Inter-rater reliability of the APD, SFU and UTD grading systems in fetal sonography and MRI.

INTRODUCTION: Antenatal hydronephrosis (ANH) is frequently detected on screening obstetric ultrasonography. Common ANH grading systems include the anterior-posterior diameter (APD) and the Society for Fetal Urology (SFU) grading system. Recent developments in the management of ANH include the use of fetal magnetic resonance imaging (MRI), and a new grading system - Urinary Tract Dilation (UTD). This study reviewed patients who underwent fetal MRI and ultrasound, and compared the grading systems across these imaging modalities. MATERIALS AND METHODS: Patients who underwent paired fetal MRI and ultrasound studies between January 2012 and January 2014 were included. Two pediatric urologists and a pediatric radiologist reviewed the studies. Data collected included APD, SFU grade, and UTD grade. Fleiss' kappa statistic determined the inter-rater reliability (IRR) of the SFU and UTD grading within each imaging modality. Intra-class correlation assessed the consistency of the APD measurements. RESULTS: Forty-seven patients and 88 renal units were evaluated. Median gestational age was 22 weeks. Kappa values of the SFU grading system indicated fair IRR for ultrasound imaging and moderate IRR for MRI imaging, while the UTD grading system reached moderate IRR for both. The IRR of the SFU grading system was improved with the use of MRI, while the UTD grading system was no different. The APD intraclass correlation coefficient improved significantly when measured by MRI. As the ultrasound SFU grade increased, the odds of the MRI SFU grade being scored higher increased by a factor of 3.7. There was no difference between ultrasound and MRI when using the UTD grading system. DISCUSSION: This study was the first to assess the UTD system in a cohort of patients who underwent paired ultrasound and MRI studies. The results suggested that the UTD system might improve IRR, compared with the SFU system. The use of fetal MRI may improve the IRR of the SFU grading system. It also found that the proportion of SFU grades was affected by the imaging modality, raising the possibility that MRI 'overcalls' the SFU grade, compared with ultrasound. This difference was not observed using the UTD grading system. The most important limitation was the selection bias favoring complex pathology with severe ANH diagnosed at an early gestational age. CONCLUSIONS: In this unique cohort, the UTD system improved IRR when compared to the SFU grading system. Fetal MRI improved the IRR of the SFU grading system, and improved the APD intraclass correlation. The SFU grading was likely to be higher when assessed by MRI vs ultrasound, but the UTD grade was not affected by the imaging modality.

Inter-rater reliability of postnatal ultrasound interpretation in infants with congenital hydronephrosis.

PURPOSE: The most common measurements of hydronephrosis are the anterior-posterior (AP) diameter and the Society for Fetal Urology (SFU) grading systems. To date, the inter-rater reliability (IRR) of these measures has not been compared in the postnatal period. The objectives of this study were to compare the IRR of the AP diameter and the SFU grading system in infants and to determine whether ultrasound findings other than pelvicalyceal dilation are associated with higher SFU grades. METHODS: Initial postnatal ultrasounds of infants seen from February 1, 2011, to January 31, 2012, with a primary diagnosis of congenital hydronephrosis were included for review. Ultrasound images were de-identified and reviewed by four pediatric urologists. IRR was calculated using the intraclass correlation (ICC) measure. A paired t test was used to compare ICCs. Associations between SFU grade and other ultrasound findings were tested using Chi-square or Fisher's exact tests. RESULTS: A total of 112 kidneys in 56 patients were reviewed. IRR of the SFU grading system was high (right kidney ICC = 0.83, left kidney ICC = 0.85); however, IRR of AP diameter measurement was higher (right kidney ICC = 00.97, left kidney ICC = 0.98; p < 0.001). Renal asymmetry (p < 0.001), echogenicity (p < 0.001), and parenchymal thinning (p < 0.001) were significantly associated with SFU grade 4 hydronephrosis on bivariable and multivariable analysis. CONCLUSIONS: The SFU grading system is associated with excellent IRR, although the AP diameter appears to have higher IRR. Physicians may consider ultrasound findings that are not explicitly included in the SFU system when assigning hydronephrosis grade, which may lead to variability in use of this classification system.

Dispersal of stable flies (Diptera: Muscidae) from larval development sites in a Nebraska landscape.

Seven mark-recapture studies were conducted over 3 yr to assess dispersal of newly emerging adult stable flies, Stomoxys calcitrans L., from larval development sites in a mixed agricultural environment in northeastern Nebraska. Infested hay debris piles were marked by dusting their surfaces with fluorescent pigments, adults were captured with surrounding grids of Alsynite sticky traps, and specimens were dissected to determine feeding histories and reproductive age. Distances and directions of 3,889 marked specimens indicated males and females dispersed equally and in all directions. Midguts of males and females were equally likely to contain blood-meal remnants. Percentage with blood remnants and percentage of females with yolk increased with distance from mark origin, indicating survival and spread were positively associated with host finding success. A time-integrated diffusion model fit to results from the seven studies indicated 50% of stable fly adults had dispersed beyond 1.6 km of their natal site, but only 5% had dispersed beyond 5.1 km. These results indicate that stable fly adults on cattle in a given area are most likely to have originated from larval development sites within an ≈ 5 km radius of the subject cattle.

The ENT emergency clinic: a prospective audit to improve effectiveness of an established service.

BACKGROUND: Ear, nose and throat emergency clinic services vary greatly between trusts. Their common aim is to enable acute conditions to be seen quickly and effectively within an optimum environment. There is however no 'gold standard' for service. OBJECTIVES: To identify an efficient model of service, and to determine whether introduction of a referral and appointment based system improves patient waiting times and appropriateness of referrals. METHODS: A prospective audit, comprising: an initial survey to appraise the existing service; telephone surveys of eight trusts in the West Midlands to determine variability of ENT emergency clinic services and to identify components of an effective service; and re-audit following implementation of a verbal referral and appointment based service. RESULTS: The new service significantly reduced patient waiting times, from 70 minutes to 35 minutes (t = 6.776; p < 0.01), with an associated reduction in the variability of waiting times. Inappropriate referrals were reduced from 7 to 2 per cent. These results were achieved when a 72 per cent referrer compliance with the service was observed. CONCLUSIONS: A verbal referral and appointment based system improves patient waiting times and appropriateness of referrals. Maintenance of high referrer compliance with such a system should be considered, and a tool for monitoring referring practitioners is suggested. This clinic construct model is offered as an example in order to aid delivery of an effective ENT emergency service in departments with similar patient demand and staff resources.

Effects of stable flies (Diptera: Muscidae) on weight gains of grazing yearling cattle.

Differences in weight gains caused by stable flies, Stomoxys calcitrans (L.), on grazing yearling steer/calves averaged 0.2 kg per steer in a 3-yr study on canyon range pastures in West Central Nebraska, Stable fly numbers averaged 0.85 per front leg on treated calves and 3.64 per front leg on control calves. In 2 of the 3 yr after the grazing trials were completed, the calves were placed in a feedlot and fed a finishing ration. Compensatory gain did not occur in the feedlot after the stable fly stress was removed.

Comparative efficacy of several insecticides for control of cattle lice (Mallophaga: Trichodectidae and Anoplura: Haematopinidae).

Several insecticides were applied to cattle at various rates, mixtures, application methods and numbers of treatments and evaluated for control of cattle lice. The insecticides included permethrin at various rates as a pour-on with and without the synergist piperonyl butoxide (PBO), and also at various rates as a spray with and without PBO. Pirimiphos-methyl was evaluated as a pour-on at various rates and with one or two applications. Lambda cyhalothrin in microencapsulated formulation was compared to a non-microencapsulated formulation. Rabon(R) was applied as a pour-on at two rates and at one or two treatments for each rate. Dimilin(R) was applied as a pour-on at two rates and mixed with permethrin and applied at two rates. Five endectocides, Eprinex(R), Ivomec(R), Dectomax(R), Cydectin(R) and Phoenectin(R) were all applied at the same rate. The cattle utilized in this research were all infested with a mixture of lice species. The species included: Bovicola (Damalinia) bovis (L.), Haematopinus eurysternus (Nitzsch), Linognthus vituli (L.) and Solenoptes capillatus (Enderlein). Most of the cattle were infested with at least two species and some had three or all four species present. All of the treatments except permethrin 1.0%+5% PBO, at a rate of 3ml/45.4kgwt. provided acceptable lice control with one application. Data indicated that applying the insecticides in early January should provide enough control to render the need for a second treatment unnecessary.

Jansen type of spondylometaphyseal dysplasia.

Metaphyseal dysplasia, type Jansen (JMD), is a rare skeletal dysplasia with characteristic radiographic abnormalities. Of the various types of metaphyseal dysplasia, JMD shows the most severe alteration in metaphyseal architecture. All of the long tubular bones, including those of the hands and feet, show metaphyseal irregularity with a fragmented appearance and slight widening. The adjacent physes are abnormally widened, while the epiphyses tend to be slightly enlarged, rounded but otherwise normal. The spine in infancy and childhood usually appears normal. This report describes a young girl with metaphyseal changes typical of JMD except for the hands and feet, which appeared normal. She also showed very unusual abnormalities of the spine. This appears, therefore, to represent a unique osteochondrodysplasia for which we propose the term spondylometaphyseal dysplasia, type Jansen.

Chiropractors and vaccination: A historical perspective.

Although there is overwhelming evidence to show that vaccination is a highly effective method of controlling infectious diseases, a vocal element of the chiropractic profession maintains a strongly antivaccination bias. Reasons for this are examined. The basis seems to lie in early chiropractic philosophy, which, eschewing both the germ theory of infectious disease and vaccination, considered disease the result of spinal nerve dysfunction caused by misplaced (subluxated) vertebrae. Although rejected by medical science, this concept is still accepted by a minority of chiropractors. Although more progressive, evidence-based chiropractors have embraced the concept of vaccination, the rejection of it by conservative chiropractors continues to have a negative influence on both public acceptance of vaccination and acceptance of the chiropractic profession by orthodox medicine.

Hepatic pulmonary fusion in neonates.

OBJECTIVE: This report discusses the relationship of supradiaphragmatic hepatic tissue that is fused to the lung (through a diaphragmatic defect) with pulmonary hypoplasia-a new constellation of findings. CONCLUSION: Hepatic pulmonary fusion should be suspected in instances of apparent diaphragmatic hernia characterized by mediastinal shift towards the hypoplastic lung or when the mediastinum does not shift away from the mass.

Fibrogenesis imperfecta ossium: imaging correlation in three new patients.

OBJECTIVE: Fibrogenesis imperfecta ossium is an extremely rare disorder that can easily be misdiagnosed. We retrospectively reviewed the clinical and imaging data of three confirmed cases of fibrogenesis imperfecta. DESIGN AND PATIENTS: The patients consisted of two men and one woman, ranging in age from 40 to 53 years. Radiography was performed in all the patients. One patient had a 3-year follow-up of the thoracolumbar spine with conventional radiography and thoracolumbar magnetic resonance (MR) imaging. Open biopsy was performed in all cases, confirming the diagnosis of fibrogenesis imperfecta ossium. RESULTS: All our cases demonstrated "fishnet" trabecular pattern by conventional radiographs, and a pelvis radiograph of one patient showed an equivocal sclerosis pattern. Multiple fractures were noted in two patients. A pseudoexostosis was present in the ilium in one patient. Thoracolumbar MR imaging demonstrated diffuse low signal intensity within the medullary space on both T1-weighed and T2-weighted images, except for a region of increased signal intensity in the L1 and L2 vertebral bodies on T2-weighed images due to edema from acute collapse. CONCLUSIONS: Although uncommon, fibrogenesis imperfecta ossium should be considered in a previously healthy patient with a combination of progressive bone pain, unexplained fractures, a radiologic pattern of fishnet osteopenia and MR imaging of low signal intensity bone marrow on both T1-weighted and T2-weighted images.

Use of nonprescription medications by patients with congestive heart failure.

OBJECTIVE: To define the utilization pattern of nonprescription therapies in patients with congestive heart failure (CHF) and to compare this pattern with that of an age- and gender-matched control group without any self-reported heart conditions. DESIGN: Survey questionnaire completed by participants at home. SETTING: Ambulatory CHF clinic in a tertiary care hospital. SUBJECTS: Patients attending the clinic between July 1995 and May 1996 who agreed to participate. Control subjects were age- and gender-matched participants identified and approached by participating patients. OUTCOME MEASURES: Nonprescription therapies used at least once weekly. RESULTS: Completed questionnaires were received from 180 (75%) of the 239 patients who agreed to participate and from 133 controls. Mean age of responding patients was 69 years (63% men). Controls were younger, with a mean age of 64 years (63% men). The most commonly used nonprescription medication categories for both patients and controls, with no significant intergroup differences, were vitamins and minerals (59% patients, 50% controls), pain relievers (48% and 43%, respectively), herbal or health food products (38% and 38%), antacids (26% and 28%), and laxatives (24% and 21%). Significantly fewer patients than controls used cough and cold products (9% vs. 17%; p < 0.05), specifically oral decongestants (0.6% vs. 5%; p < 0.01), and more patients than controls used nutritional supplements (17% vs. 4%; p < 0.01). CONCLUSIONS: Overall, use of nonprescription therapies by our CHF clinic patients is similar to that of an age- and gender-matched population without a self-reported heart condition. The differences in medication use observed between patients and controls included cough and cold products that might be harmful. This likely reflects appropriate caution with which CHF patients approach nonprescription therapies.

Malignancies in pediatric patients with ataxia telangiectasia.

BACKGROUND: Patients with ataxia telangiectasia (AT), known to have an inherent increased susceptibility to the development of cancer, may present with malignancies that are unusual for the patient's age, are often difficult to diagnose clinically and radiographically and respond poorly to conventional therapy. MATERIALS AND METHODS: We reviewed the clinical presentation and imaging studies of 12 AT patients who developed malignancies. RESULTS: Eight of the twelve patients developed non-Hodgkin's lymphoma (CNS, thorax, bone), two developed Hodgkin's disease, and two were diagnosed with gastrointestinal mucinous adenocarcinoma. CONCLUSION: The lymphomas were commonly extra nodal, and infiltrative rather than mass-like. The recognition of the tumors was often delayed due to confusion with the known infectious complications in AT patients.

Metaphyseal chondrodysplasia, type Jansen.

The Jansen type of metaphyseal dysplasia is a rare disorder with significant clinical and radiographic variability. Two cases of classical Jansen disease and one with some distinctive features suggestive of the Jansen variant are reported.

Upper extremity and rib stress fractures in a child.

Stress fractures in children are rare compared with the incidence in adults. This report describes an 11-year-old girl with stress fractures of the acromion, clavicle, and first rib on the left and contralateral fractures of the first and second ribs. It was eventually discovered that these fractures were caused by a nervous tic consisting of repetitive, vigorous shrugging and translation of the shoulders.

Susceptibility of stable flies (Diptera:Muscidae) from southeastern Nebraska beef cattle feedlots to selected insecticides and comparison of 3 bioassay techniques.

Insecticide susceptibility of field populations of stable flies, Stomoxys calcitrans (L.), was assayed using 3 exposure techniques: treated filter papers, treated glass petri dishes, and topical applications. Both topical applications and residual exposure to treated glass surfaces were suitable for testing susceptibility of stable flies to permethrin, stirofos, or methoxychlor. Residues on filter papers yielded inconsistent results with stirofos and methoxychlor. Significant concentration-mortality regression lines were generated with permethrin residues on filter papers, but approximately 1,000 times more insecticide was required to produce a toxic response when compared with permethrin residues on glass. Because of higher variability in response and the greater amount of insecticide required, residues on filter papers do not appear appropriate to test insecticide susceptibility in stable flies. Paired comparisons of field (F) and susceptible (S) stable flies resulted in field to susceptible ratios significantly > 1.0 only when the flies were treated topically, which suggests that topical application is more sensitive than residues on glass for the insecticides tested. Topical treatment with permethrin resulted in one FS(LD90) of 1.8-fold. Topical treatment with methoxychlor resulted in one FS(LD90) of 3.4-fold. However, the magnitude of these ratios is not larger than the significant differences observed within the susceptible laboratory colony from one generation to another. Intense exposure to insecticides is not known to have occurred in these field populations, indicating that the observed differences are the result of natural variation among stable fly populations and unrelated to prior selection with insecticides.

Calculating economic injury levels for stable flies (Diptera:Muscidae) on feeder heifers.

A procedure for calculating the economic injury levels for stable flies, Stomoxys calcitrans (L.), on feeder heifers was developed from reduction of average daily weight gain-stable fly population level data in 8 independent replicated experiments over 17 yr. A negative exponential was fitted to the data using nonlinear regression. Regression coefficients were then used to derive a simple predictive equation for calculating the economic injury level in relation to cost of controlling stable flies in the feedlot, and the market value of heifers. Examples for calculating the economic injury level under practical feedlot situations are presented. Also included are recommendations for a simple random sampling design for stable flies in feedlots.

The effects of disposable daily wear contact lenses on goblet cell count.

PURPOSE: The number of goblet cells on the inferior bulbar conjunctiva increases in response to daily wear contact lens use. We conducted a study to examine whether daily wear soft contact lenses worn on a 2-week disposable schedule would also induce the same goblet cell response. METHODS: Twenty-eight subjects who had never worn contact lenses were fit with 38% water polymacon lenses. The lenses were worn on a daily wear basis and replaced every two weeks over a 6-month period. Goblet cell count was determined by impression cytology of the inferior bulbar conjunctiva. RESULTS: No significant increase in goblet cell count was observed in the subjects during the 6 months period; the 3.23% baseline goblet cell count was never exceeded. In our previous study, after 6 months of conventional daily wear lens use, the goblet cell count increased from a baseline of 4.19% to 8.0%. CONCLUSIONS: It appears that wearing daily wear soft contact lenses on a disposable basis may be less irritating to the ocular surface than wearing soft contact lenses on a conventional daily wear basis.