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PubMed2002

Trends for inpatient treatment of tubal pregnancy in Maryland.

OBJECTIVE: The purpose of this study was to determine the burden of tubal pregnancy in Maryland in hospitalized patients and to elicit treatment trends. STUDY DESIGN: Patients who were admitted with tubal pregnancy from January 1, 1994, through March 31, 1999, were identified with the use of the Maryland Health Service Cost Review Commission discharge database. Combining this with census data, we calculated the incidence. Cases were then stratified by demographics, presentation, and surgeon volume. Outcome measures included type of medical treatment,conservative (salpingostomy or salpingotomy) or extirpative operation (salpingectomy, salpingo-oophorectomy, oophorectomy, hysterectomy), length of stay, charges, and disposition. The treatment groups were compared with the use of t tests and linear regression, and associations between demographics and type of operation were analyzed with logistic regression. RESULTS: The database included 3729 cases, which yielded an annual incidence of 5.2 per 10,000 women aged 15 to 45 years. Subjects averaged 29.6 years old and were predominantly African American(52.6%) and white (43.3%). Most of the women (67.8%) were seen in the emergency department and were treated surgically (90.7%). Conservative operation was performed in 18.1% of the women; extirpative operation was performed in 81.9% of the women. Significant predictors for extirpative operation were emergency department admission (odds ratio, 1.44; 95% CI, 1.18-1.75), increasing age (odds ratio, 1.07; 95% CI, 1.06-1.09), African American race (odds ratio, 1.87; 95% CI, 1.51-2.31), higher surgeon volume (odds ratio, 1.28; 95% CI, 1.04-1.57), and market area. Length of stay and total charges were higher for the extirpative group(P <.0001). The study lacked the power to detect differences in outcomes for other nonwhite races (5% power), laparoscopy versus laparotomy (15% power), or operating room charges (14% power). CONCLUSION: These data are limited to hospitalized patients and probably underestimate the true incidence of tubal pregnancy. Most patients underwent extirpative operation. Acuity of presentation and increasing age were appropriate predictors of this group. However, physician volume and black race were also predictors. This may be due to differences in the prevalence of disease, unmeasured clinical factors, patient and physician preferences for treatment, barriers that delayed care, or other socioeconomic factors.

Adolescent↗
PubMed2005

Herbicides and nitrates in groundwater of Maryland and childhood cancers: a geographic information systems approach.

This hypothesis-generating study explores spatial patterns of childhood cancers in Maryland and investigates their potential associations with herbicides and nitrates in groundwater. The Maryland Cancer Registry (MCR) provided data for bone and brain cancers, leukemia, and lymphoma, for ages 0-17, during the years 1992-1998. Cancer clusters and relative risks generated in the study indicate higher relative risk areas and potential clusters in several counties. Contingency table analysis indicates a potential association with several herbicides and nitrates. Cancer rates for the four types have a crude odds ratio (OR) = 1.10 (0.78-1.56) in relationship to atrazine, and an OR = 1.54 (1.14-2.07) for metolachlor. Potential association to mixtures of three compounds give an OR = 7.56 (4.16-13.73). A potential association is indicated between leukemia and nitrates, OR = 1.81 (1.35-2.42), and bone cancer with metolachlor, OR = 2.26 (0.97-5.24). These results give insight to generate a hypothesis of the potential association between exposure to these herbicides and nitrates and specific types of childhood cancer.

Acetamides↗
PubMed2006

Molecular epidemiology of pleural and other extrapulmonary tuberculosis: a Maryland state review.

BACKGROUND: Limited information exists about the current epidemiological characteristics of extrapulmonary tuberculosis. However, pleural tuberculosis is usually considered to be a manifestation of primary tuberculosis. Our objective was to use molecular epidemiological techniques to describe the occurrence of pleural and other extrapulmonary tuberculosis in Maryland, a state with moderate tuberculosis incidence. METHODS: We surveyed tuberculosis cases reported with a single site of disease in Maryland from 1996 through 2001. Genotyping of Mycobacterium tuberculosis isolates was performed with an IS6110-based restriction fragment-length polymorphism analysis. DNA clustering of strains with >5 IS6110 bands, with supporting epidemiologic information on patients, served as a proxy for recent transmission. RESULTS: A total of 1811 patients with tuberculosis were reported (incidence, 5.9 cases per 100,000 population). Of 1411 patients (77.9%) with cultures positive for M. tuberculosis, 1246 (88.3%) had a single site of disease, with 934 (75.0%) of these isolates having >5 IS6110 bands. Of the 934 patients included in the analyses, 729 (78.0%) had pulmonary tuberculosis, and 205 (22.0%) had extrapulmonary tuberculosis; of the latter group, 46 patients had pleural disease, and 159 patients had nonrespiratory disease. In multivariate analyses, patients with pleural tuberculosis were not significantly associated with clustered strains, compared with patients with nonrespiratory or pulmonary tuberculosis disease. Having a DNA-clustered strain was negatively associated with nonrespiratory tuberculosis, compared with pulmonary disease (adjusted odds ratio, 0.48; P = .003). CONCLUSIONS: Nonrespiratory extrapulmonary tuberculosis is less likely than pulmonary tuberculosis to be a result of recent infection. Pleural tuberculosis is not an appropriate indicator for recent transmission among our population.

Genotype↗
PubMed1988

Infection control in Maryland nursing homes.

We surveyed 53 randomly chosen Maryland nursing homes for infection control policies and practices. The majority had written infection control policies, an infection control committee, and a designated practitioner for infection control; in most facilities, however, the infection control practitioner had other major duties, spent little time on infection control, and had no specific training in the field. Thirty-four percent of homes in the survey performed routine environmental cultures, and more than half had insufficient or no isolation policies for infected decubiti and acute diarrhea. In general, the intensity of infection surveillance and the extent of infection control measures increased with the level of care provided, from domiciliary homes to homes providing chronic care. Employee health care fared generally well: 60% of homes offered influenza vaccine to employees and 66% had restriction policies for employees with upper respiratory infections. While the majority of homes offered the influenza vaccine to residents, acceptance of other vaccines recommended for the elderly was less widespread. We conclude that infection control efforts are made in most Maryland nursing homes; however, appropriate guidelines and more effort to educate nursing home personnel in proper infection control practices are badly needed.

Aged↗
PubMed1995

Occupational risk of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infections among funeral service practitioners in Maryland.

OBJECTIVE: To estimate the risk of exposure and infection with bloodborne pathogens, a seroepidemiologic survey was conducted among funeral service practitioners (FSPs) in Maryland. METHOD: Of 262 members of the Maryland State Funeral Directors Association, 130 (49%) volunteered to participate in the study. In addition to a brief questionnaire, designed to assess both occupational and non-occupational risk factors for bloodborne pathogen infection, participants were screened for markers of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and past hepatitis B virus (HBV). Titers for antibodies to hepatitis B surface antigen (anti-HBs) also were examined and compared with history of hepatitis B vaccination. RESULTS: Seroprevalence for HIV, HBV, and HCV infection was 0.8%, 4.6%, and 0%, respectively. Nearly 19% of participants reported at least one bloodborne exposure in the past 6 months. The one HIV infection and all but two of the HBV infections were correlated with well-established non-occupational risk behaviors. Disposable gloves were worn by 96%, and eating, drinking, or smoking during embalming were infrequent. Sixty-one percent of FSPs reported having received one or more doses of hepatitis B vaccine at some time in the past. Of those who reported having received all three doses of vaccine, 67% had adequate titers to hepatitis B surface antibody, the marker of protection related to vaccination. CONCLUSION: Compared with prior studies of FSPs, this study found a low rate of occupational exposures and a high rate of hepatitis B vaccination, suggesting improved compliance with recommendations for preventing transmission of bloodborne pathogens in the workplace.

Funeral Rites↗
PubMed1990

Alcohol consumption and blood pressure in the 1982 Maryland Hypertension Survey.

This study examines the relationship between alcohol consumption and blood pressure in the 1982 Maryland Hypertension Survey, a crossectional population-based household survey of blood pressure control in adults residing in Maryland. In individuals less than 50 years old, a J shaped dose-response association was found with abstainers and heavy alcohol consumers having significantly higher blood pressures than moderate alcohol consumers (1 to 2 beverages per day). In individuals 50 years and older, alcohol was associated with higher blood pressures only at the highest levels of intake (greater than 2 beverages per day). The prevalence of hypertension was similarly affected in each age group. This association between alcohol consumption and blood pressure was independent of several variables that are associated with increased blood pressure such as age, sex, race, smoking, education, Quetelet index, social participation, and physical activity. The population attributable risk for hypertension due to heavy alcohol consumption is 5 to 7% in those greater than 50 years old and 6 to 8% in those less than 50 years old. These data suggest that alcohol consumption is a potentially important risk factor for elevations in blood pressure and hypertension.

Adolescent↗
PubMed1986

Molecular epidemiology of neonatal meningitis due to Citrobacter diversus: a study of isolates from hospitals in Maryland.

Six cases of neonatal meningitis due to Citrobacter diversus were diagnosed in three Baltimore (Maryland) hospitals between 1983 and 1985. Using plasmid profiles, biotypes, serotypes, and chromosomal restriction endonuclease digests as epidemiological markers, we studied 63 isolates of C. diversus (including four isolates from cerebrospinal fluid) from these and seven other hospitals in Maryland. Within two of the three hospitals with meningitis cases, the same strain of C. diversus was isolated from case infant(s), healthy neonates, and nursery personnel. In all three hospitals, C. diversus strains different from those implicated as a cause of meningitis were also isolated. Other than the meningitis-associated strains, 15 different strains of C. diversus were isolated from infants in the hospitals studied, with several distinct clusters of asymptomatic, colonized infants identified.

Citrobacter↗
PubMed1992

Distribution, density, and Lyme disease spirochete infection in Ixodes dammini (Acari: Ixodidae) on white-tailed deer in Maryland.

A Statewide survey of ticks parasitizing white-tailed deer was carried out in Maryland during November 1989 to assess the status of the deer tick, Ixodes dammini Spielman, Clifford, Piesman & Corwin, the major vector of Lyme disease in the northeastern United States. Ticks were collected from deer carcasses brought in by hunters at 23 check stations (one per county). A total of 3,437 I. dammini were collected from 538 of 1,281 deer (42%), together with 2,013 Dermacentor albipictus (Packard) and 23 Amblyomma americanum (L.) from 34 and 0.5% of deer respectively. I. dammini prevalence ranged from 0 to 79% of deer and mean abundance from 0 to 7.3 ticks per deer at different check stations. Lyme spirochete, Borrelia burgdorferi Johnson, Schmid, Hyde, Steigerwalt & Brenner, infection rates in ticks ranged from 0 to 21%, with a mean of 8%. Deer-tick density and spirochete infection rates varied with physiographic region and were low in the Appalachian, intermediate in the Piedmont, and high in the Western and Eastern Coastal Plains regions. County-based human case rates correlated positively with I. dammini abundance. We concluded that I. dammini was well established except in the mountainous western region of Maryland and was involved in Lyme disease transmission.

Animals↗
PubMed1988

Investigation of an outbreak of Salmonella enteritidis gastroenteritis associated with consumption of eggs in a restaurant chain in Maryland.

Salmonella enteritidis ser. enteritidis was isolated from patrons and employees of three restaurants in a restaurant chain in Maryland during August and September 1985. Isolates from all three restaurants had identical plasmid profiles; this profile was present in 13 of 40 randomly selected S. enteritidis isolates received by the Maryland state health department laboratory during a comparable time period. The outbreak in one restaurant resulted in at least 71 illnesses, with 17 persons known to have been hospitalized. Scrambled eggs served on a "breakfast bar" were implicated as the vehicle of transmission in this restaurant, with eggs a possible vehicle in another of the three restaurants. The data point out the risks associated with improper handling of eggs in food service establishments, provide further evidence for the observed association between S. enteritidis and eggs in the northeastern United States, and demonstrate the utility of plasmid analysis in investigation of outbreaks involving common Salmonella serotypes.

Adolescent↗
PubMed1989

Salary, education, and managerial-level differences of physical therapists in Maryland.

The purpose of this study was to determine whether differences existed between a random sample of male and female physical therapists on selected factors. These factors included salary, managerial level, number of courses taken in management or administration, years of work experience in physical therapy, and years of seniority in an organization. A self-reported questionnaire was sent to 400 licensed physical therapists in Maryland who were also American Physical Therapy Association members. Data were analyzed on the 244 respondents using chi-square tests, t tests, and critical ratios. Results showed that female physical therapists, when employed full time in Maryland as department managers, on average, earned significantly less than their male counterparts. A significant difference existed between male and female department managers for full-time work experience in physical therapy. Neither the number of management courses taken nor seniority in an organization were significantly different for male and female physical therapists, regardless of managerial level. Conclusions were that differences existed on several factors between male and female physical therapy department managers and that schools preparing physical therapists for entry into the profession should assess the need for management preparation.

Administrative Personnel↗
PubMed1990

Seasonal and annual variation of antibody to HIV-1 among male inmates entering Maryland prisons: update.

Previous serosurveys of antibody to HIV-1 among incoming male inmates in Maryland between April and June of 1985, 1986 and 1987 have shown a prevalence of 7.0, 7.7 and 7.0%, respectively, with stability persisting after multivariate adjustment. To investigate seasonality and update annual trends, excess sera were obtained from incoming male inmates between August 1987 and August 1988. Correctional personnel also provided demographic variables of age, race, offense, category, and jurisdiction. Once rendered anonymous, specimens were assayed for antibody to HIV-1 using enzyme-linked immunosorbent assay and Western blot. For the 12-month study period, 415 (7.9%) of 5262 consecutive male entrants were seropositive. On univariate and multivariate analyses, no significant change in seroprevalence or risk by subgroup was noted by month or season. For data from April to June 1988, 113 (8.1%) of 1398 consecutive entrants demonstrated anti-HIV-1; seropositivity was associated with age greater than 25 years, Black race, and Baltimore jurisdiction. No significant change was found over time in seroprevalence or risk of HIV-1 infection by subgroup in multivariate analysis combining data for 1985-1988. These data provide additional evidence to suggest stability of HIV-1 seroprevalence in Maryland male prison entrants.

Acquired Immunodeficiency Syndrome↗
PubMed1998

The development of a risk-adjusted capitation payment system: the Maryland Medicaid model.

This article describes the risk-adjusted payment methodology employed by the Maryland Medicaid program to pay managed care organizations. It also presents an empirical simulation analysis using claims data from 230,000 Maryland Medicaid recipients. This simulation suggests that the new payment model will help adjust for adverse or favorable selection. The article is intended for a wide audience, including state and national policy makers concerned with the design of managed care Medicaid programs and actuaries, analysts, and researchers involved in the design and implementation of risk-adjusted capitation payment systems.

Ambulatory Care↗
PubMed1997

Costs to Medicaid of advancing immunosuppression in an urban HIV-infected patient population in Maryland.

Human immunodeficiency virus (HIV) infection is increasingly an urban disease in the United States, and Medicaid is the principal payer of the health care costs of patients with HIV. We wished to determine the costs to Medicaid of patients in Maryland infected with HIV as immunosuppression progresses, and to determine how costs varied by demographic characteristics of the patient. We analyzed combined economic and clinical data in patients from the Johns Hopkins HIV Service, the provider of primary and specialty care for a majority of HIV-infected patients in the Baltimore metropolitan region. All patients were enrolled in Medicaid and received care longitudinally in Maryland from July 1992 to June 1995. Monthly Medicaid payments were calculated for all inpatient and outpatient services by sex, race, age, use of injecting drugs, CD4+ count (>500, 201-500, 51-200, < or =50 cells/mm3), several opportunistic diseases, and death. Lifetime costs were also calculated by use of a Markov simulation. During 13,174 person-months of follow-up in 606 patients, a total of $18,223,700 in Medicaid payments was made. Mean monthly payments ranged from $2,436 (SE $171) for patients with CD4+ counts < or =50 cells/mm3 to $1,015 (SE $177) for patients with CD4+ counts >500 cells/mm3. Mean monthly inpatient costs ranged from $1,355 (SE $131) for CD4+ counts < or =50 cells/mm3 and $617 (SE $164) for CD4- counts >500 cells/mm3. For those with CD4+ counts < or =50 cells/mm3, outpatient pharmacy costs averaged $515 (SE $57) monthly, second only to inpatient costs. In bivariate analysis, costs were significantly higher (p = .013) in men (mean $1696; SE $126) than in women (mean $1,208; SE $101), though the difference was not significant with multivariate adjustment. Cytomegalovirus retinitis was the most costly opportunistic disease, with mean monthly costs of $7,825 (SE $1,141) within the 6 mo after diagnosis. Within 6 mo of death, mean monthly costs are $4,600 (SE $424). Lifetime costs for treating an HIV-infected patient who presents with a CD4+ count >500 cells/mm3 are $133,500 over 8.3 years of life. We concluded that in the clinic where the analysis was done, average costs to Medicaid of treating patients increase more than two-fold as the CD4+ count declines from >500 cells/mm3 to < or =50 cells/mm3. Interventions that decrease hospitalization, opportunistic disease, and the costs of terminal care may be most likely to decrease overall costs. Demographic patient characteristics do not affect costs significantly when access to care is comparable.

AIDS-Related Opportunistic Infections↗
PubMed2003

Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000.

OBJECTIVE: The epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients. DESIGN: Observational study using a state discharge database. SETTING: All hospitals in Maryland. PATIENTS: We obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18-29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0-5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5-8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8-10), and increased total hospital charges (estimated mean increase of 22,000 US dollars; 95% confidence interval, 19,000 US dollars-25,000 US dollars). CONCLUSIONS: Aspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.

Adolescent↗
PubMed2006

Predictors of caregiver unawareness and nontreatment of dementia among residents of assisted living facilities: the Maryland Assisted Living Study.

OBJECTIVE: Assisted living (AL) is a rapidly expanding residential option for the senior population. With increased utilization, it becomes important to understand the detection and treatment of dementia in this setting, but little is known. The objective of this study was to identify and evaluate factors associated with caregiver unawareness of dementia and failure to treat dementia in AL. METHODS: The setting was a cross-sectional study of a random sample of AL facilities in central Maryland (The Maryland Assisted Living Study). Geriatric psychiatrists evaluated 198 participants and assigned dementia diagnoses to 134 residents (67.7%). The extent to which dementia was recognized and treated in these facilities was estimated on the basis of caregiver interview and chart review data. Using logistic regression models, demographic, cognitive, and functional measures were evaluated as predictors of caregiver unawareness and nontreatment of dementia. RESULTS: Severity of cognitive and functional impairment, number of neuropsychiatric symptoms, and male gender were all independent predictors of caregiver unawareness of dementia. Family and caregiver unawareness of dementia and female gender were predictors of failure to treat dementia. Detection and treatment were not associated with race, age, or overall medical health. CONCLUSIONS: Caregivers were more likely to be unaware of dementia in residents who did not have severe cognitive impairment or obvious behavioral and functional problems. Caregiver and family unawareness were in turn associated with nontreatment. Observed gender differences in detection and treatment will require replication and further study. These observations suggest that systematic educational interventions for caregivers and families may improve detection and hence treatment in the AL setting.

Aged↗
PubMedDate not supplied

Driving and epilepsy: changing the law in Maryland.

The Epilepsy Association of Maryland, an affiliate of the Epilepsy Foundation of America (EFA), recognized that the Maryland state regulations and laws on driving licensing restricted the rights of individuals with epilepsy. After identifying the problem, the Association determined the needed changes and planned a legislative strategy to accomplish the change. Once the change was achieved, the Association planned and executed steps necessary for successful implementation of the change.

Accidents, Traffic↗
PubMed1990

Beliefs and policies of Maryland nursing home medical directors regarding tetanus immunization.

Tetanus is more common in the elderly, who have a higher case-fatality rate than younger age groups. Immunization against tetanus is recommended for all elderly, including nursing home residents, but the tetanus immunization policies of nursing homes are unknown. Nursing home medical directors in Maryland were surveyed about their beliefs concerning tetanus and the tetanus immunization policies of their nursing homes. One hundred twenty-five directors of 212 responded (59%). In most of the nursing homes, no policies existed for routine tetanus immunization. Medical directors graduating from medical school after 1960 and medical directors with more than 50 nursing home patients were more likely to believe that tetanus immunization is cost-effective in nursing home patients. Only 3% of the respondents always immunize their nursing home patients with chronic skin ulcers. We believe tetanus immunization is an uncommon practice in Maryland nursing homes. Nursing home medical directors should establish policies to promote tetanus immunization.

Aged↗
PubMed2001

Impact of ambulance diversion policies in urban, suburban, and rural areas of Central Maryland.

UNLABELLED: As a method to control patient flow to overburdened hospitals, effective emergency medical services (EMS) systems provide policies for ambulance diversion. The Maryland state EMS system supports two types of alert for general hospital use: red alert, aimed at limiting the delivery of patients who may require intensive care unit (ICU) admission, and yellow alert, aimed at preventing further overload of already overtaxed emergency departments (EDs). OBJECTIVE: To examine the effect of those alert policies in different geographical environments, urban, suburban, and rural. METHODS: Alert data for 23 hospitals in Central Maryland and ambulance arrival data for approximately 138,000 ambulance calls during calendar year 1996 were combined and analyzed. The impacts of diversion practices in the geographic areas were compared. RESULTS: Red alert reduced volume in all patient acuity levels in all geographic areas by a statistically significant 0.4 patient/hr. Yellow alert diverted low-acuity patients at the rate of 0.13 patient/hr (p<0.001) in urban areas and at the rate of 0.16 patient/hr (p<0.001) in suburban areas, but had minimal impact in the flow of patients in the rural environment. CONCLUSIONS: The ED diversion policy has some limited effect in preventing further patient volume in urban and suburban areas, but has virtually no impact in rural areas. However, an ICU diversion policy diverts patients of all acuities uniformly and inordinately diverts patients not likely to require ICU admissions while having only minimal impact on patients who do require ICU resources. The impact of red alert is uniform in all geographic areas. The impact and efficacy of ambulance diversion policies should be evaluated to ensure they are having the intended effect. While perhaps initially effective, the impact of alert policies may change over time.

Ambulances↗