sistent sadness, fatigue, feelings of hope- lessness and worthlessness and trouble sleeping or eating. Some women find it hard to care for their new baby. Hospitals have been urged to institute postpartum depression screening and referral programs to identify and help women struggling with their mental health. Effective programs and proce- dures for screening can be challenging to develop. A new quality improvement (QI) initiative by Cedars-Sinai investiga- tors in the Department of Obstetrics and Gynecology identified nurse training and education as key to successfully screening women in their care. “Our research also revealed that fram- ing the screening as part of the medical center’s commitment to family wellness, as opposed to only using the term ‘de- pression,’ was helpful. It allowed us to normalize the challenging transition to parenthood these patients often experi- ence,” said Accortt, a Clinical Psychologist and Assistant Professor in the Depart- ment of Obstetrics and Gynecology. The initiative, Implementing an Inpa-


tient Postpartum Depression Screening, Education, and Referral Program: A Quality Improvement Initiative, is pub- lished in the American Journal of Obstetrics & Gynecology–Maternal-Fetal Medicine. Nurses are often on the frontlines of screening programs for postpartum depression, but nursing schools rarely


require training in mental health screen- ing or education. Reviewing data involv- ing over 19,500 women who gave birth at Cedars-Sinai allowed investigators to evaluate the benefits of additional training for the nurses charged with accessing new mothers for depression. “We recognized that we needed to do a better job identifying patients at risk before they went home from the hospital,” said Sarah Kilpatrick, MD, PhD, senior author of the QI study, and the Helping Hand of Los Angeles Chair in Obstetrics and Gynecology at Cedars-Sinai. “We learned that it is a complicated process requiring dedicated collabora- tion between nurses, physicians, and in- formation technology personnel to make the system work. Our framework should be reproducible in other hospitals, thus helping even more families recognize and better manage postpartum depres- sion,” said Sarah Kilpatrick, MD, PhD, chair of Cedars-Sinai’s Department of Obstetrics and Gynecology. An important tool for evaluating a patient for postpartum depression is a special questionnaire designed to iden- tify the presence and seriousness of a mood disorder. Because many nurses called on to administer the question- naire within two days of a patient giving birth had concerns about doing it cor- rectly, an important quality improve-


Asthma, hypoxia, and lung damage


New research from scientists at La Jolla Institute for Immunology (LJI), shows that hypoxia can activate the same group of immune cells that cause inflammation during asthma attacks, according to a news release. Hypoxia, a lack of oxygen, can have long-term effects. In fact, doctors describe hypoxia as an “initial insult.” As a person gasps for breath, these cells flood the airways with molecules that damage the lungs. Experiencing hypoxia is a known trigger for developing and worsening lung conditions such as severe asthma, chronic obstructive pulmonary disease (COPD), and fibrosis. To treat and pre- vent these diseases, researchers need to understand why a lack of oxygen would affect the immune system. “We show how lack of oxygen can be


part of a feedback loop that can contrib- ute to even worse inflammation,” says LJI Professor and Chief Scientific Officer Mitchell Kronenberg, PhD, a member of the LJI Center for Autoimmunity and Inflammation. “This work gives


us insight into the causes of fibrosis of the lung and severe asthma.” Kronenberg and his colleagues


worked with a genetically altered mouse model to mimic the signals of hypoxia in the airway’s epithelial cells, which line the paths to the lungs. They discovered that combining the hypoxia signals with inflammatory signals stimulated the “innate,” or rapidly responding immunity, and an immune cell type called an ILC2. An ILC2’s job is to make signaling molecules (called cytokines) that quickly alert other immune cells to react to a pathogen. Unfortunately, ILC2s some- times over-react and respond to harm- less environmental allergens. In these cases, ILC2s churn out cytokines that drive mucus production and inflamma- tion in the lungs. All this swelling and mucus leads to hypoxia. As they report in Journal of Experi- mental Medicine, ILC2s respond to hypoxia as well, adding to the lung damage already caused during an asthma attack.


“That hypoxia may then contrib- ute further to inflammation,” says Kronenberg.


The next step was to figure out exactly how epithelial cells activate ILC2 during hypoxia. LJI Postdoctoral Fellow Jihye Han, PhD, led the work to uncover an unexpected culprit: adre- nomedullin (ADM). ADM is known for its role in helping blood vessels dilate, but until now it had no known role in immune function. Kronenberg was surprised to see ADM involved—but not shocked. “We’re finding that many molecules with no previously known role in the immune system can also be important for immune function,” says Kronenberg. The researchers showed that human lung epithelial cells exposed to hypoxia also produced ADM. This means ADM or its receptor could be targets for treat- ing inflammatory and allergic lung diseases. The challenge is to find a bal- ance between dampening the harmful immune response without leaving the body vulnerable to infections.


ment measure was in-service training; nurses observed a clinical psychologist demonstrate the process with a staff member playing the role of the patient. If the results of a new mother’s ques- tionnaire suggest she needs help before she leaves the hospital, a visit with a social worker can be scheduled. “The social worker begins by being a caring, nonjudgmental, listening ear and provides support and resources based on the patient’s needs. She might consult psychiatry if the woman seems unstable and in need of a full psychi- atric evaluation. Otherwise, she might provide a referral to our Reproductive Psychology Program or to our patient navigator, who can help connect her to care in the community,” said Accortt. The postpartum depression screen- ing program at Cedars-Sinai has ex- panded to include outpatient follow-up. A screening initiative for women who have experienced a stillbirth or who are in the obstetrics intensive care unit has also been implemented. “If we care about our patients’ mental


health, screening must be made routine, just like we screen pregnant patients for diabetes. It must be done in such a way that patients feel comfortable answering the questions truthfully, and there must be consistent follow-up of patients at risk for postpartum depression once they leave us,” said Kilpatrick.


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