Clinical and Sociodemographic Features of Alopecia Areata in Five Colombian Cities: An Analysis of the RENAAC Registry.

BACKGROUND: Alopecia areata (AA) is an autoimmune disease characterized by non-scaring hair loss and preservation of hair follicles. The information available on disease course, and clinical features of AA is scarce worldwide, and almost nonexistent in Colombia. OBJECTIVE: To determine the clinical and sociodemographic characteristics of patients diagnosed with AA who presented to a dermatology consultation in five Colombian cities. MATERIAL AND METHODS: This was a retrospective and multicenter study on data from an ongoing National Registry of Alopecia Areata in Colombia (RENAAC) collected in Bogota, Cali, Cartagena, Barranquilla, and Medellin, Colombia from March 2022 through April 2023. Data was recorded in a standardized form by trained physicians. The variables were expressed as measures of central tendency and dispersion, and absolute and relative frequencies. RESULTS: A total of 562 patients were included, 59.4% of whom were women, aged between 15 and 49 years (63.9%) with a mean disease course of 1.7 years. The most common finding was multiple plaque (53.2%), the predominant AA subtype was patchy (71.4%), and 29.5% of the patients had a past dermatological history, 18.3% had a past endocrinological history, and 8.9% had a past psychiatric history. The treatments most widely used were steroid injections (76.4%), 5% topical minoxidil (46.4%), followed by high-potency corticosteroids (42.5%). STUDY LIMITATIONS AND CONCLUSIONS: AA was slightly predominant in women. As seen in other populations, this disease had an earlier onset in men vs women. Presentation in pediatric age was uncommon. The previous history of other dermatological diseases was checked in almost one third of the patients. Analysis of the co-presentation of AA with other autoimmune diseases is biased due to excluding patients with systemic erythematous lupus from the study.

Clinical and Sociodemographic Features of Alopecia Areata in Five Colombian Cities: An Analysis of the RENAAC Registry. / [Artículo traducido] Características clínicas y sociodemográficas de la alopecia areata en 5 ciudades colombianas: un análisis del RENAAC.

BACKGROUND: Alopecia areata (AA) is an autoimmune disease characterized by non-scaring hair loss and preservation of hair follicles. The information available on disease course, and clinical features of AA is scarce worldwide, and almost nonexistent in Colombia. OBJECTIVE: To determine the clinical and sociodemographic characteristics of patients diagnosed with AA who presented to a dermatology consultation in five Colombian cities. MATERIAL AND METHODS: This was a retrospective and multicenter study on data from an ongoing National Registry of Alopecia Areata in Colombia (RENAAC) collected in Bogota, Cali, Cartagena, Barranquilla, and Medellin, Colombia from March 2022 through April 2023. Data was recorded in a standardized form by trained physicians. The variables were expressed as measures of central tendency and dispersion, and absolute and relative frequencies. RESULTS: A total of 562 patients were included, 59.4% of whom were women, aged between 15 and 49 years (63.9%) with a mean disease course of 1.7 years. The most common finding was multiple plaque (53.2%), the predominant AA subtype was patchy (71.4%), and 29.5% of the patients had a past dermatological history, 18.3% had a past endocrinological history, and 8.9% had a past psychiatric history. The treatments most widely used were steroid injections (76.4%), 5% topical minoxidil (46.4%), followed by high-potency corticosteroids (42.5%). STUDY LIMITATIONS AND CONCLUSIONS: AA was slightly predominant in women. As seen in other populations, this disease had an earlier onset in men vs women. Presentation in pediatric age was uncommon. The previous history of other dermatological diseases was checked in almost one third of the patients. Analysis of the co-presentation of AA with other autoimmune diseases is biased due to excluding patients with systemic erythematous lupus from the study.

Obesity status and obesity-associated gut dysbiosis effects on hypothalamic structural covariance.

BACKGROUND: Functional connectivity alterations in the lateral and medial hypothalamic networks have been associated with the development and maintenance of obesity, but the possible impact on the structural properties of these networks remains largely unexplored. Also, obesity-related gut dysbiosis may delineate specific hypothalamic alterations within obese conditions. We aim to assess the effects of obesity, and obesity and gut-dysbiosis on the structural covariance differences in hypothalamic networks, executive functioning, and depressive symptoms. METHODS: Medial (MH) and lateral (LH) hypothalamic structural covariance alterations were identified in 57 subjects with obesity compared to 47 subjects without obesity. Gut dysbiosis in the subjects with obesity was defined by the presence of high (n = 28) and low (n = 29) values in a BMI-associated microbial signature, and posthoc comparisons between these groups were used as a proxy to explore the role of obesity-related gut dysbiosis on the hypothalamic measurements, executive function, and depressive symptoms. RESULTS: Structural covariance alterations between the MH and the striatum, lateral prefrontal, cingulate, insula, and temporal cortices are congruent with previously functional connectivity disruptions in obesity conditions. MH structural covariance decreases encompassed postcentral parietal cortices in the subjects with obesity and gut-dysbiosis, but increases with subcortical nuclei involved in the coding food-related hedonic information in the subjects with obesity without gut-dysbiosis. Alterations for the structural covariance of the LH in the subjects with obesity and gut-dysbiosis encompassed increases with frontolimbic networks, but decreases with the lateral orbitofrontal cortex in the subjects with obesity without gut-dysbiosis. Subjects with obesity and gut dysbiosis showed higher executive dysfunction and depressive symptoms. CONCLUSIONS: Obesity-related gut dysbiosis is linked to specific structural covariance alterations in hypothalamic networks relevant to the integration of somatic-visceral information, and emotion regulation.

Valorisation of cellulosic rejections from wastewater treatment plants through sugar production.

The widespread use of wipes and other sanitary products made of nonwoven fibres has led to an enormous problem in wastewater treatment systems that has been underestimated for some time. To date, there are no practical alternatives for recycling and valorisation. In this study, cellulosic rejections recovered from a wastewater treatment plant in Barcelona (Spain) were characterised and treated using hydrothermal and enzymatic methods to obtain free sugars. Steam explosion and autoclave pre-treatments were performed at different temperatures (120, 130, or 150 °C) and residence times (10-40 min) under neutral, acidic or basic conditions. The solids obtained after the pre-treatment, as well as the untreated material, were subjected to enzymatic hydrolysis using commercial enzymes. The untreated substrate reached the highest sugar production: 29 g glucose and xylose per 100 g of the cellulosic rejections, equivalent to 86% of the sugars contained in the initial material. These sugars can subsequently be transformed into biofuels or bioproducts within a biorefinery approach.

Cognitive impairment in early stages of multiple sclerosis is associated with high cerebrospinal fluid levels of chitinase 3-like 1 and neurofilament light chain.

BACKGROUND AND PURPOSE: Chitinase 3-like 1 (CHI3L1) and neurofilament light chain (NF-L) are promising biomarkers of disability in multiple sclerosis (MS). However, their role in cognitive dysfunction remains elusive. Here, we aimed to correlate cerebrospinal fluid (CSF) levels of CHI3L1 and NF-L with cognitive status in MS. METHODS: Fifty one recently diagnosed patients were cognitively evaluated and CSF was collected. Levels of CHI3L1 and NF-L were determined by ELISA. Spearman's partial correlation coefficient was performed. RESULTS: After adjusting cognitive scores by age, anxiety and EDSS, association was detected between CHI3L1 levels and Trail Making Test A (rs = 0.348; p = 0.016) and between NF-L levels and Word List Generation (rs = -0.324; p = 0.025). CONCLUSION: High levels of CSF CHI3L1 and NF-L are associated with cognitive impairment in the early phases of MS.

The effect of Sb-surfactant on GaInP CuPtB type ordering: assessment through dark field TEM and aberration corrected HAADF imaging.

We report on the effect of Sb on the microstructure of GaInP layers grown by metal organic vapor phase epitaxy (MOVPE). These layers exhibit a CuPtB single variant ordering due to the intentional misorientation of the substrate (Ge(001) substrates with 6° misorientation towards the nearest [111] axis). The use of Sb as a surfactant during the GaInP growth does not modify the type of ordering, but it is found that the order parameter (η) decreases with increasing Sb flux. Dark field microscopy reveals a variation of the angle of the antiphase boundaries (APBs) with Sb amount. The microstructure is assessed through high angle annular dark field (HAADF) experiments and image simulation revealing Z-contrast loss in APBs due to the superposition of ordered domains.

[Association between hematopoietic stem cell transplantation and Parsonage Turner syndrome: coincidence or cause-effect relationship?] / Asociación de trasplante de progenitores hematopoyéticos y síndrome de Parsonage-Turner: ¿coincidencia o relación causa-efecto?

Parsonage-Turner syndrome or idiopathic brachial neuritis is a total or partial inflammation of the brachial plexus, with a typical presentation as a sudden and very intense pain in the shoulder, followed by weakness and early amyotrophy. The etiology is still unknown, although an immune mediated mechanism is thought to be involved. Hematopoietic stem cell transplantation is a well-established treatment for hematological malignancies, but with a growing implication in the treatment of autoimmune diseases. The neurological side effects are probably underdiagnosed. The association of the Parsonage-Turner syndrome and the hematopoietic stem cell transplantation is scarce. We describe two clinical cases of idiopathic brachial plexopathy after hematopoietic stem cell transplantation. The reconstruction of the immune system after a transplant may be the trigger of a brachial plexopathy, but more studies are necessary for the etiology of this disease to be understood and to establish a cause-effect relation with the transplant.

18F-FDG PET/CT in cardiovascular infection and inflammation.

The diagnosis of cardiovascular infection and inflammation by [18F]FDG PET/CT in Nuclear Cardiology is of growing interest, because with respect to echocardiography this technique has improved the certainty in the diagnosis of infective endocarditis in patients with prosthetic valves, the increasing number of patients with implantable cardiac devices because of the progressive ageing of the population, as well as in patients with suspected large vessel vasculitis. All are serious clinical situations which require correct diagnosis and appropriate treatment as soon as possible, because they can cause severe complications, high mortality and also increased health care costs. We review the use of [18F]FDG PET/CT in cardiovascular infection and inflammation, including the clinical point of view and the contribution of other image modalities. We focus on the appropriate methodology for this exploration, patient preparation, image acquisition and correct interpretation and the quantification possibilities, defining the specific characteristics of the diagnosis in patients with prosthetic valves, implantable cardiac devices and large vessel vasculitis in the initial diagnosis as well as during follow-up to assess treatment response. We analyze the possible causes of false positive and false negative results and emphasize the special value of a multidisciplinary team for optimal management of these patients.

[Interobserver correlation in the interpretation of 99mTc-sestamibi SPECT in reperfused acute myocardial infarction]. / Correlación interobservadores en interpretación de SPECT de perfusión con 99mTc-sestamibi en infarto agudo de miocardio reperfundido.

INTRODUCTION AND OBJECTIVES: The correct interpretation of myocardial perfusion single photon emission computed tomography (SPECT) requires knowledge of the technique reproducibility. The objective was analyze the interobserver correlation of different experience in the interpretation of myocardial perfusion SPECT in patients following acute myocardial infarction (AMI) in order to improve the quality of our site. METHODS: Sixty cases (56 +/- 11 years, 87 % men) with transmural AMI who had recently undergone successful thrombolysis were included. Resting perfusion with (99m)Tc-sestamibi was performed at one week post-AMI. ANALYSIS: Semiquantitative interpretation using 17 segment-model by 2 independent specialists and 5 observers, was performed blindly. Left ventricular ejection fraction (LVEF) was measured with isotopic ventriculography one month after AMI, with a mean of 38 %. RESULTS: Using independent and then agreed on perfusion analysis, average involved segments/patient was 9.3 +/- 4 and the sum of severity 25 +/- 13. Readings of other observers ranged from 7 +/- 3.7 to 9.4 +/- 3.9 and 16.7 +/- 9.7 to 24.6 +/- 13, respectively, consistent with the reading of the specialists of between 0.779-0.871 (kappa: 0.565-0.741). There was no significant difference when the number of segments were analyzed in 40 % of the cases and for intensity in 60 % of them in more experienced observers. Correlation with consensus reading for the number of segments ranged from 0.84 to 0.94 and for severity from 0.79 to 0.89. Identification of culprit arteries was acceptable, with r values between 0.612 and 0.683 and kappas between 0.629 and 0.656. Correlation of the number of involved segments and severity with LVEF performed one month after AMI was 0.73 and 0.74, respectively. CONCLUSIONS: There was good correlation in the interpretation of myocardial perfusion SPECT, with a significantly better fit in more experienced observers. This academic exercise was also helpful in improving our residents' skills in cardiology.

Drug Delivery Nanosystems for the Localized Treatment of Glioblastoma Multiforme.

Glioblastoma multiforme is one of the most prevalent and malignant forms of central nervous system tumors. The treatment of glioblastoma remains a great challenge due to its location in the intracranial space and the presence of the blood⁻brain tumor barrier. There is an urgent need to develop novel therapy approaches for this tumor, to improve the clinical outcomes, and to reduce the rate of recurrence and adverse effects associated with present options. The formulation of therapeutic agents in nanostructures is one of the most promising approaches to treat glioblastoma due to the increased availability at the target site, and the possibility to co-deliver a range of drugs and diagnostic agents. Moreover, the local administration of nanostructures presents significant additional advantages, since it overcomes blood⁻brain barrier penetration issues to reach higher concentrations of therapeutic agents in the tumor area with minimal side effects. In this paper, we aim to review the attempts to develop nanostructures as local drug delivery systems able to deliver multiple agents for both therapeutic and diagnostic functions for the management of glioblastoma.

Contraceptive practices and trends in Spain: 1997-2003.

OBJECTIVE: To know the contraceptive use and trends in the Spanish female population. STUDY DESIGN: Since 1997, we have conducted a survey every 2 years on the use of contraceptive methods among a representative sample of Spanish women of childbearing potential (15-49 years). RESULTS: In the period 1997-2003, the percentage of use of contraceptive methods in Spain rose from 55.6% to 71.2%. The most commonly used method was the condom (21% in 1997, 21.9% in 1999, 29.5% in 2001 and 35.7% in 2003), followed by the contraceptive pill (14.2%, 16.5%, 19.2% and 18.3%, respectively). Male or female sterilization remained stable with percentages of use of 5-7%. IUDs are used by about 5% of women. CONCLUSIONS: The use of contraceptive methods among Spanish women of childbearing potential generally fits quite well the patterns found in other developed countries, and we observed a trend towards increased use of effective methods.

[Antenatal care in immigrants]. / Control de gestación en inmigrantes.

The phenomenon of immigration has had an impact on the health care of the population. The immigrant population in Spain today represents approximately 8% of the total population. The majority of this population proceeds from countries with low income, and its origin and distribution is diverse. The immigrant population is characterised by its being young and healthy, and with a capacity to adapt to changes, but its social, economic and labour conditions are frequently insecure and favour vulnerability to disease. In spite of the number of immigrants of the male sex being globally higher than that of women, the percentage of immigrants of the female sex is growing. This increase of the female immigrant population has resulted in the appearance of specific health care needs, especially with respect to sexual and reproductive health. To which we must add a substantial increase in pathologies prevalent in the countries of origin, such as anaemia, tuberculosis, malnutrition, haemoglobinopathies, consanguinity, hypocalcaemia, hepatitis B and/or C, sexually transmitted infections, infectious diseases transmitted by arthropods, such as Chagas disease and other parasitoses, as well as genital mutilations. The aim of this article is to analyse the factors that make it difficult to control gestation in the immigrant population, as well as to establish guidelines for acting in antenatal care consultations. Insistence is placed on health education and prevention during pregnancy, and consideration is given to the appearance of rare diseases related to some of these groups.

Effects of maternal gestational diabetes and adiposity on neonatal adiposity and blood pressure.

OBJECTIVE: To determine the effects of maternal factors, including prepregnancy maternal adiposity, weight gain during pregnancy, degree of abnormality of the glucose tolerance test, glycemia during pregnancy, and treatment with insulin versus diet therapy, on neonatal body weight, adiposity, and blood pressure in infants of mothers with gestational diabetes (IGDM) and control patients. RESEARCH DESIGN AND METHODS: A total of 119 term IGDM, including 57 large-for-gestational-age (LGA) and 62 appropriate-for-gestational-age (AGA) infants, and 143 term control infants, including 74 LGA and 69 AGA infants, were prospectively enrolled. Maternal measurements of prepregnancy weight, height, and weight gain were abstracted from medical records. A diagnosis of gestational diabetes was made on the basis of an initial 1-h 50-g glucose screen value > or = 130 mg/dl followed by two abnormal values in a 100-g oral glucose tolerance test. Infant anthropometric measurements were obtained, and blood pressure was measured on day 2 of life. Correlation analyses and multiple regression analyses were performed to assess the relationships among maternal factors and neonatal adiposity and blood pressure. RESULTS: Multiple regression analyses to determine the effects of significant maternal factors on infant body mass index (BMI) revealed that prepregnancy weight and weight gain were significant predictors for both IGDM and control infants. An increased glucose screen predicted BMI for control subjects, whereas the mean 2nd and 3rd trimester glucose values were the significant predictors for IGDM. Also, increased newborn triceps skinfold thickness measurements correlated with increased systolic blood pressure for IGDM (r = 0.29, P < 0.03). CONCLUSIONS: Increased maternal prepregnancy weight, weight gain in pregnancy, and glycemia in pregnancy all place IGDM at increased risk of macrosomia and adiposity. Increased adiposity in the IGDM appears to be related to increased infant blood pressure. Longitudinal evaluation is needed to determine whether neonatal adiposity in IGDM is predictive of increased adiposity and blood pressure during childhood.

Determinants of mother-infant interaction in adolescent mothers.

Mother-infant interactions of adolescent and nonadolescent mothers are compared, and the impact of maternal age, ego development, education, and child care support on these interactions is examined. Thirty primiparous, white, lower- to middle-class mothers (half less than or equal to 17 years) and their healthy full-term infants (8 months) were studied. Interactions were videotaped during face-to-face interactions and teaching sessions. Child care support and ego development were assessed. During face-to-face interactions, only one difference was found between adolescent and nonadolescent mothers: nonadolescent mothers showed more positive affect toward infants. During teaching, nonadolescent mothers talked more, showed more positive affect toward infants, and demonstrated tasks more often. Individual differences during face-to-face interactions were more related to mothers' ego development and support whereas teaching interactions were mostly associated with maternal age. Thus, maternal age was a stronger predictor of interactive style during teaching. This may partially explain noted cognitive deficits in infants of teenage mothers. However, individual differences among all mothers in ego development, education, and support were significantly related to interactions. Thus, teenage mothers with less education and support and lower ego development may represent a higher risk subgroup of adolescent mothers providing less optimal care-giving environments for their infants.

Neurodevelopmental and school performance of very low-birth-weight infants: a seven-year longitudinal study.

The changing patterns of neurologic and developmental functioning between 1 and 7 years of age were studied in very low-birth-weight infants (birth weight less than or equal to 1,500 g). Subjects included 42 infants born in 1975 who were followed for 7 years. Based on the 1-year neurologic assessment, 22 infants were classified as normal, 12 as suspect, and eight as abnormal. The three groups did not differ in birth weight, gestational age, sex, or Hollingshead socioeconomic status (SES) score. The neurologic findings at 7 years of age were significantly related to the neurologic examination findings at 1 year of age. Seventy-seven percent of the normal group, 58% of the suspect group, and 100% of the abnormal group remained in the same neurologic category at 7 years of age. Children in the abnormal group had the greatest improvement in cognitive functioning between 1 and 7 years of age but did not achieve the IQ level of children in the normal group. Forty-five percent of the normal group, 75% of the suspect group, and 100% of the abnormal group had poor visual-motor integration. Fifty-eight percent of the suspect group and 87% of the abnormal group were reading below age level. Of the total sample, 54% required special education or resource help at 7 years of age, and the three groups differed significantly in their need for a special educational plan (P less than .05). These data indicate that a neurologic classification at 1 year of age provides a guide for monitoring very low-birth-weight infants and can be helpful in alerting school personnel to potential needs.

Adolescent development and transitions to motherhood.

OBJECTIVE: To use both qualitative and quantitative methods to examine the experience of motherhood during adolescence and to evaluate developmental influences on the concept of maternal role. DESIGN: (1) A grounded theory approach was initially used to generate a hypothesis. Focus groups and individual interviews were analyzed for concept and theme. (2) A quantitative method using correlational analysis was used to test the hypothesis generated by qualitative study. A structured interview using five specific, scored questions about self and about motherhood was used to examine the relationship between developmental complexity of responses to questions about self and questions about motherhood. SETTING AND PARTICIPANTS: The qualitative study involved group and individual interviews with 42 teenage mothers. The quantitative study involved individual interviews with 25 mothers, ages 14 to 18 years, at an innercity clinic for young parents and their infants. Race and ethnicity were heterogeneous, and 100% received Aid to Families With Dependent Children. RESULTS: The major hypothesis generated from the qualitative analysis was that an adolescent mother's conceptualization of her maternal role is related to her own psychosocial and cognitive development. The quantitative study revealed a strong correlation between the developmental complexity of responses to questions about self and the complexity of responses to questions about motherhood (r2 = .81). CONCLUSION: The experience of motherhood and the conceptualization of the maternal role in adolescence is related to young mothers' psychosocial cognitive development.

Family-based intervention improves maternal psychological well-being and feeding interaction of preterm infants.

OBJECTIVE: To determine the efficacy of an individualized, family-based intervention with preterm infants and their families. DESIGN: Randomized, repeated measures intervention outcome study. SETTING: Level III neonatal intensive care nursery. PATIENTS: Random sample of 34 preterm infants < or = 1500 g and their families. INTERVENTIONS: Individualized, family-based intervention during the hospitalization and transition to home addressed problems identified by parents in four domains including: infant behavior and characteristics, family organization and functioning, caregiving environment, and home discharge and community resources. MEASUREMENTS AND MAIN RESULTS: Standardized questionnaires were administered at baseline and discharge to mothers, and predischarge bottle-feeding interactions were videotaped and coded by two blinded observers. Results were in favor of intervention (Int) versus control (Con) mothers (baseline; discharge) (P < .05) on the Parental Stressor Scale Sights and Sounds subscale (Int 2.4 +/- 1.0; 2.0 +/- 0.8 vs Con 2.4 +/- 0.9; 2.6 +/- 0.8); Child's Appearance and Behavior subscale (Int 2.8 +/- 1.0; 2.5 +/- 1.1 vs Con 2.8 +/- 0.8; 3.1 +/- 0.6); and Total Stressor Score (Int 93.9 +/- 36.6; 72.3 +/- 41.8 vs Con 87.5 +/- 26.7; 87.8 +/- 26.2). On the Beck Depression Inventory, intervention mothers had significant decreases in depressive symptoms (39%; 11%) vs control mothers (31%; 44%). Maternal self-esteem in both groups improved over time. There were no significant group differences in family environment. During feeding interactions, intervention infants grimaced (P < .001) and gagged (P < .05) less than controls. Intervention mothers less frequently interrupted feedings (P < .001); less frequently stimulated infant sucking (P < .01); smiled more (P < .001); vocalized more (P < .01); demonstrated greater sensitivity to infant behavior (P < .001), better quality of physical contact (P < .001), and more positive affect (P < .01). CONCLUSIONS: Individualized, family-based intervention appears to reduce maternal stress and depression, and to enhance early mother-infant feeding interactions. Further research is needed to determine whether these short-term beneficial effects persist beyond the newborn period.

Developmental outcome as a function of the goodness of fit between the infant's cry characteristics and the mother's perception of her infant's cry.

OBJECTIVE: To determine whether the "goodness of fit" between infant cry characteristics and the mother's perception of the cry is related to developmental outcome at 18 months of age. DESIGN: This was a prospective, longitudinal study from birth to 18 months performed in a blinded manner. SETTING: The study was conducted in a maternity hospital, including normal and special care nurseries and a laboratory for developmental follow-up. PATIENTS: The 121 term and preterm infants and their mothers were selected to meet medical criteria. MEASUREMENT: Acoustic analysis of 1-month infant cry and the mother's perception of the same cry was used to divide subjects into four groups representing matches and mismatches between infant cry characteristics and maternal cry perception. Primary outcome measures of cognitive, language, motor, and neurologic outcome were administered at 18 months. Caretaking environment measures were also recorded. RESULTS: Statistically significant (P < .05) findings showed that matched groups scored higher on measures of language and cognitive performance than infants in the mismatch groups, with a particular advantage for infants in the matched group in which mothers accurately perceived the higher-pitched cries of their infants. There were no differences between the groups in biologic or sociodemographic factors. Group differences were observed in social support and maternal self-esteem. CONCLUSIONS: Matches and mismatches between infant cry characteristics at 1 month and the mother's perception of the cry are related to cognitive and language outcome at 18 months in term and preterm infants. This relation is probably due to transactional processes in which developmental outcome is affected by the clarity of the infants' signals and by the ability of the mother to accurately perceive her infant's signals. The mother's ability to read her infant's cues may be affected by factors such as social support and self-esteem.