Arthur Owora

Evidence for using clopidogrel alone or in addition to aspirin in post coronary artery bypass surgery patients.

Clopidogrel is recommended with aspirin for patients who undergo coronary artery bypass grafting (CABG) after non-ST elevation myocardial infarctions. Cardiothoracic surgeons widely use clopidogrel in addition to aspirin for post-CABG patients, including those with stable coronary artery disease. The aim of this study was to systematically review the published research to determine whether clopidogrel use after CABG is based on good trial data. Studies reporting safety and/or efficacy data for clopidogrel use with or without aspirin after on- or off-pump CABG were included. Fourteen studies met the inclusion criteria, of which 11 were reported trials and 3 are ongoing trials. Subgroup retrospective analyses of previously reported large trials of patients presenting with acute coronary syndromes (n = 1) or patients with stable coronary artery disease (n = 3) did not show a clear clinical benefit of clopidogrel when given in addition to aspirin after CABG. In contrast, there was a trend toward increased major and minor bleeding after the use of clopidogrel plus aspirin. Two small prospective trials providing data on surrogate end points and 5 small trials involving off-pump CABG patients were not of good quality to draw meaningful conclusions. In conclusion, summarized data based on subgroup analyses, surrogate end points, and observational cohort studies fail to demonstrate a clear beneficial effect of clopidogrel alone or in combination with aspirin on clinical outcomes after CABG.

Special care needs and risk for child maltreatment reports among babies that graduated from the Neonatal Intensive Care

Newborns discharged from intensive care are at elevated risk for child welfare reports, especially for child neglect. This study investigates the role of caregiving burden as a risk predictor among the NICU graduate population. Discharge data were captured for 2,463 infants graduating from a Neonatal Intensive Care Unit (NICU) during 2005-2008, then linked to child welfare reports at a median 3.2 year follow-up. Survival analyses were used to examine child welfare report outcomes conditional on caregiving burden and its moderating relationships with other family risk factors. Caregiving burden was associated primarily with an increased risk of child welfare reporting during the first few months to first year of life, after which risk was similar to NICU graduates without caregiving burden. Caregiving burden effects were potentiated by having three or more siblings in the family. A history of prior child welfare reports predicted very high risk, regardless of caregiving burden. Young maternal age increased risk. The findings suggest that the immediate months after NICU discharge may be an important window of child neglect prevention opportunity among newborns with special caregiving needs. This may be a key time to provide caregiver support and monitoring, particularly when caregivers have multiple children.

Risk for child maltreatment among infants discharged from a neonatal intensive care unit: a sibling comparison

Studies suggest that neonatal illness may cause increased risk for child maltreatment (CM), but these findings may be biased by observed and unobserved confounding factors (social, family, and maternal characteristics) including increased surveillance by health care providers. This study expands on previous research by examining and controlling for these potential study biases and confounders using a sibling discordance retrospective cohort study design. Infants born in a Level IV neonatal intensive care unit (NICU) were matched with non-NICU born sibling controls. Cox proportional hazard models with shared frailty terms were used to account for clustering and heterogeneity in CM survival time (time to CM event). Potentially key covariates were selected using the directed acyclic graph approach, and surveillance reports were identified and systematically included or excluded from analyses. Managing these sources of bias reduced but did not eliminate the association between neonatal illness and CM report risk. Risk was especially high during the first year of the NICU infant’s life and among families with multiple well-known CM risk factors.

Mixed-methods feasibility study on the cultural adaptation of a child abuse prevention model

The current study utilized mixed-methods analyses to examine the process of adapting a home-based parenting program for a local Latino community. The study examined the: (a) acceptability and cultural congruence of the adapted SafeCare® protocol, (b) adherence to the core components of SafeCare® while adapting to local community culture, and (c) social validity of the new model in addressing SafeCare® target areas (parenting, home safety, and child health). Participants were 28 Latino mothers and eight providers. After training in the adapted model, providers demonstrated improved knowledge and skills. All providers reached national certification standards for SafeCare®, demonstrating fidelity to the core components of the original model. Positive consumer-provider relationships were developed as reflected by the results on the Working Alliance (collaboration between caregivers and parents). Themes from the integrated results of the social validity measures and individual interviews with parents were perceived benefits of the program on targeted areas and cultural congruency of the approach. Recommendations are to consider using adaptation guidelines as outlined to promote local culturally congruent practices.

Diagnostic performance of major depression disorder case-finding instruments used among mothers of young children in the United States: A systematic review

INTRODUCTION Growing recognition of the interrelated negative outcomes associated with major depression disorder (MDD) among mothers and their children has led to renewed public health interest in the early identification and treatment of maternal MDD. Healthcare providers, however, remain unsure of the validity of existing case-finding instruments. We conducted a systematic review to identify the most valid maternal MDD case-finding instrument used in the United States. METHODS We identified articles reporting the sensitivity and specificity of MDD case-finding instruments based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) by systematically searching through three electronic bibliographic databases, PubMed, PsycINFO, and EMBASE, from 1994 to 2014. Study eligibility and quality were evaluated using the Standards for the Reporting of Diagnostic Accuracy studies and Quality Assessment of Diagnostic Accuracy Studies guidelines respectively. RESULTS Overall, we retrieved 996 unduplicated articles and selected 74 for full-text review. Of these, 14 articles examining 21 different instruments were included in the systematic review. The 10 item Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale had the most stable (lowest variation) and highest diagnostic performance during the antepartum and postpartum periods (sensitivity range: 0.63-0.94 and 0.67-0.95; specificity range: 0.83-0.98 and 0.68-0.97 respectively). Greater variation in diagnostic performance was observed among studies with higher MDD prevalence. LIMITATION Factors that explain greater variation in instrument diagnostic performance in study populations with higher MDD prevalence were not examined. DISCUSSION Findings suggest that the diagnostic performance of maternal MDD case-finding instruments is peripartum period-specific.

Longitudinal Investigation of Depression, Intimate Partner Violence, and Supports Among Vulnerable Families

Intimate partner violence (IPV) affects nearly 12 million individuals and their families each year in the United States. Many negative outcomes are associated with IPV, with depression being one of the most prevalent mental health problems. Most previous studies on IPV have used cross-sectional designs to examine the potential protective effects of support on depression. The current study fills this gap by conducting a longitudinal investigation of the roles of social support and family resources on depression among caregivers of young children. The study sample consisted of 548 female caregivers. Findings suggest that among those with an IPV history, those with higher social support reported lower depressive symptoms than those with less social support. No significant interaction was found for family resources and IPV. Rather, family resources had a main effect on depressive symptoms with no differential impact based on IPV status. Findings suggest the importance of connecting vulnerable families to supports such as social support and family resources to help mitigate depressive symptoms. Future research should consider the underlying mechanisms of social support as a protective factor among IPV victims with depression.

Summary diagnostic validity of commonly used maternal major depression disorder case finding instruments in the United States: A meta-analysis

INTRODUCTION Major Depression Disorder (MDD) is common among mothers of young children. However, its detection remains low in primary-care and community-based settings in part due to the uncertainty regarding the validity of existing case-finding instruments. We conducted meta-analyses to estimate the diagnostic validity of commonly used maternal MDD case finding instruments in the United States. METHODS We systematically searched three electronic bibliographic databases PubMed, PsycINFO, and EMBASE from 1994 to 2015 to identify relevant published literature. Study eligibility and quality were evaluated using the Standards for the Reporting of Diagnostic Accuracy studies and Quality Assessment of Diagnostic Accuracy Studies guidelines, respectively. Pooled sensitivity and specificity of case-finding instruments were generated using Bayesian hierarchical summary receiver operating models. RESULTS Overall, 1130 articles were retrieved and 74 articles were selected for full-text review. Twelve articles examining six maternal MDD case-finding instruments met the eligibility criteria and were included in our meta-analyses. Pooled sensitivity and specificity estimates were highest for the BDI-II (91%; 95% Bayesian Credible Interval (BCI): 68%; 99% and 89%; 95% BCI: 62%; 98% respectively) and EPDS10 (74%; 95% BCI: 46%; 91% and 97%; 95% BCI: 84%; 99% respectively) during the antepartum and postpartum periods respectively. LIMITATION No meta-regression was conducted to examine the impact of study-level characteristics on the results. DISCUSSION Diagnostic performance varied among instruments and between peripartum periods. These findings suggest the need for a judicious selection of maternal MDD case-finding instruments depending on the study population and target periods of assessment.

Medical Surveillance and Child Maltreatment Incidence Reporting among NICU Graduates

Objective of this study is to identify background infant and maternal characteristics that predict child maltreatment (CM) incidence reporting among Neonatal Intensive Care Unit (NICU) graduates by health care providers versus community sentinels with the goal of identifying ways to improve CM risk surveillance. Demographic, medical data including diagnoses and caregiving needs at discharge for infants treated in a NICU during 2005 to 2008 were obtained from the neonatology databases. CM outcome data was obtained from child welfare databases. Latent class analysis procedures were used to identify observable infant and maternal characteristics that define unobserved groups (latent classes) that predict NICU graduates CM incidence reporting among health care providers versus community sentinels. Medical surveillance (reports made by health care providers) accounted for only 37% of the CM reports made to child welfare. Infant health was more predictive of medical surveillance than maternal characteristics suggesting that health providers may assess risk differently than community sentinels. Based on a simple, two latent class model, the latent class with high infant health indicator membership probabilities was a better predictor of health care provider related reports than the class with lower membership probabilities (odds ratio = 2.72; 95% confidence interval [1.76, 4.20]). Health care providers may be keyed more to an infants medical frailty than to caregiver (maternal) contextual characteristics and thus may miss an opportunity to identify and intervene to prevent CM among children with medical problems. Findings raise the question of whether increased attention to contextual factors can aid or increase early identification of infants at risk of child maltreatment in NICU settings.