Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois.

OBJECTIVE: The national Neonatal Resuscitation Program (NRP), started in 1987, provided training to hospital delivery room personnel to standardize knowledge and skills to reduce neonatal morbidity and mortality and increase successful resuscitation during the first few critical minutes after birth. The Apgar score continues to be used as the best established index of immediate postnatal health. The purpose of this study was to evaluate the impact of the NRP instruction in Illinois hospitals by examining Apgar scores among high-risk infants who are likely to benefit from the NRP. METHODS: A retrospective 3-time period cohort design was used (before the introduction of the NRP, 1985-1988; transition when NRP training occurred, 1989-1990; and after NRP training was completed at least once for some delivery room personnel in each Illinois hospital, 1991-1995). Illinois computerized birth certificate files on a selected group of 636 429 high-risk neonates provided information on Apgar scores and maternal characteristics. The American Academy of Pediatrics provided instructor lists to determine when NRP training started and when it was fully implemented in Illinois. Illinois Department of Public Health provided data to categorize hospitals into levels based on type and intensity of neonatal services (Level I, II, II+, III). High-risk neonates were defined as meeting 1 of the following criteria: maternal age <20 years old or >35 years old, birth weight <2500 g or >4000 g, presence of a maternal medical risk factor, and no prenatal care or prenatal care started after the first trimester. Several exclusion criteria were applied including the following: birth records with missing data, multiple birth or congenital anomaly, and hospital information that indicate no birth deliveries in 1 of the 11 study years or delivery outside of a hospital. One-minute and 5-minute Apgar scores were divided into categories for analysis (0-3, 4-6, 7-10). No change or a decrease in a low (0-6) 1-minute Apgar when compared with the 5-minute Apgar was a primary measure to evaluate effect of NRP resuscitation. Variables examined included the following: race/ethnicity, maternal age, level of education, presence of maternal medical risk factor, trimester started prenatal care, complications of labor and delivery, and a low birth weight. Analysis consisted of chi(2) tests, relative risk calculations, and logistic regression to reveal independent associations with no change in low 1-minute Apgar score or continued low (0-6) 5-minute Apgar. RESULTS: A total of 636 429 high-risk birth records was selected for detailed analyses out of 2 077 533 births in Illinois between 1985 and 1995 for 193 hospitals. The number of active NRP instructors in Illinois changed dramatically during the study period; for example, 1 to 6 between 1987 and 1988 to 1096 to 1242 between 1991 and 1995. The percentage of neonates reported to have low (<7) 1-minute Apgar score decreased in 1991 to 1995 overall and for each of 4 hospital levels. Overall and by hospital level, there was a statistically significant lower proportion of high-risk newborns who showed a decrease or no change in their 5-minute Apgar scores after the NRP instruction. After adjusting for several maternal characteristics, logistic regression analysis revealed that high-risk newborns with a low 1-minute Apgar were more likely to increase their 5-minute Apgar after the NRP instruction in 1991 to 1995. Additional analyses indicated that very low birth weight and low birth weight newborns benefited the most from NRP instruction. CONCLUSION: Although previous research has shown that the NRP instruction improves knowledge and skill among health care personnel in the delivery room, both short-term and long-term, there has been little evidence to demonstrate NRP impact on infant morbidity. Several strategies were used in this study to control for bias and to adjust for secular trends in decreased infant morbidity during the study period. This study demonstrated sufficient support for the hypothesis that a significant improvement occurred among neonates in their Apgar score after the NRP instruction in Illinois. Empirical support is provided for the clinical effectiveness of NRP instruction.

Epidemiologic paradox in multiple births among Asians in Illinois. Correlation between risk factors and outcomes.

OBJECTIVE: To determine if the plural birth rate, maternal risk factors and neonatal outcomes among Asian American populations residing in Illinois are homogeneous or heterogeneous with regard to maternal risk factors and neonatal outcomes and to attempt to establish correlations between maternal risk factors and neonatal outcomes. STUDY DESIGN: A total of 1,145,962 computerized birth certificate files were analyzed for 11 Asian subgroups giving birth in Illinois in the years 1989-1994. RESULTS: The multiple birth rates varied between 6 per 1,000 (Vietnamese) to 15 per 1,000 (Cambodian) (heterogeneity among all groups, P < .005). The percent of neonates born at gestational ages 22-33 weeks varied between 0 (Cambodian) to 28 (Thai). Japanese women showed the highest rate of neonates with birth weight less than 2,500 g after adjustment for race: 15.38 per 1,000. Women from Cambodia and Laos had the highest sum of maternal risk factors; those from the Philippines and Thailand had the least. The lowest collective adverse neonatal outcomes were in infants born to women from Cambodia and Laos. CONCLUSION: The 11 subgroups of Asians living in Illinois demonstrate heterogeneity with respect to multiple birth rate, selected maternal risk factors and adverse neonatal outcomes. After considering all maternal risk factors and neonatal outcomes, the two groups (Cambodians and Laotians) with the poorest maternal risk factors had the lowest rate of poor neonatal outcomes. This is the first time that this epidemiologic paradox has been observed in twins of Asian ancestry.

Maternal and paternal risk factors and adverse neonatal outcomes among Hispanic subgroups in Illinois (1989 through 1993).

OBJECTIVES: The study purposes were to examine maternal and paternal high-risk factors and note associated differences in birth outcomes among Hispanic subgroups compared with white and black populations in Illinois. STUDY DESIGN: Computerized birth certificate data of 131,768 Hispanic singleton neonates (14.1% of all Illinois births from 1989 through 1993) were compared among five Hispanic subgroups. Matched infant birth-death computerized files were obtained for neonatal and postneonatal mortality (1989 through 1992 birth cohorts) and separate fetal mortality tables were also examined. RESULTS: Whereas Puerto Rican mothers had higher prevalence rates for various maternal risk factors and higher infant morbidity rates among the five Hispanic groups, infants of Cuban mothers had significantly higher fetal and infant mortality rates. CONCLUSIONS: Our study identified substantial differences during the prenatal period and in birth outcomes among the five Hispanic subgroups. Those differences may help us develop innovative targeted interventions.

Multiple births among adolescent women in Illinois.

OBJECTIVE: To examine the occurrence of multiple births among adolescents using birth as the unit of analysis and to examine the association between maternal race/ethnicity and parity and the occurrence of multiple births among women less than 20 years of age. STUDY DESIGN: Computerized birth certificate files without personal identifiers were obtained from the Illinois Department of Public Health totaling 1,103,333 live births from 1989 to 1994. RESULTS: A total of 13.3% of births during this time were to mothers less than 20 years of age. The overall maternal multiple birth rate was 8.2/1,000 births. There were statistically significant differences in the numbers of pregnancies resulting in live, multiple births among black, Hispanic and white teenage mothers. There was a linear increase in maternal multiple birth rates among black (P < .0001) and Hispanic (P < .001) teenage mothers by parity as well as a linear increase among black (P < .0001), Hispanic (P < .0236) and white (P < .049) populations by age of the mother. The age- and parity-specific maternal multiple birth rate ranged from 4.4 per 1,000 pregnancies for Hispanic teenage mothers less than 18 years of age to 11.9 per 1,000 pregnancies for black teenage mothers 19 years of age. At 0 and 1 parity, black women less than 20 years of age were at the highest risk for multiple births as compared to Hispanic and white mothers. CONCLUSION: This is the first study showing ethnic and racial differences in the rates of multiple births among teenage mothers. As in older women, increased age and a higher parity were associated with a higher probability of multiple birth among adolescents.

PIP: Selected demographic characteristics associated with multiple births among female adolescents were investigated through a review of computerized birth certificate files (n = 1,103,333) obtained from the Illinois (US) Department of Public Health for 1989-94. 13.3% of these births were to women under 20 years of age. The overall multiple birth rate was 8.2/1000 births. Among women who had a multiple birth, approximately 1/6 of Black mothers, 1/11 of Hispanic mothers, and 1/25 of White mothers were teenagers. Noted was a linear increase in multiple birth rates among Black (p 0.0001) and Hispanic (p 0.001) teenage mothers by parity as well as a linear increase by maternal age among Black (p 0.0001), Hispanic (p 0.0236), and White (p 0.049) mothers. The age- and parity-specific multiple birth rate ranged from 4.4/1000 pregnancies for Hispanic women under 18 years of age to 11.9/1000 pregnancies among Black women 19 years old. At parities 0 and 1, Black women under 20 years of age were at greatest risk of multiple births. These findings indicate that the etiologic factors influencing the occurrence of multiple births may differ among teenagers compared to their older counterparts and in teenagers of different racial or ethnic backgrounds.

Declining cholesterol and mortality in a sample of older nursing home residents.

OBJECTIVE: To examine the association between declining serum cholesterol and mortality in a sample of older nursing home residents. DESIGN: A retrospective cohort study. SETTING: A 203-bed nursing home. PARTICIPANTS: Persons aged 65 and older, resident in the nursing home on January 1, 1988, or admitted through December 31, 1989, were eligible (n = 185) for the study. Follow-up for mortality was conducted until June 30, 1991. Fifty-five survivors with two or more cholesterol levels recorded before January 1, 1990, and the 76 decedents with two or more recorded cholesterol levels constituted the analytic sample (71% of eligible subjects). OUTCOME MEASURE: Mortality of the nursing home residents. RESULTS: Cholesterol declined 31.1 mg/dL/yr (95% confidence interval [CI], 19.7 to 42.6) among decedents, versus 4.2 mg/dL/yr (95% CI, -4.9 to 13.2) among survivors. The association between cholesterol decline (absolute or relative rates) and mortality was examined using logistic regression controlling for age, sex, and tube feeding. Compared with a referrent group with no change or increase, declining cholesterol greater than 45 mg/dL/yr was accompanied by an adjusted relative odds for death of 6.2 (95% CI, 2.1 to 18.4); declining cholesterol greater than 20% per year was accompanied by an adjusted relative odds for death of 7.3 (95% CI; 2.4 to 22.2). Extreme declines greater than 20% per year occurred in 47% of decedents but in only 15% of survivors. CONCLUSION: Precipitously declining cholesterol appeared to be a marker for mortality in the sample and may help explain the low cholesterol-mortality association in older nursing home residents.

Self-reported health and survival in the Longitudinal Study of Aging, 1984-1986.

Changing and often declining health among elderly individuals makes interpreting the long-standing association between self-reported health (SRH) and mortality potentially problematic. This analysis of the Longitudinal Study of Aging from 1984 through 1986 explores changes over time in the association between a single self-report of health and survival among 4380 noninstitutionalized individuals aged 70 and older. Health was reported as excellent or very good (excellent/very good), good, fair or poor. The association between SRH and survival was modeled controlling for age, race, education, marital status, body mass index, difficulty performing activities of daily living, social contacts, self-reported stroke, heart disease, cancer, diabetes and recent hospitalization. Among women, SRH and survival were associated in a nonproportional model, with relative hazard declining over time. Women with poor vs excellent/very good SRH had adjusted relative hazards at 5, 14, 23 and 32 months of 3.8 [95% confidence interval (CI) 2.0-7.1], 2.7 (95% CI: 1.8-4.1), 2.0 (95% CI: 1.3-3.0), and 1.4 (95% CI: 0.7-2.7). The declining relative hazard was due to an increasing mortality rate over time among women initially reporting excellent/very good health. SRH was associated with survival among men in a proportional model (constant relative hazard over time). Men with poor vs excellent/very good SRH had an adjusted relative hazard of 1.7 (95% CI: 1.1-2.6) over the entire follow-up. The relative hazard of lesser magnitude among men reflects the weaker SRH-survival association, possibly too weak for any interaction with time to be detected. The constant relative hazard is also consistent with a rapid decline in health before death among men. The diminishing SRH-survival association among women is consistent with their longer period of declining health before death.

Admission hyponatremia in the elderly: factors influencing prognosis.

The authors studied the occurrence of admission hyponatremia and its association with selected patient and hospitalization characteristics and in-hospital mortality in a geriatric patient cohort (n = 4,123). Prevalence of admission hyponatremia was 3.5% and higher among women (4.6% vs 2.6%). In-hospital mortality was 16% for patients with admission hyponatremia versus 8.0% for patients without admission, hyponatremia. Adjusting for patient and hospitalization characteristics with a logistic regression analysis, admission hyponatremia was a significant independent predictor of mortality (RR = 1.95). Admission hyponatremia is associated with poor prognosis in the elderly hospitalized population.

Analgesic use in home hospice cancer patients.

BACKGROUND: Pain control in hospice patients in the home may be compromised by concerns about overuse of analgesics, particularly narcotics. METHODS: A retrospective chart audit of analgesic type and amount was performed on the medical records of 100 cancer patients receiving hospice care in the home. Different types and amounts of analgesics were converted to a common standard, an oral morphine equivalent (OME) relative to 1 mg of oral morphine sulfate. Descriptive statistics were used to characterize patient analgesic use during the entire course of hospice care and the last 5 days of life. Associations between analgesic use and select patient characteristics (age, sex, cancer site, metastases, and pain intensity at admission) were explored. RESULTS: Ninety-one percent of the sample had used analgesics at some time during hospice care. The proportion of patients using analgesics increased as death approached. The mean and median daily analgesic use over the entire period were 114 and 82 OMEs and during the last 5 days 140 and 84 OMEs, respectively. The range of mean daily analgesic use was between 10 and 735 OMEs. CONCLUSIONS: Individual variability in analgesic use was demonstrated. Not all patients required analgesics, and among those who did there was remarkable variation in the amount used. Large and even enormous doses of analgesics may sometimes be required to control cancer pain.

Malignant mesothelioma with occupational and environmental asbestos exposure in an Illinois community hospital.

Clinical, radiologic, pathologic, and epidemiologic data on 32 patients with diffuse malignant mesothelioma (DMM) diagnosed between 1968 and 1984 at a 427-bed community hospital in Berwyn, Ill, were reviewed. Independent pathologists' review of light microscopy, supported by electron microscopy, immunoperoxidase staining, or autopsy, confirmed 29 pleural and three peritoneal DMMs. Clinical and radiologic characteristics were similar to those in published case series. Median age at diagnosis was 67 years, and median survival after diagnosis, seven months. Fourteen patients were women. Exposure histories were obtained through 22 interviews supplemented by hospital charts and death certificates. Thirty patients (94%) had a history of asbestos exposure through work (15 [47%]) and/or residence near an asbestos facility (27 [84%]). Medical records and death certificates underreported asbestos exposure and DMM.

Screening for alcoholism in a community hospital.

A study was conducted in a community hospital to assess the prevalence of alcoholism, to identify physician referral patterns after being notified that their patients received positive scores on an alcoholism-screening questionnaire, and to address the validity of the administered patient-screening questionnaire. Of 396 patients who completed the questionnaire, 14 percent (56) had positive scores of the Michigan Alcoholism Screening Test (MAST). Men were more likely than women to have scores indicative or suggestive of alcoholism. The hospital services with the highest percentage of patients with MAST positive scores were orthopedics, 18 percent; surgery, 19 percent; and medicine, 14 percent. Nineteen percent of those who drank alcohol had positive MAST scores. Requests for alcoholism consultation were made for only 2 of the 56 patients. A chart audit revealed that the diagnosis of alcoholism was recorded in 5 of the 56 MAST-positive patients' charts. Results are compared with other similar studies.