Perfluoroalkyl substances, bone density, and cardio-metabolic risk factors in obese 8-12 year old children: A pilot study.

BACKGROUND AND OBJECTIVE: Perfluoroalkyl substances (PFASs), including perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA), have been associated with adverse bone, and metabolic changes in adults. However association of PFASs with bone health in children is understudied. Considering their role as endocrine disruptors, we examined relationships of four PFASs with bone health in children. METHODS: In a cross sectional pilot study, 48 obese children aged 8-12 years were enrolled from Dayton's Children Hospital, Ohio. Anthropometric, clinical and biochemical assessments of serum were completed. Serum PFASs were measured by UPLC-ESI-MS/MS. In a subset of 23 children, bone health parameters were measured using calcaneal quantitative ultrasound (QUS). RESULTS: While PFASs exposure was associated with a consistent negative relationship with bone health parameters, among four PFASs tested, only PFNA showed a significant negative relationship with bone parameter (ß [95% CI], = - 72.7 [- 126.0, - 19.6], p = .010). PFNA was also associated with raised systolic blood pressure (p = .008), low density lipoprotein cholesterol (LDL-C; p < .001), and total cholesterol (TC; p = .014). In addition, both PFOA and PFOS predicted elevation in LDL-C, and PFOA predicted increased TC, as well. In this analysis, PFASs were not strongly related to thyroid hormones, 25-hydroxy vitamin D, liver enzymes, or glucose homeostasis. CONCLUSION: PFASs exposure in obese children may play a role in adverse skeletal and cardiovascular risk profiles.

Inverse associations between cardiometabolic risk factors and 25-hydroxyvitamin D in obese American children and adolescents.

OBJECTIVES: To examine the association between 25-hydroxyvitamin D [25(OH)D] concentrations and cardiometabolic risk factors in obese American children. METHODS: A cross-sectional study was conducted on 209 obese children (55% females, 25.8% black) aged between 6 and 19 years old. Study measurements included plasma 25(OH)D concentrations, blood pressure, lipids and oxidized LDL levels, insulin resistance (IR) indices from glucose, insulin and 5 hour oral glucose tolerance test. RESULTS: Fifty-one percent of the children had vitamin D deficiency. Older age [OR (95% CI) = 1.16 (1.00, 1.35)], black race/ethnicity [15.39 (5.79, 40.92)], winter/spring season [3.46 (1.69, 7.02)] and higher body mass index (BMI) [1.05 (0.99, 1.11)] were associated with increased odds of having vitamin D deficiency. None of cardiometabolic risk factors examined were significantly associated with vitamin D deficiency in age, race/ethnicity, season, and BMI adjusted models. In age, race/ethnicity, season and BMI adjusted models, total cholesterol (ß = -0.001, P = 0.013), non-HDL-C (ß = -0.001, P = 0.014), and oxidized LDL (ß = -0.087, P = 0.045) were inversely associated with log-transformed 25(OH)D. An approximate 10 mg/dl increase in total cholesterol or in non-HDL-C was associated with an approximate 1.3% decrease in the geometric mean of 25(OH)D concentration. Further a 10% increase in ox-LDL levels was associated with an approximate 0.8% decrease in the geometric mean of 25(OH)D. CONCLUSION: Vitamin D deficiency is prevalent in obese American children. There was evidence that some cardiometabolic risk factors including lipid levels and oxidized LDL levels were significantly inversely associated with 25(OH)D concentration in our sample. Am. J. Hum. Biol. 28:736-742, 2016. © 2016 Wiley Periodicals, Inc.

Association of Perfluoroalkyl Substances, Bone Mineral Density, and Osteoporosis in the U.S. Population in NHANES 2009-2010.

BACKGROUND: Perfluoroalkyl substances (PFASs), including perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA), are detectable in the serum of 95% of the U.S. OBJECTIVE: Considering the role of PFASs as endocrine disruptors, we examined their relationships with bone health. METHODS: The association between serum PFAS concentration and bone mineral density at total femur (TFBMD), femoral neck (FNBMD), lumbar spine (LSBMD), and physician-diagnosed osteoporosis was assessed in 1,914 participants using data from the National Health and Nutritional Examination Survey 2009-2010. RESULTS: The mean age of the participants was 43 years. Men had higher serum PFAS concentrations than women (p < 0.001) except for PFNA. In both sexes, serum PFOS concentrations were inversely associated with FNBMD (p < 0.05). In women, significant negative associations were observed for natural log (ln)-transformed PFOS exposure with TFBMD and FNBMD, and for ln-transformed PFOA exposure with TFBMD (p < 0.05). In postmenopausal women, serum PFOS was negatively associated with TFBMD and FNBMD, and PFNA was negatively associated with TFBMD, FNBMD, and LSBMD (all p < 0.05). With one log unit increase in serum PFOA, PFHxS, and PFNA, osteoporosis prevalence in women increased as follows: [adjusted odds ratios (aORs)] 1.84 (95% CI: 1.17, 2.905), 1.64 (95% CI: 1.14, 2.38), and 1.45 (95% CI: 1.02, 2.05), respectively. In women, the prevalence of osteoporosis was significantly higher in the highest versus the lowest quartiles of PFOA, PFHxS, and PFNA, with aORs of 2.59 (95% CI: 1.01, 6.67), 13.20 (95% CI: 2.72, 64.15), and 3.23 (95% CI: 1.44, 7.21), respectively, based on 77 cases in the study sample. CONCLUSION: In a representative sample of the U.S. adult population, serum PFAS concentrations were associated with lower bone mineral density, which varied according to the specific PFAS and bone site assessed. Most associations were limited to women. Osteoporosis in women was also associated with PFAS exposure, based on a small number of cases. CITATION: Khalil N, Chen A, Lee M, Czerwinski SA, Ebert JR, DeWitt JC, Kannan K. 2016. Association of perfluoroalkyl substances, bone mineral density, and osteoporosis in the U.S. population in NHANES 2009-2010. Environ Health Perspect 124:81-87; http://dx.doi.org/10.1289/ehp.1307909.

Bisphenol A and cardiometabolic risk factors in obese children.

BACKGROUND AND OBJECTIVE: Bisphenol-A (BPA) is an endocrine disruptor (ED) that has been associated with obesity and metabolic changes in liver in humans. Non-alcoholic fatty liver disease (NAFLD) affects 40% of all obese children in the United States. Association of BPA with NAFLD in children is poorly understood. We investigated if BPA might play a role. METHODS: In a cross sectional study of 39 obese and overweight children aged 3-8 years enrolled from the Children Medical Center of Dayton, Ohio, anthropometric, clinical and biochemical assessment of serum samples were conducted. Urinary BPA was measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and was adjusted for urinary creatinine BPA (creatinine) using linear regression and spline analyses. RESULTS: Higher urinary BPA (creatinine) concentration in overweight and obese children was associated with increasing free thyroxine. In male children BPA (creatinine) decreased with age, and was associated with elevated liver enzyme aspartate aminotransferase and diastolic blood pressure. The association of BPA (creatinine) persisted even after adjusting for age and ethnicity. Also in males, BPA concentration unadjusted for creatinine was significantly associated with serum fasting insulin and homeostasis model assessment for insulin resistance (HOMA-IR) showing non-monotonic exposure-response relationship. CONCLUSION: Urinary BPA in obese children, at least in males is associated with adverse liver and metabolic effects, and high diastolic blood pressure.

Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. METHODS: A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. RESULTS: Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. CONCLUSION: Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Environments and hominin activities across the FLK Peninsula during Zinjanthropus times (1.84 Ma), Olduvai Gorge, Tanzania.

We establish through 13 excavations the landscape context and nature of hominin activities across the Zinjanthropus land surface from which the Leakeys recovered the FLK 22 and FLK NN 1 paleoanthropological assemblages. The land surface was created by fluvial incision of the eastern margin of paleo-Lake Olduvai following a major lake withdrawal. Erosion was uneven, leaving a peninsula bounded by a river channel, the FLK Fault, and a freshwater wetland. This FLK Peninsula supported groves of trees that attracted hominins and carnivores, and that preserved the dense concentrations of carcass remains and stone tools they left behind, including those at FLK 22. Some carcasses appear to have been acquired at the ecotone of the Peninsula and Wetland, where another dense artifact and bone assemblage accumulated. A lesser topographic high at the edge of a Typha marsh in the Wetland was the site of FLK NN 1 and a scatter of large stone tools used possibly for rootstock processing. Our landscape reconstruction delimits the vegetation mosaic indicated by previous work and provides a topographical explanation for the existence of FLK 22 and FLK NN 1. Both are unexpected if the FLK area was the flat, featureless lake margin terrain typical of lake basins similar to paleo-Olduvai. The results show that the Leakeys' sites were not isolated occupation floors but rather parts of a land surface utilized intensively by hominins. Although commonly considered to have been home bases, their likely high predation risk, evidenced by large carnivore feeding traces and the remains of four hominin individuals, suggests visits to them were brief and limited to feeding. Finally, stratigraphic observations confirm that FLK NN 3 accumulated on an older land surface, refuting the hypothesis that the OH 8 foot found there is the same individual as the OH 35 leg from FLK 22.

Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group.

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

Beyond the dual degree: development of a five-year program in leadership for medical undergraduates.

The current state of physician leadership education consists mainly of executive degree programs designed for midcareer physicians. In 2004, the authors proposed that, by educating medical students in physician leadership and integrating this with a business management or public health degree program, graduates, health care organizations, and communities would benefit sooner. Given the lack of program models to guide program integration and development, the authors began a one-year inquiry to build a model leadership curriculum and integrate leadership education across degree programs. The qualitative inquiry resulted in several linked tasks. First, the authors identified a feasible method for concurrently delivering all three program components (MD degree, Leadership Curriculum, and MBA or MPH degree) during a five-year plan. Second, the authors chose a competency-based educational framework for leadership and then identified, adapted, and validated existing leadership competencies to their context. Third, the authors performed an extensive program alignment to identify existing overlaps and opportunities for integration within and across program components. Fourth, the authors performed a needs analysis to identify educational gaps, subsequently leading to redesigning two courses and to designing three new courses. A description of the Leadership Curriculum is also provided. This inquiry has led to the development of the Boonshoft Physician Leadership Development Program, which provides physician leadership education integrated with medical education and education in business management or public heath. Future program initiatives include developing leadership student assessment tools and testing the link between program activities and short- and long-term outcome measures of program success.

Late Pliocene Homo and hominid land use from Western Olduvai Gorge, Tanzania.

Excavation in the previously little-explored western portion of Olduvai Gorge indicates that hominid land use of the eastern paleobasin extended at least episodically to the west. Finds included a dentally complete Homo maxilla (OH 65) with lower face, Oldowan stone artifacts, and butchery-marked bones dated to be between 1.84 and 1.79 million years old. The hominid shows strong affinities to the KNM ER 1470 cranium from Kenya (Homo rudolfensis), a morphotype previously unrecognized at Olduvai. ER 1470 and OH 65 can be accommodated in the H. habilis holotype, casting doubt on H. rudolfensis as a biologically valid taxon.