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BMJ No 7113 Volume 315 This week in brief Saturday 11 October 1997
Chance of new renal scars in children under 4 years is small Chance of new renal scars in children under 4 years is smallUrinary tract infections may cause renal scars in young children that can lead to hypertension or renal failure, often years later. However, the age when children outgrow this risk has been uncertain; the evidence has come from intravenous urography, which may fail to show scars for years. On p 905 Vernon et al report a follow up of children in Newcastle who had urinary infections as 3 and 4 year olds and were investigated by dimercaptosuccinic acid scanning, which detects scars immediately they occur. Repeat scanning 2-11 years later showed that 2% of the 3 year olds had developed a renal scar, but none of the 4 year olds. The authors argue that children aged 4 and older with a normal scan are at little risk of developing scars and need neither surveillance nor imaging after further urinary infections. In a separate report (p 918) the same group reports referral and scarring rates among children aged 16 with a first referral for a urinary tract infection in three health districts over four years. All children had dimercaptosuccinic acid scans performed after two months free of infection. The mean annual referral rate was 0.46%; cumulative referral rates by 16 were 3.6% for boys and 11.3% for girls. Although girls outnumbered boys, the scarring rate was similar, 4.3% for boys and 4.7% for girls. Clinical features were of no value in predicting scarring. To improve diagnosis the authors suggest collecting a urine sample from any infant with an unexplained illness. Optimal fluid loading cuts hospital stay in patients having hip surgeryEach year about 57,000 patients in England and Wales fracture their femoral neck. Repair constitutes surgery, with considerable postoperative mortality and morbidity in a high risk population and often a protracted postoperative hospital stay. Improvements in outcome have been shown in high risk patients undergoing major surgery with perioperative cardiovascular optimisation protocols which used invasive monitoring of cardiac output. On p 909 Sinclair et al show how using a minimally invasive oesophageal Doppler ultrasound technique to monitor intraoperative intravascular volume optimisation resulted in significantly improved haemodynamics, faster postoperative mobilisation, and a major reduction in hospital stay in one London teaching hospital. If these figures are extrapolated to England and Wales, this simple intervention would save half a million bed days a year. Weight loss leads to regression of left ventricular hypertrophyObesity often coexists with arterial hypertension, leading to various degrees of left ventricular hypertrophy. Several studies have shown that the medical treatment of hypertension is associated with a regression in abnormal heart structure, but the few studies of the effects of weight loss on left ventricular mass and geometry have had conflicting results. Karason et al found that weight loss was followed by a distinct reduction in left ventricular mass and relative wall thickness as judged by echocardiography (p 912). The changes in heart structure were better predicted by weight loss itself than by the concomitant reduction in blood pressure. Medical students learn clinical skills as well in general practice as in hospitalDespite moves towards community based medical education, little
evidence exists on its efficacy. On p 920 Murray et al present data
from a randomised crossover trial comparing clinical skills acquisition
by first year clinical medical students in two halves of a block of
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