Evaluation of a Choir as a Non-Medical Intervention for Children with Asthma: BreathStars.

A shift in the current health policy has seen heightened focus on non-medical interventions which can be delivered out with formal health-care settings, to complement and enhance the clinical care of people with long-term conditions. Asthma is a common long-term condition managed by pharmacological and non-pharmacological interventions. Recent research activity has focused on the use of singing for respiratory health due to its similarity with the more well-known intervention of breathing exercises. The aim of this study was to determine if singing improved breathing in children with asthma. A realist evaluation study design with a mixed methods approach was adopted to evaluate a singing group for children aged 7-12. Results obtained through framework analysis of the data indicated notable improvement in asthma control with the added impact on self-esteem. Enjoyment of the singing group within a family centered approach was seen as a positive alongside the community benefit of wider asthma education. Lessons can be learnt from this evaluation which could inform future initiatives relevant to the current agenda of asset-based approaches such as social prescribing within the context of the current devolution of the health and social care budget in the North West of England.

Utilization of conventional radiography in a regional neonatal intensive care unit in Ireland.

OBJECTIVE: To audit the demand and radiation exposure of conventional radiography in a regional neonatal intensive care unit (NICU) in Ireland. METHODS: A retrospective study of radiographs performed on all admissions to the NICU in University Maternity Hospital Limerick (UMHL) over 2 years. RESULTS: A total of 1405 radiographs were performed on 506 infants. 153.5 radiographs per 1000 live births was the observed demand and 44% of radiographs were done out of hours. 47% of all radiographs were performed on infants <1500 g. Median number of radiographs per infant was one (IQR 1-2; range 1-39). Significant negative correlation was observed between number of radiographs and gestational age. Mean lung radiation doses estimated using published values for normal weight (>2500 g), very low birth weight (VLBW), and extremely low birth weight (ELBW) infants based on the median number of chest X-rays were 31.7 µGym, 84.66 and 232.75 µGy, respectively. CONCLUSIONS: Conventional radiography remains a key diagnostic tool in neonatology particularly in VLBW and ELBW infants and is invaluable in supporting timely clinical decision making. Clinicians should be aware of the cost and potential hazards of neonatal radiography and is recommend that the cumulative radiation exposure among the ELBW and VLBW infants is monitored. Increasing awareness and standardisation of point-of-care ultrasonography could decrease the reliance on conventional radiography in neonatal units.

Conservatively treated Congenital Hyperinsulinism (CHI) due to K-ATP channel gene mutations: reducing severity over time.

BACKGROUND: Patients with Congenital Hyperinsulinism (CHI) due to mutations in K-ATP channel genes (K-ATP CHI) are increasingly treated by conservative medical therapy without pancreatic surgery. However, the natural history of medically treated K-ATP CHI has not been described; it is unclear if the severity of recessively and dominantly inherited K-ATP CHI reduces over time. We aimed to review variation in severity and outcomes in patients with K-ATP CHI treated by medical therapy. METHODS: Twenty-one consecutively presenting patients with K-ATP CHI with dominantly and recessively inherited mutations in ABCC8/KCNJ11 were selected in a specialised CHI treatment centre to review treatment outcomes. Medical treatment included diazoxide and somatostatin receptor agonists (SSRA), octreotide and somatuline autogel. CHI severity was assessed by glucose infusion rate (GIR), medication dosage and tendency to resolution. CHI outcome was assessed by glycaemic profile, fasting tolerance and neurodevelopment. RESULTS: CHI presenting at median (range) age 1 (1, 240) days resolved in 15 (71%) patients at age 3.1(0.2, 13.0) years. Resolution was achieved both in patients responsive to diazoxide (n = 8, 57%) and patients responsive to SSRA (n = 7, 100%) with earlier resolution in the former [1.6 (0.2, 13.0) v 5.9 (1.6, 9.0) years, p = 0.08]. In 6 patients remaining on treatment, diazoxide dose was reduced in follow up [10.0 (8.5, 15.0) to 5.4 (0.5, 10.8) mg/kg/day, p = 0.003]. GIR at presentation did not correlate with resolved or persistent CHI [14.9 (10.0, 18.5) v 16.5 (13.0, 20.0) mg/kg/min, p = 0.6]. The type of gene mutation did not predict persistence; resolution could be achieved in recessively-inherited CHI with homozygous (n = 3), compound heterozygous (n = 2) and paternal mutations causing focal CHI (n = 2). Mild developmental delay was present in 8 (38%) patients; adaptive functioning assessed by Vineland Adaptive Behavior Scales questionnaire showed a trend towards higher standard deviation scores (SDS) in resolved than persistent CHI [-0.1 (-1.2, 1.6) v -1.2 (-1.7, 0.03), p = 0.1]. CONCLUSIONS: In K-ATP CHI patients managed by medical treatment only, severity is reduced over time in the majority, including those with compound heterozygous and homozygous mutations in ABCC8/KCNJ11. Severity and treatment requirement should be assessed periodically in all children with K-ATP CHI on medical therapy.

Feeding Problems Are Persistent in Children with Severe Congenital Hyperinsulinism.

BACKGROUND: Congenital hyperinsulinism (CHI) is a rare but severe disorder of hypoglycemia in children, often complicated by brain injury. In CHI, the long-term prevention of hypoglycemia is dependent on reliable enteral intake of glucose. However, feeding problems (FPs) often impede oral glucose delivery, thereby complicating the management of hypoglycemia. FPs have not been systematically characterized in follow-up in a cohort with CHI. AIMS: We aimed to determine the prevalence, types, and persistence of FPs in a cohort of children with CHI and investigate potential causal factors. METHODS: FPs were defined as difficulty with sucking, swallowing, vomiting, and food refusal (or a combination) in an observational study in 83 children in a specialized CHI treatment center. The prevalence of FPs at diagnosis, 6, and 12 months after diagnosis were noted. Genetic mutation status and markers of severity of CHI were tested for association with FPs. RESULTS: A third of children with CHI had FPs (n = 28), of whom 93% required antireflux medication and 75% required nasogastric and gastrostomy tube feeding. Sucking and swallowing problems were present at diagnosis but absent later. Vomiting was present in 54% at 6 months, while food refusal was present in 68% at 6 months and 52% at 12 months. The age at commencing and stopping nasogastric tube feeding did not correlate with FPs frequency at 6 and 12 months. Children with FPs had severe hypoglycemia at diagnosis and required glucagon infusion more often [odds ratio (OR) (95% confidence intervals) (95% CI) 28.13 (2.6-300.1), p = 0.006] to normalize glucose levels. FPs were more frequent in those with diffuse CHI undergoing subtotal pancreatectomy [n (%) = 10 (35%) vs. 0 (0%), p < 0.001], in contrast to those with spontaneous resolution [6 (22%) vs. 32 (58%), p = 0.002]. Those undergoing focal lesionectomy also had reduced FPs at 6 months after diagnosis [OR (95% CI) 0.01 (0.0-0.2), R (2) = 0.42, p = 0.004]. These observations suggest that persistence of hyperinsulinism was associated with FPs. CONCLUSION: FPs occur in a significant proportion of children with CHI. Severe hyperinsulinism, rather than nasogastric tube feeding or medications, is the main factor associated with FPs.

Reduced Glycemic Variability in Diazoxide-Responsive Children with Congenital Hyperinsulinism Using Supplemental Omega-3-Polyunsaturated Fatty Acids; A Pilot Trial with MaxEPA(R.).

OBJECTIVE: Congenital hyperinsulinism (CHI) is a rare condition of hypoglycemia where therapeutic options are limited and often complicated by side-effects. Omega-3-polyunsaturated fatty acids (PUFA), which can suppress cardiac myocyte electrical activity, may also reduce ion channel activity in insulin-secreting cells. PUFA supplements in combination with standard medical treatment may improve glucose profile and may reduce glycemic variability in diazoxide-responsive CHI. DESIGN: Open label pilot trial with MaxEPA(R) liquid (eicosapentaenoic and docosahexaenoic acid) PUFA (3 ml/day for 21 days) in diazoxide-responsive CHI patients (https://eudract.ema.europa.eu/, EudraCT number 201100363333). METHODS: Glucose levels were monitored pre-treatment, end of treatment, and at follow-up by subcutaneous continuous glucose monitoring systems (CGMS) in 13 patients (7 girls) who received PUFA. Outcome measures were an improved glucose profile, reduced glycemic variability quantified by a reduction in the frequency of glucose levels <4 and >10 mmol/l, and safety of PUFA. All children were analyzed either as intention to treat (n = 13) or as per protocol (n = 7). RESULTS: Mean (%) CGMS glucose levels increased by 0.1 mmol/l (2%) in intention to treat and by 0.4 mmol/l (8%) in per protocol analysis (n = 7). The frequency of CGMS <4 mmol/l was significantly less at the end of treatment than in the pre-treatment period [556 (7%) vs. 749 (10%)]. Similarly, the frequency of CGMS >10 mmol/l, was also less at the end of treatment [27 (0.3%) vs. 49 (0.7%)]. Except for one child with increased LDL cholesterol, all safety parameters were normal. CONCLUSION: MaxEPA(R) was safe and reduced glycemic variability, but did not increase glucose profiles significantly in diazoxide-responsive CHI. The supplemental value of PUFA should be evaluated in a comprehensive clinical trial.

Doses under automatic exposure control (AEC) for direct digital radiographic (DDR) X-ray systems.

Current guidelines quote tolerances for automatic exposure control (AEC) device performance for X-ray systems as 'Baseline ± X %'. However, in the situation where a baseline figure has not yet been achieved, as in the case of commissioning assessments, this tolerance is not relevant. The purpose of this work is to provide mean doses for direct digital radiography (DDR) X-ray system, operating in AEC, against which comparisons can be made. Dose measurements have been recorded under AEC operation on 29 DDR detectors from three different manufacturers. Two different testing protocols were examined: (1) water equivalent phantoms in front of the DDR detector and (2) aluminium block at the tube head. The average patient exit dose, using the aluminium block was 4.6 µGy with the antiscatter grid in place and 4.0 µGy with the grid removed. Using the water phantoms, the average dose was measured at 17.1 µGy with the antiscatter grid in place and 5.4 µGy with grid removed. Based on these results, it is clear that different testing configurations significantly impact on the measured dose.

Radionuclide impurities in proton-irradiated [18O]H2O for the production of 18F-: activities and distribution in the [18F]FDG synthesis process.

Proton- and neutron-induced activation products in the components of a high-pressure [(18)O]H(2)O target vessel used for the production of (18)F(-) in a medical cyclotron have been identified using high resolution gamma spectrometry. The activities leached from the target vessel into the [(18)O]H(2)O during irradiation, and the distribution of the identified radionuclide impurities in the various cartridges and solutions used in the [(18)F]FDG synthesis process have been measured and are discussed from the perspective of waste disposal. The results indicate that, at the energies and beam currents employed, only a few, relatively short-lived radionuclides are present in the irradiated [(18)O]H(2)O, and that the activities involved (<10 kBq in each case) are well below typical exemption limits. Activities of beta-emitting (3)H in irradiated [(18)O]H(2)O, produced via the (18)O(p,(3)H)(16)O reaction, have also been determined using liquid scintillation spectrometry. Measured activity concentrations, in the range 150-180 kBq g(-1), are consistent with those reported by other workers. Analyses of the synthesised [(18)F]FDG confirm the radiochemical purity of the product, both for (3)H and for gamma-emitting radionuclides in the energy range 25-1650 keV.

A novel approach to the sequential extraction of plutonium from oxic and anoxic sediment using sodium citrate to inhibit post-extraction resorption.

Sequential extraction has been used extensively to study the solid partitioning of radionuclides in soils and sediments. A difficulty with sequential extraction is that radionuclides released by a particular extractant can be resorbed and artificially redistributed amongst the remaining solid phases. Here, we describe experiments (on selected model phase and natural materials), which were designed to determine whether the inclusion of a chelating agent (sodium citrate) in an established sequential extraction protocol (a) inhibits post-extraction resorption of plutonium, (b) increases non-targeted dissolution of sediment phases, and (c) gives rise to unwanted ligand competition for plutonium. The results clearly demonstrate the capacity of citrate to inhibit the resorption of plutonium from the various extractants, and confirm that there is no discernible increase in non-targeted phase dissolution, but indicate significant ligand competition with the carbonate phase. The merits of using citrate are discussed and an optimised sequential extraction protocol that includes citrate is proposed. Finally, the protocol is applied to oxic and anoxic sediments sampled in the NE Irish Sea and the Roads of Cherbourg, and it is shown that the bulk of the plutonium on these sediments is associated with the more labile geochemical fractions.