Post-Partum Skin-to-Skin Care and Infant Safety: Results of a State-Wide Hospital Survey.

Objectives. Survey current experience with Skin to Skin care (SSC) in Pennsylvania Maternity Centers. Study Design. The nursing director of each Maternity Center in PA (n = 95) was sent an on-line confidential survey querying SSC practices. Responses were compared by delivery size, location, and nature of affiliation. Statistics analyzed by chi-square and student t-test. Results. Of these 64/95 MCs (67%) responded. All allowed SSC after vaginal deliveries, 55% after C-section, 73% mother's room. Monitoring included delivery room nurse (94%) with support from other providers (61%), family members (37%), and electronic monitoring (5%). If SSC occurred in mother's room all reported family education on safe practices. 40% were aware of adverse SSC events, including falls and suffocation. About 80% educated staff about infant safety during SSC. Conclusions. Gaps in education and supervision during SSC were identified. Additional education and standardization of best practices are needed to reduce risks from falls and suffocation during SSC.

Casting Protocols Following BoNT-A Injections to Treat Spastic Hypertonia of the Triceps Surae in Children with Cerebral Palsy and Equinus Gait: A Randomized Controlled Trial.

AIM: To study the effects of single versus serial casting post-Botulinum toxin A (BoNT-A) injections on hypoextensibility of triceps surae in children, 2-7 years old, with cerebral palsy and equinus gait. METHODS: A randomized, stratified, parallel, two-group trial was conducted at a pediatric health center with assessments at baseline, precast, postcast and, 1-, 2-, and 6-month follow-ups. One week following BoNT-A injections into triceps surae muscle, a single below-knee cast (n = 10) or 3 serial casts (n = 10) were applied for 3 weeks. Primary outcome measure was the Modified Tardieu Scale (MTS), secondary outcome measures were Modified Ashworth Scale (MAS), GAITRite™, Gross Motor Function Measure-66 (GMFM-66), and Pediatric Evaluation of Disability Inventory (PEDI). RESULTS: Significant effects of time, but not group-by-time, were found for MTS R1 (P < 0.001), MTS R2 (P < 0.001), MAS (P = 0.001), GMFM-66 (P = 0.002), and PEDI (P < 0.001-0.009). One participant who received a single cast did not complete the 6-month assessment. CONCLUSIONS: Magnitudes of improvements were similar using single or serial casting. If these findings are corroborated in a larger scale study, the recommendation of a single cast may be appropriate due to its greater convenience for families and clinicians.

The Effect of Physicochemical Modification on the Function of Antibodies Induced by Anti-Nicotine Vaccine in Mice.

Smoking remains one of the major causes of morbidity and mortality worldwide. One approach to assisting smoking cessation is via anti-nicotine vaccines, composed of nicotine-like haptens conjugated to a carrier protein plus adjuvant(s). We have previously shown that the carrier, hapten, linker, hapten load, degree of conjugate aggregation, and presence of adducts can each influence the function (nicotine-binding capacity) of the antibody (Ab) induced. Herein, we extend those findings and show that tertiary structure is also critical to the induction of functional immune responses and that this can be influenced by conjugation conditions. We evaluated immunogenicity in mice using six lots of NIC7-CRM, a conjugate of 5-aminoethoxy-nicotine (Hapten 7), and a single point (glycine 52 to glutamic acid) mutant nontoxic form of diphtheria toxin, cross-reactive material 197 (CRM197), which were synthesized under different reaction conditions resulting in conjugates with equivalent molecular characteristics (hapten load, aggregates, adducts), but a different tertiary structure. When tested in mice, better functional responses (reduced nicotine in the brain of immunized animals relative to non-immunized controls) were obtained with conjugates with a more closed structure than those with an open conformation. These studies highlight the need for a better understanding of the physicochemical properties of small molecule conjugate vaccines.

Swaddling and Infant Sleeping Practices.

Swaddling promotes quiet sleep and may be a useful strategy to encourage infant safe sleep practices. We explored the effect of a swaddling education intervention on infant sleep practices in an urban minority community. We compared a cohort of postpartum mothers who were given education about swaddling to a historical group. Breastfeeding and pacifier use were similar in both groups. Compared to the historical group (n = 121), mothers in the swaddling group (n = 40) were more likely to swaddle infants to sleep (52.5 vs. 23.1 %, p = .001) and less likely to bedshare (15.4 vs. 33.1 %, p = .042). No significant effect was reported on infant supine sleep (81.6 vs. 69.4 %, p = .212). A postpartum swaddling education intervention had a limited impact on infant safe sleeping practices in an urban minority community. A recent metaanalysis demonstrated an increased risk of sudden infant death in infants swaddled for sleep and recommended the need to avoid the prone and side sleep position, especially for swaddled infants, and to set an age and developmentally appropriate limit for the use of swaddling. Ongoing studies are needed to monitor the safety and effectiveness of swaddling as a tool to promote safe sleeping in infants.

Introduction to Baculovirus Molecular Biology.

The development of baculovirus expression vector systems has accompanied a rapid expansion of our knowledge about the genes, their function and regulation in insect cells. Classification of these viruses has also been refined as we learn more about differences in gene content between isolates, how this affects virus structure and their replication in insect larvae. Baculovirus gene expression occurs in an ordered cascade, regulated by early, late and very late gene promoters. There is now a detailed knowledge of these promoter elements and how they interact first with host cell-encoded RNA polymerases and later with virus-encoded enzymes. The composition of this virus RNA polymerase is known. The virus replication process culminates in the very high level expression of both polyhedrin and p10 gene products in the latter stages of infection. It has also been realized that the insect host cell has innate defenses against baculoviruses in the form of an apoptotic response to virus invasion. Baculoviruses counter this by encoding apoptotic-suppressors, which also appear to have a role in determining the host range of the virus. Also of importance to our understanding of baculovirus expression systems is how the virus can accumulate mutations within genes that affect recombinant protein yield in cell culture. The summary in this chapter is not exhaustive, but should provide a good preparation to those wishing to use this highly successful gene expression system.

The Basic Domain of Herpes Simplex Virus 1 pUS9 Recruits Kinesin-1 To Facilitate Egress from Neurons.

UNLABELLED: The alphaherpesviral envelope protein pUS9 has been shown to play a role in the anterograde axonal transport of herpes simplex virus 1 (HSV-1), yet the molecular mechanism is unknown. To address this, we used an in vitro pulldown assay to define a series of five arginine residues within the conserved pUS9 basic domain that were essential for binding the molecular motor kinesin-1. The mutation of these pUS9 arginine residues to asparagine blocked the binding of both recombinant and native kinesin-1. We next generated HSV-1 with the same pUS9 arginine residues mutated to asparagine (HSV-1pUS9KBDM) and then restored them being to arginine (HSV-1pUS9KBDR). The two mutated viruses were analyzed initially in a zosteriform model of recurrent cutaneous infection. The primary skin lesion scores were identical in severity and kinetics, and there were no differences in viral load at dorsal root ganglionic (DRG) neurons at day 4 postinfection (p.i.) for both viruses. In contrast, HSV-1pUS9KBDM showed a partial reduction in secondary skin lesions at day 8 p.i. compared to the level for HSV-1pUS9KBDR. The use of rat DRG neuronal cultures in a microfluidic chamber system showed both a reduction in anterograde axonal transport and spread from axons to nonneuronal cells for HSV-1pUS9KBDM. Therefore, the basic domain of pUS9 contributes to anterograde axonal transport and spread of HSV-1 from neurons to the skin through recruitment of kinesin-1. IMPORTANCE: Herpes simplex virus 1 and 2 cause genital herpes, blindness, encephalitis, and occasionally neonatal deaths. There is also increasing evidence that sexually transmitted genital herpes increases HIV acquisition, and the reactivation of HSV increases HIV replication and transmission. New antiviral strategies are required to control resistant viruses and to block HSV spread, thereby reducing HIV acquisition and transmission. These aims will be facilitated through understanding how HSV is transported down nerves and into skin. In this study, we have defined how a key viral protein plays a role in both axonal transport and spread of the virus from nerve cells to the skin.

Solid pseudopapillary neoplasm of the pancreas head in a pregnant woman: safe pancreaticoduodenectomy postpartum.

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare and typically arise in young women. The optimal management of a pregnant woman suspected of having an SPN of the pancreas head is unclear. We report such a case where close monitoring for tumor growth was done during pregnancy and a successful pancreaticoduodenectomy was performed after term delivery.

Capturing patient information at nursing shift changes: methodological evaluation of speech recognition and information extraction.

OBJECTIVE: We study the use of speech recognition and information extraction to generate drafts of Australian nursing-handover documents. METHODS: Speech recognition correctness and clinicians' preferences were evaluated using 15 recorder-microphone combinations, six documents, three speakers, Dragon Medical 11, and five survey/interview participants. Information extraction correctness evaluation used 260 documents, six-class classification for each word, two annotators, and the CRF++ conditional random field toolkit. RESULTS: A noise-cancelling lapel-microphone with a digital voice recorder gave the best correctness (79%). This microphone was also the most preferred option by all but one participant. Although the participants liked the small size of this recorder, their preference was for tablets that can also be used for document proofing and sign-off, among other tasks. Accented speech was harder to recognize than native language and a male speaker was detected better than a female speaker. Information extraction was excellent in filtering out irrelevant text (85% F1) and identifying text relevant to two classes (87% and 70% F1). Similarly to the annotators' disagreements, there was confusion between the remaining three classes, which explains the modest 62% macro-averaged F1. DISCUSSION: We present evidence for the feasibility of speech recognition and information extraction to support clinicians' in entering text and unlock its content for computerized decision-making and surveillance in healthcare. CONCLUSIONS: The benefits of this automation include storing all information; making the drafts available and accessible almost instantly to everyone with authorized access; and avoiding information loss, delays, and misinterpretations inherent to using a ward clerk or transcription services.

A usability framework for speech recognition technologies in clinical handover: a pre-implementation study.

A multi-disciplinary research team is undertaking a trial of speech-to-text (STT) technology for clinical handover management. Speech-to-text technologies allow for the capture of handover data from voice recordings using speech recognition software and systems. The text documents created from this system can be used together with traditional handover notes and checklists to enhance the depth and breadth of data available for clinical decision-making at the point of care and so improve patient care and reduce medical errors. This paper reports on a preliminary study of perceived usability by nurses of speech-to-text technology based on interviews at a "test day" and using a user-task-technology usability framework to explore expectations of nurses of the use of speech-to-text (STT) technology for clinical handover. The results of this study will be used to design field studies to test the use of speech-to-text (STT) technologies at the point of care in several hospital settings.

The interaction of the HSV-1 tegument proteins pUL36 and pUL37 is essential for secondary envelopment during viral egress.

The herpes simplex virus type 1 (HSV-1) tegument proteins pUL36 (VP1/2) and pUL37 are essential for viral egress. We previously defined a minimal domain in HSV-1 pUL36, residues 548-572, as important for binding pUL37. Here, we investigated the role of this region in binding to pUL37 and facilitating viral replication. We deleted residues 548-572 in frame in a virus containing a mRFP tag at the N-terminus of the capsid protein VP26 and an eGFP tag at the C-terminus of pUL37 (HSV-1pUL36∆548-572). This mutant virus was unable to generate plaques in Vero cells, indicating that deletion of this region of pUL36 blocks viral replication. Imaging of HSV-1pUL36∆548-572-infected Vero cells, in comparison to parental and resucant, revealed a block in secondary envelopment of cytoplasmic capsids. In addition, immunoblot analysis suggested that failure to bind pUL37 affected the stability of pUL36. This study provides further insight into the role of this essential interaction.

Association of postpartum maternal tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine administration and timeliness of infant immunization.

A retrospective cohort study was conducted on infants of mothers delivering at an inner-city hospital in October 2009 where postpartum maternal tetanus toxoid, reduced diptheria toxoid and acellular pertussis (Tdap) vaccination had been initiated in May 2008. We compared mothers and infants in a Tdap intervention group discharged July 2008 (n=250) with a pre-Tdap control group discharged July 2007 (n=238). Postpartum maternal Tdap impacted positively timeliness of early infant immunization.

Ultrastructural visualization of individual tegument protein dissociation during entry of herpes simplex virus 1 into human and rat dorsal root ganglion neurons.

Herpes simplex virus 1 (HSV-1) enters neurons primarily by fusion of the viral envelope with the host cell plasma membrane, leading to the release of the capsid into the cytosol. The capsid travels via microtubule-mediated retrograde transport to the nuclear membrane, where the viral DNA is released for replication in the nucleus. In the present study, the composition and kinetics of incoming HSV-1 capsids during entry and retrograde transport in axons of human fetal and dissociated rat dorsal root ganglia (DRG) neurons were examined by wide-field deconvolution microscopy and transmission immunoelectron microscopy (TIEM). We show that HSV-1 tegument proteins, including VP16, VP22, most pUL37, and some pUL36, dissociated from the incoming virions. The inner tegument proteins, including pUL36 and some pUL37, remained associated with the capsid during virus entry and transit to the nucleus in the neuronal cell body. By TIEM, a progressive loss of tegument proteins, including VP16, VP22, most pUL37, and some pUL36, was observed, with most of the tegument dissociating at the plasma membrane of the axons and the neuronal cell body. Further dissociation occurred within the axons and the cytosol as the capsids moved to the nucleus, resulting in the release of free tegument proteins, especially VP16, VP22, pUL37, and some pUL36, into the cytosol. This study elucidates ultrastructurally the composition of HSV-1 capsids that encounter the microtubules in the core of human axons and the complement of free tegument proteins released into the cytosol during virus entry.

Identification of host cell proteins which interact with herpes simplex virus type 1 tegument protein pUL37.

The herpes simplex virus type 1 (HSV-1) structural tegument protein pUL37, which is conserved across the Herpesviridae family, is known to be essential for secondary envelopment during the egress of viral particles. To shed light on additional roles of pUL37 during viral replication a yeast two-hybrid screen of a human brain cDNA library was undertaken. This screen identified ten host cell proteins as potential pUL37 interactors. One of the interactors, serine threonine kinase TAOK3, was subsequently confirmed to interact with pUL37 using an in vitro pulldown assay. Such host cell/pUL37 interactions provide further insights into the multifunctional role of this herpesviral tegument protein.

Identification of a single amino acid residue which is critical for the interaction between HSV-1 inner tegument proteins pUL36 and pUL37.

The herpes simplex virus type 1 (HSV-1) structural tegument proteins pUL36 and pUL37 are essential for secondary envelopment during the egress of viral particles. For this study, scanning alanine mutagenesis of HSV-1 pUL37, in combination with yeast two-hybrid, identified pUL37 residue D631 as a major determinant for binding of pUL36. Further analysis of the binding of this pUL37 mutant to pUL36 by coimmunoprecipitation assay confirmed the role of pUL37 D631 in mediating binding of pUL36. A trans-complementation assay using pUL37 deletion virus FRΔUL37 was then carried out, where pUL37 wild type or D631A were provided in trans. For pUL37 D631A, a significant reduction in virus titer was observed compared to that seen when pUL37 wild type was present. The results presented here underline the crucial role of the pUL36/pUL37 interaction in replication of HSV-1 and indicate a critical role for pUL37 D631 in mediating this interaction.

Tiered maternity care training in family medicine.

BACKGROUND AND OBJECTIVES: Maternity care training in family medicine is a major component of our specialty. The Association of Family Medicine Residency Directors (AFMRD) issued a position paper calling for a two-tiered system of training for family physicians based on concern that some residency programs are unable to meet the current Residency Committee-Family Medicine (RC-FM) requirements for maternity care training. This two-tiered system was also endorsed by other family medicine organizations, including the AAFP, ADFM, NAPCRG, and STFM. Despite this support of the new system, there remains concern among some family medicine educators about this two-tiered approach. The Society of Teachers of Family Medicine Group on Hospital Medicine and Procedural Training met in 2009 and 2010 to develop an alternative tiered system for the training of family medicine residents in maternity care. METHODS: Working from previous requirements for maternity care training and the AFMRD document, the group used a multi-voting process to identify the tiers and their elements. RESULTS: The group generated a three-tier system for maternity care training in family medicine residencies. These included curriculum, patient volume, faculty expectations, and institutional requirements. CONCLUSIONS: The three tiers we propose address the importance of maternity care, the limitations that some residencies face in providing adequate patient volumes, and the need to teach more advanced skills to those family medicine residents who will work in rural and underserved areas upon graduation. We urge family medicine governing bodies to adopt this system and believe that it will help preserve the essential role that family physicians serve in the care of pregnant women starting with basic maternity care and extending to advanced roles including care of complicated pregnancies and cesarean delivery.

Ethics of involving children in health-related research: applying a decision-making framework to a clinical trial.

PURPOSE: This paper explores ethical issues related to the involvement of children in health-related research through the application of a conceptual model (the Miller and Kenny framework) to a current clinical trial on casting protocols for equinus gait of children with cerebral palsy (CP). SUMMARY OF KEY POINTS: The direct involvement of children in health-related research is important for maintaining and improving standards of paediatric clinical care. Ethical considerations around investigations involving this highly vulnerable population are complex, however, requiring the involvement of many levels of decision makers-government, research ethics boards (REBs), health care providers, parents, and children. The Miller and Kenny framework is useful in distinguishing these levels and heightening awareness of the complexities of the issues around engaging children in research. Considerations include the role of parents/caregivers in decision making, individual assessment of the child's decisional capacities, close attention to the child's context and life experience, provision of developmentally appropriate information about the research study, and careful assessment of dissent prior to withdrawing the child from the study. RECOMMENDATIONS: Physical therapists involved in paediatric clinical practice and/or research must be knowledgeable about ethical principles, policies, and REB requirements. The Miller and Kenny framework is a helpful guide to clarify decision-making roles around children's participation in research.

Functional roles of the tegument proteins of herpes simplex virus type 1.

Herpes virions consist of four morphologically distinct structures, a DNA core, capsid, tegument, and envelope. Tegument occupies the space between the nucleocapsid (capsid containing DNA core) and the envelope. A combination of genetic, biochemical and proteomic analysis of alphaherpes virions suggest the tegument contains in the order of 20 viral proteins. Historically the tegument has been described as amorphous but increasing evidence suggests there is an ordered addition of tegument during assembly. This review highlights the diverse roles, in addition to structural, that tegument plays during herpes viral replication using as an example herpes simplex virus type 1. Such diverse roles include: capsid transport during entry and egress; targeting of the capsid to the nucleus; regulation of transcription, translation and apoptosis; DNA replication; immune modulation; cytoskeletal assembly; nuclear egress of capsid; and viral assembly and final egress.

Advanced procedural training in family medicine: a group consensus statement.

BACKGROUND AND OBJECTIVES: Family medicine does not have a defined scope of procedures or universal standards for procedural training. This contributes to wide variation in family physician training and difficulties obtaining hospital privileges for advanced procedures. The Society of Teachers of Family Medicine (STFM) Group on Hospital Medicine and Procedural Training previously developed a list of core procedures to be taught in all family medicine residencies. The group reconvened to develop a consensus list of advanced procedures within the scope of family medicine. METHODS: Working from a master list of procedures, the group, which consisted of 21 family medicine educators, used a multi-voting process to identify advanced procedures within the scope of family medicine. RESULTS: The group generated a list of 36 advanced procedures and added nine procedures to the previously created list of core procedures. CONCLUSIONS: The STFM Group on Hospital Medicine and Procedural Training proposes a list of advanced procedures within the scope of family medicine and urges family medicine governing bodies to use this list to define and standardize the scope of procedural training and practice in family medicine.

Assessment protocol for serial casting after botulinum toxin a injections to treat equinus gait.

PURPOSE: The purpose of this study was to investigate feasibility of an assessment protocol for a trial of post-Botox casting to treat equinus gait in cerebral palsy. METHODS: Ten children (ages, 26-75 months) were recruited. Nine were assessed 1 week before botulinum toxin-A injections and reassessed 1 week after removal of the final cast. The assessment protocol included Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), Gross Motor Function Measure-66 (GMFM-66), Pediatric Evaluation of Disability Inventory (PEDI), and GAITRite. Feasibility was based on acceptability of the protocol, inter-rater reliability, and responsiveness of outcome measures. RESULTS: The assessment protocol was acceptable and practical. Inter-rater reliability for MAS, MTS, and GMFM ranged from moderate to excellent. Improvements were found in MTS and MAS scores for dorsiflexion and hamstring (p < 0.01), GMFM-66 (p = 0.01), and Pediatric Evaluation of Disability Inventory mobility (p = 0.01), self-care (p = 0.01), and social function (p = 0.00). GAITRite revealed reductions in speed (p = 0.00) and cadence (p = 0.01). CONCLUSIONS: Feasibility was confirmed. Recommendations include raising minimum age and delaying gait analysis.

Required procedural training in family medicine residency: a consensus statement.

BACKGROUND AND OBJECTIVES: Specific procedural training standards for US family medicine residencies do not exist. As a result, family physicians graduate with highly variable procedural skills, and the scope of procedural practice for family physicians remains poorly defined. Our objective was to develop a standard list of required procedures for family medicine residencies. METHODS: The Society of Teachers of Family Medicine Group on Hospital and Procedural Training convened a working group of 17 family physician educators. A multi-voting process was used to define categories and propose a list of required procedures for US family medicine residency programs. RESULTS: The group defined five categories of procedures within the scope of family medicine. Consensus was reached for a core list of procedures that all family medicine residents should be able to perform by the time of graduation. CONCLUSIONS: Defining standards for procedural training in family medicine will help clarify family medicine's scope of practice and should benefit both patients and family physicians. We propose that with input from national family medicine organizations, the procedure list presented in this report be used to develop a national standard for required procedural training.