Disparities in Decompressive Cranial Surgery Utilization in Severe Traumatic Brain Injury Patients without a Primary Extra-Axial Hematoma: A U.S. Nationwide Study.

OBJECTIVE: Decompressive craniectomy is recommended to reduce mortality in severe traumatic brain injury (TBI). Disparities exist in TBI treatment outcomes; however, data on disparities pertaining to decompressive craniectomy utilization is lacking. We investigated these disparities, focusing on race, insurance, sex, and age. METHODS: Hospitalizations (2004-2014) were retrospectively extracted from the Nationwide Inpatient Sample. The criteria included are as follows: age ≥18 years and indicators of severe TBI diagnosis. Poor outcomes were defined as discharge to institutional care and death. Multivariable logistic regression models were used to assess the effects of race, insurance, age, and sex, on craniectomy utilization and outcomes. RESULTS: Of 349,164 hospitalized patients, 6.8% (n = 23,743) underwent craniectomy. White (odds ratio [OR] = 0.50, 95% confidence interval [CI] = 0.44-0.57; P < 0.001) and Black (OR = 0.45, 95% CI = 0.32-0.64; P = 0.003) Medicare beneficiaries were less likely to undergo craniectomy. Medicare (P < 0.0001) and Medicaid beneficiaries (P < 0.0001) of all race categories had poorer outcomes than privately insured White patients. Black (OR = 1.2, 95% CI = 1.08-2.34; P = 0.001) patients with private insurance and Black (OR = 1.39, 95% CI = 1.22-1.58; P < 0.0001) Medicaid beneficiaries had poorer outcomes than privately insured White patients (P < 0.0001). Older patients (OR = 0.74, 95%, CI = 0.71-0.76; P < 0.001) were less likely to undergo craniectomy and were more likely to have poorer outcomes. Females (OR = 0.82, 95% CI = 0.76-0.88; P < 0.001) were less likely to undergo craniectomy. CONCLUSIONS: There are disparities in race, insurance status, sex, and age in craniectomy utilization and outcome. This data highlights the necessity to appropriately address these disparities, especially race and sex, and actively incorporate these factors in clinical trial design and enrollment.

Misuse of Pediatric Medications and Parent-Physician Communication: An Interactive Voice Response Intervention.

BACKGROUND: Children take 1 medication each week on average at home. Better communication between parents and providers could support safer home medication use and prevent misuse of pediatric medications, such as intentional underdosing or overdosing. Our primary objective was to assess the impact of an interactive voice response system on parent-provider communication about medications. METHODS: Parents of children 4 months to 11 years of age with upcoming well child visits were invited to call our interactive voice response system, called Personal Health Partner (PHP), which asked questions about the child's health and medication use. Responding parents were randomized to either PHP (interview and counseling) or control (injury prevention survey). Parents' responses were embedded in the electronic health record. After the physical visit, research assistants performed a phone follow-up survey. RESULTS: Of 475 parents, including 293 PHPs and 182 controls, 93% were women. We found a high prevalence of misuse of medications: 14% reported underdosing (n = 63) fever-reducer medications and 3% reported overdosing (n = 13). Twenty percent (n = 37) of the 190 children younger than 3 years had received cold medication. Thirty-three percent (n = 19) of 62 PHP parents of children on prescription medications reported nonadherence. Among children on prescription medications, PHP significantly increased discussion of medications at the physical, but not the number who brought medications to the visit; it had no impact on those not on prescription medications. CONCLUSIONS: Pediatric medication misuse was common in this study. Use of a previsit interactive voice response system increased medication-related communication during visits and supports the need for systems that better prepare patients for visits and improve medication-related patient-physician communication.

Emulating Target Clinical Trials of Radical Nephrectomy With or Without Lymph Node Dissection for Renal Cell Carcinoma.

OBJECTIVE: To emulate two target clinical trials of radical nephrectomy (RN) with lymph node dissection (LND) vs radical nephrectomy alone. METHODS: Using the National Cancer Database, we separately emulated an index trial of patients with cT1-3cN0cM0 renal cell carcinoma (RCC), designed to resemble EORTC 30881 ("index trial emulation"), and a hypothetical trial of patients at increased risk for lymph node metastases with cT1-4cN0-1cM0 RCC ("high-risk trial emulation"). A propensity score for LND was estimated using preoperative features (Model 1) or preoperative and pathologic features (Model 2). The associations of LND with overall survival (OS) were estimated using Cox regression with stabilized inverse probability weights. RESULTS: A total of 67,388 patients were included in the index trial emulation. Median follow-up was 49.2 (interquartile range 27.2-74.3) months. LND was not associated with improved OS when adjusting using either Model 1 (hazard ratio [HR] 1.26; 95% confidence interval [CI] 1.20-1.33; P <.0001) or Model 2 (HR 1.13; 95% CI 1.07-1.20; P <.0001). A total of 69,477 patients were included in the high-risk trial emulation. Median follow-up was 48.6 (interquartile range 26.6-73.8) months. LND was not associated with improved OS when adjusting using either Model 1 (HR 1.24; 95% CI 1.18-1.30; P <.0001) or Model 2 (HR 1.09; 95% CI 1.04-1.16; P = .001). In sensitivity analyses, LND was not associated with improved OS across cN stage, pT stage, tumor grade, histologic subtype, or probability of pN1 disease. CONCLUSION: In observational analyses, that emulate target trials representing EORTC 30881 and a trial of LND in high-risk RCC, LND was not associated with improved OS.

Screening and Brief Advice to Reduce Adolescents' Risk of Riding With Substance-Using Drivers.

OBJECTIVE: Alcohol- and drug-related car crashes are a leading cause of death for adolescents in the United States. This analysis tested the effects of a computer-facilitated Screening and Brief Advice (cSBA) system for primary care on adolescents' reports of driving after drinking or drug use (driving) and riding with substance-using drivers (riding). METHOD: Twelve- to 18-year-old patients (N = 2,096) at nine New England pediatric offices completed assessments only during the initial 18-month treatment-as-usual (TAU) phase. Subsequently, the 18-month cSBA intervention phase began with a 1-hour provider training and implementation of the cSBA system at all sites. cSBA included a notebook-computer with self-administered screener, immediate scoring and feedback, and 10 pages of scientific information and true-life stories illustrating substance-related harms. Providers received screening results, "talking points" for 2 to 3 minutes of counseling, and a Contract for Life handout. Logistic regression with generalized estimating equations generated adjusted relative risk ratios (aRRR) for past-90-day driving and riding risk at 3- and 12-month follow-ups, controlling for significant covariates. RESULTS: We found no significant effects on driving outcomes. At 3 months, cSBA youth were less likely than TAU to report riding with a drinking driver (aRRR = 0.70, 95% CI [0.49, 1.00]), and less likely to report riding with a driver who had used cannabis or other drugs (aRRR = 0.46, 95% CI [0.29, 0.74]). The effect was even greater (aRRR = 0.34, 95% CI [0.16, 0.71]) for riding with drinking drivers who were adult family members. All effects dissipated by 12-month follow-up. CONCLUSIONS: Screening and pediatrician brief advice shows promise for reducing adolescents' risk of riding with substance-using drivers.

HIV Risk, Substance Use, and Personality Characteristics among Adults with History of Serious Mental Illness.

The present study examined the relationship between characteristics associated with personality disorders, substance use, and HIV risk among adults with a history of serious mental illness. Participants included 103 adults with antisocial or borderline personality disorder, serious mental illness, and recent HIV risk behavior. The sample was predominately male (64%), diverse (42% African American and 13% Hispanic), and homeless/marginally housed (76%). In order to examine the relationship between personality characteristics and risk we constructed a risk index comprising key symptoms of antisocial and borderline personality disorders, namely; impulsivity, affective instability, and disregard for safety of self/others. Contrary to our primary hypotheses, risk index scores did not predict HIV risk behavior and substance abuse did not mediate this risk. Exploratory analyses did reveal that women engaged in significantly more risk behaviors than their male counterparts and that risk scores were a significant predictor of total sex acts for women but not men. In addition, increased emotional dysregulation was a significant predictor of condomless sex acts for women but not men. Finally, recent alcohol use and increased impulsivity was associated with more condomless oral sex for men and women. These results suggest the relationship among serious mental illness, personality disorder, substance abuse, and gender is complex and merits further study.

Supporting employees' work-family needs improves health care quality: Longitudinal evidence from long-term care.

We analyzed qualitative and quantitative data from U.S.-based employees in 30 long-term care facilities. Analysis of semi-structured interviews from 154 managers informed quantitative analyses. Quantitative data include 1214 employees' scoring of their supervisors and their organizations on family supportiveness (individual scores and aggregated to facility level), and three outcomes: (1), care quality indicators assessed at facility level (n = 30) and collected monthly for six months after employees' data collection; (2), employees' dichotomous survey response on having additional off-site jobs; and (3), proportion of employees with additional jobs at each facility. Thematic analyses revealed that managers operate within the constraints of an industry that simultaneously: (a) employs low-wage employees with multiple work-family challenges, and (b) has firmly institutionalized goals of prioritizing quality of care and minimizing labor costs. Managers universally described providing work-family support and prioritizing care quality as antithetical to each other. Concerns surfaced that family-supportiveness encouraged employees to work additional jobs off-site, compromising care quality. Multivariable linear regression analysis of facility-level data revealed that higher family-supportive supervision was associated with significant decreases in residents' incidence of all pressure ulcers (-2.62%) and other injuries (-9.79%). Higher family-supportive organizational climate was associated with significant decreases in all falls (-17.94%) and falls with injuries (-7.57%). Managers' concerns about additional jobs were not entirely unwarranted: multivariable logistic regression of employee-level data revealed that among employees with children, having family-supportive supervision was associated with significantly higher likelihood of additional off-site jobs (RR 1.46, 95%CI 1.08-1.99), but family-supportive organizational climate was associated with lower likelihood (RR 0.76, 95%CI 0.59-0.99). However, proportion of workers with additional off-site jobs did not significantly predict care quality at facility levels. Although managers perceived providing work-family support and ensuring high care quality as conflicting goals, results suggest that family-supportiveness is associated with better care quality.

Marginal structural modelling of associations of occupational injuries with voluntary and involuntary job loss among nursing home workers.

OBJECTIVES: Qualitative studies have highlighted the possibility of job loss following occupational injuries for some workers, but prospective investigations are scant. We used a sample of nursing home workers from the Work, Family and Health Network to prospectively investigate association between occupational injuries and job loss. METHODS: We merged data on 1331 workers assessed 4 times over an 18-month period with administrative data that include job loss from employers and publicly available data on their workplaces. Workers self-reported occupational injuries in surveys. Multivariable logistic regression models estimated risk ratios for the impact of occupational injuries on overall job loss, whereas multinomial models were used to estimate OR of voluntary and involuntary job loss. Use of marginal structural models allowed for adjustments of multilevel lists of confounders that may be time varying and/or on the causal pathway. RESULTS: By 12 months, 30.3% of workers experienced occupational injury, whereas 24.2% experienced job loss by 18 months. Comparing workers who reported occupational injuries to those reporting no injuries, risk ratio of overall job loss within the subsequent 6 months was 1.31 (95% CI 0.93 to 1.86). Comparing the same groups, injured workers had higher odds of experiencing involuntary job loss (OR 2.19; 95% CI 1.27 to 3.77). Also, compared with uninjured workers, those injured more than once had higher odds of voluntary job loss (OR 1.95; 95% CI 1.03 to 3.67), while those injured once had higher odds of involuntary job loss (OR 2.19; 95% CI 1.18 to 4.05). CONCLUSIONS: Despite regulatory protections, occupational injuries were associated with increased risk of voluntary and involuntary job loss for nursing home workers.

Automated conversation system before pediatric primary care visits: a randomized trial.

BACKGROUND AND OBJECTIVES: Interactive voice response systems integrated with electronic health records have the potential to improve primary care by engaging parents outside clinical settings via spoken language. The objective of this study was to determine whether use of an interactive voice response system, the Personal Health Partner (PHP), before routine health care maintenance visits could improve the quality of primary care visits and be well accepted by parents and clinicians. METHODS: English-speaking parents of children aged 4 months to 11 years called PHP before routine visits and were randomly assigned to groups by the system at the time of the call. Parents' spoken responses were used to provide tailored counseling and support goal setting for the upcoming visit. Data were transferred to the electronic health records for review during visits. The study occurred in an urban hospital-based pediatric primary care center. Participants were called after the visit to assess (1) comprehensiveness of screening and counseling, (2) assessment of medications and their management, and (3) parent and clinician satisfaction. RESULTS: PHP was able to identify and counsel in multiple areas. A total of 9.7% of parents responded to the mailed invitation. Intervention parents were more likely to report discussing important issues such as depression (42.6% vs 25.4%; P < .01) and prescription medication use (85.7% vs 72.6%; P = .04) and to report being better prepared for visits. One hundred percent of clinicians reported that PHP improved the quality of their care. CONCLUSIONS: Systems like PHP have the potential to improve clinical screening, counseling, and medication management.

Health reform and shifts in funding for sexually transmitted infection services.

BACKGROUND: In the Affordable Care Act era, no-cost-to-patient publicly funded sexually transmitted infection (STI) clinics have been challenged as the standard STI care delivery model. This study examined the impact of removing public funding and instituting a flat fee within an STI clinic under state-mandated insurance coverage. METHODS: Cross-sectional database analysis examined changes in visit volumes, demographics, and payer mix for 4 locations in Massachusetts' largest safety net hospital (STI clinic, primary care [PC], emergency department [ED], obstetrics/gynecology [OB/GYN] for 3 periods: early health reform implementation, reform fully implemented but public STI clinic funding retained, termination of public funding and institution of a US$75 fee in STI clinic for those not using insurance). RESULTS: Sexually transmitted infection visits decreased 20% in STI clinic (P < 0.001), increased 107% in PC (P < 0.001), slightly decreased in ED, and did not change in OB/GYN. The only large demographic shift observed was in the sex of PC patients--women comprised 51% of PC patients seen for STI care in the first time period, but rose sharply to 70% in the third time period (P < 0.0001). After termination of public funding, 50% of STI clinic patients paid flat fee, 35% used public insurance, and 15% used private insurance. CONCLUSIONS: Mandatory insurance, public funding loss, and institution of a flat STI clinic fee were associated with overall decreases in STI visit volume, with significant STI clinic visit decreases and PC STI visit increases. This may indicate partial shifting of STI services into PC. Half of STI clinic patients chose to pay the flat fee even after reform was fully implemented.

Disparity of care for children with parent-reported autism spectrum disorders.

OBJECTIVE: Although children with autism spectrum disorders (ASDs) are eligible to receive special education services via an individualized education program (IEP), approximately 12% to 20% do not. Our objective was to determine which clinical and demographic characteristics are associated with IEP receipt among a nationally representative sample of children with ASD. METHODS: Using data from the 2007 National Survey of Children's Health, we determined which clinical and demographic covariates are associated with IEP receipt for children ages 6 to 17 years with a current, parent-reported ASD diagnosis (n = 759). Logistic regression models were used to assess the association of covariates with IEP receipt. Application of weighting techniques made the findings representative of the noninstitutionalized population of US children 6 to 17 years old. RESULTS: In the weighted model, 90% of children with ASD receive an IEP. Maternal education level above high school (adjusted odds ratio [aOR] 4.08, P = .01) and presence of perceived need for coordination of care (aOR 3.62, P = .02) were associated with IEP receipt, while Hispanic children were less likely to receive an IEP compared with white children (aOR 0.12, P = .001). The following factors were not associated with IEP receipt: severity of ASD, speech, and behavior problems. CONCLUSIONS: For children with ASD in the United States, socioeconomic factors, not disability severity, are associated with IEP receipt. Future research should address methods to overcome this disparity in care. Health care providers may help to advocate for appropriate educational services for patients with ASD.

Cross sectional: normal maximal incisal opening and associations with physical variables in children.

PURPOSE: The purpose of this investigation was to establish a normal range of maximal incisal opening (MIO) in children, and the correlation between MIO with age, height, weight, gender, race, and molar relationship. METHODS: Calibrated examiners used the TheraBite Range of Motion (ROM) scale to obtain two MIO readings from 500 enrolled subjects, accounting for overbite or open bite. The subject's height, weight, molar relationship, age, gender, and race were recorded. Subjects were stratified according to age, and mean MIO ± standard deviation for each age group was determined. RESULTS: Mean MIO was positively correlated with age (P<.001), height (P<.001), weight (P<.001), and race (P<.001). However, height became insignificant in the multivariable regression model. On average, MIO of African-Americans was 3.66 mm larger than Whites (P<.001), and MIO of Hispanics/Latinos was 2.52mm greater than Whites (P<.001). There was no statistically significant association with left or right molar relationships (P=.07, P=.26 respectively) or gender (P=.58). CONCLUSIONS: TheraBite ROM scale is a practical tool to clinically measure MIO. MIO mimics somatic growth, peaking at age 12-13 years for females and 14-15 years for males. African-Americans and Hispanics/Latinos have a greater mean MIO than Whites. The established norms will be useful in diagnosis and treatment.

Regional infant brain development: an MRI-based morphometric analysis in 3 to 13 month olds.

Elucidation of infant brain development is a critically important goal given the enduring impact of these early processes on various domains including later cognition and language. Although infants' whole-brain growth rates have long been available, regional growth rates have not been reported systematically. Accordingly, relatively less is known about the dynamics and organization of typically developing infant brains. Here we report global and regional volumetric growth of cerebrum, cerebellum, and brainstem with gender dimorphism, in 33 cross-sectional scans, over 3 to 13 months, using T1-weighted 3-dimensional spoiled gradient echo images and detailed semi-automated brain segmentation. Except for the midbrain and lateral ventricles, all absolute volumes of brain regions showed significant growth, with 6 different patterns of volumetric change. When normalized to the whole brain, the regional increase was characterized by 5 differential patterns. The putamen, cerebellar hemispheres, and total cerebellum were the only regions that showed positive growth in the normalized brain. Our results show region-specific patterns of volumetric change and contribute to the systematic understanding of infant brain development. This study greatly expands our knowledge of normal development and in future may provide a basis for identifying early deviation above and beyond normative variation that might signal higher risk for neurological disorders.

Brief report: prevalence of attention deficit/hyperactivity disorder among individuals with an autism spectrum disorder.

Currently, both the DSM-IV-TR and ICD-10 preclude the diagnosis of attention deficit/hyperactivity disorder (ADHD) in cases that present with an autism spectrum disorder (ASD). This criterion will be removed in the upcoming DSM-V, but the relationship between ASD and ADHD, and in particular the prevalence of ADHD among the ASD population, remains controversial. Previous studies have reported clinically significant ADHD symptoms in one-third to three-quarters of ASD-affected individuals (probands). In our sample of 1,838 simplex children and adolescents with ASD, we found that less than 16% met clinically significant levels of ADHD symptoms, per parent report. When both parent and teacher reports were considered, the comorbidity rate was even lower, at 2%.

Association between self-reported depression and screening colonoscopy participation.

The impact of depression on participation in screening colonoscopy is poorly characterized. This study attempts to understand this relationship by conducting a cross-sectional analysis on a nationally representative sample of adults aged 50 to 75 years without a history of colorectal cancer or inflammatory bowel disease from the 2009 Medical Expenditures Panel Survey. Multivariable analysis shows that the odds of having a current colonoscopy is 1.3 times higher for individuals with depression compared with those without depression (odds ratio = 1.3; 95% confidence interval = 1.1-1.7). These findings suggest that depression may not be a risk factor for underutilization of CRC screening.

Smoking among construction workers: the nonlinear influence of the economy, cigarette prices, and antismoking sentiment.

Little research has been conducted on the influence of macroeconomic environments on smoking among blue-collar workers, a group with high smoking prevalence and that is especially vulnerable to the effects of changing economic circumstances. Using data from 52,418 construction workers in the Tobacco Use Supplement to the United States Current Population Survey, we examined the association of labor market shock, cigarette prices, and state antismoking sentiments with smoking status and average number of cigarettes smoked daily. Data analysis included the use of multiple linear and logistic regressions, which employed the sampling and replicate weights to account for sampling design. Unemployed, American-Indian, lower-educated and lower-income workers had higher smoking rates. Labor market shock had a quadratic association, which was non-significant for smoking status and significant for number of cigarettes. The association of cigarette prices with smoking status became non-significant after adjusting for state-level antismoking sentiment. State-level antismoking sentiment had significant quadratic association with smoking status among employed workers and significant quadratic association with number of cigarettes for all smokers. The study highlights how both workplace-based smoking cessation interventions and antismoking sentiments could further contribute to disparities in smoking by employment status.

Validation of the GILLS score for tongue-lip adhesion in Robin sequence patients.

BACKGROUND: The GILLS score consists of gastroesophageal reflux disease, preoperative intubation, late surgical intervention, low birth weight, and syndromic diagnosis. The purpose of this study was to test the validity of the GILLS score in predicting success of tongue-lip adhesion (TLA) in managing Robin sequence. MATERIALS AND METHODS: Infants with Robin sequence were included in the study if they had a TLA for airway compromise subsequent to formulation of the GILLS scoring system, that is, they were not included in the original GILLS analysis. The patients were prospectively considered based on the presence of the 5 factors that constitute the GILLS score. A score of ≤ 2 predicts success of TLA. RESULTS: Twenty patients met the inclusion criteria. Tongue-lip adhesion managed the compromised airway in 18 (90%) of 20 patients. Overall, the GILLS score had a sensitivity of 83%, specificity of 50%, positive predictive value of 94%, and negative predictive value of 25%. CONCLUSIONS: The GILLS score accurately predicts a successful outcome for TLA in infants with Robin sequence. For infants with a score of 2 or less, TLA is the procedure of choice. Infants with a GILLS score of 3 or greater were 5 times more likely to fail TLA than those with a score of 2 or less. In these patients, other methods of managing the airway should be considered.

A pilot study to improve venipuncture compliance in children and adolescents with autism spectrum disorders.

OBJECTIVE: Medical procedures, particularly venipuncture (the puncture of a vein especially for the withdrawal of blood), can cause serious distress and behavior disturbance for many children. Noncompliance to blood draws can have significant ramifications in both research and clinical settings. The negative reactions may be exacerbated in individuals with autism spectrum disorders. Even so, there has been little research into the prevalence of the problem or effective intervention procedures. In response to these concerns, we developed and evaluated the Blood Draw Intervention Program. The program was designed to be easy to use, require little provider or family time, effectively reduce negative behaviors, and increase blood draw compliance. METHOD: In a quasi-randomized trial over the course of ∼ 18 months, 58 of 210 families with children with autism spectrum disorders participating in a larger study of phenotypic and genotypic factors reported significant concerns about blood draws and elected to use the Blood Draw Intervention Program. RESULTS: Completion of the program increased blood draw compliance rates from 85.4% to 96.6% (odds ratio = 4.80; 95% confidence interval = 1.12, 20.59; p = .03). CONCLUSION: Results indicate the efficacy of the program in a research setting and suggest a potential clinical application. The current intervention, unlike many others for the same or similar difficulties proposed in the past, was successful without requiring extensive time, training, or effort on the part of providers and parents or their children, nor did it require large-scale institutional changes.

Pulmonary CT angiography to evaluate for pulmonary embolism in children visiting adult-centered community hospitals.

OBJECTIVE: The objective of our study was to determine the rate of pulmonary embolism (PE) on pulmonary CT angiography (CTA) in children and adolescents visiting adult-centered community hospitals. We also investigated alternative diagnoses that may account for presenting symptoms. MATERIALS AND METHODS: We identified consecutive children and adolescents (age ≤ 19 years) who underwent pulmonary CTA during a 12- and 24-month period, respectively, at two community hospitals. Staff radiologists' clinical interpretations of pulmonary CTA studies were compared with interpretations performed by a blinded, subspecialty-trained thoracic radiologist, with a third tie-breaking interpretation performed in cases of discrepancy. A systematic review of pulmonary CTA studies for possible alternative diagnoses was completed. Diagnostic rates of PE on pulmonary CTA studies in adults at these hospitals were also reviewed for comparison. RESULTS: The study population consisted of 130 individuals (32 boys and 98 girls; median age, 18 years; age range, 11-19 years) who underwent 137 examinations, 11 as inpatients and 126 as outpatients. CTA studies were positive for PE in six patients (4.6%). CTA showed an important alternative diagnosis, such as pulmonary consolidation, in 27 patients (21%). By comparison, pulmonary CTA studies in adults at these two hospitals yielded a 16% positive rate for PE. CONCLUSION: The prevalence of PE in young ambulatory patients with clinically suspected PE at adult-centered community hospitals is substantially lower than in adults. Alternative diagnoses, such as pulmonary consolidation and pneumothorax, are discovered more frequently than PE on pulmonary CTA studies. Pulmonary CTA should be used with discretion in adolescents, especially when radiography may provide the necessary diagnosis.

Low-level environmental lead exposure in childhood and adult intellectual function: a follow-up study.

BACKGROUND: Early life lead exposure might be a risk factor for neurocognitive impairment in adulthood. OBJECTIVES: We sought to assess the relationship between early life environmental lead exposure and intellectual function in adulthood. We also attempted to identify which time period blood-lead concentrations are most predictive of adult outcome. METHODS: We recruited adults in the Boston area who had participated as newborns and young children in a prospective cohort study that examined the relationship between lead exposure and childhood intellectual function. IQ was measured using the Wechsler Abbreviated Scale of Intelligence (WASI). The association between lead concentrations and IQ scores was examined using linear regression. RESULTS: Forty-three adults participated in neuropsychological testing. Childhood blood-lead concentration (mean of the blood-lead concentrations at ages 4 and 10 years) had the strongest relationship with Full-Scale IQ (ß = -1.89 ± 0.70, p = 0.01). Full-scale IQ was also significantly related to blood-lead concentration at age 6 months (ß = -1.66 ± 0.75, p = 0.03), 4 years (ß = -0.90 ± 0.41, p = 0.03) and 10 years (ß = -1.95 ± 0.80, p = 0.02). Adjusting for maternal IQ altered the significance of the regression coefficient. CONCLUSIONS: Our study suggests that lead exposure in childhood predicts intellectual functioning in young adulthood. Our results also suggest that school-age lead exposure may represent a period of increased susceptibility. Given the small sample size, however, the potentially confounding effects of maternal IQ cannot be excluded and should be evaluated in a larger study.