Oxaliplatin desensitization for ovarian cancer in pregnancy: A case report.

•Incidence of cancer in pregnancy is rising and successful treatment of these patients requires expert multidisciplinary care.•Platinum hypersensitivity reactions in ovarian cancer are commonly treated with desensitization protocols.•To our knowledge, chemotherapy desensitization in pregnant patients has not been previously reported.•Oxaliplatin desensitization during pregnancy may be safe and feasible.

Non-surgical management of advanced ovarian cancer with maintenance PARP inhibitors.

The standard of care for advanced ovarian cancer is cytoreductive surgery followed by a platinum-taxane combination with PARP inhibition as a maintenance strategy. In practice, many advanced ovarian cancer patients are older and are either not candidates for surgery or decline surgical intervention. There are limited data for using PARP inhibitor maintenance in the non-surgical patient population. We describe two cases of patients with advanced-stage ovarian cancer who received platinum-taxane chemotherapy and declined surgical debulking. They were continued on maintenance PARP inhibitors and have no evidence of disease for over four years.

Serologic Immunity to Tetanus in the United States, National Health and Nutrition Examination Survey, 2015-2016.

BACKGROUND: Tetanus, a life-threatening infection, has become rare in the United States since introduction of tetanus toxoid-containing vaccines (TTCVs), recommended as a childhood series followed by decennial boosters beginning at age 11-12 years; vaccination uptake is high in children but suboptimal in adults. The objective of this study was to estimate the prevalence of sero-immunity to tetanus among persons aged ≥6 years in the United States and to identify factors associated with tetanus sero-immunity. Understanding population protection against tetanus informs current and future vaccine recommendations. METHODS: Anti-tetanus toxoid antibody concentrations were measured for participants of the 2015-2016 National Health and Nutrition Examination Survey (NHANES) aged ≥6 years for whom surplus serum samples were available using a microsphere-based multiplex antibody capture assay. Prevalence of sero-immunity, defined as ≥0.10 IU/mL, was estimated overall and by demographic characteristics. Factors associated with tetanus sero-immunity were examined using multivariable regression. RESULTS: Overall, 93.8% of the US population aged ≥6 years had sero-protection against tetanus. Prevalence of sero-immunity was above 90% across racial/ethnic categories, sex, and poverty levels. By age, ≥ 90% had protective sero-immunity through age 69 years, but prevalence of sero-immunity declined thereafter, with 75.8% of those aged ≥80 years having protective sero-immunity. Older age (adjusted prevalence ratio [aPR]: 0.89, 95% confidence interval [CI]: .85-.92) and being born outside the United States (aPR: 0.96, 95% CI: .93-.98) were significantly associated with lower prevalence of sero-immunity. CONCLUSIONS: The majority of the US population has vaccine-induced sero-immunity to tetanus, demonstrating the success of the vaccination program.

Evaluation of Serologic Cross-Reactivity Between Dengue Virus and SARS-CoV-2 in Patients with Acute Febrile Illness - United States and Puerto Rico, April 2020-March 2021.

The diagnosis of dengue disease, caused by the dengue virus (DENV) (a flavivirus), often requires serologic testing during acute and early convalescent phases of the disease. Some symptoms of DENV infection, such as nonspecific fever, are similar to those caused by infection with SARS-CoV-2, the virus that causes COVID-19. In studies with few COVID-19 cases, positive DENV immunoglobulin M (IgM) results were reported with various serologic tests, indicating possible cross-reactivity in these tests for DENV and SARS-CoV-2 infections (1,2). DENV antibodies can cross-react with other flaviviruses, including Zika virus. To assess the potential cross-reactivity of SARS-CoV-2, DENV, and Zika virus IgM antibodies, serum specimens from 97 patients from Puerto Rico and 12 U.S.-based patients with confirmed COVID-19 were tested using the DENV Detect IgM Capture enzyme-linked immunosorbent assay (ELISA) (InBios International).* In addition, 122 serum specimens from patients with confirmed dengue and 121 from patients with confirmed Zika virus disease (all from Puerto Rico) were tested using the SARS-CoV-2 pan-Ig Spike Protein ELISA (CDC).† Results obtained for DENV, Zika virus IgM, and SARS-CoV-2 antibodies indicated 98% test specificity and minimal levels of cross-reactivity between the two flaviviruses and SARS-CoV-2. These findings indicate that diagnoses of dengue or Zika virus diseases with the serological assays described in this report are not affected by COVID-19, nor do dengue or Zika virus diseases interfere with the diagnosis of COVID-19.

Adherence to oral oncolytics filled through an internal health-system specialty pharmacy compared with external specialty pharmacies.

BACKGROUND: Oral oncolytics are becoming increasingly common in the treatment of solid and hematological malignancies. Medication adherence is especially important to ensure adequate drug levels to treat active malignancies, notably in curative-intent therapy. Further data are needed to quantify and confirm the effects of internal health-system specialty pharmacies (HSSPs) on medication adherence. OBJECTIVE: To confirm the effect of an internal HSSP compared with external specialty pharmacies on oncolytic adherence as measured by proportion of days covered (PDC), medication possession ratio (MPR), and time to treatment (TTT). METHODS: This single-center retrospective cohort study included patients receiving oral oncolytics through an internal HSSP or external specialty pharmacies between January 2019 and June 2020. Fill data were extracted from pharmacy claims databases and electronic medical records. The primary adherence outcome was patient-level PDC. Secondary adherence outcomes included patient-level MPR and TTT. For PDC and MPR analyses, patients with at least 3 fills per oncolytic were included. All patients were included for the TTT analysis. Chi-square or Fisher's exact tests were used to analyze categorical differences between pharmacy groups. Differences in continuous variables across pharmacy groups were evaluated using Wilcoxon rank-sum tests. RESULTS: 871 prescriptions met inclusion criteria: 549 patients were included in the PDC/MPR analysis, and 758 patients were included in the TTT analysis (patients might have multiple prescriptions). Patients who filled at an internal HSSP had a higher median PDC compared with those who filled at external specialty pharmacies (0.99 [IQR = 0.89-1.00] vs 0.91 [IQR = 0.76-0.98]; P < 0.01). The adherence rate as measured by MPR was higher for patients who used an internal HSSP compared with those who used external specialty pharmacies (MPR = 1.00 [IQR = 0.90-1.00] vs 0.93 [IQR = 0.76-1.00]; P < 0.01). Median TTT was lower for patients using the internal HSSP vs an external specialty pharmacy (5 days [IQR = 2-13] vs 27 days [IQR = 2-82], respectively; P < 0.01). CONCLUSIONS: Internal HSSP services improved adherence as measured by PDC and MPR. Significantly lower TTT was seen with the internal HSSP compared with external pharmacies. These data confirm and support use of internal HSSPs to dispense oral oncolytics for treatment of solid and hematological malignancies. DISCLOSURES: This study received no financial support. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Comparison of Estimated Severe Acute Respiratory Syndrome Coronavirus 2 Seroprevalence Through Commercial Laboratory Residual Sera Testing and a Community Survey.

We compared severe acute respiratory syndrome coronavirus 2 seroprevalence estimated from commercial laboratory residual sera and a community household survey in metropolitan Atlanta during April and May 2020 and found these 2 estimates to be similar (4.94% vs 3.18%). Compared with more representative surveys, commercial sera can provide an approximate measure of seroprevalence.

Exposure to di-2-ethylhexyl terephthalate in the U.S. general population from the 2015-2016 National Health and Nutrition Examination Survey.

BACKGROUND: Di-2-ethylhexyl terephthalate (DEHTP) is used as a replacement plasticizer for other phthalates, including di-2-ethylhexyl phthalate (DEHP). Use of consumer products containing DEHTP may result in human exposure to DEHTP. OBJECTIVE: To assess exposure to DEHTP in a nationally representative sample of the U.S. general population 3 years and older from the 2015-2016 National Health and Nutrition Examination Survey (NHANES). METHOD: We quantified two DEHTP metabolites, mono-2-ethyl-5-hydroxyhexyl terephthalate (MEHHTP) and mono-2-ethyl-5-carboxypentyl terephthalate (MECPTP) in 2970 urine samples by using online solid-phase extraction coupled with isotope dilution-high-performance liquid chromatography-tandem mass spectrometry. We used linear regression to examine associations between MEHHTP and MECTPP and several parameters including age, sex, race/ethnicity, and household income. We also compared the MEHHTP and MECPTP results to those of their corresponding DEHP metabolite analogs, namely mono-2-ethyl-5-hydroxyhexyl phthalate (MEHHP) and mono-2-ethyl-5-carboxypentyl phthalate (MECPP). RESULTS: The weighted detection frequencies were 96% (MEHHTP) and 99.9% (MECPTP); urinary concentrations of the two metabolites correlated significantly (Pearson correlation coefficient = 0.89, p < 0.0001). MECPTP concentrations were higher than MEHHTP in all age, sex, race/ethnicity groups examined. Furthermore, MECPTP adjusted geometric mean (GM) concentrations were significantly higher in samples collected in the evening than in the morning or afternoon. Females had significantly higher adjusted GM concentrations of MEHHTP and MECPTP than males. We observed no significant associations between the adjusted GM concentrations of the metabolites and race/ethnicity. Both metabolite adjusted GM concentrations increased significantly with household income, and decreased significantly with age. Only household income was significantly associated with the concentrations of MECPP, but not of MEHHP, the two DEHP metabolites. The adjusted GM of the [MEHHTP]:[MECPTP] molar concentrations ratio increased with age, and was significantly higher in samples collected in the morning than in those collected in the afternoon or evening. CONCLUSIONS: Exposure to DEHTP is widespread in the U.S. general population 3 years and older. These data represent the first U.S. population-based representative background exposure to DEHTP.

Trends in exposure to polyfluoroalkyl chemicals in the U.S. Population: 1999-2008.

Since 2002, practices in manufacturing polyfluoroalkyl chemicals (PFCs) in the United States have changed. Previous results from the National Health and Nutrition Examination Survey (NHANES) documented a significant decrease in serum concentrations of some PFCs during 1999-2004. To further assess concentration trends of perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), perfluorohexane sulfonate (PFHxS), and perfluorononanoate (PFNA), we analyzed 7876 serum samples collected from a representative sample of the general U.S. population ≥12 years of age during NHANES 1999-2008. We detected PFOS, PFOA, PFNA, and PFHxS in more than 95% of participants. Concentrations differed by sex regardless of age and we observed some differences by race/ethnicity. Since 1999-2000, PFOS concentrations showed a significant downward trend, because of discontinuing industrial production of PFOS, but PFNA concentrations showed a significant upward trend. PFOA concentrations during 1999-2000 were significantly higher than during any other time period examined, but PFOA concentrations have remained essentially unchanged during 2003-2008. PFHxS concentrations showed a downward trend from 1999 to 2006, but concentrations increased during 2007-2008. Additional research is needed to identify the environmental sources contributing to human exposure to PFCs. Nonetheless, these NHANES data suggest that sociodemographic factors may influence exposure and also provide unique information on temporal trends of exposure.

Selecting adequate exposure biomarkers of diisononyl and diisodecyl phthalates: data from the 2005-2006 National Health and Nutrition Examination Survey.

BACKGROUND: High-molecular-weight phthalates, such as diisononyl phthalate (DINP) and diisodecyl phthalate (DIDP), are used primarily as polyvinyl chloride plasticizers. OBJECTIVES: We assessed exposure to DINP and DIDP in a representative sample of persons ≥ 6 years of age in the U.S. general population from the 2005-2006 National Health and Nutrition Examination Survey (NHANES). METHODS: We analyzed 2,548 urine samples by using online solid-phase extraction coupled to isotope dilution high-performance liquid chromatography-tandem mass spectrometry. RESULTS: We detected monocarboxyisooctyl phthalate (MCOP), a metabolite of DINP, and monocarboxyisononyl phthalate (MCNP), a metabolite of DIDP, in 95.2% and 89.9% of the samples, respectively. We detected monoisononyl phthalate (MNP), a minor metabolite of DINP, much less frequently (12.9%) and at concentration ranges (> 0.8 µg/L-148.1 µg/L) much lower than MCOP (> 0.7 µg/L- 4,961 µg/L). Adjusted geometric mean concentrations of MCOP and MCNP were significantly higher (p < 0.01) among children than among adolescents and adults. CONCLUSIONS: The general U.S. population, including children, was exposed to DINP and DIDP. In previous NHANES cycles, the occurrence of human exposure to DINP by using MNP as the sole urinary biomarker has been underestimated, thus illustrating the importance of selecting the most adequate biomarkers for exposure assessment.

Global surveillance of oral tobacco products: total nicotine, unionised nicotine and tobacco-specific N-nitrosamines.

OBJECTIVE: Oral tobacco products contain nicotine and carcinogenic tobacco-specific N-nitrosamines (TSNAs) that can be absorbed through the oral mucosa. The aim of this study was to determine typical pH ranges and concentrations of total nicotine, unionised nicotine (the most readily absorbed form) and five TSNAs in selected oral tobacco products distributed globally. METHODS: A total of 53 oral tobacco products from 5 World Health Organisation (WHO) regions were analysed for total nicotine and TSNAs, including 4-(methyl-nitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), using gas chromatography or liquid chromatography with mass spectrometric detection. Unionised nicotine concentrations were calculated using product pH and total nicotine concentrations. Fourier transform infrared spectroscopy was used to help categorize or characterise some products. RESULTS: Total nicotine content varied from 0.16 to 34.1 mg/g product, whereas, the calculated unionised nicotine ranged from 0.05 to 31.0 mg/g product; a 620-fold range of variation. Products ranged from pH 5.2 to 10.1, which translates to 0.2% to 99.1% of nicotine being in the unionised form. Some products have very high pH and correspondingly high unionised nicotine (eg, gul powder, chimó, toombak) and/or high TSNA (eg, toombak, zarda, khaini) concentrations. The concentrations of TSNAs spanned five orders of magnitude with concentrations of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) ranging from 4.5 to 516,000 ng/g product. CONCLUSIONS: These data have important implications for risk assessment because they show that very different exposure risks may be posed through the use of these chemically diverse oral tobacco products. Because of the wide chemical variation, oral tobacco products should not be categorised together when considering the public health implications of their use.

Rapid and chemically selective nicotine quantification in smokeless tobacco products using GC-MS.

In recent years, there has been a rapid proliferation of smokeless products with a wide range of nicotine content and flavoring formulations that may appeal to new users and existing cigarette smokers. The CDC nicotine method, which employs gas chromatography-flame ionization detection (GC-FID), provides a robust means for measuring nicotine in smokeless tobacco. However, several compounds, identified in a few flavored smokeless products, interfere with nicotine quantification using GC-FID. In response, the standard nicotine method (26.7 min run time) was modified to use faster GC ramping (3.7 min run time) and detection with mass spectrometry (GC-MS) in selected ion-monitoring mode to reduce signal interferences that can bias nicotine values. Seven conventional smokeless samples (n = 12) and blank tobacco samples spiked at three nicotine concentration levels (n = 5) were analyzed using the GC-FID and GC-MS methods and found to be in excellent agreement. However, only the GC-MS method provided confirmation of chromatographic peak purity in certain highly flavored products. The GC-MS method is not intended to replace the GC-FID method but to provide a method versatile enough to analyze a wide range of nicotine values in domestic and international samples of varying complexity. Accurate nicotine quantification is important for determining total nicotine content in tobacco and in subsequent calculations of un-protonated nicotine content.

Stability of the conjugated species of environmental phenols and parabens in human serum.

In humans, the metabolism of environmental phenols may include the formation of conjugated species (e.g., glucuronides and sulfates), but the free species-not the conjugated forms-are considered biologically active. Therefore, information on the concentration of these free species in blood or urine could be helpful for risk assessment. Because conjugates could hydrolyze to their corresponding free forms during collection, handling, and storage of biological specimens, information on the temporal stability of the conjugates is of interest. Previously, we reported the temporal stability of urinary conjugates of several environmental phenols, but data on the stability of phenols' conjugated species in serum, albeit critical if concentrations of free and conjugated species are compared, are largely unknown. In the present study, we investigate the stability of the conjugates of four phenols-bisphenol A, benzophenone-3, triclosan, and 2,5-dichlorophenol-and two parabens-methyl paraben and propyl paraben-in 16 human serum samples for 30 days at above-freezing temperature storage conditions (4 degrees C, room temperature, and 37 degrees C). These conditions reflect the worst-case scenarios that could occur during the short-term storage of biological samples before their long-term storage at controlled subfreezing temperatures. We found that the percentage of the conjugated species of the four detected compounds (2,5-dichlorophenol, triclosan, and methyl and propyl parabens) in these serum specimens even when stored at 37 degrees C for at least 30 days did not vary significantly. These preliminary data suggest that the phenols' serum conjugates appear to be more stable than their corresponding urinary conjugates, some of which started to hydrolyze within 24h under similar storage conditions. The reported stability of these conjugated species in human serum also suggests that the free species are unlikely to have resulted from the hydrolysis of their corresponding conjugates. This information could be important for interpreting the low concentrations of free phenol species detected in serum samples of nonoccupationally exposed populations. To our knowledge, this is the first study to report on the stability of conjugated species in serum, and as such requires replication.

Exposure to bisphenol A and other phenols in neonatal intensive care unit premature infants.

OBJECTIVE: We previously demonstrated that exposure to polyvinyl chloride plastic medical devices containing di(2-ethylhexyl) phthalate (DEHP) was associated with higher urinary concentrations of several DEHP metabolites in 54 premature infants in two neonatal intensive care units than in the general population. For 42 of these infants, we evaluated urinary concentrations of several phenols, including bisphenol A (BPA), in association with the use of the same medical devices. MEASUREMENTS: We measured the urinary concentrations of free and total (free plus conjugated) species of BPA, triclosan, benzophenone-3, methyl paraben, and propyl paraben. RESULTS: The percentage of BPA present as its conjugated species was > 90% in more than three-quarters of the premature infants. Intensity of use of products containing DEHP was strongly associated with BPA total concentrations but not with any other phenol. Adjusting for institution and sex, BPA total concentrations among infants in the group of high use of DEHP-containing products were 8.75 times as high as among infants in the low use group (p < 0.0001). Similarly, after adjusting for sex and DEHP-containing product use category, BPA total concentrations among infants in Institution A were 16.6 times as high as those among infants in Institution B (p < 0.0001). CONCLUSION: BPA geometric mean urinary concentration (30.3 microg/L) among premature infants undergoing intensive therapeutic medical interventions was one order of magnitude higher than that among the general population. Conjugated species were the primary urinary metabolites of BPA, suggesting that premature infants have some capacity to metabolize BPA. The differences in exposure to BPA by intensity of use of DEHP-containing medical products highlight the need for further studies to determine the specific source(s) of exposure to BPA.

Effects of perfluorooctanoic acid on mouse mammary gland development and differentiation resulting from cross-foster and restricted gestational exposures.

The adverse consequences of developmental exposures to perfluorooctanoic acid (PFOA) are established in mice, and include impaired development of the mammary gland (MG). However, the relationships between timing or route of exposure, and consequences in the MG have not been characterized. To address the effects of these variables on the onset and persistence of MG effects in female offspring, timed pregnant CD-1 dams received PFOA by oral gavage over various gestational durations. Cross-fostering studies identified the 5mg/kg dose, under either lactational- or intrauterine-only exposures, to delay MG development as early as postnatal day (PND) 1, persisting beyond PND 63. Intrauterine exposure during the final days of pregnancy caused adverse MG developmental effects similar to that of extended gestational exposures. These studies confirm a window of MG sensitivity in late fetal and early neonatal life, and demonstrate developmental PFOA exposure results in early and persistent MG effects, suggesting permanent consequences.