The acceptability and feasibility of a randomised trial exploring approaches to managing impacted fetal head during emergency caesarean section: a qualitative study.

BACKGROUND: Caesarean sections (CS) account for 26% of all births in the UK, of which at least 5% are done at full dilatation, in the second stage of labour. Second stage CS may be complicated by the fetal head being deeply impacted in the maternal pelvis, requiring specialist skills to achieve a safe birth. Numerous techniques are used to manage impacted fetal head, however, there are no national clinical guidelines in the UK. AIM: To explore health professionals' and women's views on the acceptability and feasibility of a randomised controlled trial (RCT) designed to explore approaches to managing an impacted fetal head during emergency CS. METHODS: Semi-structured interviews with 10 obstetricians and 16 women (6 pregnant and 10 who experienced an emergency second stage CS). Interviews were transcribed and analysed using systematic thematic analysis. RESULTS: The findings considered the time at which you obtain consent, how and when information about the RCT is presented, and barriers and facilitators to recruiting health professionals and women into the RCT. Obstetricians emphasised the importance of training in the techniques, as well as the potential conflict between the RCT protocol and current site or individual practices. Women said they would trust health professionals' to use the most appropriate technique and abandon the RCT protocol if necessary. Similarly, obstetricians raised the tension between the RCT protocol versus safety in reverting to what they knew under emergency situations. Both groups reflected on how this might affect the authenticity of the results. A range of important maternal, infant and clinical outcomes were raised by women and obstetricians. However, there were varying views on which of the two RCT designs presented to participants would be preferred. Most participants thought the RCT would be feasible and acceptable. CONCLUSIONS: This study suggests an RCT designed to evaluate different techniques for managing an impacted fetal head would be feasible and acceptable. However, it also identified a number of challenges that need to be considered when designing such an RCT. Results can be used to inform the design of RCTs in this area.

Supracrestal tissue esthetic management (STEM) technique and current approaches in restorative and surgical treatment of deep margins.

Carious lesions with deep margins represent a challenge in daily clinical practice. The following key points are discussed in this article: how to manage a deep margin from a restorative point of view; when and how to perform a surgical procedure; and when it is favorable to carry out definitive restoration work after surgery. The restorative materials and adhesive procedures available today allow minimally invasive techniques to be used on dental tissue with a high preservation of tooth structure. These materials and techniques help to avoid adverse periodontal tissue reactions. Depending on the clinical situation, three treatment options are available when dealing with a subgingival margin. If the depth of the cavity margin is at a maximum distance of 1.5 mm below the gingival margin, isolation with rubber dam allows the performance of interproximal margin relocation, thereby facilitating optimal restoration and periodontal tissue integration. If the margin is located deeper than 1.5 mm below the gingival margin, surgery is necessary before any restorative work can take place. When the margin is within 2 mm above the bone crest, a supracrestal tissue esthetic management (STEM) procedure is undertaken, which means that no ostectomy is required and only osteoplasty is necessary to reshape the preexisting supracrestal attachment, thereby allowing the restorative work to proceed. When the margin is less than 2 mm above the bone crest, crown lengthening with minimal ostectomy and subsequent osteoplasty becomes necessary.

Comparison of posterior indirect adhesive restorations (PIAR) with different preparation designs according to the adhesthetics classification. Part 1: Effects on the fracture resistance.

AIM: To investigate whether: 1) in the adhesive era, a full-crown restoration in a molar tooth is more resistant compared with an overlay-type restoration; b) a posterior indirect adhesive restoration (PIAR) is similar to a sound tooth from a mechanical point of view. MATERIALS AND METHODS: Seventy extracted molars were divided into five groups (1. Butt Joint; 2. Full Bevel; 3. Shoulder; 4. Full Crown; 5. Sound Tooth (control); N = 14) and prepared with four different PIAR overlay design types (according to an adhesthetics classification). Seven expert dentists performed all the preparation and cementation phases with codified protocols. A CAD/CAM workflow was used to realize the 56 monolithic lithium disilicate restorations. The samples were tested with thermomechanical aging (margin quality data will be given in Part 2 of this article series), and the resistance to fracture was then tested and analyzed. RESULTS AND CONCLUSIONS: In terms of fracture resistance in a situation of overload and within the limitations of the present study, it is possible to conclude that the Full Bevel group showed higher fracture strength than all the other groups. All PIAR restorations performed equally or better than the natural control tooth in the Sound Tooth group. The Full Crown group did not perform better than partial overlay PIAR. The fracture types were limited to the crown in 50% or more of the samples; the rest involved the cervical part of the root. The preparation design that involved the root the least was the Full Crown group (14%).

The acceptability to women of techniques for managing an impacted fetal head at caesarean section and of randomised trials evaluating those techniques: a qualitative study.

BACKGROUND: This study aimed to explore women's views on the acceptability of different techniques for managing an impacted fetal head at caesarean; and the feasibility and acceptability of conducting a trial in this area. METHODS: Qualitative semi-structured interviews with a systematic sample of women who experienced second stage emergency caesarean section at a tertiary National Health Service (NHS) hospital in England, UK. Thematic analysis was used to extract women's views. RESULTS: Women varied in their perceptions of the acceptability of different techniques for managing impacted fetal head. Trust in medical expertise and prioritising the safety of the baby were important contextual factors. Greater consensus was found around informed choice in trials where subthemes considered the timing of invitation, reduced capacity to give consent in emergency situations, and the importance of birth outcomes and having good rapport with healthcare professionals who invite women into trials. Finally, women reflected on the importance of supportive antenatal and postpartum education for impacted fetal head. CONCLUSIONS: This research provides information on the acceptability of techniques and any trial to evaluate these techniques. Findings illustrate the importance of context and quality of care to both acceptability and approaching women to take part in a future trial.

Triple-modality co-registered endoscope featuring wide-field reflectance imaging, and high-resolution multiphoton and optical coherence microscopy.

We present the design and feasibility testing of a multimodal co-registered endoscope based on a dual-path optical system integrated with a scanning piezo. This endoscope incorporates three different imaging modalities. A large field of view reflectance imaging system enables visualization of objects several millimeters in front of the endoscope, while optical coherence microscopy and multiphoton microscopy are employed in contact with tissue to further analyze suspicious areas. The optical system allows multiple different imaging modalities by employing a dual optical path. One path features a low numerical aperture and wide field of view to allow reflectance imaging of distant objects. The other path features a high numerical aperture and short working distance to allow microscopy techniques such as optical coherence microscopy and multiphoton microscopy. Images of test targets were obtained with each imaging modality to verify and characterize the imaging capabilities of the endoscope. The reflectance modality was demonstrated with a 561 nm laser to allow high contrast with blood vessels. It achieved a lateral resolution of 24.8 µm at 5 mm and a working distance from 5 mm to 30 mm. Optical coherence microscopy (OCM) was performed with a 1300 nm super-luminescent diode since this wavelength experiences low relative scattering to allow for deeper tissue imaging. Measured OCM lateral and axial resolution was 4.0 µm and 14.2 µm, respectively. Multiphoton microscopy (MPM) was performed with a custom 1400 nm femtosecond fiber laser, a wavelength suitable for exciting multiple exogenous and some endogenous fluorophores, as well as providing information on tissue composition through harmonic generation processes. A 4.0 µm MPM lateral resolution was measured.

Pharmacological properties of NAI-603, a well-tolerated semisynthetic derivative of ramoplanin.

NAI-603 is a ramoplanin derivative designed to overcome the tolerability issues of the parent drug as a systemic agent. NAI-603 is highly active against aerobic and anaerobic Gram-positive bacteria, with MICs ranging from 0.008 to 8 µg/ml. MICs were not significantly affected by pH (range, 6 to 8), by inoculum up to 10(8) CFU/ml, or by addition of 50% human serum. Against staphylococci and enterococci, NAI-603 was rapidly bactericidal, with minimum bactericidal concentration (MBC)/MIC ratios never exceeding 4. The frequency of spontaneous resistance was low at 2× to 4× MIC (≤1×10(-6) to ≤1×10(-8)) and below the detection limit (about ≤1×10(-9)) at 8×MIC. Serial subcultures at 0.5×MIC yielded at most an 8-fold increase in MICs. In a systemic infection induced by methicillin-resistant Staphylococcus aureus (MRSA), the 50% effective dose (ED50) of intravenous (i.v.) NAI-603 was 0.4 mg/kg, lower than that of oral (p.o.) linezolid (1.4 mg/kg) and subcutaneous (s.c.) teicoplanin (1.4 mg/kg) or vancomycin (0.6 mg/kg). In neutropenic mice infected with vancomycin-resistant enterococci (VRE), the ED50s for NAI-603 were 1.1 to 1.6 mg/kg i.v., compared to 0.5 mg/kg i.v. of ramoplanin. The bactericidal activity was confirmed in vivo in the rat granuloma pouch model induced by MRSA, where NAI-603, at 40 mg/kg i.v., induced about a 2- to 3-log10-reduction in viable bacteria in the exudates, which persisted for more than 72 h. The pharmacokinetic (PK) profiles of NAI-603 and ramoplanin at 20 mg/kg show similar half-lives (3.27 and 3.80 h, respectively) with the maximum concentration (Cmax) markedly higher for NAI-603 (207 µg/ml versus 79 µg/ml). The favorable pharmacological profile of NAI-603, coupled with the absence of local tolerability issues, supports further investigation.

Exploring views on satisfaction with life in young children with chronic illness: an innovative approach to the collection of self-report data from children under 11.

The objective of this study was to explore young children's views on the impact of chronic illness on their life in order to inform future development of a patient-based self-report health outcome measure. We describe an approach to facilitating self-report views from young children with chronic illness. A board game was designed in order to obtain qualitative data from 39 children with a range of chronic illness conditions and 38 healthy controls ranging in age from 3 to 11 years. The format was effective in engaging young children in a self-report process of determining satisfaction with life and identified nine domains. The board game enabled children aged 5-11 years with chronic illness to describe the effects of living with illness on home, family, friends, school and life in general. It generated direct, non-interpreted material from children who, because of their age, may have been considered unable or limited their ability to discuss and describe how they feel. Obtaining this information for children aged 4 and under continues to be a challenge.

Efficacy of the new lantibiotic NAI-107 in experimental infections induced by multidrug-resistant Gram-positive pathogens.

NAI-107 is a novel lantibiotic active against Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), glycopeptide-intermediate S. aureus (GISA), and vancomycin-resistant enterococci (VRE). The aim of this study was to evaluate the in vivo efficacy of NAI-107 in animal models of severe infection. In acute lethal infections induced with a penicillin-intermediate Streptococcus pneumoniae strain in immunocompetent mice, or with MRSA, GISA, and VRE strains in neutropenic mice, the 50% effective dose (ED(50)) values of NAI-107 were comparable or lower than those of reference compounds, irrespective of the strain and immune status (0.51 to 14.2 mg/kg of body weight for intravenous [i.v.] NAI-107, 5.1 to 22.4 for oral linezolid, and 22.4 for subcutaneous [s.c.] vancomycin). In the granuloma pouch model induced in rats with a MRSA strain, intravenous NAI-107 showed a dose-proportional bactericidal activity that, at a single 40-mg/kg dose, compared with 2 20-mg/kg doses at a 12-h or 24-h interval, caused a 3-log(10)-CFU/ml reduction of viable MRSA in exudates that persisted for more than 72 h. Rat endocarditis was induced with a MRSA strain and treated for five consecutive days. In a first experiment, using 5, 10, or 20 mg/kg/day, and in a second experiment, when 10 mg/kg at 12-h intervals was compared to 20 mg/kg/day, intravenous NAI-107 was effective in reducing the bacterial load in heart vegetations in a dose-proportional manner. Trough plasma levels, as determined on days 2 and 5, were several times higher than the NAI-107 minimal bactericidal concentration (MBC). NAI-107 binding to rat and human serum ranges between 93% and 98.6%. The rapid bactericidal activity of NAI-107 observed in vitro was thus confirmed by the efficacy in several models of experimental infection induced by Gram-positive pathogens, supporting further investigation of the compound.

An investigation of health anxiety in families where children have recurrent abdominal pain.

OBJECTIVES: To explore health anxiety in children with recurrent abdominal pain (RAP) using a symbolic play assessment. METHODS: Children with RAP and two control groups (with asthma and well children) were recruited. Eighty-four families completed play and questionnaire assessments of health anxiety and psychological functioning. RESULTS: Children with RAP demonstrated less use of psychological descriptions for feelings than control children, and were more likely to represent serious outcomes to health scenarios than well children, but not children with asthma. Mothers of children with RAP had higher levels of health anxiety, and rated their children as having more physical symptoms and anxiety. CONCLUSIONS: The symbolic play paradigm provided discriminating insights into health anxiety in children. The findings suggest that childhood RAP may be associated with higher levels of parental health anxiety. These aspects of family functioning might usefully be explored in families where a child has RAP.

Attitudes to psychological groups in a paediatric and adolescent diabetes service--implications for service delivery.

OBJECTIVE: To explore the potential interest in psychology support groups in a paediatric and adolescent diabetes service. RESEARCH DESIGN AND METHODS: A short semi-structured interview using both open and closed questions to generate quantitative and qualitative data. Sixty-four parents were interviewed on the telephone by an assistant psychologist. RESULTS: The majority of parents (81%) reported an interest in participating in a psychology group if it was offered, but preferences varied between a child/young person group (33%), parents only (15%) or family groups (11%). Twenty-three percent said that they would prefer individual work rather than a group. Parents identified groups as an opportunity to acquire practical knowledge, exchange ideas in an informal setting, share a common reality with others and gain more confidence in managing diabetes together with their child. Reasons not to attend a group included parents being able to cope well at the moment, school demands, feeling uncomfortable speaking in front of a group and use of online support groups. CONCLUSION: The majority of parents identified psychological support as having a role for families living with diabetes. The audit highlighted that families have different ideas about how they would prefer this support to look and emphasized the need to consult with service users when designing psychological support for young people and families living with a chronic condition.

Synthesis and preliminary biological characterization of new semisynthetic derivatives of ramoplanin.

Ramoplanin is a glycolipodepsipeptide antibiotic active against Gram-positive bacteria including vancomycin-resistant enterococci. Ramoplanin inhibits bacterial cell wall biosynthesis by a mechanism different from that of glycopeptides and hence does not show cross-resistance with these antibiotics. The systemic use of ramoplanin has been so far prevented because of its low local tolerability when injected intravenously. To overcome this problem, the fatty acid side chain of ramoplanin was selectively removed and replaced with a variety of different carboxylic acids. Many of the new ramoplanin derivatives showed antimicrobial activity similar to that of the natural precursor coupled with a significantly improved local tolerability. Among them the derivative in which the 2-methylphenylacetic acid has replaced the di-unsaturated fatty acid side chain (48) was selected as the most interesting compound and submitted to further in vitro and in vivo characterization studies.

Synthesis and antibacterial activity of alkyl derivatives of the glycopeptide antibiotic A40926 and their amides.

New derivatives of the glycopeptide antibiotic A40926 were synthesized and evaluated for antimicrobial activity against VRE. Deacylated A40926 was obtained by microbial transformation of the parent antibiotic with the use of Actinoplanes teichomyceticus ATCC 31121. Regioselective synthesis of alkylated derivatives of Deacyl A40926 was carried out using lipophilic aliphatic and aromatic halides or aldehydes. Further modification of the two carboxylic acids was performed to increase antibiotic activity. Poor antimicrobial activity was observed for the derivatives obtained by lipophilic mono- or dialkylation of the amino groups present on the molecule, while simultaneous condensation of both carboxylic groups, in hydrophobic derivatives, with dibasic amines led to a strong increase in antibiotic activity.

Nitrogen metabolism components as a tool to discriminate between organic and conventional citrus fruits.

The aim of this work was to develop a method for authenticity control of organically grown orange fruits. Due to the different kinds of nitrogen fertilization of the soil in organically and conventionally managed farms, the study tried to verify the possibility to differentiate Navelina and Tarocco orange fruits obtained by these production systems through the detection of markers linked to nitrogen metabolism. In addition to the classic quality parameters, total nitrogen (N) and synephrine contents in juice and (15)N/(14)N isotope ratio (expressed as delta(15)N per thousand) in proteins of pulp and amino acids of juice were determined. The results obtained indicated that total N and synephrine contents were significantly higher in conventional fruits, whereas the delta(15)N per thousand values were higher in the organic ones. The new markers identified in this research by linear discriminant analysis of the data may constitute a useful tool to differentiate organic citrus fruits or juices from conventional ones.

In vitro antistaphylococcal activity of dalbavancin, a novel glycopeptide.

OBJECTIVES: Dalbavancin is a novel, semi-synthetic glycopeptide antibiotic. The aim of this study was to further explore its activity against staphylococci. METHODS: The bactericidal activity of dalbavancin was studied using MBC and time-kill methods. The potential for resistance to dalbavancin was examined using single-step and serial-passage experiments. RESULTS: Dalbavancin was bactericidal against methicillin-susceptible and -resistant Staphylococcus aureus, in both the presence and absence of human serum. No resistance was seen with any isolate tested. After serial passage, bacterial populations were more homogeneous in their susceptibility to dalbavancin than to vancomycin or teicoplanin. CONCLUSION: Dalbavancin is bactericidal for staphylococci. Resistance to this semi-synthetic glycopeptide is not readily developed in vitro.

Efficacy of dalbavancin against methicillin-resistant Staphylococcus aureus in the rat granuloma pouch infection model.

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) are an important cause of morbidity and mortality in hospital patients. Moreover, increased incidences of outpatient MRSA have been recently reported. This study investigated the bactericidal activity of dalbavancin, a novel, semisynthetic glycopeptide antibiotic, against methicillin-sensitive S. aureus (MSSA) and MRSA in the rat granuloma pouch infection model. A single intravenous dose of 10 mg of dalbavancin/kg of body weight reduced the viable MRSA count in pouch exudates by more than 2 log CFU/ml, and regrowth was prevented for up to 120 h. Comparable results with vancomycin required four 100-mg/kg intramuscular doses. With one or two doses of vancomycin, the bacterial load declined over proportionately shorter periods of time, followed by regrowth. Reduction of the bacterial load obtained with 100- and 200-mg/kg oral doses of linezolid was relatively transient, with regrowth starting at 48 h. A single 10-mg/kg dose of dalbavancin reduced the MSSA count at 24 h to below the limit of detection, with no regrowth for at least 96 h. Dalbavancin demonstrated good exudate penetration; the ratio of the area under the curve (AUC) in plasma to the AUC in pouch exudate was 1.01. The in vivo activity of dalbavancin in this model is consistent with the antibiotic concentrations that are reached and maintained for extended periods of time after a single 10-mg/kg dose and with in vitro data showing that these concentrations are bactericidal for staphylococci. The pharmacokinetic and efficacy data seen in this relevant model of infection suggest that dalbavancin may be administered less frequently than vancomycin and linezolid.

Combinatorial modification of natural products: synthesis and in vitro analysis of derivatives of thiazole peptide antibiotic GE2270 A: A-ring modifications.

Thiazole peptide GE2270 A (1) possesses potent antimicrobial activity against many gram-positive pathogens, including methicillin resistant Staphylococcus aureus (S. aureus, MRSA; MIC(90)=0.06 microg/mL) and vancomycin resistant Enterococcus spp. (VRE; MIC(90)=0.03 microg/mL); however its poor aqueous solubility has prohibited its development for the clinical treatment of infections. An integrated combinatorial and medicinal chemistry program was employed to identify derivatives of 1 that retain activity but possess greatly enhanced aqueous solubility.

Juice components of a new pigmented citrus hybrid Citrus sinensis (L.) Osbeck x Citrus clementina Hort. ex Tan.

Fruit juice of a new pigmented citrus hybrid named Omo-31 and those of its parents clementine cv. Oroval (Citrus clementina Hort. ex Tan.) and Moro orange [Citrus sinensis (L.) Osbeck] were analyzed during fruit maturation to determine juice yield, total soluble solids (TSS), total acidity (TA), TSS/TA ratio (classical parameters of quality), and potential health beneficial components, such as vitamin C, flavanones, anthocyanins, and phenolic acids. Results showed that juice yield, TA, TSS, and TSS/TA ratio values of Omo-31 were similar to those of the Moro orange. Vitamin C content of the new hybrid was slightly higher than that of clementine and lower than that of the Moro orange, but at maturity stage no differences were observed among the three genotypes. The phenolic compounds content of the new hybrid and those of the parents and their evolution during maturation were studied. At maturity stage the amount of anthocyanins, flavanones, and hydroxycinnamic acids in Omo-31 was found to be notably higher than those of the parents. The high level of antioxidant substances makes this new fruit important for its nutritional benefits.