South African dyslipidaemia guideline consensus statement: 2018 update A joint statement from the South African Heart Association (SA Heart) and the Lipid and Atherosclerosis Society of Southern Africa (LASSA)

South Africa (SA) is home to a heterogeneous population with a wide range of cardiovascular risk factors. Cholesterol reduction in combination with aggressive management of modifiable risk factors, including nutrition, physical activity, blood pressure and smoking, can help to reduce and prevent morbidity and mortality in individuals who are at increased risk of cardiovascular events. This updated consensus guide to management of dyslipidaemia in SA is based on the updated European Society of Cardiology and European Atherosclerosis Society dyslipidaemia guidelines published in 2016. For individuals who are not considered to be at high or very high cardiovascular risk, the decision whether to treat and which interventional strategy to use is based on a cardiovascular risk score calculated using total cholesterol, high-density lipoprotein cholesterol (HDL-C), gender, age and smoking status. The cardiovascular risk score refers to the 10-year risk of any cardiovascular event and includes 4 categories of risk (low, moderate, high and very high). People with established cardiovascular disease, diabetes mellitus, chronic kidney disease and genetic or severe dyslipidaemias are considered to already be at high or very high risk and do not require risk scoring. Therapeutic lifestyle change is the mainstay of management for all patients. The need for and intensity of drug therapy is determined according to baseline low-density lipoprotein (LDL-C) levels and the target LDL-C concentration appropriate to the individual. LDL-C treatment targets are based on pre-treatment risk and are as follows: <3 mmol/L in low- and moderate risk cases; <2.5 mmol/L and a reduction of at least 50% if the baseline concentration is 2.5 - 5.2 mmol/L in high-risk cases; and <1.8 mmol/L and a reduction of at least 50% if the baseline concentration is 1.8 - 3.5 mmol/L in very high-risk cases. A statin is usually recommended first-line; the specific agent is based on the required degree of cholesterol reduction, comorbidities and co-prescribed medication. Special attention should be paid to children with a family history of genetic or severe dyslipidaemia, who should be screened for dyslipidaemia from 8 years of age. In SA, HIV infection is not considered to be a significant cardiovascular risk factor and treatment recommendations for HIV-positive individuals are the same as for the general population, with careful choice of pharmacotherapy to avoid potential adverse drug-drug interactions. The benefit of statins in individuals older than 70 years is uncertain and clinical judgement should be used to guide treatment decisions and to avoid side-effects and overmedication in this group.

Lessons learned from the Philadelphia Collaborative Preterm Prevention Project: the prevalence of risk factors and program participation rates among women in the intervention group

Background

Women who deliver preterm infants are at a much greater risk for repeating a preterm birth (PTB), compared to women without a history of PTB. However, little is known about the prevalence of the risk factors which account for this markedly increased risk. Moreover, little or nothing is known about the feasibility of providing treatments and services to these women, outside of the context of prenatal care, during the inter-conception period, which provides the best opportunity for successful risk-reduction interventions.

Methods

The Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large randomized control trial designed to identify and reduce six major risk factors for a repeat preterm birth among women immediately following the delivering of a preterm infant. For the women assigned to the PCPPP treatment group, we calculated the prevalence of the six risk factors in question, the percentages of women who agreed to receive high quality risk-appropriate treatments or services, and the of rates of participation among those who were offered and eligible for these treatments or services.

Results

Urogenital tract infections were identified in 57% of the women, while 59% were found to have periodontal disease. More than 39% were active smokers, and 17% were assessed with clinical depression. Low literacy, and housing instability were identified in, 22 and 83% of the study sample, respectively. Among women eligible for intervention, the percentages who accepted and at least minimally participated in treatment ranged from a low of 28% for smoking, to a high of 85% for urogenital tract infection. Most PCPPP enrollees (57%) had three or more major risk factors. Participation rates associated with the PCPPP treatments or services varied markedly, and were quite low in some cases, despite considerable efforts to reduce the barriers to receiving care.

Conclusion

The efficacy of individual level risk-reduction efforts designed to prevent preterm/repeat preterm in the pre- or inter-conception period may be limited if participation rates associated with interventions to reduce major risk factors for PTB are low. Achieving adequate participation may require identifying, better understanding, and eliminating barriers to access, beyond those associated with cost, transportation, childcare, and service location or hours of operation.

Trial registration

ClinicalTrials.gov (NCT01117922)

Pregnancy intention and contraceptive use at six months postpartum among women with recent preterm delivery

OBJECTIVE

To describe pregnancy intention and contraceptive use among women with a recent delivery that occurred at 35 weeks gestation or fewer and who were enrolled in a large-scale randomized control trial.

DESIGN

In this descriptive study we used data from assessments conducted at 6 months postpartum as part of a randomized controlled clinical trial, the Philadelphia Collaborative Preterm Prevention Project (PCPPP).

PARTICIPANTS AND SETTING

Participants were recruited following a preterm birth (PTB) in one of the 12 urban birth hospitals. All women enrolled in PCPPP, who completed their 6-month postpartum assessment, and who were sexually active at the time of that assessment (n = 566), were included in the analysis.

METHODS

Data were collected during face-to-face interviews. Study questionnaires included questions about participants' plans for the timing of subsequent pregnancies, contraceptive behaviors, and other health variables.

RESULTS

Nearly all of the participants (90.1%, n = 509) reported they did not want to get pregnant within one year of the index PTB. However, more than one half of these women (54.6%) reported contraceptive practices of low or moderate effectiveness. Most predictive of intending another pregnancy within the year was the death of the index PTB infant (odds ratio [OR]= 18.2,95% confidence interval [CI] [8.9, 37.0]).

CONCLUSIONS

Discordant pregnancy intention and contraceptive use were reported among this group of mothers of PTB infants who are at particularly high risk for a poor outcome of any subsequent pregnancy. The findings highlight the need for further investigation of the causes, correlates, and consequences of discordant pregnancy intentions and contraceptive practices.

Subjective social status and maternal health in a low income urban population

Appropriate measurement of socioeconomic status (SES) in health research can be problematic. Conventional SES measures based on 'objective' indicators such as income, education, or occupation may have questionable validity in certain populations. The objective of this investigation was to determine if a relatively new measurement of SES, subjective social status (SSS), was more consistently and strongly associated with multiple health outcomes for low income mothers. Data available from a large scale community-based study examining maternal and infant health for a low income urban population were used to examine relationships between SSS and a wide range of postpartum physical and emotional health outcomes. Crosstabulations and multivariate analyses focused on the breadth and depth of these relationships; in addition, the relative strength of the relationships between SSS and the health outcomes was compared to that of conventional measures of SES, including both income and education. SSS was significantly related to all physical and emotional health outcomes examined. The overall pattern of findings indicated that these relationships were independent of, as well as more consistent and stronger than, those between conventional measures of SES and postpartum health outcomes. SSS represents an important dimension of the relationship between SES and postpartum physical and emotional health. In low income populations the failure to account for this dimension likely underestimates the influence of SES on postpartum health. This has important implications for the interpretation of findings in empirical studies which seek to control for the effects of SES on maternal health outcomes.

Incident smoking during pregnancy and the postpartum period in a low-income urban population

OBJECTIVES

We determined the prevalence of first lifetime use of cigarettes during pregnancy or in the early postpartum period (incident smoking) and identified sociodemographic and health-related characteristics of incident smokers.

METHODS

We used statistics based on data from a longitudinal study of a large cohort of pregnant, low-income, urban women (n = 1,676) to describe the timing of first-time use and to compare incident smokers with those who had never smoked and those who had already smoked prior to pregnancy.

RESULTS

About one in 10 (10.2%) women who had not previously smoked initiated cigarette smoking during pregnancy or in the early postpartum period. Compared with those who had never smoked, incident smokers were more likely to report high levels of stress and to have elevated levels of depressive symptomatology, which may be rooted in relatively poor social and economic conditions.

CONCLUSION

A significant number of women may be initiating smoking during pregnancy or in the early postpartum period. These women have characteristics that are consistent with the risk factors associated with smoking. Further research is warranted to determine prevalence in other populations, identify the risk factors for incident smoking, and assess the potential for primary prevention efforts designed to help women who had previously avoided cigarette use to remain smoke-free throughout pregnancy and in the postpartum period.

Recruitment and retention of women in a large randomized control trial to reduce repeat preterm births: the Philadelphia Collaborative Preterm Prevention Project

Background

Recruitment and retention of patients for randomized control trial (RCT) studies can provide formidable challenges, particularly with minority and underserved populations. Data are reported for the Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large RCT targeting risk factors for repeat preterm births among women who previously delivered premature (< 35 weeks gestation) infants.

Methods

Design of the PCPPP incorporated strategies to maximize recruitment and retention. These included an advanced database system tracking follow-up status and assessment completion rates; cultural sensitivity training for staff; communication to the community and eligible women of the benefits of participation; financial incentives; assistance with transportation and supervised childcare services; and reminder calls for convenient, flexibly scheduled appointments. Analyses reported here: 1) compare recruitment projections to actual enrollment 2) explore recruitment bias; 3) validate the randomization process 4) document the extent to which contact was maintained and complete assessments achieved 5) determine if follow-up was conditioned upon socio-economic status, race/ethnicity, or other factors.

Results

Of eligible women approached, 1,126 (77.7%) agreed to participate fully. Of the 324 not agreeing, 118 (36.4%) completed a short survey. Consenting women were disproportionately from minority and low SES backgrounds: 71.5% consenting were African American, versus 38.8% not consenting. Consenting women were also more likely to report homelessness during their lifetime (14.6% vs. 0.87%) and to be unmarried at the time of delivery (81.6% versus 47.9%). First one-month postpartum assessment was completed for 83.5% (n = 472) of the intervention group (n = 565) and 76% (426) of the control group. Higher assessment completion rates were observed for the intervention group throughout the follow-up. Second, third, fourth and fifth postpartum assessments were 67.6% vs. 57.5%, 60.0% vs. 48.9%, 54.2% vs. 46.3% and 47.3% vs. 40.8%, for the intervention and control group women, respectively. There were no differences in follow-up rates according to race/ethnicity, SES or other factors. Greater retention of the intervention group may reflect the highly-valued nature of the medical and behavior services constituting the intervention arms of the Project.

Conclusion

Findings challenge beliefs that low income and minority women are averse to enrolling and continuing in clinical trials or community studies.

Perceived discrimination and depressive symptoms, smoking, and recent alcohol use in pregnancy

BACKGROUND

Perceived discrimination is associated with poor mental health and health-compromising behaviors in a range of vulnerable populations, but this link has not been assessed among pregnant women. We aimed to determine whether perceived discrimination was associated with these important targets of maternal health care among low-income pregnant women.

METHODS

Face-to-face interviews were conducted in English or Spanish with 4,454 multiethnic, low-income, inner-city women at their first prenatal visit at public health centers in Philadelphia, Penn, USA, from 1999 to 2004. Perceived chronic everyday discrimination (moderate and high levels) in addition to experiences of major discrimination, depressive symptomatology (CES-D >or= 23), smoking in pregnancy (current), and recent alcohol use (12 months before pregnancy) were assessed by patients' self-report.

RESULTS

Moderate everyday discrimination was reported by 873 (20%) women, high everyday discrimination by 238 (5%) women, and an experience of major discrimination by 789 (18%) women. Everyday discrimination was independently associated with depressive symptomatology (moderate = prevalence ratio [PR] of 1.58, 95% CI: 1.38-1.79; high = PR of 1.82, 95% CI: 1.49-2.21); smoking (moderate = PR of 1.19, 95% CI: 1.05-1.36; high = PR of 1.41, 95% CI: 1.15-1.74); and recent alcohol use (moderate = PR of 1.23, 95% CI: 1.12-1.36). However, major discrimination was not independently associated with these outcomes.

CONCLUSIONS

This study demonstrated that perceived chronic everyday discrimination, but not major discrimination, was associated with depressive symptoms and health-compromising behaviors independent of potential confounders, including race and ethnicity, among pregnant low-income women.

Estimating prevalence of overweight and obesity at the neighborhood level: the value of maternal height and weight data available on birth certificate records

Objective

To determine the value of maternal height and weight data on birth certificate records when estimating prevalence of overweight and obese adults at the neighborhood level.

Research Design and Methods

Regression analysis was used to determine how much variation in the percentage of the adult population with a body mass index (BMI) of ≥ 25 (based on survey data) could be accounted for by the percentage of mothers with BMI ≥ 25 (based on birth certificate data) -- alone and in combination with other sociodemographic characteristics of census tracts.

Results

Alone, the percentage of mothers with BMI ≥ 25 explained more than half (R² = .52) of the variation in the percentage of all residents in census tracts with BMI ≥ 25; in combination with several measures of the sociodemographic characteristics of the census tracts, 75% ( R² = 75.2) of the variation is explained.

Conclusions

Maternal height and weight data available from birth certificate records may be useful for identifying neighborhoods with relatively high or low prevalence of adult residents who are overweight or obese. This is especially true if used in combination with readily available census data.

Beyond marital status: the quality of the mother-father relationship and its influence on reproductive health behaviors and outcomes among unmarried low income pregnant women

In populations where the majority of pregnancies occur to unmarried women, exploring the quality of partner relationships and reproductive health is warranted. This study assesses differences in psychosocial characteristics, health behaviors, and birth outcomes between unmarried pregnant women who reported having a 'good' relationship with their baby's father, compared to those who reported having a 'fair' or 'poor' relationship with their baby's father. This research was part of a prospective study of low-income urban women. All unmarried women (n = 3,633) enrolled during their first prenatal visit were asked questions designed to differentiate between being in a good, fair or poor relationship with the baby's father. The worse the quality of the relationship, the worse the outcome, with dose-response associations between the quality of the relationship, emotional health, health behaviors, and birthweight. Compared to women in good relationships, those in poor relationships were more likely to have depressive symptoms (aPR 1.93; 95% CI: 1.65, 2.25), stress (aPR 1.24; 95% CI: 1.14, 1.35), use drugs (aPR 1.34; 95% CI: 1.11, 1.61) and smoke (aPR 1.28; 95% CI: 1.10, 1.49). Although infants born to mothers in poor relationships had the highest rate of low birth weight, the differences were not significant. Delving beyond marital status to assess the quality of partner relationships among unmarried mothers is important. Further research is needed to understand the complex interplay of individual, social and environmental factors promoting or hindering stable and supportive partner relationships among socially disadvantaged populations of pregnant women.

Postpartum physical symptoms in new mothers: their relationship to functional limitations and emotional well-being

BACKGROUND

Postpartum physical health problems are common and have been understudied. The purpose of this investigation was to explore the associations among reported physical symptoms, functional limitations, and emotional well-being of postpartum women.

METHODS

The study included data from interviews conducted at 9 to 12 months postpartum from 1,323 women who had received prenatal care at nine community health centers located in Philadelphia, Pennsylvania, United States, between February 2000 and November 2002. Emotional well-being was assessed with the Center for Epidemiological Studies Depression Scale and perceived emotional health. Functional limitations measures were related to child care, daily activities (housework and shopping), and employment. A summary measure of postpartum morbidity burden was constructed from a checklist of potential health problems typically associated with the postpartum period, such as backaches, abdominal pain, and dyspareunia.

RESULTS

More than two-thirds (69%) of the women reported experiencing at least one physical health problem since childbirth. Forty-five percent reported at least one problem of moderate or major (as opposed to minor) severity and 20 percent reported at least one problem of major severity. The presence, severity, and cumulative morbidity burden associated with postpartum health problems were consistently correlated with reports of one or more functional limitations and measures of emotional well-being including depressive symptomatology.

CONCLUSIONS

Although physical problems typically associated with the postpartum period are often regarded as transient or comparatively minor, they are strongly related both to women's functional impairment and to poor emotional health. Careful assessment of the physical, functional, and emotional health status of women in the year after childbirth may improve the quality of postpartum care.

Do public health clinics reduce rehospitalizations?: the urban diabetes study

Safety-net health clinics have been shown to reduce hospitalizations for ambulatory care-sensitive conditions. Their impact on rehospitalization after hospital discharge is unknown. We hypothesized that use of publicly-funded safety-net health clinics would reduce rates of rehospitalization among patients with diabetes. We expected this effect to be most evident among the most vulnerable patients. Linking data from the Philadelphia Health Care Centers (HCCs) with statewide hospital discharge data for 1994-2001 for patients with diabetes, we found that patients enrolled in the HCCs prior to hospitalization were rehospitalized 22% of the time, the same rate as other Philadelphians. Among those at higher risk of rehospitalization because pre-existing diabetes was not noted in hospital records, odds of rehospitalization were reduced by 24% for HCC patients. Given that patients in the HCCs are overwhelmingly poor and uninsured or underinsured, these findings suggest that access to primary care through the HCCs may have a protective effect against the poor health outcomes typically associated with lower socioeconomic status. Enrollment in publicly-funded safety-net health clinics may have prevented rehospitalizations for some vulnerable patients with diabetes.

Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study

OBJECTIVE

We evaluated the association of different types of educational visits for diabetic patients of the eight Philadelphia Health Care Centers (PHCCs) (public safety-net primary care clinics), with hospital admission rates and charges reported to the Pennsylvania Health Care Cost Containment Council.

RESEARCH DESIGN AND METHODS

The study population included 18,404 patients who had a PHCC visit with a diabetes diagnosis recorded between 1 March 1993 and 31 December 2001 and had at least 1 month follow-up time.

RESULTS

A total of 31,657 hospitalizations were recorded for 7,839 (42.6%) patients in the cohort. After adjustment for demographic variables, baseline comorbid conditions, hospitalizations before the diabetes diagnosis, and number of other primary care visits, having had any type of educational visit was associated with 9.18 (95% CI 5.02-13.33) fewer hospitalizations per 100 person-years and $11,571 ($6,377 to $16,765) less in hospital charges per person. Each nutritionist visit was associated with 4.70 (2.23-7.16) fewer hospitalizations per 100 person-years and a $6,503 ($3,421 to $9,586) reduction in total hospital charges.

CONCLUSIONS

Any type of educational visit was associated with lower hospitalization rates and charges. Nutritionist visits were more strongly associated with reduced hospitalizations than diabetes classes. Each nutritionist visit was associated with a substantial reduction in hospital charges, suggesting that providing these services in the primary care setting may be highly cost-effective for the health care system.

Hospital admission rates for a racially diverse low-income cohort of patients with diabetes: the Urban Diabetes Study

OBJECTIVE

We sought to determine the frequency and costs of hospitalization and to assess possible racial/ethnic disparities in a large cohort of low-income patients with diabetes who had received primary care at municipal health clinics.

METHODS

Administrative data from Philadelphia Health Care Centers were linked with discharge data from Pennsylvania hospitals for March 1993 through December 2001. We tested differences in hospitalization rates and mean hospital charges by age, gender, and race/ethnicity.

RESULTS

A total of 18,800 patients with diabetes experienced 30,528 hospital admissions, for a hospitalization rate of 0.35 per person-year. Rates rose with age and with the interaction of male gender and age. Rates for non-Hispanic Whites were higher than those for African Americans, whereas those for Hispanics, Asian Americans, and "others" were lower. Patients who were hospitalized at least 5 times made up 10.5% of the study population and accounted for 64% of hospital admissions and hospital charges in this cohort.

CONCLUSIONS

Hospitalization rates for this low-income cohort with access to primary care and pharmacy services were comparable to those of other diabetic patient populations, suggesting that reducing financial barriers to care may have benefited these patients. A subgroup of patients with multiple hospitalizations accounted for the majority of hospital admissions.

Diagnosing diabetes and preventing rehospitalizations: the urban diabetes study

BACKGROUND

Patients with diabetes frequently are hospitalized, and quality of inpatient care for diabetes is of great concern. Rehospitalization after hospital discharge is a frequent adverse outcome experienced by patients with diabetes.

OBJECTIVES

We assessed the frequency of and risk factors for rehospitalization among all Philadelphia residents with diabetes.

METHODS

Individual histories of hospitalization were ascertained from hospital discharge summaries for Philadelphia residents ages 25-84 who had at least 1 diabetes hospitalization from 1994 through 2001. Logistic regression was used to assess predictors of nonelective rehospitalization within 30 days of discharge, including recording of diabetes diagnosis.

RESULTS

Nonelective rehospitalizations within 30 days of hospital discharge were ascertained for 58,308 (20.0%) of 291,752 discharges. The proportion rehospitalized was 9.4% after a patient's first diabetes diagnosis hospitalization; after later discharges for which a diabetes diagnosis was not recorded, rehospitalizations occurred in 30.6% of all cases. The absence of a diabetes diagnosis was a highly significant predictor of rehospitalization after adjustment for age, year, gender, race/ethnicity, insurance status, admission type, severity code, length of stay, discharge status, and number of previous hospitalizations.

CONCLUSION

Failure to record a diabetes diagnoses in administrative hospital discharge data may reflect lack of attention to the critical needs of patients with diabetes who are being treated for other conditions, whereas the attention to patient education and follow-up planning for patients with incident diabetes diagnoses may reduce the risk of rehospitalization.

Cardiovascular comorbidities among public health clinic patients with diabetes: the Urban Diabetics Study

Background

We sought to determine the frequency and distribution of cardiovascular comorbidities in a large cohort of low-income patients with diabetes who had received primary care for diabetes at municipal health clinics.

Methods

Outpatient data from the Philadelphia Health Care Centers was linked with hospital discharge data from all Pennsylvania hospitals and death certificates.

Results

Among 10,095 primary care patients with diabetes, with a mean observation period of 4.6 years (2.8 after diabetes diagnosis), 2,693 (14.3%) were diagnosed with heart disease, including 270 (1.4%) with myocardial infarction and 912 (4.8%) with congestive heart failure. Cerebrovascular disease was diagnosed in 588 patients (3.1%). Over 77% of diabetic patients were diagnosed with hypertension. Incidence rates of new complications ranged from 0.6 per 100 person years for myocardial infarction to 26.5 per 100 person years for hypertension. Non-Hispanic whites had higher rates of myocardial infarction, and Hispanics and Asians had fewer comorbid conditions than African Americans and non-Hispanic whites.

Conclusion

Cardiovascular comorbidities were common both before and after diabetes diagnosis in this low-income cohort, but not substantially different from mixed-income managed care populations, perhaps as a consequence of access to primary care and pharmacy services.

Neighborhood poverty, mortality rates, and excess deaths among African Americans: Philadelphia 1999-2001

We used vital statistics and census data to determine whether mortality rates in Philadelphia were associated with neighborhood poverty, and to what extent excess mortality among African Americans was associated with neighborhood poverty. Gender-specific, age-adjusted mortality rates for 1999-2001 were strongly associated with neighborhood poverty among both women and men overall, and among both African Americans and non-Hispanic whites. The actual number of deaths among African Americans was 5,305 higher than it would have been if African Americans had had the same gender- and age-specific mortality rates as the average for non-Hispanic whites in Philadelphia, and 1,944 higher than if African Americans had had the same gender- and age-specific rates as non-Hispanic whites in the same neighborhood poverty categories. The excess mortality associated with neighborhood poverty and the socioeconomic factors that force large numbers of African Americans into poverty and high-poverty neighborhoods appear to be major factors in excess mortality among African Americans.

Nighttime call in house vs. out of house: a comparison of obstetric procedure rates

OBJECTIVE

To evaluate the effect of in-house vs. out-of-house nighttime call coverage on obstetric practice.

STUDY DESIGN

A retrospective analysis was performed on nighttime deliveries. Included were deliveries by 2 faculty groups that equally shared in-house and out-of-house call coverage. Included patients had an equal chance of delivering with a physician on call covering in house or out of house. Patient demographics and obstetric outcomes were compared between in-house and out-of-house call status for the delivering physician by ANOVA and chi2.

RESULTS

Of eligible nighttime deliveries, 230 were identified, 120 with in-house and 110 with out-of-house call coverage. Demographic features were not statistically different between the groups. A comparison of in-house and out-of-house deliveries yielded rates for episiotomy (28.3% vs. 30.0%), cesarean delivery (26.7% vs. 21.8%), operative vaginal delivery (11.7% vs. 18.2%), total operative delivery (38.4% vs. 40.0%) and nonoperative vaginal delivery (61.7% vs. 60.0%) that did not significantly differ by physician call status.

CONCLUSION

The nighttime call status of physicians, whether in house or out of house, did not affect cesarean delivery, operative vaginal delivery, overall (total) operative delivery or episiotomy rates.

The discrepancy between self-reported smoking status and urine continine levels among women enrolled in prenatal care at four publicly funded clinical sites

The discrepancy between self-reported smoking behavior and actual urine cotinine values among prenatal patients at four municipally operated clinical sites was examined. Face-to-face interview and birth certificate information about smoking behavior during pregnancy was compared with laboratory urine cotinine values for 74 patients. Almost three of every four (73%) self-reported nonsmokers had continine values greater than 80 ng/mL; one-half (48%) had values exceeding 100 ng/mL. Self-reported prenatal smoking behavior seems to be an unreliable indicator of actual smoking status among low-income prenatal patients, resulting in missed opportunities to lower tobacco-related exposure/risk among women with the poorest birth outcomes.

Hospital variation in episiotomy use and the risk of perineal trauma during childbirth

BACKGROUND

Episiotomies are the most frequently performed surgical procedure among United States women, but there are no published epidemiological studies of the extent of variation in episiotomy use among different obstetrical providers, or the outcomes associated with different levels of use. The objective of this study was to assess the extent of hospital variation in the use of episiotomy and the relationship between hospital episiotomy use and the incidence and risk of perineal trauma among women residing in a large urban area in the United States.

METHODS

Linked birth certificate and hospital discharge data pertaining to births to nulliparous women without prolonged labor or obstructed deliveries, and with infants weighing between 2500 and 4000 g, were analyzed for 18 major maternity hospitals. The relationship between episiotomy use and perineal trauma at the hospital level was examined using regression analysis.

RESULTS

Hospital episiotomy rates ranged from approximately 20 to 73 percent. The rate of third or fourth degree perineal lacerations varied from a low of 4 percent to a high of more than 13 percent among hospitals. Rates of episiotomy were significantly correlated with rates of a third or fourth degree perineal laceration (r = 0.70; p < 0.01), and with the hospital-specific, adjusted odds ratios for such lacerations (r = 0.65; p < 0.01).

CONCLUSIONS

Findings from the analysis of epidemiological data for this study population were consistent with those from clinical studies, indicating that liberal as opposed to restrictive use of episiotomy is unwarranted, and probably even harmful. Hospital episiotomy rates exceeded 20 percent in all cases, but such rates appear difficult to justify in face of the evidence.

The emotional and psychological impact of mass casualty incidents on forensic odontologists

Motivated by the findings of a previous research project, 38 forensic odontologists with known occupational experience of mass casualty incidents completed a questionnaire designed to elicit both quantitative and qualitative data. The questionnaire sought to provide an insight into the psychological and emotional impact of conducting work of this nature. Two psychometric scales were included in the questionnaire, The Positive and Negative Affect scale (PANAS) and the Impact of Events Scale (IOE). In addition, a number of open-ended questions relating to the personal experiences of the respondent during the mass casualty incident were also included. Quantitative findings indicate that on the whole mass casualty incidents resulted in a positive experience for the respondents, although over a third reported being distressed, upset or irritable at some time during the event. Sense of achievement and camaraderie were among the qualitative themes elicited that help explain the positive reactions. Working conditions, politics and the ictims were cited as sources of negativity.

Quantification of raindrop kinetic energy for improved prediction of splash-dispersed pathogens

ABSTRACT An electronic sensor, based on a piezoelectric transducer, was tested in the laboratory using simulated raindrops, and in natural rainfall. Data were also collected for splash dispersal using tracer dyes in laboratory experiments and the Long Ashton splashmeter in field experiments. Droplets impacting on sensor produce sound waves that are detected by an omnidirectional microphone sealed within an acoustic chamber. An electrical charge, proportional to the sound wave, is produced by the microphone and is converted to a categorical scale and then stored to provide an accumulation of impacts over a specified period of time. Calibration of the sensor was done using single-droplet impacts of known mass and impacting velocity. A linear relationship was shown between the categorical scale and the kinetic energy of impacting droplets (adjusted r(2) = 0.99). The best relationship fitted between splash dispersal from dye cup, and kinetic energy was a second-order polynomial (adjusted r(2) > 0.99). Splash height, recorded by the Long Ashton splashmeter during 41 natural rainfall events, was correlated closely with sensor output (adjusted r(2) = 0.87). Our studies indicate that the sensor provides quantitative data which could be incorporated into disease management systems to provide estimates of inoculum dispersal gradients within crop canopies.

Dental participants in mass disasters--a retrospective study with future implications

Mass casualty incidents continue to require the services of forensic dentists to determine the identity of victims. Across North America and Europe. teams of forensic dentists train, using mock disaster exercises, to prepare for such duties. It is vital that these mock exercises simulate the features of real disaster situations as far as possible. In order to inform those responsible for the design and implementation of mock exercises, a study was undertaken to determine the features of actual disasters that dental personnel had attended. Using a questionnaire, data were solicited from 38 odontologists. The average number of disasters attended by the respondents was eight, with an average casualty number of 94. Aircraft crashes were the most frequent cause of disasters that were attended by the odontologists. The authors conclude that future mock disaster exercises should replicate features of aircraft crashes as closely as possible by using commingled, fragmented, and burned remains. In addition, mock disasters should require the identification of a realistic number of individuals to ensure authenticity and the maximum logistical preparedness of participants.

Forensic implications of biting behavior: a conceptually underdeveloped area of investigation

Within the context of a criminal investigation the human bitemark traditionally provides the forensic dentist with both physical and biological evidence. In recent years, however, examples exist where in addition to discussing physical and biological evidence, expert witnesses have also testified in court regarding the behavioral aspects of biting behavior. Interested in this additional source of evidence, the authors reviewed the research literature from which biting behavior could be explained. The review found a hiatus of empirical knowledge in this respect, with only two papers seemingly related to the topic. With this dearth of knowledge in mind, the authors present a framework for further analysis and tentatively suggest reasons for biting behaviors, using a range of psychological models. The article ends with a cautionary note that vague and often misleading behavioral assumptions must not be applied to bitemark testimony until further data are available.

The design and assessment of mock mass disasters for dental personnel

Mass disasters represent a significant challenge for dental personnel who are frequently called upon to provide identifications. Recently-published materials have highlighted the need to prepare such groups for the disaster challenge and to report inadequacies in existing preparation methods with an emphasis on team integration, organization, and the psychological and emotional effects of such work. Many studies have retrospectively reported errors that have been made in disaster situations, but few have addressed the issues proactively. In an effort to provide a prepared team of dental members, a mock disaster exercise (Operation: DENT-ID) is conducted annually in Vancouver, Canada. The present study analyzes the effectiveness of this exercise in relation to team organization, assessment of preparedness, and the emotional and psychological issues. An index of preparedness is developed and described. This index, in the form of a questionnaire, can be given to participants in mock disasters to assess the effectiveness of such exercises. While the focus of this paper is on the assessment of dental personnel, the indices and methods used can be applied to any group working within the disaster team. Results indicate that the increase in preparedness as a result of the exercise was highly significant.

Complete sequences of the rRNA genes of Drosophila melanogaster

In this, the first of three papers, we present the sequence of the ribosomal RNA (rRNA) genes of Drosophila melanogaster. The gene regions of D. melanogaster rDNA encode four individual rRNAs: 18S (1,995 nt), 5.8S (123 nt), 2S (30 nt), and 28S (3,945 nt). The ribosomal DNA (rDNA) repeat of D. melanogaster is AT rich (65.9% overall), with the spacers being particularly AT rich. Analysis of DNA simplicity reveals that, in contrast to the intergenic spacer (IGS) and the external transcribed spacer (ETS), most of the rRNA gene regions have been refractory to the action of slippage-like events, with the exception of the 28S rRNA gene expansion segments. It would seem that the 28S rRNA can accommodate the products of slippage-like events without loss of activity. In the following two papers we analyze the effects of sequence divergence on the evolution of (1) the 28S gene "expansion segments" and (2) the 28S and 18S rRNA secondary structures among eukaryotic species, respectively. Our detailed analyses reveal, in addition to unequal crossing-over, (1) the involvement of slippage and biased mutation in the evolution of the rDNA multigene family and (2) the molecular coevolution of both expansion segments and the nucleotides involved with compensatory changes required to maintain secondary structures of RNA.

The distribution of satellite and main-band DNA components in the melanogaster species subgroup of Drosophila. I. Fractionation of DNA in actinomycin D and distamycin A density gradients

Fractionation of total adult DNA of five of the seven species of the melanogaster species sub-group of Drosophila in actinomycin D and distamycin A caesium density gradients has revealed the presence of three main-band DNA components, common to all species, and ten satellite DNAs that are distributed between the species. Satellite DNAs are either unique to a species or common to two or more species. The abundance of a common satellite DNA varies between species. There is no simple relationship between the presence of a satellite DNA and a branch point of phylogenetic divergence; nevertheless the arrangement of the species in a phylogeny that is based on the numbers of satellites held in common accurately reflects the pattern of relationships between the same species based on differences in inversions of polytene chromosomes. The species can be similarly arranged according to the compositions of their mitochondrial DNAs. It is possible that the same basic set of sequences, each of low frequency, is common to all species with arbitrary or selected amplification of particular sequences to differing extents in individual species. The conservation of satellites in the group and the close parallel between the distributions of satellites and inversions between the species suggests that either the processes that operate to change both chromosomal phenomena are similarly time-dependent and occurring at relatively low rates or that their rates of change are restricted according to some undetermined functions of these aspects of the genome.