Unfolding of maternal-infant bonding amidst the COVID-19 pandemic: Social support as a risk and protective factor.

BACKGROUND: Social, familial, and physiological stressors may put maternal-infant bonding at risk. Therefore, it is plausible that the stressful conditions brought on by COVID-19 could influence maternal-infant bonding. This study aimed to elucidate the contribution of COVID-19-related experience to variance in maternal-infant bonding, beyond that of established risk factors and as moderated by social support. METHODS: This longitudinal, multicenter study examined the relationship of demographic and obstetric variables, social support, postpartum depression, as well as COVID-19-related fear, exposure, and subjective difficulty with mother-infant bonding six months following birth. Participants (N = 246) were women who delivered during the pandemics' strict lockdown period and were recruited 10 weeks after a liveborn delivery and followed up six months later. RESULTS: Relationship between fear of COVID-19 and maternal-infant bonding was moderated by social support: Amongst mothers with high levels of social support, fear of COVID-19 negatively predicted bonding. DISCUSSION: Results indicate that social support, while overall a protective factor for mother-infant bonding, may lose its buffering effect when fear of COVID-19 is high. This relationship was maintained even when early bonding experiences such as forced separation and the risk incurred by postpartum depression were accounted for. Implications for providers are discussed.

A pilot study of a stepped-care brief intervention to help psychologically-distressed women displaced by conflict in Bogotá, Colombia.

BACKGROUND: Colombia's 6.5 million internally displaced persons (IDPs) have been exposed to trauma, loss, and hardships. Common mental disorders (CMDs) are prevalent in this group, yet there are few evidence-based psychosocial interventions for this population. We assessed the feasibility and acceptability of a stepped-care intervention for women IDPs in Bogota, Colombia. METHODS: Feasibility to recruit participants for an intervention trial, to screen for CMDs and displacement-related traumas, to refer high-risk cases to professional consultation, to implement evidence-based interpersonal counseling (IPC) for women with diagnosed CMDs, to retain participants in the intervention, and to conduct follow-up assessments was assessed. Assessment instruments were validated. The intervention was delivered by trained outreach personnel. Intervention acceptability was assessed by monitoring session attendance, dropout rates, and satisfaction. Potential efficacy was evaluated with pre- and post-intervention measures of CMDs. RESULTS: We recruited 279 women IDPs into the intervention. On screening, 177 (63.4%) had symptom levels suggesting a CMD. Participants endorsed a wide range of displacement-related exposures. Most participants receiving IPC decreased their symptom levels at follow-up. Many participants did not complete the recommended number of IPC sessions; loss to follow-up was 30%. The performance of the outreach personnel improved after the initial intervention team was replaced with community members trained to deliver the intervention. The Bogotá health system was unable to reliably accommodate emergency psychiatric referrals. CONCLUSIONS: The IPC intervention shows promise, but significant challenges remain for improving reach, adherence, and participant retention. We identified strategies and partnerships to redress some of the main study limitations.

9/11-related PTSD among highly exposed populations: a systematic review 15 years after the attack.

BACKGROUND: The 11 September 2001 (9/11) attacks were unprecedented in magnitude and mental health impact. While a large body of research has emerged since the attacks, published reviews are few, and are limited by an emphasis on cross-sectional research, short time frame, and exclusion of treatment studies. Additionally, to date, there has been no systematic review of available longitudinal information as a unique data set. Consequently, knowledge regarding long-term trajectories of 9/11-related post-traumatic stress disorder (PTSD) among highly exposed populations, and whether available treatment approaches effectively address PTSD within the context of mass, man-made disaster, remains limited. METHODS: The present review aimed to address these gaps using a systematic review of peer-reviewed reports from October 2001 to May 2016. Eligible reports were of longitudinal studies of PTSD among highly exposed populations. We identified 20 reports of 9/11-related PTSD, including 13 longitudinal prevalence studies and seven treatment studies. RESULTS: Findings suggest a substantial burden of 9/11-related PTSD among those highly exposed to the attack, associated with a range of sociodemographic and back-ground factors, and characteristics of peri-event exposure. While most longitudinal studies show declining rates of prevalence of PTSD, studies of rescue/recovery workers have documented an increase over time. Treatment studies were few, and generally limited by methodological shortcomings, but support exposure-based therapies. CONCLUSION: Future directions for research, treatment, and healthcare policy are discussed.

Subtypes of depressive symptoms and inflammatory biomarkers: An exploratory study on a sample of HIV-positive patients.

Depressive symptoms cause major impairment and may accelerate HIV progression despite the use of antiretroviral medication. The somatic symptoms criteria for HIV infection and depression partially overlap, which can make differential diagnosis challenging. Because of chronic inflammation caused by HIV infection, HIV-positive patients may develop somatic and affective-cognitive symptoms of depression. Inflammation-related depression is primarily characterized with severe somatic symptoms such as fatigue and sleep disturbance. This study sought to explore the patterns of somatic and cognitive-affective depressive symptoms that characterize HIV-positive patients. Our specific aims were (1) to identify subtypes of depressive symptoms in a sample of HIV-positive patients; and (2) to test the subtypes' difference on inflammatory and HIV disease progression biomarkers. HIV-positive men and women (N=102) with and without depressive symptoms were randomly selected from an Italian HIV clinic. Depressive symptoms (PHQ-9), viral load (VL), CD4+, Il-6, TNF-α, and monocytes were assessed. The three subtypes formed using Latent Class Analysis (LCA) identified patients with (1) severe cognitive-affective and somatic depressive symptoms; (2) severe/moderate somatic symptoms; and (3) absent or low depressive symptoms. The subtype with severe/moderate somatic symptoms was characterized with elevated levels of Il-6 and monocytes. No difference on HIV progression biomarkers was found. The subtypes of depressive symptoms might help differentiating depressive symptoms from HIV- and inflammatory-related somatic symptoms. When present, cognitive-affective and/or somatic symptoms cause significant impairment to patients' lives and thus warrant further assessment and treatment.

Rates of risk-reducing surgery in Israeli BRCA1 and BRCA2 mutation carriers.

The frequency of BRCA1 and BRCA2 mutations is higher in Israel than in almost all other countries. One strategy to reduce the burden of hereditary breast and ovarian cancers is to offer genetic testing followed by risk-reducing surgery (mastectomy and salpingo-oophorectomy) for mutation carriers. The extent to which Israeli women who carry mutations undergo these surgeries is not well characterized. Israeli women who are BRCA1 or BRCA2 mutation carriers and followed at a single high-risk clinic were asked to complete a questionnaire detailing their clinical histories at the time of genetic results disclosure and a follow-up questionnaire was completed 18 or more months thereafter. A total of 205 mutation carriers completed the questionnaires. Of 170 women with no cancer history, 84 (49%) had a risk-reducing bilateral salpingo-oophorectomy and 22 (13%) had a risk-reducing mastectomy. Five of 35 (14.3%) women with breast cancer opted for contralateral mastectomy. Approximately one half of Israeli women with a BRCA1 or BRCA2 mutation opt for risk-reducing oophorectomy, but the rate of risk-reducing mastectomy is only 13%.

Bowel obstruction in recurrent gynecologic malignancies: defining who will benefit from surgical intervention.

AIM: To define factors that could help select, in a cohort of gynecologic cancer patients with malignant gastro-intestinal obstruction, those most likely to benefit from palliative surgery. METHODS: In this retrospective study of patients with malignant gastro-intestinal obstruction who underwent palliative surgery in our institute over 7 years, outcome measures were oral intake, chemotherapy, and 30-day, 60-day and overall survival. Based on Cox proportional-hazards regression models and Kaplan-Meier curves with log-rank tests, a prognostic score was developed to identify those most likely to benefit from surgery. RESULTS: Sixty-eight palliative surgeries were performed in 62 patients with ovarian (69.1%), primary-peritoneal (8.8%), cervical (11.8%) or uterine (10.3%) malignancies. Procedures were colostomy (26.5%), ileostomy (39.7%), colonic stent (1.5%), gastrostomy (7.3%), gastroenterostomy (5.9%) and bypass/resection and anastomosis (19.1%). Eighteen patients died prior to discharge, within 3-81 days (median 25 days). The 30-day and 60-day mortality rates were 14.7% and 29.4%, respectively. Postoperative oral-intake and chemotherapy rates were 65% and 53%, respectively, with albumin level identified on multivariate analysis as the only significant predictor of both. Median postoperative survival was 106 days (3-1342). Bypass/resection and anastomosis was associated with improved survival. Ascites below 2 L, younger age, ovarian primary tumor, and higher blood albumin correlated with longer postoperative survival. A prognostic index based on these factors was found to identify patients with increased 30-day and 60-day mortality. CONCLUSIONS: Our proposed prognostic index, based on age, primary tumor, albumin and ascites, might help select those gynecological cancer patients most likely to benefit from palliative surgery.

Assessment of endometrial sampling as a predictor of final surgical pathology in endometrial cancer.

BACKGROUND: The histology and grade of endometrial cancer are important predictors of disease outcome and of the likelihood of nodal involvement. In most centres, however, surgical staging decisions are based on a preoperative biopsy. The objective of this study was to assess the concordance between the preoperative histology and that of the hysterectomy specimen in endometrial cancer. METHODS: Patients treated for endometrial cancer during a 10-year period at a tertiary cancer centre were identified from a prospectively collected pathological database. All pathology reports were reviewed to confirm centralised reporting of the original sampling or biopsy specimens; patients whose biopsies were not reviewed by a dedicated gynaecological pathologist at the treating centre were excluded. Surgical pathology data including histology, grade, depth of myometrial invasion, cervical stromal involvement and lymphovascular space invasion (LVSI) as well as preoperative histology and grade were collected. Preoperative and final tumour cell type and grade were compared and the distribution of other high-risk features was analysed. RESULTS: A total of 1329 consecutive patients were identified; 653 patients had a centrally reviewed epithelial endometrial cancer on their original biopsy, and are included in this study. Of 255 patients whose biopsies were read as grade 1 (G1) adenocarcinoma, 45 (18%) were upgraded to grade 2 (G2) on final pathology, 6 (2%) were upgraded to grade 3 (G3) and 5 (2%) were read as a non-endometrioid high-grade histology. Overall, of 255 tumours classified as G1 endometrioid cancers on biopsy, 74 (29%) were either found to be low-grade (G1-2) tumours with deep myometrial invasion, or were reclassified as high-grade cancers (G3 or non-endometrioid histologies) on final surgical pathology. Despite these shifts, we calculate that omitting surgical staging in preoperatively diagnosed G1 endometrioid cancers without deep myometrial invasion would result in missing nodal involvement in only 1% of cases. CONCLUSIONS: Preoperative endometrial sampling is only a modest predictor of surgical pathology features in endometrial cancer and may underestimate the risk of disease spread and recurrence. In spite of frequent shifts in postoperative vs preoperative histological assessment, the predicted rate of missed nodal metastases with a selective staging policy remains low.

Early adenocarcinoma of the cervix: is radical vaginal trachelectomy safe?

OBJECTIVE: Radical vaginal trachelectomy (RVT) is a revolutionary option for fertility preservation in young women with early cervical tumors. Several series have demonstrated outcomes comparable to radical hysterectomy (RH), but none has addressed the influence of histology. We evaluated the safety of RVT in adenocarcinomas. METHODS: Data on surgically treated adenocarcinoma (AC) and squamous cell carcinoma (SCC) cases was taken from a centralized Toronto Cervical Cancer Database. Prognostically important tumor features, lymph node status, and the use of adjuvant therapies were compared. Adenocarcinoma cases treated with RVT were compared to AC cases treated with RH, and to SCC cases that had RVT. Recurrence-free survival was calculated from the date of surgery. Medians, proportions, and survival curves were compared with the Mann Whitney test, the Chi-square test, and the Log Rank test, respectively. RESULTS: 74 patients with AC and 66 patients with SCC undergoing RVT, and 187 cases of AC undergoing RH were analyzed. Patients undergoing RVT were younger than patients having RH (31 vs. 40, p<0.001). Tumor characteristics were similar, but depth of invasion and the frequency of high grade lesions were higher in the RH group (5 mm vs. 3 mm, p<0.001; and 36% vs. 22%, p=0.04). Adjuvant treatment was given more frequently after RH (12% vs. 3%, p<0.05). There was no significant difference in recurrence-free survival between RH and RVT for AC, or between AC and SCC patients treated by RVT. CONCLUSIONS: RVT is a safe alternative for early stage cervical adenocarcinoma in appropriately selected patients wishing to preserve fertility.