Microbial associations and transfers across the One Health Triad effects on human and animal adiposity and temperament: a protocol for an observational pilot study

IntroductionIt is known that humans and pet dogs harbor microbial communities that are important regulators of health and disease. Pet dogs have been shown to promote microbial exchange between members of a household, a process that may have lasting health implications. Infancy marks a unique period of development as environmental exploration and introduction to complementary foods occur. This may lead to greater opportunities for microbial transfer between pet dogs and human infants due to a more confined shared environment, similar means of mobility, greater physical contact, and increased frequency of shared foods. This human-animal bond has led to extensive research in the areas of childhood allergies and behavioral health; however, there is a paucity in the available literature that has evaluated how this unique ecological relationship may impact both human and animal health.MethodsInfants who reside in a household with a pet dog will be recruited from the greater Phoenix metropolitan area for this longitudinal, observational pilot study and followed through the complementary feeding period. Infant and pet dog fecal, salivary, and skin samples, as well as environmental samples from feeding areas/surfaces and main indoor play areas from both infants and pet dogs will be collected through in-home visits before (~5 mos), during (~9 mos), and after (~12 mos) the complementary feeding (CF) period. Anthropometrics, temperament, and dietary habits of both infants and pet dogs along with assessment of the home condition will also be collected. Microbial comparisons between infant and pet dog samples and evaluation of microbial changes during the CF period will be evaluated. Further, we will assess relationships between microbial composition and adiposity and temperament of both infants and pet dogs.DiscussionThe proposed observational pilot study will advance the available science by exploring how microbial communities are associated and change between infants and pet dogs before, during, and after the CF period, a unique period of human growth and development. Findings from this study will provide insights into the impact these ecological relationships have on each other and how transfer across the One Health Triad impacts human and animal health

Geographic Distribution of Maternal Group B Streptococcus Colonization and Infant Death During Birth Hospitalization: Eastern Wisconsin

Purpose: Maternal group B Streptococcus (GBS) can be transmitted from a colonized mother to newborn during vaginal delivery and may or may not contribute to infant death. This study aimed to explore the geographic distribution and risk factors of maternal GBS colonization and infant death during birth hospitalization. Methods: We retrospectively studied mothers with live birth(s) in a large eastern Wisconsin hospital system from 2007 through 2013. Associations between maternal and neonatal variables, GBS colonization and infant death were examined using chi-squared, Mann-Whitney U and t-tests. Multivariable logistic regression models also were developed. Results: Study population (N = 99,305) had a mean age of 28.1 years and prepregnancy body mass index (BMI) of 26.7 kg/m2; 64.0% were white, 59.2% married, 39.3% nulliparous and 25.7% cesarean delivery. Mean gestational age was 39.0 weeks. Rate of maternal GBS colonization (22.3% overall) was greater in blacks (34.1% vs. 20.1% in whites, P < 0.0001), unmarried women (25.5% vs. 20.0% married, P < 0.0001), women with sexually transmitted or other genital infections (P < 0.0001) and residents of ZIP code group 532XX (P < 0.0001), and was associated with increasing BMI (P < 0.0001). All predictors of colonization were significant on multivariable analysis. Rate of infant death was 5.7 deaths/1,000 live births (n = 558 excluding lethal anomalies and stillbirths) and was negatively associated with maternal GBS colonization (P < 0.0001). On multivariable analysis, 532XX ZIP code group, lower gestational age, preterm labor, hyaline membrane disease, normal spontaneous vaginal delivery, hydramnios, oligohydramnios and absence of maternal GBS were associated with infant death. Conclusions: Geographic characteristics were associated with infant death and maternal GBS colonization. Further research is needed to determine if increased surveillance or treatment of mothers colonized with GBS decreases the risk of infant demise at birth

Comparison and Characterization of Prenatal Nutrition Counseling among Large-for-Gestational Age Deliveries by Pre-Pregnancy BMI

It is recommended that prenatal care include nutrition counseling; however, &lt;70% of women report receipt of nutrition counseling during pregnancy. In this study, we aimed to characterize prenatal nutrition counseling (PNC) among large-for-gestational age deliveries at a low-income and minority-serving hospital by performing a retrospective chart review of infants with a birth weight &gt; 4000 g. Of the 2380 deliveries, 165 met the inclusion criteria. Demographics, PNC receipt, and pregnancy outcomes were compared among normal-weight (NW; BMI: 18.5&ndash;24.9 kg/m2, 19%, n = 31), overweight (OW; BMI: 25&ndash;29.9 kg/m2, 29%, n = 48), and obese (OB; BMI &gt; 30 kg/m2, 52%, n = 86) women. The majority (78%, n = 129) of women were Hispanic White with a mean age of 30.4 &plusmn; 5.7 yrs and gestational weight gain of 12.1 &plusmn; 5.8 kgs. A total of 62% (n = 103) of women received PNC. A total of 57% gained above the Institute of Medicine (IOM) recommendations (n = 94). OB women were 2.6 and 2.1 times more likely to receive PNC than OW (95% CI: 1.1&ndash;2.0) and NW (95% CI: 0.9&ndash;1.9) women, respectively. Women who gained within the IOM recommendations for their pre-pregnancy body mass index (BMI) were 50% less likely to receive PNC than women who gained above the IOM recommendations for their pre-pregnancy weight (&chi; = 4.45, p = 0.035; OR = 0.48, CI: 0.24 to 0.95). Infant birthweight was significantly higher among women who received PNC (4314 &plusmn; 285 vs. 4197 &plusmn; 175 g, p = 0.004). These data suggest that PNC was directed toward women who enter pregnancy in the obese weight category and/or gain excessively across gestation. Future studies should provide PNC to all women to evaluate whether it reduces the risk of delivering large-for-gestational age deliveries across all maternal weight categories. Additionally, more work is needed to identify the types of PNC that are most effective for this high-risk population

Clinical Approach to Nonresponsive Pneumonia in Adults Diagnosed by a Primary Care Clinician: A Retrospective Study

Purpose: Community-acquired pneumonia (CAP) is commonly diagnosed in the primary care setting. Management of nonresponsive pneumonia (NRP), i.e. failure to respond to CAP treatment, is not clearly understood. The purpose of this study was to describe the initial work-up and treatment of CAP in the ambulatory primary care setting and to determine relative proportion of, diagnostic approach to and treatment of NRP. Methods: We retrospectively studied adult patients diagnosed with CAP within our large, integrated health care system from October 2006 through July 2013. Cases were defined as patients with CAP who worsened after 4 days, or did not improve within 10 days, of antibiotic treatment. Controls were CAP patients who did not meet case definition. Mann-Whitney and t-tests were used to analyze continuous variables. Chi-square or Fisher’s exact test was used to analyze categorical variables. Significant variables were used to construct a multivariable logistic regression model. Results: Of 250 total patients studied, there were 85 cases and 165 controls. The case population was significantly older (59 ± 16 vs. 53 ± 19 years, P = 0.02). Multivariable logistic regression revealed former smoker (P < 0.01), initial presentation to urgent care (P = 0.02) and myalgia (P = 0.003) as predictors of NRP. Chest X-rays were more commonly ordered for cases at initial visit (80% vs. 68%, P = 0.06). Overall, 24% of patients had additional testing at the initial visit (39% of cases vs. 16% of controls, P < 0.001). Additionally, a higher proportion of cases underwent antibiotic change at their first (62% vs. 15%, P < 0.001) or second (47% vs. 5%, P < 0.001) follow-up visit. Conclusions: Patients with NRP tended to be former smokers, report myalgia and/or present to urgent care. The majority of providers conducted chest X-rays, but no further pneumonia testing, at the initial visit. Further study is needed to determine if this strategy leads to delayed etiologic diagnosis and definitive treatment

Clinical Approach to Nonresponsive Pneumonia in Adults Diagnosed by a Primary Care Clinician: A Retrospective Study

Purpose: Community-acquired pneumonia (CAP) is commonly diagnosed in the primary care setting. Management of nonresponsive pneumonia (NRP), i.e. failure to respond to CAP treatment, is not clearly understood. The purpose of this study was to describe the initial work-up and treatment of CAP in the ambulatory primary care setting and to determine relative proportion of, diagnostic approach to and treatment of NRP. Methods: We retrospectively studied adult patients diagnosed with CAP within our large, integrated health care system from October 2006 through July 2013. Cases were defined as patients with CAP who worsened after 4 days, or did not improve within 10 days, of antibiotic treatment. Controls were CAP patients who did not meet case definition. Mann-Whitney and t-tests were used to analyze continuous variables. Chi-square or Fisher’s exact test was used to analyze categorical variables. Significant variables were used to construct a multivariable logistic regression model. Results: Of 250 total patients studied, there were 85 cases and 165 controls. The case population was significantly older (59 ± 16 vs. 53 ± 19 years, P = 0.02). Multivariable logistic regression revealed former smoker (P < 0.01), initial presentation to urgent care (P = 0.02) and myalgia (P = 0.003) as predictors of NRP. Chest X-rays were more commonly ordered for cases at initial visit (80% vs. 68%, P = 0.06). Overall, 24% of patients had additional testing at the initial visit (39% of cases vs. 16% of controls, P < 0.001). Additionally, a higher proportion of cases underwent antibiotic change at their first (62% vs. 15%, P < 0.001) or second (47% vs. 5%, P < 0.001) follow-up visit. Conclusions: Patients with NRP tended to be former smokers, report myalgia and/or present to urgent care. The majority of providers conducted chest X-rays, but no further pneumonia testing, at the initial visit. Further study is needed to determine if this strategy leads to delayed etiologic diagnosis and definitive treatment

Clinical Approach to Nonresponsive Pneumonia in Adults Diagnosed by a Primary Care Clinician: A Retrospective Study

Purpose Community-acquired pneumonia (CAP) is commonly diagnosed in the primary care setting. Management of nonresponsive pneumonia (NRP), i.e. failure to respond to CAP treatment, is not clearly understood. The purpose of this study was to describe the initial work-up and treatment of CAP in the ambulatory primary care setting and to determine relative proportion of, diagnostic approach to and treatment of NRP. Methods We retrospectively studied adult patients diagnosed with CAP within our large, integrated health care system from October 2006 through July 2013. Cases were defined as patients with CAP who worsened after 4 days, or did not improve within 10 days, of antibiotic treatment. Controls were CAP patients who did not meet case definition. Mann-Whitney and t-tests were used to analyze continuous variables. Chi-square or Fisher’s exact test was used to analyze categorical variables. Significant variables were used to construct a multivariable logistic regression model. Results Of 250 total patients studied, there were 85 cases and 165 controls. The case population was significantly older (59 ± 16 vs. 53 ± 19 years, P = 0.02). Multivariable logistic regression revealed former smoker (P \u3c 0.01), initial presentation to urgent care (P = 0.02) and myalgia (P = 0.003) as predictors of NRP. Chest X-rays were more commonly ordered for cases at initial visit (80% vs. 68%, P = 0.06). Overall, 24% of patients had additional testing at the initial visit (39% of cases vs. 16% of controls, P \u3c 0.001). Additionally, a higher proportion of cases underwent antibiotic change at their first (62% vs. 15%, P \u3c 0.001) or second (47% vs. 5%, P \u3c 0.001) follow-up visit. Conclusions Patients with NRP tended to be former smokers, report myalgia and/or present to urgent care. The majority of providers conducted chest X-rays, but no further pneumonia testing, at the initial visit. Further study is needed to determine if this strategy leads to delayed etiologic diagnosis and definitive treatment

Association Between Pregnancy Intention and Maternal Characteristics, Outcomes, and Cost of Care: A Pilot Study

Background: An estimated 51% of pregnancies in the United States are unintended. In Wisconsin, unplanned pregnancies account for 40% of all pregnancies and cost $148 million in public funds. Unintended pregnancy, which creates increased hardship for mothers and threatened well-being of infants, has been recognized as an important health, social and economic problem. Purpose: To determine the pregnancy intentions of postpartum women and the maternal characteristics, outcomes and costs of care associated with unintended pregnancies at a large urban hospital in Milwaukee, Wisconsin. Methods: Postpartum women were surveyed prior to discharge. The 20-item survey included whether or not the woman had been trying to get pregnant and how she felt about the timing of her pregnancy. Electronic medical records were reviewed to determine maternal and neonatal outcomes, including antenatal, perinatal, postpartum comorbidities and complications. To determine the most important factors influencing the binary and multicategory responses of pregnancy intention, logistic and multinomial regression models were developed using stepwise variable selection procedures. Results: A total of 338 women were asked to participate, resulting in 243 completed surveys (95 exclusions: 8 declines, 29 language barriers, 46 lost to follow-up, 12 other). Overall, 63% (142/227) of pregnancies occurred when “not trying.” Logistic and multinomial regression revealed anemia (P = 0.004–0.007), anxiety (P = 0.048) and income level (P = 0.002–0.045) as the most significant predictors of unintended pregnancy. The odds of unintended pregnancy for women at the lowest two income levels were 12.05 (odds ratio: 2.82–51.39) and 3.83 (odds ratio: 1.314–11.142) times greater than those for women at the highest income level. Significant univariate associations existed between unintended pregnancy and age (P \u3c 0.001), race (P = 0.025) and insurance (P = 0.003). Conclusion: The unintended pregnancy rate of our study population was greater than state and national levels. Maternal characteristics of income, anemia and anxiety were the most significant predictors of pregnancy intention, but unintended pregnancy also was highly associated with younger age, African-American race and Medicaid insurance. Unintended pregnancy effects included: fewer prenatal care visits, increased prevalence of intrauterine growth restriction and decreased likelihood of breastfeeding. While the relative use of contraception was significantly greater, the absolute use among women who had an unintended pregnancy is of great clinical concern

Geographic Distribution of Maternal Group B Streptococcus Colonization and Infant Death During Birth Hospitalization: Eastern Wisconsin

Purpose Maternal group B Streptococcus (GBS) can be transmitted from a colonized mother to newborn during vaginal delivery and may or may not contribute to infant death. This study aimed to explore the geographic distribution and risk factors of maternal GBS colonization and infant death during birth hospitalization. Methods We retrospectively studied mothers with live birth(s) in a large eastern Wisconsin hospital system from 2007 through 2013. Associations between maternal and neonatal variables, GBS colonization and infant death were examined using chi-squared, Mann-Whitney U and t-tests. Multivariable logistic regression models also were developed. Results Study population (N = 99,305) had a mean age of 28.1 years and prepregnancy body mass index (BMI) of 26.7 kg/m2; 64.0% were white, 59.2% married, 39.3% nulliparous and 25.7% cesarean delivery. Mean gestational age was 39.0 weeks. Rate of maternal GBS colonization (22.3% overall) was greater in blacks (34.1% vs. 20.1% in whites, P \u3c 0.0001), unmarried women (25.5% vs. 20.0% married, P \u3c 0.0001), women with sexually transmitted or other genital infections (P \u3c 0.0001) and residents of ZIP code group 532XX (P \u3c 0.0001), and was associated with increasing BMI (P \u3c 0.0001). All predictors of colonization were significant on multivariable analysis. Rate of infant death was 5.7 deaths/1,000 live births (n = 558 excluding lethal anomalies and stillbirths) and was negatively associated with maternal GBS colonization (P \u3c 0.0001). On multivariable analysis, 532XX ZIP code group, lower gestational age, preterm labor, hyaline membrane disease, normal spontaneous vaginal delivery, hydramnios, oligohydramnios and absence of maternal GBS were associated with infant death. Conclusions Geographic characteristics were associated with infant death and maternal GBS colonization. Further research is needed to determine if increased surveillance or treatment of mothers colonized with GBS decreases the risk of infant demise at birth

First-Case Operating Room Delays: Patterns Across Urban Hospitals of a Single Health Care System

Purpose Operating room delays decrease health care system efficiency and increase costs. To improve operating room efficiency in our system, we retrospectively investigated delay frequencies, causes and costs. Methods We studied all first-of-the-day nonemergent surgical cases performed at three high-volume urban hospitals of a large health system from July 2012 to November 2013. Times for patient flow from arrival to procedure start and documented reasons for delay were obtained from electronic medical records. Delay was defined as patient placement in the operating room later than scheduled surgery time. Effects of patient characteristics, late patient arrival to the hospital, number of planned procedures, years of surgeon experience, service department and hospital facility on odds of delay were examined using logistic regression. Results Of 5,598 cases examined, 88% were delayed. Patients arrived late to the hospital (surgery) in 65% of first cases. Mean time from arrival to scheduled surgery and in-room placement was 104.6 and 127.4 minutes, respectively. Mean delay time was 28.2 minutes. Nearly 60% of delayed cases had no documented reason for delay. For cases with documentation, causes included the physician (52%), anesthesia (15%), patient (13%), staff (9%), other sources (6%) and facility (5%). Regression analysis revealed age, late arrival, department and facility as significant predictors of delay. Estimated delay costs, based on published figures and representing lost revenue, were $519,388. Conclusions To improve operating room efficiency, multidisciplinary strategies are needed for increasing patient adherence to recommended arrival times, documentation of delay by medical staff and consistency in workflow patterns among facilities and departments