Qualitative study of evidence based leaflets in maternity care

ObjectiveTo examine the use of evidence based leaflets on informed choice in maternity services.DesignNon-participant observation of 886 antenatal consultations. 383 in depth interviews with women using maternity services and health professionals providing antenatal care.SettingWomen''s homes; antenatal and ultrasound clinics in 13 maternity units in Wales.ParticipantsChildbearing women and health professionals who provide antenatal care.InterventionProvision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use.ResultsHealth professionals were positive about the leaflets and their potential to assist women in making informed choices, but competing demands within the clinical environment undermined their effective use. Time pressures limited discussion, and choice was often not available in practice. A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of “right” and “wrong” choices rather than “informed” choices. Hierarchical power structures resulted in obstetricians defining the norms of clinical practice and hence which choices were possible. Women''s trust in health professionals ensured their compliance with professionally defined choices, and only rarely were they observed asking questions or making alternative requests. Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy. The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced.ConclusionsThe way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice.

What is already known on this topic

Informed Choice leaflets are widely used in maternity care but little is known about their ability to influence informed choice and decision makingHigh quality information is essential for promoting informed choice but is insufficient by itself

What this study adds

Time constraints and other pressures on health professionals resulted in a lack of discussion of the content of the leafletsFear of litigation, power hierarchies, and the technological imperative in maternity care limited the choices availableHealth professionals promoted normative practices rather than choice, and as women valued their opinions this led to the promotion of informed compliance rather than informed choice     

Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice

ObjectiveTo assess the effect of leaflets on promoting informed choice in women using maternity services.DesignCluster trial, with maternity units randomised to use leaflets (intervention units) or offer usual care (control units). Data collected through postal questionnaires.Setting13 maternity units in Wales.ParticipantsFour separate samples of women using maternity services. Antenatal samples: women reaching 28 weeks'' gestation before (n=1386) and after (n=1778) the intervention. Postnatal samples: women at eight weeks after delivery before (n=1741) and after (n=1547) the intervention.InterventionProvision of 10 pairs of Informed Choice leaflets for service users and midwives and a training session for staff in their use.ResultsThere was no change in the proportion of women who reported that they exercised informed choice in the intervention units compared with the control units for either antenatal or postnatal women. There was a small increase in satisfaction with information in the antenatal samples in the intervention units compared with the control units (odds ratio 1.40, 95% confidence interval 1.05 to 1.88). Only three quarters of women in the intervention units reported being given at least one of the leaflets, indicating problems with the implementation of the intervention.ConclusionIn everyday practice, evidence based leaflets were not effective in promoting informed choice in women using maternity services.

What is already known on this topic

Decision aids can help patients to participate in their careTen evidence based leaflets (Informed Choice) are used by maternity services in the United Kingdom to promote informed choice in women using these services

What this paper adds

The leaflets did not help to promote informed choice in maternity careDecision aids may not be effective in the real world     

Qualitative study of views of health professionals and patients on guided self management plans for asthma

ObjectivesTo explore the views held by general practitioners, practice nurses, and patients about the role of guided self management plans in asthma care.DesignQualitative study using nine focus groups that each met on two occasions.SettingSouth Wales.Subjects13 asthma nurses, 11 general practitioners (six with an interest in asthma), and 32 patients (13 adults compliant with treatment, 12 non-compliant adults, and seven teenagers).ResultsNeither health professionals nor patients were enthusiastic about guided self management plans, and, although for different reasons, almost all participants were ambivalent about their usefulness or relevance. Most professionals opposed their use. Few patients reported sustained use, and most felt that plans were largely irrelevant to them. The attitudes associated with these views reflect the gulf between the professionals'' concept of the “responsible asthma patient” and the patients'' view.ConclusionsAttempts to introduce self guided management plans in primary care are unlikely to be successful. A more patient centred, patient negotiated plan is needed for asthma care in the community.     

Roosts of Allen's Lappet-Browed Bat in Northern Arizona

ABSTRACT In Arizona, USA, Allen's lappet-browed bat (Idionycteris phyllotis) forms maternity colonies in ponderosa pine (Pinus ponderosa) snags. There is little information on the roosting habitat of males. We used radiotelemetry to locate 16 maternity, 3 postlactating, and 2 bachelor roosts and combined data with unpublished data for maternity roosts (n = 11) located in 1993–1995. Most (96%) maternity roosts were in large-diameter (x̄ ± SE: 64 ± 2.7 cm) ponderosa pine snags under sloughing bark. Models that best predicted the probability of a snag's use as a maternity roost indicated bats selected taller snags closer to forest roads than comparison snags. Maternity roosts averaged 11 bats per roost (SE = 2, n = 15; from exit counts) and were an average distance of 1.6 km from capture sites (SE = 0.3, n = 17). Bachelor roosts were in vertical sandstone cliff faces in pinyon-juniper (Pinus edulis-Juniperus spp.) woodlands approximately 12 km from capture sites; these and other capture records in Arizona indicated sexual segregation may have occurred during the maternity season. Of 11 maternity snag roosts located in 1993–1995, only one continued to function as a roost. Resource managers should maintain patches of large-diameter ponderosa pine snags with peeling bark to provide maternity roosting habitat for Allen's lappet-browed bat.     

A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand

BackgroundInternationally, a typical model of maternity care is a medically led system with varying levels of midwifery input. New Zealand has a midwife-led model of care, and there are movements in other countries to adopt such a system. There is a paucity of systemic evaluation that formally investigates safety-related outcomes in relationship to midwife-led care within an entire maternity service. The main objective of this study was to compare major adverse perinatal outcomes between midwife-led and medical-led maternity care in New Zealand.ConclusionsThere is an unexplained excess of adverse events in midwife-led deliveries in New Zealand where midwives practice autonomously. The findings are of concern and demonstrate a need for further research that specifically investigates the reasons for the apparent excess of adverse outcomes in mothers with midwife-led care. These findings should be interpreted in the context of New Zealand’s internationally comparable birth outcomes and in the context of research that supports the many benefits of midwife-led care, such as greater patient satisfaction and lower intervention rates.     

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

ObjectivesTo explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.DesignQualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.SettingSantiago, Chile.ParticipantsQualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.ResultsPrivate health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.ConclusionsPolicies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.     

Musculoskeletal Symptoms and Risk of Burnout in Child Care Workers — A Cross-Sectional Study

ObjectivesGerman child care workers'' job satisfaction is influenced by the consequences of unfavourable underlying conditions. Child care workers tend to suffer from psychosocial stress, as they feel that their work is undervalued. The objective of the present study is to investigate how the psychosocial factors of the effort-reward imbalance (ERI) model influence musculoskeletal symptoms (MS) and the risk of burnout. To our knowledge this is the first study investigating the association between the factors of the ERI model and MS in child care workers.ConclusionOvercommitment in child care workers is related to MS and risk of burnout. There is also evidence that low control is associated with MS and subjective noise exposure with risk of burnout. Effort-reward imbalance is not related to either outcome. This occupational health risk assessment identifies changeable working factors in different types of facilities.     

Consumer demand for caesarean sections in Brazil: informed decision making,patient choice,or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods

ObjectivesTo investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.DesignPopulation based birth cohort study, using ethnographic and epidemiological methods.SettingEpidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.Participants5304 women who gave birth in any of the city''s hospitals in 1993.ResultsIn both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women''s behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.ConclusionsFear of substandard care is behind many poor women''s preferences for a caesarean section. Variables pertaining to women''s role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

What is already known on this topic

Women''s preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveries

What this study adds

In Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient     

Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study

ObjectiveTo test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care.ResultsNulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio’s and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62).ConclusionsOur results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.     

Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study

ObjectiveTo clarify the practice of withholding the artificial administration of fluids and food from elderly patients with dementia in nursing homes.DesignQualitative, ethnographic study in two phases.Setting10 wards in two nursing homes in the Netherlands.Participants35 patients with dementia, eight doctors, 43 nurses, and 32 families.ResultsThe clinical course of dementia was considered normal and was rarely reason to begin the artificial administration of fluids and food in advanced disease. Fluids and food seemed to be given mainly when there was an acute illness or a condition that needed medical treatment and which required hydration to be effective. The medical condition of the patient, the wishes of the family, and the interpretations of the patients'' quality of life by their care providers were considered more important than living wills and policy agreements.ConclusionsDoctors'' decisions about withholding the artificial administration of fluids and food from elderly patients with dementia are influenced more by the clinical course of the illness, the presumed quality of life of the patient, and the patient''s medical condition than they are by advanced planning of care. In an attempt to understand the wishes of the patient doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family.

What is already known on this topic

Debate has focused on whether it is beneficial to withhold the artificial administration of fluids and food from patients with advanced dementia

What this study adds

The course of dementia, the patient''s quality of life, and the patient''s current medical condition influence doctors'' decision making more than advanced planning of careDoctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family     

儿童重症监护病房医院感染暴发白色念珠菌血流感染4例分析

摘要 目的：探讨儿童重症监护病房白色念珠菌血流感染暴发的临床表现、危险因素、控制措施等,为预防和控制院内白色念珠菌血流感染暴发提供科学依据。方法：以2018年7月我院儿童重症监护病房发生的4例白色念珠菌血流感染暴发患儿为研究对象,分析患儿临床情况、临床特征、危险因素、暴发原因以及采取的预防控制措施。结果：4例医院感染暴发白色念珠菌血流感染患儿均存在基础疾病、有机械通气史、存在中心静脉或动脉置管、静脉或动脉置管前后均使用碘伏消毒、曾使用广谱抗生素、输血制品,白色念珠菌血流感染后最突出的临床表现均是发热。药敏方面,医院感染暴发的4例白色念珠菌感染患儿对唑类及5-氟胞嘧啶均耐药,但对两性霉素B均敏感。经拔除血管置管、减少或者避免广谱抗菌药的应用,根据药敏使用卡泊芬净及两性霉素B抗真菌等积极治疗,1例患儿放弃治疗后死亡,3例患儿顺利出院。通过Fisher确切概率法分析可知,留置中心静脉或动脉置管是儿童重症监护病房发生医院感染暴发白色念珠菌血流感染的危险因素（P<0.05）。结论：留置中心静脉或动脉置管是儿童重症监护病房发生医院感染暴发白色念珠菌血流感染的危险因素,医院感染暴发白色念珠菌血流感染患儿最突出的临床表现是发热,唑类及5-氟胞嘧啶耐药的患儿使用卡泊芬净及两性霉素B可能获得较好的治疗效果。     

National survey of job satisfaction and retirement intentions among general practitioners in England

ObjectivesTo measure general practitioners'' intentions to quit direct patient care, to assess changes between 1998 and 2000, and to investigate associated factors, notably job satisfaction.DesignAnalysis of national postal surveys conducted in 1998 and 2001.SettingEngland.Participants1949 general practitioner principals, of whom 790 were surveyed in 1998 and 1159 in 2001.ResultsThe proportion of doctors intending to quit direct patient care in the next five years rose from 14% in 1998 to 22% in 2001. In both years, the main factors associated with an increased likelihood of quitting were older age and ethnic minority status. Higher job satisfaction and having children younger than 18 years were associated with a reduced likelihood of quitting. There were no significant differences in regression coefficients between 1998 and 2001, suggesting that the effect of factors influencing intentions to quit remained stable over time. The rise in intentions to quit was due mainly to a reduction in job satisfaction (1998 mean 4.64, 2001 mean 3.96) together with a slight increase in the proportion of doctors from ethnic minorities and in the mean age of doctors. Doctors'' personal and practice characteristics explained little of the variation in job satisfaction within or between years.ConclusionsJob satisfaction is an important factor underlying intention to quit, and attention to this aspect of doctors'' working lives may help to increase the supply of general practitioners.

What is already known on this topic

Early retirement is one of the factors contributing to a shortage of general practitioners in the NHS

What this study adds

The proportion of general practitioners intending to quit direct patient care within five years rose from 14% in 1998 to 22% in 2001A decrease in overall job satisfaction is the most important factor underlying this riseImproving the quality of doctors'' working lives might help improve retention     

海南栽培肾茶的化学成分研究

为了解肾茶(Clerodendranthus spicatus)的化学成分,从海南栽培肾茶地上部分分离得到11个化合物,经波谱分析分别鉴定为:吐叶醇(1)、丁香脂素(2)、3,4-二羟基苯乙醇(3)、甜橙素(4)、5,6,7,4′-四甲氧基黄酮(5)、5-羟基-6,7,3′,4′-四甲氧基黄酮(6)、6-羟基-5,7,4′-三甲氧基黄酮(7)、5-羟基-6,7,3′,4′-四甲氧基黄烷酮(8)、3,3′,5-三羟基-4′,7-二甲氧基-二氢黄酮(9)、松脂素(10)和熊果酸(11)。化合物3、9和10为首次从肾茶中分离得到。对化合物1~6进行活性测试,结果表明化合物3~5对乙酰胆碱酯酶具有一定的抑制活性。     

Worldwide evidence about infant stunting from a public health perspective: A systematic review

Introduction: According to the World Health Organization (WHO) global estimates for 2017, 9.6% of children under 5 years old are stunted. Worldwide evidence shows that actions for preventing stunting and catching-up growth are relevant if addressed by all the sectors involved. Therefore, there is a need to identify ''intersectoral actions'' to address the risk of stunting during pregnancy and the first 2 years of life.Objective: To identify and describe worldwide evidence for prevention, nutritional interventions, and ''intersectoral collaboration'' efforts against stunting in infants. Materials and methods: We conducted a systematic review in 2019 (PROSPERO CRD42019134431). The search included PubMed, OVID, and Web of Science, as well as WHO and the Food and Agriculture Organization of the United Nations (FAO) official documents and expert recommendations.Results: We selected 231 studies: 86.1% described prevention-related factors, 30.7%, nutritional interventions, and 52.8% intersectoral collaboration efforts; 36.4% of the studies were conducted in multiple regions; 61% of the studies described the importance of interventions during pregnancy, 71.9% from birth up to 6 months old, and 84.8% from 6 months up to 2 years old. The most frequent variables described were antenatal care, nutritional counseling for the mother and the newborn, and counseling on micronutrient supplementation.Conclusions: Evidence-based understanding of actions geared towards monitoring the risk of stunting-associated factors from pregnancy up to 2 years old is critical.     

Predicting child abuse: signs of bonding failure in the maternity hospital.

Fifty children referred to the Park Hospital because of actual or threatened abuse were compared with 50 controls born at the same maternity hospital. Five factors were significantly more common in the abused group than among their controls: (a) mother aged under 20 at birth of first child, (b) evidence of emotional disturbance, (c) referral of family to hospital social worker, (d) baby''s admission to special care baby unit, (e) recorded concern over the mother''s ability to care for child. Thirty-five of the abused group had two or more of these factors compared with only five of the control group. As these data were collected from information recorded routinely at the maternity hospital, it is possible to identify most abusing families when the child is born. Such identification must lead to a comprehensive assessment of each case followed by constructive preventive action.     

Primary Care Patients’ Perspectives of Barriers and Enablers of Primary Prevention and Health Promotion—A Meta-Ethnographic Synthesis

BackgroundPrimary care (PC) patients have difficulties in committing to and incorporating primary prevention and health promotion (PP&HP) activities into their long-term care. We aimed to re-interpret, for the first time, qualitative findings regarding factors affecting PC patients'' acceptance of PP&HP activities.ConclusionsSeveral factors affect PP&HP. This must be taken into account when designing PP&HP activities if they are to be successfully implemented and maintained in routine practice.     

RNA结合蛋白QKI-5对乳腺癌细胞MCF-7增殖的影响研究

目的:检测RNA结合蛋白QKI-5在乳腺癌细胞中的表达水平以及对癌细胞增殖能力的抑制作用。方法:通过免疫印迹实验检测QKI-5在不同乳腺癌细胞株中的表达水平,通过慢病毒感染构建能够稳定过表达QKI-5基因的细胞株,使用MTT,流式细胞仪检测细胞周期来观察过表达QKI-5对细胞增殖能力及周期的影响。结果:MCF-7细胞在三株乳腺癌细胞中QKI-5表达水平相对最低,MTT实验结果显示与对照相比,过表达QKI-5的MCF-7细胞增殖能力出现显著降低P0.05,同时细胞周期检测显示过表达QKI-5的MCF-7细胞组出现了明显的G1期阻滞,进入S期G2/M期细胞减少。结论:在乳腺癌中QKI-5的高表达可能通过抑制癌细胞周期致使细胞增殖变缓,从而导致肿瘤生长受限。     

Use of consensus development to establish national research priorities in critical care

ObjectivesTo test the feasibility of using a nominal group technique to establish clinical and health services research priorities in critical care and to test the representativeness of the group''s views.DesignGeneration of topics by means of a national survey; a nominal group technique to establish the level of consensus; a survey to test the representativeness of the results.SettingUnited Kingdom and Republic of Ireland.SubjectsNominal group composed of 10 doctors (8 consultants, 2 trainees) and 2 nurses.ResultsOf the 325 intensive care units approached, 187 (58%) responded, providing about 1000 suggestions for research. Of the 106 most frequently suggested topics considered by the nominal group, 37 attracted strong support, 48 moderate support and 21 weak support. There was more agreement after the group had met—overall mean of the mean absolute deviations from the median fell from 1.41 to 1.26. The group''s views represented the views of the wider community of critical care staff (r=0.73, P<0.01). There was no significant difference in the views of staff from teaching or from non-teaching hospitals. Of the 37 topics that attracted the strongest support, 24 were concerned with organisational aspects of critical care and only 13 with technology assessment or clinical research.ConclusionsA nominal group technique is feasible and reliable for determining research priorities among clinicians. This approach is more democratic and transparent than the traditional methods used by research funding bodies. The results suggest that clinicians perceive research into the best ways of delivering and organising services as a high priority.