The impact of tobacco smoking on perinatal outcome among patients with gestational diabetes.

OBJECTIVE: To determine the effects of tobacco use on perinatal outcomes among patients with gestational diabetes (GDM). STUDY DESIGN: This was a retrospective cohort study of singleton pregnancies with GDM and live births from 2003 to 2006. The primary outcome, large for gestational age (LGA) infants, was compared between smoking and nonsmoking groups. Secondary outcomes included cesarean deliveries, shoulder dystocia, birth trauma, peripartum complications, macrosomia, 5-min Apgar score < or =3, birth defects, and neonatal intensive care unit (NICU) admissions. chi(2) and Student t-tests compared the two groups; a P-value <0.05 was statistically significant and odds ratios (OR) were reported with 95% confidence intervals (CI). A multivariate logistic regression analysis controlled for variables known to affect outcomes in GDM. RESULT: We identified 915 patients with GDM, of which 130 (14.2%) smoked during pregnancy. Women who smoked during pregnancy were less likely to have LGA infants (22.4 vs 31.2%; OR, 0.61; 95% CI, 0.39 to 0.95). In a logistic regression analysis, the inverse relationship between smoking and LGA persisted (OR, 0.59; 95% CI, 0.36 to 0.97) after controlling for maternal age, multiparity, ethnicity, weight status before pregnancy, weight gain during pregnancy, and male gender. Preterm labor, preeclampsia, Cesareans, shoulder dystocia, and birth trauma were similar in both groups. PPROM was more likely to occur in nonsmokers (0 vs 4%, P=0.03), but postpartum hemorrhage was more common among smokers (OR, 2.3; 95% CI, 1.02 to 5.31). Macrosomia, low 5-min Apgar score, birth defects, and NICU admissions were similar between the groups. CONCLUSION: Patients with GDM who smoke during pregnancy were 40% less likely to have LGA infants. However, smoking was not protective of other common morbidities associated with GDM.

Medical students' experience with psychiatric diagnoses in a family medicine clerkship.

BACKGROUND: Many medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses encountered by the students. PURPOSE: This study examines patients encountered with psychiatric diagnoses using quantitative data collected by students in a family practice clerkship. METHODS: Over a 2-year period, 445 students completed 3,320 patient encounter forms for patients with a psychiatric diagnosis, noting their comfort level and responsibilities. RESULTS: The patients' diagnoses reflect those seen in a typical family practice. Of the 71,869 presenting diagnoses, 3,548 were for a psychiatric condition, most commonly depression (37.1%) and neuroses (28.0%). Students reported a high level of comfort in diagnosing and treating patients with a psychiatric disorder. The students routinely discussed these cases with their preceptors. CONCLUSIONS: By using a relatively simple computerized database, many curricular issues can be identified. For example, analysis of the database shows that the clerkship provides students with substantial practice in taking patient histories and performing initial patient examinations in patients presenting with a psychiatric problem. However, students infrequently provided patient education and counseling to patients with psychiatric disorders. Specific psychiatric diagnoses reflecting limited experience and lower levels of perceived competence include attention deficit disorder and senile and presenile organic psychotic disorders.

ENT experience in a family medicine clerkship: is there enough?

BACKGROUND: Curriculum planning is an essential process at any institution of learning. Currently, at Indiana University, a 1-week required otorhinolaryngology clerkship is being considered for removal from the curriculum, and this exposure is planned for integration into other primary care clerkships. A data collection system for patient encounters was created to obtain objective quantitative data about ear, nose, and throat conditions in the family medicine clerkship. METHODS: A total of 445 students filled out 56,151 patient encounter forms that contained the diagnoses, patient age, student comfort levels, and student responsibilities. RESULTS: Of the 56,151 encounters, 22.9% involved a condition involving an ear, nose, or throat (ENT) diagnosis, and the overall top-10 diagnoses reflect a typical family practice. Few students reported being given the opportunity to perform procedures. CONCLUSIONS: It appears that students are receiving sufficient practice in taking patient histories and performing initial patient physicals for ENT cases and that they see a sufficient number of ENT cases. However, students had more limited opportunity to perform and/or assist with ENT procedures or to be involved with patient education and ENT counseling. The number of ENT cases in the third-year clerkship is sufficient, and the experience is mostly more than adequate. Our study indicates that ENT training is a significant part of the family medicine clerkship, and curriculum integration is possible, though concerns about procedural skills will need to be addressed.

Gender and preceptors' feedback to students.

To determine whether evaluation comments differed based on preceptors' and students' genders, preceptors' evaluations of medical students were analyzed. Preceptors tended to comment on the same themes in the same proportions, regardless of gender. However, women preceptors commented about "Personality/Maturity" and "Personality/Character" more frequently for men students than they did for women students. Conversely, women preceptors commented about "Clinical Skills-Negative" more frequently for women students than for men.

Cost of hospitalizations for heart failure: sodium retention versus other decompensating factors.

OBJECTIVE: To determine the cost of heart failure-related hospital admissions and to compare the cost of admissions for sodium retention with the cost of admissions for other decompensating factors. DESIGN: Retrospective, non-experimental, cost analysis. SETTING: Midwestern university-affiliated, tertiary care, medical center. SAMPLE: Two hundred seven heart failure-related admissions, 117 (57%) of which were for sodium retention leading to volume overload. OUTCOME MEASURES: Cost of hospitalization. PROCEDURE: Data obtained from the patient and financial records of patients hospitalized for heart failure in 1992 were analyzed using the ratio of cost-to-charge accounting procedure. RESULTS: The total cost was $2,442,720 for the 207 heart failure-related admissions; the average cost was $12,400 per admission. Approximately half of the cost of the hospitalizations was expended in the 4 cost centers comprising routine and critical care services, which incorporate room charges and nursing care. Another one third of the cost was for supplies, medications, and laboratory tests. Admissions as a result of sodium retention had lower costs than admissions as a result of other factors. CONCLUSION: The cost of hospitalization for heart failure is high. Routine services, supplies, medications, and laboratory tests used by these patients contribute to the high cost of care. Improved outpatient management strategies are necessary to reduce hospital admissions as a result of sodium retention.

Assessing prenatal care in a family practice residency clinic.

BACKGROUND AND OBJECTIVES: This study demonstrates how one family practice residency clinic characterized obstetric clinic patients and assessed obstetric care using birth certificate data (demographic characteristics and risk factors) and birth outcome indicators. METHODS: We compared clinical characteristics and birth outcomes for 901 patients who were delivered by family physicians from the family practice residency clinic with a matched and unmatched group of patients who were delivered by other physicians in the county during 1990-1993. RESULTS: The study clinic patients were at higher risk and had lower use of prenatal care. However, the outcomes of the study clinic patients were significantly better (fewer labor and delivery complications, procedures, Cesarean deliveries, abnormal conditions of newborn, low birth weight deliveries, and preterm birth) or no different from the comparison group of non-clinic patients. CONCLUSIONS: The analysis of birth certificate data provided a favorable assessment of prenatal care provided by a family practice residency clinic. This type of analysis permits comparisons of birth outcomes with other local or regional providers, statewide providers, and the year 2000 national objectives established by the National Center for Health Statistics.

The Indiana Prenatal Substance Use Prevention Program: its impact on smoking cessation among high-risk pregnant women.

The Indiana Prenatal Substance Use Prevention Program (PSUPP) was established in 1988 to help pregnant women quit cigarette smoking as well as alcohol and drugs. PSUPP directors implement the Screen, Intervene and Follow-up (SIF) model to assess substance use and provide services to help clients stop smoking. During fiscal year 1995, almost 25,000 individuals were impacted directly or indirectly by the PSUPP. Of these, 1,334 pregnant women were screened for substance use by PSUPP. Of the 987 women identified with a known substance use risk factor, 42.4% (418) were high-risk smokers (more than five cigarettes per day) and 9.9% (98) were medium-risk smokers (smoking between one and four cigarettes per day). PSUPP directors counseled their high/medium risk smokers an average of four times during their pregnancy. The PSUPP appears to be effective in getting high-risk smokers to change their smoking behavior during their pregnancy. Approximately one-half (49.9%) of the 516 high- or medium-risk smokers decreased or quit smoking while participating in the PSUPP. When surveyed, about 80% of the PSUPP participants stated that the knowledge they gained through PSUPP relative to tobacco use was "very helpful." Only two-thirds of the PSUPP clients responded that they "strongly agreed" with the statement that tobacco use causes babies to have a lower birth weight. While pregnancy may provide the "teachable moment" for women who smoke, more attention needs to be placed on making women more aware of the risks involved with smoking during pregnancy.

Trends in the frequency of cesarean delivery. A 21-year experience, 1970-1990.

Cesarean delivery rates in the United States increased from about 5% in 1965 to 24.7% in 1988, with the majority attributed to four indications: dystocia, fetal distress, previous cesarean delivery and breech presentation. This study calculated one hospital's cesarean delivery rate over a 21-year period to examine the trends in the rate and in their clinical indications. From 1974 to 1979, dystocia was responsible for 39.1% of the 151.2% overall increase in cesarean deliveries at the study hospital, followed by repeat cesarean deliveries (30.1%), fetal distress (8.7%) and breech presentation (3.5%). The percentage of all repeat cesarean deliveries increased, from 6.2 in 1981 to 8.0 in 1990, while the percentage of previous cesarean patients having another cesarean delivery declined from 96.6 in 1981 to 85.5 in 1990. Although there has been a reduction in the proportion of women having repeat cesarean delivery, the number of previous cesarean patients presenting for another delivery has been increasing. The cesarean experience at individual hospitals needs to be examined to provide a better understanding of the reasons for changes in their cesarean delivery rates.

Children with special health care needs program: urban/rural comparisons.

The purposes of this study were to: (1) describe both the urban and rural clients who received services from the Indiana Children with Special Health Care Needs program (CSHCN) including both demographic and clinical characteristics; (2) conduct a health care needs assessment of the CSHCN program clients in both urban and rural areas; and (3) measure the perceived quality and adequacy of the CSHCN program services. A survey instrument was developed and mailed to all 6,459 families who participated in the Indiana CSHCN program from July 1, 1990 to June 30, 1991. Of the 2,722 questionnaires used in the analysis, 1,624 clients (59.7%) resided in urban counties and 1,098 (40.3%) resided in rural counties. The most frequently noted conditions for program eligibility were asthma, ear infections, hearing impairments, heart defects, and convulsions and seizures. Asthma had greater prevalence among the urban clients while cleft lip/palate, epilepsy, and heart defects were more common among the rural clients. The majority of program clients perceived their medical needs as being met. However, significant numbers of clients perceived unmet needs for mental health services, support groups, information about community services, resources to pay for uncovered medical expenses, and respite care. Of the 23 listed services, five were reported at significantly lower rates by rural clients as not being met: regular medical care, recreation, child care/day care, parent support group services, and speech therapy. Quality of medical services was generally perceived as being "excellent or good," while services related to information about community programs, child's rights in school, resources available to pay for uncovered medical expenses, as well as communication between the treatment center and the child's school were more often rated as "fair or poor." A smaller proportion of rural clients rated physician care and availability of staff nurses as fair or poor. A larger percentage of the rural group reported that access to treatment center location was fair or poor, compared to the urban group. Overall, the evaluation of the Indiana CSHCN program has shown that the non-medical care component seems to be in need of change, especially in the area of information and communication. Attention needs to be focused on providing more family support such as respite or child care and support groups, better information and communications, and improved availability of mental health services to better enable the CSHCN program to meet its objectives.

The incidence of adynamic ileus in postcesarean patients. Patient-controlled analgesia versus intramuscular analgesia.

With the current clinical popularity of patient-controlled analgesia pumps (PCAP) in postoperative pain management, it is prudent to be aware of the possible risk of adynamic ileus formation from intravenous narcotic administration. We hypothesized that prolonged PCAP exposure could delay bowel motility and increase post-operative morbidity. After stringent exclusionary parameters were met, we retrospectively analyzed 170 postcesarean patients who received PCAP medication and compared data with 171 postcesarean patients who received traditional intramuscular (IM) administration. The degree of adynamic ileus formation of moderate and severe intensity was higher in PCAP users (21.8%) vs. IM users (13.5%), P = .02. There was no significant difference in the average cumulative amount of analgesic administered during the first 24 postoperative hours for PCAP (442.2 mg) vs. IM (397.7 mg), reflecting that the mode of narcotic delivery is responsible for ileus formation rather than the dosage. Type of postoperative diet and speed of diet advancement were also factored into the analysis and did not statistically influence the results. We conclude that PCAP usage may increase the morbidity risk for adynamic ileus formation, and that usage should be accompanied with close monitoring of bowel motility.

Medical evaluation referral patterns for sexual abuse victims.

It has been recommended that all children suspected of being sexually abused should have medical evaluations. To better understand practices and perceptions of child sexual abuse medical evaluations, a survey was conducted of 579 professionals attending educational programs on child sexual abuse; 85.8% (N = 497) responded. Half (50%) of the respondents reported no previous training in child sexual abuse. Of the 336 nonphysician professionals, 194 (57.7%) were in positions where they make referrals of the victims, and 69% of these did not refer all of the children they saw for medical evaluations. The first referral choice for medical evaluation was most often to the victim's primary physician (57%). For those professionals who did not refer all alleged victims for medical evaluation, neither the victims' age, gender, nor accessibility to care were generally considered relevant in determining the decision to refer. However, the type of abuse and presence of physical and psychological symptoms were considered relevant in making the decision. The majority indicated that the findings of the medical exam were very useful in substantiating or refuting the allegation of abuse. Further training for both medical and nonmedical professionals is needed to increase awareness of the need for and implications of the medical evaluation if children are to receive comprehensive assessments. Physicians may play an active role in this process through education of professionals and provision of care.

Anterior wall left ventricular aneurysm repair. A comparison of linear versus circular closure.

To determine the efficacy of ventricular closure techniques, we reviewed our experience with 62 patients who survived the repair of aneurysms of the anterior wall of the left ventricular from 1984 through 1989. Forty of these patients underwent aneurysm repair by standard linear closure and 22 by a circular closure technique. After a mean follow-up interval of 3 years, there were no demonstrable differences in angina class, New York Heart Association functional classification, or survival. In 41 surviving patients, postoperative left ventricular dimensions and function were satisfactorily evaluated by standard echocardiographic measurements. No significant differences were found in postoperative long-axis left ventricular systolic diameter or in short-axis systolic or diastolic areas. There was a significantly larger long-axis diastolic diameter in the circular closure group; however, there was no difference in this parameter when the ratios of postoperative to preoperative lengths were compared. Further intragroup comparisons demonstrated an increase in short-axis areas postoperatively within the circular closure group in contrast to a decrease in patients in the linear closure group; these changes were not statistically significant. There was no significant difference in postoperative ejection fraction between the two closure groups, although minor reductions were found in the circular closure group. These data demonstrate no significant difference between the linear and circular closure techniques with respect to standard echocardiographic parameters, functional classification, and survival.

Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux.

Gastrostomy is frequently required in children with neurological impairment and feeding disability. In some centers, concomitant (prophylactic) antireflux procedures are often performed due to the increased risk of occurrence of significant gastroesophageal reflux (GER) after isolated operative or percutaneous endoscopic gastrostomy placement. This has been documented in both experimental and clinical settings. A recent clinical study suggests that placement of a gastrostomy in a lesser curvature location rather than on the greater curvature of the stomach may decrease the incidence of postoperative GER. The purpose of this study is to evaluate this clinical impression. Under ketamine anesthesia and sterile technique, 30 cats underwent laparotomy and placement of a Stamm gastrostomy tube; 15 (group A) were located on the greater curvature of the stomach. Each animal was evaluated postoperatively for the occurrence of GER using upper gastrointestinal contrast study, nuclear medicine gastric scintigraphy (technetium 99m), pH probe/Tuttle test, and lower esophageal sphincter (LES) manometrics. Contrast esophagram with barium demonstrated GER in 3 animals in group A and none in group B (P less than .05). The pH/Tuttle test was positive in 4 animals in group and none in group B (P less than .05). 99mTc gastric scintigraphy (over a 30-minute period) demonstrated GER in 7 cats in group A and in only 1 cat in group B (P less than .05). LES manometric pressures were similar among both groups. This study suggests that a gastrostomy placed in the lesser curvature may reduce the incidence of postgastrostomy GER and obviate the need for a concomitant antireflux procedure in patients with a severe feeding disability but without demonstrable GER during preoperative assessment.

Uncompensated hospital care for pregnancy and childbirth cases.

BACKGROUND: The large number of medically indigent patients in the United States is a major concern to policymakers and may be due to recent increases in the number of uninsured people. The purpose of this study was to identify the factors that affect the amount of unpaid hospital charges for services provided to pregnant women. METHODS: Individual and hospital data were collected on a representative set of 235 pregnancy and childbirth patients with unpaid hospital charges from 28 hospitals in the state of Indiana. RESULTS: Most of these patients did not have insurance coverage (63.8%), yet the majority were employed in the public or private sector (72.3%). Over half (55.5%) of the total uncompensated care amount for this group was from the $1000 to 2499 debt category. The median charge for these patients was $1468, of which the typical hospital was able to collect only 25.5%. CONCLUSIONS: The findings support the belief that any national effort to expand the availability of health insurance coverage to women through increased employment will not totally eliminate the uncompensated care problem. The findings also indicate that rural hospitals face the uncompensated care problem mainly because a significant portion of rural patients are without adequate health insurance coverage.

A determination of institutional and patient factors affecting uncompensated hospital care.

For this study, a sample of 985 patients classified as "charity" and "bad debt" cases in 1986 were identified from 28 Indiana hospitals. In a multiple regression model, insurance coverage, total hospital charge, pregnancy-related diagnoses, marital status, employment status, discharge status, urban location, and total hospital revenue were significant factors in predicting unpaid hospital bills, when controlling other demographic characteristics. Sixty percent had some form of insurance and were responsible for 40 percent of the uncompensated amount, justifying the need to examine the adequacy of patient insurance coverage. However, providing insurance coverage will not entirely eliminate the problem of uncompensated care; hospitals also need to increase collection efforts for all unpaid bills.

Patterns of child sexual abuse knowledge among professionals.

To better understand knowledge and perceptions of child sexual abuse, a survey was conducted of 902 professionals attending child sexual abuse educational programs during 1986-1987. About half (50.8%) of the group reported seeing at least two child sexual abuse cases a month, while 20.5% reported seeing five or more. Almost half (48.9%) of the respondents reported previous formal training regarding child sexual abuse. Professionals were generally knowledgeable about child sexual abuse; however, at least 20% of the professionals were not knowledgeable about some items that are important in the identification of child sexual abuse and that might hamper the legal and medical investigation of a case. Those with formal training, more years of professional practice, and who see five or more victims per month answered more questions correctly, but the differences were not always statistically significant. Further training for both medical and non-medical professionals is needed to ensure appropriate care of child sexual abuse victims and to improve communication and coordination of efforts between professions.

The impact of the prospective payment system on the treatment of hip fractures in the elderly.

A review of 386 Medicare patients with hip fractures admitted to a private, suburban, teaching hospital from 1981 through 1987 revealed that since the implementation of the prospective payment system in 1984, average hospital stays declined from 17.0 days to 12.9 days (24.1%). Although the mean number of physical therapy sessions declined from 11.1 to 9.8 (11.7%), the average number of treatments per day during the physical therapy phase actually increased from 1.2 before to 1.4 after the prospective payment system. The proportion of patients discharged to nursing homes remained the same (52.9% vs 53.6%); the proportion of patients remaining in a nursing home 6 months after hospital discharge did not differ significantly (22.6% vs 19.9%). Furthermore, there were no differences in the 6-month ambulation status. Total adjusted average hospital charges for the pre- and post-prospective payment system groups did not increase significantly ($7295 vs $7565). These findings do not support the contention that the quality of care provided Medicare patients with hip fractures has deteriorated in this hospital environment.

Skin cancer in patients with chronic radiation dermatitis.

The cases of 76 patients with chronic radiation dermatitis resulting from low-dose ionizing radiation for benign disease were reviewed retrospectively for risk factors leading to the development of neoplasia. The patients were studied with respect to original hair color, eye color, sun reactive skin type, benign disease treated, area treated, age at treatment, and age at development of first skin cancer. Analysis of data showed 37% of patients had sun-reactive skin type I, 27% had type II, and 36% had type III. Types IV through VI were not represented. There appeared to be an overrepresentation of types I and II. Increased melanin pigmentation may therefore be either directly or indirectly protective against the development of skin cancers in patients who have received low-dose superficial ionizing radiation for benign disease. The sun-reactive skin type of patients with chronic radiation dermatitis may be used as a predictor of skin cancer risk when the total dose of ionizing radiation is not known.

Hospital and patient characteristics of uncompensated hospital care: policy implications.

For this study, a sample of 1,689 patients classified as "charity" and "bad debt" cases in 1986 were identified from 27 general acute care hospitals and one tertiary hospital in Indiana. Half of the hospitals were in rural areas and 57 percent were small (less than 150 beds). Most of the patients (87.2 percent) incurred uncompensated amounts under $2,500, and 40 percent of the cases were below $500. About 72 percent of the patients with uncompensated care were from the same county as the location of the hospital (range from 30.9% to 100.0%). The majority of the cases (79.4 percent) with over $5,000 in uncompensated care were treated in urban hospitals. The average age of these patients was 27.2 years. Fifty-four percent of the patients were single, 60.7 percent were female, and nearly all (83.0 percent) were discharged to home care. Only 44.6 percent of the patients with uncompensated care had no insurance; 46.8 percent had some form of commercial insurance which covered part of the charges for care. The most common diagnosis for these patients was pregnancy and childbirth (22.8 percent), with injury and poisoning second (10.7 percent). The cases with $5,000 or more in bad debt (about 4 percent of the cases) account for 28.3 percent of the total uncollected amount. Bad debt represents a cost of doing business. Any national effort to contain health care costs must address this problem.