How has our primary-care NHS-IAPT provision for PTSD adapted to the pandemic? A service evaluation of recovery pre-COVID-19 and peri-COVID-19.

BACKGROUND: Mental health issues have been an ongoing major cause of global disability exacerbated by the COVID-19 pandemic. The unique challenges have been the high contagiousness of COVID-19 and atypical PTSD presentations e.g., ICU-PTSD. This has led to increased demand on mental health services which have had to vary their provision for example working remotely vs. the traditional face-to-face. The pandemic has also exposed the preexisting health inequalities related to sociodemographic variables. In the UK, NHS-IAPT is the main primary-care provider which has suffered these repercussions. Research from COVID-19 and previous viral outbreaks has estimated an increase in the prevalence of PTSD. Although services have been urged to monitor their provision, research on PTSD remains scanty. The current NHS-IAPT service was concerned about these ramifications of the pandemic and also wished to address the gap in the research. The aim was to conduct an evaluation of the impact of the COVID-19 on PTSD recovery. The first question evaluated the impact, and the second question evaluated the associated variables. METHODS: The study employed a quantitative data analysis method. Data were extracted and analysed from the electronic database, IAPTus. The study evaluated PTSD recovery rates during pre-pandemic and peri-pandemic periods. The comparisons determined the impact of the pandemic as well as what recovery variables were significant. The data were analysed statistically using both descriptive statistics and inferential statistics (t-test and Chi-square). The data were analyzed in reference to the national NHS-IAPT standards via NHS-Digital. RESULTS: The findings suggest that the pandemic had no significant impact on overall PTSD recovery rates, which also aligned with the national standards. These recovery rates fell below the target national standard of 50% regardless of the pandemic. Several client, service and treatment variables were shown to be associated with PTSD recovery rates. CONCLUSIONS: This evaluation highlights a pre-existing problem around the persistently low PTSD recovery rates. It also identifies variables that warrant further research in order to improve PTSD service-provision and mitigate any long-term pandemic impacts. This study also provides information for other services wishing to enhance their PTSD recovery rates.

Assessment of adherence to guidelines for using progesterone to prevent recurrent preterm birth.

OBJECTIVE: To assess if women with recurrent preterm birth had been offered, received, and adhered to progesterone supplementation guidelines and to ascertain reasons for failure to follow guidelines. METHODS: Charts of infants who were products of recurrent spontaneous preterm birth were reviewed at four neonatal intensive care units of Akron Children's Hospital. Mothers of identified infants were interviewed and charts abstracted to determine: if progesterone was offered; acceptance of progesterone; compliance with progesterone; and reasons why progesterone was declined. RESULTS: One hundred twenty-eight mothers with a recurrent spontaneous preterm birth were identified and 98 consented to participate. 62.2% (61/98) of the interviewed mothers reported that they were offered progesterone. Of the women offered progesterone, 82% (50/61) accepted treatment and 18.0% (11/61) declined. One woman who accepted progesterone did not receive it. Of the women who received progesterone, 18.4% (9/49) reported compliance failure. Of the women who did not receive progesterone, 75.5% (37/49) reported that they were not offered progesterone and 89.2% (33/37) of the women not offered progesterone reported that their care providers were aware of their prior preterm delivery. CONCLUSIONS: Only 50% (49/98) of women who were candidates for progesterone received treatment. The main reason for women not receiving treatment was not being offered progesterone by their caregiver.

Pregnant Adolescents Admitted to an Inpatient Child and Adolescent Psychiatric Unit: An Eight-Year Review.

STUDY OBJECTIVE: To assess patient outcomes and describe demographic data of pregnant adolescents admitted to an inpatient child and adolescent psychiatric unit, as well as to determine if it is safe to continue to admit pregnant adolescents to such a unit. DESIGN, SETTING, AND PARTICIPANTS: A descriptive retrospective chart review conducted at a free-standing pediatric hospital in northeast Ohio of all pregnant adolescents aged 13 to 17 years admitted to the inpatient child and adolescent psychiatric unit from July 2005 to April 2013. MAIN OUTCOME MEASURES: Data collection included details on demographic, pregnancy status, and psychiatric diagnoses. RESULTS: Eighteen pregnant adolescents were admitted to the psychiatric unit during the time frame. Sixteen of those were in the first trimester of pregnancy. Pregnancy was found to be a contributing factor to the adolescent's suicidal ideation and admission in 11 of the cases. Admission to an inpatient psychiatric facility did not lead to adverse effects in pregnancy. CONCLUSION: Pregnant adolescents did not have negative pregnancy outcomes related to admission to an inpatient psychiatric unit. Results of this study suggest that it is safe to continue to admit uncomplicated pregnant adolescents in their first trimester to an inpatient child and adolescent psychiatric unit for an acute stay.

Catheter ablation of supraventricular tachycardia without fluoroscopy during pregnancy.

BACKGROUND: Although uncommon, supraventricular tachycardia is difficult to manage during pregnancy. Catheter ablation traditionally has been deferred owing to radiation exposure risks. Three-dimensional mapping is a new tool in cardiac electrophysiology, which is being utilized to eliminate fluoroscopy during catheter ablation. We report a case of ablation of supraventricular tachycardia during pregnancy without using fluoroscopy. CASE: A 27-year-old woman with a 22-week twin gestation was referred for incessant supraventricular tachycardia. Medical management with propranolol and flecainide was unsuccessful. An electrophysiology study was performed with catheter navigation guided by a three-dimensional mapping system instead of fluoroscopy. The patient underwent successful cryoablation. The procedure was performed without fluoroscopy or sedation. The patient delivered healthy twins at 35 weeks of gestation without complications. On follow-up at 26 months, she showed no evidence of recurrence. CONCLUSION: New tools in electrophysiology now make curative procedures more readily available to pregnant women and safer for the fetus.

The use of the Cervilenz device to aid in the diagnosis of premature labor.

OBJECTIVE: A short cervix measured by transvaginal ultrasound has been correlated with increased risk for preterm delivery (PTD). Many patients presenting with a complaint of possible premature labor (PL); may not have access to cervical length (CL) screening by ultrasound. Cervilenz is an FDA cleared disposable device for obtaining vaginal CL measurements. This study was conducted to correlate Cervilenz measurements of CL with the occurrence of PTD. METHODS: Women presenting with regular uterine contractions at gestational age (GA) ≥22 and <34 weeks with intact membranes and cervical dilation <3 cm were recruited. A speculum examination was performed and Cervilenz measurement of CL was obtained. Patients were treated with tocolytics and/or corticosteroids based upon the attending physician's judgment. The occurrences of PTD as a result of PL or premature rupture of membranes within 7 days, <32 weeks, <34 weeks and <37 weeks, were determined. Patients who were delivered preterm for other maternal or fetal indications were excluded. Negative predictive value (NPV) was calculated. RESULTS: Of the 220 women recruited, 20 were subsequently excluded from analysis because they required PTD for unrelated indications. The mean GA at enrollment was 29.8 ± 2.8 (SD) weeks. One (0.5%), 2 (1.0%), 4 (2.0%) and 29 (14.5%) women delivered at ≤7 days from enrollment, ≤32 weeks, ≤34 weeks, and ≤37 weeks, inclusively. Seventy-seven (38.5%), 39 (19.5%) and 19 (9.5%) women had Cervilenz measurement of ≤30, ≤25 and ≤20 mm, respectively. The NPV for a Cervilenz measurement of >20 mm for delivery at, ≤32, ≤34 and ≤37 weeks were 99.2%, 98.3% and 86.7%, respectively. CONCLUSION: Cervilenz measurement >20 mm appears to have high NPV for PTD prior to 34 weeks.

Successful pregnancy following both endometrial ablation and uterine artery embolization.

OBJECTIVE: To present a description of the management of a pregnancy in a woman who had undergone endometrial ablation and uterine artery embolization for fibroids. DESIGN: Case report. SETTING: Division of Maternal Fetal Medicine within a tertiary community-based teaching hospital. PATIENT(S): A 43-year-old G2P1 woman who had undergone a hydrothermal ballon ablatation and a bilateral, nonselective embolization. INTERVENTION(S): Management of a high-risk pregnancy. MAIN OUTCOME MEASURE(S): Successful pregnancy. RESULT(S): The patient was prophylactically treated with 250 mg of 17 alpha-hydroxyprogesterone intramuscularly weekly, beginning at 16 weeks gestation, received a rescue McDonald cerclage at 22 weeks and 4 days, and remained on modified bed rest at home. Ultrasonically estimated fetal weights were in the 30th to 40th percentile. At 35 4/7th weeks she presented with uterine pain. Ultrasound revealed fundal elevation of the amniotic membranes, estimated fetal weight had decreased to the 20th percentile and a biophysical profile score of 4/10 was obtained. A cesarean resulted in the delivery of a vigorous infant weighing 2466 g. CONCLUSION(S): With aggressive therapy, successful pregnancy is possible in similar patients.

Totally anomalous pulmonary venous connection and complex congenital heart disease: prenatal echocardiographic diagnosis and prognosis.

OBJECTIVE: The purpose of this study was to determine the accuracy of prenatal cardiac diagnosis, prognosis, and outcome of totally anomalous pulmonary venous connection (TAPVC) and to determine echocardiographic clues in the prenatal diagnosis of isolated TAPVC or TAPVC in association with other complex congenital heart disease (CHD). METHODS: We reviewed our 13-year experience of prenatal diagnosis of TAPVC. Thirteen fetuses were identified with the diagnoses of TAPVC. We systematically analyzed the individual pulmonary veins by color and pulsed Doppler imaging, the presence of a pulmonary venous confluence, the pulsed and color Doppler evaluation of the vertical vein, and sites of connections. Prenatal diagnosis was confirmed by postnatal echocardiography, cardiac catheterization, surgery, or autopsy. RESULTS: The mean gestational age at diagnosis of TAPVC was 26.3 weeks (range, 20-33 weeks). There were 8 fetuses with TAPVC and right isomerism, 3 fetuses with other associated CHD, and 2 with isolated TAPVC. There were 7 fetuses with supracardiac TAPVC, 4 with infracardiac TAPVC, and 2 with mixed TAPVC. Pulmonary vein color and pulsed Doppler data were available in 10 of 13 fetuses. The pulmonary venous confluence was visualized in all fetuses except 1. The vertical vein was visualized in all fetuses. Five fetuses had suspected signs of obstruction. The diagnosis was confirmed postnatally or at autopsy in 12 cases. Eight patients underwent surgery; 6 died, and 2 were alive. Two patients had compassionate care and died; 3 pregnancies were terminated. CONCLUSIONS: It is possible to diagnose accurately complex CHD, including the pulmonary venous connections. When diagnosed prenatally, TAPVC carries a poor prognosis.

On the brink, and over.

All in all, this has been a most successful and rewarding period of time for the Academy. Most rewarding of all, perhaps, is the increased recognition being given to the AAPA as a leader among membership organizations in the United States. This recognition underscores our continued commitment and growing capability to help our members and advance the PA profession in the interest of all patients.

A state-wide assessment of the obstetric, anesthesia, and operative team personnel who are available to manage the labors and deliveries and to treat the complications of women who attempt vaginal birth after cesarean delivery.

OBJECTIVE: The purpose of this study was to determine on a state-wide basis the range of obstetric, anesthesia, and surgical team personnel who were available immediately to manage the labors and deliveries of women who attempted vaginal birth after cesarean delivery. Additionally, we tried to determine whether hospitals had stopped performing vaginal births after cesarean delivery or made changes in their policies regarding vaginal birth after cesarean delivery as a result of recent American College of Obstetricians and Gynecologists recommendations. STUDY DESIGN: Available immediately was defined as "being present in the hospital." All hospitals that provided obstetric care in the State of Ohio were surveyed to determine whether an obstetrician with cesarean privileges, an anesthesiologist, or an anesthetist capable of independently administering anesthesia for a cesarean section, and a surgical team were available immediately when women attempted vaginal birth after cesarean delivery. The hospitals were also asked whether they had stopped allowing vaginal births after cesarean delivery or had made changes in their vaginal birth after cesarean delivery policies in response to the recent recommendations of the American College of Obstetricians and Gynecologists. Data were computerized and analyzed by the chi(2) test. RESULTS: Seventy-seven (93.9%), 35 (100%), and 13 (100%) of level I, II, and III hospitals performed vaginal births after cesarean delivery. An obstetrician was immediately available in 27.3%, 62.9%, and 100% of level I, II, and III institutions, respectively (P