Factors influencing the utilisation of free-standing and alongside midwifery units in England: a qualitative research study

OBJECTIVE: To identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England. DESIGN: Case studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England. SETTING AND PARTICIPANTS: NHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52). MAIN OUTCOME MEASURES: Factors influencing MU use. FINDINGS: The study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust's overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo. CONCLUSIONS: There are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women's information needs. If these remain unaddressed, childbearing women's access to MUs will continue to be restricted

Structural and magnetic characterization of the complete delafossite solid solution (CuAlO2){1-x}(CuCrO2){x}

We have prepared the complete delafossite solid solution series between diamagnetic CuAlO2 and the t2g^3 frustrated antiferromagnet CuCrO2. The evolution with composition x in CuAl(1-x)Cr(x)O2 of the crystal structure and magnetic properties has been studied and is reported here. The room-temperature unit cell parameters follow the Vegard law and increase with x as expected. The effective moment is equal to the Cr^3+ spin-only S = 3/2 value throughout the entire solid solution. Theta is negative, indicating that the dominant interactions are antiferromagnetic, and its magnitude increases with Cr substitution. For dilute Cr compositions, J_BB was estimated by mean-field theory to be 2.0 meV. Despite the sizable Theta, long-range antiferromagnetic order does not develop until very large x, and is preceeded by glassy behavior. Data presented here, and that on dilute Al-substitution from Okuda et al., suggest that the reduction in magnetic frustration due to the presence of non-magnetic Al does not have as dominant an effect on magnetism as chemical disorder and dilution of the magnetic exchange. For all samples, the 5 K isothermal magnetization does not saturate in fields up to 5 T and minimal hysteresis is observed. The presence of antiferromagnetic interactions is clearly evident in the sub-Brillouin behavior with a reduced magnetization per Cr atom. An inspection of the scaled Curie plot reveals that significant short-range antiferromagnetic interactions occur in CuCrO2 above its Neel temperature, consistent with its magnetic frustration. Uncompensated short-range interactions are present in the Al-substituted samples and are likely a result of chemical disorder

Influence of positional correlations on the propagation of waves in a complex medium with polydisperse resonant scatterers

We present experimental results on a model system for studying wave propagation in a complex medium exhibiting low frequency resonances. These experiments enable us to investigate a fundamental question that is relevant for many materials, such as metamaterials, where low-frequency scattering resonances strongly influence the effective medium properties. This question concerns the effect of correlations in the positions of the scatterers on the coupling between their resonances, and hence on wave transport through the medium. To examine this question experimentally, we measure the effective medium wave number of acoustic waves in a sample made of bubbles embedded in an elastic matrix over a frequency range that includes the resonance frequency of the bubbles. The effective medium is highly dispersive, showing peaks in the attenuation and the phase velocity as functions of the frequency, which cannot be accurately described using the Independent Scattering Approximation (ISA). This discrepancy may be explained by the effects of the positional correlations of the scatterers, which we show to be dependent on the size of the scatterers. We propose a self-consistent approach for taking this "polydisperse correlation" into account and show that our model better describes the experimental results than the ISA

Realism, Objectivity, and Evaluation

I discuss Benacerraf's epistemological challenge for realism about areas like mathematics, metalogic, and modality, and describe the pluralist response to it. I explain why normative pluralism is peculiarly unsatisfactory, and use this explanation to formulate a radicalization of Moore's Open Question Argument. According to the argument, the facts -- even the normative facts -- fail to settle the practical questions at the center of our normative lives. One lesson is that the concepts of realism and objectivity, which are widely identified, are actually in tension

Regulation of Small RNA Accumulation in the Maize Shoot Apex

MicroRNAs (miRNAs) and trans-acting siRNAs (ta-siRNAs) are essential to the establishment of adaxial–abaxial (dorsoventral) leaf polarity. Tas3-derived ta-siRNAs define the adaxial side of the leaf by restricting the expression domain of miRNA miR166, which in turn demarcates the abaxial side of leaves by restricting the expression of adaxial determinants. To investigate the regulatory mechanisms that allow for the precise spatiotemporal accumulation of these polarizing small RNAs, we used laser-microdissection coupled to RT-PCR to determine the expression profiles of their precursor transcripts within the maize shoot apex. Our data reveal that the pattern of mature miR166 accumulation results, in part, from intricate transcriptional regulation of its precursor loci and that only a subset of mir166 family members contribute to the establishment of leaf polarity. We show that miR390, an upstream determinant in leaf polarity whose activity triggers tas3 ta-siRNA biogenesis, accumulates adaxially in leaves. The polar expression of miR390 is established and maintained independent of the ta-siRNA pathway. The comparison of small RNA localization data with the expression profiles of precursor transcripts suggests that miR166 and miR390 accumulation is also regulated at the level of biogenesis and/or stability. Furthermore, mir390 precursors accumulate exclusively within the epidermal layer of the incipient leaf, whereas mature miR390 accumulates in sub-epidermal layers as well. Regulation of miR390 biogenesis, stability, or even discrete trafficking of miR390 from the epidermis to underlying cell layers provide possible mechanisms that define the extent of miR390 accumulation within the incipient leaf, which patterns this small field of cells into adaxial and abaxial domains via the production of tas3-derived ta-siRNAs

Planform selection in two-layer Benard-Marangoni convection

Benard-Marangoni convection in a system of two superimposed liquids is investigated theoretically. Extending previous studies the complete hydrodynamics of both layers is treated and buoyancy is consistently taken into account. The planform selection problem between rolls, squares and hexagons is investigated by explicitly calculating the coefficients of an appropriate amplitude equation from the parameters of the fluids. The results are compared with recent experiments on two-layer systems in which squares at onset have been reported.Comment: 17 pages, 7 figures, oscillatory instability included, typos corrected, references adde

TRH: Pathophysiologic and clinical implications

Thyrotropin releasing hormone is thought to be a tonic stimulator of the pituitary TSH secretion regulating the setpoint of the thyrotrophs to the suppressive effect of thyroid hormones. The peptide stimulates the release of normal and elevated prolactin. ACTH and GH may increase in response to exogenous TRH in pituitary ACTH and GH hypersecretion syndromes and in some extrapituitary diseases. The pathophysiological implications of extrahypothalamic TRH in humans are essentially unknown. The TSH response to TRH is nowadays widely used as a diganostic amplifier in thyroid diseases being suppressed in borderline and overt hyperthyroid states and increased in primary thyroid failure. In hypothyroid states of hypothalamic origin, TSH increases in response to exogenous TRH often with a delayed and/or exaggerated time course. But in patients with pituitary tumors and suprasellar extension TSH may also respond to TRH despite secondary hypothyroidism. This TSH increase may indicate a suprasellar cause for the secondary hypothyroidism, probably due to portal vessel occlusion. The TSH released in these cases is shown to be biologically inactive

Atomistic origins of high-performance in hybrid halide perovskite solar cells

The performance of organometallic perovskite solar cells has rapidly surpassed that of both conventional dye-sensitised and organic photovoltaics. High power conversion efficiency can be realised in both mesoporous and thin-film device architectures. We address the origin of this success in the context of the materials chemistry and physics of the bulk perovskite as described by electronic structure calculations. In addition to the basic optoelectronic properties essential for an efficient photovoltaic device (spectrally suitable band gap, high optical absorption, low carrier effective masses), the materials are structurally and compositionally flexible. As we show, hybrid perovskites exhibit spontaneous electric polarisation; we also suggest ways in which this can be tuned through judicious choice of the organic cation. The presence of ferroelectric domains will result in internal junctions that may aid separation of photoexcited electron and hole pairs, and reduction of recombination through segregation of charge carriers. The combination of high dielectric constant and low effective mass promotes both Wannier-Mott exciton separation and effective ionisation of donor and acceptor defects. The photoferroic effect could be exploited in nanostructured films to generate a higher open circuit voltage and may contribute to the current-voltage hysteresis observed in perovskite solar cells.Comment: 6 pages, 5 figure