Illicit drug use and cardiometabolic disease risk: an analysis of 2005-2008 National Health and Nutrition Examination Survey data.

PURPOSE: To explore the association between illicit drug use (IDU) and cardiometabolic disease risk factors (CDRF) in a nationally representative sample of adults. METHODS: The 2005-2008 National Health and Nutrition Examination Surveys data from 20- to 45-year-old adults (n = 8738) were utilised to analyze the relationship between IDU (ever used, repeated use and current use) and CDRF (hyperlipidemia, hyperinsulinemia, hypertension, elevated C-reactive protein, body mass index, waist circumference and cigarette use) via chi square and logistic regression analyses. Age, gender, race/ethnicity, education level, poverty to income ratio (PIR), and alcohol use were included as confounders in the models. RESULTS: Individuals who reported drug use (DU) at least once in lifetime were more likely to have CDRF than non-DU (NDU) (OR = 1.3, p = 0.004). Females with DU, IDU at least once in lifetime, and with repeated IDU were about 1.5 times more likely than their NDU counterparts to have CDRF (p < 0.0001, p = 0.02, p = 0.02, respectively). CONCLUSION: Results from this study suggest that healthcare professionals should be aware that patients with a history of DU may be at heightened risk for cardiometabolic disease. Females in particular have a heightened cluster of CDRF across drug-use categories.

Intrauterine growth of full-term infants: impact of prenatal cocaine exposure.

OBJECTIVE: The objectives of this study were to estimate the effect of prenatal cocaine exposure on fetal growth and gestational age after controlling for exposure to alcohol, tobacco, and marijuana and other covariates; to evaluate whether prenatal cocaine exposure has a disproportionate adverse effect on head circumference compared with overall somatic growth; and to assess whether the effect of prenatal cocaine exposure on fetal growth is mediated by cocaine's suspected effect on gestational age. METHODS: The study population includes 476 neonates participating in the Miami Prenatal Cocaine Study, a longitudinal follow-up of in utero cocaine exposure. The sample, restricted to full-term neonates born to African-American inner-city mothers, included 253 infants exposed prenatally to cocaine (with or without alcohol, tobacco, or marijuana exposure) and 223 non-cocaine-exposed infants, of whom 147 were drug-free and 76 were exposed to varying combinations of alcohol, tobacco, or marijuana. RESULTS: Evidence based on structural equations and multiple regression models supports a hypothesis of cocaine-associated fetal growth deficits (0.63 standard deviation) and an independent mild effect on gestational age (0.33 standard deviation). There was no evidence of a disproportionate adverse effect on birth head circumference once the impact on overall growth was estimated. There was evidence that some but not all of the cocaine effect on fetal growth was direct and some was indirect, acting via an intermediate influence of cocaine on gestational age. CONCLUSIONS: Cocaine-associated growth deficits, symmetrical and partially mediated by gestational age, were observed in this sample of inner-city African-American full-term infants prospectively enrolled at birth. Long-term implications will be the subject of future reports from this longitudinal investigation.

Influence of prenatal cocaine exposure on full-term infant neurobehavioral functioning.

This study investigated infant neurobehavioral functioning during the newborn period in 334 full-term, African American neonates (187 cocaine exposed, 147 non-cocaine exposed) enrolled prospectively at birth, with documentation of drug exposure status through maternal interview and urine and meconium toxicology assays. Infants were assessed using the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) during the newborn period (0-6 postnatal days). Findings from multivariate profile analyses support a consistent, modest effect of prenatal cocaine exposure on neurobehavioral functioning in full-term neonates. All of the BNBAS cluster scores, with the exception of abnormal reflexes, were similarly affected, sharing a common slope (D=-0.14; 95% CI=-0.27, -0.003; P=.046) representing a -0.14 point difference between cocaine-exposed and non-cocaine-exposed infants after controlling for prenatal exposure to alcohol, tobacco, and marijuana (ATM); maternal age, education, employment, primigravida status, and prenatal care visits; and infant sex and postnatal age in days. Fetal growth was also related to neurobehavioral functioning and, in part, mediated the relationship between cocaine exposure and the BNBAS cluster scores. Cocaine exposure during each trimester similarly influenced infant neurobehavioral profiles, with cocaine-associated deficits most pronounced in infants with exposure in all three trimesters. Results from qualitative and quantitative urine and meconium bioassay indicators further substantiated these results. Findings, while significant, represent modest effect sizes in full-term infants.

Longitudinal investigation of task persistence and sustained attention in children with prenatal cocaine exposure.

The present study estimates the longitudinal effects of prenatal cocaine exposure on indicators of sustained attention processing at 3, 5 and 7 years of age in an urban sample of full-term African-American children (235 cocaine-exposed, 207 noncocaine-exposed). The sample was enrolled prospectively at birth, with documentation of prenatal drug exposure status through maternal interview, urine and meconium toxicology assays. Sustained attention was measured at age 3 years using a standardized measure of task persistence during a challenging task [G.A. Morgan, N.A. Busch-Rossnagel, C.A. Maslin-Cole and R.J. Harmon, Individualized Assessment of Mastery Motivation: Manual for 15-36 Month Old Children, 1992.], and at ages 5 and 7 years using omission error scores from computerized continuous performance tasks (CPT) [L. Greenberg, R. Leark, T. Dupuy, C. Corman, C. Kindschi, M. Cenedela, Test of Variables of Attention (T.O.V.A. and T.O.V.A.-A.), 22, Universal Attention Disorders, Los Alamitos, CA, 1996; C.K. Conners, Conners' Continuous Performance Test (CPT), second ed., Multi-Health Systems, Canada, 1995.]. Findings from longitudinal GLM/GEE analyses of the three measured time points support a stable influence of prenatal cocaine exposure on indicators of sustained attention, after controlling for prenatal exposure to alcohol, marijuana, tobacco and over 20 additional medical and social-demographic covariates drawn from potentially confounding influences assessed at birth and later assessment visits (D=0.21; 95% CI=0.04, 0.38; P=.017). This effect was not mediated by fetal growth or gestational age and remained highly stable with increasing levels of covariate control. Separately, using the age 7 data, a structural equations model (SEM) was constructed combining all available self-report and bioassay data to measure magnitude of cocaine exposure in relationship to attention task performance. Results indicated a gradient of influence, with each standard deviation increase in the level of prenatal cocaine exposure relating to a 16% standard deviation increase in omission error scores at age 7. Overall findings support a stable cocaine-specific effect on indicators of sustained attention processing during the early childhood years. Results are discussed within the context of neurobiological and behavioral research linking prenatal cocaine exposure to long-lasting disruption of the brain systems subserving arousal and attention.

Brief report: relationship between HIV infection and WPPSI-R performance in preschool-age children.

OBJECTIVE: To determine the neurodevelopmental effects of perinatally acquired HIV infection on children of preschool age. METHODS: Participants included 40 children infected with HIV between the ages of three and five and an equal number of noninfected controls individually matched according to ethnicity, age, sex, and prenatal drug exposure. Participants were administered the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), upon which an analysis of subtest distribution was conducted. RESULTS: Whereas both groups evidenced mean IQ and subtest scores significantly below published norms, an effect for HIV group status was not found when a factor combining Performance IQ (PIQ) and Verbal IQ (VIQ) was analyzed. However, the group infected with HIV scored significantly lower than controls on the Block Design subtest. CONCLUSIONS: Gross cognitive deficits are not evident among preschool children infected with HIV relative to matched controls. However, this study does provides some evidence for more focal deficits. Further investigation with older children should be conducted.

Neonatal fellowship. Neonatal pneumopericardium: successful treatment with nitrogen washout technique.

Pneumopericardium in the neonate is a rare event but is associated with significant morbidity and mortality. We describe a neonate with mild respiratory distress and cardiovascular compromise after delivery and resuscitation. A large isolated pneumopericardium was diagnosed. Treatment with an oxygen hood (FiO2 1.00) resulted in a complete resolution of the pneumopericardium within 12 hours.

Cocaine-exposed preterm neonates show behavioral and hormonal differences.

OBJECTIVE: Prematurity has been associated with prenatal cocaine exposure, but most studies on the behavioral effects of prenatal cocaine exposure have been restricted to full-term infant samples. The current study focused on behavioral and hormonal responses in preterm cocaine-exposed infants compared with a cohort of non-cocaine-exposed infants of similar gestational age. METHODOLOGY: A comparison between 30 cocaine-exposed and 30 non-cocaine-exposed preterm neonates suggested that the cocaine-exposed neonates were born to mothers who had higher parity and more obstetric complications. In addition, mothers of cocaine-exposed preterm neonates visited, touched, held, and fed their infants less frequently than mothers of nonexposed infants. RESULTS: The cocaine-exposed infants had smaller head circumferences at birth, spent more time in the neonatal intensive care unit, and had a greater incidence of periventricular-intraventricular hemorrhages. They also had inferior Brazelton cluster scores, including lower state regulation and range-of-state scores, and greater depression. During sleep-wake behavior observations, they showed difficulty maintaining alert states and self-regulating their behavior, and they spent more time in indeterminate sleep and had decreased periods of quiet sleep and increased levels of agitated behavior, including tremulousness, mouthing, multiple limb movements, and clenched fists. Finally, higher urinary norepinephrine, dopamine, and cortisol levels and lower plasma insulin levels were noted in the cocaine-exposed preterm neonates. CONCLUSIONS: These findings highlight the need for follow-up assessments and early intervention.

Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions.

Recent federal health financing and health care delivery programs have increased access to alcohol and other drug abuse treatment programs for low-income women, and have provided intervention and prevention services for their children and families. The Village South Families in Transition (FIT) in Miami, Florida, implemented a residential treatment program for women and their children that aims to decrease alcohol and other drug use, reduce reliance on social and health welfare systems, improve functioning in specific life-skill and vocational areas, improve parenting techniques and maternal/child relations, and provide intervention and prevention services for the clients' children in a safe and supportive environment. Program implementation required resolutions to numerous barriers, including securing a facility for women and children; recruiting, hiring and training of staff; establishing and maintaining community linkages; treatment considerations; balancing treatment versus evaluation/research; and critical decisions faced by treatment staff as they modify client-centered programs to incorporate gender-specific and family-centered programs.

m-Hydroxybenzoylecgonine: an important contributor to the immunoreactivity in assays for benzoylecgonine in meconium.

Meconium has been reported to be a more suitable specimen than maternal or neonatal urine for detecting fetal exposure to cocaine. In a study comparing various immunoassays with gas chromatography/mass spectrometry (GC/MS), several unexplained discrepancies among the assays were noted. Using methanol extracts of meconium samples, an immunoreactive spot that was more polar than benzoylecgonine was detected by thin-layer chromatography (TLC). An extract of this spot analyzed by GC/MS yielded a fragmentation pattern indicative of an aryl hydroxylated benzoylecgonine. Standards of m-hydroxybenzoylecgonine, o-hydroxybenzoylecgonine, and p-hydroxybenzoylecgonine were synthesized; it was determined that m-hydroxybenzoylecgonine had the same retention time and ion ratios as the TLC immunoreactive spot. Furthermore, m-hydroxybenzoylecgonine proved to be immunoreactive. Ten meconium samples immunoreactive for benzoylecgonine were analyzed by GC/MS. Results before and after hydrolysis with beta-glucuronidase (type IX) showed free m-hydroxybenzoylecgonine comprising 59 to 94% of the total m-hydroxybenzoylecgonine and showed total m-hydroxybenzoylecgonine values ranging from 0.2 to 6.3 times as high as benzoylecgonine. Therefore, m-hydroxybenzoylecgonine appears to be a quantitatively important cocaine metabolite in meconium, which is responsible for a significant portion of the discrepancy between benzoylecgonine concentrations in meconium extracts as measured by immunoassay and GC/MS.

Rapid cocaine screening of urine in a newborn nursery.

A rapid cocaine screening test, the Abuscreen OnTrak assay, was compared with the EMIT (enzyme-multiplied immunoassay technique) screening test to determine relative accuracy in 450 newborn infants sequentially tested for urinary cocaine during a 6-week period at a large urban hospital. The Abuscreen Ontrak screen had a sensitivity of 96% and a specificity of 100%.

Perinatal cocaine effects on neonatal stress behavior and performance on the Brazelton Scale.

Fifty-two newborns were assessed for the effects of maternal cocaine use on their performance on the Brazelton Neonatal Behavior Assessment Scale and on their stress behaviors during the Brazelton as tapped by the Neonatal Stress Scale. The cocaine-exposed newborns experienced more obstetric complications, had smaller head circumferences, showed more limited habituation abilities on the Brazelton Scale, and exhibited more stress behaviors than control newborns.

Transcutaneous oxygen tension in preterm neonates during neonatal behavioral assessments and heelsticks.

This study evaluates the effects of neonatal behavioral assessments and heelsticks on transcutaneous oxygen tension (TcPO2) in 37 preterm neonates from a neonatal intensive care unit. Two behavioral assessments were evaluated, the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) and the Neurobehavioral Assessment for Preterm Infants (NAPI). TcPO2 during heelsticks was used as a comparison because reliable decreases have typically been noted during heelsticks. Although the heelsticks resulted in significant declines in TcPO2, the behavioral assessments led to only negligible changes in TcPO2. Observed changes during the behavioral assessments occurred in a small number of infants, primarily during the few test procedures administered to the infants outside of their isolettes. Accordingly, it is suggested that time outside the isolette and associated temperature changes may be more critical variables than the assessments per se.

Cocaine-related maternal death.

Hemodynamic overload, cardiac ischemia, and arrhythmia are postulated to originate from "sex-cocaine" syndrome resulting in maternal and fetal death. High concentrations of cocaine and metabolites in maternal blood, urine, and nasal secretions confirmed recent ingestion. Changes in the maternal life-style may have contributed to the poor pregnancy outcome.

Prophylactic indomethacin for prevention of intraventricular hemorrhage in premature infants.

The impact of early prophylactic use of intravenous indomethacin on the incidence and severity of periventricular-intraventricular hemorrhage and patent ductus arteriosus in 199 oxygen-requiring premature infants (less than or equal to 1300 g birth weight) was prospectively investigated. The trial was controlled, the infants were randomized, and the investigators were unaware of the group assignments. Patients with minimal (grade I) or no periventricular-intraventricular hemorrhage determined by prestudy echoencephalography were randomized within two birth weight subgroups (500 to 899 and 900 to 1300 g) to receive either prophylactic indomethacin (n = 99) or an equal volume of saline-vehicle placebo (n = 100). The first dose (0.2 mg/kg) was given within 12 hours of delivery and two subsequent doses (0.1 mg/kg) were administered at 12 hourly intervals. Prophylactic indomethacin significantly reduced the incidence of grades II to IV periventricular-intraventricular hemorrhage. Intraventricular hemorrhage was half as common in infants given prophylactic indomethacin as in control infants (23% v 46%, P less than .002). The reduction was manifested in both birth weight subgroups. Results of this study also confirmed a lower incidence of clinically significant patent ductus arteriosus in infants who received prophylactic indomethacin in contrast to those who received placebo (11% v 42%, P less than .001). No significant differences were found between treatment and control groups in the duration of oxygen therapy, mechanical ventilation, or hospitalization or in the incidence of pneumothorax, chronic lung disease, sepsis, necrotizing enterocolitis, retinopathy of prematurity, or death. Early prophylactic indomethacin initiated within 12 hours of delivery is effective in reducing the incidence of intraventricular hemorrhage as well as clinically significant patent ductus arteriosus in very low birth weight premature infants.

Grief responses of pediatric house officers to a patient's death.

Twenty-five pediatric house officers were surveyed (14 M; 11 F) to assess their behavioral and psychophysiologic responses to patient death. Vignettes about the deaths of two pediatric patients were included as part of a self-administered questionnaire. The vignettes were followed by 14 behavioral and 20 psychophysiologic responses to the deaths depicted, and physicians were asked to indicate the expected occurrence of these reactions for themselves and for an ideal physician. Reported reactions were found to be similar to grief responses experienced with the death of a loved one. Significant differences were found between the responses of female and male house officers to patient death. Additionally, differences were found between the manner in which the physicians personally responded to a patient's death in comparison to the way they considered an ideal physician would respond. Practical suggestions are given, based on these data, for inclusion of information in death education courses for physicians.