Hypertension and cognitive decline among patients of Alzheimer's disease

Objective. The main aim of our study is to assess the effect of hypertension on the decline in cognitive impairment among Alzheimer’s patients. Methods. We analyzed the data of AD patients enrolled in Baylor ADMDC in a prospective study design. We divided AD patients into two groups based on the definition of hypertension. We described a decline in cognitive impairment as a change of 5 points in mini-mental state examination score (MMSE) from the baseline visit. Results. Independent of covariates, AD patients with hypertension did not exhibit a significant decline in cognitive impairment after adjustment of covariates, age, race and education (Hazard Ratio (HR) = 1.07, p value 0.58, 95% confidence interval 0.84-1.39) than AD patients without hypertension. In addition, AD patients with hypertension did not experience decline in cognitive impairment sooner than AD patients without hypertension. (P value 0.83). Conclusions . Hypertension is not associated with cognitive impairment over time among patients with Alzheimer’s disease enrolled in Baylor ADMDC after other potential confounders were taken into account. These findings should not be interpreted as a basis for discouraging appropriate medical treatment of hypertension in AD patients. Greater efforts should be made to improve the recognition of hypertension as a modifiable risk factor for decline in cognitive impairment in AD population. ^

A comprehensive framework for evaluating funder's performance

Evaluation methods for assessing the performance of non-profit funders are lacking. The purpose of the research was to create a comprehensive framework that systematically assesses the goals and objectives of a funder, how these relate to the funder's allocation of resources, and the potential impact of programs and services selected by the funder for resource allocation to address organizational goals and objectives. The Houston Affiliate of Susan G. Komen for the Cure, a local chapter of a national breast cancer awareness advocacy organization, was selected as the funding agency whose performance assessment was to assist in the creation of this framework. Evaluation approaches from the government sector were adapted and incorporated into the research to guide the methods used to answer the three research questions corresponding to the three phases of research within the study: (1) what are the funding goals and objectives of the Affiliate?; (2) what allocation scheme does the organization use to address these goals and objectives and select programs for funding?; and, (3) to what extent do the programs funded by the Affiliate have potential long-term impact? ^ Within the first stage of the research, document reviews of the Affiliate's mission-based documents and bylaws and interviews with organizational and community informants revealed a highly latent constellation of broad objectives that were not formalized into one guiding document, thus creating gaps in management and governance. Within the second phase of the research, reviews of grant applications from the 2008-2009 funding cycle and interviews with employees and volunteers familiar with the funding process revealed competing ideas regarding resource allocation in light of vague organizational documents describing funding goals and objectives. Within the final stage of the research, these findings translated to the Affiliate selecting programs with highly varying potential long-term impact with regards to addressing goals and objectives relating to breast cancer education, screening, diagnostics, treatment, and support. The resulting performance assessment framework, consisting of three phases of research utilizing organizational documents and key informant interviews, demonstrated the importance of clearly defined funding goals and objectives, reference documents and committee participation within the funding process, and regular reviews of potential long-term impact for selected programs, all supported by the active participation and governance of a funder's Board of Directors.^

Gender differences in colorectal cancer screening and incidence in large nationwide, population-based cohorts

Background. A few studies have reported gender differences along the colorectal cancer (CRC) continuum but none has done so longitudinally to compare a cancer and a non-cancer populations.^ Objectives and Methods. To examine gender differences in colorectal cancer screening (CRCS); to examine trends in gender differences in CRC screening among two groups of patients (Medicare beneficiaries with and without cancer); to examine gender differences in CRC incidence; and to examine for any differences over time. In Paper 1, the study population consisted of men and women, ages 67–89 years, with CRC (73,666) or without any cancer (39,006), residing in 12 U.S. Surveillance Epidemiology and End-Results (SEER) regions. Crude and age-adjusted percentages and odds ratios of receiving fecal occult blood test (FOBT), sigmoidoscopy (SIG), or colonoscopy (COL) were calculated. Multivariable logistic regression was used to assess gender on the odds of receiving CRC screening over time.^ In Paper 2, age-adjusted incidence rates and proportions over time were reported across race, CRC subsite, CRC stage and SEER region for 373,956 patients, ages 40+ years, residing in 9 SEER regions and diagnosed with malignant CRC. ^ Results. Overall, women had higher CRC screening rates than men and screening rates in general were higher in the SEER sample of persons with CRC diagnosis. Significant temporal divergence in FOBT screening was observed between men and women in both cohorts. Although the largest temporal increases in screening rates were found for COL, especially among the cohort with CRC, little change in the gender gap was observed over time. Receipt of FOBT was significantly associated with female gender especially in the period of full Medicare coverage. Receipt of COL was also significantly associated with male gender, especially in the period of limited Medicare coverage.^ Overall, approximately equal numbers of men (187,973) and women (185,983) were diagnosed with malignant CRC. Men had significantly higher age-adjusted CRC incidence rates than women across all categories of age, race, subsite, stage and SEER region even though rates declined in all categories over time. Significant moderate increases in rate difference occurred among 40-59 year olds; significant reductions occurred among patients age 70+, within subsite rectum, unstaged and distant stage CRC, and eastern and western SEER regions. ^ Conclusions. Persistent gender differences in CRC incidence across time may have implications for gender-based interventions that take age into consideration. A shift toward proximal cancer was observed over time for both genders, but the high proportion of men who develop rectal cancer suggests that a greater proportion of men may need to be targeted with newer screening methods such as fecal DNA or COL. Although previous reports have documented higher CRC screening among men, higher incidence of CRC observed among men suggests that higher risk categories of men are probably not being reached. FOBT utilization rates among women have increased over time and the gender gap has widened between 1998 and 2005. COL utilization is associated with male gender but the differences over time are small.^

Perceived gender relations and sexual relations among undergraduate female students in the Mekong Delta of Vietnam

Background. Literature worldwide has documented associations between gender-based relationship inequity, sexual communication self-efficacy, and actual use of condoms and contraceptives among young women. However studies that have rigorously tested these associations in southern Vietnam are extremely rare. This study aimed to examine these associations and other current sexual practices among undergraduate female students in the Mekong Delta. Method. A qualitative study was conducted to examine the operationalization of the Theory of Gender and Power and to obtain salient and culture-relevant dimensions of perceived gender relations in the Mekong Delta of Vietnam. Sixty-four undergraduate female students from two universities participated in eight group discussions focusing on their viewpoints regarding national and local gender equity issues. A subsequent cross-sectional survey consisting of 1181 third-year female students from Can Tho University and An Giang University was conducted. Latent variable modeling and logistic regression were employed to examine the hypothesized associations. Results. Dimensions of perceived gender relations were attributable to theoretical structures of labor, power, and cathexis. Perceptions about gender inequities were comparable to findings from several reports, in which women were still viewed as inferior and subordinate to men. Among students who had ever had a boyfriend(s) (72.4%), 44.8% indicated that their boyfriend had ever asked for sex, 13% had ever had penile-vaginal sex, and 10.3% had ever had oral sex. For those who had ever had penile-vaginal sex, 33% did not use any contraceptive method at first sex. The greater a student’s perception that women were subordinate to men, the lower her self-efficacy for sexual communication and the lower her actual frequencies of asking for contraceptive or condom use. Sexual communication self-efficacy was marginally associated with actual contraceptive use (p=.039) and condom use (p=.092) at first sex. Conclusion. Sexual health promotion strategies should address the influence of perceived unequal gender relations on young women’s sexual communication self-efficacy and the subsequent impact on actual contraceptive and condom use.^

An exploratory study of screening practices and barriers for postpartum depression in Texas

Purpose. To evaluate the prevalence of Postpartum Depression (PPD) screening among practicing obstetrician-gynecologists in Texas, and to identify factors and barriers associated with routine depression screening practices.^ Subjects. One hundred and eighty-nine fellows and junior fellows of the Texas Association of Obstetricians & Gynecologists (District XI).^ Methods. A survey questionnaire was developed and sent to 2,028 obstetriciangynecologists, asking about their current screening practices related to PPD. The survey questions were related to the physician's demographics, the patient population, screening practices, barriers to screening, and perceptions about resources in the community. Responses were analyzed to determine associations between these factors and the physician's screening practices. ^ Results. The respondents (n=189) constituted 9.3% of the surveyed population, thus the findings cannot be considered representative of all practicing Ob-Gyns in Texas. However, the following trends were observed. Of the respondents, 85.4% reported routinely screening for PPD, while 14.6% did not. However, of those that screened, only 20.2% used the Edinburgh Postnatal Depression Scale and 7.6% screened with the Postpartum Depression Screening Scale, both validated screening tools. The majority (77.2%) reported using an informal patient interview to screen. For those who did not routinely screen, inadequate training and inadequate resources to screen for PPD were the top two barriers. Physician's age was associated with routine screening practice, as older physicians were less likely to screen routinely. Primary insurance coverage of the patient population was also associated with screening practice; physicians with Medicaid and uninsured patients were less likely to screen routinely. Lastly, physicians that believed that adequate resources existed in their communities for the treatment of PPD were more likely to screen than those that did not.^ Conclusions. The present study is the first attempt at assessing Postpartum Depression screening practices and barriers in Texas. Although the response rate was low, the findings related to informal screening methods and inadequate training indicated that education and training with regards to PPD screening and validated screening tools among Ob-Gyns stand to be improved. Connecting physicians to psychiatric resources may also improve screening rates. This first look at screening practices in Texas serves as a platform for future research in order to gain definitive insight into the diagnosis and treatment of PPD, and ultimately design interventions to improve detection rates and treatment.^

Is depression associated with insulin resistance? A systematic review

Studies suggest that depression affects glucose metabolism, and therefore is a risk factor for insulin resistance. The association between depression and insulin resistance has been investigated in a number of studies, but there is no agreement on the results. The objective of this study is to survey the epidemiological studies, identify the ones that measured the association of depression (as exposure) with insulin resistance (as outcome), and perform a systematic review to assess the reliability and strength of the association. For high quality reporting, and assessment, this systematic review used the outlined procedures, guidelines and recommendations for reviews in health care, suggested by the Centre for Reviews and Dissemination, along with recommendations from the STROBE group (Strengthening the Reporting of Observational Studies in Epidemiology). Ovid MEDLINE 1996 to April Week 1 2010, was used to identify the relevant epidemiological studies. To identify the most relevant set of articles for this systematic review, a set of inclusion and exclusion criteria were applied. Six studies that met the specific criteria were selected. Key information from identified studies was tabulated, and the methodological quality, internal and external validity, and the strength of the evidence of the selected studies were assessed. The result from the tabulated data of the reviewed studies indicates that the studies either did not apply a case definition for insulin resistance in their investigation, or did not state a specific value for the index used to define insulin resistance. The quality assessment of the reviewed studies indicates that to assess the association between insulin resistance and depression, specifying a case definition for insulin resistance is important. The case definition for insulin resistance is defined by the World Health Organization and the European Group for the Study of Insulin Resistance as the insulin sensitivity index of the lowest quartile or lowest decile of a general population, respectively. Three studies defined the percentile cut-off point for insulin resistance, but did not give the insulin sensitivity index value. In these cases, it is not possible to compare the results. Three other studies did not define the cut-off point for insulin resistance. In these cases, it is hard to confirm the existence of insulin resistance. In conclusion, to convincingly answer our question, future studies need to adopt a clear case definition, define a percentile cut-off point and reference population, and give value of the insulin resistance measure at the specified percentile.^

Goals, plans, and behavior changes: A relevant part of the post-treatment cancer experience

Background. Colorectal cancer (CRC) survivors have to manage treatment side effects, psychosocial issues, and co-morbidities, as well as modify their lifestyles to decrease risk of recurrence and prolong life. Identifying survivors’ goals and key factors that influence their goals will highlight the issues cancer survivors face post-treatment and the resources needed to help them engage in health-promoting behaviors.^ Objectives and methods. This dissertation examines the health-related goals of post-treatment CRC survivors using two studies: (1) a qualitative study to identify and describe the health goals of CRC survivors during the transition from active treatment to post-treatment survivorship and follow-up care; and (2) a cross-sectional survey to identify CRC survivors’ goals, and key factors that influence their goals.^ Results. (1) The 41 qualitative interviews indicated participants’ health-related goals were to be healthy, get back to normal, and not have a cancer recurrence. Most of the CRC survivors reported they maintained healthy behaviors, made healthy behavior changes, or had goals to change their behavior. Respondents were empowered to improve their health by maintaining follow-up care and regular health screenings, and many were managing treatment side effects in an effort to improve functional abilities. (2) The cross-sectional study found that CRC survivors’ most prevalent goals were related to healthy behaviors (i.e., eat a healthy diet and engage in physical activity), and cancer care or disease management (i.e., keep up with health screenings and monitor symptoms). Goals that survivors identified as important were similar to goals they perceived were important to their providers (i.e., goals related to cancer care, disease management). Certain goals were statistically associated with age, barriers to achieving goals, social support and health-related quality of life.^ Conclusions. CRC survivors have health-promoting goals post-treatment and are interested in making health behavior changes. Goals ranged from cancer care/surveillance and disease management to healthy lifestyle modifications. Patients may need help resolving or managing treatment side effects or co-morbidities prior to implementing health promoting behaviors. Healthcare providers’ recommendations may be a powerful resource to encourage survivors to engage in health-promoting behaviors. Self-management and goal setting support could be an appropriate strategy to assist patients with achieving their post-treatment health goals.^

Understanding treatment-related symptoms, symptom management techniques, and symptom management self-efficacy in a sample of non-muscle invasive bladder cancer patients

The current literature available on bladder cancer symptom management from the perspective of the patients themselves is limited. There is also limited psychosocial research specific to bladder cancer patients and no previous studies have developed and validated measures for bladder cancer patients’ symptom management self-efficacy. The purpose of this study was to investigate non-muscle invasive bladder cancer patients’ health related quality of life through two main study objectives: (1) to describe the treatment related symptoms, reported effectiveness of symptom-management techniques, and the advice a sample of non-muscle invasive bladder cancer patients would convey to physicians and future patients; and (2) to evaluate Lepore’s symptom management self-efficacy measure on a sample of non-muscle invasive bladder cancer patients. Methods. A total of twelve (n=12) non-muscle invasive bladder cancer patients participated in an in-depth interview and a sample of 46 (n=4) non-muscle invasive bladder cancer patients participated in the symptom-management self-efficacy survey. Results. A total of five symptom categories emerged for the participants’ 59 reported symptoms. Four symptom management categories emerged out of the 71 reported techniques. A total of 62% of the participants’ treatment related symptom-management techniques were reported as effective in managing their treatment-related symptoms. Five advice categories emerged out of the in-depth interviews: service delivery; medical advice; physician-patient communication; encouragement; and no advice. An exploratory factor analysis indicated a single-factor structure for the total population and a multiple factor structure for three subgroups: all males, married males, and all married participants. Conclusion. These findings can inform physicians and patients of effective symptom-management techniques thus improving patients’ health-related quality of life. The advice these patients’ impart can improve service-delivery and patient education.^

The Open Door Mission: Measuring and predicting outcomes of one community-based substance abuse treatment program

The objectives of this study were to identify and measure the average outcomes of the Open Door Mission's nine-month community-based substance abuse treatment program, identify predictors of successful outcomes, and make recommendations to the Open Door Mission for improving its treatment program.^ The Mission's program is exclusive to adult men who have limited financial resources: most of which were homeless or dependent on parents or other family members for basic living needs. Many, but not all, of these men are either chemically dependent or have a history of substance abuse.^ This study tracked a cohort of the Mission's graduates throughout this one-year study and identified various indicators of success at short-term intervals, which may be predictive of longer-term outcomes. We tracked various levels of 12-step program involvement, as well as other social and spiritual activities, such as church affiliation and recovery support.^ Twenty-four of the 66 subjects, or 36% met the Mission's requirements for success. Specific to this success criteria; Fifty-four, or 82% reported affiliation with a home church; Twenty-six, or 39% reported full-time employment; Sixty-one, or 92% did not report or were not identified as having any post-treatment arrests or incarceration, and; Forty, or 61% reported continuous abstinence from both drugs and alcohol.^ Five research-based hypotheses were developed and tested. The primary analysis tool was the web-based non-parametric dependency modeling tool, B-Course, which revealed some strong associations with certain variables, and helped the researchers generate and test several data-driven hypotheses. Full-time employment is the greatest predictor of abstinence: 95% of those who reported full time employment also reported continuous post-treatment abstinence, while 50% of those working part-time were abstinent and 29% of those with no employment were abstinent. Working with a 12-step sponsor, attending aftercare, and service with others were identified as predictors of abstinence.^ This study demonstrates that associations with abstinence and the ODM success criteria are not simply based on one social or behavioral factor. Rather, these relationships are interdependent, and show that abstinence is achieved and maintained through a combination of several 12-step recovery activities. This study used a simple assessment methodology, which demonstrated strong associations across variables and outcomes, which have practical applicability to the Open Door Mission for improving its treatment program. By leveraging the predictive capability of the various success determination methodologies discussed and developed throughout this study, we can identify accurate outcomes with both validity and reliability. This assessment instrument can also be used as an intervention that, if operationalized to the Mission’s clients during the primary treatment program, may measurably improve the effectiveness and outcomes of the Open Door Mission.^

An examination of the cross-cultural reliability and construct validity of a measure of loneliness

Loneliness is a pervasive, rather common experience in American culture, particularly notable among adolescents. However, the phenomenon is not well documented in the cross-cultural psychiatric literature. For psychiatric epidemiology to encompass a wide array of psychopathologic phenomena, it is important to develop useful measures to characterize and classify both non-clinical and clinical dysfunction in diverse subgroups and cultures.^ The goal of this research was to examine the cross-cultural reliability and construct validity of a scale designed to measure loneliness. The Roberts Loneliness Scale (RLS-8) was administered to 4,060 adolescents ages 10-19 years enrolled in high schools along either side of the Texas-Tamaulipas border region between the U.S. and Mexico. Data collected in 1988 from a study focusing on substance use and psychological distress among adolescents in these regions were used to examine the operating characteristics of the RLS-8. A sample stratified by nationality and language, age, gender, and grade was used for analysis.^ Results indicated that in general the RLS-8 has moderate reliability in the U.S. sample, but not in the Mexican sample. Validity analyses demonstrated that there was evidence for convergent validity of the RLS-8 in the U.S. sample, but none in the Mexican sample. Discriminant validity of the measures in neither sample could be established. Based on the factor structure of the RLS-8, two subscales were created and analyzed for construct validity. Evidence for convergent validity was established for both subscales in both national samples. However, the discriminant validity of the measure remains unsubstantiated in both national samples. Also, the dimensionality of the scale is unresolved.^ One primary goal for future cross-cultural research would be to develop and test better defined culture-specific models of loneliness within the two cultures. From such scientific endeavor, measures of loneliness can be developed or reconstructed to classify the phenomenon in the same manner across cultures. Since estimates of prevalence and incidence are contingent upon reliable and valid screening or diagnostic measures, this objective would serve as an important foundation for future psychiatric epidemiologic inquiry into loneliness. ^

Type A behavior and blood pressure during adolescence

In The Woodlands, Texas, 346 students in grades 9-12, age 14-18 participated in a screening examination for cardiovascular risk factors. The relationships between blood pressure with Type-A-behavior and its components were evaluated. Type-A-behavior was measured using the Hunter-Wolf Type-A-behavior scale.^ The following results refer to the current 24-item version of the Hunter-Wolf Type-A-behavior scale and subscales derived in the Bogalusa study which thereafter were applied to The Woodlands population.^ No significant differences in blood pressure were observed among children in the highest vs. lowest quintile of the Type-A-behavior score or subscales scores. The correlation coefficients of blood pressure with the Type-A-behavior and its components were small and non-significant in both boys and girls. Multiple regression analyses conducted by sex, showed that after adjustment for age, weight and height, the addition of the total Type-A-behavior score or subscale scores did not increase significantly the amount of the variability explained for any of the blood pressure components.^ These analyses were repeated with results from the original 17-item version of the Hunter-Wolf Type-A-behavior scale and subscales derived in Bogalusa. Similarly, no relationship was observed between the 17-item Type-A-behavior score or subscales scores with blood pressure levels in The Woodlands population.^ Finally, it was important to determine whether subscales derived within The Woodlands population would differ from those described in Bogalusa and would relate differently to blood pressure among students in The Woodlands. The corresponding analyses showed that the subscales derived from the two studies were different, but in fact neither set of subscales was importantly related with blood pressure in The Woodlands population.^ The results of this study are largely consistent with those obtained by Hunter and Wolf in Bogalusa, who among the white population found only the factor "Eagerness-Energy" to be associated with fourth phase diastolic blood pressure among girls. Even this relationship which they observed was weak and inconsistent across sex-race groups and blood pressure components. This study does not support even this positive finding. In conclusion, evidence indicates that blood pressure is not associated with Type-A-behavior or its components as measured by the Hunter-Wolf Type-A-behavior scale among white adolescents. ^

A study of factors influencing high school students' attitudes and opinions about violence

Tenth grade students in a lower income neighborhood Houston school were surveyed on violence related beliefs, attitudes, and coping ability. Self-administered questionnaires were used to collect information for scale scores for statistical analysis.^ One hundred twenty six students participated of which 60% were Hispanic, 18% Black, 18% White, 2 American Indians, and 3 Asian/Pacific persons. There were 60 males, mean age 16.03, and 66 females, mean age 15.49. One-half of the sample reported repeating a grade, 53.4% of males, and 47% of females. Females' self-reported grades were slightly higher than males.^ Measures of student acceptance of violence and ability to handle conflict peacefully were studied in relation to student responses to questions about five areas: parental monitoring of the student, parent type of punishment, optimism about future prospects, frustration tolerance, and perceived peer group attitudes and practices.^ Significant gender differences included males having higher violence acceptance scores and females higher on coping with conflict peacefully. No significant race differences or gender interactions were found.^ Females' scores on future orientation were inversely related to their scores on the measure of acceptance of violence. For males, parents' punishment and perceived peer attitudes were positively related to their acceptance of violence, p $<$.0083.^ Female handling of conflict was significantly related to frustration tolerance and optimism; not significant were perceived peer attitudes, parent monitoring or punishment method. For males significantly related to handling conflict were perceived peer attitudes, parental monitoring, and severity of punishment, with the last two terms having a significant interaction effect, and inversely correlated (less monitoring, harsher punishment explained lower ability to handle conflict). ^

Prevalence and trends of substance abuse in Harris County, Texas, 1989 to 1991

In the late 1980s, Harris County, Texas began experiencing an escalation of drug-related activities. Various indicators used in this analysis tracked drug-related trends from 1989 to 1991 to determine patterns for comparison of local (Houston/Harris County, Texas) to national levels.^ An important indicator of the drug scenario was drug-related activities among youths, which increased during the period of this study. The Harris County Juvenile Probation Department showed that among arrests for drug-related activities, felonies increased from 25% in 1988 to 53% in 1991. With the rise in drug-related crimes, and substance abuse among the student body, school districts were forced to institute drug education programs in an effort to curtail such activities.^ Law enforcement agencies in the county saw increased demands for their services as a result of drug activities. Harris County Sheriffs Department reported a 32% plus increase in drug-related charges between 1986 and 1991. Houston Police Department reported an increase of 109% for the same period.^ Data from the Harris County Medical Examiner, the National Institute of Justice's Drug Use Forecasting System (Houston), and drug treatment facilities around Houston/Harris County, Texas indicated similar drug usage trends. Over a four-year period (1988-91), the drugs most frequently detected during blood and urine analyses were cocaine, followed by marijuana, heroin, LSD, and methamphetamines.^ From 1988 to 1991, most drug rehabilitation organizations experienced increased demands for their services by approximately 35%. Several other organizations experienced as much as a 70 percent increase. Males accounted for roughly 70% and females about 30% of persons seeking treatment. However, the number of females pursuing treatment increased, thereby reducing the gender gap.^ Blacks in Houston/Harris County were at higher risk for drug usage among the general population, but sought treatment more readily than other ethnic groups. Whites sought treatment in similar numbers as Blacks, but overall the risk appeared smaller because they made up a larger portion of the Houston/Harris County population.^ This analysis concluded that drug trends for the Houston/Harris County, Texas did not follow national trends, but showed patterns of its own. It was recommended that other communities carry out similar studies to determine drug use trends particular to their local. ^

The association of allergies and attention deficit hyperactivity disorder in children

To investigate the association between allergies and attention deficit hyperactivity disorder (ADHD), a case-control study was conducted using the National Longitudinal Survey of Youth population. Cases were between the ages of 4 and 11 years and were classified either by a maternal-reported diagnosis or by the Behavior Problems Index Hyperactivity Scale. Controls were chosen from the same age group but had a score of less than 14 on the overall Behavior Problems Index. A history of allergies was considered positive if any of the following conditions were reported as requiring treatment by a doctor or other health professional: asthma, allergic conditions, or food allergies. A strong association was observed between allergies and a maternal-reported diagnosis while controlling for demographic, socioeconomic, perinatal, and environmental factors (adjusted odds ratio = 2.85 (95% CI = 1.49-5.42)). Other risk factors found to be important risk factors for a diagnosis of ADHD were gender (male), gestational age ($<$36 weeks), and maternal education ($\leq$high school). No association between allergies and cases classified as ADHD based on the hyperactivity symptom scale was observed. This study confirms other studies that reported an allergy/ADHD association in diagnoses populations. Further investigation confirming the association and explanation of the reasons and underlying mechanisms of the observed association is warranted. These studies should use validated diagnostic criteria for the diagnosis of ADHD symptoms and allergies, adequate sample sizes, and control for confounding. ^

Attention-deficit hyperactivity disorder symptoms and lead exposure in children: A systematic review of literature

Blood lead levels > 10 µg/dL are known to affect various areas of the brain that influence behavior and cause many other health problems in children. As a result, the Centers for Disease Control and Prevention (CDC) set the blood lead action level at 10 µg/dL. However, recent research provides evidence that blood lead levels <10 µg/dL also may lead to behavioral problems in children. With the recent increase in diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) in children in the U.S. it is important to determine possible environmental toxins such as lead that may play a role in causing ADHD symptoms. The aim of this systematic review of the literature was to identify recent published studies that examine an association between blood lead levels < 10 µg/dL and ADHD symptoms in children in order to summarize their findings and describe major gaps in the literature. Although available research is limited, the articles reviewed indicate that blood lead at levels much below the CDC action level of 10 µg/dL may affect a child's level of attention, hyperactivity, impulsivity and ADHD diagnosis. Additional prospective research is warranted in order to inform the revision of current blood lead action levels as well as better elucidate the relationship between lead and ADHD diagnoses.^