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Women With Better Diets Enjoy Longer Life

A Prospective Study of Diet Quality and Mortality in Women 
Ashima K. Kant, PhD; Arthur Schatzkin, MD, DrPH; Barry I. Graubard, PhD; Catherine Schairer, PhD

Context  Most studies of diet and health care have focused on the role of single nutrients, foods, or food groups in disease prevention or promotion. Few studies have addressed the health effects of dietary patterns, which include complex mixtures of foods containing multiple nutrients and nonnutrients.

Objective  To examine the association of mortality with a multifactorial diet quality index.

Design and Setting  Data from phase 2 (1987-1989) of a prospective cohort study of breast cancer screening, the Breast Cancer Detection Demonstration Project, with a median follow-up of 5.6 years.

Participants  A total of 42,254 women (mean age, 61.1 years) who completed the food frequency questionnaire portion of the survey.

Main Outcome Measure  All-cause mortality by quartile of Recommended Food Score (RFS; the sum of the number of foods recommended by current dietary guidelines [fruits, vegetables, whole grains, low-fat dairy, and lean meats and poultry] that were reported on the questionnaire to be consumed at least once a week, for a maximum score of 23).

Results  There were 2065 deaths due to all causes in the cohort. The RFS was inversely associated with all-cause mortality. Compared with those in the lowest quartile, subjects in the upper quartiles of the RFS had relative risks for all-cause mortality of 0.82 (95% confidence interval [CI], 0.73-0.92) for quartile 2, 0.71 (95% CI, 0.62-0.81) for quartile 3, and 0.69 (95% CI, 0.61-0.78) for quartile 4 adjusted for education, ethnicity, age, body mass index, smoking status, alcohol use, level of physical activity, menopausal hormone use, and history of disease.

Conclusions  These data suggest that a dietary pattern characterized by consumption of foods recommended in current dietary guidelines is associated with decreased risk of mortality in women.

JAMA. 2000;283:2109-2115

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Hemodialysis Patients Suffer Neurological Deficits Brought On By Infected, Aged Dialyzer Membranes

Acute Onset of Decreased Vision and Hearing Traced to Hemodialysis Treatment With Aged Dialyzers  
  Joseph C. Hutter, PhD; Matthew J. Kuehnert, MD; Roland R. Wallis, PhD; Anne D. Lucas, PhD; Sumit Sen, PhD; William R. Jarvis, MD

Context  A recent event in which 7 patients at 1 hospital developed decreased vision and hearing, conjunctivitis, headache, and other severe neurologic symptoms 7 to 24 hours after hemodialysis drew attention to the issue of the long-term integrity of dialysis machines and materials.

Objective  To determine the cause of the adverse reactions that occurred during this event.

Design, Patients, and Setting  Retrospective cohort study of all 9 patients who received hemodialysis at hospital A on September 18, 1996, the day of the outbreak. A case-patient was defined as any hospital A patient with acute onset of decreased vision and hearing and conjunctivitis after dialysis on that day. Non–case-patients were all others who underwent dialysis at hospital A on that day but did not develop adverse reactions. In an attempt to reproduce the conditions of the event, cellulose acetate dialysis membranes of various ages were retrieved from other sources and tested for physical and chemical degradation, and degradation products were identified, characterized, and injected intravenously into rabbits.

Main Outcome Measures  Clinical signs and symptoms, time to resolution of symptoms, mortality, and dialyzer type and age, for case- vs non–case-patients.

Results  Seven of the 9 patients met the case definition. In addition to diminished vision and hearing, conjunctivitis, and headache, some case-patients had blood leak alarm activation (n=6), confusion/lethargy (n=5), corneal opacification (n=4), cardiac arrest (n=2), or other neurologic signs and symptoms. One case-patient died during hospitalization after the event; 5 of 7 case-patients died within 13 months. Resolution of signs and symptoms varied but persisted more than 3 years or until death in 3 of the 6 patients who survived hospitalization. All case-patients but no non–case-patients were exposed to 11.5-year-old cellulose acetate dialyzers (all of these dialyzers were discarded by the hospital before our investigation). Laboratory investigation of field-retrieved 0- to 13.6-year-old dialyzers of similar type indicated significant chemical degradation in the older membranes. In vivo injection of extracts of membrane degradation products produced iritis and hemorrhages in rabbits' eyes.

Conclusions  Severe patient injury was associated with exposure to aged cellulose acetate membranes of dialyzers, allowing cellulose acetate degradation products to enter the blood. Clinicians should be aware that aged cellulose acetate membranes may cause severe adverse reactions.

JAMA. 2000;283:2128-2134

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"Back" To Sleep

Factors Associated With Caregivers' Choice of Infant Sleep Position, 1994-1998
The National Infant Sleep Position Study 
  Marian Willinger, PhD; Chia-Wen Ko, PhD; Howard J. Hoffman, MA; Ronald C. Kessler, PhD; Michael J. Corwin, MD

Context  The success and simplicity of the 1994 national "Back to Sleep" campaign to reduce sudden infant death syndrome provides an opportunity to study which elements determine whether a behavior will change in the desired direction in response to a public health intervention.

Objective  To examine sociodemographic characteristics, motivation, and message exposure to ascertain which factors influenced a caregiver's choice of infant sleep position after implementation of the campaign.

Design  Annual nationally representative telephone surveys conducted between 1994 and 1998.

Setting  The 48 contiguous United States.

Participants  Nighttime caregivers of infants born within the 7 months prior to interview between 1994 and 1998. Approximately 1000 interviews were conducted each year.

Main Outcome Measures  The position the infant was usually placed in for sleep, sleep position recommendations received from specific sources, and reasons reported for position choice.

Results  Between 1994 and 1998, prone placement declined from 44% to 17% among white infants and from 53% to 32% among black infants. Supine placement increased from 27% to 58% among white infants and from 17% to 31% among black infants. During this period, reports of supine recommendations from at least 1 source doubled from 38% to 79%. From 1995 to 1998, 86% of caregivers who placed the infant prone reported receiving only nonprone recommendations. Infant comfort was given as a reason for prone placement by 82% of these caregivers. In multivariate analysis, physician recommendation of "supine not prone" had the strongest influence and was associated with decreased prone placement (odds ratio [OR], 0.25 [95% confidence interval {CI}, 0.16-0.39]) and increased supine placement (OR, 3.37 [95% CI, 2.38-4.76]). Recommendations from all 4 sources (the physician, neonatal nurse, reading materials, and radio/television) further increased the probability of supine placement (OR, 6.01 [95% CI, 4.57-7.90]). Other factors independently associated with increased prone and decreased supine placement included maternal black race, parity of more than 1, and living in a southern or mid-Atlantic state.

Conclusions  According to our study, as of 1998, approximately one fifth of infants were still placed prone, and only half were placed supine. Recommendations of supine placement during infancy by physicians at well-baby checks and by neonatal nursery staff and print and broadcast media have increased the proportion of infants placed supine. Caregiver beliefs regarding perceived advantages of prone sleeping should be addressed to attain further reduction in prone placement.

JAMA. 2000;283:2135-2142

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