The impact of sedation on the quality of initial skeletal surveys performed for suspected physical abuse in children: a comparative two-centre audit.

BACKGROUND: The impact of sedation on the quality of initial skeletal surveys performed for suspected physical abuse in children is not known. OBJECTIVE: To assess whether sedation influenced the number of, reason for and effective dose of repeat radiographs obtained as part of initial skeletal surveys, and their mean examination times. MATERIALS AND METHODS: One hundred consecutive antemortem initial skeletal survey examinations performed for suspected physical abuse in children <2 years were retrieved from two tertiary paediatric hospitals: Centre 1, where sedation is not used for initial skeletal survey imaging; and Centre 2, where sedation is used routinely. RESULTS: In total, 4055 radiographic projections were performed, of which 93 (2.3%) were repeats. Comparing centres, there was a significant difference in the total number of repeats (P=0.001) and the number of repeats in children aged <12 months (P=0.008). Mean examination times were significantly shorter in unsedated children (P=0.005), even after outliers were excluded (P=0.002). There was no significant difference between the number of routine projections (P=0.587), incompletely imaged body parts (P=0.254), rotation/suboptimal positioning (P=0.527), repeats in children aged >12 months (P=0.089), routine projections in children aged <12 months (P=0.642) or >12 months (P=0.979) or the effective doses of repeats (P=0.286). CONCLUSION: There were fewer repeat projections in sedated children and those aged <12 months but examination times were significantly longer. There was no difference in the effective doses of repeated projections. The routine use of sedation is not supported when performing skeletal survey imaging if the primary considerations are reducing radiation dose and examination time.

Paediatric trauma: experience from the UK's busiest trauma centre.

Paediatric major trauma is relatively uncommon (6% of all traumas) and therefore unfamiliar to many radiologists. The indications for and interpretation of imaging are different to those commonly encountered in adults. In a centre that rarely encounters paediatric trauma, there can be trepidation over the best way to image children due to concerns regarding radiation and the injury patterns that occur at various ages. Within paediatric trauma, as per the Royal College of Radiologists "paediatric trauma protocols" guidelines and National Institute for Health and Care Excellence (NICE) guidance, the main reliance is on computed tomography (CT) and plain radiographs. This review of paediatric trauma from a busy UK major trauma centre demonstrates the most appropriate use of different imaging techniques, the extent of imaging, and the types of injuries that occur in a selection of paediatric trauma patients with a variety of trauma mechanisms. Cases include trauma related to road traffic accidents, bicycle handlebar injuries, falls, and even stabbings. Important learning points highlighted include the use of targeted body part imaging in children, the significance of handlebar injuries, and the importance of assessing for underlying injury in paediatric rib fractures and abdominal bruising and tenderness. We hope these examples will help to support and guide radiologists when encountering paediatric trauma within their own centres.

Getting it right first time in radiology.

Getting it Right First Time (GIRFT) is a national programme designed to improve medical care in the National Health Service (NHS) in England by reducing unwarranted variation. By tackling variation in the way services are delivered across the NHS and by sharing best practice, GIRFT identifies changes that will help improve care and patient outcomes as well as delivering efficiencies.

Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA).

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the "British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)". The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

Evaluation of paediatric radiology services in hospitals in the UK.

AIM: To compare paediatric radiology provision across the UK with national standards published by the Department of Health and the Royal College of Radiologists (RCR). MATERIALS AND METHODS: Audit standards and indicators for paediatric imaging were derived from "Delivering quality imaging services for children",1 "Standards for imaging in cases of suspected non-accidental injury"2 and "Improving paediatric interventional radiology services"3 and agreed jointly by the Clinical Radiology Audit Committee and the British Society of Paediatric Radiology. A questionnaire was sent to all hospitals and NHS trusts imaging children aged 16 or younger in the UK in October 2013. The target for all indicators was 100%. Eighty-seven of 196 (44%) eligible institutions submitted data, the size distribution of the institutions was representative when compared to data from "Facing the future: a review of paediatric services"4 published by the Royal College of Paediatrics and Child health. RESULTS: Only 65% of paediatric images were obtained by staff who had had specific training and only 60% were reported by radiographers or radiologists with appropriate training. Sixty-two percent of centres did not have access to a paediatric opinion 24 hours a day, 7 days a week all year; only 34% of radiographers who regularly imaged children had had any access to continuing professional development (CPD) in the 12 months of the audit. Although all hospitals had facilities for image transfer, only 57% had any formal funding arrangements in place for external reporting of images. CONCLUSIONS: The standards set for a network approach to paediatric radiology provision in "Delivering quality imaging services for children" are largely unmet. This failure to make the most of the workforce and resources puts vulnerable children at risk. The authors urge NHS England to work with the RCR to organise and administer a national network for paediatric imaging.

Dating fractures in infants.

AIM: To document the timing of the appearance of the radiological features of fracture healing in a group of infants in which the date of injury was known and to assess the degree of interobserver agreement. MATERIALS AND METHODS: Three paediatric radiologists independently assessed 161 images of 37 long bone fractures in 31 patients aged 0-44 months. The following features were assessed: soft-tissue swelling, subperiosteal new bone formation (SPNBF), definition of fracture line, presence or absence of callus, whether callus was well or ill defined, and the presence of endosteal callus. RESULTS: Agreement between observers was only moderate for all discriminators except SPNBF. SPNBF was invariably seen after 11 days but was uncommon before this time even in the very young. In one case SPNBF was seen at 4 days. CONCLUSION: With the exception of SPNBF, the criteria relied on to date fractures are either not reproducible or are poor discriminators of fracture age.

Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?

INTRODUCTION: In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration. The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals. METHODS: A sample of thirty pelvic x-rays were selected from the local cerebral palsy database. A range of hip displacement was selected including some challenging borderline x-rays. All ten extended-role radiographers completed measurements using TraumaCAD which were repeated at a minimum of 4 weeks. Inter-rater and intra-rater reliability was calculated using intraclass correlation coefficients. The accuracy and safety of the system was evaluated by converting measurements into referral categories (red, amber or green) and cohen's kappa was calculated when categories were compared to measurements to orthopaedic surgeon RESULTS: The inter-rater reliability between radiographers was 0.938 (95% CI 0.914-0.991). The intra-rater reliability was 0.941 (95% CI 0.931-0.949). The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889-0.957). CONCLUSION: The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy. IMPLICATIONS FOR PRACTICE: We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.

Radiological features of Meckel's diverticulum and its complications.

Meckel's diverticulum is the most common congenital abnormality of the small bowel. The majority of patients with this anomaly will remain asymptomatic; however, several complications may occur, including obstruction, intussusception, perforation, diverticulitis, and gastrointestinal haemorrhage. These complications may produce a variety of different clinical features and radiological appearances. The purpose of this article is to review the potential imaging manifestations of Meckel's diverticulum and its complications and discuss the advantages and disadvantages of the imaging techniques available.

Photomophogenesis: Phytochrome takes a partner!

How light signals are transduced by phytochromes is still poorly understood. Recent studies have provided evidence that a PAS domain protein, PIF3, physically interacts with phytochromes, plays a role in phytochrome signal transduction and might be a component of a novel signalling pathway in plants.

Biochemical properties of a highly purified v-rasH p21 protein overproduced in Escherichia coli and inhibition of its activities by a monoclonal antibody.

The v-rasH oncogene of Harvey murine sarcoma virus encodes a 21,000-dalton p21 protein which has been expressed at a high level as a fusion protein in Escherichia coli. We have purified the p21 to over 90% in purity without the use of any detergent or protein denaturant. The purified p21 possesses full biochemical activities of GTP/GDP binding, autokinase, and GTPase. Scatchard analysis indicates a single class of binding sites with Kd values of 0.83 X 10(-8)M for GTP and 1.0 X 10(-8)M for GDP. The binding site can be specifically labeled with a [3H]GTP photoaffinity analog, P3-(4-azidoanilido)-5' GTP. To probe for the active center of p21, we used a battery of six monoclonal antibodies to p21 to examine their effects on p21 activities. We found that only one monoclonal antibody, Y13-259, was capable of inhibiting both GTP/GDP binding and autokinase enzymatic activities, suggesting that these p21 activities are related activities conferred by a single active center within the p21 molecule. These observations together with the recent finding that microinjection of the same monoclonal antibody into NIH 3T3 cells specifically blocks p21 in vivo function (Mulcahy et al., Nature [London] 313:241, 1985) strongly suggest that p21 in vitro activities are responsible for its cellular function.

Phytochrome B and at Least One Other Phytochrome Mediate the Accelerated Flowering Response of Arabidopsis thaliana L. to Low Red/Far-Red Ratio.

We have investigated the involvement of phytochrome B in the early-flowering response of Arabidopsis thaliana L. seedlings to low red:far-red (R/FR) ratio light conditions. The phytochrome B-deficient hy3 (phyB) mutant is early flowering, and in this regard it resembles the shade-avoidance phenotype of its isogenic wild type. Seedlings carrying the hy2 mutation, resulting in a deficiency of phytochrome chromophore and hence of active phytochromes, also flower earlier than wild-type plants. Whereas hy3 or hy2 seedlings show only a slight acceleration of flowering in response to low R/FR ratio, seedlings that are doubly homozygous for both mutations flower earlier than seedlings carrying either phytochrome-related mutation alone. This additive effect clearly indicates the involvement of one or more phytochrome species in addition to phytochrome B in the flowering response as well as indicating the presence of some functional phytochrome B in hy2 seedlings. Seedlings that are homozygous for the hy3 mutation and one of the fca, fwa, or co late-flowering mutations display a pronounced early-flowering response to low R/FR ratio. A similar response to low R/FR ratio is displayed by seedlings doubly homozygous for the hy2 mutation and any one of the late-flowering mutations. Thus, placing the hy3 or hy2 mutations into a late-flowering background has the effect of uncovering a flowering response to low R/FR ratio. Seedlings that are triply homozygous for the hy3, hy2 mutations and a late-flowering mutation flower earlier than the double mutants and do not respond to low R/FR ratio. Thus, the observed flowering responses to low R/FR ratio in phytochrome B-deficient mutants can be attributed to the action of at least one other phytochrome species.

Combination transurethral resection, systemic chemotherapy, and pelvic radiotherapy for invasive (T2-T4) bladder cancer unsuitable for cystectomy: a phase I/II Southwestern Oncology Group study.

OBJECTIVES: Primarily to evaluate the toxicity and, secondarily, the tumor response and patient survival associated with a three-phase combined modality treatment plan for patients with invasive transitional cell carcinoma (TCC) of the bladder (T2-T4,NX-N2, MO) who are medically unsuitable for or who refuse cystectomy. METHODS: Eligible patients initially underwent extensive transurethral resection (TUR) of the primary tumor with the attempt to resect disease totally. Subsequently, they received systemic combination chemotherapy consisting of two cycles of methotrexate, cisplatin, and vinblastine (MCV), followed by cystoscopic re-evaluation of the bladder tumor. Patients then received 6480 cGy radiotherapy to the bladder with concurrent systemic cisplatin. Toxicity, primary tumor response, and overall survival were evaluated. RESULTS: Of 34 eligible patients, 27 patients completed the treatment series. Twenty-two received 80% to 100% of the prescribed doses of MCV and only 2 patients experienced grade 4 hematologic toxicities. The most common toxicities were gastrointestinal (23), hematologic (21), and renal (8). The complete response (CR) rate after all treatment phases was 56% (19 of 34), 10 patients achieving a complete tumor resection of visible tumor at the initial TUR of the bladder (TURB); 3, a CR after MCV; and 6, after radiotherapy and concomitant cisplatin. The median overall survival was 21 months with 6 of 34 (18%) alive at 57 months (range, 36 to 75). Complete resection of tumor by TURB was associated with prolonged overall survival. The bladder was the initial site of recurrence in 85% of patients who had achieved a CR status. CONCLUSIONS: This older age patient group tolerated this combined modality therapy with acceptable toxicities, but the overall survival rate was not improved compared with those reported with radiotherapy alone.

Case report: colonic obstruction following small bowel barium study.

A case is described in which inspissated barium was retained in the colon for 16 months before causing large bowel obstruction. To our knowledge this is the first case described in which the time interval between barium ingestion and the onset of symptoms was more than a few weeks. Scybalum formation is due to resorption of water from the barium sulphate, which although less common with modern preparations, still appears to be possible in certain high-risk patients. Prolonged retention of barium should be avoided by increased awareness of the problem, encouraging patients to eat and drink normally after the examination, encouraging mobility and administration of lactulose in high risk patients.

Differential effect of phototherapy on the activities of human natural killer cells and cytotoxic T cells.

Exposure to ultraviolet B (UV-B) light is recognized to induce suppression of certain immune responses, particularly delayed hypersensitivity. However, its effect on cytotoxic T lymphocyte (CTL) activity, of major importance in the resistance to viruses and tumours, has not been assessed to the same extent. In this study five normal subjects, seropositive for herpes simplex virus (HSV), underwent a standard course of broadband UV-B therapy, as used in the treatment of psoriasis. They received whole-body irradiation thrice weekly for four weeks with incremental doses dependent on skin type. Blood samples were taken immediately before, at two time points during, and at the end of the therapy. An HSV-specific CTL assay was performed using autologous B cells transformed with Epstein-Barr virus as targets. No consistent modulation in CTL activity was obtained as a result of the therapy. The CTLs were separated into CD4 and CD8 subsets by positive selection and, again, no effect of irradiation on CTL activity within each of these two populations was observed. In contrast, the natural killer (NK) cell activity, assessed by the lysis of K562 cells, was significantly reduced at the first time point after the initiation of the phototherapy in all five subjects, and it continued to decline as the treatment progressed. Thus a differential effect of UV-B exposure on cytotoxic activity has been demonstrated: the HSV-specific CTL response is unchanged, while the NK response is suppressed.

Eicosanoid generating capacities of different tissues from the rainbow trout, Oncorhynchus mykiss.

The eicosanoid generating potential of the brain, gills, skin, ovary, muscle, eye, liver, spleen, heart, and alimentary canal in the rainbow trout, Oncorhynchus mykiss, was examined. All the organs/tissues examined synthesized the 12-lipoxygenase products, 12-hydroxyeicosatetraenoic acid (12-HETE), and 12-hydroxyeicosapentaenoic acid (12-HEPE), implying the widespread nature of this enzyme in trout. Both prostaglandin E and LTC were also found in variable amounts in the organs, with the greatest amount of PGE found in the gill. Leukotriene (LT) B4 and LTB5 were found in supernatants from calcium ionophore-challenged brain, skin, ovary, liver, spleen, and heart, but the lipoxins A4 and A5 were only present in brain, ovary, and spleen in relatively small amounts. As lipoxins have previously been shown to be synthesized by macrophages in rainbow trout [Pettitt et al., J. Biol. Chem. 266, 8720-8726 (1991)], and related cells (microglial cells) are found in the brain of mammals, the localization of macrophage-like cells in trout brain was investigated immunocytochemically. Monoclonal antibodies specific for trout leucocytes failed to identify any microglial-like cells in sections of the brain, although microvessels containing immuno-positive reaction products were observed. A number of distinct lipoxygenase products were found in supernatants of ionophore-challenged gill, including 14-hydroxydocosahexaenoic acid, 12-HETE, and 12-HEPE, and a large number of dihydroxy fatty acid derivatives with conjugated triene chromophores. One of these products was tentatively identified as 8(R),15(S)-dihydroxyeicosatetraenoic acid, a dual 12- and 15-lipoxygenase product, but apparently no LTB4 was generated by this tissue.

Cervical spine injuries to children under 11: should we use radiography more selectively in their initial assessment?

OBJECTIVES: To assess the effectiveness of cervical spine radiography in injured children under 11 years old, and suggest improvements. METHODS: Retrospective survey of radiographs and accident and emergency records for children examined during a one year period in a large teaching hospital. RESULTS: No cervical spine fractures occurred in this age group during the year. The recorded clinical findings did not always justify radiography. CONCLUSIONS: Clinical examination appears undervalued by those assessing injured children and is poorly recorded. Radiography can be used more selectively. Initial assessment using a single lateral projection can be followed in doubtful cases by cross sectional imaging.

Osseointegrated implants for single tooth replacement in general practice: a 1-year report from a multicentre prospective study.

The single tooth implant is a treatment option for the replacement of missing single teeth and in many cases is the treatment of choice. It is, however, an expensive treatment requiring a co-ordinated approach to the surgical and restorative aspects of treatment. In this study, a group of dentists in general and restorative dental practice and with no previous experience in implant surgery underwent an intensive training course in all aspects of implant treatment for single teeth. Using a system of simplified instrumentation with a strict adherence to protocol, the group installed and restored single tooth implants ad modum Brånemark in a wide range of clinical situations. At the one year follow-up period following crown insertion, the success rate of treatment compared favourably with results reported from centres using the specialist team approach to treatment. The results of this study indicate that further consideration should be given to the training of general dentists so that improved delivery of dental health care can be provided at a more economic level.

Regional homology in GTP-binding proto-oncogene products and elongation factors.

The mammalian ras proteins and the bacterial elongation factors share the ability to interact with guanine nucleotides. Comparison of the amino acid sequences has revealed the presence of multiple homologous regions common to all members of the ras and elongation factor families. Two homologous regions share sequence similarities and predicted secondary structure with areas of the elongation factors which have been implicated in GTP binding, suggesting that these regions are part of a common GTP-binding domain. Two other homologous regions contain critical amino acids for the activation of the transforming potential of the mammalian ras proteins. The predicted secondary structure containing residue 61, but not 12, is the same for the ras proteins and elongation factors. It is proposed that the aligned homologous regions surrounding position 12 constitute common functional binding sites with different specificities; by analogy to other GTP-binding proteins, a likely candidate to interact at such a site is a GTPase-subunit.