A necrose pulpar pode ser comumente observada no paciente odontopediátrico que sofreu trauma dentário ou que apresenta profundas lesões de cárie dentária. Sabese que existe uma falta de consonância a cerca de quais sinais são utilizados para o diagnóstico da necrose pulpar em dentes decíduos, o que acarreta em uma literatura carente de estudos que integrem todas as informações a cerca desta patologia. Assim, o objetivo desta revisão sistemática foi realizar um levantamento para compilar e discutir os critérios descritos na literatura para realizar o diagnóstico de necrose pulpar em dentes decíduos. Esta revisão foi realizada seguindo as orientações do \"PRISMA Statement\". A busca para acessar os artigos existentes foi realizada até outubro de 2017 e a base de dados bibliográficos escolhida foi o PubMed. As palavras chaves utilizadas combinaram termos relacionados a crianças, dentição decídua e necrose pulpar. Dois examinadores, de maneira independente, analisaram os critérios de inclusão e de exclusão, sem restrição de idioma, e em casos de divergência um terceiro examinador, considerado expert no assunto, foi consultado para decisão final. Dessa maneira, foram encontrados 1823 artigos, dos quais 401 foram incluídos para leitura na íntegra, restando 59 (14,7%) que compreenderam os estudos de interesse para esta revisão sistemática. A concordância entre os examinadores foi calculada através do teste de Cohen\'s Kappa, resultando em K = 1,0 para a etapa de inclusão e K = 0,97 para a etapa de exclusão. Considerando o objetivo dos estudos encontrados, 49,1% eram estudos de tratamento, no qual a necrose pulpar era abordada como critério de inclusão dos participantes no estudo, seguido de 18,6% trabalhos de levantamento, sendo todos a respeito de trauma dentário. Foi observado que em apenas 13,5% dos artigos a necrose pulpar foi abordada como o desfecho do estudo. Em 95% dos estudos a definição do conceito sobre a necrose pulpar foi fornecida pelos próprios autores. No restante, quando a referência era citada, esta também apresentava a definição de necrose pulpar através dos próprios autores. A respeito da causa da necrose pulpar, foi encontrado que a maioria dos dentes decíduos a apresenta devido a lesões de cárie dental, sendo os molares decíduos os mais afetados. Observou-se que em relação aos critérios utilizados para realizar o diagnóstico da necrose pulpar, 44% dos estudos utilizam os critérios clínicos e radiográficos de maneira conjunta. Foi permitido calcular a ocorrência dos sinais clínicos utilizados em 27,1% dos estudos, dos sinais observados nos exames complementares em 50,8%, e da necrose pulpar em 15,2%. Além disso, permitiu-se identificar sinais e sintomas que foram relacionados com a presença da necrose pulpar em 23,7% dos estudos. Assim, é possível concluir que existe uma combinação de sinais clínicos e radiográficos para realizar o diagnóstico de necrose pulpar em dentes decíduos, destacando-se a presença da fístula em 57,6% dos estudos, e a presença de lesão periapical e/ou lesão de furca em 71,2%. Concluiu-se também que 76,2% dos estudos não utilizam testes pulpares. / Pulpal necrosis may be commonly observed in children that suffered dental trauma or severe caries lesions. It is known that there is a lack of agreement regarding which signs should be used to diagnose pulpal necrosis in primary teeth, leading to a literature in needy of studies that integrate all the information about this disease. Therefore, the aim of this systematic review was to perform a data collection to compile and discuss the criteria described in the literature to perform the diagnose of pulpal necrosis in primary teeth. This systematic review was conducted following the \"PRISMA Statement\". To access the literature a search was conducted through PubMed in order to identify papers published until October 2017. The search strategy combined words related to children, deciduous teeth and pulpal necrosis. Two reviewers, independently, identified the inclusion and exclusion criteria, with no language restriction, and in cases of disagreement a third examiner, considered an expert in the subject, was consulted for the final decision. Therefore, 1823 articles were identified, from them 401 were included for complete scanning, remaining 59 (14.7%) studies that fulfilled the eligibility criteria for this systematic review. The interexaminer agreement was measured through Cohen\'s Kappa Statistic, resulting in K = 1.0 for the inclusion criteria and K= 0.97 for the exclusion criteria. Regarding the aim of the studies that were found, 49.1% were treatment studies, where pulpal necrosis was accessed as inclusion criterion for the participants of the study, followed by 18.6% studies of investigation, all about dental trauma. It was observed that only in 13.5% of the papers pulpal necrosis was approached as the outcome of the study. In 95% of the studies, the definition about the concept of pulpal necrosis was given by the authors themselves. In the remaining studies, when the reference was quoted, it also reported the definition by the authors themselves. Considering the cause of pulpal necrosis, it was found that most of the deciduous teeth were affected by caries lesions and the primary molars were the most affected. It was also observed that related to the criteria for the diagnosis of pulpal necrosis, 44% studies apply clinical and radiographic criteria combined. It was possible to calculate the occurrence of the used clinical signs in 27.1% of the studies, of the signs observed in auxiliary exams in 50,8% and of the pulpal necrosis in 15.2%. Besides, it was possible to identify signs and symptoms that were related to the presence of pulpal necrosis in 23.7% of the studies. Hence, it is possible to conclude that there is a combination of clinical and radiographic signs to perform the diagnosis of pulpal necrosis in primary teeth, highlighting the presence of sinus tract in 57.6% of the studies and the presence of periapical/ interradicular lesion in 71.2%. It was also concluded that in 76.2% of the studies do not use pulp sensibility tests.

O objetivo dessa revisão sistemática foi avaliar a prevalência de traumatismo em dentes decíduos, analisando fatores associados e possíveis tendências em relação à ocorrência desse agravo. Assim, busca com termos relacionados ao trauma dental e à dentição decídua foi realizada. Após critérios de inclusão e exclusão, os artigos selecionados foram analisados. Meta-análises com os dados de prevalência de traumatismo em dentes decíduos no mundo, e em subgrupos (classificações, dentes e idades avaliadas), assim como no Brasil e em suas regiões foram realizadas, complementadas pela análise da tendência do agravo nessas populações. Além disso, meta-análise com os valores de Odds Ratio (OR) e Intervalo de Confiança (IC) das variáveis sexo, idade, maloclusões, renda e escolaridade materna foram realizadas. A busca foi realizada para artigos que relatavam trauma dental em dentes decíduos indexados no PubMed até o dia 18 de abril de 2012 e listou 953 artigos. Após critérios de inclusão e exclusão, 34 (3,6%) estavam relacionados ao escopo dessa revisão sistemática. A prevalência agregada de traumatismo em dentes decíduos no mundo é de 23% e apresenta tendência discreta de aumento. No grupo de estudos que utilizaram classificações que avaliam trauma periodontal, a prevalência agregada é de 26% com tendência de aumento, enquanto que no grupo de estudos que utilizam classificações que não contemplam esse tipo de trauma, a prevalência agregada diminui para 20%, assim como a tendência passa a ser de diminuição da prevalência. O grupo de estudos que analisou todos os dentes anteriores apresenta prevalência agregada de 25%, enquanto que os que avaliaram apenas dentes anteriores superiores e apenas incisivos apresentam 17% e 23%, respectivamente. A meta-análise do grupo de estudos que avaliou faixas etárias maiores que um ano apresentou prevalência agregada de 23%. São fatores positivamente associados a prevalência de traumatismo em dentes decíduos: ser do sexo masculino (OR=1,20;IC:1,09;1,33), ter quatro anos (OR=2,18;IC:1,66;2,86), apresentar mordida aberta anterior (OR=2,26;IC:1,38;3,70), sobressaliência acentuada (OR=2,51;IC:1,66;3,79), incompetência labial (OR=1,66;IC:1,26;2,20), a família ter renda superior a oito salários mínimos (OR=0,79;IC:0,69;0,92) e a mãe ter mais de oito anos de estudo (OR=1,30;IC:1,01;1,66). A prevalência agregada de traumatismo em dentes decíduos no Brasil é de 26% e apresenta tendência de aumento com os anos. A região sudeste e sul apresentam prevalência agregada em torno de 29% e 31%, respectivamente, com tendência de aumento, enquanto a região nordeste apresenta 19% com tendência de diminuir a prevalência com o passar dos anos. Podemos concluir que por volta de 23% dos pré-escolares apresentam traumatismo em dentes decíduos sendo que ser do sexo masculino, ter mais idade, apresentar mordida aberta anterior, sobressaliência acentuada, incompetência labial, a família ter renda superior a oito salários mínimos e a mãe ter mais de oito anos de estudo são fatores que aumentam a chance do agravo estar presente. Além disso, a utilização de classificações que contemplam todos os tipos de trauma dental, avaliar dentes anteriores superiores e inferiores em faixas etárias amplas parece contribuir para resultados mais realistas quando o objetivo é estudar o comportamento do traumatismo em dentes decíduos. / The aim of this systematic review was to evaluate the prevalence of dental trauma in deciduous teeth, assessing associated factors and possible trends concerned to the occurrence of this disorder. For this purpose, search for terms related to dental trauma and deciduous dentition was performed. Upon considering inclusion and exclusion criteria, the selected material was analyzed. Afterwards, meta-analysis was performed based on the data recorded on the prevalence of dental trauma in deciduous teeth worldwide and in subgroups (classifications, teeth and ages assessed) as well as in Brazil and its regions, complemented by the trend analysis of this injury. Meta-analysis with Odds Ratio (OR) and Confidence Interval (CI) values of variables as sex, age, malocclusions, income and maternal level of education was performed. Literature search was carried out for articles reporting on dental trauma prevalence in deciduous teeth indexed in PubMed up to April 18, 2012, and listed 953 articles. Upon analyzing the studies for inclusion and exclusion purposes, 34 (3,6%) essays were related to the scope of this systematic review. The pooled prevalence of trauma in deciduous teeth worldwide is 23% showing a slight tendency to increase over the years. The study group that used classifications which evaluate traumas in the supportive tissue showed a pooled prevalence of 26% with a trend to increase, while in the study group which adopt classifications that do not contemplate this type of trauma, the pooled prevalence decreases to 20%, with a trend to decrease over the years. The study group which analyzed all anterior teeth demonstrated a pooled prevalence of 25%, while the study group which evaluated only anterior upper teeth and only incisors evidenced 17% and 23%, respectively. The meta-analysis of the study group that evaluates age range greater than 1 year showed pooled prevalence of 23%. The following factors are positively associated to the prevalence of traumatism in deciduous teeth: male individuals (OR=1.20;CI:1.09;1.33), older individuals (OR=2.18;CI:1.66;2.86), patients presenting anterior open-bite (OR=2.26;CI:1.38;3.70), increased overjet (OR=2.51;CI:1.66;3.79), lip incompetence (OR=1.66;CI:1.26;2.20), family with income higher than eight minimum wages (OR=0.79;CI:0.69;0.92), mother\'s education level having more than eight years at school (OR=1.30;CI:1.01;1.66). The pooled prevalence of trauma in deciduous teeth in Brazil is 26% and presents tendency to increase. The Southeast and South regions of Brazil present pooled prevalence of 29% and 31% respectively, showing a trend to increase, while the Northeast region shows 19% with a trend to decrease over the years. In conclusion, around 23% of the preschoolers present trauma in deciduous teeth, and that being male, older, with anterior open bite, increased overjet, lip incompetence, family with income higher than eight minimum wages and mother\'s education level having more than eight years at school are factors which may increase the chance this injury be present. Moreover, the use of classifications that contemplate all types of dental trauma, to evaluate upper and lower anterior teeth within large age range seems to contribute to more realistic results when the objective is to study the behavior of dental trauma in deciduous teeth.

Introdução A prevalência de sobrepeso e obesidade em adolescentes brasileiros tem sido investigada em diferentes regiões e períodos do tempo. Estudos observacionais de base escolar apresentam baixo custo e são facilmente conduzidos, comparativamente a estudos de base populacional, que requerem maior custo e tempo. Objetivos Comparar medidas sumárias de prevalências de sobrepeso e obesidade no Brasil, obtidas em metanálise de estudos observacionais de bases escolar e populacional, realizados em amostras aleatórias. Métodos Bases de dados Medline, Embase, Lilacs, IBECS, Scielo, Adolec e Banco de Teses da Capes foram revisadas sistematicamente, buscando-se estudos de prevalência de sobrepeso e obesidade realizados no Brasil, em adolescentes, com 10 a 19 anos, entre 1990 e 2010. Estudos de prevalência, transversal ou de coorte, publicados em revistas com “peer review” e na literatura “cinza”, foram identificados por dois revisores independentemente, a partir de título e resumo, e, após comparação, um terceiro decidiu discordâncias. Dados foram extraídos por dois pesquisadores independentes utilizando protocolo padronizado, discordâncias decididas por consenso ou árbitro. A classificação de sobrepeso, obesidade e/ou excesso de peso foi definida pelos critérios utilizados em cada estudo. A análise dos dados utilizou modelo aleatório, realizada no Software 6 Comprehensive Meta-Analysis 2.0®. Resultados Entre 1939 artigos elegíveis, 138 preencheram os critérios de inclusão, 58 foram excluídos, sendo 30 exclusões pelo motivo de dados em duplicata, 17 por não utilizarem amostras aleatórias populacionais ou escolares representativas e 11 por não apresentarem os dados requeridos no protocolo da metanálise. Vinte e cinco estudos foram considerados perdas por não apresentarem a prevalência de obesidade em adolescentes, após três tentativas de contato com os autores. Dos 55 estudos incluídos na metanálise, 14 eram estudos observacionais com amostras de base populacional e 41 de base escolar. A prevalência de sobrepeso e obesidade em adolescentes encontrada em estudos de base populacional foi 16,7% (95% CI: 13,2-20,8) e 5,5% (95% CI: 4,2-7,1) e nos de base escolar foi 11,9% (95% CI: 10,3-13,3) e 5,1% (95% CI: 4,3-6,0), respectivamente. A heterogeneidade encontrada nos estudos de base populacional foi Q=8,17 (P < 0,001) para sobrepeso e Q=5,88 (P < 0,001) para obesidade, enquanto nos de base escolar foi Q=30,6 (P < 0,001) e Q=33,6 (P < 0,001), respectivamente. Apesar dos estudos com amostras de base escolar mostrarem maior inconsistência dos resultados quando comparados com os estudos de amostra de base populacional (I²=7,74 vs. 0), esses valores não são considerados altos. Conclusão Estudos com amostras de adolescentes de base populacional e escolar apresentam estimativas pontuais similares de prevalência de obesidade, porém apresentam diferenças nas prevalências pontuais de sobrepeso. / Introduction In Brazil, overweight and obesity prevalence in adolescents has been investigated in different regions and periods of time. Studies of school-based samples have low cost and are easily conducted, being widely used. Otherwise, population-based studies require greatest investments, more time and researches, besides high complexity to minimize bias. Objective To undertake meta-analysis of observational studies conducted in Brazilian adolescents to calculate pooled estimates for overweight and obesity prevalence for school-based versus population-based samplings. Methods Data sources included Medline, Embase, Bireme, and CAPES-Thesis database searching for articles and grey literature about overweight and obesity prevalence in adolescents aged 10 to 19 years, from studies conducted in Brazil from 1990 to 2010. Studies were systematically reviewed, with no language restriction, and independently extracted by two investigators using a standardized protocol. Overweight, obesity and/or overweight plus obesity were defined according to the criteria used in each study. Data analysis was performed by Comprehensive Meta-Analysis 2.0®, using random effect model. Results Among 1939 articles reviewed, 138 met the inclusion criteria, 58 were excluded, and 25 were not retrieved after three attempts to contact authors. Among 55 studies included in meta-analysis 14 were population-based and 41 school-based samples. Overweight and obesity prevalence in population-based studies was 16.7% (95% CI: 13.2-20.8) and 5.5% (95% CI: 4.2-7.1) and in school-based studies it was 11.9% (95% CI: 10.3-13.3) and 5.1% (95%CI: 4.3-6.0), respectively. The heterogeneity founded in population-based studies was Q = 8.17 (P < 0.001) for overweight and Q = 5.88 (P < 0.001) for obesity, while in school-based studies it was Q=30.6 (P < 0.001) and Q=33.6 (P < 0.001), respectively. Although school-based studies showed higher inconsistency measure in the results compared with population-based samples studies (I²=7,74 vs. 0), these values are not considered high. Conclusion School-based studies as well population-based studies conducted in adolescents provide similar point estimate of obesity prevalence, but there is a difference for point prevalence of overweight.

Os prejuízos causados pelo aumento do tempo de permanência hospitalar de um paciente devido ao retardo na cicatrização de feridas têm sido foco de preocupação em diferentes contextos das práticas de saúde. Nesse sentido, o grupo de Prevenção e Tratamento de Feridas (PTTF) do Hospital de Clínicas de Porto Alegre (HCPA) vem desenvolvendo estudos sobre esta temática, a fim de contribuir à assistência de pacientes portadores de feridas. Neste sentido, o objetivo deste trabalho foi identificar o curativo prevalente que constitui tratamento para as FOs abdominais com complicações, visando à busca de evidências que possam subsidiar o desenvolvimento de um protocolo institucional para o tratamento das mesmas. Para tanto, desenvolveu-se uma revisão sistemática que teve como pergunta norteadora Qual é o curativo prevalente no tratamento dos pacientes com complicações de feridas operatórias abdominais? Sendo P = paciente cirúrgico com idade igual ou maior que 18 anos, I = tipo de curativo utilizado para o tratamento de FOs abdominais e O = número de dias para a cicatrização. Foram utilizados MeSH controlados e não controlados e operador booleano AND. Foram utilizadas sete base de dados eletrônicas:PubMed, CINAHL, Cochrane, Scopus, Web of Science, Lilacs e Scielo, resultando em 6.107 artigos. Nessa etapa, realizou-se o Teste de Relevância Preliminar, o excluindo as produções através do título e do resumo breve apresentado nos resultados das buscas em cada base, sendo excluídos 5.578 artigos. Os 426 artigos selecionados foram submetidos ao Teste de Relevância I, o qual consistiu na avaliação dos resumos dos estudos. Nessa fase, foram excluídos 372 artigos, pois não estavam em consonância com a questão norteadora. Ao final desse teste, 54 artigos estavam adequados para prosseguir no estudo. Seguiu-se, então, para a avaliação dos estudos na íntegra através do Teste de Relevância II, em que se avaliou a qualidade metodológica, a relevância e a adequação dos resultados em atenção à questão norteadora. Nessa etapa, foram excluídos 19 artigos que possuíam nível de evidência e qualidade metodológica ruim, restando 35 artigos considerados adequados para prosseguir, sendo submetidos ao Teste de Relevância III, o qual avalia a qualidade metodológica dos estudos. Ao final desse teste, decidiu-se excluir os estudos que tivessem nível de evidência maior que 4, escore de qualidade abaixo de 14 e escala de Jadad menor que 3. Assim, foram excluídos nove estudos, compondo a amostra final 26 estudos. Em resposta a questão norteadora, 16 trabalhos apontaram o uso do curativo a VAC como o mais indicado para tratar FOs abdominais que tiveram complicações. Para tanto, recomenda-se pressão negativa de 75 a 125mmHg, com trocas a cada 72 horas, mostrando uma média de cicatrização que variou entre 13,2 e 18 dias. Sugere-se novas pesquisas, como ensaio clínico randomizado, ou estudo de caso controle, para que se possa avaliar a efetividade e a viabilidade da terapia VAC na nossa realidade. / The damages caused by the increased length of a patient's hospital stay due to a delay in wound healing have been a focus of concern in different health practice contexts. The Wound Prevention and Treatment Group (WPTG) of Porto Alegre's Hospital de Clínicas (HCPA) has been conducting studies on this subject in order to contribute to the care of wounded patients. In this sense, the aim of this study was to identify the dressings used to treat abdominal surgical wounds with complications, in order to look for evidence that supports the development of an institutional protocol for handling these wounds. For this purpose, a Systematic Review was developed, which had as a guiding question: What is the prevalent dressing in the treatment of patients with dehiscence in abdominal surgical wounds? Where P = surgical patients over 18 years old, I = type of dressing used to treat abdominal surgical wounds and O = the number of days for healing the wound. MeSH were used to search for the largest possible number of studies, being used both the controlled and the uncontrolled studies and their connections via the Boolean operator AND. Seven electronic databases were used: PubMed, CINAHL, Cochrane, Scopus, Web of Science, Lilacs, and Scielo. The search for articles in databases resulted in 6,107 articles. At this stage, the Preliminary Test of Relevance was undertaken, analizing articles by the title and the brief summary presented in the search results on each base, resulting in the exclusion of 5,578 articles. The 426 remaining articles were submitted to the Relevance Test I, which consisted in the evaluation of their abstracts. At this stage, 372 articles were excluded because they did not match the research question. At the end of this test, 54 articles were considered appropriate to continue the study. The remaining studies were evaluated in their entirety through the Test Score II, which assessed the methodological quality, relevance and adequacy of the results in their relevance to the research question. At this stage, we excluded 19 articles that had a poor evidence level and methodological quality. The remaining 35 articles that were considered appropriate to proceed were submitted to the Relevance Test III, which assesses the methodological quality of studies. At the end of this test, studies that had an evidence level of more than 4, a quality score below 14 and a Jadad scale of less than 3 were excluded. Thus, 9 studies were excluded, defining a final sample of 25 studies. In response to the guiding question, 16 studies have shown the use of the VAC dressing as the best suited to treat abdominal surgical wounds with complications. To this end, a negative pressure of 75 to 125mmHg is recommended, with changes every 72 hours, showing an average healing ranging from 13.2 to 18 days. Further research is suggestes, such as a randomized clinical trial or a case-control study, so that the effectiveness and feasibility of VAC therapy in our reality can be assessed. / Los perjuicios causados por el aumento del tiempo de permanencia hospitalaria de un paciente debido al retardo en la cicatrización de heridas ha sido foco de preocupación en diferentes contextos de las prácticas de salud. En este sentido, el grupo de Prevención y Tratamiento de Heridas (PTTF) del Hospital de Clínicas de Porto Alegre (HCPA) viene desarrollando estudios sobre esta temática, a fin de contribuir con la asistencia de pacientes portadores de heridas. En este sentido, el objetivo de este estudio fue identificar los curativos que constituyen tratamiento para las FOs abdominales con complicaciones, visando la búsqueda de evidencias que puedan subsidiar el desarrollo de un protocolo institucional para el tratamiento de las mismas. Por tanto, se desarrolló una Revisión Sistemática que tuvo como pregunta orientadora ¿Cuál es el curativo prevalente en el tratamiento de los pacientes con dehiscencia de heridas operatorias abdominales? P= paciente quirúrgico con edad igual o mayor a 18 años, I= tipo de curativo utilizado para el tratamiento de FOs abdominales y O= número de días para la cicatrización. Fueron utilizadas siete bases de datos electrónicas: PubMed, CINAHL, Cochrane, Scopus, Web of Science, Lilacs y Scielo. Fueron utilizados MeSH controlados y no controlados y operador booleano AND, resultante en 6107 artículos. En esta etapa, se realizó el Test de Relevancia Preliminar, el cual constituye en la exclusión de los artículos a través del título y del resumen breve presentado en los resultados de las búsquedas en cada base, siendo excluidos 5578 artículos. Los 426 artículos seleccionados fueron sometidos al Test de Relevancia I, el cual constituyó en la evaluación de los resúmenes de los estudios. En esta etapa, fueron excluidos 372 artículos, pues no estaban en consonancia con la cuestión orientadora. Al final de este test, 54 artículos fueron considerados adecuados para proseguir en el estudio. Se siguió para la evaluación de los estudios en la íntegra a través del Test de Relevancia II, en el que se evaluó la calidad metodológica, la relevancia y la adecuación de los resultados en atención a la cuestión orientadora. En esta etapa, fueron excluidos 19 artículos que poseían un mal nivel de evidencia y calidad metodológica, restando 35 artículos que fueron considerados adecuados para proseguir, siendo sometidos al Test de Relevancia III, el cual evalúa la calidad metodológica de los estudios. Al final de este test, se decidieron excluir los estudios que tuviesen nivel de evidencia maior a 4, score de calidad por debajo de 14 y escala de Jadad menor a 3. Así, fueron excluidos 9 estudios, componiendo la muestra final 26 estudios. En respuesta a la pregunta orientadora, 16 estudios apuntaron el uso del curativo VAC como el más indicado para tratar FOs abdominales que tuvieron complicaciones. Por tanto, se recomienda presión negativa de 75 a 125mmHg, con cambios cada 72 horas, mostrando un promedio de cicatrización que varió de 13,2 a 18 días. Se sugieren nuevas investigaciones, como un ensayo clínico aleatorio, o estudio de caso control, para que se pueda evaluar la efectividad y viabilidad de la terapia VAC en nuestra realidad.

Background: Self-compassion which may be shaped by early attachment experiences involves being kind to oneself at times of difficulty and is consistently linked to psychological well-being. Self-compassion may be particularly useful in adolescence during which, difficulties associated with physiological and psychosocial transitions can lead to psychological distress. Aims: The aims of this thesis were twofold. First: to review the literature exploring the relationship between self-compassion and psychological distress in adolescents. Second: a research study to investigate the emerging theory that self-compassion may offer a healthier self-relating construct than self-esteem. The study examined whether self-compassion or self-esteem mediated the relationship between attachment and depression and anxiety in adolescents attending child and adolescent mental health services (CAMHS). Method: A systematic search of articles related to the relationship between self-compassion and psychological distress in adolescents was conducted. The quality of included papers was assessed. In the research study, 53 adolescents (mean age 15.52 years; 75% female) attending CAMHS presenting with symptoms of anxiety and/or depression were asked to complete five self-report questionnaires measuring: self-compassion, self-esteem, quality of life, satisfaction with attachment relationship and current symptoms of depression and anxiety. Results: The systematic review revealed 25 studies for inclusion. Studies reported an inverse relationship between self-compassion and psychological distress in adolescents. Quality ratings illustrated variation in methodological quality of included studies. In the research study self-compassion and self-esteem were both negatively correlated with depression and anxiety. The mediating impact of self-compassion was only apparent in the relationship between attachment availability and depression, but not anxiety. Contrary to the hypothesis, self-esteem mediated the relationship between attachment security and depression and anxiety to a greater extent than self-compassion. Conclusions: Self-compassion may have clinical implications in improving psychological well-being among adolescents. Future studies with different measures of self-compassion; varying study designs and consideration of contextual factors would increase understanding of the relationship between self-compassion and psychological distress in adolescents.

Purpose: The systematic review explored whether self-management interventions improve patient activation in long-term conditions, and if any improvements are greater than the amount of change experienced by patients in usual care or active control conditions. It also aimed to determine if positive effects on activation are maintained at follow-up. The empirical study sought to explore relationships between patient activation, psychological factors (depression and valued living), perceived clinician empathy, perceived symptom severity, self-management and demographic variables. It also examined whether depression, valued living and perceived clinician empathy are unique predictors of activation, and if activation is a unique predictor of self-management for MS, when relevant confounding variables are controlled for. Methods: For the systematic review, a comprehensive search of multiple electronic databases was conducted to identify intervention research reporting on patient activation outcomes, as measured by the short-form Patient Activation Measure (PAM-13), in people with long-term conditions. For the empirical study, a cross-sectional survey of 118 people with MS explored patient activation, MS symptom severity, valued living, depression, perceived clinician empathy, self-management for MS and demographic factors. Correlation and hierarchical regression analyses were employed to explore relationships between variables. Results: Twenty-five studies were eligible for inclusion in the systematic review, reporting a wide range of long-term conditions. Twenty-one studies (10 RCTs; 1 non-randomised study; and 10 uncontrolled studies) found an improvement in patient activation at post-intervention. Nine studies reported a significantly greater improvement in activation in self-management conditions compared with usual care or an active control at post-intervention. In six out of eight studies, gains in patient activation were maintained in the intervention group at follow-up. However, in four of these six studies, patient activation in the control group also improved over time. Findings from the empirical study suggested that only valued living was a significant predictor of patient activation after controlling for demographic variables and MS symptom severity. Neither depression nor perceived clinician empathy significantly predicted activation. After controlling for valued living, depression and perceived clinician empathy, patient activation independently predicted 5.5% of variance in self-management for MS. Both activation and perceived clinician empathy were significant predictors of self-management for MS. Conclusions: Self-management interventions improve patient activation in long-term conditions compared with usual care or active control. Patient activation gains appear to be maintained longer-term; however, the impact of self-management interventions on activation is unclear due to increases in activation in control groups over time. Valued living is associated with patient activation in MS, while patient activation and perceived clinician empathy are associated with MS self-management. Self-management interventions targeting valued living and the patient-clinician relationship may be effective for addressing low levels of activation in some patients with MS.

Purpose: The systematic review summarised the research investigating potential risk factors for impulsive behaviours in forensic populations. The empirical study examined the predictive utility of clinician rated, self-report and behavioural measures of impulsivity in detecting violence and antisocial behaviour in forensic mental health inpatient settings. Method: The review is comprised of 9 studies identified through electronic database searches using a structured search strategy and predetermined inclusion criteria. The empirical study employed a cross-sectional design using retrospective and prospective statistical analysis. Forty-three participants were recruited from secure forensic mental health inpatient settings across Scotland and data collected from clinician rated, self-report and behavioural measures of impulsivity. Results: The review found original evidence to suggest that traumatic brain injury, substance and alcohol misuse, trauma and sleep as possible predictors of impulsive behaviour in forensic populations. The empirical study found a relatively consistent relationship between impulsive behaviour and violent or antisocial behaviour in a sample of forensic mental health inpatients. Conclusions: The systematic review identified a limited number of risk factors thought to influence impulsive behaviour in forensic populations. The review highlights the need for future research with improved methodological design to further explore contributory factors for increased levels of impulsivity. Findings from the empirical study reveal clinician rating of impulsive behaviour to be the most sensitive in predicting future incidents of violent and antisocial behaviour, which may be supplemented by the addition of a self-report measure.

Purpose: A systematic review and meta-analysis tested the 'paranoia as a defence' model's original prediction that those experiencing persecutory delusions would take excessive credit for positive events as part of an attributional style that protects them from low self-esteem. The empirical project explored forensic mental health nurses' experiences of a Cognitive Analytic Therapy (CAT) training programme with an emphasis on complex case conceptualisation and implications for clinical practice. Methods: In relation to the systematic review and meta-analysis, those experiencing persecutory delusions were compared to those with non-paranoid psychosis, depression, and healthy controls, in terms of the magnitude of internalising attributional bias (IAB) for positive events. Correlation analysis also examined the association between magnitude of IAB and paranoia severity. In the empirical study, 10 forensic mental health nurses took part in semi-structured interviews to qualitatively explore their experiences and applications of CAT training. Results: Consistent with the model, an internalising attributional bias was present for those experiencing paranoid delusions when compared to individuals with depression. Contrary to the model, there were no differences between the other control groups and there was no significant correlation between IAB and paranoia severity. Internal attributions for positive events appear to be associated with depression, rather than paranoia. Analysis of the empirical data provided a rich account of nurses' experiences of the CAT training and how this helped them to conceptualise complex patients and promoted more positive ways of working. Conclusions: The findings from the systematic review and meta-analysis do not support the original model, but are consistent with the modified 'paranoia as a defence' model of persecutory delusions. Other cognitive models also help explain paranoia suggesting that refining the existing models further could be useful. The empirical findings suggest that CAT could be a valuable model of psychologically informed practice for nurses working in a forensic setting. Specifically, training appeared to help nurses develop a better understanding of their patients, greater self-reflection skills, and improved clinical care approaches.

Background: Traumatic brain injuries (TBIs) can result in a number of consequences for those who has sustained the injuries, as well as having an impact on their wider system. Estimates of divorce and relationship dissolution among couples following TBI can be as high as 54% and partners are reported to experience high levels of stress. The majority of studies have explored couples' relationships following TBI from the perspective of either the person with TBI or the partner, as opposed to exploring this dyadically and, therefore, limiting the holistic understanding to this topic. Aim: The two aims of this thesis are as follows: firstly, the mixed-method synthesis review aimed to explore the current dyad evidence-base around couples' experiences and relationships following TBI; and secondly, the qualitative study aimed to explore the impact of TBI on couples' experiences and relationships. Method: The systematic review's search strategy consisted of a computerised search across five databases and manual searches for further references in other relevant literature reviews and reference lists. The quality of the qualitative and quantitative studies were analyses separately. Metaethnography was employed to synthesize the finding from the qualitative studies. In the qualitative empirical study, five dyad-couples participated in the semi-structured interviews. The individuals with TBI and their partners were interviewed independently. The data collected was analysed using a combined deductive-inductive framework analysis approach, which supported comparisons between and within couples. Results: The systematic review yielded eight eligible studies, three quantitative and five qualitative studies. Review of the quantitative studies suggested couples reported poor relationship quality and partners reported more dyadic dissatisfaction and overall poorer relationship adjustment than the people with TBI. Analysis of the qualitative studies suggested there were significant variations in the way couples' experience and respond to TBI. This included individual responses from the people with TBI, their partners or collectively as a couple, which influenced their relationship dynamics and also how they coped. The findings also drew attention to other contextual factors that influenced couples' attributions and perceptions toward the TBI-related changes. Deductive and inductive analysis of the interviews in the qualitative empirical study identified three overarching themes: 'You begin to realise that, actually, life may not be the same ever [again]...'; perceived influences on relationship endurance following TBI; and contextual and other factors. These explored the impact of TBI on couples' relationships and the processes that interacted with or influenced their perceived relationship endurance. Conclusion: Although limited by a small number of eligible studies in the systematic review and small sample size in the qualitative empirical study, this thesis emphasized the importance of dyadic research for gaining a holistic understanding of couples' experiences and relationships following TBI. This allows the complex interplay between the TBI, the person who has suffered the TBI, their partner and their relationship to be better understood. The interconnectedness between the individuals and how the difficulties are experienced raises possible issues for healthcare services around their views and approaches to the individual with TBI, their partner and the couple's relationship during the recovery and rehabilitation journey.

The present thesis was carried out in part fulfilment of the Doctorate in Clinical Psychology at the University of Edinburgh. It is presented in portfolio format, comprising of two individual papers although a total thesis abstract provides an overview of the entire thesis. The first paper is a systematic review of existing empirical research. It explores the predictive validity of risk assessment tools for imminent (short-term) violence and aggression in forensic psychiatric settings. The second paper is an empirical study exploring how frontline nursing staff both predict and emotionally cope with experiencing violence and aggression in a high-security setting. Paper one was prepared for Aggression and Violent Behavior and paper two for The International Journal of Forensic Mental Health; so, follow their respective author guidelines. Mental health, and forensic mental health nurses have been identified as being at particular risk of experiencing patient perpetrated violence and aggression (PPVA). There is relatively little research investigating how nursing staff predict and cope with more immediate, imminent inpatient violence and aggression, specifically within secure (forensic) settings. Negative outcomes of PPVA are widely accepted and demonstrated within empirical literature, including increased anxiety and stress for staff, fractures to the therapeutic relationship between patients and staff, and difficulties with staff retention and absenteeism for the organization. Due to the extensive negative outcomes associated with PPVA, a wealth of research has focused on developing the area of violence risk assessment. Despite this, there remains limited understanding regarding the utility of existing risk assessment tools for predicting and assessing violence risk over brief time frames (i.e. days to weeks). Therefore, a systematic review was conducted to explore the predictive validity of violence risk assessment tools for imminent, short-term risk in inpatient forensic psychiatric settings. Findings demonstrated that multiple tools had decent predictive validity, however quality scores were impacted by small sample sizes. The Dynamic Appraisal of Situational Aggression- Inpatient Version was the most effective tool with the highest mean quality score. The main limitations were the small number of studies assessing some of the included tools and the level of ambiguity between studies regarding the definition of imminent, short-term violence. Developing a shared understanding of what constitutes short-term risk and improving the number and quality of studies on the largely neglected tools, should therefore be research priorities. How nurses actually recognize and predict inpatient violence and aggression in forensic psychiatric settings, and how they emotionally cope with the aftermath, are poorly explored and understood processes. A social constructivist grounded theory approach was used to analyze the transcripts from 12 interviews with frontline nursing staff from an inpatient high-security setting. A model was constructed integrating nurses' beliefs and assumptions about subtypes of violence, their efforts to use observation skills in order to aid risk prediction, and their resultant emotional experiences following PPVA. Nurses emotional coping seemed to be affected by several factors relating to the culture of the organization and the accessibility of support. Seemingly, knowing the patient helped nurses to better identify underlying needs leading to violent behavior. This understanding helped nurses to implement targeted, needs-led interventions to address these unmet needs, and so reduce recurrent and cyclical violence. Recommendations are made to build upon, and utilize nursing skills in risk prediction and management, and to help better support the emotional impact of experiencing PPVA within forensic psychiatric settings.