BackgroundResearch on the effects of maternal obesity on neonates has focused on clinical outcomes. Despite growing interest in obesity as a driver of healthcare expenditure, the financial impact of maternal obesity in the neonatal setting is little understood.ObjectiveTo determine if maternal obesity is associated with higher incurred costs in NICU and full-term nursery.MethodsData for all live births (1/1/14–12/31/19) at our academic medical center was obtained from the New York State Perinatal Data System for infants >23 weeks gestational age. Financial data was obtained from the hospital's cost-processing application. Infants with missing clinical and/or financial data were excluded. The NIH definition of obesity was used (BMI ≥ 30 kg/m2) to separate infants born to obese and non-obese mothers. Student's t-tests and chi square tests were used to compare maternal data, delivery, and infant outcomes between both groups. A logistic regression model was used to compare infant outcomes using odds ratios while controlling for maternal risk factors (smoking status, pre-pregnancy and gestational diabetes, pre-pregnancy and gestational hypertension). Multivariate regression analysis adjusting for maternal risk factors was also used to compare length-of-stay, total and direct costs in the NICU and full-term nursery between infant groups.ResultsOf the 11,610 pregnancies in this retrospective study, obese mothers more frequently had other risk factors (smoke, pre-pregnancy and gestational diabetes, and pre-pregnancy and gestational hypertension). Infants born to obese mothers were more often preterm, had Cesarean delivery, lower APGAR scores, required assisted ventilation in the delivery room, and required NICU admission. Adjusting for maternal risk factors, infants born to obese mothers were less frequently preterm (OR 0.82 [0.74–0.91], p < 0.01) and had NICU stays (OR 0.98 [0.81–0.98], p = 0.02), but more frequently had Cesarean births (OR 1.54 [1.42–1.67], p < 0.01). They also had longer adjusted LOS (2.03 ± 1.51 vs. 1.92 ± 1.45 days, p < 0.01) and higher mean costs per infant in the full-term nursery ($3,638.34 ± $6,316.69 vs. $3,375.04 ± $4,994.18, p = 0.03) but not in NICU.ConclusionsMaternal obesity correlates with other risk factors. Prolonged maternal stay may explain increased LOS and costs in the full-term nursery for infants born to obese mothers, as infants wait to be discharged with mothers.
Background: Ziconotide (ZCN), a nonopioid analgesic, is first-line intrathecal therapy for patients with severe chronic pain refractory to other management options. We describe three cases of ZCN-induced movement disorders. Cases: Case one is a 64-year-old woman who presented with oro-lingual (OL) dyskinesia with dysesthesias and bilateral upper extremity kinetic tremor. Case two is a 43-year-old man with a 20-month history of ZCN treatment who developed OL dyskinesia with dysesthesias, involuntary left hand and neck movements, hallucinations, dysesthesias on his feet, and gait imbalance. Case three is a 70-year-old man with a 4-month history of ZCN use who developed OL dyskinesia with dysesthesias. Conclusions: Intrathecal treatment of pain with ZCN may be complicated by a drug-induced movement disorder where OL dyskinesia is characteristic. The movement disorder is likely to be dose related and reversible with ZCN discontinuation, but a chronic movement disorder is also possible.
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Prescribing medicine, providing contraception, delivering babies -although we may turn to physicians, rural Rajasthani women turn to Barefoot Doctors out of necessity. Such care is available courtesy of the Barefoot College, a pioneering NGO that transforms the skills of the illiterate poor into local infrastructure. Barefoot Doctors are innovative because of their origins as dais (traditional midwives); once abundant across South Asia, dais are mostly extinct due to government/NGO interventions emphasizing "modernity", like the Accredited Social Health Activist program. Why, then, have dais survived as Barefoot Doctors when they are extinct elsewhere? Ecological niche differentiation refers to when competing species successfully coexist; one species adapts to fulfill another role. Using over fifty interviews with stakeholders, I explain the persistence of Barefoot Doctors as health resources using "professional niche differentiation". Barefoot Doctors exemplify how health infrastructure can be sustainable in resourcepoor settings when created according to local needs and ideologies.Keywords: dai; Barefoot Doctor; midwifery; rural healthcare development; reproductive careAzher: Professional Niche Differentiation 133 IntroductionBhanwari-devi was illiterate, spoke a mix of Hindi and Marwari that I could barely understand, and, by North Indian standards, was quite old (she didn't remember her age and didn't particularly care to). And yet today I was to accompany her, the village dai (traditional midwife) and now "barefoot doctor", on her daily rounds along the dusty streets of Kadampura Village. Making visits to pregnant women and veteran mothers alike, I watched Bhanwari-devi's heavy metal karas, the famous bracelets and anklets of rural Rajasthan, glimmer as she ambled along with the aid of her wooden staff. As we sought the house of her first patient, I wondered to myself how seriously Bhanwari-devi's medical services could be taken. After all, Bhanwari-devi had never been to school and had no opportunity to learn about the biology underlying reproduction or even basic germ theory. In terms of clinical significance, could she offer more than midwives' tales?Dais, or traditional midwives, have been a major part of the rural birthing experience for as long as local people can remember. Mostly illiterate, dais have relied not on formal training, but on their decades of experiences as womendaughters, sisters, and most importantly, mothers and mothers-in-law-to serve as midwives for the women of their villages. Although dais like Bhanwari-devi were once common throughout South Asia, in much of rural India, the dai profession is dying due to a healthcare development movement that stresses the importance of "modernizing" infrastructure (Das 2015, 54-56;Ghoshal 2014).Discourse on medical effectiveness, safety, and evidence-based practice is a key driver of NGO and government attitudes on the position of dais; according to anthropologist Sara Price, such programs attempt to "re-train" dais, termed "Traditional Birth Att...
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