Necrotising soft tissue infections: the effect of hyperbaric oxygen on mortality.

In a single-centre, retrospective, case-controlled study of patients attending the Alfred Hospital in Prahran, Victoria, we assessed the effect of hyperbaric oxygen therapy (HBOT) in reducing mortality or morbidity in patients with necrotising fasciitis (NF) over a 13-year period from 2002 to 2014. A total of three hundred and forty-one patients with NF were included in the study, of whom 275 received HBOT and 66 did not. The most commonly involved sites were the perineum (33.7%), lower limb (29.9%) and trunk (18.2%). The commonest predisposing factor was diabetes mellitus (34.8%). Polymicrobial NF (type 1 NF) occurred in 50.7% and Group A streptococcal fasciitis (type 2 NF) occurred in 25.8% of patients. Mortality was 14.4% overall, 12% in those treated with, and 24.3% in those not treated with, HBOT. ICU support was required in 248 (72.7%) patients. Independent factors impacting on mortality included HBOT (odds ratio [OR] 0.42 [0.22 to 0.83], P=0.01), increased age (OR 1.06 [1.03 to 1.08], P=0.001) and immunosuppression (OR 2.6 [1.23 to 5.51], P=0.01). Mortality was linked to illness severity at presentation, however when adjusted for severity score and need for intensive care management, HBOT was associated with significant reduction in mortality.

The impact on clients of a community-based infant mortality reduction program: the National Healthy Start Program Survey of Postpartum Women.

OBJECTIVES: This study assessed the effect of the national Healthy Start Program on its clients. METHODS: We used a cross-sectional survey of a sample from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) rosters of women less than 6 months postpartum who were residents of Healthy Start Program areas. RESULTS: Healthy Start clients revealed higher sociodemographic risk, but not behavioral risk, for adverse pregnancy outcome than other area residents. They did not differ from other residents in receipt of services except for a greater likelihood of receiving case management, using birth control at the time of the interview, and rating their prenatal care more highly. CONCLUSIONS: The Healthy Start Program succeeded in enrolling women at high risk. It had little effect on the immediately concluded pregnancy, but it might influence future outcomes.

Back to the future: community involvement in the Healthy Start Program.

This article discusses how community involvement is incorporated into Healthy Start, a major initiative to reduce infant mortality in selected communities with disproportionately high levels of infant mortality. Based on site visits to each of the fifteen original Healthy Start project areas, we discovered that two main community involvement strategies were used: a service consortium model and a community empowerment model. In the service consortium model, the community is involved primarily through a consortium of local providers, other professionals, and some governmental representatives who help to plan services. The community empowerment model involves the community by engaging neighborhood-based groups, contracting with community-based organizations, employing community residents as lay workers in the Healthy Start program, and creating other economic development initiatives. Important lessons drawn from this study are that the purpose and commitment to community involvement is not always clear; that it is difficult to involve community residents; that efforts to involve the community are extremely labor intensive; that given monetary incentives, it is easier to involve community providers than residents; that community involvement may conflict with efficient program operations; that increased community involvement may create program goals that differ from the program's original goals; and that community involvement may slow program development.

Household participation in the Food Stamp and WIC programs increases the nutrient intakes of preschool children.

We examined the effects of household participation in the Food Stamp and WIC Nutrition Programs on the nutrient intakes of preschoolers using data from the 1989-1991 Continuing Survey of Food Intake by Individuals. Nonbreastfeeding children, 1-4 y of age, with 3 d of dietary data and whose households had incomes < 130% of the poverty level were included in the study sample (n = 499). Nutrient adequacy ratios for each of 15 nutrients were the dependent variables in multiple regression models that controlled for the following: age, sex and ethnicity of the individual; income, size and location of the household; schooling of the household head; home ownership; school lunch and breakfast participation; and season in which the interview was conducted. WIC benefits positively influenced (P < 0. 05) the intakes of 10 nutrients. For iron and zinc, the average increase due to WIC represented 16.6 and 10.6%, respectively, of the preschooler recommended dietary allowance (RDA) for these nutrients. The same analyses of the Food Stamp Program revealed increases in five nutrients. For iron and zinc, the average increase due to Food Stamps represented 12.3 and 9.2%, respectively, of the preschooler RDA. The effects of the WIC Program on the intakes of iron and zinc were greater than that of cash income, and neither program affected the intakes of fat, saturated fat or cholesterol.

Programs that mitigate the effects of poverty on children.

This article reviews six federally funded in-kind public assistance programs that are intended to mitigate the effects of poverty on low-income children by providing access to basic human necessities such as food, housing, education, and health care. The evidence suggests that, while each program can be improved, these programs do achieve their basic objectives. In general, food stamps, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and school nutrition programs are successful at providing food assistance to low-income children, starting with the prenatal period and continuing through the school years. The Food Stamp Program provides food assistance nationwide to all households solely on the basis of financial need and is central to the food assistance safety net for low-income children. The WIC program has helped reduce the prevalence of iron-deficiency anemia in infants and children and has increased intakes of certain targeted nutrients for program participants. The school nutrition programs provide free or low-cost meals that satisfy the dietary goals of lunches and breakfasts to most school-age children. The Medicaid program has extended health insurance coverage to millions of low-income children. However, many children remain uninsured, and children enrolled in Medicaid do not have the same access to medical care as privately insured children. Relatively little is known about the effects of Medicaid on children's health status. For Head Start, empirical evidence suggests that participating children show enhanced cognitive, social, and physical development in the short term. Studies of the longer-term impacts of Head Start are inconclusive. Although housing assistance improves housing quality and reduces housing costs for recipients, there is a large unmet need for acceptable, affordable housing among poor families. Important gaps remain in our knowledge of the effects of these programs on the well-being of children. Questions regarding a program's effects over time on health and developmental outcomes particularly need more study.

Evaluating the Healthy Start program. Design development to evaluative assessment.

The national evaluation of the federally funded Healthy Start program involved translating a design for a process and outcomes evaluation and standard maternal and infant data set, both developed prior to the national evaluation contract award, into an evaluation design and client data collection protocol that could be used to evaluate 15 diverse grantees. This article discusses the experience of creating a process and outcomes evaluation design that was both substantively and methodologically appropriate given such issues as the diversity of grantees and their community-based intervention strategies; the process of accessing secondary data sources, including vital records; the quality of client level data submissions; and the need to incorporate both qualitative and quantitative approaches into the evaluation design. The relevance of this experience for the conduct of other field studies of public health interventions is discussed.

Background of the School Nutrition Dietary Assessment Study.

The National School Lunch Program (NSLP) and the School Breakfast Program (SBP) are federally sponsored nutrition programs operating daily in the nation's schools. The School Nutrition Dietary Assessment Study had three primary objectives: 1) to describe the nutrient composition of NSLP lunches and SBP breakfasts as offered to students, 2) to analyze the dietary intakes of students, and 3) to compare the dietary intakes of program participants with nonparticipants. This paper describes the school nutrition programs, discusses current program issues and policy concerns, and provides an overview of the study objectives and papers included in this journal issue.

Dietary intakes of students.

This paper relies on 24-h dietary recall data from a nationally representative sample of approximately 3350 students to analyze the dietary intakes of students. Most US students eat at least five times during the day, and nearly all eat at least three times per day. The average daily intake of vitamins and minerals at least meets the recommended dietary allowances (RDAs). Overall, students consume more food energy on average than recommended, suggesting that some may be at risk of consuming more food energy than is optimal. Students also consume more protein, total fat, saturated fat, and sodium than is recommended for good health. National School Lunch Program (NSLP) participants' mean intakes of most nutrients at lunch meet the program goal of at least one-third of the RDA. NSLP participants, however, consume more fat, saturated fat, and sodium than is recommended. School Breakfast Program (SBP) participants' mean intakes of most nutrients at breakfast also exceed the program goal of one-fourth of the RDA. However, their breakfast intakes of saturated fat as a percentage of food energy, cholesterol, and sodium exceed dietary recommendations.

Dietary effects of the National School Lunch Program and the School Breakfast Program.

In this paper we use 24-h dietary recall data to assess the dietary effects of participation in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP). After adjustment for differences in characteristics between NSLP participants and nonparticipants, NSLP participation is associated with higher lunch intakes of vitamin A, calcium, and magnesium, and a lower intake of vitamin C. Although mean intakes of other key dietary components such as food energy, iron, cholesterol, and sodium are higher for NSLP participants than for nonparticipants, these differences appear to be due to underlying differences in unobserved characteristics (eg, food preferences, appetites, or food energy needs) rather than to the NSLP. Both at lunch and over 24 h, NSLP participation is associated with consumption of a higher percentage of food energy from fat and saturated fat. SBP participation is associated with higher breakfast intakes of food energy, calcium, riboflavin, phosphorus, and magnesium, and with a higher percentage of breakfast food energy from fat and saturated fat, and a lower percentage of food energy from carbohydrate.

The School Nutrition Dietary Assessment Study: summary and discussion.

This paper summarizes the key findings of the School Nutrition Dietary Assessment Study and discusses the implications for policy and practice in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP). Reducing total fat offered in NSLP lunches to the amount set in the Dietary Guidelines, as called for in the proposed regulations published by the US Department of Agriculture in June 1994, would be facilitated by changing the legislative requirement to serve whole milk. In addition, the following menu choices and meal preparation methods would reduce considerably the amounts of fat in NSLP lunches: reducing the average meat serving from 2 to 1.5 oz; eliminating high-fat meats, high-fat cheese, nuts, and nut butters; eliminating high-fat desserts and milk-based desserts; and reducing sharply the use of added fats in food preparation.

Medicaid costs and birth outcomes: the effects of prenatal WIC participation and the use of prenatal care.

This study examines the effects of prenatal WIC participation and the use of prenatal care on Medicaid costs and birth outcomes in five states--Florida, Minnesota, North Carolina, South Carolina, and Texas. The study period is 1987 for Florida, Minnesota, North Carolina, and South Carolina and January-June 1988 for Texas. Prenatal WIC participation was associated with substantial savings in Medicaid costs during the first 60 days after birth, with estimates ranging from $277 in Minnesota to $598 in North Carolina. For every dollar spent on the prenatal WIC program, the associated savings in Medicaid costs during the first 60 days ranged from $1.77 to $3.13 across the five states. Receiving inadequate levels of prenatal care was associated with increases in Medicaid costs ranging from $210 in Florida to $1,184 in Minnesota. Prenatal WIC participation was associated with higher newborn birthweight, while receiving inadequate prenatal care was associated with lower birthweight.

An analysis of variations in U.S. fertility and female labor force participation trends.

This study is based on time series data from 1947-1977 on fertility and female labor force participation, and examines (a) the effects of male relative income and female earnings on the level and timing of fertility and female labor force participation, and (b) the relative importance of variations in relative income and female wage rates in explaining the fluctuations in both fertility and female labor supply. The results suggest that relative income exerts a significant positive effect on fertility and a negative effect on female work effort. However, female wage rates appear to be the dominant factor in explaining variations in fertility and female labor force participation over the past two decades, with increases in female earnings leading to both depressed fertility and increased labor force participation of women.