Perinatal Health Outcomes Across Rural and Nonrural Counties Within a Single Health System Catchment

Background

Perinatal health outcomes are influenced by a variety of socioeconomic, behavioral, and economic factors that reduce access to health services. Despite these observations, rural communities continue to face barriers, including a lack of resources and the fragmentation of health services.

Objective

To evaluate patterns in health outcomes, health behaviors, socioeconomic vulnerability, and sociodemographic characteristics across rural and nonrural counties within a single health system catchment area.

Methods

Socioeconomic vulnerability metrics, health care access as determined by licensed provider metrics, and behavioral data were obtained from FlHealthCHARTS.gov and the County Health Rankings. County-level birth and health data were obtained from the Florida Department of Health. The University of Florida Health Perinatal Catchment Area (UFHPCA) was defined as all Florida counties where ≥5% of all infants were delivered at Shands Hospital between June 2011 and April 2017.

Results

The UFHPCA included 3 nonrural and 10 rural counties that represented more than 64,000 deliveries. Nearly 1 in 3 infants resided in a rural county, and 7 out of 13 counties did not have a licensed obstetrician gynecologist. Maternal smoking rates (range 6.8%-24.8%) were above the statewide rate (6.2%). Except for Alachua County, breastfeeding initiation rates (range 54.9%-81.4%) and access to household computing devices (range 72.8%-86.4%) were below the statewide rate (82.9% and 87.9%, respectively). Finally, we found that childhood poverty rates (range 16.3%-36.9%) were above the statewide rate (18.5%). Furthermore, risk ratios suggested negative health outcomes for residents of counties within the UFHPCA for each measure, except for infant mortality and maternal deaths, which lacked sample sizes to adequately test.

Conclusions

The health burden of the UFHPCA is characterized by rural counties with increased maternal death, neonatal death, and preterm birth, as well as adverse health behaviors that included increased smoking during pregnancy and lower levels of breastfeeding relative to nonrural counties. Understanding perinatal health outcomes across a single health system has potential to not only estimate community needs but also facilitate planning of health care initiatives and interventions in rural and low-resource communities.

Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study

OBJECTIVE

To quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (≥500 ml) and progression to severe PPH (≥1500 ml).

DESIGN

Prospective observational study.

SETTING

Two UK maternity services.

POPULATION

Women giving birth between 1 August 2008 and 31 July 2009 (n = 10 213).

METHODS

Weighted sampling with sequential adjustment by multivariate analysis.

MAIN OUTCOME MEASURES

Incidence and risk factors for PPH and progression to severe PPH.

RESULTS

Errors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH ≥500, ≥1500 and ≥2500 ml were 33.7% (95% CI 31.2-36.2), 3.9% (95% CI 3.3-4.6) and 0.8% (95% CI 0.6-1.0). New independent risk factors predicting PPH ≥ 500 ml included Black African ethnicity (adjusted odds ratio [aOR] 1.77, 95% CI 1.31-2.39) and assisted conception (aOR 2.93, 95% CI 1.30-6.59). Modelling demonstrated how prepregnancy- and pregnancy-acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53-108.00) or emergency (aOR 40.5, 95% CI 16.30-101.00), and retained placenta (aOR 21.3, 95% CI 8.31-54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11-2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20-2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24-3.22).

CONCLUSIONS

Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.

Sequential and intermittent docetaxel (D) and imatinib (Im) in hormone-refractory prostate cancer patients (NYU 04–47)

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Background: Platelet-derived growth factor is frequently expressed in advanced prostate cancer (PC) lesions where it supports PC cell growth and neo-angiogenesis. Im. is a PDGF inhibitor that blocks cell cycle in G1-S due to MEK/erk inhibition. D blocks cell cycle progression in G2-M. Sequential block of the cell cycle progression in G2-M followed by G1-S may increase anti-tumor responses. The phase II study dose of sequential D on day 1 and Im started 24–36h later given daily for 14 d was established in a previous phase I. Methods: Eligibility: at least 2 prior hormone manipulations and up to one prior chemotherapy, PSA>5ng/ml, ECOG PS 0–2. Treatment schedule: D 70mg/m2 day 1 followed 24–36 hours later by Im 600mg PO daily × 14 days. Cycles were repeated every 21d until toxicity or progression. Pegfilgrastim was given each cycle for neutropenia prevention. A two steps design was planned to assess activity (PSA decline >50% and/or measurable or symptomatic response) and tolerance including interim analysis to determine if 37 patients (pts) should be enrolled. Results: Of 15 pts enrolled, 13 had metastasis and 5(33%) received prior chemotherapy. There were 98 cycles of trial therapy administered and 9 events (PSA or bone progression) registered at the time of analysis. Median baseline PSA 73,5ng/ml (2.1–1954.3). Median follow-up estimated by inverse Kaplan Meier: 308 days (CI95%, 133–482). Median of cycles administrated 6 (1–12). PSA decline >50% observed in 7/15pts (46.67%) of which 3 was >80% (20%). PSA decline <50%, observed in 6/15(40%). 2/15(15.3%) were non-responders. Pain scores improved in all symptomatic pts. Median duration of response was 162 days (42- 281). Estimated median progression free survival by Kaplan-Meier was 155 days (CI95%, 80–339). Toxicity: there was G1–2 fatigue, anorexia, weight change in 66% pts; nausea, vomiting, taste changes in 66% pts, anemia in 46% and neuropathy in 46% pts. G3 fatigue in 2 pts, neuropathy and CHF in 1 pt. No G4 toxicities were observed. Conclusions: Sequential and intermittent D every 21 days and Im for 14 days is tolerable and active by PSA decline and symptomatic improvement. Compared to previous report with weekly D and continuous Im, this alternative schedule appears to have similar activity with better tolerance.

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Phase I/II study of sequential-intermittent docetaxel (D) and imatinib (Im) in hormone refractory prostate cancer (HRPC) (NYU 04–47)

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Background: Platelet-derived growth factor (PDGF) is frequently expressed in advanced prostate cancer (PC) lesions where it supports PC cell growth and neo-angiogenesis. Im. is a PDGF inhibitor that blocks cell cycle progression in G1-S through inhibition of erk1–2 kinase. D. blocks cell cycle progression in G2-M. Anti-tumor responses can increase when the block to cell cycle progression in G2M precede the blocks in G1-S. This study was designed to determine tolerablity and activity of sequential D followed by Im in HRPC patients (pts). Methods: Eligibility: 2 prior hormone manipulations, any prior chemotherapy, PSA= 5 ng/ml, ECOG PS 0–2. Treatment schema: D IV day 1 followed in 24–36 hours by Im PO daily x 14 days, every 21 days until toxicity or progression. Cohorts (C) planned were: #1, D. 60 mg/m2, Im. 400 mg; #2, D 70mg/m2, Im 400 mg; #3, D 70mg/m2, Im 600 mg. Results: 12 pts enrolled: 6 in C#1, 3 each in C#2,3. Median age,73 (range: 61 to 85). Median number cycles (Cy) 3 (range: 2 to 10). Toxicity grade (TG)1–2 observed in 9 (75%) pts (6, 2, 1 in C#1, 2,3 respectively): anemia 9, neutropenia 1, lymphopenia 6, thrombocytopenia 3, hyperglycemia 8, hyponatremia 2, abnormal bicarbonate 7, hypoalbuminemia 3, fatigue 5, neuropathy 3, nausea/vomiting 3, constipation 2, pain 2, fever 2, increased creatinine 2. TG3: afebrile neutropenia, 4 pts. Cy1. TG 4: febrile neutropenia,1 pt C#1,Cy1; GI bleed/intestinal perforation, 1 pt C#3, Cy7. PSA decline =50%: 1 pt C#2; 2 pts C#3. Conclusions: sequential and intermittent dosing of D and Im was well tolerated with high doses of both drugs. The most common toxicity was neutropenia which was prevented with growth factors. The MTD was not reached. PSA responses occurred at the higher doses. An ongoing phase II study of sequential D. 70mg/m2 and Im. 600 mg x 14 days will define activity.

No significant financial relationships to disclose.

Evidence for the existence of a constitutive nitric oxide synthase in vascular smooth muscle

1. We have identified a neuronal nitric oxide synthase (NOS)-like constitutive form of NOS in vascular smooth muscle (VSM) using a functional contractility approach as well as immunohistochemical methods. 2. N(G)-Nitro-L-arginine methyl ester, N(G)-monomethyl-L- arginine and N(G)-nitro-L-arginine (L-NOARG), the competitive inhibitors of NOS, inhibited Mg(2+)-induced relaxation of de-endothelialized rat aorta precontracted with phenylephrine (PE). This Mg(2+) relaxation of VSM was not affected by inhibitors of inducible NOS. 3. Electrical field stimulation (EFS; 30-70 Hz) caused relaxation of rat aorta in the presence of tetrodotoxin (therefore not a neurogenic effect) and this EFS relaxation was effectively inhibited by L-NOARG, oxyhemoglobin and methylene blue. 4. Immunohistochemical studies of dog saphenous vein using antibodies raised against neuronal NOS indicated prominent staining along the plasmalemma in a punctate pattern similar to the distribution of antibodies against caveolin-1, a major constituent of the plasmalemmal caveolae. 5. We propose that a constitutive NOS of non-endothelial, non-neuronal origin is present in a special caveolae domain of VSM cell membranes and could be activated by an ionic mechanism yet to be characterized.

Villin, cytokeratin 7, and cytokeratin 20 expression in pulmonary adenocarcinoma with ultrastructural evidence of microvilli with rootlets

Villin (V) is a glycoprotein of microvilli associated with rootlet formation. Most colonic adenocarcinomas have a V positive (+), cytokeratin (CK) 20 (+), CK7-negative (-) immunophenotype; most lung adenocarcinomas have a CK20(-), CK7(+) immunophenotype. The reports of villin immunoreactivity in lung adenocarcinoma range from 6% to 68% in studies using various fixations and varied anti-villin antibodies. Some lung adenocarcinomas have microvilli with rootlets leading to possible diagnostic confusion with metastatic colonic adenocarcinoma to lung. Nine primary lung adenocarcinomas with rootlets on ultrastructure (including four bronchioloalveolar carcinomas [BAC]), four metastatic lung adenocarcinomas with rootlets, nine metastatic colon adenocarcinomas to lung, and 10 randomly selected lung adenocarcinomas without rootlets (including five BAC), were immunostained with monoclonal antibodies to villin (1D2C3), CK7 (OV-TL12/30), and CK20 (Ks20.8) using a streptavidin peroxidase technique with heat-induced epitope retrieval. All primary lung adenocarcinomas with rootlets were CK7(+) CK20(-), and six of nine (67%) were V(+). Cytoplasmic villin positivity occurred in a diffuse--five of nine (56%), focal--two of nine (22%), or brush border pattern--two of nine (22%). Two of four metastatic lung adenocarcinomas with rootlets were V(+). One metastatic lung adenocarcinoma had a CK7(+), CK20(+), V(-) phenotype. All metastatic colonic adenocarcinomas were V(+), CK20(+), CK7(-), and 1 of 10 (10%) lung adenocarcinomas without rootlets was V(+), and all 10 were CK20(-), and CK7(+). In summary, villin positivity is more common in lung adenocarcinoma with rootlets (67%) than those without rootlets (10%). AU primary lung adenocarcinomas were CK7(+), CK20(-). The combination of villin, CK 7, and CK 20 is helpful in differentiating metastatic colon adenocarcinoma from lung adenocarcinoma with rootlets.

Value of methylprednisolone in prevention of the arthralgia-myalgia syndrome associated with the total dose infusion of iron dextran: a double blind randomized trial

The safety and efficacy of total dose infusion (TDI) of iron dextran has been well documented. In 40% of treated patients, an arthralgia-myalgia syndrome develops. The purpose of this randomized, double-blind, prospective study was to investigate whether intravenous (i.v.) administration of methylprednisolone (MP) prevents this complication. Sixty-five patients, 34 women and 31 men, ages 36 to 80 years, received either normal saline before and after TDI (group 1), 125 mg i.v. MP before and saline after TDI (group 2), or 125 mg i.v. MP before and after TDI (group 3). Patients were observed for 72 hours and reactions were recorded and graded according to severity. Fifty-eight percent of group 1 patients, 33% of group 2, and 26% of group 3 had reactions to TDI. The severity of reactions (minimal, mild, and moderate, respectively) was as follows: group 1--6, 6, and 2; group 2--1, 5, and 0; group 3--5, 1, and 0. Data were analyzed by the two-sided Fisher's exact test using 95% confidence intervals with the approximation of Woolf. These data demonstrate that administration of MP before and after TDI reduces the frequency and severity of the arthralgia-myalgia syndrome. We conclude that 125 mg i.v. MP should be given routinely before and after TDI of iron dextran.

Clinical use of the total dose intravenous infusion of iron dextran

Eighty-seven patients with anemia and absent bone marrow hemosiderin were given treatment with total dose intravenous infusions of iron dextran. The effect of rate of infusion and premedication with diphenhydramine, aspirin, and methylprednisolone on acute and delayed reactions was assessed. All patients were monitored for 72 hours after infusion. Two patients reacted to the test dose. One responded with generalized body pain that lasted approximately 5 minutes. In one an anaphylactoid reaction developed, which was promptly terminated by intravenous methylprednisolone, subcutaneous epinephrine, and intravenous diphenhydramine. Transient delayed adverse reactions easily controlled by nonsteroidal anti-inflammatory drugs occurred in 37 patients. The most common delayed reaction was a syndrome characterized by arthralgia, myalgia, and fever. Seven subjects had a chronic disease in addition to anemia with absent bone marrow iron. In all seven normal hemoglobin and hematocrit values were attained after treatment. The results of our experience with total dose intravenous iron dextran therapy suggest that it be the preferred method of replenishment in clinical situations where parenteral administration of iron is indicated. An unexpected benefit was the efficaciousness of this method of administration in patients with iron deficiency and coexisting chronic disease. A protocol for its administration is proposed.

Double heterozygosity for hemoglobins C and Lepore in an American black man

We describe a patient doubly heterozygous for hemoglobin (Hb) C-Hb Lepore. To our knowledge, this is only the second case reported in the United States. The erythrocyte morphology and clinical findings were suggestive of Hb C-beta-thalassemia. Following Hb electrophoresis, the correct diagnosis was postulated and was subsequently confirmed by a reference laboratory. We also present the family pedigree of Hb abnormalities. The morphologic alterations of the erythrocytes presented in this article, when seen in conjunction with the distinctive electrophoretic pattern, should suggest the abnormality in undiagnosed cases.

Kaposi's sarcoma in homosexual men-a report of eight cases

The clinical findings in eight young homosexual men in New York with Kaposi's sarcoma showed some unusual features. Unlike the form usually seen in North America and Europe, it affected younger men (4th decade rather than 7th decade); the skin lesions wee generalised rather than being predominantly in the lower limbs, and the disease was more aggressive (survival of less than 20 months rather 8-13 years). All eight had had a variety of sexually transmitted diseases. All those tested for cytomegalovirus antibodies and hepatitis B surface antigen of anti-hepatitis B antibody gave positive results. This unusual occurrence of Kaposi's sarcoma in a population much exposed to sexually transmissible diseases suggests that such exposure may play a role in its pathogenesis.