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The purpose of this study is to investigate whether listening to music and white noise affects functional connectivity on scalp electroencephalography (EEG) in neonates in the neonatal intensive care unit.Nine neonates of ≥34 weeks’ gestational age, who were already undergoing clinical continuous EEG monitoring in the neonatal intensive care unit, listened to lullaby-like music and white noise for 1 hour each separated by a 2-hour interval of no intervention. EEG segments during periods of music, white noise, and no intervention were band-pass filtered as delta (0.5-4 Hz), theta (4-8 Hz), lower alpha (8-10 Hz), upper alpha (10-13 Hz), beta (13-30 Hz), and gamma (30-45 Hz). Synchronization likelihood was used as a measure of connectivity between any 2 electrodes.In theta, lower alpha, and upper alpha frequency bands, the synchronization likelihood values yielded statistical significance with sound (music, white noise and no intervention) and with edge (between any 2 electrodes) factors. In theta, lower alpha, and upper alpha frequency bands, statistical significance was obtained between music and white noise ( t = 3.12, 3.32, and 3.68, respectively; P < .017), and between white noise and no intervention ( t = 4.51, 3.09, and 2.95, respectively, P < .017). However, there was no difference between music and no intervention.Although limited by a small sample size and the 1-time only auditory intervention, these preliminary results demonstrate the feasibility of EEG connectivity analyses even at bedside in neonates on continuous EEG monitoring in the neonatal intensive care unit. They also point to the possibility of detecting significant changes in functional connectivity related to the theta and alpha bands using auditory interventions.

Objective To metasynthesize the results of qualitative studies on the factors that affect parents' participation in pain management for their infants during procedures in the NICU. Data Sources We conducted a literature search for articles published from 1976 through November 2019 using MeSH terminology in the following databases: MEDLINE, CINAHL Plus, EMBASE, PubMed, PsycINFO, Cochrane, Scopus, and Web of Science. All qualitative studies in which researchers explored parental participation and education in the NICU were included. Study Selection A total of 29,937 articles were returned. Once we removed duplicates and limited results to qualitative studies, 48 articles remained. We excluded 41 articles because the studies reported were not conducted in NICUs, involved neonatal palliative care, or were review or opinion articles. We included seven articles for review. Data Extraction Two authors reviewed all articles using the Critical Appraisal Skills Programme tool to assess study quality and independently scored each study. We reviewed and extracted authors, publication date, type of study, sample size, results, themes, and quotes and included these data elements in the analysis. Data Synthesis We used a thematic synthesis technique to review the qualitative data, entered codes into NVivo software, and compared codes to create descriptive themes. From these descriptive themes, we generated four analytic themes: Learning to Parent a Hospitalized Infant, Stress and Anxiety, Health Care Providers as Gatekeepers, and NICU Environment. Conclusion The four themes identified in this qualitative metasynthesis represent the factors that affect parents' abilities to participate in their infants' pain management. Further research is recommended to develop interventions that address these factors to optimize parents' participation in pain management for their infants during procedures in the NICU.

Background The salmon louse (Lepeophtheirus salmonis) infests farmed and wild salmonid fishes, causing considerable economic damage to the salmon farming industry. Infestations of farmed salmon are controlled using a combination of non-medicinal approaches and veterinary drug treatments. While L. salmonis has developed resistance to most available salmon delousing agents, relatively little is known about the molecular mechanisms involved. Members of the cytochrome P450 (CYP) superfamily are typically monooxygenases, some of which are involved in the biosynthesis and metabolism of endogenous compounds, while others have central roles in the detoxification of xenobiotics. In terrestrial arthropods, insecticide resistance can be based on the enhanced expression of CYPs. The reported research aimed to characterise the CYP superfamily in L. salmonis and assess its potential roles in drug resistance. Methods Lepeophtheirus salmonis CYPs were identified by homology searches of the genome and transcriptome of the parasite. CYP transcript abundance in drug susceptible and multi-resistant L. salmonis was assessed by quantitative reverse transcription PCR, taking into account both constitutive expression and expression in parasites exposed to sublethal levels of salmon delousing agents, ecdysteroids and environmental chemicals. Results The above strategy led to the identification of 25 CYP genes/pseudogenes in L. salmonis, making its CYP superfamily the most compact characterised for any arthropod to date. Lepeophtheirus salmonis possesses homologues of a number of arthropod CYP genes with roles in ecdysteroid metabolism, such as the fruit fly genes disembodied, shadow, shade, spook and Cyp18a1. CYP transcript expression did not differ between one drug susceptible and one multi-resistant strain of L. salmonis. Exposure of L. salmonis to emamectin benzoate or deltamethrin caused the transcriptional upregulation of certain CYPs. In contrast, neither ecdysteroid nor benzo[a]pyrene exposure affected CYP transcription significantly. Conclusions The parasite L. salmonis is demonstrated to possess the most compact CYP superfamily characterised for any arthropod to date. The complement of CYP genes in L. salmonis includes conserved CYP genes involved in ecdysteroid biosynthesis and metabolism, as well as drug-inducible CYP genes. The present study does not provide evidence for a role of CYP genes in the decreased susceptibility of the multiresistant parasite strain studied.

Background Despite the availability of effective, safe, and feasible pain management strategies, infant pain remains undertreated. Parents can play a key role in advocating for or delivering pain management strategies if they are educated. To date, a quantitative synthesis of the effectiveness of parental education about pain management in the neonatal period has not been performed. Objective To systematically review the effectiveness of parental education during the neonatal period on pain management in infancy. Methods MEDLINE, EMBASE, PsycInfo, CINAHL, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) and non-randomized trials (NRTs) that evaluated parental education with respect to pain management during the neonatal period in any setting from inception to February 2021. Screening of article titles and abstracts and data extraction were performed in duplicate. The risk of bias was assessed using the Cochrane Risk Bias Tool 2.0 and the Risk of Bias in Non-randomized Studies of Interventions for RCTs and NRTs, respectively. As per the GRADE methodology, critically important and important outcomes were identified. Critically important outcomes included utilization of pain management strategies and infant pain. Important outcomes included parental knowledge about pain mitigation strategies, parental attitudes, compliance with painful procedures, procedure outcomes, and safety. Data were combined and presented as relative risk (RR) or mean or standardized mean difference (MD or SMD) with 95% confidence interval (CI). Results Of the six studies eligible for inclusion, four studies were RCTs and two studies were NRTs. Written information and/or video were used to deliver parental education during the neonatal period in hospital settings in all studies. Four studies (two RCTs and two NRTs) reported on critically important outcomes. The risk of bias was low for the two RCTs and moderate to serious for the two NRTs. Utilization of pain management strategies was assessed for heel lance in the first 48 hours of life in two studies and for vaccine injection at 2 to 6 months of life in two studies. Higher utilization rate for pain management strategies was reported in the pain education group in three studies (RR 1.15, 95% CI 1.04, 1.26; N=2712). There was no difference in the mean number of pain management strategies used in one NRT tracking utilization tracking utilization as continuous data (MD 0.20, 95% CI –0.01, 0.41; N=178). Parent-reported infant pain scores were lower in the pain education group in one RCT (MD –0.16, 95% CI –0.27, –0.06; N=1615). The quality of evidence for the outcome of utilization of pain management strategies was very low while for the outcome of infant pain the quality of evidence was moderate. Five studies (3 RCTs and 2 NRTs) reported on important outcomes. The risk of bias was low for two RCTs and high for one RCT and moderate to serious for the two NRTs. Parental knowledge about pain management strategies (SMD 0.54, 95% CI 0.26, 0.82), parental confidence in their ability to manage pain (SMD 0.24, 95% CI 0.14, 0.34), parental satisfaction with education (MD 1.18, 95% CI 0.84, 1.52) and parental satisfaction with pain management (RR 1.05. 95% CI 1.01, 1.08) were increased in the pain education group. None of the included studies reported on procedural outcomes. No adverse events with the pain education nor the use of pain management interventions were reported in one study. Conclusions Parental education in the neonatal period was effective in increasing utilization of pain management strategies during painful procedures. Reduction of pain in infants is based on one study of moderate quality. Furthermore, parental education increased parental knowledge about pain management strategies, confidence in their ability to manage infant pain, and satisfaction with the education and pain management. Parental pain education should be incorporated into postnatal care.

Glucose is the primary substrate for energy metabolism in the brain and although the brain is dependent on a constant glucose supply for normal function, both local energy stores and the supply of alternate substrates are limited. In utero, the placenta provides a continuous supply of glucose to the fetus while transition to extrauterine life marks an abrupt change in substrate delivery and a major change in glucose metabolism where insufficiencies and disruptions can occur. Hypoglycemia is one of the most common biochemical disturbances in the neonatal period, affecting a wide range of neonates. Prolonged or persistent low plasma glucose concentrations can lead to neonatal brain injury and abnormal neurological outcomes. This article discusses fetal and neonatal metabolic adaptation, the physiology of glucose homeostasis, hypoglycemic brain injury (HBI), and neurodevelopmental long-term outcomes.

Hypoxic-ischemic encephalopathy (HIE) can have both transient and long-lasting effects on the neonate, including neurologic, renal, cardiac, hepatic, and hematologic. Both the disease process and the treatment option of therapeutic hypothermia can result in hemodynamic instability. Understanding the effects of HIE on the neonatal myocardium, pulmonary vascular bed, and the cardiac dysfunction that can occur is key to managing infants with HIE. This article focuses on causes of hemodynamic instability in neonates following perinatal asphyxia and how to recognize hemodynamic compromise. It reviews the underlying pathophysiology and associated management strategies to improve hemodynamics and potentially improve outcomes.

OBJECTIVES: The objective of this cohort study was to document experience with intranasal (IN) fentanyl analgesia for procedural pain management in neonates in a surgical neonatal intensive care unit. A consecutive sample of 23 neonates without intravenous access treated with IN fentanyl was included. METHODS: Data were extracted from medical charts, including infant characteristics, indication for IN fentanyl, dose, physiologic parameters (heart rate, respiratory rate, oxygen saturation, blood pressure) and pain scores. Physiologic parameters were recorded for 6 hours before and after IN fentanyl. Pain scores were recorded during and after the procedure using the Premature Infant Pain Profile (PIPP). RESULTS: The mean (SD) postmenstrual age of included infants was 31.8 weeks (4.1), and 52% were receiving some form of ventilator support. The mean dose of IN fentanyl was 1.3 mcg/kg (0.4) and most common indication was analgesia for peripheral insertion of central catheter. There were six cases of cardiorespiratory depression as defined, however, clinical factors could account for all of them. The mean PIPP score during and after the procedure was 4.3 (1.8) and 3.6 (1.5), respectively (scores

Background: On the basis of pharmacokinetic modelling, high-dose acetaminophen by rectal administration has been recommended for neonates needing antipyretic or analgesic therapy, but the safety and efficacy of this approach have not been established in vivo. Objectives: The primary objective was to assess the safety of rectal acetaminophen administration for neonates, as indicated by changes in the results of hepatic and renal function tests. The secondary objective was to assess the efficacy of rectal acetaminophen administration in terms of the Premature Infant Pain Profile-Revised (PIPP-R) score.Methods: This single-centre retrospective chart analysis was conducted in the neonatal intensive care unit at a quaternary care children’s hospital. Neonates who received all prescribed doses of acetaminophen by continu -ous rectal administration for 24 h or more, from January 1, 2011, to December 31, 2012, were included. For the primary objective, hepato-toxicity was assessed in terms of changes in liver enzyme levels, and nephrotoxicity was assessed in terms of changes from baseline serum creatinine values.Results: Twenty-five patients, who received a total of 27 courses of acetaminophen by rectal administration, met the inclusion criteria. Median gestational age at initiation of acetaminophen was 37.0 weeks (interquartile range 35.0–39.8 weeks). Values of alanine aminotransferase remained within normal limits during acetaminophen therapy for all but 3 patients, for whom the changes were attributable to confounding factors. Renal function remained unchanged. The secondary outcome of efficacy (based on PIPP-R score) could not be evaluated because of concurrent use of opioids for most patients.Conclusions: Continuous rectal administration of acetaminophen over a short period (< 48 h) appeared to be well tolerated. The conclusions that can be drawn from these results are limited because of small sample size, the prescribing of doses lower than those recommended by the hospital’s formulary, and limited blood sampling. Further studies are required.RÉSUMÉContexte : Selon une modélisation pharmacocinétique, des doses élevées d’acétaminophène administré par voie rectale ont été recommandées comme traitement antipyrétique ou analgésique chez le nouveau-né, mais l’innocuité et l’efficacité de cette modalité d’administration n’ont pas été établies in vivo. Objectifs : L’objectif principal était d’évaluer l’innocuité de l’acéta-minophène administré par voie rectale chez le nouveau-né en observant les changements dans les résultats des bilans hépatique et rénal. L’objectif secondaire était d’évaluer l’efficacité de l’acétaminophène administré par voie rectale à l’aide du score obtenu dans le Premature Infant Pain Profile-Revised (PIPP-R).Méthodes : La présente étude rétrospective menée dans un seul centre comportait une analyse des dossiers médicaux de patients admis à l’unité de soins intensifs néonatals d’un établissement de soins quaternaires pour enfants. Les nouveau-nés ayant reçu toutes les doses prescrites d’acétaminophène par administration rectale ininterrompue pendant 24 heures ou plus, entre le 1er janvier 2011 et le 31 décembre 2012, étaient admissibles à l’étude. Pour l’objectif principal, l’hépatotoxicité a été évaluée en fonction des variations observées dans les taux d’enzymes hépatiques et la néphrotoxicité a été évaluée en fonction des changements observés dans la créatininémie par rapport aux valeurs de départ.Résultats : Vingt-cinq patients qui ont reçu un total de 27 traitements par acétaminophène administré par voie rectale répondaient aux critères d’inclusion. L’âge gestationnel médian lors de l’amorce du traitement par acétaminophène était de 37,0 semaines (écart interquartile de 35,0 semaines à 39,8 semaines). Les valeurs d’alanine-aminotransférase demeuraient à l’intérieur des limites normales pendant le traitement par acétaminophène pour tous les patients à l’exception de trois pour lesquels les changements étaient attribués à des facteurs de confusion. La fonction rénale demeurait inchangée. Le critère d’évaluation secondaire quant à l’efficacité (s’appuyant sur le score obtenu dans le PIPP-R) n’a pu être évalué en raison de la prise concomitante d’opioïdes chez la plupart des patients.Conclusions : L’administration rectale ininterrompue d’acétaminophène pendant une courte période (moins de 48 heures) semblait être bien tolérée. Cependant, les conclusions qui peuvent être tirées de ces résultats sont limitées en raison de la petite taille de l’échantillon, de la prescription de doses plus faibles que celles recommandées dans la liste des médicaments de l’hôpital et de l’insuffisance des échantillons sanguins. De plus amples études sont nécessaires.

Background Orally administered sucrose is effective and safe in reducing pain intensity during single, tissue-damaging procedures in neonates, and is commonly recommended in neonatal pain guidelines. However, there is wide variability in sucrose doses examined in research, and more than a 20-fold variation across neonatal care settings. The aim of this study was to determine the minimally effective dose of 24% sucrose for reducing pain in hospitalized neonates undergoing a single skin-breaking heel lance procedure. Methods A total of 245 neonates from 4 Canadian tertiary neonatal intensive care units (NICUs), born between 24 and 42 weeks gestational age (GA), were prospectively randomized to receive one of three doses of 24% sucrose, plus non-nutritive sucking/pacifier, 2 min before a routine heel lance: 0.1 ml (Group 1; n = 81), 0.5 ml (Group 2; n = 81), or 1.0 ml (Group 3; n = 83). The primary outcome was pain intensity measured at 30 and 60 s following the heel lance, using the Premature Infant Pain Profile-Revised (PIPP-R). The secondary outcome was the incidence of adverse events. Analysis of covariance models, adjusting for GA and study site examined between group differences in pain intensity across intervention groups. Results There was no difference in mean pain intensity PIPP-R scores between treatment groups at 30 s (P = .97) and 60 s (P = .93); however, pain was not fully eliminated during the heel lance procedure. There were 5 reported adverse events among 5/245 (2.0%) neonates, with no significant differences in the proportion of events by sucrose dose (P = .62). All events resolved spontaneously without medical intervention. Conclusions The minimally effective dose of 24% sucrose required to treat pain associated with a single heel lance in neonates was 0.1 ml. Further evaluation regarding the sustained effectiveness of this dose in reducing pain intensity in neonates for repeated painful procedures is warranted. Trial registration ClinicalTrials.gov: NCT02134873. Date: May 5, 2014 (retrospectively registered).

Objective Sucrose solutions are analgesic in infants. Oral rotavirus vaccine contains sucrose, however, it is not known if it possesses analgesic properties. The objective was to compare the analgesic effectiveness of rotavirus vaccine to sucrose solution when administered prior to injectable vaccines. Methods Infants 2–4 months of age receiving oral rotavirus vaccine and two separate injectable vaccines on the same day were randomized to rotavirus vaccine (Rotarix™) first followed by the injectable vaccines and sucrose (Tootsweet™) afterwards, or vice versa. Pain was assessed by blinded raters using the Numerical Rating Scale (NRS, range 0–10) (parents, clinicians), or Modified Behavioural Pain Scale (MBPS, range 0–10) and cry duration (observers). Data were analyzed using t -tests or χ 2 -tests; Bonferroni correction was applied to correct for multiple comparisons, as appropriate. Results Altogether, 120 infants participated: 60 were randomized to rotavirus vaccine first. Groups did not differ in demographics, including; age ( p = 0.448) and sex ( p = 0.464). The mean pain score (standard deviation) for both vaccine injections did not differ between infants given rotavirus vaccine first versus sucrose solution first: observer MBPS, parent NRS and clinician NRS scores were 7.4 (1.6) vs. 7.7 (1.6), 4.9 (2.1) vs. 5.8 (2.1), and 4.2 (2.1) vs. 4.6 (2.2), respectively. Similarly, there was no difference between groups in cry duration. Conclusion Rotavirus vaccine did not differ from sucrose solution in reducing injection-induced pain. Based on the findings, it is recommended that rotavirus vaccine be administered prior to injectable vaccines in infants aged 2 and 4 months.

ObjectivesDespite multiple attempts at eradication, many ectoparasites of humans and domestic livestock remain a persistent problem in the modern world. For many years, a range of pesticide drugs including organophosphates, organochlorides and synthetic pyrethroids provided effective control of these parasites; but intensive use of these drugs has led to the evolution of resistance in many target species. This paper aims to review the effectiveness of current control methods and discuss potential alternatives for the long term sustainable control of ectoparasites.Key FindingsImportant medical ectoparasites such as scabies mites, head lice and bed bugs present a significant public health problem, and so adequate control methods are essential. Ectoparasites of domestic livestock and farmed fish (for example sheep scab mites, poultry mites and sea lice) are also of concern given the increasing strain on the world's food supply. These parasites have become resistant to several classes of pesticide, making control very difficult. Recently, an increasing amount of research has focussed on alternative control methods such as insect growth regulators, biological control using essential oils or fungi, as well as vaccine development against some ectoparasites of medical and veterinary importance.SummaryDrug resistance is prevalent in all of the ectoparasites discussed in this review. A wide variety of alternative control methods have been identified, however further research is necessary in order for these to be used to successfully control ectoparasitic diseases in the future.

Background The salmon louse, Lepeophtheirus salmonis, is an ectoparasitic copepod which feeds on the mucus, skin and blood of salmonid fish species. The parasite can persist on the surface of the fish without any effective control being exerted by the host immune system. Other ectoparasitic invertebrates produce compounds in their saliva, excretions and/or secretions which modulate the host immune responses allowing them to remain on or in the host during development. Similarly, compounds are produced in secretions of L. salmonis which are thought to be responsible for immunomodulation of the host responses as well as other aspects of crucial host-parasite interactions. Methods In this study we have identified and characterised the proteins in the excretory/secretory (E/S) products of L. salmonis using LC-ESI-MS/MS. Results In total 187 individual proteins were identified in the E/S collected from adult lice and pre-adult sea lice. Fifty-three proteins, including 13 serine-type endopeptidases, 1 peroxidase and 5 vitellogenin-like proteins were common to both adult and pre-adult E/S products. One hundred and seven proteins were identified in the adult E/S but not in the pre-adult E/S and these included serine and cysteine-type endopeptidases, vitellogenins, sphingomyelinase and calreticulin. A total of 27 proteins were identified in pre-adult E/S products but not in adult E/S. Conclusions The assigned functions of these E/S products and the potential roles they play in host-parasite interaction is discussed. Electronic supplementary material The online version of this article (10.1186/s13071-018-2885-6) contains supplementary material, which is available to authorized users.

To evaluate the safety of fentanyl in non-intubated infants undergoing peripherally inserted central catheter (PICC) placement. A retrospective chart review of PICC placements over a 3 years’ period. We compared the 12h periods before and after fentanyl for clinically significant cardiorespiratory events (spells). Of the 998 neonates screened, 258 were eligible. The mean standard deviation gestational age was 34.1 (4.3) weeks and the median (inter-quartile range) postnatal age was 4 (7, 11) days. The mean (standard deviation) fentanyl dose was 0.6 (0.2) µg/kg. Respiratory depression occurred only in two infants (prevalence rate = 0.78%, 95% CI (0, 1.85)). No cases of hypotension or chest wall rigidity occurred. There was no evidence of an increase in the number of infants with spells or in the number of spells per infant (p = 0.34 and p = 0.06, respectively). Fentanyl appears to be associated with only a small risk of respiratory depression in non-intubated infants.

All infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available for these painful procedures, including swaddling, holding, skin-to-skin care, pacifier, sweet-tasting solutions, and breast-feeding. Adoption of nonpharmacologic pain-relieving interventions into routine clinical practice is feasible and should be a standard of care in the delivery of quality health care for infants. This review summarizes current knowledge about the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions for future research.

OBJECTIVES Opioids are indicated for the management of procedural pain in neonates. There are limited data describing factors influencing patterns of use. PATIENTS AND METHODS We conducted an online English survey of Canadian neonatologists using Survey Monkey, whereby they answered questions about the frequency and pattern of use of opioids, and specifically, of morphine and fentanyl, for ventilated and spontaneously breathing infants undergoing selected painful medical procedures. RESULTS Hundred and twenty nine of 225 (57%) eligible neonatologists participated. They reported that opioids were part of their practice for managing procedural pain in 100% of ventilated infants and 93% of spontaneously breathing infants. Frequency of opioid use was associated with infant ventilation status: spontaneously breathing infants were 28% less likely to receive them (P=0.013). For morphine, the most commonly used dose was 100 microg/kg in ventilated infants and 50 microg/kg in spontaneously breathing infants. For fentanyl, 1 microg/kg was the most frequently used dose in both infant populations. Use of morphine and fentanyl were significantly associated with 2-way interactions (P

Immediate-early protein ICP0 of herpes simplex virus type 1 (HSV-1) is an E3 ubiquitin ligase of the RING finger class that is required for efficient lytic infection and reactivation from latency. Other alphaherpesviruses also express ICP0-related RING finger proteins, but these have limited homology outside the core RING domain. Existing evidence indicates that ICP0 family members have similar properties, but there has been no systematic comparison of the biochemical activities and biological functions of these proteins. Here, we describe an inducible cell line system that allows expression of the ICP0-related proteins of bovine herpes virus type 1 (BHV-1), equine herpesvirus type 1 (EHV-1), pseudorabies virus (PRV), and varicella-zoster virus (VZV) and their subsequent functional analysis. We report that the RING domains of all the proteins have E3 ubiquitin ligase activity in vitro . The BHV-1, EHV-1, and PRV proteins complement ICP0-null mutant HSV-1 plaque formation and induce derepression of quiescent HSV-1 genomes to levels similar to those achieved by ICP0 itself. VICP0, the ICP0 expressed by VZV, was found to be extremely unstable, which limited its analysis in this system. We compared the abilities of the ICP0-related proteins to disrupt ND10, to induce degradation of PML and Sp100, to affect key components of the interferon signaling pathway, and to interfere with induction of interferon-stimulated genes. We found that the property that correlated most closely with their biological activities was the ability to preclude the recruitment of cellular ND10 proteins to sites closely associated with incoming HSV-1 genomes and early replication compartments.

An omphalocele, a ventral defect of the umbilical ring resulting in herniation of the abdominal viscera, is one of the most common congenital abdominal wall defects seen in the newborn. Omphaloceles occur in 1 in 3,000 to 10,000 live births. Associated malformations such as chromosomal, cardiac, or genitourinary abnormalities are common. Postnatal management includes protection of the herniated viscera, maintenance of fluids and electrolytes, prevention of hypothermia, gastric decompression, prevention of sepsis, and maintenance of cardiorespiratory stability. A primary or staged closure approach may be used to repair the defect. Some giant omphaloceles require a skin flap or nonoperative management approach, however. Immediate postoperative complications, usually related to significant changes in intra-abdominal pressures, include compromise of interior venous blood return and hemodynamic and respiratory instability due to diaphragmatic elevation. Complications occur more frequently with giant defects. Potential short-term complications include necrotizing enterocolitis, prolonged ileus, and respiratory distress. Long-term complications include parenteral nutrition dependence, gastroesophageal reflux, parenteral nutrition– related liver disease, feeding intolerance, and neurodevelopmental delay. Overall, advances in surgical therapies and nursing care have improved outcomes for infants with omphaloceles; survival rates for those with isolated omphaloceles are reported at 75 to 95 percent. Infants with associated anomalies and giant omphaloceles have the poorest outcomes.

Sweetening agents have been recommended in position statements and consensus documents for procedural pain management in neonates; however, it is not clear if this has resulted in widespread adoption in clinical practice. The objective of this study was to investigate unit-specific protocols for the use of sweetening agents.Structured telephone survey with qualified personnel in special care (level II) nurseries and neonatal intensive care (level III) units across Canada. The frequency and pattern of recommended use of sweetening agents was documented.Eighty-six of 92 units (93.5%) participated. Sixty-four percent recommended sucrose and 2.3% recommended glucose for procedural pain management; 87.7% had a guideline. Sweetening agents were most commonly recommended for venipuncture/venous cannulation (91.2% for both), lumbar puncture (87.7%), and heel lance (82.5%). Dosing guidelines ranged from 0.05 mL of 24% sucrose solution to 3 mL of 25% sucrose solution. Sweeteners were not recommended for infants with necrotizing enterocolitis (77.2%) or those who were nil per os (75%).Sweetening agents were recommended for procedural pain management in two-thirds of special care nurseries and neonatal intensive care units across Canada with extensive variability in specific dosing guidelines. Audits of pain management practices should therefore account for unit-specific practice guidelines.

Infants in NICUs undergo a variety of painful procedures. The management of pain has become an integral part of newborn infant care with the use of both systemic and topical agents to provide analgesia and anesthesia for procedural pain. Tetracaine and prilocaine-lidocaine are the 2 topical anesthetics most frequently used. Tetracaine belongs to an ester group of local anesthetics available as a topical 4% gel (Ametop, Smith and Nephew, Canada). The major side effects reported when using topical anesthetics are cutaneous reactions. There are no definite reports of systemic toxicity in the published literature. We present a recent case of an extremely low birth weight premature infant who developed a clinically significant arrhythmia after topical tetracaine was applied before the insertion of a peripherally inserted central catheter. The infant had no other identifiable cause for the resulting bradycardia that occurred only after Ametop was applied. The cardiac symptoms resolved with treatment. This case highlights a significant potential adverse event when using topical tetracaine.

The mite Psoroptes ovis is the causative agent of sheep scab. Although not usually fatal, the disease can spread rapidly and is a serious animal welfare concern. Vaccine development against ectoparasites has primarily focussed on two sources of candidate vaccine antigens - ''exposed'' antigens that are secreted in saliva during feeding on a host and ''concealed'' antigens that are usually expressed in the parasite gut and may be involved in digestion. Here, we sought to identify genes encoding proteins important for mite feeding and digestion by a subtractive suppressive hybridisation approach comparing mRNA transcript abundance in ''fed'' and ''starved'' mites. The study identified a variety of genes which are up-regulated by feeding mites. These included group 1, 5, 7 and 13 allergens including the previously described cysteine protease Pso o 1. In addition, numerous novel genes were identified here including some encoding potential salivary gland proteins and others encoding proteins which may facilitate feeding such as a serum opacity factor. An olfactory receptor-like protein was identified in the starved mite population which may help the mite to identify a host. Psoroptes / sheep / gene / protein / feeding

SUMMARYThe sheep scab mite,Psoroptes ovis, induces an intensely pruritic exudative dermatitis which is responsible for restlessness, loss of appetite and weight loss. Within the first 24 h of infection, there is a rapid inflammatory influx of eosinophils and apoptosis of the keratinocytes at the site of infection. The former cell type is capable of a sustained respiratory burst, toxic products of which may directly damage the mite and also contribute to lesion formation. Analysis of aP. ovisexpressed sequence tag (EST) database identified a number of antioxidant enzyme-encoding sequences, including peroxiredoxin (thioredoxin peroxidase EC 1.11.1.15), all of which may help the mite endure the potentially toxic skin environment. A full length sequence encodingPo-TPx, a protein of 206 amino acids which showed high homology to a peroxiredoxin from the salivary gland of the tickIxodes scapularis, was amplified fromP. oviscDNA. RecombinantPo-TPx was expressed in bacteria and antiserum to this protein was used to localize nativePo-TPx in mite sections. Peroxiredoxin was localized, amongst other sites, to a subpharyngeal region in mite sections. The recombinant protein was recognized by sera from sheep infested with the mite suggesting that it may be secreted or excreted by the mite and interact with the host immune response.

SUMMARY A cDNA encoding a surface-associated antigen was amplified by reverse transcriptase polymerase chain reaction (PCR) from RNA extracted from Teladorsagia circumcincta exsheathed third stage larvae (xL3). The protein encoded by this cDNA, Tc -SAA-1, displays 77% identity over 162 amino acid residues to a surface associated antigen from Ancylostoma caninum ( Ac- SAA-1 ). Antiserum raised against a bacterially-expressed recombinant form of Tc -SAA-1 reacted with a native protein in somatic and surface extracts of xL3 but not with L4 or adult parasites. Limited binding of anti -Tc- SAA-1 antibody was observed on the cuticular surface of xL3 s, however, regions of localization underlying the cuticle were observed. Incubation of xL3 T. circumcincta with anti-SAA rabbit serum failed to significantly inhibit penetration of the abomasal mucosa in vitro. IgA in abomasal mucus derived from sheep that had received a trickle infection of T. circumcincta bound recombinant Tc -SAA-1.

Insertion of peripherally inserted central catheters (PICC) is a commonly performed procedure in both preterm and term infants. Tetracaine 4% gel (Ametop; SmithNephew Inc, St. Laurent, Quebec), a topical anesthetic, although reported to be effective for reducing the pain of venipuncture in neonates, has not been investigated for the management of pain associated with the PICC procedure.To determine the efficacy of tetracaine gel for managing the pain associated with the PICC procedure in preterm and term infants.A double-blind, placebo-controlled, randomized controlled trial (RCT) design was used. Infants undergoing nonurgent PICC insertion were randomized to receive either the treatment (1.0 g of tetracaine 4% gel) or placebo control (1.0 g of eucerin-plus cream) applied to the skin under occlusion for 30 minutes before the procedure. Data on the behavioral (facial expression) and physiologic (heart rate and oxygen saturation) indicators of pain were collected via videotaping and computer monitoring throughout the procedure. Data then were coded and measured by independent observers using the Premature Infant Pain Profile (PIPP; Stevens et al, 1996), and analyzed using descriptive statistics and repeated-measures analyses of variance.Forty-nine infants, gestational age 27 to 41 weeks (mean = 33; SD = 4.2) and age at time of insertion 2 to 85 days (mean = 18; SD = 22.5) participated. No differences were found between the groups at the time of randomization. There were no adverse cardiorespiratory events or local skin reactions in either group. There was a significant within-subjects main effect of time across the procedure (F[48,3] = 11.03; P0.0001). There was no significant between-subjects main effect of group (F[48,1] = 0.11; P = 0.74) and no (group x time) interaction (F[48,3] = 0.45; P = 0.72).Tetracaine gel was not effective for pain relief for PICC insertion in infants. Its use for pain relief cannot be recommended based on the results of this study. Other pharmacologic, behavioral, and physical interventions should be investigated for safety and relief of procedural pain in this population of infants.

Asparaginyl proteinases (or legumains) are a recently identified, novel class of cysteine proteinase which specifically hydrolyse peptide bonds after asparagine residues. Legumains have been implicated in the activation of cysteine proteases, particularly cathepsin B-like proteinases which are thought to help degrade the bloodmeal in blood-feeding helminths such as schistosomes, hookworms and other nematode species. An EST sequence representing a full-length legumain was identified from the Haemonchus contortus dataset. This encoded a protein with a predicted Mr of 49 kDa, the amino acid sequence of which showed good homology (34-40% identity) to legumains from Schistosoma mansoni, human and rat and contained a legumain-like active site. RT-PCR indicated that the legumain transcript was expressed from the L4 life-cycle stage onwards. The coding sequence was expressed in E. coli and antibodies to the resultant recombinant protein indicated that the enzyme was expressed in the microvillar surface of the intestinal cells. Legumain activity was detected in extracts of the adult parasite but not the host protective Thiol-Sepharose-binding fraction, although it was detectable in the latter by immunoblot. Activity was relatively insensitive to E64, an inhibitor of cysteine proteinases and completely inhibited by the alkylating agent, N-ethylmaleimide, consistent with inhibitor effects on previously characterized legumains.

Background Sheep scab is caused by the ectoparasitic mite Psoroptes ovis which initiates a profound cutaneous inflammatory response, leading to the development of the skin lesions which are characteristic of the disease. Existing control strategies rely upon injectable endectocides and acaricidal dips but concerns over residues, eco-toxicity and the development of acaricide resistance limit the sustainability of this approach. In order to identify alternative means of disease control, a deeper understanding of both the parasite and its interaction with the host are required. Methods Herein we describe the development and utilisation of an annotated P. ovis cDNA microarray containing 3,456 elements for the measurement of gene expression in this economically important ectoparasite. The array consists of 981 P. ovis EST sequences printed in triplicate along with 513 control elements. Array performance was validated through the analysis of gene expression differences between fed and starved P. ovis mites. Results Sequences represented on the array include homologues of major house dust mite allergens and tick salivary proteins, along with factors potentially involved in mite reproduction and xenobiotic metabolism. In order to validate the performance of this unique resource under biological conditions we used the array to analyse gene expression differences between fed and starved P. ovis mites. These analyses identified a number of house dust mite allergen homologues up-regulated in fed mites and P. ovis transcripts involved in stress responses, autophagy and chemosensory perception up-regulated in starved mites. Conclusion The P. ovis cDNA microarray described here has been shown to be both robust and reproducible and will enable future studies to analyse gene expression in this important ectoparasite.