A consensus statement on perinatal mental health during the COVID-19 pandemic and recommendations for post-pandemic recovery and re-build

Introduction

The COVID-19 pandemic posed a significant lifecourse rupture, not least to those who had specific physical vulnerabilities to the virus, but also to those who were suffering with mental ill health. Women and birthing people who were pregnant, experienced a perinatal bereavement, or were in the first post-partum year (i.e., perinatal) were exposed to a number of risk factors for mental ill health, including alterations to the way in which their perinatal care was delivered.

Methods

A consensus statement was derived from a cross-disciplinary collaboration of experts, whereby evidence from collaborative work on perinatal mental health during the COVID-19 pandemic was synthesised, and priorities were established as recommendations for research, healthcare practice, and policy.

Results

The synthesis of research focused on the effect of the COVID-19 pandemic on perinatal health outcomes and care practices led to three immediate recommendations: what to retain, what to reinstate, and what to remove from perinatal mental healthcare provision. Longer-term recommendations for action were also made, categorised as follows: Equity and Relational Healthcare; Parity of Esteem in Mental and Physical Healthcare with an Emphasis on Specialist Perinatal Services; and Horizon Scanning for Perinatal Mental Health Research, Policy, & Practice.

Discussion

The evidence base on the effect of the pandemic on perinatal mental health is growing. This consensus statement synthesises said evidence and makes recommendations for a post-pandemic recovery and re-build of perinatal mental health services and care provision.

(Non-)disclosure of lifetime sexual violence in maternity care: Disclosure rate, associated characteristics and reasons for non-disclosure

BACKGROUND

In maternity care, disclosure of a past sexual violence (SV) experience can be helpful to clients to discuss specific intimate care needs. Little evidence is available about the disclosure rates of SV within maternity care and reasons for non-disclosure.

AIM

The aim of this study was to examine (1) the disclosure rate of SV in maternity care, (2) characteristics associated with disclosure of SV and (3) reasons for non-disclosure.

METHODS

We conducted a descriptive mixed method study in the Netherlands. Data was collected through a cross-sectional online questionnaire with both multiple choice and open-ended items. We performed binary logistic regression analysis for quantitative data and a reflexive thematic analysis for qualitative data.

RESULTS

In our sample of 1,120 respondents who reported SV, 51.9% had disclosed this to a maternity care provider. Respondents were less likely to disclose when they received obstetrician-led care for high-risk pregnancy (vs midwife-led care for low-risk pregnancy) and when they had a Surinamese or Antillean ethnic background (vs ethnic Dutch background). Reasons for non-disclosure of SV were captured in three themes: 'My SV narrative has its place outside of my pregnancy', 'I will keep my SV narrative safe inside myself', and 'my caregiver needs to create the right environment for my SV narrative to be told'.

CONCLUSIONS

The high level of SV disclosure is likely due to the Dutch universal screening policy. However, some respondents did not disclose because of unsafe care conditions such as the presence of a third person and concerns about confidentiality. We also found that many respondents made a positive autonomous choice for non-disclosure of SV. Disclosure should therefore not be a goal in itself, but caregivers should facilitate an inviting environment where clients feel safe to disclose an SV experience if they feel it is relevant for them.

'What do I do?' A study to inform development of an e-resource for maternity healthcare professionals and students caring for people with lived experience of childhood sexual abuse

BACKGROUND

The impact of childhood sexual abuse can last a lifetime. It is more prevalent than many common complexities that require additional care during the childbirth cycle but is rarely part of the education of healthcare professionals and students. This study informed the development of an e-resource to support maternity healthcare professionals and students caring for people with lived experience of childhood sexual abuse.

OBJECTIVES

To identify any previous learning of pre-registration students and healthcare professionals in relation to care of survivors of childhood sexual abuse, explore their clinical experience in caring for survivors, identify related learning needs, explore what survivors of childhood sexual abuse would like healthcare professionals to know about their maternity care needs.

DESIGN

A qualitative descriptive study using focus groups and interviews. Data derived qualitative content analysis was employed to address the objectives.

SETTING

The study was designed in consultation with The Survivors Trust and took place in South London, UK PARTICIPANTS: Thirty seven health care professionals and students participated, comprising 25 students of midwifery, health visiting and medicine; 9 midwives, health visitors and doctors with specialist obstetric training. Eight women with lived experience took part in focus groups.

FINDINGS

Care of women and birthing people who have experienced childhood sexual abuse had not been part of the undergraduate/pre-registration curricula, nor in specialist training for obstetricians. Many practitioners felt unprepared to care for those with lived experience of abuse and their learning needs were wide-ranging. The need for a learning resource was acknowledged and the outline plan that had been produced following the focus groups was endorsed by participants with lived experience.

CONCLUSION

Care for women and birthing people with lived experience of childhood sexual abuse can be challenging for both personal and professional reasons. This study confirmed the need for a resource that could facilitate the classroom teaching of students and be used for the Continuous Professional Development of qualified practitioners.

Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review

BACKGROUND

Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences.

METHODS

Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care.

RESULTS

Forty six index studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms.

CONCLUSION

Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42020218357.

(Re)activation of survival strategies during pregnancy and childbirth following experiences of childhood sexual abuse

OBJECTIVES

To explore the pregnancy and childbearing experiences of women-survivors of childhood sexual abuse [CSA]. We aimed to generate a theory explaining those experiences for this population (women), this phenomenon (pregnancy and childbirth), and this context (those who have survived CSA).

METHOD

Participants (N=6) were recruited to semi-structured interviews about their experiences of CSA and subsequent pregnancy and childbirth. Data saturated early, and were analysed using Grounded Theory (appropriate to cross-disciplinary health research). Coding was inductive and iterative, to ensure rigour and achieve thematic saturation.

RESULTS

Open and focused coding led to the generation of super-categories, which in-turn were collapsed into three distinct, but related themes. These themes were: Chronicity of Childhood (Sexual) Abuse; Pregnancy and Childbirth as Paradoxically (Un)safe Experiences; Enduring Nature of Survival Strategies. The relationship between these themes was explained as the theory of: (Re)activation of Survival Strategies during Pregnancy and Childbirth following Experiences of Childhood Sexual Abuse.

CONCLUSION

Pregnancy and childbirth can be triggering for women-survivors of CSA. Survival strategies learnt during experiences of CSA can be (re)activated as a way of not only coping, but surviving (the sometimes unconsented) procedures, such as monitoring and physical examinations, as well as the feelings of lack of control and bodily agency.

Navigating uncertainty alone: A grounded theory analysis of women's psycho-social experiences of pregnancy and childbirth during the COVID-19 pandemic in London

PROBLEM

Maternity care underwent substantial reconfiguration in the United Kingdom during the COVID-19 pandemic.

BACKGROUND

COVID-19 posed an unprecedented public health crisis, risking population health and causing a significant health system shock.

AIM

To explore the psycho-social experiences of women who received maternity care and gave birth in South London during the first 'lockdown'.

METHODS

We recruited women (N = 23) to semi-structured interviews, conducted virtually. Data were recorded, transcribed, and analysed by hand. A Classical Grounded Theory Analysis was followed including line-by-line coding, focused coding, development of super-categories followed by themes, and finally the generation of a theory.

FINDINGS

Iterative and inductive analysis generated six emergent themes, sorted into three dyadic pairs: 1 & 2: Lack of relational care vs. Good practice persisting during the pandemic; 3 & 4: Denying the embodied experience of pregnancy and birth vs. Trying to keep everyone safe; and 5 & 6: Removed from support network vs. Importance of being at home as a family. Together, these themes interact to form the theory: 'Navigating uncertainty alone'.

DISCUSSION

Women's pregnancy and childbirth journeys during the pandemic were reported as having positive and negative experiences which would counteract one-another. Lack of relational care, denial of embodied experiences, and removal from support networks were counterbalanced by good practice which persisted, understanding staff were trying to keep everyone safe, and renewed importance in the family unit.

CONCLUSION

Pregnancy can be an uncertain time for women. This was compounded by having to navigate their maternity journey alone during the COVID-19 pandemic.

Undisturbed Physiological Birth: Insights from Women Who Freebirth in the United Kingdom

OBJECTIVE

To understand women's experiences of undisturbed physiological birth by exploring the narratives of women who have freebirthed their babies in the United Kingdom (intentionally giving birth without midwives or doctors present).

DESIGN

Unstructured narrative face-to-face interviews were carried out and data were analysed using the Voice Centred Relational Method (VCRM).

PARTICIPANTS

Sixteen women who had freebirthed their babies.

FINDINGS

Women discussed a range of phenomena including birth positions, the fetus ejection reflex, pain, altered states of consciousness, physiological third stages and postnatal experiences that were physically and emotionally positive.

KEY CONCLUSIONS

There is a paucity of literature on physiological birth and limited opportunity for practitioners to witness it. Further research is required on phenomena related to physiological birth so as to better understand how to promote it within the maternity setting and when intervention is justified.

IMPLICATIONS FOR PRACTICE

Standard maternity settings and practice may not be conducive to or reflective of physiological birth. Better understanding of physiological birth is required so that pregnant women and people can be appropriately supported during labour and birth.

Co-production of an e-resource to help women who have experienced childhood sexual abuse prepare for pregnancy, birth, and parenthood

BACKGROUND

This paper reports the development of a co-produced e-resource to support those who have experienced childhood sexual abuse through pregnancy, birth, and parenthood. These are times of major transition for any woman but can present particular challenges for those who have experienced childhood sexual abuse. Re-traumatisation during the perinatal period is common and can occur in ways that may not be anticipated by those involved. Survivors often do not disclose their abuse and the childbearing journey can be lonely.

METHODS

The work was conducted in collaboration with The Survivors Trust and in keeping with the Survivor's Charter. A participatory approach was used. There were two phases: the generation of new qualitative data and development of the resource. To encourage participation from this hidden population, data were collected by a variety of means including focus groups, telephone interviews and an on-line survey. Survivors who had children and those who hoped to one day participated. Resource development was facilitated by two workshops and email feedback.

RESULTS

Overall, 37 women participated, all of whom were positive about development of the resource. Although many issues identified during data collection were specific to the participants' history of abuse other areas of concern would be relevant for any woman contemplating the journey to parenthood. Women often assumed that they were alone in their concerns and were reassured to discover that others shared their experiences. The final resource is hosted on The Survivors Trust Website and is accessible from all electronic devices. It follows the journey from deciding to have a baby, pregnancy, labour, birth, and the postnatal period through to parenthood. Links are provided to further information and sources of support. The process of developing the resource used trauma-informed principles and it speaks with women's words in a peer-to-peer voice.

CONCLUSIONS

This paper describes the development of an innovative and accessible e-resource that is based on the words and experiences of survivors of childhood sexual abuse. It recognises the importance of control and feeling safe and aims to empower those who use the resource as they embark on pregnancy, birth, and parenthood.

Exploring the conceptualisation and study of freebirthing as a historical and social phenomenon: a meta-narrative review of diverse research traditions

Freebirthing is a clandestine practice whereby women intentionally give birth without healthcare professionals (HCPs) present in countries where there are medical facilities available to assist them. Women who make this decision are frequently subjected to stigma and condemnation, yet research on the phenomenon suggests that women's motivations are often complex. The aim of this review was to explore how freebirth has been conceptualised over time in the English-language academic and grey literature. The meta-narrative methodology employed enables a phenomenon to be understood within and between differing research traditions, as well as against its social and historical context. Our research uncovered nine research traditions (nursing, autobiographical text with birthing philosophy, midwifery, activism, medicine, sociology, law and ethics, pregnancy and birth advice, and anthropology) originating from eight countries and spanning the years 1957-2018. Most of the texts were written by women, with the majority being non-empirical. Empirical studies on freebirth were usually qualitative, although there were a small number of quantitative medical and midwifery studies; these texts often focused on women's motivations and highlighted a range of reasons as to why a woman would decide to give birth without HCPs present. Motivations frequently related to women's previous negative maternity experiences and the type of maternity care available, for example medicalised and hospital-based. The use of the meta-narrative methodology allowed the origins of freebirth in 1950s America to be traced to present-day empirical studies of the phenomenon. This highlighted how the subject and the publication of literature relating to freebirth are embedded within their social and historical contexts. From its very inception, freebirth aligns with the medicalisation of childbirth, the position of women in society, the provision of maternity care and the way in which women experience maternity services.

Disclosure of non-recent (historic) childhood sexual abuse: What should researchers do?

Non-recent (historic) childhood sexual abuse is an important issue to research, though often regarded as taboo and frequently met with caution, avoidance or even opposition from research ethics committees. Sensitive research, such as that which asks victim-survivors to recount experiences of abuse or harm, has the propensity to be emotionally challenging for both the participant and the researcher. However, most research suggests that any distress experienced is usually momentary and not of any clinical significance. Moreover, this type of research offers a platform for voices which have often been silenced, and many participants report the cathartic effect of recounting their experiences in a safe, non-judgemental space. With regard to the course of such research, lines of inquiry which ask adult participants to discuss their experiences of childhood sexual abuse may result in a first-time disclosure of that abuse by the victim-survivor to the researcher. Guidance about how researchers should respond to first-time disclosure is lacking. In this article, we discuss our response to one research ethics committee which had suggested that for a qualitative study for which we were seeking ethical approval (investigating experiences of pregnancy and childbirth having previously survived childhood sexual abuse), any disclosure of non-recent (historic) childhood sexual abuse which had not been previously reported would result in the researcher being obliged to report it to relevant authorities. We assess this to be inconsistent with both law and professional guidance in the United Kingdom; and provide information and recommendations for researchers and research ethics committees to consider.

Assessing trauma and mental health in refugee children and youth: a systematic review of validated screening and measurement tools

Background

: It is estimated that children below 18 years constitute 50% of the refugee population worldwide, which is the highest figure in a decade. Due to conflicts like the Syrian crises, children are continuously exposed to traumatic events. Trauma exposure can cause mental health problems that may in turn increase the risk of morbidity and mortality. Tools such as questionnaires and interview guides are being used extensively, despite the fact that only a few have been tested and their validity confirmed in refugee children and youth. : Our aim was to provide a systematic review of the validated screening and measurement tools available for assessment of trauma and mental health among refugee children and youth. : We systematically searched the databases PubMed, PsycINFO and PILOTS. The search yielded 913 articles and 97 were retained for further investigation. In accordance with the PRISMA guidelines two authors performed the eligibility assessment. The full text of 23 articles was assessed and 9 met the eligibility criteria. Results : Only nine studies had validated trauma and mental health tools in refugee children and youth populations. A serious lack of validated tools for refugee children below the age of 6 was identified. : There is a lack of validated trauma and mental health tools, especially for refugees below the age of 6. Detection and treatment of mental health issues among refugee children and youth should be a priority both within the scientific community and in practice in order to reduce morbidity and mortality.

Patterns of Healing in the Appendix

We compared the histologic features of healing acute appendicitis (20 cases) with those of Crohn's disease at the appendix (54 cases), including the presence of granulomas, extrasubmucosal lymphoid aggregates, and subserosal fibrosis. Healing appendicitis assumed two basic patterns: the "usual" pattern, sometimes with an intraluminal cord of granulation tissue, and a xanthogranulomatous pattern. Epithelioid cell granulomas were seen exclusively in Crohn's disease (19/54; 35%). Furthermore, large numbers of lymphoid aggregates involving the muscularis propria or dense concentric subserosal fibrosis exceeding half the width of the muscularis propria in cross-section were signifi cantly associated with Crohn's disease. Xanthogranulomatous features were not seen in the Crohn's cases. The presence of granulomas, extrasubmucosal lymphoid aggre gates, and concentric subserosal fibrosis in an appendectomy specimen may suggest the diagnosis of Crohn's disease. Int J Surg Pathol 2(1):23-30, 1994

Validation of a rapid type 1 diabetes autoantibody screening assay for community-based screening of organ donors to identify subjects at increased risk for the disease

The Network for Pancreatic Organ donors with Diabetes (nPOD) programme was developed in response to an unmet research need for human pancreatic tissue obtained from individuals with type 1 diabetes mellitus and people at increased risk [i.e. autoantibody (AAb)-positive] for the disease. This necessitated the establishment of a type 1 diabetes-specific AAb screening platform for organ procurement organizations (OPOs). Assay protocols for commercially available enzyme-linked immunosorbent assays (elisas) determining AAb against glutamic acid decarboxylase (GADA), insulinoma-associated protein-2 (IA-2A) and zinc transporter-8 (ZnT8A) were modified to identify AAb-positive donors within strict time requirements associated with organ donation programmes. These rapid elisas were evaluated by the international islet AAb standardization programme (IASP) and used by OPO laboratories as an adjunct to routine serological tests evaluating donors for organ transplantation. The rapid elisas performed well in three IASPs (2011, 2013, 2015) with 98-100% specificity for all three assays, including sensitivities of 64-82% (GADA), 60-64% (IA-2A) and 62-68% (ZnT8A). Since 2009, nPOD has screened 4442 organ donors by rapid elisa; 250 (5·6%) were identified as positive for one AAb and 14 (0.3%) for multiple AAb with 20 of these cases received by nPOD for follow-up studies (14 GADA+, two IA-2A(+) , four multiple AAb-positive). Rapid screening for type 1 diabetes-associated AAb in organ donors is feasible, allowing for identification of non-diabetic, high-risk individuals and procurement of valuable tissues for natural history studies of this disease.

Montgomery on informed consent: an inexpert decision?

Montgomery v Lanarkshire HB is a deeply troubling decision when read closely. Paradoxically, its ruling supporting the principle of autonomy could be justified only by disregarding the individual patient's actual choices and characteristics in favour of a stereotype. The decision demonstrates a lack of expertise in dealing with specific clinical issues and misrepresents professional guidance. More fundamentally, it fails to appreciate the nature of professional expertise. This calls into question the competence of the courts to adjudicate on matters of clinical judgement and makes an attractive formulation of the test for disclosure obligations inherently unpredictable.

The re-enactment of childhood sexual abuse in maternity care: a qualitative study

Background

The process of pregnancy and birth are profound events that can be particularly challenging for women with a history of childhood sexual abuse. The silence that surrounds childhood sexual abuse means that few women disclose it and those caring for them will often not be aware of their history. It is known from anecdotal accounts that distressing memories may be triggered by childbirth and maternity care but research data on the subject are rare. This paper explores aspects of a study on the maternity care experiences of women who were sexually abused in childhood that demonstrate ways that maternity care can be reminiscent of abuse. Its purpose is to inform those providing care for these women.

Methods

The experiences of women were explored through in-depth interviews in this feminist narrative study. The Voice-Centred Relational Method and thematic analysis were employed to examine interview data.

Results

Women sometimes experienced re-enactment of abuse through intimate procedures but these were not necessarily problematic in themselves. How they were conducted was important. Women also experienced re-enactment of abuse through pain, loss of control, encounters with strangers and unexpected triggers. Many of these experiences were specific to the woman, often unpredictable and not necessarily avoidable. Maternity care was reminiscent of abuse for women irrespective of whether they had disclosed to midwives and was not necessarily prevented by sensitive care. ‘Re-enactment of abuse’ occurred both as a result of events that involved the crossing of a woman’s body boundaries and more subjective internal factors that related to her sense of agency.

Conclusions

As staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.

Interest in multipurpose prevention of HIV and pregnancy: perspectives of women, men, health professionals and community stakeholders in two vaginal gel studies in southern Africa

OBJECTIVE

The pipeline of vaginal microbicides for HIV prevention has expanded to include products for multipurpose prevention, but the interests of potential users and those advising on use have not been sufficiently investigated. Rather, assumptions about interest in multipurpose prevention technologies (MPTs) are inferred from what is known about acceptability and use of microbicides or contraceptives.

DESIGN AND SETTING

This paper presents data on concerns and preferences for multipurpose prevention of HIV and pregnancy. Data were collected in two microbicide gel studies in Malawi and Zimbabwe. Participants were women using candidate vaginal products, their male partners, health professionals and community stakeholders.

METHODS

An individual interview was conducted with participants. Interviews were audio-recorded, transcribed, coded for content and analysed for key themes.

RESULTS

Participants indicated strong interest in a vaginal HIV prevention product that could also prevent pregnancy. Reasons for this interest were convenience, problems with adverse effects with current contraceptive methods, concerns about long-term effects of contraceptives, and concerns about the health burdens of HIV infection during pregnancy. The main disadvantage of an MPT was recognition that while interest in preventing HIV is constant, contraceptive needs change over time.

CONCLUSION

The study population indicated support for an MPT to prevent HIV and pregnancy. This support may be further strengthened if the product is also available for prevention of only HIV. Women and men will be more willing to use an MPT if they can be reassured that its use will have no long-term effect on fertility.

Massive splenomegaly correlates with malignancy: 180 cases of splenic littoral cell tumors in the world literature

Littoral cell tumors (LCT) are rare primary splenic neoplasms, unique for their morphologic and immunolabeling features resembling the endothelial littoral cells lining the sinusoids of the red pulp. They include the more common and typically benign littoral cell angioma, as well as the less common, potentially malignant, littoral cell hemangioendothelioma (LCHE) and the aggressive littoral cell angiosarcoma (LCAS). The most common presentation of these neoplasms is splenomegaly, and diagnosis is made histologically following biopsy or resection. To better understand these tumors, a comprehensive, international literature search was performed. Patient and tumor data, including presenting symptoms, comorbid cancers, immunosuppressive states, splenic mass and tumor size were analyzed. Massive splenomegaly (≥ 1500 g) following splenic resection, which correlates with a splenic length of 20 cm preoperatively, was found to be significantly associated with the presence of malignancy in the LCT (P<0.05).

Feeling safe: a metasynthesis of the maternity care needs of women who were sexually abused in childhood

BACKGROUND

The impact of childhood sexual abuse on birth experiences was highlighted 20 years ago in Birth. Subsequent accounts in the midwifery press testify to the emotional trauma that women who were sexually abused as children may suffer during childbirth and the potential for caregivers to make the situation worse. This study synthesizes research on the maternity care experiences of women who were sexually abused in childhood to answer the questions: what do women need during their childbearing experiences and what can health care practitioners do about it?

METHODS

A metasynthesis was conducted to integrate the findings of several qualitative studies. The eight eligible studies identified by database searches were closely read, recurring themes were extracted and compared across studies, and core themes were identified by means of an interpretative process of synthesis.

RESULTS

The key themes identified were control, remembering, vulnerability, dissociation, disclosure, and healing. If women were able to retain control and forge positive, trusting relationships with health care professionals, they felt safe and might experience healing in the process. "Safety" requires that women are not reminded of abusive situations. In the absence of control and trusting relationships, maternity care can be experienced as a re-enactment of abuse.

CONCLUSIONS

During their maternity care experience women who were sexually abused in childhood need to "feel safe." Health care professionals can help them achieve this feeling by seeking to ensure that those experiences do not re-enact abuse.

Planarians require an intact brain to behaviorally react to cocaine, but not to react to nicotine

Planarians possess a rudimentary brain with many features in common with vertebrate brains. They also display a remarkable capacity for tissue regeneration including the complete regeneration of the nervous system. Using the induction of planarian seizure-like movements (pSLMs) as a behavioral endpoint, we demonstrate that an intact nervous system is necessary for this organism to react to cocaine exposure, but not necessary to react to nicotine administration. Decapitated planarians (Girardia tigrina) display pSLMs indistinguishable from intact worms when exposed to nicotine, but cocaine-induced pSLMs are reduced by about 95% upon decapitation. Decapitated worms recover their normal sensitivity to cocaine within 5 days after head amputation. In worms where half of the brain was removed or partially dissected, the expression of cocaine-induced pSLMs was reduced by approximately 75%. Similar amputations at the level of the tail did not show a significant decrease to cocaine exposure. To the best of our knowledge, our work is the first report that explores how regenerating planarians react to the exposure of cocaine.

Trauma, exile and mental health in young refugees

OBJECTIVE

To review evidence of trauma and exile-related mental health in young refugees from the Middle East.

METHOD

A review of four empirical studies: i) a qualitative study of 11 children from torture surviving families, ii) a cohort study of 311 3-15-year-old asylum-seeking children, iii) a qualitative study of 14 members of torture surviving families and iv) a follow-up study of 131 11-23-year-old refugees.

RESULTS

The reactions of the children were not necessarily post-traumatic stress disorder specific. Seventy-seven per cent suffered from anxiety, sleep disturbance and/or depressed mood at arrival. Sleep disturbance (prevalence 34%) was primarily predicted by a family history of violence. At follow-up, 25.9% suffered from clinically relevant psychological symptoms. Traumatic experiences before arrival and stressful events in exile predicted internalizing behaviour, witnessing violence and frequent school changes in exile predicted externalizing behaviour. School participation, Danish friends, language proficiency and mother's education predicted less long-term psychological problems.

CONCLUSION

Psychological problems are frequent in refugee children, but the extents are reduced over time in exile. Traumatic experience before arrival is most important for the short-term reaction of the children while aspects of life in exile are important for the children's ability to recover from early traumatization.

Enzyme null alleles in natural populations of Drosophila melanogaster: Frequencies in a North Carolina population

A Raleigh, NC, population of Drosophila melanogaster was sampled for the presence of enzyme null alleles at 25 loci. No nulls were found at any of five X-linked loci. Nulls were recovered at 13 of 20 autosomal loci; the weighted mean frequency for all 20 autosomal loci was estimated to be 0.0025. A consideration of the effects of these null alleles on viability strongly suggests that, although they may contribute to so-called polygenic variation, they are not representative of the entire genome.

An incidental enterocolic lymphocytic phlebitis pattern is seen commonly in the rectal stump of patients with diversion colitis superimposed on inflammatory bowel disease

Aims:

Enterocolic lymphocytic phlebitis (ELP) is an uncommon cause of bowel pathology and most frequently results in ischaemia. It is characterised by an artery-sparing, venulocentric lymphoid infiltrate that causes a phlebitis and vascular compromise. Rare cases of ELP have been encountered with lymphocytic colitis in the absence of ischaemic bowel change. The present study examined the occurrence of ELP in the setting of diversion colitis and inflammatory bowel disease, as well as in random colectomy specimens.

Methods:

The study cohort comprised the following: 26 completion proctectomy specimens for ulcerative colitis with superimposed diversion colitis in the rectal stump; 3 colectomy specimens for Crohn disease with diversion colitis; 6 colectomy specimens for adenocarcinoma and/or diverticular disease with diversion colitis; 34 resection specimens with ulcerative colitis only; 19 with Crohn disease only; and 100 random colon resection specimens for adenocarcinoma, adenoma, diverticular disease and ischaemia.

Results:

ELP was present in 18 of the 26 ulcerative colitis cases with diversion colitis, 3/3 Crohn disease cases with diversion colitis, 1/6 cases of diverticular disease with diversion colitis, 6/34 cases of ulcerative colitis without diversion, 2/19 Crohn disease cases without diversion colitis, and only 1 of 100 colectomy cases without inflammatory bowel disease or diversion colitis.

Conclusion:

ELP occurs most frequently in cases that have been diverted for inflammatory bowel disease. Fewer cases of ELP were noted in cases of inflammatory bowel disease in the absence of diversion colitis. It is postulated that altered bowel flora and immune dysregulation may be pivotal in the causation of this association.

Medication-induced upper gastrointestinal tract injury

Medication-induced upper gastrointestinal (GI) tract injuries are probably fairly common, yet these injuries are rarely documented in pathology reports. Since these injuries often manifest as non-specific histological changes, making a definitive diagnosis of medication-induced injury can be challenging. Three types of evidence can assist in the establishment of a diagnosis: specific histological patterns, the presence of medication fragments in tissue, and clinical data. Histological patterns may reflect specific tissue responses to medication effects or medication toxicity. Morphological clues of medication use such as pill fragments and crystal deposition may be visible within the tissue itself. Clinical data, including medication history, endoscopic findings, and predisposing conditions can alert the pathologist to situations where medication-induced injury should merit a high ranking on the differential diagnosis list. Except for rare cases where characteristic histological changes can be diagnostic, clinical correlation is essential when diagnosing medication-induced injuries. In this review, key features of the most commonly encountered medication-induced upper GI tract injuries are briefly discussed, and a practical guide to assist the practicing pathologist in the recognition and diagnosis of these injuries is provided.

Hypermethylation of the nel-like 1 gene is a common and early event and is associated with poor prognosis in early-stage esophageal adenocarcinoma

The nel-like1 (NELL1) gene maps to chromosome 11p15, which frequently undergoes loss of heterozygosity in esophageal adenocarcinoma (EAC). NELL1 promoter hypermethylation was examined by real-time methylation-specific polymerase chain reaction in 259 human esophageal tissues. Hypermethylation of this promoter showed highly discriminative receiver-operator characteristic curve profiles, clearly distinguishing esophageal squamous cell carcinoma (ESCC) and EAC from normal esophagus (NE) (P<0.001). NELL1 normalized methylation values were significantly higher in Barrett's metaplasia (BE), dysplastic Barrett's (D) and EAC than in NE (P<0.0000001). NELL1 hypermethylation frequency was zero in NE but increased early during neoplastic progression, to 41.7% in BE from patients with Barrett's alone, 52.5% in D and 47.8% in EAC. There was a significant correlation between NELL1 hypermethylation and BE segment length. Three (11.5%) of 26 ESCCs exhibited NELL1 hypermethylation. Survival correlated inversely with NELL1 hypermethylation in patients with stages I-II (P=0.0264) but not in stages III-IV (P=0.68) EAC. Treatment of KYSE220 ESCC and BIC EAC cells with 5-aza-2'-deoxycytidine reduced NELL1 methylation and increased NELL1 mRNA expression. NELL1 mRNA levels in EACs with an unmethylated NELL1 promoter were significantly higher than those in EACs with a methylated promoter (P=0.02). Promoter hypermethylation of NELL1 is a common, tissue-specific event in human EAC, occurs early during Barrett's-associated esophageal neoplastic progression, and is a potential biomarker of poor prognosis in early-stage EAC.

Absence of previously reported variants in the SCNA (G88C and G209A), NR4A2 (T291D and T245G) and the DJ-1 (T497C) genes in familial Parkinson's disease from the GenePD study

Parkinson's disease (PD) is a neurodegenerative disorder in which relatives of the probands are affected approximately 4 times as frequently as relatives of control subjects. Several genes have been implicated as genetic risk factors for PD. We investigated the presence of six reported genetic variations in the SCNA, NR4A2, and DJ-1 genes in 292 cases of familial Parkinson's disease from the GenePD study. None of the variants were found in the GenePD families. Our results suggest that other variants or genes account for the familial risk of PD within the GenePD study.

A haplotype at the PARK3 locus influences onset age for Parkinson's disease: the GenePD study

OBJECTIVE

To identify a haplotype influencing onset age for Parkinson's disease (PD) in the PARK3 region on chromosome 2p13.

METHODS

Single nucleotide polymorphisms (SNP) spanning 2.2 Mb and located in or near potential candidate genes were used to fine map the PARK3 region in 527 patients with familial PD, from 264 families.

RESULTS

TT homozygotes for rs1876487 (G/T) had a 7.4-year younger mean age at onset (p = 0.005) compared to patients with GT and GG genotypes. Furthermore, SNP flanking the sepiapterin reductase (7,8-dihydrobiopterin: NADP+ oxidoreductase) (SPR) gene, rs1876487 (p = 0.02) and rs1150500 (p = 0.04), were associated with younger onset age among persons who did not carry the 174 allele of D2S1394. The SPR gene is implicated in dopamine synthesis. Haplotype analysis of three SNP-rs2421095, rs1876487, rs1561244-revealed an association with onset age (p = 0.023) and a haplotype of A-T-G alleles was associated with younger onset for PD (p = 0.005).

CONCLUSIONS

A haplotype at the PARK3 locus, harboring the SPR gene, is associated with onset age of PD. This may suggest a role for the SPR gene in modifying the age at onset of PD.

Calponin and h-caldesmon expression in synovial sarcoma; the use of calponin in diagnosis

AIMS

To assess the frequency of expression and potential diagnostic utility of calponin and caldesmon in synovial sarcomas.

METHODS AND RESULTS

Immunohistochemistry with antibodies to calponin and h-caldesmon was undertaken in paraffin sections from 50 synovial sarcomas (19 biphasic and 31 monophasic, of which one biphasic and eight monophasic tumours had poorly differentiated areas), 10 each of malignant peripheral nerve sheath tumour (MPNST), solitary fibrous tumour (SFT), dermatofibrosarcoma (DFSP), Ewing's sarcoma (ES/PNET), and neuroblastoma, eight alveolar rhabdomyosarcomas, five adult fibrosarcomas and five carcinosarcomas. Nine of 19 biphasic synovial sarcomas were positive for calponin in spindle and glandular areas, nine in spindle cells only, and one in glands only. All monophasic synovial sarcomas and poorly differentiated areas expressed calponin; in monophasic tumours this was focally (29% of cases), moderately (39%), or diffusely (32%) positive and the poorly differentiated areas were usually moderately or diffusely positive. Four synovial sarcomas showed focal reactivity for h-caldesmon. Calponin was found in 4/10 MPNST, 7/10 SFT, 4/10 DFSP, 3/5 fibrosarcomas and the spindle component of the carcinosarcomas. H-caldesmon was weakly positive in 1/10 MPNST, 4/10 SFT, 0/10 DFSP, 0/5 fibrosarcomas and 1/5 carcinosarcomas (glands only). Both markers were negative in the other small round cell tumours.

CONCLUSIONS

Calponin can be used as an additional marker for synovial sarcoma. Its absence argues against the diagnosis. The presence of calponin might be useful in distinguishing poorly differentiated synovial sarcoma from other small round cell tumours. H-caldesmon is not helpful in diagnosis of synovial sarcoma.

Unilateral absence of the basal ganglia plus epilepsy without motor symptoms

A patient with absence of the basal ganglia and refractory epilepsy without impairment of pyramidal or extrapyramidal motor function is reported. Imaging findings suggest a vascular insult as etiology. Preserved motor function could be explained by neuronal plasticity involving contralateral corticostriatal and pallidothalamic connections and points to a lesion received in early pregnancy.