Administration of acetylsalicylic acid after parturition in lactating dairy cows under certified organic management: Part I. Milk yield, milk components, activity patterns, fertility, and health.

Parturition is a natural process that gradually progresses from one stage to the next. However, around 5% of dairy cows will experience dystocia, which is considered to be a painful and stressful event. Studies have reported positive effects on cow performance and welfare after treatment with nonsteroidal anti-inflammatory drugs during the first postpartum days. The objectives were to assess the effects of acetylsalicylic acid administration after calving on (1) milk yield and components, (2) daily activity patterns, (3) reproductive performance, and (4) health in lactating dairy cows under certified organic management. Cows from 3 organic herds were enrolled. Within 12 h after parturition, cows were blocked by parity and calving ease and randomly assigned to 2 treatments: (1) aspirin (ASP; n = 278), in which cows received 4 consecutive treatments every 12 h with acetylsalicylic acid (100 mg/kg; 2 boluses) or (2) placebo (PLC, n = 285), in which cows received 4 treatments every 12 h with gelatin capsules (2 capsules) filled with water. Daily milk yield for the first 30 d in milk (DIM) and monthly milk yield, fat, protein, and somatic cell count (SCC) data from the first 5 Dairy Herd Improvement Association tests were collected. Activity patterns were measured using activity data loggers in the first 7 DIM. Clinical disease events (60 DIM) and fertility data were collected from on-farm computer records. Statistical analysis was performed using the MIXED (milk yield, components, and activity), LIFETEST (fertility), and GLIMMIX (health) procedures of SAS (SAS Institute Inc., Cary, NC). Overall, ASP cows produced 1.82 kg/d more milk than PLC cows during the first 30 DIM. Interestingly, cows that experienced dystocia and received ASP produced 4.48 kg/d more milk compared with cows in the PLC group that experienced dystocia. Cows treated with ASP had lower somatic cell count during the first 5 Dairy Herd Improvement Association tests. There were no differences in daily lying time, lying bouts, and lying bout duration between the ASP and PLC groups. However, cows in the ASP group had 587,64 steps/d more compared with PLC cows. In addition, ASP cows tended to require fewer days (ASP = 113.76 ± 4.99 d; PLC = 125.36 ± 4.74 d) and needed fewer services (ASP = 1.86 ± 0.21 services; PLC = 2.19 ± 0.24 services) to become pregnant compared with PLC cows. There were no differences in clinical disease events between treatments. Results from this study suggest that treating cows with ASP after calving may help improve milk yields and udder health, increase activity, and enhance fertility in dairy cattle under certified organic management.

Administration of acetylsalicylic acid after parturition in lactating dairy cows under certified organic management: Part II. Biomarkers of nociception, inflammation, and stress.

The objective was to assess the effect of oral administration of acetylsalicylic acid after calving on the concentrations of substance P (SP), haptoglobin (HP), and cortisol in lactating dairy cows. Holstein dairy cows (n = 152) from 3 organic herds were included. At parturition, cows were blocked by parity [multiparous (MULT) and primiparous (PRIM)] and calving ease [eutocia (EUT) and dystocia (DYS)] and were randomly assigned to 1 of 2 treatment groups: aspirin (ASP; n = 76), in which within 12 h after parturition cows received 4 treatments with acetylsalicylic acid (100 mg/kg; 2 boluses) at 12-h intervals, or placebo (PLC; n = 76), in which within 12 h after parturition cows received 4 consecutive treatments with gelatin capsules (2 capsules) containing water 12 h apart. Blood samples were collected immediately before treatment and at 12, 24, 36, 48, and 168 h (7 DIM) for assessment of circulating concentration of SP, HP, and cortisol. Based on farm records, cows were classified in the following clinical disease categories: no clinical disease event (NO-EVT), a single clinical disease event (SI-EVT), and more than 1 clinical disease event (MU-EVT). The study data were analyzed as a randomized complete block design using mixed multiple linear and logistic regression models. With regard to HP, there was a tendency for an interaction between treatment and parity, where MULT cows treated with ASP had lower concentration of HP compared with MULT cows treated with PLC (ASP = 124.33 ± 6.83 µg/mL; PLC = 143.9 ± 7.24 µg/mL). Analysis by calving ease showed that cows with DYS had higher concentrations of HP (DYS = 159.17 ± 5.97 µg/mL; EUT = 138.72 ± 6.22 µg/mL) and SP (only at 168 h; DYS = 64.99 pg/mL, 95% confidence interval, CI: 2.68-2.81; EUT = 60.33 pg/mL, 95% CI: 2.91-3.06) after calving compared with EUT cows. Regardless of treatment, PRIM cows had higher concentrations of SP (MULT = 55.11 pg/mL, 95% CI: 1.27-1.30; PRIM = 57.62 pg/mL, 95% CI: 1.99-2.06), HP (MULT = 134.14 ± 4.96 µg/mL; PRIM = 163.75 ± 7.76 µg/mL), and cortisol (MULT = 18.65 µg/mL, 95% CI: 1.02-1.05; PRIM = 21.92 µg/mL, 95% CI: 1.67-1.74) compared with MULT cows. In addition, cows that experienced SI-EVT or MU-EVT had higher concentrations of HP (NO-EVT = 134.13 ± 5.95 µg/mL; SI-EVT = 142.68 ± 7.32 µg/mL; MU-EVT = 170.03 ± 9.42 µg/mL) and cortisol (NO-EVT = 17.86 µg/mL, 95% CI: 1.20-1.24; SI-EVT = 21.01 µg/mL, 95% CI: 1.61-1.67; MU-EVT = 22.01 µg/mL, 95% CI: 2.08-2.18) compared with cows with NO-EVT recorded. Results from this study suggest that a short-duration anti-inflammatory therapy after calving reduced HP in MULT cows but may not have effects on SP and cortisol concentrations. Calving ease and parity affected the concentrations of markers of inflammation, nociception, and stress regardless of treatment. Further research is warranted to assess anti-inflammatory strategies aimed at decreasing inflammation and stress in DYS and PRIM cows and therefore improve welfare and performance of these high-priority groups.

Effects of sample size on neutral detergent fiber digestibility of triticale forages using the Ankom DaisyII Incubator system.

Accurate and precise determinations of fiber digestibility are essential for proper diet formulation for dairy cows. Our objectives were 3-fold: (1) regress in vitro neutral detergent fiber digestibility (NDFD) values from 48 triticale forages determined at multiple endpoints ranging from 12 to 240 h with Ankom DaisyII Incubator system (Ankom Technology Corp., Macedon, NY) methods using 0.25- or 0.50-g sample sizes on concentrations of fiber-related analytes or growth stage; (2) directly compare NDFD values determined with 0.25- or 0.50-g sample sizes by Ankom methods after 12-, 24-, 30-, 48-, 144-, or 240-h incubations; and (3) compare NDFD values determined by Ankom methods after 30 and 48 h of incubation with those determined by traditional sealed-tube procedures obtained from a commercial laboratory. Generally, plant growth stage, which was quantified with a linear model suitable for serving as an independent regression variable, proved to be a better predictor variable for NDFD than neutral detergent fiber or acid detergent lignin. For direct comparisons of 0.25- and 0.50-g sample sizes using Ankom methods, the regression relationship for a 30-h incubation was explained by a linear model [Y = 1.206x - 1.1; coefficient of determination (R2) = 0.933], in which the slope differed from unity, but the intercept did not differ from 0. After a 48-h incubation, a linear model (Y = 1.014x + 7.1; R2 = 0.964) indicated that the slope did not differ from unity, but the intercept was >0. A linear regression (Y = 1.040x - 1.8; R2 = 0.861) of the 30-h incubation results obtained by Ankom methods using the 0.25-g sample size on those from the commercial laboratory indicated the slope and intercept did not differ from unity or 0, respectively. A similar relationship was obtained from the 48-h incubation (Y = 1.021x - 3.4; R2 = 0.866). Relationships were poorer when the 0.50-g sample size was used by Ankom methods, particularly for the 30-h incubation, where the slope (0.824) was less than unity. Generally, NDFD values were greater for the 0.25-g sample size by Ankom methods, especially with 24-, 30-, and 48-h incubation times, and agreement with traditional sealed-tube methods was improved with the smaller sample size. Synchronization of results between Ankom and traditional methods needs to be further verified across a wider range of forages and harvest/preservation methods before definitive recommendations can be made.

Technical note: a near-infrared reflectance spectroscopy technique to predict particle size of starch within corn silage.

Starch particle size characteristics of 81 diverse corn silage samples, which included 27 combinations of hybrid, planting dates, and harvest dates subjected to 3 different degrees of kernel processing, were determined via vertical shaking through 9 screens with nominal square apertures of 19.0, 13.2, 9.5, 6.7, 4.75, 3.35, 2.36, 1.18, and 0.6 mm and a pan. Starch content of dry matter remaining on each screen and on the pan for each corn silage was determined, and geometric mean particle size (GMPS, mum), starch particles(SP)/g, starch surface area (SSA, cm(2)/g), kernel processing score (KPS), % starch < 4.75 mm, and the percentage of total starch remaining on each screen of the vertical shakers were calculated. Near-infrared reflectance spectra were obtained by scanning 3 types of samples: 1 mm of dried ground corn silage; whole undried, unground corn silage; and undried, unground corn silage that passed through a 19-mm screen. Calibrations to predict GMPS, SP, SSA, and KPS characteristics of corn silage starch were attempted from each spectral origin. Calibrations to predict GMPS, SP, SSA, KPS, and the percentage of total starch retained on screens of the vertical shaker was unattainable (R(2) < 0.45) using spectra obtained from 1 mm of dried ground corn silage or whole undried, unground corn silage. However, reasonable near-infrared reflectance spectra equations (R(2) > 0.81) for GMPS, SSA, and KPS were attained using spectra from undried, unground corn silage that passed through a 19-mm screen. This technique holds promise as a rapid and efficient method to determine particle size characteristics of starch within corn silage.

Utility of near-infrared reflectance spectroscopy to predict nutrient composition and in vitro digestibility of total mixed rations.

Total mixed ration (TMR) samples (n = 110) were analyzed for dry matter (DM), crude protein (CP), soluble CP, neutral detergent fiber (NDF), NDF CP, starch, ash, fat, total ethanol-soluble carbohydrate, and nonfiber carbohydrate (NFC). Rapidly and slowly degraded and undegraded in situ CP fractions and in vitro DM, organic matter, and NDF digestibility were determined on each TMR. The TMR were scanned using near-infrared reflectance spectroscopy (NIRS); spectra were retained with NIRS calibration and cross-validation statistics were determined using partial least squares regression methods. The CP, NDF, starch, in vitro DM, and in vitro indigestible NDF contents of TMR were predicted by NIRS with good degrees (R2 >0.85) of accuracy with proportionally low standard errors of prediction. Moderate utility of NIRS to predict the NFC (R2 = 0.83) and fat content (R2 = 0.81) of TMR was observed. Rapidly, slowly, and undegraded in situ CP fractions in TMR were not well predicted by NIRS. Similarly, soluble CP, NDF CP, total ethanol-soluble carbohydrate, and in vitro NDF digestibility (% of NDF) were not well predicted by NIRS. Ratios of nutrient range to reference laboratory method error were calculated and found to be positively related (R2 = 0.84) to NIRS predictability of a given TMR nutrient, suggesting some laboratory procedures were not precise enough to yield suitable NIRS predictions. Data suggest that NIRS has utility to predict basic nutrients such as CP, NDF, starch, NFC, and fat in TMR. However, difficulty was observed using NIRS in predicting key biological nutrients in TMR such as in situ CP fractions and in vitro NDF digestibility. Difficulty of NIRS in predicting these nutrients is related to the level of reference method error in relationship to the range of nutrient values in TMR, but other sources of prediction error may exist.

Phase I trial of the thymidylate synthase inhibitor AG331 as a 5-day continuous infusion.

AG331 (N6-[4-(morpholinosulfonyl)benzyl]-N6-methyl-2, 6-diaminobenz-[c,d]-indole glucuronate) is a lipophilic thymidylate synthase inhibitor with activity in solid tumor models. On the basis of preclinical data supporting regimens of frequent drug administration, we performed a Phase I trial of AG331 as a 5-day continuous infusion repeated every 3 weeks. Twenty-nine patients were entered at doses ranging from 25 to 1000 mg/m2/day. The major side effects were mild to moderate fatigue, nausea, vomiting, diarrhea, and fever. At doses >/=400 mg/m2, acute reversible elevation of bilirubin, aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltranspeptidase was observed. All patients who received >/=600 mg/m2/day experienced elevated alanine aminotransferase. Elevated liver function tests were evident by day 3 of the infusion and had resolved by day 8 in the majority. This toxicity was dose limiting at 1000 mg/m2/day, at which dose two of two patients developed grade 4 reversible hyperbilirubinemia in addition to the enzyme elevations. Serum and urine samples were analyzed by a novel high-pressure liquid chromatography method for the determination of the pharmacokinetics of AG331. Over the 50-1000 mg/m2/day dose range, mean total clearance ranged from 11.6 to 30.0 liters/h/m2, and volume of distribution at steady state ranged from 279.5 to 758.7 liters/m2. These parameters were dose independent over the dose range tested. The harmonic mean terminal half-life of AG331 was 20.2 h. Less than 5% of an AG331 dose is eliminated unchanged in the urine. Both the administered dose and exposure to the drug were related to the changes in bilirubin and aminotransferase blood levels. Evidence for inhibition of thymidylate synthase was obtained at doses ranging from 100 to 1000 mg/m2 in seven patients; plasma deoxyuridine concentrations at end-infusion were 1.8-3.8-fold higher than pretreatment values. Because of the nature of toxicity on this schedule, more extensive Phase II evaluation is not recommended, although an AG331 dose of 800 mg/m2/day for 5 days is tolerable. Exploration of less frequent dose administration is under way.

A 1-heteroaryl-4-piperidinyl-methyl pyrrolidinone, BMY 21502, delays the decay of hippocampal synaptic potentiation in vitro.

The effects of the substituted pyrrolidinone, BMY 21502, on the properties of cell membranes, synaptic transmission and synaptic plasticity, were assessed in area CA1 of hippocampal slices from the rat. Application of the compound to the bath had no consistent direct effects on parameters of the cell membrane or evoked synaptic potentials, at concentrations of less than 30 microM. In a blind experimental design, BMY 21502 at 1.0 and 10 microM, but not 25 microM, significantly delayed the decay of long-term potentiation in slices obtained from young animals; in slices obtained from very old rats (2.5-3.2 yr), 10 microM BMY 21502 significantly delayed decay of long-term potentiation. Therefore BMY 21502 was active in a physiological model that may predict of cognitive enhancement.

Sociodemographic and condition-related characteristics associated with conduct problems in school-aged children with chronic health conditions.

OBJECTIVE: To examine whether sociodemographic and condition-related characteristics are associated with conduct problems in children with chronic health conditions. DESIGN: Cross-sectional survey. PARTICIPANTS: Mothers of children 5 to 8 years old with diverse chronic health conditions who received care at 2 large urban medical centers. MEASURES: Mothers responded to a face-to-face structured interview that included the Eyberg Child Behavior Inventory, the Psychiatric Symptom Index, and questions about sociodemographic and health condition-related characteristics. RESULTS: Of the 356 children assessed, 138 (38.8%) had conduct problems as defined by criteria of the Eyberg Child Behavior Inventory. In logistic regression analyses, conduct problems were associated with younger child age, mother having a husband or partner unrelated to her child, poorer perceived prognosis, child having a learning disability, and maternal self-report of high emotional distress on the Psychiatric Symptom Index. Conduct problems were not related to child sex, maternal ethnicity or education, family receiving welfare, or a wide range of condition-related factors, including age at diagnosis, visibility to others, need to watch for sudden changes, presence of mobility or sensory-communication problems, using medication or equipment, annual hospitalizations, or physician visits. CONCLUSIONS: Conduct problems in children with chronic health conditions appear to be associated more closely with their sociodemographic and family characteristics than with condition-related risk factors. Additional research remains to be done on the ways that maternal adjustment, diagnosis-specific condition characteristics, and other risk factors influence children's behavior.

How well does the questionnaire for identifying children with chronic conditions identify individual children who have chronic conditions?

BACKGROUND: The Questionnaire for Identifying Children With Chronic Conditions (QuICCC) is an instrument based on a conceptual noncategorical definition that uses parental responses to identify children with chronic conditions for epidemiological purposes. OBJECTIVES: To determine whether the QuICCC is sufficiently valid, sensitive, and specific to be used to identify individual children as having a chronic condition or disability; whether parents are accurate enough that their answers to QuICCC items can be accepted as valid; and what kinds of errors in classification occur when the QuICCC is used to identify children with chronic conditions. METHODS: The sample consisted of 424 children who were patients of 9 physicians in separate practice settings throughout New England. Each physician was briefly trained in the conceptual definition on which the QuICCC is based and then was asked to identify 25 children in his or her practice who met the definition and 25 children who did not meet the definition. The QuICCC was administered to the parents of these children by blinded interviewers via telephone. The QuICCC classification was compared with physician categorization. Discrepant cases were then followed up by asking physicians and parents to answer the original questions a second time. RESULTS: Complete data were available on 379 (89.4%) of 424 children. There was agreement on 89% (kappa = 0.78). The sensitivity was 94%; specificity, 83%; positive predictive value, 86%; and negative predictive value, 92%. Of the 42 discordant cases, 30 parent reports on the QuICCC qualified the child as having a chronic condition when the physician classified the child as being without such a condition. Fewer (n = 12) discrepancies occurred because physicians identified children with chronic conditions that the QuICCC failed to identify. When the questions were readministered at follow-up, physicians corrected errors in rating in 9 cases; mothers changed their answers in 5 instances. In 13 instances the issues were known to both parties and appeared to arise in the "gray zone" or boundary area, where there was disagreement over whether a particular child qualified using the theoretical definition. For 11 children identified as having a chronic condition only by the parent's responses to the QuICCC, physician report appeared to be inaccurate primarily due to the physician's lack of information. In 3 cases where the physician reported the child to have a chronic condition, but the parent did not, the physician appeared to be correct. Follow-up data were incomplete on 1 child. CONCLUSIONS: These data support the validity of parent-generated information for the evaluation of health status. Although these findings should be replicated, this study suggests that the QuICCC may be applicable also as a screening tool for individual child identification, provided that several sources of error are considered.

Assessing managed care for children with chronic conditions.

This paper reviews opportunities to monitor managed care for children and adolescents with chronic conditions and considers how well the Health Plan Employer Data and Information Set, version 3.0 (HEDIS 3.0), assesses care for these children. We propose four steps to strengthen the applicability of HEDIS to children with chronic conditions: (1) develop methods of identifying and monitoring groups of children with chronic conditions; (2) report HEDIS indicators for these children separately from those for other children; (3) develop and implement consumer and provider surveys that elicit information specific to these populations; and (4) develop specific structure, process, and outcomes indicators for children with chronic conditions.

The adenosine antagonist 8-cyclopentyltheophylline reduces the depression of hippocampal neuronal responses during hypoxia.

Exposure of rat hippocampal slices to hypoxic conditions for 15 min produced a rapid, profound, but completely reversible depression of evoked synaptic potentials. The specific A1 adenosine receptor antagonist 8-cyclopentyltheophylline (8-CPT) significantly reduced hypoxia-induced synaptic depression in a concentration-dependent manner. It is concluded that adenosine, which is neuroprotective when exogenously applied during severe hypoxia because of its ability to depress synaptic transmission, may have an important and exploitable endogenous role in the protection of sensitive neurons.

Relationships of self-esteem and efficacy to psychological distress in mothers of children with chronic physical illnesses.

This study examined relationships of children's illness-related functional limitations and 2 maternal psychological resources, self-esteem and efficacy, to symptoms of psychological distress in 365 urban mothers of 5- to 9-year-old children with diverse chronic illnesses. Multiple regression controlling for sociodemographic variables indicated that presence of functional limitations in the child and lower resources each were associated with higher maternal scores on a psychological symptom scale. Self-esteem had a main effect on maternal distress; however, a significant Efficacy x Functional Status interaction term suggested that mothers experienced greater distress when their children had illness-related functional limitations and maternal efficacy was low. Interventions aimed at enhancing maternal psychological resources may reduce the likelihood of distress in mothers of children with chronic illness.

Inhibitory refinement of spatial frequency selectivity in single cells of the cat striate cortex.

Single cells in the cat striate cortex are more selective for the spatial frequency of sinewave grating stimuli than are cells of the retina or lateral geniculate nucleus. We have explored the possibility that this enhancement of selectivity results from spatial-frequency-selective inhibition. Stimulation with two superimposed gratings, one to excite the cell and one to prove for inhibition, revealed spatial frequency-dependent response suppression in 74% of the total population studied. Suppression was slightly more prevalent in simple cells (80%) than in complex cells (68%). In 93% of the cases where suppression was found, its tuning was complementary to excitatory spatial frequency tuning, and the strongest suppression was usually found where the excitatory tuning function approached zero imp./sec. Characteristics of the phenomenon were independent of cortical layers. We conclude that organized inhibitory mechanisms serve to refine the spatial frequency bandpass of striate cortical cells. This provides evidence for another degree of nonlinearity in the organization of cortical receptive fields and supports the hypothesis that a fundamental function of the visual cortex is image dissection in the domain of spatial frequency.

Metabolic acidosis, rhabdomyolysis, and cardiovascular collapse after prolonged propofol infusion.

The authors present the hospital course of a 13-year-old girl with a closed head injury who received a prolonged infusion of propofol for sedation and, subsequently, died as a result of severe metabolic acidosis, rhabdomyolysis, and cardiovascular collapse. The patient had been treated for 4 days at a referring hospital for a severe closed head injury sustained in a fall from a bicycle. During treatment for elevations of intracranial pressure, she received a continuous propofol infusion (100 microg/kg/min). The patient began to exhibit severe high anion gap/low lactate metabolic acidosis, and was transferred to the pediatric intensive care unit at the authors' institution. On arrival there, the patient's Glasgow Coma Scale score was 3 and this remained unchanged during her brief stay. The severe metabolic acidosis was unresponsive to maximum therapy. Acute renal failure ensued as a result of rhabdomyolysis, and myocardial dysfunction with bizarre, wide QRS complexes developed without hyperkalemia. The patient died of myocardial collapse with severe metabolic acidosis and multisystem organ failure (involving renal, hepatic, and cardiac systems) approximately 15 hours after admission to the authors' institution. This patient represents another case of severe metabolic acidosis, rhabdomyolysis, and cardiovascular collapse observed after a prolonged propofol infusion in a pediatric patient. The authors suggest selection of other pharmacological agents for long-term sedation in pediatric patients.

Psychosocial characteristics of inner-city children with asthma: a description of the NCICAS psychosocial protocol. National Cooperative Inner-City Asthma Study.

Previous research has demonstrated a significant reciprocal relationship between psychosocial factors and asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated both asthma-specific and non-specific psychosocial variables, including asthma knowledge beliefs and management behavior, caregiver and child adjustment, life stress, and social support. This article presents these psychosocial characteristics in 1,528 4-9-year-old asthmatic urban children and their caretakers. Caretakers demonstrated considerable asthma knowledge, averaging 84% correct responses on the Asthma Information Quiz. However, respondents provided less than one helpful response for each hypothetical problem situation involving asthma care, and most respondents had more than one undesirable response, indicating a potentially dangerous or maladaptive action. Both adults and children reported multiple caretakers responsible for asthma management (adult report: average 3.4, including the child); in addition, children rated their responsibility for self-care significantly higher than did adults. Scores on the Child Behavior Checklist indicated increased problems compared to normative samples (57.3 vs. 50, respectively), and 35% of children met the criteria for problems of clinical severity. On the Brief Symptom Inventory, adults reported elevated levels of psychological distress (56.02 vs norm of 50); 50% of caretakers had symptoms of clinical severity. Caretakers also experienced an average of 8.13 undesirable life events in the 12 months preceding the baseline interview. These findings suggest that limited asthma problem-solving skills, multiple asthma managers, child and adult adjustment problems, and high levels of life stress are significant concerns for this group and may place the inner-city children in this study population at increased risk for problems related to adherence to asthma management regimens and for asthma morbidity.

Ego development and chronic illness in adolescents.

To examine the effects of chronic illness on the psychological growth process known as ego development, scores were compared on the Loevinger Sentence Completion Test for 36 teens (16 boys, 20 girls) with chronic illness and 50 teens (16 boys, 34 girls) without chronic illness. Their ages ranged from 13 to 21 years, with a mean of 17.4 years. Most were Black (37%) or Hispanic (41%) and lived in poor or working-class neighborhoods. When age, sex, and Peabody Picture Vocabulary Test (PPVT) scores were controlled in multiple regression analyses, no direct association between ego development stage and presence of chronic illness, severity of illness, age at onset, or duration of illness was found. Analysis of the chronically ill group alone revealed a significant PPVT X Severity interaction, indicating that ego development in chronically ill teens is lower when illness is more severe and verbal IQ is higher.

Pulmonary hemosiderosis in scimitar syndrome after prolonged management of pulmonary hypertension.

OBJECTIVE: To report a fatal outcome from pulmonary hemosiderosis in an infant with scimitar syndrome after prolonged pulmonary vasodilator therapy. DESIGN: Case report. SETTING: A tertiary care pediatric intensive care unit. SUBJECT: An infant with scimitar syndrome. INTERVENTIONS: Treatment included redirection of anomalous right pulmonary venous drainage and closure of atrial septal defect, assisted ventilation via tracheostomy, and protracted nitric oxide and prostacyclin therapy until his death at 1 yr of age. RESULTS: Inhaled nitric oxide (iNO) and/or prostacyclin (PGI(2)) were administered for 6.5 months. Numerous echocardiograms demonstrated good control of pulmonary pressures and no evidence of pulmonary venous obstruction. Repeated attempts to slowly wean from the pulmonary vasodilators resulted in return of pulmonary pressures to systemic levels. Although there was no clinically apparent hemoptysis, pulmonary infiltrates worsened, prompting an open-lung biopsy that revealed pulmonary hemosiderosis. During the last 4 days of the patient's life, the pulmonary hypertensive crises with suprasystemic pressures and pulmonary infiltrates worsened regardless of aggressive vasodilator therapy with iNO, PGI(2), alkalinization, and isoproterenol. Vasodilator therapy was withdrawn and the patient rapidly died. CONCLUSION: We achieved long-term control of pulmonary hypertension with iNO and/or PGI(2) without apparent tachyphylaxis or other major reported side effects. Although pulmonary hypertension was successfully controlled with prolonged iNO and intravenous PGI(2) administration in this patient with scimitar syndrome, the patient died of hypoxemic respiratory failure from pulmonary hemosiderosis. Early evaluation of roentgenographic infiltrates for hemosiderosis and potential lung transplantation in similar patients may be warranted.

Corporal punishment.

Pediatricians differ on the optimal ways to discipline children. The major controversy surrounds the use of corporal punishment. In an effort to resolve this controversy, the American Academy of Pediatrics (AAP) cosponsored a conference entitled "The Short and Long-Term Consequences of Corporal Punishment" in February 1996. This article reviews scientific literature on corporal punishment and summarizes the proceedings from the conference. The authors conclude that, although the research data are inadequate to resolve the controversy, there are areas of consensus. Practitioners should assess the spanking practices of the parent they see and counsel parents to avoid those that are, by AAP consensus, dangerous, ineffective, or abusive.

Bilaminate synthetic dressing for partial thickness burns. Lack of cost reduction for inpatient care.

Forty-nine cases of second degree burns initially treated as inpatients from April 1984 through December 1987 are reviewed. Thirty-four patients were treated with bilaminate synthetic dressing (Biobrane) application, while 15 were treated with a topical antimicrobial, usually silver sulfadiazine. The burns ranged from 1 to 25 per cent total body surface area and were comparable in both groups. The mean age in each group was 30 years. Thirty patients were successfully treated with Biobrane, and their average hospital stay was 9.1 +/- 5.4 days compared with 9.2 +/- 8.6 days for the topically treated group. The mean hospital cost for dressings and supplies for the Biobrane group was $360 +/- $90 compared with $310 +/- $190 for the topical group. Four patients (12%) required Biobrane removal during their hospitalization, one due to increasing burn depth and three due to purulent fluid collections beneath the Biobrane. These burns were subsequently treated with topical antimicrobial agents and healed primarily. The mean total hospital stay for this group was 18.0 +/- 11.9 days with the costs being much higher secondary to the initial cost of the Biobrane, the costs associated with topical antibiotic therapy, and extended hospital stay. Although there was a decrease in nursing time and a subjective decrease in patient discomfort associated with using synthetic dressing, no benefit was found in either decreasing hospital stay or total cost of hospitalization and supplies used for inpatients treated at this institution.

The use of parent report to assess the quality of care in primary care visits among children with asthma.

OBJECTIVE: To determine the accuracy of parent report and the accuracy of the medical record in documenting physician performance of elements of pediatric asthma care in the primary care setting. METHODS: A convenience sample of 79 English-speaking parents of 4--12-year old children with asthma presenting to medical center--affiliated inner-city primary care pediatric clinics in the Bronx, Dallas, and Chicago was enrolled, and the office visit was audiotaped. Parents were interviewed 1--16 days after the visit by telephone. OUTCOME MEASURES: Accuracy of parent report was the primary outcome. The "reference standard" was an independent evaluation of the audiotaped record of the primary care visit. The National Asthma Education and Prevention Program was used as a guide to select data elements to assess quality of pediatric asthma care during primary care visits. RESULTS: Sufficient documentation was significantly (P <.001) less likely to be present in the medical record than in the follow-up interview for each element of care. When these elements were combined into a cumulative score, 71% of parent interviews but only 37% of medical records scored > or = 5 (out of a possible 6), with 29% of medical records scoring < 3. Parents were able to accurately report (concordance of parent data with audiotape reference standard) whether or not the visit had included performance of 5 of the 6 elements of care. CONCLUSIONS: Our study suggests that parent telephone interview within 2 weeks after the visit is more accurate than the medical record for documentation of the quality of asthma care in pediatric primary care visits. The medical record was not sufficient to assess the quality of primary care related to asthma, primarily because of missing data. Therefore, our data suggest that assessing quality of care using the medical record will not only bias the findings in the direction of more deficient care but will also make improvement in care more difficult. Further validation of our strategy for using parent report to assess the quality of care in primary care visits will require its application in a variety of other primary care settings.