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First published online: 09 March 2021 The Tuscan poet, playwright and democratic activist Filippo Pananti (1766–1837) was captured by Algerian corsairs in the Mediterranean on his way back to Italy from England in 1813 and was briefly held captive before being released thanks to the intervention of a British diplomat. He published a highly coloured and melodramatic account of his sufferings, together with a description of the country, in 1817; the work, called Avventure ed osservazioni sopra le coste di Barberia, went through several editions and was translated into English, French and German. This article studies Pananti’s extremely hostile view of Algeria, which draws on many earlier writings about the country and reproduces contemporary racial, political and religious stereotypes about the Muslim world. It also throws light on the contemporary international context of his call for a European expedition to free the Mediterranean of North African pirates and liberate the Christian ‘slaves’ in Algeria.

The scandalous French materialist Julien Offray de La Mettrie (1709-51) is often said to have had close links to Émilie du Châtelet. This chapter looks at the supposed evidence, showing first of all that certain remarks in his writings have mistakenly been taken to be references to du Châtelet. The main discussion concerns a ‘Lettre critique’ addressed to her, published under La Mettrie’s name as an introduction to a new edition of his Histoire naturelle de l’âme in 1747. The attribution to La Mettrie is here questioned on the basis of a detailed study of the content and argument of the letter and his use of du Châtelet’s writings in the work itself.

Escape variants of SARS-CoV-2 are threatening to prolong the COVID-19 pandemic. To address this challenge, we developed multivalent protein-based minibinders as potential prophylactic and therapeutic agents. Homotrimers of single minibinders and fusions of three distinct minibinders were designed to geometrically match the SARS-CoV-2 spike (S) trimer architecture and were optimized by cell-free expression and found to exhibit virtually no measurable dissociation upon binding. Cryo-electron microscopy (cryoEM) showed that these trivalent minibinders engage all three receptor binding domains on a single S trimer. The top candidates neutralize SARS-CoV-2 variants of concern with IC50 values in the low pM range, resist viral escape, and provide protection in highly vulnerable human ACE2-expressing transgenic mice, both prophylactically and therapeutically. Our integrated workflow promises to accelerate the design of mutationally resilient therapeutics for pandemic preparedness., One-Sentence Summary: We designed, developed, and characterized potent, trivalent miniprotein binders that provide prophylactic and therapeutic protection against emerging SARS-CoV-2 variants of concern.

The ancient Greek philosopher Epicurus (340–271 bce), though often despised for his materialism, hedonism, and denial of the immortality of the soul, has at the same time been an ongoing source of inspiration for a great variety of subsequent philosophers, poets, and political thinkers. This volume offers authoritative discussions of all aspects of Epicurus’s philosophy and then traces out some of its most important later influences throughout the Western intellectual tradition. Epicurean arguments are carefully placed in their ancient and subsequent intellectual contexts, thus offering readers the opportunity of measuring them against a wide range of opponents—from Platonists, Aristotelians, and Stoics, to Hegel and Nietzsche, and finally on to such influential contemporary philosophers as Thomas Nagel, Bernard Williams, and Jacques Derrida. The volume offers separate and detailed discussions of two fascinating and ongoing sources of Epicurean arguments, the Herculaneum papyri and the inscription of Diogenes of Oenoanda, both of which are continually enriching our understanding of Epicureanism. Contributors have been able to make ample use of this new evidence in presenting the most current understanding of Epicurus’s own views. By the same token, the second half of the volume is devoted to the extraordinary influence of Epicurean doctrines, often either neglected or misunderstood, in literature, political thought, scientific innovation, and in philosophy generally. Taken together, the contributions in this volume offer the most comprehensive and detailed account of Epicurus and Epicureanism available in English.

Multi-pass membrane proteins are important targets of biologic medicines. Given the inherent difficulties in working with membrane proteins, we sought to investigate the utility of membrane scaffold protein nanodiscs as a means of solubilizing membrane proteins to aid antibody discovery. Using a model multi-pass membrane protein, we demonstrate how incorporation of a multi-pass membrane protein into nanodiscs can be used in flow cytometry to identify antigen-specific hybridoma. The use of target protein-loaded nanodiscs to sort individual hybridoma early in the screening process can reduce the time required to identify antibodies against multi-pass membrane proteins.

BackgroundThe UK guideline recommends 3-yearly surveillance for patients with intermediate-risk (IR) adenomas. No study has examined whether or not this group has heterogeneity in surveillance needs.ObjectivesTo examine the effect of surveillance on colorectal cancer (CRC) incidence; assess heterogeneity in risk; and identify the optimum frequency of surveillance, the psychological impact of surveillance, and the cost-effectiveness of alternative follow-up strategies.DesignRetrospective multicentre cohort study.SettingRoutine endoscopy and pathology data from 17 UK hospitals (n = 11,944), and a screening data set comprising three pooled cohorts (n = 2352), followed up using cancer registries.SubjectsPatients with IR adenoma(s) (three or four small adenomas or one or two large adenomas).Primary outcomesAdvanced adenoma (AA) and CRC detected at follow-up visits, and CRC incidence after baseline and first follow-up.MethodsThe effects of surveillance on long-term CRC incidence and of interval length on findings at follow-up were examined using proportional hazards and logistic regression, adjusting for patient, procedural and polyp characteristics. Lower-intermediate-risk (LIR) subgroups and higher-intermediate-risk (HIR) subgroups were defined, based on predictors of CRC risk. A model-based cost–utility analysis compared 13 surveillance strategies. Between-group analyses of variance were used to test for differences in bowel cancer worry between screening outcome groups (n = 35,700). A limitation of using routine hospital data is the potential for missed examinations and underestimation of the effect of interval and surveillance.ResultsIn the hospital data set, 168 CRCs occurred during 81,442 person-years (pys) of follow-up [206 per 100,000 pys, 95% confidence interval (CI) 177 to 240 pys]. One surveillance significantly lowered CRC incidence, both overall [hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77] and in the HIR subgroup (n = 9265; HR 0.50, 95% CI 0.34 to 0.76). In the LIR subgroup (n = 2679) the benefit of surveillance was less clear (HR 0.62, 95% CI 0.16 to 2.43). Additional surveillance lowered CRC risk in the HIR subgroup by a further 15% (HR 0.36, 95% CI 0.20 to 0.62). The odds of detecting AA and CRC at first follow-up (FUV1) increased by 18% [odds ratio (OR) 1.18, 95% CI 1.12 to 1.24] and 32% (OR 1.32, 95% CI 1.20 to 1.46) per year increase in interval, respectively, and the odds of advanced neoplasia at second follow-up increased by 22% (OR 1.22, 95% CI 1.09 to 1.36), after adjustment. Detection rates of AA and CRC remained below 10% and 1%, respectively, with intervals to 3 years. In the screening data set, 32 CRCs occurred during 25,745 pys of follow-up (124 per 100,000 pys, 95% CI 88 to 176 pys). One follow-up conferred a significant 73% reduction in CRC incidence (HR 0.27, 95% CI 0.10 to 0.71). Owing to the small number of end points in this data set, no other outcome was significant. Although post-screening bowel cancer worry was higher in people who were offered surveillance, worry was due to polyp detection rather than surveillance. The economic evaluation, using data from the hospital data set, suggested that 3-yearly colonoscopic surveillance without an age cut-off would produce the greatest health gain.ConclusionsA single surveillance benefited all IR patients by lowering their CRC risk. We identified a higher-risk subgroup that benefited from further surveillance, and a lower-risk subgroup that may require only one follow-up. A surveillance interval of 3 years seems suitable for most IR patients. These findings should be validated in other studies to confirm whether or not one surveillance visit provides adequate protection for the lower-risk subgroup of intermediate-risk patients.Study registrationCurrent Controlled Trials ISRCTN15213649.FundingThe National Institute for Health Research Health Technology Assessment programme.

La Mettrie est un auteur qui suscite toujours autant d’interet que d’incomprehension et de confusion, en partie creees par l’auteur lui-meme, qui s’amusait a brouiller les pistes et a provoquer l’opinion, et ne se souciait pas toujours de coherence. De nombreux articles et quelques ouvrages, ainsi que des actes de colloque, lui ont ete consacres, mais nous ne disposons toujours pas d’ouvrage de reference sur l’ensemble de sa production ni d’edition fiable de ses œuvres completes, malgre quelq...

Background Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Objectives The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis. Design This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals. Setting The trial was set in acute surgical services of 93 NHS hospitals. Participants Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible. Intervention The intervention was a QI programme to implement an evidence-based care pathway. Main outcome measures The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years. Data sources Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires. Results Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon. Limitations Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated. Conclusions There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care. Future work Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available. Trial registration Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.

IntroductionPostoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and reducing postoperative short-term and long-term survival. Optimal management of perioperative intravenous fluids and inotropic drugs may reduce infection rates and improve outcomes from surgery. Previous small trials of cardiac-output-guided haemodynamic therapy algorithms suggested a modest reduction in postoperative morbidity. A large definitive trial is needed to confirm or refute this and inform widespread clinical practice.MethodsThe Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial is a multicentre, international, parallel group, open, randomised controlled trial. 2502 high-risk patients undergoing major elective gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intravenous fluid combined with low-dose inotrope infusion, or usual care. The trial intervention will be carried out during and for 4 hours after surgery. The primary outcome is postoperative infection of Clavien-Dindo grade II or higher within 30 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation; however, outcome assessors will be blinded when feasible. Participant recruitment started in January 2017 and is scheduled to last 3 years, within 50 hospitals worldwide.Ethics/disseminationThe OPTIMISE II trial has been approved by the UK National Research Ethics Service and has been approved by responsible ethics committees in all participating countries. The findings will be disseminated through publication in a widely accessible peer-reviewed scientific journal.Trial registration numberISRCTN39653756.

Objective to explore how midwives׳ personal involvement in clinical negligence litigation affects their midwifery practice. Design descriptive phenomenological study using semi-structured interviews. Setting in 2006–2007 in-depth interviews were conducted in participants׳ homes or at their place of work and focused on participants׳ experience of litigation. Participants were recruited from various regions of England. Participants 22 National Health Service (NHS) midwives who had been alleged negligent. Findings clinical practice affected was an increase in documentation, fear of practising outside clinical guidelines and electronic fetal monitoring of women at low obstetric risk; these changes were not widespread. Changes in practice were sometimes perceived negatively and sometimes positively. Forming a good relationship with childbearing women was judged to promote effective midwifery care but litigation had affected the ability of a minority of midwives to advocate for women if this relationship had not been established. Litigation could result in loss of confidence leading to self-doubt, isolation, increased readiness to seek medical assistance and avoidance of working in the labour ward, perceived as an area with a high risk of litigation. A blame culture in the NHS was perceived by several midwives. In contrast an open non-punitive culture resulted in midwives readily reporting mistakes to risk managers. Litigation lowered midwifery morale and damaged professional reputations, particularly when reported in the newspapers. Some midwives expressed thoughts of leaving midwifery or taking time off work because of litigation but only one was actively seeking other employment, another took sick leave and one had left midwifery and returned to nursing. Key conclusions litigation can have a negative effect on midwives׳ clinical practice and morale and fosters a culture of blame within the NHS. Implications for practice education regarding appropriate documentation, use or non-use of electronic fetal monitoring and the legal status of clinical guidelines will enable midwives to respond proportionately to the threat of litigation. A culture of openness and sharing the problem when adverse events occur would help to extinguish the current blame culture in the National Health Service. Litigation must be recognised by management as capable of inducing loss of confidence and reluctance to work in the labour ward. Promoting teamwork will help support these midwives. The potential for litigation in maternity care could affect retention of the midwifery workforce.

Summary Background Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding National Institute for Health Research Health Services and Delivery Research Programme.

Agonism of cell surface receptors by monoclonal antibodies is dependent not only on its ability to bind the target, but also to deliver a biological signal through receptors to the cell. Immunoglobulin G2 antibodies (IgG2s) are made up of a mixture of distinct isoforms (IgG2-A, -B and A/B), which differ by the disulfide connectivity at the hinge region. When evaluating panels of agonistic antibodies against CD200 receptor (CD200R) or βklotho receptor (βklotho), we noticed striking activity differences of IgG1 or IgG2 antibodies with the same variable domains. For the CD200R antibody, the IgG2 antibody demonstrated higher activity than the IgG1 or IgG4 antibody. More significantly, for βklotho, agonist antibodies with higher biological activity as either IgG2 or IgG1 were identified. In both cases, ion exchange chromatography was able to isolate the bioactivity to the IgG2-B isoform from the IgG2 parental mixture. The subclass-related increase in agonist activity was not correlated with antibody aggregation or binding affinity, but was driven by enhanced avidity for the CD200R antibody. These results add to the growing body of evidence that show that conformational differences in the antibody hinge region can have a dramatic impact on the antibody activity and must be considered when screening and engineering therapeutic antibody candidates. The results also demonstrate that the IgG1 (IgG2-A like) or the IgG2-B form may provide the most active form of agonist antibodies for different antibodies and targets.

Louis Bourguet (1678–1743) was a Huguenot natural scientist from Nîmes who, after studying in Switzerland and Italy, became professor of philosophy and mathematics in Neuchâtel and founded two learned journals. This article, based on his archive in Neuchâtel, looks first at his erudite, scientific, philosophical and religious interests as expressed in his extensive learned correspondence, which also reveals a mixture of curiosity about, and opposition, to irreligious writings, some of which he may, however, have helped to circulate. We then study a document found among his papers, consisting of a commentary written in French in the margins of a manuscript copy of the last two of John Toland’s Letters to Serena (1704). Bourguet combines criticism of Toland’s view of matter, identified with Spinozism, with a defence of Leibniz’s philosophy, presented as the only one capable of demonstrating the need for a god. This manuscript throws new light on interest in Toland’s philosophical works in the years following his death, and the posthumous continuation of his debate with Leibniz. More generally, Bourguet’s learned interests and networks underline the difficulty of classifying scholars of this period into neat categories and the complex relationship between science, theology and philosophy, and between religious orthodoxies and heterodoxies.

First published online: 30 August 2017 Abbé Guillaume-Thomas Raynal’s Histoire philosophique et politique des établissements et du commerce des Européens dans les deux Indes, generally known as the Histoire des deux Indes, one of the best-sellers of the Eighteenth Century, has frequently been characterized as an anticolonial work. This article shows instead its complexity and internal inconsistencies, explained in part by the context and manner of its composition and Raynal’s links to ministerial circles. It studies the work’s description of the African continent and European trade on the West coast and its treatment of explanations for the Africans’ skin colour, as well as Diderot’s famous denunciation of the slave trade, and analyses the changes these passages undergo in the course of the work’s different editions (from 1770 to 1820). By looking beyond Denis Diderot’s impassioned denunciations of the slave trade and of European treatment of extra-European peoples, we gain a better understanding of the complexity of thinking about European expansion and human diversity in the Eighteenth Century.

Published online: 16 November 2014 On revient ici sur l’histoire des « Lumières radicales » de Jonathan Israel, histoire qui a déjà fait couler beaucoup d’encre, et notamment sur son dernier volume : Democratic Enlightenment, et son traitement de Diderot et de l’Encyclopédie. On montre que le parti-pris de l’auteur — qui interprète tout à travers une opposition entre un système philosophique radical qui serait celle de l’Encyclopédie, ainsi que de Diderot, d’Holbach, Raynal etc, et celle de Locke et de Newton défendue par les « modérés » (notamment par Voltaire) et par les autorités religieuses — ne permet pas d’en comprendre les enjeux intellectuels. Le schéma simpliste qu’il impose ainsi que son ignorance de pans entiers des recherches récentes, déforment la réalité historique. This short article revisits Jonathan Israel’s history of the ‘Radical Enlightenment’, discussing in particular how the controversial latest volume,Democratic Enlightenment, presents Diderot and the Encyclopédie. It shows how the author’s rigid interpretative system — based on what is represented as a fundamental opposition between a systematic radical philosophy defended by theEncyclopédie as well as by Diderot, d’Holbach, Raynal etc, and the philosophy of Locke and Newton defended by both the ‘moderates’ (in particular Voltaire) and the religious establishment — precludes any real understanding of the thought of the period. The simplistic model he imposes, combined with his neglect of much recent research, results in a deformation of historical reality.

Au siecle des Lumieres, la notion de « despotisme oriental »fait son apparition dans les categories de pensee politique et philosophique. A mesure que l’Empire ottoman se fait moins redoutable, le sentiment europeen de menace se mue en curiosite pour l’Orient. Mais les enjeux de politique interieure viennent largement teinter la reflexion, puisque le despotisme oriental est alors envisage comme repoussoir, voire comme faire-valoir des regimes europeens, moins arbitraires, plus democratiques. La reflexion sur l’Autre est donc en partie instrumentalisee a des fins de politique interne, et la question cruciale, qui est de savoir si le despotisme ne pourrait pas egalement exister en Europe, n’est abordee que tres tangentiellement.

Immunoglobulin G (IgG) is a 150 kDa glycoprotein found in human serum and an important mediator of the humoral immune response. IgG is composed of two heavy chains and two light chains, each divided into variable and constant domains. The variable domains are responsible for antigen binding, while the constant domains are responsible for interactions with effector molecules and effector cells. Human IgG is divided into four subclasses which although having high sequence homology, offer structural variation that significantly impacts biological function.

Published online: 22 September 2014 This article looks at the discussions of natural law by the eighteenth-century French materialists Julien Offray de La Mettre, Denis Diderot, Paul Thiry d'Holbach and Claude-Adrien Helvétius. It is particularly concerned with their discussion of moral values and their attempt to find a materialistic basis for them as part of their rejection of religion. The discussion brings out the différences between them and analyses their dialogues on this question, including the other materialists' rejection of La Mettrie's amoralism, which threatened to undermine their attempt to found a natural law taught by experience and based on human nature. Particular attention is paid to Diderot's many writings which grapple with the subject, beginning with his Encyclopédie article droit naturel, probably written in 1754. He discussed the question in many of his later writings, including in his annotations on the works of Helvétius, who based natural law on the general interest. These writings reveal a tension between Diderot's emphasis on the search for individual happiness and the interests of society as he, together with d'Holbach, attempted to provide a natural basis for morality and government from which to criticise existing institutions.

van kelst l., spitz b., sermeus w. & thomson a.m. (2013) Student midwives’ views on maternity care just before their graduation. Journal of Advanced Nursing69(3), 600–609. doi: 10.1111/j.1365-2648.2012.06042.x Abstract Aim. To report a hermeneutic study of student midwives’ views on maternity care just before their graduation. Background. Woman-centred care, which is the hallmark of midwifery, is taught to midwifery students around the globe. Woman-centred care is advantageous for women at low obstetric risk. However, adopting this ideology might be a problem for student midwives whose clinical placements are mainly in a medicalized obstetric-led hospital setting. Design. A hermeneutic phenomenological study was conducted. Methods. In 2010, three focus groups were held where 19 student midwives participated. Data were transcribed verbatim and analysed using van Manen’s approach. Findings. The choice for midwifery was a ‘positive’ choice and not the result of an elimination process. Students’ description of a midwife as a coach was in line with the international definition of a midwife. With regard to maternity care, midwifery students identified two types of care, factory-style care and tailored care, both of which were ascribed to caregivers and hospital culture. Furthermore, student midwives made the distinction between hierarchy and teamwork, referring to the professional relations in maternity care. Hierarchy was driven by tradition, it implied that decisions were made top-down, and it resulted in impersonal relations. Midwifery students felt it was unjust that midwives were not allowed to perform deliveries while having the legal autonomy to do so. Conclusion. In spite of the medicalized context, midwifery education succeeded in educating midwives who hold a woman-centred ideology. Midwifery students linked style of care to a person rather than to a profession.

A significant reduction in maternal mortality was witnessed globally in the year 2010, yet, no significant reduction in the maternal mortality ratio (MMR) in Nigeria was recorded. The absence of accurate data on the numbers, causes and local factors influencing adverse maternal outcomes has been identified as a major obstacle hindering appropriate distribution of resources targeted towards improving maternal healthcare. This paper reports the first community based study that measures the incidence of maternal mortality in Ibadan, Nigeria using the indirect sisterhood method and explores the applicability of this method in a community where maternal mortality is not a rare event. A community-based study was conducted in Ibadan using the principles of the sisterhood method developed by Graham et al. for developing countries. Using a multi-stage sampling design with stratification and clustering, 3,028 households were selected. All persons approached agreed to take part in the study (a participation rate of 100%), with 2,877 respondents eligible for analysis. There was a high incidence of maternal mortality in the study setting: 1,324/6,519 (20.3%) sisters of the respondents had died, with 1,139 deaths reportedly related to pregnancy, childbirth or the puerperium. The MMR was 7,778 per 100,000 live births (95% CI 7,326-8,229). Adjusted for a published Total Fertility Rate of 6.0, the MMR was 6,525 per 100,000 live births (95% CI 6,144-6,909). Women in Ibadan were dying more from pregnancy related complications than from other causes. Findings of this study have implications for midwifery education, training and practice and for the first time provide policy makers and planners with information on maternal mortality in the community of Ibadan city and shed light on the causes of maternal mortality in the area.

Dans cet ouvrage P. Quintili poursuit l’étude du matérialisme de Diderot entamée dans sa thèse, publiée chez Champion en 2001. L’ouvrage présent, comme l’indique son titre, élargit le domaine pour aborder cette philosophie dans ses rapports avec celle d’autres auteurs et avec la pensée scientifique, pendant la période que l’auteur appelle la « deuxième modernité » qui selon lui va de la mort de Bayle en 1706 à la Révolution française. Le titre du livre reflète le souci de l’auteur d’interroge...

Point n’est besoin de présenter Gianluigi Goggi aux lecteurs de cette revue. Ses recherches, notamment sur Diderot et sur L’Histoire des Deux Indes font autorité depuis longtemps et ont permis de renouveler notre connaissance notamment de ce dernier ouvrage. Le présent livre rassemble des articles écrits depuis 1982, avec l’addition de deux textes inédits, comme l’introduction à la quatrième partie de l’ouvrage, intitulée « Le paradigme républicain et le pari révolutionnaire chez le dernier D...

The objective was to identify community members' perceptions of the causes and prevention of maternal mortality in Ibadan, North East Local Government Area of Oyo State, Nigeria. Reported in this article are the results from a pilot study, carried out in 2005, of the views of 418 community men and women aged 15–49 years in Idi ape, Iwo Road and Okeadu areas of Ibadan North East. Data were collected over a two-week period using interviews with a structured questionnaire consisting of open-ended questions. People's perceptions of the causes and prevention of maternal death varied widely. Both medical and non-medical factors were reported as being responsible. The perceived causes of maternal mortality ranged from medical/obstetrical to individual, health personnel, governmental and supernatural causes. Participants stated that to prevent maternal mortality in this setting, awareness creation of the causes of maternal mortality is crucial and that a lot of political will is needed from the government of Oyo State and Nigeria as a whole. The government should improve the provision of well-equipped health facilities staffed by qualified health professionals providing a free or subsidised service. For a fuller understanding of maternal morbidity and mortality, it is important to consider factors outside the hospital and formal medical practice. These findings have important implications for the design and implementation of safe motherhood programmes and in formulation of safe motherhood policy in Nigeria.

Background Breastfeeding prevalence in the United Kingdom is one of the lowest in Europe. The midwife provides feeding support for new mothers but research suggests that midwives' knowledge of breastfeeding is limited. Objective To discover the views of English midwives in relation to their breastfeeding support role. Design Qualitative design. Settings Two maternity hospitals in Northwest England. Participants Thirty midwives who cared for normal, healthy babies. Midwives were selected for interview using theoretical sampling principles from a pool of midwives who volunteered. Volunteers were accessed using a poster exhibited in relevant clinical areas. Methods Data were collected using audiotaped, in-depth interviews and were analysed using constant comparison techniques. Results The study highlights that differing professional knowledge and beliefs about breastfeeding support created intense, mainly negative, emotions for these midwives. Irritation and despair was experienced with the greater emphasis placed on research, rather than practice knowledge in policy and recommendations for practice. Disappointment was experienced when mothers did not conform to midwives' expectations. Conflict with differing peer-based knowledge generated feelings of intimidation and annoyance for some midwives. Some midwives demonstrated that they can sustain clinical decisions whilst based in a hostile environment, but others conformed to the practice expectations of their peers. Happiness was experienced when midwives described positive relationships with mothers, rather than their professional colleagues. Conclusions The utilisation of professional knowledge in breastfeeding practice was a highly complex issue, and generated significant negative emotional distress, for these midwives.

Aim To investigate the degree of choice pregnant women at low obstetric risk had in making informed decisions on the use of intrapartum fetal monitoring techniques. Methods An exploratory descriptive design was used as part of a larger, multi-method study. A total of 63 pregnant women at low obstetric risk were approached to complete antepartum and postpartum questionnaires. Sixty-three women completed antepartum questionnaires, 38 of these 63 women also completed postpartum questionnaires. The data were analyzed using descriptive statistics. Results More than half of the sample wanted electronic fetal monitoring (EFM) in labor despite being classified at low risk for obstetric complications. Having choices and being in control was important to all respondents whilst in labor. Despite this, almost all respondents stated that midwives had not given them a choice of monitoring method. More than a half of the sample received some form of EFM. Conclusions Intrapartum fetal monitoring practices for women with normal pregnancies do not reflect current evidence. Women still expect EFM in labor. Choice and control are very complex issues and as such are difficult to measure.

PurposeThe routine use of intrapartum electronic fetal monitoring (EFM) has resulted in an increased burden of operative and vaginal instrumental deliveries for women at low obstetric risk. Such modes of delivery increase maternal mortality and morbidity risks. This study aims to explore midwives' values, attitudes and beliefs when using intrapartum fetal monitoring techniques in clinical practice.Design/methodology/approachA total of 58 registered midwives across two NHS Trusts in one region in the north of England were interviewed using a qualitative approach.FindingsMidwives attempted to manage the psychological burden of the threat from clinical negligence by using EFM. This meant that some midwives used electronic monitoring regardless of clinical need. Midwives lack confidence in the ability of EFM to accurately detect fetal compromise but are aware that the visual monitoring record is recognised as a valuable piece of legal evidence. The midwives' perceptions of professional self‐efficacy in seeking to avoid a claim in clinical negligence contributed to defensive practice. Research limitations/implications – The study was conducted in only two hospitals in one region of England; however the Trust demographics were similar and midwifery practice within the unit reflects national maternity standards of care.Practical implicationsMultidisciplinary strategies may be required to overcome barriers to the effective implementation of clinical guidelines where intrapartum fetal monitoring is concerned and Trust audit departments must undertake regular audit cycles in order to ascertain practice compliance with best evidence.Originality/valueThe paper provides information so that midwives' knowledge regarding the limitations of EFM can be improved.

Summary Objective to discover the views of midwives in relation to baby feeding. Design and method qualitative using grounded theory. Data collection used in-depth interviews with 30 midwives who volunteered to participate. Field notes of the interaction between the researcher and participant were also recorded as data. The constant comparison process was used to generate codes and subsequent conceptualisations from the data. Setting two maternity units in the North of England, UK. Findings the core category of this study is called ‘surviving' baby feeding, and the findings reported here are a significant theme that emerged. These midwives described a management strategy termed ‘breaking the rules' for supporting mothers with baby feeding. The concept ‘breaking the rules' represented practices that were not congruent with evidence-based, baby-feeding policy and recommendations, or with some practices that were usual in the local working environment. These midwives were aware of their actions but described how they ‘hid' their behaviour from mothers and from their peers. Some of the behaviour described showed that these midwives ‘broke the rules' in relation to professional requirements and the facilitation of informed decision making about feeding practices with the women in their care. However, some midwives reported examples of practice that is woman-centred, and supportive of baby feeding, but this was not acceptable to others in the working environment. Key conclusions and implications for practice deviant behaviour was described by these midwives in relation to informed decision making and options for mothers in baby-feeding practice. These midwives ‘knowingly concealed' their deviant practices from others. These behaviours should be taken seriously as they risk being negligent in relation to UK statutory professional requirements. However, practices that depart from those that are normal in the local working environment are not always negative and detrimental to the recipients of care; they can be positive. There needs to be more research, open discussion and debate about midwifery practice that does not always ‘fit in' with professional, and ‘normal' expectations. In this study, the term ‘baby feeding' relates to how babies' nutritional needs are met.

Over the last 20 years in the United Kingdom, midwives have implemented the routine use of intrapartum fetal monitoring regardless of the risk status of laboring women. This practice is at odds with the published research. The discrepancy between practice and best evidence merits further investigation. A qualitative study was conducted to evaluate midwives' attitudes and experiences about the use of fetal monitoring for women at low obstetric risk. Fifty-eight midwives working in two hospitals in the north of England were interviewed by using a semistructured approach. The taped interviews were transcribed and analyzed by using a general thematic approach. Issues included midwives' perceptions of low-risk status, the socialization of midwives, and the loss of woman-centered care. Midwives subscribed to the notion of woman-centered care, but because of a complexity of factors experienced in their daily working lives, they felt vulnerable when attempting to implement evidence-based fetal monitoring practices. Midwives regretted the loss of a woman-centered approach to care when technologic methods of intrapartum fetal heart rate monitoring were used indiscriminately. An appreciation of the complex factors affecting the ability of midwives to implement evidence-based practice is important when attempting to facilitate the development of appropriate fetal monitoring practices for women at low obstetric risk.

To investigate midwives' attitudes, values and beliefs on the use of intrapartum fetal monitoring.Qualitative, semi-structured interviews.Fifty-eight registered midwives in two hospitals in the North of England.In this paper two main themes are discussed, these are: informed choice, and the power of the midwife. Midwives favoured the application of informed choice and shared a unanimous consensus on the definition. However, the idealistic perception of informed choice, which included contemporary notions of empowerment and autonomy for women expressing an informed choice, was not reportedly translated into practice. Midwives had to implement informed choice on intrapartum fetal monitoring within a competing set of health service agendas, i.e. medically driven protocols and a political climate of actively managed childbearing. This resulted in the manipulation of information during the midwives' interactions with women. This ultimately meant that the women often got the choice the midwives wanted them to have.The information that a midwife imparts may consciously or subconsciously affect the woman's uptake and understanding of information. Therefore, the midwife has a powerful role to play in balancing the benefits and risk ratios applicable to fetal heart rate monitoring. However, a deeply ingrained pre-occupation with technological methods of intrapartum fetal monitoring over many years has made it difficult for midwives to offer alternative forms of monitoring. This has placed limits on the facilitation of informed choice and autonomous decision making for women.

Journal of AdvancedNursing 52(3), 307–314Developing a tool to appraise fetal monitoring guidelines for women at lowobstetric riskAim. The aim of this paper is to report the development and use of a tool to appraiseguidelines for fetal heart rate monitoring and discuss the findings generated in theappraisal process.Background. Expert guidance on the appropriate method of monitoring the fetalheart in labour has been available for some time. However, practices not based onevidence were continuing routinely in the United Kingdom.Methods. We produced an 18-item tool for the appraisal of guidelines. Heads ofMidwifery Services were asked to send the guideline currently in use. Twenty-fourout of 28 responded, and sent 32 guidelines. Pairs of multidisciplinary reviewersappraised each guideline.Results. A prevalidated generic appraisal instrument was not found to be appro-priate for intrapartum fetal monitoring guidelines. When using our own specifically-developed appraisal tool for assessing the quality of fetal monitoring guidelines,only 11 reviewer pairs showed ‘good’ or ‘moderate’ agreement in their scores.Conclusions. Generically-validated guidelines may not be sufficiently discriminatoryfor specialized areas of practice such as intrapartum fetal monitoring.Keywords: appraisal, guidelines, midwifery