Philippine herpetology (Amphibia, Reptilia), 20 years on: two decades of progress towards an increasingly collaborative, equitable, and inclusive approach to the study of the archipelago's amphibians and reptiles.

A first review of the history, status, and prospects for Philippine herpetology conducted more than two decades ago (2002) summarized the diverse topics studied and highlighted the development and achievements in research up to the year 2000. This study revisits and re-assesses what Philippine herpetology has accomplished, both as a discipline and a community, during the last two decades (2002-2022). A total of 423 herpetological publications was collated, revealing a substantial increase in annual publications, rising from approximately four per year during 2002-2008 to around 28 per year in 2009-2022. Half of the published studies focused on squamate reptiles (lizards 30.5%, snakes 21%) and 28.4% on amphibians, 5.9% on turtles, and 2.6% on crocodiles. The remaining 11.6% of studies focused simultaneously on multiple taxa (i.e., faunal inventories). Diversity and distribution (35.2%) and ecological (26.5%) studies remained popular, while studies on taxonomy (14.9%), phylogenetics and biogeography (11.8%), and conservation (11.6%) all increased. However, geographical gaps persist urging immediate surveys in many understudied regions of the country. Finally, we found a balanced representation between Filipino and foreign first authors (1.0:1.1), yet a substantial gender gap exists between male and female first authors (7.1:1.0). Nonetheless, the steep increase in publications and the diversity of people engaged in Philippine herpetology is a remarkable positive finding compared to the 20 years preceding the last review (1980-2000). Our hope is that the next decades will bring increasingly equitable, internationally collaborative, and broadly inclusive engagement in the study of amphibians and reptiles in the Philippines.

Inter-household transfers of material goods among Sama "sea nomads" of the Philippines: Reciprocity, helping, signaling, or something else?

The extent to which humans share with both kin and non-kin is a defining characteristic of our species. Evolutionary research suggests that pervasive reliance on inter-individual transfers of goods and services may have evolved to support a cooperative breeding adaptation in humans. However, while intensive food sharing between individuals and families has frequently been investigated in small-scale human societies, a comprehensive analysis of the daily transfers of all material goods has not been attempted. Likewise, while much previous research on cooperative transfers focused on terrestrial foraging populations, less attention is paid to other small-scale economic modalities traditionally inhabited by humans. Drawing on over three years' worth of interviews and observational data from a community of primarily ethnic Sama people residing along the coast of Southern Mindanao Island in the Philippines, this paper examines the overall transfer patterns of material goods in a marine foraging economy. A quantitative description of resource acquisition is followed by an in-depth exploration of the characteristics of individual households and household dyads who gave and/or received more during the study period. Results indicate that a household's age and income are consistently correlated with increased inflow and outflow of material goods. Results also suggest differential motivations underlie inter-household sharing of food, money, and other goods in the study community. Most importantly, we find that both daily and long-term reciprocity overwhelmingly drive sharing within household dyads in the study community, despite secondary effects of kinship, relative need, and relative household age between household dyads.

Bringing Fundamental Insights of Induced Resistance to Agricultural Management of Herbivore Pests.

In response to herbivory, most plant species adjust their chemical and morphological phenotype to acquire induced resistance to the attacking herbivore. Induced resistance may be an optimal defence strategy that allows plants to reduce metabolic costs of resistance in the absence of herbivores, allocate resistance to the most valuable plant tissues and tailor its response to the pattern of attack by multiple herbivore species. Moreover, plasticity in resistance decreases the potential that herbivores adapt to specific plant resistance traits and need to deal with a moving target of variable plant quality. Induced resistance additionally allows plants to provide information to other community members to attract natural enemies of its herbivore attacker or inform related neighbouring plants of pending herbivore attack. Despite the clear evolutionary benefits of induced resistance in plants, crop protection strategies to herbivore pests have not exploited the full potential of induced resistance for agriculture. Here, we present evidence that induced resistance offers strong potential to enhance resistance and resilience of crops to (multi-) herbivore attack. Specifically, induced resistance promotes plant plasticity to cope with multiple herbivore species by plasticity in growth and resistance, maximizes biological control by attracting natural enemies and, enhances associational resistance of the plant stand in favour of yield. Induced resistance may be further harnessed by soil quality, microbial communities and associational resistance offered by crop mixtures. In the transition to more sustainable ecology-based cropping systems that have strongly reduced pesticide and fertilizer input, induced resistance may prove to be an invaluable trait in breeding for crop resilience.

Parasitism causes changes in caterpillar odours and associated bacterial communities with consequences for host-location by a hyperparasitoid.

Microorganisms living in and on macroorganisms may produce microbial volatile compounds (mVOCs) that characterise organismal odours. The mVOCs might thereby provide a reliable cue to carnivorous enemies in locating their host or prey. Parasitism by parasitoid wasps might alter the microbiome of their caterpillar host, affecting organismal odours and interactions with insects of higher trophic levels such as hyperparasitoids. Hyperparasitoids parasitise larvae or pupae of parasitoids, which are often concealed or inconspicuous. Odours of parasitised caterpillars aid them to locate their host, but the origin of these odours and its relationship to the caterpillar microbiome are unknown. Here, we analysed the odours and microbiome of the large cabbage white caterpillar Pieris brassicae in relation to parasitism by its endoparasitoid Cotesia glomerata. We identified how bacterial presence in and on the caterpillars is correlated with caterpillar odours and tested the attractiveness of parasitised and unparasitised caterpillars to the hyperparasitoid Baryscapus galactopus. We manipulated the presence of the external microbiome and the transient internal microbiome of caterpillars to identify the microbial origin of odours. We found that parasitism by C. glomerata led to the production of five characteristic volatile products and significantly affected the internal and external microbiome of the caterpillar, which were both found to have a significant correlation with caterpillar odours. The preference of the hyperparasitoid was correlated with the presence of the external microbiome. Likely, the changes in external microbiome and body odour after parasitism were driven by the resident internal microbiome of caterpillars, where the bacterium Wolbachia sp. was only present after parasitism. Micro-injection of Wolbachia in unparasitised caterpillars increased hyperparasitoid attraction to the caterpillars compared to untreated caterpillars, while no differences were found compared to parasitised caterpillars. In conclusion, our results indicate that host-parasite interactions can affect multi-trophic interactions and hyperparasitoid olfaction through alterations of the microbiome.

Parasitism by endoparasitoid wasps alters the internal but not the external microbiome in host caterpillars.

BACKGROUND: The microbiome of many insects consists of a diverse community of microorganisms that can play critical roles in the functioning and overall health of their hosts. Although the microbial communities of insects have been studied thoroughly over the past decade, little is still known about how biotic interactions affect the microbial community structure in and on the bodies of insects. In insects that are attacked by parasites or parasitoids, it can be expected that the microbiome of the host insect is affected by the presence of these parasitic organisms that develop in close association with their host. In this study, we used high-throughput amplicon sequencing targeting both bacteria and fungi to test the hypothesis that parasitism by the endoparasitoid Cotesia glomerata affected the microbiome of its host Pieris brassicae. Healthy and parasitized caterpillars were collected from both natural populations and a laboratory culture. RESULTS: Significant differences in bacterial community structure were found between field-collected caterpillars and laboratory-reared caterpillars, and between the external and the internal microbiome of the caterpillars. Parasitism significantly altered the internal microbiome of caterpillars, but not the external microbiome. The internal microbiome of all parasitized caterpillars and of the parasitoid larvae in the caterpillar hosts was dominated by a Wolbachia strain, which was completely absent in healthy caterpillars, suggesting that the strain was transferred to the caterpillars during oviposition by the parasitoids. CONCLUSION: We conclude that biotic interactions such as parasitism have pronounced effects on the microbiome of an insect host and possibly affect interactions with higher-order insects.

Insect species richness affects plant responses to multi-herbivore attack.

Plants are often attacked by multiple insect herbivores. How plants deal with an increasing richness of attackers from a single or multiple feeding guilds is poorly understood. We subjected black mustard (Brassica nigra) plants to 51 treatments representing attack by an increasing species richness (one, two or four species) of either phloem feeders, leaf chewers, or a mix of both feeding guilds when keeping total density of attackers constant and studied how this affects plant resistance to subsequent attack by caterpillars of the diamondback moth (Plutella xylostella). Increased richness in phloem-feeding attackers compromised resistance to P. xylostella. By contrast, leaf chewers induced a stronger resistance to subsequent attack by caterpillars of P. xylostella while species richness did not play a significant role for chewing herbivore induced responses. Attack by a mix of herbivores from different feeding guilds resulted in plant resistance similar to resistance levels of plants that were not previously exposed to herbivory. We conclude that B. nigra plants channel their defence responses stronger towards a feeding-guild specific response when under multi-species attack by herbivores of the same feeding guild, but integrate responses when simultaneously confronted with a mix of herbivores from different feeding guilds.

Exploiting chemical ecology to manage hyperparasitoids in biological control of arthropod pests.

Insect hyperparasitoids are fourth trophic level organisms that commonly occur in terrestrial food webs, yet they are relatively understudied. These top-carnivores can disrupt biological pest control by suppressing the populations of their parasitoid hosts, leading to pest outbreaks, especially in confined environments such as greenhouses where augmentative biological control is used. There is no effective eco-friendly strategy that can be used to control hyperparasitoids. Recent advances in the chemical ecology of hyperparasitoid foraging behavior have opened opportunities for manipulating these top-carnivores in such a way that biological pest control becomes more efficient. We propose various infochemical-based strategies to manage hyperparasitoids. We suggest that a push-pull strategy could be a promising approach to 'push' hyperparasitoids away from their parasitoid hosts and 'pull' them into traps. Additionally, we discuss how infochemicals can be used to develop innovative tools improving biological pest control (i) to restrict accessibility of resources (e.g. sugars and alternative hosts) to primary parasitoid only or (ii) to monitor hyperparasitoid presence in the crop for early detection. We also identify important missing information in order to control hyperparasitoids and outline what research is needed to reach this goal. Testing the efficacy of synthetic infochemicals in confined environments is a crucial step towards the implementation of chemical ecology-based approaches targeting hyperparasitoids. © 2019 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Initial Treatment of Unresectable Neuroendocrine Tumor Liver Metastases with Transarterial Chemoembolization using Streptozotocin: A 20-Year Experience.

BACKGROUND: The majority of patients with neuroendocrine tumor liver metastases (NELM) present with multifocal disease and are not surgical candidates. We present our 20-year experience with transarterial chemoembolization (TACE) using streptozotocin (STZ) in patients with initially unresectable NELM. METHODS: Patients with unresectable NELM treated with TACE using STZ at a single institution from 1995 to 2015 were identified after institutional board approval. Imaging was independently reviewed by a radiologist to evaluate for RECIST 1.1 responses. RESULTS: Ninety-one patients with NELM who underwent 474 TACE treatments during the past 20 years were identified. Median age was 62 years, and 54 % of the patients were females. Median number of TACE treatments per patient was four (range 1-22). TACE treatment with STZ was very well tolerated with 10.3 % of treatments being associated with side effects, predominantly transient, including hyper/hypotension, bradycardia, or postembolization syndrome. Median overall survival from the start of TACE was 44 months (5-year OS from TACE 40.8 % and 5-year PFS 20.3 %), and 54 % of the patients who had carcinoid syndrome reported improved symptoms after TACE treatments. Age, grade, liver tumor burden, and ability to undergo multiple TACE treatments were independent predictors of overall survival in multivariable analysis. Chromogranin A levels >115 ng/ml were associated with worse overall survival (p < 0.001). CONCLUSIONS: In patients with unresectable NELM, TACE with STZ is well tolerated with minimal toxicity and can lead to diminished carcinoid syndrome and long-term survival. This is a novel, conservative approach for the initial treatment of unresectable NELM.

A comparison of interview methods to ascertain fluoroquinolone exposure before tuberculosis diagnosis.

SUMMARY Fluoroquinolone use before tuberculosis (TB) diagnosis delays the time to diagnosis and treatment, and increases the risk of fluoroquinolone-resistant TB and death. Ascertainment of fluoroquinolone exposure could identify such high-risk patients. We compared four methods of ascertaining fluoroquinolone exposure in the 6 months prior to TB diagnosis in culture-confirmed TB patients in Tennessee from January 2007 to December 2009. The four methods included a simple questionnaire administered to all TB suspects by health department personnel (FQ-Form), an in-home interview conducted by research staff, outpatient and inpatient medical record review, and TennCare pharmacy database review. Of 177 TB patients included, 72 (41%) received fluoroquinolones during the 6 months before TB diagnosis. Fluoroquinolone exposure determined by review of inpatient and outpatient medical records was considered the gold standard for comparison. The FQ-Form had 61% [95% confidence interval (CI) 48-73] sensitivity and 93% (95% CI 85-98) specificity (agreement 79%, kappa = 0.56) while the in-home interview had 28% (95% CI 18-40) sensitivity and 99% (94-100%) specificity (agreement 68%, kappa = 0.29). A simple questionnaire administered by health department personnel identified fluoroquinolone exposure before TB diagnosis with moderate reliability.

Review article: the management of paediatric nonalcoholic fatty liver disease.

BACKGROUND: Paediatric nonalcoholic fatty liver disease (NAFLD) is a major public health concern given the recent increase in its prevalence and link to obesity and other metabolic comorbidities. Current treatment strategies involve lifestyle changes. Other surgical and pharmacologic interventions have been proposed; however, limited randomised controlled trials (RCTs) in the paediatric population restrict their use. AIM: To review the current management of paediatric NAFLD, including lifestyle and pharmacologic interventions, and to formulate recommendations for study design for future studies. METHODS: A MEDLINE, Pubmed and Cochrane Review database search used a combination of keywords, including NAFLD, nonalcoholic steatohepatitis (NASH), paediatric, treatments, lifestyle changes, bariatric surgery, orlistat, metformin, thiazolidinediones, vitamin E, cysteamine bitartrate, ursodeoxycholic acid (UDCA), probiotics, omega-3 fatty acids, pentoxyfylline, farnesoid X receptor agonist and toll-like receptor modifiers. The articles were selected based on their relevance to the review. RESULTS: Lifestyle interventions involving diet and exercise remain first-line treatment for paediatric NAFLD. Bariatric surgery, orlistat, insulin sensitisers and UDCA have been evaluated but are not recommended as first or second-line therapy. Medications such as cysteamine bitartrate, probiotics, polyunsaturated fats and pentoxyfilline share beneficial effects in trials, however, there is a paucity of adequately powered RCTs in which liver histology is evaluated. Vitamin E has been shown to be effective and safe in improving NASH histology in children. CONCLUSIONS: Lifestyle intervention should be first-line treatment for paediatric NAFLD. Vitamin E should be considered for those with biopsy-proven NASH or borderline NASH failing first-line therapy. Other therapeutics show promising results but require larger RCTs with convincing endpoints. Improved screening techniques, objective validated inclusion criteria and outcome measures as well as rigour in study design are necessary for propelling therapeutic discovery.

Changing patterns of medication use in patients with rheumatoid arthritis in a Medicaid population.

OBJECTIVE: To examine changes in patterns of medication utilization in patients with RA. METHODS: Data from Tennessee Medicaid (TennCare) databases (1995-2004) were used to identify adults with both a diagnosis of RA and at least one DMARD prescription each year. Annual age-specific utilization of DMARDs, glucocorticoids, NSAIDs and narcotics was measured on the last day of each year to determine the point prevalence of use of these agents. RESULTS: Records from 23 342 patients with treated RA were analysed. Most patients were females (78%) and white (74%). The median age was 57 yrs (interquartile range: 48-65). The proportion of patients who had a current DMARD prescription on the index date increased from 62% in 1995 to 71% in 2004 (P < 0.001). MTX was the most commonly used DMARD. By the end of 2004, 22% of patients had a current prescription for a biologic, and etanercept represented 51% of all biologic therapies. During the study period, the overall utilization of glucocorticoids decreased from 46% to 38% (P < 0.001), whereas NSAID utilization increased from 33% to 38% (P < 0.001), and use of narcotics increased from 38% to 55% (P < 0.001). A secondary analysis that identified RA patients based on diagnosis codes alone, showed similar patterns, but lower DMARD utilization which increased from 33% to 52% overall and from 0% to 16% for biologics. CONCLUSIONS: The utilization of DMARDs increased in TennCare patients with RA, and by 2004, use of biologics was substantial. Although glucocorticoid utilization decreased, use of both NSAIDs and narcotics increased.

Use of healthcare resources among medically and surgically treated patients with gastroesophageal reflux disease: a population-based study.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medically or surgically. Direct evaluations of medical resource use are needed to better understand the relative costs of these alternatives. This study compared medical care use for a group of patients receiving surgical treatment for GERD with that for a comparable group of patients receiving medical management. STUDY DESIGN: We conducted a retrospective matched cohort study of Tennessee Medicaid (TennCare) patients with GERD undergoing surgical treatment in 1996 and a group of patients who received medical therapy during the same period. Administrative TennCare data provided computerized records that could be used to identify patients and measure healthcare use. There were 7,502 people who met all of the conditions for inclusion in the study, including at least two encounters with a diagnosis of GERD. One hundred thirty-five of these who underwent fundoplication constituted the surgically treated cohort. The 250 persons in the medically treated cohort were selected randomly from the remaining nonsurgical patients and matched to the surgical cohort by age, gender, race, managed care organization, and acid suppression drug use in the baseline year. The principal outcome of interest was total use of medical resources, including prescription medication. RESULTS: The surgical and medical cohorts did not differ significantly by demographic characteristics or by baseline use of pharmaceuticals. During the baseline year the surgically treated patients were prescribed 302 (95% CI: 270-334) days ofGERD treatment and the matched medical patients were prescribed 292 (95% CI: 267-317) days of GERD treatment. Surgically treated patients used more GERD-related outpatient resources (physician visits and diagnostic testing) in the baseline year, particularly in the 3 months before operation, when they had a mean of more than four outpatient encounter-days. In the followup year, use of GERD-related pharmaceuticals decreased markedly in the surgical cohort. These patients were prescribed an average of 123 days (95% CI: 94-153) of therapy, which was only 36% of that for medical patients (339 days [95% CI: 308-370]). More than 29% of surgical patients were prescribed no GERD-related drugs in the followup year compared with 6% of the medically treated group. The mean number of inpatient days for the fundoplication procedure was 3.2 (95% CI: 2.7-3.6), with a range of 0 to 13 days. There were no differences between the two groups in other healthcare use. CONCLUSIONS: Our results show that in a 1-year period of followup, surgical treatment of severe gastroesophageal reflux disease led to a 64% postsurgical reduction in GERD medication use, with no increase in use of other medical services.

The burden of influenza illness in children with asthma and other chronic medical conditions.

OBJECTIVE: Although influenza immunization is recommended for children with high-risk medical conditions, the majority of such children do not receive influenza vaccine. This study was designed to measure the burden of influenza among children with asthma and other chronic medical conditions. STUDY DESIGN: We performed a retrospective cohort study of children younger than 15 years with medically treated asthma or other chronic medical conditions enrolled in the Tennessee Medicaid program from 1973 to 1993. We determined rates of hospitalization for acute cardiopulmonary disease, outpatient visits, and antibiotic courses throughout the year. Annual differences between event rates when influenza virus was circulating and event rates during winter months when there was no influenza in the community were used to calculate influenza-attributable morbidity. RESULTS: Influenza accounted for an average of 19, 8, and 2 excess hospitalizations for cardiopulmonary disease yearly per 1000 high-risk children aged <1 year, 1 to <3 years, and 3 to <15 years, respectively. For every 1000 children, an estimated 120 to 200 outpatient visits and 65 to 140 antibiotic courses were attributable to influenza annually. CONCLUSIONS: Children younger than 15 years with asthma and other chronic medical conditions experience substantial morbidity requiring inpatient and outpatient care during influenza season. More effective targeting of this population for annual influenza immunization is warranted.

Rates of hospitalization for respiratory syncytial virus infection among children in medicaid.

OBJECTIVE: To determine rates of hospitalization associated with respiratory syncytial virus (RSV) infection among children with and without specific medical conditions. STUDY DESIGN: Retrospective cohort study of all children <3 years old enrolled in the Tennessee Medicaid program from July 1989 through June 1993 (248,652 child-years). RESULTS: During the first year of life, the estimated number of RSV hospitalizations per 1000 children was 388 for those with bronchopulmonary dysplasia, 92 for those with congenital heart disease, 70 for children born at < or = 28 weeks' gestation, 66 for those born at 29 to <33 weeks, 57 for those born at 33 to <36 weeks, and 30 for children born at term with no underlying medical condition. In the second year of life, children with bronchopulmonary dysplasia had an estimated 73 RSV hospitalizations per 1000 children, whereas those with congenital heart disease had 18 and those with prematurity 16 per 1000. Overall, 53% of RSV hospitalizations occurred in healthy children born at term. CONCLUSIONS: Children with bronchopulmonary dysplasia have high rates of RSV hospitalization until 24 months of age. In contrast, after the first year of life, children with congenital heart disease or prematurity have rates no higher than that of children at low risk who are <12 months old.

Underutilization of controller and rescue medications among older adults with asthma requiring hospital care.

BACKGROUND: Asthma causes serious morbidity in older people, but pharmacologic therapy in older people with asthma has never been studied, at least in part because of the difficulty of defining asthma in this population. OBJECTIVE: To determine if older persons enrolled in Medicaid and hospitalized with an exacerbation of asthma receive appropriate outpatient asthma care. DESIGN: Descriptive pharmacoepidemiology of a group of older adults with asthma. SETTING: The Tennessee Medicaid Program. PARTICIPANTS: Persons aged 65 and older, enrolled in the Tennessee Medicaid program, identified through Medicaid's computerized database as having a hospital care visit for asthma in 1992 and who had their diagnosis confirmed by chart review. MEASUREMENT: Medication utilization. RESULTS: The source population included 93,686 persons aged 65 or older enrolled in the Tennessee Medicaid program. The group meeting study criteria included 512 patients with chronic asthma who had a hospital care visit for an asthma exacerbation. Eighty-one percent of these 512 persons with an asthma hospitalization confirmed by chart review were classified as having moderate to severe or potentially fatal asthma. These patients had had a median of 15 outpatient visits in the previous year, and more than half of them had an outpatient visit in the 14 days before their hospitalization. However, among those with moderate to severe or near fatal asthma only 25% filled prescriptions for inhaled corticosteroids, whereas 52% were taking theophylline, the most commonly prescribed asthma medication in this group. There was also high use of antibiotics (29%) and low use of rescue corticosteroids (5%) before the hospital care visit, despite frequent medical encounters. CONCLUSIONS: Despite widespread promulgation of the National Asthma Education Prevention Program guidelines, our study suggests that providers caring for indigent older subjects with moderate to severe or potentially fatal asthma were not following these guidelines. There was significant underutilization of inhaled anti-inflammatory agents, beta-agonists, and rescue corticosteroids in this population despite frequent outpatient medical care visits.

The effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children.

BACKGROUND: Despite high annual rates of influenza in children, influenza vaccines are given to children infrequently. We measured the disease burden of influenza in a large cohort of healthy children in the Tennessee Medicaid program who were younger than 15 years of age. METHODS: We determined the rates of hospitalization for acute cardiopulmonary conditions, outpatient visits, and courses of antibiotics over a period of 19 consecutive years. Using the differences in the rates of these events when influenzavirus was circulating and the rates from November through April when there was no influenza in the community, we calculated morbidity attributable to influenza. There was a total of 2,035,143 person-years of observation. RESULTS: During periods when influenzavirus was circulating, the average number of hospitalizations for cardiopulmonary conditions in excess of the expected number was 104 per 10,000 children per year for children younger than 6 months of age, 50 per 10,000 per year for those 6 months to less than 12 months, 19 per 10,000 per year for those 1 year to less than 3 years, 9 per 10,000 per year for those 3 years to less than 5 years, and 4 per 10,000 per year for those 5 years to less than 15 years. For every 100 children, an annual average of 6 to 15 outpatient visits and 3 to 9 courses of antibiotics were attributable to influenza. In winter, 10 to 30 percent of the excess number of courses of antibiotics occurred during periods when influenzavirus was circulating. CONCLUSIONS: Healthy children younger than one year of age are hospitalized for illness attributable to influenza at rates similar to those for adults at high risk for influenza. The rate of hospitalization decreases markedly with age. Influenza accounts for a substantial number of outpatient visits and courses of antibiotics in children of all ages.

Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions.

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991. METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery. RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births. CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

Comparison of perinatal outcomes among TennCare managed care organizations.

OBJECTIVE: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program. DESIGN: Retrospective cohort analysis. SUBJECTS: Infants born in Tennessee during 1995 to women enrolled in TennCare. PRIMARY OUTCOME MEASURES: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units. RESULTS: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO). CONCLUSION: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Early childhood mortality from community-acquired infections.

In this study, the authors identified maternal and child characteristics that were independent predictors of death from infectious diseases acquired in the community and determined if these factors could be used to identify groups of children with excess risk of mortality from infection. A historical cohort study was conducted of children less than 5 years of age between 1985 and 1994 (the study period), who were born in Tennessee, and had complete information on their birth certificates. The primary outcome was death from infection identified from death certificates and confirmed through medical record review. Among the 1,014,976 children less than 5 years of age, who contributed 3,351,568 child-years of follow-up, there were 247 deaths from infections (7.4 deaths from infections per 100,000 child-years). Respiratory infections accounted for approximately one half of the deaths. Children having three or more older siblings or birth weight of less than 1,500 g had a 3-fold and 10-fold increased risk of death from infection, respectively, while children with both characteristics had a nearly 20-fold increased risk that persisted beyond the first year of life. Interventions should be focused on prevention of these infections in vulnerable children. At-risk children should be targeted for careful follow-up and early hospitalization when signs of infection develop.

Influenza-associated morbidity and mortality in young and middle-aged women.

CONTEXT: Data are limited on rates of influenza-associated hospitalizations and deaths among adults younger than 65 years. OBJECTIVE: To quantify serious morbidity and mortality from influenza for women younger than 65 years with and without certain chronic medical conditions, including human immunodeficiency virus infection. DESIGN: Retrospective cohort study. SETTING AND POPULATION: Women aged 15 to 64 years enrolled in the Tennessee Medicaid program from 1974 to 1993. MAIN OUTCOME MEASURE: All hospitalizations for and deaths from pneumonia, influenza, and other selected acute cardiopulmonary conditions for women with and without selected chronic medical conditions during 19 consecutive years. Influenza-attributable risk was calculated by subtracting event rates during peri-influenza season (November through April of each year when influenza virus was not circulating) from adjusted rates during influenza season (November through April when influenza virus was circulating). RESULTS: During the 19 years of the study, we identified 53607 acute cardiopulmonary hospitalizations and deaths. Rates of such events were consistently higher during influenza seasons than peri-influenza seasons. Among high-risk women, the estimated annual excess was 23 hospitalizations and deaths per 10000 women aged 15 to 44 years and 58 such events per 10000 women aged 45 to 64 years. The estimated annual excess mortality due to influenza was 2 deaths per 10000 high-risk women for both age groups combined. Among women with no identified high-risk conditions, estimated annual excess hospitalizations and deaths were 4 and 6 per 10000 women aged 15 to 44 and 45 to 64 years, respectively. CONCLUSIONS: Women younger than 65 years with certain chronic medical conditions experience substantial morbidity and mortality from acute cardiopulmonary events during influenza season. More effective targeting of these populations for annual influenza immunization is warranted.