Concealed pregnancy: prevalence, perinatal measures and socio-demographics.

A target group of women who concealed their pregnancy (n = 43) was compared to an aged-matched control group (n = 30) that experienced a crisis pregnancy. Comparisons were also made with a larger dataset (n = 6363) of births in University Hospital Galway (UHG) (normative group). Data was analysed using the Chi-square test and the Kolmogorov-Smirnoff two-sample test. The number of women from the target group that were from a rural background was 28 (65%), compared to 10 (33%) from the control group. The number of women from the target group that feared a negative parental reaction to the pregnancy was 34 (79%), compared to 12 (40%) from the control group. The birth weight in the target group was 4009 lower than the normative birth weight. The average age of women who concealed was 8 years lower than the normative age. The prevalence of concealed pregnancy in UHG was one in every 148 births.

ATLANTIC DIP: pregnancy outcomes for women with type 1 and type 2 diabetes.

ATLANTIC DIP prospectively evaluated the perinatal and maternal outcomes of pregnancies complicated by Type 1 and Type 2 diabetes during 2006/2007 in 5 antenatal centres. All women with established diabetes for at least 6 months prior to the index pregnancy and booking for antenatal care between 1/1/2006 and 31/12/2007 were included in the study. Results were collected electronically via the DIAMOND Diabetes Information System. Pregnancy outcome was compared with that of the background population receiving antenatal care in the region during the same time. There were 104 singleton pregnancies during the period of study. The stillbirth rate (SBR) of 25/1000 was 5 times greater than that reported in the background population at 5/1000 and the perinatal mortality rate (PMR) of 25/1000 was 3.5 times greater than background 7/1000. The congenital malformation rate (CMR) of 24/1000 was twice that observed in the background population. Women were not well prepared for pregnancy with 28% receiving pre pregnancy care (PPC), 43% receiving pre pregnancy folic acid and 51% achieving a HbA1C < = 7% at first antenatal visit. Pregnancy induced hypertension (PIH) and/or pre eclampsia toxaemia (PET) were three times more common than in women in the background population. In conclusion women are not well prepared for pregnancy. Maternal and infant morbidity and infant mortality are greater in women with diabetes. A regional pre pregnancy care (PPC) programme and centralised glucose management are urgently needed.

Atlantic DIP: the prevalence and consequences of gestational diabetes in Ireland.

ATLANTIC DIP carried out a universal screening programme for gestational diabetes mellitus (GDM) along the Irish Atlantic seaboard. Using a 75g OGTT and new International Association of Diabetes in Pregnancy Study Groups (IADPSG) cut off points for diagnosis we found the prevalence of GDM to be 12.4%. Pregnancies complicated by GDM displayed increased morbidities for mother and infant when compared to women who had normal glucose tolerance. With rising obesity levels and older age of mothers, both risk factors for GDM, these results would support a national universal screening programme.

Undertaking a face-to-face objective structured clinical examination for medical students during the COVID-19 pandemic.

INTRODUCTION AND AIMS: Objective structured clinical examinations (OSCEs) play a pivotal role in medical education assessment. The Advanced Clinical Skills (ACS) OSCE examines clinical skills in psychiatry, general practice, obstetrics and gynaecology and paediatrics. This study examined if the 2020 ACS OSCE for fourth year medical students attending the National University of Ireland, Galway, was associated with any significant result differences compared to the equivalent 2019 OSCE. Additionally, we assessed students' satisfaction and explored any organisational difficulties in conducting a face-to-face OSCE during the COVID-19 pandemic. MATERIALS AND METHODS: This study compared anonymised data between the 2019 and 2020 ACS OSCEs and analysed anonymised student feedback pertaining to the modified 2020 OSCE. RESULTS: The mean total ACS OSCE result achieved in 2020 was statistically higher compared to the 2019 OSCE [62.95% (SD = 6.21) v. 59.35% (SD = 5.54), t = 6.092, p < 0.01], with higher marks noted in psychiatry (p = 0.001), paediatrics (p = 0.001) and general practice (p < 0.001) with more students attaining honours grades (χ2 = 27.257, df = 3, p < 0.001). No difference in failure rates were found. Students reported feeling safe performing the 2020 OSCE (89.2%), but some expressed face-mask wearing impeded their communication skills (47.8%). CONCLUSION: This study demonstrates that conducting a face-to-face OSCE during the pandemic is feasible and associated with positive student feedback. Exam validity has been demonstrated as there was no difference in the overall pass rate.

Digital fetal scalp stimulation (dFSS) versus fetal blood sampling (FBS) to assess fetal wellbeing in labour-a multi-centre randomised controlled trial: Fetal Intrapartum Randomised Scalp Stimulation Trial (FIRSST NCT05306756).

BACKGROUND: Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery. METHODS: A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5-6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group. DISCUSSION: If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections. TRIAL REGISTRATION: ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019.

Atlantic Diabetes in Pregnancy (DIP): the prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria.

AIMS/HYPOTHESIS: New diagnostic criteria for gestational diabetes mellitus (GDM) have recently been published. We wished to evaluate what impact these new criteria would have on GDM prevalence and outcomes in a predominantly European population. METHODS: The Atlantic Diabetes In Pregnancy (DIP) programme performed screening for GDM in 5,500 women with an oral glucose tolerance test at 24-28 weeks. GDM was defined according to the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and compared with previous WHO criteria; maternal and neonatal adverse outcomes were prospectively recorded. RESULTS: Of the participants, 12.4% and 9.4% were diagnosed with GDM using IADPSG and WHO criteria, respectively. IADPSG GDM pregnancies were associated with a statistically significant increased incidence of adverse maternal outcomes (gestational hypertension, polyhydramnios and Caesarean section) and neonatal outcomes (prematurity, large for gestational age, neonatal unit admission, neonatal hypoglycaemia and respiratory distress). The odds ratio for the development of these adverse outcomes remained significant after adjustment for maternal age, body mass index and non-European ethnicity. Those women who were classified as having normal glucose tolerance by WHO criteria but as having GDM by IADPSG criteria also had significant adverse pregnancy outcomes. CONCLUSIONS/INTERPRETATION: GDM prevalence is higher when using newer IADPSG, compared with WHO, criteria, and these women and their offspring experience significant adverse pregnancy outcomes. Higher rates of GDM pose a challenge to healthcare systems, but improved screening provides an opportunity to attempt to reduce the associated morbidity for mother and child.

Early gestational diabetes mellitus (GDM) is associated with worse pregnancy outcomes compared with GDM diagnosed at 24-28 weeks gestation despite early treatment.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated+ with adverse pregnancy outcomes compared with women with normal glucose tolerance in pregnancy. The WHO recommends screening at 24-28 weeks gestation for GDM. Women who are diagnosed before 24-28 weeks gestation have a longer intervention period which may impact positively on pregnancy outcomes. AIM: This study aimed to examine pregnancy outcomes of women with GDM diagnosed <24 weeks gestation compared with those diagnosed at 24-28 weeks in a large Irish cohort. METHODS: A retrospective cohort study of 1471 pregnancies in women with GDM diagnosed using IADPSG criteria between September 2012 and April 2016 was conducted. At GDM diagnosis, women were classified as early GDM <24 weeks or standard GDM 24-28 weeks gestation. RESULTS: Women with early GDM had a significantly greater risk of pregnancy-induced hypertension (12.4% vs. 5.3%; P < 0.05), post-partum haemorrhage (8.7% vs. 2.4%; P < 0.05) and post-partum glucose abnormalities (32% vs. 15.6%; P < 0.05). Their offspring had a greater risk of pre-maturity (10.9% vs. 6.6%; P < 0.05), stillbirth (1.4% vs. 0.5%; P < 0.05), large for gestational age (19.1% vs. 13.4% P < 0.05) and need neonatal intensive care (30.7% vs. 22.1%; P < 0.05) compared with offspring of women with standard GDM. Rates of C-section and pre-maturity were still higher in the early GDM group when the two groups where compared based on their post-natal OGTT. CONCLUSION: Early GDM women and their offspring are at greater risk of an adverse pregnancy outcome compared with those diagnosed at 24-28 weeks. In view of the abnormal post-natal glucose findings, early GDM may reflect a more advanced state in diabetes pathogenesis.

Activated protein C resistance (APCR) and placental fibrin deposition.

Activated protein C resistance (APCR) results in an ineffective anticoagulant response leading to an increased risk of thrombosis, particularly during pregnancy. Adverse pregnancy outcomes including pre-eclampsia (PET), intrauterine growth restriction (IUGR), recurrent miscarriage and placental abruption have been linked with thrombotic lesions compromising the utero-placental circulation. Using histological staining including Martius Scarlet Blue (MSB) and Haematoxylin and Eosin (H&E) and microscopy, we studied placental fibrin deposition and histological abnormalities in subjects (n=23) with APCR (APCR group), based on a ratio of less than or equal to 2.1s with the Coatest classic test and subjects (n=11) with an APC ratio in the normal range, greater than 2.1s (APCN group). Fibrin deposition was significantly higher (3.3-fold) in the APCR group compared to the APCN group. An inverse correlation between APC ratio and placental fibrin deposition was determined for the study group. Histological abnormalities were more than 2-fold higher in the APCR group compared to the APCN group. Molecular screening identified common thrombophilic mutations, FVL and FII-G20210A in the APCR group but not in the APCN group.

Screening for haemoglobinopathy--a comparison of two methods in an Irish maternity unit.

Two-pronged retrospective and prospective studies were carried out to compare opportunistic versus systematic screening for carriers of haemoglobinopathy in an Irish maternity unit. Identification was either performed opportunistically on the basis of ethnicity or systematically on the basis of a low mean corpuscular haemoglobin. A comparison was made between the numbers that were tested for haemoglobinopathy and subsequent detection rates. In the prospective study women were identified again on the basis of either ethnicity or a low MCH and all women identified were tested for haemoglobin variants. A comparison was made between the numbers tested and subsequent detection rates. In both studies systematic screening identified similar rates as opportunistic screening. However, opportunistic screening identified a greater absolute number of carriers. Our retrospective study showed a disappointing uptake of testing of those identified, regardless of the method of screening. Better identification of carriers requires that all those identified as at-risk of haemoglobinopathy carriage should be tested, irrespective of the method of screening.

The dexamethasone suppression test and familial subtypes of depression--a naturalistic replication.

The authors used a naturalistic design to replicate studies which validated the familial subtyping of primary depression. Ninety-three inpatients with unipolar depression had received the DST within 1 week of admission and were free of confounding medical problems. A blind rater assigned diagnoses based on chart material recorded before DST results were known. The results supported the earlier conclusions of Schlesser et al. With 8 AM sampling, 53% of familial pure depressive disease patients and 14% of depression spectrum disease patients were nonsuppressors. Differences, though smaller, remained significant with multiple sampling. Only 1 of 24 patients with secondary depression had an abnormal DST. Patterns of nonsuppression among patients with psychotic features resembled those of the larger group.

Morphological evidence for brainstem involvement in infantile autism.

Previous neurophysiological and neuroanatomic studies suggest brainstem dysfunction in infantile autism. Therefore, we investigated the brainstem structure of autistic patients by planimetric analysis of midsagittal magnetic resonance imaging scans. We found the entire brainstem and one component--the pons--to be statistically significantly smaller in the autistic group when compared with medical controls. We also noted no correlation between brainstem size and age in the autistic group--a correlation that was found in the control group. These data present morphological evidence of brainstem involvement in the infantile autism syndrome.

Family history and psychiatric comorbidity in persons with compulsive buying: preliminary findings.

OBJECTIVE: The authors explored the family history and psychiatric comorbidity of a group of compulsive buyers who volunteered for medication studies. Compulsive buying is characterized by inappropriate shopping and spending behavior that leads to impairment. METHOD: Thirty-three subjects who met the criteria of McElroy and colleagues for compulsive buying, and who scored more than two standard deviations above the mean on the Compulsive Buying Scale, were recruited. Twenty-two comparison subjects were recruited in the course of another study, and the presence of obsessive-compulsive disorder was the only reason for exclusion. Both groups were administered the Structured Clinical Interview for DSM-III-R disorders. The Family History Research Diagnostic Criteria were used to collect information about psychiatric disorders in first-degree relatives. RESULTS: Compulsive buyers had a mean age of 40 years; two (6%) were men. Comparison subjects had a mean age of 39 years; six (27%) were men. The two groups differed in gender distribution but not in age, marital status, or educational achievement. Compulsive buyers were more likely than comparison subjects to have lifetime mood disorders (especially major depression) and to have more than one psychiatric disorder. First-degree relatives of compulsive buyers were more likely than comparison relatives to suffer from depression, alcoholism, and a drug use disorder and to suffer more psychiatric disorders in general. CONCLUSIONS: These results indicate that persons who report compulsive buying behavior, and their first-degree relatives, are more likely to have a higher prevalence of psychiatric disorder than are comparison subjects.

Serum neuroleptic levels and extrapyramidal side effects in patients treated with amoxapine.

Serum neuroleptic levels were measured by radioreceptor assay in patients treated with the antidepressant amoxapine. When compared to standard neuroleptics, amoxapine produced relatively weak neuroleptic activity. Amoxapine dose correlated significantly with serum neuroleptic level. Three of eight patients developed significant extrapyramidal side effects. Neither dose of amoxapine nor neuroleptic level correlated with the presence or severity of EPS.

Forebrain structure in infantile autism.

Researchers implicate central nervous system dysfunction in infantile autism, but postmortem examinations and in vivo brain imaging studies have produced conflicting results concerning the neuronal systems involved. Magnetic resonance imaging--a new modality of in vivo brain imaging--was used to investigate the cerebral and thalamic structure of 105 autistic patients. Compared with the control group, there was an overall difference in the forebrain morphology of the autistic subjects due to subtle but statistically significant differences in the anterior ventricular horns, lateral ventricles, and the right lenticular nucleus. These results, when considered with previous studies of cerebral structure, suggest that there are subtle alterations in the forebrain of autistic patients.

Neuroimaging in child and adolescent psychiatry.

Although less well studied in child and adolescent psychiatry than in adult psychiatry, brain imaging has significantly altered psychiatric research and practice. This review focuses on the modalities that are used to image the brain. These include structural imaging techniques of computer tomography (CT) and magnetic resonance imaging (MRI), as well as functional imaging techniques of computed electroencephalography (CEEG), positron emission tomography (PET), and single photon emission computed tomography (SPECT). The technologies are reviewed, strengths and weaknesses of modalities discussed, and research progress reported.

Fluvoxamine for children and adolescents with obsessive-compulsive disorder: a randomized, controlled, multicenter trial.

OBJECTIVE: To determine the safety and efficacy of fluvoxamine for the treatment of children and adolescents with obsessive-compulsive disorder (OCD) with a double-blind, placebo-controlled, multicenter study. METHOD: Subjects, aged 8 to 17 years, meeting DSM-III-R criteria for OCD were recruited from July 1991 to August 1994. After a 7- to 14-day single-blind, placebo washout/screening period, subjects were randomly assigned to fluvoxamine 50 to 200 mg/day or placebo for 10 weeks. Subjects who had not responded after 6 weeks could discontinue the double-blind phase of the study and enter a long-term, open-label trial of fluvoxamine. Analyses used an intent-to-treat sample with a last-observation-carried-forward method. RESULTS: Mean Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores with fluvoxamine were significantly (p < .05) different from those with placebo at weeks 1, 2, 3, 4, 6, and 10. Significant (p < .05) differences between fluvoxamine and placebo were observed for all secondary outcome measures at all visits. Based on a 25% reduction of CY-BOCS scores, 42% of subjects taking fluvoxamine were responders compared with 26% taking placebo. Forty-six (19 fluvoxamine, 27 placebo) of 120 randomized subjects discontinued early. Adverse events with a placebo-adjusted rate greater than 10% were insomnia and asthenia. CONCLUSIONS: Fluvoxamine has a rapid onset of action and is well tolerated and efficacious for the short-term treatment of pediatric OCD.

Panic attacks in families of patients with mitral valve prolapse.

One explanation for the association between mitral valve prolapse (MVP) and panic attacks in clinic populations is that panic attacks represent a set of symptoms caused by mitral prolapse. Since mitral prolapse is often familial, this hypothesis predicts a higher incidence of panic attacks in relatives of persons with prolapse than the general population and the incidence of panic attacks in the relatives should be independent of panic attacks in the proband. We interviewed 50 probands with mitral prolapse and obtained family history data on panic attacks in their first degree relatives. The incidence of panic attacks in these relatives was 4.5 +/- 1.4% which is consistent with control rates which we have reported in previous studies. Twelve MVP probands also had panic attacks. The incidence of panic attacks in their relatives (15.7 +/- 5.1%) was significantly higher than the rate found among relatives of 38 probands without panic attacks (1.2 +/- 0.8%). These findings are consistent with the hypothesis that mitral prolapse and panic attacks are segregating independently in these families.