Prevalence of birth defects among infants of Gulf War veterans in Arkansas, Arizona, California, Georgia, Hawaii, and Iowa, 1989-1993

Renal agenesis: A meta-analysis of its prevalence and clinical characteristics based on 15 641 184 patients

Our objective was to analyse the newest relevant data on worldwide prevalence and associated symptoms of renal agenesis (RA). This meta-analysis builds on previous systematic reviews to include bilateral RA, its symptoms and data on gender, unilateral RA and anomaly location prevalence. Review of available data included records in English and other languages from PubMed, Embase, ScienceDirect, Web of Science, SciELO, BIOSIS, Current Content Connect Korean Journal Database and Russian Citation Index and Google. A total of 15 641 184 patients were analysed in relation to the prevalence of RA. The pooled prevalence of RA was 0.03% (95% CI: 0.03%-0.04%). Based on 500 subjects, a pooled prevalence of 47.96% (95% CI: 31.55%-64.58%) for unilateral and 52.04% (95% CI: 35.42%-68.45%) for bilateral RA has been set. Our study presents the newest generalized findings on bilateral RA. There appears to be universal disease and symptom prevalence with minor differences between world regions, although quality of future observational research should include genomic data. This will provide even further insight into the prognosis of various renal anomalies and their etiologies.

Preliminary Findings from the Gulf War Women’s Cohort: Reproductive and Children’s Health Outcomes among Women Veterans

Reproductive outcomes, such as preterm birth, miscarriage/stillbirth, and pre-eclampsia, are understudied in veterans, particularly among Gulf War veterans (GWVs). During deployment, women GWVs were exposed to toxicant and nontoxicant exposures that may be associated with adverse reproductive and developmental outcomes. The data come from a survey of 239 participants from northeastern and southern U.S. cohorts of women veterans. The questionnaire collected information about the service history, current and past general health, reproductive and family health, demographic information, and deployment exposures. Odds ratios were computed with 95% confidence intervals between exposures in theater and reproductive/children’s health outcomes. GWVs experienced adverse reproductive outcomes: 25% had difficulty conceiving, and 31% had a pregnancy that ended in a miscarriage or stillbirth. Pregnancy complications were common among GWVs: 23% had a high-risk pregnancy, and 16% were diagnosed with pre-eclampsia. About a third of GWVs reported their children (38%) had a developmental disorder. Use of pesticide cream during deployment was associated with higher odds of all reproductive and developmental outcomes. The results demonstrate that GWVs experienced reproductive and children’s health outcomes at potentially high rates, and exploratory analyses suggest pesticide exposure as associated with higher odds of adverse reproductive outcomes. Future longitudinal studies of women veterans should prioritize examining reproductive and children’s health outcomes.

Relationship between achieving Sustainable Development Goals and promoting optimal care and prevention of birth defects globally

Birth defects affect eight million newborns annually worldwide. About 8% of global under-5 mortality is attributable to birth defects. The United Nations (UN) Sustainable Development Goals (SDGs) have set 17 global goals for human growth and development to be achieved by 2030 using multi-sectorial approaches. The third goal (SDG-3) focuses on ensuring healthy lives and promoting well-being; achieving SDG-3 improves birth defects care and prevention. However, we aimed to show how achieving other SDGs also influence optimal care and prevention of birth defects. SDGs focused on poverty reduction, access to nutritious food, universal health coverage, equitable education, gender equality, environment, inclusivity through infrastructure innovation, and strengthening social justice is crucial to addressing social determinants of health for individuals and families affected by birth defects. Understanding birth defects in the context of several relevant SDGs will allow practitioners, researchers, and policymakers to leverage the momentum generated by SDGs and make a case for commitment and allocation of funding and resources for advancing birth defects surveillance, care, and prevention. SDGs are built on principles of equity and social justice and we urge policy-makers to approach birth defects using various SDGs as a catalyst. The synergy between several SDGs helps to optimize birth defect outcomes and prevention. Our effort to present a more comprehensive look at various SDGs and their relationship with birth defects is parallel to several other health advocacy groups conducting a similar mapping exercise, thus bringing to the forefront millions of lives that are impacted by birth defects worldwide.

Service utilization patterns for childbirth and neonatal mortality in the occupied Palestinian territory during conflict

BACKGROUND

The global incidence of man-made crises has increased in the last decade. Evidence on deviations in service uptake during conflict is needed to better understand the link between conflict and adverse neonatal outcomes. We assessed the association between conflict intensity in the occupied Palestinian territory (oPt) at time of birth and (i) utilization patterns for childbirth across different providers; and (ii) neonatal mortality.

METHODS

We combined data on conflict intensity with four demographic and health surveys (2004, 2006, 2010 and 2014) that included nationally representative samples of women of childbearing age. Our exposure variable was casualties per 100 000 population in defined sub-regions of the oPt. Our outcome specifications were a binary variable for neonatal deaths and a categorical variable for childbirth location. We used multivariate logistic and multinomial regressions to assess the associations.

RESULTS

High conflict intensity was associated with fewer childbirths in the private sector (RR=0.97, P=0.04), and non-governmental organizations (RR=0.95, P=0.03) compared to public facilities. Conflict intensity was not associated with higher neonatal mortality beyond 2004.

CONCLUSIONS

Policy implications include better preparedness in the public sector for childbirth during conflict and exploring reasons for the slow decline in neonatal mortality in the territory beyond conflict at time of birth.

Obstetric Outcomes in Military Servicewomen: Emerging Knowledge, Considerations, and Gaps

The number of women in the U.S. military is dramatically increasing. Similarly, the roles of active-duty women are greatly expanding, thus exposing them to new occupational risks. Determining the impact of pregnancy outcomes for women while in the military is difficult due to changing exposures over time, difficulty in utilizing appropriate comparison groups, and the lack of prospective investigations. Despite these limitations, it was concerning that the available data suggest that servicewomen delivering within 6 months of their first deployment have an increased preterm birth risk (adjusted odds ratio [aOR]: 2.1), and those with three prior deployments have an even greater risk (aOR: 3.8). Servicewomen also have an increased risk of hypertensive disorders with a rate of 13% compared with 5% in the general obstetric population. Furthermore, depression is higher for women who deploy after childbirth and are exposed to combat when compared with those who have not deployed since the birth of their child (aOR: 2.01). Due to the importance of this issue, prospective research designs are necessary to better understand and address the unique health care needs of this population.

Long Term Risks to Neonatal Health from Exposure to War-9 Years Long Survey of Reproductive Health and Contamination by Weapon-Delivered Heavy Metals in Gaza, Palestine

Introduction: High levels of environmental contaminants with long term effects and teratogenic and carcinogenic potential, such as heavy metals, were introduced by weaponry in war areas in the last decades. Poorer reproductive health and increases in non-communicable diseases were reported after wars and are the suspected long term effects of contamination by stable war remnants. Although potentially affecting millions of people, this is still an understudied issue of public health. Background: Gaza, Palestine since 2006 has been an object of repeated severe military attacks that left heavy metals remnants in the environment, in wound tissues and that were assumed by the population. Retrospective studies showed a progressive increase in birth defects since the 2006 attacks. In 2011 we started surveillance at birth alongside analysis of the heavy metals load carried by pregnant women and their babies. Methods: We used protocols for birth registration which also document the extent of exposures to attacks, war remnants and to other environmental risks that allow comparison of 3 data sets-2011, 2016 and 2018-2019 (4000-6000 women in each set). By ICP/MS analysis we determined the content of 23 metals in mothers' hair. Appropriate statistical analysis was performed. Results: Comparison of data in birth registers showed a major increase in the prevalence in birth defects and preterm babies between 2011 and 2016, respectively from 1.1 to 1.8% and from 1.1 to 7.9%, values remaining stable in 2019. Negative outcomes at birth in 2016 up to 2019 were associated with exposure of the mothers to the attacks in 2014 and/or to hot spots of heavy metals contamination. Metal loads since the attacks in 2014 were consistently high until 2018-2019 for barium, arsenic, cobalt, cadmium, chrome, vanadium and uranium, pointing to these metals as potential inducers for the increased prevalence of negative health outcomes at birth since 2016. Conclusions: Bodily accumulation of metals following exposure whilst residing in attacked buildings predispose women to negative birth outcomes. We do not know if the metals act in synergy. Trial for mitigation of the documented negative effects of high metal load on reproductive health, and ensuing perinatal deaths, could now be done in Gaza, based on this documentary record. High load of heavy metals may explain recent increases in non-communicable diseases and cancers at all ages in Gaza. Modern war's legacy of diseases and deaths extends in time to populations and demands monitoring.

The Gulf War Women's Health Cohort: Study Design and Protocol

Military service and deployment affect women differently than men, underscoring the need for studies of the health of women veterans and their receipt of health care services. Despite the large numbers of women who served during the 1990-1991 Gulf War, few studies have evaluated Gulf War illness (GWI) and other medical conditions specifically as they affect women veterans of the 1991 Gulf War. The objectives of the Gulf War Women's Health Cohort study are: (1) to establish the Gulf War women's cohort (GWWC), a large sample of women veterans who served in the 1990-1991 Gulf War and a comparison group of women who served in other locations during that period; and (2) to provide current, comprehensive data on the health status of women who served during the 1990-1991 Gulf War, and identify any specific conditions that affect Gulf War women veterans at excess rates. The study will utilize both existing datasets and newly collected data to examine the prevalence and patterns of Gulf War Illness symptoms, diagnosed medical conditions, reproductive health, birth outcomes and other health issues among women who served during the Gulf War. The Gulf War Women's Health Cohort study will address the need for information about the comprehensive health of women veterans who were deployed to the Gulf War, and other wars during the Gulf War era.

Living near an active U.S. military base in Iraq is associated with significantly higher hair thorium and increased likelihood of congenital anomalies in infants and children

In Iraq, war contamination is the result of dispensed bombs, bullets, detonation of chemical and conventional weapons, and burn-pit emissions by US bases. Increases in congenital anomalies were reported from Iraqi cities post-2003. These cities were heavily bombed and encircled by US bases with burn-pits. Thorium is a radioactive compound and a direct depleted-uranium decay-product. Radioactive materials, including depleted uranium, are routinely stored in US bases and they have been shown to leak into the environment. We conducted a case-control study to investigate associations of residential proximity to Tallil Air Base, a US military base near Nasiriyah, as well as levels of uranium and thorium in hair and deciduous teeth with congenital anomalies. The study was based on a sample of 19 cases and 10 controls who were recruited during late Summer and early Fall of 2016. We developed mixed effects logistic regression models with village as the random effect, congenital anomaly as the outcome and distance to the US base and hair metal levels (one at a time) as the predictor variable, controlling for child's age, sex and paternal education. We also explored the mediation of the association between proximity to the base and congenital anomalies by hair metal levels. We found an inverse association between distance to Tallil Air Base and risk of congenital anomalies and hair levels of thorium and uranium. The results of our mediation analyses were less conclusive. Larger studies are necessary to understand the scope of war contamination and its impact on congenital anomalies in Iraq.

Hospital centered surveillance of births in Gaza, Palestine, 2011-2017 and heavy metal contamination of the mothers reveals long-term impact of wars

Prevalence of preterm, low birth weight and birth defects increased significantly since 2011 in Gaza, Palestine. No change in known co-factors of reproductive health justified this rise. Two military attacks in 2012 and 2014 introduced novel risk factors for outcomes at birth: contamination by teratogenic and carcinogenic heavy metals weapon-remnants, ongoing impoverishment, and impaired rehabilitation of waste management. It was previously shown that mothers exposed to military attacks had higher metal load than those unexposed and mother's heavy metals trans-pass placenta. We investigated association in time of heavy metal contamination and reproductive health using hospital-based surveillance (2011-2016-2017) of births, accompanied by assessment in 2016 of metal load in mother and newborn hair. Mother's housing proximal to unmanaged waste predicted preterm birth and birth defects, and these women had highest load of heavy metals. Poor diet predicted low birth weight. Circumstances prevent investigation of heavy metals molecular impact(s) during fetal development.

Effects of armed conflict on child health and development: A systematic review

BACKGROUND

Armed conflicts affect more than one in 10 children globally. While there is a large literature on mental health, the effects of armed conflict on children's physical health and development are not well understood. This systematic review summarizes the current and past knowledge on the effects of armed conflict on child health and development.

METHODS

A systematic review was performed with searches in major and regional databases for papers published 1 January 1945 to 25 April 2017. Included studies provided data on physical and/or developmental outcomes associated with armed conflict in children under 18 years. Data were extracted on health outcomes, displacement, social isolation, experience of violence, orphan status, and access to basic needs. The review is registered with PROSPERO: CRD42017036425.

FINDINGS

Among 17,679 publications screened, 155 were eligible for inclusion. Nearly half of the 131 quantitative studies were case reports, chart or registry reviews, and one-third were cross-sectional studies. Additionally, 18 qualitative and 6 mixed-methods studies were included. The papers describe mortality, injuries, illnesses, environmental exposures, limitations in access to health care and education, and the experience of violence, including torture and sexual violence. Studies also described conflict-related social changes affecting child health. The geographical coverage of the literature is limited. Data on the effects of conflict on child development are scarce.

INTERPRETATION

The available data document the pervasive effect of conflict as a form of violence against children and a negative social determinant of child health. There is an urgent need for research on the mechanisms by which conflict affects child health and development and the relationship between physical health, mental health, and social conditions. Particular priority should be given to studies on child development, the long term effects of exposure to conflict, and protective and mitigating factors against the harmful effects of armed conflict on children.

Factors associated with congenital anomalies in Addis Ababa and the Amhara Region, Ethiopia: a case-control study

Background

The early stage of embryo development is extremely vulnerable to various teratogenic factors, leading to congenital anomalies. In Ethiopia, a significant number of babies are born with congenital anomalies, but the risk factors for the anomalies have never been studied. Understanding the specific risk factors for congenital anomalies is very essential to provide health education that aims at creating awareness and establishing preventive strategic plan/s. The main objective of this study was to assess the risk factors associated with congenital anomalies in Addis Ababa and the Amhara Region, Ethiopia.

Methods

A case-control study was conducted from January 1- June 30, 2015. The participants were recruited at the purposively selected hospitals in Addis Ababa and the Amhara Region. A total of 207 cases and 207 controls were included in the study. Cases were neonates, infants, and children 0-11 months of age with external and internal major congenital anomalies diagnosed by pediatricians. Controls were neonates, infants, and children 0-11 months of age without external and internal anomalies. Data on sociodemographic characteristics, exposure to risk factors, and reproductive history were collected by face to face interviews with children’s mothers/caregivers using a structured questionnaire. Binary logistic regression was employed to explore risk factors associated with the occurrence of the problems.

Results

About 87.4% of the children were below 6 months, and 12.6% were between 6 and 11 months. The majority (59.9%) of the children were male, with the M: F sex ratio of 1.49. The mean age of the mothers was 26 years (16-45 years). Unidentified medication use during early pregnancy (AOR = 4.595; 95% CI: 1.868-11.301, P-value = 0.001), maternal alcohol drinking (AOR = 2.394; 95% CI: 1.212-4.726, P-value = 0.012), and exposure to chemicals (AOR = 9.964; 95% CI = 1.238-80.193, P-value = 0.031) were significantly associated with the occurrence of congenital anomalies. Iron folate use (AOR = 0.051; 95% CI: 0.010-0.260, P-value = < 0.001) before and during early pregnancy had a protective effect on congenital anomaly.

Conclusion

Unidentified medication use, alcohol drinking during early pregnancy, and exposure to chemicals had a significant association with the occurrence of congenital anomalies, whereas iron folate use before and during early pregnancy had a protective effect from congenital anomalies.

Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.

A Review of Epidemiologic Studies of the Health of Gulf War Women Veterans

INTRODUCTION

In the 25 years since the 1990-1991 Gulf War (GW), studies have evaluated Gulf War Illness (GWI), sometimes referred to as medically unexplained multi symptom illness, and other medical and neurological conditions in women GW veterans.

MATERIALS AND METHODS

In this article, we review epidemiologic studies of the health of women who served in the 1990-1991 GW based upon bibliographic searches in PubMed and CINAHL with relevant search terms through September 2015.

RESULTS

A total of 56 articles were identified in the bibliographic searches. By screening abstracts or full-text articles, a total of 21 relevant studies were identified. Results from some studies, but not all, suggest that GWI is more common in women GW veterans than their male counterparts. Few studies of GW veterans focused on women's health. A small number of studies suggested excess rates of woman's health problems, e.g., breast cysts, abnormal Papanicolaou (Pap) smears, yeast infections, and bladder infections. Several studies have identified significantly elevated rates of birth defects and adverse reproductive outcomes among GW veterans. However, findings have varied with different study designs and sample sizes, with some studies showing elevated risks of stillbirths, miscarriages, and/or birth defects and others have not. In some studies, participants reported increased risks of ectopic pregnancies and spontaneous abortions.

CONCLUSION

Further research is needed to provide a comprehensive picture of the health of women GW veterans and to examine a broad range of women's health issues including adverse reproductive outcomes. Some deployment-related health problems only become apparent decades later and other conditions may worsen or improve over time. Assessments are needed of current health status, changes in health symptoms and conditions over time, and possible differences in health outcomes associated with specific experiences and exposures during the war. Future studies would be strengthened by assessing GWI symptom patterns that may be specific to women veterans, examine diagnosed medical conditions among women veterans, and evaluate changes in women's health over time, including changes potentially associated with menopause and age.

Paternal smoking and germ cell death: A mechanistic link to the effects of cigarette smoke on spermatogenesis and possible long-term sequelae in offspring

Paternal exposure to constituents of cigarette smoke (CS) is reportedly associated with infertility, birth defects and childhood cancers even though the mechanism behind this relationship is still unclear. Chronic cigarette smoking by men leads to poor sperm quality and quantity mainly through oxidative stress and also direct assault by CS metabolites. Among several carcinogenic and teratogenic components of cigarette smoke condensate (CSC), polycyclic aromatic hydrocarbons (PAHs) display a preeminent role in accelerating germ cell death via the cytoplasmic transcription factor, aryl hydrocarbon receptor (AHR) that is present across all stages of spermatogenesis. Activation of AHR by growth factors though benefits normal cellular functions, its mediation by CSC in a spermatocyte cell line [Gc2(spd)ts] adversely affects the expression of a battery of genes associated with antioxidant mechanisms, cell proliferation and apoptosis, and cell cycle progress. Besides, the CSC-mediated cross talk either between AHR and NRF2 or AHR-NRF2 and MAPKs pathways inhibits normal proliferation of the spermatogenic GC-2spd(ts) cells in vitro and cell death of spermatocytes in vivo. Pharmacological inactivation of CSC-induced AHR but not its genetic manipulation seems preventing DNA and cell membrane damage in Gc2(spd)ts. Data from recent reports suggest that the cigarette smoke affects both the genomic and epigenomic components of the sperm and attributes any associated changes to developmental defects in the offspring. Thus, the studies discussed here in this review shed light on possible mechanistic factors that could probably be responsible for the paternally mediated birth defects in the offspring following exposure to the toxic constituents of cigarette smoke.

The Genetic and Environmental Factors Underlying Hypospadias

Hypospadias results from a failure of urethral closure in the male phallus and affects 1 in 200-300 boys. It is thought to be due to a combination of genetic and environmental factors. The development of the penis progresses in 2 stages: an initial hormone-independent phase and a secondary hormone-dependent phase. Here, we review the molecular pathways that contribute to each of these stages, drawing on studies from both human and mouse models. Hypospadias can occur when normal development of the phallus is disrupted, and we provide evidence that mutations in genes underlying this developmental process are causative. Finally, we discuss the environmental factors that may contribute to hypospadias and their potential immediate and transgenerational epigenetic impacts.

Infertility care among OEF/OIF/OND women Veterans in the Department of Veterans Affairs

BACKGROUND

An increasing number of young women Veterans seek reproductive health care through the VA, yet little is known regarding the provision of infertility care for this population. The VA provides a range of infertility services for Veterans including artificial insemination, but does not provide in vitro fertilization. This study will be the first to characterize infertility care among OEF/OIF/OND women Veterans using VA care.

METHODS

We analyzed data from the OEF/OIF/OND roster file from the Defense Manpower Data Center (DMDC)-Contingency Tracking System Deployment file of military discharges from October 1, 2001-December 30, 2010, which includes 68,442 women Veterans between the ages of 18 and 45 who utilized VA health care after separating from military service. We examined the receipt of infertility diagnoses and care using ICD-9 and CPT codes.

RESULTS

Less than 2% (n=1323) of OEF/OIF/OND women Veterans received an infertility diagnosis during the study period. Compared with women VA users without infertility diagnosis, those with infertility diagnosis were younger, obese, black, or Hispanic, have a service-connected disability rating, a positive screen for military sexual trauma, and a mental health diagnosis. Overall, 22% of women with an infertility diagnosis received an infertility assessment or treatment. Thirty-nine percent of women Veterans receiving infertility assessment or treatment received this care from non-VA providers.

CONCLUSIONS

Overall, a small proportion of OEF/OIF/OND women Veterans received infertility diagnoses from the VA during the study period, and an even smaller proportion received infertility treatment. Nearly 40% of those who received infertility treatments received these treatments from non-VA providers, indicating that the VA may need to examine the training and resources needed to provide this care within the VA. Understanding women's use of VA infertility services is an important component of understanding VA's commitment to comprehensive medical care for women Veterans.

Environmental, parental and gestational factors that influence the occurrence of hypospadias in male patients

OBJECTIVE

Hypospadias is a congenital defect, which affects normal development of the male urogenital external tract. In this malformation, the urethral orifice of the penis is positioned ventrally, thus interfering with normal urination and creating, in some adults, problems during sexual intercourse. Heritability of hypospadias has been shown in some reports, and the abnormality has been associated with the presence of mutations in one of the genes involved in urogenital development. However, even for patients who were born in families with a higher incidence rate of this defect, no evident genetic alteration could be identified in known genes, indicating that the list of loci involved is still incomplete. To further complicate matters, recent reports also underline that epigenetic changes, without any identifiable gene sequence mutation, may be involved in gene function impairment. Therefore, the inheritance of most hypospadias cases is not evident, suggesting that the genetic background is not the only cause of this malformation; indeed, the majority of hypospadias cases are classified as sporadic and idiopathic.

MATERIALS AND METHODS

Evidence has accumulated highlighting the role of the environment and of its relationships with the genome in the etiology of this abnormality. In particular, the interaction between some chemicals, which are able to mimic endogenous molecules such as sexual hormones--for this reason called endocrine disrupting compounds (EDC)--and specific receptors has been extensively investigated during the pregnancy. Additionally, several articles have shown that parental and gestational factors play a significant role too. Indeed, physiological alterations, such as body weight of the mother and/or of the newborn, mother's diabetes, impaired father fertility, and exposure of one parent to job-related pollutants, show in many cases a direct correlation with hypospadias incidence. The overall prevalence of this condition has been studied in many countries, suggesting that at least in some periods and/or in specific populations there are detectable fluctuations, probably mirroring the different natural environments. However, many articles present data that do not agree with these findings and, consequently, most causes of hypospadias are still highly debated.

RESULTS

In this review, we summarize the developmental steps involved in urogenital tract formation, with a particular emphasis on the genes that most frequently are associated with this condition, or that are subject to environmental stress, or that may be the targets of hormone-like, exogenous molecules. Then, we make an overview of the identified factors able to impair the function of important genes, even in the absence of their mutations, including those for which contradictory reports have been published. Finally, we propose an explanation of sporadic cases of hypospadias that reconciles these contradictions and suggest some steps for moving forward in the research focused on this condition.

CONCLUSION

We hypothesize that most patients develop hypospadias because of gene-environment interactions acting on polymorphic genes that, in the absence of environmental stimuli, would otherwise cause no developmental anomaly during urogenital development.

Specific association of teratogen and toxicant metals in hair of newborns with congenital birth defects or developmentally premature birth in a cohort of couples with documented parental exposure to military attacks: observational study at Al Shifa Hospital, Gaza, Palestine

This study was undertaken in Gaza, Palestine, in a cohort of babies born in 2011. Hair samples of newborns were analyzed for metal load by DRC-ICP-MS. We report specific level of contamination by teratogen/toxicants metals of newborn babies, environmentally unexposed, according to their phenotypes at birth: normal full term babies, birth defects or developmentally premature. The occurrence of birth defects was previously shown to be correlated in this cohort to documented exposure of parents to weapons containing metal contaminants, during attacks in 2009. We detect, in significantly higher amounts than in normal babies, different specific teratogen or toxicant elements, known weapons' components, characteristic for each of birth defect or premature babies. This is the first attempt to our knowledge to directly link a phenotype at birth with the in utero presence of specific teratogen and/or toxicant metals in a cohort with known episodes of acute exposure of parents to environmental contamination by these same metals, in this case delivered by weaponry The babies were conceived 20-25 months after the major known parental exposure; the specific link of newborn phenotypes to war-remnant metal contaminants, suggests that mothers' contamination persists in time, and that the exposure may have a long term effect.

The aryl hydrocarbon receptor is important for proper seminiferous tubule architecture and sperm development in mice

The aryl hydrocarbon receptor (AHR) is known for its roles in xenobiotic metabolism and essential physiologic processes such as cell growth, death, and differentiation. AHR is also an important regulator of male reproductive processes. However, no studies have characterized the consequences of loss of AHR in spermatogenesis. We used Ahr knockout (Ahr(-/-)) mice to assess the effects of loss of AHR on the architecture and gene expression of the seminiferous epithelium and functional sperm outcomes. The histopathological defects of the Ahr(-/-)seminiferous epithelium included vacuoles, multinucleated giant cells, hypocellularity with widened intercellular spaces, apical sloughing, and an excess number of retained elongated spermatids. Quantitative real-time PCR revealed significant down-regulation of Testin and Magea4, indicating Sertoli cell and spermatogenic dysregulation. Moreover, the reduced expression of Hspa2, Prm1, and Prm2 as well as decreased expression of Nrf2, Sod2, and Ucp2 suggested poorly remodeled germ cells with increased vulnerability to oxidative stress. In wild-type sperm, AHR protein was localized to the acrosome and the principal piece of the mature sperm flagellum. The in vitro fertilization rate was significantly lower with Ahr(-/-) sperm as compared to wild-type sperm, and there were morphologic abnormalities of the Ahr(-/-) sperm head and tail. Taken together, our data indicate that AHR plays an important role in normal sperm development.

A nested case-control study of intrauterine exposure to persistent organochlorine pollutants and the risk of hypospadias

Background

Environmental exposures to endocrine disrupting chemicals have been suggested as a risk factor for male genital abnormalities such as hypospadias. The aim of this case-control study was to investigate the association between fetal exposure to persistent organochlorine pollutants (POP) and the risk for hypospadias.

Methodology/Principal Findings

The Southern Sweden Maternity Cohort (SSMC) contains serum samples collected in early pregnancy among women in Southern Sweden. Linkages with the Medical Birth Register, the Malformation Register and the In-patient Register resulted in 390 SSMC mothers who had given birth to a boy with hypospadias in year 1986–2002 (mean 1995). For 237 of these (cases) sufficient amounts of serum for the chemical analyses were available. For each case, a control boy from the SSMC was randomly selected, matched for maternal age, birth year, parity and maternal smoking. PCB-153, p,p’-DDE and hexachlorbenzene (HCB) were used as biomarkers for POP exposure. The exposures were categorized into quartiles based on the distributions among the controls. There were no statistically significant trends between the a priori categorisation of the exposure variables and the risk for hypospadias. However, when the upper HCB quartile (>26 ng/ml) was compared to the other quartiles an odds ratio of 1.65 (95% CI 1.02 to 2.69) was obtained. p,p′-DDE levels above median (>1.0 ng/ml) compared to levels below 0.1 ng/ml gave an OR of 1.69 (95% CI 0.97 to 2.93).

Conclusions

The present study suggests that fetal exposure to HCB and p,p’-DDE may be a risk factor for hypospadias.

Birth defects in infants born in 1998-2004 to men and women serving in the U.S. military during the 1990-1991 Gulf War era

BACKGROUND

Concerns about reproductive health persist among U.S. military members who served in the 1990-1991 Gulf War. This study explores the long-term impact of 1990-1991 Gulf War deployment on the prevalence of birth defects among infants of Gulf War veterans.

METHODS

Health care data from the Department of Defense Birth and Infant Health Registry and demographic and deployment information from the Defense Manpower Data Center were used to identify infants born between 1998 and 2004 to both male and female 1990-1991 Gulf War veterans. Multivariable logistic regression models estimated the adjusted odds of any birth defect and eight specific birth defects among infants of deployers versus non-deployers. In addition, birth defects were evaluated among infants born to 1990-1991 Gulf War veterans with deployment-specific exposures.

RESULTS

Among 178,766 infants identified for these analyses, 3.4% were diagnosed with a birth defect in the first year of life. Compared to infants of non-deployers, infants of deployers were not at increased odds of being diagnosed with a birth defect, or any of eight specific birth defects, in the first year of life. A slightly increased prevalence of birth defects was observed among infants born to men who deployed to the 1990-1991 Gulf War for 153 to 200 days compared to those who deployed for 1 to 92 days. No other deployment-specific exposures were associated with birth defects in these infants.

CONCLUSIONS

The 1990-1991 Gulf War deployers, including those with specific exposures of concern, were not found to be at increased risk for having infants with birth defects 7 to 14 years after deployment.

Aetiology of hypospadias: a systematic review of genes and environment

BACKGROUND

Hypospadias is a common congenital malformation of the male external genitalia. Most cases have an unknown aetiology, which is probably a mix of monogenic and multifactorial forms, implicating both genes and environmental factors. This review summarizes current knowledge about the aetiology of hypospadias.

METHODS

Pubmed was used to identify studies on hypospadias aetiology published between January 1995 and February 2011. Reference lists of the selected manuscripts were also searched to identify additional studies, including those published before 1995.

RESULTS

The search provided 922 articles and 169 articles were selected for this review. Studies screening groups of patients with hypospadias for single gene defects found mutations in WT1, SF1, BMP4, BMP7, HOXA4, HOXB6, FGF8, FGFR2, AR, HSD3B2, SRD5A2, ATF3, MAMLD1, MID1 and BNC2. However, most investigators are convinced that single mutations do not cause the majority of isolated hypospadias cases. Indeed, associations were found with polymorphisms in FGF8, FGFR2, AR, HSD17B3, SRD5A2, ESR1, ESR2, ATF3, MAMLD1, DGKK, MID1, CYP1A1, GSTM1 and GSTT1. In addition, gene expression studies indentified CTGF, CYR61 and EGF as candidate genes. Environmental factors consistently implicated in hypospadias are low birthweight, maternal hypertension and pre-eclampsia, suggesting that placental insufficiency may play an important role in hypospadias aetiology. Exogenous endocrine-disrupting chemicals have the potential to induce hypospadias but it is unclear whether human exposure is high enough to exert this effect. Other environmental factors have also been associated with hypospadias but, for most, the results are inconsistent.

CONCLUSIONS

Although a number of contributors to the aetiology of hypospadias have been identified, the majority of risk factors remain unknown.

Uranium and other contaminants in hair from the parents of children with congenital anomalies in Fallujah, Iraq

BACKGROUND

Recent reports have drawn attention to increases in congenital birth anomalies and cancer in Fallujah Iraq blamed on teratogenic, genetic and genomic stress thought to result from depleted Uranium contamination following the battles in the town in 2004. Contamination of the parents of the children and of the environment by Uranium and other elements was investigated using Inductively Coupled Plasma Mass Spectrometry. Hair samples from 25 fathers and mothers of children diagnosed with congenital anomalies were analysed for Uranium and 51 other elements. Mean ages of the parents was: fathers 29.6 (SD 6.2); mothers: 27.3 (SD 6.8). For a sub-group of 6 women, long locks of hair were analysed for Uranium along the length of the hair to obtain information about historic exposures. Samples of soil and water were also analysed and Uranium isotope ratios determined.

RESULTS

Levels of Ca, Mg, Co, Fe, Mn, V, Zn, Sr, Al, Ba, Bi, Ga, Pb, Hg, Pd and U (for mothers only) were significantly higher than published mean levels in an uncontaminated population in Sweden. In high excess were Ca, Mg, Sr, Al, Bi and Hg. Of these only Hg can be considered as a possible cause of congenital anomaly. Mean levels for Uranium were 0.16 ppm (SD: 0.11) range 0.02 to 0.4, higher in mothers (0.18 ppm SD 0.09) than fathers (0.11 ppm; SD 0.13). The highly unusual non-normal Fallujah distribution mean was significantly higher than literature results for a control population Southern Israel (0.062 ppm) and a non-parametric test (Mann Whitney-Wilcoxon) gave p = 0.016 for this comparison of the distribution. Mean levels in Fallujah were also much higher than the mean of measurements reported from Japan, Brazil, Sweden and Slovenia (0.04 ppm SD 0.02). Soil samples show low concentrations with a mean of 0.76 ppm (SD 0.42) and range 0.1-1.5 ppm; (N = 18). However it may be consistent with levels in drinking water (2.28 μgL-1) which had similar levels to water from wells (2.72 μgL-1) and the river Euphrates (2.24 μgL-1). In a separate study of a sub group of mothers with long hair to investigate historic Uranium excretion the results suggested that levels were much higher in the past. Uranium traces detected in the soil samples and the hair showed slightly enriched isotopic signatures for hair U238/U235 = (135.16 SD 1.45) compared with the natural ratio of 137.88. Soil sample Uranium isotope ratios were determined after extraction and concentration of the Uranium by ion exchange. Results showed statistically significant presence of enriched Uranium with a mean of 129 with SD5.9 (for this determination, the natural Uranium 95% CI was 132.1 < Ratio < 144.1).

CONCLUSIONS

Whilst caution must be exercised about ruling out other possibilities, because none of the elements found in excess are reported to cause congenital diseases and cancer except Uranium, these findings suggest the enriched Uranium exposure is either a primary cause or related to the cause of the congenital anomaly and cancer increases. Questions are thus raised about the characteristics and composition of weapons now being deployed in modern battlefields.

Genital anomalies in boys and the environment

The prevalence of male reproductive disorders, such as testicular cancer and impaired semen quality, is increasing in many, albeit not all, countries. These disorders are aetiologically linked with congenital cryptorchidism and hypospadias by common factors leading to perinatal disruption of normal testis differentiation, the testicular dysgenesis syndrome (TDS). There is recent evidence that also the prevalence of genital malformations is increasing and the rapid pace of increase suggests that lifestyle factors and exposure to environmental chemicals with endocrine disrupting properties may play a role. Recent prospective studies have established links between perinatal exposure to persistent halogenated compounds and cryptorchidism, as well as between phthalates and anti-androgenic effects in newborns. Maternal alcohol consumption, mild gestational diabetes and nicotine substitutes were also identified as potential risk factors for cryptorchidism. It may be the cocktail effect of many simultaneous exposures that result in adverse effects, especially during foetal life and infancy.

Gulf War syndrome: an emerging threat or a piece of history?

‘Gulf War syndrome’ is a phrase coined after the 1991 Gulf War to group together disparate, unexplained health symptoms in Gulf veterans. This paper examines the many hypotheses that have been put forward about the origins of the concept and gives an overview of the studies that have attempted to explain the lasting health effects associated with Gulf service. Our review finds that although in the UK there has not yet been evidence of a new Gulf War syndrome as a result of the current conflicts in Iraq and Afghanistan, there is a rise in post-conflict psychiatric disorders now being reported in the USA. We postulate that after conflicts military personnel will always face some form of post-conflict syndrome and the nature of the threats experienced is likely to dictate the form the syndrome might take. We also postulate that media reporting is likely to have influenced and to continue unhelpfully to influence the health of service personnel.

Evaluation of preterm births and birth defects in liveborn infants of US military women who received smallpox vaccine

BACKGROUND

Women serving in the US military have some unique occupational exposures, including exposure to vaccinations that are rarely required in civilian professions. When vaccinations are inadvertently given during pregnancy, such exposures raise special concerns. These analyses address health outcomes, particularly preterm births and birth defects, among infants who appear to have been exposed to maternal smallpox vaccination in pregnancy.

METHODS

This retrospective cohort study included 31,420 infants born to active-duty military women during 2003-2004. We used Department of Defense databases to define maternal vaccination and infant health outcomes. Multivariable regression models were developed to describe associations between maternal smallpox vaccination and preterm births and birth defects in liveborn infants.

RESULTS

There were 7,735 infants identified as born to women ever vaccinated against smallpox, and 672 infants born to women vaccinated in the first trimester of pregnancy. In multivariable modeling, maternal smallpox vaccination in pregnancy was not associated with preterm or extreme preterm delivery. Maternal smallpox vaccination in the first trimester of pregnancy was not significantly associated with overall birth defects (OR 1.40; 95% CI: 0.94, 2.07), or any of seven specific defects individually modeled.

CONCLUSIONS

Results may be reassuring that smallpox vaccine, when inadvertently administered to pregnant women, is not associated with preterm delivery or birth defects in liveborn infants.

Maternal diet and the risk of hypospadias and cryptorchidism in the offspring

Male genital tract birth defects have been associated in previous studies with several prenatal exposures to environmental and dietary risk factors. The purpose of this study was to explore the association between hypospadias and cryptorchidism, and the dietary habits of an agricultural population in Italy. A population-based case-control study was conducted in the Sicilian Province of Ragusa. Cases (n = 90) and controls (n = 202) included births for the period 1998-2002. Data on dietary habits of the mothers, as well as health-related social, occupational and environmental exposures prior to and during the index birth, were collected through interviews. Adjusted odds ratios (OR) were calculated by logistic regression after adjustment for confounding variables. Increased ORs were observed for mothers of children with hypospadias who, during pregnancy, frequently consumed fish (OR = 2.33 [95% confidence interval (CI) 1.03, 5.31]) and market-purchased fruit (OR = 5.10 [95% CI 1.31, 19.82]). For cryptorchidism, increased risk was observed in mothers consuming liver (OR = 5.21 [95% CI 1.26, 21.50]), and smoked products (OR = 2.46 [95% CI 1.15, 5.29]). For the two malformations pooled together, increased risk was associated with maternal consumption of liver (OR = 4.38 [95% CI 1.34, 14.26]) and with frequent consumption of wine (OR = 1.98 [95% CI 1.01, 3.86]). This study suggests that some maternal dietary factors may play a role in the development of congenital defects of the male reproductive tract. In particular, our data indicate that further research may be warranted on the endocrine-disrupting effects resulting from the bioaccumulation of contaminants (fish, liver), pesticides (marketed fruit, wine) and/or potentially toxic food components (smoked products, wine, liver).

Reproductive health and pregnancy outcomes among French gulf war veterans

Background

Since 1993, many studies on the health of Persian Gulf War veterans (PGWVs) have been undertaken. Some authors have concluded that an association exists between Gulf War service and reported infertility or miscarriage, but that effects on PGWV's children were limited.

The present study's objective was to describe the reproductive outcome and health of offspring of French Gulf War veterans.

Methods

The French Study on the Persian Gulf War (PGW) and its Health Consequences is an exhaustive cross-sectional study on all French PGWVs conducted from 2002 to 2004. Data were collected by postal self-administered questionnaire. A case-control study nested in this cohort was conducted to evaluate the link between PGW-related exposures and fathering a child with a birth defect.

Results

In the present study, 9% of the 5,666 Gulf veterans who participated reported fertility disorders, and 12% of male veterans reported at least one miscarriage among their partners after the PGW. Overall, 4.2% of fathers reported at least one child with a birth defect conceived after the mission. No PGW-related exposure was associated with any birth defect in children fathered after the PGW mission. Concerning the reported health of children born after the PGW, 1.0% of children presented a pre-term delivery and 2.7% a birth defect. The main birth defects reported were musculoskeletal malformations (0.5%) and urinary system malformations (0.3%). Birth defect incidence in PGWV children conceived after the mission was similar to birth defect incidence described by the Paris Registry of Congenital Malformations, except for Down syndrome (PGWV children incidence was lower than Registry incidence).

Conclusion

This study did not highlight a high frequency of fertility disorders or miscarriage among French PGW veterans. We found no evidence for a link between paternal exposure during the Gulf War and increased risk of birth defects among French PGWV children.

Gulf war depleted uranium risks

US and British forces used depleted uranium (DU) in armor-piercing rounds to disable enemy tanks during the Gulf and Balkan Wars. Uranium particulate is generated by DU shell impact and particulate entrained in air may be inhaled or ingested by troops and nearby civilian populations. As uranium is slightly radioactive and chemically toxic, a number of critics have asserted that DU exposure has resulted in a variety of adverse health effects for exposed veterans and nearby civilian populations. The study described in this paper used mathematical modeling to estimate health risks from exposure to DU during the 1991 Gulf War for both US troops and nearby Iraqi civilians. The analysis found that the risks of DU-induced leukemia or birth defects are far too small to result in an observable increase in these health effects among exposed veterans or Iraqi civilians. The analysis indicated that only a few ( approximately 5) US veterans in vehicles accidentally targeted by US tanks received significant exposure levels, resulting in about a 1.4% lifetime risk of DU radiation-induced fatal cancer (compared with about a 24% risk of a fatal cancer from all other causes). These veterans may have also experienced temporary kidney damage. Iraqi children playing for 500 h in DU-destroyed vehicles are predicted to incur a cancer risk of about 0.4%. In vitro and animal tests suggest the possibility of chemically induced health effects from DU internalization, such as immune system impairment. Further study is needed to determine the applicability of these findings for Gulf War exposure to DU. Veterans and civilians who did not occupy DU-contaminated vehicles are unlikely to have internalized quantities of DU significantly in excess of normal internalization of natural uranium from the environment.

The occupational role of women in military service: validation of occupation and prevalence of exposures in the Millennium Cohort Study

To better understand the US military's global peacekeeping and combat operations, which may expose a growing population of American service women to challenging occupations and environments. Concordance between self-reported and electronic occupation codes for female participants in the Millennium Cohort was measured using kappa statistics. Multivariable logistic regression modeling was used to assess the odds of five self-reported potentially toxic environmental exposures or disturbing experiences among different occupational categories, while adjusting for demographic and military characteristics, including deployment. Self-reported occupations were moderately to highly reliable when compared with electronic occupation data. Active-duty and Reserve/Guard females differentially reported witnessing death or trauma and exposure to chemical or biological warfare, depleted uranium, or pesticides. Findings suggest that self-reported occupation can be used with a high degree of confidence. Occupational groups with higher odds of reporting military exposures of concern will be followed longitudinally through 2022 and prospectively compared using baseline and follow-up evaluations.

Reproductive health of male Australian veterans of the 1991 Gulf War

Background

Since the 1991 Gulf War concerns have been raised about the effects of deployment to the Gulf War on veterans' health. Studies of the reproductive health of Gulf War veterans have reported varied findings.

Methods

We undertook a cross-sectional study of male Australian Gulf War veterans (n = 1,424) and a randomly sampled military comparison group (n = 1,548). The study was conducted from August 2000 to April 2002. A postal questionnaire included questions about difficulties achieving pregnancy, pregnancy outcomes including live births, stillbirths, miscarriages and terminations; and for all live births gestation, birth weight, sex, and any cancers, birth defects, chromosomal abnormalities or serious health problems.

Results

Male Gulf War veterans reported slightly increased risk of fertility difficulties following the Gulf War (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.0–1.8), but were more successful at subsequently fathering a child (OR 1.8; 95% CI 1.3–2.6). The study groups reported similar rates of pregnancies and live births. There was no increased risk in veterans of miscarriage, stillbirth, or terminations. Children of male Gulf War veterans born after the period of the Gulf War were not at greater risk of being born prematurely, having a low birth weight, or having a birth defect or chromosomal abnormality (OR 1.0; 95% CI 0.6–1.6). The numbers of cancers and deaths in children were too small to draw any firm conclusions.

Conclusion

The results of this study do not show an increased risk of adverse reproductive outcome in Australian male Gulf War veterans.

Reproductive health of Gulf War veterans

In this review we summarize the scientific literature on reproductive health following deployment to the first Gulf war by armed service personnel. All the studies examined had methodological limitations, making interpretation difficult. Nonetheless we conclude that for male veterans there is no strong or consistent evidence to date for an effect of service in the first Gulf war on the risk of major, clearly defined, birth defects or stillbirth in offspring conceived after deployment. Effects on specific rare defects cannot be excluded at this stage since none of the studies had the statistical power to examine them. For miscarriage and infertility, there is some evidence of small increased risks associated with service, but the role of bias is likely to be strong. For female veterans, there is insufficient information to make robust conclusions, although the weight of evidence to date does not indicate any major problem associated specifically with deployment to the Gulf. None of the studies have been able to examine risk according particular exposures, and so possible associations with specific exposures for smaller groups of exposed veterans cannot be excluded. We suggest that the way forward to address the question of veterans' reproductive health with confidence in the future is prospective surveillance following deployment. Anything less will result in further problems of interpretation and continued anxiety for parents, as well as prospective parents, in the armed forces.

Self-reported reproductive outcomes among male and female 1991 Gulf War era US military veterans

BACKGROUND

Following the 1991 Gulf War, some veterans expressed concerns regarding their reproductive health. Our objective was to assess whether an association exists between deployment to the 1991 Gulf War and self-reported adverse pregnancy outcomes.

METHODS

Using a modified Dillman technique with telephone follow-up, we conducted a survey via a postal questionnaire from February 1996-August 1997 to compare selected reproductive outcomes among 10,000 US veterans deployed to the 1991 Gulf War with those of 10,000 nondeployed Gulf War era veterans.

RESULTS

A total of 8742 individuals responded to the survey, a response rate of 51 percent. Using multivariable analyses, results showed no differences in number of reported pregnancies between Gulf War veterans and nondeployed veterans. Among 2233 female and 2159 male participants, there were no differences in birth weight of infants born to Gulf War veterans compared with nondeployed Gulf War era veterans. In multivariable models, male and female Gulf War veterans did not significantly differ in risk for ectopic pregnancies, stillbirths, or miscarriages when compared with nondeployed veterans of the same era.

CONCLUSIONS

These results do not suggest an association between service in the 1991 Gulf War and adverse reproductive outcomes for both male and female veterans during the 4 years after the war.

The possible role of endocrine disrupting chemicals in the aetiology of cryptorchidism and hypospadias: a population-based case-control study in rural Sicily

Abstract This was an open case-control study of the possible association between parental occupational and domestic exposures to potential endocrine disrupting chemicals (EDC) assessed by questionnaire and cryptorchidism and hypospadias in their offspring in the agricultural area of Ragusa. Cases of infants born between 1998 and 2002 with either of these two malformations (n=90), and controls (n=203), were recruited through the paediatric services (for cases) and a random sample of healthy infants attending the same services born in the same period of time (for controls). Data on occupational and environmental exposures of parents prior to and during the index case (or control), were collected through interviews with both parents. Concerning occupational exposures, we did not find a statistically significant increase in risk among parents directly involved in agricultural work. We did find a non-statistically significant increase in risk for cryptorchidism in mothers employed in agriculture [adjusted odds ratios (OR) 2.97; 95% confidence interval (CI) 0.77-11.47] and with probable exposure to pesticides (adjusted OR 2.74; 95% CI 0.72-10.42). Fathers who had indirect contact with agricultural products (transport and retail) had an increased risk (not statistically significant) for cryptorchidism (adjusted OR 2.45; 95% CI 0.63-9.59) and hypospadias and cryptorchidism combined (adjusted OR 2.24; 95% CI 0.67-7.48). Increases in risk of the two malformations pooled were also observed in relation to the mother's age below 25 (adjusted OR 1.99; 95% CI 0.97-4.09), to the presence of genital disease of the father (adjusted OR 2.41; 95%C I0.94-6.17), and the mother (adjusted OR 3.47;95% CI 1.34-8.99), to low birth weight of the infant (adjusted OR 4.49; 95% CI 1.23-16.31). Increased risk was also observed for mothers consuming alcohol during pregnancy (adjusted OR 3.09; 95% CI 0.98-9.66), and for couples who conceived while using condoms (adjusted OR 2.12; 95% CI 1.02-4.41). The study therefore provides only limited support to the hypothesis of a possible association between the risk of cryptorchidism and hypospadias and the occupational exposure to EDC and agricultural work.

Descriptive epidemiology of anotia and microtia, Hawaii, 1986-2002

The objective of this investigation was to describe the epidemiology of anotia and microtia with respect to various factors. The cases studied were all infants and fetuses with anotia or microtia identified by a population-based birth defects registry in Hawaii. The anotia and microtia rates were determined for selected factors and comparisons made among the subgroups by calculating the rate ratio (RR) and 95% confidence interval (CI). A total of 120 cases were identified, for a rate of 3.79 per 10,000 live births. The anotia and microtia rate increased during 1986-2002, although the trend was not significant (P = 0.715). Of 49 specific structural birth defects examined, four were found to be significantly more common in the presence of anotia and microtia. When compared with Caucasians, the anotia and microtia rates were higher among Far East Asians (RR 1.79, 95% CI 0.89-3.68), Pacific Islanders (RR 2.26, 95% CI 1.24-4.32), and Filipinos (RR 2.34, 95% CI 1.23-4.64). The defects were less common among females (RR 0.64, 95% CI 0.43-0.93) and more common with multiple birth (RR 3.72, 95% CI 1.66-7.33), birth weight < 2500 g (RR 3.35, 95% CI 2.04-5.30), and gestational age <38 weeks (RR 2.27, 95% CI 1.49-3.40). In conclusion, the rate for anotia and microtia increased in Hawaii during the study period. The rates for only a few structural birth defects were substantially greater than expected in association with anotia and microtia. Anotia and microtia rates varied significantly according to maternal race/ethnicity, infant sex, plurality, birth weight, and gestational age.

Teratogenicity of depleted uranium aerosols: a review from an epidemiological perspective

BACKGROUND

Depleted uranium is being used increasingly often as a component of munitions in military conflicts. Military personnel, civilians and the DU munitions producers are being exposed to the DU aerosols that are generated.

METHODS

We reviewed toxicological data on both natural and depleted uranium. We included peer reviewed studies and gray literature on birth malformations due to natural and depleted uranium. Our approach was to assess the "weight of evidence" with respect to teratogenicity of depleted uranium.

RESULTS

Animal studies firmly support the possibility that DU is a teratogen. While the detailed pathways by which environmental DU can be internalized and reach reproductive cells are not yet fully elucidated, again, the evidence supports plausibility. To date, human epidemiological data include case examples, disease registry records, a case-control study and prospective longitudinal studies.

DISCUSSION

The two most significant challenges to establishing a causal pathway between (human) parental DU exposure and the birth of offspring with defects are: i) distinguishing the role of DU from that of exposure to other potential teratogens; ii) documentation on the individual level of extent of parental DU exposure. Studies that use biomarkers, none yet reported, can help address the latter challenge. Thoughtful triangulation of the results of multiple studies (epidemiological and other) of DU teratogenicity contributes to disentangling the roles of various potentially teratogenic parental exposures. This paper is just such an endeavor.

CONCLUSION

In aggregate the human epidemiological evidence is consistent with increased risk of birth defects in offspring of persons exposed to DU.

Can epidemiology clear the fog of war? Lessons from the 1990-91 Gulf War

Despite over US $200 million having been spent researching illnesses following the 1990-91 Persian Gulf War, the nature and cause of such illnesses remains controversial. In this narrative review, we discuss some of the methodological issues that have affected epidemiological studies on this topic. These include low-response rates, ascertainment bias, recall bias, problems identifying suitable control groups, and problems defining the outcomes to study. From this we argue that difficulties have arisen partly owing to the significant delay between the point at which illnesses were first identified by veterans and the reporting of epidemiological studies and that health surveillance should be routine following future deployments.

Gulf war veterans and hemifacial microsomia

BACKGROUND

Concerns have been raised that more infants with Goldenhar syndrome were born to U.S. Gulf War veterans than expected. Goldenhar syndrome is considered a variant of the malformation hemifacial microsomia (HFM). We used data collected from a case-control study of HFM to estimate risk in relation to parental military service and, in particular, Gulf War service.

METHODS

Cases with HFM who were three years old or younger were identified at craniofacial clinics in 24 U.S. cities and matched to controls by age and pediatrician. The mothers of 232 cases and 832 controls were interviewed between April 1996 and November 2002 about pregnancy events and exposures, including military service before the child was born and Gulf War deployment five to 11 years before the child was born. Odds ratios were adjusted for family income, race, and body mass index in early pregnancy.

RESULTS

Four (1.7%) case mothers and 10 (1.2%) control mothers served in the military. Among fathers, 30 (12.9%) cases and 100 (12.0%) controls served in the military. The parents of four (1.7%) cases and 23 (2.8%) controls served in the Gulf War (multivariate adjusted odds ratio [MVOR], 0.8; 95% confidence interval [CI], 0.3-2.3). All four case parents with Gulf War service were in the Army compared to 9 of 23 control parents. The MVOR for parental Gulf War service in the Army was 2.8 (95% CI, 0.8-9.6). The corresponding MVOR for any parental service in the Army was 2.4 (95% CI, 1.4-4.2), based on 22 cases and 45 controls.

CONCLUSIONS

The risk of HFM in offspring was not associated with parental service in the Gulf War five to 11 years before birth. The odds ratio for service in the Army was independent of Gulf War service and was associated with a modest increase in risk. Our findings for service in the Army may be confounded by unmeasured lifestyle factors.

Resolving Disputes About Toxicological Risks During Military Conflict

In the last 15 years, the US and UK have fought two major wars in the Persian Gulf region. Controversy has arisen over the nature and causes of health problems among military veterans of these two wars. Toxic exposures have been hypothesised to cause the majority of the long-term health problems experienced by veterans of the 1991 Gulf War. The assessment of these toxic exposures and the resolution of controversy about their health effects provide a unique case study for understanding how toxicological disputes are settled in the US. Neither clinical examination of ill war veterans nor scientific research studies have been sufficient to answer contentious questions about toxic exposures. Numerous expert review panels have also been unable to resolve these controversies except for the US National Academy of Sciences Institute of Medicine (IOM). The IOM has conducted exhaustive and independent investigations based on peer-reviewed scientific literature related to potential health risks during the two Gulf Wars. In four recent studies, IOM committees identified a wide range of previously documented illnesses associated with common occupational and environmental exposures after considering thousands of relevant publications; however, they did not identify a new medical syndrome or a specific toxic exposure that caused widespread health problems among Gulf War veterans. These IOM studies have, therefore, added little to our basic knowledge of environmental hazards because most of the health effects were well known. Nevertheless, this expert review process, which is on-going, has been generally acceptable to a wide range of competing interests because the findings of the IOM have been perceived as scientifically credible and independent, and because none of the postulated toxicological risks have been completely ruled-out as possible causes of ill health among veterans.

Infertility among male UK veterans of the 1990-1 Gulf war: reproductive cohort study

OBJECTIVES

To examine the hypothesis that, theoretically at least, exposure to toxicants of the type present in the Gulf war could affect spermatogenesis, which might be observed as increased levels of infertility.

DESIGN

Retrospective reproductive cohort analysis.

SETTING

Male UK Gulf war veterans and matched comparison group of non-deployed servicemen, surveyed by postal questionnaire.

PARTICIPANTS

42,818 completed questionnaires were returned, representing response rates of 53% for Gulf veterans and 42% for non-Gulf veterans; 10,465 Gulf veterans and 7376 non-Gulf veterans reported fathering or trying to father pregnancies after the Gulf war.

MAIN OUTCOME MEASURES

Failure to achieve conceptions (type I infertility) or live births (type II infertility) after the Gulf war, having tried for at least a year and consulted a doctor; time to conception among pregnancies fathered by men not reporting fertility problems.

RESULTS

Risk of reported infertility was higher among Gulf war veterans than among non-Gulf veterans (odds ratio for type I infertility 1.41, 95% confidence interval 1.05 to 1.89; type II 1.50, 1.18 to 1.89). This small effect was constant over time since the war and was observed whether or not the men had fathered pregnancies before the war. Results were similar when analyses were restricted to clinically confirmed diagnoses. Pregnancies fathered by Gulf veterans not reporting fertility problems also took longer to conceive (odds ratio for > 1 year 1.18, 1.04 to 1.34).

CONCLUSIONS

We found some evidence of an association between Gulf war service and reported infertility. Pregnancies fathered by Gulf veterans with no fertility problems also reportedly took longer to conceive.