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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. [ABSTRACT FROM AUTHOR]

Objective: To assess the current physical status and developmental outcome of children born to mothers following renal transplantation.Methodology: A cross-sectional prevalence survey of 48 children born to 34 women transplanted at a single centre from 1971 to 1992 was performed. Data on maternal renal disease, immunosuppression, pregnancy, delivery and child development were collected using hospital records and parental questionnaire. Children underwent physical examination, urinalysis and urinary tract ultrasound examination (US).Results: Maternal renal failure was due to reflux nephropathy/chronic pyelonephritis (16), chronic glomerulonephritis (eight) and other causes (10). All mothers received prednisolone immunosuppression, as sole therapy (one), as part of triple therapy (one). Sixteen (47%) received azathioprine/prednisolone and 16 (47%) cyclosporin/prednisolone. Twenty-three girls and 25 boys aged 9 months to 18 years were studied (median age 5.2 years); 27/48 (56%) were born prematurely, 21/48 (44%) with birthweight (BW) < 2500 g 21/48 (44%) were small for gestation (BW < 10th centile). General health and physical assessment were unremarkable in 45/48 (94%) and 41/43 (95%), respectively. Development was considered normal in 47/48 (98%). Four of 40 (10%) had urinary tract abnormalities on US.Conclusions: Despite a high incidence of preterm delivery, low birth weight, intrauterine growth retardation and urinary tract abnormalities, the overall outcome for children of renal transplant recipient mothers is good. [ABSTRACT FROM AUTHOR]

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., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The Indian leafwing butterfly Kallima paralekta (Horsfield, 1829) (Nymphalidae) is an Asian forest-dwelling, leaf-mimic. Genome skimming by Illumina sequencing permitted assembly of a complete circular mitogenome of 15,200 bp from K. paralekta consisting of 79.5% AT nucleotides, 22 tRNAs, 13 protein-coding genes, two rRNAs and a control region in the typical butterfly gene order. Kallima paralekta COX1 features an atypical CGA start codon, while ATP6, COX1, COX2 , ND4 , ND4L, and ND5 exhibit incomplete stop codons completed by 3' A residues added to the mRNA. Phylogenetic reconstruction places K. paraleckta within the monophyletic genus Kallima , sister to Mallika in the subfamily Nymphalinae. These data support the monophyly of tribe Kallimini and contribute to the evolutionary systematics of the Nymphalidae., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

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.

Purpose: To determine the ability of Saccadic Vector Optokinetic Perimetry (SVOP) to detect and characterise visual field defects in children with brain tumours using eye-tracking technology, as current techniques for assessment of visual fields in young children can be subjective and lack useful detail., Methods: Case-series study of children receiving treatment and follow-up for brain tumours at the Royal Hospital for Sick Children in Edinburgh from April 2008 to August 2013. Patients underwent SVOP testing and the results were compared with clinically expected visual field patterns determined by a consensus panel after review of clinical findings, neuroimaging, and where possible other forms of visual field assessment., Results: Sixteen patients participated in this study (mean age of 7.2 years; range 2.9-15 years; 7 male, 9 female). Twelve children (75%) successfully performed SVOP testing. SVOP had a sensitivity of 100% and a specificity of 50% (positive predictive value of 80% and negative predictive value of 100%). In the true positive and true negative SVOP results, the characteristics of the SVOP plots showed agreement with the expected visual field. Six patients were able to perform both SVOP and Goldmann perimetry, these demonstrated similar visual fields in every case., Conclusion: SVOP is a highly sensitive test that may prove to be extremely useful for assessing the visual field in young children with brain tumours, as it is able to characterise the central 30° of visual field in greater detail than previously possible with older techniques.

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.

Quantitative volumes from brain magnetic resonance imaging (MRI) acquired across the life course may be useful for investigating long term effects of risk and resilience factors for brain development and healthy aging, and for understanding early life determinants of adult brain structure. Therefore, there is an increasing need for automated segmentation tools that can be applied to images acquired at different life stages. We developed an automatic segmentation method for human brain MRI, where a sliding window approach and a multi-class random forest classifier were applied to high-dimensional feature vectors for accurate segmentation. The method performed well on brain MRI data acquired from 179 individuals, analyzed in three age groups: newborns (38-42 weeks gestational age), children and adolescents (4-17 years) and adults (35-71 years). As the method can learn from partially labeled datasets, it can be used to segment large-scale datasets efficiently. It could also be applied to different populations and imaging modalities across the life course.

Preterm infants are susceptible to inflammation-induced white matter injury but the exposures that lead to this are uncertain. Histologic chorioamnionitis (HCA) reflects intrauterine inflammation, can trigger a fetal inflammatory response, and is closely associated with premature birth. In a cohort of 90 preterm infants with detailed placental histology and neonatal brain magnetic resonance imaging (MRI) data at term equivalent age, we used Tract-based Spatial Statistics (TBSS) to perform voxel-wise statistical comparison of fractional anisotropy (FA) data and computational morphometry analysis to compute the volumes of whole brain, tissue compartments and cerebrospinal fluid, to test the hypothesis that HCA is an independent antenatal risk factor for preterm brain injury. Twenty-six (29%) infants had HCA and this was associated with decreased FA in the genu, cingulum cingulate gyri, centrum semiovale, inferior longitudinal fasciculi, limbs of the internal capsule, external capsule and cerebellum (p < 0.05, corrected), independent of degree of prematurity, bronchopulmonary dysplasia and postnatal sepsis. This suggests that diffuse white matter injury begins in utero for a significant proportion of preterm infants, which focuses attention on the development of methods for detecting fetuses and placentas at risk as a means of reducing preterm brain injury., Competing Interests: All co-authors have reviewed and approved the contents of the manuscript. The authors report no real or potential conflicts of interest concerning this work.

Neuroimage analysis pipelines rely on parcellated atlases generated from healthy individuals to provide anatomic context to structural and diffusion MRI data. Atlases constructed using adult data introduce bias into studies of early brain development. We aimed to create a neonatal brain atlas of healthy subjects that can be applied to multi-modal MRI data. Structural and diffusion 3T MRI scans were acquired soon after birth from 33 typically developing neonates born at term (mean postmenstrual age at birth 39(+5) weeks, range 37(+2)-41(+6)). An adult brain atlas (SRI24/TZO) was propagated to the neonatal data using temporal registration via childhood templates with dense temporal samples (NIH Pediatric Database), with the final atlas (Edinburgh Neonatal Atlas, ENA33) constructed using the Symmetric Group Normalization (SyGN) method. After this step, the computed final transformations were applied to T2-weighted data, and fractional anisotropy, mean diffusivity, and tissue segmentations to provide a multi-modal atlas with 107 anatomical regions; a symmetric version was also created to facilitate studies of laterality. Volumes of each region of interest were measured to provide reference data from normal subjects. Because this atlas is generated from step-wise propagation of adult labels through intermediate time points in childhood, it may serve as a useful starting point for modeling brain growth during development.

Accurate whole-brain segmentation, or brain extraction, of magnetic resonance imaging (MRI) is a critical first step in most neuroimage analysis pipelines. The majority of brain extraction algorithms have been developed and evaluated for adult data and their validity for neonatal brain extraction, which presents age-specific challenges for this task, has not been established. We developed a novel method for brain extraction of multi-modal neonatal brain MR images, named ALFA (Accurate Learning with Few Atlases). The method uses a new sparsity-based atlas selection strategy that requires a very limited number of atlases 'uniformly' distributed in the low-dimensional data space, combined with a machine learning based label fusion technique. The performance of the method for brain extraction from multi-modal data of 50 newborns is evaluated and compared with results obtained using eleven publicly available brain extraction methods. ALFA outperformed the eleven compared methods providing robust and accurate brain extraction results across different modalities. As ALFA can learn from partially labelled datasets, it can be used to segment large-scale datasets efficiently. ALFA could also be applied to other imaging modalities and other stages across the life course.

DNA methylation (DNAm) plays a determining role in neural cell fate and provides a molecular link between early-life stress and neuropsychiatric disease. Preterm birth is a profound environmental stressor that is closely associated with alterations in connectivity of neural systems and long-term neuropsychiatric impairment. The aims of this study were to examine the relationship between preterm birth and DNAm, and to investigate factors that contribute to variance in DNAm. DNA was collected from preterm infants (birth<33 weeks gestation) and healthy controls (birth>37 weeks), and a genome-wide analysis of DNAm was performed; diffusion magnetic resonance imaging (dMRI) data were acquired from the preterm group. The major fasciculi were segmented, and fractional anisotropy, mean diffusivity and tract shape were calculated. Principal components (PC) analysis was used to investigate the contribution of MRI features and clinical variables to variance in DNAm. Differential methylation was found within 25 gene bodies and 58 promoters of protein-coding genes in preterm infants compared with controls; 10 of these have neural functions. Differences detected in the array were validated with pyrosequencing. Ninety-five percent of the variance in DNAm in preterm infants was explained by 23 PCs; corticospinal tract shape associated with 6th PC, and gender and early nutritional exposure associated with the 7th PC. Preterm birth is associated with alterations in the methylome at sites that influence neural development and function. Differential methylation analysis has identified several promising candidate genes for understanding the genetic/epigenetic basis of preterm brain injury.

Preterm birth is associated with altered connectivity of neural circuits. We developed a tract segmentation method that provides measures of tract shape and integrity (probabilistic neighborhood tractography, PNT) from diffusion MRI (dMRI) data to test the hypotheses: 1) preterm birth is associated with alterations in tract topology (R), and tract-averaged mean diffusivity (〈D〉) and fractional anisotropy (FA); 2) neural systems are separable based on tract-averaged dMRI parameters; and 3) PNT can detect neuroprotective treatment effects. dMRI data were collected from 87 preterm infants (mean gestational age 29(+1) weeks, range 23(+2) -34(+6)) at term equivalent age and 24 controls (mean gestational age 39(+6) weeks). PNT was used to segment eight major fasciculi, characterize topology, and extract tract-averaged〈D〉and FA. Tract topology was altered by preterm birth in all tracts except the splenium (p < 0.05, false discovery rate [FDR] corrected). After adjustment for age at scan, tract-averaged〈D〉was increased in the genu and splenium, right corticospinal tract (CST) and the left and right inferior longitudinal fasciculi (ILF) in preterm infants compared with controls (p < 0.05, FDR), while tract-averaged FA was decreased in the splenium and left ILF (p < 0.05, FDR). Specific fasciculi were separable based on tract-averaged〈D〉and FA values. There was a modest decrease in tract-averaged〈D〉in the splenium of preterm infants who had been exposed to antenatal MgSO4 for neuroprotection (p = 0.002). Tract topology is a biomarker of preterm brain injury. The data provide proof of concept that tract-averaged dMRI parameters have utility for evaluating tissue effects of perinatal neuroprotective strategies.

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.

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.

We report an unusual case of chylothorax in an infant associated with a staphylococcal paravertebral abscess secondary to discitis affecting the thoracic spine. We discuss the initial presentation with sepsis and chylothorax and the delayed diagnosis of discitis. We also discuss the imaging features and treatment in this case.

Objective: To determine whether an abdominal ultrasound scan performed by paediatric radiologists is effective in the diagnosis of abdominal injuries in children., Method: A retrospective cohort study was undertaken of all children who presented with blunt abdominal trauma to a paediatric teaching hospital (RHSC) over a 5-year period between 1 January 2001 and 31 December 2005. Hospital notes and radiology computer systems were interrogated and data were collected and analysed., Results: Of the 80 children with blunt abdominal trauma, 56 (70%) had abdominal imaging and 23 (30%) had no imaging. Of the 56 imaged, 48 (86%) had an USS of which 25 (52%) were positive (16 demonstrated solid organ injury, 8 free fluid and 1 suspected bladder rupture); 3 of these went on to have a CT scan. 23 had a normal USS; 2 of these children went on to have a CT scan because of a high index of suspicion for small bowel perforation due to their mechanism of injury and clinical signs. Both of these CT scans were normal. Eight children (14%) had a CT scan as the primary investigation, 6 of which (75%) were positive (5 demonstrated liver lacerations and 1 free fluid with no obvious source). All these abnormalities were demonstrated on follow-up USS. 23 children had no abdominal imaging and once their symptoms and signs had settled they were safely discharged home., Conclusion: Abdominal USS performed by paediatric radiologists is an accurate method of assessing abdominal injuries. However, CT scanning can assess certain abnormalities such as pancreatic or duodenal injuries and small amounts of free intraperitoneal air more accurately. The importance of serial clinical examination must not be overlooked.

Intrathoracic rib is a rare congenital anomaly that is usually discovered incidentally. It represents a benign lesion but can mimic intrathoracic pathology, so it is important to recognize it to prevent further unnecessary investigation or intervention. Typically, the classic appearance allows diagnosis with confidence on the chest radiograph alone; however, an atypical appearance of an intrathoracic rib might limit the diagnostic capabilities of plain radiography, warranting further imaging with newer technologies. We report the case of an atypical presentation of an intrathoracic rib in an 8-year-old girl where radiographs were inconclusive and helical CT scan with 3-D reconstructions were required for a definitive diagnosis.

Background: In children who have undergone both 99mTc-DMSA and 99mTc-MAG3 studies for the assessment of differential renal function (DRF) and drainage, respectively, we have noticed good agreement between the calculated DRF values, and hypothesized that there is no significant difference in DRF values calculated from these tests. Therefore, both tests may not always be necessary., Objective: To determine whether there is a statistically significant difference between DRF values calculated using 99mTc-DMSA and those calculated using 99mTc-MAG3., Materials and Methods: We retrospectively identified children imaged with 99mTc-DMSA and 99mTc-MAG3. We recorded DRF values, age, indication, and renal pelvis diameter. For the 99mTc-DMSA studies we recorded the imaging time after injection. For the 99mTc-MAG3 studies we recorded the delay between injection and data acquisition, diuretic use and evidence of delayed drainage or reflux., Results: We identified 100 episodes in 92 children where both 99mTc-DMSA and 99mTc-MAG3 scans had been performed within a few days. The commonest indication was urinary tract infection or pelviureteric junction obstruction. The mean age of the children was 6.96 years. A significant but clinically acceptable trend was seen between abnormal DRF and difference between tests. A significant link was found with the difference between tests and the time of imaging after DMSA injection, and also with scarring. No significant effect was caused by renal pelvis dilatation, delayed drainage, frusemide administration, or delayed 99mTc-MAG3 imaging., Conclusion: If a 99mTc-MAG3 study has been performed then a 99mTc-DMSA study is unnecessary provided DRF is normal on the 99mTc-MAG3 study and there is no scarring. A change in practice would lead to considerable savings in time, cost and radiation burden.

Background: A retrospective, cross-sectional study was performed to compare the rates of skeletal maturation in Scottish populations 25 years apart (1980-2005)., Methods: Two cohorts of sequentially radiographs were identified from patients at a Scottish pediatric hospital in 1980 and 2005. All radiographs were performed after trauma. The bone age was measured according to the Carpal scoring system of the Tanner-Whitehouse 2 method., Results: One hundred four and 103 radiographs were included from 1980 and 2005, respectively. The radiographs from 2005 showed the children to have achieved older bone ages for given chronological ages than in 1980 (P < 0.0001)., Conclusions: The findings have an important implication for the management of children with limb-length discrepancy. Children may not have the growth potential anticipated by chronological age; this will affect the timing of surgery and medical treatment of abnormalities of puberty and stature.

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.

Rickets fortunately remains rare in the United Kingdom, although its actual incidence is currently undetermined.1 Many still consider it to be a disease of poverty prevalent during the Victorian era. However, a number of recent articles have highlighted concern among British health professionals about the number of cases still being diagnosed in this country. These cases have nearly all involved non-Caucasian children who are considered to be at high risk due to skin colour, prolonged breast feeding, and low maternal vitamin D levels. Their presentations are variable ranging from failure to thrive, bone deformities, seizures, and even stridor. The diagnosis is usually made in babies and toddlers.We present a series of patients attending our accident and emergency (A&E) department, over a five month period, where the diagnosis of rickets was primarily a radiological diagnosis.

Objectives: To assess the effect of a change in skull x ray policy on the rate of admission, use of computed tomography (CT), radiation dose per head injury, and detection of intracranial injuries; and to compare the characteristics of patients with normal and abnormal head CT., Design: Retrospective cohort study., Setting: UK paediatric teaching hospital emergency department., Patients: 1535 patients aged between 1 and 14 years with a head injury presenting to the emergency department between 1 August 1998 and 31 July 1999 (control period), and 1867 presenting between 1 August 2002 and 31 July 2003 (first year of new skull x ray policy)., Intervention: Hospital notes and computer systems were analysed and data were collected on all patients presenting with a head injury., Results: The abolition of skull x rays in children aged over 1 year prevented about 400 normal skull x rays being undertaken in period 2. The percentage of children undergoing CT rose from 1.0% to 2.1% with no change in the positive CT pick up rate (25.6% v 25.0%). There was no significant change in admission rate (10.9% v 10.1%), and a slight decrease in the radiation dose per head injury (0.042 mSv compared to 0.045 mSv)., Conclusions: Skull x rays can be abandoned in children aged 1 to 14 without a significant increase in admission rate, radiation dose per head injury, or missed intracranial injury. The mechanism and history of the injury and a reduced Glasgow coma scale are probably the most important indicators of significant head injury in children.

Objective: Head injury is one of the commoner injuries presenting to the emergency department (ED). Infants are hard to assess clinically and emphasis has been placed on radiological examination. Skull radiographs, however, are not a reliable indicator of intracranial injury. As a result of this the policy in this ED was revised so that skull radiographs were only to be performed in those infants less than 1 year with visible evidence of head injury or a suspicious history for non-accidental injury., Methods: Retrospective cohort study of all infants less than 1 year who presented with head trauma to the ED of a paediatric teaching hospital between 1 August 1998 and 31 July 1999, and between 1 August 2002 and 31 July 2003. Hospital notes and radiology computer systems were examined and data were collected and analysed., Results: 181 infants aged less than 1 year presenting to the ED in 1998/9 and 190 infants in 2002/3. Altogether 140 (77.3%) infants had a skull radiograph in 1998/9, five (3.6%) identified skull fractures. During 2002/3, 56 (29.5%) infants had a radiograph, a reduction of 47.5%, of which three (5.4%) had skull fractures. All fractures had reported haematomas to their scalp. The change in policy decreased the total radiation dose to the population by 9.4 mSv. No significant injuries were missed as a result of the change in policy., Interpretation: In infants under 1 year, unless non-accidental injury is suspected, it is suggested that skull radiographs should only be performed when there are visible signs of a head injury.

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.

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.

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).

Background/aims: Even in the absence of retinopathy of prematurity (ROP), premature birth signals increased risk for abnormal refractive development. The present study examined the relation between clinical risk factors and refractive development among preterm infants without ROP., Methods: Cycloplegic refraction was measured at birth, term, 6, 12, and 48 months corrected age in a cohort of 59 preterm infants. Detailed perinatal history and cranial ultrasound data were collected. 40 full term (plus or minus 2 weeks) subjects were tested at birth, 6, and 12 months old., Results: Myopia and anisometropia were associated with prematurity (p<0.05). More variation in astigmatic axis was found among preterm infants (p<0.05) and a trend for more astigmatism (p<0.1). Emmetropisation occurred in the preterm infants so that at term age they did not differ from the fullterm group in astigmatism or anisometropia. However, preterm infants remained more myopic (less hyperopic) than the fullterm group at term (p<0.05) and those infants born <1500 g remained more anisometropic than their peers until 6 months (p<0.05). Infants with abnormal cranial ultrasound were at risk for higher hyperopia (p<0.05). Other clinical risk factors were not associated with differences in refractive development. At 4 years of age 19% of the preterm group had clinically significant refractive errors., Conclusion: Preterm infants without ROP had high rates of refractive error. The early emmetropisation process differed from that of the fullterm group but neither clinical risk factors nor measures of early refractive error were predictive of refractive outcome at 4 years.

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.

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.

Simple renal cysts are uncommon in children and their presentation and management has changed with increasing use of ultrasound scans. The aim of this study was to review our experience and highlight some peculiarities in diagnosis and management of these cases. Eight cases were diagnosed and two symptomatic cases underwent aspiration under ultrasound guidance; one case recurred and required re-aspiration. Differentiation of simple renal cysts from other cystic lesions of the kidney, aspiration of symptomatic cysts and the importance of long-term follow-up are discussed.

F syndrome (acropectorovertebral syndrome) is a dominantly inherited skeletal dysplasia affecting the hands, feet, sternum, and lumbosacral spine, which has previously been described in only two families. Here we report a six generation Turkish family with a related but distinct dominantly inherited acropectoral syndrome. All 22 affected subjects have soft tissue syndactyly of all fingers and all toes and 14 also have preaxial polydactyly of the hands and/or feet. In addition, 14 have a prominent upper sternum and/or a blind ending, inverted U shaped sinus in the anterior chest wall. Linkage studies and haplotype analysis carried out in 16 affected and nine unaffected members of this family showed that the underlying locus maps to a 6.4 cM interval on chromosome 7q36, between EN2 and D7S2423, a region to which a locus for preaxial polydactyly and triphalangeal thumb-polysyndactyly has previously been mapped. Our findings expand the range of phenotypes associated with this locus to include total soft tissue syndactyly and sternal deformity, and suggest that F syndrome may be another manifestation of the same genetic entity. In mice, ectopic expression of the gene Sonic hedgehog (Shh) in limb buds and lateral plate mesoderm during development causes preaxial polydactyly and sternal defects respectively, suggesting that misregulation of SHH may underlie the unusual combination of abnormalities in this family. A recently proposed candidate gene for 7q36 linked preaxial polydactyly is LMBR1, encoding a novel transmembrane receptor which may be an upstream regulator of SHH.

Two neonates were found on US to have branching linear calcification in the renal parenchyma, right sided in one and bilateral in the other. CT confirmed the presence of branching calcification in the kidneys and demonstrated calcified thrombus in the inferior vena cava in both babies. Antenatal detection of adrenal haemorrhage in one baby and presence of calcification at the age of 3 days in the other indicate that thrombosis probably occurred before birth. The kidneys remained normal in size, and uptake of 99mTc-labelled dimercaptosuccinic acid (99mTc-DMSA) was normal on follow-up examination. The presence of branching calcification and normal renal size probably indicates good prognosis for renal function in neonates in whom renal venous thrombosis is found and may indicate prenatal thrombosis.

Purpose: To compare the technical feasibility and procedural complications of fluoroscopically guided balloon dilatation with conventional surgical bouginage for the treatment of oesophageal strictures in children., Materials and Methods: A retrospective analysis of 125 balloon dilatations in 37 children with oesophageal strictures of varying aetiology. Twenty-four of the 37 children also underwent 88 procedures of surgical bouginage and comparison was made between the methods., Results: Fluoroscopic balloon dilatation had fewer technical failures (0/125 vs. 4/88, P<0.02) and fewer iatrogenic perforations (2/125 vs. 5/88 P = 0.1) than surgical bouginage., Conclusion: Fluoroscopically guided balloon dilatation is safer and has fewer technical failures than surgical bouginage and should be considered the first line of treatment for oesophageal strictures in children.

Objective: To examine features identified on US which predict success or failure of air-enema reduction of intussusception., Materials and Methods: A retrospective study of 117 consecutive episodes of intussusception, presenting for US over a 6-year period. The specific features examined were: free fluid within the peritoneum, small-bowel obstruction, colonic wall thickness, and fluid trapped between the colon and the intussusceptum., Results: The overall reduction rate, irrespective of US features, over the 6-year period was 72 %. Reduction rates were significantly higher with the absence of free fluid, trapped fluid, or small-bowel obstruction (93 %). The presence of trapped fluid predicted an unfavourable outcome, with a significantly lower success rate (25 %). Colonic wall thickness did not predict outcome; in successful reductions, mean wall thickness was 7.2 mm and in failed reductions 7.6 mm., Conclusions: Where free fluid, small-bowel obstruction, and trapped fluid are absent, almost 100 % success with air-enema reduction should be achievable. Where trapped fluid is present, air enema should be performed cautiously to avoid perforation caused by overvigorous attempts at pneumatic reduction of an incarcerated intussusception.

CT-guided percutaneous lung biopsy was performed in children with chronic respiratory disease to obtain samples for histological examination. An automatic cutting device with a 14-G needle was used with one or two cores obtained in each procedure. Seven procedures were performed in six children, mostly with local anaesthesia. Adequate tissue was obtained in all cases. Although a small pneumothorax and/or haemothorax occurred in most procedures, these were usually visible only on CT and did not require active management. A larger pneumothorax in one child also resolved with conservative management. Percutaneous CT-guided 14-G automatic cutting-needle biopsy of lung parenchyma in children is a minimally invasive alternative to open-lung biopsy with no complications in our series.

Background: Two boys suffered blunt abdominal trauma resulting in renal injury. In both cases the damaged kidney was fractured through its mid-portion, and the upper and lower fragments of the kidney became widely separated by a urinoma., Materials and Methods: US-guided drainage of the urinoma resulted in immediate apposition of the renal fragments. The drains were left on free drainage by gravity for 1 week before removal., Results: The urinomas did not reaccumulate and follow-up DMSA scans showed good residual function., Conclusion: We suggest that drainage of urinomas that separate renal fragments should be considered since this may accelerate healing and help preserve renal function.

A familial short stature syndrome is described in two sisters. Clinical features include severe pre- and post-natal growth failure, stridor, feeding difficulties in the first 2 years requiring nasogastric feeding and facial dysmorphism reminiscent of Three M syndrome. Intellectual function is normal. Skeletal surveys show short long bones, small square iliac bones, short femoral necks and vertebral bodies which are short in the antero-posterior diameter with narrowing of the interpedicular distance inferiorly.

We describe a female neonate with spondylocostal dysostosis and a translocation resulting in monosomy for the region 6q25-->qter and trisomy for the region 15q11.1-->pter. The finding of a Mendelian disorder with a chromosomal abnormality may help in the localization of the gene(s) involved in this disease.