Depression Screening in Pediatric Inflammatory Bowel Disease Clinics: Recommendations and a Toolkit for Implementation.

OBJECTIVE: Rates of youth depression are increasing, and approximately 75% of adolescents with depression go unrecognized. Research in pediatric IBD documents increased depression risk, with rates up to 25%, as well as worse adherence and treatment outcomes associated with depressive symptoms. Evidence-based psychological interventions improve the physical and emotional health of these patients, highlighting the importance of detection and treatment. Psychosocial screening has been shown to increase the accurate identification of psychosocial problems and facilitate timely psychosocial intervention. The objective of this article is to establish clinical guidelines for depression screening in youth diagnosed with IBD and to provide resources for implementation. METHODS: The psychosocial screening task force group constituted of psychologists and social workers in the ImproveCareNow (ICN) learning health system reviewed research and clinical guidelines in other fields, and consulted with physicians, nurses, other psychosocial professionals, patients with IBD, and parents of children with IBD in ICN. RESULTS/CONCLUSIONS: It is recommended that adolescents with IBD ages 12 and older be screened for depression annually. Additional practical recommendations for implementation, triage, and treatment within the pediatric gastroenterology clinic are also provided.

Creating an Optimality Index - Netherlands: a validation study.

BACKGROUND: At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL). METHODS: Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity. RESULTS: Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (ß = 6.21, P = 0.00) and for care-setting (ß = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences. CONCLUSION: OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.

Denial of a sleep deprivation message: situational and dispositional influences on message rejection.

Two studies investigated situational and dispositional influences on rejection of a sleep deprivation warning message for young adults. The hassle of protection (Study 1) and the self-relevance of the problem (Study 2) were manipulated; the disposition to use denial (threat orientation) for warning messages was measured. In both studies, it was found that both dispositional denial and the situational manipulation (more protection-hassle or self-relevance) showed at least one denial effect by reducing perceived susceptibility, perceived severity, or credibility. Indirect (mediational) effects were tested with the bootstrap method. In Study 1, judgments of credibility and severity mediated the effects of the hassle manipulation and denial orientation on message outcomes. In Study 2, credibility mediated the effects of the self-relevance manipulation and denial orientation on message outcomes of intentions to change and priority given to sleep. These studies show that both situational and dispositional sources of denial work in similar ways by lowering key message judgments and that the lower judgments lead to less priority given to a health risk and lower intentions to protect oneself.

Effects of Negative Middle Ear Pressure on Wideband Acoustic Immittance in Normal-Hearing Adults.

OBJECTIVES: Wideband acoustic immittance (WAI) measurements are capable of quantifying middle ear performance over a wide range of frequencies relevant to human hearing. Static pressure in the middle ear cavity affects sound transmission to the cochlea, but few datasets exist to quantify the relationship between middle ear transmission and the static pressure. In this study, WAI measurements of normal ears are analyzed in both negative middle ear pressure (NMEP) and ambient middle ear pressure (AMEP) conditions, with a focus on the effects of NMEP in individual ears. DESIGN: Eight subjects with normal middle ear function were trained to induce consistent NMEPs, quantified by the tympanic peak pressure (TPP) and WAI. The effects of NMEP on the wideband power absorbance level are analyzed for individual ears. Complex (magnitude and phase) WAI quantities at the tympanic membrane (TM) are studied by removing the delay due to the residual ear canal (REC) volume between the probe tip and the TM. WAI results are then analyzed using a simplified classical model of the middle ear. RESULTS: For the 8 ears presented here, NMEP has the largest and most significant effect across ears from 0.8 to 1.9 kHz, resulting in reduced power absorbance by the middle ear and cochlea. On average, NMEP causes a decrease in the power absorbance level for low- to mid-frequencies, and a small increase above about 4 kHz. The effects of NMEP on WAI quantities, including the absorbance level and TM impedance, vary considerably across ears. The complex WAI at the TM and fitted model parameters show that NMEP causes a decrease in the aggregate compliance at the TM. Estimated REC delays show little to no dependence on NMEP. CONCLUSIONS: In agreement with previous results, these data show that the power absorbance level is most sensitive to NMEP around 1 kHz. The REC effect is removed from WAI measurements, allowing for direct estimation of complex WAI at the TM. These estimates show NMEP effects consistent with an increased stiffness in the middle ear, which could originate from the TM, tensor tympani, annular ligament, or other middle ear structures. Model results quantify this nonlinear, stiffness-related change in a systematic way, that is not dependent on averaging WAI results in frequency bands. Given the variability of pressure effects, likely related to intersubject variability at AMEP, TPP is not a strong predictor of change in WAI at the TM. More data and modeling will be needed to better quantify the relationship between NMEP, WAI, and middle ear transmission.

Negative Middle Ear Pressure and Composite and Component Distortion Product Otoacoustic Emissions.

OBJECTIVES: Distortion product otoacoustic emissions (DPOAEs), a by-product of normal outer hair cell function, are used in research and clinical settings to noninvasively test cochlear health. The composite DPOAE recorded in the ear canal is the result of interactions of at least two components: a nonlinear distortion component (the generator component) and a linear reflection component. Negative middle ear pressure (NMEP) results in the tympanic membrane being pulled inward and increases middle ear impedance. This influences both the forward travel of stimuli used to induce distortion products and the reverse travel of the emissions back to the ear canal. NMEP may therefore limit the effectiveness of DPOAEs in clinical settings. DESIGN: Twenty-six normal-hearing subjects were recruited, and eight were able to reliably and consistently induce NMEP using the Toynbee maneuver. Eight interleaved measures of tympanic peak pressure (TPP) were collected for each subject at normal pressure and NMEP. DPOAEs were then collected both when middle ear pressure was normal and during subject-induced NMEP. All measures were interleaved. Two primary tones were swept logarithmically across frequency (1 second per octave) from f1 = 410 to 6560 Hz and f2 = 500 to 8000 Hz (f1/f2 = 1.22), producing 2f1 - f2 DPOAEs from 320 to 5120 Hz. DPOAEs were collected at three equal-level primary level combinations (L65, L70, L75 dB SPL). Before composite and component DPOAE analysis, analysis of the f1 DPOAE primary confirmed that subjects had successfully induced NMEP. DPOAE and component magnitudes were separately analyzed using repeated measures analysis of variances with three factors, primary level (L65, L70, L75 dB SPL), middle ear pressure (normal pressure versus NMEP), and frequency (500 to 4000 Hz). RESULTS: Mean subject-induced NMEP ranged from -65 to -324 daPa. Changes in the magnitude (dB) of the primary tones used to induce the DPOAE provided a reliable indicator of subject-induced NMEP. Composite DPOAE and component levels were significantly affected by NMEP for all the frequencies tested. Changes were most clearly observed for the generator component with one subject demonstrating a mean decrease of 12 dB in magnitude during NMEP. Results were subject-specific, and there was a correlation between the degree of negative TPP induced and the amount of change in DPOAE level. CONCLUSIONS: Mean TPPs collected during NMEP ranged from -65 to -324 daPa and significantly affected composite DPOAE, generator, and reflection component levels. Changes in the magnitude of the swept-primaries as a function of frequency were used to confirm that NMEP had been successfully induced. The patterns of change in the composite DPOAEs were clearer and easier to interpret when the components of the DPOAE were separated with evaluation of the generator component alone.

Human and non-human primate intestinal FcRn expression and immunoglobulin G transcytosis.

PURPOSE: To evaluate transcytosis of immunoglobulin G (IgG) by the neonatal Fc receptor (FcRn) in adult primate intestine to determine whether this is a means for oral delivery of monoclonal antibodies (mAbs). METHODS: Relative regional expression of FcRn and localization in human intestinal mucosa by RT-PCR, ELISA & immunohistochemistry. Transcytosis of full-length mAbs (sandwich ELISA-based detection) across human intestinal segments mounted in Ussing-type chambers, human intestinal (caco-2) cell monolayers grown in transwells, and serum levels after regional intestinal delivery in isoflurane-anesthetized cynomolgus monkeys. RESULTS: In human intestine, there was an increasing proximal-distal gradient of mucosal FcRn mRNA and protein expression. In cynomolgus, serum mAb levels were greater after ileum-proximal colon infusion than after administration to stomach or proximal small intestine (1-5 mg/kg). Serum levels of wild-type mAb dosed into ileum/proximal colon (2 mg/kg) were 124 ± 104 ng/ml (n = 3) compared to 48 ± 48 ng/ml (n = 2) after a non-FcRn binding variant. In vitro, mAb transcytosis in polarized caco-2 cell monolayers and was not enhanced by increased apical cell surface IgG binding to FcRn. An unexpected finding in primate small intestine, was intense FcRn expression in enteroendocrine cells (chromagranin A, GLP-1 and GLP-2 containing). CONCLUSIONS: In adult primates, FcRn is expressed more highly in distal intestinal epithelial cells. However, mAb delivery to that region results in low serum levels, in part because apical surface FcRn binding does not influence mAb transcytosis. High FcRn expression in enteroendocrine cells could provide a novel means to target mAbs for metabolic diseases after systemic administration.

Wideband detection of middle ear muscle activation using swept-tone distortion product otoacoustic emissions.

The measurement of efferent-induced suppression of otoacoustic emissions (OAEs) using contralateral acoustic stimulation (CAS) is complicated by potential contamination by the middle ear muscle reflex (MEMR), particularly at moderate to high CAS levels. When logarithmically sweeping primaries are used to measure distortion product otoacoustic emissions, the level and phase of the primaries at the entrance of the ear canal may be monitored simultaneously along with the OAEs elicited by the swept-tones. A method of detecting MEMR activation using swept-tones is presented in which the differences in the primaries in the ear canal with and without CAS are examined, permitting evaluation of MEMR effects over a broad frequency range. A range of CAS levels above and below expected contralateral acoustic reflex thresholds permitted evaluation of conditions with and without MEMR activation.

Just-in-Time: A Caregiver-Mediated Intervention for Toddlers With Autism.

PURPOSE: We investigated effects of an adaptive telehealth coaching model on caregiver implementation of enhanced milieu teaching (EMT) with newly diagnosed toddlers with autism. METHOD: Three caregiver-child dyads participated in a multiple-baseline-across-behaviors, single-case design. Caregivers were taught EMT via telehealth using the teach-model-coach-review approach. EMT strategies were taught sequentially in four components corresponding to design tiers. Caregivers reported their needs for support and adaptation via weekly surveys. Primary outcomes were measures of caregiver's implementation, including (a) a fidelity checklist for wholistic use of EMT and (b) a percentage of correct use of a subset of key EMT strategies (e.g., matched turns, target talk, expansions, play actions, milieu episodes). Generalization and maintenance of caregiver strategy use in uncoached home activities were measured. The number of different words used by children was measured as a secondary, descriptive outcome. Social validity data were collected through ratings and interviews at the end of the study. RESULTS: There was a functional relation between the intervention and caregiver's implementation of EMT for all dyads. Caregiver's use of EMT strategies often generalized and maintained post-intervention. Child response to intervention was variable. Social validity data indicated that the model was beneficial to caregivers and children. CONCLUSIONS: An adaptive telehealth coaching model is effective for teaching caregivers of toddlers with autism to implement EMT and potentially helps to bridge the gap between diagnosis and comprehensive intervention. Further exploration of the relation between caregiver fidelity and dosage of active ingredients and child spoken language outcomes is needed. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.25156223.

The United Kingdom and the Netherlands maternity care responses to COVID-19: A comparative study.

BACKGROUND: The national health care response to coronavirus (COVID-19) has varied between countries. The United Kingdom (UK) and the Netherlands (NL) have comparable maternity and neonatal care systems, and experienced similar numbers of COVID-19 infections, but had different organisational responses to the pandemic. Understanding why and how similarities and differences occurred in these two contexts could inform optimal care in normal circumstances, and during future crises. AIM: To compare the UK and Dutch COVID-19 maternity and neonatal care responses in three key domains: choice of birthplace, companionship, and families in vulnerable situations. METHOD: A multi-method study, including documentary analysis of national organisation policy and guidance on COVID-19, and interviews with national and regional stakeholders. FINDINGS: Both countries had an infection control focus, with less emphasis on the impact of restrictions, especially for families in vulnerable situations. Differences included care providers' fear of contracting COVID-19; the extent to which community- and personalised care was embedded in the care system before the pandemic; and how far multidisciplinary collaboration and service-user involvement were prioritised. CONCLUSION: We recommend that countries should 1) make a systematic plan for crisis decision-making before a serious event occurs, and that this must include authentic service-user involvement, multidisciplinary collaboration, and protection of staff wellbeing 2) integrate women's and families' values into the maternity and neonatal care system, ensuring equitable inclusion of the most vulnerable and 3) strengthen community provision to ensure system wide resilience to future shocks from pandemics, or other unexpected large-scale events.

Teaching Caregivers to Support Social Communication: Results From a Randomized Clinical Trial of Autistic Toddlers.

BACKGROUND: Studies of early caregiver-mediated interventions targeting social communication of young autistic children have yielded variable child outcomes. This study examined the effects of combining two caregiver-mediated interventions on caregiver strategy use and child social communication and language outcomes. METHOD: This was a multisite parallel randomized controlled trial. Participants included 120 caregivers and their autistic children between 24 and 36 months of age. Dyads were randomly assigned to receive a hybrid intervention that combined Enhanced Milieu Teaching (EMT) and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) or to a behavior management control condition, each delivered over 6 months. Caregivers in the JASP-EMT group received twice-weekly, in-home, and hour-long sessions. Outcomes were measured at baseline, the end of intervention (T1), and 6 months later (T2) and included a naturalistic language sample procedure, standardized measures, and caregiver report measures. This trial was registered at clinicaltrials.gov (NCT02595697). RESULTS: Child outcomes did not differ between conditions at T1 or T2 for child primary (social communication) or secondary (language, play, and autism symptoms) outcomes. Relative to control group caregivers, intervention group caregivers demonstrated significantly higher use of JASP-EMT strategies at T1 and T2, with the exception of two strategies (Responsiveness and Matched Responsiveness), which were used significantly more by control group caregivers. Neither autism severity nor baseline caregiver responsiveness moderated outcomes. Post hoc analyses revealed significant correlations between specific strategies and all child outcomes. CONCLUSIONS: Twice-weekly caregiver-mediated intervention that taught caregivers of autistic children to use social communication support strategies did not yield significant child outcomes. Future studies should examine possible sources for the lack of main effects including unexpected differences in linguistic features of caregiver input, changes in control group caregiver behavior, and insufficient intervention dosage. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21714278.

It was tough, but necessary. Organizational changes in a community based maternity care system during the first wave of the COVID-19 pandemic: A qualitative analysis in the Netherlands.

INTRODUCTION: The Coronavirus SARS-CoV-2pandemic necessitated several changes in maternity care. We investigated maternity care providers' opinions on the positive and negative effects of these changes and on potential areas of improvement for future maternity care both in times of crisis and in regular maternity care. METHODS: We conducted nineteen semi-structured in-depth interviews with obstetricians, obstetric residents, community-based and hospital-based midwives and obstetric nurses. The interviews were thematically analysed using inductive Thematic analysis. RESULTS: Five themes were generated: '(Dis)proportionate measures', 'A significant impact of COVID-19', 'Differing views on inter-provider cooperation', 'Reluctance to seek help' and 'Lessons learnt'. The Central Organizing Concept was: 'It was tough but necessary'. The majority of participants were positive about most of the measures that were taken and about their proportionality. These measures had a significant impact on maternity care providers, both mentally and on an organizational level. Most hospital-based care providers were positive about professional cooperation and communication, but some community-based midwives indicated that the cooperation between different midwifery care practices was suboptimal. Negative effects mentioned were a higher threshold for women to seek care, less partner involvement and perceived more fear among women and their partners, especially around birth. The most significant positive effect mentioned was increased use of eHealth tools. Recommendations for future care were to consider the necessity of prenatal and postnatal care more critically, to replace some face-to-face visits with eHealth and to provide more individualised care. CONCLUSION: Maternity care providers experienced measures and organizational changes during the first wave of the COVID19-pandemic as tough, but necessary. They believed that a more critical consideration of medically necessary care, increased use of e-health and more individualised care might contribute to making maternity care more sustainable during and after the pandemic.

Changes in amplitude and phase of distortion-product otoacoustic emission fine-structure and separated components during efferent activation.

Medial olivocochlear (MOC) efferent fibers synapse directly on the outer hair cells (OHCs). Efferent activation evoked by contralateral acoustic stimulation (CAS) will affect OHC amplification and subsequent measures of distortion-product otoacoustic emissions (DPOAEs). The aim of this study was to investigate measures of total and separated DPOAEs during efferent activation. Efferent activation produces both suppression and enhancement of the total DPOAE level. Level enhancements occurred near fine-structure minima and were associated with consistent MOC evoked upward shifts in DPOAE fine-structure frequency. Examination of the phase of the separated components revealed that frequency shifts stemmed from increasing phase leads of the reflection component during CAS, while the generator component phase was nearly invariant. Separation of the two DPOAE components responsible for the fine-structure revealed more consistent reduction of the levels of both components. Using vector subtraction (which takes into account both level and phase) to estimate the changes in the unseparated DPOAE provided consistent evidence of DPOAE suppression. Including phase information provided a more sensitive, valid and consistent estimate of CAS function even if one does not know the position of the DPOAE in the fine-structure.

Evaluating the effect of an educational intervention on student midwife self-efficacy for their role as physiological childbirth advocates.

INTRODUCTION: Midwifery education that strengthens self-efficacy can support student midwives in their role as advocates for a physiological approach to childbirth. METHODS: To assess the effect of an educational intervention on self-efficacy, a pre- and post-intervention survey was administered to a control group and an intervention group of third year student midwives. The General Self-Efficacy Scale (GSES) was supplemented with midwifery-related self-efficacy questions related to behaviour in home and hospital settings, the communication of evidence, and ability to challenge practice. RESULTS: Student midwives exposed to midwifery education designed to strengthen self-efficacy demonstrated significantly higher levels of general self-efficacy (p = .001) when contrasted to a control cohort. These students also showed significantly higher levels of self-efficacy in advocating for physiological childbirth (p = .029). There was a non-significant increase in self-efficacy in the hospital setting in the intervention group, a finding that suggests that education may ameliorate the effect of hospital settings on midwifery practice. DISCUSSION: In spite of the small size of the study population, education that focuses on strengthening student midwife self-efficacy shows promise.

Understanding the perspectives and values of midwives, obstetricians and obstetric registrars regarding episiotomy: qualitative interview study.

OBJECTIVES: Insight into perspectives and values of care providers on episiotomy can be a first step towards reducing variation in its use. We aimed to gain insight into these perspectives and values. SETTING: Maternity care in the Netherlands. PARTICIPANTS: Midwives, obstetricians and obstetric registrars working in primary, secondary or tertiary care, purposively sampled, based on their perceived episiotomy rate and/or region of work. PRIMARY AND SECONDARY OUTCOME MEASURES: Perspectives and values of care providers which were explored using semistructured in-depth interviews. RESULTS: The following four themes were identified, using the evidence-based practice-model of Satterfield et al as a framework: 'Care providers' vision on childbirth', 'Discrepancy between restrictive perspective and daily practice', 'Clinical expertise versus literature-based practice' and 'Involvement of women in the decision'. Perspectives, values and practices regarding episiotomy were strongly influenced by care providers' underlying visions on childbirth. Although care providers often emphasised the importance of restrictive episiotomy policy, a discrepancy was found between this vision and the large number of varying indications for episiotomy. Although on one hand care providers cited evidence to support their practice, on the other hand, many based their decision-making to a larger extent on clinical experience. Although most care providers considered women's autonomy to be important, at the moment of deciding on episiotomy, the involvement of women in the decision was perceived as minimal, and real informed consent generally did not take place, neither during labour, nor prenatally. Many care providers belittled episiotomy in their language. CONCLUSIONS: Care providers' underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage. Their clinical expertise was a more important component in decision-making on episiotomy than the literature. Women were minimally involved in the decision for performing episiotomy. More research is required to achieve consensus on indications for episiotomy.

Denitrification of nitrogen released from senescing algal biomass in coastal agricultural headwater streams.

Assimilation of inorganic N by photoautotrophs has positive impacts on nutrient retention; however this retention is only temporary. As the biomass senesces, organic and inorganic forms of N are released back to the stream where they can be further transformed (i.e., nitrification, denitrification) or exported downstream. The purpose of this study was to assess the fate of the remineralized N, particularly the potential for removal by denitrification. Experiments were conducted on intact sediment cores from streams in an agricultural watershed. Cores were amended with varying ages of algal leachate and denitrification rates were measured with a membrane inlet mass spectrometer. Results of this study demonstrated that senescing algal biomass stimulated denitrification rates and provided a source of N and labile C to denitrifiers. Regardless of leachate age, addition of leachate to intact cores revealed a net loss of dissolved inorganic N from the water column. Denitrification rates were most strongly related to concentrations of dissolved and particulate C in the overlying water and secondarily to C quality (molar C to N ratio of total dissolved C and N) and NO(3)(-) flux. Using a mass balance approach, the proportion of N from senescing algal biomass that was denitrified accounted for as much as 10% of the total dissolved nitrogen (TDN) and up to 100% of the NO(3)(-) during a 3-h experiment. These results suggest an important link between instream algal uptake and eventual denitrification thereby providing a pathway for permanent removal of watershed-derived N from the stream ecosystem.

Sensitization to masked tones following notched-noise correlates with estimates of cochlear function using distortion product otoacoustic emissions.

Neuronal gain adaptation has been proposed as the underlying mechanism leading to the perception of phantom sounds such as Zwicker tones and tinnitus. In this gain-adaptation theory, cochlear compression plays a significant role with weaker compression leading to stronger phantom percepts. The specific aim of this study was to find a link between the strength of neuronal gain adaptation and cochlear compression. Compression was assessed using distortion product otoacoustic emissions (DPOAEs). Gain adaptation is hypothesized to manifest itself in the sensitization observed for the detection of masked tones when preceded by notched noise. Perceptual thresholds for pure tones in notched noise were measured at multiple frequencies following various priming signals. The observed sensitization was larger than expected from the combined effect of the various maskers. However, there was no link between sensitization and compression. Instead, across subjects, stronger sensitization correlated with stronger DPOAEs evoked by low-level primaries. In addition, growth of DPOAEs correlated reliably with perceptual thresholds across frequencies within subjects. Together, the data suggest that short-term dynamic adaptation leading to perceptual sensitization is the result of an active process mediated by the outer hair cells, which are thought to modulate the gain of the cochlear amplifier via efferent feedback.

Urbanization alters coastal plain stream carbon export and dissolved oxygen dynamics.

Coastal plain streams in the southeastern United States supply carbon that supports important coastal ecosystems, but the effects of urbanization on carbon export from these streams have not been extensively studied. This study aimed to determine how urbanization changes coastal plain stream organic matter quality, rates of carbon export, and dissolved oxygen dynamics that have implications for stream ecosystem function. Organic matter quality, organic carbon export, and dissolved oxygen concentrations were measured for multiple years (2009 & 2013-2015) in North Carolina coastal plain streams that spanned a gradient of urbanization. Based on spectral characteristics, dissolved organic matter (DOM) quality appeared to shift from characteristic blackwater in minimally impacted streams to clear streamwater in urban streams due to large reductions in chromophoric DOM concentrations, aromaticity, and molecular weight. Differences in spectral indices and characteristics of dissolved organic carbon export suggest that urbanization reduced natural sources of DOM and provided various urban sources of DOM that were likely more bioavailable. Particulate organic matter in the urban streams was indicative of more labile autochthonous sources than that of the less impacted streams, and rates of particulate carbon export increased and shifted to higher flows with watershed impervious surface cover. Diel variation of dissolved oxygen increased with watershed impervious surface cover, indicating that urbanization and associated changes in carbon and nutrient cycling altered stream function. While the effects of urbanization on carbon export were similar to previous studies in other regions, the unique blackwater state of natural streams and receiving waters in the study area make them especially susceptible to negative ecological impacts from altered carbon and nutrient export. Management actions that conserve or restore natural carbon sources to the stream may help mitigate multiple negative effects of urbanization in southeastern US coastal plain streams.

Midwifery students' perspectives on how role models contribute to becoming a midwife: A qualitative study.

BACKGROUND: The dynamics of maternal and newborn care challenge midwifery education programs to keep up-to-date. To prepare for their professional role in a changing world, role models are important agents for student learning. OBJECTIVE: To explore the ways in which Dutch and Icelandic midwifery students identify role models in contemporary midwifery education. METHODS: We conducted a descriptive, qualitative study between August 2017 and October 2018. In the Netherlands, 27 students participated in four focus groups and a further eight in individual interviews. In Iceland, five students participated in one focus group and a further four in individual interviews. All students had clinical experience in primary care and hospital. Data were analyzed using inductive content analysis. RESULTS: During their education, midwifery students identify people with attitudes and behaviors they appreciate. Students assimilate these attitudes and behaviors into a role model that represents their 'ideal midwife', who they can aspire to during their education. Positive role models portrayed woman-centered care, while students identified that negative role models displayed behaviors not fitting with good care. Students emphasized that they learnt not only by doing, they found storytelling and observing important aspects of role modelling. Students acknowledged the impact of positive midwifery role models on their trust in physiological childbirth and future style of practice. CONCLUSION: Role models contribute to the development of students' skills, attitudes, behaviors, identity as midwife and trust in physiological childbirth. More explicit and critical attention to how and what students learn from role models can enrich the education program.

Nitrogen cycling processes within stormwater control measures: A review and call for research.

Stormwater control measures (SCMs) have the potential to mitigate negative effects of watershed development on hydrology and water quality. Stormwater regulations and scientific literature have assumed that SCMs are important sites for denitrification, the permanent removal of nitrogen, but this assumption has been informed mainly by short-term loading studies and measurements of potential rates of nitrogen cycling. Recent research concluded that SCM nitrogen removal can be dominated by plant and soil assimilation rather than by denitrification, and rates of nitrogen fixation can exceed rates of denitrification in SCM sediments, resulting in a net addition of nitrogen. Nitrogen cycling measurements from other human-impacted aquatic habitats have presented similar results, additionally suggesting that dissimilatory nitrate reduction to ammonium (DNRA) and algal uptake could be important processes for recycling nitrogen in SCMs. Future research should directly measure a suite of nitrogen cycling processes in SCMs and reveal controlling mechanisms of individual rate processes. There is ample opportunity for research on SCM nitrogen cycling, including investigations of seasonal variation, differences between climatic regions, and trade-offs between nitrogen removal and phosphorus removal. Understanding nitrogen dynamics within SCMs will inform more efficient SCM design and management that promotes denitrification to help mitigate negative effects of urban stormwater on downstream ecosystems.

"A powerful midwifery vision": Dutch student midwives' educational needs as advocates of physiological childbirth.

BACKGROUND: In order to internalize the midwifery philosophy of care and to learn how to advocate for physiological childbirth, student midwives in the Netherlands need learning experiences that expose them to physiological childbirth practices. Increased hospital births, wide variation in non-urgent referrals and escalating interventions impact on learning opportunities for physiological childbirth. Midwifery educators need to find ways to support student agency in becoming advocates of physiological childbirth. OBJECTIVE: To gather students' opinions of what they need to become advocates of physiological childbirth. METHODS: Focus groups with student midwives (n=37), examining attitudes regarding what educational programs must do to support physiological childbirth advocacy. RESULTS: Students reported feelings of personal power when the midwifery philosophy of care is internalized and expressed in practice. Students also identified dilemmas associated with supporting woman-centered care and promoting physiological childbirth. Perceived hierarchy in clinical settings causes difficulties, leading students to practice in accordance with the norms of midwife preceptors. Students are supported in the internalization and realization of the midwifery philosophy of care, including physiological childbirth, if they are exposed to positive examples of care in practice and have opportunities to discuss and reflect on these in the classroom. KEY CONCLUSION: Midwifery education should focus on strategies that include navigating dilemmas in practice and helping students to express the midwifery philosophy of care in communication with other professionals and with women. Preceptors need to be supported in allowing student midwives opportunities to realize the midwifery philosophy of care, also when this differs from preceptor practice.