Bird's nest filter causing symptomatic hydronephrosis following transmural penetration of the inferior vena cava.

We report a case of symptomatic hydronephrosis caused by transcaval penetration of a Bird's Nest filter. Perforation of the wall of the inferior vena cava (IVC) following insertion of a caval filter is a well-recognized complication. Whilst two cases of hydronephrosis have been described with Greenfield filters, no case involving a Bird's Nest filter has been reported previously.

Improved ultrasound detection of renal scarring in children following urinary tract infection.

A system for defining renal scarring on ultrasound is proposed and compared with DMSA scintigraphy. Renal scarring was assessed with ultrasound in children following urinary tract infection (UTI) using the following criteria: (1) proximity of sinus echoes to cortical surface; (2) loss of pyramids; (3) irregularity of outline; (4) loss of definition of capsular echo; and (5) calyceal dilatation. Three hundred and thirty-nine consecutive ultrasound scans (US) and DMSA scintigrams, comprising 648 kidneys, were performed and reported blindly and the results were compared. Using DMSA scintigraphy as the gold standard, ultrasound had a positive predictive value of 93% and a negative predictive value of 95%. Ultrasound disagreed with DMSA scintigraphy in 5.2% of kidneys. On review of the cases of disagreement where arbitration was possible by comparison with other imaging, ultrasound was incorrect in 10 kidneys and DMSA was incorrect in 13. We conclude that the sensitivity in the ultrasound detection of renal scarring can be greatly improved using this method. If no scars were detected at ultrasound an alternative explanation for an abnormal DMSA scintigram should be sought.

The role of strategic visual attention in children's drawing development.

The many variables that affect the production of visually realistic drawings in children (such as instructions and contrasting models), have been widely documented in the research literature. The experiments reported here assess one variable that has been largely ignored, namely the attention that the child pays towards the drawing model. First, it was shown that the progression from intellectual to visual realism occurred between six and eight years of age, and was accompanied by a spontaneous increase in attention towards the drawing models. A second experiment showed that the drawing performance of the 6-year-olds was enhanced by contrasting tasks and explicit instructions. At all ages, explicit instructions increased attention towards the model, and the use of an efficient attentional strategy was associated with visually realistic drawings. These studies provide further evidence that intellectual and visual realism are not distinct developmental stages, but may instead reflect the use of different attentional strategies by children.

Outcome of antenatally detected cystic dysplastic kidney disease.

Forty four fetuses with multicystic dysplastic kidney (MCDK) disease recognised on antenatal ultrasound were studied prospectively. In nine aborted fetuses and in five who died in the neonatal period the MCDK disease was bilateral or there were associated lethal abnormalities or syndromes. All surviving infants had unilateral disease and in six (20%) there was significant reflux into the normal contralateral kidney. Since 1988 the management of unilateral MCDK disease has been conservative with no child developing sepsis, hypertension, or malignancy. Serial ultrasound examinations suggest that MCDK lesions involute with time and conservative rather than operative management is favoured.

Prospective study of aetiology and outcome of adult lower-respiratory-tract infections in the community.

Community-acquired adult lower-respiratory-tract infections (LRTI) are generally thought to be caused by atypical and viral infections. We have studied 480 adults presenting to a single general practice with community-acquired LRTI between November, 1990, and December, 1991. The overall incidence was 44 cases per 1000 population per year; the incidence was 2-4 times higher in people aged 60 and over than in those aged less than 50. 206 patients were studied in detail; among this group 91 (44%) had 113 pathogens identified. There were 92 bacteria (Streptococcus pneumoniae in 62 and Haemophilus influenzae in 16), 19 viruses (influenza virus in 12), and only 2 atypical pathogens (Mycoplasma pneumoniae and Coxiella burnetii). Pneumococcal infection was common in people who were 60 or older, those who had underlying chronic disease, or people with both features. There was moderate morbidity in terms of time in bed, time to return to normal activities, and days off work. 25% of patients returned for a second consultation with the general practitioner, in most because of unsatisfactory clinical progress. Community-acquired LRTI are very common, and the range of causative pathogens is similar to that for community-acquired pneumonia. Existing management strategies seem inadequate.

The radiographic differentiation of pulmonary oedema.

A radiographic scoring system has been reported to have a high diagnostic accuracy in the differentiation of pulmonary oedema of renal, cardiac and capillary origin. In the present study, a similar scoring system was used in 51 patients with radiographic appearances of pulmonary oedema due to renal failure (n = 16), cardiac failure (n = 13) and to adult respiratory distress syndrome (ARDS) (n = 22). Evidence of increased pulmonary capillary permeability to transferrin was sought in all patients using a double-isotope method to derive a protein accumulation index (PAI). Using the clinical diagnosis of each type of pulmonary oedema as the "gold standard", sensitivity, specificity and accuracy for the chest radiographic scoring system in pulmonary oedema of cardiac origin were 46, 84 and 75%, respectively. For renal patients these values were 63, 86 and 78% and for ARDS, 89, 33 and 77%. For the PAI in ARDS, sensitivity was 85%, specificity 67% and accuracy 86%. The radiographic scoring system failed to distinguish between pulmonary oedema of renal and cardiac origin and cannot be considered of diagnostic value, but it was more successful in assessment of ARDS. Radiographic appearances suggestive of capillary injury and increased capillary permeability to transferrin occurred in all groups and such findings are not specific to ARDS as currently defined.

Prospective study of the aetiology and outcome of pneumonia in the community.

A prospective one-year study of community pneumonia was conducted in Nottingham. 236 of 251 episodes of pneumonia (defined as an acute lower respiratory tract infection, for which antibiotics were prescribed, associated with new focal signs on examination of the chest) were investigated. Acute radiographic changes were present in 93 (39%). A pathogen was identified in 129 (55%) episodes, with Streptococcus pneumoniae, Haemophilus influenzae, and influenza viruses those most frequently identified. Mycoplasma pneumoniae was uncommon and infection with Legionella pneumophila was found in only 1 episode. Hospital admission was required in 52 (22%) episodes. 7 patients died (3%), all but one of the deaths occurring in patients who had been admitted to hospital. Pneumonia in the community is common but few people die of it. Initial antibiotic therapy should always cover S pneumoniae and H influenzae.

When should we request radionuclide brain scans in elderly patients?

The radionuclide brain scans performed on a gamma camera (GC scans) in 146 patients over 65 years of age during a 6-month period are reviewed. Forty-four scans (30.1%) were reported as showing an abnormality. Three patients subsequently underwent surgery and drug therapy was commenced in 11 cases. However, in most cases the GC scan proved unhelpful in the patients' management. The usage and role of GC scanning in elderly patients admitted with a neurological disorder is examined.

Comparative radiographic features of community acquired Legionnaires' disease, pneumococcal pneumonia, mycoplasma pneumonia, and psittacosis.

The features of the chest radiographs of 49 adults with legionnaires' disease were compared with those of 91 adults with pneumococcal pneumonia (31 of whom had bacteraemia or antigenaemia), 46 with mycoplasma pneumonia, and 10 with psittacosis pneumonia. No distinctive pattern was seen for any group. Homogeneous shadowing was more frequent in legionnaires' disease (40/49 cases) (p less than 0.005), bacteraemic pneumococcal pneumonia (25/31) (p less than 0.01) and non-bacteraemic pneumococcal pneumonia (42/60) (p less than 0.05) than in mycoplasma pneumonia (23/46). Multilobe disease at presentation was commoner in bacteraemic pneumococcal pneumonia (20/31) than in non-bacteraemic pneumococcal pneumonia (15/60) (p less than 0.001) or legionnaires' disease (19/49) (p less than 0.025). In bacteraemic pneumococcal pneumonia multilobe disease at presentation was associated with increased mortality. Pleural effusions and some degree of lung collapse were seen in all groups, although effusions were commoner in bacteraemic pneumococcal pneumonia. Cavitation was unusual. Lymphadenopathy occurred only in mycoplasma pneumonia (10/46). Radiographic deterioration was particularly a feature of legionnaires' disease (30/46) and bacteraemic pneumococcal pneumonia (14/27), and these groups also showed slow radiographic resolution in survivors. Radiographic resolution was fastest with mycoplasma pneumonia; psittacosis and non-bacteraemic pneumococcal pneumonia cleared at an intermediate rate. Residual intrapulmonary streaky opacities remained in over a quarter of survivors from legionnaires' disease (12/42) and bacteraemic pneumococcal pneumonia (5/19).

Removal of common bile duct stones after emergency drainage of the gall bladder.

Because of the hazards associated with cholecystectomy and choledochotomy in acute biliary tract disease, cholecystostomy may be performed as an emergency procedure. Postoperative tube cholangiography in such patients may show calculi in the biliary ducts. The percutaneous extraction of these calculi prior to cholecystectomy simplifies the elective surgical procedure.

Erythromycin compared with a combination of ampicillin and amoxycillin as initial therapy for adults with pneumonia including Legionnaires' disease.

In a double blind trial erythromycin was compared with a combination of ampicillin and amoxycillin for treating adults admitted to hospital with primary pneumonia. The clinical course of 42 patients treated with ampicillin and amoxycillin was similar to that of the 49 in the erythromycin group. Fall in temperature, symptomatic recovery and radiographic improvement were similar (two-thirds made an uncomplicated recovery). Infusion-related phlebitis was more common with erythromycin. Otherwise adverse reactions were unusual. The outcome was related principally to the cause of the pneumonia with bacteraemic/antigenaemic pneumococcal pneumonia, Legionnaires' disease, other bacterial pneumonias and psittacosis having a poor prognosis. Both forms of antibiotic therapy gave similar results but we suggest that a combination of erythromycin with ampicillin may be logical initial treatment for severe pneumonia of unknown cause.

Intermittent epidural morphine instillation for control of postoperative pain.

Opiates such as morphine have a direct spinal effect, acting at special receptor sites in the dorsal horn. When morphine is administered epidurally, it diffuses to the cord substance, producing analgesia of improved quality after a dose of 2 to 4 mg. A protracted analgesia is produced, compared with parenteral narcotics, with a median duration of effect of 12 hours in this series. Significant side effects are uncommon, but pronounced respiratory depression can occur late and careful observation is necessary. The first instance of paraplegia in association with epidural morphine anesthesia has been reported herein.

Observations in micturating cystourethrography.

Combined studies of micturating cystourethrography (MCU), bladder pressure and urinary flow rate measurements (urodynamic studies) have been analysed in 1584 adult patients of both sexes. The combined study is called a videocystometrogram (VCM). The simple MCU is satisfactory for demonstrating vesicoureteric reflux, but in the investigation of other problems of the lower urinary tract in adults, conclusions based on the MCU alone can be misleading. It is recommended that if the MCU is performed at all in the investigation of adult incontinence and suspected urinary outflow obstruction, it should be combined with a urodynamic study. This increases the examination time by about 50% but greatly improves the diagnostic accuracy, especially in establishing whether surgery is indicated or inappropriate.

Gall-stone dissolution and recurrence: are we being misled?

Oral cholecystography repeated at six-months intervals is the standard method for determining reduction in size of gall stones (partial success) and complete dissolution of stones (complete success). In a comparative study of oral cholecystography and cholecystosonography six out of 14 patients with gall stones achieving complete success by oral cholecystographic criteria had stones still detectable by ultrasonography. Repeat oral cholecystography in a further 11 patients receiving post-dissolution maintenance treatment detected stones in two, whereas ultrasonography detected stones in seven. In future complete dissolution of gall stones should be reported only if both oral cholecystography and ultrasonographic studies give negative results and the progress of patients receiving post-dissolution maintenance treatment is monitored by ultrasonography rather than serial oral cholecystography.

Intraductal infusion of mono-octanoin: experience in 24 patients with retained common-duct stones.

Mono-octanoin (glyceryl-l-mono-octanoate), 2-4 ml/h, was instilled into the bile or hepatic ducts of twenty-four patients with retained gallstones after cholecystectomy and choledochotomy. After treatment, fifteen patients no longer had stones. In five the stones were smaller or reduced in number; and in four of these the stones were extracted mechanically via the T-tube tract. Mechanical extraction was also possible in one of the four patients with unaltered stones. With a battery-operated pump or hand injection, mono-octanoin can be safely infused as early as the 8th postoperative day and some patients can continue the treatment outside hospital.