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Summary The Women's Health Initiative (WHI) double-blind, placebo-controlled clinical trial randomly assigned 36,282 postmenopausal women in the U.S. to 1,000 mg elemental calcium carbonate plus 400 IU of vitamin D 3 daily or placebo, with average intervention period of 7.0 years. The trial was designed to test whether calcium plus vitamin D supplementation in a population in which the use of these supplements was widespread would reduce hip fracture, and secondarily, total fracture and colorectal cancer. Introduction This study further examines the health benefits and risks of calcium and vitamin D supplementation using WHI data, with emphasis on fractures, cardiovascular disease, cancer, and total mortality. Methods WHI calcium and vitamin D randomized clinical trial (CT) data through the end of the intervention period were further analyzed with emphasis on treatment effects in relation to duration of supplementation, and these data were contrasted and combined with corresponding data from the WHI prospective observational study (OS). Results Among women not taking personal calcium or vitamin D supplements at baseline, the hazard ratio [HR] for hip fracture occurrence in the CT following 5 or more years of calcium and vitamin D supplementation versus placebo was 0.62 (95 % confidence interval (CI), 0.38–1.00). In combined analyses of CT and OS data, the corresponding HR was 0.65 (95 % CI, 0.44–0.98). Supplementation effects were not apparent on the risks of myocardial infarction, coronary heart disease, total heart disease, stroke, overall cardiovascular disease, colorectal cancer, or total mortality, while evidence for a reduction in breast cancer risk and total invasive cancer risk among calcium plus vitamin D users was only suggestive. Conclusion Though based primarily on a subset analysis, long-term use of calcium and vitamin D appears to confer a reduction that may be substantial in the risk of hip fracture among postmenopausal women. Other health benefits and risks of supplementation at doses considered, including an elevation in urinary tract stone formation, appear to be modest and approximately balanced.

SummaryThe paper focuses on the identification of atypical fractures (AFFs). This paper examines the concordance between objective classification and expert subjective review. We believe the paper adds critical information about how to apply the American Society of Bone and Mineral Research (ASBMR) criteria to diagnose AFFs and is of high interest to the field.IntroductionAssess American Society of Bone and Mineral Research (ASBMR) criteria for identifying atypical femoral fractures (AFFs).MethodsTwo orthopedic surgeons independently evaluated radiographs of 372 fractures, applying ASBMR criteria. We assessed ease of applying ASBMR criteria and whether criteria-based assessment matched qualitative expert assessment.ResultsThere was up to 27% uncertainty about how to classify specific features. 84% of films were classified similarly for the presence of AFF according to ASBMR criteria; agreement increased to 94% after consensus meeting. Of 37 fractures categorized as AFFs based on ASBMR criteria, 23 (62.2%) were considered AFFs according to expert assessment (not relying on criteria). Only one (0.5%) femoral shaft fracture that did not meet ASBMR criteria was considered an AFF per expert assessment. The number of major ASBMR features present (four vs five) and whether there was periosteal or endosteal thickening (“beaking” or “flaring”) played major roles in the discrepancies between ASBMR criteria-based and expert-based determinations.ConclusionsASBMR AFF criteria were useful for reviewers but several features were difficult to interpret. Expert assessments did not agree with the ASBMR classification in almost one-third of cases, but rarely identified an AFF when a femoral shaft fracture did not meet ASBMR AFF criteria. Experts identified lateral cortical transverse fracture line and associated new-bone formation along with no or minimal comminution as crucial features necessary for the definition of atypical femoral fractures.

A new retrieval scheme for cloud optical thickness, effective radius, and thermodynamic phase was developed for ground-based measurements of cloud shortwave solar spectral transmittance. Fifteen parameters were derived to quantify spectral variations in shortwave transmittance due to absorption and scattering of liquid water and ice clouds, manifested by shifts in spectral slopes, curvatures, maxima, and minima. To retrieve cloud optical thickness and effective particle radius, a weighted least square fit that matched the modeled parameters was applied. The measurements for this analysis were made with the ground-based Solar Spectral Flux Radiometer in Boulder, Colorado, between May 2012 and January 2013. We compared the cloud optical thickness and effective radius from the new retrieval to two other retrieval methods. By using multiple spectral features, we find a closer fit (with a root mean square difference over the entire spectra of 3.1% for a liquid water cloud and 5.9% for an ice cloud) between measured and modeled spectra compared to two other retrieval methods which diverge by a root mean square of up to 6.4% for a liquid water cloud and 22.5% for an ice cloud. The new retrieval introduced here has an average uncertainty in effective radius (± 1.2 μm) smaller by factor of at least 2.5 than two other methods when applied to an ice cloud.

SummaryMethodological limitations preclude determination of the association between sleep duration and bone mineral density (BMD) from existing literature. This was the first study to use objective sleep duration to determine its association with BMD. Nocturnal sleep duration, assessed objectively (actigraphy) or subjectively (questionnaire), was not independently associated with BMD in postmenopausal women.IntroductionBoth long and short self-reported sleep durations are associated with low bone mineral density (BMD) in men and women. The association between sleep duration measured by actigraphy and BMD in postmenopausal women is unknown.MethodsThe Study of Osteoporotic Fractures (SOF) ancillary sleep study was used to determine the association between sleep duration and BMD at the total hip and femoral neck in postmenopausal women ≥ 75 years old. Sleep duration was assessed by wrist actigraphy (average 4 nights) and questionnaire. BMD was compared between postmenopausal women with short (< 6 h/night) vs. NIH-recommended (7–8 h/night) sleep durations. Data were analyzed using a 2-sample t test (unadjusted) and multivariate regression model (adjusted). Simple linear regression was used to estimate the difference in BMD per additional hour of sleep when sleep duration was considered as a continuous, rather than dichotomized, variable.ResultsTotal hip BMD was higher in women with actigraphically assessed shorter sleep duration in unadjusted models only. No clinically or statistically significant differences in total hip or femoral neck BMD were observed according to nocturnal sleep duration after adjusting for body mass index (BMI) in dichotomized (N = 874) or continuous (N = 1624) sleep duration models or when subjective sleep duration was used. When sleep duration included daytime naps, longer sleep duration was associated with lower total hip BMD (β = − 0.005, p = 0.04).ConclusionsNocturnal sleep duration, whether assessed objectively (actigraphy) or subjectively (questionnaire), was not independently associated with BMD in older postmenopausal women.

OBJECTIVE: To evaluate the risks and benefits of third‐generation oral contraceptives. DATA SOURCES: A medline search was done for English language articles published from 1985 through 1998 relating to the side‐effect profile of third‐generation oral contraceptives or their association with cardiovascular or thromboembolic disease. All articles containing original data were included. DATA SYNTHESIS: The risk of venous thromboembolism appears to be 1.5‐ to 2.7‐fold greater in users of third‐generation, compared with second‐generation, oral contraceptives. Compared with nonusers, women who use third‐generation oral contraceptives may have a 4.8‐ to 9.4‐fold greater risk of venous thromboembolism. Users of third‐generation oral contraceptives do not appear to have an increased risk of myocardial infarction compared with nonusers and may have risk of myocardial infarction of 0.26 to 0.7 compared with second‐generation users. Whether third‐generation oral contraceptives are associated with a decreased stroke risk is still not clear. CONCLUSIONS: Although third‐generation oral contraceptives most likely increase a user's risk of venous thromboembolism, their improved side‐effect profile and their possible decreased association with myocardial infarction and stroke may make them a useful new class of oral contraceptives for most women except those at increased risk of venous thrombosis.

Summary Bisphosphonate therapy reduces fracture risk but does not eliminate fracture occurrence. We determined the fracture incidence and risk factors for fractures among 14,674 bisphosphonate users in a community setting. Bisphosphonate users remained at risk of fracture, and additional measures to prevent fractures in these patients would be beneficial. Introduction Bisphosphonate therapy reduces but does not eliminate fracture occurrence. The incidence of fracture and risk factors for fractures among persistent, current users of bisphosphonates in a community setting have not been well studied. Methods We conducted a retrospective cohort study of 14,674 bisphosphonate users in a health maintenance organization. Patients were followed until a 3-month gap in therapy, creating a pool of highly compliant [mean medication possession ratio (MPR) of 94 %] current users. We used Cox proportional hazards models to identify risk factors for fractures among these persistent, current users. Results There were 867 fractures over the period of observation or 3.7 fractures per 100 users per year. Older patients who take multiple medications, have lower bone mineral density, have a history of prior fracture, and suffer from particular comorbidities (i.e., dementia, chronic kidney disease, and rheumatoid arthritis) are at higher risk of fracture while taking bisphosphonates. Conclusion Persistent, current bisphosphonate users remain at risk of fracture, and additional measures to prevent fractures in these patients would be of benefit.

Southern Africa produces almost a third of the Earth’s biomass burning (BB) aerosol particles, yet the fate of these particles and their influence on regional and global climate is poorly understood. ORACLES (ObseRvations of Aerosols above CLouds and their intEractionS) is a 5-year NASA EVS-2 (Earth Venture Suborbital-2) investigation with three intensive observation periods designed to study key atmospheric processes that determine the climate impacts of these aerosols. During the Southern Hemisphere winter and spring (June–October), aerosol particles reaching 3–5 km in altitude are transported westward over the southeast Atlantic, where they interact with one of the largest subtropical stratocumulus (Sc) cloud decks in the world. The representation of these interactions in climate models remains highly uncertain in part due to a scarcity of observational constraints on aerosol and cloud properties, as well as due to the parameterized treatment of physical processes. Three ORACLES deployments by the NASA P-3 aircraft in September 2016, August 2017, and October 2018 (totaling ~ 350 science flight hours), augmented by the deployment of the NASA ER-2 aircraft for remote sensing in September 2016 (totaling ~ 100 science flight hours), were intended to help fill this observational gap. ORACLES focuses on three fundamental science themes centered on the climate effects of African BB aerosols: (a) direct aerosol radiative effects, (b) effects of aerosol absorption on atmospheric circulation and clouds, and (c) aerosol–cloud microphysical interactions. This paper summarizes the ORACLES science objectives, describes the project implementation, provides an overview of the flights and measurements in each deployment, and highlights the integrative modeling efforts from cloud to global scales to address science objectives. Significant new findings on the vertical structure of BB aerosol physical and chemical properties, chemical aging, cloud condensation nuclei, rain and precipitation statistics, and aerosol indirect effects are emphasized, but their detailed descriptions are the subject of separate publications. The main purpose of this paper is to familiarize the broader scientific community with the ORACLES project and the dataset it produced.

The springtime atmosphere over the southeast Atlantic Ocean (SEA) is subjected to a consistent layer of biomass burning (BB) smoke from widespread fires on the African continent. An elevated humidity signal is coincident with this layer, consistently proportional to the amount of smoke present. The combined humidity and BB aerosol has potentially significant radiative and dynamic impacts. Here, we use aircraft-based observations from the NASA ORACLES (ObseRvations of Aerosols above CLouds and their intEractionS) deployments in conjunction with reanalyses to characterize covariations in humidity and BB smoke across the SEA. The observed plume–vapor relationship, and its agreement with the European Centre for Medium-Range Weather Forecasts (ECMWF) Reanalysis version 5 (ERA5) and Copernicus Atmosphere Monitoring Service (CAMS) reanalysis, persists across all observations, although the magnitude of the relationship varies as the season progresses. Water vapor is well represented by the reanalyses, while CAMS tends to underestimate carbon monoxide especially under high BB. While CAMS aerosol optical depth (AOD) is generally overestimated relative to ORACLES AOD, the observations show a consistent relationship between carbon monoxide (CO) and aerosol extinction, demonstrating the utility of the CO tracer to understanding vertical aerosol distribution. We next use k-means clustering of the reanalyses to examine multi-year seasonal patterns and distributions. We identify canonical profile types of humidity and of CO, allowing us to characterize changes in vapor and BB atmospheric structures, and their impacts as they covary. While the humidity profiles show a range in both total water vapor concentration and in vertical structure, the CO profiles primarily vary in terms of maximum concentration, with similar vertical structures in each. The distribution of profile types varies spatiotemporally across the SEA region and through the season, ranging from largely one type in the northeast and southwest to more evenly distributed between multiple types where air masses meet in the middle of the SEA. These distributions follow patterns of transport from the humid, smoky source region (greatest influence in the northeast of the SEA) and the seasonal changes in both humidity and smoke (increasing and decreasing through the season, respectively). With this work, we establish a framework for a more complete analysis of the broader radiative and dynamical effects of humid aerosols over the SEA.

Biomass burning aerosol (BBA) from agricultural fires in southern Africa contributes about one-third of the global carbonaceous aerosol load. These particles have strong radiative effects in the southeast Atlantic (SEA), which depend in part on the radiative contrast between the aerosol layer in the free troposphere (FT) and the underlying cloud layer. However, there is large disagreement in model estimates of aerosol-driven climate forcing due to uncertainties in the vertical distribution, optical properties, and life cycle of these particles. This study applies a novel method combining remote sensing observations with regional model outputs to investigate the aging of the BBA and its impact on the optical properties during transatlantic transport from emission sources in Africa to the SEA. Results show distinct variations in extinction Ångström exponent (EAE) and single-scattering albedo (SSA) as aerosols age. Near the source, fresh aerosols are characterized by low mean SSA (0.84) and high EAE (1.85), indicating smaller, highly absorbing particles. By isolating marine contributions from the total column during BBA transport across the SEA, our analysis reveals an initial decrease in BBA absorptivity, with mean FT SSA of 0.87 after 6–7 d, followed by increased absorptivity with mean FT SSA of 0.84 after 10 d, suggesting enhanced absorption due to chemical aging. These findings indicate that BBA becomes more absorbing during extended transport across the SEA, with implications for reducing model uncertainties. Our remote-sensing-based results agree well with previous in situ studies and offer new insights into aerosol–radiation interactions and the energy balance over the SEA.

Marine stratocumulus cloud properties over the Southeast Atlantic Ocean are impacted by contact between above-cloud biomass burning aerosols and cloud tops. Different vertical separations (0 to 2000 m) between the aerosol layer and cloud tops were observed on six research flights in September 2016 during the NASA ObseRvations of Aerosols above CLouds and their intEractionS (ORACLES) field campaign. There were 30 contact profiles, where an aerosol layer with aerosol concentration (Na) > 500 cm−3 was within 100 m of cloud tops, and 41 separated profiles, where the aerosol layer with Na > 500 cm−3 was located more than 100 m above cloud tops. For contact profiles, the average cloud droplet concentration (Nc) in the cloud layer was up to 68 cm−3 higher, the effective radius (Re) up to 1.3 µm lower, and the liquid water content (LWC) within 0.01 g m−3 compared to separated profiles. Free-tropospheric humidity was higher in the presence of biomass burning aerosols, and contact profiles had a smaller decrease in humidity (and positive buoyancy) across cloud tops with higher median above-cloud Na (895 cm−3) compared to separated profiles (30 cm−3). Due to droplet evaporation from entrainment mixing of warm, dry free-tropospheric air into the clouds, the median Nc and LWC for contact profiles decreased with height by 21 and 9 % in the top 20 % of the cloud layer. The impact of droplet evaporation was stronger during separated profiles as a greater decrease in humidity (and negative buoyancy) across cloud tops led to greater decreases in median Nc (30 %) and LWC (16 %) near cloud tops. Below-cloud Na was sampled during 61 profiles, and most contact profiles (20 out of 28) were within high-Na (> 350 cm−3) boundary layers, while most separated profiles (22 out of 33) were within low-Na (< 350 cm−3) boundary layers. Although the differences in below-cloud Na were statistically insignificant, contact profiles within low-Na boundary layers had up to 34.9 cm−3 higher Nc compared to separated profiles. This is consistent with a weaker impact of droplet evaporation in the presence of biomass burning aerosols within 100 m above cloud tops. For contact profiles within high-Na boundary layers, the presence of biomass burning aerosols led to higher below-cloud Na (up to 70.5 cm−3) and additional droplet nucleation above the cloud base along with weaker droplet evaporation. Consequently, the contact profiles in high-Na boundary layers had up to 88.4 cm−3 higher Nc compared to separated profiles. These results motivate investigations of aerosol–cloud–precipitation interactions over the Southeast Atlantic since the changes in Nc and Re induced by the presence of above-cloud biomass burning aerosols are likely to impact precipitation rates, liquid water path, and cloud fraction, and modulate closed-to-open-cell transitions.