A retrospective review comparing treatment outcomes of adjuvant lung resection for drug-resistant tuberculosis in patients with and without human immunodeficiency virus co-infection

OBJECTIVES

This review was undertaken to compare treatment outcomes in human immunodeficiency virus (HIV) negative versus HIV-positive patients following adjuvant lung resection for drug-resistant tuberculosis (DR-TB) in patients deemed feasible for surgery. Despite appropriate medical therapy, mortality remains extremely high and cure rates poor in patients with DR-TB and HIV co-infection. Therefore, adjuvant lung resection may warrant a more prominent role in the treatment of these patients.

METHODS

A retrospective review of all case records from 1 January 2012 to 31 March 2013 of all patients admitted to the Department of Cardiothoracic Surgery King Dinuzulu Hospital with DR-TB and treated with adjuvant lung resection was undertaken. Prior to surgery, all patients were treated for at least 3 months with appropriate drug therapy for DR-TB. This was continued for the recommended period following lung resection.

RESULTS

Fourteen patients with extensively drug-resistant tuberculosis (XDR-TB) were deemed suitable for lung resection. Of these patients, 10 patients were HIV-positive and 4 were HIV-negative. In the XDR-TB/HIV-positive group, 7 patients were cured, 2 converted and 2 patients developed a post-pneumonectomy broncho-pleural fistula. One patient was lost to follow-up. In the XDR-TB/HIV-negative group, 1 patient was cured, 3 converted and 1 patient developed a post-thoracotomy superficial wound infection. There was no in-hospital mortality in both groups. Thirty-six patients with multi-drug-resistant tuberculosis (MDR-TB) were deemed suitable for lung resection. Of these patients, 19 were HIV-positive and 17 HIV-negative. In the MDR-TB/HIV-positive group, 12 patients were cured and 6 converted. One patient developed a post-thoracotomy superficial wound infection and another patient who developed a post-pneumonectomy empyema thoracis was also regarded as a treatment failure. In the MDR-TB/HIV-negative group, 15 patients were cured, 2 converted and 1 patient developed a post-pneumonectomy lower respiratory tract infection which necessitated a short period of mechanical ventilation. There was no in-hospital mortality in both groups.

CONCLUSIONS

Lung resection for DR-TB may be safely undertaken in selected patients who are HIV-positive with cure rates equivalent to that of HIV-negative patients. More importantly, these patients also have significantly higher cure rates than those patients treated with medical therapy alone.

Clinical findings, diagnosis, prevalence and predisposing factors for lameness localised to the middle carpal joint in young Standardbred racehorses

REASONS FOR PERFORMING STUDY

Lameness related to the middle carpal joint (MCJ) occurs in up to 30% of young Standardbred horses in race training and the incidence increase with radiographic severity of third carpal bone (C3) sclerosis on DPr-DDIO (skyline) view of the carpus. Factors predisposing horses to carpal injury have not been well investigated.

OBJECTIVES

To determine the importance of MCJ lameness as a cause of wastage in young Standardbred racehorses, stage of training at which it occurs and predisposing factors, and to describe clinical findings and diagnosis.

METHODS

Standardbred horses (n = 114) entering their first year of race training were examined at approximately 3-month intervals over 12-18 months. For 87 of the horses, a training diary was available and these horses were trained at 3 different stables, each using a different exercise regime. At each examination, forelimb conformation, MCJ effusion, MCJ lameness and radiographic findings were graded, and training history and reasons for lost training days recorded. Nuclear scintigraphy and exploratory arthroscopy were performed on a limited selection of horses. Results for horses that developed MCJ lameness during the study period were compared statistically with results for horses that did not.

RESULTS

Carpal lameness occurred in 28% of horses and was present in 56% with forelimb lameness. In most cases lameness was mild, bilateral and with little or no MCJ effusion and was attributed to subchondral bone pain associated with radiographic evidence of C3 sclerosis. Carpal lameness was the most common reason for >1 month's rest during the study period. It occurred at any stage of training but, in most cases, some speed training had begun. Of the variables studied, poor forelimb conformation and more intense speed training were predisposing factors.

CONCLUSIONS AND POTENTIAL RELEVANCE

The information gained should assist in making recommendations regarding training young Standardbreds to reduce the incidence of MCJ lameness. However, further investigations to determine the optimal training regime are warranted.

Radiographic evaluation of sclerosis of the third carpal bone associated with exercise and the development of lameness in Standardbred racehorses

REASONS FOR PERFORMING STUDY

Sclerosis of the third carpal bone is a common radiographic finding in both lame and sound racehorses, but there are no guidelines correlating degree of sclerosis and incidence of lameness.

OBJECTIVES

To develop a protocol for describing subchondral bone sclerosis in C3 on dorsoproximal-dorsodistal oblique (DPr-DDiO) radiographs of the carpus and to correlate these changes with exercise history and carpal lameness.

METHODS

One hundred and six Standardbreds entering their first year of training (exercise group) and 7 age-matched Standardbreds at pasture (controls) were examined at approximately 3 month intervals over 12-18 months. Examinations consisted of lameness evaluation and carpal radiographs (DPr-DDiO and flexed lateromedial projections). A grading system (very mild, mild, moderate and severe) for C3 sclerosis seen on the DPr-DDiO radiograph was developed that utilised a combination of the criteria of trabecular thickening (trabecular score; TS) and total percent area of the C3 radial facet affected (TAA).

RESULTS

Exercise group horses showed significant increase in TS and TAA throughout training compared to control horses. Middle carpal joint lameness developed in 32/106 (30%) exercise group horses and none of the control horses. Incidence of middle carpal joint (MCJ) lameness was lower in horses with mild (2/30, 6.7%) than moderate (10/32, 31.2%) and severe (20/44, 45.4%) sclerosis throughout training.

CONCLUSIONS

Horses with higher grades of sclerosis, as defined by this novel grading system, were more likely to develop MCJ lameness at some point of training. The proposed grading system gave a quantitative assessment of radiographic sclerosis that could then be used to correlate increasing severity of sclerosis with increasing incidences of lameness.

POTENTIAL RELEVANCE

These results serve as a basis for further investigation into determining the degree of C3 sclerosis at which pathological changes and lameness can be expected.

Idiopathic pulmonary vein thrombosis: a rare cause of massive hemoptysis

The case history of an adult female with massive hemoptysis due to idiopathic left inferior pulmonary vein thrombosis necessitating lower lobectomy is presented with a review of the current literature.

Early mortality in twin pregnancies complicated by premature rupture of membranes in the United States

There is little information on mortality among multiple gestations complicated by premature rupture of membranes (PROM). In this study, we estimated the occurrence of the components of early mortality (stillbirth, neonatal and infant mortality) among twin pregnancies using the generalised estimating equation framework to account for intra-cluster correlations. Using the population-attributable risk, we also computed the level of excess mortality that could be averted by preventing PROM. Our findings reveal that the likelihood of stillbirth (odds ratio (OR) = 1.88; 95% confidence interval (CI)=1.66-2.13), neonatal mortality (OR=3.45; 95% CI=3.18-3.74) and infant mortality (OR=3.26; 95% CI=3.03-3.50) was significantly higher among twin pregnancies exposed to PROM. Approximately 6% of all stillbirths, 15% of neonatal mortality and 14% of infant mortality among twins in the United States are attributable to PROM. We conclude that PROM is associated with an increased level of early mortality among twins.

Mode of delivery and birth outcomes of macrosomic infants

This review examines and summarises the literature regarding the mode of delivery of macrosomic infants and subsequent perinatal outcomes. A search of electronic databases was conducted and supplemented with investigation of the references cited in the original articles. Although the rates of obstetric complications differ among high birth weight infants delivered by caesarean section compared to those delivered vaginally, there is currently little evidence that perinatal mortality differs significantly by delivery method. Shoulder dystocia and birth injury occur with greater frequency among macrosomic infants, yet the relative inaccuracy of clinical and ultrasonographic estimates of birth weight among high birth weight infants indicates that a trial of labour may be warranted among non-diabetic mothers with a suspected macrosomic fetus. The majority of studies identified in this review utilised small sample sizes and observational design, thereby hindering valid assessments of the impact of delivery method on the mortality of this population. Consequently, an optimal management strategy has yet to be defined.

Birth outcomes of Asian-Indian-Americans

OBJECTIVE

This study examines the maternal characteristics and birth outcomes of infants of U.S. resident Asian-Indian-American (AIA) mothers and compares those to infants of U.S. resident Whites and African-American (AA) mothers.

METHODS

Single live births to U.S. resident mothers with race/ethnicity coded on birth certificate as AIA, non-Hispanic White, or non-Hispanic AA were drawn from NCHS 1995 to 2000 U.S. Linked Live Birth/Infant Death files.

RESULTS

Compared to AAs or Whites, AIAs have the lowest percentage of births to teen or unmarried mothers and mothers with high parity for age or with low educational attainment. After taking these factors into account, AIA had the highest risk of LBW, small-for-gestational age and term SGA births but a risk of infant death only slightly higher than Whites and far less than AAs.

CONCLUSIONS

The birth outcomes of AIAs do not follow the paradigm that more impoverished minority populations should have greater proportions of low birth weight and preterm births and accordingly greater infant mortality rates.

Intrauterine tobacco smoke exposure and hyaline membrane disease amongst triplets

We assessed the association between prenatal smoking and respiratory distress syndrome (RDS) among triplets using a population-based retrospective cohort of 12,169 triplet live births in the United States between 1995 and 1997. Analysis was conducted using the generalised estimating equation framework to adjust for intra-cluster correlations. A total of 938 cases of RDS were reported comprising 35 among smoking (7.2%) and 903 among non-smoking gravidas (7.7%). The likelihood of RDS was comparable in both smoking categories [adjusted odds ratio (OR) = 0.93; 95% confidence interval (CI) = 0.65-1.32]. The risk for RDS due to smoking diminished with declining birth weight albeit non-significantly: low birth weight (OR = 0.99; 95% CI = 0.40-2.42), very low birth weight (OR = 0.85; 95% CI = 0.39-1.86), and extremely low birth weight (OR = 0.69; 95% CI = 0.30-1.58). In conclusion, among triplet neonates, smoking during pregnancy was not associated with respiratory distress syndrome.

Use of free conjunctival grafts in horses: ten cases

OBJECTIVE

To assess the effectiveness of free conjunctival grafts in the treatment of horses with a range of keratopathies.

DESIGN

A retrospective clinical study of ten client-owned horses treated at Murdoch University Veterinary Hospital from May 1996 to September 2001.

PROCEDURE

The suitability of patients for the surgical procedure was assessed using a slit lamp biomicroscope and by direct and indirect ophthalmoscopy. Surgery was performed with the aid of an operating microscope, under general anaesthesia. A subpalpebral ocular lavage catheter was used for administration of topical atropine and antibiotics postoperatively.

RESULTS

In all ten horses the affected globe was saved. In nine of the horses vision in the eye was satisfactory 6 months after surgery, and in one horse the eye was blind. Complications included further corneal ulceration or eyelid abscessation and some loss of sutures, although these did not preclude a successful outcome.

CONCLUSION

Free conjunctival grafts were successful in treating a range of keratopathies in the horse, and the technique offers a number of advantages over other forms of surgical intervention.

Preventing low birth weight: is prenatal care the answer?

OBJECTIVES

To review the evidence of effectiveness of prenatal care for preventing low birth weight (LBW).

METHODS

We reviewed original research, systematic reviews, meta-analyses and commentaries for evidence of effectiveness of the three core components of prenatal care--risk assessment, health promotion and medical and psychosocial interventions--for preventing the two constituents of LBW: preterm birth and intrauterine growth restriction (IUGR).

RESULTS

Clinical risk assessment will fail to identify the majority of pregnancies at risk for preterm delivery or IUGR. While biophysical and biochemical modalities appear promising, their cost-effectiveness has not been demonstrated, nor can their routine use be recommended in the absence of effective interventions. Smoking cessation programs appear to be modestly effective. There is insufficient evidence to conclude a benefit for nutrition interventions, work counseling or preterm birth education. Only antenatal corticosteroid therapy has demonstrated a clear benefit in the tertiary prevention of preterm delivery. Interventions for which there is insufficient evidence to conclude a benefit include bed rest, hydration, sedation, cerclage, progesterone supplementation, antibiotic treatment, tocolysis without concomitant use of corticosteroids, thyrotropin-releasing hormone, psychosocial support and home visitation. Additionally, there is a paucity of evidence supporting the effectiveness of prenatal interventions, such as low-dose aspirin, bed rest, maternal hyperoxygenation, plasma volume expansion and antenatal fetal assessment, in preventing IUGR or its associated morbidity and mortality.

CONCLUSIONS

Neither preterm birth nor IUGR can be effectively prevented by prenatal care in its present form. Preventing LBW will require reconceptualization of prenatal care as part of a longitudinally and contextually integrated strategy to promote optimal development of women's reproductive health not only during pregnancy, but over the life course.

Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research

Despite the widespread use of prenatal care, the evidence for its effectiveness remains equivocal and its primary purpose and effects continue to be a subject of debate. To provide some perspective on why the effectiveness and organization of prenatal care continue to be debated, the authors (a) briefly review the history of the development of prenatal care in the US; (b) attempt to conceptually define prenatal care in terms of its utilization, content, and quality; and, (c) highlight some of the research controversies and challenges facing investigators and advocates who seek to establish the value of prenatal care. In addition, the authors recommend directions for future research to address persistent questions regarding the function, structure, and significance of prenatal care in improving US perinatal outcomes.

Non-surgical management of rectal tears in two mares

Two mares presented with life-threatening rectal tears were successfully treated with intensive medical management. Although surgery has been regarded as mandatory for grade 3 or 4 rectal tears in the past, recent reports have indicated the value of medical management alone. The case reports presented in this article detail the use of antibiotics, flunixin meglumine, laxative diets and faecal softeners in the medical management of two mares presented with grade 3 rectal tears.

Prenatal care use among selected Asian American groups

OBJECTIVES

This study examined the predictors of 3 patterns of prenatal care use (no care, late initiation of care, and inadequate use after early initiation) for 4 Asian American ethnic groups in the United States.

METHODS

Single live births to US resident mothers of Chinese, Japanese, Korean, and Vietnamese ancestry (n = 273 604) were selected from the 1992-1996 US natality files. Logistic regression was used to analyze the effects of maternal characteristics on the 3 use measures.

RESULTS

Korean Americans and Vietnamese Americans had the lowest levels of prenatal care use. Young or single motherhood, high parity for age, and low educational attainment were the main risk factors for low use.

CONCLUSIONS

Considerable variability exists in prenatal care use among Asian American ethnic groups.

Effects of superior check desmotomy on flexor tendon and suspensory ligament strain in equine cadaver limbs

OBJECTIVE

To measure the effects of transection of the accessory ligament of the superficial digital flexor (SDF) muscle (superior check desmotomy) on flexor tendon and suspensory ligament (SL) strain in vitro.

STUDY DESIGN

In vitro experimental biomechanical investigation. ANIMALS USED: Ten equine cadaver forelimbs.

METHODS

The effects of superior check desmotomy were determined using equine cadaver forelimbs secured in a servocontrolled hydraulic testing machine. Strain sensors were used to measure strain on the superficial and deep digital flexor tendons and SL, and a goniometer was used to measure joint angles when the limb was loaded at 890 N and 3,115 N before desmotomy, and at 3,115 N after desmotomy.

RESULTS

Superior check desmotomy was associated with significantly increased strains on the SDF tendon and SL, and significant alterations in the angles of the metacarpophalangeal and carpal joints.

CONCLUSIONS

The superior check ligament has an important role in maintaining joint angles and load distribution in the forelimb. Lengthening of the SDF musculotendinous unit after superior check desmotomy may be associated with increased strain on the SL.

CLINICAL RELEVANCE

Transection of the accessory ligament of the SDF muscle may predispose horses to SL desmitis postoperatively.

Trends in preterm birth and neonatal mortality among blacks and whites in the United States from 1989 to 1997

Preterm birth, a major determinant of infant mortality, has been increasing in recent years. The authors examined trends in preterm birth and its determinants by using the US birth and infant death files for 1989-1997. The impact of trends in preterm birth rates on neonatal and infant mortality was also evaluated. Among Whites, preterm births (<37 completed weeks of gestation) increased from 8.8% of livebirths in 1989 to 10.2% in 1997, a relative increase of 15.6%. On the other hand, preterm births among Blacks decreased by 7.6% (from 19.0% to 17.5%) during the same period. An increase in obstetric interventions contributed to increases in preterm births for both races but was outweighed by other unidentified favorable influences for Blacks. Neonatal mortality among preterm Whites dropped 34% during the 8 years of the study, while the decrease was only 24% among Blacks. This large disparity countered the changes in preterm birth rates so that the percentage decline in neonatal mortality was similar in the two racial groups (18-20%). In conclusion, the anticipated mortality benefit from a lower preterm birth rate for Blacks has been blunted by suboptimal improvement in mortality among the remaining preterm infants. The widening race gap in mortality among preterm infants merits attention.

Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research

Despite the widespread use of prenatal care, the evidence for its effectiveness remains equivocal and its primary purpose and effects continue to be a subject of debate. To provide some perspective on why the effectiveness and organization of prenatal care continue to be debated, the authors (a) briefly review the history of the development of prenatal care in the US; (b) attempt to conceptually define prenatal care in terms of its utilization, content, and quality; and, (c) highlight some of the research controversies and challenges facing investigators and advocates who seek to establish the value of prenatal care. In addition, the authors recommend directions for future research to address persistent questions regarding the function, structure, and significance of prenatal care in improving US perinatal outcomes.

Trends in twin birth outcomes and prenatal care utilization in the United States, 1981-1997

CONTEXT

Multiple births account for an increasing percentage of all low-birth-weight infants, preterm births, and infant mortality in the United States. Since 1981, the percentage of women with multiple births who received intensive prenatal care (defined as a high number of visits, exceeding the recommendation of the American College of Obstetricians and Gynecologists by approximately 1 SD beyond the mean number of visits for women initiating care within each trimester) has increased significantly.

OBJECTIVES

To explore the hypothesis that more aggressive management of twin-birth pregnancies may be associated with changes in birth outcomes in this population.

DESIGN, SETTING, AND SUBJECTS

Cross-sectional and trend analysis of data from the National Center for Health Statistics' birth and infant death records for all twin births occurring in the United States between 1981 and 1997, excluding those with missing or inconsistent data.

MAIN OUTCOME MEASURES

Trends in preterm birth, low birth weight, preterm and term small-for-gestational-age (SGA) births, and infant mortality, by level of prenatal care utilization.

RESULTS

The preterm birth rate for twins increased from 40.9% in 1981 to 55.0% in 1997. The percentage of low-birth-weight infants increased from 51.0% to 54.0%. The preterm SGA rate also increased from 11.9% to 14.1%, while the term SGA rate decreased from 30.7% to 20.5%. For women with intensive prenatal care utilization, the preterm birth rate increased from 35.1% to 55.8%, compared with an increase from 50.6% to 59.2% among women with only adequate use. Twin preterm deliveries involving either induction or first cesarean delivery also increased from 21.9% to 27.3% between 1989-1991 and 1995-1997. The twin infant mortality rate for women with intensive prenatal care use declined between 1983 and 1996 and remained lower than the overall twin infant mortality rate.

CONCLUSIONS

An apparent increase in medical interventions in the management of twins may result in the seeming incongruity of more prenatal care and more preterm births; however, these data suggest that women with intensive prenatal care utilization also have a lower infant mortality rate. JAMA. 2000;283:335-341

Racial differences in temporal changes in newborn viability and survival by gestational age

This study examines trends in the rates of very preterm, moderately preterm and gestational age-specific neonatal mortality, and in the gestational age limit of viability in South Carolina (SC) from 1975 to 1994. We also investigate whether trends were similar between African-Americans and Whites. We hypothesised that disproportionate reductions in gestational age-specific mortality, rather than any major changes in the gestational age distributions of either race group, underlie any increasing racial disparity in overall mortality rates. During 1975-94, single livebirths, who were born to mothers resident in SC and were either White or African-American based on recorded maternal race, were selected for the investigation. We define the gestational age limit of viability as the gestational age at which > or = 50% of infants in the population died within 28 days of life. Although preterm percentages have not improved, there was a marked decline in neonatal mortality. Gestational age-specific neonatal mortality decreased for both race groups, although there were greater reductions for White preterm infants. By the end of the study period, the African-American neonatal mortality rate was 2.3 times that of Whites and the gestational age at which 50% of newborns died within 28 days of life was 24.5 weeks for Whites and 23.9 weeks for African-Americans. The ongoing decline in neonatal mortality continues to be mainly due to reductions in gestational age-specific neonatal mortality, probably related to high-risk obstetric and neonatal care. Technological developments in these areas may have differentially benefited Whites, resulting in an increasing racial disparity in neonatal mortality rates. Preterm African-American infants no longer have a marked survival advantage over White infants, even at the gestational age limit of viability.

1994-1996 U.S. singleton birth weight percentiles for gestational age by race, Hispanic origin, and gender

OBJECTIVES

Establishing and comparing race, ethnic, and gender-specific birth weight percentiles for gestational age is requisite for investigating the determinants of variations in fetal growth. In this study, we calculate percentiles of birth weight for gestational age for the total 1994-1996 U.S. population and contrast these percentiles by racial/ethnic and gender groups.

METHODS

Single live births to U.S. resident mothers were selected from the 1994-1996 U.S. Natality Files. After exclusions, 5,973,440 non-Hispanic Whites, 1,393,908 non-Hispanic African Americans, 1,683,333 Hispanics, 80,187 Native Americans, and 510,021 other racial/ethnic groups were used to calculate distribution percentiles of birth weight for each gestational age for which there were at least 50 cases to calculate the 50th percentile and 100 cases to calculate the 10th percentile.

RESULTS

Fetal growth patterns among the four U.S. racial/ethnic groups varied markedly and, across the gestational age range, there was considerable oscillation in the relative ranking of any one group's birth weight percentile value in comparison to the others. Males had relatively higher birth weight percentile values than females. The proportion of infants with a birth weight value less than 1994-1996 U.S. population's 10th percentile value of birth weight for their corresponding gestational age was 7.87 for non-Hispanic Whites, 15.43 for non-Hispanic African Americans, 9.30 for Hispanics, and 8.81 for Native Americans.

CONCLUSIONS

While the factors underlying trends and population subgroup differences in fetal growth are unclear, nutrition, smoking habits, health status, and maternal morbidity are possible precursors for part of the variations in patterns of fetal growth. As prenatal care has been touted as a means to reduce the risk of fetal growth restriction at term, assuring the availability and accessibility of comprehensive prenatal care services is viewed as an essential corollary in the effort to improve fetal growth patterns in the United States.

Changing pregnancy outcomes of Samoan women in Hawaii

In the state of Hawaii, Samoan mothers are known for the large average birthweight and low percentage of low birthweight (< 2500 g) of their infants, in spite of the relatively low socio-economic status of the population. This paper reports the findings of a temporal trend analysis of birth outcomes of Samoan women and identifies worrying changes. Data were obtained from Hawaii birth certificates. Single live births to Hawaii-resident Samoan and Caucasian women from 1979 to 1994 were included in the study. Infants of Samoan women experienced a 75 g decline in mean birthweight and an increase in the percentage of low (< 2500 g) and very low (< 1500 g) birthweight from 2.6 and 0.4 to 3.8 and 0.8 respectively. During the same time, infants of Caucasian mothers experienced an increase in mean birthweight and a decline in low birthweight, while very low birthweight did not change. Maternal socio-demographic characteristics explained only part of the findings and use of prenatal care did not appear to be associated with any birth outcome indicators. Multiple regression analyses identified an adjusted loss of 50.8 g in birthweight and a 1.48 increase in the odds ratio of small-for-gestational-age associated with birth at the end (1991-4) compared with the beginning (1979-82) of the study period. Further studies focusing on maternal health status and psycho-social variables, including the effect of acculturation-related stress, are warranted to identify at least some of the determinants of the changes identified by this analysis.

Trends and racial differences in birth weight and related survival

OBJECTIVE

In the past two decades, infant mortality rates in the United States declined in African-American and White populations. Despite this, racial disparities in infant mortality rates have increased and rates of low birth weight deliveries have shown little change. In this study, we examine temporal changes in birth weight distributions, birth weight specific neonatal mortality, and the birth weight threshold for an adverse risk of survival within both racial groups in order to explore the mechanisms for the disparities in infant mortality rates.

METHOD

Single live births born to South Carolina resident mothers between 1975 and 1994 and considered White or African-American based on the mother's report of maternal race on the birth certificate were selected for investigation. We define the birth weight threshold for adverse survival odds as the birth weight at which 50% or more of infants in the population died within the first month of life.

RESULTS

Despite significant increases in very low birth weight percentages, neonatal mortality rates markedly declined. Birth weight specific neonatal mortality decreased for both races, although greater reductions accrued to White low birth weight infants. By the end of the study period, the birth weight at which over 50% of newborns died within the first month of life was 696 g for Whites and 673 g for African-Americans.

DISCUSSION

The ongoing decline in neonatal mortality is mainly due to reductions in birth weight specific neonatal mortality, probably related to high-risk obstetric and neonatal care. Technological developments in these areas may have differentially benefited Whites, resulting in an increasing racial disparity in mortality rates. Moreover, the relatively greater and increasing mortality risk from postmaturity and macrosomia in infants of African-America mothers may further exacerbate the racial gap in infant mortality.

Racial differences in birthweight for gestational age and infant mortality in extremely-low-risk US populations

Using national data, we develop and contrast the birth-weight percentiles for gestational age by infants of extremely-low-risk (ELR) White and African-American women and examine racial differences in the proportion of small-for-gestational-age (SGA) births. We then scrutinise racial variations in infant mortality rates of the infants of ELR women. We further compare the infant mortality rates of infants at or below the 10th percentile of birthweight for gestational age of each race group to determine whether infants with similar restricted fetal growth have comparable risks of subsequent mortality. Single live births, 34-42 weeks' gestation, to White and African-American US-resident mothers were selected from the 1990-91 US Linked Live Birth--Infant Death File (n = 4,360,829). Extremely-low-risk mothers were defined as: married, aged 20-34 years, 13+ years of education, multiparae, with average parity for age, adequate prenatal care, vaginal delivery, and no reports of medical risk factors, tobacco use or alcohol use during pregnancy. Marked racial variation in birthweight percentiles by gestational age was evident. Compared with ELR White mothers, the risk of an SGA infant was 2.64 times greater for ELR African-American mothers and the risk of infant mortality was 1.61 times greater. For the ELR group, the infant mortality rates of African-American and White infants at or below the 10th percentile of birthweight for gestational age of their respective maternal race group were essentially identical after controlling for gestational age. In conclusion, race differences in fetal growth patterns remained after controlling for risk status. Efforts to remove racial disparities in infant mortality will need to develop aetiological pathways that can explain why African-Americans have relatively higher rates of preterm birth and higher infant mortality rates among term and non-SGA infants.

A new method to examine very low birth weight fetal and hebdomadal mortality in a regionalized system of perinatal care

OBJECTIVE

Aggressive maternal transport of very low birth weight (VLBW) live births from community hospitals to regional perinatal centers may artificially increase community fetal death rates. By allocating maternal transports according to the location of antepartum and intrapartum care and separately computing antepartum and intrapartum fetal mortality rates, a more appropriate measure of hospital-based mortality may be determined.

METHOD

Delivery charts were reviewed for 568 VLBW deliveries (including 97 fetal deaths and 77 hebdomadal deaths) occurring between 1990 and 1992 in a geographically defined perinatal region. Maternal transports were analyzed with community hospitals for antepartum mortality rates and with the regional center for intrapartum mortality rates.

RESULTS

Using traditional methods, the fetal mortality rates for community hospitals and the regional center were antepartum 385.1 vs. 45.2, respectively, and intrapartum 120.9 vs. 24.9, respectively. When regional center live births (maternal transports) are placed with community hospitals for analysis of antepartum mortality, the new antepartum mortality rates were 185.7 vs. 72.8, respectively. The hebdomadal mortality rate for community hospitals was 250.0 as compared to 145.8 for the regional center.

CONCLUSION

Maternal transports to a regional center represent successful antepartum management by community care providers. Even though they delivered in the regional center, they should be analyzed with community hospitals for antepartum fetal mortality comparisons. Therefore, antepartum and intrapartum fetal mortality should be examined separately in a functioning regionalized perinatal care program where the location of patient care differs from location of delivery.

The association between adequacy of prenatal care utilization and subsequent pediatric care utilization in the United States

OBJECTIVE

To explore the association between adequacy of prenatal care utilization and subsequent pediatric care utilization.

DESIGN

A longitudinal follow-up of a nationally representative sample of infants born in 1988.

PARTICIPANTS

Nine thousand four hundred forty women who had a live birth in 1988, and whose child was alive at the time of interview, and 8285 women from the original sample who were reinterviewed in 1991.

MAIN OUTCOME MEASURE

There were four outcome measures: number of well-child visits; adequate immunization for diphtheria, tetanus, and pertussis; adequate immunization for polio; and continuity of a regular source of care, as measured by the number of sites for pediatric care.

RESULTS

Children whose mothers had less than adequate prenatal care utilization had significantly fewer well-child visits, and were significantly less likely to have adequate immunizations, even after income, health insurance coverage, content of prenatal care, wantedness of child, sites of prenatal and pediatric care, and maternal and pregnancy risk characteristics were taken into account. Less than adequate prenatal care utilization was not associated with having more than one pediatric care site.

CONCLUSIONS

Prenatal care utilization can be used to identify and target interventions to women who are at risk for not obtaining well-child care or complete immunizations for their children.

Influence of diabetes during pregnancy on gestational age-specific newborn weight among US black and US white infants

This study examined the impact of maternal diabetes on birth weight for gestational age patterns of all term black infants and white infants in the United States using data derived from the 1990-1991 US Live Birth File of the National Center for Health Statistics. Infants of both black mothers and white mothers exhibited the expected fetal overgrowth associated with maternal diabetes. However, the increase in birth weight was much greater in infants of black than white diabetic mothers in comparison with their nondiabetic counterparts, as measured by the discrepancy in birth weight between infants of diabetic and nondiabetic mothers at each gestational week, the incidence of large for gestational age, high birth weight, small for gestational age, and low birth weight. After adjustment for maternal hypertension, prenatal care use, and sociodemographic factors, the disparity in mean birth weight associated with diabetes was 211.67 g in black infants and 115.74 g in white infants. The adjusted odds ratios of birth weight > or = 4,000 g were 2.98 (95% confidence interval 2.89-3.12) for black infants and 1.83 (95% confidence interval 1.78-1.89) for white infants. Given the potential risks for mothers and infants consequent to maternal diabetes and fetal hyperinsulinemia, further investigation of the prevalence, characteristics, and outcomes of diabetes during pregnancy among black mothers and infants is warranted.

The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices

CONTEXT

Two measures traditionally used to examine adequacy of prenatal care indicate that prenatal care utilization remained unchanged through the 1980s and only began to rise slightly in the 1990s. In recent years, new measures have been developed that include a category for women who receive more than the recommended amount of care (intensive utilization).

OBJECTIVE

To compare the older and newer indices in the monitoring of prenatal care trends in the United States from 1981 to 1995, for the overall population and for selected subpopulations. Second, to examine factors associated with receiving intensive utilization.

DESIGN

Cross-sectional and trend analysis of national birth records.

SETTING

The United States.

SUBJECTS

All live births between 1981 and 1995 (N=54 million).

MAIN OUTCOME MEASURES

Trends in prenatal care utilization, according to 4 indices (the older indices: the Institute of Medicine Index and the trimester that care began, and the newer indices: the R-GINDEX and the Adequacy of Prenatal Care Utilization Index). Multiple logistic regression was used to assess the risk of intensive prenatal care use in 1981 and 1995.

RESULTS

The newer indices showed a steadily increasing trend toward more prenatal care use throughout the study period (R-GINDEX, intensive or adequate use, 32.7% in 1981 to 47.1 % in 1995; the Adequacy of Prenatal Care Utilization Index, intensive use, 18.4% in 1981 to 28.8% in 1995), especially for intensive utilization. Women having a multiple birth were much more likely to have had intensive utilization in 1995 compared with 1981 (R-GINDEX, 22.8% vs 8.5%). Teenagers were more likely to begin care later than adults, but similar proportions of teens and adults had intensive utilization. Intensive use among low-risk women also increased steadily each year. Factors associated with a greater likelihood of receiving intensive use in 1981 and 1995 were having a multiple birth, primiparity, being married, and maternal age of 35 years or older.

CONCLUSIONS

The proportion of women who began care early and received at least the recommended number of visits increased between 1981 and 1995. This change was undetected by more traditional prenatal care indices. These increases have cost and practice implications and suggest a paradox since previous studies have shown that rates of preterm delivery and low birth weight did not improve during this time.

Ethnic-specific predictors of prenatal care utilisation in Hawaii

The state of Hawaii has had near-universal health insurance coverage for the last 20 years. Its highly diverse population offers the opportunity for a unique, natural experiment in the United States on the examination of social differences in health care utilisation when financial barriers are removed. Therefore, the objective of this study is to examine predictors of prenatal care utilisation patterns in the four major ethnic groups in Hawaii. The data used in this study are the 1979-92 Hawaii livebirth vital record files. A total of 165,301 singleton livebirths to Hawaii-resident mothers of Caucasian, native Hawaiian, Japanese or Filipino ancestry were selected. Despite near-universal health care coverage in Hawaii, a surprising number of women did not adequately utilise prenatal care, with large differences between groups. Multivariate analyses indicated that similar maternal socio-demographic factors were associated with prenatal care use in each ethnic group. Social variation continues to exist among all ethnic groups even in the presence of universal access to care. These data emphasise the need to address the distinct cultural needs of populations for providing health services, and further challenge the assumption that removal of financial barriers will ensure a high level of prenatal care use.

Prenatal care utilization in Hawaii: did it improve during the last 16 years?

This paper examines the utilization of prenatal care in Hawaii from 1979 to 1994 to determine if early and adequate utilization of prenatal care has changed during this period. Birth certificates of single live born infants of resident women were the source of data for the study. During the study period, the proportion of women receiving prenatal care in the first trimester increased by nearly 5 percent but was still below the national and state Year 2000 health objective of 90 percent. Notwithstanding this improvement, the percentage of women who did not receive the recommended number of visits in spite of starting care early significantly increased. The overall proportion of women with 'intensive' prenatal care use markedly increased (134.7%). The proportion of women with 'inadequate' care use declined (10.3%), although the proportion of women with 'no care' use doubled. Complete reporting of use of care through birth certificates markedly deteriorated. The findings of this study indicate the need for changes in the targeting and provision of counseling and education on the part of health care providers. Public health leaders, policy makers, health care providers, and advocacy groups need to collectively review programmatic directions with an aim toward the development of innovative approaches to address the emerging health needs of mothers and infants in the state.

An assessment of the use and impact of ancillary prenatal care services to Medicaid women in managed care

OBJECTIVES

Managed care plans under Medicaid are becoming a usual source of care for low-income pregnant women. This study describes an ancillary prenatal care service intervention developed by one managed care organization (MCO) for Medicaid-enrolled women, assesses the extent to which the intervention services were used, and appraises the influence of the intervention on prenatal care participation.

METHOD

There were 226 intervention and 258 control women with a single live birth delivered between 28 and 44 weeks gestation who (1) were enrolled in the MCO's Medicaid program, (2) were high-risk based on a prenatal risk assessment, and (3) started prenatal care prior to 26 weeks gestation. Less than adequate and intensive prenatal care utilization were chosen as intervention outcomes measures.

RESULTS

Family planning, a 2-month postpartum baby visit, a maternal postpartum visit, and a WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) referral were among the most self-selected intervention services for this population; home health aide and breast-feeding support were the least requested services. Over 90% of those needing family planning or breast-feeding services received the services, while over 20% of the intervention group refused child care, food assistance and family violence referrals, and home health aide and smoking cessation services. The intervention group had a significantly lower risk of less than adequate utilization of prenatal care (OR = .32; 95% CI: 0.17-0.60) and was more likely to have an intensive number of prenatal care visits (OR = 1.61; 95% CI: 1.05-2.48).

CONCLUSIONS

The ability of managed care organizations to provide ongoing prenatal care to Medicaid populations in a cost-effective manner depends partly on their development of packages of prenatal services that foster positive preventive health care utilization behaviors and good pregnancy outcomes. The results of this project suggest that the intervention was beneficial in the area of improving utilization of prenatal care.

Parental factors influencing patterns of prenatal care utilization

OBJECTIVES

The objectives of this study are to examine the influence of paternal and maternal education and marital status on the initiation and adequate use of prenatal care services.

METHODS

Data were obtained from the 1990-1991 Minnesota Live Birth file. Single live births to white resident mothers who were 21 years of age or older were selected for investigation. After these selections 102,798 cases were analyzed.

RESULTS

Logistic regression was used to examine the association of parental characteristics on the following three measures of poor prenatal care use: (1) receiving no prenatal care; (2) initiating care later than the first trimester; and (3) given a first trimester start of care, receiving less than the recommended number of prenatal care visits. Within each maternal education stratum, an increased risk of delayed initiation and less efficient use of prenatal care were observed for lower paternal educational attainment. Unmarried women, regardless of educational level, exhibited more than a tenfold risk of receiving no prenatal care, and unmarried women of low educational attainment exhibited the highest risk of delayed care.

CONCLUSIONS

A persistent positive effect of increasing paternal education on the level of adequacy of prenatal care utilization within all maternal marital status and educational attainment groups poses further challenges to our understanding of the factors that influence prenatal care use.

Temporal trends in maternal characteristics and pregnancy outcomes: their relevance to the provision of health services. Hawaii, 1979-1994

This paper examines changes in maternal sociodemographic characteristics and pregnancy outcomes in Hawaii during the period 1979-1994. The more striking changes were increases of 129% in the proportion of births to women > 35 years old and of 67% in the proportion of births to unmarried mothers. The percentage of low birth weight and small-for-gestational age infants decreased while the proportion of premature births increased. Identified changes were not limited to selected population groups, but were found in various degrees in all ethnic groups. These findings are relevant to all health practitioners and will assist in the provision of appropriate care and counseling to individual women.

After graduation, what? An analysis of the job placements of graduates of public health maternal and child health training programs. Project of the Association of Teachers of Maternal and Child Health

OBJECTIVES

In 1995, the Association of Teachers of Maternal and Child Health (ATMCH) decided that information about the employment status of program graduates was essential to attempts to improve MCH curricula.

METHOD

ATMCH requested information from 13 MCH programs in schools of public health funded by the federal Maternal and Child Health Bureau and 12 provided information about their master's degree graduates in the 1990-1994 period, including the year of graduation, degree, Bureau traineeship support, position held, and employing agency.

RESULTS

The total number of graduates was 742. Four programs averaged less than 8 graduates per year (small); six, 10-16 (midsize); and two more than 22 (large). More than 90% of graduates received a M.P.H. In the 10 programs that provided data on Bureau support, 46% received traineeship support from the Bureau. Midsize programs had the largest percentage of graduates receiving traineeship support. Overall, 45% of graduates were in administrative positions, 32% were involved in patient care, 20% were in policy-analytic positions, and 3% in other positions. Forty-seven percent of program graduates entered into or continued in community-based agencies, 18% in government agencies, 17% in academic or research agencies, and 18% in other agencies. Program size was significantly associated with both position and the agency in which the graduate was employed. Bureau traineeship support was associated with employing agency.

CONCLUSIONS

The study suggests the need for changes in MCH curricula, enhanced education opportunities in specialty skill areas, and an ongoing survey of graduates of MCH programs.

The influence of site of care on the content of prenatal care for low-income women

OBJECTIVE

To assess whether site of prenatal care influences the content of prenatal care for low-income women.

DESIGN

Bivariate and logistic analyses of prenatal care content for low-income women provided at five different types of care sites (private offices, HMOs, publicly funded clinics, hospital clinics, and other sites of care), controlling for sociodemographic, behavioral, and maternal health characteristics.

PARTICIPANTS

A sample of 3405 low-income women selected from a nationally representative sample of 9953 women surveyed by the National Maternal and Infant Health Survey, who had singleton live births in 1988, had some prenatal care (PNC), Medicaid participation, or a family income less than $12,000/year.

OUTCOME MEASURES

Maternal report of seven initial PNC procedures (individually and combined), six areas of PNC advice (individually and combined), and participation in the Women Infant Children (WIC) nutrition program.

RESULTS

The content of PNC provided for low-income women does not meet the recommendations of the U.S. Public Health Service, and varies by site of delivery. Low-income women in publicly funded clinics (health departments and community health centers) report receiving more total initial PNC procedures and total PNC advice and have greater participation in the WIC program than similar women receiving PNC in private offices.

CONCLUSIONS

Publicly funded sites of care appear to provide more comprehensive prenatal care services than private office settings. Health care systems reforms which assume equality of care across all sites, or which limit services to restricted sites, may foster unequal access to comprehensive PNC.

Using motor milestones as a multistep process to screen preterm infants for cerebral palsy

Pediatricians often informally use motor milestones to screen infant motor development, and one advantage is that they can be used during sequential office visits, as a multistep screening process. In this study we evaluated six motor milestones (roll prone to supine, roll supine to prone, sit with support, sit without support, crawl and cruise) as a multistep process in screening for cerebral palsy in 173 high-risk preterm infants (<33 weeks gestational age) who had been followed with sequential developmental assessments for at least 18 months. At the 18 to 24 month evaluation, 31 (18%) had cerebral palsy. We found that using the motor milestones as serial screening tests for cerebral palsy was more effective in terms of positive predictive value than any individual milestone alone. Limited community resources can be more efficiently used if preterm infants with delays in more than four motor milestones are referred for further evaluation and early intervention services.

Pregnancy outcomes of US-born and foreign-born Japanese Americans

OBJECTIVES

This study investigated the birth outcomes of Japanese Americans, focusing on the role of the mother's place of birth.

METHODS

Single live births to US-resident Japanese American mothers (n = 37,941) were selected from the 1983 through 1987 US linked live birth-infant death files.

RESULTS

US-born mothers were more likely than foreign-born mothers to be less than 18 years old and not married, to start prenatal care early, and to more adequately use prenatal care. Infants of foreign-born Japanese Americans had a slightly lower risk of low birthweight.No significant differences were found between nativity groups for very low birthweight or neonatal, postneonatal, and infant mortality. The mortality rates of infants of US-born (6.2) and foreign-born (5.4) Japanese American women were below the US Year 2000 objective but still exceeded Japan's 1990 rate (4.6). However, low-birthweight percentages of the US-born group (5.7%) and the foreign-born group (5.0%) were similar to that of Japan (5.5%).

CONCLUSIONS

The infants of foreign-born Japanese-American women exhibited modestly better low-birthweight percentages than those of US-born Japanese Americans. This finding supports theories of the healthy immigrant.

A United States national reference for fetal growth

OBJECTIVE

To develop a current national fetal growth curve that can be used as a common reference point by researchers to facilitate investigations of the predictors and consequences of small and large for gestational age delivery.

METHODS

Single live births to United States resident mothers in 1991 (n = 3,134,879) were used for the development of this curve, which was compared with four previously published fetal growth curves. Techniques were developed to address cases with implausible birth weight-gestational age combinations and to smooth fetal growth curves across gestational age categories.

RESULTS

In general, the previously published fetal growth curves underestimated the 1991 United States reference curve. This underestimation is most apparent during the latter weeks of gestation, approximately 33-38 weeks.

CONCLUSION

Our findings indicate that the prevalence of fetal growth restriction (FGR) will vary markedly, depending on the fetal growth curve used. Furthermore, many previously published fetal growth curves no longer provide an up-to-date reference for describing the distribution of birth weight by gestational age and for determining FGR that is consistent with the most recent live birth data for the entire United States.

Conceptualization, measurement, and use of gestational age. I. Clinical and public health practice

Despite its importance for both clinical and public health practice and the considerable effort spent during the past three decades to develop alternative estimation methods, the measurement of gestational age on both the individual and population level continues to be problematic. The availability of alternative approaches for the estimation of gestational age has to some extent obscured the basic differences in the conceptualization of these measures and influenced our current state of thinking about gestational age. As the evidence grows that these alternative gestational age estimation measures do not precisely correspond with one another, controversies have arisen regarding which method is most accurate. In the search for a single gestational age "gold standard," the potentially valuable information that these alternative measures may provide when used in combination should not be overlooked.

The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States

OBJECTIVE

To estimate the prevalence and length of gaps in health insurance coverage and their effect on having a regular source of care in a national sample of preschool-aged children.

DESIGN

Follow-up survey of a nationally representative sample of 3-year-old children in the US population by phone or personal interview.

PARTICIPANTS

A total of 8129 children whose mothers were interviewed for the 1991 longitudinal Follow-up to the National Maternal and infant Health Survey.

MAIN OUTCOME MEASURES

Report of any gap in health insurance for the children, the length of the gap, and the number of different sites where the children were taken for medical care as a measure of continuity of a regular source of care.

RESULTS

About one quarter of Us children were without health insurance for at least 1 month during their first 3 years of life. Over half of these children had a health insurance gap of more than 6 months. Less than half of US children had only one site of care during their first 3 years. Children with health insurance gaps of longer than 6 months were at increased risk of having more than one care site (odds ratio = 1.52; 95% confidence interval, 1.19 to 1.96). This risk further increased when an emergency treatment was discounted as a multiple site of care.

CONCLUSIONS

Having a gap in health insurance coverage is an important determinant for not having a regular source of care for preschool-aged children. This finding is of concern, given the sizable percentage of children in the United States who lacked continuous health care coverage during a critical period of development.

Adolescent parity and infant mortality, Minnesota, 1980 through 1988

The association of parity and infant mortality was studied using linked birth-death files for 46,985 infants born to 11- to 19-year-old Minnesota residents between 1980 and 1988. Compared with infants of primiparas, infants of multiparas were at twice the risk for infant and postneonatal death but at no increased risk for neonatal death. They were also at two to three times the risk for deaths due to accidents, infections, and sudden infant death syndrome. The higher sociodemographic disadvantage and poorer prenatal care of multiparas did not explain the excess infant mortality risk that was concentrated in causes of death that are potentially preventable through primary care and parent education.

Pregnancy outcomes of Pacific islanders in Hawaii

Percentages of low birth weight are low in American Indian and Mexican-American populations despite a high prevalence of traditional risk factors. Data derived from 1979-1990 Hawaii vital record files were used to examine birth weight, infant mortality, and their correlates in Samoan and Hawaiian residents of Hawaii to assess whether traditional risk factors are adequate predictors of low birth weight and whether low birth weight is an adequate measure of infant mortality risk in Polynesian populations. Despite very low educational attainment, high proportions of unmarried status, and inadequate prenatal care use, low and very low birth weight percentages were less than the US average. High birth weight was common. Unmarried status and primiparity after age 17 increased low birth weight risk, while high educational attainment and Samoan ethnicity decreased the risk. Adequate prenatal care was not associated with reduced low birth weight risk. Higher than expected neonatal mortality, particularly among normal birth weight infants, and high postneonatal mortality among Hawaiian infants suggest that poverty and maternal chronic disease, rather than low birth weight, may be the primary mediators of infant mortality risk in some populations. The need for clearer specification of risk factors and caution in generalized risk assessment in diverse populations is emphasized.