Variation in the diagnosis of vesicoureteric reflux using micturating cystourethrography

  Variability in the interpretation of micturating cystourethrography by paediatric radiologists for the diagnosis of vesicoureteric reflux in children was evaluated. All 265 micturating cystourethrograms (MCUs) that were available from 304 consecutive children aged 0.5 – 61 months  –  who were investigated after their first urine infection between 1993 and 1995 as part of a prospective cohort study  –  were selected for interpretation. Three experienced paediatric radiologists from the same department independently interpreted the MCUs according to the grading system of the International Reflux Study in Children, from grades 0 to V, with the presence of intrarenal reflux also noted. Apart from being informed that urine infection was the indication for the MCU, no other clinical information was given to the radiologists. The indices of variability used were the percentage of agreement and the kappa statistic, expressed as a percentage. Both measures were weighted with integers representing the number of categories from perfect agreement. Disagreement was analysed for children and kidneys. For the diagnosis of vesicoureteric reflux in individual patients, including grade, the percentage of agreement was 96% – 97% (kappa 90% – 91%) and the weighted percentage of agreement was 96% – 98% (weighted kappa 93% – 94%). The same high level of agreement was present for individual kidneys, with a percentage of agreement of 97% – 98% (kappa 89% – 92%) and a weighted percentage of agreement of 98% – 99% (kappa 94% – 95%). There was near perfect agreement in the interpretation of radiological micturating cystourethrography among three experienced paediatric radiologists for the diagnosis and grade of vesicoureteric reflux. Any variations in the medical care of children suspected of having vesicoureteric reflux are not explained by differences in the reporting of this diagnostic test. Received June 19, 1996; received in revised form November 1, 1996; accepted December 6, 1996     

Epidural abscess following epidural steroid and local anaesthetic injection

Epidural abscess is a well-recognised but rare complication of epidural catheter placement. We have found only five previous reports of epidural abscess from noncatheter-related administration of steroids and/or local anaesthetic. We describe a further case which led to critical illness and emphasise the association between diabetes mellitus and epidural infection.     

Very low versus undetectable maternal serum alpha-fetoprotein values and fetal death

Very low maternal serum alpha-fetoprotein (MSAFP) levels (less than 10 ng/mL) are known to be associated with non-viable pregnancies, including conditions such as fetal death, molar pregnancies, and non-pregnancies. There has not been agreement, however, as to whether very low MSAFP levels indicate already existing fetal deaths or are actually predictive. We analysed 230 pregnancies with MSAFP levels less than 10 ng/mL from among 15,807 women (1.5 per cent) screened consecutively during a three-year period and identified 26 non-viable pregnancies, 22 of which were diagnosed sonographically as part of the screening process (17 missed abortions, 3 blighted ova, 2 non-pregnancies). Furthermore, 20 of these 22 pregnancies were associated with essentially undetectable MSAFP levels (less than 5 ng/mL). Our data indicate that pregnancies with MSAFP values less than 5 ng/mL are the group most strongly associated with fetal non-viability and that very low MSAFP values are not strongly predictive for fetal death.     

Representation of spatial frequency and orientation in the visual cortex

Knowledge of the response of the primary visual cortex to the various spatial frequencies and orientations in the visual scene should help us understand the principles by which the brain recognizes patterns. Current information about the cortical layout of spatial frequency response is still incomplete because of difficulties in recording and interpreting adequate data. Here, we report results from a study of the cat primary visual cortex in which we employed a new image-analysis method that allows improved separation of signal from noise and that we used to examine the neurooptical response of the primary visual cortex to drifting sine gratings over a range of orientations and spatial frequencies. We found that (i) the optical responses to all orientations and spatial frequencies were well approximated by weighted sums of only two pairs of basis pictures, one pair for orientation and a different pair for spatial frequency; (ii) the weightings of the two pictures in each pair were approximately in quadrature (1/4 cycle apart); and (iii) our spatial frequency data revealed a cortical map that continuously assigns different optimal spatial frequency responses to different cortical locations over the entire spatial frequency range.     

Interaction of plasma colloid osmotic pressure and joint fluid pressure across the endothelium-synovium layer: significance of extravascular resistance

Fluid exchanges between blood and a synovial joint cavity across two membranes in series--synovial capillary wall (fenestrated) and synovial intima (modified connective tissue). The relation between transsynovial absorption of intraarticular Krebs solution (flow Qs) and plasma colloid osmotic pressure pi p was investigated in rabbit knees perfused at constant blood pressure. Intraarticular pressure Pj was independently controlled. Linear relations between transsynovial flow and plasma colloid osmotic pressure established that transsynovial flow obeys the Starling hypothesis. However osmotic conductance, dQs/d pi p, increased 3.9 times when Pj was raised from 6 cm H2O or subatmospheric pressure to 18 cm H2O--the "yield phenomenon." Comparison of the effects of pi p and capillary pressure revealed no major change in the osmotic reflection coefficient of the blood-joint barrier to albumin upon raising Pj. The large increase in osmotic conductance was predicted quantitatively by a previous model (prediction 3.8 X) based on increases in extravascular (intimal) conductance as a function of extravascular pressure. It is argued that capillary endothelium is not the sole significant hydraulic resistance in this pathway. In the terminology of Intaglietta and de Plomb (1973) synovial capillaries are functionally intermediate between "tubes" and "tunnels."     

Kinetics of specific anti-influenza antibody production by cultured lymphocytes from patients with systemic lupus erythematosus following influenza immunization.

Specific antibody responses to influenza viral antigens produced by cultured peripheral blood mononuclear leucocytes stimulated with influenza virus or pokeweed mitogen (PWM) have been measured in seven patients with systemic lupus erythematosus (SLE) before and at time intervals after influenza immunization. Cells from two patients stimulated with influenza virus in vitro produced high levels of specific antibody 7 days after immunization. Cells from a third patient produced small amounts of specific antibody at day 14. No antibody was produced by cells from the remaining four patients. Responses were of short duration and were not detectable 1 month after immunization. Specific anti-influenza antibody was induced by PWM only from cells of those patients who responded to virus antigen although absolute levels of antibody produced were not as high. In six patients serum haemagglutination inhibiting antibody to influenza virus was measured, and all six had a greater than four-fold increase. The disparity between in vitro antibody production by peripheral blood mononuclear leucocytes and changes in serum antibody suggests that in patients with systemic lupus erythematosus, in vitro functions of peripheral blood lymphocytes do not reflect the immune system as a whole.