Preconception hemoglobin A1c concentration in healthy women is not associated with fecundability or pregnancy loss.

Objective: To examine the relationship of preconception hemoglobin A1c, a marker of cumulative exposure to glucose over the preceding 2-3 months, with time to pregnancy, pregnancy loss, and live birth among fecund women without diagnosed diabetes or other medical diseases. Design: A secondary analysis of a prospective cohort of women participating in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial. Setting: Four US academic medical centers. Patients: A total of 1,194 healthy women aged 18-40 years with a history of one or two pregnancy losses attempting spontaneous conception were observed for up to six cycles while attempting pregnancy and throughout pregnancy if they conceived. Interventions: Not applicable. Main Outcome Measures: Time to pregnancy, human chorionic gonadotropin pregnancy, clinical pregnancy, pregnancy loss, and live birth. Results: Although increasing preconception A1c level was associated with reduced fecundability (fecundability odds ratio [FOR] per unit increase in A1c 0.74; 95% confidence interval [CI] 0.57, 0.96) in unadjusted models and models adjusted for age, race, smoking and treatment arm (FOR 0.79; 95% CI 0.60, 1.04), results were attenuated after further adjustment for body mass index (FOR 0.91; 95% CI 0.68, 1.21). Preconception A1c levels among women without diagnosed diabetes were not associated with live birth or pregnancy loss. Conclusionss: Among healthy women without diagnosed diabetes, we observed no association of A1c with live birth or pregnancy loss. The association between A1c and fecundability was influenced by body mass index, a strong risk factor for both diabetes and infertility. These data support current recommendations that preconception A1c screening should be reserved for patients with risk factors for diabetes. Clinical Trial Registration Number: ClinicalTrials.gov: NCT00467363.

Is Anti-Müllerian Hormone Associated With Fecundability? Findings From the EAGeR Trial.

OBJECTIVE: The objective of the study was to evaluate whether anti-Müllerian hormone (AMH) is associated with fecundability among women with proven fecundity and a history of pregnancy loss. DESIGN: This was a prospective cohort study within a multicenter, block-randomized, double-blind, placebo-controlled clinical trial ( clinicaltrials.gov , number NCT00467363). SETTING: The study was conducted at four US medical centers (2006-2012). PARTICIPANTS: Participating women were aged 18-40 years, with a history of one to two pregnancy losses who were actively attempting pregnancy. MAIN OUTCOME MEASURES: Time to human chorionic gonadotropin detected and clinical pregnancy were assessed using Cox proportional hazard regression models to estimate fecundability odds ratios (fecundability odds ratios with 95% confidence interval [CI]) adjusted for age, race, body mass index, income, low-dose aspirin treatment, parity, number of previous losses, and time since most recent loss. Analyses examined by preconception AMH levels: low (<1.00 ng/mL, n = 124); normal (referent 1.00-3.5 ng/mL, n = 595); and high (>3.5 ng/mL, n = 483). RESULTS: Of the 1202 women with baseline AMH levels, 82 women with low AMH (66.1%) achieved an human chorionic gonadotropin detected pregnancy, compared with 383 with normal AMH (65.2%) and 315 with high AMH level (65.2%). Low or high AMH levels relative to normal AMH (referent) were not associated with fecundability (low AMH: fecundability odds ratios 1.13, 95% CI 0.85-1.49; high AMH: FOR 1.04, 95% CI 0.87-1.24). CONCLUSIONS: Lower and higher AMH values were not associated with fecundability in unassisted conceptions in a cohort of fecund women with a history of one or two prior losses. Our data do not support routine AMH testing for preconception counseling in young, fecund women.

A multilingual population health management program.

Many small- and medium-sized physician practices have developed specific programs and models toward becoming a successful patient-centered medical home. This article reports on a case-control quality improvement study of a multilingual population health management program for chronic disease management at International Community Health Services. In its first 2.5 years of operation, the International Community Health Services Population Health Management program for patients with hypertension and diabetes is associated with significant improvements in key health outcome measures for blood pressure and hemoglobin A1c control. This has significant implications for similar practices.

Public health and medical education: a natural alliance for a new regional medical school.

A century ago, the Flexner Report challenged U.S. medical schools to critically evaluate their curricula in order to nurture physicians equipped to meet the needs of an evolving society. Recently, medical educators have been charged to increase the emphasis on prevention, care of populations, public health, and community medicine. The Commonwealth Medical College (TCMC) is a new MD-granting medical school inspired by and founded in response to a community need. The founders' vision was to recruit and train physicians to fill workforce needs in Northeast Pennsylvania. In its first few years, TCMC embarked on two major public health initiatives, the Regional Health Assessment and the Community Health Research Projects (CHRPs). The results of the health assessment have been used to guide TCMC's curricular development and research agenda. The CHRPs foster commitment to community involvement, regional engagement, and participatory research. TCMC partners with various organizations and community physicians to ensure that students learn (1) to apply knowledge and skills acquired through the course of their studies to public health research in varied settings; (2) the fundamentals of community engagement, collaboration, and service-based practice; and (3) to address the different needs of patient subgroups and populations. These programs provide opportunities for students to be active participants in community capacity building while achieving specific competencies in public health. Existing partnerships with community organizations are enhanced, strengthening the regional focus of the school. This model of incorporating public health into medical education can potentially be replicated in other institutions in the U.S. and internationally.

Pennsylvania's Asthma School Project and descriptive pilot investigation: a focus on environmental health tracking.

The authors reviewed asthma prevalence rates from all 501 Pennsylvania public school districts for 1997-1998 through 2002-2003. School nurses collect and report these data to the Pennsylvania Department of Health annually, and the data are aggregated by school district, county, and specified school year. The department initiated a descriptive pilot investigation in 2004 as part of the larger Asthma School Project, targeting all students with asthma in the two districts that had the highest and second highest asthma rates in Pennsylvania. The authors conclude that reporting of asthma by school nurses was a reliable data source, since most participating students had documentation of asthma diagnosis or asthma medication. The department also conducted environmental evaluations at the schools and investigated the occurrences of asthma exacerbations in participating students, but no unusual patterns or links to the schools were identified. The authors encourage other state health departments to consider designing and testing similar approaches to tracking asthma in students.

Analysis of lagoon samples from different concentrated animal feeding operations for estrogens and estrogen conjugates.

Although Concentrated Animal Feeding Operations (CAFOs) have been identified as potentially important sources for the release of estrogens into the environment, information is lacking on the concentrations of estrogens in whole lagoon effluents (including suspended solids) which are used for land application. Lagoons associated with swine, poultry, and cattle operations were sampled at three locations each for direct analysis for estrogens by GC/ MS/MS and estrogen conjugates by LC/MS/MS. Estrogen conjugates were also analyzed indirectly by first subjecting the same samples to enzyme hydrolysis. Solids from centrifuged samples were extracted for free estrogens to estimate total estrogen load. Total free estrogen levels (estrone, 17alpha-estradiol, 17beta-estradiol, estriol) were generally higher in swine primary (1000-21000 ng/L), followed by poultry primary (1800-4000 ng/L), dairy secondary (370-550 ng/L), and beef secondary (22-24 ng/L) whole lagoon samples. Swine and poultry lagoons contained levels of 17(alpha-estradiol comparable to those of 17beta-estradiol. Confirmed estrogen conjugates included estrone-3-sulfate (2-91 ng/L), 17beta-estradiol-3-sulfate (8-44 ng/L), 17alpha-estradiol-3-sulfate (141-182 ng/L), and 17beta-estradiol-17-sulfate (72-84 ng/L) in some lagoons. Enzymatic hydrolysis indicated the presence of additional unidentified estrogen conjugates not detected bythe LC/MS/MS method. In most cases estrogen conjugates accounted for at least a third of the total estrogen equivalents. Collectively, these methods can be used to better determine estrogen loads from CAFO operations, and this research shows that estrogen conjugates contribute significantly to the overall estrogen load, even in different types of CAFO lagoons.