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Biomedical subjects

Gabriel J Escobar

Publications and source records attributed to Gabriel J Escobar.

At least 19 recordsLinked to original sources
PubMed2006

Revalidation of the Score for Neonatal Acute Physiology in the Vermont Oxford Network.

OBJECTIVES: Our specific objectives were (1) to document the performance of the revised Score for Neonatal Acute Physiology and the revised Score for Neonatal Acute Physiology Perinatal Extension in predicting death in the Vermont Oxford Network, compared with published normative values; (2) to determine whether this performance could be improved through recalibration of the weights for individual score items; (3) to determine the impact of including congenital anomalies in the predictive model; and (4) to compare performance against that of the Vermont Oxford Network risk adjustment, separately and in combination. METHODS: Fifty-eight Vermont Oxford Network centers collected data prospectively for the revised Score for Neonatal Acute Physiology in the first 12 hours after admission of infants in 2002. RESULTS: Data were collected for 10,469 infants, and analyses were undertaken for 9897 who met inclusion criteria. The median revised Score for Neonatal Acute Physiology was 5, and the mean birth weight was 1951 g. Recalibration of the revised Score for Neonatal Acute Physiology and revised Score for Neonatal Acute Physiology Perinatal Extension resulted in minimal changes in their discriminatory abilities. The Vermont Oxford Network risk adjustment performed similarly, compared with the revised Score for Neonatal Acute Physiology Perinatal Extension. CONCLUSIONS: Current score performance was similar to that observed previously, which suggests that the revised Score for Neonatal Acute Physiology and revised Score for Neonatal Acute Physiology Perinatal Extension have not decalibrated over the 7 years since the first cohort was assembled, despite advances in neonatal care during that period. Addition of congenital anomalies to the revised Score for Neonatal Acute Physiology Perinatal Extension improved discrimination significantly, particularly for infants with birth weights of >1500 g. The Vermont Oxford Network risk adjustment performed similarly, compared with the revised Score for Neonatal Acute Physiology Perinatal Extension.

Apgar Score↗
PubMed2006

Outcomes among newborns with total serum bilirubin levels of 25 mg per deciliter or more.

BACKGROUND: The neurodevelopmental risks associated with high total serum bilirubin levels in newborns are not well defined. METHODS: We identified 140 infants with neonatal total serum bilirubin levels of at least 25 mg per deciliter (428 micromol per liter) and 419 randomly selected controls from a cohort of 106,627 term and near-term infants born from 1995 through 1998 in Kaiser Permanente hospitals in northern California. Data on outcomes were obtained from electronic records, interviews, responses to questionnaires, and neurodevelopmental evaluations that had been performed in a blinded fashion. RESULTS: Peak bilirubin levels were between 25 and 29.9 mg per deciliter (511 micromol per liter) in 130 of the newborns with hyperbilirubinemia and 30 mg per deciliter (513 micromol per liter) or more in 10 newborns; treatment involved phototherapy in 136 cases and exchange transfusion in 5. Follow-up data to the age of at least two years were available for 132 of 140 children with a history of hyperbilirubinemia (94 percent) and 372 of 419 controls (89 percent) and included formal evaluation at a mean (+/-SD) age of 5.1+/-0.12 years for 82 children (59 percent) and 168 children (40 percent), respectively. There were no cases of kernicterus. Neither crude nor adjusted scores on cognitive tests differed significantly between the two groups; on most tests, 95 percent confidence intervals excluded a 3-point (0.2 SD) decrease in adjusted scores in the hyperbilirubinemia group. There was no significant difference between groups in the proportion of children with abnormal neurologic findings on physical examination or with documented diagnoses of neurologic abnormalities. Fourteen of the children with hyperbilirubinemia (17 percent) had "questionable" or abnormal findings on neurologic examination, as compared with 48 controls (29 percent; P=0.05; adjusted odds ratio, 0.47; 95 percent confidence interval, 0.23 to 0.98; P=0.04). The frequencies of parental concern and reported behavioral problems also were not significantly different between the two groups. Within the hyperbilirubinemia group, those with positive direct antiglobulin tests had lower scores on cognitive testing but not more neurologic or behavioral problems. CONCLUSIONS: When treated with phototherapy or exchange transfusion, total serum bilirubin levels in the range included in this study were not associated with adverse neurodevelopmental outcomes in infants born at or near term.

Bilirubin↗
PubMed2006

Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions.

BACKGROUND: Newborns who are 35 to 36 weeks gestation comprise 7.0% of all live births and 58.3% of all premature infants in the United States. They have been studied much less than very low birth weight infants. OBJECTIVE: To examine available data permitting quantification of short-term hospital outcomes among infants born at 35 and 36 weeks gestation. DESIGN: Review of existing published data and, where possible, re-analysis of existing databases or retrospective cohort analyses. SETTING: Multiple hospitals and neonatal intensive care units in the United States and England. PATIENTS: Premature infant cohorts with infants whose dates of birth ranged from 1/1/98 through 6/30/04. MAIN OUTCOME MEASURES: 1) Death, 2) respiratory distress requiring some degree of in-hospital respiratory support during the birth hospitalization, and 3) rehospitalization following discharge home after the birth hospitalization. RESULTS: Newborns born at 35 and 36 weeks gestation experienced considerable mortality and morbidity. Approximately 8% required supplemental oxygen support for at least 1 hour, almost 3 times the rate found in infants born at > or =37 weeks. Among 35 to 36 week newborns who progressed to respiratory failure and who survived to 6 hours of age and did not have major congenital anomalies, the mortality rate was 0.8%. Following discharge from the birth hospitalization, 35 to 36 week infants were much more likely to be rehospitalized than term infants, and this increase was evident both within 14 days as well as within 15 to 182 days after discharge. In addition, late preterm infants experienced multiple therapies, few of which have been formally evaluated for safety or efficacy in this gestational age group. CONCLUSIONS: Greater attention needs to be paid to the management of late preterm infants. In addition, it is important to conduct formal evaluations of the therapies and follow-up strategies employed in caring for these infants.

Adolescent↗
PubMed2006

Place of birth and variations in management of late preterm ("near-term") infants.

BACKGROUND: The purpose of this study is to characterize variations in management late preterm infants because such variations in such a large group of neonates would have economic and health implications. METHODS: Comparison of the use of illustrative management approaches and gestational age at discharge among infants born at 33 to 34 6/7 weeks and discharged alive from 10 Massachusetts and California NICUs. RESULTS: Generally similar in birth weight and admission severity, significant differences were seen in illustrative interventions, such as the use of mechanical ventilation (range in use across hospitals from 9% to 43%) and nutritional practices (use of hyperalimentation ranged from 5% to 66%). Variations in average daily weight gain were seen with some infants averaging net losses. Postmenstrual age at discharge varied by a week between the hospital with the earliest discharge and that with the latest. CONCLUSIONS: Care for these infants would be improved by further examination of their needs and the establishment of practice guidelines to reduce unneeded variation.

California↗
PubMed2005

Prepregnancy health status and the risk of preterm delivery.

BACKGROUND: Despite extensive evaluation, our understanding of risk factors for premature delivery is incomplete. OBJECTIVE: To examine whether a woman's health status and risk factors before pregnancy are associated with a woman's risk of preterm delivery, independent of risk factors that occur during pregnancy. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort of pregnant women in the San Francisco Bay area who delivered a singleton infant (n = 1619). MAIN OUTCOME MEASURE: Preterm delivery (<37 weeks' gestational age). RESULTS: Sociodemographic characteristics alone explained 13.0% of the risk of preterm delivery, whereas risk factors that occurred before pregnancy explained 39.8% and risk factors that occurred during pregnancy explained 47.1%. After we adjusted for sociodemographic characteristics, prepregnancy risk factors, and pregnancy risk factors, women who reported poor physical function during the month before conception were nearly twice as likely to experience a preterm delivery (odds ratio, 1.97; 95% confidence interval, 1.18-3.30) as women with better physical function. CONCLUSION: A broader focus on the health of women prior to pregnancy may improve rates of preterm delivery.

Adolescent↗
PubMed2005

Combining clinical risk factors with serum bilirubin levels to predict hyperbilirubinemia in newborns.

OBJECTIVES: (1) To validate a previously reported risk index for predicting total serum bilirubin (TSB) levels of 25 mg/dL (428 micromol/L) or higher; (2) to combine a subset of this index with TSB levels measured at less than 48 hours to predict subsequent TSB levels of 20 mg/dL (342 micromol/L) or higher. DESIGN: Nested case-control study using electronic and paper records (study 1). Retrospective cohort study using electronic records only (study 2). SETTING: Northern California Kaiser Permanente hospitals. PATIENTS: Subjects for both studies were newborns weighing 2000 g or more and of 36 weeks' or more gestation. The validation study included 67 cases born 1997-1998 who developed TSB levels of 25 mg/dL or higher at less than 30 days and 208 randomly selected control subjects. Subjects for study 2 were 5706 newborns who both were discharged from the hospital and had a TSB level measured at less than 48 hours. RESULTS: The risk index performed similarly in the validation group, born in 1997-1998, and the derivation group, born in 1995-1996 (area under the receiver operating characteristic curve = 0.83 vs 0.84). Of the 5706 newborns with TSB levels measured before 48 hours, 270 (4.7%) developed a TSB level of 20 mg/dL or higher. Of these, 254 (94%) had a TSB level at the 75th percentile or higher at less than 48 hours. The risk index improved prediction over the TSB level alone, largely owing to the effect of gestational age. For example, for those with a TSB level at the 95th percentile or higher at less than 48 hours, the risk increased from 9% for newborns born at 40 weeks' or more gestation to 42% for those born at 36 weeks. CONCLUSION: Clinical risk factors significantly improve prediction of subsequent hyperbilirubinemia compared with early TSB levels alone, especially in those with early TSB levels above the 75th percentile.

Bilirubin↗
PubMed2005

Trends in severe bronchopulmonary dysplasia rates between 1994 and 2002.

OBJECTIVE: To examine temporal trends in the rates of severe bronchopulmonary dysplasia (BPD) between 1994 and 2002. STUDY DESIGN: In a retrospective cohort study, all infants with a gestational age (GA) <33 weeks in a large managed care organization were identified. Annual rates of BPD (defined as an oxygen requirement at 36 weeks corrected GA), severe BPD (defined as respiratory support at 36 weeks corrected GA), and death before 36 weeks corrected GA were examined. RESULTS: Of the 5115 infants in the study cohort, 603 (12%) had BPD, including 246 (4.9%) who had severe BPD. There were 481 (9.5%) deaths before 36 weeks corrected GA. Although the decline in BPD in this period was not significant, the rates of severe BPD declined from 9.7% in 1994 to 3.7% in 2002. Controlling for gestational age, the odds ratio (95% CI) for annual rate of decline in severe BPD was 0.890 (0.841-0.941). Controlling for gestational age, deaths before 36 weeks corrected GA also declined, with the odds ratio (CI) for the annual decline being 0.944 (0.896-0.996). CONCLUSIONS: In this study population, the odds of having of BPD remained constant after controlling for GA. However, the odds of having severe BPD declined on average 11% per year between 1994 and 2002.

Bronchopulmonary Dysplasia↗
PubMed2005

Correlates of prescription drug use during pregnancy.

PURPOSE: To evaluate the extent of prescription drug use and the use of category D or X drugs during pregnancy and examine the maternal characteristics associated with use. METHODS: Medical record and survey data from an observational cohort of pregnant women from 2001 to 2003 (n=1626) were analyzed to examine the use of prescription drugs and the use of category D or X drugs. RESULTS: A majority of these pregnant women were prescribed a prescription drug (56%), and 4% of women were prescribed a category D or X drug. The most common classes of medications prescribed were antibiotics (62%), analgesics (18%), asthma medications (18%), and antiemetics (17%). After adjustment for sociodemographic and clinical characteristics, African American women were more likely to use a prescription drug than white women. Lower levels of educational attainment were also associated with greater use of prescription drugs compared with women who had graduated from college. Women with a chronic health condition, gestational diabetes, a prenatal hospitalization, a history of infertility, or symptoms of acid reflux were also more likely to use a prescription drug than women without these conditions. Nulliparous women and women who were married or living with a partner were less likely to use category D or X drugs during pregnancy than women without these characteristics. Women with a history of infertility and those with a chronic health condition were more likely to use a category D or X drugs during pregnancy than those without these conditions. CONCLUSIONS: The common use of prescription drugs during pregnancy supports the importance of expanding the evidence about the risks and benefits of prescription drug use during pregnancy and suggests the need for systems to safeguard prescribing practices for women of reproductive age.

Adult↗
PubMed2005

Body mass index, provider advice, and target gestational weight gain.

OBJECTIVE: To study the relationships among prepregnancy body mass index (BMI), women's target gestational weight gain, and provider weight gain advice. METHODS: Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women in the San Francisco Bay area. We excluded subjects with preterm birth, multiple gestation, or maternal diabetes. RESULTS: Among overweight women (prepregnancy BMI 26.1-29.0), 24.1% reported a target weight gain above the Institute of Medicine (IOM) guidelines, compared with 4.3% of normal weight women (P < .001). Among women with a low prepregnancy BMI (< 19.8), 51.2% reported a target weight gain below the guidelines, compared with 10.4% of normal weight women (P < .001). These patterns persisted in a multivariate analysis. Latina ethnicity, lower maternal education, low prepregnancy BMI (< 19.8), lack of provider advice about weight gain, and provider advice to gain below guidelines were all independently associated with a target weight gain below IOM guidelines. Prepregnancy BMI more than 26, multiparity, lower age, and provider advice to gain above guidelines were all associated with a target gain above IOM guidelines. CONCLUSION: Women's beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain.

Body Mass Index↗
PubMed2005

Maternal ethnicity, paternal ethnicity, and parental ethnic discordance: predictors of preeclampsia.

OBJECTIVE: To examine the association of maternal and paternal ethnicity as well as parental ethnic discordance with preeclampsia. METHODS: Retrospective cohort study of all low-risk women delivered from 1995 to 1999 within a mature managed care organization. Rates of preeclampsia were calculated for maternal, paternal, and combined ethnicity using both univariate and multivariate analyses. RESULTS: Among the 127,544 low-risk women, when examining maternal ethnicity in a multivariate model controlling for maternal age, parity, education, and gestational age, we found that the rates of preeclampsia were higher among African American (5.2%; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25-1.62) women and lower among Latina (4.0%; OR 0.90, 95% CI 0.84-0.97) and Asian women (3.5%; OR 0.79, 95% CI 0.72-0.88), with all results being statistically significant as compared with white women. When paternal ethnicity was controlled for separately, however, the difference in the rate of preeclampsia among Asian women disappeared, the effect of African-American maternal ethnicity increased slightly (OR 1.49, 95% CI 1.33-1.72), and Asian paternity was found to be associated with the lowest rate of preeclampsia (3.2%; OR 0.76, 95% CI 0.68-0.85). Further, parental ethnic discordance was associated with an increase in the rate of preeclampsia (OR 1.13, 95% CI 1.02 - 1.26). CONCLUSION: We found that rates of preeclampsia were lower with Asian paternal ethnicity. We also found that having a differing paternal and maternal ethnicity was associated with increased rates of preeclampsia. For every 1,000 pregnancies, there would be approximately 10 fewer cases of preeclampsia in the setting of Asian paternity and 5 more cases of preeclampsia in the setting of parental ethnic discordance. These differences may be useful in further investigation of the cause of preeclampsia. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2005

What have we learned from observational studies on neonatal sepsis?

OBJECTIVE: To assess how observational studies on neonatal sepsis can help define the knowledge base required for neonatal randomized, clinical trials. DESIGN: Methodologic review of past observational studies and critical reviews. RESULTS: Observational studies on neonatal sepsis have suffered from important limitations: failure to employ multivariate analyses, considering infection in isolation (ignoring coexisting respiratory distress), failure to provide likelihood ratios for predictors and combinations of predictors, and ignoring the phenomenologic dimension of clinicians' experience. CONCLUSION: Future observational studies must address three key issues. They should begin with a clear analytic and sampling plan that pays careful attention to the proper use and reporting of multivariate analyses. Second, they must explicitly address two subpopulations: critically ill newborns with negative cultures and asymptomatic newborns with positive cultures. Finally, they should be theory driven and provide empirical physiologic data that permit situating their results in the context of the evolving systemic inflammatory response syndrome and PIRO (predisposition, infection, host response, organ dysfunction) models.

Bacteremia↗
PubMed2005

Changes in the health status of women during and after pregnancy.

OBJECTIVE: To characterize the changes in health status experienced by a multi-ethnic cohort of women during and after pregnancy. DESIGN: Observational cohort. SETTING/PARTICIPANTS: Pregnant women from 1 of 6 sites in the San Francisco area (N=1,809). MEASUREMENTS AND MAIN RESULTS: Women who agreed to participate were asked to complete a series of telephone surveys that ascertained health status as well as demographic and medical factors. Substantial changes in health status occurred over the course of pregnancy. For example, physical function declined, from a mean score of 95.2 prior to pregnancy to 58.1 during the third trimester (0-100 scale, where 100 represents better health), and improved during the postpartum period (mean score, 90.7). The prevalence of depressive symptoms rose from 11.7% prior to pregnancy to 25.2% during the third trimester, and then declined to 14.2% during the postpartum period. Insufficient money for food or housing and lack of exercise were associated with poor health status before, during, and after pregnancy. CONCLUSIONS: Women experience substantial changes in health status during and after pregnancy. These data should guide the expectations of women, their health care providers, and public policy.

Adolescent↗
PubMed2004

Rehospitalization in the first year of life among infants with bronchopulmonary dysplasia.

OBJECTIVE: To describe rates and identify risk factors for rehospitalization during the first year of life among infants with bronchopulmonary dysplasia (BPD). STUDY DESIGN: This was a retrospective cohort study of infants born at a gestational age (GA) <33 weeks, between 1995 and 1999. BPD was defined as requirement of supplemental oxygen and/or mechanical ventilation at 36 weeks' corrected GA. The outcome was rehospitalization for any reason before first birthday. RESULTS: In the first year of life, 118 of 238 (49%) infants with BPD were rehospitalized, more than twice the rate of rehospitalization of the non-BPD population, which was 309 of 1359 (23%) (P=<.0001). No measured factor discriminated between those infants with BPD who were and were not rehospitalized, even when only rehospitalizations for respiratory diagnoses were considered. CONCLUSIONS: Among premature infants, BPD substantially increases the risk of rehospitalization during the first year of life. Neither demographic nor physiologic factors predicted rehospitalization among the infants with BPD. Other factors, such as air quality of home environment, passive smoking exposure, respiratory syncytial virus prophylaxis, breast-feeding status, and/or parenting and primary care management styles, should be examined in future studies.

Bronchopulmonary Dysplasia↗
PubMed2004

Richardson score predicts short-term adverse respiratory outcomes in newborns >/=34 weeks gestation.

OBJECTIVES: To develop a model to predict which newborns >/=34 weeks gestation with respiratory distress will die or will require prolonged (>3 days) assisted ventilation. METHODS: Retrospective cohort study using data from Northern California newborns >/=34 weeks gestation who presented with respiratory distress. We split the cohort into derivation and validation datasets. Bivariate and multivariate data analyses were performed on the derivation dataset. After developing a simple score on the derivation dataset, we applied it to the original as well as to a second validation dataset from Massachusetts. RESULTS: Of 2276 babies who met our initial eligibility criteria, 203 (9.3%) had the primary study outcome (assisted ventilation >3 days or death). A simple score based on gestational age, the lowest PaO 2 /FIO 2 , a variable combining lowest pH and highest PaCO 2 , and the lowest mean arterial blood pressure had excellent performance, with a c-statistic of 0.85 in the derivation dataset, 0.80 in the validation dataset, and 0.80 in the secondary validation dataset. CONCLUSIONS: A simple objective score based on routinely collected physiologic predictors can predict respiratory outcomes in infants >/=34 weeks gestation with respiratory distress.

Continuous Positive Airway Pressure↗
PubMed2004

Perinatal stroke in children with motor impairment: a population-based study.

OBJECTIVE: Risk factors for perinatal arterial stroke (PAS) are poorly understood. Most previous studies lack an appropriate control group and include only infants with symptoms in the newborn period. We set out to determine prenatal and perinatal risk factors for PAS. METHODS: In a population-based, case-control study nested within the cohort of 231 582 singleton infants who were born at >or=36 weeks' gestation in Northern California Kaiser hospitals from 1991 to 1998, we searched electronically for children with motor impairment and reviewed their medical records to identify diagnoses of PAS. Control subjects were randomly selected from the study population. A medical record abstractor reviewed delivery records without knowledge of case status. RESULTS: The prevalence of PAS with motor impairment was 17/100,000 live births. Of 38 cases, 26 (68%) presented after 3 months of age with hemiparesis or seizures. All 12 newborns with acute stroke symptoms had seizures. A delayed presentation was more common in children with moderate to severe motor impairment than among infants with only mild motor abnormalities (24 of 31 vs 2 of 7). Prepartum risk factors significantly associated with PAS in multivariate analysis were preeclampsia (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.1-11.4) and intrauterine growth restriction (OR: 5.3; 95% CI: 1.5-18.6). Newborns with PAS were also at higher risk of delivery complications, such as emergency cesarean section (OR: 6.8; 95% CI: 2.7-16.6), 5-minute Apgar <7 (OR: 23.6; 95% CI: 4.1-237), and resuscitation at birth (OR: 4.5; 95% CI: 1.6-12.3). CONCLUSIONS: Preeclampsia and intrauterine growth restriction (IUGR) may be independent risk factors for perinatal stroke resulting in motor impairment. Large multicenter studies that include all children with perinatal stroke are needed to determine further the risk factors and outcome of perinatal stroke.

Age of Onset↗
PubMed2003

Chorioamnionitis and cerebral palsy in term and near-term infants.

CONTEXT: Half of all cases of cerebral palsy (CP) occur in term infants, for whom risk factors have not been clearly defined. Recent studies suggest a possible role of chorioamnionitis. OBJECTIVE: To determine whether clinical chorioamnionitis increases the risk of CP in term and near-term infants. DESIGN, SETTING, AND PATIENTS: Case-control study nested within a cohort of 231 582 singleton infants born at 36 or more weeks' gestation between January 1, 1991, and December 31, 1998, in the Kaiser Permanente Medical Care Program, a managed care organization providing care for more than 3 million residents of northern California. Case patients were identified from electronic records and confirmed by chart review by a child neurologist, and comprised all children with moderate to severe spastic or dyskinetic CP not due to postnatal brain injury or developmental abnormalities (n = 109). Controls (n = 218) were randomly selected from the study population. MAIN OUTCOME MEASURE: Association between clinical chorioamnionitis and increased risk of CP in term and near-term infants. RESULTS: Most CP cases had hemiparesis (40%) or quadriparesis (38%); 87% had been diagnosed by a neurologist and 83% had undergone neuroimaging. Chorioamnionitis, considered present if a treating physician made a diagnosis of chorioamnionitis or endometritis clinically, was noted in 14% of cases and 4% of controls (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.5-10.1; P =.001). Independent risk factors identified in multiple logistic regression included chorioamnionitis (OR, 4.1; 95% CI, 1.6-10.1), intrauterine growth restriction (OR, 4.0; 95% CI, 1.3-12.0), maternal black ethnicity (OR, 3.6; 95% CI, 1.4-9.3), maternal age older than 25 years (OR, 2.6; 95% CI, 1.3-5.2), and nulliparity (OR, 1.8; 95% CI, 1.0-3.0). The population-attributable fraction of chorioamnionitis for CP is 11%. CONCLUSION: Our data suggest that chorioamnionitis is an independent risk factor for CP among term and near-term infants.

Asphyxia Neonatorum↗