The relationship of early expressed milk quantity and later full breastmilk feeding after very preterm birth: A cohort study.

When infants cannot directly breastfeed after birth, mothers are advised to initiate lactation through mechanical expression. Families are recommended to target an expression volume of at least 500-750 mL by Day 14 after birth, as this is considered a 'critical window' to establish milk supply. This is challenging for many mothers after a very preterm birth. This article explores the relationship of early milk quantity and later full breastmilk feeding as a 'gold standard' outcome, using statistical techniques designed for diagnostic tests. A cohort of 132 mothers of infants born at 23 + 0 to 31 + 6 weeks' gestational age submitted expressing logs on Day 4, 14 and 21 after birth and provided later feeding outcome. Using receiver operating characteristic (ROC) analysis, the following 24-h milk quantities were identified as associated with high probability of full breastmilk at 36 weeks' post-menstrual age (PMA): on Day 4, ≥250 g (specificity 88%; positive predictive value 88%) and on Day 21 ≥650 g (specificity 88%; positive predictive value 91%). The following values were identified as associated with low probability of full breastmilk at 36 weeks' PMA: on Day 4 <50 g (sensitivity 92%; negative predictive value 72%) and on Day 21 <250 g (sensitivity 90%; negative predictive value 70%). Participants exceeding the high thresholds had 3-4 times increased likelihood of full breastmilk, whereas those below the low thresholds had 3-5 times lower likelihood. These thresholds have potential as targets for families, to provide individualised prognostic information and to help clinicians target more intensive lactation support.

Does Arterial Stiffness Predict Cardiovascular Disease in Older Adults With an Intellectual Disability?

BACKGROUND: Arterial stiffness has been associated with an increased risk of cardiovascular disease (CVD) in some patient populations. OBJECTIVES: The aims of this study were to investigate (1) whether there is an association between arterial stiffness, as measured by the Mobil-O-Graph, and risk for CVD in a population of individuals with intellectual disability and (2) whether arterial stiffness can predict the risk for CVD. METHODS: This cross-sectional study included 58 individuals who participated in wave 4 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Aging (2019-2020). Statistical models were used to address the first aim, whereas machine learning models were used to improve the accuracy of risk predictions in the second aim. RESULTS: Sample characteristics were mean (SD) age of 60.69 (10.48) years, women (62.1%), mild/moderate level of intellectual disability (91.4%), living in community group homes (53.4%), overweight/obese (84.5%), high cholesterol (46.6%), alcohol consumption (48.3%), hypertension (25.9%), diabetes (17.24%), and smokers (3.4%). Mean (SD) pulse wave velocity (arterial stiffness measured by Mobil-O-Graph) was 8.776 (1.6) m/s. Cardiovascular disease risk categories, calculated using SCORE2, were low-to-moderate risk (44.8%), high risk (46.6%), and very high risk (8.6%). Using proportional odds logistic regression, significant associations were found between arterial stiffness, diabetes diagnosis, and CVD risk SCORE2 (P < .001). We also found the Mobil-O-Graph can predict risk of CVD, with prediction accuracy of the proportional odds logistic regression model approximately 60.12% (SE, 3.2%). Machine learning models, k-nearest neighbor, and random forest improved model predictions over and above proportional odds logistic regression at 75.85% and 77.7%, respectively. CONCLUSIONS: Arterial stiffness, as measured by the noninvasive Mobil-O-Graph, can be used to predict risk of CVD in individuals with intellectual disabilities.

The effects of prematurity and socioeconomic deprivation on early speech perception: A story of two different delays.

There is evidence showing that both maturational and environmental factors can impact on later language development. On the one hand, preterm birth has been found to increase the risk of deficits in the preschool and school years. Preterm children show poorer auditory discrimination, reading difficulties, poor vocabulary, less complex expressive language and lower receptive understanding than their matched controls. On the other hand, socioeconomic status (SES) indicators (i.e., income, education and occupation) have been found to be strongly related to linguistic abilities during the preschool and school years. However, there is very little information about how these factors result in lower linguistic abilities. The present study addresses this issue. To do so, we investigated early speech perception in full and preterm infants from families classed as high or low SES. Seventy-six infants were followed longitudinally at 7.5, 9, 10.5 and 12 months of age. At each test point, three studies explored infants' phonetic, prosodic and phonotactic development respectively. Results showed no significant differences between the phonetic or the phonotactic development of the preterm and the full-term infants. However, a time-lag between preterm and full-term developmental timing for prosody was found. Socioeconomic status did not have a significant effect on prosodic development. Nonetheless, phonetic and phonotactic development was affected by SES, infants from lower SES showed phonetic discrimination of non-native contrast and a preference for high-probability sequences later than their more advantaged peers. Overall these results suggest that different constraints apply to the acquisition of different phonological subcomponents.

Safe threshold of capillary blood glucose for predicting early future neonatal hypoglycaemia in babies born to mothers with gestational diabetes mellitus, an observational, retrospective cohort study.

BACKGROUND: There is increasing pressure to get women and babies home rapidly after birth. Babies born to mothers with gestational diabetes mellitus (GDM) currently get 24-h inpatient monitoring. We investigated whether a low-risk group of babies born to mothers with GDM could be defined for shorter inpatient hypoglycaemia monitoring. METHODS: Observational, retrospective cohort study conducted in a tertiary maternity hospital in 2018. Singleton, term babies born to women with GDM and no other risk factors for hypoglycaemia, were included. Capillary blood glucose (BG) testing and clinical observations for signs of hypoglycaemia during the first 24-h after birth. BG was checked in all babies before the second feed. Subsequent testing occurred if the first result was < 2.0 mmol/L, or clinical suspicion developed for hypoglycaemia. Neonatal hypoglycaemia, defined as either capillary or venous glucose ≤ 2.0 mmol/L and/or clinical signs of neonatal hypoglycaemia requiring oral or intravenous dextrose (lethargy, abnormal feeding behaviour or seizures). RESULTS: Fifteen of 106 babies developed hypoglycaemia within the first 24-h. Maternal and neonatal characteristics were not predictive. All babies with hypoglycaemia had an initial capillary BG ≤ 2.6 mmol/L (Area under the ROC curve (AUC) 0.96, 95% Confidence Interval (CI) 0.91-1.0). This result was validated on a further 65 babies, of whom 10 developed hypoglycaemia, in the first 24-h of life. CONCLUSION: Using the 2.6 mmol/L threshold, extended monitoring as an inpatient could have been avoided for 60% of babies in this study. Whilst prospective validation is needed, this approach could help tailor postnatal care plans for babies born to mothers with GDM.

A Bifidobacterial pilus-associated protein promotes colonic epithelial proliferation.

Development of the human gut microbiota commences at birth, with certain bifidobacterial species representing dominant and early colonisers of the newborn gastrointestinal tract. The molecular basis of Bifidobacterium colonisation, persistence and presumed communication with the host has remained obscure. We previously identified tight adherence (Tad) pili from Bifidobacterium breve UCC2003 as an essential colonisation factor. Here, we demonstrate that bifidobacterial Tad pili also promote in vivo colonic epithelial proliferation. A significant increase in cell proliferation was detectable 5 days postadministration of B. breve UCC2003. Using advanced functional genomic approaches, bacterial strains either (a) producing the Tad2003 pili or (b) lacking the TadE or TadF pseudopilins were created. Analysis of the ability of these mutant strains to promote epithelial cell proliferation in vivo demonstrated that the pilin subunit, TadE, is the bifidobacterial molecule responsible for this proliferation response. These findings were confirmed in vitro using purified TadE protein. Our data imply that bifidobacterial Tad pili may contribute to the maturation of the naïve gut in early life through the production of a specific scaffold of extracellular protein structures, which stimulate growth of the neonatal mucosa.

Epicardial pacing wires after cardiac surgery: an Irish cross-sectional study.

BACKGROUND: Temporary epicardial pacing wires are inserted after cardiac surgery. However, there are no international guidelines on which to base best practice regarding wire insertion or removal. METHODS: Data were collected on patients following cardiopulmonary bypass and analysed in terms of use, duration of use and complications of pacing wires after surgery. RESULTS: Wires were inserted in 164 of the 167 patients. Most (74%) did not require pacing. Patients were categorised into those who had aortic valve replacement (AVR) (n=42) and those who did not (n=122). Of the AVR group, 26% (n=11) were pacemaker dependent after surgery and 10% (n=4) required permanent pacemakers. Most pacing wires were removed by day 4. The only noted complication was delayed discharge. CONCLUSION: Unused pacing wires are normally removed on day 4, but for 77 (47%) of patients they remained in place longer. Forty patients (24%) had delayed wire removal because of a policy of wire removal during business hours only. Of these 40 patients, 27 (17% of the 77 with delayed removal) had delayed discharge as a result of our wire removal policy.

Evolution of a 72-Kilobase Cointegrant, Conjugative Multiresistance Plasmid in Community-Associated Methicillin-Resistant Staphylococcus aureus Isolates from the Early 1990s.

Horizontal transfer of plasmids encoding antimicrobial resistance and virulence determinants has been instrumental in Staphylococcus aureus evolution, including the emergence of community-associated methicillin-resistant S. aureus (CA-MRSA). In the early 1990s, the first CA-MRSA strain isolated in Western Australia (WA), WA-5, encoded cadmium, tetracycline, and penicillin resistance genes on plasmid pWBG753 (∼30 kb). WA-5 and pWBG753 appeared only briefly in WA; however, fusidic acid resistance plasmids related to pWBG753 were also present in the first European CA-MRSA isolates at the time. Here, we characterize a 72-kb conjugative plasmid, pWBG731, present in multiresistant WA-5-like clones from the same period. pWBG731 was a cointegrant formed from pWBG753 and a pWBG749 family conjugative plasmid. pWBG731 carried mupirocin, trimethoprim, cadmium, and penicillin resistance genes. The stepwise evolution of pWBG731 likely occurred through the combined actions of IS257, IS257-dependent miniature inverted-repeat transposable elements (MITEs), and the BinL resolution system of the ß-lactamase transposon Tn552 An evolutionarily intermediate ∼42-kb nonconjugative plasmid, pWBG715, possessed the same resistance genes as pWBG731 but retained an integrated copy of the small tetracycline resistance plasmid pT181. IS257 likely facilitated the replacement of pT181 with conjugation genes on pWBG731, thus enabling autonomous transfer. Like conjugative plasmid pWBG749, pWBG731 also mobilized nonconjugative plasmids carrying oriT mimics. It seems likely that pWBG731 represents the product of multiple recombination events between the WA-5 pWBG753 plasmid and other mobile genetic elements present in indigenous community-associated methicillin-sensitive S. aureus (CA-MSSA) isolates. The molecular evolution of pWBG731 saliently illustrates how diverse mobile genetic elements can together facilitate rapid accrual and horizontal dissemination of multiresistance in S. aureus CA-MRSA.

Fifteen-minute consultation: Breastfeeding in the first 2 weeks of life-a hospital perspective.

The beneficial health and economic impacts of breastfeeding are considerable. However the majority of babies in the UK are not exclusively breastfeeding by 6 weeks of age. The first few weeks of life are therefore a critical period to facilitate breastfeeding. Health professionals must have a thorough knowledge of normal breastfeeding patterns in order to minimise unnecessary interference, and an understanding of how to protect the breastfeeding relationship when medical problems occur.

Patients' knowledge and opinions of ICDs during life, illness and at the time of death.

Use of an implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death. However, at the end of life, these devices can prolong the dying experience, causing physical and psychological trauma. Patients are often unaware of their options regarding ICD management at the end of their life, which highlights the need for health professionals to have these discussions with patients. This study aimed to identify patients' knowledge and opinions about their ICD and the factors influencing their knowledge and opinions. Of the 30 participants in this study, 59% had sufficient knowledge about ICDs. There was no relationship between knowledge and time since implantation (p=0.11). A relationship existed between knowledge and age; those that were older were better informed (p=0.008). The authors conclude that patient education and communication are essential for patients with ICDs to enhance decision-making about ICD management at the end of life.

Origin-of-transfer sequences facilitate mobilisation of non-conjugative antimicrobial-resistance plasmids in Staphylococcus aureus.

Staphylococcus aureus is a common cause of hospital, community and livestock-associated infections and is increasingly resistant to multiple antimicrobials. A significant proportion of antimicrobial-resistance genes are plasmid-borne, but only a minority of S. aureus plasmids encode proteins required for conjugative transfer or Mob relaxase proteins required for mobilisation. The pWBG749 family of S. aureus conjugative plasmids can facilitate the horizontal transfer of diverse antimicrobial-resistance plasmids that lack Mob genes. Here we reveal that these mobilisable plasmids carry copies of the pWBG749 origin-of-transfer (oriT) sequence and that these oriT sequences facilitate mobilisation by pWBG749. Sequences resembling the pWBG749 oriT were identified on half of all sequenced S. aureus plasmids, including the most prevalent large antimicrobial-resistance/virulence-gene plasmids, pIB485, pMW2 and pUSA300HOUMR. oriT sequences formed five subfamilies with distinct inverted-repeat-2 (IR2) sequences. pWBG749-family plasmids encoding each IR2 were identified and pWBG749 mobilisation was found to be specific for plasmids carrying matching IR2 sequences. Specificity of mobilisation was conferred by a putative ribbon-helix-helix-protein gene smpO. Several plasmids carried 2-3 oriT variants and pWBG749-mediated recombination occurred between distinct oriT sites during mobilisation. These observations suggest this relaxase-in trans mechanism of mobilisation by pWBG749-family plasmids is a common mechanism of plasmid dissemination in S. aureus.

Fluid homeostasis in the neonate.

The physiology of the neonate is ideally suited to the transition to extrauterine life followed by a period of rapid growth and development. Intravenous fluids and electrolytes should be prescribed with care in the neonate. Sodium and water requirements in the first few days of life are low and should be increased after the postnatal diuresis. Expansion of the extracellular fluid volume prior to the postnatal diuresis is associated with poor outcomes, particularly in preterm infants. Newborn infants are prone to hypoglycemia and require a source of intravenous glucose if enteral feeds are withheld. Anemia is common, and untreated is associated with poor outcomes. Liberal versus restrictive transfusion practices are controversial, but liberal transfusion practices (accompanied by measures to minimize donor exposure) may be associated with improved long-term outcomes. Intravenous crystalloids are as effective as albumin to treat hypotension, and semi-synthetic colloids cannot be recommended at this time. Inotropes should be used to treat hypotension unresponsive to intravenous fluid, ideally guided by assessment of perfusion rather than blood pressure alone. Noninvasive methods of assessing cardiac output have been validated in neonates. More studies are required to guide fluid management in neonates, particularly in those with sepsis or undergoing surgery. A balanced salt solution such as Hartmann's or Plasmalyte should be used to replace losses during surgery (and blood or coagulation factors as indicated). Excessive fluid administration during surgery should be avoided.

Functional genome analysis of Bifidobacterium breve UCC2003 reveals type IVb tight adherence (Tad) pili as an essential and conserved host-colonization factor.

Development of the human gut microbiota commences at birth, with bifidobacteria being among the first colonizers of the sterile newborn gastrointestinal tract. To date, the genetic basis of Bifidobacterium colonization and persistence remains poorly understood. Transcriptome analysis of the Bifidobacterium breve UCC2003 2.42-Mb genome in a murine colonization model revealed differential expression of a type IVb tight adherence (Tad) pilus-encoding gene cluster designated "tad(2003)." Mutational analysis demonstrated that the tad(2003) gene cluster is essential for efficient in vivo murine gut colonization, and immunogold transmission electron microscopy confirmed the presence of Tad pili at the poles of B. breve UCC2003 cells. Conservation of the Tad pilus-encoding locus among other B. breve strains and among sequenced Bifidobacterium genomes supports the notion of a ubiquitous pili-mediated host colonization and persistence mechanism for bifidobacteria.

Slow-onset and fast-onset symptom presentations in acute coronary syndrome (ACS): new perspectives on prehospital delay in patients with ACS.

BACKGROUND: Patient decision delay is the main reason why many patients fail to receive timely medical intervention for symptoms of acute coronary syndrome (ACS). STUDY OBJECTIVES: This study examines the validity of slow-onset and fast-onset ACS presentations and their influence on ACS prehospital delay times. A fast-onset ACS presentation is characterized by sudden, continuous, and severe chest pain, and slow-onset ACS pertains to all other ACS presentations. METHODS: Baseline data pertaining to medical profiles, prehospital delay times, and ACS symptoms were recorded for all ACS patients who participated in a large multisite randomized control trial (RCT) in Dublin, Ireland. Patients were interviewed 2-4 days after their ACS event, and data were gathered using the ACS Response to Symptom Index. RESULTS: Only baseline data from the RCT, N = 893 patients, were analyzed. A total of 65% (n = 577) of patients experienced slow-onset ACS presentation, whereas 35% (n = 316) experienced fast-onset ACS. Patients who experienced slow-onset ACS were significantly more likely to have longer prehospital delays than patients with fast-onset ACS (3.5 h vs. 2.0 h, respectively, t = -5.63, df 890, p < 0.001). A multivariate analysis of delay revealed that, in the presence of other known delay factors, the only independent predictors of delay were slow-onset and fast-onset ACS (ß = -.096, p < 0.002) and other factors associated with patient behavior. CONCLUSION: Slow-onset ACS and fast-onset ACS presentations are associated with distinct behavioral patterns that significantly influence prehospital time frames. As such, slow-onset ACS and fast-onset ACS are legitimate ACS presentation phenomena that should be seriously considered when examining the factors associated with prehospital delay.

A randomized controlled trial to reduce prehospital delay time in patients with acute coronary syndrome (ACS).

BACKGROUND: The literature suggests that people delay too long prior to attending emergency departments with acute coronary syndrome (ACS) symptoms. This delay is referred to as prehospital delay. Patient decision delay contributes most significantly to prehospital delay. OBJECTIVES: Using a randomized controlled trial, we tested an educational intervention to reduce patient prehospital delay in ACS and promote appropriate responses to symptoms. METHODS: Eligible patients who were admitted across five emergency departments (EDs) in Dublin were recruited to the study (n = 1944; control: 972, intervention: 972). RESULTS: Median baseline prehospital delay times did not differ significantly between the groups at baseline (Mann-Whitney U, p = 0.34) (CONTROL: 4.28 h, 25(th) percentile = 1.71, 75(th) percentile = 17.37; Intervention 3.96 h, 25(th) percentile = 1.53, 75(th) percentile = 18.51). Both groups received usual in-hospital care. In addition, patients randomized to the intervention group received a 40-min individualized education session using motivational techniques. This was reinforced 1 month later by telephone. Of the 1944, 314 (16.2%) were readmitted with ACS symptoms: 177 (18.2%) and 137 (14.1%) of the intervention and control groups, respectively. Prehospital delay times were again measured. Median delay time was significantly lower in the intervention compared to the control group (1.7 h vs. 7.1 h; p ≤ 0.001). Appropriately, those in the intervention group reported their symptoms more promptly to another person (p = 0.01) and fewer consulted a general practitioner (p = 0.02). There was no significant difference in ambulance use (p = 0.51) or nitrate use (p = 0.06) between the groups. CONCLUSION: It is possible to reduce prehospital delay time in ACS, but the need for renewed emphasis on ambulance use is important.

The relationship of milk expression pattern and lactation outcomes after very premature birth: A cohort study.

INTRODUCTION: Mothers of very premature infants often have difficulties expressing breastmilk, which can cause distress and potential negative impact on infant health. Clinical recommendations on breastmilk expression are extrapolated from term infants' breastfeeding patterns. This study's objective was to analyse the association of expressing pattern with lactation outcomes after very premature birth. METHODS: 132 participants were recruited after birth between 23+0 and 31+6 weeks' gestation. Participants recorded the milk expressed in several 24-hour periods in the three weeks after birth. RESULTS: Expressing frequency was positively associated with 24-hour milk yield, with an adjusted 30.5g increase per expressing session on day four (95% CI 15.7 to 45.3) and 94.4g on day 21 (95% CI 62.7 to 126.2). Expressing ≥8 times per day was associated with higher adjusted milk yield than expressing <6 times (on day four, 146.8g, 95% CI 47.4 to 246.1), but not in comparison to expressing 6-7 times (on day four, 82.1g, 95% CI -25.9 to 190.1). Participants with six months or more prior breastmilk feeding experience had a higher adjusted milk yield than others (on day four, 204.3g, 95% CI 125.2 to 283.3). Night-time (2300-0700 hours) expressing sessions were not associated with increased milk yield after adjustment for time since the prior session. On average, participants who had a longest gap between expressions of less than six hours achieved the UK target of 750g breastmilk, whereas those with a longer gap did not. CONCLUSION: Expressing frequency was an important determinant of milk yield. Clinical recommendations to express ≥8 times per day were supported but for some, 6-7 times was sufficient. This was particularly likely for those with six months or more of prior breastmilk feeding experience. A need to express during the night-time hours appeared to be related to minimising the gap between expressions rather than an inherent value of night-time expression.

Does extremely early expression of colostrum after very preterm birth improve mother's own milk quantity? A cohort study.

OBJECTIVE: Assess the relationship of time to first expression after very preterm birth and mothers' own milk quantity. DESIGN: A cohort study (nested within a randomised trial). SETTING: Four neonatal units in the UK. PATIENTS: 132 mothers of single or twin infants born at 23+0 to 31+6 weeks postmenstrual age. EXPOSURES: Time to the first attempt to express after birth. PRIMARY OUTCOMES: 24-hour mother's own milk yield on days 4, 14 and 21 after birth. RESULTS: Median time to first expression attempt was 6 hours. 51.7% expressed within 6 hours of birth (62/120) and 48.3% expressed more than 6 hours after birth (58/120). Expressing within 6 hours of birth was associated with higher milk yield on day 4 (88.3 g, 95% CI 7.1 to 169.4) and day 14 (155.7 g, 95% CI 12.2 to 299.3) but not on day 21 (73.6 g, 95% CI -91.4 to 238.7). There was an interaction between expressing frequency and time to first expression (p<0.005), with increased expressing frequency being associated with higher yield only in those who expressed within 6 hours. Expressing within 2 hours of birth was not associated with further milk yield increase. CONCLUSIONS: Mothers who expressed within 6 hours of birth had higher milk yield, and a greater yield per expressing session, in the first 3 weeks after birth. This information will be highly motivating for families and the clinicians supporting them. There was no evidence of further benefit of extremely early expression (first 2 hours after birth). TRIAL REGISTRATION NUMBER: ISRCTN 16356650.

Valorization of Food Waste into Single-Cell Protein: An Innovative Technological Strategy for Sustainable Protein Production.

The rapidly increasing population and climate change pose a great threat to our current food systems. Moreover, the high usage of animal-based and plant-based protein has its drawbacks, as these nutritional sources require many hectares of land and water, are affected by seasonal variations, are costly, and contribute to environmental pollution. Single-cell proteins (SCPs) are gaining a lot of research interest due to their remarkable properties, such as their high protein content that is comparable with other protein sources; low requirements for land and water; low carbon footprint; and short production period. This review explores the use of food waste as a sustainable feedstock for the advancement of SCP processes. It discusses SCP studies that exploit food waste as a substrate, alongside the biocatalysts (bacteria, fungi, yeast, and microalgae) that are used. The operational setpoint conditions governing SCP yields and SCP fermentation routes are elucidated as well. This review also demonstrates how the biorefinery concept is implemented in the literature to improve the economic potential of "waste-to-protein" innovations, as this leads to the establishment of multiproduct value chains. A short section that discusses the South African SCP scenario is also included. The technical and economic hurdles facing second-generation SCP processes are also discussed, together with future perspectives. Therefore, SCP technologies could play a crucial role in the acceleration of a "sustainable protein market", and in tackling the global hunger crisis.

Relaxation Therapy and Human Milk Feeding Outcomes: A Systematic Review and Meta-Analysis.

Importance: Human milk feeding is a key public health goal to optimize infant and maternal/parental health, but global lactation outcomes do not meet recommended duration and exclusivity. There are connections between lactation and mental health. Objective: To appraise all available evidence on whether the provision of relaxation interventions to lactating individuals improves lactation and well-being. Data Sources: Embase, MEDLINE, CINAHL, Allied and Complementary Medicine Database, Web of Science, and the Cochrane Library were searched on September 30, 2023, and topic experts were consulted. Study Selection: Two independent reviewers screened for eligibility. Inclusion criteria were full-text, peer-reviewed publications with a randomized clinical trial design. Techniques that were entirely physical (eg, massage) were excluded. A total of 7% of initially identified studies met selection criteria. Data Extraction and Synthesis: Two independent reviewers extracted data and assessed risk of bias with the Cochrane Risk of Bias 2 tool. Fixed-effects meta-analysis and Grading of Recommendations, Assessment, Development, and Evaluations guidelines were used to synthesize and present evidence. Main Outcomes and Measures: Prespecified primary outcomes were human milk quantity, length and exclusivity of human milk feeding, milk macronutrients/cortisol, and infant growth and behavior. Results: A total of 16 studies were included with 1871 participants (pooled mean [SD] age for 1656 participants, 29.6 [6.1] years). Interventions were music, guided relaxation, mindfulness, and breathing exercises/muscle relaxation. Provision of relaxation was not associated with a change in human milk protein (mean difference [MD], 0 g/100 mL; 95% CI, 0; 205 participants). Provision of relaxation was associated with an increase in human milk quantity (standardized mean difference [SMD], 0.73; 95% CI, 0.57-0.89; 464 participants), increased infant weight gain in breastfeeding infants (MD, z score change = 0.51; 95% CI, 0.30-0.72; 226 participants), and a slight reduction in stress and anxiety (SMD stress score, -0.49; 95% CI, -0.70 to -0.27; 355 participants; SMD anxiety score, -0.45; 95% CI, -0.67 to -0.22; 410 participants). Conclusions and Relevance: Results of this systematic review and meta-analysis suggest that provision of relaxation was associated with an increase in human milk quantity and infant weight gain and a slight reduction in stress and anxiety. Relaxation interventions can be offered to lactating parents who would like to increase well-being and improve milk supply or, where directly breastfeeding, increase infant weight gain.

Illness severity in community-onset invasive Staphylococcus aureus infection and the presence of virulence genes.

BACKGROUND: It is uncertain whether particular clones causing invasive community-onset methicillin-resistant and methicillin-sensitive Staphylococcus aureus (cMRSA/cMSSA) infection differ in virulence. METHODS: Invasive cMRSA and cMSSA cases were prospectively identified. Principal component analysis was used to derive an illness severity score (ISS) from clinical data, including 30-day mortality, requirement for intensive hospital support, the presence of bloodstream infection, and hospital length of stay. The mean ISS for each S. aureus clone (based on MLST) was compared with its DNA microarray-based genotype. RESULTS: Fifty-seven cMRSA and 50 cMSSA infections were analyzed. Ten clones caused 82 (77%) of these infections and had an ISS calculated. The enterotoxin gene cluster (egc) and the collagen adhesin (cna) gene were found in 4 of the 5 highest-ranked clones (ST47-MSSA, ST30-MRSA-IV[2B], ST45-MSSA, and ST22-MRSA-IV[2B]) compared with none and 1 of the lowest 5 ranked clones, respectively. cMSSA clones caused more severe infection than cMRSA clones. The lukF/lukS Panton-Valentine leukocidin (PVL) genes did not directly correlate with the ISS, being present in the second, fourth, and 10th most virulent clones. CONCLUSIONS: The clinical severity of invasive cMRSA and cMSSA infection is likely to be attributable to the isolates' entire genotype rather than a single putative virulence determinant such as PVL.

Assessment of workplace integration of migrant nurses and midwives within international health care settings: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to map the available evidence on the assessment of workplace integration of migrant nurses and midwives in international health care settings. INTRODUCTION: Internationally, migrant nurses and midwives are an increasingly important resource in government strategy for addressing the current and predicted workforce shortages in health care. Much has been documented about the orientation stages of their transition to foreign workplaces but few sources have considered the workplace integration of this population. INCLUSION CRITERIA: The review will include all studies involving migrant nurses and midwives who are working outside their country of initial nurse or midwife registration for at least one year. The context will be all hospital, community, and residential care home settings, including the mental health, intellectual disability, and maternity care sectors. METHODS: The JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews will be used to conduct this review. The databases to be searched will include CINAHL, MEDLINE, Embase, CENTRAL, and Google Scholar. Gray literature will also be searched and a hand search will be conducted of sources that fall outside these database searches. Two reviewers will independently screen titles, abstracts, and full-text articles. The extracted data will be presented in a tabulated chart accompanied by a narrative summary that aligns with the objectives and scope of this review.