Midwives and women's views on using UK recommended depression case finding questions in antenatal care.

OBJECTIVE: detecting and treating depression early on in pregnancy can improve health outcomes for women and their children. UK guidelines recommend that Midwives screen for antenatal depression (AND) at the woman's first Midwife appointment using recommended depression case finding questions. This is the first qualitative study to explore Midwives' and women's views of using these questions in the context of antenatal care. DESIGN: Semi-structured interviews with Midwives and pregnant women exploring their views and experiences of screening for AND, conducted alongside a validation study of the depression case finding questions. SETTING: the initial appointment with the Midwife when the woman is 10-12 weeks pregnant. Interviewees were working or living in Bristol, England. PARTICIPANTS: maximum variation samples of 15 Midwives and 20 pregnant women. MEASUREMENTS AND FINDINGS: Midwives and pregnant women viewed the depression case finding questions as a useful way of introducing mental health issues. Midwives often adapted the questions rather than using the phrasing specified in the UK guideline. Sometimes Midwives chose not to use the questions, for example if a partner was present. Both Midwives and women struggled to differentiate symptoms of early pregnancy from antenatal depression; yet thought that detecting depression early on in pregnancy was important. Women were unsure about the kind of help that was available; some women reported this as a reason for withholding their true feelings. There was a general lack of awareness among Midwives about the range of non-drug treatments potentially available to women and referral pathways to access them. KEY CONCLUSION: both Midwives and women regard screening for AND as acceptable and important but reported shortcomings with the recommended depression case finding questions. IMPLICATIONS FOR PRACTICE: providing training for Midwives on how to frame the questions and increase their knowledge and application of the referral pathways suggested by UK guidelines will help address some of the issues raised by Midwives and women in our study.

THE IMPACT OF DEPRESSION ON MATERNAL RESPONSES TO INFANT FACES IN PREGNANCY.

Research has suggested that prenatal depression may be associated with disrupted maternal responses to infant stimuli, with depressed pregnant women not showing the bias toward distressed infants as that observed in nondepressed pregnant women. The current study examined the effects of depression on self- reported responses to infant stimuli, in early pregnancy. Women with clinical depression (n = 38), and nondepressed women (n = 67) were recruited from a wider cognitive behavioral therapy trial. They completed Maternal Response Scales in which they were presented with images of distressed, neutral, and happy infant faces, with no time limit. The women rated their responses to these images along three dimensions--wanting to comfort, wanting to turn away, and feelings of anxiety--using Likert scales via a computerized task. There was evidence that women with depression in pregnancy showed different responses than did women without depression. Women with depression were substantially more likely to be in the highest quartile for ratings of wanting to turn away, odds (OR) ratio = 4.15, 95% confidence intervals (CIs) = 1.63-10.5, p = .003, and also were substantially less likely to be in the highest quartile for wanting to comfort a distressed infant face, OR = 0.22, 95% CIs = 0.09-0.54, p < .001. Findings are consistent with there being both a heightened avoidant and a reduced comforting response toward distressed infants in depressed pregnant women, providing some support that depression disrupts maternal preparations at a conscious level.

Development and evaluation by a cluster randomised trial of a psychosocial intervention in children and teenagers experiencing diabetes: the DEPICTED study.

OBJECTIVE: To develop and evaluate a health-care communication training programme to help diabetes health-care professionals (HCPs) counsel their patients more skilfully, particularly in relation to behaviour change. DESIGN: The HCP training was assessed using a pragmatic, cluster randomised controlled trial. The primary and secondary analyses were intention-to-treat comparisons of outcomes using multilevel modelling to allow for cluster (service) and individual effects, and involved two-level linear models. SETTING: Twenty-six UK paediatric diabetes services. PARTICIPANTS: The training was delivered to HCPs (doctors, nurses, dietitians and psychologists) working in paediatric diabetes services and the effectiveness of this training was measured in 693 children aged 4-15 years and families after 1 year (95.3% follow-up). INTERVENTIONS: A blended learning programme was informed by a systematic review of the literature, telephone and questionnaire surveys of professional practice, focus groups with children and parents, experimental consultations and three developmental workshops involving a stakeholder group. The programme focused on agenda-setting, flexible styles of communication (particularly guiding) and a menu of strategies using web-based training and practical workshops. MAIN OUTCOME MEASURES: The primary trial outcome was a change in glycosylated haemoglobin (HbA1c) levels between the start and finish of a 12-month study period. Secondary trial outcomes included change in quality of life, other clinical [including body mass index (BMI)] and psychosocial measures (assessed at participant level as listed above) and cost (assessed at service level). In addition, patient details (HbA1c levels, height, weight, BMI, insulin regimen), health service contacts and patient-borne costs were recorded at each clinic visit, along with details of who patients consulted with, for how long, and whether or not patients consulted on their own at each visit. Patients and carers were also asked to complete an interim questionnaire assessing patient enablement (or feelings towards clinic visit for younger patients aged 7-10 years) at their first clinic visit following the start of the trial. The cost of the intervention included the cost of training intervention teams. RESULTS: Trained staff showed better skills than control subjects in agenda-setting and consultation strategies, which waned from 4 to 12 months. There was no effect on HbA1c levels (p = 0.5). Patients in intervention clinics experienced a loss of confidence in their ability to manage diabetes, whereas controls showed surprisingly reduced barriers (p = 0.03) and improved adherence (p = 0.05). Patients in intervention clinics reported short-term increased ability (p = 0.04) to cope with diabetes. Parents in the intervention arm experienced greater excitement (p = 0.03) about clinic visits and improved continuity of care (p = 0.01) without the adverse effects seen in their offspring. The mean cost of training was £13,145 per site or £2163 per trainee. There was no significant difference in total NHS costs (including training) between groups (p = 0.1). CONCLUSIONS: Diabetes HCPs can be trained to improve consultation skills, but these skills need reinforcing. Over 1 year, no benefits were seen in children, unlike parents, who may be better placed to support their offspring. Further modification of this training is required to improve outcomes that may need to be measured over a longer time to see effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN61568050. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 29. See the HTA programme website for further project information.

The experiences of children and their parents in paediatric diabetes services should inform the development of communication skills for healthcare staff (the DEPICTED Study).

AIMS: The aims of this study were to describe users' experience of paediatric diabetes services to inform development of an intervention to improve communication between staff and patients in secondary care within a wider study (the DEPICTED Study). METHODS: Methods adapted for paediatric settings were used to set up six audio-recorded focus discussion groups with a total of 32 participants. Transcriptions and notes were coded thematically (supported by NVivo software) and analytic themes developed with discussion between researchers. RESULTS: Three main themes developed: the lack of two-way conversation about glycaemic control in clinic settings; the restricting experience of living with diabetes; and the difficult interactions around diabetes the children had with their schools. Doctors in particular were seen as struggling to link these themes of everyday life in their consultations with children and their parents. Children felt marginalized in clinics, despite active involvement in their own blood glucose management at home. CONCLUSIONS: Health professionals need to balance a requirement for good glycaemic control with realism and appreciation of their patients' efforts. There is a need for a systematic approach to consulting, in particular using agenda setting to ensure that the issues of both the patient and the professional are addressed. A framework for a conceptual approach is discussed. How a patient is involved is as important as what is communicated during a consultation.

Meeting the psychosocial needs of children with diabetes within routine clinical practice.

AIMS: There is little guidance for paediatric diabetes teams on how best to meet their patients' psychosocial needs. The aims of conducting this survey of practitioners were to examine the challenges they face in delivering routine care, elicit their approaches to encouraging behaviour change and to inform the development of a training package to be evaluated in the Development and Evaluation of a Psychosocial Intervention with Children and Teenagers Experiencing Diabetes (DEPICTED) Study. METHODS: A semi-structured telephone interview was completed with 44 doctors and seven paediatric diabetes specialist nurses and emergent themes identified. RESULTS: The key challenges for practitioners were categorized as engagement and communication, meeting the needs of different ages and helping patients and their families integrate diabetes into their everyday life. Approaches to behaviour change were described in terms of education, advice and listening. CONCLUSIONS: The survey demonstrates the complexities of communication with such a heterogeneous patient group and the range of approaches taken by practitioners in addressing behaviour change within routine care.

Healthcare professionals' views on two computer-based decision aids for women choosing mode of delivery after previous caesarean section: a qualitative study.

OBJECTIVE: To explore healthcare professionals' views about decision aids, developed by the DiAMOND study group, for women choosing mode of delivery after a previous caesarean section. DESIGN/METHODS: A qualitative focus group study. Data were analysed thematically. SETTING: Two city maternity units, surrounding community midwife units and general practitioner (GP) practices in southwest England. SAMPLE: Twenty-eight healthcare professionals, comprising obstetricians, hospital and community midwives and GPs, who participated in six focus groups. RESULTS: Participants were generally positive about the decision aids. Most thought they should be implemented during early pregnancy in the community, but should be accessible throughout pregnancy, with any arising questions discussed with an obstetrician nearer to term. Perceived barriers to implementation included service issues (e.g. time pressure, cost and access), computer issues (e.g. computer literacy) and people issues (e.g. women's prior delivery preferences and clinician preference). Facilitators to implementation included access to more standardised and reliable information and empowerment of the user. Self-accessing the aids, increased awareness of decision aids among healthcare professionals and incorporation of aids into usual care were suggested as possible ways to improve implementation success. CONCLUSIONS: This study gives insight into healthcare professionals' views on the role of decision aids for women choosing a mode of delivery after a prior caesarean section. It highlights potential obstacles to their implementation and ways to address these. Such aids could be a useful adjunct to current antenatal care.

An exploratory comparison of genetic counselling protocols for HNPCC predictive testing.

Most UK genetics centres offering predictive testing for hereditary non-polyposis colorectal cancer (HNPCC) use an extended counselling protocol originally developed for Huntington's disease. Shortened counselling may be more appropriate in the context of treatable genetic conditions such as HNPCC. Twenty-six high-risk individuals were randomized to extended genetic counselling (two sessions of education and reflection held 1 month apart) or shortened genetic counselling (a single educational session) prior to HNPCC testing. Prospective questionnaires, interviews and transcripts of counselling sessions were analysed. Participants were unsure what to expect prior to genetic counselling and had already decided to undergo genetic testing. There was no evidence of psychological harm caused by shortened genetic counselling, with a high level of satisfaction with the counselling received in both groups. Reflective counselling occurred in both groups but was framed in terms of practical action and information. Participants expressed differing preferences for the level of information received. This exploratory study indicates that shortened genetic counselling may be an appropriate means of supporting decisions already made by individuals about HNPCC testing. However, participants would benefit from preparatory information to help them reflect on issues not previously considered, which can then be explored more fully as part of a tailored counselling approach.

Fine needle aspiration cytology vs. needle core biopsy of soft tissue tumors. A comparison.

Fine needle aspiration (FNA) cytology is an effective modality in the diagnosis of soft tissue lesions. Previous studies compared FNA with surgical biopsies and reported high sensitivity and specificity rates. No study has evaluated the diagnostic yield of FNA to that of needle core biopsies (NCBs). One hundred seventeen FNAs were performed by our clinical staff for soft tissue lesions (1980-1992). The FNAs were divided into three categories: diagnostic 53 (37 sarcoma, 16 benign); unsatisfactory, 44; normal/inflammatory cells present, 20. Of these, 59 had concomitant NCBs: 37 on patients with sarcoma on FNA, 22 on unsatisfactory FNA and none on those with normal/inflammatory cells (followed clinically). There was 100% correlation between FNA and NCB when sarcoma was diagnosed. In 7 of these cases, the NCB further specified the type of sarcoma. No NCBs were employed to confirm the diagnosis of benign tumor on FNA; excisional biopsies showed a total correlation. The 22 NCBs for unsatisfactory FNA yielded 15 sarcomas, 2 fibromatosis and 5 benign lesions. Seventeen patients with unsatisfactory FNA had surgical biopsies (3 sarcoma, 14 benign), and 5 were lost to follow-up. In our experience, diagnostic FNA gave a yield identical to that of NCB, and the latter did not contribute to patient management. Core biopsies may have the advantage of subtyping selected sarcomas diagnosed by FNA. Unsatisfactory FNA should be evaluated further by a repeat aspirate or NCB. Performance of FNA by cytopathologists can reduce the number of unsatisfactory specimens and allow repeat aspiration. In our study most of the unsatisfactory FNAs were from retroperitoneal and pelvic lesions, were performed under radiographic guidance and could have been minimized by immediate cytologic assessment. Many of these lesions, however, may be as readily accessible via NCB as they are via FNA. Utilization of each of these modalities and of their full benefits ultimately depends on the proper clinical setting and the experience of the clinician and pathologist.

Central nervous system Whipple's disease: relapse during therapy with trimethoprim-sulfamethoxazole and remission with cefixime.

The central nervous system (CNS) is frequently involved in patients with Whipple's disease and is the most common site of disease relapse. Antibiotics such as trimethoprim-sulfamethoxazole (TMP-SMX) that have reliable CNS penetration, are therefore recommended as first-line therapy. We report a patient with Whipple's disease who was treated with TMP-SMX and presented 14 months after initiation of therapy with visual decline and severe headaches. The patient was also treated concurrently with low-dose weekly methotrexate for severe psoriasis. Evaluation by magnetic resonance imaging revealed bilateral posterior white matter abnormalities that pathologically were consistent with Whipple's disease. He was ultimately treated with cefixime, an orally administered third-generation cephalosporin. Visual function improved on this regimen and follow-up magnetic resonance imaging showed regression of the lesions. This case represents the first report of both CNS relapse during therapy with TMP-SMX and successful treatment with cefixime. We also speculate that methotrexate, which impairs cell-mediated immunity, may have contributed to the relapse.

Accidental detection of nonmetastatic ovarian adenocarcinoma in tissue samples recovered during dilatation and curettage.

We report two patients with ovarian cancer who were diagnosed with primary endometrial cancer when detached fragments of adenocarcinoma were identified in their dilatation and curettage specimens. Retrospectively, a fragment of fallopian tube and ovarian stroma were identified in the specimens. These findings served to alert the pathologist to the possibility that extrauterine sampling had occurred as a result of perforation of uterine wall during dilatation and curettage. Previous studies have focused on the cytologic detection of extrauterine cancer or on cases where metastasis to the endometrium has led to a misdiagnosis of primary endometrial cancer.

Gastrointestinal involvement in L-tryptophan (L-Trp) associated eosinophilia-myalgia syndrome (EMS).

We report a 45-year-old female who had symptomatic gastrointestinal involvement, eosinophils in the cellular infiltrate, and who proved to have L-tryptophan-associated eosinophilia-myalgia syndrome. This case illustrates that gastrointestinal disease can be a major, seemingly primary clinical presentation in this syndrome, and that a drug history, specifically L-tryptophan, needs to be included in the differential diagnosis of "eosinophilic gastroenteritis."