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Preterm birth is the most common single cause of perinatal and infant mortality, affecting 15 million infants worldwide each year with global rates increasing. Understanding of risk factors remains poor, and preventive interventions have only limited benefit. Large differences exist in preterm birth rates across high income countries. We hypothesized that understanding the basis for these wide variations could lead to interventions that reduce preterm birth incidence in countries with high rates. We thus sought to assess the contributions of known risk factors for both spontaneous and provider-initiated preterm birth in selected high income countries, estimating also the potential impact of successful interventions due to advances in research, policy and public health, or clinical practice. We analyzed individual patient-level data on 4.1 million singleton pregnancies from four countries with very high human development index (Czech Republic, New Zealand, Slovenia, Sweden) and one comparator U.S. state (California) to determine the specific contribution (adjusting for confounding effects) of 21 factors. Both individual and population-attributable preterm birth risks were determined, as were contributors to cross-country differences. We also assessed the ability to predict preterm birth given various sets of known risk factors. Previous preterm birth and preeclampsia were the strongest individual risk factors of preterm birth in all datasets, with odds ratios of 4.6-6.0 and 2.8-5.7, respectively, for individual women having those characteristics. In contrast, on a population basis, nulliparity and male sex were the two risk factors with the highest impact on preterm birth rates, accounting for 25-50% and 11-16% of excess population attributable risk, respectively (p<0.001). The importance of nulliparity and male sex on population attributable risk was driven by high prevalence despite low odds ratios for individual women. More than 65% of the total aggregated risk of preterm birth within each country lacks a plausible biologic explanation, and 63% of difference between countries cannot be explained with known factors; thus, research is necessary to elucidate the underlying mechanisms of preterm birth and, hence, therapeutic intervention. Surprisingly, variation in prevalence of known risk factors accounted for less than 35% of the difference in preterm birth rates between countries. Known risk factors had an area under the curve of less than 0.7 in ROC analysis of preterm birth prediction within countries. These data suggest that other influences, as yet unidentified, are involved in preterm birth. Further research into biological mechanisms is warranted. We have quantified the causes of variation in preterm birth rates among countries with very high human development index. The paucity of explicit and currently identified factors amenable to intervention illustrates the limited impact of changes possible through current clinical practice and policy interventions. Our research highlights the urgent need for research into underlying biological causes of preterm birth, which alone are likely to lead to innovative and efficacious interventions.

Issue Title: Preconception Care: Science, Practice, Challenges and Opportunities Guest Editors: Hani K. Atrash, MD, MPH and Louis G. Keith, MD, PhD

Preterm birth (delivery before 37 weeks and 0/7 days of gestation) is a leading cause of infant morbidity and mortality in the United States. In 2013, 11.4% of the nearly 4 million U.S. live births were preterm; however, 36% of the 8,470 infant deaths were attributed to preterm birth (1). Infants born at earlier gestational ages, especially <32 0/7 weeks, have the highest mortality (Figure) and morbidity rates. Morbidity associated with preterm birth includes respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage; longer-term consequences include developmental delay and decreased school performance. Risk factors for preterm delivery include social, behavioral, clinical, and biologic characteristics (Box). Despite advances in medical care, racial and ethnic disparities associated with preterm birth persist. Reducing preterm birth, a national public health priority (2), can be accomplished by implementing and monitoring strategies that target modifiable risk factors and populations at highest risk, and by providing improved quality and access to preconception, prenatal, and interconception care through implementation of strategies with potentially high impact.

Research on depression, suicidality, substance use disorders, and other mental health conditions in physicians and physicians-in-training reveals that these professionals struggle with higher rates of these potentially impairing conditions than the general population. Multiple regulatory bodies are involved in the assessment and treatment of impaired physicians, including the Federation of State Medical Boards of the United States, Physician Health Programs (PHPs), and individual state medical boards. States vary in their language of assessment, implementation of PHP components, and resulting outcomes. This article summarizes research on the impact of different state approaches to reporting requirements and treatments, and the impact of not reporting impairment. [Psychiatr Ann. 2024;54(10):e282–e286.]

Stress can significantly affect an individual's mental and physical well-being. Acute stress response of the body is associated with activation of various organ systems, resulting in the release of cortisol and catecholamines. Acute stress response subsides on the resolution of the precipitating stimulus. The persistence of the precipitating stimulus results in chronic stress and burn-out. Longitudinal studies have shown that chronic stress can result in both mental and physical health outcomes. The mental health outcomes include depression, anxiety, post-traumatic stress disorder, substance use disorder etc. The physical health outcomes include effects on multiple organ systems. It is, therefore, essential to identify and rectify the precipitating factors to minimize the impact of stress on the human body. [Psychiatr Ann. 2024;54(10):e272–e276.]

Psychotic symptoms can occur in mood disorders, both major depression and bipolar. The most common psychotic symptoms include hallucinations and delusions. A hallmark of psychosis in mood disorders is the presence of mood congruence. For depression, psychosis can consist of delusions of guilt and poverty, nihilism, or hallucinations that denigrate the person, remind them of failures, and encourage them to hurt themselves. Conversely, manic symptoms are often associated with grandiosity and inflated self-esteem of delusional magnitude. Sometimes, psychotic symptoms can be fleeting, trauma-based or due to substance use, all instances that careful interview can uncover. Diagnostic considerations focus on the differentiation of mood disorders from psychotic disorders such as schizophrenia, and anxiety/trauma-related disorders, given the impact on treatment selection and prognosis. Cognitive-behavioral therapy for psychosis has shown efficacy in treatment. From a pharmacological perspective, mono-therapy (antidepressant, antipsychotic, mood stabilizers) can be very effective though many patients end up on composite regimens. [Psychiatr Ann. 2023;53(4):160–165.]

This study used corpus-based methodology to analyze what, if any, differences exist in the linguistic complexity of EdD and PhD dissertations in Educational Leadership. The study is conceptually framed around language variation within discipline and genre. The corpus created for this study, DISSCORP, was comprised of 200 dissertations, 100 EdD and 100 PhD, completed in educational leadership in 2017 and 2018 randomly selected from ProQuest. The syntactic complexity and lexical richness of the two sub-corpora were compared through multiple statistical measures. Adding to the growing body of research on the EdD and PhD, this study found no significant differences between the EdD and PhD dissertations in linguistic complexity. Since the two degrees are equal in complexity, and prior research has found few if any content differences, this researcher ultimately concludes that merging the two terminal degrees into one professional doctorate in Educational Leadership is the best solution to end the confusion surrounding the two degrees.

Diabetes is an increasing problem worldwide and is placing increasing strain on the healthcare system. It often goes undiagnosed for many years until complications occur. Identifying undiagnosed disease presents a challenge to all healthcare professionals. In the UK, screening has traditionally been the role of general practitioners, although other professionals such as pharmacists have recently become involved. Optometrists may also be in a good position to carry out screening tests themselves. Their role in screening for diabetes has not been previously investigated. The first part of the thesis takes a qualitative approach to explore optometrists’ perceptions, attitudes and beliefs about diabetes and screening for the disease. It demonstrated that if certain barriers, such as cost and training, can be overcome, some optometrists are willing to carry out screening tests. It also raises issues regarding their professional roles and their relationship with other healthcare providers. The second part of the thesis describes the development and implementation of a screening scheme using random capillary blood glucose (rCBG) tests. Over three-quarters of eligible adults participated in the screening. We found that around one third (318) of those had a rCBG level requiring further investigation. Half of these people reported attending their GP and receiving further investigation. 16 (5%) were subsequently diagnosed with either diabetes or pre-diabetes. Those who participated in the screening programme found the test procedure to be comfortable, convenient and would recommend it to others. Analyses of strategies to identify those most at risk who would benefit from screening suggest that offering rCBG tests to those who are aged over 40 years with either a BMI of 25kg/m2 or more, or a family history of diabetes or both, would be effective for detection purposes. This research confirmed the feasibility of testing for diabetes in optometry practices and opens the door for another, PCT-based, study. This novel approach has never been tried before.