Should GPs have direct access to imaging for children with urinary tract infections? An observational study.

BACKGROUND: All children with urinary tract infections (UTIs) should undergo imaging of the urinary tract. The Royal College of Radiologists currently recommends that such children should be referred to a paediatric specialist prior to imaging. AIM: To investigate whether direct referral of such children by general practitioners (GPs) for imaging offers advantages over the traditional approach. METHOD: Information on 100 children with UTIs, who were referred direct for imaging by GPs according to an agreed protocol, was compared with information on 100 children with UTIs referred initially to paediatric specialists. RESULTS: Protocol-guided direct referral resulted in less delay prior to imaging, no evidence of inappropriate referral (as judged by urinalysis and yield from imaging), greater consistency of follow-up arrangements, and a considerable saving in outpatient department (OPD) appointments. There was no increase in the overall number of referrals for imaging. CONCLUSION: Given agreed protocols, there is no basis for current recommendations that GPs should not refer children with UTIs for imaging without a prior paediatric opinion.

Early phase wound healing by primary intention as shown by ultrasonography.

We present a series of high-resolution ultrasound images obtained during healing in children of appendicectomy wounds by primary intention. These show that the incision can easily be identified for several months after surgery although skin swelling subsides rapidly. Fluid collections and gas are not usually seen in uncomplicated appendicectomy wounds, whereas some degree of oedema and exudation can be expected in the first few days post-operatively and suture material can be identified for six to eight weeks. Some knowledge of the normal appearance of these wounds is clearly of help when investigating wounds in which complications are suspected. The normal features of ultrasound images of healing abdominal wall incisions in uncomplicated appendicectomy are demonstrated. This knowledge should assist in interpretation of abnormal findings when healing does not progress as expected.

The effect of wound dressings on diagnostic ultrasound imaging.

A study was carried out to determine the effect of wound and fixation dressings on diagnostic ultrasound imaging. Each dressing was scanned with four ultrasound probes at two focal depth settings and the results were independently rated by five observers on a scale of 0-5. Data were analysed using the Chi-squared test and Pearson's correlation coefficient for inter-observer rating. The effect of the dressings was found to be independent of focal depth. Three probes produced similar results while the C7-4 curved array probe produced images affected by the dressings to a significantly greater extent. The total score for each dressing allows ranking according to lucency and demonstrates that hydrogel, thin film, and tulle gras dressings have the smallest effect on diagnostic ultrasound images, whereas dressings which are dense or contain air allow poor ultrasound penetration. It is suggested that, where diagnostic ultrasound is likely to be required in patients with wounds, traditional gauze-and-tape dressings should be avoided wherever possible as modern alternatives are available which meet the requirements of the wound while allowing the ultrasound system to produce a useful image.

The use of a metal detector to locate ingested metallic foreign bodies in children.

OBJECTIVE: A pilot study to assess whether modern metal detectors can reduce unnecessary radiation in searching for ingested metallic foreign bodies. METHODS: Over a one year period, 20 children presenting to an accident and emergency department with suspected metallic foreign body ingestion were studied. Using an Adams Electronics AD15 metal detector, the radiographer recorded the location of metallic foreign bodies on a pictorial representation of neck, chest, and abdomen. The child then had plain radiographs of abdomen, chest, and neck in sequential order until the foreign body was located. RESULTS: In seven cases neither metal detector nor radiography revealed a foreign body (true negatives). In the remaining 13 cases where metal detection was positive, subsequent radiography or faecal search was also positive (true positives). The 13 foreign bodies were coins (8), gold ring (1), ball bearing (1), screw (1), staple (1), and washer (1). All were in the stomach or proximal small bowel on radiography except for one coin in the right iliac fossa. CONCLUSIONS: The detector can demonstrate ingested metallic foreign bodies reliably in children, thereby reducing unnecessary irradiation.

Late pulmonary scintigraphic defects after uneventful recovery from simple focal pneumonia of childhood.

We present a pilot study designed to determine whether pneumonia in children accompanied by focal consolidation on the chest radiograph (CXR) is associated with late abnormality as detected by radionuclide lung scintigraphy. 14 children with focal pneumonia were assessed 1 year after initial presentation. In 12 both krypton-81m ventilation and technetium-99m MAA perfusion studies were performed, while in two only perfusion studies were obtained. All cases had a further CXR. Abnormal or equivocal cases were reviewed clinically. Scans and CXRs were independently assessed by two observers and subsequently consensus reached by discussion. There were five abnormal and nine normal lung scans. Two defects matched the site of the initial pneumonia while three did not. A CXR at the time of lung scanning was normal except for one case with a small focus of consolidation on the opposite side to the initial pneumonia but with a normal lung scan. Similarly, clinical assessment at the time of scanning was unremarkable, with no history of further respiratory episodes except in one child excluded from the study because of an interval diagnosis of asthma. This pilot study indicates that lung scan defects are common in the medium term after supposedly uncomplicated pneumonia in childhood. The cause of these defects remains uncertain. The correlation with the site of the initial radiological abnormality is variable, pointing to the need for further research in this area. The importance of independent blind interpretation is also highlighted.

Initial investigation of childhood urinary tract infection: does the plain abdominal X ray still have a role?

To reassess the plain abdominal X ray (AXR) in the initial investigation of childhood urinary tract infection, radiologists from four paediatric units prospectively collected data on the yield from the AXR in 683 children. Five children had renal calculi. All were detected on ultrasound, but one was not visible on the initial AXR. Four spinal abnormalities were identified, none of which prompted any action by the clinician involved. While the costs, in both financial and radiation risk terms, may be small, the benefit of the AXR appears equally small. Where expert paediatric ultrasonography is available we would recommend that the AXR be reserved for patients with haematuria, loin pain, family history of calculus disease, or where further urinary tract infection occurs despite a normal ultrasound scan.

Paediatric parapneumonic effusions: a review of 16 cases.

Over a 2-year period, 16 children with parapneumonic effusions were identified at the Royal Alexandra Hospital for Sick Children, Brighton. The case notes of these children were retrospectively reviewed. The presenting symptoms caused diagnostic confusion in two children resulting in negative laparotomies. Isolation of the infecting organism from the parapneumonic group was comparable to other authors, 6 out of 16 patients (53%); however, when the yield from pleural aspirates is compared, there was only one positive culture out of six (17%). Possibilities for improving this disappointing isolation rate are discussed. Two children with the longest history of symptoms and shortest chest drainage time had long term problems. Diagnostic tap, which carries little risk, and drainage, if required, should be performed early.

Renal sonography in long standing Lesch-Nyhan syndrome.

The Lesch-Nyhan syndrome is an x-linked defect of purine metabolism resulting in its classical form in major neurodevelopmental abnormality, hyperuricaemia, and hyperuricosuria. Uric acid calculi and crystalluria are common. Allopurinol is the main method of reducing serum and urinary uric acid levels, but results in xanthinuria and oxypurinoluria, both of which may cause crystal nephropathy and calculi. The variable ultrasonic appearances of multiple calculi and increased medullary echogenicity in four cases of long-standing treated disease and the nature of the renal disorder, which is at least partially iatrogenic, are described.

Long term follow up after inhalation of foreign bodies.

The long term results of treatment of inhalation of foreign bodies in a district children's hospital and in a tertiary referral centre were reviewed by clinical assessment, chest radiography, and standard four view 81mKr ventilation/99mTc macroaggregated albumin perfusion imaging (V/Q lung scan). The overall incidence in the population served by the district hospital was roughly one in 14,000/year. Of the 12 children reviewed there, three had abnormal chest radiographs and four had abnormal V/Q scans as a result of inhalation of the foreign bodies. Of 21 children treated and reviewed at the referral centre, eight had abnormal chest radiographs, and 14 had abnormal V/Q lung scans. Three factors were assessed for prognostic importance: site of impaction, initial radiographic appearance, and time before removal. A child who had inhaled a foreign body into the left lung and who had collapse/consolidation on the initial chest radiograph was at greatest risk of long term complications. These children merit close follow up.

Ultrasound in intussusception: a false cystic lead point.

Lead point lesions are very rarely suspected during ultrasound (US) investigation of intussusception. We report a case of idiopathic intussusception where US suggested a cystic lead point. At operation there was no structural abnormality but fluid was noted to be trapped within intussuscepted mesentery. The incidence of 'non-idiopathic' or 'secondary' intussusception is 5-6% with Meckles diverticulum being numerically the most important single entity. The lead point is only rarely identified on ultrasound. A large Chinese series of 377 cases of diagnosis and reduction of paediatric intussusception under US control [1] makes no mention of ultrasonic identification of a secondary cause in any of their cases. A European series of 145 cases [2] noted a causative lesion in 8 (5.6%), of which 2 (lymphoma, intestinal duplication) were identified during the ultrasound study. Adamsbaum [3] recently published a case of an enterogenous cyst as a lead point identified on ultrasound. We present a case with very similar ultrasonic features but which at operation was found to represent fluid trapped within the intussuscepted mesentery rather than a true cystic lead point.

Mineral balance studies in sick preterm intravenously fed infants during the first week after birth. A guide to fluid therapy.

Mineral balance studies were performed in 61 sick preterm infants given parenteral fluids only. Their gestational ages varied from 24 to 35 weeks, and 50 required mechanical ventilation. Two consecutive balance studies were performed; the first from admission to 48 hours in all babies given maintenance fluids of 10% Dextrose, and the second from 48 hours to 7 days in those babies given intravenous feeding (IVN). At the beginning and end of each balance period, the baby was weighed and an arterial blood sample taken for blood gases, electrolyte, urea, creatinine and protein determinations. During the balance period all urine was collected and analysed for electrolyte, urea, and creatinine composition, and all fluid intake was recorded. The balance of a mineral was calculated as the difference between parenteral intake and urine output. Infants requiring IVN were allocated alternatively to regimen X or regimen Y, which had the same calcium content of 9.5 mmol/L, but different phosphate contents, regimen X containing 7.3 mmol/L and regimen Y 11.6 mmol/L. In those infants requiring prolonged IVN, 12-24 hour balance studies were performed at weekly intervals after day 10. 1. Phosphate deficiency developed in infants given regimen X, who had higher urine calcium excretion, lower percentage calcium retention and lower plasma phosphate levels than those given regimen Y. These differences were apparent by day 7 and persisted after day 10. In infants given regimen Y, mean calcium retention from admission to day 7 was 3.9 mmol/kg, and after day 10 was 0.9 mmol/kg/day. 2. In the first 48 hours, urine output and creatinine clearance varied widely and were lower in infants with higher oxygen requirements at 48 hours. Ten babies had severe oliguria with outputs less than 10 mL/kg/day. Creatinine clearance was directly related to gestational age, mean arterial blood pressure, and plasma protein concentrations on admission. After 48 hours, urine output and creatinine clearance increased considerably. 3. In the first 48 hours, metabolic acidosis was produced by increased plasma non-protein metabolisable acid concentrations, which were associated with low creatinine clearances, and were thought to be due to lactic acid accumulation in response to decreased tissue perfusion. At 7 days, metabolic acidosis was of similar severity but was produced by decreased plasma non-metabolisable base concentrations, caused by increased urine loss of net base, and not directly by IVN.(ABSTRACT TRUNCATED AT 400 WORDS)

Frusemide-induced nephrocalcinosis in very low birth weight infants.

Three very low birth weight infants, treated with frusemide for broncho-pulmonary dysplasia are described. They all developed medullary nephrocalcinosis identifiable by real time ultrasound. The sonographic findings of diffuse medullary hyper-echogenicity appears to be specific for nephrocalcinosis.

The renal parenchymal junctional line in children: ultrasonic frequency and appearances.

The kidneys of 72 children were examined ultrasonically to determine the frequency of visualisation of the parenchymal junctional line (PJL), its variation with age and its ultrasonic appearances. The PJL was seen in 47 cases, usually on the right side. No statistical variation in the frequency of visualisation with age has been established. The usual appearance is of a thin, echogenic, linear structure running from the renal sinus to the cortex in an antero-superior direction. It is believed to originate from a layer of connective tissue which is trapped when a proportion of kidneys form from the fusion of two metanephric elements. The PJL is a common ultrasonic finding in a normal child's kidney and should never be confused with a pyelonephritic scar.