Developing a career and education framework for advanced clinical practice in midwifery.

INTRODUCTION: This study outlines the nature of Advanced Clinical Practice in Midwifery (ACPiM), reporting on a stakeholder analysis as part of a national project to develop a career framework for advanced practice in midwifery on behalf of the National Health Service (NHS) in England. METHODS: Between June and July 2022, 31 advanced practice midwives were recruited across England within the NHS settings. Convenience sampling was used to identify midwives working as advanced practitioners, and those pursuing this career route. Focus group and one-to-one interviews were conducted, recorded, and transcribed. These stakeholder data were then analyzed using a reflexive thematic approach. RESULTS: ACP midwives were active across many professional settings. The findings resulted in three themes: Midwifery autonomy, Desire for progression, and Avenues of support. Midwifery autonomy highlighted a midwifery desire to utilize specialist skills and expert decision-making to provide holistic care directly to women and families. Desire for progression highlighted that, regardless of career stage, midwives aspired to advance their practice requiring a range of pathways to fulfil career satisfaction and meet local population health needs. Avenues of support discussed the barriers and facilitators to progression, highlighting the need for service vision, a multi-disciplinary approach to facilitate support for individuals, and strong midwifery leadership. CONCLUSIONS: Although the ACPiM role is desired by maternity institutions and organizations, midwives remain unclear about how to achieve this position, and employers remain unsure of how an ACPiM could transform services. If midwives are to successfully achieve ACPiM status, organizational support is needed to facilitate individuals drive for career progression, resulting in a strengthened workforce and improved patient experience.

Examining arts-based practice in midwifery education: An integrative review.

AIMS: The aim of this integrative review is to synthesise the literature on creative teaching methods in midwifery education. The review question seeks to investigate the experiences of student midwives and midwifery educators of using creative methods as a learning approach. BACKGROUND: The benefits of creative teaching methods are widely acknowledged but the ways in which this may impact midwifery students' learning processes, or how this relates to their developing professional development, is not well understood. Research focused specifically on student midwives is yet to be synthesised. DESIGN: An integrative review was undertaken using data comparison with reflexive thematic analysis to identify common themes. METHODS: Eight electronic databases were searched with key terms in June 2022. English language studies from qualitative, quantitative, mixed-methods and wider literature were included. RESULTS: Twenty-two texts were included in the synthesis. Four themes were generated from the data; 1) What is the offering - More than a lecture; exploring the educator and student exchange and environment for learning; 2) Working in parallel - examining the change in teaching dynamic and collaborative partnerships; 3) Journeying towards holism - focused on student's integration of learning processes; and 4) Stepping into the professional - engaging with how using creativity can aid students' growing sense of themselves as professionals. This highlights improvements in levels of confidence, professional development and emotional intelligence in midwifery students. CONCLUSION: Creative teaching and learning methods enable student midwives to make meaningful connections between theoretical and practice learning environments, assisting knowledge and skills acquisition.

Eye Health Service Uptake among People with Visual Impairment and Other Functional Difficulties in Bangladesh: A Cross-Sectional Study with Short-Term Follow Up.

People with visual impairments are disproportionately likely to also have other impairments. However, little is known about whether these other impairments affect access to eye health services. This study among cataract and refractive error patients in four districts in Bangladesh explores the relationship between self-reported difficulties in hearing, mobility, self-care, communication and cognition domains, eye health service uptake, and location of initial eye health assessment. Cataract and refractive errors were diagnosed through ophthalmic clinical assessment, and the Washington Group Short Set (WG-SS) was used to ascertain difficulties in other functional domains. Univariate and multivariate analyses were used to examine the relationship between functional difficulties and uptake of cataract and refractive error services. We found that people with self-reported functional difficulties were less likely to take up refractive error services compared to people with same need but with no functional difficulties, and that they were more than twice as likely to access surgical services after attending an outreach camp compared with a hospital facility. Since a high proportion of people attending eye health assessment services have difficulties in a range of functional domains, strategies to improve the uptake of hospital-based health services are urgently required.

How do informal information sources influence women's decision-making for birth? A meta-synthesis of qualitative studies.

BACKGROUND: Women approach birth using various methods of preparation drawing from conventional healthcare providers alongside informal information sources (IIS) outside the professional healthcare context. An investigation of the forms in which these informal information sources are accessed and negotiated by women, and how these disconnected and often conflicting elements influence women's decision-making process for birth have yet to be evaluated. The level of antenatal preparedness women feel can have significant and long lasting implications on their birth experience and transition into motherhood and beyond. The aim of this study was to provide a deeper understanding of how informal information sources influence women's preparation for birth. METHODS: Seven electronic databases were searched with predetermined search terms. No limitations were imposed for year of publication. English language studies using qualitative methods exploring women's experiences of informal information sources and their impact upon women's birth preparation were included, subject to a quality appraisal framework. Searches were initiated in February 2016 and completed by March 2016. Studies were synthesised using an interpretive meta-ethnographic approach. RESULTS: Fourteen studies were included for the final synthesis from Great Britain, Australia, Canada and the United States. Four main themes were identified: Menu Birth; Information Heaven/Hell; Spheres of Support; and Trust. It is evident that women do not enter pregnancy as empty vessels devoid of a conceptual framework, but rather have a pre-constructed embodied knowledge base upon which other information is superimposed. Allied to this, it is clear that informal information was sought to mitigate against the widespread experience of discordant information provided by maternity professionals. CONCLUSION: Women's access to the deluge of informal information sources in mainstream media during pregnancy have significant impact on decision making for birth. These informal sources redefine the power dynamic between women and maternal healthcare providers, simultaneously increasing levels of anxiety and challenging women's pre-existing ideations and aspirations of personal birth processes. A lack of awareness by some professionals of women's information seeking behaviours generates barriers to women-centred support, leaving an experience expectation mismatch unchecked. TRIAL REGISTRATION: CRD42016041491 17/06/16.

Repair of large osteochondritis dissecans lesions using a novel multilayered tissue engineered construct in an equine athlete.

Osteochondral lesions resulting from osteochondritis dissecans are problematic to treat and present a significant challenge for clinicians. The aims of this study were to investigate the use of a scaffold-assisted microfracture approach, employing a novel, multilayered, collagen-based, osteochondral graft substitute in the treatment of severe osteochondritis dissecans of both lateral femoral trochlear ridges in an equine athlete, and to assess the potential of this novel scaffold to enhance repair of the osteochondral unit. A 15 month-old female filly presented with large osteochondritis dissecans lesions involving both femoral lateral trochlear ridges. After routine arthroscopic debridement and microfracture of the subchondral bone, multilayered osteochondral defect repair scaffolds were implanted into the fragmentation beds in both left and right femoropatellar joints via mini-arthrotomies. Exploratory arthroscopy 5 months postimplantation revealed smooth cartilaginous repair tissue, contiguous with the adjacent cartilage, covering the defect. At 22-month follow up, the filly had no signs of lameness and was exercising at her intended level. Radiographically, although still slightly flattened, the femoral trochlear ridges were smooth, with no evidence of osteoarthritis. Ultrasonographically, the defects were filled with bone and covered with an overlying cartilaginous layer, with the trochlear ridge contour almost entirely restored. This report demonstrates the effective clinical use of this novel, multilayered, osteochondral defect repair scaffold in the treatment of osteochondritis dissecans of an equine athlete. The successful repair achieved here using this novel scaffold in an equine patient with large bilateral lesions shows the potential for clinical translation in the treatment of human patients presenting with osteochondral defects. Copyright © 2016 John Wiley & Sons, Ltd.

Techniques and Indications for Intraoperative Ultrasound in Horses.

OBJECTIVE: To describe our experience using intraoperative ultrasound for various conditions in horses. STUDY DESIGN: Retrospective case series. SAMPLE POPULATION: Horses (n=113). METHODS: Medical records including surgical reports at 2 equine hospitals (2007-2013) were reviewed to identify ultrasound-assisted surgeries. The diagnosis, reasons for using intraoperative ultrasound, the technique employed, and the surgical procedure performed (e.g., synovial endoscopy, cut-down, resection, dissection, curettage, and implant placement/removal) were recorded for each surgery. Intraoperative ultrasound was used to mark the optimal site for skin incision or to guide instrumentation within the tissues. The incision site was marked on the skin with staples. Depth soundings were taken on the ultrasound, using the caliper-measuring tool to facilitate dissection. For each surgery, the primary specialist surgeon (ACVS or ECVS) retrospectively recorded whether intraoperative ultrasound was helpful, unhelpful, or harmful. RESULTS: Intraoperative ultrasound was rated helpful in 105/113 (93%) of surgeries, unhelpful in 7/113 (6%), and harmful in 1/113 (1%) of surgeries. CONCLUSION: Intraoperative ultrasound can be a useful adjunct to surgical techniques for various conditions in horses.

Comparison of two ultrasound-guided injection techniques targeting the sacroiliac joint region in equine cadavers.

OBJECTIVES: To compare the accuracy and distribution of injectate for cranial (CR) and caudomedial (CM) ultrasound-guided injections of equine sacroiliac joints. METHODS: Both sacroiliac joints from 10 lumbosacropelvic specimens were injected using cranial parasagittal (CR; curved 18 gauge, 25 cm spinal needles) and caudomedial (CM; straight 18 gauge, 15 cm spinal needles) ultrasound-guided approaches. Injectate consisted of 4 ml iodinated contrast and 2 ml methylene blue. Computed tomographical (CT) scans were performed before and after injections. Time for needle guidance and repositioning attempts were recorded. The CT sequences were analysed for accuracy and distribution of contrast. RESULTS: Intra-articular contrast was detected in sacroiliac joints following 15/40 injections. The CR and CM approaches deposited injectate ≤2 cm from sacroiliac joint margins following 17/20 and 20/20 injections, respectively. Median distance of closest contrast to the sacroiliac joint was 0.4 cm (interquartile range [IQR]: 1.5 cm) for CR approaches and 0.6 cm (IQR: 0.95 cm) for CM approaches. Cranial injections resulted in injectate contacting lumbosacral intertransverse joints 15/20 times. Caudomedial injections were perivascular 16/20 times. LIMITATIONS: Safety and efficacy could not be established. CLINICAL RELEVANCE: Cranial and CM ultrasound-guided injections targeting sacroiliac joints were very accurate for periarticular injection, but accuracy was poor for intra-articular injection. Injectate was frequently found in contact with interosseous sacroiliac ligaments, as well as neurovascular and synovial structures in close vicinity of sacroiliac joints.

Knot Security of 5 Metric (USP 2) Sutures: Influence of Knotting Technique, Suture Material, and Incubation Time for 14 and 28 Days in Phosphate Buffered Saline and Inflamed Equine Peritoneal Fluid.

OBJECTIVES: To evaluate knot security for 3 knot types created in 3 commonly used 5 metric suture materials incubated in physiological and pathological fluids. STUDY DESIGN: In vitro mechanical study. SAMPLE POPULATION: Knotted suture loops (n = 5/group). METHODS: Loops of 3 different suture materials (glycolide/lactide copolymer; polyglactin 910; polydioxanone) were created around a 20 mm rod using 3 knot types (square [SQ], surgeon's [SK], and triple knot [TK]) and were tested to failure in distraction (6 mm/min) after tying (day 0) and after being incubated for 14 and 28 days in phosphate buffered saline (PBS) or inflamed peritoneal fluid. Failure load (N) and mode were recorded and compared. RESULTS: For polydioxanone, significant differences in force to knot failure were found between SQ and SK/TK but not between SK and TK. The force required to break all constructs increased after incubation in phosphate buffered saline (PBS). With glycolide/lactide copolymer no differences in force to knot failure were observed. With polyglactin 910, a significant difference between SQ and TK was observed, which was not seen between the other knot types. Incubation in inflamed peritoneal fluid caused a larger and more rapid decrease in force required to cause knot failure than incubation in PBS. CONCLUSIONS: Mechanical properties of suture materials have significant effects on knot security. For polydioxanone, SQ is insufficient to create a secure knot. Additional wraps above a SK confer extra stability in some materials, but this increase may not be clinically relevant or justifiable. Glycolide/lactide copolymer had excellent knot security.

Functional discomfort and a shift in midwifery paradigm.

OBJECTIVE: To determine and critically examine maternity attitudes surrounding labour pain and how midwives can best facilitate women navigating intrapartum discomfort without relying on 'pain-relief' strategies or immediate recourse for analgesic assistance. APPROACH: This article examines current literature using seminal research and wider international perspectives, exploring the complex and fluctuating needs of women negotiating the composite factors of labour discomfort are investigated. FINDINGS: Factors such as birth environment, fear, midwifery presence, and self-efficacy, have a significant impact on the uptake of intrapartum analgesia. A holistic view of intrapartum discomfort is needed to shift the current paradigm of pathologising labour pain into one which situates it as a source of positive physiology and functional discomfort. CONCLUSION: Continuing to practice with a pharmacological outlook, aiming to rid the labouring body of discomfort, is reductionist for both midwives and women. Midwives must seek to employ a new lexicon with which to communicate and facilitate women within the dynamic and continually changing territory of labour. If this conceptual shift is realised, the subsequent positive sequalae of women rediscovering their innate birthing capabilities could create a situation where birth can be considered as an aesthetic peak experience, improving satisfaction on both sides of the midwife-mother diad.

Effects of low-level light therapy on streptozotocin-induced diabetic kidney.

Hyperglycemia causes oxidative damage in tissues prone to complications in diabetes. Low-level light therapy (LLLT) in the red to near infrared range (630-1000nm) has been shown to accelerate diabetic wound healing. To test the hypothesis that LLLT would attenuate oxidative renal damage in Type I diabetic rats, male Wistar rats were made diabetic with streptozotocin (50mg/kg, ip), and then exposed to 670nm light at a dose of 9J/cm(2) once per day for 14weeks. The activity and expression of catalase and the activity of Na K-ATPase increased in kidneys of light-treated diabetic rats, whereas the activity and expression of glutathione peroxidase and the expression of Na K-ATPase were unchanged. LLLT lowered the values of serum BUN, serum creatinine, and BUN/creatinine ratio. In addition, LLLT augmented the activity and expression of cytochrome c oxidase, a primary photoacceptor molecule in the mitochondrial respiratory chain, and reduced the formation of the DNA adduct 8-hydroxy-2'-deoxyguanosine in kidney. LLLT improved renal function and antioxidant defense capabilities in the kidney of Type I diabetic rats. Thus, 670nm LLLT may be broadly applicable to the amelioration of renal complications induced by diabetes that disrupt antioxidant defense mechanisms.

Effects of low-level light therapy on hepatic antioxidant defense in acute and chronic diabetic rats.

Diabetes causes oxidative stress in the liver and other tissues prone to complications. Photobiomodulation by near infrared light (670 nm) has been shown to accelerate diabetic wound healing, improve recovery from oxidative injury in the kidney, and attenuate degeneration in retina and optic nerve. The present study tested the hypothesis that 670 nm photobiomodulation, a low-level light therapy, would attenuate oxidative stress and enhance the antioxidant protection system in the liver of a model of type I diabetes. Male Wistar rats were made diabetic with streptozotocin (50 mg/kg, ip) then exposed to 670 nm light (9 J/cm(2)) once per day for 18 days (acute) or 14 weeks (chronic). Livers were harvested, flash frozen, and then assayed for markers of oxidative stress. Light treatment was ineffective as an antioxidant therapy in chronic diabetes, but light treatment for 18 days in acutely diabetic rats resulted in the normalization of hepatic glutathione reductase and superoxide dismutase activities and a significant increase in glutathione peroxidase and glutathione-S transferase activities. The results of this study suggest that 670 nm photobiomodulation may reduce, at least in part, acute hepatic oxidative stress by enhancing the antioxidant defense system in the diabetic rat model.

Attenuation of TCDD-induced oxidative stress by 670 nm photobiomodulation in developmental chicken kidney.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), a potent developmental teratogen inducing oxidative stress and sublethal changes in multiple organs, provokes developmental renal injuries. In this study, we investigated TCDD-induced biochemical changes and the therapeutic efficacy of photobiomodulation (670 nm; 4 J/cm(2)) on oxidative stress in chicken kidneys during development. Eggs were injected once prior to incubation with TCDD (2 pg/g or 200 pg/g) or sunflower oil vehicle control. Half of the eggs in each dose group were then treated with red light once per day through embryonic day 20 (E20). Upon hatching at E21, the kidneys were collected and assayed for glutathione peroxidase, glutathione reductase, catalase, superoxide dimutase, and glutathione-S-transferase activities, as well as reduced glutathione and ATP levels, and lipid peroxidation. TCDD exposure alone suppressed the activity of the antioxidant enzymes, increased lipid peroxidation, and depleted available ATP. The biochemical indicators of oxidative and energy stress in the kidney were reversed by daily phototherapy, restoring ATP and glutathione contents and increasing antioxidant enzyme activities to control levels. Photobiomodulation also normalized the level of lipid peroxidation increased by TCDD exposure. The results of this study suggest that 670 nm photobiomodulation may be useful as a noninvasive treatment for renal injury resulting from chemically induced cellular oxidative and energy stress.

Melatonin as a principal component of red light therapy.

Melatonin is well recognized for its role as a potent antioxidant and is directly implicated in the free radical theory of aging [1] [Reiter RJ, Pablos MI, Agapito TT, Guerrero JM. Melatonin in the context of the free radical theory of aging. Ann N Y Acad Sci 1996;786:362-78]. Moreover, melatonin has been shown to retard age-related increases in lipid peroxidation and oxidative damage [2] [Okatani Y, Wakatsuki A, Reiter RJ. Melatonin protects hepatic mitochondrial respiratory chain activity in senescence-accelerated mice. J Pineal Res 2002;32:143-8] and to act directly upon the immune system [3] [Poon AM, Liu ZM, Pang CS, Brown GM, Pang SF. Evidence for a direct action of melatonin on the immune system. Biol Signals 1994;3:107-17]. This report focuses on characterizing documented functions of melatonin in the context of red light therapy and proposes that melatonin is a potential mediator of red light's therapeutic effects, a hypothesis that is as yet untested. Red light therapy (670 nm, 4J/cm(2)) has been shown to restore glutathione redox balance upon toxicological insult and enhance both cytochrome c oxidase and energy production, all of which may be affected by melatonin. The red light treatment has also been successfully implemented in the clinical setting for its effectiveness in reducing both the number of incidences and severity of oral mucositis resulting in part from the chemotherapy and/or radiation administered prior to bone marrow transplants. Moreover, red light therapy improves wound healing and is being further tested for its ability to ameliorate toxicant-induced retinal and visual cortical neuron damage. Researchers in the growing field of light therapy may be in a position to draw from and collaborate with melatonin researchers to better characterize this alternative treatment.

670 nanometer light treatment attenuates dioxin toxicity in the developing chick embryo.

2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) is an acutely toxic anthropogenic chemical. Treatment with a red to near-infrared (630-1000 nm) light-emitting diode (LED) attenuates the toxicant-induced oxidative stress and energy deficit in neuronal cell culture. For this study, fertile chicken (Gallus gallus) eggs were injected once at the start of incubation with sunflower oil vehicle or 200 pg TCDD/g egg (200 parts per trillion), an environmentally relevant dose. Daily LED treatment after TCDD exposure reduced embryonic mortality by 47%. LED treatment of TCDD-exposed eggs also decreased the hepatic oxidized-to-reduced glutathione ratio by 88%. Activities of other hepatic indicators of oxidative stress, such as glutathione reductase and catalase, were increased after LED treatment of TCDD-exposed eggs. Our study demonstrates that 670 nm phototherapy can mitigate the oxidative stress and energy deficit resulting from developmental exposure to TCDD while reducing TCDD-induced embryo mortality. Moreover, LED treatment restores hepatic enzyme activities to control levels in TCDD-exposed embryos. The effective attenuation of TCDD-induced embryo toxicity by LED treatment could extend to mitigating the effects of other teratogens that induce oxidative and energy stress.

Low-carbohydrate diet and oxidative stress in diabetic and nondiabetic rats.

Hyperglycemia of diabetes has been implicated in increased tissue oxidative stress, with consequent development of secondary complications. Thus, stabilizing glucose levels near normal levels is of utmost importance. Because diet influences glycemic control, this study investigated whether a low-carbohydrate (5.5%) diet confers beneficial effects on the oxidative status of the heart, kidney, and liver in diabetes. Male and female normal and diabetic rats were fed standard chow (63% carbohydrates) or low-carbohydrate diet for 30 days. Elevated glucose, HbA(1c), and alanine and aspartate aminotransferases in diabetic animals were reduced or normalized by the low-carbohydrate diet. While diabetes increased cardiac activities of glutathione peroxidase and catalase, low-carbohydrate diet normalized cardiac glutathione peroxidase activity in diabetic animals, and reduced catalase activity in females. Diabetic rats fed low-carbohydrate diet had altered activities of renal glutathione reductase and superoxide dismutase, but increased renal glutathione peroxidase activity in diabetic animals was not corrected by the test diet. In the liver, diabetes was associated with a decrease in catalase activity and glutathione levels and an increase in glutathione peroxidase and gamma-glutamyltranspeptidase activities. Decreased hepatic glutathione peroxidase activity and lipid peroxidation were noted in diet-treated diabetic rats. Overall, the low-carbohydrate diet helped stabilize hyperglycemia and did not produce overtly negative effects in tissues of normal or diabetic rats.

Effects of low-carbohydrate diet and Pycnogenol treatment on retinal antioxidant enzymes in normal and diabetic rats.

Because chronic hyperglycemia of uncontrolled diabetes mellitus may lead to increased reactive oxygen species and decreased enzymatic antioxidant defenses responsible for pathological processes in diabetic retinopathy, this study examined the hypothesis that a low-carbohydrate, high-fat diet, either alone or in combination with Pinus maritima can reduce hyperglycemia, restoring a more balanced, oxidative condition. Normal and streptozotocininduced diabetic rats were fed either a regular or low-carbohydrate diet for 30 or 90 d. In addition, normal and diabetic rats on the chronic (90-d) low-carbohydrate diet were treated with daily intraperitoneal Pinus maritima doses (10 mg/kg) for 14 consecutive days. Retinas were fractionated to assay activities of glutathione peroxidase, glutathione reductase, and gamma-glutamyl transferase. After 30 d, the low-carbohydrate diet reduced glycemic parameters and normalized aspartate aminotransferase activity in diabetic animals, suggesting less organ damage. No differences were observed between males and females in any measured glycemic parameters. Whereas all diabetic control animals developed cataracts bilaterally, no treated diabetic animals developed cataracts. There were no deleterious effects on retinal antioxidant defenses with either a 30-d or chronic low-carbohydrate diet. When diet was combined with Pinus maritima treatment, both retinal glutathione peroxidase and glutathione reductase activities increased, suggesting that a low-carbohydrate diet plus Pinus maritima may be an effective antioxidant and antihyperglycemic therapy, reducing the risk of diabetic retinopathy and cataract formation.

Effects of antioxidant treatment on normal and diabetic rat retinal enzyme activities.

Diabetes mellitus is characterized by hyperglycemia and, in chronic disease, by microvascular pathologies, especially in the kidney, peripheral nerve, and eye. Although hyperglycemia can be controlled with insulin and/or antihyperglycemic medications, diabetic retinopathy continues to be the leading cause of blindness in the United States. Because increased oxidative stress may be a cause of retinopathy, this study examined the hypothesis that administration of exogenous antioxidants can restore a more balanced oxidative condition. Normal and 30-day streptozotocin-induced diabetic Sprague-Dawley rats received daily intraperitoneal doses (10 mg/kg) of beta-carotene, alpha-lipoic, and Pycnogenol individually or in combinations for 14 days, after which retinae were dissected and fractionated for the assay of activities of glutathione reductase, glutathione peroxidase, gamma-glutamyl transferase, and superoxide dismutase. In normal rats, treatment with antioxidant combinations led to a decrease in gamma-glutamyl transferase activity; beta-carotene plus pycnogenol treatment decreased the activity of both glutathione-related enzymes. Decreased retinal gamma-glutamyl transferase activity of diabetic rats was normalized by the administration of pycnogenol alone or in combination with beta-carotene. In diabetic rats, retinal glutathione reductase activity increased after treatment with beta-carotene alone or with pycnogenol. Treatment with pycnogenol and alpha-lipoic acid alone or in combination decreased the activity of glutathione peroxidase, while this activity was increased after treatment with a combination of all antioxidants. Elevated activity of superoxide dismutase in diabetic retina was normalized by treatment with alpha-lipoic acid and with pycnogenol and beta-carotene in combination, but not with all three together. Antioxidants can access the retina and, once there, can alter antioxidant enzyme activities. In both normal and diabetic rats, combinations of antioxidants have different effects on retinal antioxidant enzyme activities than do individual antioxidants.