Increased Incidence of Ventilator-Acquired Pneumonia in Coronavirus Disease 2019 Patients: A Multicentric Cohort Study.

OBJECTIVES: Little is known about the epidemiology of ventilator-acquired pneumonia among coronavirus disease 2019 patients such as incidence or etiological agents. Some studies suggest a higher risk of ventilator-associated pneumonia in this specific population. DESIGN: Cohort exposed/nonexposed study among the REA-REZO surveillance network. SETTING: Multicentric; ICUs in France. PATIENTS: The coronavirus disease 2019 patients at admission were matched on the age, sex, center of inclusion, presence of antimicrobial therapy at admission, patient provenance, time from ICU admission to mechanical ventilation, and Simplified Acute Physiology Score II at admission to the patients included between 2016 and 2019 within the same surveillance network (1:1). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall incidence of ventilator-associated pneumonia, the cumulative incidence, and hazard rate of the first and the second ventilator-associated pneumonia were estimated. In addition, the ventilator-associated pneumonia microbiological ecology and specific resistant pattern in coronavirus disease 2019 exposed and nonexposed patients were compared. Medication data were not collected. A total of 1,879 patients were included in each group. The overall incidence of ventilator-associated pneumonia was higher among coronavirus disease 2019 exposed patients (25.5; 95% CI [23.7-27.45] vs 15.4; 95% CI [13.7-17.3] ventilator-associated pneumonia per 1,000 ventilation days). The cumulative incidence was higher for the first and the second ventilator-associated pneumonia among the coronavirus disease 2019 exposed patients (respective Gray test p < 0.0001 and 0.0167). The microbiological ecology and resistance were comparable between groups with a predominance of Enterobacterales and nonfermenting Gram-negative bacteria. The documented resistance pattern was similar between groups, except for a lower rate of methicillin-resistant Staphylococcus aureus in the coronavirus disease 2019 exposed patient (6% vs 23%; p = 0.013). CONCLUSIONS: There was a higher incidence of ventilator-associated pneumonia occurring among coronavirus disease 2019 patient compared with the general ICU population, with a similar microbiological ecology and resistance pattern.

[The desire and the experience of participation among children and adolescents in inpatient mental healthcare]. / Wunsch und Erleben von Partizipation für Kinder und Jugendliche in der stationären Psychiatrie.

The desire and the experience of participation among children and adolescents in inpatient mental healthcare Abstract. Objective: Children have the right to participate in decisions that affect them. However, the stages and domains of participation relevant within inpatient child and adolescent psychiatry have rarely been empirically investigated. The present study closes this research gap. Method: A prospective, multicenter, questionnaire-based survey was conducted. The questionnaire comprised 100 items, summarized in 16 scales, to assess the desire and the experience of participation. The data were quantitively evaluated. Results: 81 children and adolescents from 5 psychiatric hospitals took part in the study. Overall, they wished more participation than experienced. The higher the level of participation, the greater the difference was between wish and reality. The desire for participation is particularly high for decisions regarding communication with family and friends. The largest difference between desire and experience related to respectful and trusting interaction with patients, and for female patients, this difference was even higher. Conclusion: Participation means more than informed consent. There is still potential for expanding participation in child and adolescent psychiatry, especially at higher levels of participation and concerning decisions about communication with family and friends. A respectful and trusting interaction with patients, regardless of age, sex, or illness, is fundamental.

[Patient Participation in Child and Adolescent Psychiatry - A Scoping Review]. / Partizipation von Patienten im Kontext der stationären Kinder- und Jugendpsychiatrie ­ ein Scoping Review.

Patient Participation in Child and Adolescent Psychiatry - A Scoping Review The present study deals with the concept of participation in inpatient child- and adolescent mental health care. Aim is to analyse theoretical constructs in the light of a literature review on participation as an important method to implement patient autonomy in the specific context. The potential for conflict of patient autonomy as a greater principle and the absence of literature reviews on the topic make this study essential. The method is a scoping-review. 978 texts from three central databases have been screened for title and abstract, 27 have been included. The results show arguments, barriers and methods of participation. Most of the arguments are utilitarian: positive effects on patients, therapists and the hospital. On the other hand, there are multiple barriers of implementation: willingness of physicians, reticence of patients and systemic barriers. Structures of cooperation, key figures and interactive information brochures have already been used as methods of participation. In conclusion, a contextual concept of participation is proposed: Shared Care Planning. It is meant to be independent from the capacity to give informed consent and underlines the importance of day-to-day issues. It calls for the consideration of the mentioned barriers and a high flexibility of participation methods.

Nitrogen fertilizer is a key factor affecting the soil chemical and microbial communities in a Mollisol.

Microbial communities drive geochemical cycles in soils. Relatively few studies have assessed the long-term impacts of different types of soil amendments under field conditions in long-term experiments. The response of soil microbial organisms in a Mollisol cultivated with maize for 35 years was examined. Treatments involved the use of N, P, and K fertilizers and two doses of straw residue in isolation or combined. Real-time PCR and Illumina MiSeq sequencing methods were used to characterize the microbial community. The results showed that addition of nitrogen fertilizers decreased soil pH, but this was mitigated when a high dose of straw was also incorporated. Long-term application of inorganic fertilizers was able to alter the abundance of functional soil microbial population. Application of inorganic N fertilizer resulted in distinctive changes on N-cycle microorganisms. Phosphate-solubilizing functional genes abundance was lower in plots with no phosphate fertilizer. Sequencing analysis showed that the presence or absence of N in the fertilizer mix is a key factor affecting bacterial community diversity of agricultural soil, and pH, total organic C, and total N show a high correlation with bacterial community composition. Nitrogen addition increased the N concentration in the soil, which could cause changes in the soil pH and change the soil bacterial community. Our findings proved that interaction of N fertilizer with other fertilizers can affect microbial communities.

The influence of situational variables on ball possession in the English Premier League.

Abstract The aims of this study were twofold: (1) to examine the influence of situational variables on ball possession in elite soccer and (2) to quantify the variables that discriminate between high or low percentage ball possession teams (HPBPT and LPBPT) across different playing positions. Match performance data were collected from English Premier League matches using a multiple-camera system. Data were examined using linear regression, a 2 × 5 factorial analysis of variance and discriminant analysis. Playing against weak opposition was associated with an increase (P < 0.01) in time spent in possession while playing away decreased (P < 0.01) the time spent in possession by ~3%. Possession was increased (P < 0.01) when losing than winning or drawing. Finally, the better the ranking of a team, the higher (P < 0.01) the time spent in possession. The playing position effect was significant for all variables (P < 0.05); however, there were only interactions with team ball possession in some cases. The discriminant analysis identified functions for all five playing positions (P < 0.01). The variables that discriminated performance between HPBPT and LPBPT were different for various playing positions, although the number of successful passes was the most common discriminating variable. The results demonstrate that HPBPT and LPBPT developed different possession strategies during matches and that selected variables such as successful passes were identified to explain these data trends across various playing positions. Combinations of variables could be used to develop a probabilistic model for predicting time spent in possession by teams.

Cost of Carbon in the Total Cost of Healthcare Procedures: A Methodological Challenge.

Economic evaluations aim to compare the costs and the results of health strategies to guide the public decision-making process. Cost estimation is, thus, a cornerstone of this approach. At present, few national evaluation agencies recommend incorporating the cost of greenhouse gas (GHG) emissions from healthcare actions into the calculation of healthcare costs. Our main goal is to describe and discuss the methodology for integrating the cost of GHG emissions into the field of applied economic evaluations. To estimate this cost, three steps are required: (1) identifying and quantifying the physical flows linked to the production and management of the outputs of healthcare interventions, (2) estimating the quantity of GHG that can be attributed to each physical flow, and (3) valuing these GHG emissions in monetary terms. Integrating the cost of GHG emissions into the calculation of the costs of healthcare interventions is both useful and relevant from a perspective of collective intergenerational well-being. This approach has been made possible thanks to the existence of accounting and monetary valuation methods for emissions. Agencies specialized in health economic evaluations could take up this issue to resolve ongoing questions, thus providing researchers with a methodological framework and public decision-makers with some key insights.

Knowledge, Attitudes and Practices among Women of Reproductive Age on Human Papillomavirus Infection, Cervical Cancer and Vaccination in Otukpo, Nigeria.

Background: Knowledge, attitudes and practices (KAP) of human papilloma virus (HPV) is a necessary measure in curtailing delayed diagnosis and poor control practices. The objective of this study was to assess the knowledge, attitudes and practices vis-à-vis HPV infection, cervical cancer and vaccination among women. Methods: This cross-sectional study was conducted at 15 selected health-care facilities in Otukpo metropolis and it involved 168 pregnant women. The data were collected using structured questionnaire, and analysed for descriptive and analytical statistics using Epi Data Version 3.1 and SPSS statistical package Version 21. Results: Most of the respondents (75.0%) have heard of human papilloma virus and their information source were mostly the health-care providers. In total, 132(78.6%) agreed to take the vaccine if offered for free but 152(90.5%) stated that it is imperative to seek the opinion of health providers before vaccine uptake. However, only 27(16.1%) have undergone recommended checkup for human papilloma virus/cervical cancer and 23(13.7%) have taken at least a vaccine dose. Some respondents 66(39.3%) had good knowledge while 95(56.6%) demonstrated positive attitude. However, most respondents 161(95.8%) demonstrated poor practices. Conclusions: There is enormous need to improve HPV sensitization especially in women due to cervical cancer associated risks. Healthcare personnel are therefore encouraged to create more awareness on HPV infection and screening of cervical cancer (CC) via counseling sessions and communications tool like the new media. KAP approach is a critical tool towards successful CC screening and HPV control.

Naso alveolar molding in early management of cleft lip and palate.

Cleft lip and palate is a congenital anomaly occurring at birth. This article describes about the construction of feeding plate which is also used for naso alveolar molding (NAM). The main objective of this treatment is that this procedure minimizes the extent of surgery that should be done on newborns. Two infants with unilateral and bilateral cleft lip and palate are treated by making feeding plate and which is also used for NAM. Both the infants had favorable results, better in case of unilateral cleft lip patient; we hope that it will minimize the extent of surgery and the resultant scarring.

Pharmacognostic profiles, evaluation of analgesic, anti-inflammatory and anticonvulsant activities of Newbouldia laevis (P. Beauv.) Seem. ex Bureau leaf and root extracts in Wistar rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Newbouldia laevis is a popular medicinal plant whose leaves and roots are used in Nigeria as ethnomedicinal prescriptions for pain, inflammation, convulsion, and epilepsy. These claims have not been scientifically verified prior to this study. AIM OF THE STUDY: To determine pharmacognostic profiles of the leaves and roots and evaluate the analgesic, anti-inflammatory, and anticonvulsant activities of methanol leaf and root extracts in Wistar rats. MATERIAL AND METHODS: The pharmacognostic profiles of the leaves and roots were determined using standard procedures to serve as fingerprints for the plant. The methanol leaf and root extracts of Newbouldia laevis were tested for acute toxicity using the OECD's up and down method at the maximum dose of 2000 mg/kg (orally) in Wistar rats. Analgesic studies were carried out in acetic acid-induced writhing in rats and tail immersion. The anti-inflammatory activity of the extracts was evaluated using carrageenan-induced rat paw-oedema and formalin-induced inflammation in rats' mode. The anticonvulsant activity was determined using strychnine-induced, pentylenetetrazol-induced, and maximal electroshock-induced rat convulsion models. For each of these studies, the extracts doses of 100, 200 and 400 mg/kg were administered to the rats following the oral route. RESULTS: The pharmacognostic profiles showed that the leaves possessed deep-sunken paracytic stomata (5-8-16 mm2; adaxial, 8-11-24 mm2; abaxial epidermis), vein islets (2-4-10 mm2; adaxial), vein terminations (10-14-18 mm2; adaxial), palisade ratio (8.3-12.5-16.4 mm2; adaxial, 2.5-6.8-12.2 mm2; adaxial), covering unicellular trichome (8-14; adaxial), spheroidal calcium oxalate crystals (3-5 µm), and oval-shaped striated starch grain with no hilum (0.5-4.3 µm). The transverse section of the leaf showed the presence of spongy and palisade parenchyma as well as a closed vascular bundle. The root powder showed the presence of brachy sclereid, fibers without lumen, and lignin. All physicochemical parameters fall within the acceptable limits, phytochemical contents showed mainly glycosides, alkaloids, and steroids while acute oral toxicity (LD50) of the parts for 14 days did not produce any toxicity signs or mortality in the rats. The extracts produced dose-dependent (100-400 mg/kg) analgesic involving opioid receptors, anti-inflammatory, and anticonvulsant activities in the rats which were significant (p ≤ 0.05) when compared to the standard drugs. The leaf extract possessed the most potent analgesic and anti-inflammatory effects in the rats, while the most anticonvulsant effects were observed in rats treated with the leaf extract. Both extracts showed elevated levels of protection against strychnine-induced, pentylenetetrazol-induced, and maximal electroshock-induced seizure in rats. CONCLUSION: Our study revealed some pharmacognostic profiles of Newbouldia laevis leaves and roots that are vital for its identification from closely related species often used for adulteration in traditional medicine. The study further showed that the leaf and root extracts of the plant possessed dose-dependent analgesics, anti-inflammatory and anti-convulsant activities in rats, thus, justifying its use for the treatment of these diseases in Nigerian traditional medicine. There is a need to further study its mechanisms of action towards drug discovery.

Leptin affects insulin action in astrocytes and impairs insulin-mediated physical activity.

BACKGROUND/AIMS: Impaired insulin action is an early event in the pathogenesis of obesity and type 2-diabetes, and among the metabolic confounders in obese, hyperleptinaemia is constantly present; however its impact on insulin action in the brain and locomotor activity is unknown. METHODS: We examined insulin action by Western Blot analysis and glycogen synthesis in primary astrocytes and brain tissue and detected locomotion in C57BL/6 mice. The insulin-mediated desire to move was evaluated in healthy volunteers and correlated to leptin levels. RESULTS: Leptin treatment led to a significant decrease in insulin-mediated phosphorylation of the insulin receptor and Akt473 which was accompanied by a decline in glycogen synthesis in primary astrocytes and significantly decreased insulin-induced phosphorylation of the insulin receptor and insulin receptor substrate-2 in brain tissues of mice. Intracerebroventricular insulin failed to promote locomotion in the presence of elevated leptin levels. Lean human subjects reported an increase in the desire to move following insulin which failed in obese and there was an inverse correlation between the insulin-mediated desire to move and leptin levels. CONCLUSIONS: Our data suggest a crosstalk of leptin and insulin in the brain which leads to a decline in locomotor activity. This might represent a molecular mechanism in obese to inhibit physical activity.

Identification of Avian pathogenic Escherichia coli genes that are induced in vivo during infection in chickens.

Avian pathogenic Escherichia coli (APEC) is associated with extraintestinal infections in poultry causing a variety of diseases collectively known as colibacillosis. The host and bacterial factors influencing and/or responsible for carriage and systemic translocation of APEC inside the host are poorly understood. Identification of such factors could help in the understanding of its pathogenesis and in the subsequent development of control strategies. Recombination-based in vivo expression technology (RIVET) was used to identify APEC genes specifically expressed during infection in chickens. A total of 21 clones with in vivo-induced promoters were isolated from chicken livers and spleens, indicative of systemic infection. DNA sequencing of the cloned fragments revealed that 12 of the genes were conserved E. coli genes (metH, lysA, pntA, purL, serS, ybjE, ycdK [rutC], wcaJ, gspL, sdsR, ylbE, and yjiY), 6 of the genes were phage related/associated, and 3 genes were pathogen specific (tkt1, irp2, and eitD). These genes are involved in various cellular functions, such as metabolism, cell envelope and integrity, transport systems, and virulence. Others were phage related or have yet-unknown functions.

Endotracheal tube biofilm in critically ill patients during the COVID-19 pandemic : description of an underestimated microbiological compartment.

Biofilm (BF) growth is believed to play a major role in the development of ventilator-associated pneumonia (VAP) in the intensive care unit. Despite concerted efforts to understand the potential implication of endotracheal tube (ETT)-BF dispersal, clinically relevant data are lacking to better characterize the impact of its mesostructure and microbiological singularity on the occurrence of VAP. We conducted a multicenter, retrospective observational study during the third wave of the COVID-19 pandemic, between March and May 2021. In total, 64 ETTs collected from 61 patients were included in the present BIOPAVIR study. Confocal microscopy acquisitions revealed two main morphological aspects of ETT-deposited BF: (1) a thin, continuous ribbon-shaped aspect, less likely monobacterial and predominantly associated with Enterobacter spp., Streptococcus pneumoniae or Viridans streptococci, and (2) a thicker, discontinuous, mushroom-shaped appearance, more likely characterized by the association of bacterial and fungal species in respiratory samples. The microbiological characterization of ETT-deposited BF found higher acquired resistance in more than 80% of analyzed BF phenotypes, compared to other colonization sites from the patient's environment. These findings reveal BF as a singular microbiological compartment, and are of added clinical value, with a view to future ETT-deposited BF-based antimicrobial stewardship in critically ill patients. Trial registration NCT04926493. Retrospectively registered 15 June 2021.

Systematic Analysis of Readability of Patient Information on Internet Pages from Departments for Trauma Surgery of German University Hospitals. / Systematische Analyse der Lesbarkeit von Patienteninformationstexten auf Internetseiten von Abteilungen für Unfallchirurgie deutscher Universitätskliniken.

INTRODUCTION: The need-based information transfer in education as well as for the recruitment of patients becomes more and more relevant. Here, the internet has emerged as an increasingly important factor in recent years and therefore information pages on hospital homepages can be very helpful. However, it is known that basic text comprehension skills are lacking among large populations. METHOD: The aim of the present study was to evaluate the readability of the patient information available on the websites of trauma departments of German university hospitals. For this purpose, a search for information material on 10 different diagnoses was carried out. Out of 360 texts possible, 185 were found and assigned to 2 superordinate thematic areas (emergency vs. elective operations), subjected to a systematic text analysis via software "Text-Lab" and rated using 5 known readability indices (Amstad, G-SMOG, LIX, HIX, WSTF). RESULTS: The indices used for both thematic complexes consistently showed poor readability, so that the texts only seem sufficiently comprehensible to readers with higher education. (Amstad: 21.4 ± 20.8; G-SMOG: 11.6 ± 2.0; WSTF 13.3 ± 2.1; LIX: 60.9 ± 7.6; HIX: 4.1 ± 3.2). CONCLUSION: For the medical information provided by university hospitals, there is a clear need for improvement in order to make the adequate acquisition of knowledge accessible to a broader spectrum of patients.

Potential impacts of climate change on geographical distribution of three primary vectors of African Trypanosomiasis in Tanzania's Maasai Steppe: G. m. morsitans, G. pallidipes and G. swynnertoni.

In the Maasai Steppe, public health and economy are threatened by African Trypanosomiasis, a debilitating and fatal disease to livestock (African Animal Trypanosomiasis -AAT) and humans (Human African Trypanosomiasis-HAT), if not treated. The tsetse fly is the primary vector for both HAT and AAT and climate is an important predictor of their occurrence and the parasites they carry. While understanding tsetse fly distribution is essential for informing vector and disease control strategies, existing distribution maps are old and were based on coarse spatial resolution data, consequently, inaccurately representing vector and disease dynamics necessary to design and implement fit-for-purpose mitigation strategies. Also, the assertion that climate change is altering tsetse fly distribution in Tanzania lacks empirical evidence. Despite tsetse flies posing public health risks and economic hardship, no study has modelled their distributions at a scale needed for local planning. This study used MaxEnt species distribution modelling (SDM) and ecological niche modeling tools to predict potential distribution of three tsetse fly species in Tanzania's Maasai Steppe from current climate information, and project their distributions to midcentury climatic conditions under representative concentration pathways (RCP) 4.5 scenarios. Current climate results predicted that G. m. morsitans, G. pallidipes and G swynnertoni cover 19,225 km2, 7,113 km2 and 32,335 km2 and future prediction indicated that by the year 2050, the habitable area may decrease by up to 23.13%, 12.9% and 22.8% of current habitable area, respectively. This information can serve as a useful predictor of potential HAT and AAT hotspots and inform surveillance strategies. Distribution maps generated by this study can be useful in guiding tsetse fly control managers, and health, livestock and wildlife officers when setting surveys and surveillance programs. The maps can also inform protected area managers of potential encroachment into the protected areas (PAs) due to shrinkage of tsetse fly habitats outside PAs.

What are the characteristics that lead physicians to perceive an ICU stay as non-beneficial for the patient?

PURPOSE: We sought to describe the characteristics that lead physicians to perceive a stay in the intensive care unit (ICU) as being non-beneficial for the patient. MATERIALS AND METHODS: In the first step, we used a multidisciplinary focus group to define the characteristics that lead physicians to consider a stay in the ICU as non-beneficial for the patient. In the second step, we assessed the proportion of admissions that would be perceived by the ICU physicians as non-beneficial for the patient according to our focus group's definition, in a large population of ICU admissions in 4 French ICUs over a period of 4 months. RESULTS: Among 1075 patients admitted to participating ICUs during the study period, 155 stays were considered non-beneficial for the patient, yielding a frequency of 14.4% [95% confidence interval (CI) 8.9, 19.9]. Average age of these patients was 72 ±12.8 years. Mortality was 43.2% in-ICU [95%CI 35.4, 51.0], 55% [95%CI 47.2, 62.8] in-hospital. The criteria retained by the focus group to define a non-beneficial ICU stay were: patient refusal of ICU care (23.2% [95%CI 16.5, 29.8]), and referring physician's desire not to have the patient admitted (11.6% [95%CI 6.6, 16.6]). The characteristics that led physicians to perceive the stay as non-beneficial were: patient's age (36.8% [95%CI 29.2, 44.4]), unlikelihood of recovering autonomy (61.9% [95%CI 54.3, 69.6]), prior poor quality of life (60% [95%CI 52.3, 67.7]), terminal status of chronic disease (56.1% [95%CI 48.3, 63.9]), and all therapeutic options have been exhausted (35.5% [95%CI 27.9, 43.0]). Factors that explained admission to the ICU of patients whose stay was subsequently judged to be non-beneficial included: lack of knowledge of patient's wishes (52% [95%CI 44.1, 59.9]); decisional incapacity (sedation) (69.7% [95%CI 62.5, 76.9]); inability to contact family (34% [95%CI 26.5, 41.5]); pressure to admit (from family or other physicians) (50.3% [95%CI 42.4, 58.2]). CONCLUSIONS: Non-beneficial ICU stays are frequent. ICU admissions need to be anticipated, so that patients who would yield greater benefit from other care pathways can be correctly oriented in a timely manner.

Immune Reconstitution Inflammatory Syndrome in Patients with AIDS and Disseminated Coccidioidomycosis: A Case Series and Review of the Literature.

Coccidioidomycosis causes substantial morbidity and mortality in endemic areas, and dissemination is frequent in patients with impaired cellular immunity such as AIDS. Immune reconstitution inflammatory syndrome (IRIS) is paradoxical clinical worsening after initiation of antiretroviral therapy (ART) in a patient with HIV and a simultaneous opportunistic infection (OI). Immune reconstitution inflammatory syndrome has been well described for a host of mycobacterial, viral, and fungal OIs and malignancies such as Kaposi sarcoma. To date, only 3 cases of IRIS due to coccidioidomycosis have been reported in the literature. At our institution, we report 4 cases of IRIS in HIV-infected patients with disseminated coccidioidomycosis. Unfortunately, all 4 patients died of worsening coccidioidal infection after initiating ART. The optimal timing of ART in patients with AIDS and coccidioidomycosis remains to be elucidated.

Heritability of the second to fourth digit ratio (2d:4d): A twin study.

The second to fourth finger length ratio (2d:4d) has been the subject of much recent work and is thought to be related to diverse gender and hormone-related traits including sports ability, disease susceptibility, attractiveness and sexuality. It is established in utero and remains constant in adulthood. Familial clustering has been thought to contribute to the development of 2d:4d from early studies but no twin studies exploring heritability have been reported to date. In this study, a sample of 456 female twin pairs (148 monozygotic [MZ], 308 dizygotic [DZ]) aged 18 to 79 years was used to estimate the heritability of 2d:4d for the right and left hands. Finger lengths were derived from hand x-rays. Variance components analysis was used to estimate and contrast genetic and environmental effects on this phenotype. The mean 2d:4d was 0.92 (SD = 0.001) for both hands. The MZ intraclass correlation was higher than in DZ (.66 vs. .35 for right 2d:4d, and .71 vs. .37 for left 2d:4d). The best fit model included additive polygenic and unique environmental effects ('AE' model), with no significant common environmental effects detected. Heritability was estimated to be approximately 66% for 2d:4d (95% confidence interval 0.5-0.78). These results suggest a substantial genetic contribution to the determination of this hormonally related skeletal ratio in women, which could be more influential than the effects of common prenatal environmental factors. However the current study design does not preclude the possibility of confounding between heritability estimates and unobserved prenatal effects.