Sociocultural barriers to maternity services delivery: a qualitative meta-synthesis of the literature.

OBJECTIVES: Maternal and neonatal healthcare outcomes in Sub-Saharan Africa (SSA) remain poor despite decades of different health service delivery interventions and stakeholder investments. Qualitative studies have attributed these results, at least in part, to sociocultural beliefs and practices. Thus there is a need to understand, from an overarching perspective, how these sociocultural beliefs affect maternal and neonatal health (MNH) outcomes. STUDY DESIGN: A qualitative meta-synthesis of primary studies on cultural beliefs and practices associated with maternal and neonatal health care was carried out, incorporating research conducted in any country within SSA, using data from men, women and health professionals gathered through focus group discussions, structured and semistructured interviews. METHODS: A systematic search was carried out on seven electronic databases, Scopus, Ovid Medline, PubMed, CINAHL Plus, Humanities and Social Sciences (Informit), EMBASE and Web of Science, and on Google Scholar, using both manual and electronic methods, between 1st January 1990 and 1st January 2017. The terms 'cultural beliefs'; 'cultural beliefs AND maternal health'; 'cultural beliefs OR maternal health'; 'traditional practices' and 'maternal health' were used in the search. RESULTS: Key components of cultural beliefs and practices associated with adverse health outcomes on pregnancy, labour and the postnatal period were identified in five overarching factors: (a) pregnancy secrecy; (b) labour complications attributed to infidelity; (c) mothers' autonomy and reproductive services; (d) marital status, trust in traditional medicines and traditional birth attendants; and (e) intergenerational beliefs attached to the 'ordeal' of giving birth. CONCLUSION: Cultural beliefs and practices related to maternal and neonatal health care are intergenerational. Therefore, intensive community-specific education strategies to facilitate behaviour changes are required for improved MNH outcomes. Adopting practical approaches such as involving husbands/partners and communities in antenatal care services in a health facility and community settings can enhance improved MNH outcomes.

Lycra splinting garments for adults with intellectual disabilities who fall due to gait or balance issues: a feasibility study.

BACKGROUND: Adults with intellectual disabilities (IDs) experience high rates of falls and have high rates of gait or balance issues which contribute to falls. Lycra splinting garments (LSGs) have potential to improve gait or balance, but they have never before been tested with adults with IDs who fall due to gait or balance issues. The aim of this study was to test in adults with IDs, the feasibility of using LSGs to improve movement and function and reduce falls, whilst also exploring usability and likely compliance. METHOD: A convenience sample of nine adults with IDs wore tailored LSGs over a 6-week assessment period. Laboratory-based foot clearance, balance, and gait measures were collected pre- and post-LSG-wear. Falls charts and questionnaires on usability and likely compliance were also completed. RESULTS: Seven participants experienced a reduction in falls during their six weeks of LSG wear; most notably in the group of five participants who wore lycra splinting socks, compared with only two in the group of four who wore lycra splinting shorts or leggings only. CONCLUSION: Lycra splinting socks are likely to bring about positive outcomes for adults with IDs who fall due to gait/balance issues on an individual case by case basis over time, but further research is required to test this hypothesis under randomised controlled trial conditions. Potential benefits of more intrusive LSGs are outweighed by reported problems with usability and compliance.

RANK receptor oligomerisation in the regulation of NFκB signalling.

The interaction of receptor activator of NFκB (RANK), a member of the tumour necrosis factor receptor superfamily, with RANK ligand is crucial for the formation, function and survival of osteoclasts. The role of the cytoplasmic oligomerisation domain (pre-ligand assembly domain; PLAD or 'IVVY' motif) in the ligand-dependent activation of downstream NFκB signalling has not been studied previously. The discovery of truncating mutations of TNFRSF11A (W434X and G280X that lack the PLAD) as the cause of rare cases of osteoclast-poor osteopetrosis offered the opportunity for functional study of this region. Recapitulating the W434X mutation by transcription activator-like effector nuclease (TALEN)-mediated targeted disruption of Tnfrsf11a within the region homologous to W434X in the mouse macrophage-like cell line RAW264.7 impaired formation of osteoclast-like cells. Using overexpression studies, we demonstrated that, in contrast to WT-RANK, the absence of the PLAD in G280X-RANK and W434X-RANK prevented ligand-independent but not ligand-dependent oligomerisation. Cells expressing W434X-RANK, in which only two of the three TRAF6-binding motifs are present, continued to exhibit ligand-dependent NFκB signalling. Hence, the absence of the PLAD did not prevent ligand-induced trimerisation and subsequent NFκB activation of RANK, demonstrating that therapeutic targeting of the PLAD in the prevention of osteoporosis may not be as effective as proposed previously.

New knowledge on critical osteoclast formation and activation pathways from study of rare genetic diseases of osteoclasts: focus on the RANK/RANKL axis.

Functional, biochemical and genetic studies have over the past decade identified many causative genes in the osteoclast diseases osteopetrosis and Paget's disease of bone. Here, we outline all osteoclast diseases and their genetic associations and then focus specifically on those diseases caused by mutations in the critical osteoclast molecule Receptor Activator of Nuclear factor Kappa B (RANK). Both loss and gain-of-function mutations have been found in humans leading to osteopetrosis and high bone turnover phenotypes, respectively. Osteopetrosis-associated RANK mutations are widely distributed over the RANK molecule. It is likely that some negatively affect ligand binding, whereas others preclude appropriate association of RANK with downstream signalling molecules. In the Paget-like disorders, familial expansile osteolysis, early onset Paget's disease and expansile skeletal hyperphosphatasia, heterozygous insertion mutations are found in the RANK signal peptide. These prevent signal peptide cleavage, trapping the protein translated from the mutated allele in the endoplasmic reticulum. Whole animal studies replicate the hyperactive osteoclast phenotype associated with these disorders and present only with heterozygous expression of the mutation, suggesting an as yet unexplained effect of the mutant allele on normal RANK function. We discuss the cell biological studies and animal models that help us to understand the nature of these different RANK defects and describe how careful dissection of these conditions can help understand critical pathways in osteoclast development and function. We highlight areas that require further study, particularly in light of the pharmacological interest in targeting the RANK signalling pathway to treat diseases caused by excessive bone resorption.

PECAM-1 functions as a negative regulator of laminin-induced platelet activation.

SUMMARY BACKGROUND: Interaction of resting platelets with exposed components of the subendothelial matrix is an important early activating event that takes place at sites of vascular injury. Platelet responses to collagen are mediated by integrin alpha(2)beta(1) and the glycoprotein (GP)VI-Fc receptor (FcR) gamma-chain complex, whereas platelet activation by laminin is mediated by the related integrin, alpha(6)beta(1), and similarly requires signaling through GPVI-FcR gamma-chain. OBJECTIVE: Because the cell adhesion and signaling receptor PECAM-1 has previously been shown to dampen collagen-induced platelet activation, we sought to determine whether PECAM-1 might similarly regulate platelet activation by laminin. METHODS/RESULTS: We found that PECAM-1 became tyrosine phosphorylated on its cytoplasmic immunoreceptor tyrosine-based inhibitory motifs following adhesion of either human or murine platelets to immobilized laminin. Whereas the presence or absence of PECAM-1 had no effect on either the rate or extent of platelet adhesion or spreading on laminin, PECAM-1 inhibited laminin-induced phosphorylation of GPVI-FcR gamma-chain immunoreceptor tyrosine-based activation motifs (ITAMs) and activation of its downstream effector, Syk kinase, and suppressed granule secretion. CONCLUSIONS: Taken together, these data are consistent with previous findings in platelets and other blood and vascular cells that PECAM-1 functions by modulating ITAM-mediated signaling pathways that amplify cellular activation.

The development and validation of the Pre-operative Intrusive Thoughts Inventory (PITI).

Pre-operative anxiety is common and influences postoperative pain, hospital stay and patient satisfaction. We set out to explore anxiety content and develop a tool to evaluate patient anxiety at the pre-operative assessment clinic. We recruited 128 day surgery patients. Pre-operative anxiety content was explored and six factors (themes) were identified: 'preoccupation', 'outcome concerns', 'being unconscious', 'loss of control', 'dependence on others' and 'pain/discomfort'. The Pre-operative Intrusive Thoughts Inventory (PITI) was constructed and evaluated using exploratory and confirmatory factor analysis. The PITI demonstrated internal consistency for the full scale (Cronbach's alpha = 0.91) and for the subscales (Cronbach's alpha 0.74-0.85) as well as sensitivity (0.88) and specificity (0.60) to clinically significant anxiety assessed using the Hospital Anxiety and Depression Scale. The properties of the PITI suggest that it has potential as an additional tool for the evaluation of pre-operative anxiety.

Multicomponent treatment for blood-injury-injection phobia in a young man with mental retardation.

Blood-Injury-Injection Phobia (BIIP) is a subtype of specific phobia, characterized by fear and avoidance of seeing blood, an injury, or receiving an injection. In the current case report, we describe the treatment of BIIP in a young man with mental retardation. The multicomponent treatment consisted of fading (graduated exposure), modeling, noncontingent and differential reinforcement, presession anxiolytic medication, and topical analgesic cream.

Effects of noncontingent reinforcement on problem behavior and stimulus engagement: the role of satiation, extinction, and alternative reinforcement.

This study examined the effects of noncontingent reinforcement (NCR) with and without extinction on problem behavior and stimulus engagement (consumption of reinforcement) of 4 participants. Reductions in problem behavior using NCR have frequently been attributed to both satiation of the reinforcer and extinction. In the current study, aspects of the NCR treatment effects were difficult to explain based solely on either a satiation or an extinction account. Specifically, it was found that stimulus engagement remained high throughout the NCR treatment analysis, and that problem behavior was reduced to near-zero levels during NCR without extinction. The implications of these findings are discussed with respect to the satiation and extinction hypotheses frequently described in the applied literature. Findings from basic studies examining the effects of response-independent schedules are presented, and are used as the basis for a matching theory account of NCR-related effects. It is proposed that reductions in problem behavior observed during NCR interventions may be a function of the availability of alternative sources of reinforcement.

Sources cited most frequently in the experimental analysis of human behavior.

We conducted an analysis of the sources cited most frequently in primary empirical reports in the experimental analysis of human behavior (EAHB) published in four journals between 1990 and 1999. Citation patterns suggest that modern EAHB is topically focused and relatively independent of both animal operant research and human research conducted outside of behavior analysis.

Posterior sagittal anorectoplasty in adults: secondary repair for persistent incontinence in patients with anorectal malformations.

PURPOSE: Posterior sagittal anorectoplasty, regarded as a standard surgical primary repair for anorectal malformations in infancy, was evaluated for effectiveness when performed as a secondary operation for establishing continence in the adult. The purpose of this review was to evaluate our results of performing posterior sagittal anorectoplasty in adult patients and to emphasize the extensive evaluation required to perform proper patient selection. METHOD: From January 1, 1992, to December 31, 1996, eight patients with Grade 3 incontinence underwent posterior sagittal anorectoplasty. The ages ranged from 13 to 40 (mean, 26) years. RESULTS: All patients had diverting stomas at the time of repair and all but one had restoration of intestinal continuity. Of eight patients who underwent posterior sagittal anorectoplasty, one failed secondary to rectal ischemia and retained a diverting stoma. Six patients had restoration of continuity. Five patients were continent and one had incontinence only to gas. DISCUSSION: We have established that posterior sagittal anorectoplasty can effectively be used to establish continence as a secondary procedure for a select group of adult patients.

zA map for sequence analysis of the Arabidopsis thaliana genome.

Arabidopsis thaliana has emerged as a model system for studies of plant genetics and development, and its genome has been targeted for sequencing by an international consortium (the Arabidopsis Genome Initiative; http://genome-www. stanford.edu/Arabidopsis/agi.html). To support the genome-sequencing effort, we fingerprinted more than 20,000 BACs (ref. 2) from two high-quality publicly available libraries, generating an estimated 17-fold redundant coverage of the genome, and used the fingerprints to nucleate assembly of the data by computer. Subsequent manual revision of the assemblies resulted in the incorporation of 19,661 fingerprinted BACs into 169 ordered sets of overlapping clones ('contigs'), each containing at least 3 clones. These contigs are ideal for parallel selection of BACs for large-scale sequencing and have supported the generation of more than 5.8 Mb of finished genome sequence submitted to GenBank; analysis of the sequence has confirmed the integrity of contigs constructed using this fingerprint data. Placement of contigs onto chromosomes can now be performed, and is being pursued by groups involved in both sequencing and positional cloning studies. To our knowledge, these data provide the first example of whole-genome random BAC fingerprint analysis of a eucaryote, and have provided a model essential to efforts aimed at generating similar databases of fingerprint contigs to support sequencing of other complex genomes, including that of human.

Assessment of ventilation during the performance of a percutaneous dilatational tracheostomy: hypoventilation is not a common complication.

Percutaneous dilatational tracheostomy (PDT) is becoming an accepted cost-effective alternative to surgical tracheostomy. PDT is performed by progressive dilatation of a tracheal opening placed under bronchoscopic guidance. Case reports of hypoventilation with associated hypercarbia during the performance of PDT have raised concerns about the utility of this procedure in patients in whom hypercarbia is problematic (e.g., patients with closed head injury). In a prospective cohort analysis of 11 critically ill patients, we evaluated the effect of PDT on ventilation during and after the procedure using end tidal capnography. We found that hypercarbia does not occur during or after the performance of PDT as compared to baseline levels.

Hepatic hydrothorax: possible etiology of recurring pleural effusion.

A case of hepatic hydrothorax is presented as a reminder that a large, recurring pleural effusion may have an abdominal source, even in patients with minimal or no apparent ascites. One of the known mechanisms for hepatic hydrothorax is a peritoneopleural communication, as demonstrated in this case. A simple radionuclide imaging procedure, in which technetium 99m-sulfur colloid is injected into the peritoneal cavity prior to imaging of the chest and abdomen, can be used to document this finding. Treatment may include therapeutic thoracentesis, salt and water restriction, diuretics, tube thoracostomy with pleurodesis, surgical repair or placement of a portosystemic shunt.

Developing nurse leaders for today and tomorrow. Part 2, Implementing a model of leadership for community-based practice.

In part 1 of this two-part series, the authors described the Manager as Developer Model and its use in acute care settings and a community-based nursing administration curriculum. In this article, they predict its use to guide development of leadership and education for the future of community-based practice.

Developing nurse leaders for today and tomorrow, Part 1, foundations of leadership in practice.

Primary care, with a community-based orientation, is the driving force of healthcare reform. To prepare nurses to provide leadership in this changing healthcare environment, the Manager as Developer Model, useful in the acute care setting, is discussed as a useful model for primary care. Part 1 describes the Manager as Developer Model of Leadership Preparation with its seven major concepts as the basis for development of professionals. Its application to nurse managers in acute care settings is supported by research studies undertaken in those settings. Also discussed is how the model is used as a process framework in a nursing administration curriculum and the research to date, with its application. In part 2 (October 1996), the authors predict how the model's use can guide the development of leadership and education for the future of community-based practice.

A possible role of protein kinase C in augmenting H+ secretion by nonsteroidal anti-inflammatory drugs.

The effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on H+ secretion were studied in frog gastric mucosa and rabbit parietal cells (PC). In frog gastric mucosa, aspirin (10(-5) M) and ibuprofen (10(-4) M), but not indomethacin, naproxen and carprofen (10(-4) M each), enhanced histamine- and dibutyryl adenosine 3',5'-cyclic monophosphate-stimulated H+ secretion by 20 to 34%. Similarly, a protein kinase C (PKC) inhibitor, 1-(5-isoquinolinesulfonyl)- 2-methyl piperazine (H7, 5 x 10(-5) M), and a calcium ionophore, A23187 (10(-6) M) augmented basal and the aforementioned secretagogue-stimulated H+ secretion by approximately 50% and 20%, respectively, but a PKC activator, phorbol ester (12-O-tetradecanoyl phorbol 13-acetate, 10(-7)-10(-6) M), had no effect. The augmentation of H+ secretion by these agents was blocked by a calcium antagonist, lanthanum chloride (5 x 10(-4) M). In rabbit PC, H7 augmented secretagogue-stimulated H+ secretion by 60 to 150%, whereas 12-O-tetradecanoyl phorbol 13-acetate (10(-7) M) inhibited carbachol- and histamine-stimulated H+ secretion, respectively, by 65% and 52% without affecting dibutyryl adenosine 3',5'-cyclic monophosphate-stimulated H+ secretion. Furthermore, NSAIDs and H7-induced augmentation of dibutyryl cyclic adenosine monophosphate-stimulated H+ secretion was prevented by 12-O-tetradecanoyl phorbol 13-acetate (10(-7)-10(-6) M) in frog gastric mucosa and rabbit PC. Unlike H7, NSAIDs had no direct inhibiting action on PC membrane or cytosolic fractions of PKC, but they inhibited Sn-1,2-diacylglycerol level in PC by 20 to 30%.(ABSTRACT TRUNCATED AT 250 WORDS)

Collisional activation of a series of homoconjugated octadecadienoic acids with fast atom bombardment and tandem mass spectrometry.

High-energy collisional activation (CA) of long-chain fatty acid ions induces decompositions that occur remote from the charge site. These charge-remote fragmentations (CRFs) have been shown to provide much structural information. In this report, the CRF of a continuous series of 12 homoconjugated octadecadienoic acids was studied with fast atom bombardment and tandem mass spectrometry. Each fatty acid was desorbed as the carboxylate anion, [M - H](-), the dilithiated species, [M - H+2Li](+), or the bariated species, [M - H+Ba](+), giving three ways of localizing the charge. A characteristic pattern is generated for CRF of the 1,4-diene functional group, and this allows for the rapid identification of the functional group and its location on the chain. Minor variations of this pattern are observed for the different ionic precursors and for different locations of the double bonds. Furthermore, there are a few complications from different types of charge-proximate reactions, especially of the fatty acid carboxylates.

Early and late results of coronary angioplasty without antecedent thrombolytic therapy for acute myocardial infarction.

Direct coronary angioplasty without antecedent thrombolytic therapy was performed in 500 consecutive patients with acute myocardial infarction. Anterior and inferior infarctions were noted in 217 and 283 patients, respectively. Two hundred fifteen patients (43%) had 1-vessel disease, 85 patients (17%) were greater than 70 years of age and 39 (8%) presented in cardiogenic shock. Successful angioplasty of the infarct vessel was achieved in 94% of patients. The overall in-hospital mortality was 7.2%. Cardiogenic shock, 3-vessel disease and failed angioplasty were the 3 strongest multivariate correlates of early mortality. Reocclusion of the infarct-vessel was noted in 47 (15%) of the 307 patients with angiographic follow-up before hospital discharge. Significant bleeding complications occurred in only 3% of patients; stroke or myocardial rupture was not seen. The global ejection fraction increased from 53% on the preangioplasty ventriculograms to 59% at 1 week (p less than 0.001). Significant regional wall motion improvement in the infarct segments was noted in 53% of patients. Global ejection fraction improved most dramatically in patients presenting with baseline ejection fractions less than or equal to 45% (increasing from 36 to 50%). The 1- and 5-year survival rates after hospital discharge were 95 and 84%, respectively. The 1-year reinfarction rate was 3%. Thus, direct coronary angioplasty was highly effective in reestablishing infarct-vessel patency and salvaging ischemic myocardium, resulting in low in-hospital and long-term mortality.

Gene expression caused by alkylating agents and cis-diamminedichloroplatinum(II) in Escherichia coli.

Previous work has demonstrated heterogeneous effects of methylating agents on induction of DNA damage inducible genes in Escherichia coli. These studies employed E. coli mutants that have fusions of the lac operon to genes induced by treatment with sublethal levels of alkylating agents. These mutants were selected from random insertions of the Mu-dl (Apr lac) phage by screening for induction of beta-galactosidase activity in the presence of methylmethanesulfonate or N-methyl-N'-nitro-N-nitrosoguanidine. The current report extends these findings by analyzing gene expression caused by mechlorethamine, chloroethylnitrosoureas and cis-diamminedichloroplatinum(II) (cis-DDP). The results demonstrate heterogeneous effects by these agents on gene expression. While 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea induces alkA, other nitrosoureas, mechlorethamine, and cis-DDP do not cause expression of this gene. Further, while all nitrosoureas caused expression of aidC, mechlorethamine and cis-DDP did not. Lastly, cis-DDP caused marked expression of a sulA fusion mutant while not inducing any of the other E. coli fusion mutants.