Glucose turnover in type I diabetic subjects during exercise. Effect of selective and nonselective beta-blockade and insulin withdrawal.

OBJECTIVE: To assess the effect of selective beta 1-blockade (atenolol and betaxolol) and nonselective beta-blockade (propranolol) on glucose turnover in subjects with insulin-dependent (type I) diabetes mellitus during moderate exercise. RESEARCH DESIGN AND METHODS: Five subjects with type I diabetes were infused with insulin and then exercised for 1 h, after pretreatment with each of the three drugs or saline and, on a separate day, after withdrawal of insulin. Glucose turnover was measured using tritiated glucose. RESULTS: Plasma glucose, initially 9.2 +/- 0.5 mmol/L (mean +/- SE) when insulin infused and 14.0 +/- 0.8 when insulin was withdrawn, fell on exercise by 3.4 +/- 1.1 mmol/L (P < 0.05) saline, 4.0 +/- 0.8 mmol/L (P < 0.01) with betaxolol, 3.8 +/- 0.7 mmol/L (P < 0.01) with atenolol, 5.0 +/- 0.6 mmol/L (P < 0.005) with propranolol, and 1.7 +/- 1.0 mmol/L (NS) when insulin was withdrawn. Propranolol, but not the other beta-blockers, caused a significantly greater fall in glucose on exercise than during the control study. Glucose appearance rate (Ra) was similar basally and rose to an almost identical level in all five groups during exercise. Glucose disappearance rate (Rd) rose similarly during exercise, except after propranolol when the rise was significantly greater than with saline (P < 0.01). Failure of glucose to change significantly during exercise when insulin had been withdrawn was associated with the smallest rise in Rd and the highest nonesterified fatty acid concentrations. Propranolol and betaxolol, but not atenolol, reduced nonesterified fatty acids. CONCLUSIONS: We conclude that the greater fall in glucose on exercise after beta-blocking drugs is probably largely a direct effect of beta 2-blockade on muscle, increasing the exercise-induced rise in Rd glucose. This offers support to the use of beta 1-specific drugs, where beta-blockade is necessary in type I diabetes.

Maltoma of the thyroid in a man with Hashimoto's thyroiditis.

We report the case of a 42-yr-old man with primary thyroid lymphoma arising from mucosa-associated lymphoid tissue (MALT-lymphoma, maltoma). The patient underwent a hemithyroidectomy for a growing mass in the right lobe of the thyroid while being treated with 1-thyroxine for Hashimoto's thyroiditis. The clinical diagnosis of Hashimoto's disease was confirmed by aspiration biopsy of the mass during the course of L-thyroxine treatment. Postoperatively, histology showed atypical lymphoproliferative infiltrates suspicious of low-grade non-Hodgkin's lymphoma of mucosa-associated lymphoid tissue-type, coexisting with a reactive process typical of chronic lymphocytic thyroiditis. Immunophenotyping showed a mixed B- and T-lymphocyte population, which was nondiagnostic. However, Southern blot analysis revealed a clonal rearrangement of the Ig heavy chain gene. This case demonstrates that cytology or histology may not distinguish between reactive or low-grade lymphomatous thyroid processes. The use of molecular technique was essential to prove clonality and the presence of lymphoma.

Receptive language development in preterm children as related to caregiver-child interaction.

Fifty preterm children who had experienced a range of biological hazards were divided into two competence groups on the basis of their receptive language development at 24 months. The groups were then compared in terms of the kinds of caregiver-child interactions the children and their primary caregivers engaged in three months earlier in a laboratory assessment. The two language skill groups did not differ on perinatal factors such as birth weight and gestational age, or on length of hospitalization, but did differ in social transactions. The more competent group as compared to the less competent group had caregivers who were more stimulating, the children themselves emitted more vocalization, and the caregivers and children engaged in more reciprocal social transactions.

Infants and children with convulsions and hypotonic-hyporesponsive episodes following diphtheria-tetanus-pertussis immunization: follow-up evaluation.

In a prior prospective study, we evaluated the nature and rates of adverse reactions occurring within 48 hours following 15,752 diphtheria-tetanus-pertussis (DTP) immunizations. Nine children had convulsions, and nine had hypotonic-hyporesponsive episodes. After an interval of 6 to 7 years, we were successful in contacting the families of 16 of these children to determine whether any had evidence of neurologic impairment too subtle to have been detected at the time of initial evaluation. All 16 were considered normal by their parents and were doing well in school. A complete neurologic and psychometric evaluation was performed on 13 of these children. No child had significant neurologic deficit, although four had minor neurologic abnormalities. Psychometric testing revealed normal performance IQ scores (104.3 +/- 15.8) but low verbal IQ scores (91.8 +/- 18.4); however, these lower verbal IQ scores can be explained by the proportion of Hispanic and bilingual children in this sample. Therefore, there is no evidence that any of these 16 children have any serious neurologic damage as a result of a convulsion or a hypotonic-hyporesponsive episode temporally associated with a prior diphtheria-tetanus-pertussis immunization.

Prenatal exposure to drugs: behavioral distortions reflecting CNS impairment?

In order to disentangle the effects on development of prenatal drug exposure from the effects of poor prenatal care, perinatal complications, and low socioeconomic status, toddlers prenatally exposed to drugs were compared to high risk preterm toddlers of similar ethnicity and social class. Intellectual functioning and quality of play were assessed. The drug exposed toddlers had significantly lower developmental scores and less representational play. Furthermore elements of their play were characterized by the investigators as a soft neurological sign. The question of possible CNS impairment is raised.

Development of infants born to cocaine-abusing women: biologic/maternal influences.

This study investigated the influence of gestational age, birthweight, caregiving, and maternal personality characteristics on the development of 51 six-month-old infants born to and being reared by cocaine-abusing mothers. Two self-report measures were administered to the pregnant women at intake: the ASI (quantifying drug use) and the MCMI (describing DSM-III Axis II personality characteristics and Axis I clinical syndromes). Infants' biologic vulnerability was assessed by gestational age and birthweight. Caregiving was assessed 6 months later in the home, using the HOME Inventory and maternal caregiving behavior rating scales. Infant development was assessed in the laboratory at 6 months using the Bayley Scales of Infant Development. Higher Bayley scores were associated with heavier birthweight and increased maternal sensitivity. Furthermore, mothers of infants with shorter gestations were found to be more sensitive caregivers, whereas mothers who reported more histrionic-gregarious, narcissistic, borderline-cycloid, and/or paranoid personality characteristics during pregnancy were less sensitive caregivers. Surprisingly, mothers who reported more depressive symptoms during pregnancy provided more sensitive care.

Maternal sensitivity during infancy and subsequent life events relate to attachment representation at early adulthood.

A prospective longitudinal research study of 86 prematurely born children from birth to age 18 years provided empirical evidence for continuity from infancy experience to representations of attachment at age 18 years. Young adults whose representation of attachment was dismissing had been objectively observed during infancy, 16-17 years earlier, to receive less sensitive maternal care than those infants who were later judged at early adulthood to have secure or preoccupied representations. Infancy experience alone did not differentiate young adults with secure representations from those with preoccupied representations. Rather, adverse life events through age 12, particularly parental divorce, reduced the likelihood of secure representations and increased the likelihood of preoccupied representations. The absence of adverse life events did not increase the likelihood of security for those who had not experienced early sensitive caregiving.

Maternal ego development and mother-infant interaction in drug-abusing women.

The purpose of this study was to expand our knowledge about factors in substance-abusing women, other than chronic drug abuse, that may influence maternal caregiving behaviors. Specifically, the study explored relationships between maternal characteristics and mother-infant interaction in a sample of drug-abusing women to determine whether drug-addicted mothers' level of ego development affected mother-infant interaction at 1 month. Data collection occurred during a prenatal lab visit and 1 month postpartum and included a clinical interview, self-report on participants' addiction severity, clinical personality inventory, ego development test, and videotaped observation of mother-infant feeding interactions. Only ego development, and to a lesser degree psychological symptoms associated with substance abuse, were found to be significant predictors of maternal-child interaction at 1 month. This points to the need to focus on building internal resources in providing substance abuse treatment and other services for substance-abusing mothers.

Cognitive development in preterm infants: birth to 8 years.

This report summarizes the outcome at age 8 of a group of preterm infants followed intensively from birth. The study was designed primarily to follow the processes of interaction between biological and environmental factors in determining the childhood outcome of infants born preterm rather than to report the incidence of particular types of outcomes for special subgroups of infants. A high percentage of the children were performing within the normal range. Social factors played a major role in determining the outcome regardless of neonatal complications. Functional assessment of newborn visual attention and sleep organization showed a modest relation to outcome. A subgroup of preterm infants from Spanish-speaking families, for cultural and language integration reasons, followed a somewhat different course from infancy to childhood outcome than did the group from English-speaking families. The results suggest that in longitudinal studies of preterm infants, different cultural and language groups should be analyzed separately so that one may understand the developmental processes and outcomes.

Metastatic signet ring carcinoma of the breast as a source of positive cervicovaginal cytology. A case report.

The cellular manifestations of extrauterine cancer have been well documented. While finding metastatic carcinoma in gynecologic specimens should not be unexpected, descriptions of certain types of neoplasms are not well represented in the cytology literature. We describe the clinical, cytopathologic and histologic features of a case of signet ring cell breast carcinoma metastatic to the uterine cervix. Signet ring cell breast carcinoma is a rare neoplasm, and its possible histogenesis is discussed.

Intervention with disadvantaged parents of sick preterm infants.

Infants born preterm are, as a group, at increased risk for a wide variety of later developmental problems (Kopp and Parmelee 1979), although many preterm infants do well (Hack et al. 1983; Saigal et al. 1984). The perinatal vulnerability, however, is amplified in disadvantaged families (Sameroff and Chandler 1975), increasing the likelihood of later emotional and cognitive difficulties (Werner and Smith 1977). A preventive intervention project was designed, therefore, that would provide and then evaluate the effectiveness of supportive home visitor services to parents of infants who were at double jeopardy, both biologically and socially--that is, sick preterm infants being reared by low-income parents. E. Baxter, K. Weiler and I hypothesized that if intervention could increase mothers' involvement and level of responsive interactions with their children, that increased maternal commitment and responsiveness to the infant would act as a protective factor ameliorating or preventing later problems in the child (Beckwith and Cohen 1984; Werner and Smith 1982).

Infant mental health and biological risk.

Parents seldom seek help directly for infant mental health problems. Parents enter the health care system seeking advice for identified or presumed biological problems in their infants. Many of these biological problems, however, have major psychosocial components of importance to infant mental health. It is important that physicians deal directly with the psychosocial issues and avoid converting them into biological medical problems unintentionally. Three common types of problems and appropriate methods of management are discussed to ensure special recognition and effective handling by the physician of psychosocial problems and the promotion of mental health. The problems discussed are the following: Infants seen with defined medical conditions that generally have associated psychosocial problems including child abuse. Infants seen who have fully recovered from critical illnesses but are considered "at risk" for later developmental disability. Infants seen with normal variations of behavior that are misinterpreted by their parents or physicians as due to a medical problem. In infancy medical and psychosocial issues are so closely interwoven that it is critical that physicians learn to recognize the major psychosocial consequences of primary medical problems and the medical manifestations of primary psychosocial problems and their management.

Intervening in severe physical child abuse cases: mental health, legal, and social services.

OBJECTIVE: To examine the child protection process in cases of severe physical abuse, to compare characteristics of the families with risk factors previously reported in the published literature, and to develop recommendations about the use of mental health professionals in such cases. METHOD: Reviewers examined 30 case records of severely physically abused children under age 5, nominated by child protection workers and mental health providers. The reviewers recorded demographic, clinical, and case process information such as mental health and other referrals, reunification status, and frequency of criminal prosecution. A case study was described. RESULTS: The parents displayed a range of psychological characteristics (e.g., depression, anxiety, personality disorders) and life problems (e.g., domestic violence, substance abuse, abused as child). The majority of parents denied the abuse. The children were very young (more than half under 6 months old) and many had difficult births or medical problems prior to the abuse. The most common services offered were individual psychotherapy and parenting classes. More than half of the children reunified with at least one parent within I year. Forty percent of the cases involved criminal prosecution. CONCLUSIONS: Reunification occurred more quickly and more often than expected based on the severity of the injuries. The system often relies on psychotherapy to correct the abusive behavior, even when the perpetrator remains unknown and specific risks such as substance abuse or domestic violence are present. The authors advise utilizing multidisciplinary teams for recommendations regarding reunification.

Mothers' use of personal pronouns when talking with toddlers.

The verbal interaction of 2-year-old children (N = 46; 16 girls, 30 boys) and their mothers was audiotaped, transcribed, and analyzed for the use of personal pronouns, the total number of utterances, the child's mean length of utterance, and the mother's responsiveness to her child's utterances. Mothers' use of the personal pronoun we was significantly related to their children's performance on the Stanford-Binet at age 5 and the Wechsler Intelligence Scale for Children at age 8. Mothers' use of we in social--vocal interchange, indicating a system for establishing a shared relationship with the child, was closely connected with their verbal responsiveness to their children. The total amount of maternal talking, the number of personal pronouns used by mothers, and their verbal responsiveness to their children were not related to mothers' social class or years of education.

Issues in subject recruitment and retention with pregnant and parenting substance-abusing women.

To advance knowledge about the treatment of addiction among pregnant women and other women of childbearing age, investigators must adhere to the requirements of a strict experimental research design while concurrently providing clinical services. This means that researchers must address a variety of difficult questions, including the following: Was the sample large enough? Were the criteria for subject inclusion and exclusion well defined? Did the process of recruitment result in a sample that could be generalized to a larger population, or was the sample biased in some way? Was assignment to groups clearly random? What was the attrition rate? Was attrition the same in both experimental and comparison groups? Did baseline measures collect enough information to permit a description of the facts that were associated with attrition in each group? Was the attrition rate so high that the retained sample had special characteristics? If so, what were these features? This chapter highlights several problems related to these questions, describes the difficulties that investigators have faced in meeting clinical and research challenges to date, and suggests strategies for overcoming some obstacles. In establishing the Perinatal-20 project, the National Institute on Drug Abuse took an informed first step in organizing a substantial research effort to investigate treatment modalities that incorporate services specific to the needs of substance-abusing women who have children. This initial effort has resulted in a beginning knowledge base that can be used to refine and expand future treatment efforts. Even the issue of the "study unit" for this population is evolving. Today's researchers are attempting to determine whether the mother alone or the mother along with her dependent children constitutes the study unit. This question also has led professionals in the field to examine a range of specific outcome priorities, and investigators just now are beginning to determine exactly what needs to be evaluated in gauging the effectiveness of treatment. Is success measured on the basis of the woman's progress with abstinence alone, or does it also include her role with her children? Is it determined on the basis of her relationship with her children or the children's growth and development? Compared with providing services for and studying single adult subjects, developing treatment for women and their children presents researchers with a more complex task and requires expanded clinical services (Gallagher 1990, pp. 540-559). As in most fields of study, initial research data in substance abuse treatment for pregnant and parenting women are derived from samples of convenience, as described above. To put this information in perspective, future research will require a wider and more representative spectrum of the population. Furthermore, tensions between clinical needs and research requirements must be considered in advance, and methods for relaxing these tensions will be critical to the success of future efforts. For example, members of both the research and clinical staff teams must be absolutely clear about the study design and the requirements of reliable research. Where possible, potential ambiguities about group assignment, project services, subjects' responsibilities, and so forth must be incorporated into subject consent forms so that the subjects also are apprised of potential problems and their solutions. A final caution to future investigators is to be aware of the economic, physical, and personnel limitations of the range of treatment services that can be provided in a research demonstration study involving this population. Because of these limitations and the extensive range of services the subjects of the studies require, treatment components must be discrete and carefully defined to prevent programs from becoming impractically diverse and unclear. Research goals must be attainable and measurable.(ABSTRACT TRUNCATED)

Intrusive caregiving and quality of attachment in prenatally drug-exposed toddlers and their primary caregivers.

The relation between caregiver intrusiveness and the quality of attachment was tested among 51 prenatally drug-exposed toddlers and their primary caregivers. Biological mothers and kinship/foster caregivers neither differed as to caregiver intrusiveness nor as to their toddlers' attachment security and attachment organization. Insecure and disorganized/disoriented attachments were found to be more prevalent in this sample than in normal samples. In keeping with recent findings in non-drug-abusing samples (Isabella & Belsky, 1991; Lyons-Ruth, Repacholi, McLeod, & Silva, 1991), more caregivers of toddlers with avoidant or disorganized/disoriented attachments were found to be intrusive than caregivers of toddlers with secure or resistant attachments.

Preterm children at early adolescence and continuity and discontinuity in maternal responsiveness from infancy.

Patterns in mother-child interaction from infancy to age 12 were investigated in a prospective, longitudinal study of 44 English-speaking mothers and their preterm children. Maternal responsiveness was assessed by home observations during infancy and the Family Interaction Q-Sort at age 12, derived from 2 structured laboratory situations requiring cooperation of mother and child. A cluster of maternal behaviors of critical control toward the toddler was assessed at age 2 years. Children of mothers who were consistently more responsive during both infancy and early adolescence, as well as children whose mothers became more responsive by age 12, achieved higher IQ and arithmetic scores, had more positive self-esteem, and their teachers reported fewer behavioral and emotional problems than children of mothers who were consistently less responsive both during infancy and at age 12. Continuity in parenting behaviors was related to control and criticism beginning in the toddler period and not to degree of responsiveness to the infant.

Preterm infant interaction with the caregiver in the first year of life and competence at age two.

Caregiver-infant interactions were studied for 50 preterm infants and their primary caregivers. Naturalistic observations in the home were made when the infants were 1, 3, and 8 months of age. The social transactions in the first year were related to competence at age 2, thereby extending a previous report showing a moderate association between caregiver-infant interaction and competence at 9 months. The frequency of early social transactions was predictive of the infant's competence at age 2 on the Gesell Developmental Schedules, a sensorimotor scale, a measure of receptive language, and the Bayley Mental Scale. Early social transactions were as predictive of 2-year competence as were caregiver-child transactions at age 2. The study suggests that social transactions as early as 1 month reflect some quality of the relationship between the caregiver and the infant that is important to the child's later mental performance.

Caregiving behaviors and early cognitive development as related to ordinal position in preterm infants.

Naturalistic home observations of 54 preterm infants and their caregivers were made when the infants were 1, 3 and 8 months of age. Differences were found in the kinds of everyday transactions which occur with preterm infants raised with and without siblings. At 1 month of age the care of firstborn and later-born infants was similar in most ways. At 3 months and 8 months firstborn infants clearly received more responsive care and more stimulation from their mothers than later-born infants. Furthermore, the firstborn infant received more social transactions from anybody. Firstborn preterm infants obtained higher Gesell developmental scores than later-born infants, replicating results reported with infant test performance of full-term infants.