Lyophilized (freeze-dried) human milk for preterm infants: a scoping review.

Freeze-drying (FD), or lyophilization, is commonly used to preserve foods. FD offers potential to create a human milk-derived human milk fortifier, and an alternative to freeze-storing human milk. However, processing human milk is known to affect its components. This scoping review explores the effect of FD on the; macronutrient, micronutrient, vitamin, bioactive components, microbes and anti-microbial factors in human milk, and studies where lyophilized human milk has been given to newborn infants. 48 articles were identified after full text review. FD human milk reduces the fat globule size and as well as the quantity of enzymes, vitamin C and immunoglobulin. Common serum electrolyte disturbances have been reported when preterm infants' are fed FD human milk however it appears a promising method to avoid exposure of preterm infants' to cows' milk. Due to limited data, further studies exploring the safety and efficacy of FD human milk in preterm infants are needed.

A Quality Improvement Initiative to Reduce Necrotizing Enterocolitis in Very Preterm Infants.

OBJECTIVE: To reduce the incidence of necrotizing enterocolitis (NEC) among very preterm infants in the Calgary Health Region to ≤2% within 2 years. METHODS: A multidisciplinary team developed key drivers for NEC. Targeted interventions included strategies to increase mothers' own milk (MOM), improve compliance with feeding regimens, standardize management of feeding intolerance, prevent intestinal microbial aberrations, and feed conservatively during blood transfusion and the treatment of patent ductus arteriosus. The outcome measure was NEC (≥ stage 2). Changes in NEC rates were examined among racial and ethnic groups. Process measures included MOM feeding at discharge, the difference between actual and expected time to reach full feeds, lowest hemoglobin, and the duration of empirical antibiotics. Growth, the rate of blood transfusion, and the duration of parenteral nutrition were balancing measures. The preintervention, intervention, and sustainment periods were January 2013 to June 2016, July 2016 to December 2018, and December 2018 to December 2021, respectively. RESULTS: We included 2787 infants born at ≤326/7 weeks' gestation (1105 preintervention, 763 during intervention, and 919 in sustainment). NEC decreased from 5.6% to 1.9%. Process measures indicated increased MOM feeding at discharge, improved compliance with feeding regimens, increased lowest hemoglobin levels, and shorter durations of empirical antibiotics. Balancing measures revealed improved weight Z-scores, shorter durations on parenteral nutrition, and increased rates of blood transfusion. CONCLUSIONS: Quality improvement initiatives to increase MOM, improve compliance with feeding regimens, feed conservatively during blood transfusion and treatment of patent ductus arteriosus, and prevent intestinal microbial aberrations were associated with reduced NEC.

Gestational Development of the Human Immune System.

Building an immune system is a monumental task critical to the survival of the fetus and newborn. A functional fetal immune system must complement the maternal immune system in handling in utero infection; abstain from damaging non-self-reactions that would compromise the materno-fetal interface; mobilize in response to infection and equip mucosal tissues for pathogen exposure at birth. There is growing appreciation that immune cells also have noncanonical roles in development and specifically may contribute to tissue morphogenesis. In this review we detail how hematopoietic and lymphoid organs jointly establish cellular constituents of the immune system; how these constituents are organized in 2 mucosal sites-gut and lung-where early life immune function has long-term consequences for health; and how exemplar diseases of prematurity and inborn errors of immunity reveal dominant pathways in prenatal immunity.

The Big Four: Functional Assessment Research Informs Preventative Behavior Analysis.

Current practice guidelines suggest that the assessment and treatment of challenging behavior should consist of conducting a functional behavior assessment following the onset of problem behavior. This assessment process can include indirect and direct assessment, as well as manipulation of variables to determine function. The purpose of this article is to outline a proposal that would add prevention practices to early intervention guidelines for problem behavior. Based on decades of research, the suggestion is to proactively teach children at risk for problem behavior to navigate four of the most common conditions that have been demonstrated to occasion problem behavior. Prevention is made a possibility because a large body of research examining the conditions under which challenging behavior occurs has been reliably replicated. Preventative approaches are an emerging phenomenon and reflect a progression in the practice of behavior analysis. Prevention may lead to acquisition of prosocial behavior before problems arise, to expedited and enhanced treatment, to increased access to favorable learning environments, and, we hope, to improvement in the quality of life for many children at risk for the development of problem behavior.

A multicenter audit of the use of bronchoscopy during open and thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

BACKGROUND: Esophageal atresia (EA) with tracheoesophageal fistula is usually repaired in the neonatal period. Preferential ventilation through the fistula can lead to gastric distension. Bronchoscopy has a role in defining the site and size of the fistula, and may be carried out by the surgeon or the anesthetist. The use of bronchoscopy varies across different institutions. METHODS: This is a multicenter case note review of infants with EA with tracheoesophageal fistula who underwent surgery between January 2010 and December 2015. This retrospective audit aims primarily to document the use of bronchoscopy during open and thoracoscopic repair at a selection of United Kingdom centers. Respiratory complications, that is relating to airway management, the respiratory system, and difficulty with ventilation, at induction and during surgery, are recorded. The range of techniques for anesthesia and analgesia in these centers is noted. RESULTS: Bronchoscopy was carried out in 52% of cases. The incidence of respiratory complications was 7% at induction and 21% during surgery. Thoracoscopic repair usually took longer. One center used high-frequency oscillatory ventilation, on an elective basis during thoracoscopic repair, to facilitate surgical access and address concerns about hypoxemia and hypercarbia. CONCLUSION: The use of bronchoscopy varies considerably between institutions. Infants undergoing tracheoesophageal fistula repair are at risk of perioperative respiratory morbidity. The advent of thoracoscopic repair has introduced further variation.

Recent outbreaks of infectious syphilis, United Kingdom, January 2012 to April 2014.

Six outbreaks of infectious syphilis in the United Kingdom, ongoing since 2012, have been investigated among men who have sex with men (MSM) and heterosexual men and women aged under 25 years. Interventions included case finding and raising awareness among healthcare professionals and the public. Targeting at-risk populations was complicated as many sexual encounters involved anonymous partners. Outbreaks among MSM were influenced by the use of geospatial real-time networking applications that allow users to locate other MSM within close proximity.

A self-completed nutrition screening tool for community-dwelling older adults with high reliability: a comparison study.

OBJECTIVES: Malnutrition is common in community-dwelling older adults and is associated with poor outcomes including hospitalization and mortality. Recently, a 6-question short form mini nutritional assessment (SF-MNA) was validated for rapid nutrition screening. Ideally, nutrition screening could be performed by individuals or their caregivers prior to or during an outpatient clinical visit, thus allowing for the ongoing monitoring of nutritional status among older adults. DESIGN: We compared the SF-MNA administered by a healthcare professional (HCP) to a 6-item self-administered screening tool (Self-MNA) in 463 community dwelling older adults who gave informed consent. The population was 60% women with a mean age of 76.8±6.8 years. The HCP was blinded to the results of the Self-MNA questionnaire. RESULTS: Using the SF-MNA, 27% of subjects were malnourished, 38% were at risk, and 35% had normal nutrition status. The agreement between the Self-MNA and the SF-MNA was 99% (Self-MNA sensitivity 99%, specificity 98%, false negative rate 1%, false positive rate 2%) for identifying Malnourished subjects and 83% (sensitivity 89%, specificity 77%, false negative rate 11%, false positive rate 23%) for identifying At Risk of Malnutrition compared to the MNA-SF administered by a HCP. CONCLUSION: We found that the Self-MNA demonstrates sufficient inter-rater reliability for use in nutrition screening among community-dwelling older adults. Further validation studies and the possible impact of language translation should be pursued.

Laboratory-based surveillance of Campylobacter and Salmonella infection and the importance of denominator data.

Laboratory data are the cornerstone in surveillance of infectious disease. We investigated whether changes in reported incidence of Campylobacter and Salmonella infection might be explained by changes in stool sampling rates. Data were extracted from a national database on 585 843 patient stool samples tested by microbiology laboratories in Wales between 1998 and 2008. Salmonella incidence fell from 43 to 19 episodes/100 000 population but Campylobacter incidence after declining from 111/100 000 in 1998 to 84/100 000 in 2003 rose to 119/100 000 in 2008. The proportion of the population sampled rose from 2·0% in 1998 to 2·8% in 2008, mostly due to increases in samples from hospital patients and older adults. The proportion of positive samples declined for both Salmonella and Campylobacter from 3·1% to 1·1% and from 8·9% to 7·5%, respectively. The decline in Salmonella incidence is so substantial that it is not masked even by increased stool sampling, but the recent rise in Campylobacter incidence may be a surveillance artefact largely due to the increase in stool sampling in older people.

Two waves of pandemic influenza A(H1N1) 2009 in Wales--the possible impact of media coverage on consultation rates, April-December 2009.

In the United Kingdom, the influenza A(H1N1) 2009 pandemic had a distinct two-wave pattern of general practice consultations for influenza-like illness (ILI). We describe the epidemiology of the influenza pandemic in Wales between April and December 2009 using integrated data from a number of independent sources: GP surveillance, community virology surveillance, hospital admissions and deaths, and media enquiries monitoring. The first wave peaked in late July at 100 consultations per 100,000 general practice population and attracted intensive media coverage. The positivity rate for the A(H1N1)2009 influenza did not exceed 25% and only 44 hospitalisations and one death were recorded. By contrast, the second wave peaked in late October and although characterised by lower ILI consultation rates (65 consultations per 100,000 general practice population) and low profile media activity, was associated with much higher positivity rates for pandemic influenza A(H1N1)2009 (60%) and substantially more hospital admissions (n=379) and deaths (n=26). The large number of ILI-related consultations during the first wave in Wales probably reflected the intensive media activity rather than influenza virus circulating in the community. Data from community surveillance schemes may therefore have considerably overestimated the true incidence of influenza. This has implications for the future interpretation of ILI surveillance data and their use in policy making, and underlines the importance of using integrated epidemiological, virological and hospital surveillance data to monitor influenza activity.

Why has oral health promotion and prevention failed children requiring general anaesthesia for dental extractions?

OBJECTIVES: Many children in the UK still require dental treatment under general anaesthesia (DGA). Why oral health promotion and prevention, in this cohort of children, has failed is poorly understood. By questioning the parents/carers of children undergoing DGA this study aimed to establish: 1 previous exposure to oral health education and promotion activities; 2 beliefs and behaviours about dental caries and prevention; and 3 what parents perceive useful in preventing dental caries. BASIC RESEARCH DESIGN: A cross-sectional questionnaire based study. CLINICAL SETTING: Dental general anaesthetic centres in Wales, UK. PARTICIPANTS: 207 consecutively attending parents of children aged < 10 years requiring a DGA. RESULTS: In total, 150 (76%) parents/carers claimed to have received previous oral health advice and 103 (52%) had received toothbrushing instruction from a dentist. Only 18 (9%) reported the application of topical fluoride. Sixty seven (34%) believed "tooth decay runs in families" and 53 (27%) it was simply bad luck that their child had dental decay. The majority (89%) believed that information leaflets on oral health would be useful and 133 (67%) would find information on a website helpful. CONCLUSIONS: This study suggests that there is a significant scope for increasing the exposure of high risk children to fluoride. A sense of fatalism and erroneous beliefs were evident amongst some parents/carers of children needing DGA. These issues need to be addressed in the future design of oral health promotion/prevention activities.

Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status.

OBJECTIVE: To validate a revision of the Mini Nutritional Assessment short-form (MNA(R)-SF) against the full MNA, a standard tool for nutritional evaluation. METHODS: A literature search identified studies that used the MNA for nutritional screening in geriatric patients. The contacted authors submitted original datasets that were merged into a single database. Various combinations of the questions on the current MNA-SF were tested using this database through combination analysis and ROC based derivation of classification thresholds. RESULTS: Twenty-seven datasets (n=6257 participants) were initially processed from which twelve were used in the current analysis on a sample of 2032 study participants (mean age 82.3y) with complete information on all MNA items. The original MNA-SF was a combination of six questions from the full MNA. A revised MNA-SF included calf circumference (CC) substituted for BMI performed equally well. A revised three-category scoring classification for this revised MNA-SF, using BMI and/or CC, had good sensitivity compared to the full MNA. CONCLUSION: The newly revised MNA-SF is a valid nutritional screening tool applicable to geriatric health care professionals with the option of using CC when BMI cannot be calculated. This revised MNA-SF increases the applicability of this rapid screening tool in clinical practice through the inclusion of a "malnourished" category.

Practitioners' perspectives and experiences of the new National Health Service dental contract.

BACKGROUND: In April 2006, fundamental changes were made to the arrangements for commissioning state funded (National Health Service, NHS) dental care in England and Wales. These involved the dissolution of a universal national contract and the introduction of locally commissioned primary dental care services. Suggested advantages included the elimination of a fee-for-item 'treadmill', an increased emphasis on prevention and improved patient access. This change came at a time when many practitioners were opting to provide care outside the NHS. OBJECTIVES: This study investigated dentists' experience of the new contract and compared this with attitudes determined in a previous survey of the same cohort of dentists conducted immediately before the changed commissioning arrangements. METHODS: Data were collected via a postal questionnaire, comprising a combination of 60 open and closed questions, mailed to 608 general dental practitioners in Wales. RESULTS: Four hundred and ninety-six (77%) questionnaires were returned. Four hundred and seventeen practitioners continued to provide NHS dental care. Only 46 (11%) of the 417 practitioners agreed that they liked the new method of remuneration and the majority (362 [86.8%]) perceived that they still delivered state-funded care in a 'treadmill' environment. This compares with 34.9% of dentists who perceived the new system as a 'treadmill' immediately before its implementation. Three hundred and forty-eight (83.4%) disagreed that they were able to spend more time on prevention and 356 (85.3%) did not feel they had more time to spend with patients--key objectives of the reforms. Two hundred and seventy-five (65.9%) respondents agreed that local NHS commissioners were controlling their business. CONCLUSION: This survey, conducted 18 months after the implementation of the new commissioning arrangements, suggests that practitioners are deeply unhappy with local commissioning. It raises questions as to whether the changes have achieved the Government's stated objectives in reforming state-funded primary dental care.

Systemic inflammatory markers in older persons: the effect of oral nutritional supplementation with prebiotics.

OBJECTIVE: To evaluate the effect of oral nutritional supplementation with and without oligosaccharides on gut bacteriology, in particular the bifidogenic flora, and on immunology and inflammatory parameters in older persons at risk of malnutrition. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: Division of Geriatric Medicine, St. Louis University, Missouri, United States. PARTICIPANTS: Seventy-four community dwelling elderly and/or nursing home subjects (age superior 70 y; 84 +/- 7 years) either undernourished or at risk of undernutrition. INTERVENTION: Daily liquid supplements, with (1.3 g/250 ml) and without oligosaccharides (OS) for 12 weeks. MEASUREMENTS: Nutritional evaluation, serum immunoglobulins, lymphocyte subsets, various cytokines and the endotoxin soluble receptor CD14 (sCD14) in serum, and cytokines specific mRNA in peripheral blood mononuclear cells at baseline and 12 weeks, and fecal bacteriologicy. RESULTS: Specific mRNA extracted from blood leucocytes showed a different level of pro-inflammatory gene activation: TNF-alpha mRNA and IL-6 mRNA diminished in the OS group after 12 weeks, while no changes were detected in the control group (P=0.05 and P=0.04 respectively). Serum levels of sCD14, a product shed by activated macrophages, decreased only in the OS group without reaching statistical significance (P=0.08). No significant differences were detected in the fecal gut flora or in the nutritional parameters. CONCLUSIONS: This study shows that the administration of supplements in older persons at risk of malnutrition may benefit from the addition of prebiotics that can improve the low noise inflammatory process frequently observed in this population.

Domestic and travel-related foodborne gastrointestinal illness in a population health survey.

Routine surveillance data underestimate incidence of foodborne gastrointestinal (FGI) illness and provide little information on illness related to travel. We analysed data from the Welsh Health Survey to estimate population incidence, and to examine risk factors for FGI and factors associated with consulting a doctor. Reported frequency of any FGI in the 3 months before interview was 20.0% [95% confidence interval (CI) 19.5-20.4; equivalent to 0.8 episodes per person-year], and for travel-related FGI was 1.6% (95% CI 1.5-1.8). In the final model, sex, age group, marital status, self-reported health, long-term illness, smoking and alcohol consumption were all independent predictors of FGI. People who consulted a doctor were likely to be older, in poorer health, taking regular medication, or to report mental illness. FGI is common but risk factors for illness and consultation differ and impressions of the epidemiology of the disease based on surveillance data are therefore distorted.

A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients.

BACKGROUND: A number of frail, older, undernourished patients cannot maintain adequate oral intake to meet protein-calorie needs after an illness, even when high-density nutritional supplements are added. Tolerance to enteral nutrition by gastric tube is poor in this group of patients. Peripheral parenteral nutrition is an effective method of administering nutritional support to patients with mild to moderate nutritional deficiencies who are unable to receive enteral nutrition or for whom enteral nutrition alone cannot meet energy needs. However, no data exists for the use of peripheral parenteral nutrition longer than two weeks and overall there are remarkably few studies on the efficacy of peripheral parenteral nutrition. METHODS: A Phase 4, single center, prospective, randomized, parallel group design clinical trial was conducted to evaluate long-term safety of peripheral parenteral nutrition in post-acute patients receiving inadequate enteral nutrition. Nutritional status was measured by the Mini-Nutritional Assessment and functional status by the Functional Inventory Measure. Subjects received a mean duration for peripheral parenteral nutrition of 15.8 +/- 6.7 days (range 8-23). RESULTS: The peripheral parenteral nutrition group demonstrated several trends towards improvement in prealbumin, CD4 cell count, and functional status compared to the untreated control group. Two patients in the peripheral parenteral nutrition group developed low-grade phlebitis; however, this did not result in discontinuing intravenous therapy. No other adverse events occurred. This study demonstrates that peripheral parenteral nutrition is feasible and safe in postacute care. CONCLUSIONS: We conclude that peripheral parenteral nutrition can be safely administered in post-acute settings with a low rate of complications.

Tuberculosis education in an endemic setting: application of participatory methods to video development in The Gambia.

OBJECTIVE: To produce an educational video for tuberculosis (TB) awareness in The Gambia using participatory methods and integrated formative evaluation. METHODS: A steering group was formed of key people working in TB research, health education, the health service and the media. They developed a script and commissioned local production of the video in three local languages and English. A formative participatory evaluation of the project was conducted using document review, attendance at rehearsals and semi-structured interviews. A pilot version of the video was evaluated through focus groups in Banjul and remote villages. Data were analysed using a general inductive approach. RESULTS: Five major themes emerged from evaluation of the project participatory process: collaboration, knowledge sharing, networking, ownership and a common desire to sustain the project goals for video dissemination. The video was well received and described as informative, entertaining and professional. Audiences were able to identify the key messages, prevailing attitudes about TB were challenged, and many participants expressed a desire to act on their new knowledge. CONCLUSION: A participatory approach to the development of a video in The Gambia proved to be empowering to local participants and led to the production of a resource well received by Gambian people.

The relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality.

BACKGROUND: Prediction of in-hospital mortality may direct hospital resources towards those patients most at risk. A number of single domain risk instruments have been developed, indicating that functional status, nutritional assessment, and severity of illness individually predict in-hospital mortality. The interaction among these predictors is less well described. OBJECTIVE: To determine the relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality. DESIGN, SETTING, SUBJECTS: Cohort study of 1712 consecutive admissions over a one year period to an Internal Medical Service at a tertiary university teaching hospital. MAIN OUTCOME MEASURES: Death during hospital admission. RESULTS: Dependency in activities of daily living (OR = 3.37, 95% CI 1.78 to 6.37, p = 0.0002) and body mass index less than 20 (OR = 2.38, 95% CI 1.20 to 4.74, p = 0.01) predicted in-hospital mortality after adjusting for nutritional risk assessment, and severity of illness score. CONCLUSIONS: Impairment in functional status and low body mass index produce the best predictors of inhospital mortality, after adjusting for nutritional risk and severity of illness score. Among these factors, functional impairment may be amenable to correction.

Psychosocial effects of acne.

This article discusses the psychological effect of acne vulgaris. It is shown that acne has significant effect on self-image and impacts quality of life. The impact of acne may be equivalent to that of asthma or epilepsy. Anxiety and depression and a reduction in social functioning are a consequence of this condition. Effective treatment results in improvement of quality-of-life measurement. Most of the data is gathered from case control studies. Further work, particularly prospective longitudinal cohort studies, needs to be performed to validate the impact of acne on quality of life. Acne severity grading should incorporate life quality scores to better establish the true impact of this condition on our patients in order to optimize therapy.

[3H]-SB-269970 radiolabels 5-HT7 receptors in rodent, pig and primate brain tissues.

The selective 5-HT7 receptor antagonist radioligand, [3H]-SB-269970, has been reported to radiolabel the human cloned 5-HT7(a) receptor and 5-HT7 receptors in guinea pig cortex (thomas et al, 2000). Saturation analysis of [3H]-SB-269970 binding to mouse forebrain, rat cortex, pig cortex, marmoset cortex and human thalamus membranes was consistent with labelling a homogenous population of binding sites in each tissue. K(D) values for [3H]-SB-269970 binding in these tissues ranged from 0.9 to 2.3 nM, being similar to those reported for the human cloned and guinea pig cortex 5-HT7 receptors (1.3 and 1.7 nM, respectively). Bmax values for [3H]-SB-269970 binding to the mouse, rat, pig, marmoset and human brain membranes were 20, 30, 31, 14 and 68 fmoles x mg x protein(-1), respectively. For each species the profile of inhibition of [3H]-SB-269970 binding, using a number of 5-HT7 receptor agonists and antagonists, correlated well with that reported for the human cloned 5-HT7(a) receptor (correlation coefficients were 0.95, 0.94, 0.92, 0.95, 0.97 versus the mouse, rat, pig, marmoset and human tissues, respectively). In conclusion, [3H]-SB-269970 has been shown to radiolabel 5-HT7 receptors in rodent, pig and primate brain and represents a valuable tool with which to further characterise the distribution and function of 5-HT7 receptors in native tissues and elucidate their potential role in disease states.

An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH).

BACKGROUND: Currently, there is no instrument that provides an accurate and simple method of monitoring pressure ulcer healing in clinical practice. This article reports the two studies that were conducted to assess the validity of the Pressure Ulcer Scale for Healing (PUSH) as a tool to monitor healing of stage II-IV pressure ulcers. METHODS: Subjects in both studies (N = 103 and N = 269) were elderly (mean Study 1, 75 years, mean Study 2, 80 years), and the majority were women (Study 1, 51%, Study 2, 70%). Study data were extracted from patients' permanent records. RESULTS: Principal components analysis confirmed that the PUSH tool accounted for 58% to 74% of the wound healing variance over a 10-week period in Study 1 and 40% to 57% of the wound healing variance over a 12-week period in Study 2. In addition, multiple regression analysis, used to measure the sensitivity of the model to total healing, showed PUSH accounted for 39% of the variance in 6 weeks and 31% of the variance over 12 weeks (p <.001; Studies 1 and 2, respectively). CONCLUSIONS: Data from these two studies confirmed that the PUSH tool, with the components of length times width, exudate amount, and tissue type, is a valid and sensitive measure of pressure ulcer healing. It is a practical approach that provides clinically valid data regarding pressure ulcer healing. Further testing is needed to confirm these findings.