Potential pitfalls in imaging of paediatric cerebral sinovenous thrombosis

Paediatric cerebral sinovenous thrombosis (CSVT) is a rare but serious condition. The imaging signs may be subtle with a number of potential pitfalls. We present a pictorial essay of the pitfalls of diagnosis of CSVT on CT and MRI. We describe, using examples, potential pitfalls on both imaging modalities including anatomical variants of the cerebral venous system, extra-axial fluid collections and enhancement of chronic thrombus. Pitfalls particular to CT are discussed including beam-hardening artefact, image windowing and neonatal physiological intravascular hyperdensity. We review the potential variability in the appearance of thrombus on MRI, dependent largely on the stage of thrombus evolution and the pulse sequence. The signal intensity of thrombi, although described as evolving in a typical pattern on T1- and T2-weighted MRI, may be affected by variability in the degree of oxygenation of red cells in the forming thrombus, dilution and secondary propagation of thrombosis. Individual MRI sequences should not be interpreted in isolation, but as a set, and compared with CT images if available.     

Potential pitfalls in cranial sonography

BACKGROUND: We present several anatomic variants of the brain and artifacts related to scanning techniques which could be misinterpreted as lesions on neonatal cranial sonography. MATERIALS AND METHODS: The findings were derived from US studies performed on 176 premature infants and 26 full-term newborns, using the anterior, posterior and mastoid fontanelles as acoustic windows. RESULTS: The pseudolesions are divided into three groups: ventricular system (asymmetric lateral ventricle size and coarctation of the lateral ventricles); choroid plexus ("split" choroid, "truncated" choroid and choroid cyst); and brain parenchyma (peritrigonal blush, thalamic pseudolesion, pseudo-absence of the inferior vermis, occipital pseudomass and calcar avis simulating intraventricular clot). We provide images of these pseudolesions and clues to their differentiation from true brain pathology. Images of several brain disorders are included for comparison. Knowledge of these potential pitfalls is essential for proper interpretation of US brain studies and will help to avoid the use of other more invasive diagnostic tests. CONCLUSIONS: Misleading images seen on US examination of the neonatal brain that could be misinterpreted as pathology are presented, with clues to their differentiation from true lesions.     

Adolescent medicine in paediatric practice

Adolescents are a growing area in paediatric practice in both hospital and community settings. They make up around one quarter of the practice of many paediatricians. Yet until recently there has been little formal interest in young people's health in the UK. The situation is now changing, particularly following the publication of the "National Service Framework for children, young people and maternity services", which places a major emphasis on adolescent health. Given that this area is relatively new to many paediatricians, this article aims to provide an overview of the range of health problems that affect young people, to provide practical advice for working with this group in paediatric practice, and to outline current and future opportunities for training in adolescent health in the UK.     

Quality in paediatric emergency medicine: Measurement and reporting

There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality ‘scorecard’ that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.     

Adolescent medicine in paediatric practice.

Adolescents are a growing area in paediatric practice in both hospital and community settings. They make up around one quarter of the practice of many paediatricians. Yet until recently there has been little formal interest in young people's health in the UK. The situation is now changing, particularly following the publication of the "National Service Framework for children, young people and maternity services", which places a major emphasis on adolescent health. Given that this area is relatively new to many paediatricians, this article aims to provide an overview of the range of health problems that affect young people, to provide practical advice for working with this group in paediatric practice, and to outline current and future opportunities for training in adolescent health in the UK.     

Magnetic resonance urography and laparoscopy in paediatric urology: a case series

Paediatric urology often presents challenging scenarios. Magnetic resonance urography (MRU) and laparoscopy are increasingly used. We retrospectively studied children affected by a disease of the upper urinary tract who after MRU were elected for laparoscopic treatment. This pictorial essay draws on our experience; it illustrates some specific MRU findings and highlights the usefulness of MRU for the diagnosis of upper urinary tract pathology in children. It also offers some examples of the potential additional diagnostic information provided by laparoscopy as well as its therapeutic role.     

Medication errors in a paediatric teaching hospital in the UK: five years operational experience

BACKGROUND: In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients. AIMS: To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence. METHODS: Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions. RESULTS: Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year. CONCLUSION: The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.     

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients: practical aspects and pitfalls

Purpose  Continuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery. Methods  Data were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400–4,300 g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre. Results  Epidural placement was achieved easily in all cases, with high quality analgesia for 24–96 h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (n = 1), surgeon’s request (n = 2), and systemic opioid administration before epidural anaesthesia was considered (n = 1). Intraoperative complications included haemodynamic instability (n = 1) and vascular catheter placement (n = 5). Postoperative complications included meningitis (n = 1), insertion site erythema (n = 7), apnoea (n = 6; 4 premature and 2 full-term infants) and tracheal re-intubation (n = 6). Conclusions  Continuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication).     

Surrogate markers of airway inflammation: inflammometry in paediatric respiratory medicine

Until recently, there has not been any practical way to assess airway inflammation non-invasively in paediatrics. Surrogate markers of airway inflammation are potentially of great importance in the diagnosis and monitoring of inflammatory airways disease in children. A large number of substances in blood, urine and exhaled air or induced sputum are currently under study to evaluate their possible usefulness as markers of airway inflammation. To be useful, a marker should be valid, preferably non-invasive, quick, reproducible, repeatable and cheap. In addition, markers should be studied in relation to their specific purpose because different markers may be useful for different types of airway inflammation. Few, if any, markers will fulfill all these requirements. Most research has focused on applications of markers in asthma, some data refer to cystic fibrosis, infections and ciliary dyskinesia. Of all surrogate markers, exhaled nitric oxide has been studied the most and seems to offer information that should be evaluated for its relevance to clinical practice. Before introducing markers of inflammation into daily practice, analysis of benefits and costs are needed. There is little doubt that 'inflammometry' will be a major step forward and will be useful in differentiating airways diseases and improving treatment.