A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study

BACKGROUND

Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder.

METHODS

A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created.

RESULTS

In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%.

CONCLUSION

Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Baseline glucose levels moderate the association between burn-related mortality inpatients with obesity

BACKGROUND

Differing findings concerning outcomes for burn patients with obesity indicate additional factors at play. One possible explanation could lie in determining metabolically healthy versus unhealthy obesity, which necessitates further study.

METHODS

A retrospective study was conducted using the Cerner Health Facts® Database. Deidentified patient data from 2014 to 2018 with second or third-degree burn injuries were retrieved. A moderator analysis was conducted to determine if the association between increased body mass index (BMI) and mortality is moderated by baseline glucose level, a surrogate marker associated with metabolically unhealthy obesity.

RESULTS

The study included 4682 adult burn patients. BMI alone was not associated with higher mortality (β = 0.106, p = 0.331). Moderation analysis revealed that baseline glucose level significantly modulated the impact of BMI on burn-related obesity; patients with higher BMI and higher baseline blood glucose levels had higher mortality than those with lower baseline blood glucose levels (β = 0.277, p = 0.009). These results remained unchanged after adjusting for additional covariates (β = 0.285, p = 0.025) and inthe sensitivity analysis.

CONCLUSIONS

Increased baseline glucose levels indicate increased mortality in obese patients with burn injuries, emphasizing the differentiation between metabolically unhealthy versus healthy obesity.

Comparing Outcomes of Sub-Total Cholecystectomy Versus Open Cholecystectomy as Bailout Procedures for the Difficult Gallbladder

BACKGROUND

Although laparoscopic cholecystectomy is one of the most common operations performed, there is no consensus on the best surgical approach when inflammation obscures hepatocystic anatomy in severe cholecystitis. Traditionally, this situation triggered conversion to open cholecystectomy (COC); however, in recent decades, alternative approaches have been described. We compared outcomes of bailout procedures for severe cholecystitis, primarily focusing on COC versus laparoscopic subtotal cholecystectomy (LSTC).

STUDY DESIGN

Retrospective review comparing outcomes of intended laparoscopic cholecystectomy cases that were converted to bailout procedures between 2015-2020 at a single institution. Bailout procedures were categorized into LSTC and COC groups. Demographics, clinical presentation, time to surgery, operative indications, operative duration, and post-operative outcomes were compared using independent sample t-tests with Welch-Satterthwaite correction or Wilcoxon rank-sum tests (continuous variables) or Fisher's exact/χ2 tests. A P-value of less than .05 was considered significant.

RESULTS

Final analysis included 158 subjects: 55 LSTC and 99 COC. Patient demographics and clinical presentations were similar between groups. LSTC had shorter operative time, fewer ICU admissions, and shorter length of stay than COC (P < .05). There were 9 (9.2%) cases of ileus, 4 (4.0%) cases of post-operative bleeding, and 2 (2.0%) cases of bile duct injury in COC. There was 1 (1.8%) case of ileus, 1 (1.8%) case of post-operative bleeding, and no bile duct injury in LSTC.

CONCLUSION

LSTC was associated with fewer complications than COC, which had higher rates of biliary injury, bleeding, ileus, ICU admission, and longer hospital stay.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study

Objectives

The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap.

Methods

This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R.

Results

Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves.

Conclusion

Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity.

Level of evidence

III.

Treatment of Severe Road Rash with ReCell® Autologous Skin Cell Suspension

Road rash injuries are often variable in severity, with injuries ranging from simple scrapes to full thickness burns. Autologous skin cell suspension (ASCS) devices, such as ReCell®, have shown increased promise by creating results comparable to the current standard of care, split-thickness skin grafting (STSG) with significantly less donor skin required. We present a case of a 29-year-old male with significant road rash after a motorcycle accident at highway speeds, who was successfully treated solely with ReCell application. After surgery, he reported decreased pain with wound care and showed overall wound improvement with no changes in range of motion at 2-week follow-up. This case demonstrates the potential of ReCell as an independent treatment modality for pain and skin injury secondary to severe road rash.

Mail and Telephone Outreach from Electronic Health Records for Research Participation on Cognitive Health and Aging

OBJECTIVES

This report describes the efficacy and utility of recruiting older individuals by mail to participate in research on cognitive health and aging using Electronic Health Records (EHR).

METHODS

Individuals age 65 or older identified by EHR in the Mount Sinai Health System as likely to have Mild Cognitive Impairment (MCI) were sent a general recruitment letter (N=12,951). A comparison group of individuals with comparable age and matched for gender also received the letter (N=3,001).

RESULTS

Of the 15,952 individuals who received the mailing, 953 (6.0%) responded. 215 (1.3%) declined further contact. Overall rate of expression of interest was 4.6%. Of the 738 individuals who responded positively to further contact, 321 indicated preference for further contact by telephone. Follow-up of these individuals yielded 30 enrollments (0.2% of 15,952). No differences in response rate were noted between MCI and comparison groups, but the comparison group yielded higher enrollment. 6 individuals who were not the intended recipients of mailing but nevertheless contacted our study were also enrolled.

CONCLUSIONS

Mailings to individuals identified through a trusted source, such as a medical center from which they have received clinical care, may be a viable means of reaching individuals within this age group as this effort yielded a low rejection rate. However, EHR information did not enhance study enrollment. Implications for improving recruitment are discussed.

Daylight photodynamic therapy is an option for the treatment of actinic keratosis in patients with xeroderma pigmentosum in Africa

BACKGROUND

Xeroderma pigmentosum (XP) is a very rare and severe genetic disorder with a DNA repair defect of ultraviolet (UV)-induced damage. Photodynamic therapy (PDT) has been successfully used in XP patients to treat actinic keratosis (AK) and daylight PDT (DL-PDT) has demonstrated similar efficacy to conventional PDT (C-PDT) for AK.

OBJECTIVES

To assess DL-PDT for the treatment of AK in patients with XP.

METHODS

Patients with XP were evaluated by a group of Spanish and African dermatologists. Clinical characteristics of the patients were assessed and divided in mild, severe or moderate affectation of AK in the face. A topical photosensitizer was extended on the patients' faces and after two hours of indoor light exposure, fluorescence was assessed and the cream was removed. Patients were examined two and seven days later to assess the reaction to PDT and followed up three months later.

RESULTS

A total of 13 patients were treated on the whole face. Three were classified as severe AK, six as moderate AK and four as mild AK. Fluorescence assessment showed a soft yellow-green colour and a pink-color delineating the AK. Two days after treatment patients presented a scaly reaction. After one week the reaction healed, there was improvement and after three months no adverse events were noticed.

CONCLUSIONS

PDT is an option for treatment of AK in patients with XP.

Characterizing cognitive deficits and dementia in an aging urban population in India

Rapid rise in the population of older adults in India will lead to the need for increased health care services related to diagnosis, management, and long-term care for those with dementia and cognitive impairment. A direct approach for service provision through memory clinics can be an effective, successful, and sustaining means of delivering specialized health care services. We have established a memory clinic in Mumbai, India by employing the diverse clinical skills available in Indian academic institutions, diagnostic and research expertise of clinicians and psychologists, and the support of the U.S. National Institutes of Health. Our project involved recruitment of patients, clinical and neuropsychological assessment, and standardized diagnostic procedures, demonstrating the feasibility of using research methods to develop a memory clinic. In this paper, we describe the development of a community-based memory clinic in urban India, including linguistic and cultural factors and present detailed results, including diagnostic characterization, on 194 subjects with various stages of cognitive deficits. Our findings support the feasibility of developing a memory clinic in a public hospital and successful use of research diagnostic criteria to categorize cognitive deficits observed in this population, which may be used to inform the development of other such clinics.

Final results from a phase II trial of systemic chemotherapy in a small cell urothelial cancer: Evidence supporting neoadjuvant chemotherapy from the M.D. Anderson Cancer Center

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Background: Previously reported retrospective data supported a potential role for neoadjuvant chemotherapy in small cell urothelial cancer (SCUC). We now report final results from a phase II clinical trial in SCUC. Methods: Since 2001, 30 patients with biopsy proven SCUC received alternating doublet chemotherapy with Ifosfamide + Doxorubicin, and Etoposide + Cisplatin. Patients with surgically resectable disease (<=cT4aN0M0) received a total of 4 cycles followed by cystectomy, while those with unresectable disease (>=cT4b, N+, or M+) received 2 cycles beyond maximal response. Results: Neoadjuvant chemotherapy was given in 18 patients (cT2:14, cT3:4), while 12 patients were treated for metastatic SCUC. For those receiving neoadjuvant therapy, the median OS is 58 months, with a 5-year survival of 48%; 8 remain alive and NED beyond 2.5 years. There have been only 5 deaths for the neoadjuvant group (3 SCUC, 1 post-op infection, 1 AML). For those with metastatic disease, the median OS is 14 months. Two were rendered resectable with chemotherapy (cT4b:1,N+:1); 1 died of recurrent SCUC, while the other is currently undergoing therapy for TCC of the ureter. Brain metastases developed in 7 patients (cT3b:2, initial M+:5). Chemotherapy has been well-tolerated with only 2 G4 toxicities (catheter infection and neutropenia). The most frequent G3 toxicities include transfusion (10), neutropenic fever (7), infection (5), and vomiting (3). There was only one post-surgical death; a case of sepsis in a patient with diverticulitis and abscess requiring sigmoid colon resection. Conclusions: These prospective results, which are consistent with our previously reported retrospective review, provide additional support for 4 cycles of neoadjuvant chemotherapy in the setting of SCUC. Unfortunately, once metastases are present, the prognosis remains poor with few long-term survivors. These results may also predict a patient subset for which prophylactic cranial irradiation may be potentially beneficial.

No significant financial relationships to disclose.

Age, gender, and education norms on the CERAD neuropsychological battery in the oldest old

OBJECTIVE

To evaluate the performance of nondemented subjects 85 years and older on the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, and to assess its relationship with sociodemographic variables.

METHODS

We studied 196 subjects enrolled in an Alzheimer's Disease Research Center study who had a complete CERAD neuropsychological assessment. We used multiple regression analysis to predict performance on the neuropsychological tests from age, education, and sex. Eight representative hypothetical individuals were created (for example, an 87-year-old man, with high education). For each test, estimates of performance at the 10th, 25th, 50th, and 75th percentiles were reported for the eight representative hypothetical individuals.

RESULTS

Mean age was 89.2 years (SD = 3.2), mean years of education was 14.9 (SD = 3.2), and 66% of the sample were women. For 11 of the 14 neuropsychological tests, there was a significant multiple regression model using education, age, and sex as predictors. Neither the models nor the predictors used individually were significant for Delayed Recall, Savings, or correct Recognition. Among the significant results, seven had education as the strongest predictor. Lower age and higher education were associated with better performance. Women performed better than men in three of four tests with significant results for sex.

CONCLUSIONS

In a sample of oldest old whose primary language is English, neuropsychological testing is influenced mainly by education and age. Cutoff scores based on younger populations and applied to the oldest old might lead to increased false-positive misclassifications.

Early-onset substance abuse and community violence by outpatients with chronic mental illness

OBJECTIVE

This study examined the relationship between violence and substance abuse among patients with chronic mental illness living in the community.

METHODS

All referrals over a one-year period to an urban assertive community treatment team were evaluated systematically with a standardized intake protocol. Thirty-seven patients with a history of violence in the community were compared with 27 patients without such a history on a variety of clinical and demographic variables.

RESULTS

More than half of the patients (58 percent) had a history of violence in the community. The only significant differences between those with a history of violence and those without involved alcohol or drug use. The single best predictor of violence was the onset of alcohol or drug abuse in late childhood or early adolescence.

CONCLUSIONS

In this sample, very early onset of substance abuse among people who developed mental illness was associated with the greatest risk of community violence. Thus at least some of the causal determinants of violence in this sample may precede the onset of adult mental illness.

Cognitive performance and regional brain volume in human immunodeficiency virus type 1 infection

BACKGROUND

Brain atrophy has been reported to occur in advancing human immunodeficiency virus (HIV) infection, particularly in patients with HIV-related dementia. Atrophy of the caudate region, as assessed by magnetic resonance imaging measures, has been reported to correlate with cognitive impairment in patients with HIV infection; however, differences in the severity of HIV-induced immunosuppression may have contributed to these findings.

OBJECTIVE

To determine the relationship between regional brain volumes and cognitive performance in individuals with HIV infection.

PATIENTS AND METHODS

We evaluated 11 patients with advanced HIV disease by using neuropsychologic tests and quantitative magnetic resonance imaging volume analysis.

SETTING

University hospital, involving patients from a clinical trial.

RESULTS

Caudate volume, expressed as a ratio of total intracranial volume, correlated with performance on the Trails A and Grooved Pegboard tests, but not with other tests of memory, motor speed, or mood (adjusted for age and education). Hippocampal volume did not correlate with any of the neuropsychologic tests.

CONCLUSIONS

Caudate volume in patients with advanced HIV disease is associated with poor performance on neuropsychologic tests of complex motor and sequencing skills. Hippocampal volume does not appear to be related to impairment on neuropsychologic tests. These findings are independent of the degree of immunosuppression and the overall extent of brain atrophy; however, these results must be interpreted with some caution, given the limited sample size.

Liver preservation with UW solution. I. Evidence that hydroxyethyl starch is not essential

Preservation of rat livers by simple ice-storage has been demonstrated after 24 hr using the University of Wisconsin (UW) solution. Equally good preservation could be obtained by substituting hydroxyethyl starch (HES) from another source or by omission of HES from the UW formulation. Survival, early and late function, and morphology at the end of a 3-month follow-up period were essentially similar for all three test groups. It is concluded that HES is not required for optimum preservation of the rat liver in this treatment model.

Vertex epidural hematomas

Four cases of vertex epidural hematomas are presented to illustrate the unique management problems which set them apart from their more common counterparts located over the temporal convexity. Diagnosis requires a high degree of suspicion as vertex epidural hematomas are often missed by conventional horizontal scanning. Coronal computed tomographic scanning should be undertaken in all suspected cases. Clinical symptoms exceeding the small volume of clot may be present due to venous obstruction and disruption of cerebrospinal fluid absorption. Evacuation of the clot usually leads to clinical improvement.

Tardive dyskinesia: a five year follow-up

A group of chronic schizophrenic patients receiving prolonged treatment with neuroleptics was assessed in 1978 at an outpatient clinic to determine the prevalence of Tardive Dyskinesia. Those with TD were reassessed after two and five years with regard to change in TD severity. The Smith scale was used every time and, on the last assessment, the AIMS scale and videotaped interviews were added. Because of the high attrition rate, results, though interesting, cannot be generalized.

The importance of the hepatic artery in rat liver transplantation

The hepatic artery is important in preventing biliary ischemia and obstruction after bile duct reconstruction or orthotopic liver transplantation in the rat. A technique of orthotopic liver transplantation in the rat with reestablishment of the arterial inflow is described, suitable for studies in immunology and preservation. Reestablishment of both venous and arterial inflow is required to minimize biliary complications. General survival, hepatic cellular function, and biliary drainage are all improved by rearterialization. In all these features, the rat illustrates characteristics applicable to human liver transplantation. The vital requirement of the adequacy of blood supply to the bile duct in liver transplantation surgery in all species is highlighted by these findings, which indicate clearly the importance of an arterial blood supply in rat liver transplantation and bile duct surgery.

Preoperative embolization in the treatment of osseous metastases from renal cell carcinoma

Metastatic lesions due to renal cell carcinoma are frequently hypervascular. This study reports the results of preoperative embolization of skeletal metastases from hypernephroma. Reported for the first time in the English literature is the use of this technique for preoperative devascularization of metastatic lesions to the spine in eight patients. Effective devascularization was achieved in all peripheral lesions. Blood loss for peripheral lesions averaged 940 cc and compared favorably to 20 nonembolized cases, in whom average blood loss was 1975 cc. Spinal embolization requires careful identification and preservation of any segmental arteries that supply the anterior spinal artery. Effective spinal devascularization was achieved in six of eight patients. In two patients significant bleeding occurred as a result of incomplete embolization. This series supports the growing evidence for the efficacy and safety of selective arterial embolization in the preoperative control of hemostasis in patients with metastatic hypernephroma. Embolization of spinal metastases, although technically demanding, has been effective in devascularizing these lesions without serious neurologic complications.

Formation of double-walled microtubules and multilayered tubulin sheets by basic proteins

Some basic proteins enable microtubule protein to form special assembly products in vitro, known as double-walled microtubules. Using histones (H1, core histones) as well as the human encephalitogenic protein to induce the formation of double-walled microtubules, we made the following electron microscopic observations: (1) Double-walled microtubules consist of an "inner" microtubule which is covered by electron-dense material, apparently formed from the basic protein, and by a second tubulin wall. (2) The tubulin of the second wall seems to be arranged as protofilaments, surrounding the inner microtubule in a helical or ring-like manner. (3) The surface of double-walled microtubules lacks the projections of microtubule-associated proteins, usually found on microtubules. (4) In the case of protofilament ribbons (incomplete microtubules), H1 binds exclusively to their convex sides that correspond to the surface of microtubules. Zn2+-induced tubulin sheets, consisting in contrast to microtubules of alternately arranged protofilaments, are covered by H1 on both surfaces. Furthermore, multilayered sheet aggregates appeared. The results indicate that the basic proteins used interact only with that protofilament side which represents the microtubule surface. In accordance with this general principle, models on the structure of double-walled microtubules and multilayered tubulin sheets were derived.

Pathogenetic role of HIV infection in Kaposi's sarcoma of equatorial East Africa

Thirty residents of north-central Tanzania with various forms of Kaposi's sarcoma (KS) were evaluated. The absolute number of peripheral blood OKT4 lymphocytes in patients and Tanzanian control subjects tended to be low (in comparison with healthy young American adults), and many had inverted T4/T8 ratios. Plasma polyclonal beta- and gamma-globulin concentrations were increased in many patients with KS and in control patients in Tanzania with chronic dermatopathies, but not in African hospital employees and patients undergoing elective surgery. Three of nine patients with locally aggressive KS possessed antibodies to human T-cell lymphotropic virus type III/lyphadenopathy-associated virus (HIV), but none had evidence of the acquired immunodeficiency syndrome (AIDS) or the AIDS-related complex. Three patients with disseminated, rapidly progressive KS and high HIV-antibody titers had an immunologic and clinical picture consistent with AIDS. Two of 13 patients with the classic plaque/nodular form of KS had low plasma titers of HIV antibody, but the significance of these serologic findings is not known. The evidence suggests that HIV plays a role in the pathogenesis of some cases of KS in East Africa, but most patients with KS in East Africa have no evidence of overt immunologic deficiency or HIV infection.

Congenital scoliosis and urinary tract abnormalities: are intravenous pyelograms necessary?

One hundred patients with a diagnosis of congenital scoliosis were reviewed with regard to their urologic history, chemistries, and excretory urography. A 40% incidence of urologic abnormality was found in these asymptomatic patients. Twenty-five additional patients were evaluated by excretory urography and ultrasonography. Of six patients identified by ultrasonography as having abnormalities five had results confirmed by excretory urography. Urologic evaluation of all patients with congenital scoliosis is recommended; however, diagnostic ultrasonographic evaluations of the urinary tract have proven to be an acceptable alternative as an initial screening modality.

Subdural hematoma in systemic lupus erythematosus: report and review of the literature

A patient with systemic lupus erythematosus (SLE) and subdural hematoma is described. Pathophysiological concepts are discussed and a link between this lesion and active SLE is suggested. The disastrous consequences of failure to recognize subdural hematoma in this context is emphasized.

Diagnostic imaging in pediatrics: the state of the art

The results of the study panels, both at national and international levels, have shown that much can be done to increase the efficiency and efficacy of diagnostic imaging in all areas of medical practice including pediatrics. Much remains to be done, however. The work that has been done must be expanded into a thorough investigation of the safety, yield, and cost of diagnostic imaging. It is the responsibility of all physicians to continue efforts toward more rational use of diagnostic imaging at all levels of society and to make sure that established guidelines are implemented. Flexibility in attitudes, cooperation between clinician and radiologist, and a willingness to learn and keep up with advances are essential to this process--not only to improve the benefits from diagnostic imaging, but to preserve the ability of society to pay for it. Those who would proclaim that this or that recommendation is the "last word" must realize that half of what is said today may well be proven false 10 years from now, and, further that we have no way of knowing what techniques and imaging approaches will comprise that half, nor should the imaging "standards" be self-serving. Guidelines drawn up in an academic vacuum where all imaging techniques are readily available may have little practical application in pediatric practice and impact on health care in areas of the world where diagnostic imaging, if available at all, will consist only of basic radiographic imaging. At the same time, experience gained in countries using all advanced imaging modalities must be shared with less fortunate nations: such knowledge may have important implications for even the most basic radiographic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Imaging of neuroblastoma: an overview

This review article briefly describes the pathology, clinical features, prognosis, and treatment of neuroblastoma. The emphasis is on applications of newer diagnostic modalities (sonography, nuclear scintigraphy, computed tomography) for imaging and staging. The potential role of magnetic resonance imaging and spectroscopy is discussed.

Acute median nerve compression by haemorrhage from acute myelomonocytic leukaemia

A 61-year-old male receiving treatment for acute myelomonocytic leukaemia (AMML) developed weakness and sensory loss in the thumb, index and middle finger and half of the ring finger of the left hand as a result of a spontaneous haemorrhage into the carpal tunnel and forearm, an unusual cause of median nerve compression. These findings were confirmed by CT scanning and post-mortem examination. This is the first report of spontaneous haemorrhage occurring in a patient with AMML.

Extracranial cribside sonography in infants

In 29 real-time ultrasonic studies of infants in the intensive care nursery, the technique either accurately diagnosed or led directly to the correct diagnosis in 27 (93%). Twenty-four of these infants had suspected abnormality in the abdomen or pelvis, three had congestive heart failure and bruits, one had respiratory distress and an opacified hemithorax on chest roentgenogram, and one was a child with ambiguous genitalia in whom sonography identified a uterus. We suggest that portable, real-time ultrasonography is an ideal modality with which to study seriously ill infants whose medical condition precludes transport to the radiology department.

Use of computed tomography in pediatric oncology

Computed tomography (CT) has dramatically changed the imaging of pediatric oncologic disease. CT precisely displays and characterizes cross-sectional anatomic pathology. This provides important information for diagnosing and staging tumors in infants and children. The principles, techniques, and indications for computed tomography in the evaluation of pediatric extracranial tumors are reviewed in this article. Selected applications of computed tomography for pediatric tumors of the mediastinum, chest wall, lung parenchyma, abdomen, pelvis, and extremities are discussed and illustrated.

Congenital saccular anterior urethral diverticulum

Congenital saccular diverticulum is an uncommon abnormality of the anterior urethra in the male. In seven cases (6 infants and an 8-year-old boy) the diverticulum was well demonstrated by voiding cystourethrography and/or retrograde urethrography. In patients with saccular anterior urethral diverticulum, contrast material fills an oval outpouching of the ventral aspect of the anterior urethra. The clinical presentation, unique radiologic appearance, and differential diagnostic considerations are reviewed.

Localization of the site of urinary tract infections with the bladder washout test

The data from 100 bladder washout studies on pediatric patients have been analyzed to derive criteria for interpretation of this test and to define the limitations of this procedure in localization of the site of urinary tract infections. Using the bladder washout test, infection of the upper urinary tract is characterized by an abrupt increase in the concentration of bacteria in urinary specimens collected following urinary bladder sterilization. Infection limited to the lower urinary tract is characterized by scant if any bacterial growth in the specimens of urine collected following bladder sterilization. The site of infection may be incorrectly localized to the lower urinary tract or classified as not determined in patients with scant or intermittent renal bacteriuria.

Pulmonary sarcoidosis in childhood

Clinical and radiologic characteristics of pulmonary sarcoidosis in 26 children are presented. Initial nonspecific symptomatology and decreased pulmonary function are almost invariably accompanied by radiologic evidence of pulmonary disease. Bilateral hilar lymphadenopathy frequently associated with bilateral paratracheal adenopathy is characteristic. Other mediastinal lymphadenopathy (subcarinal, anterior, and posterior) is sporadically present, and is invariably associated with the more specific bilateral patterns of thoracic adenopathy. Pulmonary parenchymal involvement is common and predominantly appears radiographically as small irregular densities. Pleural effusion, pneumothorax, and cardiomegaly are unusual findings. Extrathoracic radiographic manifestations are uncommon. Lytic lesions of the tubular bones of the hands and feet are rare in childhood.