ABSTRACT
INTRODUCTION: Antenatal depression is associated with a broad range of suboptimal outcomes in offspring, although the underlying mechanisms are not yet understood. Animal studies propose inflammation and glucocorticoids as mediators of the developmental programming effect of prenatal stress on offspring stress responses, but studies in humans are not yet at this stage. Indeed, to date no single study has examined the effects of a rigorously defined, clinically significant Major Depressive Disorder (MDD) in pregnancy on maternal antenatal inflammatory biomarkers and hypothalamic-pituitary (HPA) axis, as well as on offspring HPA axis, behavior and developmental outcomes in the first postnatal year. METHODS: A prospective longitudinal design was used in 106 women (49 cases vs. 57 healthy controls) to study the effect of MDD in pregnancy and associated antenatal biology (inflammatory and cortisol biomarkers), on offspring stress response (cortisol response to immunization, at 8 weeks and 12 months), early neurobehavior (Neonatal Behavioral Assessment Scale, NBAS, at day 6), and cognitive, language and motor development (Bayley Scales of Infant and Toddler Development at 12 months). RESULTS: Compared with healthy controls, women with MDD in pregnancy had raised interleukin (IL) IL-6 (effect size (δ)â¯=â¯0.53, pâ¯=â¯0.031), IL-10 (δâ¯=â¯0.53, pâ¯=â¯0.043), tumor necrosis factor alpha (δâ¯=â¯0.90, pâ¯=â¯0.003) and vascular endothelial growth factor (δâ¯=â¯0.56, pâ¯=â¯0.008), together with raised diurnal cortisol secretion (δâ¯=â¯0.89, pâ¯=â¯0.006), raised evening cortisol (δâ¯=â¯0.64, pâ¯=â¯0.004), and blunted cortisol awakening response (δâ¯=â¯0.70, pâ¯=â¯0.020), and an 8-day shorter length of gestation (δâ¯=â¯0.70, pâ¯=â¯0.005). Furthermore, they had neonates with suboptimal neurobehavioral function in four out of five NBAS clusters measured (range of δâ¯=â¯0.45-1.22 and pâ¯=â¯0.049-<0.001) and increased cortisol response to stress at one year of age (δâ¯=â¯0.87, pâ¯<â¯0.001). Lastly, maternal inflammatory biomarkers and cortisol levels were correlated with infant stress response, suggesting a mechanistic link. CONCLUSION: This study confirms and extends the notion that depression in pregnancy is associated with altered offspring behavior and biological stress response, and demonstrates that changes in maternal antenatal stress-related biology are associated with these infant outcomes.
Subject(s)
Depressive Disorder, Major/metabolism , Depressive Disorder, Major/physiopathology , Prenatal Exposure Delayed Effects/metabolism , Adult , Child Behavior/physiology , Child Development/physiology , Child, Preschool , Depression/metabolism , Depressive Disorder, Major/complications , Female , Humans , Hydrocortisone/analysis , Hypothalamo-Hypophyseal System , Infant , Infant, Newborn , Inflammation/metabolism , Male , Mother-Child Relations/psychology , Pituitary-Adrenal System , Pregnancy , Pregnancy Complications/metabolism , Pregnancy Complications/physiopathology , Prenatal Diagnosis , Prospective Studies , Stress, Psychological/metabolismABSTRACT
The Ministry of Health (MOH) has published clinical practice guidelines on Bipolar Disorder to provide doctors and patients in Singapore with evidence-based guidance on the management of bipolar disorders. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Bipolar Disorder, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http: //www.moh.gov.sg/content/moh_web/home/Publications/guidelines/clinical_practiceguidelines/2011/bipolar_disorder.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
Subject(s)
Bipolar Disorder , Adolescent , Adult , Child , Humans , Bipolar Disorder/diagnosis , Bipolar Disorder/therapy , Evidence-Based Medicine , Psychiatry/methods , Psychiatry/standards , SingaporeABSTRACT
Laparoscopic cholecystectomy for acute cholecystitis is a feasible but difficult operation that should only be performed by experienced laparoscopists. Specific modifications to the standard technique of laparoscopic cholecystectomy is described in this review. The conversion to open surgery rate is high, mostly due to dense adhesions obscuring Calot's triangle. However, if successfully completed without complications, the postoperative recovery is superior to the conventional procedure.
