A critical review of the first six months of operation of a trial Hospital Outreach Post-suicidal Engagement (HOPE) service in Australia.

OBJECTIVE: To review the Hospital Outreach Post-suicidal Engagement (HOPE) service in the first six months of the pilot program in a metropolitan Melbourne setting, including a description of: (a) socio-demographic, health and psychosocial stressors of people referred; (b) method of presentation; (c) interventions provided and (d) outcomes measured. METHOD: A retrospective case file analysis reviewed the first six months of HOPE service operation. RESULTS: Forty people received HOPE service during the study period, 60% female, mean age 35 years (range 17-58). The majority had previously engaged in self-harm (72.5%) or attempted suicide (67.5%). Stressors included social isolation, relationship breakdown, unemployment, financial stress, medical problems, history of mental illness, exposure to family violence and adverse childhood events. Statistically significant improvements occurred in the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) following intervention. There were no deaths by suicide during the study period. CONCLUSION: People referred to HOPE had significant health and psychosocial stressors. Engagement significantly improved subjective well-being and connection with supports. Findings highlighted the need for an integrated clinical and psychosocial model to promote hope and connection in life post suicide attempt. It remains unclear which interventions improved well-being and if this contributes to suicide prevention.

Fetal Nasal Bone Length in the East African Population.

OBJECTIVES: To establish normal ranges of fetal nasal bone length throughout gestation in the East African population and to subsequently compare these measurements with the standardized reference. METHODS: A retrospective cross-sectional study was performed at the University of Minnesota from January 2011 to December 2016. Fetal nasal bone length measurements were generated in a midsagittal plane at an angle of insonation of 45° from ultrasound images of 1407 nonanomalous fetuses of 1130 mothers of East African decent between 14 and 40 weeks' gestation. The proportion of fetal nasal bone lengths of less than 5.2 mm at week 20 of gestation in the East African population was then compared with the 5% noted by the standardized reference by a χ2 test. RESULTS: The fetal nasal bone length increased linearly with advancing gestational age in fetuses of East African mothers (R2 = 0.53; P < .0001). The fetal nasal bone lengths of the East African fetuses were found to be shorter at all ages of gestation compared with the standard reference. At 20 weeks' gestation 17% (95% confidence interval, 13%-22%) of the nasal bone lengths of the East African fetuses were less than 5.2 mm compared with 5% of white and African American fetuses. CONCLUSIONS: Using the standard reference may lead to a greater than 3.5-fold overdiagnosis of hypoplastic nasal bones in the East African population. To improve aneuploidy risk stratification and patient counseling in the East African population, the introduction of a standardized East African-based fetal nasal bone length reference seems warranted.

Velamentous Umbilical Cord Insertion and Ruptured Fetal Vessel: A Cause of Fetal-Maternal Hemorrhage: A Case Report.

Background: Fetal hemorrhage is rare but can result in rapid fetal compromise. Abnormally located fetal vessels within the membranes increase the risk for their rupture and subsequent hemorrhage. The classic example of this is vasa previa. Case: We present a case of acute fetal hemorrhage resulting from a ruptured fetal vessel. During induction of labor, significant fetal heart rate deceleration occurred, coinciding with acute vaginal bleeding and amniotomy. A depressed, live female neonate was delivered by emergency cesarean section. Examination of the placenta revealed a velamentous cord insertion and a ruptured fetal vessel coursing through the chorioamniotic membranes. Neonatal resuscitation included red blood cell transfusion for hypotension and low hematocrit. The neonate made a full recovery. Conclusion: Acute fetal hemorrhage from the rupture of aberrant fetal vessels often coincides with rupture of membranes. Identifying ruptured fetal vessels abnormally coursing through the chorioamniotic membranes on examination of the placenta provides supporting evidence for suspected fetal hemorrhage.

Medical journey of patients with polycystic ovary syndrome and obesity: a cross-sectional survey of patients and primary care physicians.

OBJECTIVES: Patients with polycystic ovary syndrome (PCOS) report dissatisfaction with the diagnostic process and are more likely to have overweight or obesity. We wanted to understand the role that primary care physicians (PCPs) play in the diagnosis of PCOS and how they contribute to treatment of patients with PCOS and obesity. METHODS: A cross-sectional online survey was completed by 251 patients with PCOS and obesity (BMI ≥30 kg/m2) and 305 healthcare providers (PCPs, obstetricians/gynecologists, reproductive and general endocrinologists). This paper focuses on the 75 PCPs treating patients with PCOS and obesity. RESULTS: In the most common patient journey, we found that most patients with PCOS and obesity (53%) have initial discussions about PCOS symptoms with PCPs. However, less than one quarter of patients receive a PCOS diagnosis (22%) or initial treatment (24%) for PCOS from a PCP. One quarter of patients also reported receiving a misdiagnosis from a PCP prior to their PCOS diagnosis. Compared to other healthcare providers surveyed, PCPs were the least comfortable making a PCOS diagnosis. Compared to PCPs without an obesity management focus, PCPs with an obesity management focus were more likely to diagnose patients themselves (38% vs 62%) and initiate PCOS treatment themselves (42% vs 57%). According to PCPs, difficulty with obesity management (47%) was the top reason that patients with PCOS and obesity stop seeing them for PCOS management. CONCLUSION: PCPs are often the initial medical touchpoint for patients with PCOS and obesity. However, PCPs play a smaller role in diagnosis and treatment of PCOS. Increasing education on obesity management may encourage PCPs to diagnose and treat more patients with PCOS and offer strategies to help patients with obesity management.

Polycystic ovary syndrome (PCOS) is a condition where women may make more male hormones than usual, have irregular periods, and have trouble getting pregnant. PCOS can look very different in different patients. This can make it difficult to diagnose. Patients with PCOS are more likely to have obesity (unhealthy excess weight). Having obesity can make patients' PCOS worse and losing weight is an important treatment for PCOS.We wanted to learn more about what patients with PCOS and obesity experience as they try to manage their PCOS and the role of primary care doctors in diagnosing and treating patients with PCOS. To better understand this journey, 251 patients with PCOS and obesity and 75 primary care doctors who treat patients with PCOS and obesity took an online survey.Most patients (53%) first talked about PCOS symptoms with a primary care doctor. However, less than 25% of patients received a PCOS diagnosis or first treatment from a primary care doctor. One quarter of all patients said they were misdiagnosed by a primary care doctor before being diagnosed with PCOS. Primary care doctors were less comfortable than specialist doctors in diagnosing and treating patients with PCOS. Primary care doctors with a focus on weight management were more likely than other primary care doctors to diagnose and treat patients with PCOS themselves.Giving primary care doctors more educational support with PCOS diagnosis and weight management could help patients with PCOS get diagnosed earlier and treated better.

Polycystic Ovary Syndrome and Obesity: A Cross-Sectional Survey of Patients and Obstetricians/Gynecologists.

Background: Polycystic ovary syndrome (PCOS) is an endocrine disorder commonly affecting women of reproductive age. Compared with women without PCOS, women with PCOS are more likely to have overweight or obesity. Materials and Methods: To better understand the role of obstetricians/gynecologists (OB/GYNs) in diagnosis and treatment of patients with PCOS and obesity, we conducted an anonymous, United States population-based, cross-sectional online survey with 251 patients with PCOS and obesity and 305 health care professionals (HCPs), of which 125 were OB/GYNs. Results: In the most common patient journey, most patients were diagnosed (66%) and treated (59%) by OB/GYNs. Most patients (51%) considered OB/GYNs to be the coordinator of their PCOS care. For ongoing management of patients with PCOS and obesity, OB/GYNs reported prescribing general improvements in lifestyle (91%), oral contraceptives (91%), metformin (85%), letrozole (74%), spironolactone (71%), specific diets (60%), medroxyprogesterone (45%), and anti-obesity medications (27%). OB/GYNs were significantly more likely than other HCPs surveyed to strongly agree with the statement that they do not know enough about anti-obesity medications to feel comfortable prescribing them to their patients with PCOS and obesity (p < 0.05). Most OB/GYNs believed that consultation with a dietitian/nutritionist (75%) or access to a physician who specializes in obesity (67%) were the most beneficial types of support for their patients with PCOS and obesity. Conclusions: OB/GYNs recognize the importance of obesity management for the treatment of PCOS; however, utilization of effective obesity tools to treat these patients is low. OB/GYNs may benefit from additional education on obesity management strategies.

Complete Molar Pregnancies with a Coexisting Fetus: Pregnancy Outcomes and Review of Literature.

Objective The objective of the study was to review the obstetric outcomes of complete hydatidiform molar pregnancies with a coexisting fetus (CHMCF), a rare clinical entity that is not well described. Materials and Methods We performed a retrospective case series with pathology-confirmed HMCF. The cases were collected via solicitation through a private maternal-fetal medicine physician group on social media. Each contributing institution from across the United States ( n = 9) obtained written informed consent from the patients directly, obtained institutional data transfer agreements as required, and transmitted the data using a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant modality. Data collected included maternal, fetal/genetic, placental, and delivery characteristics. For descriptive analysis, continuous variables were reported as median with standard deviation and range. Results Nine institutions contributed to the 14 cases collected. Nine (64%) cases of CHMCF were a product of assisted reproductive technology and one case was trizygotic. The median gestational age at diagnosis was 12 weeks and 2 days (9 weeks-19 weeks and 4 days), and over half were diagnosed in the first trimester. The median human chorionic gonadotropin (hCG) at diagnosis was 355,494 mIU/mL (49,770-700,486 mIU/mL). Placental mass size universally enlarged over the surveillance period. When invasive testing was performed, insufficient sample or no growth was noted in 40% of the sampled cases. Antenatal complications occurred in all delivered patients, with postpartum hemorrhage (71%) and hypertensive disorders of pregnancy (29%) being the most frequent outcomes. Delivery outcomes were variable. Four patients developed gestational trophoblastic neoplasia. Conclusion This series is the largest report of obstetric outcomes for CHMCF to date and highlights the need to counsel patients about the severe maternal and fetal complications in continuing pregnancies, including progression to gestational trophoblastic neoplastic disease. Key Points CHMCF is a rare obstetric complication and may be associated with the use of assisted reproductive technology.Universally, patients with CHMCF who elected to manage expectantly developed antenatal complications.The risk of developing gestational trophoblastic neoplasia after CHMCF is high, and termination of the pregnancy did not decrease this risk.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Antibodies in Neonatal Cord Blood After Vaccination in Pregnancy.

BACKGROUND: Studies evaluating the safety and efficacy of currently available vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) do not include pregnant participants. No data are available to counsel on vaccine safety and potential for neonatal passive immunity. CASE: A 34-year-old multigravid patient working in health care received the Pfizer-BioNTech (BNT162b2) mRNA vaccine for SARS-CoV-2 in the third trimester of pregnancy. Uncomplicated spontaneous vaginal delivery of a female neonate with Apgar scores of 9 and 9 occurred at term. The patient's blood as well as neonatal cord blood were evaluated for SARS-CoV-2-specific antibodies. Both the patient and the neonate were positive for antibodies at a titer of 1:25,600. CONCLUSION: In this case, passage of transplacental antibodies for SARS-CoV-2 was shown after vaccination in the third trimester of pregnancy.

Obstetrician-Gynecologists' Strategies for Patient Initiation and Maintenance of Antiobesity Treatment with Glucagon-Like Peptide-1 Receptor Agonists.

Obesity is a chronic disease affecting women at higher rates than men. In an obstetrics and gynecology setting, frequently encountered obesity-related complications are polycystic ovary syndrome, fertility and pregnancy complications, and increased risk of breast and gynecological cancers. Obstetrician-gynecologists (OBGYNs) are uniquely positioned to diagnose and treat obesity, given their role in women's primary health care and the increasing prevalence of obesity-related fertility and pregnancy complications. The metabolic processes of bodyweight regulation are complex, which makes weight-loss maintenance challenging, despite dietary modifications and exercise. Antiobesity medications (AOMs) can facilitate weight loss by targeting appetite regulation. There are four AOMs currently approved for long-term use in the United States, of which liraglutide 3.0 mg is among the most efficacious. Liraglutide 3.0 mg, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), is superior to placebo in achieving weight loss and improving cardiometabolic profile, in both clinical trial and real-world settings. In addition, women with fertility complications receiving liraglutide 1.8-3.0 mg can benefit from improved ovarian function and fertility. Liraglutide 3.0 mg is generally well tolerated, but associated with transient gastrointestinal side effects, which can be mitigated. In this review, we present the risks of obesity and benefits of weight loss for women, and summarize clinical development of GLP-1 RAs for weight management. Finally, we provide practical advice and recommendations for OBGYNs to open the discussion about bodyweight with their patients, initiate lifestyle modification and GLP-1 RA treatment, and help them persist with these interventions to achieve optimal weight loss with associated health benefits.

Genetic monogamy despite frequent extrapair copulations in "strictly monogamous" wild jackdaws.

"Monogamy" refers to different components of pair exclusiveness: the social pair, sexual partners, and the genetic outcome of sexual encounters. Avian monogamy is usually defined socially or genetically, whereas quantifications of sexual behavior remain scarce. Jackdaws (Corvus monedula) are considered a rare example of strict monogamy in songbirds, with lifelong pair bonds and little genetic evidence for extrapair (EP) offspring. Yet jackdaw copulations, although accompanied by loud copulation calls, are rarely observed because they occur visually concealed inside nest cavities. Using full-day nest-box video surveillance and on-bird acoustic bio-logging, we directly observed jackdaw sexual behavior and compared it to the corresponding genetic outcome obtained via molecular parentage analysis. In the video-observed nests, we found genetic monogamy but frequently detected forced EP sexual behavior, accompanied by characteristic male copulation calls. We, thus, challenge the long-held notion of strict jackdaw monogamy at the sexual level. Our data suggest that male mate guarding and frequent intrapair copulations during the female fertile phase, as well as the forced nature of the copulations, could explain the absence of EP offspring. Because EP copulation behavior appeared to be costly for both sexes, we suggest that immediate fitness benefits are an unlikely explanation for its prevalence. Instead, sexual conflict and dominance effects could interact to shape the spatiotemporal pattern of EP sexual behavior in this species. Our results call for larger-scale investigations of jackdaw sexual behavior and parentage and highlight the importance of combining social, sexual, and genetic data sets for a more complete understanding of mating systems.

An explanatory model of factors enabling sustainability of let's talk in an adult mental health service: a participatory case study.

BACKGROUND: While effective interventions have been developed to support families where a parent has a mental illness in Adult Mental Health Services, embedding and sustaining them is challenging resulting in families not having access to support. This study developed an explanatory model of influencers that had enabled sustainability of the Let's Talk intervention in one service. METHODS: A participatory case study was used to build an explanatory model of sustainability at the service using theoretical frameworks. Qualitative and quantitative data was collected about practitioner's practice and the organisation's implementation process and capacity to support practice. A local research group worked with the researcher using a transforming data approach through description, analysis and interpretation. RESULTS: Influencers were grouped into four major categories: (1) External social, political and financial context, (2) Resources, (3) Prior organisational capacity and (4) Sustainability Factors. The last category, Sustainability factors, was divided into three subcategories: (4.1) Practitioner (4.2) Organisation and (4.3) Parent-Client. These categories form part of an explanatory model for the key influencers of continued practitioner practice and organisational capacity to support practice. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In this case study, the pre-existing organisational context along with practitioner, organisation and parent-client factors operated together to influence sustainability. The results suggest that sustainability is more likely to be supported by both linking Let's Talk to existing organisational identity, capacity, structures and relationships and by supporting mutual adaptations to improve the fit. Additionally, by understanding that setbacks are common and ongoing adjustments are needed, implementers are able to have realistic expectations of sustainability.

The effect of guidance in the use of routine outcome measures in clinical meetings.

Routine outcome measures (ROM) have now been introduced into all Australian public mental health services, but experience suggests that many clinical staff lack expertise in using them. In 2005 under the Quality Through Outcomes Network (QUATRO), the Victorian Department of Human Services set up three teams aimed at consolidating the use of ROM and furthering sustainability through a variety of peer-support activities. We report on an initiative undertaken by one of these teams. QUATRO team members attended team meetings of four adult community teams (three metropolitan and one rural) fortnightly over about 3 months. QUATRO staff contributed to discussion of outcome measures during routine clinical review, using local and national outcome measurement data and tools, and their own expertise. Attitudes of clinicians toward ROM in general and the specific instruments were assessed at the beginning and end of the period, and again after about 5 months. Qualitative findings consist of observations of factors that assist and hinder use of ROM. The initiative identified steps that staff can take to make ROM more useful in their work.

Computational model for timing of delivery in an obese population.

OBJECTIVE: To estimate the impact on stillbirth risk, cesarean deliveries, and delivery-related healthcare cost associated with induction of labor compared to expectant management of term pregnancies in an obese population. METHODS: A decision analysis model was designed to compare the delivery and cost outcomes associated with a hypothetical cohort of 100,000 term pregnancies, complicated by obesity, that were planning a vaginal delivery. The model predicted stillbirths, cesarean deliveries, and total delivery-related health care cost from routine induction at 39 weeks compared to expectant management and routine induction each week from 40 to 42 weeks. RESULTS: There were 387 stillbirths avoided by routine induction at 39 weeks compared to the worst-case model of expectant management with induction at 42 weeks. 9234 cesarean deliveries were avoided by routine induction at 39 weeks compared to the worst-case model of expectant management and induction at 41 weeks (30,888 vs. 40,122) . Routine induction at 39 weeks showed a savings in delivery-related health care cost of 30 million dollars compared to the worst-case model of expectant management and induction at 41 weeks (536 million vs. 566 million). CONCLUSION: Utilizing this computational model, routine induction at 39 weeks minimizes stillbirths, cesarean deliveries, and delivery-related health care cost.

An evaluation of tyramide signal amplification and archived fixed and frozen tissue in microarray gene expression analysis.

Archival formalin-fixed, paraffin-embedded and ethanol-fixed tissues represent a potentially invaluable resource for gene expression analysis, as they are the most widely available material for studies of human disease. Little data are available evaluating whether RNA obtained from fixed (archival) tissues could produce reliable and reproducible microarray expression data. Here we compare the use of RNA isolated from human archival tissues fixed in ethanol and formalin to frozen tissue in cDNA microarray experiments. Since an additional factor that can limit the utility of archival tissue is the often small quantities available, we also evaluate the use of the tyramide signal amplification method (TSA), which allows the use of small amounts of RNA. Detailed analysis indicates that TSA provides a consistent and reproducible signal amplification method for cDNA microarray analysis, across both arrays and the genes tested. Analysis of this method also highlights the importance of performing non-linear channel normalization and dye switching. Furthermore, archived, fixed specimens can perform well, but not surprisingly, produce more variable results than frozen tissues. Consistent results are more easily obtainable using ethanol-fixed tissues, whereas formalin-fixed tissue does not typically provide a useful substrate for cDNA synthesis and labeling.

Detailed temporal structure of communication networks in groups of songbirds.

Animals in groups often exchange calls, in patterns whose temporal structure may be influenced by contextual factors such as physical location and the social network structure of the group. We introduce a model-based analysis for temporal patterns of animal call timing, originally developed for networks of firing neurons. This has advantages over cross-correlation analysis in that it can correctly handle common-cause confounds and provides a generative model of call patterns with explicit parameters for the influences between individuals. It also has advantages over standard Markovian analysis in that it incorporates detailed temporal interactions which affect timing as well as sequencing of calls. Further, a fitted model can be used to generate novel synthetic call sequences. We apply the method to calls recorded from groups of domesticated zebra finch (Taeniopygia guttata) individuals. We find that the communication network in these groups has stable structure that persists from one day to the next, and that 'kernels' reflecting the temporal range of influence have a characteristic structure for a calling individual's effect on itself, its partner and on others in the group. We further find characteristic patterns of influences by call type as well as by individual.

Patterns of call communication between group-housed zebra finches change during the breeding cycle.

Vocal signals such as calls play a crucial role for survival and successful reproduction, especially in group-living animals. However, call interactions and call dynamics within groups remain largely unexplored because their relation to relevant contexts or life-history stages could not be studied with individual-level resolution. Using on-bird microphone transmitters, we recorded the vocalisations of individual zebra finches (Taeniopygia guttata) behaving freely in social groups, while females and males previously unknown to each other passed through different stages of the breeding cycle. As birds formed pairs and shifted their reproductive status, their call repertoire composition changed. The recordings revealed that calls occurred non-randomly in fine-tuned vocal interactions and decreased within groups while pair-specific patterns emerged. Call-type combinations of vocal interactions changed within pairs and were associated with successful egg-laying, highlighting a potential fitness relevance of calling dynamics in communication systems.

Septic abortion with placenta accreta in pregnancy after endometrial ablation.

BACKGROUND: Pregnancy after endometrial ablation is a rare event, occurring in approximately 0.7% of cases. When it occurs, serious complications may be anticipated for both mother and fetus, including abnormal placentation. Termination of pregnancy in these cases is a challenging issue, made more so by the lack of availability of these services. CASE: We report a case of pregnancy after endometrial ablation complicated by placenta accreta. Initiation of a second-trimester termination procedure with lethal fetal injection resulted in subsequent septic abortion necessitating abdominal hysterectomy. CONCLUSION: Pregnancy after endometrial ablation is a rare and potentially morbid event. Patients should be counseled about the necessity of contraception at the time of endometrial ablation. Termination should be approached with caution and requires the availability of skilled providers.