Ellen Graver

An association of human congenital cardiac malformations and drinking water contaminants

During an informal study in 1973 it was noted that approximately one third of patients with congenital heart disease lived in a small area in the Tucson Valley. In 1981 groundwater for a nearly identical area was found to be contaminated with trichloroethylene and to a lesser extent with dichloroethylene and chromium. Contamination probably began during the 1950s. Affected wells were closed after discovery of contamination. This sequence of events allowed investigation of the prevalence of congenital heart disease in children whose parents were exposed to the contaminated water area as compared with children whose parents were never exposed to the contaminated water area. The contaminated water area contained 8.8% of the Tucson Valley population and 4.5% of the labor force. Using their case registry, the authors interviewed parents of 707 children with congenital heart disease who, between 1969 and 1987, 1) conceived their child in the Tucson Valley, and 2) spent the month before the first trimester and the first trimester of the case pregnancy in the Tucson Valley. Two random dialing surveys showed that only 10.5% of the Tucson Valley population had ever had work or residence contact, or both, with the contaminated water area, whereas 35% of parents of children with congenital heart disease had had such contact (p less than 0.005). The prevalence of congenital cardiac disease (excluding syndromes, children with atrial tachycardia or premature infants with patent ductus arteriosus) in the Tucson Valley was 0.7% of live births and with syndromes was calculated to be 0.82%. The odds ratio for congenital heart disease for children of parents with contaminated water area contact during the period of active contamination was three times that for those without contact (p less than 0.005) and decreased to near unity for new arrivals in the contaminated water area after well closure. The proportion of infants with congenital heart disease as compared with the number of live births was significantly higher for resident mothers in the contaminated water area than for mothers with no exposure. No other environmental agent could be identified that was localized to the contaminated water area, but one could have been missed. The data show a significant association but not a cause and effect relation between parental exposure to the contaminated water area and an increased proportion of congenital heart disease among live births as compared with the proportion of congenital heart disease among live births for parents without contaminated water area contact.

Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities.

Ambulatory 24-hr esophageal pH monitoring isconsidered the gold standard for diagnosinggastroesophageal reflux disease (GERD). The currentapproach is to encourage patients to pursue theireveryday activity in order to obtain near-physiologicalrecordings. However, the effect of the test itself onreflux-provoking activities has never been evaluated.Thus, the aim of our study was to assess daily foodconsumption, habits, symptoms, sleep, and perceivedexperience of patients undergoing pH testing as comparedto an off test (normal) day. Patients reported type andtime spent in each activity pursued, food ingested and length of each meal, habits, frequency andseverity of GERD and other related symptoms, sleepdisturbances, side effects, and overall perceivedexperience during pH testing and four weeks later,during a normal day. Fifty-four patients enrolled. pHtesting significantly reduced time spent being active,number of meals and cups of coffee consumed, andfrequency of GERD symptoms. Almost half of the patients reported having dysphagia during the test. Mostpatients experienced side effects and stated that thetest bothered them most of the time. In conclusion, pHtesting has a significant effect on decreasing reflux-provoking activities — patientstend to assume a more sedentary lifestyle. This mayinfluence the reliability of the test as a physiologicmeasure of acid reflux.

Evaluation of the Southwest Food Frequency Questionnaire

The development of the Southwest Food Frequency Questionnaire (SWFFQ) was undertaken to provide a culturally appropriate means of collecting dietary information for the Southwest region of the United States. The study measured the reliability and validity of the SWFFQ and a modified shortened version (MSFFQ). Hispanic (n = 79) and non‐Hispanic (n = 80) subjects participated in the study and were randomized to complete two administrations of either the SWFFQ or the MSFFQ. Each subject provided four days of dietary recalls over a four month period. FFQs were administered 2 and 4 weeks after the last 24 hour recall was completed. The SWFFQ had greater mean reproducibility coefficients (0.615 to 0.832) compared with the MSFFQ and greater validity coefficients (0.349 to 0.700) when disattenuated for macronutrients, vitamins and minerals. Hispanics had greater reproducibility, but non‐Hispanics had greater validity coefficients. In conclusion, the SWFFQ is an instrument that can be used effectively for its target population.

Development of a questionnaire and a database for assessing dietary D-limonene intake

OBJECTIVE Increasing recognition of the potential importance of phytochemicals in the aetiology of cancer and heart diseases has highlighted the need for methods to measure individual phytochemical consumption that are sufficiently simple to be used in large epidemiological studies and whose reproducibility and accuracy have been quantified. d-Limonene is a natural component of a variety of foods and beverages and is found mainly in citrus fruits. However, d-limonene is not assessed by any nationally available analysis database. DESIGN We designed our study to assess the d-limonene content of different citrus juices and beverages and to develop a dietary assessment instrument to measure consumption of citrus foods (fruit, juice and peel) and d-limonene intake and test it for reliability. SUBJECTS AND METHODS A total of 120 citrus juice samples were analysed and used to develop the preliminary d-limonene database. A self-administered citrus food-frequency questionnaire was developed and administered twice to participants, separated by a 2-month interval. The questionnaire was tested for reproducibility of estimates of citrus food consumption and d-limonene intake among 120 participants. RESULTS Correlation coefficients between the two administrations of the questionnaire ranged from 0.50 for citrus peel use to 0.82 for orange juice. Mean intakes (range) of d-limonene from citrus juices among consumers were 13.0 (0.24-141.9) mg day-1 and 13.2 (0.07-83.9) mg day-1 (r = 0.60, P < 0.001). CONCLUSION The citrus frequency questionnaire developed in this study provided highly reproducible estimates of citrus foods, citrus peel and d-limonene intakes. This instrument may be a useful tool in studies of the associations between citrus peel use, d-limonene intake and risk for chronic disease.