Unplanned Cesarean Birth: Can the Quality of Consent Affect Birth Experiences?

BACKGROUND: Unplanned cesarean birth is associated with high levels of patient dissatisfaction and negative birth experiences, which in turn can negatively impact birth outcomes. Previous research has demonstrated that issues of physician-patient communication, mistrust, fear of the operating room (OR), and loss of control contribute to patient dissatisfaction with unplanned cesarean birth. We hypothesized that altering the nature and structure of the informed consent prior to the surgery might improve patient satisfaction and birth experience. Specifically, we explored whether educating resident physicians in counseling skills could shift the focus of informed consent from a checklist merely informing the patient of the risks, benefits, and alternatives to a discussion that informs the physician of the patient's concerns and fears. By approaching consent in this manner, the goal of informed consent expands beyond autonomy rights to include beneficence as well. Methods: Residents received education to discuss issues of communication, fear, mistrust, and loss of control when seeking consent for an unplanned cesarean birth. Patients were randomized to receive either additional counseling that encouraged a discussion or a standard informed consent for cesarean birth. Participants were interviewed two weeks later and scored their satisfaction using a Likert scale on the four themes: communication, mistrust, fear of OR, and loss of control. Results: Both groups had very high patient satisfaction scores; there was no statistical difference between them. Conclusions: Both groups exhibited significantly higher levels of birth satisfaction than present in prior research. Training residents to discuss these issues while seeking consent for an unplanned cesarean birth may have improved patient satisfaction for all participants in this study. This suggests that educating residents to engage patients in a dialogue during informed consent counseling is more important than a specific script.

The calcineurin inhibitor RCAN1 is involved in cultured macrophage and in vivo immune response.

Studies on the role of regulator of calcineurin 1 (RCAN1) in immunity are limited, but have demonstrated an involvement in T-lymphocyte function. Here, we expand these studies to macrophages and in vivo infection. The treatment of RAW and primary mouse macrophages with lipopolysaccharide from Escherichia coli strongly induced RCAN1 isoform 4 (RCAN1-4), but not isoform 1. RCAN1-4 induction involved calcium, calcineurin, and reactive oxygen species. Subsequent analysis with whole bacteria including gram-negative E. coli and gram-positive Staphylococcus aureus revealed strong RCAN1-4 inductions by both, and where tested, dependence on calcium. Staphylococcus aureus cell wall components peptidoglycan and lipoteichoic acid also strongly induced RCAN1-4. In vivo, a significant induction in the proinflammatory cytokines monocyte chemotactic protein-1, interleukin-6, interferon-γ, and tumor necrosis factor-α was observed in knockout (KO) lung vs. wild-type (WT) mice 7 days after nasal infection with Fransicella tularensis. This induction was not accompanied by a significant increase in F. tularensis burden in the KO lung. Additionally, a modest increase in respiratory burst activity in KO vs. WT macrophages was observed. Combined, these studies indicate that RCAN1 is involved in macrophage and the overall in vivo immune response, and provide additional evidence that RCAN1 plays an important role in cell immunity and infectious disease.

Brain expression of the calcineurin inhibitor RCAN1 (Adapt78).

RCAN1 (Adapt78) is an endogenous inhibitor of calcineurin, an important intracellular phosphatase that mediates many cellular responses to calcium. RCAN1 is expressed in multiple organs, especially heart, skeletal muscle and brain. In brain, it is thought to be important due to its strong expression, developmental regulation, abundance of target protein (calcineurin), and putative links to multiple brain-related disorders. Surprisingly, however, few studies have examined RCAN1 protein expression here. This has led to some confusion in the field over the exact nature and cell-type expression of isoform 4, the more studied of the two major RCAN1 protein isoforms, in brain. Here we characterize RCAN1 brain isoforms in more detail by assessing their size and distribution under conditions of calcium elevation, a hallmark of the isoform 4 response, and using rodent models to allow for more expanded analyses. We find that the 25-29kDa version of this protein, reported in many non-brain studies, is indeed also present in neurons, and most observable after calcium induction. We also observe that expression of isoform 4 is not specific to neurons, as both microglia and astrocyte cells in culture exhibit a strong induction of isoform 4 protein following calcium stress that is not observable in non-stressed tissue sections. Isoform 1 expression is also observable in a primary glial cell-type (rat microglia). Finally, our observations confirm previous reports of low or non-detectable constitutive isoform expression in non-stressed glia, and of a larger sized, RCAN1 antibody-interacting species. These studies extend and complement previous studies on RCAN isoforms toward better understanding the role of RCAN1 in brain function and as a potential new target for treating calcineurin-related brain disorders.