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Biomedical subjects

P H Wise

Publications and source records attributed to P H Wise.

At least 19 recordsLinked to original sources
PubMed1999

Implementation of Fetal and Infant Mortality Review (FIMR): experience from the national Healthy Start program.

OBJECTIVES: The implementation of the Fetal and Infant Mortality Review (FIMR) process was examined as part of the evaluation of the national Healthy Start program, a federal program designed to reduce infant mortality in several communities. The implementation of the FIMR process over the 5-year funding period is described in terms of productivity, barriers and facilitators to implementation, and project expenditures. METHODS: Data were derived from grant continuation applications and personal interviews with program staff to produce a qualitative description. RESULTS: As of the summer of 1996, 14 of the 15 Healthy Start sites in the national evaluation had successfully implemented the FIMR process. Most sites had developed a two-tiered review process for examination of case data in which a review by health and social services professionals was followed by community review. In the period 1993 to 1995, the percentage of fetal and infant deaths reviewed had a median of 34% with a range of 4-79% across the sites at a cost of $600 to $3400 per death reviewed. Recommendations were variably implemented. CONCLUSIONS: The FIMR process provides an important opportunity to contribute to the knowledge base regarding infant mortality in these communities. The process, however, has important logistical requirements and may require substantial financial resources that may affect implementation of confidential inquiries into infant mortality and other health problems.

Data Collection↗
PubMed1999

The scope of unmet maternal health needs in pediatric settings.

OBJECTIVE: Previous work has focused attention on the prevalence of specific maternal health problems known to affect children, such as smoking or depression. However, the cumulative health burden experienced by mothers and the potential for a practical pediatric health services response have not been examined. The aims of this study were to characterize: 1) the prevalence and cumulative burden of maternal health behaviors and conditions, 2) maternal access to a source of comprehensive adult primary care, and 3) maternal perceptions of a pediatric role in screening and referral. METHODS: We surveyed 559 consecutive women bringing a child 18 months of age or less to one of four pediatric primary care sites between July 1996 and May 1997. The pediatric sites included one outpatient program in an academic hospital, one in a community health center, and two in-staff model practices of a managed care organization (these last two were combined for analysis). The self-administered questionnaire contained previously validated questions to assess health behaviors and conditions (smoking, alcohol abuse, depression, violence, risk for unintended pregnancy, serious illness, self-reported health) and access to care (regular source, regular provider, health insurance, care delayed or not received). Maternal attitudes toward a pediatric role in screening and referral were also elicited. RESULTS: In the three settings, response rates ranged from 75% to 84%. The average age of the women ranged from 25.1 to 32. 1 years and the average age of the children ranged from 6.5 to 8.0 months. Across the settings, the percentage of women reporting at least one health condition (66%-74%) was similarly high, despite significant demographic differences among sites. Many women reported more than one condition (31%-37%); among all women who smoked, 33% also screened positive for alcohol abuse, 31% for emotional or physical abuse, and 48% for depression. Access to comprehensive adult primary care was variable with 23% to 58% of women reporting one or more barriers depending on the site. Across all sites, >85% of mothers reported they would "not mind" or "would welcome" a pediatric role in screening and referral. CONCLUSIONS: Two-thirds of women bringing their children for pediatric care had health problems regardless of the site of care. Many women also reported substantial barriers to comprehensive health care. Most women reported acceptance of a pediatric role in screening and referral. Given the range and depth of maternal health needs, strategies to connect or reconnect mothers to comprehensive adult primary care from a variety of pediatric settings should be explored.

Adult↗
PubMed1998

Policies towards pregnancy and addiction. Sticks without carrots.

Throughout this century in the United States, tension has existed between those who believe drug abuse is best combatted through the criminal justice system and those who emphasize a medical/public health model of prevention and treatment. In the last decade this debate has centered around the person of the pregnant addict. The former have construed her addiction as willful harm to the fetus punishable on criminal and child abuse grounds. The latter have countered that pregnancy is a moment of increased motivation for treatment and focused on expansion and improvement of treatment options. Both managed care and welfare reform have exacerbated conditions between these opposing policy approaches. The addicted woman is increasingly caught between policies that punish her drug use without options for overcoming addiction.

Child↗
PubMed1998

National survey of the states: policies and practices regarding drug-using pregnant women.

OBJECTIVES: This study assessed the impact of national policy shifts on state policies and practices regarding substance-using mothers. METHODS: A 1995 telephone survey of substance abuse and child protective services directors in all 50 states and the District of Columbia was compared with a similar 1992 survey. RESULTS: There have been significant increases in state interventions for drug-using pregnant women (e.g., criminal prosecution, toxicology testing of women and neonates). Federal resources for treatment and oversight are being replaced by state control of reduced funds for treatment. CONCLUSIONS: The earlier policy of expanding treatment for addicted women is being replaced by reduction of services and increased state intervention.

Data Collection↗
PubMed1997

Maternal and infant health: effects of moderate reductions in postpartum length of stay.

BACKGROUND: The Newborns' and Mothers' Health Protection Act of 1996 prohibits payers from restricting "benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours." The law recognizes the basic right of women and physicians to make decisions about aptness of discharge timing. OBJECTIVE: To provide data as a basis for decisions about aptness of discharge timing by studying the effect of voluntary, moderate reductions in length of postpartum hospital stay on an array of maternal and infant health outcomes. DESIGN: A prospective cohort study. Patients were surveyed by telephone at 3 and 8 weeks postpartum. SETTING: A teaching hospital where 38% of the patients are in a managed care health plan with a noncompulsory reduced stay program offering enhanced prepartum and postpartum services, including home visits. PATIENTS: Consecutive mothers discharged after vaginal delivery during a 3-month period. MAIN OUTCOME MEASURES: The outcomes were health services use within 21 days, breast-feeding, depression, sense of competence, and satisfaction with care. Multivariate analyses adjusted for sociodemographic factors, payer status, services, and social support. RESULTS: Of 1364 eligible patients, 1200 (88%) were surveyed at 3 weeks; of these 1200, 1015 (85%) were resurveyed at 8 weeks. The mean length of stay was 41.9 hours (SD, 12.2 hours). Of patients going home in 30 hours or less, 60.8% belonged to a managed care health plan. The length of stay was not related to the outcomes, except that women hospitalized shorter than 48 hours had more emergency department visits than those staying 40 to 48 hours (adjusted odds ratio, 5.78; 95% confidence interval, 1.19-28.05). CONCLUSIONS: When adequate postpartum outpatient care is accessible, a moderately shorter length of postpartum stay after an uncomplicated vaginal delivery had no adverse effect on an array of outcomes. Researchers and policy makers should seek to better define the content of postpartum services necessary for achieving optimal outcomes for women and newborns; funding should be available to provide such services, regardless of the setting in which they are provided.

Adolescent↗
PubMed1997

Ethics in context.

Explore the source record for details and available documents.

Communication↗
PubMed1997

Fertility therapy and the risk of very low birth weight.

OBJECTIVE: To test the hypothesis of an association between maternal infertility therapy and the risk of very low birth weight (VLBW), defined as birth weight less than 1500 g, independent of the risk of multiple births, and to estimate the contribution of infertility therapy to the national incidence of VLBW. METHODS: The National Maternal and Infant Health Survey conducted in 1988 was used to develop statistics describing outcomes among this birth cohort and to construct logistic regression models evaluating fertility therapy as an independent risk factor for VLBW. RESULTS: An estimated 10.1% of live births and 18.2% of VLBW births nationally were associated with either maternal subfertility or infertility therapy (6.8% and 11.4%, respectively). The risk of VLBW among women concerned with subfertility (i.e., receiving diagnostic testing or advice on timing intercourse) was 1.4 (95% confidence interval [CI] 1.1, 1.9), whereas that for women undergoing therapeutic interventions (ie, ovarian stimulation, surgery, in vitro fertilization, or artificial insemination) was 2.6 (95% CI 2.1, 3.2). Accounting for effects of multiple gestation, maternal age, and a history of miscarriage, the odds ratios for the concerned and therapy groups were 1.5 (95% CI 1.1, 1.9) and 2.0 (95% CI 1.5, 2.5), respectively. Black women were less likely to use fertility therapy but more likely to experience a therapy-related VLBW. CONCLUSION: Fertility therapy is associated with an important portion of all VLBW and with an elevated risk of VLBW, related only in part to an increased risk of multiple gestations. Women expressing concern about subfertility but not receiving therapy are also at increased risk of VLBW, suggesting that a history of infertility may mediate part of the risk associated with fertility therapy.

Adult↗
PubMed1997

Treatment of vitamin D deficient osteomalacia may unmask autonomous hyperparathyroidism.

Two cases of vitamin D deficient osteomalacia with secondary hyperparathyroidism are presented. In both cases treatment with vitamin D replacement therapy resulted in elevated calcium levels and a failure of parathormone levels to normalise, indicating autonomous parathyroid activity. Subsequent surgery in one case resulted in removal of a parathyroid adenoma. The importance of osteomalacia and its complications are discussed.

Adult↗
PubMed1997

War experiences and distress symptoms of Bosnian children.

OBJECTIVE: The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae. METHODS: A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms. RESULTS: The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city. CONCLUSIONS: The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children.

Bosnia and Herzegovina↗
PubMed1997

Risk status at discharge and cause of death for postneonatal infant deaths: a total population study.

OBJECTIVES: To obtain population-based, clinical information regarding potentially modifiable factors contributing to death during the postneonatal period (28 to 364 days), we examined all postneonatal infant deaths in four areas of the United States to determine: (1) the cause of death from clinical and autopsy data rather than vital statistics, (2) whether death occurred during initial hospitalization or after discharge, and (3) the portion of postneonatal mortality attributable to infants who left the hospital with identified high-risk medical conditions. DESIGN AND SETTING: Retrospective medical record review of all postneonatal infant deaths with birth weights greater than 500 g (total N = 386) born to mothers residing in: (1) the city of Boston (1984 and 1985, N = 55), (2) the city of St Louis and contiguous areas (1985 and 1986, N = 123), (3) San Diego County (1985, N = 112), and (4) the state of Maine (1984 and 1985, N = 96). Deaths were identified using linked birth and death vital statistics, and medical record audits of infants' and mothers' charts were performed. Causes of death were obtained from medical record review in conjunction with autopsy if performed (72%, N = 278), medical record alone (17%, N = 67), or vital statistics if no other source was available (11%, N = 41). The medical conditions at the time of discharge for each infant were reviewed and, if judged to confer an increased risk of morbidity or mortality, were classified as high risk. RESULTS: The causes of death were sudden infant death syndrome (47%, N = 181), congenital conditions (20%, N = 77), prematurity-related conditions (11%, N = 43), infections (9%, N = 34), external causes (including injuries, drownings, ingestions, and burns) (7%, N = 25), and other (6%, N = 23). In 24% of congenital and 25% to 44% of prematurity-related deaths, infection was the acute or associated cause of death. Infants born to black mothers were more likely than those born to white mothers to die during the postneonatal period of all major causes of death (7.3 per 1000 vs 3.0 per 1000). Overall, 18% (N = 68) of deaths occurred to infants who never left the hospital; 79% (N = 305) of the infants were discharged before death; and discharge status was unknown in 3% (N = 13). Eighty-one percent of all infants with prematurity-related postneonatal deaths were never discharged, and of the total infants who were initially discharged, only 1% (N = 4) subsequently died of prematurity-related causes. Of all postneonatal deaths, only 16% (N = 62) left the hospital with identified high-risk medical conditions. CONCLUSIONS: These findings suggest that the etiology of postneonatal mortality is heterogeneous, with significant complexity in attributing specific causes of death and making designations of "preventability." The vast majority of infants who died of prematurity-related postneonatal causes never left the hospital, and only a small percentage of all infants that left the hospital before death were identified as being at high medical risk. Therefore, strategies for further decreasing postneonatal mortality must link high-risk follow-up programs to more comprehensive strategies that address risk throughout pregnancy and early childhood.

Cause of Death↗
PubMed1997

High variability of glycated hemoglobin concentrations in patients with IDDM followed over 9 years. What is the best index of long-term glycemic control?

OBJECTIVE: To determine variability of long-term glycemic control in patients with IDDM. RESEARCH DESIGN AND METHODS: A retrospective analysis of HbA1 among 122 IDDM patients followed over 9 years. RESULTS: Annual group mean HbA1 ranged from 8.4 to 9.3% with large standard deviations (1.7-2.0%), indicating marked variability among individuals. Fluctuations of more than +/- 1% HbA1 occurred in 50% of the patients year to year, and over 9 years the minimum-maximum range was > 3 and > 5% HbA1 in 55 and 11% of patients, respectively. In any one year, 22-43% of patients had HbA1 < 8%, but over 9 years only 3.3% were consistently < 8%. Groups divided according to baseline HbA1 of < 8, 8-10, and > 10% were significantly separated over 9 years by frequency distribution analysis of individual mean HbA1 but were indistinguishable when analyzed by individual HbA1 interquartile range (measure of variability). CONCLUSIONS: High variability of long-term glycemic control is a marked feature of IDDM, the extent of which may be relevant to microvascular risk.

Adult↗
PubMed1997

Inadequate hepatitis B vaccination of adolescents and adults at an urban community health center.

Hepatitis B remains a major public health problem in the United States, but public vaccination policy has targeted infants rather than the high-risk adults who constitute the vast majority of patients at imminent risk of infection. The effects of this policy were studied at a community health center in Boston. Adolescents and adults who attended a community health center between January 1, 1992 and May 31, 1993 and had human immunodeficiency virus (HIV) or another sexually transmitted disease (STD)--indications for vaccination according to the Centers for Disease Control and Prevention--were identified through chart review. The vaccination rate and missed opportunities were determined. In addition, directors of Boston health centers were surveyed on hepatitis B vaccine at their clinics. Of 178 individuals with HIV or another STD and without serologic evidence of prior exposure to hepatitis B, two (1.1%) received the vaccine. There were 342 missed opportunities. Only two of 14 medical directors said their clinics routinely offered vaccine to individuals with STDs. The medical directors rated financial barriers as more important obstacles to hepatitis B vaccination than nonfinancial barriers. These results indicate that many high-risk adolescents and adults do not receive a preventive intervention that is federally recommended, potentially life saving, and cost effective. Inadequate public funding for vaccine may be a key barrier for this population.

Adolescent↗
PubMed1996

The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites.

BACKGROUND: Surfactant therapy reduces morbidity and mortality among premature infants with the respiratory distress syndrome (RDS). Fetal pulmonary surfactant matures more slowly in white than in black fetuses, and therefore RDS is more prevalent among whites than among blacks. We reasoned that the increased use of surfactant after its approval by the Food and Drug Administration (FDA) in 1990 might have reduced neonatal mortality more among whites than among blacks. METHODS: We merged vital-statistics information for all 1563 infants with very low birth weights (500 to 1500 g) born from 1987 through 1989 or in 1991 and 1992 to residents of St. Louis with clinical data from the four neonatal intensive care units in the St. Louis area; we then compared neonatal mortality during two periods, one before and one after the FDA's approval of surfactant for clinical use (1987 through 1989 and 1991 through 1992). RESULTS: The use of surfactant increased by a factor of 10 between 1987 through 1989 and 1991 through 1992. The neonatal mortality rate among all very-low-birth-weight infants decreased 17 percent, from 220.3 deaths per 1000 very-low-birth-weight babies born alive (in 1987 through 1989) to 183.9 per 1000 (in 1991 through 1992; P = 0.07). This decrease was due to a 41 percent reduction in the mortality rate among white newborns with very low birth weights (from 261.5 per 1000 to 155.5 per 1000; P = 0.003). In contrast, among black infants, the mortality rate for very-low-birth-weight infants did not change significantly (195.6 per 1000 and 196.8 per 1000). The relative risk of death among black newborns with very low birth weights as compared with white newborns with similar weights was 0.7 from 1987 through 1989 and 1.3 from 1991 through 1992 (P = 0.02). The differences in mortality were not explained by differences in access to surfactant therapy, by differences in mortality between black and white infants who received surfactant, or by differences in the use of antenatal corticosteroid therapy. CONCLUSIONS: After surfactant therapy for RDS became generally available, neonatal mortality improved more for white than for black infants with very low birth weights.

Adrenal Cortex Hormones↗
PubMed1996

Racial disparities in outcomes of military and civilian births in California.

OBJECTIVE: To examine racial disparities in prenatal care utilization, birth weight, and fetal and neonatal mortality in a population for whom financial barriers to health care services are minimal. STUDY-DESIGN: Using linked birth, fetal death, and infant death certificate files, we examined prenatal care utilization, birth weight distribution, and fetal and neonatal mortality rates for all white and black births occurring in military hospitals in California from January 1, 1981, to December 31, 1985. These patterns were compared with the experience of their civilian counterparts during the same time period. RESULTS: Black mothers had higher percentages of births occurring in teenaged and unmarried mothers than did white mothers in military and civilian populations. First-trimester prenatal care initiation was lower for blacks in the military (relative risk, 0.79; 95% confidence interval, 0.75-0.82) and civilian (relative risk, 0.51; 95% confidence interval, 0.50-0.52) populations. However, the scale of the disparity in prenatal care utilization was significantly smaller (P < .001) in the military group. Rates of low birth weight and fetal and neonatal mortality among blacks were elevated in the military and civilian groups. However, the racial disparity in low birth weight was significantly smaller in the military group (P < .01 and P < .001, respectively). CONCLUSIONS: In populations with decreased financial barriers to health care, racial disparities in prenatal care use and low birth weight were reduced. However, the persistence of significant disparities suggests that more comprehensive strategies will be required to ensure equity in birth and neonatal outcome.

California↗
PubMed1996

Development and evaluation of a novel patient information system.

A comprehensive patient information datafile of 320 topics has been developed, subserving the domains of medicine, surgery, gynaecology and paediatrics. The system was designed as loose-leaf sheets capable of being photocopied, as well as a computer-based datafile. In a four-practice study, 73% of consecutive general practice attenders could be issued with the relevant disorder or procedure information sheet. With a questionnaire return rate of 79%, 886 patients rated the three criteria of readability, understandability and usefulness of their leaflets as very or quite easy and very or quite useful in more than 94% of instances. This system could be a valuable adjunct to patient education in both general and hospital practice settings.

Family Practice↗