Prenatal maternal stress and risk of neurodevelopmental disorders in the offspring: a systematic review and meta-analysis.

PURPOSE: Exposure to prenatal stress has been reported to affect the risk of adverse neurodevelopmental outcomes in the offspring; however, there is currently no clear consensus. The aim of this systematic review and meta-analysis was to examine the existing literature on the association between prenatal stress and autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in the offspring. METHODS: Based on a registered protocol, we searched several electronic databases for articles in accordance with a detailed search strategy. We performed this study following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). RESULTS: Prenatal stress was significantly associated with an increased risk of both ASD (pooled OR 1.64 [95% CI 1.15-2.34]; I2 = 90%; 15 articles) and ADHD (pooled OR 1.72 [95% CI 1.27-2.34]; I2 = 85%; 12 articles). CONCLUSIONS: This study suggests that prenatal stress may be associated with ASD and ADHD; however, several limitations in the reviewed literature should be noted including significant heterogeneity and there is a need for carefully controlled future studies in this area.

Comparing Main, Goldwyn, and Hesse (Berkeley) and Crittenden (DMM) coding systems for classifying Adult Attachment Interview transcripts: an empirical report.

Few studies have compared different systems in classifying Adult Attachment Interview (AAI) transcripts. In this study, the AAI was administered to 90 Italian parents (45 couples), and the AAI transcripts were independently classified according to Main, Goldwyn, and Hesse's (Berkeley) and Crittenden's (Dynamic-Maturational Model [DMM]) criteria. The two classification systems were not significantly associated, with some limited convergent results only when the interviews resulted in organized (Berkeley) and normative (DMM) attachment classifications. Otherwise, the Berkeley system identified more secure individuals than the DMM system, and many texts judged secure on the Berkeley system were identified as insecure on the DMM system. Since the Berkeley and the DMM systems rest on remarkably different conceptualizations of the nature and functioning of the attachment behavioral system (e.g. fear is conceived as organizing in the DMM and as potentially disorganizing in the Berkeley), the attachment classifications resulting from their applications should not be considered measurements of the same phenomena.

A Psychometric Study of the Perinatal Assessment of Maternal Affectivity (PAMA) for the Screening of Perinatal Affective Disorders in Mothers.

Recently, empirical evidence from perinatal studies has led researchers to pay more attention to fathers. The need to evaluate male suffering led at first to using the same screening tools developed for mothers. However, these instruments present validity concerns with fathers, and today the need to assume a gender-based perspective is clear. The Perinatal Assessment of Paternal Affectivity (PAPA) is a self-reported questionnaire for the screening of a variety of psychological and behavioral dimensions related to affectivity as experienced by fathers during the perinatal period. In the present study, the psychometric properties of the maternal version of the scale (Perinatal Assessment of Maternal Affectivity; PAMA) were examined. The study, based on 225 mothers and their partners (n = 215), used a cross-sectional design with a single assessment at the third trimester of pregnancy. Results indicated a one-factor structure for a seven-item version of the PAMA, which showed adequate internal consistency reliability and was associated in the expected direction with other clinically relevant variables (depression, psychological distress, perceived stress and dyadic adjustment). The findings suggest the usefulness of developing gender sensitive screening tools for the detection of perinatal affective disorders.

Management and outcome of 308 cases of liver trauma in Bologna Trauma Center in 10 years.

INTRODUCTION: Management of Liver Trauma may vary widely from NOM +/- angioembolization to Damage Control Surgery. Multidisciplinary management is essential for achieving better outcomes. MATERIAL AND METHODS: During 2000-2009 period 308 patients with liver injury were admitted to level 1 trauma center and recorded in Trauma Registry. Collected data are demographics, AAST grade, initial treatment (operative or non-operative treatment) and outcome (failure of NOM), death. All patients were initially assessed according to ATLS guidelines. In case of haemodynamic instability and FAST evidence of intra-abdominal free fluid, the patients underwent immediate laparotomy. Hemodynamically stable patients, underwent CT scan and were admitted in ICU for NOM. RESULTS: Two hundred fourteen patients (69.5%) were initially managed with NOM. In 185 patients this was successful. Within the other 29 patients, failure of NOM was due to liver-related causes in 12 patients and non-liver-related causes in 17 Greater the grade of liver injury, fewer patients could be enrolled for NOM (85.8% in I-II and 83.3% in III against 39.8% in IV-V). Of those initially treated non-operatively, the likelihood of failure was greater in more severely injured patients (24.4% liver-related failure rate in IV-V against the 1.3% and 1.0% in I-II and III respectively). One hundred twenty-three patients (40% of the whole population study--308 patients) underwent laparotomy: 94 immediately after admission, because no eligible for NOM; 29 after NOM failure . In the 81 patients in which liver bleeding was still going on at laparotomy, hemostasis was attempted in two different ways: in the patients affected by hypothermia, coagulopathy and acidosis, perihepatic packing was the treatment of choice. In the other cases a "direct repair" technique was preferred. "Early mortality" which was expected to be worse in patients with such metabolic derangements, was surprisingly the same of the other group. This proves efficacy of the packing technique in interrupting the "vicious cicle" of hypothermia, coagulopathy and acidosis, therefore avoiding death ("early death" in particular) from uncontrollable bleeding. CONCLUSION: NOM +/- angioembolization is safe and effective in any grade of liver injury provided hemodynamic stability. DCS is Gold Standard for hemodynamically unstable patients.

Being the Father of a Preterm-Born Child: Contemporary Research and Recommendations for NICU Staff.

Background: Most studies on parental reactions to a preterm birth and to hospitalization of the newborn in Neonatal Intensive Care Units (NICUs) have involved mothers. However, emotional responses and behaviors of fathers are equally important. Usually, the father is the first to meet the preterm newborn, to find out information about baby's condition and to communicate to the mother and other family members. In this context he is often left alone and can show psychological difficulties including affective disorders such as depression or anxiety. This paper describes the role of fathers in the NICU, the best practices to support fathers, and to explain the role of a psychologist in the NICU staff. Considerations and suggestions are provided on the difficulties encountered to support parents, with a focus on the role of fathers during the COVID-19 pandemic. Methods and Discussion: Considering contemporary research data and following an attachment perspective, we analyze the role of the father of a preterm-born child in the relation with the partner and in newborn caring. Research has shown that involving fathers in newborn care in NICU and at home is essential not only because it promotes the father/son attachment relationship and has positive effects on the psychological and somatic development of the newborn, but also for the health of the mother and whole family. Conclusion: Recommendations are provided to enhance the functions of fathers in the NICU, promote their involvement in the care of their infant, and interventions to prevent the manifestation of psychological suffering and/or perinatal affective disorders. The commitments of a psychologist in a NICU team are presented and require not only clinical skills, but also the ability to manage the emotional and relational difficulties of fathers, family and NICU staff. Considerations and suggestions are provided on the difficulties encountered by parents in the NICU during the COVID-19 pandemic.

Packing for damage control of nontraumatic intra-abdominal massive hemorrhages.

BACKGROUND: The Damage Control Surgery (DCS) approach to massive intraperitoneal hemorrhage has been shown to significantly reduce the morbidity and mortality in severely injured trauma patients. We applied the same principles to patients who developed a massive hemorrhage and the "lethal triad" (acidosis, hypothermia, coagulopathy) during a surgical procedure in order to assess feasibility and efficacy of DCS on nontraumatic grounds. METHODS: A retrospective analysis of eight consecutive cases was performed aimed at collecting information on laboratory parameters, fluids requirements, operative times, APACHE II score, damage control surgery procedure, angioembolization, morbidity, mortality, and need for repacking. RESULTS: Average APACHE II score was 25.5 (predicted mortality rate = 54%); overall and early mortality in the nontraumatic group was nil, while the intra-abdominal septic (packing-related) complication rate was 12.5%. CONCLUSIONS: Intra-abdominal packing was shown to be feasible, safe, and effective for patients with intra-abdominal nontraumatic massive hemorrhage, and the application of the principles of DCS may improve survival in cases of surgical hemorrhage with development of the lethal triad.

Gastroesophageal reflux disease (GERD) and inflammatory bowel disease (IBD): attachment styles and parental bonding.

The attachment styles and parental bonding by 64 patients (M age = 43.2 yr., SD = 13.3) with Gastroesophageal Reflux Disease (GERD) were compared with those of 64 patients (M age = 42.2 yr., SD = 13.5) with Inflammatory Bowel Disease (IBD) and 126 Healthy participants (M age = 42.2 yr., SD = 12.1). Analysis of scores on the Attachment Style Questionnaire indicated insecure attachment in both the patient and control groups. The Parental Bonding scores indicated perceptions of Affectionless Control by parents in both patient groups. In particular, the mean Father-Protection subscale scores were significantly higher for in the GERD group than in the Healthy and IBD groups.

[What does it mean to be a trauma center? 1989-2009: results of the last year and review of 20 years experience in managing trauma patients]. / Che cos'è un Trauma Center? 1989-2009: bilancio dell'ultimo anno ed alcune considerazioni su 20 anni d'attività.

It has been two decades since Maggiore Hospital Trauma Center started its formal activity focused on improving and developing Trauma management and Surgery of Trauma. Whilst evaluating the results of the last year, we can not avoid to look behind at the beginning, comparing the actual activity with the settings we have started from, in 1989. Before this date in our hospital all the Emergency and Trauma Surgery was managed by General Surgeons. However since 1989 few surgeons and ICU anaesthetists started to focus their training and activity on management of Trauma. From there has born the first organized, structured Level I Trauma Center holding all diagnostic and therapeutic resoureces and recognized by the Health Management Plan of the Emilia - Romagna Region Authority, within a region including almost two millions inhabitants. The Trauma Surgery team adopted the evolving concept of Damage Control Surgery, applying extensively the intraabdominal packing and improving the perihepatic packing with a relevant refinement in the operative technique. Furthermore Non Operative Management has extensively spread All the above cited improvements, particularly the extensive use of NOM and the reduction of operative times, following the DCS philosophy and techniques, contributed to decrease morbidity and mortality rates of the abdominal trauma surgery patients. Mortality has been brought significantly down to 2.4%, in all cases related to extra-abdominal reasons. Last but least needs to be mentioned our scientific and research activity, including several published articles and scientific presentations at Italian, European and International Conferences. Finally we organize since 8 years a nationally relevant educational event: the "Corso Teorico-Pratico di Chirurgia del Politrauma". It is a theoretic and practical Trauma Surgery Course for Consultant/Attending Surgeons and Senior Registrars/Residents who want to improve their skills in Trauma Surgery and Management, and is now running its XIX edition.

[The Elhers-Danlos syndrome: an insidious pathology. Presentation of a familiary group]. / La sindrome di Elhers-Danlos: una patologia insidiosa. Presentazione di un gruppo familiare.

INTRODUCTION: Elhers-Danlos Syndrome (EDS) is an hereditary disease of the connective tissue, which may have clinical appearances varying in its severity from subclinical asymptomatic forms up to dramatic uncontrollable haemorrhage. MATERIALS AND METHODS: We have observed three siblings who were carriers of vascular type EDS. They were otherwise healthy at the time of the disease presentation and have become symptomatic since then, developing severe and uncontrollable haemorrhage. RESULTS: We have reported the clinical presentation of this syndrome, the clinical and laboratory characteristics, the treatment and the outcome. CONCLUSIONS: Although the severity of this disease, Elhers-Danlos Syndrome becomes symptomatic lately and suddenly in its course, often during emergency surgery for haemorrhagic shock. Several issues are raised such as the possibility for early diagnosis of this disease, the psychological features of a genetic counseling, the need for the patients to have adequate lifestyle and last but not least the risk of genetic transmission of the disease.

Screening for Early Signs of Paternal Perinatal Affective Disorder in Expectant Fathers: A Cluster Analysis Approach.

Previous studies documented gender-related differences in the expression of Perinatal Affective Disorders. However, little attention has been paid to screening the male population during the perinatal period. This study was based on three aims: (1) to investigate the mental health of expectant fathers based on their levels of depression, anxiety, addiction, anger attacks/hostility, and somatization, identifying psychological profiles; (2) to analyze the association between these profiles and the individual variable of perceived stress; (3) and to examine the association between these profiles and the couple's variable of marital adjustment. A total of 350 Italian expectant fathers in the last trimester of pregnancy were asked to fill in questionnaires concerning perceived stress, dyadic adjustment, psychiatric symptomatology, and depression. Three different clusters were found: "psychologically healthy men" (68%) with low levels of symptoms on all the scales; "men at risk of externalized behavioral problems" (17.1%), characterized by one or more addictive or risky behaviors and moderate levels of scales scores; and "men experiencing psychological distress" (14.9%), with the highest scores on all the scales. A significant association emerged among the perceived stress, marital adjustment, and cluster membership. These results highlight the importance of screening fathers in perinatal health services, which are still predominantly mother-centered, and underscore the necessity to create tailored and personalized interventions.

[Penetrating abdominal trauma: 20 years experience in a Western European Trauma Center]. / Traumi penetranti dell'addome. Esperienza di 20 anni in Trauma Center dell'Europa Occidentale.

BACKGROUND: The incidence of penetrating abdominal trauma in Western Europe is low. While non-operative management of blunt trauma has become the gold standard, the management of penetrating trauma is still controversial. Nonoperative management (NOM) and laparoscopy are currently used in selected patients, reducing the rate of unnecessary laparotomy. METHODS: We retrospectively reviewed a 20-years period from the Trauma Registry of our Trauma Center. 6523 patients were admitted for thoraco-abdominal trauma (5861 blunt vs 662 penetrating). We sorted the 114 patients with penetrating abdominal trauma in 2 groups for period (1989-2000 vs 2001-08, before and after the establishment of dedicated trauma unit) analyzing their demographics, clinical, therapeutic characteristics and the outcome in comparison. RESULTS: In the latest period a significant increase in the incidence of penetrating trauma has been observed (doubled from 4.17/year up to 8.53/year, accounting now for 13.95% of all trauma laparotomies vs 7.8% in the past decade). A reduction of GSW (30% vs 12.5%, p = ns) occurred while no differences have been recorded in sex, age, prognostic parameters at arrival such as mean GCS (11.8 vs 13.2), ISS (22 vs 18), pH, BE and blood transfusion (6.4 vs 4.3 U) requirement. Interestingly a markedly significant change has been observed in the demographics of the victims (67.2% were of extra-EU origin vs 8% in the previous decade, p < 0.01). Recently the use of NOM spread widely in selected stable patients (21.9%). The failure rate of NOM was 14.3%. The percentage of unnecessary laparotomies decreased from 36% to 21.1% (p = ns). The introduction of laparoscopy was helpful in achieving a reliable, less invasive exploration, allowing detection of the peritoneal penetration and complete visceral exploration. Two GSW (4%) vs 3 (5.8%) cases of the latest years required Damage Control Surgery. A recent significant reduction in mortality and morbidity rate has been recorded (respectively 3.85% vs 18%, p < 0.05; 20% vs 39%, p = ns). CONCLUSION: The recent immigration phenomenon and social changes contributed towards a significant rise in the incidence of penetrating trauma in Italy in the last decade associated to changes in the mechanism of injury. The increased use of NOM and laparoscopy contributed in decreasing the incidence of unnecessary laparotomies as well as overall morbidity and mortality.

[The damage control surgery]. / Damage control surgery: orientamenti attuali.

AIM OF THE STUDY: To evaluate our experience in the treatment of complex abdominal injuries with the principles of Damage Control Surgery (DCS). METHOD: A retrospective review was conducted of 55 patients with multiple abdominal injuries and severe haemorrhage induced hypothermia and acidosis admitted to the "Ospedale Maggiore Trauma Center" in Bologna from 1989 to June 2005. RESULTS: All the patients but one had major blunt trauma. Mean age was 40.1; mean ISS 42; mean RTS 4.11; extimated loss of blood was greater than 4000 ml. Packing provide definitive control of bleeding in 44 patients but 10 had recurrent bleeding or bleeding from different injuries such as bone fractures and required further surgery (2) or arterial embolization (8). Twenty eights patients (50.9%) died. Survival was strongly associated with the ISS, GCS, the loss of blood and acidosis. CONCLUSION: The Authors concluded that in selected circumstances the traditional approach to severe abdominal injuries is not appropiate. In this situation, alternative and aggressive treatment such as the Damage Control Surgery has been recommended as the procedure of choice.

[The education of the trauma surgeon: the "trauma surgery course" as advanced didactic tool]. / Modelli educazionali in chirurgia del trauma: il "Corso Teorico-Pratico di Chirurgia del Politrauma" come proposta di didattica avanzata.

BACKGROUND: The consequences of low incidence of penetrating injuries in Europe and of the increasing in nonoperative management of blunt trauma are a decrease in surgeons' confidence for managing traumatic injuries. The Corso Teorico Pratico di Chirurgia del Politrauma was developed as model for teaching operative trauma techniques. The aim of this retrospective study is to evaluate the effectiveness of the course and compare it with other similar courses. METHOD: The Corso Teorico Pratico di Chirurgia del Politrauma is a two day course and consists of lecture on trauma topics and porcine operative experience. Data on the first 124 participants were collected and analyzed. RESULTS: One hundred twenty general surgeons and 2 pediatric surgeons had participated at the course. All the participants judged the course an efficient model to improve knowledge on surgical treatment of trauma. CONCLUSION: A two days course, focused on trauma, with didactic lectures and operative life-like situations, can be a model for simulated education and useful to improve surgeons' confidence in trauma patients.

Preterm infant development, maternal distress and sensitivity: The influence of severity of birth weight.

OBJECTIVE: To evaluate the influence of the severity of prematurity based on birth weight on maternal distress and sensitivity and on infant development. METHODS: Sixty-eight mothers and their preterm babies (30 babies classified into Extremely-Low-Birth Weight-ELBW and 38 into Very-Low-Birth Weight-VLBW) were assessed at 9months of infant corrected age, using: Griffiths Scales for infant development, CARE-Index for maternal sensitivity during 5-minute of mother-infant interaction, and Parenting Stress Index-Short Form (PSI-SF) for maternal distress. Sixty-six healthy full-term infants (FT) and their mothers were assessed with the same procedure. RESULTS: ELBW, VLBW and FT groups showed similar levels at CARE-Index and PSI-SF. Nevertheless, considering infant development as outcome, a significant interaction between birth weight and maternal distress emerged, with higher Hearing & Language mean quotients in association with Non-Distressed mothers, but only in VLBW infants, compared to FT ones. Also the interaction between birth weight and maternal sensitivity influenced infant development: higher quotients (Eye-hand coordination, Hearing & Language, Locomotor) were significantly associated with sensitive mothers but only in ELBW infants. CONCLUSION: The severity of prematurity, in interaction with the degree of maternal distress and sensitivity, influenced the level of infant development. PRACTICAL IMPLICATIONS: Taken together, these results suggest the relevance of considering severity of prematurity and maternal variables in order to implement appropriate interventions for supporting parenting role after a preterm birth and promoting an adequate infant development.

[Diagnosis and treatment of retroperitoneal traumatic injuries. Our experience on 221 patients]. / Le lesioni traumatiche del retroperitoneo: inquadramento diagnostico e terapeutico. Nostra esperienza su 221 pazienti.

BACKGROUND: The management of traumatic retroperitoneal injuries is still confusing to many surgeons. The presence of injuries of retroperitoneum generally worsens the prognosis in trauma patients and need more attention both the diagnosis and treatment and mortality is high comparated to abdominal traumati injuries. METHOD: A retrospective review was conducted of 221 patients with retroperitoneal injuries admitted to the Ospedale Maggiore Trauma Center in Bologna from 1989 to March 2005. RESULTS: Two hundred seven were blunt traumas and 14 penetrating. Mean age was 40.3; 25 patients died in operating room and 25 were treated with Damage Control Surgery for both abdominal and retroperitoenal injuries. The mortality rate was 15%. Data about surgical treatments, associate treatments for abdominal injuries, and need of reoperation are reported. CONCLUSION: Retroperitoneal traumatic injuries are challenging emergencies and need of attention and expertise by the suorgeon. Only with a careful judgement on the tactics and the procedure to carry on it is possible to gain valid results, which often means to safe the patients life.

Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma.

BACKGROUND: since 2005, we refined the technique of perihepatic packing including complete mobilization of the right lobe and packing around the posterior paracaval surface, lateral right side, and anterior and posteroinferior surfaces. METHODS: two groups of patients with grade IV/V liver trauma underwent perihepatic packing before and after 2005. The study group included 12 patients treated with the new technique. The control group included 23 patients treated with the old technique. RESULTS: all 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P < .02); the liver-related mortality was 8.3% versus 34.8% (P = not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P = not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P = not significant). The overall (81.8% vs 100%, P = not significant) and liver-related morbidity rate (18.2% vs 41.7%, P = not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P = not significant) decreased. CONCLUSIONS: our refined technique of perihepatic packing seems to be safe and effective.

Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

BACKGROUND/PURPOSE: Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high. METHODS: The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed. RESULTS: In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team. CONCLUSIONS: Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.