Relapse of depression during pregnancy following antidepressant discontinuation: a preliminary prospective study

Summary. Objective: Pregnancy has frequently been referred to as a time of emotional well-being for patients. However, systematic data about the risk for relapse of depression during pregnancy are sparse.Method: We completed a longitudinal cohort study of thirty-two (N=32) women with histories of depression who were euthymic at conception and who either discontinued or attempted to discontinue antidepressant therapy proximate to conception. Subjects were prospectively followed across pregnancy once per trimester using structured clinical interviews. Rates of relapse and time to relapse were examined. Factors distinguishing the population with respect to risk for relapse including demographic characteristics and illness history were also examined.Results: Seventy-five percent (N=24) of patients relapsed during pregnancy. The majority of relapses (79%, N=19) occurred in the first trimester, and relapse was more prevalent in women with histories of more chronic depression.Conclusions: Pregnancy is not protective with respect to risk for relapse of depression. Careful treatment planning is necessary for those women on antidepressants who plan to conceive or who become pregnant.     

Stress and decision making: neural correlates of the interaction between stress,executive functions,and decision making under risk

Stress and additional load on the executive system, produced by a parallel working memory task, impair decision making under risk. However, the combination of stress and a parallel task seems to preserve the decision-making performance [e.g., operationalized by the Game of Dice Task (GDT)] from decreasing, probably by a switch from serial to parallel processing. The question remains how the brain manages such demanding decision-making situations. The current study used a 7-tesla magnetic resonance imaging (MRI) system in order to investigate the underlying neural correlates of the interaction between stress (induced by the Trier Social Stress Test), risky decision making (GDT), and a parallel executive task (2-back task) to get a better understanding of those behavioral findings. The results show that on a behavioral level, stressed participants did not show significant differences in task performance. Interestingly, when comparing the stress group (SG) with the control group, the SG showed a greater increase in neural activation in the anterior prefrontal cortex when performing the 2-back task simultaneously with the GDT than when performing each task alone. This brain area is associated with parallel processing. Thus, the results may suggest that in stressful dual-tasking situations, where a decision has to be made when in parallel working memory is demanded, a stronger activation of a brain area associated with parallel processing takes place. The findings are in line with the idea that stress seems to trigger a switch from serial to parallel processing in demanding dual-tasking situations.     

Antidepressants reverse corticosterone-mediated decrease in brain-derived neurotrophic factor expression: differential regulation of specific exons by antidepressants and corticosterone

Earlier studies have implicated brain-derived neurotrophic factor in stress and in the mechanism of action of antidepressants. It has been shown that antidepressants upregulate, whereas corticosterone downregulates, brain-derived neurotrophic factor expression in rat brain. Whether various classes of antidepressants reverse corticosterone-mediated downregulation of brain-derived neurotrophic factor is unclear. Also not known is how antidepressants or corticosterone regulates brain-derived neurotrophic factor expression. To clarify this, we examined the effects of various classes of antidepressants and corticosterone, alone and in combination, on the mRNA expression of total brain-derived neurotrophic factor and of individual brain-derived neurotrophic factor exons, in rat brain. Normal or corticosterone pellet-implanted (100 mg, 21 days) rats were injected with different classes of antidepressants, fluoxetine, desipramine, or phenelzine, intraperitoneally for 21 days and killed 2 h after the last injection. mRNA expression of total brain-derived neurotrophic factor and of exons I-IV was measured in frontal cortex and hippocampus. Given to normal rats, fluoxetine increased total brain-derived neurotrophic factor mRNA only in hippocampus, whereas desipramine or phenelzine increased brain-derived neurotrophic factor mRNA in both frontal cortex and hippocampus. When specific exons were examined, desipramine increased expression of exons I and III in both brain areas, whereas phenelzine increased exon I in both frontal cortex and hippocampus but exon IV only in hippocampus. On the other hand, fluoxetine increased only exon II in hippocampus. Corticosterone treatment of normal rats decreased expression of total brain-derived neurotrophic factor mRNA in both brain areas, specifically decreasing exons II and IV. Treatment with desipramine or phenelzine of corticosterone pellet-implanted rats reversed the corticosterone-induced decrease in total brain-derived neurotrophic factor expression in both brain areas; however, fluoxetine reversed the decrease only partially in hippocampus. Interestingly, antidepressant treatment of corticosterone pellet-implanted rats increased only those specific exons that are increased during treatment of normal rats with each particular antidepressant. We found that although corticosterone and antidepressants both modulate brain-derived neurotrophic factor expression, and antidepressants reverse the corticosterone-induced brain-derived neurotrophic factor decrease, antidepressants and corticosterone differ in how they regulate the expression of brain-derived neurotrophic factor exon(s).     

Evaluation of the Patient Activated Learning System (PALS) to improve knowledge acquisition,retention, and medication decision making among hypertensive adults: Results of a pilot randomized controlled trial

BackgroundThere are few engaging, patient centered, and reliable e-Health sources, particularly for patients with low health literacy.ObjectivesWe tested the Patient Activated Learning System (PALS) against WebMD. We hypothesized that participants using PALS would have higher knowledge scores, greater perceived learning, comfort, and trust than participants using WebMD.MethodsParticipants with hypertension from an urban Internal Medicine practice were randomized to view 5 web pages in PALS orWebMD containing information about chlorthalidone. We assessed knowledge, learning perceptions, comfort, and trust through surveys immediately and one week following the intervention.Results104 participants completed both survey sets (PALS = 51,WebMD = 53). Immediate post intervention mean knowledge scores were higher for the PALS participants [(4.33 vs. 3.62 (P = .003)]. A greater proportion of PALS participants answered ≥4/5 questions correctly (82% vs. 57%; IRR 1.46 [95% CI 1.13–1.89]). A greater proportion of PALS participants agreed they would feel comfortable taking chlorthalidone if prescribed to them (73% vs. 55%; IRR 1.38 [95% CI 1.04–1.84]). One-week recall and trust were similar in the two groups.ConclusionsPALS may have advantages overWebMD for immediate knowledge acquisition, perceived learning, and comfort.ImplicationsPALS is a promising new approach to eHealth patient education.ClinicalTrials.gov registration identifier: NCT03156634     

Reproductive decision making of aunts and uncles of a child with cystic fibrosis: genetic risk perception and attitudes toward carrier identification and prenatal diagnosis.

This paper evaluates the perceived genetic risk, the perceived burden, the impact on reproductive decision making, and the attitudes of aunts and uncles of a child with cystic fibrosis toward carrier identification, prenatal diagnosis, and pregnancy termination. A mailed questionnaire was sent to the aunts and uncles of 32 CF children (1) who attended the Paediatric Department of the University Hospital and (2) whose parents agreed to give the names and addresses of their sibs. The results for the 109 respondents aged less than 40 years are discussed. About one-fourth of them was aware of the "approximate" level of the risk to be a carrier of the CF gene and/or of the risk of having a CF child themselves. Nevertheless the subjective evaluation of the genetic risk has played a part in the reproductive decision-making process of at least 39% of the respondents. About three-fourths would (probably) make use of heterozygote detection and would (probably) ask for prenatal diagnosis should they become pregnant. It is striking that less than half of the group would interrupt the pregnancy should the fetus be affected. The intention to use prenatal diagnosis was significantly correlated with age and educational level while the acceptance of pregnancy interruption was significantly correlated with perceived burden, respondents' age, and health situation of the proband.     

江苏地区中孕期妇女巨细胞病毒感染率及感染状态与不良妊娠结局的关系

目的江苏省中孕期妇女的巨细胞病毒（cytomegalovirus,CMV）血清流行率,探讨母孕期感染状态与不良妊娠结局的相关性。方法根据2002-2004年江苏省12个市县17661例孕妇的新生儿结局,527例有不良妊娠结局的孕妇纳入病例组,同时随机选取496例正常妊娠结局的孕妇为正常对照。检测孕妇妊娠15～20周外周血CMV IgG、IgM和IgG亲合力指数（avidity index,AI）。结果1023例孕妇的CMV IgG阳性率为98.7％,其中病例组和对照组孕妇阳性率分别为99.4％和98.0％（P=0.039）。病例组孕妇活动感染率,即CMV IgG＋／IgM＋,明显高于正常对照组（3.8％vs.1.6％,P=0.033）。CMV IgG AI检测结果显示,对照组孕妇AI均大于30%,说明无原发感染,而病例组孕妇5例（0.9％）AI〈30％,提示原发感染（P=O.084）,这5例母亲的新生儿均出现不良妊娠结局,包括新生儿死亡、头颅畸形和化脓性脑膜炎各1例,生长发育迟缓2例。多因素回归分析表明,母孕期CMV活动性感染是不良妊娠结局的独立危险因素（aOR 8.65,95％CI 1.85～40.41,P=0.006）。此外,母亲低学历和有既往不良妊娠史亦增加妊娠不良结局的发生风险。结论CMV感染在江苏地区孕妇人群中普遍存在。尽管仅少部分孕妇在孕期发生活动性感染,但仍是造成妊娠不良结局的独立危险因素。因此,应监测孕妇CMV感染状态并正确进行胎儿或新生儿感染风险的评估。     

Group B streptococcus colonization of Greek pregnant women and neonates: prevalence, risk factors and serotypes

Objective  To evaluate the prevalence and risk factors of group B streptococcus (GBS) colonization among pregnant women and their neonates in Greece, and to examine the serotype distribution of the GBS strains isolated and their susceptibility to antibiotics.
Methods  A vaginal and a rectal swab were obtained from 1014 pregnant or parturient women followed at public and private hospitals in Athens and in a city of northern Greece. Cultures were also taken 24 h after birth from 428 neonates born to these women.
Results  The overall maternal and neonatal colonization rates were 6.6% and 2.4%, respectively. The vertical transmission rate was 22.5%. By logistic regression analysis, multiparity (≥III) was associated with a lower colonization rate (odds ratio 4.4, 95% confidence interval 1.08–18.63). In contrast with other studies, middle-class women followed privately were more frequently colonized (10%) than those followed at the public hospital (3.9%) (odds ratio 3.1, 95% confidence interval 1.83–5.42). A higher number of prenatal visits was also associated with a higher colonization rate (change in true odds ratio when visits increased by one, 1.3; 95% confidence interval 1.14–1.60). No association was found between colonization and maternal age, previous obstetric history, marital status, nationality, prematurity, Caesarean section, or infant birth weight. The most common serotypes were II (26.9%), III (22.4%), Ia (19%), Ib (12%), and V (9%). A considerable proportion of the isolated strains was resistant to erythromycin (4.5%), clindamycin (6%), or both (6%).
Conclusion  The rate and risk factors of maternal and neonatal GBS colonization may vary in different communities. These rates, as well as the incidence of neonatal disease, need to be thoroughly evaluated in each country to allow the most appropriate preventive strategy to be selected.     

Brief detection and co-occurrence of violence,depression and alcohol risk in prenatal care settings

Summary The purpose of the study was to examine the rates and inter-relationships among violence receipt, alcohol use problems, and depression in women seeking prenatal care. While waiting for their prenatal care appointment, women (n = 1054) completed measures of past year partner and non-partner violence receipt, alcohol misuse (TWEAK and quantity and frequency of alcohol use in past year), and depression (Center for Epidemiological Studies Depression Scale – CESD and prior history of depression). Over 30% of women reported either violence receipt, alcohol use problems or depression risk. Significant inter-relationships among all measured risk variables were found. Although violence receipt was significantly related to alcohol misuse, cigarette use, less education, and scoring above the cutoff on the CESD (≥ 16) was most strongly associated with violence. Practitioners should be well-equipped to provide assessment, interventions, or referrals as needed to the high numbers of women encountered in prenatal care settings experiencing psychosocial and behavioral problems that may affect their pregnancy.     

HIV risk perception and prevalence in a program for prevention of mother-to-child HIV transmission: comparison of women who accept voluntary counseling and testing and those tested anonymously

OBJECTIVE: To determine whether data from voluntary counseling and testing (VCT)/prevention of mother-to-child transmission (PMTCT) programs can be used for HIV surveillance. METHODS: Women attending an antenatal clinic at the district hospital in Entebbe, Uganda, from May 2002 to April 2003 were offered counseling and HIV testing with same-day results (VCT) and nevirapine for PMTCT was provided for HIV-positive women and their babies. Those who declined VCT were tested for HIV anonymously. RESULTS: Overall, 2635 women accepted VCT; 883 were tested anonymously. HIV prevalence was higher in VCT than in anonymously tested women in the first month of the program (20% vs. 11%, P=0.05) and in months with <70% VCT uptake (17% vs. 8%, P<0.001) but was similar in months with high uptake. Uptake of VCT was higher in women who had risk factors for HIV, especially those who believed themselves to have been exposed (84% vs. 73%, P<0.001). CONCLUSION: There was a bias to accepting VCT in women with HIV, or risk factors for HIV infection, the former most apparent when there was low coverage. Data from VCT/PMTCT programs cannot replace anonymous surveillance for monitoring of HIV epidemic trends where coverage is incomplete within clinics or communities.     

Providing prenatal care to pregnant women with overweight or obesity: Differences in provider communication and ratings of the patient-provider relationship by patient body weight

ObjectiveTo examine the association of women’s body weight with provider communication during prenatal care.MethodsWe coded audio recordings of prenatal visits between 22 providers and 117 of their patients using the Roter Interaction Analysis System. Multivariate, multilevel Poisson models were used to examine the relationship between patient pre-pregnancy body mass index and provider communication.ResultsCompared to women with normal weight, providers asked fewer lifestyle questions (IRR 0.66, 95% CI 0.44–0.99, p = 0.04) and gave less lifestyle information (IRR 0.51, 95% CI 0.32–0.82, p = 0.01) to women with overweight and obesity, respectively. Providers used fewer approval (IRR 0.68, 95% CI 0.51–0.91, p = 0.01) and concern statements (IRR 0.68, 95% CI 0.53–0.86, p = 0.002) when caring for women with overweight and fewer self-disclosure statements caring for women with obesity (IRR 0.40, 95% CI 0.19–0.84 p = 0.02).ConclusionLess lifestyle and rapport building communication for women with obesity may weaken patient-provider relationship during routine prenatal care.Practice implicationsInterventions to increase use of patient-centered communication – especially for women with overweight and obesity – may improve prenatal care quality.     

Epidemiology,risk factors and antimicrobial profile of Vulvovaginal Candidiasis (VVC): A study among women in the central region of Saudi Arabia

BackgroundCandida spp. is a fungal resident of the normal microbiota of gastrointestinal tract, reproductive mucosa and oral cavity. Hence, a majority of the healthy population may be prone to the most common fungal infection such as candidiasis that can be caused by any species of Candida. In women, vaginitis or vulvovaginal candidiasis (VVC) forms a significant part of urogenital infections with a high recurrence rate thus posing a public health issue worldwide.ObjectivesThe aim of this study was to determine the prevalence of VVC, its possible risk factors and the antifungal susceptibility of the species isolated from women attending a hospital in the central region of Saudi Arabia.MethodsSamples of high vaginal swabs (HVS) were obtained from 208 women aged 15–64 years with signs and symptoms of VVC. The samples were cultured on Sabouraud agar plates (SDA) and incubated at 30 °C for 10 days. Candida spp. were initially identified using morphologic characteristics, wet mount, germ tube test and finally confirmed with Vitek 2.ResultsAmong the samples, 34% were culture positive. Out of the positive samples, 68% were Candida albicans, followed by C. tropicalis (27%) and C. glabrata (2.7%). Majority of the C. albicans (16%) were observed in women between ages of 21–30 years. All the isolates were sensitive to the antifungals tested. Also, the presence of Candida spp. did not correlate to risk factors such as pregnancy, diabetes and use of antibiotics.ConclusionsPrevalence of vulvovaginal candidiasis was observed in the central region of Saudi Arabia with the predominant organism as Candida albicans.     

Reactivation of Epstein-Barr virus in pregnant women: Social factors,and immune competence as determinants of lymphoproliferative diseases—A hypothesis

In normal pregnant women, reactivation of Epstein-Barr virus (EBV) frequently occurs. Cellular immune responses are apparently suppressed, but high titer EBV-specific antibodies of IgG class may compensate. The antibodies cross the placenta and protect the infant against primary infection for many months. Reactivation of EBV in pregnancy and oral excretion of virus by normal pregnant women could be one explanation why young children in large sibships (among families of low social classes) become infected early in life. Infants are likely infected by EBV from their pregnant mothers who shed virus in saliva. Moreover, the natural protection for several months in the perinatal period against Burkitt lymphoma and fatal EBV-induced lymphoproliferative diseases in congenitally immune deficient children is explained. The maturity and immunocompetence of the immune system at the time of primary infection by EBV and the size of the sibship seem to determine whether infectious mononucleosis occurs. Gammaglobulin derived from human cord blood may be a valuable source of viral-specific antibodies for serotherapy in immune deficient patients.     

Disparities of HIV risk and PrEP use among transgender women of color in South Florida

BackgroundThe majority of the transgender female population in South Florida are Latina and Black, and are at greatest risk for acquiring HIV, yet there is limited research focused on South Florida transgender women of color. The study objective was to describe the disparities among racial/ethnic minority transgender women regarding HIV screening, pre exposure prophylaxis (PrEP) knowledge and PrEP utilization.MethodsSixty transgender women, recruited from South Florida community-based organizations, completed a questionnaire on HIV prevention and PrEP awareness and use. Univariate statistics were generated to describe sexual risk behavior, PrEP awareness and use, and HIV screening by race/ethnicity.ResultsOf the 60 participants, 50.0% were Latina, 35.0% African American/non-Hispanic Black (AA/NHB), 11.7% white and 3.3% other race/ethnicity. 75.0% reported being screened for HIV in the last 12 months, 15.3% of the participants reported living with HIV (PLWH), while 18.6% reported an unknown status. Compared to Latinas, AA/NHB demonstrated more risk (≥2 sexual partners: 76.2% vs 53.3%; transactional sex: 47.6% vs. 26.7%; unprotected receptive anal sex: 42.9% v. 26.7%), and more engagement in routine care (81.0% vs. 76.7%) at least once a year. PrEP knowledge was 76.7% among Latinas, 71.4% among whites, 47.6% among Blacks, and 50.0% among other race/ethnicity. 65.0% of participants knew about PrEP. Of the 8.2% with current or previous PrEP use, none were AA/NHB.ConclusionFindings suggest that education and public health campaigns in South Florida that promote HIV prevention should focus on increasing awareness and utilization of PrEP among racial/ethnic minority transgender, particularly among AA/NHB transgender women who are most at risk and had the lowest knowledge and use of PrEP.     

母妊高征对新生儿血糖、胰岛素及皮质醇水平的影响

目的　探讨妊娠高血压综合征对新生儿血糖、胰岛素、皮质醇水平与临床的影响。方法　对 14 4例妊高征母亲所生新生儿及健康对照组 11例 ,于出生 2 4～ 4 8小时内采取股静脉血 ,测定血糖、胰岛素、皮质醇水平进行前瞻性临床研究。结果　 (1)妊高征母亲所生新生儿血糖、胰岛素水平均未受母妊高征影响 ,与对照组比较均无显著性差异 ,P >0 0 5 ;(2 )妊高征组皮质醇水平明显高于对照组 ,P <0 0 5 ;(3)妊高征母亲所生新生儿血糖、胰岛素、皮质醇水平不因母亲妊高征程度不同而发生变化 ,均为P >0 0 5。结论　妊高征母亲所生新生儿血糖、胰岛素水平并依母亲疾病程度不同而改变 ;而皮质醇水平明显增高 ,说明此即妊高征母亲所生早产儿较其它同胎龄儿少发生RDS的重要机理之一。且一但发生妊高征 ,不论其程度如何 ,新生儿血糖、胰岛素、皮质醇水平变化是一致的     

Mirtazapine: treatment of depression, anxiety, and hyperemesis gravidarum in the pregnant patient. A report of 7 cases

Summary Objective: Though selective serotonin re-uptake inhibitors have been studied in pregnancy (Gupta, 1998), there is little information on the efficacy and safety of mirtazapine (Remeron^?), a central alpha-2 blocker for treatment of depression and anxiety in pregnancy. Since mirtazapine blocks the 5HT-3 receptor postsynaptically, like ondansetron (Zofran^?) but unlike any other antidepressant, there is reason to believe that mirtazapine may be of great use in treating not only depression and anxiety in pregnancy but also nausea and the more severe condition, hyperemesis gravidarum. Method: Seven cases are reviewed in which mirtazapine was given in pregnancy for hyperemesis and depression. Five patients were treated as outpatients. Two patients were begun on mirtazapine as inpatients already on transparenteral nutrition, one having had a negative reaction to ondansetron and metoclopramide. Results: All patients demonstrated improvement of depressed mood, and reduced nausea and vomiting. All seven babies were born at term, each with APGAR scores of 7 or 8 at one minute, 9 at five minutes. Conclusions: Mirtazapine may prove a valuable treatment in pregnancy for depression, anxiety and/or hyperemesis, based on its dual action (serotonin and norepinephrine), efficacy in treating depression, and antagonism of 5HT-3. Further studies of its potential therapeutic use in pregnancy are warranted.     

Quality of life in alcohol misuse: comparison of men and women

Summary ¶The theoretical and practical basis for Quality of Life assessment is briefly discussed. In the absence of a specific QoL measure for alcohol misusers, generic and symptom-specific measures have been used. Application of these instruments to alcohol misusers indicate severely impaired QoL, worse than that of patients with malignant disease. QoL improves with abstinence and deteriorates with relapse.Comparison of QoL in males and females indicates that for nearly all parameters, QoL in females is worse than in males, for comparable levels of dependency: Disturbed sleep with depression is a particular feature of the impaired QoL in female alcohol misusers. Comparison of the patients perceptions of their QoL with that of their attending physician shows only a weak correlation between the two scores with that of the patients being consistently higher. Assessment of QoL in alcoholics is a valuable measure of clinical status and is more relevant than simple measures of alcohol consumption, or liver toxicity tests. It also helps to identify predictors of relapse and issues of major concern to the individual patient.Received February 3, 2003; accepted March 11, 2003 Published online June 26, 2003     

Neonatal outcomes in offspring of women with anxiety and depression during pregnancy

Summary Background: The presence of mental disorder during pregnancy could affect the offspring.Aims: To examine the effects of anxiety disorder and depression in pregnant women on neonatal outcomes, and to compare neonatal outcomes between offspring of attendees and non-attendees in a general population-based health survey.Method: Pregnant women (n = 680) were identified from the population-based health study of Nord-TrØndelag County (HUNT-2) by linkage with the Medical Birth Registry of Norway. The women rated themselves on the Hospital Anxiety and Depression Rating Scale (HADS). Outcome variables were gestational length, birth weight, and Apgar scores.Results: HADS-defined anxiety disorder during pregnancy was associated with lower Apgar score at one minute (score < 8; odds ratio = 2.27; p = .03) and five minutes (score < 8; odds ratio = 4.49; p = .016). No confounders were identified. Anxiety disorder and depression during pregnancy was not associated with low birth weight or preterm delivery. Offspring of non-attendees had a lower birth weight (77 g; t = 3.27; p = 0.001) and a shorter gestational length (1.8 days; t = 2.76; p = 0.006) than that of offspring of attendees, a difference that may be explained by a higher load of psychosocial risk factors among the non-attendees.Conclusion: In our study that may be biased towards the healthier among pregnant women, anxiety disorder or depression during pregnancy were not strong risk factors for adverse neonatal outcomes although low Apgar score in offspring of women with anxiety disorder may indicate poor neonatal adaptation.