Sleeping position: change in practice, advice, and opinion in the newborn nursery.

OBJECTIVE: Sudden infant death syndrome (SIDS) is a major cause of infant mortality and is associated with the prone sleeping position. The goal of this study was to determine changes in newborn nursery policies and practices regarding infant sleeping position between 1992 and 1999. STUDY DESIGN: The researchers conducted telephone interviews with the head nurses in all of the newborn nurseries in Missouri. POPULATION: In 1992 there were 79 hospitals in Missouri with newborn nurseries; in 1999 that number had decreased to 75. OUTCOMES MEASURED: During the interviews, the researchers solicited nursery infant sleep position policy and practice, head nurses' opinions about the supine sleep recommendation, and nurses' advice to parents regarding sleep position. RESULTS: In 1992, 32% of the nurseries used the prone position for sleep, and 58% of the head nurses interviewed disagreed with the recommendations of the American Academy of Pediatrics (AAP). By 1999, all newborn nurseries in Missouri placed infants on their backs or sides for sleep. The rate of disagreement with the AAP recommendation had decreased, with 25% of respondents indicating that they disagreed. CONCLUSIONS: From 1992 to 1999 nurseries in Missouri have changed from predominantly using prone and lateral positioning to lateral and supine positioning for newborns. Some nurses continue to voice concern about placing infants on their backs and expressed a willingness to place babies prone. Since there is agreement between nurses' usual infant positioning and the advice given to parents, and because both are important influences on infant positioning by parents, future campaigns to decrease SIDS should emphasize correcting nurses' positioning behavior and advising parents to increase infant supine positioning.

Using geographic information systems to understand health care access.

BACKGROUND: Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts. OBJECTIVE: To combine the patient data of a community health center (CHC) with health care survey data to display the CHC service area, the community's health care access needs, and relationships among access, poverty, and political boundaries. DESIGN: Georeferencing, analyzing, and mapping information from 2 databases. SETTING: Boone County, Missouri. PARTICIPANTS: Community health center patients and survey respondents. MAIN OUTCOME MEASURES: Maps that define the CHC service area and patient demographics and show poor health care access in relation to the CHC service area, CHC utilization in relation to poverty, and rates of health care access by geopolitical region. RESULTS: The CHC serves a distinctly different area than originally targeted. Subpopulations with unmet health care access needs and poverty were identified by census tract. These underserved populations fell within geopolitical boundaries that were easily linked to their elected officials. CONCLUSIONS: Geographic information systems are powerful tools for combining disparate data in a visual format to illustrate complex relationships that affect health care access. These systems can help evaluate interventions, inform health services research, and guide health care policy. Arch Fam Med. 2000;9:971-978

Development of a surveillance program for occupational pesticide poisoning: lessons learned and future directions.

The authors describe the growth from 1987 through 1996 of the Occupational Pesticide Poisoning Surveillance Program at the Texas Department of Health. The program was initially based on a Sentinel Event Notification System for Occupational Risks (SENSOR) model, using sentinel providers to report cases, supplementing the passive reporting by physicians that was required by law. The model was evaluated after five years, and significant changes were implemented to improve case ascertainment. Current active surveillance methods emphasize collaboration with a number of agencies and organizations for identification of cases and follow-up. The number of confirmed occupational cases increased from 9 workers in 1987 to 99 workers in 1996. The evolution from a passive system to an active surveillance program expanded the number of reported cases and strengthened inter-agency collaborations.

Adolescent occupational injuries: Texas, 1990-1996.

BACKGROUND: A comprehensive surveillance system for occupational injuries to adolescents does not exist in Texas, as in most states. Therefore, the magnitude, severity, nature, and source of injuries to working adolescents have not been well described in Texas. METHODS: The investigators used three data sources to investigate work-related injuries and deaths in Texas: (1) Texas Workers' Compensation Commission (TWCC) claims data from 1991 through April 1996; (2) 1993 TWCC/Bureau of Labor Statistics (BLS) Annual Survey of Occupational Injuries and Illnesses; and (3) work-related fatalities identified from Texas death certificates from 1990-1995. RESULTS: There were 9,027 injuries reported to the TWCC for adolescents 14-17 years of age during slightly more than 5 years. Injuries for which indemnity payments were made (more than 7 days out of work) occurred among 21.7% of the adolescents. Based on BLS data in 1993, of 992 non-fatal injuries involving days away from work, 35% were caused by contact with objects, 27% by bodily reaction, and 24% by falls. Two-thirds of these injuries occurred while working in eating and drinking places and grocery stores. Three-quarters of the 30 deaths from 1990-1995 were accounted for equally by motor vehicle and homicide. CONCLUSIONS: In conclusion, a substantial number of adolescents are injured or killed in the workplace each year in Texas. Although improved population-based surveillance is needed, sufficient knowledge exists to begin prevention efforts now.

Spatial distribution of the intensity noise of a vertical-cavity surface-emitting semiconductor laser.

We studied anticorrelated quantum fluctuations between the TEM(00) and the TEM(01) transverse modes of a vertical-cavity surface-emitting semiconductor laser by measuring the transverse spatial distribution of the laser beam intensity noise. Our experimental results are found to be in good agreement with the predictions of a phenomenological model that accounts for quantum correlations between transverse modes in a light beam.

Surveillance for silicosis, 1993--Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin.

PROBLEM/CONDITION: Silicosis is an occupational respiratory disease caused by the inhalation of respirable dust containing crystalline silica. Public health surveillance programs to identify workers at risk for silicosis and target workplace-specific and other prevention efforts are currently being field-tested in seven U.S. states. REPORTING PERIOD COVERED: Confirmed cases ascertained by state health departments during the period January 1, 1993, through December 31, 1993; the cases and associated workplaces were followed through December 1994. DESCRIPTION OF SYSTEMS: As part of the Sentinel Event Notification System for Occupational Risks (SENSOR) program initiated by CDC's National Institute for Occupational Safety and Health (NIOSH), development of state-based surveillance and intervention programs for silicosis was initiated in 1987 in Michigan, New Jersey, Ohio, and Wisconsin and in 1992 in Illinois, North Carolina, and Texas. RESULTS: From January 1, 1993, through December 2, 1994, the SENSOR silicosis programs in Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin confirmed 256 cases of silicosis that were initially ascertained in 1993. Overall, 185 (72%) were initially identified through review of hospital discharge data or through hospital reports of silicosis diagnoses; 188 (73%) were associated with silica exposure in manufacturing industries (e.g., foundries; stone, clay, glass, and concrete manufacturers; and industrial and commercial machinery manufacture). Overall, 42 (16%) cases were associated with silica exposure from sandblasting operations. Among the 193 confirmed cases for which information was available about duration of employment in jobs with potential exposure to silica, 37 (19%) were employed < or = 10 years in such jobs and 156 (81%) were employed > or = 11 years. A total of 192 primary workplaces associated with potentially hazardous silica exposures were identified for the 256 confirmed silicosis cases. Of these, nine (5%) workplaces were inspected by state health department (SHD) industrial hygienists, 19 (10%) were referred to the Occupational Safety and Health Administration (OSHA) for follow-up, and seven (4%) were routinely monitored by the Mine Safety and Health Administration. Of the 157 (82%) remaining workplaces, follow-up activities determined that 82 were no longer in operation, eight were no longer using silica, 18 were assigned a lower priority for follow-up, six were associated with building trades and could not be inspected because of the transient nature of work in the construction industry, and 43 workplaces were not inspected for other reasons. Fourteen (7%) of the 192 workplaces were inspected. At 10 of the 14 workplaces, airborne levels of crystalline silica were measured; in nine, silica levels exceeded the NIOSH-recommended exposure level of 0.05 mg/m, and in six, airborne silica levels also exceeded federal permissible exposure limits. ACTIONS TAKEN: Employee-specific and other preventive interventions have been initiated in response to reported cases. In addition, special silicosis prevention projects have been initiated in Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin. To facilitate the implementation of silicosis surveillance by other states, efforts are ongoing to identify and standardize core data needed by surveillance programs to describe cases and the workplaces where exposure occurred. These core variables will be incorporated into a user-friendly software system that states can use for data collection and reporting.

"They don't come in!" Stories told, lessons taught about poor families in therapy.

Although it is widely accepted that socioeconomic status effects mental health, poverty and class remain neglected areas in formal clinical training. Filling these gaps are certain narratives, stories told about poor people, that question their responsibility, cognitive competence, and moral sensitivity. Integrating community experience and relevant research findings into clinical training is proposed as an antidote to such stories and a means of realigning clinical priorities and improving services offered to poor clients.

Paternal occupation and risk of birth defects in offspring.

Several epidemiologic studies indicate that some paternal occupations are associated with an increased risk of birth defects in offspring. We evaluated this relation using data from a population-based case-control study. Cases are infants with a major birth defect registered with the Metropolitan Atlanta Congenital Defects Program between 1968 and 1980. We selected controls from livebirths in the Atlanta area using frequency matching for race, year, and hospital of birth. Case and control parents were interviewed to solicit information on several factors, including occupation. We classified paternal occupation according to the job held during the time from 6 months before until 1 month after the estimated date of conception. We compared fathers in one occupational category with fathers in all other categories combined. We identified a number of associations including: firemen with cleft lip [odds ratio (OR) = 13.3; 95% confidence interval (CI) = 4.0-44.4]; painters with atrial septal defect (OR = 2.7; 95% CI = 1.0-7.4); and farmers with cleft lip and palate (OR = 3.3; 95% CI = 0.9-11.9). This study, however, did not corroborate several associations found in previous studies, such as painters and neural tube defects. We identified several additional occupations as potential risk factors for some defects, including printers, electronic equipment operators, and vehicle manufacturers.

A classification scheme for aggregating U.S. census occupation and industry codes.

The use of occupation as a surrogate for workplace exposures when more specific information is unavailable is common yet is particularly challenging in studies involving many diverse occupations. A classification scheme that aggregates workers based on similar job tasks and potential exposures was developed for use in a Canadian study, and its adaptation for a similar U.S. study is described. The 56 occupational categories and 1980 U.S. census occupation and industry codes used to create each are presented. The scheme was developed using the distribution of occupations and industries in two limited study populations, and no exposure measurements were taken in its preparation. However, the aggregation of jobs with similar exposures has practical utility in the analysis of a large number of specific occupations, each with a small number of workers. As a result, the scheme presented can provide a starting point for researchers facing this task in the analysis of case-control occupational data.

Validity of mother's report of father's occupation in a study of paternal occupation and congenital malformations.

Agreement between the mother's and father's report of the father's occupation was assessed in a case-control study of paternal occupation and birth defects. Cases were identified from births registered with the Metropolitan Atlanta Congenital Defects Program between 1968 and 1980; controls were selected from liveborn infants without defects. Both parents were sought for interview, and each parent was asked about the father's job history for 2 years prior to the infant's death. This concordance analysis is based on 3,739 case infants and 2,279 control infants for whom both parents were interviewed. The authors considered the father's report of his occupation as correct, and they assessed the ability of the mother to report the same occupation(s) during a 7-month period around conception. The exact agreement between mother's and father's report of the father's occupation was 59%. Agreement improved slightly with increasing family income and when fathers were college graduates. Female partners were not accurate proxy respondents in this study of paternal occupation and birth defects, which suggests that investigators should interview both parents in studies of paternal exposures and reproductive outcomes, i.e., mothers for pregnancy history and maternal confounders and fathers for occupational history and paternal confounders.

Injuries to women in the United States: an overview.

This review summarizes the descriptive epidemiology of injuries among women in the United States, highlighting major problems as well as needs and opportunities for intervention and research. Injury mortality rates for 1984-88 were calculated from the National Center for Health Statistics mortality data tapes. Additional injury mortality and all injury morbidity information were derived from existing literature. Studies providing gender-specific U.S. injury information during the last ten years were reviewed. Injuries are the leading causes of death for females to age 34 and are responsible for more years of potential life lost than any other cause of death. The lifetime cost of injuries to females is approximately 50 billion dollars annually. Motor vehicle related injuries, falls, and violence are the most significant injury problems for women. Although morbidity is far greater than mortality, access to information about nonfatal injuries is extremely limited. What evidence does exist points to the importance of domestic assault as a major, underrecognized source of preventable injury. Though the greater magnitude of injury among men frequently eclipses the significance of injury as a problem for women, this paper presents evidence that injury is a problem which should feature prominently in the women's health agenda for the nation. There are pressing research needs to understand the changing trends in injuries to females and to identify appropriate intervention strategies. In addition, the study points to the needs for improvement in data systems to document injury morbidity.

Paternal age and the risk of congenital heart defects.

The effect of paternal age on the risk of birth defects among offspring is less well studied than the effect of maternal age, with few comprehensive epidemiologic studies having been conducted. Advanced paternal age has been shown to be associated with an increase in new dominant mutations that result in particular congenital anomalies. The relationship between paternal age and more common birth defects, for example, cardiac defects, has not been as extensively evaluated. Therefore, a total of 4,110 cases of congenital heart defects was identified from the British Columbia Health Surveillance Registry. Matched controls were obtained from the birth files of British Columbia for the years 1952-1973. Prevalence odds ratios for paternal age, adjusted for maternal age and other factors, were estimated for 8 cardiac defect groups. A suggestive general pattern of increasing risk with increasing age among cases (excluding chromosomal anomalies) relative to controls was found for ventricular septal defects (VSD), atrial septal defects (ASD), and patent ductus arteriosus (PDA). In addition, an increased risk among men younger than 20 yr was found for VSD and ASD. These findings are consistent with the results of some previous epidemiologic studies. Based on the results of this study it is estimated that for cardiac defects such as VSD, approximately 5% of cases may be due to advanced paternal age (> 35 yr), possibly through dominant mutations.

The prevalence of cervical infection with human papillomaviruses and cervical dysplasia in Alaska Native women.

Alaska Native women historically have high rates of sexually transmitted diseases (STDs) and invasive cervical cancer. Their prevalence of cervical infections with human papillomavirus (HPV) in relation to cervical dysplasia was determined with a commercial dot hybridization test for seven HPV genotypes. Type-specific HPV DNA, similarly distributed between genotype groups 16/18 and 31/33/35, was detected in 234 cervical specimens (21%) from 1126 Alaska Native women seeking routine care and colposcopy or from population-based lists. The prevalence of HPV DNA declined with age and increased with sexual activity and cigarette smoking. It was unrelated to use of oral contraceptives or condoms or to STDs. Relative risks associating HPV with increasing severe grades of cervical dysplasia increased markedly with HPV infection, up to 7.1 for high-risk genotypes 16/18 and 14.4 for coinfection with 31/33/35. These genotypes were detected in 8% of women without dysplasia seeking routine care. Screening for strain-specific HPV DNA may identify women at highest risk for cervical neoplasia.

Tales of the absent father: applying the "story" metaphor in family therapy.

Father-absent families often function with a lively father-presence conveyed by stories the family members share. The metaphor of "story" proposed by social constructionist and narrative approaches to therapy helps us to conceptualize the role these family stories play. The story metaphor draws attention to four issues: the rendition of what is said and unsaid about the father; the connections among past, present, and future ideas about father and family; the reciprocal influences of expression and experiences, seen in the family's stories and interactions; and the impact on the family and the therapeutic process of dominant narratives about father-absence. Exploration of these issues demonstrates how client and therapist stories about the absent father mediate the impact of father-absence on the family.

Occupational injury deaths in Alaska's fishing industry, 1980 through 1988.

OBJECTIVES: Studies from other countries have identified fishing as a hazardous industry, but little is known about occupational injury mortality related to fishing in the United States. Alaska was chosen for this study because approximately 45,000 people annually participate in Alaska's fishing industry and fishing is thought to be a major contributor to occupational injury mortality in the state. METHODS: Work-related injury deaths in Alaska's fishing industry were identified by means of death certificates and US Coast Guard mortality data. Fatality rates were calculated by using average annual fishing industry employment estimates. RESULTS: The 5-year average annual fishing-related fatality rate was 414.6 per 100,000 fishermen. The majority of the decedents were Caucasian men who drowned while fishing. CONCLUSIONS: This study emphasizes that fishing is a dangerous industry in Alaska and demonstrates the benefit of using multiple data sources to identify fishing-related deaths in the state.

Surveillance of traumatic occupational fatalities in Alaska--implications for prevention.

Data on occupational injury fatalities in Alaska for the period 1980-85 were complied from workers' compensation claims and death certificates. These data yielded 422 unique cases for the 6-year period, for an average annual fatality rate of 36.3 per 100,000 workers. This rate is 5 times higher than the Bureau of Labor Statistics estimate of 7.6 per 100,000 for the United States during the same period. The four industries with the highest fatality rates were the same for Alaska as for the nation (agriculture-forestry-fishing, construction, mining, and transportation-communication-public utilities). The leading causes of occupational fatalities in Alaska, however, were considerably different than for the United States as a whole. Nationally, motor vehicles and industrial equipment accidents are the leading causes of death. In Alaska, the leading causes of occupational injury mortality are aircraft crashes and drowning. These findings highlight the benefit of local surveillance in planning prevention strategies.

Medicolegal documentation of prehospital triage.

Patients evaluated by paramedics but not transported to the hospital account for 50% to 90% of emergency medical services lawsuits. We reviewed 2,698 consecutive paramedic run reports to examine documentation in these cases. Documentation criteria for prehospital patient release were history, physical examination, vital signs, mental status, lack of significant mental impairment, and for patients refusing care, that risks of refusing were understood. Criteria for appropriate release were met in 65.2% of cases. Criteria omitted in inappropriate releases were risks of refusing care in 481 (51.3% of inappropriate releases), vitals in 320 (34.1%), mental status in 188 (20.0%), lack of impairment in 120 (12.8%), and history or physical in 19 (2.0%) cases. Age from 0 to 14 and 65 or more years and prehospital assessment of hyperventilation, psychiatric emergency, choking, infection, and patient deceased were significantly associated with appropriate release. Age from 35 to 54 years and prehospital diagnosis of no injury, head injury, seizure, minor trauma, and ethanol use were significantly associated with inappropriate releases. There was no association of appropriate release or inappropriate release with patient sex, contact with medical control, length of encounter, or time of day. Only one patient complication was believed due to inappropriate triage; this could be improved by implementation of standardized criteria.

Outcome of self-inflicted gunshot wounds of the brain.

A consecutive series of 67 patients who had sustained self-inflicted gunshot wounds of the brain was reviewed retrospectively to evaluate factors determining outcome. Weapon caliber, site of bullet entry, degree of brain wounding on computerized tomographic scan, and presenting Glasgow Coma Scale (GCS) score were examined. Overall mortality, degree of disability in survivors, and survival time after injury in fatally wounded patients were assessed. Ninety-eight percent of all patients with an initial GCS score of 8 or less died. When the GCS score was more than 8, 91% of patients survived (P less than .0001). Survival rate was significantly increased in patients with injury limited to one lobe of the brain, compared with patients with brain wounds of greater severity demonstrated on computerized tomographic scan (P less than .05), while a missile crossing both vertical anatomic planes of the brain or coming to rest in the posterior fossa was lethal in 100% of cases. Survivors scored relatively well on the Glasgow Outcome Scale. Almost all (98%) fatally injured patients maintained vital functions for a time ample for transportation and evaluation at a major referral center. These findings hold important implications for trauma center and critical care resource allocation as well as organ transplantation programs.