The need to update NCRP 151 data for 10 MV linear accelerator bunker shielding based on new measurements and Monte Carlo simulations.

Linear accelerator bunker shielding protocols such as NCRP 151 have previously been tested against a large sample of measured data from real bunkers and machines but differences in per-energy concrete penetration (TVLs) for 10 MV has not yet been resolved. These differences are likely due to historical beam data and can potentially result in over-exposure of radiation workers and the public. This study examines a cohort of clinical linac bunker survey measurements and compares them to popular shielding protocols. Differences were investigated using contemporary beam data for both Monte Carlo simulation and in analytical equations. For primary barriers, NCRP 151 underestimates the dose rate through concrete by on average a factor of 2 with secondary barriers and maze entrance doses having much better agreement. Use of contemporary beam data in Monte Carlo simulation and an analytical equation yielded TVL values much closer to the measured values compared to NCRP 151. The TVL data in NCRP 151 is outdated and needs to be updated based upon the energy spectra of modern linear accelerators. Until then, physicists should use the TVL values shown in this study instead.

Abnormal preschool Lung Clearance Index (LCI) reflects clinical status and predicts lower spirometry later in childhood in cystic fibrosis.

BACKGROUND: Clinical and prognostic value of preschool Multiple Breath Washout (MBW) remains unclear. METHODS: Initial MBW results (Exhalyzer® D, EcoMedics AG) in preschool Cystic Fibrosis (CF) subjects (age 2-6 years) at a time of clinical stability were compared to (1) concurrent clinical status measures and (2) later spirometry outcomes. Abnormal Lung Clearance Index (LCI) was defined using published reference data (ULN for LCI 8.0). RESULTS: LCI was abnormal in 56% (28/50), with mean (SD) LCI 8.61(1.85) at age 4.71(1.3) years. Abnormal LCI was associated with higher dornase alfa use, previous positive bacterial cultures and pF508.del homozygous genotype. Later spirometry (n = 44; mean (SD) 2.3(0.5) years after MBW) demonstrated that abnormal initial preschool LCI was a strong predictor of lower later spirometry outcomes. CONCLUSION: Abnormal preschool LCI was associated with concurrent measures of clinical status and later spirometry deficits, suggesting early prognostic utility of MBW testing in this age range.

Trainee perspectives on postdoctoral recruitment in clinical neuropsychology: reflections on commentaries by Bodin and Grote (2016) and Nelson et al. (2016).

OBJECTIVE: The aim of the current invited paper is to provide the trainees' perspective on recent commentaries on recruitment for postdoctoral fellowship in clinical neuropsychology. The current system of recruitment includes both a match and non-match process and has been problematic for trainees and training programs alike. METHOD: The author team completed a non-systematic review of previously published commentaries on the current state of postdoctoral fellowship recruitment, which are briefly summarized in the current paper. The trainee perspective is addressed using both survey data and anecdotal experiences of the authors. RESULT: Trainees report high levels of dissatisfaction with the current dual recruitment system; however, there is no clear preference from trainees for either a match or non-match system. Trainees from both recruitment systems report high levels of satisfaction with their training experience. CONCLUSION: It seems that either a match or non-match approach, if it led to a unified system, would improve trainee satisfaction.

Clinical assessment, management and outcomes of a group of adolescents presenting with complex medico-psychosocial conditions.

BACKGROUND: Adolescents with complex medico-psychosocial presentations are often seen as a management challenge. The Medical Family Therapy model provides a useful framework for working with these patients in the context of a multidisciplinary approach to treatment. MATERIALS AND METHODS: A retrospective case analysis of 38 patients referred over a two-year period to the Department of Adolescent Medicine was carried out. These patients met DSM-IV criteria for somatoform disorder or had a diagnosis of chronic fatigue syndrome (CFS). Duration of symptomatology, diagnosis, the presence of psychiatric conditions in the young person and their immediate family and the type and duration of the intervention were examined in relation to outcome. Two case presentations illustrate the complexity of the assessment and treatment process. RESULTS: Clinicians rated 47% of patients who engaged with the service as improved. There was no relationship between diagnosis, length of intervention and outcome. No significant differences emerged between the group of young people diagnosed with CFS and those with somatoform disorders in terms of outcome. Nine patients presented with symptoms which were similar or identical to those of one of their parents. Physical illness was more likely to be reported as a precipitating factor in the CFS group. Poor school attendance and psychiatric morbidity were linked to poor outcome. CONCLUSIONS: A comprehensive evaluation of presenting symptomatology and focussed intervention with measurable outcomes are important aspects of the clinical approach to complex medico-psychosocial conditions in adolescents. Families' beliefs about the presenting symptomatology and experiences of illness should be explored.

Assessment of the child with recurrent respiratory infections.

BACKGROUND: Children with atopy, daycare attendance, crowding or exposure to cigarette smoke are predisposed to recurrent respiratory infection. The young child who 'is always sick' is a common problem, creating concern for their parents and doctors. OBJECTIVE: To outline an approach for determining which children with recurrent respiratory infections are normal, which have an allergic disorder and which have an underlying immune or other problem. DISCUSSION: The majority of children with recurrent respiratory tract infections are normal, however, it is important to consider atopy and underlying immunodeficiency. In those children where there are features suggesting an underlying immunological disorder, specialist assessment is warranted.

The musculoskeletal complications of cystic fibrosis.

OBJECTIVE: To determine the spectrum of musculoskeletal complications of cystic fibrosis (CF) in a paediatric population in Australia. METHOD: Clinical assessment followed by serology and bone scan on patients attending a specialized CF clinic. RESULTS: Of 125 patients studied, 21 had musculoskeletal complications, 17 attributable to CF. Eleven had joint involvement (six hypertrophic pulmonary osteoarthropathy (HPOA)), one CF arthropathy, two ciprofloxacin induced arthralgia, one joint contracture following long-line placement, one chest infection associated arthralgia), four kyphosis (two also with HPOA) and two thoracic deformity. HPOA was associated with older age, lower average pulmonary function and lower average Shwachman score. Three patients with HPOA died within 12 months of reporting symptoms. Kyphosis was also associated with older age and lower pulmonary function. CONCLUSION: Increasing age with deteriorating clinical and pulmonary function were associated with a higher incidence of musculoskeletal involvement. The development of symptomatic HPOA is a marker of poor prognosis.

Chronic illness perception in adolescence: implications for the doctor-patient relationship.

OBJECTIVE: To describe the inter-relationship of chronic illness severity as perceived by adolescents with both psychosocial well-being and objective measures of illness severity. Additionally to compared the adolescents' perception of illness severity with how their physicians believe that the adolescents perceive their illness severity. METHODS: The psychological well-being of 48 adolescents with either cystic fibrosis (CF) or insulin-dependent diabetes mellitus (IDDM) was measured by four standardized questionnaires. The adolescents' perception of severity of illness was measured using an original instrument (PSCI), and this measure was compared to their physicians' estimates of how the adolescents perceived the severity of their illness and clinical illness. RESULTS: There were 24 patients in both the CF and IDDM groups. Both groups were found to function well psychosocially; although, there were more patients with low self image compared to normative values. Depression and low self image were associated with a greater adolescent perception of illness severity. For both chronic illness groups, physicians' assessment of assumed adolescent perception of disease severity correlated with clinical indices of disease severity and was higher than the perception of illness severity reported by the adolescents. For adolescents with CF, but not with IDDM, perception of severity of chronic illness correlated with clinical indices. CONCLUSIONS: For adolescents with chronic illness, their perception of illness severity is an important indicator of psychosocial well-being. Physicians do not accurately infer their patients' perception of illness severity.

Role of acetyl salicylic acid and sodium metabisulfite in chronic childhood asthma.

The role of a commonly ingested food additive, the preservative sodium metabisulfite (MBS), and aspirin (ASA), in chronic asthma has been studied in 29 children. After 1 week on a strict elimination diet, all 29 children were challenged, in a single-blind fashion, in the pulmonary function laboratory on three consecutive days with placebo, MBS (capsule form and solution), and ASA. Children with a positive response to MBS were prescribed a diet that excluded foods containing MBS. Patients with a positive response to ASA were prescribed a diet excluding medications containing aspirin and natural salicylates. After 3 months on these restricted diets, the children were reassessed to determine whether there had been any therapeutic response. There was a 66% (19/29) incidence of positive challenge (greater than 20% decrease in forced expiratory volume in one second) with MBS and a 21% (6/29) incidence of positive challenge with ASA. None of the children reacted to MBS in capsule form (maximum dose = 100 mg), but 19/29 reacted to MBS in solution with 30 mL of 0.5% citric acid. After 3 months on the restricted diet, four of 19 children on the MBS-free diet and one of six on the salicylate-free diet had objective signs of improvement, namely, reduction in asthma medications and/or improvement in lung function. Unfortunately, compliance with the restrictive diet during this 3-month period was poor, particularly with the ASA-sensitive children.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic delay in cystic fibrosis: lessons from newborn screening.

Newborn screening for cystic fibrosis (CF) by dried blood spot immunoreactive trypsin (IRT) assay is now feasible, but the benefits are disputed. We have studied the symptoms and signs at diagnosis in 48 babies detected during a newborn screening programme, and also the delay between presentation with symptoms and diagnosis in all 33 babies diagnosed at our CF clinic in the two years before screening began. Eleven of the 48 screened babies had meconium ileus, 16 had gastrointestinal symptoms only, and 14 had both respiratory and gastrointestinal symptoms at the time of diagnosis. Five of the remaining 7 babies developed clear cut symptoms or signs soon after diagnosis. Thus, 96% (46 of 48) of the babies had symptoms by 3 months of age. Of the 33 infants diagnosed clinically in the two years immediately before screening, 13 (39%) were over 12 months of age at diagnosis. Moreover, the mean delay between presentation with symptoms and diagnosis of CF in these infants was 2.6 years. Our data show that the delay between onset of symptoms and diagnosis is far greater than previously supposed and that most babies detected by our screening programme already had symptoms that warranted treatment at the time of their diagnosis.

Bronchodilator effects of salbutamol powder administered via Rotahaler and of terbutaline aerosol administered via Misthaler. A comparison study in children with asthma.

A study to compare the bronchodilator effect of salbutamol powder (Ventolin, 200 micrograms) administered via a Rotahaler (SR), with that of terbutaline sulphate (Bricanyl, 500 micrograms) administered via a Misthaler (TM) was carried out in 25 children with stable moderate to severe asthma. The bronchodilator effects of salbutamol powder and terbutaline sulphate were measured by means of spirometry and clinical assessment in a double-blind, randomized fashion. The children were monitored for three hours after administration of the medication on three consecutive days. The administration of salbutamol via a Rotahaler and of terbutaline sulphate via a Misthaler resulted in significant bronchodilatation as measured by peak expiratory flow rate and spirometry. There was a significant trend for SR to give greater bronchodilatation than TM at several time intervals. Over 70% (18 of 25) of the children in this study preferred the Ventolin Rotahaler to the Bricanyl Misthaler. Both SR and TM give effective bronchodilatation and, consequently, these devices should be particularly useful in younger children who have difficulty with managing standard, metered aerosols.