenesis of pelvic organ prolapse (pop). the lysyl oxidase (lox) family of enzymes direct cross linking of collagen and elastin polymers, however to-date no information is available on the expression and localization of these proteins in human vaginal tissue. our objectives were to study the expression and in situ localization of lox, loxl , loxl and loxl proteins in the vaginal tissue of patients with advanced pop and asymptomatic controls. pre-menopausal caucasian patients affected by pop ( grade by pop-q) and control patients (no pop) matched for age and bmi, undergoing vaginal and abdominal hysterectomy respectively were recruited. full thickness anterior vaginal epithelial tissue was obtained from the surgical cuff of patients and controls in the proliferative phase of the menstrual cycle. total protein was extracted using ripa lyses buffer and western immunoblot analysis was performed (patients: n= , controls: n= ). pfa-fixed vaginal biopsy tissues (n= for each group) were used for immunohistochemical study. vaginal biopsy samples from both patient and control groups expressed all four members of lox family proteins: lox ( kda pro-form and kda active form), loxl ( kda pro-form and kda active form), loxl ( kda) and loxl ( kda). the expression of all lox family proteins was reduced in patients with pop compared to controls; however only the pro-form of lox of making the diagnosis of endometriosis from an endometrial biopsy. objective: to evaluate the diagnostic value of examining endometrial biopsy specimens for small nerve fibers in women with pelvic pain or infertility in a double-blinded prospective comparison with laparoscopy. methodology: we undertook to compare the detection of endometrial nerve fibers with laparoscopy and peritoneal biopsy for the diagnosis of endometriosis in women (aged . years; range - years) who presented with chronic pelvic pain or infertility. small nerve fibers were detected in the functional layer of endometrium using immuno-histochemical staining with the highly specific pan-neuronal marker pgp . , using a carefully validated technique and blinded assessment of nerve fiber density. laparoscopic assessment of the presence of endometriosis and peritoneal biopsies was undertaken by three experienced gynecologic endoscopic surgeons. data from these assessments were recorded independently of endometrial findings and maintained under blinded coding until the codes were broken. results: small nerve fibers were detected in all of the women in whom endometriosis was surgically diagnosed and in none of the women in whom endometriosis was excluded at laparoscopy, giving the specificity and sensitivity of %. the density of nerve fibers in the endometriosis cases was . per mm²± . (mean ± sd). conclusions: endometrial biopsy provided a reliability of detection or exclusion of endometriosis which was equal to that of diagnostic laparoscopy carried out by experienced gynecologic laparoscopists. background: erk / are mapk intracellular signaling proteins involved in cell survival and differentiation. endometriosis requires angiogenesis for ectopic implant growth. we hypothesized that the endometriotic peritoneal environment, known to be high in estrogen (e ), vegf, and cytokines such as il- and mcp- , stimulates angiogenesis in human endometrial endothelial cells (heec) through erk signaling. methods: serial sections from normal (n= ) and ectopic (n= ) endometrium were immunostained for total-(t-) and phospho-(p-) erk / and cd (an endothelial progenitor cell marker); results were quantified by computer densitometry and grouped by menstrual phase. cultured normal heec were treated with control, e ( - m), il- , mcp- , and vegf (all ng/ml) for min, and western blotted for p-/t-erk (n= ). heec were treated with peritoneal fluid (pf; diluted : in basal media) from normal (n= ) and endometriotic (n= ) women, with or without pd erk / inhibitor ( m) for h, and cell viability was analyzed by mtt assay. statistical analysis was done with one-way anova. results: tissue staining revealed that ectopic cd + endothelial progenitor cells undergoing angiogenesis (vessel sprouting and/or angiogenic cell cord formation) exhibited the strongest levels of p-erk. heec of ectopic foci showed moderate-high p-erk staining, while surrounding mesothelial capillaries were weak for p-erk. in normal endometrium, p-erk was cycledependent, with low levels in the late secretory phase vs. other phases (p< . ). p-erk of ectopic heec showed no cycle dependence, with moderate-high levels in all phases. t-erk in all tissues was high and invariable. in cultured heec, treatment with pf from endometriotic women significantly increased heec viability after h compared to normal pf (p< . ). this effect was abrogated by erk / inhibitor. among factors known to be high in endometriotic pf, vegf increased p-erk in cultured heec in and min (p< . ), while e , il- , and mcp- had no effect. conclusions: high p-erk found specifically in sprouting endothelial progenitor cells and focal ectopic capillaries suggests that erk / is involved in endometriotic angiogenesis. the peritoneal microenvironment of endometriosis may be persistently stimulating erk-mediated endometrial angiogenesis through vegf. further investigation into erk / inhibitors may offer a novel treatment of endometriosis. the events leading to the development of post operative adhesions are unknown, though recent observations emphasize the crucial role played by the superoxide ion generated by hypoxia. exposure of normal peritoneal fibroblasts to hypoxia caused the development of the adhesion phenotype, which is characterized by increased extracellular matrix molecules and inflammatory cytokines as well as high protein nitration and low nitric oxide. superoxide dismutases (sod) are a family of metalloenzymes that eliminates superoxide by converting it to hydrogen peroxide, protecting mammalian organisms against superoxide. objective: to determine whether sod is differentially expressed between normal peritoneal and adhesion fibroblasts and whether its expression is modulated by hypoxia. methods: fibroblasts from normal peritoneal and adhesion tissues were cultured under normal ( % o ) and hypoxia ( % o ) conditions for and hours. real time rt/pcr was utilized to measure the absolute mrna levels for sod in both cell lines before and after hypoxia exposure. results: normal peritoneal fibroblasts exhibited significantly higher basal mrna levels for sod ( . pg/ grna, p< . ) as compared to adhesion fibroblasts ( . pg/ grna, p< . ). short exposure to hypoxia resulted in a significant increase in sod mrna levels to . and pg/ grna in normal and adhesion fibroblasts respectively, p< . . in contrast, long exposure to hypoxia resulted in a significant decrease in sod mrna levels to . and . pg/ grna in normal peritoneal and adhesion fibroblasts respectively, p< . . conclusion: sod mrna levels are lower in adhesion as compared to normal fibroblasts, both basally and following short and longer exposure to hypoxia. reduced sod expression creates an milieu with greater free radical levels, which leads to the development of the adhesion phenotype. enhancement of sod levels and/or function are likely to be of benefit for reduction of postoperative adhesion development. objectives: development of endometriosis requires ectopic attachment and proliferation of endometrial tissue. the invasive process required to establish endometriosis may involve matrix metalloproteinases (mmps), including mmp- . recently, we have demonstrated that statins inhibit proliferation of endometrial stroma. this study evaluated the effects of simvastatin on a nude mouse model of endometriosis and on modulation of mmp- . methods: proliferative phase human endometrial biopsies were established as organ cultures or utilized for stromal cell isolation. to establish endometriosis in the nude mouse, endometrial tissues were maintained in nm estradiol (e) for hrs and subsequently injected intraperitoneally into ovariectomized nude mice. mice were treated with e ( μg, silastic capsule implants) and simvastatin ( - mg/kg/day) by gavage for days beginning day after tissue injection. control mice received e+vehicle. subsequently, animals were sacrificed and endometrial implants were evaluated. studies of endometrial stroma involved plating the cells in the presence of e ( nm) or e+medroxyprogesterone acetate (mpa; pm) with and without simvastatin ( - μm). some cultures additionally received interleukin- (il- , ng/ml). conditioned media was subjected to western analysis for expression of mmp- . results: in vivo studies demonstrated a dose-dependent inhibitory effect of simvastatin on number and volume of endometrial implants in mice. at the highest dose of simvastatin ( mg/kg/day), the number of endometrial implants was decreased by % and the volume by % in comparison to the control group. isolated stromal cells expressed abundant levels of mmp- following treatment with e, but minimal levels in cultures additionally receiving mpa or simvastatin. although il- induced a dramatic increase in mmp- secretion from cells pretreated with e alone, treatment with either mpa or simvastatin prevented this induction. cultures receiving e+mpa+simvastatin were the most resistant to mmp- induction by il- . objective: to increase awareness of potential presentations of adenomyosis and the differential of a uterine mass. material and method: in a tertiary medical center, a patient was being evaluated for a uterine cystic mass and cyclic dysmenorrhea. the patient is a year old nulliparous woman who has been complaining of cyclic dysmenorrhea for several years. the pain starts with the onset of menses and lasts around weeks. the patient did not improve on contraceptives. the patient had prior laparoscopy and imaging studies which misdiagnosed the mass as either a leiomyoma or an adnexal hemorrhagic cyst. the patient underwent exploratory laparotomy and resection of the mass. results: on ultrasound, the mass appeared as an echodense cyst within the uterus. intraoperatively, a cm thick-walled well circumscribed uterine chocolate cyst was identified. the resection of the cyst was performed in similarly to an ovarian cystectomy. tissue examination confirmed the diagnosis of cystic adenomyosis. following surgical intervention, the patient reported significant improvement of symptoms. conclusion: this case highlights an unusual presentation and treatment of adenomyosis and cyclic dysmenorrhea. cystic adenomyosis should be on the differential of uterine cystic mass, particularly in young women with cyclic dysmenorrhea and menorrhagia. the earlier misdiagnosis probably resulted from the unfamiliarity of physicians with this condition. similar clinical presentations may occur with congenital uterine anomalies (with an obstructed uterine segment) and cystic degeneration of a leiomyoma. the incidence and pathogenesis of cystic adenomyosis are unknown. oral contraceptives may be helpful as a first line therapy. however, resection of the adenomyotic cyst appears to be more effective, particularly in women seeking fertility. objective: it is hypothesized that abnormalities within the eutopic endometrium of females with endometriosis can cause the ectopic growth of the endometrial tissue at extrauterine sites. previous studies have shown that gene expression in eutopic endometrium of women with endometriosis is markedly different from disease-free females. inflammatory cytokines and receptor-dependent kinase pathways are widely recognized as therapeutic targets for immune disorders, which is believed to be the underlying pathogenesis of endometriosis. in this study we asked whether responses of primary eutopic endometrial cell cultures are dysregulated between females with or without endometriosis. methods: a total of biopsies of endometriotic eutopic endometrium (eee) and disease-free endometrium (dfe) were obtained from proliferative phase females. the primary cell cultures established from these biopsies were treated with tnfa to induce expression of inflammatory mediators. parallel cultures were also treated with kinase inhibitors of p , mek, pi k and ikk. after a period of or hours, concentrations of il- , mcp- , and gm-csf in cell culture supernatants were analyzed by elisa. results: in eee, basal concentrations of mcp- and gm-csf were - times higher, while il- was times higher compared to dfe. as expected, tnfa treatment stimulated higher levels of cytokine secretion in dfe mimicking disease state, however, the same treatment had almost no effect on eee. kinase inhibitors were very effective in lowering the cytokine levels of dfe, however, their effect on eee were less dramatic. conclusion: eee expresses higher levels of inflammatory cytokines under basal conditions, which is in concert with the current literature. our results validate that high il- levels in endometrium are diagnostic for females with disease. the increase of gm-csf, il- and mcp- following tnfa treatment was expected in dfe however; tnfa's effect was blunted in eee, which implies that eee are already highly activated. the effect of kinase inhibitors on cytokine production from eee was unaltered relative to dfe, which implies that tnfa stimulated kinase pathways are modified even in eee. endometrial cancer is the fourth leading cause of cancer in women, and hyperplasia and adenocarcinoma are more commonly seen in women with polycystic ovary syndrome (pcos). mig- , a negative inhibitor of egf signaling, is expressed in normal secretory phase endometrium and associated with hyperplasia in mig- knockout mice. objective: we examined and compared endometrium from normal and pcos women for mig- expression and characterized its regulation using in vivo and in vitro models. methods: immunohistochemistry (ihc) and real-time pcr were performed in endometrium from normal (n= ) women and pcos (n= ) women. regulation of mig- was studied in ishikawa and ecc- endometrial cell lines, treated with sex steroids or egf. endometrial xenografts from normal and pcos women were implanted in ovxd rag -(c) immunocompromised mice, treated with e or e + p pellets to mimic a natural cycle. results: mig- protein expression was low in the functionalis of the proliferative phase and high in the secretory phase; this pattern was reversed in the basalis layer. pcos secretory phase endometrium had significantly less mig- protein and mrna than normal endometrium (p < . ). xenografts using pcos samples had paradoxically elevated expression of mig- compared to normal, and appeared unresponsive to steroid treatments. mig- expression in endometrial cell lines was regulated by egf but not by ovarian steroids, e or e + p. conclusions: mig- expression is low in proliferating endometrium and regulated by egf. risk of hyperplasia or cancer in pcos women can be explained by altered expression of mig- . reduced expression mig- provides insight into endometrial function and may lead to better treatment options for disorders of endometrial proliferation including endometriosis, adenomyosis, endometrial hyperplasia and cancer. supported in part by nih-u -hd (sly), u hd (lcg) and u hd (fjd). could androgens influence human luteal cells function? anna tropea, mariateresa orlando, maria francesca gangale, federica romani, isamaria loiudice, federica tiberi, stefania catino, antonio lanzone, rosanna apa. cattedrà di fisiopatologia della riproduzione, università cattolica del s. cuore (ucsc), roma, italy; istituto scientifico internazionale (isi) "paolo vi", ucsc, roma, italy; istituto di ricerca "associazione oasi maria ss onlus", troina (en), italy. in pcos patients reproductive dysfunctions are frequently observed even if ovulation occurs. an impaired luteal function could partially explain this subfertility, since luteal steroidogenesis deficiency and premature luteal degeneration have been described in pcos patients. based on the frequent observation of high plasmatic levels of androgens in pcos, we investigated whether hyperandrogenism could negatively affect luteal function.to this aim, we tested the in vitro effects of androgens on progesterone (p) and on vascular endothelial growth factor (vegf) production by human luteal cells. indeed, vegf is essential for normal luteal development and function being an important regulator of angiogenesis and vascular permeability. since prostaglandins (pgs) play a central role in modulating luteal function, the influence of androgens on pge and pgf a secretion was also investigated. in order to investigate whether testosterone and androstenedione act directly or after local aromatisation, we tested the in vitro effects of estriol, estrone and --estradiol on p, vegf, pge and pgf secretion by human luteal cells. moreover, we tested the effects of testosterone and androstenedione in presence of exemestane -an aromatase inactivator. highly purified human luteal cells were cultured for h with medium alone (control) or in presence of increasing concentrations of testosterone or dihydrotestosterone or androstenedione (from - to - m) or in presence of increasing concentrations of estriol, estrone and --estradiol (from . to ng/ml). moreover, testosterone and androstenedione - m were tested in presence of exemestane (from to nm). in the culture medium vegf, p, pge and pgf secretion was assayed by commercially available elisa kits. in order to evaluate the influence of androgens and estrogens on vegf mrna expression on luteal cells real-time rt-pcr has been performed. our results demonstrated that testosterone, androstenedione and dihydrotestosterone were all able to significantly reduce vegf secretion in human luteal cells, while no effect was seen on vegf mrna expression. androgens were also able to significantly decrease p and pgf secretion, while an increase was observed on pge production. moreover our preliminary results demonstrated that in human isolated luteal cells estriol, estrone and -estradiol at all tested doses are able to mimic androgens effects on p and pge production. on the contrary estrogens were able to increased vegf release. estrogens seemed to have no effect on pgf  released. data regarding exemestane inhibition of testosterone and androstenedione are still in progress. increased levels of androgens were able to decrease luteal vegf, p and pgf release and might be involved in pcos-luteal phase defect. nevertheless, the observed effects could probably be attributed -at least in part -to estrogens locally produced via the aromatase enzyme, rather than be directly mediated by testosterone and androstenedione. the in vitro effect of proghrelin-derived peptides on purified human luteal cells. anna tropea, mariateresa orlando, maria francesca gangale, federica romani, isamaria loiudice, federica tiberi, stefania catino, antonio lanzone, rosanna apa. cattedrà di fisiopatologia della riproduzione, università cattolica del s. cuore (ucsc), roma, italy; istituto scientifico internazionale (isi) "paolo vi", ucsc, roma, italy; istituto di ricerca "associazione oasi maria ss onlus", troina (en), italy. ghrelin, well known mediator of neuroendocrine effects, has been demonstrated to have a role as signal for energy insufficiency. several evidences suggested that ghrelin might also operate as regulator of reproductive function. indeed, we recently demonstrated that both p and vegf released were significantly decreased by ghrelin in isolated human luteal cells. moreover ghrelin was also able to reduce prostaglandin (pg) e and increase pgf luteal cells release. in the present work we investigated whether two ghrelin-related peptides derived by the same ghrelin precursor (unacylated ghrelin and obestatin) might affect human isolated luteal cells function. conventionally regarded as an inert form of ghrelin, unacylated ghrelin has been recently proven as biologically active in specific cellular contexts. obestatin has been suggested to directly control porcine ovarian cell functions. in these assumptions, we investigated whether unacylated ghrelin and obestatin could directly affect luteal progesterone (p) release. moreover, since vascular endothelial growth factor (vegf) is known to play a critical role in luteal development and function, the influence of unacylated ghrelin and obestatin on luteal vegf, pgf and pge production was also analysed. highly purified human luteal cells were incubated for h with medium alone (control) or with hcg ( ng/ml) or with cocl ( μm) or in presence of increasing concentrations of unacylated ghrelin ( - nm) and obestatin ( - nm). in the culture medium vegf, pgf , pge and p secretion was assayed by commercially available elisa kits. moreover real-time rt-pcr has been performed in order to evaluate whether unacylated ghrelin and obestatin could affect vegf mrna in human luteal cells. our preliminary results demonstrated that either unacylated ghrelin or obestatin are able to negatively affect luteal steroidogenesis. moreover, both peptides seemed to increase the release of two luteotropic factors -vegf and pge and to reduce pgf release -a luteolytic prostanoid -from isolated human luteal cells. finally data regarding the expression of vegf mrna are still in progress. our results suggest that unacylated ghrelin and obestatin -two ghrelin-related peptides -could play a role in regulating luteal function affecting both luteal steroidogenesis and luteotropic/luteolytic imbalance. the mechanisms responsible for labor progression have yet to be fully elucidated. in a previous study, over-expression of small conductance calcium-activated k + channel isoform (sk ) in transgenic mice compromised parturition, suggesting a role for sk channels in this process. based on these findings, we hypothesized that sk channel expression is reduced late in pregnancy to enable the uterus to produce the forceful contractions required for parturition. we investigated the effects of sk channel expression on gestation and parturition by comparing transgenic mice over-expressing mice sk (sk t/t ) mice to wild-type (wt). in wt mice, sk transcript and protein are significantly reduced during pregnancy. the force produced by uterine strips from sk t/t mice on the day of delivery was significantly less than wt or sk knockout control (sk dox ), and the contractile force reached wt levels by application of the sk channel inhibitor, apamin. moreover, lipopolysaccharide and ru , which induce pre-term labor in wt mice, failed to result in completion of delivery in sk t/t mice. thus, stimuli that initiate parturition under normal circumstances are insufficient to coordinate the uterine contractions needed for the completion of delivery when sk channel activity is in excess. the mechanism(s) down-regulating this channel in the uterus during pregnancy is unknown. the sk gene promoter region contains two specificity protein (sp) binding sites; ) sp , is a transcription factor known to enhance the transcription of genes in response to estrogen, and ) sp , which competes for the same binding motif as sp , reduces gene expression. sp protein expression in mice uteri dramatically decreases in late pregnancy, while sp protein level remains consistent. our data indicate that sk channels must be downregulated for the gravid uterus to generate labor contractions sufficient for delivery in both term and preterm mice. the changes in sk channel expression may be transcriptionally regulated by sp and sp .