Color Doppler sonography of the scrotum

Color Doppler sonography is a noninvasive, rapidly performed, and relatively inexpensive imaging technique for use in the diagnosis of scrotal pathology. Its major and proven role is in the evaluation of patients with acute scrotal pain, for which it is likely to become the primary imaging modality. Further work is needed to determine whether color Doppler is a useful diagnostic adjunct in evaluating patients with varicoceles and scrotal masses.     

Multicystic dysplastic kidney: observations of contralateral disease in the fetal population

To evaluate multicystic dysplastic kidney (MDK) and associated contralateral renal abnormalities in the fetal population, 27 cases detected and followed in utero were reviewed retrospectively. The sonographic assessment included estimation of amniotic fluid volume and interval growth, evaluation for non-genitourinary anomalies, and postnatal follow-up study. Contralateral renal anomalies were detected in 41% of the fetuses and included obstruction of the ureteropelvic junction, renal agenesis, renal hypoplasia, and bilateral MDK. The incidences of these malformations were compared with results of earlier studies of MDK in the pediatric and adult populations. Lethal anomalies, such as bilateral MDK and MDK associated with contralateral agenesis, are common (19% and 11%, respectively) in the fetal population; obstruction of the contralateral ureteropelvic junction, a nonlethal anomaly, was seen less commonly (7%). Perinatal death from lethal abnormalities may spuriously raise the incidence of nonlethal contralateral abnormalities in the pediatric and adult populations. Contralateral mild fetal pyelectasis, found in 15% of fetuses with MDK, was not clinically significant.     

The effect of oral nitroglycerin on portal blood velocity as measured by ultrasonic Doppler. A double blind, placebo controlled study

We studied the effect of oral nitroglycerin on portal blood velocity (PBV) in 20 cirrhotic patients by a double blind, placebo controlled method using noninvasive Doppler sonography. After we obtained baseline Doppler in the fasting state, 0.6 mg nitroglycerin or placebo was given orally and the mean of 3 s averaged mean PBVs was repeated at 5 min intervals for 60 min. Ten patients each received nitroglycerin or placebo. Portal vein flows were antegrade in all. Of the 10 patients receiving nitroglycerin, seven (P = 0.002) showed a greater than 10% fall in the mean PBVs for at least 15 min. Of these seven "responders," five patients had a 10% decrease in mean systemic blood pressure for at least 15 min. None of the "nonresponders" had systemic hypotension. Our study suggests that the PBV-reducing effect of nitroglycerin in cirrhotics may be explained in part by systemic hypotension.     

Resolving duodenal-jejunal hematoma in abused children

Acute intramural duodenal-jejunal hematoma is a classical finding in the battered child syndrome. The radiographic findings of a large obstructing intramural mass associated with the "coiled-spring" appearance generally raise the question of child abuse in any patient without appropriate accidental injury. In this study the radiologic features of resolving duodenal-jejunal hematoma are detailed in five abused children. The results show that the coiled-spring appearance is an acute phenomenon associated with a well-localized intramural hematoma. In the resolving phase, localized mural masses in the lateral aspect of the descending duodenum and fold thickening are indications of prior intramural hemorrhage. When these radiologic features are encountered in a child with nonspecific abdominal complaints, child abuse should be suspected. Furthermore, in patients with suspected occult trauma, resolution of abdominal symptoms should not deter the radiologist from performing an upper gastrointestinal tract series, which may provide evidence of child abuse.     

Increased plasma thyroid stimulating hormone in treated congenital hypothyroidism: relation to severity of hypothyroidism, plasma thyroid hormone status, and daily dose of thyroxine

Plasma thyroid stimulating hormone (TSH) concentrations obtained during the first four years of treatment in 418 children with congenital hypothyroidism, identified by neonatal screening, were examined in relation to paired measurements of plasma thyroxine (n = 1945), free thyroxine (n = 836), triiodothyronine (n = 480), and free triiodothyronine (n = 231), and estimated daily dose of thyroxine at the time of blood sampling. Overall, plasma TSH was above 7 mU/l in 1280 out of 2960 samples (43%); the percentage was not related to severity of hypothyroidism at diagnosis. Mean values for thyroxine and free thyroxine, and to a lesser extent free triiodothyronine, were consistently lower in samples with TSH concentrations over 7 mU/l and this was the case in patients with either severe or less severe hypothyroidism. Raised TSH concentrations were also associated with lower mean doses of thyroxine (micrograms/kg/day) but here the mean doses of thyroxine in children with severe hypothyroidism were higher than in the children with less severe hypothyroidism. The mean dose of thyroxine associated with low/normal TSH values was highest in the first 6 months and fell progressively. Thyroxine dose was significantly related to thyroxine and free thyroxine concentrations but not to triiodothyronine and free triiodothyronine and the latter appeared to be of limited value as measures of plasma thyroid hormone status during treatment.     

Redo pullthrough for Hirschsprung disease

Pullthrough procedures for Hirschsprung diseases typically have favorable results. However, some children experience long-term postoperative complications comprising stooling disorders, such as intermittent enterocolitis, severe stool retention, intestinal obstruction, as well as incontinence. Reoperative Hirschsprung Disease surgery is complex. This begins with the workup after the initial presentation following primary pullthrough, continues with the definitive surgical correction with redo pullthrough, and ends with long-term follow-up of individuals. The decision tree can be varied with each patient. The operating pediatric surgeon must be able to utilize different operations and treatment options available. While lesser procedures may provide relief in a select population, those with residual aganglionosis or transition zone pathology or mechanical problems will likely require a redo pullthrough. Thus, the diagnostic workup, treatment plan, and definitive surgical care should be coordinated, and executed by an experienced, specialized team at a pediatric referral center.     

Perioperative Quality Initiative consensus statement on intraoperative blood pressure,risk and outcomes for elective surgery

Background

Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017.

Detecting fetomaternal hemorrhage: a comparison of five methods

Appropriate postpartum administration of Rh immune globulin relies on sensitive detection and accurate quantitation of fetomaternal hemorrhage (FMH). Recently, the microscopic Du test (micro Du) enhanced with polyethylene glycol (PEG Du) and flow cytometry (FC) have been advocated for this purpose. Three qualitative methods (micro Du, rosette test, and PEG Du) and two quantitative methods (acid elution and FC) for assessing FMH were evaluated with particular attention given to PEG Du and FC. In vitro studies comprised 10 series of dilutions of D+ cord cells in D- adult cells to yield D+ cell concentrations of 0.06, 0.12, 0.25, 0.50, 0.75, 1.0, and 2.0 percent. Additionally, 26 postpartum samples were tested. Of the qualitative techniques, the micro Du test was the least sensitive with 20 percent false-negative results occurring at 0.5 percent fetal cells. The PEG Du test was only slightly more sensitive and offered no clinical advantage. The rosette test was the most sensitive, consistently detecting fetal cells at concentrations of 0.25 percent or greater. FC and acid elution showed similar results, with good correlation obtained between measured and expected quantities of fetal cells (r = 0.99 and 0.96, respectively). One of 26 postpartum samples was positive by all screening techniques; acid elution and FC detected 0.3-percent concentrations of fetal cells and 0.17-percent concentrations of D+ cells, respectively. Although acid elution is a more commonly used method for quantitating FMH, FC offers an acceptable alternative that is capable of analyzing large numbers of cells with objectivity and reproducibility.