Gottman Processes and Couple Outcomes While Navigating Infertility

Infertility remains one of the most difficult relational contexts for couples. However, some research suggests that some couples actually increase their overall satisfaction in their relationship through infertility due to a deeply shared emotional experience. To the knowledge of the author of this dissertation, no studies exist which explain how couples arrive at their relational outcomes through the experience of infertility. These studies within this dissertation add to the present literature by explaining how couples may arrive at their relational outcome through the lens of Gottman Method Couple Therapy (GMCT). For both studies presented here, 902 participants were recruited through various social media platforms. Participants completed scales regarding their overall satisfaction in their couple relationship, their perceived relational impact of their experience of infertility, as well as the Sound Relationship House Questionnaire (SRH-Q). Various aspects of the Gottman theoretical framework were examined, including Friendship and Intimacy, Shared Meaning, and Quality Sex, Passion, and Romance. These Gottman factors were also examined as a mediator between the relationship between overall couple satisfaction and the relational impact of infertility Further, Gottman Conflict Processes were also examined as a mediator, with Gottman Conflict Management (i.e., Compromise and Effective Repair Attempts) acting as a moderator within the mediation model. Significant bivariate correlations were found between relational quality of life during infertility and overall couple satisfaction (r = .354, p \u3c .001). Friendship and Intimacy (β = .066), Shared Meaning (β = .191), and Quality Sex, Passion, and Romance (β = .155), along with Gottman Conflict Processes (β = .016), were all found to be mediators between relational quality of life during infertility and couple satisfaction. However, Gottman Conflict Management was found to moderate the relationship between quality of life during infertility and Gottman Conflict Processes within the moderated mediation model. Thus, Gottman couple therapy processes provided pathways to explain how couples within this sample arrived at their outcomes amidst infertility. Future directions for research will be discussed, as well as clinical implications and specific Gottman interventions for GMCT with this special population

Enterobacter Bacteremia Secondary to Pyelonephritis

INTRODUCTION: Pyelonephritis, an infection of the kidney, occurs in 16/10,000 women in the U.S. The rate in pregnancy is 2% versus 1% in the general population. Escherichia coli is the most common cause of pyelonephritis. Enterobacter is identified in <3% of cases. Fifteen percent of women with pyelonephritis develop bacteremia. We present a case of acute pyelonephritis in a postpartum patient who developed Enterobacter bacteremia and sepsis. CASE DESCRIPTION: Previously healthy 16-year-old female presented to ED with acutely worsening back pain and fever 3 days after vaginal birth to a healthy baby. She reported back pain for several weeks but contributed it to pregnancy. On arrival, she was tachycardic, febrile and initial labs showed WBC of 17,000 and UA suggestive of infection. CXR was normal. Blood and urine cultures were obtained. IV sulfamethoxazole/trimethoprim was started; a fluid bolus given. Over 24 hours, she became more ill and preliminary blood cultures were positive for gram-positive cocci. Antibiotic coverage was expanded to vancomycin and piperacillin/tazobactam. Kidney ultrasound showed possible pyelonephritis. Urine cultures grew Enterobacter with blood cultures positive for methicillin-sensitive Staphylococcus aureus and Enterobacter. Antibiotics were changed to cefazolin and piperacillin/tazobactam. After 48 hours, she remained tachycardic and febrile. Abdominal CT showed only kidney changes consistent with pyelonephritis. Infectious Disease was consulted and recommended meropenem and cefazolin. The next blood cultures were negative at 48 hours. Clinical improvement occurred over the next several days. She was discharged with PICC line for outpatient administration of antibiotic regimen for two more weeks. Follow-up with Infectious Disease and weekly CMP, CBC, ESR and CRP was scheduled. DISCUSSION: This case of postpartum pyelonephritis was complicated in many aspects. The patient’s recent pregnancy created delay in care as back pain and UTI symptoms were easily mistaken for pregnancy/postpartum-associated pain. The UTI developed into pyelonephritis and eventually bacteremia. The initial antibiotic regimen, targeted at UTI, proved ineffective against the pyelonephritis and bacteremia. Additionally, although only one culture grew MSSA, the antibiotic course should have covered it due to high virulence and associated morbidity. Many surrounding circumstances made this a difficult case. Although recommendations are to use antibiotics targeted at the likely infection, when treating sepsis, broad spectrum coverage should not be narrowed without ruling out blood stream infection. Due to her recent delivery and associated pain from pregnancy, this patient presented late with her condition, which allowed for a severe and life-threatening illness.N

Proton Therapy for Head and Neck Adenoid Cystic Carcinoma: Initial Clinical Outcomes

Background The purpose of this study was to report outcomes of proton therapy in head and neck adenoid cystic carcinoma. Methods We conducted a retrospective analysis of 26 patients treated between 2004 and 2012. Twenty patients (77%) had base of skull involvement; 19 (73%) were treated for initial disease and 7 (27%) for recurrent disease. Twenty patients were treated postoperatively, 6 after biopsy alone and 24 had positive margins or gross residual disease. Median dose delivered was 72 Gy (relative biological effectiveness [RBE]). Results Median follow-up was 25 months (range, 7–50 months). The 2-year overall survival was 93% for initial disease course and 57% for recurrent disease (p = .19). The 2-year local control was 95% for initial disease and 86% for recurrent disease (p = .48). The 2-year distant metastatic rate was 25%. Late toxicity of grade 0 or 1 was seen in 17 patients, grade 2 in 5, grade 3 in 2, grade 4 in 1, and grade 5 in 1. Conclusion Initial outcomes of proton therapy are encouraging. Longer follow-up is required

Zuber-Jarrell House

Prepared by the Fall 1994 Conservation of Historic Building Materials class. This Historic Structure Report contains the history of the Zuber-Jarrell House, the existing conditions of the interior, exterior, infrastructure and grounds of the home, and a master plan of recommendations for the site. The main purpose of this report is to provide a restoration and management plan (presented in Section 3.0) that responds to both the historic character of the property as well as to the intentions expressed by its owner.https://scholarworks.gsu.edu/history_heritagepreservation/1046/thumbnail.jp

Ability of the National Surgical Quality Improvement Program Risk Calculator to Predict Complications Following Total Laryngectomy

Importance The accuracy of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) risk calculator has been assessed in multiple surgical subspecialties; however, there have been no publications doing the same in the head and neck surgery literature. Objective To evaluate the accuracy of the calculator’s predictions in a single institution’s total laryngectomy (TL) population. Design, Setting, and Participants Total laryngectomies performed between 2013 and 2014 at a tertiary referral academic center were evaluated using the risk calculator. Predicted 30-day outcomes were compared with observed outcomes for return to operating room, surgical site infection, postoperative pneumonia, length of stay, and venous thromboembolism. Main Outcomes and Measures Comparison of the NSQIP risk calculator’s predicted postoperative complication rates and length of stay to what occurred in this patient cohort using percent error, Brier scores, area under the receiver operating characteristic curve, and Pearson correlation analysis. Results Of 49 patients undergoing TL, the mean (SD) age at operation was 59 (9.3) years, with 67% male. The risk calculator had limited efficacy predicting perioperative complications in this group of patients undergoing TL with or without free tissue reconstruction or preoperative chemoradiation or radiation therapy with a few exceptions. The calculator overestimated the occurrence of pneumonia by 165%, but underestimated surgical site infection by 7%, return to operating room by 24%, and length of stay by 13%. The calculator had good sensitivity and specificity of predicting surgical site infection for patients undergoing TL with free flap reconstruction (area under the curve, 0.83). For all other subgroups, however, the calculator had poor sensitivity and specificity for predicting complications. Conclusions and Relevance The risk calculator has limited utility for predicting perioperative complications in patients undergoing TL. This is likely due to the complexity of the treatment of patients with head and neck cancer and factors not taken into account when calculating a patient’s risk

Measurement issues: measures of infant mental health

Background: Emotional and behavioural problems emerging in very young children can represent a challenge to the child and family and warrant early identification and appropriate support or intervention. Diagnostic systems are being developed that allow for specific difficulties to be identified and this review summarises them. The review describes the psychometric properties and potential for use in clinical practice of a range of instruments and methods that are available to identify infant mental health difficulties, and which may be suitable for use in primary care settings, including observations, questionnaires and checklists. Conclusions: While debate continues about whether infant mental health problems can or should be identified, the use of standardised tools may help clinicians to compare observations of infants so that those emerging as atypical can receive additional attention, reflecting a more targeted approach to primary care services (DH 2009; DH 2010)

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis.

BACKGROUND: Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems. OBJECTIVES: To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment. STUDY DESIGN: For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views. PARTICIPANTS: Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months. INTERVENTIONS: Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment. MAIN OUTCOME MEASURES: Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability. METHODS: Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible. RESULTS: We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself. CONCLUSIONS: It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions. LIMITATIONS: Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses. FUTURE WORK: Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013003889. FUNDING: The National Institute for Health Research Health Technology Assessment programme

Treatment of obstructive sleep apnea in children

Obstructive sleep apnea (OSA) in children is a frequent disease for which optimal diagnostic methods are still being defined. Treatment of OSA in children should include providing space, improving craniofacial growth, resolving all symptoms, and preventing the development of the disease in the adult years. Adenotonsillectomy (T&A) has been the treatment of choice and thought to solve young patient's OSA problem, which is not the case for most adults. Recent reports showed success rates that vary from 27.2% to 82.9%. Children snoring regularly generally have a narrow maxilla compared to children who do not snore. The impairment of nasal breathing with increased nasal resistance has a well-documented negative impact on early childhood maxilla-mandibular development, making the upper airway smaller and might lead to adult OSA. Surgery in young children should be performed as early as possible to prevent the resulting morphologic changes and neurobehavioral, cardiovascular, endocrine, and metabolic complications. Close postoperative follow-up to monitor for residual disease is equally important. As the proportion of obese children has been increasing recently, parents should be informed about the weight gain after T&A. Multidisciplinary evaluation of the anatomic abnormalities in children with OSA leads to better overall treatment outcome