Health-care professionals' views about safety in maternity services: a qualitative study.

OBJECTIVE: to explore health-care professionals' views about safety in maternity services. This paper identifies aspects of care that are less safe than they should be, possible ways to improve safety, and potential obstacles to achieving these improvements. This study was part of the King's Fund inquiry into the safety of maternity services in England. DESIGN: qualitative study with a sample of health-care professionals who work in maternity services and who responded to the call for evidence. Data were collected by questionnaire and analysed using thematic content analysis. SETTING: maternity professionals throughout England were invited to take part. PARTICIPANTS: midwives, obstetricians, student midwives, nurses, neonatal nurses, general practitioners, managers, hospital doctors and paediatricians. In total, there were 591 respondents. MEASUREMENTS AND FINDINGS: participants were asked to respond to open-ended questions identifying aspects of maternity care that were less safe than they should be, potential solutions to improve safety of care, and any barriers to implementing these improvements. Problems described included the increasing social and medical complexity of the pregnant population, low staffing levels, inappropriate skill mix, low staff morale, inadequate training and education, medicalisation of birth, poor management, lack of resources and reconfiguration. Proposed solutions included more staff, better teamwork and skill mix, improved training, more one-to-one care, caseloading, better management, more resources, better guidelines and learning from incidents. Barriers to implementing improvements included stressed staff who were resistant to change, inadequate management/poor staff management relationships and financial restraints. KEY CONCLUSIONS: the responses of maternity professionals convey a deep sense of staff anxiety regarding how the problems they face pose a threat to safety. IMPLICATIONS FOR PRACTICE: policy makers and professional bodies need to take the concerns expressed by staff seriously. Concerted efforts are required to improve maternity services and support maternity professionals.

Dopamine antagonist modulation of amphetamine response as detected using pharmacological MRI.

Functional magnetic resonance imaging (fMRI), employing BOLD-contrast, was used to measure changes in regional brain activation following amphetamine administration, either alone or after pre-treatment with the dopamine D1 receptor antagonist SCH23390, or the dopamine D2 receptor antagonist, sulpiride, in anaesthetised rat. After obtaining baseline data, rats (n=8) were given amphetamine (3 g/kg i.v) and volume data sets collected for 90 mins. Acute amphetamine challenge caused widespread increases in BOLD signal intensity in many subcortical structures with rich dopaminergic innervation, with decreases in BOLD contrast observed in the superficial layers of the cortex. Pretreatment with SCH23390 (n=8, 0.5 mg/kg, i.v) substantially attenuated the increases in BOLD activity in response to amphetamine, with lesser effects on the amphetamine-evoked decreases in BOLD signal. In contrast, sulpiride (n=8, 50 mg/kg, i.v) predominantly blocked the decrease in BOLD signal, having a smaller effect on the increases in BOLD signal. In summary, these data are supportive of the notion that different dopamine receptor types are responsible for separate components of the full amphetamine response. Furthermore the utility of BOLD contrast fMRI as a means of characterising the mechanisms of drug action in the whole brain has been demonstrated. Such studies may be of particular use for investigation of localised action and interaction of different dopaminergic agents.

Detection of cannabinoid agonist evoked increase in BOLD contrast in rats using functional magnetic resonance imaging.

BOLD-contrast functional magnetic resonance imaging (fMRI) was used to investigate the effects of the synthetic cannabinoid agonist HU210 on the rat brain in order to determine potential CNS sites of action for the functional effects of cannabinoids. After obtaining basal data, rats (n=8) were given the cannabinoid agonist HU210 (10 microg/kg i.v.) and volume data sets collected for 85 mins. Significant increases in functional BOLD activity were observed in specific brain regions including those important in pain (PAG), reward (VTA and accumbens) and motor function (striatum). In order to confirm cannabinoid receptor involvement in the HU210 evoked functional BOLD activity, rats (n=8) were pre-treated with the CB1 cannabinoid receptor antagonist SR141716A (100 microg/kg i.v.) prior to HU210. Pretreatment with SR141716A abolished all significant evoked HU210 functional BOLD activity. To exclude the involvement of potential systemic effects induced by the cannabinoid agonist administration on the observed evoked functional BOLD activity a separate experiment investigated the effect of HU210 (10 microg/kg i.v.) on mean arterial pressure and showed that HU210 had no significant effect on pressure under chloral hydrate anaesthesia. In summary, this study demonstrates that the cannabinoid agonist HU210 evokes a significant increase in BOLD functional activity in specific regions and that this was cannabinoid receptor mediated. Furthermore the study indicates the potential value of fMRI in rodents to delineate pharmacologically induced changes in regional brain function.

Cognitive therapy for the management of sickle cell disease pain: an evaluation of a community based intervention

Sickle cell disease [SCD] is the most prevalent haemoglobinopathy in Northern Europe [WHO, 1985]. It primarily affects the Caribbean and African population as well as small numbers of people from Mediterranean and India [NAHAT,19991]. SCD's most common symptoms is the vaso-occlusive cricis or "painful cricis". Painful crises are the principal cause of morbidity among patients with SCD and account for the second greatest number of hospital admissions with an average of seven days. Whilst numbers vary, most patient experience at least one severe episode per year requiring hospital admission for control. This inevitably causes severe disruption to educational and social aspects of patients' lives, which in turn, has consequences for achievement capabilities and psycho-social adjustment[Thomas and Westerdale,1996]. Nevertheless, traditionally the focus of treatment for SDC pain has been upon its physical aspects.This has been at the expense of consideration of the psycho-social and socio-cultural factors involved and may account for some of the difficulties fraught within the current treatment for SCD pain. [AU]

The expectancy bias model of selective associations: the relationship of judgements of CS dangerousness, CS-UCS similarity and prior fear to a priori and a posteriori covariation assessments.

This paper describes three experiments examining predictions from the expectancy bias model of selective associations (Davey, 1995). In a simulated 'threat' conditioning procedure, Experiment 1 showed that UCS expectancy following both ontogenetic and phylogenetic CSs was significantly predicted by: (1) ratings of the dangerousness of the CS, perceptions of CS-UCS similarity, and level of prior fear to the CS; and (2) ratings of CS-UCS similarity on the dimensions of valence, arousal and anxiety. Experiment 2 used a covariation assessment procedure which confirmed the findings of Experiment 1, and also showed that both phylogenetic and ontogenetic fear-relevant CSs exhibited both a priori and a posteriori covariation biases. Experiment 3 found that Ss high and low in fear to a fear-relevant CS exhibited a significant a priori UCS expectancy bias, but this bias was significantly larger in high fear Ss. Only high fear Ss exhibited an a posteriori covariation bias. These results are consistent with predictions from the expectancy bias model.