A mixed methods study of the follow up of extremely preterm babies in the North East of England

M.D Thesis1. Background Neonatal intensive care medicine has improved considerably over time, leading to increased neonatal survival, and improved survival of preterm babies (babies born before 37 weeks gestation). In 2012, the WHO declared their commitment to reducing the mortality and morbidity related to prematurity by several interventions, including updated approaches to community-based follow up care for preterm babies. According to the Office for National Statistics (ONS), 2,490 babies were born in England and Wales in 2018 between 23- and 27- weeks gestation, accounting for approximately 0.3% of all live births. The 2017 National Institute for Health and Care Excellence (NICE) guideline made recommendations for the developmental follow up of children and young people born preterm and acknowledged the conditions linked to preterm delivery. The follow up of preterm babies determines the baby’s outcomes, their parents’ needs, and informs planning of health and social care resources. Previous research on barriers and facilitators to neonatal follow up showed that the birth of a preterm baby is a stressful event, for both mothers and fathers. Parents develop a different pattern of parenting, stemming from the concept of increased vulnerability of the preterm baby. The communication between parents and health professionals is important, and poor communication increases parental stress levels. Studies underlined the relevance of the relationships established between parents and neonatal staff to parents’ experiences. 2. Aim This study used a mixed methods design to assess the neonatal follow up of extremely preterm babies, focusing on attendance rates in relation to morbidities and demographic characteristics, as well as parents’ and health professionals’ perceptions of the neonatal follow up.3. Methods This study involved two phases. Phase one was an analysis of demographic, morbidity, mortality, and 2- year neurodevelopmental outcomes data of a cohort of babies born before 28 weeks gestation in the North East of England, over a 12-month period between July 2015 and June 2016, recorded in the Badger database. Phase two was a qualitative study of parents’ and health professionals’ (HPs) views, perceptions, and experience of the follow up of extremely preterm babies. Parents were recruited to the study during their attendance for their baby’s follow up appointments and were interviewed using a topic guide. Seventeen semistructured interviews were carried out with 23 parents of babies born before 28 weeks completed gestation, between January and December 2018. Thematic analysis based on the Braun and Clarke model was used. Twenty one-to-one, semi-structured interviews were carried out with HPs involved in the follow up care of preterm babies, between October and December 2018. Data were analysed using thematic analysis.4. Results The recruitment rate for phase one was 61% of the eligible babies; 86.2% of the babies included were born after 24 weeks gestation, with a mean gestation age (GA) of 25+3 weeks and a mean birth weight (BW) of 805 grams. More than three quarters of babies were discharged home on oxygen. Of the cases where information was available, half of the babies showed developmental delay, with half of these cases showing moderate to severe delay. There was no formal diagnosis of cerebral palsy recorded in the Badger database. The analysis of the parents’ interviews identified two key themes: ‘Emotions’ and ‘Here and now’. The first theme, ‘Emotions’, included three subthemes: ‘The emotions related to the preterm birth - a rollercoaster’, ‘The post-traumatic stress syndrome’ and ‘The overprotective parent’. Following the birth of their preterm baby, parents experienced mixed and contradictory emotions, compared to a rollercoaster, which may contribute to developing symptoms suggestive of post-traumatic stress syndrome. Parent participants developed an overprotective type of parenting, as previously described in literature. 4. Results The recruitment rate for phase one was 61% of the eligible babies; 86.2% of the babies included were born after 24 weeks gestation, with a mean gestation age (GA) of 25+3 weeks and a mean birth weight (BW) of 805 grams. More than three quarters of babies were discharged home on oxygen. Of the cases where information was available, half of the babies showed developmental delay, with half of these cases showing moderate to severe delay. There was no formal diagnosis of cerebral palsy recorded in the Badger database. The analysis of the parents’ interviews identified two key themes: ‘Emotions’ and ‘Here and now’. The first theme, ‘Emotions’, included three subthemes: ‘The emotions related to the preterm birth - a rollercoaster’, ‘The post-traumatic stress syndrome’ and ‘The overprotective parent’. Following the birth of their preterm baby, parents experienced mixed and contradictory emotions, compared to a rollercoaster, which may contribute to developing symptoms suggestive of post-traumatic stress syndrome. Parent participants developed an overprotective type of parenting, as previously described in literature. The second theme, ‘Here and now’, included four subthemes: ‘The storytelling’, ‘The coping mechanism’, ‘The impact of being born early’ and ‘The value of the follow up’. Future parents expected a normal term pregnancy, followed by a normal birth; the normality was interrupted by the onset of preterm labour. This interruption marked the beginning of a different experience, the quality of which impacted on the bonding and relationship between baby and parents, and the relationships between parents and HPs. Parents reported that follow up offered reassurance. The analysis of the HPs’ interviews identified two key themes: ‘Communication’ and ‘The Child Not Brought’. The first theme, ‘Communication’, included two subthemes: ‘The Journey’ and ‘The multi-disciplinary team post discharge’. The HPs described the experience of the birth and the follow up of a preterm baby as a journey and continuity of care was a marker of quality. HPs understood that the follow up offers reassurance and support to parents. There was a diversity of job roles of HPs involved in the care and follow up of preterm babies, leading to the formation of a multi-disciplinary team (MDT). Communication occurred in every direction between the members of the MDT, in many ways (written/verbal, formal/informal, paper/electronic). The second theme, ‘The Child Not Brought’ included three subthemes: ‘The impact on the baby’, ‘The NHS point of view’ and ‘Why do parents not attend?’. HPs suggested several potential reasons why parents may not bring their child(ren) to the follow up appointments: parents may not understand the role of the follow up, especially if the child is well; parents fear bad news; families may have a busy life, have too many appointments or have just seen another HP; communication breakdown (related to system or human factors); neglect; distance and travel; psychological issues (fear to leave the house, bad memories linked to the hospital environment). 5. Discussion Findings from this research provide important insights into the views and experiences of parents of preterm babies with regards to their baby’s follow up appointments. The birth of a preterm baby is a stressful event; parents develop a different pattern of parenting, stemming from the concept of the increased vulnerability of the preterm baby. HPs described the birth and follow up of an extremely preterm baby as a journey. The continuity of care and good communication contribute to improving this journey. Due to the complexity of the team involved in the follow up of the extremely preterm baby, there were challenges in communication, at different levels. Relatively small changes in practice, such as allowing for normality by encouraging the parents to read to their baby at night-time, and ensuring adequate communication and appropriate reassurance, could improve the parents’ experience, their engagement with follow up appointments, and therefore their baby’s outcomes. NICE recommends follow up of babies born extremely preterm to school age, however there is no established referral pathway into the paediatric services. Parents value continuity of care, which may be challenging if there is no clear transition process between neonates and paediatrics. Ensuring a smooth transition at every level by designing a clear pathway for the neonatal follow up of extremely preterm babies and the transition to paediatric services may improve the follow up process, parents’ engagement with the system and their baby’s outcomes.South Tees Hospitals NHS Foundation Trus

Applications of synchrotron x-ray powder diffraction in hydrated cements: high-resolution and high-pressure studies

The main aim of this study is to apply synchrotron radiation techniques for the study of hydrated cement pastes. In particular, the tetracalcium aluminoferrite phase, C4AF in cement nomenclature, is the major iron-containing phase in Ordinary Portland Cement (OPC) and in iron rich belite calcium sulfoaluminate cements. In a first study, the hydration mechanism of pure tetracalcium aluminoferrite phase with water-to-solid ratio of 1.0 has been investigated by HR-SXRPD (high resolution synchrotron X-ray powder diffraction). C4AF in the presence of water hydrates to form mainly an iron-containing hydrogarnet-type (katoite) phase, C3A0.84F0.16H6, as single crystalline phase. Its crystal structure and stoichiometry were determined by the Rietveld method and the final disagreement factors were RWP=8.1% and RF=4.8% [1]. As the iron content in the product is lower than that in C4AF, it is assumed that part of the iron also goes to an amorphous iron rich gel, like the hydrated alumina-type gel, as hydration proceeds. Further results from the high-resolution study will be discussed. In a second study, the behavior of pure and iron-containing katoites (C3AH6 and C3A0.84F0.16H6) under pressure have been analyzed by SXRPD using a diamond anvil cell (DAC) and then their bulk moduli were determined. The role of the pressure transmitting medium (PTM) has also been studied. In this case, silicone oil as well as methanol/ethanol mixtures have been used as PTM. Some “new peaks” were detected in the pattern for C3A0.84F0.16H6 as pressure increases, when using ethanol/methanol as PTM. These new peaks were still present at ambient pressure after releasing the applied pressure. They may correspond to crystalline nordstrandite or doyleite from the crystallization of amorphous aluminium hydroxide. The results from the high-pressure study will also be discussed.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech. Acknowledgments: We thank CELLS-ALBA (Barcelona, Spain) for providing synchrotron beam time. We also thank the financial support by BIA2014-57658-C2-1-R and BIA2014-57658-C2-2-R (FEDER)

Neurobiology of Vascular Dementia

Vascular dementia is, in its current conceptual form, a distinct type of dementia with a spectrum of specific clinical and pathophysiological features. However, in a very large majority of cases, these alterations occur in an already aged brain, characterized by a milieu of cellular and molecular events common for different neurodegenerative diseases. The cell signaling defects and molecular dyshomeostasis might lead to neuronal malfunction prior to the death of neurons and the alteration of neuronal networks. In the present paper, we explore some of the molecular mechanisms underlying brain malfunction triggered by cerebrovascular disease and risk factors. We suggest that, in the age of genetic investigation and molecular diagnosis, the concept of vascular dementia needs a new approach

PMA-Treatment of Human Monocytes Induces a M1 Phenotype in Adherent Macrophages

Background: Human monocyte lines are widely used in basic research as model of inflammation, mostly following adherence with phorbol 12-myristate 13-acetate (PMA). However, the SC line, of normal human monocytes is not well documented, unlike tumour-derived cell lines, such as THP-1. Aim: The purpose of this study was to determine the phenotype of adherent macrophages, induced after the treatment with PMA in three different concentrations, starting from the most widely reported concentration in the literature. Methods: Normal human monocytes SC (ATCC CRL-9855) were routinely maintained according to manufacturer’s instructions. Cells were treated with Phorbol 12-myristate 13-acetate (PMA Sigma Aldrich P1585), in concentrations of 200 ng/mL, 100 ng/mL, 25 ng/mL and adhesion was documented using an Evos phase-contrast inverted microscope. Cell behaviour was validated by real-time impedance readings. The adhered cells were treated with bacterial lipopolysaccharide (LPS) in concentrations of 50 ng/mL (mimicking chronic inflammation) and 1 μg/mL (mimicking acute inflammation). The supernatant was collected twice, after 4 hours, respectively after 18 hours of treatment with LPS. A screening of pro- and anti-inflammatory cytokines was performed using the multiplexing platform Luminex 200. ELISA tests were performed to validate the cytokines secretion: IL-6, IL-8, IL-10, IL-23 and TNF-ɑ, using a LEGEND MAX Human ELISA kit specific to each cytokine.   Results: Cell adhesion was studied by time-lapse microscopy for 48 hrs. The lowest concentration of PMA which induced cell adherence was 25 ng/mL. Multiplex screening of cytokines showed a pro-inflammatory phenotype of macrophages stimulated with LPS. This finding was validated by ELISA tests for IL-6, IL-8, IL-23 and TNF-ɑ (as pro-inflammatory cytokine) and IL-10 (an anti-inflammatory molecule). For the first category, we noticed a time-dependent response, present in adherent macrophages, but not in circulating monocytes. Regarding the second category of cytokines, the secretion is present only for the adhered and LPS treated cells. It is also present in a time-dependent manner (a higher concentration can be noticed in the collected supernatant after 18 hours of treatment compared with the one collected after 4 hours of treatment). Conclusion: The macrophages obtained from normal human monocytes with PMA are M1 type, regardless of the concentration used for differentiation

Surveying Position Based Routing Protocols for Wireless Sensor and Ad-hoc Networks

A focus of the scientific community is to design network oriented position-based routing protocols and this has resulted in a very high number of algorithms, different in approach and performance and each suited only to particular applications. However, though numerous, very few position-based algorithms have actually been adopted for commercial purposes. This article is a survey of almost 50 position-based routing protocols and it comes as an aid in the implementation of this type of routing in various applications which may need to consider the advantages and pitfalls of position-based routing. An emphasis is made on geographic routing, whose notion is clarified as a more restrictive and more efficient type of position-based routing. The protocols are therefore divided into geographic and non-geographic routing protocols and each is characterized according to a number of network design issues and presented in a comparative manner from multiple points of view. The main requirements of current general applications are also studied and, depending on these, the survey proposes a number of protocols for use in particular application areas. This aims to help both researchers and potential users assess and choose the protocol best suited to their interest

Analysis of Tourism Development Disparities in Romania

In 1998 eight development regions were set up in Romania (North-West, North-East, South-West, South-East, South, West, Center, Bucharest and Ilfov), with a view to efficiently absorb the EU funds, in order to reduce the socio-economic development disparities. Tourism is an important sector of the world economy and also of the development regions, contributing to economic growth in less developed areas, which yet have a high tourism potential. The main aim of the present paper is the analysis of development disparities of tourism in Romania, by tracking the changes that have taken place since the moment of creation of the development regions, in the periods of pre-accession and post-accession of Romania to the EU. The research comprises a cluster analysis based on tourism supply and demand indicators in the regions and counties of Romania; the main hypothesis of the study is that the development differences of Romanian tourism have diminished after the accession, as within the regions there are counties with greater tourism activity, that may turn into engines of regional economic growth

The development of intangible assets through the cohesion policy

Intangible assets in general and intellectual capital in particular are important to both society and organizations. It can be a source of competitive advantage for business and stimulate innovation that leads to wealth generation. Technological revolutions, the rise of the knowledgebased economy and the networked society have all led to the same conclusion that intangibles and how they contribute to value creation have to be appreciated so that the appropriate decisions can be made to protect and enhance them. The Cohesion Policy represents the main EU measure to ensure a balanced and sustainable growth in Europe by promoting harmonious development and reducing the regional disparities. The general objective of the paper is to highlight the important role of the Cohesion Policy in the development of intangible assets. The objectives and the instruments of the Cohesion Policy are designed to support programs on regional development, economic change, enhanced competitiveness and territorial cooperation through the European Union, to develop human resources and employability. The article also attempts to outline the trends of the Cohesion policy for the future by presenting a series of measures suggested by the European Commission through the Europe 2020 Strategy in order to develop intangible assets

Semantic lexicon adaptation for use in query interpretation

We describe improvements to the use of semantic lexicons by a state-of-the-art query interpretation system powering a major search engine. We successfully compute concept la-bel importance information for lexicon strings; lexicon aug-mentation with such information leads to a 6.4 % precision increase on affected queries with no query coverage loss. Fi-nally, lexicon filtering based on label importance leads to a 13 % precision increase, but at the expense of query cover-age

The development of intangible assets through the cohesion policy

Intangible assets in general and intellectual capital in particular are important to both society and organizations. It can be a source of competitive advantage for business and stimulate innovation that leads to wealth generation. Technological revolutions, the rise of the knowledge-based economy and the networked society have all led to the same conclusion that intangibles and how they contribute to value creation have to be appreciated so that the appropriate decisions can be made to protect and enhance them. The Cohesion Policy represents the main EU measure to ensure a balanced and sustainable growth in Europe by promoting harmonious development and reducing the regional disparities. The general objective of the paper is to highlight the important role of the Cohesion Policy in the development of intangible assets. The objectives and the instruments of the Cohesion Policy are designed to support programs on regional development, economic change, enhanced competitiveness and territorial cooperation through the European Union, to develop human resources and employability. The article also attempts to outline the trends of the Cohesion policy for the future by presenting a series of measures suggested by the European Commission through the Europe 2020 Strategy in order to develop intangible assets