Breaking Bad News: A Study on Formal Training in a High-Risk Obstetrics Setting.

Background: Breaking bad news is a frequent task in high-risk obstetrics clinics. Few studies have examined the role of training in improving such a difficult medical task. Aim: To evaluate the influence of a training program on the participants' perceptions of bad news communication at a high-risk obstetrics center. Design: This prospective study was conducted at the Department of Obstetrics/Gynecology, Hospital das Clinicas, from March 2016 to May 2017. Setting/Participants: Maternal-fetal health specialists were invited to complete an institutional questionnaire based on the SPIKES protocol for communicating bad news before and after training. The training consisted of theoretical lectures and small group practice using role play. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol. Results: In total, 110 physicians were invited to participate. Ninety completed the pretraining questionnaire and 40 answered the post-training questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (p = 0.010), feeling able to transmit bad news (p < 0.001), and to discuss the prognosis (p = 0.026), feeling capable of discussing ending the pregnancy (p = 0.003), and end-of-life issues (p = 0.007) and feeling confident about answering difficult questions (p = 0.004). The comparison of the grouped responses following the steps of the SPIKES protocol showed significant differences for "knowledge" (p < 0.001), "emotions," (p = 0.004) and "strategy and summary" (p = 0.002). Conclusion: The implementation of institutional training in breaking bad news changed the perception of the physicians in the communication setting.

Pica and Eating Attitudes: A Study of High-Risk Pregnancies.

OBJECTIVE: To describe and determine the association between the occurrence of pica and eating attitudes in women with high-risk pregnancies and to determine the prevalence of pica during pregnancy. METHODS: A cross-sectional and prospective 24-month study was conducted with 913 women with high-risk pregnancies. Structured interviews were carried out and the Eating Attitudes Test was applied. RESULTS: Pica was diagnosed in 5.7 % of the pregnant women, and its most commonly practiced type was geophagia (57.7 %). The association between pica and signs related to the eating attitudes: "to be considered too thin by others" (p < 0.02), and "to spend too much time thinking about food" (p = 0.05); and the association between pica and the risk of both anorexia nervosa and bulimia nervosa (p < 0.01) were statistically significant. CONCLUSIONS: The absence of validated instruments in the literature for assessing pica reinforces the difficulty of investigating this practice and the need for further studies. Moreover, additional efforts need to focus in the improvement of screening for other eating disorders with obstetric consequences associated with pica and be incorporated into the routine of healthcare professionals.

The self-rated Inventory of Depressive Symptomatology for screening prenatal depression.

OBJECTIVE: To examine whether the self-reported version of the Inventory of Depressive Symptomatology (IDS-SR), which is used for major depression, is a reliable tool for screening and assessment of prenatal depression. METHODS: Between June 2006 and July 2008, pregnant women attending a teaching hospital in São Paulo, Brazil, completed the Portuguese version of the IDS-SR. Trained psychologists diagnosed depression via the Primary Care Evaluation of Mental Disorders questionnaire, which is based on the Diagnostic and Statistical Manual of Mental Disorders IV. RESULTS: Of 543 participants, 60 (11%) were diagnosed with depression. The Cronbach α of the IDS-SR was 0.89, and the area under the ROC curve was 0.8. The IDS-SR cutoff score at 30 gave a sensitivity and specificity of 78% and 76%, respectively, for diagnosis of prenatal depression. Exploratory and confirmatory analyses revealed a 2-factor structure for the IDS-SR, characterized by symptoms of "mood/cognition" and "irritability/anxiety/pain". CONCLUSION: The IDS-SR gave satisfactory internal consistency and accuracy for diagnosing prenatal depression, showing that it can improve early diagnosis and treatment of this condition, thereby minimizing the burden. In addition, a 2-factor model was found to account for depressive symptomatology during pregnancy, which will be useful for developing further depression subscales specific to prenatal depression.

Twin pregnancies: evaluation of major depression, stress, and social support.

BACKGROUND: Twin pregnancies are at increased physiological and psychosocial risks. OBJECTIVE: To investigate the prevalence of major depression in twin pregnancies and correlate with stress and social support. METHOD: The study included 51 pregnant women under specialized prenatal care who were evaluated by a Portuguese version of the semi-structured questionnaire Primary Care Evaluation of Mental Disorders (PRIME-MD) for Major Depression, and the Prenatal Psychosocial Profile (PPP) for evaluation of stress and social support. RESULTS: Major depression was found in 33.3% of pregnant women, and prevailing symptoms were fatigue or loss of energy (100%), insomnia or hypersomnia (82.4%), changes in appetite (82.4%), decreased interest in daily activities (82.4%), and psychomotor agitation or retardation (82.4%). Among pregnant women who were diagnosed depressive, 76.5% also had a high level of stress and 47.1% complained about lack of social support. Statistical significance was found when correlating depression with perception of negative aspects of having twins and belief in significant body changes during pregnancy (p = .005 and .03, respectively). Marital status, occupation, and pregnancy planning were not significantly associated with the diagnosis of depression. CONCLUSION: Major depression occurs in one-third of pregnant women expecting twins and is associated with higher levels of stress and lack of social support. A multidisciplinary approach in these cases is fundamental to minimize further risks and complications.

Feelings of women regarding end-of-life decision making after ultrasound diagnosis of a lethal fetal malformation.

OBJECTIVE: this study investigated the feelings of women regarding end-of-life decision making after ultrasound diagnosis of a lethal fetal malformation. The aim of this study was to present the decision making process of women that chose for pregnancy termination and to present selected speeches of women about their feelings. DESIGN: open psychological interviews conducted by a psychologist immediately after the diagnosis of fetal malformation by ultrasound. Analysis of the results was performed through a content analysis technique. SETTING: the study was carried out at a public university hospital in Brazil. PARTICIPANTS: 249 pregnant women who had received the diagnosis of a severe lethal fetal malformation. FINDINGS: fetal anencephaly was the most frequent anomaly detected in 135 cases (54.3%). Termination of pregnancy was decided by 172 (69.1%) patients and legally authorised by the judiciary (66%). The reason for asking for termination was to reduce suffering in all of them. In the 77 women who chose not to terminate pregnancy (30.9%), the reasons were related to feelings of guilt (74%). KEY CONCLUSIONS: the results support the importance of psychological counselling for couples when lethal fetal malformation is diagnosed. The act of reviewing moral and cultural values and elements of the unconscious provides assurance in the decision-making process and mitigates the risk of emotional trauma and guilt that can continue long after the pregnancy is terminated.

Cognitive impairments in patients with low grade gliomas and high grade gliomas.

OBJECTIVE: The relationship between brain tumors and cognitive deficits is well established in the literature. However, studies investigating the cognitive status in low and high-grade gliomas patients are scarce, particularly in patients with average or lower educational level. This study aimed at investigating the cognitive functioning in a sample of patients with low and high-grade gliomas before surgical intervention. METHOD: The low-grade (G1, n=19) and high-grade glioma (G2, n=8) patients underwent a detailed neuropsychological assessment of memory, executive functions, visuo-perceptive and visuo-spatial abilities, intellectual level and language. RESULTS: There was a significant impairment on verbal and visual episodic memory, executive functions including mental flexibility, nominal and categorical verbal fluency and speed of information processing in G2. G1 showed only specific deficits on verbal and visual memory recall, mental flexibility and processing speed. CONCLUSION: These findings demonstrated different levels of impairments in the executive and memory domains in patients with low and high grade gliomas.

Cognitive impairments in patients with low grade gliomas and high grade gliomas / Comprometimentos cognitivos em pacientes com gliomas de baixo grau e gliomas de alto grau

OBJECTIVE: The relationship between brain tumors and cognitive deficits is well established in the literature. However, studies investigating the cognitive status in low and high-grade gliomas patients are scarce, particularly in patients with average or lower educational level. This study aimed at investigating the cognitive functioning in a sample of patients with low and high-grade gliomas before surgical intervention. METHOD: The low-grade (G1, n=19) and high-grade glioma (G2, n=8) patients underwent a detailed neuropsychological assessment of memory, executive functions, visuo-perceptive and visuo-spatial abilities, intellectual level and language. RESULTS: There was a significant impairment on verbal and visual episodic memory, executive functions including mental flexibility, nominal and categorical verbal fluency and speed of information processing in G2. G1 showed only specific deficits on verbal and visual memory recall, mental flexibility and processing speed. CONCLUSION: These findings demonstrated different levels of impairments in the executive and memory domains in patients with low and high grade gliomas.

OBJETIVO: A associação entre tumores cerebrais e déficits cognitivos é bem estabelecida na literatura. No entanto, estudos sobre a cognição de pacientes com gliomas de baixo e alto grau são escassos, especialmente, em sujeitos com baixa escolaridade. Este estudo investigou o funcionamento cognitivo de uma amostra de pacientes com gliomas de baixo e alto grau antes da intervenção cirúrgica. MÉTODO: Os pacientes com glioma de baixo grau (G1, n=19) e alto grau (G2, n=8) foram avaliados quanto à memória, funções executivas, habilidades visuo-perceptivas e visuo-espaciais, nível intelectual e linguagem. RESULTADOS: Houve prejuízo significativo em G2 na memória episódica verbal e visual, funções executivas incluindo flexibilidade mental, fluência verbal nominal e categórica e velocidade de processamento de informações. G1 demonstrou apenas déficits específicos de evocação verbal e visual, flexibilidade mental e velocidade de processamento. CONCLUSÃO: Estes achados demonstraram níveis diferenciados de comprometimento nos domínios executivos e mnésticos de pacientes com gliomas de baixo e alto grau.

Women's opinions about mode of birth in Brazil: a qualitative study in a public teaching hospital.

OBJECTIVE: to describe women's feelings about mode of birth. DESIGN: exploratory descriptive design. Semi-structured interviews were conducted using a questionnaire that had been developed previously (categorical data and open- and closed-ended questions). Qualitative analysis of the results was performed through a context analysis technique. SETTING: the largest public university hospital in Brazil. PARTICIPANTS: 48 women in their third trimester of pregnancy. FINDINGS: most women expressed a preference for vaginal birth, as they perceived that they would have a faster recovery. Women who expressed a preference for caesarean section did so because of lack of pain during the birth and the need for tubal sterilisation. The majority of women considered it important to have experience with a mode of birth in order to choose a preference. Complications associated with maternal illness were very influential in the decision-making process. KEY CONCLUSIONS: these results provide a useful first step towards the identification of aspects of women's feelings about modes of birth. Most women expressed a preference for vaginal birth. Further exploration of women's feelings regarding parturition and the decision-making process is required.

Alterações cognitivas associadas à síndrome de Kojewnikoff / Cognitive alterations associated with the Kojewnikoff syndrome

Introdução: A síndrome de Kojewnikoff, associada ao estado de mal epiléptico (EME), também denominada de Epilepsia Parcial Contínua (EPC), é caracterizada por crises somatomotoras,com marcha jacksoniana e mioclonias que afetam a extremidade contralateral sendo o giro pré-central a principalregião cerebral afetada. São raros os estudos na literatura que descrevem as alterações cognitivas destes pacientes. Objetivo: descrever o funcionamento cognitivo de uma pacientecom EPC através de um protocolo de testes neuropsicológicos. Método: Foram realizadas duas sessões com duas horas de duração cada, utilizando-se para tanto, uma bateria de testes neuropsicológicos. Resultados: Os resultados da avaliação indicaram comprometimento de velocidadede processamento de informações, atenção, fluência verbal e memória episódica. Conclusão: Os resultados da avaliação neuropsicológica são compatíveis com os déficits cognitivos esperados em lesões corticais na área motora primária e com os resultados da avaliação clínica pré-existente.