"No, You Need to Explain What You Are Doing": Obstetric Care Experiences and Preferences of Adolescent Mothers With a History of Childhood Trauma.

STUDY OBJECTIVE: To understand the pregnancy and childbirth experiences and preferences of adolescent mothers with a history of childhood trauma in order to develop trauma-informed care practice recommendations for this unique group. DESIGN: Mixed methods convergent parallel design involving completion of the Adverse Childhood Experiences (ACE) questionnaire, a survey of care experiences and preferences during pregnancy and delivery, and a one-on-one interview. SETTING: hHospital-based medical home program for pregnant and parenting adolescents. PARTICIPANTS: Adolescent and young adult mothers aged 12-22 years, receiving care between June 2018 and June 2019. RESULTS: A total of 29 adolescent mothers completed the questionnaire, out of a potential 38 in the program (76.3% participation). Five went on to complete an interview. The average age was 17.9 years (standard deviation 1.8 years). The mean ACE score was 5.1 out of 10, indicating childhood exposure to an average of 5 different types of potential trauma. A total of 19 participants (65.5%) reported being triggered during pregnancy or postpartum. Trauma memories were elicited during vaginal examinations in the clinic (27.6%) and in the hospital (27.6%), abdominal examinations (13.8%), measurement of vital signs (17.2%), and labor (17.2%). Ten participants (34.5%) felt that the providers delivering their baby knew how to help them cope with trauma memories. Themes that emerged included the following: acknowledgment of trauma by provider, avoiding re-telling of story, building a relationship with provider, choice and control in care, and providing coping strategies. CONCLUSION: A majority of adolescent mothers in our sample experienced trauma memories during pregnancy and postpartum medical interactions. Priorities for trauma-informed care in this population are described.

Protocol for a cluster randomised controlled trial of the DAFNEplus (Dose Adjustment For Normal Eating) intervention compared with 5x1 DAFNE: a lifelong approach to promote effective self-management in adults with type 1 diabetes.

INTRODUCTION: The successful treatment of type 1 diabetes (T1D) requires those affected to employ insulin therapy to maintain their blood glucose levels as close to normal to avoid complications in the long-term. The Dose Adjustment For Normal Eating (DAFNE) intervention is a group education course designed to help adults with T1D develop and sustain the complex self-management skills needed to adjust insulin in everyday life. It leads to improved glucose levels in the short term (manifest by falls in glycated haemoglobin, HbA1c), reduced rates of hypoglycaemia and sustained improvements in quality of life but overall glucose levels remain well above national targets. The DAFNEplus intervention is a development of DAFNE designed to incorporate behavioural change techniques, technology and longer-term structured support from healthcare professionals (HCPs). METHODS AND ANALYSIS: A pragmatic cluster randomised controlled trial in adults with T1D, delivered in diabetes centres in National Health Service secondary care hospitals in the UK. Centres will be randomised on a 1:1 basis to standard DAFNE or DAFNEplus. Primary clinical outcome is the change in HbA1c and the primary endpoint is HbA1c at 12 months, in those entering the trial with HbA1c >7.5% (58 mmol/mol), and HbA1c at 6 months is the secondary endpoint. Sample size is 662 participants (approximately 47 per centre); 92% power to detect a 0.5% difference in the primary outcome of HbA1c between treatment groups. The trial also measures rates of hypoglycaemia, psychological outcomes, an economic evaluation and process evaluation. ETHICS AND DISSEMINATION: Ethics approval was granted by South West-Exeter Research Ethics Committee (REC ref: 18/SW/0100) on 14 May 2018. The results of the trial will be published in a National Institute for Health Research monograph and relevant high-impact journals. TRIAL REGISTRATION NUMBER: ISRCTN42908016.

First case of near haploid philadelphia negative B-Cell acute lymphoblastic leukaemia relapsing as acute myeloid leukemia following allogeneic hematopoietic stem cell transplantation.

Herein we present a female patient aged 61 with Philadelphia negative acute lymphoblastic leukaemia demonstrating near haploid karyotype and abnormal TP53 expression at diagnosis, who relapsed with lineage switch as Acute Monocytic Leukemia post allogeneic stem cell transplantation. Molecular analysis established that both neoplasms were derived from the same founder clone. The leukemic lineage switch phenomenon has recently re-attracted interest as mechanism of leukemic evasion post treatment with chimeric antigen receptor T-cells but there is paucity of data on its presence post allograft or following novel antibody treatments such as Inotuzumab Ozogamicin or Blinatumomab. Our proposition for cancer research is that near haploidy in ALL could be linked to leukemic stem cell plasticity evading stem cell transplantation and other immunotherapy approaches.

Role of MRI in uterine didelphys with co-existing endometrial carcinosarcoma.

A case report reviewing MRI in a patient diagnosed with carcinosarcoma and uterine didelphys following presentation with post-menopausal bleeding. Staging MRI images demonstrate the anatomical anomaly and pathological features in these co-existing conditions. This report presents an interesting case of carcinosarcoma in a uterine didelphys. This anatomical abnormality is an uncommon finding and is very rarely complicated by carcinosarcoma. There are very few cases reported to date of this unusual condition. Our case is of a 77-year-old female, para 9, who presented with post-menopausal bleeding for 1 month. She followed the pathway for endometrial cancer using Northern Ireland Cancer Network clinical guidelines. This female's co-existing uterine anomaly and malignant pathology are outlined, staged and beautifully illustrated with dedicated pelvic MRI. The images captured by MRI are used in all aspects of the patients care and treatment planning, and show the benefit of this modality in multidisciplinary meetings guiding gynaecological-oncology surgeons, who must aware of the anatomical variants before embarking on definitive surgery.

Three hundred babies born to underhoused mothers in Toronto-understanding the problem and how we can help.

Little is known about pregnancy in underhoused women, possibly because the number of underhoused mothers with babies in Toronto has been significantly underestimated. Using a novel data collection method, it has been found that there are approximately 300 babies being born each year to underhoused women in Toronto. This finding has significant public health implications, as these women are at increased risk of multiple issues related to physical health, mental health, child protection, poverty and safety. This commentary presents a new data collection strategy, highlights the importance of accurate data collection and offers suggestions for supports for this over-looked population.

Meeting the needs of adolescent parents and their children.

Adolescent parents and their children present to health care practitioners as two paediatric patients, each with unique health care needs. Young parents and their children may be at risk for negative health outcomes, not directly as a consequence of maternal age but because of poverty and other inequities in the social determinants of health. The health needs of child and mother are best assessed using a nonjudgmental approach, appropriate screening tools and open questions that address both preventative and acute health issues. The dyad's coexisting needs may be anticipated as they relate to growth and development, infant and adolescent mental health, nutrition and food security, safety, relationships, parenting, education, sexual health and the facilitation of supports and resources. Care providers who understand adolescent development and integrate medical home elements of a patient-centred 'medical home' into their practices are ideally positioned to facilitate positive health outcomes for both mother and child.

Les parents adolescents et leurs enfants sont deux patients d'âge pédiatrique pour les dispensateurs de soins, et ont chacun leurs propres besoins de santé. Les jeunes parents et leur enfant peuvent être à risque de voir leur santé en souffrir, non pas directement à cause de l'âge de la mère, mais de la pauvreté et des autres inégalités en matière de déterminants sociaux de la santé. Pour bien évaluer les besoins de santé de l'enfant et de sa mère, il faut privilégier une approche objective, des outils de dépistage appropriés et des questions ouvertes qui tiennent compte à la fois de la prévention et des problèmes de santé aigus. Il est possible d'anticiper les besoins coexistants de cette dyade, car ils portent sur la croissance et le développement, la santé mentale du nourrisson et de l'adolescente, l'alimentation et la sécurité alimentaire, la sécurité, les relations, les pratiques parentales, l'éducation, la santé sexuelle et l'aide à trouver du soutien et des ressources. Les dispensateurs de soins qui comprennent le développement des adolescentes et intègrent des éléments du « foyer médical ¼ axé sur les patients à leur pratique sont les mieux placés pour favoriser des résultats de santé positifs, tant pour la mère que pour son nourrisson.

Demographic characteristics and needs of the Canadian urban adolescent mother and her child.

INTRODUCTION: There is a paucity of Canadian-based literature on urban adolescent mothers and their children. To inform clinical assessment and interventions and to mitigate the risks that adolescent mothers and their children face, it is essential to understand the characteristics of this high-risk population. METHODS: A retrospective review of 116 adolescent mothers attending an urban academic hospital-based outpatient clinic in Canada from 2005 to 2009 was conducted. The following information was collected: demographic characteristics, maternal maltreatment history, substance use, postpartum depression symptoms, and child socioemotional and developmental functioning. RESULTS: The mean maternal age was 16.1 years and the mean education level was grade 9. Ninety-nine percent of adolescent mothers were single, 47% had a history of child welfare involvement and 18% had previous involvement with the judicial system. More than one-half of participants reported a history of both maltreatment and substance abuse, and 20% of adolescent mothers scored in the clinical range for postpartum depression. A substantial proportion of children scored in the clinical range for behavioural problems, regulatory difficulties and suspected developmental delays. CONCLUSION: The present study serves to illustrate the high-risk nature of urban adolescent mothers. These observations can be used to improve clinical practice for health care providers in community and hospital-based settings working with this population.

INTRODUCTION: Peu de publications scientifiques canadiennes portent sur les mères adolescentes et leur enfant en milieu urbain. Pour attester les évaluations et interventions cliniques et réduire les risques que courent les mères adolescentes et leurs enfants, il est essentiel de comprendre les caractéristiques de cette population à haut risque. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective auprès de 116 mères adolescentes qui fréquentaient la clinique ambulatoire d'un hôpital universitaire canadien en milieu urbain entre 2005 et 2009. L'information suivante a été colligée : caractéristiques démographiques, antécédents de maltraitance des mères, consommation de substances psychoactives, symptômes de dépression postpartum et fonctionnement socio-affectif et développemental des enfants. RÉSULTATS: Les mères avaient un âge moyen de 16,1 ans et un niveau de scolarité moyen de 9e année. De plus, 99 % des mères adolescentes étaient monoparentales, 47 % avaient déjà été en contact avec les services de protection de l'enfance et 18 % avaient déjà eu des démêlés avec la justice. Plus de la moitié avait des antécédents de maltraitance et de consommation de substances psychoactives, et 20 % obtenaient un score clinique de dépression postpartum. Une forte proportion d'enfants obtenait un score clinique de troubles de comportement, de troubles de régulation et de présomptions de retards de développement. CONCLUSION: La présente étude démontre le haut risque que courent les mères adolescentes en milieu urbain. Ces observations peuvent contribuer à améliorer la pratique clinique des travailleurs de la santé en milieu communautaire et hospitalier qui œuvrent auprès de cette population.

Family policy, family structure, and children's educational achievement.

This study explored the interface between policy, the family, and educational outcomes. More specifically, this research examined how the association between single motherhood and children's literacy achievement is affected by a country's family policy environment. Using data from the Program for International Student Assessment (PISA) and national level comparative policy data, the results from the 2-level hierarchical linear models indicate that in those countries that have policies that favor low-income single-parent families, the literacy gap decreases in size between students who reside in single-mother households and their counterparts who reside in two-parent families.

Tea tree oil (5%) body wash versus standard care (Johnson's Baby Softwash) to prevent colonization with methicillin-resistant Staphylococcus aureus in critically ill adults: a randomized controlled trial.

OBJECTIVES: To determine whether the daily use of 5% tea tree oil (TTO) body wash (Novabac 5% Skin Wash) compared with standard care [Johnson's Baby Softwash (JBS)] had a lower incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization. PATIENTS: The study setting was two intensive care units (ICUs; mixed medical, surgical and trauma) in Northern Ireland between October 2007 and July 2009. The study population comprised 391 patients who were randomized to JBS or TTO body wash. METHODS: This was a Phase 2/3, prospective, open-label, randomized, controlled trial. TRIAL REGISTRATION: ISRCTN65190967. The primary outcome was new MRSA colonization during ICU stay. Secondary outcomes included the incidence of MRSA bacteraemia and maximum increase in sequential organ failure assessment score. RESULTS: A total of 445 patients were randomized to the study. After randomization, 54 patients were withdrawn; 30 because of a positive MRSA screen at study entry, 11 due to lack of consent, 11 were inappropriately randomized and 2 had adverse reactions. Thirty-nine (10%) patients developed new MRSA colonization (JBS n = 22, 11.2%; TTO body wash n = 17, 8.7%). The difference in percentage colonized (2.5%, 95% CI - 8.95 to 3.94; P = 0.50) was not significant. The mean maximum increase in sequential organ failure assessment score was not significant (JBS 1.44, SD 1.92; TTO body wash 1.28, SD 1.79; P = 0.85) and no study patients developed MRSA bacteraemia. CONCLUSIONS: Compared with JBS, TTO body wash cannot be recommended as an effective means of reducing MRSA colonization.

Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience.

OBJECTIVE: DAFNE (Dose Adjustment For Normal Eating), a structured education program in flexible insulin therapy, has been widely adopted in the U.K. after validation in a randomized trial. To determine benefits in routine practice, we collected biomedical and psychological data from all participants attending during a 12-month period. RESEARCH DESIGN AND METHODS: HbA(1c), weight, self-reported hypoglycemia awareness, severe hypoglycemia frequency, PAID (Problem Areas In Diabetes), HADS (Hospital Anxiety and Depression Scale), and EuroQol Group 5-Dimension Self-Report Questionnaire scores were recorded prior to DAFNE and after 1 year. RESULTS: Complete baseline and follow-up HbA(1c) data were available for 639 (54.9%) of 1,163 attendees. HbA(1c) fell from 8.51 ± 1.41 (mean ± SD) to 8.24 ± 1.29% (difference 0.27 [95% CI 0.16-0.38]; P < 0.001), with a greater mean fall of 0.44% from baseline HbA(1c) >8.5%. Severe hypoglycemia rate fell from 1.7 ± 8.5 to 0.6 ± 3.7 episodes per person per year (1.1 [0.7-1.4]) and hypoglycemia recognition improved in 43% of those reporting unawareness. Baseline psychological distress was evident, with a PAID score of 25.2 and HADS scores of 5.3 (anxiety) and 4.8 (depression), falling to 16.7 (8.5 [6.6-10.4]), 4.6 (0.7 [0.4-1.0]), and 4.2 (0.6 [0.3-0.8]), respectively (all P < 0.001 at 1 year). Clinically relevant anxiety and depression (HADS ≥ 8) fell from 24.4 to 18.0% and 20.9 to 15.5%, respectively. CONCLUSIONS: A structured education program delivered in routine clinical practice not only improves HbA(1c) while reducing severe hypoglycemia rate and restoring hypoglycemia awareness but also reduces psychological distress and improves perceived well-being.

Impaired endothelium-dependent vasodilatation is a novel predictor of mortality in intensive care.

OBJECTIVE: Endothelial function may be impaired in critical illness. We hypothesized that impaired endothelium-dependent vasodilatation is a predictor of mortality in critically ill patients. DESIGN: Prospective observational cohort study. SETTING: Seventeen-bed adult intensive care unit in a tertiary referral university teaching hospital. PATIENTS: Patients were recruited within 24 hrs of admission to the intensive care unit. INTERVENTIONS: The SphygmoCor Mx system was used to derive the aortic augmentation index from radial artery pulse pressure waveforms. Endothelium-dependent vasodilatation was calculated as the change in augmentation index in response to an endothelium-dependent vasodilator (salbutamol). MEASUREMENTS AND MAIN RESULTS: Demographics, severity of illness scores, and physiological parameters were collected. Statistically significant predictors of mortality identified using single regressor analysis were entered into a multiple logistic regression model. Receiver operator characteristic curves were generated. Ninety-four patients completed the study. There were 80 survivors and 14 nonsurvivors. The Simplified Acute Physiology Score II, the Sequential Organ Failure Assessment score, leukocyte count, and endothelium-dependent vasodilatation conferred an increased risk of mortality. In logistic regression analysis, endothelium-dependent vasodilatation was the only predictor of mortality with an adjusted odds ratio of 26.1 (95% confidence interval [CI], 4.3-159.5). An endothelium-dependent vasodilatation value of 0.5% or less predicted intensive care unit mortality with a sensitivity of 79% (CI, 59-88%) and specificity of 98% (CI, 94-99%). CONCLUSIONS: In vivo bedside assessment of endothelium-dependent vasodilatation is an independent predictor of mortality in the critically ill. We have shown it to be superior to other validated severity of illness scores with high sensitivity and specificity.

A randomized controlled trial of tea tree oil (5%) body wash versus standard body wash to prevent colonization with methicillin-resistant Staphylococcus aureus (MRSA) in critically ill adults: research protocol.

BACKGROUND: Over the past ten years MRSA has become endemic in hospitals and is associated with increased healthcare costs. Critically ill patients are most at risk, in part because of the number of invasive therapies that they require in the intensive care unit (ICU). Washing with 5% tea tree oil (TTO) has been shown to be effective in removing MRSA on the skin. However, to date, no trials have evaluated the potential of TTO body wash to prevent MRSA colonization or infection. In addition, detecting MRSA by usual culture methods is slow. A faster method using a PCR assay has been developed in the laboratory, but requires evaluation in a large number of patients. METHODS/DESIGN: This study protocol describes the design of a multicentre, phase II/III prospective open-label randomized controlled clinical trial to evaluate whether a concentration of 5% TTO is effective in preventing MRSA colonization in comparison with a standard body wash (Johnsons Baby Softwash) in the ICU. In addition we will evaluate the cost-effectiveness of TTO body wash and assess the effectiveness of the PCR assay in detecting MRSA in critically ill patients. On admission to intensive care, swabs from the nose and groin will be taken to screen for MRSA as per current practice. Patients will be randomly assigned to be washed with the standard body wash or TTO body wash. On discharge from the unit, swabs will be taken again to identify whether there is a difference in MRSA colonization between the two groups. DISCUSSION: If TTO body wash is found to be effective, widespread implementation of such a simple colonization prevention tool has the potential to impact on patient outcomes, healthcare resource use and patient confidence both nationally and internationally.

The role of CTLs in persistent viral infection: cytolytic gene expression in CD8+ lymphocytes distinguishes between individuals with a high or low proviral load of human T cell lymphotropic virus type 1.

The proviral load in human T cell lymphotropic virus type 1 (HTLV-1) infection is typically constant in each infected host, but varies by >1000-fold between hosts and is strongly correlated with the risk of HTLV-1-associated inflammatory disease. However, the factors that determine an individual's HTLV-1 proviral load remain uncertain. Experimental evidence from studies of host genetics, viral genetics, and lymphocyte function and theoretical considerations suggest that a major determinant of the equilibrium proviral load is the CD8+ T cell response to HTLV-1. In this study, we tested the hypothesis that the gene expression profile in circulating CD8+ and CD4+ lymphocytes distinguishes between individuals with a low proviral load of HTLV-1 and those with a high proviral load. We show that circulating CD8+ lymphocytes from individuals with a low HTLV-1 proviral load overexpressed a core group of nine genes with strong functional coherence: eight of the nine genes encode granzymes or other proteins involved in cell-mediated lysis or Ag recognition. We conclude that successful suppression of the HTLV-1 proviral load is associated with strong cytotoxic CD8+ lymphocyte activity in the peripheral blood.

Bulking in activated sludge plants treating paper mill wastewaters.

As part of a larger project to examine the causes of bulking in activated sludge plants treating wastewaters from paper mills, two laboratory-scale activated sludge plants were run in parallel. This was to evaluate the impact of variable environmental and operational parameters on the sludge ecology, and in particular, on the filamentous bacteria in the sludge. A survey of paper mills in the UK showed that there was a significant difference between the activated sludge plants at the paper mills using virgin fibre and those using recycled fibre. An examination of samples from activated sludge plants at the paper mills showed that there did not appear to be any significant correlation between filament abundance and the settlement characteristics as measured by stirred specific volume index (SSVI). The surface charge carried by the sludge particles was also measured and it was found that this parameter was better related to the SSVI. Similar results were found for samples from the laboratory plants. Seven different sets of operational conditions were applied to the laboratory-scale plants. These were aimed at simulating the conditions noted for the full-scale plants during the mill survey. The effects of low dissolved oxygen and low organic loading rates were examined. The effect of inorganic sulphur compounds and volatile fatty acids was studied. A change in raw material from virgin fibre to recycled fibre (corrugated paper) caused an immediate and continuous deterioration in settlement. Divalent cations, calcium and magnesium, were found to be successful in controlling settlement in the final clarifier.