Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population

BACKGROUND

Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access.

METHODS

A quasi-experimental, retrospective cohort design was used to compare short-term breastfeeding duration between a pre-BFHI and a post-BFHI cohort. Among the post-BFHI cohort, logistic regression models were fitted to predict short-term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9).

RESULTS

Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

CONCLUSION

These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

The Use of Bioelectrical Impedance to Assess Shelf-Life of Beef Longissimus Dorsi

ObjectivesTo evaluate quality attributes of beef longissimus dorsi (LD) during 15 d of simulated retail display using surface and internal bioelectrical impedance analysis (BIA) measurement techniques.Materials and MethodsThe experiment was designed as a split-plot with loin as the whole-plot and pairekd steaks as the sub-plot. Display day (DD) was treated as the sub-plot treatment. Postmortem age time (PM) and DD were treated as fixed effects. Beef strip loins (N = 18; IMPS #180), obtained from 3 commercial processors (PM = 27, 34, or 37 d), were fabricated into 12 2.54-cm thick steaks (N = 216). Steaks were subdivided into 6 consecutively cut pairs and pairs were randomly assigned to one of 6 display days: 0, 3, 6, 9, 12, and 15. For all pairs, one steak was allocated to microbiological analysis and pH and the paired steak for BIA, objective color assessment, proximate composition, and TBARS. Surface BIA (S-BIA) and internal BIA (I-BIA) assessment were compared. Steaks were packaged on styrofoam trays with a moisture absorbent pad, overwrapped with polyvinyl chloride film, and displayed under fluorescent lighting at 0–4°C in coffin-style retail cases.ResultsThere was a PM × DD interaction (P < 0.05) for S-BIA values. From d 0 to 12 of display, steaks aged 27 d had higher (P < 0.05) S-BIA values than steaks aged 34 and 37 d; however, on d 15 of display, steaks aged 34 d had 22% higher (P < 0.05) S-BIA values than steaks aged 37 d, but had similar (P > 0.05) values compared to steaks aged 27 d. There was no PM × DD interaction (P < 0.05) for I-BIA values; however, an effect on PM and DD was found (P < 0.05). Steaks aged 27 d were 17% higher for I-BIA values (P < 0.05) than 37 d, but similar (P > 0.05) to steaks aged 34 d. For all PM aging times, d 0 had the lowest (P < 0.05) I-BIA values among all display days with 81.44. D 3 was the second lowest (P < 0.05) and 8% higher than d 0 for I-BIA values. D 6 was 16% higher (P < 0.05) than d 3 but similar (P > 0.05) to d 9 and d 12. D 12 and D 15 were similar (P > 0.05). There was a DD × BIA method interaction (P < 0.05). On d 0, 3, and 6, BIA values were different (P < 0.05); however, after d 6 onward, BIA values were similar (P > 0.05). Covariance component was smaller in I-BIA than S-BIA. There were no PM × DD interactions (P > 0.05) for a* and b* values; however, there was an interaction for L* values. Postmortem aging had no effect (P > 0.05) on L*; however, an effect on a* and b* was found (P < 0.05). For APC populations, there was a PM × DD interaction (P < 0.05). No PM × DD interaction or PM effect (P > 0.05) were found for TBARS; however, there was a DD effect (P < 0.05). There was no PM day × DD interaction (P > 0.05) or PM day (P > 0.05) for moisture content. Display day (P < 0.05) had an effect on moisture content. Moderate negative correlations occurred between S-BIA values and a*, b*, and moisture content with –0.48, –0.46, and –0.46, respectively; and –0.51, –0.48, and –0.43, respectively, for I-BIA. Conversely, moderate positive correlation was found between S-BIA values and APC and TBARS with 0.34 and 0.53, respectively; and 0.29 and 0.51, respectively, for I-BIA.ConclusionI-BIA has potential for use to assess shelf-life of retail steaks and it was more precise than S-BIA; however, I-BIA may translocate bacteria into the muscle. Protein degradation and WHC should be evaluated to better understand BIA changes over time.

Lamin B1 regulates somatic mutations and progression of B-cell malignancies

Somatic hypermutation (SHM) is a pivotal process in adaptive immunity that occurs in the germinal centre and allows B cells to change their primary DNA sequence and diversify their antigen receptors. Here, we report that genome binding of Lamin B1, a component of the nuclear envelope involved in epigenetic chromatin regulation, is reduced during B-cell activation and formation of lymphoid germinal centres. Chromatin immunoprecipitation-Seq analysis showed that kappa and heavy variable immunoglobulin domains were released from the Lamin B1 suppressive environment when SHM was induced in B cells. RNA interference-mediated reduction of Lamin B1 resulted in spontaneous SHM as well as kappa-light chain aberrant surface expression. Finally, Lamin B1 expression level correlated with progression-free and overall survival in chronic lymphocytic leukaemia, and was strongly involved in the transformation of follicular lymphoma. In summary, here we report that Lamin B1 is a negative epigenetic regulator of SHM in normal B-cells and a 'mutational gatekeeper', suppressing the aberrant mutations that drive lymphoid malignancy.

Comprehensive analysis of two Shank3 and the Cacna1c mouse models of autism spectrum disorder

To expand, analyze and extend published behavioral phenotypes relevant to autism spectrum disorder (ASD), we present a study of three ASD genetic mouse models: Feng's Shank3^tm2Gfng model, hereafter Shank3/F, Jiang's Shank3^tm1Yhj model, hereafter Shank3/J and the Cacna1c deletion model. The Shank3 models mimick gene mutations associated with Phelan-McDermid Syndrome and the Cacna1c model recapitulates the deletion underlying Timothy syndrome. This study utilizes both standard and novel behavioral tests with the same methodology used in our previously published companion report on the Cntnap2 null and 16p11.2 deletion models. We found that some but not all behaviors replicated published findings and those that did replicate, such as social behavior and overgrooming in Shank3 models, tended to be milder than reported elsewhere. The Shank3/F model, and to a much lesser extent, the Shank3/J and Cacna1c models, showed hypoactivity and a general anxiety-like behavior triggered by external stimuli which pervaded social interactions. We did not detect deficits in a cognitive procedural learning test nor did we observe perseverative behavior in these models. We did, however, find differences in exploratory patterns of Cacna1c mutant mice suggestive of a behavioral effect in a social setting. In addition, only Shank3/F showed differences in sensory-gating. Both positive and negative results from this study will be useful in identifying the most robust and replicable behavioral signatures within and across mouse models of autism. Understanding these phenotypes may shed light of which features to study when screening compounds for potential therapeutic interventions.

Shorter anogenital and anoscrotal distances correlate with the severity of hypospadias: A prospective study

INTRODUCTION

Anogenital distance (AGD) is a recognised marker of in utero androgen action.

OBJECTIVE

This study aimed to evaluate the relationship between severity of hypospadias and AGD.

STUDY DESIGN

Boys undergoing hypospadias repair in a single tertiary centre between May 2012 and February 16 were included in the study. Anogenital distance was measured from the centre of the anus to the base of the penis, and anoscrotal distance (ASD) from the centre of the anus to the junction between the smooth perineal skin and scrotal skin. Trained paediatric urologists made all measurements using digital callipers.

RESULTS

Fifty-nine boys with hypospadias and 31 age-matched controls undergoing circumcision (median age 1.37 years, range 1.01-1.96) had AGD and ASD measured under anaesthetic. The patients were divided into two groups, according to hypospadias severity: group 1 - distal penile/subcoronal/glandular (n = 40); and group 2 - perineal/penoscrotal/midshaft (n = 19). The median AGD for controls was 74.0 mm (range 53.2-87.8) and for hypospadias it was 72.3 mm (range 50.7-90.0) (P = 0.816). The median ASD for controls was 42.3 mm (range 31.0-56.1) and for hypospadias it was 39.4 mm (range 20.7-77.0) (P = 0.224). Considering severity of hypospadias, the median AGD for group 1 and group 2 was 73.7 mm (range 50.7-90.0) and 63.3 mm (range 53.6-77.0), respectively (P < 0.001). The median ASD was also higher in group 1, at 41.3 mm (range 20.7-65.0), compared to 35.2 mm (range 23.5-77.0) in group 2 (P = 0.119) (Summary Fig.).

DISCUSSION

This study showed that more severe forms of hypospadias are associated with shorter AGD and ASD. These findings agree with two previous studies that identified reduced AGD in boys with hypospadias. However, these studies did not investigate an association with severity of hypospadias. As hypospadias is multifactorial, only a small proportion of cases are thought to be associated with impaired in utero androgen exposure. The shorter AGD in boys with severe hypospadias compared with mild hypospadias would indicate that AGD is a marker of the severity of androgen production. This may also suggest that less severe forms of hypospadias have a different aetiology involving a later stage of development, and that they are not the result of reduced androgen exposure in the male programming window between the 8-14 weeks gestation.

CONCLUSION

This study identified that boys with more severe hypospadias are more likely to have a shorter AGD and ASD than boys with mild hypospadias. This may indicate that there is a more profound impairment of in utero androgen action in severe hypospadias.

Real-time monitoring of swimming performance

This article presents the performance results of a novel algorithm for swimming analysis in real-time within a low-power wrist-worn device. The estimated parameters are: lap count, stroke count, time in lap, total swimming time, pace/speed per lap, total swam distance, and swimming efficiency (SWOLF). In addition, several swimming styles are automatically detected. Results were obtained using a database composed of 13 different swimmers spanning 646 laps and 858.78 min of total swam time. The final precision achieved in lap detection ranges between 99.7% and 100%, and the classification of the different swimming styles reached a sensitivity and specificity above 98%. We demonstrate that a swimmers performance can be fully analyzed with the smart bracelet containing the novel algorithm. The presented algorithm has been licensed to ICON Health & Fitness Inc. for their line of wearables under the brand iFit.

A large multicenter study analysis of adverse events associated with single operator cholangiopancreatoscopy

AIM

Cholangiopancreatoscopy (CP) is an endoscopic technique that allows for direct visualization of the biliary and pancreatic ducts using a narrow caliber endoscope that passes through the working channel of a duodenoscope directly into the bile and/or pancreatic ducts. Little data is available on the safety of CP. We performed a multicenter retrospective study to evaluate the frequency and severity of adverse events with single operator CP.

METHODS

A multicenter retrospective study was conducted.

RESULTS

A total of 282 single operator peroral CP procedures were performed in 224 patients (128 M, 96 F). Most procedures involved the performance of therapeutic maneuvers, with most cases including multiple therapeutic maneuvers. Cholangioscopic or pancreatoscopic-assisted tissue sampling was performed in 222 procedures. Thirty-seven patients underwent electrohydraulic lithotripsy (EHL) for the treatment of common bile duct stones. Adverse events in patients undergoing single cholangioscopy and pancreatoscopy included post-ERCP pancreatitis (N.=11, 3.9%, all mild), post-ERCP cholangitis (N.=4, 1.4%), bleeding (N.=3, 1%), and perforation (N.=2, 0.7%).

CONCLUSION

Overall, our data shows that ERCP performed with single operator cholangioscopy or pancreatoscopy is safe with adverse events similar to that seen in large studies of ERCP performed without these additional techniques. Of note, vigorous irrigation of the bile ducts was not associated with increased rates of post-procedure cholangitis in our study.

Endoscopic appearance and location dictate diagnostic yield of biopsies in eosinophilic oesophagitis

BACKGROUND

Acknowledging that eosinophilic esophagitis (EoE) is a disease with variable involvement throughout the oesophagus, studies have suggested a minimum of five biopsies to diagnose EoE. Although it is accepted that furrows and exudates appear to represent areas of inflammation, no research to date has looked specifically at EoE endoscopic findings to see if eosinophilic infiltrate correlates with specific endoscopic findings.

AIM

To evaluate the distribution of eosinophils in EoE and determine whether endoscopic appearances predict the degree of eosinophilia at various locations of the oesophagus.

METHODS

We performed a prospective cross sectional study of EoE (treated and untreated) patients to study the distribution of eosinophils according to endoscopic findings. The oesophagus of 10 EoE patients were biopsied up to 32 times in a circumferential manner. The mucosal changes were documented at the site of each biopsy. Histological determination of eosinophil counts and related histopathology of the oesophagus were then correlated with endoscopic findings. Similar biopsy assessments were made in treated (resolved) EoE patients (n = 6) to determine the permanence of specific endoscopic appearances.

RESULTS

A total of 16 patients were biopsied (10 EoE, 6 treated EoE). A total of 432 biopsies were obtained in all with 294 biopsies from 10 EoE subjects. Eosinophil density was increased distally in the majority of EoE patients. Biopsies performed in areas of exudates and furrows demonstrated higher eosinophil counts. Lines and normal-appearing oesophagi in EoE subjects were not commonly associated with elevated eosinophil counts (>15 eos/HPF). Rings alone without associated furrows or plaques did not demonstrate elevated eosinophil counts and were seen in resolved EoE (Rx-EoE) as well as in active EoE patients.

CONCLUSIONS

Eosinophilic esophagitis remains a variable disease with some patients manifesting extensive disease throughout the oesophagus. Characteristics of furrows and exudates found during endoscopy are associated with higher peak eosinophil counts, requiring fewer biopsies to make a diagnosis. Lines and otherwise normal appearances of the oesophagus suggest a milder mucosal eosinophilia, requiring substantial biopsies to adequately identify fields with diagnostic eosinophil counts.

Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands

Evaluation is often used as a vehicle to improve program implementation. To evaluate the implementation of programs that provide care for frail older people a Community of Practice (CoP) was developed in the Netherlands. The purpose of this paper is to describe and reflect on the role of a CoP in the implementation of these programs. Using a responsive evaluation approach this study was based on interviews with participating stakeholders and transcripts of the CoP meetings with 13 professionals, project managers and patient representatives. Findings showed that CoP members had unanticipated concerns regarding the pro-active approach of the programs and older people not being open to receiving care. The heterogenic composition was appreciated and fostered learning. A social infrastructure was created for active learning inside and outside the CoP. We conclude that a CoP is a useful strategy as part of an evaluation aimed at improving program implementation. Lessons learned include the importance of creating ownership among CoP members by sharing responsibilities and paying attention to the heterogenic group composition and professional language spoken to involve all members.

Validation of a technique using microbubbles and contrast enhanced ultrasound (CEUS) to biopsy sentinel lymph nodes (SLN) in pre-operative breast cancer patients with a normal grey-scale axillary ultrasound

BACKGROUND

In patients with breast cancer, grey-scale ultrasound often fails to identify lymph node (LN) metastases. We aimed to validate the technique of contrast-enhanced ultrasound (CEUS) as a test to identify sentinel lymph node (SLN) metastases and reduce the numbers of patients requiring a completion axillary node clearance (ANC).

METHODS

371 patients with breast cancer and a normal axillary ultrasound were recruited. Patients received periareolar intra-dermal injection of microbubble contrast agent. Breast lymphatics were visualised by CEUS and followed to identify and biopsy axillary SLN. Patients then underwent standard tumour excision and either SLN excision (benign biopsy) or axillary clearance (malignant biopsy) with subsequent histopathological analysis.

RESULTS

The technique failed in 46 patients, 6 patients had indeterminate biopsy results and 24 patients were excluded. In 295 patients with a conclusive SLN biopsy, the sensitivity of the technique was 61% and specificity 100%. Given a benign SLN biopsy result, the post-test probability that a patient had SLN metastases was 8%. 35 patients were found to have SLN metastases and had a primary ANC (29 macrometastases and 6 micrometastases/ITC). There were 22 false negative results (10 macrometastases and 12 micrometastases). Macrometastases in core biopsy specimens correlated with LN macrometastases on surgical excision.

CONCLUSION

Pre-operative biopsy of SLN reduced the numbers of patients requiring completion ANC. Despite the low sensitivity, only 22 patients (8%) with a benign SLN biopsy were subsequently found to have LN metastases. Without the confirmation of macrometastases on core biopsy specimens, patients with micrometastases/ITC may be inadvertently selected for primary ANC.

A common peripheral blood gene set for diagnosis of operational tolerance in pediatric and adult liver transplantation

To identify biomarkers of operational tolerance in pediatric and adult liver transplant recipients, transcriptional profiles were examined from 300 samples by microarrays and Q-PCR measurements of blood specimens from pediatric and adult liver transplant recipients and normal tissues. Tolerance-specific genes were validated in independent samples across two different transplant programs and validated by Q-PCR. A minimal set of 13 unique genes, highly expressed in natural killer cells (p = 0.03), were significantly expressed in both pediatric and adult liver tolerance, irrespective of different clinical and demographic confounders. The performance of this gene set by microarray in independent samples was 100% sensitivity and 83% specificity and the AUC was 0.988 for only three genes by Q-PCR. 26% of adults and 64% of children with excellent liver allograft function, on minimal or dual immunosuppression, showed high prediction scores for tolerance. Novel peripheral transcriptional profiles can be identified in operational tolerance in pediatric and adult recipients of liver allografts, suggesting a high incidence of a pro-tolerogenic phenotype in stable patients on chronic immunosuppression. Given the high incidence of viral infections and malignancies in liver transplant recipients, this gene set provides an important monitoring tool that can move the field toward personalized and predictive medicine in organ transplantation.

Temperature-related natural selection in a wind-pollinated tree across regional and continental scales

Adaptive genetic variation is a key factor in evolutionary biology, but the detection of signatures of natural selection remains challenging in nonmodel organisms. We used a genome scan approach to detect signals of natural selection in the Black alder (Alnus glutinosa), a widespread wind-pollinated tree. Gene flow through pollen dispersal is believed to be high in this species, and we therefore expected to find a clear response to natural selection. In combination with two different landscape genetic approaches, we determined which environmental variables were most associated with the inferred selection. This analysis was performed on a regional scale (northern Belgium) and on a continental scale (Europe). Because climate-related differences are much more pronounced at the continental scale, we expected to find more selection-sensitive genetic markers across Europe than across northern Belgium. At both spatial scales, a substantial number of genetic loci were considered outliers, with respect to neutral expectations, and were therefore identified as selective. Based on results from our combined approach, four putative selective loci (or 2.5%) were recovered with high statistical support. Although these loci seemed to be associated with different environmental variables, they were mainly temperature-related. Our study demonstrates that the use of complementary methods in landscape genetics allows the discovery of selective loci which otherwise might stay hidden. In combination with a genome scan, the selective loci can be verified and the nature of the selection pressure can be identified.

Identification and quantitation of ketamine in biological matrices using gas chromatography-mass spectrometry (GC-MS)

Ketamine hydrochloride, a Schedule III drug under the Controlled Substances Act, is a dissociative anesthetic that has a combination of stimulant, depressant, hallucinogenic, and analgesic properties. This procedure utilizes solid phase extraction of blood, tissue, or urine samples to isolate ketamine (special K) and its metabolite norketamine. The extract is then assayed using selected ion monitoring gas chromatography/mass spectrometry for absolute structural confirmation of the compound and the compounds quantified by comparing responses of the unknown samples to the responses of standards.

Preoperative localization of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasonography in patients with breast cancer

BACKGROUND

Sentinel lymph node (SLN) biopsy is the standard procedure for axillary staging in early breast cancer. Lymphatic imaging after intraparenchymal microbubble injection has been reported in animal models. The aim of this study was to identify and localize SLNs before surgery by contrast-enhanced ultrasonography after intradermal injection of microbubbles in patients with breast cancer.

METHODS

Fifty-four consecutive, consenting patients with primary breast cancer were recruited. Patients received a periareolar intradermal injection of microbubble contrast agent. Breast lymphatics were visualized by ultrasonography and followed to identify putative axillary SLNs. A guidewire was deployed to localize the SLN. The next day, patients underwent standard tumour excision and SLN biopsy.

RESULTS

SLNs were identified and guidewires inserted in 48 patients. In these patients operative findings confirmed that the wired lymph nodes were SLNs. The sensitivity of SLN detection, compared with radioisotope and blue dye, was 89 per cent. Five patients were found to have metastases in SLNs. In these patients the SLNs were identified correctly and localized before surgery with guidewires.

CONCLUSION

SLNs may be identified and localized before surgery using contrast-enhanced ultrasonography after injection of microbubbles.