Change in timing of induction protocol in nulliparous women to optimise timing of birth: results from a single centre study.

BACKGROUND: Induction of labour (IOL) is a common obstetric intervention. When planning IOL, especially in women at risk for complications at delivery, the aim should be for delivery to occur when senior staff are available to optimise safe care. METHODS: A change in timing of IOL protocol at our institution was introduced in November 2018 aiming to increase births occurring "in-hours" defined as 08:00 to 20:00 h. This retrospective cohort study compares the odds of "in-hours" birth before and after the intervention and the association on birth outcomes. The study compared outcomes during the new IOL pathway period to a historical birth cohort from January to December 2017. Inclusion criteria were nulliparous women undergoing planned IOL at term with a cephalic singleton pregnancy. Logistic regression was used to compare odds of in-hours birth for the 2 periods with adjustment for maternal age at delivery, gestation, more than 2 cervical ripening agents required, undergoing IOL for post-dates pregnancy, mode of birth, whether or not IOL proceeded according to planned protocol and missing values using multiple imputation. RESULTS: The rate of deliveries occurring in-hours were higher following the intervention; n = 118/285 (45.6%) pre-intervention versus n = 251/470 (53.4%) post-intervention; adjusted OR = 1.47, 95% CI = 1.07-2.01, p = 0.02). The percentage of caesarean sections (CS) occurring in-hours was significantly lower in the pre-intervention group n = 71/153 (28.3%) compared with the post intervention group = 35/132(46.4%) (p < 0.001)). The rate of CS was higher in the pre intervention n = 132/285(46.3%) compared with the post intervention group n = 153/470 (32.4%)). CONCLUSIONS: The change in induction procedures was associated with a significantly higher rate of births occurring in-hours and a lower rate of overall of CS. This policy change led to a better pattern of timing of birth for nulliparous women undergoing IOL.

A regional approach to the education of nurse practitioner candidates to meet the health needs of rural Australians.

BACKGROUND: Local health services expressed interest in supporting a nurse practitioner (NP) program specifically designed for rural practice environments. AIM: To develop and deliver a generalist NP program that prepares candidates for practice in rural contexts. METHODS: The Master of Clinical Nursing (Nurse Practitioner) program was designed with an understanding of the burden of disease impacting on rural Australians, application of the national health priorities, the Australian Government's refocus on preventative health care and rural health workforce shortages. RESULTS: This program offers nurses who work in rural and remote settings an opportunity to advance their careers. Increasing the numbers of rural NPs will improve rural populations access to healthcare and potentially improve health outcomes. CONCLUSION: This program will equip those seeking endorsement as a NP to effectively work in rural contexts.

Comparison of the impact of wireless versus catheter-based pH-metry on daily activities and study-related symptoms.

AIMS: To evaluate the variation in tolerance to wireless pH-metry compared with catheter-based pH-metry, and to determine clinical characteristics that might predict reduced tolerance to wireless pH-metry. METHODS: Consecutive outpatients (n=341) completing wireless (n=234) or catheter-based pH-metry (n=106) were evaluated. All patients completed the pH-Metry Impact Scale and the pH-Metry Symptoms Scale to assess the impact of the pH-metry on activities of daily living and pH-metry associated changes in study-related symptoms. All data are presented as mean (SD) or odds ratios (95% confidence interval). RESULTS: The impact of pH-metry on activities of daily living were modest, but wireless pH-metry had less impact than catheter-based pH-metry (P=0.01). A sense of foreign body in the chest, chest discomfort, and chest pain were reported more frequently during wireless pH-metry. Difficulty swallowing and painful swallowing were more common during catheter-based pH-metry. Noncardiac chest pain was associated with increased symptom severity. Patients with poor tolerance were twice as likely to have a diagnosis of noncardiac chest pain (odds ratio=2. 53; 95% confidence interval, 1.4-4.6). CONCLUSIONS: Wireless pH-metry has less of an impact on activities of daily living but is not associated with fewer study-related symptoms compared with catheter-based pH-metry. The prevalence of specific study-related symptoms does differ between the 2 groups and noncardiac chest pain seems to be the primary risk factor for more severe study-related symptoms and reduced tolerance for wireless pH-metry. This information may be useful in helping to decide which patients should undergo the wireless pH-metry or receive additional counseling on procedural expectations.

Obesity is associated with increased 48-h esophageal acid exposure in patients with symptomatic gastroesophageal reflux.

OBJECTIVES: Obesity has been associated with gastroesophageal reflux disease (GERD) but the relationship between body mass index (BMI) and esophageal acid exposure remains poorly understood. We hypothesized that overweight (OW) and obese (OB) patients with GER symptoms would have a higher degree of esophageal acid exposure than with normal weight (NW) patients. METHODS: 157 patients separated in groups according to BMI were studied for 48h while off antisecretory medications using ambulatory wireless capsule pH-metry. The pH capsule was appropriately positioned and esophageal pH data were collected. Appropriate univariate and multivariate statistical methods were used. RESULTS: Groups did not differ in age, but more women were in the NW group. OB patients had a fivefold increase in odds for abnormal total acid exposure compared with NW (OR=5.01; 95% CI 2.94, 12.95). Total acid exposure time (AET) was elevated in OB (8.7%+/-5.1%) compared with NW (5.3%+/-5.2%; P<0.05). AET was highest during awake, upright periods. The DeMeester score was higher in OB (31.7+/-19.2) and OW (26.0+/-16.8) groups compared with the NW (19.8+/-17.6) group (P<0.001). AET increased from day 1 to day 2 in the OB group only. CONCLUSIONS: This is the first study to report a positive relationship between BMI and esophageal acid exposure time using prolonged, continuous wireless esophageal pH-metry. Abnormal AET was more frequent in OB patients. Variability in AET increased from day 1 to day 2 in the OB group, supporting the use of more prolonged pH studies in subsets of patients.

Mechanism of interferon-gamma-induced increase in T84 intestinal epithelial tight junction.

Interferon-gamma (IFN-gamma) is an important proinflammatory cytokine that plays a central role in the intestinal inflammatory process of inflammatory bowel disease. IFN-gamma induced disturbance of the intestinal epithelial tight junction (TJ) barrier has been postulated to be an important mechanism contributing to intestinal inflammation. The intracellular mechanisms that mediate the IFN-gamma induced increase in intestinal TJ permeability remain unclear. The aim of this study was to examine the role of the phosphatidylinositol 3-kinase (PI3-K) pathway in the regulation of the IFN-gamma induced increase in intestinal TJ permeability using the T84 intestinal epithelial cell line. IFN-gamma caused an increase in T84 intestinal epithelial TJ permeability and depletion of TJ protein, occludin. The IFN-gamma induced increase in TJ permeability and alteration in occludin protein was associated with rapid activation of PI3-K; and inhibition of PI3-K activation prevented the IFN-gamma induced effects. IFN-gamma also caused a delayed but more prolonged activation of nuclear factor-kappaB (NF-kappaB); inhibition of NF-kappaB also prevented the increase in T84 TJ permeability and alteration in occludin expression. The IFN-gamma induced activation of NF-kappaB was mediated by a cross-talk with PI3-K pathway. In conclusion, the IFN-gamma induced increase in T84 TJ permeability and alteration in occludin protein expression were mediated by the PI3-K pathway. These results show for the first time that the IFN-gamma modulation of TJ protein and TJ barrier function is regulated by a cross-talk between PI3-K and NF-kappaB pathways.

Effects of methodological variation on assessment of riboflavin status using the erythrocyte glutathione reductase activation coefficient assay.

Riboflavin status is usually measured as the in vitro stimulation with flavin adenine dinucleotide of the erythrocyte enzyme glutathione reductase, and expressed as an erythrocyte glutathione reductase activation coefficient (EGRAC). This method is used for the National Diet and Nutrition Surveys (NDNS) of the UK. In the period between the 1990 and 2003 surveys of UK adults, the estimated prevalence of riboflavin deficiency, expressed as an EGRAC value > or = 1.30, increased from 2 to 46 % in males and from 1 to 34 % in females. We hypothesised that subtle but important differences in the detail of the methodology between the two NDNS accounted for this difference. We carried out an evaluation of the performance of the methods used in the two NDNS and compared against an 'in-house' method, using blood samples collected from a riboflavin intervention study. Results indicated that the method used for the 1990 NDNS gave a significantly lower mean EGRAC value than both the 2003 NDNS method and the 'in-house' method (P < 0.0001). The key differences between the methods relate to the concentration of FAD used in the assay and the duration of the period of incubation of FAD with enzyme. The details of the EGRAC method should be standardised for use in different laboratories and over time. Additionally, it is proposed that consideration be given to re-evaluating the basis of the EGRAC threshold for riboflavin deficiency.

Patient perspectives on the Poole PCT cancer genetics service.

Focussing on the primary care aspects of the Kenilworth model, the Poole Primary Care Trust (PCT) cancer genetics service has aimed to develop a high quality primary care-led service for the assessment and counselling of people concerned about their genetic risk of cancer. The service has been available through General Practitioner (GP) surgeries within the PCT since early 2006, and is delivered by Community Cancer Nurses as part of their role to provide proactive care and support to cancer patients, their families and the local population. Acting as a point of reference for cancer genetics at each practice, the nurses have supplied basic education to both health professionals and lay staff about the aims of the service and the genetic risk of cancer. Feedback from service users is one of the key elements of the Poole evaluation. This article is based on the views of some of the first patients referred. The patients consulted one of the cancer nurses between June and December 2006, and were interviewed by a researcher about their experience. The interviews focussed on the psychosocial aspects of the patients' experiences, which are less accessible through quantitative methods. The patients were encouraged to talk specifically and generally about their experiences, and described some of the feelings and emotions from the time of their referral onwards.