Prenatal depression, fetal neurobehavior, and infant temperament: Novel insights on early neurodevelopment from a socioeconomically disadvantaged Indian cohort.

This article extends the research focusing on the early origins of psychopathology into the prenatal period, by exploring the association between maternal prenatal depression and offspring (fetal and infant) neurobehavior. The sample is recruited from a rural population in South India where women in the third trimester of pregnancy were assessed for depression and the heart rate responses of their fetuses to extrinsically applied vibroacoustic stimuli were studied. At 2 months postbirth, infant temperament and cortisol responsivity to immunization were assessed. The association between maternal prenatal depression and fetal responsivity to vibroacoustic stimulation, and infant responsivity to immunization, was U shaped with higher levels of responsivity noted in the offspring of mothers with very high and very low depression scores, and lower levels noted in the offspring of mothers with moderate depression scores. Maternal prenatal depression was not associated with infant temperament. The findings highlight the importance of environmental influences in the developmental origins of neurobehavior, suggesting that such differences, not evident at baseline, may emerge upon exposure to stressors. The study also emphasizes the need for further investigation in low- and middle-income contexts by providing preliminary evidence of the differing patterns of association observed between high- and low-income populations.

Maternal prenatal depression is associated with decreased placental expression of the imprinted gene PEG3.

BACKGROUND: Maternal prenatal stress during pregnancy is associated with fetal growth restriction and adverse neurodevelopmental outcomes, which may be mediated by impaired placental function. Imprinted genes control fetal growth, placental development, adult behaviour (including maternal behaviour) and placental lactogen production. This study examined whether maternal prenatal depression was associated with aberrant placental expression of the imprinted genes paternally expressed gene 3 (PEG3), paternally expressed gene 10 (PEG10), pleckstrin homology-like domain family a member 2 (PHLDA2) and cyclin-dependent kinase inhibitor 1C (CDKN1C), and resulting impaired placental human placental lactogen (hPL) expression. METHOD: A diagnosis of depression during pregnancy was recorded from Manchester cohort participants' medical notes (n = 75). Queen Charlotte's (n = 40) and My Baby and Me study (MBAM) (n = 81) cohort participants completed the Edinburgh Postnatal Depression Scale self-rating psychometric questionnaire. Villous trophoblast tissue samples were analysed for gene expression. RESULTS: In a pilot study, diagnosed depression during pregnancy was associated with a significant reduction in placental PEG3 expression (41%, p = 0.02). In two further independent cohorts, the Queen Charlotte's and MBAM cohorts, placental PEG3 expression was also inversely associated with maternal depression scores, an association that was significant in male but not female placentas. Finally, hPL expression was significantly decreased in women with clinically diagnosed depression (44%, p < 0.05) and in those with high depression scores (31% and 21%, respectively). CONCLUSIONS: This study provides the first evidence that maternal prenatal depression is associated with changes in the placental expression of PEG3, co-incident with decreased expression of hPL. This aberrant placental gene expression could provide a possible mechanistic explanation for the co-occurrence of maternal depression, fetal growth restriction, impaired maternal behaviour and poorer offspring outcomes.

Imaging of mesothelioma of tunica vaginalis testis.

OBJECTIVES: To describe the imaging findings in a series of patients with mesothelioma of the tunica vaginalis testis. METHODS: We reviewed clinical data, imaging findings and follow-up information in a series of 10 pathology-proven cases of mesothelioma (all had US; 2 had MR) of the tunica vaginalis. RESULTS: A variety of patterns could be observed, the most common (5/10) being a hydrocele with parietal, solid and hypervascular vegetations; one patient had a septated hydrocele with hypervascular walls; one had multiple, solid nodules surrounded by a small, physiological quantity of fluid; one a cystic lesion with thick walls and vegetations compressing the testis; two had a solid paratesticular mass. MR showed multiple small nodules on the surface of the tunica vaginalis in one case and diffuse thickening and vegetations in the other one; lesions had low signal intensity on T2-w images and were hypervascular after contrast injection. CONCLUSIONS: A preoperative diagnosis of mesotheliomas presenting as solid paratesticular masses seems very difficult with imaging. On the contrary, the diagnosis must be considered in patients in whom a hydrocele with parietal vegetations is detected, especially if these show high vascularity. KEY POINTS: Mesotheliomas of the tunica vaginalis are rare, often challenging to diagnose preoperatively. Most common finding is a complex hydrocele with hypervascular parietal vegetations. Septated hydrocele, nodules without hydrocele, a thick-walled paratesticular cyst are less common. Preoperative diagnosis may allow aggressive surgical approach and, possibly, a better prognosis.

The acute psychobiological impact of the intensive care experience on relatives.

There is a growing awareness amongst critical care practitioners that the impact of intensive care medicine extends beyond the patient to include the psychological impact on close family members. Several studies have addressed the needs of relatives within the intensive care context but the psychobiological impact of the experience has largely been ignored. Such impact is important in respect to health and well-being of the relative, with potential to influence patient recovery. The current feasibility study aimed to examine the acute psychobiological impact of the intensive care experience on relatives. Using a mixed methods approach, quantitative and qualitative data were collected simultaneously. Six relatives of patients admitted to the intensive care unit (ICU) of a District General Hospital, were assessed within 48 h of admission. Qualitative data were provided from semi-structured interviews analysed using interpretative phenomenological analysis. Quantitative data were collected using a range of standardised self-report questionnaires measuring coping responses, emotion, trauma symptoms and social support, and through sampling of diurnal salivary cortisol as a biomarker of stress. Four themes were identified from interview: the ICU environment, emotional responses, family relationships and support. Questionnaires identified high levels of anxiety, depression and trauma symptoms; the most commonly utilised coping techniques were acceptance, seeking support through advice and information, and substance use. Social support emerged as a key factor with focused inner circle support relating to family and ICU staff. Depressed mood and avoidance were linked to greater mean cortisol levels across the day. Greater social network and coping via self-distraction were related to lower evening cortisol, indicating them as protective factors in the ICU context. The experience of ICU has a psychological and physiological impact on relatives, suggesting the importance of identifying cost-effective interventions with evaluations of health benefits to both relatives and patients.

Foetal exposure to maternal depression predicts cortisol responses in infants: findings from rural South India.

BACKGROUND: Maternal depression during pregnancy is associated with an increased risk of adverse child outcomes. One potential mechanism is the influence of antenatal depression on the foetal hypothalamic-pituitary-adrenal axis. This can be observed as disturbances in baseline cortisol secretion during childhood. The influence of antenatal depression on infant cortisol reactivity to a stressor may provide further insight into this association. In addition, the dose-response relationship between foetal exposure to antenatal depression and infant cortisol reactivity is unclear. METHODS: A consecutive sample of 133 pregnant women in their third trimester was recruited from an antenatal clinic in Karnataka, South India. Women were assessed for depression before and after birth on the Edinburgh Postnatal Depression Scale (EPDS) and the Kessler 10 Scale. Salivary cortisol response to immunization was measured in 58 infants at 2 months of age. We aimed (i) to investigate the association between antenatal depression and infant cortisol reactivity to immunization and (ii) to explore whether the relationship is dose-dependent. RESULTS: Exposure to antenatal depression independently predicted elevated infant cortisol responses to immunization (ß = 0.53, P = 0.04). The association was found to be U-shaped, for antenatal depression measured on the EPDS, with the infants exposed to the highest and lowest levels of maternal antenatal EPDS scores during intra-uterine life showing elevated cortisol responses to immunization (R(2) = 0.20, P = 0.02). Infants exposed to moderate levels of maternal antenatal depression showed the lowest cortisol response to immunization. CONCLUSIONS: These findings suggest that the association between antenatal depression and infant cortisol reactivity is dose-dependent and U-shaped, implying that infants exposed to both low and high levels of maternal depression showed greater reactivity. The study provides the first evidence of such an association from a low-income setting.

Infant temperament and childhood psychiatric disorder: longitudinal study.

BACKGROUND: Temperamental characteristics emerge early in life and can shape children's development, adjustment and behaviour. We aimed to investigate the association between early infant temperament and later childhood psychiatric disorder in a community sample. METHODS: This prospective, population-based study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). In a sample of 7318 children, we investigated whether temperamental characteristics assessed at the ages of 6 months and 24 months are associated with an independent diagnosis of psychiatric disorder ascertained at age 7 years. RESULTS: After adjusting for confounders, temperamental characteristics assessed at 6 and 24 months of age were associated with psychiatric disorder at age 7 years. In particular, intensity of emotional reaction at age 6 months was associated with later disorder (adjusted odds ratio = 1.56; 95% confidence interval 1.19, 2.04; P = 0.002). These associations were stronger in girls and in those children with high levels of intensity at both 6 and 24 months of age. CONCLUSIONS: Temperamental characteristics involving high levels of emotional intensity within the first year of life are longitudinally associated with psychiatric disorder in mid-childhood, suggesting that the roots of psychiatric disorder may, in some cases, lie very early in life.

Expressed emotion as an assessment of family environment with mothers and fathers of 1-year-old children.

BACKGROUND: High levels of expressed emotion (EE) in parents have been found to put children at risk for emotional and behavioural problems. However, the majority of existing studies have focused on mothers of school-aged children and adolescents rather than younger children, and have only rarely included fathers. METHODS: The present study examined the reliability of EE in mothers and fathers of 1-year old children. It also investigated whether depression and marital problems in the postnatal period predicted EE toward the child at 12 months. EE was assessed with the Preschool Five Minute Speech Sample in 163 families. RESULTS: The rater-interrater and code-recode reliability was high for most EE dimensions. Mothers and fathers were found to display quite similar EE scores. Regression analyses showed that depression and couple relationship significantly predicted EE in mothers, but not fathers. CONCLUSIONS: The findings suggest that EE provides a reliable and useful assessment of the family environment in families of young children.

Depressed fathers' speech to their 3-month-old infants: a study of cognitive and mentalizing features in paternal speech.

BACKGROUND: Depression in fathers in the postnatal period is associated with an increased risk of child behaviour problems. A key potential pathway of risk transmission is exposure of the child to negative cognitions and affect in the context of early parenting. This study examines paternal speech during face-to-face father-infant interactions at 3 months. METHOD: Currently depressed (n=19) and non-depressed (n=19) fathers were individually matched on age and education. Speech was coded for cognitive biases and mentalizing statements using a modified version of previous measures of maternal speech. Paternal depression was diagnosed using a structured psychiatric interview. RESULTS: Depression in fathers was associated with more speech focused on the paternal experience and less on the infants' experience. Depressed fathers' speech comprised more negative and critical utterances, compared with non-depressed fathers. CONCLUSIONS: Important differences emerge in the speech of fathers who experience depression. Examining negative cognitions in the speech of these fathers as early as 3 months may help in understanding children's risk in relation to paternal psychopathology.

Parental depression and child outcomes--is marital conflict the missing link?

BACKGROUND: Both maternal and paternal depression during the perinatal period are associated with adverse effects on child outcomes. Attention has started to focus on the mechanisms mediating these relationships. Marital conflict may play a role in this context. METHODS: In a large cohort study, the Avon Longitudinal Study of Parents and Children (n = 14,541 pregnancies), we aimed to (i) investigate the relative influences of parental postnatal depression and marital conflict on child outcomes and to attempt to determine the pathway(s) of risk; (ii) investigate the impact of two types of antenatal stress (parental depression and marital conflict) on child outcomes; and (iii) determine the relative contributions of antenatal and postnatal risk. Parents completed the Edinburgh Postnatal Depression Scale and a marital conflict scale during the second trimester and at 8 months postnatally. Child outcomes were assessed at 42 months using the Rutter revised pre-school scales. RESULTS: Marital conflict partially mediated the relationship between postnatal depression in both mothers and fathers and child outcomes, and acted as an independent risk for adverse outcomes. Parental depression (maternal and paternal) and marital conflict in the antenatal period were both associated with adverse effects which persisted even when postnatal stresses were taken into account. CONCLUSIONS: These findings, if replicated, suggest that screening and intervention programmes targeted at parental depression and marital problems should be considered antenatally, as well as postnatally.

Comparison of provision of maxillofacial emergency service during the two COVID-19 national lockdowns in the United Kingdom.

We previously published a study on the provision of emergency maxillofacial services during the first UK COVID-19 pandemic national lockdown. We repeated the study during the second lockdown and now present our findings that highlight the main differences and learning issues as the services have evolved.

Provision of Emergency Maxillofacial Service During the COVID-19 Pandemic : A Collaborative Five Centre UK Study.

The global pandemic of Coronavirus disease (COVID-19) represents one of the greatest challenges to healthcare systems, and has forced medical specialties to rapidly adapt their approaches to patient care. Oral and Maxillofacial Surgery is considered particularly at risk of disease transmission due to aerosol generation during surgical interventions, patient proximity and operating environment. On day 2 (26th March, 2020) of when severe restrictions in population movement were instigated in the United Kingdom, we began a study to prospectively monitor the presentation and management of maxillofacial emergencies at five hospital trusts. Data was collected onto an online live database fed through a smartphone application. Of the total 529 patients over six weeks, 395 attended for face-to-face consultations and 134 patients received remote consultations via telephone or video link. There were 255 trauma related cases, 221 infection and 48 cases of postoperative complications. Most trauma cases were minor soft tissue injury related to slip, trip or fall at home. There were 44 cases of facial fractures with a tendency for conservative treatment. 19 cases were related to domestic violence or self-harm. Of the 216 dental related emergencies, 68% could have been managed in the primary care setting. A quarter of all emergency patients were satisfactorily managed by remote consultations. There was a significant change in the provision of emergency maxillofacial service during the pandemic lockdown. We discuss the study findings as well as the potential implications in relation to planning for possible further COVID- 19 spikes and future pandemics.

Synchronous metastatic renal cell carcinoma to the genitourinary tract: two rare case reports and a review of the literature.

Synchronous metastasis of renal cell carcinoma (RCC) to the ureter or the bladder represents an extremely rare event. We report one case of synchronous metastasis of RCC to the ipsilateral ureter and one case of solitary synchronous metastasis of RCC to the urinary bladder. We review the literature and discuss possible mechanisms of dissemination. We discuss the surgical management of metastases from RCC as well as the surgical options in the treatment of these rare occurrences.

Intraosseous venous malformation of the craniofacial region: diagnosis and management.

Vascular lesions mainly affect soft tissues, and less than 1% affect bone. In 1982, they were categorised by Mulliken and Glowacki as haemangiomas or vascular malformations, and an updated classification was subsequently published by the International Society for the Study of Vascular Anomalies. These lesions, however, continue to be termed haemangiomas and there is little attempt to differentiate between them. We report eight cases of intraosseous venous malformation that were inappropriately labelled as haemangioma by clinicians, pathologists, and radiologists. We highlight tailored management, and describe the clinical features, results of investigations to aid accurate designation (histological and immunohistochemical, including GLUT1 staining and cross-sectional imaging), and outcomes.

Sensory recovery of noninnervated free flap in oral and oropharyngeal reconstruction.

The sensory recovery of noninnervated free flaps used in oral and oropharyngeal reconstruction is analysed retrospectively to evaluate the degree of sensory recovery in different free flaps; and to assess the influence of various clinical and surgical factors on the recovery. A total of 40 patients who underwent oral and oropharyngeal reconstruction with noninnervated radial forearm (24), jejunal (10) or gastro-omental (6) free flaps were studied for at least 12 months postoperatively. The modalities examined were light touch, sharp prick, hot and cold temperature and static two-point discrimination. All the modalities showed statistically significant recovery in all flaps (p<0.05). The degree of sensory recovery for each modality is highest in the radial forearm followed by gastro-omental and lastly jejunal flaps. The differences between radial forearm and gastro-omental/jejunal flaps are statistically significant (p<0.05) except for light touch. The differences between the later two groups of flaps did not show statistical significance (p>0.05). Sensory recovery for all modalities in all flaps was not dependent on sex, age, smoking, flap size, postoperative radiotherapy or follow-up period (p>0.05).

Metastasising pleomorphic adenoma of the parotid gland.

A 33-year-old man had a left superficial parotidectomy for a pleomorphic adenoma. He remained well, but 28 years later developed a metastasis in a lymph node in the left supraclavicular fossa.

Herpes zoster associated with tooth resorption and periapical lesions.

A 72-year-old woman presented with multiple periapical lesions and resorption of teeth in a single quadrant 17 years after an attack of herpes zoster (shingles) of the maxillary division of the trigeminal nerve. It is possible that cases of tooth resorption that were previously classified as idiopathic may have a viral aetiology and we suggest that these patients should be asked about a previous attack of shingles.

Minimally-invasive neck dissection and free flap reconstruction in patients with cancer of the head and neck.

We describe our experience of cervical lymphadenectomy with microvascular anastomoses involving levels I to V through a minimally-invasive neck dissection. We retrospectively studied 12 patients who had levels I to IV neck dissection with free flap reconstruction between July 2013 and April 2015 at Poole Hospital (male:female ratio 8:4, mean (range) age 66 (49 - 83) years). The mean (range) operating time was 7 (5 - 8) hours, and the total volume drained from the neck was 105 (60-300) ml. The mean (range) number of harvested lymph nodes was 26 (13-39) from levels I to III, and 33 (20-42) from levels I to IV. Four patients developed weakness of the marginal mandibular nerve, but there were no serious complications. All flaps were successful, there was no regional recurrence, and most patients were discharged on postoperative day 15. This technique provides adequate exposure for lymphadenectomy and anastomosis, and we think that head and neck surgeons should include it in the armamentarium of reconstruction.

Cognitive-behavioural interventions for children who have been sexually abused.

BACKGROUND: Despite differences in perceptions of what constitutes child sexual abuse there is a general consensus amongst clinicians and researchers that this is a substantial social problem which affects large numbers of children and young people worldwide. The effects of sexual abuse manifest themselves in a wide range of symptoms, including fear, anxiety, post-traumatic stress disorder and behaviour problems such as externalising or internalising, or inappropriate sexual behaviours. Child sexual abuse is associated with increased risk of psychological problems in adulthood. Knowing what is most likely to benefit children already traumatised by these events is important. OBJECTIVES: The aim of this review was to assess the efficacy of cognitive-behavioural approaches (CBT) in addressing the immediate and longer-term sequelae on children who have been sexually abused. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2005), MEDLINE (1966-November 2005); EMBASE (1980-November 2005); CINAHL (1982-November 2005), PsycINFO (1897-November 2005); LILACS (1982-November 2005); SIGLE (1980 to November 2005) and the register of the Cochrane Developmental, Psychosocial and Learning Problems Group (November 2005) were searched. SELECTION CRITERIA: Included studies were randomised or quasi-randomised controlled trials investigating the efficacy of cognitive behavioural therapy on children and adolescents up to age 18 years who had experienced sexual abuse. DATA COLLECTION AND ANALYSIS: Titles and abstracts identified in the search were independently assessed for eligibility by two reviewers (GM and PR). Data were extracted and entered into REVMAN (JH and GM), and synthesised and presented in both written and graphical form (forest plots). MAIN RESULTS: Ten trials, including 847 participants, were included in this review. Data suggest that CBT may have a positive impact on the sequelae of child sexual abuse, but most results were statistically non-significant. AUTHORS' CONCLUSIONS: The review confirms CBT's potential as a means of addressing the adverse consequences of child sexual abuse, but highlights the tenuousness of the evidence base and the need for more carefully conducted and better reported trials.

Laugier-Hunziker syndrome: a rare cause of mucocutaneous pigmentation.

An 80-year-old white woman presented with brown pigmentation on both sides of the buccal mucosa and lower lip and patchy freckling in her nails, which was diagnosed as Laugier-Hunziker syndrome.

Paclitaxel plus carboplatin in advanced carcinoma of the urothelium: an active and tolerable outpatient regimen.

PURPOSE: To determine the toxicity and efficacy of an outpatient regimen of paclitaxel plus carboplatin in patients with advanced carcinoma of the urothelium. PATIENTS AND METHODS: Patients received paclitaxel 150 to 225 mg/m2 over 3 hours followed by carboplatin (targeted area under the concentration-time curve [AUC], 6 mg/mL x min) every 3 weeks. During phase I accrual, 16 patients were treated; 17 additional patients were enrolled at the phase II dose. The median age was 70 years (range, 47 to 82). The median serum creatinine concentration was 1.1 mg/dL (range, 0.7 to 2.7) and the median estimated creatinine clearance was 52 mL/min (range, 24 to 110). RESULTS: During phase I accrual, the maximum-tolerated dose (MTD) of the regimen was not defined. Phase II accrual occurred at the paclitaxel 225 mg/m2 dose level. A total of 156 cycles were administered. The median number of cycles received was five (range, one to eight). Sensorimotor neuropathy was the principal nonhematologic toxicity. Significant granulocytopenia was common, but significant thrombocytopenia was not. Objective responses were demonstrated at all dose levels. At the phase II dose (paclitaxel 225 mg/m2 followed by carboplatin at AUC 6 mg/mL x min), the objective response rate was 50% (95% confidence interval [CI], 28% to 72%). CONCLUSION: Paclitaxel plus carboplatin is an active and tolerable outpatient treatment for patients with advanced carcinoma of the urothelium. The ability to administer this combination over multiple cycles even to patients with advanced age and abnormal renal function makes it well suited for this patient population. Confirmatory trials of this regimen are ongoing.