Constructing 3D Macroporous Microfibrous Scaffolds with a Featured Surface by Heat Welding and Embossing.

Three-dimensional (3D) microfibrous scaffolds hold great promise for biomedical applications due to their good mechanical properties and biomimetic structure similar to that of the fibrous natural extracellular matrix. However, the large diameter and smooth surface of microfibers provide limited cues for regulating cell activity and behaviors. In this work, we report a facile heat-welding-and-embossing strategy to develop 3D macroporous microfibrous scaffolds with a featured surface topography. Here, solid monosodium glutamate (MSG) particles with crystalline ridge-like surface features play a key role as templates in both the formation of scaffold pores and the surface embossing of scaffold fibers when short thermoplastic polypropylene microfibers were heat-welded. The embossing process can be programmed by adjusting heating temperatures and MSG/fiber ratios. Compared to traditional 3D microfibrous scaffolds, the as-welded 3D scaffolds show higher compressive strength and modulus. Taking mouse C2C12 myoblasts as a model cell line, the scaffolds with embossed surface features significantly promoted the growth of cells, interactions of cells and scaffolds, and formation of myotubes. The findings indicate that the as-prepared 3D scaffolds are a good platform for cell culture study. The facile strategy can be applied to fabricate different fibrous scaffolds by changing the combination of templates and thermoplastic polymer fibers with a melting temperature lower than that of the template. The obtained insights in this work could provide a guide and inspiration for the design and fabrication of functional 3D fibrous scaffolds.

Evaluation of subchronic administration of antiseizure drugs in spontaneously seizing rats.

OBJECTIVE: Approximately 30% of patients with epilepsy do not experience full seizure control on their antiseizure drug (ASD) regimen. Historically, screening for novel ASDs has relied on evaluating efficacy following a single administration of a test compound in either acute electrical or chemical seizure induction. However, the use of animal models of spontaneous seizures and repeated administration of test compounds may better differentiate novel compounds. Therefore, this approach has been instituted as part of the National Institute of Neurological Disorders and Stroke Epilepsy Therapy Screening Program screening paradigm for pharmacoresistant epilepsy. METHODS: Rats were treated with intraperitoneal kainic acid to induce status epilepticus and subsequent spontaneous recurrent seizures. After 12 weeks, rats were enrolled in drug screening studies. Using a 2-week crossover design, selected ASDs were evaluated for their ability to protect against spontaneous seizures, using a video-electroencephalographic monitoring system and automated seizure detection. Sixteen clinically available compounds were administered at maximally tolerated doses in this model. Dose intervals (1-3 treatments/d) were selected based on known half-lives for each compound. RESULTS: Carbamazepine (90 mg/kg/d), phenobarbital (30 mg/kg/d), and ezogabine (15 mg/kg/d) significantly reduced seizure burden at the doses evaluated. In addition, a dose-response study of topiramate (20-600 mg/kg/d) demonstrated that this compound reduced seizure burden at both therapeutic and supratherapeutic doses. However, none of the 16 ASDs conferred complete seizure freedom during the testing period at the doses tested. SIGNIFICANCE: Despite reductions in seizure burden, the lack of full seizure freedom for any ASD tested suggests that this screening paradigm may be useful for testing novel compounds with potential utility in pharmacoresistant epilepsy.

EMSY expression affects multiple components of the skin barrier with relevance to atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common, complex, and highly heritable inflammatory skin disease. Genome-wide association studies offer opportunities to identify molecular targets for drug development. A risk locus on chromosome 11q13.5 lies between 2 candidate genes, EMSY and LRRC32 (leucine-rich repeat-containing 32) but the functional mechanisms affecting risk of AD remain unclear. OBJECTIVES: We sought to apply a combination of genomic and molecular analytic techniques to investigate which genes are responsible for genetic risk at this locus and to define mechanisms contributing to atopic skin disease. METHODS: We used interrogation of available genomic and chromosome conformation data in keratinocytes, small interfering RNA (siRNA)-mediated knockdown in skin organotypic culture and functional assessment of barrier parameters, mass spectrometric global proteomic analysis and quantitative lipid analysis, electron microscopy of organotypic skin, and immunohistochemistry of human skin samples. RESULTS: Genomic data indicate active promoters in the genome-wide association study locus and upstream of EMSY; EMSY, LRRC32, and intergenic variants all appear to be within a single topologically associating domain. siRNA-knockdown of EMSY in organotypic culture leads to enhanced development of barrier function, reflecting increased expression of structural and functional proteins, including filaggrin and filaggrin-2, as well as long-chain ceramides. Conversely, overexpression of EMSY in keratinocytes leads to a reduction in markers of barrier formation. Skin biopsy samples from patients with AD show greater EMSY staining in the nucleus, which is consistent with an increased functional effect of this transcriptional control protein. CONCLUSION: Our findings demonstrate an important role for EMSY in transcriptional regulation and skin barrier formation, supporting EMSY inhibition as a therapeutic approach.

Replication of It's Your Game Keep It Real! in Southeast Texas.

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).

Student-led simulation: preparing students for leadership.

It is vital to prepare nurses to become informed leaders with the required knowledge and skills to support effective patient care and outcomes. This article describes an innovative teaching method that enables students to create simulation scenarios based on their clinical experiences, to lead simulations and to take part in self-reflection and peer review activities. The article shows how the method can help prepare nursing students to become future leaders by allowing them to practise 'real-life', real-time leadership skills, and apply theory to practice in the safety of a simulated scenario.

Simulation using 'live' adult service users and moulage in a variety of settings.

This article shows how simulation can be modified and adapted to benefit higher education institutions (HEIs) in a variety of situations. These situations can involve the engagement of service users (SUs) and moulage, or application of make-up to simulate clinical presentations, to ensure skill enhancement, ultimately to support and empower students so they can achieve their potential. This article describes a unique collaboration between staff at an HEI and SUs, who have worked together in simulation activities. The development of simulation using SUs is at the heart of developing nursing student education and recruitment. It has created communities of practice working across traditional departmental boundaries to provide innovative learning opportunities for students. This collaboration links to the political imperative to improve education in the health and social care sector, highlights the integration of skills development into theory, focuses on person-centred care and demonstrates how the HEI produces a compassionate and caring workforce.

Results of cross-faculty 'capstone' assessments involving nursing and performing arts students.

This article describes how 'capstone' assessments were created to provide two different student groups, nursing and performing arts students, with a lived experience of learning together about their own fields of practice. Capstone assessments combine 'live' human simulation with self-reflection and peer review. A capstone assessment is the integration of a body of relatively fragmented knowledge and learning to form a unified whole and can be used as a transitional assessment and a bridging experience to connect knowledge between modules or courses. The capstone assessments involved two faculties and four modules, three nursing and one performing arts. Case studies were designed to represent real-life situations that students were likely to encounter during their careers, either playing a patient as an actor or performing a caring role as a nurse. Assessments for the capstone simulation were formative, and involved the students engaging in self-reflection and peer review. Videos were available to enhance the self-reflection and peer-review process. Evaluation was undertaken through verbal feedback during debrief, written feedback, video footage and nursing student and acting student peer review. The experience of capstone assessments for two diverse student groups provided valuable learning from their own and from a different group outside their subject area.

Development and pharmacologic characterization of the rat 6 Hz model of partial seizures.

OBJECTIVE: The mouse 6 Hz model of psychomotor seizures is a well-established and commonly used preclinical model for antiseizure drug (ASD) discovery. Despite its widespread use both in the identification and differentiation of novel ASDs in mice, a corresponding assay in rats has not been developed. We established a method for 6 Hz seizure induction in rats, with seizure behaviors similar to those observed in mice including head nod, jaw clonus, and forelimb clonus. METHODS: A convulsive current that elicits these seizure behaviors in 97% of rats (CC97 ) was determined using a Probit analysis. Numerous prototype ASDs were evaluated in this model using stimulus intensities of 1.5× and 2× the CC97 , which is comparable to the approach used in the mouse 6 Hz seizure model (e.g., 32 and 44 mA stimulus intensities). The ASDs evaluated include carbamazepine, clobazam, clonazepam, eslicarbazepine, ethosuximide, ezogabine, gabapentin, lacosamide, lamotrigine, levetiracetam, phenobarbital, phenytoin, rufinamide, tiagabine, topiramate, and sodium valproate. Median effective dose (ED50 ) and median toxic (motor impairment) dose (TD50 ) values were obtained for each compound. RESULTS: Compounds that were effective at the 1.5 × CC97 stimulus intensity at protective index (PI) values >1 included clobazam, ethosuximide, ezogabine, levetiracetam, phenobarbital, and sodium valproate. Compounds that were effective at the 2 × CC97 stimulus intensity at PI values >1 included ezogabine, phenobarbital, and sodium valproate. SIGNIFICANCE: In a manner similar to the use of the mouse 6 Hz model, development of a rat 6 Hz test will aid in the differentiation of ASDs, as well as in study design and dose selection for chronic rat models of pharmacoresistant epilepsy. The limited number of established ASDs with demonstrable efficacy at the higher stimulus intensity suggests that, like the mouse 6 Hz 44 mA model, the rat 6 Hz seizure model may be a useful screening tool for pharmacoresistant seizures.

Latency to vaginal mesh exposure with mesh placed abdominally versus vaginally in pelvic floor surgery: A retrospective comparative study.

The primary aim was to compare the difference in time to mesh exposure between mesh placed abdominally versus vaginally. This is a retrospective comparative study of patients presented with vaginal mesh exposure between January 2001 and July 2012. This study compares patients who had undergone vaginally placed mesh procedures to those who had had abdominally placed mesh. Kaplan-Meier survival analysis was used to measure the time to mesh exposure. There were 68 patients with mesh exposure in our cohort. Thirty eight patients had undergone vaginal placement of mesh and 30 patients had abdominal mesh. There was a statistically significant difference in time to mesh exposure between abdominal and vaginal meshes (p≤.0001). Mean time to vaginal mesh exposure with abdominal mesh was 59.8 months (95%CI 46.2-73.3) compared to 23 months (95%CI 15.9-30.2) for vaginal mesh. When controlling for age, BMI and surgeon at index surgery, the Hazard Ratio for mesh exposure in our Cox Regression model was 0.53 (95%CI 0.39-0.71) (p ≤.0001). The mean time to vaginal mesh exposure after abdominal mesh was longer compared to the time to exposure with vaginally placed mesh (60 versus 23 months, p ≤.0001). These results support the evolving evidence that mesh exposures can occur many years distant from the procedure and warrant some level of surveillance or provision of warning signs by the providers who perform procedures with mesh.

What nursing students reveal about and learn from mentors when using stories of clinical practice.

Aim This article considers findings from a narrative research analysis that illustrate what nursing students can reveal about being mentored through their stories of clinical practice experience. The aim is to advocate the use of stories as tools to assist mentors in their roles, and to express to them students' concerns, sensitivities and priorities about clinical placement experiences. The findings are extracted from the author's unpublished doctoral thesis Learning from Practice: The Value of Story in Nurse Education ( Edwards 2013 ). Method The data are drawn from nursing students' stories about clinical practice experiences when engaged in the care of patients, and their perceived learning from them. Results Findings suggest stories can help develop understanding of nursing students' concerns, sensitivities and priorities, and can support mentors' important roles in students' learning. Conclusion The article illustrates the value of stories as learning tools in the workplace and, by looking at nursing students' stories about clinical practice, shows that paying attention to their concerns, sensitivities and priorities can improve the already significant role played by mentors in student learning.

Changes in pelvic organ prolapse mesh mechanical properties following implantation in rats.

BACKGROUND: Pelvic organ prolapse (POP) is a multifactorial disease that manifests as the herniation of the pelvic organs into the vagina. Surgical methods for prolapse repair involve the use of a synthetic polypropylene mesh. The use of this mesh has led to significantly higher anatomical success rates compared with native tissue repairs, and therefore, despite recent warnings by the Food and Drug Administration regarding the use of vaginal mesh, the number of POP mesh surgeries has increased over the last few years. However, mesh implantation is associated with higher postsurgery complications, including pain and erosion, with higher consecutive rates of reoperation when placed vaginally. Little is known on how the mechanical properties of the implanted mesh itself change in vivo. It is assumed that the mechanical properties of these meshes remain unchanged, with any differences in mechanical properties of the formed mesh-tissue complex attributed to the attached tissue alone. It is likely that any changes in mesh mechanical properties that do occur in vivo will have an impact on the biomechanical properties of the formed mesh-tissue complex. OBJECTIVE: The objective of the study was to assess changes in the multiaxial mechanical properties of synthetic clinical prolapse meshes implanted abdominally for up to 90 days, using a rat model. Another objective of the study was to assess the biomechanical properties of the formed mesh-tissue complex following implantation. STUDY DESIGN: Three nondegradable polypropylene clinical synthetic mesh types for prolapse repair (Gynemesh PS, Polyform Lite, and Restorelle) and a partially degradable polypropylene/polyglecaprone mesh (UltraPro) were mechanically assessed before and after implantation (n = 5/ mesh type) in Sprague Dawley rats for 30 (Gynemesh PS, Polyform Lite, and Restorelle) and 90 (UltraPro and Polyform Lite) days. Stiffness and permanent extension following cyclic loading, and breaking load, of the preimplanted mesh types, explanted mesh-tissue complexes, and explanted meshes were assessed using a multi-axial (ball-burst) method. RESULTS: The 4 clinical meshes varied from each other in weight, thickness, porosity, and pore size and showed significant differences in stiffness and breaking load before implantation. Following 30 days of implantation, the mechanical properties of some mesh types altered, with significant decreases in mesh stiffness and breaking load, and increased permanent extension. After 90 days these changes were more obvious, with significant decreases in stiffness and breaking load and increased permanent extension. Similar biomechanical properties of formed mesh-tissue complexes were observed for mesh types of different preimplant stiffness and structure after 90 days implantation. CONCLUSION: This is the first study to report on intrinsic changes in the mechanical properties of implanted meshes and how these changes have an impact on the estimated tissue contribution of the formed mesh-tissue complex. Decreased mesh stiffness, strength, and increased permanent extension following 90 days of implantation increase the biomechanical contribution of the attached tissue of the formed mesh-tissue complex more than previously thought. This needs to be considered when using meshes for prolapse repair.

A Multidimensional Approach to Characterizing Psychosocial Health During Pregnancy.

Objectives Domains of psychosocial health have been separately connected to pregnancy outcomes. This study explores the relationship between five domains of psychosocial health and their joint association with prenatal health and pregnancy outcomes. Methods Women from a prospective cohort study in Durham, North Carolina were clustered based on measures of paternal support, perceived stress, social support, depression, and self-efficacy. Clusters were constructed using the K-means algorithm. We examined associations between psychosocial health and maternal health correlates, pregnancy intention, and pregnancy outcomes using Chi square tests and multivariable models. Results Three psychosocial health profiles were identified, with the first (Resilient; n = 509) characterized by low depression and perceived stress and high interpersonal support, paternal support, and self-efficacy. The second profile (Vulnerable; n = 278) was marked by high depression and perceived stress, and low interpersonal support, paternal support, and self-efficacy. The third profile (Moderate, n = 526) fell between the other profiles on all domains. Health correlates, pregnancy intention, and pregnancy outcomes varied significantly across profiles. Women with the vulnerable profile were more likely to have risky health correlates, have an unintended pregnancy, and deliver preterm. Women with the resilient profile had better birth outcomes and fewer deleterious health correlates, preconception and prenatally. Conclusions We posit that vulnerable psychosocial health, deleterious health correlates, and the stress which often accompanies pregnancy may interact to magnify risk during pregnancy. Identifying and intervening with women experiencing vulnerable psychosocial health may improve outcomes for women and their children.

Narrative analysis: how students learn from stories of practice.

AIM: To describe and recommend a variety of data analysis methods when engaging in narrative research using story as an aid to nursing students' learning. BACKGROUND: Narrative research methodology is used in many nursing research studies. However, narrative research reports are generally unspecific regarding the analysis and interpretive process. DISCUSSION: This article examines the qualitative analytical approaches of Lieblich et al's ( 1998 ) narrative processes of holistic content and analysis of form, incorporated as overarching theories. To support these theories and to provide a more rounded analytical process, other authors' work is included. Approaching narrative analysis from different perspectives is recommended. For each cycle of analysis, it is important to conceptualise the analysis using descriptors drawn from the initial literature review and the initial text. Rigour and transparency are foremost, and tables are generated that reflect each stage of the analysis. The final stage of analysis is to clearly report, organise and present findings to reflect the richly varied and diverse potential of stories. CONCLUSION: Engaging in narrative research and then dealing with the large quantities of data to analyse can be daunting, difficult to manage and appear complex. It is also challenging and rewarding. With clear descriptors, examining the data using multiple lenses can serve to develop a greater level of insight into understanding nursing students' learning from their clinical experiences, presented as stories, when involved in the care of individuals. IMPLICATIONS FOR PRACTICE: There are many approaches to narrative analysis in nursing research and it can be difficult to establish the main research approach best suited to the study. There is no single way to define narrative analysis and a combination of strategies can be applied.

Advances in military resuscitation.

Trauma is a leading cause of death and disability worldwide, in civilian environments and on the battlefield. Trauma-induced haemorrhage is the principal cause of potentially preventable death, which is generally attributable to a combination of vascular injury and coagulopathy. Survival rates following severe traumatic injury have increased due to advanced trauma management initiatives and treatment protocols, influenced by lessons learned from recent conflicts in Iraq and Afghanistan. The use of tourniquets and intraosseous needles, early blood and blood product transfusion, administration of tranexamic acid in pre-hospital settings, and consultant-led damage control resuscitation incorporating damage control surgery have all played their part. All are quantified by trauma governance processes, including a robust trauma registry. Some of the lessons learned in combat are equally applicable to civilian environments, and this article describes several of the most important of these. It also gives an overview of advancements in UK military trauma management of severely injured combat casualties, honed over a decade of conflict.

Transforming the findings of narrative research into poetry.

AIM: To offer dramatic poetry as representing findings from narrative research that is more accessible. BACKGROUND: This article is drawn from the author's doctorate work on how students' stories about their 'clinical' experiences can aid learning. DATA SOURCES: Nursing students' stories of clinical practice experiences when engaged in the care of patients represented as dramatic poetry. REVIEW METHODS: Qualitative analytical approaches in narrative data analysis to provide a review of student stories from a variety of perspectives. DISCUSSION: This article illustrates a method for converting story data to poetry. It suggests that a range of audiences can learn from nursing students' stories of clinical practice when translated into dramatic poetry. CONCLUSION: Audiences can come close to understanding what students are experiencing in practice when engaged in the care of patients and learning from their practice experiences, when these experiences are expressed as dramatic poetry. IMPLICATIONS FOR RESEARCH/PRACTICE: Representing findings from narrative research as dramatic poetry can help audiences engage with nursing students' experiences at an emotional level. Enabling researchers and readers to become immersed in the poem transforming their understanding of what the students have learned.

Assessing the impact of race, social factors and air pollution on birth outcomes: a population-based study.

BACKGROUND: Both air pollution exposure and socioeconomic status (SES) are important indicators of children's health. Using highly resolved modeled predictive surfaces, we examine the joint effects of air pollution exposure and measures of SES in a population level analysis of pregnancy outcomes in North Carolina (NC). METHODS: Daily measurements of particulate matter <2.5 µm in aerodynamic diameter (PM2.5) and ozone (O3) were calculated through a spatial hierarchical Bayesian model which produces census-tract level point predictions. Using multilevel models and NC birth data from 2002-2006, we examine the association between pregnancy averaged PM2.5 and O3, individual and area-based SES indicators, and birth outcomes. RESULTS: Maternal race and education, and neighborhood household income were associated with adverse birth outcomes. Predicted concentrations of PM2.5 and O3 were also associated with an additional effect on reductions in birth weight and increased risks of being born low birth weight and small for gestational age. CONCLUSIONS: This paper builds on and complements previous work on the relationship between pregnancy outcomes and air pollution exposure by using 1) highly resolved air pollution exposure data; 2) a five-year population level sample of pregnancies; and 3) including personal and areal level measures of social determinants of pregnancy outcomes. Results show a stable and negative association between air pollution exposure and adverse birth outcomes. Additionally, the more socially disadvantaged populations are at a greater risk; controlling for both SES and environmental stressors provides a better understanding of the contributing factors to poor children's health outcomes.

Access to healthcare: removing barriers for the APRN.

As nurses face changes in the healthcare arena, we must be aware and involved in the legislation that affects our delivery of care to our clients. While many do not perceive their ability to influence legislative matters, there are things we can do. Such endeavors can include inviting legislators to APRN's practice, encouraging clients to talk with their legislators, and share evidence-based information on the outcomes of APRN practice. Nursing is a strong profession and has faced many challenges in the past. Nursing now needs to advocate for our profession and thus provide a positive impact on the healthcare of the clients.

Planned dose reduction of ocrelizumab in relapsing-remitting multiple sclerosis: a single-centre observational study.

Background: Ocrelizumab, a humanised anti-CD20 monoclonal, is a highly effective treatment for relapsing-remitting multiple sclerosis (RRMS). The long-term safety of B-cell depletion in RRMS, however, is uncertain and there are no data on dose reduction of ocrelizumab as a risk mitigation strategy. This study aimed to evaluate the effectiveness and safety of reducing ocrelizumab dose from 600 to 300 mg in patients with RRMS. Method: Data were collected through the Townsville neurology service. Following the standard randomised controlled trial regimen of 600 mg every 6 months for 2 years, sequential patients consented to dose reduction to 300 mg every 6 months. Patients were included if they were diagnosed with RRMS and received at least one reduced dose of ocrelizumab. Relapse, disability progression, new MRI lesions, CD19+ cell counts and immunoglobulin concentrations were analysed. Results: A total of 35 patients, treated with 177 full and 107 reduced doses, were included. The mean follow-up on reduced dose was 17 (1-31) months. We observed no relapses or new MRI activity in the cohort receiving the reduced dose, accompanied by persistent CD19+B cell depletion (≤0.05×109/L). Mean IgG, IgA and IgM levels remained stable throughout the study. No new safety concerns arose. Conclusions: In this single-centre observational study, dose reduction of ocrelizumab from 600 to 300 mg every 6 months after 2 years appeared to maintain efficacy in terms of new inflammatory disease activity. A randomised trial may be warranted to confirm this and explore the impact of dose reduction on long-term safety.

Effects of maternal prenatal smoking and birth outcomes extending into the normal range on academic performance in fourth grade in North Carolina, USA.

BACKGROUND: Research has documented the adverse relationship of child cognitive development with maternal prenatal smoking and poor birth outcomes. The potential, however, for maternal prenatal smoking to modify the association between birth outcomes and cognitive development is unclear. METHODS: We linked statewide North Carolina birth data for non-Hispanic white and non-Hispanic black children to end-of-grade test scores in reading and mathematics at fourth grade (n = 65 677). We fit race-stratified multilevel models of test scores regressed on maternal smoking, birth outcomes (as measured by continuous and categorical gestational age and birthweight percentile for gestational age), and their interaction, controlling for maternal- and child-level socio-economic factors. RESULTS: Smoking was consistently associated with decrements in test scores, and better birth outcomes were associated with improvements in test scores, even in clinically normal ranges. Test scores increased quadratically with improving birth outcomes among smoking and non-smoking mothers. Among non-Hispanic white children, the magnitude of the association between gestational age and test scores was larger for children whose mothers smoked during pregnancy compared with the non-smoking group. However, among non-Hispanic black children, birth outcomes did not appear to interact with maternal smoking on test scores. CONCLUSIONS: Maternal prenatal smoking may interact with birth outcomes on reading and mathematics test scores, particularly among non-Hispanic white children. Improvements in birth outcomes, even within the clinically normal range, may be associated with improved academic performance. Pregnancy-related exposures and events exert a significant and long-term impact on cognitive development.