A predictive model for perinatal hypoxic ischemic encephalopathy using linked maternal and neonatal hospital data.

PURPOSE: To build an evidence-based model to estimate case-specific risk of perinatal hypoxic ischemic encephalopathy. METHODS: A retrospective, cross-sectional study of all births in Hawaii, Michigan, and New Jersey between 2010 and 2015, using linked maternal labor/delivery and neonatal birth records. Stepwise logistic regression and competitive Akaike information criterion were used to identify the most parsimonious model. Predictive ability of the model was measured with bootstrapped optimism-adjusted area under the ROC curve. RESULTS: Among 836,216 births there were 376 (0.45 per 1000) cases of hypoxic ischemic encephalopathy. The final model included 28 variables, 24 associated with increased risk, and 4 that were protective. The optimism-adjusted area under the ROC curve was 0.84. Estimated risk in the study population ranged from 1 in ∼323,000 to 1 in 2.5. The final model confirmed known risk factors (e.g., sentinel events and shoulder dystocia) and identified novel risk factors, such as maternal race and insurance status. CONCLUSION: Our study shows that risk of perinatal hypoxic ischemic encephalopathy injury can be estimated with high confidence. Our model fills a notable gap in the study of hypoxic ischemic encephalopathy prevention: the estimation of risk, particularly in the United States population which is unique with respect to racial and socioeconomic disparities.

Response to "Scrutinizing the causal link between excited delirium syndrome and restraint - a commentary on: 'The role of restraint in fatal excited delirium: a research synthesis and pooled analysis' by E.M.F. Strömmer, W. Leith, M.P. Zeegers and M.D. Freeman".

de Boer et al. criticize the conclusions in our 2020 paper on the validity of Excited Delirium Syndrome (ExDS) as "egregiously misleading." Our conclusion was that there "is no existing evidence that indicates that ExDS is inherently lethal in the absence of aggressive restraint." The basis for de Boer and colleague's criticism of our paper is that the ExDS literature does not provide an unbiased view of the lethality of the condition, and therefore the true epidemiologic features of ExDS cannot be determined from what has been published. The criticism is unrelated to the goals or methods of the study, however. Our stated purpose was to investigate "how the term ExDS has evolved in the literature and been endowed with a uniquely lethal quality," and whether there is "evidence for ExDS as a unique cause of a death that would have occurred regardless of restraint, or a label used when a restrained and agitated person dies, and which erroneously directs attention away from the role of restraint in explaining the death." We cannot fathom how de Boer et al. missed this clearly stated description of the study rationale, or why they would endorse a series of fallacious and meaningless claims that gave the appearance that they failed to grasp the basic design of the study. We do acknowledge and thank these authors for pointing out 3 minor citation errors and an equally minor table formatting error (neither of which altered the reported results and conclusions in the slightest), however.

Estimating the number of traffic crash-related cervical spine injuries in the United States; An analysis and comparison of national crash and hospital data.

BACKGROUND: Cervical spine injury is a common result of traffic crashes, and such injuries range in severity from minor (i.e. sprain/strain) to moderate (intervertebral disk derangement) to serious and greater (fractures, dislocations, and spinal cord injuries). There are currently no reliable estimates of the number of crash-related spine injuries occurring in the US annually, although several publications have used national crash injury samples as a basis for estimating the frequency of both cervical and lumbar spinal disk injuries occurring in lower speed rear impact crashes. PURPOSE: To develop a reliable estimate of the number of various types of cervical spine injuries occurring in the US by comparing data from national crash injury to national hospital ED and inpatient samples. STUDY DESIGN: Comparative cross-sectional METHODS: Cervical spine injury data were accessed, analyzed, and compared from 3 national databases; the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS), Nationwide Emergency Department Sample (NEDS), and the Nationwide Inpatient Sample (NIS). RESULTS: It is estimated that there are approximately 869,000 traffic crash-related cervical spine injuries seen in hospitals in the US annually, including around 841,000 sprain/strain (whiplash) injuries, 2800 spinal disk injuries, 23,500 fractures, 2800 spinal cord injuries, and 1500 dislocations. Because of a highly restrictive inclusion criteria for both crash and injury types, as well as a very small sample size, the NASS-CDS underestimated all types of crash-related cervical spine injuries seen in US hospital emergency departments by 84 %. The injury type with the largest degree of underestimation in the NASS-CDS was cervical disk injuries, which were estimated at an 88 % lower frequency than in the NEDS. National insurance claim data, which include cases of cervical disk injury diagnosed both in and outside of the ED, indicate that the NEDS likely undercounts cervical disk injuries by 92 %, and thus the NASS-CDS correspondingly undercounts such injuries by 99 % or more. CONCLUSIONS: Because of a limited sample size and restrictive criteria for both crash and injury inclusion, the NASS-CDS cannot be used to estimate the number of crash-related spinal injuries of any type or severity in the US. The most inappropriate use of the database is for estimating the number of spinal injuries resulting from low speed rear impact collisions, as the NASS-CDS samples fewer than 1 in 100,000 of the cervical spine injuries of any type occurring in low speed rear impact collisions.

Diagnostic Accuracy of Videofluoroscopy for Symptomatic Cervical Spine Injury Following Whiplash Trauma.

BACKGROUND: Intervertebral instability is a relatively common finding among patients with chronic neck pain after whiplash trauma. Videofluoroscopy (VF) of the cervical spine is a potentially sensitive diagnostic tool for evaluating instability, as it offers the ability to examine relative intervertebral movement over time, and across the entire continuum of voluntary movement of the patient. At the present time, there are no studies of the diagnostic accuracy of VF for discriminating between injured and uninjured populations. METHODS: Symptomatic (injured) study subjects were recruited from consecutive patients with chronic (>6 weeks) post-whiplash pain presenting to medical and chiropractic offices equipped with VF facilities. Asymptomatic (uninjured) volunteers were recruited from family and friends of patients. An ethical review and oversight were provided by the Spinal Injury Foundation, Broomfield, CO. Three statistical models were utilized to assess the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of positive VF findings to correctly discriminate between injured and uninjured subjects. RESULTS: A total of 196 subjects (119 injured, 77 uninjured) were included in the study. All three statistical models demonstrated high levels of sensitivity and specificity (i.e., receiver operating characteristic (ROC) values of 0.71 to 0.95), however, the model with the greatest practical clinical utility was based on the number of abnormal VF findings. For 2+ abnormal VF findings, the ROC was 0.88 (93% sensitivity, 79% specificity) and the PPV and NPV were both 88%. The highest PPV (1.0) was observed with 4+ abnormal findings. CONCLUSIONS: Videofluoroscopic examination of the cervical spine provides a high degree of diagnostic accuracy for the identification of vertebral instability in patients with chronic pain stemming from whiplash trauma.

The association between gabapentin and suicidality in bipolar patients.

The aims of this study were to assess the association between gabapentin and suicidality in patients diagnosed with bipolar disorder (BD) and to determine whether the risk is greater relative to patients prescribed lithium. This retrospective observational study utilizes US population-based claims data assembled by PharMetrics Inc., comprising 47 918 patients diagnosed with BD. Patients were included if they were at least 18 years old and initiated a new monotherapy prescription of either gabapentin (n=2421) or lithium (n=3101). Patients were followed for up to 1 year. Gabapentin patients contributed 915.8 person-years (PY) of follow-up time; lithium patients contributed 1421.3 PY. There were 21 suicide/self-harm events in the gabapentin group and 16 in the lithium group. Unadjusted incidence rates were 22.9 and 11.3/1000 PY in the gabapentin and lithium groups, respectively (P=0.03). After adjusting for concomitant medications, comorbid diagnoses, age, sex, and history of suicide/self-harm, the hazard ratio was 2.3 (95% confidence interval: 1.2-4.5). A propensity score-matched analysis accounting for pre-existing illnesses and medications supports this finding, with an adjusted hazard ratio of 2.1 (95% confidence interval: 1.02-4.5). Relative to lithium, the use of gabapentin is significantly associated with a doubling of the risk of suicidality in patients diagnosed with BD.

A multistate population-based analysis of linked maternal and neonatal discharge records to identify risk factors for neonatal brachial plexus injury.

OBJECTIVE: To evaluate the interaction and contribution of maternal and fetal risk factors associated with neonatal brachial plexus injury (BPI). METHODS: In a case-control study, matched maternal and neonatal discharge records were accessed from US State Inpatient Databases for New Jersey (2010-2012), Michigan (2010-2011), and Hawaii (2010-2011). Univariate and multivariate logistic regressions were used to evaluate associations between risk factors and BPI. Area under the receiver operating characteristic curve was used to build predictive models, including two stratified models evaluating deliveries among obese and diabetic cohorts. RESULTS: Among 376 325 deliveries, BPI was diagnosed in 274 (0.1%). Significant BPI risk factors included maternal obesity (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.7-4.4), maternal diabetes (OR 4.6, 95% CI 3.0-7.0), use of forceps (OR 4.6, 95% CI 2.3-9.0), and vacuum assistance (OR 2.3, 95% CI 1.7-3.3). After adjusting for shoulder dystocia and other predictive factors, cesarean reduced the risk of BPI by 88% (OR 0.1, 95% CI 0.07-0.2). When stratified by obesity and diabetes, the ORs for BPI increased significantly for macrosomia, forceps, and vacuum assistance. CONCLUSION: The analysis confirms and quantifies more precisely the impact of risk factors for neonatal BPI, and provides a reliable basis for evidence-based clinical decision-making models.

Personal health record use for children and health care utilization: propensity score-matched cohort analysis.

OBJECTIVES: To examine the association between caregiver personal health record (PHR) use and health care utilization by pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective observational cohort study of 2286 pediatric members aged six months to 2.5 years of Kaiser Permanente Hawaii and Northwest Regions in 2007-2011, using propensity score matching methods and t and chi-square tests to examine associations between PHR use and health care utilization. We used ANOVA to examine utilization across quartiles of PHR use. MAIN OUTCOME MEASURES: Outpatient clinic visits, telephone encounters, and emergency department visits. RESULTS: PHR-registered children, compared with propensity score-matched nonregistered children, had 21% (95% CI, 14-28; P < .0001) more outpatient clinic visits and 26% (95% CI, 16-37; P < .0001) more telephone encounters. Utilization differences were more pronounced with nonprimary care providers than with primary care providers. Outpatient clinic visits and telephone encounters increased among the quartile with the highest PHR use; no utilization differences occurred in the 3 lowest-use quartiles. CONCLUSIONS: PHR use by caregivers was associated with statistically significant increases in outpatient clinic visits and telephone encounters among pediatric patients.