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with therapy Immunosuppressive prednisone or azathioprine should not be reduced or discontinued merely because of the pregnancy; this may make the lupus very much worse. Although immunosuppressive drugs might harm the fetus many researchers feel that the baby would be at greater danger from uncontrolled maternal disease.’The view that pregnancy per se carries an increased risk of exacerbation has not been supported by comparative studies of non-pregnant control patients. Exacerbations that do occur in pregnancy are often characterised by skin and joint manifestations, which may be controlled with additional prednisone. Termination of pregnancy is not effective in bringing about remission of disease.’ Before the introduction of effective drug therapy maternal deaths were not uncommon, especially after delivery. More recently recognition of milder forms of the disease and improvements in medical management have resulted in low rates of associated maternal mortality. Nevertheless, anxiety about lifethreatening postpartum exacerbation remains and prophylactic steroid cover during the puerperium is often recommended. Wong and colleagues8 arbitrarily augmented the pre-existing dose of prednisone from the thirtieth week of gestation until 4 weeks after delivery and there were no postpartum exacerbations. A randomised trial will be required to establish the value of this approach. Fetal outcome is undoubtedly less favourable in SLE patients than in healthy women. Although there is no evidence of an increase in congenital anomalies, increased frequencies of miscarriage, stillbirth,

growth retardation, and preterm delivery are recognised. There are probably several underlying mechanisms. For example, renal disease and hypertension from any cause may compromise the uteroplacental circulation and SLE is no exception. Hayslett1 noted that the fetal survival rate was 88% in patients with quiescent lupus nephritis but only 64% in those with active disease. Antiphospholipid antibodies were originally detected in patients with SLE. Their presence (especially in high titre) undoubtedly carries an increased risk of pregnancy failure although their exact mechanism of action is uncertain. Suppression of these antibodies with high doses of prednisone improved the fetal outcome in women with a history of recurrent pregnancy loss.9 Enthusiasm for this approach has been tempered by the realisation that not all women with antibodies will lose the fetus, that suppression of antibodies does not always improve fetal outcome, and that there are substantial risks of iatrogenic disease.10 In women without a bad obstetric history, attempts to suppress antiphospholipid antibodies are probably not justified. The reported frequency of fetal loss in SLE pregnancies is highly variable and may depend upon the precise distribution of risk factors (active disease, renal impairment, antiphospholipid antibodies)

within each study population. Overall, about 70-80 % of these pregnancies will result in a livebirth. In view of the potential for obstetric complications these women should be monitored intensively for signs of fetal compromise. Maternal low-dose aspirin therapy in these high-risk cases has yet to be fully evaluated. A small proportion of the newborn infants get a neonatal lupus syndrome," the most serious component being congenital heart block. This complication occurs almost exclusively in the offspring of women with anti-Ro antibodies. The reported incidence of such heart block is 1 in 60 for all SLE pregnancies and 1 in 20 if the mother has the antibody.12 Some of these children will require a permanent pacemaker. Both recurrent pregnancy failure and the delivery of a baby with congenital heart block may predate the diagnosis of connective tissue disease in the mother by several years. After delivery, breastfeeding is generally thought to be safe if the mother is receiving only aspirin or low-dose steroids but is best avoided if other immunosuppressive agents are being taken. There is no evidence that pregnancy alters the long-term survival prospects of a woman with SLE. 1.

Hayslett JP. Effect of pregnancy in patients with SLE. Am J Kidney Dis 1982; 2: 223-28. MW, Meehan RT, Syrop CH, Strottman MP, Goplerud CP.

2. Varner

Pregnancy in patients with systemic lupus erythematosus. Am J Obstet Gynecol 1983; 145: 1025-40. 3. Fine LG, Barnett EV, Danovitch GM, et al. Systemic lupus erythematosus in pregnancy. Ann Intern Med 1981; 94: 667-77. 4. Mintz G, Niz J, Gutierrez G, Garcia-Alonso A, Karchmer S. Prospective study of pregnancy in systemic lupus erythematosus: results of a multidisciplinary approach. J Rheumatol 1986; 13: 732-39. 5. Lockshin MD, Reinitz E, Druzin ML, Murrman M, Estes D. Lupus pregnancy case-control prospective study demonstrating absence of lupus exacerbation during or after pregnancy. Am J Med 1984; 77: 893-98. 6. Meehan RT, Dorsey JK. Pregnancy among patients with systemic lupus

erythematosus receiving immunosuppressive therapy. J Rheumatol 1987; 14: 252-58. 7. Donaldson LB, De Alvarez RR. Further observations on lupus erythematosus associated with pregnancy. Am J Obstet Gynecol 1962; 83: 1461-73.

8.

Wong KL, Chan FY, Lee CP. Outcome of pregnancy in patients with systemic lupus erythematosus: a prospective study. Arch Intern Med

1991; 151: 269-73. 9. Lubbe WF, Butler WS, Palmer SJ, Liggins GC. Fetal survival after prednisone suppression of maternal lupus-anticoagulant. Lancet 1983; i: 1361-63. 10. Lockshin MD, Druzin ML, Qamar T. Prednisone does not prevent recurrent fetal death in women with antiphospholipid antibody. Am J Obstet Gynecol 1989; 160: 439-43. 11. Editorial. Neonatal lupus syndrome. Lancet 1987; ii: 489-90. 12. Ramsey-Goldman R, Hom D, Deng J, et al. Anti-SS-A antibodies and fetal outcome in maternal systemic lupus erythematosus. Arthritis Rheum 1986; 29: 1269-73.

in child abuse

Cycles of violence

physical

Although physical punishment is often used by parents to enforce compliance in young children,1,2 abuse of children by adults or the infliction of physical injury on a child more severe than that which is culturally acceptable is uncommon. In the USA,

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harsh punishments, in which the child will be hit with an object by parents, have been documented for 1 in 10 children in the general population,-* and severe physical abuse leading to fractures or serious bruising occurs in about 1 in 1000 children in the UK, with a death rate of 10%. The observations that (a) abusing parents report having been the subject of severe punishments in their own childhood; (b) abused children show high levels

(c) in some families abuse spans several generations, beg the question of to what extent the experience of being abused leads someone to become an abusing parent, thus perpetuating a cycle of aggression; and

of intrafamilial violence. Between two-thirds and three-quarters of abusing parents report punitive upbringing-a rate well in excess of that of their spouses or partners.3,5,6However, not all parents who abuse children recall being the subject of parental violence themselves, and rejection and lack of affection in childhood as well as personal and social disadvantage (eg, illegitimacy, abandonment, low socioeconomic status, large discordant families, low intelligence, personality disorder, and criminal records) are probably as relevant in the genesis of child abuse.7,gFollow-up studies of children who have been the subject of abuse have described increased levels of aggressive behaviour in these children when compared with controls,9-12 but most previously abused children appear to be neither disturbed nor aggressive. Moreover, although aggressive children show a clear tendency to persist with aggressive considerable into behaviours adulthood, discontinuities in this pattern have also been

16,17 Anomalies in attachment predict later parents. difficulties in interpersonal relationships. Such anomalies may well underlie the difficulties reported with abusing parents’ ability to develop trusting, warm relationships with others and also interfere with development of a personal sense of emotional security and self-worth. Abusing parents report an excess of self-criticism, hostility, and guilty feelings, as well as paranoid feelings and criticism of others.Cognitive anomalies are other probable contributors. A tendency to attribute hostile intent to others and to lack competent behavioural strategies to solve interpersonal problems have been described in abused children who themselves show high levels of aggressive behaviour. However, it is not known whether these anomalies continue into adulthood, nor whether, as with the emotional disturbances, they are both necessary and sufficient for maltreatment to

occur.

It is difficult to predict from the presence of social and emotional risk factors at the time of childbirth whether parents will go on to abuse a child ;18 fewer than 1 in 10 parents identified as at high risk have been found to abuse their children in prospective studies. Moreover, a considerable percentage of mothers who report abuse in their own childhood are able to provide good parenting for their children.19 In these mothers, factors that help to break the cycle of abuse and poor parenting include emotional support from a non-abusive adult during childhood, therapy during any period of their lives, and non-abusive, stable emotionally supportive and satisfying relationships with their partners.

reported. 13 There are distinct intergenerational continuities in child maltreatment in 10% of families in which abuse has been severe enough to lead to outside intervention. These families show especially high levels of disturbance in social and psychological functioning, including mental and personality disorders, criminality (mainly involving offences with personal violence), epilepsy, educational problems, mental backwardness, and experiences of care.14,15 The severity of the associated personal, family, and social breakdown is likely to be a crucial factor in the transgenerational persistence of abuse. Personality disorders are reported for over twothirds of abusing parents-a much increased rate over that of controls-and personality dysfunction, in itself a possible result of a punitive, loveless, or abusing upbringing, is regarded as an explanation for at least some intergenerational continuities.7,g Emotional and cognitive factors are likely to mediate the development of personality disorders and in some cases the continuities in neglectful and abusive parenting. Disturbances in the emotional attachment between mother and child have been documented for a high proportion of young pre-school children who have been the subject of either maltreatment, neglect, or "emotional unavailability" on the part of their

J, Newson E. Patterns of infant care in an urban community. Harmondsworth: Penguin, 1965. 2. Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors. London: 1. Newson

Sage,

1980.

JA, Oliver JE. Epidemiology and family characteristics of severely-abused children. Br J Prev Soc Med 1975; 29: 205-21. 4. Scott PD. Non-accidental injury in children. Memorandum of evidence to the Parliamentary Select Committee on Violence in the Family. Br J Psychiatry 1977; 131: 366-80. 5. Scott PD. Parents who kill their children. Med Sci Law 1973; 13: 120-26. 6. Scott PD. Fatal battered baby cases. Med Sci Law 1973; 13; 197-206. 7. Smith SM. The battered child syndrome. London: Butterworth, 1975. 8. Rutter M, Madge N. Parenting behaviour. In: Cycles of disadvantage. London: Heinemann, 1976: 224-45. 9. Kinnaird EM. Experiencing child abuse: effects on emotional adjustment. Am J Orthopsychiatry 1982; 52: 82-91. 10. George C, Main M. Social interactions of young abused children: approach, avoidance and aggression. Child Dev 1979; 50: 306-18. 11. Lynch MA, Roberts J. Consequences of child abuse. London: Academic Press, 1982. 12. Dodge KA, Bates JE, Pettit GS. Mechanisms in the cycle of violence. 3. Baldwin

Science 1990; 250: 1678-83.

Farrington DP. The family backgrounds of aggresive youths. In: Hersov L, Shaffer D, eds. Aggression and antisocial behaviour in childhood and adolescence. Oxford: Pergamon, 1978: 73-79. 14. Oliver JE. Successive generations of child maltreatment: social and medical disorders in the parents. Br J Psychiatry 1985; 147: 484-90. 15. Oliver JE. Successive generations of child maltreatment: the children. Br J Psychiatry 1988; 153: 543-53. 16. Egeland B, Sroufe LA. Attachment and early maltreatment. Child Dev 13.

1981; 52: 44-52. 17. Sroufe LA. Attachment classification from the perspective of infantcaregiver relationship and infant temperament. Child Dev 1985; 56: 1-14.

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18. Altemeir WA, O’Connor S, Vietze P, Sandler HL, Sherrod K. Prediction of child abuse: a prospective study of feasibility. Child Abuse Neglect 1984; 8: 393-400. 19. Egeland B, Jacobvitz B, Sroufe LA. Breaking the cycle of abuse. Child Dev 1988; 59: 1080-88.

IPPNW—resting on its Nobel laurels? When The Lancet publicises the work of International Physicians for the Prevention of Nuclear War (IPPNW) it can be sure of receiving hostile correspondence. IPPNW, this year celebrating its 10th anniversary, is seen by some as a talking shop for opinionated doctors, or an irrelevant attempt to impose the medical model on "politics". What claims does it have to be a force for change? At the time of its formation, the world was very much closer to nuclear war than it is now. Detente was at a low; nuclear weapons were spawning; illiberal governments were in power in the USSR, the USA, and the UK. The doctors who started IPPNW wanted to spread a different message-that humanitarian concern and the need to preserve human life should take precedence over the use of force (particularly nuclear weapons) to solve conflicts. They pointed to the long history of doctors speaking out on public health issues. IPPNW has held that the prevention of nuclear war is an issue of global public health, as great in importance as malnutrition, malaria, or diarrhoeal disease (which also have social and political causes). In the altered world of the 1990s, does IPPNW still have a role-should it continue to practise politics without a constituency to represent, or a forum to give effect to its resolutions? These questions are best answered by examining tasks that were set for the next decade at the world congress in Stockholm last month. Recurring themes were advocacy, tension reduction, and specific medical projects. IPPNW is an advocate on new issues as well as on the old one-the danger of nuclear war. Three topics were to the fore in Stockholm. First, are nuclear weapons really being destroyed? The congress heard from Prof Joseph Rotblat that no warheads have yet been dismantled, even if some delivery systems have gone to the breakers; in an era of defence secrecy, it is right to spread this information widely. Second, IPPNW has begun to speak out against all weapons of mass destruction, and to work for the prevention of war in general. This broadening of aims has come about as a result of an IPPNW team’s visit to Iraq in recent months. In Bernard Lown’s words: "In a technologic age when all wars will increasingly resort to high intensity, abysmally destructive weapons, war can never be just". Dreadful images were presented of the suffering being wreaked on the Iraqi population as a direct result of the war. 500 children are dying daily from malnutrition, diarrhoeal disease, and typhoid, owing to the destruction of power stations and health care facilities.1 The enormous cost of the military machine even in peacetime was also described: the US

army’s peacetime energy use over a year would run the American mass-transit system for 40 years. There are also moves for IPPNW to extend its advocacy function to the environment in general.2 Some say this is going too far, however broad the definition of public health. The third area in which IPPNW has apparently been effective in advocacy is in defence of its members’ human rights. Turkish doctors have been active in protests against the Gulf war,and some members of a Turkish IPPNW affiliate found themselves in prison. The intercession of a UK-led delegation resulted in their release shortly before the

Stockholm meeting. As to tension reduction, IPPNW has provided an excellent forum for discussion of regional conflicts, exemplified in Stockholm by a debate that included doctors from Iraq, Turkey, Palestine, Jordan, Israel, and Egypt-all influential figures in their own countries. Although not in agreement on every issue, the group jointly proclaimed their support for a nuclear, chemical, and biological weapons free zone in the Middle East. Empty words? But political empires are built on words, and there are few enough examples of cooperation in this region. James Grant, Director of UNICEF, said at the congress "I want to congratulate you on behalf of UNICEF for making the world a significantly safer place for children". Finally, medical projects. The most imaginative of these, conceived in 1985 as a counterbalance to ’Star Wars’, is Satel Life. A small satellite, to be launched this month, will allow health information to be beamed to isolated hospitals in poor countries. Those using this technology will require a personal computer and a ham radio-plus an electricity supply. Though there are hard questions to be answered about access to and use of the system, it is a bold concept and deserves support. Another project just come to fruition is the IPPNW Global Commission on the health and environmental effects of nuclear weapons testing.4 Since 1945, the total bomb yield of tested nuclear weapons is 40 000 times bigger than Hiroshima. In 1990, there were 19 tests: 8 by the USA, 6 by France,1 by the USSR, and 1 by the UK: the justification for this hazardous activity continues be

questioned. So, is IPPNW resting on its Nobel laurels? Since 1985, when the organisation won the Nobel Peace Prize, IPPNW’s affiliates have doubled and regional congresses have been held in the Americas, Africa, and Asia: it has become a truly global body. For those doctors worldwide who see war, and preparation for war, as a menace to the public health, IPPNW is evolving satisfactorily. to

1. Medical Educational Trust. Counting the human cost of the Gulf War. London: Medical Educational Trust (601 Holloway Road, London 2.

N19 4DJ), 1991. McCally M, Cassel C. Medical responsibility and global environmental

change. Ann Intern Med 1990; 113: 467-73. 3. Anon. Doctors confront the government. Lancet 1991; 337: 226-27. 4. IPPNW. Radioactive heaven and earth. London: Zed Press, 1991.

Cycles of violence in child physical abuse.

88 course.1 with therapy Immunosuppressive prednisone or azathioprine should not be reduced or discontinued merely because of the pregnancy; this ma...
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