Providers’ experience of abortion care: A scoping review protocol. (Preprint)

Background

Despite being one of the most common gynecological procedures in the world, abortion care remains highly stigmatized. Internationally, providers have noted negative impacts related to their involvement in the services, and abortion care has been described as “dirty work.” Though much of the existing research focuses on the challenges of providing, many have also highlighted the positive aspects of working in abortion care. Despite the steadily increasing interest in this area over the past decade, however, no one has sought to systematically review the literature to date.

Objective

The aim of this review is to systematically explore published studies on the experiences of abortion care providers to create a narrative review on the lived experience of providing abortion care, reflecting on what is already known and what areas require further exploration.

Methods

This review will be conducted according to the framework outlined by Levac et al, which expanded on the popular Arksey and O’Malley framework. We will systematically search for peer-reviewed articles in 6 electronic databases: CINAHL, the Cochrane Library, EMBASE, PsycInfo, PubMed, and Web of Science. Following a pilot exercise, we devised a search strategy to identify relevant studies. In this protocol, we outline how citations will be assessed for eligibility and what information will be extracted from the included articles. We also highlight how this information will be combined in the review.

Results

As of December 2021, at the time of writing, we have searched for articles in the electronic databases and identified 6624 unique citations. We intend to fully assess these citations for eligibility by the end of January 2022, chart and analyze data from the eligible citations by the end of March 2022, and submit a journal article for peer review by late spring 2022.

Conclusions

The findings of this review will provide a comprehensive overview on the known experiences of providing abortion care. We also anticipate that the findings will identify aspects of care and experiences that are not reflected in the available literature. We will disseminate the results via a publication in a peer-reviewed academic journal and by presenting the findings at conferences in the areas of abortion care, obstetrics, and midwifery. As this review is a secondary analysis of published articles, ethical approval was not required.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35481

Delayed immune-related adverse events with anti-PD-1-based immunotherapy in melanoma

BACKGROUND

Immune-related adverse events (irAEs) typically occur within 4 months of starting anti-programmed cell death protein 1 (PD-1)-based therapy [anti-PD-1 ± anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA4)], but delayed irAEs (onset >12 months after commencement) can also occur. This study describes the incidence, nature and management of delayed irAEs in patients receiving anti-PD-1-based immunotherapy.

PATIENTS AND METHODS

Patients with delayed irAEs from 20 centres were studied. The incidence of delayed irAEs was estimated as a proportion of melanoma patients treated with anti-PD-1-based therapy and surviving >1 year. Onset, clinical features, management and outcomes of irAEs were examined.

RESULTS

One hundred and eighteen patients developed a total of 140 delayed irAEs (20 after initial combination with anti-CTLA4), with an estimated incidence of 5.3% (95% confidence interval 4.0-6.9, 53/999 patients at sites with available data). The median onset of delayed irAE was 16 months (range 12-53 months). Eighty-seven patients (74%) were on anti-PD-1 at irAE onset, 15 patients (12%) were <3 months from the last dose and 16 patients (14%) were >3 months from the last dose of anti-PD-1. The most common delayed irAEs were colitis, rash and pneumonitis; 55 of all irAEs (39%) were ≥grade 3. Steroids were required in 80 patients (68%), as well as an additional immunosuppressive agent in 27 patients (23%). There were two irAE-related deaths: encephalitis with onset during anti-PD-1 and a multiple-organ irAE with onset 11 months after ceasing anti-PD-1. Early irAEs (<12 months) had also occurred in 69 patients (58%), affecting a different organ from the delayed irAE in 59 patients (86%).

CONCLUSIONS

Delayed irAEs occur in a small but relevant subset of patients. Delayed irAEs are often different from previous irAEs, may be high grade and can lead to death. They mostly occur in patients still receiving anti-PD-1. The risk of delayed irAE should be considered when deciding the duration of treatment in responding patients. However, patients who stop treatment may also rarely develop delayed irAE.

Exploration of Factors Associated with Intention, Initiation and Duration of Breastfeeding

Aim To assess breastfeeding intention, initiation and duration up to three months postnatal and associated factors. Methods Secondary data from 131 healthy pregnant women participating in an RCT in a Dublin hospital who recorded intention to breastfeed were included. Demographic and breastfeeding data were collected. Results Of the 131 women, 91.6% (n=120) reported intending to breastfeed. 91.7% of those subsequently initiated breastfeeding (n=110/120). Of those intending to breastfeed, 78.9% (n=86/109) and 68.9% (n=73/106) remained breastfeeding at one and three months postnatal respectively. Higher education (p<0.05) and lower BMI (p<0.05) were significantly associated with initiation and duration of breastfeeding. Ethnicity, age, parity or mode of delivery were not significantly associated with breastfeeding. Conclusion Many factors are associated with breastfeeding intention and duration including education and BMI. It is important to develop tailored support measures to encourage initiation and continuation of breastfeeding.

A novel strategy to reduce very late HIV diagnosis in high-prevalence areas in South-West England: serious incident audit

Background

Very late diagnosis of HIV is a serious public health issue. We used serious incident reporting (SIR) to identify and address reasons for late diagnoses across the patient pathway.

Methods

Cases of very late HIV diagnosis were reported via SIR in two 6-month batches between 2011 and 2012 in Bournemouth, Poole and Bristol. Case notes were reviewed for missed opportunities for earlier diagnosis using a root-cause analysis tool.

Results

A total of 33 patients (aged 30-67 years, 66% male) were diagnosed very late. Although the majority were white British (n = 17), Black African (n = 9) and Eastern European (n = 4) ethnicities were over-represented. Twenty-four (73%) patients had clinical indicator conditions for HIV, 30 (91%) had a risk factor for HIV acquisition, with 13 (39%) having 2 or more (men-who-have-sex-with-men (n = 11), partner HIV positive (n = 11), from high-prevalence area (n = 12)). Actions resulting from SIR included increasing awareness of indicator conditions, HIV education days within primary care, and initiatives to increase testing within hospital specialities.

Conclusions

SIR allowed identification of reasons for very late HIV diagnosis and provided an impetus for initiatives to address them. SIR may be part of an effective strategy to prevent late diagnosis of HIV which would have important benefits for individual and population health.

Coping with change

Although the NHS is continually changing, the qualifications and skills I have acquired will always be valuable. I have also learned that change provides an opportunity to develop new skills.

Loss of the Parkinson's disease-linked gene DJ-1 perturbs mitochondrial dynamics

Growing evidence highlights a role for mitochondrial dysfunction and oxidative stress as underlying contributors to Parkinson's disease (PD) pathogenesis. DJ-1 (PARK7) is a recently identified recessive familial PD gene. Its loss leads to increased susceptibility of neurons to oxidative stress and death. However, its mechanism of action is not fully understood. Presently, we report that DJ-1 deficiency in cell lines, cultured neurons, mouse brain and lymphoblast cells derived from DJ-1 patients display aberrant mitochondrial morphology. We also show that these DJ-1-dependent mitochondrial defects contribute to oxidative stress-induced sensitivity to cell death since reversal of this fragmented mitochondrial phenotype abrogates neuronal cell death. Reactive oxygen species (ROS) appear to play a critical role in the observed defects, as ROS scavengers rescue the phenotype and mitochondria isolated from DJ-1 deficient animals produce more ROS compared with control. Importantly, the aberrant mitochondrial phenotype can be rescued by the expression of Pink1 and Parkin, two PD-linked genes involved in regulating mitochondrial dynamics and quality control. Finally, we show that DJ-1 deficiency leads to altered autophagy in murine and human cells. Our findings define a mechanism by which the DJ-1-dependent mitochondrial defects contribute to the increased sensitivity to oxidative stress-induced cell death that has been previously reported.

General mutation databases: analysis and review

Databases of mutations causing Mendelian disease play a crucial role in research, diagnostic and genetic health care and can play a role in life and death decisions. These databases are thus heavily used, but only gene or locus specific databases have been previously reviewed for completeness, accuracy, currency and utility. We have performed a review of the various general mutation databases that derive their data from the published literature and locus specific databases. Only two--the Human Gene Mutation Database (HGMD) and Online Mendelian Inheritance in Man (OMIM)--had useful numbers of mutations. Comparison of a number of characteristics of these databases indicated substantial inconsistencies between the two databases that included absent genes and missing mutations. This situation strengthens the case for gene specific curation of mutations and the need for an overall plan for collection, curation, storage and release of mutation data.

Multiple cyclin-dependent kinases signals are critical mediators of ischemia/hypoxic neuronal death in vitro and in vivo

The mechanisms involving neuronal death after ischemic/hypoxic insult are complex, involving both rapid (excitotoxic) and delayed (apoptotic-like) processes. Recent evidence suggests that cell cycle regulators such as cyclin-dependent kinases are abnormally activated in neuropathological conditions, including stroke. However, the function of this activation is unclear. Here, we provide evidence that inhibition of the cell cycle regulator, Cdk4, and its activator, cyclinD1, plays critical roles in the delayed death component of ischemic/hypoxic stress by regulating the tumor suppressor retinoblastoma protein. In contrast, the excitotoxic component of ischemia/hypoxia is predominately regulated by Cdk5 and its activator p35, components of a cyclin-dependent kinase complex associated with neuronal development. Hence, our data both characterize the functional significance of the cell cycle Cdk4 and neuronal Cdk5 signals as well as define the pathways and circumstances by which they act to control ischemic/hypoxic damage.

Cyclin-dependent kinase 5 is a mediator of dopaminergic neuron loss in a mouse model of Parkinson's disease

Recent evidence indicates that cyclin-dependent kinases (CDKs, cdks) may be inappropriately activated in several neurodegenerative conditions. Here, we report that cdk5 expression and activity are elevated after administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), a toxin that damages the nigrostriatal dopaminergic pathway. Supporting the pathogenic significance of the cdk5 alterations are the findings that the general cdk inhibitor, flavopiridol, or expression of dominant-negative cdk5, and to a lesser extent dominant-negative cdk2, attenuates the loss of dopaminergic neurons caused by MPTP. In addition, CDK inhibition strategies attenuate MPTP-induced hypolocomotion and markers of striatal function independent of striatal dopamine. We propose that cdk5 is a key regulator in the degeneration of dopaminergic neurons in Parkinson's disease.

ACTRITE: Acute Chest Triage Rapid Intervention Team

The aim of this paper is to demonstrate how the Acute Chest Triage Rapid Intervention Team (ACTRITE), of North Mersey Community (NHS) Trust, (NMCT) was developed and how it functions. Also demonstrated is a retrospective audit of 50 patients cared for by the team. The ACTRITE Service is a development between NMCT and Aintree Chest Centre. This service integrates primary and secondary care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). The ACTRITE team is based in the Accident and Emergency (A&E) Department of Fazakerley Hospital, UK. It is a team of nurses specializing in patients with COPD, supported by senior respiratory physicians. Patients who attend A&E with an exacerbation of their chest condition will be assessed by the team to determine if, with suitable medication, nursing and social support they might safely and preferably be cared for at home. The assessment will consider all aspects of the patient problem and the aim is to care for the patient holistically. If home care is deemed appropriate, ACTRITE will provide full support for the patient at home. This includes regular visits from the ACTRITE nurses, supported in the evening and overnight by the district nursing team.

Evaluating two dressings for the prevention of nasal bridge pressure sores

Nasal intermittent positive pressure ventilation (NIPPV) can provide symptom control and improved quality of life for patients with acute and chronic respiratory failure. Many patients using a Respironics mask for NIPPV develop nasal bridge pressure sores. Two dressing were compared for effectiveness in preventing such sores. Patients using Granuflex had less skin deterioration over time compared to a comparison group and patients using Spenco Dermal.

Case mix type as a predictor of nursing workload

In the current health care service, the need to measure nursing workload has become the subject of major debate. Attempts have been made to relate workload and nurse staffing, however, despite there being systems for this there appears to be no single recognized formula. Case mix groups have been advocated as a useful tool for measuring nursing workload, particularly in Canada where work continues. Case mix groups work on the basis that patients who are clinically similar and use equivalent resources are grouped using procedure and diagnostic codes. The retrospective study examines the relationship between case mix, resource utilization and nursing effort to determine whether future workload could be predicted using these parameters. The sample included 798 patients and 30 nurses over the period 1993-1994 with analysis of data from the Patient Administration System (PAS) and TEAMWORK, which purports to measure nurse workload. Results showed that there was little relationship between nursing workload and case mix grouping and recommendations are made for future research.

A specific tetrahydrobiopterin binding domain on tyrosinase controls melanogenesis

(6R)5,6,7,8-tetrahydrobiopterin (6-BH4) directly regulates tyrosinase activity by specifically binding to a putative 13 amino acid domain. This domain has sequence homology to 6-BH4 binding sites already identified on phenylalanine hydroxylase and 4a-carbinolamine dehydratase. Furthermore, this binding sequence appears to have been conserved during the evolution of tyrosinase as it has also been identified in the frog, mouse and human enzymes. 6-BH4 controls tyrosinase activity by an uncompetitive mechanism requiring the presence of L-tyrosine for effective down-regulation. When L-dopa is substrate, 6-BH4 does not inhibit the enzyme implicating separate binding sites for L-dopa and L-tyrosine on tyrosinase. Dihydropterin and 6-biopterin, the oxidation products of 6-BH4, do not inhibit tyrosinase significantly, indicating that melanin biosynthesis is controlled by a 6-BH4/6-biopterin redox-switch mechanism which can be initiated by photo-oxidation of 6-BH4.

Hedonic response of sucrose likers and dislikers to other gustatory stimuli

The majority of individuals can be classified as sweet likers or dislikers based on their hedonic (pleasure) response to sucrose solutions of varying concentrations. Our results indicate that the sweet liker/disliker distinction generalizes to sugars other than sucrose, i.e., glucose and fructose. As well, these individual hedonic response patterns are maintained even when a flavor and color are added to sucrose solutions. However, whether one is a sweet liker or disliker does not predict hedonic response to nonsweet tastes such as salt. These results indicate that the sweet liker/disliker distinction is a robust phenomenon which appears to generalize over, but is restricted to, sweet-tasting substances. The possibility that individual differences in hedonic response may predict preferences for, and intake of, complex tastes characteristic of foods encountered in the real world, is discussed.

The effect of glibenclamide treatment on the insulin and glucagon responses to oral glucose and galactose in maturity onset diabetics

Glibenclamide has been shown to stimulate an insulin releasing factor in the duodenum. The possibility that this effect is of importance in its hypoglycaemic action was investigated by studying the effect of galactose on insulin release before and after treatment with glibenclamide; galactose stimulates insulin release when given orally but has no effect when given parenterally; thus its ability to release insulin appears to reside in an action on a gut factor. Measurements of plasma glucose, insulin and glucagon were made on twelve maturity onset diabetic patients following an oral glucose tolerance test and an oral galactose tolerance test before and after one week of treatment with glibenclamide. Glibenclamide significantly reduced the blood glucose levels. Both basal insulin and basal glucagon levels were unchanged. The insulin response to oral glucose was enhanced. Glucagon levels before treatment did not suppression of glucagon levels. Galactose stimulated insulin release but insulin levels before and after treatment were identical. An effect of glibenclamide on gut insulin releasing activity was not demonstrated but the galactose tolerance test provides a useful technique by which to examine the enteroinsular axis.