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Objective. The superior dose conformity provided by proton therapy relative to conventional x-ray radiotherapy necessitates more rigorous quality assurance (QA) procedures to ensure optimal patient safety. Practically however, time-constraints prevent comprehensive measurements to be made of the proton range in water: a key parameter in ensuring accurate treatment delivery. Approach. A novel scintillator-based device for fast, accurate water-equivalent proton range QA measurements for ocular proton therapy is presented. Experiments were conducted using a compact detector prototype, the quality assurance range calorimeter (QuARC), at the Clatterbridge cancer centre (CCC) in Wirral, UK for the measurement of pristine and spread-out Bragg peaks (SOBPs). The QuARC uses a series of 14 optically-isolated 100 × 100 × 2.85 mm polystyrene scintillator sheets, read out by a series of photodiodes. The detector system is housed in a custom 3D-printed enclosure mounted directly to the nozzle and a numerical model was used to fit measured depth-light curves and correct for scintillator light quenching. Main results. Measurements of the pristine 60 MeV proton Bragg curve found the QuARC able to measure proton ranges accurate to 0.2 mm and reduced QA measurement times from several minutes down to a few seconds. A new framework of the quenching model was deployed to successfully fit depth-light curves of SOBPs with similar range accuracy. Significance. The speed, range accuracy and simplicity of the QuARC make the device a promising candidate for ocular proton range QA. Further work to investigate the performance of SOBP fitting at higher energies/greater depths is warranted., (Creative Commons Attribution license.)

Objective: To assess the first attempt neonatal intubation success rates of pediatric trainees following the implementation of an evidence-based training package., Study Design: Data collection was undertaken from February, 1 2017, to January 31, 2018, to ascertain baseline preimplementation intubation success rates. An intubation training package, which included the use of videolaryngoscopy, preprocedure pause, and standardized instruction during the procedure, was introduced. Data on all subsequent intubations were collected prospectively from May 1, 2018, to April 30, 2020., Results: Preimplementation baseline data over a 1-year period demonstrated overall first attempt intubation success rate of junior trainees to be 37% (33/89). After implementation of the training package, 290 intubations were analyzed over a 2-year period. The overall success rate was 67% (194/290); 61% (117/192) for junior trainees and 79% (77/98) for senior clinicians. Three or more attempts were required for 13% of intubations (38/290). During the study period, the overall number of intubations being carried out decreased. Intubations with the videolaryngoscope had higher success rates for all tiers of clinician, most marked in the junior tiers., Conclusions: The introduction of a standardized intubation training package, along with videolaryngoscopy, improved trainee intubation success rates., (Copyright © 2021 Elsevier Inc. All rights reserved.)

A secure and patent airway is a prerequisite to safe interhospital transfer and this has traditionally been via endotracheal tubes. Neonatal intubation success rates are falling as there is declining opportunities amongst paediatric junior doctors and consultants, therefore being able to successfully intubate an infant before or during a transfer, especially if they have an airway anomaly, may be very challenging. The use of supraglottic airways is increasingly popular in neonatology as an alternative to facemask ventilation or endotracheal intubation. This review considers the role of supraglottic airway devices during the stabilisation and transfer of neonates., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Investigation of movement and sensory profiles across STarT Back risk subgroups., Methods: A chronic low back pain cohort (n = 290) were classified as low, medium or high risk using the STarT Back Tool, and completed a repeated spinal bending task and quantitative sensory testing. Pain summation, time taken and the number of protective behaviours with repeated bending were measured. Sensory tests included two-point discrimination, temporal summation, pressure/thermal pain thresholds and conditioned pain modulation. Subgroups were profiled against movement and sensory variables., Results: The high-risk subgroup demonstrated greater pain summation following repeated forward bending (p < 0.001). The medium-risk subgroup demonstrated greater pain summation following repeated backward bending (p = 0.032). Medium- and high-risk subgroups demonstrated greater forward/backward bend time compared to the low-risk subgroup (p = 0.001, p = 0.005, respectively). Medium- and high-risk subgroups demonstrated a higher number of protective behaviours per forward bend compared to the low-risk subgroup (p = 0.008). For sensory variables, only two-point discrimination differed between subgroups, with medium- and high-risk subgroups demonstrating higher thresholds (p = 0.016)., Conclusions: This study showed altered movement characteristics and sensory discrimination across SBT risk subgroups in people with CLBP. Membership of the high SBT risk subgroup was associated with greater pain and disability levels, greater pain summation following repeated bending, slower bending times, a greater number of protective behaviours during forward bending, and a higher TPD threshold. Treatment outcomes for higher risk SBT subgroups may be enhanced by interventions specifically targeting movement and sensory alterations., Significance: In 290 people with chronic low back pain movement profile and two-point discrimination threshold differed across risk subgroups defined by the STarT Back Tool. Conversely, pain sensitivity did not differ across these subgroups. These findings may add further guidance for targeted care in these subgroups., (© 2018 European Pain Federation - EFIC®.)

Objectives: Respiratory infections are associated with acute exacerbations of asthma and accompanying morbidity and mortality. In this study we explore inter-practice variations in respiratory infections in children with asthma and study the effect of practice-level factors on these variations., Design: Cross-sectional study., Setting: We analysed data from 164 general practices in the Royal College of General PractitionersResearch and Surveillance Centresentinel network in England., Participants: Children 5-12 years., Interventions: None. In this observational study, we used regression analysis to explore the impact of practice-level determinants on the number of respiratory infections in children with asthma., Primary and Secondary Outcome Measures: We describe the distribution of childhood asthma and the determinants of upper/lower respiratory tract infections in these children., Results: 83.5% (137/164) practices were in urban locations; the mean number of general practitioners per practice was 7; and the mean duration since qualification 19.7 years. We found almost 10-fold difference in the rate of asthma (1.5-11.8 per 100 children) and 50-fold variation in respiratory infection rates between practices. Larger practices with larger lists of asthmatic children had greater rates of respiratory infections among these children., Conclusion: We showed that structural/environmental variables are consistent predictors of a range of respiratory infections among children with asthma. However, contradictory results between measures of practice clinical care show that a purely structural explanation for variability in respiratory infections is limited. Further research is needed to understand how the practice factors influence individual risk behaviours relevant to respiratory infections., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A 14-year-old girl had experienced gross peripheral oedema for nearly 2 years. She was under review by several paediatric specialists for a variety of problems. Her local paediatric team were unable to find the cause of her oedema, despite extensive investigations. Eventually, her mother discovered the cause was inhaled fluticasone, prescribed at normal dosage for asthma. As far as the authors are aware, this is the first reported case of peripheral oedema associated with the use of fluticasone. Peripheral oedema is a rare side-effect of fluticasone in the form of either seretide or flixotide. Physicians should be aware of this possibility in cases of resistant peripheral oedema with no other identified cause.

Pustular rash in a neonate is very common and is usually associated with staphylococcal infection. The present report describes the case of a 12-day-old neonate with a pustular rash, secondary to herpes simplex infection. A high index of suspicion is necessary in neonates presenting with suggestive signs, especially with negative bacterial cultures. Prompt initiation of aciclovir treatment after obtaining diagnostic samples may be life-saving.

A patient is reported who was found to have metastatic breast cancer in pregnancy. Intravenous pamidronate was given with beneficial effect in the third trimester. There were no serious adverse effects on the foetus.