Neurocognitive development in children experiencing intrauterine growth retardation and born small for gestational age: pathological, constitutional and therapeutic pathways

Interest in the neurocognitive and psychosocial outcomes in children who are born small for gestational age (SGA) has increased since the recent approval of growth hormone (GH) therapy in this indication. The objective of GH treatment in SGA children is to provide a symptomatic treatment for growth retardation. From a patient perspective, the ultimate goals of GH therapy are the reduction in the present or future risk of neurocognitive, psychological, social or occupational impairment, not the accompanying improvements in growth velocity and final height per se. Therefore, from a scientific perspective, neurocognitive and psychosocial endpoints become relevant domains of assessment to determine the final treatment benefit experienced by the patient born SGA. This article reviews recent available studies on developmental risks in SGA, and then transforms the empirical findings into an integrated conceptual framework on the sources and mediators of neurocognitive and psychosocial outcomes in intrauterine growth retardation and SGA. This framework depicts two distinct therapeutic pathways by which GH therapy may improve neurocognitive and behavioural outcomes. The first ('traditional') pathway is the prevention of exposure to short-stature-related stressors via an improvement in growth velocity and final height. The second pathway refers to potential metabolic, and thus neurotropic and psychotropic, effects of GH binding at receptors in the central nervous system, thus changing neuronal activity. To date, the existence and potential mechanisms of such physiologically and not psychologically mediated effects of GH on neurocognitive functioning in SGA patients remain hypothetical.     

Women's psychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study

This study examined the experiences of 360 women receiving bilateral breast augmentation with Dow Corning's Silastic MSI (textured) or Silastic II (smooth) gel-filled mammary implants. Before surgery, the women completed a quantitative assessment of their surgical expectations and concerns. At 6, 12, and 24 months postoperatively, they rated their satisfaction with surgery and its specific psychosocial outcomes, their concerns, and benefits-to-risks appraisals of the augmentation. The women reported very high levels of satisfaction with the procedure and its psychosocial outcomes, which did not change over time. Throughout the 2-year period, over 90 percent of the women were satisfied with surgery and their resultant body-image changes. Their concerns about risks, reported by 19 percent before surgery, declined after surgery and remained subsequently stable. Most participants (75 to 85 percent) reported that the benefits of surgery exceeded its risks. Postoperative events such as significant capsular contracture that compromised aesthetic results diminished aspects of satisfaction, whereas less obvious events did not. Systematic analysis of attrition (i.e., missing assessments) did not indicate any biases because of complications or psychosocial outcomes. Evaluation of a possible impact of the publicity surrounding the Food and Drug Administration's voluntary moratorium on the use of silicone gel-filled breast implants, which occurred during the study, revealed a limited effect, if any, on women's psychosocial outcomes. Findings are discussed in relation to the study's methodological strengths and limitations and with respect to the broader context of patient care.     

Genome wide association study of Escherichia coli bloodstream infection isolates identifies genetic determinants for the portal of entry but not fatal outcome

Escherichia coli is an important cause of bloodstream infections (BSI), which is of concern given its high mortality and increasing worldwide prevalence. Finding bacterial genetic variants that might contribute to patient death is of interest to better understand infection progression and implement diagnostic methods that specifically look for those factors. E. coli samples isolated from patients with BSI are an ideal dataset to systematically search for those variants, as long as the influence of host factors such as comorbidities are taken into account. Here we performed a genome-wide association study (GWAS) using data from 912 patients with E. coli BSI from hospitals in Paris, France. We looked for associations between bacterial genetic variants and three patient outcomes (death at 28 days, septic shock and admission to intensive care unit), as well as two portals of entry (urinary and digestive tract), using various clinical variables from each patient to account for host factors. We did not find any association between genetic variants and patient outcomes, potentially confirming the strong influence of host factors in influencing the course of BSI; we however found a strong association between the papGII operon and entrance of E. coli through the urinary tract, which demonstrates the power of bacterial GWAS when applied to actual clinical data. Despite the lack of associations between E. coli genetic variants and patient outcomes, we estimate that increasing the sample size by one order of magnitude could lead to the discovery of some putative causal variants. Given the wide adoption of bacterial genome sequencing of clinical isolates, such sample sizes may be soon available.     

Does Early Psychosocial Stress Affect Mate Choice?

Early psychosocial stress (e.g., parental divorce, abuse) is conjectured to place individuals on a developmental trajectory leading to earlier initiation of sexual activity, earlier reproduction, and having more sex partners than those with less early psychosocial stress. But does it also affect an individual’s mate choice? The present study examined whether early psychosocial stress affects preferences and dislikes for opposite-sex faces varying in masculinity/femininity, a putative indicator of mate quality, in premenopausal women (58 with a natural cycle, 53 pill-users) and 196 men. No significant three-way interactions were found when women selected the most or least preferred face with participant group (natural cycle, pill), conception risk (low, high), and early psychosocial stress (low, high) as between-subjects factors. Early psychosocial stress did not affect men’s face preferences when selecting the most preferred face. However, men with high early psychosocial stress disliked masculine faces significantly more so than men with low early psychosocial stress. Overall it was concluded that early psychosocial stress does not affect mate choice with the exception that men with high early psychosocial stress were more likely to dislike masculine female faces. It was suggested that men with high early psychosocial stress may dislike masculine female faces because they have nothing to gain from associating with women with such faces.     

“We Are Now Free to Speak”: Qualitative Evaluation of an Education and Empowerment Training for HIV Patients in Namibia

Although numerous studies provide evidence that active patient engagement with health care providers improves critical outcomes such as medication adherence, very few of these have been done in low resource settings. In Namibia, patient education and empowerment trainings were conducted in four antiretroviral (ART) clinics to increase patient engagement during patient-provider interactions. This qualitative study supplements findings from a randomized controlled trial, by analyzing data from 10 in-depth patient interviews and 94 training evaluation forms. A blended approach of deductive and inductive coding was used to understand training impact. Findings indicated the trainings increased patients’ self-efficacy through a combination of improved HIV-related knowledge, greater communication skills and enhanced ability to overcome complex psychosocial barriers, such as fear of speaking up to providers. This study suggests patient empowerment training may be a powerful method to engage HIV patients in their own care and treatment.     

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BackgroundHospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.Methods and findingsWe evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.ConclusionsIn this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients’ social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

In a meta-analysis, Timothy Smith and colleagues study trials of the effectiveness of psychosocial support interventions for improving inpatient and outpatient survival.     

Religious factors and hippocampal atrophy in late life

Despite a growing interest in the ways spiritual beliefs and practices are reflected in brain activity, there have been relatively few studies using neuroimaging data to assess potential relationships between religious factors and structural neuroanatomy. This study examined prospective relationships between religious factors and hippocampal volume change using high-resolution MRI data of a sample of 268 older adults. Religious factors assessed included life-changing religious experiences, spiritual practices, and religious group membership. Hippocampal volumes were analyzed using the GRID program, which is based on a manual point-counting method and allows for semi-automated determination of region of interest volumes. Significantly greater hippocampal atrophy was observed for participants reporting a life-changing religious experience. Significantly greater hippocampal atrophy was also observed from baseline to final assessment among born-again Protestants, Catholics, and those with no religious affiliation, compared with Protestants not identifying as born-again. These associations were not explained by psychosocial or demographic factors, or baseline cerebral volume. Hippocampal volume has been linked to clinical outcomes, such as depression, dementia, and Alzheimer's Disease. The findings of this study indicate that hippocampal atrophy in late life may be uniquely influenced by certain types of religious factors.     

A prospective study of medical care utilization and morbidity in preschool children belonging to a prepaid group practice: background and methods

The purpose of this paper is to describe the background and methods of a prospective study of medical care utilization and morbidity in a fixed cohort of over 500 preschool children whose families belonged to a prepaid group practice affiliated with Yale University. Following baseline interviews with their mothers, study children were followed for 12 months between 1981 and 1982. Information concerning the subjects' contacts with the health care facility serving members of the group practice was collected from accompanying adults, attending clinicians, and medical records. Using these data, we were able to identify episodes of care, linking all clinical visits and phone calls for single occurrences of an illness or injury. The major aim of the study is to identify psychosocial determinants of pediatric utilization (for both acute and preventive care) and of childhood morbidity. The possible predictors of principal interest are factors associated with the family environment, such as social stress and strain, family structure, and different aspects of the mother's social network. The dual emphasis on both illness and behavior outcomes is based on the important interrelationship between epidemiologic and health services research, especially when examining psychosocial effects.     

Resilience amongst Australian Aboriginal Youth: An Ecological Analysis of Factors Associated with Psychosocial Functioning in High and Low Family Risk Contexts

We investigate whether the profile of factors protecting psychosocial functioning of high risk exposed Australian Aboriginal youth are the same as those promoting psychosocial functioning in low risk exposed youth. Data on 1,021 youth aged 12–17 years were drawn from the Western Australian Aboriginal Child Health Survey (WAACHS 2000–2002), a population representative survey of the health and well-being of Aboriginal children, their families and community contexts. A person-centered approach was used to define four groups of youth cross-classified according to level of risk exposure (high/low) and psychosocial functioning (good/poor). Multivariate logistic regression was used to model the influence of individual, family, cultural and community factors on psychosocial outcomes separately for youth in high and low family-risk contexts. Results showed that in high family risk contexts, prosocial friendship and low area-level socioeconomic status uniquely protected psychosocial functioning. However, in low family risk contexts the perception of racism increased the likelihood of poor psychosocial functioning. For youth in both high and low risk contexts, higher self-esteem and self-regulation were associated with good psychosocial functioning although the relationship was non-linear. These findings demonstrate that an empirical resilience framework of analysis can identify potent protective processes operating uniquely in contexts of high risk and is the first to describe distinct profiles of risk, protective and promotive factors within high and low risk exposed Australian Aboriginal youth.     

A utility approach to individualized optimal dose selection using biomarkers

In many settings, including oncology, increasing the dose of treatment results in both increased efficacy and toxicity. With the increasing availability of validated biomarkers and prediction models, there is the potential for individualized dosing based on patient specific factors. We consider the setting where there is an existing dataset of patients treated with heterogenous doses and including binary efficacy and toxicity outcomes and patient factors such as clinical features and biomarkers. The goal is to analyze the data to estimate an optimal dose for each (future) patient based on their clinical features and biomarkers. We propose an optimal individualized dose finding rule by maximizing utility functions for individual patients while limiting the rate of toxicity. The utility is defined as a weighted combination of efficacy and toxicity probabilities. This approach maximizes overall efficacy at a prespecified constraint on overall toxicity. We model the binary efficacy and toxicity outcomes using logistic regression with dose, biomarkers and dose–biomarker interactions. To incorporate the large number of potential parameters, we use the LASSO method. We additionally constrain the dose effect to be non-negative for both efficacy and toxicity for all patients. Simulation studies show that the utility approach combined with any of the modeling methods can improve efficacy without increasing toxicity relative to fixed dosing. The proposed methods are illustrated using a dataset of patients with lung cancer treated with radiation therapy.     

The evaluation of treatment when center-specific selection criteria vary with respect to patient risk

Many standards of medical care are based on the demonstrated effects of various treatment strategies or processes. Unlike pharmacological treatments, these strategies or processes are not necessarily subjected to rigorous clinical trials and their benefit is frequently assessed from observational data. For evaluating the influence of such medical processes on patient outcomes, not only is risk adjustment an issue, but also the "center effect" represents an important, often overlooked consideration. Both the quality of care and the tendency to use certain treatments or processes vary from one center to another. The induced similarity in outcomes within center, as well as the potential for confounding by center, needs to be addressed within the context of risk adjustment. In addition, center-specific selection criteria for a treatment strategy can vary with respect to patient risk. Because of these considerations, it is important to adequately separate the within-center effects of the treatment or strategy from the across-center effects, which relate more to center performance. The primary objective of this article is to explore and extend current methods of dealing with center confounding for dichotomous outcomes, primarily for the situation where selection on the basis of patient risk can vary from center to center. A simulation study compares results from several different analytic methods and provides evidence for the importance of considering confounding due to both risk and center when evaluating the effectiveness of a process. An example that examines the effect of early extubation after bypass surgery is also presented.     

'Well doctor, it is all about how life is lived': cues as a tool in the medical consultation

Introduction During consultations, the perspective of the patient and the family physician come together. In order to reach a shared view about the symptoms it is important to know the agenda of the patient. Cues (i.e. non-explicit remarks that can enclose a special meaning) can serve as a tool to clarify the agenda.Case report In this article, we describe a patient with unexplained palpitations during vacuuming. During one of the following consultations she provided an important psychosocial cue which changed my perspective on her palpitations, resulting in a deeper understanding of her symptoms.Discussion Recognition and exploration of cues is important for reaching mutual understanding of doctors and patients about the symptoms. Moreover, it enhances the therapeutic relationship and improves illness outcomes and patient satisfaction.Conclusion Noticing cues in the medical consultation helps the doctor to understand the patient's real worries. It gives us, as doctors, a better understanding of the patient's perspective.     

A guide to interpreting a study of patient-reported outcomes

Outcomes measured from the patient perspective are particularly important in plastic surgery, where many of the treatments are aimed at improving physical function, psychosocial function, and quality of life. Understanding the measurement of patient-reported outcomes is critical to determine the value of the interventions performed, to better inform clinical decision-making, and to guide policy debates. It is critical that physicians understand their patients' individual values when making treatment and policy recommendations based on evidence. This guide outlines the questions that readers should ask when appraising literature using patient-reported outcomes.     

Using the ALPHA form in practice to assess antenatal psychosocial health

BACKGROUND: The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial. METHODS: A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods. RESULTS: The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers. INTERPRETATION: The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form''s reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.     

The psychological outcome of constitutional delay of growth and puberty

Does being of short stature (SS) matter? Growth studies are important because endocrinologists need to be able to give not only diagnostic but also prognostic indication to those of SS, and give advice for or against treatment. Studies on body height may give significant insight into the behavioural-hypothalamic-pituitary axis underlying the surface effect on social behaviour. This research presents adult follow-up studies of 49 males who attended at a growth clinic as children and who were diagnosed as having the condition of maturational delay short stature (MDSS). From the psychological perspective, the elements of diagnosis and prognosis, attitudinal influences both social and individual, treatment, and psychological issues which could have bearing on SS are drawn together. Where there is a poor psychosocial outcome finding, the MDSS patients seem to be more like those with growth hormone (GH) deficiency. With GH deficiency (GHD), a poor psychosocial outcome of SS has been demonstrated with greater certainty. The current situation is that there remains divergence between previous SS outcome studies. Differing research SS psychosocial outcomes are analysed and a methodological explanation of past divergent outcomes is presented, being: (1) differences in sensitivity between psychological assessment tools; (2) Invalidation by confounding the psychological with sociological outcomes, and (3) confounding of results by failure to control for psychological states. An innovative new approach of changing the methodology of past SS research from the biological to the psychological perspective is employed: previous SS research has appointed height status as the independent variable, with psychosocial outcome as the dependent variable. The innovative approach in this research is to reverse that order and psychological status has been made the independent variable for both the MDSS and for a predetermined psychologically and physically healthy (PPH) comparison group of males. The results of the follow-up studies in this research indicate that there is an association between psychological distress and attained height which supports other studies where the findings indicate a poor psychological outcome associated with SS. It can therefore be concluded that the psychological status of children should be determined when they attend a growth clinic with concerns of SS.     

EEG Neurofeedback Is Under Strong Control of Psychosocial Factors

Recently, a deep impact of psychosocial effects on the outcomes of neurofeedback training was suggested. Previous findings point out an association between locus of control in dealing with technology and the individual ability to up-regulate the sensorimotor rhythm (12–15 Hz) in the EEG. Since the antecedents of locus of control in dealing with technology differ between males and females, we have investigated the effect of sex of participant and experimenter on the outcomes of neurofeedback training. Mindfulness and SMR baseline power also were assessed as possible confounding variables. Undergraduate psychology students (n?=?142) took part in a single session of neurofeedback training conducted by either male or female experimenters. Male participants as well as those female participants instructed by male experimenters were able to upregulate SMR, while female participants trained by female experimenters were not. A strong positive correlation between training outcomes and locus of control in dealing with technology was observed only in the female participants trained by female experimenters. These results are suggestive about the impact of psychosocial factors—particularly gender-related effects—on neurofeedback training outcomes and the urgent need to document it in neurofeedback studies.     

Long-term follow-up of bone marrow transplant patients

Preparation for discharge begins prior to the admission for bone marrow transplant. Assessment of the home environment and the effect of prolonged isolation on the life style of the patient and family are important factors. Once the transplant process has been accomplished and the patient meets the criteria for discharge, physical preparation of the home environment can begin. In the immediate post-transplant period, treatment or prophylaxis of graft-versus-host disease (GVHD) is monitored. Immune globulins may be replaced every three to four weeks. Long-term follow-up often continues for many years, especially when chronic GVHD is present. Continued psychosocial support is needed throughout this process to prepare the patient for re-entry into the community.     

The role of psychiatry in a craniofacial team

The psychosocial assessment of the child in the context of his family and community is, we believe, an essential factor in the decision for and the timing of major reconstructive surgery. A severe congenital facial deformity does not usually affect a child's body-image, but it can have a great impact on the total self-image (which is related to social reactions). Surgery should be performed ideally before the early school years, when the child is subjected to the most teasing, provided both parents and the patient have realistic expectations and really want the major reconstruction.     

Psychosocial profiles of youth who acquire a natural mentor during a school year

Youth who form bonds with supportive, nonparent adults within their existing social networks (i.e., natural mentors) experience a range of positive outcomes, but a relatively minimal amount is known regarding the psychosocial factors that prospectively predict the formation of natural mentoring relationships. Analyzing longitudinal youth data from the waitlist control group of a formal mentoring intervention, the current study investigates the psychosocial factors that predict the acquisition of natural mentoring relationships. Of youth who reported not having a natural mentor at baseline (n?=?193), ages 9 to 16 (M?=?11.20, SD?=?1.61), 46.1% acquired a natural mentor over a school year. A significant interaction between stress (i.e., the number of recent stressful life events) and prosocial peer engagement predicted the acquisition of a natural mentor. At low levels of stress, prosocial peer engagement significantly predicted a lower likelihood of acquiring a natural mentor. This negative association became less strong with increasing stress levels. These findings highlight the importance of addressing interactions among personal and contextual factors when examining natural mentorship. The current and future investigations of naturally occurring mentoring relationships can inform the development of community-based and contextually relevant mentoring interventions.