Cocaine exposure is associated with subtle compromises of infants' and mothers' social-emotional behavior and dyadic features of their interaction in the face-to-face still-face paradigm.

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

Neurobehavioral effects of treatment for opiate withdrawal.

A partially randomised, controlled trial was performed to test the hypothesis that opiate exposed infants treated with diluted tincture of opium (DTO) and phenobarbital would have better neurobehavioral scores than infants treated with DTO alone. Compared with those treated with DTO alone (n = 15), infants treated with DTO and phenobarbital (n = 17) were more interactive, had smoother movements, were easier to handle, and less stressed. Dual treatment results in improved neurobehavioral organisation during the first three weeks of life, which may indicate a more rapid recovery from opiate withdrawal.

Prenatal drug exposure and maternal and infant feeding behaviour.

OBJECTIVE: To evaluate feeding difficulties and maternal behaviour during a feeding session with 1 month old infants prenatally exposed to cocaine and/or opiates. METHODS: The study is part of the maternal lifestyle study, which recruited 11 811 subjects at four urban hospitals, then followed 1388 from 1 to 36 months of age. Exposure to cocaine and opiates was determined by maternal interview and meconium assay. At the 1 month clinic visit, biological mothers were videotaped while bottle feeding their infants. This sample included 364 exposed to cocaine, 45 exposed to opiates, 31 exposed to both drugs, and 588 matched comparison infants. Mothers were mostly black, high school educated, and on public assistance. Videotapes were coded without knowledge of exposure status for frequency, duration and quality of infant sucking, arousal, feeding problems, and maternal feeding activity and interaction. RESULTS: No cocaine effects were found on infant feeding measures, but cocaine-using mothers were less flexible (6.29 v 6.50), less engaged (5.77 v 6.22), and had shorter feeding sessions (638 v 683 seconds). Opiate exposed infants showed prolonged sucking bursts (29 v 20 seconds), fewer pauses (1.6 v 2.2 per minute), more feeding problems (0.55 v 0.38), and increased arousal (2.59 v 2.39). Their mothers showed increased activity (30 v 22), independent of their infants' feeding problems. CONCLUSIONS: Previous concerns about feeding behaviour in cocaine exposed infants may reflect the quality of the feeding interaction rather than infant feeding problems related to prenatal exposure. However, opiate exposed infants and their mothers both contributed to increased arousal and heightened feeding behaviour.

Pattern of lymph node metastases in clinically unilateral stage I invasive epithelial ovarian carcinomas.

PURPOSE: There is controversy regarding the pattern of lymphatic spread in unilateral stage I invasive ovarian carcinomas. The purpose of this study is to describe the incidence and distribution of lymph node (LN) metastases in ovarian carcinomas clinically confined to one ovary. METHODS: Ninety-six patients with disease visibly confined to one ovary were identified. Pathology reports were reviewed to identify metastatic LN involvement, number of involved nodes, and their locations. Patients with gross disease in the pelvis or abdomen or those who had grossly positive LNs removed for debulking were excluded from this review. RESULTS: Fourteen of ninety-six patients (15%) had microscopically positive LNs on pathologic review. All of these 14 patients had grade 3 tumors. Grade 3 tumors were more commonly seen in LN-positive versus LN-negative patients (P < 0.001). Pelvic nodes were positive in 7 patients (50%), paraaortic nodes in 5 patients (36%), and both in 2 patients (14%). Forty-two patients had LN sampling only on the side ipsilateral to the neoplastic ovary, 4 of whom (10%) had LN metastases. Fifty-four patients had bilateral sampling performed, 10 of whom (19%) had LN metastases. Of these 10 patients, isolated ipsilateral LN metastases were seen in 5 (50%) cases. Isolated contralateral LN metastases were seen in 3 (30%) cases, and bilateral metastases were seen in 2 (20%). CONCLUSIONS: In this cohort of patients with clinical stage I ovarian carcinoma with disease limited to one ovary, bilateral LN sampling increased the identification of nodal metastases. Ipsilateral sampling may result in the understaging of patients. Bilateral pelvic and paraaortic LN sampling is recommended to accurately stage ovarian carcinoma.

Splenectomy and surgical cytoreduction for ovarian cancer.

OBJECTIVE: The aim of this study was to evaluate the role of splenectomy, as a surrogate marker for aggressive tumor cytoreduction in ovarian cancer, and its impact on patient morbidity and survival. METHODS: A retrospective cohort study of 35 patients who underwent splenectomy for ovarian cancer cytoreduction between August 1986 and May 1998 was performed. Data abstracted from the medical record included patient demographics, preoperative imaging, surgical procedures, tumor distribution, postoperative complications, chemotherapy treatment, and follow-up information. RESULTS: Splenectomy was performed in 13 patients at the time of primary cytoreduction and in 22 patients at the time of secondary cytoreduction. Preoperative diagnosis of splenic involvement was frequently made prior to secondary surgery, 77.3% compared to 15.4% of primary cases. In addition, parenchymal splenic involvement was more commonly observed at recurrence, 59.1% vs 23.1% at initial presentation. Disease distribution in secondary cytoreduction cases tended to be more focal, macronodular, and have no ascites. Cytoreduction to less than 1 cm disease was achieved in 100% of primary patients and 86% of secondary patients. Major morbidity (pneumonia, PE, sepsis, pancreatitis, MI) occurred in 23.1% of primary patients and 28.6% of secondary patients. Combining splenectomy with other cytoreductive procedures may make splenectomy itself seem more morbid. With a 17-month median follow-up, median progression-free interval was 24 months in primary patients and 14 months in secondary patients. Among secondary patients, median survival time after splenectomy and cytoreduction was 41 months. CONCLUSIONS: Splenectomy at the time of primary and secondary cytoreduction for ovarian cancer can be performed with acceptable morbidity. Secondary cytoreduction patients may be selected preoperatively by their progression-free interval, prior degree of cytoreduction, and macronodular tumor involvement on imaging studies. Identification of splenic involvement allows for appropriate counseling and preoperative preparation.

The significance of atypical glandular cells on routine cervical cytologic testing in a community-based population.

OBJECTIVES: We sought to determine the follow-up rate of women with glandular atypia on routine Papanicolaou smears in a community-based population and to describe the associated pathologic findings. STUDY DESIGN: Over a 12-month period, all patients with Papanicolaou smears with atypical glandular cells of undetermined significance were reviewed for demographic and clinical characteristics and followed up for a period of 12 to 24 months. RESULTS: Of the 48,890 Papanicolaou smears examined, 141 (0.29%) were diagnosed with atypical glandular cells of undetermined significance. Of these, 22 (17.6%) had no record of any subsequent investigation, and only 64 (51.2%) were monitored with both colposcopy and biopsy. Of the 64 biopsy specimens, 39 (60.9%) were positive for disease. Twenty-six (66.7%) were of squamous origin, with the most advanced lesion being cervical intraepithelial neoplasia 3. An additional patient had a combined cervical intraepithelial neoplasia and adenocarcinoma in situ lesion. Four (10.3%) additional patients had glandular cervical lesions, 2 benign polyps and 2 adenocarcinoma in situ lesions. Seven (17.9%) patients had endometrial lesions (benign polyps, 2 patients; complex atypical endometrial hyperplasia, 1 patient; and endometrial carcinoma, 4 patients). One patient had ovarian cystadenocarcinoma. Postmenopausal women were 5 times more likely to have a glandular lesion. Women with abnormal vaginal bleeding were also more likely to have a glandular lesion. These same patient groups were also more likely to have endometrial disease. CONCLUSION: The incidence of atypical glandular cells of undetermined significance on Papanicolaou smears in this community-based population was 0.29%, which is consistent with estimates from institution-based populations. Nearly 50% of women studied were not followed up with tissue biopsy. Of those with a tissue biopsy, 61% had positive findings, including 5 with cancer. Although postmenopausal status and abnormal vaginal bleeding were associated with endometrial or glandular disease, studies of larger patient populations should be conducted to examine potential risk factors for these conditions.

Literacy promotion in primary care pediatrics: can we make a difference?

BACKGROUND: Reading skills are critical to children's success in school and the increasingly technologic workforce. Children from low-income families are at risk for home environments that fail to promote emergent literacy and for reading failure. A home environment that encourages learning and parents who are involved in their children's education are important factors in school achievement. OBJECTIVE: To evaluate the effects of a literacy promoting intervention delivered by pediatric providers as part of well-child care on parent attitudes and behaviors and on child language. DESIGN/METHODS: A multicultural group of 205 low-income families with 5- to 11-month-olds were prospectively enrolled, interviewed, and randomized to intervention (n = 106) or control (n = 99) groups. Families in the intervention group received developmentally appropriate children's books and educational materials and advice about sharing books with children, while those in the control group received no books or materials relevant to literacy. After an average of 3.4 well-child visits in both groups, 153 (75%) were reinterviewed and the children's receptive and expressive vocabulary was tested using a modified version of the MacArthur Communication and Development Inventory (Short Form). Parents were asked if their child understood (receptive vocabulary) or said (expressive vocabulary) each of 100 words, half of which were in the books given. Families were found to have a Child-Centered Literacy Orientation if they mentioned reading aloud as one of their child's favorite activities or as one of their own favorite joint activities or if they usually read together at bedtime. At follow-up toddlers were 18.4 months old on average. RESULTS: Intervention and control groups had similar literacy related characteristics at baseline. There was a 40% increase in Child-Centered Literacy Orientation among intervention families compared with 16% among controls. Intervention families read more with their toddlers (4.3 vs 3.8 days/week). Both receptive and expressive vocabulary scores were higher in older intervention toddlers (18-25 months old; n = 88), but not in younger intervention toddlers (13-17 months old; n = 62). This significant effect of the intervention on vocabulary scores in older toddlers was found for both the 50 words in the books and those not in the books. After parent education, foreign birth and language proficiency, and child age were statistically controlled, the intervention remained significantly associated with higher language outcomes in older toddlers. However, when reading aloud was added to the multivariate analysis, the influence of the intervention was no longer evident, suggesting the intervention's effect on child language was mediated through increased shared reading with these toddlers. CONCLUSION: This simple and inexpensive intervention, delivered as part of well-child care, changed parent attitudes toward the importance of reading with their infants and toddlers. These intervention parents and their children read more together and this was associated with enhanced language development in older toddlers in this diverse group of low-income families.

Interpreting research on prenatal substance exposure in the context of multiple confounding factors.

Fetal exposure to specific drugs often occurs in the context of polydrug use, medical complications, and social/environmental risks. Early reports of severe developmental consequences of fetal exposure to illicit drugs, for example, cocaine, have largely been unsupported by recent studies that take these factors into account. Using a database of published studies on cocaine exposure, this article examines how confounding factors are controlled by recruitment and statistical strategies. Rather than attempting to reduce the impact of these factors, it is suggested that multiple risks in children's lives should be included in models of developmental outcomes along with drug exposure. Understanding the complexity of multiple risks in the child's environment and the subtlety of drug exposure effects can guide the choice of clinical treatment and intervention.

Child centered literacy orientation: a form of social capital?

OBJECTIVE: To describe the home literacy environment and to identify financial, human, and social capital variables associated with the presence or lack of Child Centered Literacy Orientation (CCLO) in families with young children who regularly attend pediatric primary care clinics. DESIGN: Cross-sectional case-control analysis of structured parent interviews conducted in two hospital-based and four community-based pediatric clinics in New England. SUBJECTS: Parents of 199 healthy 1- to 5-year-old children whose mean age was 30 +/- 15 (SD) months were interviewed. Parents were primarily mothers (94%) with a mean age of 28 +/- 7 (SD) years 60% of whom were single. Educational levels of study parents varied: 43% had not graduated from high school, 29% had a high school equivalency, and 28% had at least a year of college or vocational training. This was a multiethnic parent group. Sixty-five percent were bilingual or non-English speaking. Fifty-eight percent were born outside of the continental United States. Parents were primarily of low-income status with 85% receiving Women, Infant, and Children (WIC) food supplements, Aid to Families With Dependent Children, and/or Medicaid. RESULTS: Half of the parents interviewed reported that they rarely read books. Sixty percent of children had fewer than 10 books at home and two-thirds of these households contained fewer than 50 books total. When asked open-ended questions, 28% of parents said that sharing books with their child was one of their three favorite activities together, 14% said that looking at books was one of their child's three favorite things to do, and 19% reported sharing books at bedtime at least six times each week. Thirty-nine percent of families had at least one of these three literacy-related responses present and so were said to have a CCLO. A backwards stepwise multiple logistic regression on CCLO was performed with family financial, human, and social capital variables. Parents married or living together (odds ratio [OR] 2.56, 95% confidence interval [CI] = 1.21-5.42), higher adult-to-child ratios in the home (OR 1.92, 95% CI = 1.20-3.05), households speaking only English (OR 2.67, 95% CI = 1.24-5.76), parents reading books themselves at least a few times a week (OR 2.86, 95% CI = 1.38-5.91), and homes with more than 10 children's books (OR 3.3, 95% CI = 1.6-6.83), were all independently and significantly associated with the presence of CCLO. Older child age and higher parent education remain in the model but were not significant at the P <.05 level. Ethnicity and income status were dropped for lack of additional significance from this model, which described 24% of the variance in CCLO. CONCLUSION: Although two-parent families and higher adult-to-child ratios in the home appear to be social capital variables with protective effects, low-income, single-parent, and minority or immigrant families are at significant risk for lacking both children's books and a CCLO. We suggest that CCLO may itself be another form of social capital reflecting parental goals and expectations for their children. We speculate that interventions which provide children's books and information about reading with children to impoverished families with young children may facilitate more parent-child book sharing. Pediatricians and other primary care providers serving underserved populations may have a unique opportunity to encourage activities focusing on young children and promoting literacy.

Survival impact of surgical cytoreduction in stage IV epithelial ovarian cancer.

OBJECTIVE: The aim of this study was to evaluate the influence of surgical cytoreduction on survival in patients with Stage IV epithelial ovarian cancer and to determine the survival impact of debulking extrahepatic disease in the subgroup of patients with liver metastasis. METHODS: Medical records were retrospectively reviewed for all women with International Federation of Gynecology and Obstetrics Stage IV ovarian cancer treated between 1/1/82 and 12/31/94. Clinical information abstracted included age at diagnosis, performance status, histologic subtype, tumor grade, Stage IV criteria, ascites volume, predominant peritoneal tumor pattern, surgical procedures performed, hepatic tumor residuum, extrahepatic tumor residuum, and postoperative complications. Optimal surgical status was defined as residual disease

Resection of a giant aggressive angiomyxoma in the Philippines.

INTRODUCTION: Medicine for Humanity is a multidisciplinary team of health care professionals, travelling to developing areas throughout the world on medical missions. The following is one of many technically challenging and unique cases presented for treatment. CASE: A 38-year-old woman gradually developed a giant mass arising from the right labium majus, extending into the retroperitoneum. Surgical resection was performed by abdominal and perineal teams. Intraoperative blood loss was approximately 10,000 ml, requiring 18 units of whole blood transfusion-including 6 units acutely donated by members of the surgical team. A "pack and go back" technique was used for hemostasis. The tumor weighed 19.8 kg. Final histology confirmed an aggressive angiomyxoma. CONCLUSION: This patient had the largest, histologically confirmed, aggressive angiomyxoma described to date. The surgical management of this case followed the principles in treating hemorrhagic shock, but required modifications based on availability of resources in Cebu City, Philippines.

Prenatal cocaine exposure and child development: what do we know and what do we do?

The literature remains unclear about the effects of prenatal cocaine exposure on child development. Meanwhile, the implications for public policy and treatment and for our scientific understanding of the toxicity of cocaine are substantial. In this article we describe; (1) our current understanding of the effects of prenatal cocaine use and child outcome, (2) the issues that need to be investigated, and (3) implications for treatment of cocaine exposed children. Findings from our database of the published literature shows that our knowledge is still limited, scattered, and compromised by methodological problems that mitigate any conclusions about whether or not or how prenatal cocaine exposure affects child outcome. The cocaine problem is more complicated than first envisioned--it is a multifactorial problem including the use of other drugs, parenting, and environmental lifestyle issues. However, we also show that, even though the effects may be more subtle than initially anticipated, prenatal cocaine exposure will substantially increase in the number of school age children who will need special education services. Clinicians working with these children and families need to be prepared to address psychosocial and environmental issues, as well as developmental performance, in order to optimize their assessment and intervention.

Evaluation of a clinic-based program to promote book sharing and bedtime routines among low-income urban families with young children.

OBJECTIVE: To evaluate a program of anticipatory guidance in which pediatric residents and nurse practitioners in a continuity practice gave parents books for their young children along with developmentally appropriate educational materials describing why and how to share the books and promoting reading as part of a bedtime routine. STUDY DESIGN: Comparison of 2 cross-sectional groups using consecutive, structured, face-to-face or telephone interviews of parents. One group was a historical control or a comparison group (group 1). The other was the intervention group (group 2), which included families who had received 2 books and educational materials for the children as part of the program to promote book sharing and bedtime routines. SUBJECTS: Before the institution of the program to promote book sharing and bedtime routines, the parents in 51 families with healthy children 12 to 38 months of age who regularly attended continuity clinics conducted by the house staff were interviewed; these families constituted group 1. Group 1 included a low-income population of Hispanic, African American, and non-Hispanic white families. Group 2 included 100 families with similar sociodemographic characteristics with healthy 12- to 38-month-old children who had received 2 books and educational materials at all 6- to 36-month well-child visits as part of the program. RESULTS: The intervention was found to be effective in promoting child-centered literacy activities. When asked openended questions, 4 (8%) of the parents in group 1 and 21 (21%) of the parents in group 2 said 1 of their child's 3 favorite activities included books (P=.04); 11 (22%) of the parents in group 1 and 42 (42%) of the parents in group 2 said 1 of their 3 favorite activities with their child was book sharing (P=.01); and 10 (20%) of the parents in group 1 and 35 (35%) of the parents in group 2 said that they share books 6 or 7 times a week at bedtime (P =.05). By mentioning 1 of these 3 important child-centered book-sharing activities, 17 (33%) of the parents in group 1 and 69 (69%) of the parents in group 2 (P <.001) demonstrated positive child-centered literacy orientation . A multiple logistic regression analysis controlling for parental education, ethnicity, and reading habits, as well as for the sex and age of the children, found child-centered literacy orientation more likely to be present in group 2 than in group 1 families, with an odds ratio (OR) of 4.7 (95% confidence interval [CI], 2.1-10.5; P<.001). Book sharing as part of a bedtime routine was more frequent in group 2 (mean+/-SD, 3.9+/-2.6 nights per week) than in group 1 (mean+/-SD, 2.5+/-2.7 nights per week; P=.002); however, no significant differences in prolonged bedtime struggles, parent-child co-sleeping, frequent night waking, or how children fell asleep were found between the groups. Instead, in multivariate analysis, bedtime struggles occurred more often with younger parents (P=.03) and fewer children at home (P=.02), while parent-child co-sleeping (P<.001) and frequent night waking (P=.04) were less likely to occur when children usually fell asleep alone in their own beds. CONCLUSIONS: This simple and inexpensive intervention by pediatric house staff, consisting of the provision of children's books and educational materials at well-child visits, resulted in increased enjoyment of and participation in child-centered book-related activities in low-income families. Primary care providers (ie, physicians and nurse practitioners) serving underserved pediatric populations may have a unique opportunity to promote child-centered literacy in at-risk groups.

The vulnerable preschool child: the impact of biomedical and social risks on neurodevelopmental function.

The scope of preschool children with biological risk and social disadvantage is large and includes over 1 million (28%) newborns per year. Currently in 1996, 7% of children are born with low birth weight, 1% are born with very low birth weight, 20% have alcohol exposure, and 10% have other drug exposure. Poverty is dynamic and impacts on 25% of children less than 6 years old with increased frequency in children who are minority, have mothers with less than a high school education, or are unmarried. There has been a markedly increased survival in very low birth weight and extremely low birth weight infants in the past 10 years. Outcomes of these neonatal populations reveals that parenchymal brain injury is the major predictor of cerebral palsy which occurs in 7% to 10% of very low birth weight survivors. However, poverty is the major predictor of low IQ. Fetal alcohol syndrome occurs in 1.9 per 1,000 births and is most often associated with mild mental retardation and educational underachievement. Studies investigating cocaine revealed that it is a multifactorial problem overlapping with polysubstance abuse and other risk factors for social disadvantage. The overwhelming number of children do not have cerebral palsy or severe mental retardation. The long-term impact is more subtle and needs more systematic analysis as well as critical evaluation of cognitive impairments and educational under-achievement. Hypoxic ischemic encephalopathy (HIE) cannot be determined by one biological measure. Though multiple disability occurs in 70% of children with Sarnat stage 3 HIE, 30% of survivors are not disabled. Children with mild to moderate HIE have long-term outcomes that are influenced by 9- to 12-month neurodevelopmental status and social disadvantage. By combining strategies to lessen biological risks and enhance developmentally appropriate environments, long-term outcomes of preschool children can be optimized.

Placenta previa percreta with bladder involvement: new considerations and review of the literature.

Placenta previa percreta is a life-threatening condition. Antenatal diagnosis is important to establish and to optimize a plan of management. When bladder invasion occurs, other potential complications can result, including massive hemorrhage and the development of disseminated intravascular coagulation. Numerous modalities have been used successfully to treat these patients, but hysterectomy at delivery is the treatment most commonly used. A case of placenta previa percreta with suspected bladder invasion was diagnosed in a 35-year-old woman by routine office ultrasound examination at 19 weeks 6 days' gestation. She was managed conservatively until 36 weeks 3 days' gestation, at which time she underwent a modified classical Cesarean section after amniocentesis to confirm fetal lung maturity. The placenta was left in situ immediately postpartum. The patient underwent a prophylactic embolization of her hypogastric arteries and received methotrexate chemotherapy. Eight weeks later, she developed a low-grade coagulopathy and underwent a total abdominal hysterectomy. Conservative management intrapartum is thought to be appropriate, to avoid the risk of severe hemorrhage at the time of delivery. However, elective hysterectomy ought to be considered earlier (2-4 weeks postpartum) than the time suggested in the literature, to avoid the development of further complications, including coagulopathy.

Cardiorespiratory reactivity during the Brazelton Scale in term and preterm infants.

Determined the relationship between behaviour measured with the Brazel zelton Scale and simultaneously recorded cardiorespiratory activity. The Brazelton Scale was administered and videotaped in a sample of 22 term and 22 preterm infants at term conceptional age. The videotapes were coded off line with a computer interface to time lock behavior and physiological activity for the duration of four alert, non-crying conditions. Term infants showed increases in heart rate and breathing rate when unswaddled and cuddled following cry and increases in respiratory sinus arrhythmia (RSA) during orientation and swaddling. Preterm infants showed the same general trend as term infants in heart rate and breathing rate. However, RSA decreased during orientation in preterm infants. On behavioral scores, preterm infants showed lower scores on self-regulation and a higher cost of attention. Correlations between behavior and physiological activity showed lower RSA associated with enhanced behavioral scores for the preterm infants. Results of this study are consistent with the hypothesis that attentional responsivity in the preterm infant may be at the expense of physiological stability.