Tumor involvement in hepatic veins: comparison of MR imaging and US for preoperative assessment

PURPOSE: To compare use of magnetic resonance (MR) imaging and ultrasonography (US) for diagnosis of vascular involvement by tumor at the hepatic vein confluence. MATERIALS AND METHODS: Thirty-seven consecutive patients with tumors at the hepatic vein confluence were prospectively evaluated with spin-echo and gradient-echo MR imaging and gray-scale and Doppler US. Encasement, thrombosis, occlusion, and nonvisualization were considered to be evidence of vascular involvement. Imaging results were compared with surgical and pathologic examination findings in 27 patients who underwent resection. RESULTS: Sixteen hepatic veins (nine right, four middle, three left) were seen to be involved at surgery. Twelve of 16 involved veins were identified at MR imaging (75% sensitivity, 98% specificity, 92% positive predictive value, 94% negative predictive value). Thirteen of 16 involved veins were detected at US (81% sensitivity, 97% specificity, and 87% positive and 95% negative predictive values). There was one false-positive diagnosis of inferior vena cava involvement at both MR imaging and US. Ten patients had unresectable disease. One patient had motion artifact on MR images; in the remaining nine patients, MR imaging and US yielded identical findings at 26 of 27 hepatic vein sites. CONCLUSION: MR imaging and US provide comparable results for assessment of hepatic vein involvement by tumor.     

Ultrasonography by emergency physicians in patients with suspected ureteral colic

We performed a prospective study of patients with suspected ureteral colic to evaluate the test characteristics of bedside renal ultrasonography (US) performed by emergency physicians (EPs) for detecting hydronephrosis, and to evaluate how US can be used to predict the likelihood of nephrolithiasis. Thirteen EPs performed US, recorded the presence of hydronephrosis, and made an assessment of the likelihood of nephrolithiasis. All patients underwent i.v. pyelography (IVP) or unenhanced helical computed tomography (CT). There were 126 patients in the study: 84 underwent IVP; 42 underwent helical CT. Test characteristics of bedside US for detecting hydronephrosis were: sensitivity 72%, specificity 73%, positive predictive value (PPV) 85%, negative predictive value (NPV) 54%, accuracy 72%. The PPV and NPV for the ability of the EP to predict nephrolithiasis after performing US were 86% and 75%, respectively. We conclude that bedside US performed by EPs may be used to detect hydronephrosis and help predict the presence of nephrolithiasis.     

Alternative approaches to the prognostic stratification of mild to moderate primary vesicoureteral reflux in children

PURPOSE: We compared the prognostic stratification of primary vesicoureteral reflux by performing staging voiding cystourethrography in all children with a urinary tract infection or only in those with renal scarring on 99mtechnetium-dimercapto-succinic acid (DMSA) scintigraphy. MATERIALS AND METHODS: Staging voiding cystourethrography and DMSA scintigraphy were performed in 105 children with a urinary tract infection and reflux persistence was assessed by radionuclide cystography after a 2-year followup. RESULTS: Staging voiding cystourethrography revealed no reflux in 51 children (DMSA positive in 3), grades I to II reflux in 21 (DMSA positive in 6) and grade III reflux in 33 (DMSA positive in 19). On followup radionuclide cystography no new reflux was detected, and it was no longer demonstrated in 23 children (8 with grade III and 15 with grades I to II reflux). The finding of grade III reflux on staging voiding cystourethrography had a 76% positive and a 92% negative value for predicting persistent reflux with an 87% predictive accuracy. Limiting the evaluation of voiding cystourethrography data to the 28 children with a positive DMSA scan the combination of renal scarring and grade III reflux had an 84% positive and an 83% negative predictive value with 83% accuracy. This approach would have prevented 77 children from having to undergo voiding cystourethrography. CONCLUSIONS: Performance of staging voiding cystourethrography exclusively in children with renal scarring on a DMSA scan resulted in predictive accuracy that was close to what was achieved by performing voiding cystourethrography in all children with a urinary tract infection. To be able to limit cystourethrography to a select population could prove to be cost-effective.     

Small solid renal lesions: usefulness of power Doppler US

PURPOSE: To evaluate whether the vascular pattern at power Doppler ultrasonography (US) improves diagnostic accuracy in small solid renal lesions over that at gray-scale US. MATERIALS AND METHODS: Gray-scale and power Doppler US were performed prospectively in 64 small (1.5-3.0-cm-diameter) solid renal lesions (26 renal cell carcinomas [RCCs], 34 angiomyolipomas, two oncocytomas, two pseudotumors). At gray-scale US, echogenicity and homogeneity of the lesion, an anechoic rim, intratumoral cysts, shadowing, or a central scar were sought. At power Doppler US, the vascular distribution was divided into four patterns. RESULTS: Findings at gray-scale US included an anechoic rim or intratumoral cysts in 20 of 26 RCCs (77%) and the two oncocytomas. Shadowing was seen in seven of 34 angiomyolipomas (21%). Echogenicity, homogeneity, and a central scar were not pathognomonic. At power Doppler US, pattern 3 (peripheral) or 4 (mixed penetrating and peripheral) was seen in all RCCs, seven of 34 angiomyolipomas, and the two oncocytomas. Pattern 1 (intratumoral focal) or 2 (penetrating) was seen in 27 angiomyolipomas. Pattern 1 or 2 was characteristic of angiomyolipoma. The rate of correct diagnosis was significantly increased with combined US (78%) as compared to that with gray-scale (42%) or power Doppler (45%) US alone. CONCLUSION: The vascular distribution at power Doppler US could add important information to gray-scale US findings for differential diagnosis of small solid renal lesions.     

Acute renal failure secondary to acute pyelonephritis

A six year-old girl presented with acute oliguric renal failure, secondary to acute, non-obstructive pyelonephritis. Evidence for pyelonephritis as the cause of renal failure included: the evolution of typical changes on serial intravenous pyelograms, an acute interstitial inflammatory exudate on percutaneous renal biopsy, and gram-positive cocci on gram stain of the biopsy tissue. Although a specific causative organism was not conclusively identified, enterococcus was isolated from the initial catheterized urine specimen. The patient recovered from the acute illness but was left with impaired renal function, hypertension, and cortical scarring. Acute, non-obstructive pyelonephritis can produce acute renal failure in children and must be considered in the differential diagnosis of this syndrome.     

Urinary tract infections and pregnancy in women who underwent antireflux surgery in childhood

PURPOSE: For several decades ureteroneocystostomy has been performed in children to correct primary vesicoureteral reflux. A purported indication for antireflux surgery is to prevent significant upper urinary tract infection during pregnancy. We performed a long-term followup of women who underwent antireflux surgery during childhood to determine outcome in regard to urinary tract infection history and pregnancy. MATERIALS AND METHODS: We identified 227 women of childbearing age who underwent ureteral reimplantation for primary vesicoureteral reflux from 1964 through 1981. Of the 122 women contacted 41 had been pregnant (77 total pregnancies). Cystitis or asymptomatic bacteriuria and pyelonephritis developed during 18 and 5 pregnancies, respectively. The 77 pregnancies resulted in 57 term births, 7 voluntary pregnancy interruptions and 13 spontaneous abortions. RESULTS: Patients who previously underwent successful antireflux surgery continued to have a significant number of urinary tract infections through the intervening years. Despite a higher than expected incidence of pyelonephritis, they had relatively little hypertension and renal insufficiency. During pregnancy the incidence of pyelonephritis was only slightly higher than that of the general population. However, severe complications of pregnancy, such as preeclampsia, premature birth and acute renal failure, occurred more frequently in women with a history of renal scarring or hypertension (7 of 12) than in those with a history of recurrent infection alone (3 of 10). CONCLUSIONS: When renal scarring is present, reflux should be corrected before pregnancy to minimize maternal and fetal morbidity. When scarring is not present, the literature suggests that women with a history of reflux are at increased risk for pyelonephritis during pregnancy whether or not ureterocystostomy was performed. Pregnant women with a history of reflux may benefit from prophylactic antibiotics and women with reflux nephropathy should be followed throughout life.     

Typical technetium dimercaptosuccinic acid distribution patterns in acute pyelonephritis

Technetium dimercaptosuccinic acid renal scintiscans in 37 children with clinical diagnosis of acute pyelonephritis were reviewed. In 18 children, follow-up scintigraphy was obtained after an interval ranging from 5 to 8 months. Uptake abnormalities were found in 89% of the children (74% of the kidneys). We were able to identify four typical pathological uptake patterns: (i) pole defect(s), usually wedge shaped (60%); (ii) lateral wedge shaped defect (4%); (ii) scattered multiple defects (21%); and (iv) swollen kidney without areas of diminished uptake (15%). Remaining pathology at follow-up was found in 52% of the kidneys. Vesicoureteric reflux was present in 33% of the children with scintigraphic signs of pyelonephritis. Frequencies of parenchymal changes in the acute phase and at follow-up were not significantly correlated to the presence of reflux.     

Ipsilateral adrenalectomy in the surgical treatment of renal carcinoma

OBJECTIVES: To assess the value of ipsilateral adrenalectomy during radical nephrectomy for the treatment of renal cell carcinoma as a function of preoperative computed tomography findings. METHODS: Between May 1985 and June 1994, 194 patients underwent radical nephrectomy for renal cell carcinoma in our institution. Preoperative radiological reports and postoperative pathological reports were reviewed for 185 patients. RESULTS: 148 patients underwent abdominal computed tomography before surgery. 94 adrenalectomies were performed in this group of patients. None of the 77 patients in whom computed tomography showed a normal adrenal gland had adrenal metastasis on the definitive histological examination. 17 patients had an adrenal mass on computed tomography, 3 of which proved to be neoplastic. Preoperative CT had a sensitivity of 100%, a specificity of 82%, a positive predictive value of 18% and a negative predictive value of 100%. The 185 files reviewed included 114 adrenalectomies, including 4 adrenal glands invaded by renal cell carcinoma (3.5%). In these 4 cases, the smallest diameter of the renal tumour was 4 cm and the minimum pathological stage was T3. CONCLUSIONS: It therefore appears justified not to perform adrenalectomy during nephrectomy, in the presence of a renal tumour and negative adrenal computed tomography.     

Predictors of intracranial pathologic findings in patients who seek emergency care because of headache

BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.     

Correlation of peritoneal aspiration cytology with acute appendicitis

Fifty-one patients in whom a clinical diagnosis of acute appendicitis had been made underwent peritoneal aspiration cytology (PAC). Thirty-six had a positive result, 11 had a negative result and aspiration failed in four cases. All patients had an appendicectomy and the histological findings were correlated with the PAC results. Thirty-five of the 36 patients with a positive PAC had histologically proven appendicitis. Seven of the 11 patients with a negative result had normal appendices. The sensitivity of PAC for acute appendicitis was 85% and the specificity was 70%. The positive predictive value was found to be 97% and the negative predictive value 60%. Peritoneal aspiration cytology is a useful aid in the diagnosis of acute appendicitis however, a negative result does not exclude this diagnosis.     

Bilateral hypothalamic dopamine infusion in male Zucker rat suppresses feeding due to reduced meal size

PURPOSE: To determine whether vascular, ischemic, and inflammatory causes of bowel wall thickening in children can be differentiated at gray-scale and color Doppler ultrasonography (US). MATERIALS AND METHODS: Thirty-seven children with acute bowel disease underwent graded compression US. Findings of bowel wall thickness, wall echotexture, location of bowel involvement, and presence of color Doppler flow were evaluated. Diagnoses were classified as inflammation (n = 25), vasculitis (n = 7), or ischemia (n = 5) and were confirmed with findings from colonoscopy and biopsy, stool culture analysis, surgery, and cutaneous biopsy, and with a combination of clinical and laboratory data. RESULTS: Patient age (P = .0022), bowel wall thickness (P = .0001), and color Doppler flow (P = .0013) were statistically significantly related to disease type. Wall thickening and absence of visible color Doppler flow suggested ischemia. Older patient age and visible color Doppler flow suggested inflammation, whereas younger patient age and visible color flow suggested vasculitis. Difference in location of bowel disease in patients with ischemic versus those with vascular wall thickening was statistically significant (P = .0185). No difference was found between disease type and wall stratification. CONCLUSION: Gray-scale and color Doppler flow US can aid in differentiating ischemic, vascular, and inflammatory bowel wall thickening.     

Acute pyelonephritis and subcapsular hematoma revealing nephroblastoma at the age of 15 years

BACKGROUND: Nephroblastoma' the most common renal tumor in children between 1 and 5 years, occurs rarely in the oldest child. CASE REPORT: A 16-year-old teenager suffered from acute pyelonephritis caused by Klebsiella pneumoniae. Renal ultrasonography showed a left subcapsular hematoma; the CT scan confirmed the finding and also showed renal scarring. However, a second CT scan showed pulmonary nodules suggestive of metastasis, a diagnosis that was confirmed by needle biopsy of pulmonary lesions. Recovery was obtained after chemotherapy and nephrectomy with a 3-year-follow-up. CONCLUSION: This nephroblastoma was particular because its development in an adolescent, its association with acute pyelonephritis and subcapsular hemorrhage.     

Report of the International Research Group on Reconstructive Preprosthetic Surgery: the history of the Consensus Conference on Reconstructive Preprosthetic Surgery

The management of urinary tract infection in children must take into account several factors, namely the type of bacteria, the localization of the infection, the presence of an uropathy and the age of the patient. In acute pyelonephritis, the risk of renal scarring justifies a first line treatment with two antibiotics to be administrated intravenously in newborns and infants. Treatment must be maintained for at least 10 days: double antibiotherapy for 4-5 days, followed by oral monotherapy according to the antibiogram. Cystitis requires an oral monotherapy for 3-7 days. In any case it is important to search for a cause to the infection.     

Fractures of the patella in children and adolescents

Renal scarring is considered a criterion of reflux nephropathy and the end stage of pyelonephritis. Prednisolone, a strong anti-inflammatory drug, at doses of 1 or 2 mg/kg prevented renal scarring in rats following infection with Serratia marcescens. Four or 8 mg/kg of prednisolone, however, did not inhibit renal scar formation. In a time course experiment, renal scarring was prevented when 4-day treatment with prednisolone was initiated 2, 5, or 13 days after infection. These results show that prednisolone is effective in preventing such scarring and suggest the clinical use of this drug for preventing renal scar formation after pyelonephritis and reflux nephropathy.     

Utility of scintigraphic methods in patients with fever of unknown origin

BACKGROUND: We assessed the utility of scintigraphy with indium 111-labeled polyclonal human IgG scintigraphy in patients with fever of unknown origin that fulfilled the criteria of temperature of 38.3 degrees C or more for at least 3 weeks and no diagnosis during 1 week of hospital admission. We compared the utility of this technique with results of scintigraphic techniques reported in the literature. METHODS: Data for all patients seen at our university hospital in whom 111In-IgG scanning was performed were analyzed and checked for the criteria for fever of unknown origin. The literature on the utility of scintigraphic techniques in patients with fever of unknown origin was reviewed. RESULTS: We studied 24 patients with fever of unknown origin. In 13 patients, focal 111In-IgG accumulation was observed. In nine (38%) of those, the positive 111In-IgG scintigram led to the final diagnosis; in the other four patients (17%), the scintigraphic findings were not helpful. In the 11 patients with negative 111In-IgG scans, extensive diagnostic workup produced no infection as the final diagnosis in nine patients (38%), one had an abscess in a renal cyst that was detected several months later, and in the other the cause of fever was an infected intravenous line. The overall sensitivity and specificity of 111In-IgG scintigraphy were 81% and 69%, respectively. The positive predictive value was 69% and the negative predictive value was 82%. CONCLUSIONS: Our results show that 111In-IgG scintigraphy significantly contributed to the diagnostic process in patients with fever of unknown origin. A positive scan increased the likelihood of finding the cause of the fever, and a negative scan ruled out an inflammatory component with a high degree of certainty. These data compare favorably with data in the literature concerning other radiopharmaceuticals; a larger prospective evaluation of this technique is indicated.     

Magnetic resonance imaging in acute pyelonephritis

The diagnosis of acute pyelonephritis in children remains a clinical challenge. We assessed the feasibility of magnetic resonance imaging (MRI) detection of pyelonephritis in four pediatric patients and compared the results with renal cortical scintigraphy. MRI revealed areas of high signal intensity in the kidney that coincided with photon-deficient regions in the radionuclide scans in two children with acute pyelonephritis. These findings confirm work in experimental animals and indicate that MRI can accurately detect acute pyelonephritis in children.     

Looking at homeopathy, by an allopath

A study was done to test the effectiveness of fecal occult blood as a screening test for invasive bacterial pathogens and as a substitute for the fecal leukocyte examination in adult and pediatric cases of acute diarrhea. United States citizens studying in Mexico and Mexican children, both with acute diarrhea had their stools cultured, examined for fecal leukocytes, and tested for occult blood. Using culture results as the criterion standard for detection of bacterial agents, and fecal leukocytes for diarrhea associated with diffuse colonic inflammation, occult blood was tested for its sensitivity, specificity, and predictive value using 2 x 2 tables. Analysis of the data found that occult blood negative samples were reliable indicators of a lack of invasive bacteria in both adult and pediatric patients (negative predictive values of 87% and 96%, respectively). Positive results for either test were not reliably predictive as indicators of invasive bacteria among adults. A positive occult blood test result was significantly more sensitive than a positive fecal leukocyte test result (79% versus 42%) in detecting invasive bacteria in the pediatric patients; however, the positive predictive value was only 24%. The fecal occult blood test is an uncomplicated, low-cost test that was reliable when giving a negative result in detecting a lack of invasive bacteria in adult and pediatric patients with diarrhea. In children, a positive result on a fecal occult blood test is sensitive but not specific in detecting invasive bacterial enteropathogens. These data also indicate that a commercially available test for occult blood represents a suitable alternative to microscopic examination of fecal samples for leukocytes obtained from patients with acute diarrhea.     

Colour Doppler flow in normal axillary lymph nodes

81 women with carcinoma of the breast who underwent axillary nodal dissection were studied pre-operatively with colour Doppler ultrasound. The presence of colour Doppler flow was demonstrated in 83.6% of normal lymph nodes compared with 87.5% of metastatic lymph nodes. Using the presence of colour Doppler signal as the sole diagnostic criterion for the diagnosis of metastasis gave a sensitivity of 92.5%, specificity of 9.52%, accuracy of 50%, positive predictive value of 49.3% and negative predictive value of 57.1%. Using grey scale sonographic criteria, where a metastatic node was defined as a node with loss of central fatty hilum and/or eccentric cortical hypertrophy, a sensitivity of 79.5%, specificity of 94.0%, accuracy of 87.6%, positive predictive value of 91.2% and negative predictive value of 85.5% were obtained. Colour Doppler studies of the axillary nodes in a second group of 106 women who attended for breast cancer screening and had no significant breast or axillary pathology also showed colour Doppler signal in 86.7% of nodes. It is concluded that colour Doppler flow signals can be demonstrated in both normal and metastatic axillary lymph nodes, and is highly non-specific when used as the sole diagnostic criterion in the diagnosis of malignancy.     

Periodic breathing during physical exercise: expression of a form of ventricular interdependence?]

BACKGROUND: To determine whether abnormal hepatic vein Doppler tracings can be used to predict liver transplantation rejection. METHODS: A total of 158 hepatic vein Doppler tracings were obtained on 93 postliver transplant patients (63 patients without rejection and 30 patients with biopsy-proven rejection). Hepatic vein Doppler tracings were scored according to an established grading system (0 = normal triphasic waveform, 1 = dampened waveform, with loss of flow reversal, 2 = completely flat waveform). The hepatic vein Doppler tracings were then correlated with biopsy findings. RESULTS: In the group of 63 patients without rejection, 124 Doppler examinations were performed and graded as follows: 0 = 87 (70%), 1 = 31 (25%), and 2 = 6 (5%). In the group of 30 patients with biopsy-proven rejection, 34 Doppler examinations were performed and graded as follows: 0 = 16 (47%), 1 = 14 (41%), and 2 = 4 (12%). The sensitivity of abnormal hepatic vein Doppler tracings for detection of rejection was 53% and the specificity was 70%. The positive predictive value of an abnormal hepatic vein Doppler tracing was 33% and the negative predictive value of a normal Doppler tracing was 84%. CONCLUSIONS: Abnormal hepatic vein Doppler tracings are observed in patients with and without liver transplant rejection. Abnormal tracings cannot be used to predict liver transplant rejection.     

Correlation of MRI and arthroscopic diagnosis of knee pathology in children and adolescents

The accuracy of magnetic resonance imaging (MRI) in diagnosing knee pathology in the pediatric and adolescent population is not well established. The purpose of this study was to correlate the findings of MRI and knee arthroscopy in children and adolescents. One hundred and eight consecutive knee arthroscopies performed in patients ages 4-17 years between 1992 and 1996 were retrospectively reviewed. Fifty-three of these patients underwent preoperative MRI. Age-related comparisons were then made between MRIs and observed intraoperative meniscal and anterior cruciate ligament pathology. The pediatric group (ages 4-14 years) was demonstrated to have an appreciable decrease in sensitivity, specificity, positive predictive value, and accuracy for essentially all categories of pathologic changes. Conversely, negative predictive values for the pediatric group exceeded those of the adolescent group (ages 15-17 years) in each category. The ability of MRI to predict intraarticular knee pathology among adolescents is comparable to that in adults, whereas it is much less accurate in the pediatric population.