Notification rates for syphilis in women of reproductive age and congenital syphilis in Australia, 2011-2021: a retrospective cohort analysis of national notifications data.

OBJECTIVES: To estimate notification rates for infectious syphilis in women of reproductive age and congenital syphilis in Australia. STUDY DESIGN: Retrospective cohort study; analysis of national infectious syphilis and enhanced congenital syphilis surveillance data. SETTING, PARTICIPANTS: Women aged 15-44 years diagnosed with infectious syphilis, and babies with congenital syphilis, Australia, 2011-2021. MAIN OUTCOME MEASURES: Numbers and rates of infectious syphilis notifications, by Indigenous status and age group; numbers and rates of congenital syphilis, by Indigenous status of the infant; antenatal care history for mothers of infants born with congenital syphilis. RESULTS: During 2011-2021, 5011 cases of infectious syphilis in women aged 15-44 years were notified. The notification rate for Aboriginal and Torres Strait Islander women rose from 56 (95% confidence interval [CI], 45-65) cases per 100 000 in 2011 to 227 (95% CI, 206-248) cases per 100 000 population in 2021; for non-Indigenous women, it rose from 1.1 (95% CI, 0.8-1.4) to 9.2 (95% CI, 8.4-10.1) cases per 100 000 population. The notification rate was higher for Aboriginal and Torres Strait Islander women than for non-Indigenous women (incidence rate ratio [IRR], 23.1; 95% CI, 19.7-27.1), lower for 15-24- (IRR, 0.7; 95% CI, 0.6-0.9) and 35-44-year-old women (IRR, 0.6; 95% CI, 0.5-0.7) than for 25-34-year-old women, and higher in remote regions than in major cities (IRR, 2.7; 95% CI, 2.2-3.8). During 2011-2021, 74 cases of congenital syphilis were notified, the annual number increasing from six in 2011 to a peak of 17 in 2020; the rate was consistently higher among Aboriginal and Torres Strait Islander infants than among non-Indigenous infants (2021: 38.3 v 2.1 per 100 000 live births). The mothers of 32 infants with congenital syphilis (43%) had not received antenatal care. CONCLUSIONS: The number of infectious syphilis notifications for women of reproductive age increased in Australia during 2011-2021, as did the number of cases of congenital syphilis. To avert congenital syphilis, antenatal screening of pregnant women, followed by prompt treatment for infectious syphilis when diagnosed, needs to be improved.

'Immunisation, I haven't had a problem, but once again the transport, making an appointment, the time that you waste and all of those things are an issue'-Understanding childhood under-immunisation in Mid North Coast New South Wales, Australia.

OBJECTIVES: This study aimed to understand the reasons for childhood under-immunisation in Kempsey, New South Wales, among First Nations and non-First Nations families, and potential strategies to improve coverage. DESIGN: The World Health Organization's Tailoring Immunization Programmes guide was employed. Tailoring Immunization Programmes uses social science, qualitative research methods and community participation and is underpinned by the Capabilities Opportunities Motivations-Behaviors (COM-B) theoretical model of behaviour change. A cultural lens was applied throughout the study design. Using a thematic analysis, factors found to influence childhood under-immunisation were loosely mapped against COM-B framework. SETTING: Face-to-face interviews and focus groups conducted in locations and at times convenient to participants were audio-recorded and transcribed verbatim. PARTICIPANTS: Fifty-six participants (25 First Nations and 13 non-First Nations mothers and grandmothers, and 18 health service providers) took part in the study (July-October 2019). RESULTS: Four themes were identified: (a) parents are supportive of immunisation and effective reminders would make it easier to prioritise it (b) services could be more accessible for families (c) addressing workforce shortages could improve access to immunisation services and (d) addressing entrenched racism in the community will help build cultural safety in health services. While parents in Kempsey were supportive of immunisation, resourceful and resilient, many struggled to overcome entrenched structural and cultural barriers to accessing services. This was particularly difficult for First Nations, socially disadvantaged and single mums. CONCLUSIONS: Public health services can provide more support to those mothers and grandmothers who need it most, to ensure they are able to access immunisation services without delay.

Exploring the services and management available to women experiencing complications in early pregnancy: a survey of Ontario, Canada hospitals.

This investigation surveyed the gynaecologic services and management available to women experiencing early pregnancy complications in the province of Ontario, Canada. The Chiefs of Gynaecology/Obstetrics of 61 Ontario hospitals were invited to complete a 55-item, online questionnaire using modified Dillman methodology. Forty-three hospital site respondents completed the survey (a response rate of 70.5%). It was reported that 18 (41.9%) hospitals had access to an early pregnancy assessment unit (EPAU), and 12 (66.7%) EPAUs had ≤2 days between the referral and the first appointment. Of the 25 (58.1%) hospital respondents without an EPAU, 14 (56.0%) reported previous consideration of creating an EPAU. At these hospitals, patients with early pregnancy complications have access to care through the ED (n = 22, 88.0%), obstetricians/gynaecologists (n = 22, 88.0%), person on-call (n = 16, 64.0%), family physicians (n = 11, 44.0%) or midwives (n = 9, 36.0%). This investigation found great heterogeneity in the care accessible to women experiencing early pregnancy complications in hospitals in Ontario, Canada.Impact statementWhat is already known on this subject? Early pregnancy assessment units (EPAUs) are the standard for evaluating and caring for complications of early pregnancy. It has been well documented that EPAUs result in positive health service outcomes such as more cost-effective care, more timely management, and improved quality of care and patient satisfaction.What do the results of this study add? This investigation found that the province of Ontario, Canada has begun to adopt the EPAU model; however, a great heterogeneity exists in the care accessible to women experiencing early pregnancy complications throughout the province. Nonetheless, where EPAUs are available, they provide a structured referral system for women experiencing complications of early pregnancy that require gynaecologic assessment, such as ectopic pregnancy, providing close follow-up and predictable pathways of care for this patient population.What are the implications of these findings for clinical practice and/or further research? This study highlights the need for hospitals in the province of Ontario to improve their current service delivery models for women experiencing early pregnancy complications. Further research should be undertaken to determine whether the positive health service outcomes of EPAUs are also relevant in the Canadian healthcare system.

Transfusion-associated circulatory overload risk mitigation: survey on hospital policies for compliance with AABB Standard 5.9.17.

BACKGROUND: AABB Standards for Blood Banks and Transfusion Services require accredited institutions to have a policy for handling requests for blood components on patients clinically identified as being at high risk for transfusion-associated circulatory overload (TACO; Standard 5.19.7, 31st edition). This survey elucidated how AABB accredited hospital transfusion services/blood banks around the world are complying with this Standard. METHODS: A link to a Web-based survey in English was e-mailed under the auspice of the AABB to each AABB accredited hospital transfusion service/blood bank (n = 851) asking for details on how their institution is complying with this Standard and for general information on any TACO risk mitigation strategies in place. RESULTS: Of the 290 responses received (34% response rate), 282 met the criteria for analysis. There were 174 of 282 (62%) respondents who indicated that their institution has a formal policy for complying with the Standard, and 108 of 282 (38%) who indicated that their institution does not have a formal policy. A diverse range of policies and practices were in place at the institutions with and without a formal policy ranging from writing advice/recommendations in the charts of patients at increased risk of TACO, promulgating policies from the transfusion service/blood bank or institution itself that would reduce the risk, or using decision support tools to provide education about reducing the risk of TACO. CONCLUSIONS: Many but not all AABB accredited institutions have policies to comply with the TACO risk mitigation Standard. However, the vast majority conduct activities that could mitigate risk for TACO.

Is Self-Compassion a Worthwhile Therapeutic Target for ICD-11 Complex PTSD (CPTSD)?

BACKGROUND: Two 'sibling' disorders have been proposed for the fourthcoming 11th version of the International Classification of Diseases (ICD-11): post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD). Examining psychological factors that may be associated with CPTSD, such as self-compassion, is an important first step in its treatment that can inform consideration of which problems are most salient and what interventions are most relevant. AIMS: We set out to investigate the association between self-compassion and the two factors of CPTSD: the PTSD factor (re-experiencing, avoidance, sense of threat) and the Disturbances in Self-Organization (DSO) factor (affect dysregulation, negative self-concept and disturbances in relationships). We hypothesized that self-compassion subscales would be negatively associated with both PTSD and DSO symptom clusters. METHOD: A predominantly female, clinical sample (n = 106) completed self-report scales to measure traumatic life events, ICD-11 CPTSD and self-compassion. RESULTS: Significant negative associations were found between the CPTSD DSO clusters of symptoms and self-compassion subscales, but not for the PTSD ones. Specifically it was also found that self-judgement and common humanity significantly predicted hypoactive affect dysregulation whereas self-judgement and isolation significantly predicted negative self-concept. CONCLUSIONS: Our results indicate that self-compassion may be a useful treatment target for ICD-11 CPTSD, particularly for symptoms of negative self-concept and affect dysregulation. Future research is required to investigate the efficacy and acceptability of interventions that have implicit foundations on compassion.

Co-designing a web-based education platform for patients with early pregnancy loss.

Canadian emergency departments (EDs) frequently provide care to patients undergoing early pregnancy loss. Unfortunately, in this setting, patients commonly have negative experiences, in part due to lack of appropriate follow-up and education on symptoms that may arise after discharge. In response to this gap, our team created a free, web-based, patient-informed educational platform for women to access accurate information on early pregnancy loss. This free and publicly accessible resource was launched in May 2022 at Mount Sinai Hospital in Toronto and was shared with EDs across Canada.

RéSUMé: Les services d'urgence (SU) canadiens fournissent fréquemment des soins aux patientes qui subissent une perte de grossesse précoce. Malheureusement, dans ce contexte, les patientes ont souvent des expériences négatives, en partie à cause du manque de suivi approprié et d'éducation sur les symptômes qui peuvent apparaître après la sortie de l'hôpital. Pour combler cette lacune, notre équipe a créé une plate-forme éducative gratuite, basée sur le Web et informée par les patientes, permettant aux femmes d'accéder à des informations précises sur la perte de grossesse précoce. Cette ressource gratuite et accessible au public a été lancée en mai 2022 à l'hôpital Mount Sinai de Toronto et a été partagée avec les services d'urgence de tout le Canada.

Using a performance management framework to improve quality.

In light of Lord Darzi's NHS Next Stage Review final report, which emphasises the need for clinical services to be effective and good quality, this article describes how a directorate in a mental health trust used a performance management framework to focus more closely on the quality of services.

Ectopic pregnancy outcomes in patients discharged from the emergency department.

OBJECTIVE: The objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the emergency department (ED) where ectopic pregnancy had not yet been excluded. METHODS: This was a retrospective chart review of pregnant (<12-week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule-out ectopic pregnancy, or pregnancy of unknown location over a 7-year period. RESULTS: Of the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes, and 71 (12.9%) had other outcomes that included therapeutic abortion, molar pregnancy, or resolution of ßHCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal ultrasound during their index ED visit, and 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy. CONCLUSION: These results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.

Services for emergency department patients experiencing early pregnancy complications: A survey of Ontario hospitals.

OBJECTIVES: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), because most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. METHODS: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. RESULTS: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported that they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications, including pregnancy of unknown location and threatened abortion. Respondents also stated that a radiologist-interpreted ultrasound was available to only 22 (34.9%) of hospital sites for 24 hours, 7 days per week for women with early pregnancy complications. CONCLUSIONS: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.

OBJECTIF: Les femmes qui présentent des complications en début de grossesse consultent souvent au service des urgences (SU), la plupart d'entre elles n'ayant pas encore de plan de soins déjà établi par un professionnel de la santé en obstétrique. L'étude avait pour objectif principal de relever les services (prise en charge au SU, échographie, suivi) auxquels les femmes ayant fait un avortement spontané ou étant en état de menace d'avortement en début de grossesse avaient accès au SU, dans les hôpitaux, en Ontario. MÉTHODE: Les chefs des services de médecine d'urgence de 71 hôpitaux, en Ontario, ayant reçu plus de 30 000 patients en 2017 ont été invités à répondre à un questionnaire en ligne, composé de 30 éléments et envoyé selon une version modifiée de la méthode de Dillman. RÉSULTATS: Les chefs de 63 SU, de partout en Ontario, ont rempli le questionnaire (taux de réponse : 88,7%). Sur ce nombre, 34 (54,0%) ont indiqué ne pas pouvoir offrir des services cliniques de début de grossesse aux femmes consultant au SU pour des complications gravidiques précoces, et jugées en état de retourner à domicile. D'après l'enquête, les femmes étaient suivies pour ces mêmes complications, notamment des grossesses de siège inconnu ou des menaces d'avortement, dans 14 SU (41,2%) de ces hôpitaux. De plus, les femmes connaissant des complications en début de grossesse ne pouvaient profiter de services d'interprétation d'échographies par des radiologistes, 24 heures sur 24, 7 jours sur 7, que dans 22 des hôpitaux participants (34,9%). CONCLUSION: Les résultats de l'étude font ressortir la confiance que mettent certains hôpitaux dans les SU pour offrir un suivi continu aux femmes souffrant de complications en début de grossesse. Le manque de ressources cliniques et de personnel spécialisé dans les SU, en Ontario, rend irréaliste le suivi longitudinal de ces femmes et, de ce fait, les expose à des risques indus et à des complications.

Protect the bursary.

The campaign and bursary extension that aims to attract nursing students to Wales, where I live, (online news, 9 May) is welcome.

Mutations in genes encoding the cadherin receptor-ligand pair DCHS1 and FAT4 disrupt cerebral cortical development.

The regulated proliferation and differentiation of neural stem cells before the generation and migration of neurons in the cerebral cortex are central aspects of mammalian development. Periventricular neuronal heterotopia, a specific form of mislocalization of cortical neurons, can arise from neuronal progenitors that fail to negotiate aspects of these developmental processes. Here we show that mutations in genes encoding the receptor-ligand cadherin pair DCHS1 and FAT4 lead to a recessive syndrome in humans that includes periventricular neuronal heterotopia. Reducing the expression of Dchs1 or Fat4 within mouse embryonic neuroepithelium increased progenitor cell numbers and reduced their differentiation into neurons, resulting in the heterotopic accumulation of cells below the neuronal layers in the neocortex, reminiscent of the human phenotype. These effects were countered by concurrent knockdown of Yap, a transcriptional effector of the Hippo signaling pathway. These findings implicate Dchs1 and Fat4 upstream of Yap as key regulators of mammalian neurogenesis.

The use of oral misoprostol as a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-controlled trial.

OBJECTIVE: The purpose of this study was to assess the effectiveness of oral misoprostol as a cervical ripening agent when used in operative hysteroscopy. STUDY DESIGN: This was a double-blind, placebo-controlled trial. Any patient undergoing an operative hysteroscopy (with a 9-mm to 10-mm hysteroscope) was considered eligible for the trial. Patients were randomly allocated, by means of computer-generated numbers, to receive either placebo or 400 microg of misoprostol 12 and 24 hours before surgery. The primary outcome measure in this study was the ease of cervical dilatation as measured by the largest-number Hegar dilator that could be inserted into the cervix without resistance. A subjective assessment of the ease of dilatation was also recorded on a Likert scale. Other demographic data including age, menopausal status, parity, and use of gonadotropin-releasing hormone (GnRH) analogues were also recorded. Adverse effects experienced and any other adverse outcomes were also recorded for each group. Logistic regression analysis was used to compare the two groups. RESULTS: Two hundred four patients were recruited into the study. There were no differences between the two groups in demographic variables. The misoprostol group demonstrated an increased ease of cervical dilatation (odds ratio [OR] 2.6; CI 1.28-5.29; P =.008). This was also demonstrated in the subgroup of patients who were menopausal or who had been pretreated with a gonadotropin-releasing hormone analog (OR 2.49; CI 1.11-5.58; P =.026), as well as in those who were premenopausal (OR 2.15; CI 1.04 4.45; P =.04). There were no differences between the two groups in the time required for dilatation (P =.08) or ease of dilatation (P =.12). Adverse effects were greater in the treatment group: diarrhea (28% vs 4%; P <.001), cramps (27% vs 1%; P <.0001), and bleeding (26% vs 1.3%; P <.001). CONCLUSIONS: Misoprostol demonstrates a benefit over placebo in the ease of cervical dilatation in premenopausal and postmenopausal women and in those pretreated with a gonadotropin-releasing hormone analog. Adverse effects were more common in the treatment group but did not preclude the patients from taking the medication.

Critical contribution of linker proteins to Raf kinase activation.

Genetic analysis of Ras signaling has unveiled the participation of non-enzymatic accessory proteins in signal transmission. These proteins, KSR, CNK, and Sur-8, can interact with multiple core components of the Ras/MAP kinase cascade and may contribute to the structural organization of this cascade. However, the precise biochemical nature of the contribution of these proteins to Ras signaling is currently unknown. Here we show directly that CNK and KSR are required for stimulus dependent Raf kinase activation. CNK is required for membrane recruitment of Raf, while KSR is likely required to couple Raf to upstream kinases. These results demonstrate that CNK and KSR are integral components of the cellular machinery mediating Raf activation.