Radiographic skeletal survey for non-accidental injury: systematic review and development of a national New Zealand protocol.

INTRODUCTION: Clinically occult fractures from non-accidental injury (NAI) are best detected on radiographic skeletal survey. However, there are regional variations regarding the views included in such surveys. We undertook a systematic review of the evidence supporting skeletal survey protocols to design a protocol that could be implemented across New Zealand. METHODS: In June 2013, we searched Medline, Google Scholar, the Cochrane database, UpToDate and relevant reference lists for English-language publications on skeletal survey in NAI from 1946. We included publications that contained a protocol or reported evidence supporting including, or excluding, specific views in a skeletal survey. All included publications were critically appraised. Based on this systematic review, a draft protocol was developed and presented to an Australian and New Zealand Society for Paediatric Radiology NAI symposium in October 2013. Feedback from the symposium and later discussions was incorporated into the final protocol. RESULTS: We identified 2 guidelines for skeletal survey, 13 other protocols and 15 articles providing evidence for inclusion of specific images in a skeletal survey. The guidelines scored poorly on critical appraisal of several aspects of their methods. We found no studies that validate any of the protocols or compare their performance. Evidence supporting inclusion in a skeletal survey is limited to ribs, spine, pelvis, hands and feet, and long bone views. Our final protocol is a standardised, two-tiered protocol consisting of between 17 and 22 views. CONCLUSION: A standardised protocol for radiographic skeletal survey protocol has been developed in New Zealand. We present it here for consideration by others.

Should we abandon landmark-based technique for caudal anesthesia in neonates and infants?

BACKGROUND: Caudal anesthesia is a landmark-based technique with ultrasound guidance occasionally used in the absence of landmarks. The current surface landmark remains a popular approach due to its desirable success rate. However, incomplete ossification of the posterior vertebral elements can make this procedure for neonatal caudal anesthesia difficult. The aim of this study was to describe the anatomical relationship of the posterior superior iliac spines (PSISs) to the sacral cornua in infants using ultrasound. METHODS: A total of 26 healthy infants (17 female; mean age 13 weeks) were scanned by an experienced radiologist in the prone position with hip and knee joints flexed. The PSISs and sacral cornua were identified clinically then using ultrasound to assess whether these markings corresponded with the clinical markings. The distance between the PSISs and the distance between the tip of the PSIS and tip of the sacral cornu were measured using ultrasound. RESULTS: The PSISs were clinically identified in all babies, but the sacral cornua were not palpable in four babies (15%). The PSISs and sacral cornua were easily visualized using ultrasound in all participants. The mean distance between the two left and right PSISs was 3.4 ± 0.5 cm; the mean distance between the PSISs and cornu was 2.5 ± 0.5 cm on the left and right. CONCLUSION: This study showed that the current landmark (equilateral triangle) for infant caudal anesthesia is unreliable. Importantly, the sacral hiatus is clinically identifiable only if the sacral cornua are palpable; otherwise, using ultrasound is essential.

An osteosclerotic form of Robinow syndrome.

Robinow syndrome (RS) is a clinically and genetically heterogenous condition primarily characterized by short stature, mesomelia, genital hypoplasia, oral abnormalities, and a facial gestalt that includes hypertelorism, a short nose, and a broad mouth. The disorder exists in both a dominant and a more severe recessive form. Here two unrelated cases of sporadic RS are described with the additional finding of axial and appendicular osteosclerosis. These two patients, coupled with three additional patients previously described in the literature, may represent a distinct sub-phenotype of this condition.

Low-lying placenta: who should be recalled for a follow-up scan?

INTRODUCTION: The incidence of low-lying placenta or placenta praevia in the second trimester has been reported at 1-5%; however, recent unpublished audits suggest our recall rates are higher. We wanted to assess our recall rates in a large sample size and determine whether we could reduce the placenta-os distance for recalling women with low-lying placenta, while still identifying all cases of placenta praevia at delivery. METHODS: We undertook a retrospective analysis from March 2005 to March 2008 of women attending for 18-20-week obstetric ultrasounds. Patients with a singleton pregnancy and a placenta ≤2 cm from the internal cervical os were included. Follow-up scan results and delivery data were collected. RESULTS: Four hundred eight women were identified as having a low-lying placenta at the 18-20-week scan (107 (9%) at Dunedin Hospital and 301 (5%) at Otago Radiology). Fifty-eight women (14%) were excluded, leaving 350 women included in the analysis. Three hundred seventeen (91%) had a placenta clear of the internal os on their follow-up scan while 33 women (9%) had persistent placenta praevia. At a distance of ≥1.9 cm, there was 100% sensitivity for detection of placenta praevia on the 18-20-week scan. As the placenta-os distance decreases the sensitivity for detection of placenta praevia reduces. CONCLUSIONS: Placenta praevia at term can occur where the placenta is up to 1.9 cm from the internal cervical os on the 18-20-week anatomy scan. Consequently, we will continue to recall women for a follow-up scan where the placenta is ≤2 cm from the internal os.

Integrating case-based reasoning with an electronic patient record system.

UNLABELLED: Electronic patient records (EPRs) contain a wealth of patient-related data and capture clinical problem-solving experiences and decisions. Excelicare is such a system which is also a platform for the national generic clinical system in the UK. OBJECTIVE: This paper presents, ExcelicareCBR, a case-based reasoning (CBR) system which has been developed to complement Excelicare. Objective of this work is to integrate CBR to support clinical decision making by harnessing electronic patient records for clinical experience reuse. METHODS: CBR is a proven problem solving methodology in which past solutions are reused to solve new problems. A key challenge that we address in this paper is how to extract and represent a case from an EPR. Using an example from the lung cancer domain we demonstrate our generic case representation approach where Excelicare fields are mapped to case features. Once the case base is populated with cases containing data from the EPRs database a standard weighted k-nearest neighbour algorithm combined with a genetic algorithm based feature weighting mechanism is used for case retrieval and reuse. CONCLUSIONS: We conclude that incorporating case authoring functionality and a generic retrieval mechanism were key to successful integration of ExcelicareCBR. This paper also demonstrates how the application of CBR can enable sharing of lessons learned through the retrieval and reuse of EPRs captured as cases in a case base.

Using computer aided case based reasoning to support clinical reasoning in community occupational therapy.

Community occupational therapists have long been involved in the provision of environmental control systems. Diverse electronic technologies with the potential to improve the health and quality of life of selected clients have developed rapidly in recent years. Occupational therapists employ clinical reasoning in order to determine the most appropriate technology to meet the needs of individual clients. This paper describes a number of the drivers that may increase the adoption of information and communication technologies in the occupational therapy profession. It outlines case based reasoning as understood in the domains of expert systems and knowledge management and presents the preliminary results of an ongoing investigation into the potential of a prototype computer aided case based reasoning tool to support the clinical reasoning of community occupational therapists in the process of assisting clients to choose home electronic assistive or smart house technology.

Ultrasound appearance of scrotal fat necrosis in prepubertal boys.

BACKGROUND: Scrotal fat necrosis is a rare cause of scrotal pain in prepubertal boys. Despite its characteristic clinical presentation, it is an under-recognized entity. Specific scrotal US imaging features of this condition have not been previously reported. OBJECTIVE: To describe the US imaging features of scrotal fat necrosis. MATERIALS AND METHODS: Between January 1999 and November 2006 we identified all boys with idiopathic scrotal fat necrosis presenting for ultrasound imaging. All the children were reviewed by the urology service during the initial presentation and assessment with clinical confirmation of the diagnosis of scrotal fat necrosis. The sonographic appearances in each child were reviewed. RESULTS: Over the course of 6 years we identified ten children who had the classic clinical diagnosis of idiopathic scrotal fat necrosis. The scrotal fat was characteristically hyperechoic, with posterior shadowing. This was located inferior to the testes which were displaced superiorly. The testes and epididymi were normal in all children. CONCLUSION: There are specific imaging features of scrotal fat necrosis that when combined with the characteristic clinical presentation can confirm the diagnosis of scrotal fat necrosis.