James Jetton

Hypocapnia and other ventilation-related risk factors for cerebral palsy in low birth weight infants.

Ventilatory management patterns in very low birth weight newborns, particularly iatrogenic hypocapnia, have occasionally been implicated in perinatal brain damage. However, such relationships have not been explored in large representative populations. To examine the risk of disabling cerebral palsy in mechanically ventilated very low birth weight infants in relation to hypocapnia and other ventilation-related variables, we conducted a population-based prospective cohort study of 1105 newborns with birth weights of 500–2000 g born in New Jersey from mid-1984 through 1987, among whom 777 of 902 survivors (86%) had at least one neurodevelopmental assessment at age 2 y or older. Six hundred fifty-seven of 777 assessed survivors (85%), of whom 400 had been mechanically ventilated, had blood gases obtained during the neonatal period. Hypocapnia was defined as the highest quintile of cumulative exposure to arterial Pco2 levels <35 mm Hg during the neonatal period. Disabling cerebral palsy was diagnosed in six of 257 unventilated newborns (2.3%), 30 of 320 ventilated newborns without hypocapnia (9.4%), and 22 of 80 ventilated newborns with hypocapnia (27.5%). Two additional ventilatory risk factors for disabling cerebral palsy were found—hyperoxia and prolonged duration of ventilation. In a multivariate analysis, each of the three ventilatory variables independently contributed a 2- to 3-fold increase in risk of disabling cerebral palsy. These risks were additive. Although duration of mechanical ventilation in very low birth weight newborns likely represents severity of illness, both hypocapnia and hyperoxia are largely controlled by ventilatory practice. Avoidance of arterial Pco2 levels <35 mm Hg and arterial Po2 levels >60 mm Hg in mechanically ventilated very low birth weight infants would seem prudent.

Power and sample assessments for tests of hypotheses on cost-effectiveness ratios.

We address the issue of statistical power and sample size for cost-effectiveness studies. Tests of hypotheses on the cost-effectiveness ratio (CER) are constructed from the net cost and incremental effectiveness measures. When the difference in effectiveness is known, we derive formulae for statistical power and sample size assessments for one- and two-sided tests of hypotheses of the CER. We also construct a test of the joint hypothesis of cost-effectiveness and effectiveness and derive an expression connecting power and sample size. Our methods account for the correlation between cost and effectiveness and lead to smaller sample size requirements than comparative methods that ignore the correlation. The implications of our formulae for cost-effectiveness studies are illustrated through numerical examples. When compared with trials designed to demonstrate effectiveness alone, our results indicate that a trial appropriately powered to demonstrate cost-effectiveness might require sample sizes many times greater.

On Parametric Confidence Intervals for the Cost-Effectiveness Ratio

When comparing two competing interventions, confidence intervals for cost-effectiveness ratios (CERs) provide information on the uncertainty in their point estimates. Techniques for constructing these confidence intervals are much debated. We provide a formal comparison of the Fieller, symmetric and Bonferroni methods for constructing confidence intervals for the CER using only the joint asymptotic distribution of the incremental cost and incremental effectiveness of the two interventions being compared. We prove the existence of a finite interval under the Fieller method when the incremental effectiveness is statistically significant. When this difference is not significant the Fieller method yields an unbounded confidence interval. The Fieller interval is always wider than the symmetric interval, but the latter is an approximation to the Fieller interval when the incremental effectiveness is highly significant. The Bonferroni method is shown to produce the widest interval. Because it accounts for the likely correlation between cost and effectiveness measures, and the intuitively appealing relationship between the existence of a bounded interval and the significance of the incremental effectiveness, the Fieller interval is to be preferred in reporting a confidence interval for the CER.

Association of maternal igm concentrations above the median at 15-19 weeks of gestation and early preterm delivery

IgM concentrations greater than the median in maternal serum collected at 15-19 weeks of pregnancy were strongly associated (odds ratio 15.6) with delivery before 29 weeks. Our results suggest that the postulated inflammatory component in the aetiology of very preterm delivery may elicit a measurable maternal humoral response as early as mid-trimester.

Aggressive v Expectant Care of the Extremely Premature Newborn: Outcome and Resource Utilization

Aggressive v Expectant Care of the Extremely Premature Newborn: Outcome and Resource Utilization