Early intervention to prevent adverse child emotional and behavioural development following maternal depression in pregnancy: study protocol for a randomised controlled trial.

BACKGROUND: Substantial evidence indicates that maternal depression during pregnancy (i.e., antenatal depression) is associated not only with maternal wellbeing but also with child emotional and behavioural development. Children of antenatally depressed women are at risk of emotional and behavioural problems, including internalising problems (e.g., anxiety and depression) and externalising problems (e.g., attention problems), that may last at least to adolescence. These enduring effects also constitute an enormous economic cost. Despite the seriousness of this problem, until recently there existed very few controlled studies evaluating whether active psychological treatment for antenatal depression can prevent adverse child outcomes. Our previous pilot randomised controlled trial (RCT) exploring the effect of cognitive behavioural therapy (CBT) for antenatal depression on child outcomes showed promising results. We aim to assess whether treating antenatal depression with an evidence-based 8-week structured CBT program can prevent or ameliorate adverse child developmental outcomes at 2 years of age. METHODS: Pregnant women ≤ 30 weeks gestation diagnosed with a depressive disorder are recruited and randomised to CBT or treatment as usual (TAU). The target sample size is 230 and the primary outcome measure is the infant Internalising scale of the Child Behaviour Checklist (CBCL) at 24 months of age. Secondary infant outcome measures at 24 months are the Externalising scale of the CBCL and the motor and cognitive development subscales of the Ages & Stages Questionnaire (ASQ-3). Additional secondary outcome measures are subscales of the Revised Infant Behaviour Questionnaire (IBQ-R), ASQ-3 and the ASQ-Socio-Emotional (ASQ-SE) at 3 and 12 months of age and the quality of mother-infant interaction at 3 and 24 months. Maternal measures, including demographic data, depression diagnosis, depressive and anxiety symptoms, perceived stress and parenting stress, are collected across all time points. DISCUSSION: The trial is ongoing and recruitment was slowed due to the COVID-19 pandemic. If results suggest a beneficial effect of antenatal depression treatment on infant outcomes, the project could have repercussions for standard antenatal care, for maternal and infant health services and for preventing the intergenerational transmission of mental health disorders. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register: ACTRN12618001925235 Date Registered: 27 November 2018.

Survey of Postpartum People in the United States During the First Wave of the COVID-19 Pandemic to Explore Their Perspective on Support After Discharge.

INTRODUCTION: The purpose of this study was to capture the experiences of postpartum people during the first wave of COVID-19, specifically their access to contraception and lactation support. METHODS: This cross-sectional study surveyed individuals in the United States who used the Ovia Pregnancy and Parenting app. The survey was administered via an email Web link sent to postpartum people who gave birth between March 1, 2020, and June 11, 2020. Quantitative and qualitative analyses were conducted. RESULTS: A total of 388 postpartum people completed the survey. Most participants had just given birth to their first baby (68.5%; n = 261) at term gestation (37-41 weeks) (92.9%; n = 355). From the qualitative data, using content analysis, we derived 6 themes and 2 subthemes: quarantine, changes in postpartum care, loneliness and isolation, stress, resource changes, and positive impact. The theme loneliness and isolation had 2 subthemes: depression/sadness/hopelessness and anxiety. DISCUSSION: The experience of being postpartum during the COVID-19 pandemic brought unforeseen challenges. Providing care and support to postpartum people during a pandemic, specifically during a time of quarantine, should be reimagined. Increased use of virtual postpartum care services and expanded mental health support could serve to fill the gaps identified by participants.

Feasibility of leveraging menstrual cycle tracking apps for preconception research recruitment.

Background: Mobile applications (apps) present a new opportunity to study menstrual cycles and time to pregnancy. Understanding the characteristics of cycle tracking app users is important to evaluate the feasibility of recruiting participants for preconception research. Methods: Users of a cycle tracking smartphone app, Ovia Fertility, aged 18 or older in the U.S. were randomly invited via email to complete a "fertility research" questionnaire that included demographic and reproductive characteristics. Among those attempting pregnancy without medical assistance, attempt duration, factors influencing pregnancy planning, health history and behaviors while attempting to conceive were queried. Respondents could choose to enter a raffle for a $50 gift card. Results: Initially, 639 people responded to the demographics portion of the survey representing 49 states and Washington DC. Of these, 344 (54%) were trying to conceive and of those, 297 (86%) were not using medical treatments. Of those not trying to conceive, 12% reported that they planned to start in the next 3 months. Most participants were ages 26-35 (63%), of White race (70%), reported non-Hispanic ethnicity (87%), had at least a bachelor's degree (56%) and an income between $50,000 and $200,000 (58%). One-third were of recommended BMI (35%), 24% overweight, and 41% obese. Most participants reported no fertility-related health conditions (58%). Forty-eight participants (17%) had been trying to conceive for 1 month or less, 88 (31%) had been trying for 2 months or less, and 122 (43%) for 3 months or less. Interruptions in pregnancy attempts were common, 31% reported periods without intercourse. Of those attempting pregnancy, 47% of partners completed their own questionnaire. Conclusion: This first-of its-kind analysis describes users of a cycle-tracking smartphone app who could be eligible for recruitment to a prospective time-to-pregnancy study. Survey respondents were diverse with respect to geographic location, BMI, and income. However, special recruitment efforts will be needed to recruit participants and partners who identify as other than non-Hispanic White. Participants with fertility-related conditions are not overly represented among app users who are trying to conceive. Targeting and pre-enrolling app users who are planning to begin a pregnancy attempt in the next 3 months may be an advantage of app-based recruitment.

Risk Factors Associated with Severe Macromastia among Adolescents and Young Women.

BACKGROUND: Macromastia is common among adolescents and young women and has well-documented negative physical and psychosocial effects. The pathogenesis of idiopathic macromastia has been attributed to increased end organ sensitivity to circulating gonadal hormones. Despite the known negative effects of macromastia, there is a paucity of literature examining the clinical risk factors associated with macromastia severity in this age group. METHODS: In this cross-sectional study, standardized clinical forms were administered to patients between the ages of 12 and 21 years undergoing reduction mammaplasty. Data were collected pertaining to patient demographics, biometrics, breast symptoms, medical and family history, and breast tissue resection mass at the time of reduction. Resection mass was normalized to patient body surface area in analyses. RESULTS: A total of 375 patients were included in analyses. Mean age at surgery was 18.1 years. The following risk factors were positively associated with macromastia severity in both univariate and multivariate logistic regression models: overweight or obesity, racial or ethnic minority status, patient-reported gynecologic or endocrine complaints, and early menarche ( p < 0.05, all). More severe cases of macromastia were associated with approximately three times the odds of being overweight or obese or achieving menarche before 11 years old. CONCLUSIONS: In our sample, overweight or obesity, racial or ethnic minority status, early menarche, and patient-reported gynecologic or endocrine complaints were all positively associated with macromastia severity. Awareness of these factors can empower physicians to identify and address modifiable risk factors to prevent progression to more severe disease. Macromastia itself should prompt screening for gynecologic or endocrine complaints with referral as indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Normative Values for Adolescent Quality of Life in Plastic Surgery: A Longitudinal, Cohort Study.

Background: Adolescence is a challenging time, and an increasing number of young people are seeking plastic surgery. With the rise of health-related quality of life studies in plastic surgery, it is critical to understand the natural variation and changes in health-related quality of life for this population. Methods: In this longitudinal, cohort study validated surveys were administered to cisgender participants aged 12-21 years: Short-Form 36v2, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26. Surveys were administered at baseline and up to 9 years follow-up. At the time of enrollment, participants were in a current state of good health with no considerable past or current medical, surgical, or psychological history. Results: A total of 149 female and 75 male participants were included, with a median (interquartile range) baseline age of 16.0 (4.4) years and follow-up time of 3.3 (4.1) years. Over the study period, girls who were not overweight or obese experienced significant declines in five SF-36 domains (general health, vitality, social functioning, role-emotional, and mental health) and on the Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 (P < 0.05). In contrast, boys' and overweight/obese girls' health-related quality of life largely remained stable (P > 0.05). Conclusions: Adolescence is a challenging time, on which plastic surgery-related concerns are superimposed. Our findings suggest that girls may be more at risk for developing psychosocial deficits that worsen over adolescence and young adulthood. This observation is critical for the interpretation and contextualization of health-related quality of life in adolescent plastic surgery patients.

Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men.

BACKGROUND: Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life. METHODS: Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test. RESULTS: Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively. CONCLUSIONS: Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits.

Engaging patients and parents to improve mental health intervention for youth with rheumatological disease.

BACKGROUND: Mental health disorders are common in youth with rheumatological disease yet optimal intervention strategies are understudied in this population. We examined patient and parent perspectives on mental health intervention for youth with rheumatological disease. METHODS: We conducted a mixed methods cross-sectional study, via anonymous online survey, developed by researchers together with patient/parent partners, to quantitatively and qualitatively examine youth experiences with mental health services and resources in North America. Patients ages 14-24 years with juvenile idiopathic arthritis, juvenile dermatomyositis, or systemic lupus erythematous, and parents of patients ages 8-24 with these diseases were eligible (not required to participate in pairs). Participants self-reported mental health problems (categorized into clinician-diagnosed disorders vs self-diagnosed symptoms) and treatments (e.g. therapy, medications) received for the youth. Multivariate linear regression models compared patient and parent mean Likert ratings for level of: i) comfort with mental health providers, and ii) barriers to seeking mental health services, adjusting for potential confounders (patient age, gender, disease duration, and patient/parent visual analog score for disease-related health). Participants indicated usefulness of mental health resources; text responses describing these experiences were analyzed by qualitative description. RESULTS: Participants included 123 patients and 324 parents. Patients reported clinician-diagnosed anxiety (39%) and depression (35%); another 27 and 18% endorsed self-diagnosed symptoms of these disorders, respectively. 80% of patients with clinician-diagnosed disorders reported receiving treatment, while 11% of those with self-diagnosed symptoms reported any treatment. Patients were less comfortable than parents with all mental health providers. The top two barriers to treatment for patients and parents were concerns about mental health providers not understanding the rheumatological disease, and inadequate insurance coverage. Over 60% had used patient mental health resources, and over 60% of these participants found them to be helpful, although text responses identified a desire for resources tailored to patients with rheumatological disease. CONCLUSION: Self-reported mental health problems are prevalent for youth in this sample with rheumatological disease, and obstacles to mental health treatment include disease-related and logistic factors. Strategies are needed to improve acceptance and accessibility of mental health intervention, including routine mental health screening and availability of disease-specific mental health resources.

Hidden Costs in Resident Training: Financial Cohort Analysis of First Assistants in Reduction Mammaplasty.

Graduate medical education (GME) programs are vital to developing future plastic surgeons. However, their cost-efficiency has yet to be contextualized. This cohort quality improvement (QI) project aimed to measure the indirect costs an institution assumes in training surgical residents, by comparing the differences in operative time and procedural charges between a resident and a physician assistant (PA) first-assisting during adolescent reduction mammaplasty. METHODS: From 2013 to 2019, adolescent bilateral reduction mammaplasty procedures first-assisted by either a resident or physician assistant were considered for analysis. Financial data, including all hospital and physician expenditures and operation duration, patient demographics, and outcomes data were retrospectively collected. RESULTS: A total of 49 reduction mammaplasty cases were included for analysis. Residents had an average of 5.9 ± 1.5 years of post-graduate surgical training, whereas the PA had 2 years of surgical experience. Procedures first-assisted by a surgical resident took a mean/median of 34 minutes longer and were $3750 more expensive, respectively, than cases first-assisted by a PA (P < 0.01, both). CONCLUSIONS: Reduction mammaplasty procedures were longer and accrued higher charges when first-assisted by a surgical resident than by a PA. Although Graduate Medical Education programs are necessary to train the next generation of surgeons, they may result in unintended opportunity costs for teaching hospitals. Federal support to academic medical centers aims to cushion the cost of residential training, but is insufficient to compensate for resident inefficiency. Hospitals may consider incorporating PAs into the Graduate Medical Education paradigm to alleviate administrative burden, lower operational charges, and enhance resident training curricula.

Implementing a Rapid, Two-Step Delirium Screening Protocol in Acute Care: Barriers and Facilitators.

BACKGROUND/OBJECTIVES: An effective and efficient protocol for delirium identification is needed to improve health outcomes for older adults and reduce healthcare costs. This study describes the barriers and facilitators related to the implementation of the ultra-brief confusion assessment method (UB-CAM), a rapid two-step delirium identification protocol (ultra-brief screen, followed by CAM in positives), field tested with hospitalized older adults (70+). DESIGN: A qualitative descriptive design using observational data collection and brief semi-structured interviews. SETTINGS: An urban academic medical center and a community teaching hospital. PARTICIPANTS: Participants included 50 physician hospitalists, 189 registered nurses, and 83 nursing assistants (NAs). MEASUREMENTS: Field researchers guided by a modified multi-level implementation framework, collected observational data as participants administered the UB-CAM (n = 767). Thematic analysis was conducted on five observational categories: structural, organizational, patient, clinician, and innovation. Field notes and brief semi-structured interviews (n = 231) with clinicians, explored the utility, acceptability, and feasibility of the protocol, and supplemented the observations. RESULTS: The UB-CAM was generally positively received by all three clinician types. Six themes describe barriers and/or facilitators to implementing the UB-CAM: (1) physical setting and milieu; (2) practice environment; (3) integrating into role; (4) adaptive techniques; (5) patient responses; and (6) systematic assessment. The composition and interaction of the six themes determined if the theme was expressed as a barrier or facilitator, affirming the importance of context when implementing system-level delirium screening. CONCLUSION: This is one of the first studies to test a two-step process for delirium identification, and to involve NAs in screening, and the findings demonstrate overall support from clinicians for delirium identification, and describe the need for a multifaceted, contextualized, and systemic approach to implementation and evaluation of delirium screening.

Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults.

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction. METHODS: This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016. RESULTS: Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%). CONCLUSIONS: This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.