Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up

Preeclampsia is a multisystemic disorder of pregnancy that affects 250,000 pregnant individuals in the United States and approximately 10 million worldwide per annum. Preeclampsia is associated with substantial immediate morbidity and mortality but also long-term morbidity for both mother and offspring. It is now clearly established that a low dose of aspirin given daily, beginning early in pregnancy modestly reduces the occurrence of preeclampsia. Low-dose aspirin seems safe, but because there is a paucity of information about long-term effects on the infant, it is not recommended for all pregnant individuals. Thus, several expert groups have identified clinical factors that indicate sufficient risk to recommend low-dose aspirin preventive therapy. These risk factors may be complemented by biochemical and/or biophysical tests that either indicate increased probability of preeclampsia in individuals with clinical risk factors, or more importantly, identify increased likelihood in those without other evident risk. In addition, the opportunity exists to provide this population with additional care that may prevent or mitigate the short- and long-term effects of preeclampsia. Patient and provider education, increased surveillance, behavioral modification, and other approaches to improve outcomes in these individuals can improve the chance of a healthy outcome. We assembled a group with diverse, relevant expertise (clinicians, investigators, advocates, and public and private stakeholders) to develop a care plan in which providers and pregnant individuals at risk can work together to reduce the risk of preeclampsia and associated morbidities. The plan is for care of individuals at moderate to high risk for developing preeclampsia, sufficient to receive low-dose aspirin therapy, as identified by clinical and/or laboratory findings. The recommendations are presented using the GRADE methodology with the quality of evidence upon which each is based. In addition, printable appendices with concise summaries of the care plan's recommendations for patients and healthcare providers are provided. We believe that this shared approach to care will facilitate prevention of preeclampsia and its attendant short- and long-term morbidity in patients identified as at risk for development of this disorder.

The intentionality model and language acquisition: engagement, effort, and the essential tension in development

The purpose of the longitudinal research reported in this Monograph was to examine language acquisition in the second year of life in the context of developments in cognition, affect, and social connectedness. The theoretical focus for the research is on the agency of the child and the importance of the child's intentionality for explaining development, rather than on language as an independent object. The model of development for the research is a Model of Intentionality with two components: the engagement in a world of persons and objects that motivates acquiring a language, and the effort that is required to express and articulate increasingly discrepant and elaborate intentional state representations. The fundamental assumption in the model is that the driving force for acquiring language is in the essential tension between engagement and effort for linguistic, emotional, and physical actions of interpretation and expression. Results of lag sequential analyses are reported to show how different behaviors--words, sentences, emotional expressions, conversational interactions, and constructing thematic relations between objects in play--converged, both in the stream of children's actions in everyday events, in real time, and in developmental time between the emergence of words at about 13 months and the transition to simple sentences at about 2 years of age. Patterns of deviation from baseline rates of the different behaviors show that child emotional expression, child speech, and mother speech clearly influence each other, and the mutual influences between them are different at times of either emergence or achievement in both language and object play. The three conclusions that follow from the results of the research are that (a) expression and interpretation are the acts of performance in which language is learned, which means that performance counts for explaining language acquisition; (b) language is not an independent object but is acquired by a child in relation to other kinds of behaviors and their development; and (c) acquiring language in coordination with other behaviors in acts of expression and interpretation takes work, so that acquiring language is not easy.

Early conversations and word learning: contributions from child and adult

Temporal and topic contingencies between child and mother speech are reported at 2 achievements in language development in the second year. Measured against their respective baseline rates of speech, children were most likely to talk before mother speech and mothers most likely to talk after child speech. This pattern, evident at both language achievements, increased in amplitude with development. These early conversations were generated by the children; neither their interactions nor word learning depended on adult-scaffolded formats. Only about one-third of all child speech occurred in response to something mothers said; only half of all child speech received a topic-related response. When mothers responded, they most often simply acknowledged, repeated, or clarified what the child said. The results supported the intentionality model for language development, in which the child's role is primary: Children learn words for expression and interpretation in order to share contents of mind, bringing words to their conversations that they've already learned in other contexts.