The challenges and opportunities for implementing group antenatal care ('Pregnancy Circles') as part of standard NHS maternity care: A co-designed qualitative study.

OBJECTIVE: To identify the challenges and opportunities for rolling out a bespoke model of group antenatal care called Pregnancy Circles (PC) within the National Health Service: what kind of support and training is needed and what adaptations are appropriate, including during a pandemic when face-to-face interaction is limited. DESIGN: Exploratory qualitative study (online focus group). Study co-designed with midwives. Data analysed thematically using an ecological model to synthesise. SETTING: Five maternity services within the National Health Service. PARTICIPANTS: Seven midwives who facilitated PCs. Three senior midwives with implementation experience participated in the co-design process. FINDINGS: Three themes operating across the ecological model were identified: 'Implementing innovation', 'Philosophy of care' and 'Resource management'. Tensions were identified between group care's focus on relationships and professional autonomy, and concepts of efficiency within the NHS's market model of care. Midwives found protected time, training and ongoing support essential for developing the skills and confidence needed to deliver this innovative model of care. Integrating Pregnancy Circles with continuity of carer models was seen as the most promising opportunity for long-term implementation. Midwives perceived continuity and peer support as the most effective elements of the model and there was some evidence that the model may be robust enough to withstand adaptation to online delivery. KEY CONCLUSIONS: Midwives facilitating group care enjoyed the relationships, autonomy and professional development the model offered. Harnessing this personal (micro-level) satisfaction is key to wider implementation. Group care is well aligned with current maternity policy but the challenges midwives face (temporal, practical and cultural) must be anticipated and addressed at macro and meso level for wider implementation to be sustainable. The PC model may be flexible enough to adapt to online delivery and extend continuity of care but further research is needed in these areas. IMPLICATIONS FOR PRACTICE: Implementation of group care in the NHS requires senior leadership and expertise in change management, protected time for training and delivery of the model, and funding for equipment. Training and ongoing support, are vital for sustainability and quality control. There is potential for online delivery and integrating group care with continuity models.

The identification of key indicators to drive quality improvement in obstetric anaesthesia: results of the Obstetric Anaesthetists' Association/National Perinatal Epidemiology Unit collaborative Delphi project.

A three-stage Delphi survey process was undertaken to identify the quality indicators considered the most relevant to obstetric anaesthesia. The initial quality indicators assessed were derived from national peer-reviewed publications and were divided into service provision, service quality and clinical outcomes. A range of stakeholders were invited to participate and divided into three panels: obstetric anaesthetists; other maternity care health professionals; and women who had used maternity services. In total, 133 stakeholders registered to participate with 80% completing all three phases of the survey process. Participants ranked indicators for their relative importance using the grading of recommendations assessment, development and evaluation scale. From an initial list of 31 quality indicators, 11 indicators were rated as extremely important by > 90% of participants in at least two panels. These 11 indicators were presented to stakeholders; they were asked to vote for the five indicators they considered most relevant and useful for assessing and benchmarking the quality of obstetric anaesthesia provided. The indicators chosen were: the percentage of women who had an epidural/combined spinal-epidural for labour analgesia with accidental dural puncture; the presence of guidelines for the referral of patients to an anaesthetist for antenatal review; whether there are dedicated elective caesarean section lists; the availability of point-of-care testing for estimation of haemoglobin concentration; and the percentage of epidurals for labour analgesia that provided adequate pain relief within 45 min of the start of epidural insertion. These indicators may be used for quality improvement and national benchmarking to support the implementation of quality standards in obstetric anaesthesia.

Reducing the level of nutrition of twin-bearing ewes during mid to late pregnancy produces leaner prime lambs at slaughter.

The Australian prime lamb industry is seeking to improve lean meat yield (LMY) as a means to increasing efficiency and profitability across the whole value chain. The LMY of prime lambs is affected by genetics and on-farm nutrition from birth to slaughter and is the total muscle weight relative to the total carcass weight. Under the production conditions of south eastern Australia, many ewe flocks experience a moderate reduction in nutrition in mid to late pregnancy due to a decrease in pasture availability and quality. Correcting nutritional deficits throughout gestation requires the feeding of supplements. This enables the pregnant ewe to meet condition score (CS) targets at lambing. However, limited resources on farm often mean it is difficult to effectively manage nutritional supplementation of the pregnant ewe flock. The impact of reduced ewe nutrition in mid to late pregnancy on the body composition of finishing lambs and subsequent carcass composition remains unknown. This study investigated the effect of moderately reducing ewe nutrition in mid to late gestation on the body composition of finishing lambs and carcass composition at slaughter on a commercial scale. Multiple born lambs to CS2.5 target ewes were lighter at birth and weaning, had lower feedlot entry and exit weights with lower pre-slaughter and carcass weights compared with CS3.0 and CS3.5 target ewes. These lambs also had significantly lower eye muscle and fat depth when measured by ultrasound prior to slaughter and carcass subcutaneous fat depth measured 110 mm from the spine along the 12th rib (GR 12th) and at the C-site (C-fat). Although carcasses were ~5% lighter, results showed that male progeny born to ewes with reduced nutrition from day 50 gestation to a target CS2.5 at lambing had a higher percentage of lean tissue mass as measured by dual energy X-ray absorptiometry and a lower percentage of fat during finishing and at slaughter, with the multiple born progeny from CS3.0 and CS3.5 target ewes being similar. These data suggest lambs produced from multiple bearing ewes that have had a moderate reduction in nutrition during pregnancy are less mature. This effect was also independent of lamb finishing system. The 5% reduction in carcass weight observed in this study would have commercially relevant consequences for prime lamb producers, despite a small gain in LMY.

Experiences, utilisation and outcomes of maternity care in England among women from different socio-economic groups: findings from the 2010 National Maternity Survey.

OBJECTIVE: The objective of this analysis was to explore the healthcare-seeking behaviours and experiences of maternity care among women from different socio-economic groups in order to improve understanding of why socially disadvantaged women have poorer maternal health outcomes in the UK. DESIGN: Secondary analysis of a national survey of women conducted 3 months after they had given birth. SETTING: England. SAMPLE: A total of 5332 women. METHODS: Logistic regression analysis to investigate differences in outcomes among different socio-economic groups, classified by the Index of Multiple Deprivation (IMD). MAIN OUTCOME MEASURES: Healthcare-seeking behaviours, outcomes and experiences of maternity care. RESULTS: With each increase in IMD quintile (decrease in socio-economic position), women were shown to be 25% (adjusted odds ratio [aOR] 0.75; 95% confidence interval [95% CI] 0.63-0.90) less likely to have had any antenatal care and 15% (aOR 0.85; 95% CI 0.80-0.90) less likely to have had a routine postnatal check-up. They were 4% (aOR 1.04; 95% CI 0.99-1.10) more likely to have had an antenatal hospital admission, 7% (aOR 1.07; 95% CI 0.99-1.16) more likely to have been transferred during labour and 4% (aOR 1.04; 95% CI 0.99-1.09) more likely to have had a caesarean birth, although these results were not statistically significant. With decreasing socio-economic position women were more likely to report that they were not treated respectfully or spoken to in a way they could understand by doctors and midwives. CONCLUSIONS: This analysis suggests the need for a focusing of professionals and services towards pregnant women from lower socio-economic groups and more targeted maternal public health education towards socially disadvantaged women.

Clinical evaluation of expanded input dynamic range in Nucleus cochlear implants.

OBJECTIVE: The aim of this study was to investigate whether expanded instantaneous input dynamic ranges (IIDRs) in the Nucleus cochlear implant system benefit speech perception in the laboratory and listening in the real world. DESIGN: Until recently, Nucleus cochlear implants have used an IIDR of approximately 30 dB. In this study, an IIDR of 31 dB was compared with 46 dB and 56 dB in the SPEAR3 research processor with nine adult implant recipients. Subjects were given two, 2-wk blocks of take-home experience with each of the three IIDRs. A single IIDR setting was used in each trial period. During the take-home experience with the expanded IIDRs, subjects used two programs: a standard program (with clinically measured electrode dynamic ranges) and a program with adjusted thresholds (decreased T levels). After each block of take-home experience, speech perception testing was conducted for CNC words in quiet (at 45 dB and 55 dB SPL) and for CUNY sentences in the presence of multi-taker babble. RESULTS: On average, CNC word recognition at low presentation levels was significantly better with the 46 dB and 56 dB IIDRs, compared with the 31 dB IIDR; however, there was no significant difference between the 46 dB and 56 dB IIDR conditions. These benefits were greater for standard programs than for reduced T level programs. For CUNY sentences in babble, group results indicated no significant difference in performance across IIDR. The three IIDRs were rated similarly in real-life listening situations, and two of the subjects expressed tolerance problems with the expanded standard IIDRs. CONCLUSIONS: IIDRs of 46 and 56 dB provided benefit in accessing low-level speech without a decrement in sentence perception in babble. Most subjects accepted the standard, wider IIDR programs in everyday life. No significant differences were found between the 46 dB and 56 dB IIDR programs.

Effect of direct-fed microbials on performance, diet digestibility, and rumen characteristics of Holstein dairy cows.

The objective of this study was to determine the effect of feeding direct-fed microbial (DFM) products containing Lactobacillus acidophilus and Propionibacteria freudenreichii on the performance, nutrient digestibility, and rumen fermentation of Holstein dairy cows in midlactation. Experiments were conducted from February to May 2003. Cows were fed 1 of 3 dietary treatments: 1) 1 x 10(9) colony-forming units (cfu)/d of live L. acidophilus strain LA747 and 2 x 10(9) cfu/d of live P. freudenreichii strain PF24 (DFM1); 2) 1 x 10(9) cfu/d of live L. acidophilus strain LA747, 2 x 10(9) cfu/d of live P. freudenreichii strain PF24, and 5 x 10(8) cfu/d of L. acidophilus strain LA45 (DFM2); or 3) lactose (control). Treatments were administered by mixing 45 g of finely ground corn with 5 g of DFM products or lactose and top dressing on the total mixed rations once daily. All cows received the same total mixed ration: 12.7% alfalfa hay, 46.2% corn silage, and 41.1% concentrate on a dry matter (DM) basis. In study 1 (lactation study), 39 multiparous and 18 primiparous Holstein cows were blocked by parity and randomly assigned to treatments for 84 d. Starting on d 35, fecal grab samples were collected from each cow at 5- to 8-h intervals over 48 h for digestibility measurements. A rumen fermentation study (study 2) was conducted concurrently with the lactation study. Three rumenfistulated, multiparous Holstein cows were randomly assigned to dietary treatments DFM1, DFM2, and control in a 3 x 3 Latin square design with 28-d periods. In study 1, there was no difference in average DM intake (23.9, 23.6, and 24.2 kg/d) or 4% fat-corrected milk (36.8, 35.3, and 36.2 kg/d) for treatments DFM1, DFM2, and control. Percentage or yield of milk components also did not differ among treatments. Feed efficiency averaged 1.52 kg of 4% fat-corrected milk/kg of DM intake and did not differ among treatments. There were no differences in apparent DM, crude protein, neutral detergent fiber, or starch digestibility among treatments. In study 2, there was no difference in rumen pH and concentrations of ammonia or total volatile fatty acids measured at 0, 1, 3, and 6 h after feeding. Under the conditions of these studies, supplementing midlactation cows with DFM products containing L. acidophilus and P. freudenreichii did not affect cow performance, diet digestibility, or rumen fermentation.

Preliminary results with the AVR ImpaCt frequency-transposing hearing aid.

Currently, the only behind-the-ear hearing aid that provides a frequency transposition function is the ImpaCt DSR675, recently introduced by AVR Communications Ltd. of Israel. In tests with three hearing-impaired adults, the performance of the ImpaCt aid(s) was compared with that of each subject's own (nontransposing) hearing aids. Recognition of monosyllabic words and medial consonants did not differ significantly between the two types of aids. This suggests that the transposition function of the ImpaCt was not effective at providing these subjects with increased high-frequency speech information, at least for the programmable parameters applied in the experiments. However, the subjects' understanding of sentences in a competing noise was significantly poorer with the ImpaCt than with the subjects' own aids. In that test, the ImpaCt aids were programmed to attenuate parts of the noise. The decreased sentence recognition may have resulted from this program, which effectively reduced the bandwidth of the ImpaCt aids.

Delayed treatment with AM-36, a novel neuroprotective agent, reduces neuronal damage after endothelin-1-induced middle cerebral artery occlusion in conscious rats.

BACKGROUND AND PURPOSE: AM-36 is a novel arylalkylpiperazine with combined antioxidant and Na(+) channel blocking actions. Individually, these properties have been shown to confer neuroprotection in a variety of in vitro and in vivo animal models of stroke. Preliminary studies have shown that AM-36 is neuroprotective in vivo. The purpose of the present study was to assess the neuroprotective and behavioral outcome after delayed administration of AM-36 in an endothelin-1-induced, middle cerebral artery model of cerebral ischemia in conscious rats. METHODS: Conscious male hooded Wistar rats were subjected to middle cerebral artery occlusion by perivascular microinjection of endothelin-1 via a previously implanted cannula. AM-36 (6 mg/kg IP) or vehicle was administered intraperitoneally 30, 60, or 180 minutes after middle cerebral artery occlusion. Functional outcome was determined 24, 48, and 72 hours after stroke by neurological deficit score, motor performance, and sensory hemineglect tests. Rats were killed at 72 hours, and infarct area and volume were determined by histology and computerized image analysis. RESULTS: Endothelin-1-induced middle cerebral artery occlusion resulted in marked functional deficits and neuronal damage. AM-36 significantly reduced cortical damage when administration was delayed until 30, 60, or 180 minutes after stroke. Interestingly, neuronal damage was time-dependently reduced, with the greatest protection found when AM-36 was administered 180 minutes after stroke. Striatal damage was significantly reduced after treatment with AM-36 at 180 minutes after stroke. Functional outcome paralleled histopathology. Rota-rod performance, sensory hemineglect, and neurological deficit scores returned to preischemia levels in AM-36-treated rats by 72 hours after stroke when administration was delayed by 180 minutes after stroke. CONCLUSIONS: AM-36 potently protects against both neuronal damage and functional deficits even when administered up to 180 minutes after induction of stroke. In fact, the greatest protection was found when administration was delayed by 180 minutes after stroke. The possible mechanisms of action of AM-36 are discussed. The present findings suggest that AM-36 may have great promise in the acute treatment of human stroke.

The moss, Physcomitrella patens, transformed with apoaequorin cDNA responds to cold shock, mechanical perturbation and pH with transient increases in cytoplasmic calcium.

The gene for apoaequorin has been used previously to indicate cytosolic calcium changes in higher plants. Here we report the transformation of the moss Physcomitrella patens with the cDNA for apoaequorin. Stable transformants were obtained in the wild type which reconstitute the calcium-sensitive luminescent protein aequorin in vivo after incubation in coelenterazine, and continue to grow normally. The wild type responds to cold-shock (0-10 degrees C) with increases in cytosolic calcium. Mechanical perturbation, in the form of touch, also induces transient increases in cytosolic calcium. A smaller response to pH, distinct from the touch response and exhibiting different kinetics, can also be detected.

Ontogenetic regulation and photoregulation of members of the Phaseolus vulgaris L. rbcS gene family.

The rbcS1, 2 and 3 genes of Phaseolus vulgaris are identical in coding sequence and we have studied their expression using gene-specific probes derived from their 3' non-coding regions. The genes differ in their relative levels of expression but show only minor qualitative differences in their regulation. Transcripts of the three genes are undetectable in primary leaves in the imbibed seed, accumulate early in leaf expansion reaching a maximum 7-10 d after sowing and decrease to low levels by the time expansion is complete. Both dark-grown and light-grown primary leaves exhibit this ontogenetic pattern of expression, although the light-grown leaves have two to three times more rbcS transcripts. Light can over-ride the ontogenetic control of rbcS expression; for example, when 7-d-old dark-grown primary leaves are illuminated there is a 6- to 12-fold increase in the transcript levels of the rbcS genes. Transfer of illuminated leaves to darkness results in the loss of transcripts of all three genes, but rbcS2 transcripts persist in the dark-adapted leaves. Possible physiological mechanisms of the ontogenetic regulation of expression are discussed.

The complete structure of human class IV alcohol dehydrogenase (retinol dehydrogenase) determined from the ADH7 gene.

A novel human alcohol dehydrogenase (ADH) gene called ADH7 has been characterized and determined to encode class IV ADH, an ADH isozyme which is very active as a retinol dehydrogenase. A nearly full-length cDNA for ADH7 was isolated from a human stomach cDNA library, and a 5' genomic clone containing exons 1 and 2 was isolated from a human genomic library. DNA sequence analysis of the cDNA and genomic clones revealed the complete coding region of the gene and the deduced full-length amino acid sequence of human class IV ADH composed of 373 amino acids following the initiator methionine. The class IV identity of the sequence was confirmed by agreement with previously determined sequences for several human stomach class IV ADH peptides. Alignment of the full-length predicted amino acid sequence of human class IV ADH with the full-length sequences of the other four known human ADH classes revealed sequence identities of 69% (class I), 59% (class II), 61% (class III), and 60% (class V). The higher sequence identity shared with human class I ADH suggests that the genes for ADH classes I and IV may have diverged from a common ancestor after the separation of the other classes, and may still share common physiological functions. Discussed is the possibility that one of these functions is retinol oxidation for the synthesis of retinoic acid, a hormone important for cellular differentiation.

Toxicity of melaleuca oil and related essential oils applied topically on dogs and cats.

Cases of melaleuca oil toxicosis have been reported by veterinarians to the National Animal Poison Control Center when the oil was applied dermally to dogs and cats. In most cases, the oil was used to treat dermatologic conditions at inappropriate high doses. The typical signs observed were depression, weakness, incoordination and muscle tremors. The active ingredients of commercial melaleuca oil are predominantly cyclic terpenes. Treatment of clinical signs and supportive care has been sufficient to achieve recovery without sequelae within 2-3 d.

Genes encoding the small subunit of ribulose 1,5-bisphosphate carboxylase/oxygenase in Phaseolus vulgaris L.: nucleotide sequence of cDNA clones and initial studies of expression.

The small subunit of ribulose 1,5-bisphosphate carboxylase/oxygenase (EC 4.1.1.39) in the French bean Phaseolus vulgaris L. is encoded by a small gene family consisting of a minimum of three members. Three small subunit genes (rbcS genes) represented in a light-grown primary leaf cDNA library were characterised by sequencing two cDNAs which were full-length and one which was deficient in part of the sequence encoding the transit peptide. The cDNA clones are identical in their coding sequences, for both the transit peptide and the mature polypeptide, but divergent in their untranslated sequences. The derived amino acid sequence is very similar to that reported for other species, although the first amino acid of the mature polypeptide is isoleucine, which differs from the methionine found in all other higher plant rbcS genes. Surprisingly, one of the cDNA clones contains two introns, which are at positions conserved in rbcS genes from other species. It is concluded that this cDNA resulted from the cloning of an unprocessed transcript. Alternative polyadenylation sites are found for two of the genes. Expression of the rbcS genes in the primary leaves is stimulated by light, although transcripts can readily be detected in dark-grown leaves. Expression is also organ-specific, as in other species. The frequency of cDNA clones in the library indicates that the different genes show quantitative differences in expression and S1 nuclease analysis suggests that individual rbcS genes are photoregulated.

Lipid peroxidation in newborn rabbits: effects of oxygen, lipid emulsion, and vitamin E.

The extent of in vivo lipid peroxidation and the in vivo antioxidant effects of alpha-tocopherol and alpha-tocopheryl acetate were studied in newborn rabbits exposed to one of two oxidant stresses: hyperoxia (FIO2 greater than 0.9) or parenteral lipid emulsion infusion. Lipid peroxidation was monitored by measurement of expired ethane and pentane, tissue thiobarbituric acid (TBA) reactants, and tissue lipid peroxides. Seventy-two h of hyperoxia did not increase any of the parameters of lipid peroxidation although mortality was higher in oxygen exposed animals. alpha-Tocopherol (100 mg/kg, intravenous) lowered expired hydrocarbons and tissue TBA reactants, but raised liver lipid peroxides in both air and hyperoxia exposed pups. Infusion of soybean oil emulsion increased production of ethane and pentane, liver TBA reactants, and lung lipid peroxides. Both alpha-tocopherol and alpha-tocopheryl acetate prevented the soybean oil emulsion induced increase in volatile hydrocarbons. alpha-Tocopherol (100 mg/kg, intravenous) administration also prevented the increase in liver TBA reactants and lung lipid peroxides. In identically treated animals, alpha-tocopheryl acetate administration decreased liver TBA reactants but had no effect on lung lipid peroxides. We conclude that alpha-tocopherol reduces lipid peroxidation in newborn rabbits including animals exposed to hyperoxia or infused with lipid emulsions. alpha-Tocopheryl acetate results in lower tissue alpha-tocopherol concentrations and is less effective as an antioxidant in lipid emulsion infused rabbits.

Phenothiazine and butyrophenone intoxication in children.

Antipsychotic agents are widely used for the treatment of psychotic disorders as well as for the acute treatment of nausea and vomiting, cough and cold treatments, and as supplementary agents for sedation for minor surgical or diagnostic procedures. There are many different circumstances in which the clinician may encounter a child who has experienced antipsychotic drug toxicity, such as from an acute accidental ingestion or as a side effect from therapeutic use. The phenothiazines and butyrophenone drugs have many pharmacologic actions. Thus, a wide range of clinical symptoms and signs may be encountered with their use. Treatment of antipsychotic drug toxicity includes general supportive care and monitoring, along with specific treatment of certain situations such as acute extrapyramidal syndromes and neuroleptic malignant syndrome. An awareness of the diverse and complex manifestations that may be associated with these agents will greatly aid in the evaluation of a child who presents with unusual behavioral or neurologic problems. Due to the unpredictable toxicity of these drugs, routine therapeutic use for such conditions as nausea and vomiting and as cough or cold aids is not recommended.

Multihandicapped children's preferences for pure tones and speech stimuli as a method of assessing auditory capabilities.

Residual hearing capabilities of nine severely and profoundly retarded multihandicapped deaf-blind children were determined with an operant procedure that allowed the children to respond by making a selection between two alternative responses. One response option resulted in the presentation of auditory reinforcement (pure tones and speech stimuli of various frequencies); the other option resulted in no reinforcement. Levels of the sound intensity were varied systematically to obtain a "threshold" for selective responding. Each of the severely damaged "untestable" children made numerous meaningful responses throughout the testing sessions, thereby revealing the levels of intensity that could be heard and those that were not high enough to elicit preferential responding. The children responded comparably in conditions employing pure tones and speech. The responses of most of the children were comparable across frequency conditions, although some of the children's records show selective responding at lower levels of intensity for certain frequencies than for others. We also found that varying the level of intensity of the stimuli not only affected the children's selective behavior, but also their time on task measures and their individual patterns of responding.

Volvulus of the sigmoid colon.

The clinical presentation and treatment of 31 consecutive patients with sigmoid volvulus are reviewed. Nearly half of these patients had a history of mental illness and one-third of all patients were chronically constipated. The main clinical features of abdominal pain and gross abdominal distension had been present for an average of 8 days before presentation of the patient to hospital. The clinical diagnosis of sigmoid volvulus was not difficult but the presence of non-viable bowel was more difficult to establish. A silent abdomen was the most valuable indication of the presence of gangrenous bowel. Conservative measures, including sigmoidoscopy and therapeutic barium enema, successfully reduced the volvulus in half of the cases so treated. In those patients undergoing surgery the procedure associated with the lowest mortality was sigmoid resection with end-to-end anastomosis. The overall mortality was 35%.