Individual and center-level factors affecting mortality among extremely low birth weight infants.

OBJECTIVE: To examine factors affecting center differences in mortality for extremely low birth weight (ELBW) infants. METHODS: We analyzed data for 5418 ELBW infants born at 16 Neonatal Research Network centers during 2006-2009. The primary outcomes of early mortality (≤12 hours after birth) and in-hospital mortality were assessed by using multilevel hierarchical models. Models were developed to investigate associations of center rates of selected interventions with mortality while adjusting for patient-level risk factors. These analyses were performed for all gestational ages (GAs) and separately for GAs <25 weeks and ≥25 weeks. RESULTS: Early and in-hospital mortality rates among centers were 5% to 36% and 11% to 53% for all GAs, 13% to 73% and 28% to 90% for GAs <25 weeks, and 1% to 11% and 7% to 26% for GAs ≥25 weeks, respectively. Center intervention rates significantly predicted both early and in-hospital mortality for infants <25 weeks. For infants ≥25 weeks, intervention rates did not predict mortality. The variance in mortality among centers was significant for all GAs and outcomes. Center use of interventions and patient risk factors explained some but not all of the center variation in mortality rates. CONCLUSIONS: Center intervention rates explain a portion of the center variation in mortality, especially for infants born at <25 weeks' GA. This finding suggests that deaths may be prevented by standardizing care for very early GA infants. However, differences in patient characteristics and center intervention rates do not account for all of the observed variability in mortality; and for infants with GA ≥25 weeks these differences account for only a small part of the variation in mortality.

A proposed method to predict preterm birth using clinical data, standard maternal serum screening, and cholesterol.

OBJECTIVE: The objective of the study was to create a predictive model for preterm birth (PTB) from available clinical data and serum analytes. STUDY DESIGN: Serum analytes and routine pregnancy screening plus cholesterol and corresponding health information were linked to birth certificate data for a cohort of 2699 Iowa women with serum sampled in the first and second trimester. Stepwise logistic regression was used to select the best predictive model for PTB. RESULTS: Serum screening markers remained significant predictors of PTB, even after controlling for maternal characteristics. The best predictive model included maternal characteristics, first-trimester total cholesterol, total cholesterol change between trimesters, and second-trimester alpha-fetoprotein and inhibin A. The model showed better discriminatory ability than PTB history alone and performed similarly in subgroups of women without past PTB. CONCLUSION: Using clinical and serum screening data, a potentially useful predictor of PTB was constructed. Validation and replication in other populations, and incorporation of other measures that identify PTB risk, like cervical length, can be a step toward identifying additional women who may benefit from new or currently available interventions.

Infantile hemangiomas and retinopathy of prematurity: clues to the regulation of vasculogenesis.

UNLABELLED: Retinopathy of prematurity (ROP) and infantile hemangiomas are vascular disorders that may share common mechanisms. This study examined a potential clinical association between these disorders in populations of preterm infants at two hospitals in the USA and Hungary. Clinically collected data from infants with gestational ages less than 32 weeks born between May 1, 2007 and December 31, 2010 seen in the University of Iowa Children's Hospital or the Department of Obstetrics and Gynecology, University of Pécs, were abstracted from electronic medical records and entered into a study database. Demographic and clinical variables were examined as potential covariates to the disorders of interest. Data were initially analyzed by center and then combined through meta-analysis. Six hundred eighty-four subjects were studied: 236 from Pécs and 448 from Iowa. There were no significant demographic differences between populations. Univariate analysis on each study population yielded covariates to ROP in each population, including infantile hemangioma, which were entered into a logistic regression model. These models were combined through random-effects meta-analysis and demonstrated a significant relationship between infantile hemangioma and ROP (odds ratio = 1.84, 95 % confidence interval 1.08-3.12). CONCLUSION: Infantile hemangioma and ROP co-occur in premature infant populations. Further studies are needed to investigate the pathogenesis of both disorders.

No observed association for mitochondrial SNPs with preterm delivery and related outcomes.

BACKGROUND: Preterm delivery (PTD) is the leading cause of neonatal morbidity and mortality. Epidemiologic studies indicate recurrence of PTD is maternally inherited, creating a strong possibility that mitochondrial variants contribute to its etiology. This study examines the association between mitochondrial genotypes and PTD and related outcomes. METHODS: This study combined, through meta-analysis, two case-control, genome-wide association studies: one from the Danish National Birth Cohort Study and one from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. The outcomes of PTD (≤36 wk), very PTD (≤32 wk), and preterm prelabor rupture of membranes (PPROM) were examined. A total of 135 individual single-nucleotide polymorphism (SNP) associations were tested using the combined genome from mothers and neonates (case vs. control) in each population and then pooled via meta-analysis. RESULTS: After meta-analysis, there were four SNPs for the outcome of PTD below P ≤ 0.10 and two below P ≤ 0.05. For the additional outcomes of very PTD and PPROM, there were three and four SNPs, respectively, below P ≤ 0.10. CONCLUSION: Given the number of tests, no single SNP reached study-wide significance (P = 0.0006). Our study does not support the hypothesis that mitochondrial genetics contributes to the maternal transmission of PTD and related outcomes.

Medical tourism services available to residents of the United States.

BACKGROUND: There are growing reports of United States (US) residents traveling overseas for medical care, but empirical data about medical tourism are limited. OBJECTIVE: To characterize the businesses and business practices of entities promoting medical tourism and the types and costs of procedures being offered. DESIGN, PARTICIPANTS, AND OUTCOMES: Between June and August 2008, we conducted a telephone survey of all businesses engaged in facilitating overseas medical travel for US residents. We collected information from each company including: the number of employees; number of patients referred overseas; medical records security processes; destinations to which patients were referred; treatments offered; treatment costs; and whether patient outcomes were collected. RESULTS: We identified 63 medical tourism companies and 45 completed our survey (71%). Companies had a mean of 9.8 employees and had referred an average of 285 patients overseas (a total of approximately 13,500 patients). 35 (79%) companies reported requiring accreditation of foreign providers, 22 (50%) collected patient outcome data, but only 17 (39%) described formal medical records security policies. The most common destinations were India (23 companies, 55%), Costa Rica (14, 33%), and Thailand (12, 29%). The most common types of care included orthopedics (32 companies, 73%), cardiac care (23, 52%), and cosmetic surgery (29, 66%). 20 companies (44%) offered treatments not approved for use in the US--most commonly stem cell therapy. Average costs for common procedures, CABG ($18,600) and knee arthroplasty ($10,800), were similar to previous reports. CONCLUSIONS: The number of Americans traveling overseas for medical care with assistance from medical tourism companies is relatively small. Attention to medical records security and patient outcomes is variable and cost-savings are dependent on US prices. That said, overseas medical care can be a reasonable alternative for price sensitive patients in need of relatively common, elective medical procedures.