Epidemiology, Clinical and Laboratory Features and Course of Chikungunya among a Cohort of Children during the First Caribbean Epidemic.

This study describes the epidemiology, the clinical features and the course of confirmed chikungunya among a cohort of children. It is a prospective audit of chikungunya cases among children registered for routine medical care at a primary care center. Children presenting with suspected chikungunya were confirmed using real-time reverse transcription polymerase chain reaction. There were 203 suspected cases of chikungunya; of these, 115 samples were tested and 69 (59.0%) were confirmed. The attack rate of chikungunya was 10.2% and 3.5% for the suspected and confirmed cases, respectively. Only six (8.7%) of the children with confirmed chikungunya required hospitalization. Joint pain was a clinical feature in 68 of 69 (98.6%) and skin rash was seen in 32 (46.4%) confirmed cases. The duration of illness was <2 weeks in 89.9% and less than a week in 62.3% of cases. In conclusion, most children had mild clinical manifestations and recovered fully within 2 weeks.

Regenerative Peripheral Nerve Interface (RPNI) Surgery for Mitigation of Neuroma and Postamputation Pain.

Background: A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. Symptomatic neuromas are a common cause of postamputation pain that can lead to substantial disability1-3. Regenerative peripheral nerve interface (RPNI) surgery may benefit patients through the use of free nonvascularized muscle grafts as physiologic targets for peripheral nerve reinnervation for mitigation of neuroma and postamputation pain. Description: An RPNI is constructed by implanting the distal end of a transected peripheral nerve into a free nonvascularized skeletal muscle graft. The neuroma or free end of the affected nerve is identified, transected, and skeletonized. A free muscle graft is then harvested from the donor thigh or from the existing amputation site, and the distal end of each transected nerve is implanted into the center of the free muscle graft with use of 6-0 nonabsorbable suture. This can be done acutely at the time of amputation or as an elective procedure at any time postoperatively. Alternatives: Nonsurgical treatments of neuromas include desensitization, chemical or anesthetic injections, biofeedback, transcutaneous electrical nerve stimulation, topical lidocaine, and/or other medications (e.g., antidepressants, anticonvulsants, and opioids). Surgical treatment of neuromas includes neuroma excision, nerve capping, excision with transposition into bone or muscle, nerve grafting, and targeted muscle reinnervation. Rationale: Creation of an RPNI is a simple and reproducible surgical option to prevent neuroma formation that leverages several biologic processes and addresses many limitations of existing neuroma-treatment strategies. Given the understanding that neuromas will form when regenerating axons are not presented with end organs for reinnervation, any strategy that reduces the number of aimless axons within a residual limb should serve to reduce symptomatic neuromas. The use of free muscle grafts offers a vast supply of denervated muscle targets for regenerating nerve axons and facilitates the reestablishment of neuromuscular junctions without sacrificing denervation of any residual muscles. Expected Outcomes: Articles describing RPNI surgery for postamputation pain have shown favorable outcomes, with significant reduction in neuroma pain and phantom pain scores at approximately 7 months postoperatively4,5. Neuroma pain scores were reduced by 71% and phantom pain scores were reduced by 53%4. Prophylactic RPNI surgery is also associated with substantially lower incidence of symptomatic neuromas (0% versus 13.3%) and a lower rate of phantom limb pain (51.1% versus 91.1%)5 compared with the rates in patients who did not undergo RPNI surgery. Important Tips: Ask the patient preoperatively to point at the site of maximal tenderness, as this can serve as a guide for where the symptomatic neuroma may be located. The incision can be made either through the previous site of the amputation or directly over the site of maximal tenderness longitudinally. The pitfall of incising directly over the site is creating another incision with its attendant risk of wound infection.Excise the terminal neuroma with a knife until healthy-appearing axons are visualized.The free nonvascularized skeletal muscle graft can be obtained from local muscle (preferred) or from a separate donor site. A separate donor site can introduce donor-site morbidity and complications, including hematoma and pain.The harvested skeletal muscle graft should ideally be approximately 35 mm long, 20 mm wide, and 5 mm thick in order to ensure survivability and to prevent central necrosis. The harvesting can be performed with curved Mayo scissors.The peripheral nerve should be implanted parallel to the direction of the muscle fibers, and the epineurium should be secured to the free muscle graft at 1 or 2 places. One suture should be utilized to tack the distal end of the epineurium to the middle of the bed of the muscle graft. Another suture should be utilized to start the wrapping of the muscle graft around the nerve using a bite through the muscle, a bite through the epineurium of the proximal end of the nerve, and another bite through the other muscle edge in order to form a cylindrical wrap around the nerve.Wrap the entire muscle graft by taking only bites of muscle graft around the nerve to secure the muscle graft in a cylindrical structure using 2 to 4 more sutures.Avoid locating the RPNI near weight-bearing surfaces of the residual limb when closing. The RPNI should be in the muscular tissue, deep to the subcutaneous tissue and dermis.Do perform intraneural dissection for large-caliber nerves to create several (normally 2 to 4) distinct RPNIs, to avoid too many regenerating axons in a single free muscle graft.

Climate-Dependent Heat-Triggered Opening Mechanism of Banksia Seed Pods.

Heat-triggered fruit opening and delayed release of mature seeds are widespread among plants in fire-prone ecosystems. Here, the material characteristics of the seed-containing follicles of Banksia attenuata (Proteaceae), which open in response to heat frequently caused by fire, are investigated. Material analysis reveals that long-term dimensional stability and opening temperatures of follicles collected across an environmental gradient increase as habitats become drier, hotter, and more fire prone. A gradual increase in the biaxial curvature of the hygroscopic valves provides the follicles in the driest region with the highest flexural rigidity. The irreversible deformation of the valves for opening is enabled via a temperature-dependent reduction of the elastic modulus of the innermost tissue layer, which then allows releasing the stresses previously generated by shrinkage of the fiber bundles in the adjacent layer during follicle drying. These findings illustrate the level of sophistication by which this species optimizes its fruit opening mechanism over a large distribution range with varying environmental conditions, and may not only have great relevance for developing biomimetic actuators, but also for elucidating the species' capacity to cope with climatic changes.

Overseas experience of the neonatal nurse practitioner role: lessons for Australia.

The Nurse Practitioner role is currently being implemented in most Australian states. This model of practice has existed overseas, predominantly in North America,for many years. The experiences of those countries can help inform the implementation of the role in Australia. This paper reviews the overseas literature concerning one practice context, that of the Neonatal Nurse Practitioner. The scope of the role, issues surrounding educational preparation, impact of the role on health outcomes, and factors identified as facilitating and constraining the role, are all discussed. The implications for the Australian context are highlighted.

Doctors' and nurses' perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice.

BACKGROUND: The importance of interdisciplinary collaboration has been attested to by a number of authors. Some have suggested that Nurse Practitioners (NPs) may be able to improve collaboration between doctors and nurses, but this assertion does not appear to have been researched. AIMS AND OBJECTIVES: To investigate doctors' and nurses' perceptions of interdisciplinary collaboration in two neonatal intensive care units, and to assess the impact of a Neonatal Nurse Practitioner (NNP) practice model on these perceptions. The study was conducted as part of a larger project to develop a NNP model of practice. DESIGN: Survey, pre- and post-intervention. METHODS: Medical and nursing staff in both units were surveyed before and after introduction of the NP model of practice. The instrument consisted of 25 statements relating to nurse-doctor interactions, with which respondents indicated their level of agreement on a five-point Likert scale. The Mann-Whitney U-test was used to compare scores for individual items and for overall collaboration between various groups of staff, and between the first and second surveys. RESULTS: Significant differences between the responses of nurses and doctors were found on both surveys. Areas of disagreement chiefly concerned doctors' behaviour and their attitudes towards nurses, rather than nurses' behaviour or environmental factors. Doctors consistently reported a higher degree of collaboration than did nurses. Few differences were found between first and second surveys. CONCLUSIONS: Results suggest that problems in nurse-physician interactions exist in both units. No impact of the NNP role, as established in this project, on interdisciplinary collaboration could be demonstrated. Further research in this area is warranted.