Culturally capable and culturally safe: Caseload care for Indigenous women by Indigenous midwifery students.

BACKGROUND: Evidence is emerging of the benefits to students of providing continuity of midwifery care as a learning strategy in midwifery education, however little is known about the value of this strategy for midwifery students. AIM: To explore Indigenous students' perceptions of providing continuity of midwifery care to Indigenous women whilst undertaking a Bachelor of Midwifery. METHODS: Indigenous Bachelor of Midwifery students' experiences of providing continuity of midwifery care to Indigenous childbearing women were explored within an Indigenous research approach using a narrative inquiry framework. Participants were three Indigenous midwifery students who provided continuity of care to Indigenous women. FINDINGS: Three interconnected themes; facilitating connection, being connected, and journeying with the woman. These themes contribute to the overarching finding that the experience of providing continuity of care for Indigenous women creates a sense of personal affirmation, purpose and a validation of cultural identity in Indigenous students. DISCUSSION AND CONCLUSIONS: Midwifery philosophy aligns strongly with the Indigenous health philosophy and this provides a learning platform for Indigenous student midwives. Privileging Indigenous culture within midwifery education programs assists students develop a sense of purpose and affirms them in their emerging professional role and within their community. The findings from this study illustrate the demand for, and pertinence of, continuity of care midwifery experiences with Indigenous women as fundamental to increasing the Indigenous midwifery workforce in Australia. Australian universities should provide this experience for Indigenous student midwives.

Development of the Awareness of Cultural Safety Scale: A pilot study with midwifery and nursing academics.

BACKGROUND: Rates of academic success of Indigenous students compared to other students continues to be significantly lower in many first world countries. Professional development activities for academics can be used to promote teaching, learning and support approaches that value Indigenous worldviews. However, there are few valid and reliable tools that measure the effect of academic development strategies on awareness of cultural safety. OBJECTIVES: To develop and validate a self-report tool that aims to measure nursing and midwifery academics' awareness of cultural safety. METHODS: This study followed a staged model for tool development. This included: generation of items, content validity testing and expert Indigenous cultural review, administration of items to a convenience sample of academics, and psychometric testing. An online survey consisting of demographic questions, Awareness of Cultural Safety Scale (ACSS), and awareness of racism items was completed by academics undertaking a professional development program on cultural safety. FINDINGS: Ratings by experts revealed good content validity with an index score of 0.86. The 12-item scale demonstrated good internal reliability (Cronbach's alpha of 0.87). An evaluation of construct validity through factor analysis generated three factors with sound internal reliability: Factor 1 (Cultural Application, Cronbach's alpha=.85), Factor 2 (Cultural Support, Cronbach's alpha=.70) and Factor 3 (Cultural Acknowledgement, Cronbach's alpha=.85). The mean total scale score was 46.85 (SD 7.05, range 31-59 out of a possible 60). There was a significant correlation between scores on the Awareness of Cultural Safety Scale and awareness of racism scores (r=.461, p=.002). CONCLUSION: Awareness of cultural safety is underpinned by principles of respect, relationships, and responsibility. Results indicated the ACSS was valid and reliable. Completion of the scale aimed to foster purposeful consideration by nursing and midwifery academics about their perceptions and approaches to teaching in order to improve Indigenous student success.

Perianal fistulas in Crohn's disease are predominantly colonized by skin flora: implications for antibiotic treatment?

In this study we aimed to determine the microorganisms found in perianal fistulas in Crohn's disease and whether treatment with ciprofloxacin affects these microorganisms. Thirteen patients (males/females, 7/6; median age, 34 years; range, 18-61 years) with fistulas were treated with infliximab, 5 mg/kg intravenously, at weeks 6, 8, and 12 and randomized to double-blind treatment with ciprofloxacin, 500 mg bd (n = 6), or placebo (n = 7) for 12 weeks. Samples were taken at baseline and at weeks 6 and 18. In the ciprofloxacin group 10 different genera of microorganisms were identified, while 13 genera could be identified in the placebo group. Gram-negative enteric floras were present in a small minority. The genera found in patients with perianal fistulas were predominantly gram-positive microorganisms. Therefore, antimicrobial treatment should be directed toward these microorganisms.

Clinical and endosonographic effect of ciprofloxacin on the treatment of perianal fistulae in Crohn's disease with infliximab: a double-blind placebo-controlled study.

BACKGROUND: Ciprofloxacin is effective in perianal Crohn's disease but after treatment discontinuation symptoms reoccur. Infliximab is effective but requires maintenance therapy. AIM: To evaluate the effect of combined ciprofloxacin and infliximab in perianal Crohn's disease. METHODS: A double-blind placebo-controlled study was conducted. Patients were randomly assigned to receive 500-mg ciprofloxacin twice daily or a placebo for 12 weeks. All patients received 5-mg/kg infliximab in week 6, 8 and 12 and were followed for 18 weeks. Primary end-point was clinical response, defined as a 50% or greater reduction from baseline in the number of draining fistulae. Secondary end-points were the change in Perianal Disease Activity Index and hydrogen peroxide enhanced three-dimensional endoanal ultrasonography findings. Analysis was by intention-to-treat. RESULTS: Twenty-four patients were included but two discontinued treatment. At week 18, response was 73% (eight of 11) in the ciprofloxacin group and 39% (five of 13) in the placebo group (P = 0.12). Using logistic regression analysis patients treated with ciprofloxacin tended to respond better (OR = 2.37, CI: 0.94-5.98, P = 0.07). The Perianal Disease Activity Index score only improved (P = 0.008) in the ciprofloxacin group. Three-dimensional endoanal ultrasonography improved in three patients with a clinical response. CONCLUSIONS: A combination of ciprofloxacin and infliximab tended to be more effective than infliximab alone.

Nurses begin a national plan for the integration of supportive care in health research, practice, and policy.

The demand for and use of health, social, and other human services is related not to the type or severity of disease but rather to a person's socio-economic, cognitive, and emotional characteristics and environmental circumstances. A workshop on supportive care was held to promote a robust research environment, the creation of new knowledge, the setting of an integrated health research agenda, a focusing of attention on the evolving health-care system, and anticipation of emerging health challenges. While the workshop was intended to address a research mandate for the Canadian Institutes of Health Research, a larger vision emerged, to include advocacy, information system, surveillance, and policy development required by institutional, community, voluntary, private sector, family caregiver, and provider systems. The development of a national supportive care strategy will enable Canadians with disease and disability to live with all of their challenges, and could engage researchers, clinicians, advocacy groups, and people experiencing major health challenges.

The inferior parietal lobule is the target of output from the superior colliculus, hippocampus, and cerebellum.

The inferior parietal lobule (IPL) is a functionally and anatomically heterogeneous region that is concerned with multiple aspects of sensory processing and sensorimotor integration. Although considerable information is available about the corticocortical connections to the IPL, much less is known about the origin and importance of subcortical inputs to this cortical region. To examine this issue, we used retrograde transneuronal transport of the McIntyre-B strain of herpes simplex virus type 1 (HSV1) to identify the second-order neurons in subcortical nuclei that project to the IPL. Four monkeys (Cebus apella) received injections of HSV1 into three different subregions of the IPL. Injections into a portion of the lateral intraparietal area labeled second-order neurons primarily in the superficial (visual) layers of the superior colliculus. Injections of HSV1 into a portion of area 7a labeled many second-order neurons in the CA1 region of the hippocampus. In contrast, virus injections within a portion of area 7b labeled second-order neurons in posterior regions of the dentate nucleus of the cerebellum. These observations have some important functional implications. The IPL is known to be involved in oculomotor and attentional mechanisms, the establishment of maps of extrapersonal space, and the adaptive recalibration of eye-hand coordination. Our findings suggest that these functions are subserved by distinct subcortical systems from the superior colliculus, hippocampus, and cerebellum. Furthermore, the finding that each system appears to target a separate subregion of the IPL provides an anatomical substrate for understanding the functional heterogeneity of the IPL.

Randomized controlled trial of a midwife-delivered brief smoking cessation intervention in pregnancy.

OBJECTIVE: To evaluate the efficacy of a brief smoking cessation intervention with pregnant women practicable routinely by midwives. DESIGN: Midwives were randomized to deliver the experimental intervention or usual care. The 10-15-minute intervention was based on brief counselling, written materials, arrangements for continuing self-help support and feedback on expired-air carbon monoxide levels. The intervention was tailored to the women's needs: those who did not want to stop smoking received a brief motivational intervention, those who wanted to stop received an intervention designed to assist them and those that had stopped recently (recent ex-smokers) received a relapse prevention intervention. SETTING: Booking interviews with pregnant women in nine hospital and community trusts. SUBJECTS: A total of 1120 pregnant women in the third month of pregnancy (249 recent ex-smokers and 871 current smokers). MAIN OUTCOME MEASURES: Three indicators of biochemically validated abstinence were collected. Continuous abstinence for at least 3 months prior to delivery, point prevalence abstinence immediately post-delivery, and continuous abstinence from 3 months pre-delivery to 6 months post-delivery. RESULTS: Only a small proportion of the women who would have been eligible to take part in the trial were actually recruited by 178 recruiting midwives, with lack of time being cited as the main barrier. The intervention and usual care groups differed in post-delivery point prevalence abstinence rates for recent ex-smokers (65% vs. 53%, p < 0.05, one-tailed), but not in other outcome measures. Overall, 54% of "recent ex-smokers" at booking and 7% of "current smokers" at booking had been abstinent for at least 3 months at the time of delivery, and 23% and 3%, respectively, were still abstinent by the time the child was 6 months old (i.e. 12 months post-intervention). Smoking status at follow-up was predicted by dependence indexed by time to first cigarette in the morning. CONCLUSIONS: A brief "one-off" smoking cessation intervention by midwives does not seem to be a practicable or effective method of helping pregnant smokers to stop. Other options such as tailored self-help materials and telephone counselling and other specialist treatments should be examined. Current smoking cessation rates in pregnancy are very low.

Smoking cessation guidelines for health professionals: an update. Health Education Authority.

This paper updates the evidence base and key recommendations of the Health Education Authority (HEA) smoking cessation guidelines for health professionals published in Thorax in 1998. The strategy for updating the evidence base makes use of updated Cochrane reviews supplemented by individual studies where appropriate. This update contains additional detail concerning the effectiveness of interventions as well as comments on issues relating to implementation. The recommendations include clarification of some important issues addressed only in general terms in the original guidelines. The conclusion that smoking cessation interventions delivered through the National Health Service are an extremely cost effective way of preserving life and reducing ill health remains unchanged. The strategy recommended by the guidelines involves: (1) GPs opportunistically advising smokers to stop during routine consultations, giving advice on and/or prescribing effective medications to help them and referring them to specialist cessation services; (2) specialist smokers' services providing behavioural support (in groups or individually) for smokers who want help with stopping and using effective medications wherever possible; (3) specialist cessation counsellors providing behavioural support for hospital patients and pregnant smokers who want help with stopping; (4) all health professionals involved in smoking cessation encouraging and assisting smokers in use of nicotine replacement therapies (NRT) or bupropion where appropriate. The key points of clarification of the previous guidelines include: (1) primary health care teams and hospitals should create and maintain readily accessible records on the current smoking status of patients; (2) GPs should aim to advise smokers to stop, and record having done so, at least once a year; (3) inpatient, outpatient, and pregnant smokers should be advised to stop as early as possible and the advice recorded in the notes in a readily accessible form; (4) there is currently little scientific basis for matching individual smokers to particular forms of NRT; (5) NHS specialist smokers' clinics should be the first point of referral for smokers wanting help beyond what can be provided through brief advice from the GP; (6) help from trained health care professionals specialising in smoking cessation such as practice nurses should be available for smokers who do not have access to specialist clinics; (7) the provision of specialist NHS smokers' clinics should be commensurate with demand; this is currently one or two full time clinics or their equivalent per average sized health authority, but demand may rise as publicity surrounding the services increases.

Aerobic biodegradation of dichloroethylenes in surface and subsurface soils.

Laboratory studies were conducted to examine the aerobic biodegradation of dichloroethylenes (cis-1,2-DCE, trans-1,2-DCE and 1,1-DCE) in soil and groundwater. Authentic surface and subsurface materials with no reported DCE exposure history were used. All DCE isomers were observed to biodegrade to varying degrees in the soils examined. Use of radiolabeled [14C] test chemicals allowed correlation of DCE disappearance with mineralization to 14CO2. Study results indicate that naturally occurring microorganisms in soil and groundwater are capable of degrading cis-1,2-, trans-1,2- and 1,1-DCE without laboratory supplementation of exogenous organic nutrients, or previous exposure history. The data further suggest that degradative potential may vary with soil type, DCE isomer structure, and concentration.

Establishment of an in-use testing method for evaluating disinfection of surgical instruments using the duck hepatitis B model.

Nosocomial transmission of hepatitis B virus (HBV), associated with interventional procedures, has been attributed to its survival on improperly decontaminated instruments. To date, guidelines for chemical disinfection of potentially contaminated heat-sensitive instruments have been based largely on extrapolation of data from in-vitro disinfectant testing. Direct infectivity testing has not been possible for HBV because of the lack of a practical culture assay or susceptible experimental animal model. In this study the related duck hepadnavirus was used to simulate in-vivo transmission of a HBV during surgery, and to evaluate the effectiveness of 2% glutaraldehyde disinfection of surgical laparoscopes. Multiple laparoscopic liver biopsies were performed on 'biohazardous' duck hepatitis B (DHBV) positive ducks. Laparoscopes were then subjected to different disinfection regimes using 2% glutaraldehyde, and residual infectivity tested by placing their tips into the peritoneal cavities of uninfected four-day-old ducklings. Direct transmission of DHBV occurred in all ducks when laparoscopes were not washed. Rinsing with water lowered the transmission rate to 64% and no infection transmission occurred after 5 min of contact time with the disinfectant. In contrast, previous in-vitro studies had shown complete viral inactivation after a shorter period of disinfection. It is postulated that the longer inactivation time observed in our study may be a result of surface interactions of virus and instrument, interfering with disinfectant access or activity. Tests of instrument surface samples for viral DNA by the polymerase chain reaction (PCR) did not correlate with transmission of virus infection in vivo. PCR is an inappropriate test for evaluating the efficacy of disinfectant action despite its sensitivity. This in use method will allow testing of other decontamination procedures and their effectiveness on more complex surgical instruments.

Myelodysplasia, chemical exposure, and other environmental factors.

This paper describes a case-control study of the occupational and environmental exposures of patients with myelodysplasia. The methodology, first described in Canada for solid tumors, estimates lifetime exposures to a number of potential toxic hazards or carcinogens. This pilot study confirms that the methodology, with the use of questionnaires and interviews, can estimate exposures to specific chemicals and shows some significant associations with myelodysplasia, including exposure to petrol or diesel compounds.

Solitary silent venous papillary loops and ocular hypertension.

A series of 24 eyes in 23 patients is described showing solitary silent venous papillary loops. These loops are usually associated with a considerable degree of ocular hypertension, presenting when this hypertension is being investigated. They are silent, usually with no previous ocular history, single with a large diameter, affecting veins at the optic disc and not extending into the vitreous. The optic disc is cupped, but usually not more than 0.6 disc diameter, there is good central vision and either a full visual field or only early field loss. Fluorescein angiography shows the loops to be competent with no evidence of any other retinal vascular abnormality. Rarely loss of central vision may occur due to progression to advanced glaucoma. The condition is distinct from prepapillary vascular arterial papillary loops, neovascularization at the optic disc and optociliary shunt vessels. It is also distinct from the venous collateral vessels which develop at the optic disc after acute central or branch retinal vein occlusion. These collaterals are usually multiple, the accompanying ocular hypertension is of lesser degree, cupping of the disc and field loss are usually much more advanced and, while visual acuity may be normal, it is often grossly reduced. On fluorescein angiography all these cases of venous collaterals after retinal vein occlusion showed evidence of other retinal vascular dysfunction. Solitary silent venous papillary loops appear to develop from venules on the optic disc as a bypass to a low grade venous occlusion which is seldom clinically manifest. They form a distinct entity with a good prognosis if the accompanying ocular hypertension is carefully controlled.

Malnutrition in infants receiving cult diets: a form of child abuse.

Severe nutritional disorders, including kwashiorkor, marasmus, and rickets, were seen in four children and were due to parental food faddism, which should perhaps be regarded as a form of child abuse. All disorders were corrected with more normal diets and vitamin supplements. In view of the potentially serious consequences of restricted diets being fed to children, families at risk should be identified and acceptable nutritional advice given. When children are found to be suffering from undernutrition due to parental food faddism a court order will normally be a necessary step in providing adequate treatment and supervision.

The effect of cholestyramine on intestinal absorption.

Cholestyramine in a mean dosage of 0-6 g/kg/day has been given to 18 children with familial hypercholesterolaemia for between one and two and a half years. With prolonged treatment folate deficiency occurred, as evidenced by a fall in the mean serum folate concentration from 7-7 ng/ml before treatment to 4-4 ng/ml for patients on treatment for over one year; a corresponding lowering of red cell folate was also seen. Oral folic acid 5 mg daily overcame this depletion, and should be given to all patients on long-term anion exchange resins. Prothrombin time has remained normal in all patients; there has been a significant decrease in the mean serum concentrations of vitamins A and E and of inorganic phosphorus over the first two years of treatment, although values remain within the normal range. The routine administration of fat-soluble vitamins appears unnecessary but it is prudent to measure prothrombin time and serum vitamins A and E at intervals. In children who were having a normal intake of dietary fat five out of seven tested had faecal fat of over 5 g/day while on cholestyramine. No chold has developed diarrhoea, and growth has been normal. The concentrations of serum iron, vitamin B12, plasma calcium, and protein did not change significantly in any patient.