Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

Microbial cell budgets of an Arctic glacier surface quantified using flow cytometry

Uncertainty surrounds estimates of microbial cell and organic detritus fluxes from glacier surfaces. Here, we present the first enumeration of biological particles draining from a supraglacial catchment, on Midtre Lovénbreen (Svalbard) over 36 days. A stream cell flux of 1.08 × 10(7)  cells m(-2)  h(-1) was found, with strong inverse, non-linear associations between water discharge and biological particle concentrations. Over the study period, a significant decrease in cell-like particles exhibiting 530 nm autofluorescence was noted. The observed total fluvial export of ~7.5 × 10(14) cells equates to 15.1-72.7 g C, and a large proportion of these cells were small (< 0.5 μm in diameter). Differences between the observed fluvial export and inputs from ice-melt and aeolian deposition were marked: results indicate an apparent storage rate of 8.83 × 10(7)  cells m(-2)  h(-1). Analysis of surface ice cores revealed cell concentrations comparable to previous studies (6 × 10(4)  cells ml(-1)) but, critically, showed no variation with depth in the uppermost 1 m. The physical retention and growth of particulates at glacier surfaces has two implications: to contribute to ice mass thinning through feedbacks altering surface albedo, and to potentially seed recently deglaciated terrain with cells, genes and labile organic matter. This highlights the merit of further study into glacier surface hydraulics and biological processes.

Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial

BACKGROUND

Asthma self-management plans that include doubling the dose of inhaled corticosteroid when the condition deteriorates improve asthma control. Whether doubling the dose of corticosteroid in isolation is effective is unknown. We undertook a randomised controlled trial to investigate the effects of doubling the dose of inhaled corticosteriods when asthma deteriorates.

METHODS

390 individuals with asthma who were at risk of an exacerbation monitored their morning peak flow and asthma symptoms for up to 12 months. When peak flow or symptoms started to deteriorate, participants added an active or placebo corticosteroid inhaler to their usual corticosteroid for 14 days to produce a doubling or no change in dose. The primary outcome was the number of individuals starting oral prednisolone in each group.

FINDINGS

During 12 months, 207 (53%) started their study inhaler and 46 (12%) started prednisolone--22 (11%) of 192 and 24 (12%) of 198 in the active and placebo groups, respectively. The risk ratio for starting prednisolone was therefore 0.95 (95% CI 0.55-1.64, p=0.8).

INTERPRETATION

We recorded little evidence to support the widely recommended intervention of doubling the dose of inhaled corticosteroid when asthma control starts to deteriorate.

Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial

BACKGROUND

Patients with asthma are interested in the use of breathing exercises but their role is uncertain. The effects of the Buteyko breathing technique, a device which mimics pranayama (a yoga breathing technique), and a dummy pranayama device on bronchial responsiveness and symptoms were compared over 6 months in a parallel group study.

METHODS

Ninety patients with asthma taking an inhaled corticosteroid were randomised after a 2 week run in period to Eucapnic Buteyko breathing, use of a Pink City Lung Exerciser (PCLE) to mimic pranayama, or a PCLE placebo device. Subjects practised the techniques at home twice daily for 6 months followed by an optional steroid reduction phase. Primary outcome measures were symptom scores and change in the dose of methacholine provoking a 20% fall in FEV(1) (PD(20)) during the first 6 months.

RESULTS

Sixty nine patients (78%) completed the study. There was no significant difference in PD(20) between the three groups at 3 or 6 months. Symptoms remained relatively stable in the PCLE and placebo groups but were reduced in the Buteyko group. Median change in symptom scores at 6 months was 0 (interquartile range -1 to 1) in the placebo group, -1 (-2 to 0.75) in the PCLE group, and -3 (-4 to 0) in the Buteyko group (p=0.003 for difference between groups). Bronchodilator use was reduced in the Buteyko group by two puffs/day at 6 months; there was no change in the other two groups (p=0.005). No difference was seen between the groups in FEV(1), exacerbations, or ability to reduce inhaled corticosteroids.

CONCLUSION

The Buteyko breathing technique can improve symptoms and reduce bronchodilator use but does not appear to change bronchial responsiveness or lung function in patients with asthma. No benefit was shown for the Pink City Lung Exerciser.

Sensitivity of sleep stages to painful thermal stimuli

Many modalities of both acute and chronic pain have been shown to disrupt sleep. Any differences in the intensity of thermal noxious stimulus required to produce arousal from stage 2, slow-wave sleep (SWS) and rapid eye movement (REM) sleep is unclear. An assessment of reactions of seven male (age 22 +/- 2.9 years) and three female subjects (age 21.0 +/- 1.0 years) to a range of gradually increasing temperatures was used both when awake and asleep. When awake, subjects assigned five different descriptors to the increasing heat stimulus. During the different stages of sleep, temperatures were increased over the same range as when awake until the subjects aroused from sleep. The possible fluctuations in pain perception due to a time-of-night effect were assessed in awake subjects over a 12-h period from 19:00 to 07:00 hours. During sleep, arousals occurred at significantly higher temperatures during SWS (P < 0.01) and REM sleep (P < 0.05) than during stage 2 sleep. The temperatures causing arousals during SWS and REM sleep were not significantly different and were equivalent to temperatures causing pain tolerance when awake. No changes in pain perception due to time of night were observed. The results show that a higher intensity of thermal noxious stimulus is required to cause arousal from SWS and REM sleep when compared with stage 2 sleep. This would confirm the suspicion that REM sleep and SWS are relatively, and possibly equally, resistant to disruption by noxious stimuli.

A bold new direction for environmental health research

The biotechnology revolution has opened new opportunities for addressing current inadequacies in decision making regarding environmental health. Strategic investments need to be made (1) to develop high-throughput technologies that could accelerate toxicity testing and generate a mechanistic understanding of toxicity, (2) to incorporate individual susceptibility into risk assessments, and (3) to establish a rational basis for testing and regulatory decision making. New initiatives of the National Institute of Environmental Health Sciences, including the Environmental Genome Project and the Toxicogenomics Center, are discussed.

My experience with the Cancer Survival Toolbox

Nurses are instrumental in educating patients and their families about how to navigate the cancer experience. Patients often state that they would not know much about their disease and treatment if not for their nurse's teaching. The Cancer Survival Toolbox, a comprehensive set of audiotapes, is a free resource that helps people dealing with cancer develop and use key coping skills--communicating, finding information, making decisions, solving problems, negotiating, and standing up for their rights. Supplemental modules deal with issues facing the underinsured and uninsured, barriers to care for older cancer survivors, and concerns of caregivers. The Cancer Survival Toolbox Group Facilitator's Training Manual is a valuable resource for anyone working with cancer support groups. All healthcare professionals, cancer survivors, and lay caregivers can use the toolbox in a variety of ways. This article offers suggestions about how to ensure that cancer survivors and caregivers have the opportunity to use this unique resource.

Hypothyroxinemia of prematurity and infant neurodevelopment: a pilot study

To assess whether hypothyroxinemia has specific effects on neurodevelopment in premature infants, thyroid hormone levels were determined at 2 weeks of life and 40 weeks postconceptional age (PCA), and infants were evaluated at 3 months corrected age using the Bayley Scales of Infant Development and Early Infancy Temperament Questionnaire. Additional attention scales were derived from the factor analysis of relevant Bayley items. Fifteen infants born between 30 and 35 weeks and 21 full-term infants were studied. Results indicated no group differences on the Bayley or derived attention scales, whereas the temperament questionnaire revealed lower sensory thresholds and greater reactivity in the preterm group. The preterm group had normal thyroxine (T4) levels at 2 weeks of age, which declined by 40 weeks PCA for both free T4 (p < .01 for reference value and p < .0001 for gestational age-adjusted value) and total T4 (p < .05 for age-adjusted value). Correlations revealed that higher 40-week PCA free T4 levels were associated with better attentiveness ratings (p < .01 for reference and p < .0001 for gestational-age values) and sustained attention (p < .05) and higher 40-week total T4 with better motor skills (p < .05 for gestational-age value). These findings signify that a mild degree of hypothyroxinemia is evident in preterm infants without neurological risk and predicts subsequently poorer cognitive and motor abilities.

Persistent Post-Concussive Syndrome: A proposed methodology and literature review to determine the effects, if any, of mild head and other bodily injury

Following mild head injury, a subgroup of individuals exhibit a constellation of chronic symptoms, a condition Alexander (1995) labeled Persistent Post-Concussive Syndrome (PPCS). He implicated neurological factors in the initial phase of the syndrome but psychological factors in the maintenance of symptoms. However, it is unclear as to whether an initial mild head injury is necessary or sufficient to cause the symptoms of PPCS. We first outline a study design comparing a mild closed-head injury group to both a normal and an other injury control group to answer this question. Next, we review the literature since 1960 to determine the findings of any studies using this design. The results of the literature review indicate that few such studies exist. To date, those that have been done suggest that there is no strong evidence for a specific effect for mild head injury on cognitive functioning. We discuss directions for future research given these findings.

Glucocorticoids inhibit proliferation and interleukin-4 and interleukin-5 secretion by aeroallergen-specific T-helper type 2 cell lines

BACKGROUND

Glucocorticoids play an important role in the treatment of allergic disease. The atopic process, itself, may reduce the response of peripheral blood mononuclear cells (PBMC) to these drugs.

OBJECTIVE

In this study we compared the effect of hydrocortisone (HC), beclomethasone (BDP), and mometasone (MF) on interleukin (IL)-4 and IL-5 secretion by aeroallergen-specific T-helper type 2 cells (Th2) and proliferation of PBMC from atopic donors.

METHODS

Cells were incubated with drug before stimulating with phytohemagglutinin and assessing proliferation (PBMC) and cytokine secretion (Th2).

RESULTS

The glucocorticoids concentration dependently inhibited proliferation and cytokine secretion, but had less effect on proliferation of cells from severe atopics than on cells from those whose symptoms required little treatment. The rank order of potency was MF (average IC50 0.01 nM) > BDP (4.0 nM) > HC (250 nM).

CONCLUSIONS

These experiments demonstrate glucocorticoid inhibition of IL-4 and IL-5 secretion by human Th2-like cells and proliferation of PBMC from severely and mildly allergic donors.

An overview of Canadian physician work force databases

Physician-resource planning activities have increased dramatically in Canada since the release of the Barer-Stoddart report, "Toward Integrated Medical Resource Policies for Canada" in 1991. One of the key concepts of the Barer-Stoddart report is the "medical career life cycle," beginning with entry to medical school and ending with exit from practice. To apply this concept in a planning context, it is essential to have a current information base that will contain data on numbers of physicians, where they are, what they do, and how active they are. In addition, a longitudinal capability is important for understanding issues such as retention and attrition. The objective of this article is to review and assess recent initiatives in the establishment of physician-resource databases in Canada by medical associations, governments, licensing bodies, certifying colleges, and other groups with a respect to comprehensiveness and comparability of key data elements and their ability to address key policy questions in physician-resource planning and to identify opportunities for collaboration and links.

T-helper 1 dominated responses to erythrocyte Band 3 in NZB mice

Band 3, the red blood cell (RBC) anion channel protein, is the target autoantigen for the pathogenic RBC autoantibodies and T-helper (Th) cells in New Zealand Black (NZB) mice with autoimmune haemolytic anaemia (AIHA). To determine the subpopulation of these Th cells, they were stimulated with Band 3 and the profile of the cytokines elaborated by the responding cells was measured. NZB T cells stimulated with Band 3 produced high levels of the Th1 cytokine, interferon-gamma (IFN-gamma), but little or no interleukin-4 (IL-4), IL-5 or IL-10. Similar patterns were produced by NZB T cells responding to a spectrin preparation from the RBC membrane skeleton, or to mycobacterial heat-shock protein (hsp) 65 following immunization of mice with hsp 65 in incomplete adjuvant. By contrast, T cells from CBA mice similarly immunized with hsp 65 produced high levels of IL-4 and IL-5 in response to hsp 65. Examination of the isotype of the RBC-bound immunoglobulins in NZB mice revealed that immunoglobulin G2a (IgG2a) autoantibodies were the first to be detected in most mice and that later in the disease, IgG3 autoantibodies were often prominent. It is concluded that, contrary to expectation, the development of RBC autoantibodies in NZB mice is associated with Th1 cytokine-dominated responses.

Lateralization of pectoral stridulation sound production in the channel catfish

Sounds of the channel catfish Ictalurus punctatus were found to consist of a rapid series of pulses produced by rubbing a ridged process on the first pectoral spine against the rough surface of a groove in the pectoral girdle during fin abduction. Although sounds can be made with either fin, approximately half of the individuals exhibited a fin preference, and 90% of these preferred the right fin. Unlike examples of handedness in other invertebrates and fishes, this preference is not simply a matter of anatomical asymmetry, but as in humans, reflects a preference between two equally developed limbs.

Bone-selective analogs of human PTH(1-34) increase bone formation in an ovariectomized rat model

Intermittent parathyroid hormone (PTH) therapy increases bone mass. The purpose of this study was to determine if analogs of human PTH(1-34) (hPTH[1-34]), which differ from the native sequence in their receptor-activating properties, could promote bone formation in an ovariectomized (OVX) osteopenic rat model. We synthesized two hPTH(1-34) analogs with single substitutions for serine in the 3-position that in vitro are partial agonists in kidney. In the renal cell line OK, maximal cyclic adenosine monophosphate (cAMP) activation by [His(3)]hPTH(134) was 50%, and maximal cAMP activation by [Leu(3)]hPTH(1-34) was 20% of that produced by hPTH(1-34). Both analogs were full agonists in UMR-106 rat osteosarcoma cells and other bone-derived systems, but both had reduced potency compared with hPTh(1-34). Six-month-old retired breeder Sprague-Dawley rats were ovariectomized, and five animals underwent sham operation. On day 56 post-OVX, five sham-operated and five pre-PTH treatment OVX animals were sacrificed, and the remaining animals were randomized into 10 groups of six animals each. All other animals were injected with one of the hPTH analogs or hPTH(1-34) at 0, 4, 40, or 400 mu g/kg of body weight (BW)/day and were killed on day 84. Histomorphometry of the proximal tibia metaphysis and biochemical markers of bone turnover (osteocalcin and pyridinoline cross-links) were the primary endpoints. The cancellous bone volume was significantly lower at day 56 post-OVX (pretreatment) and at day 84 post-OVX (post-vehicle treatment) than at baseline. None of the compounds significantly increased the cancellous bone volume. Trabecular number declined after OVX and did not change with hPTH treatment. In contrast, the trabecular thickness declined after OVX but was higher after treatment with 40 mu g/kg of BW/day or 400 mu g/kg of BW/day of hPTH(1-34). In OVX rats, the mineralizing surface was higher than baseline at day 56 and fell toward control levels by day 84. All three peptides produced marked dose-related increases in the mineralizing surface and bone formation rates, but the two analogs were less potent than hPTH(1-34). Likewise, all peptides produced significant dose-related increases in the serum osteocalcin level. The osteoclast surface was not affected by OVX but was decreased with medium and high doses of hPTH(1-34). Pyridinoline cross-link excretion was not significantly affected by treatment with hPTH(1-34) but responded with a dose-dependent decrease to treatment with [His3]hPTH(1-34). These data suggest that bone selective analogs of hPTH(1-34) maintain the ability to induce bone formation but are less potent than hPTH(1-34).

Maternal work in the NICU: a case study of an "NICU-experienced" mother

This study explored one woman's experience in becoming a mother to her premature son during his prolonged hospitalization. This paradigm case is an exemplar selected from a larger phenomenological study that examined the high-risk perinatal experience. Hermeneutic analysis led to the discovery of the phenomenon of maternal work embedded in the experience of this mother. Dimensions of her maternal work included working for love, working for meaningful moments, working amid uncertainty, working against the odds, and working overtime. Understanding the experience of maternal work can assist nurses to acknowledge and support the work inherent in becoming a mother within the neonatal intensive care unit.

Genetic contamination of Dahl SS/Jr rats. Impact on studies of salt-sensitive hypertension

The Dahl salt-sensitive rat (SS/Jr) is a widely used animal model of salt-sensitive hypertension. SS/Jr rats are believed to be highly inbred and uniformly sensitive to the hypertensinogenic effects of sodium chloride, but we have recently observed that SS/Jr rats from Harlan Sprague Dawley, Inc, exhibit considerable variability in their blood pressure response to supplemental dietary salt. To test the possibility that commercially available SS/Jr rats are genetically contaminated and therefore no longer fully inbred, we performed molecular genetic studies and blood pressure measurements in several groups of SS/Jr rats purchased from Harlan Sprague Dawley. We found molecular evidence of heterozygosity and/or atypical allelic variants involving loci on at least five different chromosomes. Many of the rats also failed to exhibit a salt-sensitive blood pressure phenotype. We conclude that SS/Jr rats being sold by the only commercial vendor of Dahl rats in the United States are genetically contaminated and resistant to the hypertensinogenic effects of salt. These findings raise serious questions about the interpretation of research conducted with SS/Jr rats obtained from Harlan Sprague Dawley.

Nucleotide sequence of the first cosmid from the Mycobacterium leprae genome project: structure and function of the Rif-Str regions

The nucleotide sequence of cosmid B1790, carrying the Rif-Str regions of the Mycobacterium leprae chromosome, has been determined. Twelve open reading frames were identified in the 36716bp sequence, representing 40% of the coding capacity. Five ribosomal proteins, two elongation factors and the beta and beta' subunits of RNA polymerase have been characterized and two novel genes were found. One of these encodes a member of the so-called ABC family of ATP-binding proteins while the other appears to encode an enzyme involved in repairing genomic lesions caused by free radicals. This finding may well be significant as M. leprae, an intracellular pathogen, lives within macrophages.

Lysogenization of Salmonella choleraesuis by phage 14 increases average length of O-antigen chains, serum resistance and intraperitoneal mouse virulence

Three clones from a strain of Salmonella choleraesuis (serogroup C1) were lysogenized with phage 14 (P14) which converts the O-antigen of serogroup C1 salmonellae from O-6,7 to O-6,7,14. The lysogens were compared with their parental non-lysogenic clones with respect to the following properties: average length of O-antigen polysaccharide chains, sensitivity to normal human serum, and mouse-virulence. SDS-polyacrylamide gel electrophoresis of lipopolysaccharides extracted from these bacteria showed that samples from lysogens consisted mainly of long-chained molecules whereas those from non-lysogens contained mainly short-chained molecules. The O-antigen polysaccharide from a lysogen was estimated by chemical analysis to be six times as long as that from a non-lysogen. Lysogens were serum-resistant whereas non-lysogens were serum-sensitive. About 10 times more colony forming units of a lysogen than of a non-lysogen were recovered from the livers and spleens of mice on day 1 and 3 after intraperitoneal inoculation of equal doses. By comparison with S. choleraesuis, lysogenization of S. typhimurium with phage P22 or phage A4 did not affect the chain-length distribution of O-antigen polysaccharide. Our data suggest that phage 14-coded determinants increase efficiency of O-antigen biosynthesis in S. choleraesuis leading to increase in average length of O-polysaccharide chains. Increased serum resistance and mouse virulence are logical consequences of increase in average length of O-polysaccharide chains and represent phage-conferred selective advantage not previously described in Salmonella.

Expression of immunogenic epitopes of hepatitis B surface antigen with hybrid flagellin proteins by a vaccine strain of Salmonella

A nonvirulent Salmonella dublin flagellin-negative, aromatic-dependent live vaccine strain has been used to express hepatitis B virus surface antigen epitopes in an immunogenic form. The envelope proteins of the virion are encoded by the S gene, which contains the pre-S1, pre-S2, and S coding regions. Synthetic oligonucleotides corresponding to amino acid residues S-(122-137) and pre-S2-(120-145) were inserted in-frame into the hypervariable region of a cloned Salmonella flagellin gene, and the recombinant plasmids were introduced into a flagellin-negative aroA mutant live vaccine strain of S. dublin, SL5928. The flagellin gene was expressed in bacteria carrying the plasmids as detected by immunoblotting with anti-flagellin (H1-d) serum. Both the S and pre-S2 epitopes were detected in bacteria carrying the relevant plasmid by immunoblotting with anti-HBs (antibody to hepatitis B virus surface antigen) and anti-peptide antisera. Animals immunized intramuscularly or orally with the live recombinant bacteria developed antibodies specific to these hepatitis B virus epitopes as detected by ELISA.

Increased uptake of bone radiopharmaceutical in diabetic neuropathy

Uptake of radiopharmaceutical was markedly abnormal in all phases of the bone scan in the feet of patients with diabetic neuropathy. Bone scans were performed in three groups of patients; diabetics with neuropathic osteoarthropathy (Charcot joints); diabetics with neuropathy but no evidence of osteoarthropathy and non-diabetic controls. Uptake was monitored in three phases; during the first 2 min after injection, then at 4 min and finally at 4 h. Uptake in all three phases was markedly increased in the neuropathic subjects, not only in those with osteoarthropathy but also in those with no radiological abnormalities. Increased uptake at 2 and 4 min indicates increased blood flow which can also result in increased uptake at 4 h. Increased blood flow secondary to peripheral neuropathy may lead to excessive bone resorption, susceptibility to fracture and finally the development of neuropathic osteoarthropathy of the diabetic foot.