SNAP Scores Research Articles

Is it or is it not a pathogenic mutation? Is it or is it not the podocyte?

Is it or is it not a pathogenic mutation? Is it or is it not the podocyte?

734 Prevalence of a positive screening score for attention deficit hyperactivity disorder in children with early repair of congenital heart disease

734 Prevalence of a positive screening score for attention deficit hyperactivity disorder in children with early repair of congenital heart disease

Association of bronchopulmonary dysplasia and hypercarbia in ventilated infants with birth weights of 500-1,499 g.

Bronchopulmonary dysplasia (BPD) continues to be a major pulmonary complication in very low birth weight (VLBW) and extremely low birth weight (ELBW) survivors of neonatal intensive care units (NICUs). Many factors including partial pressures of carbon dioxide (PaCO: (2)) have been implicated as possible causes. Permissive hypercapnia has become a more common practice in ventilated infants, but its effect on BPD is unclear. The hypothesis of this study was that hypercarbia is associated with increased BPD in infants with birth weights of 500-1,499 g. Nine hospitals were involved in this observational cohort study. Maternal and infant information including socio-demographics, antenatal steroids, gender, race, gestational age, birth weight, intubation and ventilator status, physiologic variables and data on therapies were collected by chart abstraction. SNAP scores were assigned. Candidate BPD risk factors, including cumulative exposures derived from blood gas and ventilation data in the first 6 days of life, were identified. Risk models were developed for 425 preterm infants who survived to 36 weeks post-menstrual age. BPD occurrence was associated with the cumulative burden of MAP >0 cm H(2)O in the first 6 days of life (P < 0.0001). After adjustment for the burden of MAP, the occurrence of hypercarbia (PaCO: (2) >50 torr) was associated with a greater incidence of BPD (P = 0.024). Among 293 intubated, mechanically ventilated infants, those with hypercarbia occurring only when MAP ≤ 8 cm H(2)O, a scenario more comparable to permissive hypercapnia, also had increased BPD incidence compared to infants without hypercarbia (P = 0.0003). Hypercarbia during the first 6 days of life was associated with increased incidence of BPD in these infants. Mechanically ventilated infants with hypercarbia during low MAP also had a significant increase in BPD. Permissive hypercapnia in ventilated infants needs further close review before the practice becomes even more widespread.

Psychometric properties of the Schedule for Nonadaptive and Adaptive Personality in a PTSD sample.

This study evaluated the psychometric characteristics of the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1996) in 280 individuals who screened positive for posttraumatic stress disorder (PTSD). The SNAP validity, trait, temperament, and personality disorder (PD) scales were compared with scales on the Brief Form of the Multidimensional Personality Questionnaire (Patrick, Curtin, & Tellegen, 2002). In a subsample of 86 veterans, the SNAP PD, trait, and temperament scales were also evaluated in comparison to the International Personality Disorder Examination (IPDE; Loranger, 1999), a semistructured diagnostic interview. Results revealed that the SNAP scales have good convergent validity, as evidenced by their pattern of associations with related measures of personality and PD. However, evidence for their discriminant validity in relationship to other measures of personality and PD was more mixed, and test scores on the SNAP trait and temperament scales left much unexplained variance in IPDE-assessed PDs. The diagnostic scoring of the SNAP PD scales greatly inflated prevalence estimates of PDs relative to the IPDE and showed poor agreement with the IPDE. In contrast, the dimensional SNAP scores yielded far stronger associations with continuous scores on the IPDE. The SNAP scales also largely evidenced expected patterns of association with a measure of PTSD severity. Overall, findings support the use of this measure in this population and contribute to our conceptualization of the association between temperament, PTSD, and Axis II psychopathology.

SNAP-II and SNAPPE-II and the Risk of Structural and Functional Brain Disorders in Extremely Low Gestational Age Newborns: The ELGAN Study

Background: Illness severity measures predict death and illnesses in the newborn. It is unknown how well they predict brain lesions evident on ultrasound scans or neurodevelopmental dysfunctions in preterm infants. Methods: A total of 1,399 inborn infants born before the 28th week of gestation were given Scores for Neonatal Acute Physiology (SNAP-II and SNAPPE-II) based on data collected within the first 12 h of admission to the intensive care unit and had a protocol brain ultrasound scan read independently by 2 sonologists. Of the surviving 1,149 infants, 1,014 (88%) had a neurologic examination at approximately 24 months post-term equivalent, and 975 (85%) had a Bayley Scales of Infant Development assessment. SNAP-II and SNAPPE-II were dichotomized at arbitrary cut-offs (30 for SNAP-II and 45 for SNAPPE-II), using the highest quartile and decile of the week of gestation as a cut-off, and at a Z score of >1 standard deviation from an external mean. Results: After adjustment for gestational age, high SNAP-II and SNAPPE-II scores predicted intraventricular hemorrhage, moderate/severe ventriculomegaly and echodense lesions in cerebral white matter. Only 2 SNAP-II extremes, the highest decile for gestational age and a Z score >1, also predicted echolucent lesions in the white matter. Neither SNAP-II nor SNAPPE-II predicted any statistically significant diagnosis of cerebral palsy. MDI and PDI scores <55 were consistently predicted by both high SNAP-II and SNAPPE-II, whereas scores in the 55–69 range were inconsistently predicted. High SNAP-II and SNAPPE-II inconsistently predicted a positive screen for autism spectrum disorder and small head circumference at 24 months. Conclusion: The physiologic instability in the first 12 post-natal hours identified by illness severity scores conveys information about the risks of brain damage and neurodevelopmental dysfunctions. This risk information might reflect postnatal characteristics in the causal chain. On the other hand, high SNAP scores might be indicators of immaturity and vulnerability.

Effectiveness of Methylphenidate in the 10-Month Continuation Phase of the Preschoolers with ADHD Treatment Study (PATS)

The aim of this study was to examine immediate-release methylphenidate effectiveness during the 10-month open-label continuation phase of the Preschoolers with Attention-Deficit/Hyperactivity Disorder (ADHD) Treatment Study (PATS). One hundred and forty preschoolers with ADHD, who had improved with acute immediate-release methylphenidate (IR-MPH) treatment, entered a 10-month, open-label medication maintenance at six sites. Assessments included the Clinical Global Impression-Severity (CGI-S), CGI-Improvement (CGI-I), Children's Global Assessment Scale (C-GAS), Swanson, Nolan, and Pelham Questionnaire (SNAP), Scale Strengths and Weaknesses of ADHD-Symptoms and Normal Behaviors (SWAN), Social Competence Scale, Social Skills Rating System (SSRS), and Parenting Stress Index-Short Form (PSI-SF). For the 95 children who completed the 10-month treatment, improvement occurred on the CGI-S (p = 0.02), CGI-I (p < 0.01), C-GAS (p = 0.001), and SSRS (p = 0.01). SNAP and SWAN scores remained stable. Forty five children discontinued: 7 for adverse effects, 7 for behavior worsening, 7 for switching to long-acting stimulants, 3 for inadequate benefit, and 21 for other reasons. The mean MPH dose increased from 14.04 mg/day +/- SD 7.57 (0.71 +/- 0.38 mg/kg per day) at month 1 to 19.98 mg/day +/- 9.56 (0.92 +/- 0.40 mg/kg per day) at month 10. With careful monitoring and gradual medication dose increase, most preschoolers with ADHD maintained improvement during long-term IR-MPH treatment. There was substantial variability in effective and tolerated dosing.

Incremental validity of the Structured Interview for the Five‐Factor Model of Personality (SIFFM)

This study examined the incremental validity of the Structured Interview for the Five‐Factor Model (SIFFM; Trull &amp; Widiger, 1997) scores in the prediction of borderline, antisocial, and histrionic personality disorder symptoms above and beyond variance accounted for by scores from the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993), a self‐report questionnaire that includes items relevant to both normal (i.e. Big Three) and abnormal personality traits. Approximately 200 participants (52 clinical outpatients, and 149 nonclinical individuals from a borderline‐features‐enriched sample) completed the SIFFM, the SNAP, and select sections of the Personality Disorder Interview—IV (PDI‐IV; Widiger, Mangine, Corbitt, Ellis, &amp; Thomas, 1995). We found support for the incremental validity of SIFFM scores, further indicating the clinical utility of this instrument. However, results also supported the incremental validity of SNAP scores in many cases. We discuss the implications of the findings in terms of dimensional approaches to personality disorder assessment. Copyright © 2005 John Wiley &amp; Sons, Ltd.

A Double-Blind, Placebo-Controlled Trial of Dexmethylphenidate Hydrochloride and d,l-threo-Methylphenidate Hydrochloride in Children With Attention-Deficit/Hyperactivity Disorder

To evaluate the efficacy and safety of dexmethylphenidate hydrochloride (d-MPH, Focalin) for the treatment of attention-deficit/hyperactivity disorder (ADHD) and to test an a priori hypothesis that d-MPH would have a longer duration of action than d,l-threo-methylphenidate (d,l-MPH). This was a randomized, double-blind study conducted at 12 U.S. centers. One hundred thirty-two subjects received d-MPH (n=44), d,l-MPH (n=46), or placebo (n=42) twice daily for 4 weeks, with titration of the dose based on weekly clinic visits. The primary efficacy variable was change from baseline to last study visit on teacher-completed Swanson, Nolan, and Pelham Rating Scale (Teacher SNAP). Secondary efficacy measures included the change on parent-completed SNAP (Parent SNAP), Clinical Global Impressions Scale-Improvement (CGI-I) score, and Math Test performance. Assessments at home in late afternoon were included to test the hypothesis that d-MPH would have a longer duration of efficacy than d,l-MPH. Safety was assessed through monitoring occurrence and severity of adverse events and discontinuations related to them. Treatment with either d-MPH (p=.0004) or d,l-MPH (p=.0042) significantly improved Teacher SNAP ratings compared with placebo. The d-MPH group showed significant improvements compared with placebo on the afternoon Parent SNAP ratings (p=.0003) and scores on the Math Test (p=.0236) obtained late in the afternoon at 6:00 p.m. Sixty-seven percent of patients showed improvement on d-MPH and 49% on d,l-MPH based on CGI-I scores. Both d-MPH and d,l-MPH were well tolerated, no patient in the d-MPH group and only two patients each in the d,l-MPH and placebo groups discontinued the study. For the treatment of ADHD, an average titrated dose of 18.25 mg/day of d-MPH is as efficacious and safe as an average titrated dose of 32.14 mg/day of d,l-MPH. Both active treatments have large effect sizes. Thus, d-MPH and d,l-MPH appear to provide similar efficacy, and d-MPH may have longer duration of action after twice-daily dosing, but additional studies are needed to determine the statistical and clinical significance of this possibility.

Verbessert die Kombination von primärer Hochfrequenzoszillationsbeatmung und prophylaktischer Surfactantgabe die Prognose extrem kleiner Frühgeborener?

Although animal data show a clear advantage of HFOV compared with CMV in the therapy for IRDS, clinical data are still heterogeneous. We have compared our clinical results of HFOV with those of CMV to evaluate the potential benefit. During the observation period primary care of all extremely low birth weight infants was done in a standardised way with a restricted indication for endotracheal intubation. Intubated patients received surfactant immediately after intubation. Patients requiring an FiO (2) > 0.4 after administration of surfactant received HFOV. 52 patients were included into the study. 21 received CMV and 31 received HFOV. There were no differences between both groups in mortality and morbidity, but patients in the HFOV group were significantly more immature and smaller than those in the CMV group. They also had higher CRIB, SNAP and SNAP-PE scores, thus having a much higher risk of morbidity and mortality. In our study babies who were extremely immature and small might have had a profit from the very early administration of surfactant and start of HFOV immediately after endotracheal intubation. Similar results in other small retrospective analyses and also in animal experiments suggest the need for a large randomised controlled trial using early surfactant administration and starting HFOV immediately after intubation.

Relationship of race and severity of neonatal illness

Objective: Our goal was to determine whether there are racial differences in the severity of illness on admission for premature newborn infants independent of gestational age. Study Design: The study population consisted of all African American and Caucasian singleton infants with gestational ages <34 weeks who were admitted to the neonatal intensive care unit at Brigham and Women’s Hospital between December 1994 and November 1995. Illness severity was measured with a neonatal severity of illness score, the SNAP score (Score for Neonatal Acute Physiology). The SNAP score is a physiologic scoring system that ranks the worst physiologic derangements in each organ system in the first 12 hours of life. It is an objective measure of neonatal illness severity with scores ranging from 0 (healthy) to 42 (most severely ill). Student t tests, χ2 analysis, and Fisher exact tests were used to assess statistical significance. Linear and logistic regression analyses were used to examine associations while confounding factors were controlled for. Results: There were 129 (79%) Caucasian and 36 (22%) African American newborns included in the analysis. Caucasian newborns had significantly higher mean SNAP scores than African American newborns (8.8 vs 6.3; P <.05). Compared with African American newborns, Caucasian newborns were more than twice as likely to have a SNAP score >10 (33% vs 14%; P <.05). In a linear regression analysis in which we controlled for gestational age, birth weight, preterm premature rupture of membranes, preterm labor, preeclampsia, intrapartum fever ≥100.4°F, route of delivery, and other maternal and fetal factors, African American newborns were predicted to have a SNAP score that was on average 3.0 points lower than that of Caucasian newborns (P =.005). In a logistic regression in which we controlled for the above-mentioned confounders, African American newborns were only 14% as likely to have a SNAP score >10 when compared with Caucasian newborns (odds ratio, 0.14; 95% confidence interval, 0.04-0.51). Conclusions: Over a broad range of prematurity, Caucasian newborns were more ill than African American newborns on admission to the neonatal intensive care unit. (Am J Obstet Gynecol 2001;184:668-72.)

Assessing the efficacy of the recombinant human granulocyte colony-stimulating factor "rhG-CSF" in the treatment of early neonatal sepsis in premature neonates

OBJECTIVE: To evaluate the efficacy of the recombinant human granulocyte colony-stimulating factor (rhG-CSF) in the treatment of early-onset neonatal sepsis among premature infants.MATERIALS AND METHODS: A double-blind, randomized, placebo-controlled trial was performed among forty-four preterm neonates who had "clinical diagnosis" of early-onset sepsis. The treatment group (n=22) received 10 micro g/kg/d of rhG-CSF, IV once daily for three consecutive days, and the placebo group (n=22) received the same volume of a visually-indistinguishable vehicle. Prior to the first dose, and prior to the second and third doses, and again 10 days after the first dose, we measured tumor necrosis factor-a, interleukin-6, granulocyte-macrophagocyte colony-stimulating factor, G-CSF, leukocyte count, absolute neutrophil count, immature/total neutrophil ratio, platelet count, and hemoglobin concentration. A bone marrow aspiration was performed seven days after the first dose, and both the neutrophil storage pool (NSP) percent and the NSP/NPP (neutrophil proliferative pool) ratios were tabulated.RESULTS: The treatment and placebo groups were of similar gestational age (29-/+ 3 vs 31-/+ 3 weeks) and birth weight (1376 -/+ 491 vs 1404 -/+ 508 grams). They had similar Apgar scores and 24 hour SNAP scores. No deaths occurred during the first week of life among the treatment group while three deaths occurred in the placebo group. RhG-CSF treatment did not alter the serum concentrations of the cytokines measured (except for G-CSF). Serum G-CSF levels, blood leukocyte counts, absolute neutrophil counts, NSP percentages, and NSP/NPP ratios were higher in the treatment group 24 hours and 72 hours after dosing. The occurrence of a subsequent infection over the two week period following dosing was significantly lower in the treatment group (n=2) than in the placebo group (n=9; p<0.02, RR 0.19 [0.05-0.78]). The overall mortality rate during the entire hospitalization was not different between treatment and placebo groups.CONCLUSIONS: Administration of rhG-CSF to premature neonates with the clinical diagnosis of early-onset sepsis was associated with lower incidence of nosocomial infection over the ensuing three weeks period, but it did not change the overall mortality rate.

Congenital heart disease: The impact of delivery in a tertiary care center on SNAP scores (scores for neonatal acute physiology)

Objective: It has been hypothesized that delivery in a tertiary care center might improve the clinical condition and outcome of infants born with congenital heart disease. The purpose of this study was to determine the effect of delivery in a tertiary care center on SNAP scores (scores for neonatal acute physiology) of infants admitted to the neonatal intensive care unit with major structural cardiac defects. Study Design: This retrospective cohort study included 195 infants with major congenital heart disease admitted to the neonatal intensive care unit at the New England Medical Center between July 1, 1992, and June 30, 1998. SNAP scores were abstracted from the medical record. The values of 97 neonates with major cardiac defects born at the New England Medical Center were compared with those of 98 neonates transferred to our center after delivery in a community setting. A 2-tailed Student t test for independent samples was used to compare the mean SNAP scores between the 2 cohorts. Results: The SNAP scores for infants with major cardiac defects who were born at the New England Medical Center ranged from 0 to 41, with a mean of 10.6 ± 8.8. The values for infants with congenital heart disease who were transferred to our center after birth in community-based hospitals ranged from 0 to 34, with a mean of 11.1 ± 7.0. There was no significant difference between the 2 populations (P = .646). A comparison of the mean SNAP scores of infants with prenatally diagnosed disease who were delivered at our center versus infants with postnatally diagnosed disease who were delivered in community hospitals was also statistically not significant (P = .824). Conclusion: Delivery in a tertiary care center does not improve SNAP scores of infants with major structural cardiac defects. (Am J Obstet Gynecol 2000;182:184-91.)

A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL OF RECOMBINANT HUMAN GRANULOCYTE COLONY-STIMULATING FACTOR (G-CSF) ADMINISTRATION TO WOMEN WITH AN IMMINENT PRETERM DELIVERY. • 1747

Bacterial infection occurs in as many as 50 percent of extremely preterm infants and is a major cause of morbidity and mortality. A single dose(50μg/kg) of rG-CSF given to pregnant rats one day prior to delivery resulted in transplacental passage of G-CSF sufficient to stimulate neutrophil production, elevate blood neutrophil concentrations, and improve the outcome of pups who were inoculated with group B β-hemolytic streptococci(Medlock, Blood 1993). In our previous pilot study, transplacental passage of G-CSF appeared to occur when given 12 hours prior to delivery, but an increase in absolute neutrophil count (ANC) was only seen in infants whose mothers received rG-CSF 30 hours before delivery (Calhoun, Am J Ob Gyn, 1996). To determine whether administration of rG-CSF more than 30 hours prior to delivery would improve fetal neutrophil production and favorably effect neonatal outcome, a randomized placebo controlled trial was conducted in 20 women about to deliver at <30 weeks gestation. Serum concentrations of G-CSF and neutrophils were measured in the blood of mothers, and in the umbilical venous cord blood following a single intravenous dose (25μg/kg) of rG-CSF to women in whom delivery was not likely to occur for 30 hours. ANC's were followed for one week in the infants, bone marrow aspirations were performed at 24±8 hours of age to assess neutrophil storage pools and hematopoietic progenitor cultures, and SNAP scores were completed on days of life one and seven. Ten mothers delivered 11 infants. The G-CSF had no apparent adverse effect on pregnancy duration, maternal comfort, or maternal temperature. The bone marrow neutrophil proliferative pool was significantly increased in the G-CSF-treated neonates (23±8% vs 14±3%)(mean±SD,p<.05), but no difference was observed in ANC. Infants in the G-CSF-treated group had improvement (lowering) in SNAP scores between the first (16.3±3.1) and seventh days (7.3±6.1) (p<.05), while no significant change was noted in the control group(14.5±6.5, day 1 and 6.3±5.6, day 7). This pilot study suggests that administration of rG-CSF to certain women prior to preterm delivery might increase fetal neutrophil production and improve outcome of the infants.

Coagulase-Negative Staphylococcal Bacteremia Among Very Low Birth Weight Infants: Relation to Admission Illness Severity, Resource Use, and Outcome

To examine the impact of admission-day illness severity on nosocomial bacteremia risk after consideration of traditional risk determinants such as birth weight and length of stay. The hospital courses for 302 consecutive very low birth weight (less than 1500 g) infants admitted to two neonatal intensive care units were examined for the occurrence of nosocomial coagulase-negative staphylococcal bacteremia. Using both cumulative incidence and incidence density as measures of bacteremia risk, we explored the relation between illness severity (as measured by the Score for Neonatal Acute Physiology [SNAP]) and bacteremia both before and after birth weight adjustment. In addition, the effect of bacteremia on hospital resource use was estimated. Coagulase-negative staphylococcus was the most common pathogen noted in blood cultures drawn at 48 hours after admission or later. It was isolated on at least one occasion in 53 patients (cumulative incidence of 17.5 first episodes per 100 patients). These episodes occurred during 7652 days at risk, giving an incidence density of 6.9 initial bacteremias per 1000 patient-days at risk. As expected, when compared with the nonbacteremic group, bacteremic patients were of lower birth weight (888 +/- 231 vs 1127 +/- 258 g; P < .01) and gestational age (26.4 +/- 2.1 vs 28.9 +/- 2.8 weeks; P < .01). In addition, these patients were more severely ill on admission (SNAP 17.3 +/- 6.5 vs 12.2 +/- 5.8; P < .01). Even after birth weight stratification, the risk of bacteremia by both measures increased with higher SNAP scores. For example, among infants with birth weights greater than 1 kg, 25% of the most severely ill patients (SNAP 20 and higher) experienced at least one bacteremic episode, whereas the rates seen in infants with intermediate (SNAP 10 to 19) and low illness severity (SNAP 0 to 9) were 8.6% and 3.0%, respectively (chi 2 for trend = 7.25; P < .01). Multivariate linear regression showed that bacteremia was associated with a prolongation of neonatal intensive care unit stay of 14.0 +/- 4.0 days (P < .01) and an increase in hospital charges of $25,090 +/- 12,051 (P < .05), even after adjustment for birth weight and admission-day SNAP. Nosocomial coagulase-negative bacteremia is an important complication among very low birth weight infants. Assessment of illness severity with SNAP provides information regarding nosocomial infection risk beyond that available from birth weight alone.

Symptoms and traits of personality disorder: Two new methods for their assessment.

This study examines the reliability and validity of 2 dimensional methods for the assessment of personality disorder symptoms and traits. In Study 1, three groups that varied in personality pathology level completed the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993), a self-report questionnaire that measures traits relevant to Axis II pathology. Differences among the groups, which were patterned in theoretically interesting ways, are discussed. In Study 2, two independent judges rated 22 clusters of Axis II symptoms in 56 state hospital inpatients based on chart information. Good interrater reliability was obtained (median coefficient =.71), and personality-related pathology was quite prevalent. Relations among symptom ratings, SNAP scores, and chart diagnoses were generally systematic, but anomalous findings also emerged

Lodging Response of Certain Selections of Oats, Avena sativa L., and Their Hybrid Progenies1

Lodging responses of certain oat selections and their hybrid progenies were studied for three seasons at Madison, Wisconsin. Progeny rows were evaluated for lodging response by a “snap test” and by estimating actual lodging percentages. Analyses of variance indicated that lines were more accurately characterized by snap values than by lodging percentages. On the basis of intergenerational comparisons and genotype ✕ environment interactions, snap scores were more repeatable than were lodging percentages. Genotypic and phenotypic as well as simple correlations of snap scores with lodging percentages indicated that the snap test could be useful in evaluating oat lines for lodging responses.