[Surgical resection with ophthalmoplastic reconstruction : Gold standard in periocular basal cell carcinoma]. / Chirurgische Resektion mit ophthalmoplastischer Rekonstruktion : Goldstandard beim periokulären Basalzellkarzinom.

The gold standard for the treatment of periocular basal cell carcinoma is surgical resection followed by ophthalmoplastic reconstruction. The highest priority in most cases is the complete histopathologically controlled tumor excision. The histopathological preparation can be carried out in two stages by rapid overnight embedding or intraoperatively by a rapid frozen section procedure. A variety of reconstruction methods enable a customized and in most cases also a cosmetically and functionally attractive defect coverage. Postoperatively, a regularly performed tumor aftercare is essential.

[Clinico-echographic diagnostics of iris tumors]. / Klinisch-echographische Diagnostik bei Iristumoren.

BACKGROUND: The differentiation of iridic space-occupying lesions represents a regularly reoccurring diagnostic challenge. OBJECTIVE: This article presents an overview of the epidemiological data and describes the diagnostic procedure for iris tumors. MATERIAL AND METHODS: The article provides a review of the literature from PubMed and own clinical results. RESULTS: Melanocytic lesions comprise the vast majority of all iris tumors and include nevi and melanomas. Slit lamp biomicroscopy with standardized photography reveals two-dimensional planar tumor growth over time, which is the only recognized clinical surrogate finding for a malignant event. Ultrasound biomicroscopy (UBM) is additionally obligatory because it is the only method which enables documentation of the extent of tumor penetration, ciliary body involvement and internal structure of iris tumors. CONCLUSION: Serial slit lamp and UBM examinations with reproducible pupillary diameters are indispensable for the differentiation of cystic, solid and tumor-simulating lesions and for the detection of malignant transformation in iris tumors.

[New treatment options for iridociliary tumors]. / Neue therapeutische Möglichkeiten bei iridoziliären Tumoren.

BACKGROUND: Benign iridal tumors rarely necessitate a therapeutic intervention. In contrast, malignant tumors of the iris can threaten the patient's life and eyesight and require early treatment to prevent the development of metastases. OBJECTIVE: Presentation of current treatment options for iridal tumors with special emphasis on iridal melanoma. METHODS: This article gives an overview of the current literature based on a PubMed search as well as own clinical experience. RESULTS: Treatment options for iridal and ciliary body melanomas comprise radiotherapeutic and surgical (eyeball-sparing and non-sparing) approaches. The eyeball-sparing surgical procedure of choice is block excision. While local tumor control rates and metastasis rates of block excision and radiotherapy are comparable, there are distinct differences especially between the spectra of complications. New treatment procedures include immunomodulatory approaches and targeted therapies. Using checkpoint inhibitors, no convincing enhancement of overall survival could be demonstrated for metastatic iridal melanoma, as is the case for cutaneous melanoma. In contrast, tumor vaccination with the help of tumor RNA-laden patient-derived dendritic cells seems to be a promising option for a subgroup of high-risk patients. Targeted therapies aiming to suppress the MAPK and PI3K/Akt pathways could not achieve any improvement in patient survival. CONCLUSION: For the primary treatment of iridal melanoma a surgical, eyeball-sparing approach and also when appropriate, radiotherapy can be recommended. In the future, eligible high-risk patients could profit from a tumor vaccination. To date, there is no effective systemic treatment for metastatic iridal melanoma.

[CyberKnife®: new treatment option for uveal melanoma]. / CyberKnife®: Eine neue Therapieoption bei uvealem Melanom.

BACKGROUND: CyberKnife® stereotactic radiosurgery is a new treatment option for uveal melanoma. OBJECTIVE: This review outlines the technique of robot-assisted CyberKnife® therapy, as well as the pros and cons in the treatment of uveal melanoma. METHODS: The study provides a PubMed literature review and own preliminary clinical experiences. RESULTS: CyberKnife® therapy for choroidal and ciliary body melanomas shows comparable results concerning local tumor control and overall survival matching those of conventional therapies. With only low complication rates, a high level of quality of life can be conserved by possible preservation of visual acuity as well as the ocular globe. CONCLUSION: Stereotactic radiosurgery using CyberKnife® seems to be an efficient and safe therapeutic option for malignant melanomas affecting the choroid and ciliary body. Comparative studies with conventional radiation strategies are now a high priority.

Changing pregnancy outcomes of Samoan women in Hawaii.

In the state of Hawaii, Samoan mothers are known for the large average birthweight and low percentage of low birthweight (< 2500 g) of their infants, in spite of the relatively low socio-economic status of the population. This paper reports the findings of a temporal trend analysis of birth outcomes of Samoan women and identifies worrying changes. Data were obtained from Hawaii birth certificates. Single live births to Hawaii-resident Samoan and Caucasian women from 1979 to 1994 were included in the study. Infants of Samoan women experienced a 75 g decline in mean birthweight and an increase in the percentage of low (< 2500 g) and very low (< 1500 g) birthweight from 2.6 and 0.4 to 3.8 and 0.8 respectively. During the same time, infants of Caucasian mothers experienced an increase in mean birthweight and a decline in low birthweight, while very low birthweight did not change. Maternal socio-demographic characteristics explained only part of the findings and use of prenatal care did not appear to be associated with any birth outcome indicators. Multiple regression analyses identified an adjusted loss of 50.8 g in birthweight and a 1.48 increase in the odds ratio of small-for-gestational-age associated with birth at the end (1991-4) compared with the beginning (1979-82) of the study period. Further studies focusing on maternal health status and psycho-social variables, including the effect of acculturation-related stress, are warranted to identify at least some of the determinants of the changes identified by this analysis.

Racial differences in birthweight for gestational age and infant mortality in extremely-low-risk US populations.

Using national data, we develop and contrast the birth-weight percentiles for gestational age by infants of extremely-low-risk (ELR) White and African-American women and examine racial differences in the proportion of small-for-gestational-age (SGA) births. We then scrutinise racial variations in infant mortality rates of the infants of ELR women. We further compare the infant mortality rates of infants at or below the 10th percentile of birthweight for gestational age of each race group to determine whether infants with similar restricted fetal growth have comparable risks of subsequent mortality. Single live births, 34-42 weeks' gestation, to White and African-American US-resident mothers were selected from the 1990-91 US Linked Live Birth--Infant Death File (n = 4,360,829). Extremely-low-risk mothers were defined as: married, aged 20-34 years, 13+ years of education, multiparae, with average parity for age, adequate prenatal care, vaginal delivery, and no reports of medical risk factors, tobacco use or alcohol use during pregnancy. Marked racial variation in birthweight percentiles by gestational age was evident. Compared with ELR White mothers, the risk of an SGA infant was 2.64 times greater for ELR African-American mothers and the risk of infant mortality was 1.61 times greater. For the ELR group, the infant mortality rates of African-American and White infants at or below the 10th percentile of birthweight for gestational age of their respective maternal race group were essentially identical after controlling for gestational age. In conclusion, race differences in fetal growth patterns remained after controlling for risk status. Efforts to remove racial disparities in infant mortality will need to develop aetiological pathways that can explain why African-Americans have relatively higher rates of preterm birth and higher infant mortality rates among term and non-SGA infants.

Influence of diabetes during pregnancy on gestational age-specific newborn weight among US black and US white infants.

This study examined the impact of maternal diabetes on birth weight for gestational age patterns of all term black infants and white infants in the United States using data derived from the 1990-1991 US Live Birth File of the National Center for Health Statistics. Infants of both black mothers and white mothers exhibited the expected fetal overgrowth associated with maternal diabetes. However, the increase in birth weight was much greater in infants of black than white diabetic mothers in comparison with their nondiabetic counterparts, as measured by the discrepancy in birth weight between infants of diabetic and nondiabetic mothers at each gestational week, the incidence of large for gestational age, high birth weight, small for gestational age, and low birth weight. After adjustment for maternal hypertension, prenatal care use, and sociodemographic factors, the disparity in mean birth weight associated with diabetes was 211.67 g in black infants and 115.74 g in white infants. The adjusted odds ratios of birth weight > or = 4,000 g were 2.98 (95% confidence interval 2.89-3.12) for black infants and 1.83 (95% confidence interval 1.78-1.89) for white infants. Given the potential risks for mothers and infants consequent to maternal diabetes and fetal hyperinsulinemia, further investigation of the prevalence, characteristics, and outcomes of diabetes during pregnancy among black mothers and infants is warranted.

Ethnic-specific predictors of prenatal care utilisation in Hawaii.

The state of Hawaii has had near-universal health insurance coverage for the last 20 years. Its highly diverse population offers the opportunity for a unique, natural experiment in the United States on the examination of social differences in health care utilisation when financial barriers are removed. Therefore, the objective of this study is to examine predictors of prenatal care utilisation patterns in the four major ethnic groups in Hawaii. The data used in this study are the 1979-92 Hawaii livebirth vital record files. A total of 165,301 singleton livebirths to Hawaii-resident mothers of Caucasian, native Hawaiian, Japanese or Filipino ancestry were selected. Despite near-universal health care coverage in Hawaii, a surprising number of women did not adequately utilise prenatal care, with large differences between groups. Multivariate analyses indicated that similar maternal socio-demographic factors were associated with prenatal care use in each ethnic group. Social variation continues to exist among all ethnic groups even in the presence of universal access to care. These data emphasise the need to address the distinct cultural needs of populations for providing health services, and further challenge the assumption that removal of financial barriers will ensure a high level of prenatal care use.

Prenatal care utilization in Hawaii: did it improve during the last 16 years?

This paper examines the utilization of prenatal care in Hawaii from 1979 to 1994 to determine if early and adequate utilization of prenatal care has changed during this period. Birth certificates of single live born infants of resident women were the source of data for the study. During the study period, the proportion of women receiving prenatal care in the first trimester increased by nearly 5 percent but was still below the national and state Year 2000 health objective of 90 percent. Notwithstanding this improvement, the percentage of women who did not receive the recommended number of visits in spite of starting care early significantly increased. The overall proportion of women with 'intensive' prenatal care use markedly increased (134.7%). The proportion of women with 'inadequate' care use declined (10.3%), although the proportion of women with 'no care' use doubled. Complete reporting of use of care through birth certificates markedly deteriorated. The findings of this study indicate the need for changes in the targeting and provision of counseling and education on the part of health care providers. Public health leaders, policy makers, health care providers, and advocacy groups need to collectively review programmatic directions with an aim toward the development of innovative approaches to address the emerging health needs of mothers and infants in the state.

Temporal trends in maternal characteristics and pregnancy outcomes: their relevance to the provision of health services. Hawaii, 1979-1994.

This paper examines changes in maternal sociodemographic characteristics and pregnancy outcomes in Hawaii during the period 1979-1994. The more striking changes were increases of 129% in the proportion of births to women > 35 years old and of 67% in the proportion of births to unmarried mothers. The percentage of low birth weight and small-for-gestational age infants decreased while the proportion of premature births increased. Identified changes were not limited to selected population groups, but were found in various degrees in all ethnic groups. These findings are relevant to all health practitioners and will assist in the provision of appropriate care and counseling to individual women.

Pregnancy outcomes of US-born and foreign-born Japanese Americans.

OBJECTIVES: This study investigated the birth outcomes of Japanese Americans, focusing on the role of the mother's place of birth. METHODS: Single live births to US-resident Japanese American mothers (n = 37,941) were selected from the 1983 through 1987 US linked live birth-infant death files. RESULTS: US-born mothers were more likely than foreign-born mothers to be less than 18 years old and not married, to start prenatal care early, and to more adequately use prenatal care. Infants of foreign-born Japanese Americans had a slightly lower risk of low birthweight.No significant differences were found between nativity groups for very low birthweight or neonatal, postneonatal, and infant mortality. The mortality rates of infants of US-born (6.2) and foreign-born (5.4) Japanese American women were below the US Year 2000 objective but still exceeded Japan's 1990 rate (4.6). However, low-birthweight percentages of the US-born group (5.7%) and the foreign-born group (5.0%) were similar to that of Japan (5.5%). CONCLUSIONS: The infants of foreign-born Japanese-American women exhibited modestly better low-birthweight percentages than those of US-born Japanese Americans. This finding supports theories of the healthy immigrant.

Pregnancy outcomes of Pacific islanders in Hawaii.

Percentages of low birth weight are low in American Indian and Mexican-American populations despite a high prevalence of traditional risk factors. Data derived from 1979-1990 Hawaii vital record files were used to examine birth weight, infant mortality, and their correlates in Samoan and Hawaiian residents of Hawaii to assess whether traditional risk factors are adequate predictors of low birth weight and whether low birth weight is an adequate measure of infant mortality risk in Polynesian populations. Despite very low educational attainment, high proportions of unmarried status, and inadequate prenatal care use, low and very low birth weight percentages were less than the US average. High birth weight was common. Unmarried status and primiparity after age 17 increased low birth weight risk, while high educational attainment and Samoan ethnicity decreased the risk. Adequate prenatal care was not associated with reduced low birth weight risk. Higher than expected neonatal mortality, particularly among normal birth weight infants, and high postneonatal mortality among Hawaiian infants suggest that poverty and maternal chronic disease, rather than low birth weight, may be the primary mediators of infant mortality risk in some populations. The need for clearer specification of risk factors and caution in generalized risk assessment in diverse populations is emphasized.

Determinants of prenatal care use in Hawaii: implications for health promotion.

This study examines the association between maternal sociodemographic characteristics and the receipt of different levels of prenatal care use (no care, inadequate, intermediate, adequate) in order to determine different patterns in the relationships between maternal characteristics and these distinct categories of prenatal care use. Using the 1979-1992 Hawaii live birth vital record file, single live births to Hawaii resident mothers of white, Hawaiian/part-Hawaiian, Filipino, or Japanese ethnicity, who did not indicate on the birth certificate that either parent was active duty military, were selected. Over one quarter of this study population did not initiate prenatal care in the first trimester. Given the high level of insurance coverage found in Hawaii, this finding is disconcerting, particularly in relation to the U.S. Year 2000 Objective of 90% initiation in the first trimester. Overall, the factors that predicted receipt of any prenatal care predicted more adequate use of prenatal care as well. Noteworthy exceptions were maternal age and ethnicity. Identifying these exceptions is important for the development of a more detailed understanding of risk factors related to use of prenatal care to better target program responses aimed at improving prenatal care use. In addition, these data suggest that removing financial barriers to access to care does not guarantee universal use of disease prevention and health promotion services.

Similarities and disparities in maternal risk and birth outcomes of white and Japanese-American mothers.

This study compares the maternal sociodemographic and prenatal care characteristics and birth outcomes of US resident white and Japanese-American mothers, using data from the state of Hawaii. The specific focus is to determine to what extent these factors can explain variations in newborn maturity and mortality indicators. Single livebirths to resident, non-military dependent white and Japanese-American mothers were selected for analysis from the 1979-1990 linked livebirth-infant death files from Hawaii. Compared with white mothers, Japanese-American mothers were significantly more likely to be married, age 18 years and older, have higher educational attainment, and have adequate prenatal care utilisation. The majority of Japanese-American mothers were born in Hawaii, while the majority of white mothers were born on the US mainland. The mean birthweight of Japanese-American infants was 200 g lighter than that of white infants. Infant mortality rates (IMRs) for both groups were below the US Year 2000 Health Objective. After controlling for maternal sociodemographic and prenatal care factors with logistic regression, Japanese-American infants had significantly higher risks of low birthweight, preterm and very preterm birth and of being small-for-gestational age. These findings indicate that populations with preferential maternal sociodemographic and prenatal care risk indicators may still exhibit higher low birthweight percentages, but achieve comparatively low IMRs.

The perinatal and infant health status of Native Hawaiians.

Hawaii vital record data for 1979 through 1990 were analyzed to examine potentially differing relationships between maternal and infant risks and outcomes in native Hawaiian and White infants. Despite high rates of inadequate prenatal care and teenage and unmarried childbearing, the Hawaiian low-birth-weight rate was below the US average. Hawaiian infants experienced an elevated risk of mortality, particularly among those of normal birthweight during the postneonatal period. Public health initiatives to reduce infant mortality must go beyond preventing teenage pregnancy and low birthweight to address Hawaiian infants' unique pattern of risk factors and the social and economic environment in which such risks abound.

Multiethnic variations in the pregnancy outcomes of military dependents.

OBJECTIVES: We examined the pregnancy outcomes of three ethnic groups: African-American Blacks, non-Hispanic Whites, and Filipinos. In an attempt to reduce ethnic dissimilarities in parental employment and access to health care, this investigation compared the single-live-birth outcomes of married, adult women who resided in the state of Hawaii and who indicated that their spouse was on active-duty status in the US military. METHODS: The data for this study were obtained from the 1979-1989 Hawaii vital-record file that provides linked live birth-infant death information. Multiple logistic regression was used to calculate odds ratios for the independent effects of maternal factors on low birthweight and neonatal mortality. RESULTS: Significant differences in maternal age, maternal education, paternal education, parity, hospital of delivery, and use of prenatal care were observed among the ethnic groups. The results of a logistic regression analysis of low birthweight indicated significantly higher risks for Filipinos and Blacks compared with Whites. For very low birthweight, only an increased risk for Blacks was observed. No ethnic differences in neonatal mortality were found. CONCLUSIONS: This investigation revealed more comparable infant mortality experiences among the ethnic groups in spite of persistent birthweight differences.

Birth outcomes of Korean women in Hawaii.

Since the end of the Korean War, immigration of Koreans to the United States has increased rapidly. In 1990, 11.6 percent of all Asians in the United States were of Korean ethnicity, and it is projected that Koreans will outnumber all other Asian groups, except Filipinos, in the United States by the year 2030. Despite the growing size of this population, very little is known about their health status. This study, using 1979-89 Hawaii vital record data, investigates the relationship between maternal sociodemographic characteristics, prenatal care utilization factors, and birth outcomes among Koreans as compared with Caucasians. The ethnic term "Caucasian" is used in Hawaii's vital records and is synonymous with non-Hispanic whites. Korean mothers were more likely to be older and have lower educational attainment, and less likely to be adolescent, single, or to have received adequate prenatal care than Caucasian mothers. More than 80 percent of the Korean mothers were foreign born. Significantly higher risks for very preterm delivery (less than 33 weeks) and very low birth weight births were observed for Koreans as compared with Caucasians. Nativity had no effect on birth outcome in this population. The results of this study suggest that prevention of preterm birth is an important focus for improving pregnancy outcomes in this growing ethnic group.