Intra- and interobserver variability of novel magnetic resonance imaging parameters for hip screening and treatment outcomes at age 5 years.

BACKGROUND: The outcome measure of neonatal hip screening is usually the radiographic acetabular index. OBJECTIVE: To assess the feasibility of magnetic resonance imaging (MRI) without sedation and compare the utility of outcome parameters measured from MRI images. MATERIALS AND METHODS: The invitation for MRI scanning at 5 years of age was incorporated into follow-up for babies who had more than one ultrasound examination during treatment or surveillance. RESULTS: Diagnostic images were obtained in 132 of 134 children. The mean osseous acetabular index (standard deviation [SD]) was 16.6 (3.3) degrees for the right hip and 17.8 (3.2) for the left; the values for the cartilaginous acetabular index were 3.1 (3) and 3.4 (3.2). The mean downslope of a tangent to the lateral bony acetabular roof was 10.4 (4.5) and 9.0 (4.3) with respect to Hilgenreiner's line and that of a line drawn through the apex to the margin of the acetabulum was 3.7 (4.6) and 3.9 (4.7). Intra- and interobserver variation was greater for measures specific to the lateral acetabular roof than for ossific and cartilaginous indices. There was significant negative correlation between the downslope of the tangent to the lateral roof index and the age at onset of treatment on both sides, but no significant correlation for ossific or cartilaginous acetabular indices or apex-marginal index. CONCLUSION: MRI without sedation at 5 years of age is feasible as an outcome measure for hip screening programmes. Parameters specific to the lateral acetabulum may better reflect acetabular sufficiency, despite having greater observer variation than cartilaginous and ossific acetabular indices.

Neonatal hip ultrasound: tangent to lateral roof angle correlates better with stability than alpha angle according to Graf or percentage femoral head coverage.

The aim of this study was to determine the relationship of tangent to the lateral roof angle (TLRA), Graf's alpha angle and percentage femoral head cover (PHC) and to observed stability, and to establish intraobserver and interobserver errors for measurement of alpha angle and TLRA. In total, 2235 babies referred to the hip review clinic over a period of 8 years. Intraobserver and interobserver errors were calculated from readings of 383 hip images by an experienced paediatric radiologist and a trainee. Taking TLRA <70° as abnormal resulted in sensitivity for unstable right hips of 88% compared with 77% for alpha angle <60° (P = 0.002) and 81% for PHC <60% (P = 0.028) and specificity of TLRA 89%, alpha angle 90% (P = 0.07) and PHC 83% (P < 0.001). Corresponding figures for left hips are sensitivity of TLRA 99%, alpha angle 91% (P < 0.001) and PHC 96% (P = 0.013), and specificity TLRA 86%, alpha angle 83% (P = 0.001) and PHC 67% (P < 0.001). Mean intraobserver errors for alpha angle were 1.85° and 1.81° for consultant and trainee compared to 2.54 and 2.55 for TLRA. Mean interobserver errors were 2.22 for alpha angle and 3.42 for TLRA. TLRA, a new parameter, correlated better with observed stability with significant improvement in sensitivity in both hips and specificity in left hips compared with Graf's alpha angle, and significantly improved sensitivity and specificity in both hips compared with percentage femoral head cover.

Values for bony acetabular roof angle and percentage femoral head cover in a selective ultrasound neonatal hip-screening programme: effect of age, sex and side.

Published maturation curves for bony acetabular roof or α angle (AA) and percentage femoral head cover (FHC) with age are sparse. We aimed to determine typical values for AA and FHC in 2236 infants referred to a selective ultrasound screening programme. There was increase in the values of first measurement of AA and FHC related to the logarithm of age. Males had greater values than females (P<0.001) and right hips had greater values than left (P<0.001) for both measurements. Significant side differences have not been reported previously. Treatment decisions should be made on the basis of sex, side and age-specific data.

Ovarian volume throughout life: a validated normative model.

The measurement of ovarian volume has been shown to be a useful indirect indicator of the ovarian reserve in women of reproductive age, in the diagnosis and management of a number of disorders of puberty and adult reproductive function, and is under investigation as a screening tool for ovarian cancer. To date there is no normative model of ovarian volume throughout life. By searching the published literature for ovarian volume in healthy females, and using our own data from multiple sources (combined n=59,994) we have generated and robustly validated the first model of ovarian volume from conception to 82 years of age. This model shows that 69% of the variation in ovarian volume is due to age alone. We have shown that in the average case ovarian volume rises from 0.7 mL (95% CI 0.4-1.1 mL) at 2 years of age to a peak of 7.7 mL (95% CI 6.5-9.2 mL) at 20 years of age with a subsequent decline to about 2.8 mL (95% CI 2.7-2.9 mL) at the menopause and smaller volumes thereafter. Our model allows us to generate normal values and ranges for ovarian volume throughout life. This is the first validated normative model of ovarian volume from conception to old age; it will be of use in the diagnosis and management of a number of diverse gynaecological and reproductive conditions in females from birth to menopause and beyond.

Paediatric interventional uroradiology.

Paediatric interventional uroradiology lies at the intersection of the disciplines of paediatric interventional radiology and paediatric endourology. Interdisciplinary collaboration has led to the development of new techniques and refinement of procedures adopted from adult practice. This article reviews the major procedures used in paediatric interventional uroradiology, with emphasis on nephrostomy, percutaneous nephrolithotomy, balloon-burst pyeloplasty, and antegrade ureteric stenting.

Epidemiological review and proposed management of 'scaphoid' injury in children.

BACKGROUND: The epidemiology and optimal management of injury to the paediatric scaphoid (carpal navicular) is unknown.The objective of this study is to evaluate these parameters in the Emergency Department of a tertiary children's hospital. METHODS: A retrospective study of a 12-month period of all children attending a single Paediatric Emergency Department who underwent plain radiography of the scaphoid bone. RESULTS: One hundred and seventeen children (aged 8-12 years inclusive) were included (0.4% of all attendances). On the initial plain radiographs, 17 children showed definite or suspected fractures. At follow-up, only 12 had confirmed fractures. All these children had fallen onto their outstretched hand. Only one patient with normal plain radiographs at presentation was subsequently diagnosed with a scaphoid fracture. All healed without evidence of avascular necrosis. CONCLUSION: Pain in the anatomical snuff box is a poor indicator of bone injury to the scaphoid of any sort. Scaphoid fracture is a rare injury in childhood and from this study, it is extremely unlikely to occur under the age of 9 years.The actual bone pathology of an injured paediatric scaphoid may not be clear, but these children have significant pain and tenderness. Further studies are warranted to improve the diagnostic process and the management of paediatric scaphoid injury.

Endoluminal balloon dilatation for pelvi-ureteric junction obstruction in children: an effective alternative to open pyeloplasty.

OBJECTIVE: Pelvi-ureteric junction obstruction (PUJO) is one of the commonest causes of paediatric urinary tract obstruction. Open pyeloplasty has always been the reference standard treatment with variable results. Recently, attention has turned to minimally invasive procedures. We reviewed our 8-year experience with endoluminal balloon dilatation to ascertain whether this procedure is an effective minimally invasive alternative. PATIENTS AND METHODS: The hospital databases, case notes, and radiology records of 14 patients who underwent 15 balloon dilatations for PUJO were examined. Patient demographics, clinical presentation, radiological investigations, operative details, morbidity and follow up were noted. RESULTS: The median age was 10.5 years (range 19 months to 14 years); 33% female and 66% male. Nine primary dilatations, five dilatations following open pyeloplasty, and one re-dilatation were performed. The median stenting time was 44 days (range 1-63 days) and the median in-patient stay was 2 days (range 1-17). There were six minor complications due to blocked stents, misplaced stents, or stents falling out. All patients were followed up at 12 months, and nine had further follow up. The median length of follow up was 44 months (range 22-75). Median diameter of the renal pelvis and MAG3 drainage scores improved from 34 to 16 mm and 4 to 3, respectively, from pre-dilatation to most recent follow up. At the most recent follow up, none of the patients had symptoms attributable to PUJO. CONCLUSIONS: Our results suggest that, using specialized techniques and a multidisciplinary surgeon-radiologist approach, balloon dilatation can be an effective alternative to open pyeloplasty.

Use of a cutting balloon in the dilatation of caustic oesophageal stricture.

A 14-year-old boy was admitted with absolute dysphagia 1 year after he had swallowed drain cleaner. Contrast swallow showed a tight stricture of the whole of the oesophagus below the level of T2. Attempted dilatation to 8 mm using conventional balloons was performed on two occasions, but there was residual waisting. An 8-mm cutting balloon (Peripheral Cutting Balloon, Boston Scientific) was used to abolish this waisting, and full dilatation to 10 mm was performed in the same procedure. Subsequent serial dilatation to 20 mm has been successful and the patient is now able to swallow normal food with cessation of gastrostomy feeding. This is believed to be the first report of the use of a cutting balloon to treat an oesophageal stricture.

Cystoscopic and DMSA findings in relation to types of reflux demonstrated on percutaneous direct radionuclide cystography in children.

BACKGROUND: The new technique of percutaneous direct radionuclide cystography (PDRC) allows the accurate demonstration of vesicorenal reflux under physiological conditions during resting and micturition phases. Five types of reflux have been described, the clinical relevance of which is uncertain. OBJECTIVE: To determine whether a relationship exists between the type of reflux identified on PDRC and the appearance of the ureteric orifice at cystoscopy or the prevalence of renal abnormalities. MATERIALS AND METHODS: The reports of 281 PDRC examinations were reviewed and 76 children with reflux formed the population of this study. Studies of these children were reviewed to classify the reflux as types 1-5, and patient records were searched for cystoscopy and DMSA scan reports. RESULTS: Regardless of the type of reflux, the ureteric orifices were found to be open at cystoscopy in 60-66% of refluxing units. DMSA scan abnormalities were present in 68% of units with reflux at rest, 61% of units with reflux on micturition and 86% of units with reflux on both resting and micturition phases. In comparison with contralateral units that did not reflux, the presence of reflux had a significant association with openness of the ureteric orifice ( p<0.00001) and DMSA abnormality ( p<0.005). CONCLUSIONS: Reflux of any type is strongly associated with an open ureteric orifice. Units that reflux during both resting and micturition phases had a higher incidence of DMSA abnormality than those refluxing during one phase only, but this was not statistically significant.

Pressure-assisted micturating cystourethrography: reduction in duration of procedure and fluoroscopy time.

BACKGROUND: Micturating cystourethrography (MCU) can be a prolonged and uncomfortable examination when contrast medium is instilled by gravity through a narrow-bore catheter. Some radiologists increase the filling rate by injecting contrast medium using syringes, but this is cumbersome. In our hospital, one radiologist routinely injects air into the bottle of contrast medium to speed flow. OBJECTIVE: To assess whether pressure-assisted flow of contrast medium shortens examination times compared with gravity feed. MATERIALS AND METHODS: A prospective study of MCU in 142 children aged 0.04-13.3 years, of which 41 procedures were assisted by air injected into the bottle of contrast medium to maintain a steady stream of contrast medium and 101 were gravity fed. The time from starting contrast medium infusion to the end of the procedure, fluoroscopy time and dose-area product were recorded. A 6-Fr catheter was used in all examinations. RESULTS: The mean duration of the examination was reduced from 9.1 to 3.4 min ( P<0.0001), the mean fluoroscopy time was reduced from 1.5 to 1.0 min ( P<0.0002) and the mean dose-area product was reduced from 27.4 to 17 cGy.cm(2).

The efficacy of the Pavlik harness, the Craig splint and the von Rosen splint in the management of neonatal dysplasia of the hip. A comparative study.

We have reviewed the outcome of 134 hips in 96 children with Graf type-III or type-IV dysplasia of the hip on ultrasound examination. We treated 28 affected hips in 22 children with the Craig splint, 43 hips in 30 children with the Pavlik harness, and 26 hips in 16 children with the von Rosen splint. A total of 37 affected hips in 28 children was not splinted. All children were less than three months of age at referral. Those treated with the von Rosen splint had a significantly better ultrasound appearance at 12 to 20 weeks of age and fewer radiological abnormalities than those not splinted or treated with the Pavlik harness. In the von Rosen group no hip required further treatment with an abduction plaster or operation compared with ten in the Pavlik harness group, three in the Craig splint group and eight in the group without splintage. Our results suggest that the von Rosen splint is more likely to improve the outcome of neonatal dysplasia of the hip and a definitive, large-scale randomised trial is therefore indicated.

Percutaneous direct radionuclide cystography in children: description of technique and early experience.

AIMS: To describe a new test for vesicoureteric reflux in children and assess patient preference compared to indirect radionuclide cystography. MATERIALS AND METHODS: One hundred and three toilet-trained children aged between 2.1 and 15.6 years underwent percutaneous injection of 10-20 MBq of 99m-technetium-labelled mercapto-acetyl-triglycine (MAG3) into the full bladder after the application of anaesthetic cream. Gamma camera images of the bladder and renal areas were recorded during a 5-min resting period and during micturition. RESULTS: All procedures were successful, 97 with a single stab. Fifty-four of the 66 children who expressed a preference preferred percutaneous suprapubic injection to intravenous injection. Images were easy to interpret and there were no indeterminate results. Of 200 renal units, 33 refluxed during the resting phase and 31 during micturition. In 24 renal units, reflux was only demonstrated during the resting phase. Reflux was significantly associated with abnormalities on dimercaptosuccinic acid (DMSA) scans ( P<0.001). CONCLUSIONS: The new technique of direct percutaneous radionuclide cystography is described. It was well tolerated by patients. It detects reflux during the resting phase that would be missed on the indirect study and avoids doubt as to whether activity in the renal areas is due to reflux or excretion. Free pertechnetate could be used and would be much cheaper.