Faculty Bibliography

The authors studied toddlers with low-level lead exposure to determine whether adverse developmental effects were evident. The study sample consisted of a cohort of 68 children aged 12 to 36 months who had blood lead levels lower than 25 microg/dL on a routine screening in a large urban public hospital clinic. Children with blood lead levels between 10 and 24.9 microg/dL had a mean Mental Developmental Index (Bayley Scales of Infant Development, Second Edition) score that was 6.3 points lower than that of children with blood lead levels between 0 and 9.9 microg/dL (95% confidence interval: 0.6, 11.9). After adjusting for confounders, the difference was 6.2 points (95% confidence interval: 1.7, 10.8). Pediatricians and public health entities should continue in their efforts to reduce the lead burden through environmental control and ongoing surveillance

OBJECTIVES: The overall goal of this study was to prospectively assess risk factors for retinopathy of prematurity (ROP) in infants of birth weight <1250 g in an urban population at Bellevue Hospital Center, New York, New York. The hypothesis tested was that lack of prenatal care increases the incidence of ROP. METHODS: A consecutive sample of patients admitted to Bellevue Hospital Center's neonatal intensive care unit/special care nursery who weighed <1250 g at birth and survived until their ophthalmology screening examinations were included in the study. The main outcome measures were presence or absence of ROP and prenatal care. Additional relevant clinical information was collected on the patients. RESULTS: Ninety infants were evaluated. Sixty-one (68%) had ROP; 29 (32%) had no ROP. No differences in incidence or severity of ROP were detected with regard to prenatal care when the 2 groups were compared. In this population <1250 g, there were no differences in birth weight or gestational age with respect to prenatal care or lack of prenatal care. CONCLUSIONS: Lack of prenatal care was not associated with an increased risk for ROP in infants with birth weight <1250 g in this urban population

OBJECTIVE: To assess risk factors associated with the development of retinopathy of prematurity (ROP) in an urban population. DESIGN: Observational cohort study. SETTING: Bellevue Hospital Center, a regional perinatal referral center in New York City. PATIENTS: Surviving inborn infants with birth weight less than 1250 g undergoing an ophthalmologic screening examination. MAIN OUTCOME MEASURES: Screening examination results for ROP were obtained. Additional data included birth weight, gestational age, maternal factors, and common neonatal diagnoses and exposures. RESULTS: Sixty-three infants were included in the analysis. Mean +/- SD birth weight was 981+/-179 g and mean gestational age was 27.8+/-2.4 weeks. Infants whose mothers received antenatal dexamethasone developed significantly less ROP that was stage 2 or higher than infants without a history of antenatal dexamethasone exposure--8.7% (2/23) vs 35% (14/40), respectively (P=.04). Birth weight, gestational age, respiratory distress syndrome, bronchopulmonary dysplasia, and patent ductus arteriosus were also significantly associated with the development of ROP that was stage 2 or higher. After controlling for these confounders by multiple logistic regression analysis, antenatal dexamethasone administration was associated with a significantly decreased risk of development of ROP stage 2 or higher (adjusted odds ratio [OR], 0.14; 95% confidence interval [CI], 0.02-0.93). The association was stronger when the analysis was restricted to the 36 infants who were 24 to 28 weeks of gestational age (adjusted OR, 0.02; 95% CI, 0.00-0.76). CONCLUSION: Antenatal dexamethasone administration appears to be associated with a decreased incidence of development of ROP of stage 2 or higher in this urban population

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 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

In a series of investigations with poor minority families, we examined the reliability and validity of the StimQ, an office-based interview of children's cognitive home environment. Researchers and practitioners alike recognize the importance of assessing meaningful dimensions of children's early experiences, particularly in families where children may be at risk for later cognitive delay. To date, methodological approaches to the study of parenting have most often relied on home visits and/or labour-intensive observations and coding. Our findings suggest that valid and reliable data about the cognitive environments of poor children can be obtained through maternal report, thereby offering applied scientists a useful alternative to assessing children's early experiences. (C)1996 by John Wiley and Sons, Ltd.

Results of coronary artery bypass grafting with and without mitral valve replacement were analyzed retrospectively in 101 patients with preoperative ischemic mitral regurgitation to determine the effects of severity and surgical treatment of mitral regurgitation on survival. Between 1980 and 1984, a total of 1,475 patients (mean age 59, 77% male) underwent coronary bypass. These patients were divided into three groups: (1) patients without ischemic mitral regurgitation who underwent isolated coronary bypass (1,374; 93%), (2) patients with ischemic mitral regurgitation who underwent isolated coronary bypass without valve replacement (85; 6%), and (3) patients with ischemic mitral regurgitation who underwent combined mitral valve replacement and coronary bypass (16; 1%). Preoperatively, patients with ischemic mitral regurgitation compared to those without regurgitation were significantly older (+6 years, p less than 0.001), had more severe coronary artery disease (p less than 0.001), a higher incidence of congestive heart failure (24% versus 5%, p less than 0.001) and recent myocardial infarction (16% versus 8%, p less than 0.01), and a lower mean ejection fraction (45% versus 61%, p less than 0.001). Operative mortality was significantly increased in patients with ischemic mitral regurgitation who underwent coronary bypass alone (p less than 0.01) and in those who underwent coronary bypass and mitral valve replacement (p less than 0.01)--11% and 19%, respectively--than in the coronary bypass patients without ischemic mitral regurgitation (3.7%). The severity of mitral regurgitation (0 to 4+) proved to be the most significant predictor of operative mortality. The actuarial survival rate at 5 years for the coronary bypass patients without ischemic mitral regurgitation was 85% compared to 91% (p less than 0.05) for the coronary bypass patients without ischemic mitral regurgitation. These results indicate that patients with ischemic mitral regurgitation have a higher prevalence of cardiac risk factors and are at an increased risk of operative mortality. Although the severity of the ischemic mitral regurgitation was strongly predictive of early survival, it proved to have an unexpectedly modest effect on long-term survival after surgical treatment