A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part I: Effects on pain.

INTRODUCTION: Neurogenic heterotopic ossification (NHO) is a complication of a neurological injury following traumatic brain injury (TBI) and may be present around major synovial joints. It is often accompanied by severe pain, which may lead to limitation in activities of daily living. Currently, a common intervention for NHO is surgery, which has been reported to carry many additional risks. This study was designed to assess the effect of extracorporeal shock wave therapy (ESWT) on pain in patients with TBI with chronic NHO. METHODS: A series of single-case studies (n = 11) was undertaken with patients who had TBI and chronic NHO at the hip or knee. Each patient received four applications of high-energy EWST delivered to the affected joint over 8 weeks. Two-weekly follow-up assessments were carried out, and final assessments were made 3 and 6 months post-intervention. Pain was measured using the Faces Rating Scale, and X-rays were taken at baseline and 6-months post-intervention to physiologically measure the size of the NHO. RESULTS: The application of high-energy ESWT was associated with significant overall reduction of pain in patients with TBI and NHO (Tau-0.412, 95% confidence interval -0.672 to -0.159, p = 0.002). CONCLUSIONS: ESWT is a novel non-invasive intervention for reducing pain resulting from NHO in patients with TBI.

Right internal carotid pseudoaneurysm mimicking a retropharyngeal abscess in a child.

A 7-year-old girl with tonsillar infection with antibiotics. Two weeks later, there was a right sided neck lump. Computed tomography scans demonstrated a predominantly hypodense right retropharyngeal area with peripheral enhancement and mass effect. There was intense enhancement within the postero-superior aspect of the lesion which was continuous with the right internal carotid artery. Ultrasound demonstrated tapering of the right internal carotid artery. Magnetic resonance imaging and magnetic resonance arteriography showed a right internal carotid artery pseudoaneurysm. Surgical exploration confirmed the finding. This case highlights an unusual presentation of an internal carotid pseudoaneurysm and how imaging provided the diagnosis.

Red flags in patients presenting with headache: clinical indications for neuroimaging.

Headache is a very common patient complaint but secondary causes for headache are unusual. Neuroimaging is both expensive and has a low yield in this group. Most patients with intracranial pathology have clinical features that would raise a "red flag". Appropriate selection of patients with headache for neuroimaging to look for secondary causes is very important. Red flags act as screening tools to help in identifying those patients presenting with headache who would benefit from prompt neuroimaging, and may increase the yield. The aim of this study is to evaluate clinical features in patients with headache using neuroimaging as a screening tool for intracranial pathology. 20 red flags were defined. A retrospective study of 111 patients was performed and the outcomes were divided into positive and negative. Abnormal neuroimaging was present in 39 patients. Results were analysed using the Logistic Regression model. Sensitivity and specificity of red flags were analysed to establish the cut-off point to predict abnormal neuroimaging and a receiver operating characteristic (ROC) curve plotted to show the sensitivity of the diagnostic test. Three red flag features proved to be statistically significant with the p-value of less than 0.05 on both univariate and multivariate analysis. These were: paralysis; papilloedema; and "drowsiness, confusion, memory impairment and loss of consciousness". In addition, if three or more red flags from the list were present, this showed strong indication of abnormal neuroimaging, from cut-off point of ROC curve (area under the curve =0.76).

High rates of Chlamydia trachomatis infections in young Papua New Guinean infants.

OBJECTIVE: Determine the importance of Chlamydia trachomatis in the etiology of severe infection in young Papua New Guinean infants. METHODS: Between March, 1991, and April, 1993, children <3 months old were recruited as outpatients at Goroka Base Hospital, Papua New Guinea, as part of a multicenter study in four developing countries. Children with predefined inclusion criteria were enrolled. C. trachomatis was identified by direct fluorescent antibody staining in nasopharyngeal aspirates (NPAs) collected from children with and without signs of severe disease and eye swabs from children with and without conjunctivitis. Two to three radiologists read chest radiographs without knowledge of clinical and laboratory findings. RESULTS: Of 3280 outpatients seen 2168 enrolled, 955 NPAs were tested for C. trachomatis and 549 chest radiographs were read. Of 210 eye swabs from children with conjunctivitis 57% were positive for C. trachomatis compared with 8% from 167 children with no conjunctivitis. The prevalence of C. trachomatis in NPAs was 9% in asymptomatic children and 18 and 33% in children with nonsevere or severe pneumonia, respectively. C. trachomatis in NPAs was strongly associated with clinically severe pneumonia [odds ratio (OR), 2.91], reduced arterial oxygen saturation (OR 2.58) and radiographic evidence of pneumonia (OR 5.84) and was also associated with pneumococcal bacteremia (OR 3.48). CONCLUSIONS: In Papua New Guinea Chlamydia must be considered as a cause when treating pneumonia in infants, and effective treatment and prevention of sexually transmitted diseases are urgently needed for a number of reasons, including the need to curb high rates of chlamydial infection in women and infants.

Glomerulocystic disease with hepatoblastoma in a neonate: a case report.

Glomerulocystic disease (GCD) is a very rare condition. Only two previous reports have linked this condition with hepatoblastoma. We report a neonate with US evidence of grossly enlarged echogenic kidneys and features typical of hepatic fibrosis, complicated by the presence of a hepatoblastoma. The report discusses the differential diagnosis and highlights GCD as one cause of large, bright kidneys on US. It also adds further evidence to the suggested association between GCD and hepatoblastoma.

Neonatal cranial ultrasound screening for intraventricular haemorrhage.

The cost effectiveness of performing routine neonatal cranial ultrasound scans to diagnose intraventricular haemorrhage (IVH) on cohorts of high risk infants is in question. In the early 1980s cranial ultrasound scans were performed on preterm infants to expand knowledge of the incidence, aetiology, pathogenesis and evolution of IVH. In many neonatal units high risk infants are scanned on days 5-7 and 10-14 and prior to discharge for extremely low birthweight (ELBW) infants. Cranial ultrasound scanning is often used as a surrogate for assessment of neurodevelopmental outcome with information from meta analyses used to counsel parents about the likelihood of subsequent neurosensory disability.

An investigation into perihilar inflammatory change on the chest radiographs of children admitted with acute respiratory symptoms.

PURPOSE: To determine the incidence, correlation with selected parameters and interobserver variability of radiographic perihilar inflammatory change (PIC) in previously well children under 3 years of age, who were hospitalized with acute respiratory symptoms. PATIENTS AND METHODS: A total of 113 previously well children under 3 years of age who were hospitalized with acute respiratory symptoms, and whose chest radiographs (CRGs) showed no focal pulmonary abnormality, were prospectively identified. The CRGs were read blindly by two radiologists. Each scored the degree of PIC on a five point scale as absent (0), borderline/equivocal/indeterminate (1), mild but definite (2), moderate (3) and severe (4). RESULTS: PIC was read as definitely present (mean PIC score greater than or equal to 2) in 65 (58%) patients. The mean PIC score correlated with overinflation (r = 0.45, P < 0.01) and patient temperature (r = 0.22, P < 0.05). The mean PIC score was significantly higher (2.1 vs 1.5, P < 0.01) in those receiving antibiotics (n = 69). It was also significantly higher (2.4 vs 1.7, P < 0.01) in those receiving supplemental oxygen (n = 26). PIC was not associated with duration of admission, presence of wheeze (n = 79), use of nebulized bronchodilators (n = 61) or RSV positivity (n = 32). The k value for interobserver variability indicated only fair agreement (k = 0.29) between the two readers on the five point scale and moderate agreement (k = 0.41) when the data was pooled into two groups (0 and 1 vs 2, 3 and 4). CONCLUSIONS: PIC is a common radiographic finding in children under 3 years of age who are hospitalized with acute respiratory symptoms. It is positively but weakly correlated with temperature, hyperinflation, antibiotic usage and supplemental oxygen administration. It is subject to substantial interobserver variability.

AIDS in Africa: what drugs do the carers want or need?

Our objectives were: (1) to discover requirements for treatment of patients with AIDS (PWAs) for health-care workers in eight English-speaking African countries; (2) to establish policies for supply of drugs, and develop a method for determining the contents of parcels (PWA-BOXes) for the relief of PWAs. Fifty-seven questionnaires were sent to non-government medical units treating PWAs, supplied by the charity Inter Care. Of these 37 units replied, two had no known PWAs, three were swamped by refugees; therefore, the total number analysed was 32. Only 24 units had access to HIV testing and the mean number of PWAs per unit was 58. The reported complications of AIDS were: diarrhoea 28 units; tuberculosis 27 units; pneumonia 28 units; sexually transmitted diseases 26; candidiasis 28 units; and herpes zoster 20. Lists of drug requirements were received. We present a protocol for calculation of contents of PWA-BOXes in the hope that this will provide guidelines for other workers in this field.

PIP: Inter Care, a UK charitable organization, provides essential drugs to 120 medical units in Africa. To upgrade support to units caring for substantial numbers of acquired immunodeficiency syndrome (AIDS) patients, Inter Care sent a questionnaire to 57 of its small rural hospitals and health and maternity units. Of the 37 units that returned the questionnaire, 24 reported access to human immunodeficiency virus (HIV) laboratory tests while another seven relied on clinical diagnostic methods. The number of AIDS patients treated per month ranged from 0 to 200 (mean, 50). Diseases and conditions most commonly associated with AIDS included diarrhea, pneumonia, candidiasis, tuberculosis, and sexually transmitted diseases. The most commonly used drugs were metronidazole, micronazole oral gel, and oxytetracycline. On the basis of these findings, Inter Care was able to modify the contents of AIDS boxes provided to its affiliates. An assumption was made that a patient with AIDS spends only two weeks in the hospital before death given the rapid progression of the disease in Africa. The drugs supplied vary according to specific requests and the type of facility, but seek to treat the AIDS-related conditions identified in the survey with the least expensive drug available. Also provided, depending on need, are HIV test kits and educational posters.

Early management and postnatal investigation of prenatally diagnosed hydronephrosis.

The prime objective of this study was to assess the benefits and practicalities of an investigation protocol to identify, follow-up and investigate fetal uropathies in a manner to maximize efficiency. Over a one-year-period, antenatal ultrasound examinations were performed on 4268 consecutive pregnancies. Eighty fetuses had renal tract dilatation; these were followed up postnatally according to the protocol; 17 had significant structural abnormalities requiring further follow-up. Hospital attendances were estimated to have been reduced by approximately 66% through the use of the protocol. The protocol for investigation and management of these patients is presented. The system implemented worked very smoothly and the subsequent findings and implications are discussed.

Ultrasound assessment of liver and kidney brightness in infants. Use of the gray-level histogram.

RATIONALE AND OBJECTIVES: Ultrasonic image analysis aims to provide information related to tissue histology. Routine ultrasonography uses subjective criteria for analysis. Quantitation of the image is expected to aid diagnosis and may be helpful in follow-up of pathology. The authors describe normal findings in infant liver and kidney. METHODS: Texture parameters derived from the gray-level histogram and the first order statistics from the ultrasound images of the liver, right kidney, and a tissue-mimicking phantom in 50 newborn infants were studied. RESULTS: A set of normal values for mean and standard deviation of the histogram for infant liver and kidney was established. Results of a time-related study indicate that in infants the liver is not a good internal standard for tissue characteristic comparison. CONCLUSIONS: The method described and results obtained provide a basis of normality for further studies of pathology in infant renal and hepatic disease.

Real time ultrasonography in the assessment of movement at the site of a scaphoid fracture non-union.

We investigated the use of real time linear ultrasonography in determining movement at a scaphoid fracture site in 27 patients with non-united scaphoid fractures. 24 of these patients had surgical treatment. Fracture movement was observed at the time of surgery and this was compared with the ultrasonographic findings. The technique proved to be 100% specific for visualization of movement at the fracture site and it was non-invasive. However, it was of no benefit in assessing proximal pole non-union.

Overlap in the clinical features of pneumonia and malaria in African children.

Pneumonia and malaria are common causes of childhood morbidity and mortality in many developing countries and simple guidelines have been proposed to facilitate their diagnosis by relatively unskilled health workers. We have studied children in The Gambia attending out-patient and under-five clinics with clinically suspected pneumonia (cough or difficulty in breathing and a raised respiratory rate) during periods of high or low malaria transmission. During a period of high malaria transmission, 33% of these children had radiological evidence of pneumonia (with or without malaria parasitaemia) compared to 38% who had malaria parasitaemia, no radiological evidence of pneumonia and no other obvious cause of fever. Corresponding figures during a period of low malaria transmission were 48% and 6% respectively. The clinical overlap between pneumonia and malaria has important implications for case management strategies and evaluation of disease-specific interventions in regions in which both pneumonia and malaria are prevalent.

The reliability of ultrasonographic assessment of neonatal hips.

Ultrasound scans were made of the hips of 209 neonates born consecutively over a two-week period. Of the 418 scans, 62 images were selected at random and 25 of these were duplicated to give a total of 87 scans. These static images were then presented to five experienced observers who each made nine different assessments and measurements. Interobserver and intraboserver agreement was calculated and expressed as kappa values. Our results showed poor reliability on both counts.

The effect of temperature reduction on respiratory rate in febrile illnesses.

A raised respiratory rate is a useful sign in the diagnosis of pneumonia in children. It was observed that children with malaria and other febrile illnesses may also present with a raised respiratory rate. To determine the extent to which increased body temperature contributes to the raised respiratory rate observed in these children the effect of change in body temperature on respiratory rate was measured in 186 sick Gambian children with a raised respiratory rate, including those with pneumonia or malaria. A temperature dependent effect on respiratory rate of 3.7 breaths per minute per degree centigrade was demonstrated for the whole study cohort, with no significant difference between children with pneumonia or malaria. Twenty three per cent of children with pneumonia whose temperature fell had a final respiratory rate below that currently recommended by the World Health Organisation for the diagnosis of pneumonia. It is concluded that respiratory rate is to some extent dependent on body temperature in children with febrile illnesses such as pneumonia and malaria, but that this does not alone account for the raised respiratory rate seen in these children. The effect of reduction in body temperature on respiratory rate does not help to distinguish children with pneumonia from those with malaria. A history of recent use of an antipyretic or other measures to control fever is important when evaluating children for possible pneumonia.