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.

Getting it right first time in radiology.

Getting it Right First Time (GIRFT) is a national programme designed to improve medical care in the National Health Service (NHS) in England by reducing unwarranted variation. By tackling variation in the way services are delivered across the NHS and by sharing best practice, GIRFT identifies changes that will help improve care and patient outcomes as well as delivering efficiencies.

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.

Evaluation of paediatric radiology services in hospitals in the UK.

AIM: To compare paediatric radiology provision across the UK with national standards published by the Department of Health and the Royal College of Radiologists (RCR). MATERIALS AND METHODS: Audit standards and indicators for paediatric imaging were derived from "Delivering quality imaging services for children",1 "Standards for imaging in cases of suspected non-accidental injury"2 and "Improving paediatric interventional radiology services"3 and agreed jointly by the Clinical Radiology Audit Committee and the British Society of Paediatric Radiology. A questionnaire was sent to all hospitals and NHS trusts imaging children aged 16 or younger in the UK in October 2013. The target for all indicators was 100%. Eighty-seven of 196 (44%) eligible institutions submitted data, the size distribution of the institutions was representative when compared to data from "Facing the future: a review of paediatric services"4 published by the Royal College of Paediatrics and Child health. RESULTS: Only 65% of paediatric images were obtained by staff who had had specific training and only 60% were reported by radiographers or radiologists with appropriate training. Sixty-two percent of centres did not have access to a paediatric opinion 24 hours a day, 7 days a week all year; only 34% of radiographers who regularly imaged children had had any access to continuing professional development (CPD) in the 12 months of the audit. Although all hospitals had facilities for image transfer, only 57% had any formal funding arrangements in place for external reporting of images. CONCLUSIONS: The standards set for a network approach to paediatric radiology provision in "Delivering quality imaging services for children" are largely unmet. This failure to make the most of the workforce and resources puts vulnerable children at risk. The authors urge NHS England to work with the RCR to organise and administer a national network for paediatric imaging.

Dating fractures in infants.

AIM: To document the timing of the appearance of the radiological features of fracture healing in a group of infants in which the date of injury was known and to assess the degree of interobserver agreement. MATERIALS AND METHODS: Three paediatric radiologists independently assessed 161 images of 37 long bone fractures in 31 patients aged 0-44 months. The following features were assessed: soft-tissue swelling, subperiosteal new bone formation (SPNBF), definition of fracture line, presence or absence of callus, whether callus was well or ill defined, and the presence of endosteal callus. RESULTS: Agreement between observers was only moderate for all discriminators except SPNBF. SPNBF was invariably seen after 11 days but was uncommon before this time even in the very young. In one case SPNBF was seen at 4 days. CONCLUSION: With the exception of SPNBF, the criteria relied on to date fractures are either not reproducible or are poor discriminators of fracture age.

Radiological features of Meckel's diverticulum and its complications.

Meckel's diverticulum is the most common congenital abnormality of the small bowel. The majority of patients with this anomaly will remain asymptomatic; however, several complications may occur, including obstruction, intussusception, perforation, diverticulitis, and gastrointestinal haemorrhage. These complications may produce a variety of different clinical features and radiological appearances. The purpose of this article is to review the potential imaging manifestations of Meckel's diverticulum and its complications and discuss the advantages and disadvantages of the imaging techniques available.

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.

Cervical spine injuries to children under 11: should we use radiography more selectively in their initial assessment?

OBJECTIVES: To assess the effectiveness of cervical spine radiography in injured children under 11 years old, and suggest improvements. METHODS: Retrospective survey of radiographs and accident and emergency records for children examined during a one year period in a large teaching hospital. RESULTS: No cervical spine fractures occurred in this age group during the year. The recorded clinical findings did not always justify radiography. CONCLUSIONS: Clinical examination appears undervalued by those assessing injured children and is poorly recorded. Radiography can be used more selectively. Initial assessment using a single lateral projection can be followed in doubtful cases by cross sectional imaging.

Infection of murine keratinocytes with herpes simplex virus type 1 induces the expression of interleukin-10, but not interleukin-1 alpha or tumour necrosis factor-alpha.

Herpes simplex virus (HSV) is known to possess several mechanisms whereby it can evade the normal host immune defences. In this study the expression of the immunosuppressive cytokine, interleukin (IL)-10, was monitored following infection of a murine keratinocyte cell line (PAM-212) and compared with the expression of two proinflammatory cytokines: IL-1 alpha and tumour necrosis factor (TNF)-alpha. The PAM-212 cells were infected at a multiplicity of 0.5 with a clinical isolate of HSV type 1, and the mRNA of the three cytokines was assessed by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) over the following 24 hr. By 12 hr postinfection the amount of IL-10 mRNA had increased significantly to five-fold greater than that found in uninfected cells (P < 0.01), and this elevated level was maintained until at least 24 hr postinfection. In contrast, IL-1 alpha and TNF-alpha mRNAs were not significantly up-regulated by the HSV infection. Immunostaining with an IL-10 monoclonal antibody (mAb) revealed that cytoplasmic IL-10 protein had increased by 6-12 hr postinfection. This quantity was further increased at 24 hr postinfection, when the viral cytopathic effect was apparent. Viral replication was necessary, but not sufficient on its own, for IL-10 induction. Experiments with HSV mutants lacking functional transactivating factors suggested that the viral transactivating proteins ICP-0 and VP-16 may be necessary for HSV-induced IL-10 expression. Thus, the up-regulation in the expression of IL-10 mRNA and protein induced by HSV early in the infection of keratinocytes represents a specific response and may be part of the viral strategy to avoid local immune defence mechanisms in the skin.

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.

SRL1: a new locus specific to the phyB-signaling pathway in Arabidopsis.

As part of an effort to isolate new Arabidopsis mutants specifically defective in responsiveness to red light, we identified srl1 (short hypocotyl in red light) by screening an EMS-mutagenized M2 population derived from a phytochrome B (phyB)-overexpressor line (ABO). The srl1 mutant shows enhanced responsiveness to continuous red but not far-red light, in both wild-type and ABO backgrounds, consistent with involvement in the phyB-signaling pathway but not that of phyA. The hypersensitive phenotype of srl1 is not due to overexpression of endogenous phyA or phyB, and the locus maps to the center of chromosome 2, distinct from any other known photomorphogenic mutants. srl1 seedlings display enhancement of several phyB-mediated responses, including shorter hypocotyls, more expanded cotyledons, shorter petioles and modestly higher levels of CAB gene expression under red light than the wild type. Double mutant analyses show that the hypersensitive phenotype of srl1 is completely phyB-dependent. The data suggest, therefore, that SRL1 may encode a negatively acting component specific to the phyB-signaling pathway.

poc1: an Arabidopsis mutant perturbed in phytochrome signaling because of a T DNA insertion in the promoter of PIF3, a gene encoding a phytochrome-interacting bHLH protein.

The phytochrome family of informational photoreceptors has a central role in regulating light-responsive gene expression, but the mechanism of intracellular signal transduction has remained elusive. In a genetic screen for T DNA-tagged Arabidopsis mutants affected in early signaling intermediates, we identified poc1 (photocurrent 1), which exhibits enhanced responsiveness to red light. This phenotype is absent in a phyB (phytochrome B) null mutant background, indicating that the poc1 mutation enhances phyB signal transduction. The T DNA insertion in poc1 was found to be located in the promoter region of PIF3, a gene encoding a basic helix-loop-helix protein. The mutant phenotype seems to result from insertion-induced overexpression of this gene in red-light-grown seedlings, consistent with PIF3 functioning as a positively acting signaling intermediate. These findings, combined with data from a separate yeast two-hybrid screen that identified PIF3 as a phytochrome-interacting factor necessary for normal signaling, provide evidence that phytochrome signal transduction may include a direct pathway to photoresponsive nuclear genes via physical interaction of the photoreceptor molecules with the potential transcriptional regulator PIF3.

Photomophogenesis: Phytochrome takes a partner!

How light signals are transduced by phytochromes is still poorly understood. Recent studies have provided evidence that a PAS domain protein, PIF3, physically interacts with phytochromes, plays a role in phytochrome signal transduction and might be a component of a novel signalling pathway in plants.

Overexpression of rice phytochrome A partially complements phytochrome B deficiency in Arabidopsis.

The red/far-red reversible phytochromes play a central role in regulating the development of plants in relation to their light environment. Studies on the roles of different members of the phytochrome family have mainly focused on light-labile, phytochrome A and light-stable, phytochrome B. Although these two phytochromes often regulate identical responses, they appear to have discrete photosensory functions. Thus, phytochrome A predominantly mediates responses to prolonged far-red light, as well as acting in a non-red/far-red-reversible manner in controlling responses to light pulses. In contrast, phytochrome B mediates responses to prolonged red light and acts photoreversibly under light-pulse conditions. However, it has been reported that rice (Oryza sativa L.) phytochrome A operates in a classical red/far-red reversible fashion following its expression in transgenic tobacco plants. Thus, it was of interest to determine whether transgenic rice phytochrome A could substitute for loss of phytochrome B in phyB mutants of Arabidopsis thaliana (L.) Heynh. We have observed that ectopic expression of rice phytochrome A can correct the reduced sensitivity of phyB hypocotyls to red light and restore their response to end-of-day far-red treatments. The latter is widely regarded as a hallmark of phytochrome B action. However, although transgenic rice phytochrome A can correct other aspects of elongation growth in the phyB mutant it does not restore other responses to end-of-day far-red treatments nor does it restore responses to low red:far-red ratio. Furthermore, transgenic rice phytochrome A does not correct the early-flowering phenotype of phyB seedlings.

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.

Differential effect of phototherapy on the activities of human natural killer cells and cytotoxic T cells.

Exposure to ultraviolet B (UV-B) light is recognized to induce suppression of certain immune responses, particularly delayed hypersensitivity. However, its effect on cytotoxic T lymphocyte (CTL) activity, of major importance in the resistance to viruses and tumours, has not been assessed to the same extent. In this study five normal subjects, seropositive for herpes simplex virus (HSV), underwent a standard course of broadband UV-B therapy, as used in the treatment of psoriasis. They received whole-body irradiation thrice weekly for four weeks with incremental doses dependent on skin type. Blood samples were taken immediately before, at two time points during, and at the end of the therapy. An HSV-specific CTL assay was performed using autologous B cells transformed with Epstein-Barr virus as targets. No consistent modulation in CTL activity was obtained as a result of the therapy. The CTLs were separated into CD4 and CD8 subsets by positive selection and, again, no effect of irradiation on CTL activity within each of these two populations was observed. In contrast, the natural killer (NK) cell activity, assessed by the lysis of K562 cells, was significantly reduced at the first time point after the initiation of the phototherapy in all five subjects, and it continued to decline as the treatment progressed. Thus a differential effect of UV-B exposure on cytotoxic activity has been demonstrated: the HSV-specific CTL response is unchanged, while the NK response is suppressed.