Knowing in Childbirth

Research on knowing in childbirth has largely been a quantitative process. The purpose of this study was to better understand the ways nine, first-time mothers learn about birth. A phenomenological approach using a feminist view was used to analyze two in-depth interviews and journals to understand first time expectant mothers\u27 experiences of knowing in childbirth. The findings demonstrated a range of knowledge that contributed to issues of control, confidence, hope, and conflict. The participants also described an increased dependency on their mothers and a lack of intuition contiguous to the birth process. These findings contribute understanding as to how expectant mothers know birth, suggesting that their knowing does not diminish conflict surrounding and may even exacerbate it. Childbirth educators may want to include instruction on negotiating power differential in relationships encountered during childbirth, and to assess the expectant mother\u27s view of birth and her expectations for birth. Schools of nursing should consider the inclusion of women-centered care curricula in schools of nursing at both the undergraduate and graduate levels. Clearly, the politics surrounding birthing remain in place and must be removed to provide a supportive environment for normal birth

Knowing in Childbirth

Research on knowing in childbirth has largely been a quantitative process. The purpose of this study was to better understand the ways nine, first-time mothers learn about birth. A phenomenological approach using a feminist view was used to analyze two in-depth interviews and journals to understand first time expectant mothers\u27 experiences of knowing in childbirth. The findings demonstrated a range of knowledge that contributed to issues of control, confidence, hope, and conflict. The participants also described an increased dependency on their mothers and a lack of intuition contiguous to the birth process. These findings contribute understanding as to how expectant mothers know birth, suggesting that their knowing does not diminish conflict surrounding and may even exacerbate it. Childbirth educators may want to include instruction on negotiating power differential in relationships encountered during childbirth, and to assess the expectant mother\u27s view of birth and her expectations for birth. Schools of nursing should consider the inclusion of women-centered care curricula in schools of nursing at both the undergraduate and graduate levels. Clearly, the politics surrounding birthing remain in place and must be removed to provide a supportive environment for normal birth

More Than Skin Deep: Detection of subclinical enthesopathy and early psoriatic arthritis in patients with psoriasis in primary and secondary care and assessment of the response to anti-IL-12/IL-23p40 monoclonal antibody skin-directed therapy using ultrasound and whole-body MRI

Objectives: Primary care cohort: To determine the rates of undiagnosed psoriatic arthritis (PsA) amongst patients with psoriasis using clinical examination and screening questionnaires, and test the performance a new PsA screening questionnaire alongside the current standard (Psoriasis Epidemiology Screening Tool, PEST). Secondary care cohort: To develop novel ultrasound and whole body magnetic resonance imaging (WBMRI) protocols to facilitate the comprehensive assessment of subclinical abnormalities within the peripheral and axial skeleton of immunomodulatory therapy-naïve patients with psoriasis referred to secondary care, and to use these protocols to assess the imaging response of abnormalities over 52 weeks of skin- directed treatment with a licensed IL-12/23p40 inhibitor (ustekinumab). Methods: Primary care cohort: 932 patients, across five diverse primary care practices, who were coded as having a diagnosis of psoriasis, were invited by their General Practitioner to attend an evening appointment at their surgery for a consultation with a dermatologist and a rheumatologist. Half of patients were sent an educational leaflet regarding PsA with their invitation letter. Attendees were examined and asked to complete a PEST questionnaire and a new PsA screening questionnaire (CONTEST). Secondary care cohort: 73 immunomodulatory therapy-naive patients, without musculoskeletal disease or symptoms, who were referred to dermatology for treatment of moderate to severe psoriasis were screened using an extensive ultrasound protocol to assess for the presence of subclinical enthesitis. Patients who had at least one inflammatory abnormality, and in whom biologic therapy was not contraindicated, were invited to receive standard-dose skin directed therapy with ustekinumab for 52 weeks. Ultrasound examination of 13 entheses and structures within the adjacent synovio- entheseal complex were performed at weeks 0, 12, 24 and 52. WBMRI was performed at week 0, 24 and 52, to assess the axial skeleton and sites in the peripheral skeleton inaccessible by ultrasound. 23 healthy volunteers had one ultrasound scan and WBMRI using the same protocols, for comparison. Results: Primary care cohort: 20.5% of patients invited for screening attended. The provision of an educational leaflet did not have an impact on attendance for screening, except in the most deprived areas. 191 patients were examined, of which 169 had current or previous psoriasis (11.5% misdiagnosis rate). 17 patients were newly diagnosed with PsA (10.1%). The best sensitivity and specificity of the CONTEST questionnaires were 76.5% and 56.5% respectively, without the joint mannequin (cut off 33), and 70.6% and 63.3% respectively, with the joint mannequin (cut off 34). The sensitivity and specificity of the PEST questionnaire in this cohort, using the validated cut off 33, was 52.9% and 66.0%. Lowering the cut off 32, the sensitivity improved to 82.4% with a specificity of 44.9%. Secondary care cohort: 36 patients (49.3%) had at least inflammatory subclinical abnormality on screening ultrasound. 28 of these 36 were eligible for a biologic therapy and agreed to undergo a more detailed ultrasound scan and WBMRI. 5 patients subsequently chose conventional therapy, and 23 patients consented to treatment with ustekinumab and long-term review. 23 patients reached the primary end point of week 24, and 20 reached week 52. Inflammatory and chronic damage abnormalities were seen with greater frequency in the peripheral rather than axial skeleton, mostly involving the larger entheses of the knee, foot, ankle and elbows. Healthy volunteers exhibited a similar pattern of abnormalities but at a significantly lower frequency (inflammatory lesions 4.5% vs. 31.1%, chronic damage lesions 6.0% vs. 27.0%, both p<0.00001). Synovitis was seen in 82.1% of patients, while bursitis and tenosynovitis were uncommon. Following treatment with ustekinumab, ultrasound inflammation scores reduced by 42.2% at the primary end point (week 24, p<0.001), and by 51.5% after 52 weeks (p=0.01). Chronic damage scores remain unchanged (p=0.082 week 24, p=0.512 week 52). In the axial skeleton, more patients than volunteers had vertebral unit bone marrow oedema (64.3% vs. 30.4%, p<0.00001). Sacroiliac joint inflammation was minimal in both groups. Axial structural changes occurred in 14.3% in patients and were absent in volunteers. No significant change in spine or SIJ osteitis (p=0.656 week 24, p=0.627 week 52), or structural abnormalities were observed after ustekinumab therapy. Conclusions: A proportion of patients with psoriasis have undiagnosed PsA in primary care, even with signs and symptoms of inflammatory arthritis. Screening questionnaires are useful to detect some, but not all patients and further measures are required to capture all cases of PsA. Early identification and treatment is essential to prevent future pain, functional limitation and disability. Treating patients for psoriasis with a therapeutic agent that is effective at reducing the development of PsA is one means of addressing the failings of clinical examination and screening questionnaires, although the evolution from subclinical enthesitis (a common finding in patients with psoriasis) to PsA is not understood. This thesis provides preliminary data to suggest that anti-IL-12/23p40 therapy may reduce the burden of subclinical inflammation at the primary site of lesion development in PsA (the enthesis), and further longitudinal studies are now encouraged to confirm these observations with ustekinumab and other immunomodulatory therapies

Multiple Elements RegulateMash1Expression in the Developing CNS

AbstractMash1, a transcription factor of the basic helix–loop–helix class, is expressed during embryogenesis in restricted regions of the nervous system. An essential role for Mash1 in neural development was demonstrated previously in mice carrying a targeted disruption of theMash1gene. Regulation of the precise temporal and spatial expression ofMash1is thus likely to be important for proper neural development. In this study, sequences that regulateMash1expression in the central nervous system were characterized by assaying the expression oflacZreporter genes in transgenic embryos. A 1158-bp enhancer localized ∼7 kb upstream of theMash1coding region was identified. Deletions within this enhancer region reveal the presence of both positive and negativecis-acting elements. Analysis of multiple sequences within the enhancer demonstrate that different elements preferentially function in different regions within theMash1-specific CNS expression domain. In addition, a role for sequences 3′ of theMash1coding region is revealed, providing evidence for posttranscriptional control ofMash1expression in multiple CNS domains

La adaptabilidad institucional en tiempos de la COVID-19

La capacidad de un sistema de asilo para adaptar sus procesos es importante y desempeña un papel clave para garantizar la sostenibilidad a lo largo del tiempo. Sin embargo, la adaptación nunca debe hacerse a expensas de otros elementos vitales de un sistema de asilo fuerte y justo

Cognitive and affective reassurance and patient outcomes in primary care:a systematic review

In the context of uncertainty about aetiology and prognosis, good clinical practice commonly recommends both affective (creating rapport, showing empathy) and cognitive reassurance (providing explanations and education) to increase self-management in groups with nonspecific pain conditions. The specific impact of each of these components in reference to patients' outcomes has not been studied. This review aimed to systematically evaluate the evidence from prospective cohorts in primary care that measured patient-practitioner interactions with reference to patient outcomes. We carried out a systematic literature search and appraisal of study methodology. We extracted measures of affective and cognitive reassurance in consultations and their associations with consultation exit and follow-up measures of patients' outcomes. We identified 16 studies from 16,059 abstracts. Eight studies were judged to be high in methodological quality. Pooling could not be achieved as a result of heterogeneity of samples and measures. Affective reassurance showed inconsistent findings with consultation exit outcomes. In 3 high-methodology studies, an association was found between affective reassurance and higher symptom burden and less improvement at follow-up. Cognitive reassurance was associated with higher satisfaction and enablement and reduced concerns directly after the consultations in 8 studies; with improvement in symptoms at follow-up in 7 studies; and with reduced health care utilization in 3 studies. Despite limitations, there is support for the notion that cognitive reassurance is more beneficial than affective reassurance. We present a tentative model based on these findings and propose priorities for future research. © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved

Silicon isotopes in an Archaean migmatite confirm seawater silicification of TTG sources

Funding: This work was made possible by PhD funding to MM by the University of St Andrews School of Earth and Environmental Sciences and the Handsel scheme, in addition to NERC grant NE/R002134/1 to PS.Unraveling ancient melting processes is key to understanding how the earliest, tonalite-trondhjemite-granodiorite (TTG)-dominated continental crust formed from partial melting of amphibolite. Application of silicon isotope analysis to ancient crust reveals that Archaean TTGs exhibit consistently high Si isotope values (δ30Si) compared to modern granitoids, attributed to seawater-derived silica introduced by either (a) partial melting of variably silicified basalts or (b) assimilation of authigenic silica-rich marine lithologies in the melt source. However, both mechanisms can introduce highly variable δ30Si, conflicting with the strikingly consistent δ30Si compositions of Archaean TTGs. This study investigates an alternative model, whereby the distinct mineralogy and chemistry of TTG melt sources impart a distinct silicon isotope composition to the melt, compared with “modern” granitoids. We measured δ30Si in component parts (melanosome and leucosome) of an Archaean (2.7 Ga) mafic migmatite and coeval amphibolites and mafic granulites from the Kapuskasing uplift, Canada, to explore how Si isotopes fractionate during incipient TTG melt formation. Our data reveal leucosome (i.e., melt) exhibits consistently high δ30Si values compared to a relatively isotopically lighter melanosome (i.e., residuum). We also derive inter-mineral silicon isotope fractionation factors for mineral separates that agree well with those of ab initio estimates for the same minerals and show that the magnitude of equilibrium fractionation between TTG source rock and melt replicates that in Phanerozoic granitoids. We conclude the effects of magmatic differentiation on δ30Si have remained consistent throughout Earth history, meaning that Archaean TTGs must require a source isotopically heavier than unaltered basalt, as reflected by our amphibolites and mafic migmatite components. The consistently heavy δ30Si of seawater through Earth history, and the high SiO2 content of amphibolites relative to coeval leucosome-free granulites in our study area, imply seawater silicification is the source of the observed high δ30Si. Thus, the consistently heavy Si isotope compositions measured in Archaean melt products define a unique aspect of ancient crust formation: that of the silicification of TTG source rock, implying the intrinsic involvement of a primeval hydrosphere.Publisher PDFPeer reviewe

Chronic rhinosinusitis:a qualitative study of patient views and experiences of current management in primary and secondary care

OBJECTIVES: To explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care. DESIGN: Semistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis). SETTING: Primary care and secondary care ear, nose and throat outpatient clinics in the UK. PARTICIPANTS: Twenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis. RESULTS: CRS has a significant impact on patients' quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more 'holistic' approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored. CONCLUSIONS: Patients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes