Long-term survival and competing causes of death in patients with early-stage Hodgkin's disease treated at age 50 or younger.

PURPOSE: To analyze the long-term survival and the pattern and timing of excess mortality in patients with early-stage Hodgkin's disease. PATIENTS AND METHODS: Between 1969 and 1997, 1,080 patients age 50 or younger were treated for clinical stage IA to IIB Hodgkin's disease. Overall survival was determined, and prognostic factors were assessed. Relative risk and absolute excess risk (AR) of mortality were calculated for the entire cohort and by prognostic groups (on the basis of B symptoms, mediastinal status, and number of sites, modified from the European Organization for Research and Treatment of Cancer). RESULTS: The median follow-up was 12 years. The 15- and 20-year Kaplan-Meier survival estimates were 84% and 78%, respectively. Cox proportional hazards models showed that number of involved sites (P =.006), mediastinal status (P =.02), and histology (P =.02) were independent predictors of death from all causes. The AR of mortality in patients with a favorable prognosis increased over time, whereas for those with an unfavorable prognosis, the AR peaked in the first 5 years, predominantly from Hodgkin's disease. The relative risk of mortality from all causes, causes other than Hodgkin's disease, second tumors, and cardiac disease remained significantly elevated more than 20 years after treatment. CONCLUSION: Patients treated for early-stage Hodgkin's disease have a sustained excess mortality risk despite good control of the disease. Treatment reduction efforts in patients with early-stage, favorable-prognosis disease should continue, but for patients with an unfavorable prognosis, modified treatment may not be advisable. The excess mortality noted beyond two decades underscores the importance of long-term follow-up care in patients treated for Hodgkin's disease.

Maternal and infant characteristics associated with perinatal arterial stroke in the infant.

CONTEXT: Perinatal arterial ischemic stroke (PAS) is a common cause of hemiplegic cerebral palsy. Risk factors for this condition have not been clearly defined. OBJECTIVE: To determine maternal and infant characteristics associated with PAS. DESIGN, SETTING, AND PATIENTS: Case-control study nested within the cohort of all 199,176 infants born from 1997 through 2002 in the Kaiser Permanente Medical Care Program, a managed care organization providing care for more than 3 million residents of northern California. Case patients were confirmed by review of brain imaging and medical records (n = 40). Three controls per case were randomly selected from the study population. MAIN OUTCOME MEASURE: Association of maternal and infant complications with risk of PAS. RESULTS: The population prevalence of PAS was 20 per 100,000 live births. The majority (85%) of infants with PAS were delivered at term. The following prepartum and intrapartum factors were more common among case than control infants: primiparity (73% vs 44%, P = .002), fetal heart rate abnormality (46% vs 14%, P<.001), emergency cesarean delivery (35% vs 13%, P = .002), chorioamnionitis (27% vs 11%, P = .03), prolonged rupture of membranes (26% vs 7%, P = .002), prolonged second stage of labor (25% vs 4%, P<.001), vacuum extraction (24% vs 11%, P = .04), cord abnormality (22% vs 6%, P = .01), preeclampsia (19% vs 5%, P = .01), and oligohydramnios (14% vs 3%, P = .01). Risk factors independently associated with PAS on multivariate analysis were history of infertility (odds ratio [OR], 7.5; 95% confidence interval [CI], 1.3-45.0), preeclampsia (OR, 5.3; 95% CI, 1.3-22.0), prolonged rupture of membranes (OR, 3.8; 95% CI, 1.1-12.8), and chorioamnionitis (OR, 3.4; 95% CI, 1.1-10.5). The rate of PAS increased dramatically when multiple risk factors were present. CONCLUSIONS: Perinatal arterial ischemic stroke in infants is associated with several independent maternal risk factors. How these complications, along with their potential effects on the placenta and fetus, may play a role in causing perinatal stroke deserves further study.

Declining diagnosis of birth asphyxia in California: 1991-2000.

OBJECTIVE: Birth asphyxia is recognized as an important cause of neonatal morbidity and mortality. Whether advances in perinatal care have altered the incidence of birth asphyxia is unknown. We determined the incidence of birth asphyxia diagnoses made over a 10-year period in California. METHODS: In a population-based retrospective cohort study of 5,364,663 live births, we determined the incidence and case fatality of birth asphyxia between 1991 and 2000. Using a statewide administrative hospital discharge database, we identified all newborn admissions that generated a diagnosis of birth asphyxia (International Classification of Diseases, Ninth Revision, Clinical Modification codes 768.5, 768.6, or 768.9) or a diagnosis that overlaps with birth asphyxia, such as congenital encephalopathy or fetal distress. We determined incidence and in-hospital case fatality rates adjusted for birth weight and demographic characteristics and stratified by associated perinatal complications. RESULTS: The 24 330 newborns who received a diagnosis of birth asphyxia yielded a population incidence of 4.5 per 1000 live births. Black ethnicity (relative risk [RR]: 1.3; 95% confidence interval [CI]: 1.2-1.3), male gender (RR: 1.2; 95% CI: 1.1-1.2), and low socioeconomic status (RR: 1.2; 95% CI: 1.1-1.2) all were associated with increased risk. The diagnosis of birth asphyxia decreased by 91% from 14.8 to 1.3 per 1000 live births during the study years. This decrease could not be explained by an increased diagnosis of overlapping conditions. Overall case fatality was 4%, and the majority of deaths in infants >2000 g occurred in the presence of congenital anomalies, cord abnormalities, or maternal hemorrhage. In newborns <2000 g, case fatality was highest in the presence of chorioamnionitis (48%). CONCLUSION: The diagnosis of birth asphyxia has decreased dramatically in recent years. The factors that are responsible for this decline are unclear and deserve additional investigation.