Pregnancy and breastfeeding in mental health policy: a narrative review.

OBJECTIVES: Mental health difficulties are often exacerbated during the perinatal period. Policy and guidelines are increasingly being used to enhance the quality of healthcare. We conducted a literature review of published research relating to pregnancy and breastfeeding in mental health policy. METHODS: Relevant terms were searched in Medline, CINAHL, APA PsycINFO and EMBASE for articles published in English from 1970 until 2020. Only papers that referenced policy, guidance, legislation or standards were included. While a systematic approach was used, the nature of the results necessitated a narrative review. RESULTS: Initially, 262 papers were identified, 44 met the inclusion criteria. Reproductive health is given sparse consideration in research relating to mental health policy. Despite this, some key areas emerged. These included: the need for proactive preconception psychoeducation, proactive screening of mothers of infants and young children for perinatal mental health issues, enhanced prescribing practice for women of child-bearing age, enhanced monitoring during pregnancy, development of safe modification of coercive practices should they need to be employed in emergency circumstances and targeted measures to reduce substance misuse. Themes that arose relating to breastfeeding and bonding are also described. CONCLUSIONS: Female reproductive health is often ignored in research relating to mental health policy, guidelines and standards. These tools need to be harnessed to promote good healthcare. Reproductive health should be included in the care plan of all mental health patients. These topics need to be integrated into existing relevant policies and not isolated to a separate policy.

Assessment of Patient Satisfaction Among Cancer Patients Undergoing Radiotherapy.

The patient-provider relationship is a key driver of patient satisfaction as it relates to overall healthcare experience. We surveyed patients undergoing radiation therapy to determine what they consider to be the most valued qualities in their interactions with the healthcare team. An ethics-approved 35-item patient satisfaction survey was developed in-house to gain insights on patients' perception of their relationship with the healthcare team throughout their cancer journey. There were 199 completed survey, median age 68 years, 54% women and 45% men. Almost all (95%) "agreed" or "strongly agreed" that their physicians had been sensitive and compassionate. Over 90% felt that they received adequate explanations about their treatment, and had their questions answered. The vast majority (93%) felt included in the decision-making process. Patients reported the 5 most highly rated qualities among their healthcare providers (HCPs) as knowledge, kindness, honesty, good communication, and a cheerful attitude. Overall satisfaction was high but areas for improvement were identified including being offered future appointments for further discussion, more information about clinical trials, other treatments, and community resources. Patients noted their HCPs tended to focus on the physical and emotional needs of patients, but spiritual and cultural needs were rarely addressed. Patients receiving radiotherapy reported high rates of satisfaction across many aspects of their care. These findings also reinforce the different aspects of holistic care that can be improved, and serve as a reminder to clinicians that patients perceive their role as more than just that of a medical expert.

Lessons learned evaluating the baby friendly spaces program for south Sudanese refugees in Gambella, Ethiopia: strengthening research and programmatic partnerships to address maternal and child health and psychosocial needs in humanitarian emergencies.

BACKGROUND: During humanitarian crises, women and children are particularly vulnerable to morbidity and mortality. To address this problem, integrated child health interventions that include support for the well-being of mothers must be adapted and assessed in humanitarian settings. Baby Friendly Spaces (BFS) is a holistic program that aims to improve the health and wellbeing of pregnant and lactating women and their children under two years of age by providing psychosocial support and enhancing positive infant and young child-care practices. Using a mixed-methods, pre-post design, this study explored ways to strengthen the implementation and acceptability of the BFS program, and assess outcomes associated with participation among South Sudanese mothers and their children living in the Nguenyyiel refugee camp in Gambella, Ethiopia. DISCUSSION: A stronger evidence-base for integrated maternal and child health interventions, like BFS, in humanitarian emergencies is needed, but effectively conducting this type of research in unstable settings means encountering and working through myriad challenges. In this paper we discuss lessons learned while implementing this study, including, challenges related to ongoing local political and tribal conflicts and extreme conditions; implementation of a new digital data monitoring system; staff capacity building and turnover; and measurement were encountered. Strategies to mitigate such challenges included hiring and training new staff members. Regular weekly skype calls were held between Action Against Hunger Paris headquarters, the Action Against Hunger team in Gambella and Johns Hopkins' academic partners to follow study implementation progress and troubleshoot any emerging issues. Staff capacity building strategies included holding brief and focused trainings continuously throughout the study for both new and current staff members. Lastly, we engaged local Nuer staff members to help ensure study measures and interview questions were understandable among study participants. CONCLUSIONS: Research focused on strengthening program implementation is critically important for improving maternal and child health in humanitarian emergencies. Research in such settings demands critical problem-solving skills, strong supervision systems, flexibility in timeline and logistics, and tailor-made training for program and research staff members and context- adapted strategies for retaining existing staff.

Public attitudes towards novel reproductive technologies: a citizens' jury on mitochondrial donation.

STUDY QUESTION: Does an informed group of citizens endorse the clinical use of mitochondrial donation in a country where this is not currently permitted? SUMMARY ANSWER: After hearing balanced expert evidence and having opportunity for deliberation, a majority (11/14) of participants in a citizens' jury believed that children should be able to be born using mitochondrial donation. WHAT IS KNOWN ALREADY: Research suggests that patients, oocyte donors and health professionals support mitochondrial donation to prevent transmission of mitochondrial disease. Less is known about public acceptability of this novel reproductive technology, especially from evidence using deliberative methods. STUDY DESIGN, SIZE, DURATION: This study comprised a citizens' jury, an established method for determining the views of a well-informed group of community members. The jury had 14 participants, and ran over one and a half days in 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Jurors were members of the public with no experience of mitochondrial disease. They heard and engaged with relevant evidence and were asked to answer the question: 'Should Australia allow children to be born following mitochondrial donation?' MAIN RESULTS AND THE ROLE OF CHANCE: Eleven jurors decided that Australia should allow children to be born following mitochondrial donation; 7 of whom added conditions such as the need to limit who can access the intervention. Three jurors decided that children should not (or not yet) be born using this intervention. All jurors were particularly interested in the reliability of evidence, licensing/regulatory mechanisms and the rights of children to access information about their oocyte donors. LIMITATIONS, REASONS FOR CAUTION: Jurors' views were well informed and reflected critical deliberation and discussion, but are not intended to be representative of the whole population. WIDER IMPLICATIONS OF THE FINDINGS: When presented with high quality evidence, combined with opportunities to undertake structured deliberation of novel reproductive technologies, members of the public are able to engage in detailed discussions. This is the first study to use an established deliberative method to gauge public views towards mitochondrial donation. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by a University of Sydney Industry and Community Collaboration Seed Award (2017), which was awarded contingent on additional funding from the Mito Foundation. Additional funding was provided by the Mito Foundation. The Foundation was not involved in jury facilitation or deliberation, nor analysis of research data. TRIAL REGISTRATION NUMBER: Not applicable.

A management strategy that reduces NICU admissions and decreases charges from the front line of the neonatal abstinence syndrome epidemic.

OBJECTIVE: The purpose of this study was to test a specialized needs-based management model for a high volume of babies born with neonatal abstinence syndrome (NAS) while controlling costs and reducing neonatal intensive care unit (NICU) bed usage. STUDY DESIGN: Data were analyzed from inborn neonates >35 weeks' gestational age with the diagnosis of NAS (ICD9-CM 779.5), requiring pharmacologic treatment and discharged from 2010 through 2015. Significance was determined using Kruskal-Wallis and Mann-Whitney as well as χ2 for trend. RESULTS: NAS requiring medication treatment increased from 34.1 per 1000 live births in 2010 to 94.3 per 1000 live births in 2015 (P<0.0001 for trend). Hospital charges were significantly different in the three described locations (P<0.0001). Median per patient hospital charges for medically treated NAS were $90 601 (interquartile range (IQR) $64 489 to $128 135) for NAS patients managed in the NICU, $68 750 (IQR $44 952 to $92 548) for those managed in an in-hospital dedicated unit and $17 688 (IQR $9933 to $20 033) for those cared for in an outpatient neonatal withdrawal center. NICU admission was avoided in 78% of the population once both alternative locations were fully implemented. CONCLUSIONS: In this cohort of infants, a 219% increase in the number of infants treated for NAS overwhelmed the capacity of our traditional resources. There was a need to develop new treatment approaches dealing with the NAS crisis and a growing population of prenatally exposed babies. We found that the described model of care significantly reduced charges and stabilized admissions to our NICU despite the marked increase in cases. Without this system, our NICU would be in a critical state of gridlock and diversion; instead, we have efficient management of a large NAS population.

Identifying the needs for competency-based education in Europe: a needs assessment of cardiologists across 52 countries.

Objective: This international needs assessment was mandated by the European Society of Cardiology (ESC) to obtain an in-depth understanding of the current gaps and challenges of European cardiology professionals, with the aim to provide evidence for the development of needs-driven educational and professional development activities. Methods: This ethics-approved needs assessment was conducted among cardiologists from all sub-specialties across 56 countries of Europe and the Mediterranean basin. A mixed-methods research approach was used, combining qualitative in-depth interviews and focus groups with a quantitative survey. Results: Seventy-four (74) cardiologists participated in the qualitative phase and 866 completed the survey. Respondents represented 52 of the 56 targeted countries. Three themes were identified: 1) Challenges in the clinical decision-making process, 2) Challenges in establishing the patient-physician relationship, and 3) Sub-optimal team communication and collaboration. Specific gaps and causalities related to each challenge were found. Although most of the gaps were common across countries and sub-specialties, some significant differences were noted. Conclusion: The findings of this needs assessment indicate gaps and challenges in clinical practice across countries and across sub-specialities. Taking cardiology as an example, this study identifies clear areas of focus, especially around issues of collaboration and communication, for targeted competency-based education in Europe.

Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo.

BACKGROUND: Conflict-affected communities face poverty and mental health problems, with sexual violence survivors at high risk for both given their trauma history and potential for exclusion from economic opportunity. To address these problems, we conducted a randomized controlled trial of a group-based economic intervention, Village Savings and Loans Associations (VSLA), for female sexual violence survivors in the Democratic Republic of Congo. METHODS: In March 2011, 66 VSLA groups, with 301 study participants, were randomized to the VSLA program or a wait-control condition. Data were collected prior to randomization, at 2-months post-program in June 2012, and 8-months later for VSLA participants only. Outcome data included measures of economic and social functioning and mental health severity. VSLA program effect was derived by comparing intervention and control participants' mean changes from baseline to 2-month follow-up. RESULTS: At follow-up, VSLA study women reported significantly greater per capita food consumption and significantly greater reductions in stigma experiences compared with controls. No other study outcomes were statistically different. At 8-month follow-up, VSLA participants reported a continued increase in per capita food consumption, an increase in economic hours worked in the prior 7 days, and an increase in access to social resources. CONCLUSIONS: While female sexual violence survivors with elevated mental symptoms were successfully integrated into a community-based economic program, the immediate program impact was only seen for food consumption and experience of stigma. Impacts on mental health severity were not realized, suggesting that targeted mental health interventions may be needed to improve psychological well-being.

Accelerating clinical drug development for children with tuberculosis.

Despite urgent need, the development, approval and availability of child-friendly anti-tuberculosis drugs lag significantly behind that of adults, with children having been ignored in anti-tuberculosis drug development research. This paper outlines possible strategies for accelerating and better integrating the development of drugs and regimens for pediatric tuberculosis (TB) into existing drug development pathways for adults: initiation of pediatric studies of new treatments as soon as promising efficacy data have been generated in adults following successful phase II studies, shifting from the current age de-escalated approach to concomitant enrollment of children from the various age groups in studies, and leveraging the concepts of both the Unified Pathway and regimen development that have helped speed the study and development of novel regimens in adults.

Assessing standardization of molecular testing for non-small-cell lung cancer: results of a worldwide external quality assessment (EQA) scheme for EGFR mutation testing.

BACKGROUND: The external quality assurance (EQA) process aims at establishing laboratory performance levels. Leading European groups in the fields of EQA, Pathology, and Medical and Thoracic Oncology collaborated in a pilot EQA scheme for somatic epidermal growth factor receptor (EGFR) gene mutational analysis in non-small-cell lung cancer (NSCLC). METHODS: EQA samples generated from cell lines mimicking clinical samples were provided to participating laboratories, each with a mock clinical case. Participating laboratories performed the analysis using their usual method(s). Anonymous results were assessed and made available to all participants. Two subsequent EQA rounds followed the pilot scheme. RESULTS: One hundred and seventeen labs from 30 countries registered and 91 returned results. Sanger sequencing and a commercial kit were the main methodologies used. The standard of genotyping was suboptimal, with a significant number of genotyping errors made. Only 72 out of 91 (72%) participants passed the EQA. False-negative and -positive results were the main sources of error. The quality of reports submitted was acceptable; most were clear, concise and easy to read. However, some participants reported the genotyping result in the absence of any interpretation and many obscured the interpretation required for clinical care. CONCLUSIONS: Even in clinical laboratories, the technical performance of genotyping in EGFR mutation testing for NSCLC can be improved, evident from a high level of diagnostic errors. Robust EQA can contribute to global optimisation of EGFR testing for NSCLC patients.

Ethnic disparities in the oral health of three- to four-year-old children in East London.

AIM: To report ethnic differences related to caries experience among three- to four-year-old children living in three of the most deprived boroughs in the UK in Inner North East London: Tower Hamlets, Hackney and Newham. METHODS: This cross-sectional survey used a cluster sampling study design following the British Association for the Study of Community Dentistry protocol. Twenty nurseries from each borough were randomly selected and all three- to four-year-old children in selected nurseries were invited to participate (n = 2,434). Calibrated dentists examined children. Demographic information was obtained from schools. RESULTS: One thousand, two hundred and eighty-five children were examined in 60 nurseries (response rate = 52.8%). Twenty-four percent of three- to four-year-old children had caries experience (mean dmft = 0.92). Few children (2.1%) had filled teeth. Children living in Hackney had significantly lower dmft scores (mean = 0.63) than children living in Newham (mean = 1.06) and Tower Hamlets (mean = 1.06). White European (mean = 1.91), Bangladeshi (mean = 1.05) and Pakistani (mean = 1.11) children had a significantly higher number of untreated carious teeth than White British children (mean = 0.56). CONCLUSION: Preschool children from a White Eastern European, Bangladeshi and Pakistani background are likely to experience significantly poorer oral health than their White British counterparts. These findings have profound implications for commissioning dental services and oral health promotion.

Metrics for monitoring local inequalities in access to maternity care: developing a basket of markers from routinely available data.

BACKGROUND: Equal access for all based on need is part of a conceptualisation of quality underpinning recent UK NHS policies. OBJECTIVE: To develop metrics for access to maternity care from routinely available data in order to inform inequalities monitoring and commissioning. DESIGN: Cross-sectional cohort design using case-note audit and postnatal questionnaire. SETTING: London hospital, UK, in an area of relative socio-economic deprivation. METHODS: Stage 1: Identification of potential markers. Stage 2: Testing of markers via case note audit and postnatal questionnaire. Stage 3: Selection of final basket of markers of access to maternity services. RESULTS: Of 71 possible markers identified, 32 used information obtainable from maternity case notes. After testing in the case-note audit, 21 were discarded, and 11 included in the final basket covering: timely entry to maternity care; appropriate assessment and identification of needs of individuals; referral and communication with other related health and social care services. CONCLUSION: It is possible to devise a local basket of markers covering a range of important entry and in-system access metrics. Such a tool offers an unobtrusive means to audit the effectiveness of some of the processes intended to help women move through the maternity and related health and social care systems during pregnancy, and to monitor progress on reducing social inequalities in access over time.

Screened individuals' preferences in the delivery of abdominal aortic aneurysm repair.

BACKGROUND: This study aimed to determine preferences for service attributes in a population screened for abdominal aortic aneurysm. METHODS: A questionnaire was designed to encompass various aspects of service provision. Questions were calibrated against the time an individual was willing to travel to access specific attributes. Subjects attending an aneurysm screening programme were asked to complete a questionnaire before their screening ultrasound scan. Statistical analysis was through pairwise analysis of the median travel times with the signed rank test. The Wilcoxon rank sum, analysed by the Kruskal-Wallis test, was used to compare preference ratings. RESULTS: A total of 262 individuals were asked to complete the questionnaire; the response rate was 98.5 per cent. Approximately 92 per cent of individuals stated a willingness to travel for at least 1 h beyond their nearest hospital in order to access services with a 5 per cent lower perioperative mortality rate, a 2 per cent lower amputation or stroke rate, a high annual caseload of aneurysm repairs, and routine availability of endovascular repair. CONCLUSION: Patients attending aneurysm screening were willing to travel beyond their nearest hospital to access a service with better outcomes, higher surgical volumes and endovascular surgery.

Assessing and improving out-of-hours palliative care in a deprived community: a rapid appraisal study.

Recent changes to out-of-hours primary care in the UK have generated concerns about care for palliative care patients. The aim of this study was to identify key challenges and improvements to out-of-hours palliative care in a mixed urban and rural deprived area. We integrated data from three sources: interviews with patients and professionals, direct observations of services, and routine statistics. Key issues in the provision of care were the importance of good communication and having information available, the unwieldy process of accessing medical care out of hours, professionals bypassing routine out-of-hours care for palliative care patients, and out-of-hours care being provided by practitioners unaware of local services. We recommend provision to out-of-hours services of an enhanced 'special note' for palliative care patients, to be completed early in the course of the illness and updated regularly. The provision for certain complex patients to bypass NHS24 should be considered if routine care is not satisfactory.

Lung transplantation in the United States, 1998-2007.

This article highlights trends and changes in lung and heart-lung transplantation in the United States from 1998 to 2007. The most significant change over the last decade was implementation of the Lung Allocation Score (LAS) allocation system in May 2005. Subsequently, the number of active wait-listed lung candidates declined 54% from pre-LAS (2004) levels to the end of 2007; there was also a reduction in median waiting time, from 792 days in 2004 to 141 days in 2007. The number of lung transplants performed yearly increased through the decade to a peak of 1 465 in 2007; the greatest single year increase occurred in 2005. Despite candidates with increasingly higher LAS scores being transplanted in the LAS era, recipient death rates have remained relatively stable since 2003 and better than in previous years. Idiopathic pulmonary fibrosis became the most common diagnosis group to receive a lung transplant in 2007 while emphysema was the most common diagnosis in previous years. The number of retransplants and transplants in those aged > or =65 performed yearly have increased significantly since 1998, up 295% and 643%, respectively. A decreasing percentage of lung transplant recipients are children (3.5% in 2007, n = 51). With LAS refinement ongoing, monitoring of future impact is warranted.

Heart and lung transplantation in the United States, 1997-2006.

This article highlights trends in heart and lung transplantation between 1997 and 2006, drawing on data from the OPTN and SRTR. The total number of candidates actively awaiting heart transplantation declined by 45% over the last decade, dropping from 2414 patients in 1997 to 1327 patients in 2006. The overall death rates among patients awaiting heart transplantation declined over the same period. The distribution of recipients among the different status groups at the time of heart transplantation changed little between the inception of the new classification system in 1999 and 2005. Deaths in the first year after heart transplantation have steadily decreased. At the end of 2006, 2885 candidates were awaiting a lung transplant, up 10% from the 1997 count. The median time-to-transplant for listed patients decreased by 87% over the decade, dropping from 1053 days in 1997 to 132 days in 2006. Selection for listing and transplantation has shifted toward more urgent patients since the May 2005 implementation of a new lung allocation system based on survival benefit and urgency rather than waiting time. Only 31 heart-lung transplants were performed in 2006, down from a high of 62 in 1997.

Construction and characterization of two bacterial artificial chromosome libraries of pea (Pisum sativum L.) for the isolation of economically important genes.

Pea (Pisum sativum L.) has a genome of about 4 Gb that appears to share conserved synteny with model legumes having genomes of 0.2-0.4 Gb despite extensive intergenic expansion. Pea plant inventory (PI) accession 269818 has been used to introgress genetic diversity into the cultivated germplasm pool. The aim here was to develop pea bacterial artificial chromosome (BAC) libraries that would enable the isolation of genes involved in plant disease resistance or control of economically important traits. The BAC libraries encompassed about 3.2 haploid genome equivalents consisting of partially HindIII-digested DNA fragments with a mean size of 105 kb that were inserted in 1 of 2 vectors. The low-copy oriT-based T-DNA vector (pCLD04541) library contained 55 680 clones. The single-copy oriS-based vector (pIndigoBAC-5) library contained 65 280 clones. Colony hybridization of a universal chloroplast probe indicated that about 1% of clones in the libraries were of chloroplast origin. The presence of about 0.1% empty vectors was inferred by white/blue colony plate counts. The usefulness of the libraries was tested by 2 replicated methods. First, high-density filters were probed with low copy number sequences. Second, BAC plate-pool DNA was used successfully to PCR amplify 7 of 9 published pea resistance gene analogs (RGAs) and several other low copy number pea sequences. Individual BAC clones encoding specific sequences were identified. Therefore, the HindIII BAC libraries of pea, based on germplasm accession PI 269818, will be useful for the isolation of genes underlying disease resistance and other economically important traits.

Heart and lung transplantation in the United States, 1996-2005.

This article examines the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients data on heart and lung transplantation in the United States from 1996 to 2005. The number of heart transplants performed and the size of the heart waiting list continued to drop, reaching 2126 and 1334, respectively, in 2005. Over the decade, post-transplant graft and patient survival improved, as did the chances for survival while on the heart waiting list. The number of deceased donor lung transplants increased by 78% since 1996, reaching 1407 in 2005 (up 22% from 2004). There were 3170 registrants awaiting lung transplantation at the end of 2005, down 18% from 2004. Death rates for both candidates and recipients have been dropping, as has the time spent waiting for a lung transplant. Other lung topics covered are living donation, recent surgical advances and changes in immunosuppression regimens. Heart-lung transplantation has declined to a small (33 procedures in 2005) but important need in the United States.

Development of the new lung allocation system in the United States.

This article reviews the development of the new U.S. lung allocation system that took effect in spring 2005. In 1998, the Health Resources and Services Administration of the U.S. Department of Health and Human Services published the Organ Procurement and Transplantation Network (OPTN) Final Rule. Under the rule, which became effective in 2000, the OPTN had to demonstrate that existing allocation policies met certain conditions or change the policies to meet a range of criteria, including broader geographic sharing of organs, reducing the use of waiting time as an allocation criterion and creating equitable organ allocation systems using objective medical criteria and medical urgency to allocate donor organs for transplant. This mandate resulted in reviews of all organ allocation policies, and led to the creation of the Lung Allocation Subcommittee of the OPTN Thoracic Organ Transplantation Committee. This paper reviews the deliberations of the Subcommittee in identifying priorities for a new lung allocation system, the analyses undertaken by the OPTN and the Scientific Registry for Transplant Recipients and the evolution of a new lung allocation system that ranks candidates for lungs based on a Lung Allocation Score, incorporating waiting list and posttransplant survival probabilities.

Holes a plenty: oral health status a major issue for newly arrived refugees in Australia.

BACKGROUND: Dental health needs of newly arrived refugees are much greater than for the wider Australian community. This paper identifies the disparities and highlights major dental health issues for Australia's growing and constantly changing refugee population. METHODS: Using available data and the decayed, missing and filled teeth (DMFT) index as a measure of oral health, the reported oral health status of refugee groups in Australia was compared with that of the general population, Indigenous Australians, recipients of public dental services, special needs groups in Australia and other refugee groups outside Australia. RESULTS: The reported oral health status of Australian refugees compared poorly with the comparison groups. Of particular concern was the number of reported untreated decayed teeth (D). This ranged from a mean of 2.0 to 5.2 compared with 0.6 to 1.4 for the general Australian population. Refugee groups also reported fewer filled teeth (1.0 to 5.8) compared with the general population (4.1 to 9.3). Similar results were found when reported D, M and F teeth for refugees were compared to Indigenous Australians, public dental service recipients, immigrants and special needs groups in Australia. CONCLUSIONS: Dental health of refugees, particularly untreated decay, compared poorly to that of Indigenous Australians, and special needs populations in Australia who all have known worse dental health than the general population. There is an urgent need for the inclusion of this at risk population among targeted dental services. In addition, sources of health related data must clearly identify refugees to enable appropriate comparisons with other population groups. Recommendations for refugees are made regarding on-arrival dental assessment and treatment, and community based oral health programmes.