Virginia Skinner

Factors that may influence midwives work-related stress and burnout

RESEARCH QUESTION To determine the incidence and level of work-related stress and burnout in midwives and contributing and protective demographic factors that may influence those levels. PARTICIPANTS AND METHOD All registered midwives (152) working in two public hospital maternity units within the same health service district in NSW completed the Maslach Burnout Inventory Human Services Survey and a demographic survey including care model, shift work, lifestyle data and exercise level. FINDINGS There was a response rate of 36.8% with 56 (56/152) midwives completing the surveys. Almost two thirds (60.7%) of midwives in this sample experienced moderate to high levels of emotional exhaustion, a third (30.3%) scoring low personal accomplishment and a third (30.3%) experiencing depersonalization related to burnout. Significant differences were found among groups of midwives according to years in the profession, shifts worked, how many women with multiple psychosocial issues were included in the midwifes workload and the midwifes uptake of physical exercise. Those midwives who had spent longer in the profession and exercised scored low burnout levels. CONCLUSION The impact of years in the profession, shifts worked, how many women with multiple psychosocial issues were included in their workload and the midwifes level of exercise significantly affected how these midwives dealt with burnout and provided care for women. As the response rate was low, and the study cannot be generalised to the entire midwifery workforce but provides important insights for further research. Understanding factors related to burnout can benefit health care institutions financially and in terms of human costs, especially in view of consistent international shortages of midwives.

TAS2R38 bitter taste genetics, dietary vitamin C, and both natural and synthetic dietary folic acid predict folate status, a key micronutrient in the pathoaetiology of adenomatous polyps

Taste perception may influence dietary preferences and nutrient intakes contributing to diet-related disease susceptibility. This study examined bitter taste genetics and whether variation in the TAS2R38 gene at three polymorphic loci (A49P, V262A and I296V) could alter dietary and systemic folate levels and dietary vitamin C intake, and whether a nutrigenetic circuit existed that might link bitter taste, folate/antioxidant status and risk for a colonic adenomatous polyp. TAS2R38 diplotype predicted bitter taste (PROP) phenotype (p value <0.00001) and red cell folate status (p=0.0179) consistent with the diplotype that has the broadest range of bitter perception (AVI/PAV) also possessing the highest average red cell folate value. However, TAS2R38 diplotype did not predict dietary intake of methylfolic acid, pteroylmonoglutamic acid or total folic acid. Neither did it predict dietary intake of vitamin C. Despite this, intake of dietary folate predicts red cell folate with analysis pointing to a key nutrient-nutrient interaction between vitamin C intake and systemic folate status. Analysis of 38 patients with an adenomatous polyp and 164 controls showed that individually, dietary nutrient intake, nutrient status and taste diplotype did not influence polyp risk. However, red cell folate status (in individuals below the population median value) did interact with bitter taste diplotype (AVI/PAV) to predict polyp risk (p=0.0145). Furthermore, synthetic folic acid (below median intake) was statistically associated with adenoma occurrence (p=0.0215); individuals with adenomatous polyps had a 1.77× higher intake than controls. Additionally, stepwise regression taking account of all dietary nutrients showed a tight relationship between methylfolic acid (but not pteroylmonoglutamic acid) intake and red cell folate level in those with a low folate status and occurrence of an adenomatous polyp (p=0.0039). These findings point to a role for folate in the pathoaetiology of adenomatous polyps, with the natural and synthetic vitamers not necessarily having the same biological effect.

Methylation diet and methyl group genetics in risk for adenomatous polyp occurrence

Purpose The aim of this study is to explore whether a methylation diet influences risk for adenomatous polyps (AP) either independently, or interactively with one-carbon metabolism-dependent gene variants, and whether such a diet modifies blood homocysteine, a biochemical phenotype closely related to the phenomenon of methylation. Methods 249 subjects were examined using selective fluorescence, PCR and food frequency questionnaire to determine homocysteine, nine methylation-related gene polymorphisms, dietary methionine, 5-methyltetrahydrofolate, vitamins B6 and B12. Results 1). Both dietary methionine and 5-methyltetrahydrofolate intake are significantly associated with plasma homocysteine. 2). Dietary methionine is related to AP risk in 2R3R-TS wildtype subjects, while dietary B12 is similarly related to this phenotype in individuals heterozygous for C1420T-SHMT, A2756G-MS and 844ins68-CBS, and in those recessive for 2R3R-TS. 3). Dietary methionine has a marginal influence on plasma homocysteine level in C1420T-SHMT heterozygotes, while B6 exhibits the same effect on homocysteine in C776G-TCN2 homozygote recessive subjects. Natural 5-methyltetrahydrofolate intake is interesting: Wildtype A1298C-MTHFR, heterozygote C677T-MTHFR, wildtype A2756G-MS and recessive A66G-MSR individuals all show a significant reciprocal association with homocysteine. 4). Stepwise regression of all genotypes to predict risk for AP indicated A2756G-MS and A66G-MSR to be most relevant (p = 0.0176 and 0.0408 respectively). Results were corrected for age and gender. Conclusion A methylation diet influences methyl group synthesis in the regulation of blood homocysteine level, and is modulated by genetic interactions. Methylation-related nutrients also interact with key genes to modify risk of AP, a precursor of colorectal cancer. Independent of diet, two methylation-related genes (A2756G-MS and A66G-MSR) were directly associated with AP occurrence.

Interferon treatment for chronic hepatitis C : a family impact study

Hepatitis C virus is estimated to affect 170 million people worldwide. Infection can lead to cirrhosis, liver failure, or liver cancer. Hepatitis C is unique among chronic illnesses, in that potentially curative treatment is available. Therapy is of prolonged duration and associated with multiple physiological and psychological side effects. These side effects have the potential to impact not only the individual receiving therapy but also their family and the day-to-day functioning of the family unit. This paper describes data and findings obtained from a family impact study instigated to explore the repercussions of interferon treatment for chronic hepatitis C on family life, from both the perspectives of individuals who had received treatment and their family members. An exploratory study was conducted using semi-structured focus groups. Findings reveal the treatment impacted on physical, emotional, relational, and financial domains. The major themes identified were resilience, loss, hardship, anger and irritability, and secrecy. The side-effect profile of therapy exerted significant and previously unforeseen impacts on family relationships, both negatively and positively. Treatment receivers tended to view their experiences as having more adverse impact, while family members, although affected, demonstrated considerable resilience and coping.

A feasibility randomised controlled trial of acupressure to assist spontaneous labour for primigravid women experiencing a post-date pregnancy

OBJECTIVE this Australian feasibility study aimed to determine; the willingness of women experiencing a post-date pregnancy to participate in a randomised controlled trial (RCT) of acupressure and compliance with the study protocol. The study also aimed to determine the effect size of the primary outcome in order to calculate a sample size for a future appropriately powered RCT. DESIGN a two-arm randomised controlled trial. Staff providing clinical care were blinded to group allocation unless the participant disclosed study participation. SETTING maternity services at two outer metropolitan public hospitals in New South Wales, Australia PARTICIPANTS sixty seven healthy primigravid women experiencing a singleton cephalic pregnancy at 40 weeks±2 days gestation were assessed as eligible to participate and were provided with study information. INTERVENTION both groups received standard clinical care, with the intervention group also receiving verbal and written instructions on the self-administration of three acupoints (Spleen 6, Large Intestine 4, and Gall Bladder 21) to be used until spontaneous or induced labour began. MEASUREMENTS assessment of feasibility included determining recruitment rate and acceptability of an RCT for a CAM modality, and acupressure treatment compliance, via participant surveys. The primary clinical outcome was spontaneous onset of labour. FINDINGS from the 67 women eligible during the timeframe for the study, 44 women (65.6%) agreed to participate and were randomised. There was no statistically significant difference in rate of spontaneous onset of labour (50% acupressure vs 41% control). Twenty nine participant surveys were returned (65.9%). In the intervention group there was a high compliance with the acupressure protocol (83%) and the use of the three acupoints (94%). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE this feasibility study revealed that pregnant women are interested in the use of CAM, and acupressure in particular, for the initiation of labour. Most women found it acceptable to be randomised to receive the intervention. While the 9% difference in the primary outcome was not statistically significant it is the best estimate of the treatment effect for calculating a sample size of 994 for a future RCT with 80% power, alpha 0.05. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Register (ANZCTR): ANZCTR:12613000145707.

Mifepristone by prescription: not quite a reality in the Northern Territory of Australia

Drs. Grossman and Goldstones [1] commentary in Contraception discussed the prescribing requirements of mifepristone and lamented its slow uptake, comparing the United States (USA) with Australia. It suggested that Australia was ahead of the USA. We support and provide abortion services and legal research in Australia and use our local knowledge to correct this commentary. Sadly the hope that Australia is leading the USA in womens health care is false. The maps in Grossman and Goldstones commentary imply full coverage in the Northern Territory with reference to ‘certified prescribers’ and ‘pharmacist dispensers’. This may be accurate in terms of numbers of professional certification at the time the maps were produced but it is not accurate in terms of access to mifepristone for early medical abortion. This is for two reasons: firstly, finding professionally qualified health care professionals to work in the Territory is difficult and those who do often stay for short periods of time. Commonly there are fewer than four doctors providing a surgical service. Secondly, current legislation is prohibitive so that mifepristone is not prescribed at all for first trimester abortion [2]. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines on mifepristone use for medical abortion recently removed the requirement that mifepristone be administered in the presence of the doctor. However, section 208B of the Northern Territory Criminal Code provides a criminal offence of ‘procuring abortion’. A person is guilty of an offence if the person administers a drug to a woman or causes a drug to be taken by a woman. Explanatory notes in section 11 of the Medical Services Act (MSA) [3] state, it is lawful for a medical practitioner to give medical treatment with the intention of terminating a womans pregnancy. However, ‘medical treatment’ is defined to include all forms of surgery. The MSA also specifically provides that the treatment is given in a hospital and other restrictive provisions relating to consent and the opinions for treatment be formed by a gynecologist/obstetrician, thus limiting service provision. In practice surgical termination of pregnancy only occurs in three hospitals located in Darwin and Alice Springs that are 1500 km apart. There is no provision of early medical abortion for suburban, rural or remote communities, whatever their local health provider may have by way of certification. On insurance advice doctors do not prescribe mifepristone for early medical abortion in general practices, remote area clinics or clinical settings such as outpatient or day surgery models. Women need to travel long distances to reach surgical abortion services. Similarly in the state of South Australia, criminal law provisions restrict abortion treatment to prescribed hospitals, only five of which have established medication abortion services. It follows that the Grossman and Goldstone suggestion that large parts of Australia have doctor prescribers and pharmacists widely available who supply mifepristone is misleading. The laws are impediments to best practice. Despite our correction, we join with Drs. Grossman and Goldstone in the disappointment that womens reproductive health rights are so poorly observed.

Gene-Nutrient Interaction between Folate and Dihydrofolate Reductase in Risk for Adenomatous Polyp Occurrence: A Preliminary Report.

Folate and related gene variants are significant risk factors in the aetiology of colorectal cancer. Dihydrofolate reductase (DHFR) is critical in the metabolism of synthetic folic acid (pteroylmonoglutamatamic, PteGlu) to tetrahydrofolate following absorption. Therefore, the 19bp deletion variant of DHFR may lead to the alteration of folate-related colorectal disease susceptibility. This study examined the association between PteGlu and 19bp del-DHFR, and adenomatous polyp (AP) occurrence, an antecedent of colorectal cancer. A total of 199 subjects (162 controls and 37 AP cases) were analysed to determine dietary intake of total folate, natural methylfolate and synthetic PteGlu, level of erythrocyte folate and plasma homocysteine (tHcy), and genotype of 19bp del-DHFR. Dietary folate intake, erythrocyte folate, tHcy and 19bp del-DHFR variants did not independently predict the occurrence of AP. However, a gene-nutrient interaction was observed when subjects were stratified according to dietary folate intake. In subjects with a folate intake above the median value due to significant dietary PteGlu content, the presence of the 19bp-deletion allele decreased the risk for AP (OR=0.35, 95% CI: 0.13-0.97). However, such association was not evident in individuals with a folate intake below the median value. In conclusion, the finding suggests that folate nutrition and 19bp del-DHFR variation may interact to modify AP risk.

Design, rationale and feasibility of a multidimensional experimental protocol to study early life stress

There is a rapidly accumulating body of evidence regarding the influential role of early life stress (ELS) upon medical and psychiatric conditions. While self-report instruments, with their intrinsic limitations of recall, remain the primary means of detecting ELS in humans, biological measures are generally limited to a single biological system. This paper describes the design, rationale and feasibility of a study to simultaneously measure neuroendocrine, immune and autonomic nervous system (ANS) responses to psychological and physiological stressors in relation to ELS. Five healthy university students were recruited by advertisement. Exclusion criteria included chronic medical conditions, psychotic disorders, needle phobia, inability to tolerate pain, and those using anti-inflammatory medications. They were clinically interviewed and physiological recordings made over a two-hour period pre, during and post two acute stressors: the cold pressor test and recalling a distressing memory. The Childhood Trauma Questionnaire and the Parental Bonding Index were utilised to measure ELS. Other psychological measures of mood and personality were also administered. Measurements of heart rate, blood pressure, respiratory rate, skin conductance, skin blood flow and temporal plasma samples were successfully obtained before, during and after acute stress. Participants reported the extensive psychological and multisystem physiological data collection and stress provocations were tolerable. Most (4/5) participants indicated a willingness to return to repeat the protocol, indicating acceptability. Our protocol is viable and safe in young physically healthy adults and allows us to assess simultaneously neuroendocrine, immune and autonomic nervous system responses to stressors in persons assessed for ELS.

Genetic Variation in Glutamate Carboxypeptidase II and Interaction with Dietary Natural Vitamin C May Predict Risk for Adenomatous Polyp Occurrence.

BACKGROUND The C1561T variant of the glutamate carboxypeptidase II (GCPII) gene is critical for natural methylfolylpolyglutamte (methylfolate) absorption, and has been associated with perturbations in folate metabolism and disease susceptibility. However, little is known on C1561T-GCPII as a risk factor for colorectal cancer. Therefore, this study examined whether C1561T-GCPII influences folate metabolism and adenomatous polyp occurrence. MATERIALS AND METHODS 164 controls and 38 adenomatous polyp cases were analysed to determine blood folate and plasma homocysteine (Hcy) level, dietary intake of natural methylfolate, synthetic pteroylglutamic acid (PteGlu), vitamin C and C1561T-GCPII genotype. RESULTS In controls and cases, 7.3 and 18.4 percent of subjects respectively, were found to have the CT genotype, increasing the risk for adenomatous polyp occurrence 2.86 times (95% CI:1.37-8.0, p=0.035). Total dietary folate, methylfolate and PteGlu intake and the level of erythrocyte folate and plasma Hcy did not predict the occurrence of an adenomatous polyp. However, dietary natural vitamin C intake was associated with adenomatous polyp risk within C1561T-GCPII CT genotype subjects (p=0.037). CONCLUSIONS The findings suggest that C1561T-GCPII variation may be associated with risk for adenomatous polyp, and vitamin C may modify risk by interacting with the variant gene, its expression product and/or folate substrates.