Paediatric dentists' identification and management of underweight and overweight children.

Introduction: Dental caries and obesity are growing challenges for the NHS. Dentists are in the unique position of being able to identify both conditions and intervene, following UK government strategy of 'making every contact count'. Aims: Identify specialists in paediatric dentistry's (SPD) current practice regarding diagnosis and management of underweight or overweight/obese children presenting to dental services. Materials and methods: An online survey was emailed to the UK SPD group. Questions investigated whether height, weight or body mass index (BMI) were measured, actions taken, and dentists' feelings regarding their role. Results: 49/118 (42%) SPDs responded. All felt they had a responsibility to identify underweight or overweight/obese children. Around a quarter (26%) measured BMI 'always' or 'often', while 37% did not measure BMI. Only 41% of SPDs who measured BMI took action more than twice in a year. Most commonly (90%) the child's GP was informed. Conclusions: SPDs were supportive of the identification of underweight or overweight/obese children. However, many felt uncertain about BMI interpretation. Thus, few routinely measured BMI or acted on abnormal results. SPDs would benefit from training, alongside development of a local protocol, regarding BMI calculation and interpretation.

Near-concentric Fabry-Pérot cavity for continuous-wave laser control of electron waves.

Manipulating free-space electron wave functions with laser fields can bring about new electron-optical elements for transmission electron microscopy (TEM). In particular, a Zernike phase plate would enable high-contrast TEM imaging of soft matter, leading to new opportunities in structural biology and materials science. A Zernike phase plate can be implemented using a tight, intense continuous laser focus that shifts the phase of the electron wave by the ponderomotive potential. Here, we use a near-concentric cavity to focus 7.5 kW of continuous-wave circulating laser power at 1064 nm into a 7 µm mode waist, achieving a record continuous laser intensity of 40 GW/cm2. Such parameters are sufficient to impart a phase shift of 1 rad to a 10 keV electron beam, or 0.16 rad to a 300 keV beam. Our numerical simulations confirm that the standing-wave phase shift profile imprinted on the electron wave by the intra-cavity field can serve as a nearly ideal Zernike phase plate.

Do you see what I see? Identification of child protection concerns by hospital staff and general dental practitioners.

Aim An exploration of the threshold that dentists, doctors and nurses recognise for dental and child protection (CP) actions in sample clinical cases, and any differences between these professional groups.Method We present a cross-sectional survey of dentists, doctors and nurses (50 each), who regularly examine children, utilised five fictitious vignettes, combining an oral examination image and clinical history reflecting dental and CP issues. Demographics were collected, and each participant gave their likely action for the cases presented.Results Dentists were significantly better at answering the dental element than the doctors and nurses, (P <0.0001) with no significant difference between these two; only 8% of the latter had undergone any training in assessment of dental health. Although 90.6% of all professionals had undergone CP training, dentists were significantly less accurate at identifying the CP component than doctors and nurses, (P <0.0001) between whom there were no significant differences. Those with higher levels of CP training were most accurate at identifying correct CP actions.Conclusions CP training is effective at improving recognition of child maltreatment, although there remains a worrying lack of knowledge about thresholds for action among dentists. Doctors and nurses have minimal training in, or knowledge of, dental health in children, thus precluding appropriate onward referrals.

Penicillium subrubescens, a new species efficiently producing inulinase.

Inulin is a reserve carbohydrate in about 15 % of the flowering plants and is accumulated in underground tubers of e.g. chicory, dahlia and Jerusalem artichoke. This carbohydrate consists of linear chains of ß-(2,1)-linked fructose attached to a sucrose molecule. Inulinases hydrolyse inulin into fructose and glucose. To find efficient inulin degrading fungi, 126 fungal strains from the Fungal Biotechnology Culture Collection (FBCC) at University of Helsinki and 74 freshly isolated strains from soil around Jerusalem artichoke tubers were screened in liquid cultures with inulin as a sole source of carbon or ground Jerusalem artichoke tubers, which contains up to 19 % (fresh weight) inulin. Inulinase and invertase activities were assayed by the dinitrosalicylic acid (DNS) method and a freshly isolated Penicillium strain originating from agricultural soil (FBCC 1632) was the most efficient inulinase producer. When it was cultivated at pH 6 and 28 °C in 2 litre bioreactors using inulin and Jerusalem artichoke as a carbon source, inulinase and invertase activities were on day 4 7.7 and 3.1 U mL(-1), respectively. The released sugars analysed by TLC and HPLC showed that considerable amounts of fructose were released while the levels of oligofructans were low, indicating an exoinulinase type of activity. Taxonomic study of the inulinase producing strain showed that this isolate represents a new species belonging in Penicillium section Lanata-divaricata. This new species produces a unique combination of extrolites and is phenotypically and phylogenetically closely related to Penicillium pulvillorum. We propose the name Penicillium subrubescens sp. nov. (CBS 132785(T) = FBCC 1632(T)) for this new species.

New penicillin-producing Penicillium species and an overview of section Chrysogena.

Species classified in Penicillium sect. Chrysogena are primary soil-borne and the most well-known members are P. chrysogenum and P. nalgiovense. Penicillium chrysogenum has received much attention because of its role in the production on penicillin and as a contaminant of indoor environments and various food and feedstuffs. Another biotechnologically important species is P. nalgiovense, which is used as a fungal starter culture for the production of fermented meat products. Previous taxonomic studies often had conflicting species circumscriptions. Here, we present a multigene analysis, combined with phenotypic characters and extrolite data, demonstrating that sect. Chrysogena consists of 18 species. Six of these are newly described here (P. allii-sativi, P. desertorum, P. goetzii, P. halotolerans, P. tardochrysogenum, P. vanluykii) and P. lanoscoeruleum was found to be an older name for P. aethiopicum. Each species produces a unique extrolite profile. The species share phenotypic characters, such as good growth on CYA supplemented with 5 % NaCl, ter- or quarterverticillate branched conidiophores and short, ampulliform phialides (< 9 µm). Conidial colours, production of ascomata and ascospores, shape and ornamentation of conidia and growth rates on other agar media are valuable for species identification. Eight species (P. allii-sativi, P. chrysogenum, P. dipodomyis, P. flavigenum, P. nalgiovense, P. rubens, P. tardochrysogenum and P. vanluykii) produce penicillin in culture.

Prescribing competence of junior doctors: does it add up?

BACKGROUND: Prescribing errors complicate a significant number of paediatric admissions. Ongoing training and monitoring of prescribing competency in junior doctors has occurred in Cardiff since 2001, alongside national measures aimed at improving training and competency. AIM: Ongoing monitoring of junior doctors' prescribing competency to assess the effect of these national and local initiatives. METHODS: Junior doctors receive training and subsequent assessment on prescribing competency at induction. A 1 h bleep-free session concerning paediatric prescribing precedes completion of four prescribing tasks. British National Formulary for children and calculators are provided. Those scoring 0 or 1 are retrained before prescribing is permitted. Our previously published data of doctors between 2001 and 2004 was compared with assessment in 2007. RESULTS: 30 junior doctors were assessed in 2007 (32 in 2001-2004). All four questions were answered correctly by 22/30, compared to 10/32 (31%) in 2001-2004. The mean score in 2007 was 93.3% compared to 57.8% previously (see table 1). Comparison of means with previous results demonstrated statistically significant improvement with a mean difference of 36% (95% CI 24 to 47). In 2007, eight (27%) doctors got just one question wrong and no doctor answered all questions incorrectly. In 2001-2004, 22/32 (67%) made at least one error during previous assessment, and one doctor answered all questions incorrectly. Table 1Prescribing assessment scores in 2001-2004 and 2007 Answer scores2001-2004 (n=32)2007 (n=30)All questions correct10 (31%)22 (73%)One incorrect08 (27%)Two incorrect13 (41%)0Three incorrect8 (25%)0All questions incorrect1 (3%)0 CONCLUSION: Ongoing monitoring of junior doctors' prescribing ability has demonstrated improvements which may be due to local and national training initiatives.

A simplified gentamicin dosing chart is quicker and more accurate for nurse verification than the BNFc.

BACKGROUND: At least 5% of paediatric admissions are complicated by medication error. Nurses can prevent some errors by correctly verifying prescriptions before administering drugs, which requires adequate drug calculation skills and familiarity with the BNFc. We wished to explore whether a newly devised chart would improve nurses' dose calculation ability and thus potentially reduce doctors' prescription errors. AIMS: To explore nurses' ability to calculate doses of gentamicin for neonates and children using a new simple dosing chart compared with the BNFc. METHODS: Two gentamicin dosing charts (paediatric and neonatal) devised by a multidisciplinary group to simplify dose calculation and selection of frequency were compared with the BNFc using four questions (two neonatal, two paediatric) asking ward nurses to calculate gentamicin doses. Answers were scored for both the correct dosage and correct frequency. RESULTS: 51 nurses participated. 11 nurses (22%) answered all four questions correctly. A higher proportion correctly answered both the dosage and frequency questions simultaneously when using the chart compared with the BNFc: paediatric questions 100% (51/51 chart) versus 80% (41/51 BNFc) (OR 0.20) and neonatal questions 55% (28/51 chart) versus 35% (18/51 BNFc) (OR 0.2). Errors when using the BNFc were due to selection of the incorrect regimen (23%), wrong frequency (17%) and one 10-fold dosing error. When using the chart, there were no dosing errors, only frequency errors for the neonatal regimen. CONCLUSION: The chart was more reliable, quicker and may be useful for patient safety. Revising the format of the BNFc may be beneficial for nurses.

How much do junior staff know about common legal situations in paediatrics?

BACKGROUND: Recent high-profile medico-legal cases such as the death of Victoria Climbie and the subsequent Laming report have highlighted widespread deficiencies in child protection practice. Junior doctors are the frontline staff regularly facing issues with potentially major legal implications, including child protection, Gillick competence, consent, and professional responsibility/accountability. It is therefore important for them to be aware and understand the Children Act, common medico-legal principles and practices, particularly in the current, increasingly litigious climate. AIMS: (1) To determine junior medical staff's knowledge of legal issues involved in child protection and common basic legal situations, and (2) to assess whether experience and training improved this knowledge. METHODS: A standardized structured interview was developed exploring common issues with important legal implications for paediatric practice. It focused on: legal issues in child protection, the Children Act, awareness of the General Medical Council (GMC), principles of professional responsibility/accountability, the Bolam principle for good medical practice and Gillick competence. Basic demographic data were recorded. We attempted to contact all 180 paediatric junior medical staff in Wales by telephone. RESULTS: Interviews were conducted with 119/180 (66%) doctors: 46/56 specialist registrars (SpRs; 82%) and 73/124 senior house officers (SHOs; 59%). SpRs scored a median of 6.5 correct responses from a possible of 12 (range 3-11), compared with a median of 5 (range 1-11) by the SHOs (P < 0.0001; Mann-Whitney test). A third of SHOs and a fifth of SpRs were unaware that the GMC was the organization responsible for good medical practice in the UK. Similarly, a fifth of all juniors were ignorant of the legal age for consent. Approximately two-thirds of the SHOs and half of the SpRs were ignorant that the police and social services have the legal power to protect the child in child protection cases. Alarmingly, none of the SHOs and only 11% of the SpRs were aware of the Bolam principle. SpRs scored significantly higher on topics of Gillick competence, legal right to see medical notes, consent, Children Act, burden of proof in civil and criminal court, and on Bolam principle. They also had received training more frequently than SHOs, which, when combined with their greater experience, probably explains these statistically significant differences. CONCLUSION: Few junior staff have adequate knowledge of the basic legal principles and practice as they relate to children. Widespread deficiencies concerning the understanding of the Children Act and child protection powers exist.

The changing clinical presentation of coeliac disease.

BACKGROUND: There has been a growing recognition that coeliac disease is much more common than previously recognised, and this has coincided with the increasingly widespread use of serological testing. AIM: To determine whether the age at presentation and the clinical presentation of coeliac disease have changed with the advent of serological testing. METHODS: A 21-year review of prospectively recorded data on the mode of presentation of biopsy confirmed coeliac disease in a single regional centre. Presenting features over the past 5 years were compared with those of the previous 16 years. Between 1983 and 1989 (inclusive), no serological testing was undertaken; between 1990 and 1998, antigliadin antibody was used with occasional use of antiendomysial antibody and antireticulin antibody. From 1999 onwards, anti-tissue transglutaminase was used. RESULTS: 86 patients were diagnosed over the 21-year period: 50 children between 1999 and 2004 compared with 25 children between 1990 and 1998 and 11 children between 1983 and 1989. The median age at presentation has risen over the years. Gastrointestinal manifestations as presenting features have decreased dramatically. In the past 5 years, almost one in four children with coeliac disease was diagnosed by targeted screening. CONCLUSION: This study reports considerable changes in the presentation of coeliac disease-namely, a decreased proportion presenting with gastrointestinal manifestations and a rise in the number of patients without symptoms picked up by targeted screening. Almost one in four children with coeliac disease is now diagnosed by targeted screening. Most children with coeliac disease remain undiagnosed. Paediatricians and primary care physicians should keep the possibility of coeliac disease in mind and have a low threshold for testing, so that the potential long-term problems associated with untreated coeliac disease can be prevented.

Resolution of cryptosporidiosis with probiotic treatment.

Cryptosporidium infection is usually self limited, but can be a life threatening illness in immunocompromised patients. Probiotics have been used successfully in the treatment of acute diarrhoea and they have also been shown to limit Cryptosporidium parvum infection in animal models. The first case of successful resolution of prolonged cryptosporidiosis with probiotic treatment is reported.

Randomized double-blind controlled trial on the effects on iron status in the first year between a no added iron and standard infant formula received for three months.

UNLABELLED: Recent research has not only questioned the necessity of iron supplementation in human milk substitutes prior to weaning, but also suggested some potential adverse effects. This study investigated the hypothesis that infant formula need not contain added iron in the first 3 mo. Healthy term infants were recruited into a double-blind controlled trial and randomized to receive either a new no added iron formula (New; <0.1 mg Fe 100 ml(-1)) or a standard formula (Standard; 0.5 mg Fe 100 ml(-1)) for the first 3 mo of life. A breastfed reference group was also studied. Iron status was assessed at 3 and 12 mo from heel-prick capillary blood samples evaluated by full blood-count analysis, including reticulocytes and serum ferritin. In total, 149 infants were entered (51 New, 49 Standard, 49 breastfed) with no differences between the groups in gender distribution, birthweight, gestation or numbers completing the study. There were no significant differences between the principal outcome measures: mean values for haemoglobin, mean cell volume and ferritin, between the two formula-fed groups, and the proportion with a haemoglobin level <11 g dl(-1) or ferritin <10 microg l(-1) did not differ. CONCLUSION: The use of a "no added iron" infant formula in place of an iron-fortified formula during the first 3 mo of life did not clinically affect iron status at 3 and 12 mo of age. The universal supplementation of formulae with iron during this initial period needs further consideration.

Development of an animal model for assessment of the hemostatic efficacy of fibrin sealant in vascular surgery.

PURPOSE: Sustained hemostatic function of fibrin sealant (FS) is crucial when it is used in cardiovascular surgery. The purpose of this study was to develop a model that can determine the long-term hemostatic efficacy of tissue sealants in a vascular surgery. METHODS: To determine the ability of the model to detect differences in FS performance, various concentrations of FS were prepared and tested. Tensile strength of FS clots was determined in vitro using a tensiometer. Laparotomy was performed on 49 anesthetized rabbits, and a segment of the aorta was occluded, transected, and then sutured in an end-to-end fashion with four or eight interrupted 9-O sutures. The four-suture repair was covered with FS or placebo, and blood flow restored. Spilled blood was absorbed with gauze and weighed to estimate blood loss. Four weeks after surgery the animals were euthanized and the vessels recovered for histology. RESULTS: Average tensile strength of FS clots at 120, 90, and 60 mg/ml topical fibrinogen complex (TFC) concentration was 0.42 +/- 0.07 N, with no significant difference among them. The lowest TFC concentration, 30 mg/ml, produced weaker clots than either 120 or 90 mg/ml (P < 0.05). All rabbits with four-suture anastomoses that were treated with placebo bled to death after the vessel was unclamped (n = 6). Treatment of suture line with standard FS concentration (120 mg/ml TFC, n = 8) sealed the anastomosis and prevented blood loss. Hemostasis was sustained for 4 weeks, allowing vascular healing. All rabbits with the eight-suture anastomosis survived the operation but lost 42 +/- 9.2 ml blood (n = 5). Hemostatic efficacy of FS was unchanged when TFC was diluted to 90 mg/ml (n = 6) but further dilution to 60 mg/ml with water (n = 8) produced significantly less effective clots, with an average blood loss of 5.5 +/- 7.6 ml (P < 0.05) and two fatal clot failures postoperatively. When FS was diluted to 60 mg/ml TFC with a buffer, it maintained its hemostatic strength (n = 6). Further TFC dilution to 30 mg/ml led to consistent bleeding with an average blood loss of 35.3 +/- 10.3 ml (P < 0.001, n = 6). CONCLUSIONS: The four-suture anastomosis of rabbit aorta offers a consistent and reliable method for evaluating the short- and long-term hemostatic efficacy of FS products. This model is not only able to determine the functional differences in various concentrations of FS, but it is also sensitive to detect the subtle changes in FS preparation (e.g., medium composition) that is not detected by in vitro testing.

Metabolic and hemodynamic effects of CO2 pneumoperitoneum in a controlled hemorrhage model.

BACKGROUND: Intracavity infusion of fibrin sealant-based agents, as a novel modality to control internal bleeding, is associated with an increase of pneumoperitoneum (PP) pressure. The safe limit of such increase has not been well defined in hypovolemic subjects. The purpose of this study was to evaluate the hemodynamic and metabolic effects of increasing PP pressure and to define the limits of carbon dioxide (CO2) insufflation in a controlled hemorrhage rat model. METHODS: Ninety male rats (474 +/- 6 g, 37 degrees +/- 1 degrees C) were anesthetized, and mechanically ventilated. Animals were randomly distributed among 14 groups (n = 6-8) with an increasing amount of blood loss (0, 10, 15, and 17.5 mL/kg) and 15 minutes of CO2 insufflation at 0, 5, 10, and 15 mm Hg starting 15 minutes after hemorrhage, followed by desufflation. Mean arterial pressure (MAP), heart rate, and survival were recorded and arterial and venous blood samples were collected at baseline, at 15 minutes after hemorrhage, after insufflation, and after desufflation procedures to determine arterial blood gases and lactic acid levels. RESULTS: In nonhemorrhaged animals, increasing PP pressure up to 15 mm Hg produced only transient changes in MAP and no increase in lactate level. A moderate hemorrhage (10 mL/kg) limited the safe abdominal pressure to 10 mm Hg with metabolic changes that were restored 15 minutes after desufflation. Higher PP pressure (15 mm Hg) at this hemorrhage level produced a significant decline in MAP (42%, p < 0.001) and progressive metabolic acidosis with a 2.1-fold increase (p < 0.01) in lactate level. The more severe hemorrhage (15 mL/kg) further reduced the limits of PP pressure such that 10 and 15 mm Hg resulted in a progressive decline of blood pressures (52% and 54%, respectively; p < 0.001) and severe metabolic acidosis as manifested by 3.3- and 3.1-fold rises in lactate levels, respectively. In the most severe hemorrhaged animals (17.5 mL/kg), the 50% mortality was primarily determined by the severity of the blood loss and the additional PP at 5 mm Hg had no significant impact. CONCLUSION: The safe limit of PP pressurization with CO2 is dependent on the amount of blood loss. In this mechanically ventilated rat model, increasing the amount of blood loss from 0 to 15 mL/kg reduces the tolerable level of abdominal insufflation pressure from 15 mm Hg to 5 mm Hg. A 5-mm Hg PP pressure appears safe even in the most severely hemorrhaged animals.

Assessment of topical hemostats in a renal hemorrhage model in heparinized rats.

Various topical hemostatic agents or devices have been employed to address the challenges associated with hemorrhage from parenchymal organs during surgery or trauma. Their relative efficacy, however, has not been assessed in a single animal model. The objective of this study was to develop a small animal renal hemorrhage model for comparing hemostatic efficacy of various topical agents, and then to compare fibrin sealant (FS) to an existing standard of care for topical hemostasis. A left heminephrectomy was performed in anesthetized adult male Sprague-Dawley rats. Animals were anticoagulated with 2000 IU/kg heparin IV and various topical hemostatic agents were applied to the injury. Treatment groups included FS applied as a spray; FS applied through a cannula; gelatin sponge (GS) soaked in 1000 IU/mL thrombin solution; GS soaked in 300 IU/mL thrombin; dry GS; and fibrinogen without thrombin applied as a spray. The main endpoints of the study were incidence of hemostasis, blood loss, acute survival trends, and maintenance of mean arterial pressure (MAP). Three treatment groups, the two FS groups and the GS soaked in 1000 IU/mL thrombin, afforded significant hemostasis compared to the controls (P < 0.01). Both FS groups had significantly less blood loss, longer survival times, and maintained higher MAPs than the GS-treated groups. Quantitative dose effects and functional deficiencies in topical hemostatic products could be assessed using this animal model. The study demonstrated that liquid FS was significantly more efficacious than a GS soaked in thrombin for abating hemorrhage from a renal excision in a heparinized rat.