Lead and hypertension in a sample of middle-aged women.
OBJECTIVES: The role of lead exposure as a risk factor for hypertension is less well defined among women than among men. This case-control study assessed the relation of blood and bone lead concentrations to hypertension in women. METHODS: Cases and controls were a subsample of women from the Nurses' Health Study. Hypertension was defined as a physician diagnosis of hypertension between 1988 and 1994 or measured systolic blood pressure > or = 140 mm Hg or diastolic blood pressure > or = 90 mm Hg. RESULTS: Mean (SD) blood lead concentration was 0.15 (0.11) mumol/L; mean tibia and patella lead concentrations by K-x-ray fluorescence were 13.3 (9.0) and 17.3 (11.1) micrograms/g, respectively. After adjustment for potentially confounding factors, an increase from the 10th to the 90th percentile of patella lead values (25 micrograms/g) was associated with approximately 2-fold (95% confidence interval = 1.1, 3.2) increased risk of hypertension. There was no association between hypertension and either blood or tibia lead concentrations. CONCLUSIONS: These findings support a potentially important role for low-level lead exposure as a risk factor for hypertension among non-occupationally exposed women. (+info)
Continuous quality improvement decreases length of stay and adverse events: a case study in an interventional cardiology program.
A study was performed to assess the effectiveness of continuous quality improvement in achieving a better quality of care for patients undergoing coronary interventions. Increasing utilization of new coronary interventional devices has incurred a higher incidence of complications, prolonged hospital stay, and related costs. Using a clinical information system, we adopted continuous quality improvement to control the incidence of complications and postprocedural length of stay. Multiple regression analysis and a matched case-control study were performed to detect complications related to postprocedural length of stay and their causes among 342 patients. The results led to the modification of the postprocedural heparin anticoagulation protocol, which was followed by the introduction of a ticlopidine-based poststent anticoagulation regimen. Two sequential groups of patients (n = 261, n = 266) were selected to compare postprocedural length of stay and frequency of complications with those for the first group. Adjustments were made for patients and procedural characteristics through stratification and multiple regression methods. Blood transfusion was the most important predictor of prolonged hospital stay (partial R2 = 0.26, P < 0.01). A high level of postprocedural anticoagulation and intracoronary stent use were significantly associated with blood transfusion (P = 0.01, P = 0.02, respectively). The comparison among the three groups showed that heparin protocol change reduced only postprocedural length of stay (P < 0.001) for patients without stents, whereas the stent change in anticoagulation protocol significantly reduced both transfusion and hospital stay for patients with stents (P < 0.001, P < 0.05, respectively). Continuous quality improvement based on clinical information is promising to control both complications and hospital costs. Physician involvement is necessary throughout the process. (+info)
A community-wide infant mortality review: findings and implications.
The authors present the results of a community-wide infant mortality review, describe implications for the delivery of maternal and child health services, and discuss the value of such reviews in addressing local public health concerns. The review included an analysis of birth and death certificates and medical record data; maternal interviews; review of cases and development of recommendations by provider panels; and convening of community groups to develop strategies to improve the health and health care of women and infants. The review focused on 287 infant deaths during 1990-1993. More than half of all neonatal deaths were attributable to "previable" or "borderline viable" births. Sexually transmitted infections were the most frequently identified underlying risk, and smoking was the most frequently identified prenatal risk. Homelessness, physical and sexual abuse, and alcohol use were at least twice as likely among women whose babies died than among a high risk comparison group. Panelists identified fragmented health care over the course of women's reproductive lives as a predominant theme. The authors conclude that: (a) The focus of maternal and child health care should shift to a model of women's health care that addresses the chronicity of social and clinical risks. (b) Infant mortality reviews are a valuable tool for community education, systems review, and policy development and can be applied to other public health issues with local significance. (c) Expectations about the review process's ability to produce conclusions about causality or recommendations narrowly geared to reducing infant mortality rates need to be reframed. (d) The model will be strengthened by greater participation of families affected by infant death. (+info)
Discontinuity of care: urgent care utilization within a health maintenance organization.
OBJECTIVE: To determine the demographic characteristics, attitudes, and perceived barriers to primary care reported by patients seen in the urgent care department of a health maintenance organization (HMO) health center. STUDY DESIGN: Cross-sectional survey. PATIENTS AND METHODS: Patients aged 18 years or older who sought care at the urgent care department of a large, urban health center of a staff-model HMO were eligible for the study. Patients were handed a survey as they registered in the urgent care department. Demographic and visit diagnoses data were obtained through review of the computerized medical record. RESULTS: Patients seeking treatment at the urgent care department were significantly younger than those seen at a primary care physician's office (mean age, 40 years versus 46 years; P < or = 0.0001) but otherwise had similar demographic characteristics. Nearly 90% of 421 patients seen in the urgent care department reported having a primary care physician. When asked to list the reasons why they came to the urgent care department instead of the primary care offices, 64% said they needed to be seen immediately, 47% came because the primary care offices were closed, 27% cited the constraints of work or childcare, and 25% said they were unable to get an appointment with their primary care physician. Almost half of patients (47%) said they would have preferred to see their primary care physician within a day or two rather than seeking care at the urgent care department. CONCLUSIONS: Patients treated in the urgent care department reported various barriers to seeing their primary care physician. Improving same-day access to primary care providers will help alleviate this problem and may increase patient satisfaction. (+info)
Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center.
Despite improvements in dialysis care, mortality of patients with end-stage renal disease (ESRD) remains high. One factor that has thus far received little attention, but might contribute to morbidity and mortality, is the timing of referral to the nephrologist. This study examines the hypothesis that late referral of patients to the nephrologist might lead to suboptimal pre-ESRD care. Clinical and laboratory data were obtained from the patient records and electronic databases of New England Medical Center, its affiliated dialysis unit (Dialysis Clinics, Inc., Boston), and the office records of the outpatient nephrology clinic. Early (ER) and late (LR) referral were defined by the time of first nephrology encounter greater than or less than 4 mo, respectively, before initiation of dialysis. Multivariate models were built to explore factors associated with LR, and whether LR is associated with hypoalbuminemia or late initiation of dialysis. Of the 135 patients, 30 (22%) were referred late. There were no differences in age, gender, race, and cause of ESRD between ER and LR patients. However, there were significant differences in insurance coverage between these two groups. In the multivariate analysis, patients covered by health maintenance organizations were more likely to be referred late (odds ratio = 4.5) than patients covered by Medicare. Compared to ER, LR patients were more likely to have hypoalbuminemia (56% versus 80%), hematocrit <28% (33% versus 55%), and predicted GFR <5 ml/min per 1.73 m2 (17% versus 40%) at the start of dialysis, and less likely to have received erythropoietin (40% versus 17%) or have a functioning permanent vascular access for the first hemodialysis (40% versus 4%). It is concluded that late referral to the nephrologist is common in the United States and is associated with poor pre-ESRD care. Pre-ESRD care of patients treated by nephrologists was also less than ideal. The patient-, physician-, and system-related factors behind this observation are unclear. Meanwhile, pre-ESRD educational efforts need to target patients, generalists, and nephrologists. (+info)
Comparing pediatric intentional injury surveillance data with data from publicly available sources: consequences for a public health response to violence.
OBJECTIVE: A hospital based intentional injury surveillance system for youth (aged 3-18) was compared with other publicly available sources of information on youth violence. The comparison addressed whether locally conducted surveillance provides data that are sufficiently more complete, detailed, and timely that clinicians and public health practitioners interested in youth violence prevention would find surveillance worth conducting. SETTING: The Boston Emergency Department Surveillance (BEDS) project was conducted at Boston Medical Center and the Children's Hospital, Boston. METHOD: MEDLINE and other databases were searched for data sources that report separate data for youth and data on intentional injury. Sources that met these criteria (one national and three local) were then compared with BEDS data. Comparisons were made in the following categories: age, gender, victim-offender relationship, injury circumstance, geographic location, weapon rates, and violent injury rates. RESULTS: Of 14 sources dealing with violence, only four met inclusion criteria. Each source provided useful breakdowns for age and gender; however, only the BEDS data were able to demonstrate that 32.6% of intentional injuries occurred among youth aged 12 and under. Comparison data sources provided less detail regarding the victim-offender relationship, injury circumstance, and weapon use. Comparison of violent injury rates showed the difficulties for practitioners estimating intentional injury from sources based on arrest data, crime victim data, or weapon related injury. CONCLUSIONS: Comparison suggests that surveillance is more complete, detailed, and timely than publicly available sources of data. Clinicians and public health practitioners should consider developing similar systems. (+info)
Association between iron deficiency and low-level lead poisoning in an urban primary care clinic.
OBJECTIVES: The purpose of this study was to examine the association between iron deficiency and low-level lead poisoning. METHODS: Data were collected in an urban primary care clinic from 3650 children aged 9 to 48 months. Iron deficiency was defined as a red cell mean corpuscular volume (MCV) of less than 70 fL and a red cell distribution width (RDW) of more than 14.5 in children younger than 2 years, and an MCV of less than 73 fL and RDW of more than 14.5 in those 2 years or older. RESULTS: After adjustment for age, hemoglobin concentration, and insurance status, the odds ratios for iron deficiency predicting blood lead levels greater than or equal to 5 micrograms/dL and greater than or equal to 10 micrograms/dL were 1.63 (95% confidence interval [CI] = 1.29, 2.04) and 1.44 (95% CI = 1.004, 2.05). CONCLUSIONS: Iron deficiency is significantly associated with low-level lead poisoning in children aged 9 to 48 months. (+info)
Maternal pregnancy hormone levels in an area with a high incidence (Boston, USA) and in an area with a low incidence (Shanghai, China) of breast cancer.
Characteristics probably associated with the fetal hormonal milieu have recently been shown to increase (birth size indicators, prematurity, neonatal jaundice) or decrease (pregnancy toxaemia) breast cancer risk in the female offspring. However, it is unknown whether differences in pregnancy hormone levels may contribute to the marked geographical variation in breast cancer incidence. We have compared, in a highly standardized manner, pregnancy hormone levels in a population with high incidence and one with low incidence of breast cancer. Three hundred and four pregnant Caucasian women in Boston and 334 pregnant Chinese women in Shanghai were enrolled from March 1994 to October 1995. Levels of oestradiol, oestriol, prolactin, progesterone, human growth hormone, albumin and sex hormone-binding globulin were measured in maternal blood at weeks 16 and 27 of gestation and compared between the two study sites using non-parametric Wilcoxon's rank-sum test. Demographical, anthropometrical and pregnancy characteristics were ascertained through interview, and relevant variables concerning delivery and the newborn were abstracted from medical records and paediatric charts. During the first visit, median serum levels of all studied hormones were statistically significant, and in most instances substantially, higher among Chinese women, who have a low incidence of breast cancer, compared with American women, who have a high incidence of breast cancer. An analogous pattern was evident during the second visit, although the relative differences tended to be smaller. Further research is needed to identify lifestyle or other exogenous determinants of pregnancy hormone levels, as well as possible mechanisms by which they may influence carcinogenic processes in the breast and possibly other organs. (+info)