Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale-Revised

OBJECTIVE

This study aimed to assess the agreement between patients presenting to the pediatric emergency department (ED) with acute pain and their caregivers when using the Wong-Baker FACES (WBF) and Faces Pain Scale-Revised (FPS-R).

METHODS

This was a prospective, observational study examining patients 3 to 7.5 years old presenting to a pediatric ED with acute pain. Participants completed the WBF and FPS-R twice during their ED evaluation. Caregivers rated their child's pain using both the WBF and FPS-R at the same time points. Intraclass correlations (ICCs) were calculated between caregiver and child reports at each time point, and Bland-Altman plots were created.

RESULTS

Forty-six subjects were enrolled over 5 months. Mean age was 5.5 ± 1.2 years. Average initial child pain scores were 6.6 ± 2.8 (WBF) and 6.1 ± 3.3 (FPS-R), and repeat scores were 3.3 ± 3.4 (WBF) and 3.1 ± 3.3 (FPS-R). Average initial caregiver pain scores were 6.3 ± 2.4 (WBF) and 6.2 ± 2.3 (FPS-R), and repeat scores were 3.4 ± 2.0 (WBF) and 3.4 ± 2.1 (FPS-R). On initial assessment, ICCs between children and caregivers using the FPS-R and WBF were 0.33 and 0.22, respectively. On repeat assessment, the ICCs were 0.31 for FPS-R and 0.26 for WBF. Bland-Altman plots showed poor agreement but no systematic bias.

CONCLUSION

There was poor agreement between caregivers and children when using the WBF and FPS-R for assessment of acute pain in the ED. Caregiver report should not be used as a substitute for self-report of pain if possible.

Analysis of Milk-Based Infant Formula. Phase IV. Iodide, Linoleic Acid, and Vitamins D and K: U.S. Food and Drug Administration-Infant Formula Council: Collaborative Study

In 1982, the U.S. Food and Drug Administration, the Infant Formula Council and its member companies, contract laboratories, and other government laboratories began a study of analytical methods for the nutrients listed in the Infant Formula Act of 1980. Phases I, II, III, and V have been completed. The present report provides data on Phase IV, in which 13 laboratories collaboratively studied an ion-selective electrode method for analyzing iodide, a gas chromatographic method for linoleic acid, and 2 liquid chromatographic (LC) methods each for vitamins D and K. Data were insufficient to evaluate one each of the LC methods studied for vitamins K and D. The relative standard deviations (RSD) are sufficient for the nutrient levels found in infant formula. RSDs (%) for repeatability (RSDr) and reproducibility (RSDR), respectively, were as follows: iodide, 4.0-11.4 and 13.5-18.2; linoleic acid, 1.0-1.6 and 3.5-5.1; vitamin K1, 3.2-16.0 and 6.2-19.4; and vitamin D3,4.2 and 35.0. The recommendation to adopt the method for vitamin D was supported by the results of a ministudy. All laboratories were capable of using these methods with little training. The methods for determination of iodide, linoleic acid, and vitamins D and K in ready-to-feed milkbased infant formula have been adopted first action by AOAC International.

Pediatric Thoracic Trauma: Recognition and Management

Thoracic injuries account for less than one-tenth of all pediatric trauma-related injuries but comprise 14% of pediatric trauma-related deaths. Thoracic trauma includes injuries to the lungs, heart, aorta and great vessels, esophagus, tracheobronchial tree, and structures of the chest wall. Children have unique anatomic features that change the patterns of observed injury compared with adults. This review article outlines the clinical presentation, diagnostic testing, and management principles required to successfully manage injured children with thoracic trauma.

Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures

OBJECTIVES

We compared the tolerability and efficacy of intranasal subdissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger noninferiority trial that could investigate the potential opioid-sparing effects of intranasal ketamine.

METHODS

This randomized controlled trial compared 1 mg/kg intranasal ketamine to 1.5 μg/kg intranasal fentanyl in children 4 to 17 years old with acute pain from suspected isolated extremity fractures presenting to an urban Level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under U.S. regulations. All patients were monitored until 6 hours after their last dose of study drug or until admission to the hospital ward or operating room.

RESULTS

Of 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median (interquartile range) age was 8 (6-11) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73 ± 26) and fentanyl (69 ± 26; mean difference [95% CI] = 4 [-7 to 15]). The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30; 73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44 ± 36 for ketamine and 35 ± 29 for fentanyl (mean difference = 9 [95% CI = -4 to 23]). Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study.

CONCLUSIONS

Intranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, noninferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid-sparing benefits of intranasal ketamine analgesia for children with acute pain.

Subdissociative intranasal ketamine plus standard pain therapy versus standard pain therapy in the treatment of paediatric sickle cell disease vaso-occlusive crises in resource-limited settings: study protocol for a randomised controlled trial

INTRODUCTION

Pediatric sickle cell disease, highly prevalent in sub-Saharan Africa, carries great morbidity and mortality risk. Limited resources and monitoring make management of acute vaso-occlusive crises challenging. This study aims to evaluate the efficacy and safety of subdissociative intranasal ketamine as a cheap, readily available and easily administered adjunct to standard pain therapy. We hypothesise that subdissociative, intranasal ketamine may significantly augment current approaches to pain management in resource-limited settings in a safe and cost-effective manner.

METHODS AND ANALYSIS

This is a multicentred, randomised, double-blind, placebo-controlled trial enrolling children 4-16 years of age with sickle cell disease and painful vaso-occlusive pain crises. Study sites include two sub-Saharan teaching and referral hospitals with acute intake areas. All patients receive standard analgesic therapy during evaluation. Patients randomised to the treatment arm receive 1 mg/kg intranasal ketamine at onset of therapy, while placebo arm participants receive volume-matched intranasal normal saline. All participants and clinical staff are blinded to the treatment allocation. Data will be analysed on an intention-to-treat basis. Primary endpoints are changes in self-report pain scales (Faces Pain Scale-Revised) at 30, 60 and 120 minutes and rates of adverse events. Secondary endpoints include hospital length of stay, total analgesia use and quality of life assessment 2-3 weeks postintervention.

ETHICS AND DISSEMINATION

The research methods for this study have been approved by the Cameroon Baptist Convention Health Board Institutional Review Board (IRB2015-07), the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol. IX/2299), Muhimbili National Hospital IRB (MNH/IRB/I/2015/14) and the Tanzanian Food and Drugs Authority (TFDA0015/CTR/0015/9). Data reports will be provided to the Data and Safety Monitoring Board (DSMB) periodically throughout the study as well as all reports of adverse events. All protocol amendments will also be reviewed by the DSMB. Study results, regardless of direction or amplitude, will be submitted for publication in relevant peer-reviewed journals.

TRIAL REGISTRATION

ClinicalTrials.Gov, NCT02573714. Date of registration: 8 October 2015. Pre-results.

Study protocol of a randomised controlled trial of intranasal ketamine compared with intranasal fentanyl for analgesia in children with suspected, isolated extremity fractures in the paediatric emergency department

INTRODUCTION

Fentanyl is the most widely studied intranasal (IN) analgesic in children. IN subdissociative (INSD) ketamine may offer a safe and efficacious alternative to IN fentanyl and may decrease overall opioid use during the emergency department (ED) stay. This study examines the feasibility of a larger, multicentre clinical trial comparing the safety and efficacy of INSD ketamine to IN fentanyl and the potential role for INSD ketamine in reducing total opioid medication usage.

METHODS AND ANALYSIS

This double-blind, randomised controlled, pilot trial will compare INSD ketamine (1 mg/kg) to IN fentanyl (1.5 μg/kg) for analgesia in 80 children aged 4-17 years with acute pain from a suspected, single extremity fracture. The primary safety outcome for this pilot trial will be the frequency of cumulative side effects and adverse events at 60 min after drug administration. The primary efficacy outcome will be exploratory and will be the mean reduction of pain scale scores at 20 min. The study is not powered to examine efficacy. Secondary outcome measures will include the total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the ED stay, number and reason for screen failures, time to consent, and the number and type of protocol deviations. Patients may receive up to 2 doses of study drug.

ETHICS AND DISSEMINATION

This study was approved by the US Food and Drug Administration, the local institutional review board and the study data safety monitoring board. This study data will be submitted for publication regardless of results and will be used to establish feasibility for a multicentre, non-inferiority trial.

TRIAL REGISTRATION NUMBER

NCT02521415.

Parasitic scabies mites and associated bacteria joining forces against host complement defence

Scabies is a ubiquitous and contagious skin disease caused by the parasitic mite Sarcoptes scabiei Epidemiological studies have identified scabies as a causative agent for secondary skin infections caused by Staphylococcus aureus and Streptococcus pyogenes. This is an important notion, as such bacterial infections can lead to serious downstream life-threatening complications. As the complement system is the first line of host defence that confronts invading pathogens, both the mite and bacteria produce a large array of molecules that inhibit the complement cascades. It is hypothesised that scabies mite complement inhibitors may play an important role in providing a favourable micro-environment for the establishment of secondary bacterial infections. This review aims to bring together the current literature on complement inhibition by scabies mites and bacteria associated with scabies and to discuss the proposed molecular link between scabies and bacterial co-infections.

Investigation into the validity of extrapolation in setting maximum residue levels for pesticides in crops of similar morphology

Field trials were initiated to investigate if extrapolation procedures, which were adopted to limit costs of pesticide registration for minor crops, are valid. Three pairs of crops of similar morphology; carrots/swedes, cauliflower/calabrese (broccoli) and French beans/edible-podded peas; were grown in parallel at four different geographical locations within the UK. The crops were treated with both systemic and non-systemic pesticides under maximum registered use conditions, i.e. the maximum permitted application rates and the minimum harvest intervals. Once mature, the crops were harvested and analysed for residues of the applied pesticides. The limits of quantification were in the range 0.005-0.02 mg kg(-1). Analysis of variance and bootstrap estimates showed that in general, the mean residue concentrations for the individual pesticides were significantly different between crop pairs grown on each site. Similarly, the mean residue concentrations of most of the pesticides in each crop across sites were significantly different. These findings demonstrate that the extrapolations of residue levels for most of the selected pesticide/crop combinations investigated; chlorfenvinphos and iprodione from carrots to swedes; carbendazim, chlorpyrifos, diflubenzuron and dimethoate from cauliflower to calabrese; and malathion, metalaxyl and pirimicarb from French beans to edible-podded peas; appear invalid.

Occurrence and risks associated with chlormequat residues in a range of foodstuffs in the UK

Trends in the usage pattern of chlormequat (a plant growth regulator) on cereal crops in the UK over the past 6 years are presented. The figures have been supplemented by monitoring of chlormequat residues in food commodities through the UK surveillance programme, and for cereals, the carry-through into a number of processed cereal-based foods has been followed. A downward trend of chlormequat residue levels in pears sampled between 1997 and 2002 was observed. This decline reflects changes that were introduced in European and national regulations and which have proven to be extremely effective in reducing both the frequency of detection and levels of chlormequat residues. Both acute and chronic risk assessments were undertaken based on aggregate dietary exposure data. Even when the highest residues observed were used in the calculations, the assessments showed that both the short- and long-term intakes for all consumer groups would be unlikely to cause adverse health effects and were therefore not of any cause for concern.

Guardianship primavera: a first look at factors associated with having a legal guardian using a nationally representative sample of community-dwelling adults

Although guardianship is an intrusive intervention that usually removes an adult's basic civil rights, studies of factors that place adults at risk for guardianship have largely been based on small studies of court files. While important and informative, these studies do not allow us to draw anything but tentative conclusions on risk factors for guardianship. The purpose of this article is to examine risk factors for having a legal guardian using a nationally representative sample for the first time. Logistic regression was conducted on the probability of having a legal guardian, using the Andersen model of health care utilization adapted for factors implied by the guardianship literature. The National Health Interview Supplement on Disability (1995) sample consisted of 65,013 adults aged 19 and older, and a sub-sample aged 60 and older (n = 13,784). Results indicate, first, that the prevalence of guardianship in community-dwelling adults is 0.3 percent, or over 750,000 people. Second, particularly for older adults, increasing age, having physical or emotional limitations, a small family network, and not living with a spouse are associated with having a guardian. Decreasing size of family networks and increasing marital disruption in future cohorts of older adults may suggest increasing need for legal guardianship. Further study should be conducted to replicate these findings in other large data sets and in extensive community studies.

Assessment of the stability of pesticides during cryogenic sample processing. 1. Apples

An assessment of the stability of a large number (106) of pesticides and related compounds during the cryogenic sample processing of apples has been undertaken. For the first time the procedure included an assessment of the losses during the freezing of the fruits, prior to processing. The stability of each pesticide during processing was assessed by comparing the mean recovery for the laboratory-spiked samples with the mean "survival" of the pesticides in cryogenically processed samples. The results clearly demonstrate that the vast majority, 94 of 106, of pesticides were stable during cryogenic processing. Of particular importance was that losses of several pesticides [bitertanol (95%), heptenophos (50%), isofephos (40%), and tolylfluanid (48%)] reported to occur during ambient processing of apples did not occur during cryogenic processing. Losses of dichlofluanid (54%), chlozolinate (22%), and etridiazole (40%), previously reported to occur during ambient processing of apples, were reduced to barely significant levels (10, 17, and 14%, respectively) by cryogenic processing. Small apparent losses for a few of the compounds were attributable to analytical and sample handling difficulties, rather than to losses during processing, and need further investigation.

Examining the direct costs and effectiveness of syphilis detection by selective screening and partner notification

Selective screening and partner notification are two principal means of preventing and controlling syphilis in the United States, yet few studies have been undertaken to compare and evaluate the cost or effectiveness of detecting syphilis using either strategy. The objective of this paper is to assess from the perspective of a health department the cost-effectiveness of selective screening compared with the strategy of partner notification in the detection of early syphilis in Houston, Texas, in 1994 and 1995. The cost-effectiveness analysis was performed using the recurring direct costs associated with detecting syphilis by both strategies. The middle estimates for the total direct costs associated with selective screening and partner notification were $579,101 and $229,529, respectively, for the 1466 and the 567 cases of early syphilis detected. On a cost per case basis, selective screening was more cost-effective than partner notification in the detection of primary, secondary and maternal syphilis cases. However, when consideration was given to prophylactic treatment, partner notification was more cost-effective in the detection of all early stage disease. Our findings suggest that the relative benefit of partner notification over selective screening depends on prophylactic treatment and an increase in worker productivity.

Taxon-specific oligonucleotide primers for detection of two ancient endomycorrhizal fungi, Glomus occultum and Glomus brasilianum

A unique oligonucleotide pair, GOCC56:GOCC427, was designed that correctly primed specific amplification of a approximately 370-bp sequence spanning the ITS and 5.8S rDNA regions of Glomus occultum and Glomus brasilianum. In addition, this primer pair successfully detected G. occultum and G. brasilianum DNA in nested PCR using a primary PCR product amplified from highly diluted extracts of colonized corn (Zea mays) roots using modified ITS1:ITS4 primers. A second primer pair, GBRAS86:GBRAS388, primed specific amplification of a approximately 200-bp sequence spanning the ITS and 5.8S rDNA regions present only in G. brasilianum and Glomus strain GR582. Combined use of both primer pairs provides the means to detect and differentiate two ancient endomycorrhizal species, G. occultum and G. brasilianum, undetectable by standard root staining procedures. Sequence analysis showed that the purported G. occultum strain GR582 is likely a strain of G. brasilianum.

Correlates of open- and locked-facility placement in a population of decisionally impaired adults

OBJECTIVES

This study compares characteristics of public conservatees placed in locked facilities with those in less restrictive settings. Given the principle of the least restrictive alternative, the study seeks to identify factors, including the role of aging and advanced age, associated with restrictive placement within conservatorship.

METHODS

Management Information Systems data on 1,534 adult conservatees in Los Angeles County in July, 1993, are examined in cross-section. Models exploring individual and environmental characteristics of conservatees and linear, curvilinear, and multiplicative aging effects are tested on the probability that adults are placed in locked facilities versus all other placement types.

RESULTS

Locked facility placement is associated with being female, receiving SSI, a diagnosis of dementia, and being identified as a danger to oneself and to others. Locked-facility placement is associated with increasing age until age 60, when the effect becomes inversely related; the multiplicative effect of older age and impaired functioning is also inversely related.

DISCUSSION

The curvilinear nature of age and the interaction effect of Age x Functioning implies that increasing frailty in older adults makes locked facility-placement less likely. Further research is needed on whether alternative placement types, such as special care units with secured perimeters, can further reduce the need for locked facilities.

Guidelines for in-house validation of analytical methods for pesticide residues in food and animal feeds

Criteria are presented by which analytical methods may be judged to have been validated for the determination of pesticide residues. All stages of analysis are addressed, from initial preparation of samples to the production of results, but with a focus on simplicity and cost-effectiveness of the requirements. Criteria are provided for both quantitative and qualitative (screening) methods and they may be applied to single- or multi-residue methods.

Trends in health and ability to work among the older working-age population

OBJECTIVES

Because of recent changes in Social Security regulations that will soon begin to raise the age of eligibility for full retirement benefits, it is important to determine whether health and ability to work at older ages have improved in recent years.

METHODS

Individual-level data from the National Health Interview Survey from 1982 through 1993 are used in this analysis. Trends in self-reported ability to work, presence of disease, and causes of actual work limitation are examined.

RESULTS

Men and women in their 60s, that is those in the older working ages and younger retirement ages, report significant improvement in their ability to work. The change in work ability is large enough so the percentage unable to work at age 67 in 1993 is lower than the percentage unable to work at age 65 in 1982. This improvement appears to have been similar for racial and ethnic groups and across educational subgroups of the population, although African Americans and those with lower educational attainment are less healthy to begin with. The improvement in health is due to the changing educational composition of the population, which is linked to better life-long health, different occupational circumstances, and better health behaviors. In addition, the improvement in work ability is explained by decline in the prevalence of cerebro/cardiovascular diseases and arthritis.

DISCUSSION

The level of observed improvement in work ability means that the legislated rise in age of full eligibility for Social Security benefits should be more than compensated for by the improved ability to work.

Does the use of ultrasonography improve the outcome of children with appendicitis?

OBJECTIVE

To determine whether the use of ultrasonography (US) improves the outcome of children with appendicitis.

METHODS

All cases of patients (<17 years old) with pathologically confirmed appendicitis treated in the ED between July 1992 and December 1995 were retrospectively reviewed.

RESULTS

231 charts met criteria for analysis. 100 (43%) patients had US prior to surgery. Age, race, and insurance status were similar for children in the US and non-US groups; there were no differences between the groups at presentation in mean temperature, mean WBC count, or percentage of children with vomiting, diarrhea, abdominal tenderness, or guarding. Those in the non-US group were more often male (71%, p=0.002) and more frequently had right lower quadrant pain (65%, p=0.003). Time from ED triage to the OR was 17.1 hours (US group) vs 10.4 hours (non-US group) (p=0.002). The perforation rates and the complication (abscess, wound infection, wound dehiscence) rates were similar for children in the two groups. Hospital charges were higher in the US group than in the non-US group ($14,123 vs $13,021, p=0.007).

CONCLUSION

The use of US did not result in early diagnosis of appendicitis, nor was it associated with a reduction in perforation or complication rates. Among children with clinical evidence of appendicitis, US was associated with a delay in surgery and an increase in hospital charges.

Cohort differences in disability and disease presence

Using the National Health Interview Surveys conducted from 1982 through 1993, this article examines cohort patterns in disability and disease presence for adults born between 1915 and 1959, at ages ranging from 30 to 69 years. In general, disability decreases for cohorts born between 1916 and the early 1940s (for men) or the early 1950s (for women), but begins to increase for cohorts born after those dates. Later-born cohorts have significantly lower levels of some diseases, most importantly cardiovascular diseases, arthritis, and emphysema. However, some diseases and conditions are more prevalent in later-born cohorts: asthma, musculoskeletal disorders, and orthopedic impairments. The results presented here indicate that adults born in the late 1940s and 1950s will be in better cardiovascular health but may be in worse musculoskeletal condition when they enter old age compared with current cohorts of older persons.

The carry-through of residues of maleic hydrazide from treated potatoes, following manufacture into potato crisps and 'jacket' potato crisps

Potatoes, which had been treated 'in the field' with a commercial formulation of maleic hydrazide, were processed into potato crisps and jacket potato crisps on a factory production line using standard manufacturing conditions. Samples were taken at strategic points throughout the process and analysed to determine the degree of carry-through of residues. Results demonstrated that ca 56% of the maleic hydrazide residue in a potato could be carried through into the potato crisps, irrespective of which type of crisp was being manufactured. Results from a similarly constructed study investigating the fate of pesticides applied post-harvest showed that carry-through was less than 10%. This difference is explained in terms of the different modes of action of the two classes of pesticides being investigated. It is known that, as maleic hydrazide is a systemic pesticide, it will be located within the flesh of the potato tuber and is therefore likely to be protected from the various stages of the crisping process. However, the post-harvest non-systemic pesticides are applied to the exterior surface of the tuber and are therefore not likely to be protected in the same way. The results also showed that, due to the concentration effect caused by the loss of moisture during crisp manufacture, the levels of maleic hydrazide residues in crisps (on a mg/kg product basis) were approximately twice those measured in the original potatoes.

The analysis of cyhexatin residues in apples, pears and kiwi fruit using inductively coupled plasma mass spectrometry as an initial screen for total tin, with confirmation by gas chromatography-mass spectrometry

Inductively coupled plasma-mass spectrometry (ICP-MS) has been used to determine concentrations of total tin in samples of apples, pears and kiwi fruit, following acid digestion. It was found that the background levels of tin in these fruits were normally below 0.06 mg/kg, which was equivalent to the target reporting limit for cyhexatin for this work of 0.2 mg/kg. The procedure was used to screen a total of 72 retail samples. Three apple samples contained tin at concentrations greater than 0.06 mg/kg. These three samples were re-analysed by a second confirmatory method using gas chromatography-mass spectrometry (GC-MS) as the determinative step. Results obtained by this method demonstrated that in fact, none of the samples contained cyhexatin residues at or above a reporting limit of 0.1 mg/kg. The use of ICP-MS as a preliminary screen substantially reduced the number of samples requiring analysis by GC-MS, thus reducing the cost of the survey (in terms of staff hours) by approximately 30%. The screening method could potentially be applied to other organometallic pesticide residues.

Criteria for placing older adults in public conservatorship: age as proxy for need

This study was conducted on a sample of 589 adult public conservatees in Los Angeles County, California, to determine whether the process used to assign them into conservatorship is age-blind, as California law suggests. Findings indicate that age is not associated with the amount of time spent evaluating adults for conservatorship but that increasing age, rather than need, is associated with assignment into Probate conservatorship. The association of age with Probate conservatorship appears to result from the vagueness of the criteria for Probate conservatorship-unable to manage-resulting in the use of age as a proxy for need in the case of decisionally impaired older adults.

Further evidence on recent trends in the prevalence and incidence of disability among older Americans from two sources: the LSOA and the NHIS

The Longitudinal Study on Aging (LSOA) and the National Health Interview Survey (NHIS) are used to examine change in the prevalence of disability from 1982 through 1993 for persons 70 years of age and over. Changes in the likelihood of becoming disabled and the likelihood of recovering from disability also are investigated with the LSOA. There is some evidence for improving disability status among the old. The prevalence of disability is somewhat lower in more recent years in the NHIS; also, the incidence of disability is lower, and the rate of recovery higher during 1988-90 than in the 1984-86 interval. On the other hand, the prevalence of disability increases at some dates after 1984 in the LSOA sample. In both datasets, there is fluctuation rather than a clear trend in the prevalence of disability. Continued steady improvement in rates of onset and recovery and a consistent trend toward improving prevalence is needed before concluding that we are witnessing the beginning of an ongoing trend toward improving health among the older population.

Determination of the pesticide fenbutatin oxide in tomatoes, cucumbers and bananas by high performance liquid chromatographic/atmospheric pressure chemical ionization-mass spectrometry

A rapid method, using high-performance liquid chromatography (HPLC)/ atmospheric pressure chemical ionization-mass spectrometry, has been developed for the determination of fenbutatin oxide in tomatoes, cucumbers and bananas. Samples were homogenized with sodium carbonate and ethyl acetate, filtered through sodium sulphate, concentrated and solvent exchanged into acetonitrile prior to analysis. HPLC was performed on a Hypercarb column with 10:90 acetic acid (5% v/v glacial acetic acid in water)/acetonitrile at a flow rate of 1 mL/min. Positive ionization selected-ion monitoring was performed on the 7 isotopic cluster ions from the tris(2-methyl-2-phenylpropyl) tin fragment. A comparison of solvent-based and extract-based standards showed that tomato and cucumber matrices had a slight enhancement effect on the signal intensity, whereas the banana matrix exerted a signal suppression effect. Calibration was linear over the range 0.25-5.0 ng/microL. The mean spike recoveries (extracts spiked at 0.5 mg/kg) were 88% for tomatoes and 80% for both cucumbers and bananas with relative standard deviations of 6%, 7% and 8% respectively. Limits of detection were commodity dependent and ranged from 0.06-0.12 ng/microL (equivalent to 0.01-0.02 mg/kg in the crop). Ionization was stable for long analytical time periods.

Extraction of maleic hydrazide residues from potato crisps and their determination using high-performance liquid chromatography with UV and atmospheric pressure chemical ionisation mass spectrometric detection

A method was required for the determination of maleic hydrazide residues in potato crisps. A published method for the extraction of the analyte from onions and potatoes was evaluated and found to be inappropriate due to the inability of the extracting solvent to penetrate the oily matrix. A method was developed to overcome this problem; the resulting recovery data (mean = 92.9%, R.S.D. = 8.3%, n = 16) confirmed its efficiency, and was used to analyse 48 retail potato crisp samples. To confirm possible residues identified by screening with HPLC-UV, an HPLC-atmospheric pressure chemical ionization MS method was developed. There was good agreement between the data obtained from the two detection techniques (R2 = 0.978, slope = 1.11).

Accreditation in the UK for pesticide residue analysis in foods

A brief background is provided of the European national bodies which accredit laboratories to the EN 45001 standard and their mutual recognition through the European Cooperation for Accreditation of Laboratories. Some of the requirements for accreditation of a laboratory, for example, the need to demonstrate traceability of measurements, are selectively illustrated with particular reference to the determination of pesticide residues in foods. The costs and benefits of accreditation are discussed.

The carry-through of residues of thiabendazole, tecnazene and chlorpropham from potatoes following manufacture into potato crisps and jacket potato crisps

Potatoes, commercially treated with thiabendazole, tecnazene and chlorpropham, were processed into potato crisps and jacket potato crisps at a crisp factory using standard manufacturing conditions. A multi-residue method based on gas chromatography with mass spectrometric detection was developed and used to determine pesticide residue levels in the potatoes and potato crisps. Results showed that the residues of all three pesticides were significantly reduced to less than 2% and less than 10% of the maximum theoretical residue carry-through level for potato crisps and jacket potato crisps respectively.

Survey of baked goods for propionic acid and propionates

One hundred and thirty samples comprising bread (64), hamburger buns (33), pittas (16), cakes (9) and Christmas puddings (8) from various retail outlets in the UK, have been analysed for the preservative propionic acid. Only one sample of bread, two samples of hamburger buns and three samples of pitta contained propionic acid in excess of 1000 mg/kg (range 1110-2625 mg/kg). The three samples of pitta exceeded 2000 mg/kg of propionic acid, which is the maximum amount permitted for these products under a recently adopted European Union directive.

Determination of the pesticide diflubenzuron in mushrooms by high-performance liquid chromatography-atmospheric pressure chemical ionisation mass spectrometry

A method using high-performance liquid chromatography-atmospheric pressure chemical ionisation mass spectrometry (HPLC-APCI-MS) has been developed and validated for the determination of the insecticide diflubenzuron [1-(4-chlorophenyl)-3-(2,6-difluorobenzoyl)urea] in mushrooms. Samples were homogenised with acetone, extracted into dichloromethane-cyclohexane and further cleaned-up by size-exclusion chromatography (SEC). HPLC was performed on an ODS column with methanol-water at 1 ml/min. The limit of detection was 0.02 ng/microl (equivalent to 0.017 mg/kg in the crop). The calibration was linear over the range 0.025-1.0 ng/microl. Recovery of diflubenzuron from spiked mushrooms (0.06-0.58 mg/kg) was 85.5% with a relative standard deviation of 14.5% (n = 56).

Rethinking alternatives to guardianship

This article describes, compares, and analyzes the roles and functions of guardianship and several decision-making interventions previously identified as potential alternatives to guardianship. An analytical framework, comprised of capacity, risk, complexity, and support, is developed to assess performance expectations and identify limitations of four types of decision-making interventions. Using case examples to illustrate how the framework applies to practice, the capacity of different types of interventions to address needs and to substitute or divert older adults from guardianship is examined. The article concludes with propositions introduced to guide future research.

Determination of the pesticides diflubenzuron and clofentezine in plums, strawberries and blackcurrant-based fruit drinks by high performance liquid chromatographic/atmospheric pressure chemical ionization-mass spectrometry

A high performance liquid chromatographic/atmospheric pressure chemical ionization-mass spectrometric (HPLC/APCI-MS) method has been developed for the determination of the pesticides diflubenzuron (1-(4-chlorophenyl)-3-(2,6-difluorobenzoyl)urea) and clofentezine (3,6-bis(2-chlorophenyl)-1,2,4,5-tetrazine) in plums, strawberries and blackcurrant-based fruit drinks. Samples were homogenized with acetone, extracted into dichloromethane + cyclohexane and cleaned-up by high performance gel permeation chromatography. HPLC was performed on an ODS column with methanol + water at 1 mL/min. Detection was by negative-ion selected-ion monitoring APCI-MS. Comparison of response with solvent and matrix-matched standards showed some enhancement of response for the latter, and these standards were consequently used for quantification. The calibration was linear over the range 0.05-0.50 ng/microL in all three matrices. The mean overall recovery of diflubenzuron and clofentezine from spiked extracts (0.086 mg/kg) in all three matrices was 76% and 70% respectively with relative standard deviations of 15% and 12% respectively (n = 12). The limit of detection was both compound and commodity dependent and ranged from 0.01-0.05 ng/microL, equivalent to 0.003-0.014 mg/kg in the crop.

Plasma beta-endorphin levels and childhood intussusception

To determine whether childhood intestinal intussusception is associated with elevated plasma beta-endorphin levels, a series of patients was studied prospectively. Fourteen patients (age range between 3 months and 7 years) presented to two university pediatric emergency departments in Chicago with clinical symptoms and signs of intussusception. Venous blood (2cc) was withdrawn for plasma beta-endorphin determination, followed by barium enema. Plasma beta-endorphin levels were measured by radioimmunoassay. The mean beta-endorphin level of the 8 patients with barium enema proven intussusception was 14.1 +/- 12.0 pg/ml. Two of these patients presented with marked lethargy and had beta-endorphin levels of 7.5 and 21.2 pg/ml. The mean plasma beta-endorphin level of the 5 patients with negative barium enema studies was 18.1 +/- 10.0 pg/ml (P = 0.56). A sixth control patient had a plasma beta-endorphin level of 1569 pg/ml. In conclusion, childhood intestinal intussusception is not associated with elevated plasma beta-endorphin levels.

Age differences and changes in reaction time: the Baltimore Longitudinal Study of Aging

This study analyzed auditory reaction time (RT) data from 1,265 community-dwelling volunteers (833 males and 432 females) who ranged in age from 17 to 96. Cross-sectional analyses revealed slowing of simple (SRT) and relatively greater slowing of disjunctive (DRT; aka "go-no-go") reaction time across decades for both males and females. Repeated testing within participants (longitudinal analyses) over eight years showed consistent slowing and increased variability with age. Males were faster than females cross age groups, RT tasks, and visits. Beginning at about age 20, RTs increased at a rate of approximately 0.5 msec/yr for SRT and 1.6 msec/yr for DRT. Errors also increased, making unlikely a tradeoff of accuracy for faster responses. The findings are consistent with the hypotheses that slowing of behavior is: (a) a continuous process over the adult life span; (b) characterized by age-associated increases in within-participant variability; (c) a direct function of task complexity and, presumably, the degree of mediation by higher regions in the central nervous system; and (d) greater in women than men.

Compartment syndrome secondary to prolonged intraosseous infusion

Intraosseous infusions are a valuable means of establishing intravascular access in pediatric emergencies. We report a case of compartment syndrome from prolonged intraosseous infusion (53 hours). We postulate that chemical irritation from medications, infections, the tenuous nature of intraosseous infusions, and the use of infusion pumps may all play a role in the development of compartment syndrome. We recommend that, when possible, intraosseous lines be used only temporarily until more permanent vascular access is established, that lines that do not flow with gravity be removed, and that drugs known to cause chemical burns be used with caution. In addition, the use of x-ray and hourly measurement of leg circumference may help to determine whether a line is still in place. Also, given the changing circumstances and technology under which intraosseous infusions are used, new prospective studies of their complications are needed.

Characterization of the principal colouring components of annatto using high performance liquid chromatography with photodiode-array detection

The principal colouring components of the natural food colouring material annatto, the 9'-cis- and all-trans- isomers of bixin and norbixin, have been prepared in pure form. A reverse-phase HPLC method utilizing photodiode-array detection has been developed to enable their chromatographic and spectroscopic characterization. One minor component, a di-cis-isomer of norbixin has also been identified and characterized.

A rapid capillary gas chromatographic method for the determination of propionic acid and propionates in bread and bread products

A rapid method for the determination of propionic acid and propionates in bread and bread products is reported. The method employs solvent extraction, filtration and quantification by capillary gas chromatography using an internal standard. The limit of determination was 10 mg kg-1 propionic acid. The mean recovery rates for spiked bread samples were 108% at approximately 1,000 mg kg-1 (range of 106-110%, coefficient of variation 1.1%), 97% at approximately 2,000 mg kg-1 (range 96-98%, coefficient of variation 0.7%) and 98% at approximately 3,000 mg kg-1 (range of 97-100% and coefficient of variation of 1.1%). The method offers improved sensitivity, precision, chromatographic resolution and a wider sample analyte concentration range over a previously reported packed-column gas chromatographic method and has been applied to the analysis of bread, rolls, pitta breads and hamburger buns.

The effect of home processing on postharvest fungicide residues in citrus fruit: residues of imazalil, 2-phenylphenol and thiabendazole in 'home-made' marmalade, prepared from late Valencia oranges

The effects of domestic marmalade-making procedures on residues of imazalil, 2-phenylphenol and thiabendazole in 'sweet' oranges were investigated by comparing residue levels in raw fruit and in marmalades, prepared by heating the oranges with water and sugar for about 4 h in a preserving pan on a gas ring or for about 1 h in a microwave oven. Determination of residues in raw oranges and in marmalades was carried out by extraction with dichloromethane, followed by clean-up and reversed phase HPLC with UV detection for imazalil and fluorescence detection for 2-phenylphenol and thiabendazole. Residue analysis showed that the extent of carry-through of imazalil, 2-phenylphenol and thiabendazole residues into the marmalades depended on the method of marmalade-making and the nature of the fungicide. Persistence of fungicides was higher in the marmalade prepared in the microwave oven than in that prepared in the preserving pan. An increase (about 50%) in levels of imazalil in the fruit portions of marmalades compared with raw fruit residue levels indicated that imazalil was more readily extracted from oranges after processing. Comparison of 2-phenylphenol levels in raw fruit and fruit portions of marmalades showed that the longer exposure to heat, needed for marmalade-making in a preserving pan, reduced residue levels more severely (48%) than cooking in the microwave oven (13%). Thiabendazole levels in the fruit portion of marmalade prepared in the microwave oven stayed the same as in the raw fruit, but cooking in the preserving pan decreased residue levels by about 22%.

The print media and aging policy: how differential coverage of Medicare Catastrophic led congress astray

This article examines the role of the print media in covering complex policy issues. Two models of journalism are considered. "Pack journalism" predicts that print media coverage will be highly consistent in content due to the reliance by those in the media on the same sources of information. In this article, another model--"Beltway journalism"--is proposed. It implies that coverage by the print media indigenous to the Washington, D.C. area (inside the Beltway) will diverge from that of other print media, presenting a potentially distorted view of the world to policymakers in Washington. Using the Washington Post and the Los Angeles Times as possible indicators of the two models, aging policy is addressed through a case study of newspaper coverage during passage and repeal of the Medicare Catastrophic Coverage Act of 1988. Findings suggest that Congress was unduly influenced by the way that Medicare Catastrophic was framed in the Washington Post, lending credence to the Beltway journalism model. By paying insufficient attention to the way Medicare Catastrophic was being framed by sources of print outside the Beltway area, lawmakers allowed themselves to assume a grassroots-level understanding of the issue and support for the bill, both of which turned out to be illusory.

Theophylline toxicity in children: a retrospective review

Theophylline has been a mainstay of asthma therapy despite its narrow therapeutic index, which makes toxicity a common problem. To study toxicity in children, we reviewed hospital laboratory records (1980 to 1988) and identified cases (n = 163) with theophylline concentrations of > 133 mumol/L (24 micrograms/ml). We reviewed these cases for symptoms of theophylline intoxication; we were interested in associating symptoms with serum drug concentrations and in understanding how intoxication occurred. The median patient age was 3.0 years; 40/163 were younger than one year. Males were 90/163 patients (55%). Patients were classified by pattern of ingestion: 20 patients had acute ingestions; 17 patients had an acute ingestion while on chronic medication; and 126 patients became toxic on chronic therapy. Symptoms were absent in 44/150 patients (29%) with theophylline concentrations of 139 to 278 mumol/L (25-50 micrograms/ml); concentrations of > 278 mumol/L (50 micrograms/ml) were always associated with symptoms. The most common clinical symptoms were tachycardia (47%) and vomiting (52%); both occurred more frequently with higher theophylline concentrations (P < 0.002 and P < 0.01). Nine patients had seizures, including five who were previously neurologically normal. Seizures developed with a theophylline concentration of < 278 mumol/L (50 micrograms/ml) in four of these five patients. There was no association between seizures and patient age or between seizures and a particular pattern of theophylline use. In 105/126 cases of intoxication associated with chronic use, the cause of the intoxication could not be determined. Appropriate management of theophylline toxicity can occur only if toxicity is recognized.(ABSTRACT TRUNCATED AT 250 WORDS)

Missed appendicitis in a pediatric emergency department

Appendicitis is the most common cause of abdominal pain requiring surgery in children. Missed appendicitis is also a frequent cause of professional liability in an emergency department (ED). A retrospective review of all patients with appendicitis diagnosed in the ED was undertaken to identify: 1) how many patients required more than one visit to diagnose appendicitis and 2) the clinical characteristics that distinguished the patients who visited twice from patients who were diagnosed on the first visit. A total of 87 patients with appendicitis were seen by pediatricians in the ED from 1987 to 1989. The patients included 43 girls and 44 boys (mean age, 8.9 years). Six patients (7%) were seen twice before the diagnosis of appendicitis was made. They returned to the ED on average 29 hours after the first visit. The ED discharge diagnosis of the six "missed" patients included: probable Campylobacter (n = 1), viral urinary tract infection (n = 1), gastroenteritis (n = 2), and abdominal pain (n = 2). The six missed patients were different from the other patients with appendicitis. They were more likely to have a normal appetite, to have diarrhea, and to be afebrile. All the patients had at least two of the four following signs and symptoms: vomiting, tenderness, guarding, and right lower quadrant (RLQ) pain. At the time of surgery, 23/81 (28%) of the one-visit group had a ruptured appendix, whereas 3/6 (50%) of the missed patients had a ruptured appendix.

CONCLUSIONS

1) Seven percent of the patients were seen twice in our ED before the diagnosis of appendicitis was made.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosing abdominal pain in a pediatric emergency department

We undertook a prospective study of 377 children (two to 16 years old) presenting with abdominal pain to determine: 1) common discharge diagnoses; 2) what signs and symptoms are associated with appendicitis; and 3) follow-up of patients discharged from the emergency department (ED). Nine diagnoses accounted for 86% of all diagnoses made. The most common final diagnosis was "abdominal pain" (36%). The following findings were significantly associated with appendicitis: vomiting, right lower quadrant(RLQ) pain, tenderness, and guarding (all P less than 0.001). Ninety-seven percent (28/29) of patients with appendicitis had at least two of these four signs and symptoms, as did 28% (96/348) of patients without appendicitis. The sensitivity of the model is 0.96, and the specificity is 0.72 (positive predictive value = 0.24; negative predictive value = 0.99). Of the patients contacted within one week of the visit (237), 75% reported that the pain had resolved (mean contact time, 2.6 days). We conclude that 1) patients presenting to the ED with abdominal pain often leave with the diagnosis of abdominal pain; 2) of the patients contacted, the majority reported that their pain has resolved; and 3) a diagnosis of appendicitis should be considered in any patient with any two of the following signs or symptoms: vomiting, guarding, tenderness, or RLQ pain. Such patients should be evaluated and observed carefully for the possible diagnosis of appendicitis.

Survey of animal livers for vitamin A content

Retail samples of livers from calf (23), ox (18), lamb (17), pig (15), chicken (16) and turkey (1) were analysed to determine levels of vitamin A (all trans-retinol) and to aid assessment of the effects of using vitamin supplemented compound feedingstuffs for livestock. For comparison, 22 liver samples from lambs reared on diets not containing vitamin-supplemented compound feedingstuffs and four samples of liver from ox which had received supplemented feed but not during the last four months prior to slaughter were also analysed. The chosen method of analysis utilized saponification, solvent extraction and normal-phase high performance liquid chromatography with fluorescence detection. For all species analysed, the levels of vitamin A ranged from 10 to 1100 mg/kg, with all but seven at or below 400 mg/kg. For lamb and ox livers, the mean levels were 310 mg/kg and 200 mg/kg respectively for retail samples. The mean levels were 220 mg/kg (lamb) and 120 mg/kg (ox) in liver samples from animals fed controlled diets. The results are of the same order as those reported over recent years.

Emergency department laboratory evaluation of children with seizures: dogma or dilemma?

Seizure is a common problem evaluated in pediatric emergency departments. Serum chemistry analysis is often performed as a routine part of the diagnostic evaluation of children who arrive in the ED with seizure. From this retrospective study, we sought to determine 1) how often serum electrolytes (Na, K, Cl, CO2), total calcium, magnesium, ammonia, and glucose chemistries were performed, 2) the frequency of abnormalities detected, and 3) whether abnormalities resulted in a change in patient care. Three hundred eight ED charts from 12 consecutive months were reviewed. Data collected included age, sex, ED diagnosis, medical history, and physical examination. Charts were also reviewed for diagnostic tests ordered and patient management. Children were classified as having febrile (FS) or nonfebrile seizures (NFS) to establish diagnostic evaluation practices for each group as well as to determine rates of laboratory abnormalities. Three hundred eight children were enrolled, 108 (35%) FS and 200 (65%) NFS. The mean ages of FS and NFS patients were 2.1 and 5.7 years, respectively (P less than 0.05, t-test). One hundred twenty-four of 308 (40%) children had at least one test performed; no abnormal test was thought to have caused seizure; none was treated. One hundred five of 308 (34%) were experiencing their first seizure. There was no difference in the likelihood of having a test ordered for children with a first seizure, regardless of seizure category. We concluded that 1) abnormal serum electrolytes, total calcium, magnesium, and glucose rarely cause seizure in children and 2) routine use of these tests in the ED is costly and does not contribute to seizure therapy.

The effects of microwave-baking and oven-baking on thiabendazole residues in potatoes

The effect of microwave- and oven-baking on residues of the postharvest fungicide thiabendazole (E 233) in potatoes was investigated by comparing amounts present in raw, microwave- and oven-baked tubers. The levels of residues in the whole potato tubers were based on the determination of thiabendazole in peelings and flesh of potato tubers by reversed-phase HPLC analysis with fluorescence and UV detection after extraction with dichloromethane in the presence of anhydrous sodium sulphate. Amounts of thiabendazole determined after microwave- and oven-baking showed that thiabendazole was predominantly retained in the peelings (96.3-98.8%) and not lost during the two types of processing treatments at ca. 100 degrees C. Thus residues did not migrate into the flesh of the tubers.

Children with abdominal pain: evaluation in the pediatric emergency department

In a retrospective study of children with abdominal pain in a pediatric emergency department, 371 children were identified during four seasonally diverse months. Half of the children were two to six years old, 32% were seven to 11 years old, and 19% were 12 to 16 years old. Forty-eight different diagnoses were made, but 10 diagnoses were given to 83% of the patients. We found an increased frequency of respiratory illnesses (12%) as compared to other studies. Appendicitis was the only surgical problem that occurred in more than one percent of the children. The diagnoses were classified as medical (64.4%), surgical (6.5%), and nonspecific (29.1%). chi 2 and multinomial logit analysis revealed that guarding and abdominal tenderness were the two symptoms which were most strongly associated with a surgical diagnosis. The goal of this work is to assist the busy emergency clinician with the difficult task of making expeditious and accurate diagnoses for children with abdominal pain.

Uteroplacental blood flow in the hypertensive, term pregnant, spontaneously hypertensive rat

Carbohydrate overfeeding throughout pregnancy prevents the progressive fall in blood pressure to normotensive levels during the last week of gestation in the spontaneously hypertensive rat. Cardiac output, organ blood flows, and vascular resistances, measured with radioactive-labeled microspheres, were compared in three groups: carbohydrate-supplemented (hypertensive) term-pregnant rats, control-fed (normotensive) term-pregnant rats, and control-fed (hypertensive) nonpregnant rats. Blood pressure remained elevated in the carbohydrate-supplemented pregnant rats because the normal decrease in total peripheral resistance did not occur. There were no significant differences in organ blood flows between hypertensive and normotensive pregnant rats, with the exception of a 26% lower placental blood flow in the hypertensive versus the normotensive rats. Carbohydrate overfeeding was associated with reduced litter size but did not affect fetal growth. Both placental blood flow and litter size were inversely related to mean arterial blood pressure at term. This may be a useful model of essential hypertension during pregnancy.

The effect of hydralazine on placental perfusion in the spontaneously hypertensive rat

Intravenous hydralazine was administered to 16 spontaneously hypertensive rats on day 21 of gestation. The radioactive labeled microsphere technique was used to assess the change in organ perfusion produced by the drug. Vascular resistance to most organs was decreased, except to the placentas, stomach, and cecum, where it increased by 43%, 104%, and 44%, respectively. Blood flow to the organs was redistributed, and although it was increased to the lungs, kidneys, liver, and adrenals, it was significantly reduced to the spleen, stomach, placentas, cecum, large intestine, and pancreas. The effect of hydralazine on placental perfusion was opposite to the effect on the uterus (myometrium). Patients with the highest blood pressures tend to have the poorest placental perfusion. Intravenous hydralazine should be used cautiously in these patients.

The effect of carbohydrate overfeeding on blood pressure in the pregnant, spontaneously hypertensive rat

Carbohydrate overfeeding increases blood pressure in the spontaneously hypertensive rat. This study was undertaken to determine if dietary carbohydrate supplementation throughout pregnancy could prevent the normal fall in blood pressure during the last week of gestation. Systolic blood pressure in the control-fed pregnant rats decreased progressively during the last week and was in the normotensive range by term; that of the carbohydrate-supplemented, pregnant rats remained high and was not significantly lower than that of nonpregnant rats at any time. At term, daily urinary norepinephrine excretion, but not epinephrine excretion, by the carbohydrate-supplemented pregnant rats was twice that of control-fed nonpregnant and pregnant rats, suggesting that the hypertension was due to increased sympathetic nervous activity. Carbohydrate supplementation had no effect on blood pressure or catecholamine excretion in pregnant, normotensive Wistar-Kyoto rats. There were no differences in litter size or mean birth weight between diet treatment groups of either strain.

Catecholamine-mediated reduction in uteroplacental blood flow in the diet-restricted, term-pregnant rat

To determine whether the reduction in maternal placental blood flow associated with malnutrition during pregnancy results from alpha-adrenergic vasoconstriction, we measured cardiac output, uteroplacental blood flow and uteroplacental vascular resistance in ad libitum-fed and in 50% diet-restricted term-pregnant rats, using radioactive-labeled microspheres before, and again after, alpha-adrenergic receptor blockade with phenoxybenzamine. Uteroplacental blood flow in the diet-restricted rats was 40% lower than that of the ad libitum-fed rats, before phenoxybenzamine. Phenoxybenzamine caused a 50% reduction in mean blood pressure in both the ad libitum-fed and diet-restricted rats, but did not alter cardiac output. Phenoxybenzamine decreased preplacental vascular resistance in the diet-restricted rats, resulting in no significant reduction of placental blood flow. In the ad libitum-fed rats, on the other hand, phenoxybenzamine did not alter preplacental vascular resistance, and placental blood flow decreased 45% with the fall in blood pressure. Myometrial vascular resistance was unaffected by phenoxybenzamine in either group, and myometrial blood flow decreased with the fall in blood pressure in both groups. Thus, the decreased uteroplacental blood flow associated with diet restriction is the result of increased uteroplacental alpha-adrenergic vasomotor tone.