Testing the effectiveness of REACH Pregnancy Circles group antenatal care: protocol for a randomised controlled pilot trial

Background Antenatal care is an important public health priority. Women from socially disadvantaged, and culturally and linguistically diverse groups often have difficulties with accessing antenatal care and report more negative experiences with care. Although group antenatal care has been shown in some settings to be effective for improving women’s experiences of care and for improving other maternal as well as newborn health outcomes, these outcomes have not been rigorously assessed in the UK. A pilot trial will be conducted to determine the feasibility of, and optimum methods for, testing the effectiveness of group antenatal care in an NHS setting serving populations with high levels of social deprivation and cultural, linguistic and ethnic diversity. Outcomes will inform the protocol for a future full trial. Methods This protocol outlines an individual-level randomised controlled external pilot trial with integrated process and economic evaluations. The two trial arms will be group care and standard antenatal care. The trial will involve the recruitment of 72 pregnant women across three maternity services within one large NHS Acute Trust. Baseline, outcomes and economic data will be collected via questionnaires completed by the participants at three time points, with the final scheduled for 4 months postnatal. Routine maternity service data will also be collected for outcomes assessment and economic evaluation purposes. Stakeholder interviews will provide insights into the acceptability of research and intervention processes, including the use of interpreters to support women who do not speak English. Pre-agreed criteria have been selected to guide the decision about whether or not to progress to a full trial. Discussion This pilot trial will determine if it is appropriate to proceed to a full trial of group antenatal care in this setting. If progression is supported, the pilot will provide authoritative high-quality evidence to inform the design and conduct of a trial in this important area that holds significant potential to influence maternity care, outcomes and experience

Implementing a structured education program for children with diabetes: lessons learnt from an integrated process evaluation

There is recognition of an urgent need for clinic-based interventions for young people with type 1 diabetes mellitus that improve glycemic control and quality of life. The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured educational group program, using psychological techniques, delivered primarily by diabetes nurses. Composed of four modules, it is designed for children with poor diabetic control and their parents. A mixed methods process evaluation, embedded within a cluster randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived impact of CASCADE

Uniform CPA examination content specifications update study: general business knowledge required by CPAs in public accounting

https://egrove.olemiss.edu/aicpa_exam/1165/thumbnail.jp

Evaluation of a microfluidic atmospheric-pressure plasma reactor for water treatment

A dielectric barrier discharge (DBD) microfluidic plasma reactor, operated at atmospheric pressure, was studied for its potential to treat organic contaminants in water. The proposed microfluidic plasma reactor (MPR) allows in situ production of plasma in a continuous flow, operated under atmospheric pressure, for plasma-based water treatment. The MPR operates with glass as the dielectric barrier, where plasma is generated in the continuous gas flow stream of a gas-liquid two-phase annular flow regime in the microchannels. The microchannels have dimensions of 100 µm depth, 250 µm width and the plasma is generated in an approximately 21 cm length of microchannel arranged in a serpentine pattern. Methylene blue (MB) in solution was used as a model organic to investigate its degradation by plasma generated in the microchannels. The influence of discharge time, residence time and gas sources, i.e. air, argon and oxygen, on MB degradation was studied. The percentage degradation increased with lower liquid flow rates, with maximum degradation of MB achieved at a liquid flow rate of 35 µL/min and inlet gas pressure of 1 bar using oxygen as the working gas. Liquid chromatography/mass spectrometry analysis of the MB solution after treatment suggests degradation through fragmentation of MB. It is intended that the device will be used as proof of concept to introduce plasma technology as an advanced oxidation process for water treatment, with the potential to achieve total mineralization of dissolved organic materials and microbial inactivation, replacing water treatment chemicals and consumables

Epidermal Notch1 recruits RORγ+ group 3 innate lymphoid cells to orchestrate normal skin repair

Notch has a well-defined role in controlling cell fate decisions in the embryo and the adult epidermis and immune systems, yet emerging evidence suggests Notch also directs non-cell-autonomous signalling in adult tissues. Here, we show that Notch1 works as a damage response signal. Epidermal Notch induces recruitment of immune cell subsets including RORγ + ILC3s into wounded dermis; RORγ + ILC3s are potent sources of IL17F in wounds and control immunological and epidermal cell responses. Mice deficient for RORγ + ILC3s heal wounds poorly resulting from delayed epidermal proliferation and macrophage recruitment in a CCL3-dependent process. Notch1 upregulates TNFα and the ILC3 recruitment chemokines CCL20 and CXCL13. TNFα, as a Notch1 effector, directs ILC3 localization and rates of wound healing. Altogether these findings suggest that Notch is a key stress/injury signal in skin epithelium driving innate immune cell recruitment and normal skin tissue repair

The Role of TLR4 in the Paclitaxel Effects on Neuronal Growth In Vitro

Paclitaxel (Pac) is an antitumor agent that is widely used for treatment of solid cancers. While being effective as a chemotherapeutic agent, Pac in high doses is neurotoxic, specifically targeting sensory innervations. In view of these toxic effects associated with conventional chemotherapy, decreasing the dose of Pac has been recently suggested as an alternative approach, which might limit neurotoxicity and immunosuppression. However, it remains unclear if low doses of Pac retain its neurotoxic properties or might exhibit unusual effects on neuronal cells. The goal of this study was to analyze the concentration-dependent effect of Pac on isolated and cultured DRG neuronal cells from wild-type and TLR4 knockout mice. Three different morphological parameters were analyzed: the number of neurons which developed neurites, the number of neurites per cell and the total length of neurites per cell. Our data demonstrate that low concentrations of Pac (0.1 nM and 0.5 nM) do not influence the neuronal growth in cultures in both wild type and TLR4 knockout mice. Higher concentrations of Pac (1-100 nM) had a significant effect on DRG neurons from wild type mice, affecting the number of neurons which developed neurites, number of neurites per cell, and the length of neurites. In DRG from TLR4 knockout mice high concentrations of Pac showed a similar effect on the number of neurons which developed neurites and the length of neurites. At the same time, the number of neurites per cell, indicating the process of growth cone initiation, was not affected by high concentrations of Pac. Thus, our data showed that Pac in high concentrations has a significant damaging effect on axonal growth and that this effect is partially mediated through TLR4 pathways. Low doses of Pac are devoid of neuronal toxicity and thus can be safely used in a chemomodulation mode. © 2013 Ustinova et al

Evaluation of community-level interventions to increase early initiation of antenatal care in pregnancy: protocol for the Community REACH study, a cluster randomised controlled trial with integrated process and economic evaluations

BACKGROUND: The provision of high-quality maternity services is a priority for reducing inequalities in health outcomes for mothers and infants. Best practice includes women having their initial antenatal appointment within the first trimester of pregnancy in order to provide screening and support for healthy lifestyles, well-being and self-care in pregnancy. Previous research has identified inequalities in access to antenatal care, yet there is little evidence on interventions to improve early initiation of antenatal care. The Community REACH trial will assess the effectiveness and cost-effectiveness of engaging communities in the co-production and delivery of an intervention that addresses this issue. METHODS/DESIGN: The study design is a matched cluster randomised controlled trial with integrated process and economic evaluations. The unit of randomisation is electoral ward. The intervention will be delivered in 10 wards; 10 comparator wards will have normal practice. The primary outcome is the proportion of pregnant women attending their antenatal booking appointment by the 12th completed week of pregnancy. This and a number of secondary outcomes will be assessed for cohorts of women (n = approximately 1450 per arm) who give birth 2-7 and 8-13 months after intervention delivery completion in the included wards, using routinely collected maternity data. Eight hospitals commissioned to provide maternity services in six NHS trusts in north and east London and Essex have been recruited to the study. These trusts will provide anonymised routine data for randomisation and outcomes analysis. The process evaluation will examine intervention implementation, acceptability, reach and possible causal pathways. The economic evaluation will use a cost-consequences analysis and decision model to evaluate the intervention. Targeted community engagement in the research process was a priority. DISCUSSION: Community REACH aims to increase early initiation of antenatal care using an intervention that is co-produced and delivered by local communities. This pragmatic cluster randomised controlled trial, with integrated process and economic evaluation, aims to rigorously assess the effectiveness of this public health intervention, which is particularly complex due to the required combination of standardisation with local flexibility. It will also answer questions about scalability and generalisability. TRIAL REGISTRATION: ISRCTN registry: registration number 63066975 . Registered on 18 August 2015

Effectiveness of a structured educational intervention using psychological delivery methods in children and adolescents with poorly controlled type 1 diabetes: a cluster randomised controlled trial of the CASCADE intervention

Introduction: Type 1 diabetes in children and adolescents is increasing worldwide with a particular increase in children < 5 years. Fewer than one in six children and adolescents achieve recommended HbA1c values. Methods: A pragmatic, cluster randomised control trial assessed the efficacy of a clinic-based structured educational group incorporating psychological approaches to improve long-term glycaemic control, quality of life and psychosocial functioning in children and adolescents with T1D. 28 paediatric diabetes services were randomised to deliver the intervention or standard care. 362 children (8-16 years) HbA1c ≥ 8.5% were recruited. Outcomes were HbA1c at 12 and 24 months, hypoglycaemia, admissions, self-management skills, intervention compliance, emotional and behavioural adjustment and quality of life. A process evaluation collected data from key stakeholder groups in order to evaluate the feasibility of delivering the intervention. Results: 298/362 patients (82.3%) provided HbA1c at 12 months and 284/362 (78.5%) at 24 months. The intervention did not improve HbA1c at 12 months (intervention effect 0.11, 95% CI −0.28 to 0.50, P=0.584), or 24 months (intervention effect 0.03, 95% CI -0.36 to 0.41, P=0.891). There were no significant changes in remaining outcomes. 96/180 (53%) families in the intervention arm attended at least one module. The number of modules attended did not affect outcome. Reasons for low uptake included difficulties organising groups and work and school commitments. Those with highest HbA1cs were less likely to attend. Mean cost of the intervention was £683 per child. Conclusions: Significant challenges in the delivery of a structured education intervention using psychological techniques to enhance engagement and behaviour change delivered by diabetes nurses and dietitians in routine clinical practice were found. The intervention did not improve HbA1c in children and adolescents with poor control

Involving women with limited English proficiency in group antenatal care: findings from the integrated process evaluation of the Pregnancy Circles pilot trial

Abstract Problem In the United Kingdom, poor experiences and outcomes of antenatal care among women with limited English proficiency (LEP) are widely documented. Background Group antenatal care aims to address some limitations of traditional care by combining health assessment, information sharing and peer support, but the inclusion of women with LEP in mixed-language groups has not been explored. Aim This qualitative study used observations and interviews to explore whether linguistic diversity could be incorporated into group antenatal care (Pregnancy Circles). Women with LEP were invited to take part in mixed-language groups in a large urban NHS trust as part of the Pregnancy Circles pilot trial (ISRCTN66925258 Retrospectively registered 03 April 2017; North of Scotland Research Ethics Service 16/NS/0090). Findings Three Pregnancy Circles including women with LEP were implemented. Linguistically integrated groups required additional resources (time, interpreters, midwifery skills). Four themes emerged: ‘Interpreting as helping’, ‘Enhanced learning’, ‘Satisfaction and belonging’ and ‘Complex lives’. Discussion Women with LEP accessing interpreting in Pregnancy Circles reported high levels of satisfaction, contrasting with reported experiences in traditional care. Three theories of effect emerged as relevant for women with LEP: social support

Group antenatal care: findings from a pilot randomised controlled trial of REACH Pregnancy Circles

BACKGROUND: Antenatal care has the potential to impact positively on maternal and child outcomes, but traditional models of care in the UK have been shown to have limitations and particularly for those from deprived populations. Group antenatal care is an alternative model to traditional individual care. It combines conventional aspects of antenatal assessment with group discussion and support. Delivery of group antenatal care has been shown to be successful in various countries; there is now a need for a formal trial in the UK. METHOD: An individual randomised controlled trial (RCT) of a model of group care (Pregnancy Circles) delivered in NHS settings serving populations with high levels of deprivation and diversity was conducted in an inner London NHS trust. This was an external pilot study for a potential fully powered RCT with integral economic evaluation. The pilot aimed to explore the feasibility of methods for the full trial. Inclusion criteria included pregnant with a due date in a certain range, 16 + years and living within specified geographic areas. Data were analysed for completeness and usability in a full trial; no hypothesis testing for between-group differences in outcome measures was undertaken. Pre-specified progression criteria corresponding to five feasibility measures were set. Additional aims were to assess the utility of our proposed outcome measures and different data collection routes. A process evaluation utilising interviews and observations was conducted. RESULTS: Seventy-four participants were randomised, two more than the a priori target. Three Pregnancy Circles of eight sessions each were run. Interviews were undertaken with ten pregnant participants, seven midwives and four other stakeholders; two observations of intervention sessions were conducted. Progression criteria were met at sufficient levels for all five measures: available recruitment numbers, recruitment rate, intervention uptake and retention and questionnaire completion rates. Outcome measure assessments showed feasibility and sufficient completion rates; the development of an economic evaluation composite measure of a 'positive healthy birth' was initiated. CONCLUSION: Our pilot findings indicate that a full RCT would be feasible to conduct with a few adjustments related to recruitment processes, language support, accessibility of intervention premises and outcome assessment. TRIAL REGISTRATION: ISRCTN ISRCTN66925258. Retrospectively registered, 03 April 2017