Are abusive fractures in young children becoming less common? Changes over 24 years.

OBJECTIVE: To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children. METHODS: Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979-1983, 1991-1994, and 1999-2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR). RESULTS: In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period (p<.001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI=.15, .62) for the middle group and .45 (95% CI=.23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI=.69, 3.08). CONCLUSIONS: The proportion of abusive fractures in young children decreased substantially from 1979-1983 to 1991-1994 and 1999-2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.

Warm or cold contrast medium in the micturating cystourethrogram (MCUG): which is best?

AIM: The purpose of this study was to determine what difference using room temperature ("cold") or body temperature ("warm") contrast medium had on the outcome of MCUG examinations in infants under 1 year of age. MATERIALS AND METHODS: One hundred infants (50 males and 50 females) referred for an MCUG were identified. Individuals with known bladder neuropathy were excluded. Each was randomized to receive either warm or cold contrast medium. The screening time, volume of contrast instilled, number of attempts at voiding, patient distress, completeness of bladder emptying and incidence of reflux were measured and the results between the two groups compared. RESULTS: No difference was found between the two groups with regards to screening time, volume of contrast instilled or number of attempts at voiding. There was a statistically significant (p<0.05, chi square) difference in distress levels, with more children crying during instillation of cold contrast medium than warm. Bladder emptying was more often to completion when using cold contrast medium (32 compared with 16%), and vesicoureteric reflux (VUR) was more commonly demonstrated when using warm contrast medium (16 compared with 6%), although these values did not reach statistical significance. CONCLUSION: Warm contrast medium causes significantly less distress than cold contrast medium, but does not prolong screening time or increase the volume of contrast required.

Paediatric manifestations of Langerhans cell histiocytosis: a review of the clinical and radiological findings.

Langerhans cell histiocytosis is a rare disease in children. However, its ability to present in many ways, to mimic other conditions, and to manifest itself in many organs makes it a fascinating disease for radiologists. This article reviews the history of the disease, the features that are most useful in determining prognosis, and the various radiological findings seen in paediatric patients.

"Low-risk" prediction rule for pediatric oncology patients presenting with fever and neutropenia.

PURPOSE: To prospectively derive and validate a clinical prediction rule to allow a more tailored approach to the management of pediatric oncology outpatients presenting with fever and neutropenia. PATIENTS AND METHODS: The clinical prediction rule was derived over a 1-year period and then validated over the following 8 months in a new set of fever and neutropenia episodes. Patients were excluded if they presented with comorbidity or an abnormal chest x-ray (CXR). RESULTS: Significant bacterial infection (SBI; defined as any blood or urine culture positive for bacteria, interstitial or lobar consolidation on CXR, or unexpected death from infection) was documented in 43 of the 227 episodes. Multivariate analysis found four significant factors: bone marrow disease, general appearance unwell on initial examination, monocyte count less than 0.1 x 10(9)/L, and peak oral or oral equivalent temperature greater than 39 degrees C. Only the monocyte count contributed to determining a low-risk group, excluding SBI with 84% sensitivity (95% confidence interval [CI], 61% to 100%), 42% specificity (95% CI, 38% to 46%), and a negative predictive value of 92% (95% CI, 76% to 100%). If the monocyte count was >/= 0.1 x 10(9)/L at the time of presentation (low risk), the incidences of SBI and bacteremia were 8% and 5%, respectively, versus 25% and 17% in the high-risk group. When validated in a new population of 136 episodes of fever and neutropenia, the incidences of SBI and bacteremia in the low-risk group were 12% and 5%, respectively, and 25% and 19% in the high-risk group. CONCLUSION: Pediatric oncology outpatients with fever and neutropenia who present with an initial monocyte count of >/= 0.1 x 10(9)/L and do not have comorbidity or an abnormal CXR at the time of presentation are at lower risk for SBI and can be considered for less aggressive initial therapy.

Ultrasound detection of pneumothorax.

OBJECTIVE: To determine the accuracy of ultrasound in the detection of pneumothorax. METHODS: Prospective blinded study comparing ultrasound, CT and radiographic findings in 29 patients following 41 CT-guided lung biopsies. Ultrasound examination of the chest was limited to the biopsy needle entry site. RESULTS: Thirteen patients developed a post-biopsy pneumothorax demonstrated by CT. Seven of these were detected by ultrasound and six were visible on erect chest radiographs. Six of the 13 pneumothoraces were not detected by ultrasound, but five of these were loculated away from the biopsy needle entry site and were therefore in areas not examined during the limited ultrasound examination. There were no false-positive diagnoses of pneumothorax using ultrasound. The positive predictive value for ultrasound was 100% and the negative predictive value was 82%. CONCLUSION: In this patient group, ultrasound was more sensitive than erect chest radiography in the detection of pneumothorax. Both have a specificity of 100%. This study suggests that ultrasound may prove valuable in pneumothorax detection when rapid conventional radiography is not possible or practical, and in circumstances where ultrasound is readily available, such as during ultrasound-guided interventional procedures.

Paediatric xanthogranulomatous pyelonephritis.

Xanthogranulomatous pyelonephritis (XGP) is a well recognised but rare type of chronic pyelonephritis classically occurring in middle-aged women. It is increasingly being recognised in children in whom it can be mistaken for Wilms' tumour. Awareness of the possibility of this condition occurring in children may allow early recognition and possible treatment. Two cases of XGP in children are described and the literature reviewed.