Contingent screening for down syndrome is an efficient alternative to non-disclosure sequential screening

Objective To present a first and second trimester Down syndrome screening strategy, whereby second-trimester marker determination is contingent on the first-trimester results. Unlike non-disclosure sequential screening (the Integrated test), which requires all women to have markers in both trimesters, this allows a large proportion of the women to complete screening in the first trimester. Methods Two first-trimester risk cut-offs defined three types of results: positive and referred for early diagnosis; negative with screening complete; and intermediate, needing second-trimester markers. Multivariate Gaussian modelling with Monte Carlo simulation was used to estimate the false-positive rate for a fixed 85% detection rate. The false-positive rate was evaluated for various early detection rates and early test completion rates. Model parameters were taken from the SURUSS trial. Results Completion of screening in the first trimester for 75% of women resulted in a 30% early detection rate and a 55% second trimester detected rate (net 85%) with a false-positive rate only 0.1% above that achievable by the Integrated test. The screen-positive rate was 0.1% in the first trimester and 4.7% for those continuing to be tested in the second trimester. If the early detection rate were to be increased to 45% or the early completion rate were to be increased to 80%, there would be a further 0.1% increase in the false-positive rate. Conclusion Contingent screening can achieve results comparable with the Integrated test but with earlier completion of screening for most women. Both strategies need to be evaluated in large-scale prospective studies particularly in relation to psychological impact and practicability.

Social identification and prevalence of PTSD in Northern Ireland

Background Understanding of the psychological impact of politically motivated violence is poor. Aims To examine the prevalence of post-traumatic symptoms subsequentto the ‘troubles’ in Northern Ireland. Method A telephone survey of 3000 adults, representative of the population in Northern Ireland and the border counties of the Irish Republic, examined exposure to political violence, post-traumatic stress disorder (PTSD) and national identity. Results Ten per cent of respondents had symptoms suggestive of clinical PTSD. These people were most likely to come from low-income groups, rate national identity as relatively unimportant and have higher overall experience of the ‘troubles’than other respondents. Conclusions Direct experience of violence and poverty increase the risk of PTSD, whereas strong national identification appears to reduce this risk.

Complex PTSD, interpersonal trauma and relational consequences: Findings from a treatment-receiving Northern Irish sample

Background:
The relationship between PTSD and complex PTSD remains unclear. As well as further addressing this issue, the current study aimed to assess the degree to which DESNOS (complex PTSD) was related to interpersonal trauma and had relational consequences.

Methods:
Eighty one treatment-receiving participants with a history of exposure to the ‘Troubles’ in Northern Ireland, were assessed on various forms of interpersonal trauma, including exposure to the Troubles, and measures of interpersonal and community connectedness.

Results:
DESNOS symptom severity was related to childhood sexual abuse and perceived psychological impact of Troubles-related exposure. A lifetime diagnosis of DESNOS was related to childhood Troubles-related experiences, while a current diagnosis of DESNOS was associated with childhood emotional neglect. PTSD avoidance predicted current DESNOS diagnosis and severity. Feeling emotionally disconnected from family and friends (i.e., interpersonal disconnectedness) was related to all three indices of DESNOS (i.e., lifetime diagnosis, current diagnosis and current symptom severity).

Limitations:
Sample characteristics (i.e., treatment-receiving) and size may limit the generalizability of findings.

Conclusions:
Complex PTSD is associated with PTSD but when present should be considered a superordinate diagnosis.

“It’s like a problem that doesn’t exist”: The emotional well-being of mothers caring for a child with brain injury.

Background: Although research has shown that significant burden and adverse psychological impact are associated with caring for a child with brain injury, limited knowledge exists concerning the qualitative experience and impact of this burden.
Objective: To provide an account of the experiences of mothers who care for a childhood survivor of brain injury.
Research design: Postal survey.
Methods and procedures: A self-report questionnaire was sent to a consecutive sample of mothers (n=86) of children (aged 8-28) with acquired brain injury, registered with a UK children’s brain injury charity. Five essay style questions enabled mothers to reflect on and describe at length their caring experiences, with particular emphasis placed on the perceived impact on emotional well-being.
Main outcomes and results: Thematic analysis identified five key themes: Perpetually Anxious, The Guilty Carer, The Labour of Caring, A Self-Conscious Apologist and Perpetually Grieving. Collectively, these themes highlight two core processes shaping mothers’ caring experiences and concomitant mental well-being. Firstly, the collective and enduring nature of caregiver burden over time. Second, the crucial role played by socio-cultural values in perpetuating caregiver burden.
Conclusions: Societal norms, particularly those relating to the nature and outcome of brain injury and motherhood, serve to marginalise mothers and increase feelings of isolation. Findings suggest the value of peer support programs as an effective means of providing appropriate social support.

An exploration into the palliative and end-of-life experiences of carers of people with Parkinson's disease

Although most people with Parkinson's disease are cared for in the community, little is known about family members' lived experiences of palliative or end-of-life care. The aim of this study was to explore former carers' lived experiences of palliative and end-of-life care. In total, 15 former family caregivers of patients who had died with Parkinson's disease were interviewed using a semi-structured topic list. Findings indicated that some palliative and end-of-life care needs had not been fully addressed. Lack of communication, knowledge and coordination of services resulted in many people caring for someone with Parkinson's disease not accessing specialist palliative care services. Participants also reflected upon the physical and psychological impact of caring in the advanced stage of Parkinson's. A multi-disciplinary team-based approach was advocated by participants. These findings provide important insights into the experience of caregiving to patients with Parkinson's disease in the home at the end-of-life stage. According to palliative care standards, patients and their carers are the unit of care; in reality, however, this standard is not being met.

Different frequencies of acupuncture for treatment for chronic low back pain: an-assessor blinded pilot randomised controlled trial.

OBJECTIVES:
To examine the feasibility of a main RCT to compare the effectiveness of two frequencies (2 versus 5 times/week) of acupuncture treatment for chronic low back pain (LBP).
METHODS:
Participants (n=30) with chronic LBP were randomised into two groups to receive 10 acupuncture treatments: Low Frequency Group, 2 times/week for five weeks (n=15); High Frequency Group, 5 times/week for two weeks (n=15). The following outcomes were measured blindly at baseline, 2 weeks, 5 weeks, 3 months and 1 year: pain on a VAS, functional disability using the RMDQ, quality of life using the Measure Yourself Medical Outcome Profile (MYMOP-2), psychological impact with the Coping Strategies Questionnaire (CSQ) and Pain Locus of Control (PLC) questionnaire. Two objective outcomes, the Shuttle Walk Test (SWT) and Lateral Trunk Flexibility (LTF), were also measured.
RESULTS:
The compliance rate was 100% for each group. Some of the measurements were shown to be sensitive (VAS, RMDQ, MYMOP-2 Wellbeing). 66-330 participants would be required for a fully powered non-inferiority trial. The groups were balanced at baseline for LBP and demographic characteristics. There were no significant differences between the groups in terms of any of the outcomes, at each follow-up time point. It was notable however that the clinically important improvement in terms of pain, functional disability, quality of life, and SWT in both groups was achieved within the first two weeks, which was maintained at one year follow-up.
CONCLUSIONS:
It is feasible to conduct a main RCT, to compare different frequencies of acupuncture for LBP, using sensitive measurements. Also the trend for early clinically important improvement within a minimum of four measurements is worthy of further study.

Perceived positive and negative consequences after surviving cancer and their relation to quality of life

Surviving childhood cancer has multiple implications on both physical and psychological domains of the individual. However, its study and possible effects on health-related quality of life (HRQoL) outcomes of adolescent survivors has been understudied. The objective of this study was twofold; to assess positive and negative cancer-related consequences (psychosocial and physical) in a sample of adolescent cancer survivors and to explore their relationship with HRQoL outcomes. Forty-one participants answered two questions about positive and negative consequences in the aftermath of cancer and filled in the KIDSCREEN-52 self-reported version. Data were analysed using mixed methods approach. 87.8% of the sample identified positive consequences and 63.4% negative consequences in survivorship. Four positive categories and five negative categories with regard to cancer-related consequences were found. Changed perspectives in life narratives seem to be the positive consequence more related to HRQoL (physical well-being, mood & emotions, autonomy, social support & peers), followed by useful life experience (physical well-being, autonomy, social support & peers). Psychological impact was the most referred negative consequence with a significant detrimental effect on social support and peers HRQoL dimension. Even if the majority of survivors reported benefit finding in the aftermath of cancer, concomitant positive and negative consequences have been found. However, findings only reveal a significant relationship between positive narratives and HRQoL, and negative consequences do not seem to have a significant influence on overall HRQoL in survivorship.

Avaliação dos níveis de ansiedade e depressão e sua correlação com a intensidade de dor em doentes oncológicos com doença avançada e progressiva

Tese de mestrado, Cuidados Paliativos, Faculdade de Medicina, Universidade de Lisboa, 2015

Interstitial pregnancies' diagnosis and management: an eleven cases series.

PRINCIPLES: Interstitial pregnancy represents 2% of ectopic pregnancies, but it is a highly morbid condition with a 2.5% of maternal mortality. Its diagnostic and therapeutic management remains controversial. The aim of this review is to describe the management of interstitial pregnancy in our institution between 2001 and 2011 and to define some general rules for the clinical practice. METHODS: Single institution retrospective study. RESULTS: Eleven women were treated for interstitial pregnancy. The median age was 33 years and the median gestity was 4. Seven patients had a history of gynaecological surgery and four interstitial pregnancies followed in vitro fertilisation. The diagnosis was made at a median gestational age of seven weeks with a median beta-HCG level of 5,838 U/l. Six of the eleven patients received an initial treatment with intracornual methotrexate, three with intramuscular methotrexate and two with surgery. The median time to beta-HCG resolution was 58 days. Three of the eleven patients needed a second line treatment: two after intramuscular methotrexate and one after intracornual methotrexate. Six patients had further pregnancies and delivered by caesarean section. CONCLUSIONS: A high prevalence of previous ectopic pregnancies, gynaecological surgery and of pregnancies resulting from in vitro fertilisation was observed. The earliness of the diagnosis was the factor that allowed a conservative treatment in most cases. Beta-HCG level follow up was fundamental in allowing a second line therapy but beta-HCG can persist over a long period of time and this must be taken into account due to its possible psychological impact. Intracornual methotrexate seems to be more efficacious than intramuscular methotrexate in our series.

L’expérience de l’isolement de contact à l’hôpital pour des personnes âgées lors d’une infection au Clostridium difficile

Sommaire La situation actuelle des infections nosocomiales dans les établissements de santé est préoccupante. En ce qui concerne le Clostridium difficile (C. difficile), son émergence et son impact sur la morbidité et la mortalité sont bien connus. De plus, la population vieillissante est à risque élevé d’avoir des diarrhées associées au C. difficile et, de ce fait, de se retrouver en isolement de contact. Les personnes âgées sont déjà vulnérables au moment d’une hospitalisation, alors qu’en est-il lors d’un isolement de contact relié à une infection au C. difficile? Dans cette perspective, les connaissances sur l’expérience des personnes âgées lors d’un isolement étant peu développées, cette étude s’est intéressée au vécu des personnes âgées durant l’isolement de contact et aux effets de cet isolement sur leur vécu. Le but de cette étude phénoménologique, prenant appui sur la Théorie de l’humain en devenir de Parse (2003), était de décrire et comprendre l’expérience de personnes âgées de 75 ans et plus lors d’un isolement de contact en milieu hospitalier causé par une infection au C. difficile. Ainsi, des entrevues semi-structurées furent réalisées auprès de cinq personnes âgées qui ont accepté de participer à l’étude, puis la transcription de leurs propos fut analysée selon la méthode proposée par Giorgi (1997). De cette analyse sont ressortis trois thèmes : 1) Vivre les effets du Clostridium difficile; 2) Vivre de l’inquiétude et 3) Vivre de la déception dans la relation avec le personnel soignant. Poussant plus loin l’analyse des thèmes et sous-thèmes, il a été possible de proposer que l’essence de l’expérience de personnes âgées de 75 ans et plus lors d’un isolement de contact en milieu hospitalier causé par une infection au C. difficile était de « vivre à la fois en conjonction avec le besoin d’être isolé pour protéger son univers et en séparation avec le besoin de recevoir des soins qui respectent leur dignité, et ce, malgré la vulnérabilité induite par leur état de santé ». Ces résultats pourront sensibiliser les personnes soignantes qui accompagnent au quotidien les personnes âgées en isolement. La compréhension de leur vécu pourra favoriser la mise en place de soins davantage centrés sur la personne qui tiennent compte de leurs inquiétudes, de leurs craintes et de l’importance de préserver leur dignité. Mots clés : Effets psychologiques, expérience de l’isolement de contact, Clostridium difficile, personnes âgées, phénoménologie, théorie de l’humain en devenir.

Impacts des processus judiciaires sur la santé mentale des victimes d’actes criminels violents

Rapport de stage présenté en vue de l’obtention du grade de Maître ès sciences (M.Sc) en Criminologie option stage en intervention

Prevalencia de depresión y síntomas de ansiedad en mujeres adultas un mes posterior a un aborto inducido y espontáneo 2010 -2011

Introducción: El aborto espontáneo corresponde a la complicación más frecuente durante el embarazo, afectando entre el 12% al 24% de las gestaciones clínicamente identificables en Latinoamérica. Los abortos inducidos (legales o ilegales) suman al problema una importante cantidad de casos. El aborto representa un complejo evento biológico y psicológico con importantes repercusiones a nivel mental, principalmente de ansiedad y depresión. En Colombia no existen estudios que midan la prevalencia de estos síntomas en mujeres con pérdidas gestacionales. Objetivos: Determinar la prevalencia de síntomas depresivos y de ansiedad y factores asociados, en mujeres adultas atendidas por aborto inducido y espontáneo un mes posterior a su ocurrencia. . Resultados: El grupo de mujeres que cumplieron con los criterios de selección fueron 112. El promedio de edad fue de 30.4±6.1 años y estrato socioeconómico I (54.1%) y II (38.7%). La prevalencia de síntomas de depresión fue de 67.9% y de ansiedad de 12.5%. La prevalencia de síntomas depresivos disminuyó significativamente al aumentar el estrato, I (71.7%), II (67.4%) y III (16.7%), (p=0.035). La mediana de la edad del primer embarazo fue mayor significativamente en las mujeres con ansiedad (25 vs. 19, p=0.01). Cerca de mostrar diferencias entre antecedentes de aborto (p=0.084), menor número de años educativos aprobados (p=0.075) y mayor edad de la paciente con ansiedad (p=0.096). No hubo diferencias estadísticamente significativas entre los dos tipos de aborto en cuanto a síntomas depresivos o de ansiedad.

Impacto de la auto - percepción de imagen corporal en sujetos con VIH y lipoatrofia facial.

La lipoatrofia facial es uno de los efectos secundarios que con más frecuencia se presenta y afecta la calidad de vida del paciente con VIH que recibe tratamiento antiretroviral. Metodología: Estudio observacional de corte transversal que involucró 126 sujetos, a quienes se aplicó una encuesta semi-estructurada para determinar cómo percibe el paciente que la lipoatrofia facial lo afecta en áreas afectiva, social, laboral y ocupacional; evaluar la percepción de la imagen corporal; caracterizar sociodemográficamente; determinar la prevalencia de lipoatrofia facial y establecer si hay diferencias de percepción de la imagen corporal según la caracterización sociodemográfica. Resultados: La Prevalencia de lipoatrofia facial fue del 57.1%. El grado de satisfacción en cuanto a apariencia física tuvo un promedio de 5.01±2.69. El 88.7% y 80.3% de los pacientes evaluados sintieron tristeza y frustración con su apariencia respectivamente. El 53.5% y el 42.9% informaron menos oportunidades laborales y educativas. La orientación sexual reportada con mayor frecuencia fue homosexualidad. No hubo diferencias estadísticamente significativas entre el grado de satisfacción de apariencia con aspectos sociodemográficos excepto en pacientes que recibieron apoyo psicológico. Conclusión: Primer estudio en el país que evalúa el impacto de la lipoatrofia facial en pacientes con VIH y tratamiento antiretroviral. Aunque la presencia de lipoatrofia facial sobre la cotidianidad no es estadísticamente significativa, si resulta trascendental pues existen porcentajes importantes de emociones y alteraciones psicológicas que afectan directamente a estos sujetos en las áreas afectiva, social, laboral y ocupacional. Se hace necesaria la realización de más estudios que permitan obtener mayor de evidencia.

Impacto de dos técnicas quirúrgicas sobre la recaída local de carcinoma de mama en pacientes de una clínica de Bogotá D.C.

Introducción: El carcinoma de mama es el tumor maligno más frecuente entre las mujeres y representa una significativa mortalidad en los países en vías de desarrollo. Según datos del Instituto Nacional de Cancerología en el 2010 se reportaron 672 nuevos casos de cáncer de mama, lo que representó el 18% de todos los tumores malignos en mujeres. Durante las últimas 3 décadas las técnicas quirúrgicas para el tratamiento del cáncer de mama han presentado un cambio significativo y proponen disminución de procedimientos agresivos y radicales, intervenciones como: mastectomía radical modificada, cirugía conservadora y la disección de ganglio centinela son ejemplos claros de esta evolución asociado al incremento de la reconstrucción mamaria inmediata. Metodología: Estudio observacional tipo cohorte retrospectivo en el cual se revisó una base de datos de pacientes con cáncer de mama de las cuales 632 fueron sometidas a mastectomía radical con preservación de piel y complejo areola-pezón y mastectomía radical con preservación de piel sin preservación del complejo areola-pezón, los dos procedimientos asociados a reconstrucción mamaria inmediata y se comparó la frecuencia de recaída local entre los dos grupos. Resultados: De las 632 pacientes estudiadas al 30.5% se les realizo preservación del complejo areola pezón. Las mujeres a quienes se les realizó preservación del complejo areola pezón presentaron menor sobrevida a la recaída local a 10 años (80.51%) comparado con las mujeres a quienes no se les preservó el complejo areola pezón (87.40%), sin embargo no se encontró diferencia estadísticamente significativa para determinar que las probabilidades de sobrevida sean diferentes. Discusión: No se evidenció diferencia estadísticamente significativa entre los 2 procedimientos quirúrgicos (con y sin preservación del complejo areola pezón) en relación a la recaída local, estudios retrospectivos no han evidenciado una mayor tasa de recaídas locales en pacientes a quienes se les preserva el complejo areola-pezón, sin embargo hacen falta estudios prospectivos y aleatorizados que puedan otorgar un mayor sustento científico que garantice la seguridad de la preservación del complejo areola-pezón.

Impacto de dos técnicas quirúrgicas sobre la recaída local de carcinoma de mama en pacientes de una clínica de Bogotá D.C.

Introducción: El carcinoma de mama es el tumor maligno más frecuente entre las mujeres y representa una significativa mortalidad en los países en vías de desarrollo. Según datos del Instituto Nacional de Cancerología en el 2010 se reportaron 672 nuevos casos de cáncer de mama, lo que representó el 18% de todos los tumores malignos en mujeres. Durante las últimas 3 décadas las técnicas quirúrgicas para el tratamiento del cáncer de mama han presentado un cambio significativo y proponen disminución de procedimientos agresivos y radicales, intervenciones como: mastectomía radical modificada, cirugía conservadora y la disección de ganglio centinela son ejemplos claros de esta evolución asociado al incremento de la reconstrucción mamaria inmediata. Metodología: Estudio observacional tipo cohorte retrospectivo en el cual se revisó una base de datos de pacientes con cáncer de mama de las cuales 632 fueron sometidas a mastectomía radical con preservación de piel y complejo areola- pezón y mastectomía radical con preservación de piel sin preservación del complejo areola-pezón, los dos procedimientos asociados a reconstrucción mamaria inmediata y se comparó la frecuencia de recaída local entre los dos grupos. Resultados: De las 632 pacientes estudiadas al 30.5% se les realizo preservación del complejo areola pezón. Las mujeres a quienes se les realizó preservación del complejo areola pezón presentaron menor sobrevida a la recaída local a 10 años (80.51%) comparado con las mujeres a quienes no se les preservó el complejo areola pezón (87.40%), sin embargo no se encontró diferencia estadísticamente significativa para determinar que las probabilidades de sobrevida sean diferentes. Discusión: No se evidenció diferencia estadísticamente significativa entre los 2 procedimientos quirúrgicos (con y sin preservación del complejo areola pezón) en relación a la recaída local, estudios retrospectivos no han evidenciado una mayor tasa de recaídas locales en pacientes a quienes se les preserva el complejo areola-pezón, sin embargo hacen falta estudios prospectivos y aleatorizados que puedan otorgar un mayor sustento científico que garantice la seguridad de la preservación del complejo areola-pezón.