Are women with obesity and infertility willing to attempt weight loss prior to fertility treatment?

OBJECTIVE: To assess attitudes towards weight loss interventions in patients seeking infertility treatment. METHODS: We evaluated prior weight loss experiences, attitudes towards future interventions by body mass index (BMI), and willingness to delay fertility treatment for weight loss interventions stratified by BMI using logistic regression amongst women ≤45years old with infertility over three months or recurrent pregnancy loss. RESULTS: The average age of our convenience sample of respondents (148 of 794 eligible women, 19%) was 34.5 years old, with a mean BMI of 26.7±7.4kg/m2, including 37 with a BMI >30kg/m2 (25%). Most women had attempted conception over 1year. The majority of women with overweight or obesity were attempting weight loss at the time of survey completion (69%). While 47% of these women reported interest in a supervised medical weight loss program, 92% of overweight women and 84% of women with obesity were not willing to delay fertility treatment more than 3 months to attempt weight loss. CONCLUSION: Most women with obesity and infertility in our population are unwilling to postpone fertility treatment for weight loss interventions.

Predicting the likelihood of live birth for elective oocyte cryopreservation: a counseling tool for physicians and patients.

Study question: Can a counseling tool be developed for women desiring elective oocyte cryopreservation to predict the likelihood of live birth based on age and number of oocytes frozen? Summary answer: Using data from ICSI cycles of a population of women with uncompromised ovarian reserve, an evidence-based counseling tool was created to guide women and their physicians regarding the number of oocytes needed to freeze for future family-building goals. What is known already: Elective oocyte cryopreservation is increasing in popularity as more women delay family building. By undertaking elective oocyte freezing at a younger age, women hope to optimize their likelihood of successful live birth(s) using their thawed oocytes at a future date. Questions often arise in clinical practice regarding the number of cryopreserved oocytes sufficient to achieve live birth(s) and whether or not additional stimulation cycles are likely to result in a meaningful increase in the likelihood of live birth. As relatively few women who have electively cryopreserved oocytes have returned to use them, available data for counseling patients wishing to undergo fertility preservation are limited. Study design, size, duration: A model was developed to determine the proportion of mature oocytes that fertilize and then form blastocysts as a function of age, using women with presumably normal ovarian reserve based on standard testing who underwent ICSI cycles in our program from January, 2011 through March, 2015 (n = 520). These included couples diagnosed exclusively with male-factor and/or tubal-factor infertility, as well as cycles utilizing egg donation. Age-specific probabilities of euploidy were estimated from 14 500 PGS embryo results from an external testing laboratory. Assuming survival of thawed oocytes at 95% for women <36 y and for egg donors, and 85% for women ≥36 y, and 60% live birth rate per transferred euploid blastocyst, probabilities of having at least one, two or three live birth(s) were calculated. Participants/materials, setting, method: First fresh male-factor and/or tubal-factor only autologous ICSI cycles (n = 466) were analyzed using Poisson regression to calculate the probability that a mature oocyte will become a blastocyst based on age. Egg donation cycles (n = 54) were analyzed and incorporated into the model separately. The proportion of blastocysts expected to be euploid was determined using PGS results of embryos analyzed via array comparative genomic hybridization. A counseling tool was developed to predict the likelihood of live birth, based on individual patient age and number of mature oocytes. Main results and the role of chance: This study provides an evidence-based model to predict the probability of a woman having at least one, two or three live birth(s) based on her age at egg retrieval and the number of mature oocytes frozen. The model is derived from a surrogate population of ICSI patients with uncompromised ovarian reserve. A user-friendly counseling tool was designed using the model to help guide physicians and patients. LIMITATIONS, REASONS FOR CAUTION: The data used to develop the prediction model are, of necessity, retrospective and not based on patients who have returned to use their cryopreserved oocytes. The assumptions used to create the model, albeit reasonable and data-driven, vary by study and will likely vary by center. Centers are therefore encouraged to consider their own blastocyst formation and thaw survival rates when counseling patients. Limitations, reasons for caution: Our model will provide a counseling resource that may help inform women desiring elective fertility preservation regarding their likelihood of live birth(s), how many cycles to undergo, and when additional cycles would bring diminishing returns. Study funding/competing interests: None. Trial registration number: Not applicable.

Building a model to increase live birth rate through patient-specific optimization of embryo transfer day.

PURPOSE: Many practices are moving away from cleavage-stage transfer in favor of blastocyst transfer. The purpose of this study is to evaluate how the overall live birth rate for fresh IVF cycles may increase by optimizing the day of transfer for each patient. METHODS: This is a retrospective cohort study of 1225 first fresh autologous IVF cycles performed between May 2012 and November 2013. Stepwise logistic regression was used to determine characteristics associated with live birth following cleavage-stage versus blastocyst transfer. The optimal transfer day (i.e., the day that maximized the odds of live birth) was determined for each patient, and the actual live birth rate was compared with the projected rate had each patient undergone transfer on her optimal day. RESULTS: With transfer on the optimal day for each patient, the overall birth rate would have increased from its actual value of 34.8 % to a projected 43.0 %, a 24 % increase. The majority of this increase (21 %) was due to optimization of patients who underwent cleavage-stage transfer but had a higher projected birth rate from blastocyst transfer. These patients were older (37.8 versus 36.0 years, p < 0.01) and had more follicles ≥18 mm than patients who should have remained with a cleavage-stage transfer. CONCLUSIONS: A model can be built enabling patient-specific identification of optimal transfer day; within this discovery cohort, such optimization was estimated to increase live birth following a fresh transfer by 24 %. This study suggests blastocyst transfer should be more widely offered; however, there remain patients for whom a cleavage-stage transfer may yield better outcomes.

Use of a job-exposure matrix to assess occupational exposures in relation to birth defects.

Accurate exposure assessment remains a challenge in occupational epidemiology. We evaluated one approach, use of a job-exposure matrix (JEM), by applying the National Institute for Occupational Safety and Health (NIOSH) JEM to a large case-control birth defects study that included parental occupation information. We investigated the JEM exposure predictions in several ways and found that for a substantial proportion of the parents in the birth defects study, the JEM yielded either no exposure data or nonsense predictions. Among exposure predictions that were plausible, most were of low probability. The high probability exposure predictions were statistically unstable, and neither low nor high probability exposure predictions were reliable. There was considerable discrepancy between the JEM predictions and expert assessments for five exposures of interest. Application of the NIOSH JEM to the birth defects study database (and probably other databases as well) does not provide a useful means of assessing occupational exposures.

Prioritizing back injury risk in hospital employees: application and comparison of different injury rates.

To identify high risk areas for back injury in a large teaching hospital, we calculated standard injury rates and newly developed composite statistics for nursing and non-nursing work groups. Data were extracted from the hospital's workers' compensation database. The hospital-wide total injury rate was 4.6 reports per 100 full-time equivalents (FTE); Compensation Case Rate, 1.4 cases per 100 FTE; Compensation Severity Rate, 76 days lost per 100 FTE; and the Cost Rate, $3742 per 100 FTE. The Total Injury Reports Rate for nursing varied from 14.2 per 100 FTE for Intensive Care Unit (ICU) Nursing to 3.8 per 100 FTE for Pediatric Nursing. Non-nursing areas also demonstrated increased rates for back injury. Individual statistical rates ranked areas differently in risk, whereas composite statistical measures consistently ranked ICU Nursing, Buildings and Grounds, and Orthopedics/Neurological Nursing as the top three. Patient handling was the precipitating event in the majority of nursing back injuries, indicating the need for ergonomic intervention. The use of combined statistical measures provided a more integrative measure for describing and following back injury risk over time.

Incorporating an environmental/occupational medicine theme into the medical school curriculum.

Medical schools have been slow in teaching students how to recognize and intervene in occupationally and environmentally related illnesses. In this article, we report on the efforts at one medical school, in which an occupational medicine physician teamed with medical school educators developed, implemented, and evaluated an environmental/occupational medicine (EOM) curriculum that was introduced in several locations, using a thematic approach. This effort resulted in new EOM content being added to eight core courses in a developmental sequence and the creation of several elective experiences. We describe techniques and strategies that might be useful at other institutions in promoting the EOM theme and improving communication. Occupational/environmental physicians and educators can play leadership roles in raising interest in EOM within the medical school setting and in developing and implementing an EOM curriculum.

Injuries caused by hazardous materials accidents.

STUDY OBJECTIVE: To describe exposures that prehospital and ED personnel may encounter as a result of hazardous material incidents. METHODS: Retrospective analysis of hazardous material incident reports from six district hazardous material teams in Massachusetts from their inception through May 1996. RESULTS: The chemicals most frequently involved were various hydrocarbons and corrosive materials. Chlorine derivatives were involved in 18% of all incidents and 23% of all incidents resulting in victims. Victims were produced by 47 of 162 (29%) incidents. Respiratory exposures were the most frequent type of exposure and resulted in the largest number of victims transported to a hospital. Overall 24 of 26 (92%) incidents with chemical exposures resulted in symptomatic victims and 33 of 35 (94%) incidents produced victims requiring hospital transport. Respiratory symptoms were the most frequent, both in the number of incidents where they were observed and the total number of victims with symptoms. CONCLUSION: Multiple victim transport to EDs from a single hazardous material incident is most likely to result from an inhalation exposure to a respiratory irritant. Information from descriptive studies should allow improved preparation for potential hazardous material victims.

Methods of prioritizing and measuring occupational health risks utilizing hospital back injury data. Development of composite comparative statistics.

The employee health service of a Boston hospital wanted a method to prioritize the risk of occupational injury or illness among its employees as the first step in developing a comprehensive ergonomics program. Data from the safety office and workers' compensation third-party administrator (TPA) was combined with hospital payroll data to create rates that compared all work areas based on the common denominator of 100 full-time equivalents (FTE). Rates for four different aspects of injury experience were calculated: incidence of total reported injuries, incidence of serious injuries, level of severity of injuries, and cost. The use of these simple rates alone was inadequate to accurately prioritize risk. Because most work areas ranked differently from one rate scale to the next, it was unclear which, if any, single rate most accurately defined risk. Composite statistics that combined all of the rates were needed. The Composite Risk Indicator (CRI), the Average Relative Risk (ARR), and the Justified Average Relative Risk (JARR) were developed and examined for their utility. The JARR emerged as the best choice in this setting because it captured all available information about injury or illness experience and provided a meaningful single indicator of risk that could be followed over time.

Mechanisms of and facility types involved in hazardous materials incidents.

The purpose of this study was to systematically investigate hazardous materials (hazmat) releases and determine the mechanisms of these accidents, and the industries/activities and chemicals involved. We analyzed responses by Massachusetts' six district hazmat teams from their inception through May 1996. Information from incident reports was extracted onto standard coding sheets. The majority of hazardous materials incidents were caused by spills, leaks, or escapes of hazardous materials (76%) and occurred at fixed facilities (80%). Transportation-related accidents accounted for 20% of incidents. Eleven percent of hazardous materials incidents were at schools or health care facilities. Petroleum-derived fuels were involved in over half of transportation-related accidents, and these accounted for the majority of petroleum fuel releases. Chlorine derivatives were involved in 18% of all accidents and were associated with a wide variety of facility types and activities. In conclusion, systematic study of hazardous materials incidents allows the identification of preventable causes of these incidents.

Are reference intervals for carboxyhemoglobin appropriate? A survey of Boston area laboratories.

CO is a leading cause of poisoning deaths in the US today. Treating physicians use the carboxyhemoglobin (COHb) % saturation to guide the diagnosis and treatment of CO intoxication. We conducted a telephone survey of hospitals and laboratories in the Boston area, focusing on methodology for COHb determination and accompanying COHb reference intervals. Among 130 facilities, 23 (18%) provide COHb analysis. All facilities that perform the COHb test utilize dedicated multiwave-length photometry. Reference intervals for COHb varied widely among facilities. Eight of 21 (38%) facilities give unacceptably high "normal intervals" for nonsmokers when compared with values available in the literature. Thirteen of 20 (65%) use reference intervals for smokers that are too low, and 3 of 20 (15%) use values that are too high. These reference values provided by the testing facilities may be misleading to the ordering physicians unfamiliar with background COHb saturations. This may lead to misdiagnoses, false reassurances, and perhaps less aggressive treatment than might be warranted. The results of this study argue for wider adoption of COHb reference intervals supported by the current literature.

Lead poisoning from mobilization of bone stores during thyrotoxicosis.

We describe a case of thyrotoxicosis accompanied by markedly elevated blood lead levels (initially 53 micrograms/dl) in a 37-year-old woman. No current source of lead exposure was found; the woman gave a history indicative of lead exposure as a child and as an adult 7 years previously, however. In addition, she was found to have markedly elevated bone lead levels, as measured by K-x-ray fluorescence (154 +/- 5 in the mid-tibia and 253 +/- 6 micrograms/g bone mineral in the patella), and an increased serum osteocalcin level (2.76 nmol/l), reflecting the increased bone turnover that often accompanies hyperthyroidism. During treatment with propylthiouracil, serial observations demonstrated a decline in serum osteocalcin that paralleled a decline in blood lead levels. Bone lead levels did not change appreciably. The patient also continued to have lingering neuropsychological symptoms consistent with chronic lead effects. We suggest that increased bone turnover accompanying thyrotoxicosis led to clinically significant lead poisoning in this patient, due to mobilization of accumulated bone lead stores acquired many years earlier. This phenomenon raises the general issue of more subtle forms of lead exposure from increased bone turnover states (e.g., osteoporosis).

Medical surveillance in the biotechnology industry.

A medical program appropriate for employees in biomedical laboratories should be based upon specific understanding of the risks and hazards associated with the work activities. Components of a medical program might include: preplacement examinations, periodic monitoring evaluations, tracking of prolonged or unusual illness, specific illness or exposure-related evaluations, epidemiological studies, immunization programs, and exit (or termination) evaluations.

Lead poisoning in automobile radiator mechanics.

Exposure to lead occurs during automobile radiator repair when soldered joints are heated, but this relatively common hazard has received little public recognition. We therefore studied lead exposure among automobile radiator mechanics in the Boston area. Twenty-seven shops were surveyed, and most were found to be small and poorly ventilated. Seventy-five workers were interviewed and tested for blood lead and free erythrocyte protoporphyrin levels. Fifty-six of the 75 actually repaired radiators, and they had a mean blood lead level of 37.1 micrograms per deciliter (range, 16 to 73). Thirty-nine percent of these mechanics had levels higher than 40 micrograms per deciliter; hematologic, neurologic, and renal effects are known to develop at or above this blood lead level. Multiple regression analysis showed that the number of radiator repair work stations (an index of exposure) was the variable most significantly associated with increased blood lead levels. We conclude that excessive exposure to lead occurs frequently among radiator repair workers and should be prevented by improved ventilation, engineering controls, and the use of respirators (if indicated) while working.

General occupational health history and examination.

This paper presents a method for developing occupational medical examinations using the preplacement examination (PPE) and the periodic monitoring examination (PME). The steps for developing an appropriate PPE include goal definition, analysis of job requirements and potential exposures, an occupational and medical history, and a targeted physical examination derived from the preceding steps. The PPE should result in the proper placement of the worker. It also serves as a baseline for comparison to future testing or health-related developments. The PME checks the effectiveness of more primary preventive measures such as plant engineering controls and personal protection. The contents and frequency of the PME depend on the pathophysiology and toxicology of the hazardous exposures, the interval exposure and medical history, and legal requirements. Individual and group results should be assessed periodically for trends suggesting work-related problems that would need further evaluation.

Italian occupational health: concepts, conflicts, implications.

This paper examines Italy's worker-based model for occupational health, especially its key concepts and its relation to social conflict. It briefly reviews the history of three approaches to occupational health in Italy: university-based, industry-based, and government-based. It then analyzes the worker-based approach, which emerged in the late 1960s and early 1970s as worker groups and trade unions mobilized around new concepts of occupational health. Five key concepts are discussed: the workers' homogeneous group; workers' subjectivity; the use of contract language; the development of local occupational health institutions; and the use of occupational hazard risk maps. The analysis illustrates how the social processes of mobilization and institutionalization affected the ideas and structures of Italian occupational health. Worker mobilization in Italy produced ideological changes in the nation's occupational health system, institutional changes in universities and governments, and legislative changes at national and local levels. The institutionalization of reforms, however, created new conflicts and problems and tended to restrict worker participation and promote expert intervention. The paper concludes with a brief outline of the history of occupational health approaches in the United States and then discusses the implications of the five Italian concepts for US occupational health policy.

The occupational and environmental health history.

Occupational and environmental diseases frequently masquerade as routine medical disorders. Yet environmental factors rarely enter into the clinician's differential diagnosis. This article provides a sequence of steps that can be used by the practicing physician for detecting occupational diseases: Step 1: Routine screening questions for all patients (List of job titles? Exposure to fumes, dusts, chemicals, loud noise, or radiation? Temporal relationship of the chief complaint to activities at work or at home?). Step 2: Consideration of sources of exposure (workplace or home surroundings). Step 3: Identification and handling of the hazardous agent. Step 4: Follow-up, consultation, and resolution of the problem. Equipped with this approach, the clinician can play an important role in the detection and prevention of occupational- and environmental-related diseases.

Effect of chronic potassium depletion on digitalis-induced inotropy and arrhythmias.

The arrhythmogenic and inotropic effects of digoxin were studied in normokalemic controls, chronically hypokalaemic, and potassium-repleted dogs instrumented to maintain heart rate, mean aortic pressure, mean left atrial pressure and autonomic tone constant. The duration of digoxin infusion needed to produce ventricular tachycardia (VT) was 56.7 +/- 3.6 min in depleted dogs, 69.0 +/- 2.7 min in controls (P less than 0.005 compared with depleted dogs), and 60.5 +/- 3.0 min in repleted dogs. Baseline left ventricular dP/dt (LV dP/dt) was similar in all groups. After digoxin, LV dP/dt increased more in controls and repleted dogs than in chronically hypokalaemic dogs; eg, after 45 min of digoxin infusion LV dP/dt increased 12.7 +/- 4.4% in hypokalaemic dogs; eg, after 45 min of digoxin infusion LV dP/dt increased 12.7 +/- 4.4% in hypokalaemic dogs, 43.8 +/- 3.3% in controls (P less than 0.025) and 39.3 +/- 8.5% in repleted dogs (P less than 0.025). The inotropic response to isoprenaline was also attenuated in the chronically hypokalaemic dogs. Plasma digoxin was similar in all groups. LV digoxin was also similar in control and depleted dogs. Although inhibition of Na+, K+-ATPase and the initial velocity of 3[H]-ouabain specific binding was less in depleted dogs at VT than in controls (P less than 0.05), the magnitude of this difference was not sufficient to explain the attenuated inotropic response. No histological abnormalities were seen on light or electron microscopy in any of the groups. Therefore chronic hypokalaemia has two deleterous effects. It increases sensitivity to the arrhythmogenic effects of digoxin and impairs the inotropic response to digoxin, and isoprenaline.

The family and home hemodialysis: adolescents' reactions to a father on home dialysis.

Quality of life is the most controversial issue surrounding home hemodialysis. We examined how sixteen adolescents and their six families reacted to having a father on home hemodialysis, exploring the interplay between adolescent developmental conflicts and family stresses. Family members underwent role changes to adjust to alterations imposed by hemodialysis. Some adolescents helped relieve family stresses by taking an active role in dialysis. These eight adolescents developed greater self-esteem which enhanced identity growth and facilitated separation. Psychological responses were observed that resembled the "death guilt," "psychic numbing," and "invisible contamination" described in Hiroshima survivors. Adolescent developmental problems can be dwarfed by family conflicts around chronic illness and dialysis. Families adjusted to home hemodialysis showing new growth, managing with a barely workable arrangement, or adapting unsuccessfully. Understanding more about how home hemodialysis can influence family interactions can enable the medical staff to facilitate beneficial changes, and thereby improve the quality of life for patient and family.