Maternal, fetal, and placental conditions associated with medically indicated late preterm and early term delivery: a retrospective study.

OBJECTIVE: Our objectives were: (1) to examine the association between maternal, fetal, and placental phenotypes of preterm delivery and medically indicated early delivery of singletons during the late preterm and early term periods; and (2) to identify the specific maternal, fetal, and placental conditions associated with these early deliveries. DESIGN: Retrospective study. SETTING: City of London and Middlesex County, Ontario, Canada. SAMPLE: Singleton live deliveries, at 34-41 weeks of gestation to women in London and Middlesex. METHODS: We obtained data from a city-wide perinatal database (2002-2011; n = 25 699). We used multinomial logistic regression for multivariable analyses. MAIN OUTCOME MEASURE: The outcome was the occurrence of medically indicated late preterm (34-36 weeks of gestation) and early term (37-38 weeks of gestation) delivery, versus delivery at full term (39-41 weeks of gestation). RESULTS: After controlling for confounding factors, all phenotypes were associated with increased odds of medically indicated late preterm and early term delivery. Within the maternal phenotype, chronic maternal medical conditions were associated with increased odds of medically indicated early term delivery (e.g. for gastrointestinal disease, adjusted odds ratio, aOR 1.72, 95% CI 1.47-2.00; for anaemia, aOR 1.40, 95% CI 1.20-1.63), but not late preterm delivery. CONCLUSIONS: The aetiology of medically indicated early delivery close to full term is heterogeneous. Patterns of associations suggest slightly different conditions underlying the late preterm and early term phenotypes, with chronic maternal medical conditions being associated with early term delivery but not with late preterm delivery. These results have implications for the prevention of early delivery as well as the identification of high-risk groups among those born early. TWEETABLE ABSTRACT: The aetiology of medically indicated late preterm and early term delivery is heterogeneous.

Biological determinants of spontaneous late preterm and early term birth: a retrospective cohort study.

OBJECTIVE: Our aim was to examine the association between biological determinants of preterm birth (infection and inflammation, placental ischaemia and other hypoxia, diabetes mellitus, other) and spontaneous late preterm (34-36 weeks) and early term (37-38 weeks) birth. DESIGN: Retrospective cohort study. SETTING: City of London and Middlesex County, Canada. SAMPLE: Singleton live births, delivered at 34-41 weeks to London-Middlesex mothers following spontaneous labour. METHODS: Data were obtained from a city-wide perinatal database on births between 2002 and 2011 (n = 17,678). Multivariable analyses used multinomial logistic regression. MAIN OUTCOME MEASURE: The outcome of interest was the occurrence of late preterm (34-36 weeks) and early term (37-38 weeks) birth, compared with full term birth (39-41 weeks). RESULTS: After controlling for covariates, there were associations between infection and inflammation and late preterm birth (aOR = 2.07, 95% CI 1.65, 2.60); between placental ischaemia and other hypoxia and late preterm (aOR = 2.21, 95% CI 1.88, 2.61) and early term (aOR = 1.25, 95% CI 1.13, 1.39) birth; between diabetes mellitus and late preterm (aOR = 3.89, 95% CI 2.90, 5.21) and early term (aOR = 2.66, 95% CI 2.19, 3.23) birth; and between other biological determinants (polyhydramnios, oligohydramnios) and late preterm (aOR = 2.81, 95% CI 1.70, 4.64) and early term (aOR = 1.89, 95% CI 1.32, 2.70) birth. CONCLUSIONS: Our findings show that delivery following spontaneous labour even close to full term may be a result of pathological processes. Because these biological determinants of preterm birth contribute to an adverse intrauterine environment, they have important implications for fetal and neonatal health.

Evaluation of an epilepsy education program for Grade 5 students: a cluster randomized trial.

OBJECTIVE: Epilepsy is a common and often highly stigmatized disorder. Several international organizations indicate a need to assess the stigma that exists and to develop and evaluate interventions to dispel myths about epilepsy. METHODS: A stratified cluster randomized controlled trial evaluated whether an epilepsy education program (intervention) increases knowledge of and positive attitudes about epilepsy in Grade 5 students (ages 9-11). The study also investigated characteristics of the individuals (gender, language spoken at home, familiarity with epilepsy) and schools (Catholic vs public, size of school, and school level socioeconomic status) that affect epilepsy knowledge and attitudes. We assessed epilepsy knowledge and attitudes at baseline and 1 month following the program using a 33-item questionnaire. RESULTS: In total, 24 schools (783 individuals) were cluster randomized. Those in the intervention group had an average 11.8-point increase (95% confidence interval (CI)=11.4-12.5) in knowledge 1 month following the program, compared with the control group increase of 2.2 points (95% CI=1.8-2.6) out of a total of 57 points. For attitudes, the intervention group had a mean increase of 8.15 points (95% CI=4.70-11.60), compared with the control group increase of 1.64 points (95% CI=-0.84-4.42) out of a total of 50 points. The intervention was responsible for 63% of the variation in postprogram epilepsy knowledge and 28% of the variation in postprogram attitudes about epilepsy. CONCLUSIONS: The epilepsy education program was associated with a significant increase in epilepsy knowledge and positive attitudes in the intervention group 1 month later compared with the control group.

Influential observations in weighted analyses: examples from the National Longitudinal Survey of Children and Youth (NLSCY).

This paper highlights the impact of survey weights on model fit in multiple linear regression with specific reference to the National Longitudinal Survey of Children and Youth (NLSCY) and provides recommendations for the treatment of influential observations. Multiple linear regression was used to estimate the association between child and family factors in the preschool years and vocabulary development at school age. Analyses were performed with and without survey weights. The model fit was assessed by examining the distribution of the studentized residuals and the change in the regression coefficients that would occur if an observation were removed. Two summary measures of influence, Dffits and Cook's D are reported. The models were refit excluding influential observations. Weighting of the linear model resulted in previously non-influential observations having an undue influence on the estimation of the regression parameters in the weighted model. The influential observations were driven primarily by the size of the survey weight as opposed to unusual values of x and y. Researchers working with large national health surveys such as the NLSCY and the National Population Health Survey (NPHS) are advised to include a detailed influence analysis before any final conclusions are made.

Referral patterns of family physicians may allow population-based incidence studies of childhood epilepsy.

PURPOSE: To evaluate the burden of illness of childhood epilepsy on patient, care giver, and society, representative incidence cohorts must be followed longitudinally. Case ascertainment through pediatricians and neurologists would be a valid method if family physicians refered all new cases of childhood epilepsy. The study objective was to determine whether family physicians' referral patterns in Southwestern Ontario make it possible to conduct a population-based incidence study of childhood epilepsy by sampling only from specialists' practices. METHODS: Of the 1,718 family physicians practicing in Southwestern Ontario, a systematic sample participated in a mailed survey. Case simulations describing seven types of childhood seizures were presented to physicians with instructions to respond as to whether they would investigate/manage without referral; refer to a specialist only if problems occurred; or refer to a specialist always. RESULTS: Of 214 family physicians, 185 (86.4%) returned completed surveys; 86% would not refer a child with a febrile seizure. Referral to a specialist would be made always by 93% of family physicians for patients with status epilepticus, 95% for worsening partial epilepsy, 82% for a first, brief, generalized clonic seizure, 80% for absence epilepsy, and 99% for neonatal seizures. Only 50% of family physicians would always refer a neurodevelopmentally abnormal child with generalized clonic epilepsy, but a further 37% would refer if problems occurred. CONCLUSIONS: It is feasible to recruit a representative population-based cohort of recently diagnosed patients for epidemiologic studies of childhood epilepsy by surveying pediatricians and neurologists. These survey results could be used to adjust estimates of incidence obtained through specialists' practices for the bias in case ascertainment that may result from this practical method.

Mutual concurrent validity of the child health questionnaire and the health utilities index: an exploratory analysis using survivors of childhood cancer.

Mutual concurrent validity of 2 generic measures of health-related quality of life (HRQL), the Child Health Questionnaire (CHQ) and the Health Utilities Index Mark 2 (HUI2) and HUI3, was assessed. Data were from 3 centers participating in a Canadian multi-center retrospective cohort study currently in progress to assess psycho-social and physical late effects in children surviving >/=5 years after cancer diagnosis between 1981 and 1990. Exploratory results are from 244 parent reports on HRQL in children <16 years old when studied. Spearman rank-order correlations between sub-scale scores for the CHQ and single-attribute utility scores for the corresponding attribute from the HUI2 and HUI3 were used. As predicted, the correlation between CHQ bodily pain and HUI2 and HUI3 pain was strong, 0.58 and 0.60, respectively, while correlations between CHQ physical functioning and HUI2 mobility and HUI3 ambulation were moderate, both 0.45. Correlations between CHQ mental health and HUI2 and HUI3 emotion were strong, 0.64 and 0.54, respectively, rather than moderate, as predicted. Both the CHQ general health scale and the general health single item were moderately correlated with the HUI2 and HUI3 global utility scores rather than weakly, as predicted (CHQ general health scale and HUI2 and HUI3 global utility were 0.43 and 0.44, respectively; CHQ general health single item and HUI2 and HUI3 global utility were 0. 38 and 0.42, respectively). The CHQ and HUI, which are based on different methodologies (summative Likert scaling and utility analysis, respectively), appear to capture similar constructs in childhood cancer survivors.

Canadian-French, German and UK versions of the Child Health Questionnaire: methodology and preliminary item scaling results.

Using emerging international guidelines, stringent procedures were used to develop and evaluate Canadian-French, German and UK translations/adaptions of the 50 item, parent-completed Child Health Questionnaire (CHQ-PF50). Multitrait analysis was used to evaluate the convergent and discriminant validity of the hypothesized item sets across countries relative to the results obtained for a representative sample of children in the US. Cronbach's alpha coefficient was used to estimate the internal consistency reliability for each of the health scales. Floor and ceiling effects were also examined. Seventy-nine percent of all the item-scale correlations achieved acceptable internal consistency (0.40 or higher). The tests of the item convergent and discriminant validity were successful at least 87% of the time across all scales and countries. Equal item variance was observed 90% of the time across all countries. The reliability coefficients ranged from a low of 0.43 (parental time impact, Canadian English) to a high of 0.97 (physical functioning index, Canadian French) across all scales (median 0.80). Negligible floor effects were observed across countries. Noteworthy ceiling effects were observed, as expected, for the hypothesized physical scales (mean effect 73%). Conversely, fewer ceiling effects were observed for the psychosocial scales (range 3-17% behaviour-parental emotional impact). The item-scaling results obtained in these pilot studies support the psychometric properties of the American-English CHQ-PF50 and its respective translations.

Health behaviours and socio-economic status in Ontario, Canada.

Data from the 1990 Ontario Health Survey were used to investigate the association of socioeconomic status with the likelihood of meeting current recommendations for four health behaviours (smoking, fat intake, alcohol consumption, and physical activity level) in adults living in Ontario (Canada). Health behaviours were categorised as 'unhealthy' if they did not meet current recommendations in Ontario (smoking, fat intake > 30% of dietary energy, alcohol intake > 14 units per week, low level of leisure-time physical activity). Two summary variables based on the number of 'unhealthy' behaviours were also examined: the crude number of 'unhealthy' behaviours reported and the likelihood of reporting 3 or 4 'unhealthy' behaviours. Four measures of socio-economic status were used: educational achievement, household income status, source of household income, and occupational prestige. Multiple logistic and linear regression analyses were performed to explore the association of each 'unhealthy' behaviour and of the summary variables with socio-economic status indicators (taken independently or simultaneously), controlling for demographic characteristics. Except for the positive relationship between income status and high alcohol intake, measures of 'unhealthy' behaviours were inversely associated with the socio-economic indices, suggesting that individuals in lower socioeconomic groups are at an increased risk for health problems.

Admission to a neonatal intensive care unit as a predictor of long-term health: a 12-year follow-up.

Long-term physical, emotional, and social health of neonatal intensive care unit (NICU) graduates was assessed. Twelve-year follow-up interviews were conducted with 253 (86.3%) mothers from a cohort interviewed after their child's birth. One hundred and sixteen children had been admitted to the NICU and 137 to the normal neonatal nursery (NNN) at a tertiary care hospital (1978 to 1980). NICU boys have more chronic physical health problems and have been hospitalized more often than NNN boys. A larger proportion of NICU boys have a physical impairment. NICU girls have lower social competence, social support, and self-esteem than NNN girls, and the impact of NICU admission on these outcomes was significantly greater for girls than boys. Long-term follow-ups should not be limited to very low birth weight infants. NICU admission could be a simple flag for primary care providers to identify children at risk for problems in adolescence, especially psychosocial problems among girls. Physical and emotional health should continue to be monitored into adolescence for all NICU graduates.

Correlates of body mass index in the 1990 Ontario Health Survey.

OBJECTIVES: To determine the average body mass index (BMI) and the prevalence of overweight and obesity among people aged 20 to 64 years, to identify sociodemographic, lifestyle and health variables that correlate with overweight and obesity, and, through a comparison of the results with those from an earlier survey, to determine whether prevalence has changed over time. DESIGN: Cross-sectional survey. SETTING: Ontario. PARTICIPANTS: The 1990 Ontario Health Survey surveyed 61,239 people representative of the Ontario population. The authors' analyses were restricted to those aged 20 to 64 years, excluding pregnant women. In the multivariate analyses they included only people with no missing values for any of the variables in the models (n = 26,306). OUTCOME MEASURES: BMI (weight in kilograms divided by height in metres squared) was used to measure healthy weight (BMI between 20 and 25), overweight (BMI greater than 25) and obesity (BMI greater than 27). RESULTS: The prevalence of obesity among men and women was 33.6% and 22.8% respectively (adjusted odds ratio [OR] 1.78, 95% confidence interval [CI] 1.63 to 1.95). There was a positive relation with age (adjusted OR 1.53 [95% CI 1.24 to 1.89] for age 25 to 29 years and 2.78 [95% CI 2.20 to 3.51] for age 50 to 54 years compared with age 20 to 24 years) and an inverse relation with education level (postsecondary education v. primary education: adjusted OR 0.65 [95% CI 0.54 to 0.79]). Analysis of birthplace showed that the prevalence of obesity was lowest among those born in Asia (compared with Canadian born: adjusted OR 0.36 [95% CI 0.27 to 0.47]). The prevalence was higher among former smokers than among those who had never smoked (adjusted OR 1.20 [95% CI 1.18 to 1.22]). People with more health problems and those who rated their health as fair or poor were more likely to be obese. The estimates of the prevalence of obesity were higher than those reported in the 1985 Health Promotion Survey for both sexes in all three age groups examined. CONCLUSIONS: These self-reported data indicate that overweight and obesity remain important health problems in Ontario, and the prevalence appears to be increasing.

Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices.

The importance of psychological and social issues for children's well-being has long been recognized and their importance in the practice of pediatrics is well documented. However, many of the studies looking at this issue have emphasized psychiatric problems rather than issues commonly referred to as the new morbidity. The goal of this research was to refocus interest on the problems of the new morbidity. This study examined the rates and predictors of psychological problems in 19 of 23 randomly chosen pediatric practices in the greater New Haven area. Families of all 4- to 8-year-old children were invited to participate and to complete the Child Behavior Checklist prior to seeing a clinician. Clinicians completed a 13-category checklist of psychosocial and developmental problems based on a World Health Organization-sponsored primary care, child-oriented classification system. Of the 2006 eligible families, 1886 (94%) participated. Clinicians identified at least one psychosocial or developmental problems in 515 children (27.3%). Thirty-one percent of the children with problems received no active intervention, 40% received intervention by the clinician, and 16% were referred to specialty services. Not surprisingly, children whose problems were rated as moderate or severe were twice as likely to be referred compared with children with mild problems. Recognition of a problem was related to four characteristics: if the visit was for well child rather than acute care; if the clinician felt he or she knew a child well; if the child was male; and if the child had unmarried parents (all P less than or equal to .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Surviving childhood cancer, social support, and parents' psychological adjustment.

Assessed whether the continuing emotional strain of parenting a child cancer survivor is associated with elevated levels of psychological distress (depression and anxiety) in parents. The role of social support in moderating this relationship was also evaluated. When parents of cancer survivors (63 mothers and 49 fathers) were compared to a matched sample of parents (64 mothers and 62 fathers) with healthy children there were no differences in levels of depression or anxiety overall but among parents experiencing low levels of social support, parents of cancer survivors were more depressed and anxious than parents of healthy children. Perceived social support has a significant inverse relationship with psychological distress for both parents but seems to be more important for mothers. The elevated risk for psychological distress noted for those experiencing low levels of support appears to be more generalized for fathers than mothers.

A longitudinal study of smoking status and weight loss following gastroplasty in a group of morbidly obese patients.

A study of morbidly obese patients was carried out to determine the frequency of preoperative smoking, the effect of smoking status on weight loss after vertical banded gastroplasty, and the effect of gastroplasty on postoperative smoking. There were 93 of 104 eligible patients (89.4 percent) available for study, 86 percent female and 14 percent male. All had a gastroplasty more than one year before with a mean follow-up of 22.9 +/- 7.8 months. Preoperative and postoperative weights were 124.4 +/- 19.5 kg and 89.4 +/- 17.9 kg for females and 156.5 +/- 22.3 kg and 102 +/- 17.4 kg for males. Preoperatively 38 percent smoked (females 36.7 percent, males 46.2 percent) and 57 percent were heavy smokers (greater than 25 cigarettes per day). Ten smokers quit postoperatively but seven nonsmokers started smoking. Those who smoked before operation lost more weight (43.26 kg) than nonsmokers (34.97 kg) and ex-smokers (32.41 kg); P less than 0.05. Those who smoked postoperatively lost more weight (44.47 kg) than nonsmokers (35.06 kg) and ex-smokers (33.07 kg); P less than 0.05. Because of the health risks of smoking, cessation is encouraged in spite of the advantage in weight loss for smokers after gastroplasty. More effective methods of controlling smoking and severe obesity are needed.

Ethnic differences in the marital status and psychological distress relationship.

This paper examines the relationship between marital status, as a measure of social support, and psychological distress among three ethnic minorities (Japanese Americans, Filipino Americans, and Native Hawaiians) and Caucasians in Hawai'i. A secondary analysis is conducted on survey data collected from a statewide sample of adults. The analyses show that the relationship between marital status and distress conforms to expectations among Caucasians: married adults have a lower level of distress than the non-married. However, the marital status and distress relationship is not consistent across ethnic minorities. We discuss the implications of these findings to the study of social support and distress among ethnic minorities.

Smoking habits of the morbidly obese prior to gastroplasty.

Smokers weigh less on average than nonsmokers, but there is little data on the smoking habits of the severely obese. Cigarette smoking increases the risk of cardiovascular disease and may add to the existing risk among obese individuals. The purpose of this article is to report on smoking habits of a group of morbidly obese individuals being considered for surgery, to compare these smoking levels to those in the general population, and to assess the relationship between smoking and hypertension in this group. In Canada as in other countries, smoking prevalence has decreased in recent years, but it remains a major health problem.

The discharged psychiatric patient: a review of social, social-psychological, and psychiatric correlates of outcome.

The authors review research over the past decade on the social, social-psychological, and psychiatric correlates of community adaptation among discharged psychiatric patients. A review of 33 studies suggests that little theoretical or methodological progress has been made in identifying the factors that are conductive to the adjustment of discharged patients on their return to the community. To stimulate subsequent efforts in this area, the authors suggest applying new approaches, such as the stress process perspective that has been used to study mental health in the general population.

Smoking status among a group of morbidly obese men and women referred for gastroplasty.

The smoking habits of all morbidly obese patients referred for possible gastroplasty (between January 1, 1983 and December 31, 1985) were assessed. There were 240 patients, 198 women 83 percent) and 42 men (17 percent). Mean age for women was 38 +/- 9 years and weight 121 +/- 17 kg. Men were 36 +/- 9 years old and weighed 154 +/- 24 kg. Forty percent of each group smoked cigarettes daily and 10 percent of women and 12 percent of men were ex-smokers. Twenty percent of the females and 47 percent of the males were heavy smokers (greater than 25 cigarettes per day). Female ex-smokers were much more apt to be on treatment for hypertension than non-smokers (55 vs 10 percent, P less than 0.001). These morbidly obese patients in Southern Ontario smoked more heavily and in higher proportion than reported for adults in Ontario or Canada. Low socioeconomic status may partially explain these results. Better methods of controlling smoking and eating are needed for the morbidly obese.