The Public Health Impact of Maternal Smoking Cessation during Pregnancy : The San Bernardino County Experience

Most studies of maternal tobacco cessation during pregnancy have estimated measures of effect that can be useful in identifying the exposure as an etiologic risk factor in maternal and child health. However, in the case of maternal tobacco use there is overwhelming evidence for a causal role in adverse infant outcomes, and public health needs to focus on measures of potential impact in order to better prioritize and allocate resources toward interventions. The aims of this dissertation were: 1) to investigate the public health impact of smoking cessation during pregnancy among mothers giving birth in San Bernardino County, California; and 2) to examine the relationship between indices of prenatal care utilization and smoking cessation during pregnancy. The first study showed that, among 65,228 total live births in 2007 and 2008, a single low birth weight or preterm outcome in the county could have been prevented either by at least 35 mothers quitting smoking during pregnancy or by 25 mothers being never smokers during pre-pregnancy. The second study among 4,059 women reporting tobacco use in San Bernardino County found a dose-response relationship for prenatal care initiation in which women were more likely to quit smoking for every two months earlier they initiated their prenatal care visits. Examining the adequacy of received prenatal care services indicated a threefold increase in odds of smoking cessation for women receiving more than half the number of prenatal care visits recommended by the American College of Obstetricians and Gynecologists. Based on the findings from these studies of San Bernardino County we can conclude that there is a burden of adverse infant outcomes due to maternal smoking that can be reduced by relatively small numbers of women quitting smoking during pregnancy. We gained the additional insight from analysis of maternal smokers that indicated that those with adequate prenatal care utilization were most likely to quit smoking during their pregnancy

Predictors of Non-Utilization of the Supplemental Nutrition Program for Women, Infants, and Children (WIC) in San Francisco, CA 2008-2011

Background and Purpose: Non-utilization of nutrition-related services is high, especially among women who are at high risk of outcomes such as low birth weight. We investigated predictors of nonutilization of the Supplemental Nutrition Program for Women, Infants and Children (WIC) during 2008- 2011 in San Francisco, California. Methods: Using California Birth Cohort Files, we identified 35,295 singleton births from 2008-2011; 25,884 did not use WIC services. Results: Major findings from Classification and Regression Tree (CRT) analysis were: 1) the strongest predictor of WIC non-utilization was no insurance; 2) 97.3% of the private insurance/self-pay population did not utilize WIC and of this population, non-Hispanic whites, Hispanics, and Asian/Pacific Islanders, with some college or more, and fathers with some college or more were least likely to utilize WIC services. Medi-Cal insurance coverage was protective against non-use of WIC, while maternal or paternal completion of at least some college. Non-Hispanic white ethnicity and maternal or paternal age of 35 years or older were predictors of nonutilization of WIC. Conclusions: Sociodemographic variables and insurance status were predictive of WIC non-utilization, suggesting groups that may be targeted in efforts to increase WIC uptake. Current efforts for targeting traditionally underserved populations should continue, while adding additional efforts to serve other women from traditionally advantaged backgrounds who meet the eligibility requirements for WIC

Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation

10.1186/cc10469Critical Care155R22

Perioperative Morbidity in Cirrhotic Patients Undergoing Orthopedic Surgery

Background/Aims: Previous studies have shown an increased risk of morbidity and mortality in cirrhotic patients undergoing surgery. However, there is a paucity of studies evaluating the perioperative risks of cirrhotics who undergo orthopedic surgery. The aim of this study was to examine outcomes in cirrhotic patients who have undergone orthopedic surgery. Methods: This is a retrospective matched-cohort study using data from Kaiser Permanente Southern California. Study participants received a diagnosis for cirrhosis from 1/1/2003 through 12/31/2013, and initial case selection criteria included age \u3e 18 years, ≥ 6 months continuous health plan membership, and a procedure code for orthopedic surgery. At least 3 and up to 5 controls were optimally matched based on age, gender and cirrhosis diagnosis date. Data abstraction and summary were subsequently performed for demographic, socioeconomic, comorbid history and decompensation events data. Decompensation events included new onset ascites, variceal bleeding and hepatic encephalopathy. Multivariable conditional logistic regression estimated the risk of decompensation from surgery. Results: We matched 4,263 eligible controls with 853 cirrhotic surgical patients. Mean age of the cohort was 60.5 (standard deviation: 11.44) years and 52.2% were female. Within 90 days after surgery, cases had more decompensation events compared to matched controls (24.1% vs. 19.1%). Discussion: In this large database study including patients from a large managed care organization, cirrhotics experienced more decompensation within 90 days after orthopedic surgery compared to matched controls. Decompensation events result in significant increases in health care costs and utilization. Further, the increased morbidity seen in cirrhotics is a potential cause of quality issues for the managed care organization. Examination and mitigation of the factors, such as surgery, that can result in decompensation may help improve systems for better quality of care

Serum phosphorus and association with anemia among a large diverse population with and without chronic kidney disease.

BackgroundWe hypothesized that phosphorus has an effect on anemia in both normal kidney function and early chronic kidney disease (CKD). We sought to determine whether higher phosphorus levels are associated with anemia in a large diverse population without CKD and early CKD.MethodsThis study is a historical population-based study within the Kaiser Permanente Southern California health system (1 January 1998 to 31 December 2013) among individuals aged 18 years and older with estimated glomerular filtration rate >30 mL/min/1.73 m(2) and measurements of serum phosphorus, creatinine and hemoglobin. Individuals were excluded if they had secondary causes of anemia. Odds ratio (OR) estimated for moderate anemia defined as hemoglobin <11 g/dL for both sexes. Mild anemia was defined as <12 g/dL (females) and <13 g/dL (males).ResultsAmong 155 974 individuals, 4.1% had moderate anemia and 12.9% had mild anemia. Serum phosphorus levels ≥3.5 mg/dL were associated with both mild and moderate anemia. Moderate anemia OR (95% confidence interval) was 1.16 (1.04-1.29) for every 0.5 mg/dL phosphorus increase and 1.26 (1.07-1.48) in the highest versus middle phosphorus tertile. Additional independent anemia risk factors, including female sex, Asian race, diabetes, low albumin and low iron saturation, were observed, but did not alter the anemia-phosphorus association.ConclusionsHigher phosphorus levels were associated with a greater likelihood for anemia in a population with early CKD and normal kidney function. Phosphorus may be a biomarker for anemia and may affect aspects of hematopoiesis

Serum phosphorus and association with anemia among a large diverse population with and without chronic kidney disease.

BackgroundWe hypothesized that phosphorus has an effect on anemia in both normal kidney function and early chronic kidney disease (CKD). We sought to determine whether higher phosphorus levels are associated with anemia in a large diverse population without CKD and early CKD.MethodsThis study is a historical population-based study within the Kaiser Permanente Southern California health system (1 January 1998 to 31 December 2013) among individuals aged 18 years and older with estimated glomerular filtration rate >30 mL/min/1.73 m(2) and measurements of serum phosphorus, creatinine and hemoglobin. Individuals were excluded if they had secondary causes of anemia. Odds ratio (OR) estimated for moderate anemia defined as hemoglobin <11 g/dL for both sexes. Mild anemia was defined as <12 g/dL (females) and <13 g/dL (males).ResultsAmong 155 974 individuals, 4.1% had moderate anemia and 12.9% had mild anemia. Serum phosphorus levels ≥3.5 mg/dL were associated with both mild and moderate anemia. Moderate anemia OR (95% confidence interval) was 1.16 (1.04-1.29) for every 0.5 mg/dL phosphorus increase and 1.26 (1.07-1.48) in the highest versus middle phosphorus tertile. Additional independent anemia risk factors, including female sex, Asian race, diabetes, low albumin and low iron saturation, were observed, but did not alter the anemia-phosphorus association.ConclusionsHigher phosphorus levels were associated with a greater likelihood for anemia in a population with early CKD and normal kidney function. Phosphorus may be a biomarker for anemia and may affect aspects of hematopoiesis

Effect of Serum Triglycerides on Clinical Outcomes in Acute Pancreatitis: Findings From a Regional Integrated Health Care System.

ObjectivesThe aim of this study was to evaluate the effect of serum triglycerides on the development of multiple or persistent organ failure in patients with acute pancreatitis.MethodsA retrospective cohort study was conducted among patients hospitalized for acute pancreatitis between 2006 and 2013. Triglyceride levels measured before and within 72 hours of admission were compared. In addition, the effect of triglyceride levels on the development of multiple or persistent organ failure during hospitalization for acute pancreatitis was assessed.ResultsAmong 2519 patients, 267 patients (10.6%) developed organ failure, of which 75 patients developed multiple system organ failure and 82 patients developed persistent organ failure. Triglyceride levels in patients who developed organ failure were initially much higher than in patients who did not develop organ failure, but by 72 hours into admission, approached levels of patients who did not develop organ failure. Approximately 8% of patients had triglyceride levels greater than 500 mg/dL, the majority of which had similarly high levels before admission.ConclusionsIncreased triglyceride levels were associated with the development of multiple or persistent organ failure among patients hospitalized with acute pancreatitis. Patients with high triglyceride levels at the time of admission were likely to have high triglyceride levels before admission

Dynamic Measurement of Disease Activity in Acute Pancreatitis: The Pancreatitis Activity Scoring System

ObjectivesAcute pancreatitis has a highly variable course. Currently there is no widely accepted method to measure disease activity in patients hospitalized for acute pancreatitis. We aimed to develop a clinical activity index that incorporates routine clinical parameters to assist in the measurement, study, and management of acute pancreatitis.MethodsWe used the UCLA/RAND appropriateness method to identify items for inclusion in the disease activity instrument. We conducted a systematic literature review followed by two sets of iterative modified Delphi meetings including a panel of international experts between November 2014 and November 2015. The final instrument was then applied to patient data obtained from five separate study cohorts across Southern California to assess profiles of disease activity.ResultsFrom a list of 35 items comprising 6 domains, we identified 5 parameters for inclusion in the final weighted clinical activity scoring system: organ failure, systemic inflammatory response syndrome, abdominal pain, requirement for opiates and ability to tolerate oral intake. We applied the weighted scoring system across the 5 study cohorts comprising 3,123 patients. We identified several distinct patterns of disease activity: (i) overall there was an elevated score at baseline relative to discharge across all study cohorts, (ii) there were distinct patterns of disease activity related to duration of illness as well as (iii) early and persistent elevation of disease activity among patients with severe acute pancreatitis defined as persistent organ failure.ConclusionsWe present the development and initial validation of a clinical activity score for real-time assessment of disease activity in patients with acute pancreatitis