Association between exposure to household cigarette smoking behavior and cigarette smoking in Hispanic adults: Findings from the Hispanic Community Health Study/Study of Latinos.

BACKGROUND: Cigarette smoking behavior is highly determined by social influences during childhood and adolescence. This phenomenon has not been fully evaluated in the Hispanic/Latino population. PURPOSE: To examine the association between exposure to household cigarette smoking behavior (HCSB) and adult cigarette smoking among a diverse Hispanic/Latino population living in four US urban centers. The effect of acculturation on cigarette smoking was also evaluated. METHODS: Data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) (n=13,231, ages 18-74years, collected between March 2008 and June 2011) were analyzed using logistic regression. RESULTS: HCSB exposure was an independent risk factor for adult current cigarette smoking in Hispanic/Latinos (OR 1.7; 95% CI 1.4, 2.1) after controlling for relevant confounders including socio-demographic and cultural factors. Cubans and Puerto Ricans had the highest prevalence of HCSB exposure (59% and 47% respectively) and highest prevalence of current cigarette smoking (26% and 32%) compared with other Hispanic/Latino groups, (p<.01). CONCLUSIONS: Our data suggest that exposure to HCSB in Hispanics/Latinos living in the US is an independent predictor of adult cigarette smoking, and this association appears to be strongest in Cubans and Puerto Ricans.

Pregnancy discovery and acceptance among low-income primiparous women: a multicultural exploration.

OBJECTIVES: As part of a larger study exploring psychosocial factors that influence self-care and use of health care services during pregnancy, we investigated the process of pregnancy discovery and acceptance among a culturally diverse group of women who had given birth to their first child in the year preceding data collection. METHODS: Eighty-seven low-income women from four cultural groups (African American, Mexican, Puerto Rican, and white) participated in eight focus groups held in their communities. The focus groups were ethnically homogenous and stratified by early and late entry into prenatal care. A social influence model guided the development of focus group questions, and the study followed a participatory action research model, with community members involved in all phases of the research. RESULTS: Issues that emerged from the focus groups as possible influences on timing of pregnancy recognition include the role of pregnancy signs and symptoms and pregnancy risk perception in the discovery process, the role of social network members in labeling and affirming the pregnancy, concerns about disclosure, "planning" status of the pregnancy, and perceived availability of choices for resolving an unintended pregnancy. CONCLUSIONS: The pregnancy discovery process is complex, and when protracted, can potentially result in delayed initiation of both prenatal care and healthful pregnancy behaviors. Enhancing our understanding of pregnancy discovery and acceptance has clear implications for primary and secondary prevention. Future research is needed to further explain the trajectory of pregnancy discovery and acceptance and its influence on health behaviors and pregnancy outcome.

Models of critical care delivery: physician staffing in the ICU.

Although a consensus has emerged over the value of intensive care units (ICUs) in improving both the outcome and efficiency of critical care, the optimal staffing configuration of physicians who provide this care remains controversial. The value of open ICUs, where many clinicians can admit and care for patients, versus closed ICUs, where an on-site intensivist or housestaff team (or both) provides primary care of the critically ill patient is one aspect of this controversy. The roles of the intensivist, the ICU housestaff team, and the ICU director have also been debated. This article reviews the available literature on physician staffing in critical care units and its relationship to outcome and cost-effectiveness of care.

An ecological approach to physical activity in African American women.

Physical activity in women has assumed increasing significance as a policy issue as a result of the release of the 1996 Surgeon General's Report on Physical Activity and Health. This report revealed that women in the United States were less likely than men to adhere to the recommended guidelines for physical activity. African American women are less likely than white women to participate in leisure time physical activity across age, occupational, and income groups. The purpose of this study was to use the Ecological Model of Health Promotion to explore policy, environmental, and individual factors influencing physical activity of middle- to older-aged African American women in a mixed income community in a large midwestern city. Focus group discussions were held with 3 groups of women -- administrators/community leaders, exercisers, and nonexercisers. Thirty-three women between the ages of 40 and 78 participated in the study. The women identified 6 themes influencing physical activity: perceptions of physical activity and exercise; perceived barriers to exercise; perceived benefits of and motivators to exercise; past and present opportunities for exercise; factors that enhance the successful delivery of an exercise program; and coalition building to deliver an exercise program to women in the community. The results of this study reveal that to successfully increase physical activity in an ethnic urban community, researchers and other concerned individuals need to collaborate at multiple ecological levels, with an initial emphasis on establishing coalitions between institutions, community groups, policy makers, and individuals.

Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?

CONTEXT: Two important areas of medicine, care of the critically ill and management of pulmonary disease, are likely to be influenced by the aging of the US population. OBJECTIVE: To estimate current and future requirements for adult critical care and pulmonary medicine physicians in the United States. DESIGN, SETTING, AND PARTICIPANTS: Analysis of existing population, patient, and hospital data sets and prospective, nationally representative surveys of intensive care unit (ICU) directors (n = 393) and critical care specialists (intensivists) and pulmonary specialists (pulmonologists) (n = 421), conducted from 1996 to 1999. MAIN OUTCOME MEASURES: Influence of patient, physician, regional, hospital, and payer characteristics on current practice patterns; forecasted future supply of and demand for specialist care through 2030. Separate models for critical care and pulmonary disease. Base-case projections with sensitivity analyses to estimate the impact of future changes in training and retirement, disease prevalence and management, and health care reform initiatives. RESULTS: In 1997, intensivists provided care to 36.8% of all ICU patients. Care in the ICU was provided more commonly by intensivists in regions with high managed care penetration. The current ratio of supply to demand is forecast to remain in rough equilibrium until 2007. Subsequently, demand will grow rapidly while supply will remain near constant, yielding a shortfall of specialist hours equal to 22% of demand by 2020 and 35% by 2030, primarily because of the aging of the US population. Sensitivity analyses suggest that the spread of current health care reform initiatives will either have no effect or worsen this shortfall. A shortfall of pulmonologist time will also occur before 2007 and increase to 35% by 2020 and 46% by 2030. CONCLUSIONS: We forecast that the proportion of care provided by intensivists and pulmonologists in the United States will decrease below current standards in less than 10 years. While current health care reform initiatives and modification of existing practice patterns may temporarily forestall this problem, most anticipated effects are minor in comparison with the growing disease burden created by the aging US population. JAMA. 2000;284:2762-2770.

Unintended pregnancy and depressive symptoms among first-time mothers and fathers.

The consequences of unintended first pregnancy on the mental health of cohabitating couples (N = 124) were examined in the third trimester of pregnancy and at four months postpartum. Results indicated that the influence of unintended pregnancy on parental depressive symptoms is complex and via different mechanisms for men and women. Pregnancy viewed as unintended by males and intended by their partners appeared to pose the greatest risk for postpartum depressive symptoms, particularly in women.

Breakthrough pneumococcal bacteremia in patients being treated with azithromycin and clarithromycin.

Streptococcus pneumoniae strains have exhibited decreasing susceptibility to penicillins and macrolides during the past several years. We reviewed the medical charts of all patients with pneumococcal bacteremia who were admitted to a university hospital over a period of 1 year, to identify failures of outpatient therapy. Of 41 patients admitted with pneumococcal bacteremia, 4 had previously taken either azithromycin or clarithromycin for 3-5 days. All 4 had pneumococcal strains that exhibited low-level resistance to macrolide antibiotics. Among pneumococci, low-level resistance to macrolides can lead to clinical failure, and resistance to macrolides should be considered during the selection of empiric therapy for patients with presumed pneumococcal infections.

The first decade of the American Board of Internal Medicine certification in critical care medicine: an overview of examinees and certificate holders from 1987 through 1996.

OVERVIEW: This study reviews the first decade of critical care medicine (CCM) certification by the American Board of Internal Medicine (1987-1996). Included are the characteristics of examinee and certificate-holder groups; examination performances from different underlying disciplines of internal medicine, with or without formal CCM training; and the influence of background and a training program as correlates of examination performance. DATA SOURCES: The CCM certification examination has been offered biennially since November 1987. Performance data on the American Board of Internal Medicine examinations in internal medicine and its subspecialties and added qualifications were available for candidates taking the CCM examinations. For examinees with formal CCM training, residency program director ratings, and information regarding the program characteristics of size and percentage of United States and Canadian medical graduates were also available. STUDY SELECTION: All examinees who ever attempted certification were included in this study. The study cohort for each of the five examination administrations consists of all first-time takers. CONCLUSIONS: Cohort sizes have decreased since formal training became an admission requirement in 1993. Percentages of International Medical Graduates and women attempting and achieving certification have increased steadily. Examination performance was positively associated with formal training, internal medicine examination performance, recent medical training, and pulmonary disease certification. For those with formal training, performance was also positively associated with training program director ratings of overall clinical competence and completion of a training program with a higher proportion of United States and Canadian medical graduates.

The hospitalist: a new medical specialty?

Economic forces have stimulated a growing role for physician "hospitalists" in caring for patients hospitalized by other physicians, and the question of whether hospital care constitutes a new medical specialty has been raised. Three recently recognized specialties--emergency medicine, family practice, and critical care--originated from trends in medical practice. All three fulfill the major criteria for a medical specialty: scientific legitimacy, the development of new training pathways, and the existence of academic departments. The hospitalist movement is currently underdeveloped in each of these areas. By training, most hospitalists are internists who are well prepared to care for inpatients. Internal medicine must determine how this new movement fits into the traditional framework of general internal medicine and medical subspecialties. Until it does, the future of inpatient medicine as a recognized specialty will remain uncertain.

Triage and management of the pregnant hypertensive patient.

Hypertension during pregnancy is a leading cause of maternal and perinatal mortality and morbidity. Current thinking on the diagnosis and management of the hypertensive disorders of pregnancy is presented, along with triage and risk management issues.

Health care characteristics associated with women's satisfaction with prenatal care.

OBJECTIVES: The objective of this study was to explore the relation between prenatal care characteristics and satisfaction among Medicaid recipients. METHODS: African-American (n = 75) and Mexican-American (n = 26) nonadolescent primiparous pregnant women who had at least three prenatal care visits participated in a 25-minute telephone survey that asked them about satisfaction with prenatal care (art of care, technical quality, physical environment, access, availability and efficacy); prenatal care characteristics (practitioner attributes, service availability, and features of the delivery of care); and, personal characteristics (sociodemographics, health status and behaviors, and pregnancy-related variables). Univariate and multivariable analyses were conducted to explore the relations between personal characteristics and satisfaction and between care characteristics and satisfaction. RESULTS: For the overall sample, the following prenatal care characteristics were associated with increased satisfaction: having procedures explained by the provider, short waiting times at the prenatal care site, the availability of ancillary services, and reporting that the prenatal care practitioner was male. When examining the data by ethnicity, whether the provider explained procedures was the most important determinant of satisfaction for both African-American and Mexican-American women. CONCLUSIONS: Knowledge of the care characteristics that impact low-income pregnant women's satisfaction can be utilized to alter service delivery to increase use of prenatal care and ultimately to improve perinatal outcomes.

Core competency-based education, certification, and practice: the nurse-midwifery model.

It has been more than 70 years since the first nurse-midwives came to practice in the United States, and over 20 years since the American College of Nurse-Midwives (ACNM) established nationally recognized standards and core competencies for nurse-midwifery education, certification, and practice. Certified nurse-midwives are licensed in all 50 states and in the District of Columbia (DC) and have prescribing privileges in 45 states plus DC. More recent standard-setting activities include the establishment of a national mechanism for continuing competency assessment; adoption of the bachelor's degree as the minimum academic requirement for certification; development of national standards for education and certification of direct entry midwives; and placement of an 8-year time limit on certificates.

Postpartum depressive symptomatology in new mothers and fathers: parenting, work, and support.

Control and social gratification at work and in other social roles have been shown to be predictive of depression in general adult populations, yet the potential importance of these factors in the postpartum period has not been explored. This study examines the influence of self-reported social gratification, support, and control at work and in the parenting role on depressive symptomatology for both men and women in the postpartum period. A model including perceptions of control, social gratification, and support in these two life domains is tested at 6 months postpartum in a sample of 108 first-time parents. When this model is compared to a parallel model using information obtained 6 months before the birth, strong support for the increased significance of these variables in the postpartum period is found. The need to include work and role-related variables in a comprehensive stress-diathesis model of postpartum depression for both men and women is discussed.

Prospective recruitment of women receiving prenatal care from diverse provider arrangements: a potential strategy.

OBJECTIVES: This study describes the use of a Medicaid managed care list to prospectively recruit into a research project pregnant women receiving care from a variety of providers. METHOD: A list of women enrolled in Medicaid managed care was used to recruit pregnant African-American and Latina women into a study of prenatal care satisfaction. Due to privacy concerns, the researchers were not able to directly access names from the list. Instead, a managed care contract agency sent recruitment letters to 1009 pregnant African-American and Latina Medicaid recipients. Response rates by ethnicity and several other key variables are calculated. The biases associated with this method of recruiting pregnant women from a variety of providers are discussed. RESULTS: Thirty-five percent of the women contacted returned consent forms and agreed to have researchers approach them; the response rate for African-American women was 43% and for Latinas was 29% (p < 0.0001). Respondents were younger and later in their pregnancies than nonrespondents, but did not differ from them by zip code of residence. The women recruited into the study obtained prenatal care from a diverse group of providers. CONCLUSIONS: While the use of a prospectively generated list of pregnant Medicaid recipients to recruit low-income pregnant women into a research study may be associated with some selection bias, the potential cost savings, decreased effort, and diminished recall bias may make their use a feasible sampling alternative, particularly when the researcher desires to recruit women seeking care from a variety of provider arrangements.

Pulmonary embolism and mortality in patients with COPD.

BACKGROUND: Previous studies suggest that most patients with pulmonary embolism die of their underlying diseases and pulmonary embolism is itself responsible for a minority of deaths. It has not been determined whether pulmonary embolism is associated with increased mortality among patients with different specific diseases. METHODS: We assessed the mortality in 1,487 patients who had lung scans to pursue the diagnosis of pulmonary embolism. An outcome classification committee prospectively reviewed deaths occurring up to 1 year after each patient's entry into the study. RESULTS: Ninety-five (23.8%) patients with pulmonary embolism and 189 (18.9%) without pulmonary embolism died within 1 year of study entry (estimated relative risk, 1.34; 95% confidence interval, 1.01 to 1.79). Mortality according to pulmonary embolism status was different among patients with COPD from mortality among patients who did not have COPD (interaction p = 0.03). Of 45 patients with COPD and pulmonary embolism, 24 (53.3%; 95% confidence interval, 38.8 to 67.9%) died within 1 year. After adjustment for patient characteristics, the estimated risk of dying within 1 year was 1.94 times (95% confidence interval, 1.17 to 3.24) for patients with COPD and pulmonary embolism compared with those without pulmonary embolism, and 1.14 (95% confidence interval, 0.85 to 1.54) for patients without COPD (interaction p = 0.08). CONCLUSIONS: Patients with COPD and pulmonary embolism have an increased 1-year mortality. Further study is needed to clarify the reason(s) for the increase in mortality.

Women's satisfaction with prenatal care settings: a focus group study.

BACKGROUND: Patient satisfaction is considered, together with health status, to be an outcome of the delivery of health care services as well as a measure of its quality. A focus group study of 50 low-income Mexican-American Puerto Rican, African-American, and white women in Chicago, Illinois, explored the characteristics of prenatal care that affect women's satisfaction. METHODS: Transcripts from the focus groups were analyzed using researcher-derived coding categories to develop broad themes. RESULTS: Despite their diverse ethnic backgrounds, participants revealed few differences with respect to what they value in prenatal care. Aspects of care that appeared to affect women's satisfaction included the "art of care, " the technical competence of the practitioner, continuity of caregiver, and the atmosphere and physical environment of the care setting. The one characteristic that did not appear to affect satisfaction was the caregiver's ethnicity. CONCLUSION: Knowledge of how the characteristics of prenatal care affect women's satisfaction can help increase use of care and ultimately improve perinatal outcomes.