Occurrence and Treatment of Pediatric Appendicitis in Finland 2004-2014.

BACKGROUND: We aimed to investigate the trends in occurrence and the treatment approaches of appendicitis in Finnish children. MATERIAL AND METHODS: All patients aged <16 y hospitalized for appendicitis in Finland in 2004-2014 were included. Data were retrospectively collected from the Finnish Care Register for Health Care and Statistics Finland. RESULTS: Altogether 8494 children were hospitalized for appendicitis, with standardized incidence rate of 80.7 (95% confidence interval 79.0-82.0)/100,000 person years. The incidence rate of appendicitis decreased by 3.3% per year during the study period. Appendicitis was more common with increasing age, in boys compared to girls at 8 to 15 y of age, and during the summer compared to the other seasons. Most children (83.2%) were treated with conventional open appendectomy, but laparoscopic appendectomies were slowly increasing during the study period. The length of hospital stay (LOS) was shorter in boys than girls, in those treated laparoscopically, and in those with uncomplicated appendicitis. There was no significant seasonal variation in the LOS. However, the LOS decreased during the study period. CONCLUSIONS: The incidence of pediatric appendicitis is decreasing, and there is a decreasing trend in LOS. While still relatively rare in the Finnish pediatric surgical centers, the use of laparoscopic appendectomy is increasing.

Health-related quality of life in very low birth weight children at nearly eight years of age.

AIM: This study examined the impact of prematurity-related morbidity on the health-related quality of life (HRQoL) of premature children at eight years of age, compared to term born controls of same age. METHODS: We focused on 155 premature, very low birth weight (VLBW) infants weighing up to 1500 g who were born from 2001 to 2006 in Turku University Hospital, Finland, and compared them with 129 full-term controls. Cognitive development and length was assessed at five years of age and the children self-reported 17 dimensions of HRQoL at eight years of age. The VLBW group was subdivided into healthy children and those with prematurity-related morbidities. RESULTS: Our findings showed that 64.5% of the VLBW children did not have prematurity-related morbidities. The HRQoL of the healthy preterm VLBW children was very good and did not differ significantly from the controls. However, the VLBW children with one or more morbidities had significantly lower scores in nine of the 17 HRQoL dimensions than the children in the control group. CONCLUSION: The majority of the VLBW children survived without prematurity-related morbidities, and their HRQoL was very good and similar to the control children. The main goal of neonatal care for preterm infants should be to prevent long-term morbidities.

5-year morbidity among very preterm infants in relation to level of hospital care.

OBJECTIVE: To determine whether birth and care in the highest-level hospitals (level III) compared with birth in or postnatal transfer to lower-level hospitals (level II) are associated with 5-year morbidity in very preterm children. DESIGN: A cohort study. SETTING: Finland. PARTICIPANTS: All surviving 5-year-old children born very preterm (gestational age <32 weeks or birth weight ≤1500 g) born in level II or level III hospitals (n = 2168) and full-term (gestational age, 37-42 weeks) children (n = 238 857) born from January 1, 2000, through December 31, 2004. MAIN OUTCOME MEASURES: Diagnoses issued after the first discharge home and overrepresented in very preterm compared with full-term children. Diagnoses were analyzed between very preterm children (1) born and treated in level III hospitals (group III), (2) born in level III and transferred to lower-level hospitals (group III/II), and (3) born and treated in level II hospitals (group II). RESULTS: Group III/II children had an increased incidence of retinal disorders (odds ratio, 2.43 [95% CI, 1.66-3.56]) and asthma (1.41 [1.09-1.81]) but fewer viral infections (0.75 [0.59-0.95]) compared with group III infants. The risks for epilepsy (odds ratio, 2.71 [95% CI, 1.29-5.70]) and hyperkinetic disorders (2.19 [1.13-4.25]) were higher among group II than among group III children. No statistically significant differences between the groups for the 14 other diagnoses were found. CONCLUSIONS: The increased incidence of retinopathy and asthma among infants transferred from level III to lower-level hospitals calls for analysis of the differences in treatment practices between hospital levels.

PERFECT preterm infant study.

INTRODUCTION: This article summarizes the main findings of the preterm infant sub-study of the Performance, Effectiveness and Costs of Treatment episodes (PERFECT) study. We studied effects of birth hospital level and time of birth on mortality and morbidity and cost-effectiveness of care of very low gestational age (VLGA)/very low birth weight (VLBW) infants. MATERIAL AND METHODS: The study included all infants born below 32 weeks or 1501 g in Finland in 2000-2007. Different cohorts were used depending on the time point. RESULTS: The one-year mortality of live-born VLBW/VLGA infants was higher if born in level II versus level III hospitals, or if born during out-of-office hours in level II versus office hours in level III hospitals. Two out of three VLGA/VLBW subjects did not have any of the prematurity-related morbidities studied. The average cost of quality-adjusted life years was €19,245 by four years of age; the cost was higher in VLGA/VLBW infants with long-term morbidities. DISCUSSION: Birth in a level III hospital improved survival of VLGA/VLBW infants. Results suggest inadequate overnight competence in small hospitals. Despite high initial costs, care of VLGA/VLBW infants was already cost-effective by four years of age. Cost-effectiveness can be improved by reducing long-term morbidities.

Hospital costs and quality of life during 4 years after very preterm birth.

OBJECTIVE: To evaluate the effect of gestational age and prematurity-related morbidities on hospital costs and cost per quality-adjusted life-year (QALY) during the first 4 years of life. DESIGN: Population-based study using national register data and parental questionnaires. SETTING: Finland. PARTICIPANTS: All 2064 very preterm children (gestational age <32 weeks or birth weight <1501 g) and all 200 609 full-term control individuals (mean [SD] gestational age, 37 [0] to 41 [6] weeks) born from January 1, 2000, through December 31, 2003. MAIN EXPOSURE: Prematurity. MAIN OUTCOME MEASURES: Costs of hospital care and cost per QALY at 4 years of age according to gestational age and prematurity-related morbidities. RESULTS: By 4 years of age, the cost per QALY for full-term controls (in 2008 currency) was euro1181 (US$1736). In very preterm children, the average cost per QALY was euro19 245 ($28 290), ranging from euro11 824 to euro54 324 ($17 381 to $79 856) and increasing with decreasing gestational age. The cost per QALY was euro14 368 ($21 121) for those without any of the studied morbidities and euro36 110 ($53 082) for those with 2 or more morbidities. The costs of the initial hospital stay comprised 79.5% of the total 4-year hospital costs in very preterm children. CONCLUSIONS: We conclude that the cost per QALY in this patient group is at an acceptable level by 4 years of age. Because the initial hospital care episode accounted for most of the costs, the cost per QALY will decrease with each additional follow-up year.

Impact of very preterm birth on health care costs at five years of age.

OBJECTIVE: We assessed the effects of very preterm birth (gestational age <32 weeks or birth weight <1501 g) and prematurity-related morbidities on health care costs during the fifth year of life. METHODS: The study population consisted of 588 very preterm children and 176 term control subjects born in 2001-2002. Costs of hospitalizations, visits to health care professionals and therapists, and the use of other social welfare services were assessed during the fifth year of life. Hospital visits were derived from register data and other health care contacts, and the use of social welfare services were derived from parental reports. The effects of 6 prematurity-related morbidities (cerebral palsy [CP], seizure disorder, obstructive airway disease, hearing loss, visual disturbances or blindness, and other ophthalmologic problems) on the costs of health care were studied. RESULTS: The average health care costs during the fifth year of life were 749 euro in the term control subjects, 1023 euro in the very preterm children without morbidities, and 3265 euro in those with morbidities. The costs of social welfare services and therapies exceeded the hospitalization costs in all groups. Among children who were born preterm, CP was associated with 5125 euro higher costs, whereas later obstructive airway diseases increased the costs by 819 euro compared with individuals without these morbidities. CONCLUSIONS: The health care costs during the fifth year of life in very preterm children with morbidities were 4.4-fold and in those without morbidities 1.4-fold compared with those of term control subjects. This emphasizes the importance of prevention of morbidities, especially CP, to reduce the long-term costs of prematurity.

Development and behaviour of 5-year-old very low birthweight infants.

The place and time of birth influence the mortality of premature infants. We studied the effect of prematurity, time of birth, birth hospital level and district on the development and behaviour in a national cohort of 5-year-old Finnish very low birthweight infants (VLBWI). All surviving VLBWI (gestational age <32 weeks or birthweight

Relations between brain volumes, neuropsychological assessment and parental questionnaire in prematurely born children.

The objective of this study is to assess the relationship between brain volumes at term equivalent age and neuropsychological functions at 5 years of age in very low birth weight (VLBW) children, and to compare the results from a neuropsychological assessment and a parental questionnaire at 5 years of age. The study group included a regional cohort of 97 VLBW children and a control group of 161 children born at term. At term equivalent age, brain magnetic resonance imaging (MRI) was performed on the VLBW children, and analysed for total and regional brain volumes. At 5 years of age, a psychologist assessed the neuropsychological performance with NEPSY II, and parents completed the Five to fifteen (FTF) questionnaire on development and behaviour. The results of the control group were used to give the age-specific reference values. No significant associations were found between the brain volumes and the NEPSY II domains. As for the FTF, significant associations were found between a smaller total brain tissue volume and poorer executive functions, between a smaller cerebellar volume and both poorer executive functions and motor skills, and, surprisingly, between a larger volume of brainstem and poorer language functions. Even after adjustment for total brain tissue volume, the two associations between the cerebellar volume and the FTF domains remained borderline significant (P = 0.05). The NEPSY II domains Executive Functioning, Language and Motor Skills were significantly associated with the corresponding FTF domains. In conclusion, altered brain volumes at term equivalent age appear to affect development still at 5 years of age. The FTF seems to be a good instrument when used in combination with other neuropsychological assessment.

Morbidities and hospital resource use during the first 3 years of life among very preterm infants.

OBJECTIVE: The objective of this study was to determine how the use of hospital resources during the first 3 years of life was associated with prematurity-related morbidity in very preterm infants (gestational age of <32 weeks or birth weight of <1501 g). METHODS: The study was a retrospective, national register study including all very preterm infants born alive in Finland between 2000 and 2003 (N = 2148). Infants who died before the age of 3 years (n = 264) or who had missing register data (n = 88) were excluded from the study. The relationship between 6 morbidity groups and the need for hospital care during the first 3 years of life was studied by using a negative binomial model. RESULTS: A total of 66.2% of the infants did not have any of the morbidities studied. Infants who were subsequently diagnosed as having cerebral palsy (6.1% of the study group), later obstructive airway disease (20.0%), hearing loss (2.5%), visual disturbances or blindness (3.8%), or other ophthalmologic problems (13.4%) had initial hospital stays that were a mean of 7, 8, 12, 17, and 3 days longer, respectively, than those for infants without these conditions. All morbidity groups were associated with increased numbers of hospital visits during either the second or third year of life, compared with infants without these morbidities. The need for hospitalizations and outpatient hospital care decreased with postnatal age for infants with later morbidities and for infants without later morbidities. CONCLUSIONS: Most very preterm infants born in Finland survived without severe morbidities and required relatively little hospital care after the initial discharge. However, those with later morbidities had a long initial length of stay and more readmissions and outpatient visits during the 3-year follow-up period.

Health-related quality of life in 5-year-old very low birth weight infants.

OBJECTIVE: To investigate the effect of preterm birth, the time of birth, and birth hospital level and district on health-related quality of life (HRQoL) and quality-adjusted life years (QALYs). STUDY DESIGN: This national study included all very low birth weight infants (VLBWIs; birth weight

Differences in the length of initial hospital stay in very preterm infants.

AIM: To investigate the effect of maternal, infant and birth hospital district related factors on the length of initial hospital stay in very preterm infants. In addition, rehospitalization rate within the first year from the initial discharge was studied. METHODS: A register study covering all very preterm infants (gestational age < 32 weeks or birthweight < 1501 g) born alive in Finland between years 2000 and 2003 (N = 2148). Factors affecting length of stay (LOS) were studied using generalized linear model (GLM). RESULTS: The proportion of very preterm infants born in a level III unit varied in the hospital districts from 53% to 94%. Median LOS was 53 days (interquartile range: 38-76). There were large regional differences in the LOS, the difference being up to 10.5 days among the hospital districts (p < 0.0001). Rehospitalization rate was 47.2% within the first year from the initial discharge, and the absence of rehospitalization was associated with a 4.1 days shorter initial LOS (p < 0.0001). CONCLUSION: Our study showed large regional variation in LOS of very preterm infants despite similar case mix. We speculate that the variation depends on differences in treatment practices and discharge criteria.

The effect of birth in secondary- or tertiary-level hospitals in Finland on mortality in very preterm infants: a birth-register study.

OBJECTIVE: Our goal was to test the hypothesis that the level of the delivery hospital affects 1-year mortality of very preterm infants in Finland. PATIENTS AND METHODS: This retrospective national medical birth-register study included 2291 very preterm infants (gestational age of < 32 weeks at birth or birth weight of < or = 1500 g) born in 14 level II (central) and 5 level III (university) hospitals in 2000-2003. The main outcome measures were adjusted total mortality (including stillbirths) and mortality of live-born infants until the age of 1 year. RESULTS: Both the total 1-year mortality and the 1-year mortality of live-born infants were higher in level II hospitals compared with level III hospitals. Total mortality was higher in very preterm infants who were not born during office hours. In theory, delivery of all very preterm infants in level III instead of level II hospitals translates into an annual prevention of 69 of the 170 total deaths and prevention of 18 of the 45 deaths of live-born infants. CONCLUSIONS: Resources in neonatal intensive care should be increased, especially during non-office hours, to have an equally distributed service through the 24-hour day. More efficient regionalization of very preterm deliveries may improve 1-year survival of very preterm infants in Finland.

Acoustic quality of cry in very-low-birth-weight infants at the age of 1 1/2 years.

BACKGROUND: Infant cry characteristics reflect the integrity of the central nervous system. Previous studies have shown that preterm infants and infants with neurological conditions have different cry characteristics such as fundamental frequency compared to healthy full-term infants. Cry characteristics of preterm infants after the first year of life have not been studied. AIMS: The aim of this study was to assess the quality of cry in 1 1/2-year-old very-low-birth-weight infants (VLBWI, < or =1500 g at birth). STUDY SUBJECTS AND DESIGN: Study groups included 21 VLBWI and 25 healthy full-term controls. Thirty seconds of pain cry after vaccination was recorded at well-baby clinics. The first cry utterance was acoustically analyzed using Praat software. The quality of cry was compared between the groups. In addition, the association of cry quality to patient characteristics, to developmental outcome, and to findings in brain imaging studies of the VLBWI was studied. RESULTS: The cry response was elicited in 20 of the 21 VLBWI and in 20 out of 25 full-term infants. VLBWI had higher minimum fundamental frequency and fourth formant values. Patient characteristics that were associated with cry quality were 5-min Apgar scores, the occurrence of bronchopulmonary dysplasia, Bayley Psychomotor Index scores at 12 months, and current weight and head circumference. CONCLUSIONS: Differences found between the study groups were not explained primarily by brain pathology or by patient characteristics, so it seems that prematurity has an impact on cry quality still at the age of 1 1/2 years.