Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

BACKGROUND

Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.

AIM

To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.

METHODS

The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.

RESULTS

One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.

CONCLUSION

This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Personality Assessment Inventory suicidality scales: Suicidal Ideation (SUI), Suicide Potential Index (SPI), and S_Chron in an Afghanistan/Iraq-era active and Veteran military sample

INTRODUCTION

This study validated Personality Assessment Inventory (PAI) Suicidal Ideation (SUI), Suicide Potential Index (SPI), and S_Chron scales against chronic and acute suicide risk factors and symptom validity measures.

METHODS

Afghanistan/Iraq-era active-duty and Veteran participants completed a prospective study on neurocognition (N = 403) that included the PAI. The Beck Depression Inventory-II (specifically item 9) administered at two time points assessed acute and chronic suicide risk; the Beck Scale for Suicide Ideation item 20 identified history of suicide attempts. Major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and traumatic brain injury (TBI) were evaluated using structured interviews and questionnaires.

RESULTS

All three PAI suicide scales were significantly related to independent indicators of suicidality, with the largest effect for SUI (AUC 0.837-0.849). All three suicide scales were significantly related to MDD (r = 0.36-0.51), PTSD (r = 0.27-0.60), and TBI (r = 0.11-0.30). The three scales were not related to suicide attempt history for those with invalid PAI protocols.

CONCLUSIONS

Although all three suicide scales do show significant relationships to other indicators of risk, SUI showed the highest association and greatest resistance to response bias.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Do social support and community engagement act as mechanisms in the association between neighbourhood income inequality and the mental health of mothers in Calgary, Canada? A mediation analysis

PURPOSE

According to the social determinants of health framework, income inequality is a potential risk factor for adverse mental health. However, few studies have explored the mechanisms suspected to mediate this relationship. The current study addresses this gap through a mediation analysis to determine if social support and community engagement act as mediators linking neighbourhood income inequality to maternal anxiety and depressive symptoms within a cohort of new mothers living in the City of Calgary, Canada.

METHODS

Data collected at three years postpartum from mothers belonging to the All Our Families (AOF) cohort were used in the current study. Maternal data were collected between 2012 and 2015 and linked to neighbourhood socioeconomic data from the 2006 Canadian Census. Income inequality was measured using Gini coefficients derived from 2006 after-tax census data. Generalized structural equation models were used to quantify the associations between income inequality and mental health symptoms, and to assess the potential direct and indirect mediating effects of maternal social support and community engagement.

RESULTS

Income inequality was not significantly associated with higher depressive symptoms (β = 0.32, 95%CI = -0.067, 0.70), anxiety symptoms (β = 0.11, 95%CI = -0.39, 0.60), or lower social support. Income inequality was not associated with community engagement. For the depression models, higher social support was significantly associated with lower depressive symptoms (β = -0.13, 95%CI = -0.15, -0.097), while community engagement was not significantly associated with depressive symptoms (β = 0.059, 95%CI = -0.15, 0.27). Similarly, for the anxiety models, lower anxiety symptoms were significantly associated with higher levels of social support (β = -0.17, 95%CI = -0.20, -0.13) but not with higher levels of community engagement (β = 0.14, 95%CI = -0.14, 0.41).

CONCLUSION

The current study did not find clear evidence for social support or community engagement mediating the relationship between neighbourhood income inequality and maternal mental health. Future investigations should employ a broader longitudinal approach to capture changes in income inequality, potential mediators, and mental health symptomatology over time.

077 Long-term safety and efficacy of mexiletine for patients with myotonic dystrophy type 1 and 2

Introduction

Myotonic dystrophies type 1 and 2 (DM1 and DM2) are progressive, inherited multisys- tem disorders characterized by muscle weakness, myotonia and life-threatening cardiac dysrythmias. Treatment of myotonia is important for quality of life, mobility, and functional independence. Mexiletine is a sodium channel blocker, which has so far been shown to be effective in myotonia management in non-dystrophic myotonias. However, cardiac side effects are reported. Its long-term safety and efficacy in DM1 has not been established.

Methods

25 patients with DM1 or DM2 have been treated with mexiletine in the NHNN cohort. Efficacy and tolerance was determined by patient report. PR interval, QRS duration and corrected QT interval (QTc) were noted.

Results

Mean duration of treatment was 32.9 months. 21/25 patients reported efficacy, 3/25 partial efficacy, and 4/25 discontinued treatment due to gastrointestinal side effects.

Mexiletine did not precipitate symptomatic arrhythmia in any patient. Paired assessment of ECG param- eters at baseline and at the highest treatment dose revealed no significant change in PR interval, QRS complex duration, or QTc.

Conclusions

This small retrospective analysis suggests long-term efficacy and cardiac safety of mexiletine for treatment of myotonia in patients with myotonic dystrophies.

christinamousele92@gmail.com

Improving management of needle distress during the journey to dialysis through psychological education and training-the INJECT study feasibility pilot protocol

BACKGROUND

Needle-related distress is a common yet poorly recognised and managed problem among haemodialysis (HD) patients. The aim of this pilot study is to test the feasibility and acceptability of the INJECT Intervention-an innovative psychology-based intervention to empower patients to self-manage needle distress with the support of dialysis nurses.

METHODS

This investigator-initiated, single-arm, non-randomised feasibility study will take place in a large dialysis service in Adelaide, Australia. Participants will include patients aged ≥ 18 years, commencing or already receiving maintenance HD, recruited through dialysis physicians and nursing staff as individuals believed to be at risk of needle distress. They will be screened for inclusion using the Dialysis Fear of Injection Questionnaire (DFIQ) and enrolled into the study if the score is ≥ 2. The multi-pronged intervention encompasses (i) psychologist review, (ii) patient self-management program and (iii) nursing education program. The primary aim is to evaluate feasibility and acceptability of the intervention from patient and dialysis nurse perspectives, including recruitment, retention, engagement with the intervention and completion. Secondary exploratory outcomes will assess suitability of various tools for measuring needle distress, evaluate acceptability of the nursing education program and measure cannulation-related trauma and vascular access outcomes.

CONCLUSION

The results will inform the protocol for larger trials addressing needle distress in HD patients.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000229875, approved 4 April 2021, https://www.anzctr.org.au/ .

959 Extinction of The Stoma Clinic. Virtual Support for The Newly Formed Stoma

Aim

214 stomas were created between January 2019 and January 2020 at our Tertiary Colorectal Centre. We surveyed patients to identify desirable features for a mobile stoma support application to mitigate potential challenges of limited in-person review. The aim is three-fold: To survey stoma patients, identify literature on mobile applications supporting stoma patients and evaluate available stoma support applications.

Method

A survey of 60 newly formed stoma patients focused on mobile application support. A systematic search, following the PRISMA checklist, determined the use of mobile applications in supporting stoma patients. A comprehensive search of mobile applications on IOS and Android stores was performed.

Results

79% of patients under 70 years old, and 58% of patients over 70, were interested in using a mobile application. 45 patients wanted an application that could photograph their output. Output and soft tissue management were the most cited reasons for contacting the stoma care nurse. The literature search yielded 196 publications; 4 studies met the eligibility criteria. One study found self-efficacy of stoma care improved after the app-based intervention. One stoma mobile application met the inclusion criteria: ‘Ostobuddy osto companion’; features include measurement of output volume, photography and diary keeping. 21 fluid intake applications included features to customise water input and record fluid history.

Conclusions

Mobile applications can ease the strain on services whilst improving care. This study indicates, a mobile application including a stoma output diary and photography would be well received by patients and could improve self-efficacy and care of the stoma.

Regulating emotion following severe traumatic brain injury: a randomized controlled trial of heart-rate variability biofeedback training

BACKGROUND

While difficulties regulating emotions are almost ubiquitous after traumatic brain injury (TBI), remediation techniques are limited. Heart-rate variability (HRV) is a physiological measure of emotion regulation and can be modified using biofeedback training. The aim of the current study was to evaluate the efficacy of repeated biofeedback training for improving emotion regulation difficulties following TBI.

DESIGN

Fifty adults with severe TBI were allocated to either biofeedback or waitlist conditions. Treatment consisted of six biofeedback sessions whereby participants were taught to breathe at their resonant frequency. Outcomes included changes in physiological and subjective reactivity to anger-induction, emotional well-being, and physiology at rest, together with symptoms of psychological distress and sleep disturbances (ACTRN12618002031246).

RESULTS

While biofeedback led to reduced skin conductance, it did not affect any other objective or subjective response to the mood induction procedure. Biofeedback led to fewer sleep disturbances, and reduced negative mood valence and depression during follow-up.

CONCLUSIONS

HRV biofeedback training is a feasible technique following TBI that transfers to improved symptoms of general emotional well-being, psychological distress, and sleep. Biofeedback does not transfer to a laboratory-based emotional provocation task. HRV biofeedback training may represent a novel adjunct for generalized emotional difficulties following injury.

Occupational Therapy Interventions for Clients with Ehlers-Danlos Syndrome (EDS) in the Presence of Postural Orthostatic Tachycardia Syndrome (POTS)

Postural orthostatic tachycardia syndrome (POTS) is often seen in clients with Ehlers-Danlos syndrome (EDS), primarily hypermobile EDS. Research has shown clients with EDS and POTS may experience limitations affecting not only their physical function, but also their social, emotional, and mental well-being. Using a client-centered approach, occupational therapy practitioners assess health, well-being, symptomatology (fatigue, muscle pain, dizziness, etc.), participation and engagement in occupation, and provide interventions to improve quality of life. This paper will address occupational therapy interventions to treat common symptomatology for clients with EDS in the presence of POTS, including environmental modifications, use of adaptive equipment and orthoses, exercise and fall prevention, energy conservation and pacing, sleep hygiene, and routine and habit development to promote optimal engagement in meaningful occupations.

Effectiveness of Adaptive Silverware on Active Range of Motion in Individuals With Rheumatoid Arthritis

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

The purpose of this study was to quantify active range of motion (ROM) required for individuals with rheumatoid arthritis (RA) using built-up spoons with electrogoniometry. Statistical analysis provided quantitative evidence supporting our hypothesis that using a built-up handle requires less active ROM for grasp. Clinical implications suggest built-up handles may be used for people with other conditions with limited hand and wrist ROM, not just RA, increasing participation and independence in daily activiti

Primary Author and Speaker: Susan McDonald

Additional Authors and Speakers: David Levine, Hensley Barnes, Anna Cornett, Caroline Craig, Sally Langager, Lauren Yeager, and Michael Britt

Effectiveness of Adaptive Silverware on Active Range of Motion (ROM) in Individuals With Rheumatoid Arthritis

Date Presented 03/26/20

The purpose of this study was to quantify active ROM required for individuals with rheumatoid arthritis using built-up spoons with electrogoniometry. Statistical analysis provided quantitative evidence supporting our hypothesis that using a built-up handle requires less active ROM for grasp. Clinical implications suggest that built-up handles may be used for other conditions with limited hand and wrist ROM, not just RA, increasing participation and independence in daily activities.

Primary Author and Speaker: Susan McDonald

Additional Authors and Speakers: David Levine, Hensley Barnes, Anna Cornett, Kathleen Craig, Sally Langager

Contributing Authors: Lauren Yeager, Michael Britt

Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

High-Sensitivity Dry Rehydratable Film Method for Enumeration of Coliforms in Dairy Products: Collaborative Study

A dry-film coliform count plate that is inoculated with 5 mL sample was compared with the Violet Red Bile Agar plate method in a collaborative study by 18 laboratories. Products analyzed were 2% milk, chocolate milk, cream, vanilla ice cream, cottage cheese, and cheese. Collaborators tested blind duplicate uninoculated samples and samples inoculated at low, medium, and high level. Significantly (P< 0.05) higher numbers of coliforms were recovered by the dry-film method from 2% milk samples at the 3 inoculum levels, the chocolate milk at the low- and high-inoculum levels, and the cream at the high-inoculum level. Significantly higher counts were obtained by the agar method for cottage cheese samples at the low-inoculum level. The repeatability standard deviation for the dry-film method was significantly higher for the high-inoculum level chocolate milk sample and the medium-inoculum level cottage cheese. The same statistic was significantly higher for the agar method at all 3 inoculum levels in the 2% milk and the medium-inoculum level cream. The high-sensitivity dry rehydratable film method for enumeration of coliforms in dairy products has been adopted first action by AOAC INTERNATIONAL.

Who decides to have sex? Exploring the perceptions of Timorese women and men through a reproductive justice lens

Despite national policies to support sexual rights, Timorese women are constrained when making sexual and reproductive health decisions. Contextual understanding of sexual decision making is vital for effective engagement by sexual and reproductive health service providers with communities. An intersectional reproductive justice approach broadens the sexual rights lens allowing for an examination of multi-system factors impacting on sexual rights and health. Using the Matrix of Domination as a conceptual framework, we explored Timorese perceptions around decisions to have sex, and examined intersecting systems of oppression impacting on these decisions. Our study adopted a critical medical anthropological approach using ethnographic methods. A decolonising methodology aimed to make Timorese worldviews central to the analysis. Nine focus group discussions with 80 men and 17 individual reproductive history interviews with women were held in 4 of Timor-Leste's 13 municipalities during October 2015. Findings suggest that decisions to have sex are framed in terms of wishes and rights; however, it was the perceived entitlements of men that were prioritised and predominantly men who made these decisions. Violence, coercion and unwanted pregnancies were linked to decisions about sex, and identified as potential consequences for women, impacting on women's health and sexual rights.

The changing nature of dairy production in Victoria, Australia: are we ready to handle the planning and development of large, intensive dairy operations?

Around the world, dairy production continues to intensify, with farmers increasing stocking rates, feeding more supplements, and transitioning into fully housed systems. Dairy production in Victoria is no exception and farmers are starting a move towards intensive (i.e. permanently housed) dairy operations. Challenges associated with these transformations have included difficulties, or failure, to obtain planning approval and public concern around the effect of intensive developments on environmental degradation, animal welfare and industry image. We examined current land-use planning provisions, environmental requirements, animal-welfare regulations, industry guidelines and codes of practice for their applicability and suitability to the implementation of intensive dairy-production operations, particularly large-scale ones, in Victoria, Australia. Our aim was to clearly identify factors that have the potential to hinder the growth and expansion of existing dairy-production systems into intensive operations, and the establishment of new intensive dairy enterprises. The majority of legislation examined posed no obstacles to the development of large-scale intensive dairy operations. New definitions for intensive livestock production and the inclusion of an intensive dairy-farm category in the State planning provisions will reduce current confusion across and within planning departments. A standard methodology to determine separation distances is required and a code for intensive dairy farming would greatly assist with the planning-approval process. Many advisory publications fall short when applied to intensive dairy operations as they are currently written for pasture-based farms with limited infrastructure for regularly feeding or housing large herds of >700 cows.

Safety of retigabine in adults with partial-onset seizures after long-term exposure: focus on unexpected ophthalmological and dermatological events

BACKGROUND

Retigabine is an antiepileptic drug developed for the adjunctive treatment of adults with epilepsy and partial-onset seizures (POS). Following its approval in 2011, reports of ophthalmological/dermatological pigmentation/discoloration led to a restriction of the indication in 2013, and in 2017, retigabine was voluntarily withdrawn from the market because of its limited usage. Here, data are reported from four open-label extension studies focusing on long-term safety with particular emphasis on ophthalmological and dermatological events.

METHODS

Studies 113413 (NCT01336621), 114873 (NCT01777139), 115097 (NCT00310388), and 115098 (NCT00310375) were multicenter, open-label extension studies of retigabine (300-1200 mg/day) for the adjunctive treatment of adults with POS. Safety assessments included monitoring treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs). When new safety issues were identified, protocols were amended to include additional on-treatment safety evaluations, including ophthalmological and dermatological examinations. Patients who had abnormal retinal pigmentation, unexplained vision change, pigmentation of nonretinal ocular tissue, or abnormal discoloration of skin, lips, nails, and/or mucosa at the end of the treatment phase were asked to enter a safety follow-up continuation phase comprising 6-monthly ophthalmological/dermatological assessments.

RESULTS

The safety population (patients receiving ≥1 dose of retigabine in the open-label phase) comprised 98, 30, 376, and 181 patients for studies 113413, 114873, 115097, and 115098, respectively. Mean (standard deviation) treatment exposure ranged from 529 (424) to 1129 (999) days. In total, 68%-96% and 4%-27% of patients across the studies experienced TEAEs and TE SAEs, respectively. There were seven on-treatment deaths and two after discontinuation. Overall, 14%-73% of patients had an on-treatment eye examination, of whom 8/53, 4/22, 17/54, and 14/36 had abnormal retinal pigmentation and 15/53, 7/22, 15/54, and 11/36 had nonretinal ocular pigmentation in studies 113413, 114873, 115097, and 115098, respectively. Four patients had confirmed acquired vitelliform maculopathy. In patients with unresolved events at discontinuation and ≥1 posttreatment follow-up, retinal pigmentation resolved completely in 1/3, 0/3, 0/10, and 1/7 patients and nonretinal ocular pigmentation in 1/4, 0/3, 8/10, and 4/6 patients, respectively. Overall, 12%-83% of patients had an on-treatment dermatological examination, of whom 11/58, 0/25, 23/46, and 23/37 had any-tissue discoloration, respectively. In patients with unresolved events at discontinuation and ≥1 posttreatment follow-up, discoloration of skin, lips, nails, and/or mucosa resolved completely in 2/3, 0/0, 7/13, and 1/11 patients, respectively.

CONCLUSIONS

The safety profile of retigabine in adults with POS across four open-label studies was generally consistent with data from previous placebo-controlled studies. Discoloration of various tissues occurred in a proportion of patients treated with retigabine and resolved completely in a small number of these patients following treatment discontinuation. In addition, comprehensive eye examination identified a new adverse reaction of acquired vitelliform maculopathy in a limited number of patients.

Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study

BACKGROUND

Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence.

AIM

To identify risk factors for severe PPH.

MATERIALS AND METHODS

Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL).

RESULTS

Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors.

CONCLUSIONS

Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.

Exploring patient attitudes to behaviour change before surgery to reduce peri-operative risk: preferences for short- vs. long-term behaviour change

Pre-operative intervention to improve general health and readiness for surgery is known as prehabilitation. Modification of risk factors such as physical inactivity, smoking, hazardous alcohol consumption and an unhealthy weight can reduce the risk of peri-operative morbidity and improve patient outcomes. Interventions may need to target multiple risk behaviours. The acceptability to patients is unclear. We explored motivation, confidence and priority for changing health behaviours before surgery for short-term peri-operative health benefits in comparison with long-term general health benefits. A total of 299 participants at three UK hospital Trusts completed a structured questionnaire. We analysed participant baseline characteristics and risk behaviour profiles using independent sample t-tests and odds ratios. Ratings of motivation, confidence and priority were analysed using paired sample t-tests. We identified a substantial prevalence of risk behaviours in this surgical population, and clustering of multiple behaviours in 42.1% of participants. Levels of motivation, confidence and priority for increasing physical activity, weight management and reducing alcohol consumption were higher for peri-operative vs. longer term benefits. There was no difference for smoking cessation, and participants reported lower confidence for achieving this compared with other behaviours. Participants were also more confident than motivated in reducing their alcohol consumption pre-operatively. Overall, confidence ratings were lower than motivation levels in both the short- and long-term. This study identifies both substantial patient desire to modify behaviours for peri-operative benefit and the need for structured pre-operative support. These results provide objective evidence in support of a 'pre-operative teachable moment', and of patients' desire to change behaviours for health benefits in the short term.

Survival of Staphylococcus aureus on therapeutic ultrasound heads

Therapeutic ultrasound (US) is commonly used in the rehabilitation of soft tissue injuries including wounds. US heads and coupling gel come into direct contact with patient skin, increasing the risk for health care-associated infections owing to cross contamination. In this study, nearly 80% of Staphylococcus aureus placed on US heads in gel survived for 1 hour, with survival of 3 days possible in other types of organic matter.

Informing the development midwifery standards for practice: A literature review for policy development

AIM

To critically appraise and synthesise the literature regarding the role and scope of midwifery practice, specifically to inform the evidence based development of standards for practice for all midwives in Australia.

DESIGN

A structured scoping review of the literature DATA SOURCES: CINAHL Complete, MEDLINE Complete and Cochrane Libraries databases, online and grey literature databases REVIEW METHODS: Comprehensive searches of databases used key words and controlled vocabulary for each database to search for publications 2006-2016. Studies were not restricted by research method.

FINDINGS

There is no substantive body of literature on midwifery competency standards or standards for practice. From 1648 papers screened, twenty-eight papers were identified to inform this review. Eight studies including systematic reviews were annotated with three research papers further assessed as having direct application to this review. To inform the development of Midwife standards for practice, the comprehensive role of the midwife across multiple settings was seen to include: woman centred and primary health care; safe supportive and collaborative practice; clinical knowledge and skills with interpersonal and cultural competence.

KEY CONCLUSIONS

Midwifery practice is not restricted to the provision of direct clinical care and extends to any role where the midwife uses midwifery skills and knowledge. This practice includes working in clinical and non-clinical relationships with the woman and other clients as well as working in management, administration, education, research, advisory, regulatory, and policy development roles.

IMPLICATIONS FOR PRACTICE

This review articulates the definition, role and scope of midwifery practice to inform the development of contemporary standards for practice for the Australian midwife.

What influences a woman's decision to access contraception in Timor-Leste? Perceptions from Timorese women and men

Timor-Leste's Maternal Mortality Ratio remains one of the highest in Asia. There is ample evidence that maternal deaths may be reduced substantially through the provision of good-quality modern methods of contraception. Many Timorese women wish to stop or delay having children. However, even when health services make contraception available, it does not mean that people will use it. Collaborating with Marie Stopes Timor-Leste, this qualitative research project used decolonising methodology to explore perceived influences contributing to contraceptive choices, and gain insight into how women's decisions to access contraception in Timor-Leste occur. Over two fieldwork periods (2013 and 2015), we used focus group discussions and structured interviews to speak with 68 women and 80 men, aged 18-49 years, across four districts of Timor-Leste. Findings demonstrate that the decision to access contraception is often contentious and complicated. These tensions echo concerns and ambiguities contained within global and national reproductive health policy. Overwhelmingly, participants emphasised that despite her wishes, a woman can only rarely exercise her right to access contraception freely and independently. She is most often constrained by family, cultural, traditional and educational influences.

Investigation of the use of inertial sensing equipment for the measurement of hip flexion and pelvic rotation in horse riders

Equestrian sports report three to five times higher incidence rates for lower back pain than that of the general population, with hip flexion angles of 50-60° suggested as a causal factor. Inertial motion capture technology enables dynamic measurement of rider kinematics but data extraction is time-consuming. The aim of this study was to develop a software tool to automate the process of extracting biomechanical data from the Xsens™ MVN (MoCap) system to investigate postural changes in riders, comparing static position at halt with dynamic position during the sit phase of rising trot. The software was found to be efficient, reducing data extraction time by 97% when used with a sample of 16 riders. Good correlation was found between hip flexion and pelvic anterior-posterior rotation and between halt and trot but with significantly greater values of hip flexion and pelvic anterior rotation in trot. No riders showed hip flexion >50° at halt but 11 riders (69%) showed hip flexion >50° during the sit phase of rising trot, indicating that dynamic assessment is important when considering rider postural faults that may put them at risk of back injury.

Body Mapping to Explore Reproductive Ethno-Physiological Beliefs and Knowledge of Contraception in Timor-Leste

Maternal mortality remains a significant public health challenge for Timor-Leste. Although access to quality family planning measures may greatly reduce such deaths, consideration of indigenous perceptions, and how they influence reproductive health decision-making and behavior, is crucial if health services are to provide initiatives that are accepted and helpful in improving reproductive health outcomes. We aimed to demonstrate that body mapping is an effective method to traverse language and culture to gain emic insights and indigenous worldviews. The authors' two qualitative research projects (2013 and 2015) used a decolonizing methodology in four districts of Timor-Leste, body mapping with 67 men and 40 women to illuminate ethno-physiology and indigenous beliefs about conception, reproduction, and contraception. Body mapping provided a beneficial conduit for identifying established indigenous reproductive perceptions, understandings, and vocabulary, plus fears surrounding contraception. This may inform health service provision and engagement, ultimately improving the reproductive health of community members.

Exploring psychological mechanisms of clinical response to an internet-delivered psychological pain management program

BACKGROUND

The evidence for Internet-delivered pain management programs for chronic pain is growing, but there is little empirical understanding of how they effect change. Understanding mechanisms of clinical response to these programs could inform their effective development and delivery.

METHODS

A large sample (n = 396) from a previous randomized controlled trial of a validated internet-delivered psychological pain management program, the Pain Course, was used to examine the influence of three potential psychological mechanisms (pain acceptance, pain self-efficacy, fear of movement/re-injury) on treatment-related change in disability, depression, anxiety and average pain. Analyses involved generalized estimating equation models for clinical outcomes that adjusted for co-occurring change in psychological variables. This was paired with cross-lagged analysis to assess for evidence of causality. Analyses involved two time points, pre-treatment and post-treatment.

RESULTS

Changes in pain-acceptance were strongly associated with changes in three (depression, anxiety and average pain) of the four clinical outcomes. Changes in self-efficacy were also strongly associated with two (anxiety and average pain) clinical outcomes. These findings suggest that participants were unlikely to improve in these clinical outcomes without also experiencing increases in their pain self-efficacy and pain acceptance. However, there was no clear evidence from cross-lagged analyses to currently support these psychological variables as direct mechanisms of clinical improvements. There was only statistical evidence to suggest higher levels of self-efficacy moderated improvements in depression.

CONCLUSIONS

The findings suggest that, while clinical improvements are closely associated with improvements in pain acceptance and self-efficacy, these psychological variables may not drive the treatment effects observed.

SIGNIFICANCE

This study employed robust statistical techniques to assess the psychological mechanisms of an established internet-delivered pain management program. While clinical improvements (e.g. depression, anxiety, pain) were closely associated with improvements in psychological variables (e.g. pain self-efficacy and pain acceptance), these variables do not appear to be treatment mechanisms.

Transdiagnostic internet-delivered cognitive-behaviour therapy (CBT) for adults with functional gastrointestinal disorders (FGID): A feasibility open trial

Many people with functional gastrointestinal disorders (FGIDs) face significant barriers in accessing psychological treatments that are known to reduce symptoms and their psychological sequelae. This study examined the feasibility and initial outcomes of a transdiagnostic and internet-delivered cognitive behaviour therapy (iCBT) intervention, the Chronic Conditions Course, for adults with functional gastrointestinal disorders (FGIDs). A single-group feasibility open trial design was employed and administered to twenty seven participants. The course ran for 8 weeks and was provided with weekly contact from a Clinical Psychologist. Seventy percent of participants completed the course within the 8 weeks and 81.5% provided data at post-treatment. High levels of satisfaction were observed and relatively little clinician time (M = 42.70 min per participant; SD = 46.25 min) was required. Evidence of clinical improvements in FGID symptoms (ds ≥ 0.46; avg. improvement ≥21%), anxiety symptoms (ds ≥ 0.99; avg. improvement ≥42%), and depression symptoms (ds ≥ 0.75; avg. improvement ≥35%) were observed, which either maintained or continued to improve to 3-month follow-up. Evidence of improvement was also observed in pain catastrophising and mental-health related quality of life, but not physical-health related quality of life. These findings highlight the potential value of transdiagnostic internet-delivered programs for adults with FGIDs and support for the conduct of larger-scale controlled studies.