Impact of Antenatal Care Modifications on Gestational Diabetes Outcomes During the COVID-19 Pandemic

BACKGROUND

Many of the adverse outcomes of gestational diabetes mellitus (GDM) are linked to excessive fetal growth, which is strongly mediated by the adequacy of maternal glycemic management. The COVID-19 pandemic led to a rapid adoption of virtual care models. We aimed to compare glycemic management, fetal growth, and perinatal outcomes before and during the COVID-19 pandemic.

METHODS

A retrospective cohort study was conducted between 2017 and 2020. Singleton pregnancies complicated by GDM were included in the study. The cohort was stratified into "before" and "during" COVID-19 subgroups, using March 11, 2020, as the demarcation time point. Women who began their GDM follow-up starting March 11, 2020, and thereafter were allocated to the COVID-19 era, whereas women who delivered before the demarcation point served as the pre-COVID-19 era. The primary outcome was the rate of large-for-gestational-age (LGA) neonates. Secondary outcomes included select maternal and neonatal adverse outcomes.

RESULTS

Seven hundred seventy-five women were included in the analysis, of which 187 (24.13%) were followed during the COVID-19 era and 588 (75.87%) before the COVID-19 era. One hundred seventy-one of the 187 women (91.44%) followed during COVID-19 had at least 1 virtual follow-up visit. No virtual follow-up visits occurred before the COVID-19 era. There was no difference in the rate of LGA neonates between groups on both univariate (5.90% vs 7.30%, p=0.5) and multivariate analyses, controlling for age, ethnicity, parity, body mass index, gestational weight gain, chronic hypertension, smoking, and hypertensive disorders in pregnancy (adjusted odds ratio [aOR] 1.11, 95% confidence interval [CI] 0.49 to 2.51, p=0.80). In the multivariate analysis, there was no difference in composite neonatal outcome between groups (GDM diet: aOR 1.40, 95% CI 0.81 to 2.43, p=0.23; GDM medical treatment: aOR 1.20, 95% CI 0.63 to 2.43, p=0.5).

CONCLUSIONS

After adjusting for differences in baseline variables, the combined virtual mode of care was not associated with a higher rate of LGA neonates or other adverse perinatal outcomes in women with GDM. Larger studies are needed to better understand the specific impact of virtual care on less common outcomes in pregnancies with GDM.

Building Healthy Babies: A Mixed-Methods Needs Assessment for a Pre-Conception Program in Ontario

OBJECTIVES

The objective of this study was to gather Ontario clinicians' and public members' views on the design of a pre-conception patient education program.

METHODS

In this mixed-methods study, online surveys comprised of rank order, multiple choice, and short answer questions were completed by clinicians and public members. Semi-structured focus groups consisting of 2-6 participants each were then held via videoconference. Demographic variables and survey responses were analyzed quantitatively using descriptive and summary statistics. Descriptive thematic qualitative analysis using the constant comparative method of grounded theory was completed on each transcript to generate themes.

RESULTS

A total of 168 public members and 43 clinicians in Ontario completed surveys, while 11 clinicians and 11 public members participated in the focus groups. A pre-conception program in Ontario was felt to be important. An individual appointment with a primary care provider was the favoured program format per survey responses, whereas a virtual format with an interactive component was preferred among focus group participants. Important topics to include were pre-conception health (infertility, genetic screening, folic acid), prenatal and postpartum counselling (diet, activity, substance use, prenatal care, postpartum course), and medical optimization in pregnancy (high-risk medical conditions, medications, mental health). Both groups emphasized the need to consider accommodations for marginalized populations and various cultures and languages.

CONCLUSION

A standardized pre-conception patient education program is felt to be of high value by Ontario clinicians and public members. A pre-conception program may help improve obstetrical outcomes and decrease rates of major congenital anomalies in Ontario.

Prenatal opioid exposure and well-child care in the first 2 years of life: population-based cohort study

OBJECTIVES

To quantify well-child visits by age 2 years and developmental screening at the 18-month enhanced well-child visit among children with prenatal opioid exposure (POE) and to identify factors associated with study outcomes.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

22 276 children with POE born 2014-2018 were classified as (1) 1-29 days of prescribed opioid analgesia, (2) 30+ days of prescribed opioid analgesia, (3) medication for opioid use disorder (MOUD), (4) MOUD and opioid analgesia, or (5) unregulated opioids.

MAIN OUTCOME MEASURES

Attending ≥5 well-child visits by age 2 years and the 18-month enhanced well-child visit. Modified Poisson regression was used to examine factors associated with outcomes.

RESULTS

Children with POE to 1-29 days of analgesics were most likely to attend ≥5 well-child visits (61.2%). Compared with these children, adjusted relative risks (aRRs) for ≥5 well-child visits were lower among those exposed to 30+ days of opioid analgesics (0.95, 95% CI 0.91 to 0.99), MOUD (0.83, 95% CI 0.79 to 0.88), MOUD and opioid analgesics (0.78 95% CI 0.68 to 0.90) and unregulated opioids (0.89, 95% CI 0.83 to 0.95). Relative to children with POE to 1-29 days of analgesics (58.5%), respective aRRs for the 18-month enhanced well-child visit were 0.92 (95% CI 0.88 to 0.96), 0.76 (95% CI 0.72 to 0.81), 0.76 (95% CI 0.66 to 0.87) and 0.82 (95% CI 0.76 to 0.88). Having a regular primary care provider was positively associated with study outcomes; socioeconomic disadvantage, rurality and maternal mental health were negatively associated.

CONCLUSION

Well-child visits are low in children following POE, especially among offspring of mothers receiving MOUD or unregulated opioids. Strategies to improve attendance will be important for child outcomes.

Long-term Mortality in Individuals Diagnosed With Cancer During Pregnancy or Postpartum

Importance

Outcomes among patients with pregnancy-associated cancers (diagnosed during pregnancy or 1-year postpartum) other than breast cancer have received relatively little research attention. High-quality data from additional cancer sites are needed to inform the care of this unique group of patients.

Objective

To assess mortality and survival in premenopausal women with pregnancy-associated cancers, with a particular focus on cancers other than those of the breast.

Design, Setting, and Participants

This population-based retrospective cohort study included premenopausal women (aged 18-50 years) living in 3 Canadian provinces (Alberta, British Columbia, and Ontario) diagnosed with cancer between January 1, 2003, and December 31, 2016, with follow-up until December 31, 2017, or date of death. Data analysis occurred in 2021 and 2022.

Exposures

Participants were categorized as being diagnosed with cancer during pregnancy (from conception to delivery), during the postpartum period (up to 1 year after delivery), or during a time that was remote from pregnancy.

Main Outcomes and Measures

Outcomes were overall survival at 1 and 5 years and time from diagnosis to death due to any cause. Cox proportional hazard models were used to estimate mortality adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs), adjusting for age at cancer diagnosis, cancer stage, cancer site, and days from diagnosis to first treatment. Meta-analysis was used to pool results across all 3 provinces.

Results

During the study period there were 1014, 3074, and 20 219 participants diagnosed with cancer during pregnancy, postpartum, and periods remote from pregnancy, respectively. One-year survival was similar across the 3 groups, but 5-year survival was lower among those diagnosed with cancer during pregnancy or postpartum. Overall, there was a greater risk of death due to pregnancy-associated cancer among those diagnosed during pregnancy (aHR, 1.79; 95% CI, 1.51-2.13) and postpartum (aHR, 1.49; 95% CI, 1.33-1.67); however, these results varied across cancer sites. Increased hazard of mortality was observed for breast (aHR, 2.01; 95% CI, 1.58-2.56), ovarian (aHR, 2.60; 95% CI, 1.12-6.03), and stomach (aHR, 10.37; 95% CI, 3.56-30.24) cancers diagnosed during pregnancy, and brain (aHR, 2.75; 95% CI, 1.28-5.90), breast (aHR, 1.61; 95% CI, 1.32-1.95), and melanoma (aHR, 1.84; 95% CI, 1.02-3.30) cancers diagnosed postpartum.

Conclusions and Relevance

This population-based cohort study found that pregnancy-associated cancers had increased overall 5-year mortality, though not all cancer sites presented the same risk.

Pre-Pregnancy eGFR and the Risk of Adverse Maternal and Fetal Outcomes: A Population-Based Study

SIGNIFICANCE STATEMENT

Pregnancies in women with CKD carry greater risk than pregnancies in the general population. The small number of women in prior studies has limited estimates of this risk, especially among those with advanced CKD. We report the results of a population-based cohort study in Ontario, Canada, that assessed more than 500,000 pregnancies, including 600 with a baseline eGFR < 60 ml/min per 1.73 m 2 . The investigation demonstrates increases in risk of different adverse maternal and fetal outcomes with lower eGFR and further risk elevation with baseline proteinuria.

BACKGROUND

CKD is a risk factor for pregnancy complications, but estimates for adverse outcomes come largely from single-center studies with few women with moderate or advanced stage CKD.

METHODS

To investigate the association between maternal baseline eGFR and risk of adverse pregnancy outcomes, we conducted a retrospective, population-based cohort study of women (not on dialysis or having had a kidney transplant) in Ontario, Canada, who delivered between 2007 and 2019. The study included 565,907 pregnancies among 462,053 women. Administrative health databases captured hospital births, outpatient laboratory testing, and pregnancy complications. We analyzed pregnancies with serum creatinine measured within 2 years of conception up to 30 days after conception and assessed the impact of urine protein where available.

RESULTS

The risk of major maternal morbidity, preterm delivery, and low birthweight increased monotonically across declining eGFR categories, with risk increase most notable as eGFR dropped below 60 ml/min per 1.73 m 2 . A total of 56 (40%) of the 133 pregnancies with an eGFR <45 ml/min per 1.73 m 2 resulted in delivery under 37 weeks, compared with 10% of pregnancies when eGFR exceeded 90 ml/min per 1.73 m 2 . Greater proteinuria significantly increased risk within each eGFR category. Maternal and neonatal deaths were rare regardless of baseline eGFR (<0.3% of all pregnancies). Only 7% of women with an eGFR <45 ml/min per 1.73 m 2 received dialysis during or immediately after pregnancy.

CONCLUSIONS

We observed higher rates of adverse pregnancy outcomes in women with low eGFR with concurrent proteinuria. These results can help inform health care policy, preconception counseling, and pregnancy follow-up in women with CKD.

Association of the Cerebro-Placental Ratio With Adverse Outcomes in Pregnancies Affected by Gestational Diabetes Mellitus

OBJECTIVES

Cerebro-placental ratio (CPR) is a doppler tool contributes to clinical decision-making in pregnancies affected by small for gestational age weight (SGA). Pregnancies affected by gestational diabetes mellitus (GDM) tend to have higher newborn weight, but greater risk of adverse perinatal outcomes. We hypothesized that in GDM-complicated-pregnancies CPR will be associated with adverse perinatal outcomes even in the absence of SGA.

METHODS

This prospective single-center cohort study included non-anomalous singleton pregnancies in women with GDM. Those with pre-pregnancy diabetes mellitus, hypertensive disorder or suspected SGA were excluded. Routine fetal sonographic assessment included CPR-defined as middle cerebral artery pulsatilty index/umbilical artery pulsatilty index. Masked CPR measurement closest to birth was used, classified as >10th (normal) or ≤10th centile (low). Primary outcome was a composite, consisting of stillbirth, Caesarean birth due to abnormal fetal heart rate pattern, 5-minute Apgar <7, cord arterial pH < 7.0, hypoxic ischemic encephalopathy, or NICU admission >24 hours.

RESULTS

Of 281 participants, 24 (8.5%) had low CPR, at a mean gestational age of 36.3 weeks (IQR 34.0-37.4). Birthweight percentile was significantly lower among the low CPR group (35th [IQR 16-31] versus 60th [IQR 31-82]; P = .002). There was no statistically difference in the primary composite outcome between the groups (8.3% versus 7.0%, P = .68). Low CPR was significantly associated with a higher risk of neonatal hypoglycemia (adjusted odds ratio 3.2, 95% CI 1.2-8.3).

CONCLUSION

In pregnancies affected by GDM, CPR ≤10th percentile was not associated with adverse perinatal outcome but was associated with neonatal hypoglycemia.

Parent-child nature visits and young Finnish childreńs nature connectedness

Background

It is well-known that frequent nature visits are associated with health benefits in children. Global climate crisis and environmental challenges emphasize the need for reconnecting children to nature, as well. Young children’s nature connectedness (NC) involves enjoyment of nature, sense of responsibility, empathy, and awareness of nature. The study examines whether there is an association between the frequency of parent-child nature visits and young children’s NC.

Methods

The study uses WEB survey data from the Finnish Empowered by Nature project. Respondents, n = 1463, were parents of children aged 2 to 7 years old. NC was assessed by 11-items derived from the NC questionnaire of Sobko et al (2018). Multinomial logistic regression analysis was used and the lowest tertile of NC was used as reference group. Analysis were adjusted for child’s age and gender, and highest education of parent.

Results

Children with moderate (1-2 times a week in previous month) or high (3 times a week or more) frequency of parent-child nature visits were more likely to have strong than weak NC compared to children with low frequency (less than once a week) of adult-child nature visits. Odds ratios (OR) in adjusted models were: moderate frequency 1.67 (1.21- 2.32), and high frequency 2.31 (1.67-3.18). The odds of having medium NC compared to weak NC were more likely in moderate frequency compared to low frequency of parent-child nature visits in the adjusted model (OR 1.46; 1.07-2.00).

Conclusions

The results highlight the importance of parents visiting nature frequently with their children during early childhood. It promotes young children’s NC and may further contribute to raising environmentally responsible children.

Key messages

• More frequent parent-child visits promote young children’s nature connectedness which involves enjoyment of nature, sense of responsibility, empathy, and awareness of nature.

• A strong nature connectedness among children is highly relevant, as it may contribute to raise environmentally responsible children.

LärMiljö (Learning Environment) - study protocol: movement, outdoor learning and well-being in school

Background

Outdoor education (OE) is a teaching method aiming to promote children’s learning, physical activity (PA) and wellbeing. OE in green areas may further increase positive effects. There is little knowledge on use of OE and its possible effects in a Finnish context. Also, there is a need to evaluate OE from a teacher perspective. The aim of the LärMiljö-study is to: a) survey the use of OE in Swedish-language primary schools and investigate factors related to its use; b) investigate the associations between OE and PA, wellbeing, nature relations and learning among children aged 9-13 years, considering other related factors.

Methods

The self-determination theory (SDT) is used as theoretical framework. Data is collected via electronic surveys in Swedish-language primary schools, including: a) national surveys among principals and teachers; b) surveys among children and guardians. Children’s PA is measured for a 7-day period via accelerometers and a diary is kept. Teachers keep a class diary on OE provided. Academic tests are performed. Data will be analyzed using quantitative methods.

Results

This abstract describes the study protocol. The investigation of associations between OE and outcomes among children is mainly done by comparing classes that regularly use OE with classes that do not. Main outcomes are PA, psychosocial wellbeing, academic performance and nature connectedness; secondary outcomes are school motivation, social relations and sleep. Teachers’ experience and use of OE is explored, as is perceived effects of and barriers to OE use. Based on SDT, associations between OE and need satisfaction at work, competence, motivation and work engagement are studied.

Conclusions

The study represents a unique opportunity to explore OE use in primary schools, its effects among children and teachers, and what the supporting and hindering factors for its use are. The study contributes knowledge that can be used to promote learning and wellbeing in school.

Key messages

• Outdoor education in primary school may promote schoolchildren’s learning, physical activity, wellbeing and nature relation, but more knowledge is needed, including the perspective of teachers.

• The LärMiljö-study will broaden the understanding of the potential effects of OE in primary education and school health promotion, and on factors supporting and hindering its use.

Added value of Joint ENT-Rheumatology clinic in the management of ANCA-associated vasculitis: One year's experience

PURPOSE

ANCA-associated vasculitides (AAV) represent a group of diagnoses, including granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). Most commonly, they present initially with ENT-associated symptomatology, and therefore they often pose a diagnostic challenge. We aim to present our one-year experience in the joint management of AAV in a multi-disciplinary setting.

METHODS

We performed a retrospective analysis based on the records of 39 patients who were seen in the joint clinic, during a period of one year.

RESULTS

After clinical assessment, 13 patients had changes made to their ENT treatment, 2 had some changes in their immunosuppression, while 11 had changes in both ENT and Rheumatology treatment. Six patients did not require any alterations to their therapeutic scheme. On average three separate appointments were reduced to a single appointment in the joint clinic where definitive treatment decisions were made. This led to significant cost reductions.

CONCLUSIONS

Cost-effectiveness, patient satisfaction, rapid multi-disciplinary evaluation, avoidance of unnecessary immunosuppression, patient education and medical training are only a few of the many advantages of this proposed joint service.

312Long-term survival of women diagnosed with cancer during pregnancy or postpartum

Background

Cancer is the second leading cause of death in reproductive-aged women, and the incidence of pregnancy-associated cancer is rising. We assessed long-term survival of women diagnosed with cancer during pregnancy or postpartum.

Methods

A population-based retrospective cohort study included all reproductive-aged women (18-50 years) with a cancer diagnosis in Alberta, Canada, 2004 to 2016. Hazard ratios (HR) were calculated for all-cause and cancer-specific mortality, comparing 244 women who were diagnosed with cancer during pregnancy and 670 women diagnosed with cancer within one year postpartum, with 3,680 women diagnosed with cancer outside of these periods as the referent. Cox regression adjusted for age at cancer diagnosis, parity, cancer stage, and type of cancer.

Results

Rates of cancer in pregnancy and postpartum did not increase across the study period (trend p-value=0.49). Women diagnosed with cancer in pregnancy had an adjusted HR of 1.61 (95% CI 1.07-2.41) for all-cause mortality, 1.67 (95% CI 1.09-2.57) for cancer-specific mortality, relative to the referent. Those diagnosed with cancer postpartum did not have a greater risk of all-cause (HR = 1.10, 95% CI 0.80-1.50) or cancer-specific (HR = 1.15, 95% CI 0.82-1.60) mortality.

Conclusions

The risk of all-cause and cancer-specific mortality is increased in women diagnosed with cancer during pregnancy.

Key messages

Women diagnosed with cancer during pregnancy experience poorer survival than those diagnosed in postpartum or remote from a pregnancy. These findings should be used by physicians to guide care of women diagnosed with pregnancy-associated cancers.

Protocol for a randomised trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada)

INTRODUCTION

The 'Developmental Origins of Health and Disease' hypothesis suggests that a healthy trajectory of growth and development in pregnancy and early childhood is necessary for optimal health, development and lifetime well-being. The purpose of this paper is to present the protocol for a randomised controlled trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada). The primary objective of HeLTI Canada is to determine whether a 4-phase 'preconception to early childhood' lifecourse intervention can reduce the rate of child overweight and obesity. Secondary objectives include improved child: (1) growth trajectories; (2) cardiometabolic risk factors; (3) health behaviours, including nutrition, physical activity, sedentary behaviour and sleep; and (4) development and school readiness at age 5 years.

METHOD AND ANALYSIS

A randomised controlled multicentre trial will be conducted in two of Canada's highly populous provinces-Alberta and Ontario-with 786 nulliparous (15%) and 4444 primiparous (85%) women, their partners and, when possible, the first 'sibling child.' The intervention is telephone-based collaborative care delivered by experienced public health nurses trained in healthy conversation skills that includes detailed risk assessments, individualised structured management plans, scheduled follow-up calls, and access to a web-based app with individualised, evidence-based resources. An 'index child' conceived after randomisation will be followed until age 5 years and assessed for the primary and secondary outcomes. Pregnancy, infancy (age 2 years) and parental outcomes across time will also be assessed.

ETHICS AND DISSEMINATION

The study has received approval from Clinical Trials Ontario (CTO 1776). The findings will be published in peer-reviewed journals and disseminated to policymakers at local, national and international agencies. Findings will also be shared with study participants and their communities.

TRIAL REGISTRATION NUMBER

ISRCTN13308752; Pre-results.

A culture of caring: the essence of healthcare interprofessional collaboration

Collaboration among healthcare professionals is essential in creating a synergy to provide efficient, safe, and high-quality patient care. Interprofessional collaborative practice (IPCP) has become a core measure in promoting healthcare practice. An understanding of the underlying mechanism for healthcare professionals to collaborate can provide strategies to foster IPCP. The purpose of the study was to investigate healthcare professionals' perspectives on ways to promote IPCP. This was a qualitative descriptive study. Thirty-six healthcare professionals from a university-affiliated hospital participated in the study. Data were collected via face-to-face in-depth interviews and analyzed using a thematic networks framework. The findings indicated that the underlying facilitator of IPCP was a culture of caring - human connections among interprofessional team members. The culture of caring could be fostered through five processes: building caring relationships, developing an ownership mentality, providing constructive feedback, applying the strengths-based practice, and acting as the first and last lines of defense. An Interprofessional Caring Model (ICM) was proposed in this study. Creating a caring culture is a dynamic process requiring all team members' efforts. The ICM can have significant clinical implications. It can be used as a framework to design and implement specific strategies to improve interprofessional collaboration.

The application of a haemorrhage assessment tool in evaluating control of bleeding in a pilot trauma haemorrhage trial

OBJECTIVES

To determine whether it was feasible to use a haemorrhage assessment tool (HAT) within a trauma trial and whether the data obtained could differentiate patients who had achieved haemostasis.

BACKGROUND

Major haemorrhage is one of the leading causes of death worldwide, affecting 40% of trauma patients. Clinical trials evaluating haemostatic interventions often use transfusion outcomes as a primary endpoint. Transfusion is highly dependent on local practice, limiting its reliability as a robust, transferable endpoint.

METHODS

A five-point HAT questionnaire was applied to participants enrolled into the EFIT-1 trial. This RCT evaluated the feasibility of administering a 6 g fibrinogen concentrate to patients with severe trauma haemorrhage.

RESULTS

Of participants, 98% completed a HAT; 75% participants had 'achieved haemostasis' at the time of tool completion, as determined by clinical acumen alone. HAT scores were able to differentiate which participants required transfusion after 3 h. Of participants, 56% were transfused red blood cells when they scored 0-2, compared to 17% with HAT scores between 3 and 5.

CONCLUSION

This study has confirmed the feasibility of using a HAT during the emergency care of patients suffering trauma haemorrhage, and future studies should be conducted to determine its value as an endpoint in haemostasis studies.

Exploring the association between ingestion of foods with higher potential salicylate content and symptom exacerbation in chronic rhinosinusitis. Data from the National Chronic Rhinosinusitis Epidemiology Study

INTRODUCTION

Pharmacological salicylates are known to trigger respiratory exacerbations in patients with Non-Steroidal Exacerbated Respiratory Disease (N-ERD), a specific phenotype of Chronic Rhinosinusitis (CRS) and asthma. The impact of dietary sources of salicylates across subgroups of CRS is not well understood. The hypothesis is that in patients with nasal polyps present, there is likely to be a higher incidence of symptom exacerbation due to dietary salicylates regardless of any known response to pharmacological salicylate.

METHODS

The Chronic Rhinosinusitis Epidemiology Study (CRES) was a questionnaire-based case-control study which sought to characterise the UK CRS population in terms of sociological, economic and medical factors. Using specific questions to examine participant responses relating to symptom exacerbation from food groups thought to be high in salicylate content, this analysis of the CRES database sought to compare an estimate of the prevalence of dietary sensitivity due to food with higher potential salicylate content across patients with CRS with (CRSwNPs) and without nasal polyposis (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

RESULTS

The CRSwNPs group were significantly more likely than controls to report symptom exacerbation due to ingestion of food groups with higher potential dietary salicylate content. The same trend was observed amongst CRSsNPs participants to a lesser degree. Reported response to the individual specific food groups wine, nuts, spicy foods, fruit and vegetables demonstrated that a statistically significant proportion of CRSwNPs and AFRS participants reported sensitivity to wine.

CONCLUSIONS

This analysis suggests that there is an association between symptom exacerbation in response to food products with higher potential salicylate content, specifically wine, in CRS patients both with and without nasal polyposis when compared to controls, but especially in the CRSwNPs and AFRS phenotypes. Further studies are needed to detail if this relationship represents a causal relationship to dietary salicylate. The data present the possibility that a wider group of CRS patients may elicit salicylate sensitivity than those with known N-ERD.

Circulating miRNAs as non-invasive biomarkers to predict aggressive prostate cancer after radical prostatectomy

BACKGROUND

Prostate cancer is an extremely heterogeneous disease. Despite being clinically similar, some tumours are more likely to recur after surgery compared to others. Distinguishing those that need adjuvant or salvage radiotherapy will improve patient outcomes. The goal of this study was to identify circulating microRNA that could independently predict prostate cancer patient risk stratification after radical prostatectomy.

METHODS

Seventy-eight prostate cancer patients were recruited at the Odette Cancer Centre in Sunnybrook Health Sciences Centre. All patients had previously undergone radical prostatectomy. Blood samples were collected simultaneously for PSA testing and miRNA analysis using NanoString nCounter technology. Of the 78 samples, 75 had acceptable miRNA quantity and quality. Patients were stratified into high- and low-risk categories based on Gleason score, pathological T stage, surgical margin status, and diagnostic PSA: patients with Gleason ≥ 8; pT3a and positive margin; pT3b and any margin; or diagnostic PSA > 20 µg/mL were classified as high-risk (n = 44) and all other patients were classified as low-risk (n = 31).

RESULTS

Using our patient dataset, we identified a four-miRNA signature (miR-17, miR-20a, miR-20b, miR-106a) that can distinguish high- and low-risk patients, in addition to their pathological tumour stage. High expression of these miRNAs is associated with shorter time to biochemical recurrence in the TCGA dataset. These miRNAs confer an aggressive phenotype upon overexpression in vitro.

CONCLUSIONS

This proof-of-principle report highlights the potential of circulating miRNAs to independently predict risk stratification of prostate cancer patients after radical prostatectomy.

Effect of postpartum glucose tolerance results on subsequent weight retention in women with recent gestational diabetes: A retrospective cohort study

AIMS

Glucose tolerance normalizes postpartum in most women with gestational diabetes (GDM), which may provide false reassurance and decrease weight-reducing behaviours. We evaluated whether awareness of normal postpartum glucose tolerance was associated with higher weight retention than being unaware of glucose tolerance.

METHODS

This cohort study of women with GDM collected survey data during pregnancy and in the first and second postpartum year. We compared women who reported normal glucose tolerance ('aware, normal') in the first year to those reporting no testing or unsure of results ('unaware'). The primary outcome was self-reported weight in the second year compared between groups using multivariable linear regression.

RESULTS

Among 319 women, 110 (34.5%) were 'aware, normal'; 183 (57.4%) were 'unaware'; and 26 (8.2%) were 'aware, abnormal'. After adjusting for baseline weight and covariates, women with normal results had a mean 3.66 kg higher weight (CI 1.08-6.24 kg, p = 0.0056) by the second year than those unaware of results.

CONCLUSIONS

Women with GDM with normal postpartum glucose tolerance had significantly higher weight by the second year than those unaware of their results. Normal glucose tolerance after pregnancy may be misinterpreted as resolution of diabetes risk and decrease risk-reducing behaviours.

Hypoglycemia in unmonitored full-term newborns-a surveillance study

Background and objectives

Hypoglycemia monitoring is not recommended for most full-term newborns. We wished to determine the incidence, presentation and case characteristics of hypoglycemia in low-risk newborns.

Methods

With the assistance of the Canadian Paediatric Surveillance Program, we conducted a national study of severe hypoglycemia in apparently low-risk full-term newborns. Paediatricians who reported a case were sent a detailed questionnaire and the data were analyzed.

Results

All 93 confirmed cases were singletons, 56% were first-borns and 65% were male. An 8% rate of First Nations cases was twofold the population rate. Maternal hypertension rate was 23%, fourfold the general pregnancy rate. Maternal obesity was double the general pregnancy rate at 23%. Concerning signs or feeding issues were noted in 98% at the time of diagnosis. Median time to diagnosis was 4.1 hours. Mean blood glucose at intravenous (IV) start was 1.4 ± 0.5 hours (SD). Seventy-eight per cent had at least one of four potential stress indicators and were more likely to have early diagnosis (P=0.03). Major signs were present in 20%. Those cases presented later and had lower glucose levels (median=0.8 mmol/L versus 1.6 mmol/L, [P<0.001). Twenty-five per cent of cases had birth weight less than the 10th centile. Neurodevelopmental concern was reported in 20%. Of the 13 cases which had brain magnetic resonance imaging, 11 were abnormal.

Conclusion

Hypoglycemia in unmonitored newborns is uncommon but is associated with significant morbidity. We provide a range of clues to help identify these newborns soon after birth. Widespread adoption of norm-based standards to identify small-for-gestational age infants is supported.

Unusual Cause of Pediatric Vaginal Bleeding: Infantile Capillary Hemangioma of the Cervix

BACKGROUND

The differential diagnosis for pediatric prepubertal vaginal bleeding is wide. Rare etiologies include vascular malformations and tumors, such as infantile hemangiomas (IHs), which validate the usefulness of exam under anesthesia, vaginoscopy, and tissue diagnosis.

CASE

We report a case of an IH in a 6-year-old girl causing vaginal bleeding requiring transfusion. Vaginoscopy revealed a cervical IH of less than 1 cm. Expectant management and oral propranolol were successful management options.

SUMMARY AND CONCLUSION

Rare, even small soft tissue tumors such as IH can lead to impressive blood loss via vaginal bleeding. Accurate tissue diagnosis and a multidisciplinary approach are essential to planning safe, effective treatment, and follow-up.

Health Equity in Cancer Screening in Calgary – A Geographic Approach to Account for Population Socioeconomic Status

IntroductionThere is substantial evidence that cancer screening rates are lower among Canadians with low socioeconomic status (SES) than they are among those with higher SES. In order to optimize cancer screening, there is a need to reduce inequities in cancer screening. Objectives and ApproachThe purpose of this study is to understand how breast, colorectal and cervical cancer screening participation varies by socioeconomic status within local geographic areas (LGAs) in the city of Calgary. A Bayesian multilevel regression method with a spatial component was used to estimate Standardized Incidence Rates (SIR) at the LGA level. Bivariate spatial clustering analyses between screening rates at the Dissemination Area (DA) level and Pampalon material and social deprivation index was performed to better understand spatial structures of low and high screening rates compared to high and low material and social deprivation scores within LGAs. ResultsThe effect of material (income, education and employment) and social (living alone, separated, and divorced or windowed) deprivation on lower screening rates was stronger for breast cancer screening, compared to cervical and colorectal screening. Estimated likelihood of screening significantly decreased from the least deprived to the most deprived (9% for the material component and 18% for the social component for Breast cancer; 8% for the material component and 10% for the social component for cervical cancer screening). Clusters of lower screening rates and higher social and material deprivation were identified in the northeastern and central areas of the city. Conclusion/ImplicationsThe study allowed identifying LGAs and neighborhoods within those LGAs that have lower screening rates likely to be explained by the material and social deprivation of the population. The approach provides additional evidence for planning targeted interventions and reducing inequities for screening.

Intergenerational teen pregnancy: a population based cohort study

IntroductionMothers can influence on a teen’s knowledge and attitude about sexual and reproductive health practices. Prior studies on intergenerational teen pregnancy between mother and daughter were largely limited to livebirths. Objectives and ApproachTo estimate the odds of intergenerational teenage pregnancy, and whether there is a coupling tendency between mother and daughter in how their teen pregnancies end, such as induced abortion (IA) vs. livebirth. A cohort study was conducted in Ontario, Canada among 15,097 mothers and their 16,177 daughters. The mother and her daughter were each assessed, between ages 15-19 years, for the number and nature of teenage pregnancy. The nature of teen pregnancy was categorized as i) no teen pregnancy, ii) ≥1 teen pregnancy, all exclusively ending with livebirth, and iii) ≥1 teen pregnancy, with at least one ending with IA. Results13,036 daughters’ mothers had a teen pregnancy and 3,141 daughters’ mothers did not. Teen pregnancy occurred among 3,777(29.0%) and 513(16.2%) daughters, respectively. The adjusted odds ratio (aOR) of a daughter having a teen pregnancy was 1.42 (95% CI 1.25-1.61) if her mother had 1, 1.97 (95% CI 1.71-2.26) if her mother had 2, and 2.17 (95% CI 1.84-2.56) if her mother had ≥3 teen pregnancies, relative to none. If a mother had ≥1 teen pregnancy ending with IA, then her daughter had an aOR of 2.12 (95% CI 1.76-2.56) for having a teen pregnancy also ending with IA; whereas, if a mother had ≥1 teen pregnancy, all ending with livebirth, then her daughter had an aOR of 1.73 (95% CI 1.46-2.05) for that same outcome. Conclusion/ImplicationsThere is a strong intergenerational occurrence of teenage pregnancy between a mother and daughter, including a coupling tendency in how the pregnancy ends. Such evidence supports the use of family-centered interventions that engage parents to reduce unprotected sex and unintended pregnancies among teenagers.

Microwave absorption properties of reduced graphene oxide strontium hexaferrite/poly(methyl methacrylate) composites

The key factors to consider when designing microwave absorber materials for eradication of electromagnetic (EM) pollution are absorption of incident EM waves and good impedance matching. By keeping these things in mind, flexible microwave absorber composite films can be fabricated by simple gel casting techniques using reduced graphene oxide (RGO) and strontium ferrite (SF) in a poly(methyl methacrylate) (PMMA) matrix. SF nanoparticles are synthesized by the well known sol-gel method. Subsequently, reduced graphene oxide (RGO) and SF nanocomposite (RGOSF) are prepared through a chemical reduction method using hydrazine. The structure, morphology, chemical composition, thermal stability and magnetic properties of the nanocomposite are characterized in detail by various techniques. The SF particles are found to be nearly 500 nm and decorated on RGO sheets as revealed by field emission scanning electron microscopy and transmission electron microscopy analysis. Fourier transform infrared and and Raman spectroscopy clearly show the presence of SF in the graphene sheet by the lower peak positions. Finally, ternary polymer composites of RGO/SF/PMMA are prepared by an in situ polymerization method. Magnetic and dielectric studies of the composite reveal that the presence of RGO/SF/PMMA lead to polarization effects contributing to dielectric loss. Also, RGO surrounding SF provides a conductive network in the polymer matrix which is in turn responsible for the magnetic loss in the composite. Thus, the permittivity as well as the permeability of the composite can be controlled by an appropriate combination of RGO and SF in PMMA. More than 99% absorption efficiency is achieved by a suitable combination of magneto-dielectric coupling in the X-band frequency range by incorporating 9 wt% of RGO and 1 wt% of SF in the polymer matrix.

From inter-agency to multidisciplinary work in a sector generic mental health team

The effects of establishing a full multidisciplinary community psychiatric team in central London are described. The nature of referrals, and referrers' satisfaction with the service were examined during two comparable six-month periods, before and after the changes. The number and severity of referrals increased, and referrers were more satisfied with the new service. In contrast to the inter-agency model, the new multidisciplinary team was associated with more appropriate referral of those patients with the greatest need for specialist services. Clinical skill mix in the team and referrer education are the two factors most likely to have promoted these important changes. The key role of the psychiatrist in a full multidisciplinary team who can empower multi-professional case managers in their day-to-day management of severely ill patients is highlighted.

Antipsychotic and Antidepressant Drug Use in the Elderly and the Risk of Venous Thromboembolism

Preliminary evidence suggests that use of antipsychotic drugs is associated with an increased risk of venous thromboembolism.

To evaluate the relationship between antipsychotic or antidepressant drug use and venous thromboembolism among adults aged 65 years and older.

Retrospective cohort study using linked health care administrative databases over a nine year period.

The entire province of Ontario, Canada.

Individuals aged 65 years and over exclusively prescribed either antipsychotic drugs (n = 22514), antidepressant drugs (n = 75649) or thyroid replacement hormones (33033), the referent control group. We excluded those with an antecedent history of cardiovascular disease, venous thromboembolism or cancer, as well as those dispensed warfarin before study entry.

Diagnosis of deep vein thrombosis or pulmonary embolism.

Relative to those prescribed thyroid hormones, neither anti-depressant (adjusted hazard ratio 1.02, 95% CI 0.91-1.14) nor anti-psychotic (adjusted hazard ratio 1.13, 95% CI 0.96-1.32) drug use was associated with an increased risk for deep vein thrombosis. Similar risk estimates were found for deep vein thrombosis or pulmonary embolism. In a sub-group analysis, only butyrophenone use was found to be associated with a slightly increased risk of deep vein thrombosis (adjusted HR 1.51, 95% CI 1.23-1.86) as well as deep vein thrombosis or pulmonary embolism (adjusted HR 1.43, 95% CI 1.18-1.74).

In a large cohort of adults aged 65 years and older, neither antipsychotic or antidepressant drug use was associated with an increased risk of venous thromboembolism, with the exception of a slightly increased risk among those prescribed butyrophenones. Further data are required before use of these psychoactive drugs can be considered a risk factor for venous thromboembolism.

Canadian stroke best practice consensus statement: Secondary stroke prevention during pregnancy

The Canadian Stroke Best Practice Consensus Statement: Secondary Stroke Prevention during Pregnancy, is the first of a two-part series devoted to stroke in pregnancy. This document focuses on unique aspects of secondary stroke prevention in a woman with a prior history of stroke or transient ischemic attack who is, or is planning to become, pregnant. Although stroke is relatively rare in this cohort, several aspects of pregnancy can increase stroke risk during or immediately after pregnancy. The rationale for the development of this consensus statement is based on the premise that stroke in this group requires a specifically-tailored management approach. No other broad-based, stroke-specific guidelines or consensus statements exist currently. Underpinning the development of this document was the concept that maternal health is vital for fetal wellbeing; therefore, management decisions should be based on the confluence of two clinical considerations: (a) decisions that would be made if the patient was not pregnant and (b) decisions that would be made if the patient had not had a stroke. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include general management considerations for secondary stroke prevention, the use of antithrombotics, blood pressure management, lipid management, diabetes care, and management for specific ischemic stroke etiologies in pregnancy. The focus is on maternal and fetal health while minimizing risks of a recurrent stroke, through counseling, monitoring, and the safety of select pharmacotherapy. These statements are appropriate for health care professionals across all disciplines.

Curtailment of Higher Surgical Training in the UK: Likely Effects in Otology

Higher surgical training in the UK faces a cut of two years. We conducted a questionnaire survey to assess the operative experience of current higher surgical trainees in otological surgery and the likely effect of the proposed reduction from six to four years.

91 (65%) of the 142 higher surgical trainees responded with details of major otological procedures performed (independently or assisting) over one year. In the present six-year scheme a typical trainee performs 72 myringoplasties, 79 mastoidectomies, 7 skull base procedures and 28 other procedures. In the first four years, however, his or her experience is only 39 myringoplasties, 44 mastoidectomies, 4 skull base procedures and 7 others.

The large shortfall in experience that might result from shortening of the training programme would need to be met by intensification of the training or institution of accredited otology fellowships. Very similar dilemmas are faced by other surgical specialties.

Risk factors for tick exposure in suburban settings in the Northeastern United States

Prevention of tick-borne diseases requires an understanding of when and where exposure to ticks is most likely. We used an epidemiologic approach to define these parameters for residents of a Lyme-endemic region. Two persons in each of 500 Connecticut households were asked to complete a log each night for one week during June, 2013. Participants recorded their whereabouts in 15min increments (indoors, outdoors in their yard, outdoors on others' private property, or outdoors in public spaces) and noted each day whether they found a tick on themselves. Demographic and household information was also collected. Logs were completed for 934 participants in 471 households yielding 51,895 time-place observations. Median participant age was 49 years (range 2-91 years); 52% were female. Ninety-one participants (9.8%) reported finding a tick during the week, with slightly higher rates among females and minors. Household factors positively associated with finding a tick included having indoor/outdoor pets (odds ratio (OR)=1.7; 95% confidence interval (CI): 1.1-2.9), the presence of a bird feeder in the yard (OR=1.9; CI:1.2-3.2), and presence of an outdoor dining area (OR=2.2; CI:1.1-4.3). Individual factors associated with finding a tick on a given day were bathing or showering (OR=3.7; CI:1.3-10.3) and hours spent in one's own yard (OR=1.2, CI:1.1-1.3). Nineteen participants found ticks on multiple days, more than expected assuming independence (p<0.001). Participants who found ticks on multiple days did not spend more time outdoors but were significantly more likely to be male than those finding ticks on a single day (p<0.03). Our findings suggest that most tick exposures in the study area occurred on private property controlled by the respective homeowner. Interventions that target private yards are a logical focus for prevention efforts.

trans-4,4'-Dihydroxystilbene (DHS) protects PC12 cells from oxidative damage but induces reactive oxygen species-mediated apoptosis in SHSY-5Y cell line

Polyphenols can exert both, antioxidant and pro-oxidant properties, depending on cell types as well as their concentrations. Hence, it was of interest to examine if the naturally occurring resveratrol analog, trans-4,4'-dihydroxystilbene (DHS) also exert both these activities in a biphasic or cell-specific manner. In this study, we established the cytoprotective action of DHS against hydrogen peroxide (H2O2)-induced apoptotic death of the PC12 cells. DHS reduced mitochondrial membrane permeabilization and deactivated reactive oxygen species (ROS)-mediated caspase-3 activation in the H2O2-treated PC12 cells. However, it induced apoptosis in the human neuroblastoma SHSY-5Y cell line by destabilizing mitochondrial membrane, augmenting ROS and activating caspapse-3. DHS showed better activity than resveratrol in both the chosen models.