提高小儿肾积水诊治水平

小儿肾积水多因先天性泌尿生殖系统发育畸形所致,其中约2／3为肾盂输尿管连接部梗阻,1／3为膀胱输尿管返流或梗阻。小儿肾积水的诊断和治疗并不困难,日益进步的产前超声检查,使胎儿期肾积水即可明确诊断;内镜和腹腔镜下手术也得以逐步推广,实现微创解除梗阻和改善肾功能。但是,在选择影像学诊断时机及制定治疗策略方面,尤其是婴幼儿肾积水,仍不规范和存在争论。     

小婴儿肾积水手术治疗及预后评价

目的 探讨小婴儿肾积水手术指征、治疗及预后.方法 总结40例小婴儿肾积水的手术治疗.全部病例术前均行彩超、IVP、静脉肾盂造影后三维CT重建及SPECT检查.所有患儿均行肾盂输尿管成形术,术后病理证实为肾盂输尿管交接处梗阻所致肾积水.术后常规随访,行彩超和SPECT检查.结果 所有患儿手术经过顺利,无手术并发症.术后3个月彩超示所有患儿肾盏扩张明显减轻,肾盂前后径和肾实质厚度均较术前好转,术前肾实质平均厚度为(4.37±1.57)mm,术后为(5.89±1.66)mm;两者比较有显著差异,P=0.000.术前.肾盂前后径为(4.20±1.66)cm,术后为(1.93±0.98)cm,两者比较有显著性差异,P=0.000.32例单侧肾积水术后25例肾脏功能稳定,7例有不同程度的恢复,没有恶化者.8例双侧肾积水较重侧手术,术后对侧积水均明显减轻.结论 小婴儿肾积水肾盂前后径增大并出现肾盏扩张、肾实质变薄者,即使肾功能正常也以手术为佳.肾功能恶化、肾积水加重或出现临床症状者应积极手术.肾盂前后径小于2 cm,肾功能在40%以上,但肾图为梗阻曲线者应密切观察.小婴儿肾积水手术效果良好,术后肾脏形态恢复显著,肾脏功能可以保存.     

儿童肾积水的影像学诊断策略

儿童肾积水最常见的病因是肾盂输尿管连接部(uteropelvic junction,UPJ)狭窄,表现为肾盂肾盏扩张积水。临床上对儿童肾积水的诊断依赖于超声、静脉肾盂造影(intravenous pyelography,IVP)、MR尿路成像(MR urography,MRU)、CT尿路成像(CT urography,CTU)、核素扫描(SPECT肾动态扫描)等多种影像学检查。不同医疗机构设备和技术不尽相同,目前诊断儿童肾积水主要有超声+IVP+MRU、超声+CTU、超声+SPECT+MRU等几种影像学检查组合。本文就儿童肾积水各种影像学诊断方法的优缺点及最佳组合方式进行解读。     

先天性肾积水实验研究进展

小儿先天性肾积水临床多见 ,约占新生儿的 1% [1] 。虽已进行大量临床和实验研究 ,其病理生理机制仍未完全阐明。现代影像学及肾功能测定方法的发展改变了过去“肾脏扩张即存在梗阻需要手术治疗”的观念。已发现许多肾积水患儿不必手术可长期保持良好稳定的肾功能[2 4] 。动物实验已显示 ,轻度输尿管不全梗阻虽能引起明显肾积水 ,肾功能并不一定进行性下降[3] 。但临床也确有不少肾盂输尿管交界处不全梗阻患儿如不及时手术解除梗阻 ,肾功能将进行性损害。然而 ,如何精确诊断输尿管梗阻程度及预测肾积水发展趋势 ,临床尚无可靠方法。Ｂ超、…     

先天性畸形产前超声诊断与临床价值评估

目的探讨产前诊断先天性畸形的超声影像学特点及临床价值。方法总结我院1999年6月～2007年1月接诊的156例产前诊断先天性畸形的临床和超声检查资料并分析。结果典型超声征象：①食管闭锁：羊水过多和胃泡影消失；②十二指肠梗阻：“双泡征”，伴羊水过多；③小肠闭锁：腹部多个囊泡；④脐膨出与腹裂：腹腔脏器于中腹部膨出腹腔外，有包膜为脐膨出，无包膜为腹裂；⑤先天性膈疝：腹腔脏器疝入胸腔伴纵隔、心脏移位及腹围减小；⑥肾积水：肾盂扩张；⑦腹腔囊性肿物：根据囊肿部位、性质、与周围脏器关系等进行诊断；⑧血管瘤、淋巴管瘤：根据瘤体质地、部位和血供情况等进行诊断；⑨脑积水：不同程度和部位的脑室扩张。结论超声检查为先天性畸形产前诊断的主要手段。常见的十二指肠梗阻、脐膨出、腹裂、肾积水等畸形的产前诊断准确率高。了解产前超声检查征象、诊断价值及临床意义，有助于临床医生更好地把握畸形儿病情、向家长解释病情和制定正确的治疗方案。     

新生儿先天性重度肾积水诊疗分析

目的 探讨产前超声诊断的重度肾积水胎儿出生后围新生儿期的诊断、手术治疗及疗效.方法 对新生儿期入院的肾积水患儿7例进行分析,超声提示存在4级肾积水,行IVP或ECT 及 MRU检查后提示重度UEJ0肾积水.6例直接行离断式肾盂成型术（Anderson-Hynes术）.另1例行肾穿刺造瘘术.引流38 d后再行肾盂成形术.结果 7例患儿均无近期手术并发症.术后随访6个月至2年.尿常规未见明显泌尿系统感染.超声提示肾盂分离值较术前明显改善,肾皮质厚度较术前增厚.结论 肾积水围新生儿期手术治疗安全而有效,新生儿重度肾积水,明确诊断即可积极手术治疗,以保存患肾功能.超声检查对于肾积水患儿术前诊断及术后随访有重要意义.     

梗阻性肾积水各种检查技术的评价

由于超声的广泛应用 ,胎儿肾积水和无症状肾积水的诊断率大大提高 ,对于这些儿童肾积水的正确评价及处理有很大争议 ,因为肾积水不一定和有临床意义的尿路梗阻相关 (即尿流受阻引起进行性肾损害 ) ,并且可能代表一种无进行性肾功能损害的非梗阻性扩张 ,因此 ,需要区分这两种情况 ,以决定是否需要手术。但目前还没有一个诊断生理性肾积水的标准 ,为此 ,国外许多学者做了大量研究 ,现将各种检查技术的评价作如下综述以指导临床。一、Ｗｈｉｔａｋｅｒ试验Ｗｈｉｔａｋｅｒ试验是诊断上尿路梗阻的一种方法 ,经皮肾造瘘 ,以 10ｍｌ/ｍｉｎ的速度…     

产前MRI在胎儿中重度肾积水评估中的作用探讨

目的探讨产前MRI在评估胎儿中重度肾积水程度及病因中的作用。方法选取本院2015年4月至2017年3月间经超声筛查发现异常,行产前MRI检查诊断为胎儿中重度肾积水的患者共26例,扫描序列包括半傅立叶单次激发快速自旋回波(HASTE)序列、真稳态进动快速成像(True-FISP)序列、T1WI及DWI。将产前磁共振影像学资料与产后影像学检查及手术情况相对照。结果 26例中重度肾积水胎儿中,23例经手术或尸检病理证实,其中肾盂输尿管移行处狭窄15例,先天性巨输尿管4例,先天性巨输尿管伴重复肾3例;后尿道梗阻1例;产前MR诊断正确20例;其余3例仍在随访观察中。结论产前胎儿MRI检查作为产前筛查的一种辅助检测手段,能进一步明确肾积水的病因、严重程度及累及范围,填补超声检查的不足。同时,也可让临床医生更加直观地了解病情,为临床诊疗提供更贴切的依据。     

新生儿肾积水

目的　探讨新生儿肾积水盂管交界处狭窄段的病理变化、手术及保守治疗的指征。方法　总结 10例新生儿肾积水的治疗。 10例均行B超、IVU或CTU、ECT检查。 7例 8个肾因肾盂及肾盏明显扩张、肾功能中至重度损害 ,行切除盂管狭窄段、肾盂成形及肾盂输尿管吻合手术治疗 ,切除的盂管狭窄段行病理及超微结构观察 ;1例由输尿管末端囊肿引起的肾积水 ,经膀胱行输尿管囊肿开窗术 ;另 3例肾积水较轻 ,肾功能正常或轻度受损 ,未手术只行长期观察随访。结果　 7例手术患儿术后恢复顺利 ,术后随访 3个月～ 3年 ,肾积水减轻 ,肾功能明显改善。病理检查 ,见管腔内上皮细胞无明显变化 ,管壁平滑肌细胞排列紊乱、退化、变性 ,细胞间隙增大 ,管壁内有大量胶原纤维增生致管腔狭窄。 3例观察随访的患儿无明显变化。结论　①对肾盂轻度扩张 (肾盂直径 <12mm) ,肾功能正常或接近正常 (相对肾功能大于 4 0 % )的患儿 ,可随访观察 ;②对肾盂扩张 ,积水程度严重 (中～重度 ) ,肾功能受损 ;或在观察治疗过程中 ,肾功能进行性减退的患儿 ,应行手术治疗 ,这类患儿多已存在不可逆的病理组织变化     

产前检出的肾积水的临床特征和随访结果

目的 探讨产前检出的肾积水的临床特征及生后处理.方法 对2001年6月～2006年6月间收治的产前检出的89侧肾积水、15侧肾输尿管积水患儿进行回顾性分析.患儿生后利用超声检查和利尿性肾图进行随访.患儿出现相关症状或肾功能下降则行手术治疗.对无需手术患儿仅观察自然病程.结果 89侧单纯肾积水中,42侧(47.2%)自行缓解,24侧(27.0%)需行手术,另23侧仍处于观察中.15侧肾输尿管积水中,10侧肾输尿管积水消失,4侧肾输尿管积水需接受手术,1例仍在观察中.结论 胎儿期出现的肾积水存在明显的自发缓解倾向,患儿生后需进行超声检查和利尿性肾图随访,出现相关症状或肾功能下降即手术干预.     

Primary non-refluxing megaureters

Megaureters may be primary or secondary, and the dilatation may be due to obstruction or reflux, or both or neither. The cause of primary obstructed megaureter is the aperistaltic and narrowed pre-vesical portion of the ureter. The inner sheath of the terminal ureter generally shows a reduced amount of longitudinal smooth muscle bundles and an increased amount of collagen. Primary non-refluxing megaureters represent 23% of all prenatal diagnoses of hydronephrosis. They are more common in males and on the left side, and in 25% are bilateral. In older children they may become symptomatic. The diagnostic work up should include an ultrasound, a micturating cystourethrogram and an isotopic renogram. Most primary megaureters regress spontaneously or remain stable without compromising renal function, but 10-25% require surgery because of a progressive reduction in renal function or increasing dilatation, or because they become symptomatic. The basic principles of surgical repair include: resection of the obstructing segment, reduction in size of the dilated ureter, and re-implantation into the bladder using an anti-reflux technique.     

Management of the primary obstructed megaureter (POM) and indication for operative treatment.

Presented is the diagnostic and therapeutic management of the primary obstructed megaureter (POM). 42 patients presented with 53 ureteral units (UU) of POM (5 females, 37 males, 36 neonates and 6 children aged 3 to 8 years). Of the 53 megaureters 10 UU (19%) were on the right and 27 UU(51 %)were on the left. 8 patients (19%)with 16 UU (30%)showed a bilateral abnormality. In 41% of the patients, hydronephrosis had been discovered by prenatal ultrasound. All patients were evaluated postnatally by ultrasound (US), voiding cysturethrogram (VCUG), intravenous pyelogram (IVP) and diuresis renogram (MAG-3) (DR). Due to the percentage of urinary drainage,the renogram results were classified into different categories:no obstruction, functional obstruction, equivocal and obstruction. A partial renal function was also calculated. Follow-up of the patients ranges between 5 to 48 months (mean: 22.1). All patients underwent serial US and serial DR were obtained in 36 patients. Initially, 9 (17%) UU showed a functional obstruction, 34 (64.2%) an equivocal and 10 (18.8%) an obstructive urinary drainage pattern. 2 kidneys showed a significant decreased partial function of 20, respectively 26%. Surgery was performed in an initial im-paired renal function with an obstructive pattern or in cases with normal function and at least equivocal urinary drainage pattern with no improvement or deterioration of the urinary drainage and/or function in the follow-up. Considering these criteria, 5(9.6%) patients needed surgery. No loss of kidney function has been observed in follow-up. DR is the most valuable diagnostic tool. Criteria interpreting the results are demonstrated in this article.     

Comparison between ultrasonography and X-ray as evaluation methods of central venous catheter positioning and their complications in pediatrics

This study evaluates the capacity of ultrasonography as a diagnostic method to confirm the proper positioning of central venous catheter (CVC) when compared to the current gold standard, chest radiography (CR). A prospective study was performed including children from 0 to 14 incomplete years, who underwent CVC placement between March and May 2018 at a teaching hospital in Brazil. A four-chamber view of the heart was performed with ultrasound during a rapid injection of saline solution to identify hyperechoic images and confirm the central position of the catheter. After that, a CR was performed. The diagnostic quality of ultrasound was evaluated based on accuracy, sensitivity, specificity, positive and negative predictive values. A total of 21 patients were analyzed. The mean age was 3.95 ± 4.01 years. The preferred puncture site was the right internal jugular vein (71.4%). Ultrasound accuracy to detect CVC positioning was 81%. Sensitivity, specificity and positive and negative predictive values were 33%, 100%, 100% and 79%, respectively. Ultrasound is a reliable method for detection of CVC positioning. Even so, with the four-chamber cardiac view, this method is unable to identify catheters inside heart chambers, therefore, needing to confirm the positioning with CR.     

Understanding diagnostic tests 1: sensitivity, specificity and predictive values

The usefulness of diagnostic tests, that is their ability to detect a person with disease or exclude a person without disease, is usually described by terms such as sensitivity, specificity, positive predictive value and negative predictive value. In this article, the first of the series, a simple, practical explanation of these concepts is provided and their use and misuse discussed. It is explained that while sensitivity and specificity are important measures of the diagnostic accuracy of a test, they are of no practical use when it comes to helping the clinician estimate the probability of disease in individual patients. Predictive values may be used to estimate probability of disease but both positive predictive value and negative predictive value vary according to disease prevalence. It would therefore be wrong for predictive values determined for one population to be applied to another population with a different prevalence of disease. CONCLUSION: Sensitivity and specificity are important measures of the diagnostic accuracy of a test but cannot be used to estimate the probability of disease in an individual patient. Positive and negative predictive values provide estimates of probability of disease but both parameters vary according to disease prevalence.     

床旁肺部超声在新生儿肺炎中的诊断价值

目的 探讨床旁肺部超声在新生儿肺炎中的诊断价值。方法 收集2017年3月就诊于成都市妇女儿童中心医院新生儿重症医学科,以呼吸道症状为主诉,并在入院24 h内完善床旁肺部超声的49例新生儿的临床资料。对49例患儿的临床资料、肺部超声资料进行回顾性分析,对床旁肺部超声诊断新生儿肺炎进行诊断价值评价。结果 49例患儿中,根据新生儿肺炎诊断的金标准,44例诊断为新生儿肺炎;根据新生儿肺炎肺部超声诊断标准,38例诊断为新生儿肺炎。肺部超声在有呼吸道症状新生儿中诊断新生儿肺炎的敏感性为 86%,特异性为100%,阳性预测值为100%,阴性预测值为45%。44例金标准诊断的新生儿肺炎患儿中,肺部超声声像图显示,44例（100%）均出现B线,表现为异常胸膜线的比例达75%,部分患儿出现斑片/局限性弱回声区（36%）或肺泡间质综合征（27%）、支气管充气征（20%）等。结论 床旁肺部超声作为新的临床诊断技术,对新生儿肺炎的诊断敏感性高、特异性强,可作为新生儿肺炎诊断的工具。     

Diagnostic accuracy of ultrasonic examination in suspected craniosynostosis among infants

The current study was performed to assess the diagnostic accuracy of ultrasound compared to CT scan as a gold standard in the diagnosis of craniosynostosis. 44 infants (17 girls) under 1 year old, clinically suspected to have craniosynostosis, were first sonographically examined by a pediatric radiologist and were later referred to another blinded pediatric radiologist to examine CT scan with 3D reconstructed images of skull. Sensitivity, specificity, positive and negative predictive values of ultrasound versus CT scan were 96.9%, 100%, 100%, and 92.3%, respectively. The high specificity of ultrasound helps to correctly rule out craniosynostosis in clinically suspected cases and thus, can prevent unnecessary exposure of healthy infants to CT scan ionizing radiation.     

Using computer based data acquisition and analysis system for nasal potential difference measurement in cystic fibrosis

Nasal potential difference (PD) measurement has been used as a diagnostic test for cystic fibrosis (CF). It has been shown that large differences in reproducibility of nasal PD measurement can exist between different study sites. These differences reduce the validity of studies. In our study we tried to measure nasal PD values for a group of Turkish CF patients by using a computer based data acquisition system, which could eliminate the bias due to using different voltmeters. The CF group (n=40, mean age 9.3 years) value was -39.21+/-1.74 mV, and the control group (n=36, mean age 17.08 years) value was -18.24+/-1.48 mV (mean+/-SEM). Using the electronic data acquisition and analysis systems gave reliable results with high specificity (92%), sensitivity (79%), positive predictive value (95%) and negative predictive value (72%). Computer based data acquisition and analysis system provides suitable monitoring and continuous recording during measurements and facilitates repeat readings at the same distances along the nasal floor. Using electronic data acquisition may help to minimize the subjectivity in voltmeter measurements and hand analysis.     

Clinical predictors for differential diagnosis of acute scrotum.

Accurate and early diagnosis of acute scrotum is of the utmost importance to avoid testicular loss and/or needless surgery. The aim of this study is to analyze the clinical presentation and physical examination parameters together with the results of imaging studies in order to find out predictors for the differential diagnosis of acute scrotum with special emphasize on testicular torsion (TT). Patients who were treated for acute scrotum in our unit from 1970 up to and including 2000 were reviewed retrospectively. The study group was subdivided into three groups: "testicular torsion (TT)", "torsion of testicular appendage (TTA)", and "epididymoorchitis (EO)" group according to the diagnosis confirmed by radiologic and surgical findings. Presence and/or absence of various parameters related to clinical presentation, physical examination, and results of imaging studies were analyzed by statistical means in each group. One hundred and sixty children with a mean age of 12.2 years formed the study group. The mean duration of symptoms was 15 hours. No significant difference was noted between the three groups with regard to mean age and duration of symptoms. Nuclear scintigraphy and Doppler ultrasound were used as diagnostic aids in 50 and 66 children, respectively. Clinical presentation parameters including the presence of a) previous trauma, b) pain attacks, and c) nausea and vomiting, had the highest sensitivity, specificity, positive and negative predictive values in the TT group and the lowest values in the EO group. In contrast, the EO group had the highest statistical values with regard to presence of dysuria and micturition disorders. Physical examination parameters consisting of a) elevation, b) transverse location of testis, c) anterior rotation of epididymis, and d) absence of cremasteric reflex had the highest statistical values in the TT group. Contrary to this, imaging studies had the highest specificity and positive predictive values in the TTA group and the lowest values in the TT group. Previous history of trauma and pain attacks, presence of nausea and vomiting, and absence of urinary complaints are the main predictors of TT. Elevation and transverse location of testis with an anteriorly rotated epididymis associated with loss of ipsilateral cremasteric reflex strongly indicate TT. Although accuracy of imaging studies is higher for the differential diagnosis of TTA and EO, there is a considerable risk of misdiagnosis. Therefore, differential diagnosis of acute scrotum, particularly TT, still remains a clinical diagnosis, and clinical parameters deserve more importance in surgical decision making.     

UTI: diagnosis and evaluation in symptomatic pediatric patients

We retrospectively reviewed data on 260 hospitalized pediatric patients with symptomatic urinary tract infection (UTI). To ascertain the colony-forming units (CFU)/mL compatible with the diagnosis of UTI, a culture from a catheterized urine specimen containing >1,000 CFU/mL was considered diagnostic of UTI and resulted in imaging by renal ultrasound, voiding cystourethrography, and renal nuclear scan with Tc99m dimercaptosuccinic acid (DMSA). A positive DMSA renal scan is indicative of pyelonephritis. We used logistic regression analysis to determine which patient characteristics were predictive of pyelonephritis. We determined that, in hospitalized pediatric patients, the colony count of the positive urine culture, the type of organism grown in culture, and the voiding cystourethrography (VCUG) result (positive or negative for vesicoureteral reflux) did not predict which patients had pyelonephritis. In females, advancing age of the patient and positive renal ultrasound results were predictive of which patients had pyelonephritis when we controlled for other factors. We feel this emphasizes the importance of a thorough evaluation of hospitalized symptomatic patients, including patients with colony counts of 1,000 to 50,000 CFU/mL, to locate the level of infection and plan appropriate therapy.