Association of Female Menopause With Atrioventricular Mechanics and Outcomes

BACKGROUND: Despite known sex differences in cardiac structure and function, little is known about how menopause and estrogen associate with atrioventricular mechanics and outcomes. OBJECTIVE: To study how, sex differences, loss of estrogen in menopause and duration of menopause, relate to atrioventricular mechanics and outcomes. METHODS: Among 4051 asymptomatic adults (49.8 ± 10.8 years, 35%women), left ventricular (LV) and left atrial (LA) mechanics were assessed using speckle-tracking. RESULTS: Post-menopausal (vs. pre-menopausal) women had similar LV ejection fraction but reduced GLS, reduced PALS, increased LA stiffness, higher LV sphericity and LV torsion (all p < 0.001). Multivariable analysis showed menopause to be associated with greater LV sphericity (0.02, 95%CI 0.01, 0.03), higher indexed LV mass (LVMi), lower mitral e’, lower LV GLS (0.37, 95%CI 0.04–0.70), higher LV torsion, larger LA volume, worse PALS (∼2.4-fold) and greater LA stiffness (0.028, 95%CI 0.01–0.05). Increasing years of menopause was associated with further reduction in GLS, markedly worse LA mechanics despite greater LV sphericity and higher torsion. Lower estradiol levels correlated with more impaired LV diastolic function, impaired LV GLS, greater LA stiffness, and increased LV sphericity and LV torsion (all p < 0.05). Approximately 5.5% (37/669) of post-menopausal women incident HF over 2.9 years of follow-up. Greater LV sphericity [adjusted hazard ratio (aHR) 1.04, 95%CI 1.00–1.07], impaired GLS (aHR 0.87, 95%CI 0.78–0.97), reduced peak left atrial longitudinal strain (PALS, aHR 0.94, 95%CI 0.90–0.99) and higher LA stiffness (aHR 10.5, 95%CI 1.69–64.6) were independently associated with the primary outcome of HF hospitalizations in post-menopause. Both PALS < 23% (aHR:1.32, 95%CI 1.01–3.49) and GLS < 16% (aHR:5.80, 95%CI 1.79–18.8) remained prognostic for the incidence of HF in post-menopausal women in dichotomous analyses, even after adjusting for confounders. Results were consistent with composite outcomes of HF hospitalizations and 1-year all-cause mortality as well. CONCLUSION: Menopause was associated with greater LV/LA remodeling and reduced LV longitudinal and LA function in women. The cardiac functional deficit with menopause and lower estradiol levels, along with their independent prognostic value post-menopause, may elucidate sex differences in heart failure further

'Thinking together' - a grass-roots project addressing an analogous experience of training issues in CAMHS and Paediatrics

Fisher and Teodorczuk highlight significant concerns in the care of the elderly population: that geriatricians are not suitably trained in mental health treatment and old age psychiatrists are similarly underprepared to recognise and manage physical health problems. They identify the unhelpful splits between services which should work hand in hand, as well as being trained side-by-side. The problem is a familiar one for those of us working at the other end of the age spectrum. With the precipitous rise in mental health problems in those under 18, paediatricians are increasingly presented with problems in which they feel they lack expertise, particularly risk management in crisis admissions with self-harm or overdose. Equally, CAMHS trainees tend to deskill rapidly and lose confidence with regards physical health issues (even those as basic as physical examinations, reading ECGs and interpreting blood tests). Both sets of trainees have a number of mandatory curricular competencies which can be difficult to come by in day-to-day practice, especially as services come under increasing strain. Just as in the elderly population, specific local services may be delivered by one specialty or another, but there is little consistency on whom leads (for example ADHD or ASD services). To solve this worsening problem, a small group of trainees from London devised a 6 month pilot scheme to link trainees from each specialty - we called this the "Thinking Together" project. The simple and cost-neutral concept was to forge links between the specialties at a trainee level, by allowing attendance and participation in each other's outpatient clinics. We hoped to foster a novel, joint way of learning and working together

Thinking together: a pilot scheme linking paediatric and CAMHS trainees to improve collaboration and address training gaps

Background: Mental health presentations are an increasing part of the paediatric caseload and there is growing evidence that paediatric trainees feel ill-equipped to manage these patients. Only 33% of trainees we surveyed felt that their current training programme enabled them to achieve their curriculum requirements in paediatrics or mental health respectively. CAMHS services are increasingly stretched, raising referral thresholds and making the need for closer working together across disciplines paramount. Aim: A working group of paediatric and psychiatry trainees developed the concept of Thinking Together, to tackle this training gap. The scheme involves pairing paediatric and CAMHS trainees to share in each other’s clinical encounters to foster a joint way of learning and working together, while fulfilling curriculum competencies that are otherwise difficult to achieve. Method: A pilot was launched in March 2016 where trainees from both specialties were paired for a period of 6 months, attending at least two clinical encounters in each setting. Curriculum competencies for both specialties were outlined in a resource pack. Trainees were encouraged to explore a variety of learning possibilities, including clinics, referral meetings and signposting their partner to other relevant clinical opportunities. Results: 30 trainees were surveyed and 16 of these completed pre and post pilot evaluation. Prior to participating in Thinking Together, 70% stated they had no experience of working in a jointly delivered paediatric/mental health clinic. 93% of participants felt that their patients benefitted from access to the jointly delivered paediatric and mental health clinics. Confidence in achieving curriculum competencies in paediatrics and mental health respectively, increased to 93% following involvement in the project. Conclusion: Our results highlighted that trainees felt they had achieved curriculum competencies in their linked specialty, while improving their capabilities in collaborative, patient-centred practice. Trainees felt the scheme benefited both their patients and themselves, thinking together through cases and developing a greater appreciation of different professionals’ roles and responsibilities. As the burden of mental health grows, with it’s irrefutable link to physical well being, we feel schemes such as ours will improve understanding for future trainees between the cross over of mind and body

Allegations of child sexual abuse in family court cases: A qualitative analysis of psychiatric evidence

Allegations of child sexual abuse in Family Court cases have gained increasing attention. The study investigates factors involved in Family Court cases involving allegations of child sexual abuse. A qualitative methodology was employed to examine Records of Judgement and Psychiatric Reports for 20 cases distilled from the data corpus of 102 cases. A seven-stage methodology was developed utilising a thematic analysis process informed by principles of grounded theory and phenomenology. The explication of eight thematic clusters was undertaken. The findings point to complex issues and dynamics in which child sexual abuse allegations have been raised. The alleging parent’s allegations of sexual abuse against their ex-partner may be: the expression of unconscious deep fears for their children’s welfare, or an action to meet their needs for personal affirmation in the context of the painful upheaval of a relationship break-up. Implications of the findings are discussed

Ernesto Maltravers

Publicado probablemente na primeira metade do século X

Thinking Together: A collaboration of pediatricians and psychiatrists to improve patient care at the mental-physical interface for children and young people

Only 33 percent of London trainees surveyed felt that their current training program enabled them to achieve curriculum requirements in pediatrics or child and adolescent mental health. Child and adolescent mental health services (CAMHS) are increasingly stretched, raising referral thresholds, and making the need for working closer together across disciplines paramount. A working group of pediatric and psychiatry trainees developed the concept of Thinking Together to tackle this training gap. The scheme involves pairing pediatric and CAMHS trainees to share in each other's clinical encounters to foster a joint way of learning and working together, while fulfilling curriculum competencies that are otherwise difficult to achieve