Benign and malignant pediatric scrotal masses

Pediatric patients presenting with painless scrotal masses can be perplexing because of the long differential diagnosis. A careful plan based on the physical examination and sonogram findings localizes the mass to the testis or an extratesticular location. Sonography distinguishes solid from cystic lesions. Subsequent management is based on the location and nature of the mass. Intratesticular masses are assumed to be malignant, but testis-sparing surgery is possible in pediatric patients. Extratesticular cystic lesions are likely benign and are managed according to the specific diagnosis. Solid extratesticular lesions require exploration to establish the correct diagnosis.     

Diagnostic value of Doppler ultrasound in evaluation of breast tumors

Angiogenesis is an essential condition for tumor growth. Therefore, it seems to be of interest to prove if blood flow and vascularization of breast tumors give information concerning their dignity. Consequently, 205 patients with palpable and/or mammographically detected breast tumors were examined prior to surgery by doppler sonography for blood flow in the area of the tumor. In 174 patients of this group the corresponding area of the contralateral breast was also screened by doppler ultrasound. With third doppler generation angiodynography tumors can be visualized as B-images with simultaneous information on vascularization. An integrated doppler system shows the detected blood flow in form of a doppler curve, also allowing quantification according to doppler criteria (Resistance Index RI). Blood flow detection in the tumor itself was successful in 71% of all malignancies, whereas in only 6.6% of the 76 benign lesions (n = 5) blood flow was found in the central tumor area. In the area surrounding the tumor blood flow was detected in 83% of all carcinomas, but only in 29% of benign findings. Blood flow could be detected significantly higher in malignancies than in benign lesions (p = 0.003). Blood flow detection in the tumor itself was a highly specific (93%) method of discrimination between malignant and benign breast tumors. Further quantification by means of doppler parameters only increases insignificantly specificity, quantification of blood flow in the area surrounding the tumor using the RI and the comparison with the contralateral breast could improve the diagnostic value as our findings RI < 8 for benign vs. > or = 8 for malignant lesions demonstrated. Detection of malignant tumors showed a sensitivity of 80%, a specificity of 90%, and a positive predictive value of 93%. In patients with breast cancer (histologically confirmed) the detection rate of blood flow in tumors and surrounding areas was independent of tumor size or nodal status.     

Diagnostic imaging for pediatric scrotal disorders

Classification of pediatric scrotal disorders into three typical clinical manifestations--acute scrotal disorders, scrotal masses, and cryptorchidism--provides a practical basis for evaluation with the most commonly used modalities--sonography, scintigraphy, and magnetic resonance (MR) imaging. Acute scrotal disorders of children include acute epididymitis, torsion of an appendix testis or appendix epididymis, and torsion of the spermatic cord. Either scintigraphy or sonography may be used as the first imaging study, and both can aid in distinguishing among the disorders to different degrees. However, sonography is becoming the preferred modality, primarily because of the superior anatomic detail provided. Scrotal masses are also best depicted with sonography, although MR imaging can occasionally be a useful adjunctive modality. In cases of suspected cryptorchidism with equivocal clinical findings, both sonography and MR imaging may be useful, although sonography is usually the initial study. Knowledge of characteristic imaging appearances, as well as benefits and limitations of the available modalities, enables appropriate, expeditious radiologic evaluation of pediatric scrotal disorders.     

Endoscopic ultrasound for peripancreatic masses

BACKGROUND: Pancreatic neoplasms can be difficult to diagnose and stage preoperatively. Accurate staging allows the surgeon to select which patients can benefit from resection versus palliative therapy. Endoscopic ultrasound (EUS) with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a diagnostic modality that provides visualization of peripancreatic tumors and their relationship to the surrounding structures as well as enabling cytologic diagnosis of the tumor and adjacent lymphadenopathy. METHODS: To define the role of this technique, a retrospective study was performed on 20 patients in the past year with peripancreatic tumors. RESULTS: Twelve men and 8 women ranging in age from 28 to 84 years (mean 67) were included in the study. Each patient underwent computed tomography followed by EUS-FNA, and the results were compared with operative findings or clinical course. The EUS-FNA findings included 10 pancreatic ductal carcinomas (50%), 5 pancreatitis (25%), 2 spindle cell neoplasms (10%), 1 cholangiocarcinoma (5%), 1 cystadenoma (5%), and 1 metastatic breast carcinoma (5%). Overall, EUS-FNA led to a significant change in the management of 12 patients (60%) through either diagnosing benign pathology, upstaging of the carcinoma, or determination that the peripancreatic mass represented a metastatic lesion. Five patients underwent resection of their peripancreatic tumors, and 3 patients had palliative procedures. Operative findings corresponded with EUS-FNA in all 8 patients. The 5 patients diagnosed with pancreatitis continued to be followed up for the possibility of a false negative FNA, but to date none have developed malignancy. CONCLUSIONS: EUS-FNA is a useful tool for the imaging and staging of peripancreatic tumors and will aid in the proper preoperative selection of patients who will benefit from resectional therapy.     

Diagnostic reliability of vaginal ultrasound in ectopic pregnancy

The therapeutic approach to ectopic pregnancy (EP) has changed over the last decade. A prerequisite for a differentiated management is an early diagnosis of EP. This can be achieved by transvaginal sonography (TVS). The purpose of this study was to evaluate the accuracy of TVS in the diagnosis of EP. 184 patients with clinically suspected ectopic pregnancy were examined by TVS. In 103 cases suspicion of EP was confirmed, in 81 cases it was ruled out. All cases were evaluated by laparoscopy, D&C, serial HCG determinations or sonographic follow-up in case of an intrauterine pregnancy. Sensitivity of TVS in the diagnosis of EP was 96%, specificity 88%, the positive predictive value was 89%, the negative predictive value was 95%. Four cases with a false negative result at TVS were very early in pregnancy and were subjected to laparoscopy because of persistent high HCG values without demonstration of an intrauterine pregnancy. Five cases of sonographically confirmed ectopic pregnancies were missed by the first laparoscopy. These cases required intervention because of clinical symptoms and had low levels of HCG. TVS has a high diagnostic accuracy in the diagnosis of ectopic pregnancy.     

Diagnostic radiography and ultrasound in the perinatal intensive care unit

A range of possible solutions to common problems associated with radiographic examination of the newborn is presented. The various modes in which ultrasound is currently used as a diagnostic modality are reviewed together with recent innovations that have greatly increased the clinical utility of the technique.     

Diagnostic ultrasound in the management of patients using intrauterine contraceptive devices

A group of 80 patients was scanned by ultrasound within 24 hours of insertion of an intrauterine contraceptive device (IUCD) and re-examined clinically and/or by ultrasound after the next menstrual period. An attempt was made to identify factors such as uterine size, uterine flexion and the position of the IUCD which might be related to its expulsion or removal when, on initial scanning, the device was not located in the fundal area; removal was necessary in 5 out of 6 patients. In patients with an endometrial cavity of less than 40 mm length and/or acute uterine flexion, the overall figure for expulsion and removal was 54 per cent (13 out of 24). It is hoped that a consideration of these factors will lead to a reduction of the failure rate of the IUCD.     

Accurate and cost-effective evaluation of breast masses in males

OBJECTIVE: The primary objective was to evaluate the effect of 7 days treatment with nimesulide on bleeding time. Blood coagulation, von Willebrand factor and platelet aggregation ex vivo were investigated as a secondary objective. METHOD: A randomised, double-blind, placebo-controlled, parallel group, single centre study performed on 20 healthy male volunteers who received either placebo or nimesulide 100 mg twice daily for 7 days. Bleeding time, platelet count and platelet aggregation, thromboplastin time (prothrombin time), activated partial thromboplastin time, fibrinogen, Factor VIII:C, vWF:Ag, vWF:RCof and platelet-rich plasma aggregation following stimulation with adenosine 5'-diphosphate, collagen, arachidonic acid, ristocetin, thrombin and thrombin receptor-activating peptide were measured at baseline (day 0), and then 3 h after the first (day 1) and last (day 7) treatment. RESULTS: The bleeding times for all subjects remained within the normal range throughout the study period, with no significant differences between the two treatment groups. There were no significant changes from baseline in platelet aggregation studies or in any of the other haemostasis tests, with no significant differences between the two groups. No clinically significant adverse events were reported or observed. CONCLUSIONS: Daily administration of 200 mg nimesulide for 7 days neither prolongs bleeding time nor modifies any of the other haemostasis variables measured. The lack of interactions with important haemostatic mechanisms suggests that nimesulide may also be used in patients with bleeding problems. This expectation has still to be confirmed by clinical experience.     

Differentiation of benign from malignant pancreatic masses by endoscopic ultrasound

BACKGROUND: It is often difficult to determine whether a mass in the pancreas is benign or malignant. The goal was to evaluate whether endoscopic ultrasound (EUS) can reliably establish whether a mass is benign or malignant. METHODS: One hundred five patients with possible pancreatic tumors were referred for EUS. Those who were found to have a lesion suspicious for carcinoma and did not have a known malignancy also underwent EUS-guided FNA. RESULTS: A mass suspicious for cancer was identified in 73 patients, whereas inflammatory changes or a normal pancreas was noted in 32 patients. Four of the latter 32 patients were subsequently found to have cancer. EUS-guided FNA was performed on 47 of the 73 patients with a suspicious mass and was read as cancer in 27 patients, atypia in 10 patients, and benign in 10 patients. All 10 patients with atypia were subsequently confirmed to have cancer, and 6 of the 10 patients with a benign FNA were proved to have a tumor at surgery. EUS could differentiate the lesion as malignant with a sensitivity of 95%, specificity 88%, positive predictive value 95%, and negative predictive value 88%. CONCLUSIONS: Radial array EUS is helpful in supporting or refuting a diagnosis of cancer in a patient with a pancreatic mass. Although EUS-guided FNA can confirm the diagnosis, a negative FNA should not preclude exploration when clinically indicated.     

Diagnostic imaging in the evaluation of constipation in adults

Acute and chronic constipation are common conditions. In most instances, a thorough history and digital rectal examination provide sufficient information to begin treatment. Occasionally, imaging studies can be useful to confirm the presence of a suspected abnormality. The acute onset of constipation suggests colonic obstruction. Plain abdominal radiographs may be sufficient to determine the level and cause of the obstruction, such as sigmoid or cecal volvulus. Barium enema radiographic examination or colonoscopy may also be useful to detect the cause of obstruction. In patients with chronic constipation, plain abdominal radiographs can be used to show the extent of fecal impaction. Colonic transit time can be assessed on serial abdominal radiographs after the patient has ingested radiopaque markers. Evacuation proctography can be used to diagnose a variety of functional disorders of the rectum and anus, such as rectocele, intussusception and abnormal perineum floor descent.     

Diagnostic ultrasound in threatened abortion and suspected ectopic pregnancy

200 women threatened with abortion during the first 16 weeks of pregnancy were examined with diagnostic ultrasound to determine whether there were signs of intrauterine life. Of the 90 who showed positive signs, 8 aborted spontaneously later, the other 82 continued their pregnancy. The ultrasound investigation revealed no signs of intrauterine life in 110 patients. Of these, spontaneous abortion or later evacuation because of missed abortion 101 (histopathological examination showed degenerated villi in 98), not pregnant 4, mola hydatidosa 3, extrauterine pregnancies 2. An ultrasound examination was performed to ascertain whether 136 women with suspected ectopic pregnancy had intrauterine pregnancies. 61 of them had an intrauterine gestational sac, confirmed at clinical follow-up. One of the 61 was operated on with laparoscopy because of pain; no abnormalities were found. In 36 of the other 75, laparoscopy was performed. Ectopic pregnancy 21, ovarian or parovarian cyst 11, adhesions 2, salpingitis 1, and normal 1. Diagnostic ultrasound is excellent for accurate prognosis in threatened abortion. Unnecessary operations avoided; hospitalization in suspected ectopic pregnancies reduced.     

Diagnostic evaluation of the cervical nystagmus in cervical torsion test

The long-term effects of streptozotocin (30-70 mg/kg) were studied on plasma glucose and insulin levels, islet morphology, and glucose-stimulated insulin secretion in rats. In addition, the protective effect of short-term (7 days) insulin treatment on streptozotocin-induced diabetes was examined. Streptozotocin administration at dose levels exceeding 40 mg/kg resulted in a long-term, stable hyperglycemia with no insulin response to glucose at 3 months and with a marked derangement of islet morphology (few insulin cells, accumulation of glucagon cells). In contrast, at 30 and 40 mg/kg, streptozotocin induced a transient diabetes. Thus, the blood glucose levels, being elevated at days 1-7, returned to normal levels within 10 days after streptozotocin administration and the glucose-induced insulin secretion, being absent at day 1, was normal at 3 months. Furthermore, the islet morphology was also normal in these groups at 3 months. Short-term (7 days) insulin treatment normalized the long-term diabetes in rats given 50 mg/kg streptozotocin, but not in rats given 60 or 70 mg/kg streptozotocin. Thus, after insulin treatment, all rats receiving 50 mg/kg streptozotocin returned to normoglycemia within the following 2 weeks, and the glucose-induced insulin secretion was normal after 3 months, as was islet morphology.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnostic evaluation of urinary incontinence in geriatric patients

In most cases, the evaluation of urinary incontinence requires only a history, a physical examination, urinalysis and measurement of postvoid residual urine volume. The initial purposes of the evaluation are to identify conditions requiring referral or specialized work-up and to detect and treat reversible causes that may be present. If the patient does not appear to require referral and a reversible cause is not identified, the next step is to categorize the patient's symptoms as typical of either urge or stress incontinence and treat the patient accordingly. If treatment fails or a presumptive diagnosis of urge or stress incontinence cannot be reached, the final step would be to perform more sophisticated tests or refer the patient for testing to define the cause and determine the best treatment.     

Clinical evaluation of ultrasound hyperthermia system

The plasma membrane represents an impermeable barrier to proteins and other macromolecules. However, certain exogenous proteins are able to cross cellular membranes and gain access to the cytosol. The best examples are bacterial and plant protein toxins, acting on intracellular targets. During last few years the number of known proteins possessing the capability to cross cellular membranes in the reverse direction and reach the nucleus has increased (acidic and basic fibroblast growth factor, interleukin 1, angiogenin, Schwannoma derived growth factor, homeoprotein Antennapedia, HIV-1 Tat protein are some examples). Here, the role of transport of exogenous acidic fibroblast growth factor to the nuclear location as a part of the growth factor signaling is discussed, and the current knowledge on this issue is reviewed.     

Diagnostic sleep testing in the evaluation of snoring and sleep apnea

The dilemma frequently encountered by the dentist wishing to offer an appliance for treatment of snoring or sleep apnea is whether there is a need for extensive testing of patients who present with a complaint of snoring. This article describes diagnostic sleep testing in the evaluation of patients with snoring and sleep apnea.     

The evaluation of breast masses in women younger than forty years of age

BACKGROUND: Breast masses in young women are common, but carcinoma is rare. This study was undertaken to determine how often a complaint of mass was found to represent a dominant mass and to define the role of breast imaging and fine-needle aspiration cytology (FNA) in the evaluation of clinically nonworrisome masses. METHODS: A retrospective review was made of 605 patients younger than 40 years of age with a breast mass between February 1994 and February 1996. RESULTS: Dominant masses were confirmed by surgeon examination in 36% of 484 self-detected masses compared with 29% of physician-detected masses (difference not significant). With pathologic confirmation, 29% of self-detected masses had a dominant mass compared with 19% of physician-detected masses (P = .02). Carcinoma was present in 5% of both groups and not predicted by family history. Imaging studies were not useful in patients with normal examinations but were more likely to identify dominant masses in patients with an examination described as benign (P < .001). FNA did not identify any cancers in normal or benign examinations. CONCLUSIONS: Self-examination is as reliable as a general physician examination in detecting breast masses. When an examination by an experienced surgeon is normal, imaging studies and FNA are low yield. When the examination is equivocal, directed ultrasonography is a useful adjunct.     

Three-dimensional ultrasound evaluation of fetal tooth germs

Thirty children have had percutaneous endoscopic gastrostomy (PEG) inserted for feeding purposes. During a follow-up period of 5-45 months (mean 24 months), complications were recorded in 13 patients. Some patients had more than one complication. Complications included colocutaneous fistula, gastro-oesophageal reflux, wound infection, granulation tissue formation, tube leakage, tube blockage and bleeding. The authors present a retrospective review of the results and discuss the management of these complications.     

Endoscopic ultrasound in the evaluation of gastric small lymphocytic mucosa-associated lymphoid tumors

In this study, we examined the effects of recombinant bovine gamma interferon (rIFN-gamma) and nitric oxide (NO) on the interaction of M. avium subsp. paratuberculosis with bovine monocytes. Monocytes pretreated with rIFN-gamma exhibited slightly increased phagocytosis of M. avium subsp. paratuberculosis and modest inhibition of the intracellular growth of this microorganism. The number of viable intracellular bacilli decreased earlier in rIFN-gamma-pretreated monocytes than in control monocytes. After infection with M. avium subsp. paratuberculosis, NO was not constitutively released, but NO release from infected monocytes was induced by treatment with rIFN-gamma or with rIFN-gamma and lipopolysaccharide (LPS). Release of nitric oxide was inhibited by addition of N(G)-monomethyl-L-arginine; however, inhibition of nitric oxide did not alter the pattern of intracellular survival of M. avium subsp. paratuberculosis in rIFN-gamma-treated bovine monocytes. Although chemically generated nitric oxide killed M. avium subsp. paratuberculosis in a cell-free system in vitro, the amount of nitric oxide required was far greater than that released from infected monocytes stimulated with rIFN-gamma and LPS. Our data suggest that rIFN-gamma activates M. avium subsp. paratuberculosis-infected bovine monocytes to release nitric oxide but only modestly increases antimycobacterial activity of monocytes against this organism. This may be due, in part, to the fact that the amount of nitric oxide produced by rIFN-gamma-activated bovine monocytes is insufficient to kill intracellular M. avium subsp. paratuberculosis bacilli in vitro.