Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants. (1/381)

OBJECTIVE: To evaluate the effectiveness of one rather than two hospital neonatal examinations in detection of abnormalities. DESIGN: Randomised controlled switchback trial. SETTING: Postnatal wards in a teaching hospital in north east Scotland. PARTICIPANTS: All infants delivered at the hospital between March 1993 and February 1995. INTERVENTION: A policy of one neonatal screening examination compared with a policy of two. MAIN OUTCOME MEASURES: Congenital conditions diagnosed in hospital; results of community health assessments at 8 weeks and 8 months; outpatient referrals; inpatient admissions; use of general practioner services; focused analysis of outcomes for suspected hip and heart abnormalities. RESULTS: 4835 babies were allocated to receive one screening examination (one screen policy) and 4877 to receive two (two screen policy). More congenital conditions were suspected at discharge among babies examined twice (9.9 v 8.3 diagnoses per 100 babies; 95% confidence interval for difference 0.3 to 2.7). There was no overall significant difference between the groups in use of community, outpatient, or inpatient resources or in health care received. Although more babies who were examined twice attended orthopaedic outpatient clinics (340 (7%) v 289 (6%)), particularly for suspected congenital dislocation of the hip (176 (3.6/100 babies) v 137 (2.8/100 babies); difference -0.8; -1.5 to 0.1), there was no significant difference in the number of babies who required active management (12 (0.2%) v 15 (0.3%)). CONCLUSIONS: Despite more suspected abnormalities, there was no evidence of net health gain from a policy of two hospital neonatal examinations. Adoption of a single examination policy would save resources both during the postnatal hospital stay and through fewer outpatient consultations.  (+info)

Using perinatal audit to promote change: a review. (2/381)

Close to half of all infant deaths world-wide now occur in the first week of life, almost all in developing countries, and the perinatal mortality rate (PNMR) is used as an indicator of the quality of health service delivery. Clinical audit aims to improve quality of care through the systematic assessment of practice against a defined standard, with a view to recommending and implementing measures to address specific deficiencies in care. Perinatal outcome audit evaluates crude or cause-specific PNMRs, reviewing secular trends over several years or comparing rates between similar institutions. However, the PNMR may not be a valid, reliable and sensitive indicator of quality of care at the institutional level in developing countries because of variations in the presenting case-mix, various confounding non-health service factors and the small number of deaths which occur. Process audit compares actual practice with standard (best) practice, based on the evidence of research or expert consensus. Databases reviewing the management of reproductive health problems in developing countries are currently being prepared so as to provide clinicians and health service managers with up-to-date information to support the provision of evidence-based care. Standard practice should be adapted and defined in explicit management guidelines, taking into account local resources and circumstances. Forms of process audit include the review of care procedures in cases which have resulted in a pre-defined adverse outcome, know as 'sentinel event audit'; and the review of all cases where a particular care activity was received or indicated, known as 'topic audit'. These are complementary and each depends on the quality of recorded data. The forum for comparing observed practice with the standard may be external, utilising an 'expert committee', or internal, in which care providers audit their own activities. Local internal audit is more likely to result in improvements in care if it is conducted in a structured and culturally sensitive way, and if all levels of staff are involved in reviewing activities and in formulating recommendations. However, further research is needed to identify the factors which determine the effectiveness and sustainability of perinatal audit in different developing country settings.  (+info)

The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system. (3/381)

The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs.  (+info)

Can children's health be predicted by perinatal health? (4/381)

BACKGROUND: The purpose of this paper was to investigate how well children's health until age 7 years can be predicted by perinatal outcome using routine health registers. METHODS: Follow-up of one year cohort (N = 60192) was performed by record linkages with personal identification number. The data came from the 1987 Finnish Medical Birth Register, from six other national registers and from education registers of one county. RESULTS: All perinatal health indicators showed a strong correlation with subsequent health, and prediction of good health was satisfactory: 85% of children who were healthy in the perinatal period did not have any reported health problems in early childhood, and 91% of children healthy in early childhood had been healthy in the perinatal period. However, it was not possible to predict poor health outcome: 76% of the children with reported perinatal problems were healthy in early childhood, and 87% of the children with long-term morbidity in childhood did not have any perinatal problems. CONCLUSIONS: Our findings suggest that in assessing risk factors and health care technology, monitoring perinatal health is not enough and long-term follow-ups are needed.  (+info)

Viral load and CD69 molecule expression on freshly isolated and cultured mitogen-stimulated lymphocytes of children with perinatal HIV-1 infection. (5/381)

HIV-1 in adults changes the proportion of mitogen-stimulated lymphocytes expressing the CD69 activation molecule, but little is known about this molecule expression on lymphocytes of HIV-1-infected (HIV-1+) children. Freshly isolated CD3+, CD4+, CD8+ and CD19+ and phytohaemagglutinin (PHA)-stimulated CD3+, CD4+ and CD8+ lymphocytes co-expressing CD69 were investigated cross-sectionally (adopting a MoAb double-staining technique) in 24 HIV-1+ children with severe disease and given anti-retroviral therapy and in 24 age-matched healthy children. CD69 results in HIV-1+ children were correlated with plasma HIV-1 RNA load prospectively determined. HIV-1+ compared with healthy children had higher frequencies of freshly isolated CD3+CD69+ (2.4 +/- 2.2% versus 0.9 +/- 0.5%; P = 0.002) and CD8+CD69+ (1.5 +/- 1.1% versus 0. 5 +/- 0.2%; P < 0.0001) lymphocytes. The frequencies of CD4+CD69+ and CD19+CD69+ lymphocytes were similar. High viral load correlated with an elevated proportion of freshly isolated CD3+CD69+ and CD8+CD69+ lymphocytes. HIV-1+ children showed reduced frequencies of PHA-stimulated CD3+CD69+ (60.7 +/- 7.6% versus 86.1 +/- 7.6%; P < 0. 001), CD4+CD69+ (73.6 +/- 18.2% versus 92.6 +/- 5.1%; P < 0.001), and CD8+CD69+ (51.0 +/- 19.1% versus 65.3 +/- 15.4%; P = 0.007) lymphocytes. Virologic worsening within 6 months correlated with a low proportion of PHA-stimulated CD3+CD69+ and CD8+CD69+ lymphocytes. CD69 molecule expression reflected the coexistence of immune activation and immune deficiency in HIV-1 infection. Changes partly differed from those observed in HIV-1+ adults. CD8+CD69+ (but not CD4+CD69+) lymphocyte proportion correlated with virologic course, and an impaired ability of CD8+ lymphocytes to express CD69 upon PHA stimulation preceded a virologic worsening.  (+info)

Innovative methods for monitoring perinatal health outcomes in cities and in smaller geographic areas. (6/381)

OBJECTIVES: Monitoring health in small localities such as cities or local communities is important, because rates of adverse outcomes often vary widely by geographic area. This article explores the utility of CUSUM (cumulative summation), a method developed and refined in industry, for monitoring health outcomes in cities and smaller geographic areas. METHODS: CUSUM monitoring methods were applied to rates of late or no prenatal care initiation and very low birthweight for the city of Baltimore as a whole and for a cluster of high-risk areas within the city. The performance of supplementary runs criteria was also assessed. The ability of both methods to flag significant increases or decreases in prenatal care initiation and very low birthweight rates was assessed. RESULTS: CUSUM and runs criteria detected most significant rate changes. The 2 methods performed better in regard to outcomes with higher prevalence and in larger geographic areas. CONCLUSIONS: CUSUM methods are convenient and reliable for use in the monitoring of moderately low prevalence outcomes in small geographic areas. Future research should examine their applicability to other health outcomes and further refine these methods, especially for rarer outcomes.  (+info)

A polymorphism in the regulatory region of the CC-chemokine receptor 5 gene influences perinatal transmission of human immunodeficiency virus type 1 to African-American infants. (7/381)

There are natural mutations in the coding and noncoding regions of the human immunodeficiency virus type 1 (HIV-1) CC-chemokine coreceptor 5 (CCR5) and in the related CCR2 protein (the CCR2-64I mutation). Individuals homozygous for the CCR5-Delta32 allele, which prevents CCR5 expression, strongly resist HIV-1 infection. Several genetic polymorphisms have been identified within the CCR5 5' regulatory region, some of which influence the rate of disease progression in adult AIDS study cohorts. We genotyped 1,442 infants (1,235 uninfected and 207 HIV-1 infected) for five CCR5 and CCR2 polymorphisms: CCR5-59353-T/C, CCR5-59356-C/T CCR5-59402-A/G, CCR5-Delta32, and CCR2-64I. The clinical significance of each genotype was assessed by measuring whether it influenced the rate of perinatal HIV-1 transmission among 667 AZT-untreated mother-infant pairs (554 uninfected and 113 HIV-1 infected). We found that the mutant CCR5-59356-T allele is relatively common in African-Americans (20.6% allele frequency among 552 infants) and rare in Caucasians and Hispanics (3.4 and 5.6% of 174 and 458 infants, respectively; P < 0.001). There were 38 infants homozygous for CCR5-59356-T, of whom 35 were African-Americans. Among the African-American infants in the AZT-untreated group, there was a highly significant increase in HIV-1 transmission to infants with two mutant CCR5-59356-T alleles (47.6% of 21), compared to those with no or one mutant allele (13.4 to 14.1% of 187 and 71, respectively; P < 0.001). The increased relative risk was 5.9 (95% confidence interval, 2.3 to 15.3; P < 0.001). The frequency of the CCR5-59356-T mutation varies between population groups in the United States, a low frequency occurring in Caucasians and a higher frequency occurring in African-Americans. Homozygosity for CCR5-59356-T is strongly associated with an increased rate of perinatal HIV-1 transmission.  (+info)

New uses of legacy systems: examples in perinatal care. (8/381)

In this article, new uses of the Perinatal Information System at the Uruguayan Social Security health care facilities are described. The perinatal information system has been in place for over 13 years, with about 40 thousand clinical records on electronic files. A newly created Web interface allows a distributed access to existing perinatal information within the National Social Security Wide Area a Network. Perinatal data is also exported to a management information system, allowing to dynamically answer questions and make managerial decisions, and eventually link these data with other sources. Future steps regarding clinical information systems are outlined.  (+info)

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