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The results from previous studies have provided evidence to support the hypothesised association between intrauterine oestrogen exposure and subsequent risk of breast cancer. Information has not been available to study this relationship for several perinatal factors thought to be related to pregnancy oestrogen levels. Data collected from the mothers of women in two population-based case-control studies of breast cancer in women under the age of 45 years (510 case mothers, 436 control mothers) who were diagnosed between 1983 and 1992 in three western Washington counties were used to investigate further the relationship between intrauterine oestrogen exposure and risk of breast cancer. A pregnancy weight gain of 25-34 pounds was associated with breast cancer risk (odds ratio [OR] = 1.5; 95% confidence interval [CI] 1.1, 2.0); however, women whose mothers gained 35 pounds or more were not at increased risk. Use of antiemetic medication in women with any nausea and vomiting (OR = 2.9; 95% CI 1.1, 8.1) and use of diethylstilboestrol (DES) (OR = 2.3; 95% CI 0.8, 6.4) appeared to be positively associated with breast cancer risk. The results from this study provide limited support for the hypothesis that in utero oestrogen exposure may be related to subsequent breast cancer risk among young women.
The relation between diet and endometrial cancer was examined in a population-based case-control study conducted in Shanghai, People's Republic of China, between 1988 and 1990, involving interviews with 268 cases and 268 controls aged 18-74 years. The subjects' usual dietary intake of 63 major foods during the previous 10 years (disregarding any recent changes) was measured by means of a structured quantitative food questionnaire. Although women in the highest quartile of total caloric intake had a 2.1-fold increased risk of endometrial cancer, risk varied according to the source of calories. The highest quartiles of caloric intake from fat and protein were associated with odds ratios of 3.9 and 3.1, respectively, while calories from carbohydrates, the major contributor of total calories in this population, were not related to risk. The association of fat and protein with endometrial cancer risk was confined to foods of animal origin in the diet. After adjustment for age, body mass index (weight (kg)/height (m)2), and number of pregnancies, odds ratios were 3.5 (95% confidence interval (CI) 2.0-6.0) and 3.0 (95% CI 1.7-5.1) for women in the highest quartiles of intake of animal fat and animal protein, respectively. Food group analyses showed a similar pattern, with high consumption of meat, eggs, and fresh fish being associated with elevated risks. After adjustment for total calories, no significant association of risk was found with intake of vegetables or dark green/yellow vegetables, or with estimated carotene intake, although fruit and allium vegetables were associated with some reduction in risk. These results suggest that diets rich in animal fat and animal protein may play an important role in the etiology of endometrial cancer.
A population-based case-control interview study of 486 adult leukemia cases and 502 healthy controls was carried out in Shanghai, People's Republic of China during 1987-89 to evaluate the etiologic role of prior medical conditions, medications, and diagnostic X-rays. Risks were examined separately for 236 cases with acute non-lymphocytic leukemia (ANLL), 79 with chronic myeloid leukemia (CML), 81 with acute lymphocytic leukemia (ALL), and 21 with chronic lymphocytic leukemia (CLL). Little difference was found between cases and controls for prior history of diabetes, hypertension, allergic conditions, most medications, and diagnostic X-rays. A few significant associations were observed for appendectomy, tuberculosis, and for several other chronic disorders with specific leukemia cell types, but the odds ratio estimates for most of these ranged from two to three and, with the exception of the two specified above, were based generally on five or fewer exposed controls. In contrast to an association with childhood leukemia in Shanghai, prior use of chloramphenicol was not linked with ANLL or other forms of adult leukemia. Further research is needed to clarify the relation of specific medical conditions and exposures with particular subtypes of leukemia, and to examine reasons for the low incidence of CLL in China and other Asian populations.
To describe secular trends in pneumonia hospitalizations in the Bronx, New York City from 1982-1986, we analysed all cases with a discharge diagnosis of pneumonia, excluding Pneumocystis carinii pneumonia (PCP), for Bronx residents by age, sex, neighbourhood, and length of stay (N = 21,822). Hospital deaths from PCP and immune disorders were analysed separately as a non-recurrent indicator of human immunodeficiency virus (HIV) related disease prevalence by age, sex and geographical areas. From 1982 to 1986, pneumonia hospitalizations increased 132% among males and 100% among females aged 25-54, an age group accounting for 90% of adult AIDS cases in the Bronx, as compared to a 21% rise among males and 38% among females in all other age groups (p less than 0.001). Pneumonia rates increased most in those population groups with the highest rates of PCP and immune disorders. An ecological correlation of pneumonia hospitalization with this measure of AIDS prevalence for residents of a small geographical area is evident (r2 = 0.92). The observed increase in pneumonia hospitalizations, believed to be related to underlying prevalence patterns of HIV in this population, accounts for a significant and previously unrecognized burden on the local health care system. From 1983-1986, these 'excess' pneumonias in the Bronx accounted for 14,707 days of hospitalization--equal to 42% of the total days attributed to all hospital admissions for AIDS per se.
In a single decade, the pandemic of human immunodeficiency virus (HIV) infection has become an international health, social, and economic emergency. Early and effective intervention is urgently needed for both prevention of HIV infection and for the amelioration of clinical disease. Results of therapeutic trials have suggested expanding the population for which chemotherapy is indicated. In this paper, we first review the findings from selected recent drug trials, using zidovudine and pentamidine as examples. We then discuss six issues that we believe to be crucial for future epidemiologic research in the service of vaccine and drug development: 1. To identify which complications of HIV infection most urgently require development of new therapies, we must characterize the frequency and severity of specific medical events (outcomes) in persons taking a variety of treatments. 2. Currently, acquired immunodeficiency syndrome (AIDS) therapeutic trials gauge the effectiveness of new therapies by their impact on such clinical parameters as the time to development of AIDS or death. These approaches take too long to provide information. We urgently need to identify surrogate markers of clinical outcome that will be useful in the early assessment of treatment efficacy. 3. Progress in vaccine development is being retarded because we do not have enough data from natural history studies on host immunologic responses to suggest that a given response is protective. We therefore need to identify natural correlates of immunity, which can help set priorities in vaccine development. 4. Discovery that a therapy works in the setting of a clinical trial is only a first step in intervention. We must also assess the impact of new therapies on the health of the public, evaluating access to health care, compliance, and other barriers to treatment. 5. Clinical trials are usually associated with the effort to prevent disease in infected persons. However, other trials are needed to assess efforts to interrupt viral transmission through use of condoms, use of virucides, and treatment of sexually transmitted diseases, and by effecting specific behavioral changes. 6. Traditional methods of conducting clinical therapeutic research may not be adequate to address urgent questions in the AIDS/HIV epidemic. We must develop innovative clinical research methods, including better use of data from observational studies, to infer what we can about the effect of treatment on the clinical course.
During the acellular pertussis vaccine trial in Sweden, 4 children who were randomly assigned to receive the vaccine died of suspected or confirmed bacterial infections compared to 1 expected. There were no deaths in the placebo arm. This raised concern about the role of pertussis immunization in the development of serious infections. Through linking computerized immunization records with an active surveillance system for serious bacterial infections in children, the authors studied a cohort of 64,591 children immunized through Tennessee county health clinics who had a total of 158 episodes of invasive bacterial infections after a diphtheria and tetanus toxoids and pertussis (DTP) immunization. There were 8 invasive bacterial infections that occurred within the first 7 days following DTP immunization, yielding an age-adjusted relative risk (95% confidence interval) of 1.0 (0.5 to 2.0), compared to the interval 29 or more days following immunization. There were 7 and 20 infections in the 8- through 14- and 15- through 28-day intervals following DTP immunization, giving relative risks of 0.8 (0.4 to 1.7) and 1.2 (0.7 to 1.9), respectively. These data provide reassurance that the use of DTP vaccine is not followed by a large increased risk of serious bacterial infections.
Acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) are growing problems among U.S. adolescents. By examining recent data on AIDS surveillance and HIV seroprevalence, surveys on teenagers' knowledge, beliefs, and behaviors related to HIV/AIDS, key treatment issues, and barriers to prevention, this manuscript reviews the problem and proposes possible ways of combating it. African American youth have the highest rates of AIDS and white youth the lowest. However, the largest number of AIDS cases overall has been recorded in white males, reflecting relatively high case rates in boys with hemophilia and in young male homosexuals. Predominant HIV risk factors for adolescents are unprotected sex and/or sharing injection drug equipment with an infected partner. Relatively high rates of HIV infection in adolescent females may indicate their greater physiological vulnerability than adult females to sexually transmitted diseases (STDs). Data from HIV seroprevalence studies suggest a substantially increased heterosexual epidemic in the 1990s, especially in large east coast cities and southeastern rural areas where drug use and/or STDs are highly prevalent. More comprehensive prevention and treatment services are needed to prevent ongoing expansion of HIV infection and AIDS in the adolescent age group.