Publications by authors named "Paula McGee"

35 Publications

The association of race and ethnicity with severe maternal morbidity among individuals diagnosed with hypertensive disorders of pregnancy.

Am J Perinatol 2022 Jun 28. Epub 2022 Jun 28.

Obstetrics & Gynecology, University of Texas Health Sciences Center at Houston, Houston, United States.

Objective: To examine racial disparities in severe maternal morbidity in patients with hypertensive disorder of pregnancy (HDP).

Study Design: Secondary analysis of an observational study of 115,502 patients who had a live birth at ≥ 20 weeks in 25 hospitals in the US, 2008-2011. Only patients with HDP were included in this analysis. Race and ethnicity were categorized as non-Hispanic White (NHW), non-Hispanic Black (NHB) and Hispanic. Associations were estimated between race and ethnicity and the primary outcome of severe maternal morbidity, defined as any of the following: blood transfusion ≥4 units, unexpected surgical procedure, need for a ventilator ≥ 12 hours, intensive care unit (ICU) admission, or failure of ≥ 1 organ system, were estimated by unadjusted logistic and multivariable backward logistic regressions. Multivariable models were run classifying HDP into 3 levels: 1) gestational hypertension; 2) preeclampsia (mild, severe or superimposed); and 3) eclampsia or HELLP.

Results: A total of 9,612 individuals with HDP were included. The frequency of the primary outcome, composite severe maternal morbidity, was higher in NHB patients compared with that in NHW or Hispanic patients (11.8% vs. 4.5% in NHW and 4.8% in Hispanic, p<0.001). This was driven by a higher frequency of blood transfusions and ICU admissions among NHB individuals. After adjusting for sociodemographic and clinical factors, hospital site, and the severity of HDP, the odds ratios of composite severe maternal morbidity did not differ between the groups (adjusted OR 1.26, 95% CI 0.95, 1.67 for NHB and adjusted OR 1.29, 95% CI 0.94, 1.77 for Hispanic, compared to NHW patients).

Conclusion: NHB patients with HDP had higher rates of the composite maternal morbidity compared with NHW, driven mainly by higher frequencies of blood transfusions and ICU admissions. However, once severity and other confounding factors were taken into account, the differences did not persist.
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http://dx.doi.org/10.1055/a-1886-5404DOI Listing
June 2022

Comparison of Cesarean Deliveries in a Multicenter U.S. Cohort Using the 10-Group Classification System.

Am J Perinatol 2022 Jun 3. Epub 2022 Jun 3.

Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon.

Objective:  We sought to (1) use the Robson 10-Group Classification System (TGCS), which classifies deliveries into 10 mutually exclusive groups, to characterize the groups that are primary contributors to cesarean delivery frequencies, (2) describe inter-hospital variations in cesarean delivery frequencies, and (3) evaluate the contribution of patient characteristics by TGCS group to hospital variation in cesarean delivery frequencies.

Study Design:  This was a secondary analysis of an observational cohort of 115,502 deliveries from 25 hospitals between 2008 and 2011. The TGCS was applied to the cohort and each hospital. We identified and compared the TGCS groups with the greatest relative contributions to cohort and hospital cesarean delivery frequencies. We assessed variation in hospital cesarean deliveries attributable to patient characteristics within TGCS groups using hierarchical logistic regression.

Results:  A total of 115,211 patients were classifiable in the TGCS (99.7%). The cohort cesarean delivery frequency was 31.4% (hospital range: 19.1-39.3%). Term singletons in vertex presentation with a prior cesarean delivery (group 5) were the greatest relative contributor to cohort (34.8%) and hospital cesarean delivery frequencies (median: 33.6%; range: 23.8-45.5%). Nulliparous term singletons in vertex (NTSV) presentation (groups 1 [spontaneous labor] and 2 [induced or absent labor]: 28.9%), term singletons in vertex presentation with a prior cesarean delivery (group 5: 34.8%), and preterm singletons in vertex presentation (group 10: 9.8%) contributed to 73.2% of the relative cesarean delivery frequency for the cohort and were correlated with hospital cesarean delivery frequencies (Spearman's rho = 0.96). Differences in patient characteristics accounted for 34.1% of hospital-level cesarean delivery variation in group 2.

Conclusion:  The TGCS highlights the contribution of NTSV presentation to cesarean delivery frequencies and the impact of patient characteristics on hospital-level variation in cesarean deliveries among nulliparous patients with induced or absent labor.

Key Points: · We report on the cesarean delivery frequencies in a multicenter U.S.

Cohort: . · NTSV gestations (groups 1 and 2) are a primary driver of cesarean deliveries.. · Patient characteristics contributed most to hospital variation in cesarean deliveries in group 2..
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http://dx.doi.org/10.1055/s-0042-1748527DOI Listing
June 2022

An evaluation of seasonal maternal-neonatal morbidity related to trainee cycles.

Am J Obstet Gynecol MFM 2022 05 2;4(3):100583. Epub 2022 Feb 2.

Department of Obstetrics & Gynecology, University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, TX (Dr Blackwell).

Background: The existence of the "July phenomenon" (worse outcomes related to the presence of new physician trainees in teaching hospitals) has been debated in the literature and media. Previous studies of the phenomenon in obstetrics are limited by the quality and detail of data.

Objective: To evaluate whether the months of June to August, when transitions in trainees occur, are associated with increased maternal and neonatal morbidity.

Study Design: Secondary analysis of an observational cohort of 115,502 mother-infant pairs that delivered at 25 hospitals from March 2008 to February 2011. Inclusion criteria were an individual who had a singleton, nonanomalous live fetus at the onset of labor, and delivered at a hospital with trainees. The primary outcomes were composites of maternal and neonatal morbidity. We evaluated the outcomes by academic quarter during which the delivery occurred, beginning July 1, and by duration of the academic year as a continuous variable. To account for clustering in outcomes at a given delivery location, we applied hierarchical logistic regression with adjustment for hospital as a random effect.

Results: Of 115,502 deliveries, 99,929 met the inclusion criteria. Race and ethnicity, insurance, body mass index, drug use, and the availability of 24/7 maternal-fetal medicine, anesthesia, and neonatology varied by quarter. In adjusted analysis, the frequency of the composite maternal and neonatal morbidity did not differ by quarter. No differences in composite morbidity were observed when using day of the year as a continuous variable (maternal morbidity adjusted odds ratio, 1.00; 95% confidence interval, 0.99-1.00 and neonatal morbidity adjusted odds ratio, 1.00; 95% confidence interval, 1.00-1.01) and after adjustment for hospital as a random effect. Odds of major surgical complications in quarter 2 were twice those in quarter 1. Neonatal injury and intensive care unit were less frequent in later quarters.

Conclusion: Maternal and neonatal morbidity in teaching hospitals was not associated with the academic quarter during which delivery occurred, and there was no evidence of a "July phenomenon".
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http://dx.doi.org/10.1016/j.ajogmf.2022.100583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9081218PMC
May 2022

Comparison of central laboratory HbA1c measurements obtained from a capillary collection versus a standard venous whole blood collection in the GRADE and EDIC studies.

PLoS One 2021 15;16(11):e0257154. Epub 2021 Nov 15.

The Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD, United States of America.

Background: We compared HbA1c values obtained from capillary blood collection kits versus venous whole blood collections in study participants with type 1 or type 2 diabetes.

Methods: A total of 122 subjects, 64 with type 2 diabetes participating in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) Study and 58 with type 1 diabetes from the Epidemiology of Diabetes Interventions and Complications (EDIC) Study, participated in the validation study. Capillary tubes were filled by fingerstick by the participants on the same day as the collection of venous whole blood samples in EDTA-containing test tubes and were mailed to the central laboratory. HbA1c in all samples was measured with the same high-performance liquid chromatography. GRADE participants also completed a questionnaire on the ease of performing capillary collections.

Results: Participants from 22 clinical centers (GRADE n = 5, EDIC n = 17) were between 35 and 86 years of age, with 52% male and diverse race/ethnicities. Venous HbA1c results ranged between 5.4-11.9% (35.5-106.6 mmol/mol) with corresponding capillary results ranging between 4.2-11.9% (22.4-106.6 mmol/mol). The venous and capillary results were highly correlated (R2 = 0.993) and 96.7% differed by ≤0.2% (2.2 mmol/mol). Of participants surveyed, 69% indicated that the instructions and collection were easy to follow and 97% felt the collection method would be easy to do at home.

Conclusions: The capillary blood HbA1c results compared well with the conventional venous whole blood results. The capillary kits can be employed in other studies to reduce interruption of critical data collection and potentially to augment clinical care when in-person visits are not possible.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257154PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8592405PMC
December 2021

Fetal Tachycardia in the Setting of Maternal Intrapartum Fever and Perinatal Morbidity.

Am J Perinatol 2021 Oct 20. Epub 2021 Oct 20.

Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio.

Objective:  The fetal consequences of intrapartum fetal tachycardia with maternal fever or clinical chorioamnionitis are not well studied. We evaluated the association between perinatal morbidity and fetal tachycardia in the setting of intrapartum fever.

Study Design:  Secondary analysis of a multicenter randomized control trial that enrolled 5,341 healthy laboring nulliparous women ≥36 weeks' gestation. Women with intrapartum fever ≥ 38.0°C (including those meeting criteria for clinical chorioamnionitis) after randomization were included in this analysis. Isolated fetal tachycardia was defined as fetal heart rate (FHR) ≥160 beats per minute for at least 10 minutes in the absence of other FHR abnormalities. FHR abnormalities other than tachycardia were excluded from the analysis. The primary outcome was a perinatal composite (5-minute Apgar's score ≤3, intubation, chest compressions, or mortality). Secondary outcomes included low arterial cord pH (pH < 7.20), base deficit ≥12, and cesarean delivery.

Results:  A total of 986 (18.5%) of women in the trial developed intrapartum fever, and 728 (13.7%) met criteria to be analyzed; of these, 728 women 336 (46.2%) had maternal-fetal medicine (MFM) reviewer-defined fetal tachycardia, and 349 of the 550 (63.5%) women during the final hour of labor had validated software (PeriCALM) defined fetal tachycardia. After adjusting for confounders, isolated fetal tachycardia was not associated with a significant difference in the composite perinatal outcome (adjusted odds ratio [aOR] = 3.15 [0.82-12.03]) compared with absence of tachycardia. Fetal tachycardia was associated with higher odds of arterial cord pH <7.2, aOR = 1.48 (1.01-2.17) and of infants with a base deficit ≥ 12, aOR = 2.42 (1.02-5.77), but no significant difference in the odds of cesarean delivery, aOR = 1.33 (0.97-1.82).

Conclusion:  Fetal tachycardia in the setting of intrapartum fever or chorioamnionitis is associated with significantly increased fetal acidemia defined as a pH <7.2 and base excess ≥12 but not with a composite perinatal morbidity.

Key Points: · The perinatal outcomes associated with fetal tachycardia in the setting of maternal fever are undefined.. · Fetal tachycardia was not significantly associated with perinatal morbidity although the sample size was limited.. · Fetal tachycardia was associated with an arterial cord pH <7.2 and base deficit of 12 or greater..
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http://dx.doi.org/10.1055/a-1675-0901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9018887PMC
October 2021

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed.

Am J Obstet Gynecol 2021 10 2;225(4):430.e1-430.e11. Epub 2021 Apr 2.

Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR.

Background: Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

Objective: The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

Study Design: This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

Conclusion: Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.
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http://dx.doi.org/10.1016/j.ajog.2021.03.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486887PMC
October 2021

Encounters between children's nurses and culturally diverse parents in primary health care.

Nurs Health Sci 2020 Jun 14;22(2):273-282. Epub 2020 Jan 14.

IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.

The objective of this study was to analyze the healthcare encounters between nurses and parents of different cultural backgrounds in primary health care. An ethnographic study was carried out using participant observations in health centers and interviews with nurses. Data were analyzed using thematic content analysis and constant comparative method. Four main themes were identified when nurses met parents of other cultural backgrounds: lack of mutual understanding, electronic records hamper the interaction, lack of professionals' cultural awareness and skills, and nurses establish superficial or distant relationships. The concepts of ethnocentrism and cultural imposition are behind these findings, hampering the provision of culturally competent care in primary health services. There were difficulties in obtaining and registering culturally related aspects that influence children's health and development. This was due to e-records, language barriers, and the lack of cultural awareness and skills in health professionals making the encounters difficult for both nurses and parents. These findings show that there is a clear threat for health equity and safety in primary care if encounters between nurses and parents do not improve to enable nursing care to be tailored to any individual family needs.
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http://dx.doi.org/10.1111/nhs.12683DOI Listing
June 2020

Daytime Compared With Nighttime Differences in Management and Outcomes of Postpartum Hemorrhage.

Obstet Gynecol 2019 01;133(1):155-162

Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, Columbia University, New York, New York, the University of Utah Health Sciences Center, Salt Lake City, Utah, the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, the University of Texas Southwestern Medical Center, Dallas, Texas, the University of Pittsburgh, Pittsburgh, Pennsylvania, The Ohio State University, Columbus, Ohio, the University of Alabama at Birmingham, Birmingham, Alabama, the University of Texas Medical Branch, Galveston, Texas, Wayne State University, Detroit, Michigan, Brown University, Providence, Rhode Island, the University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, Texas, and Oregon Health & Science University, Portland, Oregon; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To assess whether postpartum hemorrhage management or subsequent morbidity differs based on whether delivery occurred during the day or night.

Methods: We conducted a secondary analysis of a multicenter observational obstetric cohort of more than 115,000 mother-neonate pairs from 25 hospitals (2008-2011). This analysis included women delivering singleton or twin births who experienced postpartum hemorrhage (estimated blood loss greater than 500 cc for vaginal delivery, estimated blood loss greater than 1,000 cc for cesarean delivery, or documented treatment for postpartum hemorrhage). Nighttime delivery was defined as that occurring between 8 PM and 6 AM. The primary outcome was a composite of maternal morbidity (death, hysterectomy, intensive care unit admission, transfusion, or unanticipated procedure for bleeding). Secondary outcomes included estimated blood loss, uterotonic use, and procedures to treat bleeding that occurred during the postpartum hospitalization. Multivariable logistic, linear, quantile, and multinomial regression models were used to assess associations between nighttime delivery and outcomes, adjusting for potential patient-level confounders and hospital as a fixed effect.

Results: In total, 2,709 (34.2%) of 7,917 women with postpartum hemorrhage delivered at night. Women who delivered at night were younger, had a lower body mass index, and were more likely to have government-sponsored insurance, be nulliparous, have hypertension, use neuraxial analgesia, and deliver vaginally. After adjusting for potential confounders, the primary composite outcome of maternal morbidity was similar regardless of night compared with day delivery (15.5% night vs 17.5% day; adjusted odds ratio 0.89, 95% CI 0.77-1.03). Some secondary outcomes, including mean EBL, frequency of uterotonic use, and time from delivery to first uterotonic dose, differed on unadjusted analyses, but these associations did not persist in multivariable analysis. The study had limited power to assess differences in uncommon outcomes.

Conclusion: Nighttime delivery was not associated with significant differences in postpartum hemorrhage-related management or morbidity.
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http://dx.doi.org/10.1097/AOG.0000000000003033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309479PMC
January 2019

Variation in the Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rate.

Obstet Gynecol 2018 06;131(6):1039-1048

Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; Northwestern University, Chicago, Illinois; MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio; Columbia University, New York, New York; the University of Utah Health Sciences Center, Salt Lake City, Utah; the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the University of Texas Southwestern Medical Center, Dallas, Texas; the University of Pittsburgh, Pittsburgh, Pennsylvania; The Ohio State University, Columbus, Ohio; the University of Texas Medical Branch, Galveston, Texas; Wayne State University, Detroit, Michigan; Brown University, Providence, Rhode Island; the University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, Texas; Oregon Health & Science University, Portland, Oregon; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To estimate the contributions of patient and health care provider-hospital characteristics to the variation in the frequency of nulliparous, term, singleton, vertex cesarean delivery in a multi-institutional U.S. cohort.

Methods: We performed a secondary analysis of the multicenter Assessment of Perinatal Excellence cohort of 115,502 mother and neonatal pairs who were delivered at 25 hospitals between March 2008 and February 2011. Women met inclusion criteria if they were nulliparous and delivered a singleton in vertex presentation at term. Hospital ranks for nulliparous, term, singleton, vertex cesarean delivery frequency were determined after risk adjustment. The fraction of variation in nulliparous, term, singleton, vertex cesarean delivery frequency attributable to patient and health care provider-hospital characteristics was assessed using hierarchical logistic regression.

Results: Of the 115,502 deliveries in the initial cohort, 38,275 nulliparous, term, singleton, vertex deliveries met inclusion criteria. The median hospital nulliparous, term, singleton, vertex cesarean delivery frequency was 25.3% with a range from 15.0% to 35.2%. The majority of hospitals (16/25) changed rank quintiles after risk adjustment; overall the changes in rank were not statistically significant (P=.53). Patient characteristics accounted for 24% of the nulliparous, term, singleton, vertex cesarean delivery variation. The analyzed health care provider-hospital characteristics were not significantly associated with cesarean delivery frequency.

Conclusion: Although patient characteristics accounted for some of the variation in nulliparous, term, singleton, vertex cesarean delivery frequency and accounting for case mix had implications for hospital cesarean delivery rankings, the majority of the variation was not explained by the characteristics evaluated. These findings emphasize the importance of continued efforts to understand aspects of obstetric care, including case mix, that contribute to cesarean delivery variation.
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http://dx.doi.org/10.1097/AOG.0000000000002636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033063PMC
June 2018

Manipulating mentors' assessment decisions: Do underperforming student nurses use coercive strategies to influence mentors' practical assessment decisions?

Nurse Educ Pract 2016 Sep 28;20:154-62. Epub 2016 Aug 28.

Birmingham City University, Faculty of Health, Education and Life Sciences, City South Campus, Birmingham B15 3TN, United Kingdom.

There is growing evidence of a culture of expectation among nursing students in Universities which leads to narcissistic behaviour. Evidence is growing that some student nurses are disrespectful and rude towards their university lecturers. There has been little investigation into whether they exhibit similar behaviour towards their mentors during practical placements, particularly when they, the students, are not meeting the required standards for practice. This paper focuses on adding to the evidence around a unique finding - that student nurses can use coercive and manipulative behaviour to elicit a successful outcome to their practice learning assessment (as noted in Hunt et al. (2016, p 82)). Four types of coercive student behaviour were identified and classified as: ingratiators, diverters, disparagers and aggressors, each of which engendered varying degrees of fear and guilt in mentors. The effects of each type of behaviour are discussed and considered in the light of psychological contracts. Mechanisms to maintain effective working relationships between student nurses and mentors and bolster the robustness of the practical assessment process under such circumstances are discussed.
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http://dx.doi.org/10.1016/j.nepr.2016.08.007DOI Listing
September 2016

Failing securely: The processes and support which underpin English nurse mentors' assessment decisions regarding under-performing students.

Nurse Educ Today 2016 Apr 28;39:79-86. Epub 2016 Jan 28.

Birmingham City University, Faculty of Health, Education and Life Sciences, City South Campus, Birmingham B15 3TN, United Kingdom.

Background: This study was undertaken in response to concerns that mentors who assessed practical competence were reluctant to fail student nurses which generated doubts about the fitness to practise of some registered nurses. Limited evidence was available about the experiences of mentors who had failed underperforming students and what had helped them to do this.

Aim: To investigate what enabled some mentors to fail underperforming students when it was recognised that many were hesitant to do so.

Method: An ethically approved, grounded theory approach was used to explore thirty-one nurses' experiences of failing student nurses in practical assessments in England. Participants were recruited using theoretical sampling techniques. Semi-structured interviews were conducted. Analysis was undertaken using iterative, constant comparative techniques and reflexive processes. The theoretical framework which emerged had strong resonance with professionals.

Findings: Five categories emerged from the findings: (1) Braving the assessment vortex; (2) Identifying the 'gist' of underperformance; (3) Tempering Reproach; (4) Standing up to scrutiny; and (5) Drawing on an interpersonal network. These categories together revealed that mentors needed to feel secure to fail a student nurse in a practical assessment and that they used a three stage decision making process to ascertain if this was the case. Many of the components which helped mentors to feel secure were informal in nature and functioned on goodwill and local arrangements rather than on timely, formal, organisational systems. The mentor's partner/spouse and practice education facilitator or link lecturer were identified as the key people who provided essential emotional support during this challenging experience.

Conclusion: This study contributes to understanding of the combined supportive elements required for robust practical assessment. It presents a new explanatory framework about how mentors formulate the decision to fail a student nurse and the supportive structures which are necessary for this to occur.
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http://dx.doi.org/10.1016/j.nedt.2016.01.011DOI Listing
April 2016

Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes?

Am J Obstet Gynecol 2015 Jul 4;213(1):86.e1-86.e6. Epub 2015 Feb 4.

Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX.

Objective: We sought to evaluate whether the presence of condition-specific obstetric protocols within a hospital was associated with better maternal and neonatal outcomes.

Study Design: This was a cohort study of a random sample of deliveries performed at 25 hospitals over 3 years. Condition-specific protocols were collected from all hospitals and categorized independently by 2 authors. Data on maternal and neonatal outcomes, as well as data necessary for risk adjustment were collected. Risk-adjusted outcomes were compared according to whether the patient delivered in a hospital with condition-specific obstetric protocols at the time of delivery.

Results: Hemorrhage-specific protocols were not associated with a lower rate of postpartum hemorrhage or with fewer cases of estimated blood loss >1000 mL. Similarly, in the presence of a shoulder dystocia protocol, there were no differences in the frequency of shoulder dystocia or number of shoulder dystocia maneuvers used. Conversely, preeclampsia-specific protocols were associated with fewer intensive care unit admissions (odds ratio, 0.28; 95% confidence interval, 0.18-0.44) and fewer cases of severe maternal hypertension (odds ratio, 0.86; 95% confidence interval, 0.77-0.96).

Conclusion: The presence of condition-specific obstetric protocols was not consistently shown to be associated with improved risk-adjusted outcomes. Our study would suggest that the presence or absence of a protocol does not matter and regulations to require protocols are not fruitful.
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http://dx.doi.org/10.1016/j.ajog.2015.01.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485531PMC
July 2015

Life-long battle: Perceptions of type 2 diabetes in Thailand.

Chronic Illn 2015 Mar 6;11(1):56-68. Epub 2014 Mar 6.

Faculty of Nursing, Mahidol University, Bangkok, Thailand.

Background: The number of people in Thailand who have Type 2 diabetes has increased dramatically making it one of the country's major health problems. The rising prevalence of diabetes in Thailand is associated with dietary changes, reduced physical activity and health education. Although there is much research about health education programmes, the most effective methods for promoting sustainability and adherence to self-management among diabetics remains unclear.

Objectives: To examine the perceptions of participants in Thailand regarding Type 2 diabetes and to utilize the findings to formulate a model for patient education.

Methods: A grounded theory approach was selected and semi-structured face to face interviews and focus group were used to gather data from 33 adults with Type 2 diabetes.

Results: Five explanatory categories emerged from the data: causing lifelong stress and worry, finding their own ways, after a while, still cannot and wanting a normal life.

Conclusion: A new approach to patient education about Type 2 diabetes in Thailand is needed to give patients a better understanding, provide recommendations that they can apply to their daily lives, and include information about alternative medication. The Buddhist way of thinking and effective strategies enhancing self-efficacy should be applied to patient education to promote sustainability and adherence to self-management.
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http://dx.doi.org/10.1177/1742395314526761DOI Listing
March 2015

Developing cultural competence in palliative care.

Br J Community Nurs 2014 Feb;19(2):91-3

Professor of Diversity in Health and Social Care, De Montfort University.

Increasing ethnic or cultural diversity in the population served by health-care services requires improved competence and updated provision. Both individual staff and institutions need to reflect on and prepare to meet new challenges. Three key elements-reflective self-awareness, knowledge of others, and skills in managing difference-must be developed. Recognition of diversity and a database of appropriate information are essential for both workers and management of organisations. Above all, some preparedness for continual change and learning is essential. This article provides some suggestions and examples to assist with this.
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http://dx.doi.org/10.12968/bjcn.2014.19.2.91DOI Listing
February 2014

Haptoglobin phenotype and abnormal uterine artery Doppler in a racially diverse cohort.

J Matern Fetal Neonatal Med 2014 Nov 13;27(17):1728-33. Epub 2014 Jan 13.

Department of Obstetrics, Gynecology and Reproductive Science, Magee-Womens Research Institute, University of Pittsburgh , Pittsburgh, PA , USA .

Objective: The anti-oxidant and proangiogenic protein haptoglobin (Hp) is believed to be important for implantation and pregnancy, although its specific role is not known. The three phenotypes (1-1, 2-1 and 2-2) differ in structure and function. Hp 2-2 is associated with increased vascular stiffness in other populations. We examined whether Hp phenotype is associated with abnormal uterine artery Doppler (UAD) in pregnancy.

Methods: We conducted a secondary analysis of a preeclampsia prediction cohort nested within a larger placebo-controlled randomized clinical trial of antioxidants for prevention of preeclampsia. We determined Hp phenotype in 2184 women who completed UAD assessments at 17 weeks gestation. Women with notching were re-evaluated for persistent notching at 24 weeks' gestation. Logistic regression was used to assess differences in UAD indices between phenotype groups.

Results: Hp phenotype did not significantly influence the odds of having any notch (p = 0.32), bilateral notches (p = 0.72), or a resistance index (p = 0.28) or pulsatility index (p = 0.67) above the 90th percentile at 17 weeks' gestation. Hp phenotype also did not influence the odds of persistent notching at 24 weeks (p = 0.25).

Conclusions: Hp phenotype is not associated with abnormal UAD at 17 weeks' gestation or with persistent notching at 24 weeks.
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http://dx.doi.org/10.3109/14767058.2013.876622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4096612PMC
November 2014

Association of cord blood digitalis-like factor and necrotizing enterocolitis.

Am J Obstet Gynecol 2014 Apr 8;210(4):328.e1-328.e5. Epub 2013 Nov 8.

University of Pittsburgh School of Medicine, Pittsburgh, PA.

Objective: Endogenous digoxin-like factor (EDLF) has been linked to vasoconstriction, altered membrane transport, and apoptosis. Our objective was to determine whether increased EDLF in the cord sera of preterm infants was associated with an increased incidence of necrotizing enterocolitis (NEC).

Study Design: Cord sera from pregnant women enrolled in a randomized trial of MgSO4 for fetal neuroprotection were analyzed for EDLF using a red cell Rb(+) uptake assay in which the inhibition of sodium pump-mediated Rb(+) transport was used as a functional assay of EDLF. Specimens were assayed blinded to neonatal outcome. Cases (NEC, n = 25) and controls (neonates not developing stage 2 or 3 NEC, n = 24) were matched by study center and gestational age. None of the women had preeclampsia. Cases and controls were compared using the Wilcoxon test for continuous and the Fisher exact test for categorical variables. A conditional logistic regression analysis was used to assess the odds of case vs control by EDLF level.

Results: Cases and controls were not significantly different for gestational age, race, maternal steroid use, premature rupture of membranes, or MgSO4 treatment. In logistic models adjusted for treatment group, race, premature rupture of membranes, and gestational age, cord sera EDLF was significantly associated with development of NEC (P = .023).

Conclusion: These data demonstrated an association between cord sera EDLF and NEC.
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http://dx.doi.org/10.1016/j.ajog.2013.11.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4130335PMC
April 2014

Impact of C-peptide preservation on metabolic and clinical outcomes in the Diabetes Control and Complications Trial.

Diabetes 2014 Feb 2;63(2):739-48. Epub 2013 Oct 2.

The Biostatistics Center, The George Washington University, Rockville, MD.

The Diabetes Control and Complications Trial established that a stimulated C-peptide concentration ≥0.2 nmol/L at study entry among subjects with up to a 5-year diabetes duration is associated with favorable metabolic and clinical outcomes over the subsequent 7 years of follow-up. Herein we further examine the association of both fasting and stimulated C-peptide numerical values with outcomes. In the intensive treatment group, for a 50% higher stimulated C-peptide on entry, such as from 0.10 to 0.15 nmol/L, HbA1c decreased by 0.07% (0.8 mmol/mol; P = 0.0003), insulin dose decreased by 0.0276 units/kg/day (P < 0.0001), hypoglycemia risk decreased by 8.2% (P < 0.0001), and the risk of sustained retinopathy was reduced by 25% (P = 0.0010), all in unadjusted analyses. Other than HbA1c, these effects remained significant after adjusting for the HbA1c on entry. While C-peptide was not significantly associated with the incidence of nephropathy, it was strongly associated with the albumin excretion rate. The fasting C-peptide had weaker associations with outcomes. As C-peptide decreased to nonmeasurable concentrations, the outcomes changed in a nearly linear manner, with no threshold or breakpoint. While preservation of stimulated C-peptide at ≥0.2 nmol/L has clinically beneficial outcomes, so also does an increase in the concentration of C-peptide across the range of values.
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http://dx.doi.org/10.2337/db13-0881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900540PMC
February 2014

Developing cultural competence in palliative care.

Br J Community Nurs 2013 Jun;18(6):296-8

Brimingham City University, Leicester.

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http://dx.doi.org/10.12968/bjcn.2013.18.6.296DOI Listing
June 2013

Relationship of glycated albumin to blood glucose and HbA1c values and to retinopathy, nephropathy, and cardiovascular outcomes in the DCCT/EDIC study.

Diabetes 2014 Jan 29;63(1):282-90. Epub 2013 Aug 29.

Diabetes Unit and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

The association of chronic glycemia, measured by HbA(1c), with long-term complications of type 1 diabetes has been well established in the Diabetes Control and Complications Trial (DCCT) and other studies. The role of intermediate-term and acute glycemia and of glucose variability on microvascular and cardiovascular disease (CVD) is less clear. In order to examine the interrelationships among long-term, intermediate-term, and acute measures of glucose and its daily variability, we compared HbA(1c), glycated albumin (GA), and seven-point glucose profile concentrations measured longitudinally in a case-cohort subpopulation of the DCCT. HbA(1c) and GA were closely correlated with each other and with the mean blood glucose (MBG) calculated from the seven-point profile. The associations of glucose variability and postprandial concentrations with HbA(1c) and GA were relatively weak and were further attenuated when MBG was included in multivariate models. In the case-cohort analyses, HbA(1c) and GA had similar associations with retinopathy and nephropathy, which were strengthened when both measures were considered together. Only HbA(1c) was significantly associated with CVD. The demonstrated interrelationships among different measures of glycemia will need to be considered in future analyses of their roles in the development of long-term complications of type 1 diabetes.
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http://dx.doi.org/10.2337/db13-0782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868040PMC
January 2014

Haptoglobin genotype and the rate of renal function decline in the diabetes control and complications trial/epidemiology of diabetes interventions and complications study.

Diabetes 2013 Sep 12;62(9):3218-23. Epub 2013 Jun 12.

Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Many patients with type 1 diabetes develop renal disease despite moderately good metabolic control, suggesting other risk factors may play a role. Recent evidence suggests that the haptoglobin (HP) 2-2 genotype, which codes for a protein with reduced antioxidant activity, may predict renal function decline in type 1 diabetes. We examined this hypothesis in 1,303 Caucasian participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study. HP genotype was determined by polyacrylamide gel electrophoresis. Glomerular filtration rate was estimated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and albumin excretion based on timed urine samples. Participants were followed up for a mean of 22 years. HP genotype was significantly associated with the development of sustained estimated glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) and with end-stage renal disease (ESRD), with HP 2-2 having greater risk than HP 2-1 and 1-1. No association was seen with albuminuria. Although there was no treatment group interaction, the associations were only significant in the conventional treatment group, where events rates were much higher. We conclude that the HP genotype is significantly associated with the development of reduced GFR and ESRD in the DCCT/EDIC study.
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http://dx.doi.org/10.2337/db13-0256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749329PMC
September 2013

Haptoglobin phenotype, preeclampsia risk and the efficacy of vitamin C and E supplementation to prevent preeclampsia in a racially diverse population.

PLoS One 2013 3;8(4):e60479. Epub 2013 Apr 3.

Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America.

Haptoglobin's (Hp) antioxidant and pro-angiogenic properties differ between the 1-1, 2-1, and 2-2 phenotypes. Hp phenotype affects cardiovascular disease risk and treatment response to antioxidant vitamins in some non-pregnant populations. We previously demonstrated that preeclampsia risk was doubled in white Hp 2-1 women, compared to Hp 1-1 women. Our objectives were to determine whether we could reproduce this finding in a larger cohort, and to determine whether Hp phenotype influences lack of efficacy of antioxidant vitamins in preventing preeclampsia and serious complications of pregnancy-associated hypertension (PAH). This is a secondary analysis of a randomized controlled trial in which 10,154 low-risk women received daily vitamin C and E, or placebo, from 9-16 weeks gestation until delivery. Hp phenotype was determined in the study prediction cohort (n = 2,393) and a case-control cohort (703 cases, 1,406 controls). The primary outcome was severe PAH, or mild or severe PAH with elevated liver enzymes, elevated serum creatinine, thrombocytopenia, eclampsia, fetal growth restriction, medically indicated preterm birth or perinatal death. Preeclampsia was a secondary outcome. Odds ratios were estimated by logistic regression. Sampling weights were used to reduce bias from an overrepresentation of women with preeclampsia or the primary outcome. There was no relationship between Hp phenotype and the primary outcome or preeclampsia in Hispanic, white/other or black women. Vitamin supplementation did not reduce the risk of the primary outcome or preeclampsia in women of any phenotype. Supplementation increased preeclampsia risk (odds ratio 3.30; 95% confidence interval 1.61-6.82, p<0.01) in Hispanic Hp 2-2 women. Hp phenotype does not influence preeclampsia risk, or identify a subset of women who may benefit from vitamin C and E supplementation to prevent preeclampsia.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0060479PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3616124PMC
October 2013

Fall in C-peptide during first 2 years from diagnosis: evidence of at least two distinct phases from composite Type 1 Diabetes TrialNet data.

Diabetes 2012 Aug 11;61(8):2066-73. Epub 2012 Jun 11.

Benaroya Research Institute, Seattle, Washington, USA.

Interpretation of clinical trials to alter the decline in β-cell function after diagnosis of type 1 diabetes depends on a robust understanding of the natural history of disease. Combining data from the Type 1 Diabetes TrialNet studies, we describe the natural history of β-cell function from shortly after diagnosis through 2 years post study randomization, assess the degree of variability between patients, and investigate factors that may be related to C-peptide preservation or loss. We found that 93% of individuals have detectable C-peptide 2 years from diagnosis. In 11% of subjects, there was no significant fall from baseline by 2 years. There was a biphasic decline in C-peptide; the C-peptide slope was -0.0245 pmol/mL/month (95% CI -0.0271 to -0.0215) through the first 12 months and -0.0079 (-0.0113 to -0.0050) from 12 to 24 months (P < 0.001). This pattern of fall in C-peptide over time has implications for understanding trial results in which effects of therapy are most pronounced early and raises the possibility that there are time-dependent differences in pathophysiology. The robust data on the C-peptide obtained under clinical trial conditions should be used in planning and interpretation of clinical trials.
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http://dx.doi.org/10.2337/db11-1538DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402330PMC
August 2012

Sample size requirements for studies of treatment effects on beta-cell function in newly diagnosed type 1 diabetes.

PLoS One 2011 10;6(11):e26471. Epub 2011 Nov 10.

The Biostatistics Center, The George Washington University, Rockville, Maryland, United States of America.

Preservation of β-cell function as measured by stimulated C-peptide has recently been accepted as a therapeutic target for subjects with newly diagnosed type 1 diabetes. In recently completed studies conducted by the Type 1 Diabetes Trial Network (TrialNet), repeated 2-hour Mixed Meal Tolerance Tests (MMTT) were obtained for up to 24 months from 156 subjects with up to 3 months duration of type 1 diabetes at the time of study enrollment. These data provide the information needed to more accurately determine the sample size needed for future studies of the effects of new agents on the 2-hour area under the curve (AUC) of the C-peptide values. The natural log(x), log(x+1) and square-root (√x) transformations of the AUC were assessed. In general, a transformation of the data is needed to better satisfy the normality assumptions for commonly used statistical tests. Statistical analysis of the raw and transformed data are provided to estimate the mean levels over time and the residual variation in untreated subjects that allow sample size calculations for future studies at either 12 or 24 months of follow-up and among children 8-12 years of age, adolescents (13-17 years) and adults (18+ years). The sample size needed to detect a given relative (percentage) difference with treatment versus control is greater at 24 months than at 12 months of follow-up, and differs among age categories. Owing to greater residual variation among those 13-17 years of age, a larger sample size is required for this age group. Methods are also described for assessment of sample size for mixtures of subjects among the age categories. Statistical expressions are presented for the presentation of analyses of log(x+1) and √x transformed values in terms of the original units of measurement (pmol/ml). Analyses using different transformations are described for the TrialNet study of masked anti-CD20 (rituximab) versus masked placebo. These results provide the information needed to accurately evaluate the sample size for studies of new agents to preserve C-peptide levels in newly diagnosed type 1 diabetes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0026471PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213096PMC
May 2012

Serving within the British Army: research into mental health benefits.

Br J Nurs 2011 Oct 28-Nov 9;20(19):1256-61

British Army.

The mental health (MH) of soldiers remains extremely newsworthy and is regularly featured in high profile media forums that focus on post-traumatic stress disorder. However, the authors feel that there are distinct benefits to serving within the Army, and that it provides effective occupational medical, MH and welfare support. This research study explores potential benefits and stressors of being in the Army and provides an overview of Army mental health services (AMHS) through the perspectives of AMHS personnel, 84% of which were nurses. The study indicated that the Army can provide a protective community, sharing a bond based on common values and experiences. The Army can provide soldiers with career opportunities that are not available in civilian life, and there are opportunities to develop an employment profile, enhanced by internal and external educational training, and encapsulated within a progressive career pathway. The Army can also be seen to offer an escape route, preventing soldiers entering a life of crime, and supplying the stable family these soldiers had never experienced. The provision of leadership, within an environment where soldiers are valued and stigma is not tolerated can potentially shield against MH problems.
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http://dx.doi.org/10.12968/bjon.2011.20.19.1256DOI Listing
January 2012

Effect of rituximab on human in vivo antibody immune responses.

J Allergy Clin Immunol 2011 Dec 9;128(6):1295-1302.e5. Epub 2011 Sep 9.

Department of Surgery, Indiana University, Indianapolis, IN, USA.

Background: B-lymphocyte depletion with rituximab has been shown to benefit patients with various autoimmune diseases. We have previously demonstrated that this benefit is also apparent in patients with newly diagnosed type 1 diabetes.

Objectives: The effect of rituximab on in vivo antibody responses, particularly during the period of B-lymphocyte depletion, is incompletely determined. This study was designed to assess this knowledge void.

Methods: In patients with recent-onset type 1 diabetes treated with rituximab (n = 46) or placebo (n = 29), antibody responses to neoantigen phiX174 during B-lymphocyte depletion and with hepatitis A (as a second neoantigen) and tetanus/diphtheria (as recall antigens) after B-lymphocyte recovery were studied. Anti- tetanus, diphtheria, mumps, measles, and rubella titers were measured before and after treatment by means of ELISA. Antibody titers and percentage IgM versus percentage IgG to phiX174 were measured by means of phage neutralization. B-lymphocyte subsets were determined by means of flow cytometry.

Results: No change occurred in preexisting antibody titers. Tetanus/diphtheria and hepatitis A immunization responses were protective in the rituximab-treated subjects, although significantly blunted compared with those seen in the controls subjects, when immunized at the time of B-lymphocyte recovery. Anti-phiX174 responses were severely reduced during the period of B-lymphocyte depletion, but with B-lymphocyte recovery, anti-phiX174 responses were within the normal range.

Conclusions: During the time of B-lymphocyte depletion, rituximab recipients had a decreased antibody response to neoantigens and significantly lower titers after recall immunization with diphtheria and tetanus toxoid. With recovery, immune responses return toward normal. Immunization during the time of B-lymphocyte depletion, although ineffective, does not preclude a subsequent response to the antigen.
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http://dx.doi.org/10.1016/j.jaci.2011.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659395PMC
December 2011

Rituximab selectively suppresses specific islet antibodies.

Diabetes 2011 Oct 10;60(10):2560-5. Epub 2011 Aug 10.

Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado, USA.

Objective: The TrialNet Study Group evaluated rituximab, a B-cell-depleting monoclonal antibody, for its effect in new-onset patients with type 1A diabetes. Rituximab decreased the loss of C-peptide over the first year of follow-up and markedly depleted B lymphocytes for 6 months after administration. This article analyzes the specific effect of rituximab on multiple islet autoantibodies.

Research Design And Methods: A total of 87 patients between the ages of 8 and 40 years received either rituximab or a placebo infusion weekly for four doses close to the onset of diabetes. Autoantibodies to insulin (IAAs), GAD65 (GADAs), insulinoma-associated protein 2 (IA2As), and ZnT8 (ZnT8As) were measured with radioimmunoassays. The primary outcome for this autoantibody analysis was the mean level of autoantibodies during follow-up.

Results: Rituximab markedly suppressed IAAs compared with the placebo injection but had a much smaller effect on GADAs, IA2As, and ZnT8As. A total of 40% (19 of 48) of rituximab-treated patients who were IAA positive became IAA negative versus 0 of 29 placebo-treated patients (P < 0.0001). In the subgroup (n = 6) treated within 50 days of diabetes, IAAs were markedly suppressed by rituximab in all patients for 1 year and for four patients as long as 3 years despite continuing insulin therapy. Independent of rituximab treatment, the mean level of IAAs at study entry was markedly lower (P = 0.035) for patients who maintained C-peptide levels during the first year of follow-up in both rituximab-treated and placebo groups.

Conclusions: A single course of rituximab differentially suppresses IAAs, clearly blocking IAAs for >1 year in insulin-treated patients. For the patients receiving insulin for >2 weeks prior to rituximab administration, we cannot assess whether rituximab not only blocks the acquisition of insulin antibodies induced by insulin administration and/or also suppresses preformed insulin autoantibodies. Studies in prediabetic non-insulin-treated patients will likely be needed to evaluate the specific effects of rituximab on levels of IAAs.
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http://dx.doi.org/10.2337/db11-0674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178300PMC
October 2011

Increased T cell proliferative responses to islet antigens identify clinical responders to anti-CD20 monoclonal antibody (rituximab) therapy in type 1 diabetes.

J Immunol 2011 Aug 20;187(4):1998-2005. Epub 2011 Jul 20.

Department of Immunobiology, Yale University, New Haven, CT 06511, USA.

Type 1 diabetes mellitus is believed to be due to the autoimmune destruction of β-cells by T lymphocytes, but a single course of rituximab, a monoclonal anti-CD20 B lymphocyte Ab, can attenuate C-peptide loss over the first year of disease. The effects of B cell depletion on disease-associated T cell responses have not been studied. We compare changes in lymphocyte subsets, T cell proliferative responses to disease-associated target Ags, and C-peptide levels of participants who did (responders) or did not (nonresponders) show signs of β-cell preservation 1 y after rituximab therapy in a placebo-controlled TrialNet trial. Rituximab decreased B lymphocyte levels after four weekly doses of mAb. T cell proliferative responses to diabetes-associated Ags were present at baseline in 75% of anti-CD20- and 82% of placebo-treated subjects and were not different over time. However, in rituximab-treated subjects with significant C-peptide preservation at 6 mo (58%), the proliferative responses to diabetes-associated total (p = 0.032), islet-specific (p = 0.048), and neuronal autoantigens (p = 0.005) increased over the 12-mo observation period. This relationship was not seen in placebo-treated patients. We conclude that in patients with type 1 diabetes mellitus, anti-B cell mAb causes increased proliferative responses to diabetes Ags and attenuated β-cell loss. The way in which these responses affect the disease course remains unknown.
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http://dx.doi.org/10.4049/jimmunol.1100539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150302PMC
August 2011

Assessment of student nurses in practice: a comparison of theoretical and practical assessment results in England.

Nurse Educ Today 2012 May;32(4):351-5

Department of Practice Learning, Faculty of Health, Birmingham City University, B15 3TN, United Kingdom.

This study was undertaken in response to concerns raised by Duffy (2003) that assessors of practice were reluctant to fail student nurses in assessments. This generated doubts about the fitness to practice of some registered nurses. An investigation was undertaken into whether quantitative evidence supported the view that pre-registration nurses rarely failed practical assessments. Comparative failure rates from theoretical and practical assessments were requested from all 52 universities in England that offered pre-registration nursing programmes. Responses were received from 27. Findings indicated that a very small proportion of students failed practical assessments; failure rates for theory outstripped practice by a ratio of 5:1. A quarter of universities failed no students in practice. Students were most likely to fail in year one and least likely in year three. This study supports the belief that assessors of practice are reluctant to fail student nurses. It raises a number of questions about the influence that the systems and practices of professional bodies and universities have on practical assessment. However it also indicates that some student nurses have failed practical assessments and that some universities do have systems in place to address this issue.
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http://dx.doi.org/10.1016/j.nedt.2011.05.010DOI Listing
May 2012

Predisposing factors leading to depression in the British Army.

Br J Nurs 2010 Nov 25-Dec 8;19(21):1355-62

Post Graduate Department of Research, Birmingham City University.

Few studies have explored the predisposing factors leading to depression within the British Army, and this qualitative investigation provides a novel approach to advance knowledge in this poorly researched area. Information was provided by army mental health (MH) clinicians, with results aligned to theoretical groupings under the headings of: occupational stressors; macho culture, stigma and bullying; unhappy young soldier; relationships and gender. These issues were influenced by peacetime and operational settings; the support offered by the Army Medical Services and unit command. The results indicate that Army personnel are exposed to multi-factorial stressors that are incremental/accumulative in nature. Soldiers can cope with extreme pressures, often in hostile environments, but often cannot cope with a failing relationship. Officers were worried about the occupational implications of reporting ill, and the negative impact on their career, and might seek support from private civilian agencies, which have potentially dangerous ramifications as they may still deploy. GPs refer female soldiers more frequently for a mental health assessment because women express their emotions more openly then men. Young disillusioned soldiers who want to leave the Army form the main group of personnel accessing mental health support, although often they are not clinically depressed.
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http://dx.doi.org/10.12968/bjon.2010.19.21.80000DOI Listing
March 2011
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