Maternity services response to the COVID-19 pandemic: how Public Health England guidance was implemented in practice

Introduction

The rapidly evolving COVID-19 pandemic required systemic change in how healthcare was delivered to minimize virus transmission whilst maintaining safe service delivery. Deemed at ‘moderate-high risk’, maternity patients are an important patient group that require consideration. Public Health England (PHE) issued national guidance on how to adjust these services.

Aim

To explore how maternity units in England implemented PHE guidance.

Methods

An online survey of 22 items was distributed to individuals that had worked on an England-based maternity unit during the COVID-19 pandemic. The questionnaire was designed and tested by the multidisciplinary research team. Data was collected from November 2020 to July 2021.

Findings

Forty-four participants across 33 maternity units responded. Ninety-three percent were able to test all women requiring an overnight stay for COVID-19. Only 27% reported birth partners were tested for COVID-19. Only 73% reported they were able to isolate all COVID-19-positive patients in single rooms. Eighty-four percent stated they were aware of current PHE guidance on personal protective equipment (PPE) and 82% felt ‘confident’ in donning/doffing of PPE. Priorities for the future include rapid testing and a focus on community service provision.

Conclusions

PHE COVID-19 guidance was implemented differently in maternity units across England due to the varying resources available at each trust leading to variable ability to test and isolate patients as recommended. More specific, tailored guidance for infection control measures against COVID-19 is needed for maternity settings due to their unique position.

A midwifery-led prevalence programme for caesarean section surgical site infections

Caesarean section (CS) is a common procedure accounting for 29% of all deliveries. Surgical site infections (SSI) are a risk with any surgical procedure. A CS SSI prevalence programme led by a midwife, who is also an infection prevention and control matron, was implemented to determine the rate of CS SSI within the trust. The initial CS SSI rate was 26% over a 3-month period (June-August 2012). Targeted interventions were put in place to reduce the CS SSI rate, and by 2019, it had decreased to 8%. Hospitals should consider implementing CS SSI surveillance and prevention programmes. Real benefits can be realized with minimal resources.

COVID-19: how prepared are front-line healthcare workers in England?

National efforts are underway to prepare the UK National Health Service (NHS) for the COVID-19 pandemic; however, the efficacy of these interventions is unknown. In view of this, a cross-sectional survey of front-line healthcare workers (HCWs) at two large acute NHS hospital trusts in England was undertaken to assess their confidence and perceived level of preparedness for the virus. The survey found that there has been moderate success in readying HCWs to manage COVID-19, but that more still needs to be done, particularly in relation to educating HCWs about laboratory diagnostics.

Detection of CMB-Cluster Lensing using Polarization Data from SPTpol

We report the first detection of gravitational lensing due to galaxy clusters using only the polarization of the cosmic microwave background (CMB). The lensing signal is obtained using a new estimator that extracts the lensing dipole signature from stacked images formed by rotating the cluster-centered Stokes QU map cutouts along the direction of the locally measured background CMB polarization gradient. Using data from the SPTpol 500  deg^{2} survey at the locations of roughly 18 000 clusters with richness λ≥10 from the Dark Energy Survey (DES) Year-3 full galaxy cluster catalog, we detect lensing at 4.8σ. The mean stacked mass of the selected sample is found to be (1.43±0.40)×10^{14}M_{⊙} which is in good agreement with optical weak lensing based estimates using DES data and CMB-lensing based estimates using SPTpol temperature data. This measurement is a key first step for cluster cosmology with future low-noise CMB surveys, like CMB-S4, for which CMB polarization will be the primary channel for cluster lensing measurements.

Cosmological Constraints from Multiple Probes in the Dark Energy Survey

The combination of multiple observational probes has long been advocated as a powerful technique to constrain cosmological parameters, in particular dark energy. The Dark Energy Survey has measured 207 spectroscopically confirmed type Ia supernova light curves, the baryon acoustic oscillation feature, weak gravitational lensing, and galaxy clustering. Here we present combined results from these probes, deriving constraints on the equation of state, w, of dark energy and its energy density in the Universe. Independently of other experiments, such as those that measure the cosmic microwave background, the probes from this single photometric survey rule out a Universe with no dark energy, finding w=-0.80_{-0.11}^{+0.09}. The geometry is shown to be consistent with a spatially flat Universe, and we obtain a constraint on the baryon density of Ω_{b}=0.069_{-0.012}^{+0.009} that is independent of early Universe measurements. These results demonstrate the potential power of large multiprobe photometric surveys and pave the way for order of magnitude advances in our constraints on properties of dark energy and cosmology over the next decade.

Using proliferative markers and Oncotype DX in therapeutic decision-making for breast cancer: the B.C. experience

BACKGROUND

Proliferative scoring of breast tumours can guide treatment recommendations, particularly for estrogen receptor (er)-positive, her2-negative, T1-2, N0 disease. Our objectives were to □ estimate the proportion of such patients for whom proliferative indices [mitotic count (mc), Ki-67 immunostain, and Oncotype dx (Genomic Health, Redwood City, CA, U.S.A.) recurrence score (rs)] were obtained.□ compare the indices preferred by oncologists with the indices available to them.□ correlate Nottingham grade (ng) and its subcomponents with Oncotype dx.□ assess interobserver variation.

METHODS

All of the er-positive, her2-negative, T1-2, N0 breast cancers diagnosed from 2007 to 2011 (n = 5110) were linked to a dataset of all provincial breast cancers with a rs. A 5% random sample of the 5110 cancers was reviewed to estimate the proportion that had a mc, Ki-67 index, and rs. Correlation coefficients were calculated for the rs with ng subcomponent scores. Interobserver variation in histologic grading between outside and central review pathology reports was assessed using a weighted kappa test.

RESULTS

During 2007-2011, most cancers were histologically graded and assigned a mc; few had a Ki-67 index or rs. The ng and mc were significantly positively correlated with rs. The level of agreement in histologic scoring between outside and central pathology reports was good or very good. Very few cases with a low mc had a high rs (1.8%).

CONCLUSIONS

Patients with low ng and mc scores are unlikely to have a high rs, and thus are less likely to benefit from chemotherapy. In the context of limited resources, that finding can guide clinicians about when a rs adds the most value.

Promoting smoking cessation among prisoners: feasibility of a multi-component intervention

OBJECTIVE

To conduct a pilot study to determine the feasibility and effectiveness of a multi-component smoking cessation intervention among prison inmates.

METHODS

A prospective study conducted within a maximum-security prison located near Sydney, New South Wales, and housing around 330 men. Participants received a smoking cessation intervention with six-month follow-up to determine abstinence. The smoking cessation intervention consisted of two brief cognitive behavioural therapy sessions, nicotine replacement therapy, bupropion and self-help resources. Point prevalence and continuous abstinence at follow-up were verified with expired carbon monoxide measures.

RESULTS

Thirty male inmates participated in the intervention. At six months, the biochemically validated point prevalence and continuous abstinence rates were 26% and 22% respectively. Reasons for relapse to smoking included: transfers to other prisons without notice, boredom, prolonged periods locked in cells, and stress associated with family or legal concerns. Those inmates who relapsed, or continued to smoke following the intervention, smoked less tobacco than at baseline and 95% stated they were willing to try to quit again using our intervention.

CONCLUSIONS

Prison inmates are able to quit or reduce tobacco consumption while in prison but any smoking cessation intervention in this setting needs to address prison-specific issues such as boredom, stress, transfers to other prisons, court appearances, and isolation from family and friends.

IMPLICATIONS

The prevalence of smoking within Australian prisons is alarmingly high. Further work into how to encourage prisoners to quit smoking is required.

An investigation of sequence deletions of amelogenin (AMELY), a Y-chromosome locus commonly used for gender determination

BACKGROUND

Accurate gender determination is crucial in many scientific disciplines, but especially so in prenatal diagnosis of X-linked diseases and forensic investigations. Today, molecular techniques, especially typing for a length variation in the X-Y homologous amelogenin gene (AMELX and AMELY), are used for gender assignation. This amelogenin test is an integral part of most PCR multiplex kits that are used for DNA profiling, but in 1998 there was a report of two normal males being typed as female with this test. Subsequently, a small number of amelogenin negative (or AMELY null) males have been reported in various populations but little data are available characterising these deletions.

AIMS

The study aims to determine the size of the deletion in five AMELY null males by typing DNA samples for markers surrounding this gender-determining locus. The possible relationships among the AMELY null samples are examined through analysis of their deletion size and associated Y-chromosome microsatellite haplotypes. We also attempt to determine the frequency of AMELY negative males in Australia.

SUBJECTS AND METHODS

DNA samples from five AMELY null males, from different geographical regions, were made available for this study. The samples were typed for eight sites, all located on the short arm of the Y chromosome, using PCR and gel electrophoresis. Eleven Y-chromosome specific microsatellites were also typed on each sample in order to generate haplotypes for phylogenetic analysis. A questionnaire was sent to all Australian forensic centres requesting information on the frequency of AMELY negative males observed in their laboratories.

RESULTS

Two different sized deletions were seen in the five AMELY null samples. One deletion (in two samples) has a size of between 304 and 731 kbp, whereas the other (in three samples) ranges between 712 and 1001 kbp. Y-microsatellite haplotypes indicate that the smaller deletion is probably identical in the two samples, but this is not the case with the larger deletion. The frequency of AMELY negative is rare in Australia, with an overall frequency of 0.02%.

CONCLUSION

Comparisons of both deletion size and haplotypes with published data suggest that most AMELY nulls are the result of independent evolutionary events, even in those populations where the frequency is relatively high. Although AMELY null males are extremely rare in most populations, typing an additional gender-determining locus should be considered in forensic investigations where the reference sample is of unknown gender.

Patients, caregivers, and managing care

Providing care to patients who have Alzheimer's disease requires that professional care providers have an understanding not only of the disease and its progression, but also of informal caregivers, their roles, capabilities, and needs. Using experience from the Medicare Alzheimer's Demonstration Project and subsequent work of the Legacy Health System in Portland, OR, this paper reviews the perspectives of case managers and caregivers regarding a variety of strategies that have been implemented.

Proviral insertions induce the expression of bone-specific isoforms of PEBP2alphaA (CBFA1): evidence for a new myc collaborating oncogene

The til-1 locus was identified as a common retroviral integration site in virus-accelerated lymphomas of CD2-myc transgenic mice. We now show that viral insertions at til-1 lead to transcriptional activation of PEBP2alphaA (CBFA1), a transcription factor related to the Drosophila segmentation gene product, Runt. Insertions are upstream and in the opposite orientation to the gene and appear to activate a variant promoter that is normally silent in T cells. Activity of this promoter was detected in rodent osteogenic sarcoma cells and primary osteoblasts, implicating bone as the normal site of promoter activity. The isoforms encoded by the activated gene all encompass the conserved runt DNA-binding domain and share a novel N terminus different from the previously reported PEBP2alphaA products. Minor products include isoforms with internal deletions due to exon skipping and a novel C-terminal domain unrelated to known runt domain factors. The major isoform expressed from the activated til-1 locus (G1) was found to account for virtually all of the core binding factor activity in nuclear extracts from its corresponding lymphoma cell line. Another member of this gene family, AML1(CBFA2), is well known for its involvement in human hemopoietic tumors. These results provide evidence of a direct oncogenic role for PEBP2alphaA and indicate that the Myc and Runt family genes can cooperate in oncogenesis.

A supportive partnership for CAPD patients

CAPD patient education is a continuous process. The renal training centre maintains close relationships with patients' community CAPD nurses. A high nurse/patient ratio allows time to deal with individual problems.

Head nurses' perceptions of their roles--Part I & Part II

The head nurse is in a critical management position in a nursing department. It is the head nurse who sets the standards and directions for nursing practice on a nursing unit and manages the staff delivering the care. Due to the decentralization of managerial decisions in many nursing organizations and the change from functional to primary nursing in the care delivery systems, the head nurse role has changed considerably. The purpose of this exploratory, descriptive research study was to explore head nurses' own perception of their roles. The findings showed that head nurses are readily able to describe their work in the context of Mintzberg's ten managerial roles. Some of the roles are more familiar than others and receive more emphasis depending upon the situation. Three roles, the leader, resource allocator, and entrepreneur emerged as the most significant. Knowledge about the behaviours described by the subjects in this study may provide information to improve the educational preparation for the head nurse position. As well, increased understanding about the managerial roles should enable the head nurses to facilitate high quality patient care.

Assaults by patients: the experience and attitudes of psychiatric hospital nurses

Four hundred and twenty-five nurses working in a 420 bed metropolitan psychiatric hospital were asked to complete a questionnaire about their experience of physical assault by patients and their attitude toward the problem. 61% returned the questionnaire. The overall mean annual rate of assault per nurse was 2.0, with student psychiatric nurses (mean 6.7) significantly more at risk than any other group. Nurses working in the psychogeriatric area reported more than double the rate of assaults reported by nurses working in rehabilitation services. 60% of respondents were female; there were very few sex differences in attitudes to assault. Overall, nurses reported a high tolerance for assault, although they recognised it as an experience that was often very traumatic psychologically. Views about managing assaultiveness differed widely, and this lack of consensus probably hinders the development of optimal strategies to deal with what is a major problem in many psychiatric units.

Breastfeeding. Setting a standard: the challenge for health visiting

Health visitors agree that breast is best. But how far is this principle translated into practice? Copious evidence exists of conflicting advice and views on breastfeeding among health professionals and even between health visitors themselves. Marianne Cowpe, Ann MacLachlan and Elizabeth Baxter describe how north east Fife health visitors drew up an agreed standard of practice to boost local breastfeeding rates.

Leucine metabolism as a source of acetate in the synthesis of hyaluronic acid

Synovial fibroblasts were incubated in nutrient medium with either L-[U-14C]leucine or L-[4,5-3H]leucine to reveal peptides associated with hyaluronic acid. Isotope was found in hyaluronic acid extracted from culture medium by repeated density gradient ultracentrifugation, but 76-98% of the labelled hyaluronic acid fraction was recovered as oligosaccharide by Sephadex G-25 gel chromatography after digestion with protease-free staphylococcal hyaluronidase (EC 4.2.99.1). Radioactivity in acid digests of the oligosaccharide fractions (i) was volatile, (ii) separated similarly to acetate in Biogel P2 chromatography, and (iii) was identified as acetate by melting point after conjugation as a p-phenylphenacyl ester crystallized to constant specific activity. The synovial fibroblast thus possesses metabolic pathways for complete transformation of leucine to acetylCoA, which operate freely in adequate nutrient medium and are a significant source of acetyl groups in hyaluronic acid synthesis.

Activation of human synovial cells by cholera enterotoxin: correlation of morphological responses with adenylate cyclase activities, and the reversing effects of hyaluronidase

Previously described morphological changes in human synovial cell cultures due to cholera enterotoxin (CT) were studied in relation to activation of adenylate cyclase. A single pulse of CT at nanomolar concentration or less induced at least two-fold activation of adenylate cyclase, which persisted for 7 days or more. The enzyme hyaluronidase was found to cause a rapid reversal of the morphological effects of CT. There was also a reduction in adenylate cyclase activity but only with hyaluronidase concentrations greater than those required to produce maximum reversal of the CT-induced morphological changes. Removal of hyaluronidase was followed by reappearance of the CT-associated morphological effects and a slower reactivation of adenylate cyclase. The mechanism by which hyaluronidase produces the observed changes in synovial cells is not known, but might be related to the dispersal of hyaluronic acid gels bound to the surface of these cells.

Plasma clearance, tissue distribution and metabolism of hyaluronic acid injected intravenously in the rabbit

The plasma clearance, tissue distribution and metabolism of hyaluronic acid were studied with a high average molecular weight [3H]acetyl-labelled hyaluronic acid synthesized in synovial cell cultures. After intravenous injection in the rabbit the label disappeared from the plasma with a half-life of 2.5--4.5 min, which corresponds to a normal hyaluronic acid clearance of approx. 10 mg/day per kg body weight. Injection of unlabelled hyaluronic acid 15 min after the tracer failed to reverse its absorption. Clearance of labelled polymer was retarded by prior injection of excess unlabelled hyaluronic acid. The maximum clearance capacity was estimated in these circumstances to be about 30 mg/day per kg body wt. The injected material was concentrated in the liver and spleen. As much as 88% of the label was absorbed by the liver, where it was found almost entirely in non-parenchymal cells. Degradation was rapid and complete, since volatile material, presumably 3H2O, appeared in the plasma within 20 min. Undegraded [3H]hyaluronic acid, small labelled residues and 3H2O were detected in the liver, but there was little evidence of intermediate oligosaccharides. No metabolite except 3H2O was recognized in plasma or urine. Two-thirds of the radioactivity was retained in the body water 24 h later, and small amounts were found in liver lipids. Radioactivity did not decline in the spleen as rapidly as in the liver. The upper molecular weight limit for renal excretion was about 25 000. Renal excretion played a negligible part in clearance. It is concluded that hyaluronic acid is removed from the plasma and degraded quickly by an efficient extrarenal system with a high reserve capacity, sited mainly in the liver.

Patterns of induced variation in the morphology, hyaluronic acid secretion, and lysosomal enzyme activity of cultured human synovial cells

In contrast with newly isolated cells or early primary cultures, synovial cell lines in standardised growth conditions assume a rather uniform fibroblast-like appearance. However, 2 distinct variations in the cytological pattern can be induced at this stage. The first is characterised primarily by increased numbers of small phase-dense organelles that show the distinctive fluorescence of lysosomes after supravital staining, and are interspersed with vacuoles. The associated functional changes include increased enzyme activity and decreased net synthesis of hyaluronic acid. This variation can be induced by exposure to indigestible neutral sugars, adenosine, or its 5' nucleotides. The second variation consists of a striking reorganisation of cytoplasm by condensation into dense ridges or a dendritic network of processes. It is accompanied by increased hyaluronic acid secretion and is induced by agents that enhance intracellular activity of cyclic adenosine monophosphate, such as dibutyryl cyclic adenosine monophosphate and cholera enterotoxin. It appears possible to direct differentiation in synovial cell lines to correspond at least in part with the presumed functions of the different cell types in the parent tissue. The 2 patterns may be useful markers to correlate with other aspects of synovial cell function in vitro.

Effects of carrageenin on human synovial cells in vitro: morphology, hyaluronic acid production, growth, and the lysosomal system

Some in-vitro effects of the arthritogenic polysaccharide carrageenin were studied on cells from human synovium. Synovial cells were isolated from intact human knee joints, and cell lines were developed by passaging with trypsin. Carrageenin was ingested by the cells but did not significantly affect cell growth, numbers of lysosomes, intracellular lysosomal enzyme activity (N-acetyl-beta-D-glucosaminidase), or release of lysosomal enzyme from cells. Carrageenin produced a reduction in net hyaluronic acid synthesis. It also induced a striking morphological change in a high proportion of synovial cells, characterised by increased spreading over the culture surface and apparent condensation of the cytoplasm into a pattern of ridges. Nonrheumatoid and rheumatoid synovial cells behaved similarly to one another.

Carrageenin-induced arthritis. III. Proteolytic enzymes present in rabbit knee joints after a single intraarticular injection of carrageenin

A single intraarticular injection of carrageenin into the rabbit knee joint initiates an inflammatory reaction in the synovial tissues. the exudate from the joint was able to degrade proteoglycan at pH 5.2 and pH 7.2. Further characterization of proteolytic enzymes in the inflamed synovial tissues showed the presence of cathepsin D, a neutral protease, and cathepsin B1. Maximum activities of two lysosomal enzymes, acid phosphatase and cathepsin D, were observed within 7 days of injection. Most of this activity was found to be associated with cells in the synovial fluid.

The nature of the protein moieties of cartilage proteoglycans of pig and ox

Proteoglycans extracted with 4M-guanidinium chloride from pig laryngeal cartilage and bovine nasal septum were purified by density-gradient centrifugation in CsCl under 'associative' followed by 'dissociative' conditions [Hascall & Sajdera (1969) J. Biol. Chem. 244, 2384-2396]. Proteoglycans were then digested exhaustively with testicular hyaluronidase, which removed about 80% of the chondroitin sulphate. The hyaluronidase was purified until no proteolytic activity was detectable under the conditions used for digestion. The resulting 'core' proteins of both species were fractionated by a sequence of gel-chromatographic procedures which gave four major fractions of decreasing hydrodynamic size. Those that on electrophoresis penetrated 5.6% (w/v) polyacrylamide gels migrated as discrete bands whose mobility increased with decreasing hydrodynamic size. The unfractionated 'core' proteins had the same N-terminal amino acids as the intact proteoglycan, suggesting that no peptide bonds had been cleaved during hyaluronidase digestion. Alanine predominated as the N-terminal residue in all the fractions of both species. Fractions were analysed for amino acid, amino sugar, uronic acid and neutral sugar compositions. In pig 'core' proteins, the glutamic acid content increased significantly with hydrodynamic size, but in bovine 'core' proteins this trend was less marked. Significant differences in amino acid composition between fractions suggested that in each species there was more than one variety of proteoglycan. The molar proportions of xylose to serine destroyed on alkaline beta-elimination were equivalent in most fractions, indicating that the serine residues destroyed were attached to the terminal xylose of chondroitin sulphate chains. The ratio of serine residues to threonine residues destroyed on beta-elimination, was similar in all fractions of both species. Since the fractions of smallest hydrodynamic size contained less keratan sulphate than those of larger size, it implies that in the former the keratan sulphate chains were shorter than in the latter.