AIM: To assess the incidence and risk factors associated with colonic perforation due to colonoscopy.
METHODS: This was a retrospective cross-sectional study. Patients were retrospectively eligible for inclusion if they were 18 years and older and had an inpatient or outpatient colonoscopy procedure code in any facility within the Geisinger Health System during the period from January 1, 2002 to August 25, 2010. Data are presented as median and inter-quartile range, for continuous variables, and as frequency and percentage for categorical variables. Baseline comparisons across those with and without a perforation were made using the two-sample t-test and Pearson’s χ2 test, as appropriate.
RESULTS: A total of 50 perforations were diagnosed out of 80118 colonoscopies, which corresponded to an incidence of 0.06% (95%CI: 0.05-0.08) or a rate of 6.2 per 10000 colonoscopies. All possible risk factors associated with colonic perforation with a P-value < 0.1 were checked for inclusion in a multivariable log-binomial regression model predicting 7-d colonic perforation. The final model resulted in the following risk factors which were significantly associated with risk of colonic perforation: age, gender, body mass index, albumin level, intensive care unit (ICU) patients, inpatient setting, and abdominal pain and Crohn’s disease as indications for colonoscopy.
CONCLUSION: The cumulative 7 d incidence of colonic perforation in this cohort was 0.06%. Advanced age and female gender were significantly more likely to have perforation. Increasing albumin and BMI resulted in decreased risk of colonic perforation. Having a colonoscopy indication of abdominal pain or Crohn’s disease resulted in a higher risk of colonic perforation. Colonoscopies performed in inpatients and particularly the ICU setting had substantially greater odds of perforation. Biopsy and polypectomy did not increase the risk of perforation and only three perforations occurred with screening colonoscopy.
Colonoscopic perforation; Colon cancer; Endosocopy
We previously developed a post-traumatic stress disorder (PTSD) screening instrument, ie, the New York PTSD Risk Score (NYPRS), that was effective in predicting PTSD. In the present study, we assessed a version of this risk score that also included genetic information.
Utilizing diagnostic testing methods, we hierarchically examined different prediction variables identified in previous NYPRS research, including genetic risk-allele information, to assess lifetime and current PTSD status among a population of trauma-exposed adults.
We found that, in predicting lifetime PTSD, the area under the receiver operating characteristic curve (AUC) for the Primary Care PTSD Screen alone was 0.865. When we added psychosocial predictors from the original NYPRS to the model, including depression, sleep disturbance, and a measure of health care access, the AUC increased to 0.902, which was a significant improvement (P = 0.0021). When genetic information was added in the form of a count of PTSD risk alleles located within FKBP5, COMT, CHRNA5, and CRHR1 genetic loci (coded 0–6), the AUC increased to 0.920, which was also a significant improvement (P = 0.0178). The results for current PTSD were similar. In the final model for current PTSD with the psychosocial risk factors included, genotype resulted in a prediction weight of 17 for each risk allele present, indicating that a person with six risk alleles or more would receive a PTSD risk score of 17 × 6 = 102, the highest risk score for any of the predictors studied.
Genetic information added to the NYPRS helped improve the accuracy of prediction results for a screening instrument that already had high AUC test results. This improvement was achieved by increasing PTSD prediction specificity. Further research validation is advised.
post-traumatic stress disorder; psychological trauma; diagnostic screening; test development; genotype; single nucleotide polymorphism
Children prenatally exposed to cocaine may be at increased risk for behavioral problems due to disruptions of monaminergically regulated arousal systems and/or environmental conditions.
To assess behavioral outcomes of cocaine (CE) and non-cocaine exposed (NCE) children, 4 through 10 years old, controlling for other prenatal drug exposures and environmental factors.
Low socioeconomic status (SES), primarily African-American children (n = 381 (193 (CE), 188 (NCE)) were recruited from birth. Generalized Estimating Equation (GEE) analyses were used to assess the predictive relationship of prenatal cocaine exposure to odds of caregiver reported clinically elevated behavioral problems at 4, 6, 9 and 10 years of age, controlling for confounders.
Prenatal cocaine exposure was associated with increased rates of caregiver reported delinquency (OR=1.93, CI: 1.09-3.42, p<.02). A significant prenatal cocaine exposure by sex interaction was found for delinquency indicating that only females were affected (OR=3.57, CI: 1.67-7.60, p<.001). There was no effect of cocaine on increased odds of other CBCL subscales. Higher prenatal tobacco exposure was associated with increased odds of externalizing symptoms at 4, 9 and 10 years of age. For CE children, those in foster or adoptive care were rated as having more behavior problems than those in biologic mother or relative care. Greater caregiver psychological distress was associated with increased behavioral problems. There were no independent effects of elevated blood lead level on increased behavior problems after control for prenatal drug exposure and other environmental conditions.
Prenatal cocaine and tobacco exposure were associated with greater externalizing behavior after control for multiple prenatal drug exposures, other environmental and caregiving factors and lead exposure from 4 through 10 years of age. Greater caregiver psychological distress negatively affected caregiver ratings of all CBCL domains. Since cocaine and tobacco use during pregnancy and maternal psychological distress have the potential to be altered through prenatal educational, drug treatment and and mental health interventions, they warrant attention in efforts to reduce rates of problem behaviors in children.
behavior; delinquency; prenatal cocaine-exposure; lead exposure; longitudinal
Research suggests that posttraumatic stress disorder (PTSD) is associated with increased alcohol use, but the findings have not been consistent. We assessed alcohol use, binge drinking, and psychotropic medication use longitudinally in 1,681 New York City adults, representative of the 2000 census, 2 years after the World Trade Center attacks. We found that, with the exception of a modified CAGE Questionnaire index for alcohol, alcohol use showed a modest increase over time and was related to PTSD symptoms, with an increase of about 1 more drink per month for those with PTSD, even though overall levels appeared to be within the National Institute on Alcohol Abuse and Alcoholism’s safe range. Psychotropic medication use followed a similar trend; those with PTSD used psychotropics about 20 more days over the past year than those without. Because the study analyses adjusted for key psychosocial variables and confounders, it is not clear if the increased alcohol use following trauma exposure is associated with self-medication of PTSD symptoms, whether increased alcohol use prior to exposure is a risk for delayed-onset PTSD, or whether a third unmeasured variable is involved. Further research is warranted.
The objective was to develop a brief posttraumatic stress disorder (PTSD) screening instrument that is useful in clinical practice, similar to the Framingham Risk Score used in cardiovascular medicine.
We used data collected in New York City after the World Trade Center disaster (WTCD) and other trauma data to develop a new PTSD prediction tool — the New York PTSD Risk Score. We used diagnostic test methods to examine different clinical domains, including PTSD symptoms, trauma exposures, sleep disturbances, suicidal thoughts, depression symptoms, demographic factors and other measures to assess different PTSD prediction models.
Using receiver operating curve (ROC) and bootstrap methods, five prediction domains, including core PTSD symptoms, sleep disturbance, access to care status, depression symptoms and trauma history, and five demographic variables, including gender, age, education, race and ethnicity, were identified. For the best prediction model, the area under the ROC curve (AUC) was 0.880 for the Primary Care PTSD Screen alone (specificity=82.2%, sensitivity=93.7%). Adding care status, sleep disturbance, depression and trauma exposure increased the AUC to 0.943 (specificity=85.7%, sensitivity=93.1%), a significant ROC improvement (P < .0001). Adding demographic variables increased the AUC to 0.945, which was not significant (P=.250). To externally validate these models, we applied the WTCD results to 705 pain patients treated at a multispecialty group practice and to 225 trauma patients treated at a Level I Trauma Center. These results validated those from the original WTCD development and validation samples.
The New York PTSD Risk Score is a multifactor prediction tool that includes the Primary Care PTSD Screen, depression symptoms, access to care, sleep disturbance, trauma history and demographic variables and appears to be effective in predicting PTSD among patients seen in healthcare settings. This prediction tool is simple to administer and appears to outperform other screening measures.
Posttraumatic stress disorder; Psychological Trauma; Diagnostic testing; Patient screening; Area under receiver operating characteristic (ROC) curve
The impact of bacteriuria on mortality and cardiovascular risk has not been previously reported for patients with chronic kidney disease (CKD).
To assess the relationship between outpatient episodes of bacteriuria and mortality and cardiovascular risk among women with CKD.
Retrospective cohort study using an electronic health database from an integrated healthcare system in central Pennsylvania.
Adult women with CKD receiving primary care at Geisinger Health System between January 1, 2004 and December 31, 2009 were eligible, and were followed through December 31, 2010 for study outcomes.
The study exposure was bacteriuria, defined as an outpatient urine culture with bacterial growth of 104 cfu/mL. Treatment history (antibiotic prescription within 90 days) was identified. Study outcomes were death and the composite of hospitalization for myocardial infarction, congestive heart failure, or stroke. Multivariate-adjusted Cox models incorporated all bacteriuria episodes and antibiotic prescriptions in time-dependent fashion (in addition to other covariates) to account for the cumulative impact of infections, treatment, and hospitalization during follow-up.
6807 women were followed for a median (interquartile range) of 5.2 (3.4, 5.9) years. In adjusted models, each untreated bacteriuria episode was associated with an increased risk of death (hazard ratio [HR] 1.56, 95% CI 1.35–1.81) and the composite cardiovascular outcome (HR 1.32, 95% CI 1.05–1.65); treated episodes were not associated with an increased risk of death or cardiovascular events.
Among female patients with CKD, untreated bacteriuria occurring in the outpatient setting is associated with an increased risk of death and cardiovascular morbidity.
bacteriuria; cardiovascular; chronic kidney disease; death; mortality
M.tuberculosis (M.tb) is associated with enhanced T helper cell type 1 (Th1) immune responses while helminth infection is associated with T helper cell type 2 (Th2) immune responses. Our aim was to investigate whether helminth infection could influence the ability to generate an appropriate Th1 immune response that is characterized by a positive tuberculin skin test (TST), in M.tb exposed children.
We completed a community-based, cross sectional household contact tracing study, using matched enrolment of HIV negative children with and without documented household M.tb exposure. We documented demographics, clinical characteristics, HIV status, M.tb exposure (using a standard contact score) and M.tb infection status (TST > = 10 mm). Ascaris lumbricoides-specific IgE was used as proxy for Ascaris infection/exposure.
Of 271 children (median age 4 years (range: 4 months to 15 years)) enrolled, 65 participants (24%) were serum positive for Ascaris IgE. There were 168 (62%) children with a documented household tuberculosis contact and 107 (40%) were (TST) positive overall.
A positive TST was associated with increasing age (Odds Ratio (OR) =1.17, p < 0.001), increasing M.tb contact score (OR = 1.17, p < 0.001), previous tuberculosis treatment (OR = 4.8, p = 0.06) and previous isoniazid preventive treatment (OR = 3.16, p = 0.01). A visible bacillus Calmette-Guérin (BCG) scar was associated with reduced odds of being TST positive (OR = 0.42, p = 0.01).
Ascaris IgE was not associated with TST status in univariate analysis (OR = 0.9, p = 0.6), but multivariable logistic regression analysis suggested an inverse association between Ascaris IgE status and a positive TST (OR = 0.6, p = 0.08), when adjusted for age, and M.tb contact score. The addition of an age interaction term to the model suggested that the age effect was stronger among Ascaris IgE positive children; the effect of being Ascaris IgE positive significantly reduced the odds of being TST positive amongst younger children while this effect weakened with increasing age.
Our preliminary findings highlight a high prevalence of both Ascaris exposure/infection and M.tb infection in children in an urban setting. Helminth exposure/infection may reduce the immune response following M.tb exposure when controlling for epidemiological and clinical covariates. These findings might be relevant to the interpretation of immunological tests of M.tb infection in children.
Tuberculosis; Helminth infection; Ascaris, M.tb infection; Immune polarization; Paediatric tuberculosis
We previously developed a posttraumatic stress disorder (PTSD) screening instrument – the New York PTSD Risk Score – that was effective in predicting PTSD. In the present study, we assessed a 12-month prospective version of this risk score, which is important for patient management, follow-up, and for emergency medicine.
Using data collected in a study of New York City adults after the World Trade Center Disaster (WTCD), we developed a new PTSD prediction tool. Using diagnostic test methods, including receiver operating curve (ROC) and bootstrap procedures, we examined different prediction variables to assess PTSD status 12 months after initial assessment among 1,681 trauma-exposed adults.
While our original PTSD screener worked well in the short term, it was not specifically developed to predict long-term PTSD. In the current study, we found that the Primary Care PTSD Screener (PCPS), when combined with psychosocial predictors from the original NY Risk Score, including depression, trauma exposure, sleep disturbance, and healthcare access, increased the area under the ROC curve (AUC) from 0.707 to 0.774, a significant improvement (p<0.0001). When additional risk-factor variables were added, including negative life events, handedness, self-esteem, and pain status, the AUC increased to 0.819, also a significant improvement (p=0.001). Adding Latino and foreign status to the model further increased the AUC to 0.839 (p=0.007).
A prospective version of the New York PTSD Risk Score appears to be effective in predicting PTSD status 12 months after initial assessment among trauma-exposed adults. Further research is advised to further validate and expand these findings.
Posttraumatic stress disorder; Psychological Trauma; Diagnostic screening; Emergency Medicine
Adolescents are predisposed to short sleep duration and irregular sleep patterns due to certain host characteristics (e.g., age, pubertal status, gender, ethnicity, socioeconomic class, and neighborhood distress) and health-related variables (e.g., ADHD, asthma, birth weight, and BMI). The aim of the current study was to investigate the relationship between such variables and actigraphic measures of sleep duration and variability.
Cross-sectional study of 247 adolescents (48.5% female, 54.3% ethnic minority, mean age of 13.7 years) involved in a larger community-based cohort study.
Significant univariate predictors of sleep duration included gender, minority ethnicity, neighborhood distress, parent income, and BMI. In multivariate models, gender, minority status, and BMI were significantly associated with sleep duration (all p<.05), with girls, non-minority adolescents, and those of a lower BMI obtaining more sleep. Univariate models demonstrated that age, minority ethnicity, neighborhood distress, parent education, parent income, pubertal status, and BMI were significantly related to variability in total sleep time. In the multivariate model, age, minority status, and BMI were significantly related to variability in total sleep time (all p<.05), with younger adolescents, non-minority adolescents, and those of a lower BMI obtaining more regular sleep.
These data show differences in sleep patterns in population sub-groups of adolescents which may be important in understanding pediatric health risk profiles. Subgroups that may particularly benefit from interventions aimed at improving sleep patterns include boys, overweight, and minority adolescents.
We conducted a prospective longitudinal study evaluating candida skin testing among international adoptees presenting to our clinic between 2000 to 2006. Nineteen (17%) and seventeen (15%) children had negative tests at presentation and at 6-month respectively – only 3 were negative at both points. Our study suggests that candida skin test reactivity is an unstable measure of anergy among international adoptees.
Tuberculosis; tuberculosis testing; adoptees; Bacille Calmette-Guérin vaccination
Internationally adopted children often arrive from institutional settings where they have experienced medical, nutritional and psychosocial deprivation. This study uses a validated research assessment tool to prospectively assess the impact of baseline (immediately post adoption) nutritional status on fifty-eight children as measured by weight-for-age, height-for-age, weight-for-height and head circumference-for-age z scores, as a determinant of cognitive (MDI) and psychomotor development (PDI) scores longitudinally. A statistical model was developed to allow for different ages at time of initial assessment as well as variable intervals between follow up visits. The study results show that both acute and chronic measures of malnutrition significantly affect baseline developmental status as well as the rate of improvement in both MDI and PDI scores. This study contributes to the body of literature with its prospective nature, unique statistical model for longitudinal evaluation, and use of a validated assessment tool to assess outcomes.
malnutrition; international adoption; cognitive impairment; developmental delay; nutrition
Objective This study examined associations among adolescent sleepiness, sleep duration, variability in sleep duration, and psychological functioning (symptoms of anxiety, depression, externalizing behaviors, and perceived health). Methods This was a cross-sectional analysis of data from a community-based cohort study of sleep and health. Participants were 247 adolescents (48.6% female, 54.3% ethnic minority, mean age of 13.7 years). Sleep duration and variability in sleep duration were measured by actigraphy and sleepiness was measured by adolescent questionnaire. Primary outcomes were measured by parent, teacher, and adolescent questionnaires. Results Sleepiness was associated with higher scores on measures of anxiety (Adjusted partial r2 = .28, p < .001), depression (Adjusted partial r2 = .23, p < .001), and perceived health (indicating more negative outcomes) (Adjusted partial r2 = .19, p < .01). Significant associations between sleep duration or variability in sleep duration with psychological variables were not found. Conclusions Findings highlight the inter-relationships between sleepiness and psychological functioning and the potential importance of addressing sleepiness in health and psychological evaluations of adolescents.
adolescents; sleep; psychosocial functioning.
In analyzing data from a larger study, we noticed significant disagreement between results of 2 commonly used developmental screening tools (Parents’ Evaluation of Developmental Status [PEDS; parent concern questionnaire] and Ages & Stages Questionnaires [ASQ; parent report of developmental skills]) delivered to children at the same visit in primary care. The screens have favorable reported psychometric properties and can be efficient to use in practice; however, there is little comparative information about the relative performance of these tools in primary care. We sought to describe the agreement between the 2 screens in this setting.
Parents of 60 children aged 9 to 31 months completed PEDS and ASQ screens at the same visit. Concordance (PEDS and ASQ results agree) and discordance (results differ) for the 2 screens were determined.
The mean age of children was 17.6 months, 77% received Medicaid, and 50% of parents had a high school education or less. Overall, 37% failed the PEDS and 27% failed the ASQ. Thirty-one children passed (52%) both screens; 9 (15%) failed both; and 20 (33%) failed 1 but not the other (13 PEDS and 7 ASQ). Agreement between the 2 screening tests was only fair, statistically no different from agreement by chance.
There was substantial discordance between PEDS and ASQ developmental screens. Although these are preliminary data, clinicians need to be aware that in implementing revised American Academy of Pediatrics screening guidelines, the choice of screening instrument may affect which children are likely to be identified for additional evaluation.
developmental screening; primary care; well-child visit
The impact of early postnatal lead exposure measured at age 4 on children’s IQ and academic achievement at 4, 9, and 11 years of age was examined. The sample consisted of 278 inner-city, primarily African American children who were polydrug exposed prenatally. Regression analyses indicated a linear effect of lead exposure on outcomes and no moderating effects of polydrug exposure. An IQ loss of about 4.1–5.4 Full Scale IQ points was estimated for each 10 ug/dl increase in blood lead level at ages 4, 9, and 11 years as a function of blood lead level at age 4. Decrements in scores on tests of non-verbal reasoning were consistently associated with higher lead levels at age 4, while verbal decrements became apparent only at age 11. Lower reading summary scores at 9 and 11 years were consistently associated with higher lead exposure, while decrements in mathematics were not apparent until 11 years. Subgroup analyses on children with blood lead levels < 10 μg/dL showed detrimental lead effects even at the 5 μg/dL level, providing additional evidence of adverse effects occurring at blood lead levels below the current 10 μg/dL public health blood lead action level.
lead; cognitive development; school achievement; prenatal drug exposure; restricted cubic splines
The current study investigated the daily relationship between pain, activity restriction and depression in children and adolescents with chronic pain, and compared participants’ responses on diary and retrospective assessment measures.
Data collection included the administration of diary and retrospective measures of pain, activity restriction, and depression to 93 children with recurrent headache, juvenile chronic arthritis, and sickle cell disease. The study used HLM to examine the relationship between daily pain and activity restriction, and analyses compared participants’ responses on diary and retrospective assessment measures.
Using diary measures, daily pain intensity was related to children’s levels of activity restriction. Diary completion was predicted by age and diary-type, with younger children and children utilizing electronic diaries demonstrating higher compliance. Pain intensity was significantly higher on retrospective compared to diary measures, demonstrating inflation in retrospective reports of pain. No significant differences between measures of activity restriction emerged.
These preliminary results suggest that while retrospective reports of activity restriction may be an acceptable alternative to daily diary assessment for children with chronic pain, retrospective measures of pain intensity may show inflated pain levels. To provide support for the findings, longitudinal research comparing responses to diary versus retrospective measures is recommended.
chronic pain; activity restriction; depression; children; adolescents
The American Academy of Pediatrics recommends periodic administration of standardized developmental screening instruments during well-child visits to facilitate timely identification of developmental delay. However, little is known about how parents and physicians communicate about child development or how screening impacts communication.
Our goal was to examine whether parent-physician communication about child development is affected by (1) administration of a developmental screen or (2) video presentation on child development before well-child visits.
Six primary care pediatricians in a practice serving predominantly Medicaid-insured children participated. Fifteen parents of children 9 to 31 months of age per pediatrician were assigned to 1 of 3 previsit conditions (n = 89): (1) usual care; (2) parent completed the Parents’ Evaluation of Developmental Status screen; or (3) parent viewed 5-minute "activation" video before completing the Parents’ Evaluation of Developmental Status. Visits were audiorecorded and coded by blinded raters using a classification system that assesses communication content. Outcomes included visit length, physicians’ questions, information giving, reassurance or counseling about development, and parents’ concerns and requests for developmentally related services.
Mean visit duration was similar for the 3 groups (22.5 minutes). Physicians made more information-giving and counseling statements about development and raised more developmental concerns in group 3 (video plus the Parents’ Evaluation of Developmental Status) than in group 1 (usual care) visits. A trend toward increased use of such communication was also seen in group 2 (Parents’ Evaluation of Developmental Status only). Parents were more likely to raise a developmental concern in group 3 than in group 1. No parent requested early intervention, therapy, or other related services.
Use of a validated screening test did not increase average visit duration, an important consideration in primary care. Although use of the Parents’ Evaluation of Developmental Status alone led to some increase in parent-physician communication about development and developmental concerns, additional increase in communication was seen with the addition of a brief parent activation video shown before the Parents’ Evaluation of Developmental Status was completed.
developmental screening; parent activation; primary care; well-child visit
Previously published data from the Cleveland Children’s Sleep and Health Study (CCSHS) demonstrated that preterm infants are especially vulnerable both to sleep disordered breathing (SDB) and its neurocognitive sequelae at age 8–11 years. In this analysis, we aimed to identify the components of the neonatal medical history associated with childhood SDB among children born prematurely.
This analysis focuses on the 383 children in the population-based CCSHS cohort who were born <37 weeks gestational age and who had technically acceptable sleep studies performed at ages 8–11 years (92% of all preterm children). Logistic regression was used to evaluate the associations between candidate perinatal and neonatal risk factors and the presence of childhood SDB by sleep study.
Twenty-eight preterm children (7.3%) met the definition for SDB at age 8–11 years. Having a single mother and mild maternal pre-eclampsia were strongly associated with SDB in unadjusted and race-adjusted models. Unadjusted analyses also identified xanthine use and CPR and/or intubation in the delivery room as potential risk-factors for SDB. We did not find a significant link between traditional markers of severity of neonatal illness -- such as gestational age, birth weight, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), or duration of ventilation -- and childhood SDB at school age.
These results represent a first step in identifying prenatal and neonatal characteristics which place preterm infants at higher risk for childhood SDB. The strong association between mild pre-eclampsia and childhood SDB underscores the importance of research aimed at understanding in utero risk factors for neurorespiratory development.
sleep disordered breathing (SDB); obstructive sleep apnea (OSA); pre-eclampsia; snoring; neonate
Increased variability in ventilation may contribute to the pathogenesis of obstructive sleep apnea (OSA) by promoting ventilatory instability, fluctuations of neuromuscular output to the upper airway, and pharyngeal collapsibility. We assessed the association of a measure of ventilatory variability measured at the wake-sleep transition with OSA and associated covariates.
485 participants in the Cleveland Family Study underwent overnight polysomnography with independent derivation of the Ventilatory Variability Index and the Apnea Hypopnea Index. The Ventilatory Variability Index was calculated from the variability in the power spectrum of the abdominal inductance signal over a 2-minute period beginning at sleep onset.
The Ventilatory Variability Index was strongly correlated with the Apnea Hypopnea Index (r=0.43, p<0.001). After adjusting for age, body mass index, sex, and race, the Ventilatory Variability Index remained significantly associated with Apnea Hypopnea Index (p<0.001). The adjusted odds ratio for obstructive sleep apnea (Apnea Hypopnea Index ≥ 15) with each half standard deviation increase in Ventilatory Variability Index was 1.41 [1.25–1.59]. In a subgroup analysis of obese snorers, to limit analyses to those with a presumed anatomic predisposition for apnea, Ventilatory Variability Index remained associated with an elevated Apnea Hypopnea Index.
Increased ventilatory variability may be a useful phenotype in characterizing obstructive sleep apnea.
Sleep apnea syndromes; sleep disordered breathing; polysomnography; apnea
To assess school age cognitive and achievement outcomes after prenatal cocaine exposure, controlling for confounding drug and environmental factors.
At 9 years, 371 children (192 cocaine exposure, CE; 179 non-exposure, NCE) were assessed for IQ and school achievement in a longitudinal, prospective study from birth. An extensive number of confounding variables were controlled, including quality of caregiving environment, polydrug exposure, lead, iron deficiency anemia (IDA), and foster/adoptive care.
CE predicted poorer Perceptual Reasoning IQ with a linear relationship of the concentration of the cocaine metabolite, benzoylecgonine, to degree of impairment. Effects were mediated through birth head circumference, indicating a relationship with fetal brain growth. Negative effects of alcohol, lead, and marijuana exposure and positive effects of home environment were additive. Children with CE in foster/adoptive care had better home environments and lower lead levels. School achievement was not affected.
There were persistent teratologic effects of CE on specific cognitive functions and additive effects of alcohol, lead, marijuana, IDA, and home environment. Documenting environmental factors in behavioral teratology studies is important because in this sample, CE was associated with better home environments and lower environmental risk for a substantial number of children.
Lead; alcohol; marijuana; iron deficiency anemia; home environment; cognition; school achievement; poverty; behavioral teratogen
Dysmorphologic and anthropometric assessments were performed on 154 6-year-old children prenatally exposed to cocaine (PCE) and 131 high-risk controls (NCE) of similar race and social class. Adjusted mean height z scores demonstrated a dose-response with metahydroxybenzoylecgonine above a threshold of 100 ng/g of meconium and greater cocaine exposure predicted lower weight for height z score. Higher average alcohol exposure throughout pregnancy and 3rd trimester predicted lower head circumference and weight z scores, respectively. Severity of marijuana use also predicted lower height for age but greater weight for height. There was not an increased rate of minor anomalies among the PCE cohort, nor was a consistent phenotype identified. After controlling for covariates, higher average prenatal cigarette exposure predicted higher incidence of cranial facial abnormalities. First trimester alcohol exposure predicted greater rates of ear abnormalities and third trimester marijuana exposure predicted greater rates of chest and head shape abnormalities. These finding indicate that prenatal cocaine exposure has a negative effect on specific growth outcomes including standardized height and weight for height, but not a systematic pattern of structural abnormalities.
Dysmorphology; Prenatal cocaine-exposure; Anthropometric; Height; Cocaine metabolite; Meconium
Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to investigate the factor structure of coping in mothers with high levels of life stress. In Study 1, EFA of the Coping Orientation to Problems Experienced (C. S. Carver, M. F. Scheier, & J. K. Weintraub, 1989) in a sample of mothers of full-term or very low birth weight 2-year-old children yielded 7 reliable coping factors. Each factor accounted for significant variance in at least 1 of 6 outcomes measuring maternal–child well-being. In Study 2, CFA was used to cross-validate the EFA model on the basis of the responses of mothers of 2-year-old children with prenatal polysubstance exposure. CFA results revealed a moderately good fit, confirming the factor structure in a 2nd, independent sample of mothers with high levels of life stress.
factor analysis; coping; stress; mothers; 2-year-old children
To assess 6-year-old cocaine- and noncocaine-exposed children's mental health outcomes controlling for potential confounders.
The sample consisted of 322 children [169 cocaine exposed (CE) and 153 noncocaine exposed (NCE)] enrolled in a longitudinal study since birth. At age 6, children were assessed for mental health symptoms using the Dominic Interactive (DI), a child self-report measure, and the Child Behavior Checklist (CBCL), a caregiver report of behavioral problems.
CE children were more likely to self-report symptoms in the probable clinical range for oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). In contrast, prenatal cocaine exposure was not related to child behavior based on the CBCL. After control for exposure, CE children in adoptive or foster care were rated as having more problems with aggression, externalizing behaviors, and total behavioral problems than NCE children and CE children in maternal or relative care. Also, CE children in adoptive or foster care self-reported more externalizing symptoms than CE children in maternal or relative care and NCE children. Findings could not be attributed to caregiver intelligence or depressive symptoms, or to the quality of the home environment.
CE children report more symptoms of ODD and ADHD than nonexposed children. Adoptive or foster caregivers rated their CE children as having more behavioral problems than did maternal or relative caregivers of CE children or parents of NCE children. Although further studies are needed to understand the basis for the more negative ratings by adoptive or foster caregivers of their CE children, the self-report of CE children indicates a need for psychological interventions.
ADHD; adoptive or foster care; CBCL; Dominic Interactive; mental health outcomes; oppositional defiant disorder; prenatal cocaine exposure
Rationale: Metabolic syndrome (MetS) affects 4 to 10% of adolescents. Risk factors include overweight, male sex, and Hispanic ethnicity. Although sleep-disordered breathing (SDB) has been implicated as a risk factor for MetS in adults, its association with SDB in adolescents is unknown.
Objectives: To define the association of SDB with MetS in adolescents.
Methods: Standardized measurements of SDB, anthropometry and bioassays, were made in 270 adolescents, aged 13.6 ± 0.7 years. MetS was identified if threshold levels were exceeded in three of five areas: waist circumference, blood pressure, triglyceride level, high-density lipoprotein cholesterol level, and glucose levels.
Measurements and Main Results: Although 70% of children with SDB (apnea–hypopnea index ⩾ 5) were overweight and 59% had MetS, 16% of children without SDB had MetS. Twenty-five percent of those with MetS had SDB. After adjusting for age, race, sex, and preterm status, children with SDB had a 6.49 (95% confidence interval, 2.52, 16.70) increased odds of MetS compared with children without SDB. Indices of SDB stress associated with MetS included respiratory event frequency, degree of oxygen desaturation, and sleep efficiency. Analyses of individual metabolic parameters showed that, after adjustment for body mass index, SDB was associated with systolic and diastolic blood pressure, low-density lipoprotein cholesterol, and fasting insulin levels.
Conclusions: A majority of adolescents with SDB are overweight and meet criteria for MetS. The close association between MetS and SDB and their putative interacting pathophysiologies suggests a need to develop screening, prevention, and treatment strategies for both disorders in high-risk, overweight adolescents.
sleep apnea; metabolic syndrome; obesity
To determine the relationship between fatty acid ethyl esters (FAEE) in meconium and neurodevelopment in infants exposed to alcohol in utero at 6.5 months, 1 year, and 2 years of age.
A secondary analysis of a prospective cohort of high risk mothers and their infants recruited after admission to a labor and delivery unit. Mothers were screened for drug and alcohol use during pregnancy using clinical interview and urine screening. Meconium was analyzed for FAEE in 216 newborn infants. Outcome measures included the Bayley Scales of Infant Development Mental (MDI) and Psychomotor (PDI) Developmental Index scores in infants at 6.5 months, 1 year, and 2 years of age.
After controlling for prenatal visits and maternal factors, increasing concentrations of FAEE were significantly associated with poorer mental and psychomotor development (β±standard error) at all follow-up visits: ethyl myristate (MDI −2.46±1.24, P=0.05; PDI −3.88±1.67, P=0.02), ethyl oleate (MDI −1.94± 0.65, P<0.01; PDI −2.60±0.93, P<0.01), ethyl linoleate (MDI −1.92±0.60, P<0.01; PDI −2.28±0.84, P<0.01), ethyl linolenate (MDI −1.99±0.74, P<0.01; PDI −2.98±1.04, P<0.01), and ethyl arachidonate (MDI −2.40±1.11, P=0.03; PDI −3.32±1.51, P=0.03).
FAEE in meconium may be a marker for identifying newborns at risk for neurodevelopmental delay from alcohol exposure in utero.
ethanol; pregnancy; prenatal alcohol exposure; fetal alcohol syndrome; fetal alcohol spectrum disorder; neurodevelopment