Paranoid Thinking as a Function of Minority Group Status and Intersectionality: An International Examination of the Role of Negative Beliefs

BACKGROUND

Paranoia is higher in minority group individuals, especially those reporting intersecting aspects of difference. High negative and low positive self and other beliefs, and low social rank, are predictive of paranoia overtime; however, data are typically from majority group participants. This study examined whether social defeat or healthy cultural mistrust best characterizes paranoia in minority groups.

STUDY DESIGN

Using cross-sectional, survey design, with a large (n = 2510) international sample, moderation analyses (PROCESS) examined whether self and other beliefs, and perceived social rank, operate similarly or differently in minority vs majority group participants. Specifically, we tested whether beliefs moderated the influence of minority group, and intersecting aspects of difference, on paranoia.

STUDY RESULTS

Paranoia was consistently higher in participants from minority vs majority groups and level of paranoid thinking was significantly higher at each level of the intersectionality index. Negative self/other beliefs were associated with elevated paranoia in all participants. However, in support of the notion of healthy cultural mistrust, low social rank, and low positive self/other beliefs were significantly associated with paranoia in majority group participants but unrelated to paranoia in respective minority group members.

CONCLUSIONS

Although mixed, our findings signal the need to consider healthy cultural mistrust when examining paranoia in minority groups and bring into question whether "paranoia" accurately describes the experiences of marginalized individuals, at least at low levels of severity. Further research on paranoia in minority groups is crucial to developing culturally appropriate ways of understanding people's experiences in the context of victimization, discrimination, and difference.

The Pandemic Paranoia Scale (PPS): factor structure and measurement invariance across languages

BACKGROUND

Globally, the corona virus disease 2019 (COVID-19) pandemic has created an interpersonally threatening context within which other people have become a source of possible threat. This study reports on the development and validation of a self-report measure of pandemic paranoia; that is, heightened levels of suspicion and mistrust towards others due to the COVID-19 pandemic.

METHODS

An international consortium developed an initial set of 28 items for the Pandemic Paranoia Scale (PPS), which were completed by participants from the UK (n = 512), USA (n = 535), Germany (n = 516), Hong Kong (n = 454) and Australia (n = 502) using stratified quota sampling (for age, sex and educational attainment) through Qualtrics and translated for Germany and Hong Kong.

RESULTS

Exploratory factor analysis in the UK sample suggested a 25-item, three-factor solution (persecutory threat; paranoid conspiracy and interpersonal mistrust). Confirmatory factor analysis (CFA) on the remaining combined sample showed sufficient model fit in this independent set of data. Measurement invariance analyses suggested configural and metric invariance, but no scalar invariance across cultures/languages. A second-order factor CFA on the whole sample indicated that the three factors showed large loadings on a common second-order pandemic paranoia factor. Analyses also supported the test-retest reliability and internal and convergent validity.

CONCLUSION

The PPS offers an internationally validated and reliable method for assessing paranoia in the context of a pandemic. The PPS has the potential to enhance our understanding of the impact of the pandemic, the nature of paranoia and to assist in identifying and supporting people affected by pandemic-specific paranoia.

We live in a virtual world: Training the trainee using an integrated visual reality simulator curriculum

Background

Gynaecology trainees struggle to obtain adequate procedural experience. Training programs integrating virtual reality simulators (VRS) have been suggested as a solution.

Aims

The study aimed to assess if a VRS training program (LapSim^®, Surgical Sciences, Göteborg, 2017) improved live operating performance at six months for novice and experienced trainees. Additional outcomes included the association between LapSim^® logged time and live operating performance at six months, LapSim^® scores and live operating performance at zero and sixmonths and the difference in benefit for novice and experienced gynaecology trainees.

Methods

A prospective intervention study was conducted. Novice and experienced trainees were enrolled, and comparisons made at zero‐ and six‐month time points. The intervention groups were provided with a laparoscopic gynaecology curriculum incorporating VRS. Controls underwent routine training only. Assessment of live operating performance was conducted after six months training.

Results

Thirty‐five trainees participated, and 25 had access to the VRS curriculum (17 novice and eight experienced trainees). Access to the VRS curriculum and time spent training on the LapSim^® made no difference to live operating ability for either intervention group (P > 0.05). The median (interquartile range) hours of VRS usage were 7.9 (4.5–10.8) and 6.0 (4.0–6.8) for novice and experienced trainees respectively. The intervention group provided positive feedback on the utility of VRS in their laparoscopic skill development.

Conclusion

Optimal utilisation of VRS in Australian training paradigms remains incompletely understood. Further research is required to establish the most effective integration of VRS into training models to ensure uptake and transferability to the operating theatre.

Preoperative Imaging in Patients with Deep Infiltrating Endometriosis (DIE): An Important aid in Predicting Depth of Infiltration in Rectosigmoid Disease

STUDY OBJECTIVE

To determine the diagnostic accuracy of specialist transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histological specimens obtained at surgery.

DESIGN

A retrospective analysis, which met the STARD (2015) guidelines for a diagnostic accuracy study.

SETTING

Tertiary teaching hospital.

PATIENTS

194 cases who underwent preoperative discussion at the Gynaecological Endosurgery Unit multidisciplinary meeting (MDM) between January 2012 and December 2019 were eligible for inclusion.

INTERVENTIONS

Retrospective assessment of the accuracy of TVUS and MRI in predicting histological depth of rectosigmoid DIE following operative management.

MEASUREMENTS AND MAIN RESULTS

135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, 63 had no rectosigmoid surgery. Of the 52 patients with full thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histological depth in 48 (92%) cases (sensitivity 94%, specificity 50%, positive predictive values (PPV) 97.9%, negative predictive value (NPV) 25.0%; area under the receiver operating curves (AUROC) 0.720, 95%CI: 0.229, 1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity 93.6%, specificity 50.0%, PPV 97.8%, NPV 25.0%; AUROC 0.718, 95%CI: 0.227, 1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity 86.4%, specificity 100%, PPV 100%, NPV 14.2).

CONCLUSION

Specialised performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement and their use is justified in the preoperative planning of these gynaecological surgeries.

Hysteroscopic management of retained products of conception: A systematic review

BACKGROUND

The management of retained products of conception (RPOC) is not well standardised due to a lack of evidence-based guidelines. Hysteroscopic resection has been proven to be safe and is hypothesised to have lower risk than dilation and curettage, but data comparing the two directly are limited.

AIM

The aim of this study is to evaluate the outcomes for hysteroscopic resection for the management of RPOC in comparison to current standard management techniques.

METHODS

A literature search was conducted in September 2019 using MEDLINE, Scopus, The Cochrane Library and Web of Science. The key search terms were 'hysteroscopy'/'hysteroscopic resection' and 'retained products of conception'/'RPOC'. Both prospective and retrospective studies were included. A total of 19 studies were included (n = 2314). Due to a critical risk of bias in all studies with a comparison arm, a meta-analysis was not performed. Meta-analysis techniques were still used to provide summary estimates for primary and secondary outcomes, including conception rate, time to conception, live birth rate, intrauterine adhesions (IUAs), surgical complications and future pregnancy complications.

RESULTS

The overall conception rate for hysteroscopic resection was 81.1% (live birth rate 87.3%) compared to 65.4% for non-hysteroscopic management (live birth rate 93.8%). After hysteroscopic resection the overall complication rate was 1.9% and the IUA rate was 6.8%.

CONCLUSIONS

Due to the poor quality and overall scarcity of comparative data, the question whether hysteroscopic resection is superior to traditional curettage for the management of RPOC remains unanswered. This review provides summary data, which will enable the design of adequately powered future studies.

The myometrial-cervical ratio (MCR): Assessing the diagnostic accuracy of a novel ultrasound measurement in the diagnosis of adenomyosis

BACKGROUND

Adenomyosis is histologically defined by the presence of endometrial glands and stroma in the myometrium. To date, there are no standardised ultrasound findings that reliably predict histological adenomyosis.

AIMS

This study aimed to determine the diagnostic accuracy of a novel sonographic measurement for adenomyosis, the myometrial-cervical ratio (MCR), when compared with histopathological diagnosis.

MATERIALS AND METHODS

A single-centre retrospective study was performed. The MCR was calculated from the pre-operative ultrasound, and histopathology reviewed for each case. Accuracy data were analysed in the form of 2 × 2 tables. The discriminative value of the MCR was summarised with a receiver operator characteristic (ROC) curve. Sub-analysis examined the impact of fibroids, hormonal suppression, menopausal status, parity and indication for surgery.

RESULTS

Between 1 January 2016 and 31 December 2018, 982 patients underwent hysterectomy for benign non-obstetric indication and adequate pre-operative ultrasound was available for 260. The MCR demonstrated limited diagnostic ability for adenomyosis (area under the receiver operating characteristic curve (AUROC) 0.58, 95% CI 0.51-0.65). However, when applied to cases with no uterine fibroid included in the MCR calculation (n = 133) there was a strong association between MCR and diagnosis of adenomyosis (odds ratio: 5.79, 95% CI: 2.15, 15.62, P = 0.001) with AUROC for this model 0.68 (95% CI: 0.59, 0.77). At an MCR cut-point of 1.74, sensitivity is 67.16% and specificity is 66.15%, with 66.67% of samples correctly classified.

CONCLUSIONS

While diagnostic accuracy was suboptimal, the MCR outperforms traditional ultrasound diagnostic features of adenomyosis. The MCR may offer a simple imaging measurement for adenomyosis.

Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes

Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.

Botulinum toxin A (Botox) injection into muscles of pelvic floor as a treatment for persistent pelvic pain secondary to pelvic floor muscular spasm: A pilot study

BACKGROUND

Persistent pelvic pain (PPP) remains an important cause of morbidity. Pelvic floor muscle spasm is an important contributor to PPP.

AIMS

The study's primary aim was to assess if botulinum toxin (BoNT) injection to pelvic floor muscles altered pain scores or quality of life (QoL) at six, 12 and 26 weeks. Secondary aims included investigating the impact of BoNT on opiate usage, examining the role of pain catastrophising, and assessing for complications.

MATERIALS AND METHODS

A single-centre prospective cohort study enrolled 21 patients with PPP who had failed physiotherapy techniques. Each participant underwent BoNT injection to muscles of the pelvic floor and pudendal nerve block. Questionnaires and digital vaginal examinations were conducted at baseline, six, 12 and 26 weeks. Pain score quantification used visual analogue scales (VAS) and numerical rating scales (NRS). Other outcome assessments included The World Health Organization Quality of Life instrument (WHOQoL-BREF), Pain Catastrophising Scale (PCS), and modified Australian Pelvic Floor Questionnaire (APFQ). ACTRN12620000067976.

RESULTS

Following BoNT injection, median VAS scores decreased for all domains at six and 12 weeks, with VAS for dyspareunia significant at six weeks (P = 0.026). Scores returned to baseline by 26 weeks. Opiate usage was significantly less following BoNT injection, with a percentage reduction of 23.8% (95% CI -48.3 to 0.7, P = 0.06). Sexual function improved significantly (P < 0.01), and at six months, four previously apareunic participants reported successful penetrative vaginal intercourse. Health-related QoL and PCS demonstrated sustained improvement (P = 0.02-0.05). NRS for muscle tenderness decreased for all assessed muscle groups (P < 0.001).

CONCLUSIONS

BoNT requires further assessment as a treatment modality for select women with PPP.

A randomised trial comparing a brief online delivery of mindfulness-plus-values versus values only for symptoms of depression: Does baseline severity matter?

BACKGROUND

Acceptance/mindfulness-based interventions often focus on (a) developing dispositional mindfulness and (b) pursuing personally meaningful and valued activities. Acceptance/mindfulness-based interventions can reduce depression, but little is known about the combined effects of components or the influence of baseline variables on outcomes. This study tested whether practicing a brief (10-min) mindfulness meditation over a 2-week period followed by a single values session (mindfulness+values) was more effective than values alone (values only) in reducing symptoms of depression. The study was delivered online and modules were fully self-help (i.e., no therapist contact).

METHODS

206 participants (M_age=23.4 years, SD=6.53) with elevated depression scores (DASS-depression ≥ 10) were randomised to: mindfulness+values condition or a 2-week wait period followed by the values session (i.e., values only condition). Symptoms of depression were assessed at baseline, after the 2-week mindfulness practice/wait period, and 1-week following the values session.

RESULTS

Reductions in depression and recovery rates were significantly greater following mindfulness+values than values only. Baseline severity affected outcomes: mindfulness+values was significantly more beneficial than values only for individuals with high baseline levels of depression. Outcomes did not differ for those with low levels of depression. Rates of deterioration were higher than expected for values only participants.

LIMITATIONS

Conclusions are preliminary and tentative due to no follow-up period and a small sample. Drop-out was high (50%) and findings cannot be assumed to generalise to treatment seeking or more diverse samples.

CONCLUSIONS

Tentatively, results suggest mindfulness+values can significantly reduce depression, especially for individuals with higher baseline depression.

Can Narrowband Imaging Improve the Laparoscopic Identification of Superficial Endometriosis? A Prospective Cohort Trial

STUDY OBJECTIVE

To assess the usefulness of narrowband imaging (NBI) to detect additional areas of endometriosis not identified by standard white light in patients undergoing laparoscopy for the investigation of pelvic pain.

DESIGN

A prospective cohort trial (Canadian Task Force classification II). Evidence obtained from a well-designed cohort study.

SETTING

A tertiary laparoscopic subspecialty unit in Melbourne, Australia.

PATIENTS

Fifty-seven patients undergoing laparoscopy for the investigation of pelvic pain were recruited. Fifty-three patients were eligible for analysis.

INTERVENTIONS

Patients underwent standard white-light laparoscopy of the pelvis followed by NBI survey to assess for any additional areas suspicious for endometriosis.

MEASUREMENTS AND MAIN RESULTS

All identified areas of possible endometriosis were resected and sent for blinded histopathological analysis. The additional predictive value of NBI was 0% if the preceding white-light survey was negative and 86% if the preceding white-light survey was positive.

CONCLUSION

The use of NBI at laparoscopy for the investigation of pelvic pain is beneficial in finding additional areas of endometriosis if endometriosis is already suspected after white-light survey in a tertiary laparoscopic unit. Further research in nonspecialized units may show additional benefit and requires further research. NBI may also be useful as a diagnostic aid for trainees.

Vinorelbine Potently Induces Placental Cell Death, Does Not Harm Fertility and is a Potential Treatment for Ectopic Pregnancy

Ectopic pregnancies complicate 1–2 pregnancies and are a leading cause of maternal death. An effective oral drug therapy that replaces surgery might make its treatment safer, cheaper, simpler and therefore more widely accessible. The only current medical treatment offered to women is intramuscular methotrexate, but this only reliably resolves smaller ectopic pregnancies. As such, many ectopic pregnancies require surgical excision. We show that vinorelbine, an orally available chemotherapeutic agent, potently induced placental cell death but did not harm fertility in mice. Vinorelbine was 100–1000 times more potent than methotrexate in inducing placental cell death in vitro, and more potent than combination methotrexate and gefitinib (another proposed treatment for ectopic pregnancy being evaluated in phase III trials). Mechanistically, it caused microtubule condensation, blocked mitosis and activated the apoptosis cascade in placental cells. Vinorelbine was more efficacious than methotrexate ± gefitinib in reducing the volume of placental cell tumors xenografted subcutaneously in SCID mice. Mice exposed to vinorelbine and allowed to breed, following a four week washout period, displayed normal fertility, however long-term fertility was not assessed. Human Fallopian tubes treated with vinorelbine did not exhibit up-regulation of apoptosis molecules. Our findings show that placental cells appear sensitive to vinorelbine and it has potential as a tablet-only approach to treat ectopic pregnancy.

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We have identified vinorelbine, a well tolerated chemotherapeutic, as a potential therapeutic for ectopic pregnancy.

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Vinorelbine potently reduced placental cell viability in-vitro and in-vivo and proved more efficacious than the current medical therapeutic.

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Vinorelbine did not impact upon subsequent fertility in a mouse breeding model.

Ectopic pregnancy occurs when a conceptus implants outside of the womb. They are life threating and are a leading cause of maternal death in early pregnancy. Currently, the large majority of ectopic pregnancies are removed surgical, partly owing to the limited efficacy of the only available medical therapeutic, methotrexate. Here, we have identified a potential new medical therapeutic for ectopic pregnancy, vinorelbine. Vinorelbine, which is orally available chemotherapeutic, reduced placental cell viability both in-vitro and in-vivo and did not impact upon mice fertility in a breeding model. As such, vinorelbine may be an efficacious treatment for ectopic pregnancy and further human studies into its application are warranted.

Is outpatient hysteroscopy the new gold standard? Results from an 11 year prospective observational study

BACKGROUND

In Australia, gynaecologists continue to investigate women with abnormal bleeding and suspected intrauterine pathology with inpatient hysteroscopy despite some evidence in the literature that that there is no difference in safety and outcome when compared to an outpatient procedure.

AIMS

This prospective study assessed the safety, effectiveness and acceptability of outpatient hysteroscopy over 11 years at a tertiary hospital in Australia. Resource savings were then calculated.

MATERIALS AND METHODS

A prospective database was analysed from March 2003 to January 2014 (130 months, 990 women).

RESULTS

Successful hysteroscopic access was obtained in 94% of cases. Twenty-six percent of patients required a second procedure, including 132 for endometrial polyps and 33 for submucosal fibroids that were not able to be treated in the outpatient setting. On questioning, 88% of women would be happy to have the procedure again. Factors affecting success were pre-procedure pain, menopausal status and previous vaginal delivery. The difference between pain experienced versus pain expected was a major factor in patient acceptability. A vasovagal episode occurred in 5% of cases.

CONCLUSION

Outpatient hysteroscopy was demonstrated to be safe, effective and acceptable to women. Provision of an outpatient hysteroscopy service saves theatre time and approximately $1000 per case. Improved techniques and technology will allow progression to a 'see and treat' service, providing further savings. With budget constraints, increasing wait times for major procedures and concerns about trainee surgical experience, an outpatient hysteroscopy service should be considered the 'gold standard' investigation over hysteroscopy in theatre.

Are endometrial nerve fibres unique to endometriosis? A prospective case-control study of endometrial biopsy as a diagnostic test for endometriosis in women with pelvic pain

STUDY QUESTION

Can the presence of endometrial nerve fibres be used as a diagnostic test for endometriosis in women with pelvic pain?

SUMMARY ANSWER

Endometrial fine nerve fibres were seen in the endometrium of women both with and without endometriosis, making their detection a poor diagnostic tool for endometriosis.

WHAT IS KNOWN ALREADY

Laparoscopy and biopsy are currently the gold standard for making a diagnosis of endometriosis. It has been reported that small density nerve fibres in the functional layer of the endometrium are unique to women with endometriosis and hence nerve fibre detection could function as a less invasive diagnostic test of endometriosis. However, it may be that other painful conditions of the pelvis are also associated with these nerve fibres. We therefore focused this prospective study on women with pelvic pain to examine the efficacy of endometrial nerve fibre detection as a diagnostic test for endometriosis.

STUDY DESIGN, SIZE, DURATION

This prospective case-control study conducted between July 2009 and July 2013 included 44 women with pelvic pain undergoing laparoscopic examination for the diagnosis of endometriosis. Immunohistochemical nerve fibre detection in endometrial curettings and biopsies using anti-protein gene product 9.5 was compared with surgical diagnosis.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Paired endometrial biopsies and curettings were taken from patients with (n = 22, study group) and without (n = 22, control group) endometriosis. Tissue was analysed by immunohistochemistry and nerve fibres were counted whenever they were present in the functional layer of the endometrium.

MAIN RESULTS AND THE ROLE OF CHANCE

Fine nerve fibres were present in the eutopic endometrium of patients both with and without endometriosis. The presence of nerve fibres in curettings was not effective for either diagnosing or excluding endometriosis; sensitivity and specificity were 31.8 and 45.5% respectively, positive predictive value was 36.8% and negative predictive value was 40.0%. Few endometrial biopsy specimens were found to have nerve fibres present; sensitivity and specificity for endometrial biopsy were 13.6 and 68.2% respectively, positive predictive value was 30.0% and negative predictive value was 44.1%.

LIMITATIONS, REASONS FOR CAUTION

This was a relatively small sample size and studies like this are subject to the heterogeneous nature of the patient population and tissue samples, despite our best efforts to regulate these parameters.

WIDER IMPLICATIONS OF THE FINDINGS

Our results demonstrate that fine nerve fibres are present in women with and without endometriosis. Future work should focus on the function of endometrial nerves and whether these nerves are involved with the subfertility or pain that endometriosis sufferers experience. Our study does not support the detection of endometrial nerve fibres as a non-invasive diagnostic test of endometriosis in women with pelvic pain.

Instructional practices in mainstreamed secondary classrooms

This study examined the skills of secondary students that teachers considered necessary for success in mainstreamed regular education classrooms and intervention strategies teachers would be willing to use. Teachers (N = 89) from three high schools rated the importance of 14 student skills and the reasonability of 35 intervention strategies. Student skills deemed important included following directions, coming to class prepared with materials, using class time wisely, and making up assignments and tests. Factor analysis of intervention strategy results revealed seven factors: using supplemental resources; simplifying instruction; providing support and extra instructional cues; enhancing classroom behavior management; facilitating grade improvement; modifying learning environment; and teaching study skills and providing a positive, cooperative learning environment. Secondary teachers appear to prefer intervention strategies that they can implement in their own classroom, that can apply to all students, and that require little extra time.