Exclusive Breastfeeding at Discharge in Regional New South Wales, Australia: The Role of Antenatal Care (2011-2020)

Increasing the number of infants exclusively breastfeeding on discharge from the hospital after birth is a key goal of breastfeeding policy in New South Wales (NSW), Australia. Despite consistent efforts, exclusive breastfeeding on discharge rates have declined over the past decade. Using pooled data from the New South Wales Perinatal Data Collection from 2011 to 2020, we examined the association between antenatal care (ANC) and exclusive breastfeeding at discharge from birth admission outcomes for mother-baby dyads in Southern New South Wales Local Health District (SNSWLHD). Our study confirmed that exclusive breastfeeding rates in SNSWLHD have declined over the past decade, providing local evidence to support action. Late entry to ANC and a failure to attend the recommended number of ANC visits were important predictors of a lower rate of exclusive breastfeeding on discharge. Improving accessibility to ANC visits for rural and regional mothers has potential to positively impact breastfeeding rates in SNSWLHD. We suggest that wider implementation of caseload midwifery models may have a positive impact on breastfeeding outcomes in the region for all mother-baby dyads, but particularly for Aboriginal mothers and infants, younger mothers and mothers experiencing disadvantage.

Impact of Antenatal Care on Perinatal Outcomes in New South Wales, Australia: A Decade-Long Regional Perspective

Low birth weight (LBW) and preterm birth are adverse perinatal outcomes that pose a significant risk to a child's healthy beginning. While antenatal care (ANC) is an established intervention for pregnancy care, little is understood about how the number and timing of ANC visits can impact these adverse health outcomes. This study aimed to examine the impact of the number and timing of ANC visits on LBW and preterm birth in a regional setting. A decade-long perinatal dataset related to singleton live births that took place in the Southern New South Wales Local Health District (SNSWLHD) was utilized. The outcomes of interest were LBW and preterm birth, and the exposure variables were based on the Australian pregnancy guidelines on the number and timing of ANC visits. A multivariable logistic regression was performed to measure the association between outcome and exposure while adjusting for potential confounders. A greater level of protection against LBW and preterm birth was observed among mothers who had an adequate number of visits, with early entry (first trimester) into ANC. The protective effect of an adequate number of ANC visits against LBW and preterm birth among mothers with late entry into ANC (third trimester) was found to be statistically non-significant.

Effects of omega-3 fatty acids on dementia and cognitive Impairment in the ASCEND trial

Background

Observational data suggest that higher fish consumption is associated with a lower risk of dementia and supplementation with omega-3 fatty acid (FA) is associated with better cognition. The aim of this study is to assess the effect of omega-3 fatty acid (FA) supplementation on the risk of dementia and cognitive impairment in a pre-specified secondary analysis, with longer follow-up, of a randomized comparison in the ASCEND trial.

Methods

The study included 15,427 people in the United Kingdom with diabetes and no history of prior cardiovascular disease or recorded dementia randomized in the ASCEND trial between June 2005 and July 2011 randomly assigned to 1g capsules daily containing omega-3 fatty acids or matching placebo for a mean of 7.4 years. The main pre-specified comparison by randomized treatment in this cognitive study was a “broad dementia outcome” of dementia, cognitive impairment or confusion ascertained through participant, carer or general practitioner report or hospital admission diagnosis, by 31 March 2019 (∼2 years beyond the scheduled treatment period).

Results

During a mean follow-up of 7.4 years within the scheduled treatment period and 1.7 years afterwards, the broad dementia outcome occurred in 1146 participants, a similar percentage of participants in the omega-3 FA group and placebo groups: 574 participants (7.4%) vs. 572 (7.4%), rate ratio 1.00 (95% CI, 0.89–1.12) p=0.99. Allocation to omega-3 FA was not associated with any significant effect on measured cognitive function at end of the scheduled treatment period.

Conclusions

Omega-3 FA allocation was not associated with risk of the broad dementia outcome in this population of people with diabetes and the results excluded a proportional impact greater than 11%. Further trials are needed to assess the impact of higher dose omega-3 FA supplementation, but the current evidence does not support supplementation with omega-3 FA for dementia prevention.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation, UK Medical Research Council

Thromboxane metabolite excretion is associated with serious vascular events in diabetes mellitus: a sub-study of the ASCEND trial

Background

Platelet activation plays a major role in the atherothrombotic complications of diabetes. Thromboxane (TX)A2 is a pro-thrombotic prostanoid, synthesized via cyclooxygenase-1 and released by activated platelets. The metabolism of TXA2 in vivo leads to a major stable end-product, 11-dehydro-TXB2 (TXM), measurable in urine and reflecting the whole-body rate of TXA2 biosynthesis. In two large trials of high-risk, aspirin-treated (mostly, without diabetes) patients, (CHARISMA and HOPE trials), the baseline rate of urinary TXM excretion was an independent predictor of future cardiovascular events.

Purpose

The aim of the ASCEND (A Study of Cardiovascular Events in Diabetes) TXM sub-study was to investigate the association between baseline urinary TXM and future serious vascular events or revascularization (SVE-R), major bleeds and incident cancer independent of other risk factors and treatment, in people with diabetes and no manifest cardiovascular disease at trial entry.

Methods

Urinary TXM was measured by a previously GC/MS-validated, immunoassay in 6,487 participants with eligible baseline samples. Analyses excluded 539 participants using NSAIDs. TXM appeared log-normally distributed, so analyses were by quintiles and per SD (=0.622) of continuous loge TXM. The association of loge TXM with outcome was adjusted by basic factors (age, sex, sample volume and randomized treatment allocation) and by the predictors of log TXM (smoking, type 2 diabetes treated with insulin or oral hypoglycaemics, HDL cholesterol, body mass index, urinary albumin/creatinine ratio, eGFR). The association of log TXM with non-vascular, non-cancer MedDRA outcomes was investigated to determine whether TXM had a general effect on outcome. During a mean of 6.6 years follow-up there were 618 SVE-Rs, 206 bleeds and 700 cancers among these patients.

Results

Log TXM correlated significantly with SVE-R, hazard ratio (HR) per 1 SD of log TXM: 1.13 (1.04–1.23), p=0.003 (Figure 1, panel a), non-significantly with major bleeds [HR 1.15 (1.00–1.32), p=0.055] (Figure 1, panel b), and marginally significantly with cancer [HR 1.09 (1.01–1.17), p=0.03] (Figure 1, panel c). There was no association of log TXM with non-vascular non-cancer MedDRA outcomes (HR per 1 SD, 0.99; 99% CI, 0.94–1.05).

Conclusion

The rate of urinary TXM excretion, a non-invasive biomarker of TXA2-mediated platelet activation in vivo, is log-linearly associated with serious vascular events independent of other risk factors in people with diabetes. Its potential association with cancer must be viewed as hypothesis-generating and needs confirmation.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): IMI1: Surrogate markers for micro- and macro-vascular hard endpoints for innovative diabetes tools (SUMMIT).

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Prospective evaluation of quality of life in children treated in UKALL 2003 for acute lymphoblastic leukaemia: A cohort study

BACKGROUND

Health-related quality of life (HRQoL) from diagnosis until end of treatment for children with acute lymphoblastic leukaemia was investigated, examining effects of age, gender, risk-stratified treatment regimen, and therapy intensity (one vs. two 'delayed intensifications' [DIs]).

METHOD

In a multi-centre prospective study, parents reported their child's generic and disease-specific HRQoL and their own care-giving burden at five time points. From 1,428 eligible patients, 874 parents completed questionnaires at least once during treatment.

RESULTS

At each time point, generic HRQoL was significantly lower than equivalent norm scores for healthy children. HRQoL decreased significantly at the start of treatment, before recovering gradually (but remained below pre-treatment levels). Parents reported that older children worried more about side effects and their appearance, but showed less procedural anxiety than younger children. Concern for appearance was greater among girls than boys. Compared to Regimen B (i.e. additional doxorubicin during induction and additional cyclophosphamide and cytarabine during consolidation chemotherapy), patients receiving Regimen A had fewer problems with pain and nausea. There were no statistically significant differences in HRQoL by number of DI blocks received.

INTERPRETATION

HRQoL is compromised at all stages of treatment, and is partly dependent on age. The findings increase understanding of the impact of therapy on children's HRQoL and parental care-giving burden, and will contribute to the design of future trials.

Burden of illness in systemic lupus erythematosus: results from a UK patient and carer online survey

Objective The objective of this study was to assess the impact of systemic lupus erythematosus (SLE) on patients and carers. Methods Adults with SLE and carers of SLE patients completed a UK-specific online survey covering many aspects of the disease. Surveys were developed in collaboration with an NHS lupus unit and a lupus patient organization. Results A total of 121 patients and 31 carers completed the surveys. Of the 70% of patients initially misdiagnosed with another condition, 59% received treatment for the misdiagnosis. Fatigue was the most debilitating symptom, experienced daily by 79% of patients. The proportion of patients not reporting flares to healthcare providers varied with flare severity: mild flares (43%), moderate flares (15%) and severe flares (5%). Most patients (89%) reported reduced ability to socialize, and 76% had changed employment; of these, 52% stopped working completely. Over one-half (52%) of carers in paid employment missed time from work, and 55% of carers reported a worsened financial status. Most carers (87%) experienced interference with social activities. Conclusion SLE is commonly misdiagnosed and has a considerable impact on the physical, social and financial status of patients and carers. Increased awareness of the disease among healthcare providers and employers of patients and their carers is needed.

Peritonitis after percutaneous endoscopic gastrostomy and jejunostomy: where there is smoke, there may not be fire

Extensive reviews have been published regarding complications arising from percutaneous enteral access and ways of managing them. However, few data are available regarding unnecessary clinical interventions resulting from misinterpretation of benign postprocedural findings. We present here three representative cases of negative surgical abdominal cavity explorations for presumed peritonitis after percutaneous endoscopic gastrojejunostomy and jejunostomy.

Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins

BACKGROUND

Results of previous randomised trials have shown that interventions that lower LDL cholesterol concentrations can significantly reduce the incidence of coronary heart disease (CHD) and other major vascular events in a wide range of individuals. But each separate trial has limited power to assess particular outcomes or particular categories of participant.

METHODS

A prospective meta-analysis of data from 90,056 individuals in 14 randomised trials of statins was done. Weighted estimates were obtained of effects on different clinical outcomes per 1.0 mmol/L reduction in LDL cholesterol.

FINDINGS

During a mean of 5 years, there were 8186 deaths, 14,348 individuals had major vascular events, and 5103 developed cancer. Mean LDL cholesterol differences at 1 year ranged from 0.35 mmol/L to 1.77 mmol/L (mean 1.09) in these trials. There was a 12% proportional reduction in all-cause mortality per mmol/L reduction in LDL cholesterol (rate ratio [RR] 0.88, 95% CI 0.84-0.91; p<0.0001). This reflected a 19% reduction in coronary mortality (0.81, 0.76-0.85; p<0.0001), and non-significant reductions in non-coronary vascular mortality (0.93, 0.83-1.03; p=0.2) and non-vascular mortality (0.95, 0.90-1.01; p=0.1). There were corresponding reductions in myocardial infarction or coronary death (0.77, 0.74-0.80; p<0.0001), in the need for coronary revascularisation (0.76, 0.73-0.80; p<0.0001), in fatal or non-fatal stroke (0.83, 0.78-0.88; p<0.0001), and, combining these, of 21% in any such major vascular event (0.79, 0.77-0.81; p<0.0001). The proportional reduction in major vascular events differed significantly (p<0.0001) according to the absolute reduction in LDL cholesterol achieved, but not otherwise. These benefits were significant within the first year, but were greater in subsequent years. Taking all years together, the overall reduction of about one fifth per mmol/L LDL cholesterol reduction translated into 48 (95% CI 39-57) fewer participants having major vascular events per 1000 among those with pre-existing CHD at baseline, compared with 25 (19-31) per 1000 among participants with no such history. There was no evidence that statins increased the incidence of cancer overall (1.00, 0.95-1.06; p=0.9) or at any particular site.

INTERPRETATION

Statin therapy can safely reduce the 5-year incidence of major coronary events, coronary revascularisation, and stroke by about one fifth per mmol/L reduction in LDL cholesterol, largely irrespective of the initial lipid profile or other presenting characteristics. The absolute benefit relates chiefly to an individual's absolute risk of such events and to the absolute reduction in LDL cholesterol achieved. These findings reinforce the need to consider prolonged statin treatment with substantial LDL cholesterol reductions in all patients at high risk of any type of major vascular event.

Adverse impact of bone marrow transplantation on quality of life in acute myeloid leukaemia patients; analysis of the UK Medical Research Council AML 10 Trial

The increasing success of intensive consolidation chemotherapy (CCT) as an alternative to bone marrow transplant (BMT) in acute myeloid leukaemia (AML) necessitates comparison of the impact on quality of life (QoL) of these two treatment modalities. Most QoL studies following BMT involve small patient numbers and provide ambivalent results. The present study examines QoL in a large number of patients 1 year from the end of treatment within the United Kingdom Medical Research Council (UK MRC) AML10 trial of BMT versus CCT. Allogeneic-BMT (Allo-BMT) was observed to have an adverse impact on most QoL dimensions compared with Autologous-BMT (A-BMT) and CCT. More patients receiving BMT had mouth dryness problems and worse sexual and social relationships, professional and leisure activities than CCT patients. QoL in A-BMT patients was less impacted than Allo-BMT. Intention-to-treat analysis showed similar results. These results indicate that a reconsideration of treatment strategies is warranted, and that further, good prospective studies are needed to evaluate more clearly the effects of these treatments in long-term survivors.

Experience and extensions to the ASM2 family of models

The development of ASM2 has created a complex model for biological phosphorus removal. Most of the published work on calibrating this model has focused on the design of experiments to maximise information with which to calibrate the model, or the use of hourly data collected around and within an aeration tank. But many sewage works do not collect such data, nor have such instrumentation. The application of ASM2 with sparse data collected at a low frequency, and mostly only input-output, is considered in this paper, based on data collected at a Swedish sewage works. This paper shows that ASM2 can be calibrated with such measurements. This paper also looks at a modification to ASM2d to better handle heterotrophic usage of volatile fatty acids, and the use of this model to study the effects of large increases in in-sewer storage on sewage treatment works. Concern about the generation of large quantities of VFAs, and their effect on the sewage treatment processes, was unfounded.

Prediction of fetal anemia with Doppler measurement of the middle cerebral artery peak systolic velocity in pregnancies complicated by maternal blood group alloimmunization or parvovirus B19 infection

OBJECTIVES

To confirm the relationship between the middle cerebral artery peak systolic velocity (MCA PSV) and hemoglobin values in fetuses at risk for anemia (due to maternal blood group alloimmunization or parvovirus B19 infection) and to investigate the clinical value of this method in the management of these pregnancies regardless of previous transfusions.

SUBJECTS AND METHODS

Forty singleton pregnancies, 30 affected by alloimmunization and 10 by intrauterine parvovirus B19 infection, were referred to our tertiary center between 1998 and 2000. All cases underwent Doppler measurement of the MCA PSV immediately before fetal blood sampling and just before and after intrauterine transfusion. Hemoglobin determination was always performed after diagnostic cordocentesis, before starting and after terminating fetal transfusion.

RESULTS

Overall, we performed 165 fetal blood samplings (hemoglobin values) and obtained 165 corresponding MCA PSV values, 140 in pregnancies complicated by red-cell alloimmunization and 25 by parvovirus B19 infection. In order to adjust for the effect of gestational age on the measurements, the data were expressed in multiples of the median (MoM). We found a good correlation between MCA PSV MoM and Hb MoM in both groups (alloimmunization, r2 = 0.6; y = 2.21 - 1.41 x + 0.24 x 2; parvovirus infection, r2 = 0.68; y = 2.09 - 0.58 x - 0.16 x 2). The reduction of post-transfusion MCA PSV values was statistically significant ( P < 0.0001). Using a threshold of 1.29 for MoM PSV, the sensitivity and the specificity of MCA pulsatility indices on pretransfusion values in predicting any degree of fetal anemia (Hb < or = 0.84 MoM) were 73.1% and 81.5% in the alloimmunization group and 100% and 100% in the parvovirus infection group, respectively.

CONCLUSION

We can confirm the presence of an inverse correlation between MCA PSV measurements and hemoglobin values in fetuses at risk for anemia due to maternal blood group alloimmunization and fetal parvovirus B19 infection. The MCA PSV is a reliable method for the prediction of anemia not only in fetuses before the first intrauterine transfusion, but also in those which have undergone one or more transfusions, with good sensitivity and specificity in both groups of fetuses at risk.

Exposure to Schistosoma mansoni infection in a rural area in Brazil. II: household risk factors

A number of studies have pointed out the potential importance of the household in the transmission of schistosomiasis. The clustering of domestic activities associated with water collection, storage, and usage can result in the sharing of transmission sites and infective water contact behaviours. In this study, we employed a variance component method to estimate effects due to individual risk factors and shared residence on the variance in faecal egg counts during Schistosoma mansoni infection. A suite of covariates, which included demographic, socioeconomic, water supply, and water contact behaviour terms, contributed 15% to the variance in faecal egg counts. Shared residence alone accounted for 28% of the variance in faecal egg excretion. When both the suite of covariates and shared residence were considered in the same model, shared residence still contributed 22% to the variance in infection intensity. These results point to the importance of shared residence as a means of capturing the complex interrelationship between shared demographic, socioeconomic, physical environmental, and behavioural factors that influence transmission of schistosomiasis at the household level.

Controlling for the effects of hospital attributes. The efficacy of factor analysis

PURPOSE: The assessment of risk often requires controlling for the potentially confounding effects of hospital attributes. This paper (1) describes the use of factor analysis as a means of quantifying hospitals' obstetrical care, and (2) compares within respective unconditional logistic regression models the performance of factor scores with that of the "obstetrical unit service level" (OBUSL) classification as defined by the American Hospital Association (AHA).METHODS: A principal components factor analysis was performed on fourteen variables from 116 hospitals in Upstate New York. These variables, descriptive of hospitals' obstetrical care, were obtained from the 1992 AHA's Annual Survey of Hospitals. Factor scores were correlated with the OBUSL. Factor scores were matched to 89,341 women with vaginal deliveries in the 1992 Live Birth Registry for Upstate New York. The performance of factor scores and the OBUSL variable was compared in separate unconditional logistic regression analysis designed to identify determinants of obstetrical anesthesia care.RESULTS: Principal components factor analysis with varimax rotation identified three factors which were strongly correlated with hospital OBUSL. In a model which included the OBUSL variable, the adjusted odds ratios (AORs) or receiving an epidural for vaginal delivery were lower among mothers with Medicaid, HMO, or no insurance coverage (i.e., 0.45 [95% CI, 0.43-0.48], 0.68 [0.64-0.71], and 0.44 [0.38-0.52], respectively) than among those with private coverage. In a model in which factor scores were substituted for the OBUSL variable, respective AORs were 0.48 (0.45-0.52), 0.63 (0.60-0.66), and 0.45 (0.39-0.53).CONCLUSIONS: Factor analysis provided a parsimonious description of 14 hospital variables, was useful as a control within the regression model, and may prove similarly useful in other areas of clinical care.

Measuring functional status and family support in older school-aged children with cerebral palsy: comparison of three instruments

OBJECTIVE

To compare a pediatric and an adult version of a functional status measure and a family support measure for assessing school-age children with spastic cerebral palsy.

DESIGN

A prospective study involved functional status measurements using the Pediatric Functional Independence Measure (WeeFIM), the Adult Functional Independence Measure (FIM), and a family support measure, the Amount of Assistance Questionnaire (AAQ).

PARTICIPANTS

The feasibility sample consisted of 47 children aged 2 to 12 yrs with cerebral palsy. The study sample consisted of 20 children aged 7 to 16 yrs with spastic cerebral palsy (50% diplegia, 50% quadriplegia).

INTERVENTIONS

Initial assessment interview included the WeeFIM, developmental milestones, educational achievement information, and the AAQ. Within 1 month, a follow-up phone interview using the FIM was completed.

MAIN OUTCOME MEASURE

The WeeFIM and FIM measure independence in self-care, sphincter control, mobility, locomotion, communication, and social cognition. The AAQ measures the time and assistance required by a child in essential daily tasks.

RESULTS

Pearson's correlation coefficient exceeded .97 for WeeFIM and FIM total score in the total sample as well as in two subgroups of children: those with diplegia and quadriplegia. Total scores in WeeFIM and FIM as well as domain scores were significantly different between children with diplegia and quadriplegia. Parental amount of assistance on the AAQ was significantly correlated with WeeFIM and FIM scores.

CONCLUSION

Either the WeeFIM or FIM can be used for monitoring functional status through adolescence in children with spastic cerebral palsy. Functional limitations are highly related to requirements for parental assistance.

Penicillin minimum inhibitory concentration drift in identical sequential Streptococcus pneumoniae isolates from colonized healthy infants

We monitored the timing of acquisition of nasopharyngeal colonization of Streptococcus pneumoniae in 125 healthy infants during their first 2 years of life. S. pneumoniae was isolated at least once from 59 (47%) of 125 infants aged between 2 and 18 months. Twenty-four infants (19%) were colonized with penicillin-resistant S. pneumoniae at some time during the study. During the course of this investigation, we identified sequential pneumococcal isolates of the same serotype from 5 infants, in which the penicillin minimum inhibitory concentration (MIC) increased over time. For 4 of the 5 infants, sequential isolates were identical, as determined by pulsed-field gel electrophoresis. Sequential S. pneumoniae nasopharyngeal isolates from some healthy infants demonstrated drift in penicillin MIC values over time, from penicillin-susceptible to penicillin-resistant.

Interactions between listeriae and lectins

Interactions between members of the genus Listeria and lectins are described. L. monocytogenes was shown to be heterogenous with respect to agglutination by lectins. L. monocytogenes serotype 4b had a pattern of lectin binding distinct from the other listeriae. Titration of the listeriae with lectins proved to be useful in further distinguishing serotype 4b. The results show that lectins may provide useful probes as diagnostic reagents for listeriae.

Side effects and discontinuation rates of intrauterine contraceptive device use in the Jilin Province of China

Data from the Fertility and Contraception Survey undertaken in the Jilin Province in 1988 were used to examine both the rates of side effects and discontinuation among women using intrauterine devices (IUDs). The results show that among the 1,912 first time IUD users, the combined side effects rate comprising excessive bleeding, irregular menstruation, or abdominal pain was 11.7 percent; 0.2 percent of first time IUD users became seriously ill due to faulty insertion techniques. The gross cumulative failure rates at the end of the first, second and third year following insertion were 5.3%, 9.2% and 11.9%, respectively. Total gross cumulative discontinuation rates for these three time periods were 9.9%, 19.3%, and 28.3%, respectively. It was also found that selected social and service factors such as nationality, farm/non-farm residency, medical institution where the insertion was provided, interval between the data of last pregnancy and the date of the insertion, and the number of children at the time of insertion were associated with IUD-related side effects and/or discontinuation. The findings are further discussed with respect to governmental intervention in regulating family size, in terms of the reliability of the self-reported data, and other IUD related effects.

Relation of Lake Ontario fish consumption, lifetime lactation, and parity to breast milk polychlorobiphenyl and pesticide concentrations

Lactating female members and spouses of male members of the New York State Angler Cohort who agreed to provide breast milk samples were the subjects of this study. Questionnaires were provided to participants focusing on Lake Ontario fish consumption, reproductive history, and lactation history. Milk samples were analyzed for 77 polychlorinated biphenyls (PCB) congeners, 1,1-dichloro-2,2-bis (p-chlorophenyl)-ethylene (DDE), a metabolite of dichlorodiphenyltrichloroethane (DDT), hexachlorobenzene (HCB), and 1,1a,2,2,3,3a, 4,5,5,5a,5b,6-dodecachlorooctahydro-1,3, 4-methano-1H-cyclobuta[cd]pentalene (Mirex). The percentage of samples with quantifiable levels, above the limit of detection (LOD), varied among the individual congeners from 10 to 100%. Nine PCB congeners (designated by their IUPAC No.) and DDE were found in all of the 100 samples analyzed. These include the following, in decreasing order of concentration: DDE>153>138>180>118>187>188>177>200. Total PCB concentrations were estimated by taking the sum of the concentrations of all PCB congeners (up to 77 congeners) above their respective LOD in a given sample. PCB concentrations increased with increasing concentration of milk lipid. Lipid adjusted PCB concentrations increased as a function of maternal age. PCB congener profiles in milk favored the higher chlorinated congeners, with the four highest congeners having 5 to 7 chlorine atoms. Fish eaters had a significantly higher level of several major PCB congeners with congeners 153 and 138 being 1.36 and 1.34 times higher, respectively. PCB and DDE concentrations, expressed on a lipid basis, varied inversely with parity. The total number of months of lifetime lactation varied inversely with the total PCB concentration in breast milk. A similar relationship was evident for DDE. These data are of use for risk assessment in estimating the relative exposure to these environmental contaminants in breast fed infants whose mothers consumed contaminated Lake Ontario fish.

Treatment of fetal erythroblastosis by intravascular transfusions: outcome at 6 years

OBJECTIVE

To assess 6 years' neurologic outcome of a complete cohort of survivors of intrauterine intravascular transfusions.

METHODS

From January 1986 to December 1991, 136 intravascular transfusions were performed in 43 fetuses presenting with signs of severe erythroblastosis. Before the initial transfusion, 11 of 43 fetuses had some degree of hydrops fetalis, and hemoglobin values ranged between 1.5 and 10.7 g/dL. Neurologic outcome of a complete cohort of 35 long-time survivors was assessed for up to 6 years by reviewing the hospital charts and questionnaires sent to the family physicians or pediatricians.

RESULTS

Long-time follow-up was available in all survivors with hydrops at initial transfusion (seven of seven) and in 23 of 28 survivors without hydrops. Only one of 35 survivors had mild psychomotoric disabilities up to 1 year of age, but was free of sensorineural problems on further examination. In a second case, delayed speech development was observed. Fetuses presenting with hydrops fetalis before initial transfusion tended to have a higher perinatal mortality and had a significantly higher rate of preterm delivery (P = .03). However, moderate or severe neurologic impairment was never observed, even when severe cases with hydrops fetalis or extremely low hemoglobin levels were included.

CONCLUSION

Treatment of severe fetal erythroblastosis by intrauterine intravascular transfusions is associated with a favorable neurologic long-time outcome.

Findings from the American College of Epidemiology's survey on Ethics guidelines. The American College of Epidemiology Ethics and Standards of Practice Committee

PURPOSE

A survey to establish both the need and subject areas for a possible new set of ethics guidelines for epidemiologists was conducted among a random sample of 300 North American (Canada, Mexico, and United States) members of three major United States-based professional epidemiology organizations.

METHODS

An 88% response rate revealed wide agreement on topics to be included in any new set of guidelines, but uncertainty prevailed about the need for new guidelines; 41% agreed that there was a need to develop a new set, 43% had no opinion, and 16% disagreed.

RESULTS

There was almost no difference in preferences between men and women for topics to be included in a new set of guidelines, or between those aware or unaware of extant ethics guidelines in epidemiology. Fifty-four percent were aware of such guidelines and only 29% of these said they could describe the content of the guidelines.

CONCLUSION

More needs to be done to evaluate the utility of ethics codes in epidemiology.

Metabolic crisis: hyperemesis gravidarum

Nausea and vomiting during pregnancy affect approximately 50% to 70% of all pregnant women. Although most cases of nausea and vomiting in pregnancy resolve spontaneously and are not associated with compromised nutritional status, a small percentage of cases progress to hyperemesis gravidarum (severe nausea and vomiting during pregnancy). Hyperemesis gravidarum is a serious disorder that can lead to weight loss, dehydration, electrolyte disturbances, and occasionally death if improperly treated or left untreated. The article summarizes recent research on hyperemesis gravidarum, focusing on the definition, etiology, epidemiology, and current treatment of symptoms.

Maternal cigarette smoking, regular use of multivitamin/mineral supplements, and risk of fetal death: the 1988 National Maternal and Infant Health Survey

Data from the 1988 National Maternal and Infant Health Survey were used to examine whether regular use of multivitamin/mineral supplements could modify the relation between maternal smoking and fetal death. Maternal smoking was defined as the self-reported average number of cigarettes smoked after recognition of pregnancy. Regular supplement use was defined as use of multivitamin/mineral supplements for at least 3 days per week during the 3 months before and/or after recognition of pregnancy. The sample comprises 12,465 singleton pregnancies, including 9,402 livebirths and 3,063 fetal deaths. Odds ratios were derived from logistic regression analyses after adjustment for a number of demographic and reproductive variables. Major findings are that 1) smoking increased the risk of fetal death; 2) regular supplement use either before or after recognition of pregnancy did not affect the risk of fetal death in the absence of maternal smoking; 3) odds ratios for fetal death among smoking women who regularly used supplements were generally smaller than those for women who did not regularly use supplements but who smoked a comparable number of cigarettes; and 4) a significant negative excess risk due to interaction was observed among women who regularly used supplements before recognition of pregnancy and smoked 20 or more cigarettes a day. These findings suggested that regular multivitamin/mineral supplement use might reduce the risk of fetal death associated with maternal smoking.

Can regular multivitamin/mineral supplementation modify the relation between maternal smoking and select adverse birth outcomes?

PURPOSE

The purpose of this study was to examine whether or not regular multivitamin/mineral supplementation can modify the relation between maternal smoking and preterm birth (gestational age < 37 weeks), very-low-birthweight (VLBW) (< 1500 g), moderately-low-birthweight (MLBW) (< 2499 g), or small-for-gestational-age (SGA) (< 10th percentile of birth weight for gestational age).

METHODS

Live birth data from the 1988 National Maternal and Infant Health Survey (NMIHS) were used for the analysis. Maternal smoking referred to self-reported average number of cigarettes smoked after recognition of pregnancy, while regular multivitamin/mineral supplementation referred to use of multivitamin/mineral supplements for at least three days per week during the three months before and/or after recognition of pregnancy. Sample sizes included 9402 singleton infants for the analysis of preterm birth, 9395 for very or moderately low birthweight, and 9363 for small-for-gestational-age. Odds ratios were derived from logistic regression analyses after adjusting for a number of demographic and reproductive variables.

RESULTS

Major results include: 1) increased risks for the adverse outcomes studied were observed among smoking women; 2) no effect of regular multivitamin/mineral supplementation in the absence of maternal smoking was revealed; and 3) relative excess risks due to interaction at different smoking levels and overall interactions between smoking and supplementation were not observed.

CONCLUSIONS

These results suggest that regular multivitamin/mineral supplementation does not minimize the adverse effects associated with maternal smoking.

Prenatal diagnosis of heterozygosity for biotinidase deficiency by enzymatic and molecular analyses

Biotinidase deficiency is characterized by neurological and cutaneous abnormalities that can be prevented or ameliorated by oral biotin therapy. A child with biotinidase deficiency went undiagnosed for a long period and has irreversible neurological deficits despite biotin treatment. This child is homozygous for the most common mutation (G98:d7i3) found in symptomatic children with the disorder. The parents insisted on having prenatal diagnosis in a subsequent pregnancy to alleviate their anxiety about having another affected child. Mutation analysis of DNA obtained directly from amniotic fluid and from cultured amniocytes revealed that the fetus was heterozygous for the mutation. Maternal cell contamination of the amniocytes was excluded by genotype analysis. Biotinidase activity in extracts of cultured amniocytes revealed 40 per cent of mean normal activity. At birth, the infant was confirmed to be heterozygous by serum enzyme analysis. This is the first report of the use of molecular analysis for the prenatal diagnosis for biotinidase deficiency.

Specificity of human cytotoxic T lymphocytes induced by a human papillomavirus type 16 E7-derived peptide

In order to establish tumour-specific cytotoxic T lymphocyte (CTL) cell lines, T cells from a human papillomavirus (HPV) type 16-positive patient with a cervical carcinoma in situ and from a healthy volunteer were stimulated in vitro with autologous dendritic cells loaded with peptides derived from the viral transforming proteins E6 and E7 and corresponding to potential HLA-A*0201-restricted T cell epitopes. From each donor a small number of low-affinity CTL lines against the peptide E7/86-93 was obtained, which specifically lysed HLA-A*0201-expressing B-lymphocytes (cell line 721) loaded with this peptide. Cytotoxicity was also observed against two HLA-A*0201-E7-positive epithelial cell lines, the cervical carcinoma cell line CaSki and the HPV-16-immortalized foreskin-keratinocyte cell line HPK IA. However, since none of the CTL recognized both cell lines, and E7-expressing 721 transfectants were never lysed, it was concluded that the reactivity against CaSki and HPK IA cells was due to cross-reactivity on allogeneic HLA molecules rather than to E7 recognition, which emphasizes that the specificity of tumour cell lysis by peptide-induced CTL has to be interpreted with caution.

Removal of gonads in Y-chromosome-bearing gonadal dysgenesis and in androgen insensitivity syndrome by laparoscopic surgery

BACKGROUND

This paper addresses the value of laparoscopic surgery for the removal of gonads in patients with Y-chromosome-bearing gonadal dysgenesis and androgen insensitivity syndrome, who are otherwise faced with a high rate of gonadal malignancy.

METHODS

Three patients with Y-chromosome-bearing gonadal dysgenesis and one patient with androgen insensitivity syndrome were operated upon laparoscopically. Removal of gonads was accomplished by their mobilization and dissection from the pelvic side walls, with ligation and transection of the utero-ovarian and infundibulopelvic ligaments.

RESULTS

Surgery was without complications. Histological examination of the gonads showed complete removal and absence of malignancy in each patient. Patients were discharged the day after surgery.

CONCLUSIONS

The laparoscopic approach is a safe and effective alternative to laparotomy in the management of patients with Y-chromosome-bearing gonadal dysgenesis and with androgen insensitivity syndrome.

Osteopenia in primary and secondary amenorrhea

This study aimed at investigating the prevalence of osteopenia among a hypoestrogenic group of patients with primary or secondary amenorrhea. Twenty-seven patients with amenorrhea were examined. Sixteen of them presented with secondary amenorrhea (mean age 27.8 +/- 1.9 yrs), and 11 with primary amenorrhea (mean age 21.3 +/- 1.6 yrs). Ten regularly menstruating women (mean age 28.9 +/- 1.4 yrs) served as controls. Estradiol serum levels as well as lumbar spine bone mineral density were measured. All 11 patients with primary amenorrhea showed osteopenia with a mean bone mineral density Z-score of 71 +/- 2% and mean estradiol levels of 30.6 +/- 5.9 pg/ml. The secondary amenorrheic patients were significantly demineralized with a mean Z-score of 82 +/- 3%; 10 of them had osteopenia. Their mean estradiol levels were 34.3 +/- 2.9 pg/ml. The bone density in the primary amenorrheic patients was significantly lower as compared with the secondary amenorrheic women. In comparison, lumbar spine bone density in all control women was normal with a mean Z-score of 104 +/- 3%. In summary, 21 of the 27 patients had osteopenia, higher than that reported in post-menopausal women. Since it is not proven whether the bone mineral deficit of amenorrheic patients can ever be compensated, early diagnostic steps and estrogen-progestogen replacement for the prevention of further bone loss and subsequent fractures are recommended.

Laparoscopic creation of a neovagina: modified Vecchietti method

A new surgical technique for the treatment of vaginal aplasia is described. It consists of a modification of Vecchietti's method, allowing laparoscopic performance of the operation. 9 patients have been treated in this way since January, 1991 with good results. No complications were seen. Being virtually atraumatic, this method requires only brief hospitalisation, which is of vital importance in view of the psychological and physical problems this particular condition entails. Results are identical, so that this technique should always take precedence over the conventional Vecchietti method.

Cystic periventricular leukomalacia and type of cerebral palsy in preterm infants

A case series design was used to identify cases of cystic periventricular leukomalacia (N = 31) identified by neurosonography at one regional tertiary intensive care nursery. Patients were preterm infants born at < or = 32 weeks of gestation who had cysts involving predominantly the middle-posterior or posterior periventricular regions. Neurodevelopmental evaluations were made for 26 (96%) of 27 survivors. All infants assessed had cerebral palsy (i.e., 54% quadriplegia, 42% diplegia, and 4% hemiplegia). Most cognitive delays and all sensory impairments occurred in children with quadriplegia. Periventricular cysts were most extensive on parasagittal, anteroposterior views. The parasagittal, anteroposterior extent of periventricular cysts was most accurate in predicting the type and severity of motor and cognitive disabilities. Quadriplegia was associated with larger and more extensive cysts.

Mycobacterium abscessus pseudoinfection traced to an automated endoscope washer: utility of epidemiologic and laboratory investigation

After 15 patients had positive cultures for Mycobacterium abscessus without evidence of infection (i.e., pseudoinfection) following endoscopy, retrospective cohort studies of patients undergoing endoscopy and microbiologic sampling of the environment were done to examine potential nosocomial transmission and to identify the source and risk factors for M. abscessus pseudoinfection. In the epidemic period, M. abscessus-positive cultures were significantly more likely to be obtained during bronchoscopy than gastroendoscopy (16/149 vs. 1/860, P < .001) and during procedures using bronchoscopes disinfected in an automated washer rather than by other methods (16/54 vs. 0/95, P < .001). M. abscessus was recovered from the automated washer, the inlet water feeding the washer, and a flexible bronchoscope. Environmental and case-patient isolates had identical large restriction fragment (LRF) patterns of genomic DNA separated by pulsed-field gel electrophoresis. Molecular typing using LRF analysis supported the epidemiologic results and demonstrate the utility of combined epidemiologic and laboratory investigations in nosocomial outbreaks of nontuberculous mycobacteria.

Developmental disabilities prevention and the distribution of risk among American Indians

Selected risk factors for developmental disabilities demonstrate an apparent differential pattern of risk for American Indians as compared to the U.S. general population. Indian children appear to experience comparable or even lower rates of certain congenital anomalies which are associated with developmental disabilities and are difficult to prevent. Conversely, Indians are reported to experience higher rates of conditions which can be effectively targeted for prevention, including those related to prenatal exposure to alcohol, cigarette smoking, and maternal diabetes, as well as disabling sequelae of accidents and otitis media. Primary prevention is critical because of the long-term chronic nature of developmental disabilities and strategies focused on risk factors of particular relevance to Indian communities can achieve the greatest potential benefit.

Silent aspiration prominent in children with dysphagia

Children with neurologically-based dysphagia are at high risk for silent aspiration. Aspiration can lead to complications such as acute pneumonia and chronic lung disease. Thorough evaluation of the oral, pharyngeal, and esophageal phases of swallowing is crucial for patients with dysphagia. The videofluoroscopic modified barium swallow study (MBS) is the procedure of choice for children to delineate the pharyngeal and upper esophageal phases of the swallow that can only be inferred by bedside clinical assessment. This study describes attributes of aspiration and pharyngeal motility in a large sample of infants and children assessed with MBS. Aspiration was observed in 48 (26%) of 186 children, primarily on liquid before or during swallows. Aspiration was trace (less than 10% of a bolus) and silent in 94%. Relationships to clinical history and implications for management are discussed. Given the lack of objective clinical information to identify children at risk for aspiration, MBS should be considered in all children with severe dysphagia to rule out or confirm aspiration.

Characteristics of dysphagia in children with cerebral palsy

Videofluoroscopic modified barium swallow (VMBS) examinations may provide clinically relevant information regarding deglutition in children with cerebral palsy and dysphagia. A retrospective review of clinical evaluations and VMBS studies on 90 consecutive children with cerebral palsy and dysphagia was completed. Most children were referred because of concerns regarding airway protection during oral feedings. Most children had multiple disabilities and 93% were nonambulatory. The majority of children were totally dependent for oral feedings (80%). Oral and pharyngeal phase abnormalities were present in almost all patients. Abnormalities of deglutition were observed only while swallowing specific food textures in the majority of patients. Aspiration of specific food textures was significantly more common than aspiration of all food textures (p < 0.0001). Finally, aspiration was silent in 97% of the patients. VMBS studies can provide clinicians with valuable information regarding the most appropriate food textures and rates of oral feeding for children with cerebral palsy and dysphagia.

Mortality patterns among the youth of a northeastern American Indian cohort

Mortality patterns prevalent among American Indian youth have not been well documented. This investigation reports on mortality patterns among the Seneca Nation of Indians from January 1, 1955, through December 31, 1989. The study cohort consisted of 3,033 Seneca tribal members born during the study period. Deaths occurring among cohort members younger than age 25 were identified through a computer match against New York State vital record files. Sex-specific standardized mortality ratios were calculated on the basis of mortality patterns exhibited by the general population of New York State, exclusive of New York City. Males exhibited significantly elevated mortality for all causes combined, for deaths due to all accidents combined, for motor vehicle accidents, and for suicide. Females demonstrated significantly elevated mortality from all accidents combined, for motor vehicle accidents, and for all other types of accidents. Age-specific mortality patterns also varied both by sex and by calendar time. These findings are important to consider in the design of programs aimed at reducing premature mortality among American Indian populations from preventable causes of death.

Emergence and control of methicillin-resistant Staphylococcus aureus in a children's hospital and pediatric long-term care facility

BACKGROUND

After a 6-year quiescence, methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 30 patients in a children's hospital and a pediatric long-term care facility from November 1987 through April 1989. After six nosocomial cases had occurred at the children's hospital, increased infection control measures directed at MRSA were initiated in August 1988. Because MRSA had been identified in three patients in the pediatric long-term care facility within 24 hours of their admission to the children's hospital, other patients transferred from the pediatric long-term care facility to the children's hospital were isolated and screened for MRSA.

METHODS

We reviewed the medical records of these patients and evaluated their response to therapy with rifampin alone or in combination with trimethoprim-sulfamethoxazole.

RESULTS

In the 8-month period after initiation of infection control measures, MRSA was identified in 10 residents of the pediatric long-term care facility; there was also one nosocomial children's hospital case. Phage typing showed that one MRSA strain predominated in patients at the pediatric long-term care facility but did not implicate this strain as the source for MRSA introduction into the children's hospital. Of 16 patients with MRSA who completed therapy and were available for follow-up, 13 (81%) had elimination of colonization.

CONCLUSION

Prompt institution of MRSA surveillance, barrier isolation, and therapy to eliminate colonization should be considered in hospitals with a new introduction of MRSA.

The genomic organization and transcription of the ubiquitin genes of Trypanosoma cruzi

We describe here the organization of the ubiquitin genes of the parasitic protozoan Trypanosoma cruzi. T. cruzi contains greater than 100 ubiquitin coding sequences all of which are clustered into a 27 kb segment of the genome. Two types of ubiquitin coding sequences were found. There are five fusion genes (FUS1-5) consisting of a ubiquitin coding sequence fused to a basic non-ubiquitin sequence. The T. cruzi ubiquitin fusion protein is 84% homologous to the product of the UBI gene of Saccharomyces cerevisiae. The non-ubiquitin domains of the two proteins are 67% homologous. There are five polyubiquitin coding genes (PUB) each consisting of varying lengths of polyubiquitin coding sequence and terminating with a single copy of the larger fusion gene. Transcription of the ubiquitin genes results in the generation of six major poly(A)+ mRNAs. The pattern of transcription accurately reflects the genomic organization, in that the transcripts consist of either a single copy of the ubiquitin fusion coding sequence or varying lengths of polyubiquitin (up to 52 copies of the ubiquitin coding unit) each ending with a single copy of the ubiquitin fusion sequence. Finally, there are heat shock elements 5' to the PUB genes and transcription patterns are altered under conditions of stress.