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This paper is a response to an article previously published in JNM's Issues and Opinions column. It provides another perspective regarding the recent troubles of Boston City Hospital's nurse-midwifery service.
This article describes the experiences of 11 staff CNMs practicing in an inner-city hospital serving low-income women. A history of the conflicts between the OB/GYN Department and the Midwifery Service at Boston City Hospital is presented, as well as an overview of events in 1987-88 that resulted in the unanimous resignation of the staff CNMs and the closing of the service. Discussion of the issues is presented, as well as implications for midwifery practice.
This study examines placement outcomes of 206 severely maltreated children 7.5 years after arraignment in Boston Juvenile Court (BJC) on Care and Protection Petitions. Sixty-seven percent (n = 138) of the sample had been permanently removed from their parents and 33% (n = 68) had their cases dismissed in the BJC. At time of this follow-up, 21% of the full sample (n = 44) were still in temporary custody awaiting permanent placement. In addition, 4% (n = 8) of children had "drifted" back to their abusive/neglectful parents despite prior permanent removal. The average time children in this sample spent in probate proceedings (awaiting permanent placement) had increased substantially to 2.1 years since the last overview study of this sample 4 years ago. The rate of court referral for incidences of reabuse (a C&P filing), or delinquency was significantly lower among children who had been permanently placed (p < .003). Rates of court-referral for reabuse charges were the same (16%) for children who were in temporary custody at the time of follow-up and children who had been dismissed back to the parent for whom the original C&P had been filed. Results are discussed in light of the urgent need to restructure time limits in juvenile court proceedings, integrate adequate tracking of child abuse and neglect cases through and across court and agency boundaries, and the use standardized assessments of abused and neglected children as a tool in the adjudication process.
This study examined cigarette smoking among Puerto Rican adolescents in the Boston area in its sociocultural context by describing who uses cigarettes, and by identifying factors that encourage or discourage cigarette use. The study, conducted from 1986-87, used two approaches. The first was to survey 605 Puerto Rican households with adolescents 11-20 years old. Households were identified from a random sample of census blocks in five neighborhoods. In each household, interviews were completed with one adolescent and his or her female caretaker. The second approach was to conduct ethnographic interviews with 40 adolescents selected through a purposive sample of survey respondents from three of the study neighborhoods. Bivariate and multivariate statistical analyses were used to examine the relationships between smoking behavior and characteristics of the adolescents. The results of these analyses were examined in light of the ethnographic data. Overall, 13.7% reported smoking in the month preceding the interview. Smoking was most prevalent among males 17-20. Patterns of smoking were associated with teens' social networks. The Puerto Rican adolescents in this study were more likely to smoke when their friends and household members smoked, if they participated in recreational activities such as sports or unsupervised games, and if they were not in school. These effects varied according to the gender of the respondent.
A program using a strategy of donating a single automatic external defibrillator to 35 schools in the Boston area resulted in compliance with American Heart Association guidelines on automatic external defibrillator placement and training and 2 successful resuscitations from sudden cardiac arrest. Participating schools indicated a high degree of satisfaction with the program.
STUDY OBJECTIVE: Studies indicate that running a marathon can be associated with increases in serum cardiac troponin levels. The clinical significance of such increases remains unclear. We seek to determine the prevalence of troponin increases and epidemiologic factors associated with these increases in a large and heterogeneous cohort of marathon finishers. METHODS: Entrants in the 2002 Boston Marathon were recruited 1 to 2 days before the race. Data collected included demographic and training history, symptoms experienced during the run, and postrace troponin T and I levels. Simple descriptive statistics were performed to describe the prevalence of troponin increases and runner characteristics. RESULTS: Of 766 runners enrolled, 482 had blood analyzed at the finish line. In all, 34% were women, 20% were younger than 30 years, and 92% had run at least 1 previous marathon. Most runners (68%) had some degree of postrace troponin increase (troponin T > or = 0.01 ng/mL or troponin I > or = 0.1 ng/mL), and 55 (11%) had significant increases (troponin T > or = 0.075 ng/mL or troponin I > or = 0.5 ng/mL). Running inexperience (< 5 previous marathons) and young age (< 30 years) were associated with elevated troponins. These correlates were robust throughout a wide range of troponin thresholds considered. Health factors, family history, training, race performance, and symptoms were not associated with increases. CONCLUSION: Troponin increases were relatively common among marathon finishers and can reach levels typically diagnostic for acute myocardial infarction. Less marathon experience and younger age appeared to be associated with troponin increases, whereas race duration and the presence of traditional cardiovascular risk factors were not. Further work is needed to determine the clinical significance of these findings.
The Boston lead safe yards low cost lead in soil treatment, demonstration, and evaluation was developed to explore the viability and effectiveness of low-cost soil interventions to reduce exposure to soil lead hazards. Buildings that had been abated for lead to Massachusetts's deleading standards in the previous 5 yrs and met other program requirements were recruited for the evaluation. Following individual property assessments, yards were treated with application of ground coverings and ground barriers in 2000-2001 and followed up at 1 yr. The treatment cost ranged from 1095 dollars to 5643 dollars with an average of 2798 dollars. Soil lead levels at the building dripline, measured with a field-portable X-ray fluorescence analyzer (Niton Model 702 Spectrum Analyzer), dropped from 2021 PPM at baseline to 206 PPM at 1-yr follow-up. Most of the barrier treatments continued to block access to the lead-contaminated soil at 1yr. At the follow-up, few properties with grass treatment had areas that were completely bare, but 28% had more than a small amount of treated areas bare. Treatments were effective in reducing entryway dust lead in the rear of the building if the residents reported they had maintained the yard treatments. Each additional yard work activity reported was predicted to lower 1-yr floor dust lead loading at the rear common/main and dwelling unit entries by about 20%. Each additional 100 ft2 of yard treated was predicted to lower 1-yr floor dust loading at the rear dwelling unit entry by 19%. Treatments did not show a dust lead effect at 1 yr in the front entryway of the building, but the investigators believe that this may be due to the effect of resident cleaning overshadowing the treatment effect.
The year 1992 marked the 50th anniversary of one of the worst civilian disasters in American history. On November 28, 1942, fire destroyed Boston's Cocoanut Grove nightclub, killing 491 people and sending hundreds more to area hospitals. The disaster came at a unique time in the history of burn care and resulted in a number of important advances in burn treatment, including the first comprehensive descriptions of inhalation injury, improvements in topical treatment of burn wounds, resuscitation of shock, use of antibiotics, and understanding of the metabolic response to injury. In addition, the fire stimulated organization of burn care facilities, public safety legislation, and burn prevention. The history of the fire is reviewed, emphasizing its role in stimulating advances that formed some of the foundations of modern burn treatment.
Infants with congenital diaphragmatic hernia (CDH) show a wide range of anatomic and physiological abnormalities, making it difficult to compare the efficacy of management protocols between institutions. The purpose of this study was twofold: (1) to analyze the results of treatment of CDH in a large tertiary care pediatric center using conventional mechanical ventilation (CMV) with extracorporeal membrane oxygenation (ECMO) as rescue therapy, and (2) to compare these results with those of a parallel study by a similar large urban center that used high-frequency oscillating ventilation (HFOV) as rescue therapy without ECMO. All patients who had CDH diagnosed within the first 12 hours of life and were referred for treatment before repair (between 1981 and 1994) were included in the analysis (n = 196). CMV was used initially in all patients, with conversion to ECMO for refractory hypoxemia or hypercapnea. Between 1981 and 1984, ECMO was not available. Between 1984 and 1987, ECMO was offered postoperatively. Between 1987 and 1991, ECMO was offered preoperatively. In all three groups, aggressive hyperventilation and alkalosis was the norm. Since 1991, permissive hypercapnia has been used. HFOV was used in three patients as stand-alone therapy with one survivor. Twenty patients died without repair: Ten had other lethal anomalies, eight died before ECMO could be instituted, and two died of ECMO-related complications. Overall, 104 patients (53%) survived and 92 (47%) died. Ninety-eight patients (50%) received ECMO, and 43 (44%) survived. Survivors had significantly higher 1- and 5-minute Apgar scores and higher postductal Po2s than did nonsurvivors. Associated anomalies were present in 39%, who had a significantly lower survival than those with isolated CDH. Antenatal diagnosis and side of the defect had no impact on outcome. Survival was not improved with the institution of ECMO or delayed repair but rose significantly to 69% (84% with isolated CDH, P = .007) with the introduction of permissive hypercapnea. Autopsy results from nonsurvivors showed other lethal anomalies and significant barotrauma as the primary causes of death. Comparisons between the Boston and Toronto series showed similar patient demographics and no significant differences in survival in any time period. The two series differed in the number of associated anomalies, their impact on survival, and in the prognosis of right-sided CDH. From the individual and combined analyses the authors concluded: (1) CMV with ECMO as rescue produced an overall survival in CDH patients equivalent to CMV with HFOV in a parallel series, (2) neither HFOV nor ECMO has significantly improved outcome in CDH patients, (3) institution of permissive hypercapnia has resulted in a significant increase in survival, and (4) the leading causes of death in CDH patients appear to be associated anomalies and pulmonary hypoplasia, which are currently untreatable. Barotrauma, which may contribute in up to 25% of deaths in CDH patients is avoidable.
The concentrations of 16 US EPA priority pollutant polycyclic aromatic hydrocarbons (PAHs) were analyzed in four size fractions (< 62, 62-125, 125-250, and > 250 microm) in three contaminated Boston Harbor sediments. Total PAH concentrations ranged from 7.3 to 358 microg/g dry wt. and varied largely among the different size fractions in these sediments. For all three sites, the highest PAH concentrations were associated with the large size (> 250 microm) fractions while the fine silt and clay fractions (< 62 microm) contained relatively low PAHs. Despite the great concentration differences, the composition of PAHs in the four size fractions of these sediments showed similar patterns dominated by PAHs with three or more rings. By examining the distribution patterns of selected alkyl homologs to parent compounds, the results indicate that the major PAHs contributing to the high contamination in the inner harbor sediments were from pyrogenic sources. A positive correlation between PAHs and sedimentary organic carbon exists for all size fractions in the sediments. Calculated organic carbon normalized partition coefficients (log K(oc)) for selected major PAHs indicate near-equilibrium partitioning of PAHs among the different size fractions despite their large concentration variations. Sedimentary organic matter associated with different size fractions was the controlling factor for the observed distribution differences of PAHs among the size fractions. Our results also suggest that sedimentary organic matter with different origins and maturities may have somewhat different PAH sorption characteristics. Particulate organic matter of charcoal, plant detritus and Capitella fecal pellets in the sediments appear to sorb PAHs more strongly than organic matter associated with clay minerals. The strong association of PAHs with these organic particles in sediments will have a great influence not only on their distribution but also on long-term environmental impact.
In light of a 10-year infant mortality crisis in Boston, a comprehensive public health approach was undertaken in which an extensive community-based needs assessment was used to develop a citywide maternal and child health improvement agenda. On the basis of the needs assessment, recommendations were made calling for community-based perinatal initiatives and midwifery services as critical elements in care for underserved communities and enhancement of perinatal services. A case description of one perinatal initiative illustrates the challenges of public health practice and describes a practice setting in which midwives provided leadership and guidance by using an interdisciplinary team approach in the implementation of a community empowerment project.
Effluent from a large combined sewer overflow (CSO) in Boston and receiving waters near the CSO outfall were sampled during dry and wet weather conditions. Surficial sediments were also collected from the vicinity of the CSO and at nearby sites. The samples were analyzed for a variety of organic constituents including organic carbon and nitrogen, linear alkylbenzenes (LABs), coprostanol and polychlorinated biphenyls (PCBs). As judged by the presence of waste-specific markers (LABs, coprostanol), the CSO effluent contains sewage under both dry and wet weather conditions. When rainfall occurs, the concentration of suspended solids and all organic constituents in the particulate phase increase, ultimately approaching those characteristic of untreated sewage. The concentrations of LABs and PCBs in the effluent are strongly correlated, indicating that PCBs in the CSO are derived from sewage inputs. During heavy rainfall, the vast majority (> 90%) of the hydrophobic organic substances are associated with suspended particulate matter, whereas during dry weather, a significant fraction resides in the operationally defined 'dissolved' phase. Estimates of the mass emission rates of CSO constituents show that > 70% of the suspended particles and > 90% of the particulate organic carbon, hydrocarbons and trace organics are discharged during wet weather. Particles in the receiving water appear to be strongly influenced by the CSO effluent during wet weather. Concentrations of PCBs in surficial sediments near the CSO are correlated with those of coprostanol and the LABs, indicating that these compounds are derived from similar sources. Based on the observed correlations, approximately 60-80% of the sedimentary PCBs originate from sewage. Comparison of sigma LAB/coprostanol ratios of effluent particles, surficial sediments and sewage sludges suggest that the vast majority of the marker compounds and the PCBs in sediments are not from the CSO, but are derived from one of two sewage treatment plants that discharged sludge into the harbor until 1991. The sludge-derived contaminants were probably carried by tidal currents into Dorchester Bay and deposited in shallow, quiescent embayments where sedimentation is favored. These results illustrate the potential importance of long-range transport of waste-derived contaminants in urban harbors and their rapid accumulation in localized depocenters.
OBJECTIVES: The study examined child, parent, and case characteristics in a sample of 200 cases of serious child maltreatment brought before the Boston Juvenile Court (BJC) on Care and Protection petitions in 1994. Whether recent changes in Massachusetts law have been effective in reducing delays in adjudication and helping children achieve permanent placements more quickly was also examined. METHOD: Data were abstracted from court records by the research team. The 200 cases were followed prospectively for 4 years. Retrospective data on the families' previous involvement with the protective service system were also abstracted from the records. Data from the 1994 cases were compared to that obtained from a sample of cases brought before the BJC in 1985-1986. RESULTS: Children permanently removed from parental custody in the 1994 sample required less time post-disposition to achieve permanent placements. However, overall, time frames for the 1994 cases remained remarkably similar to those in 1985-1986: children were in the protective service system an average of 5 years; cases required an average of 1.6 years in court; and half of the children permanently removed from parental custody were still in "temporary" foster care at 4-year follow-up. CONCLUSIONS: Although some improvements have occurred since 1985-1986, the system still fails to meet the needs of seriously maltreated children to achieve permanent placements promptly. The implications of the findings for system reform are discussed.
There is increasing demand for measurement tools to assess health related quality of life among the Chinese elderly population in the United States. Health services questionnaires, developed largely in English, often under-represent Chinese Americans. Based on conventional mortality statistics, the public mistakenly views Chinese Americans as a "model" minority with no health problems. This general perception has masked the serious health problems among the elderly Chinese Americans. Using the newly developed Chinese version of the MOS SF-36, we aim to explore how elderly Chinese perceive their own health. Based on 219 elderly Chinese recruited in Boston, the study provided mixed results with regard to the perception of a healthy minority model. While the study subjects perceived similar or better physical health to the U.S. norm, they reported worse mental health than the U.S. norm. We explored possible explanations for this discrepancy and discussed the implications as well as directions for future research.
The authors of this qualitative study explored the health-illness beliefs and practices of Haitians with HIV disease. The authors obtained a purposive sample of five Haitian men and four Haitian women with symptomatic HIV disease or AIDS living in Boston. Five themes were identified through content analysis of interviews and medical record review: (a) incorporation of traditional health-illness beliefs into beliefs about HIV disease; (b) A perceived need to hide HIV disease to avoid rejection, humiliation, and isolation; (c) use of spirituality to help cope with HIV disease; (d) history of limited contact with doctors prior to diagnosis of HIV disease; and (e) use of traditional healing practices for HIV disease. The findings have implications for improving cross-cultural communication between Haitians with HIV disease and their healthcare providers.
BACKGROUND: Recent studies have suggested that mouse allergen exposure and sensitization are common in urban children with asthma. The effectiveness of environmental intervention in reducing mouse allergen exposure has not been established. OBJECTIVE: To evaluate whether environmental intervention of mouse extermination and cleaning results in a reduction in mouse allergen levels. METHODS: Eighteen homes of children with positive mouse allergen skin test results and at least mild persistent asthma in urban Boston, MA, with evidence of mouse infestation or exposure were randomized in a 2:1 ratio (12 intervention and 6 control homes). The intervention homes received an integrated pest management intervention, which consisted of filling holes with copper mesh, vacuuming and cleaning, and using low-toxicity pesticides and traps. Dust samples were collected and analyzed for major mouse allergen (Mus m 1) and cockroach allergen (Bla g 1) at baseline and 1, 3, and 5 months after the intervention was started and compared with control homes. RESULTS: Mouse allergen levels were significantly decreased compared with control homes by the end of the intervention period at month 5 in the kitchen and bedroom (kitchen intervention, 78.8% reduction; control, 319% increase; P = .02; bedroom intervention, 77.3% reduction; control, 358% increase; P < .01; and living room intervention, 67.6% reduction; control, 32% reduction; P = .07). CONCLUSIONS: Mouse allergen levels were significantly reduced during a 5-month period using an integrated pest management intervention.
Emission from automobile catalysts has resulted in elevated platinum concentration in the urban and roadside environment. The work presented here investigates the chronological record of platinum in sediments from the Upper Mystic Lake near Boston, MA, and aims at providing a better understanding of the environmental platinum cycle. Sediment cores were collected by freeze-coring and dated using 210Pb activities, laminations, and depth profiles of elements with a well-known history. Platinum concentrations were determined by quadrupole ICP-MS. While platinum concentration remained relatively low and steady from 1870 to 1975 (<5 ng g(-1)), the time of automobile catalyst introduction is followed by a sharp concentration increase, reaching a plateau in 1992 with 29.2 ng g(-1). Platinum deposition likewise remains low with 0.8 microg m(-2) yr(-1) before 1975, increases from 1975 to 1990, and then remains relatively constant throughout the 1990s with a deposition rate of 7.2 microg m(-2) yr(-1). The average size for Pt-containing particles was estimated to be 17 microm, corresponding to the deposition of approximately 14,000 particles m(-2) yr(-1).
Characteristics probably associated with the fetal hormonal milieu have recently been shown to increase (birth size indicators, prematurity, neonatal jaundice) or decrease (pregnancy toxaemia) breast cancer risk in the female offspring. However, it is unknown whether differences in pregnancy hormone levels may contribute to the marked geographical variation in breast cancer incidence. We have compared, in a highly standardized manner, pregnancy hormone levels in a population with high incidence and one with low incidence of breast cancer. Three hundred and four pregnant Caucasian women in Boston and 334 pregnant Chinese women in Shanghai were enrolled from March 1994 to October 1995. Levels of oestradiol, oestriol, prolactin, progesterone, human growth hormone, albumin and sex hormone-binding globulin were measured in maternal blood at weeks 16 and 27 of gestation and compared between the two study sites using non-parametric Wilcoxon's rank-sum test. Demographical, anthropometrical and pregnancy characteristics were ascertained through interview, and relevant variables concerning delivery and the newborn were abstracted from medical records and paediatric charts. During the first visit, median serum levels of all studied hormones were statistically significant, and in most instances substantially, higher among Chinese women, who have a low incidence of breast cancer, compared with American women, who have a high incidence of breast cancer. An analogous pattern was evident during the second visit, although the relative differences tended to be smaller. Further research is needed to identify lifestyle or other exogenous determinants of pregnancy hormone levels, as well as possible mechanisms by which they may influence carcinogenic processes in the breast and possibly other organs.