Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Joint Commission journal on quality and patient safety / Joint Commission Resources 2016; 42 (7): 309-315
The California Perinatal Quality Care Collaborative led the Breastmilk Nutrition Quality Improvement Collaborative from October 2009 to September 2010 to increase the percentage of very low birth weight infants receiving breast milk at discharge in 11 collaborative neonatal ICUs (NICUs). Observed increases in breast milk feeding and decreases in necrotizing enterocolitis persisted for 6 months after the collaborative ended. Eighteen to 24 months after the end of the collaborative, some sites maintained or further increased their gains, while others trended back toward baseline. A study was conducted to assess the qualitative factors that affect sustained improvement following participation.Collaborative leaders at each of the 11 NICUs that participated in the Breastmilk Nutrition Quality Improvement Collaborative were invited to participate in a site-specific one-hour phone interview. Interviews were recorded and transcribed and then analyzed using qualitative research analysis software to identify themes associated with sustained improvement.Eight of 11 invited centers agreed to participate in the interviews. Thematic saturation was achieved by the sixth interview, so further interviews were not pursued. Factors contributing to sustainability included physician involvement within the multidisciplinary teams, continuous education, incorporation of interventions into the daily work flow, and integration of a data-driven feedback system.Early consideration by site leaders of how to integrate best-practice interventions into the daily work flow, and ensuring physician commitment and ongoing education based in continuous data review, should enhance the likelihood of sustaining improvements. To maximize sustained success, future collaborative design should consider proactively identifying and supporting these factors at participating sites.
View details for PubMedID 27301834
Estimating Length of Stay by Patient Type in the Neonatal Intensive Care Unit AMERICAN JOURNAL OF PERINATOLOGY 2016; 33 (8): 751-757
ObjectiveDevelop length of stay prediction models for neonatal intensive care unit patients. Study DesignWe used data from 2008 to 2010 to construct length of stay models for neonates admitted within 1 day of age to neonatal intensive care units and surviving to discharge home. ResultsOur sample included 23,551 patients. Median length of stay was 79 days when birth weight was<1,000g, 46 days for 1,000 to 1,500g, 21 days for 1,500 to 2,500g, and 8 days for 2,500 g. Risk factors for longer length of stay varied by weight. Units with shorter length of stay for one weight group had shorter lengths of stay for other groups. ConclusionRisk models for comparative assessments of length of stay need to appropriately account for weight, particularly considering the cutoff of 1,500 g. Refining prediction may benefit counseling of families and health care systems to efficiently allocate resources.
View details for DOI 10.1055/s-0036-1572433
View details for Web of Science ID 000378888600005
View details for PubMedID 26890437
Impact of antenatal steroids on intraventricular hemorrhage in very-low-birth weight infants JOURNAL OF PERINATOLOGY 2016; 36 (5): 352-356
To determine the association between antenatal steroids administration and intraventricular hemorrhage rates.We used cross-sectional data from the California Perinatal Quality Care Collaborative during 2007 to 2013 for infants 32 weeks gestational age. Using multivariable logistic regression, we evaluated the effect of antenatal steroids on intraventricular hemorrhage, stratified by gestational age.In 25979 very-low-birth weight infants, antenatal steroid use was associated with a reduction in incidence of any grade of intraventricular hemorrhage (odds ratio=0.68, 95% confidence interval: 0.62, 0.75) and a reduction in incidence of severe intraventricular hemorrhage (odds ratio=0.51, 95% confidence interval: 0.45, 0.58). This association was seen across gestational ages ranging from 22 to 29 weeks.Although current guidelines recommend coverage for preterm birth at 24 to 34 weeks gestation, our results suggest that treatment with antenatal steroids may be beneficial even before 24 weeks of gestational age.
View details for DOI 10.1038/jp.2016.38
View details for Web of Science ID 000374914900006
View details for PubMedID 27010109
The Association of Level of Care With NICU Quality. Pediatrics 2016; 137 (3): 1-9
Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.
View details for DOI 10.1542/peds.2014-4210
View details for PubMedID 26908663
Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates. Pediatrics 2016; 137 (3): 1-8
To examine the availability of donor human milk (DHM) in a population-based cohort and assess whether the availability of DHM was associated with rates of breast milk feeding at NICU discharge and rates of necrotizing enterocolitis (NEC).Individual patient clinical data for very low birth weight infants from the California Perinatal Quality Care Collaborative were linked to hospital-level data on DHM availability from the Mothers' Milk Bank of San Jos for 2007 to 2013. Trends of DHM availability were examined by level of NICU care. Hospitals that transitioned from not having DHM to having DHM availability during the study period were examined to assess changes in rates of breast milk feeding at NICU discharge and NEC.The availability of DHM increased from 27 to 55 hospitals during the study period. The availability increased for all levels of care including regional, community, and intermediate NICUs, with the highest increase occurring in regional NICUs. By 2013, 81.3% of premature infants cared for in regional NICUs had access to DHM. Of the 22 hospitals that had a clear transition to having availability of DHM, there was a 10% increase in breast milk feeding at NICU discharge and a concomitant 2.6% decrease in NEC rates.The availability of DHM has increased over time and has been associated with positive changes including increased breast milk feeding at NICU discharge and decrease in NEC rates.
View details for DOI 10.1542/peds.2015-3123
View details for PubMedID 26908696
Optimal Criteria Survey for Preresuscitation Delivery Room Checklists. American journal of perinatology 2016; 33 (2): 203-207
ObjectiveTo investigate the optimal format and content of delivery room reminder tools, such as checklists. Study DesignVoluntary, anonymous web-based surveys on checklists and reminder tools for neonatal resuscitation were sent to clinicians at participating hospitals. Summary statistics including the mean and standard deviation of the survey items were calculated. Several key comparisons between groups were completed using Student t-test. ResultsFifteen hospitals were surveyed and 299 responses were collected. Almost all (96%) respondents favored some form of a reminder tool. Specific reminders such as "check and prepare all equipment" (mean 3.69, SD 0.81) were ranked higher than general reminders and personnel reminders such as "introduction and assigning roles" (mean 3.23, SD 1.08). Rankings varied by profession, institution, and deliveries attended per month. ConclusionsClinicians perceive a benefit of a checklist for neonatal resuscitation in the delivery room. Preparation of equipment was perceived as the most important use for checklists.
View details for DOI 10.1055/s-0035-1564064
View details for PubMedID 26368913
International Perspectives: Reducing Birth Asphyxia in China by Implementing the Neonatal Resuscitation Program and Helping Babies Breathe Initiative NeoReviews 2016; 17 (8)
Inhaled nitric oxide use in preterm infants in California neonatal intensive care units. Journal of perinatology : official journal of the California Perinatal Association 2016
To describe inhaled nitric oxide (iNO) exposure in preterm infants and variation in neonatal intensive care unit (NICU) use.This was a retrospective cohort study of infants, 22 to 33+6/7 weeks of gestational age (GA), during 2005 to 2013. Analyses were stratified by GA and included population characteristics, iNO use over time and hospital variation.Of the 65824 infants, 1718 (2.61%) received iNO. Infants, 22 to 24+6/7 weeks of GA, had the highest incidence of iNO exposure (6.54%). Community NICUs (n=77, median hospital use rate 0.7%) used less iNO than regional NICUs (n=23, median hospital use rate 5.8%). In 22 to 24+6/7 weeks of GA infants, the median rate in regional centers was 10.6% (hospital interquartile range 3.8% to 22.6%).iNO exposure varied with GA and hospital level, with the most use in extremely premature infants and regional centers. Variation reflects a lack of consensus regarding the appropriate use of iNO for preterm infants.Journal of Perinatology advance online publication, 31 March 2016; doi:10.1038/jp.2016.49.
View details for DOI 10.1038/jp.2016.49
View details for PubMedID 27031320
Temperature Management in the Delivery Room and During Neonatal Resuscitation NeoReviews 2016; 17 (8)
Case 1: Constipation, Irritability, and Poor Feeding in 2-month-old Boy. Pediatrics in review / American Academy of Pediatrics 2016; 37 (9): 391-3
Postnatal growth failure in very low birthweight infants born between 2005 and 2012. Archives of disease in childhood. Fetal and neonatal edition 2016; 101 (1): 50-55
Postnatal growth restriction is common in preterm infants and is associated with long-term neurodevelopmental impairment. Recent trends in postnatal growth restriction are unclear.Birth and discharge weights from 25899 Californian very low birthweight infants (birth weight 500-1500g, gestational age 22-32weeks) who were born between 2005 and 2012 were converted to age-specific Z-scores and analysed using multivariable modelling.Birthweight Z-score did not change between 2005 and 2012. However, the adjusted discharge weight Z-score increased significantly by 0.168 Z-scores (0.154, 0.182) over the study period, and the adjusted fall in weight Z-score between birth and discharge decreased significantly between those dates (by 0.016 Z-scores/year). The proportion of infants who were discharged home below the 10th weight-for-age centile or had a fall in weight Z-score between birth and discharge of >1 decreased significantly over time. The comorbidities most associated with poorer postnatal growth were medical or surgical necrotising enterocolitis, isolated gastrointestinal perforation and severe retinopathy of prematurity, which were associated with an adjusted mean reduction in discharge weight Z-score of 0.24, 0.57, 0.46 and 0.32, respectively. Chronic lung disease was not a risk factor after accounting for length of stay.Postnatal, but not prenatal, growth improved among very low birthweight infants between 2005 and 2012. Neonatal morbidities including necrotising enterocolitis, gastrointestinal perforations and severe retinopathy of prematurity have significant negative effects on postnatal growth.
View details for DOI 10.1136/archdischild-2014-308095
View details for PubMedID 26201534
Effect of time of birth on maternal morbidity during childbirth hospitalization in California AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2015; 213 (5)
This observational study aimed to determine the relationship between time of birth and maternal morbidity during childbirth hospitalization.Composite maternal morbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification and vital records codes, using linked hospital discharge and vital records data for 1,475,593 singleton births in California from 2005 through 2007. Time of birth, day of week, and sociodemographic, obstetric, and hospital volume risk factors were estimated using mixed effects logistic regression models.The odds for pelvic morbidity were lowest between 11 PM-7 AM compared to other time periods and the reference value of 7-11 AM. The odds for pelvic morbidity peaked between 11 AM-7 PM (adjustedodds ratio [AOR], 1101-1500= 1.07; 95% confidence interval [CI], 1.06-1.09; 1501-1900= 1.08; 95% CI, 1.06-1.10). Odds for severe morbidity were higher between 11 PM-7 AM (AOR, 2301-0300= 1.31; 95% CI, 1.21-1.41; 0301-0700 =1.30; 95% CI, 1.20-1.41) compared to other time periods. The adjusted odds were not statistically significant for weekend birth on pelvic morbidity (AOR, Saturday= 1.00; 95% CI, 0.98-1.02]; Sunday= 1.01; 95% CI, 0.99-1.03) or severe morbidity (AOR, Saturday= 1.09; 95% CI, 1.00-1.18; Sunday= 1.03; 95% CI, 0.94-1.13). Cesarean birth, hypertensive disorders, birthweight, and sociodemographic factors that include age, race, ethnicity, and insurance status were also significantly associated with severe morbidity.Even after controlling for sociodemographic factors and known risks such as cesarean birth and pregnancy complications such as hypertensive disorders, birth between 11 PM-7 AM is a significant independent risk factor for severe maternal morbidity.
View details for DOI 10.1016/j.ajog.2015.07.018
View details for Web of Science ID 000365763400029
View details for PubMedID 26196454
Effects of race/ethnicity and BMI on the association between height and risk for spontaneous preterm birth AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2015; 213 (5)
Multimodality Renal Failure in a Patient with OEIS Complex. AJP reports 2015; 5 (2): e161-4
Omphalocele-exstrophy of the bladder-imperforate anus-spinal defect (OEIS) complex is a rare constellation of clinical abnormalities with wide phenotypic presentation. We describe a case of a preterm neonate with OEIS complex with acute renal failure, and the challenges in diagnosis and management of this patient as renal failure can be a multifactorial process when encountered with this rare complex.
View details for DOI 10.1055/s-0035-1554799
View details for PubMedID 26495176
Maternal Asthma, Preterm Birth, and Risk of Bronchopulmonary Dysplasia JOURNAL OF PEDIATRICS 2015; 167 (4): 875-?
Neonatal Intensive Care Unit Antibiotic Use PEDIATRICS 2015; 135 (5): 826-833
Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay.In a retrospective cohort study of 52061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles.Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile.Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.
View details for DOI 10.1542/peds.2014-3409
View details for Web of Science ID 000353728400044
Obstetric Ultrasound Quality Improvement Initiative-Utilization of a Quality Assurance Process and Standardized Checklists AMERICAN JOURNAL OF PERINATOLOGY 2015; 32 (6): 599-604
ObjectiveOur aim was to assess whether mandated completion of an electronic checklist and a quality assurance (QA) process improved obstetric (OB) ultrasound image documentation. Study DesignA checklist of mandated images based on the American Institute of Ultrasound in Medicine guidelines was created. A baseline QA assessment was performed with a lead senior sonographer reviewing eight random OB examinations for each sonographer. An electronic checklist was then instituted for all OB examinations on each ultrasound machine. It was mandated that each anatomical structure be checked off during real-time image acquisition. A repeat QA assessment of each sonographer was then performed quarterly. ResultsBaseline assessments were performed between September 2011 and November 2011. Out of the 110 examinations analyzed, only 49% were deemed "complete" with none of the sonographers having a 100% complete examination rate. Following institution of the mandated electronic checklist, a repeat assessment revealed an 81% complete examination rate for the next quarter, and 90% were complete at the end of a year. All sonographers improved their image acquisition regardless of baseline skill level at the initial QA. ConclusionA QA process and a mandated standardized electronic checklist improved the image documentation.
View details for DOI 10.1055/s-0035-1545667
View details for Web of Science ID 000354342400013
View details for PubMedID 25730132
Correlation of continuous glucose monitoring profiles with pregnancy outcomes in nondiabetic women. American journal of perinatology 2015; 32 (5): 461-468
ObjectiveTo determine whether hyperglycemic excursions detected by continuous glucose monitoring (CGM) correlate with birth weight percentile and other pregnancy outcomes, and whether CGM correlates better with these outcomes than a single glucose value from a 1-hour glucose challenge test (GCT). Study DesignThis was a prospective observational study of 55 pregnant patients without preexisting diabetes, who wore a CGM device for up to 7 days, between 24 and 28 weeks' gestation. The area under the curve (AUC) of hyperglycemic excursions above various thresholds (110, 120, 130, 140, and 180 mg/dL) was calculated. These AUC values, and results from a standard 50-g GCT, were correlated with our primary outcome of birth weight percentile, and secondary outcomes of unplanned operative delivery, pregnancy complications, delivery complications, fetal complications, and neonatal complications. ResultsA consistent correlation was seen between all AUC thresholds and birth weight percentile (r=0.29, p<0.05 for AUC-110, -120, -130, and -140; r=0.25, p=0.07 for AUC-180). This correlation was stronger than that of 1-hour oral GCT (r=-0.02, p=0.88). There was no association between AUC values and other outcomes. ConclusionsAmong nondiabetic pregnant patients, hyperglycemic excursions detected by CGM show a stronger correlation to birth weight percentile than blood glucose values obtained 1-hour after a 50-g oral GCT.
View details for DOI 10.1055/s-0034-1390344
View details for PubMedID 25262455
Impact of a novel decision support tool on adherence to Neonatal Resuscitation Program algorithm RESUSCITATION 2015; 88: 52-56
Studies have shown that healthcare professionals (HCPs) display a 16-55% error rate in adherence to the Neonatal Resuscitation Program (NRP) algorithm. The aim of this study was to evaluate adherence to the Neonatal Resuscitation Program algorithm by subjects working from memory as compared to subjects using a decision support tool that provides auditory and visual prompts to guide implementation of the Neonatal Resuscitation Program algorithm during simulated neonatal resuscitation.Healthcare professionals (physicians, nurse practitioners, obstetrical/neonatal nurses) with a current NRP card were randomized to the control or intervention group and performed three simulated neonatal resuscitations. The scenarios were evaluated for the initiation and cessation of positive pressure ventilation (PPV) and chest compressions (CC), as well as the frequency of FiO2 adjustment. The Wilcoxon rank sum test was used to compare a score measuring the adherence of the control and intervention groups to the Neonatal Resuscitation Program algorithm.Sixty-five healthcare professionals were recruited and randomized to the control or intervention group. Positive pressure ventilation was performed correctly 55-80% of the time in the control group vs. 94-95% in the intervention group across all three scenarios (p<0.0001). Chest compressions were performed correctly 71-81% of the time in the control group vs. 82-93% in the intervention group in the two scenarios in which they were indicated (p<0.0001). FiO2 was addressed three times more frequently in the intervention group compared to the control group (p<0.001).Healthcare professionals using a decision support tool exhibit significantly fewer deviations from the Neonatal Resuscitation Program algorithm compared to those working from memory alone during simulated neonatal resuscitation.
View details for DOI 10.1016/j.resuscitation.2014.12.016
View details for Web of Science ID 000352508400023
Hospital Variation in Medical and Surgical Treatment of Patent Ductus Arteriosus AMERICAN JOURNAL OF PERINATOLOGY 2015; 32 (4): 379-385
ObjectiveThis study aims to characterize population risks for diagnosis, medical treatment, and surgical ligation of patent ductus arteriosus (PDA) in very low-birth-weight infants. Study DesignMaternal and neonatal data were collected in 40 hospitals in California during 2011 for infants with birth weight1,500g without any congenital malformation, with a diagnosis of PDA. Multivariable logistic regression was used to determine independent risks for PDA diagnosis and for surgical ligation. ResultsThere were 770/1,902 (40.4%) infants diagnosed with PDA. Low birth weight, gestational age, respiratory distress syndrome, and surfactant administration were associated with PDA diagnosis. Ligation occurred in 43% of patients with birth weight750g, in 24% of patients weighing between 715 and 1,000g, and in 12% of patients weighing from 1,001 to 1,500 g. Older gestational age (1week, odds ratio 0.55, 95% confidence interval 0.48-0.63) and absence of respiratory distress syndrome (odds ratio 0.14, 95% confidence interval 0.03-0.59) were associated with lower ligation risk. The median hospital ligation rate was 14% (interquartile range 0-38%). ConclusionMost patients with PDA receive treatment for closure. Practice variation may set the stage for further exploration of experimental trials.
View details for DOI 10.1055/s-0034-1387931
View details for Web of Science ID 000351664400011
View details for PubMedID 25241108
Magnesium sulfate exposure and neonatal intensive care unit admission at term JOURNAL OF PERINATOLOGY 2015; 35 (3): 181-185
Objective:The aim of this study was to investigate the effect of maternal magnesium sulfate (MgSO4) exposure for eclampsia prophylaxis on neonatal intensive care unit (NICU) admission rates for term newborns.Study Design:A secondary analysis of the Maternal-Fetal Medicine Unit Network Cesarean Registry, including primary and repeat cesarean deliveries, and failed and successful trials of labor after cesarean was conducted. Singleton pregnancies among women with preeclampsia and >37 weeks of gestation were included. Pregnancies with uterine rupture, chorioamnionitis and congenital malformations were excluded. Logistic regression analysis was used to determine associations between MgSO4 exposure and NICU admission. P<0.05 was considered statistically significant.Result:Two thousand one hundred and sixty-six term pregnancies of women with preeclampsia were included, of whom 1747 (81%) received MgSO4 for eclampsia prophylaxis and 419 (19%) did not. NICU admission rates were higher among newborns exposed to MgSO4 vs unexposed (22% vs 12%, P<0.001). After controlling for neonatal birth weight, gestational age and maternal demographic and obstetric factors, NICU admission remained significantly associated with antenatal MgSO4 exposure (adjusted odds ratio 1.9, 95% confidence interval 1.3 to 2.6, P<0.001). Newborns exposed to MgSO4 were more likely to have Apgar scores <7 at 1 and 5min (15% vs 11% unexposed, P=0.01 and 3% vs 0.7% unexposed, P=0.008). There were no significant differences in NICU length of stay (median 5 (range 2 to 91) vs 6 (3 to 15), P=0.5).Conclusion:Antenatal maternal MgSO4 treatment was associated with increased NICU admission rates among exposed term newborns of mothers with preeclampsia. This study highlights the need for studies of maternal MgSO4 administration protocols that optimize maternal and fetal benefits and minimize risks.Journal of Perinatology advance online publication, 16 October 2014; doi:10.1038/jp.2014.184.
View details for DOI 10.1038/jp.2014.184
View details for Web of Science ID 000350082200005
Referral of Very Low Birth Weight Infants to High-Risk Follow-Up at Neonatal Intensive Care Unit Discharge Varies Widely across California JOURNAL OF PEDIATRICS 2015; 166 (2): 289-295
To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative.Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral.In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; 750 g vs 1251-1499g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment.There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.
View details for DOI 10.1016/j.jpeds.2014.10.038
View details for Web of Science ID 000348496200021
View details for PubMedID 25454311
Regional Variation in Antenatal Corticosteroid Use: A Network-Level Quality Improvement Study PEDIATRICS 2015; 135 (2): E397-E404
Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort. JAMA pediatrics 2015; 169 (2)
Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.Varying levels of intensive care.Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.The study cohort included 15779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.
View details for DOI 10.1001/jamapediatrics.2014.3676
View details for PubMedID 25642906
Effect of Deregionalized Care on Mortality in Very Low-Birth-Weight Infants With Necrotizing Enterocolitis JAMA PEDIATRICS 2015; 169 (1): 26-32
There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.
View details for DOI 10.1001/jamapediatrics.2014.2085
View details for Web of Science ID 000347349300011
Platelet count and associated morbidities in VLBW infants with pharmacologically treated patent ductus arteriosus. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2015: 1-4
Characterize the diagnosis of PDA and the distribution of pretreatment platelet count in pharmacologically managed PDA in infants 1500g and assess the relationship of platelet count to serious morbidities.This is a retrospective, observational study. In 40 hospitals, data were collected on PDA, including pretreatment platelet count. Distribution of platelet count was examined. The association of platelet count and clinical outcomes of IVH, NEC and PDA closure prior to discharge were examined. Chi-square test was used to compare outcomes by platelet count groups.There were 311 patients treated with medically treated PDA. Pretreatment platelet counts were categorized as 0-119K, 120-199K, 200-299K, >300K. Incidence and grade of IVH were not significantly different by platelet group. Across all groups: No IVH 62-83%, Grades 1-2 IVH 13-25%, Grades 3-4 IVH 2-13%. NEC occurred in 0-11% of all patients studied. PDA closure rate was 33-45%.PDA closure was not significantly affected by platelet count. Platelet count was not a statistically significant factor for development of IVH and NEC in infants born <1500g with pharmacologically treated PDA.
View details for DOI 10.3109/14767058.2015.1076785
View details for PubMedID 26365622
Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants. Pediatrics 2015
Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI.Retrospective cohort study of 13327 infants with 15567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type.Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1.Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.
View details for DOI 10.1542/peds.2015-0573
View details for PubMedID 26574587
Protocol for delivery room management of hydrops Neonatology: Clinical Practice and Procedures edited by Stevenson, D. K., Cohen, R. S., Sunshine, P. McGraw Hill Education. 2015: 999-1004
The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants. Journal of perinatology : official journal of the California Perinatal Association 2015
Objective:Survival of preterm and very low birth weight (VLBW) infants has steadily improved. However, the rates of mortality and morbidity among the very smallest infants are poorly characterized.Study Design:Data from the California Perinatal Quality Care Collaborative for the years 2005 to 2012 were used to compare the mortality and morbidity of profoundly low birth weight (ProLBW, birth weight 300 to 500g) and profoundly small for gestational age (ProSGA, <1st centile for weight-for-age) infants with very low birth weight (VLBW, birth weight 500 to 1500g) and appropriate for gestational age (AGA, 5th to 95th centile for weight-for-age) infants, respectively.Result:Data were available for 44561 neonates of birth weight <1500g. Of these, 1824 were ProLBW and 648 were ProSGA. ProLBW and ProSGA differed in their antenatal risk factors from the comparison groups and were less likely to receive antenatal steroids or to be delivered by cesarean section. Only 14% of ProSGA and 21% of ProLBW infants survived to hospital discharge, compared with >80% of AGA and VLBW infants. The largest increase in mortality in ProSGA and ProLBW infants occurred prior to 12h of age, and most mortality happened in this time period. Survival of the ProLBW and ProSGA infants was positively associated with higher gestational age, receipt of antenatal steroids, cesarean section delivery and singleton birth.Conclusion:Survival of ProLBW and ProSGA infants is uncommon, and survival without substantial morbidity is rare. Survival is positively associated with receipt of antenatal steroids and cesarean delivery.Journal of Perinatology advance online publication, 15 January 2015; doi:10.1038/jp.2014.233.
View details for DOI 10.1038/jp.2014.233
View details for PubMedID 25590218
Implementation Methods for Delivery Room Management: A Quality Improvement Comparison Study PEDIATRICS 2014; 134 (5): E1378-E1386
Hypothermia Therapy for Neonatal Hypoxic Ischemic Encephalopathy in the State of California JOURNAL OF PEDIATRICS 2014; 165 (2): 267-273
To characterize the implementation of hypothermia for neonatal hypoxic ischemic encephalopathy (HIE) in a population-based cohort.Using the California Perinatal Quality Care Collaborative and California Perinatal Transport System linked 2010-2012 datasets, we categorized infants 36weeks' gestation with HIE as receiving hypothermia or normothermia. Sociodemographic and clinical factors were compared, and multivariable logistic regression was used to determine factors associated with hypothermia therapy.There were 238 reported encephalopathy cases in 2010, 280 in 2011, and 311 in 2012. Hypothermia therapy use in newborns with HIE increased from 59% to 73% across the study period, mainly occurring in newborns with mild or moderate encephalopathy. A total of 36 centers provided hypothermia and cared for 94% of infants, with the remaining 6% being cared for at one of 25 other centers. Of the centers providing hypothermia, 12 centers performed hypothermia therapy to more than 20 patients during the 3-year study period, and 24 centers cared for <20 patients receiving hypothermia. In-hospital mortality was 13%, which primarily was associated with the severity of encephalopathy.Our findings highlight an opportunity to explore practice-site variation and to develop quality improvement interventions to assure consistent evidence-based care of term infants with HIE and appropriate application of hypothermia therapy for eligible newborns.
View details for DOI 10.1016/j.jpeds.2014.04.052
View details for Web of Science ID 000341435800011
Caesarean delivery for twin gestation at 32-38 weeks does not lead to improved clinical outcomes for neonates or mothers. Evidence-based medicine 2014; 19 (3): 119-?
Urine culture results and adverse outcomes in women with pyelonephritis. Obstetrics and gynecology 2014; 123: 138S-?
A retrospective cohort study of patients with pyelonephritis in pregnancy and immediately postpartum was conducted. Participants delivered between 2005 and 2009 at a single university center (Lucile Packard Children's Hospital at Stanford) were reviewed. Pyelonephritis was defined by a temperature greater than 38.0C, flank pain or costovertebral angle tenderness, and bacteruria or pyuria on urinalysis. All patients with pyelonephritis and urine culture results were included. Univariate analyses were performed with the test. Means were compared with the Student's t test.One hundred thirteen patients were admitted with pyelonephritis and had a urine culture performed. Of the entire cohort, 70% of patients were Hispanic, 53% were nulliparous, and most were diagnosed in the third trimester. A total of 94 patients (83%) had positive urine cultures. There were no differences in adverse outcomes (preterm birth, anemia, bacteremia, acute respiratory distress syndrome, and hospital stay) between those with positive and negative urine cultures. Among those with positive cultures, there was a statistically significant increase in preterm birth (less than 37 weeks of gestation) between those with resistant uropathogens and those with pan-sensitive pathogens (26.5% compared with 7.6%, P=.01) ().(Table is included in full-text article.): Among women with pyelonephritis, complications did not differ between those with positive and negative urine culture results. Women with resistant bacterial uropathogens are at increased risk for preterm birth compared with those with sensitive pathogens.
View details for DOI 10.1097/01.AOG.0000447112.69038.68
View details for PubMedID 24770006
Emergency Department Visits in the Neonatal Period in the United States PEDIATRIC EMERGENCY CARE 2014; 30 (5): 315-318
This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.
View details for DOI 10.1097/PEC.0000000000000120
View details for Web of Science ID 000335749100004
View details for PubMedID 24759490
On-time scheduled cesarean delivery start time process-improvement initiative. Obstetrics and gynecology 2014; 123: 138S-9S
Cesarean deliveries comprise approximately 30% of all births, many of which are scheduled. Given the labile nature of labor and delivery units, scheduled cesarean deliveries are often delayed. Our aim was to improve on-time scheduled cesarean delivery start times.A multidisciplinary team (obstetrician-gynecologist, nursing, anesthesia, and hospital administration) met to review scheduled cesarean delivery data, identify logistic barriers to on-time starts, and develop a plan to improve cesarean delivery start times. After identifying possible barriers to on-time starts, the following process was instituted: planned preoperative visit 1-2 days before scheduled cesarean delivery, mandatory submission of History & Physical and consent forms by the time of the preoperative visit, and initial preparation of the first scheduled patient for cesaren delivery by nighttime nursing before morning change of shift. The process launched on March 1, 2013. Data from scheduled cesarean deliveries 6 months before and 3 months after the initiative were reviewed and analyzed.Of 1,298 total cesarean deliveries, 423 were scheduled, defined as cesarean delivery scheduled at least 24 hours in advance (300 before and 123 after the initiative). Sixty-four of 300 scheduled cesarean deliveries (21.3%) were on time before compared with 67 of 123 (54.5%) after the initiative began (P<.001). Among delayed cases, there was no difference in the average delay time between those before and after the initiative (55.7 compared with 54.4 minutes P=.93); however, 50.7% of cases were either on time or delayed by 15 minutes or less before the initiative compared with 69.9% of cases after (P<.001).A multidisciplinary initiative significantly increased scheduled cesarean delivery on-time start times.
View details for DOI 10.1097/01.AOG.0000447113.07157.f3
View details for PubMedID 24770007
The impact of an intervention package promoting effective neonatal resuscitation training in rural China. Resuscitation 2014; 85 (2): 253-259
To evaluate an intervention package promoting effective neonatal resuscitation training at county level hospitals across China.The intervention package was implemented across 4 counties and included expert seminars, training workshops, establishment of hospital-based resuscitation teams, and supervision of training by national and provincial instructors. Upon completing the activities, a survey was conducted in all county hospitals in the 4 intervention counties and 4 randomly selected control counties. Data on healthcare providers' knowledge and self-confidence, and incidence of deaths from birth asphyxia from 2009 to 2011 in all hospitals were collected and compared between the two groups.Eleven intervention and eleven control hospitals participated in the evaluation, with 97 and 87 health providers, respectively, completing the questionnaire survey. Over 90% of intervention hospitals had implemented neonatal resuscitation related practice protocols, while in control hospitals the proportion was less than 55%. The average knowledge scores of health providers in the intervention and control counties taking a written exam were 9.21.2 and 8.41.5, respectively (P<0.001) out of maximum possible score of 10, and the average self-confidence scores were 57.32.5 and 54.18.2, respectively (P<0.001). Incidence of birth asphyxia (defined as 1-min Apgar score7) decreased from 8.8% to 6.0% (P<0.001) in the intervention counties, and asphyxia-related deaths in the delivery room decreased from 27.6 to 5.0 per 100,000 (P=0.076). There was no difference over time in asphyxia rates for the control counties.The intervention has not only improved skills of health providers, decreased the mortality and morbidity of birth asphyxia, but also resulted in effective implementation of guidelines and protocols within hospitals.
View details for DOI 10.1016/j.resuscitation.2013.10.020
View details for PubMedID 24176723
Oral misoprostol versus vaginal dinoprostone for labor induction in nulliparous women at term JOURNAL OF PERINATOLOGY 2014; 34 (2): 95-99
Objective:To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.Study design:Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24h, mode of delivery and maternal and fetal outcomes.Result:A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9h, P<0.0001) and were more likely to deliver vaginally in <24h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.Conclusion:Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.
View details for DOI 10.1038/jp.2013.133
View details for Web of Science ID 000331138400003
View details for PubMedID 24157494
Consequences of the Affordable Care Act for Sick Newborns. Pediatrics 2014
Maternal determinants of breast milk feeding in a level III neonatal intensive care unit Journal of Neonatal Nursing 2014; 21 (4): 150-156
Outcomes of extremely preterm infants after delivery room cardiopulmonary resuscitation in a population-based cohort. Journal of perinatology : official journal of the California Perinatal Association 2014
Objective:To describe the relationship of delivery room cardiopulmonary resuscitation (DR-CPR) to short-term outcomes of extremely preterm infants.Study design:This was a cohort study of 22 to 27+6/7 weeks gestational age (GA) infants during 2005 to 2011. DR-CPR was defined as chest compressions and/or epinephrine administration. Multivariable logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) associated with DR-CPR; analysis was stratified by GA.Result:Of the 13758 infants, 856 (6.2%) received DR-CPR. Infants 22 to 23+6/7 weeks receiving DR-CPR had similar outcomes to non-recipients. Infants 24 to 25+6/7 weeks receiving DR-CPR had more severe intraventricular hemorrhage (OR 1.36, 95% CI 1.07, 1.72). Infants 26 to 27+6/7 weeks receiving DR-CPR were more likely to die (OR 1.81, 95% CI 1.30, 2.51) and have intraventricular hemorrhage (OR 2.10, 95% CI 1.56, 2.82). Adjusted hospital DR-CPR rates varied widely (median 5.7%).Conclusion:Premature infants receiving DR-CPR had worse outcomes. Mortality and morbidity varied by GA.Journal of Perinatology advance online publication, 18 December 2014; doi:10.1038/jp.2014.222.
View details for DOI 10.1038/jp.2014.222
View details for PubMedID 25521563
Neurodevelopmental Outcomes for Infants Born With Congenital Heart Disease NeoReviews 2014; 15 (8): e344-53
Incidence and Impact of CMV Infection in Very Low Birth Weight Infants. Pediatrics 2014
Congenital cytomegalovirus (CMV) is the leading cause of nongenetic deafness in children in the United States and can cause neurodevelopmental impairment in term infants. Limited data exist regarding congenital CMV infections in preterm infants. We aimed to determine the incidence and association with outcomes of congenital CMV in very low birth weight (VLBW) preterm infants.VLBW infants born in 1993 to 2008 and admitted to the University of Alabama in Birmingham Regional Neonatal ICU were screened on admission for congenital CMV. CMV status and clinical outcomes were identified by using internal patient databases and hospital-based medical records. The primary outcome was death. Secondary outcomes included evidence of neurologic injury in the form of abnormal cranial ultrasound findings, sensorineural hearing loss, or abnormal motor development. Multivariate analysis was performed.Eighteen of 4594 VLBW infants had congenital CMV (0.39%; 95% confidence interval, 0.25%-0.62%). An additional 16 infants (0.35%; 95% confidence interval, 0.21%-0.57%) were identified who acquired CMV postnatally. Congenital CMV was not associated with death. Compared with controls, congenitally infected VLBW infants were more likely to have hearing loss at initial screening (67% vs 9%, P < .0001) and confirmed at follow-up (83% vs 2.1%, P < .0001). Congenital CMV was also associated with abnormal neuroimaging (72% vs 25%, P < .0001) and adverse developmental motor outcomes (43% vs 9%, P = .02). Acquired CMV was not associated with any adverse outcomes.Congenital CMV in VLBW infants is associated with high rates of neurologic injury and hearing loss but not death.
View details for DOI 10.1542/peds.2013-2217
View details for PubMedID 24488749
Evaluating and Improving the Safety and Quality of Neonatal Intensive Care Fanaroff and Martin's Neonatal-Perinatal Medicine edited by Martin, R., Fanaroff, A., Walsh, M. Elsevier. 2014; 10: 59-88
Accounting for variation in length of NICU stay for extremely low birth weight infants. Journal of perinatology 2013; 33 (11): 872-876
Objective:To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants.Study Design:We included infants from the California Perinatal Quality Care Collaborative with birth weight 401 to 1000g who were discharged to home. Exclusion criteria were congenital anomalies, surgery and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers to risk-adjusted LOS.Results:There were 2012 infants with median LOS 79 days (range 23 to 219). Lower birth weight, lack of antenatal steroids and lower Apgar score were associated with longer LOS. There was negligible correlation between risk-adjusted LOS and hospital mortality rates (r=0.0207) and transfer-out rates (r=0.121).Conclusion:Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.
View details for DOI 10.1038/jp.2013.92
View details for PubMedID 23949836
Measuring hospital quality using pediatric readmission and revisit rates. Pediatrics 2013; 132 (3): 429-436
To assess variation among hospitals on pediatric readmission and revisit rates and to determine the number of high- and low-performing hospitals.In a retrospective analysis using the State Inpatient and Emergency Department Databases from the Healthcare Cost and Utilization Project with revisit linkages available, we identified pediatric (ages 1-20 years) visits with 1 of 7 common inpatient pediatric conditions (asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders, and epilepsy). For each condition, we calculated rates of all-cause readmissions and rates of revisits (readmission or presentation to the emergency department) within 30 and 60 days of discharge. We used mixed logistic models to estimate hospital-level risk-standardized 30-day revisit rates and to identify hospitals that had performance statistically different from the group mean.Thirty-day readmission rates were low (<10.0%) for all conditions. Thirty-day rates of revisit to the inpatient or emergency department setting ranged from 6.2% (appendicitis) to 11.0% (mood disorders). Study hospitals (n = 958) had low condition-specific visit volumes (37.0%-82.8% of hospitals had <25 visits). The only condition with >1% of hospitals labeled as different from the mean on 30-day risk-standardized revisit rates was mood disorders (4.2% of hospitals [n = 15], range of hospital performance 6.3%-15.9%).We found that when comparing hospitals' performances to the average, few hospitals that care for children are identified as high- or low-performers for revisits, even for common pediatric diagnoses, likely due to low hospital volumes. This limits the usefulness of condition-specific readmission or revisit measures in pediatric quality measurement.
View details for DOI 10.1542/peds.2012-3527
View details for PubMedID 23979094
The Continuum of Maternal Sepsis Severity: Incidence and Risk Factors in a Population-Based Cohort Study PLOS ONE 2013; 8 (7)
To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI=9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR=1.29; 35 years: aOR=1.41), had high-school education (aOR=1.63), public/no-insurance (aOR=1.22) or a cesarean section (primary: aOR=1.99; repeat: aOR=1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI=4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR=2.09), Asian (aOR=1.59), Hispanic (aOR=1.42), had public/no-insurance (aOR=1.52), delivered in hospitals with <1,000 births/year (aOR=1.93), were primiparous (aOR=2.03), had a multiple birth (aOR=3.5), diabetes (aOR=1.47), or chronic hypertension (aOR=8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR=3.72; aOR=4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI=17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI=40.8-74.4).The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.
View details for DOI 10.1371/journal.pone.0067175
View details for Web of Science ID 000321341000034
View details for PubMedID 23843991
Perspectives on Promoting Breastmilk Feedings for Premature Infants During a Quality Improvement Project BREASTFEEDING MEDICINE 2013; 8 (2): 176-180
This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants.From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion.Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders.Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.
View details for DOI 10.1089/bfm.2012.0056
View details for Web of Science ID 000317472700007
View details for PubMedID 23186387
The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: Implications for delivery of care, training and technology design RESUSCITATION 2013; 84 (3): 369-372
Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation.Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochran's Q and chi square test were used to compare HR detection by method and across scenarios.Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination.Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.
View details for DOI 10.1016/j.resuscitation.2012.07.035
View details for Web of Science ID 000318164200028
Hospital-wide breastfeeding rates vs. breastmilk provision for very-low-birth-weight infants ACTA PAEDIATRICA 2013; 102 (3): 268-272
To investigate the relationship between breastmilk feeding in very-low-birth-weight infants in the neonatal intensive care unit and breastmilk feeding rates for all newborns by hospital.This was a cross-sectional study of 111 California hospitals in 2007 and 2008. Correlation coefficients were calculated between overall hospital breastfeeding rates and breastmilk feeding rates of very-low-birth-weight infants. Hospitals were categorized in quartiles by crude and adjusted very-low-birth-weight infant rates to compare rankings between measures.Correlation between breastmilk feeding rates of very-low-birth-weight infants and overall breastfeeding rates varied by neonatal intensive care unit level of care from 0.13 for intermediate hospitals to 0.48 for regional hospitals. For hospitals categorized in the top quartile according to overall breastfeeding rate, only 46% were in the top quartile for both crude and adjusted very-low-birth-weight infant rates. On the other hand, when considering the lowest quartile for overall breastfeeding hospitals, three of 27 (11%) actually were performing in the top quartile of performance for very-low-birth-weight infant rates.Reporting hospital overall breastfeeding rates and neonatal intensive care unit breastmilk provision rates separately may give an incomplete picture of quality of care.
View details for DOI 10.1111/apa.12096
View details for Web of Science ID 000314656600022
View details for PubMedID 23174012
Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial BMJ QUALITY & SAFETY 2013; 22 (2): 124-129
To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC).A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test.Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use.The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.
View details for DOI 10.1136/bmjqs-2012-001336
View details for Web of Science ID 000314211900005
"Breastfeeding" by Feeding Expressed Mother's Milk PEDIATRIC CLINICS OF NORTH AMERICA 2013; 60 (1): 227-?
This article provides the pediatric community with a practical overview of milk expression and an update on the recent literature. Approaches for working mothers, preterm infants, critically ill infants, and mothers before lactogenesis II are presented separately, as these groups may benefit from practices tailored to individual needs.
View details for DOI 10.1016/j.pcl.2012.10.003
View details for Web of Science ID 000313137500012
View details for PubMedID 23178067
HYPOXIC ISCHEMIC ENCEPHALOPATHY IN THE COOLING ERA: SHORT TERM OUTCOMES IN THE STATE OF CALIFORNIA LIPPINCOTT WILLIAMS & WILKINS. 2013: 166-166
A Quality Improvement Project to Increase Breast Milk Use in Very Low Birth Weight Infants PEDIATRICS 2012; 130 (6): E1679-E1687
To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.
View details for DOI 10.1542/peds.2012-0547
View details for Web of Science ID 000314802000033
View details for PubMedID 23129071
Utilization of available prenatal screening and diagnosis: effects of the California screen program JOURNAL OF PERINATOLOGY 2012; 32 (12): 907-912
In 2009, the California Genetic Disease Branch introduced an aneuploidy screening program allowing Medi-Cal (state insured) patients access to state-sponsored first-trimester screening. The objective of this study was to assess the effect of greater access to prenatal screening on available resources at a single center.Data of prenatal screening and diagnostic procedures performed 4 months before the introduction of the program were compared with those of 12 months following the introduction.Between December 2008 and March 2010, 7689 women underwent first trimester screening, 1286 underwent amniocentesis and 398 underwent chorionic villus sampling. When a comparison was made between the 4 months before and the 12 months after the program's introduction, a greater number of nuchal translucency (NT) examinations was seen to have been performed (384 per month vs 513 per month, P=0.001). Prenatal diagnostic procedures did not increase, but a greater proportion was performed for positive screen results.Introduction of the California screening program was associated with increased NT procedures and fewer invasive procedures for advanced maternal age.
View details for DOI 10.1038/jp.2012.8
View details for Web of Science ID 000311831700002
View details for PubMedID 22402484
Maternal morbidity during childbirth hospitalization in California JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 2012; 25 (12): 2529-2535
To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization.Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005-2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models.The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity.Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.
View details for DOI 10.3109/14767058.2012.710280
View details for Web of Science ID 000311678300011
View details for PubMedID 22779781
Factors Associated with Failure to Screen Newborns for Retinopathy of Prematurity JOURNAL OF PEDIATRICS 2012; 161 (5): 819-823
To evaluate ROP screening rates in a population-based cohort; and to identify characteristics of patients that were missed.We used the California Perinatal Quality Care Collaborative data from 2005-2007 for a cross-sectional study. Using eligibility criteria, screening rates were calculated for each hospital. Multivariable regression was used to assess associations between patient clinical and sociodemographic factors and the odds of missing screening.Overall rates of missed ROP screening decreased from 18.6% in 2005 to 12.8% in 2007. Higher gestational age (OR = 1.25 for increase of 1 week, 95% CI, 1.21-1.29), higher birth weight (OR = 1.13; 95% CI, 1.10-1.15), and singleton birth (OR = 1.2; 95% CI, 1.07-1.34) were associated with higher probability of missing screening. Level II neonatal intensive care units and neonatal intensive care units with lower volume were more likely to miss screenings.Although ROP screening rates improved over time, larger and older infants are at risk for not receiving screening. Furthermore, large variations in screening rates exist among hospitals in California. Identification of gaps in quality of care creates an opportunity to improve ROP screening rates and prevent impaired vision in this vulnerable population.
View details for DOI 10.1016/j.jpeds.2012.04.020
View details for Web of Science ID 000310370600013
View details for PubMedID 22632876
Intestinal malrotation and catastrophic volvulus in infancy. journal of emergency medicine 2012; 43 (1): e49-51
Intestinal malrotation in the newborn is usually diagnosed after signs of intestinal obstruction, such as bilious emesis, and corrected with the Ladd procedure.The objective of this report is to describe the presentation of severe cases of midgut volvulus presenting in infancy, and to discuss the characteristics of these cases.We performed a 7-year review at our institution and present two cases of catastrophic midgut volvulus presenting in the post-neonatal period, ending in death soon after the onset of symptoms. These two patients also had significant laboratory abnormalities compared to patients with more typical presentations resulting in favorable outcomes.Although most cases of intestinal malrotation in infancy can be treated successfully, in some circumstances, patients' symptoms may not be detected early enough for effective treatment, and therefore may result in catastrophic midgut volvulus and death.
View details for DOI 10.1016/j.jemermed.2011.06.135
View details for PubMedID 22325550
Clinician Perspectives on Barriers to and Opportunities for Skin-to-Skin Contact for Premature Infants in Neonatal Intensive Care Units BREASTFEEDING MEDICINE 2012; 7 (2): 79-84
Our objective was to investigate key factors in promoting skin-to-skin contact (STSC) in the neonatal intensive care unit (NICU).As part of a California Perinatal Quality Care Collaborative on improving nutrition and promoting breastmilk feeding of premature infants, a multidisciplinary group of representatives from 11 hospitals discussed the progress and barriers in pursuing the project. A key component of the collaborative project was promotion of STSC. Sessions were audio-recorded, transcribed, and assessed using qualitative research methods with the aid of Atlas Ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Two primary investigators studied the transcripts for themes related to STSC. Using an iterative approach, selected themes were explored, and representative quotes were selected.Barriers to promoting STSC fell into broad themes of implementation, institutional, and familial factors. The main challenge identified in implementation was defining a clinically stable eligible population of patients. Key institutional factors were education and motivation of staff. Familial factors involved facilitation and sustained motivation of mothers. In response to these barriers, opportunities for promoting STSC were enacted or suggested by the group, including defining clinical stability for eligibility, facilitating documentation, strategies to increase parent and staff education and motivation, and encouraging maternal visitation and comfort.Our findings may be useful for institutions seeking to develop policies and strategies to increase STSC and breastmilk feeding in their NICUs.
View details for DOI 10.1089/bfm.2011.0004
View details for Web of Science ID 000302777000003
View details for PubMedID 22011130
Trends in Cesarean Delivery for Twin Births in the United States: 1995-2008 Reply OBSTETRICS AND GYNECOLOGY 2012; 119 (3): 658-659
Trends in Cesarean Delivery for Twin Births in the United States 1995-2008 OBSTETRICS AND GYNECOLOGY 2011; 118 (5): 1095-1101
To estimate trends and risk factors for cesarean delivery for twins in the United States.This was a cross-sectional study in which we calculated cesarean delivery rates for twins from 1995 to 2008 using National Center for Health Statistics data. We compared cesarean delivery rates by year and for vertex compared with breech presentation. The order of presentation for a given twin pair could not be determined from the available records and therefore analysis was based on individual discrete twin data. Multivariable logistic regression was used to estimate independent risk factors, including year of birth and maternal factors, for cesarean delivery.Cesarean delivery rates for twin births increased steadily from 53.4% to 75.0% in 2008. Rates rose for the breech twin category (81.5%-92.1%) and the vertex twin category (45.1%-68.2%). The relative increase in the cesarean delivery rate for preterm and term neonates was similar. After risk adjustment, there was an average increase noted in cesarean delivery of 5% each year during the study period (risk ratio 1.05, 95% confidence interval 1.04-1.05).Cesarean delivery rates for twin births increased dramatically from 1995 to 2008. This increase is significantly higher than that which could be explained by an increase in cesarean delivery for breech presentation of either the presenting or second twin.
View details for DOI 10.1097/AOG.0b013e3182318651
View details for Web of Science ID 000296292600018
View details for PubMedID 22015878
The Impact of Statistical Choices on Neonatal Intensive Care Unit Quality Ratings Based on Nosocomial Infection Rates ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2011; 165 (5): 429-434
To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings.Cross-sectional study based on risk-adjusted nosocomial infection rates.NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008.One hundred twenty-six California NICUs and 10 487 VLBW infants.Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years.Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the ? statistic.Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89.The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.
View details for Web of Science ID 000290113500009
View details for PubMedID 21536958
Hypothermia in very low birth weight infants: distribution, risk factors and outcomes JOURNAL OF PERINATOLOGY 2011; 31: S49-S56
The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria.A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression.In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death.Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.
View details for DOI 10.1038/jp.2010.177
View details for Web of Science ID 000289236900008
View details for PubMedID 21448204
Improved outcomes with a standardized feeding protocol for very low birth weight infants JOURNAL OF PERINATOLOGY 2011; 31: S61-S67
The objective of this study was to evaluate the impact of a standardized enteral feeding protocol for very low birth weight (VLBW) infants on nutritional, clinical and growth outcomes.Retrospective analysis of VLBW cohorts 9 months before and after initiation of a standardized feeding protocol consisting of 6-8 days of trophic feedings, followed by an increase of 20?ml/kg/day. The primary outcome was days to reach full enteral feeds defined as 160?ml/kg/day. Secondary outcomes included rates of necrotizing enterocolitis and culture-proven sepsis, days of parenteral nutrition and growth end points.Data were analyzed on 147 VLBW infants who received enteral feedings, 83 before ('Before') and 64 subsequent to ('After') feeding protocol initiation. Extremely low birth weight (ELBW) infants in the After group attained enteral volumes of 120?ml/kg/day (43.9 days Before vs 32.8 days After, P=0.02) and 160?ml/kg/day (48.5 days Before vs 35.8 days After, P=0.02) significantly faster and received significantly fewer days of parenteral nutrition (46.2 days Before vs 31.3 days After, P=0.01). Necrotizing enterocolitis decreased in the After group among VLBW (15/83, 18% Before vs 2/64, 3% After, P=0.005) and ELBW infants (11/31, 35% Before vs 2/26, 8% After, P=0.01). Late-onset sepsis decreased significantly in the After group (26/83, 31% Before vs 6/64, 9% After, P=0.001). Excluding those with weight <3rd percentile at birth, the proportion with weight <3rd percentile at discharge decreased significantly after protocol initiation (35% Before vs 17% After, P=0.03).These data suggest that implementation of a standardized feeding protocol for VLBW infants results in earlier successful enteral feeding without increased rates of major morbidities.
View details for DOI 10.1038/jp.2010.185
View details for Web of Science ID 000289236900010
View details for PubMedID 21448207
Nosocomial Infection Reduction in VLBW Infants With a Statewide Quality-Improvement Model PEDIATRICS 2011; 127 (3): 419-426
To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants.This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors.During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals.The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.
View details for DOI 10.1542/peds.2010-1449
View details for Web of Science ID 000287845400043
View details for PubMedID 21339273
Antenatal Steroid Administration for Premature Neonates in California OBSTETRICS AND GYNECOLOGY 2011; 117 (3): 603-609
To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term.Clinical data for premature neonates born in 20052007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors.Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 20052007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999 2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001).A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.
View details for DOI 10.1097/AOG.0b013e31820c3c9b
View details for Web of Science ID 000287649400013
View details for PubMedID 21446208
Translating evidence into practice, policy, and public health in perinatal medicine NeoReviews 2011; 12 (8): e431-438
Hematologic abnormalities and jaundice Rudolph's Pediatrics McGraw-Hill Medical Publishing Co.. 2011; 22nd ed.
Transition to Oral Feeding in Preterm Infants NeoReviews 2011; 12 (8): e141-147
The Effect of Preterm Premature Rupture of Membranes on Neonatal Mortality Rates LIPPINCOTT WILLIAMS & WILKINS. 2010: 1381-1386
To estimate the effect of preterm premature rupture of membranes (PROM) on neonatal mortality.A cross-sectional study using a state perinatal database (California Perinatal Quality Care Collaborative) was performed. Prenatal data, including ruptured membranes, corticosteroid administration, maternal age, maternal race, maternal hypertension, mode of delivery, and prenatal care, were recorded. Mortality rates were compared for neonates born between 24 and 34 weeks of gestation without preterm PROM to those with recent (less than 18 hours before delivery) and prolonged (more than 18 hours before delivery) preterm PROM. Neonatal sepsis rates were also examined.Neonates born between 24 0/7 and 34 0/7 weeks of gestation from 127 California neonatal intensive care units between 2005 and 2007 were included (N=17,501). When analyzed by 2-week gestational age groups, there were no differences in mortality rates between those born with and without membrane rupture before delivery. The presence of prolonged preterm PROM was associated with decreased mortality at 24 to 26 weeks of gestation (18% compared with 31% for recent preterm PROM; odds ratio [OR] 1.79; confidence interval [CI] 1.25-2.56) but increased mortality at 28 to 30 weeks of gestation (4% compared with 3% for recent preterm PROM; OR 0.44; CI 0.22, 0.88) when adjusted for possible confounding factors. Sepsis rates did not differ between those with recent or prolonged preterm PROM at any gestational age.The presence of membrane rupture before delivery was not associated with increased neonatal mortality in any gestational age group. The effects of a prolonged latency period were not consistent across gestational ages.
View details for DOI 10.1097/AOG.0b013e3181fe3d28
View details for Web of Science ID 000284491000021
View details for PubMedID 21099606
Low Apgar score and mortality in extremely preterm neonates born in the United States ACTA PAEDIATRICA 2010; 99 (12): 1785-1789
To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates.Infant birth and death certificate data from the US National Center for Health Statistics for 2001-2002 were analysed. Primary outcome was 28-day mortality for 690, 933 neonates at gestational ages 24-36 weeks. Mortality rates were calculated for each combination of gestational age and 5-min Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age.Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30-36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0-3 vs. 7-10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks.? Low Apgar score was associated with increased mortality in premature neonates, including those at 24-28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.
View details for DOI 10.1111/j.1651-2227.2010.01935.x
View details for Web of Science ID 000283690300010
View details for PubMedID 20626363
Prediction of Death for Extremely Premature Infants in a Population-Based Cohort PEDIATRICS 2010; 126 (3): E644-E650
Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.
View details for DOI 10.1542/peds.2010-0097
View details for Web of Science ID 000281535700047
View details for PubMedID 20713479
Ultrasound estimation of fetal weight in small for gestational age pregnancies JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 2010; 23 (8): 790-793
Approximately half of small for gestational age (SGA) cases are due to maternal or fetal pathology, and may result in significant neonatal morbidity and mortality. The estimated fetal weight (EFW) measurement is the cornerstone of ultrasonographic findings when diagnosing and managing SGA pregnancies. Our objective was to determine the ultrasound accuracy of EFW in SGA pregnancies.A retrospective chart review was performed of all pregnancies complicated by SGA from a single institution (Stanford University) over a 2-year-period (2004-2006). SGA was defined as EFW < or = 10%. 98 neonates whose last ultrasound for EFW occurred within 7 days of delivery were included in the study. The absolute differences between the EFW and birthweight (BW) were analyzed, and the absolute percent errors were calculated as (EFW - BW)/BW x 100. The mean absolute differences and mean absolute percent errors were analyzed across all gestational ages (GA) and EFWs using one-way analysis of variance.The mean absolute percent error for the entire cohort was 8.7% (+/-6.3%). There was no statistically significant difference in the mean absolute percent error across all GAs (<32 weeks, 32-36 weeks, >36 weeks), and EFWs (<1500 g, 1500-2000 g, >2000 g).Ultrasound measurement of EFW in SGA pregnancies is consistent across all GAs and EFW measurements.
View details for DOI 10.3109/14767050903387052
View details for Web of Science ID 000280592200006
View details for PubMedID 19968588
A National Survey of Pediatric Residents and Delivery Room Training Experience JOURNAL OF PEDIATRICS 2010; 157 (1): 158-U211
To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.
View details for DOI 10.1016/j.jpeds.2010.01.029
View details for Web of Science ID 000278649200037
View details for PubMedID 20304418
Morbidity Risk at Birth for Asian Indian Small for Gestational Age Infants AMERICAN JOURNAL OF PUBLIC HEALTH 2010; 100 (5): 820-822
Whether the traditional definition of small for gestational age (SGA) is an appropriate marker of risk for populations that have relatively lower birthweight is unclear. We determined proportions of White and Asian Indian SGA infants and those admitted to the special care nursery. Compared with White infants, Asian Indian infants were more likely to be SGA (14.5% versus 2.7%) and more likely to be admitted to the special care nursery (20.7% versus 3.7%), suggesting that traditional definitions of SGA may be applicable as a marker of risk.
View details for DOI 10.2105/AJPH.2009.165001
View details for Web of Science ID 000276828800015
View details for PubMedID 20299660
Factors Influencing Breast Milk versus Formula Feeding at Discharge for Very Low Birth Weight Infants in California JOURNAL OF PEDIATRICS 2009; 155 (5): 657-U94
To investigate incidence and factors influencing breast milk feeding at discharge for very low birth weight infants (VLBW) in a population-based cohort.We used data from the California Perinatal Quality Care Collaborative to calculate incidence of breast milk feeding at hospital discharge for 6790 VLBW infants born in 2005-2006. Multivariable logistic regression was used to examine which sociodemographic and medical factors were associated with breast milk feeding. The impact of removing risk adjustment for race was examined.At initial hospital discharge, 61.1% of VLBW infants were fed breast milk or breast milk supplemented with formula. Breast milk feeding was more common with higher birth weight and gestational age. After risk adjustment, multiple birth was associated with higher breast milk feeding. Factors associated with exclusive formula feeding were Hispanic ethnicity, African American race, and no prenatal care. Hospital risk-adjusted rates of breast milk feeding varied widely (range 19.7% to 100%) and differed when race was removed from adjustment.A substantial number of VLBW infants were not fed breast milk at discharge. Specific groups may benefit from targeted interventions to promote breast milk feeding. There may be benefit to reporting risk-adjusted rates both including and excluding race in adjustment when considering quality improvement initiatives.
View details for DOI 10.1016/j.jpeds.2009.04.064
View details for Web of Science ID 000271570900014
View details for PubMedID 19628218
Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis FERTILITY AND STERILITY 2009; 92 (2): 471-480
To evaluate the cost effectiveness of laparoscopy for unexplained infertility.We performed a cost-effectiveness analysis using a computer-generated decision analysis tree. Data used to construct the mathematical model were extracted from the literature or obtained from our practice. We compared outcomes following four treatment strategies:  no treatment,  standard infertility treatment algorithm (SITA),  laparoscopy with expectant management (LSC/EM), and  laparoscopy with infertility therapy (LSC/IT). The incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analyses assessed the impact of varying base-case estimates.Academic in vitro fertilization practice.Computer-simulated patients assigned to one of four treatments.Fertility treatment or laparoscopy.Incremental cost-effectiveness ratios.Using base-case assumptions, LSC/EM was preferred (ICER =$128,400 per live-birth in U.S. dollars). Changing the following did not alter results: rates and costs of multiple gestations, penalty for high-order multiples, infertility treatment costs, and endometriosis prevalence. Outcomes were most affected by patient dropout from infertility treatments-SITA was preferred when dropout was less than 9% per cycle. Less important factors included surgical costs, acceptability of twins, and the effects of untreated endometriosis on fecundity.Laparoscopy is cost effective in the initial management of young women with infertility, particularly when infertility treatment dropout rates exceed 9% per cycle.
View details for DOI 10.1016/j.fertnstert.2008.05.074
View details for Web of Science ID 000268915200011
View details for PubMedID 18722609
Changes in Attendance at Deliveries by Pediatric Residents 2000 to 2005 AMERICAN JOURNAL OF PERINATOLOGY 2009; 26 (2): 129-134
We sought to determine if pediatric resident attendance at deliveries for newborn assessment and resuscitation had changed over the years at a training hospital. Data were abstracted from medical records of newborns discharged during the same 6-week periods for 5 consecutive academic years spanning a period before and after resident duty hour regulation changes were implemented. Names of personnel attending deliveries were noted in delivery records. The proportions of deliveries attended by any practitioner were compared by year, as well as the proportion of deliveries attended by practitioner type and training level. A total of 2666 delivery records were reviewed. The proportions of deliveries attended by any practitioner over the 5 years were similar, ranging from 43 to 49%. The proportion of deliveries attended by pediatric residents was highest at 51 to 57% from 2000 to 2002, declined to a low of 5% during 2002 to 2003, and rose to 20 to 23% during 2003 to 2005 ( P < 0.0001). The decrease in attendance by residents was compensated by an increase in attendance by hospitalists. At this training institution, pediatric resident attendance at deliveries declined substantially over recent years, likely due in part to resident duty hour regulations and increased use of hospitalists in roles previously held by residents.
View details for DOI 10.1055/s-0028-1091395
View details for Web of Science ID 000262934700006
View details for PubMedID 18850515
PEDIATRIC RESIDENT ATTENDANCE AT DELIVERIES LIPPINCOTT WILLIAMS & WILKINS. 2009: 238-238
A quality improvement project to improve admission temperatures in very low birth weight infants JOURNAL OF PERINATOLOGY 2008; 28 (11): 754-758
To review the results of a quality improvement (QI) project to improve admission temperatures of very low birth weight inborn infants.The neonatal intensive care unit at Lucile Packard Children's Hospital underwent a QI project to address hypothermic preterm newborns by staff education and implementing processes such as polyethylene wraps and chemical warming mattresses. We performed retrospective chart review of all inborn infants with birth weight <1500 g during the 18 months prior to (n=134) and 15 months after (n=170) the implementation period. Temperatures were compared between periods. Multivariable logistic regression was used to account for potential confounding variables. We compared mortality rates and grade 3 or 4 intraventricular hemorrhage rates between periods.The mean temperature rose from 35.4 to 36.2 degrees C (P<0.0001) after the QI project. The improvement was consistent and persisted over a 15-month period. After risk adjustment, the strongest predictor of hypothermia was being born in the period before implementation of the QI project (odds ratio 8.12, 95% confidence interval 4.63, 14.22). Although cesarean delivery was a strong risk factor for hypothermia prior to the project, it was no longer significant after the project. There was no significant difference in death or intraventricular hemorrhage detected between periods.There was a significant improvement in admission temperatures after a QI project, which persisted beyond the initial implementation period. Although there was no difference in mortality or intraventricular hemorrhage rates, we did not have sufficient power to detect small differences in these outcomes.
View details for DOI 10.1038/jp.2008.92
View details for Web of Science ID 000260795100005
View details for PubMedID 18580878
Population trends in cesarean delivery for breech presentation in the United States, 1997-2003 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2008; 199 (1)
The objective of the study was to determine whether cesarean delivery for breech has increased in the United States.We calculated cesarean rates for term singletons in breech/malpresentation from 1997 to 2003 using National Center for Health Statistics data. We compared rates by sociodemographic groups and state. Multivariable logistic regression models were constructed to see whether factors associated with cesarean delivery differed over time.Breech cesarean rates increased overall from 83.8% to 85.1%. There was a significant increase in rates for most sociodemographic groups. There was little to no increase for mothers younger than 30 years old. There was wide variability in rates by state, 61.6-94.2% in 1997. Higher breech incidence correlated with lower cesarean rates, suggesting potential state bias in reporting breech.In the United States, breech infants are predominantly born by cesarean. There was a small increase in this trend from 1998 to 2002. There is wide variability by state, which is not explained by sociodemographic patterns and may be due to reporting differences.
View details for DOI 10.1016/j.ajog.2007.11.059
View details for Web of Science ID 000257205200021
View details for PubMedID 18295181
School outcomes of late preterm infants: Special needs and challenges for infants born at 32 to 36 weeks gestation JOURNAL OF PEDIATRICS 2008; 153 (1): 25-31
Because limited long-term outcome data exist for infants born at 32 to 36 weeks gestation, we compared school outcomes between 32- to 33-week moderate preterm (MP), 34-36 week late preterm (LP) and full-term (FT) infants.A total of 970 preterm infants and 13 671 FT control subjects were identified from the Early Childhood Longitudinal Study-Kindergarten Cohort. Test scores, teacher evaluations, and special education enrollment from kindergarten (K) to grade 5 were compared.LP infants had lower reading scores than FT infants in K to first grade (P < .05). Adjusted risk for poor reading and math scores remained elevated in first grade (P < .05). Teacher evaluations of math skills from K to first grade and reading skills from K to fifth grade were worse for LP infants (P < .05). Adjusted odds for below average skills remained higher for math in K and for reading at all grades (P < .05). Special education participation was higher for LP infants at early grades (odds ratio, 1.4-2.1). MP infants had lower test and teacher evaluation scores than FT infants and twice the risk for special education at all grade levels.Persistent teacher concerns through grade 5 and greater special education needs among MP and LP infants suggest a need to start follow-up, anticipatory guidance, and interventions for infants born at 32 to 36 weeks gestation.
View details for DOI 10.1016/j.jpeds.2008.01.027
View details for Web of Science ID 000257154800010
View details for PubMedID 18571530
Ambiguous Genitalia in the Newborn NeoReviews 2008; 9 (2): e78-84
Oropharyngeal atresia in a preterm infant: A case report and review of the literature INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY 2007; 71 (9): 1485-1489
Oropharyngeal atresia is a rare and often fatal condition that presents soon after birth with severe respiratory distress. We present a case of a premature infant who initially was suspected to have tracheo-esophageal atresia due to prenatal ultrasound findings of polyhydramnios and absent stomach bubble, but was found instead to have oropharyngeal atresia and a complete persistent buccopharyngeal membrane. This case is the first described in which the patient was successfully intubated through a small slit in the persistent membrane.
View details for DOI 10.1016/j.ijport.2007.05.026
View details for Web of Science ID 000249164000020
View details for PubMedID 17597231
Diagnosis of patent ductus arteriosus by a neonatologist with a compact, portable ultrasound machine JOURNAL OF PERINATOLOGY 2007; 27 (5): 291-296
To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training.Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist.There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%).A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.
View details for DOI 10.1038/sj.jp.7211693
View details for Web of Science ID 000246105400008
View details for PubMedID 17363908
Postnatal cytomegalovirus infection from frozen breast milk in preterm, low birth weight infants PEDIATRIC INFECTIOUS DISEASE JOURNAL 2007; 26 (3): 276-276
Delivery mode by race for breech presentation in the US JOURNAL OF PERINATOLOGY 2007; 27 (3): 147-153
To determine if there are differential cesarean delivery rates by race and other socio-demographic factors for women with breech infants.We calculated cesarean delivery rates for 186 727 White, African American, Hispanic and Asian women delivering breech singletons with gestational age 26 to 41 weeks born in 1999 and 2000 using data from the National Center for Health Statistics. Multivariable logistic regression was used to determine differences in mode of delivery by race, adjusting for socio-demographic and medical factors.Cesarean rates for breech were >80% in most gestational age groups. In 14 of 18 groups, Whites had higher cesarean delivery rates than African Americans. However, this finding did not persist after risk adjustment. Hispanics were more likely to deliver by cesarean delivery than African Americans and Whites.Breech singleton infants are predominantly born by cesarean delivery. Although African-American women with breech presentation have lower cesarean delivery rates than Whites, this difference is not present after adjusting for socio-demographic and medical factors. Hispanics were more likely to be delivered by cesarean delivery and this difference was amplified after risk adjustment. Asians had slightly lower cesarean rates after risk adjustment, but this varied widely according to Asian subgroup.
View details for DOI 10.1038/sj.jp.7211668
View details for Web of Science ID 000244420900003
View details for PubMedID 17314983
Survival rates and mode of delivery for vertex preterm neonates according to small- or appropriate-for-gestational-age status PEDIATRICS 2006; 118 (6): E1836-E1844
The goal was to characterize the relationship between cesarean section delivery and death for preterm vertex neonates according to intrauterine growth.Maternal and infant data from the National Center for Health Statistics for 1999 and 2000 were analyzed. Neonates with gestational ages of 26 to 36 weeks were characterized as small for gestational age (<10th percentile) or appropriate for gestational age (10th to 90th percentile). Mortality rates at 28 days and relative risks were calculated for each gestational age group according to mode of delivery.Cesarean section rates were higher for small-for-gestational-age neonates compared with appropriate-for-gestational-age neonates, most prominently from 26 weeks to 32 weeks of gestation, at which small-for-gestational-age neonates had cesarean section rates of 50% to 67%, whereas appropriate-for-gestational-age neonates had rates of 22% to 38%. Small-for-gestational-age neonates at gestational ages of <31 weeks had increased survival rates associated with cesarean section, whereas small-for-gestational-age neonates at >33 weeks and appropriate-for-gestational-age neonates overall had decreased survival rates associated with cesarean section. After adjustment for sociodemographic and medical factors, the survival advantage for small-for-gestational-age neonates at gestational ages of 26 to 30 weeks persisted.Cesarean section delivery was associated with survival for preterm small-for-gestational-age neonates but not preterm appropriate-for-gestational-age neonates. We speculate that vaginal delivery may be particularly stressful for small-for-gestational-age neonates. We found no evidence that prematurity alone is a valid indication for cesarean section for preterm appropriate-for-gestational-age neonates.
View details for DOI 10.1542/peds.2006-1327
View details for Web of Science ID 000242478900081
View details for PubMedID 17142505
Survival advantage associated with cesarean delivery in very low birth vertex neonates OBSTETRICS AND GYNECOLOGY 2006; 107 (1): 97-105
To identify the indications for and any survival advantage associated with very low birth weight (VLBW) neonates delivered by cesarean.Maternal and infant data from the National Center for Health Statistics linked birth/death data set for 1999 to 2000 were analyzed. Maternal conditions associated with cesarean delivery were compared among birth weight groups for vertex neonates. Birth weight-specific 28-day mortality rates and relative risks were calculated with 95% confidence intervals. Multivariate logistic regression was performed to adjust for other factors that may be associated with survival.Cesarean delivery occurred frequently, more than 40% in most VLBW birth weight groups. Conditions associated with cesarean delivery in VLBW vertex neonates differed from those seen in non-VLBW vertex neonates. A survival advantage was associated with cesarean delivery in the birth weight analysis up to 1,300 g (P < .05). This decreased mortality for VLBW neonates delivered by cesarean persisted after adjusting for other factors associated with mortality.Very low birth weight vertex neonates are often born by cesarean delivery and have different maternal risk profiles from non-VLBW vertex neonates born by this route. Neonatal mortality was decreased in VLBW neonates delivered by cesarean. Further study is warranted to determine whether this may be a causal relationship or a marker of quality of care.II-2.
View details for Web of Science ID 000234287700016
Visual Diagnosis: A Newborn Who Has Everted Eyelids NeoReviews 2004; 5 (9): e390
Visual Diagnosis: Poor Feeding and Emesis in a 1-day-old Male NeoReviews 2004; 5 (11): e498
Crosslinked hemoglobin inhibits endothelium-dependent relaxations in isolated canine arteries GENERAL PHARMACOLOGY-THE VASCULAR SYSTEM 1996; 27 (2): 239-244
1. Several previous in vivo studies demonstrated that crosslinked hemoglobin is a potent vasoconstrictor capable of significantly increasing arterial blood pressure following systemic administration. The precise mechanisms underlying the vascular effects of crosslinked hemoglobin are not clear. The present study was designed to determine the effect of crosslinked hemoglobin on the endothelial L-arginine-nitric oxide biosynthesis pathway in isolated canine arteries. 2. Isolated femoral and renal arteries were suspended in organ chambers for isometric tension recordings. Endothelium-dependent relaxations to acetylcholine and calcium ionophore A23187 were studied in the absence or in the presence of crosslinked hemoglobin or hemoglobin. A radioimmunoassay technique was used to determine levels of guanosine 3',5'-cyclic monophosphate (cyclic GMP) and adenosine 3',5'-cyclic monophosphate (cyclic AMP). 3. A nitric oxide synthase inhibitor L-NAME (10(-4)M) selectively inhibited endothelium-dependent relaxations to acetylcholine and calcium ionophore A23187. The inhibitory effect of L-NAME was reversed by L-arginine (3 x 10(-4)M). Crosslinked hemoglobin (10(-7), 10(-6) and 10(-5)M) inhibited endothelium-dependent relaxations to acetylcholine (10(-9)-10(-5)M) or A23187 (10(-9)-10(-6)M). In the same concentration range, purified bovine hemoglobin exerted a similar inhibitory effect on relaxations mediated by activation of endothelial cells. Crosslinked hemoglobin (10(-6)M) significantly reduced basal production of cyclic GMP, but did not affect production of cyclic AMP. Acetylcholine (10(-6)M) stimulated production of cyclic GMP. This effect of acetylcholine was abolished in the presence of crosslinked hemoglobin. 4. These studies demonstrate that crosslinked hemoglobin impairs endothelium-dependent relaxations in isolated large conduit arteries. This effect appears to be mediated by the chemical antagonism of crosslinked hemoglobin against nitric oxide released from the endothelium. Inhibition of the endothelial L-arginine-nitric oxide biosynthesis pathway, with subsequent decrease of cyclic GMP in smooth muscle, may help to explain vasoconstrictor and pressor effects of crosslinked hemoglobin.
View details for Web of Science ID A1996UD24400008
View details for PubMedID 8919636