Prevalence and predictors of poor mental health among pregnant women in Wales using a cross-sectional survey.

OBJECTIVES: To assess the prevalence of self-reported mental health problems in a cohort of women in early pregnancy. To describe the relationship between poor mental health and sociodemographic characteristics, self-efficacy and support networks. To assess if participants were representative of the local antenatal population. RESEARCH DESIGN AND SETTING: The UK government has pledged money to provide more support for women with perinatal mental health issues. Understanding the prevalence and predicting women who may need support will inform clinical practice. This paper reports part of the larger 'Mothers Mood Study', which explored women's and midwives' experience of mild to moderate perinatal mental health issues and service provision. Routinely collected population level data were analysed and a smaller cross-sectional survey design used to assess predictors of poor mental health in early pregnancy in one health board in Wales. PARTICIPANTS: Routinely collected data were extracted for all women who registered for maternity care between May 2017 and May 2018 (n = 6312) from the electronic maternity information system (pregnant population). Over a three month period 302 of these women completed a questionnaire at the antenatal clinic after an ultrasound scan (participants). Eligible women were aged ≥18 years, with sufficient spoken and written English to complete the questionnaire and a viable pregnancy of ≤18 weeks' gestation. The questionnaire collected data on sociodemographic status, self-efficacy and support networks, self-reported mental health problems. Current anxiety and depression were assessed using the General Anxiety Disorders Assessment and Edinburgh Postnatal Depression Scale. FINDINGS: Among the pregnant population 23% (n = 1490) disclosed a mental health problem during routine questioning with anxiety and depression being the most common conditions. Participants completing the detailed questionnaire were similar in age and parity to the pregnant population with similar levels of depression (15.6%; n = 15.6 v 17.3%, n = 1092). Edinburgh Postnatal Depression Scale and General Anxiety Disorder 7 scores identified 8% with symptoms of anxiety (n = 25) or depression (n = 26) and a further 24.2% (n = 73) with symptoms of mild anxiety and 25.2% (n = 76) with mild depression. Low self-efficacy (OR 1.27, 95% CI 1.12-1.45), a previous mental health problem (OR 3.95, 95% CI 1.37-11.33) and low support from family (OR 1.13, 95% CI 1.00-1.27) were found to be associated with early pregnancy anxiety and/or depression. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Around one in five women who register for maternity care may have a mental health problem. Mild to moderate anxiety and depression are common in early pregnancy. Services need to improve for women who do not currently meet the threshold for referral to perinatal mental health services. Assessment and active monitoring of mental health is recommended, in particular for pregnant women with risk factors including a history of previous mental health difficulties, poor family support or low self-efficacy.

Risk factors for excessive gestational weight gain in a UK population: a biopsychosocial model approach.

BACKGROUND: Gestational weight gain (GWG) can have implications for the health of both mother and child. However, the contributing factors remain unclear. Despite the advantages of using a biopsychosocial approach, this approach has not been applied to study GWG in the UK. This study aimed to investigate the risk factors of excessive GWG in a UK population, employing a biopsychosocial model. METHODS: This study utilised data from the longitudinal Grown in Wales (GiW) cohort, which recruited women in late pregnancy in South Wales. Specifically, data was collected from midwife recorded notes and an extensive questionnaire completed prior to an elective caesarean section (ELCS) delivery. GWG was categorised according to Institute of Medicine (IOM) guidelines. The analysis was undertaken for 275 participants. RESULTS: In this population 56.0% of women had excessive GWG. Increased prenatal depression symptoms (Exp(B)=1.10, p=.019) and an overweight (Exp(B)=4.16, p<.001) or obese (Exp(B)=4.20, p=.010) pre-pregnancy BMI, consuming alcohol in pregnancy (Exp(B)=.37, p=.005) and an income of less than £18,000 (Exp(B)=.24, p=.043) and £25-43,000 (Exp(B)=.25, p=.002) were associated with excessive GWG. CONCLUSION: GWG is complex and influenced by a range of biopsychosocial factors, with the high prevalence of excessive weight gain in this population a cause for concern. Women in the UK may benefit from a revised approach toward GWG within the National Health Service (NHS), such as tracking weight gain throughout pregnancy. Additionally, this research provides evidence for potential targets for future interventions, and potentially at-risk populations to target, to improve GWG outcomes.

Prenatal symptoms of anxiety and depression associated with sex differences in both maternal perceptions of one year old infant temperament and researcher observed infant characteristics.

BACKGROUND: Sex differences in the behaviour of children exposed to prenatal maternal depression and anxiety have been reported. This study compared depression and anxiety symptoms reported by mothers at term with maternal perceptions of one year old male and female infant temperament and with researcher observed infant characteristics, identifying differences for males and females with both approaches. METHODS: Infant behaviour and temperament was assessed via maternally completed questionnaires including Infant Behavioural Questionnaire Revised - Short form and by researcher administered subcomponents of Laboratory Temperament Assessment Battery and Bayley Scales of Infant Development III. RESULTS: For female infants, higher prenatal scores for depression and anxiety were associated with maternal perceptions of lower bonding, higher aggression and negativity, and lower soothability (n = 67 mother-infant dyads). In the laboratory assessment, intensity of escape was the only female infant factor significantly associated with maternal mood (n = 41). For male infants, there was minimal association between prenatal mood scores and maternal perceptions (n = 46) whereas in the laboratory assessment (n = 35) depression scores were associated with expressive language, facial interest and facial fear while anxiety scores were associated with expressive and receptive language, parent behaviour and facial fear. LIMITATIONS: Findings may be restricted to a single ethnicity or mode of delivery. Fewer infants attended the infant assessment. A laboratory setting may mask symptomatology in females. CONCLUSIONS: Atypical maternal perceptions may present a barrier to the early identification of male infants impacted by maternal depression and anxiety.

Factors affecting survival in juvenile systemic sclerosis.

OBJECTIVES: To determine whether demographic, clinical and immunological features may predict the outcome in juvenile SSc (JSSc). METHODS: Clinical and laboratory characteristics of patients with JSSc collected from paediatric rheumatology centres worldwide were analysed. First, univariate tests identified those features significantly related with fatal outcome, and then multivariate logistic regression analysis was applied to determine the predictors of mortality. RESULTS: One hundred and thirty-four patients from 40 centres were eligible for the analysis. Sixteen patients died and a rapidly fatal course was observed in most of them: 4/16 died within 1 yr after diagnosis and 10/16 within 5 yrs. At the moment of diagnosis, patients with poor outcome showed a significantly higher frequency of internal organ involvement, particularly cardiac, respiratory and gastrointestinal systems. No significant difference emerged for entity of skin, vascular and musculo-skeletal involvement, nor for auto-antibodies profile and laboratory tests. Multivariate analysis showed the following factors to be significant predictors of mortality: fibrosis on chest X-rays [odds ratio (OR) 11.2], raised creatinine levels (OR 22.7) and pericarditis (OR 41.3), while a short disease duration at diagnosis conferred protection (OR 0.3). CONCLUSIONS: All patients with JSSc and fatal outcome were affected by the diffuse form of the disease, and most of them showed a very rapid progression and early signs of internal organ involvement. This suggests that, in children, SSc may have two possible courses: a rapid development of internal organ failure leading to severe disability and eventually to death, or a slow course of the disease with lower mortality.

Oropharyngeal dysphagia in juvenile dermatomyositis (JDM): an evaluation of videofluoroscopy swallow study (VFSS) changes in relation to clinical symptoms and objective muscle scores.

OBJECTIVE: To determine if objective, validated scores of muscle weakness and function [manual muscle testing (MMT), childhood myositis assessment scale (CMAS)] or scores of general disease activity or function [childhood health assessment questionnaire and physician global assessment of disease activity visual analogue scale (VAS)], can predict children at risk of swallow abnormalities in juvenile dermatomyositis (JDM) measured by videofluoroscopic swallow studies (VFSS). METHODS: Patients were referred for speech and language dysphagia assessment upon diagnosis of JDM or flare of disease. VFSS was used to document a swallow score indicating severity of swallow dysfunction. Clinical symptoms, examination findings and objective scores of disease activity were analysed. Any correlation was looked for using chi-squared Fisher exact test and linear regression models. RESULTS: Fourteen patients with inflammatory myopathy (age 2-16 years) had clinical assessments and VFSS. VFSS was abnormal in 11 children (79%). Only two children were asymptomatic at assessment, but both had swallow dysfunction, including aspiration, on VFSS. In contrast, three of the symptomatic children had a normal VFSS. No relationship was found between objective disease severity scores and VFSS swallow score. CONCLUSIONS: This study failed to show any correlation between swallow score and objective measures of muscle strength and function (MMT/CMAS) or general disease activity and function [physician VAS/childhood health assessment questionnaire (CHAQ)]. In the absence of a more accurate assessment method to determine which children with active JDM are most at risk of swallow dysfunction and aspiration, all children with active dermatomyositis should be referred for speech and language assessment and VFSS.

Juvenile localized scleroderma: clinical and epidemiological features in 750 children. An international study.

OBJECTIVE: Juvenile localized scleroderma (JLS) includes a number of conditions often grouped together. With the long-term goal of developing uniform classification criteria, we studied the epidemiological, clinical and immunological features of children with JLS followed by paediatric rheumatology and dermatology centres. METHODS: A large, multicentre, multinational study was conducted by collecting information on the demographics, family history, triggering environmental factors, clinical and laboratory features, and treatment of patients with JLS. RESULTS: Seven hundred and fifty patients with JLS from 70 centres were enrolled into the study. The disease duration at diagnosis was 18 months. Linear scleroderma (LS) was the most frequent subtype (65%), followed by plaque morphea (PM) (26%), generalized morphea (GM) (7%) and deep morphea (DM) (2%). As many as 15% of patients had a mixed subtype. Ninety-one patients (12%) had a positive family history for rheumatic or autoimmune diseases; 100 (13.3%) reported environmental events as possible trigger. ANA was positive in 42.3% of the patients, with a higher prevalence in the LS-DM subtype than in the PM-GM subtype. Scl70 was detected in the sera of 3% of the patients, anticentromere antibody in 2%, anti-double-stranded DNA in 4%, anti-cardiolipin antibody in 13% and rheumatoid factor in 16%. Methotrexate was the drug most frequently used, especially during the last 5 yr. CONCLUSION: This study represents the largest collection of patients with JLS ever reported. The insidious onset of the disease, the delay in diagnosis, the recognition of mixed subtype and the better definition of the other subtypes should influence our efforts in educating trainees and practitioners and help in developing a comprehensive classification system for this syndrome.

Inhaled mometasone furoate reduces oral prednisone requirements while improving respiratory function and health-related quality of life in patients with severe persistent asthma.

BACKGROUND: Inhaled corticosteroid therapy in severe persistent asthma has been shown to reduce or eliminate oral corticosteroid (OCS) use while retaining effective asthma control. OBJECTIVE: We sought to evaluate the ability of mometasone furoate (MF) delivered by means of dry powder inhaler to reduce daily oral prednisone requirements in OCS-dependent patients with severe persistent asthma. METHODS: We performed a 12-week, double-blind, placebocontrolled trial (21 centers, 132 patients) comparing 2 doses of MF (400 and 800 microg administered twice daily) with placebo, followed by a 9-month open-label phase in which 128 patients received treatment with MF. RESULTS: At the endpoint of the double-blind trial, MF 400 and 800 mg twice daily reduced daily OCS requirements by 46.0% and 23.9%, respectively, whereas placebo increased OCS requirements by 164.4% (P <.01). Oral steroids were eliminated in 40%, 37%, and 0% of patients in the MF 400 and 800 mg twice daily and placebo groups, respectively. Pulmonary function and quality of life significantly increased for MF-treated patients. Further reductions in OCS requirements were achieved with long-term MF treatment in the open-label phase. CONCLUSION: MF inhaled orally as a dry powder is an effective alternative to systemic corticosteroids in patients with severe persistent asthma.

Review: pneumothorax in patients with AIDS-related Pneumocystis carinii pneumonia.

A retrospective review was performed to describe the clinical characteristics, course, and outcome of pneumothorax for all patients admitted to Bellevue Hospital, New York, with AIDS who had Pneumocystis carinii pneumonia (PCP) diagnosed between January 1985, through July 1991. Of 1360 patients with AIDS and PCP, 67 patients (4.9%) were identified with pneumothorax; a group of 50 is the subject of this review. Of these 50 patients, 22 patients (44%) developed spontaneous pneumothorax, 15 patients (30%) developed pneumothorax during mechanical ventilation, and 13 patients (26%) had pneumothorax after an invasive procedure. Of the 22 patients with spontaneous pneumothorax, 8 had cystic parenchymal abnormalities on the chest radiograph and 6 had a history of PCP. The majority of patients were treated with tube thoracostomy and/or surgical intervention. All 15 patients who developed pneumothorax during mechanical ventilation died. Results of pathologic studies revealed varying degrees of interstitial inflammation and fibrosis interspersed with areas of hemorrhage and necrosis, and presence of P carinii cysts. Autopsy specimens obtained in two cases demonstrated multiple parenchymal cavities and evidence of an alveolar eosinophilic exudate with P carinii organisms. Spontaneous pneumothorax in patients with AIDS usually occurs in association with PCP and is associated with significant morbidity. Patients at risk include those with cystic lesions on chest radiograph and those patients with a history of PCP. Patients with AIDS and PCP who develop pneumothorax during mechanical ventilation have a poor outcome.

Unusual lymphoproliferative disorders in nine adults with HIV or AIDS: CT and pathologic findings.

PURPOSE: To identify characteristic computed tomographic (CT) findings in unusual pulmonary lymphoproliferative disorders seen in adults with the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS: The authors retrospectively reviewed the CT scans and pathologic specimens from nine patients with pulmonary lymphoproliferative disorders. CT scans were evaluated for nodules, reticulation, areas of ground-glass attenuation, consolidation, and bronchial disease. Changes seen in pathologic specimens were classified as consistent with classic lymphocytic interstitial pneumonitis (LIP), mucosa-associated lymphoid tissue lymphoma (MALTOMA), or atypical lymphoproliferative disorder (ALD). Immunopathologic results were reviewed when available. RESULTS: Eight patients had AIDS. Five patients had classic LIP. One patient had MALTOMA, and three patients had ALD. Altogether, 2-4-mm-diameter nodules were the predominant CT finding in eight patients; these were peribronchovascular in four patients. The presence of interstitial nodules correlated with the pathologic finding of nodular disease in seven patients. CONCLUSION: Familiarity with these AIDS-related disorders and their CT appearance should assist in the differential diagnosis.

Cytomegalovirus pneumonitis: spectrum of parenchymal CT findings with pathologic correlation in 21 AIDS patients.

PURPOSE: To identify characteristic features of cytomegalovirus (CMV) pneumonitis at computed tomography (CT), particularly markers that may help differentiate CMV from Pneumocystis carinii pneumonia. MATERIALS AND METHODS: Bronchoalveolar lavage (BAL) and biopsy results in 21 patients with acquired immunodeficiency syndrome, cytopathologic evidence of CMV infection without other infections, and available CT scans were retrospectively evaluated. CT findings were correlated with radiographic and pathologic findings when available. RESULTS: BAL findings were positive for CMV in only six cases, 13 patients had extrathoracic CMV infection, and 10 had Kaposi sarcoma. CT findings included ground-glass attenuation, dense consolidation, bronchial wall thickening or bronchiectasis, and interstitial reticulation without air-space disease (12 patients had discrete pulmonary nodules or masses). Biopsy revealed air-space disease as the dominant process in eight cases. Histopathologic findings correlated well with CT appearances. CONCLUSION: CMV pneumonitis should be suspected in patients with either extrathoracic CMV or documented Kaposi sarcoma, especially when radiographic or CT evidence of pulmonary nodules or masses exists.

Pleural tuberculosis and HIV infection.

Human immunodeficiency virus infection changes the clinical presentation of tuberculosis infection with atypical radiographs and more common extra-pulmonary involvement. We retrospectively studied pleural tuberculosis in HIV-positive patients over a 5-year period. We identified 70 patients with pleural tuberculosis by positive Mycobacterium tuberculosis cultures of pleural fluid and/or pleural tissue, including 43 HIV-positive and 27 HIV-negative patients. The HIV-positive patients were significantly younger (mean age, 38 +/- 1 years in HIV-positive vs 52 +/- 3 years in HIV-negative patients, p < 0.05). There were more intravenous drug abusers in the HIV-positive group (74 vs 30 percent, p < 0.01). The HIV-positive group had significantly fewer positive tuberculin skin tests (41 percent vs 76 percent, p < 0.03). Both groups had similar pleural fluid cellularity and pleural biopsy histologic conditions, but the HIV-positive patients demonstrated significantly more acid-fast bacteria identifiable in pleural tissue (69 percent vs 21 percent, p < 0.01), and a higher incidence of positive M tuberculosis cultures of sputum (53 percent vs 23 percent, p = 0.02). Pleural tuberculosis in HIV-positive patients presented more often as a manifestation of a greater burden of microorganisms and impaired host response.

Hemoptysis: prospective high-resolution CT/bronchoscopic correlation.

The precise roles of fiberoptic bronchoscopy (FOB) and computed tomography (CT) of the chest in the evaluation of patients presenting with hemoptysis have not been clearly defined. On the assumption that both procedures would likely provide unique and complementary information, a prospective study with blinded interpreters using a modified high-resolution CT technique (HRCT) and FOB was designed to evaluate 57 consecutive patients admitted to Bellevue Hospital with hemoptysis. Etiologies included bronchiectasis (25 percent), tuberculosis (16 percent), lung cancer (12 percent), aspergilloma (12 percent), and bronchitis (5 percent): in an additional 5 percent of cases, hemoptysis proved to be due miscellaneous causes, while in 19 percent hemoptysis proved to be cryptogenic. Patients with lung cancer all were at least 50 years old, smoked an average of 78 pack-years, and had less severe hemoptysis but of longer duration. All had conditions diagnosed both by HRCT and FOB. High-resolution CT proved of particular value in diagnosing bronchiectasis and aspergillomas, while FOB was diagnostic of bronchitis and mucosal lesions such as Kaposi's sarcoma. Fiberoptic bronchoscopy localized bleeding in only 51 percent of cases. The high sensitivity of CT in identifying both the intraluminal and extraluminal extent of central lung cancers in conjunction with its value in diagnosing bronchiectasis suggest that CT should be obtained prior to bronchoscopy in all patients presenting with hemoptysis.

Accessory cardiac bronchus: CT features and clinical significance.

PURPOSE: The accessory cardiac bronchus is a rare congenital anomaly of the tracheobronchial tree that arises from the medial wall of the bronchus intermedius. This report documents the computed tomographic (CT) appearance of this anomaly. MATERIALS AND METHODS: Six patients with this anomaly were identified. All six underwent CT; three underwent correlative bronchoscopy, and one had both bronchoscopic and surgical confirmation. RESULTS: In all six cases, a distinct airway could be identified originating from the medial wall of the bronchus intermedius. Associated lung parenchymal tissue was identified in four cases, while in three cases a discrete soft-tissue mass was seen, presumably representing vascularized bronchial or vestigial parenchymal tissue. In two cases, the lumen of the airway was filled with debris. CONCLUSION: Recognition of this anomaly is important, as associated clinical complications, including recurrent episodes of both infection and hemoptysis, may be anticipated in a small percentage of patients.

Juvenile onset Reiter's syndrome. A retrospective study of 26 patients.

Clinical, laboratory and radiological findings were evaluated in 26 children with Reiter's syndrome, all of whom met the 1982 diagnostic criteria of A. Calin. Twenty-two of the patients (85%) were male and 4 were female (15%); the mean age at onset was 10.5 years (range 4-15.5 yrs). Mean follow-up time was 28.6 months. Diarrhea prior to onset was observed in 18 cases (69%), but there was no report of venereal disease. The full classic triad was initially observed in only 9 patients (35%), urethritis alone in 6 (23%) and conjunctivitis alone in 4 (15%). Arthritis was present in all patients, with the lower limb joints involved in 25 cases (96%); the pattern was pauciarticular in 18 (69%), polyarticular in 7 (27%) and monoarticular in one (4%). There was complete remission in 15 out of the 26 patients (58%), while a sustained and fluctuating course was seen in 7 (27%) and 3 (11.5%) patients, respectively; a single patient showed a remitting course. Balanitis was present in 11 out of the 22 male (50%) cases. Twelve out of 18 patients tested (67%) proved to be HLA B27 positive and there was radiological evidence of sacroiliitis in 5 out of 24 patients (21%). Reiter's syndrome should be included in the differential diagnosis of the arthritic child. As a rule, the course of joint involvement is remittent and sequelae affecting functional capacity are indeed exceptional.

Radiographic evaluation of focal lung disease.

Optimal clinical management of patients with focal lung pathology necessitates thorough familiarity with basic concepts in imaging. Over the past decade, radiologic evaluation has undergone rapid change, reflecting considerable growth in imaging technology. As this article discusses and illustrates at length, improvements in computed tomography technology in particular have resulted in a significant alteration in our approach to both the diagnosis and treatment of patients with focal lung disease.

Imaging of the intensive care unit patient.

Despite advances in "high tech," it is anticipated that plain chest film radiography will continue to play a significant role in the management of patients in the ICU. Digital radiography will most likely displace conventional approaches. As demonstrated throughout this article, CT has played an increasingly important role in the evaluation of the critically ill patient. The results are especially impressive, because most were obtained on earlier-generation CT machines, which are now totally outdated. Newer scanners have many technical improvements, including rapid scanning, which permits breathholding, and thin-section scanning, which has been discussed in great detail throughout this volume. Whether MR imaging will play an important role in ICU care remains to be determined.

Evaluation of the measurement methods for protrusio acetabuli in normal children.

The normal values of the radiological lines most frequently used as references in the diagnosis of adult protrusio acetabuli were prospectively determined in 150 children (300 hips) without femoral pathology and aged between 2 and 15 years, mean age 8 years. The teardrop shape was modified according to the child's age, the "crossed" type predominating (48.7%). The mean centre edge (CE) angle fluctuated, with a median value of 31.2 degrees +/- 6.2 degrees, increasing with age and with slightly greater values in females; a large spread of CE angle values was observed within age groups. Acetabular ilioischial line values ranged from +7 to -5 mm, with a mean of +1.8 +/- 2 mm. This last method was the most suitable because it was not modified by changes in incidence of X-rays in radiological studies. With this method protrusio is diagnosed in children when the acetabular line is projected medially, provided that the ilioischial line is 1 or 3 mm or more for boys and girls, respectively. We conclude that the most trustworthy method available to evaluate PA in children should be "line crossing".

Kaposi's sarcoma. CT-radiographic correlation.

The role of CT in the diagnosis of intrathoracic Kaposi's sarcoma (KS) was evaluated retrospectively in 24 patients, in the absence of coexistent opportunistic infections. In all cases the diagnosis of KS was initially established by histologic evaluation of extrathoracic disease: 15 patients had verified parenchymal KS and nine patients endobronchial KS. (Chest roentgenograms were analyzed separately for each group: in 14 patients serial films were available for review. The predominant radiographic findings was the presence of nonspecific, bilateral, perihilar infiltrates in 22 of 24 cases (92 percent). Corresponding CT scans documented the presence of abnormal hilar densities characteristically extending into the adjacent pulmonary parenchyma along distinctly perivascular and peribronchial pathways. Discrete, poorly marginated nodules were identified radiographically in ten cases (42 percent); these proved to be randomly distributed throughout the parenchyma on CT. Radiographic evidence of mediastinal adenopathy was distinctly unusual, seen in only two cases (8 percent). While CT typically demonstrated shotty adenopathy, significantly enlarged nodes (greater than 1 cm) were rarely identified. We concluded that CT is more specific than routine roentgenograms for identifying pulmonary KS. While not pathognomonic, peribronchial and perivascular disease is sufficiently characteristic to obviate more invasive diagnostic procedures, especially in patients with established KS.

Septic pulmonary emboli: CT-radiographic correlation.

Radiographic and CT findings in 15 patients with clinically documented septic pulmonary emboli were compared retrospectively. In most cases, radiographic changes were nonspecific. In comparison, on CT a combination of specific signs could be identified in all patients. These included peripheral nodules with clearly identifiable feeding vessels associated with metastatic lung abscesses (10 [67%] of 15 cases), and subpleural, wedge-shaped densities with and without necrosis caused by septic infarcts (11 [73%] of 15 cases). Ancillary pleural, mediastinal, axillary, and pericardial abnormalities also were more easily identified with CT. We conclude that CT is complementary to other imaging techniques in the recognition of septic pulmonary emboli.