Obstetric outcomes in the second birth of women with a previous caesarean delivery: a retrospective cohort study from Peru

PURPOSE: To examine obstetric outcomes in the second birth of women who had undergone a previous cesarean delivery. METHODS: This was a large hospital-based retrospective cohort study. We included pregnant women who had a previous delivery (vaginal or cesarean) attending their second birth from 2001 to 2009. Main inclusion criteria were singleton pregnancies and delivery between a gestation of 24 and 41 weeks. Two cohorts were selected, being women with a previous cesarean delivery (n=7,215) and those with a vaginal one (n=23,720). Both groups were compared and logistic regression was performed to adjust for confounding variables. The obstetric outcomes included uterine rupture, placenta previa, and placental-related complications such as placental abruption, preeclampsia, and spontaneous preterm delivery. RESULTS: Women with previous cesarean delivery were more likely to have adverse outcomes such as uterine rupture (OR=12.4, 95%CI 6.8-22.3), placental abruption (OR=1.4, 95%CI 1.1-2.1), preeclampsia (OR=1.4, 95%CI 1.2-1.6), and spontaneous preterm delivery (OR=1.4, 95%CI 1.1-1.7). CONCLUSIONS: Individuals with previous cesarean section have adverse obstetric outcomes in the subsequent pregnancy, including uterine rupture, and placental-related disorders such as preeclampsia, spontaneous preterm delivery, and placental abruption.

Maternal age and adverse perinatal outcomes in a birth cohort (BRISA) from a Northeastern Brazilian city

PURPOSE:To verify the existence of associations between different maternal ages and the perinatal outcomes of preterm birth and intrauterine growth restriction in the city of São Luís, Maranhão, Northeastern Brazil.METHODS:A cross-sectional study using a sample of 5,063 hospital births was conducted in São Luís, from January to December 2010. The participants comprise the birth cohort for the study "Etiological factors of preterm birth and consequences of perinatal factors for infant health: birth cohorts from two Brazilian cities" (BRISA). Frequencies and 95% confidence intervals were used to describe the results. Multiple logistic regression models were applied to assess the adjusted odds ratio (OR) of maternal age associated with the following outcomes: preterm birth and intrauterine growth restriction.RESULTS:The percentage of early teenage pregnancy (12–15 years old) was 2.2%, and of late (16–19 years old) was 16.4%, while pregnancy at an advanced maternal age (>35 years) was 5.9%. Multivariate analyses showed a statistically significant increase in preterm births among females aged 12–15 years old (OR=1.6; p=0.04) compared with those aged 20–35 years. There was also a higher rate in preterm births among females aged 16–19 years old (OR=1.3; p=0.01). Among those with advanced maternal age (>35 years old), the increase in the prevalence of preterm birth had only borderline statistical significance (OR=1.4; p=0.05). There was no statistically significant association between maternal age and increased prevalence of intrauterine growth restriction.

Treatment of low-risk gestational trophoblastic neoplasia comparing biweekly eight-day Methotrexate with folinic acid versus bolus-dose Actinomycin-D, among Brazilian women

PURPOSE: To compare two single-agent chemotherapy (ChT) regimens evaluating, in first-line treatment, response and side effects and, in final single-agent treatment, the outcomes, among Brazilian patients with low-risk gestational trophoblastic neoplasia (GTN), according to International Federation of Gynecology and Obstetrics (FIGO) 2002. METHODS: Retrospective analysis of two concurrent cohorts with 194 low-risk GTN patients: from 1992 to 2012, as first-line treatment, 115 patients received 4 intramuscular doses of methotrexate alternated with 4 oral doses of folinic acid (MTX/FA) repetead every 14 days and, since 1996, 79 patients received an endovenous bolus-dose of actinomycin D (Act-D), biweekly. At GTN diagnosis, patient opinion was taken into consideration when defining the initial single-agent ChT regimen, and when there was resistance or toxicity to one regimen, the other drug was used preferentially. This study was approved by the Irmandade da Santa Casa de Misericórdia de Porto Alegre Ethical Committee. RESULTS: Both groups were clinically similar (p>0.05). In first-line treatments, frequency of complete response was similar (75.7% with MTX/FA and 67.1% with bolus Act-D); the number of ChT courses -median 3 (range: 1-10) with MTX/FA and 2 (range: 1-6) with bolus Act-D - and the time to remission -median 9 weeks (range: 2-16) with MTX/FA and 10 weeks (range: 2-16) with bolus Act-D) - were not different between the groups. In both groups, first-line side effects frequency were high but intensity was low; stomatitis was higher with MTX/FA (p<0.01) and nausea and vomit with Act-D (p<0.01). Final single-agent ChT responses were high in both groups (94.8% with MTX/FA and 83.5% with bolus Act-D; p<0.01) and 13% higher in the group initially treated with MTX/FA. Rates of hysterectomy and of GTN recurrence were low and similar. No patient died due to GTN. CONCLUSION: The two regimens had similar first-line ChT response. Final single-agent response rates were high and similar in both groups but the final single-agent remission rate was higher in the MTX/FA group.

Hearing Impairment and Tinnitus in the Elderly

The purpose of this study was to gather information on hearing impairment and related factors among elderly people. The HHIE-S questionnaire (Hearing Handicap Inventory for Elderly-Screening) and a single hearing question (”Do you feel you have a hearing loss”) were compared to audiometric hearing thresholds (N=164). HHIE-S was reliable for detecting moderate or worse hearing impairment. The single question was equally sensitive and more specific in identifying mild hearing impairment. The prevalence of hearing impairment was evaluated in four age cohorts (70, 75, 80 and 85 years, N=4067) in Turku, Finland. The HHIE-S cut-off score >8 as an indicator of at least mild hearing impairment yielded prevalence values of 37.7% - 54.1%, and a score >18 (moderate or more severe hearing impairment) was 21.1% - 38.9%. The single question test was positive in 25.5% - 46.2%. Hearing aid compliance and problems experienced by hearing aid users were recorded as informed by the participants in a mailed interview (N=249/4067). The hearing aids were used daily by 55.4%, and never by 10.7%. Use sank with advancing age. The disturbance caused by tinnitus among 583 subjects was compared to their level of alexithymia (TAS-20) and depressiveness (BDI). Depressiveness was weakly associated with annoying tinnitus, but not alexithymia. The prevalence of hearing impairment can be measured by enquiry. Hearing aid compliance should be improved by technical means and better counseling. The factors affecting the distress experienced by tinnitus patients need further study.

Syntyykö Suomeen puulaaksoja - Suomen puutuoteteollisuuden pk-yritysten tila ja tulevaisuus

Metsäteollisuus on tullut Suomeen ulkomaisen pääoman ja tietotaidon avulla vajaat kaksisataa vuotta sitten. Se on toiminut melkein koko jatkosodan jälkeisen ajan suojatussa ympäristössä ja ulkomaisesta kilpailusta riippumattomassa toimintaympäristössä. Kuten Porter ja muut ovat todistaneet, tällainen toimintaympäristö ei kehitä kansainvälisesti kilpailukykyistä teollisuutta globaaleilla markkinoilla. Liittyminen Euroopan unioniin ja sittemmin Euroopan rahaliittoon saattoi puunjalostusteollisuuden täysin uudenlaiseen kilpailutilanteeseen. Sama tapahtui myös alan pk-yrityksille, jotka olivat joutuneet toimimaan heikosti kilpailluilla raaka-ainemarkkinoilla. Tutkimus on tulevaisuudentutkimus, jossa tutkimusongelmia lähestytään kolmen teorian avulla. Porterin klusteriteoria tarjoaa mahdollisuuden arvioida metsäteollisuutta sekä kokonaisuutena että toimivana monimuotoisena organisaationa, jossa kustannukset ja hinta muodostuvat arvoketjun toimijoiden osakustannuksista. Bionomiateoria eli darvinistinen talousteoria testaa suomalaisen puunjalostusteollisuuden pk-yritysten kilpailukykyä ja paineita hakeutua edullisemmille toiminta- alueille. Evoluutioteoria tarkastelee sukupolvenvaihdoksen problematiikkaa. Sukupolvenvaihdoksen onnistuminen muodostuu puutoimialan elämän ja kuoleman kysymykseksi. Tämä on etenkin pk-yrityksiä kohtaava ongelma. Asiaa selvitettiin Mauno Rintalan suorittamalla kyselytutkimuksella Puuteollisuusyrittäjien jäsenistön keskuudessa. Ongelma johtuu suurista sodan jälkeen syntyneistä ikäluokista. Nämä vuosina 1945– 50 syntyneet ovat siirtymässä eläkkeelle vuosien 2005 ja 2015 välillä. Kyseisissä ikäluokissa yritystiheys on noin kaksi kertaa suurempi kuin sen jälkeisissä ikäluokissa. Suoritetun kyselyn sekä muiden suomalaisten ja kansainvälisten tutkimusten perusteella näyttää siltä, että eläkkeelle siirryttäessä vain noin 30 %:lla yrityksistä on jatkaja tiedossa suvusta tai lähipiiristä. Tämä merkitsee sitä, että 70 % eläköityvän ikäluokan omistamista yrityksistä poistuu pysyvästi markkinoilta. Suomessa poistuma merkitsee noin 40 % koko yritysvarannosta eli noin 80 000 yritystä. Tilastot toimivien yritysten määrästä ovat kuitenkin hyvin ristiriitaisia, joten todellista määrää on mahdoton arvioida. Noin suuren määrän poistuminen markkinoilta uhkaa jo hyvinvointivaltion perusrakenteita. Tutkimustulos edellyttää nopeita toimenpiteitä teollisten pkyritysten pelastamiseksi ja säilyttämiseksi Suomessa. Sukupolvenvaihdoksen onnistuminen on tässä prosessissa ensiarvoisessa asemassa. Kaikkien edellä mainittujen yritysten poistuminen markkinoilta edellyttäisi noin 400 000 uuden yrityksen perustamista, koska ainoastaan noin 20 % yrityksistä selviää ensimmäiset kolme vuotta. Tutkimukseen perustuen esitetään prosessimalli sukupolvenvaihdoksen suorittamiseksi. Suomen tärkeimmissä kilpailijamaissa valtioiden metsäomistus on määräävässä asemassa. Meillä metsät ovat yksityisessä omistuksessa ja vain pieni osa valtion omistuksessa. Puumarkkinat toimivat markkinatalouden ehdoilla ilman valtion ohjausta. Ongelmaksi on kehittymässä puun saanti. Metsänomistus on sukupolvien myötä hajaantunut hyvin pieniksi metsälöiksi. Nykyiset metsänomistajat asuvat kaupungeissa ja ovat pääosin palkkatyössä. He eivät ole samalla tavoin riippuvaisia puutuloista kuin heidän esi-isänsä. Metsäverotuksen uudistuminen lisää puun saannin epävarmuutta. Se on muuttumassa pinta-alaverotuksesta puun myynnin verotukseen. Puun myynti on vilkasta ennen järjestelmien vaihtumista ja vähäisempää sen jälkeen. Myös näitä ongelmia on pyritty ratkomaan uudenlaisen metsänomistusmallin avulla. Puuteollisuus on hyvin vanha teollisuudenala. Raaka-aine muodostaa määräävän osan kustannuksista. Muutokset ovat hitaita ja todelliset innovaatiot pitkäkestoisia. Uusia innovaatioita tapahtuu harvoin. Kannattavuutta parannetaan tuoteprosessien ja arvoketjujen kehittämisen kautta. Yhteiskunnan osuus alan kehittämisessä ja säilyttämisessä on ratkaiseva. Asioiden moninaisuus tekee tutkimuksen vaikeaksi, mutta sitäkin tärkeämmäksi kansantalouden kannalta. Tällaisissa suurissa murroksissa korostuu kaikkien päättävien tahojen henkinen valmius ja tahto tehdä oikeita ratkaisuja oikeaan aikaan.

Composite artistry in the Book of Numbers : a study in biblical narrative conventions

The present thesis discusses the coherence or lack of coherence in the book of Numbers, with special regard to its narrative features. The fragmented nature of Numbers is a well-known problem in research on the book, affecting how we approach and interpret it, but to date there has not been any thorough investigation of the narrative features of the work and how they might contribute to the coherence or the lack of coherence in the book. The discussion is pursued in light of narrative theory, and especially in connection to three parameters that are typically understood to be invoked in the interpretation of narratives: 1) a narrative paradigm, or ‘story,’ meaning events related to each other temporally, causally, and thematically, in a plot with a beginning, middle, and end; 2) discourse, being the expression plane of a narrative, or the devices that an author has at hand in constructing a narrative; 3) the situation or languagegame of the narrative, prototypical examples being factual reports, which seeks to depict a state of affairs, and storytelling narratives, driven by a demand for tellability. In view of these parameters the present thesis argues that it is reasonable to form four groups to describe the narrative material of Numbers: genuine narratives (e.g. Num 12), independent narrative sequences (e.g. Num 5:1-4), instrumental scenes and situations (e.g. Num 27:1-5), and narrative fragments (e.g. Num 18:1). These groups are mixed throughout with non-narrative materials. Seen together, however, the narrative features of these groups can be understood to create an attenuated narrative sequence from beginning to end in Numbers, where one thing happens after another. This sequence, termed the ‘larger story’ of Numbers, concerns the wandering of Israel from Sinai to Moab. Furthermore, the larger story has a fragmented plot. The end-point is fixed on the promised land, Israel prepares for the wandering towards it (Num 1-10), rebels against wandering and the promise and is sent back into the wilderness (Num 13-14), returns again after forty years (Num 21ff.), and prepares for conquering the land (Num 22-36). Finally, themes of the promised land, generational succession, and obedience-disobedience, operate in this larger story. Purity is also a significant theme in the book, albeit not connected to plot in the larger story. All in all, sequence, plot, and theme in the larger story of Numbers can be understood to bring some coherence to the book. However, neither aspect entirely subsumes the whole book, and the four groups of narrative materials can also be understood to underscore the incoherence of the work in differentiating its variegated narrative contents. Numbers should therefore be described as an anthology of different materials that are loosely connected through its narrative features in the larger story, with the aim of informing Israelite identity by depicting a certain period in the early history of the people.

Benzodiazepines and Cognitive Functioning in Older Adults. With Emphasis on Long-Term Use and Withdrawal

Benzodiazepines (BZD) and benzodiazepine related drugs (RD) are the most commonly used psychotropics among the aged. The use of other psychotropics taken concomitantly with BZD/ RD or their cognitive effects with BZD/RD have not been studied frequently. The aim of this academic thesis was to describe and analyse relationships between the use of BZD/RD alone or concomitantly with antipsychotics, antidepressants, opioids, antiepileptics, opioids and anticholinergics in the aged and their health. Especially, the relationships between long-term use of BZD/RD and cognitive decline were studied. Additionally, the effect of melatonin on BZD/RD withdrawal and the cognitive effects of BZD/RD withdrawal were studied. This study used multiple data sets: the first study (I) was based on clinical data containing aged patients (≥65 years; N=164) admitted to Pori City Hospital due to acute disease. The second data set (Studies II and III) was based on population-based data from the Lieto Study, a clinico-epidemiological longitudinal study carried out among the aged (≥65 years) in the municipality of Lieto. Follow-up data was formed by combining the cohort data collected in 1990-1991 (N=1283) and in 1998-1999 (N=1596) from those who participated in both cohorts (N=617). The third data set (Studies IV and V) was based on the Satauni Study’s data. This study was performed in the City of Pori in 2009-2010. In the RCT part of the Satauni Study, ninety-two long-term users of BZD/RD were withdrawn from their drugs using melatonin against placebo. The change of their cognitive abilities was measured during and after BZD/ RD withdrawal. BZD/RD use was related to worse cognitive and functional abilities, and their use may predict worse cognitive outcomes compared with BZD/RD non-users. Hypnotic use of BZD/RD could be withdrawn with psychosocial support in motivated participants, but melatonin did not improve the withdrawal results compared to those with placebo. Cognitive abilities in psychomotor tests did not show, or showed only modest, improvements for up to six months after BZD/RD withdrawal. This suggests that the cognitive effects of BZD/RD may be longlasting or permanent.

Hoitotyön koulutuksen opiskelijavalinnat. Seurantatutkimus kahden valintakoemenetelmän yhteydestä opiskelijoiden osaamiseen ja opiskelumotivaatioon

Hoitotyön koulutukseen pyritään valitsemaan alalle soveltuvia, motivoituneita sekä teoreettisissa ja kliinisissä opinnoissa menestyviä opiskelijoita. Tämän seurantatutkimuksen tarkoituksena oli vertailla soveltuvuuskokeella ja kirjallisella kokeella valittujen hoitotyön opiskelijoiden osaamista ja opiskelumotivaatiota. Tutkimuksen tavoitteena oli tehdä tutkimustulosten perusteella hoitotyön koulutuksen opiskelijavalintoihin liittyviä kehittämisehdotuksia. Tutkimuksen kohderyhmänä olivat yhteen ammattikorkeakouluun syksyn 2002 ja syksyn 2004 välisenä aikana hoitotyön koulutukseen kahdella eri valintakoemenetelmällä valitut hoitotyön opiskelijat (N=626) (sairaanhoitotyö, terveydenhoitotyö, kätilötyö). Opiskelijaryhmistä muodostettiin kaksi kohorttia valintakoemenetelmän perusteella: soveltuvuuskoe (VAL1, N=368) ja kirjallinen koe (VAL2, N=258). Seurantatutkimuksen aineisto kerättiin opiskelijoiden opintorekisteristä sekä kahdella strukturoidulla mittarilla, joilla kartoitettiin hoitotyön opiskelijoiden itsearvioitua hoitotyön osaamista (OSAA-mittari) ja opiskelumotivaatiota (MOTI-mittari). Seurantatutkimuksen aineistonkeruu ajoittui opiskelijoiden kolmannelle lukukaudella (1. mittaus, 2004‒2006, VAL1 n=234, VAL2 n=126) ja valmistumisvaiheeseen (2. mittaus, 2006‒2009, VAL1 n=149, VAL2 n=108). Ensimmäisen mittauksen vastausprosentti oli 75,0 % ja toisen mittauksen 92,4 %. Aineistojen analysoinnissa käytettiin pitkittäistutkimukseen soveltuvia monimuuttujamenetelmiä. Kahdella valintakoemenetelmällä valikoitui pienistä eroista huolimatta osaamiseltaan ja opiskelumotivaatioltaan hyvin samanlaisia opiskelijoita. Soveltuvuuskokeella valitut opiskelijat kokivat ryhmän kannustavuuden vahvemmaksi valmistumisvaiheessa kuin kirjallisella kokeella valitut. Kirjallisella kokeella valittujen opiskelijoiden kolmannen lukukauden arvosanoihin perustuva osaaminen oli parempaa kuin soveltuvuuskokeella valittujen opiskelijoiden. Suuntautumisvaihtoehto, hoitoalan työkokemus, peruskoulutus ja hakusija olivat merkittävimmin yhteydessä opiskelijoiden osaamiseen ja opiskelumotivaatioon. Valintakoemenetelmä selitti eniten opiskelijoiden osaamisessa ja opiskelumotivaatiossa ilmenneitä eroja, joskin selitysosuudet jäivät alhaisiksi. Kehittämisehdotukset kohdistuvat valintakoemenetelmien kehittämiseen ja säännölliseen arviointiin sekä alalle motivoituneisuuden määrittelyyn ja mittaamisen kehittämiseen. Jatkotutkimusaiheina ehdotetaan eri valintakoemenetelmien testaamista ja tutkimuksessa käytettyjen mittareiden edelleen kehittämistä.

Cesarean section - short term maternal complications related to the mode of delivery

Cesarean section (CS) is the most common major surgery performed on women worldwide. CS can save the life of the mother or the fetus, but is associated with the typical complications of any major surgery: hemorrhage, infection, venous thromboembolism and complications of anesthesia, sometimes leading to maternal death. Recently there have been several reports from well resourced countries on increased severe maternal morbidity and even mortality. Increased rates of CS, obesity and older mothers may explain this rise. The aim of this thesis is to study the rates and risk factors of short term maternal complications associated with CS. Also, we compared maternal morbidity by mode of delivery and over time. The complication rates were assessed in a prospective study involving 2496 CS performed in the 12 largest delivery units in Finland in 2005. The rates of severe complications were studied by mode of delivery in a register-based study comparing national cohorts in 1997 and 2002. The impact of several risk factors on severe maternal morbidity by mode of delivery was studied in a register-based study of all singleton deliveries in 2007-2011. In the prospective study, 27% of the women who underwent CS had one or more intraoperative or postoperative complications during their hospital stay, and 10% had a severe complication. In the register-based study the incidence of life-threatening maternal complications was 7.6 in 1000 deliveries. The incidence was lowest for vaginal delivery (VD), followed by instrumental VD and elective CS, and highest in emergency CS. An attempt of VD, including the risks associated with emergency CS, seems to be the safest mode of delivery, even for most high-risk women.

Periprocedural prognostic factors in coronary interventions – retrospective studies

Background: Approximately 11,000 revascularization procedures, either percutaneous coronary interventions (PCI) or coronary artery bypass grafting surgery (CABG), are performed yearly in Finland for coronary artery disease. Periprocedural risk factors for mortality and morbidity as well as long-term outcome have been extensively studied in general populations undergoing revascularization. Treatment choice between PCI and CABG in many high risk groups and risk-stratification, however, needs clarification and there is still room for improvement in periprocedural outcomes. Materials and methods: Cohorts of patients from Finnish hospitals revascularized between 2001 and 2011 were retrospectively analyzed. Patient records were reviewed for baseline variables and postprocedural outcomes (stroke, myocardial infarction, quality of life measured by the EQ-5D –questionnaire, repeat revascularization, bleeding episodes). Data on date and mode of death was acquired from Statistics Finland. Statistical analysis was performed to identify predictors of adverse events and compare procedures. Results: Postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets) after isolated CABG independently and dose-dependently increases the risk of stroke. Patients 80 years or older who underwent CABG had better survival at 5 years compared to those who underwent PCI. After adjusting for baseline differences survival was similar. Patients on oral anticoagulation (OAC) for atrial fibrillation (AF) treated with CABG had better survival and overall outcome at 3 years compared to PCI patients. There was no difference in incidence of stroke or bleeding episodes. Differences in outcome remained significant after adjusting for propensity score. Lower health-related quality of life (HRQOL) scores as measured by the visual analogue scale (VAS) of the EQ-5D questionnaire at 6 months after CABG predicted later major adverse cardiac and cerebrovascular events (MACCE). Deteriorating function and VAS scores between 0 and 6 months on the EQ-5D also independently predicted later MACCE. Conclusions: Administration of blood products can increase the risk of stroke after CABG and liberal use of transfusions should be avoided. In the frail subpopulations of patients on OAC and octogenarians CABG appears to offer superior long-term outcome as compared to PCI. Deteriorating HRQOL scores predict later adverse events after CABG. Keywords: percutaneous coronary intervention, coronary artery bypass grafting, age over 80, transfusion, anticoagulants, coronary artery disease, health-related quality of life, outcome.

A cost-effective melting temperature assay for the detection of single-nucleotide polymorphism in the MBL2 gene of HIV-1-infected children

We report a fast (less than 3 h) and cost-effective melting temperature assay method for the detection of single-nucleotide polymorphisms in the MBL2 gene. The protocol, which is based on the Corbett Rotor Gene real time PCR platform and SYBR Green I chemistry, yielded, in the cohorts studied, sensitive (100%) and specific (100%) PCR amplification without the use of costly fluorophore-labeled probes or post-PCR manipulation. At the end of the PCR, the dissociation protocol included a slow heating from 60º to 95ºC in 0.2ºC steps, with an 8-s interval between steps. Melting curve profiles were obtained using the dissociation software of the Rotor Gene-3000 apparatus. Samples were analyzed in duplicate and in different PCR runs to test the reproducibility of this technique. No supplementary data handling is required to determine the MBL2 genotype. MBL2 genotyping performed on a cohort of 164 HIV-1-positive Brazilian children and 150 healthy controls, matched for age and sex and ethnic origin, yielded reproducible results confirmed by direct sequencing of the amplicon performed in blind. The three MBL2 variants (Arg52Cys, Gly54Asp, Gly57Glu) were grouped together and called allele 0, while the combination of three wild-type alleles was called allele A. The frequency of the A/A homozygotes was significantly higher among healthy controls (0.68) than in HIV-infected children (0.55; P = 0.0234) and the frequency of MBL2 0/0 homozygotes was higher among HIV-1-infected children than healthy controls (P = 0.0296). The 0 allele was significantly more frequent among the 164 HIV-1-infected children (0.29) than among the 150 healthy controls (0.18; P = 0.0032). Our data confirm the association between the presence of the mutated MBL2 allele (allele 0) and HIV-1 infection in perinatally exposed children. Our results are in agreement with the literature data which indicate that the presence of the allele 0 confers a relative risk of 1.37 for HIV-1 infection through vertical transmission.

Do socioeconomic factors explain why maternal smoking during pregnancy is more frequent in a more developed city of Brazil?

The prevalence of smoking during pregnancy in Ribeirão Preto, a rich Brazilian city, was significantly higher (21.4%) than in São Luís (5.9%), a less developed city. To assess which variables explain the difference in prevalence of smoking during pregnancy, data from two birth cohorts were used, including 2846 puerperae from Ribeirão Preto, in 1994, and 2443 puerperae from São Luís, in 1997/98. In multivariable analysis, risk of maternal smoking during pregnancy was higher in São Luís for mothers living in a household with five or more persons (OR = 1.72, 95%CI = 1.12-2.64), aged 35 years or older (OR = 1.98, 95%CI = 0.99-3.96), who had five or more children (OR = 2.10, 95%CI = 1.16-3.81), and whose companion smoked (OR = 2.20, 95%CI = 1.52-3.18). Age of less than 20 years was a protective factor (OR = 0.55, 95%CI = 0.33-0.92). In Ribeirão Preto there was association with maternal low educational level (OR = 2.18, 95%CI = 1.30-3.65) and with a smoking companion (OR = 3.25, 95%CI = 2.52-4.18). Receiving prenatal care was a protective factor (OR = 0.24, 95%CI = 0.11-0.49). Mothers from Ribeirão Preto who worked outside the home were at a higher risk and those aged 35 years or older or who attended five or more prenatal care visits were at lower risk of smoking during pregnancy as compared to mothers from São Luís. Smoking by the companion reduced the difference between smoking rates in the two cities by 10%. The socioeconomic variables in the model did not explain the higher prevalence of smoking during pregnancy in the more developed city.

Connections: can the 20th century coronary heart disease epidemic reveal something about the 1918 influenza lethality?

This essay proposes that the ecologic association shown between the 20th century coronary heart disease epidemic and the 1918 influenza pandemic could shed light on the mechanism associated with the high lethality of the latter. It suggests that an autoimmune interference at the apoB-LDL interface could explain both hypercholesterolemia and inflammation (through interference with the cellular metabolism of arachidonic acid). Autoimmune inflammation, then, would explain the 1950s-60s acute coronary events (coronary thrombosis upon influenza re-infection) and the respiratory failure seen among young adults in 1918. This hypothesis also argues that the lethality of the 1918 pandemic may have not depended so much on the 1918 virus as on an immune vulnerability to it, possibly resulting from an earlier priming of cohorts born around 1890 by the 1890 influenza pandemic virus.

Examining life-course influences on chronic disease: the Ribeirão Preto and São Luís birth cohort studies (Brazil)

More than any other low- and middle-income country, Brazil has the longest research tradition of establishing, maintaining and exploiting birth cohort studies. This research pedigree is highlighted in the present issue of the Brazilian Journal of Medical and Biological Research, which contains a series of twelve papers from the Ribeirão Preto and São Luis birth cohort studies from the Southeast and Northeast of Brazil, respectively. The topics covered in this raft of reports vary and include predictors of perinatal health and maternal risk factors, early life determinants of cardiovascular risk factors in childhood and adolescence, use of health services, and a description of dietary characteristics of young adults, amongst other topics. There is also a guide to the background, objectives, sampling and protocols employed across these studies, which, together with similar pieces published in past issues of the Brazilian Journal, serve as a very useful starting point, particularly for potential collaborators. In the fervent hope that further follow-up of these cohorts will take place - we provide our own justification for cohort maintenance and extension in this issue - future data collection could include: genetic material, atherosclerosis, ascertained, for instance, by intima-media thickness, and IQ testing in children - scores from which are emerging as potentially important predictors of adult health outcomes up to six decades later.

Examining life-course influences on chronic disease: the importance of birth cohort studies from low- and middle- income countries. An overview

The objectives of this overview are to describe the past and potential contributions of birth cohorts to understanding chronic disease aetiology; advance a justification for the maintenance of birth cohorts from low- and middle-income countries (LMIC); provide an audit of birth cohorts from LMIC; and, finally, offer possible future directions for this sphere of research. While the contribution of birth cohorts from affluent societies to understanding disease aetiology has been considerable, we describe several reasons to anticipate why the results from such studies might not be directly applied to LMIC. More than any other developing country, Brazil has a tradition of establishing, maintaining and exploiting birth cohort studies. The clear need for a broader geographical representation may be precipitated by a greater collaboration worldwide in the sharing of ideas, fieldwork experience, and cross-country cohort data comparisons in order to carry out the best science in the most efficient manner. This requires the involvement of a central overseeing body - such as the World Health Organization - that has the respect of all countries and the capacity to develop strategic plans for `global' life-course epidemiology while addressing such issues as data-sharing. For rapid progress to be made, however, there must be minimal bureaucratic entanglements.