Incidence and mortality from cervical cancer and other malignancies after treatment of cervical intraepithelial neoplasia: a systematic review and meta-analysis of the literature.

BACKGROUND: Although local treatments for cervical intraepithelial neoplasia (CIN) are highly effective, it has been reported that treated women remain at increased risk of cervical and other cancers. Our aim is to explore the risk of developing or dying from cervical cancer and other human papillomavirus (HPV)- and non-HPV-related malignancies after CIN treatment and infer its magnitude compared with the general population. MATERIALS AND METHODS: Design: Systematic review and meta-analysis. Eligibility criteria: Studies with registry-based follow-up reporting cancer incidence or mortality after CIN treatment. DATA SYNTHESIS: Summary effects were estimated using random-effects models. OUTCOMES: Incidence rate of cervical cancer among women treated for CIN (per 100 000 woman-years). Relative risk (RR) of cervical cancer, other HPV-related anogenital tract cancer (vagina, vulva, anus), any cancer, and mortality, for women treated for CIN versus the general population. RESULTS: Twenty-seven studies were eligible. The incidence rate for cervical cancer after CIN treatment was 39 per 100 000 woman-years (95% confidence interval 22-69). The RR of cervical cancer was elevated compared with the general population (3.30, 2.57-4.24; P < 0.001). The RR was higher for women more than 50 years old and remained elevated for at least 20 years after treatment. The RR of vaginal (10.84, 5.58-21.10; P < 0.001), vulvar (3.34, 2.39-4.67; P < 0.001), and anal cancer (5.11, 2.73-9.55; P < 0.001) was also higher. Mortality from cervical/vaginal cancer was elevated, but our estimate was more uncertain (RR 5.04, 0.69-36.94; P = 0.073). CONCLUSIONS: Women treated for CIN have a considerably higher risk to be later diagnosed with cervical and other HPV-related cancers compared with the general population. The higher risk of cervical cancer lasts for at least 20 years after treatment and is higher for women more than 50 years of age. Prolonged follow-up beyond the last screening round may be warranted for previously treated women.

Causes for delay before specialist consultation in head and neck cancer.

BACKGROUND: Head and neck cancers are often diagnosed at a late stage, thus resulting in a generally poor prognosis. This is partly attributable to patients' hesitancy in seeking treatment. However, the length and causes of these patient delays remain relatively unknown. MATERIAL AND METHODS: We included all new head and neck cancer patients treated at our tertiary care center between 2016 and 2017. Using a patient questionnaire, we collected data on patients' symptoms and other factors related to seeking medical care, and recorded both patient- and primary health care-related delays. We then compared the data collected from these patients to patient and tumor characteristics collected from hospital records, and analyzed various causes for delay before a specialist consultation to the Department of Otorhinolaryngology - Head and Neck Surgery. RESULTS: Among the patients (n = 142) in our study, the median patient delay was 35 d with 73% of patients seeking medical care within 3 months. In comparison, the median primary health-care delay was 20 d. Certain symptoms influenced patient delay. Hoarseness and breathing difficulties correlated with longer patient delay while patients with a lump on the neck had a shorter delay. Patient delay was associated with certain tumor-related factors such as the tumor site and the presence of regional metastases, which resulted in shorter patient delay. None of the patient-related factors appeared to impact delay. Important factors influencing primary health-care delay included the initial location visited and whether any follow-up visit was scheduled or not. CONCLUSIONS: Although most patients sought medical advice without a major delay and were adequately referred, we found that long delays existed. Raising awareness of the symptoms of head and neck cancer among general population and health-care providers is probably the best way to get patients to curative treatment without delay.

The co-developmental dynamic of sport and school burnout among student-athletes: The role of achievement goals.

Student-athletes who strive for success in high-level sports while pursuing upper secondary education may be prone to sport and school burnout. This study examined the co-developmental dynamic of sport and school burnout in Finnish adolescent student-athletes (Ntime 1  = 391; Ntime 2  = 373) across the first year of upper secondary school using cross-lagged structural equation modeling (SEM). Furthermore, we used sport and school-related achievement goals as predictors of sport and school burnout, namely sport and school-related exhaustion, cynicism, and feelings of inadequacy. The results showed that burnout dimensions in a particular domain were substantially stable within the same domain during the first year of upper secondary school and that school-related exhaustion at the beginning of upper secondary school predicted sport-related exhaustion at the end of the school year. Mastery goals in sport and school were negatively associated with cynicism and feelings of inadequacy within the same domain. Furthermore, performance goals in school were positively associated with school-related cynicism. The results can be used by healthcare professionals for early prevention of student-athletes' burnout.

Gaming is related to enhanced working memory performance and task-related cortical activity.

Gaming experience has been suggested to lead to performance enhancements in a wide variety of working memory tasks. Previous studies have, however, mostly focused on adult expert gamers and have not included measurements of both behavioral performance and brain activity. In the current study, 167 adolescents and young adults (aged 13-24 years) with different amounts of gaming experience performed an n-back working memory task with vowels, with the sensory modality of the vowel stream switching between audition and vision at random intervals. We studied the relationship between self-reported daily gaming activity, working memory (n-back) task performance and related brain activity measured using functional magnetic resonance imaging (fMRI). The results revealed that the extent of daily gaming activity was related to enhancements in both performance accuracy and speed during the most demanding (2-back) level of the working memory task. This improved working memory performance was accompanied by enhanced recruitment of a fronto-parietal cortical network, especially the dorsolateral prefrontal cortex. In contrast, during the less demanding (1-back) level of the task, gaming was associated with decreased activity in the same cortical regions. Our results suggest that a greater degree of daily gaming experience is associated with better working memory functioning and task difficulty-dependent modulation in fronto-parietal brain activity already in adolescence and even when non-expert gamers are studied. The direction of causality within this association cannot be inferred with certainty due to the correlational nature of the current study.

Media multitasking is associated with distractibility and increased prefrontal activity in adolescents and young adults.

The current generation of young people indulges in more media multitasking behavior (e.g., instant messaging while watching videos) in their everyday lives than older generations. Concerns have been raised about how this might affect their attentional functioning, as previous studies have indicated that extensive media multitasking in everyday life may be associated with decreased attentional control. In the current study, 149 adolescents and young adults (aged 13-24years) performed speech-listening and reading tasks that required maintaining attention in the presence of distractor stimuli in the other modality or dividing attention between two concurrent tasks. Brain activity during task performance was measured using functional magnetic resonance imaging (fMRI). We studied the relationship between self-reported daily media multitasking (MMT), task performance and brain activity during task performance. The results showed that in the presence of distractor stimuli, a higher MMT score was associated with worse performance and increased brain activity in right prefrontal regions. The level of performance during divided attention did not depend on MMT. This suggests that daily media multitasking is associated with behavioral distractibility and increased recruitment of brain areas involved in attentional and inhibitory control, and that media multitasking in everyday life does not translate to performance benefits in multitasking in laboratory settings.

Trends in the 15D health-related quality of life over the first year following diagnosis of head and neck cancer.

Management of head and neck cancer influences both physical and mental wellbeing. Measuring the health-related quality of life (HRQoL) is important, as various treatment modalities are associated with significant morbidity and mortality. In this prospective cohort study, we tested the feasibility of the generic 15D HRQoL instrument in 214 head and neck cancer patients managed with surgery, definitive (chemo)radiotherapy, or with combined modality treatment. HRQoL was assessed at baseline and three times after treatment onset during 1 year, and compared with that of general population standardized for age and sex. At baseline, the patients' mean 15D score was significantly worse compared with general population. Overall HRQoL was at lowest at 3 months after treatment onset, it gradually improved towards 12 months but never reached baseline levels. The dimensions "vitality", "distress", "depression" and "sexual activity" showed marked deterioration at 3 months after the treatment onset, but improved gradually during 12 months. The 15D instrument seems useful for evaluation of HRQoL of head and neck cancer patients. Dimensions reflecting mental wellbeing improved gradually after 3 months, but they seldom reached baseline levels. The support for patients at the time of diagnosis, during treatment, and recovery is emphasized.

Personality types during transition to young adulthood: how are they related to life situation and well-being?

The present longitudinal study examined personality types, their change, and their relations with life outcomes and well-being in a sample of young Finns (N=493) that was followed from age 15 to 23. The Big Five traits were measured at ages 20 and 23, and four personality types - Resilients, Overcontrollers, Anti-Resilients, and "Averages" - emerged at both time points. Those with higher initial well-being were more likely to be later classified as Resilients, whereas those with low and decreasing well-being were more likely to be classified as Anti-Resilients. At age 23, Anti-Resilients were less likely to have reached normative educational goals than others, and more likely to be unemployed than others, but Overcontrollers were less likely to be in a romantic relationship than others. The results question the universality of the three-type structure, but support the predictive validity of personality types.

Obstetric outcome after intervention for severe fear of childbirth in nulliparous women - randomised trial.

OBJECTIVE: To compare the numbers of vaginal deliveries and delivery satisfaction among women with fear of childbirth randomised to either psychoeducation or conventional surveillance during pregnancy. DESIGN: Randomised controlled trial. SETTING: Maternity unit of Helsinki University Central Hospital. POPULATION: Fear of childbirth was screened during early pregnancy by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A). Of 4575 screened nulliparous women, 371 (8.1%) scored ≥ 100, showing severe fear of childbirth. METHODS: Women with W-DEQ-A ≥ 100 were randomised to intervention (n = 131) (psychoeducative group therapy, six sessions during pregnancy and one after childbirth) or control (n = 240) (care by community nurses and referral if necessary) groups. Obstetric data were collected from patient records and delivery satisfaction was examined by questionnaire. MAIN OUTCOME MEASURES: Delivery mode and satisfaction. RESULTS: Women randomised to the intervention group more often had spontaneous vaginal delivery (SVD) than did controls (63.4% versus 47.5%, P = 0.005) and fewer caesarean sections (CSs) (22.9% versus 32.5%, P = 0.05). SVD was more frequent and CSs were less frequent among those who actually participated in intervention (n = 90) compared with controls who had been referred to consultation (n = 106) (SVD: 65.6% versus 47.2%, P = 0.014; CS: 23.3% versus 38.7%, P = 0.031). Women in intervention more often had a very positive delivery experience (36.1% versus 22.8%, P = 0.04, n = 219). CONCLUSIONS: To decrease the number of CSs, appropriate treatment for fear of childbirth is important. This study shows positive effects of psychoeducative group therapy in nulliparous women with severe fear of childbirth in terms of fewer CSs and more satisfactory delivery experiences relative to control women with a similar severe fear of childbirth.

Mental health problems common in women with fear of childbirth.

OBJECTIVE: To investigate whether women with fear of childbirth have more mental health problems than women of childbearing age in general. DESIGN: Register-based retrospective study. SETTING: The maternity clinic of Helsinki University Central Hospital. POPULATION: In all, 2405 women referred for consultation because of fear of childbirth during 1996-2002 and 4676 comparable control women. METHODS: Data were linked to the Medical Birth Register, the Hospital Discharge Register and the Drug Reimbursement Register 5-12 years before and after the initial childbirth (during 1990-2008). MAIN OUTCOME MEASURES: Prevalence of psychiatric care as evidenced by the use of psychotropic medication, and episodes of either psychiatric inpatient or outpatient care in women with fear of childbirth compared with nonfearful controls. RESULTS: Women with fear of childbirth had significantly more often had psychiatric care (54.0% versus 33.6%, P < 0.001) during the study period. Fearful and nonfearful women differed from each other (P < 0.001) regarding psychiatric inpatient care (7.2% versus 3.6%), outpatient care (19.0% versus 9.8%) and the use of psychotropic medication (51.3% versus 31.3%). Mood and anxiety disorders were the most common psychiatric diagnoses in both groups. The major predictors for a need for psychiatric care after the initial childbirth were previous psychiatric care (adjusted odds ratio 4.5; 95% CI 4.0-5.1) and fear of childbirth (adjusted odds ratio 1.9; 95%CI 1.7-2.1). CONCLUSIONS: A remarkable mental morbidity was seen among women of childbearing age. Mental health problems were twice as common among women with a fear of childbirth as in nonfearful controls. Clinical practice on how to evaluate and treat women fearing childbirth should be developed.

Fear of childbirth according to parity, gestational age, and obstetric history.

OBJECTIVE: To examine fear of childbirth according to parity, gestational age, and obstetric history. DESIGN: A questionnaire study. POPULATION AND SETTING: 1400 unselected pregnant women in outpatient maternity clinics of a university central hospital. METHODS: Visual analogue scale (VAS) and Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and preferred mode of delivery. MAIN OUTCOME MEASURES: W-DEQ and VAS scores according to parity, gestational age, obstetric history, and preferred mode of delivery. RESULTS: The W-DEQ and VAS scores were higher in nulliparous (W-DEQ 72.0 +/- 20.0 [mean +/- SD] and VAS 4.7 [median]) than parous women (65.4 +/- 21.9; 3.2, P < 0.001 for both W-DEQ and VAS). Higher W-DEQ and VAS scores were found for those beyond 21 weeks of gestation compared with those before (W-DEQ 71.6 +/- 23.0 versus 66.6 +/- 20.0, P < 0.001; VAS 4.7 versus 3.2, P < 0.001). Caesarean section was preferred mode of delivery for 8.1% and these women scored higher on fear (W-DEQ 87.6 +/- 26.5, VAS median 7.0) than those who preferred vaginal delivery (W-DEQ 61.8 +/- 18.7, VAS 2.7, P < 0.001, respectively). Those with a previous caesarean scored higher on fear (W-DEQ 73.2 +/- 23.5, VAS 5.1) than parous women without previous caesarean (W-DEQ 63.3 +/- 20.8, VAS 2.9, P < 0.001, respectively). Those with a history of a vacuum extraction (VE) (W-DEQ 70.6 +/- 19.7, VAS 5.0) had higher fear scores than those without (W-DEQ 64.8 +/- 22.0, P < 0.05 and VAS 3.0, P < 0.001). CONCLUSION: Severe fear of childbirth was more common in nulliparous women, in later pregnancy, and in women with previous caesarean section or VE. Caesarean section as a preferred mode of childbirth was strongly associated with high score in both W-DEQ and VAS.

A randomized controlled trial of intervention in fear of childbirth.

OBJECTIVE: To compare intensive and conventional therapy for severe fear of childbirth. METHODS: In Finland, 176 women who had fear of childbirth were randomly assigned at the 26th gestational week to have either intensive therapy (mean 3.8 +/- 1.0 sessions with obstetrician and one with midwife) or conventional therapy (mean 2.0 +/- 0.6 sessions), with follow-up 3 months postpartum. Pregnancy-related anxiety and concerns, satisfaction with childbirth, and puerperal depression were assessed with specific questionnaires. Power analysis, based on previous studies, showed that 74 women per group were necessary to show a 50% reduction in cesarean rates. RESULTS: Birth-related concerns decreased in the intensive therapy group but increased in the conventional therapy group (linear interaction between the group and birth-concerns P =.022). Labor was shorter in the intensive therapy group (mean +/- standard deviation 6.8 +/- 3.8 hours) compared with the conventional group (8.5 +/- 4.8 hours, P =.039). After intervention, 62% of those originally requesting a cesarean (n = 117) chose to deliver vaginally, equally in both groups. Cesarean was more frequent for those who refused to fill in the questionnaires than for those who completed them (57% compared with 27%, P =.001). In the log-linear model, parous women who had conventional therapy and refused to fill in the questionnaires chose a cesarean more often than expected (standardized residual 2.54, P =.011). There were no differences between groups in satisfaction with childbirth or in puerperal depression. CONCLUSION: Both kinds of therapy reduced unnecessary cesareans, more so in nulliparous and well-motivated women. With intensive therapy, pregnancy- and birth-related anxiety and concerns were reduced, and labors were shorter.

Psychosocial characteristics of women and their partners fearing vaginal childbirth.

OBJECTIVES: To examine the personal characteristics and socio-economic background of women and their partners fearing vaginal childbirth. DESIGN: Questionnaire survey by the 30th week of pregnancy. SETTING: Sixteen outpatient maternity centres in the capital area of Finland. PARTICIPANTS: Two hundred and seventy-eight women and their partners. MAIN OUTCOME MEASURES: Personality traits, socio-economic factors, life and partnership satisfaction and pregnancy- and delivery-associated anxiety and fear. RESULTS: The more anxiety, neuroticism, vulnerability, depression, low self-esteem, dissatisfaction with the partnership, and lack of social support the women reported, the more they showed pregnancy-related anxiety and fear of vaginal delivery. In multiple regression analyses psychological variables of the woman contributed most to the prediction of pregnancy-related anxiety (increase in R2 = 0.20, P < 0.001), the strongest predictor being general anxiety (beta = 0.28, P < 0.001). Lack of support contributed most to the prediction of severe fear of vaginal delivery (increase in chi2 = 13.66, P < 0.01), the strongest predictor being dissatisfaction with the partnership (Wald 8.61, P < 0.01). Life-dissatisfaction reported by the partner contributed to pregnancy-related anxiety and his dissatisfaction with the partnership contributed to the woman's fear of vaginal delivery. CONCLUSIONS: The personalities of a pregnant woman and her partner, and their relationship, influences the woman's attitude to her pregnancy and her forthcoming delivery.

Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study.

BACKGROUND: To examine the extent to which personality characteristics, depression, fear and anxiety about pregnancy and delivery, and socio-economic background, predict disappointment with delivery and the risk of puerperal depression. METHODS: Two hundred and eleven women filled in questionnaires measuring personality traits, socio-economic factors, and marital satisfaction once before and once after the 30th week of pregnancy, and 2 3 months after delivery, when obstetric data about pregnancy and delivery was also collected. RESULTS: The women who were disappointed with their delivery or suffered from puerperal depression had been more depressed already in early pregnancy. Regression analysis showed that the strongest predictors of disappointment with delivery were labor pain (increase in R2 = 0.14, p<0.001) and emergency Cesarean (increase in R2 = 0.18, p<0.001). Puerperal depression was predicted by depression (increase in R2 = 0.16, p<0.001), and by personal traits such as general anxiety, vulnerability and neuroticism (increase in R2 = 0.32, p<0.001), both before 30 weeks of pregnancy and prior to the delivery (for depression increase in R2 = 0.05, p<0.001, and for anxiety and vulnerability increase in R2 = 0.04, p<0.01). The strongest predictors were depression at both time points before delivery (beta = 0.51, p<0.001, and beta = 0.39, p<0.001). Pregnancy- and delivery-related anxiety prior to the delivery also predicted puerperal depression, but complications of the pregnancy and delivery did not. CONCLUSIONS: Depression in early pregnancy predicts disappointment with the delivery and is a strong predictor of puerperal depression.

Goal reconstruction and depressive symptoms during the transition to motherhood: evidence from two cross-lagged longitudinal studies.

Two cross-lagged longitudinal studies were carried out to investigate the extent to which the adjustment of personal goals to match the particular stage-specific demands of the transition to motherhood has consequences for women's depressive symptoms. In Study 1. 348 women filled out a revised version of Little's (1983) Personal Project Analysis and a revised version of Beck's Depression Inventory (A. T. Beck. C. H. Ward. M. Mendelsohn, L. Mock, & J. Erlaugh. 1961) 4 times: during early pregnancy, 1 month before childbirth, 3 months after childbirth. and 2 years after childbirth. In Study 2. 140 women who reported high levels of fear of childbirth filled out identical measures during early pregnancy, 1 month before childbirth, and 3 months after childbirth. The results showed that an increase in family-related goals during pregnancy and after the birth of the child predicted a decline in women's depressive symptoms. By contrast, an increase in self-focused goals predicted an increase in women's depressive symptoms.

Women's and men's personal goals during the transition to parenthood.

To investigate how women's and men's personal goals change during the transition to parenthood, the authors studied 348 women (152 primiparous and 196 multiparous) and 277 of their partners at 3 times: early in pregnancy, 1 month before the birth, and 3 months afterward. At each measurement, participants completed the Personal Project Analysis questionnaire (B. R. Little, 1983). The results showed that during pregnancy women became more interested in goals related to childbirth, the child's health, and motherhood and less interested in achievement-related goals. After the birth women were more interested in family- and health-related issues. These changes were more substantial among the primiparous than among the multiparous mothers. Although the men's personal goals changed during the transition to parenthood, these changes were less substantial than those found among the women.

Social strategies and loneliness.

Although substantial research has been done on loneliness, in only a few studies has the extent of its association with the cognitive and attributional strategies people apply in social situations been investigated. Two studies were carried out among Finnish students to examine this association. In Study 1, 70 men and 202 women filled in the Cartoon-Attribution-Strategy Test (CAST) and Rosenberg's Self-Esteem Scale (RSE), then 1 year later, the revised UCLA Loneliness Scale. In Study 2, 25 men and 35 women filled in the CAST and the RSE, then 4 months later, the UCLA Loneliness Scale. In both studies, a pessimistic avoidance strategy was associated with subsequent feelings of loneliness, even after controls for the level of self-esteem. Both an optimistic planning strategy and a self-serving attributional bias were negatively associated with feelings of loneliness among men but not among women.

Personal goals of young social drop-outs.

To examine the extent to which personal goals and their appraisals are associated with problems in socialization, 20 young 'social drop-outs' (15 men, 5 women) and 21 students from a vocational school (20 men, 1 woman) were interviewed about their personal goals, related views of internality, externality, and likelihood of accomplishing goals. Analysis indicated that young adults who showed problems in socialization mentioned less frequently personal goals related to future education and housing than did the control group. Second, social drop-outs held more external and less internal views and were less optimistic about accomplishing personal goals than was the control group.

Struggling with self: the personal projects of students seeking psychological counseling.

Personal projects can be described as self-articulated goals and related sequences of actions. In order to investigate what kind of personal projects people with psychological problems have, and how they work on them, 28 counselling client students, 44 students of psychology, and 45 students of technology completed a Finnish version of Little's (1987) Personal Project Inventory. The results showed that the clients scored lower on project accomplishment than other groups. Their personal projects were frequently self-related, while those of the technology students were often task-related. The higher their sense of coherence, self-esteem, mental health and life satisfaction, the more subjects expected to accomplish their projects, the more frequently they described task-related projects, the less negative affect they reported, and the less frequently they described self-related projects. These results suggest that psychologically distressed individuals struggle with self-related projects and have problems in accomplishing their projects.

Age differences in adults' control beliefs related to life goals and concerns.

Control beliefs play an important role in how people direct their own development during their life span. However, research into age differences in control beliefs has produced inconsistent results. In this study, 381 subjects (19 to 71 years old) completed a questionnaire in which they were asked to write down their goals and concerns. They were then asked to rate each on a 4-point bipolar rating scale measuring internality-externality. The results showed that subjects' control beliefs became more external with age. However, part of the increase in externality was found to be caused by increasing interest in domains that are generally considered uncontrollable. Subjects' beliefs about health-, self-, offspring-, and property-related goals became more external with age, unlike goals concerning future education, occupation, family, and travel.