Investigating febrile UTI in infants: is a cystogram necessary?

OBJECTIVE: Current imaging recommendations for investigating any infantile febrile urinary tract infection (UTI) are ultrasound scan (US), micturating cystourethrogram (MCUG) and dimercaptosuccinic acid (DMSA) scan. The aim of this retrospective cohort study was to determine the need and indications for MCUG in the investigation of a first febrile infantile UTI, as doubts have been raised over its benefit. PATIENTS AND METHODS: Information on 427 infants who had undergone US, MCUG and DMSA following a first febrile UTI was prospectively recorded. The infants were divided into two groups: A (354) with normal renal US and B (73) with abnormal US. DMSA findings were correlated with findings on MCUG. Main outcome measures were incidence of recurrent UTIs, change in management or intervention as a result of MCUG, and outcome at discharge. RESULTS: Only 21/354 (6%) infants in Group A had both scarring on DMSA and vesicoureteric reflux (VUR), predominantly low-grade on MCUG. In Group B (abnormal US), 23/73 (32%) had scarring on DMSA and vesicoureteric reflux, predominantly high grade on MCUG. Of the infants with non-scarred kidneys, 73% had dilating reflux. Successful conservative treatment was performed in 423 infants, and 4 infants in Group B required surgery. CONCLUSION: We recommend US and DMSA in all infantile febrile UTI cases. Where US is normal, MCUG should be reserved for those cases with abnormal DMSA. Where US is abnormal, MCUG should be performed irrespective of findings on DMSA scan. A randomized prospective study is necessary to evaluate this further.

Advanced Trauma Life Support instructor training in the UK: an evaluation.

The paper reports on a questionnaire evaluation of the UK-based ATLS (Advanced Trauma Life Support) instructor course. The trainee instructors who responded were mainly at consultant grade with some senior registrars. The course was regarded as being very effective in achieving most of its objectives and in raising the confidence of postgraduate medical instructors, especially those lacking previous training in instructional methods. This is particularly so for practical skills training. The least effective areas of the course concern small group teaching and questioning techniques.

Routine examination in the neonatal period.

OBJECTIVE: To assess the value of the second neonatal examination as a medical surveillance procedure. DESIGN: Prospective survey of routine neonatal examinations and the abnormalities identified during 8 March-30 June 1988. SETTING: Maternity unit with an annual birth rate of 5700. SUBJECTS: For first neonatal examination: 1795 babies born in the unit during the 115 day observation period. For second routine examination: 1747 babies (97.3%) discharged from postnatal ward. MAIN OUTCOME MEASURES: Missed abnormalities (present but not previously noted); minor abnormalities (superficial infection or trivial or transient abnormalities not requiring intervention); and important abnormalities (unlikely to have been present at first examination but requiring intervention). RESULTS: An abnormality was detected in 158 (8.8%) infants on first neonatal examination. 1428 (79.6%) babies had a routine second examination, which disclosed 63 previously undetected abnormalities. Of these, seven (11%) would have been present on first examination, 49 (78%) were considered minor, and seven (11%) important--the most consequential being dislocatable hips (four infants). Thus an important finding was detected by only 0.5% of second examinations. CONCLUSIONS: A second thorough examination in the early neonatal period cannot be justified as a screening procedure. A repeat examination of the hips alone in the first week of life is necessary.

Femoral artery laceration complicating an intertrochanteric hip fracture: a multi-disciplinary therapeutic problem.

Major arterial injuries are uncommon complications of intertrochanteric hip fractures. Described is transcatheter embolization of a lacerated femoral artery complicated by a large hematoma, discovered following surgical repair of an eight day old intertrochanteric fracture. The case was complicated due to a history of aspirin usage, marked obesity, and thrombocytopenia. Interventional radiology techniques may provide an alternative to surgery in selected cases.

CT demonstration of an ectopic pancreatic tail causing a renal pseudotumor.

Renal pseudotumors may be intrinsic or extrinsic to the renal parenchyma. A case in which an ectopic position of the pancreatic tail simulated a solid left renal mass on nephrotomography and ultrasonography is presented. Computed tomography was important in confirming the etiology of the mass.