High-risk Clinic Research Articles

Giving women WOICE postpartum: prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument

BackgroundThere are no accurate estimates of the prevalence of non-severe maternal morbidities. Given the lack of instruments to fully assess these morbidities, the World Health Organization (WHO) developed an instrument called WOICE. We aimed to evaluate the prevalence of non-severe maternal morbidities in puerperal women and factors associated to impaired clinical, social and mental health conditions.MethodA cross-sectional study with postpartum women at a high-risk outpatient clinic in southeast Brazil, from November 2017 to December 2018. The WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. Data collection was supported by Tablets with REDCAP software. Initially, a descriptive analysis was performed, with general prevalence of all variables contained in the WOICE, including scales on anxiety and depression (GAD-7 and PHQ-9- impaired if ≥10), functionality (WHODAS- high disability scores when ≥37.4) and data on violence and substance use. Subsequently, an evaluation of cases with positive findings was performed, with a Poisson regression to investigate factors associated to impaired non-clinical and clinical conditions.ResultsFive hundred seventeen women were included, majority (54.3%) multiparous, between 20 and 34 years (65.4%) and with a partner (75,6%). Over a quarter had (26.2%) preterm birth. Around a third (30.2%) reported health problems informed by the physician, although more than 80% considered having good or very good health. About 10% reported any substance use and 5.9% reported exposure to violence. Anxiety was identified in 19.8% of cases, depression in 36.9% and impaired functioning in 4.4% of women. Poisson regression identified that poor overall health rating was associated to increased anxiety/depression and impaired functioning. Having a partner reduced perception of women on the presence of clinical morbidities.ConclusionDuring postpartum care of a high-risk population, over one third of the considered women presented anxiety and depression; 10% reported substance use and around 6% exposure to violence. These aspects of women’s health need further evaluation and specific interventions to improve quality of care.

405 The Effect of a Patient Survey in the Evaluation of Obstructive Sleep Apnea in a High Risk Cardiology Outpatient Population

Abstract Introduction Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. The estimated prevalence is approximately 15 to 30 percent in males and 10 to 15 percent in females. Patients with OSA have an increased propensity for cardiovascular diseases and obesity. Observational studies have demonstrated a consistent association between OSA and hypertension, coronary artery disease, cardiac arrhythmias, and heart failure. The purpose of this study is to evaluate if a patient survey can improve the diagnosis of OSA in a high-risk outpatient cardiac clinic. Methods In an outpatient cardiac clinic, a retrospective analysis of OSA evaluations was done before and after the use of patient surveys in a high-risk population. The high-risk patient group was defined by the presence of two or more of the following conditions: hypertension, heart failure, cardiac arrhythmias, atrial fibrillation, obesity with a BMI of 30 or more, coronary artery disease, diabetes mellitus, chronic lung disease, history of cerebrovascular accident (CVA), hypothyroidism and chronic renal insufficiency. The patient survey included questions on the presence of daytime sleepiness, presence of snoring, ESS score, choking in sleep, witness apnea, and frequent waking in sleep. Results During the four months of patient survey use, a total of 143 patients were evaluated as compared to 86 patients in the prior four months without the use of the survey. A significant increase (66.3%) of OSA evaluations was observed during the patient survey period. Conclusion The use of patient surveys showed a significant improvement in OSA diagnoses in the defined high-risk patient group. Patient surveys might be beneficial to improve the under diagnosis of sleep apnea in high-risk patient populations. Additional research needs to be done to establish the impact of such intervention on patient outcomes. Support (if any):

Obesity and Classification Grades Analyzed in Pregnant Women at the High-Risk Prenatal Clinic: What is their Importance?

Objective: Obesity is a frequent disease in pregnancy; however, the pathophysiological mechanisms that associate maternal obesity with unfavorable obstetric events during prenatal care, delivery and postpartum are not known, and therefore, adequate studies are lacking. Methods: Documentary and exploratory study was carried out with data obtained during consultation from 370 medical charts of patients seen at the high-risk prenatal outpatient clinic in a primary care unit, a reference center for six other units, in the city of Barueri, Sao Paulo, Brazil. In prenatal care, the guidelines of the Stork Network Program (Programa Rede Cegonha) of the Ministry of Health were used and include a pregnancy risk and obesity stratification system for pregnant women. Results: It was observed that 65% of the pregnant women were between 20 and 34 years old, 48.9% were white; most were in their first pregnancy. The mean gestational age at birth was 37.9 weeks. At the beginning of gestation, the women weighed an average of 71.2 kilograms, with a height of 159 cm and Body Mass Index (BMI) of 27.9 kg/m2. BMI with overweight or obesity prepregnancy had a lower risk of having a low-birth-weight NB (62% and 69%, respectively) when compared to pregnant women of adequate weight. Cesarean delivery prevailed, and among women with morbid obesity, the cesarean section rate was 90%. Conclusion: Epidemiological knowledge of this population is important for proposing policies to control chronic diseases that may affect pregnancy and to adjust the risk stratification according to the local reality.

Assessing the prevalence and correlates of prenatal cannabis consumption in an urban Canadian population: a cross-sectional survey.

Background:Recreational cannabis use was legalized in Canada in October 2018. We aimed to determine the prevalence and correlates of cannabis consumption among pregnant individuals in a single Canadian city following national legalization.Methods:Over the period May to October 2019, we distributed an anonymous cross-sectional survey to pregnant patients attending family practice, midwifery, and low-risk and high-risk obstetrics clinics in Hamilton, Ontario. Eligibility was based on English literacy and current pregnancy. The survey included questions regarding lifetime and in-pregnancy cannabis use, intent for postpartum use and patterns of use. We also collected demographic information. We calculated descriptive statistics and performed logistic regression analyses to explore the relations between cannabis consumption and demographic characteristics.Results:Of 531 pregnant individuals approached, 478 agreed and were able to participate, for a 90% participation rate. Among these 478 respondents, 54 (11%) reported consuming cannabis at some point during the pregnancy and 20 (4%) reported currently consuming cannabis. Among the 460 respondents who intended to breastfeed, 23 (5%) planned to consume cannabis during the postpartum period. Of 20 current users, 13 (65%) reported consuming cannabis at least weekly and 19 (95%) reported nausea, sleep problems or anxiety as reasons for use. Respondents without postsecondary education had 10.0-fold (95% confidence interval [CI] 4.6–23.5) greater odds of prenatal cannabis consumption than university-educated respondents. In addition, respondents who reported that their partners used cannabis had 3.9-fold (95% CI 2.2–7.3) greater odds of prenatal cannabis consumption than those who reported that their partners did not use cannabis.Interpretation:Lower educational attainment and partners’ cannabis consumption were associated with greater odds of inpregnancy cannabis use. These results may help to inform early intervention strategies to decrease cannabis consumption during this vulnerable period of fetal and neonatal development.

Randomized control trial of postpartum visits at 2 and 6 weeks

The postpartum period is critical, and women are at highest risk of perinatal complications; however, patient attendance at postpartum clinic visits is low. This study aimed to determine whether decreasing the time to an initial postpartum visit from 6 weeks to 2 weeks can increase the attendance rates of patients in routine postpartum visits. We conducted a parallel, randomized, nonblinded trial at a publicly insured clinic comparing a single 6-week postpartum visit (control) with 2 visits at 2 and 6 weeks after delivery (intervention). The primary outcome was attendance at 1 or more routine postpartum visits. Secondary outcomes were emergency department visits within 30 days after delivery and nonroutine clinic visits. Multivariable regression was performed to identify predictors of clinic nonattendance. To demonstrate a significant increase from the baseline clinic attendance rate of 70% to 85%, 250 participants were needed. Between November 2018 and March 2020, 250 patients were randomized and analyzed. The patient population had multiple comorbidities, notably obesity (53%), diabetes mellitus (30%), mental health disorders (22%), and hypertensive disorders (21%). The attendance at 1 or more postpartum visits was not significantly different among the control and intervention arms (58% vs 70%; P=.065). The 2-week visit had an attendance rate of 41% (51 of 125), and the 6-week visit had an attendance rate of 60% (151 of 250). After adjusting for confounders, significant predictors of postpartum visit nonattendance included younger age, multiparity, and being a patient from the high-risk obstetrical clinic. The rate of emergency department visits was similar between the control and intervention arms (8% vs 6%; P=.635). However, more patients in the control arm come to the clinic for nonroutine visits (30% vs 16%; P=.010). In response to a patient satisfaction survey on the optimal timing of the postpartum visit, most respondents (59%) would have preferred both the 2- and 6-week visits. The addition of a 2-week postpartum visit to the 6-week postpartum visit did not increase the likelihood of attendance of patients in a routine visit but did decrease the number of urgent clinic visits.

The prevalence of abnormal Doppler's of the umbilical artery in a low-risk pregnant population in South Africa.

BackgroundThe assessment of fetal blood flow using Doppler waveform can be used to identify placental insufficiency, and hence is a tool to identify fetuses at risk of stillbirth due to fetal growth restriction (FGR). In South Africa the largest category of perinatal deaths is ‘unexplained intrauterine death’. The majority of the mothers are clinically healthy women. This study was performed to determine the prevalence of abnormal umbilical resistance indices (abnormal RI) to see if screening a low-risk pregnant population is worthwhile.MethodsA descriptive study across 9 sites in 8 provinces of South Africa was performed to determine the prevalence of abnormal RI of the umbilical artery in women classified as having a low-risk pregnancy. The study was conducted from 1st September 2017- February 2020.The pregnant women classified were screened using a continuous wave Doppler ultrasound apparatus (Umbiflow™) between 28 and 34 weeks’ gestation. Women with fetuses with an abnormal RI were referred to a high-risk clinic and were managed according to standard protocol. The outcomes of all the deliveries were recorded.FindingsUmbiflow™ screening of the umbilical artery was performed in 7088 women across nine sites; 919 (13·0%) fetuses had an abnormal RI. Absent end diastolic flow (AEDF) was found in 87 (1·2%) fetuses. The prevalence of small for gestational ages (SGA) babies was 23·1% in the normal RI group and was significantly higher in the abnormal RI group 32·1% (p<0·0001). There was a statistical difference in the perinatal mortality rate between the normal RI (9.8/1000) and abnormal RI group (21.4/1000) [RR 0·046; 95% CI -0·06–0·98].InterpretationThe prevalence of abnormal RI and AEDF in this screened low-risk population was about ten times higher than that previously recorded in high income countries. Continuous wave Doppler ultrasound screening detected previously undiagnosed growth restricted babies. The prevalence of AEDF warrants continuous wave Doppler ultrasound screening of the low-risk pregnant population in South Africa.FundingThis study was funded by the South African Medical Research Council (SAMRC) and the Council for Scientific and Industrial Research (CSIR)

Efficiency of Detecting New Primary Melanoma Among Individuals Treated in a High-risk Clinic for Skin Surveillance

A previous single-center study observed fewer excisions, lower health care costs, thinner melanomas, and better quality of life when surveillance of high-risk patients was conducted in a melanoma dermatology clinic with a structured surveillance protocol involving full-body examinations every 6 months aided by total-body photography (TBP) and sequential digital dermoscopy imaging (SDDI). To examine longer-term sustainability and expansion of the surveillance program to numerous practices, including a primary care skin cancer clinic setting. This prospective cohort study recruited 593 participants assessed from 2012 to 2018 as having very high risk of melanoma, with a median of 2.9 years of follow-up (interquartile range, 1.9-3.3 years), from 4 melanoma high-risk clinics (3 dermatology clinics and 1 primary care skin cancer clinic) in New South Wales, Australia. Data analyses were conducted from February to September 2020. Six-month full-body examination with the aid of TBP and SDDI. For equivocal lesions, the clinician performed SDDI at 3 or 6 months. All suspect monitored or excised lesions were recorded, and pathology reports obtained. Outcomes included the incidence and characteristics of new lesions and the association of diagnostic aids with rates of new melanoma detection. Among 593 participants, 340 (57.3%) were men, and the median age at baseline was 58 years (interquartile range, 47-66 years). There were 1513 lesions excised during follow-up, including 171 primary melanomas. The overall benign to malignant excision ratio, including keratinocyte carcinomas, was 0.8:1.0; the benign melanocytic to melanoma excision ratio was 2.4:1.0; and the melanoma in situ to invasive melanoma ratio was 2.2:1.0. The excision ratios were similar across the 4 centers. The risk of developing a new melanoma was 9.0% annually in the first 2 years and increased with time, particularly for those with multiple primary melanomas. The thicker melanomas (>1-mm Breslow thickness; 7 of 171 melanomas [4.1%]) were mostly desmoplastic or nodular (4 of 7), self-detected (2 of 7), or clinician detected without the aid of TBP (3 of 7). Overall, new melanomas were most likely to be detected by a clinician with the aid of TBP (54 of 171 [31.6%]) followed by digital dermoscopy monitoring (50 of 171 [29.2%]). The structured surveillance program for high-risk patients may be implemented at a larger scale given the present cohort study findings suggesting the sustainability and replication of results in numerous settings, including a primary care skin cancer clinic.

Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients.

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p < 0.001), while the opposite trend was seen with buprenorphine dose (p < 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse.

P40.03 Report on a Phytochemical-rich Dietary Intervention Trial to Prevent Lung Cancer: Implementation in a High-Risk Lung Screening Clinic

The BeWell Trial, Black Raspberry Beverage for the Prevention of Lung Cancer, is currently underway at The Ohio State University (OSU) James Cancer Hospital. The study is a placebo-controlled, randomized, cross-over pilot study to assess the impact of a novel black raspberry food product on the microbiome and immune functions in a high risk cohort for lung cancer. Our central hypothesis is that phytochemical–rich black raspberries (BRB) will increase the diversity of the gut microbiome, increase the abundance of specific desirable microbes, such as Akkermansia muciniphila, and inhibit cancer by indirect effects on host inflammatory cascades, perhaps via impact on the microbiota. This report will describe the trial progress, including challenges in accrual/retention, compliance, safety, and additional insights on conducting BRB and cancer trials. BeWell Study participants are recruited from the OSU Lung Screening Clinic, pulmonary clinics, and social media (e.g. Facebook). Inclusion criteria include: age 55-77 years, 30+ pack years smoking history, and smoked within the last 15 years. Exclusion criteria include: oral corticosteroid use and uncontrolled gastrointestinal or metabolic disorders. Participants are asked to follow a low-phenolic diet and we obtain a 24-hour urine sample, stool sample, blood draw and weight/vitals at each clinic visit. They are randomized to receive the BRB or placebo beverage, (blocked by gender and smoking status) for 4-weeks (170 ml, 2X/day), have a 2-week washout period, and then cross-over to 4 weeks of BRB or placebo (10 weeks total). The crossover design greatly minimizes variation, which is particularly beneficial in microbiome studies. Participants also complete diet compliance, medical history, food frequency and physical activity questionnaires. Of the accrual target of 42 patients, 32 have been fully consented, and 2 have fully completed the 10-week study. Thirteen individuals are former smokers (6 females and 7 males), with 7 current smokers (all female). Their ages range from 58 to 76 years. The dropout rate is 37%. Participants mostly dropped out before the first study visit. Nearly half of dropouts occurred during the holidays. We have approached 244 eligible participants who declined (13% consent rate). The reasons given for non-participation include: not interested, too busy, hard to get to appointments, dislike home urine/stool tests, live too far and work conflicts. One adverse event was reported event (diarrhea). Current accrual rates suggest study completion in December, 2020. The accrual and retention process for this study of high risk smokers has been challenging, with 13% of individuals agreeing to enroll and high dropout rate (37%). As a result, we extended our estimated recruiting period from 6 to 12 months, increased the compensation level and increased the number of targeted advertisements on social media, with A/B testing to optimize text and images. Objective measures of various recruitment and advertising success are being captured. We suggest that future trials with similar groups consider time of year and season when recruiting, ensure adequate reimbursement and offer any possible incentives or conveniences to increase participation and retention, thus increasing the success of similar future trials.

Abstract PS7-20: Identification of pathogenic mutations in otherwise unaffected patients through the CARE program

Abstract Introduction Approximately one out of eight women are diagnosed with breast cancer in their lifetime. Women are recommended to begin annual mammograms at age 40 unless they are high-risk risk for breast cancer based on risk algorithms or positive germline mutations. Unfortunately, genetic testing and risk counseling are often not offered until a cancer diagnosis is already made. It is estimated that 5-10% of the general population has genetic predisposition to cancer. Purpose We established the Comprehensive Assessment, Risk &amp; Education (CARE) Program at our mammogram center. Offered in partnership with Ambry Genetics, the CARE Program’s goal is to facilitate unaffected women in obtaining genetic testing and risk-counseling who otherwise may not have access to these services. Methods Patients undergoing a screening mammogram were given a tablet with a preprogrammed Progeny questionnaire. This questionnaire included questions on the patient’s gynecological history and family history. It calculates a Tyrer-Cuzick risk score and assesses National Comprehensive Cancer Network (NCCN) genetic testing criteria. Patients qualifying for genetic testing received pretest counseling by video and were offered genetic testing the same day as their mammogram appointment. Our genetic counselors performed follow-up counseling for patients receiving positive test results. Patients testing negative or inconclusive received a letter generated by Ambry. Our CARE program began on June 7th, 2019, and data was assessed through July 6th, 2020. Results 1,065 women met NCCN criteria for genetic testing. Of those women, 464 (43.6%) proceeded with testing, 387 (36.3%) declined testing and 214 (20.1%) were not able to obtain day-of genetic testing due to operational/personnel limitations. Of those who submitted tests, 403 (86.9%) completed testing and 61 tests were cancelled due to out of pocket costs or patient preference. Of the 403 patients who completed testing, 262 (65%) tested negative, 105 (26%) tested inconclusive and 35 (8.7%) tested positive. Positive test results were found in 15 genes (Table 1). Clinical Impact Over 13 months, we identified 35 patients at increased risk for cancer based on positive genetic test results. Based on these results, 6 (17%) patients were offered prophylactic surgeries, 16 (45.7%) were offered breast MRIs and enrollment in our high-risk breast clinic, 14 (40%) were offered increased colonoscopies and 9 (25.7%) were offered pancreatic screening based on family history. All patients were offered family variant testing. Conclusion Our experience integrating a screening questionnaire into our mammogram clinic shows that 44% of patients meeting NCCN criteria agree to do day of testing. Of those completing testing, 9% tested positive. This result is consistent with the national expected positive rate. Our CARE Program offers unaffected patients an opportunity to be tested in a comfortable low stress setting through the mammography suite. These patients and their families will now benefit from cancer prevention options that may not have been offered to them had they not been pre-emptively screened by our program. Table1. Positive test results for 35 patients.MutationNumber of patients identified (%)CHEK29 (25.7)MUTYH5 (14.2)HOXB134 (11.4)ATM3 (8.6)APC2 (5.7)BARD12 (5.7)PALB22 (5.7)BRCA21 (2.9)BRIP11 (2.9)MRE11A1 (2.9)MSH21 (2.9)MSH61 (2.9)RAD501 (2.9)RAD51D1 (2.9)TP531 (2.9) Citation Format: Lida Mina, Rebecca Luiten, Jennifer Siettmann, Vilert Loving. Identification of pathogenic mutations in otherwise unaffected patients through the CARE program [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-20.

Considerations in the provision of teleconsultations for outpatient obstetric anaesthesia care during the Covid-19 pandemic

Evidence has emerged that pregnant women who contract coronavirus disease 2019 (Covid-19) are at increased risk of certain forms of severe illness as well as complications requiring intensive care unit admission and resultant mortality. Teleconsultations can facilitate continuing care for obstetric patients during the Covid-19 pandemic while reducing their risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this short report, we share our experience in the provision of teleconsultations for ambulatory obstetric anaesthesia patients in our high-risk obstetric anaesthesia clinic during the Covid-19 pandemic. Appropriate labour analgesia or anaesthesia plans were able to be formulated and communicated to the patients by teleconsultation, resulting in no delay or compromise in their peripartum care. Both patients and clinicians reported satisfaction with the teleconsultation process and outcome. The considerations and challenges in setting up a teleconsultation service as well as the factors in favour of teleconsultation are also explored.

Creation of a Novel Shared Decision-Making Tool in Pediatric High-Risk Asthma Clinic

Best practices regarding communication using shared-decision making (SDM) strategies in pediatric high-risk asthma remain unexplored. This project examines whether the addition of a written communication tool based on principles of SDM facilitates improves communication between patient families and the care team in a pediatric high-risk asthma clinic (HRA), when compared to established communication practices.

Objective Controller Medication Adherence Patterns in Pediatric Patients with Asthma in a High-Risk Multidisciplinary Asthma Clinic

Objective Controller Medication Adherence Patterns in Pediatric Patients with Asthma in a High-Risk Multidisciplinary Asthma Clinic

57 Randomized Control Trial of Postpartum Visits at 2 weeks and 6 weeks

To determine if decreasing the time to initial postpartum visit (PPV) from six weeks to two weeks can increase attendance. We conducted a parallel, randomized, non-blinded trial at a publicly insured clinic comparing a single six-week postpartum visit (control) to two visits at two and six weeks postpartum (intervention). The primary outcome was attendance at one or more routine PPV. Secondary outcomes were emergency department (ED) visits within 30 days of delivery and urgent clinic visits. Multivariable regression was performed to identify predictors of clinic non-attendance. To demonstrate an increase of clinic attendance from 70% to 85%, 250 participants were needed. Between November 2018 and March 2020, 250 patients were randomized with outcome data available. The patient population had multiple comorbidities, notably obesity (53%), diabetes (30%), mental health disorders (22%) and hypertensive disorders (21%). The attendance at one or more PPV was similar among the control and intervention arms (58% vs 70%, p=0.065). (Figure 1) The 2-week visit had an attendance rate of 41% (51/125) and the 6-week visit had an attendance rate of 60% (151/250). The primary reasons for non-attendance at the 2-week appointment was never scheduling the appointment (73%), scheduling but not attending (15%) and scheduling but cancelling (12%). After adjusting for confounders, predictors of PPV non-attendance included younger age, multiparity and being a patient of the high-risk obstetric clinic. (Table 1) ED usage was similar among the control and intervention arm (8% vs 6%, p=0.635), however more patients in the control arm utilized the clinic for urgent visits (30% vs 16%, p=0.010). 59% of patients among both study groups preferred both visits. The addition of a 2-week postpartum visit to the routine 6-week postpartum visit did not increase the likelihood of attendance at a routine visit but did decrease the amount of urgent clinic visits. This visit may fulfill the role of close postpartum follow-up that patients of a medically complex obstetrics population often require.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pregnant Hispanic women's views and knowledge of prenatal genetic testing.

Pregnant Hispanic women are underserved with their needs for genetic counseling, despite birth defects remaining the leading cause of infant death in the United States. We present the qualitative findings of a study to understand knowledge and perceptions of prenatal testing in a sample of hard‐to‐reach underrepresented Hispanic pregnant women in South Texas. The sample for this study was 10 Hispanic pregnant women who were recruited from a high‐risk prenatal clinic in South Texas in 2019. The semi‐structured interview questions were created based on the researchers' clinical experiences with this population and were designed to examine knowledge and perceptions of participants toward prenatal testing. Analysis of the qualitative data yielded several themes related to prenatal testing: (a) knowledge, (b) confusion, (c) partner's and support persons' opinions, (d) information sharing from providers, (e) psychological benefits, (f) preparation for baby, (g) obstacles, (h) religious influence, and (i) educational tools to assist with understanding. Women's understanding and knowledge of prenatal testing was limited, specifically regarding its purpose, how it works, the benefits, and why it was recommended by their provider. Lack of clarity about why they should take the test and its risks for them and their babies was perceived as something that could impede their acceptance of prenatal testing. All participants agreed that healthcare providers should share more information about prenatal testing in a way that uses ‘everyday language' so that they can understand it better. All respondents mentioned that prenatal testing provides information about their baby's health conditions, alleviates their stress and concerns, and psychologically prepares them and their family for what is to come. Identifying ways to increase culturally appropriate education delivered by genetic counselors such as through the adoption of telemedicine and mobile technology can help fill the gap for this underserved population.

Myasthenia Gravis and Pregnancy: Toronto Specialty Center Experience.

Myasthenia gravis (MG) is an autoimmune disorder that frequently affects young women of reproductive age. The multidirectional interplay between MG, pregnancy, and fetal health poses a complex scenario for pregnant women with MG and the healthcare team. Here, we reviewed our local experience with MG, pregnancy, and outcomes. We performed a retrospective chart review of patients with MG attending the Prosserman Family Neuromuscular Clinic from 2001 to 2019 and who were referred to a high-risk pregnancy clinic. MG status was defined as stable, better, or worse. Information was collected on the delivery route, pregnancy, and neonatal complications. We identified 20 women with MG for a total of 28 pregnancies. Worsening was observed in 50% of pregnancies: 18% during pregnancy, 25% following delivery, and 7% during both. 66.7% of patients with MG duration of 2 years or less had worsening during pregnancy. Three patients who stopped immunosuppressive treatment during pregnancy worsened and one had a crisis. C-section was done in 29% of pregnancies. The rate of delivery complications was 7% and of neonatal MG was 7%. A high proportion of MG patients worsened during pregnancy, particularly those with disease duration less than 2 years, and those who discontinued immunosuppression during pregnancy. However, pregnancy was largely unaffected, rate of neonatal MG was low, frequencies of C-section, delivery complications, and premature births were similar to the general population. While the study has limitations due to the retrospective nature, these insights provide some guidance when counseling young myasthenic women about family planning.

Adesão, não-adesão e abandono do acompanhamento infantil: abordagem de métodos mistos

Objetivo: analisar a adesão, não-adesão e abandono do acompanhamento das crianças encaminhadas aos centros de referência de alto risco da Rede Mãe Paranaense. Método: Estudo misto paralelo convergente. O local de estudo será representado pelos ambulatórios de alto risco da Rede Mãe Paranaense de uma Regional de Saúde do Estado do Paraná. A população serão as crianças encaminhadas aos ambulatórios de janeiro de 2015 a dezembro de 2019, familiares de crianças que realizaram, não aderiram e/ou abandonaram o acompanhamento nestes centros, bem como gestores dos municípios e profissionais lotados na sede da Regional de Saúde. A análise dos dados quantitativos será realizada através da autocorrelação espacial, pretende-se utilizar a análise exploratória de dados espaciais para determinação de existência de Autocorrelação Espacial Global e Índice de Autocorrelação Espacial Local. Os dados das entrevistas serão analisados no software NVivo, e analisados seguindo os preceitos propostos pelo Discurso do sujeito coletivo.

FamEvent: An R Package for Generating and Modeling Time-to-Event Data in Family Designs.

FamEvent is a comprehensive R package for simulating and modelling age-at-disease onset in families carrying a rare gene mutation. The package can simulate complex family data for variable time-to-event outcomes under three common family study designs (population, high-risk clinic and multi-stage) with various levels of missing genetic information among family members. Residual familial correlation can be induced through the inclusion of a frailty term or a second gene. Disease-gene carrier probabilities are evaluated assuming Mendelian transmission or empirically from the data. When genetic information on the disease gene is missing, an Expectation-Maximization algorithm is employed to calculate the carrier probabilities. Penetrance model functions with ascertainment correction adapted to the sampling design provide age-specific cumulative disease risks by sex, mutation status, and other covariates for simulated data as well as real data analysis. Robust standard errors and 95% confidence intervals are available for these estimates. Plots of pedigrees and penetrance functions based on the fitted model provide graphical displays to evaluate and summarize the models.

Nature and extent of outpatient podiatry service utilisation in people with diabetes undergoing minor foot amputations: a retrospective clinical audit

BackgroundPeople with diabetes are at high risk of foot complications that can lead to lower extremity amputations. National standards suggest that early assessment and management by a podiatry led multidisciplinary high-risk foot clinic (HRFC) helps to reduce complications. This review is a retrospective audit of the Central Coast Local Health District (CCLHD) podiatry department service utilisation in people with diabetes who had undergone a minor foot amputation.MethodsAll people with diabetes who had minor foot amputations in the calendar year 2017 in the CCLHD in New South Wales were identified. Podiatry occasions of service from all podiatry service clinics (e.g. general, orthoses, wound, HRFC) and hospital stays for 12 months prior to, and 12 months, post the minor foot amputation were extracted.ResultsData on 74 people with diabetes who underwent 85 minor foot amputations were collected. In the 12-month period leading up to their minor foot amputation less than half, 42% (n=31), of the patients had attended any of the available podiatry service clinics within the CCLHD system. Post-amputation and discharge from hospital there was an overall rise of 26% in numbers attending all CCLHD podiatry- led clinics bringing the total to 68% (51). However, attendance at the HRFC rose by only 2% from 16% (n=12) to 18% n= (13).ConclusionThis study shows that there was underutilisation of Podiatry Services in the CCLHD in 2017 with some participants not meeting national treatment guidelines for foot health services. Revision of current referral pathways both prior to, during and following hospitalisation and expanding the multidisciplinary HRFC to accommodate the population by providing more accessible locations has since been undertaken to increase service access. Further provision of education to those highlighted to be at high risk has also been implemented.

Non-exclusive breastfeeding amongst high-risk children: Factors and barriers associated with non-exclusive breastfeeding at a tertiary care hospital in Southern India.

In the first 6 months of life, non-exclusive breastfeeding (NEBF) is estimated to be the cause of 1.4 million deaths worldwide and contributes to 10% of the disease burden in under-five children. The objective of the study was to determine the prevalence of NEBF amongst the high-risk children and the factors associated with NEBF. This cross-sectional study was conducted amongst high-risk babies admitted between August 2016 and February 2018 who also attended the high-risk follow-up clinic at the neonatology department. Data were collected using a pre-tested structured questionnaire. Chi-square test was used to determine the factors associated with NEBF and prevalence ratios (PR) with 95% confidence interval (CI) were calculated. Amongst 304 children, 56.3% were male and 87% had birth weight <2500 g. Nearly three-fourth of the mothers were <30 years of age. The prevalence of NEBF was 49.3% (95% CI: 43.7-55.0). There was a significant association of NEBF with employment status of the mother (PR = 1.45; 95% CI: 1.1-1.9), NEBF in previous child (PR = 2.3; 95% CI: 1.4-3.9) and EBF at the point of discharge (PR = 2.3; 95% CI: 2-2.6). The barriers reported by the mothers leading to NEBF were insufficient or less milk secretion, poor breastfeeding attachment, perceived thirst and poor maternal health. One out of every two children admitted in neonatal intensive care unit were non-exclusively breastfed before 6 months of age. The employment status of mother, practice of exclusively breastfeeding the previous child and EBF at the time of discharge were significantly associated with NEBF.