Efficacy of recycled sand or organic solids as bedding sources for lactating cows housed in freestalls.

Our objective was to compare the composition of bedding materials and manure, cow welfare and hygiene assessments, measures of milk production and quality, and incidence of mastitis during a 3-yr trial with lactating Holstein cows housed in a freestall barn containing 4 identical pens with 32 freestalls/pen. Bedding systems evaluated included deep-bedded organic manure solids (DBOS), shallow-bedded manure solids spread over mattresses (MAT), deep-bedded recycled sand (RSA), and deep-bedded new sand (NSA). The experiment was designed as a 4 × 4 Latin square with 4 bedding systems and 4 experimental periods, but was terminated after 3 yr following discussions with the consulting statistician; therefore, data were analyzed as an incomplete Latin square. A total of n = 734 mostly primiparous cows (n = 725 primiparous, n = 9 multiparous; 224 to 267 cows/yr) were enrolled in the trial. Before placement in freestalls, organic solids (OS) exhibited lower concentrations of dry matter (36.5 vs. 94.3%), and greater concentrations of volatile solids, C, N, NH4-N, P, water-extractable P, K, and S compared with RSA or NSA. Cow comfort index was greater for sand-bedded systems compared with those using OS (88.4 vs. 82.8%). Cows bedded in systems using OS (DBOS and MAT) exhibited greater mean hock scores (1 = no swelling, no hair loss; 2 = no swelling, bald area on hock) than those bedded in sand (1.25 vs. 1.04), but this effect was entirely associated with use of mattresses (MAT), which differed sharply from DBOS (1.42 vs. 1.07). Generally, hygiene scores for legs, flanks, and udders were numerically similar for DBOS, NSA, and RSA bedding systems, and differences between bedding systems were associated entirely with MAT, yielding detectable contrasts between MAT and DBOS for legs (2.94 vs. 2.20), flanks (2.34 vs. 1.68), and udders (1.83 vs. 1.38). No significant contrast comparing bedding systems was detected for measures of milk production or quality. Documented cases of clinical mastitis requiring treatment ranged from a low rate of 7.4 cases/yr for RSA to a high of 23.1 cases/yr for DBOS, based on a mean enrollment of 60.7 to 63.0 cows/treatment per yr. Cows bedded with OS exhibited a greater incidence of mastitis than those bedded with sand (19.0 vs. 8.4 cases/yr), but no differences were observed for comparisons within individual bedding-material types. Collectively, these results generally favored use of sand-bedding materials over systems using OS.

Visits to emergency departments for gynecologic disorders in the United States, 1992-1994.

OBJECTIVE: To assess rates of visits to emergency departments for gynecologic disorders among women of reproductive age in the United States. METHODS: Data from the National Hospital Ambulatory Medical Care Survey for 1992-1994 were analyzed to determine rates of visits to emergency departments among women, ages 15-44 years. Average annual rates per 1000 women were calculated using age, race, and region-specific population estimates. Rate ratios were used to compare rates among subgroups. RESULTS: Approximately 1.4 million gynecologic visits were made to emergency departments annually, for an average annual rate of 24.3 visits per 1000 women, ages 15-44 years (95% confidence interval [CI] 22.0, 26.6). The most frequent diagnoses were pelvic inflammatory disease (average annual rate 5.8, 95% CI 5.0, 6.6), lower genital tract infections including sexually transmitted diseases (average annual rate 5.7, 95% CI 4.8, 6.6), and menstrual disorders (average annual rate 2.9, 95% CI 2.3, 3.5). Nearly half of all gynecologic visits resulted in diagnoses of genital tract infections. Younger women (ages 15-24 years) were 2.3 (95% CI 2.0, 2.6) times as likely as older women (ages 25-44 years), and black women were 3.6 (95% CI 2.9, 4.3) times as likely as white women, to visit emergency departments for gynecologic disorders. Rate ratios for genital tract infections were 10-20 times higher for younger black women than for older, white women. CONCLUSION: Almost half of gynecologic visits to emergency departments were related to genital tract infections, which largely are preventable.

Female genital mutilation. Female circumcision. Who is at risk in the U.S.?

Female genital mutilation/female circumcision (FGM/FC) refers to a group of traditional practices that involve partial or total removal of the external female genitalia or other injury to the female genital organs for cultural, religious, or other non-therapeutic reasons. These practices are usually performed by a nonmedical practitioner in the home or other nonclinical setting. Complications occurring immediately after the practice as well as those encountered months and years afterward can result in disability or premature death. In 1996 Congress directed the Department of Health and Human Services to develop estimates of the prevalence of women and girls with or at risk for FGM/FC in the United States. This paper reports those estimates, as derived by the Centers for Disease Control and Prevention, which showed that in 1990 there were an estimated 168,000 girls and women living in the United States with or at risk for FGM/FC.

Farm health surveillance in the Marshfield Epidemiologic Study Area: a pilot study.

Surveillance of agricultural work-related illness and non-fatal injuries is limited and considered to be a major gap in prevention and policy-making capacity. This pilot study evaluated the utility of the Marshfield Epidemiologic Study Area (MESA) and its farm residency cohort to identify and monitor potential priorities for prevention and control. MESA is a defined geographic region that serves as a resource for conducting population-based health research. Nearly all of the residents receive their health care from the Marshfield Clinic and affiliated hospitals, providing archived electronic medical information to characterize past and present diagnoses. Based on scientific literature and national research priorities, five broad health issues (injuries, back problems, hearing loss, respiratory conditions, and dermatologic conditions) were selected. To estimate age-specific and age-adjusted incidence and prevalence, we followed a fixed cohort of 1995 MESA residents through 2002. Standardized incidence ratios and standardized prevalence ratios were also estimated to quantify the potential impact of farm residency. Linking MESA, its farm residency cohort, and the clinic's data archives allowed successful identification of significant associations with agricultural exposure for a few conditions and subconditions related to consensus priorities in agricultural health, particularly among men. These included extrinsic alveolitis, organic dust toxic syndrome, back pain, osteoarthrosis, and certain injuries. However, the system was generally not able to demonstrate strong influence of farm residency on disease occurrence for many conditions specifically selected for their likely capacity to show such influence. Future surveillance systems should supplement clinical data with other sources of information on health events and should be adequately powered to focus on narrower ranges of health conditions.

Tubal sterilization in the United States, 1994-1996.

CONTEXT: Although the number and rate of tubal sterilizations, the settings in which they are performed and the characteristics of women obtaining sterilization procedures provide important information on contraceptive practice and trends in the United States, such data have not been collected and tabulated for manyyears. METHODS: Information on tubal sterilizations from the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery was analyzed to estimate the number and characteristics of women having a tubal sterilization procedure in the United States during the period 1994-1996 and the resulting rates of tubal sterilization. These results were compared with those of previous studies to examine trends in clinical setting, in the timing of the procedure and in patient characteristics. RESULTS: In 1994-1996, more than two million tubal sterilizations were performed, for an average annual rate of 1 1.5 per 1,000 women; half were performed postpartum and half were interval procedures (i. e., were unrelated by timing to a pregnancy). All postpartum procedures were performed during inpatient hospital stays, while 96% of interval procedures were outpatient procedures. Postpartum sterilization rates were higher than interval sterilization rates among women 20-29 years of age; interval sterilization procedures were more common than postpartum procedures at ages 35-49. Sterilization rates were highest in the South. For postpartum procedures, private insurance was the expectedprimary source of payment for 48% and Medicaid was expected to pay for 41 %; for interval sterilization procedures, private insurance was the expected primary source of payment for 68% and Medicaid for 24%. CONCLUSIONS: Outpatient tubal sterilizations andprocedures using laparoscopy have increased substantially since the last comprehensive analysis of tubal sterilization in 1987, an indication of the effect of technical advances on the provision of this service. Continued surveillance of both inpatient and outpatient procedures is necessary to monitor the role of tubal sterilization in contraceptive practice.

Trends in hospitalizations for abnormal uterine bleeding in the United States: 1980-1992.

We examined trends in hospital discharges, length of hospital stay, and procedures performed for abnormal uterine bleeding from 1980 through 1992. We used data from the National Hospital Discharge Survey. Discharges involving patients with reproductive tract cancers or pregnancy-related diagnoses were excluded. The overall discharge rate for abnormal uterine bleeding decreased 66% during the study period, from 56 discharges per 10,000 women in 1980 to 19 per 10,000 in 1992. The discharge rate declined significantly for hospitalizations during which hysterectomy was not performed and remained relatively stable for hospitalizations with hysterectomy. Discharge rates decreased among all age and race groups and in all geographic regions. The percentages of discharges following hysterectomy steadily increased from 25% in 1980 to 72% in 1992. The average length of stay decreased significantly only for discharges for stays during which hysterectomy was performed, from 7.6 days in 1980 to 3.7 days in 1992. During the study period, abnormal uterine bleeding contributed to more than 5 million hospitalizations, 2 million hysterectomies, and 20 million hospital days. Our findings are consistent with a decreased likelihood of hospitalization for abnormal uterine bleeding if hysterectomy was not performed and shorter hospital stays for women undergoing hysterectomy for bleeding. These findings highlight the impact of abnormal uterine bleeding on the U.S. health care system.

Human papillomavirus-associated cervical cytologic abnormalities among women with or at risk of infection with human immunodeficiency virus.

OBJECTIVE: Correlates of abnormal human immunodeficiency virus cervical cytologic findings were examined among women infected with human immunodeficiency virus and uninfected women. STUDY DESIGN: We performed a cross-sectional analysis of baseline data on demographically similar women with infection or risk factors for it. RESULTS: Among 1050 women without hysterectomy, squamous intraepithelial lesions were more common among women infected with human immunodeficiency virus than among uninfected women (18.8% vs 5.3%; P <.001). In multivariate analysis the association of squamous intraepithelial lesions with human papillomavirus infection was strong; adjusted prevalence ratios were 27 for high-risk, 25 for intermediate-risk, and 10 for low-risk types (95% confidence intervals, 12-58, 12-54, and 4-25, respectively). Much lower adjusted prevalence ratios were seen for the only other factor significantly associated with squamous intraepithelial lesions, namely, infection with human immunodeficiency virus in conjunction with a reduced CD4(+) cell count. Adjusted prevalence ratios were 1.9 for CD4(+) cell counts <200 and 1.6 for CD4(+) cell counts between 200 and 500 (95% confidence intervals, 1.2-3.0 and 1.0-2.5, respectively). Adjusted attributable fractions calculated for this study population indicated that if both human immunodeficiency virus and human papillomavirus were removed, 47.6% of the observed lesions with atypical squamous cells of uncertain significance and 93.4% of the observed squamous intraepithelial lesions would be prevented. CONCLUSION: Squamous intraepithelial lesions are more common among human immunodeficiency virus-infected women and are associated most commonly with high- and intermediate-risk human papillomavirus types and secondarily with human immunodeficiency virus-associated immune compromise.

Hysterectomy surveillance--United States, 1980-1993.

PROBLEM/CONDITION: In the United States, approximately 600,000 hysterectomies are performed each year, and the procedure is the second most frequently performed major surgical procedure among reproductive-aged women. REPORTING PERIOD COVERED: 1980-1993. DESCRIPTION OF SYSTEM: This surveillance system uses data obtained from CDC's National Hospital Discharge Survey (NHDS) to describe the epidemiology of hysterectomy. The NHDS is an annual probability sample of discharges from non-Federal, short-stay hospitals in the United States. RESULTS: In the United States during 1980-1993, an estimated 8.6 million women aged > or =15 years had a hysterectomy. The overall rate of hysterectomy declined slightly from 1980 (7.1 hysterectomies per 1,000 women) to 1987 (6.6 per 1,000 women). The redesign of the NHDS in 1988 resulted in a decrease in estimated rates (i.e., the average annual rate for 1988-1993 was 5.5 per 1,000 women). Rates differed by age, with women aged 40-44 years most likely to have this procedure. Overall annual rates of hysterectomy did not differ significantly by race. The diagnosis most often associated with hysterectomy was uterine leiomyoma; during 1988-1993, this diagnosis accounted for 62% of hysterectomies among black women, 29% among white women, and 45% among women of other races. During 1988-1993, the percentage of hysterectomies performed by the vaginal route increased significantly; furthermore, an increasingly higher percentage of vaginal hysterectomies were accompanied by bilateral oophorectomy. From 1991 through 1993, laparoscopy was associated more frequently with vaginal hysterectomy than in previous years. INTERPRETATION: The rate of hysterectomy decreased slightly during the first half of the 14-year surveillance period, then leveled off during the second half. The increase in simultaneous coding of laparoscopy and vaginal hysterectomy on hospital discharge forms probably reflected the growing use of laparoscopically assisted vaginal hysterectomy. ACTIONS TAKEN: Continued surveillance for hysterectomy will enable changes in clinical practice (e.g., the use of LAVH) to be identified, and information derived from the surveillance system may assist in directing biomedical assessment priorities (e.g., to determine the reasons for race-specific differences in the prevalence of uterine leiomyoma).

Racial differences in the patterns of singleton preterm delivery in the 1988 National Maternal and Infant Health Survey.

OBJECTIVES: To determine if the association between race and preterm delivery would persist when preterm delivery was partitioned into two etiologic pathways. METHODS: We evaluated perinatal and obstetrical data from the 1988 National Maternal and Infant Health Survey and classified preterm delivery as spontaneous or medically indicated. Discrete proportional hazard models were fit to assess the risk of preterm delivery for Black women compared with White women adjusting for potential demographic and behavioral confounding variables. RESULTS: Preterm delivery occurred among 17.4% of Black births and 6.7% of White births with a Black versus White unadjusted hazard ratio (HR) of 2.8 (95% CI = 2.4-3.3). The adjusted HR for a medically indicated preterm delivery showed no racial difference in risk (HR = 1.0, 95% CI = 0.4-2.6). However, for spontaneous preterm delivery between 20 and 28 weeks gestation, the Black versus White adjusted hazard ratio (HR) was 4.9 (95% CI = 3.4-7.1). CONCLUSIONS: Although we found an increased unadjusted HR for preterm delivery among Black women compared with White women, the nearly fivefold increase in adjusted HR for the extremely preterm births and the absence of a difference for medically indicated preterm delivery was unexpected. Given the differences in the risks of preterm birth between Black and White women, we recommend to continue examining risk factors for preterm delivery after separating spontaneous from medically indicated preterm birth and subdividing preterm delivery by gestational age to shed light on the reasons for the racial disparity.

A multicenter study of bacterial vaginosis in women with or at risk for human immunodeficiency virus infection.

BACKGROUND: Bacterial vaginosis is a common gynecologic infection that has been associated with a variety of gynecologic and obstetric complications, including pelvic inflammatory disease, postabortal infection and premature delivery. Recent studies suggest that bacterial vaginosis may increase a woman's risk for human immunodeficiency virus (HIV). We undertook this study to assess whether the prevalence and characteristics of bacterial vaginosis differed according to HIV status in high-risk US women. METHODS: Prevalence of bacterial vaginosis was assessed by Gram's stain and clinical criteria for 854 HIV-infected and 434 HIV-uninfected women enrolled in the HIV Epidemiology Research (HER) Study. Multiple logistic regression techniques were used to determine whether HIV infection independently predicted bacterial vaginosis. RESULTS: Almost half (46%) the women had bacterial vaginosis by Gram's stain. The prevalence of bacterial vaginosis was 47% in the HIV-positive women compared with 44% in the HIV-negative women; this difference was not statistically significant (p = 0.36). After adjustment for other covariates, HIV-positive women were more likely than HIV-negative women to have bacterial vaginosis (odds ratio (OR) 1.31; 95% confidence interval (CI) 1.01-1.70) by Gram's stain but not by clinical criteria (OR 1.16; CI 0.87-1.55). Among HIV-positive women, use of antiretroviral drugs was associated with a lower prevalence of bacterial vaginosis (adjusted OR 0.54; Cl 0.38-0.77). CONCLUSIONS: In this cross-sectional analysis of high-risk US women, HIV infection was positively correlated with bacterial vaginosis diagnosed by Gram's stain.