Use of Lung Ultrasound in Reducing Radiation Exposure in Neonates with Respiratory Distress: A Quality Management Project.

Background and Objectives: Our quality management project aims to decrease by 20% the number of neonates with respiratory distress undergoing chest radiographs as part of their diagnosis and monitoring. Materials and Methods: This quality management project was developed at Life Memorial Hospital, Bucharest, between 2021 and 2023. Overall, 125 patients were included in the study. The project consisted of a training phase, then an implementation phase, and the final results were measured one year after the end of the implementation phase. The imaging protocol consisted of the performance of lung ultrasounds in all the patients on CPAP (continuous positive airway pressure) or mechanical ventilation (first ultrasound at about 90 min after delivery) and the performance of chest radiographs after endotracheal intubation in any case of deterioration of the status of the patient or if such a decision was taken by the clinician. The baseline characteristics of the population were noted and compared between years 2021, 2022, and 2023. The primary outcome measures were represented by the number of X-rays performed in ventilated patients per year (including the patients on CPAP, SIMV (synchronized intermittent mandatory ventilation), IPPV (intermittent positive pressure ventilation), HFOV (high-frequency oscillatory ventilation), the number of X-rays performed per patient on CPAP/year, the number of chest X-rays performed per mechanically ventilated patient/year and the mean radiation dose/patient/year. There was no randomization of the patients for the intervention. The results were compared between the year before the project was introduced and the 2 years across which the project was implemented. Results: The frequency of cases in which no chest X-ray was performed was significantly higher in 2023 compared to 2022 (58.1% vs. 35.8%; p = 0.03) or 2021 (58.1% vs. 34.5%; p = 0.05) (a decrease of 22.3% in 2023 compared with 2022 and of 23.6% in 2023 compared with 2021). The frequency of cases with one chest X-ray was significantly lower in 2023 compared to 2022 (16.3% vs. 35.8%; p = 0.032) or 2021 (16.3% vs. 44.8%; p = 0.008). The mean radiation dose decreased from 5.89 Gy × cm2 in 2021 to 3.76 Gy × cm2 in 2023 (36% reduction). However, there was an increase in the number of ventilated patients with more than one X-ray (11 in 2023 versus 6 in 2021). We also noted a slight annual increase in the mean number of X-rays per patient receiving CPAP followed by mechanical ventilation (from 1.80 in 2021 to 2.33 in 2022 and then 2.50 in 2023), and there was a similar trend in the patients that received only mechanical ventilation without a statistically significant difference in these cases. Conclusions: The quality management project accomplished its goal by obtaining a statistically significant increase in the number of ventilated patients in which chest radiographs were not performed and also resulted in a more than 30% decrease in the radiation dose per ventilated patient. This task was accomplished mainly by increasing the number of patients on CPAP and the use only of lung ultrasound in the patients on CPAP and simple cases.

Research Review: Integrated healthcare for children and young people in secondary/tertiary care - a systematic review.

BACKGROUND: Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce. AIM AND METHODS: This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index. FINDINGS: A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used. CONCLUSIONS: The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.

Early Intervention Guided by the General Movements Examination at Term Corrected Age-Short Term Outcomes.

BACKGROUND AND AIM: The early identification of the former premature neonates at risk of neurologic sequelae could lead to early intervention and a better prognosis. This pilot study aimed to investigate whether the General Movement patterns observed at term-equivalent age in former premature infants could serve as predictors for guiding early intervention and improving prognosis. MATERIALS AND METHODS: In a population of 44 premature neonates (mean gestational age 33.59 weeks (+2.43 weeks)) examined at term-equivalent age, 10 neonates with a cramped-synchronized General Movements motor pattern were identified. These neonates were included in an early intervention program consisting of physiotherapy executed both by the therapist and by the parents at home. They were again examined at a corrected age of 12 weeks. The presence or absence of fidgety movements and the MOS-R (motor optimality score revised) was noted. The examinations were performed by certified specialists. RESULTS: Normal fidgety movements and a MOS-R of 20-24 were presented in 9/10 of the former premature infants, with normal foot to foot contact present in 7/10, and normal hand to hand contact present in 5/10. The atypical patterns noted were side to side movements of the head in 5/10, a non-centered head in 9/10, asymmetric tonic neck reflex in 9/10 and jerky movements in 10/10. One patient presented with no fidgety movements and a MOS-R score of 9. CONCLUSION: Early intervention in our group of patients allowed for an improvement in the neurologic status, demonstrated by the presence of fidgety movements. We suggest that early intervention should be indicated in all premature infants that present with a cramped-synchronized GM pattern during examination at term-equivalent age. However, due to the small sample size, the absence of statistical analysis and a control group, and the limited follow-up period, the conclusions must be approached with caution.

Correlations between Head Ultrasounds Performed at Term-Equivalent Age in Premature Neonates and General Movements Neurologic Examination Patterns.

BACKGROUND AND AIM: Our research aims to find correlations between the brain imaging performed at term-corrected age and the atypical general movement (GM) patterns noticed during the same visit a-cramped-synchronized (CS) or poor repertoire (PR)-in formerly premature neonates to provide evidence for the structures involved in the modulation of GM patterns that could be injured and result in the appearance of these patterns and further deficits. MATERIALS AND METHODS: A total of 44 preterm neonates ((mean GA, 33.59 weeks (+2.43 weeks)) were examined in the follow-up program at Life Memorial Hospital Bucharest at term-equivalent age (TEA). The GM and ultrasound examinations were performed by trained and certified specialists. Three GM pattens were noted (normal, PR, or CS), and the measurements of the following cerebral structures were conducted via head ultrasounds: ventricular index, the short and long axes of the lateral ventricles, the midbody distance of the lateral ventricle, the diagonal of the caudate nucleus, the width of the basal ganglia, the width of the interhemispheric fissure, the sinocortical width, the length and thickness of the callosal body, the anteroposterior diameter of the pons, the diameter of the vermis, and the transverse diameters of the cerebellum and vermis. The ultrasound measurements were compared between the groups in order to find statistically significant correlations by using the FANOVA test (significance p < 0.05). RESULTS: The presence of the CS movement pattern was significantly associated with an increased ventricular index (mean 11.36 vs. 8.90; p = 0.032), increased midbody distance of the lateral ventricle-CS versus PR (8.31 vs. 3.73; p = 0.001); CS versus normal (8.31 vs. 3.34; p = 0.001), increased long and short axes of the lateral ventricles (p < 0.001), and decreased width of the basal ganglia-CS versus PR (11.07 vs. 15.69; p = 0.001); CS versus normal pattern (11.07 vs. 15.15; p = 0.0010). The PR movement pattern was significantly associated with an increased value of the sinocortical width when compared to the CS pattern (p < 0.001) and a decreased anteroposterior diameter of the pons when compared to both the CS (12.06 vs. 16.83; p = 0.001) and normal (12.06 vs. 16.78; p = 0.001) patterns. The same correlations were present when the subgroup of infants with a GA ≤ 32 weeks was analyzed. CONCLUSIONS: Our study demonstrated that there are correlations between atypical GM patterns (cramped-synchronized-CS and poor repertoire-PR) and abnormalities in the dimensions of the structures measured via ultrasound at the term-equivalent age. The correlations could provide information about the structures that are affected and could lead to a lack of modulation in the GM patterns.

Concentration dependent rate constants of sodium substitute functionalities during wheat dough development.

Chloride salts can serve as sodium chloride (NaCl) substitutes in wheat dough for sensory or technological reasons. Therefore, the effect of different substitutes on wheat dough development during mixing (optimum water absorption, dough development time, stability) and fermentation (maximum dough height) with a material-adapted water addition and mixing time were investigated. The substitutes had effects on all measures at a level of 2 g salt 100 g-1 wheat flour, with the exception of KCl. The intensity of the effect significantly followed the Hofmeister series due to an altered hydration behavior of the structure-determining gluten proteins. The experiments were supported by CLSM micrographs combined with image analysis. Next to an absolute substitution, the main focus of the study were concentration dependent functionalities of the chloride salts. Therefore, concentration dependent rate constants were calculated based on the application of different concentration levels of the chloride salts. These rate constants showed in all cases a similar tendency following the Hofmeister series.