Vascularized Bone Grafts from the Lateral Femoral Condyle for the Treatment of Avascular Lunate Necrosis (Kienböck's).

Background: Avascular necrosis of the lunate (Kienböck's disease) is rare and one of the main causes of progressive painful arthritis, requiring surgical intervention. Various approaches have shown benefits in treating Kienbock's disease but with limitations. The article aims to analyze the functional outcome using lateral femoral condyle free vascularized bone grafts (VBGs) as the first choice of treatment for Kienböck`s. Materials and methods: This was a retrospective analysis of 31 patients with Kienbock's who had microsurgical revascularization or reconstruction of the lunate between 2016 and 2021 using either corticocancellous or osteochondral VBGs from the lateral femoral condyle. The characteristics of lunate necrosis, choice of VBG and postoperative functional outcome were reviewed. Results: Corticocancellous VBGs were used in 20 patients (64.5%), while osteochondral VBGs in 11 patients (35.4%). The lunate was reconstructed in 11 patients, revascularized in 19 patients, and one patient received augmentation of a luno-capitate arthrodesis with a corticocancellous graft. We noted postoperative irritation of the median nerve (n = 3) and screw loosening requiring removal (n = 1) as minor complications. All patients had complete graft healing at eight-month follow-up and acceptable functional outcomes. Conclusions: Free VBG from the lateral femoral condyle represent a reliable method of lunate revascularisation or reconstruction in advanced Kienböck's. Their main advantages are the constant vascular anatomy, straightforward graft harvesting technique and possibility to harvest several graft types according to the requirements at the donor site. Postoperatively, the patients become pain-free and have an acceptable functional outcome.

[Hematogenous osteomyelitis due to clavicular fracture : A rare complication after conservative treatment]. / Hämatogene Osteomyelitis bei Klavikulafraktur : Eine seltene Komplikation nach konservativer Behandlung.

We present a case of a nondislocated clavicular fracture that was conservatively treated for 4 weeks with a sling. The patient was a smoker and suffered from type 2 diabetes mellitus. After 2 months a suppurative infection occurred due to an escalation based on a clavicular osteomyelitis. Through antibiotic treatment and an aggressive surgical approach the infection was cured but ended up with a painful malunion of the clavicle. The bone reconstruction was achieved with a long locking plate with an additional vascularized medial femoral condyle free flap. After 18 months the patient was subjectively very satisfied with the outcome, had no pain and excellent functional results in the Constant Murley and DASH (Disabilities of Arm, Shoulder and Hand) scores. The X­ray assessment showed full bone union.

A collaborative and evolving response to the needs of frontline workers, patients and families during the COVID-19 pandemic at Tygerberg Hospital, Western Cape Province, South Africa.

The global devastation caused by the COVID-19 pandemic and its mental health impact is undeniable. The physical and psychological consequences are wide-ranging - affecting patients fighting the disease, frontline workers in the trenches with them, healthcare staff deployed in high-care settings, and families disconnected from their loved ones in their darkest hours. Within 6 weeks of the COVID-19 outbreak in South Africa, the Department of Psychiatry at Stellenbosch University established the TBH/SU COVID Resiliency Clinic to provide psychological support to frontline workers at Tygerberg Hospital. Identified barriers in healthcare workers accessing mental healthcare resulted in moving towards an on-site visibility to try to remove some of these barriers. This greater on-site presence enabled networking and building of relationships with frontline staff that over time highlighted other frontline needs, such as providing psychosocial and spiritual support to patients and their families. We share challenges, lessons learned and recommendations from two initiatives: the TBH/SU COVID-19 Resiliency Clinic, and an embedded COVID Care Team (CCT). We describe the establishment, roll-out and progress of the Clinic and the subsequent CCT.

Increased prevalence of metabolic syndrome in patients with bipolar disorder compared to a selected control group-a Northern Netherlands LifeLines population cohort study.

OBJECTIVES: Metabolic syndrome (MetS) is highly prevalent among patients with bipolar disorder (BD). The aims of this cross-sectional study were to determine the prevalence of MetS in Dutch BD subjects and compare it with a control group, to examine the association of demographic and clinical characteristics with MetS in BD, and to determine the extent to which metabolic dysregulation is treated in those patients. METHODS: 493 Dutch adult patients (≥ 18 years) with BD receiving psychotropic drugs and 493 matched control subjects were compared using data from the biobank Lifelines. We determined MetS according to the National Cholesterol Education Program Adult Treatment Panel III-Adapted (NCEP ATP III-A) criteria. The difference in the prevalence of MetS and the associations with characteristics were analyzed with logistic regression. RESULTS: BD subjects (30.6%) showed a significantly higher prevalence of MetS compared to the control group (14.2%) (p < .001, OR:2.67, 95% CI:1.94-3.66). Univariate analysis showed that smoking, body mass index (BMI) and antidepressant drug use were associated with MetS. Multivariate analysis showed that smoking (OR:2.01) was independently associated with MetS in BD. For hypertension, hyperglycemia and lipid disorder pharmacological treatment was provided to respectively 69.5%, 24% and 18.4% of the BD subjects in our sample. LIMITATIONS: Duration of illness of BD subjects was unknown. CONCLUSIONS: This study demonstrated a higher prevalence of MetS in Dutch BD subjects compared to persons without BD. In addition, a remarkable undertreatment of some of the components of MetS was found.

The utility of PET-CT in the staging and management of advanced and recurrent malignant melanoma.

BACKGROUND: Accurate pre-operative staging and correct surgical selection of patients with malignant melanoma reduces unnecessary morbidity and mortality, improves distant control and may improve survival. 18F-fluorodeoxyglucose Positron Emission Tomography Computed Tomography (18F-FDG PET-CT) has been shown to be useful in exclusion of metastatic sites and aids in surgical planning in stage III and potentially resectable stage IV disease. The primary objective of the study was to determine whether the use of PET-CT alters the initial staging and management of patients with advanced and recurrent melanoma. METHOD: Retrospective analysis of clinical records of patients with malignant melanoma referred for staging PET-CT over a three-year period at our institution was performed. Pre- and post-PET-CT stage was recorded and a descriptive analysis was done to determine whether PET-CT resulted in a change in stage grouping and whether this change effected a change in clinical management. RESULTS: A change in stage grouping occurred in 21/39 (53.8%) of patients, 76.2% of which were up-staged and 23.8% down staged. On analysis of stage III/IV and recurrent melanoma, a change in stage occurred in 90% of stage III, 50% of stage IV and 50% of recurrent melanoma patients. This effected a change in management in 86.7% of patients with stage III, IV and recurrent melanoma collectively. CONCLUSION: PET-CT is a useful tool in the staging and subsequent management of melanoma. Its utility is pronounced in advanced and recurrent melanoma.

Investigation of the potential of buffalo and couch grasses to grow on AFIs and for removal of nutrients from paper mill wastewater.

The potential growth of buffalo grass (Stenotaphrum secundatum) and couch grass (Cynodon dactylon) on artificial floating islands (AFIs) and their ability to remove total nitrogen (TN) and total phosphorus (TP) from a simulated paper mill wastewater was studied. This was done to assess the potential of AFIs for removal of nutrients from aerated stabilization basins (ASBs) that had occasional growth of blue-green algae (BGA) to bloom levels. Small scale AFIs were prepared using polyethylene foam and planted with the grasses in 30 L of tested water. Trials were conducted in a plastic covered greenhouse over a three-month period where temperatures ranged from 15 to 44 °C. The results showed that both buffalo and couch grasses can adapt to planting in AFIs showing increases of 125% and 148% in wet weight, respectively. Nutrient uptake by buffalo grass and couch grass were found to be similar. Percentage uptakes of TP and TN from the synthetic water by the buffalo grass were 82% and 47%, whereas by couch grass, uptakes were 83% and 45%, respectively.

The distress thermometer as a prognostic tool for one-year survival among patients with lung cancer.

INTRODUCTION: The use of patient-reported outcome measures is increasingly advocated to support high-quality cancer care. We therefore investigated the added value of the Distress Thermometer (DT) when combined with known predictors to assess one-year survival in patients with lung cancer. METHODS: All patients had newly diagnosed or recurrent lung cancer, started systemic treatment, and participated in the intervention arm of a previously published randomised controlled trial. A Cox proportional hazards model was fitted based on five selected known predictors for survival. The DT-score was added to this model and contrasted to models including the EORTC-QLQ-C30 global QoL score (quality of life) or the HADS total score (symptoms of anxiety and depression). Model performance was evaluated through improvement in the -2 log likelihood, Harrell's C-statistic, and a risk classification. RESULTS: In total, 110 patients were included in the analysis of whom 97 patients accurately completed the DT. Patients with a DT score ≥5 (N = 51) had a lower QoL, more symptoms of anxiety and depression, and a shorter median survival time (7.6 months vs 10.0 months; P = 0.02) than patients with a DT score <5 (N = 46). Addition of the DT resulted in a significant improvement in the accuracy of the model to predict one-year survival (P < 0.001) and the discriminatory value (C-statistic) marginally improved from 0.69 to 0.71. The proportion of patients correctly classified as high risk (≥85% risk of dying within one year) increased from 8% to 28%. Similar model performance was observed when combining the selected predictors with QoL and symptoms of anxiety or depression. CONCLUSIONS: Use of the DT allows clinicians to better identify patients with lung cancer at risk for poor outcomes, to further explore sources of distress, and subsequently personalize care accordingly.

Recurrent Bacteremia After Heart Transplantation Due to Abandoned Lead Fragment in an Anonymous Vein-A Case Report.

Heart transplantation (HTx) represents the "gold standard" in end-stage heart failure therapy. Due to their severe heart failure and for prevention of sudden cardiac death, the majority of patients presenting for HTx will have a history of an implanted cardioverter-defibrillator (ICD). Usually, within the scope of HTx, all cardiac-implanted electronic device components are removed. In rare cases these efforts fail and some material remains. The abandoned lead fragments can cause serious complications. The case presented herein involves a patient with recurrent bacteremia after successful HTx originating from an abandoned and infected lead fragment. In 2016, a 64-year-old man received a donor heart transplant due to end-stage heart failure. Unfortunately, during the procedure, not all components of an ICD implanted in 2007 could be removed. An initially event-free period was followed by recurrent fever attacks and staphylococcal bacteremia was diagnosed. After an extensive search, the source of the bacteremia was identified by positron emission tomography-computed tomography (PET-CT), and percutaneous extraction of the abandoned and infected ICD lead fragment was scheduled. The fragment was extracted using a minimally invasive approach via percutaneous femoral vein access. The patient was discharged 3 days later, with no further complications. This case highlights the need for conscientious and complete removal of foreign material in the HTx setting. Difficult-to-diagnose sources of infection could be reliably identified by PET-CT. When required, extraction of the foreign body should be done using a minimally invasive approach.

Physiological movement disorder-like features during typical motor development.

AIM: To compare physiological age-relatedness between dyskinesia (dystonia/choreoathetosis), dystonia and ataxia rating scale scores in healthy children. METHOD: Three movement disorders specialists quantified dyskinetic-like features in healthy children (n = 52; 4-16 years) using the Dyskinesia Impairment Scale (DIS = DIS-choreoathetosis (DIS-C) + DIS-dystonia (DIS-D)). We compared the age-related regression coefficients of the DIS with data processed from previous studies on dystonia and ataxia rating scales (Burke-Fahn-Marsden Movement and Disability Scales (BFMMS and BFMDS) and Scale for Assessment and Rating of Ataxia (SARA), International Cooperative Ataxia Rating Scale (ICARS) and Brief Ataxia Rating Scale (BARS)). RESULTS: Dyskinetic scores were obtained in 79% (DIS); 65% (DIS-D) and 17% (DIS-C) versus dystonic and ataxic scores in 98% (BFMMS) and 89% (SARA/ICARS/BARS) of the children. Age-related DIS and DIS-D scores (B = -0.90 and 0.77; p < 0.001) were correlated with age-related BFMMS scores (B = -0.49; p < 0.001; r = 0.87; p < 0.001), whereas DIS-C scores were age-independent. Ataxic scores revealed stronger age-related regression coefficients than dyskinetic and dystonic scores (4-8 years; p < 0.05). INTERPRETATION: In healthy children, comparison between physiological dyskinesia, dystonia and ataxia rating scale scores revealed: 1. inverse age-relatedness for dystonic and ataxic scores, but not for choreoathetotic scores, 2. interrelated dystonic DIS-D and BFMMS scores, 3. the strongest age-related expression by ataxic scores. In healthy children, these physiological movement disorder-like features are interpreted as an expression of the developing underlying motor centres.

Modulation of key lipid raft constituents in primary rat hepatocytes by fumonisin B1 - Implications for cancer promotion in the liver.

Fumonisin B1 (FB1), a group 2B natural occurring carcinogenic mycotoxin, modulated lipid and fatty acid (FA) constituents of lipid rafts isolated from primary hepatocytes following exposure to a cytotoxic concentration of FB1 (250 µM). The major effects observed in rafts, included a significant (p < 0.05) increase in raft cholesterol (CHOL) and glycerophospholipid such as phosphatidylethanolamine (PE), whereas sphingomyelin (SM) decreased (p < 0.05). Changes in lipid constituents resulted in the disruption of important membrane fluidity parameters represented as a decreased (p < 0.05) in the phosphatidylcholine (PC)/PE and PC/(PE+SM) ratios and an increase (p < 0.05) in the CHOL/PL (PL=PC+PE) ratio, suggesting the preservation of lipid raft rigidity and integrity. Observed FA changes in the raft PE fraction included a significant (p < 0.05) increase in C18:2ω-6, C20:3ω-6, C20:4ω-6, C22:4ω-6, C22:5ω-3 and C22:6ω-3, with an increase in total ω-6 and ω-3 polyunsaturated fatty acids (PUFAs). Modulation of the FA content in PE, specifically the C20:4ω-6 PC/PE ratio and PUFA levels, together with changes in CHOL and SM are key determinants regulating the integrity and function of lipid rafts. In primary hepatocytes these changes are associated with the inhibition of cell proliferation and induction of apoptosis. A lipogenic mechanism is proposed whereby FB1 modulates lipid rafts and differentially target cell survival indices of normal and preneoplastic hepatocytes during cancer promotion in the liver.

[The dysregulated brain - Consequences of spatial and temporal brain complexity for bipolar disorder pathophysiology and diagnosis]. / Het ontregelde brein; consequenties van ruimtelijke en temporele complexiteit van het brein voor pathofysiologie en diagnostiek van de bipolaire stoornis.

BACKGROUND: Despite the existence of several pathophysiological theories about bipolar disorder, it has so far been difficult to find diagnostic biomarkers and to develop new pharmacologic treatments based on the more novel theories. AIM: To reflect on the causes and consequences of problems that beset pathophysiological research into psychiatric disorders in general and bipolar disorder in particular. METHOD: In this essay we address the problems facing professionals engaged in research into bipolar disorder and we interpret these problem in the light of brain complexity. RESULTS: The complexity of the brain can be divided into two types: spatial complexity, which reflects the various physiological levels of the central nervous system (genetic, molecular, cellular, neuronal circuits and phenomenological levels), and temporal complexity, i.e. neurodevelopment. We discuss the consequences of these two types of complexity and make suggestions relating to clinical practice and pathophysiological psychiatric research. CONCLUSION: To achieve further progress in the field of brain research, we need to acquire a deeper understanding of the spatial and temporal complexity of the brain and consider the possible consequences of such knowledge for the pathophysiology and treatment of psychiatric illnesses such as bipolar disorder.

Reconstruction of the mandibular condyle using the microvascular lateral femoral condyle flap.

The lateral femoral condyle (LFC) flap is a new flap first reported in 2015 for the treatment of osteomyelitis in hand surgery. This paper introduces a technique of osteochondral LFC flap harvest for mandibular condyle reconstruction and reports on the use of this flap in temporomandibular joint reconstruction. For condyle resection, a pre-auricular approach saving the temporal artery and vein is performed. A step osteotomy technique is used for condyle resection. LFC harvesting starts with dissection of the popliteal artery and vein. The superior genicular artery and vein are identified and followed along their periosteal branches. An osteochondral flap according to the condyle defect is harvested from the anterior pole of the knee. The flap is banded according to the defect and fixed to the mandibular neck with three miniscrews. Follow-up computed tomography scans should be performed at 1 week, 6 months, and 1year after surgery. The case of a 58-year-old female patient with osteomyelitis of the left mandibular condyle after multiple preoperative therapies is reported. The LFC flap technique was used for left condyle reconstruction, resulting in good functional and morphological outcomes at the 6-month postoperative follow-up. In conclusion, the osteochondral LFC flap is a new and promising technique for mandibular condyle reconstruction for special indications.

Establishing a multidisciplinary AIDS-associated Kaposi's sarcoma clinic: Patient characteristics, management and outcomes.

BACKGROUND: Kaposi's sarcoma (KS) typically occurs in the setting of immunodeficiency and specifically in the presence of HIV infection, when it is called AIDS-associated KS (AIDS-KS). In spite of impressive gains in the South African (SA) antiretroviral therapy (ART) roll-out programme since 2004, AIDS-KS still causes significant morbidity and mortality, and the treatment of advanced disease can be challenging owing to the centralisation of oncology services and the high incidence of concurrent infections. In 2014, a multidisciplinary AIDS-KS clinic (MKSC) was established at Tygerberg Hospital, Cape Town, with the goal of optimising management of AIDS-KS patients. OBJECTIVES: To report on the characteristics and outcomes of patients seen during the first 6 months after the inception of the MKSC. METHODS: A retrospective observational study was performed of all new cases referred to the MKSC from February to August 2014. RESULTS: Forty-two patients were included in the study. The median age was 34 years (range 20 - 60). Forty-one patients were on ART at time of diagnosis or were initiated by a median of 3 months after diagnosis. The median CD4+ count before diagnosis was 147 cells/µL (range 4 - 811). The HIV viral load was undetectable in 22 cases (52.4%). Thirty-eight patients (90.5%) were classified as AIDS Clinical Trials Group (ACTG) poor risk, 10 patients (23.8%) had visceral KS, 14 patients (33.3%) were on tuberculosis (TB) treatment at time of presentation, and 22 patients (52.4%) received oncological therapy in addition to ART. After median follow-up of 25.6 months, 2-year overall survival (OS) was 61.1%. On univariate analysis, factors significantly associated with poor 2-year OS included ACTG S1 stage (S = systemic illness), visceral KS, being on TB treatment, and Eastern Cooperative Oncology Group performance status score >2. In the T1 (T = tumour extent) subgroup, receiving chemotherapy was significantly associated with improved 2-year OS. CONCLUSIONS: Advanced AIDS-KS significantly affects young people in the Western Cape Province of SA despite 10 years of ART roll-out. There is a high prevalence of concomitant TB infection that could adversely affect adherence and response to treatment. Despite advanced disease at presentation and palliative treatment intent, survival outcomes are encouraging and seem to be positively affected by the increased use of chemotherapy. A multidisciplinary approach to diagnosis, staging and treatment and the exploration of prognostic indices specific to the sub-Saharan setting would be valuable in designing appropriate treatment algorithms.

Study protocol for the OPTion randomised controlled trial on the effect of prioritising treatment goals among older patients with cancer in a palliative setting.

PURPOSE: Traditionally, general practitioners (GPs) are not involved in cancer-related treatment decisions, despite their often long relationship with patients, and their unique position to explore patients' values, especially with older patients. Therefore, we designed a randomised controlled trial to study the effect, on self-efficacy related to treatment decisions, of a conversation about treatment goals between GPs and patients with cancer in a palliative setting. METHODS: We aim to include 168 patients aged ≥70 years with a diagnosis of non-curable cancer, due to consult their oncologist about treatment options. In the intervention group, patients will consult their GP using an Outcome Prioritisation Tool (OPT). The control group will receive care as usual. The primary outcome will be the score on a decision self-efficacy scale after the consultation with the oncologist. Secondary outcomes will be symptoms of depression, anxiety, or fatigue. In an embedded observational study of the intervention group, we aim to assess the prioritisation of treatment goals (i.e., OPT scores), and their determinants, over a six-month period. CONCLUSIONS: The OPTion study should provide relevant information about the effect on self-efficacy of a consultation between GPs and older patients with cancer, concerning preferred treatment goals in a palliative setting. Dutch Trial Register NTR5419.

Differential modulation of the lipid metabolism as a model for cellular resistance to fumonisin B1-induced cytotoxic effects in vitro.

Differential sensitivity of primary hepatocytes and Chang cells to the cancer promoter fumonisin B1 (FB1)-induced cytotoxic effects were investigated in relation to changes in membrane lipid distribution. In contrast to primary hepatocytes, Chang cells were resistant to FB1-induced cytotoxic effects. This was associated with a high cholesterol (Chol) and sphingomyelin (SM) and low phosphatidylcholine (PC) content, resulting in a significant (P<0.05) decrease in phosphatidylethanolamine (PE)/PC ratio, increased Chol/total phosphoglyceride (TPG) ratios and low total polyunsaturated fatty acids (PUFA) content in PC and PE, suggesting a more rigid membrane structure. High levels of C18:1 and reduced polyunsaturated fatty acid (PUFA) levels are likely to provide selective resistance to FB1-induced oxidative stress. FB1-associated lipid changes included decreases in SM and Chol, increases in sphinganine (Sa) and PE with the increases in key saturated, monounsaturated, and PUFAs in PE as key role players in the differential responses to FB1-induced cell growth responses in cells.

One-stage reconstruction of isolated and combined tendon defects with the vascularized adductor magnus tendon graft: Surgical technique and preliminary results.

INTRODUCTION: Secondary reconstructions of isolated and combined tendon defects are still a challenge for plastic surgeons. Due to its reliable anatomy, reconstructive potential and low donor-site morbidity, the medial femoral condyle is an ideal area for harvesting isolated and combined tendon flaps. This study evaluates our preliminary results with the vascularized adductor magnus tendon flap. PATIENT AND METHODS: The study included six patients who received a vascularized tendon flap (upper extremity: three patients; lower extremity: three patients) from 2011 to 2015. For three patients, the adductor magnus tendon was used as a single flap; for the other three patients, the tendon was included in a composite flap. A retrospective chart review provided the patients' demographic data, surgical details and the post-operative course. The further objective and patient-reported outcome was evaluated with a long-term follow-up. RESULTS: All of the free vascularized flaps healed without complications and with good vascularization upon duplex ultrasonography. One patient did, however, require revision surgery in the late post-operative course. At the end point, all patients showed good functional results without any donor-site morbidity. CONCLUSION: For carefully selected isolated and combined tendon defects on the upper and lower extremities, the vascularized adductor magnus tendon flap provides a reliable and versatile method for microsurgical reconstruction.

Evaluation of a smartphone human activity recognition application with able-bodied and stroke participants.

BACKGROUND: Mobile health monitoring using wearable sensors is a growing area of interest. As the world's population ages and locomotor capabilities decrease, the ability to report on a person's mobility activities outside a hospital setting becomes a valuable tool for clinical decision-making and evaluating healthcare interventions. Smartphones are omnipresent in society and offer convenient and suitable sensors for mobility monitoring applications. To enhance our understanding of human activity recognition (HAR) system performance for able-bodied and populations with gait deviations, this research evaluated a custom smartphone-based HAR classifier on fifteen able-bodied participants and fifteen participants who suffered a stroke. METHODS: Participants performed a consecutive series of mobility tasks and daily living activities while wearing a BlackBerry Z10 smartphone on their waist to collect accelerometer and gyroscope data. Five features were derived from the sensor data and used to classify participant activities (decision tree). Sensitivity, specificity and F-scores were calculated to evaluate HAR classifier performance. RESULTS: The classifier performed well for both populations when differentiating mobile from immobile states (F-score > 94 %). As activity recognition complexity increased, HAR system sensitivity and specificity decreased for the stroke population, particularly when using information derived from participant posture to make classification decisions. CONCLUSIONS: Human activity recognition using a smartphone based system can be accomplished for both able-bodied and stroke populations; however, an increase in activity classification complexity leads to a decrease in HAR performance with a stroke population. The study results can be used to guide smartphone HAR system development for populations with differing movement characteristics.

Consistency in recognizing microinvasion in breast carcinomas is improved by immunohistochemistry for myoepithelial markers.

Microinvasion is the smallest morphologically identifiable stage of invasion. Its presence and distinction from in situ carcinoma may have therapeutic implications, and clinical staging also requires the recognition of this phenomenon. Microinvasion is established on the basis of several morphological criteria, which may be difficult and not perfectly reproducible among pathologists. The aim of this study was to assess the consistency of diagnosing microinvasion in the breast on traditional haematoxylin and eosin (HE) stained slides and to evaluate whether immunohistochemistry (IHC) for myoepithelial markers could improve this. Digital images were generated from representative areas of 50 cases stained with HE and IHC for myoepithelial markers. Cases were specifically selected from the spectrum of in situ to microinvasive cancers. Twenty-eight dedicated breast pathologists assessed these cases at different magnifications through a web-based platform in two rounds: first HE only and after a washout period by both HE and IHC. Consistency in the recognition of microinvasion significantly improved with the use of IHC. Concordance rates increased from 0.85 to 0.96, kappa from 0.5 to 0.85, the number of cases with 100% agreement rose from 9/50 to 25/50 with IHC and the certainty of diagnosis also increased. The use of IHC markedly improves the consistency of identifying microinvasion. This corroborates previous recommendations to use IHC for myoepithelial markers to clarify cases where uncertainty exists about the presence of microinvasion. Microinvasive carcinoma is a rare entity, and seeking a second opinion may avoid overdiagnosis.

Anxiety and depression during pregnancy in Central America: a cross-sectional study among pregnant women in the developing country Nicaragua.

BACKGROUND: Around the world, maternal psychopathology during pregnancy is associated with a range of negative consequences for mother and child. Nevertheless, in Central America the magnitude of this public health problem is still unknown. The objective of this first explorative study was to investigate the prevalence and severity of anxiety and depression during pregnancy in the Central American developing country Nicaragua, as well as the availability of mental health care and to compare with a developed country. METHODS: A population-based cohort of pregnant women in Nicaragua (N = 98) was compared with a parallel cohort in the Netherlands (N = 4725) on symptoms of anxiety (Spielberger State Trait Anxiety Inventory) and depression (Edinburgh Postnatal Depression Scale). Associations with the women's knowledge how to reach professional psychological support were assessed using multivariable linear regression analyses. RESULTS: Of the Nicaraguan women, 41 % had symptoms of anxiety and 57 % symptoms of depression, versus 15 % and 6 % of the Dutch women. Symptom scores of both anxiety and depression were significantly higher in Nicaragua (p < 0.001). However, only 9.6 % of the women indicated that professional psychological help was available for the Nicaraguan pregnant women, which was associated with an increased anxiety score. CONCLUSIONS: In Nicaragua, both prevalence and severity of symptoms of antenatal anxiety and depression are substantially higher than in developed countries. However, availability of psychological help is very limited for pregnant Nicaraguan women. These findings indicate that there is need for further research and support for these women, to prevent negative consequences for both mother and child.