A double-blinded randomised controlled study of fluid restriction versus liberal fluid during induction of labour: A pilot study.

BACKGROUND: Excess intravenous fluid for women requiring an induction of labour may adversely affect the duration of labour and maternal/neonatal outcomes. AIMS: This study aimed to determine the difference in duration of labour and outcomes with a low background infusion rate, compared to liberal background intravenous fluid management. MATERIALS AND METHODS: A double blind randomised controlled pilot study was performed on 200 women who underwent induction of labour at a single institution. Women were randomised to an intravenous rate of 40 mL/h versus 250 mL/h of Hartmann's solution. Fluid boluses were strictly controlled to limit bias. This trial was registered with the Australian clinical trial registry: ACTRN12621001298808. RESULTS: Analysis of the total amount of fluid received showed good separation with Group 1 (40 mL/h) receiving 1,736 mL less than Group 2 (250 mL/h), median (interquartile range) 841 mL (458, 1691) versus 2,577 mL (1620, 4326) (P < 0.001). Median duration of labour was shorter in Group 1 by 24 min (P = ns). Subset analysis of nulliparous women showed that duration of labour was shorter in Group 1 by 83.5 min (P = ns). CONCLUSION: As this was a pilot study, a significant difference in duration of labour or secondary outcomes was not seen. Given the increasing numbers of nulliparous women having an induction of labour, potential for adverse maternal and neonatal outcomes and the associated higher rate of operative birth, this study guides power calculations and supports proof of concept for future research into optimum fluid management during induction of labour for these women.

Building Resilience and Attachment in Vulnerable Adolescents: The Feasibility of a Virtually Delivered Group Intervention for Adolescents with Suicidal Ideation and Their Caregivers.

Background: The COVID-19 pandemic required many interventions to be conducted virtually. Building Resilience and Attachment in Vulnerable Adolescents (BRAVA) is a group intervention designed for adolescents and their caregivers to reduce adolescent suicidal ideation (SI). Objective: We aimed to adapt BRAVA for virtual delivery and evaluate its acceptability and feasibility. Methods: We conducted an 8-week pre-post trial between October and December 2020. Six adolescents and six primary caregivers were recruited from a pediatric hospital in Ontario, Canada. Families completed a virtual intake and exit assessment together and 6 weekly BRAVA group sessions separately. Satisfaction feedback was collected after each group session and during their exit, and clinical outcomes were collected at intake and exit. Weekly team meetings were conducted to gather clinician feedback. Results: The study uptake rate was 42.9% of eligible participants. There were no dropouts. Adolescent and caregiver attendance rates for group sessions were high (median = 6). Most youth (83.4%) and caregivers (66.7%) reported that the virtual process worked well. All caregivers (100%) agreed they would participate in a virtual group session again, compared with youth (50%). Providers approved of the virtual adaptation but identified potential improvements (e.g., manual content, safety procedures). Adolescent SI decreased significantly post-treatment (Mpre = 50.7, Mpost = 29.7, p = 0.002). Conclusions: Virtual delivery of BRAVA is acceptable and feasible and may help reduce SI in adolescents. Uptake, retention, and satisfaction were high for adolescents and caregivers. Feedback collected will improve BRAVA for future evaluations, including a randomized controlled trial.

Nitrous Oxide Use in Australian Health Care: Strategies to Reduce the Climate Impact.

Nitrous oxide is a useful inhaled analgesic. Due to its high global warming potential and ozone-depleting properties, the nitrous oxide emissions related to health care are being increasingly scrutinized. In this narrative review, we will discuss the clinical uses of nitrous oxide relevant to anesthetists, in addition to its contribution as a greenhouse gas. Using available data from Australia, we will explore potential strategies for reducing the impact of those emissions, which are likely to be applicable in other countries. These include destruction of captured nitrous oxide, minimizing nitrous oxide waste and reducing clinical use. Anesthesia clinicians are well placed to raise awareness with colleagues and consumers regarding the environmental impact of nitrous oxide and to promote cleaner alternatives. Reducing use is likely to be the most promising reduction strategy without large-scale changes to infrastructure and subsequent delay in action.

Meeting the service needs of youth with and without a self-reported mental health diagnosis during COVID-19.

Background: The COVID-19 pandemic catalyzed major changes in how youth mental health (MH) services are delivered. Understanding youth's MH, awareness and use of services since the pandemic, and differences between youth with and without a MH diagnosis, can help us optimize MH services during the pandemic and beyond. Objectives: We investigated youth's MH and service use one year into the pandemic and explored differences between those with and without a self-reported MH diagnosis. Methods: In February 2021, we administered a web-based survey to youth, 12-25 years, in Ontario. Data from 1373 out of 1497 (91.72%) participants were analyzed. We assessed differences in MH and service use between those with (N=623, 45.38%) and without (N=750, 54.62%) a self-reported MH diagnosis. Logistic regressions were used to explore MH diagnosis as a predictor of service use while controlling for confounders. Results: 86.73% of participants reported worse MH since COVID-19, with no between-group differences. Participants with a MH diagnosis had higher rates of MH problems, service awareness and use, compared to those without a diagnosis. MH diagnosis was the strongest predictor of service use. Gender and affordability of basic needs also independently predicted use of distinct services. Conclusion: Various services are required to mitigate the negative effects of the pandemic on youth MH and meet their service needs. Whether youth have a MH diagnosis may be important to understanding what services they are aware of and use. Sustaining pandemic-related service changes require increasing youth's awareness of digital interventions and overcoming other barriers to care.

Contexte: La pandémie de la COVID-19 a catalysé des changements majeurs de la manière dont les services de santé mentale (SM) sont dispensés aux jeunes. Comprendre la SM des jeunes, la connaissance et l'utilisation des services depuis la pandémie, et les différences entre les jeunes avec et sans un diagnostic de SM peut nous aider à optimiser les services de SM durant la pandémie et au-delà. Objectifs: Nous avons investigué la SM et l'utilisation des services des jeunes un an après le début de la pandémie et exploré les différences entre ceux avec et sans un diagnostic de SM auto-rapporté. Méthodes: En février 2021, nous avons administré un sondage en ligne à des jeunes de 12 à 25 ans en Ontario. Les données de 1373 participants sur 1497 (91,72 %) participants ont été analysées. Nous avons évalué les différences de SM et d'utilisation des services entre ceux avec (N = 623, 45,38 %) et sans (N = 750, 54,62 %) un diagnostic de SM auto-rapporté. Les régressions logistiques ont servi à explorer le diagnostic de SM comme prédicteur de l'utilisation de services tout en contrôlant les confusions. Résultats: 86,73 % des participants ont rapporté une SM pire depuis la COVID-19, sans différences entre les groupes. Les participants ayant un diagnostic de SM avaient des taux plus élevés de problèmes de SM, de connaissance et d'utilisation des services comparé à ceux sans diagnostic. Le diagnostic de SM était le prédicteur le plus fort de l'utilisation de services. Le sexe et l'abordabilité des besoins de base prédisaient aussi indépendamment l'utilisation de services distincts. Conclusion: Divers services sont nécessaires pour atténuer les effets négatifs de la pandémie sur la SM des jeunes et répondre à leurs besoins de service. Savoir si les jeunes ont un diagnostic de SM peut être important pour comprendre quels services ils connaissent et utilisent. Soutenir les changements de services liés à la pandémie exige d'accroître la connaissance des jeunes des interventions numériques et de surmonter d'autres obstacles des soins.

Peripheral and neural correlates of self-harm in children and adolescents: a scoping review.

BACKGROUND: Self-harm in children and adolescents is difficult to treat. Peripheral and neural correlates of self-harm could lead to biomarkers to guide precision care. We therefore conducted a scoping review of research on peripheral and neural correlates of self-harm in this age group. METHODS: PubMed and Embase databases were searched from January 1980-May 2020, seeking English language peer-reviewed studies about peripheral and neural correlates of self-harm, defined as completed suicide, suicide attempts, suicidal ideation, or non-suicidal self-injury (NSSI) in subjects, birth to 19 years of age. Studies were excluded if only investigating self-harm in persons with intellectual or developmental disability syndromes. A blinded multi-stage assessment process by pairs of co-authors selected final studies for review. Risk of bias estimates were done on final studies. RESULTS: We screened 5537 unduplicated abstracts, leading to the identification of 79 eligible studies in 76 papers. Of these, 48 investigated peripheral correlates and 31 examined neural correlates. Suicidality was the focus in 2/3 of the studies, with NSSI and any type of self-harm (subjects recruited with suicidality, NSSI, or both) investigated in the remaining studies. All studies used observational designs (primarily case-control), most used convenience samples of adolescent patients which were predominately female and half of which were recruited based on a disorder. Over a quarter of the specific correlates were investigated with only one study. Inter-study agreement on findings from specific correlates with more than one study was often low. Estimates of Good for risk of bias were assigned to 37% of the studies and the majority were rated as Fair. CONCLUSIONS: Research on peripheral and neural correlates of self-harm is not sufficiently mature to identify potential biomarkers. Conflicting findings were reported for many of the correlates studied. Methodological problems may have produced biased findings and results are mainly generalizable to patients and girls. We provide recommendations to improve future peripheral and neural correlate research in children and adolescents, ages 3-19 years, with self-harm.

Parenting during the COVID-19 pandemic: The sociodemographic and mental health factors associated with maternal caregiver strain.

INTRODUCTION: The COVID-19 pandemic has introduced new stressors for parents ("caregivers") that may affect their own and their child's mental health (MH). We explored self-reported levels of caregiver strain (parents' perceived ability to meet parenting demands), and the MH and sociodemographic factors of caregivers to identify predictors of strain that can be used to guide MH service delivery for families. METHODS: We administered a web-based survey to Ontario caregivers with a child between 4 and 25 years old, between April and June 2020. We analyzed information from 570 maternal caregivers on their sociodemographics, youngest (or only) child's MH, their own MH, and the degree of caregiver strain experienced since the pandemic. We used linear regressions (unadjusted and adjusted models) to explore the relationship between caregiver strain and sociodemographics, child MH and caregiver MH. RESULTS: Over 75% of participants reported "moderate-to-high" caregiver strain. More than 25% of caregivers rated their MH as "poor" and 20% reported moderate-to-severe anxiety. Forty-five percent of the variance in caregiver strain was accounted for by child age, caregiver anxiety, and multiple child and caregiver MH variables. Younger child age and higher caregiver anxiety were the greatest predictors of caregiver strain. CONCLUSION: We found a relationship between child age, child and caregiver MH variables, and caregiver strain. Given the interrelatedness of these factors, supporting caregivers' MH and lessening their role strain becomes critical for family well-being. Evidence-based individual, family, and public health strategies are needed to alleviate pandemic-related strain. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Building Resilience and Attachment in Vulnerable Adolescents (BRAVA): a brief group intervention for adolescents with mild-to-moderate suicidal ideation and their caregivers.

INTRODUCTION: Suicidal Ideation (SI) is common in adolescents and increases the risk of completed suicide. Few brief interventions have been shown to reduce SI in adolescents. The objective of this study was to evaluate the feasibility of a novel brief group intervention, building resilience and attachment in vulnerable adolescents (BRAVA), designed for adolescents and their caregivers to reduce adolescent SI. METHODS: The study was a pre-post, noncontrolled trial in which 46 adolescents were enrolled in the BRAVA intervention. Adolescents and caregivers completed an intake assessment, six BRAVA group sessions, and an exit assessment 1-week post-BRAVA. RESULTS: Adolescents' SI decreased significantly after completing the BRAVA treatment (pre-post difference = 18.1, 95% CI = 10.01-26.12). Significant improvements in associated symptoms of depression, anxiety, and perceived stress were also observed. Caregivers had reduced perceived stress (pre-post difference = 2.7, 95% CI = 0.30-5.16) and reduction in attachment avoidance (difference = 1.6, 95% CI = 0.29-2.91). Treatment satisfaction was high across the six modules. The rolling entry feature of the intervention allowed participants to begin treatment approximately 2 weeks sooner compared to waiting for the next group cycle. CONCLUSIONS: Study results demonstrate that the BRAVA intervention has the potential to reduce SI among adolescents who present to hospital services in crisis. Further studies are required to establish BRAVA's efficacy in a randomized controlled trial.

Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements.

BACKGROUND: Health care itself contributes to climate change. Anesthesia is a "carbon hotspot," yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement. METHODS: A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons. RESULTS: Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum). CONCLUSIONS: All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity.