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Christensen R.D.,Women and Newborns Clinical Program | Christensen R.D.,y Dee Hospital Center | Baer V.L.,Women and Newborns Clinical Program | Baer V.L.,y Dee Hospital Center | And 8 more authors.
Pediatrics | Year: 2012

BACKGROUND AND OBJECTIVE: Both high and low lymphocyte counts at birth have been associated with adverse outcomes. However, the validity of defining a lymphocyte count as "abnormal" depends on having an accurate reference range. We established a reference range for neonatal lymphocyte counts by using multihospital data and used this to assess previously reported relationships between abnormal counts and early onset sepsis (EOS), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), periventricular leukomalacia, and birth asphyxia. METHODS: We first created a data set that excluded counts fromneonates with diagnoses previously associated with abnormal lymphocyte counts. Then the complete data (counts excluded plus included in the reference range) were used to test associations between abnormal counts and EOS, IVH, ROP, periventricular leukomalacia, and outcomes after birth asphyxia. RESULTS: Lymphocyte counts were retrieved from 40 487 neonates, 10 860 of which were excluded from the reference range. A count >95th percentile was associated with EOS (2.07; 95% confidence interval [CI]: 1.80-2.38) and IVH ≥grade 3 (2.93; 95% CI: 1.83-4.71). A count <5th percentile was associated with EOS (odds ratio:1.24; 95% CI: 1.04-1.48), IVH≥grade 3 (3.23; 95% CI: 1.95-5.36), and ROP ≥stage 3 (4.80: 95% CI: 2.38-9.66). Among 120 meeting criteria for birth asphyxia, those with a low count and a high nucleated red cell count had higher mortality (37% vs 11%, P = .001), more transfusions (P = .000), and more neurology referrals (P < .01). CONCLUSIONS: A reference range for lymphocytes can identify neonates with abnormal counts, which can be useful because these neonates are at higher risk for certain adverse outcomes. Copyright © 2012 by the American Academy of Pediatrics. Source

Keren R.,Childrens Hospital of Philadelphia | Keren R.,University of Pennsylvania | Luan X.,Childrens Hospital of Philadelphia | Localio R.,Childrens Hospital of Philadelphia | And 6 more authors.
Archives of Pediatrics and Adolescent Medicine | Year: 2012

Objective: To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics. Design: Retrospective analysis of administrative and billing data for hospital encounters. Setting: Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009. Participants: Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges. Main Outcome Measures: Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters. Results: Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter. Conclusions: Detailed administrative and billing data can be used to standardize hospital costs and identify highpriority conditions for comparative effectiveness research - those that are high cost, are high prevalence, and demonstrate high variation in resource utilization. ©2012 American Medical Association. All rights reserved. Source

Stoddard G.J.,University of Utah | Henry E.,Institute for Healthcare Delivery Research
American Journal of Obstetrics and Gynecology | Year: 2013

Objective: Our aim was to compare good candidates for trial of labor after cesarean (TOLAC) who underwent repeat cesarean to those who chose TOLAC. Study Design: Data for all deliveries at 14 regional hospitals over an 8-year period were reviewed. Women with a primary cesarean and 1 subsequent delivery in the dataset were included. The choice of elective repeat cesarean vs TOLAC was assessed in the first delivery following the primary cesarean. Women with ≥70% chance of successful vaginal birth after cesarean as calculated by a published nomogram were considered good candidates for TOLAC. Good candidates who chose an elective repeat cesarean were compared to those who chose TOLAC. Women who were delivered at 2 preselected tertiary centers by a general obstetrician-gynecologist practice were subanalyzed to determine whether there was an effect of physician group. Results: In all, 5445 women had a primary cesarean and a subsequent delivery. A total of 3120 women were calculated to be good TOLAC candidates. Of this group, 925 (29.7%) chose TOLAC. Women managed by a family practitioner or who were obese were less likely to choose TOLAC while women who were managed by a midwife or had a prior vaginal delivery were more likely to choose TOLAC. At the 2 tertiary centers, 1 general obstetrician-gynecologist group had significantly more patients who chose TOLAC compared to the other obstetrician-gynecologist physician groups (P <.001), with 63% of their patients choosing TOLAC. Conclusion: Less than one-third of the good candidates for TOLAC chose TOLAC. Managing provider influences this decision. © 2013 Mosby, Inc. Source

Jensen J.D.,Institute for Healthcare Delivery Research | Henry E.,Institute for Healthcare Delivery Research | Silver R.M.,University of Utah | Christensen R.D.,Women and Newborns Clinical Program
American Journal of Perinatology | Year: 2011

It is unclear whether neonates born to women with thrombocytopenia during pregnancy are themselves at increased risk for thrombocytopenia at birth. In the current retrospective study, platelet count reference ranges were developed for pregnant women according to trimester, and correlations were sought between the platelet counts of mothers at delivery and their neonates. During the study period, 92,518 platelet counts were recorded on 41,887 pregnant women. A progressive shift toward lower platelet counts in a similarly shaped histogram occurred during pregnancy, with the lower reference range (2.5 percentile) for platelets during the third trimester being 113×10 9/L. Among 11,797 maternalneonatal pairs following delivery, no correlation was observed between maternal and neonatal counts. However, if the mother's lowest count was <50×10 9/L, the relative risk of any degree of thrombocytopenia in their neonate was 4.6 (95% confidence interval [CI], 1.8 to 33.3) and the relative risk of severe neonatal thrombocytopenia was 7.8 (95% CI, 1.8 to 33.3). The results of the current study demonstrate that platelet counts >75×10 9/L in pregnant women were not associated with an increased risk of neonatal thrombocytopenia, and maternal platelet counts of <50×10 9/L were accompanied by an almost fivefold risk increase of neonatal thrombocytopenia. Copyright © 2011 by Thieme Medical Publishers, Inc. Source

Henry E.,Institute for Healthcare Delivery Research | Andres R.L.,Women and Newborns Clinical Program | Andres R.L.,University of Utah | Andres R.L.,y Dee Hospital Center | And 3 more authors.
Journal of Perinatology | Year: 2013

Objective: The best practices for the care of a neonate born after a tight nuchal cord have not been defined. As a step toward this, we compared the outcomes of neonates born after a tight nuchal cord vs those born after a loose nuchal cord vs those born after no nuchal cord. Study Design: This was a retrospective comparison using electronic data of all deliveries during a 6-year period (2005 to 2010) in a multihospital healthcare system in the western United States. At the time of delivery, each birth was recorded as having a tight nuchal cord, a loose nuchal cord or no nuchal cord. Nuchal cord was defined as a loop of umbilical cord ≥360° around the fetal neck. 'Tight' was defined as the inability to manually reduce the loop over the fetal head, and 'loose' as the ability to manually reduce the loop over the head. Result: Of 219 337 live births in this period, 6.6% had a tight nuchal cord and 21.6% had a loose nuchal cord. Owing to the very large number of subjects, several intergroup differences were statistically significant but all were judged as too small for clinical significance. For instance, those with a tight nuchal cord had a very slightly older gestational age, a very slightly lower birth weight, a preponderance of male fetuses, primagravid women, singleton pregnancies and shoulder dystocia (all P<0.001). Term neonates with a tight nuchal cord were slightly more likely to be admitted to a Neonatal Intensive Care Unit (6.6% vs 5.9% admission rate, P=0.000). Those with a tight nuchal cord were not more likely to have dopamine administered or blood hemoglobin measured on the first day, nor were they more likely to receive a transfusion or to die. The subset of very low birth weight neonates with a tight nuchal cord, compared with those with no nuchal cord, were of the same gestational age and birth weight, with the same Apgar scores, and were not more likely to have severe intraventrucular hemorrhage, retinopathy of prematurity or periventricular leukomalacia, or to die. Conclusion: The presence of a tight nuchal cord is not uncommon, occurring in 6.6% of over 200 000 consecutive live births in a multihospital health system. No differences in demographics or outcomes, judged as clinically significant, were associated with a tight nuchal cord. Thus, we speculate that the best practices for neonatal care after a tight nuchal cord do not involve an obligation to conduct extra laboratory studies or extra monitoring solely on the basis of the report of a tight nuchal cord. Copyright © 2013 Nature America, Inc. Source

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