Pregnancy and cystic fibrosis

A 20-year old parturient with moderate to severe cystic fibrosis presented for an Elective Caesarean Delivery at 31 weeks gestation due to intra-uterine growth retardation and persistent maternal weight loss. The procedure was successfully performed using a combined spinal-epidural anaesthetic technique. A review of the literature is presented and the anaesthetic implications of pregnancy in cystic fibrosis patients are discussed.

Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial

OBJECTIVE

To compare the effectiveness of clomifene citrate and unstimulated intrauterine insemination with expectant management for the treatment of unexplained infertility.

DESIGN

Three arm parallel group, pragmatic randomised controlled trial.

SETTING

Four teaching hospitals and a district general hospital in Scotland.

PARTICIPANTS

Couples with infertility for over two years, confirmed ovulation, patent fallopian tubes, and motile sperm.

INTERVENTION

Expectant management, oral clomifene citrate, and unstimulated intrauterine insemination.

MAIN OUTCOME MEASURES

The primary outcome was live birth. Secondary outcome measures included clinical pregnancy, multiple pregnancy, miscarriage, and acceptability.

RESULTS

580 women were randomised to expectant management (n=193), oral clomifene citrate (n=194), or unstimulated intrauterine insemination (n=193) for six months. The three randomised groups were comparable in terms of age, body mass index, duration of infertility, sperm concentration, and motility. Live birth rates were 32/193 (17%), 26/192 (14%), and 43/191 (23%), respectively. Compared with expectant management, the odds ratio for a live birth was 0.79 (95% confidence interval 0.45 to 1.38) after clomifene citrate and 1.46 (0.88 to 2.43) after unstimulated intrauterine insemination. More women randomised to clomifene citrate (159/170, 94%) and unstimulated intrauterine insemination (155/162, 96%) found the process of treatment acceptable than those randomised to expectant management (123/153, 80%) (P=0.001 and P<0.001, respectively).

CONCLUSION

In couples with unexplained infertility existing treatments such as empirical clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.

TRIAL REGISTRATION

ISRCT No: 71762042.

Birth weight and cognitive ability in childhood among siblings and nonsiblings

OBJECTIVES

The purpose of this work was to examine whether the positive association between birth weight and childhood cognitive ability is seen within siblings from the same family, as well as between nonsiblings, and to determine whether these associations vary with age.

METHODS

We compared the association of birth weight with cognitive ability measured at ages 5 to 6, 7 to 9, and 11 to 12 years among a total of 5402 children from different families with that among 2236 to 3083 sibships from the National Longitudinal Study of Youth 1979-Children.

RESULTS

In the whole cohort, there were positive associations between birth weight and cognitive ability at all ages, with the association increasing with age from a 0.81-point increase at ages 5 to 6 years to 1.30 and 1.44 points at ages 7 to 9 and 11 to 12 years, respectively, per 1 SD of gestational age- and gender-adjusted birth weight z score. With adjustment for covariates, there was marked attenuation of these associations. Mean differences were 0.28 points in children aged 5 to 6 years, 0.67 points in those aged 7 to 9 years, and 0.52 points in those aged 11 to 12 years after adjusting for child's gender, race or ethnicity, year of birth, and age at test; maternal age, height, parity, education, smoking during pregnancy, and cognitive ability; and household income. Our family-based analyses that separated within- and between-family effects found that the between-family associations were much stronger than the within-family associations. However, adjustment for potential confounders attenuated the between-family associations, and there was no evidence for a difference in association comparing the between- and within-family associations.

CONCLUSIONS

In these data, the positive association between birth weight and childhood cognitive ability at ages 5 to 12 years is explained largely by family characteristics rather than a specific intrauterine effect.

An overview of methods for monitoring social disparities in cancer with an example using trends in lung cancer incidence by area-socioeconomic position and race-ethnicity, 1992-2004

The authors provide an overview of methods for summarizing social disparities in health using the example of lung cancer. They apply four measures of relative disparity and three measures of absolute disparity to trends in US lung cancer incidence by area-socioeconomic position and race-ethnicity from 1992 to 2004. Among females, measures of absolute and relative disparity suggested that area-socioeconomic and race-ethnic disparities increased over these 12 years but differed widely with respect to the magnitude of the change. Among males, the authors found substantial disagreement among summary measures of relative disparity with respect to the magnitude and the direction of change in disparities. Among area-socioeconomic groups, the index of disparity increased by 47% and the relative concentration index decreased by 116%, while for race-ethnicity the index of disparity increased by 36% and the Theil index increased by 13%. The choice of a summary measure of disparity may affect the interpretation of changes in health disparities. Important issues to consider are the reference point from which differences are measured, whether to measure disparity on the absolute or relative scale, and whether to weight disparity measures by population size. A suite of indicators is needed to provide a clear picture of health disparity change.

The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction

Background

Patients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction (AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation-wide longitudinal study we wanted to evaluate long-term survival after AMI in relation to socioeconomic position (SEP) and use of revascularization.

Methods

From the Swedish Myocardial Infarction Register we identified all 45 to 84-year-old patients (16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5-year survival after the AMI.

Results

Patients with the highest cumulative income (adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co-morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long-term mortality among patients who did not undergo revascularization.

Conclusion

This nationwide Swedish study showed that patients with high income had a better long-term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.

Emergence of socioeconomic inequalities in smoking and overweight and obesity in early adulthood: the national longitudinal study of adolescent health

OBJECTIVES

We examined whether socioeconomic inequalities in smoking and overweight and obesity emerged in early adulthood and the contribution of family background, adolescent smoking, and body mass index to socioeconomic inequalities.

METHODS

Using data from the National Longitudinal Study of Adolescent Health we employed multinomial regression analyses to estimate relative odds of heavy or light-to-moderate smoking to nonsmoking and of overweight or obesity to normal weight.

RESULTS

For smoking, we found inequalities by young adult socioeconomic position in both genders after controlling for family background and smoking during adolescence. However, family socioeconomic position was not strongly associated with smoking in early adulthood. For overweight and obesity, we found socioeconomic inequalities only among women both by young adult and family socioeconomic position after adjusting for birthweight, other family background, and body mass index during adolescence.

CONCLUSIONS

Socioeconomic inequalities in smoking emerged in early adulthood according to socioeconomic position. Among women, inequalities in overweight or obesity were already evident by family socioeconomic position and strengthened by their own socioeconomic position. The relative importance of family background and current socioeconomic circumstances varied between smoking and overweight or obesity.

Influence of socioeconomic factors on survival after breast cancer--a nationwide cohort study of women diagnosed with breast cancer in Denmark 1983-1999

The reasons for social inequality in breast cancer survival are far from established. Our study aims to study the importance of a range of socioeconomic factors and comorbid disorders on survival after breast cancer surgery in Denmark where the health care system is tax-funded and uniform. All 25,897 Danish women who underwent protocol-based treatment for breast cancer in 1983-1999 were identified in a clinical database and information on socioeconomic variables and both somatic and psychiatric comorbid disorders was obtained from population-based registries. We used Cox proportional hazards models to estimate the association between socioeconomic position and overall survival and further to analyse breast cancer specific deaths in a competing risk set-up regarding all other causes of death as competing risks. The adjusted hazard ratio (HR) for death was reduced in women with higher education (HR, 0.91; 95% confidence interval (CI), 0.85-0.98), with higher income (HR, 0.93; 95% CI, 0.87-0.98) and with larger dwellings (HR, 0.90; 95% CI, 0.85-0.96 for women living in houses larger than 150 m(2)). Presence of comorbid disorders increased the HR. An interaction between income and comorbid disorders resulting in a 15% lower survival 10 year after primary surgery in poor women with low-risk breast cancer having comorbid conditions ( approximately 65%) compared to rich women with similar breast cancer prognosis and comorbid conditions ( approximately 80%) suggests that part of the explanation for the social inequality in survival after breast cancer surgery in Denmark lies in the access to and/or compliance with management of comorbid conditions in poorer women.

Web-based training tool for interpreting dental radiographic images

A web-based training tool for interpreting dental radiographic images was developed at University of Wisconsin - Milwaukee (UWM) and evaluated at Marquette University (MU) dental school. The tool provides a self-instructional environment that will simulate the teacher- student interaction in the instruction of the interpretation of dental diagnostic images and allows students to review various abnormalities that the general practitioner may encounter. The training tool also can support off-site instruction and continuing education programs.

Factors Controlling Particle Size during Nebulization of DNA–Polycation Complexes

Pulmonary gene therapy has the potential to treat or cure respiratory diseases such as cystic fibrosis. Much work has focused on the delivery of genes to the lung using viral vectors with varying degrees of success. Viral vectors are problematic and undesirable for use in the lung because they can provoke an acute immune response. This study has focused on the characterization of nonviral, polymer-based gene vectors for use with nebulizers. Calf thymus DNA has been used as a model, and was complexed with each of the three polycations; 22 kDa linear polyethyleneimine, 25 kDa branched polyethyleneimine, and 29.5 kDa polylysine using water, glucose solution, and phosphate-buffered saline (PBS) as carrier liquids. Fourier transform infrared spectroscopy has shown that the DNA retains the B form during the complex formation. The complexes prepared at N:P ratios of 10, have been nebulized using a vibrating plate nebulizer and the particle size and Zeta potentials measured before and after nebulization. The particle size distributions of the DNA complexes prepared in water and glucose solution were unimodal before and after nebulization with a small increase in particle size following nebulization. Choice of complexing polymer is shown to have only a small effect on particle size with the dominant effect coming from the ionic character of the dispersion fluid. Complexes prepared in PBS, although originally unimodal, showed pronounced agglomeration on nebulization. With all polymers in water or glucose solution, the Zeta potential increases after nebulization, but with PBS as the carrier liquid the potential falls and is clearly associated with the observed agglomeration. Gel electrophoresis shows that the complexing polymers protect the DNA through the nebulization process in all cases.

High Throughput Cell-Based Immunoassays Using Filtration Plates (132.1)

Cell-based immunoassays require time consuming centrifugation/wash steps which can cause a substantial cell loss. We describe here automation compatible cell-based immunoassays using 96 well filtration plates. The method is rapid and robust, requiring no centrifugation based washing steps, and enables easy yet rigorous removal of unbound antibodies with little cell loss (&lt;20%) even after extensive filtration (&gt;10x).

We tested the method for detecting surface and intracellular proteins via a high throughput flow cytometer. In all cases, reproducible results with excellent signal to noise ratio were detected.

For surface protein detection, Jurkat cells were stained for CD45 and MFI (mean fluorescence intensity) of 504 +/-19 (CD45) and 12 +/-2 (isotype control) were obtained. For intracellular protein detection, anisomycin treated Jurkat cells and INF-γ treated U937 cells were stained for phospho-p38 (pT180/pY182) and phospho-Stat1 (pY701), respectively. MFI was 19.6 +/-1.8 (induced) and 5.2 +/-0.4 (not induced) for phosph-p38, and 44 +/-0.8 (induced) and 4.8+/-0.6 (not induced) for phospho-Stat1.

In conclusion, reported method allows for sample incubation/preparation in the same plate, while removing the rate limiting centrifugation/wash steps. While we demonstrate its use in flow cytometry, the method is suitable for other cell-based immunoassays such as chemiluminescent protein detection.

Trends in the black-white life expectancy gap in the United States, 1983-2003

CONTEXT

Since the early 1980s, the black-white gap in life expectancy at birth increased sharply and subsequently declined, but the causes of these changes have not been investigated.

OBJECTIVE

To determine the contribution of specific age groups and causes of death contributing to the changes in the black-white life expectancy gap from 1983-2003.

DESIGN AND SETTING

US vital statistics data from the US National Vital Statistics System, maintained by the National Center for Health Statistics. Standard life table techniques were used to decompose the change in the black-white life expectancy gap by combining absolute changes in age-specific mortality with relative changes in the distribution of causes of death.

MAIN OUTCOME MEASURE

The gap in life expectancy at birth between blacks and whites.

RESULTS

Among females, the black-white life expectancy gap increased 0.5 years in the period 1983-1993, primarily due to increased mortality from human immunodeficiency virus (HIV) (0.4 years) and slower declines in heart disease (0.1 years), which were somewhat offset by relative improvements in stroke (-0.1 years). The gap among males increased by 2 years in the period 1983-1993, principally because of adverse changes in HIV (1.1 years), homicide (0.5 years), and heart disease (0.3 years). Between 1993 and 2003, the female gap decreased by 1 year (from 5.59 to 4.54 years). Half of the total narrowing of the gap among females was due to relative mortality improvement among blacks in heart disease (-0.2 years), homicide (-0.2 years), and unintentional injuries (-0.1 years). The decline in the life expectancy gap was larger among males, declining by 25% (from 8.44 to 6.33 years). Nearly all of the 2.1-year decline among males was due to relative mortality improvement among blacks at ages 15 to 49 years (-2.0 years). Three causes of death accounted for 71% of the narrowing of the gap among males (homicide [-0.6 years], HIV [-0.6 years], and unintentional injuries [-0.3 years]), and lack of improvement in heart disease at older ages kept the gap from narrowing further.

CONCLUSIONS

After widening during the late 1980s, the black-white life expectancy gap has declined because of relative mortality improvements in homicide, HIV, unintentional injuries, and, among females, heart disease. Further narrowing of the gap will require concerted efforts in public health and health care to address the major causes of the remaining gap from cardiovascular diseases, homicide, HIV, and infant mortality.

Income inequality and mortality: a multilevel prospective study of 521 248 individuals in 50 US states

BACKGROUND

Some of the most consistent evidence in favour of an association between income inequality and health has been among US states. However, in multilevel studies of mortality, only two out of five studies have reported a positive relationship with income inequality after adjustment for the compositional characteristics of the state's inhabitants. In this study, we attempt to clarify these mixed results by analysing the relationship within age-sex groups and by applying a previously unused analytical method to a database that contains more deaths than any multilevel study to date.

METHODS

The US National Longitudinal Mortality Study (NLMS) was used to model the relationship between income inequality in US states and mortality using both a novel and previously used methodologies that fall into the general framework of multilevel regression. We adjust age-sex specific models for nine socioeconomic and demographic variables at the individual level and percentage black and region at the state level.

RESULTS

The preponderance of evidence from this study suggests that 1990 state-level income inequality is associated with a 40% differential in state level mortality rates (95% CI = 26-56%) for men 25-64 years and a 14% (95% CI = 3-27%) differential for women 25-64 years after adjustment for compositional factors. No such relationship was found for men or women over 65.

CONCLUSIONS

The relationship between income inequality and mortality is only robust to adjustment for compositional factors in men and women under 65. This explains why income inequality is not a major driver of mortality trends in the United States because most deaths occur at ages 65 and over. This analysis does suggest, however, the certain causes of death that occur primarily in the population under 65 may be associated with income inequality. Comparison of analytical techniques also suggests coefficients for income inequality in previous multilevel mortality studies may be biased, but further research is needed to provide a definitive answer.

Trends in socioeconomic inequalities in adult health behaviors among U.S. states, 1990-2004

OBJECTIVE

The purpose of this study was to measure state trends in educational inequalities in smoking, binge alcohol use, physical inactivity, obesity, and seatbelt use.

METHODS

The authors calculated the Relative Concentration Index of educational inequality for five health behaviors on adults from all 50 states and the District of Columbia using data from 1990 to 2004 in the Behavioral Risk Factor Surveillance System (n=2,118,562). Linear regression was used to measure changes and trends in the Relative Concentration Index of health inequality across education groups in each state.

RESULTS

Except for binge alcohol use, poorer health behaviors were concentrated among the less educated. The largest educational inequalities were for physical inactivity. From 1990 to 2004, significant increases in relative educational inequalities occurred in 40 states for smoking and 31 states for physical inactivity. For binge alcohol use, 27 states showed significant declining inequality trends, but educational inequalities reversed direction and binge alcohol use is now more prevalent among the less educated in 19 states. Significant decreases in educational inequalities occurred in 36 states for obesity and 24 states for seat belt use. Changes in educational inequalities across the different health behaviors were not associated, except for a modest correlation between changes in inequality in smoking and binge alcohol use (r=0.40; p=0.004). Similarly, there was little association between changes in the population prevalence of health behaviors and changes in educational inequality in health behaviors, with substantial heterogeneity among states.

CONCLUSIONS

State trends in relative educational inequality among health behaviors were mixed, increasing for smoking and physical inactivity and decreasing for obesity and seat belt use. The factors influencing relative inequality trends may differ from those affecting overall prevalence trends.