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Maternal hypothalamic-pituitary-adrenal (HPA) axis activity may prenatally program sex-specific stress response pathways. We investigated associations between maternal cortisol during pregnancy and infant parasympathetic responsivity to stress among 204 mother-infant pairs. Cortisol indices included 3(rd) trimester hair cortisol, as well as diurnal slope and area under the curve, derived from saliva samples collected during pregnancy. Mother-infant dyads participated in the Repeated Still-Face Paradigm (SFP-R) at age 6 months. We calculated respiration-adjusted respiratory sinus arrhythmia (RSA(c)), an indicator of parasympathetic activation, from infant respiration and cardiac activity measured during the SFP-R. We used multivariable linear mixed models to examine each cortisol index in relation to infant RSA(c) and investigated sex differences using cross-product terms. Diurnal cortisol indices were not associated with RSA(c). There was no association between hair cortisol and baseline RSA(c). However, hair cortisol was associated with sex-specific changes in RSA(c) over the SFP-R such that, among girls, parasympathetic withdrawal was reduced with increasing prenatal exposure to cortisol. Consistently higher levels of prenatal cortisol exposure may lead to dampened parasympathetic responsivity to stress during infancy, particularly among girls. Maternal hair cortisol may be particularly valuable for studying the effects of prenatal cortisol exposure on infant autonomic reactivity.

To analyse any delays in breast cancer diagnosis and surgical treatment, influence of clinical and biological factors and influence of delays on survival. A descriptive, observational, and retrospective study was conducted between 2006 and 2016 on stages I–III breast cancer patients. This is a retrospective review of health records to collect data on delays, patients’ clinical data, biological features of the tumour and information on treatment. Mortality data from the National Death Index. In 493 evaluable patients, the median of days from the first symptom to mammography, biopsy, and surgery was 41, 57, and 92, respectively. The median of days from screening mammography to biopsy and surgery was 10 and 51, respectively. From biopsy to surgery, the median was 34 days in every case. Over the last 5 years, an increase in biopsy–surgery delay has been observed (p = 0.0001). Tumour stages I and II vs. stage III (RR 1.74. 95% CI 1.08–2.80, p = 0.027), diagnosis in screening (RR 0.66. 95% CI 0.45–0.96, p = 0.030), and use of magnetic resonance imaging (RR 2.08. 95 CI 1.21–3.56, p = 0.008) condition a greater biopsy–surgery delay. No influence of delays on survival has been identified. Delays in diagnosis and surgery in the case of women diagnosed on the basis of symptoms may be improved. There is a temporary tendency to a greater delay in surgery. Some clinical and biological factors must be taken into account to optimise delays. Survival results are not adversely affected by delays.

Background The universalisation of mammographic screening has caused an increase in ultralow risk breast cancer diagnosis. Identifying subgroups with no events related to mortality due to breast cancer in the long term (overdiagnosis) may be useful so as not to subject them to unnecessary treatment (overtreatment). Methods New ultralow risk criteria are described by means of mammographic screening diagnosis, tumour palpability, tumour phenotype, and absence of axillary node involvement. We identified patients with no events related to breast cancer mortality through a descriptive, observational, and retrospective study. Results Among the 746 patients with stage I and IIA breast cancer attended between 1/1/2001 and 31/12/2014, 110 (14.75%) came from mammographic screening with non-palpable tumours. The median age was 58 years old (38-71). 88 (80%) were hormone receptor positive (HR+), 10 (9.10%) were triple negatives, and 11 (10%) were HER-2. The median follow-up was 10 years (3.5-17). Only 3 patients developed metastasis, there were no loco-regional recurrence, 7 showed second primary tumours, and there were 4 deaths, 2 due to breast cancer and 2 due to other reasons. Overall survival (OS) was 92.80%, disease-free survival (DFS) was 85.20%, and the distant metastasis-free interval (DMFI) was 95.60%. In 88 patients with HR+ tumours, OS was 95.7%, DFS was 86.50%, and DMFI was 96.30%. In 34 (38.60%) histological grade 1 HR+ tumours (probably Luminal A), and in 54 (61.40%) histological grade 2-3 HR+ tumours (probably Luminal B), OS was 93.80% and 96.90% (p = 0.669), DFS was 81.90% and 89.30% (p = 0.400), and DMFI was 100% and 94.40% (p = 0.307). In triple negatives, OS was 85.70%, DFS 77.10%, and DMFI was 100%. In subgroup HER-2, there were no events. In tumours smaller and larger than 1 cm, OS was 100% and 90.20% (p = 0.168), DFS was 93.20% and 84.10% (p = 0.742), and DMFI was 100% and 95.50% (p = 0.296). Conclusions Patients with non-palpable tumours detected in mammographic screening have an ultralow risk. The absence of events related to breast cancer mortality makes them candidates for overdiagnosis. De-escalation of treatment should be considered. The authors will incorporate genomic risk to optimise the identification of overdiagnosis. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

Hospitals have traditionally been the place where the follow-up of breast cancer patients occurs in Spain.To describe the evolution of long-term survivors of breast cancer according to type of follow-up received (in primary or specialist/hospital care), measuring impact of care type on health, cost, health-related quality of life (HRQL) and satisfaction results.Retrospective study of cohorts with disease-free patients followed up for at least 5 years in Oncology. Using personal questionnaires, the type and cost of the follow-up, events, HRQL and satisfaction were analysed.Ninety-eight women were surveyed, 60 in primary and 38 in specialist care. There were no differences between groups in diagnosis of metastasis or new primary tumours. The number of annual visits per patient was 0.98 (0.48) in primary and 1.11 (0.38) in specialist care (P = 0.19). In primary, 44.6% were programmed and 55.4% on demand; in specialist, 94.6% were programmed and 5.4% on demand (P = 0.0001). The costs of follow-up in primary care were lower--€112.86 (77.54) versus €184.61 (85.87) per patient and year (P = 0.0001). No differences were reported in HRQL. Preference for specialist care was expressed by 80%, versus 10% for primary, with 10% indifferent. Patients showed greater satisfaction with specialist care in all questionnaire dimensions.Compliance with follow-up protocol was high in both groups. In specialist care nearly all the visits were programmed and in primary almost half were on demand. In our locality, primary is more cost-effective than specialist care, but patients express greater satisfaction with specialist follow-up and hence prefer it.

Aim of the study The authors analyse the effect of chemotherapy on the use of additional health-care resources and report the clinical and demographic factors associated with such use. Patients and methods In women with breast cancer, eligible to receive first-line (neo)-adjuvant or palliative chemotherapy, consultations with health-care practitioners (general practitioners [GPs] and specialists) and admissions to emergency department and to hospital were prospectively recorded. Differences were studied according to these clinical and demographic variables: age, tumour stage, performance status, weight, height, body mass index, surgery type, chemotherapy type, number of courses, comorbidity, marital status, educational level, social status and occupational status. Results Among 268 patients, 124 (42.2%) required one or more non-protocol health-care encounters. 180 visits were generated (GP 23.3%, specialist 35.5%, emergency department admission 21.1%, hospital admission 8.3%, others 3.3% and more than one resource 8.3%). Of total consultations 150 (83.3%) were chemotherapy-related. The number of visits was higher in the first courses. Fever and infection were the most frequent reasons for consultation in all resources. The dependent variable: ‘need for non-protocol health-care encounter in any course' was statistically associated with age ( p =0.002) and marital status ( p =0.021); no association was found with other variables. In multivariate analysis, age ( p =0.001) and marital status ( p =0.009) remained statistically significant. Younger and married patients consumed less extra health resources. Concluding statement Many patients receiving chemotherapy consume health-care resources in addition to their routine visits, usually treatment-related. Patients consult less in the later courses. Older and unmarried women in particular need extra care during chemotherapy.

Treatment of unruptured intracranial aneurysms based on critical size and predictive risk factors is generally accepted, but several factors contribute to the clinical outcome in a patient with subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm. We decided to evaluate other parameters that might contribute to the clinical outcome of patients with a ruptured posterior communicating artery aneurysm. A retrospective review of the medical records of patients diagnosed and/or treated of cerebral aneurysms at our institution was carried out. We selected patients with Pcom aneurysms that presented with SAH and reviewed conventional and tridimensional angiographic images to determine its anatomical orientation and correlated the data with amount of SAH and clinical presentation and outcome. A total of 112 Pcom aneurysms presented with SAH and were included in this study. 92 patients were women and 20 were men, with a mean age of 57 years (range 25–81). According to anatomical orientation, 43 were inferolateral, 30 lateral, 13 superolateral, three inferomedial, two in medial location, two superomedial, 11 inferoposterior, five posterior and three superoposterior. Aneurysms in superolateral location are to be watched carefully, it is likely that this location joins several conditions for these aneurysms to grow faster or have a higher hemodynamic stress which makes them more at risk of rupture and contribute to a worse clinical outcome.

The objective of this study was to assess the factors implicated in an increased or decreased risk of pneumonia, with particular attention to the response to highly active antiretroviral therapy (HAART) and the effect of the polysaccharide 23-valent pneumococcal vaccination in 300 human immunodeficiency virus (HIV)-infected adults followed-up for a median of 35.6 months. Pneumococcal pneumonia occurred in 12 patients and all bacterial pneumonia (pneumonia caused by Streptococcus pneumoniae or other bacteria, as well as those with negative cultures but presumably bacterial in origin) in 40 patients. In the univariate analysis, immunodepressed patients (defined as those with less than 200 CD4+ T cell/microl), those without immunological response to HAART (defined as an increase of 25% of CD4+ T lymphocyte count), patients with previous admissions to hospital and those with cotrimoxazole or Mycobacterium avium intracellulare prophylaxis showed a higher incidence of both pneumococcal and all bacterial pneumonia. Multivariate analysis demonstrated that the presence of pneumococcal pneumonia was associated with a CD4+ lymphocyte count at the time of HIV diagnosis

Patient of 32 years old, sent to the psychiatric unit, because he had an aggressive behaviour after he suffered a car accident with a traumatic brain injury. The patient had a huge amount of problems with family, friends and even with police (even being in jail), due to the impulsive conduct the brain injury had created. It was added a self-referential, which produced a disruptive behaviour that he could not avoid, when someone looked at him in a strange way or was not agreeing with him. After the aggressive response, he regretted of his actions, getting to try to commit suicide in several times. It was decided, reaching to an agreement with the patient, to use the paliperidone palmitate long-acting injectable. After the first dose, the patient began to be more serene and calm, the aggressive conducts were reducing until being disappeared, improving his mood and reaching a normal life, with a better relationships with his family and social environment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Fundamentos: la prevalencia de fobia social en la población general oscila entre el 8-15,6%, considerándose un trastorno de ansiedad infradiagnosticada. Se desconoce su prevalencia en personal sanitario, quien precisa de realizar actividades de educación a la comunidad y de comunicación científica. Objetivos: determinar la prevalencia de síntomas relacionados con fobia social en personal sanitario. Diseño: observacional, descriptivo transversal. Ámbito de estudio: distrito sanitario de Atención Primaria. Sujetos: se incluyen como participantes personal sanitario (médico y enfermero) con ejercicio en 15 centros de salud. Mediciones: se solicita cumplimentación, de forma anónima y voluntaria, de un cuestionario elaborado al efecto, escalas de ansiedad social de Liebowitz (LSAS) y de ansiedad/depresión de Goldberg (EADG) al personal médico y de enfermería trabajadores de 13 centros de salud, en un distrito sanitario de Atención Primaria (población a estudio = 266 sujetos). Resultados: grado de respuesta del 39% (n=104). Se detectó ansiedad social grave en el 1,8% de los casos (2 individuos), moderada en el 25,7% (22 individuos) y leve o no patológica en el 76,5% (80 individuos). Para el conjunto global de profesionales a estudio, se detecta coexistencia entre síntomas relacionados con fobia social y subescalas de la EADG para la ansiedad y depresión con significación estadística (p

Aim: In Spain women do not make an informed choice on participation in breast cancer screening. The aim of the study was to evaluate the influence of receiving adequate information on the real benefits and risks of mammography on the level of knowledge of participants in the screening program, and how such information might influence the participants' attitude, decision to participate, anxiety/depression, and worries about cancer. Methods: A randomized, controlled clinical trial was conducted in a Mammography Screening Program Centre in one local Health District in Spain. 434 women aged between 45 and 69 years called for mammography screening were randomly assigned, 216 to the intervention group (IG), 218 to the control group (CG). Of these 355 were analysed, 177 in the IG and 178 in the CG. At the first interview they received either the information contained in the document created by the Nordic Cochrane Centre on breast cancer screening or the standard information of the program. Specific questionnaires were administered in the second interview within a month. The principal objective was to evaluate participants' level of knowledge on benefits and risks of mammography screening. Secondary objectives were to assess their attitude, decision, anxiety and depression, and worry about cancer (this last item was analysed only in 62 and 59 women respectively due to being included later in the study). Results: Good knowledge was acquired by 32 of 177 women (18.10%) in the IG, and by 15 of 178 (8.40%) in the CG (p = 0.008). Women of the IG have a relative risk of acquiring good knowledge 2.39 times greater than those of the CG (95% confidence interval 1.24–4.60). No differences were found in any of the secondary objectives. Basic characteristics of the participants in the control and intervention groups Characteristics Standard information group N(%) Experimental information group N (%) p value Score on the knowledge questionnaire. Mean (SD) 2.97 (1.08) 2.96 (1.23) 0.930 Score on the attitude questionnaire. Mean (SD) 3.17 (2.69) 3.26 (2.62) 0.720 Score on the Hospital Anxiety and Depression Scale. Mean (SD) Anxiety Depression 1.94 (3.52) 1.78 (3.00) 0.620 0.76 (2.15) 0.69 (1.84) 0.710 Score on the Cancer Worry Scale. Mean (SD) 9.92 (3.28) 8.87 (2.69) 0.056 Decision Decided 218 (100) 216 (100) 1.000 Conclusions: Women receiving information based on the Nordic Cochrane Centre document were better informed. This means of providing information on mammography screening is not very efficacious for helping women to decide, nor does it modify attitude, decision, feelings or worries about cancer. Disclosure: All authors have declared no conflicts of interest.

Aim: Participants in breast cancer screening programmes may benefit from early detection but may also be exposed to the risks of overdiagnosis and false positives. Women usually accept the invitation to participate in screening programmes, yet receive little information, with most women deciding to participate on the basis of convenience, gratitude or trust in the welfare state, rather than on the basis of a benefit-risk assessment. We surveyed a sample of Spanish women to assess knowledge, information sources, attitudes and psychosocial impact. Methods: 434 breast cancer screening programme participants aged 45-69 years were administered questionnaires regarding knowledge, information sources, attitudes and psychosocial impact. Scores of 5 or more (out of 10) and 12 or more (out of 24) were established as indicating adequate knowledge and a positive attitude, respectively. Psychosocial impact was measured using the Hospital Anxiety and Depression Scale and the Cancer Worry Scale. Results: Only 42 women (9.7%) had adequate knowledge. The mean knowledge score was 2.97 (1.16). Women with compared to women without experience of false positives were less knowledgeable (RR, 0.21 (0.05-0.90); P = 0.03). Better educated compared to minimally educated women were more knowledgeable (RR, 3.33 (1.68-6.62); P = 0.001). Employed, unemployed and retired women were more knowledgeable than homemakers (RR, 2.15 (1.05-4.41); P = 0.03). Only previous false positives and education level were significant in the multivariate model. The main sources of information were television, press, Andalusian Health Service documentation and family and friends. Most participants (99.1%) had a positive attitude, with a mean score of 3.21 (2.66). Mean anxiety, depression and cancer worry scores were 1.86 (3.26), 0.72 (1.99) and 9.4 (3.04). Conclusions: Spanish women have a very positive attitude to breast cancer screening, but are poorly informed and use television as their main information source. They experience no negative psychosocial impact from participation in breast cancer screening programmes. Improving the information provided to women in the interest of informed decision making should be prioritized. Disclosure: J. Nieto-Vera: JNV worked as epidemiologist in the Screening Program in the previous 3 years; there are no other relationships or activities that could appear to have influenced the submitted work. All other authors have declared no conflicts of interest.

IntroductionShared psychotic disorder (DSM-IV-TR) or induced delusional disorder (ICD-10) is a condition involving the appearance of delusions to two or more subjects who generally live in close proximity. We compare three cases and their management described in Ramón y Cajal Hospital in Madrid.Clinical casesThe first case involves a mother and daughter shared delusion of injury with respect to the neighborhood. In the second case involves two sisters living together, with delusion of persecution and prejudice and without psychiatric history. The third one was admitted to our unit after a suicide attempts. It was a middle-aged man who shared with four members of his family the perception of supernatural entities in his home.ManagementAt the first and second cases it was necessary mechanical and pharmacological restraint. One of the therapeutic indications is the separation of subjects and It generated significant moments of tension and resources of the emergency department. In the third case was not accurate mechanical and pharmacological restraint. The most effective in this case was the regulation of sleep-wake cycle and separation of the individual during a time of home and family. In all three cases the perception of illness worked individually and kept contact with the therapists to plan responsible for monitoring the treatment plan and management in the future.ConclusionsWe must be prepared before the arrival of an event of this kind to the emergency of the hospital.It's necessary to elaborate an effective joint therapeutic strategy both during their hospital stay or as outpatients.

IntroductionDementia is an acquired syndrome of organic nature, characterized by permanent impairment of memory and other intellectual functions, often associated with psychological and behavioral symptoms without impairment of consciousness. There are psychopathological manifestations.There are different subtypes of dementia. To determine a mild cognitive impairment, the average score of Minimental scale test must be between 21 and 26.Clinical evidenceIt has been shown that patients with cognitive impairment have a decreased activity of acetylcholine and increased activity of glutamate. Therefore there is a decline in cognitive ability with significant memory impairment and increased aurousal. There is an impairment of cognitive function to perceive, process and use information, which contributes, along with the intelligence, plan and solve problems, learn from the experience, plan tasks and predict results.HypothesisFor this postulate two fundamental ways in the treatment by use of cholinesterase inhibitors using memantine that blocks NMDA receptors.ConclusionsHowever in mild cognitive impairment there is no evidence that these treatments improve patient outcome. Therefore we start treatment with cholinesterase inhibitors when Minimental score between 14 and 24. We'll use cholinesterase inhibitors in combination with memantine when the Minimental score between 10 and 14. We will use only memantine when the score between 3-14. It has been shown that only 30% of mild cognitive impairment progress to dementia. It is important to consider the use of these treatments because it is'nt shown a clear benefit in mild cognitive impairment and have side effects.

Introduction:Induced delusional disorder (also known as shared paranoid disorder or folie à deux) is an uncommon disturbance characterized by the presence of similar psychotic symptoms in two or more individuals. Most commonly a primary case can be distinguished from other one or more cases, in whom the symptoms are induced. the patients implied in the shared delusional symptoms are frequently linked by close relationship bonds, mostly family ties. Its epidemiology remains unclear, because very few data is available. There are some requirements concerning the persons involved for the development of this disorder:1.Close coexistence and intimate emotional links between the two people are observed;2.The delusional content is plausible and can be based on past events or expectations;3.Typically, the induced individual has an easily influenciable personality.Case report:We describe and comment one case of shared paranoid disorder between a 29 year old schizophrenic patient and her 43 years old sister. both share a persecution and prejudice delusion involving the Chinese community of their hometown. after a few days of inward treatment at separated psychiatric wards, the delusional symptoms in the older sister started to improve.Conclusion:Our intention is making a review on a diagnosis that remains controversial nowadays. Treatment should begin with the separation of the induced and the inducer. Anyhow, a psychopharmacological treatment is required in both individuals. It seems clear, however, that the prognosis of the induced and the inducer is different, according to a variety of factors.

Introduction:Ramón y Cajal Hospital is the reference centre for Madrid-Barajas airport. Passengers at the airport who need medical assistance are brought to this hospital. A percentage of these passengers require psychiatric evaluation and frequently need to stay inward for a certain term.Objective:Calculate the approximate costs derived from the inward stay at the Psychiatry ward of patients referred from Madrid-Barajas airport.Methods:Revise retrospectively clinical histories of inward psychiatric patients referred from Barajas airport in the last 5 years. The Department of Economic management of the hospital has provided the costs of stay at the Psychiatry ward for the year 2007 (395 euros per day). Data is analyzed using the SPSS software 15.0 version.Results:The average stay of these patients is 13.96 days. Then, the average cost is 5514.2 euros. Extrapolating these data to our sample, we notice that being the reference centre for an international airport supposes an estimated cost of 545.905.8 euros (109181.16 per year) due to inward stay of psychiatric patients.Conclusion:The psychiatric attention to the airport population represents an economic extra charge that has an impact on the hospital and the National Health System. We only expose the charge derived from inward stay. To obtain a more realistic overall result we should add the costs of the attention at the emergency room to the result above.

Background In anti-phospholipase A2 receptor (PLA2R) membranous nephropathy (MN) there is controversy whether spontaneous remission (SR) can be predicted using a single titre or by assessing the dynamic changes in anti-PLA2R antibody (ab) titres. The study objective was to identify the optimal dynamics of anti-PLA2Rab titres to predict SR in MN. Methods A total of 127 nephrotic patients with anti-PLA2R-MN were prospectively followed up for 6 months under conservative treatment. Anti-PLA2Rabs and proteinuria were assessed at diagnosis and monthly thereafter. The primary endpoint (PEP) was a reduction of proteinuria ≥50% at 6 months. Logistic models with baseline and evolutive anti-PLA2Rab titres were developed to predict the PEP. Results A total of 28 patients (22%) reached the PEP. These patients were more frequently female and had significantly lower baseline proteinuria and anti-PLA2Rab titres. An anti-PLA2R titre ≤97.5 RU/mL at diagnosis had a sensitivity of 71% and a specificity of 81% to predict the PEP. The model including baseline anti-PLA2Rabs and a reduction ≥15% at 3 months predicted the PEP with a sensitivity of 93% and a specificity of 80%, with an area under the curve that was significantly greater than that obtained with relative changes of proteinuria in the same period of time {odds ratio [OR] 0.95 [95% confidence interval (CI) 0.91–0.98 versus OR 0.79 [95% CI 0.70–0.88], respectively; P = 0.0013}. Conclusions Combining the baseline anti-PLA2Rab titres with their relative changes at 3 months after diagnosis gives the earliest prediction for achieving a reduction of urinary protein excretion ≥50% at 6 months in MN, thereby shortening the observation period currently recommended to make individualized decisions to start immunosuppressive therapy., Graphical Abstract Graphical Abstract