Elena V Kuklina , MD, PhD, Senior Service Fellow, Epidemiology & Surveillance Branch (ESB) Division for Heart Disease and Stroke Prevention (DHDSP) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) Centers for Disease Control and Prevention (CDC) 4770 Buford Hwy, NE; Mailstop K-47, Atlanta, GA 30341
Abstract: Several epidemiologic studies suggested that higher sodium and lower potassium intakes were associated with increased risk of cardiovascular diseases (CVD). Few studies have examined joint effects of dietary sodium and potassium intake on risk of mortality.
Abstract: Background: Hypertension is a modifiable risk factor for cardiovascular disease. It affects one in three adults in the United States and contributes to one out of every seven deaths and nearly half of all cardiovascular disease--related deaths in the United States. Methods: CDC analyzed data from the National Health and Nutrition Examination Survey (NHANES) on the prevalence, treatment, and control of hypertension among U.S. adults aged ≥18 years. Hypertension was defined as an average blood pressure ≥140/90 mmHg or the current use of blood pressure--lowering medication. Control of hypertension was reported as an average treated systolic/diastolic blood pressure <140/90 mmHg. Multivariate analysis was performed to assess changes in prevalence of hypertension, use of pharmacologic treatment, and control of blood pressure between the 1999--2002 and 2005--2008 survey cycles. Results: During 2005--2008, approximately 68 million (31%) U.S. adults aged ≥18 years had hypertension, and this prevalence has shown no improvement in the past decade. Of these adults, 48 million (70%) were receiving pharmacologic treatment and 31 million (46%) had their condition controlled. Although 86% of adults with uncontrolled blood pressure had medical insurance, the prevalence of blood pressure control among adults with hypertension was especially low among participants who did not have a usual source of medical care (12%), received medical care less than twice in the previous year (21%), or did not have health insurance (29%). Control prevalence also was low among young adults (31%) and Mexican Americans (37%). Although the prevalence of hypertension did not change from 1999--2002 to 2005--2008, significant increases were observed in the prevalence of treatment and control. Conclusions: Hypertension affects millions of persons in the United States, and less than half of those with hypertension have their condition controlled. Prevalence of treatment and control are even lower among persons who do not have a usual source of medical care, those who are not receiving regular medical care, and those who do not have health insurance. Implications for Public Health Practice: To improve blood pressure control in the United States, a comprehensive approach is needed that involves policy and system changes to improve health-care access, quality of preventive care, and patient adherence to treatment. Nearly 90% of persons with uncontrolled hypertension have health insurance, indicating a need for health-care system improvements. Health-care system improvements, including use of electronic health records with registry and clinical decision support functions, could facilitate better treatment and follow-up management, and improve patient-physician interaction. Allied health professionals (e.g., nurses, dietitians, health educators and pharmacists) could help increase patient adherence to medications. Patient adoption of healthy behaviors could improve their blood pressure control. Reducing dietary intake of salt would greatly support prevention and control of hypertension; a 32% decrease in average daily consumption, from 3,400 mg to 2,300 mg, could reduce hypertension by as many as 11 million cases. Further reductions in sodium intake to 1,500 mg/day could reduce hypertension by 16.4 million cases.
Abstract: Background: High levels of low-density lipoprotein cholesterol (LDL-C), a major risk factor for coronary heart disease (CHD), can be treated effectively. Methods: CDC analyzed data from 1999--2002 and 2005--2008 to examine the prevalence, treatment, and control of high LDL-C among U.S. adults aged ≥20 years. Values were determined from blood specimens obtained from persons participating in the National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional, stratified, multistage probability sample survey of the U.S. civilian, noninstitutionalized population. The National Cholesterol Education Program Adult Treatment Panel-III guidelines set LDL-C goal levels of <100 mg/dL, <130 mg/dL, and <160 mg/dL for persons with high, intermediate, and low risk for developing CHD during the next 10 years, respectively. A person with high LDL-C was defined as either a person whose LDL-C levels were above the LDL-C goal levels or a person who reported currently taking cholesterol-lowering medication. Control of high LDL-C was defined as having a treated LDL-C value below the goal levels. Results: Based on data from the 2005--2008 NHANES, an estimated 71 million (33.5%) U.S. adults aged ≥20 years had high LDL-C, but only 34 million (48.1%) were treated and 23 million (33.2%) had their LDL-C controlled. Among persons with uncontrolled LDL-C, 82.8% reported having some form of health insurance. The proportion of adults with high LDL-C who were treated increased from 28.4% to 48.1% between the 1999--2002 and 2005--2008 study periods. Among adults with high LDL-C, the prevalence of LDL-C control increased from 14.6% to 33.2% between the periods. The prevalence of LDL-C control was lowest among persons who reported receiving medical care less than twice in the previous year (11.7%), being uninsured (13.5%), being Mexican American (20.3%), or having income below the poverty level (21.9%). Conclusions: The prevalence of control of high LDL-C in the United States, although improving, remains low, especially among low-income adults and those with limited access to health care. Strengthening the use of preventive services through improvement in health-care access and quality of care is expected to help achieve better control of high LDL-C in the United States. Implications for Public Health Practice: To improve LDL-C control levels, a comprehensive approach that involves improved clinical care, as well as improved health-care access, sustainability, and affordability, is needed. A standardized system of patient care incorporating electronic health records, registries, and automated reminders for practitioners, focusing on achieving regular patient follow-up, has the potential to improve control of high LDL-C. Lower out-of-pocket costs and simplification of the drug regimen, as well as involvement of nurses, dietitians, health educators, pharmacists and other allied health-care professionals in direct patient care also could be used to improve patient adherence to prescribed regimens.
Abstract: OBJECTIVE: The aim of this study was to determine acute stroke hospitalization rates for children and young adults and the prevalence of stroke risk factors among children and young adults hospitalized for acute stroke. METHODS: The study population consisted of 1995-2008 hospitalizations from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic stroke hospitalizations were identified by the primary International Classification of Diseases, 9th ed, Clinical Modification (ICD-9-CM) code. Seven consecutive 2-year time intervals were selected. Three age groups were utilized: 5 to 14 years, 15 to 34 years, and 35 to 44 years. Stroke risk factors and comorbidities among those hospitalized with acute stroke were identified by secondary ICD-9-CM codes. RESULTS: During the period of study, the prevalence of hospitalizations of acute ischemic stroke increased among all age and gender groups except females aged 5 to 14 years. Females aged 15 to 34 years and males and females aged 35 to 44 years showed a decrease in the prevalence of hospitalizations for subarachnoid hemorrhage, whereas females aged 5 to 14 years showed increases for subarachnoid hemorrhage. Hypertension, diabetes, obesity, lipid disorders, and tobacco use were among the most common coexisting conditions, and their prevalence increased from 1995 to 2008 among adolescents and young adults (aged 15-44 years) hospitalized with acute ischemic stroke. INTERPRETATION: Increases in the prevalence of ischemic stroke hospitalizations and coexisting traditional stroke risk factors and health risk behaviors were identified among acute ischemic stroke hospitalizations in young adults. Our results from national surveillance data accentuate the need for public health initiatives to reduce risk factors for stroke among adolescents and young adults. ANN NEUROL 2011;
Abstract: Stroke is an important contributor to maternal morbidity and mortality, but there are no recent data on trends in pregnancy-related hospitalizations that have involved a stroke. This report describes stroke hospitalizations for women in the antenatal, delivery, and postpartum periods from 1994 to 1995 to 2006 to 2007 and analyzes the changes in these hospitalizations over time.
Abstract: OBJECTIVE: The objective of the study was to examine the trends in the rate of peripartum hysterectomy and the contribution of changes in maternal characteristics to these trends. STUDY DESIGN: This was a cross-sectional study of peripartum hysterectomy identified from hospitalizations for delivery recorded in the 1994-2007 Nationwide Inpatient Sample. RESULTS: The overall rate of peripartum hysterectomy increased by 15% during the study period. The rate of hysterectomy for abnormal placentation increased by 1.2-fold; adjustment for previous cesarean delivery explained nearly all of this increase. The rate of hysterectomy for uterine atony following repeat cesarean delivery increased nearly 4-fold, following primary cesarean delivery approximately 2.5-fold, and following vaginal delivery about 1.5-fold. This fast growing trend in peripartum hysterectomy secondary to uterine atony was also largely explained by increasing rates of primary and repeat Cesareans. CONCLUSION: Rates of peripartum hysterectomy increased substantially in the United States from 1994 to 2007; much of this increase was due to rising rates of cesarean delivery.
Abstract: The objectives of the present study were to determine whether an optimal low-density lipoprotein cholesterol (LDL-C) combined with hypertriglyceridemia was associated with cardiovascular disease (CVD) mortality and whether these associations differ by gender.
Abstract: OBJECTIVE: The purpose of this study was to estimate the incidence of postpartum hemorrhage (PPH) in the United States and to assess trends. STUDY DESIGN: Population-based data from the 1994-2006 National Inpatient Sample were used to identify women who were hospitalized with postpartum hemorrhage. Data for each year were plotted, and trends were assessed. Multivariable logistic regression was used in an attempt to explain the difference in PPH incidence between 1994 and 2006. RESULTS: PPH increased 26% between 1994 and 2006 from 2.3% (n = 85,954) to 2.9% (n = 124,708; P < .001). The increase primarily was due to an increase in uterine atony, from 1.6% (n = 58,597) to 2.4% (n = 99,904; P < .001). The increase in PPH could not be explained by changes in rates of cesarean delivery, vaginal birth after cesarean delivery, maternal age, multiple birth, hypertension, or diabetes mellitus. CONCLUSION: Population-based surveillance data signal an apparent increase in PPH caused by uterine atony. More nuanced clinical data are needed to understand the factors that are associated with this trend.
Abstract: BACKGROUND: We evaluated the influence of type and timing of prophylaxis on perinatal HIV transmission in St. Petersburg, Russia. METHODS: We linked surveillance data for 1498 HIV-infected mothers delivering from 2004 to 2007 with polymerase chain reaction data for 1159 infants to determine predictors of transmission. RESULTS: The overall perinatal transmission rate was 6.3% [73 of 1159, 95% confidence interval (CI) 4.9% to 7.7%]. Among the 12.8% (n = 149) of mother-infant pairs receiving full course (antenatal, intrapartum, postnatal) dual/triple antiretroviral prophylaxis, the transmission rate was 2.7%. Among the 1010 receiving less complete regimens (full course zidovudine, single-dose nevirapine, or incomplete), transmission ranged from 4.1% to 12.2%. Among the 28.9% (330) of mothers initiating antiretroviral drugs <or=20 weeks gestation, perinatal transmission was 1.8%, compared with 4.0%, 8.6%, and 11.3% for those initiating antiretrovirals at 21-28 weeks, 29-42 weeks, or during labor and delivery, respectively (P for trend <0.0001). Compared with those initiating antepartum prophylaxis <or=20 weeks, those initiating antepartum prophylaxis >or=29 weeks (or not at all) had increased transmission odds (adjusted odds ratio: 4.9, 95% CI: 1.8 to 12.9; odds ratio: 5.1, 95% CI: 2.0 to 13.1, respectively). CONCLUSIONS: In St. Petersburg, the potential for further reductions in perinatal transmission is evident, given low transmission among women receiving early combination prophylaxis.
Abstract: BACKGROUND AND PURPOSE: The common medical complications after ischemic stroke are associated with increased mortality and resource use. METHOD: The study population consisted of 1 150 336 adult hospitalizations with ischemic stroke as a primary diagnosis included in the 1998 to 2007 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Multiple logistic regression analyses were used to examine changes between 1998 to 1999 and 2006 to 2007 in the prevalence of acute myocardial infarction, pneumonia, deep venous thrombosis, pulmonary embolism, or urinary tract infection, in-hospital mortality, and length of stay. RESULTS: In 2006 to 2007, the prevalence of hospitalizations with a secondary diagnosis of acute myocardial infarction, pneumonia, deep venous thrombosis, pulmonary embolism, and urinary tract infection was 1.6%, 2.9%, 0.8%, 0.3%, and 10.1%, respectively. The adjusted ORs for a hospitalization in 2006 to 2007 complicated by acute myocardial infarction, deep venous thrombosis, pulmonary embolism, or urinary tract infection, using 1998 to 1999 as the referent, were 1.39, 1.68, 2.39, and 1.18, respectively. The odds of pneumonia did not change significantly between 1998 to 1999 and 2006 to 2007. In-hospital mortality was significantly lower in 2006 to 2007 than in 1998 to 1999. Despite the overall length of stay decreasing significantly from 1998 to 1999 to 2006 to 2007, it remained the same for hospitalizations with acute myocardial infarction, pneumonia, deep vein thrombosis, and pulmonary embolism. CONCLUSIONS: Although in-hospital mortality decreased over the study period, 4 of the 5 complications were more common in 2006 to 2007 than they were 8 years earlier with the largest increase observed for deep venous thrombosis and pulmonary embolism.
Abstract: PURPOSE: Previous studies have reported low rates of screening for high cholesterol levels among young adults in the United States. Although recommendations for screening young adults without risk factors for coronary heart disease (CHD) differ, all guidelines recommend screening adults with CHD, CHD equivalents, or 1 or more CHD risk factors. This study examined national prevalence of CHD risk factors and compliance with the cholesterol screening guidelines among young adults. METHODS: National estimates were obtained using results for 2,587 young adults (men aged 20 to 35 years; women aged 20 to 45 years) from the 1999-2006 National Health and Nutrition Examination Surveys. We defined high low-density lipoprotein cholesterol (LDL-C) as levels higher than the goal specific for each CHD risk category outlined in the National Cholesterol Education Program Adult Treatment Panel III guidelines. RESULTS: About 59% of young adults had CHD or CHD equivalents, or 1 or more of the following CHD risk factors: family history of early CHD, smoking, hypertension, or obesity. In our study, the overall screening rate in this population was less than 50%. Moreover, no significant difference in screening rates between young adults with no risk factors and their counterparts with 1 or more risk factors was found even after adjustment for sociodemographic and health care factors. Approximately 65% of young adults with CHD or CHD equivalents, 26% of young adults with 2 or more risk factors, 12% of young adults with 1 risk factor, and 7% with no risk factor had a high level of LDL-C. CONCLUSIONS: CHD risk factors are common in young adults but do not appear to alter screening rates. Improvement of risk assessment and management for cardiovascular disease among young adults is warranted.
Abstract: OBJECTIVE To examine trends in the prevalence of diabetes among delivery hospitalizations in the U.S. and to describe the characteristics of these hospitalizations. RESEARCH DESIGN AND METHODS Hospital discharge data from 1994 through 2004 were obtained from the Nationwide Inpatient Sample. Diagnosis codes were selected for gestational diabetes mellitus (GDM), type 1 diabetes, type 2 diabetes, and unspecified diabetes. Rates of delivery hospitalization with diabetes were calculated per 100 deliveries. RESULTS Overall, an estimated 1,863,746 hospital delivery discharges contained a diabetes diagnosis, corresponding to a rate of 4.3 per 100 deliveries over the 11-year period. GDM accounted for the largest proportion of delivery hospitalizations with diabetes (84.7%), followed by type 1 (7%), type 2 (4.7%), and unspecified diabetes (3.6%). From 1994 to 2004, the rates for all diabetes, GDM, type 1 diabetes, and type 2 diabetes significantly increased overall and within each age-group (15-24, 25-34, and >/=35 years) (P < 0.05). The largest percent increase for all ages was among type 2 diabetes (367%). By age-group, the greatest percent increases for each diabetes type were among the two younger groups. Significant predictors of diabetes at delivery included age >/=35 years vs. 15-24 years (odds ratio 4.80 [95% CI 4.72-4.89]), urban versus rural location (1.14 [1.11-1.17]), and Medicaid/Medicare versus other payment sources (1.29 [1.26-1.32]). CONCLUSIONS Given the increasing prevalence of diabetes among delivery hospitalizations, particularly among younger women, it will be important to monitor trends in the pregnant population and target strategies to minimize risk for maternal/fetal complications.
Abstract: OBJECTIVES: To estimate the rate of pregnancy hospitalizations for women with two groups of myocardial disorders, cardiomyopathy and other myocardial disorders, and report the rate of severe obstetric complications among these hospitalizations in delivery and postpartum periods. METHODS: We performed a cross-sectional study using 14,323,731 hospitalizations for pregnancy identified from the 2004-2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. We reported rates of pregnancy hospitalizations with cardiomyopathy and other myocardial disorders per 1,000 deliveries and rates of severe complications per 1,000 hospitalizations during delivery and postpartum periods by myocardial disease status. We compared these rates by using chi2 tests with adjustment of P values for multiple comparisons using the Bonferroni method. RESULTS: Among all pregnancy hospitalizations, the overall prevalence of hospitalizations with myocardial disorders was 1.33 per 1,000 deliveries. The rate of pregnancy hospitalizations with cardiomyopathy was 0.46 per 1,000 deliveries (0.18 for apparent peripartum cardiomyopathy and 0.28 for other cardiomyopathies). The rate of pregnancy hospitalizations with other myocardial disorders was 0.87 per 1,000 deliveries. Myocardial disorders were rare during delivery hospitalizations (0.01%) but not uncommon among postpartum hospitalizations (4.2%). Among hospitalizations with myocardial disorders, the rate of severe complications ranged from 13.2 for acute myocardial infarction to 128.6 for adult respiratory distress syndrome and from 10.7 for pulmonary edema to 193.0 for fluid and electrolyte disorders per 1,000 delivery and postpartum hospitalizations, respectively. Among hospitalizations without myocardial disorders, the rate of severe complications ranged from 0.07 to 1.9 and from 0.4 to 65.5 for cardiac arrest and for fluid and electrolyte disorders per 1,000 hospitalizations, in delivery and postpartum periods, respectively. CONCLUSION: Although only a minority of hospitalizations for cardiomyopathy are consistent with peripartum cardiomyopathy, cardiomyopathy and other myocardial disorders are important contributors to severe obstetric complications. LEVEL OF EVIDENCE: III.
Abstract: OBJECTIVE: We sought to examine rates of birth trauma in 2 groupings (all International Classification of Diseases, Ninth Revision codes for birth trauma, and as defined by the Agency for Healthcare Research and Quality Patient Safety Indicator [PSI]) among infants born by vaginal and cesarean delivery. STUDY DESIGN: Data on singleton infants were obtained from the 2004-2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. RESULTS: The rates of Agency for Healthcare Research and Quality PSI and all birth trauma were 2.45 and 25.85 per 1000 births, respectively. Compared with vaginal, cesarean delivery was associated with increased odds of PSI birth trauma (odds ratio [OR], 1.71), primarily due to an increased risk for "other specified birth trauma" (OR, 2.61). Conversely, cesarean delivery was associated with decreased odds of all birth trauma (OR, 0.55), due to decreased odds of clavicle fractures (OR, 0.07), brachial plexus (OR, 0.10), and scalp injuries (OR, 0.55). CONCLUSION: Infants delivered by cesarean are at risk for different types of birth trauma from infants delivered vaginally.
Abstract: OBJECTIVE: To compare maternal and fetal outcomes among women with and without diagnosed depression at the time of delivery. METHODS: Hospital discharge data from the 1998-2005 Nationwide Inpatient Sample (NIS) were used to examine delivery-related hospitalizations for select maternal and fetal outcomes by depression diagnosis. RESULTS: The rate of depression per 1000 deliveries increased significantly from 2.73 in 1998 to 14.1 in 2005 (p < 0.001). Women diagnosed with depression were significantly more likely to have cesarean delivery, preterm labor, anemia, diabetes, and preeclampsia or hypertension compared with women without depression. Fetal outcomes significantly associated with maternal depression were fetal growth restriction, fetal abnormalities, fetal distress, and fetal death. CONCLUSIONS: These findings suggest that depression is associated with adverse maternal and fetal outcomes. Our results provide additional impetus to screen for depression among women of reproductive age, especially those who plan to become pregnant.
Abstract: OBJECTIVE: The purpose of this study was to examine trends in hospitalizations for gynecologic disorders in the United States. STUDY DESIGN: Data on hospitalizations from 1998-2005 among women 15-54 years old were from the Nationwide Inpatient Sample, a nationally representative survey of inpatient hospitalizations. Hospitalizations with a principal diagnosis of a gynecologic disorder were used to estimate rates per 10,000 women. RESULTS: Gynecologic disorders accounted for 7% and 14% of all hospitalizations among women 15-44 and 45-54 years old, respectively. The most common diagnoses were uterine leiomyomas (rate = 27.5), menstrual disorders (rate = 12.3), endometriosis (rate = 9.5), genital prolapse (rate = 7.0), benign ovarian cysts (rate = 6.5), and pelvic inflammatory disease (rate = 6.1). The hospitalization rate for menstrual disorders increased from 9.8 in 1998 to 13.3 in 2005 (P trend < .001). In contrast, rates declined for pelvic inflammatory disease, genital prolapse, benign ovarian cysts, and endometriosis (P trend < .05) and were unchanged for uterine leiomyoma. CONCLUSION: Gynecologic disorders are an important contributor to inpatient hospitalization among women in the United States.
Abstract: OBJECTIVE: To examine trends in the rates of severe obstetric complications and the potential contribution of changes in delivery mode and maternal characteristics to these trends. METHODS: We performed a cross-sectional study of severe obstetric complications identified from the 1998-2005 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regression was used to examine the effect of changes in delivery mode and maternal characteristics on rates of severe obstetric complications. RESULTS: The prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998-1999 to 0.81% (n=68,433) in 2004-2005. Rates of complications that increased significantly during the study period included renal failure by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57). In logistic regression models, adjustment for maternal age had no effect on the increased risk for these complications in 2004-2005 relative to 1998-1999. However, after adjustment for mode of delivery, the increased risks for these complications in 2004-2005 relative to 1998-1999 were no longer significant, with the exception of pulmonary embolism (odds ratio 1.30) and blood transfusion (odds ratio 1.72). Further adjustment for payer, multiple births, and select comorbidities had little effect. CONCLUSION: Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery. LEVEL OF EVIDENCE: III.
Abstract: In 2005-2006, an estimated 29% of U.S. adults had hypertension (i.e., high blood pressure), and another 28% had prehypertension. Hypertension increases the risk for heart disease and stroke, the first and third leading causes of death in the United States. Greater consumption of sodium can increase the risk for hypertension. The main source of sodium in food is salt (sodium chloride [NaCl]); uniodized salt is 40% sodium by weight. In 2005--2006, the estimated average intake of sodium among persons in the United States aged >/=2 years was 3,436 mg/day. In 2005, the U.S. Department of Health and Human Services and U.S. Department of Agriculture recommended that adults in the United States should consume no more than 2,300 mg/day of sodium (equal to approximately 1 tsp of salt), but those in specific groups (i.e., all persons with hypertension, all middle-aged and older adults, and all blacks) should consume no more than 1,500 mg/day of sodium. To estimate the proportion of the adult population for whom the lower sodium recommendation is applicable, CDC analyzed data from the National Health and Nutrition Examination Survey (NHANES) for the period 1999--2006. The results indicated that, in 2005--2006, the lower sodium recommendation was applicable to 69.2% of U.S. adults. Consumers and health-care providers should be aware of the lower sodium recommendation, and health-care providers should inform their patients of the evidence linking greater sodium intake to higher blood pressure.
Abstract: OBJECTIVE: To examine trends in the rates of hypertensive disorders in pregnancy and compare the rates of severe obstetric complications for delivery hospitalizations with and without hypertensive disorders. METHODS: We performed a cross-sectional study using the 1998-2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regressions and population-attributable fractions were used to examine the effect of hypertensive disorders on severe complications. RESULTS: The overall prevalence of hypertensive disorders among delivery hospitalizations increased significantly from 67.2 per 1,000 deliveries in 1998 to 81.4 per 1,000 deliveries in 2006. Compared with hospitalizations without any hypertensive disorders, the risk of severe obstetric complications ranged from 3.3 to 34.8 for hospitalizations with eclampsia/severe preeclampsia and from 1.4 to 2.2 for gestational hypertension. The prevalence of hospitalizations with eclampsia/severe preeclampsia increased moderately from 9.4 to 12.4 per 1,000 deliveries (P for linear trend <0.001) during the period of study. However, these hospitalizations were associated with 38% of hospitalizations with acute renal failure and 19% or more of hospitalizations with ventilation, disseminated intravascular coagulation syndrome, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. Overall, hospitalizations with hypertensive disorders were associated with 57% of hospitalizations with acute renal failure, 27% of hospitalizations with disseminated intravascular coagulation syndrome, and 30% or more of hospitalizations with ventilation, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. CONCLUSION: The number of delivery hospitalizations in the United States with hypertensive disorders in pregnancy is increasing, and these hospitalizations are associated with a substantial burden of severe obstetric morbidity. LEVEL OF EVIDENCE: III.
Abstract: CONTEXT: Studies show that a large proportion of adults with high levels of low-density lipoprotein cholesterol (LDL-C) remain untreated or undertreated despite growing use of lipid-lowering medications. OBJECTIVE: To investigate trends in screening prevalence, use of cholesterol-lowering medications, and LDL-C levels across 4 study cycles (1999-2000, 2001-2002, 2003-2004, and 2005-2006). DESIGN, SETTING, AND PARTICIPANTS: The National Health and Nutrition Examination Survey (NHANES) is a cross-sectional, stratified, multistage probability sample survey of the US civilian, noninstitutionalized population. After we restricted the study sample to fasting participants aged 20 years or older (n = 8018) and excluded pregnant women (n = 464) and participants with missing data (n = 510), our study sample consisted of 7044 participants. MAIN OUTCOME MEASURE: High LDL-C levels, defined as levels above the specific goal for each risk category outlined in guidelines from the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III). All presented results are weighted and age-standardized to 2000 standard population estimates. RESULTS: Prevalence of high LDL-C levels among persons aged 20 years or older decreased from 31.5% in 1999-2000 to 21.2% in 2005-2006 (P < .001 for linear trend) but varied by risk category. By the 2005-2006 study cycle, prevalence of high LDL-C was 58.9%, 30.2%, and 11.0% for high-, intermediate-, and low-risk categories, respectively. Self-reported use of lipid-lowering medications increased from 8.0% to 13.4% (P < .001 for linear trend), but screening rates did not change significantly, remaining less than 70% (P = .16 for linear trend) during the study periods. CONCLUSIONS: Among the NHANES population aged 20 years or older, the prevalence of high LDL-C levels decreased from 1999-2000 to 2005-2006. In the most recent period, the prevalence was 21.2%.
Abstract: OBJECTIVES: The accuracy of maternal morbidity estimates from hospital discharge data may be influenced by incomplete identification of deliveries. In maternal/infant health studies, obstetric deliveries are often identified only by the maternal outcome of delivery code (International Classification of Diseases code = V27). We developed an enhanced delivery identification method based on additional delivery-related codes and compared the performance of the enhanced method with the V27 method in identifying estimates of deliveries as well as estimates of maternal morbidity. METHODS: The enhanced and standard V27 methods for identifying deliveries were applied to data from the 1998-2004 Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationwide representative survey of U.S. hospitalizations. Odds ratios (ORs) and 95% confidence intervals (CIs) from logistic regression were used to examine predictors of deliveries not identified using the V27 method. RESULTS: The enhanced method identified 958,868 (3.4%) more deliveries than the 27,128,539 identified using the V27 code alone. Severe complications including major puerperal infections (OR = 3.1, 95% CI 2.8-3.4), hysterectomy (OR = 6.0, 95% CI 5.3-6.8), sepsis (OR = 11.9, 95% CI 10.3-13.6) and respiratory distress syndrome (OR = 16.6, 95% CI 14.4-19.2) were strongly associated with deliveries not identified by the V27 method. Nationwide prevalence rates of severe maternal complications were underestimated with the V27 method compared to the enhanced method, ranging from 9% underestimation for major puerperal infections to 40% underestimation for respiratory distress syndrome. CONCLUSION: Deliveries with severe obstetric complications may be more likely to be missed using the V27 code. Researchers should be aware that selecting deliveries from hospital stay records by V27 codes alone may affect the accuracy of their findings.
Abstract: OBJECTIVE: The purpose of this study was to describe trends in the prevalence of eating disorders among delivery hospitalizations in the United States from 1994 to 2004 and to compare hospital, demographic, and obstetrical outcomes among women with and without eating disorders. METHODS: Hospital discharge data for 1994 to 2004 from the Nationwide Inpatient Sample (NIS) were used to assess the relationship between eating disorders (anorexia nervosa and bulimia nervosa) and obstetrical complications. Analyses were limited to delivery-related hospitalizations. RESULTS: There were an estimated 1,668 delivery hospitalizations with an eating disorder diagnosis in the United States in the 11-year period, resulting in an overall rate of 0.39 per 10,000 deliveries. After adjustment for hospital and demographic characteristics, delivery hospitalizations with an eating disorder were significantly more likely than those without an eating disorder to have fetal growth restriction (odds ratio [OR] 9.08, 95% confidence interval [CI] 6.45-12.77), preterm labor (OR 2.78, 95% CI 2.10-3.69), anemia (OR 1.73, 95% CI 1.25-2.38), genitourinary tract infections (OR 1.66, 95% CI 1.03-2.68), and labor induction (OR 1.32, 95% CI 1.01-1.73). CONCLUSIONS: Although the prevalence of eating disorders among delivery hospitalizations is lower than in the general population, the fact that women with eating disorders are at increased risk of adverse pregnancy outcomes highlights the importance of screening for and appropriate clinical care of eating disorders in pregnancy.
Abstract: OBJECTIVE: Most studies of peripartum hysterectomy are conducted in single institutions, limiting the ability to provide national incidence estimates and examine risk factors. The objective of this study was to provide a national estimate of the incidence of peripartum hysterectomy and to examine factors associated with the procedure. METHODS: We used data for 1998-2003 from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationally representative survey of inpatient hospitalizations. Peripartum hysterectomy was defined as a hysterectomy and delivery occurring during the same hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for maternal and hospital characteristics using logistic regression. RESULTS: During 1998-2003, an estimated 18,339 peripartum hysterectomies occurred in the United States (0.77 per 1,000 deliveries). Compared with vaginal delivery without a previous cesarean delivery, the ORs of peripartum hysterectomy for other delivery types were as follows: repeat cesarean, 8.90 (95% CI 8.09-9.79); primary cesarean, 6.54 (95% CI 5.95-7.18); and vaginal birth after cesarean, 2.70 (95% CI 2.23-3.26). Multiple births were associated with an increased risk compared with singleton births (OR 1.41, 95% CI 1.16-1.71). CONCLUSION: Our results suggest that vaginal birth after cesarean, primary and repeat cesarean deliveries, and multiple births are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern, given the increasing rate of both cesarean deliveries and multiple births in the United States. LEVEL OF EVIDENCE: III.
Abstract: BACKGROUND: Small size at birth and in early childhood has been associated with impaired neurodevelopment in studies from developing countries, but few have examined associations with growth. AIMS: The objective of this study was to assess the relationship between growth and neurodevelopment during early childhood (birth-36 months). DESIGN: Multivariate regression models were used to analyze the data collected in the course of a study of pregnancy outcomes and early childhood growth and development carried out in rural Guatemala in 1991-1999. Motor and mental development scores were based on the Psychomotor and Mental Development Indices, respectively, derived from the administration of an adapted version of the Bayley Scales of Infant Development (Second Edition, 1993) at 6, 24 and 36 months. Z-scores for height-for-age (HAZ), weight-for-age (WAZ), and head circumference-for-age (HCZ) were used as indicators of attained size; changes in these Z-scores over time represent growth. RESULTS: Birth size was significantly associated with child development at 6 and 24 months. Gains in length and weight during the first 24 months were positively associated with child development, whereas growth from 24 to 36 months age was not associated with child development at 36 months. Motor development was more strongly and consistently related to child growth than was mental development. Head circumference gain after 6 months was not a significant predictor of child development at 24 and 36 months. CONCLUSIONS: Small size at birth and poor physical growth during the first 24 months are related to neurodevelopmental delays. More evidence from developing countries will help explain the underlying mechanisms and identify appropriate interventions to prevent neurodevelopmental delay in early childhood.
Abstract: The attainment of gross motor milestones is an important indicator of motor development in early life; however, little is known about factors affecting gross motor development in children from developing countries. The purpose of this study was to examine the relation of nutritional factors (physical growth and dietary intake) and morbidity during the first year of life to the age of walking without support. Multivariate regression models were used to analyze data collected prospectively between 1991 and 1999 in rural Guatemala. Attainment of children's gross motor milestones was assessed monthly by trained field workers using the 17-milestone Gross Motor Development Scale, morbidity was assessed by biweekly recall, and dietary intakes were measured at 9 and 12 mo of age using repeated 24-h dietary recalls. Median age of walking was 15 mo (range 10-24 mo; n = 174) with no differences by gender. Models were adjusted for birth order, gender, gestational age, maternal age and education, socioeconomic status, and community. Growth in length (-0.57 +/- 0.27 mo length for age Z-score; P = 0.04) and weight (-0.54 +/- 0.19 mo weight for age Z-score, P = 0.005) during the first year of life, rather than size at birth, predicted age of walking. Animal protein intake from complementary foods, while low (mean < 1 g/d) overall, was positively associated with earlier age of walking (P = 0.02). Morbidity during infancy was not associated with age of walking. These findings indicate the importance of prevention of postnatal growth retardation and improvement of diet quality for children's gross motor development.
Abstract: BACKGROUND: The increasing proportion of iron-replete individuals in industrialized countries and the possible increased risk of cardiovascular disease (CVD) among men with high iron stores raise concerns regarding improved iron status in women of reproductive age. OBJECTIVE: This study examined the association between iron stores and a set of established CVD risk factors among nonpregnant women aged 20-49 y. DESIGN: Data from the third National Health and Nutrition Examination Survey (1988-1994) were used to examine the relation between race-ethnicity-specific quartiles of serum ferritin (SF) and a set of CVD risk factors [body mass index (BMI), total cholesterol, triacylglycerol, HDL cholesterol, plasma glucose, and blood pressure (BP)]. Women with a history of CVD or liver disease were excluded. We controlled for age, session of measurement, prevalent infection, recent blood donation, and treatment with iron for anemia. RESULTS: Mean SF values were 53.22 +/- 2.08 micro g/L (n = 1178), 58.93 +/- 2.39 micro g/L (n = 1093), and 43.33 +/- 1.39 micro g/L (n = 1075) among non-Hispanic white, non-Hispanic black, and Mexican American women, respectively. Iron stores were positively associated with CVD risk factors only among non-Hispanic black and Mexican American women after adjustment for confounding variables. The strongest associations were seen among Mexican American women: compared with the middle 2 quartiles, the lowest and highest quartiles of SF had lower and higher values, respectively, for BMI, total cholesterol, triacylglycerol, glucose, and diastolic BP. CONCLUSION: These findings suggest that CVD risk factors, especially those related to glucose and lipid metabolism, are positively associated with iron status in women.
