Biomedical subjects

C McCord

Publications and source records attributed to C McCord.

17 recordsLinked to original sources

PubMed2003

A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care.

Mortality has improved dramatically in most of South Asia as a consequence of modest economic improvement, better nutrition and a combination of health education, immunization, family planning and home treatment of certain common diseases, especially diarrhea and respiratory infections. However, death rates are still much higher than in parts of the world with fully developed health services and residual mortality is largely due to conditions which require very basic hospital services such as surgery for complications of pregnancy, infections and trauma, transfusion, intravenous fluids, oxygen and intensive antibiotics. All of these can be made available in very simple and unsophisticated hospital facilities. It has generally been assumed that the cost of such facilities would be high, and cost effectiveness much less than that of preventive, educational and home care programs. In 1995, our 50 bed hospital in rural Bangladesh had a cost per patient-day of 525 Bangladesh Takas (US dollars 13.15) and a cost per capita for the population served of 25 Takas (US dollars 0.62) per year. Every month 180 patients were admitted, one-third with clearly life-threatening or disabling conditions which could be successfully treated in such a facility. We adapted the Disability Adjusted Life Year (DALY) method of cost effectiveness analysis to calculate the DALYs (years of disability-free life) preserved for individual patients during a 3-month period, using what we considered to be very conservative estimates of the threat to life and the efficacy of treatment. The total cost of all hospital activities over the 3 months was divided by the sum of the DALYS for those patients who were successfully treated for clearly life threatening or disabling conditions, to give a cost per DALY of 437 Takas (US dollars 10.93). This compares favorably with estimates by others of a cost per DALY of US dollars 30 for measles immunization, 20 for acute lower respiratory infection detection and home treatment, or 2 for tetanus immunization of pregnant women. Sixty-two percent of the DALYS saved came from emergency obstetric care (EmOC) related activities. We conclude that cost effective basic hospital service can be added to immunization, family planning and other basic health services now available in countries like Bangladesh with a very low increase in total cost and that the benefits which would accrue, particularly for maternal and perinatal mortality, would be great.

Bangladesh↗

PubMed2001

Efficient and effective emergency obstetric care in a rural Indian community where most deliveries are at home.

OBJECTIVES: Most life threatening obstetric complications require hospital treatment to avert maternal mortality. Some assume that in developing countries hospital service for the poor must be in government hospitals and that a large proportion of deliveries needs to be in these hospitals to provide timely access to emergency care. This presents a major problem in countries like India, where almost all rural deliveries are at home and accessible government hospitals generally do not provide surgical treatment for obstetric emergencies. The study's objective was to determine obstetric outcomes, patterns and costs of obstetric care in a part of rural Maharashtra, India, where obstetric outcomes appear relatively good even though most deliveries are at home and government hospitals do not provide emergency obstetric care (EmOC). METHODS: 2905 pregnancies were identified and followed to term to learn the number and types of complications, where these complications were treated, how many women received EmOC and how these services affected outcome. RESULTS: Eighty-five percent of 2861 deliveries after 24 weeks were at home. A total of 14.4% of deliveries after 24 weeks had identified complications. Of these complicated deliveries, 78.9% were in a hospital. Forty-eight percent of hospital deliveries were in a private hospital, 35% in our project hospital and 18% in a government hospital. Hospitalized patients with obstetric complications constituted 11.4% of all deliveries. The cesarean section rate for all deliveries was 2.0%. Twenty-two of the cesareans were in private hospitals, 32 in our hospital and four in a government hospital. Hospital case fatality (deaths of mothers with identified complications) was 0.3%. Overall case fatality was 0.5%. However, there were only two maternal deaths from obstetric causes (70 per 100,000 live births), making these rates less than robust. The perinatal mortality rate was 36 per thousand live and still births. These outcome and process indicators are better than those reported in most of India, but both maternal deaths could have been prevented by early referral to hospital and 64% of perinatal deaths were to infants delivered at home. CONCLUSIONS: A network of private clinics with a voluntary, low cost hospital is providing effective EmOC in a remote rural area at very low per capita cost in the absence of easily accessible government service and with only 15% of deliveries in hospitals. Charges are low but low per capita cost is primarily due to intelligent self-selection of patients who need hospital care. Even though overall cost is low, cost is still an important barrier for many poor families. Improving the purchasing power of poor families through insurance or subsidy could be a more effective way to improve EmOC than trying to improve inadequate government facilities.

Emergency Medical Services↗

PubMed1999

Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis.

For reasons not yet determined, chronic liver disease (CLD) has been a leading cause of excess morbidity and mortality in central Harlem. We conducted a case series and case-control analysis of demographic, clinical, epidemiological, and alcohol-intake-related information from patients with CLD and age- and sex-matched hospitalized control patients. Patients' sera were tested for markers of viral hepatitis. The presumed etiology of CLD among case-patients was as follows: both alcohol abuse and hepatitis C virus (HCV) infection, 24 persons (46% of case-patients); alcohol abuse alone, 15 (29%); HCV infection alone, 6 (12%); both alcohol abuse and chronic hepatitis B virus (HBV) infection, 3 (6%); and 1 each (2%) from: 1) schistosomiasis, 2) sarcoidosis, 3) unknown causes, and 4) alcohol abuse, chronic HBV, and HCV combined. In the case-control analysis, patients who had both alcoholism and either HBV (odds ratio [OR]: 6.3; 95% CI: 0. 5-334) or HCV (OR: 2.9; 95% CI: 1.3-6.2) were at increased risk for CLD, whereas patients who had only one of these three factors were not at increased risk for CLD. Patients who tested positive for the hepatitis G virus (HGV) did not have a significantly increased risk of CLD, and neither severity of CLD nor mortality was greater among these patients. Most patients in central Harlem who had CLD had liver damage from a combination of alcohol abuse and chronic viral hepatitis. Alcohol and hepatitis viruses appear to be synergistically hepatotoxic; this synergy appears to explain both the high rate of CLD in central Harlem and the recent reductions in this rate. Persons at risk for chronic HBV and HCV infection should be counseled about their increased risk of CLD if they consume excessive alcohol. Morbidity and mortality from liver disease could be decreased further by a reduction in alcohol consumption among persons who have chronic HBV and HCV infection, avoidance of needle sharing, and hepatitis B vaccination.

Adult↗

PubMed1999

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey.

INTRODUCTION: In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS: From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS: Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS: This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Adolescent↗

PubMed1998

Contribution of smoking to excess mortality in Harlem.

The New York City neighborhood of Harlem has mortality rates that are among the highest in the United States. In absolute numbers, cardiovascular disease and cancer account for the overwhelming majority of deaths, especially among men, and these deaths occur at relatively young ages. The aim of this research was to examine self-reported smoking habits according to measures of socioeconomic status among Harlem men and women, in order to estimate the contribution of tobacco consumption to Harlem's remarkably high excess mortality. During 1992-1994, in-person interviews were conducted among 695 Harlem adults aged 18-65 years who were randomly selected from dwelling unit enumeration lists. The self-reported prevalence of current smoking was strikingly high among both men (48%) and women (41%), even among highly educated men (38%). The 21% of respondents without working telephones reported an even higher prevalence of current smoking (61%), indicating that national and state-based estimates which rely on telephone surveys may seriously underestimate the prevalence of smoking in poor urban communities. Among persons aged 35-64 years, the smoking attributable fractions for selected causes of death were larger in Harlem than in either New York City as a whole or the entire United States for both men and women. Tobacco consumption is likely to be one of several important mediators of the high numbers of premature deaths in Harlem.

Adolescent↗

PubMed1990

Excess mortality in Harlem.

In recent decades mortality rates have declined for both white and nonwhite Americans, but national averages obscure the extremely high mortality rates in many inner-city communities. Using data from the 1980 census and from death certificates in 1979, 1980, and 1981, we examined mortality rates in New York City's Central Harlem health district, where 96 percent of the inhabitants are black and 41 percent live below the poverty line. For Harlem, the age-adjusted rate of mortality from all causes was the highest in New York City, more than double that of U.S. whites and 50 percent higher than that of U.S. blacks. Almost all the excess mortality was among those less than 65 years old. With rates for the white population as the basis for comparison, the standardized (adjusted for age) mortality ratios (SMRs) for deaths under the age of 65 in Harlem were 2.91 for male residents and 2.70 for female residents. The highest ratios were for women 25 to 34 years old (SMR, 6.13) and men 35 to 44 years old (SMR, 5.98). The chief causes of this excess mortality were cardiovascular disease (23.5 percent of the excess deaths; SMR, 2.23), cirrhosis (17.9 percent; SMR, 10.5), homicide (14.9 percent; SMR, 14.2), and neoplasms (12.6 percent; SMR, 1.77). Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh. Of the 353 health areas in New York, 54 (with a total population of 650,000) had mortality rates for persons under 65 years old that were at lest twice the expected rate. All but one of these areas of high mortality were predominantly black or Hispanic. We conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.

Adolescent↗

PubMed1989

Malnutrition: an important determinant of fatal outcome in surgically treated pulmonary suppurative disease.

Eighty patients required surgical drainage of infections in the pleural space or lung during a four-year period (1984-1987). Thirty-nine patients had a history of heavy intravenous drug use and 28 of those not addicted to drugs were addicted to alcohol. Impaired immunity was believed to be present in 72 (90%) due to malnutrition (45 patients), acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (13), hepatic cirrhosis (1), diabetes (1), or multiple causes (12). Sixty-four patients had acute purulent empyema; 9, tuberculous empyema (often a mixed infection); 2, tuberculous pleural effusion with complications; 2, lung abscesses requiring open drainage; 2, chronic bronchopleural fistulae; and 1, empyema secondary to an esophageal perforation. Fifty-three (66%) were treated with tube thoracostomy only and 27 required additional procedures, including open drainage (19 patients), decortication (5), lung resection (2), chest wall resection (1), and parietal pericardiectomy (1). Overall mortality was high (30%); mortality had a strong correlation with malnutrition or immune deficiency. Very low serum albumin levels were common and were the most important single determinant of a fatal outcome: (table; see text) Other important determinants of mortality were: total lymphocytes less than 1000 (50% mortality); anergy to tests for delayed hypersensitivity (39% mortality); AIDS or AIDS-related complex (54% mortality). Analysis of the records of the 24 patients who died has led to the conclusion that despite the advanced disease present and the poor condition of most patients at least one third of the deaths could have been avoided if important errors in diagnosis and medical or surgical management could have been prevented.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1986

What is "high"? The development of reference points for "high" and "low".

Young children have been characterized as interpreting relative adjectives as if they were nominal or categorical terms. The categorical interpretation of relative terms, however, may be quite complex. Indeed, the mature understanding of relative terms would seem to include a complex system of reference points for the terms' categorical usages. In 5 experiments we examined the complexity of 3-5-year-old children's and adults' categorical interpretations. We specifically examined how reference points for the categorical interpretation of high and low are defined. The definition of reference points relative to the object judged, the vertical position of the observer, and the extent of vertical variation were assessed. 3 major developmental trends were observed: a trend from the application of the terms to only extreme values to their application to broader categories; a trend from nominal-like categories to ones defined flexibly relative to context (e.g., nature of object judged, and extent of vertical variation); and a trend from reference points functioning as focal points to their operating as directional category boundaries. In brief, the results suggest that the categorical usage of relative terms involves a rich and intricate knowledge system and that it takes children considerable time to acquire and organize the relevant pieces of knowledge.

Child, Preschool↗

PubMed1978

Weight-for-age as an index of risk of death in children.

Between April, 1968, and May, 1973, the Department of International Health of Johns Hopkins University studied the effects of the interaction of nutrition and infection in fourteen villages of Punjab, North India. Serial anthropometric measurements (used as index of nutritional status) and vital statistics of almost 3000 children aged 1-36 months showed that, on average, child mortality doubled with each 10% decline below 80% of the Harvard weight median. The relation between season and mortality showed that mortality-rates were highest just before and during the main (wheat) harvest, reflecting the effects of food scarcity, relative child neglect, and climate on child deaths among those already underweight.

Age Factors↗

PubMed1978