Abstracts from the NIH Office of Research on Women's Health Tenth Annual Interdisciplinary Women's Health Research Symposium October 24,2013

1 Mayo Clinic 2 Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute P-2: Detecting Endometrial Cancer Using the Common Tampon

Background and Objective: Endometrial cancer (EC) is the most common gynecologic cancer in the United States. Survival is improved in earlier stage disease and when precancerous lesions exist. A screening test for endometrial cancer does not exist. The objective was to determine whether genes commonly methylated in EC can be detected in the lower genital tract secretions of women with EC.

Methods: A pilot study of women with biopsy-proven endometrial cancer and women undergoing hysterectomy for benign conditions underwent collection of the lower genital tract secretions via intravaginal tampon and endometrial brushings with a Tao brush prior to hysterectomy. DNA methylation status of RASSF1A was determined in tampon and Tao brush samples. Thirty-seven women with endometrial cancer and 29 women undergoing hysterectomy for presumed benign conditions (benign endometrium [BE]) were prospectively enrolled.

Results: Methylation of RASSF1A was first determined via direct sequencing for four subjects (1 EC, 3 BE). No methylation was observed in the three BE cases; methylation of the same sites in DNA from both tampon and Tao brush was observed in the EC case. Larger scale pyrosequencing of tampon DNA revealed significantly higher methylation among all 16 RASSF1A CpG sites within the EC cohort compared to the BE cohort. RASSF1A is hypermethylated in EC (compared to BE), and this DNA alteration can be detected in the lower genital tract fluid via intravaginal tampon among women with EC.

Conclusions: Combining a well-accepted collection technique with sensitive DNA analyses may lead to a screening test for EC.

1 University of Rochester 2 University of Rochester Medical Center P-6: Regenerative Polymer Therapeutics: Next-generation Osteoporosis Therapies

Background and Objective: Targeting drugs specifically to bone will provide novel, specific, efficacious, and safe therapies for osteoporosis, a debilitating and costly musculoskeletal disorder. We aim to exploit peptide-targeting to selectively deliver bone anabolic drugs to resorption surfaces. By combining peptides that bind to resorption sites with high affinity and drugs to enhance bone production, we aim to improve bone regeneration selectively at the sites of resorption to treat osteoporosis.

Methods: Polymers were formulated with controlled, radical polymerizations and tested for specific bone affinity using surface plasmon resonance. Drug tethering and release was achieved using incorporation of hydrolytically degradable bonds, as analyzed using liquid chromatography.

Results: We synthesized multivalent, highly controlled peptide-based polymer architectures that home to bone with high affinity.

Conclusions: We have demonstrated simple and reproducible incorporation and controlled Wnt/β-catenin agonist drug release to enhance osteoblast bone production. Future studies focus on identifying appropriate doses and dosing regimes and testing the efficacy of drug delivery in osteoporosis models. Successful completion of this research will significantly advance our ability to treat osteoporosis specifically through rejuvenation of osteoblasts and, more broadly, develop bone-specific drugs. The proposed work possesses great transformative and translational potential based on the wide applicability of drug delivery systems developed in this study.

1 Division of Hematology/Oncology/Transplantation, University of Minnesota 2 Biostatistics Core, University of Minnesota 3 Masonic Cancer Center, University of Minnesota 4 College of Pharmacy, University of Minnesota P-7: Angiotensin Converting Enzyme Inhibitors (ACEI) and Doxorubicin (DOX) Pharmacokinetics in Women Undergoing Chemotherapy for Breast Cancer

Background and Objective: Doxorubicin (DOX) chemotherapy can cause cardiac complications in breast cancer survivors. Angiotensin converting enzyme inhibitors (ACEI) may protect against these complications. We performed a pharmacokinetics study to determine whether DOX exposure is altered in breast cancer patients receiving DOX concurrently with ACEI.

Methods: Women with locally advanced breast cancer prescribed DOX and cyclophosphamide every 14 days were randomized to receive enalapril 10 mg daily or no enalapril during DOX chemotherapy. Blood samples for pharmacokinetics (DOX and doxorubicinol levels) were drawn at baseline, 0.5, 1.0, 2.0, 4.0, 24.0, and 48.0 hours after infusion with and without enalapril. Correlative laboratories were also obtained. Pharmacokinetic data was analyzed using non-compartmental methods and DOX and doxorubicinol area under the curve (AUC) 0 to infinity, Cmax, and half-life were estimated. Paired t-tests, two tailed, were used to determine whether DOX and its metabolite were altered with the use of enalapril (P < .05).

Results: Nine women (median age, 41 years) with no cardiac history received 60 mg/m² DOX every 2 weeks for 4 cycles. Mean (SD) AUC 0 to ∞ for DOX and doxorubicinol with enalapril exposure was 1235 (168.1) hr*ng/mL and 954.6 (219.6) hr*ng/mL, respectively. AUC 0 to ∞ for DOX and doxorubicinol without enalapril was 1238 (193.2) hr*ng/mL and 984.4 (219.9) hr*ng/mL, respectively. There appears to be no interaction between DOX (P = .97) or doxorubicinol (P = .78) and enalapril. Enalapril was well tolerated (33% grade 1 dizziness).

Conclusions: ACEI, enalapril, does not appear to alter the pharmacokinetics of DOX chemotherapy. Ongoing efforts to determine the effectiveness of ACEI as a cardioprotective agent in women receiving DOX chemotherapy should be continued.

1 Division of Kidney Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University 2 Division of Hematology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University P-8: Utility of Thrombophilia Screening in Children Awaiting Kidney Transplantation: Sex Does Not Associate With Thrombophilia-related Thromboembolic Events

Background and Objective: Vascular thrombosis is a common cause of early allograft loss in children after kidney transplantation (KTx). Screening for acquired/ inherited thrombophilia is controversial. We posited that universal pretransplant screening for thrombophilia had low predictive value, and did not differ by sex, for postoperative outcomes.

Methods: We reviewed 84 children, 1 to 18 years old, who underwent comprehensive thrombophilia evaluations (protein C, S, anti-thrombin 3 [AT], homocysteine, antiphospholipid antibody, lupus anticoagulant; factor V Leiden [FVL], prothrombin, and MTHFR gene mutations) prior to KTx.

Results: Pre-operative screening demonstrated thrombophilia in 91% (76/84) of patients. In 10/84 (12%) children, a bleeding (5/84, 6%) or clotting (7/84, 8%) event occurred after KTx. A pre-KTx thromboembolic event occurred in 8/84 patients (10%). Post-operative events were associated with history of pre-KTx thromboembolic events (P = .019), FVL mutation (P = .002), and low AT (P = .016). History of a pre-KTx thromboembolic event and FVL mutation were associated with poorer graft survival at 3 years and 3 months, respectively (P < .0001 for both); low AT levels were associated with poorer graft survival at 1 and 3 years (P < .0001 for both). Two of 84 grafts were lost to thrombosis. Sex was not associated with pre- or post-KTx thromboembolic events; neither were age or race.

Conclusions: Analysis of long-term follow-up data demonstrates that the value of comprehensive thrombophilia evaluation before KTx is low. Focused universal investigation, however, with more detailed testing in those with a previous thrombosis, may be advisable, as these patients may benefit from perioperative anticoagulation.

1 Department of Public Health and Preventive Medicine, Oregon Health & Science University 2 School of Community Health, Portland State University P-9: Fetal Growth Restriction and Maternal Obesity: Shared or Competing Processes?

Background and Objective: Maternal obesity increases risk for both small and large birth size. Despite ongoing research on the causes and effects of fetal growth restriction, little is known about the drivers of small birth size among obese mothers. The objective was to estimate interactive effects of maternal pre-pregnancy body mass index (BMI) with risk factors for fetal growth restriction on birth size in a population-based sample.

Methods: We used data from the Oregon Pregnancy Risk Assessment Monitoring System (2004–2007; n = 6,302) and linked birth records. Using multinomial logistic regression, we estimated interactive effects of prenatal smoking and gestational hypertension with pre-pregnancy BMI (underweight, normal weight, overweight, obese class I, obese class II-III) on small, appropriate, or large for gestational age (SGA, LGA, AGA). Models excluded women with gestational diabetes or multiple births and controlled for pregnancy weight gain, parity, and sociodemographic characteristics.

Results: Non-obese women who smoked or had gestational hypertension exhibited the highest risk of SGA [Odds Ratio (OR) (95% CI) range: 2.6 (1.4, 4.5) to 5.1 (2.6, 10.0)]. Gestational hypertension combined with class II or III obesity was also associated with elevated SGA risk [OR (95% CI): 4.4 (1.9, 10.2)] compared to normal weight, non-smoking, or non-hypertensive women. Increased LGA risk with greater BMI was not apparent in the presence of prenatal smoking or gestational hypertension.

Conclusions: Extreme maternal obesity and gestational hypertension may induce common processes leading to SGA, while competing fetal under- and over-growth may be involved in LGA. Investigation of inflammatory and other mechanisms that underlie these associations is needed.

1 Department of Radiology, UC Davis School of Medicine 2 Signal and Image Processing Institute, University of Southern California 3 Department of Medicine, UC Davis School of Medicine P-14: Sex-based Imaging Biomarkers of Carpal Bone Motion and Shape in Hand Osteoarthritis

Background and Objective: Hand osteoarthritis (HOA) prevalence in women is more than double that in men across all ages. Our hypothesis is that joint motion and bone shape will differ by sex and will contribute differently to the development of HOA in each sex. The objective was to develop imaging approaches (real-time MRI during active hand motion, morphometric analysis) to understand better the sex-specific shape and motion-related variations for components of the hand.

Methods: The MRI data acquisition protocol was based on balanced steady-state free precession. Magnetic susceptibility artifacts that are usually introduced during motion were mitigated by the use of a wrist harness and susceptibility pads attached to the carpal region of the hand. Two healthy men and 2 healthy women were scanned using the imaging protocol. Carpal bone shapes obtained from a publicly-available database for women (n = 10) and men (n = 10) without HOA were analyzed using spectral theory (2D-Helmholtz equation and the Laplace-Betrami operator) and finite element modeling. This shape analysis approach was independent of scale and bone orientation.

Results: We were able to track the carpal bones and soft tissue components during different hand maneuvers for the initial 2 healthy men and women. Sex-based comparisons based on morphometric analysis for the 10 healthy men and 10 healthy women showed statistically significant shape differences (P < .05) between the sexes.

Conclusions: Women and men appear to differ in carpal bone motion metrics and shape. Our future work will validate the imaging approaches and start to determine if the derived imaging metrics correlate with HOA risk.

1 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University 2 Department of Obstetrics & Gynecology, Oregon Health & Science University P-16: Cytochrome P4502C9 Activity Is Unaffected by Oral Contraceptive Use Among Obese Women

Background and Objective: Variability in drug metabolism is a critical contributor to inter-individual variability in drug response. Cytochrome-P4502C9 (CYP2C9) metabolizes 15% to 20% of prescribed drugs. Obesity and contraceptive use were identified as independent contributors to variability in CYP2C9. While obesity was shown to increase CYP2C9 activity, contraceptive use decreases activity in normal body mass index (BMI) women. However, there is a lack of knowledge about the status of CYP2C9 among obese women who are also contraceptive users. This is important to understand, given that about 50% of reproductive-aged women are either obese or overweight. We have determined the status of CYP2C9 activity in obese women before and after the use of oral contraceptives.

Methods: Institutional review board approval was obtained. Obese women (BMI > 30 kg/m²; n = 34) were consented, and CYP2C9 status was determined pre- and post- oral contraceptive regimen (daily dose of 100μg of levonorgestrel per 20 μg of ethinylestradiol for 21 days). Tolbutamide (125 mg tablet) was administered, single blood sampled at 24 hours, and plasma concentrations measured using liquid chromatography and mass spectrometry. Plasma concentration at 24 hours is a measure of CYP2C9 activity. Analysis was performed with a paired t-test.

Results: Tolbutamide levels were unchanged before and after oral contraceptive use (pre: 1.98 ± 1.50 μg/mL, mean ± S.D.; post: 1.90 ± 1.30 μg/mL).

Conclusions: Unlike in normal BMI women, oral contraceptive use did not alter CYP2C9 activity in obese users. These results are reassuring that the use of oral contraceptives in obese women may not interfere with other pharmacotherapies metabolized through similar pathways. We speculate that the effects of obesity and contraceptive use counteract each other, and, hence, lack of alteration is seen in CYP2C9 activity.

1 Division of Transplant Surgery, University of Illinois, Chicago 2 Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic P-19: Greater Pancreatic Beta-cell Mass in Female Compared With Male Organ Donors May Be Associated With a Lower Propensity for Pancreatic Apoptosis and Viral-mediated Destruction in Females

Background and Objectives: Pancreatic insulin-producing beta cells proliferate during pregnancy, but the influence of sex on the maintenance and regulation of beta-cell mass independent of pregnancy is unknown. Such data could provide insight into why type 1 diabetes (T1D), caused by destruction of beta cells, is the only autoimmune disorder not more prevalent in females. The objectives were to determine whether beta-cell mass differs between female and male pancreas organ donors, and if so, whether inflammatory genes mediate the sex difference.

Methods: Nondiabetic cadaveric organ donor (n = 12 female, n = 15 male; mean age 48.9 ± 12.8 years) pancreatic biopsies were assessed using immunohistochemistry and enumeration for the proportion of beta cells. Microarray analysis included 11 inflammatory genes selected a priori. Donor data (e.g., age, body mass index, cause of death, biochemical profiles) were obtained from medical records. Multivariable linear regression and mediation analyses were conducted.

Results: The proportion of beta cells was greater in females than males (74.8% vs. 69.0%, P = .09). The difference was confounded only by donor white blood cell count; after adjustment, the greater proportion in females was more pronounced (75.9% vs. 67.7%, P = .03). Mediation analysis revealed that lower pancreatic gene expression of interleukin (IL)-24 and higher IL-28 receptor alpha (Ra) in females, compared to males, explained 70% of this sex difference.

Conclusions: Greater beta-cell mass in females was associated with lower IL-24, which can promote pancreatic cell apoptosis, and with higher IL-28Ra, recently found to protect beta cells during viral infection. These factors may lessen the T1D risk in women, particularly in light of evidence that viral infection precipitates T1D onset.

1 Department of Psychiatry, Yale University School of Medicine 2 VA Connecticut Healthcare System P-20: Subjective and Physiological Responses to IV Nicotine: Effects of Sex and Menstrual Phase

Background and Objective: Sex differences are widely documented in the population rates, clinical characteristics, and treatment-responsiveness of addictive behaviors, including nicotine-dependence. Gonadal hormones (progesterone, estradiol) are neuroactive and interact with addiction-relevant neurotransmitter receptors while also differing by sex and fluctuating across the menstrual cycle. Therefore, the study of cycle phase effects on nicotine response may elucidate the biological mechanisms contributing to sex differences in nicotine-dependence. The objective was to investigate sex and menstrual cycle phase effects on abstinence-related withdrawal and both subjective and physiological responses to nicotine.

Methods: Following overnight abstinence, nicotine-dependent adults received 2 intravenous (IV) doses of nicotine (0.5 and 1.0 mg/70 kg) and IV saline (placebo). Subjective drug-effects ratings and physiological measures were collected throughout the session. Nicotine withdrawal symptoms were assessed at baseline and end-of-session. Serum progesterone levels confirmed women's menstrual cycle phases. Analyses addressed sex (49 women, 111 men) and menstrual cycle phase (26 follicular, 18 luteal) differences.

Results: Follicular phase women reported more withdrawal symptoms than luteal-phase women following overnight abstinence. Following IV nicotine administration, women demonstrated greater increases in heart rate, yet less robust subjective nicotine-effects than men. Luteal phase women reported dampened subjective nicotine-effects relative to follicular phase women.

Conclusions: Phase-related fluctuations in nicotine response may contribute to sex differences. Phase-related fluctuations in nicotine-response, perhaps accounted for by gonadal hormones, may have important clinical implications. That luteal-phase women experienced less withdrawal and diminished subjective nicotine-reactivity may partially explain previous reports of greater success amongst women initiating quit-attempts in the luteal rather than the follicular phase.

1 Division of Geriatric Medicine, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus 2 Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus P-21: Ovarian Hormone Suppression in Premenopausal Women Reduces Fat-free Mass and Resting and 24-hour Energy Expenditure

Background and Objective: Compelling evidence from animal studies suggests that estradiol (E₂) deficiency disrupts energy balance and causes excess weight gain, but the effects of sex hormone suppression in women have not been well studied. The objective was to compare the effects of ovarian hormone suppression with add-back of placebo (PL) or E₂ therapy in premenopausal women on body composition, resting energy expenditure (REE), and 24-h energy expenditure (EE).

Methods: Forty-five premenopausal women underwent 5 months of gonadotropin releasing hormone agonist therapy (GnRH_AG, monthly injections of leuprolide acetate 3.75 mg) to suppress ovarian hormones, with add-back of transdermal E₂ (0.075 mg/d, GnRH_AG + E₂, n = 21) or placebo patch (GnRH_AG + PL, n = 24). At study entry (mean ± SD): age, 35 plus or minus 8 years; body mass index (BMI), 27.1 plus or minus 6.2 kg/m².

Results: GnRH_AG + PL caused a decrease in fat-free mass (FFM; −0.5 ± 0.2 kg, P = .02; mean ± SE) with no change in fat mass (FM; −0.2 ± 0.4 kg, P = .65). E₂ prevented the decrease in FFM (0.5 ± 0.3 kg, P = 0.11), but FM increased (0.8 ± 0.3 kg, P = .02). GnRH_AG + PL resulted in decreases in REE (-57.3 ± 21.9 kcal/d, P = .02) and 24-h EE (-128 ± 42 kcal/d, P = .005); the decrease in REE was attenuated by E₂ (-4.2 ± 16.5 kcal/d, P = .80) but 24-h EE was not (-100 ± 30 kcal/d, P = .003).

Conclusions: Ovarian hormone suppression led to decreases in FFM, REE, and 24-h EE. E₂ add-back therapy had a favorable effect on some, but not all, bioenergetic changes resulting from chronic suppression of ovarian hormones. Loss of ovarian function at menopause may influence metabolism in a way that reduces energy expenditure.

Support: NIH R01 AG018198, P30 DK048520, UL1 TR000154

1 Adult and Pediatric MS Center, University of California, San Francisco 2 Oklahoma Medical Research Foundation, Oklahoma City 3 National Pediatric MS Center, Stony Brook, New York P-23: Gender Modifies the Effect of HHV6 IgG Response on Relapse Rate in Children With Multiple Sclerosis

Background and Objective: Antibody responses against herpes viruses are associated with the risk of multiple sclerosis (MS). Women have a higher risk of MS (3:1), but men have a higher risk for severe MS. We sought to determine if the effects of herpes virus antibody responses on MS relapse rate (RR) were modified by gender. Pediatric MS patients are an ideal population for study, as they are closer to the age of primary exposure to herpes viruses.

Methods: Batched ELISA IgG assays (EBV, CMV, HSV-1) and IgG immunofluorescence assay (HHV6) were performed for patients from two Pediatric MS Centers. Genotyping of strongest MS genetic risk factor, HLA-DRB1*1501, was performed by Taqman assay. Patients were followed prospectively for relapses. Repeated events models adjusted for disease-modifying therapy, demographic variables, and vitamin D level.

Results: For 171 subjects, 416 relapses were captured over 516 patient-years of follow-up. High levels of HHV6 responses were associated with increased hazard for relapse compared with lower response levels (HR 1.54, 95% CI 1.15–2.05; P = .003). Girls constituted 64% of all cases and 89% of those with high HHV6 responses. The effect of HHV6 response was modified by gender (P interaction = .07) and DRB1*1501 status (P = .05). The magnitude of effect on relapse hazard was stronger in men (OR 2.27, 95% CI 1.39–3.71, P = .001) than in women (OR 1.47, 95% CI 0.95–2.26, P = .08). No association was seen for other viruses.

Conclusions: Elevated HHV6 IgG responses are associated with higher relapse rates in children with MS. This effect varies by gender and genetic background.

1 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina 2 College of Medicine, Medical University of South Carolina 3 Department of Obstetrics and Gynecology, Medical University of South Carolina 4 Department of Psychiatry, University of Pennsylvania 5 Department of Obstetrics and Gynecology, Temple University P-24: Altered Th1/Th2 Cytokines in Pregnancy and Risk for Postpartum Anxious Depression

Background and Objective: Alterations in Th-1/Th-2 cytokine represent a promising biomarker for risk of major depression, but findings have been inconsistent due to disease heterogeneity. Further, cross-sectional studies preclude inference regarding directionality of cytokines and depression. Depression with comorbid anxiety is common during the postpartum period and likely represents a distinct subclass of depressive symptoms (anxious depression). Moreover, the postpartum period can be anticipated, allowing prospective assessment of cytokine levels. The objective was to determine if cytokines in pregnancy are associated with subsequent postpartum anxious depression (ppAD).

Methods: Medical records were reviewed to identify cases of depression and anxiety during pregnancy and the year postpartum in participants in a prospective study of cytokines in pregnancy. Signature Th-1/Th-2 cytokines (7 in total) were measured at 34 to 42 weeks' gestation. Logistic regression methods were used to assess the relationship between individual cytokines and ppAD.

Results: A total of 231 women with a complete cytokine profile were included in the analysis. After controlling for potentially confounding variables, women were more likely to experience ppAD with lower interferon gamma (IFN-γ) (OR 0.78; 95% CI 0.61–0.99), higher interleukin (IL) 6 (OR 1.6; 95% CI 1.002–2.79) and higher IL-10 (OR 1.2; 95% CI 1.01–2.79).

Conclusions: We report a novel temporal relationship between an altered Th-1/Th-2 cytokine profile in pregnancy and subsequent risk of ppAD. One therapeutic mechanism of selective-serotonin reuptake inhibitors is upregulation of IFN-γ; therefore our finding of an association between lower IFN-γ and increased ppAD has biologic validity. Higher IL-6/IL-10 levels suggest that maternal inflammatory response to pregnancy may mediate mood and/or anxiety symptoms. Further prospective evaluation of these relationships are needed.

1 Department of Pediatrics and Department of Epidemiology and Public Health, University of Maryland School of Medicine 2 University of Maryland School of Social Work P-25: Association Between Perceived Implementation of School Wellness Policies and Health Behaviors Among Middle School Girls

Background and Objective: Childhood obesity disproportionately effects African American (AA) adolescent girls. School wellness policies are federally mandated but are effective only if implemented. Few studies have examined perceived implementation of school wellness policies. The objective was to examine how perceived school wellness policies relate to health behaviors (diet and physical activity [PA]) among AA adolescent girls.

Methods: Adolescent girls were recruited from urban schools serving low-income, predominantly AA neighborhoods. Questionnaires on diet (food frequency [FFQ], summarized with Healthy Eating Index [HEI] and My Pyramid Equivalents [MPE]) and food/physical activity policies (F/PA-P, scales and individual items) were used. A subset of participants wore an accelerometer for at least 7 days (minutes/day moderate-vigorous PA [MVPA]). We measured height/weight converted to gender-specific body mass index (BMI)-for-age z-scores. Multi-level regression was used to determine associations adjusting for within-school clustering and BMI-for-age z-scores.

Results: Recruitment yielded 789 girls in 22 schools: Over half (54.2%) were 6th graders, mean age was 12.2 ± 0.72 years; 90.4% were AA; 51.1% were overweight/obese; mean HEI-2005 score was 60.8 ± 7.7. Mean minutes/day spent in MVPA was 42.0 ± 28.7 (n = 560). F/PA policies scales were not associated with MVPA or diet. Access to the school for PA on weekends (26.6% endorsed) was associated with MVPA (β = 7.7, P = .008); access to water at school (58%) was marginally associated with HEI (β = 0.38, P = .096); teachers rewarding with food (35.3%) was associated with added sugar (β = 1.60, P < .001).

Conclusions: Three individual policies (school access for weekend PA, access to school water, and unhealthy reward mechanisms) are associated with diet and PA among low-income, urban, AA adolescent girls. The relationship between wellness policy implementation (perceived and real) needs further examination to inform policymakers of strategic and effective approaches to promoting school wellness.

1 College of Medicine, Department of Obstetrics and Gynecology 2 College of Nursing, University of Illinois at Chicago P-26: Long-acting Reversible Contraception for Adolescents: Addressing the Provider Barrier

Background and Objective: Implantable and intrauterine contraception (IUD) methods, also known as long-acting reversible contraception (LARC), are highly effective but under-utilized by adolescent women. Research on barriers to LARC use among adolescents has focused primarily on family physicians' and obstetrician gynecologists' knowledge and practices. To more fully understand barriers to use, it is important to include a broader range of providers, especially pediatricians—who provide care to a substantial proportion of adolescents. The objective was to compare contraception-related knowledge, attitudes, and practices across provider specialties and describe perceived barriers to LARC provision.

Methods: A cross-sectional study of family physicians, pediatricians, obstetrician gynecologists, and certified nurse midwives from Chicago-area hospitals was conducted. An online, electronic mail survey, with up to four reminders, was sent to 211 providers, and 77 surveys were received (34% response rate). Analyses were conducted using cross-tabs and ANOVA.

Results: Despite reporting similar numbers of adolescent visits, pediatricians were less likely than other providers to ask adolescents about contraception (P = .01). Knowledge about adolescents' eligibility for LARC was high and did not differ by specialty. However, only one-half (51%) and one-third (36%) of providers recommended IUDs or implants to adolescents, respectively. Compared with other providers, pediatricians reported less LARC-specific knowledge (P < .05) and comfort (P < .05) with counseling. Although cost and time were not identified barriers, perceived lack of patient interest was the most commonly reported (54%) barrier to providing LARC.

Conclusions: Provision of LARC to adolescents remains low. Interventions should address providers' attitudes and focus on patient-provider communication. Efforts that target pediatricians are particularly needed.

1 Institute for Social Research, University of Michigan 2 Department of Obstetrics and Gynecology; Institute for Social Research, University of Michigan P-27: The Effect of Mental Health Symptoms on Young Women's Risk of Unintended Pregnancy

Background and Objective: Depression and stress have been linked with poor contraceptive behavior, but whether existing mental health symptoms influence women's subsequent risk of unintended pregnancy is unclear.

Methods: We prospectively examined the effect of depression and stress on young women's 1-year unintended pregnancy risk. We used panel data from a longitudinal study of 992 U.S. women ages 18 to 20 years, 97% of whom reported a strong desire to avoid pregnancy. Weekly journals measured relationship, contraceptive, and pregnancy outcomes. We examined 27,572 journals from 940 women over the first year. Our outcome was self-reported pregnancy. At baseline, we assessed moderate/severe depression (CESD-5) and stress (PSS-4) symptoms. We estimated the effect of baseline mental health symptoms on pregnancy risk with discrete-time, mixed-effects, proportional hazard models using logistic regression.

Results: At baseline, 24% and 23% of women reported moderate/severe depression and stress symptoms, respectively. Ten percent of women became pregnant during the study. Rates of pregnancy were higher among women with baseline depression (14% vs. 9%, P = .04) and stress (15% vs. 9%, P = .03) compared to women without symptoms. In multivariable models, the risk of pregnancy was 1.6 times higher among women with stress compared to those without stress (RR 1.6, CI 1.1–2.7); the risk was even higher among women with comorbid stress and depression symptoms (RR 2.1, CI 1.1–3.8).

Conclusions: Women with stress and especially comorbid mental health symptoms had an elevated risk of unintended pregnancy over 1 year. We are further investigating women's time-varying mental health symptoms throughout their unintended pregnancy experiences.

1 Yale University School of Medicine 2 Department of Psychology, University of South Carolina P-29: Examining Direct and Indirect Pathways Between Psychological, Physical, and Sexual IPV Victimization, Avoidance Coping, and Mental Health and Substance Use Problems Among Women Experiencing Bidirectional IPV

Background and Objective: Mental health and substance use problems are highly prevalent and frequently co-occur among women who experience intimate partner violence (IPV). This population of women frequently has limited treatment options and access to resources. Investigating avoidance coping strategies, which are often malleable through intervention and are known to influence mental health outcomes among women who experience IPV, is one underrepresented avenue to inform potential pathways for treatment for this large population of women. This study examined the direct and indirect relationships between psychological, physical, and sexual IPV victimization and post-traumatic stress, depression, and alcohol and drug use problems through avoidance coping.

Methods: Our sample was composed of 362 community women who reported both physical IPV victimization and use of physical IPV in their current intimate relationship. Four separate path models were examined, one for each outcome variable.

Results: Unique direct and indirect pathways were found between each type of IPV victimization and each mental health and substance use outcome.

Conclusions: Findings highlight the differential effects of psychological, physical, and sexual IPV on avoidance coping and on mental health and substance use outcomes among women. Findings also suggest that avoidance coping is a critical factor for researchers and clinicians to consider in future research efforts and in the development and delivery of mental health treatments for women experiencing IPV.

This manuscript is the result of work supported, in part, by resources from the National Institutes on Drug Abuse (T32DA019426), the National Institute of Mental Health (T32MH020031), the National Institute of Justice (NIJ2001-WT-BX-0502) the Swiss National Science Foundation (PBLAP1-140055 and PBLAP1-145873), and the University of South Carolina Research Foundation.

1 Department of Molecular Microbiology and The Center for Women's Infectious Disease Research, Washington University in Saint Louis 2 Department of Medicine, National University of Singapore and Genome Institute of Singapore P-31: Positive Selection Analysis Identifies a Role for Arginine Metabolism in Chronic Bladder Colonization by Uropathogenic E. coli

Background and Objective: Urinary tract infections (UTIs) caused by uropathogenic Escherichia coli (UPEC) account for more than 85% of community acquired UTIs, affecting 50% of women during the course of their lifetime. Understanding the molecular basis of UTIs has proven difficult due to severe population bottlenecks, abrogating the feasibility of generic screens in vivo. sTo better understand the bacterial mechanisms needed for development of UTI, we used whole-genome in silico positive selection analysis of clinical UPEC isolates that identified 29 genes under positive selection. We sought to determine the role of these positively selected genes in UPEC pathogenesis.

Methods: We made isogenic mutants in each of the 29 genes in the prototypical UPEC isolate, UTI89, and assessed their ability to cause acute and chronic UTIs in mouse models.

Results: Mutations in 7 positively selected genes demonstrated competitive colonization defects in our murine UTI models, including genes with functional roles in outer membrane permeability, small molecule efflux, iron uptake, DNA repair, protein localization, tRNA modification and arginine metabolism. Specifically, the ornithine transcarbomylase gene argI, necessary for arginine biosynthesis, demonstrated a strong competitive colonization defect, suggesting a role for arginine metabolism in urinary tract colonization. Further mutational analysis of the gene in both the arginine anabolic and catabolic pathways revealed roles for both the synthesis and breakdown of arginine in successful bladder colonization.

Conclusions: These results reveal that positive selection analysis effectively identifies genes with critical roles in UPEC UTIs and that arginine metabolism is critical for competitive chronic colonization of the bladder.

1 Department of Epidemiology, Boston University School of Public Health 2 Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine P-32: Gender Differences in Tuberculosis Rates Among Older Adults in the United States

Background and Objective: Older adults (≥65 years) are at increased risk for tuberculosis disease (TB). There are 40% more older women than men in the U.S., and about 75% of long-term care facility (LTCF) residents are women. The objective of the study was to examine rates and identify risk factors for TB among older adults in the U.S.

Methods: Average rates and rate ratios (RR) for TB by gender, age group, and LTCF residence were calculated using Centers for Disease Control and Prevention TB case reports and Census Bureau data.

Results: Older adults accounted for 21.9% of TB cases in the U.S. between 1993 and 2008. Rates per 100,000 declined from 11.8 in 1993 to 4.5 in 2008 in older women and from 26.3 to 9.0 in older men. Over the 16 years, older men had higher TB rates than older women (RR 2.1; 95% CI, 2.1–2.2). Adults at or over 85 years of age had higher rates per 100,000 than those aged 65 to 74 (9.5 and 6.5 in women and 25.6 and 13.4 in men, respectively). Older people in LTCFs are also at higher risk for TB than those in the community (RR 2.3; 95% CI 2.2–2.3).

Conclusions: Although rates are declining, elimination of TB in the U.S. will require addressing the substantial burden of disease among older people, including older women and those in LTCFs. Studies are needed to determine whether the gender differences in TB rates reflect dissimilar rates of latent TB infection or biological factors that promote reactivation of latent TB in men.

1 Mayo Clinic 2 Oregon Health & Science University P-33: Factor Analysis of the Longitudinal Maternal Immune Response to Pregnancy

Background and Objective: The maternal immune response to pregnancy is increasingly recognized as a dynamic phenomenon. Few studies have used a high-throughput, longitudinal approach to identifying the key immune components associated with and possibly responsible for the dynamic changes.

Methods: To better understand which cytokines and growth factors exhibit patterns of fluctuation during pregnancy, we tested thawed longitudinal serum samples from 16 healthy primigravidas on multiplex cytokine arrays. We determined protein levels of 42 cytokines and growth factors, using the Millipore® MILLIPLEX MAP Human Cytokine/Chemokine Kit. An average of 18 samples, from the first trimester through parturition, were tested in this study. To incorporate within-subject correlation and to identify those factors demonstrating a change in concentration over time, we normalized the data by (log(1 + fold change from baseline value)). We identified two “factors” (independent clusters of variables that can help identify physiologic relationships) consisting of 3 cytokines each that could explain 80% of the variance in the data.

Results: Factor 1 accounted for 43.2% of the variation and consisted of proteins important for myeloid homeostasis—VEGF, fractalkine, and GM-CSF. Factor 2 consisted of IL-1b, IL-15, and IL-13—cytokines important for Th1/Th2 homeostasis.

Conclusions: Factor analysis helps to reduce dimensionality of data without a priori assumptions about relationships and can assist in hypothesis generation for testing of previously unobserved interconnectedness of variables. In our longitudinal study of 16 healthy primigravidas, we identified a potential regulatory network involving VEGF, GM-CSF, and fractalkine, which appears to be independently affected by the pregnancy state.

1 Department of Pathology, Duke University 2 Department of Radiation Oncology, Duke University 3 Department of Molecular Genetics, Duke University P-34: Up-regulation of Fas Expression in Human Breast Carcinomas Treated With Preoperative Radiation

Background and Objective: Clinical data suggest that breast cancer subtypes respond differently to therapeutic radiation. We previously identified a link between subtype-specific radiation-induced gene expression and radiation sensitivity. Here we extend our initial cell culture findings and evaluate a potential biomarker of radiation sensitivity in tissue from early stage breast cancer patients treated on a novel clinical trial evaluating preoperative radiation.

Methods: Annexin V/PI staining was used to evaluate the downstream impact of radiation-induced Fas induction on tumor cell apoptosis in a subset of breast cancer cell lines. Immunohistochemistry (IHC) was performed using a Fas antibody (Santa Cruz sc715) on human breast cancer tissue before and after radiation. A histoscore was created using the average membrane and cytoplasmic staining intensity multiplied by the percentage of positive cells. Paired Fas expression data was available for 16 of 32 cases.

Results: Apoptosis was significantly increased in response to radiation for 3 of the 4 cell lines tested. The degree of induction and percent cell death appear to correlate with radiation sensitivity. Furthermore, IHC confirmed the up-regulation of Fas after radiation in human tumor tissue. The mean combined post-treatment histoscore was about twice as high as the mean pre-treatment score. Six of 16 paired cases showed significant Fas up-regulation after radiation.

Conclusions: Apoptotic cell death is increased after radiation to a greater extent in cell lines known to exhibit Fas induction. We have previously linked this induction to radiation sensitivity in cell culture and now confirmed that this phenomenon exists in breast cancer patients.

1 Brigham and Women Hospital and Harvard Medical School 2 Joslin Diabetes Center and Harvard Medical School 3 University of Michigan School of Public Health P-35: Association Between Phthalate Metabolites in Pregnancy and Risk of Gestational Diabetes

Background and Objective: Studies show higher phthalate levels are associated with increased type 2 diabetes risk, likely through binding and activation of peroxisome proliferator-activated receptors. Yet, few have examined the association between phthalate metabolites and gestational diabetes (GDM) risk. The purpose of the study was to evaluate the associations between urinary phthalate metabolites and GDM risk, as well as pre- pregnancy weight (PPwt), gestational weight gain (GWG), and glucose levels.

Methods: We analyzed 350 women who participated in the Predictors of Preeclampsia cohort study. Seven urinary phthalate metabolites were measured at 4 points throughout pregnancy and divided into quartiles (reference lowest concentration). GDM was defined by Carpenter-Coustan criteria. PPwt, GWG and glucose levels were categorized as less than vs. greater than the median. We used logistic regression to calculate odds ratios and 95% confidence intervals adjusting for maternal age.

Results: Phthalate concentrations remained similar throughout pregnancy; however, they varied by race/ethnicity (P < .003). Women with the highest first trimester levels of mono-(3-carboxypropyl) phthalate had 2 times the odds of greater-than-median PPwt (95% CI: 1.09–3.71). Women in the second quartile of mono-benzyl phthalate (MBzP) had 2.32 times the odds of greater-than-median GWG and 1.62 times the odds of greater glucose (95% CI: 1.17–4.59 and 0.78–3.36, respectively). Higher MBzP levels were associated with four-fold increased odds of GDM (95% CI for fourth quartile: 0.52–36.37).

Conclusions: Certain phthalates were associated with PPwt, GWG, and glucose levels, with some indication of elevated GDM risk. If replicated, lowering exposure to certain phthalates may reduce GDM risk and potentially women's future type 2 diabetes risk.

1 Brigham and Womens Hospital 2 University of Michigan School of Public Health P-36: Bisphenol A in Pregnancy and Risk of Gestational Diabetes

Background and Objective: Studies show a positive association between Bisphenol A (BPA) and type 2 diabetes, likely through its ability to bind to estrogen-related receptor and peroxisome proliferator–activated receptor. Yet, few have evaluated the association between BPA and gestational diabetes (GDM). The objective of this study was to evaluate the association between BPA levels during pregnancy and risk of high pre-pregnancy weight, gestational weight gain, and GDM.

Methods: A total of n = 298 women who delivered at term and were participants of the Predictors of Preeclampsia study had BPA measurements and had data on GDM diagnosis. BPA was divided into quartiles. Pre-pregnancy weight was measured using weight at first trimester (8–10 weeks gestation). Gestational weight gain was measured as the difference between weight at delivery and pre-pregnancy weight. Both were categorized as less than or as greater than or equal to the median. GDM was defined using the Carpenter-Coustan criteria. We used logistic regression to calculate odds ratios and 95% confidence intervals, adjusting for maternal age.

Results: BPA levels remained similar across the first 2 trimesters of pregnancy. Women who had higher first trimester BPA levels were twice as likely to have greater-than-or-equal-to-median pre-pregnancy weight (95% CI for second quartile, 1.14–3.93). There was no association between BPA and gestational weight gain. However, women with the high first trimester BPA levels had over 5-fold increased odds of GDM (OR for fourth quartile: 5.92; 95% CI, 1.28- 27.60).

Conclusions: BPA was associated with increased odds of high pre-pregnancy weight and GDM, but not with gestational weight gain. If these findings are replicated, women may benefit from reductions in BPA exposure before and during pregnancy to reduce risk of GDM.

1 Department of Pediatrics, Northwestern University Feinberg School of Medicine 2 Northwestern Comprehensive Center on Obesity, Northwestern University Feinberg School of Medicine 3 Department of Preventive Medicine, Northwestern University Feinberg School of Medicine 4 Department of Medicine, Northwestern University Feinberg School of Medicine P-37: In Women With Normal Glucose Levels on Fasting 75-g Oral Glucose Tolerance Tests, Excessive Gestational Weight Gain Was Not Associated With Increased Neonatal Adiposity

Background and Objective: Excessive gestational weight gain (GWG) among American women has steadily increased over the past 20 years, in parallel with the increasing prevalence of maternal obesity. Evidence suggests that newborns with increased adiposity have increased risk of childhood obesity. Whether excessive GWG is associated increased neonatal adiposity requires further study. The objective was to determine whether weight gain above Institute of Medicine–recommended amounts in an ethnically diverse obstetric population is associated with increased neonatal adiposity.

Methods: Women carrying singleton pregnancies with normal glucose levels on 2-hour fasting 75-gram oral glucose tolerance tests (OGTT) who delivered full term were enrolled. Gestational weight gain was calculated from weights measured at first and last prenatal visits. Neonatal adiposity was measured by air displacement plethysmography at 24 to 72 hours of life.

Results: Preliminary analysis of 100 participants (BMI categories: 3% underweight, 58% normal weight, 21% overweight, and 18% obese) demonstrated no difference in body fat of neonates born to mothers who met (34%) or exceeded (44%) GWG guidelines. The 22% of women who gained less than GWG guidelines had neonates with significantly lower median body fat (8.3%) compared with neonates of mothers who met (11.1%, unadjusted P = .01) or exceeded guidelines (11.2%, unadjusted P < .01). Mean glucose levels (sd) on 75-gram OGTT were as follows: fasting: 76.3 (5.8); 1 hour: 115.8 (27.1); 2 hours: 101.3 (19.5) mg/dL, all lower than thresholds of 92, 180, and 153 mg/dL, respectively, recommended by the International Association of Diabetes and Pregnancy Study Groups.

Conclusions: In this cohort of women with normal 75-gram oral glucose tolerance tests, excessive GWG was not associated increased neonatal adiposity.

1 Department of Medicine, University of Colorado Denver 2 Bolivian Institute of High Altitude Biology 3 Department of Obstetrics and Gynecology, University of Colorado Denver P-38: Inhibition of Peroxisome Proliferator Gamma (PPARγ): A Potential Link Between Chronic Maternal Hypoxia and Impaired Fetal Growth

Background and Objective: Chronic maternal hypoxia impairs fetal growth and increases the incidence of intrauterine growth restriction (IUGR). To identify the mechanisms underlying these hypoxia-related effects, we evaluated whether exposure to chronic hypoxia during pregnancy alters maternal gene-expression patterns relative to normoxic pregnancy and, if so, to define the dominant genes and pathways involved.

Methods: Gene expression profiles were generated using NimbleGen Human Gene Expression microarrays for 79 peripheral blood mononuclear cell samples collected from 43 women residing at high (n = 25, 3600–4300 m) or low (n = 18, 300 m) altitude in the non-pregnant state or during pregnancy (20 or 36 weeks). Transcriptional differences between altitudes were detected using Limma, Lme4, and Car packages in R; the relationship of such differences to biological processes and pathways was assessed in IPA.

Results: Gene expression differed at high versus low altitude in the non-pregnant state (43 genes), at 20 weeks of pregnancy (59 genes) and at 36 weeks of pregnancy (985 genes). Several genes of known pathologic significance for IUGR varied between altitudes during pregnancy but not in the non-pregnant state. Among the pathways enriched by these genes was the peroxisome proliferator-activated receptor gamma (PPARγ) signaling pathway. Transcriptional changes were consistent with the negative regulation of PPARγ at high versus low altitude during pregnancy, but not in the non-pregnant state.

Conclusions: Pregnancy magnifies the influence of environmental hypoxia on gene expression in ways that may be related to fetal growth. Given its involvement in the regulation of inflammation, vascular function, and glucose metabolism, we consider PPARγ to be an important candidate for future study.

1 Department of Kinesiology, Michigan State University 2 Department of Epidemiology and Biostatistics, Michigan State University P-40: Associations Among Domains of Maternal Physical Activity and Lipid Levels During Pregnancy

Background and Objective: High and low lipids during pregnancy are associated with poor birth outcomes. Higher physical activity (PA) has been related to lower lipids in early pregnancy, but these relations have not been examined later in pregnancy, when lipids naturally increase. The objective was to examine associations between PA domains and lipids among pregnant women in the 2nd and 3rd trimesters.

Methods: Women completed the Pregnancy PA Questionnaire. Percentages of total MET-min/wk (%PA) spent in Household, Work, and Exercise domains were calculated. A fingerstick blood sample determined non-fasting levels of total (TC), high- (HDLc), and low-density-lipoprotein cholesterol (LDLc) and triglycerides (TG). Partial correlations examined relations among %PA in each domain and lipids, controlling for total MET-min/wk. Multiple linear regression examined relations among tertiles of %PA in all domains and TC.

Results: There were 69 participants (2nd trimester, n = 40; 3rd trimester, n = 29). No significant relations were observed among 3^rd-trimester women. Among 2^nd-trimester women, Household accounted for 49%; Work, 19%; and Exercise, 2% of total PA, on average. Household %PA (r = −0.39) and Work %PA (r = 0.42) were related to TC (P < .05). No significant relations were found for other lipids. In regression analyses including all %PA domains, only tertiles of Household %PA was associated with significantly lower TC (β = −27.5, P < .05, adjR² = 0.21).

Conclusions: In this sample of low-income women, Household %PA accounted for most of the total PA and was associated with lower TC levels in the 2nd trimester. Pregnancy-related increases in lipids in the 3rd trimester may overwhelm any effect of PA.

1 University of Illinois at Chicago 2 University of Chicago P-41: A Need for Culturally Tailored Group Prenatal Programs for Obese Minority Women to Meet Gestational Weight Gain Recommendations

Background and Objective: Interventions have not been effective in assisting obese women to meet gestational weight gain (GWG) recommendations. Culturally tailored prenatal programs may be needed. The objective of the study was to investigate minority women's perceptions about obesity and GWG and their motivations and barriers to improving health behaviors during pregnancy.

Methods: Sixteen primarily non-Hispanic black pregnant women with a pre-pregnancy body mass index greater than 30 kg/m² receiving prenatal care at an inner-city hospital–based clinic participated in focus groups. Discussion topics included GWG goals, body image, health behaviors, stress management, and group prenatal care.

Results: Women frequently stated a target GWG of greater than 20 pounds. They expressed fear of gaining weight, but also frustration when told to restrict weight gain. Women described a body image not in line with clinical recommendations: “200 pounds is not that big”; “[to] maintain my weight between 250 and 245 would be good.” They avoided the term “obese” and more commonly used “thick.” They were interested in learning more about nutrition and in culturally specific healthy cooking resources. Women stated they would enjoy massage and exercise in a group setting, though definitions of “exercise” varied. There were mixed feelings about support systems; family members could be helpful, but generational differences posed challenges (grandmothers would “curse them out” for exercising during pregnancy). As a result, most felt the need to “encourage myself” and “do this for me and the baby.”

Conclusions: Culturally tailored programs that use acceptable terms for obesity, provide education regarding healthy eating and safe exercise, and encourage appropriate support from social networks may be effective in addressing GWG in obese minority women.

1 Division of Health Policy and Management, University of Minnesota School of Public Health 2 The Children's Hospital of Philadelphia P-42: Born Too Soon: Trends in Childbirth Before 39 Weeks Gestation Without Medical Indication, 1995–2009

Background and Objective: Childbirth is the most common and costly reason for hospitalization in the U.S. There is increasing clinical and policy attention to labor induction and cesarean delivery occurring without medical indication between 37 and 39 weeks of completed gestation (“early term” deliveries). The objective was to measure prevalence, change over time, and individual characteristics associated with early term nonindicated delivery.

Methods: We conducted a retrospective, longitudinal analysis using linked hospital discharge and birth certificate data for all 7,296,363 full-term, uncomplicated births that occurred between 1995 and 2009 in 3 states: Missouri, California, and Pennsylvania. The primary outcome is early term nonindicated delivery, either medical induction of labor or cesarean delivery, and calculated among all uncomplicated deliveries between 37 and 44 weeks gestation. Gestational age is from birth certificates, and medical procedures and indications are from hospital discharge records. Secondary outcomes include infant prolonged length of stay and respiratory distress.

Results: Across all uncomplicated births, the rate of early term nonindicated delivery was 3.18%, increasing from 2.12% in 1995 to 3.74% in 2009. After controlling for clinical, sociodemographic, and hospital factors, the risk of having a nonindicated delivery before 39 weeks was 78% higher in 2009 compared with 1995 (hazard ratio (HR) = 1.78; 95% CI [1.73–1.82]). Factors associated with greater odds of early term nonindicated delivery included advanced maternal age, white race, higher education levels, private health insurance, and delivering at smaller volume or nonteaching hospitals. There were racial/ethnic differences in the risk of early term nonindicated birth by mode of delivery, with nonwhite women having substantially lower rates of nonindicated induction, compared with white women; however, black women had higher rates of nonindicated cesarean delivery (HR = 1.26 [1.23–1.29]) compared with white women. Early term nonindicated delivery was associated with 25% greater odds of prolonged length of stay (AOR = 1.25 [1.23–1.27]) and with 52% greater odds of respiratory distress (AOR = 1.52 [1.49–1.56]).

Conclusions: Early term nonindicated delivery has increased over the past 15 years. In 2009, nearly 4% of all full term infants without complications were born too soon in the U.S., with no medical indication, and these births were associated with adverse infant outcomes.

1 University of Alabama 2 University of Texas Medical Branch 3 University of Texas M.D. Anderson Cancer Center P-44: Preferences of Breast Cancer Survivors for Traditional and New Media Delivery of Health Promotion Interventions

Background and Objective: Internet-delivered health promotion interventions are increasingly implemented among breast cancer survivors, but little is known about their acceptability and uptake. This questionnaire study assessed cancer survivors' interest in health promotion interventions delivered in clinics, by telephone, or by computer or smartphone.

Methods: Cancer survivors (breast, colorectal, and prostate) were sent a brief survey by mail. Of 1,871 who received the survey, 1,053 completed and returned it. Interest in health promotion interventions using various delivery methods (clinic, telephone, computer, and smartphone) was assessed. Frequencies and chi squared tests were used to investigate differences across cancer sites.

Results: Participants were mean 63 (11, SD) years old and 4.6 (3.1, SD) years from diagnosis; 55% were female. Most (50.1%) were breast cancer survivors; 39.8% were prostate and 10.1% colorectal cancer survivors. Breast cancer survivors were more interested in all intervention modalities than were survivors of other cancers (P < .001 for clinic, telephone, and computer; P = .016 for smartphone). Their interest was highest for computer-based interventions (37% extremely or very interested); 25% were extremely or very interested in clinic-based programs, and 23% were extremely or very interested in telephone-based programs. Smartphone-based interventions produced the least interest, with only 12%.

Conclusions: Breast cancer survivors are interested in technology-mediated interventions but prefer computers to smartphones. Further investigation is needed to determine whether greater reported interest leads to improved uptake or behavior change.

1 Department of Pediatrics and 2 Department of Molecular Microbiology, Washington University School of Medicine P-55: A New Murine Model of Urinary Tract Infection Identifies Sex Differences in Pathogenesis

Background and Objective: Between the ages of 2 and 60 years, community-onset urinary tract infection (UTI) occurs almost exclusively in females, a sex predilection attributed solely to anatomical differences. Technical challenges in catheterizing male mice have heretofore precluded extensive study of male UTI and sex differences in these model hosts. The objective was to develop a model of UTI to infect both male and female mice and define sex differences contributing to sexual disparity in UTI.

Methods: We developed a novel mini-surgical inoculation technique that yields reliable infection of the upper and lower urinary tract by uropathogenic Escherichia coli (UPEC), without peritonitis or systemic complications. Following infection, outcomes were analyzed by tissue bacterial load and other measures.

Results: Male C57BL/6 mice developed significantly higher UPEC titers in the kidney at 24 hours post-infection (hpi) and 2 weeks post-infection (wpi) compared with females. Following resolution of acute infection, female C57BL/6 showed significantly more bacteria in chronic reservoirs in the bladder (a seed for recurrent UTI). In the C3H/HeN background, male mice had higher bladder titers than females at 6 hpi and 2 wpi. By LacZ staining and confocal microscopy, there was no difference in the number or structure of intracellular bacterial communities in the bladder between males and females. Most striking, males showed significantly higher renal bacterial loads at all time points examined, and a much higher incidence of renal abscesses.

Conclusions: Our mini-surgical model of UTI will be useful in identifying and characterizing sex differences in pathogenesis, host responses, and susceptibility to these common infections.

1 Department of Nutrition, University of North Carolina 2 Department of Psychiatry and Behavioral Sciences, Duke University 3 Department of Psychiatry, University of Connecticut Health Center P-57: Use of Supplemental Calcium Is Associated With Brain Lesion Volumes in Older Adults

Background and Objective: Ischemic brain lesions promote several catastrophic conditions, including depression, stroke, and dementia, in older adults. Arterial calcification and dietary calcium intakes have been associated with brain lesions. Use of calcium supplements has been linked to negative cardiovascular outcomes. The objective of the study was to investigate the association between use of calcium-containing dietary supplements and brain lesion volumes in older adults.

Methods: Food and supplemental calcium intakes were assessed, using a Block 1998 food frequency questionnaire, in 227 older adults who were participating in a study of depression. Participants with supplemental calcium intakes above zero were categorized as supplement users. Total brain lesion volume was determined from magnetic resonance imaging (1.5 Tesla), using a semi-automated segmentation technique. Subjects were aged 60 or older.

Results: An analysis of covariance model showed that supplement users had greater lesion volumes than non-users, even after controlling for dietary food calcium, age, sex, race, education, energy intake, depression, and hypertension (calcium supplement use: â = 0.34; SE = 0.10; F9,217 = 10.98, P = .0011).

Conclusions: This study indicates that the use of calcium-containing dietary supplements, even low dose supplements, by older adults may be associated with greater lesion volumes. Longitudinal studies are warranted to determine if this relationship is a causal one. Potential adverse effects of high intakes of calcium need to be elucidated.

1 University of CA, Davis 2 Kaiser Permanente, Sacramento, CA P-59: HIV-associated Mucosal Dysfunction Is Augmented by Deregulation of Estrogen Receptor Expression

Background and Objective: HIV disease progression correlates with immune activation, which is higher in women compared to men, in the blood and gut. Compromised mucosal integrity allows for increased microbial translocation in women, which stimulates systemic immune activation. Estradiol (E2)–estrogen receptor β (ER-β) interaction plays an important role in the maintenance of mucosal integrity. The effects of HIV infection on this process are unknown. The objective of the study was to determine if HIV infection is associated with decreased ER-β levels in the epithelial monolayer of the gut mucosa.

Methods: Plasma E2 levels in HIV positive (HIV+; n = 13) and HIV negative (n = 13) healthy women were measured using ELISA, gut epithelial ER-β levels by Real-time PCR assay and in vitro epithelial integrity by analysis of the trans-epithelial resistance.

Results: In vitro, epithelial integrity was decreased by 25% in the presence of SIV/HIV. No significant differences were observed in the plasma E2 levels between HIV+ women and age-matched healthy controls. However, a significant decrease in ER-β levels (25%) was observed in HIV+ women and a further decrease to 50% of normal was observed in women on HAART (n = 7). A similar decrease was observed in vitro in epithelial cells grown in the presence of SIV/HIV, and topical application of exogenous E2 protected the intestinal mucosa from loss of integrity and restored expression of ER-β.

Conclusions: These preliminary data suggest that HIV infection is associated with decreased ER-β levels in the gut epithelium and increased microbial translocation. Low levels of exogenous E2 may help overcome the HIV-associated decline in epithelial integrity in women.

1 Department of Public Health Sciences, University of California, Davis 2 Department of Pediatrics, University of California, Davis 3 Department of Psychiatry and Behavioral Sciences, Medical Investigation of Neurodevelopmental Disorders (MIND) I, University of California, Davis P-61: Maternal Intake of Supplemental Iron and Risk for Autism Spectrum Disorders

Background and Objective: Iron deficiency affects 40% to 50% of pregnancies. Iron is critical for early neurodevelopmental processes, including ones that are dysregulated in autism spectrum disorders (ASD). Our objective was to examine maternal supplemental iron intake in relation to ASD risk.

Methods: Children enrolled in the CHARGE population-based case-control study from 2003 to 2009 with diagnoses of ASD (n = 510) or typical development (TD, n = 341) confirmed at the UC Davis MIND Institute using standardized clinical assessments were included. Mean daily iron intake was quantified based on dose, brands, and frequency of use reported in parental interviews for prenatal vitamins, multivitamins, iron-specific supplements, other supplements, and cereal for each month from 3 months before through the end of pregnancy and during breastfeeding (index period). Associations with ASD were evaluated using logistic regression.

Results: Compared to mothers of TD children, mothers of children with ASD were significantly less likely to report taking iron-specific supplements any time during the index period after adjustment for confounders (OR = 0.62, 95% CI 0.4, 0.9; P = .01). Mean (SD) daily iron intake was also lower for mothers of children with ASD (51.7 [34.0] versus 57.1 [36.6] mg/d, P = .04). Odds of ASD declined as iron intake increased (Ptrend = .02). Compared to the lowest quintile of iron intake (<30 mg/d), the highest quintile (86 + mg/d) was associated with significantly lower adjusted ASD risk (OR = 0.55, 95% CI 0.34, 0.89).

Conclusions: This is the first study to show a protective association between maternal supplemental iron and ASD. Further studies of this association and potential prevention strategies are warranted.

1 Department of Radiation Oncology, Washington University School of Medicine 2 Department of Pathology, Washington University School of Medicine 3 Washington University School of Medicine P-62: A Next Generation Sequencing (NGS) Method to Identify HPV16 Integration Sites in Human Cervical Cancer

Background and Objective: Human Papilloma Virus (HPV) DNA can integrate in the tumor genome and cause mutagenesis. Current methods to detect HPV integration sites in human DNA are labor intensive. The study's objective was to design an NGS assay to determine HPV16 integration sites with single nucleotide accuracy.

Methods: DNA was obtained from four pretreatment cervical biopsies and assessed for HPV16 viral copy number using RT-PCR. Sample DNA was prepared and ligated to standard Illumina sequencing primers and then hybridized with synthetic 120 bp oligonucleotide HPV16 capture probes designed to span the entire 8 kb of the HPV16 genome (NC_001526.2). Captured DNA was indexed by limited-cycle PCR and sequenced on a single HiSeq2000 lane using 2x101bp reads. The resulting sequencing data was aligned to the human genome (hg19) and the HPV16 genome. Integration sites were identified by chimeric read pairs that spanned both the HPV and the human genomes using ClusterFASTQ. Average HPV16 sequence coverage was >30,000x in all cases.

Results: HPV16 viral genome deletions in the E1 and L1 regions were identified in 2 of 4 cases, suggesting inactive virus. A viral integration site was identified in 1 of 4 cases and mapped to the SPDYE3 gene on chromosome 7. This region included a ∼7 kb deletion of exonic and intronic human (host) sequence.

Conclusions: Here we show that HPV16 integration sites can be rapidly identified using a combination of next generation sequencing and informatics. Large-scale studies of the HPV genome and viral integration sites in tumor DNA may identify new mechanisms of HPV-associated carcinogenesis.

1 Penn State College of Medicine 2 Pennsylvania State University P-63: Risk Factor Differences for Female Adolescent Iron Deficiency as Defined by Body Iron and Ferritin Models

Background and Objective: Body iron (BI) has been proposed as an alternative to the traditional ferritin model (FM) for diagnosis of iron deficiency. The objective was to examine risk factors for iron deficiency by BI versus FM among females 12 to 18 years old using data from the National Health and Nutrition Examination Survey (NHANES), 2003–2006 (n = 1,747).

Methods: Iron deficiency by FM is defined as having 2 of 3 laboratory values (transferrin saturation, ferritin, erythrocyte protoporphyrin) out of range. BI measures iron deficiency with a formula involving transferrin receptor and ferritin. Bivariate analyses examined associations between social and behavioral risk factors from NHANES and a diagnosis of iron deficiency by BI versus FM, based on NHANES laboratory data.

Results: Older age (OR 1.17, 95% CI 1.05–1.29, P = .003), non-white race (1.92, 1.24–2.99, P = .004), more physical activity (2.01, 1.05–3.87, P = .036), and Spanish vs. English language of interview (1.94, 1.19–3.18, P = .008) increased the odds of iron deficiency measured by FM. Less food consumption in the FM was protective (0.43, 0.23–0.80, P = .008). In contrast, older age (1.22, 1.07–1.39, P = .004), non-white race (1.75, 1.04–2.95, P = .035), and a past pregnancy (4.08, 1.14–14.62, P = .031) increased the odds of iron deficiency measured by BI. In both models, use of Depo-Provera was protective.

Conclusions: Risk factors for female adolescent iron deficiency vary by the method of measuring iron deficiency, complicating the identification of high-risk individuals for screening. Future work will assess which combination of risk factors better predicts clinically relevant iron deficiency.

1 Department of Physiological Nursing, University of California, San Francisco 2 Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco 3 Department of Physical Therapy, Samuel Merritt University P-65: Mechanosensitivity in the Upper Limb Following Breast Cancer Treatment

Background and Objective: Nerve injury may result from breast cancer (BC) treatment (i.e., positional traction, forceful retraction, laceration, or contusion during surgery; or entrapment/compression from fibrosis and scarring). Peripheral nerves may become “sensitized” when subjected to trauma and become less tolerant to movement, resulting in pain and limited mobility. The goal of the study was to evaluate neural mechanosensitivity through elbow extension range of motion (ROM) during upper limb neurodynamic testing (ULNT) post BC treatment.

Methods: 145 women post BC treatment and 25 healthy controls (HC) participated. Bilateral ULNT elbow ROM was measured and symptoms assessed. The BC group was further divided by presence or absence of pain (+/-PAIN) and lymphedema (+/-LYMPH). T-tests, ANOVA, chi-square, and non-parametric tests were used to test for significance of differences.

Results: ULNT elbow extension ROM for the BC group was 6.9° less on the unaffected limb compared to the dominant limb of the HC group (95% CI 1.2°, 12.6°) and 8.8° less on the affected limb compared to the non-dominant limb of the HC group (95% CI 2.9°, 14.6°). Compared to the HC group, ULNT elbow extension ROM was 12.8° less for the unaffected limb (P = .004) and 16.6° less in the +PAIN/+LYMPH group for the affected limb (P < .001). Symptoms were more frequent and more intense in the affected limb compared to the unaffected limb in women with BC (P < .05).

Conclusions: Women with lymphedema and pain post BC treatment have greater alterations in neural mechanosensitivity and limited ULNT elbow extension. Neural mechanosensitivity should be assessed following BC treatment, particularly for women with pain and lymphedema.

1 Univerisity of California, Davis 2 Vanderbilt University 3 United States Department of Agriculture, Western Human Nutrition Research Center P-66: Compared With Aspartame, Consumption of High Fructose Corn Syrup– and Sucrose-sweetened Beverages Increases Triglycerides, Cholesterol, Non-HDL cholesterol, Apolipoprotein-B, and Uric Acid in Young Men and Women

Background and Objective: The risk of cardiovascular disease is higher in men than in pre-menopausal women; however, the etiology of this is unclear.

Methods: We compared lipid responses in young men and women who consumed beverages sweetened with high fructose corn syrup (HFCS), sucrose, or aspartame for 2 weeks. In a parallel, double-blinded study, young adults (18–40 years of age) were assigned to beverage groups matched on sex, BMI, and fasting triglycerides. During inpatient baseline testing over 3.5 days, participants consumed energy-balanced diets containing 55% of energy requirements (EReq) as complex carbohydrates. For 12 outpatient days they consumed usual diets and 3 servings/day of HFCS-, sucrose- (providing 25% EReq), or aspartame-sweetened beverage (n = 24/group). Participants then consumed energy-balanced diets, which included the experimental beverages, during inpatient testing.

Results: HFCS and sucrose sweetening increased plasma levels of triglycerides, cholesterol, apolipoprotein B, apolipoprotein CIII, and uric acid compared with aspartame. These sugar-induced increases of fasting triglycerides (men: 18% ± 3%; women: 7% ± 5%, P < .05 for sex difference) and mean triglycerides from 32 samples collected over 24 hours (men: 16% ± 3%; women: 9% ± 4%, P < .05) were significantly higher in men than women. Postprandial cholesterol (men: 18% ± 4%; women: 11% ± 2%, P = .13 for sex difference), non-HDL-cholesterol (men: 19% ± 6%; women: 12% ± 3%, P = .14), apolipoprotein B (men: 13% ± 3%; women: 13% ± 3%, P = .75), apolipoprotein CIII (men: 22% ± 3%; women: 20% ± 3%, P = .62), and uric acid (men: 13% ± 2%; women: 11% ± 2%, P = 96) were not significantly higher in men than women.

Conclusions: Except for triglycerides, risk factors for metabolic disease were comparably increased in young men and women consuming 25% EReq as sucrose- or HFCS- sweetened beverages for 2 weeks.

1 University of Minnesota 2 University of Pittsburgh 3 Duke-National University of Singapore P-69: Prospective Association Between Mitochondrial Copy Number and Stage of Breast Cancer

Background and Objective: Mitochondrial DNA (mtDNA) copy number in peripheral blood is prospectively associated breast cancer risk when blood was collected within 3 years of diagnosis. Results from a previous retrospective study suggests that breast cancer stage can influence mtDNA copy number in peripheral blood. We evaluated the prospective association between mtDNA copy number in peripheral blood and breast cancer at different stages.

Methods: We utilized data from a previously reported nested case-control study of 88 breast cancer cases with pre-diagnostic blood samples and 252 individually matched controls among participants of the Singapore Chinese Health Study in whom blood was collected within 3 years of breast cancer diagnosis to evaluate the association between mtDNA copy number and breast cancer stage.

Results: Conditional logistic regression analyses showed that a positive association between mtDNA copy number and breast cancer risk only among women with advanced breast cancer (stages III and IV); OR (95% CIs) for 2nd and 3rd tertile of mtDNA copy numbers were 2.41 (0.71–8.13) and 4.28 (1.23–14.83), respectively, compared with the 1st tertile (P _trend = .02). There was no association between mtDNA copy number and breast cancer risk among women with localized breast cancer (stages I and II) (P _trend = .50).

Conclusions: This study supports a prospective association between increased mtDNA copy number and breast cancer risk that is dependent on the stage of breast cancer. Future studies are warranted to confirm these findings and evaluate the utility of mtDNA copy number as a biomarker for early detection of breast cancer.

1 University of Kentucky 2 University of Maryland P-71: Managing the Competing Demands of Low-wage Employment and Breast Cancer Treatment

Background and Objective: Low-wage employment, ever more prevalent in today's economy, offers women minimal autonomy, schedule inflexibility, limited paid time off, minimal health benefits, and economic insecurity. Indeed, these workplace characteristics become even more significant in the event of a breast cancer diagnosis. The goal of the study was to understand how breast cancer survivors employed in low-wage jobs manage treatment within the context of work.

Methods: In-depth, semi-structured interviews were conducted with 24 women in Kentucky who were who were diagnosed with a new, primary breast cancer in the past 3 years and who were employed in low-wage positions (<$15.00/hour) at the time of diagnosis.

Results: At the time of diagnosis, the mean hourly wage was $11.25 (SD = 2.18); 18 of the 24 (75%) women had household incomes of less than $40,000. Retail, healthcare, social assistance, manufacturing, and food services were the most commonly represented industries (n = 19). Over half of the women (n = 13, 54%) continued working during treatment due to financial stress, fiscal necessity, lack of paid time off, and fear of health insurance loss. Women provided detailed explanations of how they managed the competing demands of work and treatment, concurrent with medical and economic challenges. Access to paid time off, Family Medical Leave, and short-term disability; understanding of health insurance benefits; and work environments with supportive supervisors and co-workers influenced treatment-related behaviors.

Conclusions: Management of breast cancer treatment and employment may be complex for women who work low-wage jobs. Future research should focus on employment and healthcare system supports that help women successfully complete breast cancer treatment and maintain employment.

1 Physical Therapy and Rehabilitation Science, University of Kansas Medical Center 2 College of Medicine, Ohio State University 3 Preventive Medicine and Public Health, University of Kansas Medical Center 4 Ellis Fischel Cancer Center, Sinclair School of Nursing, University of Missouri P-72: Systematic Review of Cancer-associated Lymphedema Risk Factors

Background and Objective: Lymphedema is a chronic state of progressive extracellular accumulation with an insidious onset. Cancer-associated lymphedema accounts for the majority of lymphedema cases in the U.S., with incidence rates up to 75% depending on tumor type. The body of knowledge is shifting from interventions to risk reduction strategies and modeling. This systematic review was conducted to determine the strength of evidence regarding patient-related, disease-related, and treatment-related risk factors of lymphedema for various cancer types over the past decade (2003 to 2012).

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 framework was utilized for the systematic review. Multiple databases, including PubMed, CINAHL, and the Cochrane Database of Systematic Reviews, were searched. The initial screen identified articles within the years and topics of interest. Two reviewers assessed full-text articles for eligibility. Then 2 reviewers utilized the quality rating and strength of evidence systems published by the Agency for Healthcare Research and Quality's Evidence-based Practice Centers Program to evaluate 53 risk factors related to lymphedema.

Results: We assessed 112 articles published between 2003 and 2012. Body mass indices (BMI) greater than 30 kg/m² and regional and radical lymph node dissections had high strength of evidence (SOE) scores as risk factors for lymphedema. High SOE scores refuted the role of smoking, diabetes, and strength training in increasing the risk of lymphedema. Moderate SOE scores were reported for 19 risk factors.

Conclusions: Cancer-associated lymphedema is a multi-factorial condition, but higher BMIs and more aggressive cancer treatment may be the best predictors of risk.

1 Penn State College of Medicine 2 Pennsylvania State University P-76: Sex Moderates the Association Between Volume of the Striatum and Interest in Quitting Smoking in Adult Cigarette Smokers

Background and Objective: Compared to male cigarette smokers, female smokers express less interest in quitting and are less confident in their ability to achieve abstinence. Non-human animal research suggests that these effects may be linked to the structure and function of a brain region called the striatum (an area strongly implicated in the development of addiction). The goal of the study was to test the hypothesis that sex differences in the structure (specifically, gray matter [GM] volume) of the striatum are associated with sex differences in self-reported interest in quitting smoking.

Methods: The sample included 108 male and 42 female smokers (>15 cigarettes/day). Interest in quitting was measured via self-report during a baseline session that preceded the experiment using a single item (0–10 scale). High-resolution brain images were acquired within 2 weeks of the baseline session using magnetic resonance imaging. Voxel-based morphometry (a brain imaging data analysis technique) was used to measure GM volume in the striatum and control regions.

Results: Striatal GM volume was higher in female than male smokers, while interest in quitting was lower in the former (Ps <.001). Sex moderated the relation between striatal GM volume and interest in quitting, such that there was a substantially stronger negative association between the two for females than males (P = .03).

Conclusions: Findings extend preclinical data by indicating that the striatum may play a greater role in maintaining cigarette use in female relative to male smokers. Additional research further characterizing these sex-specific effects would provide insight into the unique factors that maintain cigarette use in female smokers.

1 Whitehead Institute for Biomedical Research, Department of Biology, and Howard Hughes Medical Institute 2 Department of Pharmacology and Cancer Biology, Duke University School of Medicine P-77: Notch1 Activation Confers Broad-spectrum Drug Resistance in Breast Cancer

Background and Objective: Drug resistance is a significant clinical problem in breast cancer, particularly because we have only a basic understanding of the signaling events that confer resistance to relevant therapies. We sought to catalog the signaling pathways whose activation confers resistance to targeted therapies relevant to breast cancer: tamoxifen and fulvestrant (ER modulators), lapatinib (HER2i), BKM120 (PI3Ki), MK2206 (AKTi), BEZ235 (PI3K/mTORi), Torin1 (mTORC1/2i), and rapamycin (mTORC1i).

Methods: We developed a library of lentiviral genetic constructs that individually activate every major oncogenic signaling pathway. Using this library, we screened each of the drugs above to identify the pathways whose activation confers resistance to each drug.

Results: Resistance is typically driven by either the activation of classical pro-growth pathways (Ras-MAPK, PI3K-mTOR) or pathways that control differentiation (Notch1). Interestingly, Notch1 activation confers resistance to all drugs in question as well as cytotoxic agents like doxorubicin. Notch1 activation causes an epithelial-mesenchymal transition which results in a stem cell–like phenotype that decreases proliferation rates and drug sensitivities in breast cancer cells. Breast cancer cell lines evolved in vitro to exhibit resistance to tamoxifen expressed higher levels of Notch1 and Notch pathway members than their parental counterparts, and RNAi knockdown of Notch1 reversed resistance in these cells. Finally, in human breast cancer patients, Notch1 expression predicts for significantly worse survival outcomes following treatment with doxorubicin.

Conclusions: Notch1 activation confers broad-spectrum drug resistance in breast cancer. Additionally, pathway-centric screening has the potential to accelerate the search for drug resistance pathways in many other cancer types.

1 Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry 2 Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai 3 Division of Endocrinology, Department of Medicine, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute O-1: Exposure to Prenatal Life Events Stress Is Associated With Masculinized Play Behavior in Girls

Background and Objective: Previous research on humans and animal models suggests that exposure to prenatal stress not only affects fetal development, but also can do so in different ways in males and females. Only one published study has prospectively examined the relationship between exposure to prenatal stress and gender-specific play behavior during childhood, finding masculinized play behavior in girls who experienced high prenatal life events stress, but no associations in boys. Here we examine the relationship between exposure to prenatal stress and play behavior during childhood in a second prospective cohort from the Study for Future Families.

Methods: Pregnant women completed questionnaires on stressful life events during pregnancy, and those who reported 1 or more stressors were considered highly stressed. Families were re-contacted several years later (mean age of index child: 4.9 years), and mothers completed a questionnaire including the validated Preschool Activities Inventory (PSAI), which measures sexually dimorphic play behavior.

Results: In sex-stratified analyses, after adjusting for child's age, parental attitudes toward gender-atypical play, age and sex of siblings, and other relevant covariates, girls (n=72) exposed to high prenatal life events stress had higher scores on the PSAI masculine sub-scale (β=3.48, P=.006) and showed a trend towards higher (more masculine) composite scores (β=2.63, P=.08). By contrast, in males (n=74), prenatal stress showed a trend towards association with higher PSAI feminine sub-scale scores (β=2.23, P=.10), but no association with masculine or composite scores.

Conclusions: These data provide further evidence that prenatal stress may have androgenic effects on female fetuses and anti-androgenic effects on male fetuses.

1 Department of Obstetrics and Gynecology, University of Michigan 2 Department of Dermatology, University of Michigan O-2: Urinary Biomarkers of Lower Urinary Tract Symptoms in Women With Cystoceles

Background and Objective: Although poorly understood, women with cystocele often have lower urinary tract symptoms (LUTS), and LUTS frequently resolve after prolapse reduction. The aims of this pilot study are to compare levels of urinary biomarkers in 1) women with and without cystoceles, and 2) women whose LUTS do or do not improve after prolapse repair.

Methods: This is a case-control study of women with cystoceles (cases) and controls with normal support undergoing benign gynecologic surgery. Baseline demographics were recorded. All subjects completed the MESA and PFDI-20 questionnaires preoperatively. Intraoperative urine specimens were obtained, processed, and the supernatants frozen. Cases repeated the surveys at the 6 week postoperative time point. Urinary biomarker concentrations were assayed and normalized to creatinine concentration.

Results: Ninety-three cases and 61 controls were recruited. Cases were significantly older, of higher parity, and slightly lower body mass index (BMI) than controls. Cases reported more severe LUTS and had significantly higher urinary levels of MCP-1 than controls. Cases were then stratified into those whose LUTS improved (responders) and those whose symptoms worsened/did not significantly improve (non-responders). Demographics were similar in responders and non-responders. Responders had higher concentrations of IL-6 (P=.01), IL-10 (P=.09), and MIP-1β (P=.02), and lower NGF concentrations (P=.03) than non-responders.

Conclusions: Women with cystocele have more severe LUTS and higher urinary MCP-1 concentrations than women with normal support. Prolapse repair leads to improved LUTS for nearly 70%. Urinary biomarkers associated with postoperative improvement of LUTS include higher levels of IL-6, IL-10, and MIP-1β, and lower levels of NGF, suggesting new targets for research and treatment.

1 Department of Psychiatry, Tulane University 2 School of Public Health, Tulane University O-4: Sex and Pubertal Stage Moderate the Association Between Negative Life Events and Telomere Length in African American Youth

Background and Objective: Negative early life stress (ELS) is associated with cardiovascular disease, cognitive decline, and psychopathology. One biomarker of ELS, associated in adults with both negative health and ELS, is telomere length (TL). The utility of this biomarker in children has rarely been examined. The objective was to examine the association between ELS and TL in African American youth and whether the relation is moderated by sex or pubertal stage.

Methods: Fifty-six African American youth (mean age, 9.64 years) were recruited from at-risk neighborhoods in New Orleans, Louisiana. Salivary DNA was extracted, and adjusted telomere length (sTL) was determined using qPCR. sTL was calculated controlling for parental age at conception and child age and subsequently standardized. Negative early life events were determined by parental report. Pubertal stage was determined by parent and child self-report.

Results: Mean number of early life events was 4.4 for boys and 4.8 for girls (range 0 to 13). sTL was significantly different between sex (P=.01). For boys, z-score transformed sTL=−.12 (n=32) and for girls, sTL=.02 (n=24). ELS was associated with sTL in both sexes. Pubertal stage was not associated in girls (P=.18), but was associated with sTL among boys (P=.005) and mediated the association between ELS and sTL. The full model, with both genders, predicted 37% of the variance in sTL (P<.0001, r=.37. f=10.51, n=56)

Conclusions: In African American youth, exposure to ELS is significantly associated with decreased sTL. TL may represent a biological indicator of ELS mediated by pubertal stage in boys.

1 Medical University of South Carolina 2 Ralph H. Johnson Veterans Affairs Medical Center O-6: Varenicline Versus Nicotine Patch for Smoking Cessation in Women: Efficacy Findings from a 4-Week Double-blind Trial

Background and Objective: Women may have more difficulty quitting smoking than men; comparative evaluation of cessation pharmacotherapies in women may be critical to inform clinical practice. Within a parent study examining ovarian hormone effects on smoking cessation, we conducted the first double-blind trial directly comparing the efficacy of varenicline versus nicotine patch.

Methods: Treatment-seeking nicotine-dependent female smokers (aged 18–45, n=137) were randomized to receive a 4-week course of (a) varenicline tablets and placebo patches or (b) placebo tablets and nicotine patches, via a double-blind, double-dummy design. All participants received a 1-week titration lead-in (tablets only) before a targeted quit date, followed by goal dosing (tablets and patches) for an additional 4 weeks. All participants received 2 brief cessation counseling sessions. Abstinence was assessed at weekly visits and analyzed via an intent-to-treat approach.

Results: During the last week of the 4-week treatment, 46.9% of varenicline participants achieved 7-day point prevalence abstinence, compared with 20.6% of nicotine patch participants (OR 3.3 [95% CI 1.5–6.9]; P=.002). At the end of a 4-week post-treatment follow-up, 7-day point prevalence abstinence numerically favored varenicline, but did not meet statistical significance (23.4% vs. 13.7%, OR 1.9 [95% CI 0.8–4.7]; P=0.15).

Conclusions: Varenicline, compared with nicotine patch, more than doubled the odds of abstinence at end of 4-week treatment. Absolute abstinence rates with both treatments were lower than those in a prior open-label trial inclusive of both men and women (Aubin et al., 2008). Nonetheless, these preliminary findings support varenicline as a preferred pharmacotherapy for smoking cessation in women.

Funding sources: NIDA P50DA16511 Component 4 (KMG & MES), NIDA K23DA020482 (MJC), and NCRR UL1RR029882 (MUSC Clinical and Translational Research Center). Varenicline and matched placebo were supplied by Pfizer, Inc.

1 Department of Orthopedic Surgery, Mayo Clinic (Rochester, MN) 2 Department of Orthopedic Surgery, Mayo Clinic (Jacksonville, FL) O-9: The Role of Loading Mechanics in Sex Differences of Knee Osteoarthritis

Background and Objective: Women have a higher incidence of knee osteoarthritis (KOA) than men do. Mechanisms attributing to this difference are unclear. We hypothesize that the difference could result in part from loading mechanics placed on the knee during walking. The objective was to characterize and compare knee loading mechanics between adult men and women with medial KOA.

Methods: Adults (221 women and 73 men) with medial compartment KOA underwent bilateral knee x-rays to determine radiographic OA severity and cartilage thickness. Gait analysis was performed during level walking to determine measures of cadence, magnitude of knee loading, rate of knee loading, and timing of peak loads during the gait cycle. ANCOVA analyses were performed to test the main effects of sex on gait. Results were adjusted for OA severity, age, body mass index, and knee alignment.

Results: Medial compartment cartilage thickness and estimated loading during walking were lower in women compared with men. There was no sex difference in the ratio of medial compartment cartilage thickness to medial compartment loading or in loading rates. Women walked with a faster cadence, and women applied peak loads during terminal stance, while men tended to apply peak loads during the initial loading response after heel strike.

Conclusions: Knee loading rate and magnitude are not indicated as risk factors in women; however, over a constant distance, women take more steps than men and experience peak loading later in the gait cycle. Differences in cumulative loading mechanics could contribute to sex differences in the onset and progression of KOA.

1 Cincinnati Children's Hospital Medical Center 2 University of Cincinnati O-10: The Dek Oncogene Drives Breast Cancer Progression and Chemotherapeutic Resistance

Background and Objective: Late-stage breast cancer (BC) patients are faced with poor survival rates, drug resistance, and risk of tumor recurrence. Novel drivers of advanced disease must be identified that also may be targets of new therapies. This study was needed to investigate an oncogene that may determine disease progression and drug resistance. The goal was to determine if the Dek oncogene was required for breast cancer progression in vivo and drug resistance. Furthermore, we studied the role of Dek in maintaining the breast cancer stem cell population, which has been implicated as the causative factor for drug resistance and disease recurrence.

Methods: Dek-/- mice were bred to the MMTV-Ron breast cancer model. Histological and biochemical analyses were performed on tissues and cell lines derived from murine tumors.

Results: Dek expression is upregulated upon Ron receptor activation. Loss of the Dek oncogene significantly delayed tumor initiation in vivo due, in part, to decreased proliferation in pre-neoplastic glands. In cell lines derived from the murine model, Dek loss was associated with decreased BCSC numbers, fewer overt lung metastases, and Wnt pathway inhibition. Finally, the loss of Dek enhanced the cytotoxicity of cisplatin.

Conclusions: Dek is an important driver of BC progression and supports the maintenance of the BCSC population, which is thought to be responsible for disease recurrence and drug resistance. Targeted genetic inhibition of Dek may enhance therapeutic response to several classes of drugs. Pre-clinical testing of DEK inhibition should proceed as a method to enhance drug sensitivity in BCSCs, thus resulting in improved survival.

1 Center for Human Genetics, Vanderbilt University 2 Department of Obstetics and Gynecology, Institute for Medicine and Public Health, Vanderbilt Epidemiology Center, Vanderbilt University 3 Department of Biomedical Informatics, Vanderbilt University 4 School of Biomedical Informatics, University of Texas Health Science Center, Houston O-12: Drug Treatment for Type 2 Diabetes Modifies Fibroid Risk

Background and Objective: Uterine fibroids (UFs) affect 77% of women by menopause, and account for $9.4 billion in yearly health care costs. Studies have shown that type 2 diabetes (T2D) associates with UF protection. Whether protection derives from having T2D or T2D pharmacologic management (treatment) is unclear. The objective was to further evaluate the relationship between UFs and T2D treatment.

Methods: UF status was determined from pelvic imaging. Women with T2D were identified from their clinical records and had not been diagnosed with UFs at T2D diagnosis. Cox regression, adjusted for confounders, was used to test for association between UF presence and T2D treatments (metformin [n=1,089], thiazolidinedione [n=353], insulin [n=1,477], or other treatment [n=332]). We also tested for interactions between T2D treatment and race and body mass index.

Results: We identified 2,321 women with T2D, with average age of diagnosis of 47. Seventeen percent developed UFs after T2D diagnosis. Insulin, compared with other treatments, conferred protection from UFs in European Americans (EAs) and African Americans (AAs) (EAs, adjusted hazard ratio [aHR]=0.50, 95% confidence interval [CI] 0.36–0.69; AA, aHR=0.53, 95% CI 0.37–0.74). We observed increased UF risk with metformin treatment among EAs (aHR=1.94, 95% CI 1.37–2.74), but not among AAs (aHR=1.07, 95% CI 0.76–1.51). Normal weight and overweight T2Ds had the most protection from UFs due to insulin compared with obese T2Ds. Thiazolidinedione and other T2D treatments did not associate with UFs.

Conclusions: These data support the hypothesis that protection from UFs linked to T2D diagnosis may derive from T2D treatments, specifically insulin. Further research is required to dissect the biological mechanisms of this effect, as well as the link between metformin and UF risk.