Are UK radiologists satisfied with the training and support received in suspected child abuse?

AIM: To determine current practice and perceptions of the adequacy of training and support received for the reporting of skeletal surveys in suspected physical child abuse. MATERIALS AND METHODS: A list of telephone numbers of UK hospitals with a radiology department was obtained from the Royal College of Radiologists. One hundred hospitals were then randomly selected for inclusion in the survey. An 18-item questionnaire was successfully administered to consultant radiologists from 84 departments. RESULTS: Sixty-one percent of departments had a named radiologist to report their skeletal surveys, 16% assigned surveys to a random radiologist, and 23% referred them elsewhere. Only 52% of departments had a dedicated paediatric radiologist, thus in a significant proportion of departments (25%) initial reports on skeletal surveys for physical abuse were provided by non-paediatric radiologists. Fifteen percent did not have ready access to a paediatric radiology opinion. Sixty-one percent thought that the service could be improved. Expert evidence was provided by 5% of respondents. Seventy-three percent would never consider providing expert evidence, even if given adequate radiology and/or legal training. CONCLUSION: The survey shows significant dissatisfaction amongst consultant radiologists with the current service, confirms a low number of paediatric radiologists taking on this work, and suggests the potential to increase numbers of radiology child abuse experts by 27% if given improved training and support. Appropriate service and education strategies should be implemented.

Refractory hypertension and sleep apnoea: effect of CPAP on blood pressure and baroreflex.

This study was undertaken to determine whether abolition of obstructive sleep apnoea (OSA) by continuous positive airway pressure (CPAP) could reduce blood pressure (BP) in patients with refractory hypertension. In 11 refractory hypertensive patients with OSA, the acute effects of CPAP on nocturnal BP were studied during sleep and its longer term effects on 24-h ambulatory BP after 2 months. During a single night's application, CPAP abolished OSA and reduced systolic BP in stage 2 sleep from 138.3 +/- 6.8 to 126.0 +/- 6.3 mmHg. There was also a trend towards a reduction in average diastolic BP (from 77.7 +/- 4.5 to 72.9 +/- 4.5). CPAP usage for 2 months was accompanied by an 11.0 +/- 4.4 mmHg reduction in 24-h systolic BP. In addition, both the nocturnal and daytime components of systolic BP fell significantly by 14.4 +/- 4.4 and 9.3 +/- 3.9 mmHg, respectively. Diastolic BP was reduced significantly at night by 7.8 +/- 3.0 mmHg. In patients with refractory hypertension, acute abolition of obstructive sleep apnoea by continuous positive airway pressure reduces nocturnal blood pressure. These data also suggest that continuous positive airway pressure may reduce nocturnal and daytime systolic blood pressure chronically. Randomised trials are needed to confirm the latter results.

High prevalence of unrecognized sleep apnoea in drug-resistant hypertension.

OBJECTIVES: To determine the prevalence of obstructive sleep apnoea (OSA) in adult patients with drug-resistant hypertension, a common problem in a tertiary care facility. DESIGN: Cross-sectional study. SETTING: University hypertension clinic. PATIENTS AND METHODS: Adults with drug-resistant hypertension, defined as a clinic blood pressure of > or = 140/90 mmHg, while taking a sensible combination of three or more antihypertensive drugs, titrated to maximally recommended doses. Each of the 41 participants completed an overnight polysomnographic study and all but two had a 24 h ambulatory blood pressure measurement. RESULTS: Prevalence of OSA, defined as an apnoea-hypopnoea index of > or = 10 obstructive events per hour of sleep, was 83% in the 24 men and 17 women studied. Patients were generally late middle-aged (57.2 +/- 1.6 years, mean +/- SE), predominantly white (85%), obese (body mass index, 34.0 +/- 0.9 kg/m2) and taking a mean of 3.6 +/- 0.1 different antihypertensive medications daily. OSA was more prevalent in men than in women (96 versus 65%, P = 0.014) and more severe (mean apnoea-hypopnoea index of 32.2 +/- 4.5 versus 14.0 +/- 3.1 events/h, P = 0.004). There was no gender difference in body mass index or age. Women with OSA were significantly older and had a higher systolic blood pressure, lower diastolic blood pressure, wider pulse pressure and slower heart rate than women without OSA. CONCLUSIONS: The extraordinarily high prevalence of OSA in these patients supports its potential role in the pathogenesis of drug-resistant hypertension, and justifies the undertaking of a randomized controlled trial to corroborate this hypothesis.

Nevus of Ota: a new classification based on the response to laser treatment.

BACKGROUND AND OBJECTIVE: For 60 years, Tanino's classification has been used to classify the extent of nevus of Ota. However, such classification not only fails to address variants such as phacomatosis pigmentovascularis but also cannot be used to predict the therapeutic outcome. Our objective is to retrospectively study our series of laser-treated patients with the aim of re-classifying nevus of Ota, so that such important issues can be taken into account. STUDY DESIGN/MATERIALS AND METHODS: One hundred nineteen patients that had received Q-switched laser treatment were recruited into the study. They were recalled for interview and examination for evidence of coexisting birthmarks and extracutaneous involvement. Two observers assessed the pre- and posttreatment clinical photographs for evidence of periorbital under-response (panda's sign), defined as the degree of periorbital laser clearing significantly less than clearing in the other area. RESULTS: A total of 47.8% of the patients with periorbital pigmentation were considered by the observers to have significant periorbital under-response (panda's sign). Additionally, 10.1% had other birthmarks, and extracutaneous involvement was seen in 31.4% of the patients. CONCLUSION: Periorbital under-response is commonly seen in patients with periorbital pigmentation. Taking this and other factors into consideration, we have proposed a new classification for nevus of Ota that allows for the prediction of the clinical outcome of laser treatment.

A retrospective analysis of complications in the treatment of nevus of Ota with the Q-switched alexandrite and Q-switched Nd:YAG lasers.

BACKGROUND: Studies on the use of Q-switched alexandrite (QS alex) and QS Nd:YAG lasers in the treatment of nevus of Ota were limited to case reports and small series. There was no study that looked at the complication rate of these systems. OBJECTIVE: To retrospectively study the complication rate of nevus of Ota patients that were treated with QS alex laser, QS Nd:YAG laser, or a combination of both. METHODS: The study was performed in a teaching hospital and a private hospital, where 513 patients with nevus of Ota had been treated since 1993. The 171 patients with 211 treatment sites were evaluated retrospectively following treatment with QS alex laser only (n = 58), QS Nd:YAG laser (n = 105) only, or a combination of both systems (n = 48). Patients were called back to be interviewed and examined by two independent clinicians to look for evidence of complications. RESULTS: Of the treatment sites, 15. 3% had hypopigmentation, 2.9% had hyperpigmentation, and texture changes and scarring were seen in 2.9% and 1.9%, respectively. The combined treatment group was associated with a significantly higher risk of complications. Thirteen patients had recurrence of their nevus after complete or near-complete clearance with laser treatment. CONCLUSION: Hypopigmentation is common after the use of QS laser for lightening of nevus of Ota. This particularly applies when alternate treatment with QS alex and QS Nd:YAG is used. Recurrence is an important issue and must be taken into consideration, especially when children are treated.

Long term treatment of refractory congestive heart failure by continuous positive airway pressure.

A 26-year-old woman developed congestive heart failure (CHF) secondary to idiopathic dilated cardiomyopathy. Despite aggressive pharmacological therapy, her disease progressed over the next year, causing massive edema and dyspnea at rest. Although a sleep study showed no clinically significant sleep apnea, she was treated with nocturnal continuous positive airway pressure (CPAP). Following application of CPAP, a remarkable improvement in her condition was observed, with resolution of her edema and alleviation of dyspnea. Left ventricular ejection fraction increased from 29% to 43% and left ventricular dimensions decreased. Previous studies have demonstrated that nocturnal CPAP exerts a number of favourable effects on cardiovascular function in patients with CHF who suffer from a coexisting sleep apnea disorder. This report illustrates that CPAP can also have beneficial long term effects on the failing heart even in the absence of clinically significant sleep apnea.

Entrainment of blood pressure and heart rate oscillations by periodic breathing.

Cheyne-Stokes respiration (CSR) is a form of periodic breathing associated with periodic oscillations in blood pressure (BP) and heart rate (HR), which have been attributed to hypoxia and arousals from sleep. We hypothesized that periodic alterations in ventilation alone would promote oscillations in BP and HR. Seven healthy, wakeful subjects breathed in three patterns, as follows: (1) regular breathing (RB); (2) periodic breathing with three (PB3: cycle frequency = 0.035 Hz) augmented breaths alternating with 20-s apneas; and (3) periodic breathing with five (PB5: cycle frequency = 0.030 Hz) augmented breaths alternating with 20-s apneas. SaO2 remained above 95% throughout. During periodic breathing, peaks in BP and HR occurred during the ventilatory period and troughs occurred during apnea. The magnitudes of systolic BP oscillations increased significantly from RB (14 +/- 5 mm Hg) to PB3 (20 +/- 4 mm Hg) and PB5 (25 +/- 7 mm Hg; p < 0.005). HR oscillations also increased from regular breathing (13 +/- 6.0 beats/min) to PB3 (20.2 +/- 2.3 beats/min) and PB5 (20.2 +/- 4.7 beats/ min; p < 0.01). Spectral analysis showed that during periodic breathing there were discrete peaks in the spectral power of ventilation, BP, and R-wave-to-R-wave interval at the periodic breathing cycle frequencies. We conclude that oscillations in ventilation occurring during periodic breathing can amplify and entrain oscillations in BP and HR in the absence of hypoxia or arousals from sleep.

Characterization of the mitochondrial inner membrane translocase complex: the Tim23p hydrophobic domain interacts with Tim17p but not with other Tim23p molecules.

Tim23p is a mitochondrial inner membrane protein essential for the import of proteins from the cytosol. Tim23p contains an amino-terminal hydrophilic segment and a carboxyl-terminal hydrophobic domain (Tim23Cp). To study the functions and interactions of the two parts of Tim23p separately, we constructed tim23N, encoding only the hydrophilic region of Tim23p, and tim23C, encoding only the hydrophobic domain of Tim23p. Only the Tim23C protein is imported into mitochondria, indicating that the mitochondrial targeting information in Tim23p resides in its membrane spans or intervening loops. Tim23Cp, however, cannot substitute for full-length Tim23p, suggesting that the hydrophilic portion of Tim23p also performs an essential function in mitochondrial protein import. We found that overexpression of Tim23Cp is toxic to yeast cells that carry the tim23-1 mutation. Excess Tim23Cp causes Tim23-1p to disappear, leaving tim23-1 cells without a full-length version of the Tim23 protein. If Tim17p, another inner membrane import component, is overexpressed along with Tim23Cp, the toxicity of Tim23Cp is largely reversed and the Tim23-1 protein no longer disappears. In coimmunoprecipitations from solubilized mitochondria, Tim17p associates with the Tim23C protein. In addition, we show that Tim23p and Tim17p can be chemically cross-linked to each other in intact mitochondria. We conclude that the hydrophobic domain encoded by tim23C targets Tim23p to the mitochondria and mediates the direct interaction between Tim23p and Tim17p. In contrast, Tim23Cp cannot be coimmunoprecipitated with Tim23p, raising the possibility that the hydrophobic domain of Tim23p does not interact with other Tim23 molecules.

The Tim54p-Tim22p complex mediates insertion of proteins into the mitochondrial inner membrane.

We have identified a new protein, Tim54p, located in the yeast mitochondrial inner membrane. Tim54p is an essential import component, required for the insertion of at least two polytopic proteins into the inner membrane, but not for the translocation of precursors into the matrix. Several observations suggest that Tim54p and Tim22p are part of a protein complex in the inner membrane distinct from the previously characterized Tim23p-Tim17p complex. First, multiple copies of the TIM22 gene, but not TIM23 or TIM17, suppress the growth defect of a tim54-1 temperature-sensitive mutant. Second, Tim22p can be coprecipitated with Tim54p from detergent-solubilized mitochondria, but Tim54p and Tim22p do not interact with either Tim23p or Tim17p. Finally, the tim54-1 mutation destabilizes the Tim22 protein, but not Tim23p or Tim17p. Our results support the idea that the mitochondrial inner membrane carries two independent import complexes: one required for the translocation of proteins across the inner membrane (Tim23p-Tim17p), and the other required for the insertion of proteins into the inner membrane (Tim54p-Tim22p).

Neutrophil zinc levels in psoriasis and seborrhoeic dermatitis.

The median zinc content of neutrophils was significantly reduced in 16 patients with psoriasis in comparison to both normal controls and six patients with seborrhoeic dermatitis (P less than 0.05). This reduction was unrelated to the extent of skin involvement. Plasma and erythrocyte zinc levels were unchanged.

Aplasia cutis congenita presenting as a familial triad of atrophic alopecia, ocular defects and a peculiar scarring tendency of the skin.

We report two siblings with atrophic alopecia, ocular defects and an abnormal tendency to cutaneous scarring. To our knowledge this appears to be the first report of this familial oculocutaneous association and of this peculiar cutaneous scarring.