Quiet Time to Increase Breastfeeding Rates and Enhance Women’s Hospital Experiences in the Postpartum Period

ObjectiveTo facilitate optimal hospital experiences and breastfeeding clinical outcomes among women by reducing interruptions during their first 24 hours in the postpartum period.DesignEvidence-based practice change initiated by a registered nurse staff member.Setting/Local ProblemThere was concern that numerous visitor and staff interruptions to women during their early postpartum hours were interfering with establishing breastfeeding and maintaining a restful environment on our 21-bed postpartum unit within a 377-bed, Magnet-recognized, religiously affiliated hospital in suburban southern California.ParticipantsMedically stable women with uncomplicated childbirth during the previous 24 hours and women in the postpartum period whose responses were recorded in facility databases maintained by the departments of Lactation Services and Nursing Research.Intervention/MeasurementsA daily quiet time from 1:00 p.m. to 3:00 p.m. was instituted on the postpartum unit. Measurements before and after implementing quiet time included data on (a) interruptions, as the number of times someone opened or entered women’s room doors; (b) exclusive breastfeeding rates; and (c) women’s postdischarge reports of their hospital experiences.ResultsAfter quiet time was implemented, interruptions fell from an average of 74 to an average of 37 per day (n = 21, p = .02), and the percentage of women breastfeeding rose from 34% to 48% (n = 193, p = .39). Women’s ratings of unit quietness improved significantly (n = 169, p = .008) to above the benchmark, and their overall facility rating and willingness to recommend the facility remained above the benchmark on surveys from the Hospital Consumer Assessment of Healthcare Providers and Systems.ConclusionA daily afternoon quiet time for women hospitalized in the postpartum period may reduce interruptions to women and thereby potentially increase breastfeeding rates and improve women’s perceptions of their hospital experiences. Unsolicited reports from staff suggested that quiet time was well received by nurses providing postpartum care.     

RESILIENCE AND RECOVERY IN AMERICAN SĀMOA: A CASE STUDY OF THE 2009 SOUTH PACIFIC TSUNAMI

Case study methodology was used to explore the culturally situated response and recovery efforts following a tsunami in American Sāmoa. Data indicated that cultural mechanisms were effective in meeting physical needs but insufficient to manage the emotional trauma caused by such a large‐scale event. Samoan cultural norms strongly discourage uncontrolled emotional expression outside of ritualized grieving events. Disruptions in social networks and activities, combined with a lack of available emotional support, resulted in significant psychological distress for many survivors. Sixteen months after the tsunami residents continued to exhibit numerous symptoms of posttraumatic stress. In response to this need for emotional support, some groups within American Sāmoa are setting an example of how their culture can adapt by forging new, culturally grounded methods for addressing emotional needs that arose in the wake of the tsunami. Findings are analyzed through the lens of the social support deterioration deterrence model and activity settings theory.     

HLA-DRB1 alleles control allergic bronchopulmonary aspergillosis-like pulmonary responses in humanized transgenic mice

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) is a lung hypersensitivity disease mediated in part by CD4(+) T(H)2 cells. There is a significant association between ABPA and the HLA-DR2 genotypes DRB1(*)1501 and DRB1(*)1503, whereas resistance might be associated with HLA-DRB1(*)1502. OBJECTIVE: We sought to elucidate the role of HLA-DR alleles in allergic inflammation in lungs. METHODS: HLA-DR humanized transgenic mice expressing either the susceptible or resistant alleles were analyzed for the nature and extent of pulmonary inflammation after exposure to Aspergillus species antigens. RESULTS: Exposed DRB1(*)1501 and DRB1(*)1503 transgenic mice displayed infiltrates made up prominently of eosinophils, which is consistent with the inflammation found in ABPA. The resistant DRB1(*)1502 mice, on the other hand, displayed minimal to moderate inflammation, consisting mainly of T-cell infiltrates. Significantly more mucin was produced in the DRB1(*)1503 and DRB1(*)1501 mice, and their ability to limit the number of Aspergillus species conidia within the lung parenchyma was impaired. Despite their differences, both the DRB1(*)1503 and DRB1(*)1502 strains mounted comparable T cell-proliferative responses to Aspergillus species antigens. CONCLUSION: The HLA-DR2 alleles DRB1(*)1501 and DRB1(*)1503 play a major role in the development of allergic pulmonary inflammation. In contrast, the HLA-DR2 allele DRB1(*)1502 mediates a nonallergic T(H)1-like response to the organism, possibly explaining an ABPA resistance factor. These results are in support of our published human studies in patients with cystic fibrosis and asthma. CLINICAL IMPLICATIONS: HLA-DR typing in patients with cystic fibrosis and asthma will aid in the identification of individuals at risk for ABPA.     

Fear-avoidance beliefs—a moderator of treatment efficacy in patients with low back pain: a systematic review

Background contextPsychological factors are believed to influence the development of chronic low back pain. To date, it is not known how fear-avoidance beliefs (FABs) influence the treatment efficacy in low back pain.PurposeTo summarize the evidence examining the influence of FABs measured with the Fear-Avoidance Belief Questionnaire or the Tampa Scale of Kinesiophobia on treatment outcomes in patients with low back pain.Study design/settingThis is a systematic review.Patient samplePatients with low back pain.Outcome measuresWork-related outcomes and perceived measures including return to work, pain, and disability.MethodsIn January 2013, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. A hand search of the six most often retrieved journals and a bibliography search completed the search. Study eligibility criteria, participants, and interventions: research studies that included patients with low back pain who participated in randomized controlled trials (RCTs) investigating nonoperative treatment efficacy. Out of 646 records, 78 articles were assessed in full text and 17 RCTs were included. Study quality was high in five studies and moderate in 12 studies.ResultsIn patients with low back pain of up to 6 months duration, high FABs were associated with more pain and/or disability (4 RCTs) and less return to work (3 RCTs) (GRADE high-quality evidence, 831 patients vs. 322 in nonpredictive studies). A decrease in FAB values during treatment was associated with less pain and disability at follow-up (GRADE moderate evidence, 2 RCTs with moderate quality, 242 patients). Interventions that addressed FABs were more effective than control groups based on biomedical concepts (GRADE moderate evidence, 1,051 vs. 227 patients in studies without moderating effects). In chronic patients with LBP, the findings were less consistent. Two studies found baseline FABs to be associated with more pain and disability and less return to work (339 patients), whereas 3 others (832 patients) found none (GRADE low evidence). Heterogeneity of the studies impeded a pooling of the results.ConclusionsEvidence suggests that FABs are associated with poor treatment outcome in patients with LBP of less than 6 months, and thus early treatment, including interventions to reduce FABs, may avoid delayed recovery and chronicity. Patients with high FABs are more likely to improve when FABs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if FABs are present.     

An adenoviral vector deleted for all viral coding sequences results in enhanced safety and extended expression of a leptin transgene

Adenoviral (Ad)-mediated in vivo gene transfer and expression are limited in part by cellular immune responses to viral-encoded proteins and/or transgene immunogenicity. In an attempt to diminish the former responses, we have previously developed and described helper-dependent (HD) Ad vectors in which the viral protein coding sequences are completely eliminated. These HD vectors have up to 37 kb insert capacity, are easily propagated in a Cre recombinase-based system, and can be produced to high concentration and purity (>99.9% helper-free vector). In this study, we compared safety and efficacy of leptin gene delivery mediated by an HD vector (HD-leptin) and a first-generation E1-deleted Ad vector (Ad-leptin) in normal lean and ob/ob (leptin-deficient) mice. In contrast to evidence of liver toxicity, inflammation, and cellular infiltration observed with Ad-leptin delivery in mice, HD-leptin delivery was associated with a significant improvement in associated safety/toxicity and resulted in efficient gene delivery, prolonged elevation of serum leptin levels, and associated weight loss. The greater safety, efficient gene delivery, and increased insert capacity of HD vectors are significant improvements over current Ad vectors and represent favorable features especially for clinical gene therapy applications.     

Clinical utility of the reticulocyte hemoglobin content in the diagnosis of iron deficiency

Determination of the reticulocyte hemoglobin content (CHr) provides an early measure of functional iron deficiency because reticulocytes are the earliest erythrocytes released into blood and circulate for only 1 to 2 days. The CHr in 78 patients undergoing bone marrow examination was measured to assess its clinical utility for the diagnosis of iron deficiency. Twenty-eight patients were iron deficient, based on the lack of stainable iron in the aspirate. The diagnostic power of CHr is limited in patients with high mean cellular volume (MCV) or red cell disorders such as thalassemia. However, when patients with MCV more than 100 fL are excluded, receiver operator curve analysis of CHr, ferritin, transferrin saturation, and MCV demonstrates that CHr has the highest overall sensitivity and specificity of these peripheral blood tests for predicting the absence of bone marrow iron stores.