Learning before leaping: integration of an adaptive study design process prior to initiation of BetterBirth, a large-scale randomized controlled trial in Uttar Pradesh, India

Background: Pragmatic and adaptive trial designs are increasingly used in quality improvement (QI) interventions to provide the strongest evidence for effective implementation and impact prior to broader scale-up. We previously showed that an on-site coaching intervention focused on the World Health Organization Safe Childbirth Checklist (SCC) improved performance of essential birth practices (EBPs) in one facility in Karnataka, India. We report on the process and outcomes of adapting the intervention prior to larger-scale implementation in a randomized controlled trial in Uttar Pradesh (UP), India. Methods: Initially, we trained a local team of physicians and nurses to coach birth attendants in SCC use at two public facilities for 4–6 weeks. Trained observers evaluated adherence to EBPs before and after coaching. Using mixed methods and a systematic adaptation process, we modified and strengthened the intervention. The modified intervention was implemented in three additional facilities. Pre/post-change in EBP prevalence aggregated across facilities was analyzed. Results: In the first two facilities, limited improvement was seen in EBPs with the exception of post-partum oxytocin. Checklists were used <25 % of observations. We identified challenges in physicians coaching nurses, need to engage district and facility leadership to address system gaps, and inadequate strategy for motivating SCC uptake. Revisions included change to peer-to-peer coaching (nurse to nurse, physician to physician); strengthened coach training on behavior and system change; adapted strategy for effective leadership engagement; and an explicit motivation strategy to enhance professional pride and effectiveness. These modifications resulted in improvement in multiple EBPs from baseline including taking maternal blood pressure (0 to 16 %), post-partum oxytocin (36 to 97 %), early breastfeeding initiation (3 to 64 %), as well as checklist use (range 32 to 88 %), all p < 0.01. Further adaptations were implemented to increase the effectiveness prior to full trial launch. Conclusions: The adaptive study design of implementation, evaluation, and feedback drove iterative redesign and successfully developed a SCC-focused coaching intervention that improved EBPs in UP facilities. This work was critical to develop a replicable BetterBirth package tailored to the local context. The multi-center pragmatic trial is underway measuring impact of the BetterBirth program on EBP and maternal-neonatal morbidity and mortality. Trial registration Clinical trials identifier: NCT02148952

Variation in histone configurations correlates with gene expression across nine inbred strains of mice.

The diversity outbred (DO) mice and their inbred founders are widely used models of human disease. However, although the genetic diversity of these mice has been well documented, their epigenetic diversity has not. Epigenetic modifications, such as histone modifications and DNA methylation, are important regulators of gene expression, and as such are a critical mechanistic link between genotype and phenotype. Therefore, creating a map of epigenetic modifications in the DO mice and their founders is an important step toward understanding mechanisms of gene regulation and the link to disease in this widely used resource. To this end, we performed a strain survey of epigenetic modifications in hepatocytes of the DO founders. We surveyed four histone modifications (H3K4me1, H3K4me3, H3K27me3, and H3K27ac), and DNA methylation. We used ChromHMM to identify 14 chromatin states, each of which represented a distinct combination of the four histone modifications. We found that the epigenetic landscape was highly variable across the DO founders and was associated with variation in gene expression across strains. We found that epigenetic state imputed into a population of DO mice recapitulated the association with gene expression seen in the founders suggesting that both histone modifications and DNA methylation are highly heritable mechanisms of gene expression regulation. We illustrate how DO gene expression can be aligned with inbred epigenetic states to identify putative cis-regulatory regions. Finally, we provide a data resource that documents strain-specific variation in chromatin state and DNA methylation in hepatocytes across nine widely used strains of laboratory mice

A research agenda to improve incidence and outcomes of assisted vaginal birth

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth. [Abstract copyright: (c) 2023 The authors; licensee World Health Organization.

Physical deterioration in an acute mental health unit : A quantitative retrospective analysis of medical emergencies

Nursing management of physical deterioration of patients within acute mental health settings is observed, recorded, and actively managed with the use of standardized Adult Deterioration Detection System (ADDS) charts. Patient deterioration may require the urgent assistance of a hospital rapid response or Medical Emergency Team. A five-and-a-half-year (2011–2016) audit of hospital-wide Medical Emergency Team attendances was conducted in an acute mental health unit of a single large 250 bed regional hospital in Victoria, Australia. Data were extracted from the hospitals’ quality and patient safety program, RISKMan, and entered into a statistical data program for analysis. A total of 140 patient records were analysed, and the ‘Worried’ category (34%, n = 47) was the principle reason for a Medical Emergency Team call in a mental health ward, followed by hypotension (23%, n = 31) and a low Glasgow Coma Score (16%, n = 22). Upon further investigation of the ‘Worried’ category, the most common conditions recorded were an altered conscious state (22%, n = 9), low oxygen saturation (20%, n = 8), or chest pain (17%, n = 7). Activation of Medical Emergency Team calls predominantly occurred in the daylight morning hours (6am–12md). When data were compared to the general hospital patients, the context of the physiological deterioration of the mental health patients was strikingly similar. Further research is recommended to ascertain the extent and frequency with which staff working in mental health units are performing vital signs monitoring as an essential component of detection of early signs of physiological deterioration

A Feminist HCI Approach to Designing Postpartum Technologies: &quot;When I first saw a breast pump I was wondering if it was a joke.&quot;

ABSTRACT In recent years, the CHI community has begun to discuss how HCI research could improve the experience of motherhood. In this paper, we take up the challenge of designing for this complex life phase and present an analysis of data collected from a design process that included over 1,000 mothersubmitted ideas to improve the breast pump, a technology that allows mothers around the world to collect and store their breast milk. In addition to presenting a range of ideas to improve this specific technology, we discuss environmental, legal, social, and emotional dimensions of the postpartum period that suggest opportunities for a range of additional supportive technologies. We close with insights linking our findings to ongoing discussions related to Feminist HCI theory, crowdsourcing, and participatory design

A Feminist HCI Approach to Designing Postpartum Technologies "When I first saw a breast pump I was wondering if it was a joke"

In recent years, the CHI community has begun to discuss how HCI research could improve the experience of motherhood. In this paper, we take up the challenge of designing for this complex life phase and present an analysis of data collected from a design process that included over 1,000 mother-submitted ideas to improve the breast pump, a technology that allows mothers around the world to collect and store their breast milk. In addition to presenting a range of ideas to improve this specific technology, we discuss environmental, legal, social, and emotional dimensions of the postpartum period that suggest opportunities for a range of additional supportive technologies. We close with insights linking our findings to ongoing discussions related to Feminist HCI theory, crowdsourcing, and participatory design

Correction: An Automated, Adaptive Framework for Optimizing Preprocessing Pipelines in Task-Based Functional MRI.

Base and iron fence of the Washington Monument (Robert Mills, 1815-1829); Mount Vernon is a neighborhood located just to the north of downtown Baltimore, Maryland. Designated a National Landmark Historic District and a city Cultural District, it is one of the city's oldest neighborhoods and originally was home to the city's most wealthy and fashionable families. The name derives from the Mount Vernon home of George Washington; the original Washington Monument, a massive pillar commenced in 1815 to commemorate the first president of the United States, is the defining feature of the neighborhood. Source: Wikipedia; http://en.wikipedia.org/wiki/Main_Page (accessed 5/8/2011