Birth weight, maternal weight and childhood leukaemia.

There is mounting evidence that childhood leukaemia is associated with high birth weight, but few studies have examined the relationship between leukaemia and other perinatal factors that influence birth weight, such as maternal weight or gestational weight gain. This case-cohort study included 916 acute lymphocytic leukaemia (ALL) and 154 acute myeloid leukaemia (AML) cases diagnosed prior to age 10 years between 1985 and 2001 and born in New York State excluding New York City between 1978 and 2001. Controls (n=9686) were selected from the birth cohorts for the same years. Moderate increased risk of both ALL and AML was associated with birth weight 3500 g or more. For ALL, however, there was evidence of effect modification with birth weight and maternal prepregnancy weight. High birth weight was associated with ALL only when the mother was not overweight while heavier maternal weight was associated with ALL only when the infant was not high birth weight. Increased pregnancy-related weight gain was associated with ALL. For AML, birth weight under 3000 g and higher prepregnancy weight were both associated with increased risk. These findings suggest childhood leukaemia may be related to factors influencing abnormal fetal growth patterns.

Endoscopic transsphenoidal treatment of empty sella turcica syndrome using a silastic coil.

An empty sella turcica is due to the presence of an arachnoid diverticulum with its fluid content in the sella turcica, exerting pressure on the pituitary gland. In most cases this condition has an asymptomatic course, and is discovered by accident. Some patients, however, develop empty sella turcica syndrome with headaches, mild dishormonose, dysopsia and, rarely, spontaneous rhinorrhoea. Surgical treatment of empty sella turcica consists of filling the sella, through the transsphenoid route, with tissues collected from the patient or with artificial material. The aim of this report is to present our own experience of endoscopic extradural sella elevation using a silicone spiral, in 4 patients with primary empty sella turcica syndrome. The main indication for surgery was progressing dysopsia. The microinvasive endoscopic transsphenoidal method has been used, based upon the Jho technique with our own modifications. For the elevation of the sella, we used a coiled section of a Pudenz valve intraventricular silicone drain, adjusting its size to the dimensions of the operated sella. Both the implantation of the helix, and the postoperative course were uncomplicated for all surgically treated patients. The follow-up of several months confirmed improvement of the dysopsia in all surgically treated patients. MR examinations confirmed the correct location of the silicone spiral placed in the sella. It seems that the good results achieved are due to a correct indication for surgical treatment. The follow-up period ranges from 12 to 30 months and, so far, the clinical improvement is stable and satisfying both for the patients who underwent treatment and for the neurosurgeons.

Effect of external peer review on cesarean delivery rates: a statewide program.

OBJECTIVE: To assess the effectiveness of a joint-specialty society and health department statewide peer-review program to reduce cesarean rates. METHODS: Forty-five of the 165 hospitals with active delivery services were reviewed between 1989 and 1993. Differences in total and repeat cesarean rates and vaginal birth after cesarean (VBAC) rates were compared by hospital review status using Student t tests and linear regression for the years before and after completion of the program. RESULTS: Reviewed hospitals reduced their total cesarean rate by 3% and repeat cesarean rate by 0.7%, and increased their VBAC rate by 14.6% compared with nonreviewed hospitals, for which the respective reduction in rates was 1%, 0.6%, and 12.7%. Statistically, there was no difference between reviewed and nonreviewed hospitals in terms of rate changes. CONCLUSION: This joint-specialty society and health department peer review had no apparent impact on cesarean rates.

Diet in the epidemiology of postmenopausal breast cancer in the New York State Cohort.

A number of authors have presented evidence that high dietary fat increases the risk of breast cancer, and a number have presented evidence to the contrary. In this study, dietary histories were obtained in 1980 from 18,586 postmenopausal women in New York State. These women were followed through 1987 to ascertain their incidence of breast cancer and other cancers and deaths from all causes, as registered in the New York State Tumor Registry and Office of Vital Statistics. Survival analysis revealed that the incidence of breast cancer increased with age, was higher among the nulliparous, was higher for those with a late (> 26 years) age at first pregnancy, and increased with increasing socioeconomic status--all risk factors discovered before for breast cancer. No increase in risk was related to the ingested amount of calories, vitamins A, C, or E, dietary fiber, or fat. Although dietary fat has been found to be associated with higher risk of cancer at a number of other sites, e.g., the lung, colon, and rectum, and although some previous writers have suggested an association with risk of breast cancer, the findings in three cohort studies as well as in eight substantial case-control studies are negative and suggest that a relation is far from established.

Cesarean childbirth in New York state: trends and directions.

During 1987 the New York State Department of Health prepared a report that showed trends in cesarean childbirth from 1970 through 1986 and analyzed related factors for the period 1984-1986. As a result, a joint task force was formed consisting of members of the state health department, The American College of Obstetricians and Gynecologists, and the Hospital Association of New York State. The task force met regularly through 1988 to discuss obstetric care in New York state. These discussions led to a joint education and research project intended to improve the understanding of the patterns of obstetric care in the state, to assess a method of quality-of-care review of obstetric programs to improve maternal and fetal outcomes, and to establish an educational framework within this review process. The project will continue through June 1990, when recommendations will be made leading to a more formal, continuing review process for ongoing improvements in quality of obstetric care and institutional management.

Frequency, spacing, and outcome of pregnancies subsequent to primary cesarean childbirth.

A prospective study was conducted to determine the frequency, spacing, and outcome of pregnancies that occur subsequent to primary cesarean childbirth. A cohort of 5513 women, pregnant for the first time and with these pregnancies terminating with a live birth via cesarean childbirth, were followed for 5 years with use of the vital records registration system of the New York State Department of Health. Also followed was a group of women whose first pregnancy terminated with a live birth via vaginal delivery. The cesarean childbirth study group was found to have had 11% fewer pregnancies terminating during the follow-up period than did the vaginal delivery group. Subsequent live births among the cesarean delivery study group were, on the average, 1 week shorter in gestation and lower in birth weight than those of the vaginal delivery group. However, there was no excess of very low- or low-birth weight infants among the cesarean delivery study group. There was no difference between study groups in the spacing of subsequent pregnancies.

Evaluation of latex-Rickettsia rickettsii test for Rocky Mountain spotted fever in 11 laboratories.

A latex-Rickettsia rickettsii test for detection of antibodies to Rocky Mountain spotted fever (RMSF) was evaluated during the 1980 RMSF season in 11 laboratories in nine states where the disease is endemic. In a double-blind study, all sera submitted to each laboratory for RMSF testing were also examined by the latex-R. rickettsii test. A portion of each specimen was then sent to the New York State laboratory for testing by latex-R. rickettsii and by the reference microimmunofluorescence test. Results were exchanged at the end of the examination period. At the usual ratio of reactive to nonreactive sera encountered in a diagnostic laboratory on a day-to-day basis, the efficiency of the latex-R. rickettsii test relative to microimmunofluorescence was 96.79% for New York and 93.30% for the collaborating laboratories. Both the latex and microimmunofluorescence tests detected antibodies to RMSF within 7 to 9 days of onset. With the latex-R. rickettsii test--but not necessarily with microimmunofluorescence--a high titer (greater than or equal to 128) on a single serum was diagnostic of active RMSF. Changes in serum titer for patients with multiple sera were similar for both tests. The test detects rickettsial antibodies in patients with active infection, but in most cases it does not detect antibody in patients with past infection. Test reactivity could not be uniquely linked to a particular immunoglobulin class.

Differences in trends of postneonatal mortality by birthweight in upstate New York, 1968-1979.

Postneonatal mortality among neonatal survivors and the distribution of age at death among infant deaths were examined for births occurring in upstate New York, 1968-1979. Postneonatal mortality rates increased among infants weighing 501-1500 grams. Infants weighing 1501-2000 grams experienced an increase in postneonatal mortality during the mid-1970s, later returning to the level of 1968. Among infants 2001+ grams, postneonatal mortality declined throughout the study period. Among all levels of birthweight, the proportion of infant deaths occurring as postneonatal deaths increased.

Considerations in evaluating changes in outcome for infants weighing less than 1,501 grams.

Neonatal mortality for 285 infants and developmental outcome for 158 infants with birth weights of 751 to 1,500 gm, born in the Capital Regional Perinatal Center between July 1975 and December 1979, were compared with the findings in 1952, in 1965 to 1967, and in 1968 to 1970. In the 1,001- to 1,500-gm group, mortality decreased and there was an 18% incidence of major neuropsychiatric disability compared to the 48% found in 1952 when the same examination techniques and diagnostic criteria were used. More 751- to 1,000-gm infants survive now also, but 40% have a major handicap. There is a high incidence of preconceptional, prenatal, perinatal, and postnatal abnormalities in this group of very low-birth-weight infants, but the incidence is significantly higher in those with major disabilities. The infants who die and those who have subsequent major neuropsychiatric abnormalities require the sophisticated techniques of neonatal intensive care, whereas these procedures are not needed or are used only briefly for the infants who are normal. In upper New York State, the demographic shifts in race, age, parity, education, and induced abortions account for 13% of the drop in neonatal mortality in the 1,001- to 1,500-gm group. These demographic as well as social and medical care changes must be taken into account in any evaluation of the decreasing mortality and morbidity that has occurred. Improvements in prenatal, obstetric, and neonatal care appear to be doing for the 751- to 1,000-gm group now what the then high-level care in 1952 did for the 1,001- to 1,500-gm group, when mortality decreased but only half of those who survived were normal.

Cesarean sections in upstate New York, 1968-1978.

Data from birth certificates were used to examine the changing trends in the use of cesarean section from 1968 to 1978 in upstate New York. Differences in the percentages of primary cesarean section among population subgroups are cited. Hospital-to-hospital variation in the use of primary cesarean section is shown, as is the relationship among per cent primary cesarean section, hospital size, neonatal mortality, and the per cent of breech deliveries. The percentage of births delivered via cesarean section in 1978 is four times the percentage of 1968 (from 2.5-10.2% for whites, from 3.1-11.5% for nonwhites). Among the subgroups of the population, the increase has ranged from one and one-half to five times the 1968 percentage. There was little hospital-to-hospital variation in the percentage of primary cesarean section in 1968-1969; however, in 1977-1978 the per cent of deliveries performed by primary cesarean section varied from 1-22%. While neonatal mortality was found to be related to the percentage of cesarean section performed in hospitals in 1968-1969, no such association was found in 1977-1978. An inverse relationship was found between the percentage of breech deliveries and the percentage of cesarean sections performed in hospitals in 1977-1978.

Where people die.

Death certificates for 1977 filed with the New York State Department of Health were studied to determine where people died. Data were examined by the location and cause of death and by the age, sex, race, and marital status of the decedent. Comparisons were made with a similar study in which U.S. data were used for 1958 events. Approximately 60 percent of all the 1977 deaths in upstate New York occurred in hospitals; only 27 percent occurred outside an institution. The location of death varied by all the factors studied. Within all age categories, males had a higher percentage of hospital deaths. In those age categories in which nursing home deaths comprised a significant proportion of total deaths, females had a higher percentage of such deaths than males. Differences in the location of death according to its cause reflect the nature of the cause of death, for example, whether it was of sudden onset or the result of chronic disease. Most people do not consider in advance where they might die. The idea that age, sex, and marital status, as well as the more obvious cause, all play a part in the location may seem surprising. Yet all these factors were found to be associated withe location of deaths in upstate New York, and there is no reason to believe that this association does not hold true for the entire nation. More research, however, needs to be done based on more years and other geographic artal stutus may be instructive as to the present state of health resources.

Prenatal monitoring in upstate New York.

In upstate New York, birth certificates of all babies born in hospitals include response to a question on procedures used in fetal monitoring. During the first six months of 1978, some form of monitoring was reported on 47 per cent of all live births in hospitals, 33.6 per cent being monitored externally. The primary cesarean section rate in monitored women was over twice that among those not monitored.