Terry Leet

Gestational weight gain and pregnancy outcomes in obese women: how much is enough?

OBJECTIVE: To examine the effect of gestational weight change on pregnancy outcomes in obese women. METHODS: A population-based cohort study of 120,251 pregnant, obese women delivering full-term, liveborn, singleton infants was examined to assess the risk of four pregnancy outcomes (preeclampsia, cesarean delivery, small for gestational age births, and large for gestational age births) by obesity class and total gestational weight gain. RESULTS: Gestational weight gain incidence for overweight or obese pregnant women, less than the currently recommended 15 lb, was associated with a significantly lower risk of preeclampsia, cesarean delivery, and large for gestational age birth and higher risk of small for gestational age birth. These results were similar for each National Institutes of Health obesity class (30–34.9, 35–35.9, and 40.0 kg/m2), but at different amounts of gestational weight gain. CONCLUSION: Limited or no weight gain in obese pregnant women has favorable pregnancy outcomes. LEVEL OF EVIDENCE: II

Evaluation of Gestational Weight Gain Guidelines for Women With Normal Prepregnancy Body Mass Index

OBJECTIVE: To investigate the relationship between gestational weight gain and adverse pregnancy outcomes among women with normal prepregnancy body mass index. METHODS: We conducted a population-based cohort study of women with normal prepregnancy body mass index who delivered full-term singletons using Missouri birth certificate data for 1999–2001. The cohort was divided into three groups (less than recommended [less than 25 lb], n=16,852; recommended [25–35 lb], n=37,292; more than recommended [more than 35 lb], n=40,552) based on Institute of Medicine gestational weight gain guidelines. Logistic regression was used to adjust for known confounders. RESULTS: Compared with women gaining 25–35 lb, women gaining less than 25 lb during pregnancy had lower odds for preeclampsia (adjusted odds ratio [aOR] 0.56, 95% confidence interval [CI] 0.49–0.64), cephalopelvic disproportion (aOR 0.64, 95% CI 0.55–0.75), failed induction (aOR 0.68, 95% CI 0.59–0.78), cesarean delivery (aOR 0.82, 95% CI 0.78–0.87), and large for gestational age infants (aOR 0.40, 95% CI 0.37–0.44) and increased odds for small for gestational age infants (aOR 2.14, 95% CI 2.01–2.27). Likewise, women gaining more than 35 lb had lower odds for small for gestational age infants (aOR 0.48, 95% CI 0.45–0.50) and increased odds for preeclampsia (aOR 1.88, 95% CI 1.74–2.04), failed induction (aOR 1.51, 95% CI 1.39–1.64), cesarean delivery (aOR 1.35, 95% CI 1.29–1.40), and large for gestational age infants (aOR 2.43, 95% CI 2.30–2.56). CONCLUSION: Our study shows that adherence to the current Institute of Medicine guidelines results in lower risks for adverse pregnancy, labor, and delivery outcomes when comparing all outcomes collectively. LEVEL OF EVIDENCE: II

To Gown or Not to Gown: The Effect on Acquisition of Vancomycin-Resistant Enterococci

Infection-control recommendations include the use of gowns and gloves to prevent horizontal transmission of vancomycin-resistant enterococci (VRE). This study sought to determine whether the use of a gown and gloves gives greater protection than glove use alone against VRE transmission in a medical intensive care unit (MICU). From 1 July 1997 through 30 June 1998 and from 1 July 1999 through 31 December 1999, health care personnel and visitors were required to don gloves and gowns upon entry into rooms where there were patients infected with nosocomial pathogens. From 1 July 1998 through 30 June 1999, only gloves were required under these same circumstances. During the gown period, 59 patients acquired VRE (9.1 cases per 1000 MICU-days), and 73 patients acquired VRE during the no-gown period (19.6 cases per 1000 MICU-days; P<.01). The adjusted risk estimate indicated that gowns were protective in reducing VRE acquisition in an MICU with high VRE colonization pressure.

Socioeconomic factors and adolescent pregnancy outcomes: distinctions between neonatal and post-neonatal deaths?

BackgroundYoung maternal age has long been associated with higher infant mortality rates, but the role of socioeconomic factors in this association has been controversial. We sought to investigate the relationships between infant mortality (distinguishing neonatal from post-neonatal deaths), socioeconomic status and maternal age in a large, retrospective cohort study.MethodsWe conducted a population-based cohort study using linked birth-death certificate data for Missouri residents during 1997–1999. Infant mortality rates for all singleton births to adolescent women (12–17 years, n = 10,131; 18–19 years, n = 18,954) were compared to those for older women (20–35 years, n = 28,899). Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for all potential associations.ResultsThe risk of infant (OR 1.95, CI 1.54–2.48), neonatal (1.69, 1.24–2.31) and post-neonatal mortality (2.47, 1.70–3.59) were significantly higher for younger adolescent (12–17 years) than older (20–34 years) mothers. After adjusting for race, marital status, age-appropriate education level, parity, smoking status, prenatal care utilization, and poverty status (indicated by participation in WIC, food stamps or Medicaid), the risk of post-neonatal mortality (1.73, 1.14–2.64) but not neonatal mortality (1.43, 0.98–2.08) remained significant for younger adolescent mothers. There were no differences in neonatal or post-neonatal mortality risks for older adolescent (18–19 years) mothers.ConclusionSocioeconomic factors may largely explain the increased neonatal mortality risk among younger adolescent mothers but not the increase in post-neonatal mortality risk.

Improving the public health workforce: evaluation of a training course to enhance evidence-based decision making.

An evidence-based public health (EBPH) course was developed in 1997 by the Prevention Research Center at Saint Louis University School of Public Health to train the public health workforce to enhance dissemination of EBPH in their public health practice. An on-line evaluation of the course was conducted among participants who attended the course from 2001 to 2004 to determine the impact the course had on the implementation of EBPH within their Respective public health agencies (n = 107). The majority of these individuals were program directors, managers, or coordinators working in state health departments. Results from the evaluation Revealed that 90 percent of participants indicated that the course helped them make more informed decisions in the workplace. Respondents identified improvement in their ability to communicate with their coworkers and Read Reports. When asked to identify potential barriers, participants specified that time constraints were the biggest impediment to using EBPH skills in the workplace. These data suggest the importance of professional training opportunities in EBPH for public health practitioners. Future endeavors should focus on overcoming the barriers to the dissemination of EBPH.

A cost-benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: Is it worth the price?

OBJECTIVE To determine the net benefit and costs associated with gown use in preventing transmission of vancomycin-resistant Enterococcus (VRE). DESIGN A cost-benefit analysis measuring the net benefit of gowns was performed. Benefits, defined as averted costs from reduced VRE colonization and infection, were estimated using a matched cohort study. Data sources included a step-down cost allocation system, hospital informatics, and microbiology databases. SETTING The medical intensive care unit (MICU) at Barnes-Jewish Hospital, St. Louis, Missouri. PATIENTS Patients admitted to the MICU for more than 24 hours from July 1, 1997, to December 31, 1999. INTERVENTIONS Alternating periods when all healthcare workers and visitors were required to wear gowns and gloves versus gloves alone on entry to the rooms of patients colonized or infected with VRE. RESULTS On base-case analysis, 58 VRE cases were averted with gown use during 18 months. The annual net benefit of the gown policy was dollar 419,346 and the cost per case averted of VRE was dollar 1,897. The analysis was most sensitive to the level of VRE transmission. CONCLUSIONS Infection control policies (eg, gown use) initially increase the cost of health services delivery. However, such policies can be cost saving by averting nosocomial infections and the associated costs of treatment. The cost savings to the hospital plus the benefits to patients and their families of avoiding nosocomial infections make effective infection control policies a good investment.

Acquisition of Vancomycin-Resistant Enterococci during Scheduled Antimicrobial Rotation in an Intensive Care Unit

Scheduled rotation of treatment of gram-negative antimicrobial agents has been associated with reduction of serious gram-negative infections. The impact of this practice on other nosocomial infections has not been assessed. The purpose of this study was to determine if scheduled antimicrobial rotation reduced rates of acquisition of enteric vancomycin-resistant enterococci (VRE) among 740 patients admitted to an intensive care unit (ICU). The preferred gram-negative agent was ceftazidime during rotation 1 and ciprofloxacin during rotation 2. Unadjusted VRE acquisition rates were 8.5 cases per 1000 ICU days and 11.7 cases per 1000 ICU days during rotations 1 and 2, respectively (P<.01). However, scheduled antimicrobial rotation of ceftazidime with ciprofloxacin had no effect on the risk of acquiring VRE in the ICU after adjustment for known risk factors. Independent predictors of acquisition of VRE were enteral feedings, higher colonization pressure, and increased duration of anaerobic therapy. Our findings can confirm no additional beneficial or adverse effect on VRE acquisition among ICU patients as a result of this practice.

Results of a comprehensive infection control program for reducing surgical-site infections in coronary artery bypass surgery.

OBJECTIVE To evaluate the efficacy of a comprehensive infection control program on the reduction of surgical-site infections (SSIs) following coronary artery bypass graft (CABG) surgery. DESIGN Prospective cohort study. SETTING 1,000-bed tertiary-care hospital. PATIENTS Persons undergoing CABG with or without concomitant valve surgery from April 1991 through December 1994. INTERVENTIONS Prospective surveillance, quarterly reporting of SSI rates, chlorhexidene showers, discontinuation of shaving, administration of antibiotic prophylaxis in the holding area, elimination of ice baths for cooling of cardioplegia solution, limitation of operating room traffic, minimization of flash sterilization, and elimination of postoperative tap-water wound bathing for 96 hours. Logistic regression models were fitted to assess infection rates over time, adjusting for severity of illness, surgeon, patient characteristics, and type of surgery. RESULTS 2,231 procedures were performed. A reduction in infection rates was noted at all sites. The rate of deep chest infections decreased from 2.6% in 1991 to 1.6% in 1994. Over the same period, the rate of leg infections decreased from 6.8% to 2.7%, and of all SSI from 12.4% to 8.9%. The adjusted odds ratio (OR) for all SSIs for the end of 1994 compared to December 31, 1991, was 0.37 (95% confidence interval [CI95], 0.22-0.63). For deep chest and mediastinal infections, the adjusted OR comparing the same period was 0.69 (CI95, 0.28-1.71). CONCLUSIONS We observed significant reductions in SSI rates of deep and superficial sites in CABG surgery following implementation of a comprehensive infection control program. These differences remained significant when adjusted for potential confounding covariables.

Risk factors and infant outcomes associated with umbilical cord prolapse: A population-based case-control study among births in Washington State

OBJECTIVE Our goal was to quantify the magnitude of risk associated with conditions resulting in umbilical cord prolapse and adverse infant outcome after cord prolapse. STUDY DESIGN This population-based case-control study used birth certificate data from 709 cases and 2407 randomly selected controls. Odds ratios were used as measures of association, with stratification performed to control for confounding. RESULTS Case infants were more likely to weigh < 2500 mg (odds ratio 4.8, 95% confidence interval 3.7 to 6.2) and to born prematurely (odds ratio 2.9, 95% confidence interval 2.2 to 3.7). Other risk factors were breech presentation (birth weight-adjusted odds ratio 2.5, 95% confidence interval 1.7 to 3.9) and being a second-born twin (odds ratio 5.0, 95% confidence interval 3.3 to 11.7). Subsequent adverse infant outcomes included an increased risk of mortality (relative risk 2.7, 95% confidence interval 1.9 to 4.0), with mortality being less likely to occur among cases delivered by cesarean section (relative risk 0.4, 95% confidence interval 0.2 to 0.6). CONCLUSIONS This study confirms previously suspected risk factors and supports clinical management of cord prolapse by cesarean section delivery.

Effect of exercise on birthweight.

Research evaluating the effect of physical activity on perinatal outcomes can be divided into two categories: work-related activities and exercise. According to previous qualitative reviews, the results from studies focusing on work-related activities have been inconsistent. Some studies have reported associations between specific activities (eg, prolonged standing and walking or heavy lifting) and an increased risk for preterm delivery and small-for-gestational age (SGA) infants. Others have argued that the associations may be due to other workrelated stressors or unknown confounders. Two meta-analyses have been conducted to evaluate the effect of maternal exercise on perinatal outcomes. In 1991, Lokey et al reported no difference in birthweight or gestational age at delivery for infants by maternal exercise status during pregnancy. They also reported no differences for the infants of women who exercised within or above the American College of Obstetricians and Gynecologists recommendation for exercise intensity ( 140 beats per minute) that were in effect when the meta-analysis was completed. In 2002, Kramer showed no weighted mean differences for birthweight or gestational age at delivery for infants born of mothers who did and did not participate in regular aerobic exercise while pregnant. The results for his meta-analysis were based on 10 clinical trials, whereas the Lokey et al meta-analysis included 18 studies regardless of design. Although both meta-analyses suggest that maternal exercise during pregnancy may not have any effect on specific fetal outcomes, a few questions remain as to whether differences in birthweight are dependent upon the physical conditioning of the mother previous to pregnancy, how long she continued to exercise during her pregnancy, and the type of controls used for comparison. Our meta-analysis addresses these questions using all published and unpublished studies as of December 31, 2002, that evaluated the effect of maternal exercise during pregnancy on birthweight.