Variable interpretation of ultrasonograms may contribute to variation in the reported incidence of white matter damage between newborn intensive care units in New Zealand.

BACKGROUND: The incidence of cerebral white matter damage reported to the Australian and New Zealand Neonatal Network (ANZNN) varies between neonatal intensive care units (NICUs). HYPOTHESIS: Differences in the capture, storage, and interpretation of the cerebral ultrasound scans could account for some of this variation. METHODS: A total of 255 infants of birth weight <1500 g and gestation <32 weeks born between 1997 and 2002 and drawn equally from each of the six NICUs in New Zealand were randomly selected from the ANZNN database. Half had early cerebral ultrasound scans previously reported to ANZNN as normal, and half had scans reported as abnormal. The original scans were copied, anonymised, and independently read by a panel of three experts using a standardised method of reviewing and reporting. RESULTS: There was considerable variation between NICUs in methods of image capture, quality, and completeness of the scans. There was only moderate agreement between the reviewers' reports and the original reports to the ANZNN (kappa 0.45-0.51) and between the reviewers (kappa 0.54-0.64). The reviewers reported three to six times more white matter damage than had been reported to the ANZNN. CONCLUSION: Some of the reported variation in white matter damage between NICUs may be due to differences in capture and interpretation of cerebral ultrasound scans.

Does variation in interpretation of ultrasonograms account for the variation in incidence of germinal matrix/intraventricular haemorrhage between newborn intensive care units in New Zealand?

BACKGROUND: The incidence of germinal matrix/intraventricular haemorrhage (GM/IVH) reported to the Australian and New Zealand Neonatal Network (ANZNN) varies between neonatal intensive care units (NICUs). HYPOTHESIS: Differences in the capture, storage, and interpretation of the cerebral ultrasound scans may account for some of this variation. METHODS: A total of 255 infants with birth weight <1500 g and gestation <32 weeks born between 1997 and 2002 were randomly selected from the ANZNN database, 44 from each of the six NICUs in New Zealand. Twenty two infants from each NICU had cerebral ultrasound scans previously reported to ANZNN as normal; another 22 had scans reported as abnormal. The original scans were copied using digital photography and anonymised and independently read by a panel of three experts using a standardised method of reviewing and reporting. RESULTS: There was considerable variation between NICUs in methods of image capture and quality and completeness of the scans. However, there was little variation in the reporting of scans between the reviewers and the reports to ANZNN (weighted kappa 0.75-0.91). Grade 1 GM/IVH was generally over-reported and grade 4 under-reported to the ANZNN. CONCLUSION: For all NICUs, a high level of agreement was found between the reviewers' reports and the reports to the ANZNN. Thus the variation between NICUs in the incidence of GM/IVH reported to the ANZNN is unlikely to be due to differences in capture, storage, and interpretation of the cerebral ultrasound scans. Further investigation is warranted into the reasons for the variation in incidence of GM/IVH between NICUs.

A randomized trial of two dexamethasone regimens to reduce side-effects in infants treated for chronic lung disease of prematurity.

OBJECTIVE: Dexamethasone has been widely used to reduce the incidence of chronic lung disease in preterm infants. However side-effects are common, and the ideal dose of dexamethasone has not been identified. We aimed to determine whether an individualized course of dexamethasone given to preterm babies at risk of chronic lung disease reduced the total dose of dexamethasone administered and reduced side-effects compared with a standard 42-day course. METHODS: Thirty-three infants in a regional neonatal unit with a birthweight of < or =1250 g who required mechanical ventilation at 7 days of age were randomly assigned to a 42-day course of dexamethasone or an individualized course tailored to their respiratory status. The primary outcome was linear growth at 36 weeks corrected gestational age. RESULTS: Infants in the individualized course received a 40% lower total dose of dexamethasone. However, there was no difference between the two groups in linear growth or in the incidence of any other side-effects of treatment. There was also no difference in respiratory status or neurodevelopmental outcome. CONCLUSION: The individualized course of dexamethasone used in this study reduced the total dose of dexamethasone administered but did not significantly reduce side-effects of treatment or alter outcome in infants at risk of chronic lung disease.

Measurement of the subarachnoid space by ultrasound in preterm infants.

BACKGROUND: Measurements of the subarachnoid space during routine cranial sonography may provide an indirect method of monitoring brain growth in preterm infants. METHODS: The width of the subarachnoid space was measured on coronal views during head sonography. Initial scans (within five days of birth) were compared with follow up scans. RESULTS: A total of 361 scans were performed on 201 preterm infants. The mean width of the subarachnoid space was < 3.5 mm for 95% of initial scans. It was slightly larger in neonates born closer to term, the equivalent of an increase of 0.02 mm/gestational week (95% confidence interval 0 to 0.10 mm) for initial scans. When the scans of all infants, born at 24-36 gestational weeks who were 36 weeks corrected gestational age were compared, the mean (SD) subarachnoid space was 60% larger for follow up scans than for initial scans: 3.2 (1.38) v 1.95 (1.35) mm (p = 0.002) or the equivalent of a mean increase of 0.20 mm/week (95% confidence interval 0.15 to 0.30 mm) for follow up scans. At 36 weeks corrected gestational age, mean head circumference was not different between those having initial or follow up scans (33.0 (2.0) v 32.2 (1.9) cm; p = 0.31). CONCLUSION: The mean subarachnoid space is normally < 3.5 mm in preterm infants. The difference between initial and follow up scans suggests reduced brain growth in extrauterine preterm babies.

The use of renal Doppler ultrasonography to diagnose patent ductus arteriosus in preterm infants.

OBJECTIVE: To prospectively study the diagnostic usefulness of altered renal waveforms in patent ductus arteriosus. METHODS: We studied preterm infants undergoing echocardiography for a suspected patent ductus arteriosus. A spectral Doppler display was acquired for both renal arteries, and a resistive index was obtained. Sensitivity, specificity, and likelihood ratios were calculated using a clinically significant patent ductus arteriosus (>1.5-mm diameter on color Doppler ultrasonography) as the standard of reference. RESULTS: Fifty infants had 78 scans. A significant patent ductus arteriosus was present on 39 scans. When the renal resistive index was greater than 1.0, the likelihood ratio for a significant patent ductus arteriosus was 24.8 (specificity, 97.2%; SD, 3.8%). When the renal resistive index was 1.0 or less, the likelihood ratio for a significant patent ductus arteriosus was 0.2 (sensitivity, 77.2%; SD, 9.4%). CONCLUSIONS: Renal resistive index measurement is a simple investigation that can predict a significant patent ductus arteriosus in patients without congenital heart disease or other causes of diastolic runoff when echocardiography is unavailable.

The screening pelvic radiograph in pediatric trauma.

BACKGROUND: Pelvic radiographs are routinely obtained in adult trauma to optimise early management. In adults, pelvic fractures are associated with high early transfusion requirement, high injury severity scores and an increased incidence of other abdominal and thoracic injuries. It is unclear whether this holds true in children. OBJECTIVE: To determine whether the screening pelvic radiograph is necessary in paediatric trauma. MATERIALS AND METHODS: The notes of all patients who presented after trauma to the Starship Children's Hospital and were triaged to the resuscitation room during 1997 were reviewed. Results of initial radiography were obtained and correlated with later imaging. RESULTS: Our review of 444 injured children seen over a period of 1 year revealed that of 347 children who had screening pelvic radiographs, only 1 had a pelvic fracture. The fracture in this child was clinically apparent and required no specific treatment. CONCLUSIONS: The presence of a pelvic fracture is rare in injured children. By omitting screening pelvic radiographs there are potential benefits, including reduced radiation exposure to children and cost savings. Uninterpretable or abnormal clinical examination or haematuria requires further investigation, but routine screening for pelvic fracture is unnecessary.

A normal sonogram does not exclude malrotation.

We present case reports of three recent patients to reinforce the argument that upper gastrointestinal series is the method of choice with which to document malrotation. It has been 9 years since there was a major discussion of this subject in the literature. Ultrasonography cannot confidently exclude malrotation. Radiographic study with contrast continues to be the best diagnostic tool.

Early chest radiographs in very low birth weight babies receiving corticosteroids for lung disease.

We set out to determine whether chest radiographs obtained in premature infants between 9-16 days of age are predictive for the development of chronic lung disease of the newborn (CLD). This was a prospective cohort study. The study included 40 babies who were enrolled in a randomized trial of corticosteroid therapy for the prevention of CLD. Chest radiographs were obtained for clinical indications between 9-16 and 25-35 days of age. All chest radiographs were assessed by a single pediatric radiologist who was unaware of the treatment allocation and who used a previously published scoring system devised by Weinstein et al. [Pediatr Pulmonol 1994;18:284-289]. The radiographic score at 9-16 days correlated well with the radiographic score at 25-35 days of age (correlation coefficient, 0.69, P < or = 0.001). The scores at 9-16 days were significantly higher in those babies who had CLD at 28 days postnatal age (PNA) (P = 0.03) and at 36 weeks postmenstrual age (PMA) (P = 0.002). Using a receiver-operator characteristic curve, we have determined that for a radiographic score of 3 or greater at 9-16 days, the sensitivity for CLD was 0.64, and specificity was 0.84. We conclude that a chest radiograph taken between 9-16 days may help predict which at-risk preterm infants will develop CLD.

Chest physiotherapy and porencephalic brain lesions in very preterm infants.

OBJECTIVE: National Women's Hospital is one of two hospitals to report a destructive brain lesion, namely encephaloclastic porencephaly (ECPE), in extremely preterm infants. It has been associated with non-cephalic presentation, early hypotension and the number of chest physiotherapy treatments in the first month. The aim of the present study was to determine the temporal relationship between ECPE and chest physiotherapy use in very low-birth weight (VLBW) infants in our unit. METHODOLOGY: Cerebral ultrasound scan reports, post-mortem reports, clinical and physiotherapy records and, if indicated, original ultrasound films were reviewed for all VLBW babies admitted between 1985 and 1998. RESULTS: Over the 14 year period in question, 2219 babies with a birth weight < or = 1500 g were admitted. Encephaloclastic porencephaly was found in only the 13 previously reported babies born between 1992 and 1994. Encephaloclastic porencephaly was excluded in 1564 (70%) babies. In 621 (28%) babies who did not have late ultrasound scans, ECPE was thought to be unlikely either because the babies never had any chest physiotherapy (n=479) or because they had chest physiotherapy but were known to be neurodevelopmentally normal on follow up (n=142). Data were incomplete for 21 babies (0.9%). The number of chest physiotherapy treatments per baby decreased from a median of 95 prior to 1989 to 38 and the age of starting treatment increased from 5 to 8 days after 1990. The use of chest physiotherapy ceased in 1995. CONCLUSIONS: Encephaloclastic porencephaly emerged as a problem at a time when the use of chest physiotherapy had decreased. The cluster of cases seen between 1992 and 1994, although associated with the number of chest physiotherapy treatments given, began to appear because of some other factor.

Femoral growth lines: bony birthmarks in infants.

OBJECTIVE: During a study of infants who were being examined for antenatal renal dilatation, we noted that many had growth lines in their proximal femur on postnatal radiographs. We decided to determine the prevalence of growth lines in healthy infants. MATERIALS AND METHODS: Voiding cystourethrograms of 791 neonates and infants, 0-6 months old, were reviewed. All who had documented severe illness or no reasonable view of the proximal femur were excluded, resulting in a cohort of 633 healthy infants. Each study was coded for presence or absence of a growth line in the proximal femur, and the distance of the growth line from the metaphyseal edge was measured to the nearest 0.5 mm. Radiographs were obtained on a unit with fixed tube-film distance. Data on the mode of delivery were collected for 136 infants. RESULTS: Of 633 eligible infants, 247 (39%) of 633 had a discernible growth line. The distance of the growth line from the metaphysis, in millimeters, correlated significantly with age in days (r = .81, p < .01). Infants delivered vaginally were more likely to have a growth line than were those born by cesarean delivery (p = .049). CONCLUSION: A growth line in the proximal femur is common in healthy infants. The rate of longitudinal growth of the proximal femoral metaphysis, on radiographs, is approximately 1 mm per 11 days (1 mm per 13 days when corrected for magnification). Approximation of the timing of prenatal and postnatal stressful events that result in a growth disturbance line may be possible.

Inter- and intra-observer variability in the assessment of atelectasis and consolidation in neonatal chest radiographs.

BACKGROUND: Radiology is an essential part of neonatal intensive care. Interpretation of chest radiographs frequently contributes to respiratory management of neonates, but there has been little assessment of the consistency of this interpretation. OBJECTIVE: To assess the inter- and intra-observer variability for the reporting of atelectasis and/or consolidation in neonatal chest radiographs. MATERIALS AND METHODS: A total of 585 chest radiographs from the 220 babies ventilated in our nursery over a 2-year period were coded by two radiologists for generalised, lobar and segmental atelectasis and/or consolidation. Two months later one of the radiologists re-coded a random sample of these films (n = 117, 20 %). Agreement was assessed by the kappa statistic and by proportions of agreement for normality and abnormality. RESULTS: The reported incidence of focal atelectasis was low (5-6 %). Focal changes of any nature were found in 21-26 % of films. Inter-observer agreement was fair to moderate (kappa = 0.25-0.44). Intra-observer agreement was mostly moderate to good (kappa = 0.38-0.66). CONCLUSION: The poor inter-observer agreement for the diagnosis of pulmonary parenchymal abnormalities on chest radiographs of neonates receiving intensive care suggests that abnormalities should be described rather than diagnoses given or that a list of differential diagnoses be offered. When research involves radiographic interpretation, the potential lack of consistency in reporting abnormalities must be borne in mind.

The role of neonatal chest physiotherapy in preventing postextubation atelectasis.

We retrospectively assessed atelectasis in 297 postextubation radiographs from 220 babies who underwent ventilation over a 2-year period. All 95 babies in the first year received peri-extubation chest physiotherapy; none of the 125 babies in the second year received chest physiotherapy. There was no difference in the incidence of postextubation atelectasis between the two groups.

Sclerosing encapsulating peritonitis associated with continuous ambulatory peritoneal dialysis: surgical management.

Sclerosis of the peritoneum with encapsulation of the small intestine is one of the most serious complications of continuous ambulatory peritoneal dialysis (CAPD) and is associated with a high mortality rate. Its presence should be suspected in patients treated by CAPD who develop small bowel dysfunction with associated abdominal pain and progressive loss of ultrafiltration. In its severest form, it leads to complete high small intestinal obstruction and requirement for total parenteral nutrition. We report the successful surgical management of two young, severely emaciated patients who had this complication of CAPD. Each had entrapment of their bowel by a thick, fibrosed, and calcified membrane. Both were treated by surgically peeling the membrane away from the intestines.

Reversal of left carotid arterial flow as a sign of type C interruption of the aortic arch.

While performing neurosonography on an 8-day-old baby boy, we noted antegrade flow in the right carotid and basilar arteries but retrograde flow in the left carotid artery. The child was diagnosed as having a severe cardiac malformation and associated interruption of the aortic arch on echocardiography. Our finding is explained by the site of interruption-between the innominate and left carotid arteries, or type C interruption.