Maternal Adaptive Capacity: A Strengths-Based Theory to Guide Maternal Health Research.

The United States is experiencing a rise in maternal morbidity and mortality that disproportionately affects marginalized groups. Maternal health research is often designed through a lens of deficit, which perpetuates bias and negatively affects care. The purpose of this article is to describe the development of the theory of maternal adaptive capacity, a strengths-based approach to maternal health research that has the potential to promote new discovery in research, reduce biases, empower individuals and improve health outcomes. Walker and Avant's approach to theory derivation is applied to the framework of vulnerability to climate change, a theory commonly used in environmental research. In this derivation the authors explore the parallels between the concept of adaptive capacity related to climate change and maternal health. The new theory of maternal adaptive capacity should be applied and tested in various research modalities to confirm its utility.

Utility of a "Lavender Lounge" to Reduce Stress Among Critical Care Registered Nurses: A Cross-Sectional Study.

BACKGROUND: Work-related stressors are present in almost every profession, but many believe nurses caring for critically ill patients experience additional and unique stresses. Results of previous studies have demonstrated the potential benefits of various interventions to reduce stress among intensive care nurses. However, the practicality of nurses taking time out from a busy unit to meet their own needs remains in question. OBJECTIVES: To assess intensive care nurses' perceptions of the usability of a lounge designed to support them in refreshing and renewing themselves after stressful clinical situations. METHODS: This study used a descriptive, cross-sectional design and survey methodology with a convenience sample of registered nurses from a medical intensive care unit. RESULTS: Of 250 registered nurses eligible for participation, 54 (21.6%) completed surveys, and of those, 31 (57%) reported having used the lounge within the past month. Nurses reported having coverage provided by colleagues, visiting during their lunch break, and having low unit acuity were facilitators of lounge use. Barriers included high unit acuity, high unit census, and high patient care demands with no one available to cover patient assignments. CONCLUSIONS: The variables that lead to stress and burnout among medical intensive care unit nurses also prevent nurses from using a "relaxation room." A more effective approach may be organizational change that supports reduction of workload through increased staffing, prearranged breaks during shifts, and increased recovery time between shifts by limiting work to no more than 40 hours per week.

Evaluation of an Elective Induction Protocol at a Regional Tertiary Obstetric Care Centre.

OBJECTIVES: To evaluate the safety of elective induction (EI) at or beyond 39 weeks gestation in the setting of a regional tertiary obstetric care centre. METHODS: We conducted a prospective cohort feasibility study of low-risk pregnant women who delivered at a regional tertiary obstetric care centre. We compared maternal and neonatal outcomes of low-risk pregnant women who opted for EI at or beyond 39 weeks gestation (n = 112) to a comparison group who opted for expectant management (n = 116). All deliveries occurred between May 1, 2019, and November 30, 2019, and February 15, 2020, and August 15, 2020. RESULTS: There were no significant differences in the rates of cesarean deliveries or hypertensive disorders between women who underwent EI and those who chose expectant management. There were also no differences in neonatal outcomes. Women in the EI group received significantly more cervical ripening agents (P < 0.0001) and had significantly longer stays on the antepartum (P < 0.0001) and labour and delivery units (P = 0.0015) but experienced significantly shorter stays on the postpartum unit (P = 0.0368). There was no difference in the total length of hospital stay between groups. CONCLUSIONS: EI protocols can be safely implemented in our regional tertiary obstetric care centre without increased risk of maternal complications or neonatal morbidity. Women considering EI should be adequately counselled on the use of cervical ripening agents and length of stay on antepartum and labour and delivery units.

Lifestyle and the hypertensive disorders of pregnancy in nulliparous women in the United States: a secondary data analysis of the nuMom2b.

BACKGROUND: Hypertensive disorders of pregnancy are a leading cause of maternal and fetal morbidity and mortality and a significant risk factor for future cardiovascular disease development in women. This study aimed to explore lifestyle wellness-related variables and how they impact the risk of hypertension in pregnancy. METHODS: This is a secondary analysis of data from the prospective cohort study Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be (nuMoM2b). Data was collected through questionnaires, clinical evaluations, and medical records review at 8 academic medical centers in the United States. Four study visits were scheduled throughout the participant's pregnancy (visits one-four): 60-136, 160-216, and 220-296 weeks gestation and birth. A series of statistical modeling and logistical regression were performed using 15 lifestyle variables related to sleep, nutrition, resilience, illness avoidance, and physical activity were selected as predictor variables with an outcome variable of hypertension. RESULTS: Of 9289 nulliparous participants considered for inclusion in our analyses, 1464 had any HDP during study participation, and 554 participants had complete data available for the study and were included in our final sample. Results were statistically significant at a level of p < 0.05. Of the sleep variables, snoring at visit 1 increased the risk of hypertension in pregnancy. Greater vegetable consumption reported at visit one decreased risks of hypertension in pregnancy. Physical activity reported at visit two and visit three were associated with decreased risk of hypertension. Physical activity reported at visit three combined with more hours of sleep each night, or through napping habit reported at visit one decreased hypertension risk. Increased fish oil consumption combined with more hours of sleep at visit one increased odds of hypertension in pregnancy. CONCLUSIONS: Our results support that lifestyle wellness-related variables relating to sleep, physical activity and nutrition affect hypertension in pregnancy. The studied variables and others should be considered in future research and intervention development to reduce hypertension in pregnancy and improve maternal wellness.

Skin-to-Skin Contact and the Incidence of Transient Tachypnea of the Newborn.

OBJECTIVES: To compare the incidence of transient tachypnea of the newborn (TTN) before and after the implementation of a Baby-Friendly protocol and to determine changes in the rates of TTN symptoms, interventions, completion of skin-to-skin contact. DESIGN: Retrospective cohort study using data in the electronic medical record. SETTING: Community-based tertiary obstetric facility. PARTICIPANTS: We reviewed 934 charts of neonates born at or greater than 34 weeks gestation to women ages 18 years or older and included 790 neonates: 491 in the preimplementation group and 299 in the postimplementation group. Group assignment was based on time of Baby-Friendly protocol implementation. The preimplementation group included neonates born in April, August, and December of 2014, and the postimplementation group included neonates born during these months in 2018. METHODS: The primary outcome was incidence of TTN. Secondary outcomes were rates of the following: tachypnea symptoms, hypoglycemia, antibiotic administration, and completion of skin-to-skin contact. RESULTS: The incidence of TTN was 2% (n = 8/491) in the preimplementation group and 1% (n = 4/299) in the postimplementation group (p = 1.000). The rate of tachypnea symptoms decreased from 5% (n = 25/491) to 1% (n = 3/299, p = .003), the rate of hypoglycemia decreased from 11% (n = 54/491) to 3% (n = 10/299, p < .001), and the rate of antibiotic administration decreased from 13% (n = 66/491) to 4% (n = 11/299, p < .001). The skin-to-skin completion rate increased from 16% (n = 79/491) to 61% (n = 183/299, p < .001). CONCLUSION: Although skin-to-skin contact facilitates physiologic transition to extrauterine life, incidence of TTN was not significantly reduced after the implementation of the Baby-Friendly protocol. However, increased practice of skin-to-skin contact was an improvement in care with implications for the transition to extrauterine life.

Cognitive screening for adult psychiatric outpatients: Comparison of the Cognivue® to the Montreal Cognitive Assessment.

In this editorial we comment on the article by Cahn-Hidalgo D published in a recent issue of the World Journal of Psychiatry 2020; 10(1); 1-11. We focus on the importance of utilizing psychometrically valid cognitive screening tools when assessing for cognitive decline in older adults in a psychiatric outpatient setting. We compared the use of Cognivue® to use of the montreal cognitive assessment (MoCA) as a cognitive screening tool. A total of 58 patients aged 55 and over participated in this comparison study. Patients completed cognitive screening on Cognivue®, a new Food and Drug Administration-cleared computer screening device, and the MoCA. The results of patient performance using these two instruments were analyzed. Sixteen (28%) patients screened negative for cognitive impairment on both assessments. Forty-two (72%) patients screened positive on one or both of the assessments. There was 43% agreement between Cognivue® and the MoCA in identifying patients with cognitive impairment, and individual subtests were weakly correlated. The MoCA was determined to be the preferred instrument due to its high sensitivity and specificity (100% and 87%, respectively) when screening for cognitive impairment. We propose that the use of Cognivue® cognitive screening tool be closely reviewed until more research proves that the test meets the standards for reliability and validity. It is important for clinicians to remember that screeners should not be used to diagnosis patients with neurocognitive disorders; instead, they should be used to determine whether further evaluation is warranted. Additionally, misdiagnosing of neurocognitive disorders can pose unnecessary psychological and emotional harm to patients and their families and also lead to incorrect treatment and undue healthcare costs.

An Initiative to Increase Resident Performance of Operative Vaginal Deliveries.

The objective of this single-centre, action research study was to increase resident experience performing operative vaginal deliveries. The secondary objective was to assess the incidence of maternal and neonatal complications. The rate of forceps deliveries increased in the post-training period (1.8%-4.0%; P < 0.001) but the overall rate of operative vaginal delivery did not change. The composite maternal complications rate following forceps delivery was lower in the post- training period (P = 0.006). There were no significant differences in maternal or neonatal complications with vacuum delivery between the periods before and after the initiative. Experiential training of residents may be a viable alternative to simulation training as it does not require expensive state-of-the-art simulation technology.

Effect of preventive (beta blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial.

OBJECTIVE: To determine if the addition of preventive drug treatment (ß blocker), brief behavioural migraine management, or their combination improves the outcome of optimised acute treatment in the management of frequent migraine. DESIGN: Randomised placebo controlled trial over 16 months from July 2001 to November 2005. SETTING: Two outpatient sites in Ohio, USA. PARTICIPANTS: 232 adults (mean age 38 years; 79% female) with diagnosis of migraine with or without aura according to International Headache Society classification of headache disorders criteria, who recorded at least three migraines with disability per 30 days (mean 5.5 migraines/30 days), during an optimised run-in of acute treatment. INTERVENTIONS: Addition of one of four preventive treatments to optimised acute treatment: ß blocker (n=53), matched placebo (n=55), behavioural migraine management plus placebo (n=55), or behavioural migraine management plus ß blocker (n=69). MAIN OUTCOME MEASURE: The primary outcome was change in migraines/30 days; secondary outcomes included change in migraine days/30 days and change in migraine specific quality of life scores. RESULTS: Mixed model analysis showed statistically significant (P≤0.05) differences in outcomes among the four added treatments for both the primary outcome (migraines/30 days) and the two secondary outcomes (change in migraine days/30 days and change in migraine specific quality of life scores). The addition of combined ß blocker and behavioural migraine management (-3.3 migraines/30 days, 95% confidence interval -3.2 to -3.5), but not the addition of ß blocker alone (-2.1 migraines/30 days, -1.9 to -2.2) or behavioural migraine management alone (-2.2 migraines migraines/30 days, -2.0 to -2.4), improved outcomes compared with optimised acute treatment alone (-2.1 migraines/30 days, -1.9 to -2.2). For a clinically significant (≥50% reduction) in migraines/30 days, the number needed to treat for optimised acute treatment plus combined ß blocker and behavioural migraine management was 3.1 compared with optimised acute treatment alone, 2.6 compared with optimised acute treatment plus ß blocker, and 3.1 compared with optimised acute treatment plus behavioural migraine management. Results were consistent for the two secondary outcomes, and at both month 10 (the primary endpoint) and month 16. CONCLUSION: The addition of combined ß blocker plus behavioural migraine management, but not the addition of ß blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment. Combined ß blocker treatment and behavioural migraine management may improve outcomes in the treatment of frequent migraine. TRIAL REGISTRATION: Clinical trials NCT00910689.

Botulinum toxin type-A (BOTOX) in the treatment of occipital neuralgia: a pilot study.

OBJECTIVE: To determine the efficacy of occipital nerve blocks using reconstituted botulinum toxin type-A (BTX-A) in providing significant and prolonged pain relief in chronic occipital neuralgia. BACKGROUND: Occipital neuralgia is a unilateral or bilateral radiating pain with paresthesias commonly manifesting as paroxysmal episodes and involving the occipital and parietal regions. Common causes of occipital neuralgia include irritation or injury to the divisions of the occipital nerve, myofascial spasm, and focal entrapment of the occipital nerve. Treatment options include medication therapy, occipital nerve blocks, and surgical techniques. BTX-A, which has shown promise in relief of other headache types, may prove a viable therapeutic option for occipital neuralgia pain. METHODS: Botulinum toxin type-A (reconstituted in 3 cc of saline) was injected into regions traversed by the greater and lesser occipital nerve in 6 subjects diagnosed with occipital neuralgia. Subjects were instructed to report their daily pain level (on a visual analog pain scale), their ability to perform daily activities (on several quality of life instruments) and their daily pain medication usage (based on a self-reported log), 2 weeks prior to the injection therapy and 12 weeks following injection therapy. Data were analyzed for significant variation from baseline values. RESULTS: The dull/aching and pin/needles types of pain reported by the subjects did not show a statistically significant improvement during the trial period. The sharp/shooting type of pain, however, showed improvement during most of the trial period except weeks 3-4 and 5-6. The quality of life measures exhibited some improvement. The headache-specific quality of life measure showed significant improvement by 6 weeks which continued through week 12. The general health- and depression-related measures showed no statistical improvement. No significant reduction in pain medication usage was demonstrated. CONCLUSIONS: Our results indicate that BTX-A improved the sharp/shooting type of pain most commonly known to be associated with occipital neuralgia. Additionally, the quality of life measures assessing burden and long-term impact of the headaches, further corroborated improvement seen in daily head pain.

Feasibility assessment of telephone-administered behavioral treatment for adolescent migraine.

OBJECTIVES: To examine the feasibility of administering behavioral migraine management training by telephone (TAT) and the acceptability of TAT to adolescents with episodic migraine. METHODS: 34 adolescents (M = 14 years) with migraine (M = 3.6 migraines/month; M = 29.2 hours duration) were randomly assigned to a two-month telephone administered behavioral migraine management program (TAT) or to a standard Triptan Treatment (TT). Outcome was assessed at three- and eight-month evaluations. Participants completed a daily migraine diary that yielded information about number, duration and severity of migraines and migraine-related disability, as well as the Migraine Specific Quality of Life Questionnaire - Adolescent. In addition, TAT participants evaluated key aspects of the TAT program using 5-point Likert-like rating scales. Lastly, the ability of adolescents to demonstrate specific headache management skills following TAT was assessed. RESULTS: All fifteen adolescents who entered TAT successfully demonstrated either full or partial mastery of two or more skills and nearly half demonstrated at least partial mastery of all four skills evaluated. Ninety three percent of the TAT participants reported having a positive relationship with their phone counselor. They also reported a preference for the telephone-based treatment over in-clinic visits and rated the manual and tapes as helpful. Treatment effects (in terms of percent improvement) ranged from consistently large across both evaluations for improvement in number of migraines (54% and 71%), disability equivalent hours (80% and 63%) and quality of life (44% and 48%), to moderate or variable for migraine duration (35% and 23%) and severity (30% and 34%). The TT group also showed clinically meaningful reductions in headache parameters and improvements in quality of life. CONCLUSIONS: Completion rates for TAT were high; adolescents evaluated their experience with TAT positively and were able to exhibit key behavioral headache management skills following treatment. While clinically significant improvements in migraine and migraine-related disability/quality of life were observed with both TAT and treatment as usual (triptan therapy), the small study size and the absence of a control group do not permit conclusions about the effectiveness of either treatment. Nonetheless these results indicate TAT may be a promising treatment format for improving access to behavioral treatments for underserved adolescents and justifies further evaluation of TAT both alone and in combination with drug therapy.

Factors associated with migraine-related quality of life and disability in adolescents: a preliminary investigation.

OBJECTIVES: This study examined factors associated with impaired quality of life and functioning in a sample of treatment-seeking adolescent migraineurs. Subjects.-The 37 participants were 51.4% female, and averaged 14.3 years of age and 4.1 migraines per month for the previous 36 months. PROCEDURE: The Migraine-Specific Quality of Life Questionnaire, questionnaire items inquiring about missed activities, and headache diary recordings of missed and impaired activity time served as dependent measures. Variables studied were age; gender; migraine frequency, duration, and severity; presence of nausea, photophobia, or phonophobia; and number of visits to an emergency department in the previous year. RESULTS: Three hierarchical forward regressions and one logistic regression, controlling for age and gender, revealed that the presence of nausea and at least one emergency department visit predicted poorer quality of life and a greater number of missed activities in these adolescent migraineurs. The presence of migraine-related missed activity hours from headache diaries was predicted by being male, having higher combined photophobia and phonophobia sensitivity scores, as well as more frequent and severe migraines. Greater impairment was predicted by having longer average duration attacks. CONCLUSIONS: These preliminary findings suggest that the continued development of effective treatment approaches to alleviate pain, suffering, and disability in adolescent migraineurs is required. In particular, evidence for the impact of nausea and sensitivities suggests that they may be important targets for treatment. As well, adolescent migraineurs with a history of a visit to an emergency department in the previous year likely experience greater individual and family distress, more disability, and poorer quality of life that require thoughtful, comprehensive treatment to prevent the development of more severe headache difficulties.

Perceptions and needs of patients with migraine: a focus group study.

OBJECTIVE: This study's purpose was to identify the areas that people find most difficult in living with migraines and, in that regard, what kinds of assistance would be most helpful to them and to other people who have migraine headaches. STUDY DESIGN: Four focus groups, each consisting of 4 to 8 participants, were held. Discussions, which were recorded and organized according to category and theme, focused on problems in living with migraines and effective treatment of migraines. POPULATION: Participants were 24 people who had been experiencing 1 to 2 migraines a month, each lasting 1 to 2 days, for at least 6 months. RESULTS: Five themes emerged: (1) impact on family, (2) misunderstanding by others, (3) effect on work, (4) physician care issues, and (5) issues related to medical insurance and drug companies. A majority of participants identified early treatment as the most important consideration for new migraine sufferers. Many participants preferred to have a relationship with their physicians in which they developed a treatment plan together rather than receiving generic educational materials. CONCLUSIONS: Results suggest that patients are interested in understanding their migraines and securing relevant information in addition to obtaining pain relief. Patients desired collaborative relationships with their physicians and a team approach to treatment. Suggestions for physicians who treat patients who have migraines are reviewed.