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The Munchausen's Syndrome, first described by the English doctor Richard Asher in 1951, refers to a factitious disorder present in patients who are repeatedly admitted in medical emergencies for apparent serious diseases and are looking forward to intensive medical care. The authors present a challenging case report, highlighting the importance of a thorough medical investigation before setting into Munchausen's Syndrome stigmatizing diagnosis.
The authors present a case studied in an Oncological Center, with emphasis on the medical data, diagnostic process, multidisciplinary approach, family-social-occupational implications and outcome. A review on Munchausen's Syndrome, using Medline database, focusing on the last decade publications on the subject, was carried out.
The clinical presentation initially led to strong suspicion towards Munchausen's Syndrome, since it was an young adult, single, health related profession (doctor), with life event triggers (family and social isolation; affective rupture).With the on going diagnostic process, it ended out on an atypical presentation of Crohn's Disease. However, the stigmatizing label had already been set, adding psychological damage to the patient (adjustment depressive disorder).
From the Munchausen's Syndrome review in recent literature, the authors conclude that this rare diagnosis is even rarer on oncologic settings. It should always be an exclusion diagnosis, made after a careful medical screening carried on by an expert and multi-disciplinary team, which should include a liaison psychiatrist. The patient presented classical Munchausen's clinical profile, which can be misleading by it self, incurring into a misdiagnosis.
Some studies in the literature have reported voice hallucinations in prelingually deaf patients with psychosis. There has been scientific debate on whether those correspond to the real experience of deaf patients with psychosis or are simply a reflex of the limitations of psychiatric terminology or insufficient knowledge of the neurobiology of hallucinations.
The aim of this study is to review literature on hallucinations in deaf people based on a clinical vignette of a case of an adolescent with psychosis, congenital deafness and hallucinations.
Literature review of peer reviewed studies in PubMed and Medline using the terms deafness, auditory verbal hallucinations and psychosis.
There are only few studies addressing the characteristics of hallucinations in deaf patients with psychosis. The hallucinatory experience of deaf people is very diverse, and seems to be related with the individual experience with language, sensorial input and grade of residual hearing.
The perceptual characteristics of the hallucinations in persons with deafness seem to be related to the individual auditory experience and to the patient language modality. This group of patients consist of a minority within a minority and their unique psychopathology is a challenge to the current understanding of psychiatric symptoms and classifications. Further research on this area can bring new insights to the understanding of the neurobiology of hallucinations and contribute to improved diagnosis and management of these rare cases.
From Hippocrates to Freud and not forgetting Charcot and Janet, psychogenic disorders have intrigued generations of neurologists and psychiatrists.
The authors' aim is to present a clinical vignette of a 44-year-old female who suffered from a neurologic disorder with a psychogenic origin. A literature review about the diagnosis and management of psychogenic neurologic disorders was also made.
A 44-year-old female presented to the hospital complaining of increasingly frequent tremor of the upper limbs over the past month and pronounced weight loss (19 pounds in 3 months). She was discharged with a prescription of sertraline and oxazepam. One month later, she reported worsening of the symptoms, with tremor of upper limbs, chest and head and she was hospitalized to undergo a diagnostic workup.
Diagnostic testing included: brain cranial tomography and magnetic resonance imaging which were normal; laboratory tests with thyroid function, electroencephalogram, syphilis detection test and examinations of serum and urine, also normal. Neurologic examination was normal.
During the hospitalization, inconsistent characteristics of the symptom were found. the patient exhibited depressed mood and she stated that her symptoms had begun after the death of her mother, with whom she lived. the patient accepted psychiatric referral and the symptoms improved after she started psychiatric treatment.
Despite their psychogenic basis, neurologic disorders are generally truly disabling. the diagnosis and treatment of neurologic disorders of psychogenic origin are still a challenge in clinical practice, nowadays.
Perfectionism and perseverative negative thinking/PNT are both associatedwith eating disorders symptoms. PNT is a prime candidate when investigating the pathway that links perfectionism to psychopathology.
To investigate if PNT mediates the relationshipbetween perfectionismcognitions and ED symptoms.
114 young women(mean age=23.78±6.340; mean BMI=21.59±3.127; 49.4% students) fill in the Portuguese validated versions of Eating Attitudes Test/EAT-25 (to evaluateBulimic behaviors, Diet and Social pressure to eat), MultidimensionalPerfectionism Cognitions Inventory (Concern over mistakes/CM, Personal standards/PS,Pursuit of Perfection) and Perseverative Thinking Questionnaire/PTQ-15(Repetitive Thought/RT, Cognitive interference and unproductiveness). Onlyvariables significantly correlated with the outcomes (EAT-25_Total and itsdimensions) were entered in the multiple regression models. Mediation analysesusing Preacher and Hayes bootstrapping methodology were performed.
Significantpredictors of EAT_Total were CM (b=.180)and RT (b=.169)(both p<.05). RT partially mediatedthe relationship between EAT_Total and CM. (95%CI=.0671-.0290).
Bulimicbehaviors were predicted by the same variables (b=.359;b=.154;p<.05) and RT also partially mediated the relationship between Bulimic behaviorsand CM (95%CI=.0071-.0190). Diet and Social Pressure to Eat were only predictedby PS (b=.154;b=.257,respectively; p<.05).
Although PNT mediates the relationship between perfectionist cognitions andbulimic behavior, the effect of the perfectionism on other disordered eatingdimensions, such as diet and SPE, seems to be independent of the PNT levels. Aspreviously reported in other studies with community samples, disordered eatingbehaviors are associated to negative perfectionism dimensions, but also todimensions that have been considered not entirely maladaptive.
Brain tumors may present with multiple psychiatric symptoms (> 50%) and in 80% of the cases tumors are located in the frontal or limbic regions. Neuropsychiatric symptoms may be the first clinical indication of a brain tumor in 18% of the patients.
Brain metastatic tumors may be associated with a greater incidence of mental symptoms and are probably due to the tumors being scattered throughout the brain substance.
The authors report a case of a patient where the severe psychiatric symptoms, secondary to a metastatic brain tumor, were the initial presentation of a primary lung tumor.
A comprehensive review of the literature was conducted for reports of brain tumors and psychiatric symptoms, through PubMed, between Jan 1970 and Out 2010.
We also reviewed the patient medical records and computed tomography (CT) scans in detail.
Neither tumor location nor type is associated with specific psychiatric symptoms.
Mood symptoms may be a harbinger to an evolving brain tumor.
There is a statistically significant correlation of anorexia, without disturbance of body image perception, with hypothalamic tumors.
We conclude that brain tumors can be neurologically silent and only present with psychiatric symptoms. The diagnosis and treatment in the early phase of the disease are determinant for the survival and quality of life of patients with brain tumors.
Neuroimaging (CT and MRI scan) should be considered in patients with new-onset psychosis, recurrence of previously well-controlled psychiatric symptoms, occurrence of atypical symptoms and in patient's refractory to psychiatric treatment.
In a recent study developed with a community sample, we have found that although PNT mediated the relationship between perfectionist cognitions and bulimic behavior, the effect of perfectionism on other disordered eating dimensions, such as diet, was independent of the PNT levels (Monteiro et al., 2015).
To investigate if PNT mediates the relationship between perfectionism and disordered eating behaviors in a clinical sample.
Fifty-two patients with eating disorders/ED (mean age = 22.54 ± 7.637; mean BMI = 20.07 ± 4.192; 14.5% Anorexia Nervosa cases; 7.8% Bulimia Nervosa and 9.0% EDNOS) were assessed with the ED section of the Diagnostic Interview for Genetic Studies and fill in the Portuguese validated versions of Eating Attitudes Test/EAT-25 (to evaluate Bulimic behaviors/BB, Diet and Social pressure to eat), Multidimensional Perfectionism Scales (to evaluate perfectionism composite dimensions Evaluative Concerns/EC and Perfectionistic Strivings/PS) and Perseverative Thinking Questionnaire/PTQ-15 (to evaluate Repetitive Thought/RT, Cognitive interference and unproductiveness/CIU). Only variables significantly correlated with the outcomes (EAT-25_Total and its dimensions) were entered in the regression models. Mediation analyses using Preacher and Hayes bootstrapping methodology were performed.
EC, PS, CIU and RT were significant predictors of EAT_Total. PA, CIU and PR were significant predictors of BB. EC and PS were significant predictors of Diet. CIU partially mediated the relationship between EC and EAT_Total (95% CI = 0.0025–0.3296) and between EC and BB (95% CI = 0.0037–0.1877).
Also in a clinical sample, CII, the most pernicious dimension of PNT, mediates the relationship between perfectionism and disordered eating behavior, particularly bulimic behavior; diet is predicted by perfectionism independently of PNT.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Infertility is not only a medical condition and its impact in mental health is well established. Although most couples facing fertility problems and the demands of medical treatment are able to adjust, some of them may show psychological difficulties with clinical relevance, such as depression and anxiety. The Mindfulness Based Program for Infertility (MBPI) is a group intervention designed for infertile women and data from its efficacy study revealed impact in depressive symptoms reduction as well as in internal and external shame, entrapment and defeat. Based on the MBPI, a mindfulness app targeting infertile patients was developed – the MindfulSpot.
This study addresses the MindfulSpot development.
The MindfulSpot is a prototype mobile app, which seeks to offer the chance of practicing mindfulness in a comfortable and accessible way. This app covers informative audio and written texts. The audio contents correspond to mindfulness formal practices and suggestions for informal practice, making possible its use throughout different moments of the day. Beyond the practices mentioned above, users are invited to explore the informative menu, including information on the impact that infertility may have in several aspects of the patients’ lives.
The efficacy of the MindfulSpot is still under analysis and results are expected to be available soon.
The MindfulSpot was designed as a medium for training mindfulness skills and it includes useful information regarding specific aspects of the emotional impact of infertility. Additionally to its independent use, it may also be used as a support tool of the MBPI.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The prevalence of severe mental illness (SMI) is estimated to be 4%. There are increased risk factors for cancer in SMI patients. People with SMI have deficient access and referral to routine cancer screening and psychiatric illness is often associated to late oncological diagnosis.
Characterize the population of SMI patients that undergoes oncological treatment; establish a comparison with the general population in terms of stage at the time of diagnosis and the type of follow-up that ensued; characterize the psychiatric care available to these patients; propose the necessary changes to ensure adequate healthcare for SMI patients.
To assess and improve the quality of oncological care for SMI patients in our hospital.
We analyzed the data from SMI patients suffering from SMI observed by our group during a 12 month period.
Low percentage of SMI patients being treated in our center regarding general rates; surprisingly high referral time to psychiatry unity; good compliance with treatments and appointments; have mostly been submitted to the standard oncological protocols of treatment.
In spite of serious psychiatric co-morbidity and psychosocial deficits, our SMI patients are able for standard cancer treatment and present sufficient compliance. We value the help of family members and social workers. We have to insist in educational sessions and psychiatric screening procedures for oncological teams. It is also fundamental to implement educational programs for mental health centers in Lisbon in order to sensitize for cancer risks among SMI and alert for the pivotal role of mental health staff, namely the psychiatrists.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The treatment of first-episode psychosis patients is different from those with multiple-episode schizophrenia: the response to antipsychotics is better, the required doses are lower and the sensitivity to side-effects is higher. As such, current guidelines recommend a “start slow, go slow” strategy and an active avoidance of side-effects.
To know the patterns of antipsychotic prescription in first-episode psychosis patients of our inpatient unit.
We retrospectively reviewed the clinical data of all non-affective first-episode psychosis patients admitted to the Inpatient Unit C of Hospital de Magalhães Lemos during 2015. The antipsychotics prescribed at admission and discharge were recorded, as well as the doses.
A total of 29 patients were identified. The mean age was 36.6 and 65.5% were man. At admission, all patients were medicated with second-generation antipsychotics: 62.1% with risperidone, 27.6% with olanzapine, 6.9% with paliperidone and 3.4% with aripiprazol. The mean dose of risperidone was 3.5 mg/day. By the time of discharge, 34.5% of patients were prescribed a depot antipsychotic, half of them risperidone. Among those with oral medication only, 55.5% were prescribed risperidone, 22.2% paliperidone and the remainder 22.3% other antipsychotics (aripiprazol, olanzapine or quetiapine). The mean dose of risperidone was 3.7 mg/day.
Second-generation antipsychotics are clearly preferred. The mean dose by the time of discharge is similar to that used in clinical trials. However, antipsychotics are initiated at doses above the minimum effective dose. On discharge, an important proportion of patients are prescribed depot antipsychotics, which are known to improve medication adherence.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Progesterone (P4) plays a key role in pregnancy establishment and maintenance; during early pregnancy, P4 stimulates the production and release of uterine secretions necessary for conceptus growth prior to implantation; therefore, exogenous P4 supplementation may improve embryo development. This study evaluated the effects of supplementation during early pregnancy with long-acting injectable progesterone or altrenogest on embryonic characteristics of sows and gilts. Thus, a total of 32 sows and 16 gilts were used. On day 6 of pregnancy sows and gilts were allocated to one of the following groups: non-supplemented; supplemented with 20 mg of altrenogest, orally, from days 6 to 12 of pregnancy; supplemented with 2.15 mg/kg of long-acting injectable progesterone on day 6 of pregnancy. Animals were killed on day 28 of pregnancy, and ovulation rate, embryo survival, embryo weight, crown-to-rump length, uterine glandular epithelium and endometrial vascularization were assessed. Treatments had no effect on pregnancy rate, embryo survival or endometrial vascular density (P > 0.05). Non-supplemented gilts presented larger and heavier embryos compared to gilts from supplemented groups (P < 0.05). Sows in the altrenogest group presented larger and heavier embryos compared to non-supplemented sows and sows supplemented with long-acting injectable progesterone. In conclusion, supplementation of sows and gilts with progestagen from day 6 of pregnancy can be used as a means to improve embryo survival without deleterious effects.
Regeneration from seed affects species assembly in plant communities, and temperature is the most important environmental factor controlling the germination process. Thermal dependence of seed germination is thus associated with species occurrence in an ecosystem. Hence, we aimed to investigate the role of temperature on seed germination of ten tree species from the western Brazilian Amazon. Seeds were collected in the state of Rondônia, Brazil, and set to germinate under constant temperatures ranging from 10 to 40°C in germination chambers. We calculated germination capacity (G%), germination rate (GR50, reciprocal of germination time), and thermal parameters, such as cardinal temperatures and thermal time requirements. Most species had a large range of temperatures showing G% ≥80%, with optimal temperature varying from 20 to 40°C. Base temperature ranged from 6 to 12°C and ceiling temperatures were mainly >40°C. Astronium lecointei and Parkia nitida showed high germination capacity under temperatures of 35–40°C, while germination of Theobroma cacao dropped from 100% to zero under temperatures between 37 and 40°C. The climax species Cedrela fissilis had the slowest germination time (10 days) and highest thermal time requirement, while seeds of Enterolobium schomburgkii (a late-successional species) germinated within the first day of the experiment. Rapid recruitment of Amazon species could be favoured with treefall disturbance, which increases temperatures in the understory, but sharp limits might be found in the supra-optimal range of temperatures. Such patterns might indicate different regeneration strategies in the tropical rainforest, providing important information regarding seed germination among Amazon species.
Graded exercises tests are performed in adult populations; nonetheless, the use of this type of assessment is greatly understudied in overweight and obese adolescents.
To investigate heart rate autonomic responses to submaximal aerobic exercise in obese and overweight adolescents.
We recruited 40 adolescents divided into two groups: (1) overweight group comprising 10 boys and 10 girls between Z-score +1 and +2 and (2) obese group comprising 10 boys and 10 girls above Z-score >+2. Heart rate variability was analysed before (T1) and after exercise (T2–T4) on treadmill at a slope of 0%, with 70% of the maximal estimated heart rate (220 – age) for 20 minutes.
Heart rate in the overweight group was: 93.2±10.52 bpm versus 120.8±13.49 bpm versus 94.6±11.65 bpm versus 93.0±9.23 bpm, and in the obese group was: 92.0±15.41 bpm versus 117.6±16.31 bpm versus 92.1±12.9 bpm versus 91.8±14.33 bpm. High frequency in the overweight group was: 640±633.1 ms2 versus 84±174.66 ms2 versus 603.5±655.31 ms2 versus 762.6±807.21 ms2, and in the obese group was: 628.4±779.81 ms2 versus 65.4±119.34 ms2 versus 506.2±482.70 ms2 versus 677.9±939.05 ms2; and root mean square of successive differences in the overweight group was: 37.9±18.81 ms versus 10.9±8.41 ms versus 32.8±24.07 ms versus 36.7±21.86 ms, and in the obese group was: 38.7±23.17 ms versus 11.5±8.62 ms versus 32.3±16.74 ms versus 37.3±24.21 ms. These values significantly changed during exercise compared with resting values in overweight and obese groups. Moreover, we also reported no significant difference of resting parasympathetic control of heart rate between obese and overweight adolescents.
There was no significant difference of autonomic responses elicited by submaximal aerobic exercise between overweight and obese adolescents.
The pestiviruses bovine viral diarrhea virus 1 (BVDV-1), 2 (BVDV-2), and HoBi-like (HoBiPeV) are endemic among Brazilian cattle, the world's largest commercial bovine herd. In the last two decades (1998–2018) over 300 bovine pestiviruses have been partially or fully sequenced in Brazil, including viruses from different regions, different epidemiological backgrounds, and associated with diverse clinical presentations. Phylogenetic analysis of these viruses demonstrated a predominance of BVDV-1 (54.4%), with subgenotypes −1a (33.9% of total) and −1b (16.3%) being more frequent and subgenotypes −1d, −1e, and −1i at very low frequencies. The overall BVDV-2 frequency was 25.7% but it varied largely by region, reaching up to 48% in Southern states. BVDV-2b was the predominant subgenotype (84.8% of BVDV-2), followed by BVDV-2a (8.86%). HoBiPeV accounted for 19.9% (61/307) of the genotyped viruses and were detected at high frequency in cattle from Northeastern states. These findings demonstrate a unique mix of pestivirus species and subgenotypes, unlike that seen in Europe or North America. The design of effective diagnostic tools, vaccines, and control programs for limiting bovine pestivirus infections in Brazil must take into consideration this unique mix of viruses. This article provides a critical review of two decades of genetic identification of pestiviruses in Brazil.
The aim of this study was to evaluate the effect of nerolidol free (N-F) and nerolidol-loaded in nanospheres (N-NS) on the hepatic antioxidant/oxidant status of mice experimentally infected by Trypanosoma evansi. In the liver it was measured: reactive oxygen species (ROS), thiobarbituric reactive acid substances (TBARS) and non-protein thiols (NPSH), catalase (CAT), superoxide dismutase (SOD) and glutathione-S-transferase (GST) and performed histopathological examination. In addition, seric levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were measured. Liver samples from mice infected by T. evansi showed increased (P < 0·05) ROS, TBARS, AST and ALT levels and SOD activity, and decreased NPSH levels and CAT activity (P < 0·05) compared with uninfected animals. N-NS treatment prevented (P < 0·05) ROS and TBARS increase, and increased NPSH levels, and ameliorate CAT and SOD activities on liver of infected mice. Moreover, N-NS treatment reduced (P < 0·05) AST and ALT levels, and prevented histopathological changes caused by the parasite. N-NS protected the liver from the oxidative stress caused by T. evansi, which might be due to its antioxidant properties. Nerolidol might be considered a promising therapeutic agent against oxidative stress, and nanotechnology is an encouraging approach to be explored.
To evaluate the clinical and histopathological factors affecting the prognosis of patients with squamous cell locoregional advanced laryngeal cancer.
A retrospective chart review was conducted of 121 patients with locoregional advanced laryngeal cancer, primarily treated with surgery from 2007 to 2011. Disease-free survival and overall survival rates were analysed as oncological outcomes. Prognostic variables, namely gender, pharyngeal invasion, pathological assessment of tumour and nodal stage, adjuvant therapy, margin status, nodal extracapsular extension, tumour differentiation, lymphovascular and perineural invasion, and predominant growth pattern, were also analysed.
One-year and three-year disease-free survival rates were 81.3 per cent and 63.5 per cent, respectively. One-year and three-year overall survival rates were 88.3 per cent and 61.4 per cent, respectively. Multivariate analysis showed that nodal extracapsular extension (p < 0.05) and an infiltrative growth pattern (p < 0.05) were associated with disease progression. Nodal extracapsular extension (p < 0.05) was associated with higher mortality.
Nodal extracapsular extension and an infiltrative growth pattern were the main prognostic factors in locoregional advanced laryngeal cancer. The presence of pharyngeal invasion, pathologically confirmed node-positive stage 2–3 disease, close or microscopic positive margins, and lymphovascular and perineural invasion have a negative impact on prognosis.
The discrepancy between abundances computed using optical recombination lines (ORLs) and collisionally excited lines (CELs) is a major, unresolved problem with significant implications for the determination of chemical abundances throughout the Universe. In planetary nebulae (PNe), the most common explanation for the discrepancy is that two different gas phases coexist: a hot component with standard metallicity, and a much colder plasma enhanced in heavy elements. This dual nature is not predicted by mass loss theories, and direct observational support for it is still weak. In this work, we present our recent findings that demonstrate that the largest abundance discrepancies are associated with close binary central stars. OSIRIS-GTC tunable filter imaging of the faint O ii ORLs and MUSE-VLT deep 2D spectrophotometry confirm that O ii ORL emission is more centrally concentrated than that of [Oiii] CELs and, therefore, that the abundance discrepancy may be closely linked to binary evolution.
In order to compare estimates by one assessment scale across various cultures/ethnic groups, an important aspect that needs to be demonstrated is that its construct across these groups is invariant when measured using a similar and simultaneous approach (i.e., demonstrated cross-cultural measurement invariance). One of the methods for evaluating measurement invariance is testing for differential item functioning (DIF), which assesses whether different groups respond differently to particular items. The aim of this study was to evaluate the cross-cultural measurement invariance of the Revised Child Anxiety and Depression Scale (RCADS) in societies with different socioeconomic, cultural, and religious backgrounds.
The study was organised by the International Child Mental Health Study Group. Self-reported data were collected from adolescents residing in 11 countries: Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, Palestinian Territories, the Philippines, Portugal, Romania and Serbia. The multiple-indicators multiple-causes model was used to test the RCADS items for DIF across the countries.
Ten items exhibited DIF considering all cross-country comparisons. Only one or two items were flagged with DIF in the head-to-head comparisons, while there were three to five items flagged with DIF, when one country was compared with the others. Even with all cross-culturally non-invariant items removed from nine language versions tested, the original factor model representing six anxiety and depressive symptoms subscales was not significantly violated.
There is clear evidence that relatively small number of the RCADS items is non-invariant, especially when comparing two different cultural/ethnic groups, which indicates on its sound cross-cultural validity and suitability for cross-cultural comparisons in adolescent anxiety and depressive symptoms.