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Background: Early mobilization protocols have been successfully implemented to improve function in critically ill patients; however, no study has focused on the oncology population., Objectives: To investigate the feasibility of early mobilization and describe the rehabilitation interventions and discharge outcomes in a cohort of critically ill patients with cancer., Design: Retrospective review., Methods: A retrospective analysis of patients with cancer who participated in occupational and physical therapy while on mechanical ventilation utilizing an institutional early mobilization protocol from June 2010 - July 2011, was completed. Demographic and clinical variables were abstracted, as well as occupational and physical therapy interventions., Results: A cohort of 42 cancer patients on mechanical ventilation in the mixed medical/surgical intensive care unit of a comprehensive cancer center received early mobilization during the study period. The majority of participants demonstrated improved cognitive and functional status from the intensive care unit to hospital discharge. There were no reported adverse events during the occupational and physical therapy sessions. Among the 30 hospital survivors, 53% required continued rehabilitation services in their home environment and 40% were transferred to a rehabilitation facility., Limitations: Due to the small sample size, these findings are not generalizable to all critically ill cancer patients. There was no post-acute care follow-up of cognitive and physical functional performance., Conclusion: Early mobilization appears feasible in addressing the cognitive and functional needs of oncology patients in the intensive care unit.

In Cambodia, children's feces are rarely disposed of in an improved sanitation facility. This study examines current practices and the role that enabling products may play in increasing hygienic management of infant and young child (IYC) feces in households with access to improved sanitation. A survey was conducted with the primary caregiver of a child under 5 years of age in 130 homes with an improved latrine in 21 villages across two provinces in Cambodia. Two focus group discussions per province were conducted after the survey to obtain caregiver feedback on new enabling products for hygienic management. Among caregivers, 63% reported child feces disposal in an improved latrine but only 36% reported doing so consistently. Besides child age, years of latrine ownership, caregiver age, consistency of adult latrine use, and presence of child feces management tools in the latrine were associated with hygienic disposal. The youngest caretakers with the newest latrines and youngest children were least likely to dispose of IYC feces hygienically, representing a key target group for interventions to improve hygienic disposal in Cambodia. Reusable diapers, child-friendly potties, and possibly latrine seats, that offer child safety, time and cost savings, and easy disposal and cleaning could potentially facilitate hygienic disposal for these ages., (© The American Society of Tropical Medicine and Hygiene.)

Objectives: QT dispersion (QT(d)) measures the variability of the ventricular recovery time. QT(d) may identify patients at risk for ventricular arrhythmias and sudden cardiac death (SCD). The purpose of our study was to determine the effect of obstructive sleep apnea (OSA) on QT(d)., Methods: There were 199 patients studied: 101 patients (28 women, 73 men) with OSA diagnosed in our sleep center and 98 patients (49 women, 49 men) without OSA from the outpatient clinic, representing the control group. QT intervals (milliseconds) were measured in each of the 12 leads of a standard surface electrocardiogram during wakefulness and QT(d) calculated (QT(max) - QT(min)). QT(c)(d), which corrects for heart rate, was also calculated., Results: Mean age and heart rate were similar in men and women with or without OSA. Control patients exhibited a significant difference (p < 0.001) in QT(d) between men (48 ± 19) and women (31 ± 13). Men and women with OSA had similar QT(d) (56 ± 35 vs. 54 ± 21) but higher QT(d) compared to the control group. QT(c)(d) results were similar to QT(d)., Conclusions: Patients with OSA and no structural heart disease have a higher QT(d)/QT(c)(d) compared to an overtly healthy patient population, possibly serving as a marker for an increased risk of SCD., (Copyright © 2011 S. Karger AG, Basel.)

Introduction: Limited data are available regarding the relationship of premortem clinical diagnoses and postmortem autopsy findings in cancer patients who die in an oncologic intensive care unit (ICU). The purposes of this study were to compare the premortem clinical and postmortem diagnoses of cancer patients who died in the ICU and to analyze any discrepancies between them., Methods: This is a retrospective review of medical records and autopsy reports of all cancer patients who died in a medical-surgical ICU and had an autopsy performed between 1 January 1999 and 30 September 2005 at a tertiary care cancer center. Premortem clinical diagnoses were compared with the postmortem findings. Major missed diagnoses were identified and classified, according to the Goldman criteria, into class I and class II discrepancies., Results: Of 658 deaths in the ICU during the study period, 86 (13%) autopsies were performed. Of the 86 patients, 22 (26%) had 25 major missed diagnoses, 12 (54%) patients had class I discrepancies, 7 (32%) had class II discrepancies, and 3 (14%) had both class I and class II discrepancies. Class I discrepancies were due to opportunistic infections (67%) and cardiac complications (33%), whereas class II discrepancies were due to cardiopulmonary complications (70%) and opportunistic infections (30%)., Conclusion: There was a discrepancy rate of 26% between premortem clinical diagnoses and postmortem findings in cancer patients who died in a medical-surgical ICU at a tertiary care cancer center. Our findings underscore the need for enhanced surveillance, monitoring, and treatment of infections and cardiopulmonary disorders in critically ill cancer patients.

Objective: To report the development of the Brugada electrocardiographic (ECG) pattern in the immediate postoperative setting., Design: Case report., Setting: Postanesthesia care unit at Memorial Sloan-Kettering Cancer Center., Patient: A 51-yr-old white male who developed new ST-segment elevation in leads V(1)-V(3) typical of the ECG changes of the Brugada syndrome immediately after undergoing head and neck surgery for cancer. The patient was asymptomatic, and the cardiac enzymes and echocardiogram were normal; therefore, electrophysiologic study was not performed., Conclusions: We postulated that the Brugada ECG abnormalities were induced primarily by an increase in parasympathetic tone resulting from vagal nerve manipulation during deep neck dissection and partially by the fever he developed during the postoperative period. In addition to the more common causes of ST-segment elevation, the Brugada ECG pattern or syndrome should be considered in patients undergoing deep neck dissection who develop characteristic ECG changes in association with normal cardiac enzymes and echocardiogram.

The objective of this study was to assess the feasibility of DDD pacing from a standard single-pass VDD pacemaker system. Over the past 2 decades significant advances have been made in the development of single-pass VDD pacing systems. These have been shown in long-term prospective studies to effectively preserve atrioventricular (AV)synchrony in patients with AV block and normal sinus node function. What remains problematic is the development of a single-pass pacing system capable of DDD pacing. Such a lead configuration would be useful in those patients with peripheral venous anomalies and in younger patients with congenital anomalies, which may require lead revisions in the future. In addition, with the increased use of resynchronization (biventricular pacing) therapy, the availability of a reliable single-pass lead will minimize operative time, enhance patient safety, and minimize the amount of hardware within the heart. The feasibility of DDD pacing via a Medtronic Capsure VDD-2 (Model #5038) pacing lead was evaluated. Twenty patients who presented with AV block and normal sinus node function were recruited for this study. Atrial pacing thresholds and sensitivities were assessed intraoperatively in the supine position with various respiratory maneuvers. Five patients who agreed to participate in long-term follow-up received a dual-chamber generator and were evaluated periodically over a 12-month period. Mean atrial sensitivity was 2.35 +/- 0.83 mV at the time of implantation. Effective atrial stimulation was possible in all patients at the time of implantation (mean stimulation threshold 3.08 +/- 1.04 V at 0.5 ms [bipolar], 3.34 +/- 0.95 V at 0.5 ms [unipolar]). Five of the 20 patients received a Kappa KDR701 generator, and atrial electrical properties were followed up over a 1-year period. There was no significant change in atrial pacing threshold or incidence of phrenic nerve stimulation over the 1-year follow-up. A standard single-pass VDD pacing lead system was capable of DDD pacing intraoperatively and during long-term follow-up. Despite higher than usual thresholds via the atrial dipole, pacemaker telemetry revealed < 10% use of atrial pacing dipole over a 12-month period, which would minimally deplete the pacemaker's battery. In addition, the telemetry confirmed appropriate sensing and pacing of the atrial dipole throughout the study period. At this time such systems can serve as back-up DDD pacing systems with further refinements required to optimize atrial thresholds in all patients.

Background: There have been several epidemiologic studies investigating the association between circulating levels of insulin-like growth factor I (IGF-I), insulin-like growth factor binding protein 3 (IGFBP-3), and insulin in relation to the risk of prostate carcinoma, with conflicting results. To examine this issue further, the authors conducted a nested case-control study within the Cardiovascular Health Study cohort., Methods: In men who were diagnosed with prostate carcinoma (cases) between 1990 and 1999 (n=174), the levels of IGF-I, IGFBP-3, and insulin were measured on blood samples that were obtained 1-9 years prior to diagnosis (mean, 3.4 years). Similar measurements were made on 174 male participants without prostate carcinoma (controls) who were matched to cases based on the year blood was drawn, survival until the date of diagnosis, race, and age., Results: Relative to the men with IGF-I levels in the first (lowest) quartile of the distribution, the risk of prostate carcinoma for men in the second, third, and fourth (upper) quartiles were 0.77 (95% confidence interval [95% CI], 0.43-1.38), 0.73 (95% CI, 0.41-1.30), and 0.67 (95% CI, 0.37-1.25), respectively. The results were influenced little by adjustment for levels of IGFBP-3 or, instead, by evaluating the molar IGF-I/IGFBP-3 ratio. An analysis that was restricted to men who had plasma prostate-specific antigen levels <4 ng/mL at the time of the blood draw yielded similar results. The corresponding relative risks for IGFBP-3 were 0.91 (95% CI, 0.49-1.68), 0.47 (95% CI, 0.25-0.94), and 0.65 (95% CI, 0.35-1.20), respectively. The distribution of serum insulin levels in cases and controls were nearly identical., Conclusions: The IGF-I level was not associated positively with the risk of prostate carcinoma; however, an increase in the IGFBP-3 level was associated with a modest decrease in risk.

A 27-year-old morbidly obese man diagnosed with severe obstructive sleep apnea (OSA) and experiencing significant ventricular asystoles at times exceeding 8 seconds, during polysomnography. The bradyarrhythmias were successfully corrected with the application of a nasal continuous positive airway pressure (CPAP) mask. Follow-up 24-hour ambulatory Holter monitoring without the aid of a nasal CPAP mask and repeat polysomnography with a CPAP mask after several weeks of continuous CPAP therapy during sleep revealed no evidence of ventricular asystole, despite no change in the patient's body mass index. We discuss several mechanisms explaining the findings in this particular patient.

Most wide-complex tachycardias encountered in the emergency department (ED) are ventricular in origin, most commonly associated with structural heart disease. Ventricular tachyarrhythmias range in severity from life-threatening rhythms (eg, ventricular fibrillation and hemodynamically compromising ventricular tachycardia [VT]) to idiopathic forms of VT, which have a benign clinical course and a more favorable prognosis. The authors present the case of a 34-year-old woman who presented to the ED, with a wide-complex tachycardia with a right-bundle-branch block (RBBB) morphology and a right inferior axis, which was terminated with adenosine. The patient was previously misdiagnosed as suffering from a paroxysmal supraventricular tachycardia (SVT), which was unresponsive to beta-blocker therapy. Although the tachycardia responded to adenosine, suggestive of an SVT, the patient was referred to the arrhythmia service, where further work-up revealed an uncommon form of an idiopathic VT, originating from the left anterior fascicle. The authors discuss the unique electrocardiographic and electrophysiologic properties and useful diagnostic maneuvers required to properly identify this form of VT.

The authors present a case of early (within 4 days) development of torsade de pointes (TdP) associated with oral amiodarone therapy. Consistent with other reports this case of TdP occurred in the context of multiple exacerbating factors including hypokalemia and digoxin excess. Transient prolongation of the QT during bladder irrigation prompted the episode of TdP. It is well known that bradycardia exacerbates acquired TdP. The authors speculate that the increased vagal tone during bladder irrigation, a vagal maneuver, in the context of amiodarone therapy resulted in amiodarone-induced proarrhythmia. In the absence of amiodarone therapy, a second bladder irrigation did not induce TdP despite hypokalemia and hypomagnesemia.

To investigate the association between recreational physical activity and endometrial cancer risk, a population-based case-control study was conducted in Washington State. The study included 822 incident cases of endometrial cancer diagnosed between 1985 and 1991 and 1,111 randomly selected population-based controls. Detailed information on recreational physical activities as well as other endometrial cancer risk factors was obtained in structured, in-person interviews. Unconditional logistic regression, adjusted for age, county, energy intake, unopposed estrogen use, income, and, in separate models, body mass index (kg/m(2)), was used to estimate the odds ratios and their 95% confidence intervals, relating endometrial cancer to each level of physical activity. A greater proportion of controls (49.3%) than cases (40.5%) reported doing regular exercise (compared with no exercise: adjusted odds ratio = 0.62, 95% confidence interval: 0.51, 0.76) in the 2-year period prior to diagnosis date. There was little evidence of a trend of decreasing risk with increasing duration or intensity of recreational physical activities. These results provide support for an association between the lack of recent recreational physical activity and endometrial cancer risk. However, the absence of a difference by duration or intensity levels and the inconsistent results from other studies suggest caution before interpreting this association as causal.

Objective: Postmenopausal women who receive sequential hormone replacement therapy with estrogen combined with progestogen for 10 to 24 d/mo for a prolonged period may have an elevated endometrial cancer risk relative to those who have never received hormone replacement therapy. We investigated whether daily use of estrogen and progestogen (continuous combined hormone replacement therapy) could diminish any excess endometrial cancer risk., Study Design: A population-based study in Washington State obtained interview data from 969 women aged 45 to 74 years with endometrial cancer diagnosed during 1985 through 1991 or 1994 through 1995 and from 1325 age-matched control subjects selected primarily by random digit dialing. Women who had received only continuous combined hormone replacement therapy were compared with women who had only received another hormone replacement therapy regimen or who had never received hormone replacement therapy., Results: The risk of endometrial cancer among users of continuous combined hormone replacement therapy (n = 9 case patients, n = 33 control subjects) relative to women who had never received hormone replacement therapy was 0.6 (95% confidence interval, 0.3-1.3); the risk relative to women who received hormone replacement that included progestogen for 10 to 24 d/mo was 0.4 (95% confidence interval, 0.2-1.1). Most continuous combined hormone replacement therapy use was short-term (<72 months) or recent (in the previous 24 months)., Conclusion: Women who had received continuous combined hormone replacement therapy for several years did not appear to be at any increased risk for endometrial cancer relative to women who had never received hormone replacement therapy and may in fact be at decreased risk for endometrial cancer.

Background: Breast and thyroid cancer have been observed to occur more frequently than expected as multiple primary tumors in women. The study presented herein focuses on the effects of age at diagnosis and treatment for the first cancer on the development of the second cancer., Methods: This retrospective cohort study used a study population consisting of 38,632 women diagnosed with primary invasive breast cancer and 2189 women diagnosed with primary invasive thyroid cancer between 1974 and 1994. Cases were identified from records of the Cancer Surveillance System of western Washington and followed for subsequent cancer development through 1995., Results: Seventy-one women were diagnosed during their lives with both breast and thyroid cancers. Including cancers diagnosed during the same month as or after the initial cancer, the relative risk (RR) of breast cancer among women with thyroid cancer was 1.5 (95% confidence interval [CI] 1.1-2.0), and the RR of thyroid cancer among women with breast cancer was 1.5 (95% CI 1.1-2.2). Among women with thyroid cancer, risk of breast cancer was greatest when the latter cancer was diagnosed under 45 years of age (RR = 2.3, 95% CI 1.1-4.4). First course of treatment, including radiation or hormonal therapy to treat thyroid cancer, and radiation, chemotherapy, or hormonal therapy to treat breast cancer, did not alter a woman's risk of developing the second cancer., Conclusions: The data suggest that the incidence of breast and thyroid cancer may be related, and that in particular women with thyroid cancer may be at a moderately increased risk of developing breast cancer before age 45.

Histamine (H2) receptor antagonists, such as cimetidine and ranitidine, became available in the late 1970s and presently number among the most commonly used drugs. Cimetidine has been hypothesized to exert a cancer preventive effect on the prostate due to its ability to inhibit the binding of dihydrotestosterone to androgen receptors. Other hormonal effects of this drug include increases in serum prolactin levels and inhibition of 2-hydroxylation of estradiol. We assessed risk of prostate and breast cancers in a cohort of 48,512 members of the Group Health Cooperative of Puget Sound prescribed cimetidine or another H2 blocker between 1977 and 1995. Standardized incidence ratios were calculated comparing the observed numbers of cancers to those expected based on population rates in western Washington State. Because cimetidine, but not other H2 blockers, influences hormonal activity and metabolism, we conducted nested case-control studies comparing cancer risk among individuals treated with cimetidine to individuals who used other H2 blockers. Risks of breast and prostate cancers were identical among users of cimetidine and users of other H2 blockers (relative risk, 1.0 for both cancers). We observed no trend in risk of breast cancer according to time since first or last cimetidine prescription or number of cimetidine prescriptions filled. For prostate cancer, our findings were similar save for a modest increase in risk among men who had filled > or =21 cimetidine prescriptions (relative risk, 1.4; 95% confidence interval, 1.0-1.9). Our results suggest that use of cimetidine does not influence risk of female breast cancer. Further, these data provide little evidence to support the previously hypothesized preventive effect of cimetidine on risk of prostate cancer.

We analyzed data from a population-based case-control study of endometrial cancer. Our goal was to identify a subgroup of women in whom the additional cancer risk associated with unopposed estrogen use was sufficiently small so as to not be a deterrent to taking a hormone preparation of this type. Researchers interviewed women with endometrial cancer (N = 553) and controls (N = 752) regarding hormone use. The additional risk of endometrial cancer associated with unopposed estrogen use did not vary substantially in the presence or absence of hypertension, parity, oral contraceptive use, or smoking. The results suggest that, although heavier women may experience a greater risk of endometrial cancer associated with unopposed estrogen use (8.2 per 1,000 per year) than lighter women (4.2 per 1,000 per year), long-term users in the latter group nonetheless face a substantial absolute increase in risk. We conclude that subdividing women on the basis of the presence or absence of other known risk factors for endometrial cancer fails to delineate a subgroup that is exempt from the increased risk of this cancer associated with use of unopposed estrogens. 83.6% of estrogen users reported taking conjugated estrogens.

Objective: To evaluate the prevalence of recreational physical activity in middle-aged women and to identify characteristics predisposing women to an active or sedentary lifestyle., Design: In this population-based survey study of 492 women aged 50-64 years, women were interviewed between 1988 and 1993 regarding their recreational exercise habits, other health habits, and medical history. Women were selected from the general population of western Washington State through random-digit-dialing of telephones. Physical activities in a recent 2-year period were recorded, including specific types, frequency, and duration of each activity., Results: Fewer than half of the women reported doing any regular physical activity and only 27% engaged in any high intensity exercise. Obesity, current cigarette smoking, low income, low education, and some dietary factors were associated with a sedentary lifestyle., Conclusions: These results suggest that only about half of middle-aged women engage in any regular recreational exercise, and that less than 25% follow the National Institutes of Health recommended guidelines for light to moderate exercise for at least 30 min per day, 6 days per week.

We analyzed data from a population-based case-control study to investigate whether combined hormone replacement therapy influences the incidence of high-grade and -stage endometrial cancer. Subjects were women with epithelial endometrial cancer (N = 730) diagnosed during 1985-1991 and controls identified through random digit dialing (N = 1,002). Relative to hormone nonusers, women who took unopposed estrogens (mostly conjugated estrogens) for 3 or more years had a fivefold increase in the risk of tumors with myometrial invasion; the corresponding relative risk associated with combined therapy (estrogen and cyclic or continuous progestogen) for 3 or more years was only 1.3 (95% confidence interval = 0.8-2.2). We found a similar pattern of association for high-grade tumors.

Objective: To compare selected characteristics of women with and without augmentation mammaplasty to identify differences between these 2 groups of women., Design and Study Participants: White women identified as controls in previously conducted population-based, case-control studies formed the study population for the present cross-sectional analysis (N=3570)., Main Outcome Measure: Interview information on selected characteristics was compared between women who had received augmentation mammaplasty (n=80) and other women (n=3490) using the prevalence odds ratio (pOR) as the measure of association., Results: Women with breast implants were more likely to drink a greater average number of alcoholic drinks per week (for > or =7 drinks vs 0 drinks: pOR=2.9, 95% confidence interval [CI]=1.5-5.5), be younger at first pregnancy (for age <20 years vs age 20-29 years: pOR=1.6, 95% CI=1.0-2.7), be younger at first birth (for age <20 years vs age 20-29 years: pOR=1.9, 95% C1=1.1-3.3), have a history of terminated pregnancies (for > or =1 termination vs 0 terminations: pOR=2.0, 95% CI=1.2-3.4), have ever used oral contraceptives (pOR=2.2, 95% CI=1.0-4.7), have ever used hair dyes (pOR=4.5, 95% CI=1.3-15.4), and have had a greater lifetime number of sexual partners (for > or =14 partners vs < or =4 partners: pOR=8.9, 95% CI=3.1-25.5) than other women. A history of smoking, lactation, high blood pressure, or thyroid disorders, as well as the number of pregnancies, full-term births, or miscarriages, differed little between women with and without implants. Women with breast augmentation were much less likely to be heavy than other women (for > or =74 kg vs <56 kg: pOR=0.1, 95% CI=0.03-0.3)., Conclusion: The differences we found between women with and without breast implants suggest that consideration and evaluation of confounding factors in future studies will help to clarify some of the long-term health consequences of having breast implants.

Background: Postmenopausal oestrogen therapy reduces the risk of osteoporosis and cardiovascular diseases but is associated with an increased risk of endometrial cancer. We have assessed the impact of a regimen of oestrogen with cyclic progestagen on risk of endometrial cancer for postmenopausal women., Methods: We did a population-based case-control study of women aged 45-74 years in western Washington State, USA. Cases were identified from a regional cancer registry as having histologically confirmed endometrial cancer during 1985-91. 832 (72%) of 1154 eligible cases completed interviews. Controls were identified by random digit dialling, screened for intact uterus, frequency matched for age and county, and randomly assigned a reference date within 1985-91. Interviews with 1114 (73%) of 1526 eligible controls were done. The women provided information about use of hormone replacement therapy, and reproductive and medical history before diagnosis date (cases) or reference date (controls)., Findings: Relative to women who had never used hormones (for > 6 months), women who had taken unopposed oestrogen had a four-fold increase (95% CI 3.1-5.1) in risk of endometrial cancer. Women who used a combined therapy of oestrogen with cyclic progestagen (eg. medroxyprogesterone acetate) had a relative risk of 14 (1.0-1.9). Among women with fewer than 10 days of added progestagen per month, the relative risk was 3.1 (1.7-5.7). Whereas that for women with 10-21 days of added progestagen was 1.3 (0.8-2.2). The use of these combined regimens for 5 or more years was associated with risks of 3.7 (1.7-8.2) and 2.5 (1.1-5.5), respectively, relative to non-users of hormones., Interpretation: Postmenopausal women who use combined therapy of oestrogen with cyclic progestagen on a long-term basis have an increased risk of endometrial cancer compared with those who are not on hormone replacement, even when progestagen is added for 10 or more days per month. This increase is much smaller than that associated with unopposed oestrogen, but needs to be confirmed.

Data from a population-based case-control study were used to evaluate the risk of endometrial cancer among women who have used an intra-uterine device (IUD). Incident cases were identified between 1985 and 1991 among women aged 45-74 years who were residents of one of 3 counties in Washington State. Controls were selected by random digit dialing, and both groups of subjects received an in-person detailed interview. In this study population, women who had ever used an IUD were estimated to have a risk of endometrial cancer that was 0.61 times that of other women (95% CI 0.41-0.89). The reduction in cancer risk was not found to be dependent on duration of IUD use. There was a suggestion that women who had used intra-uterine contraception relatively late in reproductive life experienced a greater reduction in risk than those whose use was more distant or at a younger age. The relative risk among the small number of women who were currently using an IUD was 0.49 (95% CI 0.12-2.80). These results apply to the use of inert and copper IUDs as there was no use of progestin-releasing IUDs among women in the study population. The data from this and several other studies of the question support the hypothesis that use of an IUD has a favorable effect on the subsequent risk of endometrial cancer. The reason(s) for such a reduced risk is unclear.

Premature rupture of the amniotic membranes (PROM) occurs in up to 20% of all births. Although many studies have examined risk factors for PROM and, in particular, preterm PROM (PPROM, if less than 37 weeks' gestation), the aetiology of PROM recurrence has not been examined as closely. This study investigated factors that may increase the risk of PROM among women who have already experienced one PROM birth. Maternally linked Washington State birth certificates from 1984 to 1993 identified 208 women with consecutive PROM births. Controls were a random sample (n = 848) of women who had one birth on record complicated by PROM, but whose subsequent birth was not. Among women with a prior term PROM, increased risk for PROM recurrence (term PROM or PPROM) was associated with an intervening fetal death at less than 20 weeks' gestation (OR = 2.4, 1.3-4.5) and with parity of two or more (OR = 2.0, 1.3-3.4). None of the factors assessed significantly increased the risk of recurrence of PROM (term PROM or PPROM) among women with a prior PPROM. Other potential risk factors for PROM recurrence were evaluated within the two PROM groups (PPROM or term PROM at first birth) by stratifying among the cases according to gestational length at subsequent birth.

While there are a number of benefits to the health of postmenopausal women from use of unopposed estrogens, the increased risk of endometrial cancer related to these hormones has led many women to use combined estrogen-progestogen therapy instead, or not to use hormones at all. Most women who take hormones do so only in the early portion of their postmenopausal years, so the risk of endometrial cancer following cessation of use might bear heavily on the overall risk/benefit evaluation. We analyzed data from a case-control study of women in western Washington (United States) to assess the magnitude of excess risk of endometrial cancer following discontinuation of estrogen use. Cases (n = 661) consisted of women aged 45 to 74 diagnosed between 1985 and 1991 who resided in one of three countries in Washington State. Controls (n = 865) were identified by random-digit dialing. Subjects were interviewed in-person to ascertain current and prior hormone use. The analysis was restricted to women who had not received combined estrogen-progestin therapy. Among women who had used unopposed estrogens at some time, risk of endometrial cancer declined as time since last use increased. Nonetheless, even among women who used these hormones for just a few years, the risk remained elevated by 30 to 70 percent almost a decade after cessation. These results, combined with those of most (but not all) other studies of this issue, suggest that a women who has discontinued unopposed estrogen therapy may retain a small increased risk of endometrial cancer for a long period of time.

Background: This study investigates whether a positive family history of breast carcinoma is associated with improved survival after invasive breast carcinoma among women ages 21 through 45., Methods: Subjects were 733 nonadopted women born after 1944 who were diagnosed with primary invasive breast carcinoma between January 1983 and April 1990 while residing in the metropolitan Seattle area and who provided information on family history of breast carcinoma. Information on clinical characteristics and survival was obtained from a population-based cancer registry. Subjects were followed for survival through 1994. Cox proportional hazards models were used to estimate the relative risk (RR) of dying in relation to family history of breast carcinoma, adjusting for selected clinical characteristics, age and year of diagnosis, and prior mammograms., Results: The risk of dying among women with a first-degree family history of breast carcinoma was half that of women with no family history of breast carcinoma (RR = 0.5%; 95% confidence interval [CI], 0.3-0.9). There was no evidence of a reduction in the risk of dying among women with only a second-degree family history of breast carcinoma (RR = 1; 95% CI, 0.6-1.4). These associations were adjusted for age and year of diagnosis, stage of disease, tumor size, bilaterality, and mammogram history. These findings were not further influenced by adjustment for initial treatment or the numbers and ages of relatives at risk for breast carcinoma., Conclusions: Compared with women with neither a first- nor second-degree family history of breast carcinoma, the authors found that women who had a first-degree family history experienced increased survival. This finding did not appear to be attributable to differences in screening or treatment. To the extent that this difference is attributable to underlying biologic mechanisms, new insights into the natural history and treatment of breast carcinoma could result. Future studies should investigate whether specific susceptibility genes are associated with differential survival from breast carcinoma.

Cocaine is an extremely addictive local anesthetic which can produce stimulation of the sympathetic nervous system due to the inhibition of catecholamine reuptake at the synaptic junction. Because of the rapid metabolism of cocaine, the probability of a patient presenting to the operating room with acute intoxication is unlikely. However, the physiological effects of chronic cocaine abuse on various organ systems have an impact on anesthesia management. A preoperative review of major organ systems is essential. Selective beta 1 antagonists (i.e., esmolol) may need to be titrated with a direct vasodilator (i.e., nitroprusside) to manage hypertension and tachycardia. The nonselective beta antagonist effects of labetalol are much more potent than its alpha antagonist effects, which could result in unopposed alpha vasoconstriction. In addition, the equal affinity of the alpha adrenergic antagonist, phentolamine, for both alpha 1 and alpha 2 receptors may result in significant tachycardia. Nitroglycerin has also been used in management of hypertension associated with coronary vasoconstriction. There is controversy regarding management of ventricular dysrhythmias and asystole. Lidocaine is an amide local anesthetic that may have addictive effects, in the presence of cocaine, which may lower the seizure threshold. In addition, the use of epinephrine to treat asystole is controversial in the presence of a state of excess catecholamines induced by cocaine. General anesthesia may include barbiturates, nitrous oxide, and opioids. Inhalational agents may be used with caution due to their myocardial depressant effects. Regional anesthesia may be a good choice if coagulopathies and hypovolemia are corrected before the procedure.

Objective: To determine the risk of breast cancer in relation to the use of combined estrogen and progestin hormone replacement therapy (HRT)., Design: A population-based case-control study., Setting: The general female population of King County in western Washington State., Participants: Middle-aged (50 to 64 years) women, including 537 patients with incident primary breast cancer diagnosed between January 1, 1988, and June 30, 1990, who were ascertained through the Seattle-Puget Sound Surveillance, Epidemiology, and End Results cancer registry and 492 randomly selected control women without a history of breast cancer., Main Outcome Measure: Breast cancer risk in relation to use of menopausal hormones., Results: Menopausal hormones of some type had been used by 57.6% of breast cancer cases and 61.0% of comparison women. The women who had ever taken combined estrogen-progestin HRT, representing 21.5% of cases and 21.3% of controls, were not at increased risk of breast cancer (relative odds [RO] = 0.9; 95% confidence interval [CI], 0.7 to 1.3). Compared with nonusers of menopausal hormones, those who used estrogen-progestin HRT for 8 or more years had, if anything, a reduced risk of breast cancer (RO = 0.4; 95% CI, 0.2 to 1.0)., Conclusions: On the whole, the use of estrogen with progestin HRT does not appear to be associated with an increased risk of breast cancer in middle-aged women. Nonetheless, since the use of combined estrogen-progestin HRT has only recently become prevalent, future investigations must assess whether breast cancer incidence is altered many years after estrogen-progestin HRT has been initiated, particularly among long-term users.

The authors analyzed data from a population-based case-control study of breast cancer in middle-aged women residing in King County, Washington, to examine the relation between occupation and breast cancer risk. A total of 537 cases and 492 controls completed in-person interviews. Subjects provided job titles and years of employment for their three main occupations since age 18. While there were case-control differences in the frequency with which certain jobs were reported, all were within the limits of chance, given no true association. Also, few additional increases in risk were associated with long-term employment. Relative risk (RR) estimates were elevated for women working in precision textile and apparel jobs (six cases and one control, RR = 5.2). To a lesser extent, RR estimates were also elevated for receptionists, cosmetologists, and the category of painters/sculptors/printmakers. A slight increase in risk was associated with several occupations, including nursing and teaching.

Background: Certain events of reproductive life, especially completed pregnancies, have been found to influence a woman's risk of breast cancer. Prior studies of the relationship between breast cancer and a history of incomplete pregnancies have provided inconsistent results. Most of these studies included women beyond the early part of their reproductive years at the time induced abortion became legal in the United States., Purpose: We conducted a case-control study of breast cancer in young women born recently enough so that some or most of their reproductive years were after the legalization of induced abortion to determine if certain aspects of a woman's experience with abortion might be associated with risk of breast cancer., Methods: Female residents of three counties in western Washington State, who were diagnosed with breast cancer (n = 845) from January 1983 through April 1990, and who were born after 1944, were interviewed in detail about their reproductive histories, including the occurrence of induced abortion. Case patients were obtained through our population-based tumor registry (part of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute). Similar information was obtained from 961 control women identified through random digit dialing within these same counties. Logistic regression analysis was used to estimate odds ratios and confidence intervals (CIs)., Results: Among women who had been pregnant at least once, the risk of breast cancer in those who had experienced an induced abortion was 50% higher than among other women (95% CI = 1.2-1.9). While this increased risk did not vary by the number of induced abortions or by the history of a completed pregnancy, it did vary according to the age at which the abortion occurred and the duration of that pregnancy. Highest risks were observed when the abortion was done at ages younger than 18 years--particularly if it took place after 8 weeks' gestation--or at 30 years of age or older. No increased risk of breast cancer was associated with a spontaneous abortion (RR = 0.9; 95% CI = 0.7-1.2)., Conclusion: Our data support the hypothesis that an induced abortion can adversely influence a woman's subsequent risk of breast cancer. However, the results across all epidemiologic studies of this premise are inconsistent--both overall and within specific subgroups. The risk of breast cancer should be reexamined in future studies of women who have had legal abortion available to them throughout the majority of their reproductive years, with particular attention to the potential influence of induced abortion early in life.

There is some evidence that sex hormones may influence the incidence of rheumatoid arthritis. Obesity has been found to increase endogenous estrogens, particularly among postmenopausal women. Although the association of endogenous hormones with smoking and alcohol use is less clear, we examined the relation of these three factors with rheumatoid arthritis in women. We conducted a population-based case-control study of rheumatoid arthritis in King County, WA, and Group Health Cooperative of Puget Sound. We compared 349 incident cases of rheumatoid arthritis with 1,457 controls selected by random digit dialing or by random selection from the enrollment files of Group Health Cooperative. We conducted personal interviews to collect data on weight, smoking, alcohol history, reproductive variables, and other demographic variables. Women with 20 or more pack-years of smoking had a relative risk of 1.5 [95% confidence interval (CI) = 1.0-2.0] compared with never-smokers. Post-menopausal women who averaged more than 14 alcoholic drinks per week had a reduced risk of rheumatoid arthritis (relative risk = 0.5; 95% CI = 0.2-1.7). Women in the highest quartile of body mass index had a risk of 1.4 (95% CI = 1.0-2.0) relative to women with lowest body mass index.

Objective: To examine the relationship of rheumatoid factor (RF) to HLA-DR4 and alleles of DRB1 in women with recent-onset rheumatoid arthritis (RA)., Methods: Incident cases of RA were identified as part of a prospective, population-based case-control study. HLA typing was completed for 246 cases meeting criteria for definite or classic RA., Results: One hundred thirty-six patients (55%) were positive for DR4, and 130 (53%) were RF positive. DR4 was found to be strongly associated with seropositivity (odds ratio 4.1, P < 0.0001). Patients with a shorter interval from RA onset to RF testing had a higher frequency of seropositivity than those with a longer interval (< or = 18 months 60%, > 18 months 33%). Further analysis of patients who had RF testing within 18 months of RA onset showed that the frequency of seropositivity was significantly greater among DR4-positive patients who had the shared sequence stretch of DR beta 1 associated with RA susceptibility (76% RF positive) than among DR1-positive patients who had this sequence (45% RF positive) (odds ratio 3.8, P = 0.01). Moreover, the frequency of seropositivity among DR1-positive patients with the sequence did not differ from that among all patients without the shared sequence (47%) (odds ratio 0.9, P = 0.8)., Conclusion: HLA-DR4 is strongly associated with seropositivity in women with recent-onset RA. The amino acid sequence of DR beta 1 that is associated with susceptibility to RA and is shared between DR4 and DR1 appears not to be the primary determinant of seropositivity in these women.

Women who have used combined oral contraceptives (COC) have a reduced risk of endometrial cancer relative to that of women who have never used oral contraceptives, but it is unclear whether the size of the reduction is influenced by the progestin content of the preparation. We analyzed data from two population-based case-control studies of endometrial cancer to investigate this question. Among women aged 40 to 59 years who were residents of King or Pierce Counties, Washington (United States), incident cases who were diagnosed during 1975-77 or 1985-87 were identified. Personal interviews were conducted with 316 such women and their responses compared with those of 501 controls who were selected by household surveys or random-digit dialing. A reduced risk of endometrial cancer associated with COC use was present only among users of five or more years' duration, and even then only in women who were not long-term users of unopposed postmenopausal estrogens. Among these women, the relative risk (RR) of endometrial cancer did not differ according to the progestin potency of the COC used: it was equally low for women who had used a COC with low progestin content (RR = 0.2, 95 percent confidence interval [CI] = 0.1-0.8) as for women who had used a COC with high progestin content (RR = 0.3, CI = 0.1-0.9). Our results argue that, if the reduced risk of endometrial cancer in long-term users of COCs is due to the progestins contained in these preparations, that amount of progestin in most COCs exceeds the threshold amount needed to produce this beneficial effect.

Objective: To determine whether pelvic damage is associated with positive Chlamydia trachomatis serology in women with tubal ectopic pregnancy., Design: Cross-sectional retrospective study., Setting: A prepaid health maintenance organization., Patients: Two-hundred eighty-one women admitted with confirmed tubal ectopic pregnancy were interviewed for history of sexually transmitted diseases. Chlamydia serology was obtained for 135 subjects, and operative findings were available for 121 of these., Interventions: None., Main Outcome Measure: Pelvic damage, as determined by review of operative findings of the pelvis at the time of ectopic surgery., Results: Pelvic damage was associated with positive chlamydia serology with an adjusted odds ratio of 4.2 (95% confidence interval: 1.8 to 9.7). Moderate and severe pelvic damage were more strongly associated with positive serology than mild damage., Conclusions: Women with ectopic pregnancies and antibodies to C. trachomatis are more likely to have damaged pelves than women with ectopic pregnancies without such antibodies. Prevention or early treatment of C. trachomatis infection may reduce pelvic damage and, therefore, reduce incidence of ectopic pregnancy.

Objective: To examine fecundity prior to disease onset in women with rheumatoid arthritis (RA)., Methods: Two hundred fifty-nine RA patients with an opportunity for pregnancy were compared with 1,258 control women as part of a prospective case-control study of recent-onset RA in women., Results: A 12-month or longer interval to pregnancy was found in 42% of RA cases compared with 34% of controls (odds ratio = 1.44, 95% confidence interval 1.10, 1.91). This difference was not accounted for by an older age when attempting to become pregnant among the RA cases compared with the controls. The result was unrelated to rheumatoid factor or HLA-DR4 status., Conclusion: Women with RA were found to have decreased fecundity prior to disease onset, compared with control women.

Pregnancy outcome before disease onset was evaluated for women with rheumatoid arthritis (RA) and control women as part of a prospective case-control study of newly diagnosed RA. An analysis of women who were ever gravid revealed no statistically significant difference in any adverse pregnancy outcome between RA cases (n = 144) and controls (n = 605) including spontaneous abortions and stillbirths. Thus, in contrast to reports both of an increase of adverse pregnancy outcomes and a decrease in women who subsequently develop RA, we found no evidence for any difference in pregnancy outcome in the RA group.

As part of a prospective case-control study of newly diagnosed rheumatoid arthritis (RA) in women, we identified all cases of probable, definite, or classic RA diagnosed in 1987-1989 in 18-64-year-old women who were members of a health maintenance organization based in the Seattle, Washington area. Using both the 1958 and the 1987 American Rheumatism Association criteria for the diagnosis of RA and enrollment data from the health maintenance organization, we calculated the incidence by age and diagnostic class. Rates of RA incidence in women increased steadily with age. The incidence of probable, definite, or classic RA ranged from 13.1 per 100,000 person-years at risk for 18-29-year-old women to 82.1 per 100,000 person-years for 60-64-year-old women. The overall incidence rate, age-adjusted to the 1980 US female population, was 27.9/100,000 person-years. The overall incidence rate for definite/classic RA, age-adjusted to the 1980 US female population, was 23.9 per 100,000 person-years. When compared with adjusted rates of incidence of definite RA in Rochester, Minnesota, in 1950-1974, the incidence rates we found were 44.7% lower. Methodologic differences, changes in diagnostic criteria, and a declining incidence of RA among women over time may all be partial explanations for these results. The possible effects of reproductive factors, including oral contraceptives use, are discussed.

In a population-based study of ectopic pregnancy, a card-back system of initial subject contact yielded a positive response from 85.1% of potential cases and 65.0% of potential controls. We subsequently recontacted by telephone potential controls who had declined to participate and offered them $10 compensation for participation. We recontacted 205 of the 330 control women who had refused to participate. Twenty-eight were found to be ineligible, and 75.7% of the remaining 177 agreed to participate on recontact. The additional 125 women were not recontacted, 9 because of firm initial refusals and 116 because the study ended before contact could be sought or made. Controls who initially declined to participate but subsequently agreed differed from those who initially agreed on a number of demographic and reproductive characteristics, and estimates of ectopic pregnancy risk associated with induced abortion and tubal sterilization changed slightly with the inclusion of initial nonparticipants. We conclude that use of a card-back system of subject contact yields a low level of positive response among reproductive-aged women and that many initial nonparticipants can be converted into participants by personal contact and the offer of compensation.

The favourable effects of exogenous progestagen on the endometrium are well known, but have not been adequately quantified with respect to endometrial cancer. The benefits of progestagen need to be weighted against its possible untoward effects on the risk of breast cancer and cardiovascular disease. A population-based case-control study of endometrial cancer was undertaken to evaluate the benefits of progestagen use. 158 incident cases were identified between 1985 and 1987 among women aged 40-64 years who were residents of King County, Washington. Detailed interviews were conducted and the responses were compared with those of 182 controls selected by random telephone digit dialling. The risk of endometrial cancer among women who had used unopposed oestrogen for more than 3 years was over five times that of women who had used no hormones (relative risk [RR] 5.7, 95% confidence interval [Cl] 2.5-12.8), whereas those who had also used a progestagen for at least six months of that time had an RR of only 1.6 (95% Cl 0.6-3.9). The RR differed according to days per month that progestagen was used: 2.4 (0.6-9.3) for progestagen use of less than 10 days per month versus 1.1 (0.4-3.6) for use of 10 or more days per month. These results provide additional evidence that the use of progestagen for 10 or more days per cycle can reduce the excess risk of endometrial cancer associated with long-term postmenopausal oestrogen use.

Two hundred nine female enrollees of the Group Health Cooperative of Puget Sound who developed advanced-stage breast cancer during the period 1982-1988 were interviewed about their practice of breast self-examination (BSE), use of other breast cancer screening modalities, and medical and reproductive histories. Each subject's description of how she performed the examination was scored according to her mention of up to 10 recommended BSE techniques. A random sample of 433 women without advanced-stage breast cancer from the same population was interviewed for comparison. Relative to women not practicing BSE, the risk of advanced-stage breast cancer among BSE users was 1.15 (95% confidence interval, 0.73-1.81). Frequency of BSE did not differ between women with advanced-stage breast cancer and control subjects, whether in all subjects or in subgroups defined by age, use of mammography, or frequency of clinical breast examinations. While self-described proficiency in BSE was generally low in both case and control subjects, the small percentage of women reporting more thorough self-examinations, regardless of frequency, had about a 35% decrease in the occurrence of advanced-stage breast cancer compared to women who did not perform BSE. These results suggest that, while carefully performed BSE may avoid the development of some advanced-stage breast cancers, BSE as practiced by most Seattle-area women is of little or no benefit.

The history of cesarean delivery was evaluated in a population-based case-control study of secondary infertility in King County, Washington. Sixty-one married women diagnosed with secondary infertility due to tubal problems who had a previous viable pregnancy were compared to 343 married women who had a previous viable pregnancy and then had a live birth that was conceived at the same time the infertile women began trying to conceive. The risk of tubal infertility was not substantially elevated in women who had a previous cesarean delivery in the most recent viable pregnancy compared to women with vaginal delivery (odds ratio = 1.2; 95% confidence interval = 0.4, 3.7).

Random digit dialing is a method commonly used to select random population samples in epidemiologic research. Although random digit dialing is generally presumed to provide representative samples, coverage and nonresponse errors may affect the degree to which the sample is representative. The present investigation was undertaken to determine whether the geographic distributions of samples selected using variations of the basic random digit dialing technique accurately reflect the underlying population distribution, and if not, whether such samples tend to be either more or less dispersed than the populations from which they were selected. Data regarding control groups from three case-control studies conducted from 1983-1986 were utilized. The residence addresses of 998 controls were located and assigned an X-Y coordinate and census tract designation within a three-county geographic area in northwest Washington State. Initially, the spatial distributions of controls were examined graphically in relation to the age-sex structure of the underlying population. No differences in geographic pattern were apparent. A more formal statistical evaluation was conducted based on centrographic techniques utilizing two measures to describe the spatial distribution of a set of points. Results indicate that the samples chosen were neither more nor less dispersed than the underlying populations. However, the geographic centers of samples selected using primary numbers tended to be shifted from the centers of their respective populations. Several possible explanations for such shifts are considered, and extensions of the analytical approach are suggested in relation to the further evaluation of population sampling and the investigation of space-time aggregations of disease.

To determine the role of previous abdominal surgery in tubal pregnancy risk, we compared 337 women diagnosed with tubal pregnancy during 1981-1986 with 893 population-based controls concerning their medical, reproductive, and sexual histories. After excluding types of abdominal surgery that involve the fallopian tubes directly and after adjusting for age, gravidity, and reference year, we found no increased risk for tubal pregnancy related to previous cesarean delivery (relative risk 0.6, 95% confidence interval 0.3-1.2), ovarian surgery (relative risk 1.2, 95% confidence interval 0.6-2.5), or removal of an unruptured appendix (relative risk 1.2, 95% confidence interval 0.7-2.2). An increased risk was noted for tubal pregnancy associated with previous ruptured appendix (relative risk 1.8, 95% confidence interval 0.6-5.5), but the increase was well within the limits of chance. With the possible exception of ruptured appendix, our study indicates that abdominal surgery that does not directly involve the fallopian tubes has little or no influence on the occurrence of tubal pregnancy.

A population-based case-control study was conducted to examine the relationship between maternal smoking and the occurrence of abruptio placentae and to assess the joint relationship of smoking and small for gestational age (SGA) status with abruption. Cases (N = 1089) reported on Washington state birth certificates from 1984-1986 were compared with randomly selected births (N = 2323) from the same period. The occurrence of placental abruption was associated with both smoking (relative risk = 1.6; 95% confidence interval 1.3-1.8) and SGA status (relative risk = 2.6; 95% confidence interval 2.0-3.3). The association with SGA status was identical for smokers and non-smokers. Thus, the increase of SGA infants in women whose pregnancies are complicated by abruption is not explained by maternal smoking, and in some cases may result from placental dysfunction induced by the process of placental separation.

As part of a case-control study of tubal pregnancy, we sought to evaluate the potential etiologic role of maternal cigarette smoking. Between 1975-1979, 192 women who were treated for a tubal pregnancy in five Seattle hospitals were interviewed with regard to smoking habits and reproductive, contraceptive, and medical histories. For comparison, 459 Seattle-area women who delivered during the same period were also interviewed. Current cigarette smokers had a more than twofold increase in risk of tubal pregnancy (adjusted relative risk 2.2; 95% confidence interval 1.4-3.4) when compared with women who had never smoked. The risk for women who had stopped smoking before conception was 1.6 (95% confidence interval 1.0-2.8). There was no consistent trend between the risk of tubal pregnancy and the duration of smoking, average number of cigarettes smoked per day, age at which a woman began to smoke, pack-years of cigarettes smoked, or (among former smokers) the recency of smoking. Although several sources of bias in the present study may have created a spurious association between cigarette smoking and the occurrence of tubal pregnancy, it could well be that an increased risk of tubal pregnancy is yet another untoward consequence of cigarette smoking.

One hundred twenty-seven women who had been given diagnoses of tubal infertility between 1979 and 1981 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, we adjusted for the effects of variables that in this population were related both to having an induced abortion and to the occurrence of infertility, i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A. H. Robins Company, Richmond, VA) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70 to 1.89). For women with two or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39 to 4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72 to 1.97). Our results suggest that legal abortion, as performed during the past decade in the United States, does not carry an excess risk for future tubal infertility.

All cases (884) of placental abruption reported on Washington State birth or fetal death certificates in 1980 and 1981 were compared with 789 randomly selected births from the same time period. The incidence of reported cases of placental abruption was 6.5 per 1000 total births. The combined stillbirth and first month death rate of all abruption cases was 21%. Increased risks of placental abruption were associated with pre-eclampsia, diabetes, and unmarried status. Neither parity nor maternal age was associated with an increased risk. Infants born after abruption were significantly smaller-for-gestation than control infants, more likely to be male, and had malformations more frequently than control infants. Apgar scores of liveborn abruption infants were significantly lower than those of controls after adjustment for infant weight, gestational age, and sex.