The effects of smoking on birthweight-for-gestational-age curves in teenage and adult primigravidae.

OBJECTIVE: To compare the effect of smoking on the birthweight-for-gestational-age curves of teenage and adult primigravidae. METHODS: A retrospective analysis of the perinatal database at the Liverpool Women's Hospital for the years 1997-1999 for teenage and adult primigravidae. RESULTS: Records on 1157 primigravidae were available. There were no significant differences between the mean birthweight (3220 g +/- 666 vs 3244 g +/- 680, P = 0.43) and the proportion with low birthweight (LBW) babies (8.9% vs 10.6%, P = 0.39) between teenage and adult primigravidae, respectively. The percentage of women who smoked increased from the middle class (Townsend score -6- - 3) to the working class group (Townsend score +4- + 12) for both teenagers (33.3-51.3%) and adults (6.9-29.6%). The mean birthweight of babies of smoking mothers was significantly lower than for non-smoking mothers (3112 g +/- 639 vs 3327 g +/- 663, P = 0.00002). The birthweight-for-gestational-age pattern was lower at all gestational ages for smoking mothers in both the teenage and adult groups. Risk of LBW was significantly increased in teenagers who smoked (10.8% vs 3.9%, P < 0.01), but not in adult smokers. CONCLUSION: Lower birthweights at all gestational ages were observed in babies of teenage and adult mothers who smoked.

Breast-feeding knowledge and attitudes of teenage mothers in Liverpool.

OBJECTIVES: To determine the knowledge and attitudes of teenage mothers towards breast-feeding. DESIGN: A questionnaire of teenage (< 20 years) and non-teenage (> or = 20 years) primigravidae attending the antenatal care services at the Liverpool Women's Hospital, during the period April-May 2000. RESULTS: Forty teenage primigravidae and 40 non-teenage primigravidae registered for the survey. Teenagers had poorer knowledge about breast-feeding than the non-teenagers, and fewer teenagers considered breast milk the best food for their baby. More teenagers than non-teenagers planned to bottle feed [23 (57.5%) vs. 9 (22.5%), P=0.002]. Only one teenager had knowledge about colostrum. Teenagers were more often single, had a lower level of education, higher unemployment, higher smoking frequency and less contact with a person who had previously breast-fed. CONCLUSION: Teenage primigravidae have poor knowledge regarding breast-feeding compared with non-teenage primigravidae. A greater proportion of teenagers opted not to breast-feed compared with non-teenagers. Health education classes stressing the importance of breast-feeding should be emphasized in antenatal teenage clinics. More research is needed to understand how to improve the knowledge and motivation of adolescent girls to breast feed.

Barriers and resistance to informatics in behavioral health.

The levels of resistance to a new informatics system can vary widely both between and among specific groups. The relevance to today's behavioral medicine area is obvious. The aim of effective change management techniques is not to eliminate all resistance. This is typically impossible when a group of any size is involved. The aims are (1) to keep initial general resistance at reasonable levels, (2) to pre-vent that initial resistance from growing to serious levels, and (3) to identify and deal with any pockets of serious resistance that do occur despite the previous efforts. His article outlines areas of resistance to behavioral informatics and offers suggestions for overcoming the resistance.

Characteristics of children hospitalized with severe dehydration and persistent diarrhoea in Bangladesh.

The study analyzed data from a systematic sample of children, aged less than five years, who presented with persistent diarrhoea (diarrhoea of more than 14 days duration). It aims to differentiate (a) non-severe persistent diarrhoea (with no or mild dehydration) and (b) severe persistent diarrhoea (with moderate or severe dehydration), and to identify individual characteristics associated with severe persistent diarrhoea. In total, 7,505 patients, who represented a 4% systematic sample of the patient population, were seen during January 1993-December 1995. Of them, 297 (4%) presented with persistent diarrhoea. The male:female ratio was 2:1. Eighty-three percent of them had mild or no dehydration, and 17% had moderate or severe dehydration. Severe malnutrition of the study patients defined as weight-for-age z-score < -3, weight-for-length z-score < -3 and length-for-age z-score < -3 were 33.9%, 9.7%, and 22.7% respectively. Only 3% had oedematous malnutrition, and 11% had xerophthalmia. Factors independently associated with severe persistent diarrhoea by logistic regression analyses were: number of watery stool > 10 times during the last 24 hours prior to admission (OR, 10.0; CI, 1.2-87, p = 0.03), lower respiratory tract infection (OR, 111; CI, 4.2-2955, p = 0.004), and lack of mothers' education (OR, 7.8; CI, 1.4-41.9, p = 0.016) after controlling for confounders. Awareness and health education of mothers or caregivers and better case management during acute diarrhoeal episode might prevent the development of severe persistent diarrhoea in young children. In addition, children with severe persistent diarrhoea might need special attention to have adequate rehydration and control of extraintestinal infections, including respiratory tract infection.

The National Outcomes Management Project: a benchmarking collaborative.

Traditional evaluation of health care quality usually involves the measurement of the structure, process, and outcome of care. Most quality improvement programs involve a cycle that includes a setting of goals, a measurement of either process or outcomes, and a real-time or retrospective feedback of the results of data measurement. Benchmarking, a well-known efficient business technology, can lead to practice innovations necessary to survive in an environment that has a need for decreasing cost and increasing quality. The purpose of this article is to present a novel use of benchmarking in managed ambulatory behavioral health care and its application in a model collaborative outcome management project at more than 16 sites and nine states in the United States.

Pharmacoeconomic evaluation of COPD.

STUDY OBJECTIVES: The clinical outcomes and health-care costs of a cohort of 413 patients with COPD are reported. DESIGN: This study was a retrospective pharmacoeconomic analysis. SETTING: University teaching hospital and affiliated clinics. PATIENTS: COPD patients with an FEV(1) < 65% of predicted and an FEV(1)/FVC ratio < 70% were eligible to be included in this analysis. INTERVENTIONS: Health-care resource utilization and costs were identified through chart review and were stratified according to the severity of COPD using the American Thoracic Society stages I, II, and III. The pharmacoeconomic analysis was a cost-of-illness evaluation that included the acquisition costs of initially prescribed pulmonary drugs, acquisition cost of pulmonary drugs added during the follow-up period, oxygen therapy, laboratory and diagnostic test costs, clinic visit costs, and emergency department and hospital costs. RESULTS: Total treatment cost was highly correlated with disease severity, with stage I COPD having the lowest cost ($1,681 per patient per year), stage III COPD having the highest cost ($10, 812 per patient per year), and stage II COPD having a cost intermediate to stage I and stage III ($5,037 per patient per year). With the exception of add-on drug acquisition cost, all cost variables were the highest in stage III COPD, the lowest in stage I COPD, and intermediate in stage II COPD. Hospitalization was the most important cost variable for all three stages of COPD severity. When stratified by both disease severity and initial bronchodilator drug selection, ipratropium alone in stage I COPD patients and the combination of ipratropium plus a ss-agonist (with or without steroid therapy) in stage II and stage III COPD patients had the lowest total costs. Reasons for the lower total cost of the ipratropium and ipratropium plus ss-agonist treatment groups included lower add-on drug costs, fewer diagnostic and laboratory tests, and a lower utilization rate for clinic visits, emergency department visits, and hospitalizations. CONCLUSIONS: Our study demonstrates a strong correlation between disease severity and total treatment cost in COPD. In addition, the type of bronchodilator therapy impacts total cost in COPD. In stage I COPD, ipratropium alone had the lowest total cost, while in stage II and stage III COPD, a combination of ipratropium plus a ss-agonist had the lowest total cost. These data support the concept that adherence to published treatment guidelines will result in lower health-care costs due to COPD.

Isolation of the opioid peptide Leu-Val-Val-hemorphin-7 from bronchoalveolar lavage fluid of a patient with non-small cell lung cancer.

The decapeptide Leu-Val-Val-Tyr-Pro-Trp-Thr-Gln-Arg-Phe was isolated in high yield (1.5 nmol/ml) from bronchoalveolar lavage (BAL) fluid from a patient with an adenocarcinoma of the lung. This peptide, termed LVV-hemorphin-7 represents residues 32-41 of the beta-chain of hemoglobin and has been shown to be an endogenous ligand for opioid receptors. The N-terminal flanking peptide of LVV-hemorphin-7 [residues (1-31) of hemoglobin beta-chain] was also isolated in high yield. Neither peptide was detected in BAL fluid from the tumor-free lung of the same patient or from patients with non-neoplastic inflammatory lung disease. LVV-hemorphin-7 was not identified in BAL fluid from seven additional patients with non-small cell lung cancer, indicating that the formation of the peptide is unlikely to be of any diagnostic significance. However, the ability of LVV-hemorphin-7 to inhibit angiotensin-converting enzyme suggests that its formation may be of pathophysiological significance in the regulation of tumor blood flow in certain patients.

Acute exacerbation of COPD: factors associated with poor treatment outcome.

OBJECTIVES: To determine the effect of age, severity of lung disease, severity and frequency of exacerbation, steroid use, choice of an antibiotic, and the presence of comorbidity on the outcome of treatment for an acute exacerbation of COPD. DESIGN: A retrospective chart analysis over 24 months. SETTING: A university Veterans Affairs medical center. PATIENTS: Outpatients with COPD who were treated with an antibiotic over a period of 24 months for an acute exacerbation of COPD. METHODS: Severity of an acute exacerbation of COPD was defined using the criteria of Anthonisen et al: increased dyspnea, increased sputum volume, and increased sputum purulence. Severity of lung disease was stratified based on FEV(1) percent predicted using American Thoracic Society guidelines (stage I, FEV(1) > or = 50%; stage II, FEV(1) 35 to 49%; stage III, FEV(1) < 35%). Treatment outcome was judged successful when the patient had no return visit in 4 weeks for a respiratory problem. Failure was defined as a return visit for persistent respiratory symptoms that required a change of an antibiotic in < 4 weeks. RESULTS: One-hundred seven patients with COPD (mean age +/- SD, 66.9 +/- 9.5 years) experienced 232 exacerbations over 24 months. First-line antibiotics (trimethoprim-sulfamethoxazole, ampicillin/amoxicillin, and erythromycin) were used to treat 78% of all exacerbations. Treatment failure was noted in 12.1% of first exacerbations and 14. 7% of all exacerbations, with more than half the failures requiring hospitalization. Host factors that were independently associated with treatment failure included the following: FEV(1) < 35% (46.4% vs 22.4%; p = 0.047), use of home oxygen (60.7% vs 15.6%; p < 0. 0001), frequency of exacerbation (3.8 +/- 2.0 vs 1.6 +/- 0.91; p < 0. 001), history of previous pneumonia (64.3% vs 35.1 p < 0.007), history of sinusitis (28.6% vs 8.8%; p < 0.009) and use of maintenance steroids (32.1% vs 15.2% p = 0.052). Using stepwise logistic regression analysis to identify the top independent variables, the use of home oxygen (p = 0.0002) and frequency of exacerbation (p < 0.0001) correctly classified failures in 83.3% of the patients. Surprisingly, age, the choice of an antibiotic, and the presence of any one or more comorbidity did not affect the treatment outcome. CONCLUSION: The results of our study suggest that patient host factors and not antibiotic choice may determine treatment outcome. Prospective studies in appropriately stratified patients are needed to validate these findings.

Psychiatric practice variations in the diagnosis and treatment of major depression.

OBJECTIVE: Practice variations in the diagnosis, treatment, and outcomes of patients with major depression were examined within six psychiatric practices participating in a national outcomes-management project. METHODS: Six of 20 psychiatric clinics met selection criteria for this study and provided a database of 5, 106 patients. Patients completed the BASIS-32, the Short-Form-36 Health Survey, and a Beginning Services Survey. Treatment information was also obtained directly from the clinician or through a medical record review. RESULTS: Although 73.1 to 77 percent of patients screened positive for a depressive disorder, only 18.5 to 36.8 percent were diagnosed with major depression (p<.001). Between 39 and 72 percent of patients received psychotropic medications, a significant difference across sites (p<.001). In addition, the number of psychotherapy sessions was significantly different across sites (p<.001). CONCLUSIONS: Patient care varies considerably across psychiatric practices, a finding that is particularly relevant for developers of performance indicators and risk-adjustment strategies for mental health.

Clinical and economic considerations in the treatment of acute exacerbations of chronic bronchitis.

Limited data exist to guide physicians in the cost-effective treatment of acute exacerbation of chronic bronchitis (AECB). Therefore, the main objective of this study was to determine the antimicrobial efficacy and related costs for patients with AECB. A retrospective review of 60 outpatient medical records with a diagnosis of chronic obstructive pulmonary disease (COPD) and chronic bronchitis episodes from a pulmonary clinic of a teaching institution was undertaken. The participating patients had a total of 224 episodes of AECB requiring antibiotic treatment. Before review, empirical antibiotic choices were divided into first-line (amoxycillin, co-trimoxazole, tetracyclines, erythromycin), second-line (cephradine, cefuroxime, cefaclor, cefprozil) and third-line (co-amoxiclav, azithromycin, ciprofloxacin) agents. Patients receiving first-line agents failed significantly more frequently than third-line agents (19% vs 7%, P < 0.05). Additionally, patients prescribed first-line agents were hospitalized significantly more often for AECB within 2 weeks of outpatient treatment as compared with patients prescribed third-line agents (18.0% vs 5.3% third-line agents; P < 0.02). Time between subsequent AECB episodes requiring treatment was significantly longer for patients receiving third-line agents compared with first-line and second-line agents (P < 0.005). Pharmacy costs were lowest with first-line agents (first-line US$10.30 +/- 8.76; second-line US$24.45 +/- 25.65; third-line US$45.40 +/- 11.11; P < 0.0001), but third-line agents showed a trend towards lower mean total costs of AECB treatment (first-line US$942 +/- 2173; second-line, US$563 +/- 2296; third-line, US$542 +/- 1946). The use of third-line antimicrobials, co-amoxiclav, ciprofloxacin or azithromycin, significantly reduced the failure rate and need for hospitalization, prolonged the time between AECB episodes, and showed a lower total cost for the management of AECB. Prospective studies are needed to confirm these findings.

Nutritional status and diarrhoeal pathogen in hospitalized children in Bangladesh.

We studied the relationship between nutritional status and infection due to specific enteropathogens in young children with diarrhoea. Overall, 26% of the children were severely underweight, 27% were severely wasted and 19% were severely stunted. Children with Shigellae and V. cholerae O1 were significantly more severely underweight, wasted and stunted than those with rotavirus diarrhoea (p < 0.0001). Our results indicate that an effective nutrition programme for young children might have greater impact on diarrhoeal illness caused by Shigella and V. cholerae than by rotavirus diarrhoea.

Likelihood of malignancy in a solitary pulmonary nodule: comparison of Bayesian analysis and results of FDG-PET scan.

OBJECTIVE: To compare the probability of cancer in a solitary pulmonary nodule using standard criteria with Bayesian analysis and result of 2-[F-18] fluoro-2-deoxy-D-glucose-positron emission tomographic (FDG-PET) scan. SETTING: A university hospital and a teaching Veteran Affairs Medical Center. METHODS: Retrospective analysis of 52 patients who had undergone both CT scan of the chest and a FDG-PET scan for evaluation of a solitary pulmonary nodule. FDG-PET scan was classified as abnormal or normal. Utilizing Bayesian analysis, the probability of cancer using "standard criteria" available in the literature, based on patient's age, history of previous malignancy, smoking history, size and edge of nodule, and presence or absence of calcification were calculated and compared to the probability of cancer based on an abnormal or normal FDG-PET scan. Histologic study of the nodules was the gold standard. RESULTS: The likelihood ratios for malignancy in a solitary pulmonary nodule with an abnormal FDG-PET scan was 7.11 (95% confidence interval [CI], 6.36 to 7.96), suggesting a high probability for malignancy, and 0.06 (95% CI, 0.05 to 0.07) when the PET scan was normal, suggesting a high probability for benign nodule. FDG-PET scan as a single test alone was more accurate than the standard criteria and standard criteria plus PET scan in correctly classifying nodules as malignant or benign. CONCLUSION: FDG-PET scan as a single test was a better predictor of malignancy in solitary pulmonary nodules than the standard criteria using Bayesian analysis. FDG-PET scan can be a useful adjunct test in the evaluation of solitary pulmonary nodules.

Laparoscopic hernia repair--what are the results?

The two widely practised laparoscopic groin hernia repairs are: a) trans-abdominal preperitoneal (TAPP) and b) trans-extraperitoneal preperitoneal (TEPP) approaches. Early results are encouraging with both the techniques being associated with low recurrence rates (0% to 2%) comparable to the best, reported for standard open repair (Shouldice and Lichtenstein's). Other complications are higher in the beginning following laparoscopic hernia repair compared to the conventional method. These complications are related to the learning curve and expected to come down significantly with increasing experience of surgeons. Laparoscopic repair of recurrent groin hernia appears to be considerably superior to the conventional technique. The recurrence rates following conventional repair of recurrent groin hernias are between 1.5% and 35% (Table I) compared to none for laparoscopic repair of recurrent inguinal hernias. The disadvantages of laparoscopic repair include greater technical difficulty, higher incidence of serious complications and increased cost. Sutured open repair is associated with high postoperative discomfort, greater difficulty of repairing recurrent hernia with higher societal cost (due to prolonged time-off from work for 12% to 57% of patients operated for various open technique-Table II). The techniques of laparoscopic hernia repairs are nearly standardised today. Laparoscopic surgeons have an obligation to offer the new alternative and to ensure that it is safely used. Laparoscopic repair is another technique used for the repair of inguinal hernias, which is going to stay as a safe and effective alternative to open repair as the learning curve is over. There is an urgent need to have well-designed prospective randomised trials in the near future.

A case of unilateral bronchiolitis obliterans organizing pneumonia (BOOP).

A patient with unilateral bronchiolitis obliterans organizing pneumonia (BOOP) is described in this report. The disease responded well to glucocorticoid therapy, as is characteristic. Although BOOP is being more frequently recognized as bilateral disease to the best of our knowledge, only three previous cases of unilateral disease have been recognized and reported.

Mediastinal lymph node staging of non-small-cell lung cancer: a prospective comparison of computed tomography and positron emission tomography.

We compared the abilities of positron emission tomography and computed tomography to detect N2 or N3 lymph node metastases (N2 or N3) in patients with lung cancer. Positron emission tomography detects increased rates of glucose uptake, characteristic of malignant cells. Patients with peripheral tumors smaller than 2 cm and a normal mediastinum were ineligible. All patients underwent computed tomography, positron emission tomography, and surgical staging. The American Thoracic Society lymph node map was used. Computed and positron emission tomographic scans were read by separate radiologists blinded to surgical staging results. Lymph nodes were "positive" by computed tomography if larger than 1.0 cm in short-axis diameter. Standardized uptake values were recorded from areas on positron emission tomography corresponding to those from which biopsy specimens were taken; if greater than 4.2, they were called "positive." Seventy-five lymph node stations (2.8 per patient) were analyzed in 27 patients. Computed tomography incorrectly staged the mediastinum as positive for metastases in three patients and as negative for metastases in three patients. Sensitivity and specificity of computed tomographic scans were 67% and 83%, respectively. Positron emission tomography correctly staged the mediastinum in all 27 patients. When analyzed by individual node station, there were four false positive and four false negative results by computed tomography (sensitivity = 60%, specificity = 93%, positive predictive value = 60%). Positron emission tomography mislabeled one node station as positive (100% sensitive, 98% specific, positive predictive value 91%). The differences were significant when the data were analyzed both for individual lymph node stations (p = 0.039) and for patients (p = 0.031) (McNemar test). Positron emission tomography and computed tomography are more accurate than computed tomography alone in detecting mediastinal lymph node metastases from non-small-cell lung cancer.