David A. Bateman

Dose-response effect of fetal cocaine exposure on newborn neurologic function.

Background. Studies of fetal cocaine exposure and newborn neurologic function have obtained conflicting results. Although some studies identify abnormalities, others find no differences between cocaine-exposed and cocaine-unexposed infants. To determine the effects of prenatal cocaine exposure on intrauterine growth and neurologic function in infants, we prospectively evaluated 253 infants shortly after birth. Methods. Women who delivered a live singleton >36 weeks by dates were eligible for enrollment. Maternal exclusionary criteria were known parenteral drug use, alcoholism, and acquired immunodeficiency syndrome; infant exclusionary criteria were Apgar scores ≤4 at 5 minutes, obvious congenital malformations, seizures, or strokes. A total of 98% of infants were evaluated between 1 to 7 days of age. Newborns were assessed with the Neurological Examination for Children (NEC) by a pediatric neurologist (C.A.C.) who was blinded to exposure status. Gestational age was determined by Ballards examination. Cocaine exposure was determined for the last trimester by radioimmunoassay of maternal hair (RIAH). Exposure values ranged from 2 to 4457 ng/10 mg hair. Infants were excluded if a maternal hair sample was missing (N = 13). The sample comprises 240 woman and infant pairs—104 cocaine-exposed and 136 cocaine-unexposed. Results. Compared with unexposed controls, cocaine-exposed infants exhibited higher rates of intrauterine growth retardation (24% vs 8%), small head circumference ([HC] <10th% percentile) (20% vs 5%) and neurologic abnormalities: global hypertonia (32% vs 11%), coarse tremor (40% vs 15%), and extensor leg posture (20% vs 4%). We found increasing odds (odds ratio) of growth and neurologic impairment with increasing level of cocaine exposure in stratified analyses. The odds ratio associated with three levels of cocaine exposure (no exposure, low exposure = RIAH 2–66 ng/mg; and high exposure = RIAH 81–4457 ng/mg) respectively are: 1.0, 3.3, and 6.1 for small head size (χ2 for trend); 1.0, 3.3, and 4.3 for global hypertonia (χ2 for trend); 1.0, 3.4, and 7.4 for extensor leg posturing (χ2 for trend); and 1.0, 3.8, and 3.8 for coarse tremor (χ2 for trend). Significant associations between cocaine exposure and neurologic signs were found in logistic regression equations that controlled for 20 or more variables. Conclusion. We conclude that adverse neonatal effects associated with fetal cocaine exposure follow a dose–response relationship: newborns with higher levels of prenatal cocaine exposure show higher rates of impairments in fetal head growth and abnormalities of muscle tone, movements, and posture. Significant relationships between cocaine exposure and these outcomes remain in controlled analyses.

The ductus arteriosus rarely requires treatment in infants > 1000 grams.

We sought to determine the rate of spontaneous closure of the ductus arteriosus (DA) in very-low-birth-weight infants. This prospective observational study included 65 infants whose birth weight (BW) < 1500 g. Echocardiograms were done on day of life (DOL) 3 and 7, weekly for the first month, and bimonthly until ligation, discharge, or death. Treatment was reserved for infants with heart failure, acute renal impairment, or those with significant persistent or escalating respiratory support. Chi-square tests, Student T tests, and logistic regression models were used to identify possible associations between spontaneous ductal closure by DOL 7 and predictor variables. Patterns of spontaneous DA closure over time were examined using Kaplan-Meier survival analysis. The DA closed spontaneously in 49% infants by DOL 7. Rates of spontaneous closure by DOL 7 differed significantly by BW strata: 67% for BW > 1000 g, 31% for BW <or= 1000 g ( P < 0.01). Ninety-seven percent of infants > 1000 g did not require intervention, and the DA closed spontaneously prior to discharge in 94%. In a logistic regression model, only BW > 1000 g and male gender were significantly associated with spontaneous closure by 1 week of life. The median time to spontaneous closure differed significantly between infants in the two BW strata: 7 days for > 1000 g versus 56 days for <or= 1000 g ( P < 0.001). Intervention for the patent DA in infants > 1000 g BW is rarely indicated. In infants <or= 1000 g BW, deferring treatment decisions until at least 1 week of life may avoid unnecessary treatment exposure.

Cost-Utility Analysis of Telemedicine and Ophthalmoscopy for Retinopathy of Prematurity Management

OBJECTIVE To evaluate the cost-effectiveness of telemedicine and standard ophthalmoscopy for retinopathy of prematurity (ROP) management. METHODS Models were developed to represent ROP examination and treatment using telemedicine and standard ophthalmoscopy. Cost-utility analysis was performed using decision analysis, evidence-based outcome data from published literature, and present value modeling. Visual outcome data were converted to patient preference-based time trade-off utility values based on published literature. Costs of disease management were determined based on 2006 Medicare reimbursements. Costs per quality-adjusted life year gained by telemedicine and ophthalmoscopy for ROP management were compared. One-way sensitivity analysis was performed on the following variables: discount rate (0%-7%), incidence of treatment-requiring ROP (1%-20%), sensitivity and specificity of ophthalmoscopic diagnosis (75%-100%), percentage of readable telemedicine images (75%-100%), and sensitivity and specificity of telemedicine diagnosis (75%-100%). RESULTS For infants with birth weight less than 1500 g using a 3% discount rate for costs and outcomes, the costs per quality-adjusted life year gained were

Prenatal cocaine exposure and school-age intelligence

3193 with telemedicine and

Reference values of urinary neutrophil gelatinase-associated lipocalin in very low birth weight infants.

5617 with standard ophthalmoscopy. Sensitivity analysis resulted in ranges of costs per quality-adjusted life year from

Inhaled nitric oxide and gentle ventilation in the treatment of pulmonary hypertension of the newborn: a single-center, 5-year experience

1235 to

Packed red blood cell transfusion is an independent risk factor for necrotizing enterocolitis in premature infants

18,898 for telemedicine and from

Urinary Neutrophil Gelatinase-Associated Lipocalin Is a Promising Biomarker for Late Onset Culture-Positive Sepsis in Very Low Birth Weight Infants

2171 to

The hospital cost of congenital syphilis

27,215 for ophthalmoscopy. CONCLUSIONS Telemedicine is more cost-effective than standard ophthalmoscopy for ROP management. Both strategies are highly cost-effective compared with other health care interventions.

Comparison of fluconazole and nystatin oral suspensions for prophylaxis of systemic fungal infection in very low birthweight infants.

Assessments of the possible consequences of prenatal exposure to cocaine have been limited by lack of control for socio-demographic confounders and lack of follow-up into the school years. We evaluated intelligence at ages 6-9 years in 88 children from a cohort of 280 born between September 1, 1985 and August 31, 1986 and identified at birth as cocaine-exposed, and in a group of unexposed (n = 96) births of comparable gender and birthweight. IQ scores did not differ between children with and without prenatal exposure to cocaine (mean 82.9 vs. 82.4, difference = 0.5 points, 95% CI-3.1, 4.1); results were unchanged with adjustment for child height, head circumference and prior residence in a shelter or on the street, and for caregiver IQ and home environment (mean difference = 2.2 points, 95% CI-1.5, 5.8).