A Process Evaluation of Nurses' Implementation of an Infant Feeding Counseling Protocol for HIV-infected Mothers: The Breastfeeding, Antiretroviral and Nutrition (BAN) Study in Lilongwe, Malawi

In prevention of mother to child HIV transmission programs, nurses are responsible for counseling HIV-infected mothers about infant feeding. Studies of nurses' infant feeding counseling in African countries suggest that counseling quality is often poor and may be associated with nursing culture, inadequate training, and health system factors. Few studies, however, have conducted theory-informed process evaluations to assess nurses' implementation of an infant feeding counseling protocol. This study conducted the process evaluation of an infant feeding counseling protocol for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, an ongoing clinical trial in Lilongwe, Malawi. Six nurses, trained on World Health Organization recommendations, counseled HIV-infected mothers to exclusively breastfeed for 6 months and stop breastfeeding at 6 months. This study adapted and applied patient-provider communication theoretical concepts to assess nurses' counseling behaviors through: (1) direct observation and audio-taping of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) using a checklist to document nurses' adherence to specific protocol items; and (2) in-depth interviews with each nurse to document adherence perceptions and attitudes toward the protocol. Analysis included calculating a percent adherence of checklists and constant comparison techniques and visual display matrices for the observation and interview data. Results indicate that nurses were implementing the protocol at an average adherence level of 90% or above. Adherence to protocol items during the antenatal sessions was 100%. During postnatal sessions, adherence ranged from 92.7% to 97.8%. Nurses' implementation inconsistencies occurred when addressing breast health and breastfeeding cessation issues. An unexpected finding was nurses counseling mothers on proper infant formula preparation, although not detailed in the protocol. Interviews revealed a high nurse to mother ratio and additional counseling training on infant formula and complementary feeding preparation as perceived barriers toward complete protocol adherence. Findings illustrate that with minimal training, nurses implemented the BAN Study infant feeding counseling protocol as designed. The process evaluation results will help to interpret the BAN Study's impact and health outcomes related to evaluating mother's feasibility to follow infant feeding recommendations. The implication for HIV/AIDS clinical trials is to conduct process evaluations to identify and address potential implementation inconsistencies and, thereby, improve protocol implementation adherence

Knowledge and information needs of informal caregivers in palliative care : a qualitative systematic review

Objectives: To review current understanding of the knowledge and information needs of informal caregivers in palliative settings. Data sources: Seven electronic databases were searched for the period January 1994–November 2006: Medline, CINAHL, PsychINFO, Embase, Ovid, Zetoc and Pubmed using a meta-search engine (Metalib®). Key journals and reference lists of selected papers were hand searched. Review methods: Included studies were peer-reviewed journal articles presenting original research. Given a variety of approaches to palliative care research, a validated systematic review methodology for assessing disparate evidence was used in order to assign scores to different aspects of each study (introduction and aims, method and data, sampling, data analysis, ethics and bias, findings/results, transferability/generalizability, implications and usefulness). Analysis was assisted by abstraction of key details of study into a table. Results: Thirty-four studies were included from eight different countries. The evidence was strongest in relation to pain management, where inadequacies in caregiver knowledge and the importance of education were emphasized. The significance of effective communication and information sharing between patient, caregiver and service provider was also emphasized. The evidence for other caregiver knowledge and information needs, for example in relation to welfare and social support was weaker. There was limited literature on non-cancer conditions and the care-giving information needs of black and minority ethnic populations. Overall, the evidence base was predominantly descriptive and dominated by small-scale studies, limiting generalizability. Conclusions: As palliative care shifts into patients’ homes, a more rigorously researched evidence base devoted to understanding caregivers knowledge and information needs is required. Research design needs to move beyond the current focus on dyads to incorporate the complex, three-way interactions between patients, service providers and caregivers in end-of-life care setting

Platelet Factor XIIIa Release During Platelet Aggregation and Plasma Clot Strength Measured by Thrombelastography in Patients with Coronary Artery Disease Treated with Clopidogrel.

It has been estimated that up to half of circulating Factor XIIIa (FXIIIa) is stored in platelets. The release of FXIIIa from platelets upon stimulation with ADP in patients with coronary artery disease treated with dual antiplatelet therapy has not been previously examined. Samples from 96 patients with established coronary artery disease treated with aspirin and clopidogrel were examined. Platelet aggregation was performed by light transmittance aggregometry (LTA) in platelet rich plasma (PRP) with platelet poor plasma (PPP) as reference and ADP 5μM as agonist. Kaolin activated TEG was performed in citrate PPP. PRP after aggregation was centrifuged and plasma supernatant (PSN) collected. FXIIIa was measured in PPP and PSN.Platelet aggregation after stimulation with ADP 5μM resulted in 24% additional FXIIIa release in PSN as compared to PPP (99.3 ± 27 vs. 80.3 ± 24 %, p<0.0001). FXIIIa concentration in PSN correlated with maximal plasma clot strength (TEG-G) (r=0.48, p<0.0001), but not in PPP (r=0.15, p=0.14). Increasing quartiles of platelet derived FXIIIa were associated with incrementally higher TEG-G (p=0.012). FXIIIa release was similar between clopidogrel responders and non-responders (p=0.18). In summary, platelets treated with aspirin and clopidogrel release a significant amount of FXIIIa upon aggregation by ADP. Platelet derived FXIIIa may contribute to differences in plasma TEG-G, and thus in part provide a mechanistic explanation for high clot strength observed as a consequence of platelet activation. Variability in clopidogrel response does not significantly influence FXIIIa release from platelets

Stockyard Road, Siler City, North Carolina, Chatham County : a community assessment including secondary and qualitative data collection and analysis

Stockyard Road , a small, rural community in Southwestern Chatham County, North Carolina, is located three miles west of Siler City. We first met the residents of this community in August of 1997 when, as five first-year master’s students at the School of Public Health, we were assigned to Stockyard Road to conduct a “community diagnosis:” A community diagnosis... aims to understand many facets of a community including culture, values and norms, leadership and power structure, means of communication, helping patterns, important community institutions and history. A good diagnosis suggests what it is like to live in a community, what the important health problems in a community are, what interventions are most likely to be efficacious, and how the program would be best evaluated (Steuart, GW and Kark, SL, 1962). As we researched secondary data and talked with residents of Stockyard Road, we frequently struggled with the question of how to define the geographic and social boundaries of this community. None of the service providers that we spoke with actually described Stockyard Road as a "community." The residents themselves rarely used the term community to refer to Stockyard Road unless they were responding to one of our questions about it. Nonetheless, it is apparent that the residents who live here have a unified sense of where their community begins and ends, both in terms of physical and psychological boundaries. As one community member said, "I would say it's this area from highway 64 up to, ya know that intersection I told ya about [Bish Road]. It's not the whole Stockyard Road to me. Further up, that's a different community to me." Said another resident in regard to community boundaries "It's like the White and Black are separated and the people around the curve are separated." Although the primary concern of a community diagnosis is the health of the community, the process recognizes other aspects of a community that impact its wellness. Our team assessed the Stockyard Road community over the course of two semesters, collecting secondary data and interviewing 25 community members and service providers. In the fall, the major focus was on collecting quantitative data from a number of county, state and national sources. However, the conclusions we can draw from this data are limited. This limitation is partly due to the fact that most of the data were only available at the county level, and the demographics of Stockyard Road differ from other parts of Chatham County; namely, it is a small, predominantly African-American neighborhood. Thus, we have placed greater emphasis on the primary data collected during the spring semester through interviews with community members. During the course of interviewing, Stockyard Road residents graciously shared their thoughts and experiences with our team. The following summarizes several important findings that have emerged through observations and conversations with community members and service providers. Stockyard Road is comprised of primarily African American residents. Estimates suggest that there are approximately 60-70 individuals living within this community. Many of the community members have lived in the community all their lives and have extended family in the area. Two churches are located in the Stockyard Road community, the Unity Powerhouse Holiness Church and the Mt. Cavalry Holiness Church. Together these two churches offer a variety of activities and programs to residents. These include adult choirs, children’s choirs, women’s groups and weekly worship services. Stockyard Road residents have many individual talents and skills to offer the community. Residents play musical instruments, sing in the church choir, stake out vegetable gardens and run small businesses. Others find time to volunteer at local civic organizations and schools. The Stockyard Road community is located in an Extra Territorial Jurisdiction and is therefore not within the Siler City limits. This has both political implications and implications in terms of residents’ access to services (mail delivery, trash, sewage and water hook-up, etc.) In recent years, housing conditions in Stockyard Road have deteriorated. On March 10, 1998, ten homes in the area were officially condemned and occupants were issued eviction notices. Many residents in Stockyard Road lack indoor plumbing. As a result, some residents are forced to use neighbors’ facilities or one of two functioning outhouses. Crime and safety are also a major concern to residents of Stockyard Road. Some residents blame rising crime on a recent influx of inexpensive rental housing. Transportation is an issue for the many residents that do not own cars because there is no public transportation system in Chatham County. Many depend on neighbors to drive them to work, to buy groceries, or to receive medical care. Compared to nearby Siler City, there are few economic opportunities available to residents of Stockyard Road. Most of the employees who work at the Carolina Stockyards, located within the community, are from neighboring towns. Residents of Stockyard Road face many barriers to receiving adequate health care. These include lack of insurance, dissatisfaction with the quality of service and inaccessibility to services located in Pittsboro, Greensboro and Chapel Hill. Historically, Stockyard Road is a community that has garnered very little attention within Chatham County. Nonetheless, the complex social, economic and political issues facing this community pose serious challenges for Stockyard Road residents. By utilizing some of the existing resources and developing new ones, Stockyard Road can continue to strengthen community ties and move towards increased community cohesion.Master of Public Healt

Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi

BACKGROUND: To prevent postnatal transmission of HIV in settings where safe alternatives to breastfeeding are unavailable, the World Health Organization (WHO) recommends exclusive breastfeeding followed by early, rapid cessation of breastfeeding. Only limited data are available on the attitudes of health workers toward this recommendation and the impact of these attitudes on infant feeding counselling messages given to mothers. METHODS: As part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) clinical trial, we carried out an in-depth qualitative study of the attitudes, beliefs, and counselling messages of 19 health workers in Lilongwe, Malawi. RESULTS: Although none of the workers had received formal training, several reported having counseled HIV-positive mothers about infant feeding. Health workers with counselling experience believed that HIV-infected mothers should breastfeed exclusively, rather than infant formula feed, citing poverty as the primary reason. Because of high levels of malnutrition, all the workers had concerns about early cessation of breastfeeding. CONCLUSION: Important differences were observed between the WHO recommendations and the attitudes and practices of the health workers. Understanding these differences is important for designing effective interventions

Benefits of Automated Crystallization Plate Tracking, Imaging, and Analysis

SummaryWe describe the design of a database and software for managing and organizing protein crystallization data. We also outline the considerations behind the design of a fast web interface linking protein production data, crystallization images, and automated image analysis. The database and associated interfaces underpin the Oxford Protein Production Facility (OPPF) crystallization laboratory, collecting, in a routine and automatic manner, up to 100,000 images per day. Over 17 million separate images are currently held in this database. We discuss the substantial scientific benefits automated tracking, imaging, and analysis of crystallizations offers to the structural biologist: analysis of the time course of the trial and easy analysis of trials with related crystallization conditions. Features of this system address requirements common to many crystallographic laboratories that are currently setting up (semi-)automated crystallization imaging systems

The Role of Public Schools in HIV Prevention: Perspectives from African Americans in the Rural South

Though African American youth in the south are at high risk for HIV infection, abstinence until marriage education continues to be the only option in some public schools. Using community-based participatory research methods, we conducted 11 focus groups with African American adults and youth in a rural community in North Carolina with high rates of HIV infection with marked racial disparities. Focus group discussions explored participant views on contributors to the elevated rates of HIV and resources available to reduce transmission. Participants consistently identified the public schools’ sex education policies and practices as major barriers toward preventing HIV infection among youth in their community. Ideas for decreasing youth’s risk of HIV included public schools providing access to health services and sex education. Policymakers, school administrators, and other stakeholders should consider the public school setting as a place to provide HIV prevention education for youth in rural areas

Motor Agency: A New and Highly Sensitive Measure to Reveal Agency Disturbances in Early Psychosis

Background: Early diagnosis of young adults at risk of schizophrenia is essential for preventive approaches of the illness. Nevertheless, classic screening instruments are difficult to use because of the non-specific nature of the signs at this preonset phase of illness. The objective of the present contribution was to propose an innovating test that can probe the more specific symptom of psychosis, i.e., the sense of agency, which is defined as being the immediate experience of oneself as the cause of an action. More specifically, we tested whether motor agency is abnormal in early psychosis. Methods: Thirty-two young symptomatic patients and their age-matched controls participated in the study. 15 of these patients were at ultra high-risk for developing psychosis (UHR), and 17 patients were suffering from first-episode psychosis (FEP). Patients ’ neurocognitive capacities were assessed through the use of seven neuropsychological tests. A motor agency task was also introduced to obtain an objective indicator of the degree of sense of agency, by contrasting force levels applied during other and self-produced collisions between a hand-held objet and a pendulum. Results: As reported in the literature for adult controls, healthy adolescents used more efficient force levels in self than in other-imposed collisions. For both UHR and FEP patients, abnormally high levels of grip force were used for self-produced collisions, leading to an absence of difference between self and other. The normalized results revealed that motor agency differentiated patients from controls with a higher level of sensitivity than the more classic neuropsychological test battery

The CS1 segment of fibronectin is involved in human OSCC pathogenesis by mediating OSCC cell spreading, migration, and invasion

<p>Abstract</p> <p>Background</p> <p>The alternatively spliced V region or type III connecting segment III (IIICS) of fibronectin is important in early development, wound healing, and tumorigenesis, however, its role in oral cancer has not been fully investigated. Thus, we investigated the role of CS-1, a key site within the CSIII region of fibronectin, in human oral squamous cell carcinoma (OSCC).</p> <p>Methods</p> <p>To determine the expression of CS-1 in human normal and oral SCC tissue specimens immunohistochemical analyses were performed. The expression of CS1 was then associated with clinicopathological factors. To investigate the role of CS-1 in regulating OSCC cell spreading, migration and invasion, OSCC cells were assayed for spreading and migration in the presence of a CS-1 peptide or a CS-1 blocking peptide, and for invasion using Matrigel supplemented with these peptides. In addition, integrin α4siRNA or a focal adhesion kinase (FAK) anti-sense oligonucleotide was transfected into OSCC cells to examine the mechanistic role of integrin α4 or FAK in CS1-mediated cell spreading and migration, respectively.</p> <p>Results</p> <p>CS-1 expression levels were significantly higher in OSCC tissues compared to normal tissues (p < 0.05). Also, although, high levels of CS-1 expression were present in all OSCC tissue samples, low-grade tumors stained more intensely than high grade tumors. OSCC cell lines also expressed higher levels of CS-1 protein compared to normal human primary oral keratinocytes. There was no significant difference in total fibronectin expression between normal and OSCC tissues and cells. Inclusion of CS-1 in the in vitro assays enhanced OSCC cell spreading, migration and invasion, whereas the CS1 blocking peptide inhibited these processes. Suppression of integrin α4 significantly inhibited the CS1-mediated cell spreading. Furthermore, this migration was mediated by focal adhesion kinase (FAK), since FAK suppression significantly blocked the CS1-induced cell migration.</p> <p>Conclusion</p> <p>These data indicate that the CS-1 site of fibronectin is involved in oral cancer pathogenesis and in regulating OSCC cell spreading, migration and invasion.</p