Developmental Care in North American Pediatric Cardiac Intensive Care Units: Survey of Current Practices

BACKGROUND

Developmental care practices across pediatric cardiac intensive care units (CICUs) have not previously been described.

PURPOSE

To characterize current developmental care practices in North American CICUs.

METHODS

A 47-item online survey of developmental care practices was developed and sent to 35 dedicated pediatric CICUs. Staff members who were knowledgeable about developmental care practices in the CICU completed the survey.

FINDINGS/RESULTS

Completed surveys were received from 28 CICUs (80% response rate). Eighty-nine percent reported targeted efforts to promote developmental care, but only 50% and 43% reported having a developmental care committee and holding developmental rounds, respectively. Many CICUs provide darkness for sleep (86%) and indirect lighting for alertness (71%), but fewer provide low levels of sound (43%), television restrictions (43%), or designated quiet times (21%). Attempts to cluster care (82%) and support self-soothing during difficult procedures (86%) were commonly reported, but parental involvement in these activities is not consistently encouraged. All CICUs engage in infant holding, but practices vary on the basis of medical status and only 46% have formal holding policies.

IMPLICATIONS FOR PRACTICE

Implementation of developmental care in the CICU requires a well-planned process to ensure successful adoption of practice changes, beginning with a strong commitment from leadership and a focus on staff education, family support, value of parents as the primary caregivers, and policies to increase consistency of practice.

IMPLICATIONS FOR RESEARCH

Future studies should examine the short- and long-term effects of developmental care practices on infants born with congenital heart disease and cared for in a pediatric CICU.

Genetic or pharmacologic disruption of the calcineurin-nuclear factor of activated T-cells axis prevents social stress-induced voiding dysfunction in a murine model

OBJECTIVE

Social stress can suppress the voiding reflex, with resultant diminished voiding frequency and increased volumes. The calcineurin-NFAT (nuclear factor of activated T cells) pathway is important in memory development. It was hypothesized that interruption of the calcineurin-NFAT pathway might prevent social stress-induced voiding dysfunction.

METHODS

Mice were subjected to social stress in an established resident-intruder model for 1 h, followed by 23 h of barrier separation. NFATc3, NFATc4 knockout (KO) and wild-type (WT) mice were studied. At two weeks, voiding patterns were collected; this was followed by sacrifice. Corticotropin-releasing factor (CRF) mRNA expression in Barrington's nucleus (BN) was determined by in-situ hybridization.

RESULTS

Social stress decreased voiding frequency and increased voided volumes in WT strains. At baseline, NFATc3 KO mice showed decreased voids and increased volumes, while the NFATc4 KO mice resisted social stress. However, CRF mRNA increased in WT mice following social stress and was increased at baseline in NFATc3 KO mice. It was found that CRF mRNA did not increase following social stress in NFATc4 KO mice. The administration of CsA to WT mice normalized voiding patterns following social stress, albeit with no effect on CRF mRNA in BN.

CONCLUSION

Disrupting the calcineurin-NFAT axis by either genetic or pharmacologic approaches confers resistance to the development of social stress-induced voiding and dysfunction.

First Report of Fusarium Rot of Garlic Bulbs Caused by Fusarium proliferatum in North Carolina

In August of 2013, garlic bulbs (Allium sativum) of the variety Chesnok Red grown and stored under dry conditions by a commercial producer in Buncombe County showed water-soaked, tan to salmon-pink lesions. Lesions on cloves became soft over time, slightly sunken, and had mycelium near the center of the bulb, which is characteristic of Fusarium rots on garlic (1,2). Approximately 10 to 20% of the bulbs inspected in the drying storage room were affected. Surface-sterilized tissue was excised from the margin of lesions on eight bulbs, plated onto acid potato dextrose agar (APDA), and incubated in the dark at room temperature (21°C). White to light pink colonies with abundant aerial mycelium and a purple pigment were obtained from all samples after 2 to 3 days of incubation. Inspection of colony morphology and reproductive structures under a microscope revealed that isolate characteristics were consistent with Fusarium proliferatum (Matsushima) Nirenberg. Microscopic morphological characteristics of the isolate included hyaline, septate hyphae; slender, slightly curved macroconidia with three to five septae produced in sporodochia; curved apical cell; and club-shaped, aseptate microconidia (measuring 3.3 to 8.3 × 1.1 to 1.3 μm) produced in chains by mono and polyphyalides. To further define the identity of the isolate, the beta-tubulin (Btub), elongation factor 1a (EF1a), and internal transcribed spacer (ITS) regions were amplified and sequenced (3). The resulting sequences were compared against the GenBank nucleotide database by using a BLAST alignment, which revealed that the isolate had 100% identity with F. proliferatum for the Btub, EF1a, and ITS regions (GenBank Accession Nos. AF291055.1, JX118976.1, and HF930594.1, respectively). Sequences for the isolate were deposited in GenBank under accessions KJ128963, KJ128964, and KJ128965. While there have been other reports of F. proliferatum causing bulb rot of garlic in the United States (1), to our knowledge, this is the first report in North Carolina. The finding is significant since F. proliferatum can produce a broad range of mycotoxins, including fumonisins, when infecting its host, which is a concern for food safety in Allium crops. References: (1) F. M. Dugan et al. Plant Pathol. 52:426, 2003. (2) L. J. du Toit and F. M. Dugan. Page 15 in: Compendium of Onion and Garlic Diseases and Pests. H. F. Schwartz and S. K. Mohan, eds. The American Phytopathological Society, St. Paul, MN, 2008. (3) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, CA, 1990.

Liquidus tracking: controlled rate vitrification for the cryopreservation of larger volumes and tissues

BACKGROUND

Vitrification of cells or tissue at controlled cooling rates suitable for larger volumes, and with reduced cryoprotectant toxicity.

OBJECTIVE

To set out the current understanding of the LiquidusTracking (LT) vitrification technique, and to discuss the challenges and benefits of translating the method into laboratory protocols more generally applicable to meet requirements of large volume and 3-D cryo-banking in the era of regenerative medicine.

METHODS

By adding small amounts of cryoprotectants at each step and subsequently cooling the sample just above its freezing point before further increasing CPA concentration, cryoprotectant toxicity is minimized.

RESULT

CPA toxicity can be reduced by lowering the temperature. Different manual approaches to LT were evaluated and further improved.

CONCLUSIONS

Manual liquidus tracking is complicated and exhibits potential high variability. Nevertheless, this approach offers the possibility of testing several conditions simultaneously and could be used to pre-test conditions prior to automatic LT development.

Male killing Spiroplasma protects Drosophila melanogaster against two parasitoid wasps

Maternally transmitted associations between endosymbiotic bacteria and insects are diverse and widespread in nature. Owing to imperfect vertical transmission, many heritable microbes have evolved compensational mechanisms to enhance their persistence in host lineages, such as manipulating host reproduction and conferring fitness benefits to host. Symbiont-mediated defense against natural enemies of hosts is increasingly recognized as an important mechanism by which endosymbionts enhance host fitness. Members of the genus Spiroplasma associated with distantly related Drosophila hosts are known to engage in either reproductive parasitism (i.e., male killing) or defense against natural enemies (the parasitic wasp Leptopilina heterotoma and a nematode). A male-killing strain of Spiroplasma (strain Melanogaster Sex Ratio Organism (MSRO)) co-occurs with Wolbachia (strain wMel) in certain wild populations of the model organism Drosophila melanogaster. We examined the effects of Spiroplasma MSRO and Wolbachia wMel on Drosophila survival against parasitism by two common wasps, Leptopilina heterotoma and Leptopilina boulardi, that differ in their host ranges and host evasion strategies. The results indicate that Spiroplasma MSRO prevents successful development of both wasps, and confers a small, albeit significant, increase in larva-to-adult survival of flies subjected to wasp attacks. We modeled the conditions under which defense can contribute to Spiroplasma persistence. Wolbachia also confers a weak, but significant, survival advantage to flies attacked by L. heterotoma. The host protective effects exhibited by Spiroplasma and Wolbachia are additive and may provide the conditions for such cotransmitted symbionts to become mutualists. Occurrence of Spiroplasma-mediated protection against distinct parasitoids in divergent Drosophila hosts suggests a general protection mechanism.

Promising effects of donepezil when added to patients treated with gabapentin for neuropathic pain

Aims

The clinical relevance of adding the acetylcholinesterase inhibitor donepezil to existing gabapentin treatment in patients with post-traumatic neuropathic pain was explored in this open-label study. The two drugs have previously shown synergism following co-administration in nerve-injured rats [1,2].

Methods

The study comprised two consecutive periods of minimum six weeks: (1) titration of gabapentin until highest tolerable dose or maximum 24GG mg daily; and (2) addition of donepezil 5 mg once daily to the fixed gabapentin dose. Efficacy and tolerability were assessed by ratings of pain intensity, questionnaires for pain and health-related quality of life, and reporting of adverse events and analgesic rescue medication. Pain scores were also analyzed using mixed-effects analysis (i.e. incorporating inter-subject variability) with the software NONMEM.

Results

Eight patients commenced treatment with donepezil upon the gabapentin titration period, of which two withdrew due to adverse events. Addition of donepezil reduced pain by >35% in four of six patients compared to gabapentin monotherapy. Mixed-effects analysis revealed that pain scores were significantly lower during co-administration (p < 0.05 combination vs. monotherapy). Donepezil was well tolerated in combination with gabapentin. At the end of study, three patients wished to continue combination therapy with gabapentin and donepezil.

Conclusions

Donepezil may provide additional analgesia to neuropathic pain patients with insufficient pain relief from gabapentin as monotherapy. Further confirmation in controlled clinical trials is justified. Mixed-effects analysis was sensitive enough to detect statistically significant effects, showing its usefulness in small-scale trials and/or when data is associated with high variability.

BRCA1 testing should be offered to individuals with triple-negative breast cancer diagnosed below 50 years

BACKGROUND

Triple-negative (TN) tumours are the predominant breast cancer subtype in BRCA1 mutation carriers. Recently, it was proposed that all individuals below 50 years of age with TN breast cancer should be offered BRCA testing. We have evaluated the BRCA1 mutation frequency and the implications for clinical practice of undertaking genetic testing in women with TN breast cancer.

METHODS

We undertook BRCA1 mutation analysis in 308 individuals with TN breast cancer, 159 individuals from unselected series of breast cancer and 149 individuals from series ascertained on the basis of young age and/or family history.

RESULTS

BRCA1 mutations were present in 45 out of 308 individuals. Individuals with TN cancer <50 years had >10% likelihood of carrying a BRCA1 mutation in both the unselected (11 out of 58, 19%) and selected (26 out of 111, 23%) series. However, over a third would not have been offered testing using existing criteria. We estimate that testing all individuals with TN breast cancer <50 years would generate an extra 1200 tests annually in England.

CONCLUSION

Women with TN breast cancer diagnosed below 50 years have >10% likelihood of carrying a BRCA1 mutation and are therefore eligible for testing in most centres. However, implementation may place short-term logistical and financial burdens on genetic services.

A study of thromboprophylactic practices of Scottish orthopaedic surgeons in patients undergoing total hip replacements. Should practice change with new guidelines?

Despite increasing scientific investigation, the best method for preventing postoperative thromboembolism in patients undergoing a total hip replacement (THR) remains unclear. National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the prevention of thromboembolism have caused much controversy. We surveyed Scottish surgeons regarding their thromboprophylaxis prescribing after THR. Questionnaires were sent to all Scottish orthopaedic consultants. They were asked about routine pharmacological and mechanical prophylaxis in patients undergoing a THR. Comparison was made with a previous survey done in 2003. The response rate was 75%. The survey showed an increased use of pharmacological prophylaxis from 93% to 100%. This was due to the increased use of aspirin from 51% to 64%. The use of low molecular weight heparin has remained constant at 51%. No surgeons routinely use warfarin, un-fractionated heparin or fondaparinux. Use of graded compression stockings has increased from 59% to 70%. In conclusion, there is increasing evidence that patients undergoing THR should receive extended prophylaxis for up to 35 days. Oral agents such as dabigatran and rivaroxaban have offered a new option for oral extended prescribing. The results in change of practice must be closely audited.

Recent trends and clinical features of childhood vitamin D deficiency presenting to a children's hospital in Glasgow

BACKGROUND

The incidence of vitamin D deficiency is unclear in the context of continuing demographic changes and the introduction of new public health measures.

METHODS

All cases in which vitamin D deficiency was suspected as the primary cause of the clinical presentation were studied.

RESULTS

Between 2002 and 2008, 160 cases of symptomatic vitamin D deficiency were identified with twice as many cases in 2008 (n, 42) as in the previous years. The median age of the cohort was 24 months (range 2 weeks-14 years).Three cases were recorded in children of European background, whereas the rest were in children of South Asian, Middle Eastern or sub-Saharan ethnic background. Presenting features included bowed legs in 64 (40%) and a fit in 19 (12%). In one infant, concerns were raised following a presentation with cardiac failure and hypocalcaemia.

SUMMARY

Symptomatic vitamin D deficiency remains prevalent in the West of Scotland. There is a need for effective public health education, action and surveillance.

An audit to identify factors that are more commonly associated with depressed patients on augmentation therapy under the befordshire east community mental health team (BECMHT)

Background

Whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care.

Aims and methods

An Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression.

Results

Of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy.

Discussion

There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and ‘other suicide risk factors’.

Conclusion

Generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.