Hormonal and behavioral responses to an infant simulator in women with and without children.

We investigated the impact of maternal status on hormonal reactivity and behavioral responses to an infant simulator in 117 women (54 primiparous, 63 nulliparous). The amount of affectionate touch and motherese were analyzed as behavioral measures of caregiving. Saliva was collected before and 10 min after interaction with the infant simulator to analyze oxytocin, testosterone, cortisol, and estradiol levels. Nulliparous women also provided information about their fertility motivation. Linear mixed models indicated that greater use of affectionate touch was associated with lower overall testosterone levels. Cortisol decreased in response to the interaction in both groups. In the primiparous group, the amount of affectionate touch associated inversely with cortisol levels, whereas in the nulliparous group such association was not found. Oxytocin or estradiol reactivity to the simulator did not differ between the groups, nor were these hormones associated with behavior. Higher fertility motivation in nulliparous women was related to more motherese, and lower testosterone levels. Our results indicate that the simulator elicits hormonal reactivity both in mothers and nonmothers, but the patterns of associations between caregiving behavior and hormonal levels may be partially different. These results encourage using the infant simulator to explore hormonal processes related to the transition to parenthood.

Attachment goes to court: child protection and custody issues.

Attachment theory and research are drawn upon in many applied settings, including family courts, but misunderstandings are widespread and sometimes result in misapplications. The aim of this consensus statement is, therefore, to enhance understanding, counter misinformation, and steer family-court utilisation of attachment theory in a supportive, evidence-based direction, especially with regard to child protection and child custody decision-making. The article is divided into two parts. In the first, we address problems related to the use of attachment theory and research in family courts, and discuss reasons for these problems. To this end, we examine family court applications of attachment theory in the current context of the best-interest-of-the-child standard, discuss misunderstandings regarding attachment theory, and identify factors that have hindered accurate implementation. In the second part, we provide recommendations for the application of attachment theory and research. To this end, we set out three attachment principles: the child's need for familiar, non-abusive caregivers; the value of continuity of good-enough care; and the benefits of networks of attachment relationships. We also discuss the suitability of assessments of attachment quality and caregiving behaviour to inform family court decision-making. We conclude that assessments of caregiver behaviour should take center stage. Although there is dissensus among us regarding the use of assessments of attachment quality to inform child custody and child-protection decisions, such assessments are currently most suitable for targeting and directing supportive interventions. Finally, we provide directions to guide future interdisciplinary research collaboration.

Costs and Cost-Utility of Critical Care and Subsequent Health Care: A Multicenter Prospective Study.

OBJECTIVES: The number of critical care survivors is growing, but their long-term outcomes and resource use are poorly characterized. Estimating the cost-utility of critical care is necessary to ensure reasonable use of resources. The objective of this study was to analyze the long-term resource use and costs, and to estimate the cost-utility, of critical care. DESIGN: Prospective observational study. SETTING: Seventeen ICUs providing critical care to 85% of the Finnish adult population. PATIENTS: Adult patients admitted to any of 17 Finnish ICUs from September 2011 to February 2012, enrolled in the Finnish Acute Kidney Injury (FINNAKI) study, and matched hospitalized controls from the same time period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We primarily assessed total 3-year healthcare costs per quality-adjusted life-years at 3 years. We also estimated predicted life-time quality-adjusted life-years and described resource use and costs. The costing year was 2016. Of 2,869 patients, 1,839 (64.1%) survived the 3-year follow-up period. During the first year, 1,290 of 2,212 (58.3%) index episode survivors were rehospitalized. Median (interquartile range) 3-year cumulative costs per patient were $49,200 ($30,000-$85,700). ICU costs constituted 21.4% of the total costs during the 3-year follow-up. Compared with matched hospital controls, costs of the critically ill remained higher throughout the follow-up. Estimated total mean (95% CI) 3-year costs per 3-year quality-adjusted life-years were $46,000 ($44,700-$48,500) and per predicted life-time quality-adjusted life-years $8,460 ($8,060-8,870). Three-year costs per 3-year quality-adjusted life-years were $61,100 ($57,900-$64,400) for those with an estimated risk of in-hospital death exceeding 15% (based on the Simplified Acute Physiology Score II). CONCLUSIONS: Healthcare resource use was substantial after critical care and remained higher compared with matched hospital controls. Estimated cost-utility of critical care in Finland was of high value.

Night Awakening and Its Association With Executive Functioning Across the First Two Years of Life.

Longitudinal associations between signaled night awakening and executive functioning (EF) at 8 and 24 months in children with (≥ 3 awakenings, n = 77) and without parent-rated fragmented sleep (≤ 1 awakening, n = 69) were studied. EF was assessed with the Switch task at 8 and 24 months. At 24 months, behavioral tasks and parental ratings of EF (Behavior Rating Inventory of Executive Function-Preschool version) were also used. In the Switch task, children with fragmented sleep were less able to learn stimulus sequences and inhibit previously learned responses than children without fragmented sleep. The groups differed only marginally in parental ratings of EF, and no differences were found in behavioral EF tasks. These results suggest that eye movement-based measures may reveal associations between sleep and EF already in infancy and toddlerhood.

A performance comparison of patient pathways in Nordic capital areas - a pilot study for ischaemic stroke patients.

Aims: This article describes and discusses the extension of performance measurement using an episode-based approach so that the measurement includes primary care, and social and long-term-care services. By using data on incident stroke patients from the capital areas of four Nordic countries, this pilot study: (a) extended the disease-based performance analysis to include new indicators that better describe patient care pathways at different levels of care; (b) described and compared the performance of care given in the four areas; (c) evaluated how additional information changed the rankings of performance between the areas; and (d) described the trends in performance in the capital areas. Methods: The construction of data was based on a common protocol that used routinely collected national registers and statistics linked with local municipal registers. We created new variables describing the timing of discharge to home and institutionalisation, as well as describing the use and cost of primary and social hospital services. Risk adjustment was performed with four different sets of confounders. Results: Differences existed in various performance indicators between the four metropolitan areas. The ranking was sensitive to the risk-adjustment method. The study showed that for stroke patients a performance comparison with data that are only from secondary and tertiary care, and without a valid severity measure, is not sufficient for international comparisons. Conclusions: Extending and deepening international performance analysis in order to cover patient pathways, including primary care and social services, is very useful for benchmarking activities when focusing on diseases affecting older people.

Disorganized attachment representations, externalizing behavior problems, and socioemotional competences in early school-age.

Multifactorial research must examine if disorganized attachment is specifically associated with either ODD- or ADHD-symptoms,and the mechanisms through which disorganization may become associated with externalizing problems. The present short-term longitudinal study therefore examined attachment representations, and several competences important for socio-emotional functioning, in relation to ODD- and ADHD-symptoms at T1 (N = 105, M age = 80 months) and T2 (N = 80, M age = 104 months). There was a main effect of disorganized attachment on ODD-symptoms at both time points but not on ADHD-symptoms. Disorganized children also showed lowered attention to facial expressions, a diminished ability to discriminate facial expressions, and elevated emotional reactivity. Emotional reactivity mediated the link between disorganization and ODD-symptoms at T1, but not at T2. The findings support disorganized attachment as a risk-factor for ODD-symptoms rather than ADHD-symptoms, and suggest that disorganization may become associated with ODD-symptoms through broad effects on multiple competences.

Attachment security and cortical responses to fearful faces in infants.

The present study measured event-related potentials (ERPs) to investigate whether cortical responses to facial expressions of fear are associated with the development of secure and insecure patterns of infant-mother attachment during the first year. Based on previous findings showing reduced attentional biases to fearful faces in infants with insecure and disorganized attachment, we hypothesized that insecure and disorganized attachment would be associated with reduced ERP differentiation of fearful from non-fearful faces. ERPs to facial expressions were measured at 7 months of age and attachment was assessed at 14 months of age with the Strange Situation Procedure (n = 61). Occipitotemporal face-sensitive ERP responses particularly in the time range of the N290 component were related to attachment security at 14 months. Only securely attached infants showed age-typical cortical discrimination of fearful from non-fearful faces at 7 months, whereas a similar pattern of ERP responses was not observed in infants with insecure and disorganized attachment. These results add to previous findings by suggesting that patterns of secure and insecure infant attachment are related to early-emerging differences in the perceptual processing of facial emotions, which could have implications for the development of social competence.

Early postoperative mortality similar between cemented and uncemented hip arthroplasty: a register study based on Finnish national data.

Background and purpose - Implant survival of cemented total hip arthroplasty (THA) in elderly patients is higher than that of uncemented THA. However, a higher mortality rate in patients undergoing cemented THA compared with uncemented or hybrid THA has been reported. We assessed whether cemented fixation increases peri- or early postoperative mortality compared with uncemented and hybrid THA. Patients and methods - Patients with osteoarthritis who received a primary THA in Finland between 1998 and 2013 were identified from the PERFECT database of the National Institute for Health and Welfare in Finland. Definitive data on fixation method and comorbidities were available for 62,221 THAs. Mortality adjusted for fixation method, sex, age group, and comorbidities among the cemented, uncemented, and hybrid THA was examined using logistic regression analysis. Reasons for cardiovascular death within 90 days since the index procedure were extracted from the national Causes of Death Statistics and assessed separately. Results - 1- to 2-day adjusted mortality after cemented THA was comparable to that of the uncemented THA group (OR 1.2; 95% CI 0.24-6.5). 3- to 10-day mortality in the cemented THA group was comparable to that in the uncemented THA group (OR 0.54; CI 0.26-1.1), and in the hybrid THA group (OR 0.64, CI 0.25-1.6). Pulmonary embolism or cardiovascular reasons as a cause of death were not over-represented in the cemented THA group. Interpretation - Early peri- and postoperative mortality in the cemented THA group was similar compared with that of the hybrid and uncemented groups.

Maternal and infant characteristics connected to shared pleasure in dyadic interaction.

The aim of the study was to analyze which maternal factors (depressive symptoms, effect of life events, maternal sensitivity and structuring) and infant characteristics (temperament, social withdrawal symptoms, interactive behavior, genotype, gender) contribute to shared pleasure (SP) in parent-infant interaction. Participants were 113 mother-infant dyads. The mothers filled in the Edinburgh Postnatal Depression Scale, the Infant Behavior Questionnaire, and the Life Events Questionnaire. The dyads were videotaped in a free-play situation, and the videos were analyzed using the Alarm Distress Baby Scale and the Emotional Availability Scales. The infants were genotyped for four genes involved in emotion regulation. The occurrence and duration of SP (SP-MD) in mother-infant interactions were analyzed from the videotapes. Higher maternal sensitivity and depressive symptoms, better infant responsiveness, and the infant having the GG variant of the gene tryptophan hydroxylase isoform 2 (TPH2) -307 were associated with the occurrence of SP. Lower level depressive symptoms, better maternal structuring, and greater infant involvement were associated with the longer duration of SP. Those dyads where the mother and infant were best able to read each other's positive cues and to respond to them were more likely to experience mutual positive affect, as seen in SP.

El propósito de este estudio fue analizar cuáles factores maternos (síntomas depresivos, efectos de eventos vividos, sensibilidad y estructuración maternas) y características del infante (temperamento, síntomas de despego social, comportamiento interactivo, genotipo, género sexual) contribuyen al placer compartido (SP) en la interacción progenitor-infante. En el estudio participaron 113 díadas madre-infante. Las madres completaron la Escala de Depresión Postnatal de Edimburgo, el Cuestionario de Comportamiento del Infante y el Cuestionario de Eventos de Vida. A las díadas se les grabó en video durante una sesión de juego libre y los videos se analizaron usando la Escala de Alarma de la Angustia del Bebé y las Escalas de Disponibilidad Emocional. A los infantes se les determinó el genotipo en el caso de cuatro genes que tienen que ver con la regulación emocional. Con base en las videograbaciones, se analizó la incidencia y duración de SP (SP-MD) en las interacciones madre-infante. Una más alta sensibilidad materna y síntomas depresivos, mejor sensibilidad por parte del infante, y el hecho de que el infante tenía la variante GG del gen TPH2 -307 se asociaron con la incidencia de SP. Síntomas depresivos de bajo nivel, una mejor estructuración materna y una mayor participación del infante se asociaron con una más larga duración de SP. Aquellas díadas en que la madre y el infante eran más capaces de comprender las señales positivas de cada uno y de responder a las mismas, estaban en mejor condición de experimentar un mutuo afecto positivo, como el que se ve en SP.

Le but de cette étude était d'analyser quels facteurs maternels (symptômes dépressifs, effet d'événements de la vie, sensibilité maternelle et structuration maternelle) et quelles caractéristiques du nourrisson (tempérament, symptômes de retrait social, comportement interactif, génotype, genre) contribuent au plaisir partagé (abrégé ici en français PP) dans l'interaction parent-nourrisson. Les participants ont consisté en 113 dyades mère-nourrisson. Les mères ont rempli l'Echelle de Dépression Postnatale d'Edinbourg, le Questionnaire du Comportement du Nourrisson, et le Questionnaire d'Evénements de la Vie. Les dyades ont été filmées à la vidéo pendant une situation de jeu libre et les vidéos ont été analysées en utilisant l'Echelle d'Alarme de Détresse du Bébé et les Echelles de Disponibilité Emotionnelle. Les nourrissons ont été génotypés pour quatre gènes impliqués dans la régulation de l'émotion. L'apparition et la durée du PP (en anglais SP-MD) dans les interactions mère-nourrisson ont été analysées à partir des vidéos. Une sensibilité maternelle plus élevée et des symptômes dépressifs, une meilleure réaction du nourrisson, le nourrisson ayant la variante GG du gène TPH2 -307 étaient liés à l'apparition du PP. Des niveaux plus bas de symptômes dépressifs, une meilleure structuration maternelle et un engagement plus important du nourrisson étaient liés à une durée plus longue du PP. Les dyades où la mère et le nourrisson étaient le plus capables de lire leurs signaux positifs réciproques et d'y répondre étaient moins à même de faire l'expérience d'une affect positif mutuel, comme on le voit dans le PP.

Infants' attention bias to faces as an early marker of social development.

Infants have a strong tendency to look at faces. We examined individual variations in this attentional bias in 7-month-old infants by using a face-distractor competition paradigm and tested in a longitudinal sample whether these variations were associated with outcomes reflecting social behavior at 24 and 48 months of age (i.e., spontaneous helping, emotion understanding, mentalizing, and callous-unemotional traits; N = 100-138). The results showed a robust and distinct attention bias to faces at 7 months, particularly when faces were displaying a fearful expression. This bias declined between 7 and 24 months and there were no significant correlations in attention dwell times between 7 and 24 months of age. Variations in attention to faces at 7 months were not associated with emotion understanding or mentalizing abilities at 48 months of age, but increased attention to faces at 7 months (regardless of facial expression) was related to more frequent helping responses at 24 months and reduced callous-unemotional traits at 48 months of age. Thus, while the results fail to associate infants' face bias with later-emerging emotion understanding and mentalizing capacities, they are consistent with a model whereby increased attention to faces in infancy is linked with the development of affective empathy and responsivity to others' needs.