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ABSTRACT: Objectives To describe the trend and factors associated with the autopsy over the past decade at a level III neonatal intensive care unit (NICU) where all patients are presented with an option.Study Design Retrospective study of the autopsy in a cohort of infants who died in the NICU from January 1, 2001, to December 31, 2010.Results Of 446 deaths, 33.9% received the autopsy and rates decreased from the 2 years prior to the study. The autopsy was associated with gestational age at birth and chronologic age at death. On multivariable logistic regression analyses, the odds of an autopsy increased with gestational age (p = 0.001), death in the postneonatal period (odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.28, 3.16), and absence of a major congenital anomaly (OR = 1.96, 95% CI = 1.22, 3.23).Conclusion Autopsy rates continue to decline despite ensuring that all parents are presented with the option. Infants born at term and those who die after 1 month without known congenital anomalies are most likely to receive the autopsy. The persistently low rates may highlight the importance of helping families understand that the autopsy has utility even when the cause of death may appear to be obvious.
American Journal of Perinatology 01/2013; · 1.32 Impact Factor
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ABSTRACT: To assess the trends for smoking during pregnancy for whites and blacks in Missouri, a state with a high prevalence of smoking, for the period 1990-2009.
Retrospective cohort study of annual pregnancy smoking rates recorded on birth certificates. Trends were assessed by regression analyses for all births, births to whites and blacks, births to whites and blacks in aggregate, and by zip codes within the combined jurisdictions of Kansas City, St Louis City, and St Louis County. Zip code smoking during pregnancy rates matched with the respective zip code race-specific population compositions were analyzed by chi-square tests.
Smoking during pregnancy rates trends for whites and blacks differed significantly during the 2 decades. Although rates for whites declined over time, they were relatively stable from 1999 through 2007. Rates for blacks exhibited a steep decline in the early 1990s, remaining stable after 1995. Within the combined jurisdictions, rates for blacks who smoked during pregnancy surpassed those of whites beginning in 2001. The lack of prenatal care for either race was the only maternal characteristic consistently associated with lack of reduction in smoking during pregnancy. There also were no declines among young birth mothers of either race who had 12 or fewer years of education. Rates of smoking during pregnancy for blacks and whites were highest in zip codes with a ≥50% black population.
Rates for smoking during pregnancy for whites and blacks in Missouri overall have not changed appreciably from 2000 to 2009. Beneficial antismoking during pregnancy effects that could reverse this trend may be achievable via improved access to prenatal care, especially for young, uneducated women.
Southern medical journal 12/2012; 105(12):636-44. · 0.92 Impact Factor
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ABSTRACT: Background A Midwestern neonatal intensive care unit (NICU) employs a multidisciplinary conference, the Comprehensive Care Round (CCR), to facilitate communication and consensus building and thereby prevent or address moral distress within the health care team.Methods A cross-sectional survey, 3 years after implementation of CCR, to evaluate health care providers' (HCP) perceptions of comfort with expressing distress, support from team members in care situations that evoke moral distress, barriers to communication, and attainment of CCR objectives.Results Of 370 HCP, 116 (31%) participated in the survey (42% nurses, 37% allied health, and 21% medical); 51% had previously attended CCR. CCR attendance was higher among HCP aged >35 years, those who cared for CCR patients, and nonnurses. Neonatologist were more likely than others (44% versus 4%, p <0.01) to report that referred cases were not overdue for discussion and that families appreciated the attention their child received from CCR. Of note, HCP who were comfortable with expressing distress also felt supported by team members (R = 0.5, p <0.001).Conclusion CCR, developed to prevent or address moral distress, occurs later than most NICU HCP consider appropriate and appears to better serve HCP who are already comfortable with discussing moral distress. Helping HCP become comfortable with crucial conversations should support meaningful participation and contribution to multidisciplinary conferences.
American Journal of Perinatology 05/2012; 29(9):687-92. · 1.32 Impact Factor
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ABSTRACT: The study objective was to identify demographic risk factors associated with emergency room visits caused by benzodiazepine poisoning.
A retrospective study was conducted utilizing Missouri Hospital Discharge Data for Kansas City, Missouri, USA, for 2001-2007. The data included patients' demographics such as racial group, age, sex, health insurance status and annual income. Emergency room visits due to benzodiazepine poisoning were identified by ICD-9 code 969.4. The frequencies of patient visits were calculated according to categories of each demographic variable. Chi-square tests were used to assess the difference of emergency room visits among categories of each demographic variable. A multiple logistic regression analysis was performed, where the outcome variable was emergency room visits due to benzodiazepine poisoning (yes/no), and the independent variables were the demographic variables.
Of 1317566 emergency room visits over the 7-year period, 562 were due to benzodiazepine poisoning. Seventy-seven per cent of these visits were made by patients who were white, of whom 53% were 30-49years old, 56% were female, 74% had health insurance and 44% lived in zip codes with median family incomes of $40000-59999. Chi-square tests were significant for racial group, age and annual income (P<0.01). In the logistic regression white patients were 73% more likely than black patients to have emergency room visits caused by benzodiazepine poisoning (P<0.01), with an odds ratio (95% confidence interval) of 5.63 (4.33-7.30). Compared with those aged 0-19 years, the odds ratio for patients aged 30-39 to have such visits was 2.73 (2.09-3.57), and the odds ratio for patients aged 40-49 was 2.84 (2.17-3.71).
White patients and patients aged 30-49years were at higher risk for emergency room visits due to benzodiazepine poisoning. Health interventions such as medication review by pharmacists may reduce the risk of benzodiazepine poisoning for these patients.
International Journal of Pharmacy Practice 06/2011; 19(3):166-70.
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ABSTRACT: Care of the very sick infant can be complicated by extraneous factors that challenge the cohesiveness of the health care team. Chaos results from low levels of professional agreement and certainty about outcomes and manifests in stress and miscommunication among care providers. This milieu is fertile ground for errors of commission and omission. Effective communication and collaboration are recognized as essential for reducing medical errors in such stressful environments. This article describes a multidisciplinary conference, the Comprehensive Care Rounds, at a neonatal intensive care unit of a Magnet-recognized midwestern pediatric hospital. The Comprehensive Care Round provides a forum for open communication among team members and builds on the hospital's efforts at systems approach to developing a culture of safety and quality.
Advances in Neonatal Care 12/2010; 10(6):301-6.
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ABSTRACT: The ponderal index (PI) is evaluated in the context of its distribution within a given population. Low PI (<10th percentile for gestational age) has been extensively studied but not much is known about the distribution and factors associated with a high (>90th percentile) PI among small-for-gestational-age (SGA) infants. This retrospective study of singleton live first births from 1990 to 2007 in a Midwestern city explores factors associated with a high PI, particularly among SGA infants. Independent variables included exposures (none, smoke, hypertension) and maternal and infant demographic characteristics. There were 45,453 births, 28 to 42 weeks' gestational age, 55% Whites and 51% male. Mean PI increased with gestational age and was highest among Hispanics and lower among SGA infants. High PI was present in 11% of appropriate-for-gestational-age and 4% of SGA infants. Among SGA infants, odds ratios (ORs) of high PI were higher for smoke exposure (1.21; 95% confidence interval 0.97, 1.87) and lower for males (0.66; 0.47, 0.93). In conclusion, the distribution of PI varies by exposures and of high PI by race/ethnicity/gender. SGA infants with high PI have relative surplus of mass, and ostensibly, adiposity, for their frame. There is a need to use PI in exploring and defining previously observed associations between SGA and adult-onset obesity/metabolic syndrome.
American Journal of Perinatology 12/2009; 27(5):353-60. · 1.32 Impact Factor
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ABSTRACT: The two objectives of this study were to (1) examine factors associated with changes in pre-pregnancy overweight to pre-pregnancy normal/underweight or obese Body Mass Index (BMI) in the subsequent pregnancy, and (2) assess select pregnancy and newborn outcomes associated with changes in pre-pregnancy BMI.
Birth certificates from 1995-2004 for residents of Kansas City, Missouri, were used to identify overweight nulliparous women who had a singleton birth and subsequently a second singleton birth. Maternal factors associated with changes in BMI between pregnancies were determined. Hypertension in pregnancy, preterm birth, emergency cesarean section, small-for-gestational age, and large-for-gestational age outcomes were examined.
At second pregnancy, 55% of the women remained overweight, 33% were obese, and 12% had normal/underweight BMIs. The upward shift in BMI was associated with being unmarried and having a birth interval of 18 or more months, while the downward shift was associated with gestational weight gain. Of the five outcomes variables, only emergency cesarean section was significantly associated with an upward shift in BMI.
Clinical interventions for pre-pregnancy overweight women should focus on appropriate weight gain during pregnancy and motivators for loss of pregnancy-related weight during the postpartum period.
Journal of Women s Health 09/2009; 18(9):1413-7. · 1.57 Impact Factor
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ABSTRACT: The objective of our study was to determine whether there were combined effects of smoking, alcohol, and illicit drug use during pregnancy on the frequency of preterm births, and if so, the magnitude of the association after adjusting for confounding factors.
We conducted a retrospective cohort study of singleton live births in Kansas City, Missouri from 1990-2002. We defined health compromising behaviors as the use of cigarettes, alcohol, and illicit drugs. The effect of these behaviors on preterm births was considered for each substance individually, and in combination. The rates of preterm births for these groups were calculated. Using logistic regression, adjusted odds ratios were used to estimate the relative risk of preterm births among these groups.
Over 13% of infants born to women who smoked were preterm, compared to 9.6% for non-smokers. Of infants born to women who reported alcohol use, 17.3% were preterm compared to 10.1% for non-drinkers. Smoking and alcohol use in combination was associated with 18.0% preterm births, while alcohol and drug use in combination was associated with 20.8% preterm births. The use of all three substances was associated with 31.4% preterm births.
Women who engaged in health compromising behaviors during pregnancy showed an increased proportion of preterm births compared to those who did not. There is significant interaction between these behaviors leading to higher rates of preterm births than predicted by their additive effects. To decrease preterm births, we must deal with the effects of smoking, drinking, and drug use simultaneously.
Maternal and Child Health Journal 06/2007; 11(3):227-33. · 2.24 Impact Factor
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ABSTRACT: This retrospective cohort study examines the relationship between changing pregnancy-smoking behaviors, from the first to the second pregnancy, on second-pregnancy rates of small for gestational age (SGA) neonates. Electronic birth records provided data on 5107 pregnant women who had two singleton births in Kansas City, MO, from 1994 to 2003. Pregnancy-smoking behavior was classified by smoking status (nonsmoker [NS] or smoker [SMK]) during the first (previous)/second (current) pregnancy: NS/NS, NS/SMK, SMK/SMK, and SMK/NS. The overall second-pregnancy SGA rate was 6.7% and varied with pregnancy-smoking behavior: 5.9%, NS/NS; 6.6%, SMK/NS; 12.5%, NS/SMK; and 12%, SMK/SMK; P < 0.001 Current pregnancy-smoking was associated with increased odds ratio (OR) of SGA; SMK/SMK (OR, 2.80; 95% confidence interval [CI], 2.00 to 3.93) versus NS/SMK (OR, 1.83; 95% CI, 1.19 to 2.82) versus SMK/NS (OR, 1.31; 95% CI, 0.65 to 2.65) versus NS/NS (OR, 1.00; 95% CI, reference). Being black (OR, 3.73; 95% CI, 2.91 to 4.79) and having medical risk factors (OR, 1.31; 95% CI, 1.09 to 1.74) also were significantly associated with a SGA neonate in second pregnancy. In conclusion, risk of delivering a SGA neonate in a current pregnancy is related to current rather than previous pregnancy-smoking. Therefore, antismoking socialization during pregnancy should focus on preventing and stopping current pregnancy-smoking, irrespective of past behavior.
American Journal of Perinatology 04/2007; 24(3):191-6. · 1.32 Impact Factor
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ABSTRACT: To estimate the association between term-gestation low birth weight (term-LBW) rates and increasing numbers of health-compromising behaviors during pregnancy.
Retrospective cohort study of 78,397 term live births in Kansas City, Missouri, 1990-2002. Information on maternal and newborn characteristics was obtained form birth certificate records. Health-compromising behavior, specifically, smoking, alcohol, and drug use, was classified by the numbers and combinations of behaviors engaged in during pregnancy. Covariates included race, age, interconception interval, education, Medicaid status, medical risk factors, adequacy of prenatal care, and marital status.
The cohort was 61% white, 16% less than 20 years of age, 45% on Medicaid, 24% with medical risk factor, and 45% single pregnant women. Overall term-LBW rate was 3.3%, and it increased with numbers of health-compromising behaviors: 2.6% (none), 5.5% (1), 10.8% (2), and 18.5% (3), P < .001. Unadjusted odds ratio (OR) for term-LBW increased with increasing numbers of behaviors (OR 1.0 [none]; 2.3, 95% confidence interval 2.0-2.4 [smoking]; 0.9, 0.6-1.4 [alcohol]; 2.1, 1.5-3.0 [drugs]; 4.6, 3.6-5.8 [smoking + alcohol]; 4.4, 3.6-5.4 [smoking + drugs]; 4.2, 1.5-11.9 [drugs + alcohol]; 8.4, 6.2-11.5 [smoking + alcohol + drugs]). However, on adjusting for covariates, smoking, alone (OR 2.3, 2.0-2.5) or in combinations with other behaviors (OR 4.4, 3.4-5.7 [smoking + alcohol]; 2.0, 1.6-2.6 [smoking + drugs]; and 3.3, 2.2-4.7 [smoking + alcohol + drugs]) remained the major risk factor for term-LBW.
Smoking alone or in combination with alcohol and/or drug use is associated with term-LBW among women who engage in health-compromising behaviors. The effect is especially pronounced when smoking is combined with alcohol consumption.
Obstetrics and Gynecology 04/2005; 105(3):543-50. · 4.73 Impact Factor
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ABSTRACT: In this retrospective study, we tested the following hypotheses: rates of severe intraventricular hemorrhage (SIVH) and early neonatal survival are similar among extremely low birth weight (ELBW) infants treated with combination prophylaxis of phenobarbital and indomethacin compared with phenobarbital alone or no prophylaxis; and rates of patent ductus arteriosus (PDA) and necrotizing enterocolitis (NEC) are similar among indomethacin-exposed and nonexposed ELBW infants. Data were abstracted on 265 ELBW infants admitted into a level 3 neonatal intensive care unit from 1994 through 2002. Combination prophylaxis neither reduced the odds ratio (OR) of SIVH (OR = 1.53; 95% confidence interval [CI], 0.43 to 1.16) versus phenobarbital (OR = 2.91; 95% CI, 0.91 to 9.27 versus none (OR = 1; 95% CI, reference) nor increased the odds of early neonatal survival (OR = 0.72; 95% CI, 0.17 to 3.09 for combination prophylaxis versus OR = 0.66; 95% CI, 0.16 to 2.67 for phenobarbital versus OR = 1; 95% CI, reference for none). Indomethacin exposure reduced the odds of PDA (OR = 0.35; 95% CI, 0.17 to 0.75) without increasing the risk of NEC (OR = 1.37; 95% CI, 0.60 to 3.12). In conclusion, combination prophylaxis does not improve SIVH and early neonatal survival outcomes. Early exposure to indomethacin offers some benefits without any added risks.
American Journal of Perinatology 02/2005; 22(1):11-7. · 1.32 Impact Factor
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ABSTRACT: The object of the study was to test the hypothesis that mental illness is associated with drug abuse by pregnant smokers. We abstracted data from the State of Missouri Risk Appraisal of Pregnant Women database on 239 (115 black and 124 white) women who attended an inner-city hospital from 1999 through 2000. Thirty-four percent abused drugs, 16% used alcohol, and 8% reported having a history of mental illness or psychiatric treatment. On multivariable logistic regression analyses, pregnant smokers were more likely to use drugs if they had mental illness (odds ration [OR], 7), consumed alcohol (OR, 2), or were black (OR, 3). In conclusion, drug abuse is associated with mental illness, suggesting that this behavior may be a marker of underlying mental illness among pregnant smokers. Therefore, in addition to initiating social service intervention, the identification of drug abuse by pregnant smokers should prompt a mental health evaluation.
American Journal of Perinatology 08/2004; 21(5):299-304. · 1.32 Impact Factor
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ABSTRACT: To identify predictors of future adoption of home smoking restriction (HSR), given that 40% of inner-city smokers report current HSR.
Secondary analysis of data on smokers enrolled in a double-blind, placebo-controlled, randomized trial of bupropion hydrochloride for smoking cessation.
Community health center in Kansas City, Kan, from August 1, 2000, to December 31, 2001.
Six hundred eligible black smokers, at least 18 years old, who smoked at least 10 cigarettes per day and were interested in quitting within the next 30 days. Enrollment was limited to 1 smoker per household.
Adoption of HSR by 6 months by those who did not have it at baseline. Result Baseline HSR was reported by 36% of all smokers. Of 383 smokers without baseline HSR, 311 smokers had complete baseline and 6-month data. Thirty-seven percent of households without HSR at baseline had adopted HSR by 6 months. Adoption was associated with a nonsmoking adult or children in the home, progress in stage of change, and smoking cessation. Odds of adopting HSR increased with progress in stage of change (odds ratio [OR], 4.20), baseline preparatory stage of change (OR, 3.28), and having a nonsmoking partner (OR, 2.35) or children (OR, 1.75) in the home.
A smoker's motivation to quit and the presence in the home of a nonsmoking adult or of children predict adoption of HSR by inner-city black smokers. Therefore, health professionals should motivate the smoker toward HSR and the nonsmoking partner toward advocating home smoking bans, thereby eliminating environmental tobacco smoke in the home.
Archives of Pediatrics and Adolescent Medicine 01/2004; 157(12):1202-5. · 4.14 Impact Factor
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Felix A Okah
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ABSTRACT: Autopsy rates have declined steadily throughout the 1970s and 1980s. This trend, if not reversed, could negatively affect information provided to families as well as the training of physicians. In the 1980s, low autopsy rates among neonatal deaths, 50-72%, were attributed to limited parental understanding and to physicians' attitudes. In the early 1990s, alternatives to the routine autopsy, such as limited endoscopic/needle autopsies, were widely popularised, and the physician's education about autopsy vigorously addressed. The effects of these efforts on autopsy rates in the latter part of the 1990s have not been well studied. The study population consisted of 643 infants who died at an Ohio, USA, neonatal intensive care unit (NICU) between 1 January 1986 and 31 December 1998. Neonatologists obtained consent for autopsy. Information obtained from the computer database included birth hospital, gestational age, age at death, birth and death weight, race, sex, death year and maternal age, religion, gravidity and parity. The overall autopsy rate during the 13-year study period was 54% [95% CI 44.1%, 63.1%]. There was a trend towards progressive decrease in autopsy rates, 59% in 1986-89, 52% in 1990-94 and 47% in 1995-98 (P = 0.078). Autopsy was associated with increasing gestational age (P < 0.001) and decreasing parity [OR = 0.53 for >2 compared with <or=2, 95% CI 0.36, 0.99], but not with other variables. Autopsy rates remain suboptimum and may be declining despite efforts at educating the medical and general community about its benefits. Among infants who die in the NICU, autopsy is more likely the more mature the infant at birth and the fewer children the mother has. Physicians need to seek autopsy more conscientiously, with consideration for the emotional well-being of the family, and for its potential diagnostic and research value to science.
Paediatric and Perinatal Epidemiology 10/2002; 16(4):350-4. · 2.31 Impact Factor
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ABSTRACT: The home is the site of the most significant environmental tobacco smoke (ETS) exposure for children. Surveys show that adults, including smokers, agree that smoking should be restricted in homes of smokers with children. However, in a national survey, only 12.5% of such homes are actually smoke-free. This study examined factors associated with home smoking restriction among inner-city smokers.
A cross-sectional survey of 598 adult smokers who attended an inner-city community health center was conducted.
Home smoking restriction was reported by 38.2% of all smokers (95% confidence interval [CI]: 33.6%-42.8%). Univariate analysis showed smoking restriction was positively associated with presence of children and of a nonsmoking adult partner in the home, intentional limiting of smoking, stages of change, and fewer number of cigarettes smoked daily. On multivariate analysis, home smoking restriction was more likely with the presence of a child (odds ratio: 2.63; 95% CI: 1.70-4.08) and a nonsmoking adult partner (odds ratio: 2.30; 95% CI: 1.32-4.02) in the home.
The presence of children and of nonsmoking adults is associated with the practice of smoking restriction in the homes of inner-city smokers. These findings suggest that inner-city smokers are concerned about health effects of ETS on children. Health professionals should target nonsmoking adult members of households with children and smokers but no home smoking restriction and emphasize the health effects of ETS on children as a motivation for smoking parents to limit exposure and to quit smoking.
PEDIATRICS 03/2002; 109(2):244-9. · 4.47 Impact Factor
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ABSTRACT: To assess changes in maternal smoking behavior at the second pregnancy.
First and second birth certificates were matched for 5241 white and black mothers in Kansas City, Mo, who had singleton births between 1994 and 2003.
The pregnancy-smoking quit rate was 24.9%, and the pregnancy-smoking initiation rate was 4.8%.
Twenty-five percent of women who smoked and 5% of women who did not smoke during their first pregnancy changed their behavior during their second pregnancy. These findings reflect a minimal net shift in pregnancy-smoking between pregnancies and support the importance of persistent antismoking socialization that is independent of a pregnant woman's previous pregnancy-smoking status.
American journal of health behavior 31(6):583-90. · 1.31 Impact Factor
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ABSTRACT: To determine whether pregnancy-smoking rates have changed in last decade.
Retrospective cohort study of 67,395 pregnancies in Kansas City over 2 epochs, 1993-1997 and 1998-2002, using computer files of birth certificates.
Overall pregnancy-smoking rates decreased from 18.1% (95% CI=17.7-18.5%) to 14.2% (13.8-14.5%). Among smokers, there was a distribution shift toward light smoking; light [39% (38.9-40.3%) vs 49% (47.6-50.4%)], moderate [36.8% (34.8%-38.8%) vs 34.4% (32.1-36.7%)], and heavy [23.1% (21.9-26.3%) vs 16.6% (14-19.1%)].
The results suggest decreasing heavier smoking. However, the trend toward light smoking suggests decreasing self-reporting. These findings highlight the dilemma in using self-reports for public health policy and emphasize the importance of antismoking socialization for all pregnancies.
American journal of health behavior 29(5):456-61. · 1.31 Impact Factor
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ABSTRACT: We assessed excess fetal-infant mortality for Hispanic, non-Hispanic white, and non-Hispanic black populations in five contiguous counties of Missouri and Kansas.
We conducted a perinatal periods of risk (PPOR) assessment of fetal-infant mortality using electronic linked birth-death record files from 2001 through 2005. We generated an internal reference group in accordance with established PPOR protocol. We used Kitagawa analysis to determine whether excess deaths were due to birthweight distribution (a higher frequency of prematurity or growth retardation) or to higher mortality rates once born at that birthweight (birthweight-specific mortality).
We found the excess fetal-infant death rates for Hispanic and non-Hispanic white populations to be similar and considerably lower than that for non-Hispanic black populations. Among Hispanic children, we judged 21.6% of fetal-infant mortality to be excess in relation to the reference population. Within the PPOR matrix, Hispanic excess mortality rates were distributed differently from those of non-Hispanic white and non-Hispanic black populations. Among Hispanic children, 93.6% of the excess mortality could be explained by low birthweight and birthweight-specific mortality, with the greatest contribution attributable to low birthweight.
The excess fetal-infant mortality experience of Hispanic people in the five-county region was similar to that of the non-Hispanic white population, but was distributed differently in the PPOR model, which has significance regarding interventions targeting reductions in fetal-infant mortality.
Public Health Reports 124(5):711-7. · 1.27 Impact Factor
