text:
Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports
- Jerome Melton
- 2 years ago
- Views:
1 open access Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports Jennita Reefhuis, 1 Owen Devine, 1 Jan M Friedman, 2 Carol Louik, 3 Margaret A Honein 1 1 National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA 2 Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada 3 Slone Epidemiology Center at Boston University, Boston, MA, USA Correspondence to: J Reefhuis Additional material is published online only. To view please visit the journal online (http://dx.doi. org/ /bmj.h3190) Cite this as: BMJ 2015;350:h3190 doi: /bmj.h3190 Accepted: 29 May 2015 ABSTRACT Objective To follow up on previously reported associations between periconceptional use of selective serotonin reuptake inhibitors (SSRIs) and specific birth defects using an expanded dataset from the National Birth Defects Prevention Study. Design Bayesian analysis combining results from independent published analyses with data from a multicenter population based case-control study of birth defects. Setting 10 centers in the United States. Participants mothers of infants with birth defects and 9857 mothers of infants without birth defects, identified through birth certificates or birth hospitals, with estimated dates of delivery between 1997 and Exposures Citalopram, escitalopram, fluoxetine, paroxetine, or sertraline use in the month before through the third month of pregnancy. Posterior odds ratio estimates were adjusted to account for maternal race/ethnicity, education, smoking, and prepregnancy obesity. Main outcome measure 14 birth defects categories that had associations with SSRIs reported in the literature. Results Sertraline was the most commonly reported SSRI, but none of the five previously reported birth defects associations with sertraline was confirmed. For nine previously reported associations between maternal SSRI use and birth defect in infants, findings were consistent with no association. High posterior odds ratios excluding the null value were observed for five birth defects with paroxetine (anencephaly 3.2, 95% credible interval 1.6 to 6.2; atrial septal defects 1.8, 1.1 to 3.0; right ventricular outflow tract obstruction defects 2.4, 1.4 to 3.9; gastroschisis 2.5, 1.2 to 4.8; What is already known on this topic Selective serotonin reuptake inhibitors (SSRIs) are increasingly used by women of reproductive age and during pregnancy However, inconsistent reports on the association with birth defects have limited opportunities for clinicians to carefully evaluate the risk compared with benefit of specific SSRIs during pregnancy What this study adds This study combined summarized results from published literature with data from the National Birth Defects Prevention Study using bayesian analysis It showed consistent results for 7 of 21 evaluated associations between specific SSRIs and birth defects and omphalocele 3.5, 1.3 to 8.0) and for two defects with fluoxetine (right ventricular outflow tract obstruction defects 2.0, 1.4 to 3.1 and craniosynostosis 1.9, 1.1 to 3.0). Conclusions These data provide reassuring evidence for some SSRIs but suggest that some birth defects occur times more frequently among the infants of women treated with paroxetine or fluoxetine early in pregnancy. Introduction The association between maternal use of antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), during pregnancy and birth defects in the infants has been the topic of much discussion in recent years. After initial reports of an association between paroxetine and heart defects, the US Food and Drug Administration published an advisory warning of this potential association in December Recent meta-analyses and systematic reviews combining data from more than 20 epidemiological studies have reached conflicting conclusions and this uncertainty influences perceptions of the safety of antidepressant use in pregnancy. 2 3 In a recent study, 69% of women thought that it was definitely or probably acceptable to take such drugs when not pregnant or breast feeding, but only 33% of women thought that it was definitely or probably acceptable to do so when pregnant. 4 SSRIs are increasingly used by women of reproductive age and during pregnancy, but the inconsistent reports have limited opportunities for clinicians to carefully evaluate the risk compared with benefit of specific SSRIs for a given patient during pregnancy. 5-7 We reviewed the literature for any reports that assessed the relation between specific SSRIs and one or more of the specific birth defects that are also included in the US National Birth Defects Prevention Study (NBDPS) To provide a more robust estimate of the association between individual SSRIs and birth defects, information that is necessary for decision making by patients who are being treated with these drugs and their physicians, we used bayesian methods both to summarize independent findings identified in the literature and to update those findings using the entire set of data from the NBDPS. 14 Methods Study population For this analysis we used data from the NBDPS, a population based case-control study of birth defects. The study s methods have been described previously Briefly, cases of birth defects were identified through birth defects surveillance systems in the US states of Arkansas, California, Georgia, Iowa, Massachusetts, the bmj BMJ 2015;350:h3190 doi: /bmj.h3190 1
2 New Jersey, New York, North Carolina, Texas, and Utah. could be live born, stillborn, or induced abortions with one of over 30 major birth defects. The NBDPS excluded cases with known chromosomal or monogenic disorders. Unmatched liveborn controls from the same geographical region and time period were selected from birth certificates or birth hospital records. More cases than controls were included overall because the study was designed for the assessment of individual defects, where controls, which were the same for all case groups, outnumbered even the largest case group. Mothers were asked to participate in a telephone interview in English or Spanish between six weeks and two years after the estimated date of delivery. For this analysis we included cases and controls if they were born on or after 1 October 1997 and had an estimated date of delivery on or before 31 December Overall participation was 67.4% for cases and 64.8% for controls. A previous NBDPS analysis of the association between SSRI use during pregnancy and birth defects, included in table 1 as Alwan and colleagues, included data from 1997 to To avoid double counting, these NBDPS data were excluded from the meta-analyses used to calculate prior odds ratios in the current study, but we used significant findings from the previous analysis along with those of the other studies listed in table 1 to determine which birth defect-ssri combinations to assess. Because of the strong association between diabetes and birth defects, we excluded case and control mothers who reported pregestational diabetes (type 1 or type 2). 18 We also excluded mothers who reported the use of any of the following known teratogenic treatments: misoprostol, methotrexate, mycophenolate mofetil, thalidomide, or isotretinoin. 19 SSRI use During the interview for the NBDPS, no specific question addressed depression. Mothers were asked if they had any illnesses other than the ones already discussed (for example, hypertension or diabetes) and whether they took any medication for the illness. Women could report depression here, which would then be followed by a question about any medications taken for the illness. There were also specific medication related questions: between three months before conception and [the baby s] date of birth, did you take any of the following medications? Prozac? Paxil? Zoloft? Celexa? There was no specific question for Lexapro. For this analysis, we considered women exposed if they reported taking citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) at least once in the period from one month before conception through the third month of pregnancy. Women who reported taking more than one type of SSRI were only included in the multiple SSRI category. We considered women as unexposed if they did not take any antidepressants in the period from three months before to the end of the pregnancy and did not report any depression, anxiety, bipolar disorder, or obsessive compulsive disorder. Women who did not answer all medication related questions, used SSRIs in a period other than the period of interest, or took antidepressants other than SSRIs (for example, bupropion and venlafaxine) were excluded. Birth defects The NBDPS includes over 30 categories of major birth defects. After ascertainment in population based surveillance systems, the diagnostic information was Table 1 Previous studies that assessed use of individual selective serotonin reuptake inhibitors (SSRIs) during early pregnancy in mother and individual birth defects in infant Authors Study design Alwan et al Case-control (subset of current study) / comparison group Liveborn infants without major defects Louik et al Case-control Non-malformed infants Bakker et al Case-control Fetuses and children with chromosomal or single gene disorder Kornum et al Cohort Children of women without SSRI prescription Reis and Kallen Cohort Children of women without antidepressant use Malm et al Cohort Children of women without SSRI prescription reimbursements Population Included birth years SSRIs 10 sites in USA Fluoxetine, Boston, Philadelphia, Toronto, San Diego, New York State Population based birth defects registry in Northern Netherlands Citalopram, fluoxetine, Birth defect categories assessed All defects, with at least three exposed All defects Paroxetine Heart defects categories Northern Denmark Citalopram, escitalopram, fluoxetine, Sweden Citalopram, fluoxetine, Finland Citalopram, escitalopram, fluoxetine, Septal heart defects Hypospadias All defects Included confounders Race/ethnicity, obesity, smoking, income Maternal age, race/ethnicity, education, year of last menstrual period, study center, smoking, alcohol, family history, body mass index, parity, seizures, diabetes, infertility, hypertension, folic acid use Year of birth Smoking, age, birth order, birth year Year of birth, age, parity, smoking and body mass index Age, parity, year of birth, marital status, smoking, other psychiatric medicines, diabetes 2 doi: /bmj.h3190 BMJ 2015;350:h3190 the bmj
3 the bmj BMJ 2015;350:h3190 doi: /bmj.h3190 reviewed by clinical geneticists at each site to establish eligibility. Designated individual clinical geneticists reviewed all cases with a particular defect to ensure consistency across sites. 16 Because the primary intent of this analysis was to assess previously reported associations with SSRIs and to determine if those associations were supported by NBDPS data, we included only outcomes with at least one previous report in the peer reviewed literature suggesting a possible association with SSRIs: neural tube defects (international classification of diseases, ninth revision (ICD-9): ), anencephaly (ICD-9: 740), all septal defects (ICD-9: 745), ventricular septal defects (ICD-9: 745.4), right ventricular outflow tract obstructions (ICD-9: ), cleft palate (ICD-9: 749.0), cleft lip with or without cleft palate (ICD-9: ), esophageal atresia (ICD-9: 750.3), anal atresia (ICD-9: ), hypospadias (ICD- 9:752.6), any limb reduction defect (ICD-9: 755.2), craniosynostosis (ICD-9: 756.0), gastroschisis (ICD-9: ), and omphalocele (ICD-9: ). Some defects reported in other studies (for example, cystic kidney) could not be evaluated in this analysis because they were not included in NBDPS. 13 Development of priors A bayesian approach requires specification of prior distributions for each of the variables in the model used to estimate the potential association between risk of birth defect and use of SSRIs. These prior distributions are probabilistic summaries of beliefs about the true values of the unknown variables before assessment of new data. The bayesian approach allowed us to incorporate existing information on the association between each SSRI and the birth defect outcome of interest. Prior distributions were developed based on literature review. A systematic review identified six studies published before 2010 that had available specific information on SSRI-birth defect combinations (table 1) We created categories of birth defects based on those reports, which corresponded as closely as possible to the NBDPS birth defect categories (table 1) The approach used to summarize the information presented in these publications for each of the SSRI-birth defect combinations of interest depended on the number of available studies; to avoid duplication of cases in the current analysis, we did not include the results from the earlier NBDPS analysis. 8 If one published assessment was only available, then the prior distribution for the log of the odds ratio relating the birth defect and use of SSRIs was assumed to be normal, with a mean given by the log odds ratio estimate reported in the study and variance defined using the corresponding reported confidence interval. If two or more studies were identified, we used bayesian meta-analysis methods to summarize the results. The goal of the meta-analysis was to produce an estimate of the log odds ratio relating the specific birth defect and SSRI across studies, taking into account the study specific estimates and their associated sampling errors. The assumed meta-analysis model included a term corresponding to the true underlying log odds ratio relating SSRI use and risk of birth defects and a collection of random study level effects. 20 All available information was included in developing the meta-analysis based prior estimates, including results indicating no association between risk of birth defects and SSRI use from other published studies. If no information other than the previous NBDPS analysis 8 was identified, then we assumed the log odds ratio relating birth defects and SSRI use to have a noninformative prior distribution, defined using a normal distribution with mean zero and a variance of Using this non-informative prior places virtually the entire weight in developing the bayesian estimates on the information contained in the full NBDPS data. An alternative approach to this analysis would be to develop estimates of the association between SSRI consumption and risk of birth defects using frequentist methods only focused on the NBDPS data. These results could be summarized and then included as an additional point in a larger meta-analysis of available information. We chose the bayesian approach for two primary reasons. Firstly, we viewed the collection of information summarized by the meta-analysis as the state of current knowledge concerning potential association between SSRIs and risk of birth defects and the NBDPS data as new information available to update that knowledge. This view is consistent with the bayesian updating paradigm as applied in this analysis. In addition, we believe that only utilizing summary values (for example, estimated odds ratios and their standard errors) from the NBDPS data would be an unnecessary sacrifice of information as opposed to utilizing the individual level data informed by the meta-analysis priors. Bayesian analysis We used a bayesian approach to develop estimates for a logistic regression model relating the log odds of a specific defect and the mother s use of SSRIs (see supplementary appendix 1). In addition to a term reflecting the log odds ratio relating birth defects and use of SSRIs, the model also included confounders selected a priori and obtained through the maternal interview: maternal race/ethnicity (non-hispanic white versus other), maternal education (0-12 years versus >12 years), obesity (body mass index <30 versus 30), and smoking (any smoking versus no smoking from one month before to the end of the first trimester). Although prior probabilities for the variable relating birth defect risk and use of SSRIs were developed, we assumed non-informative priors for the odds ratios associated with maternal race/ethnicity, education, obesity, and smoking in the logistic regression model. Posterior estimates for the model variables were developed using Markov Chain Monte Carlo methods. BUGS was used for the bayesian analyses. 21 The primary results presented here were derived using an analysis based only on NBDPS participants who reported values for all the variables used in the logistic regression model. We also conducted sensitivity analyses focused on assessing the impact of not including participants with missing information, including consideration of a potential association between being 3
4 missing and the unknown outcome. This analysis utilized bayesian imputation for missing data both under an assumption that the missing information was missing at random and under plausible assumptions on mechanisms for informative missingness (see supplementary appendix 1). Results A total of women with births between 1997 and 2009 were interviewed for the NBDPS. We excluded women reporting pre-existing diabetes (n=719), known use of teratogenic drugs (n=65), or depression, anxiety, bipolar disorder, or obsessive compulsive disorder but not reporting any antidepressant use (n=30). And, after excluding defects with no previous reported associations with SSRIs, the final analyses included unexposed cases, 659 cases exposed to citalopram, escitalopram, fluoxetine, paroxetine or sertraline, 9559 unexposed controls, and 298 controls that were exposed to one of these SSRIs (figure). Sertraline was the most commonly used SSRI; approximately 40% of control mothers who reported use of an SSRI used sertraline (table 2 ). Although there was some difference in overall SSRI use by state, the distribution of the specific SSRIs was similar across the study sites. There was no difference in the age distribution among SSRI users except for sertraline, which was more often reported among older mothers. Reported use of citalopram and escitalopram started in 2000 and 2002, respectively, and increased over time. Fluoxetine reports decreased over time, but not as much as paroxetine use decreased, and sertraline use stayed relatively constant. There was no difference in the use of the specific SSRIs before or after 1 December 2006, the date the American College of Obstetricians and Gynecologists published their committee opinion on SSRI use in pregnancy In a bayesian analysis of the current NBDPS data that takes into account non-nbdps individual drug-specific birth defect associations previously reported in the literature, no association with maternal use of citalopram or escitalopram monotherapy was found, except for a marginal association between citalopram and neural tube defects (table 3 ). For fluoxetine treatment, associations were seen for ventricular septal defects, right ventricular outflow tract obstruction cardiac defects, and craniosynostosis. Paroxetine had the most previously reported associations, and significant associations were observed for five of the seven defects assessed. Associations between paroxetine and anencephaly, atrial septal defects, and right ventricular outflow tract obstruction cardiac defects found in other studies were confirmed in this independent dataset, and two other associations seen in the previous NBDPS analysis 8 (gastroschisis and omphalocele) were again seen in this analysis. For sertraline, the most commonly used SSRI in our study, the findings for all five defects assessed were not significant. A bayesian analysis using a non-informative prior (that is, assuming there were no previously published studies to help develop an informative prior), and Women interviewed (n=38 009) Excluded (n=814): Pre-existing diabetes (n=719) Teratogenic medications reported (n=65) Reported depression, anxiety, bipolar disorder, or obsessive compulsive disorder but no antidepressants (n=30) No antidepressant use reported (n=34 843) Reported use of antidepressant other than SSRI (n=467) SSRI use reported (n=1624) Unknown or not all medication questions answered (n=261) SSRIs used previous to 1 month before conception or after 1 st trimester Any SSRIs used from one month before conception through 1 st trimester (n=1285) No SSRIs (n=34 843) Citalopram (n=129) Escitalopram (n=112) Fluoxetine (n=331) Paroxetine (n=214) Sertraline (n=440) Multiple SSRIs (n=56) Fluvoxamine (n=3) Exclude cases with defects not included in 6 previously published analyses (n=8316) No SSRIs (n=26 852) Citalopram (n=93) Escitalopram (n=80) Fluoxetine (n=242) Paroxetine (n=165) Sertraline (n=335) Multiple SSRIs (n=42) Fluvoxamine (n=1) (n=17 293) (n=9559) (n=64) (n=29) (n=54) (n=26) (n=168) (n=74) (n=123) (n=42) (n=220) (n=115) (n=30) (n=12) Flow chart of participants through study 4 doi: /bmj.h3190 BMJ 2015;350:h3190 the bmj
5 Table 2 Descriptive statistics of control mothers (n=9857) who reported periconceptional use of selective serotonin reuptake inhibitors (SSRIs), National Birth Defects Prevention Study, No (%) using SSRIs Variables Any SSRIs Citalopram Escitalopram Fluoxetine Paroxetine Sertraline Multiple SSRIs Total 298 (3.0) 29 (9.7) 26 (8.7) 74 (24.8) 42 (14.1) 115 (38.6) 12 (4.0) Study site*: New Jersey 7 (1.2) (14) 3 (43) 3 (43) 0 Texas 17 (1.4) 1 (6) 1 (6) 3 (18) 2 (12) 9 (53) 1 (6) California 24 (2.1) 1 (4) 2 (8) 8 (33) 2 (8) 8 (33) 3 (13) Georgia 23 (2.2) 3 (13) 1 (4) 8 (35) 1 (4) 9 (39) 1 (4) New York 21 (2.5) 2 (10) 1 (5) 4 (19) 5 (24) 8 (38) 1 (5) Arkansas 43 (3.5) 3 (7) 4 (9) 11 (26) 2 (5) 20 (47) 3 (7) North Carolina 28 (3.6) 2 (7) 5 (18) 4 (14) 5 (18) 12 (43) 0 Massachusetts 42 (3.6) 5 (12) 2 (5) 12 (29) 7 (17) 16 (38) 0 Iowa 42 (3.9) 3 (7) 5 (12) 9 (21) 10 (24) 13 (31) 2 (5) Utah 51 (6.1) 9 (18) 5 (10) 14 (27) 5 (10) 17 (33) 1 (2) Maternal age (years): <20 14 (1.4) 2 (14) 0 4 (29) 3 (21) 5 (36) (2.4) 5 (9) 4 (7) 13 (24) 7 (13) 21 (38) 5 (9) (3.0) 6 (7) 5 (6) 23 (28) 14 (17) 31 (38) 2 (2) (4.0) 12 (12) 12 (12) 23 (23) 11 (11) 38 (38) 4 (4) (3.6) 3 (7) 5 (12) 9 (22) 5 (12) 18 (44) 1 (2) 40 5 (3.0) 1 (20) 0 2 (40) 2 (40) 0 0 Maternal race/ethnicity : Hispanic 21 (0.9) 0 1 (5) 8 (38) 3 (14) 8 (38) 1 (5) Non-Hispanic black 13 (1.2) 1 (8) 0 3 (23) 1 (8) 6 (46) 2 (15) Other 15 (2.1) 3 (20) 1 (7) 3 (20) 2 (13) 6 (40) 0 Non-Hispanic white 249 (4.4) 25 (10) 24 (10) 60 (24) 36 (14) 95 (38) 9 (4) Maternal education (years) : (0.8) (25) 1 (25) 2 (50) (2.4) 2 (7) 0 7 (26) 7 (26) 9 (33) 2 (7) (2.8) 3 (5) 6 (9) 21 (32) 9 (14) 24 (36) 3 (5) (3.8) 13 (13) 9 (9) 19 (19) 16 (16) 37 (38) 4 (4) (3.3) 11 (11) 11 (11) 25 (25) 9 (9) 43 (42) 3 (3) Prepregnancy maternal body mass index (kg/m 2 ) : < (1.6) 1 (13) 0 2 (25) 3 (38) 2 (25) (3.2) 13 (8) 14 (9) 41 (25) 24 (15) 65 (40) 5 (3) (3.1) 11 (16) 5 (7) 18 (27) 5 (7) 23 (34) 5 (7) (3.7) 4 (7) 7 (12) 12 (20) 10 (17) 25 (42) 2 (3) Periconceptional maternal smoking: No 215 (2.7) 21 (10) 19 (9) 59 (27) 25 (12) 83 (39) 8 (4) Yes 82 (4.7) 8 (10) 7 (9) 14 (17) 17 (21) 32 (39) 4 (5) Periconceptional maternal alcohol use: No 147 (2.4) 16 (11) 11 (7) 31 (21) 20 (14) 64 (44) 5 (3) Yes 149 (4.2) 13 (9) 14 (9) 42 (28) 22 (15) 51 (34) 7 (5) Year of due date: (2.0) (32) 9 (26) 14 (41) (2.2) 4 (11) 0 14 (39) 5 (14) 11 (31) 2 (6) (2.8) 7 (16) 1 (2) 9 (21) 6 (14) 17 (40) 3 (7) (4.5) 2 (3) 8 (11) 18 (24) 14 (18) 31 (41) 3 (4) (3.1) 5 (10) 8 (15) 13 (25) 6 (12) 19 (37) 1 (2) (3.6) 11 (19) 9 (16) 9 (16) 2 (4) 23 (40) 3 (5) *Sites are statewide for Arkansas, Iowa, and Utah. All other sites are selected regions. Years included: Arkansas , California , Georgia , Iowa , Massachusetts , New Jersey , New York and , North Carolina , Texas , and Utah Variables were recoded to dichotomous categories for adjusted analyses; non-hispanic white versus other, 0-12 years education versus >12 years, body mass index <30 versus 30 kg/m 2. the bmj BMJ 2015;350:h3190 doi: /bmj.h3190 sensitivity analyses using bayesian methods in which missing data for confounders were replaced with imputed values showed similar results for most associations except for the association between citalopram and neural tube defects. The prior for that association was based on one cohort study, which found a higher odds ratio, and our logistic regression analysis without considering this prior study showed no association (see supplementary table). Discussion Using data from the US National Birth Defects Prevention Study (NBDPS), we confirmed previously reported associations between right ventricular outflow tract 5
6 Table 3 Odds ratios and 95% confidence interval, resulting prior odds ratio, and bayesian complete case analysis posterior odds ratio with 95% credible interval, National Birth Defects Prevention Study (NBDPS), Birth defect by SSRI Odds ratio (95% CI) Bakker et al, 9 Kornum Louik et al 11 et al, 10 Reis and Kallen 13 Malm et al 12 Prior odds ratio (95% CI)* Odds ratio (95%CI): Posterior odds ratio (95% Alwan et al 8 CrI): NBDPS Citalopram: Neural tube defects 2.5 (1.2 to 5.1) (n=8) 2.5 (1.2 to 5.1) 1.8 (1.0 to 3.0) (n=5) Ventricular septal defects 1.3 (0.9 to 1.8) (n=36) 1.3 (0.9 to 1.8) 1.3 (0.9 to 1.8) (n=6) Cleft lip with or without cleft 3.2 (0.9 to 11.9) (n=4) 3.2 (0.9 to 11.9) 1.4 (0.7 to 2.7) (n=8) palate Hypospadias 1.9 (0.4 to 8.8) (n=4) 1.3 (0.9 to 1.8) 13 (n=38) 1.3 (0.6 to 2.5) 1.2 (0.7 to 2.0) (n=8) Escitalopram: Septal defects 4.2 (1.0 to 17.1) 10 (n=3) 1.5 (0.7 to 3.0) (n=8) 1.7 (0.7 to 3.7) 1.3 (0.7 to 2.1) (n=11) Fluoxetine: Ventricular septal defects 1.5 (1.0 to 2.2) (n=26) 1.5 (1.0 to 2.2) 1.4 (1.0 to 1.9) (n=16) RVOTO 1.0 (0.2 to 3.4) (n=4) 2.7 (0.9 to 8.5) (n=3) 1.5 (0.6 to 3.6) 0.9 (0.3 to 2.7) (n=4) 2.0 (1.4 to 3.1) (n=27) Esophageal atresia Non-informative prior 2.4 (0.9 to 6.4) (n=5) 1.8 (0.8 to 3.4) (n=10) Craniosynostosis Non-informative prior 2.8 (1.3 to 6.1) (n=10) 1.9 (1.1 to 3.0) (n=21) Paroxetine: Anencephaly Neural tube defect: 3.3 (1.1 to 10.4) (n=4) 3.3 (1.1 to 10.4) 5.1 (1.7 to 15.3) (n=5) 3.2 (1.6 to 6.2) (n=6) Atrial septal defects 5.7 (1.4 to 23.7) 9 (n=3) 1.3 (0.4 to 4.0) (n=3) 1.8 (0.7 to 4.5) 1.8 (1.1 to 3.0) (n=15) RVOTO 3.3 (1.3 to 8.8) (n=6) 5.2 (1.6 to 16.3) (n=3) 3.9 (1.4 to 10.4) 2.5 (1.0 to 6.0) (n=7) 2.4 (1.4 to 3.9) (n=16) Cleft palate 1.5 (0.4 to 5.3) (n=3) 2.7 (1.0 to 7.1) (n=4) 1.7 (0.7 to 4.0) 1.7 (0.6 to 4.8) (n=5) 1.3 (0.7 to 2.3) (n=10) Hypospadias 1.0 (0.3 to 3.3) (n=3) 2.5 (1.1 to 4.6) 13 (n=9) 1.6 (0.6 to 3.4) 0.6 (0.2 to 2.4) (n=3) 1.1 (0.6 to 1.9) (n=9) Gastroschisis Non-informative prior 2.9 (1.0 to 8.4) (n=5) 2.5 (1.2 to 4.8) (n=13) Omphalocele Non-informative prior 8.1 (3.1 to 20.8) (n=6) 3.5 (1.3 to 8.0) (n=6) Sertraline: Anencephaly 0.8 (0.1 to 6.3) (n=1) 0.8 (0.1 to 6.3) 3.2 (1.1 to 9.3) (n=4) 1.2 (0.5 to 2.5) (n=7) Septal defects 2.0 (1.2 to 4.0) (n=13) 3.3 (1.5 to 7.5) 10 (n=6) 0.5 (0.2 to 1.3) (n=5) 1.5 (0.6 to 2.9) 0.7 (0.3 to 1.5) (n=10) 1.0 (0.8 to 1.4) (n=47) Anal atresia 4.4 (1.2 to 16.4) (n=3) 4.4 (1.2 to 16.4) 0.7 (0.2 to 2.8) (n=4) 1.4 (0.8 to 2.3) (n=11) Any limb reduction 3.9 (1.1 to 13.5) (n=3) 3.9 (1.1 to 13.5) Transverse: 1.2 (0.4 to 4.0) (n=3) 1.2 (0.7 to 2.0) (n=13) Omphalocele 5.7 (1.6 to 20.7) (n=3) 5.7 (1.6 to 20.7) 1.5 (0.4 to 6.6) (n=3) 1.4 (0.7 to 2.8) (n=4) SSRI=selective serotonin reuptake inhibitor; RVOTO=right ventricular outflow tract obstruction cardiac defects. Adjusted for maternal race/ethnicity, maternal education, obesity, and smoking. *Priors are only based on studies described in first three column and exclude Alwan et al. 8 No informative prior was calculated if the only available data were from Alwan et al, but this association was reported in that earlier analysis using a subset of NBDPS data. Ventricular septal defect. 6 doi: /bmj.h3190 BMJ 2015;350:h3190 the bmj
7 the bmj BMJ 2015;350:h3190 doi: /bmj.h3190 obstruction cardiac defects in infants and maternal use of fluoxetine 12 or paroxetine early in pregnancy, and between anencephaly 8 11 or atrial septal defects 9 in infants and maternal use of paroxetine. This analysis also confirmed associations between gastroschisis or omphalocele and paroxetine and between craniosynostosis and fluoxetine that were reported in the analysis of an earlier subset of NBDPS data; 8 however, these still require corroboration in an independent data source. It is reassuring that none of the five previously reported associations between sertraline and birth defects were confirmed in this analysis, particularly since about 40% of women reporting use of an SSRI in early pregnancy used sertraline. In addition, we did not find support for nine other previously reported associations between maternal SSRI treatment and selected birth defects in the child. Although our analysis strongly supports the validity of the associations that were observed, the increase in the absolute risks, if the associations are causal, is small. The two strongest posterior odds ratios were seen for maternal paroxetine treatment and anencephaly (3.2) or right ventricular outflow tract obstruction cardiac defects (2.4) in the infant. If these associations are causal, the absolute risks in the children of women who are treated with paroxetine early in pregnancy would increase for anencephaly from 2 per to 7 per , and for right ventricular outflow tract obstruction cardiac defects from 10 per to 24 per The absolute risks for these birth defects are still low. This analysis confirms the need to assess the association between specific SSRIs and specific birth defects rather than combining an entire drug class or heterogeneous group of birth defects. Although SSRIs are similar pharmacologically, there are chemical differences, and if any of them do have teratogenic activity, it may be completely unrelated to the inhibition of serotonin receptors. SSRIs also differ pharmacokinetically, 26 and this could account for differences in teratogenic activity, whether or not the mechanism involved inhibition of serotonin receptors. 27 Limitations of this study This analysis does not address whether the birth defect associations we observed were caused by maternal SSRI treatment, underlying maternal disease, or some other factor. Since there was no specific question on depression and we cannot identify all participants with untreated depression, there is the possibility of confounding by indication. A recent publication by Furu and colleagues combined data from five Nordic countries. 28 Some overlap occurred between the data included in this recent study and the three Nordic studies we included in our meta-analysis, but this study also included data from Norway and Iceland that is not included in our analyses Many of the associations we assessed for septal heart defects and right ventricular outflow tract obstruction cardiac defects showed similar risk estimates in our analysis and the recent study. One clear different finding is the association reported by Furu and colleagues for anal atresia and sertraline that was also reported by Louik and colleagues but is not evident in the NBDPS data Additional limitations of this analysis need to be acknowledged. Periconceptional exposure was based on maternal self report, with interviews conducted six weeks to 24 months after the expected date of delivery. However, Kwon and colleagues reported good concordance between self report of antidepressants and claims data. 29 We made 21 comparisons between exposure and outcome using five different models, and it is possible that some statistically significant findings occurred owing to the occurrence of false positive associations expected with multiple comparisons. 30 Another limitation is that the small numbers for some of the individual birth defects and some of the specific exposures resulted in unstable estimates. Finally, exposure ascertainment is known to be more complete when women are specifically asked about their use of drugs by name; 31 the interview did not include a specific question about use of escitalopram. Strengths of this study This analysis also has some important strengths. The bayesian analysis enabled consideration of evidence both for and against an association between use of SSRIs and risk of birth defects from previous epidemiological studies in the analyses and used relatively homogenous and discrete classes of birth defects and SSRI monotherapy. As a result, our study provides strong evidence for the reproducibility and validity of the associations that were observed. The sensitivity assessment showed that missing data were unlikely to have affected the results. The association between SSRIs and heart defects is biologically plausible; Sadler 27 has suggested that the association may be a result of the key role that the neurotransmitter serotonin (5-hydroxytryptamine) plays in embryonic development of the heart. A major advantage of this analysis over some previous reports is the ability to assess individual SSRIs and individual birth defects, while accounting for earlier reported associations. Although the data are self reported, they do represent reported use of the medications and not just filling of the prescription. Approximately 30% of mothers stop taking SSRIs during pregnancy, 32 and this might not be captured if we relied on prescription information or medical records, since prescriptions might have been filled but not taken after the pregnancy was recognized. We have previously used NBDPS data to show that antidepressant prescription patterns have changed over time, 5 making it more challenging to study these associations. Our analyses of a large population based case- control dataset combined with prior odds ratios based on the literature allowed us to show and refine associations between maternal fluoxetine or paroxetine treatment during pregnancy and right ventricular outflow tract obstruction cardiac defects and between maternal use 7
8 of paroxetine and anencephaly or atrial septal defects. In contrast, we found no evidence to support 14 other previously reported associations between maternal SSRI use and birth defects. Continued scrutiny of the association between SSRIs and birth defects is warranted, and additional studies of specific SSRI treatments during pregnancy and birth defects are needed to enable women and their healthcare providers to make more informed decisions about treatment. Meanwhile, the current analysis can help guide healthcare providers and women to the safest options for treatment during early pregnancy to minimize the risk of major birth defects, while providing adequate treatment of maternal depression. We thank Tiffany Colarusso and Jennifer Lind for their valuable contributions to this paper. Coding of drug information in the National Birth Defects Prevention Study used the Slone Drug Dictionary under license from the Slone Epidemiology Center of Boston University. Contributors: JR designed the study, did the frequentist data analyses, and wrote the first draft of the manuscript. She is the guarantor. OD performed the bayesian statistical analyses and revised the drafted manuscript. JMF, CL, and MAH provided epidemiological feedback on initial data tables and revised the drafts. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding: Data collection was funded by the US Centers for Disease Control and Prevention. Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: This study was approved by the institutional review board of the Centers for Disease Control and Prevention and all participating sites. Data sharing: Previous publications with a subset of this data: Alwan S, Reefhuis J, Rasmussen SA, et al. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med 2007;356: and Alwan S, Reefhuis J, Rasmussen SA, et al. Patterns of antidepressant medication use among pregnant women in a United States population. J Clin Pharmacol 2011;51: Transparency: The leader author (JR) hereby affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: by-nc/4.0/. 1 FDA. FDA advising of risk of birth defects with paxil www. fda.gov/newsevents/newsroom/pressannouncements/2005/ ucm htm 2 Gentile S. Selective serotonin reuptake inhibitor exposure during early pregnancy and the risk of birth defects. Acta Psychiatr Scand 2011;123: Wurst KE, Poole C, Ephross SA, et al. First trimester paroxetine use and the prevalence of congenital, specifically cardiac, defects: a meta-analysis of epidemiological studies. Birth Defects Res A Clin Mol Teratol 2010;88: Goodman JH. Women s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth 2009;36: Alwan S, Reefhuis J, Rasmussen SA, et al. Patterns of antidepressant medication use among pregnant women in a United States population. J Clin Pharmacol 2011;51: Huybrechts KF, Palmsten K, Mogun H, et al. National trends in antidepressant medication treatment among publicly insured pregnant women. Gen Hosp Psychiatry 2013;35: Tinker SC, Broussard CS, Frey MT, et al. Prevalence of prescription medication use among non-pregnant women of childbearing age and pregnant women in the United States: NHANES, Matern Child Health J 2015;19: Alwan S, Reefhuis J, Rasmussen SA, et al. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med 2007;356: Bakker MK, Kerstjens-Frederikse WS, Buys CH, et al. First-trimester use of paroxetine and congenital heart defects: a population-based case-control study. Birth Defects Res A Clin Mol Teratol 2010;88: Kornum JB, Nielsen RB, Pedersen L, et al. Use of selective serotoninreuptake inhibitors during early pregnancy and risk of congenital malformations: updated analysis. Clin Epidemiol 2010;2: Louik C, Lin AE, Werler MM, et al. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med 2007;356: Malm H, Artama M, Gissler M, et al. Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstet Gynecol 2011;118: Reis M, Kallen B. Delivery outcome after maternal use of antidepressant drugs in pregnancy: an update using Swedish data. Psychol Med 2010;40: Gelman A, Shalizi CR. Philosophy and the practice of Bayesian statistics. Br J Math Stat Psychol 2013;66: Yoon PW, Rasmussen SA, Lynberg MC, et al. The National Birth Defects Prevention Study. Public Health Rep 2001;116(Suppl 1): Rasmussen SA, Olney RS, Holmes LB, et al. Guidelines for case classification for the National Birth Defects Prevention Study. Birth Defect Res A Clin Mol Teratol 2003;67: Reefhuis J, Gilboa SM, Anderka M, et al. The national birth defects prevention study: a review of the methods. Birth Defect Res A Clin Mol Teratol 2015; published online 2 Jun. 18 Correa A, Gilboa SM, Besser LM, et al. Diabetes mellitus and birth defects. Am J Obstet Gynecol 2008;199:237 e Obican S, Scialli AR. Teratogenic exposures. Am J Med Genet Part C 2011;157C: Sutton AJ, Abrams KR. Bayesian methods in meta-analysis and evidence synthesis. Stat Methods Med Res 2001;10: Lunn D, Jackson C, Best N, et al. The BUGS book: a practical introduction to Bayesian analysis, CRC Press, Abuhamad AZ. ACOG Practice Bulletin, clinical management guidelines for obstetrician-gynecologists number 98, October 2008 (replaces Practice Bulletin No 58, Dec 2004). Ultrasonography in pregnancy. Obstet Gynecol 2008;112: Practice ACoO. ACOG committee opinion No 354: treatment with selective serotonin reuptake inhibitors during pregnancy. Obstet Gynecol 2006;108: Parker SE, Mai CT, Canfield MA, et al. Updated national birth prevalence estimates for selected birth defects in the United States, Birth Defects Res A Clin Mol Teratol 2010;88: Bedard T, Lowry RB, Sibbald B, et al. Folic acid fortification and the birth prevalence of congenital heart defect cases in Alberta, Canada. Birth Defects Res A Clin Mol Teratol 2013;97: Edwards JG, Anderson I. Systematic review and guide to selection of selective serotonin reuptake inhibitors. Drugs 1999;57: Sadler TW. Selective serotonin reuptake inhibitors (SSRIs) and heart defects: potential mechanisms for the observed associations. Reprod Toxicol 2011;32: Furu K, Kieler H, Haglund B, et al. Selective serotonin reuptake inhibitors and venlafaxine in early pregnancy and risk of birth defects: population based cohort study and sibling design. BMJ 2015;350:h Kwon A, Bungay KM, Pei Y, et al. Antidepressant use: concordance between self-report and claims records. Med Care 2003;41: Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology 1990;1: Mitchell AA, Cottler LB, Shapiro S. Effect of questionnaire design on recall of drug exposure in pregnancy. Am J Epidemiol 1986;123: Reefhuis J, Rasmussen SA, Friedman JM. Selective serotonin-reuptake inhibitors and persistent pulmonary hypertension of the newborn. N Engl J Med 2006;354: ; author reply BMJ Publishing Group Ltd 2015 Appendix table: Odds ratios for associations between selected SSRIs and birth defects using different statistical methods Appendix: statistical methods No commercial reuse: See rights and reprints Subscribe:
Maternal Exposure to Venlafaxine (Effexor ) and Risk for Birth Defects. Kara Duwe, Sonja Rasmussen, Carol Louik, Carla van Bennekom,
s p Maternal Exposure to Venlafaxine (Effexor ) and Risk for Birth Defects Kara Duwe, Sonja Rasmussen, Carol Louik, Carla van Bennekom, Tiffany Colarusso, Jennita Reefhuis August 17, 2011 Disclaimer TheMore information
Antidepressants in Pregnancy D R S N E H A P A R G H I
Antidepressants in Pregnancy D R S N E H A P A R G H I Overview Depression and its effects Antidepressants and their effects Birth defects Miscarriage Neonatal withdrawal Longterm consequences BreastfeedingMore information
Facts about Cleft Palate (CP) 1994-2004, Arizona
1994-2004, Arizona Arizona Birth Defects Monitoring Program (ABDMP) 150 N. 18th Ave, Suite 550 Phoenix, AZ 85007-3248 Phone: 602-364-1302 Fax: 602-542-7447 E-mail: firstname.lastname@example.com Definition and Types CleftMore information
Preconception Clinical Care for Women Medical Conditions
Preconception Clinical Care for Women All women of reproductive age are candidates for preconception care; however, preconception care must be tailored to meet the needs of the individual. Given that preconceptionMore information
A BS TR AC T. Background The risk of birth defects after antenatal exposure to selective serotonin-reuptake inhibitors (SSRIs) remains controversial.
The new england journal of medicine established in 1812 june 28, 2007 vol. 356 no. 26 First-Trimester Use of Selective Serotonin-Reuptake Inhibitors and the Risk of Birth Defects Carol Louik, Sc.D., AngelaMore information
MAJOR DEPRESSION DURING CONCEPTION AND PREGNANCY: A Guide for Patients and Families
MAJOR DEPRESSION DURING CONCEPTION AND PREGNANCY: A Guide for Patients and Families David A. Kahn, MD, Margaret L. Moline, PhD, Ruth W. Ross, MA, Lee S. Cohen, MD, and Lori L. Altshuler, MD www.womensmentalhealth.orgMore information
Principals of Birth Defects Surveillance
Principals of Birth Defects Surveillance Hani K. Atrash, MD, MPH Associate Director for Program Development National Center on Birth Defects and Developmental Disabilities Centers for Disease control andMore information
Diabetes and Birth Defects
Diabetes and Birth Defects Adolfo Correa, MD, PhD National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention 1 st Central and Eastern European Summit onMore information
Algorithm for Initiating Antidepressant Therapy in Depression
Algorithm for Initiating Antidepressant Therapy in Depression Refer for psychotherapy if patient preference or add cognitive behavioural office skills to antidepressant medication Moderate to Severe depressionMore information
The Patterns and Public Health Impact of Heart Defects in Texas Pediatric Cardiac Care Conference VI Dell Children s Medical Center, Feb.
The Patterns and Public Health Impact of Heart Defects in Texas Pediatric Cardiac Care Conference VI Dell Children s Medical Center, Feb. 7-8, 2013 Mark Canfield, Ph.D. Manager, Birth Defects EpidemiologyMore information
Methodology for Safety Surveillance of Adverse Events Following Vaccination During Pregnancy
Methodology for Safety Surveillance of Adverse Events Following Vaccination During Pregnancy C. Jouquelet-Royer September 2012 Fondation Merieux NAME OF PRESENTATION 1 Presentation Outline Background CompanyMore information
Table. List of Currently Reportable Birth Defects and the Corresponding ICD-9-CM and ICD-10-CM Codes
Addendum 4: List of Notifiable conditions and ICD9/ICD10 Codes BIRTH DEFECTS CASE DEFINITION FOR SURVEILLANCE Case definition Case definition for Washington State Birth Defects Surveillance System is basedMore information
Deepa Singal, PhD Candidate. 1 Manitoba Centre for Health Policy
Childhood Neurodevelopmental, Heath & Educational Outcomes of Children Exposed to Antidepressants and Maternal Depression During Pregnancy Study Protocol Deepa Singal, PhD Candidate 1 Manitoba Centre forMore information
Population prevalence rates of birth defects: a data management and epidemiological perspective
Population prevalence rates of birth defects: a data management and epidemiological perspective Merilyn Riley Abstract The Victorian Birth Defects Register (VBDR) is a population-based surveillance systemMore information
Birth Defects Monitoring in Japan -Possible Effects of Environmental Endocrine Disrupters-
Birth Defects Monitoring in Japan -Possible Effects of Environmental Endocrine Disrupters- Fumiki Hirahara Yokohama City University School of Medicine Thank you, Paul. It is my great pleasure to be hereMore information
TOOL KIT FOR THE MANAGEMENT OF ADULT POSTPARTUM DEPRESSION TOOL KIT FOR THE MANAGEMENT OF ADULT POSTPARTUM DEPRESSION The clinical tool kit is intended to assist the PCP in assessing the postpartum needsMore information
Tool Kit for Postnatal Depression Management
Tool Kit for Postnatal Depression Management Tool Kit for the Management of Adult Postnatal Depression The clinical tool kit is intended to assist the PCP in assessing the postnatal needs of women regardingMore information
Antidepressants and suicidal thoughts and behaviour. Pharmacovigilance Working Party. January 2008
Antidepressants and suicidal thoughts and behaviour Pharmacovigilance Working Party January 2008 PhVWP PAR January 2008 Page 1/15 1. Introduction The Pharmacovigilance Working Party has on a number ofMore information
Safety of Antidepressants in Pregnancy and Breastfeeding
Safety of Antidepressants in Pregnancy and Breastfeeding Exceptional healthcare, personally delivered Background Depression and anxiety disorders are common during pregnancy, affecting nearly one in everyMore information
POSTPARTUM DEPRESSION: A Guide for Patients and Families
POSTPARTUM DEPRESSION: A Guide for Patients and Families Margaret L. Moline, PhD, David A. Kahn, MD, Ruth W. Ross, MA, Lori L. Altshuler, MD, and Lee S. Cohen, MD www.womensmentalhealth.org The birth ofMore information
Espen Jimenez-Solem. ATC Anatomical Therapeutic Chemical Classification System
PHD THESIS DANISH MEDICAL JOURNAL - Espen Jimenez-Solem This review has been accepted as a thesis together with three previously published papers by University of Copenhagen on 6th September 2013 and defendedMore information
What are the best treatments?
What are the best treatments? Description of Condition Depression is a common medical condition with a lifetime prevalence in the United States of 15% among adults. Symptoms include feelings of sadness,More information
Medication Management of Depressive Disorders in Children and Adolescents. Satya Tata, M.D. Kansas University Medical Center
Medication Management of Depressive Disorders in Children and Adolescents Satya Tata, M.D. Kansas University Medical Center First Line Medications SSRIs Prozac (Fluoxetine): 5-605 mg Zoloft (Sertraline):More information
Taking SSRI Antidepressants During Pregnancy: Considerations and Risks
Taking SSRI Antidepressants During Pregnancy: Considerations and Risks For pregnant women or women contemplating pregnancy, reading literature about depression, pregnancy and medication often leaves themMore information
MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES Division for Vital Records and Health Statistics Michigan Birth Defects Registry
MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES Division for Vital Records and Health Statistics Michigan Birth Defects Registry BIRTH DEFECTS IN MICHIGAN All Cases Reported and Processed by April 30, 2014More information
Can folic acid protect against congenital heart defects in Down syndrome?
Chapter 4 Can folic acid protect against congenital heart defects in Down syndrome? Willemijn M Meijer Martha M Werler Carol Louik Sonia Hernandez-Diaz Lolkje TW de Jong-van den Berg Allen A Mitchell BirthMore information
Assisted reproductive technology and major structural birth defects in the United States
Human Reproduction pp. 1 7, 2008 Hum. Reprod. Advance Access published November 16, 2008 doi:10.1093/humrep/den387 Assisted reproductive technology and major structural birth defects in the United StatesMore information
Big data size isn t enough! Irene Petersen, PhD Primary Care & Population Health
Big data size isn t enough! Irene Petersen, PhD Primary Care & Population Health Introduction Reader (Statistics and Epidemiology) Research team epidemiologists/statisticians/phd students Primary careMore information
Chapter 3: Healthy Start Risk Screening
Introduction Healthy Start legislation requires that all pregnant women and infants be offered screening for risk factors that may affect their pregnancy, health, or development. The prenatal and infantMore information
Popular Depression Medications A Helpful Guide to Antidepressant Drugs POPULAR DEPRESSION MEDICATIONS A Helpful Guide to Antidepressant Drugs Popular Depression Medications A Helpful Guide to AntidepressantMore information
Motor Vehicle Injuries
Motor Vehicle Injuries Prenatal Counseling about Seat Belt Use during Pregnancy and Injuries from Car Crashes during Pregnancy Background The CDC has identified prevention of motor vehicle injuries asMore information
Maternal Smoking and the Risk of Congenital Birth Defects: A Cohort Study
ORIGINAL ARTICLES Maternal Smoking and the Risk of Congenital Birth Defects: A Cohort Study Scott E. Woods MD, MPH, MEd, and Uma Raju, MD Background: The literature linking gestational smoking to congenitalMore information
For the full report please visit the Victorian Birth Defects Register Website:
Summary of ten most frequently reported birth defects in Victoria 2003-2004 The Victorian Birth Defects Register has collected information on birth defects in all reported pregnancies occurring in VictoriaMore information
BIRTH DEFECTS IN MICHIGAN All Cases Reported and Processed by April 15, 2008
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH Division for Vital Records and Health Statistics MICHIGAN BIRTH DEFECTS SURVEILLANCE REGISTRY BIRTH DEFECTS IN MICHIGAN All Cases Reported and Processed by AprilMore information
Medicines for Treating Depression. A Review of the Research for Adults
Medicines for Treating Depression A Review of the Research for Adults Is This Information Right for Me? Yes, if: A doctor or other health care professional has told you that you have depression. Your doctorMore information
Ana M. Viamonte Ros, M.D., M.P.H. State Surgeon General
Florida Department of Health Division of Disease Control Bureau of Epidemiology Chronic Disease Epidemiology Section Charlie Crist Governor Ana M. Viamonte Ros, M.D., M.P.H. State Surgeon General FloridaMore information
49. INFANT MORTALITY RATE. Infant mortality rate is defined as the death of an infant before his or her first birthday.
49. INFANT MORTALITY RATE Wing Tam (Alice) Jennifer Cheng Stat 157 course project More Risk in Everyday Life Risk Meter LIKELIHOOD of exposure to hazardous levels Low Medium High Consequences: Severity,More information
NBDPN Guidelines for Conducting Birth Defects Surveillance rev. 06/04. Chapter 5 Classification and Coding
Chapter 5 Classification and Coding Table Contents 5.1 Introduction... 5-1 5.2 Disease Classification Systems... 5-2 5.2.1 Description and Format... 5-2 5.2.2 ICD-9-CM and the 6-digit CDC Code A Comparison...More information
Birth Defects in Kettleman City
Birth Defects in Kettleman City One in every 33 babies is born with a birth defect, including structural defects, metabolic disorders, and some types of developmental disabilities. For this reason, CaliforniaMore information
Monitoring Infants and Children with Special Health Needs
Monitoring Infants and Children with Special Health Needs Birth Defects Prevalence and Mortality in Michigan, 1992-2008 A report prepared by Michigan Department of Community Health Bureau of Disease Control,More information
Case-Control Studies. Sukon Kanchanaraksa, PhD Johns Hopkins University
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on thisMore information
Case: 3:14-cv-00870-jdp Document #: 14-9 Filed: 01/07/15 Page 1 of 6 APPENDIX 8
Case: 3:14-cv-00870-jdp Document #: 14-9 Filed: 01/07/15 Page 1 of 6 APPENDIX 8 Case: 3:14-cv-00870-jdp Document #: 14-9 Filed: 01/07/15 Page 2 of 6 AMERICAN MEDICAL ASSOCIATION Pregnant women will beMore information
Overview of Mental Health Medication Trends
America s State of Mind Report is a Medco Health Solutions, Inc. analysis examining trends in the utilization of mental health related medications among the insured population. The research reviewed prescriptionMore information
Facts about Diabetes in Massachusetts
Facts about Diabetes in Massachusetts Diabetes is a disease in which the body does not produce or properly use insulin (a hormone used to convert sugar, starches, and other food into the energy neededMore information
Obesity and hypertension among collegeeducated black women in the United States
Journal of Human Hypertension (1999) 13, 237 241 1999 Stockton Press. All rights reserved 0950-9240/99 $12.00 http://www.stockton-press.co.uk/jhh ORIGINAL ARTICLE Obesity and hypertension among collegeeducatedMore information
FACILITATOR/MENTOR GUIDE Descriptive analysis variables table shells hypotheses Measures of association methods design justify analytic assess calculate analysis problem stratify confounding statisticalMore information
Renal cell carcinoma and body composition:
Renal cell carcinoma and body composition: Results from a case-control control study Ryan P. Theis, MPH Department of Epidemiology and Biostatistics College of Public Health and Health Professions UniversityMore information
Controversy: Is IVF Associated with Increased Rate of Birth Defect
Controversy: Is IVF Associated with Increased Rate of Birth Defect R 5 謝佳琳 In Vitro Fertilization as Associated with an Increase in Major Birth Defects Christine K. Olson, M.D Division of ReproductiveMore information
Diabetes. Prevalence. in New York State
Adult Diabetes Prevalence in New York State Diabetes Prevention and Control Program Bureau of Chronic Disease Evaluation and Research New York State Department of Health Authors: Bureau of Chronic DiseaseMore information
Occurrence of Congenital Heart Defects in Relation to Maternal Multivitamin Use
American Journal of Epidemiology Copyright by The Johns Hopkins University School of Hygiene and Public Health All rights reserved Vol., 9 Printed in U.S.A. ORIGINAL CONTRIBUTIONS Occurrence of CongenitalMore information
Pregnant and Parenting Youth in Foster Care in Washington State: Comparison to Other Teens and Young Women who Gave Birth
January 2014 RDA Report 11.202 Olympia, Washington Pregnant and Parenting in Care in Washington State: Comparison to Other and Women who Gave Birth Laurie Cawthon, MD, MPH Barbara Lucenko, PhD Peter Woodcox,More information
Parental Recreational Drug Use and Risk for Neural Tube Defects
American Journal Epidemiology Copyright O 1996 by The Johns Hopkins University School Hygiene and PubBc Health All rights reserved Vol 144, No. 12 Printed In U S.A Parental Recreational Drug Use and RiskMore information
Recognition and Treatment of Depression in Parkinson s Disease
Recognition and Treatment of Depression in Parkinson s Disease Web Ross VA Pacific Islands Health Care System What is depression? Depression is a serious medical condition that affects a person s feelings,More information
Wendy Martinez, MPH, CPH County of San Diego, Maternal, Child & Adolescent Health
Wendy Martinez, MPH, CPH County of San Diego, Maternal, Child & Adolescent Health Describe local trends in birth Identify 3 perinatal health problems Identify 3 leading causes of infant death Age ClassMore information
Clinical Policy Title: Home uterine activity monitoring
Clinical Policy Title: Home uterine activity monitoring Clinical Policy Number: 12.01.01 Effective Date: August 19, 2015 Initial Review Date: July 17, 2013 Most Recent Review Date: July 15, 2015 Next ReviewMore information
A Strategic Plan for Improving Preconception Health and Health Care: Recommendations from the CDC Select Panel on Preconception Care
1 A Strategic Plan for Improving Preconception Health and Health Care: Recommendations from the CDC Select Panel on Preconception Care Presentation by Kay A. Johnson, MPH, EdM Research Assistant Professor,More information
Depression during pregnancy and lactation. Hedvig Nordeng Marte Jettestad
Depression during pregnancy and lactation Hedvig Nordeng Marte Jettestad Recommendations Depression should be treated, because untreated disease could itself have major negative consequences for the motherMore information
Chapter 6 Case Ascertainment Methods
Chapter 6 Case Ascertainment Methods Table of Contents 6.1 Introduction...6-1 6.2 Terminology...6-2 6.3 General Surveillance Development...6-4 6.3.1 Plan and Document... 6-4 6.3.2 Identify Data Sources...More information
Disclosures Christer Allgulander
How Patients With Generalized Anxiety Disorder (GAD) Are Treated in Specialized Care: A Pharmacoepidemiological Case Register Study in Sweden Christer Allgulander MD, Karolinska Institutet, Sweden JanMore information
MONITORING, SERVICES AND PREVENTION OF BIRTH DEFECTS IN MINNESOTA: THE MINNESOTA BIRTH DEFECTS MONITORING AND ANALYSIS PROGRAM Barbara Frohnert, MPH Epidemiologist Kristin Peterson Oehlke, MS, CGC GeneticMore information
OET: Listening Part A: Influenza
Listening Test Part B Time allowed: 23 minutes In this part, you will hear a talk on critical illnesses due to A/H1N1 influenza in pregnant and postpartum women, given by a medical researcher. You willMore information
Newborn Screening for Critical Congenital Heart Disease: CDC Activities
Newborn Screening for Critical Congenital Heart Disease: CDC Activities Stuart K. Shapira, MD, PhD Associate Director for Science Chief Medical Officer National Center on Birth Defects and DevelopmentalMore information
Outcome and future of children born after ART. M. Aboulghar Professor, Cairo University Clinical Director, The Egyptian IVF center
Outcome and future of children born after ART M. Aboulghar Professor, Cairo University Clinical Director, The Egyptian IVF center Possible effects on the babies could be from 1. Prematurity and multipleMore information
Drug and Alcohol Dependence
Drug and Alcohol Dependence 109 (2010) 243 247 Contents lists available at ScienceDirect Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep Short communication CharacteristicsMore information
BORN Ontario: Clinical Reports Hospitals Part 1 May 2012
BORN Ontario: Clinical Reports Hospitals Part 1 May 2012 Hospital Reports Release dates Report types Use and interpretation Access Questions and Answers 2 Clinical Reports Release Dates Available in theMore information
Additional information and program contacts on population-based birth defects surveillance programs are available on page S122.
STATE BIRTH DEFECTS SURVEILLANCE PROGRAM DATA S Major Birth Defects Data from Population-based Birth Defects Surveillance Programs in the United States, - Updated August Prepared by the National CenterMore information
Appendix G STATISTICAL METHODS INFECTIOUS METHODS STATISTICAL ROADMAP. Prepared in Support of: CDC/NCEH Cross Sectional Assessment Study.
Appendix G STATISTICAL METHODS INFECTIOUS METHODS STATISTICAL ROADMAP Prepared in Support of: CDC/NCEH Cross Sectional Assessment Study Prepared by: Centers for Disease Control and Prevention NationalMore information
AUSTRALIA AND NEW ZEALAND FACTSHEET What is Stillbirth? In Australia and New Zealand, stillbirth is the death of a baby before or during birth, from the 20 th week of pregnancy onwards, or 400 grams birthweight.More information
TITLE: Cannabinoids for the Treatment of Post-Traumatic Stress Disorder: A Review of the Clinical Effectiveness and Guidelines
TITLE: Cannabinoids for the Treatment of Post-Traumatic Stress Disorder: A Review of the Clinical Effectiveness and Guidelines DATE: 01 December 2009 CONTEXT AND POLICY ISSUES: Post-traumatic stress disorderMore information
All Patient Refined DRGs (APR-DRGs) An Overview. Presented by Treo Solutions
All Patient Refined DRGs (APR-DRGs) An Overview Presented by Treo Solutions Presentation Highlights History of inpatient classification systems APR-DRGs: what they are, how they work, and why they areMore information
ANTIDEPRESSANT MEDICINES. A GUIDE for ADULTS With DEPRESSION
ANTIDEPRESSANT MEDICINES A GUIDE for ADULTS With DEPRESSION August 2007 FAST FACTS ON ANTIDEPRESSANTS The antidepressants in this guide work for treating depression. Most people can find one that makesMore information
Contra Costa County Fetal Infant Mortality Review Program
Contra Costa County Fetal Infant Mortality Review Program Suzzette C. Johnson, MSW MPA Sylvia V. Taqi-Eddin, MA-CP Family, Maternal and Child Health Programs Contra Costa Health Services National NFIMRMore information
Post traumatic Stress Associated with Cancer
Post traumatic Stress Associated with Cancer BCCA Survivorship Forum June 8, 2016 Alan Bates, MD, PhD, FRCPC Provincial Practice Leader for Psychiatry BC Cancer Agency None Disclosures AcknowledgmentsMore information
The Health and Well-being of the Aboriginal Population in British Columbia
The Health and Well-being of the Aboriginal Population in British Columbia Interim Update February 27 Table of Contents Terminology...1 Health Status of Aboriginal People in BC... 2 Challenges in VitalMore information
DEPRESSION DURING THE TRANSITION TO MENOPAUSE: A Guide for Patients and Families
DEPRESSION DURING THE TRANSITION TO MENOPAUSE: A Guide for Patients and Families David A. Kahn, MD, Margaret L. Moline, PhD, Ruth W. Ross, MA, Lori L. Altshuler, MD, and Lee S. Cohen, MD www.womensmentalhealth.orgMore information
Maternal overweight and obesity and risk of congenital heart defects in offspring
City University of New York (CUNY) CUNY Academic Works Publications and Research CUNY School of Public Health January 2014 Maternal overweight and obesity and risk of congenital heart defects in offspringMore information
About the Lactation Consultant Education Program
About the Lactation Consultant Education Program Oklahoma State University-Oklahoma City (OSU-OKC) offers continuing education courses that encourage participants to customize their self-directed studyMore information
Prenatal screening and diagnostic tests
Prenatal screening and diagnostic tests Contents Introduction 3 First trimester routine tests in the mother 3 Testing for health conditions in the baby 4 Why would you have a prenatal test? 6 What areMore information
Birth defects. Report by the Secretariat
EXECUTIVE BOARD EB126/10 126th Session 3 December 2009 Provisional agenda item 4.7 Birth defects Report by the Secretariat 1. In May 2009 the Executive Board at its 125th session considered an agenda itemMore information
Partner Engagement Overview: NCBDDD Strategic Plan 2010
Partner Engagement Overview: NCBDDD Strategic Plan 2010 National Center on Birth Defects and Developmental Disabilities December15, 2010 National Center on Birth Defects and Developmental DisabilitiesMore information
The following is a sample of psychotropic drug warnings that drug regulatory agencies
Chronology of International Drug Regulatory Agency Warnings about Psychotropic Drugs The following is a sample of psychotropic drug warnings that drug regulatory agencies around the world have issued.More information
FAA EXPERIENCE WITH NEUROPSYCHOLOGICAL TESTING FOR AIRMEN WITH DEPRESSION ON SSRI MEDICATIONS Presented to: 2013 Aerospace Medical Association Annual Scientific Meeting By: James R. DeVoll, M.D. Date:More information
Family History, Inheritance, and Breast Cancer Risk
Cornell University Program on Breast Cancer and Environmental Risk Factors in New York State (BCERF) July 2003 Family History, Inheritance, and Breast Cancer Risk All breast cancer results from multipleMore information
Pre-pregnancy Binge Drinking and Postpartum Depression. In Oklahoma: Introduction:
OKLAHOMA PREGNANCY RISK ASSESSMENT MONITORING SYSTEM VOL 17 NO 1 SUMMER 2013 Pre-pregnancy Binge Drinking and Postpartum Depression Introduction: The National Institute on Alcohol Abuse and AlcoholismMore information
Infant Mortality in California
Infant Mortality in California Michael Curtis, PhD Jennifer Troyan, MPH Nannie Song, MPH Carrie Florez, MPH Maternal, Child and Adolescent Health Division Center for Family Health Overview Data sourcesMore information
Genetic Aspects of Mental Retardation and Developmental Disabilities
Prepared by: Chahira Kozma, MD Associate Professor of Pediatrics Medical Director/DCHRP email@example.com email@example.com Genetic Aspects of Mental Retardation and Developmental DisabilitiesMore information
Randomized trials versus observational studies
Randomized trials versus observational studies The case of postmenopausal hormone therapy and heart disease Miguel Hernán Harvard School of Public Health www.hsph.harvard.edu/causal Joint work with JamesMore information
MOH CLINICAL PRACTICE GUIDELINES 6/2011 DEPRESSION Executive summary of recommendations Details of recommendations can be found in the main text at the pages indicated. Clinical evaluation D The basicMore information
SIXTY-THIRD WORLD HEALTH ASSEMBLY A63/10 Provisional agenda item April Birth defects. Report by the Secretariat
SIXTY-THIRD WORLD HEALTH ASSEMBLY A63/10 Provisional agenda item 11.7 1 April 2010 Birth defects Report by the Secretariat 1. The report aims to inform the discussion on birth defects, including definition,More information
Welcome. How Do I Ask Questions? Agenda. Thank you for joining us today. The webinar will begin in a few moments.
Welcome How Do I Ask Questions? Thank you for joining us today. The webinar will begin in a few moments. If you are experiencing technical problems with the GoToWebinar program, contact the GoToWebinarMore information
Meena Abraham, DrPH, MPH Director of Epidemiology Services Baltimore City Health Department
Meena Abraham, DrPH, MPH Director of Epidemiology Services Baltimore City Health Department 271 Neighborhood Statistical Areas 55 Community Statistical Areas 26 Zip Codes Characteristic Baltimore CityMore information
Depression. Medicines To Help You
Medicines To Help You Depression Use this guide to help you talk to your doctor, pharmacist, or nurse about your medicines for depression. The guide lists all of the FDA-approved products now availableMore information
Psychopharmacotherapy for Children and Adolescents
TREATMENT GUIDELINES Psychopharmacotherapy for Children and Adolescents Guideline 7 Psychopharmacotherapy for Children and Adolescents Description There are few controlled trials to guide practitionersMore information
Trimethoprim use in early pregnancy and the risk of miscarriage: a register-based nationwide cohort study
Epidemiol. Infect., Page I of 7. Cambridge University Press 2012 doi:io.1017is0950268812002178 Trimethoprim use in early pregnancy and the risk of miscarriage: a register-based nationwide cohort studyMore information
Confounding in health research
Confounding in health research Part 1: Definition and conceptual issues Madhukar Pai, MD, PhD Assistant Professor of Epidemiology McGill University email@example.com 1 Why is confounding so importantMore information
Texas Mandated Benefit Cost and Utilization Summary Report. October 2005 - September 2006 Reporting Period. Texas Department of Insurance
Texas Mandated Benefit Cost and Utilization Summary Report October 2005 - September 2006 Reporting Period Texas Department of Insurance Table of Contents Executive Summary.. 1 Survey Overview..... 5 Legislation...........More information
Focus: Children and Youth With Special Health Care Needs (CYSHCN) Children & Youth With Developmental Delays
Focus: Children and Youth With Special Health Care Needs (CYSHCN) Children & Youth With Developmental Delays "The early years of a child's life are crucial for cognitive, social and emotional development.More information
Preconception Health: Physician Practices in Ontario
Preconception Health: Physician Practices in Ontario A collaborative project of Best Start Resource Centre and Motherisk. 2009 The Best Start Resource Centre thanks you for your interest in and supportMore information
UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Health Savings Account (HSA) Plan 7PD of Educators Benefit Services, Inc. Enrolling Group Number: 717578More information


text:
Find a copy in the library
Finding libraries that hold this item...
|Document Type:
|Musical Score
|Music Type:
|Chansons, polyphonic; Madrigals; Motets
|All Authors / Contributors:
Martin Picker; Thomasin K LaMay; Jane M Bowers; Margaret, of Austria Regent of the Netherlands; Paola Massarenghi; Caterina Assandra
|OCLC Number:
|Language Note:
|French, Italian, or Latin words.
|The 1st work for 3 voices, unacc.; the 2nd work for 5 voices, unacc.; the 3rd work for 3 voices and continuo.
Includes program and biographical notes in English, and texts with English translations.
|1 score ([v], 14 pages) ; 28 cm
|Se je souspire/Ecce iterum / Margaret of Austria ; Martin Picker, editor --
Quando spiega / Paola Massarenghi ; Thomasin LaMay, editor --
O dulcis amor Jesu / Caterina Assandra ; Jane Bowers, editor ; basso continuo realized by Peter Wolf.
|by Margaret of Austria, Paola Massarenghi, Caterina Assandra ; edited by Martin Picker, Thomasin LaMay, Jane Bowers.
User-contributed reviews
Similar Items
Related Subjects:(6)
- Polyphonic chansons.
- Part songs.
- Madrigals, Italian.
- Motets.
- Sacred trios with continuo.
- Part songs, Sacred.

subset: commoncrawl


text:
Season's Greetings!
December 4th, 2010 Leave a comment Go to comments
Hi everyone, to celebrate the season, it's now snowing at Cory's Story! Even if you live somewhere warm, you can enjoy the snowflakes (just as long as you visit us every now and then!).
Warmest wishes for you and your family, from all of us at Cory's Story.
Canine Epilepsy: An Owner's Guide to Understanding & Living with Canine Seizures
This guide will help you and your canine companion deal with canine epilepsy. You'll learn how to detect symptoms of an upcoming seizure, treat during and after a seizure, and prevent future seizures.
Ready to read Cory's Story? Read Chapter 1 Now.
Categories: Uncategorized


text:
What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
Why am I not receiving my form submissions for the Americas Request Form?Asked by LindaMuscatell on April 05, 2016 at 09:35 AM
At the end of last year and beginning of this year I ran into a problem where I stopped receiving form submissions from the Americas Marketing Request Form (http://form.jotform.us/form/50364160294148). I'm not sure how the problem was fixed but later in January it starting working again. I seem to be having this same issue again now. I currently have a notification email set up for 5 people in my group to receive the submissions. 3 of those people are receiving it and 2 of us are not (me - email@example.com and email@example.com). The other 3 people are receiving the emails notifications. Can you please look into this for me?
JotForm Support
I just checked our logs and can only find the form submissions sent to firstname.lastname@example.com on February 19 then the latest one which is a test made today. There are no logs for firstname.lastname@example.com email.
Please do the following then test the form again by submitting an actual data:
1. In the Advance Settings of the Notifier, uncheck the "Attach PDF" option
2. In the same settings, change your sender email to email@example.com
If this works, try to check the Attach PDF again leaving email@example.com as the sender email. Test it and see if it works on all emails.
Please note that the Attach PDF will only work if you are using email@example.com or the firstname.lastname@example.com.


text:
The Eastern Maine Class B boys basketball championship has been largely the personal domain of Kennebec Valley Athletic Conference schools for more than a decade. Not since Hermon won the 2000 regional title has a team from the rival Big East Conference represented the East in the Class B state …
Guidelines for posting on bangordailynews.com
The Bangor Daily News encourages comments about stories, but you must follow our terms of service.
- Keep it civil and stay on topic
- No vulgarity, racial slurs, name-calling or personal attacks.
- People who harass others or joke about tragedies will be blocked.
It should be noted this is not a comprehensive list.
- Don't insult one another or the subjects of BDN stories. You may be ticked off at what someone did or said, but you can explain that without resorting to name-calling or obscenity. Remember that young people are on this site too.
- That nasty line that makes your buddies go "haw, haw"? You're better than that.
- Comments should be your own work, not copied and pasted from elsewhere, though brief quoted passages to make your point are fine. And please don't use all capital letters. There's no need to shout.
- Stay focused on the issue in the article. Off-topic posts will be deleted.
- This isn't a forum to chat about your personal life.
- Some ideas — the fate of the earth, abortion, gun control, the nature of God — aren't going to be resolved in a reader forum, so no need to get frustrated if others don't see your point of view. State your position once and leave it at that.
- If you mouse over each comment you will see a "Flag" button. Please use it if you feel comments on the site are out of line. Quite often, we won't see a comment until it's reported.
- Questions about why a comment was — or wasn't — deleted? E-mail us at firstname.lastname@example.com and let us know your username and where you posted or saw the comment.


text:
TastelessC... Clothing Designer
Blaze StarreModel Female Union, New Hampshire, US
Boston, Massachusetts, US
Portland, Maine, US
My Website: Blaze Starre's Facebook PageMy MM URL: http://www.modelmayhem.com/blaze_starre
Mayhem # 2672475
About MeI have alot of experience in all the genres I selected as well as a few others. I would like to eventually find a reputable agency to sign with. I came to Model Mayhem to meet new people exchange ideas and of course to work, work, work. Send me a detailed message if your interested in my look.... Look Forward To Working With You....
P.S. I will travel within reason though if it is more than an hours drive I would ask paid travel... Gas prices are outragious!!! Thank you ahead of time
Have you worked with Blaze Starre? Add Credits for Blaze Starre! >>
TastelessC... Clothing Designer
HQ Retouch Retoucher
Rodger Lodgepole Model
INVOKE Photographer
JT Kennedy Photographer
David Stasiak Photographer
Loading Content


text:
Five reasons why we should study Primates
What is an a priori prediction?
true or false: Correlation equals causation
How do primates serve as an UMBRELLA in conservation?
How often do Orangutangs give birth? How important is each individual member?
What is the most likely way that Platrryhines entered the New World(central and south America)?
All darts hit one area, but not on the dart board.
All darts hit the same area and on the dart board.
All darts hit the dart board but in different areas.
The darts do not hit the dart board and are all over the place.
True or False: The size of brains is all primates are the same.
True or false: Under a comparative study we can uncover broad primate behavior patterns.
What is evolutionary Ecology?
What does it mean when we say science is empirical based, impartial, and falsifiable?
This type of plant grows in the tropics. It starts out as an epiphyte that grow downward into the soil and eventually engulf the host tree, which dies.
Which of the following is not a generalized characteristic of primates?
A. Prehensile Tail
B. Shortened snout
C. Underdeveloped olfaction
D. Eyes rotated forwards
True or False: Plant Masting(plants giving nuts all at once) is related to El Nino(warming of the ocean).
Which of the following is NOT a characteristic of Prosimii?(lemurs, lorises, galagos)
A. wet nose
B. tooth comb
C. grooming claw
D. post orbital enclosure
Explain in a few words what zoochory is.
In terms of seed dispersal, Anemochory serves as what kind of mechanism?
Do all primates have grasping hands and feet? Opposable thumbs?
What are the benefits from having eyes rotated forward in primates?
true or false: Anthropoides have wet noses and longer snouts.
Where in world can you find Catarrhini?
Where in the world can you find Platarrhini?
True or false: Catarrhini(Old world monkeys) have the dental formula 2123?
True or false: Cercopithecoidea have bilophodant molars while Hominoidea have Y-5 Molars
What are leaf eaters in Africa called? Taxonomy
What are the leaf eaters called that can be found in Asia?
What does the primary diet of red leaf monkeys(Maroon Langur) consist of? (think about it.......) Also, what is their primary mating/social system?
What are the five families that can be found in the superfamily Hominoidea?
What Families make up the great apes and where can we find them in the world?
True or False: Primates live in the tropics
What are the Six defining traits of the tropical rainforest?
What are Epiphytes?
in terms of seed dispersal, what does Barochory do?
What is Hydrochory?
Explain what phenology is?
Why is the preservation of non-human primates important for ecology?
List and describe 4 out of the 7 discussed characteristics:
T/F: Primates generally have longer lives compared to other mammals?
T/F: Haplorrhines have a reflective layer behind the retina called the tapetum lucidum?
Large primates generally have larger groups than smaller primates
Among the Hominoidea, which species is the most sexually dimorphic?
What are the 4 reasons we should study primates?
what is an umberalla species?
T/F: all scientif measurements have associated error
TRUE/FALSE? More efficient travelers should leave patches more quickly.
True or False? A new item of a primates diet is added if it is LOWER in net energy than the net energy of the normal diet.
TRUE//FALSE? Optimal Foraging theory assumes that animals forage in a way to maximize their E/T(Net rate of energy uptake)
TRUE/FALSE? According to the diet breadth model Feeding and Searching are mutually exclusive.
In an environment with ____ _____Patches, the primate will spend LESS time per patch. (HIGH/LOW QUALITY)
true/false: Sumatra in general, has much more food available then Borneo.
When do climbers (trees that attach onto other trees) become an important food source in relation to the forest type of trees that mast?
What are the four ways that seeds can be dispersed?
what are the 3 characteristics that Primates have that distinguish them from other animals? (derived traits away from mammals)
Do folivores thrive in peat swamps? yes/no
In the context of seed dispersal systems, what does hydrochory mean?
True/false: New world monkeys and old world monkeys share a common dentition formula
What are 2 differences between the primates in the infraorders platyrrhini and catarrhini (OWM vs NWM)
According to the geographical definition, the tropics can be defined as all of the following except: A) 23°N to 23°S of the equator
B) Between the Tropic of Cancer and the Tropic of Capricorn
C) Having an average temperature above 64°F
D) A cold place
E) Having variable rainfall, although usually averaging 100mm of rain each month
True/False: Primates have a short juvenile period compared to other mammals
What are some advantages of forward-facing eyes?
Describe the various ways in which seeds can be dispersed and how animals, such as primates, contribute to the process.
In what range are the tropics found in? A. Near the Equator
B. Above the Tropic of Cancer (23* 27' N)
C. Between (23* 27' N) and (23* 27' S)
D. Above Tropic of Capricorn (23* 27' S)
Which of these is not a form of seed dispersal?
a. Anemochory
b. Hydrochory
c. Biochory
d. Barochory
e. Zoochory
Which of the following characteristic(s) describe primates within the infraorder Catarrhini?
a. are located within the Asian and African continents
b. have a 2133 dental formula
c. have narrow nostrils
d. both b and c
e. both a and c
What is one characteristic of tropical forests?
a. Rich soil
b. Very poor soil
c. little diversity
d. well studied
Which of the following is NOT a characteristic of a primate?
a) stereoscopic vision
b) post-orbital closure
c) pentadactyl
d) tactile pads on the toes and fingers
e) complex brain
true/false: The crown of a tree includes roots.
What two primate species are the closest relative to humans?
Which of the following are common characteristics of the primates in the suborder Anthropoidea?
A: Smaller noses, All nails, and post orbital closure
B: Dry noses, tooth comb, and all nails
C: Smaller noses, post orbital closure, and grooming claw
D: Dry noses, no tooth comb, and longer snouts
The poor soil quality in peat swamp forests has driven some plant species to invest heavily in herbivory defense mechanisms. This is one of the reasons that peat swamps are described as _______ quality habitats.
a. high
b. low
c. average
True or false: Hemiepiphyte plant species are always parasitic.
Anthropoids are divided into two categories: ____________ , which include New World Monkeys, and _____________ , which includes Old World Monkeys.
True or false:
Anemochory is the dispersal of seeds by gravity, while barochory is the dispersal of seeds by wind.
True or False?
The Bornean white-bearded gibbon is socially polygamous and subsists primarily as a folivore.
True or false: The rain forest's alarming disappearance due to the desire of agricultural growth results in a higher crop yield for farmers because of the rain forests abundance of rich soil.
True or False:
There are no exceptions to the Jarman-Bell Principle.
Species adapt to processing ______ rather than preferred foods.
T/F: Staple fallback foods are utilized only during a period of fruit scarcity but which never comprise 100% of the diet.
Name one vitamin that is water soluble:
T/F: Plant secondary compounds (i.e. tannins) are involved in plant metabolism, growth and reproduction.
What is an example of a plant secondary compound? What is its function?
What are the 2 components of primate food?
Leaf monkeys have teeth with __________, specialized for chewing leaves
a) low, rounded cusps (for grinding)
b) high, sharp cusps, with thin enamel
c) high, sharp cusps, with thick enamel
e) sharp incisors
What aspect of the gut is especially important for digesting gums?
What is the purpose for secondary compounds in plants?
Which of the following is a bad source of primate food consumption?
A) Macronutrients
B) Toxins
C) Micronutrients
D) Digestion inhibitors
E) Both B and D
What is Zoochory?
What are three main sources of protein for primates?
Thin molar enamel and high cusps are characteristic of what kind of eater?
a. Leaf
b. Insect
c. Gum
d. Fruit
What is 1 characteristic of gum eaters?
What are leaf eating primate's guts characterized by?
Smaller primates can handle toxins better than larger primates. Why?
A primate's digestive tract is primarily influenced by its (preferred food/fallback food)
Plants want to deter animals from eating
A. leaves
B. seeds
C. fruit
D. all of the above
E. A and B Plants want to deter animals from eating
A. leaves
B. seeds
C. fruit
D. all of the above
E. A and B
T/F Is there such a thing as a 100% frugiverous monkey?
Short answer: What are fallback foods?
What polysaccharides are used for structural functions?
A. Chitin
B. Starch
C. Cellulose
D. A and C
E. B and C
In relation to the Jarman-Bell Principle, explain why an insect-eating primate would more likely be found as a solitary animal in comparison to a grass-eating primate. (SHORT ANSWER)
Why are primate species adapted for processing their fallback foods and not their preferred foods?
A. There are more toxins in fallback foods that primates need to be able to process.
B. Historically, their fallback foods used to be their preferred foods.
C. Typically, preferred foods are easy to process and do not require specialized processing abilities.
D. Both A and C.
Fill in the Blank:
_________ (Rarely/Commonly) found in mature leaves, unripe fruits, and seeds, ________ (toxins/tannins/anti-feedants), are metabolically cheap and will _______ (reduce/increase) digestibility
Which of the following is not a fat-soluble vitamin that primates need to acquire from their diet?
A. Vitamin E
B. Vitamin B
C. Vitamin K
D. Vitamin A
T/F species are specially adapted to processing preferred foods.
What is the purpose of tannins in plant matter, and how do they function? (short answer)
Why are primates specialized to consume fallback foods, rather than preferred ones?
What is the difference between micronutrients and macronutrients?
True or False
Colobine monkeys are known to be aggressive relative to other primate species.
What is an example of a micronutrient?
A. grass
B. collagen
C. vitamin A
D. sunlight
Which of the following tooth adaptations differ between folivores and frugivores?
a. Shearing crest height.
b. Molar enamel thickness.
c. Both lack incisors.
d. A and B only
What kind of individuals survive "crunch" periods (periods of resource scarcity).
What kind of individuals survive "crunch" periods (periods of resource scarcity).
Sharp incisors and sharp cusps corresponds to which of the following:
A) Frugivores
B) Folivores
C) Insectivores
T/F: More efficient travelers should leave patches more quickly.
True or False.
A new item is added to a diet if the net energy of the new item is less than the net energy of the average diet.
True or False: An item that is abundant in an environment is going to be consumed by a primate.
What is optimality theory? (short answer)
Name at least 2 of the marginal value theorem assumptions.
**** True or False:
The maximum benefit to cost ratio occurs when the benefit curve and the cost curve intersect.
Fill in the blank:
Foragers should________ when the environment is unproductive and ________ when environment is productive.
According to the Marginal Value Theorem, patch residence time depends on patch ____ and patch ____.
True/False: It is an assumption of the marginal value theorem that within a prey type, handling and search time are constants.
According to the diet breadth model, a new prey item can be added into an existing diet, as long as:
a. Net energy sustains daily life
b. Search time is less than the search time of normal prey
c. Net energy of new item is equal or greater than net energy of normal items
d. a & b
A low search time and high handling time results in foragers abiding by a _ diet.
What are some reasons why many studies on primate feeding selectivity were limited? (short answer)
Explain when an individual should be a generalist and when an individual should be a specialist. (SHORT ANSWER)
What factors does patch residence time depend on?
Created by Stephanie Vasque over 3 years ago


text:
Patricia Benner
From Novice to Expert
Dorothea Orem's
Self-Care Deficit Theory
Madeleine Leininger
Cultural Care Theory
Nursing Theories
Dorothea Orem
Self-Care Deficit Theory
Patricia Benner
From Novice to Expert
Madeleine Leininger Cultural Care Theory
A Comparison Between:
Nursing is such a complex profession that it is only through lived experience that we gain expertise. Expertise is when we act on intuition rather than concrete reasoning
A Star Wars Comparison
A Baby Comparison
Relationship Between the Elements
Benner's Nursing Levels of Experience
Knowledge Level
Method of Thought
Key Points
Orem's Concepts
Healthy Individual
Maintain Good Physical and Mental Health
Maintain Health and Well-Being
Prevent Illness or Accident
Care for Minor Ailments and Long-Term Conditions
Meet Social and Psychological Needs
the nurse accomplishes ALL of the patient's self-care, as well as, supports & protects the patient
Partly Compensatory
Nursing Systems
the nurse assists the patient as required, compensates for the self-care limitation
the patient regulates self-care agency through performance of their own self-care
the patient accomplishes self-care while the nurse helps them to exercise and develop of self-care agency
There is a Need for Nursing When:
Self-Care Deficit
Ability to Meet Demand
Conceptual Framework
Key Points
Wholly Compensatory
Nurses must be able to recognize and interpret cultural differences in values and beliefs
Instead of
Seeing everyone as the same
The core of nursing is caring. This sets it apart from other professions
Fail to meet cultural care needs = less patient satisfaction = longer recovery time
Care must be
Cultural awareness is NOT always conducive to
a conceptual guide that represents factors to be considered in relation to the theory principles and the area of analysis
The Sunrise Model
Most general information during assessment of individual or group
insider (indigenous) views & values of a phenomenon
outsider views & values of a phenomenon
incorporate both into basic nursing care practices
The decisions made and actions taken should allow for preservation/maintenance, accommodation/negotiation, and/or repatterning/restructuring of culture care
All concepts together form
"assist, support, facilitate or enable individuals or groups to maintain or regain their health or well-being in a culturally meaningful and beneficial ways, or to help individuals face handicaps or deaths"
Culture is the background of Benner's theory
Culture is the central focus of Leininger's theory
Implicit knowledge is used by both:
Leininger differentiates between curing and caring
Benner differentiates between illness and disease
ILLNESS in Benner's theory relates to CARING in Leininger's theory
DISEASE to Benner relates to CURING to Leininger
Both are not logically constructed
Orem's theory
logically constructed,
Benner's is
Orem only describes patient-based information as relevant
Benner describes features of nurses and their experience
Benner is
Orem is
Orem is
Benner is
Leininger is
Orem neglects to incorporate culture whereas it
is the of Leininger's theory
Leininger is all about CULTURE to influence health experience
Orem is all about SELF-CARE to return to optimal state
experience of care
Orem focuses on
of care
BOTH believe
understanding a
person's culture is
required to provide
Leininger expects nurses to have knowledge of all cultures for culturally congruent care. In reality culture is defined differently by each person & it is unrealistic to expect each nurse know how to provide care accordingly
Application to Practice
Since Benner based her theory on observation of nurses in the clinical setting, it clearly defines the reality of practice
Nursing is more than JUST focusing on the deficit or the disease. Orem's theory is shallow in not considering any aspect of the patient other than their deficits, therefore, it is not reflective of actual practice
Comparison of Benner & Leininger
Orem & Leininger
Both focus on Patient Care
Comparison between
Orem & Benner
found within
our written
Cultural and social structure dimensions are the factors that influence health; those that are assessed vary according to the situation
Present Remotely
Send the link below via email or IMCopy
Present to your audienceStart remote presentation
- Invited audience members will follow you as you navigate and present
- People invited to a presentation do not need a Prezi account
- This link expires 10 minutes after you close the presentation
- A maximum of 30 users can follow your presentation
- Learn more about this feature in our knowledge base article
Do you really want to delete this prezi?
Neither you, nor the coeditors you shared it with will be able to recover it again.
Make your likes visible on Facebook?
Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.
Nursing Theories
A Comparison of Orem, Benner & Leininger
Karlie Harperon 24 October 2013
Comments (0)
Please log in to add your comment.


text:
Reviewed By Brad B (KIRKSVILLE, MO) Reviewed for a 2011 Ford F-350 —7/10/2017 10:10 PM
I had Wet Okole for my last truck. These are better quality, install far easier and cost 25% less. Crazy...
Reviewed By John S (OVIEDO, FL) Reviewed for a 1999 Ford Expedition —6/22/2017 7:58 AM
I would have given this a 5 star except for two concerns. The bottom seats are cut a little short on the sides so the original seat cover is visible. I have tugged and re-arranged but still a little short on material. Also lacking is a matching cover for the console. Seats and armrests are covered in new material, and right in the middle is the old dingy worn out console....HELLO!


text:
14-year-old Joshua Otieno was one of the best performers at the 2016 KCPE results released on December 1, 2016, by Education CS Fred Matiang'i.
A poor boy from Siaya passed his Kenya Certificate of Secondary Education (KCSE) but his family cannot afford his school fees for high school.
Otieno scored 386 marks from Kakamega Primary School and was selected to join St. Anthony High School, Kitale, Kenya.
Unfortunately, he could not get fees to join school. His parents had separated. His father remained in Siaya and his mother lives in Kakamega town, who has been reported to be a drunkard as she spends most of her time in chang'aa dens in the area.
However, it took the efforts of Joshua's teachers to see him sit for his KCPE exams and also took care of him as his mother did not care.
Joshua had to trek for six nights from Siaya to Kakamega when the results were out, and when he narrated what had happened, it was crystal clear he couldn't join high school as he had no fees.
His story touched many when it was published by the Standard.
Joshua has now found a sponsor who has promised to pay his fees from form 1 to 4. The sponsor, according to Ndung'u Nyoro, is from the US and wants to remain anonymous.
Make Money Online in Nigeria... Click HERE To Start Now!