The Role of Community Health Agents in Promoting Social Change in Peru

BACKGROUND

Community health agents (CHAs) provide basic health services and increase health care access thereby improving health outcomes for peri-urban regions in Peru. Few studies analyze the effect that becoming a CHA has on women's interpersonal interactions. We aim to explore the impact CHAs may have on gender and social norms through their roles as trusted leaders in male-dominated communities.

METHODS

We conducted six 90-minute group discussions with CHAs working in Huancayo and Trujillo, Peru. We designed the discussions to extract data about family and community norms that changed as a result of working as a CHA.

RESULTS

A total of 53 female CHAs participated in six discussion groups. CHAs reported shifting family support (a change in how their family supported them in their role as a CHA), gaining status within their family (feeling more valued for their knowledge and experience), and shifting family gender roles (men and boys taking on more household responsibilities) as a result of their work. CHAs also reported a change in community norms and felt they were more valued and respected within their communities as women leaders.

CONCLUSIONS

Working as a CHA creates an opportunity to enact social change through altering family dynamics and community perceptions. Moreover, empowering women to become CHAs not only generates tangible benefits in community health, but can help create social change that ultimately improves the lives of women and realize their human rights.

Racial and Ethnic Differences in Openness to Communication From Local Faith-Based Congregations During Public Health Emergencies

OBJECTIVES

During public health emergencies, people at risk of exposure or illness will likely be presented with extensive information about an unfamiliar topic and be asked to make decisions quickly. In difficult situations, people often turn to trusted leaders, including from their local faith-based congregation (FBC). We examined how people receive, interpret, and respond to health communication information from clergy and lay leaders from their local FBC during public health emergencies.

METHODS

We analyzed responses to 10 questions from a 2021 nationally representative US survey. Porter Novelli designed the survey and administered it to 4510 US adults aged ≥18 years, of whom 3553 people completed the survey. We examined sociodemographic characteristics, trust of health information from clergy and lay leaders, and willingness to engage in health behaviors recommended by their FBC and receive health services through their local FBC. All estimates were weighted. We conducted bivariate analysis with contrast t tests for proportions at α = .05.

RESULTS

More than half of adults (55.4%), including 65.8% of non-Hispanic Black and 58.8% of Hispanic or Latino adults, were members of an FBC. Among FBC members, a higher percentage of Hispanic or Latino (29.1%) and non-Hispanic Black (36.3%) adults than non-Hispanic White adults (20.4%) reported trust in their FBC for health information (P < .05). This trust translated into greater intent to engage in health behaviors promoted by the local FBC among non-Hispanic Black respondents (31.4%) compared with non-Hispanic White respondents (22.5%) (P < .05).

CONCLUSIONS

Public health officials can consider ways to better understand how the cultures and practices of populations being served influence people's health perceptions and behaviors. Collaboration between federal, state, and local public health officials and FBCs can promote health equity during public health emergencies.

Do Gender-Based Violence Interventions Consider the Impacts of Climate Change? A Systematic Review

Climate change and extreme weather events have been shown to increase incidences of gender-based violence (GBV). Numerous organizations have devoted significant time, resources, and effort to the design and implementation of interventions aimed at reducing GBV in Africa. Some interventions effectively reduce violence, but GBV persists and remains pervasive. The United Nations has called for GBV interventions that consider the impact of climate change on violence. This review aims to determine whether public health interventions intended to reduce GBV in Africa take into account the effects of climate change on the region and the population. PubMed, PsychArticles, and CINAHL databases were searched systematically in February 2023 for interventions conducted in Africa published between 2010 and 2023. There were a total of 86 articles in the final review that described 40 distinct interventions. The intervention designs included empowerment and participatory approaches (microfinance, microfinance plus, community education, and community engagement), changing social and cultural norms (community education, community engagement, and media), and school-based programs. None of the 40 interventions mentioned climate, weather, or climate change as a component of the intervention. There are several opportunities to improve existing, successful GBV interventions in order to increase their efficacy. GBV interventions could incorporate economic independence programs that do not rely on agriculture and include climate change education. These findings could facilitate the integration of two previously distinct research disciplines-climate change and GBV prevention-to inform future research and develop more effective and cost-efficient interventions.

Climate Change, Extreme Weather, and Intimate Partner Violence in East African Agrarian-Based Economies

Severe weather events can be a catalyst for intimate partner violence, particularly in agricultural settings. This research explores the association between weather and violence in parts of East Africa that rely on subsistence farming. We used IPUMS-DHS data from Uganda in 2006, Zimbabwe in 2010, and Mozambique in 2011 for intimate partner violence frequency and EM-DAT data to identify weather events by region in the year of and year prior to IPUMS-DHS data collection. This work is grounded in a conceptual framework that illustrates the mechanisms through which violence increases. We used logistic regression to estimate the odds of reporting violence in regions with severe weather events. The odds of reporting violence were 25% greater in regions with severe weather compared to regions without in Uganda (OR = 1.25, 95% CI: 1.11-1.41), 38% greater in Zimbabwe (OR = 1.38, 95% CI: 1.13-1.70), and 91% greater in Mozambique (OR = 1.91, 95% CI: 1.64-2.23). Our results add to the growing body of evidence showing that extreme weather can increase women's and girls' vulnerability to violence. Moreover, this analysis demonstrates that climate justice and intimate partner violence must be addressed together.

Communicating Effectively With People Experiencing Homelessness to Prevent Infectious Diseases

Background

People experiencing homelessness (PEH) are disproportionately affected by many infectious diseases, including coronavirus disease 2019 (COVID-19). However, communication efforts during public health emergencies like the COVID-19 pandemic often do not consider the unique needs of PEH. We examined how PEH seek and receive health information and how traditional health communication methods resonate with them.

Methods

We conducted in-person focus groups with PEH in 4 jurisdictions (Cincinnati, Ohio; Denver, Colorado; Sacramento, California; and the Bronx, New York) during July 2021.

Results

Findings from 15 focus groups with PEH (n = 53) revealed the need for trusted messengers and consistent messaging across local organizations, as PEH seek to verify information they receive from multiple sources. PEH overwhelmingly preferred to receive health information through face-to-face conversations, especially with healthcare providers with whom they had an established relationship, but they also cited news media, the internet, and social media as their main sources for obtaining health information. PEH reported that effective communication products pair a recommended action with instructions and resources about how to take that action within their community.

Conclusions

These findings support healthcare providers collaborating with public health agencies to ensure that infectious disease prevention messages for PEH are provided by trusted messengers, multimodal, paired with resources, and consistent.

Community Health Agents Advancing Women's Empowerment: A Qualitative Data Analysis

Community health agents (CHAs) play a critical role in primary healthcare delivery and health promotion in low-resource settings. Though there is substantial evidence of the benefits of CHAs in achieving targeted community health outcomes, there is limited research into the impact of empowerment experienced by CHAs themselves. This study examined how working as a CHA impacts the lives and self-perceptions of women in Peru volunteering with Catholic Medical Mission Board’s (CMMB) markedly successful robust CHA model. We conducted six focus group discussions (FGDs) of 53 CHAs who implement CMMB programming in Trujillo and Huancayo, Peru. The FGDs were designed to explore themes related to empowerment, changes in women’s lives, and perceptions of themselves. We identified four major themes related to women’s empowerment: achievements, agency, meaningfulness, and resources. The most common empowerment theme was achievements, expressed through subthemes of changes in family behavior, self worth, education, health and nutrition, and rights and politics. The second most common empowerment theme was agency, with subthemes related to increases in using their voice, confidence, decision making, and participation. CHAs also reported experiencing empowerment through enhanced meaningfulness. CMMB’s CHA model is an example of how well-structured community programs can facilitate women’s empowerment. Providing meaningful community leadership opportunities can have far-reaching effects on women’s perceptions of themselves as valuable, capable, and empowered leaders. This work deepens our understanding of how to practically improve community health through empowering women to catalyze gender equality in communities with disproportionate barriers and limited opportunities burdening them.

Kenyan Women Bearing the Cost of Climate Change

Climate change-induced crises can aggravate intimate partner violence (IPV); the loss of income when weather affects the agricultural industry can exacerbate violence at home. In Kenya, climate change has increased precipitation during the rainy season and raised temperatures during the dry season, resulting in floods and droughts. For 75% of Kenyans, agricultural activities are their primary source of income. This research aims to assess patterns in IPV and severe weather events (SWE). We examined Integrated Public Use Microdata Series-Demographic Health Survey (IPUMS-DHS) data from 2008 and 2014 for IPV severity and frequency. We used Emergency Events Database (EM-DAT) data along with GPS coordinates to identify SWEs (defined as any flood >10 days) by county in Kenya. Overall, women were more likely to experience IPV if their spouse worked in agriculture (Odds Ratio (OR) = 1.22, 95% Confidence Interval (CI): 1.10–1.36). There was a 60% increase in the odds of reporting IPV in counties that experienced an SWE as compared to counties that did not experience an SWE (OR = 1.60, 95% CI: 1.35–1.89). This analysis further supports the growing body of research that suggests a relationship between climate change-related weather events and violence against women.

Association of COVID-19 With Achieving Time-to-Surgery Benchmarks in Patients With Musculoskeletal Trauma

Question

Were resource constraints due to the COVID-19 pandemic associated with a delay in urgent fracture surgery beyond national time-to-surgery benchmarks?

Findings

In this cohort pre-post study that included 3589 patients, there was no association between time to surgery and COVID-19 in either open fracture or closed femur/hip fracture cohorts.

Meaning

Despite concerns that the unprecedented challenges associated with the COVID-19 pandemic would delay acute management of urgent surgery, many hospital systems within the US were able to implement strategies in keeping with time-to-surgery standards for orthopedic trauma.

Importance

In response to the COVID-19 pandemic, many hospital systems were forced to reduce operating room capacity and reallocate resources. The outcomes of these policies on the care of injured patients and the maintenance of emergency services have not been adequately reported.

Objective

To evaluate whether the COVID-19 pandemic was associated with delays in urgent fracture surgery beyond national time-to-surgery benchmarks.

Design, Setting, and Participants

This retrospective cohort study used data collected in the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma among at 20 sites throughout the US and Canada and included patients who sustained open fractures or closed femur or hip fractures.

Exposure

COVID-19–era operating room restrictions were compared with pre–COVID-19 data.

Main Outcomes and Measures

Surgery within 24 hours after injury.

Results

A total of 3589 patients (mean [SD] age, 55 [25.4] years; 1913 [53.3%] male) were included in this study, 2175 pre–COVID-19 and 1414 during COVID-19. A total of 54 patients (3.1%) in the open fracture cohort and 407 patients (21.8%) in the closed hip/femur fracture cohort did not meet 24-hour time-to-surgery benchmarks. We were unable to detect any association between time to operating room and COVID-19 era in either open fracture (odds ratio [OR], 1.40; 95% CI, 0.77-2.55; P = .28) or closed femur/hip fracture (OR, 1.01; 95% CI, 0.74-1.37; P = .97) cohorts. In the closed femur/hip fracture cohort, there was no association between time to operating room and regional COVID-19 prevalence (OR, 1.07; 95% CI, 0.70-1.64; P = .76).

Conclusions and Relevance

In this cohort study, there was no association between meeting time-to-surgery benchmarks in either open fracture or closed femur/hip fracture during the COVID-19 pandemic compared with before the pandemic. This is counter to concerns that the unprecedented challenges associated with managing the COVID-19 pandemic would be associated with clinically significant delays in acute management of urgent surgical cases and suggests that many hospital systems within the US were able to effectively implement policies consistent with time-to-surgery standards for orthopedic trauma in the context of COVID-19–related resource constraints.

The effectiveness of germicidal wipes and ultraviolet irradiation in reducing bacterial loads on electronic tablet devices used to obtain patient information in orthopaedic clinics: evaluation of tablet cleaning methods

BACKGROUND

Electronic tablet devices are commonly used in outpatient clinics to obtain patient information for both clinical and research purposes. These devices are often colonized with bacteria; there are many cleaning methods to reduce this bacterial load.

AIM

The primary purpose of this study was to evaluate whether regular cleaning with either germicidal wipes or ultraviolet (UV) irradiation leads to lower bacterial levels compared with irregular cleaning.

METHODS

A randomized blinded trial was conducted of tablet cleaning strategies between each patient encounter in orthopaedic clinics. The cleaning method was randomized to either germicidal wipes, UV irradiation, or cleaning only when the tablet was visibly soiled. Research assistants (blinded to the treatment) obtained bacterial cultures from the tablets at the beginning and end of each clinic day.

FINDINGS

Using germicidal wipes between each patient encounter vs no routine cleaning resulted in a marked decrease in the amount of bacterial contamination (risk ratio (RR) = 0.17 (0.04-0.67)). Similarly, using UV irradiation between each patient encounter led to significantly lower bacterial contamination rates (RR = 0.29 (95% confidence interval (CI) = 0.09-0.95)) compared with no routine cleaning. The majority of bacteria identified were normal skin flora. No meticillin-resistant Staphylococcus aureus was identified and only sparse colonies of meticillin-sensitive S. aureus.

CONCLUSION

Electronic tablets used in orthopaedic trauma clinics are colonized with bacteria if no routine cleaning is performed. Routine use of either UV irradiation or germicidal wipes significantly decreases this bacterial burden. Providers should implement routine cleaning of tablets between each patient encounter to minimize exposure to potential pathogens.

Facilitators and Barriers of Cervical Cancer Screening and Human Papilloma Virus Vaccination Among Somali Refugee Women in the United States: A Qualitative Analysis

INTRODUCTION

Eastern Africa has the highest rates of cervical cancer incidence (42.7 per 100,000) and mortality (27.6 per 100,000), substantially higher than worldwide incidence (14.0 per 100,000) and mortality (6.8 per 100,000). The purpose of this study was to explore facilitators and barriers to cervical cancer screening and human papilloma virus (HPV) vaccination among Somali refugee women and their children.

METHOD

Focus group discussions were conducted in August of 2016. Investigators performed systematic, comparative, and thematic data analyses.

RESULTS

The 31 Somali refugee participants ranged from 23 to 64 years old. Four major themes emerged: (1) knowledge, (2) facilitators, (3) decision making, and (4) views on intervention strategies. Doctor recommendation and family support were important facilitators. Community education was the most popular strategy in promoting screening and vaccine uptake.

DISCUSSION

Multilevel targeted interventions should increase knowledge and include family members to increase cervical cancer screening and HPV vaccination uptake in the Somali community.

Rural-Urban Differences in Access to Preventive Health Care Among Publicly Insured Minnesotans

PURPOSE

Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota.

METHODS

This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities.

RESULTS

Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees.

CONCLUSIONS

Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence.

Abstract B65: Barriers to recommended screening among U.S. immigrants: A literature review

Purpose/Objectives: Maximizing cancer screening uptake has been a high public health priority in the United States, particularly for three prevalent and high-mortality cancers which benefit from early detection: breast, cervical, and colorectal cancers. However, screening rates for these cancers remain very low for US immigrants. Immigrants face unique barriers in accessing preventative healthcare that may or may not be specific to particular cultural and socioeconomic backgrounds. This review aims to synthesize literature on barriers to cancer screening among US immigrants in order to help design interventions that aim to increase screening in these diverse populations.

Methods: We conducted a comprehensive search in Ovid Medline using Medical Subject Headings to capture articles discussing broadly defined barriers to screening for breast, cervical, or colorectal cancer in any immigrant communities in the United States. An initial 1148 articles was reduced to a final sample of 90 based on the following inclusion criteria: (1) population-based studies that were not evaluating an intervention (2) at least 80% of the study population immigrants or refugees to the United States (3) focus on uptake or receipt of any screening procedure for one or more of the three cancers of interest (4) study population did not include cancer patients or survivors (5) outcomes included factors influencing screening uptake (studies showing a disparity in screening but not seeking to explain it were excluded) and (6) publication year of 2000 or later.

Results: Of the 90 studies included in the analysis, 26 (28.8%) were qualitative in design while the rest were quantitative survey studies. Men and women from most major immigrant groups in the United States were represented. Studies reported a large range but generally reported higher rates of having ever been screened (25-96%), and low rates of regular screening for all cancers (20-60%). Studies identified a wide-range of barriers including structural barriers such as insurance/cost (n=61), not having a regular provider or not receiving screening recommendation (n=47), language barriers (n=40), discrimination (n=18), navigating health systems (n=11) work/family responsibilities (n=9), and transportation (n=7). Fear and stigma of cancer and screening, concerns about pain, modesty, embarrassment, and lack of knowledge about availability or reason for screening were also identified. Some groups expressed fatalistic conceptions of health, or cultural/religious barriers, however many expressed interest in prevention. General themes important for increasing screening among US immigrants emerged: (1) It is important to disaggregate immigrant groups from racial categories and (2) it is equally important to understand communities' unique cultural or religious concerns. (3) The effects of cultural or psychosocial barriers were less inhibitory than structural barriers. (4) Structural and language barriers, socioeconomic status, and time in the US, were most important for predicting screening uptake.

Conclusions: There is no one-size-fits-all solution for increasing cancer screening among all US immigrants. Results suggest the importance of providers taking time to counsel all patients but perhaps especially those who were raised in cultures with differing conceptions of health. Community-based educational and motivational programs in conjunction with programs to increase structural access may help to increase screening uptake. For providers, identifying community members and/or friends and relatives of patients who can be motivators to screening is likely an effective method to improve screening rates. Targeted interventions that address both individual and structural barriers may be most effective in increasing cancer screening in immigrant communities.

Citation Format: Elizabeth M. Allen, John O. Loftus. Barriers to recommended screening among U.S. immigrants: A literature review. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B65.

Cancer incidence among Minnesota taconite mining industry workers

PURPOSE

To evaluate cancer incidence among Minnesota taconite mining workers.

METHODS

We evaluated cancer incidence between 1988 and 2010 in a cohort of 40,720 Minnesota taconite mining workers used between 1937 and 1983. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were estimated by comparing numbers of incident cancers with frequencies in the Minnesota Cancer Surveillance System. SIRs for lung cancer by histologic subtypes were also estimated. We adjusted for out-of-state migration and conducted a probabilistic bias analysis for smoking-related cancers.

RESULTS

A total of 5700 cancers were identified, including 51 mesotheliomas and 973 lung cancers. The SIRs for lung cancer and mesothelioma were 1.3 (95% CI = 1.2-1.4) and 2.4 (95% CI = 1.8-3.2), respectively. Stomach, laryngeal, and bladder cancers were also elevated. However, adjusting for potential confounding by smoking attenuated the estimates for lung (SIR = 1.1, 95% CI = 1.0-1.3), laryngeal (SIR = 1.2, 95% CI = 0.8-1.6), oral (SIR = 0.9, 95% CI = 0.7-1.2), and bladder cancers (SIR = 1.0, 95% CI = 0.8-1.1).

CONCLUSIONS

Taconite workers may have an increased risk for certain cancers. Lifestyle and work-related factors may play a role in elevated morbidity. The extent to which mining-related exposures contribute to disease burden is being investigated.

Occupational exposures and lung cancer risk among Minnesota taconite mining workers

OBJECTIVE

To examine the association between employment duration, elongate mineral particle (EMP) exposure, silica exposure and the risk of lung cancer in the taconite mining industry.

METHODS

We conducted a nested case-control study of lung cancer within a cohort of Minnesota taconite iron mining workers employed by any of the mining companies in operation in 1983. Lung cancer cases were identified by vital records and cancer registry data through 2010. Two age-matched controls were selected from risk sets of cohort members alive and lung cancer free at the time of case diagnosis. Calendar time-specific exposure estimates were made for every job and were used to estimate workers' cumulative exposures. ORs and 95% CIs were estimated using conditional logistic regression. We evaluated total lung cancer risk and risk of histological subtype by total work duration and by cumulative EMP, and silica exposure by quartile of the exposure distribution.

RESULTS

A total of 1706 cases and 3381 controls were included in the analysis. After adjusting for work in haematite mining, asbestos exposure and sex, the OR for total duration of employment was 0.99 (95% CI 0.96 to 1.01). The ORs for quartile 4 versus 1 of EMP and silica exposure were 0.82 (95% CI 0.57 to 1.19) and 0.97 (95% CI 0.70 to 1.35), respectively. The risk of each histological subtype of lung cancer did not change with increasing exposure.

CONCLUSIONS

This study suggests that the estimated taconite mining exposures do not increase the risk of developing lung cancer.

Mortality and cancer incidence in ammonium perfluorooctanoate production workers

OBJECTIVE

To evaluate mortality and cancer incidence in a cohort of ammonium perfluorooctanoate (APFO) exposed workers.

METHODS

We linked a combined cohort (n=9027) of employees from APFO and non-APFO production facilities in Minnesota to the National Death Index and to cancer registries of Minnesota and Wisconsin. Industrial hygiene data and expert evaluation were used to create a task-based job exposure matrix to estimate APFO exposure. Standardised mortality ratios were estimated using Minnesota population rates. HRs and 95% CIs for time-dependent cumulative APFO exposure were estimated with an extended Cox model. A priori outcomes of interest included cancers of the liver, pancreas, testes, kidney, prostate and breast, and mortality from cardiovascular, cerebrovascular and chronic renal diseases.

RESULTS

Mortality rates in the APFO-exposed cohort were at or below the expected, compared with Minnesota. The HR for dying from the cancer and non-cancer outcomes of interest did not show an association with APFO exposure. Similarly, there was little evidence that the incident cancers were associated with APFO exposure. Compared to the non-exposed population, modestly elevated, but quite imprecise HRs were observed in the higher-exposure quartiles for bladder cancer (HR=1.66, 95% CI 0.86 to 3.18) and pancreatic cancer (HR=1.36, 95% CI 0.59 to 3.11). No association was observed between APFO exposure and kidney, prostate or breast cancers.

CONCLUSIONS

This analysis did not support an association between occupational APFO exposure and the evaluated health endpoints, however, the study had limited power to evaluate some conditions of interest.

Perceptions of communicative competence after traumatic brain injury: implications for ecologically-driven intervention targets

The present study investigated the relationship between non-verbal behaviours and perceptions of the communication abilities of an individual with anomia secondary to traumatic brain injury (TBI). Thirty-four university students studying Communication Sciences and Disorders were randomly assigned to watch or listen to six short clips of an individual with TBI engaged in conversation. Participants rated the individual on communication parameters from a modified version of the Pragmatic Protocol and four other dependent measures of communicative competence. A significant positive correlation was identified between perceptions of gestures and ratings of overall communicative competence, and between perceptions of hand and arm movements and ratings of overall communicative competence. Participant raters who viewed the individual's movements as inappropriate also rated her overall communication abilities less favourably. This finding highlights individuality in perception of communication competence and the importance of assessing communication partners' perceptions in a client's environment to determine socially relevant treatment goals.

Periodontitis and type 2 diabetes: is oxidative stress the mechanistic link?

Periodontitis is a common, chronic inflammatory disease initiated by bacteria which has an increased prevalence and severity in patients with type 2 diabetes. Recent studies indicate that the co-morbid presence of periodontitis can, in turn, adversely affect diabetic status and the treatment of periodontitis can lead to improved metabolic control in diabetes patients. Current evidence points to a bidirectional interrelationship between diabetes and inflammatory periodontitis. The importance of oxidative stress-inflammatory pathways in the pathogenesis of type 2 diabetes and periodontitis has recently received attention. Given the bidirectional relationship between these two conditions, this review discusses the potential synergistic interactions along the oxidative stress-inflammation axis common to both type 2 diabetes and periodontitis, and the implications of this relationship for diabetic patients.

Attitudes, awareness and oral health-related quality of life in patients with diabetes

The purpose of this study was to assess the knowledge diabetic patients have of their risk for periodontal disease, their attitude towards oral health and their oral health-related quality of life (OHRQL). One hundred and one consecutive patients (age range 31-79 years) recruited from a diabetic outpatient clinic participated in the study. Twenty-seven per cent of participants had type 1 diabetes, 66% type 2 and 7% did not know what type of diabetes they had. The length of time since participants were diagnosed as diabetic ranged from 1 to 48 years. Metabolic control of diabetes as determined by HbA1c levels ranged from 6.2% to 12.0% compared with the normal range of 4.5-6.0%. Thirty-three per cent of participants were aware of their increased risk for periodontal disease, 84% of their increased risk for heart disease, 98% for eye disease, 99% for circulatory problems and 94% for kidney disease. Half of the participants who were aware of their increased risk for periodontal disease had received this information from a dentist. Dental attendance was sporadic, with 43% reporting attendance within the last year. OHRQL was not significantly affected by the presence of diabetes in the group surveyed, in comparison with a previous survey of non-diabetic patients. A significant association was found between metabolic control and dentate status. Awareness of the potential associations between diabetes, oral health and general health needs to be increased in diabetic patients.

Base-pairing between untranslated regions facilitates translation of uncapped, nonpolyadenylated viral RNA

Translationally competent mRNAs form a closed loop via interaction of initiation factors with the 5' cap and poly(A) tail. However, many viral mRNAs lack a cap and/or a poly(A) tail. We show that an uncapped, nonpolyadenylated plant viral mRNA forms a closed loop by direct base-pairing (kissing) of a stem loop in the 3' untranslated region (UTR) with a stem loop in the 5' UTR. This allows a sequence in the 3' UTR to confer translation initiation at the 5'-proximal AUG. This base-pairing is also required for replication. Unlike other cap-independent translation mechanisms, the ribosome enters at the 5' end of the mRNA. This remarkably long-distance base-pairing reveals a novel mechanism of cap-independent translation and means by which mRNA UTRs can communicate.

Base-pairing between untranslated regions facilitates translation of uncapped, nonpolyadenylated viral RNA

Translationally competent mRNAs form a closed loop via interaction of initiation factors with the 5' cap and poly(A) tail. However, many viral mRNAs lack a cap and/or a poly(A) tail. We show that an uncapped, nonpolyadenylated plant viral mRNA forms a closed loop by direct base-pairing (kissing) of a stem loop in the 3' untranslated region (UTR) with a stem loop in the 5' UTR. This allows a sequence in the 3' UTR to confer translation initiation at the 5'-proximal AUG. This base-pairing is also required for replication. Unlike other cap-independent translation mechanisms, the ribosome enters at the 5' end of the mRNA. This remarkably long-distance base-pairing reveals a novel mechanism of cap-independent translation and means by which mRNA UTRs can communicate.

IL-10 kinetics in thyroiditis-prone BB/Wor rats

Cytokines modulate the course of autoimmunity, but their role in the evolution of spontaneous disease is unclear. This study compared the cytokine kinetics of T cell cultures from thyroiditis (LT)-prone NB line BB/Wor rats with those of Wistar (Wis) rat controls following activation with the thyroid-specific antigen thyroglobulin (Tg) or Concanavalin A (Con A).

DESIGN

T cell enhanced splenocytes from 60 day old Wis and NB rats were activated with 0.5 microg/ml rat thyroglobulin (Tg) or Con A in the presence of homologous irradiated splenocytes as antigen presenting cells (APC's). In addition, the effect of APC's was determined in a crisscross experiment which examined NB T cell responses to Con A in the presence of Wis APC's. ELISA and RT-PCR were used to examine IL-2, IL-4, IL-10, TNFalpha, IFNgamma, IL-I0 concentrations and mRNA expression in the supernatant and cells from parallel cultures harvested at specific intervals. Frozen thyroids from 60 day old NB, Wis and Fisher rats were examined for the presence of IL-10 by immunohistochemistry. T cell proliferation was measured by 3H thymidine uptake.

RESULTS

Following activation with either Tg or Con A, IL-10 concentrations exceeded IFNgamma in NB rat cultures, but IFNgamma exceeded IL-10 in Wis cultures. Wis splenocytes significantly enhanced NB T cell proliferation and cytokine responses to Con A. Thyroids from 60 day NB rats contained IL-10, but no IFNgamma. There was no IL-10 in thyroids from Wistar or Fisher rats.

CONCLUSION

Splenocyte responses in LT-prone BB/Wor rats favor IL-10 production. Future investigations will examine the source of intrathyroidal IL-10 and its role in LT.

Liver transplantation improves cirrhosis-associated impaired oral glucose tolerance

BACKGROUND

Thirty-five percent to 80% of cirrhotic patients have impaired glucose tolerance (IGT) or diabetes mellitus (DM). Diabetic cirrhotics have higher morbidity and mortality than nondiabetics. Therefore, it would be worthwhile to determine whether liver transplantation improves glucose homeostasis in these patients.

METHOD

A total of 26 patients awaiting liver transplantation were evaluated for impaired glucose homeostasis by fasting blood glucose and/or oral glucose tolerance tests (OGTT). Five patients underwent transplant surgery within 1 year of OGTT and had a repeat OGTT 3-6 months after transplantation.

RESULTS

Sixty-five percent (17/26) of the patients had abnormal glucose homeostasis. Twenty-three percent (6/26) met American Diabetes Association criteria for DM, and another 42.3% (11/26) had IGT. All patients had normal HbA1C levels. After transplantation, the 2-hr blood glucose improved in four patients and the mean 2-hr glucose level was reduced (204 +/- 94 vs. 132 +/- 53 mg/dl [mean +/- SD, P=0.051]).

CONCLUSION

Liver transplantation can reverse cirrhosis-associated impaired glucose tolerance.

Water fluoridation and the sudden infant death syndrome

AIMS

To determine whether exposure to fluoridated water supplies prenatally or postnatally at the time of death increases the risk of sudden infant death syndrome (SIDS).

METHODS

A nationwide, case-control study, with infant's water fluoridation status determined from census area unit information for mother's usual address at the time of the infant's birth, infant's usual address at the time of death / nominated sleep and address where infant died / was at nominated sleep. SIDS risk associated with fluoride exposure postnatally was assessed according to method of infant feeding (breast or reconstituted formula), for the two days prior to infant's death / nominated sleep.

RESULTS

Infants exposed to fluoridated water supplies during pregnancy were not at increased risk for SIDS, adjusted odds ratio (OR) 1.19 (95% confidence interval (CI) 0.82, 1.74). For breast-fed infants at the time of death / nominated sleep, fluoridated water exposure was not associated with an increased risk for SIDS, adjusted OR 1.09 (95% CI 0.66, 1.79). Similarly, 'fluoridated' formula feeding, when compared with 'unfluoridated' formula feeding, showed no increased risk of SIDS, adjusted OR 1.25 (95% CI 0.73, 2.13). There was no evidence of an interaction between fluoridation and infant feeding for the last two days (chi2 = 0.171, df = 1, p = 0.68).

CONCLUSION

Exposure to a fluoridated water supply prenatally or postnatally at the time of death did not affect the relative risk for SIDS.

The effect of methimazole, iodine and splenocytes on thyroid transplants in BB/Wor rats

BACKGROUND

BB/Wor rats develop spontaneous autoimmune insulin-requiring diabetes mellitus and lymphocytic thyroiditis (LT). Our investigations examined the effect of the thyroid-specific agents, iodine and methimazole (MMI) on thyroid graft survival in BB/Wor rats, compared the intrathyroidal cytokine mRNA expression of endogenous and engrafted thyroids, and ascertained whether unfractionated splenocytes could protect thyroid grafts from lymphocytic infiltration.

METHODS

In study 1, 0.025% iodine water-treated LT-prone NB line BB/Wor rats were randomized to receive one of the following treatments: (1) 1.0 x 10(8) splenocytes, IV from LT-resistant WA line BB/Wor rats, (2) WA rat thyroid transplants, (3) both, or (4) neither (controls). In study 2, after thyroid transplantation, LT-prone BB/Wor rats were randomized to receive (1) WA splenocytes, (2) 0.025% iodine water, (3) 0.05% MMI water or, (4) tap water (controls). The incidence of LT was determined by microscopic inspection after hematoxylin and eosin staining. Lymphocytic infiltrates were characterized by immunohistochemistry. Cytokine mRNA was detected by RT-PCR.

RESULTS

Grafts from MMI-treated rats had a significantly lower incidence of lymphocytic infiltration (MMI: 2/5; Tap: 5/5; I 5/5, P<0.05, chi2). IL-10 mRNA was expressed in 77% (7/9) endogenous thyroids and 20% (1/5) of the transplanted WA thyroids (P<0.05, chi2) from iodine-treated rats with LT. There was no difference in IL-12 mRNA expression. Lymphocytic infiltration occurred in 100% of the splenocyte-treated graft recipients. Both endogenous and engrafted thyroids contained CD4 and C8 T cells with scattered IgG staining.

CONCLUSION

Target organ-specific interventions that suppress antigen presentation may have an adjunctive role in transplantation tolerance. The differential expression of IL-10 may indicate preferential Th2 lymphocyte activation in the endogenous tissues.

A randomized, controlled study of the 1-hour and 24-hour effects of inhaled nitric oxide therapy in children with acute hypoxemic respiratory failure

STUDY OBJECTIVE

To determine whether 24 h of inhaled nitric oxide improves oxygenation greater than conventional therapy alone in children with acute hypoxemic respiratory failure.

DESIGN

Prospective, randomized, controlled study.

SETTING

Twenty-six-bed pediatric ICU in a tertiary children's hospital.

PATIENTS

Twenty-four patients with acute bilateral lung disease requiring a positive-end expiratory pressure >6 cm H2O and a fraction of inspired oxygen >0.5 for >12 h.

INTERVENTIONS

Twelve patients were treated with 10 ppm inhaled nitric oxide from the onset of randomization and 12 control patients were initially maintained on a regimen of conventional therapy alone. After a period of 24 h, control patients were also treated with 10 ppm inhaled nitric oxide. Hemodynamic and blood gas measurements were performed at baseline, at 1 h after randomization, and at 24-h intervals for 2 days.

MEASUREMENTS AND RESULTS

Inhaled nitric oxide decreased the ratio of pulmonary to systemic vascular resistance and improved oxygenation indexes during the initial hour following randomization. However, 24 h after randomization, the oxygenation indexes of 11 surviving treated patients were not improved in comparison to baseline or the oxygenation indexes of 10 surviving control patients. Oxygenation indexes acutely improved in control patients when inhaled nitric oxide was started after 24 h of conventional therapy. Oxygenation indexes remained improved in the initial control patients after 24 h of inhaled nitric oxide.

CONCLUSIONS

Pulmonary vascular resistance and systemic oxygenation are acutely improved by 10 ppm inhaled nitric oxide in some children with severe lung disease. However, a sustained improvement in oxygenation may not occur during prolonged therapy. Thus, inhaled nitric oxide may have a limited therapeutic role in children with acute hypoxemic respiratory failure.

Life events, social support and the risk of sudden infant death syndrome

The effects of a lack of maternal social support and stressful life events on the risk of Sudden Infant Death Syndrome (SIDS) were examined by case-control design: 390 cases and 1592 control infants. A seven item index of mother's social support was used. A possible 21 life events experienced by each family were summed and then put into one of three categories: 0-2, 3-5, and 6 or more life events. Similar levels of maternal social support were found for both groups. SIDS families experienced significantly more stressful life events than control families, but once social factors had been taken into account this association was lost.

Hemodynamic effects of N-acetylamrinone in a porcine model of group B streptococcal sepsis

High plasma concentrations of N-acetylamrinone, a primary metabolite of amrinone, are measured in some children during prolonged amrinone infusion. The purpose of this investigation was to determine if N-acetylamrinone has direct hemodynamic effects independent of amrinone. Twenty neonatal piglets received an infusion of 6 x 10(9) colony-forming units/kg of group B Streptococcus to induce sepsis. Subsequently, they were divided into 1 of 3 groups and received a 1-hr infusion of either normal saline (N = 4); 8 mg/kg amrinone, followed by 20 micrograms/kg/min (N = 9); or 8 mg/kg N-acetylamrinone, followed by 20 micrograms/kg/min (N = 7). Hemodynamic measurements and arterial/venous blood-gas determinations were obtained every 30 min during the study. Systemic vascular resistance and pulmonary vascular resistance were calculated. One milliliter of blood was obtained every 30 min during drug administration to determine plasma amrinone and N-acetylamrinone concentrations. The mean amrinone plasma concentrations measured at 30 and 60 min during the infusion time in the group receiving amrinone were 8.8 +/- 1.1 and 6.9 +/- 0.7 micrograms/ml, respectively. These animals experienced a significant decrease in mean pulmonary artery pressure and pulmonary vascular resistance, compared with saline controls after a 30-min infusion of amrinone. The mean N-acetylamrinone plasma concentrations measured at 30 and 60 min during the N-acetylamrinone infusion were 7.3 +/- 0.8 and 5.7 +/- 0.6 micrograms/ml, respectively. There was no difference between any hemodynamic parameter measured in these animals, compared with saline controls at any time during the infusion. We conclude that amrinone, but not N-acetylamrinone, causes pulmonary vasodilation in a porcine model of sepsis and that the parent drug is the sole active component in amrinone.

HPLC micromethod for amrinone and metabolites in patients receiving concurrent cephalosporin therapy

Amrinone (AMR), a bipyridine derivative, is receiving increasing use in postoperative cardiac patients as an inotrope and vasodilator. The hemodynamic response to amrinone in adults is linearly related to AMR concentrations, warranting therapeutic drug monitoring. We report a rapid microsample HPLC method for monitoring AMR and its principal metabolites, N-acetyl (N-ac) and N-glycolyl (N-gly) AMR. Serum was precipitated with acetonitrile, and the supernatant fluid was then injected into a C18 narrow-bore column. The mobile phase consisted of a 0.1 mol/L sodium phosphate buffer (pH 6) with a gradient of acetonitrile going from 50 to 100 mL/L of eluent. Detection with a diode-array detector (DAD) concurrently monitored the absorbances at 320 and 345 nm. Monitoring 320 nm allows optimal quantification of AMR, N-gly, and N-ac. Patients often receive concurrent cephalosporin therapy, which is detectable at 320 nm but not 345 nm. Because cephalosporins coelute with AMR or metabolites, monitoring at 345 nm allows separation of these antibiotics from AMR and metabolites while retaining a detection limit of 0.5 mg/L.

HPLC micromethod for amrinone and metabolites in patients receiving concurrent cephalosporin therapy

Amrinone (AMR), a bipyridine derivative, is receiving increasing use in postoperative cardiac patients as an inotrope and vasodilator. The hemodynamic response to amrinone in adults is linearly related to AMR concentrations, warranting therapeutic drug monitoring. We report a rapid microsample HPLC method for monitoring AMR and its principal metabolites, N-acetyl (N-ac) and N-glycolyl (N-gly) AMR. Serum was precipitated with acetonitrile, and the supernatant fluid was then injected into a C18 narrow-bore column. The mobile phase consisted of a 0.1 mol/L sodium phosphate buffer (pH 6) with a gradient of acetonitrile going from 50 to 100 mL/L of eluent. Detection with a diode-array detector (DAD) concurrently monitored the absorbances at 320 and 345 nm. Monitoring 320 nm allows optimal quantification of AMR, N-gly, and N-ac. Patients often receive concurrent cephalosporin therapy, which is detectable at 320 nm but not 345 nm. Because cephalosporins coelute with AMR or metabolites, monitoring at 345 nm allows separation of these antibiotics from AMR and metabolites while retaining a detection limit of 0.5 mg/L.

The pathogenicity of spontaneously-occurring thyroglobulin-reactive T lymphocytes from BB/WOR rats

Autoantigen-reactive T lymphocytes have been implicated in the pathogenesis organ-specific autoimmune disease. Thyroglobulin (Tg) is one of the primary autoantigens associated with autoimmune lymphocytic thyroiditis (LT). These experiments investigated the pathogenicity of a lymphocyte line derived from spontaneously-occurring Tg-reactive T lymphocytes isolated from unprimed NB line BB/Wor rats which have nearly a 100% incidence of spontaneous LT. Adoptive transfer of LT was accomplished by injecting 1.0 x 10(5) Tg-reactive lymphocytes into the tail vein of MHC compatible, non LT-prone BB line BB/Wor rats. All of the Tg-reactive cell line recipients (5/5) developed LT compared to only 20% (1/5) of the control rats given a parallel tetanus toxoid-reactive T cell line (p < 0.05, Fisher's exact test). Furthermore, despite the presence of LT, only one Tg-reactive cell line recipient developed insulitis. When Tg-reactive lymphocytes were incubated with an MHC compatible Wistar rat thyrocyte line at increasing effector: target ratios, the T cell line lysed thyrocytes in a dose-response fashion (r = 0.99, p < 0.05, linear regression), but did not lyse smooth muscle cell targets. FACS analysis established that this cell line is CD8 predominant. This is the first study to demonstrate that spontaneously-occurring Tg-reactive T lymphocytes from a nonimmunized animal model for LT are pathogenic. Further investigations into the repertoire of Tg-reactive lymphocytes in BB/Wor rats should provide insight into the pathogenesis of autoimmune thyroid disease and provide a basis for targeted immunotherapy.

Difference between the measured and ordered dose of catecholamine infusions

OBJECTIVE

To measure the actual concentrations of dopamine, dobutamine, and epinephrine in infusates prepared for patients, and to compare these concentrations with those of the dopamine HCl, dobutamine, and epinephrine HCl infusates that had been prescribed to evaluate drug preparation accuracy.

DESIGN

Prospective, unblind study.

SETTING

Pediatric intensive care unit in a tertiary-care teaching hospital.

PARTICIPANTS

All dopamine, dobutamine, and epinephrine infusions ordered for patients during the 2-month study period were eligible for inclusion in the study.

MEASUREMENTS

Daily samples of dopamine, dobutamine, and epinephrine infusates that were prepared for 41 pediatric patients were obtained; the infusate catecholamine concentration was measured by HPLC and compared with the ordered concentration. The concentration than was multiplied by the rate of infusion to determine the catecholamine dose.

MAIN RESULTS

There were significant differences between the measured doses of dopamine, dobutamine, and epinephrine and the dopamine HCl, dobutamine, and epinephrine HCl doses (p = 0.0001, p = 0.039, and p = 0.0009, respectively) that had been ordered because of preparation inaccuracies. Failure to account for the HCl salt in the stock drug accounted for some, but not all, of the inaccuracy of the dopamine HCl and epinephrine HCl infusates. There was a wide interday variability in the measured catecholamine dosage in patients receiving the same dose for 3 days or more.

CONCLUSIONS

There are daily fluctuations in the preparation of dopamine, dobutamine, and epinephrine infusates that could alter the amount of drug actually delivered to critically ill patients and potentially contribute to their hemodynamic instability.

Antenatal and intrapartum factors associated with sudden infant death syndrome in the New Zealand Cot Death Study

OBJECTIVE

To describe the relationship between antenatal and intrapartum factors and sudden infant death syndrome (SIDS).

METHODOLOGY

The New Zealand Cot Death Study was a 3 year case-control study, with 485 infants who died from SIDS in the postneonatal period and 1800 randomly selected control infants. Data were obtained from obstetric records, parental interview and community nursing records.

RESULTS

This study confirms many of the antenatal and intrapartum risk factors for SIDS noted in studies from both the southern and northern hemispheres. After controlling for potential confounders, such as occupational group and marital status, significant inverse effects were noted for interpregnancy interval, birthweight and gestation. Other factors that retained a significantly increased risk of SIDS were: increasing parity, bacteriological evidence of urinary tract infection (UTI) (adjusted odds ratio 1.73, 95% CI 1.10-2.73); smoking antenatally (AdjOR 2.14, 95% CI 1.61-2.84); less than six antenatal checks attended (AdjOR 1.84, 95% CI 1.19-2.84); second stage of labour less than 16 min (AdjOR 2.06, 95% CI 1.35-3.14) and multiple birth (AdjOR 3.23, 95% CI 1.70-6.02). No interaction was observed between maternal haemoglobin and antenatal smoking. Interactions were tested for and not found between antenatal smoking and three antenatal risk factors (UTI, short second stage of labour and number of antenatal appointments). The only significant interaction between these three factors and three modifiable postnatal risk factors (prone sleeping, bed sharing and bottle feeding) was between bed sharing and fewer antenatal appointments. The risk of SIDS associated with bed sharing was greater among those whose mothers had fewer antenatal appointments.

CONCLUSIONS

Although many of the previously identified antenatal and intrapartum risk factors for SIDS are confirmed, the risks of SIDS associated with obstetric factors are in general considerably lower than the risks associated with the four modifiable postnatal risk factors.

Oral dimercaptosuccinic acid and ongoing exposure to lead: effects on heme synthesis and lead distribution in a rat model

Lead (Pb) exposure and subsequent toxicity continues to be a significant problem in the United States. Treatment with meso-2,3-dimercaptosuccinic acid (DMSA) has been reported to be effective in reducing the body's Pb burden, with fewer adverse side effects than other chelating agents. The oral availability and relative safety of DMSA presents the controversial option of treating patients with Pb poisoning on an outpatient basis. Despite recommendations that children be removed from the Pb contaminated environment, some children will inevitably be exposed to environmental Pb while receiving oral DMSA therapy. The study hypothesized that oral DMSA chelation therapy is beneficial even when faced with continued dietary Pb. Sprague-Dawley rats were exposed to Pb in water for 35 days and then placed in various treatment groups, including groups administered oral DMSA with and without concurrent Pb exposure. The concentration of Pb in blood and critical organs and Pb diuresis were measured. The effect of Pb on heme synthesis was determined by assaying the urinary delta-aminolevulinic acid (delta-ALA), and blood zinc protoporphyrin (ZPP). DMSA reversed the hematological effects of Pb, decreased the blood, brain, bone, kidney, and liver Pb concentration, and produced a marked Pb diuresis, even when challenged with ongoing Pb exposure. In conclusion, even though DMSA treatment without exposure to Pb is optimal, oral DMSA could be beneficial even when challenged with ongoing Pb exposure.

Thyroglobulin-reactive T lymphocytes in thyroiditis-prone BB/Wor rats

Autoimmune lymphocytic thyroiditis (LT) is a common cause of primary hypothyroidism. Autoreactive T lymphocytes are clearly associated with this disorder, but their pathogenic role in spontaneously occurring LT remains to be established. In the present study, thyroglobulin-reactive T lymphocytes were cultured from young, unprimed LT-prone BB/Wor rats before the age of spontaneously-occurring LT. Although similar investigations have been conducted in animal models for experimental autoimmune thyroiditis (EAT), this study is unique because it examines a mammalian model for spontaneous LT. Splenic T lymphocytes were isolated from unprimed 30 to 45-day-old Fisher and LT-prone BB/Wor rats before the onset of LT, then tested for activation by normal (NL), iodine-poor (LI), and iodine-rich (HI) rat thyroglobulin (Tg) in bulk proliferation assay. BB/Wor rat lymphocytes were activated by all three Tg preparations, but Fisher lymphocytes were unresponsive (BB/Wor vs Fisher; p < 0.0001, Student's t-test). There was no difference between BB/Wor rat responses to the three preparations (p > 0.05, ANOVA). Based on these results, we conclude that Tg-responsive T lymphocytes can be cultured from young, unprimed LT-prone BB/Wor rats. Isolating such lymphocytes before the onset of histologically demonstrable LT strengthens the argument that antigen-specific T cells have a pathogenic role in the development of spontaneous autoimmune thyroid disease. The fact that these lymphocytes recognized normal, iodine-rich and iodine poor preparations of rat Tg equally well suggest that unlike the EAT model, spontaneously-occurring Tg-reactive T cells are not influenced by thyroglobulin's iodine content.

Factors adversely associated with breast feeding in New Zealand

Control data from 1529 infants studied in a multicentre case-control study of sudden infant death in New Zealand were analysed to identify factors that might hinder the establishment and duration of breast feeding. Although 1300 infants (85%) were exclusively breast-fed at discharge from the obstetric hospital, this fell to 940 (61%) by 4 weeks. Logistic regression was used to identify factors that might adversely influence breast feeding 'at discharge', 'at 4 weeks' and the overall 'duration' of breast feeding. When adjusted for confounding factors, not exclusive breast feeding 'at discharge' was significantly associated with: twin pregnancy, being a Pacific Islander, mother not bedsharing, subsequent dummy use, birthweight less than 2500 g, heavy maternal smoking, not attending antenatal classes and mother less than 20 years old at first pregnancy. Mothers smoking more than 20 cigarettes a day were nearly twice as likely to not exclusively breast feed on discharge compared to those who did not smoke. A 'dose response' was apparent with the heaviest smokers having the least likelihood of establishing exclusive breast feeding. Being exclusively breast-fed at discharge but not 'at 4 weeks' was associated with: twin pregnancy, admission to a neonatal intensive care unit, subsequent dummy use and not being married. A shorter overall 'duration' of breast feeding was associated with maternal smoking, subsequent dummy use, mother not bedsharing, twin pregnancy, mother less than 20 years old at first pregnancy, low occupational status and not attending antenatal classes. These effects persisted when social and demographic factors, including birthweight, were taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)

Lithium sustains the acute antidepressant effects of sleep deprivation: preliminary findings from a controlled study

Early morning sleep deprivation (patient awake from 0200 to 2200 hours) produces a same-day antidepressant effect in approximately one-half of patients with major depression. Unfortunately, these antidepressant effects are short-lived and patients usually relapse to baseline depression levels within 48 hours. Recent work suggests, however, that the use of lithium with early morning sleep deprivation sustains this rapid antidepressant effect and makes it clinically useful. In a 30-day study, we compared the abilities of four different treatments (lithium plus early morning sleep deprivation, lithium plus a control sleep deprivation procedure, and desipramine with either of the two sleep manipulations) to induce a rapid (next-day) and sustained antidepressant response in 16 depressed patients. Lithium plus early morning sleep deprivation produced a quicker response than lithium with the control sleep deprivation, and the response was sustained for at least 30 days. In this design, however, lithium/early morning sleep deprivation was no faster than either of the two desipramine/sleep deprivation conditions in inducing remission. These results support the results of previous studies and suggest further investigation of this novel sleep/pharmacologic intervention is warranted.

Bed sharing, smoking, and alcohol in the sudden infant death syndrome. New Zealand Cot Death Study Group

OBJECTIVES

To investigate why sharing the bed with an infant is a not consistent risk factor for the sudden infant death syndrome in ethnic subgroups in New Zealand and to see if the risk of sudden infant death associated with this practice is related to other factors, particularly maternal smoking and alcohol consumption.

DESIGN

Nationwide case-control study.

SETTING

Region of New Zealand with 78% of all births during 1987-90.

SUBJECTS

Home interviews were completed with parents of 393 (81.0% of total) infants who died from the sudden infant death syndrome in the postneonatal age group, and 1592 (88.4% of total) controls who were a representative sample of all hospital births in the study region.

RESULTS

Maternal smoking interacted with infant bed sharing on the risk of sudden infant death. Compared with infants not exposed to either risk factor, the relative risk for infants of mothers who smoked was 3.94 (95% confidence interval 2.47 to 6.27) for bed sharing in the last two weeks and 4.55 (2.63 to 7.88) for bed sharing in the last sleep, after other confounders were controlled for. The results for infants of non-smoking mothers were inconsistent with the relative risk being significantly increased for usual bed sharing in the last two weeks (1.73; 1.11 to 2.70) but not for bed sharing in the last sleep (0.98; 0.44 to 2.18). Neither maternal alcohol consumption nor the thermal resistance of the infant's clothing and bedding interacted with bed sharing to increase the risk of sudden infant death, and alcohol was not a risk factor by itself.

CONCLUSION

Infant bed sharing is associated with a significantly raised risk of the sudden infant death syndrome, particularly among infants of mothers who smoke. The interaction between maternal smoking and bed sharing suggests that a mechanism involving passive smoking, rather than the previously proposed mechanisms of overlaying and hyperthermia, increases the risk of sudden infant death from bed sharing.

Breastfeeding and the risk of sudden infant death syndrome

The New Zealand Cot Death Study, a multicentre case-control study, was set up to identify risk factors associated with sudden infant death syndrome (SIDS). In the 3 years of the study there were 485 infant deaths classified as SIDS in the study areas and 1800 infants who were randomly selected as controls. Data were collected by parent interviews and from obstetric notes. A full set of data for this analysis was available from 356 cases and 1529 control infants. The relationship between length of any breastfeeding and SIDS was examined: 92% of the controls were initially breastfed compared to 86% of the cases. As time went by, cases stopped breastfeeding sooner than controls: by 13 weeks, 67% controls were breastfed versus 49% cases. A reduced risk for SIDS in breastfed infants persisted during the first 6 months after controlling for confounding demographic, maternal and infant factors. Infants exclusively breastfed 'at discharge from the obstetric hospital' (odds ratio [OR] = 0.52, 95% confidence interval (CI): 0.35-0.71) and during the last 2 days (OR = 0.65, 95% CI: 0.46-0.91) had a significantly lower risk of SIDS than infants not breastfed after controlling for potential confounders. We have shown a substantial association of breastfeeding with a lowered risk for SIDS. This supports the need for more positive promotion and active community support to further enhance the level and length of exclusive breastfeeding.

Subclass reactivity of pemphigus foliaceus autoantibodies with recombinant human desmoglein

Pemphigus foliaceus (PF) and its endemic form, Fogo Selvagem (FS), are autoimmune disorders characterized by subcorneal vesicles and IgG4 subclass autoantibodies that recognize a surface antigen of normal epidermal cells. FS and PF autoantibodies have been shown to bind desmoglein (DGI), a desmosomal glycoprotein classified as a member of the cadherin family of calcium-dependent cell adhesion molecules. In the present study we report the isolation of three overlapping cDNA clones representing greater than 90% of the extracellular domain of human DGI. Recombinant proteins encoded by these clones, designated DGI-1, DGI-2, and DGI-3, were produced in bacteria and analyzed for immunoblot (IB) reactivity with a panel of FS, PF, and control sera. FS and PF autoantibodies possessing reactivity with each of the three recombinant fusion proteins (FPs) were identified. FP DGI-3 (containing 123 amino acids of the membrane proximal region of the DGI ectodomain) showed reactivity with the largest number of patient sera--seven FS and one PF. IB reactivity with the DGI-1 FP (encoding 205 amino acids of the N-terminal region of DGI) could be eliminated by truncation of the C-terminal portion of this protein, indicating that autoantibodies were not binding the R-A-L motif. Autoantibodies reactive with two of the three FPs were predominantly restricted to IgG4, the subclass shown to be pathogenic in the passive transfer mouse model. The findings of this study demonstrate that the extracellular domain of DGI contains at least three antigenic sites recognized by FS and PF autoantibodies. The region near the membrane-spanning domain of DGI appears to contain an immunodominant site. This study is the first to document immunoblot reactivity of FS and PF autoantibodies with recombinant forms of DGI. The use of such molecular tools should facilitate the identification and characterization of relevant antigen/antibody systems in FS and PF.

Smoking and the sudden infant death syndrome

OBJECTIVE

Maternal smoking has been shown to be a risk factor for sudden infant death syndrome (SIDS). The effect of smoking by the father and other household members has not previously been examined.

METHODS

A large nationwide case-control study. Four hundred eighty-five SIDS deaths in the postneonatal age group were compared with 1800 control infants.

RESULTS

Infants of mothers who smoked during pregnancy had a 4.09 (95% confidence interval [CI] = 3.28, 5.11) greater risk of death than infants of mothers who did not smoke. Infants of mothers who smoked postnatally also had an increased risk of SIDS compared with infants of nonsmokers and, furthermore, the risk increased with increasing levels of maternal smoking. Smoking by the father and other household members increased the risk (odds ratio [OR] = 2.41, 95% CI = 1.92, 3.02 and OR = 1.54, 95% CI = 1.20, 1.99, respectively). Smoking by the father increased the risk of SIDS if the mother smoked, but had no effect if she did not smoke. In analyses controlled for a wide range of potential confounders, smoking by the mother and father was still significantly associated with an increased risk of SIDS.

CONCLUSION

Passive tobacco smoking is causally related to SIDS.

Acute iodine ingestion increases intrathyroidal glutathione

In genetically predisposed individuals, autoimmune lymphocytic thyroiditis (LT) is potentiated by excess dietary iodine (I). There have been data which suggest that oxidative stress may have a role in iodine-induced LT. These in vivo studies were undertaken to examine the effect of iodine on intrathyroidal levels of the potent antioxidant glutathione (GSH) and see if the thyroids of LT-prone BB/Wor rats have aberrant GSH responses after iodine-loading. LT-prone BB/Wor, non LT-prone BB/Wor and Wistar rats were randomized to receive either 0.05% I (as Nal) or tap water. Thyroid and liver homogenates were assayed individually for GSH. Following the administration of 0.05% iodine water overnight, all of the animals demonstrated a rise in intrathyroidal GSH regardless of LT-proneness. To determine whether this was a dose-dependent response, Wis rats were randomized to receive tap, 0.0125%, 0.025%, 0.05%, or 0.075% I, overnight. Intrathyroidal GSH levels rose with increasing iodine concentrations peaking at 0.025% I. Hepatic GSH levels were unaltered by iodine treatment. Ten days of 0.05% I water did not result in any difference between the GSH levels of thyroids from treated and control rats. Frozen sections of the thyroids and livers from iodine-treated rats were compared to tap-water controls after staining with Mercury Orange for GSH and Schiff's reagent for evidence of lipid peroxidation. Iodine-treated thyroids had an apparent shift of GSH staining from the apical border to the cytoplasm. However, there was no Schiff's staining indicative of lipid peroxidation in the iodine-treated thyroids.(ABSTRACT TRUNCATED AT 250 WORDS)

Dummies and the sudden infant death syndrome

The association between dummy use and sudden infant death syndrome (SIDS) was investigated in 485 deaths due to SIDS in the postneonatal age group and compared with 1800 control infants. Parental interviews were completed in 87% of subjects. The prevalence of dummy use in New Zealand is low and varies within New Zealand. Dummy use in the two week period before death was less in cases of SIDS than in the last two weeks for controls (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.57 to 1.02). Use of a dummy in the last sleep for cases of SIDS or in the nominated sleep for controls was significantly less in cases than controls (OR 0.44, 95% CI 0.26 to 0.73). The OR changed very little after controlling for a wide range of potential confounders. It is concluded that dummy use may protect against SIDS, but this observation needs to be repeated before dummies can be recommended for this purpose. If dummy sucking is protective then it is one of several factors that may explain the higher mortality from SIDS in New Zealand than in other countries, and may also explain in part the regional variation within New Zealand.

Ethnic differences in mortality from sudden infant death syndrome in New Zealand

OBJECTIVES

To examine the factors which might explain the higher mortality from sudden infant death syndrome in Maori infants (7.4/1000 live births in 1986 compared with 3.6 in non-Maori children).

DESIGN

A large nationwide case control study.

SETTING

New Zealand. 485 infants who died of sudden infant death syndrome were compared with 1800 control infants. There were 229 Maori and 240 non-Maori cases of sudden infant death syndrome (16 cases unassigned) and 353 Maori and 1410 non-Maori controls (37 unassigned).

RESULTS

Maori infants had 3.81 times the risk (95% confidence interval 3.06 to 4.76) of sudden infant death syndrome compared with non-Maori infants. The risk factors for sudden infant death syndrome within groups were remarkably similar. When Maori and non-Maori controls were compared the prevalence of many of the known risk factors was higher in Maori infants. In particular, mothers were socioeconomically disadvantaged, younger, and more likely to smoke and their infants were of lower birth weight and more likely to share a bed with another person. Multivariate analysis controlling for potential confounders found that simply being Maori increased the risk of sudden infant death syndrome by only 1.37 (95% CI = 0.95 to 2.01), not statistically significantly different from 1. Population attributable risk was calculated for prone sleeping position, maternal smoking, not breast feeding, and infants sharing a bed with another person. In total these four risk factors accounted for 89% of deaths from sudden infant death syndrome in Maori infants and 79% in non-Maori infants.

CONCLUSION

The high rate of sudden infant death syndrome among Maori infants is based largely on the high prevalence in the Maori population of the major risk factors. Other risk factors, not related to ethnicity, probably explain remaining differences between Maori and non-Maori children.