Fathers: The Lost Ring in the Chain of Family-Centered Care: A Phenomenological Study in Neonatal Intensive Care Units of Iran.

BACKGROUND: The basic principles of family-centered care in neonatal intensive care unit (NICU) include the unlimited presence of parents and their participation in infant's care. Nurses play a central role in encouraging parental attachment with their infant. PURPOSE: This study was carried out with the aim of understanding NICU nurses' lived experiences of family participation in family-centered care. METHODS: This interpretative phenomenological study was conducted on the basis of Heideggerian philosophy. The data were collected using semistructured interviews and field notes and analyzed through the 7-stage Diekelmann, Allen, and Tanner approach. FINDINGS: Two overarching themes emerged including "mother's centrality in the care chain" and "fathers; the lost ring in the care chain" each of which consisted of 3 and 4 subthemes, respectively. Interviews indicated that in Iran's NICUs, conditions for the presence of parents were appropriate for the mothers and they were encouraged to engage in family-centered care but the fathers' participation was limited due to traditional attitudes, cultural-religious background, and difficulties relating to the hospitals' organizational rules. IMPLICATIONS FOR PRACTICE: Fathers' participation in family-centered care seems to be enhanced through providing facilities, altering the organizational rules, attempting to modify traditional social attitudes, and educating parents and nurses. IMPLICATIONS FOR RESEARCH: Future research should explore the experience of mothers and fathers of infants in NICU in Iran to achieve a comprehensive understanding of their role in family-centered care.

Potential Threats Posed by New or Emerging Marine Biotoxins in UK Waters and Examination of Detection Methodologies Used for Their Control: Cyclic Imines.

Cyclic imines (CIs) are a group of phytoplankton produced toxins related to shellfish food products, some of which are already present in UK and European waters. Their risk to shellfish consumers is poorly understood, as while no human intoxication has been definitively related to this group, their fast acting toxicity following intraperitoneal injection in mice has led to concern over their human health implications. A request was therefore made by UK food safety authorities to examine these toxins more closely to aid possible management strategies. Of the CI producers only the spirolide producer Alexandrium ostenfeldii is known to exist in UK waters at present but trends in climate change may lead to increased risk from other organisms/CI toxins currently present elsewhere in Europe and in similar environments worldwide. This paper reviews evidence concerning the prevalence of CIs and CI-producing phytoplankton, together with testing methodologies. Chemical, biological and biomolecular methods are reviewed, including recommendations for further work to enable effective testing. Although the focus here is on the UK, from a strategic standpoint many of the topics discussed will also be of interest in other parts of the world since new and emerging marine biotoxins are of global concern.

Potential Threats Posed by Tetrodotoxins in UK Waters: Examination of Detection Methodology Used in Their Control.

Tetrodotoxin is a neurotoxin responsible for many human fatalities, most commonly following the consumption of pufferfish. Whilst the source of the toxin has not been conclusively proven, it is thought to be associated with various species of marine bacteria. Whilst the toxins are well studied in fish and gastropods, in recent years, there have been a number of reports of tetrodotoxin occurring in bivalve shellfish, including those harvested from the UK and other parts of Europe. This paper reviews evidence concerning the prevalence of tetrodotoxins in the UK together with methodologies currently available for testing. Biological, biomolecular and chemical methods are reviewed, including recommendations for further work. With the recent development of quantitative chromatographic methods for these and other hydrophilic toxins, as well as the commercial availability of rapid testing kits, there are a number of options available to ensure consumers are protected against this threat.

Testing and application of a refined rapid detection method for paralytic shellfish poisoning toxins in UK shellfish.

The Scotia Rapid Test for PSP is designed for qualitative identification of saxitoxins at levels in shellfish equivalent to the limit of detection of the biological reference method. However, issues with the method have been reported, including the low assay cross reactivity for some toxins, high numbers of false positive results and the subjective test interpretation. This study focussed on approaches to improve each of these issues. A refined test was found to improve GTX1&4 test sensitivity in samples containing high proportions of GTX1&4. The subjectivity of the test was successfully eliminated through use of an automated scanner, which enabled both the reliable identification of test results as well as the provision of a numerical result which could be utilised for more refined results interpretation. Finally the high proportion of false positive results in comparison with the LC-FLD was investigated, with a modified approach incorporating an additional extract dilution applied to a range of shellfish samples with different toxicities. Results showed highly variable limits of detection of the method and no significant reduction in false positive results when applying the additional dilution, which may be of concern to laboratories in receipt of high numbers of samples containing low concentrations of toxins.

Potential threats posed by new or emerging marine biotoxins in UK waters and examination of detection methodology used in their control: brevetoxins.

Regular occurrence of brevetoxin-producing toxic phytoplankton in commercial shellfishery areas poses a significant risk to shellfish consumer health. Brevetoxins and their causative toxic phytoplankton are more limited in their global distribution than most marine toxins impacting commercial shellfisheries. On the other hand, trends in climate change could conceivably lead to increased risk posed by these toxins in UK waters. A request was made by UK food safety authorities to examine these toxins more closely to aid possible management strategies, should they pose a threat in the future. At the time of writing, brevetoxins have been detected in the Gulf of Mexico, the Southeast US coast and in New Zealand waters, where regulatory levels for brevetoxins in shellfish have existed for some time. This paper reviews evidence concerning the prevalence of brevetoxins and brevetoxin-producing phytoplankton in the UK, together with testing methodologies. Chemical, biological and biomolecular methods are reviewed, including recommendations for further work to enable effective testing. Although the focus here is on the UK, from a strategic standpoint many of the topics discussed will also be of interest in other parts of the world since new and emerging marine biotoxins are of global concern.

Interlaboratory comparison of two AOAC liquid chromatographic fluorescence detection methods for paralytic shellfish toxin analysis through characterization of an oyster reference material.

An interlaboratory ring trial was designed and conducted by the Centre for Environment, Fisheries, and Aquaculture Science to investigate a range of issues affecting the analysis of a candidate Pacific oyster paralytic shellfish toxin reference material. A total of 21 laboratories participated in the study and supplied results using one or more of three instrumental methods, specifically precolumn oxidation (Pre-COX) LC with fluorescence detection (FLD; AOAC Official Method 2005.06), postcolumn oxidation (PCOX) LC-FLD (AOAC Official Method 2011.02), and hydrophilic interaction LC/MS/MS. Each participant analyzed nine replicate samples of the oyster tissue in three separate batches of three samples over a period of time longer than 1 week. Results were reported in a standardized format, reporting both individual toxin concentrations and total sample toxicity. Data were assessed to determine the equivalency of the two AOAC LC methods and the LC/MS/MS method as well as an assessment of intrabatch and interbatch repeatability and interlaboratory reproducibility of each method. Differences among the results reported using the three methods were shown to be statistically significant, although visual comparisons showed an overlap between results generated by the majority of tests, the exception being the Pre-COX quantitation of N-hydroxylated toxins in post ion-exchange fractions. Intralaboratory repeatability and interlaboratory reproducibility were acceptable for most of the results, with the exception of results generated from fractions. The results provided good evidence for the acceptable performance of the PCOX method for the quantitation of C toxins. Overall the study showed the usefulness of interlaboratory analysis for the characterization of paralytic shellfish poisoning matrix reference materials, highlighting some issues that may need to be addressed with further method assessment at individual participant laboratories.

A feasibility study into the production of a freeze-dried oyster reference material for paralytic shellfish poisoning toxins.

Matrix reference materials are an essential component for the validation and quality control of analytical methodologies for the quantitation of marine biotoxins in shellfish. Given the potential advantages of reference materials in powder form, a study was conducted to assess the feasibility for the production of a freeze-dried oyster tissue reference material containing a range of important paralytic shellfish poisoning toxins. One bulk sample of a wet oyster tissue homogenate was generated following mass culturing of toxic Alexandrium and oyster feeding experiments. The bulk tissue was used to prepare untreated wet frozen aliquots with the remainder being freeze-dried and processed into appropriately-sized powder samples. A pre-column oxidation LC-FLD analysis was used to confirm the absence of any chromatographic artefacts resulting from the processing and to confirm acceptable homogeneity of the tissues. Excellent stability over both the short-term (1 month) and long-term (1 year) of the freeze-dried material was demonstrated as compared with the stability of the untreated wet tissue. A post-column oxidation LC-FLD method was used to confirm the absence of toxin epimerisation in freeze-dried tissues which were observed in the wet tissues. Overall the work showed the feasibility of an approach to produce a homogenous freeze-dried oyster matrix material with enhanced stability in comparison to the untreated wet tissue. The potential for use of the process for preparation of large scale production batches of a freeze-dried CRM for paralytic shellfish poisoning toxins has therefore been demonstrated.

Feasibility studies into the production of gamma-irradiated oyster tissue reference materials for paralytic shellfish poisoning toxins.

A study was conducted to assess the feasibility for the production of sterile, stable and homogenous shellfish reference materials containing known concentrations of paralytic shellfish poisoning (PSP) toxins. Pacific oysters were contaminated with toxins following mass culturing of toxic algae and shellfish feeding experiments. Live oysters were shucked and tissues homogenised, before measuring into multiple aliquots, with one batch subjected to gamma irradiation treatment and the other remaining untreated. The homogeneity of both batches of samples was assessed using a pre-column oxidation liquid chromatography with fluorescence detection (Pre-COX LC-FLD) method and shown to be within the limits of normal within-batch repeatability. A twelve-month stability experiment was conducted for both untreated and gamma irradiated batches, specifically examining the effects of long term storage at -20 °C, +4 °C and +40 °C. Results indicated mostly good stability of PSP toxins in both materials when stored frozen at -20 °C, but with the instability of GTX2&3 concentrations in the untreated tissues eliminated in the irradiated tissues. Analysis using a post-column oxidation (PCOX) LC-FLD method also showed epimerisation in both GTX1&4 and GTX2&3 epimeric pairs in untreated samples after only 6 months frozen storage. This issue was not present in the tissues irradiated before long term storage. Biological activity testing confirmed the absence of bacteria in the irradiated samples throughout the 12 month study period. With such results there was clear evidence for the potential of increasing the scale of the mass culturing and shellfish feeding for the production of large batches of tissue suitable for the preparation of a certified matrix reference material. Overall results demonstrated the feasibility for production of oyster reference materials for PSTs, with evidence for prolonged stability following gamma irradiation treatment and storage at -20 °C.

Transformation of paralytic shellfish poisoning toxins in Crassostrea gigas and Pecten maximus reference materials.

Matrix reference materials are an important requirement for the assessment of method performance characteristics and for routine quality control. In the field of marine toxin testing where biological assays have been used and where modern analytical testing methods are now becoming available, this requirement has become an urgent one. Various approaches are utilised for preparation of such materials in the absence of available naturally occurring toxic shellfish samples. Toxin-free shellfish may be artificially fortified through the addition of cultured toxic phytoplankton or shellfish may be incurred through natural feeding on toxic algae in a laboratory environment. Both of these approaches may be potentially affected by issues relating to the degradation or transformation of toxin analytes, so studies were conducted to assess these effects within our laboratory. A range of PSP-toxic shellfish tissues were prepared using the two approaches, in both Pacific oyster (Crassostrea gigas) and king scallops (Pecten maximus). Additionally, sub-samples of incurred Pacific oyster tissue were further treated, through addition of artificial chemical stabilisers and gamma irradiation. Two separate month-long stability trials were conducted at +4 °C on each material. Results highlighted clear evidence for improved stability of materials following shellfish feeding experiments in comparison with the tissues which had been spiked with plankton. In addition, there were clear differences in stability of toxins between the two shellfish species studied. There was evidence for good stability of C1&2 toxins in both the incurred tissues and improved stability of some toxins in tissues which had been subjected to either gamma irradiation or treatment with chemical additives. The results therefore highlighted the benefits of conducting shellfish feeding if suitable stable reference materials are to be prepared containing a full range of PSP toxin analytes. The study also highlighted the benefits of post-production treatment to prolong the stability of the materials. Work is ongoing to assess the full characteristics of candidate reference materials prepared with these approaches with the aim of producing a homogenous and stable PSP reference material in Pacific oysters.

Comparison of AOAC 2005.06 LC official method with other methodologies for the quantitation of paralytic shellfish poisoning toxins in UK shellfish species.

A refined version of the pre-column oxidation liquid chromatography with fluorescence detection (ox-LC-FLD) official method AOAC 2005.06 was developed in the UK and validated for the determination of paralytic shellfish poisoning toxins in UK shellfish. Analysis was undertaken here for the comparison of PSP toxicities determined using the LC method for a range of UK bivalve shellfish species against the official European reference method, the PSP mouse bioassay (MBA, AOAC 959.08). Comparative results indicated a good correlation in results for some species (mussels, cockles and clams) but a poor correlation for two species of oysters (Pacific oysters and native oysters), where the LC results in terms of total saxitoxin equivalents were found to be on average more than double the values determined by MBA. With the potential for either LC over-estimation or MBA under-estimation, additional oyster and mussel samples were analysed using MBA and ox-LC-FLD together with further analytical and functional methodologies: a post-column oxidation LC method (LC-ox-FLD), an electrophysiological assay and hydrophilic interaction liquid chromatography with tandem mass spectrometric detection. Results highlighted a good correlation among non-bioassay results, indicating a likely cause of difference was the under-estimation in the MBA, rather than an over-estimation in the LC results.

A feasibility study into the provision of Paralytic Shellfish Toxins laboratory reference materials by mass culture of Alexandrium and shellfish feeding experiments.

As the official control laboratory for biotoxin testing in England, Wales and Scotland, Cefas employs two approaches for the detection of Paralytic Shellfish Poisons (PSP) in bivalve shellfish: a qualitative HPLC method for oysters, whole king scallops and cockles (with PSP bioassay confirmation of positive HPLC samples) with subsequent quantitation of positive samples by mouse bioassay and a quantitative HPLC method for mussels (no PSP bioassay confirmation required). To aid the validation of the quantitative HPLC method for native oysters, Pacific oysters, cockles and king scallops and ultimately remove the need for the PSP bioassay for these species, appropriate contaminated shellfish matrices were required. As it was not possible to obtain naturally contaminated material for these species, shellfish were contaminated in-house through feeding experiments with high concentrations of Alexandrium species. A number of feeding experiments with two Alexandrium strains were performed successfully. The contaminated shellfish materials generated contained a number of different profiles of PSP toxins. This work has demonstrated the feasibility of these methods for the production of laboratory reference materials in a variety of bivalve shellfish species. Based on this study laboratory reference material production via these methods is now undertaken routinely within Cefas. By running two concurrent feeding trials per year for each species, enough laboratory reference material is produced for approximately 1 year of the programme. This removes the necessity for natural contaminated material which is not always available for reference material production. Additionally, such materials enable both the comparative testing of different PSP methodologies and the ongoing generation of long-term precision data for the HPLC method.

Potential use of gamma irradiation in the production of mussel and oyster reference materials for paralytic shellfish poisoning toxins.

Bivalve shellfish samples containing paralytic shellfish poisoning toxins were subjected to gamma irradiation dosage trials in order to assess the potential suitability of the technique in the production of toxin reference materials. Two candidate reference materials of tissue homogenates, mussels (Mytilus sp.) and native oysters (Ostrea edulis), were prepared in-house. Both were subjected to gamma irradiation at four different dose levels, 3.0, 6.0, 13.0 and 18.1 kGy. Bacterial levels were shown to be eliminated in the mussels and significantly reduced in the oysters following irradiation at all four dose levels. Paralytic shellfish poisoning (PSP) toxin concentrations were not significantly reduced in any of the samples indicating the treatment had no adverse affect on the initial stability of any of the PSP toxins monitored. Chromatographic results showed near-identical profiles for treated and non-treated samples inferring that no fluorescent toxin degradation products or matrix interferences were produced during the irradiation process. Results therefore proved that gamma irradiation treatment reduced bacterial levels within paralytic shellfish poisoning reference materials without compromising analyte content, with the subsequent potential to enhance the stability of future candidate reference materials treated in this manner.

First evidence of an extensive northern European distribution of azaspiracid poisoning (AZP) toxins in shellfish.

Azaspiracids have recently been identified as the toxins responsible for a series of human intoxications in Europe since 1995, following the consumption of cultured mussels (Mytilus edulis) from the west coast of Ireland. Liquid chromatography-mass spectrometric (LC-MS) methods have been applied in the study reported here to investigate the new human toxic syndrome, azaspiracid poisoning. Separation of azaspiracid (AZA1) and its analogues, 8-methylazaspiracid (AZA2) and 22-demethylazaspiracid (AZA3), was achieved using reversed-phase LC and coupled, via an electrospray ionisation source, to an ion-trap mass spectrometer. These azaspiracids have now been identified in mussels from Craster (north-east England) and Sognefjord (south-west Norway) using source collision induced dissociation-MS and multiple tandem MS detection. AZA1 was the predominant toxin and toxin profiles were similar to those found in contaminated Irish shellfish. This is the first report of the occurrence of these azaspiracids outside Ireland with the significant implications that these toxins may occur in shellfish throughout northern Europe.