Guideline on multimodal rehabilitation for patients with post-intensive care syndrome.

BACKGROUND: Intensive Care Unit (ICU) survivors often experience several impairments in their physical, cognitive, and psychological health status, which are labeled as post-intensive care syndrome (PICS). The aim of this work is to develop a multidisciplinary and -professional guideline for the rehabilitative therapy of PICS. METHODS: A multidisciplinary/-professional task force of 15 healthcare professionals applied a structured, evidence-based approach to address 10 scientific questions. For each PICO-question (Population, Intervention, Comparison, and Outcome), best available evidence was identified. Recommendations were rated as "strong recommendation", "recommendation" or "therapy option", based on Grading of Recommendations, Assessment, Development and Evaluation principles. In addition, evidence gaps were identified. RESULTS: The evidence resulted in 12 recommendations, 4 therapy options, and one statement for the prevention or treatment of PICS. RECOMMENDATIONS: early mobilization, motor training, and nutrition/dysphagia management should be performed. Delirium prophylaxis focuses on behavioral interventions. ICU diaries can prevent/treat psychological health issues like anxiety and post-traumatic stress disorders. Early rehabilitation approaches as well as long-term access to specialized rehabilitation centers are recommended. Therapy options include additional physical rehabilitation interventions. Statement: A prerequisite for the treatment of PICS are the regular and repeated assessments of the physical, cognitive and psychological health in patients at risk for or having PICS. CONCLUSIONS: PICS is a variable and complex syndrome that requires an individual multidisciplinary, and multiprofessional approach. Rehabilitation of PICS should include an assessment and therapy of motor-, cognitive-, and psychological health impairments.

Bilateral Arm Training vs Unilateral Arm Training for Severely Affected Patients With Stroke: Exploratory Single-Blinded Randomized Controlled Trial.

OBJECTIVE: To compare the effects of unilateral and bilateral arm training on arm impairment in severely affected patients with stroke. DESIGN: Single-blinded, randomized controlled trial. SETTING: Inpatient rehabilitation center. PARTICIPANTS: First-time subacute patients (N=69) with stroke and a nonfunctional hand. Patients were stratified according to lesion location post hoc. INTERVENTIONS: Repetitive bilateral arm training on an arm cycle followed by synchronized bilateral repetitive distal hand training or an identical unilateral arm training performed by the paretic limb only. Both unilateral and bilateral trainings were administered twice daily over 6 weeks. MAIN OUTCOME MEASURES: The primary outcome measure was the Fugl-Meyer Assessment (FMA) score for the arm, and secondary measures were biomechanical parameters measuring isometric force and rate of force generation. Outcome measures were assessed before, at the end of, and 2 weeks after intervention. RESULTS: Patients were homogeneous at study onset. All patients improved regarding the FMA arm score and most biomechanical parameters after intervention. Yet the post hoc analysis stratifying patients according to lesion location showed that patients with pure subcortical stroke, but not patients with cortical involvement of stroke, showed a significantly greater improvement (P=.022) following the bilateral training in FMA arm score (from 6.8±5.7 to 17.8±15.8) compared with unilateral training (from 6.5±7.8 to 8.7±8.6). CONCLUSIONS: The benefit of bilateral arm training followed by repetitive bilateral hand training for motor control of the severely paretic upper limb may depend on lesion location. Further studies with larger sample size are required for the validation of these results.

Exploratory Study of the Influence of Posture and Hand Task on Corticomotor Excitability of Upper Extremity Muscles After Stroke.

OBJECTIVE: To explore the interaction between postural stability and hand task on the corticospinal excitability (CE) of upper extremity muscles and how it is affected by lesion location. DESIGN: Cross-sectional explorative survey. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants (N=81) were neurologically healthy subjects (volunteer sample, n=36) and patients with stroke (convenience sample, n=45; mean time since stroke, 45d), stratified according to lesion location: pure subcortical strokes (n=25) and strokes with cortical involvement (n=20). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Motor-evoked potentials were recorded simultaneously from the first dorsal interosseus (FDI) muscle and biceps brachii (BB) during rest and during low and forceful activation of the FDI in 4 different postural positions (supine, sitting, sitting unsupported, standing) and compared. RESULTS: Posture modulated CE of the FDI and BB during performance of a motor task but not at rest. The influence of postural position on CE of the FDI depended on force demand and lesion location: the control and subcortical stroke group demonstrated significantly higher CE of the FDI when performing the forceful task in the supine and stable sitting positions, respectively, compared with standing. In contrast, the cortical stroke group exhibited significantly higher CE of the FDI when performing the low-force task in a stable sitting position compared with standing. CONCLUSIONS: Posture influences CE of the FDI and BB in healthy subjects and patients with stroke differentially depending on hand task, but not at rest. A stable sitting posture increased excitability of the FDI in patients with stroke. These findings imply that hand rehabilitation protocols may be influenced by posture.

Fetal Exposure to Carcinogens With Tobacco Use in Pregnancy: Phase 1 MAW Study Findings.

INTRODUCTION: The high prevalence of smoking and smokeless tobacco (ST) use during pregnancy in Alaska Native (AN) women is concerning due to the detrimental effects of these products to the mother and the developing fetus. We sought to correlate maternal cotinine levels with fetal exposure to a tobacco-specific carcinogen to incorporate in a biomarker feedback intervention to motivate tobacco cessation during pregnancy. METHODS: Demographic and tobacco use data were collected from a convenience sample of pregnant AN smokers, ST users, and non-users. Maternal and neonatal urine were collected at delivery. Maternal urine cotinine and neonatal urine total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL, a tobacco-specific carcinogen) levels in smokers and ST users were analyzed and their correlations determined by Spearman correlation coefficients. RESULTS: During 2012-2014, we enrolled 64 non-users, 54 smokers, and 30 ST (20 homemade iqmik; 10 commercial ST) users (n = 148). Analyses of paired maternal-infant urine samples obtained for 36 smokers demonstrated a moderate to strong correlation (r = 0.73, P < .001) between maternal cotinine and infant NNAL levels. The correlation was not significant for 25 iqmik users (r = 0.36, P = .17) or 9 commercial ST users (r = 0.60, P = .09). No analysis was conducted for 55 non-users with cotinine and NNAL levels < limits of quantification. CONCLUSIONS: There is a moderate to strong correlation between maternal smoking and fetal exposure to the tobacco-specific carcinogen NNAL. IMPLICATIONS: The correlation between maternal smoking and fetal carcinogen exposure may provide an education tool to help motivate smoking cessation among pregnant AN women. Further investigation is warranted to determine correlations between maternal commercial ST and iqmik use and neonatal NNAL.

Group therapy task training versus individual task training during inpatient stroke rehabilitation: a randomised controlled trial.

OBJECTIVE: To compare the efficacy of intensive daily applied progressive group therapy task training with equally dosed individual progressive task training on self-reported mobility for patients with moderate to severe stroke during inpatient rehabilitation. DESIGN: Randomized controlled clinical trial. SETTING: In-patient rehabilitation center. SUBJECTS: A total of 73 subacute patients with stroke who were not able to walk without physical assistance at randomisation. INTERVENTIONS: Patients were allocated to group therapy task training (GT) or individual task training (IT). Both interventions were intended to improve walking competency and comprised 30 sessions of 90 minutes over six weeks. MAIN MEASURES: Primary outcome was the mobility domain of the Stroke Impact Scale (SIS-3.0). Secondary outcomes were the other domains of SIS-3.0, standing balance, gait speed, walking distance, stair climbing, fatigue, anxiety and depression. RESULTS: No adverse events were reported in either arm of the trial. There were no significant differences between groups for the SIS mobility domain at the end of the intervention (Z= -0.26, P = 0.79). No significant differences between groups were found in gait speed improvements (GT:0.38 ±0.23; IT:0.26±0.35), any other gait related parameters, or in non-physical outcomes such as depression and fatigue. CONCLUSION: Inpatient group therapy task training for patients with moderate to severe stroke is safe and equally effective as a dose-matched individual task training therapy. Group therapy task training may be delivered as an alternative to individual therapy or as valuable adjunct to increase time spent in gait-related activities.

Genetic and phenotypic variation in UGT2B17, a testosterone-metabolizing enzyme, is associated with BMI in males.

OBJECTIVE: A number of candidate gene and genome-wide association studies have identified significant associations between single nucleotide polymorphisms, particularly in FTO and MC4R, and body weight. However, the association between copy number variation and body weight is less understood. Anabolic androgenic steroids, such as testosterone, can regulate body weight. In humans, UDP-glucuronosyltransferase 2B17 (UGT2B17) metabolizes testosterone to a metabolite, which is readily excreted in urine. We investigate the association between genetic and phenotypic variation in UGT2B17 and body weight. MATERIALS AND METHODS: UGT2B17 deletion was genotyped and in-vivo UGT2B17 enzymatic activity (as measured by the 3-hydroxycotinine glucuronide to free 3-hydroxycotinine ratio) was measured in 400 Alaska Native individuals and 540 African Americans. RESULTS: In Alaska Native people, UGT2B17 deletion was strongly associated with lower BMI in male individuals (P<0.001), but not in female individuals, consistent with testosterone being a male dominant steroid. The sex-specific association between UGT2B17 deletion and lower BMI was also observed in African Americans (P=0.01 in male individuals). In both populations, UGT2B17 deletion was significantly associated with lower measured in-vivo UGT2B17 activity. In male individuals, lower in-vivo UGT2B17 activity was associated with lower BMI, as observed in the sex-specific genotypic association. CONCLUSION: These data suggest that UGT2B17 deletion leads to reduced UGT2B17 activity, and lower BMI in male individuals. This is consistent with the hypothesis that reduced UGT2B17-mediated testosterone excretion results in higher testosterone levels. Future studies could confirm this hypothesis by directly measuring serum testosterone levels.

Alaska Native smokers and smokeless tobacco users with slower CYP2A6 activity have lower tobacco consumption, lower tobacco-specific nitrosamine exposure and lower tobacco-specific nitrosamine bioactivation.

Nicotine, the psychoactive ingredient in tobacco, is metabolically inactivated by CYP2A6 to cotinine. CYP2A6 also activates procarcinogenic tobacco-specific nitrosamines (TSNA). Genetic variation in CYP2A6 is known to alter smoking quantity and lung cancer risk in heavy smokers. Our objective was to investigate how CYP2A6 activity influences tobacco consumption and procarcinogen levels in light smokers and smokeless tobacco users. Cigarette smokers (n = 141), commercial smokeless tobacco users (n = 73) and iqmik users (n = 20) were recruited in a cross-sectional study of Alaska Native people. The participants' CYP2A6 activity was measured by both endophenotype and genotype, and their tobacco and procarcinogen exposure biomarker levels were also measured. Smokers, smokeless tobacco users and iqmik users with lower CYP2A6 activity had lower urinary total nicotine equivalents (TNE) and (methylnitrosamino)-1-(3)pyridyl-1-butanol (NNAL) levels (a biomarker of TSNA exposure). Levels of N-nitrosonornicotine (NNN), a TSNA metabolically bioactivated by CYP2A6, were higher in smokers with lower CYP2A6 activities. Light smokers and smokeless tobacco users with lower CYP2A6 activity reduce their tobacco consumption in ways (e.g. inhaling less deeply) that are not reflected by self-report indicators. Tobacco users with lower CYP2A6 activity are exposed to lower procarcinogen levels (lower NNAL levels) and have lower procarcinogen bioactivation (as indicated by the higher urinary NNN levels suggesting reduced clearance), which is consistent with a lower risk of developing smoking-related cancers. This study demonstrates the importance of CYP2A6 in the regulation of tobacco consumption behaviors, procarcinogen exposure and metabolism in both light smokers and smokeless tobacco users.

Tobacco use among southwestern Alaska Native people.

INTRODUCTION: We examined the characteristics, attitudes, beliefs, and exposure to tobacco products in a cohort of rural dwelling Alaska Native (AN) people. METHODS: We conducted a study of 400 of AN adult tobacco users and nonusers living in Southwestern Alaska. Questionnaires covered variables such as demographics, tobacco-use history, current tobacco use and dependence scales, general health status, attitudes and beliefs about tobacco, and quitting history. RESULTS: The study population smoked 7.8 cigarettes per day compared with 16.8 on average for the U.S. population: a significant proportion of the population engaged in dual use of cigarettes and smokeless tobacco products. Over one third (40.9%), first tried tobacco at age 11 or younger. The mean measures of tobacco addiction (e.g., Fagerstrom Test for Nicotine Dependence, Severson Scale of Smokeless Tobacco Dependence) scores were lower compared with other U.S. populations. CONCLUSIONS: Very high tobacco-use prevalence, dual product use, and early tobacco use are observed in Southwestern AN people. Unexpectedly these did not appear to be correlated with heavier individual tobacco use or higher levels of addiction in this population.

Chemical analysis of Alaskan Iq'mik smokeless tobacco.

INTRODUCTION: Iq'mik, a form of smokeless tobacco (ST), is traditionally used by Cup'ik and Yup'ik Eskimo people of western Alaska. Iq'mik is sometimes incorrectly considered to be a healthier alternative to smoking because its ingredients are perceived as "natural." Our chemical characterization of iq'mik shows that iq'mik is not a safe alternative to smoking or other ST use. METHODS: We measured nicotine and pH levels of tobacco and ash used to prepare iq'mik. We also characterized levels of toxins which are known to be present in ST including tobacco-specific nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) using chromatographic separations coupled with isotope dilution mass spectrometry. RESULTS: Nicotine content in the iq'mik tobacco was very high, ranging from 35 to 43 mg/g, with a mean of 39 mg/g. The pH of the iq'mik tobacco-ash mixture was 11, an extremely high level compared with most ST products. High levels of PAHs were seen in the fire-cured tobacco samples with a benzo[a]pyrene level of 87 ng/g. Average TSNA levels in the tobacco were 34, 2,700, and 340 ng/g for 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), N'-nitrosonornicotine (NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), respectively. CONCLUSIONS: Iq'mik contains high levels of the more easily absorbed unionized nicotine as well as known carcinogenic TSNAs and PAHs. The perception that iq'mik is less hazardous than other tobacco products due to the use of "natural" ingredients is not warranted. This chemical characterization of iq'mik gives a better understanding of the risk of possible adverse health effects of its use.

CYP2A6 and CYP2B6 genetic variation and its association with nicotine metabolism in South Western Alaska Native people.

OBJECTIVES: Alaska Native (AN) people have a high prevalence of tobacco use and associated morbidity and mortality when compared with the general USA population. Variations in the CYP2A6 and CYP2B6 genes, encoding enzymes responsible for nicotine metabolic inactivation and procarcinogen activation, have not been characterized in AN and may contribute toward the increased risk. METHODS: AN people (n=400) residing in the Bristol Bay region of South Western Alaska were recruited for a cross-sectional study on tobacco use. They were genotyped for CYP2A6*1X2A, *1X2B, *1B, *2, *4, *7, *8, *9, *10, *12, *17, *35 and CYP2B6*4, *6, *9 and provided plasma and urine samples for the measurement of nicotine and metabolites. RESULTS: CYP2A6 and CYP2B6 variant frequencies among the AN Yupik people (n=361) were significantly different from those in other ethnicities. Nicotine metabolism [as measured by the plasma and urinary ratio of metabolites trans-3'-hydroxycotinine to cotinine (3HC/COT)] was significantly associated with CYP2A6 (P<0.001), but not CYP2B6 genotype (P=0.95) when controlling for known covariates. It was noteworthy that the plasma 3HC/COT ratios were high in the entire Yupik people, and among the Yupik CYP2A6 wild-type participants, they were substantially higher than those in previously characterized racial/ethnic groups (P<0.001 vs. Caucasians and African Americans). CONCLUSION: Yupik AN people have a unique CYP2A6 genetic profile that associated strongly with in-vivo nicotine metabolism. More rapid CYP2A6-mediated nicotine and nitrosamine metabolism in the Yupik people may modulate the risk of tobacco-related diseases.

The influence of gender on the injury severity, course and outcome of traumatic brain injury.

OBJECTIVE: To examine the independent association of gender with injury severity, clinical course, pituitary dysfunction and outcome after traumatic brain injury (TBI). DESIGN: Prospective cohort, analysis of a data sub-set collected as part of the nation-wide database 'The Structured Data Assessment of Hypopituitarism after TBI and SAH'. METHODS AND PROCEDURES: Four hundred and twenty-seven patients following TBI were observed from acute care through neurological rehabilitation. Outcome was measured by Glasgow Outcome Scale (GOS), employment status and living situation post-injury. As a secondary outcome measure anterior pituitary function was assessed. RESULTS: There were no differences in injury severity between men and women. Age had a significant effect on the GCS score (p = 0.0295), but gender did not (p = 0.4105). The outcome was equivalent between men and women once corrected for age. Logistic regression revealed that gender had no effect (p = 0.8008), but age (p = 0.0021) and initial injury severity (p = 0.0010) had an effect on the GOS. After correcting for pre-injury living situation and employment only initial injury severity (p = 0.0005) influenced GOS. Pituitary insufficiency was not affected by sex or age. CONCLUSION: Gender does not seem to influence the course and outcome of TBI. Outcome parameters were affected foremost by initial injury severity and by age, but not by sex.

Differences in cigarette and smokeless tobacco use among American Indian and Alaska Native people living in Alaska and the Southwest United States.

INTRODUCTION: This study analyzed self-reported tobacco use among American Indian and Alaska Native (AI/AN) people enrolled in the Education and Research Towards Health Study in Alaska (n = 3,821) and the Southwest United States (n = 7,505) from 2004 to 2006. METHODS: Participants (7,060 women and 4,266 men) completed a computer-assisted self-administered questionnaire on cigarette and smokeless tobacco (ST) use. RESULTS: Current use of cigarettes was considerably higher in Alaska than in the Southwest United States (32% vs. 8%). Current ST use was also more common in Alaska than in the Southwest United States (18% vs. 8%). Additionally, smoking was more common among men, younger age, those who were not married, and who only spoke English at home, while ST use was more common among men, those with lower educational attainment and those who spoke an AI/AN language at home (p < .01). Compared with the U.S. general population, AI/AN people living in Alaska were more likely and those living in the Southwest United States were less likely to be current smokers. Rates of ST use, including homemade ST, in both regions were much higher than the U.S. general population. DISCUSSION: Tobacco use among AI/AN people in the Southwest United States, who have a tradition of ceremonial tobacco use, was far lower than among Alaska Native people, who do not have a tribal tradition. Tobacco use is a key risk factor for multiple diseases. Reduction of tobacco use is a critical prevention measure to improve the health of AI/AN people.

Feasibility of a tobacco cessation intervention for pregnant Alaska Native women.

BACKGROUND: Among Alaska Native women residing in the Yukon-Kuskokwim (Y-K) Delta region of Western Alaska, about 79% smoke cigarettes or use smokeless tobacco during pregnancy. Treatment methods developed and evaluated among Alaska Native pregnant tobacco users do not exist. This pilot study used a randomized two-group design to assess the feasibility and acceptability of a targeted cessation intervention for Alaska Native pregnant women. METHODS: Recruitment occurred over an 8-month period. Enrolled participants were randomly assigned to the control group (n = 18; brief face-to-face counseling at the first visit and written materials) or to the intervention group (n = 17) consisting of face-to-face counseling at the first visit, four telephone calls, a video highlighting personal stories, and a cessation guide. Interview-based assessments were conducted at baseline and follow-up during pregnancy (>or=60 days postrandomization). Feasibility was determined by the recruitment and retention rates. RESULTS: The participation rate was very low with only 12% of eligible women (35/293) enrolled. Among enrolled participants, the study retention rates were high in both the intervention (71%) and control (94%) groups. The biochemically confirmed abstinence rates at follow-up were 0% and 6% for the intervention and control groups, respectively. DISCUSSION: The low enrollment rate suggests that the program was not feasible or acceptable. Alternative approaches are needed to improve the reach and efficacy of cessation interventions for Alaska Native women.

Prevalence and correlates of tobacco use among middle and high school students in western Alaska.

OBJECTIVES: Tobacco use is the leading cause of preventable death in the United States and contributes to increased incidence, morbidity and mortality from cancer, heart disease, stroke, complications of pregnancy and respiratory illness. Tobacco use rates are highest among American Indians and Alaska Natives. This study examined the prevalence and correlates of tobacco use among youth residing in rural western Alaska. STUDY DESIGN: Data were analysed from the 2003 Youth Risk Behavior Survey (YRBS) administered to a regional sample of adolescents attending school in western Alaska. METHODS: Data were analysed from 260 middle school (52% female, 87% Alaska Native) and 258 high school (48% female, 93% Alaska Native) students. RESULTS: Among middle school students, 39% reported current use of ST, 24% reported cigarette smoking and 50% reported current use of any tobacco product. On multivariate analysis, independent correlates of current use of any tobacco were Alaska Native ethnicity (p=0.002) and ever use of marijuana (p<0.001). Among high school students, 38% reported current ST use, 43% reported cigarette smoking and 60% reported current use of any tobacco product. Independent correlates of current use of any tobacco were increasing age (p=0.007), ever use of marijuana (p<0.001), current use of marijuana (p=0.005) and reporting a suicide attempt within the past 12 months (p=0.003). No significant gender differences on tobacco use emerged for middle or high school students. CONCLUSIONS: This study documents the high tobacco use rates among youth residing in western Alaska, with over half of the adolescents reporting tobacco use. Developing interventions to promote tobacco use prevention and cessation is an essential step towards reducing tobacco-related health disparities in this rural population. Expanded efforts are needed to address tobacco use among youth residing in this region of Alaska.

Change of strength and rate of rise of tension relate to functional arm recovery after stroke.

OBJECTIVE: To examine the relationship between individual strength parameters and functional motor ability over time during rehabilitation in stroke patients. DESIGN: A multiple-baseline experiment with assessment at inclusion and after 3 and 6 weeks. SETTING: Secondary-care rehabilitation center. PARTICIPANTS: A convenience sample of 16 subacute stroke patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Maximal voluntary force and rate of rise of tension of hand grip, wrist extension, and elbow flexion and extension were recorded at all 3 times. At the same time, functional motor assessments were evaluated by the Action Research Arm Test (ARAT), Box and Block test, and Rivermead Test. RESULTS: We found no correlation between maximal voluntary force increases of various muscle contractions measurements. Neither the increase of grip strength nor that of wrist extension force correlated with improvement in ARAT score. Yet the improvement in the rate of rise of tension of hand grip (Spearman rho=.91) and of wrist extension (Spearman rho=.73) correlated with the improvement of the ARAT score and explained 77% of the variance of the ARAT. CONCLUSIONS: The change in the rate of rise of tension of the hand grip has a better predictive value for the functional recovery compared to the change in maximal voluntary force in patients with moderate arm and hand weakness after stroke. The rate of rise of tension of hand grip seems an adequate quantifiable parameter to detect small improvements during functional recovery.

Isotonic and isometric contractions exert the same amount of corticomotor system excitability in healthy subjects and patients after stroke.

OBJECTIVE: Active, voluntary training of the centrally paretic upper limb is crucial for functional recovery after brain damage. The aim of this study was to determine whether the type of voluntary contraction has a differential influence on corticomotor system excitability in healthy subjects and patients after stroke. DESIGN: Experimental cross-sectional study. SUBJECTS: Fifteen healthy volunteers and 15 patients after stroke. METHODS: Participants performed dynamic isotonic and isometric voluntary wrist extensions with the non-dominant or the paretic hand, respectively, with force levels of 10%, 20% and 30% of the maximum voluntary surface electromyogram. Excitability was measured by comparing the amplitude of motor evoked potentials elicited by transcranial magnetic stimulation. RESULTS: The type of contraction did not have any effect on the amplitude of motor evoked potentials, either in healthy subjects or in patients after stroke. CONCLUSION: Dynamic isometric and isotonic voluntary contractions seem to have the same effect on the excitability of the corticomotor system.

Tobacco use and cessation among pregnant Alaska Natives from Western Alaska enrolled in the WIC program, 2001-2002.

OBJECTIVES: This study examined the rate of tobacco use (cigarette smoking and smokeless tobacco [ST]) at three time points: during the 3 months before pregnancy, during pregnancy, and at 6 weeks postpartum among Alaska Native women residing in the Y-K Delta region of Western Alaska. METHODS: A retrospective, non-randomized observational cohort design was utilized. The sample consisted of 832 Alaska Natives (mean maternal age = 26.2 years, average length of gestation = 3.8 months) seen at their first prenatal visit and enrolled in the women, infant, and children (WIC) program at the Yukon-Kuskokwim Delta Regional Hospital in Bethel, Alaska, during a 2-year-period (2001-2002). Tobacco use was assessed using an interview format at the first prenatal and at the 6-week postpartum visits. RESULTS: The rates of any tobacco use were 48% (95% CI 45%, 52%) 3 months before pregnancy, 79% (95% CI 76%, 82%) during pregnancy, and 70% (95% CI 67%, 74%) at 6 weeks postpartum. The proportion of women using ST changed significantly (P < 0.001) over the three time points (14%, 60%, and 61%, respectively) as well as the proportion of women who smoked cigarettes (P < 0.001) (40%, 42%, and 19%, respectively). CONCLUSIONS: This study documents the high rate of tobacco use, particularly ST use, during pregnancy among Alaska Native women. Development of tobacco use prevention and cessation interventions during pregnancy for Alaska Native women is warranted.

Urine 4-(methylnitrosamino)-1-(3) pyridyl-1-butanol and cotinine in Alaska native postpartum women and neonates comparing smokers and smokeless tobacco users.

OBJECTIVE: Foetuses and neonates of women who use tobacco are exposed to nicotine and tobacco-derived carcinogens. We determined the relationship between urine biomarkers of tobacco toxicant exposure postpartum and in the neonates of Alaska Native (AN) women, comparing smokers and smokeless tobacco (ST) users, including iqmik, a homemade ST product. METHODS: AN women, including 36 smokers, 9 commercial ST and 16 iqmik users their neonates participated. Urine from the woman at the time of delivery and her neonate's first urine were analysed for cotinine, the major metabolite of nicotine, and 4-(methylnitrosamino)-1-(3) pyridyl-1-butanol (NNAL), a tobacco-specific carcinogen biomarker. RESULTS: Maternal urine cotinine and neonatal urine cotinine were strongly correlated in all tobacco use groups (r from 0.83 to 0.9, p < 0.002). Correlations between maternal cotinine and neonatal NNAL were moderately strong for cigarettes and commercial smokeless but weaker for iqmik users (r 0.73, 0.6 and 0.36, respectively). CONCLUSION: Correlations between maternal and neonatal biomarkers of tobacco toxicant exposure vary, dependent on tobacco product use. SIGNIFICANCE: This study provides novel data on biomarkers of tobacco exposure among postpartum AN women and their neonates. The results could be useful to guide future epidemiological studies of health risks associated with use of various tobacco products during pregnancy.