P 2018, 'The paranoia as defence model of persecutory delusions: A systematic review and meta-analysis ', Lancet Psychiatry, vol. 5,no. 11,. https://doi. AbstractBackground An influential psychological model of persecutory delusions proposed they are caused by a bias towards holding others responsible for negative events, which serves to prevent underlying low self-esteem from reaching awareness. An early (1994) version of the model predicted self-esteem would therefore be preserved in people with these delusions, whereas a later (2001) version suggested it would be unstable, and that there would be a discrepancy between their explicit and implicit self-esteem, with the latter being lower. Our aim was to perform the first comprehensive meta-analytical test of the key predictions of this model, taking into account evidence quality. MethodsReports identified in previous systematic reviews were collated. Electronic databases (i.e., PsycINFO, MEDLINE, EMBASE and Web of Science) were searched from 2012 to September 2016. The review was pre-registered (PROSPERO registration number: CRD42016032782). Cross-sectional data from case-control, longitudinal or experimental studies that examined self-esteem or the externalising attributional bias in individuals diagnosed with schizophrenia-spectrum disorder were eligible for meta-analyses of group differences, but only if at least 50% of participants with psychosis also had current persecutory delusions. Uncontrolled and longitudinal studies were included in meta-analyses of correlations and self-esteem instability, respectively. Study and outcome quality were assessed using the Agency for Healthcare Research and Quality (AHRQ) assessment tool, and a modified version of Grading of Recommendations Assessment, Development and Evaluation (GRADE), respectively. ResultsWe screened 3053 records, examined 104 full-text reports, and included 64 eligible studies. Consistent with the predictions of both versions of the model, paranoia severity in psychosis was positively correlated with the degree of externalising attributional bias (k=21, N=1128, r=0.18, 95% CI 0.08, 0.27; moderate quality). People with persecutory delusions also had a greater externalising attributional bias compared to non-clinical (k=27, N=1442, g=0.48, 95% CI 0.23, 0.73; moderate quality) and depressed individuals (k=10, N=421, g=1.06, 95% CI 0.48, 1.63; moderate quality), and those with psychosis without persecutory delusions (k=11; N=480; g=0.40, 95% CI 0.12, 0.68; moderate quality). Contrary to the 1994 version's predictions, paranoia severity in psychosis was negatively correlated with explicit self-esteem (k=23, N=1866, r=-0.26, 95% CI -0.34, -0.17; high quality). People with persecutory delusions also had lower explicit self-esteem than non-clinical individuals (k=22, N=1256, g=-0.88, 95% CI -1.10, -0.66; high quality) and similarly low explicit self-esteem to people with psychosis without persecutory delusions (k=11; N=644, g=-0.26; 95% CI -0.54, 0.02; moderate quality). Consistent with the 2001 version's pr...

Case reportA 22 year old Asian primigravida, known to have severe factor X deficiency with a factor X level 4 % of normal activity (normal range 50-150 YO), booked for antenatal care at 12 weeks of gestation. Her parents were first cousins and two siblings were heterozygous carriers of the factor X deficiency trait. Her husband had a normal factor X level. Factor X deficiency was first diagnosed in 1983 when she presented with prolonged bleeding from cuts. She also suffered from menorrhagia and was given fresh frozen plasma as prophylaxis against excessive bleeding before a dental extraction. An ultrasound scan confirmed the gestational age and showed a singleton pregnancy. Combined antenatal care by an obstetrician and a haematologist was planned.She was well at 18 weeks of gestation and an ultrasound scan showed apparently normal fetal anatomy. At 22 weeks she was admitted to hospital with vaginal bleeding, abdominal pain and tenderness over the fundus of the uterus. An ultrasound scan showed a fundal retroplacental haematoma measuring 55 x 25 mm. Fetal growth and the amniotic fluid volume were normal. A Kleihauer-Betke test was negative. Her factor X level was only 2 % of normal activity. After administration of two units of Bio-Product Laboratory (BPL) Factor IXA (composition per unit: 500 iu factor X, 500 iu antithrombin 111, 550 iu factor IXA, 600iu factor I1 and 5OOOiu heparin), her factor X level rose to 37% of normal activity.The day after BPL Factor IXA infusion she developed chest pain and shortness of breath. Her lungs were clinically clear, and there was no associated calf pain. Oxygen saturation (PaO,) was 97 %. There was concern about possible pulmonary embolism, but the clinical signs improved rapidly, and a chest X-ray and an electrocardiogram (ECG) were normal. After two days, the vaginal bleeding stopped. Four days later a repeat ultrasound scan showed that the haematoma had not increased in size, and she was discharged home with a follow up appointment in the antenatal clinic a week later. At antenatal visits at 23,27, 31 and 33 weeks fetal growth was satisfactory on ultrasound scans and the haematoma was getting smaller.At 34 weeks of gestation she was readmitted with a pyrexia of 37.8 "C, mild haemoptysis, shortness of breath, Correspondence: Dr J. C. Konje, Department of Obstetrics and Gynaecology, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.and generalised lower abdominal tenderness. There was no vaginal bleeding, and fetal movements were normal. An ECG and a chest X-ray were normal, and a viral illness was diagnosed. After a few days the chest symptoms improved, but the abdominal pain increased and an ultrasound scan revealed another retroplacental haematoma, in a different site, measuring 48 x 56 mm. The old haematoma was still present and measured 15 x 12 mm. Later the same day she started having regular uterine contractions and was transferred to the labour ward where she was rehydrated and given two units of BPL Factor IXA. Four units of blood were cro...