Neonatal Intensive Care Unit (NICU) survival is increasing in extremely premature or severely ill neonates which can result in the development of chronic medical problems in survivors. The mental health care burden on a family and child with chronic illness is well documented. This perspective review article serves to explore the mental health needs of families of NICU graduates with chronic illness. It also serves to discuss the opportunities for improvement in addressing mental health needs of families in the NICU and after NICU discharge with recommended opportunities at the individual, institutional, and national level.

Background Neonatal intensive care unit (NICU) parental emotional trauma can distort parental perceptions of child vulnerability (PPCV), resulting in adverse child developmental outcomes, known as Vulnerable Child Syndrome (VCS). We hypothesize utilizing a novel trauma-informed cognitive behavioral therapy (CBT) intervention will reduce PPCV in premature NICU infants’ parents. Methods English and Spanish speaking parents of preterm infants (<31 weeks gestational age) were randomized from April 2019 to March 2020 to receive either a 5-session trauma-informed CBT intervention created for this study educating parents on PPCV concepts, or to a control group receiving standard of care. Principal outcome measure was PPCV change measured by the Vulnerable Baby Scale (VBS) scores from enrollment (33 weeks post menstrual age) to study end (6 months chronological age). Results 8 control and 12 intervention families completed the study ( n = 42 randomized) due to COVID-19 mandatory research pause. CBT intervention group had a median VBS decrease of 6 points vs. 0 point in controls ( P = 0.07). Post-hoc Bayesian analysis of VBS PPCV reduction (utilized due to limited n ) favored CBT to control by 95%. Conclusion This is the first parental trauma-informed CBT intervention to demonstrate a PPCV decrease and lower risk of development of VCS in a high-risk NICU population. Impact A brief intervention shows promise in fostering improved parenting perceptions, behaviors, and outcomes. NICU parental trauma negatively impacts parental perceptions of child vulnerability and their parenting styles resulting in poor child developmental outcomes, summarized as Vulnerable Child Syndrome (VCS). Currently, there is no effective treatment standard of care to address this important clinical issue. This manuscript contributes to our understanding of the following: Trauma-informed cognitive behavioral therapy lowers parents’ perceptions of vulnerability in an at-risk NICU population. This is the first published intervention to demonstrate efficacy in reducing NICU parental perceptions of child vulnerability, a key contributor to VCS. Implementation of this intervention with NICU families has the potential to reduce the risk of VCS and improve parent-child outcomes and child developmental outcomes. Clinical Trial Registration ClinicalTrials.gov identifier: NCT03906435.

Abstract In this study, optical photothermal infrared (O-PTIR) spectroscopy combined with machine learning algorithms were used to evaluate 46 tissue cores of surgically resected cervical lymph nodes, some of which harboured oral squamous cell carcinoma nodal metastasis. The ratios obtained between O-PTIR chemical images at 1252 cm−1 and 1285 cm−1 were able to reveal morphological details from tissue samples that are comparable to the information achieved by a pathologist’s interpretation of optical microscopy of haematoxylin and eosin (H&E) stained samples. Additionally, when used as input data for a hybrid convolutional neural network (CNN) and random forest (RF) analyses, these yielded sensitivities, specificities and precision of 98.6 ± 0.3%, 92 ± 4% and 94 ± 5%, respectively, and an area under receiver operator characteristic (AUC) of 94 ± 2%. Our findings show the potential of O-PTIR technology as a tool to study cancer on tissue samples.

BackgroundEstimation of prognosis of oral squamous cell carcinoma (OSCC) is inaccurate prior to surgery, only being effected following subsequent pathological analysis of the primary tumour and excised lymph nodes. Consequently, a proportion of patients are overtreated, with an increase in morbidity, or undertreated, with inadequate margins and risk of recurrence. We hypothesise that it is possible to accurately characterise clinical outcomes from infrared spectra arising from diagnostic biopsies. In this first step, we correlate survival with IR spectra derived from the primary tumour.MethodsInfrared spectra were collected from tumour tissue from 29 patients with OSCC and subject to classification modelling.ResultsThe model had a median AUROC of 0.89 with regard to prognosis, a median specificity of 0.83, and a hazard ratio of 6.29 in univariate Cox proportional hazard modelling.ConclusionThe data suggest that FTIR spectra may be a useful early biomarker of prognosis in OSCC. Estimation of prognosis of oral squamous cell carcinoma (OSCC) is inaccurate prior to surgery leading to over treatment in a proportion of patients. Infrared spectra were collected from OSCC tumour tissue and subject to classification modelling. The model had a median AUROC of 0.89 with regard to prognosis, a median specificity of 0.83 and a hazard ratio of 6.29 in univariate Cox proportional hazard modelling. The data suggest that FTIR spectra may be a useful early biomarker of prognosis in OSCC.image

Parental mental health is an essential sixth vital sign that, when taken into consideration, allows clinicians to improve clinical outcomes for both parents and infants. Although standards exist for screening, referral, and treatment for perinatal mood and anxiety disorders (PMADs), they are not reliably done in practice, and even when addressed, interventions are often minimal in scope. Quality improvement methodology can accelerate the implementation of interventions to address PMADs, but hurdles exist, and systems are not well designed, particularly in pediatric inpatient facilities. In this article, we review the effect of PMADs on parents and their infants and identify quality improvement interventions that can increase screening and referral to treatment of parents experiencing PMADs.

The World Health Organization in its recommendations for the care of preterm infants has drawn attention to the need to address issues related to family involvement and support, including education, counseling, discharge preparation, and peer support. A failure to address these issues may translate into poor outcomes that extend across the lifespan. In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on the parent-child interaction, attachment, and the styles of parenting. This paper addresses the following topics: (1) neurodevelopmental outcomes in preterm infants, including cognitive, sensory, and motor difficulties, (2) long-term mental health issues in premature infants that include elevated rates of anxiety and depressive disorders, autism, and somatization, which may affect social relationships and quality of life, (3) adverse mental health outcomes for parents that include elevated rates of depression, anxiety, and symptoms of post-traumatic stress, as well as increased rates of substance abuse, and relationship strain, (4) negative impacts on the parent-infant relationship, potentially mediated by maternal sensitivity, parent child-interactions, and attachment, and (5) impact on the parenting behaviors, including patterns of overprotective parenting, and development of Vulnerable Child Syndrome. Greater awareness of these issues has led to the development of programs in neonatal mental health and developmental care with some data suggesting benefits in terms of shorter lengths of stay and decreased health care costs.

To examine associations between maternal mental health and involvement in developmental care in the NICU. Mothers of infants born <32 weeks gestation (n = 135) were approached to complete mental health screening questionnaires at two weeks after admission. Mothers who completed screening (n = 55) were further classified as with (n = 19) and without (n = 36) elevated scores. Mothers’ frequency, rate, and duration of developmental care activities were documented in the electronic health record. 35% of screened mothers scored above the cutoff for clinical concern on ≥1 measure. No significant differences between the 3 groups were identified for rates, frequency, or amount of all developmental care, kangaroo care, and swaddled holding. Elevated scores on maternal mental health questionnaires did not relate to developmental care. Maternal developmental care engagement may not indicate mental health status. Universal screening for psychological distress is required to accurately detect symptoms in mothers of hospitalized preterm infants.

OBJECTIVE:Proliferative verrucous leukoplakia (PVL) is a rare form of oral leukoplakia with a relatively high transformation rate resulting in oral squamous cell carcinoma (OSCC). Molecular analysis of PVL at the genome level is limited and has only identified molecular similarities between PVL and OSCC. However, the clinical profile of PVL suggests that molecular differences may be more important.STUDY DESIGN:Whole exome sequencing of 5 PVL-associated OSCC (PVL-OSCC) and paired blood samples was used to identify somatic mutations common to the tumors. Whole methylome analysis of samples from 4 PVL-associated OSCC and 3 OSCC of non-PVL origin samples was conducted to explore differential methylation.RESULTS:In contrast to conventional OSCC, PVL-associated OSCC showed infrequent TP53 mutation and altered spectra of PIK3CA and NOTCH1 mutations. Unsupervised hierarchical clustering identified 63 probes that discriminated between PVL-associated OSCC and OSCC of non-PVL origin. Differences in methylation were most significant for divalent metal ion transport, particularly calcium movement.CONCLUSIONS:Specific differences in mutation and methylation profiles between PVL-derived OSCC and OSCC of non-PVL origin suggest differences in their transformation pathways. Further studies of early PVL lesions may identify markers of transformation that are also applicable to more common oral premalignant disorders such as oral epithelial dysplasia.

Objective: Child survival after intensive care unit (ICU) hospitalization has increased, yet many children experience acute stress that may precipitate mental/behavioral health comorbidities. Parents report stress after their child's hospitalization. Little is known about the individual and family characteristics that may moderate intergenerational relationships of acute stress. Design: Following ICU admission at a large academic medical center, a prospective cross-sectional cohort study assessed the associations between intergenerational characteristics and acute stress among children and families. Patients: Parent-child dyads (N = 88) were recruited from the pediatric ICU and pediatric cardiovascular ICU (CVICU) following ICU discharge. Eligible children were between 8 and 18 years old with ICU stays longer than 24 hours. Children with developmental delays were excluded. Caregivers were proficient in English or Spanish. Surveys were collected before hospital discharge. Measurements/Main Results: The primary outcome was "child stress" defined as a score≥17, measured by the Children's Revised Impact of Events Scale (CRIES-8). "Parent stress" was defined as an elevated composite score on the Stanford Acute Stress Reaction Questionnaire. We used validated scales to assess the child's clinical and family social characteristics. Acute stress was identified in 34 (39.8%) children and 50 (56.8%) parents. In multivariate linear regression analyses adjusting for social characteristics, parent stress was associated with increased risk of child stress (adjusted odds ratio 2.58, 95% confidence interval 0.69, 4.46, p < .01). In unadjusted analyses, Hispanic ethnicity was associated with greater child stress. In adjusted analyses, race, income, ICU length of stay, and language were not associated with child stress and did not moderate the parent-child stress relationship. Conclusions: Parent stress is closely correlated with child stress during ICU hospitalization. Hispanic ethnicity may be associated with increased risk for child stress, but further studies are required to define the roles of other social and clinical measures.

Caregiving relationships in the postnatal period are critical to an infant's development. Preterm infants and their parents face unique challenges in this regard, with infants experiencing separation from parents, uncomfortable procedures, and increased biologic vulnerability, and parents facing difficulties assuming caregiver roles and increased risk for psychological distress. To better understand the NICU parent-infant relationship, we conducted a review of the literature and identified 52 studies comparing observed maternal, infant, and dyadic interaction behavior in preterm dyads with full-term dyads. Eighteen of 40 studies on maternal behavior found less favorable behavior, including decreased sensitivity and more intrusiveness in mothers of preterm infants, seven studies found the opposite, four studies found mixed results, and 11 studies found no differences. Seventeen of 25 studies on infant behavior found less responsiveness in preterm infants, two studies found the opposite, and the remainder found no difference. Eighteen out of 14 studies on dyad-specific behavior reported less synchrony in preterm dyads and the remainder found no differences. We identify confounding factors that may explain variations in results, present an approach to interpret existing data by framing differences in maternal behavior as potentially adaptive in the context of prematurity, and suggest future areas for exploration.

Background: Trauma-Focused Cognitive Behavioral Therapy (trauma-focused CBT) is an effective treatment for PTSD in mothers of preterm infants, with the trauma narrative (TN) component providing an opportunity for mothers to process their NICU experience. Yet trauma-focused CBT, including its distinctive TN component, has only recently been provided in a group format for this population. The acceptability and feasibility of writing and reading aloud a trauma narrative in a group format has not been evaluated in parents of preterm infants. Methods: After participating in a six-session trauma-focused CBT group intervention, mothers (N=19) of premature infants in a Neonatal ICU (NICU) completed Trauma Narrative Questionnaires and Distress Rating Forms before and after the trauma narrative components of trauma-focused CBT sessions. Results: Mothers perceived the writing and recounting of their Trauma Narrative (TN) exercises as positive and helpful. While mothers reported increased distress while writing and reading their trauma narrative, they also endorsed decreased levels of distress at the end of treatment as well as decreased isolation. Conclusions: These findings support the writing and reading of a TN in group therapy, and demonstrate the TN as a viable method to target maternal isolation with a brief, focused intervetnion and to help process trumatic experiences associated with a NICU stay.

The COVID-19 pandemic is having a significant impact on the provision of non-COVID-19 related clinical services. Early recommendations for head and neck reconstructive surgery were based on guidance from expert groups, advocating de-intensification of surgery. Since then, patient outcomes derived data has suggested that the continued practice of head and neck reconstructive surgery based upon pre-pandemic standard of care is safe if appropriate measures are in place for appropriate screening and segregation of care pathways for patients. In addition, adequate levels of personal protective equipment (PPE) are vital for both patients and the healthcare team. We present the current practice guidance within the UK National Health Service (NHS) for head and neck reconstructive surgery in the COVID-19 pandemic era in the following areas: COVID-19 testing/screening, care pathways for patients, the potential future role of immunisation against SARS-CoV-2, airway management, selection of the type of reconstruction, postoperative care and rehabilitation. The guidance produced reflect the evolving nature of the response of NHS to the COVID-19 pandemic, some of the suggested practice protocols could differ from local policies in various parts of the world however the principles which underlie these standards are the results of regular review of the needs of the patients and health service, balanced against the background of the ebb and flow of the prevalence of COVID-19 infection within the community and healthcare settings.

Supplementary Table S1. Age and gender comparison between the current study and the UK incidence data (2002-2011); Supplementary Table S2. Comparison of age distribution in cases from 2002-2006 vs. 2007-2011; Supplementary Table S3. Type-specific HPV prevalence among single infected HPV-positive tumours

BACKGROUND:Elective neck dissection improves survival in early oral cancer. Sentinel lymph node biopsy may also do this with less morbidity. This systematic review compared health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer.METHODS:PRISMA guidelines were followed. Thirteen studies met inclusion criteria.RESULTS:Results favoring sentinel lymph node biopsy were found in complications, scar length and appearance, length of hospital stay, time to drain removal, and objective shoulder measures at timepoints up to 12 months. Where differences in health-related quality of life were found, methodological issues make their clinical significance questionable.CONCLUSIONS:Sentinel lymph node biopsy was associated with fewer complications and statistically better outcomes in a number of physical measures. There is as yet no strong evidence to suggest it is associated with better health-related quality of life outcomes. While a number of health-related quality of life outcome measures show promise, their interpretation is hampered by methodological concerns. Further rigorous research is required to address this.

The objectives were to: 1) obtain a national consensus on pediatric consultation-liaison psychiatry (PCLP) competencies; and 2) conduct a needs assessment to establish the interest in the development of online, self-based learning modules specific to PCLP. In 2017, a survey of AACAP members associated with the Physically Ill Child Committee (PICC) was conducted to generate a list of proposed core competencies in consultant-liaison psychiatry (CLP) that tracked the Accreditation Council for Graduate Medical Education (ACGME) competencies. In 2019, a follow-up assessment of PICC listserv members was conducted to evaluate barriers to teaching and interest in the development of a national teaching curriculum. Among the 200 members, 22% responded to the first survey, with 74% to 91% of the respondents endorsing an interest in learning resources, reading materials, and milestone-based assessment tools. Competencies in Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, Practice-based Learning, and System-based Practice were identified as specific to PCLP. In the second survey, there was a response rate of 28%. All respondents endorsed the need for standardized teaching materials in the common topics in PCLP, with highly ranked topics including catatonia, anti–N-methyl-D-aspartate (anti-NMDA) encephalitis, delirium, and psychiatric complications of medical illness. Respondents also expressed an interest in nationally developed competencies in PCLP. Given the wide variability in the nature of clinical practice and expertise in diverse PCLP programs, it is not always possible for trainees to be offered state-of-the-art teaching resources and content. However, with the expertise of AACAP PCLP faculty, there is the potential to create a library of curriculum resources to enhance and standardize educational practices in PCLP programs. The existence of these sources will help provide access to expert teaching materials and may also lead to ways to improve the evaluation of training practices and outcomes. The needs assessment demonstrates that new paradigms are needed to develop standardized curriculum and assessment resources for PCLP.