Preeclampsia associated with chronic hypertension among African-American and White women.

OBJECTIVE: To examine the racial differences in preeclampsia/eclampsia (preeclampsia) associated with chronic hypertension among African-American and White women. METHODS: Using hospital discharge summary records from the National Hospital Discharge Survey from 1988 to 1996, we conducted a case-control study to assess the risk of preeclampsia among women with chronic hypertension in two separate identical models: one for African-American and another for White women. Cases were pregnant women who developed preeclampsia. Controls were women without preeclampsia. The main exposure was chronic hypertension. Logistic regression was used to derive odds ratios (OR) and 95% confidence intervals (CI) and to assess interaction between hypertension and preeclampsia. Population attributable risk percent associated between chronic hypertension and preeclampsia was calculated for each ethnic group. RESULTS: Preeclampsia was more than eleven times likely among women with chronic hypertension compared to normotensive women for both African-American (OR = 12.4, 95% CI = 10.2-15.2) and White women (OR = 11.3, 95% CI = 9.7-13.2). Among African-American women, we found an interaction between chronic hypertension and region on preeclampsia. The effect of region magnified the risk of preeclampsia associated with chronic hypertension in general for African-American women, but the effect was lower for the Southern region (OR = 8.9, 95% CI = 6.4-12.3). We also found that the point estimate of population attributable risk percent of preeclampsia attributable to chronic hypertension was significantly higher for African-American women (10.3, 95% CI = 8.6-12.5) compared to White women (5.3, 95% CI = 4.7-6.4). CONCLUSION: The more than eleven-fold higher risk of preeclampsia among both African-American and White women with chronic hypertension compared to normotensive women underscores the potential risk of chronic hypertension for adverse pregnancy outcomes. Furthermore, the two-fold higher population attributable risk percent of preeclampsia among African-American compared to White women quantifies the burden of preeclampsia attributable to chronic hypertension, and indicates a greater opportunity for prevention.

Maternal hypertension and spontaneous preterm births among black women.

OBJECTIVE: To examine effects of maternal hypertension on spontaneous preterm birth (birth at less than 37 weeks' gestation) among black women. METHODS: Using hospital discharge summary records from the National Hospital Discharge Survey between 1988 and 1993, we conducted a case-control study to assess the risk of spontaneous preterm birth among black women with chronic hypertension preceding pregnancy and pregnancy-induced hypertension. Logistic regression was used to derive odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Preterm births were almost two times more likely for women with pregnancy-induced hypertension (OR = 1.8; 95% CI, 1.5, 2.2), more than 1.5 times more likely for women with chronic hypertension preceding pregnancy (OR = 1.6; 95% CI, 1.3, 2.1), and more than four times more likely for women with pregnancy-aggravated hypertension (OR = 4.4; 95% CI, 2.9, 6.7) compared with normotensive women. Preterm births also were associated significantly with antepartum hemorrhage, poor fetal growth, marital status, and source of payment. The odds of preterm birth by maternal hypertension were increased among women with chronic hypertension and genitourinary infection, whereas the odds of preterm birth were reduced among women with pregnancy-induced hypertension and genitourinary infection. CONCLUSION: These findings are important in demonstrating the relation between type of hypertension in pregnancy and preterm birth. The relationships between maternal hypertension and preterm birth need to be further investigated to provide some guidelines in the management of hypertension in pregnancy and assessment of prenatal care compliance for black women, particularly when genitourinary infection is present.

Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village.

Hand washing with soap and water can prevent the spread of diarrhoeal diseases in areas where comparatively costly interventions, such as supply of safe water and improved sanitation, are not possible. In this study, the practice of hand washing with soap and water was instituted in a periurban slum of Dhaka city, and the surveillance for diarrhoea sustained for a one-year period. Rates of primary and secondary attacks were compared to those of a non-intervention area similar in age structure, economic status, education, and other relevant variables. Rectal swabs of cases and contacts established aetiologies. There was a large (2.6 fold) reduction in diarrhoeal episodes in the intervention area during the observation period. Rates of bacterial pathogens were also lower in the intervention area. Significant reduction in diarrhoeal incidences was observed in all age groups for all pathogens except for rotavirus. These observations if implemented as health policy could reduce the spread of diarrhoeal diseases at low cost in high risk areas.

Risk factors for self-reported uterine fibroids: a case-control study.

To identify risk factors for uterine fibroids, a case-control design used to analyze data from control subjects enrolled in the Cancer and Steroid Hormone Study. Case patients were 201 women who reported a history of uterine fibroids, and control subjects were 1503 women without fibroids, individually matched by age to case patients. Reporting of fibroids was more frequent among premenopausal women, women who had frequent Papanicolaou (Pap) smears, women who used oral contraceptives and had infrequent Pap smears, and women with higher education. Reporting of fibroids was less frequent among women with a lower body mass index who were current or long-time smokers.

Maternal hypertension and associated pregnancy complications among African-American and other women in the United States.

OBJECTIVE: To characterize maternal hypertension and related pregnancy complications among African-American and other women in the United States. METHODS: Using data from the National Hospital Discharge Survey, we analyzed the incidence and clinical spectrum of maternal hypertension among African-American women who delivered in hospital during 1988-1992. Maternal hypertension consisted of pregnancy-induced hypertension and chronic hypertension preceding pregnancy, including pregnancy-aggravated hypertension. Pregnancy-induced hypertension included preeclampsia, eclampsia, and transient hypertension. Incidence rates (per 1000 deliveries) and 95% confidence intervals (CI) were calculated by type of hypertension and demographic characteristics. Risk ratios and 95% CIs for adverse pregnancy outcomes among women with hypertension were also calculated. RESULTS: The overall incidence of all causes of maternal hypertension was 64.2, and of chronic hypertension preceding pregnancy it was 25.0 per 1000 deliveries among African-American women, an excess of 15.6 and 14.5 cases per 1000 deliveries, respectively, compared with rates for other women. The risks of preterm delivery and inadequate fetal growth were similarly increased for all hypertensive women, regardless of race. However, hypertensive African-American women were at a threefold greater risk of pregnancies complicated by antepartum hemorrhage, an association that was not observed, in other women. Development of preeclampsia and eclampsia irrespective of race was about four times higher among women with chronic hypertension preceding pregnancy than among those without chronic hypertension. CONCLUSION: The excess incidence of maternal hypertension, particularly chronic hypertension, may contribute to adverse maternal and fetal pregnancy outcomes and the disparity in outcomes observed between African-American and other women in the U.S. These findings provide a specific focus for further clinical outcomes research and assessment of prenatal management in African-American women.

Neonatal tetanus in rural Bangladesh: risk factors and toxoid efficacy.

OBJECTIVES: Tetanus continues to be a leading cause of neonatal death in Bangladesh as in other developing countries, yet little is known about risk factors or the efficacy of tetanus toxoid in this setting. METHODS: In May 1990, mothers of 6148 infants born alive between March 15, 1989, and March 14, 1990, in 30 rural unions of Rajshahi Division in Bangladesh were interviewed. Three surviving controls for each neonatal tetanus death were matched for sex, residence, and date of birth. RESULTS: Of 330 neonatal deaths, 112 met the case definition for tetanus. Risk was increased with a history of neonatal tetanus in a previous child, application of coconut oil to the vagina, and use of multiple ties on the umbilical cord. Risk was reduced by the birth attendant washing hands and using a cleaned cord-cutting tool. Risk was not reduced by a maternal history of two doses of tetanus toxoid (TT2), although estimated efficacy of TT2 was 45% (95% confidence interval = 16% to 64%). Subsequent to the survey, a reference laboratory reported to potency in three consecutive lots of tetanus vaccine from the production laboratory in Bangladesh. CONCLUSIONS: These findings identify high-risk mothers, stress the importance of washing hands and cleaning the cord-cutting tool, and demand improved quality control of tetanus vaccine production.

U.S. residency directors' views of the importances of seven roles that pediatrics residents should master.

Pediatrics residency programs should define and evaluate for their residents and faculty the competencies that residents should acquire during their three years of training. This 1987 survey of 129 pediatrics residency directors sought data about the demographic characteristics of the programs and asked the program directors to what degree they agreed that seven roles (each comprising several competencies) of the general and ambulatory-care pediatrician were essential. There was strong agreement on the seven roles and no demonstrated association between these responses and the residency programs' university affiliations, types of facilities, ages, lengths of training, or geographic locations. The results of this survey may be useful in developing ways to document and evaluate residents' performances and define subspecialty objectives that are consistent with the seven basic roles.

A reassessment of risk factors for neonatal tetanus.

A hospital-based case-control study was conducted to further examine the risk factors for neonatal tetanus (NNT) in the North-west Frontier Province of Pakistan. Three control infants were concurrently evaluated for each of 102 consecutively diagnosed NNT cases hospitalized over an 8-week period. Application of clarified butter (ghee) during the first few days of life was shown to be a significant risk factor, confirming our previously reported finding. However, the risk appeared to be limited to ghee made in the home from cow's milk. The tool used to cut the umbilical cord was again refuted to be a risk factor; application of topical antibiotics conferred significant protection. Multivariate analysis of the matched data showed that delivery by persons with academic training (physicians, nurses, and lady health visitors) was also protective. Mothers with a past history of NNT babies were shown to have a significantly increased risk, and accounted for more than one-third of all cases in the present study. The findings suggest possible ways to augment the effectiveness of NNT elimination programmes.

PIP: A hospital-based case-control study was conducted to further examine the risk factors for neonatal tetanus (NNT) in the Northwest Frontier Province of Pakistan. 3 control infants were concurrently evaluated for each of 102 consecutively diagnosed NNT cases hospitalized for over an 8-week period. Application for clarified butter (ghee) during the 1st few days of life was seen as a significant risk factor, confirming the previously reported finding of the authors. However, the risk appeared to be limited to ghee made in the home from cow's milk. The tool used to cut the umbilical cord was again refuted to be a risk factor; application of topical antibiotics conferred significant protection. Multivariate analysis of the matched data showed that delivery by persons with academic training (physicians, nurses, and lady health visitors) was also protective. Mothers who had a past history of NNT babies were shown to have a significantly increased risk and accounted for more than 1/3 of all cases in the present study. The findings suggest possible ways to augment the effectiveness of NNT elimination programs. (author's)

Plasmid characterization of Shigella spp. isolated from children with shigellosis and asymptomatic excretors.

Strains of Shigella dysenteriae type 1 and Sh. flexneri isolated during 1981-82 from children with shigellosis and also from asymptomatic excretors were examined for drug resistance and for the presence of plasmids. Shigella strains isolated from dysenteric children showed multiple plasmid bands. Thirty-eight percent of the strains transferred the drug resistance factor(s), either partially or fully to a recipient Escherichia coli K12 strain. Plasmids in the molecular weight range from between 44-76 Mdal were correlated with drug resistance. It was found that multi-resistant clinical isolates generally harbour a single large transmissible plasmid. Strains isolated from asymptomatic excretors demonstrated plasmid patterns different from those isolated from children with shigellosis although the bands were relatively homogeneous within each group. Both the groups showed the presence of a 140 Mdal plasmid band conferring invasiveness and such strains gave a positive Sereny test. This study thus shows that Shigella strains from asymptomatic excretors also retain invasiveness.

Risk factors for death in complicated diarrhoea of children.

A total of 1330 children with complicated diarrhoea who were admitted to the general ward of the International Centre for Diarrhoeal Diseases Research, Bangladesh Health Complex, during 1979 were examined. The risk of death by complication of diarrhoea, aetiology, age, and nutritional state was analysed by a logit regression model. Serum sodium concentration and coma were found to be significant predictors of death, death being related directly to coma and inversely to serum sodium concentration. An earlier study had shown that the incidence of hyponatraemia was directly related to the degree of malnutrition, but the results of logit regression analysis did not show the nutritional state to be a predictor of death. Owing to lack of data, however, serum albumin concentration could not be taken as a variable in the logit regression analysis. To determine the relation of serum albumin concentration to hyponatraemia and the cause of death in hyponatraemia further prospective studies would be necessary.

Oral rehydration therapy: efficacy of sodium citrate equals to sodium bicarbonate for correction of acidosis in diarrhoea.

Forty patients with moderate degrees of dehydration and acidosis because of acute watery diarrhoea were successfully treated randomly with either WHO recommended oral rehydration solution containing 2.5 g sodium bicarbonate or an oral solution containing 2.94 g sodium citrate in place of sodium bicarbonate per litre of oral rehydration rehydration solution. Efficacies were compared by measuring oral fluid intake, stool and vomitus output, change in body weight, hydration status, and rate of correction of acidosis during a period of 48 hours. Seventy five per cent (21 cases) in the citrate group and 83% (19 cases) in the bicarbonate group were successfully rehydrated (p greater than 0.05). There were no significant differences in intake, output, gain in body weight, fall in haematocrit and plasma specific gravity, and correction of acidosis between the two groups of patients within 48 hours after initiation of therapy. The solution with sodium citrate base was as effective as WHO-oral rehydration solution for management of diarrhoea. This study shows the efficacy, safety, and acceptability of citrate containing oral rehydration solution for rehydration and correction of acidosis in diarrhoea.

PIP: 40 patients with moderate degrees of dehydration and acidosis because of acute watery diarrhea were successfully treated randomly with either World Health Organization (WHO) recommended oral rehydration solution containing 2.5 g sodium bicarbonate or an oral solution containing 2.94 g sodium citrate in place of sodium bicarbonate/liter of oral rehydration solution. Efficacies were compared by measuring oral fluid intake, stool and vomitus output, change in body weight, hydration status, and rate of correction of acidosis during a 48 hour period. 75% (21 cases) in the citrate group and 83% (19 cases) in the bicarbonate group were successfully rehydrated (P 0.05). There were no significant differences in intake, output, gain in body weight, fall in hematocrit, and plasma specific gravity, and correction of acidosis between the 2 groups of patients within 48 hours after therapy initiation. The solution with sodium citrate base was as effective as WHO-oral rehydration solution for diarrhea management. This study shows the efficacy, safety, and acceptability of citrate-containing oral rehydration solution for rehydration and correction of acidosis in diarrhea.

Persistence of plasmids, cholera toxin genes, and prophage DNA in classical Vibrio cholerae O1.

Plasmid profiles, the location of cholera toxin subunit A genes, and the presence of the defective VcA1 prophage genome in classical Vibrio cholerae isolated from patients in Bangladesh in 1982 were compared with those in older classical strains isolated during the sixth pandemic and with those in selected eltor and nontoxigenic O1 isolates. Classical strains typically had two plasmids (21 and 3 megadaltons), eltor strains typically had no plasmids, and nontoxigenic O1 strains had zero to three plasmids. The old and new isolates of classical V. cholerae had two HindIII chromosomal digest fragments containing cholera toxin subunit A genes, whereas the eltor strains from Eastern countries had one fragment. The eltor strains from areas surrounding the Gulf of Mexico also had two subunit A gene fragments, which were smaller and easily distinguished from the classical pattern. All classical strains had 8 to 10 HindIII fragments containing the defective VcA1 prophage genome; none of the Eastern eltor strains had these genes, and the Gulf Coast eltor strains contained a different array of weakly hybridizing genes. These data suggest that the recent isolates of classical cholera in Bangladesh are closely related to the bacterial strain(s) which caused classical cholera during the sixth pandemic. These data do not support hypotheses that either the eltor or the nontoxigenic O1 strains are precursors of the new classical strains.

Simultaneous classical and El Tor cholera in Bangladesh.

PIP: Cholera appears annually in Bangladesh, with peak incidence from September through December and April through June. After being absent for a decade, the classical biotype of Vibrio cholerae reappeared in Commilla and Dhaka on September 1 and 3, 1982, and soon thereafter appeared in many other districts. Cases due to the newly emerged classical biotype of V. cholerae rapidly surpassed those due to the El Tor biotype. Before 1970, classical V. cholerae had been responsible globally for both endemic and epidemic cholera. In Bangladesh, El Tor was first isolated in 1964. By 1973, it has replaced the classical strain. Subsequently until 1981, only 6 classical isolates were noted. The new classical strains were almost identical to those isolated a decade earlier, except for their ability to successfully displace El Tor in an epidemic setting. Investigation of the first 10 cholera cases suggests a multiple source outbreak. The age distribution of the classical and El Tor was similar, suggesting a lack of important new antigenic determinants, which could circumvent existing immunity in the population. Both strains followed known seasonal patterns.^ieng

First isolation of Yersinia intermedia from stool during an epidemiological investigation in Bangladesh.

Following the first isolation of Yersinia intermedia (Y. intermedia) in the Microbiology Branch of ICDDR, B from two postmortem cases, one of whom suffered from pneumonia and septicaemia and the other from enteric fever, an epidemiological investigation was carried out in the communities from where these postmortem cases had come. The stools from both postmortem cases were negative for Yersinia. One hundred and twenty five contacts of the first postmortem case and 135 contacts of the second postmortem case along with 175 animals of Dhaka Zoo were examined. Y. intermedia was isolated from only a five-year-old healthy contact of the first postmortem case. This was the first isolation of Y. intermedia from stool of a healthy child in Bangladesh.

Classical Vibrio cholerae biotype displaces EL tor in Bangladesh.

The EL Tor biotype of Vibrio cholerae caused all endemic and epidemic cholera in Bangladesh from 1973 until Sept. 3, 1982, when the first classical strain was isolated from a patient in Matlab. Since then the number of isolations of the classical biotype has increased very rapidly and spread to other districts, replacing the EL Tor biotype as the main epidemic strain. The classical strains isolated in the 1982 outbreak were indistinguishable by the standard tests from those isolated a decade ago and the very few isolates in 1979, 1980, and 1981. This suggests that beyond the taxonomic traits used to identify the classical and EL Tor strains, there may be other more crucial biological characteristics that have given this new strain an advantage over the existing strains. The mechanism by which a new biotype of V. cholerae 01 achieves such a crucial biological advantage to displace the existing strains may be a key point in control of the global spread of cholera.