Background: Prenatal alcohol consumption is one of the leading preventable causes of birth defects, including fetal alcohol syndrome and learning disabilities. Although there is strong evidence of the benefits of screening and alcohol brief interventions (ABIs) in reducing hazardous and harmful drinking among the primary care population, evidence of its effectiveness with the antenatal care population is limited. Nevertheless, the Scottish Government is incorporating an alcohol screening and ABI programme as part of the routine antenatal care provided to women in a bid to protect the health and safety of the unborn child and improve subsequent health and developmental outcomes. This research therefore seeks to increase understanding of the factors that are likely to influence the effectiveness of this recently implemented programme. It also aims to explore the extent to which contemporary issues such as change in guidelines regarding alcohol consumption during pregnancy influences perceptions and attitudes, and the possible implications of these on the screening and ABI delivery. Methods: The study described in this thesis employed a realistic evaluation methodology. Realistic evaluation is a theory-driven approach to investigating social programmes. It is concerned with hypothesising, testing and refining programme theories by exploring the interaction of contexts, mechanisms and outcomes. To identify the relevant screening and ABI programme theories, two separate systematic reviews, a critical review and four face-to-face interviews were undertaken with health policy implementers. The findings were used to construct context, mechanism and outcomes propositions. The propositions were then tested by conducting individual interviews with seventeen pregnant women and fifteen midwives, a further six midwifery team leaders were involved in a focus group discussion. A thematic approach using a hybrid of inductive and deductive coding and theme development informed the qualitative analysis. Results: In the context of uncertainties regarding the threshold of drinking that causes fetal harm, pregnant women reported that screening assessment helped them to reflect on their drinking behaviour and facilitate behaviour change. For women who drank at hazardous and harmful levels before attending the booking appointment, screening and ABI may be helpful in terms of eliciting behaviour change. However, they may not be very beneficial in terms of reducing harm to the fetus as it has been found that drinking during the first trimester poses the most risk to the fetus. Training and resources provided to midwives as part of the screening and ABI programme were found to be facilitating mechanisms that midwives indicated improved their skills and confidence. However, most of the midwives had not subsequently employed the motivational interviewing skills required for the ABI delivery, as many of the pregnant women reported that they reduced or abstained from alcohol consumption once pregnancy was confirmed. The outcome noted was that midwives confidence decreased leading to missed opportunities to appropriately deliver the ABI to eligible women. The small numbers of women being identified for ABI meant midwives rarely delivered the ABI. This negatively influenced midwives attitudes as they then accorded ABI low priority in their workload. Other disenabling mechanisms noted to be hampering the implementation of the screening and ABI initiative included midwives contending with competing priorities at the booking appointments, and the lack of adequate rapport between midwives and pregnant women at the booking appointment to discuss alcohol issues appropriately, leading to women providing socially desirable responses to screening questions. Conclusions: The findings of this study has generated greater explanations of the working of the screening and ABI programme in antenatal care setting and has provided transferable lessons that can be used by others intending to implement similar programmes in other settings.

No description available.

The effects from prenatal alcohol exposure have been found to cause a range of congenital physical and cognitive abnormalities (Chasnoff, Wells, Telford, Schmidt, & Messer, 2010; Kable & Coles, 2004a). The neurological impairments associated with the effects from prenatal alcohol exposure often cause learning problems, most notably in mathematics (Kable & Coles, 2004a; Howell et al., 2006). Studies have indicated that when provided instructional interventions in mathematics, children affected by prenatal alcohol exposure made gains in learning. However, the studies did not provide specifics as to how children with FAS construct the understanding of a skill or concept (Kable, Coles, & Taddeo, 2007; Coles, Kable, & Taddeo, 2009). This study contributes to the literature by examining how children affected by prenatal alcohol exposure learn the concept of equivalence through their use of gestures in contrast to their learning outcomes. Previous studies have shown that children’s use of gestures while learning mathematics assist with the integration of verbal and visual stimuli, support concept formation, and facilitate flexible encoding of problems (Goldin-Meadow, Cook, & Mitchell, 2009; McNeil & Alibali, 2004). The results from this study indicated that children in the Alcohol Exposed group showed little to no learning after the intervention as compared to a control group matched by age and IQ. The study showed that children affected by prenatal alcohol exposure used fewer conceptual gestures while learning equivalence as compared to a control group. According to the gesture analysis, the children in the Alcohol Exposed group mentally represented the concept of equivalence as a series of isolated steps or procedures. The procedural representation was not transitioned into a flexible conceptual format and applied to solve different problem types accurately (McNeil & Alibali, 2004). Future studies need to investigate whether teaching children affected by prenatal alcohol exposure to gesture during mathematics instruction would be effective to increase concept formation, accurate encoding, and learning mathematics / Inclusive Education / D. Ed. (Inclusive Education)

A grande prevalência do consumo de álcool por mulheres em idade reprodutiva aliada à gravidez não planejada expõe a gestante a um elevado risco de se alcoolizar em algum momento da gestação, principalmente no início do período gestacional em que a maioria delas ainda não tomou ciência do fato. Assim, torna-se extremamente relevante o desenvolvimento de métodos de detecção precoce de recém-nascidos em risco de desenvolvimento de problemas do espectro dos transtornos relacionados à exposição fetal ao álcool. O objetivo desse estudo foi desenvolver, validar e avaliar a eficácia de um método de quantificação de ésteres etílicos de ácidos graxos (FAEEs) no mecônio de recém-nascidos para avaliação da exposição fetal ao álcool. Os FAEEs avaliados foram: palmitato de etila, estearato de etila, oleato de etila e linoleato de etila.O método consistiu no preparo das amostras pela extração líquido-líquido utilizando água, acetona e hexano, seguida de extração em fase sólida empregando cartuchos de aminopropilsilica. A separação e quantificação dos analitos foi realizada por cromatografia em fase gasosa acoplada à espectrometria de massas. Os limites de quantificação (LQ) variaram entre 50-100ng/g. A curva de calibração foi linear de LQ até 2000ng/g para todos os analitos. A recuperação variou de 69,79% a 106,57%. Os analitos demonstraram estabilidade no ensaio de pós-processamento e em solução. O método foi aplicado em amostras de mecônio de 160 recém-nascidos recrutados em uma maternidade pública de Ribeirão Preto-SP. O consumo de álcool materno foi reportado utilizando questionários de rastreamento validados T-ACE e AUDIT e relatos retrospectivos da quantidade e frequência de álcool consumida ao longo da gestação. A eficácia do método analítico em identificar os casos positivos foi determinada pela curva Receiver Operating Characteristic (ROC). O consumo alcoólico de risco foi identificado pelo T-ACE em 31,3% das participantes e 50% reportaram o uso de álcool durante a gestação. 51,3% dos recém-nascidos apresentaram FAEEs em seu mecônio, sendo que 33,1% apresentaram altas concentrações para a somatória dos FAEEs (maior que 500ng/g), compatível com um consumo abusivo de álcool. O oleato de etila foi o biomarcador mais prevalente e o linoleato de etila foi o biomarcador que apresentou as maiores concentrações. Houve uma variabilidade no perfil de distribuição dos FAEEs entre os indivíduos, e discordâncias entre a presença de FAEEs e o consumo reportado pela mãe. A concentração total dos FAEEs nos mecônio mostrou-se como melhor indicador da exposição fetal ao álcool quando comparado com o uso de um único biomarcador. O ponto de corte para esta população foi de aproximadamente 600ng/g para uso tipo binge (três ou mais doses por ocasião) com sensibilidade de 71,43% e especificidade de 84,37%. Este estudo reforça a importância da utilização de métodos laboratoriais na identificação da exposição fetal ao álcool. / The high prevalence of alcohol consumption by women of reproductive age combined with unplanned pregnancy exposes the mother to a high risk to intoxicate at some time during pregnancy, especially in the early gestational period in which most of them have not yet became aware of the fact. Therefore, the development of methods for early detection it is extremely relevant for the prevention of fetal alcohol exposure as well for the early assessment of neonates at risk for development of problems of the fetal alcohol spectrum. The aim of this study was to develop, validate and evaluate the effectiveness of a method for quantifying fatty acid ethyl esters (FAEEs) in meconium from newborns for evaluation of fetal alcohol exposure. The evaluated FAEEs were: ethyl palmitate, ethyl stearate, ethyl oleate and linoleate etila. The method consists in preparing the samples by liquid-liquid extraction using water, acetone and hexane, followed by solid phase extraction employing aminopropyl silica cartridges. The separation and quantitation of analytes was performed by gas chromatography coupled with mass spectrometer. Limits of quantification (LOQ) ranged between 50 and 100 ng/g. The curves calibration were linear from LQ- 2000ng / g for all analytes. The recovery ranged from 69.79% to 106.57%. The analytes demonstrated stability in post-processing assay and in stability assay for standard solutions. The method was applied in meconium samples from 160 newborns recruited in a public maternity hospital of Ribeirão Preto. The maternal alcohol consumption was assessed by validated screening questionnaires (T-ACE and AUDIT) and by retrospective self-reports about the amount and frequency of alcohol consumption during pregnancy. The effectiveness of the analytical method in identifying positive cases was determined by receiver operating characteristic curve (ROC). The risk drinking was identified by the T-ACE in 31.3% of participants and 50% of them reported alcohol use during pregnancy. 51.3% of newborns tested positive for FAEEs, and 33.1% had high concentrations for sum of FAEEs (greater than 500 ng/g), compatible with alcohol abuse. The ethyl oleate was the most prevalent biomarker and ethyl linoleate was the biomarker that showed the highest concentrations. There was a variability in the distribution profile of FAEEs between individuals, and there were disagreements between the results of FAEEs and consumption reported by the mother. The cumulative sum of FAEEs was better than individual FAEEs for interpretation of positive cases. A positive cutoff of cumulative FAEE at 600 ng/g for binge drinking was stablished with 71,43% sensitivity and 84,37% specificity. This study reinforces the importance of using laboratory methods for identifying fetal alcohol exposure.

Maternal diet can have a great impact on the health and development of the fetus. Poor fetal nutrition has been linked to the development of a set of conditions in later life, such as coronary heart disease, type 2 diabetes and hypertension, while restricted growth can result in hypogylcemia, hypocalcemia, hypothermia, polycythemia, hyperbilirubinemia and cerebral palsy. High alcohol consumption during pregnancy can result in Fetal Alcohol Syndrome, a condition that can cause growth retardation, lowered intelligence and craniofacial defects. Current biometric assessment of the fetus involves size-based measures which may not accurately portray the state of fetal development, since they cannot differentiate cases of small-but-healthy or large-but-unhealthy fetuses. This thesis aims to outline a set of more appropriate measures of accurately capturing the state of fetal development. Specifically, soft tissue area and liver volume measurement are examined, followed by facial shape characterisation. A number of tools are presented which aim to allow clinicians to achieve accurate segmentations of these landmark regions. These are modifications on the Live Wire algorithm, an interactive segmentation method in which the user places a number of anchor points and a minimum cost path is calculated between the previous anchor point and the cursor. This focuses on giving the clinician intuitive control over the exact position of the segmented contour. These modifications are FA-S Live Wire, which utilises Feature Asymmetry and a weak shape constraint, ASP Live Wire, which is a 3D expansion of Live Wire, and FA-O Live Wire, which uses Feature Asymmtery and Local Orientation to guide the segmentation process. These have been designed with each of the specific biometric landmarks in mind. Finally, a method of characterising fetal face shape is proposed, using a combination of the segmentation methods described here and a simple shape model with a parameterised b-spline meshing approach to facial surface representation.

No description available.

[pt] O consumo de álcool durante gravidez pode alterar o desenvolvimento neural do feto, causando defeitos ao longo da vida. As consequências são diversas e compõe o termo coletivo: Transtorno do Espectro Alcoólico Fetal (TEAF). Esse transtorno é considerado a causa mais comum de deficiência cognitiva evitável no mundo. Estimativas apontam que no Brasil entre 1 e 1,5% das crianças nascem com alterações no sistema nervoso devido à exposição ao álcool in útero. O consumo do álcool é frequente entre mulheres grávidas muitas vezes por desconhecimento dos seus efeitos adversos no desenvolvimento do feto. Outra droga comumente utilizada por mulheres grávidas é a maconha com intuito de amenizar o enjoo durante a gestação. A presente dissertação explora os efeitos da exposição pré-natal ao álcool no feto (em conjunto ou não do uso da maconha) em estudos pré-clínicos e clínicos. Dois artigos foram gerados para a realização deste trabalho. O primeiro artigo relata os mecanismos e as consequências do consumo simultâneo de álcool e maconha durante gravidez, cujo efeito é ainda mais nocivo ao desenvolvimento do feto do que apenas a exposição ao álcool. Dados recentes demonstram a interação do etanol e da maconha com o sistema Endocanabinoide, que tem um papel importante no neurodesenvolvimento. Depois do fechamento do tubo neural, que acontece durante a terceira semana da gestação humana, os olhos e o cérebro se desenvolvem do neuroepitélio. Ambos, o álcool e maconha interferem sinergicamente nesse processo via receptores canabinóides, alterando assim a sinalização “sonichedgehog”, que por sua vez, resulta em alterações morfológicas e comportamentais em modelos animais. Além disso, o artigo relata os mais recentes achados de estudos clínicos sobre a combinação da dose e tipo de constituintes químicos da machonha, bem como os desfechos morfológicos e neurocomportamentais da exposição conjunta do álcool e da maconha. O segundo artigo é uma revisão sistemática que investiga as pesquisas realizadas no Brasil sobre o TEAF, com ênfase nos instrumentos usados para a avaliação neuropsicológica de indivíduos com TEAF. Enquanto países desenvolvidos têm décadas de pesquisa sobre o TEAF, no Brasil, inúmeros fatores comprometem o progresso nesta e outras áreas de pesquisa. Entre esses fatores podemos citar, divergências socioeconômicas, culturais e geopolíticas, que dificultam o desenvolvimento, adaptação e validação de instrumentos utilizados no diagnóstico e na avaliação neuropsicológica do TEAF. Além disso, vale ressaltar que a vulnerabilidade socioeconômica da população brasileira é um fator importante no aumento da ocorrência de formas mais graves de TEAF. A revisão sistemática aponta para a necessidade da validação das ferramentas neuropsicológicas de diagnóstico e avaliação cognitiva de pessoas com TEAF e da participação de uma equipe multidisciplinar no diagnóstico do TEAF. / [en] Alcohol consumption during pregnancy may damage the development of the fetus, resulting in the most common preventable cause of neurodevelopmental disability in the world: Fetal Alcohol Spectrum Disorders (FASD). The present dissertation aims to discuss the effects of alcohol on the developing CNS through two articles. The first article elucidates the mechanisms and outcomes of the combined alcohol and cannabis exposure in the offspring through preclinical studies. Alcohol teratogenesis is more potent when administered with cannabis and has more negative effects on the fetus than alcohol alone. Recent data demonstrate the interaction of ethanol and cannabis with the Endocannabinoid system, which plays an important role in neurodevelopment and explains the morphological and behavioral changes seen in preclinical studies. The second article is a systematic review that investigates Brazilian research on FASD, focusing on the instruments used for the neuropsychological assessment of individuals with FASD. While developed countries have decades of research on FASD, in Brazil numerous factors slow down the progress of in this and other areas of research. Socioeconomic status, cultural, and geopolitical divergences are some of these factors, which hinder the development, adaptation, and validation of instruments used in the diagnosis and neuropsychological assessment of FASD. In addition, it is worth noting that the socioeconomic vulnerability of the Brazilian population is an important factor in the increase in the occurrence of more severe forms of FASD. The systematic review points to the need to validate neuropsychological tools for the diagnosis and cognitive assessment of individuals with FASD in Brazil, and the participation of a multidisciplinary team in the diagnosis of FASD.

No description available.

Fetal Alcohol Syndrome (FAS) is a preventable cause of mental retardation and is the severest category within Fetal Alcohol Spectrum Disorder (FASD). As gestational alcohol exposure affects fetal cognitive functioning, children with FAS present with intellectual deficits. Unfortunately FASD prevalence rates are increasing amongst infants and school-going children. The main goal of this study was to compare the neurodevelopmental subscales of infants diagnosed with FAS, Partial FAS and non- FAS. Seventy-four infants with confirmed FAS, Partial FAS or Non- FAS diagnoses were assessed using the Griffiths Mental Developmental Scale. Development assessed at 7-12 and 17-29 months of age showed that, regardless of a FAS, PFAS or Non-FAS diagnosis, all infants performed weaker at their assessment at 17-29 months. The Subscales significantly affected included Personal-Social, Eye- Hand Coordination and Performance. The infants with FAS and PFAS displayed the most marked developmental delays. From this study it can be concluded that there are definite neurodevelopmental profiles for infant's diagnosed with FAS, PFAS and/or Non-FAS, highlighting the significant impact of prenatal alcohol exposure on various aspects of infant development. / Social work / M.Diac.

Population-based administrative data (2009-2012) from several sources were used to compare the health status and access to health services between a cohort of children in care with developmental disabilities (DD) (n=1,212) and a matched comparison group of children in care without DD (n=2,424). The two study groups were compared on a number of measures, including total respiratory morbidity, prevalence of diabetes, mood and anxiety disorders, continuity of care, injury-related hospitalizations, hospital-based dental care, and total number of ambulatory physician visits. Children in care with DD were significantly more likely to have a history of mood and anxiety disorders, respiratory illnesses, diabetes, hospital-based dental care, and injury-related hospitalizations compared to the matched comparison group. Children in care with DD also had significantly higher number of physician visits than children in the matched comparison group. No significant difference between the two study groups was found for continuity of care. / October 2015