Using data from a survey of deaths of children less than 5 years old conducted in 1997 in a county in Shaanxi Province, China, this paper examines gender differences in child survival in contemporary rural China. First, excess female child mortality in the county in 1994-96 is described, followed by an analysis of the mechanisms whereby the excess mortality takes place, and the underlying social, economic and cultural factors behind it. Excess female child mortality in this county is probably caused primarily by discrimination against girls in curative health care rather than in preventive health care or food and nutrition. Although discrimination occurs in all kinds of families and communities, discrimination itself is highly selective, and is primarily against girls with some specific characteristics. It is argued that the excess mortality of girls is caused fundamentally by the strong son preference in traditional Chinese culture, but exacerbated by the government-guided family planning programme and regulations. This suggests that it is crucial to raise the status of girls within the family and community so as to mitigate the pressures to discriminate against girls in China's low fertility regime. Finally, the possible policy options to improve female child survival in contemporary rural China are discussed.

Background: Poison control centers (PCCs) reduce health care costs for childhood poisonings by providing telephone advice for home management of most cases. Past research suggests that PCCs are underutilized by low-income minority and Spanish-speaking parents because of lack of knowledge and misconceptions about the PCC. A videotape intervention was designed to address these barriers to PCC use.

Objective: To evaluate the effectiveness of a videotape intervention (videotape, PCC pamphlet, and PCC stickers) in improving knowledge, attitudes, behaviors, and behavioral intention regarding use of the PCC in a low-income and predominantly Spanish-speaking population in Northern California.

Methods: Two hundred eighty-nine parents of children 6 years of age, attending educational classes at 2 Women, Infant, and Children (WIC) clinics participated in a randomized, controlled trial. WIC classes were randomized to receive the video intervention (video group) or to attend the regularly scheduled WIC class (control group). Participants completed a baseline questionnaire and 2 to 4 weeks later, a follow-up telephone interview. Changes from baseline to posttest were compared in the treatment and control groups using analysis of variance.

Results: Compared with the control group, the video group showed an increase in knowledge about the PCC's function, its hours of operation, and staff qualifications; was more likely to feel confident in speaking with and carrying out recommendations made by the PCC; was less likely to believe the PCC would report a mother for neglect; was more likely to have the correct PCC phone number posted in their homes; and when presented with several hypothetical emergency scenarios, was more likely to correctly answer that calling the PCC was the best action to take in a poisoning situation.

Conclusions: This videotape intervention was highly effective in changing knowledge, attitudes, behaviors, and behavioral intentions concerning the PCC within this population. As a result, use of this video may help increase use of the PCC by low-income and Spanish-speaking families.

Context Substantial discrepanies exist between clinical diagnoses and findings at autopsy. Autopsy may be used as a tool for quality management to analyze diagnostic discrepanies.

Objective To determine the rate at which autopsies detect important, clinically missed diagnoses, and the extent to which this rate has changed over time.

Data Sources A systematic literature search for English-language articles available on MEDLINE from 1966 to April 2002, using the search terms autopsy, postmortem changes, post-mortem, postmortem, necropsy, and posthumous, identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. Reference lists were reviewed to identify additional studies, and the final bibliography was distributed to experts in the field to identify missing or unpublished studies.

Study Selection Included studies reported clinically missed diagnoses involving a primary cause of death (major errors), with the most serious being those likely to have affected patient outcome (class I errors).

Data Extraction Logistic regression was performed using data from 53 distinct autopsy series over a 40-year period and adjusting for the effects of changes in autopsy rates, country, case mix (general autopsies; adult medical; adult intensive care; adult or pediatric surgery; general pediatrics or pediatric inpatients; neonatal or pediatric intensive care; and other autopsy), and important methodological features of the primary studies.

Data Synthesis Of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors. Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5% (range, 4.1%-49.8%) for major errors and 9.0% (range, 0%-20.7%) for class I errors. Analyses of diagnostic error rates adjusting for the effects of case mix, country, and autopsy rate yielded relative decreases per decade of 19.4% (95% confidence interval [CI], 1.8%-33.8%) for major errors and 33.4% (95% [CI], 8.4%-51.6%) for class I errors. Despite these decreases, we estimated that a contemporary US institution (based on autopsy rates ranging from 100% [the extrapolated extreme at which clinical selection is eliminated] to 5% [roughly the national average]), could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%.

Conclusion The possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, but remains sufficiently high that encouraging ongoing use of the autopsy appears warranted.

Background: Policy and clinical decisions regarding children's nutrition are often based on dietary intake estimates from self-reports. The accuracy of these estimates depends on memory of both the type of food eaten and the amount consumed. Although children's self-reports of food intake are widely used, there is little research on their ability to estimate food portions.

Objective: To assess the validity of children's estimates of the food portions they consume by means of 2 types of measurement aids: standard 2-dimensional food portion visuals and manipulative props.

Design: Randomized controlled trial.

Participants: Fifty-four African American girls aged 8 to 12 years.

Main Outcome Measures: Girls were served a standard meal and actual intake was assessed by weighing food portions before and after the meal. On completion of the meal, dietitians collected food recalls and portion size estimates from the girls by means of both manipulative props and 2-dimensional food portion visuals, administered in a randomized order.

Results: Absolute value percentage differences between actual and estimated grams of food consumed averaged 58.0% (SD, 102.7%) for manipulative props and 32.8% (SD, 72.8%) for 2-dimensional food portion visuals. Spearman correlations between actual and estimated intakes with both portion size measurement aids were high (range, r = 0.56 to 0.79; all P.001), with the exception of bread intake (r = 0.16, P =.43). Correlations with actual intakes did not differ significantly between the 2 methods.

Conclusions: Children's self-reported portion size estimates are appropriate for ranking children's relative intakes, but they result in sizable errors in quantitative estimates of food and energy intakes. Caution should be used in interpreting quantitative dietary intake estimates derived from children's self-reports.

Background: Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.

Objective: To assess the relationships between multiple measures of asthma disease status over time.

Design/Methods: We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.

Results: Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.

Conclusions: These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.

Objective. To evaluate the costs and benefits of a group B streptococci screening strategy using a new, rapid polymerase chain reaction test in a hypothetical cohort of expectant mothers in the United States.

Methods. Design. Cost-benefit analysis using the human capital method. We developed a decision model to analyze the costs and benefits of a hypothetical group B streptococci screening strategy using a new, rapid polymerase chain reaction test as compared with the currently recommended group B streptococci screening guidelines-prenatal culture performed at 35 to 37 weeks or risk-factorbased strategy with subsequent intrapartum treatment of the expectant mothers with antibiotics to prevent early-onset group B streptococcal infections in their infants.

Participants. A hypothetical cohort of pregnant women and their newborns.

Interventions. Screening strategies for group B streptococci using the new polymerase chain reaction technique, the 35- to 37-week culture, or maternal risk factors.

Outcome Measures. Infant infections averted, infant deaths, infant disabilities, costs, and societal benefits of healthy infants.

Results. A screening strategy using the new polymerase chain reaction test generates a net benefit of $7 per birth when compared with the maternal risk-factor strategy. For every 1 million births, 80 700 more women would receive antibiotics, 884 fewer infants would become infected with early-onset group B streptococci, and 23 infants would be saved from death or disability. The polymerase chain reaction-based strategy generates a net benefit of $6 per birth when compared with the 35- to 37-week prenatal culture strategy and results in fewer maternal courses of antibiotics (64 080 per million births), fewer perinatal infections with early-onset group B streptococci (218/million), and a reduction in 6 infant deaths and severe infant disability per million births. The benefits hold over a wide range of assumptions regarding key factors in the analysis.

Conclusions. Although additional clinical trials are needed to establish the accuracy of this new polymerase chain reaction test, initial studies suggest that strategies using this test will be superior to the other 2 strategies. Using the rapid polymerase chain reaction test becomes less attractive as the cost of the test increases. The test's greatest strengths lie in its ability to identify women and infants at risk at the time of labor, thereby decreasing the number of false-positives and false-negatives seen with the other 2 strategies and allowing for more accurate and effective intrapartum prophylaxis.

OBJECTIVE: In 1976, the Committee on Perinatal Health recommended that hospitals with no neonatal intensive care unit (NICU) or intermediate NICUs transfer high-risk mothers and infants that weigh 2000 g to a regional NICU. This standard was based on expert opinion and has not been validated carefully. This study evaluated the effect of NICU level and patient volume at the hospital of birth on neonatal mortality of infants with a birth weight (BW) of 2000 g.

METHODS: Birth certificates of 16 732 singleton infants who had a BW of 2000 g and were born in nonfederal hospitals in California in 1992 and 1993 were linked to death certificates and to discharge abstracts. The hospitals were classified by the level of NICU: no NICU, no intensive care; intermediate NICU, intermediate intensive care; community NICU, expanded intermediate intensive care; and regional NICU, tertiary intensive care. A logistic regression model that controlled for demographic risks, diagnoses, transfer, average NICU census, and NICU level was estimated using death within the first 28 days or first year of life if continuously hospitalized as the main outcome measure.

RESULTS: Compared with birth in a hospital with a regional NICU, risk-adjusted mortality of infants with BW of 2000 g was higher when birth occurred in hospitals with no NICU (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.81-3.13), an intermediate NICU (OR: 1.92; 95% CI: 1.44-2.54), or a small (average census 15) community NICU (OR: 1.42; 95% CI: 1.14-1.76). Risk-adjusted mortality for infants who were born in hospitals with a large (average census > or =15) community NICU was not statistically different compared with those with a regional NICU (OR: 1.11; 95% CI: 0.87-1.43). Except for large community NICUs, all of these ORs are larger when the data are restricted to infants with BW of 1500 g or BW of 1250 g and smaller for BW between 1250 g and 1999 g and 1500 g and 1999 g. For large community NICUs, the results are similar for the smaller BW intervals and significant only for the larger BW interval.

CONCLUSIONS: These results support the recommendation that hospitals with no NICU or intermediate NICUs transfer high-risk mothers with estimated fetal weight of 2000 g to a regional NICU. For infants with BW of 2000 g, birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU. Subsequent neonatal transfer to a regional NICU only marginally decreases the disadvantage of birth at these hospitals. The evidence for the few hospitals with large community NICUs is mixed. Although the data point to higher mortality in large community NICUs, they are not conclusive and additional study is needed on the mortality effects of large community NICUs. Greater efforts should be made to deliver infants with expected BW of 2000 g at hospitals with regional NICUs.

Background: Cohort and case-crossover studies were conducted to evaluate whether new Helicobacter pylori infections are followed by increased diarrhea.

Methods: Participants were 6-month-old to 12-year-old shantytown residents living near Lima, Peru. Baseline data were collected from community households. Health interviews were completed daily, and sera, drawn every 4 months, were tested for H pylori immunoglobulin G. Diarrhea rates among newly H pylori-infected (seroconverting) children were compared with rates among persistently uninfected and infected children using cohort and case-crossover analyses.

Results: Sera were obtained from 345 children from January 1, 1995, through September 1, 1997. H pylori incidence was 12% per year (36 H pylori infections in 109 866 seronegative days). In adjusted cohort analyses, seroconverters had more diarrhea days (rate ratio: 2.0; 95% confidence interval: 1.6-2.4), episodes, and sick days in the year after infection than did uninfected children; and more diarrhea days and sick days than did persistently infected children. This effect was strongest in the first 2 months. Case-crossover analyses supported these findings.

Conclusion: Preventing H pylori infection may help reduce pediatric diarrheal disease.

Objective: To examine the prevalence of overweight concerns and body dissatisfaction among third-grade girls and boys and the influences of ethnicity and socioeconomic status (SES).

Study Design: Nine hundred sixty-nine children (mean age, 8.5 years) attending 13 northern California public elementary schools completed assessments of overweight concerns, body dissatisfaction, and desired shape, height, and weight.

Results: The sample was 44% white, 21% Latino, 19% non-Filipino Asian American, 8% Filipino, and 5% African American. Twenty-six percent of boys and 35% of girls reported wanting to lose weight, and 17% of boys and 24% of girls reported dieting to lose weight. Among girls, Latinas and African Americans reported significantly more overweight concerns than Asian Americans and Filipinas, and Latinas reported significantly more overweight concerns than whites. White and Latina girls also reported greater body dissatisfaction than Asian American girls. Some differences persisted even after controlling for actual body fatness. Higher SES African American girls reported significantly more overweight concerns than lower SES African American girls, but higher SES white girls reported less overweight concerns than lower SES white girls.

Conclusion: Overweight concerns and body dissatisfaction are highly prevalent among third-grade girls and boys, across ethnicity and SES. Young Latina and African American girls manifest equivalent or higher levels of disordered eating attitudes and behaviors as white and Asian American girls.