Mental Health and Maternal Mortality-When New Life Doesn't Bring Joy.

OBJECTIVE: To characterize the incidence and risk factors associated with maternal suicide during the peripartum period in an Alberta population. Our secondary objective was to characterize the incidence and risk factors associated with traumatic death in this same population. METHODS: This is a retrospective cohort study compared all-cause mortality with death by trauma (suicide, homicide, MVA, drug toxicity) using data collected by the Alberta Perinatal Health Program from 1998 to 2015. Data were summarized using descriptive statistics. The maternal mortality rate was calculated, and χ2 tests were used to determine between group differences with the statistical significance set at P < 0.05. RESULTS: There were 206 perinatal maternal deaths in Alberta from 1998 to 2015; 68 (33%) were due to trauma, 17 (8%) were the result of suicide, 4 (2%) were the result of homicide, and 24 (12%) were related to drug toxicity. The pregnancy-related maternal mortality rate for suicide up to 365 days after birth was 2.05 deaths per 100 000 deliveries. Of these, 29.4% occurred during pregnancy and 70.6%, in the first year postpartum. For homicides, 62.5% of occurred in pregnancy and 37.5% occurred in the first year postpartum. CONCLUSION: Close to 1 in 5 maternal deaths in Alberta is related to suicide or drug toxicity. We must escalate strategies to prevent deaths from suicide and drug toxicity, as well as increase funding for mental health and addictions screening and treatment.

Appraisal of the Psychiatric Diagnostic Screening Questionnaire in a perinatal cohort: The APrON study.

BACKGROUND: Depression and anxiety are routinely screened as part of perinatal care. However, other Axis 1 disorders and specific anxiety disorders are less likely to be screened or assessed as part of obstetric care. The objective of this study was to determine whether the Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a potentially useful tool to screen for psychiatric conditions in pregnant and postpartum women in a community setting. METHODS: We compared the prevalence of DSM Axis I disorders obtained on the PDSQ with: (1) the prevalence of these disorders reported in previous studies of pregnant and postpartum women, and (2) scores obtained on the Edinburgh Postpartum Depression Scale (EPDS) and the Symptom Checklist-90-Revised (SCL-90R) anxiety scale. Data were obtained from the Alberta Pregnancy Outcomes and Nutrition (APrON) study. RESULTS: The PDSQ was completed by 1575 women prenatally and 1481 postnatally. The three most prevalent PDSQ conditions were social phobia, somatic disorder, and obsessive-compulsive disorder (OCD). The prevalence of social phobia, alcohol disorder, OCD and psychosis were higher in the APrON cohort compared with statistics in the literature. The proportion of women meeting depression and anxiety cut-offs on the PDSQ were lower than for the EPDS and the SCL-90R. The Cohens Kappa index ( k) indicated poor to fair agreement between the measures in classifying pregnant women as depressed or anxious. CONCLUSIONS: The PDSQ subscales may not be appropriate for the pregnant population. Research into instruments more specific to pregnant and postpartum women are needed to determine the prevalence of psychiatric disorders in this population.

Improvement in asthma control and inflammation in children undergoing adenotonsillectomy.

BACKGROUND: Observational studies suggest that asthma control improves after adenotonsillectomy, but longitudinal studies that correlate the effect of the procedure on the levels of biomarkers associated with airway inflammation are limited. METHODS: We conducted a longitudinal, observational study on pediatric patients, both with and without asthma, undergoing adenotonsillectomy. Asthma control test (ACT) scores and chitinase activity in the circulation were measured at time of surgery and at 6-mo follow-up. RESULTS: Sixty-six children with asthma and 64 control subjects were enrolled. Mean ACT scores improved by three points (P < 0.001) after 6 mo. 85% of children with poorly controlled asthma demonstrated an increase in ACT score of at least three points or a decrease in emergency department/urgent care visits, oral corticosteroid courses, or rescue short acting bronchodilator usage. Chitinase activity decreased significantly in asthmatics who improved (P < 0.01). Higher chitinase activity levels at baseline were associated with improved asthma control following surgery (P < 0.01). CONCLUSION: In children with high preoperative circulating chitinase activity levels, asthma control and healthcare utilization were significantly improved after adenotonsillecotmy. Chitinase activity decreased after surgery in children with improved control. This suggests that adenotonsillectomy modulates chitinase activity, affecting airway inflammation and improving airway disease.

The Alberta Pregnancy Outcomes and Nutrition (APrON) cohort study: rationale and methods.

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.

Risk factors and methods in suicides of elderly patients connected to mental health services from 1999-2024.

Introduction: Suicide prevention is an important aspect of psychiatric care, with older men being a population identified at especially high suicide risk and a recent increase in suicides among older women. Methods: Using data collected by the region's quality assurance team, we examined all suicide deaths occurring between March 1999 and February 2024 in patients aged 60 years or older who were connected to the region's Addiction and Mental Health Program at the time of death. Data were analyzed to describe which factors were most commonly identified in suicides in older adults receiving mental healthcare. We also compared male and female cases to determine whether certain factors were more commonly observed in one gender. Results: We identified 48 cases of suicide occurring in patients aged 60 or over. 60% of suicides occurred in males. Overdose and hanging were the most common suicide methods used, and all suicides occurring on inpatient units occurred via hanging. Depression was the most common diagnosis, and was diagnosed more frequently in suicides of female older adults. A greater proportion of suicides in older women were associated with previous history of suicide attempts. Discussion: Our findings support many current best practices for suicide prevention in psychiatric care, including minimizing ligatures and anchor points on inpatient settings, assessing for and limiting access to means in individuals at-risk, and assessing suicide risk in hospitalized patients prior to passes and discharge. Recognition and treatment of depression remain important aspects in the treatment of older adults to prevent suicide.

Prenatal micronutrient supplementation and postpartum depressive symptoms in a pregnancy cohort.

BACKGROUND: Postpartum depression is a serious problem for women and their offspring. Micronutrient supplements are recommended for pregnant women because of their documented protective effects for the offspring, but their potential beneficial effects on maternal mental health are unknown. This study investigated the association between prenatal micronutrient supplementation and the risk for symptoms of postpartum depression in a longitudinal pregnancy cohort from the Alberta Pregnancy Outcomes and Nutrition (APrON) study. METHODS: Participants came from a cohort of the first 600 APrON women. Supplemental nutrient intake and symptoms of depression (measured with the Edinburgh Postnatal Depression Scale (EPDS)) were collected at each trimester and 12 weeks postpartum. RESULTS: Of the 475 participants who completed the EPDS at least twice in pregnancy and at 12 weeks postpartum, 416 (88%) scored <10 and 59 (12%) scored ≥10, where an EPDS ≥10 is considered to be "at least probable minor depression". Mean nutrient intakes from supplements were higher in women with lower EPDS scores, particularly selenium (p = 0.0015) and omega-3s (p = 0.01). Bivariate analyses showed that several demographic and social/lifestyle variables were associated with EPDS ≥10: not having been born in Canada (p = 0.01), greater number of chronic conditions (p = 0.05), greater number of stressful life events during this pregnancy (p = 0.02), and lower prenatal and postnatal support (p = 0.0043 and p = 0.0001, respectively). Adjusting for covariates and nutrients known to be associated with postpartum depression, logistic regression showed that having a prenatal EPDS ≥ 10 increased the odds of postpartum depressive symptoms (second and third trimester OR = 3.29, 95% CI = 1.55 - 7.01, p = 0.004 and OR = 4.26, 95% CI = 2.05 - 8.85, p < 0.0001, respectively), while prenatal supplemental selenium (per 10 mcg, OR = 0.76, 95% CI = 0.74 - 0.78, p = 0.0019) and postnatal social support (OR = 0.87, 95% CI = 0.78 - 0.97, p = 0.0015) were protective. CONCLUSIONS: Multiple factors, including supplementary selenium intake, are associated with the risk of postpartum depressive symptoms. Future research on dietary supplementation in pregnancy with special attention to selenium intake is warranted.

Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy.

OBJECTIVE: To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged. METHODS: An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey. RESULTS: After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care. CONCLUSION: The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.

A systematic review of the safety and effectiveness of repetitive transcranial magnetic stimulation in the treatment of peripartum depression.

BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) is an efficacious treatment for major depressive disorder (MDD), however there is limited safety and efficacy data in the peripartum period. The purpose of this review is to systematically examine the safety, acceptability and effectiveness of rTMS administered during the peripartum period as an intervention for MDD. METHODS: We searched MEDLINE, EMBASE and PsychINFO from 2008 to January 2019 to identify peer reviewed publications evaluating rTMS during the peripartum period as an intervention for peripartum MDD. We systematically extracted reported adverse events, side effects, rates of discontinuation, as well as clinical response and remission. RESULTS: Data was synthesized from 1 randomized control trial, 3 uncontrolled trials, 3 case series and 5 case studies, representing a total of 87 patients. No serious adverse events were reported. Side effects occurred at rates comparable to those observed in the non-peripartum population, and obstetric and neonatal complications are infrequent and do not separate from sham-rTMS. Randomized controlled data suggests antidepressant efficacy with an effect size of 0.87. Uncontrolled studies report rates of clinical response between 41.4% and 71.4%, and rates of clinical remission between 20.7 and 30.0%. The treatment appears acceptable, with few patients opting to discontinue treatment. LIMITATIONS: Due to the paucity of research in this population, majority of data comes from sources with inherently higher risk of bias. CONCLUSIONS: rTMS in the peripartum period appears to be efficacious, acceptable and well tolerated. Additional research is required, however rTMS's risk benefit profile may be attractive to women in the peripartum period.

Plain Language Summary: Otitis Media with Effusion.

OBJECTIVE: This plain language summary serves as an overview in explaining otitis media with effusion (pronounced Oh-TIE-tis ME-dee-uh with Ef-YOO-zhun), abbreviated "OME" and often called "ear fluid." The summary applies to children aged 2 months through 12 years with OME and is based on the 2015 "Clinical Practice Guideline: Otitis Media with Effusion (Update)." The evidence-based guideline includes research to support more effective diagnosis and treatment of OME in children. The guideline was developed as a quality improvement opportunity for managing OME by creating clear recommendations to use in medical practice.

Clinical Practice Guideline: Otitis Media with Effusion (Update).

OBJECTIVE: This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME. PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old. ACTION STATEMENTS: The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME.The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.

Clinical Practice Guideline: Otitis Media with Effusion Executive Summary (Update).

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the updated "Clinical Practice Guideline: Otitis Media with Effusion." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 18 recommendations developed emphasize diagnostic accuracy, identification of children who are most susceptible to developmental sequelae from otitis media with effusion, and education of clinicians and patients regarding the favorable natural history of most otitis media with effusion and the lack of efficacy for medical therapy (eg, steroids, antihistamines, decongestants). An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

Remembering and Retelling Stories in Individual and Collaborative Contexts.

Collaborative cognition, in which two or more people work together on a cognitive task, may be typical of everyday life, and may even represent an important aspect of everyday cognitive adaptation for older adults. We examined collaborative memory for stories by comparing younger (n = 64) older (n = 66) individuals and dyads with collaborative performance produced by married spouses and stranger dyads. Overall, across four collaborative recall products (two positive and two negative performance indicators), some evidence for our hypothesis of general or selective collaborative effectiveness was observed. Moreover, such evidence was obtained at both an immediate and delayed recall episode. Discussion includes applications, limitations and suggestions for future research.

Major depression and its association with long-term medical conditions.

OBJECTIVE: To replicate previously reported associations between major depressive episodes (MDEs) and long-term medical conditions in a Canadian community sample. METHODS: A sample of 2542 household residents was selected using random digit dialing (RDD). Data were collected by telephone interview. The Composite International Diagnostic Interview (CIDI)-Short Form for major depression (CIDI-SFMD) was used to identify MDEs occurring in the previous 12 months. Long-term medical conditions were identified by self-report. RESULTS: The prevalence of MDE was elevated in those subjects who reported 1 or more long-term medical conditions. The association was not due to confounding by age, sex, social support, or stressful recent life events. CONCLUSION: This study replicates a previously reported association between depressive disorders and long-term medical conditions. These cross-sectional associations suggest that medical conditions may increase the risk of major depression or that major depression may increase the risk of medical conditions. Alternatively, comorbid medical conditions may influence the duration of depressive episodes, or vice versa. These explanations are not mutually exclusive.