Virtual bronchoscopy in the child using multi-slice CT: initial clinical experiences

PURPOSE: Virtual bronchoscopy of the pediatric patient has been reported to be more difficult because of artifacts due to breathing or motion. We demonstrate the benefit of the accelerated examination based on multislice spiral CT (MSCT) in the pediatric patient which has not been reported so far. MATERIAL AND METHODS: MSCT (tube voltage 120 kV, tube current 110 mA, 4 x 1 mm Slice thickness, 500 ms rotation time, Pitch 6) was performed on a CT scanner of the latest generation (Volume Zoom, Siemens Corp. Forchheim, Germany). In totally we examined 11 patients (median age 48 months, range 2-122 months) suspected of having tracheoesophageal fistula (n = 2), tracheobronchial narrowing (n = 8) due to intrinsic or extrinsic factors or injury of the bronchial system (n = 1). RESULTS: In all patients we obtained sufficient data for 3D reconstruction avoiding general anesthesia. 6/11 examinations were described to be without pathological finding. A definite diagnosis was obtained in 10 patients. Virtual bronchoscopy could avoid other invasive diagnostic examination in 8/11 patients (73%). CONCLUSION: Helical CT provides 3D-reconstruction and virtual bronchoscopy in the newborn as well as the infant. It avoids additional diagnostic bronchoscopy in a high percentage of all cases.     

Evaluation and Treatment of Low Responders in Assisted Reproductive Technology: A Challenge to Meet

Purpose: To investigate the various methods of evaluationand treatment of patients with a low response to controlledovarian hyperstimulation in assisted reproductive technologies (ART). Methods: Review and analysis of relevant studies publishedin the last decade, identified through the literature and Medlinesearches. Results: While a universally accepted definition for lowresponders is still lacking, these patients are reported torepresent about 10% of the ART population. Several ovarianreserve screening techniques have been proposed; however,currently the best-characterized and most sensitive screeningtools available are the basal day 3 serum follicle-stimulatinghormone level and the clomiphene citrate challenge test.When abnormal, these tests allow physicians to counselpatients that their prognosis for conception is poor. Althoughthe presence of a normal result does indicate better long-termchances for conception, an age-related decline in fecundityremains and patient age should still be considered whencounseling patients with normal screening results. Severalstimulation protocols have been applied in the low-responsegroup with varying success. Recent studies show that theuse of a minidose gonadotropin-releasing hormone-agonistprotocol may result in significantly decreased cycle cancellationsas well as increased clinical and ongoing pregnancies,and thus is proposed as a first-line therapy. Studies evaluatingsupplementary forms of treatment to the ovulation inductionregimen show improved outcome when pretreating withoral contraceptives, whereas there seems to be no benefitfrom cotreatment with growth hormone or glucocorticoids.Blastocyst culture and transfer and assisted hatching in lowresponders are still under evaluation, whereas natural cyclein vitro fertilization may be used in cases of repeated failuresas a last option before resorting to oocyte donation or adoption.Future possible forms of treatment like in vitro maturationof immature human oocytes, cytoplasm, and nucleartransfer currently are experimental in nature and their efficacyhas still to be proven.Conclusions: The evaluation and treatment of low respondersin ART remains a challenge. Understanding of the underlyingetiology and pathophysiology of this disorder may helpthe clinician to approach it successfully.     

Limitations of the medical evaluation for child sexual abuse

The purpose of this review is to highlight the inherent difficulties that a clinician faces during the evaluation of child sexual abuse cases. Each component of the medical evaluation has its own unique problems. Some of them are caused by the nature of the abusive relationship, while others are the result of the children's limited verbal skills. Readers should be aware of these limitations as they formulate an opinion at the conclusion of the examination.     

Treatment of oligoasthenospermia with human chorionic gonadotropin: hormonal profiles and results

Forty-seven oligoasthenospermic patients were treated with human chorionic gonadotropin, 5000 IU twice weekly for 12 to 15 weeks. Only three patients impregnated their wives following treatment. Sperm concentration subsequent to treatment decreased in 26 patients, increasing in only 8 cases. Sperm motility improved in 36% of the patients and deteriorated in 30%. During treatment, mean testosterone levels rose by 72%, mean estradiol levels rose by 140%, and mean follicle-stimulating hormone levels decreased by 80%. Mean prolactin levels remained unaltered. The disappointing results with human chorionic gonadotropin treatment fail to make it a recommendable therapy for patients with idiopathic oligoasthenospermia.     

Fine structure of Sertoli and Leydig cells in azoospermic human testis.

Testicular biopsy specimens taken from seven patients with azoospermia were studied by electron microscopy. We considered the possibility of a relationship between the annulate lamellae in the Sertoli cells and azoospermia. In the Leydig cells, we observed intranuclear and intracytoplasmic paracrystalline inclusions and considered their relationship with the Reinke crystalloid.     

Cardiac transplantation complicated by acute thrombotic occlusion of the right coronary artery

We report the case of a 63-year-old male patient undergoing cardiac transplantation due to fourth time aortic valve endocarditis. The postoperative course was complicated by thrombotic occlusion of the right coronary artery (RCA) causing acute right ventricular myocardial infarction, which required extracorporeal membrane oxygenation. The RCA could be reopened by catheter-based intervention and the patient stabilized. In order to avoid further immobilization, a right ventricular assist device was implanted and an aortocoronary bypass to the RCA was performed. After that, the patient stabilized progressively, could be weaned from the assist device, and was discharged home 6 weeks after transplantation. On coronary angiography, which is routinely performed 4 to 6 weeks after transplantation, a fistula from the RCA to the right ventricle was detected which was treated conservatively. Five months after transplantation, the patient is in good clinical condition without signs of recurrent endocarditis. This case shows that intense interdisciplinary cooperation of cardiac specialists allows the successful management of very complex patients in serious clinical conditions.     

Mitral valve repair provides improved outcome over replacement in active infective endocarditis

OBJECTIVES: Mitral repair in active infective endocarditis still remains controversial. Several studies demonstrate the feasibility of mitral repair in infective endocarditis; however, superiority of repair has never been shown. The aim of the investigation was to compare valve repair and valve replacement in respect to the extent of destruction and to analyze survival, recurrent endocarditis, and reoperation (event-free survival). METHODS: Sixty-eight consecutive patients underwent surgical intervention for mitral endocarditis. Thirty-four (50%) patients had valve repair, and 34 (50%) patients had valve replacement. Leaflet destruction involving at least one mitral leaflet was present in 15 (44.1%) patients of the repair group and 11 (32.4%) patients of the replacement group. Repair of the mitral annulus with pericardium was performed in 4 (11.8%) patients in the repair group and 3 (8.8%) patients in the replacement group. Patients in both groups were similar concerning the progression of valvular destructions and comorbidities. RESULTS: Hospital mortality was 11.8% (8 patients). No significant differences were found in all baseline parameters, with the exception of a higher incidence of previous septic embolism and sepsis in the repair group. Actuarial event-free survival at 1 year was 88.2% in the repair group compared with 67.7% in the replacement group, and 5-year event-free survival was 80.4% in the repair group and 54.6% in the replacement group (P = .015). Mitral valve repair remained the superior treatment regarding event-free survival in the multivariate analysis (hazard ratio, 0.33; 95% confidence interval, 0.12-0.93; P = .02). CONCLUSIONS: Mitral valve repair offers excellent early and late results and is the preferable treatment option in the surgical therapy of native infective endocarditis.     

Childhood asymmetric labium majus enlargement: mimicking a neoplasm

We report a distinctive lesion of the labium majus resected in 14 girls from 3.9 to 13.2 years of age. All presented with enlargement of 1 or occasionally both labia majora. Radiographic imaging and surgical exploration showed expansion of the labium majus without definable borders. Grossly, specimens consisted of fibro-fatty tissue from 2 to 8 cm in greatest dimension. Microscopic examination revealed the usual constituents of vulvar soft tissue, with expansion of the fibrous component. Sparsely to moderately cellular interconnected bands encircled lobules of fat, blood vessels, and nerves. The bands consisted of plump and occasionally stellate or round fibroblasts immersed in an abundant pale myxoid matrix containing thin collagen fibers. These fibrous bands merged with thinner denser fibrous septa simlar to those seen in the vulva from age-matched controls. Elastic stains showed variably abundant thin parallel elastic fibers. Fibroblasts were immunohistochemically positive for estrogen and progesterone receptors. Electron microscopy showed fibroblasts with dilated rough endoplasmic reticulum cisternae and prominent nuclear fibrous laminae; extracellular matrix contained precollagen, collagen, elastic fibers, and numerous proteoglycan granules. Cytogenetic analysis of 3 lesions revealed a normal karyotype. Recurrence was observed in 7 (50%) patients, and regression was observed in 1 whose recurrence was not reexcised. Over an 11-year period at Children's Hospital (Boston, MA), these lesions represented 22% of all pediatric vulvar soft tissue masses and 3% of all vulvar lesions biopsied. We conclude that "childhood asymmetric labium majus enlargement" is a distinctive clinicopathologic entity of pre- and early puberty. Recognition of this fairly common lesion is important, since it may clinically, radiographically, and histologically mimic an infiltrative neoplasm. Its occurrence at an age roughly coincident with the time of breast budding, capacity for spontaneous regression, histologic architecture and composition of elements native to the vulva, expression of hormone receptors, and normal karyotype suggest that it is an asymmetric physiologic enlargement in response to hormonal surges of pre- and early puberty.     

Effect of pulsed short-wave diathermy on pain and function of subjects with osteoarthritis of the knee: a placebo-controlled double-blind clinical trial

OBJECTIVE: To examine the effects of pulsed short-wave diathermy (PSWD), delivered at an intensity sufficient to induce a thermal sensation and at an athermal intensity, in comparison with a placebo short-wave diathermy treatment, on reported pain, stiffness and functional ability and on mobility performance of patients with osteoarthritis of the knee. DESIGN: A placebo-controlled double-blind trial with sequential allocation of patients to different treatment groups. SETTING: Outpatient physiotherapy department. SUBJECTS: One hundred and three consecutive patients, mean age 73.7 (+/-6.6) years with osteoarthritis of one or both knees for at least three months. INTERVENTIONS: All participants received three 20-min-long treatments per week for three weeks. One group received PSWD with mean power of 18 W (thermal effect), one group received PSWD with mean power of 1.8 W (athermal effect), and one group received sham short-wave diathermy treatment. Patients were assessed before the initial treatment, immediately following the last treatment, and at a three-month follow-up. MAIN MEASURES: Outcome measures included the WOMAC Osteoarthritis Index, which assessed reported pain, stiffness, and functional ability, and four measures of mobility performance: Timed Get Up and Go test (TGUG), stair-climbing, stair, descending and a 3-min walk. RESULTS: A difference across time was observed for the pain and stiffness categories of the WOMAC Osteoarthritis Index (p = 0.033 and p = 0.008, respectively), with no differences between groups. No other significant differences across time or between groups were observed in any of the other measures. CONCLUSION: The findings do not demonstrate pulsed short-wave diathermy, as it is utilized in clinical settings, to be effective in the treatment of osteoarthritis of the knee.