XVI. On the cure of the gout

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Carbon Monoxide Screening in Pregnancy: An Evaluation Study of a Plymouth Pilot Intervention

This report provides an analysis and evaluation of a National Institute for Health and Care Excellence (NICE) recommended pilot intervention which was designed to identify pregnant women exposed to carbon monoxide due to cigarette smoke and refers them to local stop smoking services (LSSS). The pilot intervention was carried out by community midwives working in two areas of Plymouth. The city has areas of social and health inequalities and the study drew on populations from a socially deprived neighbourhood and a socially affluent area. The pilot was instigated following new NICE guidance recommending that all women attending initial ante natal booking appointments with their community midwives be offered a Carbon Monoxide (CO) breath analyser screening to determine their smoking status and or exposure to other forms of CO. This evaluation study identifies the benefits and barriers associated with the implementation of the CO screening pilot. In particular, our aims were to explore any detrimental impact on the relationship between women and their community midwives, identify the impact on midwives in terms of time and resources, reveal the responses and acceptability or otherwise of the screening as perceived and experienced by the women being asked to participate during the booking appointment and finally to evaluate the success of the intervention overall in relation to the numbers of referrals made to Plymouth’s LSSS. A further aim was explore any differences in the two socio demographic areas. We adopted a mixed methods approach involving four focus group interviews with 23 midwives, a survey posted to the 258 women who attended initial antenatal booking appointments in the study areas, an online version of the survey to ascertain the views and experiences of pregnant women and new mothers nationally and an interrogation of an internet forum discussion board for mothers. A two page questionnaire consisting of 12 questions was designed and posted to women who attended the booking appointment with the midwife during the three month pilot period and the same survey was made available online. Questions were designed to elicit women’s views about the information given by the midwife in relation to the screening, whether they had agreed to participate in the CO screening process, their experiences and views about offering CO screening to pregnant women and their smoking status and those of other household members. Of the 258 questionnaires posted to women who had attended the clinic during the pilot intervention 40 completed responses were returned representing a 15.5% response rate. Only 4 responses were received from the online survey posting but an additional 484 comments posted on the Mumsnet website discussion board were analysed. Our findings show that in general there was a high degree of acceptability for the intervention. Midwives and their clients were generally in support of the screening being offered to all pregnant women. However, this support was dependent on a number of contextual factors. Women wanted to be properly informed about the screening and midwives wanted to be kept informed about the effects of the intervention on women’s smoking cessation. Initial and ongoing training of midwives in utilising the protocol and in instructing women to correct use the monitor was also very important. Trust was revealed to be a very important aspect of the relationship between women and their midwives. Some women felt that the CO screening was being used just to check whether or not they were smokers and some midwives also worried about the possible negative effects the CO screening may have on their relationships with women

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study

Abstract Background In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman’s care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres? Methods Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach. Results Factors influencing midwives’ care escalation decisions included the care environment, a woman’s diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used ‘workarounds’ to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable. Conclusions Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade. </jats:sec

Counting Bears, P’s And Q’s: An Efficient Sample Design for a Spatial Capture Recapture Hair Snag Study of Grizzly Bears

Accurate assessment of abundance can be expensive and managers often seek to minimize costs. Because spatial capture recapture (SCR) methods explicitly account for variation in trap effort in space and time and permit the use of covariates to explain abundance, substantial flexibility in design and thus reduction in costs may be possible. Estimates of grizzly bear (Usus arctos) densities and abundances in 4 management units in Alberta were very low  (superpopulation n =  47-133) in the latest studies occurring from 2004-2008. Since these first provincial population estimates were obtained, management, landscape, and habitat conditions have changed. Managers would like updated abundance information but also seek to reduce the costs of acquiring these data. We assessed 1) the behavior of SCR models across several general sample designs and 2) whether we could eliminate sampling in helicopter-access-only areas in the Yellowhead management unit while maintaining accurate estimates. We used a combination of retrospective subsampling of existing data from a 2004 sampling effort and simulations to evaluate several designs. Placing sampling arrays in areas with high densities of bears decreased variance, while the fine-scale configuration of traps did not greatly influence estimates. Simulations of designs for Alberta with more intensive sampling of only the areas accessible by road and no sampling of more expensive helicopter-access-only areas provided robust estimates with little loss in precision. We will describe the framework and assumptions of SCR models with covariates for abundance in comparison with traditional capture recapture models

Dealing with Complexity: Infant Feeding Choices and Experiences for Mothers with Infants in Neonatal Intensive Care Units and Transitional Care Wards

EXECUTIVE SUMMARY The central aim of the research on which this document reports was: To explore the knowledge, perceptions and experiences of infant feeding of mothers with infants in neonatal intensive care units (NICU) and transitional care wards (TCW) and the support these mothers receive from healthcare professionals and significant others with the aim of contributing to further support of mothers, significant others and healthcare professionals in the future. The objectives were: 1. To explore mothers’ with infants in NICU knowledge and understanding of infant, feeding and how this influences feeding choices. 2. To gain an understanding of mothers experiences of infant feeding, 3. To investigate the challenges of infant feeding in NICU. 4. To explore the significance of their self-identity and perception as ‘good’ or ‘not so good’ mothers in relation to this choice. 5. To ascertain the support women receive from healthcare professionals and significant others. 6. To identify further research needs, develop service provision and inform practice and policy. Background to the study is supported by a review of the clinical and sociologically relevant literature and brief detail on a previous related study (Stenhouse and Letherby 2013) which focused on the experience of mothers’ whose pregnancies were complicated by diabetes. A mixed method ethnographic approach was adopted: • Observations in the NICU and TCW were undertaken (alongside interviewing) amounting to approximately six hours. • One-to-one and dyad/group interviewing were undertaken with mothers and some of their partners. • Questionnaires (consisting of 10 questions, some of which were open to allow more respondent input) were distributed to all healthcare professionals working in NICU and TCW. An audit involving a systematic and independent examination of maternal and infant notes was undertaken at the same time as the primary data was collected. DATA AND DISCUSSION The Audit: This section provides a snapshot of infant feeding and expression of breastmilk from a cohort of mothers and babies who had previously been cared for in NICU, TCW or both. Appendix IV is a copy of a poster presented as part of the Medical Training Special Studies Unit. Interview and Questionnaire Data: This section reports on data collected from women, significant others and healthcare professionals and includes detailed reference to the significance of ‘The Journey’, the mixed experience of ‘Skills and Support’ and the experiences of ‘Pleasure, Pressure and Propaganda’. CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Six summary points 1. Training for staff is mixed and this is linked to confidence in supporting women. 2. Women ‘sensed’ the lack of confidence of some staff and this caused anxiety i.e. if the combination of staff on a shift had little experience/knowledge. 3. Women recognised that certain occupation groups had more time and experience to support them i.e. nursery nurses on TCW, midwives on NICU. 4. The physical environment was an issue for respondents. For example: a. TCW privacy, or not, when expressing and feeding. b. In NICU screens used for expressing or feeding sometimes caused anxiety given that screens are also used when baby is poorly/undergoing a procedure. 5. In TCW, formula feed was linked to early discharge resulting in some experiencing subtle pressure to formula feed. 6. Community outreach team very supportive to some and women respondents felt they would have benefited from longer support. Six recommendations 1. Training needs to be consistent for all grades of staff and a whole day annually is preferred by healthcare professional respondents. 2. Release from service essential to ensure training is undertaken and given the high priority it deserves. 3. Different coloured screens for expressing/feeding AND for procedures would be beneficial and reduce stress for mothers and significant others. 4. Active recruitment of peer supporters with experience of having a baby in NICU. 5. Ensure continued support from peer supporters when moving from breastfeeding to formula feeding. 6. More information related to equipment available in the community on discharge i.e. hospital grade breast pumps

Stretched chemical bonds in Si6H6: A transition from ring currents to localized pi-electrons?

Motivated by solid-state studies on the cleavage force in Si, and the consequent stretching of chemical bonds, we here study bond stretching in the, as yet unsynthesized, free space molecule Si6H6. We address the question as to whether substantial bond stretching (but constrained to uniform scaling on all bonds) can result in a transition from ring current behaviour, characteristic say of benzene at its equilibrium geometry, to localized pi-electrons on Si atoms. Some calculations are also recorded on dissociation into 6 SiH radicals. While the main studies have been carried out by unrestricted Hartree-Fock (HF) theory, the influence of electron correlation has been examined using two forms of density functional theory. Planar Si6H6 treated by HF is bound to be unstable, not all vibrational frequencies being real. Some buckling is then allowed, which results in real frequencies and stability. Evidence is then provided that the non-planar structure, as the Si-Si distance is increased, exhibits pi-electron localization in the range 1.2-1.5 times the equilibrium distance

Scaffolding Classroom Discourse in an Election Year: Keeping a Cool Mood in a Heated Season

Certainly, teaching about politics can be daunting, especially as the political climate in the United States becomes increasingly partisan as a result of heated political rhetoric amplified through a variety of media outlets. However, elementary teachers can help students develop the respectful dispositions they will need as young adults living in an increasingly pluralistic society. These dispositions can be fostered only if teachers are willing to engage their young learners in discussions of politics as part of the curriculum. In this article, the authors discuss ways in which teachers can promote political tolerance and respect during coverage of a presidential election, a high-profile event that social studies educators Mary Haas and Margaret Laughlin describe as the quintessential example of teaching social studies. Here, the authors also describe instructional strategies designed specifically for the upper elementary grades, although they note ways in which teachers can adapt these strategies for younger learners as well

<i>‘What retention’ means to me</i>: the position of the adult learner in student retention

Studies of student retention and progression overwhelmingly appear adopt definitions that place the institution, rather than the student, at the centre. Retention is most often conceived in terms of linear and continuous progress between institutionally identified start and end points. This paper reports on research that considered data from 38 in-depth interviews conducted with individuals who had characteristics often associated with non-traditional engagement in higher education who between 2006 and 2010 had studied an ‘Introduction to HE’ module at one distance higher education institution, some of whom had progressed to further study at that institution, some of whom had not. The research deployed a life histories approach to seek a finer grained understanding of how individuals conceptualise their own learning journey and experience, in order to reflect on institutional conceptions of student retention. The findings highlight potential anomalies hidden within institutional retention rates – large proportions of the interview participants who were not ‘retained’ by the institution reported successful progression to and in other learning institutions and environments, both formal and informal. Nearly all described positive perspectives on lifelong learning which were either engendered or improved by the learning undertaken. This attests to the complexity of individuals’ lives and provides clear evidence that institution-centric definitions of retention and progression are insufficient to create truly meaningful understanding of successful individual learning journeys and experiences. It is argued that only through careful consideration of the lived experience of students and a re-conception of measures of retention, will we be able to offer real insight into improving student retention