P–487 Couples undergoing first level assisted reproductive techniques: An Actor-Partner interdependence model of dyadic adjustment, psychological symptoms, alexithymia and romantic attachment on body-image avoidance

Study question

The study aims to assess the commonalities and interdependence of couples undergoing first-level Assisted Reproductive Techniques (ART) as regards body-image avoidance referred to body-image dissatisfaction.

Summary answer

Partners’ functioning seem specular yet not interdependent, as not showing a couple-as-a-unit modality of functioning. Body-image avoidance is only influenced by intra-personal variables. What is known already: Stressful bodily emotions and body perception related to infertility and ART are critical aspects for people desiring having children. Infertility undermines women’s self-esteem and body-image, damaging their self-identity as women, while in males infertility associates with body dissatisfaction referring to perceived reduced physical fitness and personal failure, thus undermining their body virility. For infertile women, body-image dissatisfaction associates with reduced marital adjustment, and vice-versa; yet no study has considered how males body-image dissatisfaction associates with marital satisfaction. Nonetheless, couples should be considered as a unit, considering that infertile couples’ adjustment is influenced by their own, and their partners’, perceived stress.

Study design, size, duration

The study follows a cross-sectional design and is part of an ongoing transversal and longitudinal project, started in 2012, investigating the well-being of couples undergoing ART. For the present study only a minority of the existing data were considered, thus only including couples at the first level of ART with the intent of investigating couples’ commonalities and interdependence before treatments pervasiveness increases.

Participants/materials, setting, methods

Minimum N = 79 couples needed to be considered according to Power analysis results. N = 118 couples aged 24 to 46 years (women Mage=34.92, SD = 3.98; men Mage=37.45, SD = 5.25) were included, and declaring trying to get pregnant from 1 to 8 years (M = 3.18; SD = 1.99) and to never had children, although 22.9% of women had at least an abortion. Participants completed the Body-Image Avoidance Questionnaire, Toronto Alexithymia Scale–20, Dyadic Adjustment Scale, Symptom Checklist–90-Revised and Experiences in Close Relationships Scale-Revised.

Main results and the role of chance

The sample presents non-clinical levels of functioning referring to their psychological symptoms, alexithymia and body-image avoidance. Multivariate rank tests show that females report significantly higher levels of body-image avoidance (stat=–5.73; adj.p=.001), psychological symptoms (stat=–4.58; adj.p=.001) and romantic anxious attachment (stat=–3.33; adj.p=.005). These differences were confirmed also after applying multiplicity control. Moreover, bi-variate Pearson’s r correlations show an association among partners’ dyadic adjustment (r=.293; p<.001), albeit their overall level of dyadic adjustment is low. Significant correlations among partners also emerged as regards psychological symptoms (r=.258; p<.001) and alexithymia (r=.16; p=.05). The couple-effect, thus considering the couple as the unit of analysis, was modeled through an Actor-Partner Interdependence Model. For both partners, dyadic adjustment’s actor-effect associates with body-image avoidance (women: β = 0.133, p=.026; man: β = 0.133, p=.026). Furthermore, for both men and women, psychological symptoms’ actor-effect associate to body-image avoidance (women: β = 0.467, p<.00; men: β = 0.499, p=.001). Comparing the level of influence of actor and partner effects among partners, the psychological symptoms’ actor effect results significantly more influential than the partner-effect (women: Δ = 0.378, p=.015; men: Δ = 0.587, p=.001). Only for males, alexithymia’s actor effect is significant (β = 0.499; p=.001).

Limitations, reasons for caution

Results should be considered in light of some limitations. Specifically, the cross-sectional study design, lack of a control group with no infertility issues, the use of self-report measures, homogeneity among couples and the sample small sample size (although sample size was appropriate to retain a power of at least .8).

Wider implications of the findings: Results support the differentiation of gender-specific psychosocial interventions along the ART path, preventing and mitigating the negative impact of infertility and ART on body-image dissatisfaction and avoidance and on the couples’ well-being.

Trial registration number

Not applicable

0537 Cognitive Functioning Before and After Insomnia Treatment in Women Veterans

Introduction

Women are at higher risk for cognitive impairment and dementia compared to men. Identifying potentially treatable risk factors such as insomnia is an important clinical goal. In a trial comparing two behavioral treatments for insomnia in women veterans, we hypothesized that 1) worse baseline insomnia severity would be associated with poorer cognitive function, and 2) improvement in insomnia severity with treatment would be associated with improvement in cognitive functioning.

Methods

347 women veterans with insomnia disorder [mean age 48.3 (12.9) years] completed baseline testing. Of these, 149 women were randomized to receive cognitive behavioral therapy for insomnia (CBT-I) or acceptance and commitment (ACT) based insomnia treatment (both treatments included sleep restriction, stimulus control, and sleep hygiene). Insomnia Severity Index (ISI) was assessed at baseline, post-treatment, and 3-month follow-up. Cognitive functioning was measured with Symbol Digit Coding (SDC) and Trail Making Test A and B (TMTA and TMTB). Pearson correlations were used to examine associations between insomnia severity and cognitive functioning at baseline and changes in both insomnia severity and cognitive functioning from before to after treatment.

Results

At baseline (N=347), mean ISI was 14.1 (5.3). Worse baseline ISI was associated with worse baseline cognitive functioning on TMTA (r=-.15, p<.01) and SDC (r=-.12, p<.05). In the randomized sample (N=149), ISI scores improved at post-treatment (mean ISI change= -9.0; p<.001) and 3-month follow-up (mean change= -8.0; p<.001) relative to baseline. Improvement in ISI from baseline to post-treatment was significantly associated with improvement in SDC from baseline to post-treatment (r=-.18, p<.05), but not improvement in TMTA and TMTB. Change in ISI was not significantly related to change in cognitive tasks from baseline to 3-month follow-up.

Conclusion

More severe insomnia is associated with worse cognitive functioning in women veterans. The magnitude of improvement in insomnia symptoms may be associated with improvement in cognition.

Support

NIH/NIA K23AG049955 (PI: Dzierzewski); VA/HSR&D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 (PI: Martin).

0467 Benefits of CBT-I for Women Veterans with and without PTSD

Introduction

A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.

Methods

This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.

Results

There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).

Conclusion

CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.

Support

VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health

Biogenic habitat shifts under long-term ocean acidification show nonlinear community responses and unbalanced functions of associated invertebrates

Experiments have shown that increasing dissolved CO₂ concentrations (i.e. Ocean Acidification, OA) in marine ecosystems may act as nutrient for primary producers (e.g. fleshy algae) or a stressor for calcifying species (e.g., coralline algae, corals, molluscs). For the first time, rapid habitat dominance shifts and altered competitive replacement from a reef-forming to a non-reef-forming biogenic habitat were documented over one-year exposure to low pH/high CO₂ through a transplant experiment off Vulcano Island CO₂ seeps (NE Sicily, Italy). Ocean acidification decreased vermetid reefs complexity via a reduction in the reef-building species density, boosted canopy macroalgae and led to changes in composition, structure and functional diversity of the associated benthic assemblages. OA effects on invertebrate richness and abundance were nonlinear, being maximal at intermediate complexity levels of vermetid reefs and canopy forming algae. Abundance of higher order consumers (e.g. carnivores, suspension feeders) decreased under elevated CO₂ levels. Herbivores were non-linearly related to OA conditions, with increasing competitive release only of minor intertidal grazers (e.g. amphipods) under elevated CO₂ levels. Our results support the dual role of CO₂ (as a stressor and as a resource) in disrupting the state of rocky shore communities, and raise specific concerns about the future of intertidal reef ecosystem under increasing CO₂ emissions. We contribute to inform predictions of the complex and nonlinear community effects of OA on biogenic habitats, but at the same time encourage the use of multiple natural CO₂ gradients in providing quantitative data on changing community responses to long-term CO₂ exposure.

The clinical outcome of patients with stage Ia1 and Ia2 squamous cell carcinoma of the uterine cervix: a Cooperation Task Force (CTF) study

PURPOSE OF INVESTIGATION

The objective of this retrospective multicenter study was to assess the clinical outcome of patients with microinvasive squamous cell carcinoma of the uterine cervix.

METHODS

The hospital records of 166 patients with microinvasive squamous cell carcinoma of the uterine cervix were reviewed. All cases were retrospectively staged according the 1994 International Federation of Gynecology and Obstetrics (FIGO) nomenclature. One hundred and forty-three cases were in Stage Ia1 and 23 in Stage Ia2 disease. Surgery consisted of conization alone in 30 (18.1%) patients, total hysterectomy in 82 (49.4%), and radical hysterectomy in 54 (32.5%). All patients in whom conization was the definite treatment had Stage Ia1 disease and had cone margins negative for intraepithelial or invasive lesions.

RESULTS

None of the 67 patients submitted to pelvic lymphadenectomy had histologically proven metastatic lymph nodes. Of the 166 patients, eight (4.8%) had an intraepithelial recurrence and four (2.4%) had an invasive recurrence. With regard to FIGO substage, disease recurred in nine (6.3%) out of 143 patients with Stage Ia1 and three (13.0%) out of 23 with Stage Ia2 cervical cancer. With regard to type of surgery, disease recurred in three (10.0%) out of the patients treated with conization alone, four (4.9%) out those who underwent total hysterectomy, and five (9.3%) out of those who underwent radical hysterectomy. It is worth noting that none of the 30 patients treated with conization alone had recurrent invasive cancer after a median follow-up of 45 months. However three (10%) of these patients developed a cervical intraepithelial neoplasia (CIN) III after 16, 33, and 94 months, respectively, from conization.

CONCLUSIONS

Conization can represent the definite treatment for patients with Stage Ia1 squamous cell cervical cancer, if cone margins and apex are disease-free. For patients with Stage Ia2 cervical cancer extrafascial hysterectomy with pelvic lymphadenectomy might be an adequate standard therapy, although the need for lymph node dissection is questionable.

An intervention to increase fluid intake in nursing home residents: prompting and preference compliance

OBJECTIVE

To evaluate a three-phase, behavioral intervention to improve fluid intake in nursing home (NH) residents.

DESIGN

Controlled clinical intervention trial.

SETTING

Two community NHs.

PARTICIPANTS

Sixty-three incontinent NH residents.

INTERVENTION

Participants were randomized into intervention and control groups. The intervention consisted of three phases for a total of 32 weeks: (1) 16 weeks of four verbal prompts to drink per day, in between meals; (2) 8 weeks of eight verbal prompts per day, in between meals; and (3) 8 weeks of eight verbal prompts per day, in between meals, plus compliance with participant beverage preferences.

MEASUREMENTS

Between-meal fluid intake was measured in ounces by research staff during all three phases of the intervention. Percentage of fluids consumed during meals was also estimated by research staff for a total of nine meals per participant (3 consecutive days) at baseline and at 8 and 32 weeks into the intervention. Serum osmolality, blood urea nitrogen, and creatinine values were obtained for all participants in one of the two sites at the same three time points.

RESULTS

The majority (78%) of participants increased their fluid intake between meals in response to the increase in verbal prompts (phase 1 to 2). A subset of residents (21%), however, only increased their fluid intake in response to beverage preference compliance (phase 3). There was a significant reduction in the proportion of intervention participants who had laboratory values indicative of dehydration compared with the control participants. Cognitive and nutritional status were predictive of residents' responsiveness to the intervention.

CONCLUSIONS

A behavioral intervention that consists of verbal prompts and beverage preference compliance was effective in increasing fluid intake among most of a sample of incontinent NH residents. Verbal prompting alone was effective in improving fluid intake in the more cognitively impaired residents, whereas preference compliance was needed to increase fluid intake among less cognitively impaired NH residents.

Patterns of recurrence in patients with squamous cell carcinoma of the vulva. A multicenter CTF Study

BACKGROUND

Invasive vulvar carcinoma is a rare disease with an incidence rate of 3-5% of all female genital neoplasms. The current study discusses the limited number of articles in the literature regarding the patterns of recurrence as well as the clinical outcome of patients with recurrent disease based on a consistent and consecutive series of cases.

METHODS

A common clinical chart focusing on the study of patterns of recurrence was used in five Italian gynecologic institutions with uniform criteria of surgical nomenclature, pathologic variables, and sites of recurrence. Between 1980-1994, 502 cases of primary invasive squamous carcinoma of the vulva were registered consecutively, treated, and considered for this multicentered study.

RESULTS

Of 502 patients, 187 (37.3%) developed a recurrence. Distribution of the recurrences by site was as follows: perineal, 53.4%; inguinal, 18.7%; pelvic, 5.7%; distant, 7.9%; and multiple, 14.2%. In a multivariate analysis, 3 characteristics appeared to be statistically correlated with the risk of recurrence: International Federation of Gynecology and Obstetrics Stage > II (P = 0.029), positive lymph nodes (P = 0.009), and vascular space invasion (P = 0.004). The 5-year survival rate was 60% for perineal recurrences, 27% for inguinal and pelvic recurrences, 15% for distant recurrences, and 14% for multiple recurrences.

CONCLUSIONS

In the current study the prognostic factors found to have statistical significance as prognostic factors for risk of recurrence were tumor dimension, lymph node involvement, and stromal and vascular space invasion. The presence of inguinal lymph node metastases was predictive of multiple and distant recurrences with a low rate of incidence of isolated perineal recurrence (27%) compared with negative lymph node cases (57.5%). Survival analysis of recurrent disease showed that the surgical resection of local recurrences may provide acceptable results (51% at 5 years). This observation may justify a follow-up program aimed at identifying those patients with early local recurrence suitable for radical resection.

Nighttime urinary incontinence and sleep disruption among nursing home residents

OBJECTIVE

To examine the relationship of urinary incontinence episodes to sleep disruption in a sample of nursing home residents.

DESIGN

Descriptive, case series.

SETTING

Three community nursing homes.

PARTICIPANTS

Seventy-three incontinent residents of three nursing homes participating in a trial of a behavioral intervention for nighttime urinary incontinence.

MEASUREMENTS

Data were collected during a baseline and repeat baseline period about 2 months later in nursing homes serving as controls for the intervention homes. Incontinence episodes were identified by incontinence pads, which were wired to detect wetness of 10 mL or more. Sleep was monitored by wireless wrist actigraphs. Noise and light changes were monitored by bedside recording devices.

MAIN RESULTS

Recordings covered 403 nights, during which 1715 awakenings from 10 consecutive minutes of sleep were detected as were 1168 incontinent episodes. Only 4% of the awakenings were associated with an incontinence episode, and only 23% of the incontinence episodes occurred during periods of at least 10 consecutive minutes of sleep. Of the latter episodes, only 12% appeared to awaken the resident.

CONCLUSIONS

Our data raise questions about the relevance of incontinence episodes to sleep disruption among chronically incontinent nursing home residents. Our findings must be interpreted cautiously because of limitations in the technologies and definitions we used to identify sleep, awakenings, and incontinence episodes. Although logistically and technically difficult to perform, studies using polysomnographic recordings of sleep are needed to examine further these important associations.

Analysis of failures after negative second-look in patients with advanced ovarian cancer: an Italian multicenter study

This multicenter retrospective study is based on 192 patients with advanced ovarian cancer in pathological complete response at second-look surgery. Ninety-four (48.9%) patients developed recurrent disease after a median time of 18 months (range, 4-89 months) from surgical reassessment. The recurrence involved the pelvis in 45 (47.9%) cases, the abdomen in 42 (44.7%), the retroperitoneal lymph nodes in 13 (13.8%), and distant sites in 20 (21.2%). On the whole series, 5- and 7-year disease-free survival rates after negative second-look were 47.4 and 44.5%, respectively. By log-rank test the disease-free survival rate was related to FIGO stage (P = 0.008), tumor grade (P = 0.0021), size of residual disease after initial surgery (P = 0.0038), and type of second-look (laparoscopy vs laparotomy, P = 0.0061), but not to histological type and first-line chemotherapy. Cox proportional hazard model showed that tumor grade, size of residual disease, and type of second-look were independent prognostic variables for disease-free survival. The risk ratio of relapse was 2.386 (95% CI, 1.140-4.990) for grade 2 and 3.118 (95% CI, 1.515-6.416) for grade 3 compared to grade 1 disease. For patients with residual disease 1-2 cm and > 2 cm the risk ratio was, respectively, 1.877 (95% CI, 1.117-3.156) and 2.156 (95% CI, 1.324-3.511) compared to patients with residual disease < 1 cm. The risk ratio was 1.826 (95% CI, 1.121-2.973) for patients who were submitted to a laparoscopic second-look compared to those who underwent a laparotomic reassessment. Poorly differentiated grade and large residual disease after initial surgery are the strongest prognostic variables for recurrence after a negative second-look.

Headache during pregnancy

A questionnaire was submitted to 430 women 3 days after delivery, asking mainly about features of headache before and during pregnancy, and their possible modification or recurrence; moreover, delivery modalities and the condition of the newborn were evaluated. One-hundred-and-twenty-six (29.3%) were found to be primary headache sufferers (IHS criteria, 1988), 81 of whom had migraine without aura (MO), 12 migraine with aura (MA), and 33 tension-type headache (TH). In all three groups, about 80% showed complete remission or a higher than 50% decrease in the number of attacks. The improvement was more evident after the end of the first trimester; this trend was common to the three primary headaches considered. In our series of primary headaches, there was only one case (MO) which began during pregnancy. In a subgroup of pluripara, headache maintained the improvement presented in the first pregnancy also during the following gravidic periods in about 50% of cases, whereas in the remaining 50% a worsening in parallel with successive pregnancies was found. Primary headaches "per se" do not seem to increase the pregnancy or delivery risks, nor the vitality of the newborn. During pregnancy, drug use was very much reduced and was restricted to a limited number of compounds.

Identification of viable myocardium by nitrate echocardiography after myocardial infarction: comparison with planar thallium reinjection scintigraphy

BACKGROUND

The aim of this study was to validate a new diagnostic tool, nitrate echocardiography (NE), for the identification of viable noncontracting myocardium in patients with a history of prior myocardial infarction (MI). Nitroglycerin (NTG) may be useful for this purpose for its peculiar pharmacodynamic action and may represent an option other than dobutamine echocardiography for the detection of hibernating segments in the presence of severely reduced coronary reserve.

METHODS

Twenty selected patients (pts) with an old MI were studied with NE and planar thallium scintigraphy with reinjection. NE was performed by administering i.v. NTG starting at 0.4 mcg/kg/minute with equal increments every five minutes up to 2 mcg/kg/minute or to early interruption of the test (decrease of systolic blood pressure > or = 20% or improvement of previously akinetic segments). Left ventricular wall motion was analyzed by dividing the left ventricle (LV) into 16 segments, and a wall motion score index (WMSI) was calculated. Thallium images were obtained at peak exercise, at four hours, and after reinjection. Myocardial viability was defined as an improvement in thallium uptake after reinjection in fixed defects.

RESULTS

Basal echo demonstrated 74 akinetic segments; of these 21 (28%, 11 pts) showed improved contractility during NTG infusion at a mean dose of 0.87 +/-0.33 mcg/kg/minute. WMSI decreased from 1.69 +/- 0.29 to 1.46 +/- 0.31 (P = .001). The only hemodynamic response was a drop in systolic blood pressure (136 mmHg to 124; P = .02). Thallium studies showed 29 segments with a four-hour reversible defect and 79 segments with a four-hour fixed defect; of the latter, 14 regions demonstrated improvement in tracer uptake after reinjection (17.7%; 10 pts). Nine pts had a positive echo and thallium study, while 8 showed no improvement either during NE or after thallium reinjection. Two pts had a false-positive nitrate echocardiogram. Therefore, according to an echo/thallium study match, sensitivity, specificity, and accuracy are 90%, 80%, 85%, respectively.

CONCLUSION

NE is a reliable and low-cost method for the detection of viable noncontracting myocardium in selected patients with CAD but needs further validation for widespread application.

Detecting delirium among hospitalized older patients

BACKGROUND

Delirium occurs commonly among older hospitalized patients and is frequently not recognized. In an effort to identify tools useful to clinicians in the diagnosis of delirium, test characteristics of four screening instruments were compared.

METHODS

Patients 65 years of age or older who were admitted to one of four medical and surgical wards of a university teaching hospital were followed up prospectively. Potential subjects were excluded if unavailable for interviews or discharged within 48 hours of admission, or if judged too impaired to participate in the daily interviews. Research assistants administered four instruments used to detect delirium: Digit Span Test, Vigilance 'A' Test, Clinical Assessment of Confusion, and Confusion Assessment Method. Abnormal scores on these tests or suspicion of acute confusion prompted a referral to the clinician-investigators who then assessed the patient daily for delirium based on the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria.

RESULTS

Delirium occurred in 64 (14.8%) of 432 subjects. The positive likelihood ratios for all of the instruments were significantly more than 1. The instruments remained useful when applied to selected subgroups: subjects in whom acute mental status changes were documented, subjects on surgical services, and subjects with impaired cognitive status on admission. Combinations of any two instruments did not perform substantially better than the instrument with the best test characteristics: the Clinical Assessment of Confusion. All instruments were more useful at confirming delirium than in excluding it.

CONCLUSION

The four instruments studied, which are suitable for use at the bedside, can aid the clinician in identifying patients likely to be suffering from delirium.