MMP-9 Levels in the Gingival Crevicular Fluid of Chilean Rosacea Patients.

Rosacea is a chronic inflammatory skin disease whose prevalence rates remain unknown in Chile. Laboratory benchmark testing for this disease is not useful, therefore, we aimed to evaluate the gingival crevicular fluid (GCF) levels of extracellular metalloproteinases (MMP)-2 and MMP-9 as novel rosacea biomarkers. We designed a cross-sectional study with a control group. Participants were systemically healthy adults (n = 20) and persons with rosacea (n = 18). We performed a periodontal evaluation and collected gingival crevicular fluid to measure MMP-2 and MMP-9 levels. Analysis showed mean and standard deviation of MMP-9 concentrations in the GCF for patients with rosacea was 764.52 ± 569.83 pg/mL; for healthy patients, it was 260.69 ± 170.43 pg/mL (p < 0.05). The diagnosis of rosacea was responsible for the levels of MMP-9 in the GCF (p < 0.05), as opposed to periodontitis, smoking, and age (p > 0.05). The Area under ROC for MMP-9 was 0.869 (95%, C.I: 0.719−0.956), with a sensitivity of 72.22% and specificity of 81.58% for the diagnosis of rosacea. We conclude that the quantification of MMP-9 in the GCF could be used as a biomarker of rosacea. Also, rosacea was responsible for increasing the levels of MMP-9 in the GCF independent of periodontal status.

Biomarkers in Oral Fluids as Diagnostic Tool for Psoriasis.

Psoriasis is a prevalent worldwide chronic immuno-inflammatory skin disease with various variants and atypical cases. The use of biomarkers for the diagnosis of psoriasis can favor timely treatment and thus improve the quality of life of those affected. In general, the search for biomarkers in oral fluids is recommended as it is a non-invasive and fast technique. This narrative review aimed to identify biomarkers in gingival crevicular fluid (GCF) and saliva to diagnose psoriasis. To achieve this goal, we selected the available literature using the following MESH terms: "psoriasis", "saliva" and "gingival crevicular fluid". The studies analyzed for this review cover original research articles available in English. We found three full articles available for psoriasis biomarkers in GCF and ten articles available for psoriasis biomarkers in saliva. Studies showed that in the saliva of healthy individuals and those with psoriasis, there were differences in the levels of inflammatory cytokines, immunoglobulin A, and antioxidant biomarkers. In GCF, individuals with psoriasis showed higher levels of S100A8, IL-18 and sE-selectin in comparison to healthy individuals, independent of periodontal status. Despite these findings, more studies are required to determine an adequate panel of biomarkers to use in saliva or GCF for psoriasis.

Human Immunodeficiency Virus: Attitudes and knowledge among health professionals in Santiago, Chile / Virus de Inmunodeficiencia Humana: actitudes y conocimientos de profesionales de salud en Santiago, Chile

Abstract Introduction: Nowadays there a significant increase of HIV cases is in Chile. It is imperative that health professionals have the necessary knowledge to provide adequate healthcare without stigmatizing people living with HIV/AIDS. Objective: Determine health professionals' HIV level of knowledge and their willingness to attend people living with this virus. Methods: This quantitative, cross-sectional study used an online selfadministered survey, that consisted on 15 questions. It evaluated the knowledge and attitudes in health professionals and technicians working in the West Metropolitan Health Centers in Santiago, Chile. Results: The response rate was 32.7% (n=235). 86.8% of participants said they felt safe doing medical procedures to people living with HIV, even though one out of ten said that they related the word fear with HIV; 52.4% were unaware of the clinical guidelines of the local Ministry of Health; and 42.7% incorrectly identified the use of double clinical gloves as a protective measure. Conclusions: The results of this study demonstrate that it is necessary to update and reinforce the knowledge about HIV and universal protective measures in health professionals..

Resumen Introducción: En Chile existe actualmente un aumento significativo de casos de VIH. Es imperativo que los profesionales de la salud tengamos el conocimiento necesario para poder atender adecuadamente y sin estigmatización a las personas que viven con VIH. Objetivos: Determinar nivel de conocimiento y disposición a atender a personas que viven con VIH. Métodos: Estudio transversal en el que se utilizó una encuesta online a profesionales y técnicos de salud que trabajaban en Centros Metropolitanos de Salud Occidente en Santiago, Chile. Resultados: La tasa de respuesta fue 32,7% (n=235). Los resultados mostraron que un 86,8% de los participantes se sentía seguro al realizar procedimientos médicos a personas que viven con VIH, esto a pesar de que uno de cada diez relacionaba la palabra VIH con miedo; 52,4% desconocía las pautas clínicas del Ministerio de Salud local; y el 42,7% identificó incorrectamente el uso de doble guante como medida de protección. Conclusiones: Los resultados de este estudio demuestran que es necesario actualizar y reforzar, en los profesionales y técnicos de la salud, el conocimiento sobre VIH y medidas de protección universales.

Resin cutback technique for interim implant-supported crowns.

This report describes the direct fabrication of interim implant-supported crowns in a single clinical session by applying a preheated composite resin to a clear silicone matrix made by diagnostic waxing. This technique facilitates the fabrication of custom interim restorations with appropriate soft-tissue molding and enables an inexpensive, predictable, functional, and esthetic outcome after implant surgery.

Immediate Implant Placement by Interradicular Bone Drilling before Molar Extraction: Clinical Case Report with One-Year Follow-Up.

The placement of immediate implants in the posterior sector is a widespread procedure where the success and survival rates are similar to those of traditional protocols. It has several anatomical challenges, such as the presence of interradicular bone septa that hinder a correct three-dimensional positioning of the implant and may compromise primary stability and/or cause damage of neighboring structures. The aim of this article is to present the treatment and the one-year clinical follow-up of a patient who received immediate implant placement using an interradicular bone-drilling technique before the molar extraction.

Functional and esthetic restorative treatment with preheated resins in a patient with ectodermic dysplasia: A clinical report.

Ectodermal dysplasia is a heterogeneous genetic condition affecting 1.6 to 22 per 100000 people. Oral manifestations associated with this condition include hyperdontia, hypodontia, microdontia, and conical teeth. Traditional treatment consists of a combination of orthodontic and rehabilitation therapies. The initial treatment stage uses removable prostheses and interim crowns for long periods, thus increasing risks for developing secondary caries. This clinical report describes the use of direct composite resin bonding with preheated compactable resins applied to vacuum-formed trays filled with clear silicone. This restorative treatment provides predictable, inexpensive, minimally invasive, functional, and esthetic recovery before orthodontic treatment.

Characterization of consultations for odontogenic abscesses in a major Chilean hospital

OBJECTIVES: To characterize consultations for odontogenic abscesses at the dental and maxillofacial unit of the public emergency hospital in Santiago, Chile. METHODOLOGY: descriptive study, involving consecutive sampling of patients with diagnosis of odontogenic abscess, conducted between august and september 2016. descriptive statistics were performed to determine the frequency of diagnosis, affected tooth, sex and need for hospitalization. RESULTS: odontogenic abscesses accounted for 6.3 percent (n=414) of a total of 6,535 consultations. males represented 59 percent; 42 percent of odontogenic abscesses presented in molars and maxillary premolars. the vestibular space was the most frequently affected anatomical space (50 percent), associated in 53 percent of the cases to submucosal abscesses. ninety-eight per cent of patients were successfully treated on an outpatient basis, 2 percent required hospitalization, mainly associated to abscesses involving the deep submandibular space. CONCLUSION: odontogenic abscesses account for a low percentage of dental emergencies at the public emergency hospital in Santiago, Chile. most cases receive outpatient treatment.

Breastfeeding knowledge of health professionals working in municipal healthcare centers in Maipu, Chile. / Conocimientos sobre lactancia materna de los profesionales de salud en centros de salud familiar municipales de Maipú, Chile.

INTRODUCTION: Healthcare provider's knowledge has been identified as a factor associated with clinical practice skills and exclusive breastfeeding prevalence. OBJECTIVES: To evaluate the level of knowledge and training in breastfeeding of healthcare provider's that work in family healthcare centers of Maipu, Chile, (midwifes, physicians, nurses and nutritionists). To determine association among level of knowledge, profession and breastfeeding training. METHODS: Quantitative, cross-sectional, analytical study. Participants were healthcare professionals regularly participating in healthy child exams of six month old babies. We used a validated survey based on the "Ten steps for successful breastfeeding". Statistical analyses included frequencies, percentages, measures of central tendency as well as the association among level of knowledge, profession and training in breastfeeding. RESULTS: Results showed that of the total number of participants (n=78), 42.2% classified as "average", 3.8% as "poor" and near 50% as "good" or "very good" knowledge. Nutritionists obtained the best scores in knowledge about breastfeeding with 50% of "very good", followed by nurses and midwifes, with 39% and 35% respectively. On the other hand, most physicians obtained "good" (65.4%) and only 7.7% "very good". Only 33% had had breastfeeding training at some point of their lives, and 6.4% had had one training session in the last year. We highlight that 34.6 to 42.3% of those who obtained "good" and "very good" scores had had breastfeeding training. Knowledge level was directly associated with breastfeeding training (p=0.033) and healthcare profession (p=0.019). CONCLUSION: Healthcare professionals have different levels of breastfeeding knowledge. Breastfeeding training sessions significantly increase knowledge, which could improve breastfeeding prevalence.

INTRODUCCIÓN: El conocimiento sobre lactancia materna de profesionales de la salud ha sido asociado a diferencias en la práctica y prevalencia de lactancia materna exclusiva. OBJETIVOS: Evaluar nivel de conocimientos sobre lactancia materna en los profesionales que participan del control de salud del niño en los centros de salud familiar de la comuna de Maipú (matrona o matrón, médico, enfermera o enfermero, nutricionista); y determinar si existe asociación entre el nivel de conocimientos, la profesión y el estado de capacitación en lactancia materna en el momento de la encuesta. MÉTODOS: Estudio de tipo cuantitativo, transversal y analítico. Los participantes fueron profesionales de salud que regularmente son parte del control de niño sano hasta el sexto mes de vida. Se aplicó una encuesta basada en los "Diez pasos para una lactancia materna exitosa". El análisis descriptivo consideró frecuencias, porcentajes y medidas de tendencia central, así como la asociación entre nivel de conocimiento, profesión y estado de capacitación. RESULTADOS: De un total de 78 participantes, 42,2% logró un concepto de calificación "regular", sólo el 3,8% obtuvo el concepto "malo" y más del 50% de los profesionales obtuvieron calificación "bueno" y "muy bueno". Los profesionales que obtuvieron mejor calificación por sus conocimientos en lactancia materna fueron nutricionistas con 50% de "muy bueno", seguido por enfermeras(os) y matronas(es) con 39% y 35% respectivamente. Por otra parte, el 65,4% de los médicos obtuvo calificación "regular" y sólo un 7,7% "muy bueno". Del total de los profesionales, sólo el 33% contaba con capacitación en lactancia materna (histórico) y 6,4% recibió capacitación en este tema durante el último año, destacando que el 34,6 y 42,3% de aquellos que obtuvieron conceptos "bueno" y "muy bueno" corresponden a profesionales capacitados. Se encontró asociación estadísticamente significativa entre el nivel de conocimiento en lactancia materna, profesión (p=0,019) y presencia de capacitación (p=0,033). CONCLUSIONES: Los profesionales de salud presentan distintos niveles de conocimientos en lactancia materna. Las capacitaciones en esta temática incrementan significativamente los conocimientos, lo que podría mejorar la prevalencia en lactancia materna.

Oral literacy demand in the pediatric dental clinic: a pilot study.

BACKGROUND: The parent's ability to obtain, process, and understand important oral health information (i.e., their oral health literacy) is directly related to their child's oral health status. AIM: To assess the relationship between oral literacy demands placed on parents by dentists and parents' understanding of dental information given to them. DESIGN: Thirty-one consenting primary caregivers of children attending their first dental visit completed a demographic survey, a REALD-30 test, and a survey to test understanding of dental information. Dental appointments, performed by eight pediatric dental residents, were audio-recorded and transcribed for qualitative analysis and descriptive statistics. RESULTS: Factors associated with language complexity were significantly higher in dental residents (R) than participants (P), that is, total number of words spoken (R: 1615.09 + 859.91 vs P: 480.68 + 232.034) and words per sentence (R: 8.82 + 1.74 vs P: 4.91 + 1.71). Speaking turns did not differ between resident and parent (R: 94.64 vs P: 83.27). CONCLUSIONS: Although the dialogue between the participating dentists and parents was highly unequal, parents understood about 86% of the information provided by the resident. Future studies are needed to identify factors associated with gaps in the educational process of parents in the dental setting.

Percepción de apoyo familiar de adultos mayores residentes en establecimientos de larga estadía / Perception of Familial Support among Older Adults Living in Long-term Establishments

PROPÓSITO: Describir la percepción de relaciones familiares que tienen los adultos mayores pertenecientes a Establecimientos de Larga Estadía de Temuco, 2016. MATERIALES Y MÉTODOS: Estudio cualitativo, fenomenológico. Se realizaron entrevistas en profundidad a diez adultos mayores residentes en diversos establecimientos de larga estadía, seleccionados por muestreo teórico. Se realizó análisis cualitativo temático utilizando NVivo11. RESULTADOS: Los relatos reflejan deseo de ser cuidados en sus hogares o en el de algún familiar, pero comprenden que esto es poco factible, ya que significaría una carga física, emocional y económica para el cuidador. Por tal motivo, asumen que la estadía en estos establecimientos es una buena opción. Si bien pocos entrevistados refirieron sentirse abandonados por sus familiares, todos coinciden en que existe un abandono generalizado al adulto mayor, especialmente cuando padece demencia. Los participantes sienten que, para mejorar este vínculo, solo pueden intentar evitar conflictos y mantener una buena comunicación. En todos los casos, la familia fue un factor influyente en el ingreso a la institución. CONCLUSIONES: El bienestar del adulto mayor institucionalizado refleja estar relacionado con el apoyo de familiares y una buena relación con ellos. El apoyo familiar mejora la calidad de vida y favorece la adaptación al lugar de residencia. Estos resultados son de importancia para formular intervenciones con un enfoque biopsicosocial. Se sugiere desarrollar y evaluar intervenciones que otorguen más apoyo a las familias, para que éstas realicen el cuidado del adulto mayor, sin que ello altere la dinámica familiar y calidad de vida de sus integrantes.

OBJECTIVE: To describe the perception of familial relationships of older adults living in long term-establishments in Temuco, in 2016. METHODS: Qualitative phenomenological study. We conducted 10 in depth interviews with older adults living in different long-term establishments, using a theoretical sampling process. Thematic qualitative analysis was conducted using NVivo 11. RESULTS: Participants' narratives reflect their wish to be taken care of at home or at a family member's home, though they understand that this is not very feasible, because it would represent a physical, emotional and financial burden for their caregiver. Therefore, they accept that being institutionalized is a good option. Even though only a few participants shared feeling abandoned by their families, all of them agree that there is a generalized abandonment of the elderly, especially if he or she has dementia. Participants feel that the only thing they can do to improve this relationship is to avoid conflicts and maintain good communication with their family members. In all cases, family was an important factor in the institutionalization of the older adults. CONCLUSIONS: The wellbeing of institutionalized older adults appears to be related to the support of family members and having a good relationship with them. Family support improves quality of life and favors the adaptation process to the institution. These results are important for the development of interventions that use a biopsychosocial perspective. It is suggested that intervention that provide more support to families, so they are able to care for older adults without disrupting family dynamics and quality of life, should be developed and evaluated.

Factors associated with early childhood caries in Chile / Factores asociados con la caries infantil precoz en Chile

Objective: To determine the prevalence of caries and identify the associated factors among children aged 2 and 4 years in southern Chile. Methods: A cross-sectional study was conducted in a random sample of 2,987 children. Dental examinations were performed in all participating children and a self-administered survey was administered to their primary caregivers. The statistical analysis included a zero inflated negative binomial regression model. Results: The prevalence of caries was 20.3% for 2-year-olds and 52.7% for 4-year-olds. The factors associated with caries included the following: living in the Bio-Bío region, PR2year-old: 1.65 (1.10-2.47), PR4year-old: 1.44 (1.18-1.75) and having a low socioeconomic position, PR2year-old: 5.39 (2.14-13.57), PR4year-old: 3.71 (2.68-5.13) or a medium socioeconomic position, PR2year-old: 2.79 (1.06-7.33), PR4year-old: 2.70 (1.92-3.79). In 4-year-olds, a high frequency of consuming sugary drinks at bedtime (PR: 1.30; 1.06-1.59), not brushing teeth daily (PR: 1.37; 1.18-1.60), and the presence of gingivitis (PR: 1.64; 1.28-2.09) were also associated with caries. Conclusions: The high prevalence of caries in this young group is concerning. The factors associated with caries identified in this study could help in the design of preventive interventions at early ages (AU)

Objetivo: Determinar la prevalencia y los factores asociados a la caries en niños y niñas de 2 y 4 años de edad en el sur de Chile. Métodos: Estudio transversal, con muestra probabilística de 2987 niños y niñas. Se realizaron exámenes dentales a los participantes y una encuesta autoadministrada a sus cuidadores. El análisis estadístico incluyó un modelo binomial negativo cero inflado. Resultados: La prevalencia de caries fue del 20,3% (2 años de edad) y del 52,7% (4 años de edad). Los factores asociados a la caries fueron vivir en la región del Bio-Bío, RP2años: 1,65 (1,10-2,47), RP4años: 1,44 (1,18-1,75), y la posición socioeconómica baja, RP2años: 5,39 (2,14-13,57), RP4años: 3,71 (2,68-5,13), o media, RP2años: 2,79 (1,06-7,33), RP4años: 2,70 (1,92-3,79). En los niños y las niñas de 4 años de edad, la alta frecuencia de consumo de bebestibles azucarados antes de dormir (RP: 1,30; 1,06-1,59), no lavarse los dientes a diario (RP: 1,37; 1,18-1,60) y la gingivitis (RP: 1,64; 1,28-2,09) se asociaron a tener caries. Conclusiones: Esta alta prevalencia de caries es preocupante. Los factores asociados a la caries identificados pueden ayudar en el diseño de intervenciones preventivas en etapas precoces (AU)

Factors associated with early childhood caries in Chile.

OBJECTIVE: To determine the prevalence of caries and identify the associated factors among children aged 2 and 4 years in southern Chile. METHODS: A cross-sectional study was conducted in a random sample of 2,987 children. Dental examinations were performed in all participating children and a self-administered survey was administered to their primary caregivers. The statistical analysis included a zero inflated negative binomial regression model. RESULTS: The prevalence of caries was 20.3% for 2-year-olds and 52.7% for 4-year-olds. The factors associated with caries included the following: living in the Bio-Bío region, PR 2 year-old: 1.65 (1.10-2.47), PR 4 year-old: 1.44 (1.18-1.75) and having a low socioeconomic position, PR 2 year-old: 5.39 (2.14-13.57), PR 4 year-old: 3.71 (2.68-5.13) or a medium socioeconomic position, PR 2 year-old: 2.79 (1.06-7.33), PR 4 year-old: 2.70 (1.92-3.79). In 4-year-olds, a high frequency of consuming sugary drinks at bedtime (PR: 1.30; 1.06-1.59), not brushing teeth daily (PR: 1.37; 1.18-1.60), and the presence of gingivitis (PR: 1.64; 1.28-2.09) were also associated with caries. CONCLUSIONS: The high prevalence of caries in this young group is concerning. The factors associated with caries identified in this study could help in the design of preventive interventions at early ages.

Factores asociados al dolor musculoesquelético en población trabajadora chilena / Factors associated with musculoskeletal pain in Chilean working population

OBJETIVO: Identificar factores asociados al reporte de dolor atribuido al trabajo en la población chilena. MÉTODOS: Se realizó un análisis utilizando la Primera Encuesta Nacional de Condiciones de Empleo, Trabajo, Salud y Calidad de vida de trabajadores en Chile 20092010. La variable resultado fue el número de localizaciones con reporte de dolor atribuido al trabajo. Se incluyeron en el análisis factores demográficos y socioeconómicos, condiciones de trabajo, conductas de salud y factores personales. Se utilizó regresiones de Poisson cero-inflado para estimar la contribución de los distintos factores sobre el dolor reportado. RESULTADOS: Uno de cada dos trabajadores reporta dolor. Ser mujer se asocia a un mayor reporte de dolor (RP: 1,47), disminuyendo en trabajadoras de edad avanzada (RP: 1,37). Los trabajadores expuestos a demandas físicas reportan 64% más localizaciones con dolor. La demanda psicológica, el bajo apoyo socio-laboral y la baja autonomía en el trabajo se asocian a mayor reporte de dolor (RP: 1,29, RP: 1,13, RP: 1,23, respectivamente). DISCUSIÓN Y CONCLUSIONES: El género y la edad son factores relevantes en el reporte del dolor asociado a trabajo. Este efecto es independiente de las distintas condiciones laborales, identificando importantes diferencias entre los distintos grupos de edad.

OBJECTIVE: Identify factors associated to pain due to work related activities, reported by chilean workers. METHODS: We conducted an analysis of the First National Survey of Work Conditions, Work, Health and workers' Quality of Life, conducted in Chile in 2009-2010. The result variable was the reported number of body parts with pain due to work. The analysis included sociodemographic variables, working conditions, health behaviors, and personal variables. We conducted zero inflated Poisson regressions to estimate the contribution of the factors on reported pain. RESULTS: One of every two workers reported pain. Women reported more pain than men (PR: 1.47), but this relationship diminished as age increased (PR: 1.37). Workers that were exposed to physicmands reported pain in 64% more body parts. Psychological demand, low social support in work, and low work autonomy were associated to more pain report (PR: 1.29, PR: 1.13, PR: 1.23 respectively). CONCLUSIONS: Gender and age are relevant factors associated to pain report due to work, even when adjusted for working conditions. Significant differences between age groups were identified.

Stages and transitions in the development of tooth brushing skills in children of Mexican immigrant families: a qualitative study.

OBJECTIVES: Compared with white children, the oral health of Latino children in the United States is much worse. One factor contributing to oral health is tooth brushing. Few studies have addressed the formation of the tooth brushing habit in children, and only one of them studied a Latino population. The purpose of this study is to explore the development of the tooth brushing habit in children of Mexican immigrant families and develop hypothesis based on its results. METHODS: This is an exploratory qualitative study, with a case study design based on 20 in-depth interviews. Participants were Mexican immigrant mothers living in Pittsburgh and Philadelphia, PA. Participants had at least one child six-years-old or younger. Interviews were recorded, transcribed verbatim, and analyzed using qualitative analysis procedures. RESULTS: Four stages were identified in the tooth brushing learning process: initiation and entirely dependent tooth brushing, assisted tooth brushing, road to tooth brushing independence, and independent tooth brushing. Two factors influenced parents' teaching approaches: parents' perceptions of their child's achievement of physical, cognitive, and motor developmental milestones and parents' knowledge about oral hygiene. CONCLUSIONS: We identified four distinct stages and found evidence to hypothesize that transitions from one stage to the next are triggered not by the age of the child but by parents' knowledge about oral hygiene and their perceptions of their child's achievement of physical, cognitive, and motor developmental milestones. Future quantitative research studies should be conducted to test this hypothesis in larger groups of Latinos as well as other ethnic groups.

Evaluation of an outpatient intervention for women with severe depression and a history of childhood trauma.

OBJECTIVE: The study examined the effectiveness of a three-month structured outpatient intervention developed for women with severe depression and childhood trauma that used brief psychodynamic psychotherapy by comparing it to standard treatment recommended in clinical guidelines issued by the Chilean Ministry of Health. METHODS: Eighty-seven women who sought treatment from a public health service in Curicó, Chile, and who had severe depression and a history of childhood traumatic experiences were randomly assigned to receive either the intervention (N=44) or standard treatment (N=43). The participants were assessed at baseline and at three months (completion of the intervention) and six months with use of the Hamilton Depression Scale (Ham-D); Lambert's Outcome Questionnaire (OQ-45.2), which rates psychiatric symptoms, interpersonal relationships, and social role functioning; and the Post-traumatic Stress Treatment Outcome scale (PTO 8), which assesses symptoms of posttraumatic stress disorder. An intent-to-treat design was used with multiple analyses of variance. RESULTS: At three months significant differences were found in favor of the intervention group in Ham-D scores (p<.001) and OQ-45.2 scores (p<.05). At six months a significantly greater proportion of the intervention group had indicators of remission as measured by the OQ-45.2 (39% versus 14%, p<.05) and by the Ham-D (22% versus 5%, p<.05). Scores on the PTO 8 indicated significant improvements in posttraumatic stress disorder symptoms at six months, although there were no significant differences between the groups. CONCLUSIONS: An outpatient intervention that screened for and focused on childhood traumas and that helped patients understand current psychosocial difficulties as a repetition of past traumas was effective in reducing psychiatric symptoms and improving interpersonal relationships and social role functioning among women with severe depression and a history of childhood trauma.