Biomarker feedback intervention for smoking cessation among Alaska Native pregnant women: Randomized pilot study.

OBJECTIVE: There is some evidence for biomarker feedback when combined with cessation counseling for reducing smoking in pregnancy. This randomized controlled pilot study evaluated feasibility and potential efficacy of a social-cognitive theory (SCT)-based biomarker feedback intervention among pregnant Alaska Native (AN) smokers. METHODS: Participants were randomly assigned to receive three study calls (10-20 min each): (1) biomarker feedback intervention (n = 30) including personalized cotinine results and feedback on their baby's likely exposure to carcinogen metabolite NNAL, or (2) contact control usual care condition based on the 5As (n = 30). Assessments were conducted at baseline, post-treatment, and delivery. RESULTS: High rates of treatment compliance, study retention, and treatment acceptability were observed in both groups. 7-day point prevalence smoking abstinence rates at delivery verified with urinary cotinine were the same in both study groups (20% intent-to-treat analysis, 26% per-protocol). SCT-based measures did not change differentially from baseline by study group. CONCLUSION: This trial supports the feasibility and acceptability of providing biomarker feedback within the clinical care delivery system, but the intervention did not promote increased smoking cessation during pregnancy compared to usual care. PRACTICE IMPLICATIONS: Efforts are needed to promote the usual care and to develop alternative biomarker feedback messaging for pregnant AN women.

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.

Perceived risks and reasons to smoke cigarettes during pregnancy among Alaska native women.

OBJECTIVE: The purpose of this study was to explore perceptions of the risks of smoking and reasons Alaska Native women give for smoking during pregnancy. DESIGN: A total of 118 women (54 smokers, 64 non-smokers) enrolled in a biomarker study and completed a baseline interview asking about their concerns regarding tobacco use while pregnant and reasons why pregnant women might smoke during pregnancy. Responses were collapsed into six categories of perceived risks of smoking and eight categories of reasons to smoke during pregnancy. RESULTS: The majority of both pregnant non-smokers and smokers (72.6% and 60.4%) agreed that smoking during pregnancy could negatively impact the health of their baby. However, non-smokers were more likely than smokers (77.4% vs. 58.5%) to view smoking during pregnancy as a risk factor for the baby's development (p = .029). Both non-smokers and smokers identified addiction as a reason for smoking during pregnancy (82.8% and 63%); however, non-smokers were more likely than smokers to state this was a reason for use (p = .015). Seventy-three percent of the entire sample reported a reason to smoke in pregnancy was to help manage negative affect. CONCLUSION: Results from this work may be helpful in advancing research by identifying targets for intervention specific to Alaska Native women receiving prenatal care in Anchorage, Alaska.

Developing a Biomarker Feedback Intervention to Motivate Smoking Cessation During Pregnancy: Phase II MAW Study.

INTRODUCTION: The prevalence of smoking during pregnancy for Alaska Native (AN) women is more than triple that of non-Native Alaska women. In this qualitative study, we solicited input from AN women and others to determine how best to present findings from an earlier study demonstrating a strong correlation between biomarkers for maternal smoking (cotinine) and neonatal exposure to a tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) to motivate cessation. METHODS: We developed a brochure incorporating generalized biomarker information. Using in-depth individual interviews with pregnant and postpartum AN women and partners/family members, we explored applicability and acceptability of the information. Postpartum women, who had participated in the earlier correlation study, additionally received their individual biomarker results. We assessed whether being presented general or individual biomarker information would motivate cessation using content analysis. RESULTS: We conducted 39 interviews: 16 pregnant women, 12 postpartum women, and 11 partners/family members. Overall, participants agreed the biomarker information was new, but understandable as presented. Postpartum women shared that learning their personal results inspired them to want to quit or cut back smoking while pregnant women indicated the generalized correlation information was less helpful in motivating cessation. CONCLUSION: Generalized information about fetal exposure to carcinogens may be more effective in motivating pregnant women to quit smoking when combined with individual cotinine testing. IMPLICATIONS: Using feedback from this study, we refined and are currently evaluating an intervention incorporating generalized correlation information from Phase I and cotinine testing to determine its effectiveness in motivating smoking cessation among pregnant AN women.

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.

Cesarean delivery: counseling issues and complication management.

Nearly one-third of all deliveries in the United States are cesarean deliveries. Compared with spontaneous vaginal delivery, cesarean delivery is associated with increased maternal and neonatal morbidity and mortality. Interventions that decrease the chance of a cesarean delivery include avoiding non-medically indicated induction of labor, avoiding amniotomy, and having a doula present. In North America, the most common reasons for cesarean delivery include elective repeat cesarean delivery, dystocia or failure to progress, malpresentation, and fetal heart rate tracings that suggest fetal distress. Post-cesarean delivery complications include pain, endomyometritis, wound separation/infection, urinary tract infection, gastrointestinal problems, deep venous thrombosis, and septic thrombophlebitis. Women with no risk factors for deep venous thrombosis other than the postpartum state and the operative delivery do not require thromboembolism prophylaxis other than early ambulation. A pregnant woman's decision to attempt a trial of labor after cesarean delivery or have a planned repeat cesarean delivery involves a balancing of maternal and neonatal risks, as well as personal preference after counseling by her physician. Approximately 75% of attempted trials of labor after cesarean delivery are successful. Provision of advanced maternity care practices by family physicians, including serving as primary surgeons for cesarean deliveries, is consistent with the goals of the patient-centered medical home.

Trauma in pregnancy: assessment, management, and prevention.

Trauma complicates one in 12 pregnancies, and is the leading nonobstetric cause of death among pregnant women. The most common traumatic injuries are motor vehicle crashes, assaults, falls, and intimate partner violence. Nine out of 10 traumatic injuries during pregnancy are classified as minor, yet 60% to 70% of fetal losses after trauma are a result of minor injuries. In minor trauma, four to 24 hours of tocodynamometric monitoring is recommended. Ultrasonography has low sensitivity, but high specificity, for placental abruption. The Kleihauer-Betke test should be performed after major trauma to determine the degree of fetomaternal hemorrhage, regardless of Rh status. To improve the effectiveness of cardiopulmonary resuscitation, clinicians should perform left lateral uterine displacement by tilting the whole maternal body 25 to 30 degrees. Unique aspects of advanced cardiac life support include early intubation, removal of all uterine and fetal monitors, and performance of perimortem cesarean delivery. Proper seat belt use reduces the risk of maternal and fetal injuries in motor vehicle crashes. The lap belt should be placed as low as possible under the protuberant portion of the abdomen and the shoulder belt positioned off to the side of the uterus, between the breasts and over the midportion of the clavicle. All women of childbearing age should be routinely screened for intimate partner violence.

HPV genotypes detected in cervical cancers from Alaska Native women, 1980-2007.

BACKGROUND: Human papillomavirus (HPV) vaccine prevents cervical pre-cancers and cancers caused by HPV types 16 and 18. This study provides information on the HPV types detected in cervical cancers of Alaska Native (AN) women. METHODS: Cases of invasive cervical cancer diagnosed in AN women aged 18 and above between 1980 and 2007 were identified from the Alaska Native Tumor Registry. A representative formalin-fixed, paraffin-embedded archived pathology block was retrieved and serially sectioned to allow histologic confirmation of lesion (first and last sections) and PCR testing of intervening sections. Extracted DNA was tested for HPV using Linear Array HPV Genotyping Test (Roche Diagnostics) with additional INNO-LiPA HPV Genotyping Assay (Innogenetics) testing on negative or inadequate specimens. All specimens were tested for a minimum 37 HPV types. RESULTS: Of 62 cervical cancer specimens evaluated, 57 (91.9%) contained one or more HPV types. Thirty-eight (61.2%) cancers contained HPV types 16 or 18, and 18 (29%) contained an oncogenic type other than type 16 or 18. CONCLUSIONS: Overall, almost two-thirds (61.2%) of the archived cervical cancers had detectible HPV types 16 or 18, a finding similar to studies of US women. As expected, a proportion of cancers would not be prevented by the current vaccines. HPV vaccination and cervical cancer screening are important prevention strategies for AN women.

The roundtrip to Fairbanks: the circumpolar health movement comes full circle, part II.

OBJECTIVES: Evaluate the course of the International Union for Circumpolar Health (IUCH) and the Proceedings of the International Congress(s) on Circumpolar Health (ICCH) in the context of the concomitant historical events. Make recommendations for future circumpolar health research. STUDY DESIGN: Medline search and historical archive search of ICCH Proceedings. METHODS: Search of all PubMed resources from 1966 concerning the circumpolar health movement. Two University of Alaska, Anchorage Archive Collections were searched: the C. E. Albrecht and Frank Pauls Archive Collections. RESULTS: Fourteen sets of Proceedings manuscripts and one set of Proceedings Abstracts were evaluated. There was a trend towards consistent use of the existing journals with indexing in Index Medicus; shorter intervals between the Congress and Proceedings manuscript publication; and increased online availability of either the Table of Contents or Proceedings citations. Recent additions include online publication of full-length manuscripts and 2 instances of full peer-review evaluations of the Proceedings manuscripts. These trends in Proceedings publication are described within the course of significant events in the circumpolar health movement. During this period, the IUCH funds are at an all-time low and show little promise of increasing, unless significant alternative funds strategies are pursued. CONCLUSIONS: The IUCH has matured politically over these years, but some of the same questions persist over the years. There has been a trend towards more rapid dissemination of scientific content, more analytic documentation of epidemiologic study design and trend towards wider dissemination of scientific content through the Internet. Significant progress in each of those areas is still possible and desirable. In the meantime, the IUCH should encourage alternative funding strategies by developing a foundation to support on-going expenses, for example Hildes awards; explore venues to finance Council President and At-Large members travel costs; and seek grants to fund special projects, for example special supplements in the IJCH.

The circumpolar health movement comes full circle.

OBJECTIVES: Evaluate the course of the International Congress(es) on Circumpolar Health (ICCH) and the Circumpolar movement in the context of concomitant historical events. Make recommendations for future Circumpolar health research. STUDY DESIGN: MEDLINE search and historical archive search of ICCH proceedings. METHODS: Search of all PubMed resources from 1966 concerning the Circumpolar health movement. Two University of Alaska Anchorage archive collections were searched: the C. E. Albrecht and Frank Pauls Archive Collections. RESULTS: Eleven sets of proceedings manuscripts and one set of proceedings abstracts were evaluated. There was a trend toward consistent use of existing journals with indexing in Index Medicus; shorter intervals between the Congress and proceedings manuscript publication; and increased online availability of either the table of contents or proceedings citations. Recent additions include online publication of full length manuscripts and two instances of full peer review evaluations of the proceedings manuscripts. These trends in proceedings publication are described within the course of significant events in the Circumpolar health movement. CONCLUSIONS: There has been a trend toward more rapid dissemination of scientific content, more analytic documentation of epidemiologic study design, and a trend toward wider dissemination of scientific content through the Internet. Significant progress in each of those areas is still possible and desirable.

The circumpolar health movement comes full circle.

OBJECTIVES: Evaluate the course of the International Congress(es) on Circumpolar Health (ICCH) and the Circumpolar movement in the context of concomitant historical events. Make recommendations for future Circumpolar health research. STUDY DESIGN: MEDLINE search and historical archive search of ICCH proceedings. METHODS: Search of all PubMed resources from 1966 concerning the Circumpolar health movement. Two University of Alaska Anchorage archive collections were searched: the C. E. Albrecht and Frank Pauls Archive Collections. RESULTS: Eleven sets of proceedings manuscripts and one set of proceedings abstracts were evaluated. There was a trend toward consistent use of existing journals with indexing in Index Medicus; shorter intervals between the Congress and proceedings manuscript publication; and increased online availability of either the table of contents or proceedings citations. Recent additions include online publication of full length manuscripts and two instances of full peer review evaluations of the proceedings manuscripts. These trends in proceedings publication are described within the course of significant events in the Circumpolar health movement. CONCLUSIONS: There has been a trend toward more rapid dissemination of scientific content, more analytic documentation of epidemiologic study design, and a trend toward wider dissemination of scientific content through the Internet. Significant progress in each of those areas is still possible and desirable.

The circumpolar health movement comes full circle. Part I: Historical relevance of the proceedings of the International Congresses on Circumpolar Health.

OBJECTIVES: Evaluate the course of the International Congress on Circumpolar Health (ICCH) Proceedings in the context of the concomitant historical events. Make recommendations for future circumpolar health research. STUDY DESIGN: Medline search and historical archive search of International Congress on Circumpolar Health Proceedings. METHODS: Search of all PubMed resources from 1966 concerning the circumpolar health movement. Two University of Alaska, Anchorage Archive Collections were searched: the C. E. Albrecht and Frank Pauls Archive Collections. RESULTS: Eleven sets of Proceedings manuscripts and one set of Proceedings Abstracts were evaluated. There was a trend toward consistent use of existing journals with indexing in Index Medicus; shorter intervals between the Congress and Proceedings manuscript publication; and increased online availability of either the Table of Contents, or Proceedings citations. Recent additions include online publication of full-length manuscripts and two instances of full peer review evaluations of the Proceedings manuscripts. These trends in Proceedings publication are described within the course of significant events in the circumpolar health movement. CONCLUSIONS: There has been a trend toward more rapid dissemination of scientific content, more analytic documentation of epidemiologic study design, and a trend toward wider dissemination of scientific content through the Internet. Significant progress in each of those areas is still possible and desirable.