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OBJECTIVE: To determine whether congenital anomalies are associated with breech presentation at the time of birth. STUDY DESIGN: A population-based, retrospective cohort study was conducted among 460,147 women with singleton live births using the Missouri Birth Defects Registry, which includes all defects diagnosed during the first year of life. Maternal and obstetric characteristics and outcomes between breech and cephalic presentation groups were compared using χ(2)-square statistic and Student's t-test. Multivariable binary logistic regression analysis was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULT: At least one congenital anomaly was more likely present among infants breech at birth (11.7%) than in those with cephalic presentation (5.1%), whether full-term (9.4 vs 4.6%) or preterm (20.1 vs 11.6%). The relationship between breech presentation and congenital anomaly was stronger among full-term births (aOR 2.09, CI 1.96, 2.23, term vs 1.40, CI 1.26, 1.55, preterm), but not in all categories of anomalies. CONCLUSION: Breech presentation at delivery is a marker for the presence of congenital anomaly. Infants delivered breech deserve special scrutiny for the presence of malformation.

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Deceased donor factors associated with poor graft outcome are well known, but how often these factors lead to livers left untransplanted is poorly defined. A nested, case-control study was conducted using the United Network for Organ Sharing (UNOS) database from 1987 to 2005. Only those donating >/=1 solid organ were included. Primary outcome was livers not transplanted (LNT, cases) versus transplanted (LT, controls). Primary variables for multivariate analysis were donor age and obesity. Covariates included donation after cardiac death (DCD), cerebral vascular accident death, viral serologies, cancer, ALT and bilirubin. There were 23 373 (26%) LNT's from 91 362 donors who donated at least one organ. Percent LNT fell over time (1987-1990: 48%; 1991-1995: 29%; 1996-2000: 21%; 2000-2005: 16%; p < 0.01). Increased age (odds ratio: 4.2, 95% confidence interval 3.6-4.9, p < 0.01) and obesity (2.1, 1.9-2.3, p < 0.01) were significantly associated with LNT across all time periods. Other significant factors included DCD and elevated ALT. For 2001-2005, population attributable risk indicate that age >40, abnormal ALT and obesity account for 32.6%, 25.3% and 9.2% of untransplanted livers, respectively. Use of expanded criteria livers has pushed LNT lower in spite of an aging and heavier donor population. Nevertheless, age and obesity still account for a significant portion of untransplanted livers.

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OBJECTIVE: We sought to critically assess the risk factors for neonatal pulmonary hypoplasia and perinatal death in patients with preterm rupture of the amniotic membranes from 15 to 28 weeks' gestation. STUDY DESIGN: This was a prospective cohort study. The study patients had preterm rupture of the amniotic membranes at 15 to 28 weeks' gestation and were without fetal anomalies, multiple gestation, and oligohydramnios before rupture of the membranes. The amniotic fluid volume index was determined at admission and weekly afterward until delivery. RESULTS: The incidence of pulmonary hypoplasia was 12.9% (21/163). The overall perinatal mortality rate was 54% (88/163). Logistic regression analysis revealed the following: (1) Gestational age at rupture of the membranes, the latency period, and either the initial or the average amniotic fluid index have significant influence on the development of pulmonary hypoplasia; (2) gestational age at rupture of the membranes and latency period are significant factors in predicting perinatal death. CONCLUSIONS: In this large population of patients with rupture of membranes at 15 to 28 weeks' gestation, gestational age at rupture of the membranes, latency period, and amniotic fluid index were important independent predictors of neonatal pulmonary hypoplasia. In addition, gestational age at rupture of the membranes and latency period were important independent determinants of perinatal death. Expectant management of patients with preterm rupture of the amniotic membranes during this gestational age interval was associated with improved perinatal survival, even though it may increase the risk of pulmonary hypoplasia.

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OBJECTIVE: To evaluate the efficacy of a comprehensive infection control program on the reduction of surgical-site infections (SSIs) following coronary artery bypass graft (CABG) surgery. DESIGN: Prospective cohort study. SETTING: 1,000-bed tertiary-care hospital. PATIENTS: Persons undergoing CABG with or without concomitant valve surgery from April 1991 through December 1994. INTERVENTIONS: Prospective surveillance, quarterly reporting of SSI rates, chlorhexidene showers, discontinuation of shaving, administration of antibiotic prophylaxis in the holding area, elimination of ice baths for cooling of cardioplegia solution, limitation of operating room traffic, minimization of flash sterilization, and elimination of postoperative tap-water wound bathing for 96 hours. Logistic regression models were fitted to assess infection rates over time, adjusting for severity of illness, surgeon, patient characteristics, and type of surgery. RESULTS: 2,231 procedures were performed. A reduction in infection rates was noted at all sites. The rate of deep chest infections decreased from 2.6% in 1991 to 1.6% in 1994. Over the same period, the rate of leg infections decreased from 6.8% to 2.7%, and of all SSI from 12.4% to 8.9%. The adjusted odds ratio (OR) for all SSIs for the end of 1994 compared to December 31, 1991, was 0.37 (95% confidence interval [CI95], 0.22-0.63). For deep chest and mediastinal infections, the adjusted OR comparing the same period was 0.69 (CI95, 0.28-1.71). CONCLUSIONS: We observed significant reductions in SSI rates of deep and superficial sites in CABG surgery following implementation of a comprehensive infection control program. These differences remained significant when adjusted for potential confounding covariables.

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Worker exposure to N,N-dimethylacetamide (DMAC) in an acrylic fiber manufacturing facility was measured, over a 1-year study period, by full-shift (12 hours) personal air monitoring for DMAC and by biological monitoring for levels of DMAC, N-methylacetamide (MMAC), and acetamide in spot urine samples. Ninety-three of 127 male workers in seven job classifications in the solution preparation and spinning departments of the plant were monitored on the second consecutive workday after at least 3 days off for the first 10 months of the study and on both the first and second days during the study's final 2 months. Postshift urinary MMAC levels were significantly correlated (P < .0001, r2 = .54) with DMAC in air levels. An air level of 6.7 ppm 12-hour time-weighted average (TWA) corresponded to a urine MMAC level of 62 mg/g creatinine in a postshift spot urine sample obtained after the second consecutive workday. To minimize exposure misclassification due to variability in the regression relationship, a level of 35 mg MMAC/g creatinine in a postshift spot urine sample was recommended as a biomonitoring index. Postshift urine MMAC levels did not appear to plateau at higher air levels, nor did it appear that the DMAC demethylation metabolic mechanisms became saturated at threshold limit value (TLV)-level air-exposure levels. Urine MMAC levels in postshift samples obtained the second workday appeared to be greater than levels in postshift first-day samples, but the number of days until this postshift level would plateau could not be determined from this study.(ABSTRACT TRUNCATED AT 250 WORDS)

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Worker exposure to N,N-dimethylacetamide (DMAC) in an acrylic fiber manufacturing facility was measured, over a 1-year study period, by full-shift (12 hours) personal air monitoring for DMAC and biological monitoring for levels of DMAC, N-methylacetamide (MMAC) and acetamide in post-shift spot urine samples. Evidence of liver toxicity was assessed by serum clinical chemistry tests (serum levels of total bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma-glutamyl transpeptase) at least once during the study period for all 127 male workers in the two study departments and for 217 male in-plant controls with no previous or current exposure to DMAC. If a worker's biomonitoring results exceeded one of two "trigger" values established for the study (60 mg MMAC/g creatinine or 136 mg DMAC equivalent/g creatinine), additional serum clinical chemistry tests were conducted at weekly intervals for 3 weeks. DMAC-exposed workers were classified as either high exposure, if one or more biomonitoring result exceeded one of the trigger values, or unspecified exposure if none of them did. Control-group employees were classified as no-exposure. Mean DMAC in air levels for the high- and unspecified-exposure groups appeared to differ (geometric mean DMAC in air levels of 1.9 and 1.3 ppm 12-hour time-weighted average, respectively). No significant DMAC exposure-related trends in hepatic serum clinical chemistry results were detected. Neither transient increases in serum analyte levels after a "high" biomonitoring result (one that exceeded a trigger value) nor an elevated mean level over the study period when compared with in-plant controls were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

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OBJECTIVE: Our goal was to quantify the magnitude of risk associated with conditions resulting in umbilical cord prolapse and adverse infant outcome after cord prolapse. STUDY DESIGN: This population-based case-control study used birth certificate data from 709 cases and 2407 randomly selected controls. Odds ratios were used as measures of association, with stratification performed to control for confounding. RESULTS: Case infants were more likely to weigh < 2500 mg (odds ratio 4.8, 95% confidence interval 3.7 to 6.2) and to born prematurely (odds ratio 2.9, 95% confidence interval 2.2 to 3.7). Other risk factors were breech presentation (birth weight-adjusted odds ratio 2.5, 95% confidence interval 1.7 to 3.9) and being a second-born twin (odds ratio 5.0, 95% confidence interval 3.3 to 11.7). Subsequent adverse infant outcomes included an increased risk of mortality (relative risk 2.7, 95% confidence interval 1.9 to 4.0), with mortality being less likely to occur among cases delivered by cesarean section (relative risk 0.4, 95% confidence interval 0.2 to 0.6). CONCLUSIONS: This study confirms previously suspected risk factors and supports clinical management of cord prolapse by cesarean section delivery.

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To follow-up on a proportional mortality study that showed significantly elevated proportional mortality ratios for lung cancer and a subgroup of nonmalignant respiratory diseases, we conducted a cohort mortality study (1950-1987) among 4627 employees of a metal components manufacturing facility. The findings of this study showed lower than expected mortality from all causes of death and all cancers. However, lung cancer mortality was significantly elevated (standardized mortality ratio = 131, 95% confidence interval (102-165), owing to elevated mortality among hourly workers (standardized mortality ratio = 153, 95% confidence interval 118-195). Hourly workers also showed a significantly elevated rate for the residual category "other nonmalignant respiratory disease" (standardized mortality ratio = 170, 95% confidence interval 110-251) and a significant deficit of leukemia (standardized mortality ratio = 16, 95% confidence interval 0-87). Analyses by duration of employment did not show significant trends for any cause of death. Smoking information was not available, but several indirect methods were used to estimate the potential confounding effect of smoking.

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