Perinatal mental health and pregnancy-associated mortality: opportunities for change.

Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% (n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths (n = 16, 62%) occurred in the late postpartum period and 42% (n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.

Health professional attitudes and perceptions of prehabilitation and nutrition before haematopoietic cell transplantation.

BACKGROUND: Nutritional prehabilitation may improve haematopoietic cell transplantation (HCT) outcomes, although little evidence exists. The present study aimed to understand healthcare professional (HCP) perceptions of prehabilitation and nutritional care pre-HCT in UK centres. METHODS: An anonymous online survey (developed and refined via content experts and piloting) was administered via email to multidisciplinary HCPs in 39 UK adult centres, between July 2021 and June 2022. Data are presented as proportions of responses. Routine provision denotes that care was provided >70% of time. RESULTS: Seventy-seven percent (n = 66) of HCPs, representing 61.5% (n = 24) of UK adult HCT centres, responded. All HCPs supported prehabilitation, proposing feasible implementation between induction chemotherapy (60.4%; n = 40) and first HCT clinic (83.3%; n = 55). Only 12.5% (n = 3) of centres had a dedicated prehabilitation service. Nutrition (87.9%; n = 58), emotional wellbeing (92.4%; n = 61) and exercise (81.8%; n = 54) were considered very important constituents. HCPs within half of the HCT centres (n = 12 centres) reported routine use of nutrition screening pre-HCT with a validated tool; 66.7% of HCPs (n = 36) reported using the malnutrition universal screening tool (MUST). Sixty-two percent (n = 41) of HCPs reported those at risk, received nutritional assessments, predominantly by dietitians (91.6%; n = 22) using the dietetic care process (58.3%; n = 14). Body mass index (BMI) was the most frequently reported body composition measure used by HCPs (70.2%, n = 33). Of 59 respondents, non-dietitians most routinely provided dietary advice pre-HCT (82.4%; n = 28 vs. 68%; n = 17, p = 0.2); including high-energy/protein/fat and neutropenic diet advice. Prophylactic enteral feeding pre-HCT was rare, indicated by low BMI and significant unintentional weight loss. Just under half (n = 25 of 59, 42.4%) HCPs reported exercise advice was given routinely pre-HCT. CONCLUSIONS: Nutrition and prehabilitation pre-HCT are considered important and deliverable by HCPs, but current provision in UK centres is limited and inconsistent.

Towards establishing no observed adverse effect levels (NOAEL) for different sources of dietary phosphorus in feline adult diets: results from a 7-month feeding study.

High dietary phosphorus (P), particularly soluble salts, may contribute to chronic kidney disease development in cats. The aim of the present study was to assess the safety of P supplied at 1 g/1000 kcal (4184kJ) from a highly soluble P salt in P-rich dry format feline diets. Seventy-five healthy adult cats (n 25/group) were fed either a low P control (1·4 g/1000 kcal [4184kJ]; Ca:P ratio 0·97) or one of two test diets with 4 g/1000 kcal (4184 kJ); Ca:P 1·04 or 5 g/1000 kcal (4184kJ); Ca:P 1·27, both incorporating 1 g/1000 kcal (4184 kJ) sodium tripolyphosphate (STPP) - for a period of 30 weeks in a randomised parallel-group study. Health markers in blood and urine, glomerular filtration rate, renal ultrasound and bone density were assessed at baseline and at regular time points. At the end of the test period, responses following transition to a commercial diet (total P - 2·34 g/1000 kcal [4184kJ], Ca:P 1·3) for a 4-week washout period were also assessed. No adverse effects on general, kidney or bone (skeletal) function and health were observed. P and Ca balance, some serum biochemistry parameters and regulatory hormones were increased in cats fed test diets from week 2 onwards (P ≤ 0·05). Data from the washout period suggest that increased serum creatinine and urea values observed in the two test diet groups were influenced by dietary differences during the test period, and not indicative of changes in renal function. The present data suggest no observed adverse effect level for feline diets containing 1 g P/1000 kcal (4184 kJ) from STPP and total P level of up to 5 g/1000 kcal (4184 kJ) when fed for 30 weeks.

Taking the Next Steps in Regenerative Rehabilitation: Establishment of a New Interdisciplinary Field.

The growing field of regenerative rehabilitation has great potential to improve clinical outcomes for individuals with disabilities. However, the science to elucidate the specific biological underpinnings of regenerative rehabilitation-based approaches is still in its infancy and critical questions regarding clinical translation and implementation still exist. In a recent roundtable discussion from International Consortium for Regenerative Rehabilitation stakeholders, key challenges to progress in the field were identified. The goal of this article is to summarize those discussions and to initiate a broader discussion among clinicians and scientists across the fields of regenerative medicine and rehabilitation science to ultimately progress regenerative rehabilitation from an emerging field to an established interdisciplinary one. Strategies and case studies from consortium institutions-including interdisciplinary research centers, formalized courses, degree programs, international symposia, and collaborative grants-are presented. We propose that these strategic directions have the potential to engage and train clinical practitioners and basic scientists, transform clinical practice, and, ultimately, optimize patient outcomes.

The impact of the COVID-19 pandemic on women's mental health.

The current worldwide outbreak of COVID-19 has changed the modus operandi of all segments of society. While some pandemic-related stressors affect nearly everyone, many especially affect women. PURPOSE: To review what is known about the pandemic's effect on women's mental health, what makes them more predisposed to vulnerabilities and adverse impacts, and strategies for preventing and treating these mental health consequences in the female population during specific stages across the lifespan. METHODS: The authors performed a narrative review in combination with their observations from clinical experience in the field of women's mental health and reproductive psychiatry. Articles on women's mental health and COVID-19 up to May 30, 2020, were searched using the electronic PubMed and PsychInfo databases, as well as publications by major health entities (e.g., World Health Organization, Centers for Disease Control and Prevention, the United Nations) and press releases from prime communication outlets (e.g., National Public Radio). RESULTS AND CONCLUSIONS: Women who are pregnant, postpartum, miscarrying, or experiencing intimate partner violence are at especially high risk for developing mental health problems during the pandemic. Proactive outreach to these groups of women and enhancement of social supports could lead to prevention, early detection, and prompt treatment. Social support is a key protective factor. Similarly, parenting may be substantially more stressful during a pandemic. Gender disparities may be accentuated, particularly for employed women or single parents, as women are disproportionately responsible for the bulk of domestic tasks, including childcare and eldercare.

The collective impact of rare diseases in Western Australia: an estimate using a population-based cohort.

PURPOSE: It has been argued that rare diseases should be recognized as a public health priority. However, there is a shortage of epidemiological data describing the true burden of rare diseases. This study investigated hospital service use to provide a better understanding of the collective health and economic impacts of rare diseases. METHODS: Novel methodology was developed using a carefully constructed set of diagnostic codes, a selection of rare disease cohorts from hospital administrative data, and advanced data-linkage technologies. Outcomes included health-service use and hospital admission costs. RESULTS: In 2010, cohort members who were alive represented approximately 2.0% of the Western Australian population. The cohort accounted for 4.6% of people discharged from hospital and 9.9% of hospital discharges, and it had a greater average length of stay than the general population. The total cost of hospital discharges for the cohort represented 10.5% of 2010 state inpatient hospital costs. CONCLUSIONS: This population-based cohort study provides strong new evidence of a marked disparity between the proportion of the population with rare diseases and their combined health-system costs. The methodology will inform future rare-disease studies, and the evidence will guide government strategies for managing the service needs of people living with rare diseases.Genet Med advance online publication 22 September 2016.

Gender-specific mental health care needs of women veterans treated for psychiatric disorders in a Veterans Administration Women's Health Clinic.

OBJECTIVE: This pilot study aims to ascertain the prevalence of self-reported premenstrual, perinatal, and perimenopausal influences on mental health, and of gynecologic conditions that could interact with psychiatric conditions, among women veterans receiving psychiatric care within a Veterans Administration (VA) Women's Health Clinic (WHC). METHODS: Participants included all women veterans (N=68) who received psychiatric evaluations within a VA WHC over a 5-month period. This setting encompasses colocated and coordinated primary care, gynecologic and mental health services. Evaluations included a Women's Mental Health Questionnaire, a psychiatric interview, and medical record review. Deidentified data were extracted from a clinical data repository for this descriptive study. RESULTS: High proportions of study participants reported that their emotional problems intensified premenstrually (42.6%), during pregnancy (33.3%), in the postpartum period (33.3%), or during perimenopause (18.2%). Unintended pregnancy (70.0% of pregnancies) and pregnancy loss (63.5% of women who had been pregnant) were prominent sex-linked stressors. Dyspareunia (22.1% of participants) and pelvic pain (17.6% of participants) were frequent comorbidities. CONCLUSIONS: Among women veterans receiving psychiatric care within a VA WHC, there are high rates of self-reported premenstrual, perinatal, and perimenopausal influences on mental health. This population also has substantial comorbidity of psychiatric disorders with dyspareunia and pelvic pain. This underscores the importance of recognizing and addressing women veterans' sex-specific care needs, including interactions among reproductive cycle phases, gynecologic pain, and psychiatric symptoms. The findings support the need for greater awareness of the sex-specific mental health needs of women veterans, and for more definitive studies to further characterize these needs.

Screening for bipolar disorder during pregnancy.

Bipolar disorder is a high-risk condition during pregnancy. In women receiving prenatal care, this study addresses the proportion screening positive for bipolar disorder with or without also screening positive for depression. This is a pilot study using chart abstraction of Edinburgh Postnatal Depression Scale (EPDS) and Mood Disorder Questionnaire (MDQ) scores from patients' initial prenatal visits. Among 342 participants, 289 (87.1 %) completed the EPDS, 277 (81.0 %) completed the MDQ, and 274 (80.1 %) completed both. Among EPDS screens, 49 (16.4 %) were positive. Among MDQ screens, 14 (5.1 %) were positive. Nine (21.4 %) of the 42 participants with a positive EPDS also had a positive MDQ. Of the 14 patients with a positive MDQ, five (35.7 %) had a negative EPDS. The prevalence of positive screens for bipolar disorder in an obstetric population is similar to gestational diabetes and hypertension, which are screened for routinely. Without screening for bipolar disorder, there is a high risk of misclassifying bipolar depression as unipolar depression. If only women with current depressive symptoms are screened for bipolar disorder, approximately one third of bipolar disorder cases would be missed. If replicated, these findings support simultaneous screening for both depression and bipolar disorder during pregnancy.

Bipolar disorder in women.

This article summarizes research pertinent to the clinical care of women with bipolar disorder. With bipolar disorder, female gender correlates with more depressive symptoms and different comorbidities. There is a high risk of symptom recurrence postpartum and possibly during perimenopause. Women with bipolar disorder have increased risk of sexually transmitted diseases, unplanned pregnancies, excessive weight gain, metabolic syndrome, and cardiovascular disease. Mood stabilizing medications, specific psychotherapies, and lifestyle changes can stabilize mood and improve functioning. Pharmacologic considerations include understanding interactions between mood stabilizing medications and contraceptive agents and risks and benefits of mood stabilizing medication during pregnancy and lactation.

Strategic information for hospital service planning: a linked data study to inform an urban Aboriginal Health Liaison Officer program in Western Australia.

OBJECTIVES: The aim of the present study was to provide descriptive planning data for a hospital-based Aboriginal Health Liaison Officer (AHLO) program, specifically quantifying episodes of care and outcomes within 28 days after discharge. METHODS: A follow-up study of Aboriginal in-patient hospital episodes was undertaken using person-based linked administrative data from four South Metropolitan hospitals in Perth, Western Australia (2006-11). Outcomes included 28-day deaths, emergency department (ED) presentations and in-patient re-admissions. RESULTS: There were 8041 eligible index admissions among 5113 individuals, with episode volumes increasing by 31% over the study period. Among patients 25 years and older, the highest ranking comorbidities included injury (47%), drug and alcohol disorders (41%), heart disease (40%), infection (40%), mental illness (31%) and diabetes (31%). Most events (96%) ended in a regular discharge. Within 28 days, 24% of events resulted in ED presentations and 20% resulted in hospital readmissions. Emergency readmissions (13%) were twice as likely as booked re-admissions (7%). Stratified analyses showed poorer outcomes for older people, and for emergency and tertiary hospital admissions. CONCLUSIONS: Future planning must address the greater service volumes anticipated. The high prevalence of comorbidities requires intensive case management to address case complexity. These data will inform the refinement of the AHLO program to improve in-patient experiences and outcomes.

Factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus.

Women with gestational diabetes mellitus (GDM) have a substantial risk of subsequently developing type 2 diabetes. This risk may be mitigated by engaging in healthy eating, physical activity, and weight loss when indicated. Since postpartum depressive symptoms may impair a woman's ability to engage in lifestyle changes, we sought to identify factors associated with depressive symptoms in the early postpartum period among women with recent GDM. The participants are part of the baseline cohort of the TEAM GDM (Taking Early Action for Mothers with Gestational Diabetes Mellitus) study, a one-year randomized trial of a lifestyle intervention program for women with a recent history of GDM, conducted in Boston, Massachusetts between June 2010 and September 2012. We administered the Edinburgh Postnatal Depression Scale (EPDS) at 4-15 weeks postpartum to women whose most recent pregnancy was complicated by GDM (confirmed by laboratory data or medical record review). An EPDS score ≥9 indicated depressive symptoms. We measured height and thyroid stimulating hormone, and administered a questionnaire to collect demographic data and information about breastfeeding and sleep. We calculated body mass index (BMI) using self-reported pre-pregnancy weight and measured height. We reviewed medical records to obtain data about medical history, including history of depression, mode of delivery, and insulin use during pregnancy. We conducted bivariable analyses to identify correlates of postpartum depressive symptoms, and then modeled the odds of postpartum depressive symptoms using multivariable logistic regression. Our study included 71 women (mean age 33 years ± 5; 59 % White, 28 % African-American, 13 % Asian, with 21 % identifying as Hispanic; mean pre-pregnancy BMI 30 kg/m(2) ± 6). Thirty-four percent of the women scored ≥9 on the EPDS at the postpartum visit. In the best fit model, factors associated with depressive symptoms at 6 weeks postpartum included cesarean delivery (aOR 4.32, 95 % CI 1.46, 13.99) and gestational weight gain (aOR 1.21 [1.02, 1.46], for each additional 5 lbs gained). Use of insulin during pregnancy, breastfeeding, personal history of depression, and lack of a partner were not retained in the model. Identifying factors associated with postpartum depression in women with GDM is important since depression may interfere with lifestyle change efforts in the postpartum period. In this study, cesarean delivery and greater gestational weight gain were correlated with postpartum depressive symptoms among women with recent GDM (Clinicaltrials.gov NCT01158131).

Impact of enteral immunonutrition on infectious complications and immune and inflammatory markers in cancer patients undergoing chemotherapy: A systematic review of randomised controlled trials.

BACKGROUND: There is increasing awareness of the importance of nutritional support in cancer treatment including the interaction with immunity. Immunonutrition is the provision of one or more nutrients (e.g. Vitamins A, D, or E, omega-3 fatty acids, arginine and glutamine) known to modulate immune function when given at levels above those normally encountered in the diet in order to support immune system function or modulate its activity, including control of inflammation. We reviewed the role of oral or enteral immunonutrition versus standard nutrition on infection and infection-related biomarkers in adult cancer patients undergoing chemotherapy. METHODS: A systematic search of oral or enteral immunonutrition versus standard nutrition in adult cancer patients during chemotherapy with or without radiotherapy or haematopoietic stem cell transplant was conducted in MEDLINE, EMBASE and CENTRAL. The search was limited to randomised controlled trials. Our primary outcome was infectious episodes or immune-related biomarkers (e.g. immune cell numbers, inflammatory markers). Secondary outcomes included incidence of malnutrition or cachexia, non-infection related adverse events (AEs), rate of remission, survival, and delays or incomplete cycles of chemotherapy. Risk of bias was assessed using ROB 2.0 and study quality was assessed using CASP for RCTs. RESULTS: The search yielded seven studies involving 521 patients (261 immunonutrition, 260 control) for analysis. All studies enrolled patients with solid tumours (no haematological malignancies). Studies were heterogenous for cancer type (upper gastrointestinal, head and neck, pancreatic and lung), immunonutrient composition (omega-3 fatty acids, vitamin A, E, glutamine, arginine or nucleotides), delivery route (enteral nutrition or oral nutritional supplement) and control used. Intervention period ranged from 4 to 14 weeks. No study reported absolute number of infections. Three studies reported AEs including potential infectious episodes of febrile neutropenia, pneumonitis and mucositis with oral candidiasis. Some studies report a decrease in blood concentrations of CRP and TNF-α with immunonutrition. CONCLUSION: There is currently insufficient evidence to define a role for immunonutrition on infectious episodes during chemotherapy in adult cancer patients. Further well-defined studies that account for degree of malnutrition, dose, timing and duration of immunonutrition in specific well-defined cancer groups using a standardised outcome framework are needed.

Retention, mobility, and successful transition to independence of health sciences postdocs.

INTRODUCTION: Obtaining a tenure track faculty position (TTFP) after postdoctoral appointment (PDA) completion is considered an indicator of successful transition to independence (TTI). Whether cross-institutional mobility (CIM)-moving to a different institution from that of the PDA-contributes to TTI is unclear, as data evaluating retention and mobility is lacking. We tested the hypothesis that, for postdocs (PDs) at R1 institutions, CIM is a significant predictor of successful TTI defined as TTFP-status 3 years post-PDA. MATERIALS AND METHODS: Using University of Pittsburgh data for health sciences PDs we tested the association of CIM at PDA completion (moved to a different institution (CIM = 1) or retained at Pitt (CIM = 0)) with TTFP-status 3 years post-PDA (TTFP, non-TTFP, or left faculty position) using multinomial logistic regression models. RESULTS: Among all 622 Pitt PDs, 3-year retention in a faculty position at Pitt was 21%, while 14% had a faculty position outside of Pitt. Among the analytic sample of PDs with an academic career outcome during the study period (N = 238; 50% women, 8% underrepresented minorities (URM)), at baseline PDA completion 39% moved to a different institution (CIM = 1), and 61% remained at Pitt (CIM = 0) in any job type. Those with CIM = 1 had greater odds of having a TTFP at follow-up than those with CIM = 0 [adjusted OR (95% CI): 4.4 (2.1, 9.2)]. DISCUSSION: One fifth of Pitt PDs were retained by Pitt as faculty. While Pitt PDs were equally likely to get a faculty position whether they were retained at Pitt or left, those who left had greater odds of obtaining a TTFP. Future work with longer follow-up times, expanded markers of TTI, and samples from other R1 institutions is needed to better understand the reason for these results. This knowledge can lead to better support for the next generation of PDs as they successfully transition to faculty.

Suitability of Dried Blood Spots for Accelerating Veterinary Biobank Collections and Identifying Metabolomics Biomarkers With Minimal Resources.

Biomarker discovery using biobank samples collected from veterinary clinics would deliver insights into the diverse population of pets and accelerate diagnostic development. The acquisition, preparation, processing, and storage of biofluid samples in sufficient volumes and at a quality suitable for later analysis with most suitable discovery methods remain challenging. Metabolomics analysis is a valuable approach to detect health/disease phenotypes. Pre-processing changes during preparation of plasma/serum samples may induce variability that may be overcome using dried blood spots (DBSs). We report a proof of principle study by metabolite fingerprinting applying UHPLC-MS of plasma and DBSs acquired from healthy adult dogs and cats (age range 1-9 years), representing each of 4 dog breeds (Labrador retriever, Beagle, Petit Basset Griffon Vendeen, and Norfolk terrier) and the British domestic shorthair cat (n = 10 per group). Blood samples (20 and 40 µL) for DBSs were loaded onto filter paper, air-dried at room temperature (3 h), and sealed and stored (4°C for ~72 h) prior to storage at -80°C. Plasma from the same blood draw (250 µL) was prepared and stored at -80°C within 1 h of sampling. Metabolite fingerprinting of the DBSs and plasma produced similar numbers of metabolite features that had similar abilities to discriminate between biological classes and correctly assign blinded samples. These provide evidence that DBSs, sampled in a manner amenable to application in in-clinic/in-field processing, are a suitable sample for biomarker discovery using UHPLC-MS metabolomics. Further, given appropriate owner consent, the volumes tested (20-40 µL) make the acquisition of remnant blood from blood samples drawn for other reasons available for biobanking and other research activities. Together, this makes possible large-scale biobanking of veterinary samples, gaining sufficient material sooner and enabling quicker identification of biomarkers of interest.

Clinical progression of cats with early-stage chronic kidney disease fed diets with varying protein and phosphorus contents and calcium to phosphorus ratios.

BACKGROUND: Dietary protein and phosphorus (P) restriction is the mainstay for nutritional management of chronic kidney disease (CKD). However, adequate restriction levels for cats with early CKD remain unclear. OBJECTIVES: To investigate responses in cats with early CKD to varying dietary protein, P, and calcium (Ca) : P ratio. ANIMALS: Nineteen research colony cats with International Renal Interest Society stages 1-2 CKD. METHODS: In an opportunistic longitudinal case study, cats were fed a low protein (59 g/Mcal), low P (0.84 g/Mcal) dry diet (LP-LP; Ca : P = 1.9) for 18 months and later transitioned onto a moderate protein (76-98 g/Mcal), moderate P (1.4-1.6 g/Mcal) dry-wet diet regimen (MP-MP; Ca : P = 1.4-1.6) for 22 months. Fold-changes in serum creatinine, total Ca (tCa) and P (primary outcomes) and fibroblast growth factor 23 (FGF23) were assessed by linear-mixed models. RESULTS: While feeding LP-LP, mean serum creatinine decreased (0.87-fold, 95% confidence interval [CI] 0.81, 0.93, P < .001) to within reference range after 6 months, while increases in total Ca (tCa; 1.16-fold, 95% CI 1.11, 1.22, P < .001) and FGF23 (2.72-fold, 95% CI 1.72, 4.31, P < .001), but not in P (1.03-fold, 95% CI 0.945, 1.124, P = .94), were observed after 17 months. On MP-MP, mean creatinine, tCa and P remained within reference ranges and did not significantly change (P = .11, P = .98, and P = 1, respectively), while FGF23 significantly decreased (0.58-fold, 95% CI 0.36, 0.95, P = .02) after 22 months. CONCLUSIONS AND CLINICAL IMPORTANCE: Cats with early CKD developed hypercalcemia after long-term feeding of a highly P-restricted diet. Increasing dietary P and reducing Ca : P ratio maintained renal markers, while improving Ca-P balance. Cats with early CKD could benefit from moderately protein- and P-restricted diets.