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Del Vecchio A.,Di Venere Hospital | Christensen R.D.,Intermountain Healthcare | Christensen R.D.,y Dee Hospital Center
Early Human Development | Year: 2012

Neutropenia is a relatively frequent finding in the neonatal intensive care unit, particularly in very low birth weight neonates during the first week of life. Healthy term and preterm neonates have blood neutrophil counts within the same basic range as adults, but their neutrophil function, and their neutrophil kinetics during infection, differ considerably from those of adults. Neutrophil function of neonates, particularly preterm neonates, is less robust than that of adults and might also contribute to the increase in propensity to infection. In premature infants, early-onset neutropenia is correlated with sepsis, maternal hypertension, intrauterine growth restriction, severe asphyxia, and periventricular haemorrhage, and might be associated with an increase in the incidence of early-onset sepsis, nosocomial infection, and Candida colonisation. Some varieties of neutropenia in the NICU are very common and others are extremely rare. The most common causes of neutropenia in the NICU have an underlying cause that is often evident, and require little diagnostic evaluation. Unlike, persistent neutropenia should prompt evaluation even if it is of moderate severity. The laboratory tests to consider are those that provide a specific diagnosis. The first tests that should be ordered are a blood film, a complete blood count on the mother, and, if her blood neutrophil concentration is normal, maternal neutrophil antigen typing and an anti-neutrophil antibody screen. A bone marrow biopsy can be useful in cases with prolonged, unusual, or refractory neutropenia. Various treatments have been proposed as means of enhancing neutrophil production and function in preterm infants. Both recombinant granulocyte stimulating factor and recombinant granulocyte macrophage-colony-stimulating factor have been tried with variable success. Intravenous immunoglobulin, corticosteroids, granulocyte transfusions, and gamma interferon did not show a clear adequate beneficial role for the therapy of neonatal neutropenia. © 2012 Elsevier Ireland Ltd.


Sheffield M.J.,y Dee Hospital Center | Lambert D.K.,y Dee Hospital Center | Henry E.,Institute for Healthcare Delivery Research | Christensen R.D.,y Dee Hospital Center
Journal of Perinatology | Year: 2010

Objective:Studies in adults indicate that ampicillin, in a dose-dependent manner, impairs platelet function and moderately prolongs the bleeding time (generally by 60 to 90 s). Unlike aspirin, the inhibition induced by ampicillin involves both reversible and irreversible mechanisms and is not observed immediately after initial dosing (generally requiring approximately 24 h). Ampicillin is administered commonly to neonatal intensive care unit (NICU) patients, but its effect on bleeding time in this population has not been reported earlier.Study Design:We performed neonatal template bleeding times and platelet function analyzer (PFA)-100 tests on 15 NICU patients before and at various intervals after intravenous ampicillin dosing.Result:Neonates were only studied if no beta-lactam antibiotics were administered to their mother during labor, and if they had ampicillin ordered by the clinician at a dose of 50 to 100 mg kg -1 every 12 h. Subjects ranged from 33 to 41 weeks gestation and weighed 1760 to 3835 g. Bleeding times before the first ampicillin dose (n15) averaged 134 s (95% confidence interval (CI), 120 to 148 s) and PFA-100 times averaged 123 s (95% CI, 96 to 149 s). After the first dose of ampicillin (n5), bleeding times and PFA-100 times did not increase, but after the third (n5) and fourth doses (n4) bleeding times lengthened by an average of 60 s (95% CI, 37 to 83 s, P<0.001) and PFA-100 times lengthened by an average of 20 s (95% CI, 20 to 60 s, P0.15).Conclusion:Ampicillin administered intravenously to NICU patients prolongs the bleeding time, with a magnitude-of-effect and time-to-effect similar to that shown earlier in adults. © 2010 Nature America.


Christensen R.D.,Intermountain Healthcare | Christensen R.D.,y Dee Hospital Center | Henry E.,Intermountain Healthcare | Henry E.,Institute for Healthcare Delivery Research
Pediatrics | Year: 2010

OBJECTIVES: Hereditary spherocytosis (HS) is the most common inherited hemolytic disease among people of Northern European decent. Neonates with HS can develop significant hyperbilirubinemia, but we suspect that HS is underrecognized as a cause of neonatal jaundice. METHODS: We used electronic record repositories of Intermountain Healthcare to identify all neonates with a diagnosis of HS in a recent 5-year period. We compared these with the number of new HS cases anticipated on the basis of national prevalence and also with the number who had elevations in mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), and bilirubin. We compared MCHC and RDW values of neonates who had direct antiglobulin test-positive (DAT[+]) and DAT(-) results and jaundice with values of neonates who had HS. RESULTS: Eight neonates received a diagnosis of HS; however, we may have failed to diagnose 90% of cases. To assess whether some with a missed diagnosis of HS developed significant hyperbilirubinemia, we examined records of all 670 with a bilirubin level of ≥20 mg/dL. Records of the 20 with the highest MCHC and RDW values suggested that HS was present but unrecognized in at least 7. Follow-up revealed a subsequent diagnosis of HS in 5; the other 2 are no longer in our health system. MCHC and RDW values were highest in those with HS, intermediate in the DAT(+) group, and lowest in the DAT(-) group. An MCHC of ≥36.0 g/dL had 82% sensitivity and 98% specificity for identifying HS. CONCLUSION: We speculate that HS is underrecognized as a cause of neonatal hyperbilirubinemia. We speculate further that an MCHC of ≥36.0 g/dL can alert caregivers to the possibility of HS. Copyright © 2009 by the American Academy of Pediatrics.


Christensen R.D.,Primary Childrens Medical Center | Christensen R.D.,y Dee Hospital Center
Neonatology | Year: 2011

Platelet transfusions were introduced into clinical medicine about 60 years ago when they were shown to reduce the mortality rate of patients with leukemia who were bleeding secondary to hyporegenerative thrombocytopenia. In modern neonatology units, platelet transfusions are integral and indeed lifesaving for some neonates. However, the great majority of platelet transfusions currently administered in neonatal intensive care units (NICUs) are not given in the original paradigm to treat thrombocytopenic hemorrhage, but instead are administered prophylactically with the hope that they will reduce the risk of spontaneous bleeding. Weighing the risks and benefits of platelet transfusion, although imprecise, should be attempted each time a platelet transfusion is ordered. Adopting guidelines specific for platelet transfusion will improve consistency of care and will also generally reduce transfusion usage, thereby reducing costs and conserving valuable blood bank resources. Initiating specific programs to improve compliance with transfusion guidelines can further improve NICU transfusion practice. Copyright © 2011 S. Karger AG.


Yaish H.M.,University of Utah | Christensen R.D.,y Dee Hospital Center | Agarwal A.,University of Utah
Journal of Perinatology | Year: 2013

The diagnosis of hereditary spherocytosis (HS) in a newborn infant is generally made on the basis of a positive family history, spherocytes on blood film and Coombs-negative hemolytic jaundice of variable severity with an elevated mean corpuscular hemoglobin concentration (MCHC) and a low mean corpuscular volume (MCV). In general, sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) quantification of erythrocyte membrane proteins is not needed to make the clinical diagnosis of HS. However, we observed that a neonate with no family history of HS, but with abundant spherocytosis on repeated blood films, Coombs-negative hemolytic jaundice and normal MCHC and MCV measurements, where SDS-PAGE revealed alpha-spectrin deficiency, a rare autosomal-recessive variety of HS that generally has a severe clinical phenotype. © 2013 Nature America, Inc. All rights reserved.


Miser W.F.,Ohio State University | Jeppesen K.M.,y Dee Hospital Center | Wallace L.S.,Ohio State University
Family Medicine | Year: 2013

BACKGROUND AND OBJECTIVES: Our objectives were to (1) compare Newest Vital Sign (NVS) scores and administration characteristics with the short (S) version of the Test of Functional Health Literacy in Adults (S-TOFHLA) and Spoken Knowledge in Low-Literacy Diabetes (SKILLD) tool and (2) gather information from research assistants (RAs) regarding their perceptions of patient understanding of NVS items. METHODS: Adults, age ≥ 18 years, with diabetes mellitus visiting a primary care clinic were recruited to participate. An RA orally administered a sociodemographic questionnaire. Patients completed, in random order, the NVS, S-TOFHLA, and SKILLD. Completion time for each tool was electronically recorded, while patients assessed tool difficulty using a 5-point Likert-type scale. RAs' comments regarding patients' understanding of individual NVS items were tallied. RESULTS: A total of 226 patients (mean age=53.8 years, 31% male, 45.1% African American, 28.8% high school graduate) participated. African Americans were signifcantly less likely to score ≥4 on the NVS (adjusted OR=0.23, 95% CI=0.13, 0.42) as compared to Caucasians. NVS scores were highly correlated with S-TOFHLA scores, rho=0.62, and moderately correlated with SKILLD scores, rho=0.39. NVS scores were inversely correlated with completion time, rho=-0.25 and diffculty rating, rho=-0.37. CONCLUSIONS: Related to the care of patients with diabetes, the most important feature of the NVS is that it can quickly provide a clinician with valuable insight regarding their patients' ability to complete a practical skill (i.e., interpreting a food label) needed to achieve tight blood glucose control.


Jeppesen K.M.,y Dee Hospital Center | Bahner D.P.,Ohio State University
Journal of Ultrasound in Medicine | Year: 2012

Objectives-Bedside sonography is a growing field of medicine, but there is little evidence about how to teach it to medical students. A peer-mentoring system may help preclinical medical students learn bedside sonography. Methods-In 2008 and 2009, participating first-year medical students completed an image recognition test at 0, 2, and 4 months and were randomized to an early or a late intervention group. In hands-on sessions, senior medical students taught the early intervention group how to perform a Trinity hypotensive ultrasound protocol between months 0 and 2 and then taught the late intervention group the Trinity protocol between months 2 and 4. Participants completed a practical examination at month 4. We measured the improvement in knowledge after the intervention and retention of knowledge and skills in the early intervention group at month 4. First-year medical students completed precourse and postcourse surveys about comfort and skills with sonography. Results-Eighty-six first-year medical students enrolled; 79 completed the precourse survey; 54 completed all knowledge tests; 52 completed the practical examination; and 49 completed the postcourse survey. Of the 125 nonparticipants, 109 completed the precourse survey, and 25 completed the postcourse survey. Participants' knowledge scores increased by 30% after the intervention. The early intervention group retained 92% of the knowledge gained. Thirty-six percent of participants were able to complete the Trinity protocol in 15 minutes during the practical examination, with no significant difference between the early and late intervention groups. Participants responded positively about the experience and indicated that hands-on sessions were helpful. Conclusions-Peer mentoring is a useful method for teaching sonography to preclinical medical students. © 2012 by the American Institute of Ultrasound in Medicine.


Jeppesen K.M.,y Dee Hospital Center | Hull B.P.,Ohio State University | Raines M.,Ohio State University | Miser W.F.,Ohio State University
Journal of General Internal Medicine | Year: 2012

BACKGROUND: In 2005 the Spoken Knowledge in Low Literacy in Diabetes scale (SKILLD) was introduced as a diabetes knowledge test. The SKILLD has not been validated since its introduction. OBJECTIVE: To perform a validation analysis on the SKILLD. DESIGN AND PARTICIPANTS: Cross-sectional observational study of 240 patients with diabetes at an academic family practice center. MAIN MEASURES: SKILLD's correlation with an oral form of the Diabetes Knowledge Test (DKT) was used to assess criterion validity. A regression model tested construct validity, hypothesizing that SKILLD score was independently related to health literacy and education level. Content validity was tested using Cronbach's Alpha for inter-item relatedness and by comparing SKILLD items with the content of a National Institutes of Health (NIH) diabetes education website. We assessed inter-rater reliability and bias using Spearman correlation coefficients and sign-rank tests between interviewers scoring the same interview. KEY RESULTS: The SKILLD demonstrated fair correlation with the DKT (Pearson's coefficient 0.54, 95% CI = 0.49 to 0.66, p < 0.001). Health literacy, education level, male gender, household income, and years with diabetes were independent predictors of SKILLD score in the regression model. Cronbach's Alpha for inter-item relatedness was 0.54. There were some topics on the NIH website not addressed by the SKILLD. The inter-rater correlation coefficient was 0.79 (95% CI 0.56 to 0.91, p < 0.001). CONCLUSIONS: The SKILLD is an adequate diabetes knowledge test and is appropriate for people of all literacy levels. However, it should be expanded to more completely evaluate diabetes knowledge. © 2011 Society of General Internal Medicine.


Christensen R.D.,Intermountain Healthcare | Christensen R.D.,y Dee Hospital Center
Clinics in Perinatology | Year: 2012

This article focuses on the use of rEpo, IVIG, and rG-CSF in the NICU. It discusses the most recent studies and the most definitive and clinically relevant evidence, rather than summarizing all published studies. The last section was written for NICU practice groups that choose to use any of these medications and are seeking a consistent approach for doing so. The section provides the author's approach to the use of rEpo, IVIG, and rG-CSF, revealing personal preferences, interpretations, and experiences, and is based on the dictum, "if you are going to use it, use it the same way each time." © 2012 Elsevier Inc.


Sheffield M.J.,Intermountain Healthcare | Sheffield M.J.,y Dee Hospital Center | Christensen R.D.,Intermountain Healthcare | Christensen R.D.,y Dee Hospital Center
Journal of Perinatology | Year: 2011

We identified four cases of hereditary spherocytosis (HS) in one Utah family, originally from Southwestern Mexico. The index cases were twin girls born at 35 weeks gestation, in whom the combination of hyperbilirubinemia, reticulocytosis and elevated mean corpuscular hemoglobin concentration (MCHC) led to studies that confirmed the diagnosis of HS. Scleral icterus in their 4-year-old sibling and in their mother led to the diagnosis of HS in them as well. Although much less commonly reported in Hispanic neonates than in those of Northern European ancestry, HS does occur among Hispanic neonates and can contribute to significant neonatal hyperbilirubinemia. These cases are consistent with our earlier report, which identified an MCHC cutoff of >36 as suggestive of further evaluation for HS. © 2011 Nature America, Inc. All rights reserved.

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