Qualitative study of the clinician-parent interface in discussing prognosis following MRI and US imaging of preterm infants in the UK.

OBJECTIVE: To explore communication and interaction between parents and clinicians following neonatal ultrasound (US) and MRI of the brain of babies born preterm. SETTING: This qualitative study was undertaken as part of a larger UK study of neonatal brain imaging. 511 infants were cared for in 14 London neonatal units with MR and cerebral US imaging in a specialist centre. PARTICIPANTS: Parents with infants born at <33 weeks gestation were randomised to receive prognostic information based on either MRI or US findings on their infants at term-corrected age. METHODS: Discussions between parents and clinicians about the MRI or US result were audio recorded. Parents were told about the findings and their baby's predicted outcome. A topic guide ensured essential aspects were covered. Recordings were fully transcribed. Discussion of the scan results, the content and style of the interaction and parental response were analysed qualitatively in 36 recordings using NVivo V.10. OUTCOMES: Key themes and subthemes were identified in the clinician-parent discussions. RESULTS: The overarching theme of 'the communication interface' was identified with three key themes: 'giving information', 'managing the conversation' and 'getting it right' and further subthemes. A range of approaches were used to facilitate parental understanding and engagement. There were differences in the exchanges when information about an abnormal scan was given. The overall structure of the discussions was largely similar, though the language used varied. In all of the discussions, the clinicians talked more than the parents. CONCLUSIONS: The discussions represent a difficult situation in which the challenge is to give and receive complex prognostic information in the context of considerable uncertainty. The study highlights the importance of being able to re-visit specific issues and any potential areas of misunderstanding, of making time to talk to parents appreciating their perspective and level of knowledge. TRIAL REGISTRATION NUMBER: EudraCT 2009-013888-19; Pre-results.

Explanations and information-giving: clinician strategies used in talking to parents of preterm infants.

BACKGROUND: The study is part of a larger research programme on neonatal brain imaging in the trial element of which parents were randomised to receive prognostic information based upon either magnetic resonance imaging (MRI) or ultrasound findings (ePrime study). The aim of this study was to investigate the strategies used by clinicians in communicating with parents following imaging at term age of the brain of preterm infants born before 33 weeks gestation, focusing on explanations and information-giving about prognosis  METHOD: Audio recordings of discussions between parents and clinicians were made following MRI and ultrasound assessment. Parents were given the scan result and the baby's predicted prognosis. A framework was developed based on preliminary analysis of the recordings and findings of other studies of information-giving in healthcare. Communication of scan results by the clinicians was further explored in qualitative analysis with 36 recordings using NVivo 10 and the specifically developed framework. Emerging themes and associated sub-themes were identified. RESULTS: The ways in which clinicians gave information and helped parents to understand were identified. Within the over-arching theme of clinician strategies a wide range of approaches were used to facilitate parental understanding. These included orienting, checking on previously acquired information, using analogies, explaining terminology, pacing the information, confirming understanding, inviting clarification, answering parents' questions and recapping at intervals. Ultimately four key themes were identified: 'Framing the information-giving', 'What we are looking at', 'Presenting the numbers and explaining the risk' and 'Appreciating the position of parents'. CONCLUSIONS: The interviews represent a multifaceted situation in which there is a tension between the need to explain and inform and the inherent complexity of neurological development, potential problems following preterm birth and the technology used to investigate and monitor these.

Preclinical pharmacology and toxicology of intravenous MV-NIS, an oncolytic measles virus administered with or without cyclophosphamide.

MV-NIS is an oncolytic measles virus encoding the human thyroidal sodium iodide symporter (NIS). Here, we report the results of preclinical pharmacology and toxicology studies conducted in support of our clinical protocol "Phase I Trial of Systemic Administration of Edmonston Strain of Measles Virus, Genetically Engineered to Express NIS, with or without Cyclophosphamide, in Patients with Recurrent or Refractory Multiple Myeloma." Dose-response studies in the KAS-6/1 myeloma xenograft model demonstrated a minimum effective dose of 4 x 10(6) TCID50 (tissue culture infectious dose 50)/kg. Toxicity studies in measles-naive squirrel monkeys and measles-susceptible transgenic mice were negative at intravenous doses up to 10(8) and 4 x 10(8) TCID50/kg, respectively. Abundant viral mRNA, maximal on day 8, was detected in cheek swabs of squirrel monkeys, more so after pretreatment with cyclophosphamide. On the basis of these data, the safe starting dose of MV-NIS for our clinical protocol was set at 1-2 x 10(4) TCID50/kg (10(6) TCID50 per patient).

Working together: neonatal nurse practitioners in practice.

UNLABELLED: The aim of this study was to examine the relatively new role of neonatal nurse practitioners (NNPs) in the United Kingdom, comparing practice in different types of neonatal units and work undertaken by junior medical staff (JMS). Diary checklists sent to the total population of qualified NNPs in neonatal units (NNUs) and JMS in six regional centres with qualified NNPs were returned from 68 out of 109 qualified NNPs (62%), working in 50 different NNUs and from 25 out of 48 JMS (52%). Direct observations (totalling 263.5 h) were made by an experienced neonatal nurse researcher on 30 different NNPs. Frequencies of activities and specific procedures were compared between groups. Observational measures included type and duration of activity and interactions with other members of staff. NNPs were found to be undertaking a range of activities: in the NNU, which usually involved blood sampling, siting of intravenous cannulae, presenting at ward rounds and teaching. Outside the unit, NNPs attended the delivery suite and the postnatal ward. Significant differences were found in the nature and organization of their work in different types of NNUs. A comparison between NNPs and JMS showed similar activities, with greater direct involvement by NNPs in the NNU and in teaching. The diary data were supported by observations and together these are evidence of current NNP practice. CONCLUSION: To a large extent there is an overlap in the work of JMS and NNPs in neonatal units, but although the clinical work and areas of activity are similar, there are differences in emphasis and in work organization.

How clinicians in neonatal care see the introduction of neonatal nurse practitioners.

UNLABELLED: The aim of this study was to investigate the views of UK clinicians in neonatal care who were working with nurses trained as neonatal nurse practitioners (NNPs). A questionnaire survey was used with a total sample of senior clinicians in the 66 neonatal units with one or more qualified NNPs. The main outcome measures were type and frequency of response, and similar data from NNPs were used to make comparisons. Data were returned from 57 of the 66 clinicians contacted (86%). NNP clinical practice as perceived by them was largely similar to that recorded by NNPs, though the clinicians expected more NNP involvement in some procedures (inserting central venous lines, umbilical arterial catheters, chest drains and peripheral arterial cannulae) than was actually found. Perceptions of the NNP role were similar, though the clinicians were significantly less likely to see taking a case-load, conducting a ward round, accepting outside referrals and taking charge of emergency transfers as integral elements. Reflections on the utilization of NNPs in neonatal care and the impact on junior medical staff education referred to NNPs filling gaps, a reduction in the intensity of work, improvements in training and in the quality of care. CONCLUSION: The introduction of NNPs is seen positively from the perspective of clinicians working alongside them in neonatal care. The development of similar models of care in countries where the introduction of NNPs is being considered is likely to be similarly supported.

Social, spatial and political determinants of U.S. abortion rates.

Abortion rates in the United States have risen annually since the 1973 Supreme Court decision. The regions with the greatest rate increases are the Southern and Plains states; the lowest rate increases were in regions which had high abortion rates soon after abortion was legalized. While spatial contiguity appears to influence abortion rates, that is, states with high rates of abortion are clustered spatially, social and political influence are also evident. Ratification of the equal rights amendment, the seeking of abortion outside the state of residence, and the degree of urbanization within a state are variables which influenced U.S. abortion rates between 1973 and 1977.

KIE: An analysis is presented of geographic and sociopolitical patterns in the increase in abortion rates in each of the five years following the Supreme Court's 1973 abortion decision. Clear regional patterns emerged, with the lowest abortion rates but the highest rates of increase occurring in the Southern and Plains states and the opposite occurring in states contiguous to the "lead" states of New York, California, and Washington. Degree of urbanization and per capita number of abortion facilities had a significant positive correlation, and the number of women having abortions outside their home states had a significant inverse relationship with abortion rates. Ratification of the Equal Rights Amendment showed some positive correlation, though it reached significance only in 1976 and declined the following year.

The urban system in the migration process: an evaluation of step-wise migration in Sierra Leone.

PIP: Based upon empirical evidence and indirect inference and observation, and upon a solid theoretical basis founded on concepts of sociocultural distance and the difficulty of the rural-urban transition, stepwise movement seems to be an important aspect of migration to urban centers in tropical Africa. People move for many reasons and to many different types of destinations, the city being 1 of these. In turn, stepwise migration is an important subcomponent of the urbanward drift of people. In investigating the complex migration process in Sierra Leone and the role of the urban system within it, 2 approaches were used. The 1st technique is very general and is derived from the Nystuen and Dacey graph theory analysis of nodal regions. Instead of the maximum outflows of cities, the dominant relations among the chiefdoms of Sierra Leone were investigated in terms of the pattern of population moves. Thus, rural-rural, rural-urban, and urban-urban flows were considered simultaneously. The urban hierarchy is defined simply as a 3 tiered system comprising the capital city of Freetown as the highest level, the 12 district headquarter towns as the middle tier, and the rural areas as the lowest. If the migration pattern of Sierra Leone were simply a process of movement through an urban system, a very regular pattern of "largest flow links" would occur focusing upon the major towns and cities. When this pattern is compared with that resulting from a reduction of the actual flow matrix, it can be seen that there would appear to be some reason to support the contentions of the model in certain, specific parts of the country, but not in others. The 2 maps are quite dissimilar, and not even the inclusion of the 2nd largest flow for each chiefdom assists in a replication of the "expected" pattern. A correlation of the coincidence of vectors on the 2 maps indicates that there is no significant relationship between the actual and expected pattersn. Hence, one would tend to reject the hypothesis of the operation of a stepwise migration pattern in Sierra Leone. Yet, this conclusion has to be qualified in terms of certain conditions and for certain areas within the country. While most of the districts do not conform, some do, notably Bo, Pujehun, and Kenema. The remainder of the country fails to conform to what would be considered as conditions ideal for a stepwise pattern of movement. It appears from this cursory investigation that the stepwise model of population movement through an urban system is a viable and structurally dominant pattern of population integration only in the absence of certain deviation causing characteristics such as weak local urban focus, relative proximity to larger urban center, isolation from intermediate urban center, and other, nonurban attractive forces impinging upon the migration process. A 2nd indirect model of testing the stepwide model is through simple regression analysis. Comparison of the regression coefficients or slopes for each chiefdom with the relative proportion of the population residing in urban places yields inconclusive results.^ieng