Exploring the meaning of unresolved loss and trauma in more than 1,000 Adult Attachment Interviews

Unresolved states of mind regarding experiences of loss/abuse (U/d) are identified through lapses in the monitoring of reasoning, discourse, and behavior surrounding loss/abuse in response to the Adult Attachment Interview. Although the coding system for U/d has been widely used for decades, the individual indicators of unresolved loss/abuse have not been validated independently of the development sample. This study examined the psychometric validity of U/d, using individual participant data from 1,009 parent-child dyads across 13 studies. A latent class analysis showed that subsets of commonly occurring U/d indicators could differentiate interviewees with or without unresolved loss/abuse. Predictive models suggested a psychometric model of U/d consisting of a combination of these common indicators, with disbelief and psychologically confused statements regarding loss being especially important indicators of U/d. This model weakly predicted infant disorganized attachment. Multilevel regression analysis showed no significant association between ratings of unresolved other trauma and infant disorganized attachment, over and above ratings of unresolved loss/abuse. Altogether, these findings suggest that the coding system of U/d may have been overfitted to the initial development sample. Directions for further articulation and optimization of U/d are provided.

Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers

Disorganized/Disoriented (D) attachment has seen widespread interest from policy makers, practitioners, and clinicians in recent years. However, some of this interest seems to have been based on some false assumptions that (1) attachment measures can be used as definitive assessments of the individual in forensic/child protection settings and that disorganized attachment (2) reliably indicates child maltreatment, (3) is a strong predictor of pathology, and (4) represents a fixed or static "trait" of the child, impervious to development or help. This paper summarizes the evidence showing that these four assumptions are false and misleading. The paper reviews what is known about disorganized infant attachment and clarifies the implications of the classification for clinical and welfare practice with children. In particular, the difference between disorganized attachment and attachment disorder is examined, and a strong case is made for the value of attachment theory for supportive work with families and for the development and evaluation of evidence-based caregiving interventions.

Is the ideal mother a sensitive mother? Beliefs about early childhood parenting in mothers across the globe

In this article, we test the hypothesis that beliefs about the ideal mother are convergent across cultures and that these beliefs overlap considerably with attachment theory’s notion of the sensitive mother. In a sample including 26 cultural groups from 15 countries around the globe, 751 mothers sorted the Maternal Behavior Q-Set to reflect their ideas about the ideal mother. The results show strong convergence between maternal beliefs about the ideal mother and attachment theory’s description of the sensitive mother across groups. Cultural group membership significantly predicted variations in maternal sensitivity belief scores, but this effect was substantially accounted for by group variations in socio-demographic factors. Mothers living in rural versus urban areas, with a low family income, and with more children, were less likely to describe the ideal mother as highly sensitive. Cultural group membership did remain a significant predictor of variations in maternal sensitivity belief scores above and beyond socio-demographic predictors. The findings are discussed in terms of the universal and culture-specific aspects of the sensitivity construct.

[Individualization of exercise load control for inpatient cardiac rehabilitation. Development and evaluation of a HRV-based intervention program for patients with ischemic heart failure]

BACKGROUND

The effective use of rehabilitation programs is of primary importance in order to improve the physical performance of cardiac disease patients. A modular program has been developed which is intended to structure and individualize conventional, exercise-based rehabilitation programs according to the individual needs and physical condition of each patient. The individualization of the program is based on detailed diagnostics before patients enter the program and daily measurements of heart rate variability (HRV) during cardiac rehabilitation.

METHODS

A total of 30 patients with ischemic heart disease were randomly assigned either to the intervention group (IG), completing the modular individualized rehabilitation program [n=15, mean age 54.4±4.2 years and mean left ventricular ejection fraction (LVEF) 28.53±6.25%) or to the control group (CG) taking part in the conventional rehabilitation program (n=15, mean age 56.4±4.4 years and mean LVEF 27.63±5.62). Before and after the intervention, cardiorespiratory fitness was assessed by measurement of maximal oxygen consumption (relative VO2max) during bicycle ergometry and the 6-minute walk test (6-MWT). Pre-post comparisons of cardiorespiratory fitness indicators were used to evaluate the effectiveness of the rehabilitation program. In addition to the results of the basic clinical investigations and the cardiorespiratory testing, results of standardized HRV measurements of 10 min at morning rest served as criteria for program individualization.

RESULTS

The relative VO2max increased significantly (p<0.05) in the IG whereas no change was found in the CG. Similar results were found for maximum power output during bicycle ergometry (p<0.01) and for 6-MWT distance (p<0.001). Although patients in the IG completed less aerobic exercise sessions than those in the CG (p<0.001) the physical performance of the IG improved significantly.

DISCUSSION

The results prove the effectiveness and efficacy of the modular individualized rehabilitation program. They further suggest the need for an individual program matrix instead of a maximum performance matrix in cardiac rehabilitation. Individualization should be based on clinical and performance diagnostics before and accompanying assessments of training condition, e.g. by HRV measurements, during rehabilitation programs. Each patient should only perform those intervention programs which match the results of the basic clinical investigation and additional analyses during rehabilitation.

Quality assessment of heterogeneous surface radiation network data

Abstract. The DWD national radiation measurement network comprises 82 automatic sites, 29 manned sites with shaded and unshaded pyranometer and the BSRN station at Lindenberg. The quality assessment routinely applied takes into account the basic astronomical and empirical considerations as well as some interdependencies like total to diffuse flux relation and cross checking with sunshine duration. A more advanced quality assessment approach attempts to routinely utilise timeseries of clear sky radiative transfer simulations for every site. For that purpose a link to cloud coverage obtained from Meteosat second generation geostationary satellite data, highly resolved in time and space, was established. There is a predefined calibration cycle of 30 month for automatic stations. Data analysis on this timescale allows for the detection of sensor degradation, wrong calibration or configuration and other possible local disturbances. Furthermore using satellite cloud mask enables the identification of larger clear sky regions characterized by similar atmospheric conditions. Thus, in a regionalization step correction or recalibration of moderate quality data to a higher level can be considered. The paper provides an overview of DWD surface radiation network and the current activities to improve automatic quality assessment using remotely sensed data and clear sky modeling for the upgrading of radiation data.

Putative cryptoendolithic life in Devonian pillow basalt, Rheinisches Schiefergebirge, Germany

Middle Devonian (Givetian) pillow basalt and inter-pillow breccia from the Rheinisches Schiefergebirge in Germany were found to contain putative biogenic filaments that indicate that life once proliferated within these volcanic rocks. Mineralized filaments are found in carbonate amygdules (vesicles filled by carbonate cement) in the volcanic rock, where they started to form on the internal surface of the once water-filled vesicles. Biogenicity of the filaments is indicated by (1) their size and shape resembling modern microorganisms including a constant diameter along the length of curved filaments, (2) their independence of crystal faces or cleavage planes, (3) branching patterns reminiscent of modern microorganisms, and (4) their spatial clustering and preferential occurrence close to the margin of pillows and in the inter-pillow breccias. A time lag between the deposition of pillow basalt and the activity of endoliths is revealed by the sequence of carbonate cements filling the amygdules. The putative filamentous microorganisms thrived after the formation of early fibrous rim cement, but before later equant calcite spar filled most of the remaining porosity. Microbial clay authigenesis analogous to the encrustation of prokaryotes in modern iron-rich environments led to the preservation of filaments. The filaments predominantly consist of the clay minerals chamosite and illite. Having dwelled in water-filled vesicles, the Devonian basalt-hosted filaments apparently represent cryptoendoliths. This finding suggests that a previously unrecognized niche for life exists within volcanic rock.

Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

BACKGROUND

Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.

METHODS

Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.

RESULTS

All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).

CONCLUSIONS

When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

FeMo cofactor biosynthesis in a nifE- mutant of Rhodobacter capsulatus

In all diazotrophic micro-organisms investigated so far, mutations in nifE, one of the genes involved in the biosynthesis of the FeMo cofactor (FeMoco), resulted in the accumulation of cofactorless inactive dinitrogenase. In this study, we have found that strains of the phototrophic non-sulfur purple bacterium Rhodobacter capsulatus with mutations in nifE, as well as in the operon harbouring the nifE gene, were capable of reducing acetylene and growing diazotrophically, although at distinctly lower rates than the wild-type strain. The diminished rates of substrate reduction were found to correlate with the decreased amounts of the dinitrogenase component (MoFe protein) expressed in R. capsulatus. The in vivo activity, as measured by the routine acetylene-reduction assay, was strictly Mo-dependent. Maximal activity was achieved under diazotrophic growth conditions and by supplementing the growth medium with molybdate (final concentration 20-50 microM). Moreover, in these strains a high proportion of ethane was produced from acetylene ( approximately 10% of ethylene) in vivo. However, in in vitro measurements with cell-free extracts as well as purified dinitrogenase, ethane production was always found to be less than 1%. The isolation and partial purification of the MoFe protein from the nifE mutant strain by Q-Sepharose chromatography and subsequent analysis by EPR spectroscopy and inductively coupled plasma MS revealed that FeMoco is actually incorporated into the protein (1.7 molecules of FeMoco per tetramer). On the basis of the results presented here, the role of NifNE in the biosynthetic pathway of the FeMoco demands reconsideration. It is shown for the first time that NifNE is not essential for biosynthesis of the cofactor, although its presence guarantees formation of a higher content of intact FeMoco-containing MoFe protein molecules. The implications of our findings for the biosynthesis of the FeMoco will be discussed.

[Laparoscopic palliative gastrointestinal operation in inoperable upper abdominal tumors with gastric outlet obstruction]

In the period from June 1994 to February 1997, a laparoscopic gastroenterostomy was carried out without intraoperative complications or mortality. In 12 out of 13 patients with gastric outlet obstruction due to inoperable tumor of the upper GI tract (gastric, gallbladder or pancreas carcinoma). From the above, a total of 4 patients had postoperative complications (30.7%), three of which could be treated without further operation. The average duration of the operation was 130 min (range 70-285 mins) followed by an approximal postoperative hospital stay of 17 days (8-41 days).

Geometric mismatch of the Gamma nail to the Chinese femur

The geometric mismatch of the femoral component of the Gamma nail to the Chinese femora resulted in intraoperative complications. To provide scientific data for modification of the implant, 28 pairs of normal Chinese femora were studied with the 3-dimensional reconstruction from the computed tomography scan data. Measurements were taken from the reconstituted drawings, and the anthropometric data were applied in the modification of the implant. This study is the first report on the application of Chinese anthropometric data on the design of a trauma implant. It is hoped that a larger scale of the study will provide a more comprehensive data base for wider application to orthopaedic implant design in the future.

Effect of allergen provocation on inflammatory cell profile and endothelin-like immunoreactivity in guinea-pig airways

The effect of allergen challenge on the number of leucocytes and the concentration of endothelin 1-like immunoreactivity (ET-LI) in bronchoalveolar lavage fluid (BALF) was investigated in guinea-pigs sensitized to Ascaris suum. The animals were twice exposed to allergen aerosol. All animals responded to the second challenge with bronchoconstriction. Twelve hours later, a significant increase in the number of eosinophilic granulocytes in BALF, compared to unsensitized and unprovoked control animals, was noted. Twenty-four hours after provocation, there was also an elevation of ET-LI concentration and content of neutrophils. During the first day post-challenge, the ET-LI values were moderately correlated to the eosinophil levels. One week after challenge, the ET-LI level and the neutrophil count did not differ from corresponding values in control animals whereas the number of eosinophils remained elevated. Pretreatment with dexamethasone before the second allergen challenge did not consistently affect the parameters studied during the first 24 h. Bronchoconstriction induced by carbachol aerosol affected significantly neither the ET-LI concentration nor the number of inflammatory cells in BALF. It is concluded that the allergen-induced inflammation in the guinea-pig airways causes an elevation in the ET-LI concentration in BALF and that this is moderately correlated to the influx of eosinophils during the first 24 h.

Evolution of the retrotransposons TRS/ingi and of the tubulin genes in trypanosomes

The African trypanosomes have genomes of high plasticity, as demonstrated for instance by their ability to shuffle their genes around, coding for variant-specific surface glycoproteins (VSGs). Another indication of their genome plasticity is the presence of multiple retro-elements. The retrotransposon-like element TRS/ingi is present in many copies in the genome of trypanosomes. One particular derivative of TRS/ingi, called TUBIS, had previously been found to interrupt a tubulin gene in a particular strain of T. brucei. Here both TRS/ingi and TUBIS were studied by hybridizing genomic DNA of various strains and species of trypanosomes with suitable probes in order to elucidate the evolution of this family of retro-elements. The TSR/ingi elements are highly repeated and have very long open reading frames, while TUBIS clearly is a truncated, inactivated form of this element, found in only one particular chromosomal location. Both elements were shown to be present in several strains and species of the subgenus Trypanozoon, in particular in T. brucei brucei, T. gambiense, T. rhodesiense, T. equiperdum and T. evansi. They could not be detected in species of other subgenera, in particular in T. congolense and T. cruzi. These findings suggest that the retrotransposon TRS/ingi was acquired by trypanosomes only after divergence of present day subgenera. The TUBIS element was found in exactly the same chromosomal location (at the 3' end of the tubulin gene cluster) in many different strains and species of the subgenus Trypanozoon. This shows that the element was transposed to this location before speciation of the subgenus. Although, TRS/ingi is unlikely to be involved directly in VSG switching, it may have contributed to the genome plasticity of trypanosomes.

[Postpartum thyroid gland dysfunction--a prospective study]

In a prospective study the postpartum thyroid function was investigated in 120 healthy women in the department of obstetrics and gynecology of the Medical School Hannover. A physical examination was performed in the first week after delivery and two to five and five to eleven months later. Additionally blood was drawn for the determination of thyroid hormones, thyroid autoantibodies and thyroid-stimulating hormone. In 10% of the patients pathological titers for thyroid microsomal autoantibodies and thyroglobulin autoantibodies were found, in 2.5% pathological concentrations of thyroid hormones. In none of these patients clinical symptoms of thyroid dysfunction could be found. After delivery a immunologically mediated thyroid disease should be considered in patients with clinical symptoms. Then the thyroid function needs to be investigated.

[Puerperal thyroid gland dysfunction in healthy patients]

Elevated thyroid antibodies (AB) have been described in clinically healthy women indicating a postpartum thyroid dysfunction. We evaluated the incidence of the postpartum thyroid dysfunction in Hannover, FRG. 121 women were examined 1-5 days pp and 2-4 months later; 76 were restudied 5-7 months pp. Every time T3, T4, TSH, TBG, microsomal AB and thyroglobulin AB were determined. Six patients showed increased TAB and 10 increased MAB titers. Severe clinical symptoms were not complained. In some patients these elevated titers turned to normal subsequently. Further studies must evaluate the prognosis of this disease.

Leydig cell mitoses in human testes bearing early germ cell tumors

Numerous mitoses were noted in testicular tissue from adult men with early germ cell tumors. More than 15 Leydig cells undergoing mitosis were found in the interstitial compartment. The presence of specific crystalline intracytoplasmatic inclusions demonstrated for the first time that differentiated Leydig cells are capable of proliferation. Occasionally cells are difficult to discriminate during mitosis. To establish reference criteria, the light- and electron-microscopic features of the following mitotic cells were examined: Leydig cells, fibroblasts, perivascular cells, peritubular cells, and lymphocytes. Supplementary mitoses in germ cell tumors and in a case of Leydig cell tumor were investigated. In the literature, only single reports of mitoses in Leydig cells are available. The frequent incidence of Leydig cell mitosis in early germ cell tumors may be due to the presence of growth-promoting factors in the testicular tissue.

[Comparison of Blount's sling and Kirschner wire fixation in the treatment of a dislocated supracondylar humeral fracture in childhood]

From 1979 to 1982 we were treating 63 cases of displaced supracondylar fractures of the humerus. Patients underwent either closed reduction and fixation by collar and cuff immobilization (32 cases), or fixation by means of Kirschner wires following closed or (more often) open reduction (31 cases). Follow-up controls after an average time of three years clearly showed the more favourable results of the conservative method.

[Clinical and histopathologic studies of primary glandular cancer of the uterine cervix. An analysis of 78 cases from 1972 to 1984]

In the period between 1972 and 1984 716 cervical carcinomas, of which 78 were glandular cancers, were diagnosed at the University Hospital in Hamburg-Eppendorf. The incidence of invasive adenocarcinomas of the cervix is 10.9%. When compared with a study published in 1949 (19) the incidence of adenocarcinoma has risen from 3% to 10.9%. In the period of observation, i.e., from 1972 to 1984, no trend to an increase in incidence was observed. The average age of the patients, 62.6 years, is relatively high in comparison with other studies. An earlier onset of disease has not been observed. The available data do not provide any evidence of connection between the use of oral contraceptives and later development of an adenocarcinoma. The five-year survival rate for all stages taken together was 40.4%. The five-year survival rate, and thus the prognosis for glandular carcinomas of the cervical glands, depends primarily on the clinical stage of the disease, though also on the histological type and the degree of differentiation of the tumor.

[Diagnosis and therapy of syphilitic changes of the skin and mucous membrane in the head and neck]

Since the mid seventies the German Federal Board of Statistics has recorded a decrease in the incidence of the classical venereal diseases gonorrhoea and syphilis. This decrease is based only on a decline in the morbidity of gonorrhoea. Statistics on syphilis show an increase, from about 6000 to 8900 new cases each year, that is an increase of 48% between 1974 and 1978. Some cities such as Cologne, with a total of 401 new cases each year, show an increase, while numbers in rural regions remain unchanged or show a slight decline. Between 1978 and 1980 at the ENT and Dermatologic OPC of Cologne University many ulcers of uncertain aetiology in the head and neck region have been diagnosed as primary or secondary syphilis or as unusual presentations of this disease. In our Department a primary lesion of the head and neck was the presenting symptom in about 6% of all newly diagnosed cases. The differential diagnosis of early syphilitis lesions in the head and neck, the present position of serological diagnosis, and the current treatment of syphilis are illustrated by selected typical lesions.

[The management of congenital hip luxation with arthrographic control, an individual risk-reducing and time-saving method. I. Choice of method and risk assessment based on arthrographic findings]

In 388 congenital hip dislocations arthrography was used to indicate the safest form of treatment. Immediate reduction in the squatting (human) position of plaster cast (Fettweis, Salter) was followed by 3.4% of avascular necrosis of the femoral head, while plaster casts after preliminary traction showed 14.8% necrosis and unsuccessful closed reductions preceeding open reductions 11.8%. Further investigations demonstrated the influence of mechanical factors. A higher percentage of avascular necrosis was found in a narrow capsular entrance between a deformed upper limbus (or acetabular bulge) and a protruding transverse ligament with insufficient reduction (lateral displacement greater than 5 mm) and abduction of more than 45 degrees. The percentage of avascular necrosis was also depending on the development of the epiphyseal nucleus, it was 0.9% in normal forms of nuclei, 4.5% when the nucleus had not appeared at the beginning of treatment, 4.7% in small and 12.5% in retarded nuclei. The rate of necrosis was increasing with age and the degree of dislocation. Critical arthrographic findings have been described. In sufficiently open joints and full reductions Pavliks harness or hip spicas in squatting (human) position are applied immediately. With moderate narrowing of the acetabular entrance and lateral displacement traction is used for 3-4 weeks with repeated arthrography. In severe soft tissue changes of the acetabulum and lateral displacement (greater than 5-7 mm) open reduction is safer than a forced closed reduction.

[Peripheral T-lymphocytes and delayed hypersensitivity in surgically and radiologically treated patients with early stages of larynx-carcinoma]

122 patients with squamous-cell-carcinoma of the larynx (T1-stage) were examined after surgical or radiological treatment. None of these patients showed evidence of tumor recurrence. Peripheral T-lymphocytes and delayed hypersensitivity were studied in all these patients. According to their treatment, the patients were allotted into three groups and compared with a control group, consisting of 20 patients with nonneoplastic head- and neck-disease. The main finding was a significant decrease in the peripheral T-lymphocytes in surgically- or radiologically-treated patients with a squamous-cell-carcinoma of the larynx (T1-stage). This reduction of T-cells must be interpreted as a congenital or acquired defect of the immunocompetent system. In about half of the control cases the DNCB-tests showed no evidence of delayed hypersensitivity. In view of these results and those reported in the literature, the test should be used critically. In contrast to our earlier findings, where patients received radiotherapy over large areas including big vessels, radiation over a smaller, localised area does not lead to a significant depression of peripheral T-lymphocytes.

[A new technique of triple osteotomy for turning dysplastic acetabula in adolescents and adults (author's transl)]

A new form of triple-osteotomy of the pelvis is described. The ischium is osteotomized from a dorsal approach, immediately behind the hip joint. The ischium is left in place, the ligaments giving stability to the sacrum remain in tension. After turning the patient a small medial incision is done for the osteotomy of the pubis. The The ilium is cut through with a Gigli saw from a small incision laterally. It should descend medially in a distance of 2-2,5 cm apart from the joint. The possibilities to turn the acetabulum are very good and correspond to the amount of abduction before operation. Injuries to the sciatic nerve are avoided by the dorsal approach. The evaluations of 32 patients with different degrees of dislocations are reported. The osteotomy may be done even in flat-shaped femoral heads, where the acetabulum is still congruent as long as it is possible to abduct the leg and turn the femoral head into the acetabulum. It has been done in high dislocations with secondary acetabulae as well. The operation may be used in children above 8 years, where the osteotomy of Salter and acetabuloplasties are not efficient any more. In contrary to Chiari's osteotomy the acetabulum is covered by cartilage and the angle of inclination usually normal. It can be used in adults and beginning arthrosis as long as the abduction is not limited.

A modified technique of the triple pelvic osteotomy: early results

A modification of the triple pelvic osteotomy for children over 8 years and the young adult is described. The results of the first 32 cases are reviewed. These show that the indications for the operation can be widened so that not only primary dysplasias but also subluxated or dislocated hips with secondary dysplasia can be operated on successfully. The operation is done in two stages. At first the patient is lying prone. The osteotomy of the ischial ramus is done dorsally by cutting the connection between the sciatic notch and obturator foramen immediately behind and below the acetabulum. In the second stage, with the patient lying supine, the pubic and the iliac osteotomy are performed rather circular and parallel to the hip joint. These modifications have several advantages: (a) the operator has a direct field of view at all times; (b) the osteotomy is performed close to the acetabulum, thus allowing a great amount of lateral rotation and medial displacement of the acetabulum, thereby providing good coverage of the femoral head by hyaline cartilage; and (c) the ischial ramus and its ligaments to the sacrum are left intact, leading to greater stability of the pelvis and spine.