Anxiety and depressive symptoms in pregnancy predict low birth weight differentially in male and female infants-findings from an urban pregnancy cohort in India.

PURPOSE: This study examined the contributions of antenatal anxiety, depression, and partner violence to low birth weight (LBW) in infants and to sex-specific birth weight outcomes among mothers from a cohort in urban India. METHODS: Data from 700 mothers from the PRAMMS cohort (Prospective Assessment of Maternal Mental Health Study) were used. Pregnant women were assessed in each trimester-T1, T2 and T3, for symptoms of anxiety, and depression as well as partner violence. Multivariate analyses were performed for the whole sample and then for male and female infants separately. The final multivariable logistic regression models were each built using a backward selection procedure and controlling for confounders. To accommodate longitudinally measured data, change in scores (T2-T1 and T3-T2) of anxiety and depression were included in the model. RESULTS: Of the 583 women with a singleton live birth, birth weight was available for 514 infants  and LBW was recorded in 80 infants (15.6%). Of these, 23 infants were preterm. Overall, higher T1 Depression scores (OR: 1.11; 95% CI 1.040, 1.187) and an increase in both Depression scores (OR: 1.12; 95% CI 1.047, 1.195) from T1 to T2 and Anxiety scores (OR: 1.32; 95% CI 1.079, 1.603) between T2 and T3 were predictors of LBW. Female infants had a higher chance of LBW with increase in maternal anxiety between T1-T2 (OR: 1.69; 95% CI 1.053, 2.708) and T2-T3 (OR: 1.49; 95% CI 1.058, 2.086); partner violence during pregnancy just failed to reach conventional statistical significance (OR: 2.48; 95% CI 0.810, 7.581) in girls. Male infants had a higher chance of LBW with higher baseline depression scores at T1 (OR: 1.23; 95% CI 1.042, 1.452) and an increase in depression scores (OR: 1.25; 95% CI 1.060, 1.472) from T1 to T2. CONCLUSION: Increasing prenatal anxiety and depressive symptoms in different trimesters of pregnancy were associated with LBW with sex-specific patterns of association in this sample from a Low and Middle Income Country.

CPCJ 50th Anniversary Editorial Board Commentary: Ethics and Health Policy-Then and Now.

To celebrate the 50th year of the Cleft Palate-Craniofacial Journal we look back to where we started in 1964, where we are now, and speculate about directions for the future in a Then and Now editorial series. This editorial examines 50 years of social, policy, and regulatory changes that broaden the responsibility for research integrity to include the investigator, the journal editorial review process, and institutional oversight. Internationally recognized standards for authorship, publication of recognizable cases and images, and confidentiality of peer-review are addressed in the context of the history of the CPCJ. As we look to the future, the core principles will continue to guide the endeavor of research involving human subjects while adhering to our obligations to protect the interests of the people we serve.

A model for overview of student learning: a matrix of educational outcomes versus methodologies.

A concise overview of an institution's aspirations for its students becomes increasingly elusive because dental education has evolving emphases on priorities like critical thinking and adapting to new technology. The purpose of this article is to offer a learner-oriented matrix that gives a focus for discussion and an overview of an institution's educational outcomes. On one axis of the matrix, common educational outcomes are listed: knowledge, technical skills, critical thinking, ethical and professional values, patient and practice management, and social responsibility awareness. On the other axis, methodologies are listed: definition, cultivation strategies, measures (summative/formative, objective/subjective), institutional coordination, and competency determination. By completing the matrix, an overview of the process by which students reach these outcomes emerges. Each institution would likely complete the matrix differently and, ideally, with active discussion. While the matrix can first be used to establish "Where are we now?" for an institution, it can also be a starting point for more extensive matrices and further discussion. Vertical and horizontal analyses of the matrix provide a unique lens for viewing the institution's learning environment.

Feeding tube placement in patients with advanced dementia: the beliefs and practice patterns of speech-language pathologists.

PURPOSE: To describe the beliefs and practices of speech-language pathologists (SLPs) about the use of percutaneous endoscopic gastrostomy (PEG) among patients with advanced dementia and dysphagia. METHOD: A survey was mailed to a geographically stratified random sample of 1,050 medical SLPs. RESULTS: The response rate was 57%, and 326 surveys met inclusion criteria. Fifty-six percent of SLPs recommended PEG for a patient with advanced dementia and dysphagia. Contrary to the evidence, many respondents believed that PEG improves nutritional status and increases survival. Relatively few SLPs believed that PEG improved patients' functional status or quality of life. Patient factors (e.g., age or prognosis) were more often identified as influences on recommendations for PEG than were extrinsic factors (e.g., cost). Nearly 40% believed that PEG was the standard of care, while 15% believed it should be. Very few SLPs (11%) would want a PEG themselves. Perceived standard of care was significantly related to both geographic region and population density (p < .05), but self-reported practices were not. CONCLUSIONS: Discrepancies between SLPs' beliefs, the literature, and self-reported practices were observed. The findings suggest the need to connect the evidence base to clinical practice and to include SLPs in local and national discussions about end-of-life care protocols.

What do dental students learn in an ethics course? An analysis of student-reported learning outcomes.

The purpose of this article is to report first-year dental students' perceptions of their primary learning outcomes from a course in ethics and professionalism. Students were asked to identify one topic or theme from the course that might influence their professional practice. Responses from 232 students were analyzed according to the explicit topics taught in the course. The most commonly identified topics were confidentiality (21 percent), informed consent (21 percent), and obtaining assent from children and adolescents (19 percent). An ad hoc analysis of students' narratives provides preliminary evidence that students perceive an increased awareness of their role and obligations as a professional immediately after a course in ethics and professionalism. The long-term influence of coursework in ethics and professionalism remains unknown.

Speech and language development and disorders in children.

Language disorders are identified when a person has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a person's voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a child's overall development and can be tracked using typical milestone markers. Differential diagnosis is critical to designing appropriate intervention, which should be tailored to the parents' goals along with the child's clinical and educational needs. Early identification and intervention assist in educational planning and are often associated with better long-term outcomes. Any speech-language therapy plan should be designed with measurable goals and consistent monitoring of progress toward those goals.

Caregiver and patient reported outcomes after repair of cleft lip and/or palate in the Philippines.

OBJECTIVES: To establish the feasibility of conducting outcomes research among patients treated during a medical mission and to identify the salient outcomes for patients and caregivers in one region of the Philippines. DESIGN AND SETTING: Prospective structured interview conducted in or near participants' homes on the island of Cebu, Philippines. PARTICIPANTS: Individuals who had surgery at least 6 months earlier within the study region were eligible. Recipients of surgery were located from surgical records and by word of mouth. MAIN OUTCOME MEASURES: (1) Proportion of individuals located. (2) Primary outcomes of oral cleft repair identified for the sample. RESULTS: Of 99 people on a surgical list, 52 (53%) were located, eight were excluded (ineligible, unavailable, or inaccessible), and 44 agreed to participate in the study. Ten participants were identified via word of mouth. Seventy-five interviews were conducted (21 caregiver-patient pairs, one adolescent, and 32 caregivers of a child <7 years). Nearly all participants (99%) would encourage others to pursue surgery. Open-ended questions were coded to identify primary outcomes: improved speech (52%), improved eating (25%), social benefits (14%), and improved appearance (6%). Caregivers (50%) and patients (68%) reported that improved speech was the most important change after surgery. CONCLUSIONS: Patients and caregivers ascribe positive changes related to cleft surgery. Outcomes research requires cooperation with local professionals who can communicate effectively. These data serve to demonstrate feasibility and as a model for future studies of treatment outcomes in follow-up to international medical missions.

Ethical issues in the management of dysphagia after stroke.

When patients have severe dysphagia after a stroke, tube feeding may be recommended to reduce the risks associated with malnutrition, dehydration, and/or aspiration. Patients may not be able to participate in decision making, but they may have previously expressed strong preferences related to tube feeding. Clinicians must work together with the family to establish a treatment plan that is respectful of the person's previous wishes, yet mindful of the flaws in advance care planning. Although ethical issues cannot be avoided, clinicians can reduce uncertainty by understanding current ethical and legal views on these challenging issues.

Ethical dilemmas reported by fourth-year dental students.

Ethics education in dentistry is a requirement for accreditation. Despite universal adoption of ethics courses, there is ongoing discussion about the appropriate content of these courses and about methods to engage students. Faculty who teach ethics must select a limited set of topics from the broad fields of professional ethics, bioethics, and the humanities. The purpose of this article is to describe the ethical issues reported by fourth-year dental students during community-based extramural clinical experiences. Senior dental students (n=123) wrote essays describing an ethical issue they encountered during one of two extramural rotations. Ethical issues were categorized and coded by consensus between two faculty authors. Students most often reported perceived dilemmas related to patients' limited resources (25 percent), conflict between professionals (19 percent), clinic policy or procedures (15 percent), and decision making by patients' surrogates (13 percent). One student (<1 percent) reported encountering no ethical issues. Students' perceptions of ethical issues in clinical practice offer faculty a foundation for designing a dental ethics curriculum that is practical and immediately relevant to the experience of a dental student. Students' reports may also yield a method for systematic assessment of students' abilities to apply classroom ethics instruction to clinical practice.

When "minimal risk" research yields clinically-significant data, maybe the risks aren't so minimal.

Surveys and routine clinical procedures applied in research protocols are typically considered only minimally risky to participants. The apparent benign nature of "minimal risk" tasks increases the chance that investigators and Institutional Review Boards (IRBs) will overlook the probability that clinical tools will identify signs, symptoms, or definitive test results that are clinically-relevant to subjects' welfare. "Minimal risk" procedures may also pose a particular hazard to participants in clinical research by increasing the therapeutic misconception because the tasks mimic clinical care and are often conducted in clinical settings. Investigators should anticipate which measures could yield clinically-important findings and should describe explicit plans for data monitoring, disclosure, and follow-up. Protocols that include reliable and valid clinical measures should prompt a more detailed risk assessment by the IRB, even when the tasks meet the regulatory criteria for minimal physical, psychological, or emotional risk.

Ethical issues in dysphagia: when patients refuse assessment or treatment.

The primary goal of intervention for patients with dysphagia is to restore oral feeding. When patients are unable to achieve adequate nutrition, hydration, or safety with oral feeding, then nonoral approaches are often recommended. Although patients' rights to accept or refuse clinical recommendations are widely recognized, when a patient refuses tube feeding or other recommendations, dysphagia specialists are left with a host of practical questions about their role in caring for the patient. We review the criteria for assessing patients' capacity to make informed choices, approaches to decision making when patients lack capacity, and the roles and responsibilities of clinicians when patients choose high-risk treatment options.