‘Saving our people’: health workers,medical citizenship,and vernacular sovereignties in West Papua

Much anthropology has considered the social embeddedness of medical systems, personnel, and practices and the political subjectivities that may arise among health workers. I explore what medical citizenship looks like under conditions of settler colonialism in West Papua based on an ethnographic study of Dani (Balim) and Lani HIV nurses and NGO volunteers who see themselves and their activities as part of a broader effort to save Papuans from extinction. In particular, HIV work emerges as a biosocial obligation, meaning that workers give their expertise, attention, compassion, and treatment networks to people with HIV in the name of ensuring the vitality of the wider population, but giving care is not altruistic. As HIV workers respond to erasure, constraints, and racism, they put themselves at the centre of HIV care webs. ‘Traditional’ technologies transform healthcare encounters and challenge strategic ignorance about the epidemic. A close navigation of global health and settler power allows for flexible, independent, even surreptitious HIV practices that are deceptively radical and disruptive. Papuan HIV workers’ medical citizenship is encompassed by and expresses vernacular sovereignties.     

Ectogestation ethics: The implications of artificially extending gestation for viability,newborn resuscitation and abortion

Recent animal research suggests that it may soon be possible to support the human fetus in an artificial uterine environment for part of a pregnancy. A technique of extending gestation in this way (“ectogestation”) could be offered to parents of extremely premature infants (EPIs) to improve outcomes for their child. The use of artificial uteruses for ectogestation could generate ethical questions because of the technology’s potential impact on the point of “viability”—loosely defined as the stage of pregnancy beyond which the fetus may survive external to the womb. Several medical decisions during the perinatal period are based on the gestation at which infants are considered viable, for example decisions about newborn resuscitation and abortion, and ectogestation has the potential to impact on these. Despite these possible implications, there is little existing evidence or analysis of how this technology would affect medical practice. In this paper, we combine empirical data with ethical analysis. We report a survey of 91 practicing Australian obstetricians and neonatologists; we aimed to assess their conceptual understanding of “viability,” and what ethical consequences they envisage arising from improved survival of EPIs. We also assess what the ethical implications of extending gestation should be for newborn and obstetric care. We analyze the concept of viability and argue that while ectogestation might have implications for the permissibility of neonatal life-prolonging treatment at extremely early gestation, it should not necessarily have implications for abortion policy. We compare our ethical findings with the results of the survey.     

Methicillin-resistant Staphylococcus capitis with reduced vancomycin susceptibility causes late-onset sepsis in intensive care neonates

Background

Coagulase-negative staphylococci, mainly Staphylococcus epidermidis, are the most frequent cause of late-onset sepsis (LOS) in the neonatal intensive care unit (NICU) setting. However, recent reports indicate that methicillin-resistant, vancomycin-heteroresistant Staphylococcus capitis could emerge as a significant pathogen in the NICU. We investigated the prevalence, clonality and vancomycin susceptibility of S. capitis isolated from the blood of NICU infants and compared these data to adult patients.

Methodology/Principal Findings

We conducted a retrospective laboratory-based survey of positive blood cultures in NICU infants ≥3 days of age (n = 527) and in adult ICU patients ≥18 years of age (n = 1473) who were hospitalized from 2004 to 2009 in two hospital centers in Lyon, France. S. capitis was the most frequent pathogen in NICU infants, ahead of S. epidermidis (39.1% vs. 23.5% of positive blood cultures, respectively). Conversely, S. capitis was rarely found in adult ICU patients (1.0%) compared to S. epidermidis (15.3%). S. capitis bloodstream isolates were more frequently resistant to methicillin when collected from NICU infants than from adult patients (95.6% vs. 53.3%, respectively). Furthermore, we collected and characterized 53 S. capitis bloodstream isolates from NICU infants and adult patients from six distant cities. All methicillin-resistant S. capitis isolates from NICU infants were clonally related as determined by pulsed-field gel electrophoresis. These isolates harbored a type V-related staphylococcal chromosomal cassette mec element, and constantly showed either vancomycin resistance (37.5%) or heteroresistance (62.5%). Conversely, the isolates that were collected outside of the NICU were genetically diverse and displayed much lower rates of vancomycin resistance and heteroresistance (7.7% and 23.1%, respectively).

Conclusions/Significance

A clonal population of methicillin-resistant S. capitis strains has spread into several French NICUs. These isolates exhibit reduced susceptibility to vancomycin, which is the most widely used antimicrobial agent in the NICU setting.     

Recent changes in candidemia trends in a tertiary hospital (2011–2018)

BackgroundThe epidemiology of candidemia has changed over the last decades and varies widely among geographic areas.AimsWe examined in children (aged 0–14) with candidemia the trends in the incidence rate of this infection, as well as the clinical characteristics of the patients, in order to optimize the prognosis and the control measures of this serious disease.MethodsA retrospective cohort study of candidemia in the period 2011–2018 in the neonatal intensive care unit (NICU), pediatric ICU (PICU) and pediatric wards of a tertiary hospital, was conducted. The clinical course, Candida species isolated, antifungal susceptibility, outcome and incidence rates were analyzed and compared.ResultsWe diagnosed 68 episodes of candidemia in 62 children, 48% occurred in the NICU, 31% in the PICU and 21% in pediatric wards. Candida albicans was the most frequent species isolated in NICU infants (53%), and Candida parapsilosis predominated among PICU patients (59%) and pediatric wards (50%). One third of NICU infants had invasive candidiasis (IC), most of them having extremely low birth weight (ELBW) (35%). All isolates were susceptible to the antifungal administered. Over time, the incidence of candidemia decreased in the PICU (from 2.2 to 0.3 episodes/1000 patient-days, OR = 0.6; 95%CI 0.5–0.8), whereas in the NICU and in the wards remained stable. Mortality occurred mostly in NICU patients (26%), predominated in ELBW infants and did not change over time.ConclusionsThe higher incidence and mortality of candidemia and IC observed in preterm infants requires a continuous evaluation of practices and diagnostic methods which will allow improving the prognosis of this most vulnerable population.     

Vaccination status of infants discharged from a neonatal intensive care unit.

OBJECTIVE: To determine the vaccination rate among infants discharged from a neonatal intensive care unit (NICU) and factors affecting that rate. DESIGN: Cross-sectional survey conducted when the children were 12 to 18 months of age. SETTING: NICU at the Royal University Hospital, Saskatoon, Sask. PARTICIPANTS: All 395 infants discharged from the NICU between Jan. 1 and June 30, 1992. MAIN OUTCOME MEASURES: Vaccination rate, ethnic background (native or non-native), place of residence (urban or rural), health status (number of days spent in the NICU), reasons for delay in or incomplete vaccinations (those involving parents'' responsibility, infant illness or contraindications). RESULTS: Of the 395 infants, 20 (5.0%) had died and incomplete information was available for 30 (7.6%). Complete data were available for 345 (87.3%). Of the infants for whom data were available, 8 (2.3%) had never been vaccinated and 142 (41.2%) had a delayed vaccination schedule or had not completed their scheduled vaccinations. Only 195 (56.6%) of the infants had received a full vaccination series. Non-native ethnic background was a predictor of completed vaccinations (odds ratio [OR] 5.40, 95% confidence interval [CI] 3.05 to 9.52). In a univariate model, urban area of residence was not a significant predictor of vaccination status, but when ethnic background was controlled for in a multivariate logistic regression analysis, urban area of residence was found to be inversely associated with completed vaccinations (OR 0.34, 95% CI 0.15 to 0.79). The number of days the child had spent in the NICU was not a significant predictor of vaccination status. CONCLUSION: The vaccination rate of infants discharged from the NICU is not optimal. Urban native children appears to be at risk of not being vaccinated. Non-native infants are five times more likely than native infants to have completed all of their scheduled vaccinations. Methods to improve the rate of completed vaccinations, especially for native children, must be sought and tested.     

Dimensions of Citizenship and Opportunities for Youth Development: The What,Why, When,Where, and Who of Citizenship Development

In this concluding article we consider the definition and conceptualization of citizenship, why youth should be interested in citizenship, when developmentally should we as a society try to foster it, where in youth's lives should our efforts be placed, and the existence of potentially different needs and usefulness of different strategies in diverse populations of youth. In addressing the what, why, when, where, and who of citizenship development, we review the contributions to this issue as well as other literature. We conclude the chapter with a charge for future research.     

WASHING THE CITIZEN: WASHING, CLEANLINESS AND CITIZENSHIP IN MENTAL HEALTH CARE

Participation in the community and citizenship for patients are common ideals that inspire improvements in mental health care. But what is meant by citizenship? Here an analysis is made of washing practices in psychiatric nursing in long-term mental health institutions. Four repertoires of washing are described, each oriented towards a specific notion of citizenship. In the first repertoire, washing is part of individual privacy; the patient is “enacted” as an individual whose authenticity should be respected in order to equip him or her for participation in the community. In the second repertoire, washing is a basic skill; the patient must learn to take care of her body in order to become an independent citizen. In the third repertoire washing is a precondition to citizenship; patients are to be helped to develop their potentials so that they can find their way in the community. In the fourth repertoire, washing is one opportunity among others to develop social relations; the extent and quality of these relations define a citizen. This analysis opens up not the question if, but which type of citizenship should be promoted.     

Light and magnetic fields in a neonatal intensive care unit

Effects of light and electromagnetic fields (EMFs) on pineal function could have implications for long-term risk of breast cancer, reproductive irregularities, or depression. Health-care workers in a neonatal intensive care unit (NICU) were interviewed to determine the tasks, work locations, and practices in their work environment as well as the care provided to the infants. After an initial visit, methods for measuring illuminance, luminance, and broadband resultant magnetic fields throughout the NICU were developed. Measurements were made of one nursery during a daytime (1:00 p.m.) and a night-time (12:30 a.m.) visit. Measurements relevant to both nurses and premature infants in the NICU were made. Some measurements could not be completed so as not to interfere with nurses' duties in the NICU. Illuminances measured during the daytime and nighttime averaged 184 and 34 lux (lx), respectively, much lower than those reported in other studies of illuminance in NICUs, with a maximum illuminance of 747 lx. Peak levels may be consistent with those thought to suppress melatonin. There was a high degree of variability in EMF levels, which exceeded 1,000 mG close to certain hospital equipment but averaged 1–2 mG at the nurses' workstation. Fields within incubators exceeded 10 mG. © 1996 Wiley-Liss, Inc.     

Variations in care for cottontop tamarin, Saguinus oedipus, infants as a function of parental experience and group size

We examined the effects of parental experience and group size on infant care and development. Ten cottontop tamarin families were followed across three consecutive births of offspring to examine differences in survival, quality of care, developmental maturation and physical development for infants in two experimental conditions: (1) in large groups with previous parenting experience and (2) in small groups with little or no parenting experience. Although we found no differences in infant mortality, parents treated infants differently between conditions. However, when we examined the cumulative care provided by parents and sibling helpers together across experimental conditions, there were no differences in the rates of retrieval or rejection of infants. Overall levels of infant transport and food transfers were similar between conditions, with fathers and sibling helpers contributing the bulk of care. Fathers in small groups carried infants and transferred food with infants much more than helpers but, as group size increased, helpers augmented this role. Infant development varied with the experience of the family both between conditions and within a family. The results indicate that infants receive similar levels of care regardless of group size and parenting experience, although the individual contributions of family members change with both factors. Parental experience with previous infants had effects on early infant development, but only for the first sets of infants. Copyright 2002 The Association for the Study of Animal Behaviour. Published by Elsevier Science Ltd. All rights reserved.     

Old Age Assistance: A Report by the Bureau of Research and Planning

What are some of the reasons why older persons become eligible for Old Age Assistance in California?How many become eligible because of medical care needs?This Report of the Bureau of Research and Planning draws upon recently published data of the State Department of Social Welfare and presents statistics covering a recent one-year period.     

A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport

Background

Although patent ductus arteriosus (PDA) ligations in the Neonatal Intensive Care Unit (NICU) have been an accepted practice, many are still performed in the Operating Room (OR). Whether avoiding transport leads to improved perioperative outcomes is unclear. Here we aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes.

Methods

We performed a retrospective cohort study of NICU patients, ≤37?weeks post-menstrual age, undergoing surgical PDA ligation in the NICU or OR. We excluded any infants undergoing device PDA closure. We measured the incidence of perioperative hypothermia, cardiac arrest, decreases in SpO2, hemodynamic instability and postoperative surgical site infection, sepsis and mortality.

Results

Data was collected on 189 infants (100 OR, 89 NICU). After controlling for number of preoperative comorbidities, weight at time of procedure, procedure location and hospital in the mixed-effect model, no significant difference in mortality or sepsis was found (odds ratio 0.31, 95%CI 0.07, 1.30; p?=?0.107, and odds ratio 0.40; 95%CI 0.14, 1.09; p?=?0.072, respectively). There was an increased incidence of hemodynamic instability on transport postoperatively in the OR group (12.4% vs 2%, odds ratio 6.93; 95% CI 1.48, 35.52; p?=?0.014).

Conclusion

PDA ligations in the NICU were not associated with higher incidences of surgical site infection or mortality. There was an increased incidence of hemodynamic instability in the OR group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU.

Keywords

Patent ductus arteriosus, Newborn infant, Neonatal intensive care unit, Surgical wound infection, Postoperative period, Hemodynamics

     

Care and the problem of pity

In recent years philosophers and bioethicists have given considerable attention to the concept of care. Thus we have seen important work on questions such as: whether there is a uniquely female approach to ethics, whether ethics should be partial or impartial, and whether care must be supplemented by justice. Despite this valuable and extensive work, however, some important distinctions have gone largely undiscussed. This paper tries to fill a gap left in our understanding of the concept of care itself by distinguishing between compassion and two kinds of pity. While all three are kinds of caring, we should not give them similar moral evaluations. Consequently, the distinction between compassion and different kinds of pity gives us an important insight into the question of whether we can consider care a virtue for health care professionals.     

Soul Citizenship: The Black Hebrews and the State of Israel

Based on the experiences of the Black Hebrews in Israel, this article introduces "soul citizenship," an alternate discourse that asserts the right of individuals and groups to match their self–defined identities with existing states. After years of living in the Jewish State as an illegal yet tolerated presence, the African Hebrew Israelite Community (AHIC) gained temporary residence status, or according to the postnational model of membership, de facto citizenship. Nonetheless, having reformulated their claims in terms of Jewish cultural pluralism instead of race, the Black Hebrews continue to demand full Israeli citizenship. Rejecting postnational splits among identity, legal status, and territory, their soulful claims suggest a model of citizenship that opens new space for misplaced peopled) to gain membership in the states that meet their cultural aspirations and nourish their souls. [Keywords: citizenship, Black Hebrews, Israel, diasporas]     

Different subjects: the health care system's participation in the differential construction of the cultural citizenship of Cuban refugees and Mexican immigrants

This paper explores the public health system's differential construction of Mexican and Cuban immigrants' "deservingness" of citizenship benefits and its preparation of them for different roles in U.S. society. Civic institutions such as the public health care system are charged with inculcating normative behavior in immigrants and instilling in them different conceptions about their rights and responsibilities. Faced with limited resources under the implementation of Medicaid managed care, hospital administrators created new categories of "deserving" and "undeserving" immigrants based on neoliberal standards of individual responsibility and self-discipline. As a result, hospital policies construct different types of "cultural citizenship" for Cuban and Mexican immigrants, preparing the former to be active citizens and discouraging the latter from pressing demands on American civil institutions. I show that this negative construction of Mexican immigrants' moral worth leads to unmet health needs and poor health outcomes.     

Treatment of Invasive Candida Infections in the Neonatal Intensive Care Unit

Invasive Candida infections are a leading cause of morbidity and mortality in the neonatal intensive care unit (NICU). Extremely preterm and very low birth weight infants are at the highest risk of infection. There are currently no antifungal agents that have FDA-labeling for the treatment of invasive candidiasis in the neonatal population. Based on the current IDSA guidelines, amphotericin and fluconazole are considered first-line options for neonatal candidiasis. The newer antifungal agents (i.e., echinocandins and voriconazole) are currently considered second-line or salvage therapy; however, evidence supporting their use is emerging. This review focuses on the supporting evidence for the selection of antifungal agents for treatment of invasive Candida infections in the NICU.     

Life support: the alpha4 phosphatase subunit in cell survival and apoptosis

Reversible protein phosphorylation represents a cellular response to normal physiological processes as well as to cellular insults and stress. Recently, the protein phosphatase-associated alpha4 subunit was shown to be required for sustaining cell survival. Lack of alpha4 leads to apoptotic death of multiple cell types and to the death of the organism. Here, we explore how the phosphatase network might operate in controlling life-and-death decisions. We discuss the relevance of the findings for understanding the action of alpha4 in cell survival and for better discriminating between a role in maintaining cellular homeostasis, and thus survival, or actively keeping apoptotic cell death in check by targeting effectors of the cell death machinery.     

First Outbreak with MRSA in a Danish Neonatal Intensive Care Unit: Risk Factors and Control Procedures

Introduction

The purpose of the study was to describe demographic and clinical characteristics and outbreak handling of a large methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a neonatal intensive care unit (NICU) in Denmark June 25^th–August 8^th 2008, and to identify risk factors for MRSA transmission.

Methods

Data were collected retrospectively from medical records and the Danish Neobase database. All MRSA isolates obtained from neonates, relatives and NICU health care workers (HCW) as well as environmental cultures were typed.

Results

During the 46 day outbreak period, 102 neonates were admitted to the two neonatal wards. Ninety-nine neonates were subsequently sampled, and 32 neonates (32%) from 25 families were colonized with MRSA (spa-type t127, SCCmec V, PVL negative). Thirteen family members from 11 of those families (44%) and two of 161 HCWs (1%) were colonized with the same MRSA. No one was infected. Five environmental cultures were MRSA positive. In a multiple logistic regression analysis, nasal Continuous Positive Airway Pressure (nCPAP) treatment (p = 0.006) and Caesarean section (p = 0.016) were independent risk factors for MRSA acquisition, whereas days of exposure to MRSA was a risk factors in the unadjusted analysis (p = 0.04).

Conclusions

MRSA transmission occurs with high frequency in the NICU during hospitalization with unidentified MRSA neonates. Caesarean section and nCPAP treatment were identified as risk factors for MRSA colonization. The MRSA outbreak was controlled through infection control procedures.     

A cross-cultural study of physician treatment decisions in relation to demented nursing home patients who develop pneumonia

This qualitative interview study in The Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and The Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families' wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

Breastfeeding Progression in Preterm Infants Is Influenced by Factors in Infants,Mothers and Clinical Practice: The Results of a National Cohort Study with High Breastfeeding Initiation Rates

Background and Aim

Many preterm infants are not capable of exclusive breastfeeding from birth. To guide mothers in breastfeeding, it is important to know when preterm infants can initiate breastfeeding and progress. The aim was to analyse postmenstrual age (PMA) at breastfeeding milestones in different preterm gestational age (GA) groups, to describe rates of breastfeeding duration at pre-defined times, as well as analyse factors associated with PMA at the establishment of exclusive breastfeeding.

Methods

The study was part of a prospective survey of a national Danish cohort of preterm infants based on questionnaires and structured telephone interviews, including 1,221 mothers and their 1,488 preterm infants with GA of 24–36 weeks.

Results

Of the preterm infants, 99% initiated breastfeeding and 68% were discharged exclusively breastfed. Breastfeeding milestones were generally reached at different PMAs for different GA groups, but preterm infants were able to initiate breastfeeding at early times, with some delay in infants less than GA 32 weeks. Very preterm infants had lowest mean PMA (35.5 weeks) at first complete breastfeed, and moderate preterm infants had lowest mean PMA at the establishment of exclusive breastfeeding (36.4 weeks). Admitting mothers to the NICU together with the infant and minimising the use of a pacifier during breastfeeding transition were associated with 1.6 (95% CI 0.4–2.8) and 1.2 days (95% CI 0.1–2.3) earlier establishment of exclusive breastfeeding respectively. Infants that were small for gestational age were associated with 5.6 days (95% CI 4.1–7.0) later establishment of exclusive breastfeeding.

Conclusion

Breastfeeding competence is not developed at a fixed PMA, but is influenced by multiple factors in infants, mothers and clinical practice. Admitting mothers together with their infants to the NICU and minimising the use of pacifiers may contribute to earlier establishment of exclusive breastfeeding.     

Improvement of Expressed Breast Milk in Mothers of Preterm Infants by Recording Breast Milk Pumping Diaries in a Neonatal Center in China

Objectives

Because inadequate expression of human milk (EBM) in mothers of hospitalized infants were noticed in a neonatal center of our hospital, family education program was carried out to increase the EBM.

Methods

A breast milk pumping diary was introduced to the mothers with preterm infant(s) admitted in the NICU. The ratios of EBM (days of EBM to NICU/hospitalized days), breast milk feeding (BMF) (days of infants fed with exclusive human milk/hospitalized days), mixed feeding (MF) (days of infants fed with partial breast milk and partial formula/hospitalized days), and formula feeding (FF) (days of infants fed with preterm formula/hospitalized days) were evaluated.

Results

During January to April, 2014, the ratios of EBM to the NICU, BMF, MF and FF were 28.11%, 6.6%, 32.8% and 60.6%, respectively. After the introduction of breast milk pumping diary to the mothers from May 2014, the ratio of EBM to the NICU increased significantly to 53.3% (p<0.01) within the following eight months. Both the ratios of BMF and MF also rose to 23.8% and MF 55.3%, respectively. Consequently, the ratio of FF was reduced to 20.9%. Exclusive breast milk feeding also significantly reduce the duration of nil per oral (NPO) of the very low birth weight infants during hospital stay as compared to those fed with mixed feeding and formula feeding.

Conclusion

The introduction of a breast milk pumping diary was associated with a significant increase in the intake of EBM of the hospitalized preterm newborns.