Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community

Objectives Pacific Islanders are disproportionately burdened by poorer perinatal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. The aim of this study is to examine Marshallese mothers’ beliefs, perceptions, and experiences of prenatal care and to identify potential barriers. Methods Three focus groups were conducted with Marshallese mothers, who were 18 years or older, and living in Arkansas. Focus groups focused on mothers’ beliefs, perceptions, and experiences of prenatal care. A thematic qualitative analysis was conducted to identify salient themes within the data. Results The results demonstrated that negotiating health insurance, transportation, and language barriers were all major structural barriers that constrain prenatal care. The social–cultural barriers that emerged included a lack of understanding of the importance of seeking early and consistent prenatal care, as well as how to navigate the healthcare process. The more complicated challenges that emerged were the feelings of shame and embarrassment due to the perception of their age or being unmarried during pregnancy not being acceptable in American culture. Furthermore, the participants described perceived discrimination from prenatal care providers. Lastly, the participants described fear as a barrier to seeking out prenatal care. Conclusions for Practice This study identified both structural and socio-cultural barriers that can be incorporated into suggestions for policy makers to aid in alleviating maternal health disparities among Pacific Islander women. Further research is needed to address the Marshallese mothers’ perceived discrimination from maternal health care providers.     

Treatment efficacy of social communication skills training after traumatic brain injury: a randomized treatment and deferred treatment controlled trial

Dahlberg CA, Cusick CP, Hawley LA, Newman JK, Morey CE. Harrison-Felix CL, Whiteneck GG. Treatment efficacy of social communication skills training after traumatic brain injury: a randomized treatment and deferred treatment controlled trial.

Objective

To evaluate the efficacy of a replicable group treatment program to improve social communication skills after traumatic brain injury (TBI).

Design

Randomized treatment and deferred treatment controlled trial, with follow-up at 3, 6, and 9 months post-treatment.

Setting

Community.

Participants

Volunteer sample of 52 people with TBI who were at least 1 year postinjury, who received rehabilitation, and who had identified social communication deficits.

Intervention

Twelve weekly group sessions (1.5h each) to improve social communication.

Main Outcome Measures

The Profile of Functional Impairment in Communication (PFIC), Social Communication Skills Questionnaire–Adapted (SCSQ-A), Goal Attainment Scale (GAS), Craig Handicap Assessment and Reporting Technique–Short Form social integration and occupation subscales, Community Integration Questionnaire social integration and productivity subscales, and Satisfaction With Life Scale (SWLS).

Results

Independent samples t test analysis showed significant treatment effect compared with no treatment on 7 of 10 of the PFIC subscales (P range, .024 to <.001) and the SCSQ-A (P=.005) after the first 12 weeks of the study. After 12 weeks of treatment for all participants, repeated-measures analysis showed significant improvements from baseline on 9 of 10 PFIC subscales (P range, .01−.001), SCSQ-A (P≤.001), GAS (P≤.001), and SWLS (P=.011). At 6-month follow-up, scores were significantly better than baseline on 6 of 10 PFIC scales (P range, .01−.001), the SCSQ-A (P≤.001), GAS (P≤.001), and SWLS (P≤.001).

Conclusions

TBI subjects who received social communication skills training had improved communication skills that were maintained on follow-up. Overall life satisfaction for participants was improved.     

Home Telehealth Uptake and Continued Use Among Heart Failure and Chronic Obstructive Pulmonary Disease Patients: a Systematic Review

Background

Home telehealth has the potential to benefit heart failure (HF) and chronic obstructive pulmonary disease (COPD) patients, however large-scale deployment is yet to be achieved.

Purpose

The aim of this review was to assess levels of uptake of home telehealth by patients with HF and COPD and the factors that determine whether patients do or do not accept and continue to use telehealth.

Methods

This research performs a narrative synthesis of the results from included studies.

Results

Thirty-seven studies met the inclusion criteria. Studies that reported rates of refusal and/or withdrawal found that almost one third of patients who were offered telehealth refused and one fifth of participants who did accept later abandoned telehealth. Seven barriers to, and nine facilitators of, home telehealth use were identified.

Conclusions

Research reports need to provide more details regarding telehealth refusal and abandonment, in order to understand the reasons why patients decide not to use telehealth.     

Pulmonary arterial diastolic pressure in acute myocardial infarction

Pulmonary arterial diastolic pressure has been shown to be a reliable estimate of left ventricular filling pressure. In 91 patients with acute myocardial infarction, the Swan-Ganz flow-directed catheter was used to measure pulmonary arterial diastolic pressure, which was correlated with clinical and radiographic estimates of left ventricular failure. The physical findings of a third sound gallop and rales were significantly correlated with the level of pulmonary arterial diastolic pressure. In the absence of either a third sound gallop or rales, the pulmonary arterial diastolic pressure was found to be increased in 47 percent of the patients. The presence of rales was a less sensitive determinant of left ventricular dysfunction than a third sound gallop alone or in association with rales. Radiographic findings of increasing pulmonary congestion were significantly correlated with the level of pulmonary arterial diastolic pressure. In the absence of radiographic pulmonary congestion, 24 percent of patients had abnormal pulmonary arterial diastolic pressure. We conclude that measurement of pulmonary arterial diastolic pressure increases the objectivity of the clinical evaluation in patients with acute myocardial infarction.     

Effect of sustained insecticide-treated bed net use on all-cause child mortality in an area of intense perennial malaria transmission in western Kenya

We present results from a study conducted in western Kenya where all-cause child mortality was assessed among a population with high levels of sustained insecticide-treated bed net (ITN) use for up to six years. Although ITNs were associated with significant reductions in all-cause mortality among infants 1-11 months old, there was no difference in the rate of all-cause mortality among children 12-59 months old with ITNs for 2-4 years, compared historically with children from villages without ITNs, after controlling for seasonality and underlying child mortality across calendar years (adjusted hazard ratio [AHR] = 0.91, 95% confidence interval [CI] = 0.77-1.07). There was no increase in the proportion of child deaths at older ages (12-59 months old) of all child deaths within villages with ITNs for 5-6 years (48.1%) compared historically with villages without ITNs (47.9%), after controlling for seasonality (AHR = 1.03, P = 0.834). We find no evidence that sustained ITN use increased the risk of mortality in older children in this area of intense perennial malaria transmission.     

Stenotrophomonas maltophilia infection and colonization in the intensive care units of two community hospitals: A study of 143 patients

Study Objective: To study the epidemiology of Stenotrophomonas maltophilia infections in the intensive care units (ICUs) of community general hospitals. DESIGN: Retrospective chart review of 143 patients with cultures positive for S. maltophilia over a 2-year period. SETTING: Intensive care units of 2 community general hospitals. RESULTS: Patients with S. maltophilia infection or colonization were elderly (mean age 62.4 years), intubated for a mean of 11.8 days, and had a mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16.6. A tracheostomy was present in 22.4%, and underlying chronic respiratory disease and malignancy were found in 25.9% and 15.4%, respectively. Only 2 patients (1.4%) were neutropenic. Most isolates (89.5%) were from the respiratory tract and were part of a polymicrobial culture in 52. 5% of patients. Only a slightly higher APACHE II score (mean = 18.0, SD 7.8 vs mean = 15.6, SD 6.2, P = 0.052) differentiated patients with infection from those with colonization. All but 2 patients were exposed to antibiotics before their positive culture. Crude mortality rate was 41.3% overall and was significantly higher in those with an APACHE II score of 15 or more (48.8% vs 30.5%, P = 0. 028). CONCLUSION: S. maltophilia is emerging as an important cause of nosocomial infection, especially pneumonia, in ICUs of community general hospitals. Patients tend to be elderly, intubated for a mean of about 12 days, have high APACHE II scores, and frequently have a tracheostomy or underlying chronic respiratory disease. In contrast to earlier reports, neutropenia and underlying malignancy are uncommon in our ICU population. We found prior antibiotic exposure was almost universal and similar to previous reports, but use of imipenem was much less common in our community hospital patients. Patients with a high APACHE II score should be considered infected rather than colonized, but differentiation of infection from colonization remains problematic. Isolation of S. maltophilia from a patient carries a crude mortality rate of 41.3%, and patients with an APACHE II score of 15 or more have a significantly higher mortality rate than those with lesser scores, approaching 50%. Trimethoprim-sulfamethoxazole (TMP-SMX) remains the drug of choice for infections caused by S. maltophilia.     

Phosphorylation of cytosolic proteins by resting and activated human neutrophils

A study was conducted on the phosphorylation of proteins in the neutrophil cytosol in response to phorbol myristate acetate (PMA) and N- formyl-methionyl-leucyl-phenylalanine (fMLP). Autoradiography of gel electrophoretograms prepared from neutrophils incubated with 32Pi in the presence and absence of the activators showed nine proteins whose state of phosphorylation was affected by neutrophil activation. 32P was gained by eight of these proteins and was lost by the ninth. For all but one of these proteins, the change in the extent of labeling appeared to reach completion by one to two minutes. It was possible to quantitate the changes in 32P content of three of the nine proteins. One of these was the 20-kD protein that lost label when the neutrophils were activated. Quantitation showed that over half the 32P present in this protein in the resting state was gone within 0.2 minutes after activation. The other two were proteins weighing 11 and 69 kD. The phosphorylation characteristics of these two proteins differed, depending on whether activation had been carried out with PMA or fMLP. These differences in protein phosphorylation support other evidence suggesting that PMA and fMLP do not activate neutrophils by identical biochemical pathways. Differences in phosphorylation between resting and activated cells were not affected by dibutyryl cyclic guanosine monophosphate (cGMP), dibutyryl cyclic adenosine monophosphate (cAMP), theophylline, aspirin, hydrocortisone, or colchicine. The differences were abolished, however, by 30 mumol/L trifluoperazine. This finding is consistent with the hypothesis that the calcium/calmodulin system plays a biochemical role in the activation of neutrophils.     

Intracisternal A-particle genes as movable elements in the mouse genome.

We analyzed two functionally defective mouse kappa light chain gene variants previously shown to contain novel insertions of repetitive DNA in their intervening sequences [Hawley, R. G., Shulman, M. J., Murialdo, H., Gibson, D. M. & Hozumi, N. (1982) Proc. Natl. Acad. Sci. USA 79, 7425-7429]. Heteroduplex analysis of the cloned genes shows that the insertions consist of intracisternal A-particle (IAP) genetic elements. Each insertion includes an IAP 5' long terminal repeat (LTR) sequence and extends to a characteristic IAP internal BamHI site where the IAP sequence is interrupted because the mutant genes were cloned from complete BamHI digests of the cellular DNAs. Restriction enzyme mapping indicates that the 5' LTR boundaries of the inserted IAP elements correspond closely to the previously determined rearrangement sites in the mutant genes. The IAP insertions in the two mutants can be distinguished by restriction-site differences and by the fact that one of them contains a deletion that is absent in the other. Nucleotide sequence data are presented for the LTRs of one full-length IAP gene copy randomly selected from a mouse genomic DNA library. These LTRs show many features typical of known integrated retroviral terminal repeat units, and the entire gene is bracketed by short direct repeats within the adjacent cellular DNA. Thus, the findings show that IAP genetic elements can appear in new locations in mouse cellular DNA and suggest that this may occur through a process of proviral insertion.