Social Disparities in Maternal Smoking during Pregnancy: Comparison of Two Birth Cohorts (1996-2002 and 2003-2012) Based on Data from the German KiGGS Study.

Background: Maternal smoking during pregnancy represents a significant developmental risk for the unborn child. This study investigated social differences in maternal smoking behavior during pregnancy in mothers living in Germany. The study focused on maternal age at delivery, social status and migration background. Method: The evaluation of data was based on two surveys carried out as part of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) carried out in 2003-2006 and in 2009-2012. The study compared the information given by parents of children aged between 0 and 6 years who were born either in the period from 1996 to  2002 (KiGGS baseline study, n = 4818) or in the period from 2003 to 2012 (KiGGS Wave 1, n = 4434). Determination of social status was based on parental educational levels, occupational position and income. Children classified as having a two-sided migration background either had parents, both of whom had immigrated to Germany, or were born abroad and had one parent who had immigrated to Germany; children classified as having a one-sided migration background had been born in Germany but had one parent who had immigrated to Germany. Results: The percentage of children whose mothers had smoked during pregnancy was 19.9 % for the older birth cohort and 12.1 % for the younger birth cohort. In both birth cohorts, the probability of being exposed to tobacco smoke was twice as high for children whose mothers were aged < 25 years at delivery compared to the children of older mothers. Children from socially deprived families were most affected by smoking behavior, and the relative social differences were found to have even increased over time (KiGGS baseline study: OR = 6.34; 95 % CI = 4.53-8.86; KiGGS Wave 1: OR = 13.88; 95 % CI = 6.85-28.13). A two-sided migration background was associated with a lower risk of exposure to smoking. Conclusions: The KiGGS results are in accordance with the results of other national and international studies which have shown that the percentage of mothers who smoke during pregnancy is declining. Because of a change in the method how data are collected for the KiGGS survey (written questionnaire vs. telephone interview) the trend results must be interpreted with caution. Measures aimed at preventing smoking and weaning women off smoking should focus particularly on younger and socially deprived mothers.

[Measuring subjective social status in health research with a German version of the MacArthur Scale]. / Messung des subjektiven sozialen Status in der Gesundheitsforschung mit einer deutschen Version der MacArthur Scale.

In health research, socio-economic status (SES) is traditionally assessed using objective indicators (education, occupation, income). For a couple of years, there has been a growing body of studies that additionally assess the subjective social status (SSS) of respondents, mostly using the MacArthur Scale. The aim of this study was to examine the construct validity of a German-language version of this instrument and to investigate whether SSS is associated with health over and above objective SES. Analyses were based on data from a population-based pilot study carried out within the 'German Health Update' (GEDA) study conducted by the Robert Koch Institute (n = 1,571; age: 18-79 years). SSS was measured with the MacArthur scale asking respondents to place themselves on a 10-rung "social ladder". The strongest correlations to SSS were found with measures of similar constructs such as a multidimensional index of objective SES, income level, occupational position and educational attainment (r = 0.32-0.60; p < 0.001). Weaker correlations were found between SSS and measures of dissimilar constructs such as social support, mental well-being, depressiveness, and body-mass-index (r = - 0.29-0.30; p < 0.001). Factor analysis did not show considerable loadings of SSS on factors of mental well-being and depressiveness. After adjusting for age, education, occupation, and income, lower SSS remained significantly associated with higher odds of adverse health (p < 0.05). The findings of this study provide support for the convergent and discriminant validity of the MacArthur Scale and indicate that self-perceptions of social disadvantage may have health implications beyond the impact of objective SES.

[Tobacco and alcohol consumption among 11- to 17-year-old adolescents: results of the KiGGS study: first follow-up (KiGGS Wave 1)]. / Tabak- und Alkoholkonsum bei 11- bis 17-jährigen Jugendlichen : Ergebnisse der KiGGS-Studie - Erste Folgebefragung (KiGGS Welle 1).

In this paper, tobacco and alcohol consumption among adolescents in Germany was analyzed. In addition to the current situation, we report temporal developments and trends. Data were obtained from the first follow-up of the KiGGS study (KiGGS Wave 1) conducted from 2009 to 2012. All girls and boys aged 11-17 years (n = 5,258) were included. The results show that currently 12.0% of 11- to 17-year-old adolescents in Germany smoke, 5.4% of them on a daily basis. At-risk drinking (AUDIT-C total score) was prevalent among 15.8% of adolescents, heavy episodic drinking (six or more alcoholic standard drinks on a single occasion at least once a month) among 11.5%. No significant gender differences were found for most indicators. However, among adolescents aged 14-17 years, boys revealed a greater inclination toward heavy episodic drinking than girls did (23.1 vs. 16.5 %, p < 0.01). Regarding smoking, distinct socioeconomic differences were observed. For example, adolescents from families with a low socioeconomic status (SES) smoke significantly more often on a regular or daily basis compared with their peers from high-SES families (OR = 1.95, 95% CI = 1.16-3.27 and OR = 3.71, 95% CI = 2.05-6.69, respectively). The relationship between SES and alcohol consumption is rather weak. Significant differences emerged only regarding lifetime prevalence of alcohol consumption, and indicate lower consumption rates among low-SES compared with high-SES adolescents (OR = 0.47, 95% CI = 0.33-0.68). Consideration of the KiGGS baseline study data (2003-2006) shows that smoking prevalence has dropped almost by half from 20.4 to 12.0%. The percentage of adolescents who have ever drunk alcohol has decreased from 62.8 to 54.4%. These results are consistent with the findings of other studies on adolescent tobacco and alcohol consumption and should be considered in the context of preventive efforts that have been strengthened in recent years, especially regarding tobacco use.

[Educational differences in smoking and smoking cessation among young adults. Results from the "German Health Update" (GEDA) Study 2009 and 2010]. / Bildungsunterschiede im Tabakkonsum und Rauchausstieg junger Erwachsener. Ergebnisse der Studie "Gesundheit in Deutschland aktuell" (GEDA) 2009 und 2010.

BACKGROUND: Studies show that adolescents attending upper secondary schools are less likely to smoke than their peers attending lower secondary school types. This article examines how educational differences in smoking behaviour continue in young adulthood. Besides frequency and intensity of tobacco use the main focus is on smoking cessation. METHODS: The analyses were based on information of the 18- to 29-year-old men and women who participated in the nationwide representative telephone survey "German Health Update" (GEDA) 2009 and 2010 carried out by the Robert Koch Institute (n=7,620). Smoking behaviour was measured by several questions on smoking frequency and intensity. Educational status was assessed by the highest school-leaving certificate and classified as low (no school-leaving certificate/Hauptschule certificate), middle (General Certificate of Secondary Education/Realschule certificate), and high (general qualification for university entrance (Abitur)/advanced technical college entrance qualification). In addition to prevalence estimates, age-adjusted odds ratios (OR) and corresponding 95% confidence intervals (95% CI) were calculated using logistic regression. RESULTS: According to the GEDA study, the prevalence of smoking was 42.6% among men and 36.7% among women aged 18-29 years. The prevalence of current smoking increased with decreasing educational level. The odds of current smoking was 3.72-times higher in lower as compared to higher educated men (95% CI 2.90-4.77) and 3.00-times higher in lower as compared to higher educated women (95% CI 2.30-3.92). Moreover, high intensity of tobacco use was also associated with lower education in men and women. The odds of successful quitting was significantly reduced in the lowest compared to the highest educational group (men: OR=0.45; 95% CI 0.31-0.66; women: OR=0.65; 95% CI 0.44-0.94). CONCLUSION: Our findings suggest that young adults with low education are more likely to start smoking and less likely to quit than their higher educated peers. Therefore, tobacco prevention and cessation initiatives should more focus on lower educated young adults.

[Subjective social status and health-related quality of life among adults in Germany. Results from the German General Social Survey (ALLBUS 2010)]. / Subjektiver Sozialstatus und gesundheitsbezogene Lebensqualität bei Erwachsenen in Deutschland. Ergebnisse der Allgemeinen Bevölkerungsumfrage der Sozialwissenschaften (ALLBUS 2010).

BACKGROUND: The impact of subjective perception of social status on health has been analysed in international health research for several years. However, in Germany the empirical analysis of the relation between subjective social status (SSS) and health is still in the very early stages. This study investigates if health-related quality of life (HRQoL) in German adults is associated with SSS over and above conventional measures of social status. METHODS: The results are based on the German General Social Survey (ALLBUS 2010), a representative cross-sectional survey of the adult resident population in Germany (n=2 827). HRQoL was assessed with 4 items referring to self-rated health (SRH) and impairment of well-being due to bodily pain, depressiveness, and loneliness. SSS was measured with a 10-point scale where participants rated their status in society. The impact of SSS on HRQoL was analysed separately for men and women using logistic regression models adjusted for age, school education, net equivalent household income, and occupational position. RESULTS: Poorer SRH, bodily pain, depressiveness, and loneliness occurred significantly more often in men and women with low SSS compared to those with higher SSS. After adjusting for age, education, income, and occupation, the effects of SSS on SRH and depressiveness remained significant in men and women (SRH: men: OR=4.76; 95% CI=2.52-8.99; women: OR=2.95; 95% CI=1.74-4.99; depressiveness: men: OR=2.86; 95% CI=1.60-5.10; women: OR=2.75; 95% CI=1.65-4.56). The effects of SSS on bodily pain and loneliness were observed only in women after adjustment for objective status indicators (OR=1.75; 95% CI=1.07-2.86 and OR=3.03; 95% CI=1.43-6.42, respectively). CONCLUSION: These findings indicate that self-perception of social disadvantage affects HRQoL in German adults independently and partly gender-specifically. Hence, complementary to objective status indicators the SSS offers additional potential for describing and explaining health inequalities.

[How healthy is the lifestyle of adolescents in Germany?]. / Wie gesund leben Jugendliche in Deutschland?

BACKGROUND: Studies on the health behaviour of adolescents mostly examine single health behaviour indicators in a separate manner for each one. However, health behaviours are not independently developed, but occur within a broader behavioural scheme acquired during socialisation. The aim of this study is to analyse the distribution of health-related behaviour patterns in adolescence by using a composite index made up of 6 single indicators allowing for sociodemographic and socioeconomic variables. METHODS: The data are derived from a subsample of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), carried out by the Robert Koch Institute between May 2003 and May 2006 (age: 11-17 years, n=6 813). The creation of an additive healthy lifestyle index (HLI) is based upon data regarding smoking behaviour, body mass index, physical activity, use of electronic media, alcohol intake and fruit and vegetable consumption. The highest score of HLI is taken as a single indicator of a healthy lifestyle. Independent variables are socioeconomic status (SES) of the family of origin, school type and migration background. All analyses were done taking into account potential age and gender differences. RESULTS: Girls adhere more often to a recommended healthy lifestyle than boys (25.4% and 18.7%, respectively). The proportion of adolescents adhering to all 6 HLI categories decreases with every year of life. Adolescents with a low SES and adolescents from secondary general schools ("Hauptschule") reach to a significantly lower extent the highest score of HLI than peers with a middle or high SES and adolescents attaining other types of schools. CONCLUSIONS: The results of the created HLI refer to latent potentials for prevention and specific target groups for health promotion measures.

Acquired factor VIII inhibitors in nonhemophilic patients.

Antibodies against factor VIII occur in about 15-35% of hemophilia A patients and induce refractoriness to factor VIII substitution. In most cases, these antibodies are of the IgG class. Strategies to avoid or to treat such inhibitors are controversial. In very rare cases, factor VIII inhibitors also develop in nonhemophilic patients. Although there are anecdotal reports that these antibodies may disappear spontaneously without occurrence of bleeding tendencies, in the majority of patients the clinical course is characterized by severe hemorrhages. From 1980 to 1995, we observed ten nonhemophilic patients with acquired factor VIII inhibitors at our hospital. In most cases, a sudden bleeding tendency was observed shortly after an injury or surgery. Coagulation tests showed a prolonged aPTT and a decreased F VIII level. Other deficiencies of blood-clotting factors and acquired or hereditary von Willebrand's disease were excluded. Therapy with F VIII concentrates did not produce the expected increase. Measurement of F VIII inhibitor levels in Bethesda units/ml (BU/ml) revealed maximal values in the range of 2-128 BU/ml. Immunosuppressive therapy with azathioprine or cyclophosphamide in combination with methylprednisolone led to complete disappearance of the inhibitor, normalization of the coagulation tests, and complete remission of the bleeding tendency in seven treated patients within 6 weeks. Although the clinical course is not predictable and inhibitors may disappear spontaneously, combined therapy with methylprednisolone and azathioprine or cyclophosphamide is recommended for patients with bleeding tendency. In pregnancy, therapy should be started only with methylprednisolone; post-partum, azathioprine should be used additionally if methylprednisolone as a single drug does not lead to complete remission. In emergency situations, therapy with high doses of human factor VIII concentrate may be used. When bleeding does not cease, the additional use of activated prothrombin-complex concentrates or porcine factor VIII is indicated. Possible side effects may include hepatitis and short-lived intravascular thrombin production.

Saline locks in prehospital care.

OBJECTIVES: 1) To determine if paramedics could select appropriate patients for use of the saline lock; 2) to evaluate saline-lock patency upon arrival at the emergency department (ED); and 3) to define any cost-savings associated with the use of the saline lock. POPULATION: Patients in the prehospital setting who required intravenous (IV) access, but did not require fluid resuscitation. Patients with hypotension or multiple traumatic injuries were excluded. METHODS: Paramedics were given the option for the use of either the saline lock or a routine IV set-up. Initially, the reservoir was flushed with 1 ml 0.9 N saline solution and the flush was repeated only if medications subsequently were completed for each patient. Information collected included: 1) demographics; 2) reason for selection; 3) need for fluid infusion; 4) conversion of the lock to a routine IV set-up; and 5) administration of medications through the lock. Failures included inability to flush after arrival to the ED, or local infiltration detected on flush while in the ED. Costs associated with the use of the saline locks were compared with those associated with the use of traditional IV set-ups. Cost-savings were calculated as the cost of a traditional IV set-up minus costs of the lock set-up. RESULTS: A total of 58 male and 42 female patients was enrolled. All patients were assigned appropriately. The most commonly used indications included chest pain, possible stroke, and shortness of breath. Two locks were occluded, and two had infiltrated when flushed following arrival of the patient to the ED. Five patients had IV fluid loads initiated through the locks. Cumulative cost-saving were [U.S.]$130 to the hospitals and $1,710 to the patients or their carriers. Most paramedics were pleased with the performance and utility of the locks. CONCLUSIONS: The use of saline locks is an alternative to the use of traditional IVs in certain patients in the prehospital setting.

[T-helper (CD4+) cytopenia and HLA-A1, -B8, -C27, -DR3]. / T-Helfer(CD4+)-Zytopenie und HLA-A1, -B8, -Cw7, -DR3.

HLA antigen frequencies have been evaluated in a group of 99 AIDS patients who died with low T-helper cell counts. 34 patients also had HIV-associated Kaposi's sarcoma (KS). HLA-A1, Cw7, B8, DR3 has been postulated to be associated with rapid decline of T-helper cells in AIDS patients and with fast disease progression of AIDS. The results of this study support this hypothesis. However, significant elevations of these HLA antigens solely have been found in the group of patients with opportunistic infections, but not in patients with KS.

[Resuscitation necessitated by a transfusion reaction after HLA mismatched platelets substitution]. / Reanimationsbedürftige Transfusionsreaktion nach HLA-unangepasster Thrombozytensubstitution.

A severe nonhemolytic transfusion reaction occurred to a polytransfused leukemic patient as a life-threatening anaphylactic shock with cardio-pulmonary arrest following the transfusion of HLA-nonadapted/mismatched platelets. As the only potential causative agent a lymphocytotoxic antibody with the specificity anti-HLA-A2 has been found. The HLA antibody reacted up to a dilution of 1:2,048. The recipient was negative for the corresponding antigen, but HLA-2 was present on donor's platelets. This observation demonstrates again the clinical value of HLA-matched platelet transfusion in patients who need long-term support.

[Ex-vivo bleeding time as a control for platelet transfusion]. / Ex-vivo-Blutungszeit zur Kontrolle der Thrombozytentransfusion.

Thrombocytopenia is the most common cause of bleeding tendency and, if due to impaired platelet production, is best treated by platelet transfusion. For patients with acute leukemia prophylactic platelet transfusion should be considered if platelet count is below 20 x 10(9)/l. This will be underlined by a retrospective analysis at our clinic of 231 patients suffering from acute myelocytic leukemia (AML FAB M1-7) and showing an early-death rate of 7.7% by bleeding complications. To estimate the effectiveness of platelet transfusions, not only stopping of bleeding symptoms and corrected count increment (CCI) should be taken into account but also whether the patient has fever, sepsis, hepato-splenomegaly or has taken special drugs. Measuring the in vivo bleeding time is of little use for low reproduction and is stressing for patients. In 1985 Kratzer described a new and sensitive method for the evaluation of platelet function. After modifying this method it is now possible to test platelet function even with platelet counts below 50 x 10(9)/l.

[Plasminogen activator inhibitor 1--a new thrombosis risk marker]. / Plasminogenaktivator-Inhibitor 1--ein neuer Thromboserisiko-Marker.

The plasma activity of plasminogen activator inhibitor 1 (PAI-1) was measured in 278 clinically healthy subjects (98 men, 180 women; mean age 26 [18-50] years). In 198 of them there were factors increasing the risk of thrombosis, such as smoking, over-weight and/or oral contraceptives. PAI-1 activity was within normal range (less than 4 U/ml) in male nonsmokers of normal weight and in female nonsmokers not taking oral contraceptives. In male smokers (5.76 +/- 1.93 U/ml) and in overweight subjects of both sexes (7.49 +/- 1.87 U/ml) PAI-1 was increased up to 10.6 U/ml as an indication of decreased fibrinolysis capacity. Nonsmoking females on oral contraceptives had lower PAI-1 levels (2.72 +/- 0.86 U/ml) than nonsmokers without hormonal intake (3.21 +/- 1.03 U/ml; P less than 0.001). Apparently the increased risk of thrombosis that occurs on oral contraceptives is not due to increased PAI-1 activity.

Exploring the grief of adolescents after the death of a parent.

This study explored the grief of 26 adolescents after the death of a parent during the subjects' adolescent years. Data collection involved a one-time semi-structured interview. In addition, the adolescents were asked to write and draw about death. The study identified variables and themes that appeared to have possible significance for how adolescents coped. The study conclusions were that adolescents do grieve differently from children and differently from adults; younger adolescents even grieve differently from older adolescents. No discernible differences in grieving were ascertained on the basis of sex, type of death, or prior loss experiences. The one adolescent who was perceived as grieving in an adaptive manner had the advantage of open communication with family members, had closure with the parent now dead, had seen the parent when dead, and had been involved with the rituals surrounding the death. Implications for future research and recommendations for adults involved with adolescents are included.

Elastic fiber components and protease inhibitors in pinguecula.

The nature of the abnormal elastotic materials seen in pingueculae and their insensitivity to elastase are poorly understood. The authors investigated their composition by immunoelectron microscopy using antibodies to elastic fiber components, serum and tissue components known to be associated with elastosis in other sites. The abnormal elastic fibers showed labeling for elastin, microfibrillar protein, and amyloid P where these components never co-localize normally, indicating the fibers are not simply immature but aberrant in organization. There was mild positivity for the serum protease inhibitor alpha-1 antitrypsin at the edges of the abnormal elastic tissue and marked positivity for lysozyme. The more superficial region of pingueculae had similar elastic constituents but no fiber formation and a paucity of elastic microfibrils. The subepithelial dense concretions showed strong staining for lysozyme, the first component to be identified in these aggregates. Amyloid P and lysozyme are characteristic components of dermal elastosis, postulated to have an inhibitory effect on elastolytic processes, indirectly affecting the control of elastogenesis. The greater prominence of nonfiber-forming aggregates in pingueculae may be related to their marked deficiency of elastic microfibrils compared with dermal elastoses. This difference speaks for more severe actinic cellular damage in the poorly protected conjunctival tissue.

[Prevention of HLA-alloimmunization of recipients of platelet concentrates]. / Prophylaxe von HLA-Alloimmunisierung bei Empfängern von Plättchen-Konzentraten.

Over a period of twelve months 7163 HLA-matched, single-donor platelet concentrates were prepared for 557 thrombocytopenic patients with hematologic or neoplastic disorders. 80% of the platelet recipients remained HLA-antibody-negative. Patients who developed HLA-antibodies received random platelets and/or leukocyte-contaminated blood-components simultaneously. Thus, HLA-matching, single-donor-preparations and removal of contaminating leukocytes may prevent HLA-alloimmunisation, and therefore improve the efficacy of platelet-transfusion.

Three cases of acquired factor VIII: C inhibitors in non-hemophilic patients.

During the last ten years we observed three non-hemophilic patients with factor(F) VIII: C inhibitors (2 women aged 68 and 80 and a man aged 51). In all three cases, a sudden bleeding tendency was observed shortly after an injury or surgery. Coagulation tests showed a prolonged aPTT and a decreased F VIII: C level. Other deficiencies of blood-clotting factors and acquired or hereditary von Willebrand's disease could be excluded. Therapy with F VIII: C concentrate, cryoprecipitate, or fresh-frozen plasma did not produce the expected increase in F VIII: C. Measurement of F VIII: C inhibitor levels (Bethesda Units, BU) revealed values in the range between 9 and 64 BU. The two patients subjected to long-term therapy with a combination of prednisone (initially 2-3 mg/kg BW) and azathioprine (2-3 mg/kg BW) responded positively; the F VIII: C concentration increased. The third patient, treated only with a low dose of prednisone (30 mg/day), did not show any reaction at all. Since hereditary hemophilia A could be excluded, the inhibitors apparently were acquired. Malignant tumors did not appear. In conclusion, long-term therapy of an acquired F VIII: C inhibitor with a combination of prednisone and azathioprine may lead to complete disappearance of the inhibitor, normalization of the coagulation tests, and complete remission of the bleeding tendency.

[Clinical and serological characterization of Chlamydia-induced arthritis]. / Klinische und serologische Charakterisierung der Chlamydien-induzierten arthritis.

Chlamydia-induced arthritis was diagnosed in 32 patients (18 men and 14 women; mean age 33 [17-54] years). 13 were HLA-B27 positive. In 19 patients the arthritis was largely confined to one joint. Enthesopathies occurred in 14 patients, and in 13 sacroiliitis was diagnosed radiologically. The most frequent extra-articular changes affected the urogenital system (26 cases). The full Reiter syndrome was present in seven patients (four men, three women). All patients had serum antibodies against Chlamydia. In 16 patients Chlamydia was diagnosed as the causative organism by urogenital swab. Chlamydia-induced arthritis differs from other arthritides in the high proportion of HLA-B27 negative patients.

[The immunologically-caused early abortion]. / Der immunologisch bedingte Frühabort.

Recent advances in the understanding of immunological events during pregnancy offer new diagnostic and therapeutic approaches to couples suffering from unexplained recurrent spontaneous abortion. In terms of immunology the success of pregnancy means, that the fetus as a semi-allogeneic graft is not rejected by the mothers/recipients immune system. Beside a variety of specific and non-specific mainly locally acting substances a process of active tolerance induction is responsible for fetal survival. In response to paternally inherited fetal antigens the maternal immune system produces so-called blocking factors. In most women with unexplained recurrent spontaneous abortion these blocking factors cannot be detected. By immunization with paternal or third party lymphocytes the maternal immune system can be stimulated to produce blocking factors and therefore to protect a conceptus from rejection.

Time-dependent variation of HLA-antigen-frequencies in HIV-1-infection (1983-1988).

In a 5-year-study of HLA-phenotypes in 411 HIV-1-infected individuals, a progressive decrease of the formerly elevated frequency of HLA-DR5 has been observed. HLA-DR3 seems to have a protective effect. These results are discussed with respect to the mimicry-hypothesis of HLA and disease associations. Further preliminary results indicate that HIV-associated Kaposi's sarcoma could be associated with HLA-A28, and therefore might be a different etiologic entity than HIV-infection alone.