The Association between Maternal Depression, Infant Characteristics and Need for Assistance in A Low-Income-Country.

Background: Depression in the peripartum period is prevalent in low-income-countries. The identification of women needing referral is often lacking and on the other hand, women in need of support and treatment do not make use of existing support. Objectives: To identify risk factors for fetal and postnatal consequences of depression in pregnancy and to investigate further management once women at risk have been identified. Methods: The Safe Passage Study was a large prospective multicenter international study. Extensive information, including the Edinburgh postnatal depression scale (EPDS), was collected during the study. At risk women were referred to the study's social worker (SW). Women were categorized according to risk on their EPDS results. Risk categories were characterized and investigated for infant outcomes. Results: Data from 5,489 women were available for analysis and revealed a 51% prevalence of prenatal depression. Fourteen percent of at-risk women attended SW appointments, while 36% accepted the SW referral but persistently failed to attend. At risk women were significantly younger, had less formal education, had lower monthly income, and lived in more crowded conditions. They used significantly more alcohol and cigarettes. Their infants had shorter gestational ages, lower birth weights and were more growth restricted. Infants of depressed women who missed appointments weighed less and were more growth restricted. Conclusion: Women with high EPDSs had less favorable socioeconomic conditions, used more alcohol or tobacco during pregnancy, and their infants weighed less with more growth restriction. Women who repeatedly missed their appointments came from the poorest socioeconomic conditions and their infants had worse birth outcomes.

Bereaved mothers' attitudes regarding autopsy of their stillborn baby.

BACKGROUND: Here we present additional information from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated. OBJECTIVE: To explore bereaved mothers' attitudes toward obtaining an autopsy on their stillborn baby, and the future implications of consenting or non-consenting to autopsy in retrospect. METHODS: Demographic data was obtained by a questionnaire. A largely qualitative mixed-methods approach was used to meet the aims of the study, using an exploratory and descriptive research design to provide a detailed description of maternal attitudes. A semi-structured questionnaire based on information from literature and reflections on practice was administered during individual interviews. RESULTS: We interviewed 25 women who had had a recent stillbirth. The time interval between the time of consenting to autopsy and completing this study ranged from 6 to 18 months. Most participants reported that autopsy results provided peace of mind and helped alleviate their feelings of blame. Participants who were unable to comprehend the results reported negative reactions to receiving autopsy results. The majority of participants were of the opinion that they benefited from consenting to autopsy. CONCLUSION: Autopsy and the disclosure of its results generally contribute positively to coping following stillbirth.

Mammography in the evaluation of masses in breasts reconstructed with TRAM flaps.

Patients with transverse rectus abdominis musculocutaneous (TRAM) flaps may develop physical findings, such as palpable masses, irregularities, and areas of increased tenderness that are suggestive of fat necrosis or recurrent malignancy. The purpose of this study was to evaluate these findings with mammography in an attempt to rule out recurrent malignancy in the autogenously reconstructed breast. Fifteen patients on whom mammography was performed as an aid in the evaluation of suspicious post-TRAM flap findings were reviewed. Common mammographic findings included calcifications believed to demonstrate fat necrosis, benign dermal calcifications, calcified hematoma, and clustered microcalcifications. Areas of increased or decreased density without calcifications were also identified and appeared to be related to surgical changes and fat necrosis. Twenty percent of patients had clustered microcalcifications, and 20% had detectable masses on mammography. One patient had a suspicious mass associated with clustered microcalcifications, leading to a biopsy that revealed fat necrosis. The majority of findings were consistent with normal fat within the TRAM flaps. This study supports mammography as a useful diagnostic tool in patients who have undergone TRAM flap breast reconstruction and who present postoperatively with suspicious physical findings.

War experiences and distress symptoms of Bosnian children.

OBJECTIVE: The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae. METHODS: A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms. RESULTS: The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city. CONCLUSIONS: The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children.

Hamilton Anxiety Rating Scale Interview guide: joint interview and test-retest methods for interrater reliability.

The Hamilton Anxiety Rating Scale (HARS) is the most widely used semistructured assessment scale in treatment outcome studies of anxiety. Interrater reliability coefficients for the HARS have been previously reported. However, differences in the way clinicians assess symptom severity may reduce reliability. A structured interview guide--The Hamilton Anxiety Rating Scale Interview Guide (HARS-IG)--was developed to standardize clinical probe questions and to minimize interrater variance. Joint-interview and test-retest methods of interrater reliability assessment were used in a group of 30 inpatients. Intraclass coefficient calculations revealed improved interrater agreement with the HARS-IG versus the HARS. The findings of this study demonstrate that the HARS-IG is a more reliable assessment instrument than the semistructured HARS and that it meets established standards of reliability assessment.

Management of necrotic neck wounds with a "sandwich" pectoralis myocutaneous flap.

A modified pectoralis major myocutaneous flap was used to stabilize necrotic neck wounds rapidly in irradiated patients. The flap was a "sandwich" flap that included an overlying "parasternal" pectoral skin paddle for pharyngeal reconstruction, the pectoralis muscle for carotid protection, and a meshed skin graft applied to the undersurface of the muscle to replace cervical skin. This flap has been used to reconstruct seven patients with severe wound necrosis from pharyngeal fistula and infection. All patients had carotid exposure in the infected wound. Reconstruction in all patients accomplished restoration of pharyngeal continuity, carotid protection, and cervical skin replacement. Some patients required more than one procedure for closure. There were no carotid "blowouts" in any of the patients. This technique enables the head and neck surgeon to stabilize these contaminated wounds rapidly and to reconstruct complex defects of the pharynx and cervical skin.

Choledochal cyst complicated by acute cholecystitis and bypass obstruction: diagnostic role of Tc-99m-HIDA cholescintigraphy.

An unusual case of malignant degeneration of a choledochal cyst is presented. The presence of acute cholecystitis with the cystic duct originating from the cyst as well as the subsequent obstruction of the cyst-jejunal surgical anastomosis was readily detected with Tc-99m-dimethyl-iminodiacetic (Tc-99m-HIDA) cholescintigraphy.