Maternal Sociodemographic Characteristics,Experiences and Health Behaviors Associated with Postpartum Care Utilization: Evidence from Maryland PRAMS Dataset, 2012–2013

Objectives Postpartum visits are increasingly recognized as a window of opportunity for health care providers to counsel new mothers and promote healthy behaviors, including increasing contraceptive use and screening for postpartum depression. In Maryland, there is a lack of research on postpartum visit (PPV) attendance and the specific risk factors associated with not receiving postpartum care. In this study, we estimated the proportion of mothers in Maryland who attended a PPV and assessed maternal sociodemographic characteristics and health behaviors associated with PPV non-attendance. Methods Data were analyzed from the 2012 and 2013 Maryland Pregnancy Risk Assessment Monitoring System (n?=?2204). Bivariate and multivariable logistic regression were performed to examine the association between covariates and PPV non-attendance. Results Overall, 89.6% of women reported PPV attendance. Bivariate analyses between maternal sociodemographic and health behavior characteristics and PPV non-attendance indicated that being unmarried (OR 3.03, 95% CI 2.12–4.31), experiencing infant loss (OR 7.17, 95% CI 2.57–19.97), working during pregnancy (OR 0.44, 95% CI 0.31–0.63) and not receiving dental care (OR 2.03, 95% CI 1.43–2.88) as significant risk factors for PPV non-attendance. After controlling for known and theoretical confounders, experiencing an infant loss (aOR 5.18, 95% CI 1.54–17.4), not receiving dental care (aOR 1.54, 95% CI 1.06–2.26) and working during pregnancy (aOR 0.61, 95% CI 0.41–0.93) emerged as strong predictors of PPV non-attendance. Conclusions for Practice Mothers who recently experienced an infant death were at greatest risk for not attending a PPV, suggesting the need to establish comprehensive support networks, including grief counseling and additional service reminders for mothers who experienced an infant death.     

Misperceptions of Facial Emotions Among Youth Aged 9–14 Years Who Present Multiple Antecedents of Schizophrenia

Similar to adults with schizophrenia, youth at high risk for developing schizophrenia present difficulties in recognizing emotions in faces. These difficulties might index vulnerability for schizophrenia and play a role in the development of the illness. Facial emotion recognition (FER) impairments have been implicated in declining social functioning during the prodromal phase of illness and are thus a potential target for early intervention efforts. This study examined 9- to 14-year-old children: 34 children who presented a triad of well-replicated antecedents of schizophrenia (ASz), including motor and/or speech delays, clinically relevant internalizing and/or externalizing problems, and psychotic-like experiences (PLEs), and 34 typically developing (TD) children who presented none of these antecedents. An established FER task (ER40) was used to assess correct recognition of happy, sad, angry, fearful, and neutral expressions, and facial emotion misperception responses were made for each emotion type. Relative to TD children, ASz children presented an overall impairment in FER. Further, ASz children misattributed neutral expressions to face displaying other emotions and also more often mislabeled a neutral expression as sad compared with healthy peers. The inability to accurately discriminate subtle differences in facial emotion and the misinterpretation of neutral expressions as sad may contribute to the initiation and/or persistence of PLEs. Interventions that are effective in teaching adults to recognize emotions in faces could potentially benefit children presenting with antecedents of schizophrenia.Key words: emotion recognition, high risk, child and adolescent psychopathology, social functioning, psychotic-like experiencesPeople with schizophrenia display a marked impairment in recognizing emotions in the faces of others, particularly anger, sadness, and fear, and less difficulty recognizing happy expressions.^1,2 Facial emotion recognition (FER) difficulties are associated with poor social functioning³ and have implications for the development, course, and outcome of the disorder.⁴ Yet, interventions to improve FER performance (eg, Training of Affect Recognition)⁵ can reduce these deficits and elicit generalized improvement in other social cognitive domains.⁶FER impairments are apparent not only among individuals with chronic schizophrenia (for review see Kohler et al 2010)² but also among individuals experiencing a first episode of psychosis^7,8 and among unaffected adolescent (though only for neutral facial expressions)⁹ and adult first-degree relatives of individuals with schizophrenia.¹⁰ Thus, abnormalities in FER are present at illness onset and may also index vulnerabil ity for schizophrenia. Prospective studies following individuals at elevated risk for developing schizophrenia are needed to determine the extent to which impairments of FER precede illness and represent potential targets for early intervention. Among symptomatic, help-seeking individuals meeting ultra-high risk (UHR) criteria for psychosis,^7,8,11–13 evidence for FER impairments is mixed. Two studies reported FER impairments relative to healthy participants,^7,11 while another study indicated specific difficulties in correctly identifying neutral expressions.¹³ A study of a large British birth cohort comprising 5267 children reported no association between FER at 8 years and subclinical psychotic symptoms at 12 years.¹⁴ By contrast, a recent cross-sectional study of 748 children aged 10–13 years indicated that those reporting psychotic-like experiences (PLEs) on questionnaires were poorer at recognizing facial emotional expressions, primarily sadness.¹⁵ Unfortunately, as with many previous FER studies, no information was provided about the nature of the facial emotion misperceptions committed when processing facial expressions. Though PLEs in childhood are significantly associated with later psychotic illness,^16,17 they are also associated with an increased risk of anxiety disorders¹⁶ and other psychiatric disorders including affective disorders, drug use disorders, and personality disorders,¹⁸ albeit to a lesser extent. Thus, PLEs constitute a relatively nonspecific marker of risk for subsequent psychiatric disorders. Further, cross-sectional data from the general population indicate significant comorbidity of PLEs with emotional and behavioral problems,^19,20 implying that the observed relationship between PLEs and FER reported by Roddy et al¹⁵ might reflect the presence of unreported internalizing and/or externalizing psychopathology.To better characterize the nature of FER associated with schizophrenia, several studies have examined facial emotion misperceptions. Relative to healthy adults, individuals with schizophrenia more often mislabel negative emotions to faces displaying no or neutral expressions.^21,22 Adolescent relatives of individuals with schizophrenia, compared with adolescents from healthy families, also more often incorrectly label neutral expressions as displaying negative emotions, predominantly mislabeling them as sad.⁹ Among individuals with schizophrenia, and individuals at high risk for psychosis,²³ functional imaging has revealed hyperactivation of the amygdala during the processing of neutral expressions, which could reflect emotional salience being assigned to neutral stimuli.²⁴ It has been suggested that the tendency to misinterpret neutral facial expressions as displaying emotion may contribute to the development of positive symptoms in schizophrenia.²³ Previous research indicates that facial emotion misperceptions might constitute the cognitive mechanism contributing to the social impairment that characterizes UHR samples¹³ and is a critical component to understanding FER difficulties in samples at risk for schizophrenia.Until recently, there has been no practical method for identifying children who are at elevated risk for schizophrenia. Despite the high heritability of schizophrenia, only approximately one-third of individuals with schizophrenia have a first- or second-degree relative with the illness. Consequently, a positive family history identifies only a subset of children who will develop the illness.²⁵ Prospective investigations of birth cohorts have demonstrated consistently that, by middle childhood, individuals who later developed schizophrenia presented delays in motor and language development; disturbances in social, emotional, and behavioral functioning; and PLEs.¹⁷ Based on this evidence, we developed questionnaires, to be completed by children aged 9–12 years and their primary caregiver, to identify children who present a triad of these replicated antecedents of schizophrenia (ASz).^26,27 We defined ASz to include (1) early speech and/or motor developmental delays/abnormalities; (2) social, emotional, and/or behavioral problems in the clinical range; and (3) PLEs. It is thought that the identification of children who present multiple antecedents of schizophrenia that have been replicated in prospective longitudinal studies will offer greater sensitivity and specificity for later development of schizophrenia than any one antecedent.We are currently following the development of ASz children to determine the specificity and sensitivity of the triad of antecedents for later schizophrenia development. We anticipate that some ASz children will develop schizophrenia and spectrum disorders, some will develop other disorders, and others will remain healthy. In the interim, our investigations have shown that ASz children, compared with typically developing (TD) children who present no antecedents and no family history of schizophrenia or a spectrum disorder, are characterized by features observed among adults with schizophrenia including (1) deficits in performance on standardized intelligence and neuropsychological tests of executive function and memory,²⁸ (2) dyskinetic movement abnormalities,²⁹ (3) reduction in the amplitude of the error-related negativity event-related potential component generated in the anterior cingulate that indexes internal monitoring of behavior,³⁰ and (4) structural brain abnormalities in the superior/middle temporal gyri.³¹ Further, among children aged 9–12 years, two-thirds (69%) of those presenting with the triad of antecedents report distress and/or functional impairment associated with their PLEs.²⁷This study sought to determine whether ASz children present FER difficulties similar to those reported among individuals with schizophrenia and at-risk youth, after accounting for intelligence quotient (IQ) differences between ASz and TD groups,²⁸ which may contribute to FER performance. The study examined overall performance on FER tasks, as well as the specific nature of facial emotion misperceptions. We hypothesized that ASz children would be less accurate than TD children in identifying emotions in facial expressions and that they would more often mislabel neutral faces with other emotion expressions. In particular, we anticipated that ASz children would misidentify neutral expressions as sad, as was reported in a study of youth with family histories of schizophrenia using the same FER task.⁹     

PCR-positivity in harvested bone marrow predicts relapse after transplantation with autologous purged bone marrow in children in second remission of precursor B-cell acute leukaemia

Purging of autologous bone marrow (BM) grafts of children in second remission after a relapse of precursor B acute lymphoblastic leukaemia (ALL) in the BM has been carried out in our laboratory since 1987, initially by complement mediated cell lysis. This protocol was extended by performing an immunorosette depletion before lysis with complement. The aim of the present study was to assess by polymerase chain reaction the presence of residual leukaemic cells in the BM grafts before and after purging. The results were then correlated to clinical outcome. In 24/28 patients a PCR product was obtained by amplification of IgH and/or TcR junctional regions. BM before purging was available for analysis in 13 patients. We found that leukaemic cells could be detected in 8/13 (62%) of these grafts before purging . All these eight patients experienced a relapse, regardless of whether the purging procedure had been successful (defined as achievement of PCR-negativity) or not. In contrast, none of the five patients with PCR-negative grafts before purging relapsed ( P  = 0.0008). One patient died due to transplant-related toxicity. Of the remaining 23 patients, nine patients received a PCR-positive BM graft after purging. All these nine patients experienced a relapse as compared to 6/14 whose BM was PCR-negative after purging ( P  = 0.0072). Two of eight PCR-positive BM grafts could be purged to PCR-negativity. Thus, improvements both in treatment of leukaemia and in purging efficacy are still needed.