Postnatal acetaminophen exposure and neurodevelopmental outcomes at 18-21 months corrected gestational age in preterm infants <29 weeks gestation: a retrospective cohort study.

BACKGROUND: Studies have reported prenatal acetaminophen exposure is associated with abnormal neurodevelopment. There is limited and conflicting data on neurodevelopmental outcomes following postnatal acetaminophen exposure. Our objective was to investigate the neurodevelopmental outcomes of preterm infants < 29 weeks gestation postnatally exposed to acetaminophen. METHODS: Retrospective cohort study of infants born between 2008 and 2017 at a tertiary care perinatal center. Exclusion criteria included chromosomal disorders, major congenital abnormalities, and congenital infections. The primary outcome was a composite score of <85 on the cognitive, language, or motor components of the Bayley Scales of Infant and Toddler Development, 3rd edition, assessed at 18 to 21 months corrected gestational age. Multivariate logistic regression was used to assess confounders. RESULTS: Of the 945 infants included in the study, 120 were in the acetaminophen group. There was no difference in any of Bayley-III cognitive, language or motor composite scores of < 85 between the two groups for postnatal acetaminophen exposure, adjusted odds ratios (aORs) 1.03, 95% CI 0.60-1.78, or days of acetaminophen use, aORs 1.10, 95% CI 0.93-1.29. CONCLUSIONS: There was no difference in neurodevelopmental outcome between the acetaminophen exposed and non-exposed groups. Our results need validation in larger cohorts. IMPACT: Animal research and cohort studies have suggested that prenatal acetaminophen exposure may be associated with an elevated risk of neurobehavioral abnormalities. However, there is limited and conflicting research on the impact of postnatal acetaminophen on neurodevelopment. The results of this study suggest that postnatal acetaminophen does not negatively impact neurodevelopment at 18 to 21 months in preterm infants born at <29 weeks gestational age. While these results need validation in larger and more longitudinal studies, this study provides reassurance for the use of postnatal acetaminophen in extremely preterm infants.

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study.

BACKGROUND: Patients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team. Studies have reported that physician gender can influence clinical decision making, but there is limited research on this phenomenon in the ED. The objective of this study was to determine whether emergency physician gender is associated with early pregnancy loss management. METHODS: Data were retrospectively collected from patients who presented to Calgary EDs with a non-viable pregnancy from 2014 to 2019. Pregnancies >12 weeks gestational age were excluded. The emergency physicians included saw at least 15 cases of pregnancy loss over the study period. The primary outcome was obstetrical consult rates by male versus female emergency physicians. Secondary outcomes included rates of initial surgical evacuation via dilation and curettage (D&C) procedures, ED returns, returns to care for D&Cs and total D&C rates. Data were analysed using χ2, Fisher's exact and Mann-Whitney U tests, as appropriate. Multivariable logistic regression models accounted for physician age, years of practice, training programme and type of pregnancy loss. RESULTS: 98 emergency physicians and 2630 patients from 4 ED sites were included. 76.5% of the physicians were male accounting for 80.4% of pregnancy loss patients. Patients seen by female physicians were more likely to receive an obstetrical consultation (adjusted OR (aOR) 1.50, 95% CI 1.22 to 1.83) and initial surgical management (aOR 1.35, 95% CI 1.08 to 1.69). ED return rates and total D&C rates were not associated with physician gender. CONCLUSION: Patients seen by female emergency physicians had higher rates of obstetrical consultation and initial operative management compared with those seen by male emergency physicians, but outcomes were similar. Additional research is required to determine why these gender differences exist and how these discrepancies may impact the care of early pregnancy loss patients.

Longitudinal advocacy training for medical students: a virtual workshop series.

Advocacy curricula in Canadian medical schools vary significantly. Expert-led, interactive workshops can effectively teach students how to address social determinants of health and advocate for patients. The Longitudinal Advocacy Training Series (LATS) is a free-of-charge, virtual program providing advocacy training created for Canadian medical students by students. The program was straightforward to implement and had high participation rates with 1140 participants representing 9.7% of enrolled Canadian medical students. As well, the program had high satisfaction reported by 87.6% of participants. The LATS toolkit enables health professional programs to develop similar programs for empowering effective health advocates.

Au Canada, les programmes de formation en matière de promotion et de défense des droits varient considérablement d'une faculté de médecine à l'autre. Les ateliers interactifs dirigés par des experts constituent un outil efficace pour enseigner aux étudiants la façon aborder les déterminants sociaux de la santé afin de défendre les droits des patients. La Longitudinal Advocacy Training Series (LATS) est un programme virtuel gratuit de formation à la défense des droits, créé par des étudiants pour les étudiants. Le programme, facile à mettre en œuvre, a connu un taux de participation élevé, à savoir 1140 participants représentant 9,7 % des étudiants en médecine au Canada. En outre, 87,6 % des participants se sont dits très satisfaits du programme. La trousse à outils LATS permet aux programmes de formation des professions de la santé de mettre sur pied des modules similaires pour donner aux étudiants les moyens de devenir des défenseurs de la santé efficaces.

Management of incomplete and missed spontaneous abortions: a cohort study of trends in Calgary emergency departments.

OBJECTIVES: Incomplete and missed spontaneous abortion cases often first present to the emergency department (ED), where they can be managed operatively via dilation and curettage (D&C) or non-operatively through medical or expectant management. The primary objective of this study was to determine how rates of operative management have changed over time across Calgary EDs. The secondary objective was to assess correlates of effectiveness and potential drivers in management including gynecological consults, ED return visits requiring admission, and subsequent D&Cs. METHODS: Sunrise Clinical Manager (electronic medical system) was accessed to collect data for patients who presented to a Calgary ED with an incomplete or missed spontaneous abortion from 2014 to 2019. Patients requiring resuscitation and those with complications were excluded. Return to care for D&C and ED revisits requiring admission were used as a proxy for failed non-operative management. Trends in management are reported using 95% confidence intervals. RESULTS: Of the 3845 patients included, 1110 (28.9%) received a D&C on initial ED visit. The remaining 2735 (71.1%) were initially managed non-operatively. Rates of D&Cs decreased 11.6% from 2014 to 2019, 95% CI (6.5%, 16.8%). There was minimal change in the rates of gynecological consults, ED returns requiring admission, and returns to care resulting in D&Cs over time. CONCLUSIONS: The management of incomplete and missed spontaneous abortions has shifted toward non-operative management over 6 years in Calgary. As this is not associated with increased ED returns requiring admission or subsequent D&Cs, the shift appears to be appropriate. As gynecological consults were consistent over time, further knowledge translation around non-operative spontaneous abortion management may be useful for ED physicians.

RéSUMé: OBJECTIFS: Les cas d'avortement spontané incomplets et manqués sont souvent les premiers à se présenter au service d'urgence (SU), où ils peuvent être gérés opérationnellement par dilatation et curetage (D&C) ou non opératoire par une prise en charge médicale ou d'attente. Le principal objectif de cette étude était de déterminer comment les taux de prise en charge opératoire ont changé au fil du temps dans les SU de Calgary. L'objectif secondaire était d'évaluer les corrélats de l'efficacité et les facteurs potentiels de la prise en charge, notamment les consultations gynécologiques, les visites de retour aux urgences nécessitant une admission et les D&C ultérieures. MéTHODES: Sunrise Clinical Manager (système médical électronique) a été consulté pour recueillir les données des patients qui se sont présentés à un service d'urgence de Calgary avec un avortement spontané incomplet ou manqué entre 2014 et 2019. Les patients nécessitant une réanimation et ceux présentant des complications ont été exclus. Le retour aux soins pour une D&C et les nouvelles visites aux urgences nécessitant une admission ont été utilisés comme indicateur de l'échec de la prise en charge non opératoire. Les tendances en matière de gestion sont signalées en utilisant des intervalles de confiance à 95%. RéSULTATS: Sur les 3 845 patients inclus, 1 110 (28,9%) ont reçu un D&C lors de la première visite à l'urgence. Les 2 735 autres (71,1%) ont été initialement pris en charge de manière non chirurgicale. Les taux de D&C ont diminué de 11,6% entre 2014 et 2019, IC à 95% (6,5%, 16,8%). Il y a eu un changement minime dans les taux de consultations gynécologiques, de retours aux urgences nécessitant une admission et de retours aux soins entraînant des D&C au fil du temps. CONCLUSIONS: La prise en charge des avortements spontanés incomplets et manqués a évolué vers une prise en charge non opératoire en 6 ans à Calgary. Comme cela n'est pas associé à une augmentation des retours à l'urgence nécessitant une admission ou des D&C ultérieurs, le changement semble être approprié. Les consultations gynécologiques étant constantes au fil du temps, une application plus poussée des connaissances sur la prise en charge des avortements spontanés non opératoires pourrait être utile aux médecins des urgences.

Preeclampsia and postpartum mental health: mechanisms and clinical implications.

Preeclampsia is one of the leading causes of maternal morbidity and mortality worldwide, with the short and long-term implications for maternal health being increasingly recognized. Yet the effects of preeclampsia on mental health are often overlooked, effects which can be evident both immediately postpartum and decades later. In particular, preeclampsia has been associated with increased risk and severity of cognitive impairment, psychosocial distress, and psychiatric disorders including depression, anxiety, and post-traumatic stress disorder. While these outcomes are reported, few have proposed how the pathophysiology of preeclampsia may contribute to changes in postpartum mental health. Studies have suggested that anti-angiogenic factors and pro-inflammatory cytokines released from the preeclamptic placenta may damage the blood-brain barrier endothelium, leading to long-term structural and functional cerebral changes. These changes may contribute to subsequent impairments in mental health. In addition, the pro-inflammatory profile and patterns of cerebral damage observed in preeclampsia are similar to that of psychiatric disorders and cognitive impairment, suggesting they may share common mechanisms. Yet, there is limited evidence on how these mechanisms may interact. The purpose of this review is to summarize the evidence for these pathophysiological mechanisms and propose how they may work synergistically to affect brain structure, cognition, and postpartum mental health in preeclampsia. The role of psychosocial factors, disease severity, and psychological treatment in the mental health of preeclampsia patients will also be discussed.

Aberrant limbic brain structures in young individuals at risk for mental illness.

AIM: Alterations in limbic structures may be present before the onset of serious mental illness, but whether subfield-specific limbic brain changes parallel stages in clinical risk is unknown. To address this gap, we compared the hippocampus, amygdala, and thalamus subfield-specific volumes in adolescents at various stages of risk for mental illness. METHODS: MRI scans were obtained from 182 participants (aged 12-25 years) from the Canadian Psychiatric Risk and Outcome study. The sample comprised of four groups: asymptomatic youth at risk due to family history of mental illness (Stage 0, n = 32); youth with early symptoms of distress (Stage 1a, n = 41); youth with subthreshold psychotic symptoms (Stage 1b, n = 72); and healthy comparison participants with no family history of serious mental illness (n = 37). Analyses included between-group comparisons of brain measurements and correlational analyses that aimed to identify significant associations between neuroimaging and clinical measurements. A machine-learning technique examined the discriminative properties of the clinical staging model. RESULTS: Subfield-specific limbic volume deficits were detected at every stage of risk for mental illness. A machine-learning classifier identified volume deficits within the body of the hippocampus, left amygdala nuclei, and medial-lateral nuclei of the thalamus that were most informative in differentiating between risk stages. CONCLUSION: Aberrant subfield-specific changes within the limbic system may serve as biological evidence to support transdiagnostic clinical staging in mental illness. Differential patterns of volume deficits characterize those at risk for mental illness and may be indicative of a risk-stage progression.

Testing a deep convolutional neural network for automated hippocampus segmentation in a longitudinal sample of healthy participants.

Subtle changes in hippocampal volumes may occur during both physiological and pathophysiological processes in the human brain. Assessing hippocampal volumes manually is a time-consuming procedure, however, creating a need for automated segmentation methods that are both fast and reliable over time. Segmentation algorithms that employ deep convolutional neural networks (CNN) have emerged as a promising solution for large longitudinal neuroimaging studies. However, for these novel algorithms to be useful in clinical studies, the accuracy and reproducibility should be established on independent datasets. Here, we evaluate the performance of a CNN-based hippocampal segmentation algorithm that was developed by Thyreau and colleagues - Hippodeep. We compared its segmentation outputs to manual segmentation and FreeSurfer 6.0 in a sample of 200 healthy participants scanned repeatedly at seven sites across Canada, as part of the Canadian Biomarker Integration Network in Depression consortium. The algorithm demonstrated high levels of stability and reproducibility of volumetric measures across all time points compared to the other two techniques. Although more rigorous testing in clinical populations is necessary, this approach holds promise as a viable option for tracking volumetric changes in longitudinal neuroimaging studies.