UK and North American neonatal feeding survey: a survey of practice in the feeding of preterm and very low birth weight infants with particular reference to necrotising enterocolitis

The safe and timely introduction of milk feeding is a fundamental part of neonatal care for preterm and low birth weight infants. Yet enteral feeding in such infants presents significant challenges for the neonatologist. Data from randomised controlled trials are sparse and there is limited evidence to guide clinical practice. Opinion about optimum feeding regimens varies considerably and this variation in opinion is likely to be reflected in similar variation in clinical practice. Different approaches to feeding appear to carry different risks and benefits and serious adverse clinical outcomes may accompany extremes of practice in this area.Much of the uncertainty around practice in enteral feeding has been engendered by inconsistent results from research studies. Most studies have centred upon necrotising enterocolitis (NEC), a serious and devastating bowel disease that primarily affects preterm infants. Mortality from NEC is high. The aetiology of the condition remains elusive and is likely to be multifactorial, but early and rapid enteral feeding has been implicated. In contrast, delayed feeding necessitating prolonged use of central venous catheters and parenteral nutrition may increase susceptibility of preterm infants to severe systemic infection. The potential role of enteral feeding in the development of NEC is of great interest because unlike many other factors, it is amenable to change. However, only through welldesigned trials of different practice will optimum strategies for feeding in high-risk infants begin to emerge. The design of acceptable and feasible clinical trials that fall within the known margins of safety is challenging. As studies of neonatal feeding practice would probably need to take place on an international basis to provide sufficient numbers of outcomes, disparities in practice between different countries may serve only to increase this challenge. An understanding of the variation in practice, the factors influencing this variation and the effects on feed-related outcomes is necessary to inform further research.There have been few recent detailed reports relating to opinions about feeding of preterm infants. No previous study has explored the relationship between available research evidence, clinician opinion and clinical practice. The subject of this thesis is a two-part observational study, conducted in the United Kingdom (UK) and Canada. A questionnaire survey sent to neonatal clinicians sought to investigate current opinion and reported practice with respect to enteral feeding of infants born at less than 30 weeks of gestation and/or 1501 g birth weight in the UK and Canada. This survey was complemented by a detailed retrospective review of the medical and nursing records of infants admitted to fifteen UK and three Canadian neonatal units. Opinions of neonatal clinicians were described and factors influencing feed-related decisions were explored. Analysis of infant feeding data allowed comparison and contrasting of different practices and exploration of short-term neonatal outcomes that may be related to or influenced by variation in practice.Questionnaire responses of 302 clinicians and feeding data from 670 infants were analysed. The results of the study confirmed wide variation both in opinion and in clinical practice across almost all aspects of enteral feeding. This was evident between and within neonatal units and between the two countries. Reported availability and clinicians' awareness of written guidelines to assist in decision-making were also extremely variable. The study demonstrated that a large number of factors appear to influence feeding practice, but that these, too, differ between countries. The most consistent influence affecting the advancement of enteral feeds was the presence of signs consistent with actual or suspected intra-abdominal pathology such as NEC. Occurrence of proven NEC and associated mortality were within previously reported ranges.The effects of variation on necrotising enterocolitis and other important clinical outcomes are not known. Important gaps in knowledge remain with respect to the rate of feed advancement and the relationship between therapeutic interventions and NEC. Further research is required and should be directed towards defining optimum feeding strategies that maximise benefits in terms of growth and neurodevelopment, whilst minimising morbidity and mortality associated with NEC and infection

Widening access to distance education using mobile technologies - A pilot project.

Distance learners are typically adults who struggle to find sufficient time for their studies amongst diverse domestic and work commitments. Any technology that allows them to make more effective use of available time would be welcome. Mobile devices – such as mobile phones, digital personal audio devices (mp3 players) and Personal Digital Assistants – hold the promise of extending the time available for study, by allowing learners to access programme materials during miscellaneous commuting time and waiting time. This project represents an initial attempt to explore these possibilities in Oscail. The project consists of two-phases. In the first phase, participants on selected online distance postgraduate programmes offered by Oscail were surveyed to assess their current usage of mobile devices and also to gauge interest in using mobile devices to support learning on these programmes. For the second phase sample educational resources were developed and deployed, which students were invited to access and evaluate

Expression of FoxA and GATA transcription factors correlates with regionalized gut development in two lophotrochozoan marine worms: Chaetopterus (Annelida) and Themiste lageniformis (Sipuncula)

<p>Abstract</p> <p>Background</p> <p>A through gut is present in almost all metazoans, and most likely represents an ancient innovation that enabled bilaterian animals to exploit a wide range of habitats. Molecular developmental studies indicate that <it>Fox </it>and <it>GATA </it>regulatory genes specify tissue regions along the gut tube in a broad diversity of taxa, although little is known about gut regionalization within the Lophotrochozoa. In this study, we isolated <it>FoxA </it>and <it>GATA456 </it>orthologs and used whole mount <it>in situ </it>hybridization during larval gut formation in two marine worms: the segmented, polychaete annelid <it>Chaetopterus</it>, which develops a planktotrophic larva with a tripartite gut, and the non-segmented sipunculan <it>Themiste lageniformis</it>, which develops a lecithotrophic larva with a U-shaped gut.</p> <p>Results</p> <p><it>FoxA </it>and <it>GATA456 </it>transcripts are predominantly restricted to gut tissue, and together show regional expression spanning most of the alimentary canal in each of these lophotrochozoans, although neither <it>FoxA </it>nor <it>GATA456 </it>is expressed in the posterior intestine of <it>Chaetopterus</it>. In both species, <it>FoxA </it>is expressed at the blastula stage, transiently in presumptive endoderm before formation of a definitive gut tube, and throughout early larval development in discrete foregut and hindgut domains. <it>GATA456 </it>genes are expressed during endoderm formation, and in endoderm and mesoderm associated with the midgut in each species. Several species-specific differences were detected, including an overlap of <it>FoxA </it>and <it>GATA456 </it>expression in the intestinal system of <it>Themiste</it>, which is instead complimentary in <it>Chaetopterus</it>. Other differences include additional discrete expression domains of <it>FoxA </it>in ectodermal trunk cells in <it>Themiste </it>but not <it>Chaetopterus</it>, and expression of <it>GATA456 </it>in anterior ectoderm and midgut cells unique to <it>Chaetopterus</it>.</p> <p>Conclusions</p> <p>This study of gene expression in a sipunculan contributes new comparative developmental insights from lophotrochozoans, and shows that <it>FoxA </it>and <it>GATA456 </it>transcription factors are part of an ancient patterning mechanism that was deployed during early evolution of the metazoan through gut. The common utilization of <it>FoxA </it>and <it>GATA456 </it>throughout gut formation by species with contrasting life history modes indicates that both genes are core components of a gut-specific gene regulatory network in spiralians. Despite a highly conserved pattern of early development, and probably similar ontogenic origins of gut tissue, there are molecular differences in gut regionalization between lophotrochozoan species.</p

Recasting diaspora strategies through feminist care ethics

Geoforum59206-21

Developing and piloting a resource for training assessors in use of the Mini-CEX (mini clinical evaluation exercise).

The assessment of undergraduate medical students in the clinical setting has become a key priority for medical educators. Facilitating the successful translation of undergraduate theoretical knowledge into safe and appropriate postgraduate clinical practice represents a challenge in medical education [1]. Poor clinical performance of newly qualified doctors has been highlighted as a major issue relating to patient safety [2]. Performance based assessment in the undergraduate setting may assist in addressing this issue by assessing ‘doing’ rather than ‘knowing’. The mini clinical evaluation exercise (Mini-CEX) is a formative assessment used to assess the performance of medical students in a clinical context. It incorporates assessment by, and feedback from, an assessor, based on the direct observation of a student–patient consultation [3]. Conducted in a series of stages, the Mini-CEX allows focused assessment of key competencies (see Box 1) [3]

A comprehensive fate map by intracellular injection of identified blastomeres in the marine polychaete Capitella teleta

<p>Abstract</p> <p>Background</p> <p>The polychaete annelid <it>Capitella teleta </it>(formerly <it>Capitella </it>sp. I) develops by spiral cleavage and has been the focus of several recent developmental studies aided by a fully sequenced genome. Fate mapping in polychaetes has lagged behind other spiralian taxa, because of technical limitations.</p> <p>Results</p> <p>To generate a modern fate map for <it>C. teleta</it>, we injected 1,1'-dioctadecyl-3,3,3'3'-tetramethylindocarbocyanine perchlorate (DiI) into individual identified blastomeres through fourth-quartet micromere formation. Confocal laser scanning microscopy at single-cell resolution was used to characterize blastomere fates during larval stages. Our results corroborate previous observations from classic studies, and show a number of similarities with other spiralian fate maps, including unique and stereotypic fates for individual blastomeres, presence of four discrete body domains arising from the A, B, C and D cell quadrants, generation of anterior ectoderm from first quartet micromeres, and contributions to trunk ectoderm and ventral nerve cord by the 2d somatoblast. Of particular interest are several instances in which the <it>C. teleta </it>fate map deviates from other spiralian fate maps. For example, we identified four to seven distinct origins of mesoderm, all ectomesodermal. In addition, the left and right mesodermal bands arise from 3d and 3c, respectively, whereas 4d generates a small number of trunk muscle cells, the primordial germ cells and the anus. We identified a complex set of blastomere contributions to the posterior gut in <it>C. teleta</it>, which establishes the most complete map of posterior gut territories to date.</p> <p>Conclusions</p> <p>Our detailed cellular descriptions reveal previously underappreciated complexity in the ontogenetic contributions to several spiralian larval tissues, including the mesoderm, nervous system and gut. The formation of the mesodermal bands by 3c and 3d is in stark contrast to other spiralians, in which 4d generates the mesodermal bands. The results of this study provide a framework for future phylogenetic comparisons and functional analyses of cell-fate specification.</p

Sovereign Power, Biopower, and the Reach of the West in an Age of Diaspora‐Centred Development

Why at this particular historical moment has there emerged a rousing interest in the potential contribution of diasporas to the development of migrant sending states and why is this diaspora turn so pervasive throughout the global South? The central premise of this paper is that the rapid ascent of diaspora‐centred development cannot be understood apart from historical developments in the West's approach to governing international spaces. Once predicated upon sovereign power, rule over distant others is increasingly coming to depend upon biopolitical projects which conspire to discipline and normalize the conduct of others at a distance so as to create self‐reliant and resilient market actors. We argue that an age of diaspora‐centred development has emerged as a consequence of this shift and is partly constitutive of it. We develop our argument with reference to Giorgio Agamben's “Homo Sacer” project and in particular the theological genealogy of Western political constructs he presents in his book The Kingdom and the Glory (2011). We provide for illustration profiles of three projects which have played a significant role in birthing and conditioning the current diaspora option: the World Bank's Knowledge for Development Programme (K4D); the US‐based International Diaspora Engagement Alliance (IdEA); and the EU/UN Joint Migration and Development Initiative Migration4Development project (JMDI‐M4D). Drawing upon economic theology, we make a case for construing these projects as elements of the West's emerging Oikonomia after the age of empire

"Random" gentamicin concentrations do not predict trough levels in neonates receiving once daily fixed dose regimens

BACKGROUND: Monitoring plasma gentamicin concentrations in neonates 24 hours after a once daily dose (4 mg/kg) often necessitates additional blood sampling. In adults a nomogram has been developed enabling evaluation of gentamicin doses by sampling concentrations with other blood tests, 4 – 16 hours after administration. We attempted to develop a similar nomogram for neonates. METHODS: In addition to standard 24 hour sampling to monitor trough concentrations, one additional "random" gentamicin concentration was measured in each of 50 neonates <4 days of age (median gestation 33 weeks [28–41]), when other blood samples were clinically necessary, 4 – 20 hours after gentamicin administration. 24 hour concentrations of >1 mg/L were considered high, and an indication to extend the dosing interval. RESULTS: Highest correlation (r(2 )= 0.51) of plasma gentamicin concentration against time (4 to 20 hours) was with logarithmic regression. A line drawn 0.5 mg/L below the true regression line resulted in all babies with 24 hr gentamicin concentrations >1 mg/L having the additional "random" test result above that line, i.e. 100% sensitivity for 24 hour concentrations>1 mg/L, though only 58% specificity. Having created the nomogram, 39 further babies (median gestation 34 weeks [28–41]), were studied and results tested against the nomogram. In this validation group, sensitivity of the nomogram for 24 hr concentrations >1 mg/L was 92%; specificity 14%, positive predictive value 66%, and negative predictive value 50%. Prematurity (≤ 37 weeks) was a more sensitive (94%) and specific (61%) indicator of high 24-hour concentrations. 62 (87%) of 71 preterm babies had high 24-hour concentrations. CONCLUSION: It was not possible to construct a nomogram to predict gentamicin concentrations at 24 hours in neonates with a variety of gestational ages. Dosage tailored to gestation with monitoring of trough concentrations remains management of choice