Feasibility of four consecutive high-dose chemotherapy cycles with stem-cell rescue for patients with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor after craniospinal radiotherapy: results of a collaborative study

PURPOSE

This study was designed to determine the feasibility and safety of delivering four consecutive cycles of high-dose cyclophosphamide, cisplatin, and vincristine, each followed by stem-cell rescue, every 4 weeks, after completion of risk-adapted craniospinal irradiation to children with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor (PNET).

PATIENTS AND METHODS

Fifty-three patients, 19 with high-risk disease and 34 with average-risk disease, were enrolled onto this study. After surgical resection, high-risk patients were treated with topotecan in a 6-week phase II window followed by craniospinal radiation therapy and four cycles of high-dose cyclophosphamide (4,000 mg/m2 per cycle), with cisplatin (75 mg/m2 per cycle), and vincristine (two 1.5-mg/m2 doses per cycle). Support with peripheral blood stem cells or bone marrow and with granulocyte colony-stimulating factor was administered after each cycle of high-dose chemotherapy. Treatment of average-risk patients consisted of surgical resection and craniospinal irradiation, followed by the same chemotherapy given to patients with high-risk disease. The expected duration of the chemotherapy was 16 weeks, with a cumulative cyclophosphamide dose of 16,000 mg/m2 and a planned dose-intensity of 1,000 mg/m2/wk.

RESULTS

Fifty of the 53 patients commenced high-dose chemotherapy, and 49 patients completed all four cycles. The median length of chemotherapy cycles one through four was 28, 27, 29, and 28 days, respectively. Engraftment occurred at a median of 14 to 15 days after infusion of stem cells or autologous bone marrow. The intended dose-intensity of cyclophosphamide was 1,000 mg/m2/wk; the median delivered dose-intensity was 1,014, 1,023, 974, and 991 mg/m2/wk for cycles 1 through 4, respectively; associated median relative dose-intensity was 101%, 102%, 97%, and 99%. No deaths were attributable to the toxic effects of high-dose chemotherapy. Early outcome analysis indicates a 2-year progression-free survival of 93.6% +/- 4.7% for the average-risk patients. For the high-risk patients, the 2-year progression-free survival is 73.7% +/- 10.5% from the start of therapy and 84.2% +/- 8.6% from the start of radiation therapy.

CONCLUSION

Administering four consecutive cycles of high-dose chemotherapy with stem-cell support after surgical resection and craniospinal irradiation is feasible in newly diagnosed patients with medulloblastoma/supratentorial PNET with aggressive supportive care. The early outcome results of this approach are very encouraging.

Assessing exposure to disinfection by-products in women of reproductive age living in Corpus Christi, Texas, and Cobb county, Georgia: descriptive results and methods

We conducted a field study in Corpus Christi, Texas, and Cobb County, Georgia, to evaluate exposure measures for disinfection by-products, with special emphasis on trihalomethanes (THMs). Participants were mothers living in either geographic area who had given birth to healthy infants from June 1998 through May 1999. We assessed exposure by sampling blood and water and obtaining information about water use habits and tap water characteristics. Two 10-mL whole blood samples were collected from each participant before and immediately after her shower. Levels of individual THM species (chloroform, bromodichloromethane, dibromochloromethane, and bromoform) were measured in whole blood [parts per trillion (pptr)] and in water samples (parts per billion). In the Corpus Christi water samples, brominated compounds accounted for 71% of the total THM concentration by weight; in Cobb County, chloroform accounted for 88%. Significant differences in blood THM levels were observed between study locations. For example, the median baseline blood level of bromoform was 0.3 pptr and 3.5 pptr for participants in Cobb County and Corpus Christi, respectively (p = 0.0001). Differences were most striking in blood obtained after showering. For bromoform, the median blood levels were 0.5 pptr and 17 pptr for participants in Cobb County and Corpus Christi, respectively (p = 0.0001). These results suggest that blood levels of THM species vary substantially across populations, depending on both water quality characteristics and water use activities. Such variation has important implications for epidemiologic studies of the potential health effects of disinfection by-products.

High-dose methotrexate for primary CNS lymphoma in the elderly

Primary central nervous system lymphoma (PCNSL) in the immunocompetent patient reaches a peak incidence in the sixth and seventh decades of life. This retrospective study reviewed the efficacy and tolerability of high-dose methotrexate (HDMTX) in an elderly patient population. Between May 1995 and September 1998, ten consecutive elderly patients with histologically proven PCNSL were treated with HDMTX. The median age was 72.5 years and eight patients (80%) were older than 70 years. HDMTX was well tolerated with no episodes of grade 4 toxicity nor febrile neutropenia. Toxicity included grade 3 nausea (1), grade 2 mucositis (2), and grade 2 asymptomatic elevation of liver transaminases (2). Grade 1 toxicity occurred in three patients with nausea, diarrhea, and mild reversible elevation in serum creatinine in one patient each. Six patients had a complete response and three patients achieved a partial response, giving an overall response rate of 90% (95% confidence interval, 56%-100%). The median overall survival for the cohort was 36 months (range 4-43 months). In summary, HDMTX is well tolerated in this elderly population with PCNSL and achieves response rates and median survival comparable with other chemotherapy or radiotherapy regimens.

In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler's diarrhea in four geographic regions

The emergence of resistant enteropathogens has been reported worldwide. Few data are available on the contemporary in vitro activities of commonly used antimicrobial agents against enteropathogens causing traveler's diarrhea (TD). The susceptibility patterns of antimicrobial agents currently available or under evaluation against pathogens causing TD in four different areas of the world were evaluated. Pathogens were identified in stool samples from U.S., Canadian, or European adults (18 years of age or older) with TD during 1997, visiting India, Mexico, Jamaica, or Kenya. MICs of 11different antimicrobials were determined against 284 bacterial enteropathogens by the agar dilution method. Ciprofloxacin, levofloxacin, ceftriaxone, and azithromycin were highly active in vitro against the enteropathogens, while traditional antimicrobials such as ampicillin, trimethoprim, and trimethoprim/sulfamethoxazole showed high levels and high frequencies of resistance. Rifaximin, a promising and poorly absorbable drug, had an MIC at which 90% of the strains tested were inhibited of 32 microg/ml, 250 times lower than the concentration of this drug in the stools. Amdinocillin, nalidixic acid, and doxycycline showed moderate activity. Fluoroquinolones are still the drugs of choice for TD in most regions of the world, although our study has a limitation due to the lack of Escherichia coli samples from Kenya and possible bias in selection of the patients for evaluation. Azithromycin and rifaximin should be considered as promising new agents. The widespread in vitro resistance of the traditional antimicrobial agents reported since the 1980s and the new finding of resistance to fluoroquinolones in Southeast Asia are the main reasons for monitoring carefully the antimicrobial susceptibility patterns worldwide and for developing and evaluating new antimicrobial agents for the treatment of TD.

High-dose methotrexate for primary CNS lymphoma in the elderly

Primary central nervous system lymphoma (PCNSL) in the immunocompetent patient reaches a peak incidence in the sixth and seventh decades of life. This retrospective study reviewed the efficacy and tolerability of high-dose methotrexate (HDMTX) in an elderly patient population. Between May 1995 and September 1998, ten consecutive elderly patients with histologically proven PCNSL were treated with HDMTX. The median age was 72.5 years and eight patients (80%) were older than 70 years. HDMTX was well tolerated with no episodes of grade 4 toxicity nor febrile neutropenia. Toxicity included grade 3 nausea (1), grade 2 mucositis (2), and grade 2 asymptomatic elevation of liver transaminases (2). Grade 1 toxicity occurred in three patients with nausea, diarrhea, and mild reversible elevation in serum creatinine in one patient each. Six patients had a complete response and three patients achieved a partial response, giving an overall response rate of 90% (95% confidence interval, 56%-100%). The median overall survival for the cohort was 36 months (range 4-43 months). In summary, HDMTX is well tolerated in this elderly population with PCNSL and achieves response rates and median survival comparable with other chemotherapy or radiotherapy regimens.

Etiology of travelers' diarrhea on a Caribbean island

BACKGROUND

Between December 6, 1994 and March 10, 1996, a study of the etiology of diarrhea was carried out among 332 travelers to five all-inclusive hotels in Negril, Jamaica.

METHODS

Stool specimens were collected and sent to Montego Bay for laboratory analysis. Escherichia coli strains isolated at the Jamaican laboratory were sent to Houston for toxin testing.

RESULTS

A recognized enteropathogen was found in 118 of the 332 (35.5%) cases. Enterotoxigenic E. coli (ETEC) were the most commonly identified pathogen (87/332; 26.2%) followed by Salmonella (4.2%) and Shigella (4.2%). Clustering of etiologically defined cases was studied at each hotel. A cluster was defined as 2 or more cases with the same pathogen identified in the same hotel within 7 days. In the 3 hotels with the highest number of cases of diarrhea, enteropathogens were part of a cluster in 65 of 99 cases (65.7%) of diarrhea of which an etiologic agent was identified. In the other 2 hotels, only 4 of 20 cases (20%) occurred in clusters.

CONCLUSIONS

A total of 25 clusters of travelers' diarrhea cases was detected at the five hotels during the study period. Seventeen of 25 (68%) ETEC isolations occurred as part of a clustering of diarrhea cases. The largest outbreak of pathogen-identified diarrhea consisted of 7 cases of ETEC producing both heat-stable and heat-labile enterotoxins. In the Jamaican hotels with all inclusive meal packages most diarrhea cases occurred as small clusters, presumably as the result of foodborne outbreaks.

Policy analysis for end-stage renal disease in Jamaica

We developed and applied methods for policy analysis for end-stage renal disease (ESRD) in Jamaica. Our emphasis was on methods useful for situations often found in developing countries, where both resources and data may be limited. Many countries are experimenting with ESRD treatment options, but little analysis has been done regarding how developing countries should approach policy decisions for ESRD. Methods for policy analysis in high-income countries often rely on large data sets that may be unavailable or only partially available in developing countries. We conducted technical analysis applicable in these circumstances and emphasized a process for including a wide range of policymakers and other stakeholders in both quantitative and qualitative aspects of the analysis. Our methods may also be applicable in other developing countries and for other chronic diseases. Our analysis included eight issues: (1) a review of currently available clinical and scientific understanding regarding ESRD; (2) a review of country-specific socioeconomic and clinical issues relevant to ESRD in Jamaica; (3) estimates of the magnitude of the need for treatment in the Jamaican population; (4) comparison of the need with available treatment capacity; (5) cost analysis related to options for expansion of treatment capacity; (6) comparison of costs to government budget resources and other potential sources of financing; (7) development of policy options; and (8) sensitivity testing of policy scenarios and trade-offs with competing priorities. We also identified several key decisions most developing country governments will face in setting health policy for ESRD. These include allocating funds for ESRD, identifying and selecting cost-saving clinical strategies, rationing available treatment capacity, and identifying the appropriate role for public education.

A survey of personal exposures to benzene in Mexico City

Benzene is a widely distributed environmental contaminant that causes leukemia. It is an important component in gasoline, it is used frequently as a solvent or chemical feedstock in industry, and it is emitted as a product of incomplete combustion. In Mexico City, investigators suspect that benzene exposure might be elevated and may pose a risk to the population; however, no published data are available to confirm or disconfirm this suspicion. We, therefore, conducted a survey in 3 occupational groups in Mexico City. Forty-five volunteers who used portable passive monitors measured their personal exposure to benzene during a workshift. None of the participants smoked during the monitoring period. Benzene exposure was significantly higher among service-station attendants (mean = 359.5 microg/m3 [standard deviation = 170.4 microg/m3]) than among the street vendors (83.7 microg/m3 and 45.0 microg/m3, respectively) and office workers (45.2 microg/m3 and 13.3 microg/m3, respectively). However, the benzene exposure levels observed among office workers were substantially higher than levels reported elsewhere for general populations. Our results highlight the need for more complete studies by investigators who should assess the potential benefits of setting environmental standards for benzene in Mexico.

Enteroaggregative Escherichia coli as a cause of traveler's diarrhea: clinical response to ciprofloxacin

The purpose of this study was to determine the role of enteroaggregative Escherichia coli (EAEC) in the development of traveler's diarrhea and the clinical response of patients with EAEC diarrhea following treatment with ciprofloxacin. Sixty-four travelers with diarrhea and no other recognized enteropathogen were enrolled in treatment studies in Jamaica and Mexico from July 1997 to July 1998. EAEC was isolated from 29 travelers (45.3%). There was a significant reduction in the duration of posttreatment diarrhea in the 16 patients treated with ciprofloxacin, as compared with that in the 13 patients who received placebo (mean of 35.3 versus 55.5 hours; P = .049). There was a nonsignificant reduction in the mean number of unformed stools passed during the 72 hours after enrollment in the ciprofloxacin-treated group (5.6), as compared with that in the placebo group (7.5) (P = .128). This study provides additional evidence that EAEC should be considered as a cause of antibiotic-responsive traveler's diarrhea.

Environmental exposure to volatile organic compounds among workers in Mexico City as assessed by personal monitors and blood concentrations

Benzene, an important component in gasoline, is a widely distributed environmental contaminant that has been linked to known health effects in animals and humans, including leukemia. In Mexico City, environmental benzene levels, which may be elevated because of the heavy traffic and the poor emission control devices of older vehicles, may pose a health risk to the population. To assess the potential risk, portable passive monitors and blood concentrations were used to survey three different occupational groups in Mexico City. Passive monitors measured the personal exposure of 45 workers to benzene, ethylbenzene, toluene, o-xylene and m-/p-xylene during a work shift. Blood concentrations of the above volatile organic compounds (VOCs), methyl tert-butyl ether, and styrene were measured at the beginning and the end of a work shift. Passive monitors showed significantly higher (p > 0.0001) benzene exposure levels among service station attendants (median = 330 microg/m3; range 130-770) as compared to street vendors (median = 62 microg/m3; range 49-180) and office workers (median = 44 microg/m3, range 32-67). Baseline blood benzene levels (BBLs) for these groups were higher than those reported for similar populations from Western countries (median = 0.63 microg/L, n = 24 for service station attendants; median = 0.30 microg/L, n = 6 for street vendors; and median = 0.17 microgr;g/L, n = 7 for office workers). Nonsmoking office workers who were nonoccupationally exposed to VOCs had BBLs that were more than five times higher than those observed in a nonsmoking U.S. population. BBLs of participants did not increase during the work shift, suggesting that because the participants were chronically exposed to benzene, complex pharmacokinetic mechanisms were involved. Our results highlight the need for more complete studies to assess the potential benefits of setting environmental standards for benzene and other VOCs in Mexico.

Irinotecan therapy in adults with recurrent or progressive malignant glioma

PURPOSE

To determine the activity, toxicity, and pharmacokinetics of irinotecan (CPT-11, Camptosar; Pharmacia & Upjohn, Kalamazoo, MI) in the treatment of adults with progressive, persistent, or recurrent malignant glioma.

PATIENTS AND METHODS

Patients with progressive or recurrent malignant gliomas were enrolled onto this study between October 1996 and August 1997. CPT-11 was given as a 90-minute intravenous (i.v.) infusion at a dose of 125 mg/m2 once weekly for 4 weeks followed by a 2-week rest, which comprised one course. Plasma concentrations of CPT-11 and its metabolites, SN-38 and SN-38 glucuronide (SN-38G), were determined in a subset of patients.

RESULTS

All 60 patients who enrolled (36 males and 24 females) were treated with CPT-11 and all were assessable for toxicity, response, and survival. Pharmacokinetic data were available in 32 patients. Nine patients (15%; 95% confidence interval, 6% to 24%) had a confirmed partial response, and 33 patients (55%) achieved stable disease lasting more than two courses (12 weeks). Toxicity observed during the study was limited to infrequent neutropenia, nausea, vomiting, and diarrhea. CPT-11, SN-38, and SN-38G area under the plasma concentration-time curves through infinite time values in these patients were approximately 40%, 25%, and 25%, respectively, of those determined previously in patients with metastatic colorectal cancer not receiving antiepileptics or chronic dexamethasone treatment.

CONCLUSION

Response results document that CPT-11, given with a standard starting dose and treatment schedule, has activity in patients with recurrent malignant glioma. However, the low incidence of severe toxicity and low plasma concentrations of CPT-11 and SN-38 achieved in this patient population suggest that concurrent treatment with anticonvulsants and dexamethasone enhances drug clearance.

Epidemiology, etiology, and impact of traveler's diarrhea in Jamaica

CONTEXT

Traveler's diarrhea (TD) can incapacitate travelers. Characteristics of TD could be helpful in identifying individuals who might benefit from a vaccine against TD.

OBJECTIVE

To determine epidemiology, etiology, and impact of TD in Jamaica. Design Two-armed, cross-sectional survey conducted between March 1996 and May 1997.

SETTING

Sangster International Airport and 10 hotels in Montego Bay area, Jamaica.

SUBJECTS

To investigate epidemiology and impact, 30369 short-term visitors completed a questionnaire just before boarding their homebound aircrafts. To investigate etiology, 322 patients (hotel guests) with TD provided stool samples.

MAIN OUTCOME MEASURES

Attack and incidence rates of reported diarrhea and of classically defined TD (> or =3 unformed stool samples in 24 hours and > or =1 accompanying symptom), incapacity, risk factors, and etiology.

RESULTS

The attack rate for diarrhea was 23.6% overall, with 11.7% having classically defined TD. For a mean duration of stay of 4 to 7 days, the incidence rate was 20.9% (all TD) and 10.0% (classic TD). Among airport respondents, the incapacity lasted a mean of 11.6 hours. Less than 3% of all travelers avoided potentially high-risk food and beverages. The most frequently detected pathogens were enterotoxigenic Escherichia coli, Rotavirus, and Salmonella species.

CONCLUSIONS

A realistic plan for reducing TD is needed. Preventive measures such as the improvement of hygienic conditions at the destination, and/or the development of vaccines against the most frequent pathogens associated with TD may contribute toward achieving this goal.

Informing Maternal and Child Health (MCH) policy through research

Maternal and Child Health (MCH) policy over the past two decades has been strongly influenced by research. The paper presents examples of some of the research undertaken and its significant influence in shaping health service delivery. Research in child health has focussed on oral rehydration therapy, immunization and perinatal morbidity and mortality. On the maternal side, morbidity and mortality have been examined with particular focus on problems which contribute to maternal and perinatal morbidity and mortality. Policies arising out of the outcome of these studies have influenced organization of service delivery, information system development, manpower development and deployment, maternal education, surveillance/auditing, quality of care, design of physical facilities and selection of equipment. The results of these studies have also led to the identification of areas requiring further study and testing of intervention to correct the deficiencies identified. These studies demonstrate that research can and does influence health policy, and has impacted positively on the quality and cost of care provided through our health services.

Activity of high-dose cyclophosphamide in the treatment of childhood malignant gliomas

Seventeen patients less than or equal to 20 years of age with newly diagnosed (n = 10) or recurrent (n = 7) malignant gliomas (anaplastic astrocytoma and glioblastoma multiforme) were treated with cyclophosphamide in association with hematopoietic cytokines (GM-CSF or G-CSF). Cyclophosphamide was given at a dose of 2 g/m2 daily for 2 days at 4-week intervals. Toxicity consisted of grade IV neutropenia and thrombocytopenia in 95% and 48% of cycles, respectively. There were no cyclophosphamide-related cardiac, pulmonary, or urothelial toxicities observed. Four of 10 patients with newly diagnosed disease demonstrated responses (three complete and one partial responses; one CR was only of 2 months duration). None of the seven patients with recurrent tumors demonstrated a response. We conclude that high-dose cyclophosphamide warrants further evaluation in children with newly diagnosed malignant glioma.

Body burden measurements and models to assess inhalation exposure to methyl tertiary butyl ether (MTBE)

Biomarkers of methyl tertiary butyl either (MTBE) exposure and the partitioning of inhaled MTBE into the body were investigated in a human chamber study. Two subjects were exposed to an environmentally relevant nominal 5,011 micrograms/m3 (1.39 ppm) MTBE for 1 hour, followed by clean-air exposure for 7 hours. Breath and blood were simultaneously sampled, while total urine was collected at prescribed times before, during, and after the exposure. Mass-balance and toxicokinetic analyses were conducted based upon the time series measurement of multiple body-burden endpoints, including MTBE in alveolar breath, and MTBE and tertiary butyl alcohol (TBA) in venous blood and urine. The decay of MTBE in the blood was assessed by fitting the post-exposure data to a 2- or 3-exponential model that yielded residence times(tau) of 2-3 min, 15-50 min, and 3-13 h as measured by alveolar breath, and 5 min, 60 min, and 32 h as evaluated from venous blood measurements. Based on observations of lower than expected blood and breath MTBE during uptake and a decreasing blood-to-breath ratio during the post-exposure decay period, we hypothesize that the respiratory mucous membranes were serving as a reservoir for the retention of MTBE. The decay data suggest that 6-9% of the MTBE intake may be retained by this non-blood reservoir. The compartmental modeling was further used to estimate important parameters that define the uptake of inhaled MTBE. The first of these parameters is f, the fraction of C(air) exhaled at equilibrium, estimated as 0.60 and 0.46 for the female and male subject, respectively. The second parameter is the blood-to-breath partition coefficient (P) estimated as approximately 18. The product of these parameters provides an estimate of the blood concentration at equilibrium as 8-11 times the air concentration. Blood TBA lagged MTBE levels and decayed more slowly (tau = 1.5-3 h), providing a more stable indication of longer term integrated exposure. The concentration ranges of MTBE and TBA in urine were similar to that of the blood, ranging from 0.37 to 15 micrograms/L and 2 to 15 micrograms/L, respectively. In urine, MTBE and TBA by themselves bore little relationship to the exposure. However, the MTBE:TBA ratio followed the pattern of exposure, with peak values occurring at the end of the exposure (20- and 60-fold greater than pre-exposure values) before decaying back to pre-exposure levels by the end of the 7-h decay period. Urinary elimination accounted for a very small fraction of total MTBE elimination (< 1%).

Interreader reliability for a new classification of lumbar disk disease

RATIONALE AND OBJECTIVES

The nomenclature that divides disk herniations into protrusions and extrusions may increase the specificity of magnetic resonance (MR) imaging for clinically important lesions. Our goal was to determine this terminology's interreader reliability.

METHODS

Three readers who were unaware of patients' histories independently read MR images of 34 consecutive patients with back pain. Readers classified disks at the lowest three lumbar levels as normal, bulging, protruded, or extruded. Kappa and weighted kappa values were the primary measures of agreement.

RESULTS

Weighted kappa values showed fair-to-moderate agreement. Kappas for the dichotomous decision of extrusion present or absent were more variable, ranging from 0 to .78. Major disagreements (greater than a single category) occurred with 6.2% of all comparisons and in 10 of 34 volunteers; five involved extrusions.

CONCLUSION

Overall, readers achieved moderate agreement for this new nomenclature. However, agreement for the presence or absence of an extrusion was less reliable.

Under-users of antenatal care: a comparison of non-attenders and late attenders for antenatal care, with early attenders

Demographic, behavioural, environmental, economic and obstetric history data from the Jamaican Perinatal Morbidity and Mortality Survey were examined to identify characteristics of women who do not attend for antenatal care, or present late instead of early for care, using multiple logistic regression. Non-attenders were more likely to be teenagers, unmarried, in unions of very short duration, smokers and women who felt that friends and relatives were not supportive. Multigravid non-attenders often had short inter-pregnancy intervals and included women who had experienced a post neonatal death. They were often drawn from deprived environments (lack of sanitation, water supplies). Late attenders shared features common to non-attenders (teenagers, unmarried, multigravid). Many however were self employed and did not fit the depressed profile of the non-attender. Most multigravidae who attended late had had previously uneventful pregnancies, including this one. Early attenders had little in common with non-attenders or late attenders. They were older, many had a secondary or tertiary education, were married and were generally middle class women. The group however included high risk multigravidae who had previous pregnancy complications or bad outcomes. Programmes aimed at reaching non-attenders must focus on the wider social and economic needs of these women and must give them a sense of their own power to effect change in their lives. Reaching the late attender will be more difficult and may be unnecessary with the possible exception of the teenager. She needs to be treated in a more sympathetic and non-judgmental way as this is often a high risk pregnancy. More fundamental changes require improved educational and employment opportunities for women as the best consumer is an educated consumer.

Human exposure to volatile organic compounds: a comparison of organic vapor monitoring badge levels with blood levels

We undertook a study in Albany, New York, to investigate whether volatile organic compounds (VOCs) were measurable in the blood and in the breathing-zone air of people exposed to gasoline fumes and automotive exhaust. We sampled blood of 40 subjects, placed organic vapor badges on 40 subjects, and obtained personal breathing-zone samples from 24 subjects. We limited this analysis to 19 subjects who wore the organic vapor badges for at least 5 h. VOC levels, as determined by the organic vapor badges, were highly correlated with blood levels of these same compounds. Using detection in blood as the gold standard, we found the badges to be more sensitive than conventional charcoal tube samples in detecting low levels of methyl tert-butyl ether (0.60 vs 0.08), toluene (0.95 vs 0.64), and o-xylene (0.85 vs 0.64). In this study, organic vapor badges provided data on VOC exposure that correlated with blood assay results. These organic vapor badges might provide a convenient means of determining human exposure to VOCs in epidemiologic studies.

Gender differences in adult health: an international comparison

This article uses data from the United States, Jamaica, Malaysia, and Bangladesh to explore gender differences in adult health. The results show that women fare worse than men across a variety of self-reported health measures in all four countries studies. These health status disparities between men and women persist even after appropriate corrections are made for the impact of (a) differential mortality selection by gender and (b) sociodemographic factors. Data from Jamaica indicate that gender disparities in adult health arise early and persist throughout the life cycle, with different age profiles for different measures.

The epidemiology of perinatal death in Jamaica

Information from the Jamaican Perinatal Mortality Survey was used to identify features of mothers and their pregnancies that were independently associated with perinatal death. Social, biological, environmental, life style and medical aspects of mothers and their pregnancies were collected on two inter-locking subsamples: (1) all births on the island of Jamaica in the 2 months of September and October 1986, the 'cohort months', and (2) all fetal deaths of weight 500 g or more, together with all neonatal deaths, in the 12-month period from 1 September 1986 to 31 August 1987. Singleton survivors from the cohort months were compared with all perinatal deaths in the 12-month period using logistic regression. The first model omitted items concerning past obstetric history, but these were included in the second model. In total, 21 variables entered the first model and 24 the second. The only item that became non-significant when past obstetric history was included was maternal age. The final model compared 1017 perinatal deaths with 7672 survivors. It consisted of the following: union (marital) status (married being at lower risk, P < 0.01), maternal employment status (housewives at lowest risk, P < 0.001), number of adults in household (the more the higher the risk, P < 0.05), the number of children aged < 11 (the more the lower the risk, P < 0.0001), use of toilet facilities (shared with other households increased risk, P < 0.001), maternal height (tall women at reduced risk, P < 0.001), mother's report that she was trying to get pregnant (P < 0.001), maternal alcohol consumption (drinkers had lower risk, P < 0.05), maternal syphilis (higher risk, P < 0.0001), bleeding before 28 weeks (higher risk, P < 0.0001), bleeding at 28 weeks or more (higher risk, P < 0.0001), first diastolic blood pressure (80 mm + at higher risk, P < 0.0001), highest diastolic blood pressure (100 mm + at increased risk, P < 0.0001), highest proteinuria (++ or more at increased risk, P < 0.0001), vaginal discharge/infection (untreated at increased risk, P < 0.001), pre-eclampsia diagnosed in antenatal period (increased risk, P < 0.01), maternal diabetes (increased risk, P < 0.05), start of antenatal care (first trimester at reduced risk, P < 0.01), iron taken (reduced risk, P < 0.0001), type of perinatal care available in parish of residence (reduced risk if consultant obstetricians and paediatricians available at all times, P < 0.0001), number of miscarriages and terminations (the more the higher the risk, P < 0.0001), previous stillbirth (higher risk, P < 0.0001), previous early neonatal death (higher risk, P < 0.001), previous Caesarean section (higher risk, P < 0.01). The implications for reduction in perinatal mortality rates are discussed.

Assessment of risk of perinatal death in Jamaica

Data from the Jamaican Perinatal Mortality Survey had been used to create a statistical model using logistic regression. From this a simple additive scoring system to predict perinatal death was devised and tested on the 2 cohort months of the study. The score had a theoretical range of 0-28 points, with the higher the score, the greater the likelihood of a perinatal death. For a cut-point of 7, sensitivity was 43% and specificity 84%. A cut-point of 8 resulted in 27% sensitivity and 94% specificity. Higher cut-points resulted in much reduced sensitivity but enhanced specificity (e.g. cut-point 10: 11% sensitivity, 99% specificity). However, it is likely that these estimates are optimistically high, and to achieve unbiased estimates of sensitivity and specificity the score needs to be tested on a sample of the population from which it was not derived before implementation takes place. Meanwhile, the cut-off level for implementation will depend on appropriate resources available.

Perinatal deaths as a result of immaturity in Jamaica

During the 12-month period from 1 September 1986 to 31 August 1987 an attempt was made to collect information on all perinatal deaths occurring on the island of Jamaica. Of the 2069 late fetal and early neonatal deaths identified, 19% fell into the Wigglesworth definition of 'deaths from immaturity'. Twins were 11 times more likely to die of immaturity than were singletons, and twins comprised 18% of all deaths in this group. Comparison of the singleton deaths from immaturity, with 9919 singletons born on the island during the 2-month period of September and October 1987 and who survived the first 7 days, revealed several strong risk factors. These included history of previous miscarriages, stillbirth, early neonatal death or preterm delivery, and complications of bleeding and hypertension (highest diastolic, proteinuria and eclampsia all having independent associations). None of these factors 'explained' a strong negative relationship with the number of young children in the household. There was an apparent protective effect of maternal folic acid ingestion which warrants further investigation.

The epidemiology of antepartum fetal death in Jamaica

All perinatal deaths occurring over a 12-month period on the island of Jamaica were classified using the Wigglesworth schema. In all, there were 584 antepartum fetal deaths (incidence 10.7 per 1000 total births). Comparison of the 558 singleton deaths with 9919 singleton survivors revealed, using logistic regression, strong associations with union (marital) status, maternal employment status, the composition of the household, the sole use of a toilet by the household, the parish of residence, whether the mother was trying to get pregnant and the mother's age (the older the mother the higher the risk). Independent of these factors were strong statistically significant relationships with syphilis, diabetes, maternal anaemia, third-trimester bleeding, highest diastolic blood pressure of 90mm or more and highest proteinuria of ++ or more. Mothers who had taken prophylactic iron were at substantially lower risk compared with those who had not. We conclude that appropriate identification and treatment of syphilis, diabetes, anaemia and hypertension give the best chance of reduction of the high antepartum fetal death rate on the island.