Children's Palliative Care; the identified Learning Needs of Paediatricians.

Aim To determine baseline learning needs of Paediatricians in Ireland when caring for children with palliative care needs. Methods A questionnaire based online survey was conducted. Results One hundred and fourteen paediatricians responded to the survey, the majority were Specialist Registrars but almost half were consultant paediatricians (46% n=52). Most had never had formal education in the paediatric palliative care (57% n=48). Areas of future training that were ranked as important or highly important (percentage of respondents) included: pain management (98% n=81), management of the dying child (96% n=80), palliative care resources (95%n=79), advanced care planning (95% n=79) and communication skills (86% n=71). Those surveyed were asked to comment on the challenges of recent clinical interactions, on analysis three overarching themes emerged; best interests of the child, inadequate training and confidence and co-ordinating care. Conclusion This survey highlights the learning needs of paediatricians and will inform the development of meaningful education sessions for doctors.

Assessment of isocenter alignment during CT colonography: Implications for clinical practice.

INTRODUCTION: Optimization of image quality and patient radiation dose is achieved in part by positioning the patient at the isocenter of the CT gantry. The aim of this study was to establish whether there was increased isocenter misalignment (IM) in CT colonography (CTC) scans by comparing patient position during the prone part of a CTC to patient position during renal stone protocol CT (CT-KUB) and patient position during the supine part of a CTC to patient position during abdominopelvic CT (CT-AP). METHODS: Two hundred and twenty two consecutive outpatient adult CTC studies performed between January and December 2016 were retrospectively analyzed. Automated dose-tracking software was used to quantify IM in the x and y planes. Renal stone CT-KUB (n = 100) and standard CT-AP (n = 100) were used as comparison studies. RESULTS: IM during CTC was significantly greater in the y-axis compared with the x-axis for both prone (p = 0.002) and supine (p < 0.001) scanning. IM was significantly greater during prone CTC compared with CT-KUB (p = 0.008) and during supine CTC compared with CT-AP (p = 0.0001). IM was shown to be slightly greater in studies performed by more experienced radiographers (p = 0.04). IM was not associated with patient age, gender or size (p > 0.05 for all). CONCLUSION: Isocenter misalignment is greater during CT colonography compared with CT-KUB or CT-AP. Strategies for improving patient positioning could include radiographer education and automated patient centering solutions.

A phantom study of the performance of model-based iterative reconstruction in low-dose chest and abdominal CT: When are benefits maximized?

INTRODUCTION: The aim of this study was to assess and compare the effects of CT image reconstruction techniques on low-dose CT image quality using phantoms. METHODS: Anthropomorphic torso and spatial/contrast-resolution phantoms were scanned at decreasing tube currents between 400 and 10 mA. CT thorax and abdomen/pelvis series were reconstructed with filtered back projection (FBP) alone, combined 40% adaptive statistical iterative reconstruction & FBP (ASIR40), and model-based iterative reconstruction (MBIR) [(resolution-preference 05 (RP05) and RP20 in the thorax and RP05 and noise-reduction 05 (NR05) in the abdomen)]. Two readers rated image quality quantitatively and qualitatively. RESULTS: In thoracic CT, objective image noise on MBIR RP05 data sets outperformed FBP at 200, 100, 50 and 10 mA and outperformed ASIR40 at 50 and 10 mA (p < 0.001). MBIR RP20 outperformed FBP at 50 and 10 mA and outperformed ASIR40 at 10 mA (p < 0.001). Compared with both FBP and ASIR40, MBIR RP05 demonstrated significantly better signal-to-noise ratio (SNR) at 10 mA. In abdomino-pelvic CT, MBIR RP05 and NR05 outperformed FBP and ASIR at all tube current levels for objective image noise. NR05 demonstrated greater SNR at 200, 100, 50 and 10 mA and RP05 demonstrated greater SNR at 50 and 10 mA compared with both FBP and ASIR. MBIR images demonstrated better subjective image quality scores. Spatial resolution, low-contrast detectability and contrast-to-noise ratio (CNR) were comparable between image reconstruction techniques. CONCLUSION: CTs reconstructed with MBIR have lower image noise and improved image quality compared with FBP and ASIR. These effects increase with reduced radiation exposure confirming optimal use for low-dose CT imaging.

A Rare Cause of Testicular Pain: Thrombosis of the Pampiniform Plexus.

Testicular pain is a common presentation in the emergency department. The cause includes a wide array of differentials. This report highlights a case of thrombosis of the pampiniform plexus as a rare cause of testicular pain. Doppler ultrasound should be the first line investigation. Symptomatic relief with anti-inflammatory medication should be sufficient for management.

Radiation exposure from diagnostic imaging in young patients with testicular cancer.

OBJECTIVES: Risks associated with high cumulative effective dose (CED) from radiation are greater when imaging is performed on younger patients. Testicular cancer affects young patients and has a good prognosis. Regular imaging is standard for follow-up. This study quantifies CED from diagnostic imaging in these patients. METHODS: Radiological imaging of patients aged 18-39 years, diagnosed with testicular cancer between 2001 and 2011 in two tertiary care centres was examined. Age at diagnosis, cancer type, dose-length product (DLP), imaging type, and frequency were recorded. CED was calculated from DLP using conversion factors. Statistical analysis was performed with SPSS. RESULTS: In total, 120 patients with a mean age of 30.7 ± 5.2 years at diagnosis had 1,410 radiological investigations. Median (IQR) surveillance was 4.37 years (2.0-5.5). Median (IQR) CED was 125.1 mSv (81.3-177.5). Computed tomography accounted for 65.3 % of imaging studies and 98.3 % of CED. We found that 77.5 % (93/120) of patients received high CED (>75 mSv). Surveillance time was associated with high CED (OR 2.1, CI 1.5-2.8). CONCLUSIONS: Survivors of testicular cancer frequently receive high CED from diagnostic imaging, mainly CT. Dose management software for accurate real-time monitoring of CED and low-dose CT protocols with maintained image quality should be used by specialist centres for surveillance imaging. KEY POINTS: • CT accounted for 98.3 % of CED in patients with testicular cancer. • Median CED in patients with testicular cancer was 125.1 mSv • High CED (>75 mSv) was observed in 77.5 % (93/120) of patients. • Dose tracking and development of low-dose CT protocols are recommended.

Vital signs for children at triage: a multicentre validation of the revised South African Triage Scale (SATS) for children.

OBJECTIVE: To validate a revised version of the paediatric South African Triage Scale (SATS) against admission as a reference standard and compare the sensitivity of triage using: (i) clinical discriminators; (ii) an age-appropriate physiological composite score; and (iii) a combination of both. METHODS: A prospective cohort study was undertaken validating the revised paediatric SATS against outcome markers of children at six emergency centres during a 2-month period in 2011. The primary outcome marker was the proportion of children admitted. Validity indicators including sensitivity (Se), specificity, positive predictive value and negative predictive value (NPV) were used to estimate the validity. Associated percentages for over-/under-triage were used to further assess practical application of the paediatric SATS. RESULTS: A total of 2 014 children were included. The percentage of hospital admissions increased with an increase in the level of urgency from 5% in the non-urgent patients to 73% in the emergency patients. The data demonstrated that sensitivity increased substantially when using the SATS, which is a combination of clinical discriminators and the Triage Early Warning Score (TEWS) (Se 91.0%, NPV 95.3%), compared with use of clinical discriminators in isolation (Se 57.1%, NPV 86.3%) or the TEWS in isolation (Se 75.6%, NPV 89.1%). CONCLUSION: The results of this study illustrate that the revised paediatric SATS is a safe and robust triage tool.

Implementation of a triage score system in an emergency room in Timergara, Pakistan.

Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan.

A la suite de la mise en œuvre du système d'Echelle de Triage d'Afrique du Sud (SATS) dans le Département des Urgences de l'Hôpital de District Head Quarter (DHQ) à Timergara, Pakistan, 1) nous décrivons ce processus de mise en œuvre et 2) nous signalons dans quelle mesure le système a été utilisé de manière appropriée. Sur les 370 formulaires de triage évalués, 320 (86%) ont été complétés sans erreur, avec comme conséquence une assignation correcte de la priorité de triage. On a noté des erreurs dans 50 formulaires complétés, mais 16 seulement (4%) ont entrainé l'assignation à une priorité incorrecte de triage. Cette expérience montre que le SATS peut être mis en œuvre avec succès et utilisé de manière précise par les infirmières dans un département des urgences au Pakistan.

Tras la introducción del sistema de una escala de selección (South African Triage Scale [SATS]) en el servicio de urgencias del Hospital Central del Distrito de Timergara en Paquistán, el presente artículo tuvo como objeto 1) describir el mecanismo de ejecución del proyecto y 2) rendir un informe sobre la exactitud con que el personal de urgencias utilizó el sistema. De los 370 formularios de selección analizados, 320 (86%) estaban completados sin equivocaciones, con lo cual se había asignado una prioridad correcta de atención. En 50 formularios se observaron errores, pero solo 16 de ellos (4%) tuvieron como consecuencia la asignación de una prioridad de selección inadecuada. Esta experiencia pone en evidencia la eficacia de la aplicación del SATS y confirma la precisión de su utilización por parte del personal de enfermería en un servicio de urgencias en Paquistán.

Sclerotinia Wilt of Hop (Humulus lupulus) Caused by Sclerotinia sclerotiorum in the Pacific Northwest United States.

In June 2009, wilted hop bines were observed in a yard in Marion County, OR. The wilt was associated with a stem rot that occurred ~1 m from the ground near the point where bines are tied together for horticultural purposes. Samples of affected stems were submitted to the Oregon State University Plant Clinic. White hyphae and large, black sclerotia were present on the stems, with a clear delineation between healthy and diseased tissue. The pathogen was identified as Sclerotinia sclerotiorum based on morphological characters. In June 2011, bine wilting was observed on the same farm but in a different hop yard (cv. Nugget) ~10 km from the 2009 occurrence. Affected plants had upward curled leaves with necrotic margins or wilted bines that were severed at the soil line. Wilted bines tended to have smaller diameters than bines with foliar symptoms only. Of 100 plants examined, 75% displayed some foliar symptoms and 66% had at least one bine that was wilted. Yield loss was estimated at 10 to 20% due to bine wilting before cone development. Unlike the 2009 occurrence, wilted bines did not display aerial signs of S. sclerotiorum. Rather, water-soaked lesions covered in white, cottony mycelium were apparent on affected stems 2.5 to 5 cm below the soil surface, some bearing large, irregularly shaped sclerotia. Isolations made onto potato dextrose agar yielded isolates with rapid growth rates and morphological characters consistent with S. sclerotiorum (1). DNA was extracted (2) and pathogen identity was confirmed by PCR amplification and sequencing of the internal transcribed spacer regions from isolates SS001 and SS002 as described before (4). The amplicons were sequenced bidirectionally and consensus sequences were 100% similar to S. sclerotiorum (GenBank No. AAGT01000678.1). Two nucleotide polymorphisms were present that differentiated the sequences from those of 12 S. trifoliorum accessions in GenBank that could be aligned (2). Greenhouse assays utilizing a toothpick inoculation procedure (3) were conducted to fulfill Koch's postulates. Stems of five 4-week-old hop plants of cv. Agate were pierced with a toothpick colonized with S. sclerotiorum. Five control plants were similarly inoculated with toothpicks without the fungus. Inoculated plants developed symptoms similar to those observed in the field within 11 days; four of five plants inoculated with isolate SS001 and two of five plants inoculated with isolate SS002 completely wilted. S. sclerotiorum was reisolated from all inoculated plants but not the control plants. To our knowledge, this is the first report of Sclerotinia wilt on hop in Oregon or the Pacific Northwest (1), where nearly all commercial hop production occurs in the United States. The disease appears to be localized to a limited number of yards, although given the widespread distribution and host range of S. sclerotiorum, it is plausible that the disease may occur in other yards. Recurrent outbreaks and spread of the disease among yards on the affected farm suggests that Sclerotinia wilt has the potential to become a perennial problem on hop and efforts to limit the introduction of S. sclerotiorum into other yards are warranted. References: (1) D. H. Gent. Page 32 in: Compendium of Hop Diseases and Pests. The American Phytopathological Society, St. Paul, MN, 2009. (2) E. N. Njambere et al. Plant Dis. 92:917, 2008. (3) M. L. Putnam. Plant Pathol. 53:252, 2004. (4) T. J. White et al. PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, 1990.

Development and application of confocal scanning laser microscopy methods for studying the distribution of fat and protein in selected dairy products.

Confocal scanning laser microscopy (CSLM) methods were developed to identify fat and protein in cheeses milk chocolate and milk powders. Various fluorescent probes were assessed for their ability to label fat or protein in selected food products in situ. Dual labelling of fat and protein was made possible by using mixtures of probes. Selected probes and probe mixtures were then used to study (a) structure development of Mozzarella cheese during manufacture and ripening, and (b)) the distribution of fat and protein in milk chocolate made with milk powders containing varying levels of free fat. Microstructural changes in the protein and fat phases of Mozzarella cheese were observed at each major step in processing. Aggregation of renneted micelles occurred during curd formation; this was followed by amalgamation of the para-casein into linear fibres during plasticization. Following storage, the protein phase of the Mozzarella became more continuous; entrapping and isolating fat globules. Chocolate made with a high free-fat spray-dried powder blend showed a homogeneous fat distribution, similar to that of chocolate made with roller-dried milk. Chocolate made with whole milk powder containing 10 g free fat/100 fat showed a non-homogeneous fat distribution with some fat occluded within milk protein particles. These differences in fat distribution were related to Casson yield value and Casson viscosity of the chocolates.

Mutation modification with multiplicative fertility selection.

Two diallelic loci in an infinite panmictic population of diploid individuals are modelled. The A/a locus is subject to unidirectional mutation and either multiplicative fertility selection or, equivalently, sex-asymmetric viability selection. The M/m locus acts as a selectively neutral modifier of the mutation rate at A/a. The loci recombine at rate R. If the M/m locus is initially monomorphic, and the A/a locus has reached equilibrium, the fate of a new modifier allele is found to depend not just on its relative effect on mutation but also upon the linkage, R. Each initial equilibrium may be characterized by a critical value of the recombination rate, R*. If 0 less than R* less than 0.5, a sufficiently small "down" modifier of the mutation rate will invade the population when R less than R* whereas a sufficiently small "up" modifier will succeed when R greater than R*. If R* less than 0 or R* greater than 0.5, only mutation reduction may occur. Numerical analysis of 56,000 sample equilibria indicates that mutation rates may be increased, but only when the selection regime is such that the A/a locus would remain polymorphic in the absence of mutation.

Effects of converting enzyme inhibition on blood pressure, plasma renin activity (PRA) and plasma aldosterone in hypertensive diabetics compared to patients with essential hypertension.

Hypertension with diabetes mellitus has been associated with suppression of the renin-angiotensin-aldosterone system. We have studied the effects of the converting enzyme inhibitor, captopril, on blood pressure, plasma renin activity (PRA) and plasma aldosterone in 10 stable hypertensive diabetic subjects and 10 age-matched patients with essential hypertension. There was no clinical evidence of complication in the diabetic subjects and their diabetic treatment remained unchanged throughout the study. Mean captopril doses used were similar in both groups. In the diabetics and the essential hypertensives, treatment resulted in a significant and similar decrease in blood pressure. Pre-treatment basal and stimulated PRA and the change of PRA with captopril were also similar. Pre-treatment stimulated plasma aldosterone and the response of aldosterone to postural stress was significantly lower in the diabetic group, suggesting an impaired adrenal responsiveness to stress. Despite this, our findings indicate that the hypotensive action of captopril is at least as effective in hypertension associated with otherwise uncomplicated diabetes mellitus as in essential hypertension.

Sarcoidosis with renal involvement.

Nine of ninety patients with sarcoidosis were found to have significant renal impairment. Epithelioid granulomata were present in five of eight patients who had renal biopsies and glomerular lesions were present in six. There was close correlation between hypercalcaemia, hyperuricaemia, nephrocalcinosis and creatinine clearance. In one patient, renal sarcoidosis complicated membrano-proliferative glomerulonephritis and one patient died in end-stage renal disease.