To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management. Participants included 44 critical care and infectious disease experts representing 11 international organizations. A total of 46 recommendations plus pediatric management considerations. Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.

/pdf/surviving-sepsis-campaign-guidelines-for-management-of-2my3xcb472.pdf

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

John G. Bartlett,1 Scott F Dowell,2 Lionel A. Mandell,6 Thomas M. File, Jr.,3 Daniel M. Musher,4 and Michael J. Fine5 'Johns Hopkins University School of Medicine, Baltimore, Maryland, 2Centers for Disease Control and Prevention, Atlanta, Georgia, 3Northeastern Ohio Universities College of Medicine, Cleveland, Ohio, 4Baylor College of Medicine and Veterans Affairs Medical Center, Houston, Texas, and 5University of Pittsburgh, Pennsylvania, USA; and 6McMaster University, Toronto, Canada

https://www.jstor.org/stable/pdfplus/4482307.pdf

Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults

CONTEXT: Many pregnancies are unintended, particularly in certain population groups. Determining whether unintended pregnancy rates and disparities in rates between subgroups are changing may help policymakers target reproductive health services to those women most in need.

METHODS: To calculate rates of unintended pregnancy and related outcomes, data on pregnancy intendedness from the 2002 National Survey of Family Growth were combined with birth, abortion and population data from federal, state and nongovernmental sources.

RESULTS: In 2001, 49% of pregnancies in the United States were unintended. The unintended pregnancy rate was 51 per 1,000 women aged 15–44, meaning that 5% of this group had an unintended pregnancy. This level was unchanged from 1994. The rate of unintended pregnancy in 2001 was substantially above average among women aged 18–24, unmarried (particularly cohabiting) women, low-income women, women who had not completed high school and minority women. Between 1994 and 2001, the rate of unintended pregnancy declined among adolescents, college graduates and the wealthiest women, but increased among poor and less educated women. The abortion rate and the proportion of unintended pregnancies ending in abortion among all women declined, while the unintended birth rate increased. Forty-eight percent of unintended conceptions in 2001 occurred during a month when contraceptives were used, compared with 51% in 1994.

CONCLUSIONS: More research is needed to determine the factors underlying the disparities in unintended pregnancy rates by income and other characteristics. The findings may reflect a need for increased and more effective contraceptive use, particularly among high-risk groups.

Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.

Unintended pregnancy in the United States: incidence and disparities, 2006.

Background: The incidence of unintended pregnancy is among the most essential health status indicators in the field of reproductive health. One ongoing goal of the US Department of Health and Human Services is to reduce unintended pregnancy, but the national rate has not been estimated since 2001. Study Design: We combined data on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth with a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US Census Bureau. Results: Nearly half (49%) of pregnancies were unintended in 2006, up slightly from 2001 (48%). The unintended pregnancy rate increased to 52 per 1000 women aged 15–44 years in 2006 from 50 in 2001. Disparities in unintended pregnancy rates among subgroups persisted and in some cases increased, and women who were 18–24 years old, poor or cohabiting had rates two to three times the national rate. The unintended pregnancy rate declined notably for teens 15–17 years old. The proportion of unintended pregnancies ending in abortion decreased from 47% in 2001 to 43% in 2006, and the unintended birth rate increased from 23 to 25 per 1000 women 15–44 years old. Conclusions: Since 2001, the United States has not made progress in reducing unintended pregnancy. Rates increased for nearly all groups and remain high overall. Efforts to help women and couples plan their pregnancies, such as increasing access to effective contraceptives, should focus on groups at greatest risk for unintended pregnancy, particularly poor and cohabiting women.

Original research article Unintended pregnancy in the United States: incidence and disparities, 2006

PROBLEM/CONDITION: CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions and to monitor unintended pregnancy. REPORTING PERIOD COVERED: This report summarizes and describes data reported to CDC regarding legal induced abortions obtained in the United States in 1999. DESCRIPTION OF SYSTEM: For each year since 1969, CDC has compiled abortion data by state or area of occurrence. From 1973 through 1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. Beginning in 1998, CDC compiled abortion data from 48 reporting areas. Alaska, California, New Hampshire, and Oklahoma did not report, and data for these areas were not estimated. The availability of data regarding the characteristics of women who obtained an abortion in 1999 varied by state and by the number of states reporting each characteristic. The total number of legal induced abortions is reported by state of residence and also by state of occurrence for most areas; characteristics of women obtaining abortions in 1999 are reported by state of occurrence. RESULTS: A total of 861,789 legal induced abortions were reported to CDC for 1999, representing a 2.5% decrease from the 884,273 legal induced abortions reported by the same 48 reporting areas for 1998. The abortion ratio, defined as the number of abortions per 1,000 live births, was 256 in 1999, compared with 264 reported for 1998; the abortion rate for these 48 reporting areas was 17 per 1,000 women aged 15-44 years for 1999, the same as in 1997 and 1998. The highest percentages of abortions were reported for women aged or = 21 weeks. A total of 27 reporting areas submitted data stating that they performed medical (nonsurgical) procedures (two of these areas categorized medical abortions with "other" procedures), making up < 1.0% of all procedures reported from all reporting areas. In 1998 (for which data have not been published previously and the most recent year for which such data are available), nine women died as a result of complications from known legal induced abortion; no deaths were associated with known illegal abortion. INTERPRETATION: From 1990 through 1997, the number of legal induced abortions gradually declined. In 1998 and in 1999, the number of abortions continued to decrease when comparing the same 48 reporting areas. In 1998, as in previous years, deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTION: Abortion surveillance in the United States should continue so that trends and characteristics of women who obtain legal induced abortions can be examined and efforts to prevent unintended pregnancy can be enhanced.

Abortion surveillance--United States, 1999.

PROBLEM/CONDITION: CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions. REPORTING PERIOD COVERED: This report summarizes and describes data voluntarily reported to CDC regarding legal induced abortions obtained in the United States in 2005. DESCRIPTION OF SYSTEM: For each year since 1969 CDC has compiled abortion data by state or area of occurrence. Information is requested each year from all 50 states New York City and the District of Columbia. For 2005 data were received from 49 reporting areas: New York City District of Columbia and all states except California Louisiana and New Hampshire. For the purpose of trends analysis data were evaluated from the 46 reporting areas that have been consistently reported since 1995. RESULTS: A total of 820151 legal induced abortions were reported to CDC for 2005 from 49 reporting areas the abortion ratio (number of abortions per 1000 live births) was 233 and the abortion rate was 15 per 1000 women aged 15--44 years. For the 46 reporting areas that have consistently reported since 1995 the abortion rate declined during 1995--2000 but has remained unchanged since 2000. For 2005 the highest percentages of reported abortions were for women who were known to be unmarried (81%) white (53%) and aged 15 weeks gestation (3.7% at 16--20 weeks and 1.3% at >/=21 weeks). A total of 35 reporting areas submitted data stating that they performed and enumerated medical (nonsurgical) procedures making up 9.9% of all known reported procedures from the 45 areas with adequate reporting on type of procedure. In 2004 (the most recent years for which data are available) seven women died as a result of complications from known legal induced abortion. One death was associated with known illegal abortion. INTERPRETATION: For the 46 reporting areas that have consistently reported since 1995 the number of abortions has steadily declined over the previous 10 years. The abortion rate declined from 1995 to 2000 but remained unchanged since 2000. In 2004 as in the previous years deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTION: Abortion surveillance in the United States continues to provide the data necessary for examining trends in numbers and characteristics of women who obtain legal induced abortions and to increase understanding of this pregnancy outcome. Policymakers and program planners use these data to improve the health and well-being of women and evaluate efforts to prevent unintended pregnancies.

/pdf/abortion-surveillance-united-states-2005-2p2o0phzai.pdf

Abortion surveillance--United States 2005.

The recent slowdown in the decline of infant mortality in the United States and the continued high risk of death among black infants (twice that of white infants) prompted a consortium of Public Health Service agencies to collaborate with all States in the development of a national data base from linked birth and infant death certificates. This National Infant Mortality Surveillance (NIMS) project for the 1980 U.S. birth cohort provides neonatal, postneonatal, and infant mortality risks for blacks, whites, and all races in 12 categories of birth weights. (Note: Neonatal mortality risk = number of deaths to infants less than 28 days of life per 1,000 live births; postneonatal mortality risk = number of deaths to infants 28 days to less than 1 year of life per 1,000 neonatal survivors; and infant mortality risk = number of deaths to infants less than 1 year of life per 1,000 live births.) Separate tabulations were requested for infants born in single and multiple deliveries. For single-delivery births, tabulations included birth weight, age at death, race of infant, and each of these characteristics: infant's live-birth order, sex, gestation, type of delivery, and cause of death; and mother's age, education, prenatal care history, and number of prior fetal losses at 20 weeks' or more gestation. An estimated 95 percent of eligible deaths were included in the NIMS tabulations. The analyses focus on three components of infant mortality: birth weight distribution of live births, neonatal mortality, and postneonatal mortality. The most important predictor for infant survival was birth weight, with an exponential improvement in survival by increasing birth weight to its optimum level. The nearly twofold higher risk of infant mortality among blacks was related to a higher prevalence of low birth weights and to higher mortality risks in the neonatal period for infants weighing 3,000 grams or more, and in the postneonatal period for all infants, regardless of birth weight. Regardless of other infant or maternal risk factors, the black-white gap persisted for infants weighing 2,500 grams or more.

Overview of the National Infant Mortality Surveillance (NIMS) project--design, methods, results.

Cigarette smoking as a risk factor for ectopic pregnancy.

In 1980 there were 562330 babies born in the US to teenage mothers (19 years of age or younger). The offspring of teenage mothers have long been known to be at increased risk of infant mortality largely because of their high prevalence of low birth weight (less than 2500 grams). We used data from the National Infant Mortality Surveillance (NIMS) project to examine the effect of young maternal age and low birth weight on infant mortality among infants born in 1980 to US residents. This analysis was restricted to single-delivery babies who were either black or white were born to mothers aged 10-29 years and who were born in 1 of the 48 States or the District of Columbia. Included were 2527813 births and 28499 deaths (data from Maine and Texas were excuded for technical reasons). Direct standardization was used to calculate the relative risks adjusted for birth weight of neonatal mortality and postneonatal mortality by race and maternal age. There was a strong association between young maternal age and high infant mortality and between young maternal age and a high prevalence of low birth weight. Neonatal mortality declined steadily with increasing maternal age. After adjusting for birth weight the race-specific relative risks for babies born to mothers less than 16 years of age were still elevated from 11 to 40% compared with babies born to mothers 25-29 years of age. Otherwise all the relative risks were nearly equal to 1. By contrast most of the association between young maternal age and postneonatal mortality persisted after birth weight adjustment in all maternal age groups. These results suggest that the prevention of neonatal mortality and to a lesser extent postneonatal mortality among babies born to teenagers depends on preventing low birth weight. The prevention of postneonatal mortality may depend more on other factors such as assisting teenagers with better parenting. Finally although there may be few biological reasons to postpone childbearing teenage childbearing continues to place the mother and her baby at a social disadvantage. (authors)

Lilo T. Strauss

Papers

Abortion surveillance--United States, 1999.

Abortion surveillance--United States 2005.

Overview of the National Infant Mortality Surveillance (NIMS) project--design, methods, results.

Cigarette smoking as a risk factor for ectopic pregnancy.

Young maternal age and infant mortality: the role of low birth weight.