Which radiological investigations should be performed to identify fractures in suspected child abuse?

AIMS

To determine which radiological investigations should be performed and which children should be investigated.

MATERIALS AND METHODS

An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms.

RESULTS

Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old.

CONCLUSIONS

In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Novel conjugate of moxifloxacin and carboxymethylated glucan with enhanced activity against Mycobacterium tuberculosis

Mycobacterium tuberculosis is an intracellular pathogen that persists within macrophages of the human host. One approach to improving the treatment of tuberculosis (TB) is the targeted delivery of antibiotics to macrophages using ligands to macrophage receptors. The moxifloxacin-conjugated dansylated carboxymethylglucan (M-DCMG) conjugate was prepared by chemically linking dansylcadaverine (D) and moxifloxacin (M) to carboxymethylglucan (CMG), a known ligand of macrophage scavenger receptors. The targeted delivery to macrophages and the antituberculosis activity of the conjugate M-DCMG were studied in vitro and in vivo. Using fluorescence microscopy, fluorimetry, and the J774 macrophage cell line, M-DCMG was shown to accumulate in macrophages through scavenger receptors in a dose-dependent (1 to 50 microg/ml) manner. After intravenous administration of M-DCMG into C57BL/6 mice, the fluorescent conjugate was concentrated in the macrophages of the lungs and spleen. Analyses of the pharmacokinetics of the conjugate demonstrated that M-DCMG was more rapidly accumulated and more persistent in tissues than free moxifloxacin. Importantly, therapeutic studies of mycobacterial growth in C57BL/6 mice showed that the M-DCMG conjugate was significantly more potent than free moxifloxacin.

A comparison of the Seeing Optical Stylet and the gum elastic bougie in simulated difficult tracheal intubation: a manikin study

Management of the difficult airway is one of the major challenges that anaesthetists face. The flexible fibreoptic scope is widely available but its use requires a level of skill, training and continued practice that is not universally found in all anaesthetists, particularly trainees. The Seeing Optical Stylet is a new, semirigid fibreoptic stylet 'scope. We compared the Seeing Optical Stylet with a gum elastic bougie in a simulated Cormack and Lehane Grade 3 laryngoscopy in a manikin. Forty-four anaesthetists were timed while intubating the manikin's trachea with both devices. The mean (SD) time taken with the Seeing Optical Stylet was 20.8 (9.3) s and with the bougie 30 (19.8) s (p = 0.001). Oesophageal intubation occurred six times with the bougie but did not occur with the Seeing Optical Stylet (p = 0.011). We conclude that the Seeing Optical Stylet may be superior to the bougie in difficult tracheal intubation. We feel that the results of this manikin trial are sufficiently encouraging to proceed to a clinical trial in patients.

Distinct recognition of antibodies to centromere proteins in primary Sjogren's syndrome compared with limited scleroderma

BACKGROUND

Anticentromere antibodies are characteristically observed in scleroderma but have recently been reported in other autoimmune rheumatic disorders, including Sjögren's syndrome. It is not known whether distinct centromere proteins (CENP) are targeted in primary Sjögren's syndrome (pSS) and scleroderma.

OBJECTIVE

To determine whether antibodies to CENP-B and CENP-C are present in these two disorders.

METHODS

Sera from 45 patients with pSS and 33 with limited scleroderma were studied. All patients met classification criteria for pSS and scleroderma, respectively. Sera were used to immunoprecipitate in vitro translated CENP-B and CENP-C. The proportions recognising CENP-B or CENP-C were compared.

RESULTS

10 of 45 patients (22%) with pSS and 18 of 33 (55%) with scleroderma had antibodies recognising CENPs (p = 0.004). Seven of 10 (70%) CENP positive patients with pSS recognised CENP-C alone, compared with one of 18 (6%) CENP positive patients with scleroderma (odds ratio (OR) = 40 (95% confidence interval (CI), 3.5 to 450) (p = 0.003). In contrast, the majority (15 of 18 (83%)) of CENP positive scleroderma sera recognised both CENP-B and CENP-C, compared with none of 10 pSS sera (OR = 93 (95% CI, 4.4 to 1979) (p = 0.0001).

CONCLUSIONS

The pattern of CENP recognition differs markedly in pSS and limited scleroderma. While patients with pSS predominantly recognise CENP-C alone, dual recognition of CENP-B and CENP-C is most frequent in scleroderma. These findings suggest that obtaining antibodies to specific centromere antigens is useful diagnostically, and imply that distinct mechanisms underlie the unique patterns of centromere autoreactivity in pSS and scleroderma.

The effect of lead on the metabolic and energetic status of the Yabby, Cherax destructor, during environmental hypoxia

The concomitant effects of Pb and hypoxia on respiration and muscle energy status were examined in the freshwater crayfish Cherax destructor to determine if Pb intoxication exacerbated the effects of hypoxia. C. destructor, either intoxicated for 14 days with 0.5 mgL(-1)Pb, or from Pb-free control conditions, were subjected to progressive hypoxia at -2.7 kPah(-1) to a O2 partial pressure in the water (PwO2) of 1.33 kPa. This hypoxia was then sustained for 3 h. Pb-exposure reduced O2-uptake (MO2) at all PwO2 above 1.33 kPa but without any saving in ventilation, implying that Pb either unlinked ventilation from actual O2 requirements or rendered O2 transfer across the gill less efficient. Hypoxia alone induced no change in the adenylate energy charge (AEC), total adenylate (TAN), ATP/ADP ratio or in the equilibrium constant for adenylate kinase K'(ADEN), apparently due to protection of ATP levels by arginine phosphate. Under maximal hypoxia (PwO2=1.33 kPa) the Pb-exposed crayfish increased muscle ADP by 73% (tail) and 158% (chelae) but without any change in AMP, ATP or TAN. Thus, AEC declined (chelae AEC=0.71; tail AEC=0.85), as did the ATP/ADP ratio and K'(ADEN). L-Lactate increased in the muscle tissues of control but not Pb-exposed crayfish, consistent with a lowered O2 requirement in the Pb-exposed animals. The Pb intoxication slowed respiration and probably glycolysis, possibly altering the [ATP]:[ADP] equilibrium concentrations for adenylate kinase K'(AK). Lowered MO2 during severe hypoxia slows oxidative phosphorylation and ADP accumulation could occur as non-utilised substrate and may reflect a transient disequilibrium. During this time ATP levels were protected by arginine phosphate. AEC is sensitive to Pb in hypoxic crayfish but the changes have low importance for the energetic competence of the crayfish. During sustained hypoxia the crayfish recovered their energy status regardless of the Pb-exposure and this was, therefore, not a feature of Pb intoxication. Consequently, the ADP was recovered into the ATP pool of the hypoxic crayfish, and demand on arginine phosphate relieved. The Pb exposure did not otherwise exacerbate the effect of sustained hypoxia and C. destructor appeared to cope well with Pb intoxication, apparently by a specific Pb-induced hypometabolism separate from hypoxic response. Lowered metabolism as a survival response has limitations in the longer term and the implications for crustaceans generally warrant further study.

Neonates do not need to be handled for radiographs

BACKGROUND

The handling of sick neonates may have detrimental effects such as hypoxia or bradycardia. Such handling is inevitable due to the frequent need for practical procedures; however, minimising handling reduces these adverse events and may improve outcome. Radiography is one of the commonest procedures performed on neonates. Usually the infant is lifted and placed onto the radiographic cassette; however, modern incubators often incorporate a tray beneath the mattress in which the radiographic cassette can be placed without the need to disturb the infant.

OBJECTIVE

To compare the quality of chest radiographs taken using the standard direct contact method, with those taken using the under-tray technique.

MATERIALS AND METHODS

A series of chest radiographs taken over a 21-month period were analysed independently by two consultant paediatric radiologists unaware of the radiographic details. The position of the radiograph, i.e. direct contact or under-tray, was determined by the radiographer. Radiographic quality was scored on the following features: exposure, blurring, rotation, cut-off or coning, and side markers. A subjective score was also included. The results from each radiologist were analysed separately.

RESULTS

Seventy chest radiographs were analysed-25 standard method, 45 under-tray. A statistically significant advantage for the under-tray method was seen on two analyses-radiologist 1 for exposure, and radiologist 2 for cut-off. No other significant differences were noted. There were no differences in the infants' weights or radiation exposure.

CONCLUSIONS

The under-tray method for taking radiographs may produce films of at least equivalent quality to the standard method. Since the standard method involves handling with potential desaturation and bradycardia, this technique should cease.

Economic evaluation of voriconazole compared with conventional amphotericin B for the primary treatment of aspergillosis in immunocompromised patients

OBJECTIVE

The objective of this study was to conduct an economic evaluation of voriconazole compared with conventional amphotericin B deoxycholate (CAB) using data from a recently reported randomized comparative trial in patients with various underlying immunosuppressive conditions. This trial demonstrated the superiority of voriconazole in terms of clinical response, survival and safety when used as primary therapy for invasive aspergillosis.

METHODS

A decision analytic model was designed using an expert panel and populated primarily with efficacy and resource utilization data collected prospectively during the clinical trial. The analysis was carried out from the perspective of the health care system and all costs are reported in 2002 US dollars.

RESULTS

Average total treatment costs per patient were 10% lower in the voriconazole arm ($30 664) than in the CAB arm ($34 144), resulting from reduced consumption of hospital resources and fewer changes in antifungal therapy. In the base case analysis, voriconazole provided an average saving of $3481 per treated patient, resulted in a lower cost per survivor ($43 310 versus $58 971) and a lower cost per successfully treated patient ($58 100 versus $108 124) compared with CAB. Sensitivity analyses demonstrated that the cost savings observed were maintained over a wide range of alternative values for both unit costs and resource utilization, including length of hospital stay, time spent in intensive care units, bed day costs and the cost of lipid formulations of amphotericin B.

CONCLUSION

Incremental cost-effectiveness analysis indicated the dominance of voriconazole because of both lower costs and greater efficacy.

Modulation of the mouse testis transcriptome during postnatal development and in selected models of male infertility

The aim of this study is to develop an overview of genetic events during spermatogenesis using a novel, specifically targeted gonadal gene set. Two subtracted cDNA libraries enriched for testis specific and germ cell specific genes were constructed, characterized and sequenced. The combined libraries contain >1905 different genes, the vast majority previously uncharacterized in testis. cDNA microarray analysis of the first wave of murine spermatogenesis and of selected germ cell-deficient models was used to correlate the expression of groups of genes with the appearance of defined germ cell types, suggesting their cellular expression patterns within the testis. Real-time RT-PCR and comparison to previously known expression patterns confirmed the array-derived transcription profiles of 65 different genes, thus establishing high confidence in the profiles of the uncharacterized genes investigated in this study. A total of 1748 out of 1905 genes showed significant change during the first spermatogenic wave, demonstrating the successful targeting of the libraries to this process. These findings highlight unknown genes likely to be important in germ cell production, and demonstrate the utility of these libraries in further studies. Transcriptional analysis of well-characterized mouse models of infertility will allow us to address the causes and progression of the pathology in related human infertility phenotypes.

Expression and functional implications of CCR2 expression on murine alveolar epithelial cells

Acute lung injury results in damage to the alveolar epithelium, leading to leak of proteins into the alveolar space and impaired gas exchange. Lung function can be restored only if the epithelial layer is restored. The process of reepithelialization requires migration of lung epithelial cells to cover denuded basement membranes. The factors that control the migration of lung epithelial cells are incompletely understood. We examined isolated murine type II alveolar epithelial cells (AECs) for expression of CC chemokine receptor 2 (CCR2) and functional consequences of the binding of the main CCR2 ligand monocyte chemoattractant protein-1 (MCP-1). We found that primary AECs bound MCP-1 and expressed CCR2 mRNA. These cells demonstrated functional consequences of CCR2 expression with migration in response to MCP-1 in chemotaxis/haptotaxis assays. Primary AECs cultured from mice lacking CCR2 did not respond to MCP-1. Monolayers of AECs lacking CCR2 demonstrated delayed closure of mechanical wounds compared with AEC monolayers expressing CCR2. Delayed closure of mechanical wounds of wild-type AECs was also demonstrated in the presence of anti-MCP-1 antibody. These data demonstrate for the first time that AECs express CCR2 and are capable of using this receptor for chemotaxis and healing of wounds. CCR2-MCP-1 interactions may be important in the process of reepithelialization after lung injury.

Guidelines on the management of secondary prophylaxis of vascular events in stable patients in primary care

Atherothrombosis, thrombus formation superimposed on an existing atherosclerotic plaque, is an acute process leading to ischaemic events such as myocardial infarction, stroke and critical limb ischaemia. Patients presenting with clinical conditions associated with atherothrombosis are at increased risk of subsequent vascular events. The beneficial effect of antiplatelet therapies for short-term and long-term secondary prevention of atherothrombotic events has been established. These guidelines aim to provide evidence-based recommendations that will assist in the antiplatelet-mediated secondary prophylaxis of vascular events in patients with stable cardiovascular disease treated in the primary healthcare setting. Medline and the Cochrane library were accessed using free-text strategies in the domains of antiplatelet agents and antithrombotics. Development of the guidelines was driven by a series of Steering Committee meetings, in which the quality of relevant studies was assessed and identified using narrative summary. These guidelines present evidence and recommendations for the treatment of numerous atherothrombotic indications depending on individual patient circumstances.

Head injury and limb fracture in modern playgrounds

There were no serious head injuries in modern Cardiff municipal playgrounds with safety surfaces over five years injury surveillance. The literature suggests serious head injuries did occur before the introduction of safety surfaces.

Recurrent transverse myelitis associates with anti-Ro (SSA) autoantibodies

Transverse myelitis (TM) is an idiopathic inflammatory disorder of the spinal cord. The authors observed cases of recurrent TM in patients where anti-Ro (SSA) antibodies were present and therefore performed a case-control study to examine the frequency of anti-Ro autoantibodies in patients with recurrent TM and control subjects. Antibodies to 52-kd Ro were demonstrated in 77% of cases (10/13) compared with only 33% of control subjects (4/12).