Impact of family history risk assessment on surgical decisions and imaging surveillance at breast cancer diagnosis

INTRODUCTION

In June 2013, the National Institute for Health and Care Excellence (NICE) published guidance on the management of women with a family history (FH) of breast cancer (BC) and a personal diagnosis of BC. When diagnosed with BC, pressure of timely treatment takes priority and there is potential for a significant FH to be overlooked. This can affect treatment options and follow-up imaging (FUI) surveillance.

METHODS

The practice in our breast unit was compared with the NICE guidance with regard to arranging appropriate FUI and referral to the genetics team for women diagnosed with BC with a FH of BC. Data were obtained retrospectively on 200 women with BC, identified from the breast multidisciplinary team meetings from January to March 2014. Initial audit showed poor compliance with recording of FH. A standardised history taking proforma was produced for clinic use. A re-audit was conducted on a further 200 women between May and July 2016.

RESULTS

In the initial audit, FH was taken in 151 women (76%) compared with 174 women (87%) in the re-audit. Thirty-seven women (25%) were thought to be of moderate risk (MR) or high risk (HR) based on FH in the first audit. Re-audit identified 35 women (20%) with MR or HR FH. Under half (43%) of the women of HR were referred to the genetics team initially; this increased to 70% in the second audit. While almost half (46%) of the women with MR or HR had inappropriate FUI in the initial audit, this fell to 11% in the re-audit.

CONCLUSIONS

A proportion of women diagnosed with BC would fall into the MR or HR categories as defined in the NICE FH guidance. Inadequate recording of FH could result in inadequate FUI surveillance and in some cases missing the opportunity for a genetic referral to assess suitability for gene testing.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P < 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Oxygen exchange and C-reactive protein predict safe discharge in patients with H1N1 influenza

BACKGROUND

: Pandemic influenza has potential to overwhelm healthcare resources. There is uncertainty over performance of existing triage tools for hospital admission and discharge decisions.

AIM

: Our aim was to identify clinical criteria that predict safe discharge from hospital and develop a pragmatic triage tool to guide physician decision-making.

DESIGN

: We retrospectively examined an existing database of patients who presented to the Royal Liverpool University Hospital during the 2010-11 influenza pandemic.

METHODS

Inclusion criteria: patients ≥18 years, with PCR confirmed H1N1 influenza. Exclusion criteria: died in the emergency department or case notes unavailable. Successful discharge was defined as discharge within 24 h of presentation and no readmission within 7 days.

RESULTS

Eighty-six patients were included and 16 were successfully discharged. Estimated P/F ratio and C-reactive protein predicted safe discharge in a multivariable logistic regression model (AUC 0.883). A composite univariate predictor (estimated P/F minus C-reactive protein, AUC 0.877) was created to calculate specific cut off points for sensitivity and specificity. A pragmatic decision tool was created to incorporate these thresholds and relevant guidelines. Discharge: SpO 2 (in air)   ≥ 94% and CRP <50. Observe: SpO 2  ≥   94% and CRP >50 or SpO 2  ≤   93% and CRP <50. Admit: SpO 2  ≤   93% and CRP >50.

CONCLUSIONS

We identified that oxygen exchange and CRP, a marker of acute inflammation, were the most important predictors of safe discharge. Our proposed simple triage model requires validation but has the potential to aid clinical decisions in the event of a future pandemic, and potentially for seasonal influenza.

Parasitic infection of the male breast

Breast lumps are commonly seen in clinical practice, yet deeper exploration of this particular case presented an unusual diagnostic challenge.

Abstract P2-19-10: Quality of life following mastectomy and breast reconstruction (QUEST): Learning from two feasibility randomized controlled clinical trials

Background: Breast reconstruction (BRR) aims to improve health related quality of life (HRQL) after mastectomy, but with poor evidence to date informing the optimal type or timing of surgery to guide shared-decision making. Systematic reviews show the paucity of randomised trials (RCT) with only two-singe centre RCTs. Although, an RCT has theoretical advantages, there have been concerns that clinicians may not share clinical equipoise regarding recommending types of BRR surgery that is sensitive to patient preferences. The aim of the QUEST trials (CRUK/08/027) was to determine the optimal types of latissimus dorsi (LD) BRR (Trial A) when there is no expectation for post-mastectomy radiotherapy (PMRT), and timings of LDBRR when PMRT is recommended (Trial B), that would benefit HRQL during five years post-operatively. As this was the first attempt at a multi-centre RCT, the main trial was preceded by a feasibility phase to demonstrate that recruitment was achievable and that randomization was acceptable to patients. An embedded qualitative study, the QUEST Perspective Study (QPS) assessed the perceptions of equipoise of patients and health care professionals (HCPs) for the types of surgery.

Methods: QUEST comprised two parallel phase III multicentre feasibility RCTs to assess HRQL impact of the type of LDBRR when PMRT is unlikely (Trial A, LD - implant assisted (LDI) versus extended autologous LD (ALD)). Trial B evaluated optimal timings of LDBRR comparing staged - delayed ALD (skin-preserving sub-pectoral expander implant then ALD) to immediate ALD when PMRT was likely.

Eligible patients comprised mastectomy recommended for invasive breast cancer or DCIS in the context of technical feasibility for ALD and preferred synchronous breast reduction. The primary endpoint was the proportion of eligible women approached who accepted randomisation. QPS explored patients and HCPs’ acceptability of the trial and randomisation using semi-structured telephone interviews and questionnaires.

Results: The QUEST trials opened in May 2011 with 15 UK centres participating. After 18 months of recruitment, 17 patients had been entered in Trial A and 8 in trial B with acceptance rates of 19% (17/88) and 22% (8/36) for trial A and B respectively. Patient preference was the predominant reason for eligible patients approached about the trial not being randomised with 47 of the 88 (53%) for Trial A and 22 of 36 (61%) eligible for Trial B, declining for that reason. Patient acceptance rates for randomisation increased from 19% during the first 6 months to 29% from 7-12 months for Trial A; corresponding figures for Trial B were 11% and 27%. The recruitment challenges and funding cessation caused the Trial Steering Committee to recommend trial closure in December 2012.

Conclusion: Despite the need for clinical evidence, patients retained strong preferences for breast reconstruction type and timing, amidst ‘standardised’ trial processes. Patient acceptance rates did improve during the trial, but it was not possible to meet target recruitment within the constraints of a feasibility trial.

Funding for this NCRN portfolio trial (92581226) was from Cancer Research UK (CRUK) and BUPA Foundation funding for QPS.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-19-10.

'Chemobrain': concentration and memory effects in people receiving chemotherapy - a descriptive phenomenological study

There is an international literature which claims that there is a link between chemotherapeutic agents and cognitive impairment. Deficits in concentration and memory can have a major impact on decision making about education and careers, and on general quality of life. The literature to date is generally anecdotal, or reports on quantitative research that does not address patients' interpretations of impaired cognition. It was the intention of this study to capture experiences and perceptions of cognitive impairment as told by people receiving chemotherapy. A descriptive phenomenological approach was employed and four participants were interviewed twice. Analysis was conducted using Nvivo software alongside Hycner's analysis framework so that researchers could produce narratives to represent experiences for each case. The description for each case illuminates uniqueness and commonality. 'Chemobrain' is a significant and important issue for many patients but they are often unaware, prior to chemotherapy, that cognition may be affected. There is no shared understanding between patients and healthcare professionals and there is a lack of information about the phenomena which disempower patients. Healthcare professionals should develop knowledge and skills to recognise and address chemotherapy-induced cognitive impairment.

Case report of bilateral inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare entity that makes up 1-3% of breast cancers. As the diagnosis of IBC is mainly clinical, for the inexperienced the clinical appearance can mimic mastitis leading to diagnostic delay and it is often associated with a poor prognosis. Very few cases of bilateral IBC are reported in the literature, all of which have been synchronous. We report an unusual case of bilateral metachronous IBC each with complete clinico-pathological response after treatment with neoadjuvant chemotherapy and surgery on both occasions.

Promoting Recovery for People with Long-term Mental Illness in Institutional care: An International Delphi Study of Stakeholder Views

Aims:

To identify the specific components of care that key stakeholders in ten European countries at different stages of de-institutionalization regard as most important in promoting recovery in this group; to measure consensus between and across stakeholder groups and countries; and to develop a conceptual framework of ‘domains’ of care.

Method:

Each participating country completed a series of conventional three-round Delphi exercises with four separate panels of experts; service users, mental health professionals, carers and advocates. In Round 1 an initial open question asked respondents to identify up to 10 components of care they considered most important in promoting recovery. In Round 2 these ideas were fed back to the group and rated on a 5-point scale. In Round 3 the group re-rated the components in the light of information about the whole group's response. Components achieving high importance rankings and high consensus were grouped into domains.

Results:

The 40 participating panels generated around 4,000 separate items of care. From these, eleven broad domains of recovery practice were identified. Results will be presented descriptively to show the domains and components of care considered to be most important to recovery, and to show consensus within and across countries, and between stakeholder groups. It will be seen that there was generally high consensus between groups and countries but some modest differences in priorities.

Conclusions:

Delphi methodology is useful in eliciting and evaluating different perspectives on recovery-based practice. Strengths and weaknesses of the approach will be discussed.

Factors that predict infant disorganization in mothers classified as U in pregnancy

The unresolved (U) state of mind in parents has been validated by its association with infant attachment disorganization (D), yet all studies show a transmission gap, and a proportion of individuals classified as U have infants who are not D. This paper reports on 31 mothers who showed the characteristic lapses in thinking and reasoning of the unresolved/disorganized state of mind in relation to stillbirth (U(sb)), when assessed with the Adult Attachment Interview (AAI) in the pregnancy after stillbirth. Seventeen (55%) of their infants were D at 1 year old. We evaluate social, attachment, and psychiatric variables to establish whether there are differences in U(sb) individuals that will predict infant D. In this population of U mothers, social and attachment factors did not predict infant D, but U(sb) mothers of non-D infants showed significantly higher levels of depression and of intrusive thoughts on the posttraumatic stress disorder (PTSD) scale in pregnancy, and showed higher levels of intrusive thoughts when the infant was 1 year old. We discuss possible interpretations of these findings.

Factors associated with the unresolved classification of the Adult Attachment Interview in women who have suffered stillbirth

The "unresolved" state of mind with respect to loss or trauma as assessed in the Adult Attachment Interview is common in clinical and forensic groups, as well as in mothers whose infants are classified as disorganized in their attachment relationship to them. However, questions remain about what the unresolved state represents and what factors predict the unresolved state. This case controlled study reports on 64 women who had suffered stillbirth and who were pregnant with their next child. The study explores attachment, psychiatric, and social factors associated with the unresolved state or higher unresolved scores with respect to stillbirth. Women who had experienced stillbirth were more likely to be unresolved than control women. Although a similar number of stillbirth and control women had experienced childhood trauma, only women who had experienced stillbirth were unresolved with respect to this trauma, suggesting the unresolved state may be evoked or reevoked by subsequent traumatic loss. Higher unresolved scores in relation to stillbirth were predicted by childhood trauma, poor support from family after the loss, and having a funeral for the infant. The results are discussed in terms of the woman's sense of being causal in the loss.

Work-site hypertension prevalence and control in three Central European Countries

Compared to Austria, cerebrovascular stroke (CVS) mortality is three times higher in Hungary, and twice as high in Slovakia. We hypothesized that this is due to better treatment and control of hypertension in Austria. To test this hypothesis, we carried out a cross-sectional survey of 'blue collar' employees on work sites in each of these countries. Blood pressure screening was carried out at three work sites in Austria, one in Hungary and one in Slovakia. A standardized protocol was followed in each of these countries. The Bp-TRU(TM) measuring instrument was used to provide accurate reproducible readings and eliminate interobserver error. After the exclusion of missing data and women, the study population included 323 males screened in Austria, 600 in Hungary, and 751 in Slovakia. The mean ages of the respondents ranged from 35 to 42 years. The prevalence of hypertension was 29% in Austria, 28% in Hungary and 40% in Slovakia. Of those identified as hypertensive, 73% in Austria, 45% in Hungary and 67% in Slovakia were newly diagnosed as a result of this screening. Of those treated for hypertension, 10% in Austria, 15% in Hungary and 5% in Slovakia were controlled. The differences in CVS mortality cannot be explained by better control of hypertension in Austria but indicate the involvement of other determinants.

User involvement in UK cancer services: bridging the policy gap

Recent UK government initiatives aim to increase user involvement in the National Health Service (NHS) in two ways: by encouraging service users to take an active role in making decisions about their own care; and by establishing opportunities for wider public participation in service development. The purpose of this study was to examine how UK cancer service users understand and relate to the concept of user involvement. The data were collected through in-depth interviews, which were analysed for content according to the principles of grounded theory. The results highlight the role of information and communication in effective user involvement. Perhaps more importantly, this study suggests that the concept of user involvement is unclear to many cancer service users. This paper argues the need for increased awareness and understanding of what user involvement is and how it can work.

Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study

BACKGROUND

Most maternity units have good practice protocols, advising that after stillbirth parents should be encouraged to see and hold their dead infant. Our aim was to assess whether adherence to these protocols is associated with measurably beneficial effects on the psychological health of mother and next-born child. This study forms part of a wider case-control study of the psychological effects of stillbirth.

METHODS

We identified 65 women in the pregnancy after stillbirth, and enrolled matched controls for 60 of them. Outcome measures included depression, anxiety, and post-traumatic-stress disorder (PTSD) in pregnancy and 1 year after the next birth, and disorganised attachment behaviour in the next-born infant. Comparison variables included seeing and holding the stillborn infant, having a funeral, and keeping mementoes.

FINDINGS

Behaviours that promote contact with the stillborn infant were associated with worse outcome. Women who had held their stillborn infant were more depressed than those who only saw the infant, while those who did not see the infant were least likely to be depressed (13 of 33, 39%, vs three of 14, 21%, vs one of 17, 6%; p=0.03). Women who had seen their stillborn infant had greater anxiety (p=0.02) and higher symptoms of PTSD than those who had not (p=0.02), and their next-born infants were more likely to show disorganised attachment behaviour (18 of 43, 42%, vs one of 12, 8%, p=0 x 04). Having a funeral and keeping mementoes were not associated with further adverse outcomes, but small numbers limited interpretation.

INTERPRETATION

Our findings do not support good-practice guidelines, which state that failure to see and hold the dead child could have adverse effects on parents' mourning.

The adult attachment interview: rating and classification problems posed by non-normative samples

Non-normative samples can pose major procedural and coding challenges to interviewers and raters of the Adult Attachment Interview (AAI). With reference to interview transcripts drawn from a population of personality disordered offenders detained in a high-security hospital, specific difficulties are identified and discussed. These difficulties have their roots in three separate but overlapping areas: extreme attachment-related experience; interviewees' psychological or psychiatric state; and factors relating to the context in which the interview is conducted. They raise questions about whether and when the use of the interview should be restricted, the rating rules elaborated and/or the rating system expanded. Suggestions are made as to how some of the difficulties might be addressed.

Disorganised attachment behaviour among infants born subsequent to stillbirth

There is limited evidence that siblings of stillborn infants are more vulnerable to psychological problems. This case-controlled study examines the relationship between previous stillbirth and the next child's pattern of attachment and explores factors in the mother which may be associated with and which may explain the pattern of infant attachment. We examined 53 infants next-born after a stillbirth, and 53 control infants of primigravid mothers. Maternal demographic, psychiatric, and attachment data were collected in pregnancy, and self-report measures of depression collected in the first year. Infant attachment patterns to the mothers were assessed when the infants were 12 months old using the Ainsworth Strange Situation Procedure. Infants next-born after stillbirth showed significant increase in disorganisation of attachment to the mother compared with control infants (p < .04). The difference was not accounted for by differences in psychiatric symptoms or demography. It was strongly predicted by maternal unresolved status with respect to loss as measured in the Adult Attachment Interview, and less strongly by maternal experience of elective termination of pregnancy and by the mother having seen her stillborn infant. The study adds weight to previously reported clinical observations, that infants born after stillbirth may be at risk of an increase in psychological and behavioural problems in later childhood. The strong association between disorganisation of infant attachment and maternal state of mind with respect to loss suggests that the mother's state of mind may be causal, and raises interesting questions about the mechanism of intergenerational transmission. Given the existing evidence of later developmental problems, longer-term follow-up of these children would be valuable.

The use of a hydrofibre dressing in fulminating necrotizing fasciitis

This article describes a case of necrotizing fasciitis in a 52-year-old man with previously undiagnosed diabetes. Treatment involved massive debridement and subsequent dressing of the open surgical wound. A modern hydrofibre dressing (Aquacel) was inserted intraoperatively and subsequently continued postoperatively. Wound healing occurred over 3 months and the patient was discharged with no disability. The dressing managed the exudate level and kept the wound moist. It also was well tolerated by the patient, was comfortable and easy for the nurses to remove and apply.

Incidence, correlates and predictors of post-traumatic stress disorder in the pregnancy after stillbirth

BACKGROUND

Many women may suffer psychological symptoms after stillbirth and in the subsequent pregnancy. Stillbirth has not been demonstrated previously to be a stressor for post-traumatic stress disorder (PTSD).

AIMS

To assess incidence, correlates and predictors of PTSD during and after the pregnancy following stillbirth.

METHOD

A cohort study of pregnant women whose previous pregnancy ended in stillbirth.

RESULTS

PTSD symptoms were prevalent in the pregnancy following stillbirth. Case-level PTSD was associated with depression, state-anxiety and conception occurring closer to loss. Symptoms generally resolved naturally by 1 year post-partum (birth of healthy baby).

CONCLUSIONS

Women are vulnerable to PTSD in the pregnancy subsequent to stillbirth, particularly when conception occurs soon after the loss.

Meeting the needs of people with cancer for support and self-management

Health professionals tend to consider that they are in the best position to decide treatment options for cancer patients despite research evidence that a feeling of powerlessness can affect health outcomes and the inclusion of patient empowerment within government policy. This article describes a focus group study, carried out in collaboration with the University of Warwick, aiming to elicit the needs of people with cancer and their carers/supporters, the reactions to these needs and the strategies adopted to obtain support and self-management skills. The methodology was II two-stage focus groups carried out in four English cities in 1998, involving 54 people with cancer and 14 supporters. The main study findings identified a parallel 'journey' to the previously described emotional and medical cancer journey in the form of an epistemological journey of 'identity shifts' as people progressed through their disease. People required additional emotional and psychological support when these shifts were taking place and used a variety of strategies to obtain this, including the use of complementary therapies and other strategies designed to increase their sense of control. The article concludes by describing a 'holistic' approach to cancer care which supports patient empowerment and recommendations for implementing the research findings into practice.

Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care

OBJECTIVE

To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.

DESIGN

Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).

SETTING

10 general practices in south Wales and south west England.

SUBJECTS

1368 patients requesting same day consultations.

MAIN OUTCOME MEASURES

Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.

RESULTS

Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.

CONCLUSION

This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations.

Incidence and demographic correlates of eating disorder symptoms in a pregnant population

OBJECTIVE

To obtain a picture of eating disorder symptoms in a population of pregnant women.

METHOD

Five hundred thirty women attending antenatal follow-up clinics at a large London district general hospital during a 4-week period were surveyed. The Eating Attitudes Test (EAT), the Edinburgh Postnatal Depression Scale (EPDS), and a demographic questionnaire were administered. Unadjusted relative risks and their 95% confidence intervals were calculated for a series of prognostic factors.

RESULTS

4.9% of women scored above the recommended threshold on the EAT in pregnancy. Eating disorder symptomatology was found to be associated with younger age, previous symptomatology, lower educational attainment, poorer housing, employment status, and previous miscarriage.

DISCUSSION

The meaning and potential implications of high levels of eating disorder symptomatology in a pregnant population are discussed in the light of the physiological and psychological effects of eating disorders on both pregnancy outcome and infant development.

Comparison of stage-matched and unmatched interventions to promote exercise behaviour in the primary care setting

This study examined the effectiveness of stages of change-based counselling for exercise delivered by nurses in four primary care centres. Two-hundred and ninety-four subjects enrolled, recruited from patients attending 30-min health checks. The average age of participants was 42.4 years (SD = 15.1) and 77% were female. Participants completed a questionnaire assessing stage of exercise adoption, self-efficacy and exercise levels. Each centre was assigned to either one of three experimental conditions or to a control condition. Participants were counselled accordingly, receiving either stage-oriented exercise materials with counselling (stage plus counselling), stage-oriented materials without counselling (stage no counselling), non-staged materials with counselling (counselling only) or the current level of advice (control). Sixty-one percent (n = 180) returned follow-up questionnaires. When baseline differences in self-efficacy, age and gender were controlled for, there was no significant group or interaction effect for stage. There was a significant time effect (F = 3.55, P = 0.031). Post hoc analyses showed that significant differences were between baseline and 2 (t = -3.02, P = 0.003) and 6 months (t = -2.67, P = 0.009). No changes in self-efficacy and exercise levels were observed. Stage-based interventions were not superior to the other interventions. All single-contact interventions, while having no impact on exercise behaviour and self-efficacy, did enhance motivation to change.

Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study

OBJECTIVE

To assess women's symptoms of depression and anxiety during pregnancy and the postpartum year in the pregnancy after stillbirth; to assess relevance of time since loss.

DESIGN

Cohort study with four assessments: in third trimester and 6 weeks, 6 months, and 12 months after birth.

SETTING

Outpatient departments of three district general hospitals; subjects' homes.

SUBJECTS

60 women whose previous pregnancy ended in stillbirth after 18 weeks' gestation; 60 matched controls.

MAIN OUTCOME MEASURES

Depression and anxiety measured by Edinburgh postnatal depression scale, Beck depression inventory, and Spielberger state-trait anxiety scale.

RESULTS

In the third trimester women whose previous pregnancy had ended in stillbirth were significantly more depressed than control women (10.8 v 8.2; P=0.004) and had greater state anxiety (39.8 v 32. 8, P=0.003) The difference was accounted for by those women who conceived less than 12 months after the stillbirth, who were also more depressed at 1 year. Results in those who conceived 12 months or more after stillbirth were similar to those in their controls at all points and showed lower trait anxiety 1 year post partum. One year after the birth 8% of control women and 19% of subjects scored high for depression (P=0.39), with most of the depression among the more recently bereaved (28% v 11%; P=0.18). In the women who had experienced stillbirth, depression in the third trimester was highly predictive of depression 1 year after subsequent birth (P</=0.0005).

CONCLUSION

Vulnerability to depression and anxiety in the next pregnancy and puerperium is related to time since stillbirth, with more recently bereaved women at significantly greater risk than controls. As there are problems for mother and infant associated with high anxiety and depression during and after pregnancy, there may be advantage in waiting 12 months before the next conception.

Incidence and demographic correlates of depressive symptoms during pregnancy in an inner London population

This paper reviews the literature on antenatal depression and reports on a recent survey of depressive symptoms among 407 women attending an inner London antenatal clinic. The high level of depressive symptoms in this survey was in line with that recently reported from a deprived inner-city population in the United States. Depressive symptoms were associated with having no educational qualifications, being unmarried, the woman being unemployed, having poor support from a partner if present, and being in second or subsequent pregnancy. Doctors should be aware that women are not especially protected from symptoms of depression during pregnancy. The association with socioeconomic problems suggests that this is one aspect of morbidity among disadvantaged people. There is a need for more research on the causes of depression during pregnancy and on evaluation of medical treatment and social intervention.

Public health. The missing link

The government's strategy for public health may fail because of a lack of co-operation between organisations. Primary care, as presently constituted, has little energy to take on public health. The strategy places too much stress on the role of health authorities and too little on primary care and local communities. The predominance of the medical model in public health needs to be addressed.

Giardia carriage in aboriginal and non-aboriginal children attending urban day-care centres in South Australia

A survey of Giardia lamblia prevalence was carried out in Adelaide, South Australia, among Aboriginal and non-Aboriginal children attending day-care centres. A single-stool examination in 178 children aged 6 years and under revealed an overall prevalence rate of 10.7% with all carriers being 1-4 years of age. Within this age group, Giardia prevalence among Aboriginal children (11/32) was significantly higher than that among non-Aboriginal children (eight of 99) (Chi-square analysis, P less than 0.001). Furthermore, among Aboriginal children, a significant association (P less than 0.05) was found between giardia carriage and the family's contact with rural Aboriginal settlements or people from these areas. Aboriginal children with no rural contact had a giardia prevalence similar to non-Aboriginal children.