Surgical management of rhinosinusitis for the allergist-immunologist

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease characterized by inflammation of the sinus, with or without nasal passage inflammation, occurring for more than 12 weeks at a time. CRS has historically been classified in 2 categories: CRS without nasal polyps or CRS with nasal polyps (25%-30% of cases). The mainstay of treatment for CRS with or without nasal polyps is medical management, and options may include a combination of saline irrigation, nasal steroids, allergy medications, antibiotics, oral steroids, and treatment with targeted monoclonal antibodies. Unfortunately, up to 60% of patents report symptoms refractory to maximal medical therapy. As such, a combined approach of surgery and medical therapy may be offered. Endoscopic sinus surgery for CRS is approached in a stepwise fashion, ranging from the simplest technique, such as polyp removal, to more expanded approaches that open the paranasal sinuses and allow gravity-dependent drainage. This review article provides a review and in-depth explanation of various surgical approaches for CRS, including the indications, techniques, and respective outcomes for each one.

Oral corticosteroid use and the risk of developing avascular necrosis; a large retrospective review

INTRODUCTION

The risk of adverse events, specifically avascular necrosis (AVN), associated with corticosteroid use is not well reported. The aim of this study was to evaluate the prevalence of AVN among patients with prior oral corticosteroid administration.

METHODS

An institutional database query recognized 113,734 adult patients with oral corticosteroid administration between 2006 and May 2017. A temporal query performed on this cohort determined that 789 had a diagnosis of AVN following oral corticosteroids. A retrospective review was performed on this cohort. Data collected included demographics, co-morbidities, date of initial oral corticosteroid exposure, and time-to-diagnosis of AVN. Records without radiographic confirmation of AVN were excluded from analysis. Patients with cumulative lifetime dosages greater than 10,000 mg prednisone were excluded from analysis.

RESULTS

789 patients with oral corticosteroid use prior to diagnosis of AVN were identified. 572 patients were excluded due to insufficient documentation of oral corticosteroid dosage, no radiographic evidence supporting the diagnosis of AVN, insufficient data confirming the temporal relationship between oral corticosteroids and AVN, and/or a cumulative dosing of > 10,000 mg prednisone. This left 217 patients included in the analysis. The mean duration of use prior to diagnosis of AVN was 219 (± 374) days and mean cumulative dose was 3314 (± 2908) mg prednisone-equivalents. Mean time between diagnosis of AVN and onset of pathologic fracture was 379 (± 1046) days.

CONCLUSION

For patients receiving low cumulative doses of oral corticosteroids, corticosteroids pose a small risk of development of AVN. More studies are required to better characterize risk. This article is protected by copyright. All rights reserved.

Objective sleep measures after endoscopic sinus surgery in patients with chronic rhinosinusitis

BACKGROUND

Poor sleep quality is common in chronic rhinosinusitis (CRS). Prior studies have demonstrated improvements in patient-reported measures of sleep quality following endoscopic sinus surgery (ESS). The purpose of this study was to evaluate the effect of ESS on objective sleep parameters and identify any associations between specific objective measures and patient characteristics, comorbidities, and patient-reported outcome measures (PROMs).

METHODS

Adults with CRS undergoing ESS were prospectively enrolled from 4 centers across North America. Any subject previously diagnosed with a known primary sleep disorder was excluded. Objective sleep indices were recorded using a portable sleep diagnostic device preoperatively and postoperatively. Patient-reported outcome instruments were completed including the Pittsburgh Sleep Quality Index (PSQI) and the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

Thirty-six patients (mean age 47 years, 56% male) completed baseline and postoperative sleep studies with mean ± standard deviation (SD) follow-up 9.6 ± 7.7 months. Mean PSQI and SNOT-22 before and after ESS was 10.2 ± 3.9 vs 7.8 ± 4.4 (p = 0.001); and 54.6 ± 14.6 vs 28.5 ± 15.3 (p < 0.001), respectively. Total sleep time, sleep latency, and awakenings after sleep onset did not change following ESS (all p > 0.5) despite improvements in PSQI and SNOT-22. Changes in PSQI did not correlate with comorbidities or objective sleep indices (all p > 0.1).

CONCLUSION

In this multicenter prospective cohort, objective sleep indices were not improved following ESS for CRS despite significant improvements in patient-reported sleep quality and CRS-specific QOL.

Evaluating the Relationship Between Olfactory Function and Loneliness in Community-Dwelling Individuals: A Cross-sectional Study

BACKGROUND

Olfactory dysfunction (OD) has been reported to impact social interactions. However, the relationship between OD and loneliness has received little attention. The purpose of this study was to determine the association between OD and loneliness, controlling for patient factors.

METHODS

Subjects without otolaryngic complaints were enrolled and olfactory function was assessed using: Sniffin' Sticks test to measure threshold, discrimination and identification (TDI), Questionnaire of Olfactory Disorders Negative Statements (QOD-NS) and 9 - item Olfactory-Visual Analogue Scale (VAS). Loneliness was assessed using the De Jong Gierveld (DJG) and University of California Los Angeles (UCLA) loneliness scales. Bivariate analysis was performed followed by regression analysis, controlling for confounders.

RESULTS

In total, 221 subjects were included with a mean age of 50.5 years (range 20 to 93), 133 (60.2%) females and 161 (72.9%) white. Mean TDI score was 29.3 (7.0) and 49.5% of the cohort was dysosmic. Using DJG, 36.4% of the cohort were classified as lonely, whereas 35.0% were lonely using UCLA. Olfactory measures were significantly associated with DJG, including TDI (β = -0.03, p = 0.050), olfactory discrimination (β = -0.111, p = 0.005), QOD-NS (β = 0.058, p < 0.001) and olfactory-VAS (β = 0.032, p < 0.001). UCLA scores were significantly associated with QOD-NS (PR 1.061 [CI 1.018-1.107], p = 0.005) and olfactory-VAS scores (PR 1.027, [CI 1.007-1.049], p = 0.009). After controlling for confounders, the association between DJG and olfactory discrimination, as well as DJG and olfactory-VAS remained significant.

CONCLUSIONS

In this community-based sample of older adults, both OD and loneliness were common. Those subjects with worse olfactory function were more likely to report loneliness. Further research is necessary to establish causality, as well as explore the role of depression.

Disease control after surgery for chronic rhinosinusitis: prospective, multi-institutional validation of the Sinus Control Test

BACKGROUND

The Sinus Control Test (SCT) is a 4-question, patient-reported questionnaire that assesses disease control in chronic rhinosinusitis (CRS). This prospective, multicenter study examines SCT outcomes following endoscopic sinus surgery (ESS), further validating its use as a control instrument for CRS.

METHODS

Adults with CRS undergoing ESS were prospectively enrolled from 5 centers across North America. The SCT was administered at baseline and once 6 months after surgery. Quality of life and disease burden were evaluated using the 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy endoscopy scores. Linear regression was used to determine whether specific demographic, comorbidity, or disease severity measures were independently associated with changes in SCT scores postoperatively.

RESULTS

A total of 218 patients, 111 females (50.9%) and 107 males (49.1%), were enrolled, with mean ± standard deviation age of 50.1 ± 15.6 years. Mean SCT score improved from 8.9 ± 3.5 to 4.3 ± 3.7 postoperatively (p < 0.001). Preoperatively, 21.6% were uncontrolled, 71.5% partially controlled, and 6.9% controlled. Postoperatively, 6.0% were uncontrolled, 42.6% partially controlled, and 51.4% controlled (p < 0.001). Change in SCT score correlated independently with change in SNOT-22 (r = 0.500, p < 0.001) and endoscopy scores (r = 0.310, p < 0.001). Endoscopy scores did not correlate with control status among patients with CRS without nasal polyposis (CRSsNP) nor between uncontrolled and partially controlled patients. Demographics and comorbidities were not associated with changes in SCT.

CONCLUSION

Improvement in disease control following ESS as measured by the SCT correlated with improvements in SNOT-22 and endoscopy scores. The SCT is an easily administered instrument that provides information complementary to existing patient-reported and objective measures of disease severity.

Utility of Second-Look Endoscopy with Debridement After Pediatric Functional Endoscopic Sinus Surgery in Patients with Cystic Fibrosis

OBJECTIVES

To determine the utility of Second-look endoscopy with debridement (SLED) after functional endoscopic sinus surgery (ESS) in pediatric cystic fibrosis (CF) patients. To compare outcomes in pediatric CF patients undergoing sinus surgery for chronic sinusitis with or without SLED. To describe findings present at the time of SLED.

METHODS

Retrospective chart review of 61 ESS procedures performed at a tertiary care pediatric center from 2013 to 2016. Data collected included demographics, SLED findings, and 6-month pre-/postoperative disease specific outcomes including incidence of sinonasal and pulmonary exacerbations and revisions.

RESULTS

Sixty-one cases were reviewed. SLED was performed in 38 cases on average 22.4 days postoperatively. Average preoperative Lund-Mackay score was 14.9 and 14.8 among patients undergoing ESS with and without SLED, respectively. Pre-/postoperative intranasal steroid use and extent of surgery performed was similar among all patients. At the time of SLED, rates of synechiae, polyps and maxillary antrostomy obstruction were 26.3%, 23.7%, and 7.9%, respectively. The incidence and number of days to onset of postoperative sinonasal exacerbations requiring antibiotic therapy within 6 months of ESS were 1.0 (SD 1.0) and 85 days (SD 45.7); and 1.3 (SD 1.0) and 80.4 days (SD 40.5) for patients undergoing ESS with and without SLED, respectively (P value .33). The number of days to first pulmonary exacerbation was 113.9 (SD 45.5) and 47.4 (SD 34.1) among SLED and non-SLED patients, respectively (P value .01). No significant difference was observed in revision rates and time to revision ESS (30% and overall average 1.4 years, respectively).

CONCLUSION

The utility of SLED among pediatric CF patients remains unclear. While debridement did not have a significant impact on sinonasal exacerbations or revision rates, pulmonary exacerbations for patients undergoing SLED were delayed. Further studies are needed to clarify the impact of SLED.

Odontogenic sinusitis: A review of the current literature

Objectives

To present current literature on the topic of odontogenic sinusitis.

Data Source

PubMed literature search for odontogenic sinusitis.

Results

Odontogenic sinusitis is an inflammatory condition of the paranasal sinuses that is the result of dental pathology, most often resulting from prior dentoalveolar procedures, infections of maxillary dentition, or maxillary dental trauma. Infections are often polymicrobial with an anaerobe-predominant microbiome requiring special considerations for antimicrobial therapy. Medical management and treatment of the underlying dental pathology remains a critical initial step in the treatment of odontogenic sinusitis, however recent literature suggests that a significant portion of patients may require endoscopic sinus surgery for successful disease resolution.

Conclusions

This review describes the essential epidemiological and etiological factors, relevant clinical findings and diagnostic modalities, microbiologic and antimicrobial considerations, as well as the medical and surgical treatment approaches commonly utilized for the management of odontogenic sinusitis.

Level of Evidence

NA.

Local iontophoretic administration of cytotoxic therapies to solid tumors

Parenteral and oral routes have been the traditional methods of administering cytotoxic agents to cancer patients. Unfortunately, the maximum potential effect of these cytotoxic agents has been limited because of systemic toxicity and poor tumor perfusion. In an attempt to improve the efficacy of cytotoxic agents while mitigating their side effects, we have developed modalities for the localized iontophoretic delivery of cytotoxic agents. These iontophoretic devices were designed to be implanted proximal to the tumor with external control of power and drug flow. Three distinct orthotopic mouse models of cancer and a canine model were evaluated for device efficacy and toxicity. Orthotopic patient-derived pancreatic cancer xenografts treated biweekly with gemcitabine via the device for 7 weeks experienced a mean log2 fold change in tumor volume of -0.8 compared to a mean log2 fold change in tumor volume of 1.1 for intravenous (IV) gemcitabine, 3.0 for IV saline, and 2.6 for device saline groups. The weekly coadministration of systemic cisplatin therapy and transdermal device cisplatin therapy significantly increased tumor growth inhibition and doubled the survival in two aggressive orthotopic models of breast cancer. The addition of radiotherapy to this treatment further extended survival. Device delivery of gemcitabine in dogs resulted in more than 7-fold difference in local drug concentrations and 25-fold lower systemic drug levels than the IV treatment. Overall, these devices have potential paradigm shifting implications for the treatment of pancreatic, breast, and other solid tumors.

Endoscopic endonasal transclival approaches: case series and outcomes for different clival regions

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.

Preventing Fetal Alcohol Effects: Effectiveness of a Demonstration Project

The Pregnancy and Health Program (PHP) was established in 1979 to develop effective methods of intervening in maternal alcohol abuse during pregnancy in a metropolitan US community. Services provided over a two-year period included public and professional education, an alcohol and pregnancy information and crisis telephone line, screening for alcohol problems in selected prenatal clinics, treatment and support for women concerned about their drinking during a pregnancy, and help for children possibly affected in utero by alcohol. Evaluation of PHP's educational programmes showed significant increases in awareness and knowledge of the risks associated with drinking during pregnancy, among both the public and health professionals in the community. Information was provided by telephone to over 2400 persons, including one in every 44 pregnant women in the community. A total of 304 pregnant women were personally given information as well as treatment for alcohol problems when necessary. For women seen personally, a significant decrement in drinking was associated with programme entry, which was in turn related to healthier infants at birth. This two-year programme established that intervention in pregnancy drinking is essential and feasible. Screening techniques developed by PHP simplify detection of excessive drinking. Education coupled with effective screening and referral to treatment when needed make reduction of fetal alcohol effects a goal within reach for all communities.

Preterm birth rates in Avon County, England, and urban Ukraine

OBJECTIVE

We compared rates of total and spontaneous preterm birth in Avon County, England and urban Ukraine to explore whether adverse conditions in the former eastern bloc influenced the preterm rate.

STUDY DESIGN

Women who had last menstrual period (LMP) in a specified time window were recruited from geographically defined areas. Data were gathered between 1992 and 1995, using maternal questionnaires and medical record abstraction, with comparable methods in both sites insofar as possible. There were 13731 births in Avon and 3087 in Ukraine. Rates of total and spontaneous preterm births were compared, taking account of maternal characteristics and other relevant variables.

RESULTS

The total preterm birth rates were similar (5.9%, Ukraine; 5.5%, Avon) but the spontaneous preterm rate was about 60% higher in Ukraine (5.0% versus 3.1%). Maternal characteristics and measurement differences did not explain the discrepancy.

CONCLUSION

The difference in the spontaneous preterm rates may reflect differences in obstetrical management resulting from shortages of medical supplies and equipment in Ukraine.

Survival after proton-beam irradiation of uveal melanomas

PURPOSE

To evaluate the independent prognostic factors for survival, metastasis, local recurrence, and enucleation in patients who had undergone proton-beam therapy for posterior uveal melanomas.

DESIGN

Interventional case series.

METHODS

In this retrospective study, 224 consecutive incident cases were treated at the Biomedical Cyclotron Centre (Nice, France) from June 1991 to December 1997. Overall, metastasis-free, local recurrence-free, and enucleation-free survival rates were calculated according to the Kaplan-Meier method using the log-rank test. The multivariate prognostic analysis was performed using the Cox proportional hazards model.

RESULTS

The 5-year overall survival rate was 78.1% (SE: 3.7%). A largest basal tumor diameter (LTD) below 10 mm and female sex were independently associated with a better prognosis. The 5-year metastasis-free survival rate was 75.6% (SE: 3.6%). Only an LTD above 10 mm and ciliary body involvement were independently associated with metastasis. Ten patients (4.5%) had a local recurrence, which was correlated with the risk of metastasis (P =.045). The 5-year enucleation-free survival rate was 69.6% (SE: 4.0%). Once again, an LTD below 10 mm and female sex were predictive of a better prognosis.

CONCLUSION

Our results with proton-beam therapy correspond to those reported in the literature. This treatment strategy is safe and yields predictably good results. In addition to the two independent prognostic factors for survival and metastasis, namely LTD and ciliary body involvement, sex also had a significant impact in our case series, but the clinical relevance of this finding is unknown.

Hospital admissions during pregnancy in two urban areas of Ukraine

Hospital admissions are generally regarded as a marker of severe pregnancy complications, and a low ratio of antenatal admissions to deliveries is considered an indicator of maternal-fetal well-being. We investigated the reasons for hospital admissions in a sample of deliveries from Ukraine, a country of the former eastern bloc. All hospitalisations were traced among 3099 women who delivered live singletons of at least 20 weeks gestation in two urban areas of Ukraine and data were abstracted from their medical records. More than a third of the women were admitted to hospital during their pregnancy, and 91% of the admissions were for a pregnancy complication, primarily threatened abortion or early labour. Median length of stay for all admissions was 12 days. The ratio of admissions to deliveries was 52 per 100. The Ukrainian ratio of hospitalisations to deliveries is notably higher than any that have been published in studies from the United States and Australia, reflecting patterns of care that stress hospital-based treatment. This high ratio does not necessarily mean that Ukrainian women are sicker, although that may be the case. The comparison of hospitalisation to delivery ratios is meaningful only when other factors, such as resources, patterns of care, costs and access, are taken into account.

Risk factors for spontaneous preterm birth in two urban areas of Ukraine

The economic, social and health problems faced by former eastern bloc countries after the demise of the Soviet Union are unique in the recent history of Europe. We conducted a study in two urban areas of Ukraine, asking if the traditional predictors of preterm delivery continue to be associated with risk under these conditions. Subjects were pregnant women with last menstrual period (LMP) between 25 December 1992 and 23 July 1994. Self-completed questionnaires and the medical record provided data. We compared 137 spontaneous preterm deliveries with 2,886 full-term births, using all established risk factors for which we had data. Maternal age was the variable most strongly related to preterm birth. Being 18 or less had an odds ratio (OR) of 3.7; being 30+ had an OR of 2.5 relative to the reference group of age 25-29. Placental complications and pre-existing hypertension had ORs of 2.7 and 2.3, respectively, but the confidence interval included 1.0. Low net pregnancy weight gain (less than 10 kg) was significantly associated with preterm birth, but the rate of net weight gain was not. Marital status and educational category were only weakly related. We conclude that although Ukraine faced serious difficulties during its transition to a market economy, these problems did not generally alter the outcome of pregnancy in our sample when the classic risk factors for preterm delivery were present.

Polycyclic aromatic hydrocarbons in placenta

Concentrations of chrysene, benz [a] anthracene, benzo [a]-pyrene, benzo [b] fluoranthene, indeno [1,2,3-c,d] pyrene, dibenz [a,h] anthracene, and benzo [g,h,i] perylene were measured in placentas from 200 women from two cities in Ukraine, Kyiv and Dniprodzerzhinsk. The participants had no special exposures and were chosen from among subjects in an ongoing study of reproductive health. All seven of the polycyclic aromatic hydrocarbons (PAHs) were found in all placentas, with the sole exception of benzo [a] pyrene in one placenta. Chrysene was present at the highest concentrations, with median 1.38 ng/g dry weight. Dibenz [a,h] anthracene and benzo [g,h,i] perylene had the lowest concentrations; each had median 0.73 ng/g dry weight. Concentrations in Kyiv were slightly higher than those in Dniprodzerzhinsk, but the difference was significant only for dibenz [a,h] anthracene. Dibenz [a,h] anthracene and benzo [g,h,i] perylene increased significantly with maternal body mass index, but other PAHs showed no such pattern. Placentas from deliveries in autumn or winter had slightly but not significantly higher concentrations. Concentrations were not related to maternal age. There were too few smokers in the sample for meaningful evaluation. No associations were seen between any of the placental PAH concentrations and birth weight of the infant.

Concentrations of arsenic, cadmium, copper, lead, mercury, and zinc in human placentas from two cities in Ukraine

Ukraine is a highly industrialized country with major environmental problems and deteriorating reproductive health. Heavy metals are known reproductive toxins; a study was undertaken to determine whether they were present at sufficient concentrations to be playing a major role in these health problems. Placental concentrations of arsenic, cadmium, copper, lead, mercury, and zinc were determined in 200 women from the general population of two urban areas of Ukraine, Kyiv and Dniprodzerzhinsk. Arsenic was detected in only 5% of the samples, lead in 22%, and mercury in 28%. Cadmium was detected in almost all samples, with a median of 5.2 ng/g. Concentrations of lead, mercury, and cadmium were low compared to those reported elsewhere, while zinc and copper concentrations were comparable.

Preterm birth in two urban areas of Ukraine

OBJECTIVE

To determine whether the preterm birth rate was elevated in two urban areas of Ukraine, a former eastern bloc country that experienced serious economic, social, and health problems during its transition from a socialist republic.

METHODS

We identified every pregnancy in a defined period in two urban sites where a separate study of pregnancy and childhood was being conducted. We obtained gestational age and vital status at delivery for each. Information about onset of labor and conduct of delivery was available for the subgroup enrolled in the collaborating study.

RESULTS

Among 17,137 pregnancies, all but 6774 were terminated voluntarily. Among the continuing pregnancies, the preterm birth rate was 6.6% for live-born singletons of 20 or more weeks' gestation. Only 12% of preterm births involved medical intervention, the rest were idiopathic. The preterm birth rate was higher than in Europe (4.0% to 5.4%) and Canada (5.9%) but lower than for whites in the United States (8.4%).

CONCLUSION

Live-born preterm birth rates are influenced by whether infants survive to be included in calculations. The high fetal mortality rate in Ukraine causes many preterm births to be excluded, thus lowering the rate. Frequent pregnancy termination and lack of ultrasound dating in Ukraine also might cause the preterm birth rate to be lower. Preterm birth rates, especially among live-born infants, are difficult to interpret and treacherous to compare across nations. Survival of the fetus and its health and development at birth are better indicators of reproductive outcome.

Outcomes of 17,137 pregnancies in 2 urban areas of Ukraine

OBJECTIVES

Frequent terminations of pregnancy and high rates of fetal loss have been reported, but not confirmed, in the former eastern bloc. A census of pregnancies in Ukraine, a former eastern bloc country, was conducted to determine the rates of these events.

METHODS

All pregnancies registered in 2 urban areas were enumerated. During a 19-month period between 1992 and 1994, 17,137 pregnancies and their outcomes were recorded.

RESULTS

Sixty percent of the pregnancies were voluntarily terminated, generally before the 13th week. In pregnancies delivered at 20+ weeks, fetal mortality was 29 per 1000, nearly 5 times the rate among Whites in the United States. There was a greater proportion of very early deliveries (20-27 weeks) in Ukraine, as well as higher death rates at all gestational ages. Perinatal mortality was estimated to be 35 per 1000, about 3 times the US rate.

CONCLUSIONS

This is believed to be the first study in the former eastern bloc to ascertain all of the clinically recognized pregnancies in a specified period and to determine their outcomes. The data document elevated reproductive risks in a former Soviet state.

Polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, and coplanar polychlorinated biphenyls in breast milk from two cities in Ukraine

Substantial environmental pollution has been alleged in Ukraine, but little information is available to allow an assessment of the possible impact on humans. To help remedy this lack of information, it was of interest to investigate whether certain polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), or coplanar polychlorinated biphenyls (PCBs) were elevated in people from Ukraine. Samples of breast milk were obtained from 200 women from the cities of Kyiv and Dniprodzerzhinsk; Kyiv is the capital and Dniprodzerzhinsk is a highly industrialized city. The samples were combined into four pools by city and age, and analyzed for 7 PCDDs, 10 PCDFs, and 2 coplanar PCBs (126 and 169). The total of the measured PCDDs, expressed as toxic equivalent, ranged from 5.1 to 7.6 pg/g lipid; for PCDFs from 3.6 to 5.2, and for PCBs from 11 to 18 pg/g lipid. Results from the two cities were similar; older women had slightly higher concentrations than did younger women. Levels of these compounds seen in Ukraine were similar to or lower than those seen in other recent studies from European and Asian countries.

Levels of lipid peroxides in uncomplicated pregnancy: a review of the literature

The literature on lipid peroxide levels in uncomplicated pregnancy is limited, but some reasonable conclusions are possible. Despite the lack of precision in the predominant measure of lipid oxidation, there is agreement across a large number of studies that the level of lipid peroxides in blood is generally higher in pregnant women than in nonpregnant women. During gestation, elevations appear by the second trimester and may taper off later in gestation, decreasing further after delivery. Lipid peroxides also are produced in placenta, but their pattern of change over the course of pregnancy is unclear. Lipid peroxides are important because their uncontrolled production can result in oxidative stress, with significant damage to cell integrity. There is a growing literature that associates oxidative stress with preeclampsia, a major cause of maternal and fetal morbidity. The higher levels of lipid peroxides seen in blood and the production of lipid peroxides in the placenta, even in uncomplicated pregnancies, make new baseline studies a priority. These studies should include measurements of lipids and blood volume, because they can influence marker values, with sensitive and specific measures of lipid peroxidation made at various points of gestation. From our review of the existing literature we conclude that the importance of oxidative stress in reproduction is just beginning to be appreciated and studied.

Organochlorines in breast milk from two cities in Ukraine

Reports of environmental problems in the former Soviet Union, including excess use of pesticides, have led to concerns about high levels of contamination in humans, but little information is available to assess whether these concerns are warranted. Samples of breast milk from 197 women from two cities in Ukraine were analyzed for p,p'-DDT, p,p'-DDE, endrin, dieldrin, heptachlor epoxide, trans-nonachlor, oxychlordane, hexachlorobenzene, ss-hexachlorocyclohexane (HCH), and 18 polychlorinated biphenyl congeners, and results were compared to previous reports from Europe. The median ss-HCH concentration was 731 ng/g milk fat, which is higher than other reports from Europe but lower than reports from other parts of the world. The median DDE concentration was 2,457 ng/g milk fat, which is higher than most but not all other reports from Europe. Concentrations of other chemicals were comparable to or lower than other reports from Europe. Concentrations from the city of Kyiv were generally lower than those from Dniprodzerzhinsk, but the magnitudes of these differences were modest.

Variability of lipid hydroperoxides in pregnant and nonpregnant women

Lipid peroxidation is thought to be important in numerous disease states, including pregnancy complications. Study of its role requires markers, but the variability of available markers in non-diseased populations has not been well-characterized. We examined the variability over time of blood lipid hydroperoxides, as measured by iodometric analysis, in 49 healthy young women, 21 nonpregnant and 28 pregnant. Lipid hydroperoxides from the same woman were very similar from one day to the next but were less stable over periods of a month or more. The correlation between measurements on consecutive days was 0.98; the correlation between measurements a month or more apart was 0.11. Variability over time was not attributable to seasonal effects or, among the pregnant women, to differences over the course of pregnancy. Knowledge of the variability of this and other markers of oxidative damage enables the development of appropriate study designs.

Public health in central and eastern Europe and the role of environmental pollution

The central and eastern European countries that composed the former Eastern Bloc have experienced an alarming decline in public health since the dissolution of the Soviet Union. Death rates have increased in most age groups. Life expectancy, especially among males, has decreased in many countries; in Russia, male life expectancy dropped by six years between 1989 and 1994. By 2020, these countries are projected to have smaller increases in life expectancy than any other geographic region. The conditions responsible for the excess mortality are cardiovascular disease, cancer, and injuries among adults. The major factors in the sharp increase are poverty, social disintegration, and crime, overlaid on historically high rates of smoking, alcohol use, and psychosocial stress. Environmental pollution, although common and sometimes severe in the former Eastern Bloc, is another, albeit not the chief, cause of the sharp decline in public health since 1989.

Effect of paternal alcohol consumption before conception on infant birth weight. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

Previous studies of paternal drinking and fetal growth in both animals and human have produced conflicting results. We evaluated the association between paternal drinking before conception and infant birth weight in a cohort of 9,845 liveborn singleton infant born to couples who participated in the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC), ALSPAC is a population-based cohort study in which women and their partners completed several self-administered questionnaires over the course of pregnancy. Of participating male partners, 20% were reportedly daily drinkers before conception, and 8% were considered moderately heavy or very heavy drinkers. Because maternal drinking is highly correlated with paternal, the analyses were stratified by maternal drinking in early pregnancy. We also adjusted for confounders and known predictors of birth weight. For all three maternal drinking strata, all adjusted mean differences in birth weight across levels of paternal drinking were similar, and all had confidence intervals that included zero. These findings persisted even after adjustment for other covariates and after stratification by parental smoking, race, and education. The size of the ALSPAC cohort, the large number of heavy drinkers, and the availability of data from the fathers themselves support the conclusion that paternal drinking before conception is not an important predictor of infant birth weight in humans.

Postterm delivery: a challenge for epidemiologic research

About 5% of babies are born postterm (that is, delivered after 42 completed weeks of gestation). Postterm infants experience more morbidity and mortality than term infants, prompting routine (and expensive) antenatal testing and active management of postterm pregnancies. This article reviews the epidemiology of postterm delivery. A few congenital conditions associated with disruption of the fetal-pituitary-adrenal axis as well as a rare maternal enzyme deficiency have long been identified with postterm delivery. In recent literature, environmental pollution, diet, and pharmaceutical agents have been associated with postterm birth. Very little systematic research has focused on identifying risk factors for this poorly understood birth outcome.

Birthweight of term infants and maternal occupation in a prospective cohort of pregnant women. The ALSPAC Study Team

OBJECTIVE

To study the relation between birthweight of term infants and maternal occupation.

METHODS

Information on job titles since the age of 16, and sociodemographic and other lifestyle factors were obtained by means of questionnaires as part of the Avon longitudinal study of pregnancy and childhood (ALSPAC), from a cohort of 14,000 pregnant women. The British 1990 standard occupational classification was used to code jobs within nine major job groups.

RESULTS

For 9282 women who delivered term infants and reported a job for the relevant period, there was a significant difference in mean birthweight among the nine major job groups. A 148 g difference was found between the mean birthweight of infants born to women with professional occupations and those with plant and machine operative jobs. Multiple regression analysis adjusted for sex of infant, parity, maternal height, smoking, caffeine consumption, and race. After adjustment the maternal job was no longer significantly associated with birthweight.

CONCLUSION

Despite the absence of a significant association between birthweight and job after adjustment, there were several findings which agreed with publications on maternal occupation and pregnancy outcome. The major job groups with the lowest birthweights included the following jobs; metal forming or welding, electric or electronic work, jobs in the textile trade, and assembling and working with equipment (mobile and stationary). The lack of an association may indicate that the study was of insufficient power to detect a small difference; it may indicate the presence of confounding variables that were not adjusted for or it may indicate that no association exists.

Incidence of fetal alcohol syndrome and prevalence of alcohol-related neurodevelopmental disorder

We critique published incidences for fetal alcohol syndrome (FAS) and present new estimates of the incidence of FAS and the prevalence of alcohol-related neurodevelopmental disorder (ARND). We first review criteria necessary for valid estimation of FAS incidence. Estimates for three population-based studies that best meet these criteria are reported with adjustment for underascertainment of highly exposed cases. As a result, in 1975 in Seattle, the incidence of FAS can be estimated as at least 2.8/1000 live births, and for 1979-81 in Cleveland, approximately 4.6/1,000. In Roubaix, France (for data covering periods from 1977-1990), the rate is between 1.3 and 4.8/1,000, depending on the severity of effects used as diagnostic criteria. Utilizing the longitudinal neurobehavioral database of the Seattle study, we propose an operationalization of the Institute of Medicine's recent definition of ARND and estimate its prevalence in Seattle for the period 1975-1981. The combined rate of FAS and ARND is thus estimated to be at least 9.1/1,000. This conservative rate--nearly one in every 100 live births--confirms the perception of many health professionals that fetal alcohol exposure is a serious problem.

Maternal exposure to exogenous nitrogen compounds and complications of pregnancy

Increased lipid peroxidation and reduced antioxidant activity have been reported with pregnancy complications. Given that exogenous oxidants stimulate formation of lipid peroxides, the authors investigated the relationship between exposure to nitrogen-oxidizing species and pregnancy complications and took into account markers of antioxidant and oxidant status. The study sample included pregnant women who were from an area polluted by oxidized nitrogen compounds. Methemoglobin, a biomarker of individual exposure, was determined, as were measures of oxidant/antioxidant status, including glutathione balance and lipid peroxide levels. Only 10 women experienced normal pregnancies. The most common complications were anemia (67%), threatened abortion/premature labor (33%), and signs of preeclampsia (23%). Methemoglobin was elevated significantly in all three conditions, compared with normal pregnancies. Reduced:total glutathione decreased, whereas lipid peroxide levels increased. These results suggest that maternal exposure to environmental oxidants can increase the risk of pregnancy complications through stimulation of the formation of cell-damaging lipid peroxides and from a decrease in maternal antioxidant reserves.

Agreement between self and partner reports of paternal drinking and smoking. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

BACKGROUND

We examined agreement between self and proxy reports of paternal drinking and smoking behaviour using data collected as part of the prospective, population-based Avon (England) Longitudinal Study of Pregnancy and Childhood.

METHODS

Information on the smoking and drinking habits of pregnant women's male partners was obtained through self-administered questionnaires completed by pregnant participants and by their partners. For dichotomous indicators (e.g. smoker versus non-smoker), we evaluated self/proxy agreement by calculating Kappa coefficients and per cent agreement. For ordinal measures of smoking and drinking amounts, we calculated per cent perfect agreement, per cent agreement within one category, and Spearman correlation coefficients. Data from 8414 respondent pairs were included in the analyses.

RESULTS

Men's and women's reports of paternal smoking and drinking status were in nearly complete agreement (95% and 98%, respectively). For analyses of smoking and drinking amounts, agreement within one category remained high (90% and 98% for smoking and drinking, respectively), but perfect agreement on amount was somewhat lower (81% and 71%, respectively). Per cent perfect agreement on smoking amount was especially low (50%) when non-smokers were excluded. When couples' reports were not in perfect agreement, women tended to report lower amounts of smoking and drinking for their partners compared to the men's self reports.

CONCLUSIONS

Our results suggest that women's proxy reports of their partners' drinking and smoking status can be used with considerable confidence in reproductive epidemiological studies when the enrollment of both women and men as participants is infeasible for financial or logistical reasons. Caution is warranted, however, when proxy reports are used for more detailed information on smoking and drinking amounts.

Is there an association between preconception paternal x-ray exposure and birth outcome? The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

Diagnostic x-rays are performed commonly on men of reproductive age, yet little is known about the potential effects of these x-rays on the future unborn children of such men. This study examines the possibility that preconception diagnostic x-ray studies of fathers may adversely effect their newborns. The authors used prospectively collected data from the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC) for 7,678 birth records for women who gave birth in the County of Avon, England, in 1991-1992. Birth weight, gestational age, and fetal growth of infants whose fathers received diagnostic x-ray examinations likely to deliver significant gonadal doses within one year prior to conception were compared with infants whose fathers did not receive such x-rays. The mean birth weight of babies of exposed fathers was 3,358 g compared with a mean of 3,437 g in the unexposed group (p = 0.055). A similar difference was noted for intrauterine growth, 3,374 g exposed versus 3,437 g unexposed (p = 0.078). The downward trend in birth weight and fetal growth (birth weight adjusted for gestational age) persisted despite control for infants' sex and important parental variables such as age, height, race, education, occupational exposure, parity, and maternal smoking. Because medical x-rays are the largest controllable source of man-made ionizing radiation, more detailed study of the potential effect of paternal x-irradiation on progeny seems justified.

The effect of maternal drinking before conception and in early pregnancy on infant birthweight. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

We examined the association of maternal drinking before and during early pregnancy on infant birthweight, using data collected from a population-based cohort in Avon Country, England. Participants completed several self-administered questionnaires during their index pregnancy. Our analysis included 10,539 women who provided drinking data and delivered a liveborn singleton child. Infants born to women who reported drinking one to two drinks daily with at least one binge, or three or more drinks daily with or without binges, had an adjusted mean birthweight approximately 150 gm less than that of infants whose mothers reported abstaining during (but not before) pregnancy. Mean birthweights were similar for infants of prepregnancy drinkers who drank weekly in early pregnancy, less than weekly, or not at all.

Fetal growth retardation in sudden infant death syndrome (SIDS) babies and their siblings

To evaluate the intrauterine growth potential of infants that die from sudden infant death syndrome (SIDS), the authors compared SIDS infants with their surviving siblings. The SIDS sibships themselves were also compared with sibships where all infants survived. Data from the population-based Medical Birth Registry of Norway, with 1.3 million births during 1967-1988, were used. From the birth cohorts, 1,984 SIDS cases were identified. All births were linked into sibships. The mean birth weight and gestational age were calculated across sibships of different sizes for first to fourth birth order. In a further analysis, birth weights were standardized to adjust for gestational age. Mothers of SIDS infants give birth to smaller babies in general. SIDS infants weighed, on average, 85 g less at birth than their siblings and 164 g less compared with babies in nonaffected sibships. When birth weights were standardized for gestational age, most of the weight difference between SIDS infants and siblings was due to a shorter gestational age of SIDS infants, while the difference between surviving siblings of SIDS infants and births from nonaffected sibships remained. All births in sibships with a SIDS infant were intrauterine growth retarded. This may reflect factors that contribute to SIDS risk (such as maternal smoking). The factors that contribute to shorter gestational age and further slowing of growth in the SIDS infants may specifically influence the SIDS infant and not its siblings.

Maternal smoking during lactation: relation to infant size at one year of age

This study was conducted to test the hypothesis that breast-fed infants of smokers are smaller in size at 1 year of age than breast-fed infants of nonsmokers. Three groups of infants were selected from all singletons born to women who were seen for prenatal care in their 6th month of pregnancy at a health maintenance organization in Seattle, Washington, between January 1982 and April 1983. Breast-fed infants of smokers (n = 74) were compared with breast-fed infants of nonsmokers (n = 195) and with bottle-fed infants of smokers (n = 64). Mothers were interviewed at 1 and 3 months after delivery; both the mother and the infant were seen at 1 year. Among breast feeders, smokers' infants were twice as likely as nonsmokers' infants to have body mass more than 1 standard deviation above the mean (relative risk = 2.04, 95% confidence interval 1.15-3.61). This relation persisted after control for gestational age and weight at birth, length of lactation, mother's size and diet, exposure to other drugs in breast milk, and all other variables measured in this study. Every 10 cigarettes smoked while breast feeding predicted an additional 3% infant body mass at 1 year. In summary, breast-fed infants of smokers in this study gained more weight after birth than the other two groups; at 1 year of age, they were heavier and had significantly higher body mass. Reasons for this paradoxical finding are explored.

Complications of pregnancy in relation to maternal lipid peroxides, glutathione, and exposure to metals

Lipid peroxides, glutathione, and metals (lead, cadmium, and arsenic) were measured in pregnant women residing in the vicinity of a copper smelter. A diagnosis of pregnancy complications experienced by each woman was made on the basis of interview and clinical record. Patients were assigned to groups of normal or pathologic pregnancies (threatened spontaneous abortion, toxemia, and anemia) according to this diagnosis. Biochemical changes suggestive of increased lipid peroxidation and decreased antioxidant protection (involving the reduced: oxidized glutathione balance) were found in the diagnostic groups of pregnancy complications. These changes were independent of measured maternal variables. Maternal exposure to metals (as indicated by blood lead and cadmium) was associated with a decrease in reduced glutathione in blood. Since increased lipid peroxidation has been implicated in other studies as a pathogenetic factor for maternal toxemia, it is suggested that exposure to metals during gestation could enhance the development of pregnancy complications by increasing lipid peroxidation via depletion of reduced glutathione reserves.

Host and environmental effects on plasma apolipoprotein B

In this study, levels of apo B in an unselected sample of 487 middle-aged Caucasian spouses of patients and spouses of the patients' relatives are described. In males, apo B levels increased with age until the 7th decade, then declined; apo B levels in females, which were lower than in males, increased linearly with age across the entire life-span. Height and weight, smoking, and presence of noninsulin-dependent diabetes mellitus significantly influenced age- and gender-adjusted apo B levels in this sample, whereas use of alcohol, diuretics, beta-blockers, or insulin did not. Age, gender, height, weight, smoking, and noninsulin-dependent diabetes mellitus account for 21% of the total variation in apo B levels in this sample.

Occasional binges by moderate drinkers: implications for birth outcomes

We investigated the effects of occasional alcohol binges on birth outcomes in a cohort of live singletons born to 709 moderate drinkers recruited from a Seattle, WA, health maintenance organization before their sixth month of pregnancy. We compared infants of women with one or more binges in the month before pregnancy or in the first two trimesters with those whose mothers reported no binges in either period. Mean values of birthweight, length, head circumference, gestational age, intrauterine growth, and Apgar scores did not differ notably between the two groups. The risk of having an adverse neonatal discharge diagnosis initially appeared lower in infants of binging mothers, but this difference vanished after recategorization of the variable and control for confounding. Our results indicate that occasional binges, during a broad window of exposure and among otherwise moderate drinkers, do not adversely affect the birth outcomes examined here.

Risk factors for antepartum and intrapartum stillbirth

Data from married women who participated in the 1980 National Natality Survey and the National Fetal Mortality Survey were used for a case-control study of antepartum and intrapartum stillbirth. Risk factors were identified by comparing antepartum deaths and intrapartum deaths to livebirths in separate logistic regression analyses. Risk of antepartum death was increased among black mothers, those having their first delivery, those aged 35 years or more, and those with less education. Smoking cigarettes was associated with increased risk. For intrapartum deaths, total abstention from alcohol during pregnancy was associated with increased risk in the best-fitting logistic model, as was first delivery. Body mass index was logit-linear in both models, with lower body mass index associated with lower risk. While some of these factors have already been associated with stillbirth, others have not; the new associations may reflect the continuum of loss over the gestational period, bias in the study, or clues to mechanisms by which the risk of death, before or during parturition, is increased.

Analysis of facial shape in children gestationally exposed to marijuana, alcohol, and/or cocaine

The association between fetal marijuana and/or alcohol exposure and facial features resembling fetal alcohol syndrome was investigated in a sample of 80 children. Standardized lateral and frontal facial photographs were taken of 40 children, 5 to 7 years of age, whose mothers reported frequent use of marijuana during the first trimester of pregnancy and 40 children whose mothers reported no use of marijuana during pregnancy. The marijuana-exposed and unexposed children were group-matched on alcohol exposure prior to and during pregnancy, sex, race, and age at the time of assessment. The photographs were assessed clinically by a study staff dysmorphologist and morphometrically by computerized landmark analysis. Fetal alcohol syndrome-like facial features were not associated with prenatal marijuana exposure in this study sample. No consistent patterns of facial features were identified among the marijuana-exposed group. Maternal consumption of two or more ounces of alcohol per day, on average, in early gestation was found to be associated with fetal alcohol syndrome-like facial features identified both clinically and morphometrically. Cocaine use reported by 13 of the 80 women was independently associated with mild facial dysmorphic features of hypertelorism and midfacial flattening. The results demonstrate the usefulness of this diagnostic technique for quantifying anomalies apparently unique to fetal alcohol syndrome and for targeting clusters of anomalies in new conditions for future evaluation.

Gestational duration and birthweight in white, black and mixed-race babies

Using the 1983 United States population of single live births, birthweight and gestational duration were compared for babies of these different parental racial groups: both parents White, mother White-father Black, mother Black-father White, both parents Black. The four groups differed significantly with respect to the usual sociodemographic variables. Mean birthweight and mean gestational duration decreased in that order from the White-White reference group, and conversely there were increasing trends for low birthweight and preterm delivery. Adjustment for the usual sociodemographic variables did not alter these trends appreciably. Group differences were more strongly related to the mother's race than to the father's, and the trends were related to the mother's race. Because the father's race was significant, genetic factors are probably of some importance. The evidence from this study, together with the often-demonstrated relationships between low birthweight and preterm delivery with sociodemographic variables, and the short-term downward secular trends in low birthweight, support the concept that non-genetic maternal factors are more important for these abnormal outcomes. But because neither the usually utilised sociodemographic variables nor genetic factors seem to explain much of the group differences, new approaches are necessary to understand why, irrespective of ethnic group, some women are at excess risk for suboptimal birth outcome.

The effects of maternal drinking in the reproductive period: an epidemiologic review

The major effects of maternal alcohol use during pregnancy are decreased fetal growth, morphologic abnormalities, and CNS impairment. If all three of these are present, with a characteristic facies in the infant, fetal alcohol syndrome (FAS) is diagnosed. FAS occurs only with heavy or alcoholic drinking. The individual components of the syndrome exhibit a dose-response association with ethanol intake in many, but not all studies. Discrepancies in maternal drinking and pregnancy outcome reflect the myriad difficulties of these investigations. Drinking "before" pregnancy also has been linked to decrements in fetal development, possibly because before pregnancy may include the periconceptional period. However, women who are usually abstainers before pregnancy appear to have infants at higher risk of some adverse pregnancy outcomes than women who are light drinkers. Future studies need to construct careful drinking histories to address this and other questions that deal with parents' ethanol use and reproductive health.

Drinking and smoking at 3 months postpartum by lactation history

A spontaneous decrease in maternal drinking and smoking often occurs during pregnancy. The present study was conducted to determine if these lower levels of maternal drinking and smoking during pregnancy persist into the postpartum period, and if so, to determine if they are related to breastfeeding. Drinking and smoking were estimated in three cohorts of postpartum women who had been followed since pregnancy. The first group never breastfed their infants; the second group breastfed for less than 1 month; the third group breastfed for more than three months. (Women who weaned between one and three months were not studied). Drinking and smoking in all three groups decreased sharply during pregnancy but rose again in the 3 months after delivery, though not to levels that were reported before conception. Usual drinking in the third month postpartum did not differ significantly among the three lactation groups. However, women who were still nursing were less likely to report occasional episodes of heavy drinking (binges) in this month than women who had weaned early or never breastfed. Women nursing in the third month postpartum were also significantly less likely to smoke during the month; if smoking, they were less likely to smoke heavily. These differences in postpartum drinking and smoking were not due entirely to habits before conception or to the influence of other potentially confounding variables.

Maternal marijuana use during lactation and infant development at one year

Prenatal marijuana exposure is associated with adverse perinatal effects. Very little is known about the effect of postnatal marijuana exposure on infant development. Postnatal exposure can result from maternal use of marijuana during lactation. Delta-9-tetrahydrocannabinol (THC) transfers and concentrates in the mother's milk and is absorbed and metabolized by the nursing infant. The present study investigated the relationship between infant exposure to marijuana via the mother's milk and infant motor and mental development at one year of age. One hundred and thirty-six breast-fed infants were assessed at one year of age for motor and mental development. Sixty-eight infants were exposed to marijuana via the mother's milk. An additional 68 infants were matched to the marijuana-exposed infants on pre- and postpartum maternal alcohol and tobacco use. Marijuana exposure via the mother's milk during the first month postpartum appeared to be associated with a decrease in infant motor development at one year of age.

Torsade de pointes and T-U wave alternans associated with arsenic poisoning

Arsenic intoxication is a common form of heavy metal poisoning. Although arsenic-induced circulatory collapse, seizures, and syncope are well known, the potential for serious ventricular arrhythmias is less well recognized. Reported in this study are two cases of arsenic poisoning causing torsade de pointes. Furthermore, marked prolongation of the QT-U interval and the rarely observed phenomenon of T-U wave alternans are demonstrated. Thus, arsenic intoxication may be complicated by prolongation of the QT-U interval and torsade de pointes. T-U wave alternans occurs in the presence of a long QT-U interval and may be an electrocardiographic warning sign of torsade de pointes.

Erythrocyte acid phosphatase phenotype and gestational length: no relationship in a sample of 3001 births

Erythrocyte acid phosphatase (ACP1) phenotype was examined in 3001 Caucasian infants born at the University of Michigan Women's Hospital. Contrary to reports from other studies, there was no relationship between the ACP1 phenotype and risk of preterm birth in either the total sample or when the sample was subdivided by sex of infant.

Arrhythmias after orthotopic cardiac transplantation. Prevalence and determinants during initial hospitalization and late follow-up

The prevalence of arrhythmias after orthotopic cardiac transplantation in the era of cyclosporine immunosuppression is unknown. Accordingly, we analyzed telemetry data from the initial hospitalization period for 33 cardiac transplant procedures and from 100 hospital readmissions in 23 long-term survivors. Prevalence of arrhythmias was analyzed in relation to immunosuppressive regimen, occurrence of acute rejection, and other clinical and hemodynamic variables. Atrial and ventricular arrhythmias were recorded in 55% and 79% of patients during initial hospitalization and in 39% and 43% of long-term survivors, respectively. Compared with cyclosporine-treated patients, atrial (24% vs. 88%, p less than 0.001) and ventricular (65% vs. 94%, p = 0.085) arrhythmias during the initial hospitalization were more prevalent in patients receiving azathioprine. There was no difference in the prevalence of arrhythmias during initial hospitalization between patients experiencing acute rejection and those who did not. Potential associations between arrhythmia occurrence and a prolonged donor heart ischemic time (p = 0.022), elevated pulmonary arterial pressure (p = 0.01), and a lower ejection fraction (p = 0.009) were noted. These data suggest that arrhythmias occur in the majority of patients during the initial hospitalization for transplantation, even in those who never experience acute rejection. Ventricular arrhythmias are common in patients treated with either immunosuppressive regimen; however, atrial arrhythmias are less prevalent in patients receiving cyclosporine. Arrhythmias tend to occur in the setting of altered hemodynamics.