Early life exposure of infants to benzylpenicillin and gentamicin is associated with a persistent amplification of the gut resistome

BACKGROUND

Infant gut microbiota is highly malleable, but the long-term longitudinal impact of antibiotic exposure in early life, together with the mode of delivery on infant gut microbiota and resistome, is not extensively studied.

METHODS

Two hundred and eight samples from 45 infants collected from birth until 2 years of age over five time points (week 1, 4, 8, 24, year 2) were analysed. Based on shotgun metagenomics, the gut microbial composition and resistome profile were compared in the early life of infants divided into three groups: vaginal delivery/no-antibiotic in the first 4 days of life, C-section/no-antibiotic in the first 4 days of life, and C-section/antibiotic exposed in first 4 days of life. Gentamycin and benzylpenicillin were the most commonly administered antibiotics during this cohort's first week of life.

RESULTS

Newborn gut microbial composition differed in all three groups, with higher diversity and stable composition seen at 2 years of age, compared to week 1. An increase in microbial diversity from week 1 to week 4 only in the C-section/antibiotic-exposed group reflects the effect of antibiotic use in the first 4 days of life, with a gradual increase thereafter. Overall, a relative abundance of Actinobacteria and Bacteroides was significantly higher in vaginal delivery/no-antibiotic while Proteobacteria was higher in C-section/antibiotic-exposed infants. Strains from species belonging to Bifidobacterium and Bacteroidetes were generally persistent colonisers, with Bifidobacterium breve and Bifidobacterium bifidum species being the major persistent colonisers in all three groups. Bacteroides persistence was dominant in the vaginal delivery/no-antibiotic group, with species Bacteroides ovatus and Phocaeicola vulgatus found to be persistent colonisers in the no-antibiotic groups. Most strains carrying antibiotic-resistance genes belonged to phyla Proteobacteria and Firmicutes, with the C-section/antibiotic-exposed group presenting a higher frequency of antibiotic-resistance genes (ARGs).

CONCLUSION

These data show that antibiotic exposure has an immediate and persistent effect on the gut microbiome in early life. As such, the two antibiotics used in the study selected for strains (mainly Proteobacteria) which were multiple drug-resistant (MDR), presumably a reflection of their evolutionary lineage of historical exposures-leading to what can be an extensive and diverse resistome. Video Abstract.

Impact of antibiotics on the human microbiome and consequences for host health

It is well established that the gut microbiota plays an important role in host health and is perturbed by several factors including antibiotics. Antibiotic-induced changes in microbial composition can have a negative impact on host health including reduced microbial diversity, changes in functional attributes of the microbiota, formation, and selection of antibiotic-resistant strains making hosts more susceptible to infection with pathogens such as Clostridioides difficile. Antibiotic resistance is a global crisis and the increased use of antibiotics over time warrants investigation into its effects on microbiota and health. In this review, we discuss the adverse effects of antibiotics on the gut microbiota and thus host health, and suggest alternative approaches to antibiotic use.

Tryptophan metabolic profile in term and preterm breast milk: implications for health

Breast milk is the only source of the essential amino acid tryptophan (TRP) in breast-fed infants. Low levels of TRP could have implications for infant neurodevelopment. The objectives of the present study were to compare the relationship of TRP and its neuroactive pathway metabolites kynurenine (Kyn) and kynurenic acid (KynA) in preterm and term expressed breast milk (EBM) in the first 14 d following birth, and the relationship of TRP metabolism to maternal stress and immune status. A total of twenty-four mothers were recruited from Cork University Maternity Hospital: twelve term (>38 weeks) and twelve preterm (<35 weeks). EBM samples were collected on days 7 and 14. Free TRP, Kyn and KynA were measured using HPLC, total TRP using MS, cytokines using the Meso Scale Discovery (MSD) assay system, and cortisol using a cortisol ELISA kit. Although total TRP was higher in preterm EBM in comparison with term EBM (P < 0·05), free TRP levels were lower (P < 0·05). Kyn, KynA and the Kyn:TRP ratio increased significantly in term EBM from day 7 to day 14 (P < 0·05), but not in preterm EBM. TNF-α, IL-6 and IL-8 were higher in day 7 preterm and term EBM in comparison with day 14. There were no significant differences between term and preterm EBM cortisol levels. Increased availability of total TRP, lower levels of free TRP and alterations in the temporal dynamics of TRP metabolism in preterm compared with term EBM, coupled with higher EBM inflammatory markers on day 7, may have implications for the neurological development of exclusively breast-fed preterm infants.

Parental And Clinician Views Of Consent In Neonatal Research

AIM

To determine parental and clinician views of the informed consent process in neonatal research.

METHODS

A questionnaire-based study on the informed consent process. Two questionnaires were developed and distributed to parents and clinicians over a four-month period.

RESULTS

Thirty-four parents (79%) surveyed had consented their baby to a research study. The majority of clinicians (72%) had a preference for antenatal provision of information. A desire to help future babies (97%, n=32) and a belief that their baby's healthcare would directly benefit (72%, n=28) were primary reasons for consenting. The majority (76% n=28) of parents were not in favour of a waiver of consent. However twenty clinicians (56%) agreed that a waiver of consent may be appropriate in neonatal research. Thirty-one (86%) clinicians rated GCP training as important.

DISCUSSION

Parents are generally supportive of neonatal research. Good clinical practice training is essential for clinicians involved in neonatal research.

Consent for routine neonatal procedures: A study of practices in Irish neonatal units. How do we compare with the gold standard BAPM guidelines?

The Irish National Consent Policy (NCP) proposes that the legal requirement for consent extends to all forms of interventions, investigations and treatment, carried out on or behalf of the Health Service Executive (HSE). This study employs a quantitative descriptive approach to investigate the practices for obtaining consent for an identified group of routine neonatal procedures in neonatal facilities throughout Ireland. The BAPM (British Association of Perinatal Medicine) guidelines were identified as 'gold standard' for the purposes of this study. The results indicated a lack of consistency between participating units pertaining to the modes of consent utilised and notable variances from 'gold standard' guidelines. Unanimity was evident for 3 procedures only (administering BCG, 6-in-1, and donor breast milk to infant). Significant findings related to EEG with video recordings, MRI/CT and gastro intestinal imaging, screening of an infant with suspected substance abuse or retinopathy of prematurity screening (ROP), administration of Vitamin K, and the carrying out of a lumbar puncture.

Emergency uncross-matched blood transfusions in a tertiary neonatal unit

AIM

To determine the neonatal incidence, indications and outcomes following transfusions with emergency uncross-matched O-negative blood.

METHODS

A five-year retrospective review in a single tertiary neonatal unit was conducted. The blood transfusion laboratory's database was analysed for all infants who had received an emergency released blood transfusion (ERBT) between January 2010 and December 2014.

RESULTS

We calculated a total ERBT rate of 0.91 per 1000 live births (39/42 657) and a rate of 0.43 per 1000 in infants >34 weeks' gestation (18/41 637). A rate of 0.14 per 1000 births (6/42 657) received an ERBT as part of newborn stabilisation despite almost half of our infant cohort having intrapartum haemorrhages (n = 18, 46%). One-third (13/39) of all infants who were transfused died. Outcome varied depending on underlying aetiology, gestation and birthweight. The highest mortality was in preterm infants weighing <1000 g, of whom 70% died.

CONCLUSION

This study establishes an ERBT rate of <1 per 1000 births, and 0.14 per 1000 infants received an ERBT as part of newborn delivery room stabilisation. ERBTs are associated with a high mortality rate. This study highlights the need for further research and guidelines that clarify the role of ERBTs in newborn stabilisations.

Reporting on data monitoring committees in neonatal randomised controlled trials is inconsistent

AIM

To evaluate the reported use of data monitoring committees (DMCs), the frequency of interim analysis, prespecified stopping rules and early trial termination in neonatal randomised controlled trials (RCTs).

METHODS

We reviewed neonatal RCTs published in four high-impact general medical journals, specifically looking at safety issues including documented involvement of a DMC, stated interim analysis, stopping rules and early trial termination. We searched all journal issues over an 11-year period (2003-2013) and recorded predefined parameters on each item for RCTs meeting inclusion criteria.

RESULTS

Seventy neonatal trials were identified in four general medical journals: Lancet, New England Journal of Medicine (NEJM), British Medical Journal and Journal of American Medical Association. A total of 43 (61.4%) studies reported the presence of a DMC, 36 (51.4%) explicitly mentioned interim analysis, stopping rules were reported in 15 (21.4%) RCTs and seven (10%) trials were terminated early. The NEJM most frequently reported these parameters compared to the other three journals reviewed.

CONCLUSION

While the majority of neonatal RCTs report on DMC involvement and interim analysis, there is still scope for improvement. Clear documentation of safety-related issues should be a central component of reporting in neonatal trials involving newborn infants.

The local lymph node assay in practice: a current regulatory perspective

Following the formal acceptance of the local lymph node assay (LLNA) as an Organization for Economic Cooperation and Development (OECD) guideline in April 2002, the UK Health and Safety Executive (HSE) informed notifiers that this was now the method of choice for the assessment of skin sensitization potential under the EU notification scheme for new industrial chemicals (NONS). This paper summarizes the experience of the HSE for the 2-year period immediately following the issuing of this statement, during which 48 LLNA study reports were assessed for notification purposes. The issues discussed here include adherence to the OECD guideline, interpretation of results, and classification outcomes. Generally, notifying laboratories followed the OECD guideline successfully, with regard to the sex/ strain/numbers of mice used, the precise process used for measurement of cell proliferation, and the use of recommended vehicles and positive controls. Initially, use of the individual animal approach (measuring the cell proliferation in each animal rather than for a pooled dose group) highlighted problems caused by technical inexperience, but these were overcome by practice. Toxicity or irritation were found to be minor factors in dose selection; more important was the choice of vehicle to correctly maximize the test substance concentration, while maintaining appropriate application properties. Contrary to concerns that the LLNA would prove to be less sensitive or more sensitive than the traditionally used Guinea Pig Maximization Test (GPMT), the proportion of new substances classified as skin sensitizers was within the range observed in previous years. Although the sample size is relatively small, the experience of the HSE indicates that the LLNA is satisfactory for routine regulatory use.

High rates of sexually transmitted diseases among male transvestites in Jakarta, Indonesia

Many male transvestites ( waria) in Jakarta, Indonesia engage in unprotected receptive anal and oral intercourse with homosexual and bisexual men for pay. Although this behaviour clearly puts them at risk of sexually transmitted diseases (STDs), including HIV infection, little is known about the prevalence of STD among them. To learn the STD prevalence and its risk factors, we conducted an STD prevalence survey among waria in North Jakarta, Indonesia. From August to December 1999 we offered screening for rectal and pharyngeal infections with Neisseria gonorrhoeae (Ng), Chlamydia trachomatis (Ct) by DNA probe (GenProbe PACE 2) and for Treponema pallidum (Tp) by non-treponemal and treponemal serological tests. Of 296 participants (median age 28 years), 93% reported having been paid for sex. A total of 96% reported having had oral sex (median five times/week) and/or anal sex (median three times/week) in the last week. Ng was found in the rectum of 12.8% and the pharynx of 4.2%; Ct was found in 3.8% and 2.4%, respectively. A total of 43.6% had reactive non-treponemal and treponemal tests. Of the 129 with positive treponemal tests, 42.6% had non-treponemal test titres greater than 1:8. In the logistic regression model, waria who were younger (≥25 years old) had a significantly 3.5 times risk of Ng and/or Ct infections than older waria (>25 years old). Because only 12% of waria stated that they consistently used condoms during any sex act, it is important to warn them that STD/HIV transmission can occur with either anal or oral sex and that the risk of either anal or oral transmission can be reduced by condom use. In addition, high rates of asymptomatic syphilis and rectal gonorrhoea warrant a periodic screening and treatment for these infections in this population. Because waria have the highest rates of HIV and their clients consist of homosexual and bisexual men, successful prevention efforts in waria could help curb the spread of the epidemic.

Auscultate, palpate and tap: time to re-evaluate

AIM

To determine the accuracy of current methods of heart rate (HR) assessment.

METHODS

All participants palpated a simulated pulsating umbilicus (UMB), listened to a tapping rate (TAP) and auscultated a simulated HR (AUSC). A simulated HR of 54, 88 and 128 beats per minute (bpm) was randomised for all methods.

RESULTS

Twenty-nine healthcare staff participated in this study. Correct assessment of HR of 54 bpm as being within the 0-59 range occurred in 17.2% UMB, 17.2% TAP and 31% AUSC and was obtained in <10 seconds by 48.3%, 65.5% and 62.1%, respectively. A rate of 88 bpm was correctly assessed as within the 60-100 range in 82.8% UMB, 79.3% TAP and 79.3% AUSC and was obtained in <10 seconds by 55.2%, 58.6% and 55.2%, respectively. A rate of 128 bpm was identified as >100 bpm by 96.6% UMB, 93.1% TAP, and 93.1% AUSC and was obtained in <10 seconds by 51.7%, 55.2% and 62.1%, respectively.

CONCLUSION

Current methods in assessing rates below 60 bpm are inaccurate and may overestimate HR. We recommend that these methods alone should not be relied upon in neonatal resuscitation and objective assessment of heart rate should be readily available at all newborn resuscitations.

The neonatal gut harbours distinct bifidobacterial strains

BACKGROUND

Recent studies have described the bifidobacterial composition of neonates at a species level; however, with advancing technologies we can gain insight into the diversity of the bifidobacterial microbiota residing within the infant gut.

OBJECTIVE

To compare species and strain diversity of culturable bifidobacterial populations in faecal samples obtained from healthy term infants on three different feeding regimes.

STUDY DESIGN

In total, 51 healthy term infants were recruited for this study and divided equally into three different groups (n=17) based on their feeding regime during the first 4 weeks of life. Culturable bifidobacterial populations were analysed at week 1, week 4 and 6 months of age. Isolates were characterised to species level by 16s rRNA-internally transcribed spacer (ITS) gene sequence analysis and to strain level by pulsed field gel electrophoresis (PFGE).

RESULTS

In total,173 bifidobacterial strains were detected across all three groups from 2295 isolates, 42% (72 of 173) of which were detected in the prebiotic-fed group, followed by 30% (52 of 173) and 28% (49 of 173) in the breastfed and non-prebiotic-fed groups, respectively. Surprisingly, only two of the 51 infants harboured an identical bifidobacterial strain which was not present in the other 49 infants. Prebiotic supplementation in the early neonatal period increased the prevalence of Bifidobacterium longum in infants, in addition to promoting strain diversity. B. longum was the dominant species recovered from all three groups during the first 6 months of life, followed by Bifidobacterium breve and Bifidobacterium bifidum.

CONCLUSIONS

This study reveals a hitherto unknown level of diversity at the strain level among bifidobacteria isolated from different infants and the influence prebiotic formula feeding has on the bifidobacterial population.

Perfusion index in the preterm infant immediately after birth

AIM

To evaluate PI in preterm infants during the first 10 min of life.

DESIGN/METHODS

An observational study was conducted in the delivery room on preterm infants (less than 32 week gestation). PI values were obtained from a pre ductal saturation probe placed on the right wrist. Analysis was performed on the first 10 min of data to investigate the correlation of PI with gestational age, heart rate, blood pressure, and lactate values.

RESULTS

33 infants with a median gestational age of 29 wks (IQR, 26-30 wks) and median birth weight of 1205 g (IQR, 925-1520 g) were included for analysis. The overall median PI value for the first 10 min was 1.3 (IQR, 0.86-1.68). There was no significant correlation found between delivery room PI and gestational age(r=0.28, 95% CI: -0.09, 0.59), lactate levels (r=-0.25, 95% CI: -0.62, 0.18) and blood pressure values (r=-0.18, 95% CI: -0.46, 0.20). An average correlation value of r=-0.417 (95% CI: - 0.531, -0.253) was found between PI and heart rate values. There was no statistical difference between the median of the median PI value over the first 5 min of life compared to the second 5 min (p=0.22). Variability, as quantified by the IQR, was higher in the first 5 min compared to the second 5 min: median of 0.5(IQR, 0.27, 0.92) vs 0.2(IQR, 0.10, 0.30) (p<0.00).

CONCLUSIONS

Delivery room PI values are easily obtained, however, have significant variability over the first 5 min of life and may add little to delivery room assessment.

Quantitative or qualitative carbon dioxide monitoring for manual ventilation: a mannequin study

AIM

To compare the effectiveness of an in-line EtCO2 detector (DET) and a quantitative EtCO2 detector (CAP), both attached to a t-piece resuscitator, during PPV via a face mask.

METHODS

Paediatric trainees were randomly assigned to determine the method of PPV they commenced with (No device (ND), DET or CAP). Participants used each method for 2 min. Participants were video-recorded to determine the amount of effective ventilations delivered with each method.

RESULTS

Twenty-three paediatric trainees provided a total of 6035 ventilations, and 91.2% were deemed effective. The percentages of median effective ventilations with the ND, the DET and the CAP were 91.0%, 93.0% and 94.0%, respectively. Fourteen (61%) of the trainees indicated a preference for the DET method, 8 (35%) for the CAP method, and 1 (4%) of the trainees indicated a preference for the ND method. Capnography was the most effective method per patient.

CONCLUSION

There was no adverse effect with the addition of EtCO2 detectors. Trainees favoured methods of EtCO2 monitoring during ventilation. The NeoStat device was the preferred device by the majority. The greatest efficacy was achieved with the capnography device. Capnography may enhance face mask ventilation.

Current research suggests that the future looks brighter for cerebral oxygenation monitoring in preterm infants

Brain injuries remain a significant problem for preterm infants, despite extensive physiological monitoring. Near infrared spectroscopy (NIRS) monitoring in the neonatal intensive care unit has to date remained limited to research activities.

CONCLUSION

This review highlights the increasing clinical application of NIRS in delivery suites and neonatal units. Four randomised controlled trials incorporating NIRS monitoring suggest that the future may indeed be brighter for this technology in the care of very preterm infants.

A review of carbon dioxide monitoring in preterm newborns in the delivery room

INTRODUCTION

The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements.

AIM

To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room.

METHODS

Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials.

RESULTS

The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B.

DISCUSSION

CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.

Emergence of opiate-induced neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is the clinical picture of infants withdrawing from in-utero substance exposure. The incidence of NAS rose in Dublin maternity hospitals in the 1970's and '80's in parallel with increasing in opiate abuse in that city. The purpose of this study was to determine if a similar pattern was emerging in Cork University Maternity Hospital. Data from the Erinville Hospital (2000-2007) and CUMH (2008-2011) were compared. Sixteen cases of NAS were identified, two at Erinville Hospital (22,987 deliveries; incidence = 0.09/1000 deliveries) and 14 at CUMH (37,414 deliveries; incidence = 0.38/1000 deliveries; p < 0.01). Five of the 16 mothers were using heroin, while ten were on methadone maintenance. All were multi-drug abusers. Newborns requiring pharmacotherapy for NAS (5/16) had prolonged hospitalisations compared to those requiring supportive care. NAS in Cork is increasing. Primary, secondary and tertiary preventative measures are warranted to prevent further escalation.

Efficacy and user preference of two CO2 detectors in an infant mannequin randomized crossover trial

Assessment of effective ventilation in neonatal mask ventilation can be difficult. This study aims to determine whether manual ventilation with a T-piece resuscitator containing an inline CO2 detector (either a Pedi-Cap® CO2 detector or a Neo-StatCO2 <Kg® CO2 detector connected to a facemask) facilitates effective positive pressure ventilation compared to no device in a mannequin study. Paediatric and neonatal trainees were randomly assigned to determine which method they began with (no device, Pedi-Cap or a Neo-Stat). The participants used each method for a period of 3 min. They were video-recorded to determine the amount of effective ventilations delivered and the overall percentage efficiency of each method. Efficacy of ventilation was determined by comparing the number of manual ventilations delivered with the number of times chest rise was observed in the video recording. There were 19 paediatric trainees who provided a total of 7,790 ventilations, and 93% were deemed effective. The percentage of effective ventilations with the T-piece resuscitator alone, the PediCap and the NeoStat were 90, 94 and 96%, respectively. The difference was greatest in the first minute (T-piece resuscitator alone 87.5%, PediCap 94%, NeoStat 96%). Two thirds preferred the Neo-Stat. The use of a CO2 detector improves positive pressure ventilation in a mannequin model, especially in the first minute of positive pressure ventilation. The Neo-Stat CO2 detector was the preferred device by the majority of the participants.

Parental patterns of use of over the counter analgesics in children

Over-The-Counter Analgesics (OTCA) account for over a fifth of Irish pharmacy sales. Little is known about patterns of use, specifically in children. This study investigated parents' use of OTCAs in children. A questionnaire exploring use of OTCAs and knowledge of side-effects was distributed to guardians of children attending three GP surgeries in South of Ireland from June-September 2010. The questionnaire was completed by 183 parents (response rate 95%). Many respondents (n = 121, 66.1%) were using analgesics when not required or using an inappropriate analgesic for a child's symptom. Private patients demonstrated better use (n = 31, 40%) than those with Medical Cards (n = 18, 22.5%) (p = 0.016). Identification of potential side-effects was poor, with drowsiness (n = 88, 49%), rash (n = 39, 22%) and nausea (n =3 2, 18%) listed as potential side-effects. Inappropriate use of OTCAs is prevalent in Irish children. Parents need more information and guidance on their use.

Are fathers underused advocates for breastfeeding?

Fathers' knowledge base and attitudes influence breastfeeding practice. We aimed to evaluate if Irish fathers felt included in the breastfeeding education and decision process. 67 fathers completed questionnaires, which assessed their role in the decision to breastfeed, knowledge regarding the benefits of breastfeeding and attitude towards breastfeeding.Forty-two (62.7%) of their partners were breastfeeding. Antenatal classes were attended by 38 (56.7%); 59 (88.1%) discussed breastfeeding with their partners and 26 (38.8%) felt that the decision was made together. Twelve (48%) fathers of formula fed infants were unaware that breastfeeding was healthier for the baby. Most fathers (80.6%) felt that breastfeeding was the mother's decision and most (82.1%) felt that antenatal information was aimed at mothers only. Irish fathers remain relatively uninformed regarding the benefits of breastfeeding. This may contribute to their exclusion from the decision to breastfeed. Antenatal education should incorporate fathers more, and this may result in an improvement in our breastfeeding rates.

Handover rounds in Irish hospitals

BACKGROUND

With the increasing complexities in medicine and the reduction in working hours, shift work patterns are emerging for hospital doctors and with them the possibility for discontinuity of patient care and negative outcomes for patient safety.

AIMS

The purpose of this study was to evaluate the prevalence, format and structure of formal handover rounds in Irish hospitals in four different specialties.

METHODS

A 26-item questionnaire was sent to 61 participants in 26 hospitals.

RESULTS

Just over a quarter of respondents (28%) reported formal handover rounds. Respondents from Obstetrics and Gynaecology were more likely to report handover rounds (80%). Prominent features of handover include frequent consultant (100%) and post-call staff (73%) attendance.

CONCLUSION

This study confirms that handover rounds are not universal in Irish hospitals. While this does not imply that patient safety is compromised, the need for effective and comprehensive handover is a critical aspect of patient care.

Life and death decisions for incompetent patients: determining best interests--the Irish perspective

AIMS

To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions.

METHODS

An anonymous questionnaire was distributed to consultants, trainees in neonatology, paediatrics, obstetrics and 4th medical students. It examined resuscitation scenarios of critically ill patients all needing immediate resuscitation. Outcomes were described including survival and potential long-term sequelae. Respondents were asked whether they would intubate, whether resuscitation was in the patients best interest, would they accept surrogate refusal to initiate resuscitation and in what order they would resuscitate.

RESULTS

The response rate was 74%. The majority would wish resuscitation for all except the 80-year-old. It was in the best interest of the 2-month-old and the 7-year-old to be resuscitated compared to the remaining scenarios (p value <0.05 for each comparison). Approximately one quarter who believed it was in a patient best interests to be resuscitated would nonetheless accept the family refusing resuscitation. Medical students were statistically more likely to advocate resuscitation in each category.

CONCLUSION

These results suggest resuscitation is not solely related to survival or long-term outcome and the best interest principle is applied differently, more so at the beginning of life.

Introducing random safety audits (RSA) in a neonatal intensive care unit (NICU)

Random safety audits (RSA) have been shown to be effective in improving standards of clinical practice. 19 data collection audits were performed relating to hygiene, safe prescribing, oxygen pulse oximetry monitoring and documentation in keeping with the requirements of the new Medical Practitioners Act (MPA) 2007. Hygiene audits (range from 20/25 to 21/21 80%-100%) and safe prescribing audits (range from 23/25 to 25/25 86%-100%) achieved n=25 100% compliance with unit guidelines over a 3 month period. Compliance with oxygen pulse oximetry monitoring guideline limits improved from 4/27 (15%) to 9/16 (56%). Compliance with requirement and use of Physician IMC registration number in documentation was only 10/18 (56%). RSA's led to improvements in hygiene and prescribing. Compliance with oxygen monitoring guideline limits highlighted the need for greater education. Awareness of legal requirements relating to documentation improved but this has not translated into a change in practice. RSA's can facilitate real time quality improvement in daily clinical practice.

Robust decoupling techniques to extend quantum coherence in diamond

We experimentally demonstrate over 2 orders of magnitude increase in the room-temperature coherence time of nitrogen-vacancy centers in diamond by implementing decoupling techniques. We show that equal pulse spacing decoupling performs just as well as nonperiodic Uhrig decoupling and also allows us to take advantage of revivals in the echo to explore the longest coherence times. At short times, we can extend the coherence of particular quantum states out from T2*=2.7  μs out to an effective T2>340  μs. For preserving arbitrary states we show the experimental importance of using pulse sequences that compensate the imperfections of individual pulses for all input states through judicious choice of the phase of the pulses. We use these compensated sequences to enhance the echo revivals and show a coherence time of over 1.6 ms in ultrapure natural abundance 13C diamond.

Wound signals in plants: A systemic plant wound signal alters plasma membrane integrity

Within 4 hr after wounding the lower leaves of young potato and tomato plants, a rapid and remarkable change is induced in the cells of upper undamaged leaves that results in extensive lysis of protoplasts during their isolation. Protoplast yields from unwounded upper leaves, 4 hr after wounding a lower leaf by crushing with a hemostat, decreased 25% below yields from leaves of unwounded plants. From 8 to >20 hr after wounding, protoplast yields were less than half of those from control plants. Multiple woundings decreased yields even further, as did chewing of the lower leaves by tobacco hornworms over a period of several minutes. In addition, within 4 hr of excising young tomato plants at their base with a razor blade, a 90% decrease in leaf protoplast yields was recorded. The major loss of protoplasts induced by wounding was primarily due to an increased cell lysis during protoplast isolation. Cell lysis was apparently due to a weakened cell membrane, because newly recovered protoplasts released from leaves of wounded plants were extremely fragile and exhibited 70% lysis during low speed centrifugation, compared to 20% lysis of protoplasts recovered from control plants. We conclude that a signal is released by wounding that is rapidly transmitted or transported through the plants to induce a profound change in the leaf cell membranes that renders them fragile during protoplast isolation. It is proposed that this signal may play a role in inducing cellular changes in the plant cells as part of their responses to environmental stress such as pest attacks.

A polypeptide from tomato leaves induces wound-inducible proteinase inhibitor proteins

Defensive genes in plants can be activated by several different types of nonpeptide signaling molecules. An endogenous polypeptide, consisting of 18 amino acids, was isolated from tomato leaves and was able at very low concentrations to induce the synthesis of two wound-inducible proteinase inhibitor proteins when supplied to young tomato plants. The sequence of the polypeptide was determined, and an identical polypeptide was synthesized that possessed full inducing activity. These data establish that a polypeptide factor can initiate signal transduction to regulate the synthesis of defensive proteins in plant tissues.

Wound-Induced Proteinase Inhibitor in Plant Leaves: A Possible Defense Mechanism against Insects

Wounding of the leaves of potato or tomato plants by adult Colorado potato beetles, or their larvae, induces a rapid accumulation of a proteinase inhibitor throughout the plants' tissues that are exposed to air. This effect of insect damage can be simulated by mechanically wounding the leaves. The transport of a factor out of damaged leaves takes place rapidly after the wound is inflicted and the levels of proteinase inhibitor, in both damaged and adjacent leaves, rises strikingly within a few hours. The rapid accumulation of a powerful inhibitor of major intestinal proteinases of animals in response to wounding of the leaves is probably a defense mechanism.

In vitro phosphorylation of plant plasma membrane proteins in response to the proteinase inhibitor inducing factor

A polygalacturonide purified from a tomato leaf pectic polysaccharide that induces the systemic synthesis of proteinase inhibitors in tomato plants enhances the phosphorylation of specific proteins in plasma membrane fractions isolated from tomato and potato leaves. In tomato plasma membranes, two proteins of 34 and 29 kDa show enhanced phosphorylation in response to the polyuronide. In potato plasma membranes, only a protein of 34 kDa exhibited enhanced phosphorylation due to the polyuronide. A noncarbohydrate class of proteinase inhibitor inducing factor, recently identified by workers in this laboratory, resulted in the in vitro hyperphosphorylation of a family of proteins of approximately 27 kDa. The phosphorylation of specific polypeptides in leaves in response to the same factors that induce the expression of proteinase inhibitor genes suggests that protein kinases may play an important role in the mechanism of signal transduction leading to defense gene expression.

Proteinase inhibitor-inducing factor activity in tomato leaves resides in oligosaccharides enzymically released from cell walls

The synthesis and accumulation of proteinase inhibitor I in excised tomato leaves can be induced with oligosaccharides obtained by fungal endo-alpha-1,4-polygalacturonase digestion of a pectic polysaccharide (M(r) 5000-10,000) isolated from tomato leaves. Active oligosaccharides were also released from isolated tomato leaf cell walls by endopolygalacturonases partially purified from tomato plants. It is suggested that oligosaccharides, released from plant cell wall pectic polysaccharides by either endogenous or exogenous endopolygalacturonases at a wound or infection site, may have hormone-like roles in regulating plant defense responses in unwounded tissues many centimeters away from the site of release.

In vitro synthesis of pre-proteins of vacuolar compartmented proteinase inhibitors that accumulate in leaves of wounded tomato plants

Two proteinase inhibitor proteins that are compartmented in leaf vacuoles (lysosomes) were synthesized in vitro. mRNA was isolated from 17-day-old expanding tomato leaves by extraction with chaotropic buffers followed by chromatography on oligo(dT)-cellulose and was translated with a rabbit reticulocyte lysate system. Preparations of mRNA from leaves of both wounded plants and unwounded plants directed the incorporation of equivalent amounts of label into trichloroacetic acid-precipitable proteins. Only mRNA from leaves of wounded plants directed label into proteins that could be immunoprecipitated with rabbit IgG specific for either inhibitor I or inhibitor II. These results indicate that the wound-induced accumulation of proteinase inhibitors I and II in leaf vacuoles is a result of the presence of translatable mRNA species not present in leaves of unwounded plants. Gel electrophoresis of the immunoprecipitates in NaDodSO(4)/urea/polyacrylamide gels revealed that inhibitors I and II were translated in vitro as precursors about 2000 daltons larger than the inhibitors found in leaves. The presence of the additional polypeptide sequences in the newly synthesized inhibitors indicates that the inhibitors are processed either during or after synthesis, and the presequences may be signal peptides that are part of the process of inhibitor transport into the vacuolar compartments of tomato leaf cells.

Wound-inducible expression of a potato inhibitor II-chloramphenicol acetyltransferase gene fusion in transgenic tobacco plants

A potato inhibitor II gene (IIK) was isolated from a library of potato genes in lambda bacteriophage. An 8-kilobase-pair (kbp) insert was identified using a tomato inhibitor II cDNA as a hybridization probe, and a 2.6-kbp fragment containing the gene was subcloned into the plasmid pUC13 and characterized. The nucleotide sequence of the isolated gene exhibited 87% identity with the wound-inducible tomato inhibitor II cDNA sequence. The amino acid sequence of inhibitor IIK, deduced from the potato gene, exhibited 84% identity with the tomato inhibitor II protein. A 1000-bp restriction fragment from the 5' flanking region of the gene was fused to the open reading frame of the chloramphenicol acetyltransferase (CAT) gene. This fusion was terminated in two ways: (i) with a terminator sequence from the potato inhibitor II gene and (ii) with a terminator from the 6b gene of Ti plasmid pTiA6. These chimeric genes were transferred into tobacco cells via a binary Ti vector system, and transgenic plants were regenerated. The CAT gene was expressed in leaves of transformed plants in response to wounding when fused with the inhibitor IIK promoter and terminator regions. The chimeric gene containing the 6b terminator did not express CAT in response to wounding. The wound-inducible expression of CAT activity was systemic and was induced in tissues distal to the wounded tissues. The time course of wound induction of CAT activity in transgenic tobacco leaves is similar to that found for wound-inducible inhibitor I and II mRNAs in tomato leaves. These results demonstrate that sequences necessary and sufficient for wound inducibility are present within approximately 1000 bp of the control regions of the inhibitor IIK genes and that wound-inducible components of tobacco leaf cells can regulate these sequences.

Uptake of newly introduced universal BCG vaccination in newborns

Universal neonatal BCG vaccination was discontinued in Cork in 1972. Following an outbreak of TB in 2 creches in the HSE South, a universal BCG vaccination program was re-introduced in October 2008. The aim of this study was to determine the vaccination process (in-hospital and community) and the in-hospital uptake of the vaccine. Following informed parental consent, babies of birth weight > 2.5 Kg were eligible for in-hospital vaccination if they were not: febrile, jaundiced on phototherapy, on antibiotics and if not born to HIV- positive mothers. Parents of babies not vaccinated in-hospital were asked to book an appointment in either of the 2 Cork community clinics. The immunisation nurse collected data on BCG vaccination, prospectively. This study examined vaccination uptakes in-hospital and community over a 6 month period (October 2008 to March 2009). There were 4018 deliveries during the study period. In-hospital consent was declined in only 16 babies (<1%) while the in-hospital vaccination uptake was 80% of total liv births. Although 635 newborns were admitted to the NICU, only 46 (8%) were vaccinated while in the NICU. At least 48% of planned community vaccination has been achieved to date. In conclusion, in-hospital consent was almost universal and vaccination uptake was satisfactory. NICU exclusion criteria accounted for a significant proportion of non-vaccination in-hospital. These criteria need to be readdressed considering that all premature babies are given other routine newborn vaccines at 2 months of age, regardless of weight.

Orf: contagious pustular dermatitis

Orf is a common viral infection in sheep. It spreads to humans by direct contact. It is self-limiting, treatment having no beneficial effect. Misdiagnosis by those unfamiliar with its characteristic features is common, and may result in unnecessary treatment with antibiotics or surgery. We present a series of five cases of Orf in children of farmers in the west of Ireland, seen over a 10 year period.

Benchmarking care for very low birthweight infants in Ireland and Northern Ireland

BACKGROUND

Benchmarking is that process through which best practice is identified and continuous quality improvement pursued through comparison and sharing. The Vermont Oxford Neonatal Network (VON) is the largest international external reference centre for very low birth weight (VLBW) infants. This report from 2004-7 compares survival and morbidity throughout Ireland and benchmarks these results against VON.

METHODS

A standardised VON database for VLBW infants was created in 14 participating centres across Ireland and Northern Ireland.

RESULTS

Data on 716 babies were submitted in 2004, increasing to 796 babies in 2007, with centres caring for from 10 to 120 VLBW infants per year. In 2007, mortality rates in VLBW infants varied from 4% to 19%. Standardised mortality ratios indicate that the number of deaths observed was not significantly different from the number expected, based on the characteristics of infants treated. There was no difference in the incidence of severe intraventricular haemorrhage between all-Ireland and VON groups (5% vs 6%, respectively). All-Ireland rates for chronic lung disease (CLD; 15-21%) remained lower than rates seen in the VON group (24-28%). The rates of late onset nosocomial infection in the all-Ireland group (25-26%) remained double those in the VON group (12-13%).

DISCUSSION

This is the first all-Ireland international benchmarking report in any medical specialty. Survival, severe intraventricular haemorrhage and CLD compare favourably with international standards, but rates of nosocomial infection in neonatal units are concerning. Benchmarking clinical outcomes is critical for quality improvement and informing decisions concerning neonatal intensive care service provision.

Experimental approximation of the Jones polynomial with one quantum bit

We present experimental results approximating the Jones polynomial using 4 qubits in a liquid state nuclear magnetic resonance quantum information processor. This is the first experimental implementation of a complete problem for the deterministic quantum computation with one quantum bit model of quantum computation, which uses a single qubit accompanied by a register of completely random states. The Jones polynomial is a knot invariant that is important not only to knot theory, but also to statistical mechanics and quantum field theory. The implemented algorithm is a modification of the algorithm developed by Shor and Jordan suitable for implementation in NMR. These experimental results show that for the restricted case of knots whose braid representations have four strands and exactly three crossings, identifying distinct knots is possible 91% of the time.

Potential hazard of the Neopuff T-piece resuscitator in the absence of flow limitation

OBJECTIVE

(1) To assess peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP) and maximum pressure relief (P(max)) at different rates of gas flow, when the Neopuff had been set to function at 5 l/min. (2) To assess maximum PIP and PEEP at a flow rate of 10 l/min with a simulated air leak of 50%.

DESIGN

5 Neopuffs were set to a PIP of 20, PEEP of 5 and P(max) of 30 cm H(2)O at a gas flow of 5 l/min. PIP, PEEP and P(max) were recorded at flow rates of 10, 15 l/min and maximum flow. Maximum achievable pressures at 10 l/min gas flow, with a 50% air leak, were measured.

RESULTS

At gas flow of 15 l/min, mean PEEP increased to 20 (95% CI 20 to 21), PIP to 28 (95% CI 28 to 29) and the P(max) to 40 cm H(2)O (95% CI 38 to 42). At maximum flow (85 l/min) a PEEP of 71 (95% CI 51 to 91) and PIP of 92 cm H(2)O (95% CI 69 to 115) were generated. At 10 l/min flow, with an air leak of 50%, the maximum PEEP and PIP were 21 (95% CI 19 to 23) and 69 cm H(2)O (95% CI 66 to 71).

CONCLUSIONS

The maximum pressure relief valve is overridden by increasing the rate of gas flow and potentially harmful PIP and PEEP can be generated. Even in the presence of a 50% gas leak, more than adequate pressures can be provided at 10 l/min gas flow. We recommend the limitation of gas flow to a rate of 10 l/min as an added safety mechanism for this device.

The pool chlorine hypothesis and asthma among boys

Swimming pool sanitation has largely been concerned with the microbiological quality of pool water, which is normally treated using a number of chlorine products. Recent studies have pointed to the potential hazards of chlorine by-products to the respiratory epithelium, particularly in indoor, poorly ventilated, pools. The aim of our study was to elucidate whether chronic exposure to indoor chlorinated swimming pools was associated with an increased likelihood of the development of asthma in boys.

METHODS

The subjects were boys aged between 6 and 12 years. Data was collected by means of parental responses to a standardized asthma questionnaire (ISAAC: International Study of Asthma and Allergies in Childhood), supplemented with additional questions regarding frequency of attendance, number of years attendance, whether the child is a swimming team member. The questionnaire return rate was 71/% (n = 121). 23 boys were excluded on the basis that they had asthma before they started swimming (n = 97). There was a significant association between number of years a boy had been swimming and the likelihood of wheezing in the last 12 months (p = 0.009; OR = 1.351; 95% CI = 1.077-1.693) and diagnosed asthma (p = 0.046; OR = 1.299; 95% CI = 1.004-1.506). The greater the number the number of years a boy had been attending an indoor, chlorinated pool, the greater the likelihood of wheezing in the last 12 months or "had asthma". Age, parental smoking habits and being a swimming team member had no association with any of the asthma variables examined. Swimming pool attendance may be a risk factor in asthma in boys.

Neonatal resuscitation program guidelines 2006: ready, steady, can't go!

New evidence-based guidelines have been launched with recommendations that may impact how resuscitations, particularly of LBW infants, are enacted.

AIM

to determine current resuscitation practices in Maternity units in Ireland and benchmarked these results to a recent study in the United States.

METHODS

A 20-question survey was developed and mailed to a lead neonatologist/paediatrician in each of 19 maternity units in Ireland in May 2006.

RESULTS

There was 84% response rate to the surveys mailed which included 10 level II and 6 level III units. NRP qualification was considered obligatory for all paediatrics doctors in all units, with 14/16 units running at least one NRP course per year (range 1-9). Self inflating bags were more commonly used (44%), followed by T-piece resuscitators (31%) and flow inflating bags (25%). Pulse oximeters to alter the fraction of inspired oxygen were used by (25%) of units during the management of very low birth weigh infants, with a useful signal being achieved in one minute in most cases. Air/oxygen blenders were available for (44%) of units; however, all units use 100% O2 for initial resuscitation. CO2 detectors for ETT position were used in only 2 units (12%). A third of units (31%) used plastic wrap to prevent heat loss in VLBW infants. CPAP/PEEP were used by 44% of the surveyed units, generally with initiating pressure of 5 cm H2O.

CONCLUSIONS

NRP is now an obligatory feature in all NICU's in Ireland compared to the 1990s when resuscitation training was disorganized and inconsistent. Variations in resuscitation practices still exist among different units. Many units may not be able to apply 2006 NRP guidelines especially for VLBW infants unless there is a significant investment in air/oxygen blenders, pulse oximeters, CO2 detectors and resuscitators that control peak pressures and CPAP/PEEP.