The impact of sedation on the quality of initial skeletal surveys performed for suspected physical abuse in children: a comparative two-centre audit

BACKGROUND

The impact of sedation on the quality of initial skeletal surveys performed for suspected physical abuse in children is not known.

OBJECTIVE

To assess whether sedation influenced the number of, reason for and effective dose of repeat radiographs obtained as part of initial skeletal surveys, and their mean examination times.

MATERIALS AND METHODS

One hundred consecutive antemortem initial skeletal survey examinations performed for suspected physical abuse in children <2 years were retrieved from two tertiary paediatric hospitals: Centre 1, where sedation is not used for initial skeletal survey imaging; and Centre 2, where sedation is used routinely.

RESULTS

In total, 4055 radiographic projections were performed, of which 93 (2.3%) were repeats. Comparing centres, there was a significant difference in the total number of repeats (P=0.001) and the number of repeats in children aged <12 months (P=0.008). Mean examination times were significantly shorter in unsedated children (P=0.005), even after outliers were excluded (P=0.002). There was no significant difference between the number of routine projections (P=0.587), incompletely imaged body parts (P=0.254), rotation/suboptimal positioning (P=0.527), repeats in children aged >12 months (P=0.089), routine projections in children aged <12 months (P=0.642) or >12 months (P=0.979) or the effective doses of repeats (P=0.286).

CONCLUSION

There were fewer repeat projections in sedated children and those aged <12 months but examination times were significantly longer. There was no difference in the effective doses of repeated projections. The routine use of sedation is not supported when performing skeletal survey imaging if the primary considerations are reducing radiation dose and examination time.

Paediatric trauma: experience from the UK's busiest trauma centre

Paediatric major trauma is relatively uncommon (6% of all traumas) and therefore unfamiliar to many radiologists. The indications for and interpretation of imaging are different to those commonly encountered in adults. In a centre that rarely encounters paediatric trauma, there can be trepidation over the best way to image children due to concerns regarding radiation and the injury patterns that occur at various ages. Within paediatric trauma, as per the Royal College of Radiologists "paediatric trauma protocols" guidelines and National Institute for Health and Care Excellence (NICE) guidance, the main reliance is on computed tomography (CT) and plain radiographs. This review of paediatric trauma from a busy UK major trauma centre demonstrates the most appropriate use of different imaging techniques, the extent of imaging, and the types of injuries that occur in a selection of paediatric trauma patients with a variety of trauma mechanisms. Cases include trauma related to road traffic accidents, bicycle handlebar injuries, falls, and even stabbings. Important learning points highlighted include the use of targeted body part imaging in children, the significance of handlebar injuries, and the importance of assessing for underlying injury in paediatric rib fractures and abdominal bruising and tenderness. We hope these examples will help to support and guide radiologists when encountering paediatric trauma within their own centres.

Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?

INTRODUCTION

In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration. The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals.

METHODS

A sample of thirty pelvic x-rays were selected from the local cerebral palsy database. A range of hip displacement was selected including some challenging borderline x-rays. All ten extended-role radiographers completed measurements using TraumaCAD which were repeated at a minimum of 4 weeks. Inter-rater and intra-rater reliability was calculated using intraclass correlation coefficients. The accuracy and safety of the system was evaluated by converting measurements into referral categories (red, amber or green) and cohen's kappa was calculated when categories were compared to measurements to orthopaedic surgeon RESULTS: The inter-rater reliability between radiographers was 0.938 (95% CI 0.914-0.991). The intra-rater reliability was 0.941 (95% CI 0.931-0.949). The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889-0.957).

CONCLUSION

The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy.

IMPLICATIONS FOR PRACTICE

We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.

Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA)

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the "British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)". The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

A survey of non-accidental injury imaging in England, Scotland and Wales

AIM

To identify the potential national variation in non-accidental injury (NAI) imaging in England, Scotland and Wales.

MATERIALS AND METHODS

A postal survey was sent to 323 hospitals with both paediatric and radiology departments. These were identified by a search through the Medical Directory.

RESULTS

One hundred and thirteen of 323 postal questionnaires were returned within the study period (35%). Sixteen were excluded from the study because either no NAI imaging was performed at that institution or an incorrect address had been used. The total number of completed questionnaires was 97 (30%). Extensive variation was seen in all aspects of NAI imaging including imaging techniques used, total case numbers, follow-up imaging and those who report the NAI imaging.

CONCLUSIONS

There is currently no national protocol that incorporates all aspects of NAI imaging in England, Scotland and Wales. Extensive variation in practice has been shown by this survey. Further standardization of NAI imaging practice is required. The draft BSPR skeletal survey guidelines and routine neurological imaging is recommended.

The role of the plain radiograph and renal tract ultrasound in the management of children with renal tract calculi

AIMS

The aim of this retrospective study was to assess the relative efficacy of plain abdominal radiographs and detailed renal tract ultrasound (US) examination in the diagnosis and follow-up of children with renal tract calculi.

METHODS

The records and imaging studies of 28 paediatric patients who had presented with proven renal tract calculi over a period of 5 years were examined.

RESULTS

In 23 (82%) patients, US was the first investigation. All these patients also had plain radiographs. Plain radiographs were the first investigation in five (18%) patients. All renal calculi (100%) visible on plain films were demonstrated on US. Furthermore, detailed US often provided other clinically significant findings that were not apparent on plain films.

CONCLUSION

As a result of this study it is recommend that detailed US should be the investigation of choice in children with suspected renal tract calculi.

A study on the patency of the inferior mesenteric and lumbar arteries in the incidence of endoleak following endovascular repair of infra-renal aortic aneurysms

OBJECTIVE

An endoleak is defined as the presence of contrast medium within the aneurysm sac on post-operative contrast-enhanced computed tomography scans (CT) in patients following endovascular repair (EVR) of abdominal aortic aneurysms (AAA). The aim of this study was to correlate the incidence of endoleaks with the presence of patent lumbar (LA) and inferior mesenteric arteries (IMA) as seen on pre-operative angiography.

DESIGN, MATERIALS AND METHODS

Forty-seven patients were assessed pre-operatively by both CT and angiography by a blinded radiologist prior to EVR of AAA. The number and size of patent vessels was recorded and correlated with the incidence of LA or IMA endoleaks on follow-up CT. Patent lumbar vessels were scored: 1 = small, 2 = medium, 3 = large.

RESULTS

Five patients were noted to have patent IMA on pre-operative angiography but none developed an endoleak. In this series, five patients had an endoleak due to a patent LA. The median score for patients with no endoleak was 1 (0-9) and for those with a lumbar endoleak 2 (0-5) (P = 0.26, Mann-Whitney U-test). The number of patent lumbar arteries was not predictive of a subsequent endoleak. Two out of nine (22 %) patients with large patent LA subsequently developed an endoleak. If a policy of pre-operative embolization on the basis of large patent LA had been adopted, seven patients would have had an unnecessary invasive procedure.

CONCLUSION

Pre-operative angiography to look for patent LA and IMAs is not required in patients undergoing EVR or AAA.

The ELONGATED gene of Arabidopsis acts independently of light and gibberellins in the control of elongation growth

A novel elongated mutant has been isolated from EMS-mutagenized populations of the Arabidopsis thaliana ga4 mutant. After backcrossing with the Landsberg erecta (Ler) wild-type (WT) followed by selfing, the mutant phenotype was identified in the GA4 background. Seedlings of the mutant, which has been named elg (elongated), are characterized by elongated hypocotyls and petioles, leaves that are narrow and somewhat epinastic and early flowering. Allelism tests with the hy1-hy5 mutants indicate that elg is not allelic with any of these long-hypocotyl mutants. From linkage analyses, the location of elg on chromosome 4, between cer2 and ap2 has been established. The pleiotropic phenotype of elg seedlings is suggestive of a disruption of phytochrome and/or gibberellin (GA) function. Although the elg mutant displays a light-dependent long-hypocotyl phenotype, elg seedlings retain a full range of photomorphogenic responses and the elg mutation acts additively with the photomorphogenic mutants phyB, hy1 and hy2. This suggests that ELG acts independently of phytochrome action. The elg mutation partially suppresses the effect of GA-deficiency on elongation growth, and, although elg ga1 seedlings are more elongated than ga1 seedlings, both genotypes respond in the same way to applied GA. That applied GA and the elg mutation interact additively suggests that ELG acts independently of GA action.

Eicosanoid generating capacities of different tissues from the rainbow trout, Oncorhynchus mykiss

The eicosanoid generating potential of the brain, gills, skin, ovary, muscle, eye, liver, spleen, heart, and alimentary canal in the rainbow trout, Oncorhynchus mykiss, was examined. All the organs/tissues examined synthesized the 12-lipoxygenase products, 12-hydroxyeicosatetraenoic acid (12-HETE), and 12-hydroxyeicosapentaenoic acid (12-HEPE), implying the widespread nature of this enzyme in trout. Both prostaglandin E and LTC were also found in variable amounts in the organs, with the greatest amount of PGE found in the gill. Leukotriene (LT) B4 and LTB5 were found in supernatants from calcium ionophore-challenged brain, skin, ovary, liver, spleen, and heart, but the lipoxins A4 and A5 were only present in brain, ovary, and spleen in relatively small amounts. As lipoxins have previously been shown to be synthesized by macrophages in rainbow trout [Pettitt et al., J. Biol. Chem. 266, 8720-8726 (1991)], and related cells (microglial cells) are found in the brain of mammals, the localization of macrophage-like cells in trout brain was investigated immunocytochemically. Monoclonal antibodies specific for trout leucocytes failed to identify any microglial-like cells in sections of the brain, although microvessels containing immuno-positive reaction products were observed. A number of distinct lipoxygenase products were found in supernatants of ionophore-challenged gill, including 14-hydroxydocosahexaenoic acid, 12-HETE, and 12-HEPE, and a large number of dihydroxy fatty acid derivatives with conjugated triene chromophores. One of these products was tentatively identified as 8(R),15(S)-dihydroxyeicosatetraenoic acid, a dual 12- and 15-lipoxygenase product, but apparently no LTB4 was generated by this tissue.

Biochemical properties of a highly purified v-rasH p21 protein overproduced in Escherichia coli and inhibition of its activities by a monoclonal antibody

The v-rasH oncogene of Harvey murine sarcoma virus encodes a 21,000-dalton p21 protein which has been expressed at a high level as a fusion protein in Escherichia coli. We have purified the p21 to over 90% in purity without the use of any detergent or protein denaturant. The purified p21 possesses full biochemical activities of GTP/GDP binding, autokinase, and GTPase. Scatchard analysis indicates a single class of binding sites with Kd values of 0.83 X 10(-8)M for GTP and 1.0 X 10(-8)M for GDP. The binding site can be specifically labeled with a [3H]GTP photoaffinity analog, P3-(4-azidoanilido)-5' GTP. To probe for the active center of p21, we used a battery of six monoclonal antibodies to p21 to examine their effects on p21 activities. We found that only one monoclonal antibody, Y13-259, was capable of inhibiting both GTP/GDP binding and autokinase enzymatic activities, suggesting that these p21 activities are related activities conferred by a single active center within the p21 molecule. These observations together with the recent finding that microinjection of the same monoclonal antibody into NIH 3T3 cells specifically blocks p21 in vivo function (Mulcahy et al., Nature [London] 313:241, 1985) strongly suggest that p21 in vitro activities are responsible for its cellular function.

Persistent post-enteritis diarrhoea in childhood: a prospective analysis of clinical features, predisposing factors and sequelae

To investigate the incidence, pathophysiology and clinic determinants of persistent diarrhoea (more than seven days) after childhood gastroenteritis, we prospectively evaluated 168 consecutive patients admitted to the Royal Children's Hospital, Brisbane, with gastroenteritis. Thirty-two children (19%) developed persistent diarrhoea; only two-thirds of them had an identifiable aetiological factor, including di- or monosaccharide intolerance (31%), persisting or suspected pathogen (22%) and cow's milk protein intolerance. Computer aided analysis of risk factors in the preceding enteritis showed this complication to be more frequent in young age groups (P less than 0.01) where the patient was less than 10th percentile for weight (P les than 0.02); in Aboriginals (P less than 0.01); where there was a history of previous diarrhoea (P less than 0.001), delayed hospital admission (P less than 0.001) and antibiotic/antidiarrhoeal usage (P less than 0.05); and where there was a bacterial pathogen (P less than 0.001). Severity and outcome were variable with most cases requiring a defined formula diet. These findings provide some insight into the problem of persisting diarrhoea after gastroenteritis, aid identification of at risk patients, and suggest guidelines for management and prevention.