Psychosocial Assessment and Depression Screening in Private Obstetric Care

The perinatal period offers a unique opportunity to identify women at risk of, or currently experiencing mental health disorders, to offer support to enhance resilience, and implement appropriate referral and treatment. There is international intent to standardise and make routine the psychosocial assessment and depression screening of all pregnant women as early intervention has been shown to promote better health for women, their infants, partners and the whole family. In Australia, national clinical guidelines for perinatal depression and anxiety recommend perinatal mental health assessment as best-practice for clinical care. However, despite approximately 30-40% of pregnant women choosing to birth in the private sector in Australia, little is known about such initiatives within this sector. The aims of this study were to establish what is known about psychosocial assessment and depression screening for women who choose private obstetric/maternity and postnatal care, with a particular emphasis on the availability and appropriateness of referral pathways and barriers to the implementation of screening within non-metropolitan settings. Barriers were explored from the perspective of the pregnant woman, midwives, obstetricians and other health care professionals working in private obstetric services in both regional and metropolitan settings. Using a sequential mixed methods approach, the study piloted a program of psychosocial assessment and depression screening as part of women’s obstetric ‘booking-in’ process at a regional private hospital in the state of New South Wales (NSW), Australia. A sequential mixed methods design permitted the selection of research methods appropriate to research questions posed for each of a series of study phases. In Phase 1, a retrospective audit of women’s medical records was undertaken to understand the profile and background prevalence of antenatal psychosocial issues/risk factors in women choosing to birth in a small, non-metropolitan private hospital. An integrative literature review was undertaken in Phase 2 to determine the extent and quality of international research in relation to the implementation of psychosocial assessment and depression screening in private hospital/obstetric settings. Specifically, the aim of the integrative review was to discover new knowledge and identify barriers for the development and implementation (in Phase 3) of a Perinatal Psychosocial Care Guideline and the sourcing of appropriate referral services for women identified at risk. Phase 4 used qualitative interview methods to further explore barriers to antenatal psychosocial assessment and depression screening with both health professionals at the study site, and with midwives at three other sites across NSW offering private midwifery care. The literature review confirmed that little is known about screening in private obstetric care but that evidence of positive outcomes exist. The profile and background prevalence of antenatal psychosocial issues/risk factors in women choosing to birth in a small, non-metropolitan private hospital was highlighted. The audit showed that Australian women seeking private obstetric care were older and mainly primiparas. The implementation determined that a lack of resources, perinatal mental health training, confidence and time and overall attitude to screening were the main barriers and qualitative interviews revealed that many midwives themselves expressed that they were either unsure or not necessarily committed to undertaking screening within private hospital settings. These results show that data for women at the study and local hospital sites were similar, indicating that the demographic profile of women was comparable. However, there were substantial differences in birth type with more interventions in the private sector and a lower prevalence of completed EPDS. This study not only successfully implemented psychosocial screening and assessment in one small private hospital in NSW but also explored health professionals and women’s views of perinatal screening and assessment. This is the first study to specifically represent and explore the views of private hospital midwives about psychosocial and depression screening in the Australian private obstetric context. During the follow-up telephone interview, the 209 women agreeing to continue with the study had the opportunity to expand upon their EPDS responses. Women were also recommended additional supports if a psychosocial need or risk was identified during this conversation. Nine women offered further comments during the telephone conversation and of these, seven had total EPDS scores greater than 10 (3.3%). At the study site, five midwives, two obstetricians and one social worker participated in interviews. A further 11 midwives from the three other private hospitals also participated in interviews Therefore, a total of 16 midwives, two obstetricians and one social worker form the sample of 19 interview participants in Phase 4. The themes derived from the thematic content analysis describe how participants perceived the advantages and disadvantages of psychosocial and depression screening. The three main themes were; The need to know, Awareness- knowing what, Preparation, knowing how. These added to the specific reasons that midwives and other health professionals identified for not engaging in screening. Obstetricians at the study site were generally supportive of psychosocial and depression screening but noted that they did not feel any more informed about the psychosocial health or referral of their patients to other services from the midwives than previously. New knowledge was gained and barriers were identified to the development and implementation of psychosocial screening in the private sector. The study concludes that it is crucial to understand and eliminate barriers to implementing psychosocial screening in the private sector in order for this to be successfully implemented as recommended by the 2017 Australian Commonwealth Government review and update of the Australian Perinatal Mental Health Guidelines by the national Centre of Perinatal Excellence (COPE). Once barriers are addressed implementation of psychosocial screening and assessment can be achieved in the private sector

Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia during the Postnatal Period

This chapter is a perspective literature review of published policy and literature regarding psychosocial screening and assessment in the postnatal period. The postnatal period is considered from birth until 6 weeks postpartum. This chapter focuses on the postnatal period, although some resources discussed are for women perinatally. Psychosocial assessment allows the identification of circumstances that affect a woman’s mental health. Postnatal mental health is a contemporary challenge as its risks have long-term effects on the mother, infant and their family. The first year postpartum has the highest rate of maternal death by suicide, especially between nine and 12 months postpartum. Postnatally, the peak rate of hospitalisation for mental illness is within the first 3 months postpartum. The greatest risk for incident hospital admission specifically for primiparous women is 10–19 days postpartum. Psychosocial screening and assessment in the postnatal period are recommended internationally. However, in the private sector in Australia this is at the discretion of the private healthcare providers (postnatal midwife, child and family health nurse, obstetrician, paediatrician). Considering the potentially high morbidity related to postnatal mood disorders, it is crucial that women, either at risk or symptomatic of maternal depression and anxiety, be identified as early as possible in the postnatal period and be subsequently referred for appropriate local management

Risk and protective factors of self-harm and suicidality in adolescents: An umbrella review with meta-analysis

Suicide remains the second most common cause of death in young people aged 10–24 years and is a growing concern globally. The literature reports a vast number of factors that can predispose an adolescent to suicidality at an individual, relational, community, or societal level. There is limited high-level research identifying and understanding these risk and protective factors of adolescent suicidality. The present study used an umbrella review and meta-analysis to synthesize evidence from the review literature in the past 20 years on risk and protective factors of self-harm and suicidality (behavior and ideation) in adolescents. The umbrella review included 33 quantitative reviews with 1149 individual studies on suicidality and self-harm. Based on the data synthesis, it compared the public health impact of exposure on the population of the identified exposure. Bullying victimization was the most attributed environmental exposure for suicidality. The other identified significant school and individual factors were sleeping disturbance, school absenteeism, and exposure to antidepressants. Several significant vulnerable young populations were identified with significantly higher prevalence of suicidality, including lesbian, gay, bisexual, transgender, queer (or questioning) youth and those with mental health disorders, problem behaviors, previous suicidality, self-harm, and gender (female). A person-centered approach emphasizing connectedness and bully-free school environments should be a priority focus for schools, health professionals, and public health policymakers

Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise.

BACKGROUND: An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas. METHOD: A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions. FINDINGS: The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention. DISCUSSION: These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting. CONCLUSION: This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change

Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2):a multicentre observational cohort study

Background: Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. Methods: Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. Findings: Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0–20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1–5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27–10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29–0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53–0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60–0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07–0·43, p=0·0065; and 0·33, 0·14–0·51, p=0·00059, respectively). Interpretation: In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. Funding: The Stroke Association and the British Heart Foundation

Prevalence and architecture of de novo mutations in developmental disorders.

The genomes of individuals with severe, undiagnosed developmental disorders are enriched in damaging de novo mutations (DNMs) in developmentally important genes. Here we have sequenced the exomes of 4,293 families containing individuals with developmental disorders, and meta-analysed these data with data from another 3,287 individuals with similar disorders. We show that the most important factors influencing the diagnostic yield of DNMs are the sex of the affected individual, the relatedness of their parents, whether close relatives are affected and the parental ages. We identified 94 genes enriched in damaging DNMs, including 14 that previously lacked compelling evidence of involvement in developmental disorders. We have also characterized the phenotypic diversity among these disorders. We estimate that 42% of our cohort carry pathogenic DNMs in coding sequences; approximately half of these DNMs disrupt gene function and the remainder result in altered protein function. We estimate that developmental disorders caused by DNMs have an average prevalence of 1 in 213 to 1 in 448 births, depending on parental age. Given current global demographics, this equates to almost 400,000 children born per year

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Genome-wide association identifies nine common variants associated with fasting proinsulin levels and provides new insights into the pathophysiology of type 2 diabetes.

OBJECTIVE: Proinsulin is a precursor of mature insulin and C-peptide. Higher circulating proinsulin levels are associated with impaired β-cell function, raised glucose levels, insulin resistance, and type 2 diabetes (T2D). Studies of the insulin processing pathway could provide new insights about T2D pathophysiology. RESEARCH DESIGN AND METHODS: We have conducted a meta-analysis of genome-wide association tests of ∼2.5 million genotyped or imputed single nucleotide polymorphisms (SNPs) and fasting proinsulin levels in 10,701 nondiabetic adults of European ancestry, with follow-up of 23 loci in up to 16,378 individuals, using additive genetic models adjusted for age, sex, fasting insulin, and study-specific covariates. RESULTS: Nine SNPs at eight loci were associated with proinsulin levels (P < 5 × 10(-8)). Two loci (LARP6 and SGSM2) have not been previously related to metabolic traits, one (MADD) has been associated with fasting glucose, one (PCSK1) has been implicated in obesity, and four (TCF7L2, SLC30A8, VPS13C/C2CD4A/B, and ARAP1, formerly CENTD2) increase T2D risk. The proinsulin-raising allele of ARAP1 was associated with a lower fasting glucose (P = 1.7 × 10(-4)), improved β-cell function (P = 1.1 × 10(-5)), and lower risk of T2D (odds ratio 0.88; P = 7.8 × 10(-6)). Notably, PCSK1 encodes the protein prohormone convertase 1/3, the first enzyme in the insulin processing pathway. A genotype score composed of the nine proinsulin-raising alleles was not associated with coronary disease in two large case-control datasets. CONCLUSIONS: We have identified nine genetic variants associated with fasting proinsulin. Our findings illuminate the biology underlying glucose homeostasis and T2D development in humans and argue against a direct role of proinsulin in coronary artery disease pathogenesis

Mycoplasma pneumoniae infections, 11 countries in Europe and Israel, 2011 to 2016

Background: Mycoplasma pneumoniae is a leading cause of community-acquired pneumonia, with large epidemics previously described to occur every 4 to 7 years. Aim: To better understand the diagnostic methods used to detect M. pneumoniae; to better understand M. pneumoniae testing and surveillance in use; to identify epidemics; to determine detection number per age group, age demographics for positive detections, concurrence of epidemics and annual peaks across geographical areas; and to determine the effect of geographical location on the timing of epidemics. Methods: A questionnaire was sent in May 2016 to Mycoplasma experts with national or regional responsibility within the ESCMID Study Group for Mycoplasma and Chlamydia Infections in 17 countries across Europe and Israel, retrospectively requesting details on M. pneumoniae-positive samples from January 2011 to April 2016. The Moving Epidemic Method was used to determine epidemic periods and effect of country latitude across the countries for the five periods under investigation. Results: Representatives from 12 countries provided data on M. pneumoniae infections, accounting for 95,666 positive samples. Two laboratories initiated routine macrolide resistance testing since 2013. Between 2011 and 2016, three epidemics were identified: 2011/12, 2014/15 and 2015/16. The distribution of patient ages for M. pneumoniae-positive samples showed three patterns. During epidemic years, an association between country latitude and calendar week when epidemic periods began was noted. Conclusions: An association between epidemics and latitude was observed. Differences were noted in the age distribution of positive cases and detection methods used and practice. A lack of macrolide resistance monitoring was noted