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.

Retrospective cohort study of breast cancer incidence, health service use and outcomes in Europe: a study of feasibility.

Background: Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries. Methods: Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24 years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region. Results: In total, 24 576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.2-98.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix. Conclusion: Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy.

Reduced length of uninterrupted institutional stay after implementing a fast-track protocol for primary total hip replacement.

Background and purpose - Fast-track protocols have been successfully implemented in many hospitals as they have been shown to result in shorter length of stay (LOS) without compromising results. We evaluated the effect of fast-track implementation on the use of institutional care and results after total hip replacement (THR). Patients and methods - 3,193 THRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast-track (Hospital A) and non-fast-track (Hospitals B, C, and D). We analyzed LOS, length of uninterrupted institutional care (LUIC, including LOS), discharge destination, readmission, revision rate, and mortality in each hospital. We compared these outcomes for THRs performed in Hospital A before and after fast-track implementation and we also compared outcomes, excluding readmission rates, with the corresponding outcomes for the other hospitals. Results - After fast-track implementation, median LOS in Hospital A diminished from 5 to 2 days (p < 0.001) and (median) LUIC from 6 to 3 (p = 0.001) days. No statistically significant changes occurred in discharge destination. However, the reduction in LOS was combined with an increase in the 42-day readmission rate (3.1% to 8.3%) (p < 0.001). A higher proportion of patients were at home 1 week after THR (p < 0.001) in Hospital A after fast-tracking than before. Interpretation - The fast-track protocol reduces LUIC but needs careful implementation to maintain good quality of care throughout the treatment process.

Fast-tracking for total knee replacement reduces use of institutional care without compromising quality.

Background and purpose - Fast-tracking shortens the length of the primary treatment period (length of stay, LOS) after total knee replacement (TKR). We evaluated the influence of the fast-track concept on the length of uninterrupted institutional care (LUIC) and other outcomes after TKR. Patients and methods - 4,256 TKRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast track (Hospital A) and non-fast track (Hospitals B, C and D). We analyzed length of uninterrupted institutional care (LUIC), LOS, discharge destination, readmission, revision, manipulation under anesthesia (MUA) and mortality rate in each hospital. We compared these outcomes for TKRs performed in Hospital A before and after fast-track implementation and we also compared Hospital A outcomes with the corresponding outcomes for the other 3 hospitals. Results - After fast-track implementation, median LOS in Hospital A fell from 5 to 3 days (p < 0.001) and (median) LUIC from 7 to 3 (p < 0.001) days. These reductions in LOS and LUIC were accompanied by an increase in the discharge rate to home (p = 0.01). Fast-tracking in Hospital A led to no increase in 14- and 42-day readmissions, MUA, revision or mortality compared with the rates before fast-tracking, or with those in the other hospitals. Of the 4 hospitals, LOS and LUIC were most reduced in Hospital A. Interpretation - A fast-track protocol reduces LUIC and LOS after TKR without increasing readmission, complication or revision rates.

Respiratory sinus arrhythmia moderates the impact of maternal prenatal anxiety on infant negative affectivity.

Maternal prenatal anxiety is associated with infants' temperamental negative affectivity (NA), but it is unclear to what extent children vary in their susceptibility to prenatal influences. We tested a hypothesis that infants' respiratory sinus arrhythmia (RSA), an index of parasympathetic vagal tone and a potential marker of differential susceptibility to environmental influences, moderates the effects of maternal prenatal anxiety on the development of infant NA. Prenatal anxiety was assessed during the last trimester of pregnancy in a low-risk community sample. Infant NA, baseline RSA, and maternal postnatal anxiety were assessed at 8-10 months of infant age. Regression analyses were performed to predict infant NA on the basis of prenatal anxiety, infant baseline RSA, and their interaction (N = 173). Maternal prenatal anxiety and infant RSA interactively predicted infant NA at 8-10 months. Among infants with high RSA, a significant positive association between prenatal anxiety and infant NA was observed, whereas prenatal anxiety did not predict infant NA among infants with low RSA. Vagal tone, as indexed by baseline RSA, may provide a promising marker of differential susceptibility to the long-term effects of varying intrauterine conditions.

Elevated risk of early reoperation in total hip replacement during the stage of unit closure: A population-based registry study of total hip and knee replacements in Finland, 1998-2011.

BACKGROUND AND PURPOSE: The effects of launch or closure of an entire arthroplasty unit on the first or last patients treated in these units have not been studied. Using a 3-year follow-up, we investigated whether patients who were treated at the launch or closure stage of an arthroplasty unit of a hospital would have a higher risk of reoperation than patients treated in-between at the same units. PATIENTS AND METHODS: From the Finnish Arthroplasty Register, we identified all the units that had performed total joint arthroplasty and the units that were launched or closed in Finland between 1998 and 2011. The risks of reoperation within 3 years for the 41,748 total hip and knee replacements performed due to osteoarthritis in these units were modeled with Cox proportional-hazards regression, separately for hip and knee and for the launch and the closure stage. RESULTS: The unadjusted and adjusted hazard ratios (HRs) for total hip and knee replacements performed in the initial stage of activity of the units that were launched were similar to the reoperation risks in patients who were operated in these units after the early stage of activity. The unadjusted and risk-adjusted HRs for early reoperation after total hip replacement (THR) were increased at the closure stage (adjusted HR = 1.8, 95% CI: 1.2-2.8). The reoperation risk at the closure stage after total knee replacement (TKR) was not increased. INTERPRETATION: The results indicate that closure of units performing total hip replacements poses an increased risk of reoperation. Closures need to be managed carefully to prevent the quality from deteriorating when performing the final arthroplasties.

European Regional Differences in All-Cause Mortality and Length of Stay for Patients with Hip Fracture.

The objective of this study was to compare healthcare performance for the surgical treatment of hip fractures across and within Finland, Hungary, Italy, the Netherlands, Norway, Scotland, and Sweden. Differences in age-adjusted and sex-adjusted 30-day and one-year all-cause mortality rates following hip fracture, as well as the length of stay of the first hospital episode in acute care and during a follow up of 365 days, were investigated, and associations between selected country-level and regional-level factors with mortality and length of stay were assessed. Hungary showed the highest one-year mortality rate (mean 39.7%) and the lowest length of stay in one year (12.7 days), whereas Italy had the lowest one-year mortality rate (mean 19.1 %) and the highest length of stay (23.3 days). The observed variations were largely explained by country-specific effects rather than by regional-level factors. The results show that there should still be room for efficiency gains in the acute treatment of hip fracture, and clinicians, healthcare managers, and politicians should learn from best practices. This study demonstrates that an international comparison of acute hospital care is possible using pooled individual-level administrative data.

Individual and Regional-level Factors Contributing to Variation in Length of Stay After Cerebral Infarction in Six European Countries.

Using patient-level data for cerebral infarction cases in 2007, gathered from Finland, Hungary, Italy, the Netherlands, Scotland and Sweden, we studied the variation in risk-adjusted length of stay (LoS) of acute hospital care and 1-year mortality, both within and between countries. In addition, we analysed the variance of LoS and associations of selected regional-level factors with LoS and 1-year mortality after cerebral infarction. The data show that LoS distributions are surprisingly different across countries and that there is significant deviation in the risk-adjusted regional-level LoS in all of the countries studied. We used negative binomial regression to model the individual-level LoS, and random intercept models and ordinary least squares regression for the regional-level analysis of risk-adjusted LoS, variance of LoS, 1-year risk-adjusted mortality and crude mortality for a period of 31-365 days. The observed variations between regions and countries in both LoS and mortality were not fully explained by either patient-level or regional-level factors. The results indicate that there may exist potential for efficiency gains in acute hospital care of cerebral infarction and that healthcare managers could learn from best practices.

Parameter Heterogeneity In Breast Cancer Cost Regressions - Evidence From Five European Countries.

We investigate parameter heterogeneity in breast cancer 1-year cumulative hospital costs across five European countries as part of the EuroHOPE project. The paper aims to explore whether conditional mean effects provide a suitable representation of the national variation in hospital costs. A cohort of patients with a primary diagnosis of invasive breast cancer (ICD-9 codes 174 and ICD-10 C50 codes) is derived using routinely collected individual breast cancer data from Finland, the metropolitan area of Turin (Italy), Norway, Scotland and Sweden. Conditional mean effects are estimated by ordinary least squares for each country, and quantile regressions are used to explore heterogeneity across the conditional quantile distribution. Point estimates based on conditional mean effects provide a good approximation of treatment response for some key demographic and diagnostic specific variables (e.g. age and ICD-10 diagnosis) across the conditional quantile distribution. For many policy variables of interest, however, there is considerable evidence of parameter heterogeneity that is concealed if decisions are based solely on conditional mean results. The use of quantile regression methods reinforce the need to consider beyond an average effect given the greater recognition that breast cancer is a complex disease reflecting patient heterogeneity.

Variations and Determinants of Mortality and Length of Stay of Very Low Birth Weight and Very Low for Gestational Age Infants in Seven European Countries.

The EuroHOPE very low birth weight and very low for gestational age infants study aimed to measure and explain variation in mortality and length of stay (LoS) in the populations of seven European nations (Finland, Hungary, Italy (only the province of Rome), the Netherlands, Norway, Scotland and Sweden). Data were linked from birth, hospital discharge and mortality registries. For each infant basic clinical and demographic information, infant mortality and LoS at 1 year were retrieved. In addition, socio-economic variables at the regional level were used. Results based on 16,087 infants confirm that gestational age and Apgar score at 5 min are important determinants of both mortality and LoS. In most countries, infants admitted or transferred to third-level hospitals showed lower probability of death and longer LoS. In the meta-analyses, the combined estimates show that being male, multiple births, presence of malformations, per capita income and low population density are significant risk factors for death. It is essential that national policies improve the quality of administrative datasets and address systemic problems in assigning identification numbers at birth. European policy should aim at improving the comparability of data across jurisdictions.

Attention to Faces Expressing Negative Emotion at 7 Months Predicts Attachment Security at 14 Months.

To investigate potential infant-related antecedents characterizing later attachment security, this study tested whether attention to facial expressions, assessed with an eye-tracking paradigm at 7 months of age (N = 73), predicted infant-mother attachment in the Strange Situation Procedure at 14 months. Attention to fearful faces at 7 months predicted attachment security, with a smaller attentional bias to fearful expressions associated with insecure attachment. Attachment disorganization in particular was linked to an absence of the age-typical attentional bias to fear. These data provide the first evidence linking infants' attentional bias to negative facial expressions with attachment formation and suggest reduced sensitivity to facial expressions of negative emotion as a testable trait that could link attachment disorganization with later behavioral outcomes.