Faculty Bibliography

OBJECTIVE: To assess whether small elevations in blood lead level were associated with measurable behavioral changes in a group of poor children between 1 and 3 years old. METHODS: The study population consisted of children presenting for routine well-child care to the pediatric clinic at Bellevue Hospital Center, a large urban public hospital. The following inclusion criteria were used for entry into the study: age 12 to 36 months; capillary lead screening result <1.21 micromol/L (25 microg/dL); no known prior history either of blood lead level >1.21 micromol/L (25 microg/dL) or lead exposure requiring chelation therapy; Latino or African-American; English or Spanish spoken in the home; biological mother as primary caretaker; child not presently attending day care; full-term, singleton gestation; birth weight at least 2500 g; no known neurologic or developmental disorder; and no severe chronic disease, including human immunodeficiency virus infection. Study enrollment was simultaneously stratified by capillary lead level and age. All children between 12 and 36 months attending the pediatric clinic during the study period received screening capillary blood measures of lead level following the recommendations of the Centers for Disease Control and Prevention and the American Academy of Pediatrics as part of routine primary care. During periods of enrollment, consecutive lead measurements performed in the pediatric clinic were reviewed by one of the researchers. For those children meeting entry criteria based on lead level and age, further eligibility based on the remainder of the inclusion criteria was determined through parental interview and review of the medical record. Lead exposure was assessed with a single capillary blood specimen, using atomic absorption spectrophotometry. Subjects were considered to be lead-exposed if their lead level was between 0.48 and 1.20 micromol/L (10 and 24.9 microg/dL) and nonexposed if their lead level was between 0 and 0.48 micromol/L (0 and 9.9 microg/dL). Behavior was assessed using the Behavior Rating Scale (BRS) of the Bayley Scales of Infant Development, second edition. The BRS in this age group consists of three components: an Emotional Regulation Factor that measures hyperactive/distractible/easy-frustration behaviors; an Orientation-Engagement Factor that measures fear/withdrawal/disinterest behaviors; and a Motor Quality Factor that assesses the appropriateness of movement and tone. The BRS is scored as a percentile; lower scores reflect more problematic behaviors. Researchers performing the BRS were blinded to capillary lead results. Information was collected concerning factors that might confound the relationship between lead and behavior. Demographic factors were collected, including: child's age, gender, and country of origin; mother's age, marital status, parity, country of origin, and primary language spoken; parental education, and occupation and receipt of public assistance. Socioeconomic status was determined using the Hollingshead Two-Factor Index of Social Position. Maternal verbal IQ was assessed using the Peabody Picture Vocabulary Test-Revised. Maternal depression was assessed using the Center for Epidemiologic Studies-Depression Scale. Cognitive stimulation provided in the home was assessed using a new office-based instrument, the StimQ, which measures the quantity and quality of play materials and parent-toddler activities in the child's home. To assess the child for iron deficiency, we performed a hematocrit and mean corpuscular volume at the time of the capillary lead evaluation. A presumptive diagnosis of iron deficiency was made if the child was either anemic (defined as a hematocrit <32) or had a mean corpuscular volume <72. RESULTS: The study sample consisted of 72 children. Children in the lead-exposed group (n = 41) had a mean BRS behavior score that was 15.8 points lower than that of children in the nonexposed group (n = 31), which was significant by the Stu

OBJECTIVE: To determine the secular trend in the prevalence of cervical dysplasia as evidenced by abnormal Papanicolaou smear results in sexually active adolescents. DESIGN: Descriptive case series. SETTING: Outpatient department of an urban public hospital. PARTICIPANTS: All sexually active adolescents with Papanicolaou smear results recorded during 2 periods: January 1, 1982, through December 31, 1983 (n = 577), and January 1, 1992, through December 31, 1993 (n = 871). MEASUREMENTS: Age, ethnicity, patient care location in which the Papanicolaou smear preparation was performed, and Papanicolaou smear results were obtained for each patient. For patients with more than 1 Papanicolaou smear result during the specified period, only the first result was included in this study. Papanicolaou smear results were classified according to the Bethesda system as within normal limits, benign cellular change, atypical squamous cells of undetermined significance, lowgrade squamous intraepithelial lesion, or high-grade squamous intraepithelial lesion. Any Papanicolaou smear classified as atypical squamous cells of undetermined significance or low- or high-grade squamous intraepithelial lesion was defined as abnormal. RESULTS: The prevalence of abnormal Papanicolaou smear results was 2.8% in 1982 through 1983 vs 11.7% in 1992 through 1993; prevalence odds ratio was 4.7 (95% confidence interval, 2.7-8.3). The higher rate of abnormal Papanicolaou smear results in 1992 through 1993 persisted after controlling for age, patient care location, and ethnicity in a logistic regression model (adjusted prevalence odds ratio, 5.0; 95% confidence interval, 2.8-8.9). The prevalence of benign cellular change was 8.7% in 1982 through 1983 vs 20.1% in 1992 through 1993; prevalence odds ratio was 2.7 (95% confidence interval, 1.9-3.8). CONCLUSIONS: The prevalence of abnormal Papanicolaou smear results has significantly increased in the last decade in sexually active adolescents seen at a city hospital clinic. The results of this study emphasize the importance of routine Papanicolaou smear screening for all sexually active female adolescents

OBJECTIVE: To determine whether patients' hand-held immunization cards provide accurate assessments of immunization status when compared with their corresponding medical records. SETTING: Urban hospital emergency department immunization program. DESIGN: Comparison of 2 criterion standards. PATIENTS: Children aged 4 months to 6 years who presented consecutively with their immunization cards and received routine care in the hospital's pediatric clinic. SELECTION: Of 673 eligible patients seen in the immunization program from November 1992 to October 1993, 140 were randomly selected for comparison of immunization card and medical record immunization dates; in addition, all 123 eligible patients seen between August and October 1994 were selected. Of the total of 263 children, medical records for 257 (98%) were available for review. The dates of diphtheria-tetanus-pertussis, polio, measles-mumps-rubella, and Haemophilus influenzae type b immunization from immunization cards and medical records were recorded, as were patient age, sex, and ethnicity. Immunization card-medical record immunization date pairs were compared. Each immunization card and medical record was categorized as up to date, due for immunization, or delayed 2 months or more for any immunization at the time of the visit. RESULTS: In 218 (85%) of 257 cases, the immunization card and medical record immunization dates were identical (McNemar test, P = .63). The immunization card and medical record agreed that patients were due for immunization in 91 cases and agreed that patients were not due for immunization in 138 cases (kappa = 0.77; 95% confidence interval, 0.70-0.85). The immunization card and medical record agreed that patients were delayed for 1 or more immunizations in 51 cases and agreed that patients were not delayed in 187 cases (kappa = 0.79; 95% confidence interval, 0.71-0.88). CONCLUSION: The hand-held immunization card is a suitable alternative to the medical record when the need for immunization is assessed or when rates of immunization delay in populations are determined

A retrospective review of the hospital records of New York City children aged 6 months through 6 years showed that 63 homeless children had a higher rate of immunization delay than an age- and sex-stratified sample of 63 domiciled children living at the same federal poverty level. In a logistic regression model, this difference persisted after controlling for sex, age, ethnicity, presence of chronic illness, and reason for referral. In a 6-month- to 2-year-old subgroup, homeless and domiciled children had equal rates of anemia, but homeless children were more likely to have elevated erythrocyte protoporphyrin (EP) levels consistent with iron deficiency. This difference, too, persisted after controlling for the same confounding factors. Elevated EP levels and immunization delay were likely to coexist in the homeless children. The higher rate of immunization delay is compatible with the occurrence of measles outbreaks in some New York City shelters. The higher rates of iron deficiency may reflect overall poor nutrition. All these findings have significant implications for the design of health-care programs for homeless children