Secondhand smoke exposure in Alaskan households with children.

INTRODUCTION: Secondhand smoke (SHS) exposure causes premature death and disease in children and non-smoking adults; the home is the primary source of SHS exposure. The aim of this study was to assess variance in the prevalence of children's SHS exposure in Alaskan households with an adult smoker according to rurality, race/ethnicity, income and education, household age composition, marital status, amount smoked each day, and beliefs in SHS health consequences. METHOD: Telephone interviews were conducted between 2004 and 2007 on a population-based random sample of 1119 Alaskan adult smokers with children living in the household. RESULTS: Respondents living with children over 5 years of age reported a significantly (p <0.05) higher prevalence of home SHS exposure, compared with those living with younger children. Respondents 40 years and older reported significantly more exposure than others. Alaska Native smokers reported significantly lower SHS exposure in their homes than those of other races, as did those living in very rural areas. Respondents' heavier smoking was significantly associated with more SHS exposure. The sub-population of adults living without other adults was approximately 1.5 times more likely to report SHS exposure than those living with other adults. As expected, having a no-smoking rule in the home greatly lowered the risk of SHS exposure in the home. CONCLUSIONS: Although most smokers with children believed that SHS is harmful, some need to convert those beliefs into actions. The results from this study suggest that those with school-aged children, and moderate to heavy smokers should be targeted for intervention, given their high prevalence of home SHS exposure. Future work should examine reasons for low exposure levels among Alaska Native people to inform programmatic efforts in other communities.

Assessing long-term neuroinflammatory responses to encephalopathy using MRI approaches in a rat endotoxemia model.

Sepsis-associated encephalopathy (SAE) induces neuroinflammation, which is associated with cognitive impairment (CI). CI is also correlated with aging. We used contrast-enhanced magnetic resonance imaging (MRI), perfusion MRI, and MR spectroscopy to assess long-term alterations in BBB permeability, microvascularity, and metabolism, respectively, in a rat lipopolysaccharide-induced SAE model. Free radical-targeted molecular MRI was used to detect brain radical levels at 24 h and 1 week post-LPS injection. CE-MRI showed increased Gd-DTPA uptake in LPS rat brains at 24 h in cerebral cortex, hippocampus, thalamus, and perirhinal cortex regions. Increased MRI signal intensities were observed in LPS rat brains in cerebral cortex, perirhinal cortex, and hippocampus regions 1 week post-LPS. Long-term BBB dysfunction was detected in the cerebral cortex at 6 weeks post-LPS. Increased relative cerebral blood flow (rCBF) in cortex and thalamus regions at 24 h, decreased cortical and hippocampal rCBF at 6 weeks, decreased cortical rCBF at 3 and 12 weeks, and increased thalamus rCBF at 6 weeks post-LPS, were detected. MRS indicated that LPS-exposed rat brains had decreased: NAA/Cho metabolite ratios at 1, 3, 6, and 12 weeks; Cr/Cho at 1, 3, and 12 weeks; and Myo-Ins/Cho at 1, 3, and 6 weeks post-LPS. Free radical imaging detected increased radical levels in LPS rat brains at 24 h and 1 week post-LPS. LPS-exposed rats were compared to saline-treated controls. We clearly demonstrated BBB dysfunction, impaired vascularity, and decreased brain metabolites, as measures of long-term neuroinflammatory indicators, as well as increased free radicals in a LPS-induced rat SAE model.

Epidemiologic study of 203 sibling pairs with Parkinson's disease: the GenePD study.

OBJECTIVE: To examine patterns of familial aggregation and factors influencing onset age in a sample of siblings with PD. METHODS: Sibling pairs (n = 203) with PD were collected as part of the GenePD study. Standardized family history, medical history, and risk factor data were collected and analyzed. RESULTS: The mean age at onset was 61.4 years and did not differ according to sex, exposure to coffee, alcohol, or pesticides. Head trauma was associated with younger onset (p = 0.03) and multivitamin use with later onset (p = 0.007). Age at onset correlation between sibling pairs was significant (r = 0.56, p = 0.001) and was larger than the correlation in year of onset (r = 0.29). The mean difference in onset age between siblings was 8.7 years (range, 0 to 30 years). Female sex was associated with increased frequency of relatives with PD. The frequency of affected parents (7.0%) and siblings (5.1%) was increased when compared with frequency in spouses (2.0%). CONCLUSIONS: The greater similarity for age at onset than for year of onset in sibling pairs with PD, together with increased risk for biological relatives over spouses of cases, supports a genetic component for PD. Risk to siblings in this series is increased over that seen in random series of PD cases; however, patients in this sample have similar ages at onset and sex distribution as seen for PD generally. These analyses suggest that factors influencing penetrance are critical to the understanding of this disease.

Quantity of coronary artery calcium detected by electron beam computed tomography in asymptomatic subjects and angiographically studied patients.

OBJECTIVE: To determine the prevalence and quantity of coronary artery calcium (CAC) in asymptomatic subjects from the general population, to identify asymptomatic subjects without risk factors for coronary artery disease (CAD) with CAC scores in the top quartile of the distribution, and to compare CAC scores in patients who underwent angiography with percentiles in asymptomatic subjects of the same age and sex. DESIGN: We studied two samples from Rochester, Minnesota, which consisted of 772 asymptomatic subjects from the general population and 145 patients who underwent angiography, all of whom were 20 to 59 years of age. METHODS: Asymptomatic subjects were classified on the basis of their CAD risk profile. All subjects in both study samples underwent electron beam computed tomography. Age- and sex-specific calcium score percentiles were calculated in the asymptomatic sample. RESULTS: CAC prevalence in the asymptomatic subjects was lower in female than in male subjects and increased with advancing age. Of the asymptomatic sample, 8% had a low-risk profile with calcium scores in the top quartile of the distribution. More patients than expected in the angiography sample had calcium scores above the 50th through 95th score percentiles. CONCLUSION: The quantity of CAC was substantially increased in patients who underwent angiography. Subjects with large amounts of CAC but without known CAD risk factors may be a valuable subset of the population to investigate for previously unidentified CAD risk factors.

Progression of coronary artery calcification: a pilot study.

OBJECTIVE: To describe individual changes in the quantity of coronary artery calcification (CAC) measured by electron beam computed tomography (CT) and determine the rate of change in the quantity of CAC during a 3.5-year period. MATERIAL AND METHODS: Eighty-eight consecutive participants (51 men at least 30 years of age and 37 women at least 40 years of age) from a community-based CAC study were invited for a follow-up examination. Established coronary artery disease risk factors were studied at baseline. CAC score was measured by electron beam CT at baseline and follow-up. RESULTS: Of the 88 invited participants, 82 (93%) returned for a follow-up examination. Considerable variation existed among the participants in the extent of CAC score change. On average, CAC score increased over time by an estimated 24% each year (P<0.05). The relative increase in CAC score over time was significantly lower for older than for younger participants but did not vary significantly by sex. CONCLUSION: The ability to recruit follow-up participants in this pilot study and to detect significant change in CAC score over time provides evidence that electron beam CT is useful for studying progression of CAC in a sample and may be a valuable procedure for assessing the effectiveness of clinical interventions designed to retard progression of coronary atherosclerosis.

Amnioinfusion survey: prevalence, protocols, and complications.

OBJECTIVE: To determine whether amnioinfusion is associated with labor and delivery complications, and whether complication type and reported incidence are related to infusion method. METHODS: Questionnaires regarding amnioinfusion experience were sent to every academic obstetrics and gynecology department in the United States (78 maternal-fetal medicine fellowship directors or, if the department did not have a fellowship, 206 residency directors). A literature review on amnioinfusion was also performed. RESULTS: Seventy-six percent of fellowship directors and 62% of residency directors responded to our survey, representing 644,910 deliveries per year and at least 22,833 amnionfusions per year. A wide variety of infusion protocols were reported. Forty-nine centers reported at least one associated complication; none was significantly associated with any of the various aspects of the many protocols (P > .05). The mean number (+/- standard error of the mean) of amnioinfusions performed annually was similar between centers that did (261 +/- 48) and did not (154 +/- 29) report complications (P = .06). The literature review suggested that amnioinfusion is efficacious and relatively safe. CONCLUSION: Amnioinfusion is performed nationwide according to widely varying protocols with few associated complications. Neither the method employed nor the number of infusions performed appears to significantly increase the risk of having a complication.

Amniotic fluid embolism after saline amnioinfusion: two cases and review of the literature.

BACKGROUND: Amnioinfusion is an intrapartum intervention with proven benefit in certain clinical situations. It is thought to be a safe treatment with few adverse effects. CASES: Two cases of fatal amniotic fluid (AF) embolism occurred in women who were treated during labor with a saline amnioinfusion. In both cases, amnioinfusion was administered after finding thick meconium staining of the AF. In addition to the amnioinfusion, common factors in these cases and three previously reported AF embolisms associated with amnioinfusion are the presence of rapid labor, meconium-stained fluid, or both. CONCLUSIONS: Amniotic fluid embolism is a rare cause of maternal morbidity and mortality. It is not known whether amnioinfusion increases the rate of its occurrence in laboring patients. No change in clinical practice is warranted on the basis of these reports; however, future reports must be examined so that any common factors can be identified.

Unexplained elevation in maternal serum alpha-fetoprotein and subsequent fetal loss.

OBJECTIVE: To examine the frequency and timing of fetal death and its association with maternal serum alpha-fetoprotein (MSAFP) levels. METHODS: Pregnancy outcomes were evaluated in 6927 predominantly middle-class women (83% white, 17% black) who had second-trimester MSAFP determinations performed in our laboratory. All cases of multiple gestation, preexisting fetal death, and fetal malformation were excluded. RESULTS: The overall fetal death rate was 13 per 1000 (n = 90). Black women had a higher fetal death rate than white women (35.6 per 1000 versus 8.4 per 1000; P < .001). One hundred forty-eight women (2.1%) had an adjusted MSAFP multiples of the median (MoM) value of at least 2.5, which was not explained by multiple gestation, congenital anomaly, or preexisting fetal death. As the MSAFP increased, the fetal death rate increased (MoM less than 2.0, 11 per 1000; MoM 2-2.49, 29 per 1000; MoM 2.5 or greater, 95 per 1000; P < .001). Despite the increased risk of fetal death in the elevated MSAFP group, most fetal deaths (84%) occurred in women with levels below 2.5 MoM. Furthermore, the timing of fetal loss was significantly different between the group less than 2.5 MoM and the group at or above 2.5 MoM. Fetal death occurred at or after 26 weeks in 45% of the women with normal MSAFP, compared with only 14% of women with high MSAFP (at least 2.5 MoM) (P = .023). CONCLUSIONS: Women with unexplained elevations in MSAFP are at increased risk for fetal loss, with most of the losses occurring in the second trimester. Because many of these fetal deaths occur at gestational ages when the neonatal survival is very low, it is unlikely that antepartum fetal surveillance aimed at early delivery would substantially increase fetal salvage.

Indicators of maternal nutritional status and birth weight in term deliveries.

OBJECTIVE: To determine the relationship between measures of maternal protein nutriture and fetal size at birth. METHODS: We obtained serum samples at 18 and 30 weeks' gestation from 289 indigent multiparous women. The concentrations of albumin, prealbumin, and retinol-binding protein were correlated with birth weight, fetal growth retardation, and other measures of nutritional status. RESULTS: Serum albumin levels at 18 weeks correlated inversely with birth weight (P = .05). This negative correlation was explained by an inverse relationship between albumin concentration and maternal body mass index (BMI), and disappeared in a regression analysis adjusting for BMI. There was no significant correlation between albumin levels at 30 weeks and birth weight or between birth weight and the concentrations of the other two proteins at either gestational age. In individual subjects, the concentration of each protein correlated significantly with the concentration of the other proteins, and the levels at 18 weeks correlated with those at 30 weeks. CONCLUSION: Serum protein levels are not predictive of birth weight or growth retardation at birth, but do correlate significantly with a number of other measures of nutritional status.

The predictive value of umbilical artery Doppler studies for preeclampsia or fetal growth retardation in a preeclampsia prevention trial.

OBJECTIVE: To determine the clinical utility of longitudinal Doppler umbilical artery systolic-diastolic ratios (S/D) to predict the occurrence of either preeclampsia or fetal growth retardation (FGR) in a low-risk population. METHODS: Healthy nulliparas with singleton gestations were enrolled in a double-blind trial of low-dose (60 mg) aspirin for preeclampsia prevention. Treatment was initiated at 24 weeks and continued until delivery. Continuous-wave Doppler studies were scheduled before assignment to treatment and at 27-31, 32-36, and 37-42 weeks. Preeclampsia was defined as a persistent diastolic blood pressure of at least 90 mmHg with proteinuria, and FGR was defined as birth weight below the tenth percentile. Doppler values were considered abnormal if they exceeded the 90th percentile for the gestational age range in the study population. Summary predictive values were computed for the abnormal S/D at each gestational age interval. To assess the potential effect of the administration of low-dose aspirin, logistic regression was used to model the relation between the Doppler indices, aspirin use, and these abnormal pregnancy outcomes. RESULTS: A total of 1665 Doppler examinations were performed on 565 women. Forty-four fetuses developed FGR and 21 women were diagnosed with preeclampsia. The positive predictive values of an abnormal S/D for the subsequent development of FGR were 13-17% across the gestational age ranges studied, and the positive predictive values for preeclampsia were 0-5%. Aspirin treatment did not affect the relation between the Doppler indices and these outcomes in the logistic regression model. CONCLUSION: Elevated umbilical artery S/D is not a clinically useful predictor of either FGR or preeclampsia in a low-risk population.

Partner notification in the United States: an evidence-based review.

INTRODUCTION: To conduct an evidence-based review of the literature on the effectiveness of partner notification strategies for syphilis, gonorrhea, chlamydia, and human immunodeficiency virus (HIV) in the United States. METHODS: Systematic literature searches of available databases yielded 212 English language articles on partner notification, 13 of which met the inclusion criteria. These 13 articles were systematically reviewed, abstracted, and rated for quality of study methods, analysis, and generalizability. RESULTS: Partner notification can newly detect HIV and other sexually transmitted diseases among partners. Of the six high-quality studies, the highest numbers of infections per infected person, 0.23 and 0.24, were detected by provider referral while the lowest number of infections per infected person, 0.03, was detected by self referral. None of the 13 studies examined the consequences of partner notification, such as infections or health consequences averted or changes in behavior and partnerships for infected persons or their partners. CONCLUSIONS: There is good evidence that partner notification is a means of newly detecting infections. In addition, there is fair evidence that provider referral generally ensures that more partners are notified and medically evaluated than does self referral. More research is needed to improve elicitation and notification procedures and tailor them to specific populations, to assess the effect of new testing technologies on partner notification, and to understand the consequences of partner notification for infected persons and their partners.

Tissue debris at the injury site is coated by plasma fibronectin and subsequently removed by tissue macrophages.

Fibronectin (Fn) is a normal plasma and extracellular matrix glycoprotein that is thought to be important in reticuloendothelial system function as well as in promoting adhesion of various cell types to basement membranes and to each other. Plasma Fn levels are depressed following almost any type of trauma. It opsonizes circulating tissue debris for removal by the fixed cells of the reticuloendothelial system. It has been assumed but not proven that Fn also opsonizes tissue debris at the site of the injury for subsequent phagocytosis by tissue macrophages. In this study, rats were given intracardiac injections of Fn coupled with fluorescence isothiocyanate (Fn-FITC) and human serum albumin-rhodamine isothiocyanate (HSA-RITC). Abdominal Rebuck skin windows were then prepared. Within 24 hours, debris at the sites of injury were observed to be coated with Fn-FITC but not HSA-RITC. This Fn-labeled debris was subsequently ingested by macrophages at the site. No macrophages were found that had taken up HSA-RITC. Thus, Fn is seen to coat tissue debris and effete cells within the wound, and the coated material is subsequently removed by tissue macrophages.

Arousal-induced self-awareness: an artifactual relationship?

The present research was designed to test an alternative explanation for the arousal-self-awareness link found by Wegner and Giuliano (1980). Specifically, it was suggested that the running-in-place manipulation used by Wegner and Giuliano may have increased self-awareness, not because of the increased arousal it engendered, but because of its "unusual" nature. To test this hypothesis, subjects were assigned to one of three conditions: (a) fast running (both arousing and unusual), (b) slow running (unusual but not arousing), (c) control (neither arousing nor unusual). Results supported the unusual-behavior hypothesis; subjects in both running groups, regardless of speed (and arousal), showed more self-awareness on a sentence completion form than did those subjects in the control condition. The implications of these results for self-awareness theory are considered.

Albumin levels in pregnancy: a hypothesis--decreased levels of albumin are related to increased levels of alpha-fetoprotein.

Serum albumin levels decrease during pregnancy while the concentration of most other maternal serum proteins of hepatic origin remain stable or increase. In a study of 289 women, most maternal characteristics such as race, age, smoking, a history of previous low birth-weight, infant sex and gestational age at delivery were not related to maternal serum albumin levels at 18 or 30 weeks' gestational age. The degree of maternal obesity significantly correlated with the concentration of albumin. There was a significant negative correlation in individual women between maternal serum levels of albumin and alpha-fetoprotein, with high levels of maternal serum alpha-fetoprotein predicting lower levels of albumin. We hypothesize that there may be a negative feedback effect of alpha-fetoprotein of fetal origin on the maternal production of albumin during pregnancy.

Reproductive potential after methotrexate treatment of ectopic gestation in a community hospital.

OBJECTIVE: To compare the rates of ipsilateral tubal patency after methotrexate treatment versus conservative surgical treatment in a small community hospital lacking personnel dedicated to methotrexate management. STUDY DESIGN: From hospital and clinic records, cases of ectopic gestation within a six-year interval were identified. Method of treatment and location of the ectopic gestation were documented by review of records and confirmed by patient interviews. Women desiring fertility were offered hysterosalpingography (HSG) to evaluate tubal patency. HSG was performed under fluoroscopy with water-soluble contrast medium. RESULTS: HSG was completed in 11 cases of linear salpingostomy and 11 cases of ectopic gestations treated by methotrexate. Ipsilateral patency was documented in 8 of 11 (72%) tubes treated by linear salpingostomy and 9 of 11 (81%) methotrexate-treated tubes. One methotrexate case had a prior ipsilateral ectopic treated by salpingostomy, and two additional cases had a prior contralateral ectopic removed by salpingectomy. Each of these three cases had ipsilateral tubal patency after methotrexate for the most recent ectopic gestation. CONCLUSION: Data from this study suggest comparable tubal patency rates after methotrexate and conservative surgery. Comparable tubal patency outcomes were obtained in our community hospital despite a less-rigorous-than normal follow-up protocol.

The perimenopausal process: a case for advocacy.

As women enter their midlife transition, nursing advocates need to disseminate accurate and balanced information. Given the paucity of information on menopause to assist nurses as health promoters and educators, a study was conducted to identify the most prevalent concerns of the perimenopausal process, and the perceived impact experienced by women undergoing this transition. With this data, nurses can educate, support and counsel women to make informed treatment choices and maintain a general sense of well-being.

The effect of low-dose aspirin on umbilical artery Doppler measurements.

OBJECTIVE: Our purpose was to determine if the maternal administration of low-dose (60 mg) aspirin from 24 weeks' gestation until delivery is associated with significant changes in longitudinal umbilical artery Doppler index values. STUDY DESIGN: Healthy, young nulliparous women with singleton gestations who were enrolled in a double-blind trial of low-dose aspirin for preeclampsia prevention underwent prerandomization and monthly postrandomization continuous-wave umbilical artery Doppler evaluations. The systolic-to-diastolic ratio and the resistance index were determined at each examination. Compliance with the medical regimen was assessed by pill counts and measurement of maternal serum thromboxane B2 levels. RESULTS: The prerandomization Doppler index values were similar between the two randomization groups in the 538 (aspirin 266, placebo 272) patients studied. We found no significant differences with univariate comparisons and multiple linear regression modeling in the postrandomization Doppler index values (p = 0.21 to 0.96). No differences were found when patients were assessed by randomization assignment group (intent to treat) or by biochemical evidence for compliance and absence of crossover with maternal serum thromboxane B2 levels. CONCLUSION: The use of low-dose aspirin from 24 weeks' gestation until delivery does not significantly affect umbilical artery Doppler index values.

Fetal echocardiography in gravidas with historic risk factors for congenital heart disease.

All fetal echocardiograms performed at our institution between January 1, 1986, and June 1, 1991, were reviewed. The echocardiogram referral indication and results were verified for all women studied. Historic risk factors under consideration were pregestational diabetes, anticonvulsant or lithium ingestion in the first trimester, and a family history of congenital heart disease. Women with historic risk factors who had either a fetal abnormality on antenatal sonography or a known aneuploid fetus prior to the fetal echocardiograph were excluded. Of the 994 women who had a fetal echocardiogram performed during this study period, 486 (48.9%) were evaluated solely on the basis of a historic risk factor. Four of the 486 women (0.8%) were diagnosed as having a significant fetal structural cardiac malformation. Two of the four fetuses succumbed to obstetric complications. The remaining two infants were delivered at term and are doing well after postnatal cardiac surgery. In this select group of women with risk factors but no recognized fetal abnormality, the incidence of significant cardiac lesions was low. Although indications for fetal echocardiography must be evaluated on an individual basis, our data do not support a recommendation for the routine use of fetal echocardiography as a screening test in all women with historic risk factors.

The construction and utility of an amniocentesis trainer.

OBJECTIVE: Our goal was to design an inexpensive amniocentesis trainer for instruction and practice with ultrasonography-assisted needle guidance and the freehand technique. STUDY DESIGN: The amniocentesis trainer was constructed from a commercially available 5.3-L storage box (No. 5805; Rubbermaid Incorporated, Wooster, Ohio). Sonodense sperical targets 2.3 cm in diameter were taped to the bottom, and the box was filled with a gelatin mixture. The box was covered with a rubber membrane from a pelviscopy trainer (United States Surgical Corp, Norwalk, Conn). After the gelatin mixture set overnight at 40 degreesF, the amniocentesis trainer was ready for use. RESULTS: When a needle is introduced through the membrane into the gelatin, the ultrasonographic image is a reasonable simulation of an amniocentesis. The trainer improved the ability of an operator to perform a freehand amniocentesis, orient the ultrasound transducer, follow a needle with continuous ultrasonographic guidance, and hit a 2-cm target. The gelatin also allows for evaluation of improvement between amniocentesis attempts because a faint image of the needle track from prior attempts remains visible. Once basic amniocentesis skills are mastered, the trainer is easily modifiable so that obstacles can be added that could simulate umbilical cord and fetal extremities. CONCLUSIONS: We were able to construct an inexpensive amniocentesis trainer that facilitates instruction in the freehand amniocentesis technique. This trainer enables an operator to master the skills necessary to perform the technique of freehand ultrasonography-guided amniocentesis under direct ultrasonographic visualization without putting a patient through the discomfort of participating in the learning curve.