Forearm Fractures: Diagnosis and Contemporary Treatment Strategies.

Diaphyseal forearm fractures represent a spectrum of injury patterns that include isolated radial shaft fractures, isolated ulnar shaft fractures, both-bone forearm fractures, Galeazzi fracture-dislocations, and Monteggia fracture-dislocations. Although less common than distal radius fractures, diaphyseal forearm fractures are still a frequently encountered clinical entity seen by orthopaedic surgeons, both as isolated injuries and in the patient with polytrauma. It is important to review the epidemiology of diaphyseal forearm fractures and the classification systems used to describe them, as well as to discuss the principles of the initial evaluation and management of these fractures. It is important to know the indications for nonsurgical and surgical management, along with the goals of surgical management, options for internal fixation, and surgical approaches to the forearm.

Medical Cannabis Patients Report Improvements in Health Functioning and Reductions in Opiate Use.

Purpose: Opioid use rates have dropped as North American patients gain access to medical cannabis, indicating a harm reduction role, yet health outcomes remain mostly unexplored. This study presents self-reported medical cannabis use, perceptions of health functioning, and changes in opioid pain medication use in Florida medical cannabis patients.Methods: Patients (n = 2,183) recruited from medical dispensaries across Florida completed a 66-item cross-sectional survey that included demographic, health, and medication usage items, along with items from the Medical Outcomes Survey (SF-36) to assess health functioning before and after cannabis initiation.Results: Most participants were between the ages of 20 and 70 years of age (95%), over 54% were female, 47% were employed, and most (85%) were white. Commonly reported ailment groups were Pain and Mental Health combined (47.92%), Mental Health (28.86%) or Pain (9.07%). Health domains of bodily pain, physical functioning, and social functioning improved while limitations due to physical and emotional problems were unchanged. Most patients rated medical cannabis as being important to their quality of life. Many (60.98%) reported using pain medications prior to medical cannabis, 93.36% of these reported a change in pain medication after medical cannabis. The majority of participants (79%) reported either cessation or reduction in pain medication use following initiation of medical cannabis and 11.47% described improved functioning.Conclusions: The findings suggest that some medical cannabis patients decreased opioid use without harming quality of life or health functioning, soon after the legalization of medical cannabis. The public health implications of medical cannabis as an alternative pain medication are discussed.

Maternal smoking during pregnancy and offspring personality in childhood and adulthood.

OBJECTIVE: Maternal smoking during pregnancy (MSDP) has been associated with offspring internalizing and externalizing disorders. The purpose of this research is to examine whether MSDP is also associated with variations in normal personality traits in childhood and adulthood. METHOD: This study uses four independent samples (total N = 16,323) to examine whether there are mean-level differences in offspring personality traits by MSDP, controlling for relevant sociodemographic factors. Two samples are of children (Ns = 3,782 and 3,841) and two samples are of adults (Ns = 1,786 and 6,914). RESULTS: A meta-analysis across the four samples indicated that offspring of mothers who did smoke during pregnancy scored higher in Neuroticism (p = .000) and Extraversion (p = .003) and lower in Conscientiousness (p = .002) than offspring of mothers who did not smoke during pregnancy. The association between MSDP and Neuroticism and Conscientiousness held across both childhood and adulthood and when propensity score matching was used, whereas the association with Extraversion was only apparent in adulthood and did not hold with propensity scores. CONCLUSIONS: These results suggest that MSDP is associated with individual differences in psychological traits in childhood and adulthood and may be one prenatal factor that contributes to trait Neuroticism and Conscientiousness.

Anxiety and physical health problems increase the odds of women having more severe symptoms of depression.

Severely depressed women incur substantial disability and suicide risk, necessitating an understanding of factors that may contribute to severe depression. The purpose of this research was to determine the degree to which age, physical morbidity, anxiety, and hormonal status predict the likelihood of severe depression among women with mood disorders (n = 298). Data arose from a standardized battery of measures in a multi-center clinical registry of patients with mood disorders. The women were being treated at 17 participating sites of the National Network of Depression Centers. Results of logistic regression analyses indicate that a woman's level of anxiety was the strongest predictor of her likelihood of having severe depression (Exp(B) = 1.33, p = .000), including thoughts of death or suicide. The number of physical health problems that a woman reported was also a significant predictor (Exp(B) = 1.09, p = .04). Neither age nor hormonal status was significant in the final model, although a trend was observed for women with surgically induced menopause to have more severe depression. Findings support the need to work closely with medical practitioners to address physical health problems as part of the treatment plan for depression and to give comorbid anxiety and depression equal priority in symptom management.

Are women's parenting-specific beliefs associated with depressive symptoms in the perinatal period? Development of the rigidity of maternal beliefs scale.

BACKGROUND: Perinatal depression negatively impacts women, parenting, and children's development. However, not much is known about maternal specific beliefs that may be associated with perinatal depression. We created a new measure that examined the rigidity of perinatal women's beliefs in three major domains suggested to be closely related to mood and behavior: anticipated maternal self-efficacy, perceptions of child vulnerability, and perceptions of societal expectations of mothers (PSEM). METHODS: A 26-item measure (the Rigidity of Maternal Beliefs Scale, RMBS) was developed and completed by women at two time points, pregnancy (n = 134) and postpartum (n = 113), along with the Edinburgh Postnatal Depression Scale. Exploratory factor analysis (EFA) examined the factor structure of the RMBS and validity and reliability were also tested. RESULTS: The EFA suggested that a four-factor solution was most interpretable, with few items cross-loading, and there were common themes that unified the items in each factor, resulting in a 24-item final measure. Cronbach's alpha confirmed the internal consistency, whereas bivariate correlations revealed the measure had good test-retest reliability, discriminant validity, and convergent validity. Regression analyses established predictive validity of the RMBS for postpartum depressive symptoms. CONCLUSIONS: The RMBS may be useful with clinical populations to identify maladaptive or rigid thoughts that could be a focus of intervention. This tool may also be used to guide conversation about motherhood expectations within any context where pregnant women present (e.g., prenatal care, social services), as well as potentially identifying women who are at risk for postpartum depression in clinical contexts.

Relationship of prenatal depression and comorbidities to infant outcomes.

OBJECTIVE: The purpose of this study was to provide information on the effect of prenatal depression and anxiety as assessed in the context of obstetrical care on key infant outcomes (gestational age at birth, birth weight, and APGAR scores), while simultaneously considering interactions with maternal medical conditions among primarily Medicaid enrollees. METHODS: Obstetrical medical records of 419 women presenting consecutively for prenatal care at a health system serving primarily Medicaid patients were examined. Information on maternal characteristics (age, race, education) and maternal medical health (BMI, high blood pressure, diabetes, and kidney problems), as well as mental health information, was extracted. Depression was assessed as part of routine care using the Patient Health Questionnaire-9 (PHQ-9), and any documentation of depression or anxiety by the obstetrics clinician was also used in the analyses. RESULTS: Approximately one-third of the sample showed some evidence of prenatal depression, either based on PHQ-9 score (≥10) or clinician documentation of depression, and close to 10% showed evidence of anxiety. Multivariate analyses showed significant interactions between depression and anxiety on gestational age and birth weight, between depression and high blood pressure on gestational age, and also between anxiety and kidney problems on gestational age. CONCLUSION: Among this sample, the effect of maternal depression and anxiety on birth outcomes was more evident when considered along with maternal chronic medical conditions. This information may be used to assist prenatal care clinicians to develop risk assessment based on knowledge of multiple risk factors that may exert and additive influence on poor birth outcomes.

Representativeness of obstetric patients who participate in perinatal depression research: findings from the Women's Mental Health and Infants Program (WMHIP) integrated dataset.

The aims of this study were to evaluate the feasibility of integrating archival datasets from depression projects involving pregnant women recruited from obstetric clinics and then assess the representativeness of the integrated dataset. Datasets from six studies were standardized and integrated. Chi-square, t-, and Wilcoxon rank-sum tests were used to compare characteristics between women who completed a depression screening questionnaire (DSQ) and were (1) eligible and ineligible for research participation and (2) eligible women who accepted and declined participation. The integrated dataset comprises 9,112 pregnant women, of whom 71.0 % (n = 6,472) were ineligible for participation because their DSQ scores indicated no-to-minimal depressive symptoms (NDS). Among the 23.9 % (2,176) of women identified as eligible, in part, because their DSQ scores indicated elevated levels of depressive symptoms (EDS), 29.6 % (644) of women participated (P-EDS) and 47.6 % (1,036) of women did not participate (D-EDS). While the NDS and EDS groups were significantly different on almost all variables, the P-EDS and D-EDS groups were significantly different on only a few variables. Compared to the D-EDS group, the P-EDS group was earlier in pregnancy and, on the Edinburgh Postnatal Depression Screen, was more likely to endorse impaired "ability to laugh" and "enjoy oneself", and endorse at greater severity "ability to laugh." It is a reasonable and feasible strategy to integrate thematically similar datasets to increase statistical power. Additionally, typical recruitment strategies for minimal risk perinatal depression research at obstetric clinics, during routine prenatal care visits, appear to produce an externally valid study cohort.

Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation.

BACKGROUND AND OBJECTIVES: Suicidal ideation (SI) during the postpartum phase is linked with suicide, a leading cause of death during this period. Antenatal depression and anxiety symptoms have both been linked with increased risk for postpartum SI. However, research aimed at examining the relative contributions of antenatal anxiety and depression symptoms towards postpartum SI remains nascent. In this study, we investigated the relative contribution of antenatal anxiety symptoms, depression symptoms, and SI towards postpartum SI. DESIGN: These data are from a longitudinal study in which American mothers were assessed during pregnancy and again at six- to eight weeks postpartum. METHODS: Data were analyzed using correlations and logistic regression models. RESULTS: Antenatal anxiety symptoms and antenatal depression symptoms were significantly correlated with postpartum SI. Results from a logistic regression model indicated that antenatal anxiety symptoms (T1; OR = 1.185 [1.125, 1.245], p = .004), but not antenatal depression symptoms (T1; OR = 1.018 [0.943, 1.093], p = .812) or antenatal SI (T1; OR = 1.58 [0.11, 22.29], p = 0.73), were significantly associated with postpartum SI. CONCLUSIONS: Antenatal anxiety symptoms, depression symptoms, and SI were positively associated with postpartum SI. When examined simultaneously, anxiety symptoms during the antenatal phase (but not depression symptoms or SI) predicted SI in the postpartum phase.

Study protocol for transforming health equity research in integrated primary care: Antiracism as a disruptive innovation.

Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups.

A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes.

BACKGROUND: Perinatal women with identified depression in prenatal care settings have low rates of engagement and adherence with depression-specific psychotherapy. We report the feasibility and symptom outcomes of Cognitive Behavioral Therapy (CBT) modified (mCBT) to address the needs of perinatal, low-income women with Major Depressive Disorder (MDD). METHODS: Pregnant women (n = 1421) were screened for depressive symptoms in obstetrics clinics in conjunction with prenatal care visits. A total of 59 women met diagnostic criteria for MDD; 55 women were randomly assigned to mCBT or Treatment as Usual (TAU). The mCBT intervention included an initial engagement session, outreach, specific perinatal content and interpersonal components. Measures were gathered at pre-treatment, 16 week post-randomization, and 3-month follow-up. RESULTS: Most participants attended at least one CBT session and met study criteria for treatment adherence. Active research staff outreach promoted engagement and retention in the trial. Treatment satisfaction was rated as very good. In both observed and multiple imputation results, women who received mCBT demonstrated greater improvement in depressed mood than those in TAU at 16-week post-randomization and 3-month follow-up, Cohen's d = -0.71 (95% CI -4.93, -5.70). CONCLUSIONS: Modified CBT offers promise as a feasible and acceptable treatment for perinatal women with low-incomes in prenatal care settings. Targeted delivery and content modifications are needed to engage populations tailored to setting and psychosocial challenges specific to the perinatal period.

An open pilot of cognitive-behavioral therapy for insomnia in women with postpartum depression.

Sleep disturbances and depression are commonly experienced by postpartum women. We evaluated the preliminary efficacy of a modified version of cognitive-behavioral therapy for insomnia on mood, sleep, and fatigue in postpartum women with insomnia and depression in an open pilot study. Twelve postpartum women participated in five weekly individual treatment sessions. Statistically significant improvements were observed in sleep diary-rated sleep efficiency and total wake time, and subjective mood, insomnia severity, sleep quality, and fatigue. Further evaluation of the treatment using a controlled design is warranted.

Going Virtual: Transitioning an Older Adult Community Health Clinical Course to Online During COVID-19.

BACKGROUND: Nursing students in a community health course implemented a quality improvement project with active older adults (AOA). This article describes a process for transitioning an in-person community health quality improvement (QI) project to online. METHOD: To communicate with AOA, students created a blog, "Healthy Living From Home," that enabled communication among the AOA, partner organizations staff, and students. A quick response code was created that linked to the 6-week program. At the end of the 6 weeks, participants were asked to complete a survey. RESULTS: Data collected from the QI project website tracked more than 1,000 visits to the blog. Participants rated project enjoyment, helpfulness, and educational content as 4.5 on a 5-point Likert scale. CONCLUSION: Using a multifocal online format to engage with AOA was successful and can continue to be used in the future. [J Nurs Educ. 2023;62(X):XXX-XXX.].

The role of perinatal psychiatry access programs in advancing mental health equity.

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

Clinical correlates of women endorsing premenstrual suicidal ideation: a cross-sectional study.

BACKGROUND: Prevalence of premenstrual syndrome (PMS) may be as high as 13-18%, but it remains under-recognized and is associated with increased suicidal ideation (SI), plans, and attempts in epidemiological studies. The present study reports on women endorsing premenstrual SI (PMSI) and characterizes this at-risk group and its clinical correlates. METHODS: A cross-sectional study assessed demographics, anxiety and depression severity, psychiatric diagnoses, menstrual symptoms, SI, and trauma in adult women at a major medical center over 11 months. RESULTS: Three hundred two women were assessed. Of 153 participants endorsing premenstrual symptoms, 41 (27%) reported new or worsening concurrent premenstrual passive or active SI. Women who reported PMSI were significantly more likely to be single, unemployed, and childless as well as significantly more likely to report interference from premenstrual symptoms, histories of psychiatric hospitalization, adverse childhood events, suicide attempts, and current and past depression and anxiety compared to women without PMSI. The final regression model indicated the most significant predictors of PMSI were history of a depression diagnosis, severity of current depressive symptoms, and having experienced 3 or more childhood adverse events. CONCLUSION: Nearly one-third of women reporting premenstrual symptoms endorsed concurrent SI, a clinically valuable demonstration of the importance of this predictable cyclic risk factor.

The P300 and late positive potential in pregnancy prospectively predict increases in depressive and anxious symptoms in the early postpartum period.

Postnatal depression and anxiety disorders pose a major burden on maternal mental health. While psychosocial risk factors for perinatal depression and anxiety are well-researched, there is a dearth of research examining neural biomarkers of risk for postnatal increases in depression and anxiety. Previous studies suggest two different event-related potentials, the P300 and the late positive potential (LPP), may predict the course of depressive and anxious symptoms in non-perinatal populations. In a sample of 221 perinatal women, the present study utilized an emotional interrupt task administered in pregnancy to examine whether antenatal P300 and LPP amplitudes may predict change in depressive and anxious symptoms from pregnancy to the early postpartum period. Zero-order correlations and linear regressions revealed that a reduced antenatal P300 to target stimuli and an enhanced LPP to positive infant images were uniquely associated with postnatal depressive and anxiety symptoms, respectively, and that these ERPs were independent predictors beyond antenatal self-report measures of psychological symptoms. Furthermore, individuals with increased depressive symptoms in pregnancy exhibited a stronger negative association between antenatal P300 amplitude and postnatal depressive symptoms. The present findings underscore the possibility that the measurement of ERPs during pregnancy could serve as a screening tool for risk for perinatal depression and anxiety, and thereby assist with identifying at-risk individuals who might benefit from prevention efforts.

PI3K/AKT pathway alterations are associated with clinically aggressive and histologically anaplastic subsets of pilocytic astrocytoma.

Pilocytic astrocytomas (PA) are well-differentiated gliomas having a favorable prognosis when compared with other diffuse or infiltrative astrocytomas. Molecular genetic abnormalities and activation of signaling pathways associated with clinically aggressive PA and histologically anaplastic PA have not been adequately studied. We performed molecular genetic, gene expression, and immunohistochemical studies using three PA subsets, including conventional PA (n = 43), clinically aggressive/recurrent PA (n = 24), and histologically anaplastic PA (n = 25). A clinical diagnosis of NF1 was present in 28% of anaplastic PA. Molecular cytogenetic studies demonstrated heterozygous PTEN/10q and homozygous p16 deletions in 6/19 (32%) and 3/15 (20%) cases of anaplastic PA, respectively, but in neither of the two other groups. BRAF duplication was identified in 33% of sporadic anaplastic PA and 63% of cerebellar examples. BRAF (V600E) mutation was absent in four (of 4) sporadic cases lacking duplication. IDH1(R132H) immunohistochemistry was negative in 16 (of 16) cases. Neither PDGFRA nor EGFR amplifications were present. pERK staining levels were similar among the three PA subsets, but a stepwise increase in cytoplasmic pAKT and to a lesser extent pS6 immunoreactivity was noted by immunohistochemistry in aggressive PA groups. This was particularly true in histologically anaplastic PA when compared with conventional PA (p < 0.001 and p = 0.005, respectively). In addition, PTEN expression at the mRNA level was decreased in histologically anaplastic PA when compared to the other groups (p = 0.05). In summary, activation of the PI3K/AKT in addition to MAPK/ERK signaling pathways may underlie biological aggressiveness in PA. Specifically, it may mediate the increased proliferative activity observed in histologically anaplastic PA.

Comparative performance of the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9 in pregnant and postpartum women seeking psychiatric services.

Adoption of a standard depression measures across clinics and populations is advantageous for continuity of care and facilitation of research. This study provides information on the comparative utility of a commonly used perinatal-specific depression instrument (the Edinburgh Postnatal Depression Scale-EPDS) with a general depression screener (Patient Health Questionnaire-9-PHQ-9) in a sample of perinatal women seeking psychiatry services within a large health care system. Electronic medical records (which included PHQ-9 and EDPS) were abstracted for a final sample of 81 pregnant and 104 postpartum patients (n=185). Psychometric properties were examined among women who met the criteria for Major Depressive Disorder (MDD) based on clinician diagnoses, as compared to women without any mood disorder diagnosis. Using commonly recommended cut-off scores, both measures had comparable sensitivity, specificity, PPV and NPV for both pregnant and postpartum women. Comparative AUC for ROC contrasts were not significantly different between the two measures. Thus, this study found few significant differences in the performance of the PHQ-9 and EPDS in detecting clinician-diagnosed MDD in a psychiatry outpatient sample of pregnant and postpartum women.

Stigma and depression during pregnancy: does race matter?

Rates of depression treatment are low in pregnant women, particularly Black women. Stigma is an important barrier to treatment, but little research has examined how depression stigma differs in Blacks and Whites; a key purpose of this study. Participants were 532 pregnant women recruited in obstetrics settings, who responded to measures of stigma and mood. Black women reported more depression stigma than White women, regardless of their depression status, and were more likely to endorse the view that depression should be kept secret, than White women. In White women, stigma increased as a function of depression status (current, past, never). White women's perceptions of depression stigma were positively correlated with their beliefs about keeping depression secret. Secrecy and depression stigma were uncorrelated in Black women. There are important racial differences in the way depression stigma functions in pregnant women. Implications for engaging women in mental health treatment are discussed.

Patient preferences for clinician interactional style in treatment of perinatal depression.

Most women with depression around the time of childbearing are not treated adequately, or at all. Clinical practice guidelines focus primarily on provision of information rather than on interaction factors. In this study, we explored clinician interactional style characteristics contributing to patient response to perinatal depression referral and treatment. Stratified purposeful sampling resulted in 23 participants selected by pregnancy, socioeconomic, and depression status. Participants completed semistructured interviews exploring their experiences with and preferences for clinician interactional style characteristics in the context of obstetrics-setting referral and delivery of depression treatment. Thematic analysis revealed a central theme related to interactional cues that influence women's reactions to clinical encounters, summarized by the question, "Can this person help me?" Women evaluated this question in four domains: feeling heard, developing trust in the clinician, perceiving technical competence in the clinician, and feeling that the intervention focus is effectively chosen and communicated. Our results imply that, in addition to informational factors, the way in which clinicians interact with patients about depression might strongly influence patient responses.