Diagnosis of primary hydatid cyst of thigh by fine needle aspiration cytology.

Hydatidosis is a parasitic infestation caused by larval form of the tapeworm, Echinococcus granulosus. Primary hydatid cyst in the skeletal muscles and subcutaneous tissue of thigh without involving thoracic and abdominal organs is an exceptional entity, even in countries where the Echinococcus infestation is endemic. We report an unusual case of primary hydatid cyst of thigh in proximity to skeletal muscles. This case illustrates that echinococcal disease should be considered in the differential diagnosis of every subcutaneous cystic mass. This case is presented here for its rarity.

Developing critical mass and growing our own academics.

Academic paediatrics is an exciting and rewarding career path but is not immune to the problems of recruitment and retention currently affecting most branches of medicine. The Modernising Medical Careers initiative, with its explicit academic training path, offers an unparalleled opportunity to develop novel schemes that promote recruitment and retention. Coordinated action is required to define, publicise and support the new academic training programmes and to attract the best trainees into them.

Sodium bicarbonate infusion during resuscitation of infants at birth.

BACKGROUND: For many years, intravenous sodium bicarbonate has been used to reverse acidosis during newborn resuscitation. However, controversy surrounds its use. Most of the evidence has been derived from studies in animals, adult humans, or in uncontrolled, descriptive experiments. Despite the lack of evidence from the human neonatal population and concerns about its safety, some international resuscitation guidelines still recommend the use of sodium bicarbonate in resuscitation of the newborn. OBJECTIVES: To determine whether an intravenous infusion of sodium bicarbonate, compared to placebo or no treatment, reduces mortality and morbidity (in particular regarding neurodevelopmental outcome) in infants receiving resuscitation in the delivery room at birth. SEARCH STRATEGY: We used the standard search strategy of the Cochrane Neonatal Review Group. Searches were conducted of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2005), MEDLINE (1966 - September 2005), EMBASE (1980 - September 2005) and CINAHL (1982 - September 2005) and Pediatric Research (1987 - September 2005). Unpublished trials were sought by handsearching the conference proceedings of American Pediatric Society/Society for Pediatric Research (1990 - 2005) and European Society for Paediatric Research (1993 - 2005). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of newborn infants receiving sodium bicarbonate infusion during any resuscitation in the delivery room at birth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: We found one randomised controlled trial that fulfilled the eligibility criteria (Lokesh 2004) that compared treating asphyxiated newborn infants (infants continuing to need positive pressure ventilation at 5 minutes after birth) with sodium bicarbonate infusion (N = 27) versus 5% dextrose (N = 28). They found no evidence of an effect on mortality prior to discharge [Relative risk 1.04 (95% confidence interval 0.49 to 2.21)], abnormal neurological examination at discharge [Relative risk 0.86 (95% confidence interval 0.30 to 2.50)] or a composite outcome of death or abnormal neurological examination at discharge [Relative risk 0.97 (95% confidence interval 0.59 to 1.60)]. There was no statistically significant difference in the incidence of encephalopathy [Relative risk 1.30 (95% confidence interval 0.88 to 1.92)], intraventricular haemorrhage [Relative risk 1.04 (95% confidence interval 0.23 to 4.70)] and neonatal seizures [Relative risk 1.19 (95% confidence interval 0.50 to 2.82)]. No long term neurodevelopmental outcomes were assessed. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine whether the infusion of sodium bicarbonate reduces mortality and morbidity in infants receiving resuscitation in the delivery room at birth.

Quality of care by neonatal nurse practitioners: a review of the Ashington experiment.

The Ashington experiment, an innovative neonatal service run entirely by advanced neonatal nurse practitioners (ANNPs), has been evaluated. This is a report of that evaluation and a review of the benefits, hazards, and implications of nurse practitioner led services.

UK population based study of severe retinopathy of prematurity: screening, treatment, and outcome.

BACKGROUND: Retinopathy of prematurity (ROP) is one of the few causes of childhood blindness in which severe vision impairment is largely preventable. Ophthalmic screening for ROP is required to identify disease that requires treatment whereby the development of potentially blinding disease can be minimised. OBJECTIVES: To make the first UK population based estimate of the incidence of babies with severe ROP (stage 3 or more); to document their clinical characteristics and management and to evaluate the appropriateness of current ROP screening guidelines in the UK. PATIENTS: Cases were recruited through a national surveillance programme with 1 year ophthalmic follow up and data from clinician completed questionnaires. RESULTS: Between 1 December 1997 and 31 March 1999, 233 preterm babies with stage 3 ROP were identified. Severity (location, extent, and presence of plus disease) was associated with degree of prematurity, most severe in the most premature babies. Fifty nine percent were treated. The UK screening protocol was followed in two thirds of cases, but in the remainder it was begun too late or was too infrequent. Three quarters of the cases were followed up at 1 year, and 13% had a severe vision deficit as a result of ROP. CONCLUSIONS: Visual deficit as a result of ROP in premature babies continues to be a severe disability in some of the survivors of neonatal intensive care. Further efforts are needed to organise treatment regionally to improve outcome and standards of practice.

The EPICure study: associations and antecedents of neurological and developmental disability at 30 months of age following extremely preterm birth.

AIMS: To describe perinatal factors associated with later morbidity among extremely preterm children at 30 months of age corrected for prematurity. POPULATION: Of 308 surviving children born at

Brainstem auditory-evoked responses to different rates of clicks in small-for-gestational age preterm infants at term.

AIM: To clarify further the influence of intrauterine growth retardation (IUGR) on early neural development. METHODS: In 30 small-for-gestational age (SGA) preterm infants at term, brainstem auditory-evoked responses (BAERs) were recorded with clicks of different repetition rates. All infants had a birthweight < 3rd centile, without any other major perinatal complications. RESULTS: Compared with the BAER in 36 appropriate-for-gestational age (AGA) term infants, the preterm SGA infants did not show any abnormalities at 21 s(-1) clicks, except for a slight increase in wave III amplitude. At 51 s(-1) clicks, there was an increase in III-V/I-III interval ratio (ANOVA p < 0.05). At 91 s(-1), the I-III interval shortened, whereas the III-V interval and III-V/I-III interval ratio increased (all p < 0.05). Wave V amplitude tended to increase slightly at all repetition rates of clicks used, although this increase did not reach statistical significance. The III-V interval and III-V/I-III interval ratio in the preterm SGA infants at different click rates correlated inversely with occipitofrontal head circumference at the time of testing, i.e. the smaller the head the longer the III-V interval (all p < 0.01). Wave III amplitude at 21 s(-1) also correlated inversely with head circumference (p < 0.01), suggesting that the slight increase in this amplitude in the preterm SGA infants is related to their relatively small head size. CONCLUSION: There were no major abnormalities in the BAER up to 91 s(-1) clicks at term in preterm SGA infants. The slight increase in III-V interval at high-rate stimulation suggests a subtle degree of central neural dysfunction, which is associated with small head size following IUGR.

One-third of term babies after perinatal hypoxia-ischaemia have transient hearing impairment: dynamic change in hearing threshold during the neonatal period.

AIM: To examine the process of change in hearing threshold during the neonatal period after perinatal hypoxia-ischaemia. METHODS: The threshold of brainstem auditory evoked responses (BAER) was measured serially during the first month after birth in 92 term babies who suffered hypoxia-ischaemia. RESULTS: The mean BAER threshold in these babies was significantly increased on day 1 (ANOVA p < 0.001). The elevated threshold decreased progressively on days 3 and 5, but was still significantly higher than that in normal controls (p < 0.01). The elevation continuously decreased more slowly on days 10 and 15, and to a near normal level on day 30. Threshold elevation was seen in 31.7% of the babies on day 1, and 34.5% during the first three days. The rate of elevation decreased progressively thereafter. On day 30, 10.6% of the subjects still had increased thresholds. Moderate to severe elevation occurred mainly during the first week and severe elevation occurred predominately on day 1. Threshold elevation starting after days 3-5 is likely to be due to middle-ear disorders. As a whole, during the first month, 44.6% (41/92) of the babies studied had threshold elevation. BAER threshold was correlated weakly with the stage of hypoxic-ischaemic encephalopathy on days 1 and 3. The threshold was significantly higher in babies with severe encephalopathy than in those with mild or moderate encephalopathy during the first 3 d of life. CONCLUSION: Hearing threshold is elevated in about one-third of term babies after hypoxia-ischaemia. The elevated threshold decreases progressively after birth, and returns to normal by one month in most babies. The threshold correlates weakly with the severity of encephalopathy.

The EPICure study: growth and associated problems in children born at 25 weeks of gestational age or less.

AIM: To define growth outcomes of a geographically defined population of extremely preterm babies. POPULATION: The EPICure study identified all surviving children in the United Kingdom and Ireland born at < or = 25 weeks 6 days gestation between March and December 1995. Of 308 survivors, 283 (92%) were evaluated at 30 months of age corrected for prematurity. METHODS: Growth was measured as part of a medical and full neurodevelopmental assessment. Growth parameters were evaluated in relation to other 30 month outcomes and perinatal variables. RESULTS: The children were smaller in each of the five growth measures compared with published population norms: mean (SD) standard deviation scores were -1.19 (1.32) for weight, -1.40 (1.37) for head circumference, -0.70 (1.19) for height, -1.00 (1.38) for body mass index, and -0.75 (0.95) for mid-upper arm circumference. Despite being of average size at birth, children were significantly lighter with smaller head circumferences at the expected date of delivery, compared with population norms, and only weight showed later catch up, by 0.5 SD. Poorer growth was found in children whose parents reported feeding problems and with longer duration of oxygen dependency, as a marker for neonatal respiratory illness. Although severe motor disability was associated with smaller head circumference, overall there was no relation between Bayley scores and head growth. CONCLUSIONS: Poor growth in early childhood is common in extremely preterm children, particularly when prolonged courses of systemic steroids have been given for chronic lung disease. Improving early growth must be a priority for clinical care.

The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial.

OBJECTIVE: ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of limb-threatening complications. The aim of this study was to evaluate the role of hyperbaric oxygen in the management of these ulcers. METHOD: eighteen diabetic patients with ischaemic, non-healing lower-extremity ulcers were recruited in a double-blind study. Patients were randomly assigned either to receive 100% oxygen (treatment group) or air (control group), at 2.4 atmospheres of absolute pressure for 90 min daily (total of 30 treatments). RESULTS: healing with complete epithelialisation was achieved in five out of eight ulcers in the treatment group compared to one out of eight ulcers in the control group. The median decrease of the wound areas in the treatment group was 100% and in the control group was 52% (p=0.027). Cost-effectiveness analysis has shown that despite the extra cost involved in using hyperbaric oxygen, there was a potential saving in the total cost of treatment for each patient during the study. CONCLUSION: hyperbaric oxygen enhanced the healing of ischaemic, non-healing diabetic leg ulcers and may be used as a valuable adjunct to conventional therapy when reconstructive surgery is not possible.

Retinopathy of prematurity in the UK II: audit of national guidelines for screening and treatment.

AIMS: To ascertain how closely in 1995, neonatologists and ophthalmologists were adhering to the national guidelines for the screening of retinopathy of prematurity (ROP, 1990) and those for screening and treatment (1995). METHODS: Questionnaires about the local arrangements for the screening and treatment of retinopathy of prematurity were sent to the entire consultant membership (n = 648) of the Royal College of Ophthalmologists (RCOphth) and to the clinical directors (n= 259) of neonatal units in the UK in 1995. RESULTS: One hundered and eighty-three ophthalmologists in the UK were identified as undertaking ROP screening and/or treatment, and ROP screening took place in 207 neonatal units. Seventy-seven per cent of the ophthalmologists either complied with or exceeded recommendations for determining which babies required screening, while 7% used criteria that would have resulted in substantially fewer babies being screened. Only 17% units and 12% ophthalmologists provided written information for parents, although 66% ophthalmologists talked to the parents of babies they screened. There was a lack of clarity about responsibilities for ensuring the continuation of screening on transfer to another hospital or on discharge to home. There was a wide range of views on the ophthalmic criteria that determined when screening examinations could cease and on the indications for treatment. CONCLUSIONS: While ROP screening is almost universally adopted in the UK, there is a need for the process to be more efficient and effective. Despite the delay in reporting this survey several issues remain extant and future guidelines should clarify and refine the criteria for screening and treatment. There is a need for improved communication with parents, and particularly for written information.

Retinopathy of prematurity in the UK I: the organisation of services for screening and treatment.

AIMS: To ascertain how closely services for the screening and treatment of retinopathy of prematurity (ROP) were organised on a national level in 1995. METHODS: Questionnaires about the local arrangements for the screening and treatment of retinopathy of prematurity (ROP) were sent to the entire consultant membership (n = 648) of the Royal College of Ophthalmologists (RCOphth) and to the clinical directors (n = 259) of neonatal units and other units caring for preterm babies in the UK in 1995. RESULTS: 568/648 of UK consultants (88%) and 15 non-consultant ophthalmologists and 210/259 paediatricians (81%) and 19% paediatricians in non-neonatal units responded. Thirty-one per cent responding ophthalmologists were involved in the ROP service: of these 64% screened babies, 34% screened and treated babies, while 1% ophthalmologists treated ROP but did not screen. Ninety-six per cent units caring for preterm babies had their babies screened for ROP and for almost 95% of the screening took place in the neonatal unit. About 8200 babies were screened in 1994; 277 developed stage 3, of whom 54% received treatment. Nine per cent (n = 14) and 5% (n = 8) treated babies became blind in one and both eyes respectively. A sessional commitment was identified for 9% ophthalmologists, but for less than half this was included in the contracted work programme. Sixty-five ophthalmologists treated babies with ROP, but only 10 treated more than five babies in 1994. Training needs were identified by 71 respondents. CONCLUSIONS: Several aspects of ROP screening and treatment services require improvement. Hopefully, reducing the number of identified screeners would increase skills, confidence and the ability to recognise severe disease requiring treatment, and also facilitate incorporation of this work into consultant work plans.

POSSUM and P-POSSUM overpredict mortality for carotid endarterectomy.

OBJECTIVES: the aim was to test the predictive accuracy of POSSUM and P-POSSUM on patients undergoing CEA. DESIGN: retrospective and prospective study. MATERIALS: 499 CEAs performed by four vascular surgeons from a single unit from 1992-99. The median age was 68 (range 38-86) and 60% were men. METHODS: physiological parameters, operative parameters and the 30-day mortality were collected. Predicted mortality for each patient was calculated using POSSUM and P-POSSUM equations. Patients were stratified into risk groups and observed and predicted deaths were compared. Accuracy of the prediction was assessed using chi-squared analysis. RESULTS: the observed 30-day mortality was 1.8% (9/499). The predicted deaths using POSSUM and P-POSSUM analysis were 49 and 25 respectively compared to nine observed deaths. There was significant evidence of lack of fit of both models in predicting mortality (chi-squared analysis, p<0.05). CONCLUSIONS: POSSUM and P-POSSUM overpredict mortality and are unsuitable for comparative audit of CEA. Models developed specific for CEA might accurately predict mortality.

The ica operon and biofilm production in coagulase-negative Staphylococci associated with carriage and disease in a neonatal intensive care unit.

Coagulase-negative staphylococci (CoNS) are a major cause of sepsis in the neonatal intensive care unit (NICU). We evaluated the hypothesis that the ica operon and biofilm production are associated with CoNS disease in this setting. CoNS associated with bacteremia or blood culture contamination and from the skin of infants with CoNS bacteremia or healthy controls were obtained during a prospective case-control study on a busy NICU. A total of 180 strains were identified, of which 122 (68%) were Staphylococcus epidermidis and the remainder were S. capitis (n = 29), S. haemolyticus (n = 11), S. hominis (n = 9), S. warneri (n = 8), and S. auricularis (n = 1). The presence of the genes icaA, icaB, icaC, and icaD was determined by PCR, and biofilm production was examined using qualitative (Congo red agar [CRA]) and quantitative (microtiter plate) techniques. There were no significant differences in the presence of the ica operon or CRA positivity among the four groups of strains. However, quantitative biofilm production was significantly greater in strains isolated from either the blood or the skin of neonates with S. epidermidis bacteremia. We conclude that the quantity of biofilm produced may be associated with the ability to cause CoNS infection. This conclusion suggests that the regulation of biofilm expression may play a central role in the disease process.

Risk modelling study for carotid endarterectomy.

BACKGROUND: The aims of this study were to identify factors that influence the risk of stroke or death following carotid endarterectomy (CEA) and to develop a model to aid in comparative audit of vascular surgeons and units. METHODS: A series of 839 CEAs performed by four vascular surgeons between 1992 and 1999 was analysed. Multiple logistic regression analysis was used to model the effect of 15 possible risk factors on the 30-day risk of stroke or death. Outcome was compared for four surgeons and two units after adjustment for the significant risk factors. RESULTS: The overall 30-day stroke or death rate was 3.9 per cent (29 of 741). Heart disease, diabetes and stroke were significant risk factors. The 30-day predicted stroke or death rates increased with increasing risk scores. The observed 30-day stroke or death rate was 3.9 per cent for both vascular units and varied from 3.0 to 4.2 per cent for the four vascular surgeons. Differences in the outcomes between the surgeons and vascular units did not reach statistical significance after risk adjustment. CONCLUSION: Diabetes, heart disease and stroke are significant risk factors for stroke or death following CEA. The risk score model identified patients at higher risk and aided in comparative audit.

Closure of the ductus arteriosus and development of pulmonary branch stenosis in babies of less than 32 weeks gestation.

AIMS: To define how often transient pulmonary branch stenosis (PBS) develops after closure of a patent ductus arteriosus (PDA) in babies born at less than 32 weeks gestation; to describe the natural history of PBS and the relation between PBS and a cardiac murmur. METHODS: Fifty three preterm infants born at a gestational age less than 32 weeks and who had PDA diagnosed on echocardiography were recruited. An echocardiogram was performed on alternate days until the ductus arteriosus closed. If PBS was diagnosed, the baby was followed up until PBS resolved. RESULTS: In 59%, PBS developed in one or both branches after closure of the PDA. In 21%, both pulmonary branches were affected. In 79%, the left pulmonary artery alone was involved but the right side was never affected alone. PBS had resolved in 74% by the time the infants reached 40 weeks, in 95% at a corrected age of 6 weeks, and in 100% at a corrected age of 3 months. There is a better correlation between a cardiac murmur and PBS than between a murmur and PDA. CONCLUSIONS: PBS in preterm infants is usually not present at birth but develops after closure of a PDA. PBS resolves by a corrected age of 3 months. The presence of a murmur after closure of a PDA is usually related to PBS and not to reopening of the ductus arteriosus.

Genetic population structure of coagulase-negative staphylococci associated with carriage and disease in preterm infants.

Coagulase-negative staphylococci (CoNS) are a leading cause of sepsis in the neonatal intensive care unit (NICU) setting. To evaluate the hypothesis that isolates of CoNS associated with disease belong to hypervirulent clones, as opposed to being drawn randomly from the neonatal unit carriage flora, we conducted a prospective, case-controlled study in a busy NICU. Using pulsed-field gel electrophoresis (PFGE), we compared the population structures of CoNS isolates associated with bacteremia with isolates from the skin of healthy and infected neonates and with blood culture contaminants. Endemic clones of CoNS were identified, but there was no difference in the distribution of the 6 species or 73 PFGE types between the carriage and disease isolate groups; this suggests that hypervirulent clones with an enhanced ability to cause disease were not present in this NICU setting.