Unsuccessful voluntary prenatal testing for human immunodeficiency virus infection.

Within the Kaiser Permanente system of Northern California, testing for HIV during prenatal vis its was encouraged. During a 5-year period the percentage of women agreeing to HIV testing increased from 50% to 76%. Eighty-three HIV-positive pregnancies occurred in 63 women. Only 17 (20%) of the 83 pregnancies were identified by the voluntary testing program.

The hypothalamic-pituitary-thyroid negative feedback control axis in children with treated congenital hypothyroidism.

Measurements of serum concentrations of free T4, T3, TSH, and thyroglobulin (Tg) were conducted in 42 infants (2-9 months of age) detected and treated through the Northwest Newborn Regional Screening Program and 63 children and adolescents (1-18 yr of age) with congenital hypothyroidism (CH) detected and managed in the Northern California Kaiser Permanente Medical Care Program. Normal feedback control axis data were developed by Quest Diagnostics, Inc. - Nichols Institute Diagnostics and Loma Linda University, from free T4 and TSH measurements in 589 healthy subjects, 2 months to 54 yr of age; 83 untreated hypothyroid patients; and 116 untreated hyperthyroid patients. Twenty-four of the 42 CH infants and 57 of the 63 CH children manifested serum TSH concentrations appropriate for the measured free T4 level. In the remaining 18 infants and 6 children, serum free T4 values were increased 0.2-1.4 ng/dL (2.6-18.0 pmol/L) for the prevailing TSH level, suggesting a state of mild to moderate pituitary-thyroid hormone resistance. In the treated children, the mean T3 concentration was lower (by 32%, 102 vs. 150 ng/dL; 1.57 vs. 2.31 nmol/L) than in normal children, in agreement with earlier data in hypothyroid adults treated with exogenous T4. Serum Tg concentrations were normal or elevated in 90% of the 19 children with ectopic glands and 93% of 27 children with eutopic glands in whom measurements were available. There was a positive correlation between serum TSH and Tg concentrations (P < 0.001), suggesting significant endogenous thyroid hormone production in these children. Our results suggest that the majority of infants and children with CH have a normal hypothalamic-pituitary-thyroid negative feedback control axis during treatment and that the measurement of serum TSH is a useful marker complementing the free T4 measurement in the management of children with CH. A minority have variable pituitary-thyroid hormone resistance, with relatively elevated serum TSH levels for their prevailing serum free T4 concentration. The prevalence of resistance is greater (43%) in young infants (< 1 yr of age) than in older children (10%), indicating that, in most children, the resistance improves with age.

Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life.

OBJECTIVE: To assess the effect of newborn circumcision on the incidence and medical costs of urinary tract infection (UTI) during the first year of life for patients in a large health maintenance organization. SETTING: Kaiser Permanente Medical Care Program of Northern California (KPNC). PATIENTS: The population consisted of members of KPNC. The study group consisted of a cohort of 28 812 infants delivered during 1996 at KPNC hospitals; of the 14 893 male infants in the group, 9668 (64.9%) were circumcised. A second cohort of 20 587 infants born in 1997 and monitored for 12 months was analyzed to determine incidence rates. DESIGN: Retrospective study of all infants consecutively delivered at 12 facilities. OUTCOME MEASURES: Diagnosis of UTI was determined from the KPNC computerized database using the International Classification of Diseases, Ninth Revision code for inpatients and KPNC Outpatient Summary Clinical Record codes for outpatients. A sample of 52 patient charts was reviewed to confirm the International Classification of Diseases, Ninth Revision and KPNC Outpatient Summary Clinical Record codes and provide additional data. RESULTS: Infants <1 year old who were born in 1996 had 446 UTIs (292 in females; 154 in males); 132 (86%) of the UTIs in males occurred in uncircumcised boys. The mean total cost of managing UTI was 2 times as high in males ($1111) as in females ($542). This higher total cost reflected the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared with females (7.5%); mean age at hospitalization for UTI was 2.5 months old for uncircumcised boys and 6.5 months old for girls. In 1996, total cost of managing UTI in uncircumcised males ($155 628) was 10 times higher than for circumcised males ($15 466) despite the fact that uncircumcised males made up only 35.1% of the male patient base in 1996, reflecting the more frequent occurrence of UTI in uncircumcised males (132 episodes) than in circumcised males (22 episodes), and the larger number of hospital admissions in uncircumcised males (38) than in circumcised males (4). The incidence of UTI in the first year of life was 1:47 (2.15%) in uncircumcised males, 1:455 (.22%) in circumcised males, and 1:49 (2. 05%) in females. The odds ratio of UTI in uncircumcised:circumcised males was 9.1:1. CONCLUSIONS: Newborn circumcision results in a 9. 1-fold decrease in incidence of UTI during the first year of life as well as markedly lower UTI-related medical costs and rate of hospital admissions. Newborn circumcision during the first year of life is, thus, a valuable preventive health measure, particularly in the first 3 months of life, when uncircumcised males are most likely to be hospitalized with severe UTI.

The highly protective effect of newborn circumcision against invasive penile cancer.

OBJECTIVE: We determined the relation between newborn circumcision and both invasive penile cancer (IPC) and carcinoma in situ (CIS) among adult male members of a large health maintenance organization. SUBJECTS AND METHODS: Circumcision status was ascertained by a combination of pathology reports, medical record review, and questionnaires for 213 adult male members of a large prepaid health plan who were diagnosed with IPC or CIS. RESULTS: Of 89 men with IPC whose circumcision status was known, 2 (2.3%) had been circumcised as newborns, and 87 were not circumcised. Of 118 men with CIS whose circumcision status was known, 16 (15.7%) had been circumcised as newborns. CONCLUSIONS: Our results confirm the highly protective effect of newborn circumcision against IPC and the less protective effect against CIS.

Second-trimester serum chorionic gonadotropin concentrations and complications and outcome of pregnancy.

BACKGROUND: Maternal serum chorionic gonadotropin is measured to screen for fetal chromosomal abnormalities. Whether the results can also be used to predict the risk of complications or an adverse outcome of pregnancy is not known. METHODS: We reviewed the medical records of 28,743 girls and women in whom chorionic gonadotropin was measured during the second trimester of pregnancy (between July 1, 1995, and January 31, 1997), seeking information about the complications and outcome of their pregnancies. We excluded girls and women who had preexisting risk factors for complications or an adverse outcome of pregnancy. RESULTS: Higher serum chorionic gonadotropin concentrations were associated with higher rates of stillbirth (odds ratio for every increase in chorionic gonadotropin of 1 multiple of the median, 1.4; 95 percent confidence interval, 1.1 to 1.9). There was no relation between higher serum chorionic gonadotropin concentrations and the risk of gestational diabetes, premature rupture of membranes or intrauterine growth retardation or small size for gestational age (odds ratio, 1.1; 95 percent confidence interval, 0.9 to 1.2). Higher serum chorionic gonadotropin concentrations were associated with a risk of placental abnormalities (odds ratio, 1.5; 95 percent confidence interval, 1.3 to 1.7), pregnancy-induced hypertension (odds ratio, 1.4; 95 percent confidence interval, 1.3 to 1.5), and preterm delivery without pregnancy-induced hypertension (odds ratio, 1.1; 95 percent confidence interval, 1.0 to 1.2). Inclusion in certain racial or ethnic categories (black, Filipino or Pacific Islander, unknown race or ethnic group, and "other," which included those of Middle Eastern descent and Native Americans) was a better predictor of the risk of an adverse outcome than serum chorionic gonadotropin values. CONCLUSIONS: Measurements of serum chorionic gonadotropin are of little clinical value for predicting the risk of complications and the outcome of pregnancy.

Design and implementation of genetic services within an HMO.

Clinical application of genetic knowledge is essential for providing effective preventive health care. A large HMO such as Kaiser Permanente is an ideal setting for this application. Implementing a comprehensive program for genetic screening is complex, however, and requires informed consent, laboratory testing, test interpretation, genetic counseling, follow-up for positive screening results, and database systems. This article summarizes genetic services provided by Kaiser Permanente at four subregional genetic centers in Northern California.

Compliance with voluntary prenatal HIV testing in a large health maintenance organization (HMO).

Results of a recent national clinical trial show that maternal-to-fetal transfer of HIV can be decreased threefold by prenatal, intrapartum, and neonatal treatment. The question is whether to make prenatal HIV testing compulsory or to encourage voluntary testing. Kaiser Permanente Northern California (KPNC), which has 2.5 million members, is part of a large health maintenance organization (HMO). In 1994, KPNC cared for 32,700 prenatal patients; 16,500 (50%) agreed to voluntary HIV testing. Compliance with testing ranged from 0% to 92% among the 31 KPNC locations. A study done by telephone survey identified three main factors favoring success of voluntary HIV screening: the ease and accessibility of HIV testing, a designated educator, and the presence of a registered nurse on the counseling team. In 1995, following feedback to the 31 facilities of the 1994 results, compliance rose to 19,800 of 31,300 prenatal patients (63%). KPNC, by encouraging counseled voluntary screening and following known positive cases, hopes to identify, track, and offer treatment options to all HIV-positive prenatal patients.

Managed genetic care in a large HMO.

Comprehensive clinical genetic services are offered to 2.4 million members by the Kaiser Permanente Medical Care Program (KP), a not-for-profit HMO, in its Northern California region. Four genetics centers are staffed by clinical geneticists, genetic counselors, nurses, and laboratory technologists, who together provide patient and physician education, genetic screening, and prenatal, infant, and adult evaluation. Besides offering lectures and teleconferences, the geneticists publish a newsletter on how to use the genetic services for approximately 1200 pediatricians, obstetricians, and other relevant specialists. Clinical services offered to members include individual, group, and telephone consultations, and easy access to geneticists is provided for primary care providers with genetic care questions. In-house laboratory services include blood and tissue cytogenetic analysis, DNA testing, and prenatal blood and amniotic fluid testing. A large database and a comprehensive and cost-effective program of genetic services have been developed. An interregional genetics data system is being established to link Northern and Southern California and the Northwest (Portland and Hawaii regions). Steps are also underway to include other regions in the database and to encourage utilization of regionalized KP genetic laboratories by smaller regions.

Special perinatal services in a large health maintenance organization.

The Kaiser Permanente (KP) Medical Care Program, the largest and oldest health maintenance organization in the United States, is generally considered a model and template for other health maintenance organizations and managed health care programs. Nationally, KP has almost 7 million members-about 5 million in California, 2.4 million of whom are in the KP Northern California Region (KPNCR). About 500,000 of those are children; physicians in the program see 32,000 prenatal patients and deliver more than 28,000 babies annually. KPNCR is the largest KP region; 26% of northern California's population are subscribers. This review addresses special perinatal programs in the KPNCR and emphasizes perinatal screening and genetic services.