The effect of estradiol and a combined estradiol/progestagen preparation on insulin sensitivity in healthy postmenopausal women.

Abnormalities of carbohydrate metabolism and insulin sensitivity have been reported in estrogen deficiency. Estrogen replacement appears to result in an improvement in these parameters, although progestagens may antagonize these effects. We have examined the effects of transdermal estradiol and oral norethisterone on insulin sensitivity using the hyperinsulinemic euglycemic clamp method by performing a randomized, double blind, placebo-controlled study in 22 healthy women after a surgically induced menopause. After baseline measurements, subjects were randomized to receive either transdermal 17beta-estradiol (50 microg) or matching placebo patches for 6 weeks. The subjects were then further randomized to receive either estradiol in combination with oral norethisterone (1 mg) or a matching oral placebo preparation, crossing over after 6 weeks, with assessment of insulin sensitivity at the end of each treatment. No significant increase in insulin sensitivity was observed after 6 weeks of transdermal 17beta-estradiol treatment (95% confidence interval, -0.54, 1.86; P = 0.27). Addition of norethisterone for a further 6 weeks had no detectable effect on insulin sensitivity (95% confidence interval, -1.65, 1.10; P = 0.65). The results of this study using transdermal estradiol do not support previous reports that unopposed estrogens exert potentially beneficial effects on insulin sensitivity and suggest that the addition of an oral progestagen confers no clinically important risk or benefit. It is therefore unlikely that effects on insulin sensitivity contribute appreciably to the cardioprotective benefits attributed to hormone replacement therapy.

Insulin sensitivity in pre-eclampsia.

OBJECTIVE: To investigate whether pre-eclampsia is associated with an exaggeration of the insulin resistance seen in normotensive pregnancy. DESIGN: Minimal model analysis of a frequently sampled intravenous glucose tolerance test to assess insulin sensitivity. SETTING: Royal Maternity Hospital, Belfast. PARTICIPANTS: Eleven women with pre-eclampsia and 11 matched normotensive pregnant women. RESULTS: Insulin sensitivity (S(I)) was increased in the group with pre-eclampsia compared with the normotensive women (mean [+/-SEM]: 2.6 [0.4] vs 1.6 [0.2] 10(-4) min(-1) per mU/L; P = 0.028). This was accompanied by a decrease in glucose effectiveness (SG) (1.1+/-0.1 vs 1.7+/-0.1 10(-2)min(-1), P = 0.006) in the pre-eclamptic women. In the normotensive group there was a significant inverse correlation between S(I)and mean arterial blood pressure (r = -0.65; P = 0.03), but no such relation existed in the group with pre-eclampsia. CONCLUSIONS: As with other forms of secondary hypertension, and unlike essential hypertension, the pathophysiology of pre-eclampsia is not associated with insulin resistance.

Glycosylated haemoglobin and hypertension arising in pregnancy.

We analysed a database of glycosylated haemoglobin (HbA1) in nondiabetic pregnant women to investigate the relation between glucose metabolism in the first and second trimesters and hypertensive complications of pregnancy. From a total of 1334 women, 13 had pre-existing hypertension, 225 developed gestational hypertension and 51 developed pre-eclampsia. At 28 weeks of gestation, the women who subsequently developed gestational hypertension had a significantly higher mean HbA1 than those who remained normotensive (6.33 vs 6.17%, P < 0.02). This difference remained significant after correcting for the effects of age and body mass index (regression coefficient 0.11, SE 0.06, P = 0.05). In contrast, there were no significant differences in HbA1 between the women with pre-eclampsia and their normotensive counterparts. This provides indirect evidence to support our hypothesis that gestational hypertension is associated with insulin resistance but pre-eclampsia is not.

A standardised breakfast tolerance test in pregnancy: comparison with the 75 g oral glucose tolerance test in unselected mothers and in those with impaired glucose tolerance.

There is still disagreement concerning the optimal procedure for the diagnosis of milder degrees of hyperglycaemia in pregnancy. We have compared the results of a 75 g oral glucose tolerance test (OGTT) and a standardised breakfast test performed one week apart in 102 non-diabetic women with a singleton pregnancy. There was poor correlation between the two tests (r = 0.15) at two hours, and neither test was predictive of adverse maternal or fetal outcome. One hundred and four patients with impaired glucose tolerance, diagnosed at 30 weeks' gestation by 75 g OGTT, subsequently had a breakfast and lunch meal profile. There was no significant correlation between the two-hour OGTT value and either the two hour post-breakfast value (r = 0.35) or the maximum profile value (r = 0.33). Using the WHO diagnostic criterion of > 8 mmol/l for the OGTT and a maximum glucose concentration > 6.8 mmol/l for the meal profile, there was no relationship between an abnormal result in either test and pregnancy outcome. In our obstetric environment, the 75 g OGTT, a standardised breakfast test, and a structured meal profile, all failed to provide a useful indication of pregnancy outcome in mothers not already known to have diabetes.

A medical audit and patient survey of hysterectomies performed for menstrual disorders.

The aim of the study was to carry out an audit of 283 hysterectomies performed for menstrual disorders over a one year period, and to determine the satisfaction of the women concerned towards their treatment. The medical records of these patients were examined, and they were each sent a questionnaire, 69% of which were completed and returned. The most common presenting symptoms were menorrhagia and dysmenorrhoea. In 53% of cases no clinical abnormality was postulated and in 31% of cases no pathological abnormality was found. The preoperative clinical and pathological diagnoses were in agreement for 59% of patients. Over 90% of women were satisfied with the management of their case by their GP and the gynaecology outpatient clinic. The use of patient-controlled analgesia systems was associated with better post-operative pain relief than intramuscular injections. Thirteen percent of patients required blood transfusion; 21% suffered some form of postoperative complication, most of which were minor. Ninety-four percent of the women were pleased that they had undergone hysterectomy, and 76% wished that they had had the operation sooner. It was concluded that hysterectomy is perceived positively by patients and should not necessarily be considered as a last resort treatment for menstrual disorders.

Combined simple and complex cord knots.

Both double true knots and complex knots of the umbilical cord are rare events. This report presents a case in which the two occurrences were combined. Apart from some early decelerations in the first stage of labour, there was no evidence of fetal compromise. A mid-cavity forceps delivery performed for poor maternal effort resulted in the birth of a healthy female infant. The mechanism and consequences of umbilical cord knotting are reviewed.

Survey of home visiting programs for abused and neglected children and their families.

This study reports on home visitation programs that provide services for abused and neglected children and their families. Data were collected as part of a national survey of home visiting programs. Of the 1,904 programs participating in the survey, 224 had as their primary focus services for children who were abused or neglected. For this group, data are presented on program characteristics, characteristics of home visits, credentials of home visitors, and program documentation procedures. The survey data showed that over 70% of the 224 programs identified social service as their organization affiliation which, in contrast to other providers, offered a broad range of services for the abused or neglected children and their families. The most frequently identified purpose for providing services was the social and emotional development of the child. Parenting skills and parent coping were considered the most important services. Stress management was considered more important by respondents of programs for maltreating families than by those providing services to nonmaltreating families. Approximately half the respondents reported that they required a bachelor's or master's degree for employment. Results are discussed in relation to research and practice implications.

Early education as community intervention: assisting an ethnic minority to be ready for school.

An early education program designed for an ethnic minority of Native Hawaiians implemented at the community rather than the individual child level of intervention is described. The program development effort is theory driven and provides an opportunity to investigate the application of neo-Vygotskian theory to an applied community educational problem. Though not specifically derived from the work of O'Donnell, Tharp, and Wilson (1993), the project reported here shares a common intellectual heritage. This paper demonstrates the parallels between the early education program developed for Hawaiian children and the applicability of the theory presented in the work of O'Donnell et al.

Fetal outcome in mothers with impaired glucose tolerance in pregnancy.

A 75 g oral glucose tolerance test was carried out on 953 pregnant women who were identified on the basis of clinical risk factors. The tests were analysed by the WHO criteria: 826 were normal, 120 showed impaired glucose tolerance, and 7 identified diabetes. A number of obstetric and perinatal outcome measures were compared between the groups with normal and impaired glucose tolerance, and also with 135 women who had pre-existing Type 1 diabetes and delivered during the study period. There was no significant difference in the incidence of antenatal complications between mothers with normal and impaired glucose tolerance. There was a higher rate of induced labour (p < 0.05) and caesarean section (p < 0.01) in the impaired glucose tolerance group compared to the normal group, but no difference in fetal outcome or neonatal morbidity. All of these outcome measures were increased in the Type 1 diabetic pregnancies.

Association of Chlamydia trachomatis with tubal infertility.

A study was undertaken to determine whether the positive correlation between Chlamydia trachomatis antibodies and tubal infertility, noted by workers in other countries, also applied to infertile women in Northern Ireland. Ninety-one infertile women and 106 fertile controls were tested for current cervical infection with C. trachomatis and for evidence of past chlamydial infection. The incidence of C. trachomatis infection of the cervix was 5.8% in the infertile group and 2.8% in the control group. The prevalence of C. trachomatis antibody was 22% in the infertile group and 18.9% in the control group. Previous termination of pregnancy, history of sexually transmitted disease and number of sexual partners were identified as risk factors for seropositivity and tubal disease. We concluded that it would be of value to screen women attending the infertility clinic for C. trachomatis infection of the cervix, and that testing these patients for chlamydia antibodies may also be useful in planning further investigation.

Evidence of Chlamydia infection in a Belfast antenatal population.

Chlamydia trachomatis is an important cause of postpartum endometritis and neonatal conjunctivitis. However, the prevalence of chlamydial genital infection varies considerably from one population group to another. A study was thus conducted to determine the incidence of C trachomatis infection of the cervix in an unselected group of women attending a Belfast antenatal clinic. One hundred and six patients were screened for evidence of current cervical infection with C trachomatis or serological evidence of past infection. C trachomatis was identified in 2.9%, and there was evidence of past infection in 18.9%. No significant risk factors were identified from gynaecological, contraceptive or sexual histories. C trachomatis infection was treated with erythromycin and there were no perinatal complications ascribed to chlamydia.

Family support in the home. Programs, policy, and social change.

The need for a coordinated national policy on family support in the home is discussed. First, the history of home visiting programs is reviewed. Then, recommendations for practice, training, and research in family support programs are presented. A discussion of the impact of new federal initiatives on family support programs and research demonstration efforts follows.

Psychologists' role in family-centered approach to practice, training, and research with young children.

Family-centered, community-based, coordinated care for children with special needs is presented as the best practice model for providing services to children and families. Psychologists must learn to play an active role in this frame-work that both integrates psychology with other health and education disciplines and uses the broad spectrum of psychological knowledge about families, development, community organization, and intervention strategies. Key principles of family-centered child psychology affect practice research and training. The psychologist becomes part of a team created to support families as the primary care-givers of their children. Training programs must reorganize the types of experiences both in the classroom and the field to train new psychologists within this model. As mandates for family-centered care affect policies at the state and federal levels, research will remain a critical factor in understanding the effects of these policy shifts on child and family functioning and the delivery of services.

Self-instruction: An analysis of the differential effects of instruction and reinforcement.

This study investigated the impact of training 9 first- and second-grade children to use a full self-instructional regimen, and then differentially reinforced the use of self-instruction only, accuracy only, or both self-instruction and accuracy. Three comparison children received no training in self-instruction and were reinforced for accuracy only. Children improved dramatically in academic accuracy subsequent to self-instructional training, independent of the use of self-instruction and of the specific behavior consequated. Children who were reinforced for using self-instruction did use self-instruction, and those who were not, did not. Comparison group children showed little improvement until training in problem-solving strategies was given after 9 days of reinforcement for accuracy. Self-instructional training is discussed as one type of event that increases the likelihood of accurate performance. Its effectiveness may be explained in terms of a teaching strategy rather than in terms of modifying cognitive processes.

Inadequacy of brief IQ measures in the classification of mentally retarded prisoners.

This study was designed to evaluate the use of the Slosson Intelligence Test (SIT) and a Wechsler Adult Intelligence Scale (WAIS) short form in determining the intellectual capacity and educational/treatment needs of mentally retarded offenders. The subjects were 52 male prisoners with borderline or retarded intellectual functioning. Their WAIS full-scale IQs were found to be significantly different from their WAIS short-form and SIT IQs. These results suggest that we must continue to use the full WAIS in evaluating mentally retarded offenders.