Racial differences in exposure to environmental tobacco smoke among children

Exposure to environmental tobacco smoke (ETS) is a major cause of morbidity and mortality among U.S. children. Despite African-American children's having a lower reported exposure to tobacco compared to whites, they suffer disproportionately from tobacco-related illnesses and have higher levels of serum cotinine than white children. The goal of this study was to test whether African-American children have higher levels of serum and hair cotinine, after accounting for ETS exposure and various housing characteristics. We investigated the level of cotinine in both hair and serum in a sample of 222 children with asthma. Using a previously validated survey for adult smokers, we assessed each child's exposure to ETS. We collected detailed information on the primary residence, including home volume, ventilation, and overall home configuration. Despite a lower reported ETS exposure, African-American children had higher mean levels of serum cotinine (1.41 ng/mL vs. 0.97 ng/mL; p = 0.03) and hair cotinine (0.25 ng/mg vs. 0.07 ng/mg; p < 0.001) compared with white children. After adjusting for ETS exposure, housing size, and other demographic characteristics, serum and hair cotinine levels remained significantly higher in African-American children (ss = 0.34, p = 0.03) than in white children (ss = 1.06, p < 0.001). Housing volume was significantly associated with both serum and hair cotinine but did not fully explain the race difference. Our results demonstrate that, despite a lower reported exposure to ETS, African-American children with asthma had significantly higher levels of both serum and hair cotinine than did white children. Identifying causes and consequences of increased cotinine may help explain the striking differences in tobacco-related illnesses.

Risk factors for atopic eczema in school children

OBJECTIVES: to study risk factors related to atopic eczema (AE) in school children of São Paulo. METHODS: 1972 parents or guardians of 6-7 years old children in the Southern Central area of São Paulo answered to a written questionnaire (standardized questionnaire of the International Study of Asthma and Allergies in Childhood plus a complementary questionnaire regarding family history of asthma and allergies, and exposure to environmental allergens). AE was defined by the presence of an itchy rash in the last year. Risk factors were analyzed through logical regression. RESULTS: the following factors were significantly associated with AE: history of maternal (OR: 4.1; 95%CI: 2.4 to 7.1) and paternal eczema (OR: 2.6; 95%CI: 1.4 to 5.0), dust in the child's bedroom (OR: 1.6; 95%CI: 1.1 to 2.4), lower maternal education (OR: 1.7; 95%CI: 1.1 to 2.7), rhinitis fever (OR: 1.7; 95%CI: 1.1 to 2.9) and wheezing in the last year (OR: 1.9; 95%CI: 1.2 to 2.8). CONCLUSIONS: our data suggest that AE has a specific pattern of inheritance. The presence of dust in the child's bedroom was the single environmental risk factor found. Diagnose of other allergic diseases, as well as the presence of recent symptoms were strongly associated with AE in children.

Extent of exposure to environmental tobacco smoke (ETS) and its dose-response relation to respiratory health among adults

Background

There is a dearth of standardized studies examining exposure to environmental tobacco smoke (ETS) and its relationship to respiratory health among adults in developing countries.

Methods

In 2004, the Syrian Center for Tobacco Studies (SCTS) conducted a population-based survey using stratified cluster sampling to look at issues related to environmental health of adults aged 18–65 years in Aleppo (2,500,000 inhabitants). Exposure to ETS was assessed from multiple self-reported indices combined into a composite score (maximum 22), while outcomes included both self-report (symptoms/diagnosis of asthma, bronchitis, and hay fever), and objective indices (spirometric assessment of FEV₁ and FVC). Logistic and linear regression analyses were conducted to study the relation between ETS score and studied outcomes, whereby categorical (tertiles) and continuous scores were used respectively, to evaluate the association between ETS exposure and respiratory health, and explore the dose-response relationship of the association.

Results

Of 2038 participants, 1118 were current non-smokers with breath CO levels ≤ 10 ppm (27.1% men, mean age 34.7 years) and were included in the current analysis. The vast majority of study participants were exposed to ETS, whereby only 3.6% had ETS score levels ≤ 2. In general, there was a significant dose-response pattern in the relationship of ETS score with symptoms of asthma, hay fever, and bronchitis, but not with diagnoses of these outcomes. The magnitude of the effect was in the range of twofold increases in the frequency of symptoms reported in the high exposure group compared to the low exposure group. Severity of specific respiratory problems, as indicated by frequency of symptoms and health care utilization for respiratory problems, was not associated with ETS exposure. Exposure to ETS was associated with impaired lung function, indicative of airflow limitation, among women only.

Conclusions

This study provides evidence for the alarming extent of exposure to ETS among adult non-smokers in Syria, and its dose-response relationship with respiratory symptoms of infectious and non-infectious nature. It calls for concerted efforts to increase awareness of this public health problem and to enforce regulations aimed at protecting non-smokers.

[Passive smoking]

INTRODUCTION

Environmental tobacco smoke is a recognized factor of morbidity and mortality. The first victims are children, sometimes starting from conception, but adults are not spared. In practice, evaluation of exposure to tobacco smoke can be achieved with more or less specific markers of tobacco smoke.

CURRENT KNOWLEDGE

Exposure of the fetus to maternal smoking and of the infant to environmental smoke can have a serious sometimes life-threatening impact. Such exposure increases the risk of spontaneous abortion, ectopic pregnancy, intrauterine growth retardation, premature membrane rupture, preterm birth, retroplacental hematoma, placenta praevia, and sudden infant death. Adult respiratory and cardiovascular disease are also influenced by environmental smoke. In France passive smoking causes premature death of 3000 persons per year.

PERSPECTIVES

Better knowledge of the risks of exposure to passive smoking can facilitate application of legislation with the objective of protecting non-smokers.

CONCLUSIONS

Rigorous application of current legislation is important to achieve the stated goals of prevention of smoking as well as assistance to cease smoking.

Modern diagnosis and treatment of primary eosinophilia

The recent discovery of an eosinophilia-specific, imatinib-sensitive, karyotypically occult but fluorescence in situ hybridization-apparent molecular lesion in a subset of patients with blood eosinophilia has transformed the diagnostic as well as treatment approach to eosinophilic disorders. Primary (i.e. nonreactive) eosinophilia is considered either "clonal" or "idiopathic" based on the presence or absence, respectively, of either a molecular or bone marrow histological evidence for a myeloid neoplasm. Clonal eosinophilia might accompany a spectrum of clinicopathological entities, the minority of whom are molecularly characterized; Fip1-like-1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRA(+)) systemic mastocytosis, platelet-derived growth factor receptor beta (PDGFRB)-rearranged atypical myeloproliferative disorder, chronic myeloid leukemia, and the 8p11 syndrome that is associated with fibroblast growth factor receptor 1 (FGFR1) rearrangement. Hypereosinophilic syndrome (HES) is a subcategory of idiopathic eosinophilia and is characterized by an absolute eosinophil count of > or =1.5 x 10(9)/l for at least 6 months as well as eosinophil-mediated tissue damage. At present, a working diagnosis of primary eosinophilia mandates a bone marrow examination, karyotype analysis, and additional molecular studies in order to provide the patient with accurate prognostic information as well as select appropriate therapy. For example, the presence of either PDGFRA or PDGFRB mutations warrants the use of imatinib in clonal eosinophilia. In HES, prednisone, hydroxyurea, and interferon-alpha constitute first-line therapy, whereas imatinib, cladribine, and monoclonal antibodies to either interleukin-5 (mepolizumab) or CD52 (alemtuzumab) are considered investigational. Allogeneic transplantation offers a viable treatment option for drug-refractory cases.

Exposure to environmental tobacco smoke and cognitive abilities among U.S. children and adolescents

We used the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, to investigate the relationship between environmental tobacco smoke (ETS) exposure and cognitive abilities among U.S. children and adolescents 6-16 years of age. Serum cotinine was used as a biomarker of ETS exposure. Children were included in the sample if their serum cotinine levels were less than or equal to 15 ng/mL, a level consistent with ETS exposure, and if they denied using any tobacco products in the previous 5 days. Cognitive and academic abilities were assessed using the reading and math subtests of the Wide Range Achievement Test-Revised and the block design and digit span subtests of the Wechsler Intelligence Scale for Children-III. Analyses were conducted using SUDAAN software. Of the 5,365 6- to 16-year-olds included in NHANES III, 4,399 (82%) were included in this analysis. The geometric mean serum cotinine level was 0.23 ng/mL (range, 0.035-15 ng/mL); 80% of subjects had levels < 1 ng/mL. After adjustment for sex, race, region, poverty, parent education and marital status, ferritin, and blood lead concentration, there was a significant inverse relationship between serum cotinine and scores on reading (beta = -2.69, p = 0.001), math (beta = -1.93, p = 0.01), and block design (beta = -0.55, p < 0.001) but not digit span (beta = -0.08, p = 0.52). The estimated ETS-associated decrement in cognitive test scores was greater at lower cotinine levels. A log-linear analysis was selected as the best fit to characterize the increased slope in cognitive deficits at lower levels of exposure. These data, which indicate an inverse association between ETS exposure and cognitive deficits among children even at extremely low levels of exposure, support policy to further restrict children's exposure.

The midluteal decline in serum estradiol levels is drastic but not deleterious for implantation after in vitro fertilization and embryo transfer in patients with normal or high responses

OBJECTIVE

To determine the impact of the peak E(2) level and its midluteal decline on IVF-ET outcome in a group of normal- and high-responding patients.

DESIGN

Retrospective analysis of IVF-ET data.

SETTING

Tertiary-care, university-affiliated teaching hospital.

PATIENT(S)

A total of 100 patients aged </=38 years and receiving up to three embryos per transfer who underwent a similar standard controlled ovarian hyperstimulation for IVF-ET.

INTERVENTION(S)

Morning blood was collected on days 0 (hCG day), +9, and +14.

MAIN OUTCOME MEASURE(S)

Treatment cycle hormonal characteristics and percent midluteal E(2) decline in conception and nonconception cycles.

RESULT(S)

Among all cycles, a mean decline of 95.0% in serum E(2) was observed at the midluteal phase. No significant differences were found in various parameters comparing conception with nonconception cycles. Occurrence of conception did not correlate with the absolute E(2) level or with percent E(2) decline in good and high responders. Early spontaneous abortion occurred more frequently in high responders with >98% E(2) decline; however, the difference did not reach statistical significance.

CONCLUSION(S)

Multifactorial analysis refutes the negative role of supraphysiologic levels of E(2) on the day of hCG administration or its dramatic decline at the midluteal phase on the success rate after embryo transfer. A possibly increased rate of early spontaneous abortion in the high-response group warrants further verification.

Respiratory symptoms in relation to residential coal burning and environmental tobacco smoke among early adolescents in Wuhan, China: a cross-sectional study

BACKGROUND

Cigarette smoking and coal burning are the primary sources of indoor air pollution in Chinese households. However, effects of these exposures on Chinese children's respiratory health are not well characterized.

METHODS

Seventh grade students (N = 5051) from 22 randomly selected schools in the greater metropolitan area of Wuhan, China, completed an in-class self-administered questionnaire on their respiratory health and home environment.

RESULTS

Coal burning for cooking and/or heating increased odds of wheezing with colds [odds ratio (OR) = 1.57, 95% confidence interval (CI): 1.07-2.29] and without colds (OR = 1.44, 95% CI: 1.05-1.97). For smoking in the home, the strongest associations were seen for cough (OR = 1.74, 95% CI: 1.17-2.60) and phlegm production (OR = 2.25, 95% CI: 1.36-3.72) without colds among children who lived with two or more smokers.

CONCLUSIONS

Chinese children living with smokers or in coal-burning homes are at increased risk for respiratory impairment. While economic development in China may decrease coal burning by providing cleaner fuels for household energy use, the increasing prevalence of cigarette smoking is a growing public health concern due to its effects on children. Adverse effects of tobacco smoke exposure were seen despite the low rates of maternal smoking (3.6%) in this population.

The effect of educational level on the incidence of asthma and respiratory symptoms

Few studies have examined the impact of socioeconomic status on the incidence of asthma and respiratory symptoms. Between 1985 and 1996/97, we conducted an 11-years community cohort study with 2819 subjects, aged 15-70 years at baseline, in Western Norway. We examined the cumulative incidence of asthma and respiratory symptoms by educational level (primary, secondary, and university), as well as estimating the odds ratios (ORs) of educational level on the incidences, after adjustment for sex, age, hay fever, smoking habits, pack years, and occupational exposure. For all respiratory symptoms, the incidences decreased with increasing educational level. The cumulative incidence of asthma was 5.3%, 4.1%, and 1.8%, respectively, for those with a primary educational level, secondary educational level, and university level. Subjects with a primary educational level had adjusted ORs (95% CI) from 1.4 (0.9, 2.3) for the incidence of chronic cough to 2.5 (1.6, 4.0) for the incidence of dyspnea grade 2, compared to those with a university level education. The adjusted OR (95% CI) for the incidence of asthma was 2.1 (1.01, 4.4) in subjects with a primary educational level, and 2.0 (1.04, 3.6) in subjects with a secondary educational level, compared to subjects with a university educational level. In conclusion, subjects with a lower educational level had a higher risk of developing asthma and respiratory symptoms, after adjustment for sex, age, hay fever, smoking, and occupational exposure.

Respiratory health consequences of environmental tobacco smoke

Over the last several decades there has been a growing interest in examining the health consequences of environmental tobacco smoke (ETS). As a result of a wide body of research, ETS is now considered an unacceptable and entirely preventable public health hazard, and public policy increasingly discourages the presence of tobacco smoke in the public domain. This article provides an overview of the composition of ETS and the major diseases and disorders strongly linked to ETS, emphasizing the effects of ETS on pulmonary function, asthma, and lung cancer.

Rationale for the Dutch hypothesis. Allergy and airway hyperresponsiveness as genetic factors and their interaction with environment in the development of asthma and COPD

The Dutch hypothesis, formulated in the 1960s, holds that the various forms of airway obstruction are different expressions of a single disease entity. It suggests that genetic factors (eg, airway hyperresponsiveness [AHR] and atopy), endogenous factors (eg, sex and age), and exogenous factors (eg, allergens, infections, and smoking) all play a role in the pathogenesis of chronic nonspecific lung disease. This review finds evidence that AHR and smoking are common risk factors for asthma and COPD. To prove the Dutch hypothesis definitively, however, genetic studies, preferably longitudinal, must be performed. Such studies must include subjects who have airway obstruction that does not necessarily meet the current strict definitions of asthma or COPD (ie, the extremes of these conditions) that are used in clinical studies.

Efficiency issues in sedation and monitoring

Sedation and monitoring are key elements of the endoscopy process. There continues to be intense study of better methods for sedation and monitoring to improve the endoscopic "experience" for both patient and physicians alike. Our current practices will likely change in the future with technologic advances (monitoring) and expansion of our pharmacologic armamentarium (sedation).

Could immunosuppressive drugs reduce recurrence rate after second resection for Crohn disease?

BACKGROUND

The aim of this study was to assess the possible benefit of postoperative immunosuppressive drugs administration (ie, azathioprine, 6-mercaptopurine, or methotrexate) on long-term surgical recurrence rate after second anastomotic ileocolonic resection.

METHODS

From 1984 to 2000, 26 patients with CD underwent second resection for ileocolonic anastomotic recurrence. There were 14 women and 12 men (mean age +/- SD: 34 +/- 9 years). Two groups of patients were compared according to the postoperative treatment: immunosuppressive (IS) drugs group was composed of 14 patients, and control group was composed of 12 patients receiving either salicylates (n = 5) or no treatment (n = 7).

RESULTS

Clinical recurrence rate at 3 years was significantly lower in the IS group than in the control group (3/12, 25% vs 6/10, 60%; P < 0.05). Although not significant, after a mean follow-up of 80 +/- 46 months (extr. 17-178 months) after the second resection, clinical recurrence rate at follow-up was also lower in IS group (6/14, 43%) than in control group (9/12, 75%). The mean delay of recurrence was similar in both groups (27 +/- 13 months vs 28 +/- 21; NS). A third intestinal resection was performed less frequently in the IS group than in control group (2/14, 17% vs 7/12, 58%; P < 0.02).

CONCLUSIONS

In patients treated with IS drugs, the rate of postoperative recurrence after second ileocolonic CD resection is lower than in untreated patients. Our results suggest that IS drugs should be evaluated prospectively for prevention of second postoperative CD recurrence.

Systematic review: has disease outcome in Crohn's disease changed during the last four decades?

BACKGROUND

Disease outcome in Crohn's disease might have changed during the last four decades. Disease outcome measurement in Crohn's disease has methodological difficulties because of patient selection and lack of proper definition of diagnostic and outcome measurement criteria.

AIM

To assess possible changes in disease outcome in Crohn's disease during the last four decades.

METHODS

A systematic literature search was performed using the MEDLINE search engine and major international conference libraries. Articles and abstracts were selected according to stringent inclusion criteria.

RESULTS

Forty articles and nine abstracts complied with the inclusion criteria. Seven studies with a median follow-up time between 11.1 and 17 years showed standard mortality ratios in Crohn's disease ranging between 2.16 and 0.72 with a tendency of decline during the last four decades. One study with 11.4 years mean follow-up time showed a statistically significant increased relative risk for colorectal cancer that was not confirmed by three others. Sixteen publications applied in the disease recurrence category. Probability of first resective surgery ranged between 38 and 96% during the first 15 years after diagnosis. The overall recurrence and surgical recurrence rates after first resective surgery ranged between 50 and 60, and 28 and 45% respectively during the following 15 years without an apparent time trend.

CONCLUSION

This structured literature review provides no hard evidence for change in disease outcome in Crohn's disease during the last four decades.

Cholinergic systems in brain development and disruption by neurotoxicants: nicotine, environmental tobacco smoke, organophosphates

Acetylcholine and other neurotransmitters play unique trophic roles in brain development. Accordingly, drugs and environmental toxicants that promote or interfere with neurotransmitter function evoke neurodevelopmental abnormalities by disrupting the timing or intensity of neurotrophic actions. The current review discusses three exposure scenarios involving acetylcholine systems: nicotine from maternal smoking during pregnancy, exposure to environmental tobacco smoke (ETS), and exposure to the organophosphate insecticide, chlorpyrifos (CPF). All three have long-term, adverse effects on specific processes involved in brain cell replication and differentiation, synaptic development and function, and ultimately behavioral performance. Many of these effects can be traced to the sequence of cellular events surrounding the trophic role of acetylcholine acting on its specific cellular receptors and associated signaling cascades. However, for chlorpyrifos, additional noncholinergic mechanisms appear to be critical in establishing the period of developmental vulnerability, the sites and type of neural damage, and the eventual outcome. New findings indicate that developmental neurotoxicity extends to late phases of brain maturation including adolescence. Novel in vitro and in vivo exposure models are being developed to uncover heretofore unsuspected mechanisms and targets for developmental neurotoxicants.

Glutathione S transferase deficiency and passive smoking increase childhood asthma

BACKGROUND

It has been suggested that the genetically determined deficiency of glutathione S transferase (GST) enzymes involved in the detoxification of environmental tobacco smoke (ETS) components may contribute to the development of asthma.

METHODS

A large population of German schoolchildren (n = 3054) was genotyped for deficiencies of the GST isoforms M1 and T1. The association between GSTM1 and GSTT1 genotypes and asthma as well as atopy was investigated with respect to current and in utero ETS exposure.

RESULTS

In children lacking the GSTM1 allele who were exposed to current ETS the risk for current asthma (OR 5.5, 95% CI 1.6 to 18.6) and asthma symptoms such as wheeze ever (OR 2.8, 95% CI 1.3 to 6.0), current wheezing (OR 4.7, 95% CI 1.8 to 12.6) and shortness of breath (OR 8.9, 95% CI 2.1 to 38.4) was higher than in GSTM1 positive individuals without ETS exposure. Hints of an interaction between ETS exposure and GSTM1 deficiency were identified. In utero smoke exposure in GSTT1 deficient children was associated with significant decrements in lung function compared with GSTT1 positive children not exposed to ETS.

CONCLUSIONS

GSTM1 and GSTT1 deficiency may increase the adverse health effects of in utero and current smoke exposure.

Sex and gender differences in lung development and their clinical significance

Factors that affect airway growth-as early in development as in utero-seem to cause physiologic effects that can be persistent. Reduced airway function early in life does not necessarily result in persistent symptoms, but it does increase the risk of reduced lung function and the development of persistent airflow limitation in adult life, both in men and women. Normal lung growth varies with age and sex and is affected by a number of risk factors, which we have described. The importance of the various risk factors may differ depending at what point during lung growth they come into play and whether they occur in men or in women.

Propofol for Sedation in the Endoscopy Setting

Intravenous sedation is routinely administered for endoscopic examinations to help alleviate patient anxiety and discomfort. The goal of moderate sedation is to provide patient comfort to facilitate the completion of the procedure. Nurse administration of intravenous meperidine and midazolam under the direct supervision of the gastroenterologist is the traditional method for achieving this outcome. More recently, physicians have been requesting monitored anesthesia care for the administration of propofol when performing procedures expected to be technically difficult. Propofol is a rapid acting sedative-hypnotic that produces the desired level of consciousness without the residual sedative effect that often persists with the use of benzodiazepines and analgesics. This article reviews current literature regarding the use of propofol for sedation of patients in the endoscopy setting, and highlights the trends in research that may impact future nursing practice.

Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam

BACKGROUND

Propofol provides several benefits over benzodiazepine and narcotic agents as a sedative medication for endoscopic procedures, including faster recovery and improved patient satisfaction. However, its use generally has been limited to anesthesiologists because of the risks associated with deep sedation.

METHODS

One hundred patients undergoing colonoscopy or EGD were sedated with low-dose propofol, midazolam, and fentanyl (or meperidine). Depth of sedation was assessed at 2-minute intervals by an independent observer by using the American Society of Anesthesiologists criteria. Recovery time was determined by using paired neuropsychometric tests. A post-procedure satisfaction survey and 24-hour follow-up questionnaires were administered.

RESULTS

For colonoscopy and EGD, respectively, the mean propofol dose was 98 mg and 79 mg, the mean midazolam dose was 0.9 mg and 0.8 mg, the mean fentanyl dose was 69 mcg and 63 mcg, and the mean meperidine dose was 42 mg (for both procedures). There were 628 assessments of the level of sedation performed during 74 colonoscopies and 101 assessments during 26 EGDs. The level of sedation was minimal in 77%, moderate in 21%, and deep in 2% of assessments. Nine of the 13 episodes of deep sedation were recorded during colonoscopy and 4 during EGD. In no instance was more than a single assessment of deep sedation recorded during one procedure. Ninety-eight percent of patients were satisfied with the sedation, and 71% returned to their usual activities within 2 hours of discharge. There was no serious adverse event.

CONCLUSIONS

Endoscopic sedation with low-dose propofol, a narcotic agent, and midazolam produces a moderate level of sedation. The quality of sedation and measures of recovery are comparable with the results reported with standard-dose propofol.

Development of lung function in early life: influence of birth weight in infants of nonsmokers

This study aimed to compare lung growth and development during the first year of life in healthy term infants of low or appropriate birth weight for gestation. Paired measurements of forced expiratory volume in 0.4 second, FVC, and forced expiratory flow when 75% of FVC has been exhaled were obtained, using the raised volume technique, at about 7 weeks and 9 months of age in 80 infants (32 low and 48 appropriate birth weight for gestation) of white, nonsmoking mothers. Forced flows and volumes increased with growth. Longitudinal trends in results were compared between the two groups, using random effects modeling and adjusted for potential confounding factors. After adjustment for sex, age, and length, forced expiratory volume was significantly reduced by an average (95% confidence interval) of 9% (2 to 16%) in low birth weight compared with appropriate birth weight for gestation infants throughout the first year of life, with a similar trend in forced expiratory flow (8% [-2 to 17%]) and FVC (4% [-3 to 11%]). These findings suggest that lung function is reduced in low birth weight for gestation infants born to nonsmoking white mothers and that this is independent of somatic growth during infancy.

Side-to-side isoperistaltic strictureplasty in the treatment of extensive Crohn's disease

BACKGROUND

First performed in 1992, the side-to-side isoperistaltic strictureplasty (SSIS) is a bowel-sparing surgical option for Crohn's patients presenting with sequentially occurring stenoses over long intestinal segments (>15 cm). This investigation was designed to study the outcomes and patterns of recurrence after a SSIS.

MATERIALS AND METHODS

Between 1992 and 2003, 30 patients underwent SSIS at the University of Chicago. Their data were gathered prospectively in an Institutional Review Board-approved database.

RESULTS

A total of 31 SSISs were constructed in 30 patients. As an indication of the severity of disease in these patients, 25 of 30 (83%) required a concomitant bowel resection, and 13 (43%) underwent at least one additional strictureplasty. The average length of diseased bowel used to construct the SSIS was 51 cm. The average length of residual small bowel after performance of SSIS was 275 cm, and the SSIS represented an average 19% of the remaining small bowel that would have otherwise been sacrificed with resection. Three patients experienced perioperative complications (10%) and one died (3%). Seven patients (23%) required reoperation to treat recurrence of symptoms within the first 5 years. In four of these patients, recurrence was found at or near the previous SSIS.

CONCLUSIONS

A side-to-side isoperistaltic strictureplasty (SSIS) is a safe and effective surgical option for sequentially occurring Crohn's strictures over long intestinal segments.

Addressing tobacco smoke exposure: passive and active

Many smoking parents are receptive to receiving smoking counseling messages and pediatric health care providers need to increase their efforts to address ETS exposure. Efforts to prevent smoking acquisition should continue by parents, doctors, schools, and the community. Start early in childhood to promote positive family communication and role modeling. Screen for tobacco use or intention and provide counseling to teen without the parent in room. Brief tobacco-dependence interventions are effective. Every patient/parent that uses tobacco should be identified, urged to quit, and offered treatment. Those willing to quit should be provided effective treatments using the "5 A's". Those unwilling to quit should be motivated using "5 R's". Quitting smoking is a major challenge but it is one that many people successfully achieve every day. Even a small increase in smoking cessation can be significant impact from a public health perspective and pediatric providers can play a significant role.

Does passive smoke exposure trigger acute asthma attack in children?

The relationship between asthma and passive smoking has been well established. However, it is still not clear whether an acute asthma attack can be induced by acute smoke exposure. The specific aims of this study were: 1- To assess the degree of smoke exposure through urinary cotinine levels in asthmatic children during and 4 weeks after asthma attacks and, 2- To evaluate the reliability of parental questionnaires in asthmatic children by comparing the data obtained from cotinine measurements and parental reports. Thirty-two consecutive asthmatic children who were admitted to the emergency clinic were included in the study. Parents were asked to complete a questionnaire about their smoking habits and housing conditions. Urinary cotinine and creatinine levels were measured in children during and 4 weeks after the acute asthma attack. The mean age of the patients was 5.7 +/- 3.2 years. The mean attack rate was 3.5 +/- 3.8 per year. Thirty-eight percent of the patients were taking no preventive treatment. In 80 % of patients, urinary cotinine and creatinine ratios (CCR) were significantly above the non-exposed, non-smoker levels. However, CCR levels during acute asthma attacks were not higher than those measured 4 weeks after the acute attack (314.6 +/- 299.1 vs. 203.8 +/- 165.2 ng/mg respectively, p > 0.05). Although parental reports of passive smoke exposure was 71 %, CCR levels revealed that 81 % and 97 % of children were exposed to passive smoke during acute attacks and asymptomatic periods, respectively. In conclusion, although the proportion of children with acute asthma attacks who were exposed to passive smoking was high, the degree of passive smoke exposure was not higher during acute attacks. Parental questionnaires were found to be unreliable in reporting passive smoke exposure in asthmatic children during acute attacks.

The effect of parental smoking on lung function and development during infancy

While the adverse effects of parental smoking on respiratory health during childhood are well recognized, its potential impact on early lung development is less clear. This review summarizes current evidence on the effect of parental smoking on lung function during infancy. It is difficult to separate the effects of pre- and postnatal exposure, since the majority of mothers who smoke in pregnancy (currently around 30% worldwide) continue to do so thereafter. Nevertheless, measurements undertaken prior to any postnatal exposure have consistently demonstrated significant changes in tidal flow patterns in infants whose mothers smoked in pregnancy. While there is, as yet, no convincing evidence from studies in human infants that smoking during pregnancy is associated with increased airway responsiveness at birth, many studies have demonstrated a reduction in forced expiratory flows (on average by 20%) in infants exposed to parental smoking. While maternal smoking during pregnancy remains the most significant source of such exposure and is likely to be responsible for diminished airway function in early life, continuing postnatal tobacco smoke exposure will increase the risk of respiratory infections, the combination of both being responsible for the two- to fourfold increased risk of wheezing illnesses observed during the first year of life in infants whose parents smoke. These findings emphasize the need to keep infants in a smoke-free environment both before and after birth, not least because of growing awareness that airway function in later life is largely determined by that during foetal development and early infancy.

The effect of environmental tobacco smoke on eczema and allergic sensitization in children

BACKGROUND

The negative impact of environmental tobacco smoke (ETS) on airway diseases in children is well known. Whether there is an effect on atopic eczema is not clear.

OBJECTIVES

To determine the impact of ETS on atopic eczema, allergic sensitization and allergic airway diseases in 1669 school beginners.

METHODS

The prevalence of atopy-related health outcomes was assessed by questionnaire, dermatological examination, skin prick testing and specific immunoglobulin E measurement. Exposure assessments were based on measurement of cotinine [expressed as cotinine to creatine ratio (CCR)] in spot urine samples (n = 1220) together with questionnaire and interview data on smoking behaviour of the parents.

RESULTS

In the total study group, prevalence of atopic eczema diagnosed on examination was significantly associated with urinary CCR values. The odds ratio (OR) and 95% confidence interval (CI), calculated for an increase of 100 ng mg-1 CCR was 1.97 (95% CI 1.23-3.16). The prevalence of skin manifestations according to questionnaire data as well as a history of asthma, wheezing, and hay fever were positively although not significantly associated with ETS exposure. When genetically predisposed children (defined by the presence of parental atopy) were compared with children whose parents had no atopy, the ORs of allergic outcome variables were generally higher in the first group. In the group of predisposed children, significant associations with urinary CCR were found for allergic sensitization against house dust mites as measured by skin prick test (OR 3.10, 95% CI 1.63-5.90).

CONCLUSIONS

Children are at a higher risk of developing an atopic eczema when exposed to ETS and genetically predisposed children are at higher risk of developing a sensitization against house dust mites.

Extended/advanced monitoring techniques in gastrointestinal endoscopy

The practice of sedation and analgesia is under increasing scrutiny by numerous regulatory agencies, with the aim of making these procedures safer and reducing the incidence of cardiopulmonary complications during GI endoscopy. As we move toward more evidence-based medicine, new technologies will have to be assessed in a manner that demonstrates their efficacy and utility in clinical practice. Although there have been no controlled studies examining whether more intensive monitoring during endoscopy improves outcomes, extended monitoring with capnography seems to offer an advantage over conventional monitoring in that, by providing a real-time indication of any change in adequate ventilation before oxygen desaturation occurs, it can detect early phases of respiratory depression, which can allow a more precise and safer titration of medications. There is a close agreement among experts that capnography may reduce the risk of adverse outcomes during deep sedation; therefore, its use should be required for patients undergoing advanced endoscopic procedures with the potential for deep sedation. Extended monitoring with capnography should also be endorsed whenever propofol is considered as an alternative to standard sedation with a benzodiazepine or narcotic. Our understanding of the clinical application of techniques for monitoring of depth of sedation is in its infancy, and its full contribution to the practice of endoscopy has yet to be determined. Their potential role in improving sedation practice during endoscopy needs to be confirmed by controlled trials. If we consider the lack of proven efficacy of these emerging monitoring techniques in reducing the adverse outcomes associated with sedation and analgesia, the importance of appropriate monitoring cannot be overemphasized. However, it is vital for the endoscopist to be thoroughly familiar with the type of sedation chosen, to be able to recognize the various levels of sedation, and, above all, to rescue patients should they unintentionally progress to a deeper level of sedation than intended.

Crohn's disease patients who quit smoking have a reduced risk of reoperation for recurrence

BACKGROUND

Smoking increases the risk of recurrent Crohn's disease (CD).

METHODS

We examined the impact of smoking, quitting smoking, and other factors on reoperation for recurrent CD. We distributed questionnaires to 584 patients from a surgical database whom had undergone a surgical operation for ileocecal CD to assess history of smoking, medical, behavioral, and demographic information.

RESULTS

Two hundred sixty-seven patients completed the questionnaire (46% response). Smokers were more likely to have undergone 1, 2, and 3 reoperations for recurrence at any site (relative incidence rates [RIR] 1.32, 95% confidence interval [CI]: 1.10 to 1.60; RIR 1.55, 95% CI: 1.09 to 2.20; and RIR 1.77, 95% CI: 1.02 to 3.06, respectively) and were more likely to have undergone one reoperation for recurrent ileocecal CD (RIR 1.48, 95% CI: 1.18 to 1.86). Patients who quit smoking were less likely to have undergone 1, 2, and 3 reoperations for recurrence at any site (RIR 0.25, 95% CI: 0.15 to 0.41; RIR 0.30, 95% CI: 0.16 to 0.57; and RIR 0.25, 95% CI: 0.10 to 0.71, respectively) and were less likely to have undergone one reoperation for recurrent ileocecal CD (RIR 0.27, 95% CI: 0.15 to 0.47).

CONCLUSIONS

This study indicates that patients with ileocecal CD who stop smoking reduce the risk of reoperation for recurrent CD.

Propofol: a gastroenterologist's perspective

The use of propofol for GI endoscopy has left the realm of experimentation and is now a viable alternative to standard sedation and analgesia. In the hands of appropriately trained gastroenterologists and registered nurses, propofol has been shown to be superior to standard sedation and analgesia in terms of patient satisfaction and comfort and shorter recovery parameters. Comparative studies have found it to be as safe as the regimens that are used for standard sedation and analgesia. Its narrow therapeutic window demands that specially trained personnel who are not directly involved in the endoscopic procedure administer it. Cost-effectiveness data suggest that propofol is superior to conventional sedation and analgesia, even with the use of added personnel.The importance of pre-procedural assessment and appropriate monitoring cannot be overemphasized. The endoscopist must have a thorough knowledge of the pharmacology of the agents used for sedation and the training necessary to recognize and manage over sedation. Numerous regulatory groups are carefully scrutinizing the practice of sedation and analgesia. It seems that ventilatory monitoring will be required for at least a subset of patients. Although hypercapnia and apnea can be reliably measured, the most important questions to be answered are if such monitoring affects patient outcomes and which patients are at risk for apnea and alveolar hypoventilation.

Second-hand smoke exposure and blood lead levels in U.S. children

BACKGROUND

Lead is a component of tobacco and tobacco smoke, and smokers have higher blood lead levels than do nonsmokers.

METHODS

We examined the relation between second-hand smoke exposure and blood lead levels in a nationally representative sample of 5592 U.S. children, age 4-16 years, who participated in the Third National Health and Nutrition Examination Survey (1988-1994). Linear and logistic regression modeling was used to adjust for known covariates.

RESULTS

Geometric mean blood lead levels were 1.5 mug/dL, 1.9 mug/dL, and 2.6 mug/dL for children with low, intermediate, and high cotinine levels, respectively. The adjusted linear regression model showed that geometric mean blood lead levels were 38% higher (95% confidence interval [CI] = 25-52%) in children with high cotinine levels compared with children who had low cotinine levels. The logistic regression models showed that children with high cotinine levels were more likely to have blood lead levels >/=10 mug/dL than were children with low cotinine levels (odds ratio [OR] = 4.4; CI = 1.9-10.5).

CONCLUSIONS

Second-hand smoke could be associated with increased blood lead levels in U.S. children aged 4-16 years.

Luteal phase support in assisted reproduction cycles

BACKGROUND

The aspiration of the granulosa cells that surround the oocyte and the use of gonadotropin releasing hormone agonists (GnRHa) during assisted reproduction technology (ART) treatment can interfere with the production, during the luteal phase, of progesterone, which is necessary for successful implantation of the embryo. Providing hormonal supplementation during the luteal phase with either progesterone itself, or human chorionic gonadotropin (hCG), which stimulates progesterone production, may improve implantation and, thus, pregnancy rates.

OBJECTIVES

To determine (1) if luteal phase support after assisted reproduction increases the pregnancy rate, (2) the optimal hormone for luteal phase support, i.e. hCG, progesterone, or a combination of both, and (3) the optimal route of progesterone administration.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1971 to Dec 2003), EMBASE (1985 to Dec 2003). We handsearched reference lists of relevant articles were scanned, and abstract books from scientific meetings up to December 2003.

SELECTION CRITERIA

Randomized controlled trials of luteal phase support after ART treatment, comparing hCG or progesterone with placebo or no treatment, comparing progesterone with hCG, progesterone plus hCG, or progesterone plus estrogen, or comparing different routes of progesterone administration. Quasi-randomized trials were excluded from the main analyses, but included in a secondary analysis for each comparison.

DATA COLLECTION AND ANALYSIS

For each comparison, data on live birth, ongoing and clinical pregnancy per embryo or gamete transfer procedure, miscarriage per clinical pregnancy, ovarian hyperstimulation syndrome (OHSS) per transfer, and multiple pregnancy per clinical pregnancy were extracted into 2 x 2 tables and subgrouped by use of GnRHa in the ovarian stimulation regimen. The odds ratio (OR) and risk difference (RD) were calculated.

MAIN RESULTS

Fifty-nine studies were included in the review. Luteal phase support with hCG provided significant benefit, compared to placebo or no treatment, in terms of increased ongoing pregnancy rates (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.32 to 4.29) and decreased miscarriage rates (OR 0.12, 95% CI 0.03 to 0.50), but only when GnRHa was used. The odds of OHSS increased 20-fold when hCG was used in cycles with GnRHa. Progesterone use resulted in a small but significant increase in pregnancy rates (OR 1.34, 95% CI 1.01 to 1.79) when trials with and without GnRHa were grouped together, but no effect on the miscarriage rate was observed. No significant difference was found between progesterone and hCG or between progesterone and progesterone plus hCG or estrogen in terms of pregnancy or miscarriage rates, but the odds of OHSS were more than 2-fold higher with treatments involving hCG than with progesterone alone(OR 3.06, 95% CI 1.59 to 5.86). Comparing routes of progesterone administration, reductions in clinical pregnancy rate with the oral route, compared to the intramuscular or vaginal routes, did not reach statistical significance, but there was evidence of benefit of the intramuscular over the vaginal route for the outcomes of ongoing pregnancy and live birth. No significant difference in pregnancy rate was observed between vaginal progesterone gel and other types of vaginal progesterone.

REVIEWERS' CONCLUSIONS

Luteal phase support with hCG or progesterone after assisted reproduction results in an increased pregnancy rate. hCG does not provide better results than progesterone, and is associated with a greater risk of OHSS when used with GnRHa. The optimal route of progesterone administration has not yet been established.

Technical performance of colonoscopy in patients sedated with nurse-administered propofol

OBJECTIVES

Nurse-administered propofol has gained attention as a safe and effective means of sedation for patients undergoing endoscopic procedures. However, little is known about the effect of propofol on the technical performance of colonoscopy.

METHODS

Three separate studies were conducted. In the first study, we reviewed procedure notes from consecutive colonoscopies performed by a single experienced endoscopist at our hospital endoscopy unit on patients sedated with either nurse-administered propofol (n = 162) or midazolam/narcotic (n = 164). In the second study, 100 eligible colonoscopy outpatients were randomized to receive either nurse-administered propofol (n = 50) or midazolam/fentanyl (n = 50). In both studies, the measured parameters included visualization of the cecum, time required to reach the cecum, repositioning of the patient, and the application of abdominal counterpressure. In a third study, we reviewed the rate of cecal intubation and colonic perforation in the first 2357 patients in our unit receiving nurse-administered propofol.

RESULTS

In the retrospective comparative study, there was no difference in the cecal intubation rate in those receiving propofol (99.4%) compared to those receiving midazolam/narcotic (97%; p= 0.1), and three of five failed cecal intubations in the latter group resulted from obstructing masses. Patients sedated with propofol were repositioned less frequently compared to those receiving midazolam/narcotic (3.7%vs 26.2%) (p < 0.0001). Abdominal pressure was employed in 9.9% of patients sedated with propofol compared to 19.5% (p= 0.01) of those given midazolam/narcotic. The mean time to reach the cecum was lower in the propofol group than in the midazolam/narcotic group (4.6 min vs 6.0 min, p= 0.002). In the prospective randomized study, the endoscopist intubated the cecum in all 100 patients. Patients in the propofol group were repositioned less frequently than those in the midazolam/fentanyl group (2%vs 24%, respectively, p= 0.001). The number of cases requiring abdominal counterpressure was not significantly different between the propofol and midazolam/fentanyl groups (12%vs 24%, respectively, p= 0.1). The mean time to reach the cecum in the propofol group (3.2 min) was similar to that in the midazolam/fentanyl group (3.8 min, p= 0.08). Among the first 2357 patients in our unit undergoing colonoscopy with nurse-administered propofol, the rate of complete colonoscopy was 99.2% and there were no perforations.

CONCLUSION

Nurse-administered propofol sedation is safe and simplifies the technical performance of colonoscopy compared to midazolam/narcotic sedation.

Multivariate analysis suggests improved perioperative outcome in Crohn's disease patients receiving immunomodulator therapy after segmental resection and/or strictureplasty

BACKGROUND

Medical management of moderate to severe Crohn's disease (CD) using immunomodulator agents has not eliminated surgical treatment of disease complications. The effect of improved medical treatment on perioperative CD surgical outcome is not known. We analyzed the impact of immunomodulator therapy on the rate of intraabdominal septic complications (IASC) in CD patients undergoing bowel reanastomosis or strictureplasty.

METHODS

Surgical outcome was reviewed in 100 consecutive CD patients who underwent segmental resection with primary anastomosis or strictureplasty between 1998 and 2002. Multivariate analysis was performed to determine the effect of immunomodulator therapy on rate of IASC (intraabdominal abscess, anastomotic leak, or enterocutaneous fistulae). Immunomodulator agents included azathioprine, 6-MP, methotrexate, and infliximab.

RESULTS

IASC developed in 11 of 100 (11%) operations. Immunomodulator use was associated with fewer IASC (4/72 procedures; 5.6%), compared with 7/28 (25%) cases with patients not on therapy (P<.01). IASC were not influenced by steroid use, smoking status, preoperative abscess, or fistula or albumin levels. Immunomodulator use did not affect the length of resection or the rate and number of strictureplasties.

CONCLUSION

Medical management with immunomodulator therapy is safe and significantly decreases postoperative IASC in CD patients undergoing surgical procedures requiring bowel anastomosis or strictureplasty.

Short bowel syndrome and Crohn's disease

Patients with Crohn's disease are at high risk for recurrent disease and often undergo multiple operations. Our aims were to evaluate surgical management and outcome of patients with Crohn's disease who develop short bowel syndrome (SBS) and to identify factors leading to this complication. We reviewed the records of 170 adult patients with SBS evaluated over a 20-year period. Thirty (18%) had Crohn's disease. SBS was defined as an intestinal remnant less than 180 cm with associated malabsorption. There were 20 women and 10 men ranging in age from 18 to 62 years. Eighteen (60%) presented initially with ileocolonic disease, seven (23%) with colonic disease, and five (17%) with small intestinal disease. The interval from initial diagnosis to development of SBS ranged from 2 to 32 years, with 21 patients (71%) having an interval greater than 15 years. The number of resections leading to SBS varied from 2 to 12 with 24 patients (80%) having four or fewer resections. Nineteen patients (63%) had an ostomy. Small intestinal remnant length was less than 60 cm in 10 patients, 60 to 120 cm in six patients, and greater than 120 cm in 14 patients. Only one patient underwent stricturoplasty before developing SBS. Five patients were initially diagnosed as having ulcerative colitis and underwent a pouch procedure, which was subsequently resected. Twenty patients (67%) required parenteral nutrition. Three patients have undergone reversed intestinal segment to slow intestinal transit. Two patients underwent intestinal transplantation. Two patients have died: one from parenteral nutrition-related liver failure and the other after intestinal transplantation. Crohn's disease remains a common cause of SBS. Aggressive resectional therapy, surgical complications, and errors in initial diagnosis contribute to development of SBS in these patients. Selected patients are candidates for surgical therapy for SBS.

Maternal and personal cigarette smoking synergize to increase airflow limitation in adults

Susceptibility of the lungs to cigarette smoke is poorly understood. It is not known whether maternal smoking increases chronic obstructive pulmonary disease (COPD) risk. In 1998 we reported an inverse association between maternal smoking (prerecorded) and FEV(1) in adults. Because FEV(1) and FVC are strongly correlated, it is unclear whether the association in question reflects a link with lung volume, airflow limitation, or both. We extended our original analysis to investigate whether maternal and personal smoking synergize to increase airflow limitation. We estimated residual FEV(1) to express FEV(1) variation that was not associated with FVC. Maternal smoking was inversely associated with FVC and FEV(1) irrespective of personal smoking. It was inversely associated with FEV(1)/FVC, forced midexpiratory flow rates (FEF(25-75) [mean forced expiratory flow during the middle half of the FVC], FEF(25-75)/FVC), and residual FEV(1) in current smokers but not in never or former smokers (heterogeneity p = 0.016, 0.024, 0.021, and 0.016, respectively). We tested the clinical relevance of findings in ever smokers without asthma: 10 cigarettes/day maternal smoking increased prevalent COPD by 1.7 (95% confidence interval: 1.2-2.5) after adjustment for covariates. Maternal smoking impairs lung volume irrespective of personal smoking and appears to synergize with personal smoking to increase airflow limitation and COPD.

Estimation of the impact on children's health of environmental tobacco smoke in England and Wales

In this paper, the population attributable risk (PAR), a measure of the excess risk of disease associated with a risk factor, is calculated for some of the common adverse health effects that have been associated with exposure of children to environmental tobacco smoke (ETS): childhood lower respiratory illness, chronic middle ear disease, asthma and sudden infant death syndrome (SIDS). Published data on both risk estimates and the percentage of children exposed to ETS in the home (prevalence of ETS) have been utilised. The percentage of childhood lower respiratory illness and middle ear disease typically attributable to ETS from either parent smoking ranged from 9% for asthma prevalence and for referral for glue ear, to 25% for hospital admission for lower respiratory illness. Where data were available to calculate PARs separately for mother only smoking and father only smoking, the PARs were generally larger for mothers only smoking, due mainly to higher odds ratios for mothers only smoking. The PAR for SIDS attributable to ETS from mother only smoking was 11%. Although based on a small number of studies, the PAR for SIDS attributable to smoking of fathers only was similar to that attributable to the smoking of mothers only, largely due to the higher prevalence of households where only the father smokes. This study has shown that the impact of ETS on childhood illness can be considerable, emphasising the importance of the need to develop effective strategies for reducing the risk of ETS exposure in the home and elsewhere.

Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists

BACKGROUND & AIMS

Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy.

METHODS

One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications.

RESULTS

The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5).

CONCLUSIONS

Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.

Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist

BACKGROUND

There is increasing interest in the use of propofol, an ultrashort-acting hypnotic agent, for sedation during endoscopic examinations. A protocol was developed for administration of propofol, combined with small doses of midazolam and meperidine, for endoscopic sedation under the direction of a gastroenterologist. Initial experience with using this protocol is described.

METHODS

A total of 819 consecutive endoscopic examinations under sedation with propofol, midazolam, and meperidine (or fentanyl), in adherence with the sedation protocol, were reviewed retrospectively.

RESULTS

There were 638 colonoscopies and 181 EGDs; 89% of patients were classified as American Society of Anesthesiologists (ASA) class I or II. Mean dosages of medications were: propofol 63 (33.5) mg, meperidine 48 (7.2) mg, and midazolam 1 (0.12) mg. The dose of propofol was inversely correlated with age and ASA class, and positively correlated with patient weight and duration of examination. Hypotension (>20 mm Hg decline in either systolic or diastolic blood pressure) developed in 218 (27%) patients, and hypoxemia (oxygen saturation <90%) developed in 75 (9%). All episodes of hypotension and hypoxemia were transient, and no patient required administration of a pharmacologic antagonist or assisted ventilation. The average time for recovery after colonoscopy and after EGD was, respectively, 25 minutes and 28 minutes. All EGDs and 98% of colonoscopies were completed successfully.

CONCLUSIONS

On the basis of this initial experience, it is believed that propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist. Additional research will be necessary to determine whether propofol is superior to the current methods of sedation.

Addressing parental smoking in pediatrics and family practice: a national survey of parents

BACKGROUND

Parental smoking has been associated with increased rates of sudden infant death syndrome, low birth weight, otitis media, asthma, and decreased lung growth. No prior parent surveys have assessed national rates of screening and counseling for parental tobacco use in the context of their child's visit to primary care.

OBJECTIVE

To assess and compare rates of pediatrician and family practitioner screening and counseling for parental smoking. Design/Methods. Data were collected by telephone survey of households from July to September 2001. The sample is weighted by race and gender based on 1999 US Census estimates to be representative of the US population.

RESULTS

Of 3566 eligible respondents contacted, 3002 (84%) completed surveys; 902 of those were parents who had a child seen by a pediatrician (62%) or family practitioner (38%) in the past year. About half of all parents who visited a pediatrician or family practitioner reported that they had been asked about household member smoking status (52% vs 48%). More parents who visited pediatricians had been asked if they had rules prohibiting smoking in the home than those who visited family practitioners (38% vs 29%). Of 190 (21%) parents who were smokers, fewer than half reported being counseled by either specialty about dangers of second-hand smoke (41% vs 33%) or risks of modeling smoking behavior (31% vs 28%). Similarly, fewer than half of parental smokers received advice to quit (36% vs 45%).

CONCLUSION

Overall rates of screening and counseling for parental smoking in pediatric and family practice are low. Despite some differences between specialties, significant opportunities exist to improve tobacco control activities in primary care settings that serve children.

Respiratory health in Aboriginal and Torres Strait Islander children in the Australian Capital Territory

OBJECTIVES

To measure the prevalence of respiratory symptoms and atopic disease in Aboriginal and Torres Strait Islander (indigenous) and non-indigenous children in the Australian Capital Territory (ACT).

METHODS

A two-stage questionnaire survey of children in the ACT with stage two completed for children identified by parents as having respiratory symptoms or asthma in the first stage cross-sectional survey. Participants in the study were: (i) all new entrant primary schoolchildren aged 4-6 years in 1999, 2000 and 2001, 217 being indigenous children and 10 604 being non-indigenous children (80% of eligible); and (ii) Year 1-6 primary schoolchildren in 2000, with 216 being indigenous children and 14 202 being non-indigenous children (52% of eligible). Respiratory symptoms (including recent wheeze and parent-reported asthma) and other factors were measured by parental questionnaire.

RESULTS

Indigenous kindergarten children had more recent wheeze (21%, odds ratio (OR) 1.4 95% confidence interval (CI) 1.0-2.0)) and parent-reported asthma (24%, OR 1.8 95% CI 1.3-2.5) than non-indigenous children (both 15%). However, indigenous children had less eczema (25%, OR 0.7 95% CI 0.5-0.9) and hayfever (14%, OR 0.7 95% CI 0.5-1.0) than non-indigenous children (32% and 19%, respectively). Among children with respiratory symptoms, the symptom severity did not differ between groups, but indigenous children were exposed to more environmental tobacco smoke (ETS) (63%, OR 3.5 95% CI 2.1-5.9) than non-indigenous children (32%).

CONCLUSIONS

Indigenous children in the ACT have more respiratory morbidity but less of the atopic diseases of hayfever and eczema than non-indigenous children. Whether the respiratory morbidity represents 'asthma' or results from increased ETS exposure is unclear and needs to be further explored.

The economic burden of environmental tobacco smoke in the first year of life

AIMS

To examine the population impact and economic costs associated with environmental tobacco smoke (ETS) in Chinese infants with non-smoking mothers.

METHODS

Prospective, population based birth cohort study in Hong Kong, 1997-98. Main outcome measures were: doctor consultations and hospitalisations; adjusted odds ratios for higher utilisation by service type for each of the ETS exposure variables; corresponding population attributable risks (PARs); and associated extra health care costs.

RESULTS

For the 1997 annual birth cohort, ETS exposure through the mother in utero was positively associated with higher consultation (adjusted odds ratio (OR) 1.26) and hospitalisation (OR 1.18) due to any illness. This translated into 7.4% of all inpatient episodes in the first year of life, representing an additional 1581 hospital attendances that cost over 2.1 million US dollars. The corresponding PAR for outpatient services was 7.7%, where the majority was due to respiratory or febrile illnesses, accounting for 0.44 million dollars in extra costs. Postnatal exposure to ETS at home was linked to higher rates of hospitalisations for any illness compared with non-exposed infants (OR 1.12), which led to 662 extra hospitalisations consuming 0.90 million dollars, where the associated PAR was 3.1%.

CONCLUSIONS

Assuming that ETS was causally associated with health services use, about 9% of the total direct medical costs in the first year of life can be attributed to passive smoking. The community, as well as the private citizen, needs to be made aware of the costs foregone from exposure to tobacco smoke as well as the potential savings from a smoke-free society.

Small bowel length in Crohn's disease

BACKGROUND AND AIMS

This prospective study compared jejunoileal length in patients with Crohn's disease (CD) and the general population to determine whether this parameter can be related to outcome and management of CD complications.

PATIENTS AND METHODS

Small bowel (SB) length was measured during abdominal surgery prior to bowel resection in 93 patients with CD and 92 patients without inflammatory or small bowel disease.

RESULTS

SB length was shown to be shorter in patients with CD (462 vs. 567 cm) and was correlated to sex and height. There was no correlation of SB length to clinical expression (perforating or nonperforating), site, or outcome. SB length is not a prognosis factor of postoperative relapse. The presence of perineal disease and systemic abnormalities seem to be the only prognostic factors of surgical recurrence. Sex, age at onset, time of first surgery, site of disease, and mode of onset are not predictive of surgical recurrence.

CONCLUSION

We recommend minimal intestinal resection when surgical treating CD complications in patients at high risk of surgical relapse and initial short SB. We advise using stricturoplasty or leaving asymptomatic intestinal lesions to reduce short bowel syndrome occurrence when performing iterative surgery.

Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey

OBJECTIVE

To examine parents' reported knowledge and use of harm reduction strategies to protect their infants from exposure to tobacco smoke in the home, and the relation between reported use of strategies and urinary cotinine to creatinine ratios in the infants.

DESIGN

Cross sectional survey.

SETTINGS

Coventry and Birmingham.

MAIN OUTCOME MEASURES

Parents' reported knowledge and use of harm reduction strategies and urinary cotinine to creatinine ratios in their infants.

PARTICIPANTS

314 smoking households with infants.

RESULTS

86% of parents (264/307) believed that environmental tobacco smoke is harmful, 90% (281/314) believed that infants can be protected from it in the home, and 10% (32/314) were either unaware of measures or reported using none. 65% of parents (205/314) reported using two or more measures, but only 18% (58/314) reported not allowing smoking in the home. No difference was found in mean log e transformed urinary cotinine to creatinine ratio in infants from households that used no measures compared with households that used less strict measures. Mean log cotinine to creatinine ratios were significantly different in households banning smoking in the home compared with those using less strict or no measures. Banning smoking in the home was independently associated with a significant reduction in urinary cotinine to creatinine ratio by a factor of 2.6 (1.6 to 4.2) after adjustment for average household cigarette consumption, tenure, and overcrowding.

CONCLUSIONS

Less than a fifth of parents in smoking households ban smoking in the home. Banning smoking was associated with a small but significant reduction in urinary cotinine to creatinine ratio in infants, whereas less strict measures compared with no measures had no effect on the infants' exposure to environmental tobacco smoke.